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Clinical and diagnostic challenges of metal implant allergy using the example of orthopaedic surgical implants

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Summary

The focus of this review are allergic reactions to orthopaedic-surgical metal implants. The spectrum of metal implant associated potential allergic reactions encompasses eczema, impaired wound and fracture healing, infection-mimicking reactions, effusions, pain and loosening. Nickel, cobalt and chromium seem to be the predominant eliciting allergens. Despite the growing number of respective publications the topic „metal implant allergy“ remains a diagnostic challenge. Initially, differential diagnoses should always be excluded in cooperation with surgery collegues. It is recommended to perform a combined evaluation of medical history, clinical findings, patch testing and histology. The lymphocyte transformation test (LTT) can indicate metal sensitization, but it needs careful interpretation. Allergists can provide a substantial contribution to this interdisciplinary topic.

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Abbreviations

Co:

Cobalt

CoCrMo:

Cobalt-chromium-molybdenum

Cr:

Chromium

FDA U.S.:

Food and Drug Administration

LTT:

Lymphocyte transformation test

MHRA:

Medicines and Healthcare Products Regulatory Agency

Mo:

Molybdenum

M-o-M:

Metal-on-metal

PMMA:

Polymerized polymethylmethacrylate

RKI:

Robert Koch-Institute

SI:

Stimulation index

References

  1. Schäfer T, Bohler E, Ruhdorfer S, Weigl L, Wessner D, Filipiak B et al. Epidemiology of contact allergy in adults. Allergy 2001;56:1192–6

    Article  PubMed  Google Scholar 

  2. Thomas P, Schuh A, Ring J, Thomsen M. Orthopedic surgical implants and allergies: joint statement by the implant allergy working group (AK 20) of the DGOOC (German as-sociation of orthopedics and orthopedic surgery), DKG (German contact dermatitis research group) and DGAKI (German society for allergology and clinical immunology). Orthopade 2008;37:75–88

    Article  CAS  PubMed  Google Scholar 

  3. Basko-Plluska JL, Thyssen JP, Schalock PC. Cutaneous and systemic hypersensitivity reactions to metallic implants. Dermatitis 2011;22:65–79

    PubMed  Google Scholar 

  4. Wengler A, Nimptsch U, Mansky T. Hip and Knee Replacement in Germany and the USA: Analysis of Individual Inpatient Data From German and US Hospitals for the Years 2005 to 2011. Deutsches Ärzteblatt 2014;111:407–16

    Google Scholar 

  5. Granchi D, Cenni E, Giunti A, Baldini N. Metal hypersensitivity testing in patients undergoing joint replacement: a systematic review. J Bone Joint Surg Br 2012;94:1126–34

    Article  CAS  PubMed  Google Scholar 

  6. Thyssen JP, Menne T, Schalock PC, Taylor JS, Maibach HI. Pragmatic approach to the clinical work-up of patients with putative allergic disease to metallic orthopaedic implants before and after surgery. Br J Dermatol 2011;164:473–8

    CAS  PubMed  Google Scholar 

  7. Bircher A, Friederich NF, Seelig W, Scherer K. Allergic complications from orthopaedic joint implants: the role of delayed hypersensitivity to benzoyl peroxide in bone cement. Contact Dermatitis 2012;66:20–6

    Article  CAS  PubMed  Google Scholar 

  8. Thienpont E, Berger Y. No allergic reaction after TKA in a chrome-cobalt-nickel-sensitive patient: case report and review of the literature. Knee Surg Sports Traumatol Arthrosc 2013;21:636–40

    Article  PubMed  Google Scholar 

  9. Fitzgerald SJ, Trousdale RT. Why knees fail in 2011: patient, surgeon, or device? Orthopedics 2011;34:e513–5

    PubMed  Google Scholar 

  10. Caicedo MS, Samelko L, McAllister K, Jacobs JJ, Hallab NJ. Increasing both CoCrMo-alloy particle size and surface irregularity induces increased macrophage inflammasome activation in vitro potentially through lysosomal destabilization mechanisms. J Ortho Res 2013;31:1633–42

    Article  CAS  Google Scholar 

  11. Krenn V, Morawietz L, Kienapfel H, Ascherl R, Matziolis G, Hassenpflug J et al. Revised consensus classification. Histopathological classification of diseases associated with joint endoprostheses. Z Rheumatol 2013;72:383–92

    Article  CAS  PubMed  Google Scholar 

  12. Thomas P, Helm C von der, Schopf C, Thomsen M, Frommelt L, Schneider J et al. Periimplant histology and cytokine pattern in metal-allergic knee arthroplasty patients with improvement after revision with hypoallergenic materials. Sem Arthroplasty 2012;23:268–72

    Article  Google Scholar 

  13. Claes L, Kirschner P, Perka C, Rudert M, eds. AE-Manual der Endoprothetik, Bd XVI. Hüfte und Hüftrevision. Heidelberg - Dordrecht - London - New York: Springer; 2012

  14. Medical Device Alert; Ref: MDA/2012/008.2012

  15. U.S. Food and Drug Administration (FDA), ed. Concerns about metal-on-metal hip implants. Silverspring: FDA; 2013. http://www.fda.gov/Medicaldevices/productsandmedicalprocedures/implantsandprosthetics/metalonmetalhipimplants/ucm241604.htm

  16. Australian Orthopaedic Association National Joint Replacement (AOANJR) Registry. Annual Report 2012.

  17. Eben R, Walk R, Summer B, Maier S, Thomsen M, Thomas P. Implant allergy register—a first report. Orthopade 2009;38:557–62

    Article  CAS  PubMed  Google Scholar 

  18. Holzwarth U, Thomas P, Kachler W, Goske J, Schuh A. Metallurgical differentiation of cobalt-chromium alloys for implants. Orthopade 2005;34:1046-51

  19. Merritt K, Brown SA. Distribution of cobalt chromium wear and corrosion products and biologic reactions. Clin Orthop Relat Res 1996 (329 Suppl):S233–43

    Article  PubMed  Google Scholar 

  20. Mazoochian F, Kiefl J, Fottner A, Michalke B, Schierl R, Thomas P, Jansson V. Levels of Cr, Co, Ni and Mo in erythrocytes, serum and urine after hip resurfacing arthroplasty. Acta Chir Belg 2013;113:6

    Google Scholar 

  21. Thomas P, Thomas M, Summer B, Dietrich K, Zauzig M, Steinhauser E et al. Impaired wound-healing, local eczema, and chronic inflammation following titanium osteosynthesis in a nickel and cobalt-allergic patient: a case report and review of the literature. J Bone Joint Surg Am 2011;93:e61

    Article  PubMed  Google Scholar 

  22. Breusch SJ, Kuhn KD. Bone cements based on polymethylmethacrylate. Orthopade 2003;32:41–50

    CAS  Google Scholar 

  23. Bader R, Bergschmidt P, Fritsche A, Ansorge S, Thomas P, Mittelmeier W. Alternative materials and solutions in total knee arthroplasty for patients with metal allergy. Orthopade 2008;37:136–42

    Article  CAS  PubMed  Google Scholar 

  24. Brehler R, Grabbe J, Eichelberg D. Nickelallergie nach Plattenosteosynthese. Akt Dermatol 1990;16:202–3

    Google Scholar 

  25. Kanerva L, Forstrom L. Allergic nickel and chromate hand dermatitis induced by orthopaedic metal implant. Contact Dermatitis 2001;44:103–4

    Article  CAS  PubMed  Google Scholar 

  26. Thomas P, Thomsen M. Implant allergies. Hautarzt 2010; 61: 255–62

    Article  CAS  PubMed  Google Scholar 

  27. Hayashi K, Kaneko H, Kawachi S, Saida T. Allergic contact dermatitis and osteomyelitis due to sternal stainless steel wire. Contact Dermatitis 1999;41:115–6

    Article  CAS  PubMed  Google Scholar 

  28. Kulichova T, Schaefer T, Kendoff D, Summer B, Parvizi J, Thomas P. Metal hypersensitivity mimicking periprosthetic erysipelas-like infection. J Bone Joint Surg Case Connector 2014 (accepted)

  29. Gabel B, Summer B, Thomas P. Persistierende Entzündung nach Großzehenkorrekturoperation bei einer Patientin mit Nickelallergie: Manifestation einer Überempfindlichkeit gegen Metallpartikel? Fuß & Sprunggelenk 2008;6:5

  30. Thomas P, Stauner K, Schraml A, Mahler V, Banke IJ, Gollwitzer H et al. Characteristics of 200 patients with suspected implant allergy compared to 100 symptom-free arthroplasty patients. Orthopade 2013;42:607–13

    Article  CAS  PubMed  Google Scholar 

  31. McKenzie AW, Aitken CV, Ridsdill-Smith R. Urticaria after insertion of Smith-Petersen Vitallium nail. Br Med J 1967;4:36

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  32. Thomas P, Schuh A, Eben R, Thomsen M. Allergy to bone cement components. Orthopade. 2008;37:117–20

    Article  CAS  PubMed  Google Scholar 

  33. Thomas P, Braathen LR, Dorig M, Aubock J, Nestle F, Werfel T, Willert HG. Increased metal allergy in patients with failed metal-on-metal hip arthroplasty and peri-implant T-lymphocytic inflammation. Allergy 2009;64:1157–65

    Article  CAS  PubMed  Google Scholar 

  34. Aneja S, Taylor JS, Billings SD, Honari G, Sood A. Post-implantation erythema in 3 patients and a review of reticular telangiectatic erythema. Contact Dermatitis 2011;64:280–8

    Article  PubMed  Google Scholar 

  35. Grekin S, Mesfin M, Kang S, Fullen DR. Intralymphatic histiocytosis following placement of a metal implant. J Cutan Pathol 2011;38:351–3

    PubMed  Google Scholar 

  36. Dietrich KA, Mazoochian F, Summer B, Reinert M, Ruzicka T, Thomas P. Intolerance reactions to knee arthroplasty in patients with nickel/cobalt allergy and disappearance of symptoms after revision surgery with titanium-based endoprostheses. J Dtsch Dermatol Ges 2009;7:410–3

    PubMed  Google Scholar 

  37. Thomas P, Summer B, Krenn V, Thomsen M. Allergy diagnostics in suspected metal implant intolerance. Orthopade 2013;42:602–6

    Article  CAS  PubMed  Google Scholar 

  38. Schnuch A, Aberer W, Agathos M, Becker D, Brasch J, Elsner P et al. Performing patch testing with contact allergens. J Dtsch Dermatol Ges 2008;6:770–5

    Article  PubMed  Google Scholar 

  39. Geier J, Lessmann H, Becker D, Thomas P. Allergy diagnostics in suspected implant intolerance: practical approach. A position paper of the German Contact Dermatitis Research Group (DKG). Hautarzt 2008;59:594–7

    Article  CAS  PubMed  Google Scholar 

  40. Krenn V, Otto M, Morawietz L, Hopf T, Jakobs M, Klauser W et al. Histopathologic diagnostics in endoprosthetics: periprosthetic neosynovialitis, hypersensitivity reaction, and arthrofibrosis. Orthopade 2009;38:520–30

    Article  CAS  PubMed  Google Scholar 

  41. Summer B, Paul C, Mazoochian F, Rau C, Thomsen M, Banke I et al. Nickel (Ni) allergic patients with complications to Ni containing joint replacement show preferential IL-17 type reactivity to Ni. Contact Dermatitis 2010;63:15–22

    Article  CAS  PubMed  Google Scholar 

  42. Pichler WJ, Tilch J. The lymphocyte transformation test in the diagnosis of drug hypersensitivity. Allergy 2004;59:809–20

    Article  CAS  PubMed  Google Scholar 

  43. Eis D, Wolf U. „Qualitätssicherung beim Lymphozytentransformationstest“ - Addendum zum LTT-Papier der RKI-Kommission „Methoden und Qualitätssiche-rung in der Umweltmedizin“. Mitteilung der Kommission „Methoden und Qualitätssicherung in der Umweltmedizin“. Bundesgesundheitsbl Gesundheits-forsch Gesundheitssch 2008;51:1070–6

    Article  Google Scholar 

  44. Renz H, Becker WM, Bufe A, Kleine-Tebbe J, Raulf-Heimsoth M, Saloga J et al. In vitro allergy diagnosis. Guideline of the German Society of Asthma and Immunology in conjunction with the German Society of Dermatology. J Dtsch Dermatol Ges 2006;4:72–85

    Article  PubMed  Google Scholar 

  45. Ständer S, Thomas P, Ruel F, Summer B. Comparative assessment of nickel sensitization based on medical history, patch test and lymphocyte transformation test. In: Conference abstracts, 26th Mainzer Allergy Workshop, V15. Allergo J Int 2014;23:40

    Article  Google Scholar 

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Correspondence to Peter Thomas.

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Prof. Dr. Peter Thomas was appointed as reference allergist by the German Orthopaedic Society as well as by the German Society of Dental Implantology.

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Thomas P. Clinical and diagnostic challenges of metal implant allergy using the example of orthopedic surgical implants. Allergo J Int 2014;23:179–85 DOI: 10.1007/s40629-014-0023-3

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Cite this article

Thomas, P. Clinical and diagnostic challenges of metal implant allergy using the example of orthopaedic surgical implants. Allergo J Int 23, 179–185 (2014). https://doi.org/10.1007/s40629-014-0023-3

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  • DOI: https://doi.org/10.1007/s40629-014-0023-3

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