APSA Paper
When it is not an infection: metal allergy after the Nuss procedure for repair of pectus excavatum

https://doi.org/10.1016/j.jpedsurg.2006.09.056Get rights and content

Abstract

Purpose

Increasing use of implantable bars for minimally invasive pectus excavatum repair has introduced metal allergy (nickel and chromium) to pediatric surgeons. Metal allergy is a well-recognized entity in neurologic, orthopedic, and craniofacial surgery. This study was performed to evaluate metal allergy and its effects on treatment with the Nuss procedure in 862 patients.

Methods

After institutional review board approval, we undertook a retrospective review of a prospectively gathered database of patients undergoing the Nuss procedure. Metal allergy was diagnosed either with the use of dermal patch or clinically, based on rash, fever, elevated erythrocyte sedimentation rate, cultures, and pathology specimens. Data collection included demographics, an allergy to jewelry, and history of atopy. Clinical outcomes including need for reoperation, removal of stainless steel bar, and replacement with titanium bar were evaluated.

Results

Over an 18-year period (1987-2005), 862 patients underwent the Nuss procedure. Nineteen (2.2%) were diagnosed with metal allergy, with an average age of 14.7 years (9-23 years). Eighteen (95%) were males. A history of atopy was present in 9 (56%) patients. Ten (63%) patients presented with rash and erythema, 1 (6%) with granuloma, 5 (32%) with pleural effusion, and 3 (15%) were diagnosed on preoperative screening. Stainless steel bars were removed because of allergic skin breakdown in 3 patients, with 2 patients requiring replacement titanium bars. In all 3 of these patients, symptoms resolved after removal of stainless steel bars. Titanium bars were placed in the 3 patients who were diagnosed preoperatively with metal allergy, without event.

Conclusions

Allergy symptoms often are misdiagnosed as infection, but require different treatment. If a history of metal allergy or atopy is suggested preoperatively, the patient should be tested for metal allergy, and if positive, a titanium bar used. Because the consequences of metal allergy may include the need to replace the bar, pediatric surgeons should be aware of this occurrence.

Section snippets

Materials and methods

This study is a retrospective review of patients who presented with concerns for metal allergy after undergoing minimally invasive repair of pectus excavatum by the pediatric surgery service at Eastern Virginia Medical School, a tertiary referral center. Institutional review board approval was obtained for this study (01-05-EX-0175). All data collection complied with HIPAA regulations. Inclusion criteria were (1) repair of pectus excavatum with the minimally invasive Nuss procedure and (2)

Results

During an 18-year period (1987-2005), 862 patients underwent minimally invasive repair of pectus excavatum. Of these 862 patients, 19 had suspected metal allergy on preoperative screening or postoperative follow-up, resulting in a 2.2% incidence. The average follow-up time was 25 months (range, 1-67 months). Ninety-five percent (18) of patients diagnosed with metal allergy were males (P = .513), with an average age of 14.7 years (range, 9-23 years) (P = .705). Some history of atopy (eczema,

Discussion

The 2.2% incidence of metal allergy seen in our patient population is far less than the 13% traditionally reported in the orthopedic literature [15], [16], [17]. However, those studies investigated metal hip joints, not static metal implants such as the pectus bar implant used for our patients. Ninety-five percent of the patients with allergies in our study population were males. Pectus excavatum affects males predominantly, which is why this might not have reached statistical significance.

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Presented at the 37th Annual Meeting of the American Pediatric Surgical Association, May 20–24, 2006, Hilton Head, SC.

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