Pragmatic approach to the clinical work-up of patients with putative allergic disease to metallic orthopaedic implants before and after surgery

Allergic complications following insertion of metallic orthopaedic implants include allergic dermatitis reactions but also extracutaneous complications. As metal-allergic patients and/or surgeons may ask dermatologists and allergologists for advice prior to planned orthopaedic implant surgery, and as surgeons may refer patients with complications following total joint arthroplasty for diagnostic work-up, there is a continuous need for updated guidelines. This review presents published evidence for patch testing prior to surgery and proposes tentative diagnostic criteria which clinicians can rely on in the work-up of patients with putative allergic complications following surgery. Few studies have investigated whether subjects with metal contact allergy have increased risk of developing complications following orthopaedic implant insertion. Metal allergy might in a minority increase the risk of complications caused by a delayed-type hypersensitivity reaction. At present, we do not know how to identify the subgroups of metal contact allergic patients with a potentially increased risk of complications following insertion of a metal implant. We recommend that clinicians should refrain from routine patch testing prior to surgery unless the patient has already had implant surgery with complications suspected to be allergic or has a history of clinical metal intolerance of sufficient magnitude to be of concern to the patient or a health provider. The clinical work-up of a patient suspected of having an allergic reaction to a metal implant should include patch testing and possibly in vitro testing. We propose diagnostic criteria for allergic dermatitis reactions as well as noneczematous complications caused by metal implants.     

Metal sensitivities and orthopaedic implants revisited: the potential for metal allergy with the new metal-on-metal joint prostheses

The potential of metal-containing orthopaedic prostheses to induce problems through metal allergy taxes dermatologists and orthopaedic surgeons alike. Metal-on-plastic joint replacements are not thought to induce metal allergy but wear products, principally polypropylene particles, produce a foreign body reaction in bone and may lead to aseptic loosening of the joint. Orthopaedic surgeons are increasingly using metal-on-metal joint replacements, particularly for younger patients, as some evidence suggests that there is less wear debris and hence less aseptic loosening. The original metal-on-metal hip joints of the 1960s were associated with sensitivities to cobalt, nickel and chromate when loosening occurred. The potential for modern metal-on-metal joint prostheses, with their lower production of wear debris, to sensitize the recipient to metals or to induce a problem in subjects already allergic to metals, is unclear. One uncontrolled series suggested an association between nickel allergy and prosthesis loosening in some subjects, but the question has yet to be addressed in a prospective study and to date there is no other observation in the orthopaedic literature to suggest a problem.     

Intolerance reactions to knee arthroplasty in patients with nickel/cobalt allergy and disappearance of symptoms after revision surgery with titanium‐based endoprostheses

Intolerance reactions to metal implants may present as dermatitis, impaired wound healing, effusions, pain or loosening. The clinical relevance of metal allergy in the differential diagnosis is often unclear and patients may even tolerate implants containing metals to which they are allergic. We present four patients with knee arthroplasty in whom after exclusion of infection or mechanical causes, a nickel/cobalt allergy led to replacement surgery with titanium‐based prostheses. The subsequent alleviation of symptoms underlined the relevance and usefulness of allergological diagnostics in selected cases of complicated arthroplasty.     

Rejection of metal to metal prosthesis and skin sensitivity to cobalt

Metal to metal prostheses give satisfactory results in 90% of patients. About half of the failure rate may be due to allergic reaction to the metals involved, particularly cobalt. A total of 35 patients in this unsatisfactory group have been patch-tested; 16 were positive to metals, 13 to cobalt, 4 to nickel, and 2 to chromate. Only two patients showed any skin lesions - one a localized dermatitis round the knee joint from nickel sensitivity, and one to cobalt who had a widespread scattered circular erythematous lesion suggestive of a generalized allergic vasculitis. Patients requiring a metal/metal prosthesis should have a careful history taken for metal sensitivity and be patch-tested with the metals. All the patients in this investigation had metal/metal prostheses and no reaction was seen after metal/high density polyethylene implants. Titanium 318 may be a satisfactory substitute for cobalt chrome alloy if reactions are encountered.     

Metal sensitivity in patients with orthopaedic implants: a prospective study

Background. Sensitization to orthopaedic implant materials is an unpredictable event that might affect implant performance. Objectives. In candidates for hip or knee joint prosthesis implantation, to evaluate preoperative assessments for identifying patients with metal sensitivity, to determine the percentage of patients who developed metal sensitivity at 1 year after prosthesis implantation, and to examine the clinical relevance of patch tests and lymphocyte transformation tests (LTT‐MELISA®) for the evaluation of metal sensitization. Patients and methods. A total of 100 patients referred for total hip or total knee arthroplasty were assessed preoperatively and then at 1 year post‐implantation by means of patch tests with the metals present in the implant alloys. In a pilot study, 20 patients also underwent both patch testing and a lymphocyte transformation test (LTT‐MELISA®) for the same metals. Results. Only 72 of 100 patients were patch tested both before and after surgery, and 12 of 20 also underwent LTT‐MELISA® before and after surgery. Of 31/100 patients with an apparent history of nickel sensitivity determined during preoperative assessment of subjects, 12 tested negative on both tests, and 4 with a negative history of nickel sensitivity tested positive. One year post‐implantation (72 patients), 5 patients who had initially tested negative for a metal allergy became positive for at least one or more metal constituents of the prosthesis on at least one or the other test. Conclusions. Given the discrepancies between the information obtained while taking patient histories and test results, preoperative history‐taking alone appears to be insufficient for identifying patients with metal sensitivity. Moreover, the increase in the percentage of patients who tested positive for metal sensitivity 1 year post‐implantation suggests the possibility of prosthesis‐induced sensitization. Therefore, objective determination of metal sensitivity at preoperative assessment should be considered in planning arthroplasty intervention, as it would help the surgeon in selecting the most appropriate prosthesis for the patient and could benefit implant performance.     

Intralymphatic Histiocytosis Associated with Osteoarthritis: A Case Report

Intralymphatic histiocytosis (ILH) is a rare cutaneous condition with uncertain pathogenesis. It is characterized by dilated lymphatic vessels that contain histiocytes within their lumina. Although the etiology of ILH remains unknown, it has been associated with various inflammatory and neoplastic diseases, such as rheumatoid arthritis (RA), reaction to metal joint implants and Merkel cell carcinoma, breast cancer and colon cancer. An 83-year-old female presented with an erythematous patch on the left forearm that had appeared six months previous. She had suffered from osteoarthritis (OA) and the cutaneous lesion was located in the vicinity of the affected joint. Skin biopsy from the lesion showed dilated dermal vessels and some ectatic vessels that contained many mononuclear histiocytes. Based on the clinical and histopathological findings, we diagnosed her with ILH with OA. Two sessions of intralesional triamcinolone acetonide injection (5 mg/ml) were administered to treat the skin lesion, which gradually improved over a period of a few months. We here report a rare case of ILH associated with degenerative OA.     

Orthopädisch-chirurgische Implantate und Allergien

Materials used in osteosynthesis or artificial joint replacement are usually well tolerated. Complaints after such operations are mostly related to infection or mechanical problems but may also be caused by allergic reactions. The latter encompass skin changes, e.g., eczema, delayed wound/bone healing, recurrent effusion, pain, or implant loosening. In contrast to the high incidence of cutaneous metal contact allergy, allergies associated with implants are a rare condition. However, epidemiological data on the incidence of implant-related allergic reactions are still missing. Typical elicitors are nickel, chromium, cobalt, and constituents of bone cement (acrylates und additives such as gentamicin or benzoyl peroxide). After exclusion of the most common differential diagnoses, allergy diagnostic procedures are primarily based on patch tests including a metal and bone cement component series. Additional analysis of periimplant tissue is recommended. However, further studies are necessary to show the significance of the histologic findings and the role of the lymphocyte transformation test (LTT). Which combinations of factors will induce allergic sensitization to implants or trigger periimplant allergic reactions in the case of preexisting cutaneous metal allergy is still unknown. Titanium-based osteosynthesis materials are recommended for metal allergic patients. In elective hip replacements, a ceramic/polyethylene (PE) articulation should be used, and in knee replacements "alternative materials". If a regular, potentially applicable CoCr/PE articulation is preferred, the patient must be well informed and must give his/her written consent.     

Implantation of orthopaedic devices in patients with metal allergy

Patients with a contact allergy to chromium, cobalt and/or nickel, patch test verified before implantation of a metallic orthopaedic device, were followed up years later by clinical and radiographic examination as well as with epicutaneous and intracutaneous tests. Eighteen patients had been exposed to an orthopaedic implant for several years (mean 6.3 years) containing a metal to which they were allergic. None had suffered any dermatologic or orthopaedic complications attributable to the contact allergy.     

Implantatallergien

An increasing number of patients receive and benefit from osteosynthesis materials or artificial joint replacement. The most common complications are mechanical problems or infection. Metals like nickel, chromium and cobalt as well as bone cement components like acrylates and gentamicin are potential contact allergens which can cause intolerance reactions to implants. Eczema, delayed wound/bone healing, recurrent effusions, pain and implant loosening all have been described as manifestation of implant allergy. In contrast to the high incidence of cutaneous metal allergy, allergies associated with implants are rare. Diagnosis of metal implant allergy is still difficult. Thus differential diagnoses – in particular infection – have to be excluded and a combined approach of allergologic diagnostics by patch test and histopathology of peri-implant tissue is recommended. It is still unknown which conditions induce allergic sensitization to implants or trigger peri-implant allergic reactions in the case of preexisting cutaneous metal allergy. Despite the risk of developing complications being unclear, titanium based osteosynthesis materials are recommended for metal allergic patients and the use of metal-metal couplings in arthroplasty is not recommended for such patients. If the regular CoCr-polyethylene articulation is employed, the patient should give informed written consent.     

Blau syndrome presenting with ichthyosis

A 12-year-old girl presented with uveitis, joint disease and ichthyosis resembling ichthyosis vulgaris. A biopsy taken from the affected lower leg demonstrated sarcoidal-type granulomas. Synovial biopsy from the knee also showed granulomas. There was a family history of similar clinical features in the patient's younger sister. There were no other systemic features present to suggest a diagnosis of sarcoidosis or other granulomatous disease such as Crohn's disease or tuberculosis. The familial nature of the condition also made these diagnoses less likely. A clinical diagnosis of Blau syndrome was made. Blau syndrome is an uncommon sarcoidosis-like multisystem autosomal-dominant granulomatous disorder caused by mutations in the CARD15 gene. This gene has also recently been found to be a factor in the development of psoriatic arthritis and Crohn's disease. Although many forms of skin involvement have been described in Blau syndrome, this is the first case described of ichthyosis as the primary skin manifestation.     

Hypersensitivity reactions to metallic implants - diagnostic algorithm and suggested patch test series for clinical use

Cutaneous and systemic hypersensitivity reactions to implanted metals are challenging to evaluate and treat. Although they are uncommon, they do exist, and require appropriate and complete evaluation. This review summarizes the evidence regarding evaluation tools, especially patch and lymphocyte transformation tests, for hypersensitivity reactions to implanted metal devices. Patch test evaluation is the gold standard for metal hypersensitivity, although the results may be subjective. Regarding pre-implant testing, those patients with a reported history of metal dermatitis should be evaluated by patch testing. Those without a history of dermatitis should not be tested unless considerable concern exists. Regarding post-implant testing, a subset of patients with metal hypersensitivity may develop cutaneous or systemic reactions to implanted metals following implant. For symptomatic patients, a diagnostic algorithm to guide the selection of screening allergen series for patch testing is provided. At a minimum, an extended baseline screening series and metal screening is necessary. Static and dynamic orthopaedic implants, intravascular stent devices, implanted defibrillators and dental and gynaecological devices are considered. Basic management suggestions are provided. Our goal is to provide a comprehensive reference for use by those evaluating suspected cutaneous and systemic metal hypersensitivity reactions.     

Intra-arterial angiolymphoid hyperplasia with eosinophilia of the temporal artery: Report of two cases and review of the literature

Angiolymphoid hyperplasia with eosinophilia (ALHE) is a relatively common benign vascular disorder of uncertain etiology and has many synonyms, such as pseudopyogenic granuloma, atypical pyogenic granuloma, epithelioid hemangioma, and histiocytoid hemangioma. It usually develops on the head and neck, manifesting as reddish-to-dark purpuric papules or nodules. In this article, we report two patients who had uncommon intra-arterial ALHE that occurred in the temporal artery. In both cases, the ALHE presented as skin-colored subcutaneous nodules over the forehead, mimicking temporal arteritis. Histopathologically, intravascular epithelioid endothelial cell proliferation occurred, with lymphocyte and eosinophil infiltration in the stroma. One patient also showed typical findings of ALHE in the adjacent soft tissue. We know of seven similar cases that have previously been reported in the literature to date.     

Resolution of disseminated granuloma annulare following isotretinoin therapy

Disseminated granuloma annulare is often a chronic disorder that may prove refractory to treatment and lead to prolonged cosmetic disfigurement. In a patient with disseminated granuloma annulare that was unresponsive to multiple therapeutic regimens, administration of isotretinoin resulted in rapid clearing of nearly all lesions. To our knowledge this is the first reported case in which this agent was used to treat disseminated granuloma annulare.     

Inflammatory granuloma annulare

A case of inflammatory granuloma annulare occurring on the extremities of a young girl is presented. The lesions became erythematous and edematous concurrently with a self-limited gastrointestinal disorder. Many neutrophils were present in the biopsy specimen, which exhibited the changes of granuloma annulare.     

GENERALISED GRANULOMA ANNULARE SUCCESSFULLY TREATED WITH PENTOXIFYLLINE

Generalised granuloma annulare (GA) is a chronic disease of unknown aetiology and is recalcitrant to many treatment regimes. Some investigators have suggested that an immune medicated vasculitis may be involved in the pathogenesis of GA. We describe a patient with a ten year history of generalised GA, who showed dramatic clearing of the majority of papules after four weeks of treatment with pentoxifylline. This drug has shown promising results in the treatment of many dermatologic disorders including necroboisis lipoidica diabeticorum, leukocytoclastic vasculitis and Raynaud's phenomenon. Pentoxifylline is thought to reduce blood viscosity via effects on all major blood components, and its clinical effectiveness in generalised GA lends support to a model of immunemedicated vasculitis in the pathogenesis of this disorder. Thus, pentoxifylline offers a well-tolerated and effective alternative to the treatment options available for patients with granuloma annulare.     

Benzoyl peroxide: is it a relevant bone cement allergen in patients with orthopaedic implants?

Contact allergies to orthopaedic implant material are discussed to be relevant for postoperative complaints. We aimed at determining the prevalence of sensitizations to implant metals and to bone cements in patients with implants. We investigated 13 consecutive patients with suspicion of contact allergy to implant material. Epicutaneous patch testing was performed with metals and bone cement components including benzoyl peroxide (BPO). The chief complaints were skin disorders (n = 3), loosening of implant (n = 2), swelling (n = 6), and pain (n = 2). 6 patients had a sensitization to at least 1 allergen. 3 patients reacted to BPO, being of possible relevance in 1 of these patients suffering from dermatitis. Other sensitizations, such as those to nickel, fragrance, and balsam of Peru, were observed, with no clinical relevance (n = 1, respectively). BPO in bone cements may lead to type 4 sensitizations of which the relevance, however, remains questionable. Nevertheless we recommend this allergen to be tested in patients with complicated cemented orthopaedic implants.     

The Treatment of Chondrodermatitis Nodularis Chronica Helicis with lnjectable Collagen

Chondrodermatitis nodularis chronica helicis (CNCH) consists of a painful, erythematous, often crusted, papule most commonly found on the helical rim of the ear of white men over the age of 40 years old. It is seen less commonly in women and younger individuals, where the anatomic locations may vary to include the antihelix, antitragus, and other areas on the external ear. Over the years there have been many treatments for this disorder. We present the use of injectable collagen implants as a conservative, effective, and practical method for treatment of this disorder.     

脊髓痨并发夏科关节病1例

患者男,47岁。左膝关节肿胀伴畸形8个月。自3年前遇冷热时T12以下有针刺感和紧缩感,行走时有漂浮感,以闭眼时显著,8月前无明显诱因左膝关节出现无痛性肿胀。体检:皮肤黏膜未见异常。Romberg征阳性,肱二头肌及肱三头肌反射迟钝,膝、踝反射消失,下肢关节震动觉、运动觉减退,左膝及左踝关节肿胀畸形。梅毒血清学检查示:RPR(+)和TPPA(+)。脑脊液检查示:白细胞计数及蛋白含量升高,脑脊液压力正常,TPPA(+)。左膝关节X线示:左膝关节面结构异常,股骨下端、胫骨上端关节面破坏,呈虫蚀样。关节间隙狭窄,部分消失。髌骨韧带及关节囊周围有游离钙化碎骨片。组织病理示滑膜慢性炎性改变。诊断:脊髓痨;夏科关节病。     

A woman with juxta-articular nodules—An uncommon form of subcutaneous granuloma annulare

Granuloma annulare is a benign inflammatory dermatosis that is most common in children and young adults. The subcutaneous form of granuloma annulare, which occurs mainly on the extremities in children, is rare. Lesions usually occur as painless subcutaneous nodules without inflammation of the cutaneous surface; the most frequent sites are the legs, buttocks, and scalp. Nevertheless, we present a case of subcutaneous granuloma annulare confined to the dorsa of the hand joints and right knee in a 51-year-old woman.