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MEDICAL COMMENTARY
Surgeons Beware
Jeremie M. Axe, MD; Nathan J. Sinz, BA; Michael J. Axe, MD
Does your patient have a nickel metal allergy? If so, the surgeon needs to know. Allergies to pollen and pets are easier to remedy when compared to allergies to implants. Up to 15 percent of the general population has
a metal hypersensitivity, with nickel representing the majority of allergies.1 Cobalt and chromium are also notable offenders and unfortunately all three of these metals are found in implants used in orthopaedics
and other disciplines including cardiology, dentistry, and gynecology. In fact, the high prevalence of nickel allergies led the American Contact Dermatitis Society to name it the “Allergen of the Year” in 2008.
Cutaneous manifestations including dermatitis, rash,
been reported in up to 5 percent of patients with
an orthopaedic implant.2 Metal allergy and aseptic implant failure have been correlated.3,4 Basic science research has shown these metal allergies are typically T cell-mediated delayed type IV reactions1,5,6 similar to that of poison ivy. Those with a metal allergy to an arthroplasty may have increased levels of interferon 1,7 increased levels of IL-17 may be seen in patients with symptomatic nickel allergies.8 Symptoms of metal hypersensitivity in arthroplasty patients include cutaneous reaction, joint pain, and aseptic implant loosening.9
Orthopaedic implants have varying amounts of nickel depending on the alloy.3 Stainless steel can
be composed of 8 to 35 percent nickel, while cobalt- chromium-molybdenum steel typically is less than 0.5 percent.10 Titanium-tantalum-niobium alloy, OxiniumTM and VitalliumTM, are not composed of nickel.11 Many companies have developed non-nickel prostheses for various joints. As of 2015 in shoulder arthroplasty, Tornier® (Tornier Inc, Bloomington, Minn., USA) and Biomet® (Biomet Inc, Warsaw, Ind., USA) are leaders in addressing nickel allergies12 (Figure 1).
When considering joint replacement surgery, the orthopaedic surgeon should ask the patient if he or she has a nickel allergy, as an allergy can present at any age.13 metal allergies have reached values of 82 percent and 87 percent, respectively.14 Allergic reactions to costume jewelry or metal buttons on clothing may be indicative of a nickel allergy.12,15 Perspiration in combination
with metal jewelry or buttons tends to exacerbate the allergy.16
If a patient does have a suspected allergy, there are two
series” and a “lymphocyte transformation test” (LTT).9 There is debate among dermatologists and allergists regarding which method is superior; however, the patch test is still currently the gold standard.17 There
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