Metal Allergies & How to Detect the Problem with No Rash: 5 - PowerPoint PPT Presentation

Metal Allergies & How to Detect the Problem with No Rash: 5 Quick Tips Michael P. Bolognesi, MD Professor of Orthopaedic Surgery Division Chief, Adult Reconstruction Duke University Medical Center Division of Adult Reconstruction

Disclosures • Amedica - Stock Options, Surgical Advisory Board • Zimmer Biomet - Royalties, Consulting Payments, Resident Educational Support, Design Surgeon, Research Support • Total Joint Orthopedics - Stock and Stock Options, Advisory Board Member, Resident Educational Support, Consultant Payments, Design Surgeon • Depuy - Research Support, Resident Educational Support, Principal Investigator • Exactech- Research Support, Resident Educational Support • Stryker - Resident Educational Support • Smith and Nephew- Resident Educational Support • SPR- Research Support • Omega - Fellowship Support- Fellowship Director • North American Specialty Hopsital- Advisory Board

Real Disclosures I was a little nervous when Kevin assigned this topic to me a few years ago… Nobody really wants to become “known” for management of these issues You can imagine what your clinic could turn in to if you do develop this as a “clinical interest” I do think this is a real clinical issue but we are still figuring it out…..

Be Aware ….. All metals in contact with biological systems undergo corrosion. This electrochemical process leads to the formation of metal ions, which may activate the immune system by forming complexes with endogenous proteins.

Tip One Metal Allergy may be a warning sign….

Metal allergy..a warning sign? • Has a “protective” wristband under her watch secondary to “metal allergy” • Anything multiple is bad…. • Has multiple cats Has multiple rings • Multiple allergies- this is a real issue

• 4 or more reported allergies had less improvement on SF36 PCS than those with 0–3 allergies • Regression analysis- independent of self-reported comorbidities. 4 or more allergies also had less improvement WOMAC function than those with 0–3 allergies • Similar nonsignificant trends occurred in SF36 mental and WOMAC pain and stiffness scores.

Special word of caution about allergies in general.. • Tape • Epinephrine • Tater Tots • K Mart Kola • Soap • All Metals • Water?

Tip Two Know the scope of the problem….

Scope of the Problem • Prevalence of sensitivity to metal is 10-15% in general population • Nickel, cobalt, chromium, beryllium, tantalum, titanium, and vanadium… • Nickel is the most common (14%) metal sensitizer in humans, followed by cobalt and chromium.

• Stainless steel- 15 % nickel, 19 % chrome, and 4 % molybdenum. • Chrome-cobalt- 1 % nickel, 67 % chrome, 30 % cobalt, and 2 % molybdenum. • Titanium alloy- 91 % titanium, 5 % aluminum, 3.9 % vanadium, and 0.1 % nickel

Tip Three What do you look for? ….

• Chronic dermatitis beginning weeks to months after metallic implantation • Eruption overlying the metal implant • Morphology consistent with dermatitis (erythema, induration, papules, vesicles) • Systemic allergic dermatitis reaction (characterized by universal dermatitis reactions, typically localized in body flexures) • Histology consistent with allergic contact dermatitis • Positive patch test reaction to a metal used in the implant (strong) • Serial dilution patch testing give positive reactions to low concentrations of the metal under suspicion • Positive in vitro test to metals, (lymphocyte transformation test, etc.) • Dermatitis reaction is therapy resistant • Complete recovery following removal of the offending implant

Unexplained pain and failure… Periprosthetic allergic contact dermatitis, arthralgia, radiolucent lines on radiograph, implant loosening

Tip Four How do you test for it?….

In-vivo- Patch Testing • Very high sensitivity (100 %) but a lower specificity (64 %). Diagnostic value lies in a negative test. Antigen-presenting cells localized to the skin (dendrite cells and dermal Langerhans • cells) may handle antigens differently than the cells that are systemic (macrophages and monocytes)

What do you test for? Cobalt chloride 1% pet. Nickel sulphate 5% (or 2.5%) pet. Chromium trichloride 2% pet. Potassium dichromate 0.5% (or 0.25%) pet. Gold sodium thiosulphate 0.5% pet. Titanium powder 1% pet. Vanadium trichloride 2% pet. Zirconium (IV) oxide 0.1% pet. Custom-made disc made of alloys considered for implantation (Copper sulphate 2% pet.) (Ferric chloride 2% or 5% pet.)49 (Aluminium chloride hexahydrate 10% pet.) (Sodium tetrachloropalladate 3% pet.) (Manganese chloride 2% aq.) (Tantalum powder 1% pet.) (Iridium chloride 1% aq.) (Indium sulphate 10% aq.)

In-vitro Testing • Leukocyte migration inhibition testing (LIF or MIF)- measures the limitation in migration of the leukocytes • Lymphocyte transformation test (LTT)- measures the proliferative response of lymphocytes following activation

Leukocyte migration inhibition testing • Measurement of mixed-population leukocyte migration • Leukocytes in culture actively migrate in a random fashion but in the presence of a sensitizing antigen, they migrate more slowly, losing the ability to recognize chemoattractants • Contemporary migration-testing techniques quantify the migration of through, under, or along media (agarose layers, agarose droplets, capillary tube walls, membrane filters, and collagen gels) • May not be as good as LTT for delayed type hypersensitivity (time dependent)

Lymphoctye Transformation Testing • Patients blood is drawn • A radioactive marker is added to lymphocytes along with the desired challenge agent. • This incorporation of this [H3]-thymidine marker into cellular DNA upon division facilitates the quantification of a proliferation response • After 6 days, the proliferation factor or stimulation index is calculated by using measured radiation counts per minute. • The main disadvantage of this test is the need for a specialized lab and the high cost of these tests

Tip Five What do you do if you make the diagnosis?

Before After

If you confirm diagnosis before…. Oxinium femur and titanium tibia or all poly tibia

Titanium Niobium Nitride (TiNbN)

What about after?

Extra Credit Tip….. It may not even matter….

Possible MOC credit if you idenitify the warning sign….

Summary • It does exist so likely worth asking about it at minimum… • Consider patch testing and in vitro testing for the patient at risk (pre-op and post-op) • Use appropriate implants if diagnosis is confirmed pre- op (titanium niobium nitiride, Oxinium, etc) • Revision to hypoallergenic implants can be considered but need to have a long discussion with the patient about what is know about the success of this • We probably have not completely figured this out….

Summary • It does exist so likely worth asking about it at minimum… • Consider patch testing and in vitro testing for the patient at risk (pre-op and post-op) • Use appropriate implants if diagnosis is confirmed pre- op (titanium niobium nitiride, Oxinium, etc) • Revision to hypoallergenic implants can be considered but need to have a long discussion with the patient about what is know about the success of this • We probably have not completely figured this out….

Thanks!

Moving forward. Climbing higher.