Key words: femoral fracture, osteosythesis, contact allergy, chromium, nickel, cobalt.
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In the early 1970s it was observed that metallic devices (plates, nails, and prostheses) used in bone surgery could cause the development or an increase in contact dermatitis (9). It was also supposed that contact hypersensitivity to metals might explain some orthopedic complications(1,3,4,12,14,18). This was supported by the fact that in patients developing such complications after implantation of metallic devices, the positive patch test results with metals were more frequent than in other patients (4,8,12,18). In some cases the presence of sensitized cells was detected using the lymphocyte blastic transformation test (1,3). The most sensitizing metals are nickel, chromium and cobalt (8,12,14,18). The incidence of complications caused by metal hypersensitivity is discussed, and some investigators are of the opinion that they are rare and play only a marginal role (1). However, other authors suggest that contact hypersensitivity may play a crucial role in 50% of orthopedic failures (8). On the skin, prosthesis hypersensitivity may occur as contact dermatitis or allergic vasculitis-like skin eruptions (8). However, advanced osteomyelitis caused by metal hypersensitivity can also occur without any skin symptom (6,12). Contact hypersensitivity to metals can also be a cause of failures and complications after heart pacemaker implantations (2,10,17) and in dental prosthetics (7,15,16).
A 40-years old female patient had suffered from contact eczema caused by metal hypersensitivity from for 20 years. After contact with objects containing steel, chromium or nickel a strong itching and numerous exudating papules which persisted for 2-3 days appeared. In her 28th year of life, the patient had a skiing accident, resulting in subtochanterical femoral fracture with multiple bone fragmentation. As a therapy, osteosynthesis using AO plate and nails was performed. The surgical wound healed without complications. After the surgery, however, the patient's contact dermatitis became more severe. In following months strong itching, erythema and desquamation with vesicles serous exudation appeared around the postoperative scar. After 10 months, due to the lacking progress in synosthosis and pseudocystic bone changes on radiograms, the metal plate and nails were removed. After this, a notable improvement of skin eruptions was observed. Generally, the patient was hospitalized 13 times since the accident. Because of progressing posttraumatic coxarthrosis and demarcation of the caput femoris, a replacement of the hip joint was indicated. Before giving the consent, the patient decided to attend an allergologic consultation in order to explain the problem of metal allergy.
Family anamnesis: Patient's sister and daughter manifest eczema after contact with metal-containing objects. Physical findings on the first visit: Contracture and mobility limitation of the right thigh. No skin eruptions were visible at the time of examination. Allergy tests: Patch tests with metals were performed with the following results: vehicle (-), cobalt chloride (+), nickel sulfate (++), potassium dichromate (+), mercury chloride (-), titanium oxide (-).
Analysis of the reported cases suggests that there are two groups of patients hypersensitive to metallic implants. In the first group, patients have symptoms of contact allergy before implantation and careful anamnesis and allergy test could help in choosing an adequate, non-sensitizing material, thus avoiding complications. The second group consists of persons having no signs of contact hypersensitivity before implantation. The anamnesis alone would not help in these patients. This may be an argument in favor of patch screening all patients prior to the implantation of any metal-containing devices (5,8,11,12,18).
Careful anamnesis and allergologic tests before implantation of metal-containing devices (e.g. plates, nails, dental implants, and pacemakers) can be helpful in avoiding failures and complications.
After the publication of this article, the hip replacement was carried out in the patient described. Based on the patch test results, titanium prosthesis was selected for implantation. During the first year after the implantation, there were no complications in the postoperative course and the patient's rehabilitation had been successful.
© Radoslaw Spiewak (contact).
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Document created: 25 March 1996, last updated: 4 July 2010.