Metal sensitivity to Elektra™ prostheses – two cases from a metal on metal implant for hand...
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Metal sensitivity to Elektraä prostheses – two cases from a metal on metal implant for hand joint replacement Contact Dermatitis 2009: 60: 298 Emma Smith, Anisha J Mehta and Barry N Statham Department of Dermatology, Singleton Hospital, Swansea, UK Key words: allergy; cobalt; elektra prosthesis; metacarpal joint replacement; metal sensiti- vity; nickel; trapezio-carpo-metacarpal joint replacement. Metal sensitivity relevant to joint prostheses is a controversial area with few reports of sensitivity causing fail- ure. We present two convincing cases of metal on metal implants with metal allergy histories where prosthesis removal resolved symptoms. Case 1 A 51-year-old female was referred by orthopaedic surgeons for patch test- ing. One year earlier, she had under- gone a right trapezio-metacarpal joint arthroplasty with an ElektraÔ [Small Bone Innovations Interna- tional Ò (formerly Fixano Ò ) ZA, Les Bruye`res – BP 28, Peronnas, France) cementless metal on metal prosthesis. Four months postoperatively she developed swelling and constant pain at the site but no rash. She reported previous nickel allergy. The joint was swollen but not ery- thematous. Active but not passive movements were painful. There was no evidence of infection, loosening or dislocation; bone scintigraphy revealed localized increased uptake. She was patch tested to a modified European baseline series and methac- rylate series with a 3þ positive reac- tion (ICDRG criteria) to both cobalt chloride and nickel sulphate at D4. Given the clinical picture and strongly positive patch test, the pros- thesis was removed and revised to a pyro-carbon spacer. Five months later, the patient was pain-free having regained good hand function. Case 2 A 52-year-old female referred by orthopaedic surgeons had intermittent left thumb pain and swelling following prosthesis insertion. Eight months previously, she had undergone an ElektraÔ carpo-metocarpal joint re- placement; symptoms started 2 months later. There were no signs of infection or erythema, she had good range of movement. She was atopic and noted an intolerance to metal jewellery. There were concerns because of plans for a second joint replacement in the right hand. She was tested to modified European baseline series with a 3þ positive reaction to cobalt chloride only at D4. Her prosthesis was taken out and within 2 months she was symptom-free. The histories and rapid, sustained responses to removal make allergy the likely cause of symptoms in both cases. Discussion Metal allergy has been reported to knee and more often hip replace- ments. Postoperative patch testing by Benson et al. (1) demonstrated metal allergy in 28% of subjects with metal on metal prostheses but associ- ated it only with loosening. The com- monest allergen was cobalt followed by nickel then chromate. The preva- lence of metal allergy in studies of prosthetic loosening varies from 13% to 74% (2). The single study looking at sensi- tivity causing metal-on-metal hip prosthesis failure suggested an associa- tion but used too few subjects to con- firm this (3). Reed et al. (4) recently concluded that preoperative testing could be of use in guiding device choice. ElektraÔ trapezio-metacarpal im- plants made by Small Bone Innova- tions International Ò are metal on metal, containing cobalt, chromium and titanium. The alloy is similar to early hip replacements with modifica- tion to improve wear resistance rather than reduce hypersensitivity, which is seen less in metal on plastic joints. Regnard (5) reported results of his first 100 ElektraÔ prostheses with average follow up of 54 months. Only one experienced failure due to nickel allergy, presenting as non-infectious inflammation. Small Bone Innova- tions International Ò advise of risks on their packaging but have not received other reports of symptomatic allergy. The two cases reported here are from seventy ElektraÔ procedures performed in our orthopaedics depart- ment. These findings suggest sensitivity can cause joint device failure requiring revision in some patients with known metal allergy. Dermatologists should be aware of this group and have a low threshold for patch testing them. References 1. Benson M K D, Goodwin P G, Brost- off J. Metal sensitivity in patients with joint replacement. Br Med J 1975; 4: 374–375 2. Gawkrodger D J. Metal sensitivities and orthopaedic implants revisited: the potential for metal allergy with the new metal-on-metal joint prostheses. Br J Dermatol 2003;148:1089–1093. 3. Anthony F, Dudley W, Field R, Holden C. Metal allergy resurfaces in failed hip endoprostheses. Br J Derma- tology 2001; 145 (Suppl. 59): 48. 4. Reed K B, Davie M D, Nakamura K et al. Retrospective evaluation of patch testing before or after metal device implantation. Arch Dermatol 2008; 144: 1042–2042. 5. Regnard P J. Electra trapezio meta- carpal prosthesis: results of the first 100 cases. J Hand Surg 2006; 31: 621–628. Address: Dr E Smith Dermatology Department, Singleton Hospital Sketty Lane, Swansea SA2 8QA UK Tel: 0044 1792 206816 Fax: 0044 1792 285330 e-mail: [email protected] 298 CONTACT POINTS
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Transcript of Metal sensitivity to Elektra™ prostheses – two cases from a metal on metal implant for hand...
Metal sensitivity toElektra�prostheses – two casesfrom ametal on metalimplant for hand jointreplacement
Contact Dermatitis 2009: 60: 298
Emma Smith, Anisha J Mehta andBarry N Statham
Department of Dermatology, SingletonHospital, Swansea, UK
Key words: allergy; cobalt; elektra prosthesis;metacarpal joint replacement; metal sensiti-vity; nickel; trapezio-carpo-metacarpal jointreplacement.
Metal sensitivity relevant to jointprostheses is a controversial area withfew reports of sensitivity causing fail-ure. We present two convincing casesof metal on metal implants with metalallergy histories where prosthesisremoval resolved symptoms.
Case 1
A 51-year-old female was referred byorthopaedic surgeons for patch test-ing. One year earlier, she had under-gone a right trapezio-metacarpaljoint arthroplasty with an Elektra�[Small Bone Innovations Interna-tional� (formerly Fixano�) ZA, LesBruyeres – BP 28, Peronnas, France)cementless metal on metal prosthesis.Four months postoperatively shedeveloped swelling and constant painat the site but no rash. She reportedprevious nickel allergy.
The joint was swollen but not ery-thematous. Active but not passivemovements were painful. There wasno evidence of infection, looseningor dislocation; bone scintigraphyrevealed localized increased uptake.
She was patch tested to a modifiedEuropean baseline series and methac-rylate series with a 3þ positive reac-tion (ICDRG criteria) to both cobaltchloride and nickel sulphate at D4.
Given the clinical picture andstrongly positive patch test, the pros-thesis was removed and revised to
a pyro-carbon spacer. Five monthslater, the patient was pain-free havingregained good hand function.
Case 2
A 52-year-old female referred byorthopaedic surgeons had intermittentleft thumb pain and swelling followingprosthesis insertion. Eight monthspreviously, she had undergone anElektra� carpo-metocarpal joint re-placement; symptomsstarted2 monthslater. There were no signs of infectionor erythema, she had good range ofmovement. She was atopic and notedan intolerance to metal jewellery.
There were concerns because ofplans for a second joint replacementin the right hand. She was tested tomodified European baseline serieswith a 3þ positive reaction to cobaltchloride only at D4. Her prosthesiswas taken out and within 2 monthsshe was symptom-free.
The histories and rapid, sustainedresponses to removal make allergy thelikely cause of symptoms in both cases.
Discussion
Metal allergy has been reported toknee and more often hip replace-ments. Postoperative patch testingby Benson et al. (1) demonstratedmetal allergy in 28% of subjects withmetal on metal prostheses but associ-ated it only with loosening. The com-monest allergen was cobalt followedby nickel then chromate. The preva-lence of metal allergy in studies ofprosthetic loosening varies from13% to 74% (2).
The single study looking at sensi-tivity causing metal-on-metal hipprosthesis failure suggested an associa-tion but used too few subjects to con-firm this (3). Reed et al. (4) recentlyconcluded that preoperative testingcould beof use in guidingdevice choice.
Elektra� trapezio-metacarpal im-plants made by Small Bone Innova-tions International� are metal onmetal, containing cobalt, chromiumand titanium. The alloy is similar toearly hip replacements with modifica-tion to improve wear resistance ratherthan reduce hypersensitivity, which isseen less in metal on plastic joints.
Regnard (5) reported results of hisfirst 100 Elektra� prostheses withaverage follow up of 54 months. Onlyone experienced failure due to nickelallergy, presenting as non-infectious
inflammation. Small Bone Innova-tions International� advise of risks ontheir packaging but have not receivedother reports of symptomatic allergy.The two cases reported here arefrom seventy Elektra� proceduresperformed in our orthopaedics depart-ment.These findings suggest sensitivitycan cause joint device failure requiringrevision in some patients with knownmetal allergy. Dermatologists shouldbe aware of this group and have a lowthreshold for patch testing them.
References
1. Benson M K D, Goodwin P G, Brost-off J. Metal sensitivity in patients withjoint replacement. Br Med J 1975; 4:374–375
2. Gawkrodger D J. Metal sensitivitiesand orthopaedic implants revisited:the potential for metal allergy with thenew metal-on-metal joint prostheses.Br J Dermatol 2003;148:1089–1093.
3. Anthony F, Dudley W, Field R,Holden C. Metal allergy resurfaces infailed hip endoprostheses. Br J Derma-tology 2001; 145 (Suppl. 59): 48.
4. Reed K B, Davie M D, Nakamura Ket al. Retrospective evaluation of patchtesting before or after metal deviceimplantation. Arch Dermatol 2008;144: 1042–2042.
5. Regnard P J. Electra trapezio meta-carpal prosthesis: results of the first100 cases. J Hand Surg 2006; 31:621–628.
Address:Dr E SmithDermatology Department,Singleton HospitalSketty Lane,Swansea SA2 8QAUKTel: 0044 1792 206816Fax: 0044 1792 285330e-mail: [email protected]
298 CONTACT POINTS
