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Metal allergy and failed implants

The contribution of metal allergy to the failure of metal alloy implants, with special reference to titanium: Current knowledge and controversies

A recently published review articles looks at the connection between metal hypersensitivity and implant failure, with a particular focus on titanium. There is now a considerable body of evidence showing that titanium can induce hypersensitivity.

This review gives a useful overview of several case histories where symptoms started after placement of a titanium implants and disappeared after the removal. It's also important to remember that titanium alloys can contain trace quantities of more allergenic metals such as nickel and cobalt.

Excerpt from the article:

TABLE 1. Reports of clinical reactions to implants implicating possible titanium allergy.

AuthorTypeStudy summaryTests for allergy to titanium or other metals
Tanwar et al. Case report A 56-year-old male showing allergic symptoms after 1 week of dental (Ti) implant placement with no perioral or facial signs, but eczema was shown on the distant body parts, and complete remission was attained after removing the dental implant. Not performed.
Towers and Kurtom Case report A 67-year-old female with an unreported nickel reaction clinically developed severe debilitating anorexia and fatigue 1-month post operatively, secondary to thoracic spinal fixation. Over a 2-year period, weight loss reached approximately 25 kg with loss of muscle mass and subcutaneous tissue surrounding the spinal implants. The screws and rods were removed to avoid skin erosion. Upon hardware removal, the patient had rapid weight gain, improved stamina and generalised sense of well-being. She also had a clavicular plate placed 6 weeks post spine fusion. She developed a skin rash over the clavicular plate site 9 months post operatively and it was removed. Not performed
Peters et al. Case report Patient had four cardiac pacemakers implanted and removed due to localised symptoms of pruritus, redness and swelling of the skin overlying the pacemaker that developed within 3 weeks to 17 months after insertion. These reactions were interpreted as contact sensitivity to the pure titanium encasing of the pacemaker. Patch test positive -- tested with a thin square of titanium metal applied with artificial sweat.
Hosoki et al. Case report A 69-year-old male, with no history of metal hypersensitivity, had undergone an uneventful dental implantation in 2008. In 2010, he had fractured a lower limb and underwent open reduction with titanium screws. Six months later, generalised nummular eczema developed. The titanium screws were removed a year later; however, the eczema was only reduced by 50%. All metal prostheses except the implant screw and abutment were removed, and the eczema reaction was reduced to 30%, but still remained. The entire removal of the titanium implant screw and abutment in 2014 led to a full recovery. Patch test had positive reaction to cobalt, tin, palladium, indium, iridium, copper and titanium.
Lim et al. Case report A 70-year-old woman developed contact stomatitis after treatment with titanium nitride implant abutment. Symptoms improved after the removal of titanium abutments. Patch test positive to Ti nitride.
Ishii et al. Case report A 52-year-old man with Down's syndrome was implanted with a cardiac pacemaker for advanced atrioventricular block. He developed eczema and partial exposure of the generator 1 year after implantation. After reimplantation of a pacemaker wrapped with a polytetrafluoroethylene sheet, the dermatitis did not recur. Patch test was positive for the metal of the generator (purity 99.9% titanium) after 72 h.
Hofmann et al. Case report A 27-year-old non-atopic female developed progressive painful oedema of the right inguinal area 2 weeks after hernia repair with a mesh anchored by pure Ti clips. She had a history of a pruritic inflammation in the perianal region after a haemorrhoidopexy using Ti staples at the age of 26, with symptom relief after the staples had fallen off. One-week post removal of surgical clips, the patient reported complete remission of symptoms. Histology showed a granulomatous reaction adjacent to the clips. Patch test with TiO2 and Ti clip, positive reactions to both on Day 3 reading. Patch test was repeated 3 years later, with negative results.
Buonomo et al. Case report A female developed a well-demarcated, erythematous plaque over the left breast 13 months after reconstructive breast surgery with the placement of a temporary tissue expander (TTE). The port of the TTE contained Ti. Dermatitis resolved after removal of the tissue expander. Patch test was positive for a few metals, including Ti.
van Opstal and Verheyden Case report A 46-year-old woman with persistent dermatitis following total knee arthroplasty revision with an oxidised zirconium femoral component and titanium-containing tibial baseplate. She developed persistent dermatitis 3-month post-surgery. After revision with a customised tibial component, and removal of any Ti components, symptoms resolved completely. Patch tests were negative.
Heitmiller et al. Part of case series A 53-year-old African-American female had lumbar metal implants (Ti alloy) placed for degenerative disc disease. Three months after her procedure, she experienced worsening lower back pain, bilateral leg pain and paraesthesia, as well as erythema, warmth and tenderness overlying the midline surgical scar. The spinal implant was removed and replaced with bone morphogenic protein. Pathology of the tissue samples was consistent with ALVAL. Following implant removal, the patient experienced resolution of her symptoms. The patient later disclosed a history of suspected metal allergy after a failed left foot bunionectomy, requiring removal of titanium screws used during the procedure. Initial patch test with extended metal series was not tolerated due to an asthmatic reaction and facial angioedema within 24 h of patch test placement. Limited patch tests to nickel and titanium were subsequently performed. Positive to nickel and negative to Ti at Day 3 reading. Prick tests were positive to both nickel and Ti.
Thomas et al. Case report Localised eczema and poor bone healing was observed in a 35-year-old male patient following a titanium implant for a hand fracture. After removal of the titanium material, the healed and the eczema cleared. Patch tests negative to titanium, nickel, chromium and cobalt. LTT showed a positive reaction to titanium. Post removal, LTT was negative to Ti
Egusa et al. Case report A 50-year-old Japanese woman with no history of atopy, developed persistent facial eczema post Ti dental implant. Symptoms completely resolved post removal of the Ti materials. Positive LTT to titanium.
Ko et al. Case report A 33-year-old woman developed cervical eczema 9 months after titanium dental restoration. The eczema resolved after removal of the titanium. Lymphocyte stimulation test to Ti prior to restoration was negative, but post restoration showed a positive reaction to Ti.
Müller and Valentine-Thon Cohort study Fifty-six patients who had developed clinical symptoms after receiving titanium-based dental or endoprosthetic implants were reviewed. Following removal of the implants in 54 patients (2 refused removal), all 54 showed clinical improvement. Fifty-four patients were patch tested, all with negative results. Fifty-six were tested with LTT to titanium: 21 were positive, 16 were ambiguous and 19 negative. In 15 who had a LTT repeated later, the test was negative.

Full article: The contribution of metal allergy to the failure of metal alloy implants, with special reference to titanium: Current knowledge and controversies