Should We Do Patch Testing Prior To Using Metal Implants In Patients With Reported Sensitivity?

Tracey Vlahovic DPM

Have you ever had a post-op patient with a metal implant who suddenly developed a rash, pain or loosening of the implanted device? I have had patients develop both a rash and pain following metal implantation, but attributed it to a Vicryl reaction as their reactions eventually resolved after treatment.

I still stand by that diagnosis but after reviewing a recent article in the Archives of Dermatology, I feel compelled to delve deeper into the allergy section of my patient interview prior to surgical planning.1

Mesinkovska and colleagues did a retrospective review of two groups of patients: those who had complained of metal sensitivity and had patch testing prior to implantation of an orthopedic device and those who had patch testing postoperatively.1 Those who complained of metal sensitivity self reported sensitivity to costume jewelry, belts, buckles and dental implants. They got referrals to dermatology for patch testing prior to their procedure and the patch testing result factored into the surgeon’s decision to use a different implant from their device of choice. The most common allergen was nickel, of course, followed by palladium, gold, cobalt and chromium. Patients who then had their procedure did not have any dermatitis or loosening of the implant postoperatively.

In the post-implantation group, patients had procedures ranging from ankle fracture fixation to total hip replacement. Most of these patients complained of redness, swelling and rash that continued long after the surgical procedure. Nickel was the most common culprit in their patch test results and a complaint of dermatitis most frequently occurred concurrently. Several of the patients with documented patch test allergy underwent explantation, which alleviated their skin symptoms.

This study is certainly interesting to our community and can have implications in our pre-op interview and decision making. However, there are drawbacks to the study. First, it was a small sample size. Second, the cutaneous patch testing can’t “recreate the environment in which the metal resides.”2

If a patient currently has dermatitis over an area that has a metal implant and we do patch testing, does it indicate that the metal implant caused the allergy or was the allergy there before the surgery? Can cutaneous patch testing represent what is happening in the joint space?

The truth is we don’t know. As a surgeon, you will have to determine the necessity of patch testing on a case-by-case basis. Certainly, as further studies occur in this area, we as a profession can refer patients who fit this metal sensitive profile to the local dermatologist or allergist for patch testing and further evaluation.

1. Atanaskova Mesinkovska N, Tellez A, Molina L, et al. The effect of patch testing on surgical practices and outcomes in orthopedic patients with metal implants. Arch Dermatol. 2012; 148(6):687-693.
2. Mowad CM. The role of patch testing in the selection and management of metal device implants comment on “The effect of patch testing on surgical practices and outcomes in orthopedic patients with metal implants.” Arch Dermatol. 2012; 148(6):693-694.


Regarding patch testing prior to insertion of an implant

A number of years ago, we were prepared to operate a young patient. We planned a Lepird procedure. This procedure would require at least five screws. As the patient was in the pre- op area, our resident took a history and found that the crucifix on the patient's neck caused an allergic skin reaction. We later found out that he patient had an allergy to stainless steel.

The case was canceled until we were able to get titanium screws. As I recall, several months later, the young man was again on the operating table, under anesthesia, to do the contralateral foot. Something made me ask the nurse if the titanium screws were out. A hush developed over the operating room until the circulating nurse triumphantly announced that she had them.

By the way, our resident eventually became a residency director herself and a star in our profession.

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