ISSN 0972-978X 

 
 
 
 
 
 
 
 
 
 
 
 
  About COAA
 

 

 

 

 

 

 

ORIGINAL ARTICLE

Nickel Allergy And Nickel Free Implants In Joint Replacement Surgery: An Analysis Of Current Practice In Scotland

Adam Lomax, Alexander Campbell
Monklands District General Hospital
United Kingdom
Address for Correspondence:

Alexander Campbell
Monklands District General Hospital
United Kingdom

E-mail: adam@adamlomax.wanadoo.co.uk

Abstract:

Background: Nickel is the most common metal sensitizer in humans with a prevalence of approximately 14%. The effects of nickel allergy on the performance of an orthopaedics implant are unclear and there are no UK guidelines on the use of nickel free implants for joint replacement surgery in patients with a history of nickel allergy.

 

This cohort study looks at the current practice of surgeons in Scotland in their approach to nickel allergy and use of nickel free implants in the patient undergoing major joint replacement surgery.

 

Methods: An anonymous questionnaire was sent to all orthopaedic consultants in the west of Scotland.

 

Results: Eighty-seven questionnaires were sent, with a response rate of 63.2% (55 replies). 54.5% (30) did ask patients if they had a nickel allergy. 86.7% (26) of these would go on to use a nickel free implant when the patient gave a history of allergy. Of the 25 who did not ask about nickel allergy, 72% (18) would use a nickel free implant if they knew that the patient was allergic to nickel. 

Only 12.7% (7) stated that they did have a unit policy for the use of implants in a nickel allergic patient.

 

Conclusions: This variation in practice is likely to be a reflection of the lack of evidence and guidance on this topic. It suggests that there is a variation in opinion amongst surgeons of the importance of a cutaneous hypersensitivity and its potential effects on the performance of an implant placed deep within the tissues. Further research is needed before evidence based decisions can be made on the use of nickel free implants.

 

J.Orthopaedics 2010;7(1)e5

 

Keywords:

arthroplasty; allergy

Introduction:

Nickel is the most common metal sensitizer in humans, with a prevalence in the general population of approximately 14% (1). Amongst the metal alloys most commonly used in orthopaedic practice, nickel is contained in stainless steel (13-15.5%) and in cobalt/chrome implants (1%) (2). Titanium alloys do not contain nickel and can therefore be used as an alternative to a nickel containing implant. Since all metals implanted into human tissue undergo corrosion, it is reasonable to suppose that metal ion complexes may have the potential to produce a host immune hypersensitivity response.

There are no UK or Scottish guidelines on the use of nickel free implants or on the use of metal implants in nickel allergic patients. We conducted a cohort study to examine the current practice of orthopaedic surgeons in the West of Scotland, UK, to examine their approach to nickel allergy and the use of implants in the nickel allergic patient undergoing hip or knee joint replacement surgery.

Materials and Methods:

An anonymous questionnaire was sent to all orthopaedic consultants in the West of Scotland. They were given an addressed envelope in which to return the competed questionnaire to the first author of this paper.

Results :

Eighty-seven questionnaires were sent and the response rate was 63.2% (55 replies). 54.5% (30) of consultants did ask patients if they had a history of nickel allergy during their pre-operative assessment. Of those respondents who checked for a history of nickel allergy, 86.7% (26) would use a nickel free implant on the basis of a positive history.

In the group who did not routinely ask about a history of nickel allergy pre-operatively (25), 72% (18) would use a nickel free implant if they were made aware that the patient did have a history of allergy to nickel.

Out of the total number of responses, only 12.7% (7) stated that they did have a unit policy on the use of nickel free implants.

Discussion :

Currently there is limited evidence and understanding of the effects of cutaneous nickel hypersensitivity reactions to the performance of orthopaedic implants. In a recent extensive review of available literature, Hallab et al (2) cite a number of case reports specific to orthopaedic practice, which implicate the implantation of a metal prosthesis in causing a cutaneous allergic reaction (3-8). These cases do not all involve nickel, but they do highlight a possible role for the avoidance of metal allergens in known hypersensitive patients. In a number of cases the reaction necessitated removal of the implant, with an improvement in the cutaneous symptoms noted in all cases.

It is also important to consider the potential for metal ion wear particles to impair the performance of the prosthesis resulting in early failure. Hallab (2) goes on to statistically analyse the data from 7 cohort studies. He concludes that; “the average prevalence of metal sensitivity among patients with a failed or poorly functioning implant (as judged by a variety of criteria) was approximately 60%”. Seven investigations were included (9-15). However, as they state, “this association does not prove a causal effect”.

In their conclusion, they advise that implant degradation products have been shown to be associated with dermatitis, urticaria and vasculitis. They also noted that the prevalence of dermal hypersensitivity in patents with a joint replacement device, particularly those with a failed implant, is substantially higher than that in the general population.

However, a clear causal relationship between implant degradation products and impaired performance or failure of a metal prosthesis has not yet been proven. Hallab suggests that until the roles of delayed hypersensitivity and humoral immune responses to metallic orthopaedic implants are more clearly defined, the risk to patients may be considered minimal.

Conclusion:

In this cohort it is clear that attitudes towards the importance of nickel allergy and the use of nickel free implants varies considerably amongst orthopaedic surgeons despite working in the same unit or those in a close geographical area.

It is likely that the variation in practice reflects the lack of understanding and guidance in this area of orthopaedic practice. This most probably also accounts for the small number of surgeons working within a unit with a policy covering the use of these implants.

It is unlikely that a consensus will be reached on the use of nickel free implants until further research into the roles of immune responses to metal implants allows evidence-based decisions to be made. Until then, recommendations on the use of metal implants in metal hypersensitive individuals will not be possible.

Reference :

  1. Basketter DA, Briatico-Vangosa G, Kaestner W, Lally C, Bontinick WJ: Nickel, cobalt and chromium in consumer products: a role in contact dermatitis? Contact Dermatitis 1993, 28:15-25.

  2. Hallab N, Merritt K, Jacobs JJ: Metal sensitivity in patients with orthopaedic implants. Journal of Bone and Joint Surgery 2001, 83A(3):428-436.

  3. Cramers M, Lucht U: Metal sensitivity in patients treated for tibial fractures with plates of stainless steel. Acta Orthopaedica Scandinavia 1977, 48:245-9.

  4. Barranco VP, Solomon H: Eczematous dermatitis from nickel. JAMA 1972, 220:1244

  5. Halpin DS: An unusual reaction in muscle in association with vitallium plate: a report of possible metal hypersensitivity. Journal of Bone and Joint Surgery 1975, 57B:451-3

  6. Merle C, Vigan M, Devred D, Girardin P, Adessi B, Laurent R: Generalised eczema from vitallium osteosynthesis material. Contact Dermatitis 1992, 27:257-8

  7. Rostoker G, Robin J, Binet O, Blamoutier J, Paupe J, Lessana-Liebowitch M, BedouelleJ, Sonneck JM, Garrel JB, Millet P: Dermatitis due to orthopaedics implants. A review of the literature and report of three cases. Journal of Bone and Joint Surgery 1987, 69A:1408-12.

  8. Thomas RH, Rademaker M, Goddard NJ, Munro DD: Severe eczema of the hands due to an orthopaedic plate made of vitallium. British Medical Journal (Clin Res Ed) 1987, 294:106-7.

  9. Elves MW, Wilson JN, Scales JT, Kemp HB: Incidence of metal sensitivity in patients with total joint replacements. British Medical Journal 1975, 4:376-8

  10. Duetman R, Mulder TJ, Brian R, Nater JP: Metal sensitivity before and after total hip arthroplasty. Journal of Bone and Joint Surgery 1977, 59A:862-5

  11. Mayor MB, Merrit K, Brown SA: Metal allergy in the surgical patient. American Journal of Surgery 1980, 139:477-9

  12. Evans EM, Freeman MAR, Miller AJ, Vernon-Roberts B: Metal sensitivity as a cause of bone necrosis and loosening of the prosthesis in total joint replacement. Journal of Bone and Joint Surgery 1974, 56B:626-42

  13. Munro-Ashman D, Miller AJ: Rejection of metal to metal prosthesis and skin sensitivity to cobalt. Contact Dermatitis 1976, 2:65-7

  14. Christianson K, Holmes K, Zilko PJ. Metal sensitivity causing loosened joint prosthesis. Annals of Rheumatological Disease. 1980;39:476-80

  15. Milavec-Puretic V, Orlic D, Marusic A. Sensitivity to metals in 40 patients with failed hip endoprosthesis. Archives of Orthopaedic Trauma Surgery. 1998;117:383-6.

This is a peer reviewed paper 

Please cite as: Alexander Campbell: Nickel Allergy And Nickel Free Implants In Joint Replacement Surgery: An Analysis Of Current Practice In Scotland

J.Orthopaedics 2010;7(1)e5

URL: http://www.jortho.org/2010/7/1/e5

ANNOUNCEMENTS

 


 

Arthrocon 2009


International Symposia on
Arthroplasty and Arthroscopy

Hands on Workshop, Case Discussions
Interactive Sessions
with
International Faculty

April 26, 2009

At Port City of Calicut, Kerala, India

"Download Registration Form"

For Registration
Dr Sibin Surendran,
Dept of Orthopaedics,
Medical College, Calicut, Kerala, India

Ph:+91 9447636977

E-Mail:
drsibins@rediffmail.com

 

Powered by
VirtualMedOnline

 

 

   
© Copyright of articles belongs to the respective authors unless otherwise specified.Verbatim copying, redistribution and storage of this article permitted provided no restrictions are imposed on the access and a hyperlink to the original article in Journal of Orthopaedics maintained. All opinion stated are exclusively that of the author(s).
Journal of Orthopaedics upholds the policy of Open Access to Scientific literature.