Das Allergiepotenzial von Implantatwerkstoffen auf Titanbasis

Diagnostic tests for titanium hypersensitivity in implant dentistry: a systematic review of the literature

PURPOSE

There are rising concerns about titanium hypersensitivity reaction regarding dental endosseous implants. This review aims to summarize and compare the validity and reliability of the available dermatological and laboratory diagnostic tests regarding titanium hypersensitivity. The following PICO design was used: In Patients with titanium dental implants (P) does epicutaneous testing (ECT) (I), compared to lymphocyte transformation test (LTT) or Memory Lymphocyte Immunostimulation Assay (MELISA) (C) detect hypersensitivity reactions (O)? A literature search was performed including all studies dealing with this topic. Studies regarding orthopedic implants were excluded.

METHODS

Three databases (MEDLINE PubMed, Cochrane Library, SciELO) were screened for suitable studies and an additional manual search was also performed. Literature regarding hypersensitivity reactions in orthopedic implants, hypersensitivity reactions regarding implants not related to dental or maxillofacial surgery, animal studies and in vitro studies were excluded. A quality assessment of all selected full-text articles was performed. Randomized, controlled trials were evaluated with the Cochrane Risk of Bias Tool I. Cohort studies were assessed according to the New Castle-Ottawa Scale and case series according to Moga et al. (Development of a quality appraisal tool for case series studies using a modified Delphi technique. 2012).

RESULTS

10 studies were included in the quantitative synthesis and available for the endpoint diagnostics of intolerance reactions to titanium dental implants: 2 clinical studies, 7 cohort studies and 1 case series. The potential for bias (internal validity) for these studies was overall rated as high.

CONCLUSIONS

The study of the available literature regarding ECT and MELISA or LTT in patients with suspected titanium hypersensitivity showed inconsistent results in terms of reliability and validity and thus, those tests should be regarded cautiously. There is strong evidence that titanium hypersensitivity in dental implants is associated with innate immunity: unspecific pro-inflammatory responses due to particle induced hyperreactivity of macrophages or toxicological responses especially towards nanoparticles rather than activation of the adaptive immune system. Therefore, tests detecting allergies do not seem expedient and inflammatory clinical signs should be regarded as leading parameters.

Is Allergy to Titanium Bone Fixation Plates a Problem?

Open reduction and internal fixation (ORIF) with titanium fixation plates is the gold standard for maxillofacial fracture treatment. Titanium is considered a fully compatible material. However, reports of allergic reactions to titanium implants do occur. The aim of this work is to answer the question whether titanium devices used in the treatment of fractures in the craniofacial region can cause allergic reactions. The study comprised 50 subjects treated surgically for maxillofacial injuries with the use of titanium composite devices. Allergic tests were performed by the patch method. The control group consisted of 20 healthy people who did not have any titanium elements. There were no skin changes to titanium and its compounds in both the test and control groups. Only one patient had a positive skin test which showed an allergic reaction to silver nitrate. Titanium fixing elements, as well as titanium dental implants, according to our research, do not show allergic skin reactions.

Allergies to Titanium Dental Implants: What Do We Really Know about Them? A Scoping Review

Simple Summary

The scientific literature repeatedly insists on the success of titanium implants. Nevertheless, the so-called tribocorrosion process releases titanium ions into the surrounding tissues, which can trigger a cascade of reactions, localized or at a distance, or even systemic reactions. Consequently, guidelines should be drawn up before starting treatment; when a hypersensitivity reaction following titanium dental implant placement occurs, a range of treatment alternatives should be clearly established and made available.

Abstract

The purpose of this scoping review was to describe the current state of knowledge and understanding of allergies to titanium dental implants. A scoping review was conducted following the Prisma Extension for Scoping Reviews checklist. An electronic search was performed in five databases complemented by manual and grey literature searches. Fifty-two relevant papers were included for final review. Titanium particles can be released from the surfaces of dental implants in a process called tribocorrosion, which may contribute to bone loss due to inflammatory reaction. Diverse mechanisms have been described that may trigger allergy to titanium, as well as the clinical signs that manifest as the allergy develops. Allergies to titanium are uncommon but represent a real possibility that should not be overlooked in patients requiring prosthodontic rehabilitation with dental implants. Allergy can trigger a range of symptoms. Patients who have already been diagnosed with allergies to other metals will be more predisposed to suffering an allergy to titanium. Further investigation is needed in order to measure the true scope of these allergies.

Positive Material Identification testing of dental implant to correlate their compositions with allergic conditions

BACKGROUND

Rapid increase of products containing titanium leads to the increases in percutaneous and permucosal exposure of populations to the titanium.

PURPOSE

Evaluate the various material compositions in five commercially available dental implant systems and correlate the obtained material contents with allergic conditions seen with implants.

MATERIAL AND METHODS

A total of 25 implant, with 5 samples each in 5 groups of commercially available dental implants (MKIII, Myriad, Nobel Replace, MIS and Alpha Dent) were used in the study. Positive Material Identification (PMI) testing was done to analyse the amount of different metals (percentage by mass) present in the dental implants.

RESULTS

Highest titanium content, 99.47% by mass was found in sample 2 (Myriad) and least, 89.04% by mass in sample 5(Alpha dent). Nickel was found only in sample 5 (Alpha dent) in 0.079% by mass and zinc in sample 4 (MIS) in0.084% by mass, chromium was found in sample 1 (MK III) in 0.263% by mass and in sample 2 in0.273% by mass.

CONCLUSIONS

Implant composition should be made mandatory to be disclosed on the implant packet and before implant placement patch test for the allergen present in the particular implant can be done for the patient's health benefit and long term clinical success of dental implants.

Implant allergy

Osteosynthesis materials or artificial joint replacement make part of clinical routine. In case of complaints mostly mechanical causes or infections are found. Metals like nickel, chromium and cobalt or bone cement components like acrylates and gentamicine may however potentially cause intolerance reactions to implants. Correspondingly, eczema, delayed wound/bone healing, recurrent effusion, pain or implant loosening have been described as manifestation of implant allergy. In contrast to the high incidence of cutaneous metal allergy, allergies associated with implants are rare. Diagnosis of metal implant allergy is based on excluding differential diagnoses – in particular infection – and on a combined approach of allergological diagnostics by patch test and histopathology of periimplant tissue. Risk factors for allergic sensitization to implants or triggering periimplant allergic reactions in the case of preexisting cutaneous metal allergy are unknown. Despite the risk of developing complications being unclear, titanium-based osteosynthesis materials are recommended for metal-allergic patients and the use of metal-metal couplings in arthroplasty is rather not recommended for such patients. If a regular, potentially applicable CoCr-polyethylene articulation is preferred, the patient has to be well informed and has to give his written consent.

Increased frequency of delayed type hypersensitivity to metals in patients with connective tissue disease

BACKGROUND

Connective tissue disease (CTD) is a group of inflammatory disorders of unknown aetiology. Patients with CTD often report hypersensitivity to nickel. We examined the frequency of delayed type hypersensitivity (DTH) (Type IV allergy) to metals in patients with CTD.

METHODS

Thirty-eight patients; 9 with systemic lupus erythematosus (SLE), 16 with rheumatoid arthritis (RA), and 13 with Sjögren's syndrome (SS) and a control group of 43 healthy age- and sex-matched subjects were included in the study. A detailed metal exposure history was collected by questionnaire. Metal hypersensitivity was evaluated using the optimised lymphocyte transformation test LTT-MELISA(®) (Memory Lymphocyte Immuno Stimulation Assay).

RESULTS

In all subjects, the main source of metal exposure was dental metal restorations. The majority of patients (87%) had a positive lymphocyte reaction to at least one metal and 63% reacted to two or more metals tested. Within the control group, 43% of healthy subjects reacted to one metal and only 18% reacted to two or more metals. The increased metal reactivity in the patient group compared with the control group was statistically significant (P<0.0001). The most frequent allergens were nickel, mercury, gold and palladium.

CONCLUSIONS

Patients with SLE, RA and SS have an increased frequency of metal DTH. Metals such as nickel, mercury and gold are present in dental restorative materials, and many adults are therefore continually exposed to metal ions through corrosion of dental alloys. Metal-related DTH will cause inflammation. Since inflammation is a key process in CTDs, it is possible that metal-specific T cell reactivity is an etiological factor in their development. The role of metal-specific lymphocytes in autoimmunity remains an exciting challenge for future studies.

Metal hypersensitivity in patient with posterior lumbar spine fusion: a case report and its literature review

BACKGROUND

Metal hypersensitivity, mostly documented in prosthesis implantation, is a rare complication after arthroplasty. Such cases become rarer and more difficult to diagnose when it comes to lumbar surgery.

CASE PRESENTATION

We present the case of a 52-year-old female patient with reoccured low back pain and sciatica after posterior lumbar decompression and fusion (PLDF) for her lumbar disc herniation. The initial clinical and radiological examinations showed no pathologies. Further imaging and histopathological studies in later period revealed an aseptic loosening of the hardware and an aseptic inflammatory response which was diagnosed to be metal hypersensitivity. To our knowledge, few allergic cases in the matter of spinal fusion were reported so far.

CONCLUSIONS

Metal hypersensitivity after spinal fusion should be considered in patients with representation of postoperative back pain. And elaborate history taking would conduce a lot to it's diagnose.

Allergy related to dental implant and its clinical significance

The oral cavity provides an ideal and unique environment for study of biological processes involving metallic dental aids. Dental materials within the mouth interact continually with physiological fluids. Oral tissues are exposed to a veritable bombardment of both chemical and physical stimuli as well as the metabolism of many species of bacteria; yet, for the most part, oral tissues remain healthy. The pH of saliva varies from 5.2 to 7.8. Teeth, restorations, or any prosthesis including dental implants in the oral cavity have to function in one of the most inhospitable environments in the human body. They are subject to larger temperature and pH variations than most other parts of the body. Corrosion, the graded degradation of materials by electrochemical attack, is of concern particularly when dental implants are placed in the hostile electrolytic environment provided by the human mouth. Allergic reactions may occur from the presence of ions produced from the corrosion of implants. The present article describes various manifestations of allergic reactions due to implant material in the oral cavity.

[Cementless total hip arthroplasty: a review]

The purpose of total hip replacement (THR) is the restoration of a painless functioning hip joint with the main focus on the biomechanical properties. Advances in surgical techniques and biomaterial properties currently allow predictable surgical results in most patients. Despite the overwhelming success of this surgical procedure, the debate continues surrounding the optimal choice of implants and fixation. Femoral and acetabular implants with varying geometries and fixation methods are currently available. Problems inherent with acrylic bone cement, however, have encouraged surgeons to use alternative surfaces to allow biologic fixation. Optimal primary and secondary fixation of cementless hip stems is a precondition for long-term stability. Important criteria to achieve primary stability are good rotational and axial stability by press-fit fixation. The objective of the cementless secondary fixation is the biological integration of the implant by bony ingrowth. Nevertheless, current investigations show excellent results of cementless fixation even in older patients with reduced osseous quality. The main advantages of cementless fixation include biological integration, reduced duration of surgery, no tissue damage by cement polymerization and reduction of intraoperative embolisms. In comparison to cemented THR both, cementless sockets and stems provide good long-term results.

Body piercing: complications and prevention of health risks

Body and earlobe piercing are common practices in the USA today. Minor complications including infection and bleeding occur frequently and, although rare, major complications have been reported. Healthcare professionals should be cognizant of the medical consequences of body piercing. Complications vary depending on the body-piercing site, materials used, experience of the practitioner, hygiene regimens, and aftercare by the recipient. Localized infections are common. Systemic infections such as viral hepatitis and toxic shock syndrome and distant infections such as endocarditis and brain abscesses have been reported. Other general complications include allergic contact dermatitis (e.g. from nickel or latex), bleeding, scarring and keloid formation, nerve damage, and interference with medical procedures such as intubation and blood/organ donation. Site-specific complications have been reported. Oral piercings may lead to difficulty speaking and eating, excessive salivation, and dental problems. Oral and nasal piercings may be aspirated or become embedded, requiring surgical removal. Piercing tracts in the ear, nipple, and navel are prone to tearing. Galactorrhea may be caused by stimulation from a nipple piercing. Genital piercings may lead to infertility secondary to infection, and obstruction of the urethra secondary to scar formation. In men, priapism and fistula formation may occur. Women who are pregnant or breastfeeding and have a piercing or are considering obtaining one need to be aware of the rare complications that may affect them or their child. Though not a 'complication' per se, many studies have reported body piercing as a marker for high-risk behavior, psychopathologic symptoms, and anti-social personality traits. When it comes to piercing complications, prevention is the key. Body piercers should take a complete medical and social history to identify conditions that may predispose an individual to complications, and candidates should choose a qualified practitioner to perform their piercing. As body piercing continues to be popular, understanding the risks of the procedures as well as the medical and psychosocial implications of wearing piercing jewelry is important for the medical practitioner.

Hypersensitivity reactions to metallic implants - diagnostic algorithm and suggested patch test series for clinical use

Cutaneous and systemic hypersensitivity reactions to implanted metals are challenging to evaluate and treat. Although they are uncommon, they do exist, and require appropriate and complete evaluation. This review summarizes the evidence regarding evaluation tools, especially patch and lymphocyte transformation tests, for hypersensitivity reactions to implanted metal devices. Patch test evaluation is the gold standard for metal hypersensitivity, although the results may be subjective. Regarding pre-implant testing, those patients with a reported history of metal dermatitis should be evaluated by patch testing. Those without a history of dermatitis should not be tested unless considerable concern exists. Regarding post-implant testing, a subset of patients with metal hypersensitivity may develop cutaneous or systemic reactions to implanted metals following implant. For symptomatic patients, a diagnostic algorithm to guide the selection of screening allergen series for patch testing is provided. At a minimum, an extended baseline screening series and metal screening is necessary. Static and dynamic orthopaedic implants, intravascular stent devices, implanted defibrillators and dental and gynaecological devices are considered. Basic management suggestions are provided. Our goal is to provide a comprehensive reference for use by those evaluating suspected cutaneous and systemic metal hypersensitivity reactions.

Postoperative spinal infection mimicking systemic vasculitis with titanium-spinal implants

BACKGROUND

Secondary systemic vasculitis after posterior spinal fusion surgery is rare. It is usually related to over-reaction of immune-system, to genetic factors, toxicity, infection or metal allergies.

CASE DESCRIPTION

A 14 year-old girl with a history of extended posterior spinal fusion due to idiopathic scoliosis presented to our department with diffuse erythema and nephritis (macroscopic hemuresis and proteinuria) 5 months post surgery. The surgical trauma had no signs of inflammation or infection. The blood markers ESR and CRP were increased. Skin tests were positive for nickel allergy, which is a content of titanium alloy. The patient received corticosteroids systematically (hydrocortisone 10 mg) for 6 months, leading to total recess of skin and systemic reaction. However, a palpable mass close to the surgical wound raised the suspicion of a late infection. The patient had a second surgery consisting of surgical debridement and one stage revision of posterior spinal instrumentation. Intraoperative cultures were positive to Staphylococcus aureus. Intravenous antibiotics were administered. The patient is now free of symptoms 24 months post revision surgery without any signs of recurrence of either vasculitis or infection.

LITERATURE REVIEW

Systemic vasculitis after spinal surgery is exceptionally rare. Causative factors are broad and sometimes controversial. In general, it is associated with allergy to metal ions. This is usually addressed with metal on metal total hip bearings. In spinal surgery, titanium implants are considered to be inert and only few reports have presented cases with systemic vasculitides. Therefore, other etiologies of immune over-reaction should always be considered, such as drug toxicity, infection, or genetic predisposition.

PURPOSES AND CLINICAL RELEVANCE

Our purpose was to highlight the difficulties during the diagnostic work-up for systemic vasculitis and management in cases of posterior spinal surgery.

Titanium allergy: could it affect dental implant integration?

PURPOSE

Degradation products of metallic biomaterials including titanium may result in metal hypersensitivity reaction. Hypersensitivity to biomaterials is often described in terms of vague pain, skin rashes, fatigue and malaise and in some cases implant loss. Recently, titanium hypersensitivity has been suggested as one of the factors responsible for implant failure. Although titanium hypersensitivity is a growing concern, epidemiological data on incidence of titanium-related allergic reactions are still lacking.

MATERIALS AND METHODS

A computer search of electronic databases primarily MEDLINE and PUBMED was performed with the following key words: 'titanium hypersensitivity', 'titanium allergy', 'titanium release' without any language restriction. Manual searches of the bibliographies of all the retrieved articles were also performed. In addition, a complementary hand search was also conducted to identify recent articles and case reports.

RESULTS

Most of the literature comprised case reports and prospective in vivo/in vitro trials. One hundred and twenty-seven publications were selected for full text reading. The bulk of the literature originated from the orthopaedic discipline, reporting wear debris following knee/hip arthroplasties. The rest comprised osteosynthesis (plates/screws), oral implant/dental materials, dermatology/cardiac-pacemaker, pathology/cancer, biomaterials and general reports.

CONCLUSION

This review of the literature indicates that titanium can induce hypersensitivity in susceptible patients and could play a critical role in implant failure. Furthermore, this review supports the need for long-term clinical and radiographic follow-up of all implant patients who are sensitive to metals. At present, we know little about titanium hypersensitivity, but it cannot be excluded as a reason for implant failure.

[Preclinical evaluation of coated knee implants for allergic patients]

BACKGROUND

10-15% of the population show allergic reactions against skin contact to metals as nickel, cobalt or chromium and have thus a risk of not tolerating implants containing those materials. The relationship between periimplantary hypersensivity reaction and given cutaneous contact allergy is currently unknown. A new developed multilayer coating system is supposed to prevent long-term allergic reactions that may result from uncoated implants.

METHODS

Stability and function (concerning bonding durability, wear and ion release to the serum) of the multilayer coating system has been examined in a test series.

RESULTS

The specific architecture of the multilayer coating system evidences a very good bonding durability. The results of the test in the simulator show a reduction of wear of approximately 60% compared to the uncoated implants. Ion concentrations within the serum of the wear tests were by magnitudes lower than those measured in reference tests on uncoated components.

CONCLUSION

The results of the preclinical evaluation prove that the durability and function of the multilayer coating system are as intended.

[Biodegradable synthetic implant materials : clinical applications and immunological aspects]

In the last decade biodegradable synthetic implant materials have been established for various clinical applications. Ceramic materials such as calcium phosphate, bioglass and polymers are now routinely used as degradable implants in the clinical practice. Additionally these materials are now also used as coating materials or as microspheres for controlled drug release and belong to a series of examples for applications as scaffolds for tissue engineering. Because immense local concentrations of degradation products are produced during biodegradation, this review deals with the question whether allergic immune reactions, which have been reported for classical metallic and organic implant materials, also play a role in the clinical routine for synthetic biodegradable materials. Furthermore, possible explanatory theories will be developed to clarify the lack of clinical reports on allergy or sensitization to biodegradable synthetic materials.

[Alternative materials and solutions in total knee arthroplasty for patients with metal allergy]

The annual number of total knee replacement implantations is rising continuously. A progressive cutaneous hypersensitivity rate against metallic materials in the population has been registered which can lead to an increase of allergy-induced reactions associated with implant loosening in the future although the correlation with an allergic cutaneous sensitisation has not been proven in all cases. On apparent allergy against metallic implant components different alternative solutions to standard endoprostheses should be taken into account for primary implantation or revision of total knee replacement, for example the application of implant components without metallic elements (e.g. ceramics), the use of non-allergic metallic implants, such as titanium or ZrNb alloys, or potential allergy-inducing metallic materials after masking the implant surface using a suitable coating. In the case of primary or revision surgery most patients with metal allergy are treated with a Ti(Nb)N-coated knee implant made of cobalt-chrome or titanium alloys in our hospital. Within an international multi-centre study we are currently implanting a newly developed knee endoprosthesis system with a ceramic femoral component as an alternative.

[Orthopedic surgical implants and allergies. Joint statement by the Implant Allergy Working Group (AK 20) of the DGOOC (German Association of Orthopedics and Orthopedic Surgery), DKG (German Contact Dermatitis Research Group) and DGAKI (German Society for Allergology and Clinical Immunology)]

Materials used in osteosynthesis or artificial joint replacement are usually well tolerated. Complaints after such operations are mostly related to infection or mechanical problems but may also be caused by allergic reactions. The latter encompass skin changes, e.g., eczema, delayed wound/bone healing, recurrent effusion, pain, or implant loosening. In contrast to the high incidence of cutaneous metal contact allergy, allergies associated with implants are a rare condition. However, epidemiological data on the incidence of implant-related allergic reactions are still missing. Typical elicitors are nickel, chromium, cobalt, and constituents of bone cement (acrylates und additives such as gentamicin or benzoyl peroxide). After exclusion of the most common differential diagnoses, allergy diagnostic procedures are primarily based on patch tests including a metal and bone cement component series. Additional analysis of periimplant tissue is recommended. However, further studies are necessary to show the significance of the histologic findings and the role of the lymphocyte transformation test (LTT). Which combinations of factors will induce allergic sensitization to implants or trigger periimplant allergic reactions in the case of preexisting cutaneous metal allergy is still unknown. Titanium-based osteosynthesis materials are recommended for metal allergic patients. In elective hip replacements, a ceramic/polyethylene (PE) articulation should be used, and in knee replacements "alternative materials". If a regular, potentially applicable CoCr/PE articulation is preferred, the patient must be well informed and must give his/her written consent.

Body-modifying concepts and dermatologic problems: tattooing and piercing

Recently, piercing and tattooing have gained increasing popularity worldwide, through all social classes and age groups. Besides pierced ear lobes, piercing of the tongue, nose, nipples, belly button, and even the genitals is quite common. The variety of tattoos range from temporary henna tattoos to permanent makeup and permanent tattoos, where the pigments are deposed in the dermis. These trends are supplemented by more invasive methods of body modification such as implanting, scarification, or branding. Parallel with the increasing popularity of piercing and tattoos, the knowledge about associated complications rose. Complications depend substantially on the circumstances in which body modifications are applied, the materials used, and the body region concerned. This article gives an overview of the most common complications of body modification methods, which mainly result from shortcomings in the application itself or in hygiene regimens. Consequences may be as severe as life-threatening events or permanent malfunction of different organs.

[Recurrent effusion and granulomatous synovitis following total knee arthroplasty in association with latex allergy]

An increasing number of articles report about allergic reactions in association with total knee arthroplasty. While most studies focus on allergic reactions to metallic components, few reports exist about reactions to bone cement or its ingredients. Allergy to natural rubber latex is a major occupational problem in the health care sector and a problem even in other occupations in which protective gloves are used. The allergic reaction to latex ranges from a minor skin rash to anaphylactic shock. Preventing exposure to latex is the key to managing and preventing this allergy. We report about a patient who developed recurrent effusion and granulomatous synovitis following total knee arthroplasty in association with latex allergy.

Hypersensitivity to titanium osteosynthesis with impaired fracture healing, eczema, and T-cell hyperresponsiveness in vitro: case report and review of the literature

There are very few reports on hypersensitivity reactions in association with titanium-based materials so that the existence of allergy to titanium is still put in question. We report on a patient in whom impaired fracture healing and eczema localized to the perioperative area developed upon titanium-based osteosynthesis. Patch testing gave no reactions to titanium nor to nickel, chromium, or cobalt. However, in the lymphocyte transformation test, the patient's lymphocytes showed markedly enhanced proliferation in vitro to titanium. After removal of the titanium material, fracture healing was achieved and the eczema cleared. Parallel to this, in vitro hyperreactivity to titanium disappeared. Although contact allergic reactions to titanium have been very rarely reported, these findings support a diagnosis of titanium allergy in our patient.

[Examination of granuloma of revised cemented or cementless total hip arthroplasties using inductively coupled plasma atomic emission spectrometry (ICP-OES)]

INTRODUCTION

Aseptic loosening is the most common problem in total hip arthroplasty (THA). One main aspect is inflammatory reaction against wear particles of the prosthesis materials. Analysing failure mechanisms in THA analysis of the particles and their element distribution of revised granulomatous tissue is essential to improve materials used in THA.

MATERIALS AND METHODS

23 granulomas of revised THA due to aseptic loosening, 13 of which with metal on metal bearing (M/M), were analysed using inductively coupled plasma atomic emission spectrometry (ICP-OES).

RESULTS

Elements Cr, Mn, Ni, Al, Cu, Zn, Cd, Ti, V, Zr, Nb and Fe could be detected. The maximum value of Cr was 23.88 ppb (parts per billion), Al 191.02 ppb, Ni 64.95 ppb and Zr 9.96 ppb. The highest value of Al could be found in cementless implants. The maximum value of the elements Cr and Ni could be detected in M/M. In cemented implants the highest value of Zr was found.

DISCUSSION

The origin of Zr was the used bone cement in cemented THA. The elements Cr and Ni were significantly higher in M/M bearings. The highest value of Al was detected in granulomas of revised corund rough blasted cementless implants. The histopathologic findings of the revised M/M bearings have been published recently. Inductively Coupled Plasma Atomic Emission Spectrometry (ICP-OES) could not show any differences of the alloying constituents in cases with or without allergic reactions. ICP-OES analysis seems to be not useful examination of histologic sections using SEM with cryotransfer unit.

Implant-related inflammatory arthritis

BACKGROUND

A 54-year-old woman presented with myalgia and arthralgia predominantly in the knees and small joints of the hands and feet with morning stiffness lasting for at least 2 h. The patient had received a wrought titanium 6-aluminium 4-vanadium alloy C cage implant 1.5 years previously, following a severe disc prolapse. No signs of rheumatic disease were evident before the C cage was implanted.

INVESTIGATIONS

Physical examination, radiography, skin and muscle biopsies, serology tests, white blood cell count, HLA genotyping, tumor necrosis factor release assay, skin patch test, lymphocyte transformation test.

DIAGNOSIS

Implant-related inflammatory arthritis.

MANAGEMENT

Combination therapy with corticosteroids, disease-modifying antirheumatic drugs and nonsteroidal anti-inflammatory drugs, and replacement of the titanium cage with a polyetherketone cage.