The role of metal patch testing in evaluating patients for metallic prosthetic joint failure

Existing and Novel Assessment Methods for Metal Sensitivity in Elective Lower-Limb Arthroplasty-A Scoping Review

Background

Metal sensitivity is a possible cause for revision in elective lower-limb arthroplasty. This scoping review aims to identify and evaluate all existing and novel assessment methods for metal sensitivity in elective lower-limb arthroplasty.

Methods

The Cochrane Central Register of Controlled Trials (CENTRAL), Ovid Medical Literature Analysis and Retrieval System Online (MEDLINE), PubMed, and Google Scholar databases were searched for studies published between January 1, 2000, and September 1, 2023. Studies evaluating one or more metal sensitivity assessment method preoperatively, perioperatively, or postoperatively were included. Studies were grouped based on the assessment methods reported and summarized based on the study design, outcome measure, results, and comments on the method's validity.

Results

A total of 1220 results were screened, with 39 results (15 retrospective cohort studies, 11 prospective cohort studies, 6 case reports, 5 randomized controlled trials, and 2 case control studies) included, identifying 12 assessment methods. The most used one was patch testing, featuring in 17 studies (43.6%). Lymphocyte transformation assay/testing featured in 12 studies (30.8%). Plasma/serum concentration of metal ions featured in 6 studies (15.4%). Patient history and serum cytokine testing featured in 7 (17.9%) and 4 (10.3%) studies each. Generalized serum inflammatory markers featured in 3 studies (7.7%). The remaining 6 methods each featured in one or 2 studies. Evidence of the reliability of most metrics was limited.

Conclusions

Several assessment methods were identified. However, evidence of any methods reliably predicting and diagnosing the occurrence of metal sensitivity was limited. There is a need for improved metrics of metal hypersensitivity.

Metal implant allergy: A retrospective cohort analysis at a university allergy practice

Background: Concern of metal sensitization in pre- and postsurgical evaluation is growing, with the recent guidelines remaining the criterion standard for consideration of patch testing. Information remains scarce on surgical screening in the groups of patients who reported a history of metal sensitivity versus those with no reported history. Objective: The objective of this study was to assess the utility of patch testing in surgical candidates based on reported metal allergy history. The secondary objective was to evaluate the utility and outcomes in postsurgical patch testing. Methods: Nine hundred and thirty-one patient charts of patients with the diagnosis of "contact dermatitis" who underwent an evaluation at a single allergy clinic site between January 2013 and December 2022 were identified and reviewed as part of a retrospective chart review study. Patients were included in subgroups based on the time of patch testing and history of reported metal allergy. Results: In all, 67 patients underwent patch testing, 10 (14.9%) of whom were surgical candidates without a history of metal sensitivity, 31 (46.2%) of whom were surgical candidates with a history of metal sensitivity, and 26 (38.8%) of whom were postsurgical patients. Twenty-nine (43.3%) of patients had positive patch testing results, with only one (10%) in the presurgical group, 17 (54.8%) in the presurgical with a history of metal sensitivity, and 11 (42.3%) in the postsurgical group. Zero patients in our cohort without metal sensitivity who were undergoing the Nuss procedure had positive reactions on patch testing, whereas two of four (50%) with reported metal sensitivity who were undergoing the Nuss procedure had positive relevant metal reactions. Conclusion: Ambiguity in the utility of patch testing for surgical decision making remains, despite common utilization. Recent guidelines along with coordination of care among the surgeon, allergist, and patient remains the criterion standard of care.

Metal Allergy: State-of-the-Art Mechanisms, Biomarkers, Hypersensitivity to Implants

Metal allergy is mainly an environmental disorder which can cause allergic contact dermatitis. Environmental metal exposures include jewelry, everyday metal items, mobile phones, leather, metal-rich food and implants, including stents or anchors. While consumer exposure is liable for the majority of metal hypersensitivity cases, the significance of occupational exposure to metals remains relevant. Although the most common metal allergens are nickel, chromium, and cobalt; however, lately, gold, palladium, titanium, and some others have also attracted attention. This review highlights advances in metal allergy mechanisms, biomarkers for potential patients' stratification as well as biological treatments. The most recent evidence of human exposure to metal for risk assessment is discussed, as well as the relationship between the occurrence of metal hypersensitivity and implanted devices, including non-characteristic symptoms. The latest data on the diagnosis of metal hypersensitivity are also reported.

A Critical Review on Effect of Process Parameters on Mechanical and Microstructural Properties of Powder-Bed Fusion Additive Manufacturing of SS316L

Additive manufacturing (AM) is one of the recently studied research areas, due to its ability to eliminate different subtractive manufacturing limitations, such as difficultly in fabricating complex parts, material wastage, and numbers of sequential operations. Laser-powder bed fusion (L-PBF) AM for SS316L is known for complex part production due to layer-by-layer deposition and is extensively used in the aerospace, automobile, and medical sectors. The process parameter selection is crucial for deciding the overall quality of the SS316L build component with L-PBF AM. This review critically elaborates the effect of various input parameters, i.e., laser power, scanning speed, hatch spacing, and layer thickness, on various mechanical properties of AM SS316L, such as tensile strength, hardness, and the effect of porosity, along with the microstructure evolution. The effect of other AM parameters, such as the build orientation, pre-heating temperature, and particle size, on the build properties is also discussed. The scope of this review also concerns the challenges in practical applications of AM SS316L. Hence, the residual stress formation, their influence on the mechanical properties and corrosion behavior of the AM build part for bio implant application is also considered. This review involves a detailed comparison of properties achievable with different AM techniques and various post-processing techniques, such as heat treatment and grain refinement effects on properties. This review would help in selecting suitable process parameters for various human body implants and many different applications. This study would also help to better understand the effect of each process parameter of PBF-AM on the SS316L build part quality.