Dermatitis in patients undergoing the Nuss procedure for correction of pectus excavatum

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.

Titanium nitride coating of pectus bar increases metal contamination after minimally-invasive repair of pectus excavatum

INTRODUCTION

Previous studies demonstrated a release of toxic metals, e.g. nickel and chromium, from stainless steel bars used for minimally invasive repair of pectus excavatum (MIRPE). In the present study, we investigated the impact of titanium nitride coating on the metal release and exposure of MIRPE patients.

MATERIAL AND METHODS

We analyzed the courses of nickel and chromium levels in blood, urine and local tissue in patients undergoing MIRPE with a titanium nitride coated pectus bar between 03/2017 and 10/2018. Sample collection was scheduled prior to MIRPE, at defined postoperative time points and at bar removal. Additionally, we evaluated irritative symptoms. Results were compared to a control group who received uncoated stainless steel bars in a previous time period (03/2015-02/2017).

RESULTS

12 patients received coated pectus bars (mean age 15.7 years). The control group included 28 patients. After implantation of a titanium nitride coated bar, significant increase in systemic nickel and chromium levels after one, two and three years was noted. In an interim analysis one year after MIRPE, we observed patients with coated bars to have significantly elevated trace metal values compared to the control group. This elevation persisted throughout the observation period. Tissue metal values were also significantly increased. Irritative symptoms occurred significantly more often in study patients compared to controls (50.0% vs. 14.3%).

CONCLUSIONS

Coating of pectus bars with titanium nitride failed to reduce metal contamination after MIRPE. Instead, it resulted in a significant increase of trace metal levels after MIRPE, compared to patients with stainless steel bars, which may be explained by wear of the coating and inter-component mobilization processes.

Preoperative Metal Patch Testing and Titanium Bar Use Criteria in Nuss Procedure: A 56-Patients' Cohort Study

INTRODUCTION

 Nuss procedure is the main reason for metal implants use by pediatric and thoracic surgeons. There is an ongoing debate on how to avoid allergic complications. Herein we describe our 8-year experience with systematic preoperative metal patch testing and our selective titanium bar use in Nuss procedure.

MATERIALS AND METHODS

 This is a single center retrospective observational cohort study of patients who underwent the Nuss procedure from 2013 to 2020. Preoperative metal patch testing was done in all cases. Criteria for titanium bar utilization were: a positive test for a major component of the stainless-steel bar; or a positive metal patch test and a positive history of atopy, food or metal allergy, or previous allergic reaction to an implant or device.

RESULTS

 In total, 56 patients were included. Most were male (91.1%) with a median age of 15.0 (13.0-22.0) years old. 19.6% had a positive preoperative metal patch test and 54.5% of these had no personal history of atopy. Stainless-steel bars were used in 27.3% of those patients and titanium bars were used in 72.7%. One patient had a documented minor allergy reaction. None of the 56 patients required early bar removal.

CONCLUSION

 Our study suggests that routine preoperative allergy testing and a judicious use of titanium bar are safe and avoid metal allergic complications.

Nickel contamination after minimally-invasive repair of pectus excavatum persists after bar removal

BACKGROUND

Minimally-invasive repair of pectus excavatum (MIRPE) has been shown to be associated with high release of trace metals into patient's body. The aim of our study was to analyze the kinetics of metal contamination after MIRPE and after bar removal.

METHODS

We prospectively assessed nickel and chromium changes in blood, urine, and local tissue in patients undergoing MIRPE with stainless-steel bar(s). Baseline samples were taken prior to surgery, further samples were taken at six defined time points until 30 months after bar removal. Clinical symptoms were evaluated at the time of every sample collection.

RESULTS

28 patients were included (mean age 16.4 years). At four weeks after MIRPE and persisting up to bar removal, we found significantly elevated trace metal levels in blood and urine. Tissue nickel and chromium levels were significantly elevated at the time of bar removal. After bar removal, the concentration of trace metal in urine and the concentration of chromium in plasma decreased gradually. In contrast, nickel levels in blood further increased. Five patients showed irritative symptoms after MIRPE, all symptomatic patients had elevated metal levels.

CONCLUSIONS

Following MIRPE, we found a rapid systemic increase of nickel and chromium. Our data indicate that trace metal release could cause irritative symptoms. The prolonged elevated systemic nickel levels beyond bar removal necessitate further investigations of the long-term side effects of MIRPE.

Utility of routine patch testing prior to surgical repair of pectus excavatum: A multidisciplinary experience via retrospective review at a single tertiary care center

BACKGROUND

The Nuss procedure is the only implant procedure in which routine, rather than selective, preoperative patch testing is recommended. This practice has recently been called into question.

OBJECTIVE

To evaluate an updated experience of pre-implant patch testing in patients undergoing the Nuss procedure.

METHODS

A retrospective chart review of Nuss procedures from 2012 through 2020.

RESULTS

Forty-five patients were identified for data collection. From 2012 to 2014, none of the 14 patients were patch tested. From 2015 to 2020, 26 of 31 (83.9%) were patch tested. Of those tested, only 2 had a positive patch test. A hypoallergenic titanium bar was inserted in each case. In total, there were zero bar reactions.

CONCLUSION

The risks of patch testing are extremely small and should be weighed against the serious implications of even one bar allergy when deciding on future guidelines.

Case series of metal allergy following Nuss procedure: Not only for stainless steel bars

BACKGROUND

Pectus excavatum is often managed with the Nuss procedure. Metal allergies to pectus bars occur in 5% of patients, though pre-operative testing is not generally routine.

OBJECTIVES

This study describes our experience with pre-operative metal allergy testing and post-operative allergic reactions to pectus bars.

METHODS

A retrospective study of patients who underwent a Nuss procedure at our institution from 2010-2020 was performed. Patients with documented "metal" allergy, defined by the need for and positive response to steroid treatment and the absence of infection, were included. Data on patient characteristics and clinical course were analyzed.

RESULTS

Five of 204 patients (2.5%) identified developed allergic metal reactions. Three of five patients developed allergic reactions to titanium bars, with two requiring early removal of the bar (< 2-3 years). Four patients required more than one course of steroids, and three required debridements for skin breakdown. All patients have maintained good surgical correction at one- and three-years post removal.

CONCLUSIONS

Pectus bar metal allergies occur with both stainless steel and titanium bars. Properly selected patients for pre-operative Finn^Ⓡ Chamber testing may reduce the overall incidence of stainless-steel allergies but may miss titanium bar allergies. Early recognition and treatment of bar allergies may salvage the bar and avoid premature removal.

Metal allergy after the Nuss procedure for pectus excavatum: a review

Minimally invasive repair of pectus excavatum (MIRPE) technique (the Nuss procedure) is a minimally-invasive method that is commonly used in the treatment of pectus excavatum. An allergic reaction to the metal alloy bar that is implanted in the thorax during the procedure is a reported complication. We briefly review current literature concerning epidemiology, mechanisms and research results of allergic reactions after Nuss bar implantation. This allergic reaction occurs in approximately 2.7% of patients and is caused by metals used in the medical implant. The most common symptoms include fever and skin lesions such as allergic dermatitis. Elevated levels of C-reactive protein is a frequent finding in laboratory tests. In order to minimize the risk of such complications, taking a detailed allergy-based medical history and conducting allergy tests, i.e. patch test are required. Allergic reactions can be managed with conservative treatment such as general or topical glucocorticosteroid therapy and antihistamine agents. Severe allergic reactions can be addressed by implant revision, replacement of the steel bar with a titanium substitute or removal of the stabilization at all. Although the risk of an allergic reaction to titanium is smaller it still exists, the titanium substitute is not routinely used due to its higher cost and lesser plasticity which has a negative impact on matching a stabilizing bar during the surgery. Surgeons treating pectus excavatum should remember about the possible allergic reactions after implantation of the metal bar and be familiar with methods of diagnosis and treatment of those complications.

Nickel Allergic Contact Dermatitis: Identification, Treatment, and Prevention

Nickel is a ubiquitous metal added to jewelry and metallic substances for its hardening properties and because it is inexpensive. Estimates suggest that at least 1.1 million children in the United States are sensitized to nickel. Nickel allergic contact dermatitis (Ni-ACD) is the most common cutaneous delayed-type hypersensitivity reaction worldwide. The incidence among children tested has almost quadrupled over the past 3 decades. The associated morbidities include itch, discomfort, school absence, and reduced quality of life. In adulthood, individuals with Ni-ACD may have severe disabling hand eczema. The increasing rate of Ni-ACD in children has been postulated to result from early and frequent exposure to metals with high amounts of nickel release (eg, as occurs with ear piercing or with products used daily in childhood such as toys, belt buckles, and electronics).To reduce exposure to metal sources with high nickel release by prolonged and direct contact with human skin, Denmark and the European Union legislated a directive several decades ago with the goal of reducing high nickel release and the incidence of Ni-ACD. Since then, there has been a global reduction in incidence of Ni-ACD in population-based studies of adults and studies of children and young adults being tested for allergic contact dermatitis. These data point to nickel exposure as a trigger for elicitation of Ni-ACD and, further, provide evidence that legislation can have a favorable effect on the economic and medical health of a population.This policy statement reviews the epidemiology, history, and appearances of Ni-ACD. Examples of sources of high nickel release are discussed to highlight how difficult it is to avoid this metal in modern daily lives. Treatments are outlined, and avoidance strategies are presented. Long-term epidemiological interventions are addressed. Advocacy for smarter nickel use is reviewed. The American Academy of Pediatrics supports US legislation that advances safety standards (as modeled by the European Union) that protect children from early and prolonged skin exposure to high-nickel-releasing items. Our final aim for this article is to aid the pediatric community in developing nickel-avoidance strategies on both individual and global levels.

Patch Testing for the Evaluation of Metal Hypersensitivity in the Nuss Procedure

The Nuss procedure has become the predominant reason for the use of metal implants by pediatric general and thoracic surgeons. Current guidelines recommend preimplant testing for all patients undergoing the Nuss procedure, which differs from the guidelines for all other orthopedic procedures. This review was done to further evaluate this discrepancy.

Patch Testing for Evaluation of Hypersensitivity to Implanted Metal Devices: A Perspective From the American Contact Dermatitis Society

The American Contact Dermatitis Society recognizes the interest in the evaluation and management of metal hypersensitivity reactions. Given the paucity of robust evidence with which to guide our practices, we provide reasonable evidence and expert opinion-based guidelines for clinicians with regard to metal hypersensitivity reaction testing and patient management. Routine preoperative evaluation in individuals with no history of adverse cutaneous reactions to metals or history of previous implant-related adverse events is not necessary. Patients with a clear self-reported history of metal reactions should be evaluated by patch testing before device implant. Patch testing is only 1 element in the assessment of causation in those with postimplantation morbidity. Metal exposure from the implanted device can cause sensitization, but a positive metal test does not prove symptom causality. The decision to replace an implanted device must include an assessment of all clinical factors and a thorough risk-benefit analysis by the treating physician(s) and patient.

Selective versus routine patch metal allergy testing to select bar material for the Nuss procedure in 932 patients over 10years

AIM OF THE STUDY

The aim of the study was to determine the role of patch metal allergy testing to select bar material for the Nuss procedure.

METHODS

An IRB-approved (11-04-WC-0098) single institution retrospective, cohort study comparing selective versus routine patch metal allergy testing to select stainless steel or titanium bars for Nuss repair was performed. In Cohort A (9/2004-1/2011), selective patch testing was performed based on clinical risk factors. In Cohort B (2/2011-9/2014), all patients were patch tested. The cohorts were compared for incidence of bar allergy and resultant premature bar loss. Risk factors for stainless steel allergy or positive patch test were evaluated.

MAIN RESULTS

Cohort A had 628 patients with 63 (10.0%) selected for patch testing, while all 304 patients in Cohort B were tested. Over 10years, 15 (1.8%) of the 842 stainless steel Nuss repairs resulted in a bar allergy, and 5 had a negative preoperative patch test. The incidence of stainless steel bar allergy (1.8% vs 1.7%, p=0.57) and resultant bar loss (0.5% vs 1.3%, p=0.23) was not statistically different between cohorts. An allergic reaction to a stainless steel bar or a positive patch test was more common in females (OR=2.3, p<0.001) and patients with a personal (OR=24.8, p<0.001) or family history (OR=3.1, p<0.001) of metal sensitivity.

CONCLUSION

Stainless steel bar allergies occur at a low incidence with either routine or selective patch metal allergy testing. If selective testing is performed, it is advisable in females and patients with a personal or family history of metal sensitivity. A negative preoperative patch metal allergy test does not preclude the possibility of a postoperative stainless steel bar allergy.

LEVEL OF EVIDENCE

Level III Treatment Study and Study of Diagnostic Test.

Trace metal release after minimally-invasive repair of pectus excavatum

Background

Several studies have shown a high incidence of metal allergy after minimally-invasive repair of pectus excavatum (MIRPE). We postulated that MIRPE is associated with a significant release of trace metal ions, possibly causing the allergic symptoms.

Methods

We evaluated the concentration with chromium, cobalt and nickel in blood, urine and tissue in patients prior to MIRPE and in patients who underwent an explantation of the stainless-steel bar(s) after three years.

Results

Our study group consisted of 20 patients (mean age 19 years) who had bar explantation and our control group included 20 patients (mean age 16 years) prior to MIRPE. At the time of bar removal we detected significantly elevated concentrations of chromium and nickel in the tissue compared to patients prior to the procedure (p<0,001). We also found a significant increase in the levels of chromium in urine and nickel in blood in patients three years post MIRPE (p<0,001). Four patients temporarily developed symptoms of metal allergy, all had elevated metal values in blood and urine at explantation.

Conclusions

Minimally-invasive repair of pectus excavatum can lead to a significant trace metal exposure.

Patch Testing for Metal Allergy With Manufacturer-Supplied Materials Before Nuss Bar Insertion

INTRODUCTION

The increasing use of metal implantable devices has raised awareness of nickel allergy. Preoperative patch testing for patients with pectus excavatum (PE) with a known metal allergy or history of atopy is an accepted practice before the Nuss procedure. The Nuss bar manufacturer offers a metal disc for preoperative testing for metal sensitivities. However, the efficacy of this disc is not well understood.

OBJECTIVE

The purpose of this study was to determine the sensitivity of the metal disc in detecting nickel allergy compared with that of standard patch testing.

METHODS

Two PE patients were referred for preoperative patch testing with the metal disc to screen for metal allergy before the Nuss procedure. Based on our initial findings, 7 patients without PE scheduled for patch testing for the evaluation of chronic dermatitis were additionally tested with the metal disc if they were found to have risk factors for nickel allergy. All patch testing was performed according to set standards.

CONCLUSIONS

The metal disc may not be adequately sensitive to determine nickel allergy before the Nuss procedure. Patch testing alone with standard formulations of nickel sulfate in petrolatum may be more sensitive in diagnosing nickel allergy.

Allergy to Surgical Implants

Surgical implants have a wide array of therapeutic uses, most commonly in joint replacements, but also in repair of pes excavatum and spinal disorders, in cardiac devices (stents, patches, pacers, valves), in gynecological implants, and in dentistry. Many of the metals used are immunologically active, as are the methacrylates and epoxies used in conjunction with several of these devices. Allergic responses to surgical components can present atypically as failure of the device, with nonspecific symptoms of localized pain, swelling, warmth, loosening, instability, itching, or burning; localized rash is infrequent. Identification of the specific metal and cement components used in a particular implant can be difficult, but is crucial to guide testing and interpretation of results. Nickel, cobalt, and chromium remain the most common metals implicated in implant failure due to metal sensitization; methacrylate-based cements are also important contributors. This review will provide a guide on how to assess and interpret the clinical history, identify the components used in surgery, test for sensitization, and provide advice on possible solutions. Data on the pathways of metal-induced immune stimulation are included. In this setting, the allergist, the dermatologist, or both have the potential to significantly improve surgical outcomes and patient care.

Anaesthetic considerations for pectus repair surgery

Repair of pectus is one of the most common congenital abnormality for which patient presents for thoracic surgery. In recent years, innovative minimally invasive techniques involving video assisted thoracoscopy for pectus repair have become the norm. Similarly, anaesthetic techniques have evolved to include principles of enhanced recovery, multimodal analgesia and innovative ultrasound guided neuraxial and nerve blocks. Adequate anaesthetic set up and monitoring including the use of real time intraoperative monitoring with transesophageal echocardiography (TOE) has enabled the anaesthetist to enhance patient safety by providing instantaneous imaging of cardiac compression and complications during surgery. In this review article we aim to provide non-systematic review and institutional experience of our anaesthetic strategy to provide effective peri-operative care in this patient group.

High rates of metal allergy amongst Nuss procedure patients dictate broader pre-operative testing

PURPOSE

A previous study from our group estimated that as few as 2.2% of pectus excavatum patients suffered from allergy to the implanted metal bar. We sought to assess recent changes in incidence of metal allergy and identify the benefit of metal allergy testing prior to surgery.

METHODS

A retrospective review was performed of all consenting patients undergoing pectus repair during the six years between 9/2004 and 12/2010 at our institution. Incidence was based on clinical symptoms and/or T.R.U.E.® patch testing. Demographic data, history of atopy and history of metal allergy were collected. Type and number of bars used, suture site infection, skin rash and wound infection rates were reviewed.

RESULTS

Forty one of 639 patients (6.4%) had clinical or patch test evidence of metal allergy. Family history of metal allergy and pre-operative history of metal sensitivity were found to be statistically significant correlates.

CONCLUSIONS

The rate of metal allergy in the pectus excavatum population may be higher than previously reported. Patient or family history of metal allergy or metal sensitization may indicate increased risk. Metal allergy testing should be performed before Nuss procedure.

Systemic contact dermatitis and allergy to biomedical devices

Systemic contact dermatitis (SCD) refers to a skin condition where an individual who is cutaneously sensitized to an allergen will subsequently react to that same allergen or a cross-reacting allergen via the systemic route. It occurs to allergens including metals, medications, and foods. There has been recent interest in metal allergy as it relates to the implantation of devices such as orthopedic, dental, cardiac, and gynecologic implants. This review will briefly address all causes of systemic contact dermatitis with a special and expanded focus on metal implant allergy. We present literature on SCD to various metal biomedical devices, patch testing for diagnosis of metal allergy pre and post implantation and treatment.