Skip to main content

Advertisement

SpringerLink
Log in

Hypersensitivity reactions to metals in spine surgery

  • Review
  • Published:
MUSCULOSKELETAL SURGERY Aims and scope Submit manuscript

Abstract

Hypersensitivity to orthopedic devices is a rare condition with an underestimated incidence due to the lack of diagnostic guideline and ambiguous clinical manifestations. Although hypersensitivity to metal is common, a few cases of hypersensitivity reactions have been reported after spinal instrumentation. Spinal fusion and stabilization require a wide range of devices such as screws, wires, bands, and artificial disk replacement devices. Spinal instrumented surgeries are different from total joint arthroplasty in several aspects such as degree and pattern of motion, loading environment, and adjacent tissues with distinct characteristics. The interval for hypersensitivity reactions to occur after spinal metallic implantation is usually weeks to months. The present review covers the topic of hypersensitivity reactions that have been reported after spinal surgeries with the focus on cutaneous presentations.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Basketter D, Briatico-Vangosa G, Kaestner W, Lally C, Bontinck W (1993) Nickel, cobalt and chromium in consumer products: a role in allergic contact dermatitis? Contact Dermat 28(1):15–25

    Article  CAS  Google Scholar 

  2. Cramers M, Lucht U (1977) Metal sensitivity in patients treated for tibial fractures with plates of stainless steel. Acta Orthop Scand 48(3):245–249

    Article  CAS  PubMed  Google Scholar 

  3. Gawkrodger DJ (1993) Nickel sensitivity and the implantation of orthopaedic prostheses. Contact Dermat 28(5):257–259

    Article  CAS  Google Scholar 

  4. Hallab N, Merritt K, Jacobs JJ (2001) Metal sensitivity in patients with orthopaedic implants. JBJS 83(3):428

    Article  CAS  Google Scholar 

  5. Rutherford EE, Tarplett LJ, Davies EM, Harley JM, King LJ (2007) Lumbar spine fusion and stabilization: hardware, techniques, and imaging appearances. Radiographics 27(6):1737–1749

    Article  PubMed  Google Scholar 

  6. Golish SR, Anderson PA (2012) Bearing surfaces for total disc arthroplasty: metal-on-metal versus metal-on-polyethylene and other biomaterials. Spine J 12(8):693–701

    Article  PubMed  Google Scholar 

  7. Goodwin ML, Spiker WR, Brodke DS, Lawrence BD (2018) Failure of facet replacement system with metal-on-metal bearing surface and subsequent discovery of cobalt allergy: report of 2 cases. J Neurosurg Spine 29(1):81–84

    Article  PubMed  Google Scholar 

  8. Hallab N, Merritt K, Jacobs JJ (2001) Metal sensitivity in patients with orthopaedic implants. J Bone Jt Surg Am 83(3):428–436. https://doi.org/10.2106/00004623-200103000-00017

    Article  CAS  Google Scholar 

  9. Thyssen JP, Menné T (2010) Metal allergy–a review on exposures, penetration, genetics, prevalence, and clinical implications. Chem Res Toxicol 23(2):309–318. https://doi.org/10.1021/tx9002726

    Article  CAS  PubMed  Google Scholar 

  10. Merritt K, Rodrigo JJ (1996) Immune response to synthetic materials: sensitization of patients receiving orthopaedic implants. Clin Orthop Relat Res 1976–2007(326):71–79

    Article  Google Scholar 

  11. Teo WZW, Schalock PC (2017) Metal hypersensitivity reactions to orthopedic implants. Dermatol Ther Heidelb 7(1):53–64. https://doi.org/10.1007/s13555-016-0162-1

    Article  PubMed  Google Scholar 

  12. Christiansen K, Holmes K, Zilko PJ (1980) Metal sensitivity causing loosened joint prostheses. Ann Rheum Dis 39(5):476–480. https://doi.org/10.1136/ard.39.5.476

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  13. Milavec-Puretić V, Orlić D, Marusić A (1998) Sensitivity to metals in 40 patients with failed hip endoprosthesis. Arch Orthop Trauma Surg 117(6–7):383–386. https://doi.org/10.1007/s004020050272

    Article  PubMed  Google Scholar 

  14. Martz EO, Goel VK, Pope MH, Park JB (1997) Materials and design of spinal implants—a review. J Biomed Mater Res 38(3):267–288

    Article  CAS  PubMed  Google Scholar 

  15. Marcolongo M, Sarkar S, Ganesh N (2017) Trends in materials for spine surgery. In. pp 175–198. doi:https://doi.org/10.1016/B978-0-08-100691-7.00269-X

  16. Sicilia A, Cuesta S, Coma G, Arregui I, Guisasola C, Ruiz E, Maestro A (2008) Titanium allergy in dental implant patients: a clinical study on 1500 consecutive patients. Clin Oral Implant Res 19(8):823–835. https://doi.org/10.1111/j.1600-0501.2008.01544.x

    Article  Google Scholar 

  17. Müller K, Valentine-Thon E (2006) Hypersensitivity to titanium: clinical and laboratory evidence. Neuro Endocrinol Lett 27(Suppl 1):31–35

    PubMed  Google Scholar 

  18. Lalor P, Revell P, Gray A, Wright S, Railton G, Freeman M (1991) Sensitivity to titanium: a cause of implant failure. J Bone Jt Surg Br 73(1):25–28

    Article  CAS  Google Scholar 

  19. Towers WS, Kurtom K (2020) Rare systemic response to titanium spinal fusion implant: case report. Cureus 12(2):e7109. https://doi.org/10.7759/cureus.7109

    Article  PubMed  PubMed Central  Google Scholar 

  20. Liu YK, Njus GO, Bahr P, Geng P (1990) Fatigue life improvement of nitrogen-ion-implanted pedicle screws. Spine 15(4):311–317

    Article  CAS  PubMed  Google Scholar 

  21. Kokubo T, Yamaguchi S (2010) Novel bioactive titanate layers formed on Ti metal and its alloys by chemical treatments. Materials 3(1):48–63

    Article  CAS  Google Scholar 

  22. Ong KL, Lovald S, Black J (2014) Orthopaedic biomaterials in research and practice. CRC press

  23. Jacobs J (1994) Systemic distribution of metal degradation products from titanium alloy total hip replacements: an autopsy study. Transcripts of Orthopedic Research Society; 1994; New Orleans

  24. Kim J (2020) A rare case of delayed hypersensitivity reaction to metal ions secondary to a remnant pedicle screw fragment after spinal arthrodesis. Acta Orthop Traumatol Turc 54(4):461

    Article  PubMed  PubMed Central  Google Scholar 

  25. Black J (1984) Systemic effects of biomaterials. Biomaterials 5(1):11–18. https://doi.org/10.1016/0142-9612(84)90061-9

    Article  CAS  PubMed  Google Scholar 

  26. Shang X, Wang L, Kou D, Jia X, Yang X, Zhang M, Tang Y, Wang P, Wang S, Xu Y (2014) Metal hypersensitivity in patient with posterior lumbar spine fusion: a case report and its literature review. BMC Musculoskelet Disord 15(1):1–6

    Article  Google Scholar 

  27. Hallab NJ, Cunningham BW, Jacobs JJ (2003) Spinal implant debris-induced osteolysis. Spine 28(20):S125-138. https://doi.org/10.1097/00007632-200310151-00006

    Article  PubMed  Google Scholar 

  28. Warner GL, Lawrence DA (1988) The effect of metals on IL-2-related lymphocyte proliferation. Int J Immunopharmacol 10(5):629–637. https://doi.org/10.1016/0192-0561(88)90082-3

    Article  CAS  PubMed  Google Scholar 

  29. Wang JY, Tsukayama DT, Wicklund BH, Gustilo RB (1996) Inhibition of T and B cell proliferation by titanium, cobalt, and chromium: role of IL-2 and IL-6. J Biomed Mater Res 32(4):655–661. https://doi.org/10.1002/(sici)1097-4636(199612)32:4%3c655::aid-jbm19%3e3.0.co;2-c

    Article  CAS  PubMed  Google Scholar 

  30. Savarino L, Granchi D, Ciapetti G, Stea S, Donati ME, Zinghi G, Fontanesi G, Rotini R, Montanaro L (1999) Effects of metal ions on white blood cells of patients with failed total joint arthroplasties. J Biomed Mater Res 47(4):543–550. https://doi.org/10.1002/(sici)1097-4636(19991215)47:4%3c543::aid-jbm11%3e3.0.co;2-g

    Article  CAS  PubMed  Google Scholar 

  31. Kohilas K, Lyons M, Lofthouse R, Frondoza CG, Jinnah R, Hungerford DS (1999) Effect of prosthetic titanium wear debris on mitogen-induced monocyte and lymphoid activation. J Biomed Mater Res 47(1):95–103. https://doi.org/10.1002/(sici)1097-4636(199910)47:1%3c95::aid-jbm14%3e3.0.co;2-8

    Article  CAS  PubMed  Google Scholar 

  32. Ungersböck A, Pohler O, Perren SM (1994) Evaluation of the soft tissue interface at titanium implants with different surface treatments: experimental study on rabbits. Bio-Med Mater Eng 4(4):317–325

    Article  Google Scholar 

  33. Dujardin F, Fevrier V, Lecorvaisier C, Joly P (1995) Allergic dermatitis caused by metallic implants in orthopedic surgery. Rev Chir Orthop Reparatrice Appar Mot 81(6):473–484

    CAS  PubMed  Google Scholar 

  34. Thyssen JP, Linneberg A, Menné T, Johansen JD (2007) The epidemiology of contact allergy in the general population–prevalence and main findings. Contact Dermat 57(5):287–299. https://doi.org/10.1111/j.1600-0536.2007.01220.x

    Article  Google Scholar 

  35. Fyhrquist-Vanni N, Alenius H, Lauerma A (2007) Contact dermatitis. Dermatol Clin 25(4):613–623. https://doi.org/10.1016/j.det.2007.06.002

    Article  CAS  PubMed  Google Scholar 

  36. Bao W, He Y, Fan Y, Liao Y (2018) Metal allergy in total-joint arthroplasty: case report and literature review. Medicine 97(38):e12475. https://doi.org/10.1097/md.0000000000012475

    Article  PubMed  PubMed Central  Google Scholar 

  37. Akil S, Newman JM, Shah NV, Ahmed N, Deshmukh AJ, Maheshwari AV (2018) Metal hypersensitivity in total hip and knee arthroplasty: current concepts. J Clin Orthop Trauma 9(1):3–6

    Article  PubMed  Google Scholar 

  38. Richards LJ, Streifel A, Rodrigues JM (2019) Utility of patch testing and lymphocyte transformation testing in the evaluation of metal allergy in patients with orthopedic implants. Cureus. https://doi.org/10.7759/cureus.5761

    Article  PubMed  PubMed Central  Google Scholar 

  39. Schalock PC, Thyssen JP (2013) Patch testers’ opinions regarding diagnostic criteria for metal hypersensitivity reactions to metallic implants. Dermat Contact Atopic Occup Drug 24(4):183–185. https://doi.org/10.1097/DER.0b013e31829cb113

    Article  CAS  Google Scholar 

  40. Rosner GA, Fonacier LS (2017) Hypersensitivity to biomedical implants: prevention and diagnosis. Allergy Asthma Proc 38(3):177–183. https://doi.org/10.2500/aap.2017.38.4052

    Article  CAS  PubMed  Google Scholar 

  41. Pacheco KA (2019) Allergy to surgical implants. Clin Rev Allergy Immunol 56(1):72–85

    Article  PubMed  Google Scholar 

  42. Shi C, Xi Y, Sun B, He H, Wen J, Ruan Y, Ye X (2020) Suspected allergy to titanium after anterior cervical discectomy and fusion using a Zero-P device: a case report. Br J Neurosurg. https://doi.org/10.1080/02688697.2020.1718605

    Article  PubMed  Google Scholar 

  43. Lagier M, Briere M, Giorgi H, Fuentes S, Blondel B, Tropiano P (2015) Delayed hypersensitivity reaction after cervical disc replacement: a case report. Orthop Traumatol Surg Res 101(5):643–645

    Article  CAS  PubMed  Google Scholar 

  44. El Habony R, Binay Y, Petridis AK, Scholz M (2012) Allergy to implants in lumbar screw fixation mimics postsurgical wound infection. Acta Neurochir 154(10):1821–1823

    Article  PubMed  Google Scholar 

  45. Shang X, Wang L, Kou D, Jia X, Yang X, Zhang M, Tang Y, Wang P, Wang S, Xu Y, Wang H (2014) Metal hypersensitivity in patient with posterior lumbar spine fusion: a case report and its literature review. BMC Musculoskelet Disord 15(1):314. https://doi.org/10.1186/1471-2474-15-314

    Article  PubMed  PubMed Central  Google Scholar 

  46. Guyer RD, Shellock J, MacLennan B, Hanscom D, Knight RQ, McCombe P, Jacobs JJ, Urban RM, Bradford D, Ohnmeiss DD (2011) Early failure of metal-on-metal artificial disc prostheses associated with lymphocytic reaction: diagnosis and treatment experience in four cases. Spine 36(7):E492–E497

    Article  PubMed  Google Scholar 

  47. Zairi F, Remacle JM, Allaoui M, Assaker R (2013) Delayed hypersensitivity reaction caused by metal-on-metal total disc replacement: case report. J Neurosurg Spine 19(3):389–391

    Article  PubMed  Google Scholar 

  48. Willert H-G, Buchhorn GH, Fayyazi A, Flury R, Windler M, Köster G, Lohmann CH (2005) Metal-on-metal bearings and hypersensitivity in patients with artificial hip joints: a clinical and histomorphological study. JBJS 87(1):28–36

    Article  Google Scholar 

  49. Schalock PC, Crawford G, Nedorost S, Scheinman PL, Atwater AR, Mowad C, Brod B, Ehrlich A, Watsky KL, Sasseville D (2016) Patch testing for evaluation of hypersensitivity to implanted metal devices: a perspective from the American Contact Dermatitis Society. Dermat Contact Atopic Occup Drug 27(5):241–247

    CAS  Google Scholar 

  50. Elves MW, Wilson JN, Scales JT, Kemp HB (1975) Incidence of metal sensitivity in patients with total joint replacements. BMJ 4(5993):376–378. https://doi.org/10.1136/bmj.4.5993.376

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  51. Barranco VP, Soloman H (1972) Eczematous dermatitis from nickel. JAMA 220(9):1244

    Article  CAS  PubMed  Google Scholar 

  52. Halpin DS (1975) An unusual reaction in muscle in association with Vitallium plate: a report of possible metal hypersensitivity. J Bone Jt Surg Br 57(4):451–453

    Article  CAS  Google Scholar 

  53. Merle C, Vigan M, Devred D, Girardin P, Adessi B, Laurent R (1992) Generalized eczema from vitallium osteosynthesis material. Contact Dermat 27(4):257–258. https://doi.org/10.1111/j.1600-0536.1992.tb03259.x

    Article  CAS  Google Scholar 

  54. King L Jr, Fransway A, Adkins RB (1993) Chronic urticaria due to surgical clips. N Engl J Med 329(21):1583–1584. https://doi.org/10.1056/nejm199311183292121

    Article  PubMed  Google Scholar 

  55. Zielinski J, Lacy TA, Phillips JH (2014) Carbon coated implants as a new solution for metal allergy in early-onset scoliosis: a case report and review of the literature. Spine Deform 2(1):76–80. https://doi.org/10.1016/j.jspd.2013.09.002

    Article  PubMed  Google Scholar 

  56. Curley KL, Krishna C, Maiti TK, McClendon J, Bendok BR (2020) Metal hypersensitivity after spinal instrumentation: when to suspect and how to treat. World Neurosurg 139:471–477. https://doi.org/10.1016/j.wneu.2020.04.093

    Article  PubMed  Google Scholar 

  57. Rooker G, Wilkinson J (1980) Metal sensitivity in patients undergoing hip replacement: a prospective study. J Bone Jt Surg Br 62(4):502–505

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Skin Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran

    S. Dadkhahfar

  2. Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran

    M. Chehrassan

  3. Istituto Orthopedico Rizzoli, Bologna, Italy

    C. Faldini

Authors
  1. S. Dadkhahfar
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. M. Chehrassan
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. C. Faldini
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to M. Chehrassan.

Ethics declarations

Conflict of interest

The authors declare no conflict of interest.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Dadkhahfar, S., Chehrassan, M. & Faldini, C. Hypersensitivity reactions to metals in spine surgery. Musculoskelet Surg 107, 29–35 (2023). https://doi.org/10.1007/s12306-022-00765-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12306-022-00765-8

Keywords

Search

Navigation