Titanium allergy or not? "Impurity" of titanium implant materials

Thomas Harloff, Wolfgang Hönle, Ulrich Holzwarth, Rainer Bader, Peter Thomas, Alexander Schuh

.

DOI: 10.4236/health.2010.24045                

Abstract

For patients suffering from allergies to nickel, chrome and cobalt, titanium implants are the implants of choice. Nevertheless, titanium implant sensitivity has been reported in the form of “allergies” and an increasing number of patients are confused. This paper aims to use spectral analysis as a diagnostic tool for analyzing different titanium implant alloys in order to determine the percentage of the alloy components and additions that are known to cause allergies. Different materials, such as sponge titanium, TiAl6Nb7, Ti21SRx, TiAl6V4 [forged alloy], TiAl6V4 [cast alloy], TMZF, pure titanium [c. p. 1] and iodide titanium were analyzed for the presence of the elements that have been associated with allergic reactions using spectral analysis. All the implant material samples contained traceable amounts of Be, Cd, Co, up to a maximum of 0.001 percent by weight [wt.%], Cr up to 0.033 wt.%, Cu up to 0.007 wt.%, Hf up to 0.035 wt.%, Mn up to 0.007 wt.%, Ni up to 0.031 wt.%, and Pd up to 0.001 wt.%. This paper demonstrates that all the investigated implant material samples contained a low but consistent percentage of components that have been associated with allergies. For example, low nickel contents are related to the manufacturing pro- cess and are completely dissolved in the titanium grid. Therefore, they can virtually be classified as “impurities”. Under certain circumstances, these small amounts may be sufficient to trigger allergic reactions in patients suffering from the corresponding allergies, such as a nickel, palladium or chrome allergy.

Keywords

Allergy; Implant; Nickel; Spectral Analysis; Titanium

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	Banfield, C.C., Basketter, D.A. and Powell, S.M. (1998) Cutaneous reactivity of the hands in nickel-sensitive patients with hand eczema. Contact Dermatitis, 38, 316-318.
[2]	Baur, W., Hönle, W. and Schuh, A. (2005) Pathological findings in tissue surrounding revised metal/metal arti- culations. Der Orthopäde, 34, 225-233.
[3]	Benson, M.K., Goodwin, P.G. and Brostoff, J. (1975) Metal sensitivity in patients with joint replacement arthroplasties. British Medical Journal, 15, 374-375.
[4]	Campbell, P., Mirra, J., Doorn, P., Mills, B., Alim, R. and Catelas, I. (2001) Histopathology of metal-on-metal hip joint tissues. In Rieker Ed., World Tribology Forum in Arthroplasty, 167-180.
[5]	Carlsson, A.S., Magnusson, B. and Moller, H. (1980) Metal sensitivity in patients with metal-to-plastic total hip arthroplasties. Acta Orthopaedica Scandinavica, 51, 57-62.
[6]	Christiansen, K., Holmes, K. and Zilko, P.J. (1979) Metal sensitivity causing loosened joint prosthesis. Annals of Rheumatic Diseases, 38, 476-480.
[7]	Cramers, M. and Lucht, U. (1977) Metal sensitivity in patients treated for tibial fractures with plates of stainless steel. Acta Orthopaedica Scandinavica, 48, 245-249.
[8]	Davies, A.P., Willert, H.G., Campbell, P.A., Learmonth, I.D. and Case, C.P. (2005) An unusual lymphocytic perivascular infiltration in tissues around contemporary metal-on-metal joint replacements. The Journal of Bone and Joint Surgery-American Volome, 87, 18-27.
[9]	Doorn, P.F., Mirra, J.M., Campbell, P.A. and Amstutz, H.C. (1996) Tissue reaction to metal on metal total hip prostheses. Clinical Orthopaedics, 329 (Suppl.), S187- 205.
[10]	Duchna, H.W., Nowack, U., Merget, R., Muhr, G. and Schultze-Werninghaus, G. (1998) Prospective study of the significance of contact sensitization caused by metal implants. Zentralbl Chir, 123, 1271-1276.
[11]	Elves, M.W., Wilson, J.N., Scales, J.T. and Kemp, H.B. (1975) Incidence of metal sensitivity in patients with total joint replacements. British Medical Journal, 15, 376-378.
[12]	Gawkrodger, D.J. (2003) Metal sensitivities and ortho- paedic implants revisited: The potential for metal allergy with the new metal-on-metal joint prostheses. British Journal of Dermatology, 148, 1089-1093.
[13]	Goodman, S.B. (1996) Does the immune system play a role in loosening and osteolysis of total joint replace- ments? Journal of Long-Term Effects of Medical Impl- ants, 6, 91-101.
[14]	Hallab, N., Merritt, K. and Jacobs, J.J. (2001) Metal sensitivity in patients with orthopaedic implants. The Journal of Bone and Joint Surgery, 83-A(3), 428-436.
[15]	Hallab, N.J., Anderson, S., Stafford, T., Glant, T. and Jacobs, J.J. (2005) Lymphocyte responses in patients with total hip arthroplasty. Journal of Orthopaedic Surgery and Research, 23, 384-391.
[16]	Kaplan, K., Della Valle, C.J., Haines, K., et al. (2002) Preoperative identification of a bone-cement allergy in a patient undergoing total knee arthroplasty. The Journal of Arthroplasty, 17, 788-791.
[17]	Kubba, R., Taylor, J.S. and Marks, K.E. (1981) Cuta- neous complications of orthopedic implants. A two-year prospective study. Archives of Dermatology, 117, 554- 560.
[18]	McKenzie, A.W., Aitken, C.V. and Ridsdill-Smith, R. (1967) Urticaria after insertion of Smith-Petersen Vitallium nail. British Medical Journal, 4, 36.
[19]	Merritt, K. and Rodrigo, J.J. (1996) Immune response to synthetic materials. Sensitization of patients receiving or- thopaedic implants. Clinical Orthopaedics, 326, 71-79.
[20]	Munro-Ashman, D. and Miller, A.J. (1976) Rejection of metal to metal prosthesis and skin sensitivity to cobalt. Contact Dermatitis, 2, 65-67.
[21]	Schuh, A., Thomas, P., Holzwarth, U., Reinhold, R., Zeiler, G. and Mahler, V. (2006) Allergic reaction to com- ponents of bone cement after total knee arthroplasty. Zentralbl Chir, 131, 429-31.
[22]	Swiontkowski, M.F., Agel, J., Schwappach, J., McNair, P. and Welch, M. (2001) Cutaneous metal sensitivity in patients with orthopaedic injuries. Journal of Orthopaedic Trauma, 15, 86-89.
[23]	Thewes, M., Kretschmer, R., Gfesser, M., Rakoski, J., Nerlich, M., Borelli, S., et al. (2001) Immunohistochemcical characterization of the perivascular infiltrates cells in tissues adjacent to stainless steel implants compared with titanium implants. Archives of Orthopaedic and Trauma Surgery, 121, 223-226.
[24]	Thomas, P. (2003) Allergic reactions to implant materials. Der Orthopäde, 32, 60-64.
[25]	Thomas, P. (2006) Impaired fracture healing and eczema from titanium based osteosynthesis with corresponding T-cell hyperresponsiveness in vitro: A case of titanium hypersensitivity? Contact Dermatitis, 55, 199-202.
[26]	Thomas, P., Thomas, M., Summer, B., Naumann, T., San- der, C.A. and Przybilla, B. (2000) Intolerance of osteosynthesis material: Evidence of dichromate contact allergy with concomitant oligoklonal T-cell infiltrate and TH1-type cytokine expression in the peri-implantar tissue. Allergy, 55, 969-972.
[27]	Willert, H.G., Buchhorn, G.H., Fayyazi, A., Flury, R., Windler, M., Koster, G., et al. (2005) Metal-on-metal bearings and hypersensitivity in patients with artificial hip joints. A clinical and histomorphological study. The Journal of Bone and Joint Surgery-American Volome, 87, 28-36.
[28]	Willert, H.G., Buchhorn, G.H., Gobel, D., Koster, G., Schaffner, S., Schenk, R., et al. (1996) Wear behavior and histopathology of classic cemented metal on metal hip endoprostheses. Clinical Orthopaedics and Related Research, 329 (Suppl.), 160-186.
[29]	Gawkrodger, D.J. (1996) Nickel dermatitis: How much nickel is safe? Contact Dermatitis, 35, 267-271.
[30]	Kreibich, D.N., Moran, C.G., Delves, H.T., Owen, T.D. and Pinder, I.M. (2006) Systemic release of cobalt and chromium after uncemented total hip replacement. The Journal of Bone and Joint Surgery-British Volome, 78, 18-21.
[31]	Liden, C. and Norberg, K. (2005) Nickel on the Swedish market. Follow-up after implementation of the Nickel Directive. Contact Dermatitis, 52, 29-35.
[32]	Schuh, A., Thomas, P., Kachler, W., Göske, J., Wagner, L., Holzwarth, U., et al. (2005) Allergic potential of titanium implants. Der Orthopäde, 34, 327-333.
[33]	Farronato, G., Tirafili, C., Alicino, C. and Santoro, F. (2002) Titanium appliances for allergic patients. Journal of Clinical Orthopaedics, 36, 676-679.
[34]	Tan, M. and Suzuki, H. (1995) Usefulness of titanium implants for systemic contact dermatitis due to ortho- paedic prostheses. Contact Dermatitis, 33, 202.
[35]	Basketter, D.A., Whittle, E. and Monk, B. (2000) Possi- ble allergy to complex titanium salt. Contact Dermatitis, 42, 310-311.
[36]	Bircher, A.J. and Stern, W.B. (2001) Allergic contact dermatitis from “titanium” spectacle frames. Contact Dermatitis, 45, 244-245.
[37]	Breton, J.L., Louis, J.M. and Garnier, G. (1992) Asthma caused by hard metals: Responsibility of titanium. Presse Medicale Journal, 21, 997.
[38]	Lalor, P.A., Revell, P.A., Gray, A.B., Wright, S., Railton, G.T. and Freeman, M.A. (1991) Sensitivity to titanium. A cause of implant failure? The Journal of Bone and Joint Surgery-British Volome, 73, 25-28.
[39]	Matthew, I. and Frame, J.W. (1998) Allergic responses to titanium. Journal of Oral and Maxillofacial Surgery, 56, 1466-1467.
[40]	Mitchell, D.L., Synnott, S.A. and VanDercreek, J.A. (1990) Tissue reaction involving an intraoral skin graft and CP titanium abutments: A clinical report. The Inter- national Journal of Oral & Maxillofacial Implants, 5, 79-84.
[41]	Suhonen, R. and Kanerva, L. (2001) Allergic contact dermatitis caused by palladium on titanium spectacle frames. Contact Dermatitis, 44, 257-258.
[42]	Walsh, G. and Mitchell, J.W. (2002) Free surface nickel in CE-marked and non-CE-marked spectacle frames. Ophthalmic and Physiological Optics, 22, 166-171.
[43]	Yamauchi, R., Morita, A. and Tsuji, T. (2000) Pacemaker dermatitis from titanium. Contact Dermatitis, 42, 52-53.