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Impaired Wound-Healing, Local Eczema, and Chronic Inflammation Following Titanium Osteosynthesis in a Nickel and Cobalt-Allergic PatientA Case Report and Review of the Literature
Peter Thomas, MD1; Manfred Thomas, MD2; Burkhard Summer, PhD1; Karin Dietrich, MD1; Melanie Zauzig3; Erwin Steinhauser, PhD3; Veit Krenn, MD4; Hans Arnholdt, MD5; Michael J. Flaig, MD1
1 Department of Dermatology and Allergology, Ludwig-Maximilians-University Munich, Frauenlobstrasse 9-11, D-80337 Munich, Germany. E-mail address for P. Thomas: Peter.Thomas@med.uni-muenchen.de
2 Department of Foot Surgery, Hessingpark-Clinic, Hessingstrasse 17, 86199 Augsburg, Germany
3 Department of Precision- and Micro-Engineering/Engineering Physics, Munich University of Applied Sciences, Lothstrasse 34, 80335 Munich, Germany
4 Centre for Histology, Cytology and Molecular Diagnostic, Mac-Planck-Strasse 18, 54296 Trier, Germany
5 Institute of Pathology, City Hospital, Stenglinstrasse 2, 86156 Augsburg, Germany
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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

Investigation performed at the Department of Dermatology and Allergology, Ludwig-Maximilians-University Munich, Munich; the Department of Precision- and Micro-Engineering/Engineering Physics, Munich University of Applied Sciences, Munich; the Department of Foot Surgery, Hessingpark-Clinic, Augsburg; and the Institute of Pathology, Augsburg, Germany

Copyright © 2011 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2011 Jun 01;93(11):e61 1-5. doi: 10.2106/JBJS.J.00317
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Patients known to develop allergic reactions to nickel (Ni), cobalt (Co), or chromium (Cr) often develop eczema in association with items of daily use such as jewelry, earrings, or watchbands. The overall sensitization rates to these metals may range between 1.1% (chromium) and 13% (nickel) in the general population, with further differences based on age and sex1. Chromium-cobalt alloys and stainless steel are widely used as orthopaedic implants and may release nickel, chromium, or cobalt into the surrounding tissues as a consequence of either wear or corrosion2. Some patients with a metal allergy may develop dermatitis in association with orthopaedic implants, and the prevalence of dermal sensitivity in patients with a joint replacement, particularly a failed implant, is higher than that in the general population3. Metal sensitivity rates to nickel, cobalt, or chromium may be as high as 43% in orthopaedic patients with well-functioning implants and as high as 71% in patients with poorly functioning implants3. In contrast, because of their excellent biocompatibility, titanium (Ti)-based materials are not considered to provoke allergic reactions. Our patient developed eczema and impaired wound-healing following the fixation of an ankle fracture with titanium-based implants. Histological analysis of the tissue around the implant demonstrated inflammation primarily with lymphocytes, and a contact allergy to nickel and cobalt was found in the absence of titanium hyperreactivity, raising the question of a prior unknown nickel exposure as the source of the complications. The patient was informed that data concerning this case would be submitted for publication, and she consented.
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