Implant incompatibility (overview)L23.0 + T85.9

Mostly allergic type IV reactions to implant materials.

Adverse reactions to osteosynthesis implants: localized (in the implant area) or generalized eczema (see also hematogenous contact dermatitis), wound healing disorders, recurrent pain, effusions, implant loosening. The probability of acquiring cutaneous metal sensitization is significantly higher in patients with osteosynthesis implants than in the normal population (Hartmann 2016).

• Peri-implant erysipelas-like dermatitis: sharply defined redness over the implant, itching, no fever, no general signs of inflammation.
• Peri-implant contact allergic dermatitis: local implant complaints with recurrent pain, effusions, implant loosening. Dermatologically, scaly, itchy eczema lesions appear over the implant, which histologically prove to be spongiotic dermatitis.
• Post-implant generalized hematogenous contact allergic eczema with proven contact sensitization (chromium, cobalt, nickel).
• Peri-implant sarcoid granuloma: A few weeks to months after surgical arthroplasty, grouped or confluent red-brown sarcoid plaques develop over the implant site. Histologically, an eosinophilic granulomatous dermatitis is found.
• Peri-implant intralymphoid histiocytosis: Mostly painless, chronically persistent, non-pruritic, indistinctly circumscribed 1.0-5.0 cm, by confluence also larger, red or brownish patches, plaques or nodules. Isolated livedo-like patterns have also been described.
• Peri-implant reactive angioendotheliomatosis: purpuric plaques developing over the implant site (Hartmann 2016).

Adverse reactions after pacemaker implants:

• Pacemaker-induced postimplantation erythema: Not uncommon is the usually asymptomatic, etiologically unexplained pacemaker erythema or postimplantation erythema with telangiectasias (no tenderness, no hyperthermia). This occurs days or even months after implantation of the foreign material.
• Pacemaker-induced contact allergic eczema: Clinically, there are antibiotic-resistant wound healing disorders, local eczema, or hyperthermic inflammatory erythema over the affected implant sites. Type IV sensitizations involve: parylene, epoxy resins, polyurethanes, chromium salts, cobalt salts, mercury salts and very rarely silicones.

Contact allergic gastritis/rhinitis after application of a dental implant: Clinically, inflammatory local reactions develop around the implant (swelling, redness) as well as gastritic complaints. In most cases, costume jewellery sensitisation is known (Pföhler 2016).

Adverse implant reaction as a trigger of systemic nickel allergy syndrome (SNAS): see below. Nickel allergy

Allergic (type IV reactions to implant materials) and non-allergic reactions to an implant placed in the organism (osteosynthesis implants, pacemakers, dental implants, ocular and urological implants).

Osteosynthesis implants also involve allergic reactions to bone cement components (contact allergy to gentamycin, benzoyl peroxide or acrylates). From orthopaedic implants, metals such as nickel, cobalt, chromium can be released into the surrounding tissue either by corrosion or as abrasion particles. Accordingly, higher metal levels are found in blood and urine.

• Allergological history: evidence of possible IUV:
• Complications of previous procedures with osteosynthesis/implant materials
• Incompatibility of dental plastics (indication of possible contact allergy to acrylates and additives such as benzoyl peroxide)
• Problems with metal contact (e.g. fashion jewellery incompatibility)
• Results of allergy diagnostics already performed (allergy passport available?)
• Epicutaneous test with an extended "implant test series" (metals of the standard series: chromium, cobalt, nickel [possibly in the tear-off epicutaneous test]; additional metals: manganese, molybdenum, vanadium, titanium [possibly in the tear-off epicutaneous test]; bone cement series with acrylates and additives such as gentamicin and benzoyl peroxide).
• If possible: histological evaluation of the peri-implant reaction.
• Recommended procedure in case of mainly IUV:
• Patient with acute indication without time for allergological clarification:
• If possible, choose osteosynthesis materials made of a titanium alloy.
• Patient with elective indication and time for allergological clarification:
• no prophetic allergy test (ECT and/or LTT) if the allergological history is empty.
• an allergy test should only be performed if there are indications in the allergological history (see above)
• Patient with inserted endoprosthesis and with postoperative complaints:
• Primary: Exclusion of a periprosthetic infection as well as of mechanical causes, if the allergy test indicates a late type sensitization/allergy to inserted materials, a revision operation (changing the implant) is indicated.

Metal implants are being used more and more frequently in the industrialized countries. In 2015, 900,000 dental implants, 230,000 hip implants and 170,000 knee implants were used in Germany. Revision prostheses were present in about 10% of the patients. In an Australian register, about 7% of patients with revised, complicated hip prostheses were diagnosed as "metal sensitive".

Two months after a hip joint implant, an 80-year-old patient developed completely asymptomatic red to reddish brown, surface-smooth papules and plaques on the operated proximal thigh, which developed on an approximately 20 x 10 cm large erythema. A striking feature was an almost reticular arrangement of the lesions.

DD: Clinically the diagnosis was primarily a cutaneous B-cell lymphoma, but also a sarcoidosis or an unusual angiosarcoma.

Laboratory: Inconspicuous.

Histology: striking hyperplasia of the lymphatic vessels with perivascularly arranged dense mixed-cell infiltrates of lymphocytes, plasma cells and macrophages. Only moderate increase of the Ki-67 profiling factor, no atypia of the CD31+ and CD34+ endothelia. HHV-8 was not immunoreactive.

Diagnosis: Intralymphatic histiocytosis

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