Hypersensitivity to orthopaedic implant manifested as erythroderma: Timing of implant removal

• Published in: International journal of surgery case reports 2018-01, Vol.49, p.110-114
• Main Authors: Phedy, Phedy, Djaja, Yoshi P., Boedijono, Dimas R., Wahyudi, Muhammad, Silitonga, Jamot, Solichin, Iman
• Format: Article
• Language: English
• Subjects: Implant allergy; Implant hypersensitivity; Implant removal
• ISSN: 2210-2612; 2210-2612
• DOI: 10.1016/j.ijscr.2018.06.011

•Implant hypersensitivity may manifest as a rare systemic dermatitis reaction.•Hypoallergenic implant revision is the gold standard in treating most hypersensitivity cases.•Delayed implant removal may be considered if its stability is not compromised.•Intermittent, low dose steroid is preferable to control the cutaneous lesion in long term regiment.•History of metal allergy should be obtained before choosing the appropriate implant. Incidence of hypersensitivity to orthopaedic implant, once estimated in less than 1% of population, recently has increased to 10%. Controversies about the timing of implant removal remain, especially due to the fact that implant hypersensitivity may be a contributing factor to implant failure. We present a case report and literature reviews to establish the decision making for the timing of implant removal in the presence of implant hypersensitivity. Female, 42 years old with nonunion of mid-shaft tibia and fibula which was treated with ORIF with conventional SAE16 stainless steel plate and bone graft. A week after, she developed a generalized rash, which is later diagnosed as erythroderma, that relapsed despite adequate systemic corticosteroid. Poor healing of surgical site wound were marked. After the implant removal, the cutaneous condition improved and no relapse were found. Management of hypersensitivity to implants involved corticosteroid administration, removal or replacement of implants, or implants coating with polytetrafluoroethylene. Currently there are no specific guidelines regulating the management of implant allergy based on the timing of the onset, especially in fracture cases. The decision-making would be straightforward if union was already achieved. Otherwise, controversies would still occur. In this paper, we proposed an algorithm regarding the steps in managing metal allergy due to implant in fracture cases. Despite the concerns regarding implant survival in hypersensitivity cases, the decision whether the implant should be removed or replaced should be based on the time and condition of the fracture healing process.