symptoms of body rejecting surgical hardware

Hallab NJ, Caicedo M, Finnegan A, Jacobs JJ. 2008 Feb 13. Roughened, grit-blasted, or grooved surfaces increase the surface area available for ion release from the implant and thereby increase the local levels of dissolved metal. A review of the literature and report of three cases. [63] as a rule, testing can be considered in patients with known hypersensitivity reactions. 69 (1):62-6. Hypersensitivity to Orthopedic Implants: A Review of the Literature. Late onset infection can occur in some cases where you have some focus of infection causing bacteremia,and the sign symptoms include, redness. [43]. Eltit F, Noble J, Sharma M, Benam N, Haegert A, Bell RH, et al. Because this is a diagnosis of exclusion, cases are difficult to identify, given that the signs and symptoms are very similar to those of other, more frequent causes. 2021 Sep 1. William J Hopkinson, MD, FACS, FAAOS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Orthopaedic Association, American Orthopaedic Society for Sports Medicine, Illinois Association of Orthopaedic Surgeons, Illinois State Medical SocietyDisclosure: Nothing to disclose. Human immune systems mount the allergic attacks on metal ions through skin contacts, lung inhalation and metal-containing artificial body implants. Clin Implant Dent Relat Res. 14 (6):[QxMD MEDLINE Link]. However, the clinical significance of the allergy is controversial. Imaging Studies. The presenting signs and symptoms of a nickel or other metal hypersensitivity to an implanted orthopedic device are variable but usually consist of the expected complaints of a patient with hardware failure. [2]. J Clin Orthop Trauma. Likely possibilities that may need to be considered include internal/ external Hardware placed in the midfoot and forefoot may be prominent and may need to be replaced. Metal sensitivity as a cause of bone necrosis and loosening of the prosthesis in total joint replacement. Available at https://www.sciencedaily.com/releases/2014/10/141009153817.htm. What is difference between stuffing and dressing? Szliska C, Raskoski J. Sensitization to nickel, cobalt and chromium in surgical patients. Brown SA, Merritt K, Mayor MB. 24 (1):25-36. T and B lymphocytes in contact and atopic dermatitis. When an implant is rejected by the body, the device fails. [39] If the skin patch test finding is positive, the patient can be designated as allergic. Santavirta S, Konttinen YT, Bergroth V, Grnblad M. Lack of immune response to methyl methacrylate in lymphocyte cultures. Over the ensuing 3 months, the patient's pain increased to an unbearable level. [2] Properties of biomaterials that can be manipulated (osteoimmunomodulated) to promote a positive immune response include the following [3]. Svejgaard E, Morling N, Svejgaard A, Veien NK. My dr just told me today, in 5% of cases, once you start walking, the screw can cause problems with rubbing and he can take it out, but not until at least 6 months. Your skin has a natural barrier thats disrupted when it reacts to nickel and other allergens. J Bone Joint Surg Am. X-rays can also tell if the hardware has shifted in location or broken. J Am Acad Orthop Surg Glob Res Rev. Surveillance of Patients with Metal-on-Metal Hip Resurfacing and Total Hip Prostheses: A Prospective Cohort Study to Investigate the Relationship Between Blood Metal Ion Levels and Implant Failure. 1987 Dec. 69 (9):1408-12. However, over time when the swelling settles, hardware can become prominent and in some instances, may need to be removed. TimesMojo is a social question-and-answer website where you can get all the answers to your questions. [45, 47] : Silver ions are cytotoxic to both bacteria and neutrophils, decreasing the immune response to both the implant and the bacteria. Researchers at National Jewish Health have developed a nickel lymphocyte proliferation test [QxMD MEDLINE Link]. Ital J Orthop Traumatol. In patients with suspected titanium hypersensitivity skin prick testing should be considered to confirm the diagnosis if the patch test to titanium is negative. [57] However, the typical morphologic features of an immune inflammatory reaction, including loss of the surface synovial lining, fibrin deposits, and lymphocytes in diffuse and perivascular distributions, were not consistently present. 2017. Some people report instability or feeling like their hip is going to give out. [60]. WebSymptoms of body rejecting metal plate Scott would expect for the knee to become inflamed and quite sore around the plate, Veterinarian Dr, 22 of whom had a history of During the revision surgery, debridement to remove the infection may be Wawrzynski J, Gil JA, Goodman AD, Waryasz GR. 2021 Oct. 11:20-24. 2017 Jun. However, some patients will complain of achiness in the foot or ankle related to weather changes. Gordon PM, White MI, Scotland TR. [31], Whereas some authors have suggested that metal hypersensitivity may be associated with bone loss and aseptic loosening of implanted devices, Patients can present with localized dermatitis Knopf-Marques H, Singh S, Htwe SS, Wolfova L, Buffa R, Bacharouche J, et al. [QxMD MEDLINE Link]. Nonetheless, careful radiographic assessment of the implant is required. Please pass on my bad experience so others don't suffer. 75 (6):799-801. 2019 Feb. 56 (1):72-85. However, with some individuals and with some types of surgeries, symptoms may arise. An immune response can develop against nonmetallic components of implants as well. 30 (3):181-2. The confusion is a result of the presence of different metals in the implants, different manufacturing methods, small numbers of patients in the studies, nonspecific testing modalities, and a lack of definitive clinical guidelines for making the diagnosis. Top 10 Unproven Infertility Tests and Treatments, Immunotherapy With Radiotherapy Fails to Improve Prognosis of Patients With Stage IV Non-Small Cell Lung Cancer, Body Modifications: Dermatologic Reactions and Risks, New Biomaterial Vaccines Aim to Ward Off Future Pandemic Threats, UK Scientists Develop New Testing Method for Biomaterials. Koutalos et al found a correlation between patients with adverse reactions to metal debris (ARMD) and prosthesis cup position but no correlation with metal ion levels. Hip Int. [6] (See the image below.). [QxMD MEDLINE Link]. [63], Additionally, systemic contact dermatitis has been described when a patient becomes sensitized via the cutaneous route and cross-reacts systemically. When implants degrade or corrode, the immune system also responds to surface changes and degradation products. Computed tomography (CT) is not sensitive for diagnosing implant loosening but may help characterize the location and extent of the bone resorption when present. May 15, 2013; Accessed: April 5, 2022. The results were positive for an allergy to nickel sulfate (with >20 mm of erythema noted) but negative for chromium and cobalt. Clin Oral Implants Res. WebSearch for jobs related to Symptoms of body rejecting surgical hardware or hire on the world's largest freelancing marketplace with 22m+ jobs. Chir Organi Mov. Rostoker G, Robin J, Binet O, Blamoutier J, Paupe J, Lessana-Leibowitch M, et al. J Orthop Trauma. [49, 50, 3] Initially, osteoclast activation is important for removal of necrotic tissue and as the first step for bone remodeling around the implant. Use a cotton bud to rub gently observe the colour on the bud. In addition to the percentage of a particular metal contained within an alloy, the nature of the alloy and the local exposure of the implant are important. This includes infection due to the body rejecting the implant or hardware as well as failure of the hardware that is resulting in severe spinal instability. At day 6, 3H-thymidine uptake is measured by using liquid scintillation. Are children of working mothers more successful? All material on this website is protected by copyright, Copyright 1994-2023 by WebMD LLC. 2012 Jun. On exam, the hardware may be feltunder the skin. Dobbs HS, Minski MJ. [3] In the presence of an implant, a state of "frustrated phagocytosis" may develop, consisting of a mixed pro- and anti-inflammatory state that results in chronic inflammation. Pahlavan S, Hegde V, Bracey DN, Jennings JM, Dennis DA. Although prescreening all patients for metal hypersensitivity may be costly and its clinical relevance dubious, various specific laboratory tests, including the lymphokine migration inhibition factor (MIF) test, appear to be confirmatory. Alloys are graded on a scale that measures their metal ion release rate. 1996 May. Hardware removal is usually done because of problems caused by the implant, such as pain or infection. At the first site (right hip), complete healing occurred, and the patient remained asymptomatic after the device was removed. For many implants, this can be done under regional or local anesthesia (i.e., a nerve block), which means that you can stay awake (if you want) for the procedure and not feel anything. Acta Derm Venereol. 61-70. Dermatitis. [QxMD MEDLINE Link]. Swelling, pain, draining sinuses, and inflammation at the implant site may mimic infection. In most instances, it is either retained within the bone or is not particularly prominent with adequate covering of soft tissues. The test result is considered negative if the lymphocytes migrate away from the particular metal ion solution, indicating that they are not reacting to the dissolved metal. [QxMD MEDLINE Link]. 430-9. It's a site that collects all the most frequently asked questions and answers, so you don't have to spend hours on searching anywhere else. The fate of the implant depends on the immunomodulatory properties of the implant, [29, 4]. Most allergy skin patch tests that show skin reactivity have no clinical implications. [3] These two groups of cells communicate via cytokines, signaling molecules, transcription factors, and receptors. [64, 65, 13, 5] A positive result can occur in completely asymptomatic patients. 1977 Nov. 97 (5):537-41. Philadelphia: American Society for Testing and Materials; 1992. Four years later, the patient had an intertrochanteric fracture of the contralateral left hip and again underwent ORIF with a stainless steel device (Synthes DHS) (see the image below). [QxMD MEDLINE Link]. Surgery to remove metal implants is usually performed on an ambulatory or outpatient basis (i.e., go home the same day). [QxMD MEDLINE Link]. [52], Dendritic cells control immune responses against implanted materials. [QxMD MEDLINE Link]. [QxMD MEDLINE Link]. [63] Skin test results may not return to normal after metal removal. Activated platelets stimulate migration of monocytes, which differentiate into macrophages. BMC Musculoskelet Disord. For example, the nickel content in stainless steel may vary in the range of 9-15.5%, whereas in cobalt-base alloys, the nickel content is usually specified to be no greater than 1% (< 0.2% in actual practice), and titanium content is essentially 0%. [2]. Cobalt, copper, and chromium are also common culprits. Osteoimmunology and Future Implant Design, https://www.sciencedaily.com/releases/2014/10/141009153817.htm, http://njhealth.multimedia-newsroom.com/index.php/2013/05/15/new-blood-test-finds-allergies-before-implant-surgery/, Illinois Association of Orthopaedic Surgeons, Limb Lengthening and Reconstruction Society, American Association of Hip and Knee Surgeons, American Academy of Allergy, Asthma and Immunology, American Orthopaedic Society for Sports Medicine, Association of Medical Consultants of Mumbai, Sigma Xi, The Scientific Research Honor Society. The film has a strong inhibitory effect on the production of inflammatory cytokines released by macrophages 2008 Aug. 19 (8):823-35. Cystic changes, such as occur in osteolysis, may be seen (see the image below). Antibacterial surface treatment for orthopaedic implants. [QxMD MEDLINE Link]. Arthroplast Today. Hallab N, Jacobs JJ, Black J. Hypersensitivity to metallic biomaterials: a review of leukocyte migration inhibition assays. Research into the use of anti-immunogenic coatings on implants is promising. Pores allow vascularization and provide regulatory cues to the immune system, depending on their size and number. [58, 59] which leads to a cascade of cellular reactions (including activation of monocytes/macrophages, phagocytosis, and release of cytokines) that eventually lead to increased osteoclastic activity around the prosthesis. [63, 5, 19]. It involves measuring the proliferative response of T lymphocytes after activation. Akil S, Newman JM, Shah NV, Ahmed N, Deshmukh AJ, Maheshwari AV. J Bone Joint Surg Am. [QxMD MEDLINE Link]. 1995 Oct-Dec. 80 (4):399-408. Cobalt ions induce metabolic stress in synovial fibroblasts and secretion of cytokines/chemokines that may be diagnostic markers for adverse local tissue reactions to hip implants. Xie Y, Hu C, Feng Y, Li D, Ai T, Huang Y, et al. [QxMD MEDLINE Link]. [82], Implant properties may alter the amount of surface area available for metal ion release. Furthermore, after the implanted materials are removed, these signs and symptoms improve, and the MIF test result returns to normal. How do you know if your body is rejecting screws? Immune response to synthetic materials. Metal artifact reduction sequence (MARS) magnetic resonance imaging (MRI) can be used to visualize local soft-tissue reactions; serum tests are used for screening. Fraker A, Griffin C, eds. Blood levels of cobalt and chromium are typically 30 and 45 nmol/L, respectively, in unilateral well-functioning hip prostheses but increase to 6550 and 3400 nmol/L in failed prostheses. Some patients also complain of achiness in the foot or ankle related to weather changes. [6, 83], The usual course of events in patients demonstrating true postimplantation metal hypersensitivity is such that symptoms develop over months to years; this may be long after the device has accomplished the goal of fracture stability. However, with the large number of joint replacements performed yearly, the largest group of allergic reactions to implants consists of reactions to orthopedic implants. 1974 Nov. 56-B (4):626-42. Case example. [4]. Skin patch testing may therefore be unreliable. Unusual skin cancer linked to chronic allergy from metal orthopedic implant. The effect of patch testing on surgical practices and outcomes in orthopedic patients with metal implants. Demoly P, Michel F, Bousquet J. [48]. Local exposure of metallic surfaces also affects ion release and can be a factor in the development of hypersensitivity reactions secondary to an implant. [1, 3] Cardiac stents and patches are made of nitinol (an alloy of titanium and nickel). [4], The field of osteoimmunology focuses on the crucial involvement of both immune cells and bone cells in bone remodeling and the reaction of the host to foreign bodies, including orthopedic and other implants. [81] ; thus, the lymphokine MIF result couldbe negative in osteolysis. [QxMD MEDLINE Link]. Such strategies seek to develop new biomaterials that promote the positive aspects of acute inflammation. 2014. Apply wet compresses, which can help dry blisters and relieve itching. [1]. [13], Taking these factors into consideration, many of the manufacturers of these alloys and implants are striving to make them as resistant to breakdown as possible in the hope that by limiting the quantity of ions released, it may be possible to decrease the rate of sensitization. In some cases, you may be able to feel a plate or screw if there is very little muscle or soft tissue covering them for instance, along the outside of your ankle or the top of your hand. Allergy Considerations in Implanted Neuromodulation Devices. 2020 Jan. 30 (1):64-70. 1980 Feb. 51 (1):57-62. [QxMD MEDLINE Link]. Pacheco KA. [2], Surface charge changes the immune response. 3 (4):e023. Cha c sn phm trong gi hng. You can know your body is rejecting the implant by the signs and the symptoms of the metals hypersensitivities ranging from small and localized to even 2020 Jun. [2] : An immune response always occurs. 2021 Mar 11. Lachiewicz PF, Watters TS, Jacobs JJ. Titanium, molybdenum, and cobalt have low toxicity as compared with nickel and chromium, which can cause highly toxic intracellular changes. Symptoms of infected stitches. The area around the operated site becomes red and warm. Kie-Swierczynska M. Allergy to chromate, cobalt and nickel in Ld 1977-1988. Irrigation and debridement were performed, and the patient was treated with intravenous antibiotics until intraoperative cultures proved negative. 2015. [39] Nevertheless, they are commonly performed in the workup to rule out infection as the cause of the prosthesis failure. A skin rash may develop over the metal device but is not always present. [1], The American Contact Dermatitis Society has suggested testing before device implantation in patients with a clear history of metal reactions. sores and swelling in the soft tissues of the mouth. [68, 69, 70, 71, 72, 73] The technical sophistication and high expense of the LTT for implant-related metal sensitivity has limited its use; therefore, few conclusions can be drawn. [3] Larger pores decrease inflammation. Plasma-spray coatings and grouting agents limit exposure and decrease ion release from the implant. Nadim James Hallab, PhD is a member of the following medical societies: American Association of Immunologists, Orthopaedic Research Society, Sigma Xi, The Scientific Research Honor Society, Society for Leukocyte BiologyDisclosure: Received ownership interest from Orthopedic Analysis Inc for management position; Received ownership interest from Bioengineering Solutions Inc for management position. [44], Implanted pulse generators (eg, pacemakers, gastric stimulators, and neurostimulators) are made with stainless steel, titanium alloy, platinum, and iridium but also with epoxy resins, polymethylmethacrylates (PMMAs), and isocyanates, all of which may be immunogenic in some patients. [3] IL-10 is an anti-inflammatory cytokine that has a significant role in maintaining immune homeostasis and resolving inflammation. Correct diagnosis and recommendation for a specific surgical procedure are extremely important for follow-up surgery to ensure that symptoms and spinal instability are truly resolved. Painful Hardware is a possible side effect from metal screws and plates, which are often used in surgery to fix fractures, fuse joints, or stabilize bones. These concentrations increase in loose implants, but the significance of this increase is controversial. Certain foot and ankle operations have a higher rate of needing hardware removal than others. [40] This serves as a screening test for the possible presence of asymptomatic local soft-tissue reaction. [2, 49]. At 4-year follow-up, she had no further complaints or problems (see the second image below). McGough RL III, McMahon PH. An infection can occasionally be the cause of pain as well, so your surgeon will evaluate patients for this potential problem. [1], The incidence of metal allergies is rising in the general population, probably as a consequence of increased exposure to metal from piercings, jewelry, and internal medical devices or dental restorations. [19, 4, 5] especially with superficial implants such as plates at the ankle. Rheumatol Ther. [52] On the other hand, inhibition of inflammatory cytokines is also a powerful method for reducing inflammation, inhibiting osteoclastogenesis, and preventing osteolysis and implant loosening. [23] Hence, the lymphokine MIF may bethe most useful clinical test for diagnosis of hypersensitivity reaction to orthopedic implants. What are the Materials Metal Implants? Physical signs of implant failure (popping, squeaking or pain in the hip). J Leukoc Biol. Fujishiro et al identified an association between the extent of inflammation and the amount of visible metal particles and concluded that this relation implied the occurrence of an immune response to the metal. Arch Dermatol. Acta Biomater. [24], The issue of the clinical significance of sensitization to implanted metals has long been debated in the literature. Nevertheless, it is clear that specific osteomodulatory characteristics of the implant contribute. If you log out, you will be required to enter your username and password the next time you visit. [Full Text]. New blood test finds allergies BEFORE implant surgery. Goldring SR, Clark CR, Wright TM. Markel D, Bou-Akl T, Rossi M, Pizzimenti NM, Wu B, Ren WP. [QxMD MEDLINE Link]. [5] There is no indication for workup of asymptomatic patients with stable implants. Magnetic resonance imaging (MRI) with metal artifact reduction is recommended for symptomatic patients with metal-on-metal implants or asymptomatic patients with metal-on-metal implants with metal ion levels of 7 ppb or higher to evaluate the status of the implant. [4], In light of these contradicting studies, it is difficult for the orthopedic surgeon to make the diagnosis of symptomatic metal allergy with confidence. Why does metal in your body hurt when it rains? [QxMD MEDLINE Link]. J Bone Joint Surg Am. Can metal implants cause autoimmune disease? Brown A, Mandelberg NJ, Munoz-Mendoza D, Palys V, Schalock PC, Mogilner A, et al. Trans Soc Biomaterials. [QxMD MEDLINE Link]. 96 (13):1091-1099. [QxMD MEDLINE Link]. Use soothing lotions, such as calamine lotion, which may ease itching. [4] High chromium ion concentrations may be carcinogenic, and high cobalt ion concentrations may be both cardiotoxic and neurotoxic. WebHowever since surgery and more apparent 8 -10 weeks post surgery are the symptoms of rashing up in area of neck chest throat and site of plate, burning ears and throat, chronic pain in my neck and a feeling of burning and soreness in neck and spine. William J Hopkinson, MD, FACS, FAAOS Professor, Department of Orthopedic Surgery and Rehabilitation, Loyola University, Chicago Stritch School of Medicine; Chief of Joint Replacement Service, Department of Orthopedic Surgery, Loyola University Medical Center Contact Dermatitis. Clin Rev Allergy Immunol. A short time later, the patient had a fracture of the femoral neck during therapy. What are the side effects of having titanium in your body? Adkinson NF Jr, Bochner BS, Burks AW, Busse WW, Holgate ST, Lemanske RF JR, et al, eds. You may have just overdid it. The State of the Art and Prospects for Osteoimmunomodulatory Biomaterials. Metal ion release may also be due to surgical technique in patients with metal-on-metal prostheses. This patient received three different stainless steel devices at two different sites. Like Helpful Hug 5 Reactions Vol 1: 565-74. 8th ed. McMahon PH, Skinner HB, eds. Merritt K, Brown SA. 1989. Patients with known nickel allergy who require ORIF of fractures, for example, may be best treated with titanium implants when such devices are available. [QxMD MEDLINE Link]. Did you know our resouces can be found in. 2015 Dec. 98 (6):953-62. Also, the results depend on the experience of the person visually reading the skin reaction and may be influenced by medications, the quality of the antigens chosen, and the time of reading. Limited reactions can appear as a contact dermatitis on the skin that has been exposed to the metal. Patients that have previously had surgery to fix a fracture or to fuse a bone of the foot and ankle may have retained hardware that can become prominent and/or creates discomfort. [QxMD MEDLINE Link]. 469 (4):1127-33. Hip pain, groin pain, or thigh pain are all signs that your hip replacement could have an issue, although other referred pains can cause these symptoms too. However, patients with known symptomatic metal allergies do have poorer results. If this is not acceptable for symptom relief, then consideration should be given to removing the hardware after the fracture or fusion has fully healed. Early morning nausea. A course of anti-inflammatory medicines and steroid injections to the region relieved pain only briefly. Share cases and questions with Physicians on Medscape consult. 15 (3):173-90. In allergic reactions, there is a type IV delayed cell-mediated response. [4] Although skin patch testing does not predict the stability or failure of prostheses, failure rates of joint replacement have been shown to be four times higher in patients with symptomatic metal sensitivity than in those who did not have preoperative symptoms. [5]. Macrophage responses to implants: prospects for personalized medicine. Hi there! Rejection to the hardware is uncommon and generally would not just present with swelling alone. Likely possibilities that may need to be Nicholas M Brown, MD, FAAOS Assistant Professor, Department of Orthopedic Surgery, Loyola University Medical Center, Loyola University, Chicago Stritch School of Medicine Surgically implanted devices, prostheses, grafts, and fixation materials are commonly used for joint replacement, correction of spinal pathology, repair of fractures, treatment of cardiovascular pathology, and control of chronic pain. Metal screws and plates are often used in surgery to fix fractures, fuse joints, or stabilize bones that have been cut (osteotomies) in the foot and ankle. WebImmunocompromised due to medications or medical conditions. 1979. This test selectively detects lymphokine MIF, which, when present, does indicate an active immune response and metal sensitivity. Radiography demonstrated loosening and cutout of the hip lag screw, but the fracture was healing (see the image below). The results demonstrated increased uptake and lucency around the lag screw, indicative of hardware loosening. The symptoms can often be reproduced with motion of the joint or movement of nearby tendons. Chronic allergic contact dermatitis promotes skin cancer. [2, 3] Future implant design may depend on the relatively new specialty of osteoimmunology, with a shift in emphasis from immune "evasion" to immune "reprogramming." Panigutti MA, Merritt K, Bruner RJ, et al. Use of monosaccharides as a surface coating for implants could potentially hide the implant from the host immune response in a similar manner. 2022 - 2023 Times Mojo - All Rights Reserved 2021 Jul. Memory T helper cells identify patients with nickel, cobalt, and chromium metal allergy. [QxMD MEDLINE Link]. Philadelphia: Elsevier Saunders; 2014. Bull Hosp Joint Dis. [23] Acute symptoms in patients with multipart devices may be associated with periods of increased activity. [5]. [QxMD MEDLINE Link]. [QxMD MEDLINE Link]. [QxMD MEDLINE Link]. Pain around the site of orthopedic implants has many causes, and before blame can be assigned to metal sensitivity or allergy, a thorough investigation must occur. Accordingly, the patient underwent hardware removal 6 months after the initial implantation. [74, 76, 77] Such reports seem to indicate that the LTT, compared with dermal patch testing, may be equally well or better suited for the testing of implant-related sensitivity. Elves MW, Wilson JN, Scales JT, Kemp HB. An allergic reaction could occur at a most inopportune time. Evaluation of several immunological parameters in patients with aseptic loosening of hip arthroplasty. Final follow-up image after successful total hip replacement of the left hip. 269 Chestnut St. #271 Contact Dermatitis. Symptoms of a loose hip replacement include pain in the groin or upper thigh, new popping or clicking noises, joint instability, and dislocation or subluxation (partial dislocation) of the joint. [QxMD MEDLINE Link]. Despite the introduction of highly cross-linked polyethylene in the mid 2000s, decreasing the incidence, these are historically common causes of local reaction, bone resorption, pain, and implant loosening. Osteoimmunomodulatory effects of biomaterial modification strategies on macrophage polarization and bone regeneration. [QxMD MEDLINE Link]. The same incisions used for the original surgery are typically used for the removal procedure. Traditionally, skin patch testing has been the standard screening test for metal hypersensitivity; it is cost-effective and technically simple. [66] though a significantly higher prevalence (10-15%) in the general population has also been reported with nickel.

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