Metal ion release may also be due to surgical technique in patients with metal-on-metal prostheses. 61-70. 2013 Oct. 37 (10):1925-31. 4 (5993):376-8. Sampson B, Hart A. What is the difference between aphasia and frontotemporal dementia? 1979. Cell culture methods for testing biocompatibility. 2021 Mar 11. [52], Dendritic cells sense their local environment via pattern recognition receptors and transfer information on the nature of antigens to T cells in the lymph nodes, thereby regulating the immune response to the foreign body. 2016 Feb. 24 (2):106-12. [63]. Current Diagnosis and Treatment in Orthopaedics. Svejgaard E, Thomsen M, Morling N, Hein Christiansen AH. Trans Soc Biomaterials. 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. [62] but is also nonspecific. At day 6, 3H-thymidine uptake is measured by using liquid scintillation. [2]. 1977. 12:2995-3007. [52] The strength of this foreign body reaction is variable, and research continues into the question of why some patients have a more excessive response than others. [29, 37] and the concern that the immune environment and reactive immune cells are different in the musculoskeletal tissues versus the skin. [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. Baltazar Remigio R Espiritu, MD Associate Professor of Medicine and Pediatrics, Division of Allergy, Immunology, and Rheumatology, Loyola University Medical Center; Attending Physician, Loyola University Health System and Edward Hines, Jr, VA Hospital Eltit F, Noble J, Sharma M, Benam N, Haegert A, Bell RH, et al. However, if this is not satisfactory, patients may benefit from painful hardware removal once the fracture, fusion, or bone cut has fully healed. Dermatitis. Clin Rev Allergy Immunol. [QxMD MEDLINE Link]. When implants degrade or corrode, the immune system also responds to surface changes and degradation products. Allergy to Surgical Implants. 2014 Nov. 124 (11):5037-41. Are children of working mothers more successful? Severely high serum cobalt or chromium levels can lead to systemic symptoms, cardiotoxicity, neurotoxicity, and may induce chromosomal abnormalities. These coating substances can encourage attachment of host cells and a local immune response against the infectious organism [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. [QxMD MEDLINE Link]. 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 Although some studies have found sensitization to metal implants to be prevalent, Please pass on my bad experience so others don't suffer. How do you know if your body is rejecting screws? Metal ion release after total hip replacement. Goh CL. For example, an MRI study by Galea et al found that cobalt levels in the range of 2.9-3.2 ppb were associated with an increased risk of adverse local tissue reaction in patients who underwent metal-on-metal total hip arthroplasty or hip-resurfacing arthroplasty. Available at http://njhealth.multimedia-newsroom.com/index.php/2013/05/15/new-blood-test-finds-allergies-before-implant-surgery/. 2019 Feb. 477 (2):353-360. 269 Chestnut St. #271 [QxMD MEDLINE Link]. [5, 6, 17, 18, 19] It is thought that the immune system may become sensitized to the presence of a metal implant with a resultant increase the incidence of positive skin testing, though it is unclear how often this response is pathologic. [QxMD MEDLINE Link]. 30 (3):181-2. [QxMD MEDLINE Link]. 1987 Dec. 69 (9):1408-12. [3] These two groups of cells communicate via cytokines, signaling molecules, transcription factors, and receptors. Koutalos AA, Toms AP, Cahir JG, Smith EJ. The increasing frequency of metal allergies in the general population implies the potential need for prescreening of surgical patients to prevent possible allergic reactions to implants. Adult reconstructive surgery. Contact Dermatitis. WebSearch for jobs related to Symptoms of body rejecting surgical hardware or hire on the world's largest freelancing marketplace with 22m+ jobs. [4]. Can metal implants cause autoimmune disease? Allergy Considerations in Implanted Neuromodulation Devices. 2015 Sep 16. Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug ReferenceDisclosure: Received salary from Medscape for employment. 1994. Pores allow vascularization and provide regulatory cues to the immune system, depending on their size and number. Options for surgical treatment include the following: Revision joint replacement surgery in patients with metal-on-metal prostheses have worse outcomes with more complications when the revision is due to metal reactions Human immune systems mount the allergic attacks on metal ions through skin contacts, lung inhalation and metal-containing artificial body implants. Research into the use of anti-immunogenic coatings on implants is promising. Titanium, molybdenum, and cobalt have low toxicity as compared with nickel and chromium, which can cause highly toxic intracellular changes. However, some patients will complain of achiness in the foot or ankle related to weather changes. X-rays can also tell if the hardware has shifted in location or broken. Case example. Carando S, Cannas M, Rossi P, Portigliatti-Barbos M. The lymphocytic transformation test (L.T.T.) Accordingly, the patient underwent hardware removal 6 months after the initial implantation. The symptoms or signs of a rejected implant can be: systemic, meaning symptoms affecting the whole body; or; localized, meaning the affected area is limited to the area where the hernia mesh surgery was conducted (or the incision site). The test result is considered positive if the lymphocytes stay in the metal ion solution, indicating a cellular reaction to the metal dissolved in that solution. Nickel is one of the most frequent allergens, causing significant local contact dermatitis (skin reddening and itching). Can a trust deduct investment advisory fees in 2021? The authors used a lubricated surface micro/nanostructured implant in a rabbit model. Some patients also complain of achiness in the foot or ankle related to weather changes. Measures employed have included minimizing the use of metal-on-metal bearing surfaces, utilizing nickel-free bearing materials (eg, hardened titanium, ceramic, or ceramicized metal), eliminating modular necks in femoral prostheses, and utilizing ceramic rather than metal heads to reduce reactions at the trunnion of a stem. Significantly increased cytokine levels are found in patients with aseptic loosening of implants in comparison with levels at the initial surgical procedure. 7 (3):233-245. Adkinson NF Jr, Bochner BS, Burks AW, Busse WW, Holgate ST, Lemanske RF JR, et al, eds. The proliferation factor or stimulation index is calculated by using measured radiation counts per minute (cpm), as follows: The use of proliferation testing in the assessment of metal sensitivity has been well established as a method of testing metal sensitivity in a variety of clinical settings. TimesMojo is a social question-and-answer website where you can get all the answers to your questions. [79], Another in-vitro test that has shown promise in diagnosing metal hypersensitivity involves the use of MIF. [QxMD MEDLINE Link]. However, with some individuals and with some types of surgeries, symptoms may arise. Carlsson A, Mller H. Implantation of orthopaedic devices in patients with metal allergy. 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. In allergic reactions, there is a type IV delayed cell-mediated response. If your stitches have become infected, you may notice the following symptoms: redness or swelling around the stitches. The most common sign of hip replacement rejection is pain in the hip joint, although other symptoms, such as swelling and warmth around the joint, may also occur. 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. [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. 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. Organic biomaterials include natural and synthetic polymers, polysaccharides, and proteinsfor example, chitosan, glycosaminoglycans, hyaluronic acid, collagen, and silk. 24 (1):37-44. 469 (4):1127-33. 2020 Jan. 17 (1):41-56. These concentrations increase in loose implants, but the significance of this increase is controversial. [QxMD MEDLINE Link]. [QxMD MEDLINE Link]. 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. [29, 4]. [66]. Moisturize regularly. Acta Biomater. The clinical presentation of patients with metal implant reactions is often nonspecific. Your skin has a natural barrier thats disrupted when it reacts to nickel and other allergens. The results were positive for an allergy to nickel sulfate (with >20 mm of erythema noted) but negative for chromium and cobalt. 6th ed. J Bone Joint Surg Am. MRI scans are rarely useful for painful metal implants since metal causes artifact, which prevents visualization of neighboring tissues, or even the entire foot. Arch Dermatol. 2016 Nov 23. Newer strategies recognize the close biologic interactions between the skeletal cells and the immune cells. Metal sensitivity in patients undergoing hip replacement. [23] The systemic response to deep implants can occur acutely or many years later. [2], Bone marrow provides the same microenvironment for both bone and immune cells, where they share cellular signaling pathways to cooperate tightly in bone metabolism. [56] Some authors have considered the LTT to be the most reliable test, especially when it is combined with skin patch testing and cytokine detection. A review of the literature indicates that an allergic response to stainless steel is rare, although nickel is a common allergen and is encountered continually in daily life. The immune system modulates the osteoclastogenic process via three main cytokines, as follows: An increased RANKL-to-OPG ratio leads to enhanced osteoclast activity, accelerated bone resorption, and excessive bone loss. [50], An online study by Mesinkovska showed thatpreoperative skin patch testing for metal allergy changed treatment in 68% of 31 patients undergoing revision total joint replacement. Acta Biomater. Metal sensitivities among TJA patients with post-operative pain: indications for multi-metal LTT testing. An immune response to a surgically implanted medical device begins immediately. 1989. What is difference between stuffing and dressing? Proliferation factor = (mean cpm with treatment)/(mean cpm without treatment). WebRejection to the hardware is uncommon and generally would not just present with swelling alone. Sensitivity to implant materials in patients with total knee arthroplasties. In patients with suspected titanium hypersensitivity skin prick testing should be considered to confirm the diagnosis if the patch test to titanium is negative. Swelling around the knee because of infection and formation of pus. Whittingham-Jones PM, Dunstan E, Altaf H, Cannon SR, Revell PA, Briggs TW. Available at https://www.sciencedaily.com/releases/2014/10/141009153817.htm. What are the symptoms of titanium allergy? [3] Although technically metals, metal ions are often also included under the immune response to nonmetal implants. [QxMD MEDLINE Link]. Brown SA, Merritt K, Mayor MB. Chir Organi Mov. Hip replacements usually last at least 20 years. 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. ASTM STP 1144. [2], Metal ions have cytotoxic haptenic potential and have been presumed to induce an adverse reaction to metallic debris and a delayed-type hypersensitivity response. Evaluation and management of metal hypersensitivity in total joint arthroplasty: a systematic review. [QxMD MEDLINE Link]. Everness KM, Gawkrodger DJ, Botham PA, Hunter JA. [Full Text]. Fujishiro T, Moojen DJ, Kobayashi N, Dhert WJ, Bauer TW. [3] Larger pores decrease inflammation. The barometric pressure drops when storms are rolling in, and somehow, the body detects this change, causing swelling of soft tissue or expanding of joint fluid. Once the more common causes of implant failure have been excluded, the possibility of allergic reaction to the metal must be considered, evaluated, and treated. Contact Dermatitis. An infection can occasionally be the cause of pain as well, so your surgeon will evaluate patients for this potential problem. Some of the diseases researched in connection to metal devices include: Multiple sclerosis. Patients can present with localized dermatitis or rashes but also with systemic eczematous dermatitis. 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. First, make sure your jewelry is made of 14k, 18k, or 24k yellow gold or rose gold. Another disappointment as now the hardware is coming loose from the bones and is unstable/more painful. The fracture was radiologically healed, but because of the patient's unbearable pain, technetium bone scanning and tomography of the area were performed. Sicilia A, Cuesta S, Coma G, Arregui I, Guisasola C, Ruiz E, et al. swelling. Contact with blood activates the coagulation systems, the complement system, platelets, and immune cells, resulting in a thrombus at the interface that is the transient provisional matrix. 1990 Nov. 23 (5):325-30. Cystic changes, such as occur in osteolysis, may be seen (see the image below). Irrigation and debridement were performed, and the patient was treated with intravenous antibiotics until intraoperative cultures proved negative. [34, 35] Metal sensitivity may also be associated with chronic fatigue syndrome, fibromyalgia, and autoimmune syndromes. Int Orthop. 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. Adv Healthc Mater. Clin Orthop Relat Res. 1990 Oct. 23 (4):217-20. Acta Orthop Scand. Waterman AH, Schrik JJ. [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. For example, instead of the standard stainless steel fracture fixation devices, the surgeon can substitue titanium plates and screws in patients with known nickel allergy. [3] As stated by Alobaid et al, "[t]he ability to suppress adverse immune responses and promote beneficiary regulatory and pro-healing immune responses will improve the clinical outcome for implanted materials whether used as scaffolds for regenerative medicine applications or in medical devices." 14 (4):237-40. [5]. Wawrzynski J, Gil JA, Goodman AD, Waryasz GR. A change in shoes or modification of existing shoes may also be helpful. Unusual skin cancer linked to chronic allergy from metal orthopedic implant. [61] as compared with other modes of failure. [QxMD MEDLINE Link]. 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). WebCan surgical hardware rejection symptoms? Implant Wear in Total Joint Replacement: Clinical and Biologic Issues, Material and Design Considerations. The immune response to an implant can either be a true systemic hypersensitivity reaction or be caused by local damage from the implant. Systemic lupus erythematosus (Lupus). Bone Cement Hypersensitivity in Patients With a Painful Total Knee Arthroplasty: A Case Series of Revision Using Custom Cementless Implants. First stainless steel implant in the left hip. [1] with a foreign body reaction. 2007 Dec. 28 (34):5044-8. For example, implant-grade 316L (low-carbon) stainless steel releases far less nickel than low-grade stainless steel suture. 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. Acta Derm Venereol. [52], Dendritic cells control immune responses against implanted materials. 2019 Feb. 56 (1):72-85. Contact Dermatitis. Swelling, pain, draining sinuses, and inflammation at the implant site may mimic infection. Clin Orthop Relat Res. Memory T helper cells identify patients with nickel, cobalt, and chromium metal allergy. Biomaterials. The incorporation of the radioactive marker into cellular DNA on division facilitates quantification of a proliferation response through measurement of amassed radioactivity after of 3-6 days. [QxMD MEDLINE Link]. [36]. 2022 - 2023 Times Mojo - All Rights Reserved San Francisco CA 94123. Can a minor go to Mexico without a parent? They can include itching, redness, tenderness, swelling, and warmth to the exposed area. The septic joint near the implanted hardware. 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. WebCan surgical hardware rejection symptoms? 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. [QxMD MEDLINE Link]. If a hip replacement rejection is suspected, medical attention should be sought immediately so that the problem can be properly diagnosed and treated. McGough RL III, McMahon PH. [QxMD MEDLINE Link]. Metal sensitivity as a cause of bone necrosis and loosening of the prosthesis in total joint replacement. Philadelphia: Elsevier Saunders; 2014. https://profreg.medscape.com/px/getpracticeprofile.do?method=getProfessionalProfile&urlCache=aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvMTIzMDY5Ni1vdmVydmlldw==, Macrophage colony-stimulating factor (M-CSF), Receptor activator of NF-B ligand (RANKL). Clin Mater. Biomaterials. 2015 Dec. 98 (6):953-62. 17 (6):2189-98. Hardware placed in the midfoot and forefoot may be prominent and may need to be replaced. Very high ion concentrations (>7 parts per billion [ppb]) are considered an indication for advanced imaging. Occasionally prominent, non-absorbent sutures or other forms of retained surgical material may create symptoms but may not show up on x-rays. [QxMD MEDLINE Link]. Wright TM, Goodman SB, eds. Murali Poduval, MBBS, MS, DNB Orthopaedic Surgeon, Senior Consultant, and Subject Matter Expert, Tata Consultancy Services, Mumbai, India Metal hypersensitivity in total hip and knee arthroplasty: Current concepts. 1978. Nicholas M Brown, MD, FAAOS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Hip and Knee Surgeons, Mid-America Orthopaedic AssociationDisclosure: Nothing to disclose. [1] Patients with dermatitis are more likely to have an allergy to nickel allergy than an allergy to a different metal. Although this article focuses primarily on immune responses in patients with already implanted orthopedic devices, it is also worthwhile to note that efforts to prevent the pathologic reaction to an implant, by choosing alternative prostheses or fracture fixation implants during preoperative planning, should be considered in selected patients with known metal hypersensitivity. 2021 Jan. 53 (1):43-46. 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. Initially, this may be treated with shoe modifications, padding over the area, and simple measures to reduce the local swelling and inflammation. What kind of metal do they put in your body? New York: McGraw Hill; 2021. According to the National Institute of Health, allergic symptoms resulting from exposure to metals typically appear 24 to 48 hours after exposure. A negative immune response can lead to adverse pathology, including excessive inflammation, interference with healing, fibrous encapsulation, and implant [4, 63] Thus, many people who have skin reactivity to metals may never develop any reactivity at the site of a prosthesis composed of that metal. Arthroplast Today. [QxMD MEDLINE Link]. 96 (13):1091-1099. [QxMD MEDLINE Link]. Contact Dermatitis. fever. [50], The switch from M1 to M2 is regulated by immune cells, including T cells of various subsets, cytokines, and microRNAs (miRNAs). Lachiewicz PF, Watters TS, Jacobs JJ. Symptoms of infected stitches. Plasma-spray coatings and grouting agents limit exposure and decrease ion release from the implant. The symptoms can be due to a screw or plate that rubs against a boot, or pain may be produced when the tendon or soft tissue structure rubs against the prominent screw or plate. Share cases and questions with Physicians on Medscape consult. Image shows the right hip after the hardware was removed. [QxMD MEDLINE Link]. What Is the Clinical Presentation of Adverse Local Tissue Reaction in Metal-on-metal Hip Arthroplasty? Patients can present with localized dermatitis During the revision surgery, debridement to remove the infection may be J Bone Joint Surg Am. [QxMD MEDLINE Link]. Many of the same peri-operative risks apply for hardware removal, as for any surgical procedure. In a prospective cohort study that included 597 patients with metal-on-metal hip resurfacing and total hip prostheses, Hart et al found that elevated blood levels of metal (ie, chromium and cobalt) ions were associated with an increased risk of implant failure. 85 (1):7-16. Local inflammatory symptoms similar to the symptoms of infection are also possible, including warmth, erythema, and swelling over the implant, though systemic complaints (eg, fever) are unlikely. [43]. [64, 65, 13, 5] A positive result can occur in completely asymptomatic patients. [Full Text]. [2] According to Huber et al, the presence of corrosion products and a hypersensitivity reaction in patients suggests that there is a relation between corrosion and implant-related hypersensitivity. In most instances, these screws and plates do not create symptomsand remain permanently in the foot. Presence of stiffness in the knee that is more as compared to stiffness before the surgery. Two COVID-19--Related Myocarditis Phenotypes Emerge: What Is the Impact? Sensitivity to metal as a possible cause of sterile loosening after cobalt-chromium total hip-replacement arthroplasty. [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. Practitioners should have a low threshold for ordering advanced imaging, in that many of these patients are asymptomatic, and even low metal ion levels have been associated with local tissue reaction. Anionic/neutral particles decrease inflammatory reactions, whereas cations increase inflammation. Chir Organi Mov. [QxMD MEDLINE Link]. Huber M, Reinisch G, Trettenhahn G, Zweymller K, Lintner F. Presence of corrosion products and hypersensitivity-associated reactions in periprosthetic tissue after aseptic loosening of total hip replacements with metal bearing surfaces. It is likely that she did have a true metal sensitivity reaction causing clinical failure of hardware and disabling pain. Most allergy skin patch tests that show skin reactivity have no clinical implications. This website also contains material copyrighted by 3rd parties. Li T, Wang N, Chen S, Lu R, Li H, Zhang Z. Antibacterial activity and cytocompatibility of an implant coating consisting of TiO2 nanotubes combined with a GL13K antimicrobial peptide. [QxMD MEDLINE Link]. Dobbs et al reported a case where the patient had a metal-on-metal hip prosthesis on one side and a metal-on-plastic prosthesis on the other. Galea VP, Laaksonen I, Connelly JW, Matuszak SJ, Nortje M, Madanat R, et al. Regen Biomater. Patch testers' opinions regarding diagnostic criteria for metal hypersensitivity reactions to metallic implants. Santavirta S, Konttinen YT, Bergroth V, Grnblad M. Lack of immune response to methyl methacrylate in lymphocyte cultures. [39] Nevertheless, they are commonly performed in the workup to rule out infection as the cause of the prosthesis failure. loosening of the implants (or implant failure). Granchi D, Ciapetti G, Stea S, Cavedagna D, Bettini N, Bianco T, et al. 1994 Mar. [63], Phase-contrast and laser scan confocal microscopy (LSCM) is another method of quantifying the number of positive cells involved in the immune reaction. Donati ME, Savarino L, Granchi D, Ciapetti G, Cervellati M, Rotini R, et al. There may be a bursa (fluid filled sac of tissue) or an area of inflammation associated with the area. [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. [QxMD MEDLINE Link]. 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. Furthermore, after the implanted materials are removed, these signs and symptoms improve, and the MIF test result returns to normal. [4] Nonmetallic materials can be organic or inorganic. These peptides are biocompatible with macrophages and neutrophils. [5] Coating substances in use include the following [QxMD MEDLINE Link]. However, local symptoms, squeaking, or high acetabular version or inclination may also indicate the need for advanced imaging. [QxMD MEDLINE Link]. However, in some cases, small amounts of nickel does make their way into rose gold and yellow gold alloys. Use of monosaccharides as a surface coating for implants could potentially hide the implant from the host immune response in a similar manner. While most retained hardware is asymptomatic, some patients will develop symptoms. The body can reject plates and screws as your body has no material, but titanium as a biomaterial for implants and PEEK is safe and has few complaints so far. They use this type of metal because it is the least [82], Implant properties may alter the amount of surface area available for metal ion release. A short time later, the patient had a fracture of the femoral neck during therapy. X-rays will reveal the hardware if it is metal (most screws are Ann Clin Biochem. [1] All implanted materials can be recognized by the patient's immune system as foreign bodies causing cellular and tissue immune responses. [63] The main limitation of this test is that a positive result is not indicative of a true hypersensitivity but must be considered in the context of a patient's medical history and physical findings.

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