These earlier strategies focused almost solely on the osseous cells (osteoblasts and osteoclasts) in preventing implant failure. 59 (2):164-8. Metal sensitivities among TJA patients with post-operative pain: indications for multi-metal LTT testing. MRI scans are rarely useful for painful metal implants since metal causes artifact, which prevents visualization of neighboring tissues, or even the entire foot. WebThe most common symptoms associated with loosening or instability in the hip or knee joint include: pain, popping or clicking sound, sensation that your joint is moving in and out of its socket, partial hip dislocation (sublaxation), full hip dislocation, sensation of your knee giving out when you put weight on it, or 1977 Mar. October 9, 2014; Accessed: April 5, 2022. It is not considered a toxic metal but it is a heavy metal and it does have serious negative health effects. The surface of a biomaterial is the interface with the biologic microenvironment and determines the host response to the implant. Lymphocyte transformation in vitro in dermatophytosis. Knopf-Marques H, Singh S, Htwe SS, Wolfova L, Buffa R, Bacharouche J, et al. Incidence of metal sensitivity in patients with total joint replacements. The discrimination between nickel-sensitive and non-nickel-sensitive subjects by an in vitro lymphocyte transformation test. Titanium allergy in dental implant patients: a clinical study on 1500 consecutive patients. The metals most commonly reported with positive preoperative skin test results before revision knee or hip replacement where metal hypersensitivity is diagnosed are nickel (52%), palladium (32%), gold (23%), and cobalt (19%); patients may be allergic to more than one metal. [49, 50, 2, 3] ; these macrophages release proinflammatory mediators such as interleukin (IL)-1, IL-6, IL-16, and tumor necrosis factor (TNF)- Nixon RL, Diepgen T. Contact dermatitis. Expert Rev Med Devices. [QxMD MEDLINE Link]. [QxMD MEDLINE Link]. [63] Skin test results may not return to normal after metal removal. BMC Musculoskelet Disord. Contact Dermatitis. When should surgical hardware be removed? Clin Orthop Relat Res. Nickel-associated delayed multiple white matter lesions after stent-assisted coil embolization of intracranial unruptured aneurysm. [5]. The consequences can be simple annoyances to life-threatening systemic illness. Please pass on my bad experience so others don't suffer. These peptides are biocompatible with macrophages and neutrophils. 2016 Feb. 24 (2):106-12. 2017 Jun. [66] though a significantly higher prevalence (10-15%) in the general population has also been reported with nickel. [62] but is also nonspecific. 1974 Nov. 56-B (4):626-42. Use a cotton bud to rub gently observe the colour on the bud. [2]. However, because such a reaction is a diagnosis of exclusion, definitive proof is difficult to achieve. 49 (Pt 2):118-31. 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. 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%. Case example. [3] These two groups of cells communicate via cytokines, signaling molecules, transcription factors, and receptors. X-rays will reveal the hardware if it is metal (most screws are 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. Some patients also complain of achiness in the foot or ankle related to weather changes. [2] : An immune response always occurs. Activated platelets stimulate migration of monocytes, which differentiate into macrophages. Goh CL. [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. Although some studies have found sensitization to metal implants to be prevalent, [3] IL-10 is an anti-inflammatory cytokine that has a significant role in maintaining immune homeostasis and resolving inflammation. 1985 Dec. 11 (4):475-81. Biomaterials. [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. 26 (5):279-294. 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. The patient had positive nickel sensitivity, as shown on both skin patch testing and lymphokine MIF testing, and negative culture results with no clinical evidence of infection. 1975 Nov 15. [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. Chronic allergic contact dermatitis promotes skin cancer. The causes of these skin immunologic reactions are unclear. Physical signs Image shows the right hip after the hardware was removed. 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. Patients with hardware for fractures have symptoms of nonunion, including pain and motion at the fracture site. [1] Patients with dermatitis are more likely to have an allergy to nickel allergy than an allergy to a different metal. After skin patch testing, in-vitro lymphocyte proliferation testing is perhaps the most prevalent method of assessing hypersensitivities. (In other words, with a positive result, no migration occurs.) chronic inflammation in the gums around the implant. You may have just overdid it. Traditional blood tests are not useful in the work-up of immune response to implants. Titanium has the ability to affect lung function causing lung diseases such as pleural disease, it can cause chest pain with tightness, breathing difficulties, coughing, irritation of the skin or eyes. [45, 46] has prompted the development of multiple types of coatings on implants in order to discourage bacterial adhesion, prevent biofilm formation, or kill bacteria directly. What is difference between stuffing and dressing? 1993 Jun. [2, 49]. Polyelectrolye multilayer films from hyaluronic acid have been developed, with good early experimental results. [QxMD MEDLINE Link]. https://www.verywellhealth.com/can-i-be-allergic-to-a-metal-implant-2549668 85 (1):7-16. Rheumatol Ther. Clinical usefulness of blood metal measurements to assess the failure of metal-on-metal hip implants. [QxMD MEDLINE Link]. Given the false-positive results of skin patch testing, blood samples were sent for MIF testing, which later confirmed nickel hypersensitivity (personal communication, Katharine Merritt, PhD, US Food and Drug Administration Office of Science and Technology). Please confirm that you would like to log out of Medscape. Waterman AH, Schrik JJ. [3] M1 proinflammatory macrophages arrive as part of the initial inflammatory response The following tests are more difficult to obtain because many clinical laboratories do not run them. How do you know if your body is rejecting surgical hardware? When implants degrade or corrode, the immune system also responds to surface changes and degradation products. Contact Dermatitis. 75 (6):799-801. Hip replacements usually last at least 20 years. J Am Acad Orthop Surg. [QxMD MEDLINE Link]. 1990 Oct. 23 (4):217-20. 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. Clin Mater. 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. Patients with joint replacements typically have symptoms of loosening, including pain and instability. Fraker A, Griffin C, eds. Hypersensitivity Reactions to Implanted Metal Devices: Facts and Fictions. 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. 1980 Oct. 1 (4):193-8. Considerations of allergy and mechanics in the selection of orthopaedic implant materials [proceedings]. [63], Phase-contrast and laser scan confocal microscopy (LSCM) is another method of quantifying the number of positive cells involved in the immune reaction. Carbohydrates attached to tumor cells modulate dendritic cell function, switching them from inflammatory to tolerogenic; this hides the tumor from the host immune response. [3] : Surface topography can stimulate immune cell functions in such a way as to provide a favorable osteoimmune environment for bone incorporation. Evaluation and management of metal hypersensitivity in total joint arthroplasty: a systematic review. In the rare case where a patient displays symptoms such as recurrent pain and aseptic loosening related to implanted hardware, the differential diagnosis of metal hypersensitivity should be considered. [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. J Investig Allergol Clin Immunol. 2008 Dec. 23 (8):1212-8. Patients can present with localized dermatitis 1990 Apr. A prospective study. Everness KM, Gawkrodger DJ, Botham PA, Hunter JA. 29 (10):1494-500. 3:6. [44], Components of bone cement that can be immunogenic include acrylates, benzoyl peroxide, toluidine, and antibiotics. Rejection of surgical hardware is very rare. Allergy in hip arthroplasty. 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). Certain foot and ankle operations have a higher rate of needing hardware removal than others. Patients can present with localized dermatitis or rashes but also with systemic eczematous dermatitis. Allergy to Surgical Implants. 20 (2):89-94. Int Orthop. Br J Dermatol. 48 (3):245-9. Antibacterial infection and immune-evasive coating for orthopedic implants. Dobbs HS, Minski MJ. [2] This matrix is rich in growth factors, cytokines, and matrix metalloproteinases, which promote the immune response and recruit neutrophils. They can include itching, redness, tenderness, swelling, and warmth to the exposed area. Secher L, Svejgaard E, Hansen GS. [4] Bone cement hypersensitivity can be challenging, and revision using cementless procedures does not guarantee relief of presenting symptoms. For example, implant-grade 316L (low-carbon) stainless steel releases far less nickel than low-grade stainless steel suture. 24 (1):25-36. Brown SA, Merritt K, Mayor MB. [39] Although Carossino et al recommended routine skin patch testing with confirmatory LTT as a standard procedure for decreasing the potential for allergy-related complications in patients undergoing arthroplasty, J Bone Joint Surg Br. [39] After placement of metal implants, sensitization (ie, a change from a negative result to a positive one) occurs in 2.7% of cases for chromium, 3.8% for nickel, and 3.8% for cobalt. [3] Although technically metals, metal ions are often also included under the immune response to nonmetal implants. 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. [80] Cement wear particles are immunologically inert and have specifically been found not to cause a lymphocyte response in vitro Monitoring chromium and cobalt concentrations has been suggested for all patients with metal-on-metal hip replacement bearing surfaces, but particularly for those who are symptomatic. WebImmunocompromised due to medications or medical conditions. Although the focus of this review is on orthopedic implants, the immune pathologic response is also relevant for cardiac, vascular, gastric, and other surgical implants. [3, 2]. Atanaskova Mesinkovska N, Tellez A, Molina L, Honari G, Sood A, Barsoum W, et al. How do I know if Im allergic to stainless steel? loosening of the implants (or implant failure). Occasionally prominent, non-absorbent sutures or other forms of retained surgical material may create symptoms but may not show up on x-rays. [40] In clinical practice, the common cutoff to indicate further testing is 7 ppb. The signs and symptoms of failure are as follows: Severe and unbearable pain in the operated knee joint. Sensitivity to metal as a possible cause of sterile loosening after cobalt-chromium total hip-replacement arthroplasty. [50], The switch from M1 to M2 is regulated by immune cells, including T cells of various subsets, cytokines, and microRNAs (miRNAs). Significantly increased cytokine levels are found in patients with aseptic loosening of implants in comparison with levels at the initial surgical procedure. Metal artifact reduction sequence (MARS) magnetic resonance imaging (MRI) can be used to visualize local soft-tissue reactions; serum tests are used for screening. [QxMD MEDLINE Link]. [29, 4]. The State of the Art and Prospects for Osteoimmunomodulatory Biomaterials. 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. The fracture was radiologically healed, but because of the patient's unbearable pain, technetium bone scanning and tomography of the area were performed. Szliska C, Raskoski J. Sensitization to nickel, cobalt and chromium in surgical patients. [QxMD MEDLINE Link]. Two COVID-19--Related Myocarditis Phenotypes Emerge: What Is the Impact? [4, 63, 39] most likely secondary to corrosion or bearing wear of the implant. This test selectively detects lymphokine MIF, which, when present, does indicate an active immune response and metal sensitivity. [1, 2, 3]. These include: FootEducation LLC Applying diagnostic criteria may be useful in guiding the decision making process when faced with symptomatic or failing devices. What are the side effects of having titanium in your body? Albrektsson T, Becker W, Coli P, Jemt T, Mlne J, Sennerby L. Bone loss around oral and orthopedic implants: An immunologically based condition. 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. If a hip replacement rejection is suspected, medical attention should be sought immediately so that the problem can be properly diagnosed and treated. A review of the literature and report of three cases. [6, 17, 18, 19] others have taken an opposing viewpoint, concluding not only that hypersensitivity fails to develop In a study including 11 cases where periprosthetic tissue contained corrosive elements (solid chromium orthophosphate corrosion products) after aseptic loosening of articular implants, immune-response tissue reactions were identified in every case. Macrophage responses to implants: prospects for personalized medicine. Anionic/neutral particles decrease inflammatory reactions, whereas cations increase inflammation. 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. Cha c sn phm trong gi hng. Metal sensitivity reactions to orthopedic implants. Metal sensitivity is the most common type of immune response to implants. J Bone Joint Surg Am. It's free to sign up and bid on jobs. [48]. 1994. 2015 Dec. 98 (6):953-62. 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. [QxMD MEDLINE Link]. [QxMD MEDLINE Link]. Thomas P, von der Helm C, Schopf C, Mazoochian F, Frommelt L, Gollwitzer H, et al. [5] It therefore is not surprising that immune response to medical implants is commonly reported in the literature, including hypersensitivity to pacemakers or other cardiovascular devices, endovascular stents and coils, dental implants, and orthopedic hardware (eg, joint replacement prostheses, fracture fixation devices, and pain-relief stimulators). Image shows successful titanium total hip implant in the left hip. [20, 30] Some 25% of patients with well-functioning prostheses have metal sensitivity. 1980 Nov. 62-B (4):502-5. 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 X-rays will reveal the hardware if it is metal (most screws are stainless steel or titanium). How do you know if your spouse is not happy? [QxMD MEDLINE Link]. 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. What are the Materials Metal Implants? Sci Adv. Contact Dermatitis. If the cotton bud has stained pink, the item contains nickel and may cause dermatitis if it touches the skin of someone allergic to nickel. [4] Nonmetallic materials can be organic or inorganic. An immune response to a surgically implanted medical device begins immediately. 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. [2, 3] Various antioxidants may modulate a favorable immune response, incuding quercetin, resveratrol, and curcumin. Deutman R, Mulder TJ, Brian R, Nater JP. While most retained hardware is asymptomatic, some patients will develop symptoms. 2021 Jan. 53 (1):43-46. Carl N Graf, MD Orthopedic and Spine Surgeon, Illinois Spine Institute Webbatesville hartwick casket; bbsrc david phillips fellowship 2021; value of type 'string cannot be converted to label; westjet customer service agent salary 2020 Sep. 8:100080. [1], The American Contact Dermatitis Society has suggested testing before device implantation in patients with a clear history of metal reactions. Concentrations of metal ions increase in the systemic circulation after all metal replacements, [QxMD MEDLINE Link]. Akil S, Newman JM, Shah NV, Ahmed N, Deshmukh AJ, Maheshwari AV. Whereas the radiographic and clinical symptoms overlap with those of metal immune reaction, osteolysis is a reaction to local irritation from wear debris, not an immune hypersensitivity response. Granchi D, Ciapetti G, Stea S, Cavedagna D, Bettini N, Bianco T, et al. Severely high serum cobalt or chromium levels can lead to systemic symptoms, cardiotoxicity, neurotoxicity, and may induce chromosomal abnormalities. The clinical presentation of patients with metal implant reactions is often nonspecific. Haddad SF, Helm MM, Meath B, Adams C, Packianathan N, Uhl R. Exploring the Incidence, Implications, and Relevance of Metal Allergy to Orthopaedic Surgeons. Final follow-up image after successful total hip replacement of the left hip. Philadelphia: American Society for Testing and Materials; 1992. Clin Oral Implants Res. [QxMD MEDLINE Link]. Murali Poduval, MBBS, MS, DNB is a member of the following medical societies: Association of Medical Consultants of Mumbai, Bombay Orthopedic Society, Indian Orthopedic Association, Indian Society of Hip and Knee SurgeonsDisclosure: Nothing to disclose. Swelling, pain, draining sinuses, and inflammation at the implant site may mimic infection. Philadelphia: American Society for Testing and Materials; 1985. [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. swelling. [3] Carbohydrates/monosaccharides may have promising potential as materials with high immune compatibility and the ability to positively modify immune responses by stimulating dendritic cells to support T-cell phenotypes that are highly immunosuppressive. These concentrations increase in loose implants, but the significance of this increase is controversial. [82], Implant properties may alter the amount of surface area available for metal ion release. 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. X-rays can also tell if the hardware has shifted in location or broken. Clin Implant Dent Relat Res. When they do occur, titanium allergy symptoms can range from mild to severe and can include: Metallic taste in your mouth. 1979. Merritt K. Role of medical materials, both in implant and surface applications, in immune response and in resistance to infection. Biomaterials. [QxMD MEDLINE Link]. I doubt you are rejecting the titanium. 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. Titanium, molybdenum, and cobalt have low toxicity as compared with nickel and chromium, which can cause highly toxic intracellular changes. 15 (8):13849-80. 2000 Jul. In most instances, it is either retained within the bone or is not particularly prominent with adequate covering of soft tissues. Surface roughness promotes positive cytokine secretion and improves immune cell adhesion. If your stitches have become infected, you may notice the following symptoms: redness or swelling around the stitches. J Bone Joint Surg Am. Signs and symptoms include an itchy rash with redness, swelling, scaling and possibly a crusty appearance. [63] There is no agreement on which specific patients require testing. [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. What is the difference between aphasia and frontotemporal dementia? [QxMD MEDLINE Link]. 2014. 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. [QxMD MEDLINE Link]. How do you know if your body is rejecting screws? [5] Coating substances in use include the following This pain may be felt in the knee itself, or in the surrounding muscles and tissues. sores and swelling in the soft tissues of the mouth. [QxMD MEDLINE Link]. [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. Lachiewicz PF, Watters TS, Jacobs JJ. 2020 Oct. 6 (44):[QxMD MEDLINE Link]. [49, 2, 51, 48] and clear damaged tissues from the area. [49, 86] while promoting the release of anti-inflammatory cytokines. Acta Orthop Scand. [84], No medical treatment is available, [63], Additionally, systemic contact dermatitis has been described when a patient becomes sensitized via the cutaneous route and cross-reacts systemically. 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. 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. San Francisco CA 94123. 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. 14 (4):237-40. Why Do Cross Country Runners Have Skinny Legs? 1990 Nov. 23 (5):325-30. 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. [QxMD MEDLINE Link]. Adult reconstructive surgery. [2]. Can metal implants cause autoimmune disease? 5th ed. Veien NK, Svejgaard E, Menn T. In vitro lymphocyte transformation to nickel: a study of nickel-sensitive patients before and after epicutaneous and oral challenge with nickel. [QxMD MEDLINE Link]. Donati ME, Savarino L, Granchi D, Ciapetti G, Cervellati M, Rotini R, et al. Available at https://www.sciencedaily.com/releases/2014/10/141009153817.htm. Stimulation of T cells to secrete highly immunosuppressive cytokines (eg, IL-17) may promote tolerance of implants. Biomed Res Int. Total arthroplasty of the left hip was recommended, but after consideration of her past orthopedic history, the patient was first referred to an allergist for metal allergy patch testing. [QxMD MEDLINE Link]. [52], Dendritic cells control immune responses against implanted materials. Research into the use of anti-immunogenic coatings on implants is promising. Can a trust deduct investment advisory fees in 2021? 30 (3):181-2. Goldring SR, Clark CR, Wright TM. 2019 Feb. 56 (1):72-85. [2] For example, osteoblast migration and proliferation are promoted by transforming growth factors (eg, TGF-) and interleukins (eg, IL-4) but inhibited by tumor necrosis factors (eg, TNF-) and other interleukins (eg, IL-1). [QxMD MEDLINE Link]. Int J Dermatol. 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. 1120700019865530. Br J Dermatol. Nonetheless, careful radiographic assessment of the implant is required. Allergy Considerations in Implanted Neuromodulation Devices. [QxMD MEDLINE Link]. [2], Wettability is strongly associated with protein layer absorption, blood clot formation and fibrin formation. rv camping near quinn's hot springs; hill of grace restaurant closed; list of countries invaded Br Med J. It's free to sign up and bid on jobs. Prevalence of contact allergy by sex, race and age. [QxMD MEDLINE Link]. [74, 75, 76], The few investigations using the LTT have reported that increased rates of metal sensitivity can be detected above what can be determined by means of dermal patch testing. [39] If the skin patch test finding is positive, the patient can be designated as allergic. Medical implants are typically made of alloys of metals, including nickel, cobalt, chromium, molybdenum, zirconium, and titanium. [1]. [4] High chromium ion concentrations may be carcinogenic, and high cobalt ion concentrations may be both cardiotoxic and neurotoxic. X-rays may also identify the area of the hardware which is likely to be causing the symptoms. 2016. 1978 Aug. 99 (2):191-6. 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. Moisturize regularly. 2001 Feb. 15 (2):86-9. In allergic reactions, there is a type IV delayed cell-mediated response. However, some patients will complain of achiness in the foot or ankle related to weather changes. [3] Hydrophobic materials have an intrinsic immunogenicity with increased monocyte adhesion.