The Sequelae of Metallosis Resulting in Skin Pigmentation and Tattooing: A Case Presentation and Literature Review

Abstract

With advancing technologies in orthopedics and increasing demands of the population for orthopedic interventions, younger patients are now receiving joint replacements. One of the potential risks of joint replacement is metallosis, or the local and systemic release of metal ions. Metallosis is caused by the release of metallic debris, secondary to hardware failure. The phenomenon is most commonly associated with failed metal-on-metal hip prostheses and is characterized locally by heavy staining of surrounding soft tissue, metallic synovitis, joint effusion, and gradual loosening of the prosthesis. Additionally, metallic debris can also lead to periarticular superficial skin manifestations. The release of metal ions has further been known to lead to systemic upsets including neurologic deficit (declining vision, hearing, or cognition; headaches), cardiac failure, and hypothyroidism. As the number of patients seeking major orthopedic interventions grows, the incidence of metallosis-related skin tattooing will also increase. The structural components of a failed joint replacement can be revised (improving patients' pain and functioning). However, any skin tattooing secondary to metallosis presents the treating dermatologist with clinical challenge, due to lack of research regarding treatment of this condition. Our aim is to review the published literature on metallosis, including the pathophysiology. After assessing publications on the treatment of traumatic and cosmetic tattooing, we hope to stimulate further research regarding treatment. This article should also serve to remind orthopedic surgeons that with increasing patient concern regarding cosmesis, a multispecialty approach including referral to a dermatologist is valuable.

Keywords

metallosis - metallosis treatment

• References

• 1 Corten K, Ganz R, Simon JP, Leunig M. Hip resurfacing arthroplasty: current status and future perspectives. Eur Cell Mater 2011; 21: 243-258
• 2 Keegan GM, Learmonth ID, Case CP. Orthopaedic metals and their potential toxicity in the arthroplasty patient: a review of current knowledge and future strategies. J Bone Joint Surg Br 2007; 89 (05) 567-573
• 3 Jayasekera N, Gouk C, Patel A, Eyres K. Apparent skin discoloration about the knee joint: a rare sequela of metallosis after total knee replacement. Case Rep Orthop 2015; 2015: 891904
• 4 Babis GC, Stavropoulos NA, Sasalos G, Ochsenkuehn-Petropoulou M, Megas P. Metallosis and elevated serum levels of tantalum following failed revision hip arthroplasty—a case report. Acta Orthop 2014; 85 (06) 677-680
• 5 Munro-Ashman D, Miller AJ. Rejection of metal to metal prosthesis and skin sensitivity to cobalt. Contact Dermat 1976; 2 (02) 65-67
• 6 Bradberry SM, Wilkinson JM, Ferner RE. Systemic toxicity related to metal hip prostheses. Clin Toxicol (Phila) 2014; 52 (08) 837-847
• 7 Helito CP, Buarque de Gusmão CV, Angelini FJ, Tirico LE, Pécora JR. Severe metallosis following total knee arthroplasty: a case report and review of radiographic signs. Skeletal Radiol 2014; 43 (08) 1169-1173
• 8 Sharareh B, Phan DL, Goreal W, Schwarzkopf R. Metallosis presenting as knee pain 26 years after primary total knee arthroplasty. J Orthop Case Rep 2015; 5 (02) 62-65
• 9 Tower SS. Arthroprosthetic cobaltism: neurological and cardiac manifestations in two patients with metal-on-metal arthroplasty: a case report. J Bone Joint Surg Am 2010; 92 (17) 2847-2851
• 10 Asahina A, Fujita H, Fukuda S. , et al. Extensive skin pigmentation caused by deposits of metallic particles following total elbow arthroplasty: metallosis or not?. Br J Dermatol 2007; 157 (05) 1074-1076
• 11 Matziolis G, Perka C, Disch A. Massive metallosis after revision of a fractured ceramic head onto a metal head. Arch Orthop Trauma Surg 2003; 123 (01) 48-50
• 12 Akimoto M, Hara H, Suzuki H. Metallosis of the skin mimicking malignant skin tumour. Br J Dermatol 2003; 149 (03) 653
• 13 Apfelberg DB, Maser MR, Lash H, White DN, Flores JT. Comparison of argon and carbon dioxide laser treatment of decorative tattoos: a preliminary report. Ann Plast Surg 1985; 14 (01) 6-15
• 14 Bernstein LJ, Palaia DA, Bank D, Geronemus RG. Tattoo formation from absorbable synthetic suture and successful removal with Q-switched ruby laser. Dermatol Surg 1996; 22 (12) 1040-1042
• 15 Troilius AM. Effective treatment of traumatic tattoos with a Q-switched Nd:YAG laser. Lasers Surg Med 1998; 22 (02) 103-108
• 16 Gorouhi F, Davari P, Kashani MN, Firooz A. Treatment of traumatic tattoo with the Q-switched Nd:YAG laser. J Cosmet Laser Ther 2007; 9 (04) 253-255
• 17 Sunde D, Apfelberg DB, Sergott T. Traumatic tattoo removal: comparison of four treatment methods in an animal model with correlation to clinical experience. Lasers Surg Med 1990; 10 (02) 158-164