title: When it is not an infection: metal allergy after the Nuss procedure for repair of pectus excavatum.
abstract: OBJECTIVE
  Increasing use of implantable bars for minimally invasive pectus excavatum repair has introduced metal allergy (nickel and chromium) to pediatric surgeons. Metal allergy is a well-recognized entity in neurologic, orthopedic, and craniofacial surgery. This study was performed to evaluate metal allergy and its effects on treatment with the Nuss procedure in 862 patients.
  
  
  METHODS
  After institutional review board approval, we undertook a retrospective review of a prospectively gathered database of patients undergoing the Nuss procedure. Metal allergy was diagnosed either with the use of dermal patch or clinically, based on rash, fever, elevated erythrocyte sedimentation rate, cultures, and pathology specimens. Data collection included demographics, an allergy to jewelry, and history of atopy. Clinical outcomes including need for reoperation, removal of stainless steel bar, and replacement with titanium bar were evaluated.
  
  
  RESULTS
  Over an 18-year period (1987-2005), 862 patients underwent the Nuss procedure. Nineteen (2.2%) were diagnosed with metal allergy, with an average age of 14.7 years (9-23 years). Eighteen (95%) were males. A history of atopy was present in 9 (56%) patients. Ten (63%) patients presented with rash and erythema, 1 (6%) with granuloma, 5 (32%) with pleural effusion, and 3 (15%) were diagnosed on preoperative screening. Stainless steel bars were removed because of allergic skin breakdown in 3 patients, with 2 patients requiring replacement titanium bars. In all 3 of these patients, symptoms resolved after removal of stainless steel bars. Titanium bars were placed in the 3 patients who were diagnosed preoperatively with metal allergy, without event.
  
  
  CONCLUSIONS
  Allergy symptoms often are misdiagnosed as infection, but require different treatment. If a history of metal allergy or atopy is suggested preoperatively, the patient should be tested for metal allergy, and if positive, a titanium bar used. Because the consequences of metal allergy may include the need to replace the bar, pediatric surgeons should be aware of this occurrence.
authors.affiliation: Department of Surgery, Eastern Virginia Medical School, Norfolk, VA 23507, USA.
authors.forename: Gregory D
authors.initials: GD
authors.lastname: Rushing
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Goretsky
authors.forename: Tina
authors.initials: T
authors.lastname: Gustin
authors.forename: Maripaz
authors.initials: M
authors.lastname: Morales
authors.forename: Robert E
authors.initials: RE
authors.lastname: Kelly
authors.forename: Donald
authors.initials: D
authors.lastname: Nuss
mesh_terms: D000293:Adolescent; D000328:Adult; D001672:Biocompatible Materials / Q000009:adverse effects; D002648:Child; D005260:Female; D005660:Funnel Chest / Q000601:surgery*; D006801:Humans; D006967:Hypersensitivity / Q000209:etiology* / Q000628:therapy; D008297:Male; D008670:Metals / Q000009:adverse effects*; D019736:Prostheses and Implants / Q000009:adverse effects*; D012189:Retrospective Studies; D013193:Stainless Steel / Q000009:adverse effects; D019616:Thoracic Surgical Procedures / Q000295:instrumentation*; D014025:Titanium / Q000009:adverse effects
chemical_list: D001672:Biocompatible Materials; D008670:Metals; D013193:Stainless Steel; D014025:Titanium