Pendulum Metal Hypersensitivity: What Are We Missing?

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Metal hypersensitivity affects 10-15% of foot and ankle patients, usually presenting with an eczematous-type rash overlying metallic implants and representing a type IV delayed hypersensitivity reaction. 

 

Relevance of jewelry allergy

 

A history of jewelry or contact allergy is an important clue. Research shows that 60% of patients with prosthesis-related hypersensitivity (PRH) patients had a known contact allergy – 25.7% to metals and 34.6% to other substances.

 

In a patch testing study, nickel is the most frequently identified allergen (31.5%), followed by vanadium chloride (13.7%) and gentamycin, an antibiotic often added to bone cement.

 

Current recommendations

 

There is no accepted protocol to evaluate and manage patients with suspected metal hypersensitivity reactions. Likewise, no orthopedic society or governing body has established preoperative screening guidelines for identifying at-risk patients. What we do have to guide us is a consensus statement from a panel of experts:

 

Implant allergy is rare but should be considered in cases of persistent, unexplained symptoms. Patch testing with late reading may be useful; lymphocyte transformation testing not recommended. Routine preoperative screening without a history of allergy is unnecessary.

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Ankle Fractures, Early Motion, and Outcomes

by Vince Vacketta, DPM

 

Two recent studies shed light on early weightbearing and mobilization following ankle fracture ORIF: 

 

Study 1 – Hybrid cast and brace vs. traditional cast

 

This study compared a hybrid approach (short cast followed by a functional brace) with the traditional six-week cast, evaluating function, pain, complications over two years. It found that rigid, long-duration immobilization is not necessarily superior. More flexible or functional approaches can match outcomes while potentially providing a better patient experience.

 

Study 2 – Early weightbearing after syndesmotic repair

 

This study evaluated the safety and benefits of initiating weightbearing at about two weeks after ankle fracture with syndesmosis repair. It found that early loading safe, improved pain/ROM, faster return to function, without obvious compromise in fixation integrity.

 

Key takeaways

 

What do these results mean for ankle fracture care moving forward? Here’s the big picture:



• Together, these studies support and validate a more aggressive philosophy in ankle fracture care with earlier motion and loading and less rigid immobilization.

• Patient-specific, factures (bone quality, fixation strength, comminution) likely modulate safety.

• Surgeon discretion continues to be essential in applying these findings safely and effectively.

 

 

Peroneus Longus Morbidity Is More Significant Than Appreciated

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The peroneus longus (PL) tendon is often used an autograft source with the belief that donor-site morbidity is minimal. However, this new study challenges that belief and causes us to pause before sacrificing the PL tendon.

 

Study design

 

The study is a retrospective review of 35 patients (mean age 43) who underwent PL autograft harvest between 2021–2023, with an average 22.5-month follow-up. Pre- and postoperative assessments included SANE, AOFAS, FAOS, CAIT scores, and ankle range of motion (ROM). Minimal clinically important difference (MCID) thresholds were used to assess donor-site morbidity.

 

Function preserved, but symptoms tell another story

 

• Ankle ROM: Preserved postoperatively (no significant change, P > .05).

• Patient-reported outcomes (PROMs): Significant declines from baseline (P < .05). Mean postoperative scores were SANE 92.3, AOFAS 96.7, FAOS 97.0, CAIT 27.4.

• Clinically meaningful declines: The proportion of patients exceeding the MCID was 51.4% for SANE, 31.4% for AOFAS, 34.2% for FAOS, and 5.7% for CAIT.

• Complications: Two cases of transient sural nerve hypoesthesia, both resolved spontaneously.

 

Clinical implications: donor-site morbidity is real

 

PL tendon harvest maintains ankle motion but leads to measurable, and sometimes clinically meaningful, declines in patient-reported outcomes at one year. Surgeons should weigh donor-site morbidity when selecting grafts and consider long-term monitoring.