Metallic orthopaedic implants are known to instigate cutaneous reactions; however, the mechanism by which this occurs is not fully understood. Contact dermatitis after implantation of stainless steel fracture plates was first described in 1966, and similar reactions to various implants have been documented subsequently. Leukocytoclastic vasculitis (LCV) is an inflammatory condition of small dermal blood vessels resulting from neutrophil invasion, degranulation, and cell death caused by a type III hypersensitivity reaction. No studies have reported use of titanium orthopaedic implants resulting in LCV. We describe a 66-year-old woman who developed LCV after the fusion of her second right metatarsocuneiform joint with a titanium plate and screws. At 4 months after removal of the titanium plate and screws, the LCV symptoms had resolved without further intervention. Although this rash might be a rare complication associated with orthopaedic implants, it is an important differential diagnosis for orthopaedic surgeons to consider when assessing and treating postoperative rashes

Altman, Emily M

Brown, Sarah K

Kurnik, Christopher

Miller, Richard A

English

University of New Mexico

115CASE REPORTS • UNMORJ VOL. 8 • 2019
Leukocytoclastic Vasculitis in a 
66-Year-Old Woman After Fusion of the 
Second Right Metatarsocuneiform Joint 
Using Titanium Plate and Screws: 
A Case Report  
Sarah K. Brown, BS*; Christopher Kurnik, MD†; Emily M. Altman, MD‡;  
Richard A. Miller, MD†
*School of Medicine, The University of New Mexico Health Sciences Center, Albuquerque, New Mexico
†Department of Orthopaedics & Rehabilitation, The University of New Mexico Health Sciences Center, 
Albuquerque, New Mexico
‡Department of Dermatology, The University of New Mexico Health Sciences Center, Albuquerque,  
New Mexico
Corresponding Author Richard A. Miller, MD. Department of Orthopaedics & Rehabilitation
MSC10 5600, 1 University of New Mexico, Albuquerque, NM 87131 (email: rmiller@salud.unm.edu).
Funding The authors received no financial support for the research, authorship, and publication of this article.
Conflict of Interest The authors report no conflicts of interest.
Informed Consent The patient was informed that the data concerning her case would be submitted for publication, 
and she provided verbal consent.
ABSTRACT
Metallic orthopaedic implants are known to instigate 
cutaneous reactions; however, the mechanism by which 
this occurs is not fully understood. Contact dermatitis 
after implantation of stainless steel fracture plates was first 
described in 1966, and similar reactions to various implants 
have been documented subsequently. Leukocytoclastic 
vasculitis (LCV) is an inflammatory condition of small 
dermal blood vessels resulting from neutrophil invasion, 
degranulation, and cell death caused by a type III 
hypersensitivity reaction. No studies have reported use 
of titanium orthopaedic implants resulting in LCV. We 
describe a 66-year-old woman who developed LCV 
after the fusion of her second right metatarsocuneiform 
joint with a titanium plate and screws. At 4 months 
after removal of the titanium plate and screws, the LCV 
symptoms had resolved without further intervention. 
Although this rash might be a rare complication associated 
with orthopaedic implants, it is an important differential 
diagnosis for orthopaedic surgeons to consider when 
assessing and treating postoperative rashes. 
Keywords: Leukocytoclastic Vasculitis, Titanium Implant, 
Rash
INTRODUCTION 
Leukocytoclastic vasculitis (LCV), also known as 
small vessel vasculitis or hypersensitivity vasculitis, 
is a skin condition characterized by palpable, non-
blanching, purpuric papules on the lower extremities 
and occasionally on the back and buttocks (Figure 1A 
and 1B).1-5 The condition typically involves the lower 
extremities; however, it can affect any region of the 
body.2-5 LCV may present as vesicles, skin ulcerations, 
and areas of necrosis.1-3 Although uncommon, systemic 
symptoms can include pruritus, malaise, fevers, lower-
extremity edema, arthralgias, and myalgias.2,4
LCV is a type III hypersensitivity reaction resulting 
in inflammation and vasculitis, typically caused by 
neutrophil invasion, degranulation, and cell death.1-4 Type 
III hypersensitivity reactions trigger the production of 
immune complexes that stimulate circulating neutrophils 
to release proteolytic enzymes, resulting in inflammation 
and damage of adjacent vessel walls.4 LCV is usually 
idiopathic; however, the condition is also associated with 
many chronic diseases, medications, and infections.2-5 
We were unable to find evidence to support titanium 
or other metallic orthopaedic implants mediating 
LCV reactions, but orthopaedic implants have been 
shown to instigate hypersensitivity reactions including 
dermatitis and lymphocytic vasculitis.6,7 If the instigating 
cause is removed, most patients with LCV experience 
spontaneous resolution of their skin lesions within weeks 
or months of initial onset.3-5 
Mild cases of LCV are treated with elevation, rest, and 
antihistamine therapy.3-5 In patients with more severe 
symptoms, corticosteroids are used to prevent further 
exacerbation.3-5 We describe a 66-year-old woman who 
developed LCV shortly after the fusion of her second 
right metatarsocuneiform joint with the use of a titanium 
plate and screws. 
116 CASE REPORTS • UNMORJ VOL. 8 • 2019
CASE REPORT 
A 66-year-old woman presented to the orthopaedic 
clinic with chronic pain and degenerative joint disease 
in the second and third tarsometatarsal joints of the 
right foot. The patient had a history of tenderness and 
bossing over the second and third tarsometatarsal joints, 
thus requiring her to use a walking boot due to chronic 
pain. Nonsurgical interventions were attempted without 
resolution of pain (ie, various shoe wear, bracing, and 
fluoroscopically guided injections). Her medical history 
revealed non-localized allergic concerns to stainless 
steel and certain metallic jewelry; however, she could 
not characterize the type of allergic reaction she 
experienced. Because of her unknown allergy status to 
stainless steel, the decision was made to proceed with 
surgical intervention using a titanium plate and screws.
The patient underwent fusion of the second right 
metatarsocuneiform joint, and arthrotomy and 
debridement of the third metatarsocuneiform joint. 
The joint surface of the second metatarsocuneiform 
joint was prepared for fusion. While the joint was held 
compressed, the titanium plate was placed dorsally and 
filled with titanium screws. The wound was irrigated 
and closed. The procedure resulted in successful bony 
contact and stable fixation of the joint (Figures 2A 
through 2C). Postoperatively, no complications were 
noted and the patient described feeling well.
At 2 months after the initial operation, the patient 
developed a pruritic rash on her right lower extremity, 
sparing the toes. She was evaluated by The University 
of New Mexico Department of Dermatology 1 month 
later. At that time, she had a pruritic rash on the 
right ankle and distal right lower leg, with minimal 
involvement of the left lower leg. About 36 hours before 
the onset of the rash, she described herself as feeling 
“under the weather.” It was noted during physical 
examination that the patient had non-blanching, 
palpable, purpuric papules on both legs, sparing the 
toes. Findings of two separate punch biopsies of the 
rash indicated neutrophil fragments, extravasated 
Figure 1. Representative photograph of leukocytoclastic 
vasculitis. A) Left foot. B) Both legs. Photographs reprinted 
with permission from James Heilman, MD, https://commons.
wikimedia.org/w/index.php?curid=11857197 and from DermNetNZ, 
https://knowledge.statpearls.com/chapter/0/24215?utm_
source=pubmed, respectively. 
A
B
A B
Figure 2. Radiographs showing the titanium plate  
and screws at the second right metatarsocuneiform 
joint. A) Anteroposterior view. B) Oblique view.  
C) Lateral view.
C
117CASE REPORTS • UNMORJ VOL. 8 • 2019
erythrocytes with uncommon perivascular 
neutrophils, and granular deposition in the 
vessel walls consistent with LCV of unknown 
origin (Figures 3A through 3C). The patient 
was re-evaluated by a dermatologist multiple 
times because the rash did not resolve with 
treatment using triamcinolone cream and 20 
mg of oral prednisone once a day for 5 days. 
No diagnosis was made, but it was speculated 
that the titanium plate and screws might be 
related to her condition. 
At 6 months after her metatarsocuneiform 
fusion, the patient underwent removal of 
the titanium plate and screws from the 
joint. Stress of the joint after removal of 
the plate and screws showed successful 
arthrodesis. The implants removed showed 
no damage, and there were no signs of 
debris in the adjacent soft tissues. At 1 week 
postoperatively, symptoms of LCV resolved. 
Four months later, at the final follow-up, no 
reoccurrence was noted.
DISCUSSION 
Metallic orthopaedic implants are known 
to instigate cutaneous reactions, but the 
mechanism by which this occurs is not fully 
understood.8 In 1966, contact dermatitis after 
implantation of stainless steel fracture plates 
was first described, and similar reactions to 
various implants have since been documented.6-8 
Nickel, cobalt, and chromium are more likely to 
induce cutaneous and extracutaneous reactions; 
however, other metals can be immunogenic and 
produce similar effects.6-8
Cutaneous reactions after metal exposure 
are relatively common, although reactions 
are less seen in metallic orthopaedic devices 
compared to other implants.6,7 There is an 
ongoing debate of the validity of developing 
cutaneous reactions from metallic orthopaedic 
implants, specifically because the implants 
are inserted deep within the tissue and away 
from the overlying cutaneous tissues.6,7 Metal 
hypersensitivity reactions typically present as 
contact dermatitis on the overlying skin that 
was exposed to the metal irritant, including 
both implanted metal and metal that directly 
contacts the skin on the surface.6-8 Typically, 
contact dermatitis presents as an eczematous 
reaction with erythematous scaling 
plaques and papules in the area of contact; 
however, it can occasionally present with 
microvesiculation, depending on the timing 
and extent of allergy.6 The eruptions normally 
occur over the site of the implant and do not 
spread from the site of origin or to adjacent 
extremities.6,7 
Figure 3. Tissue histological sections. A) Perivascular infiltrate 
composed of lymphocytes, eosinophils, and a few neutrophils. 
Presence of copious extravasated red blood cells (black arrows) are 
also noted. B) Dermal vessel with neutrophil fragments near vessel 
wall (black arrow). C) Dermal vessel that appears to have been 
damaged with fibrinoid material in vessel wall (black arrow).
A
B
C
118 CASE REPORTS • UNMORJ VOL. 8 • 2019
Over time, metallic orthopaedic implants experience 
normal wear-and-tear that releases haptens (antigens), 
which in-turn induces a counter hypersensitivity 
reaction.7 Haptens activate lymphocytes resulting in 
a humoral immune response, including antibody and 
immune complex formation characteristic of types 
I to III hypersensitivity reactions.7 More commonly, 
orthopaedic implants induce type IV hypersensitivity 
reactions that cause inflammation through cytokine 
secretion and macrophage recruitment.7 LCV 
is representative of a type III hypersensitivity.1-4 
We were unable to find any reports of titanium 
orthopaedic implants resulting in LCV. In the current 
case, our patient’s condition represents an atypical 
hypersensitivity reaction to a metallic orthopaedic plate 
and screws.
Currently, it is not possible to predict which patients 
will develop hypersensitivity reactions to metallic 
orthopaedic implants. Performing a patch test before 
the insertion of metallic implants can help determine 
metal hypersensitivity, but patch test results can 
be ineffective in predicting adverse outcomes.6,7,9,10 
Additionally, patch testing is not recommended or 
indicated unless the patient had a previous allergic 
reaction to a similar implant.6,7,9,10 Furthermore, the risk 
of hypersensitivity reaction is the same for patients with 
and without a history of metal sensitivity.6,10 Although 
we cannot confirm that the titanium plates and screws 
were the cause of LCV in our patient, the timing of the 
rash appearance and its disappearance after removal of 
plate and screws makes this association suspected. It is 
important for orthopaedic surgeons to be aware of this 
possibility. 
REFERENCES
1. Gota C. Overview of cutaneous small vessel vasculitis. 
UpToDate website. https://www.uptodate.com/
contents/overview-of-cutaneous-small-vessel-vasculit
is?search=leukocytoclastic vasculitis&source=search_
result&selectedTitle=1~150&usage_
type=default&display_rank=1. Updated September 21, 
2018. Accessed September 6, 2018.
2. Hardin J. Cutaneous Conditions. In: Knoop KJ, 
Stack LB, Storrow AB, Thurman R. eds. The 
Atlas of Emergency Medicine. 4th ed. New York, 
NY: McGraw-Hill; 2016. http://accessmedicine.
mhmedical.com.libproxy.unm.edu/content.
aspx?bookid=1763&sectionid=125435601. Accessed 
September 6, 2018.
3. Baigrie, D, Crane, JS. Leukocytoclastic vasculitis 
(hypersensitivity vasculitis). StatPearls website. 
Treasure Island, FL: StatPearls Publishing; 2018. 
https://www.ncbi.nlm.nih.gov/books/NBK482159/. 
Accessed September 6, 2018.
4. Koo B, Nia JK, Czernik A. Skin complications. 
In: Oropello JM, Pastores SM, Kvetan V. eds. 
Critical Care. New York, NY: McGraw-Hill; 2017. 
http://accessmedicine.mhmedical.com/content.
aspx?bookid=1944&sectionid=143518968. Accessed 
September 6, 2018.
5. Einhorn J, Levis JT. Dermatologic diagnosis: 
leukocytoclastic vasculitis. Perm J. 2015;19(3):77-78. 
doi: 10.7812/TPP/15-001
6. Teo WZW, Schalock PC. Metal hypersensitivity 
reactions to orthopedic implants. Dermatol Ther. 
2017;7(1):53-64. doi: 10.1007/s13555-016-0162-1.
7. Wawrzynski J, Gil JA, Goodman AD, Waryasz GR. 
Hypersensitivity to orthopedic implants: a review 
of the literature. Rheumatol Ther. 2017;4(1):45-56. 
doi:10.1007/s40744-017-0062-6.
8. Basko-Plluska JL, Thyssen JP, Schalock PC. 
Cutaneous and systemic hypersensitivity reactions 
to metallic implants. Derm. 2011;22(2):65-79. doi: 
10.2310/6620.2011.10055.
9. Schalock PC, Menné T, Johansen JD, et al. 
Hypersensitivity reactions to metallic implants - 
diagnostic algorithm and suggested patch test series 
for clinical use. Contact Dermatitis. 2012;66(1):4-19. 
doi: 10.1111/j.1600-0536.2011.01971.x.
10. Thyssen JP, Johansen JD, Menné T, Lidén C, Bruze 
M, White IR. Hypersensitivity reactions from metallic 
implants: a future challenge that needs to be 
addressed. Br J Dermatol. 2010;162(2):235-236. doi: 
10.1111/j.1365-2133.2009.09526.x.


Leukocytoclastic Vasculitis in a 66-Year-Old Woman After Fusion of the Second Right Metatarsocuneiform Joint Using Titanium Plate and Screws: A Case Report

https://digitalrepository.unm.edu/cgi/viewcontent.cgi?article=1069&amp;context=unm_jor

Leukocytoclastic Vasculitis in a 66-Year-Old Woman After Fusion of the Second Right Metatarsocuneiform Joint Using Titanium Plate and Screws: A Case Report

Abstract

Similar works

Full text

Available Versions

University of New Mexico