Ann Thorac Surg 1996;61:1514-1516
© 1996 The Society of Thoracic Surgeons
Case Report
Sensitivity to Sternotomy Wires May Cause Postoperative Pruritus
Patricia M. Gordon, MRCP,
Paul K. Buxton, FRCP,
Kathryn M. McLaren, FRCPath,
Roger D. Aldridge, PhD
University Departments of Dermatology and Pathology, The Royal Infirmary of Edinburgh NHS Trust, Edinburgh, Scotland
Accepted for publication November 8, 1995.
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Abstract
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An eczematous eruption developed on the anterior chest of a 58-year-old woman with known nickel sensitivity after the insertion of nickel-containing sternotomy wires. Her wound was revised with removal of the wires to give immediate and sustained relief from the itch. The electron microscopy and parasternal biopsy histology demonstrating a sarcoidal reaction are discussed.
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Introduction
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A 58-year-old woman with symptomatic Wolff-Parkinson-White syndrome, refractory to medical treatment, underwent elective division of the accessory pathway in May 1990. This was performed through a median sternotomy incision, which was closed in layers in a routine manner with Ethicon (Edinburgh, Scotland) monofilament stainless steel sutures (316L stainless steel with the following compositional limits [%]: carbon, 0.03; silicon, 1.0; manganese, 2.0; phosphorus, 0.025; sulfur, 0.001; nitrogen, 0.1; chromium, 17 to 19; molybdenum, 2.25 to 3.5; nickel, 13 to 15; copper, 0.5; iron, balance).
Approximately 2 months after the operation persistent irritation and itching developed over the site of the sternal scar and around the costal margin. Her antiarrhythmic medication had been stopped after the successful division, and her sole medication was phenelzine, a monoamine oxidase inhibitor, which she had been receiving for the preceding 10 years in the treatment of a depressive illness. She was referred to the Dermatology Outpatient Department and noted to have an active eczema at the sternotomy wound site extending onto the shoulders and back. She had a background of minor small plaque psoriasis, and gave a history suggestive of nickel intolerance. Patch testing to the European Standard Battery and to the wire itself revealed a 3+ reaction at both 48 and 96 hours to nickel sulfate 5%, but negative to the wire.
A differential diagnosis of sternal pain syndrome [1] was considered, but in view of her known sensitivity to nickel and very strong reaction to nickel at patch testing, we decided to remove the sternal wires as 1 year had elapsed since the operation and the sternum was considered stable. At wound revision all seven sternotomy wires were recovered and parasternal biopsy specimens taken to provide a tissue sample for histologic assessment. Her wound was closed in layers with Vicryl and subcuticular Prolene (both Ethicon). This led to an almost immediate elimination of her complaints of itch and eczema. Three years later she remains symptom free.
Histologic examination revealed a patchy granulomatous inflammatory infiltrate comprising epitheloid macrophages and multinucleate foreign body giant cells (Fig 1
). Occasional giant cells containing asteroid bodies were also noted (Fig 2). The histologic appearance was that of a sarcoidal reaction. It was thought that this reaction represented a response to an element of the implanted wire. At the site of removal of the wire (Fig 3) some birefringent material was noted. There was no evidence of an ongoing diffuse inflammatory response such as might suggest associated infection. Electron microscopy (Fig 4) of the monofilament stainless steel wire removed at wound exploration showed strikingly depressed pits on the surface of the wire, suggesting surface corrosion.
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Comment
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Studies employing preoperative and postoperative patch testing have shown that there is a low rate of nickel sensitization in patients receiving metal-to-plastic total hip arthroplasties [2, 3]. The safety of implanting nickel-containing prostheses into patients known to be nickel sensitive is controversial, but it is generally accepted that most patients who are metal sensitive can safely receive an orthopedic implant containing nickel without significant risk of cutaneous or systemic problems [4].
Persistent chest pain or sternal pain syndrome after median sternotomy for open heart operations is reported as a relatively common complaint [4]. Two reports [5, 6] have described resolution of disabling sternal pain after removal of wire sutures. In 1 of these cases [5] it was hypothesized that sensitivity to the nickel component in the stainless steel sutures was responsible for the patient's symptoms of severe wound pain. This was based on positive patch testing to nickel sulfate and her history of sensitivity to jewelry. Tissue biopsy at the time of suture removal was not performed.
Tissue biopsy in our case demonstrated discrete granulomas with multinucleate giant cells containing particulate matter. Granulomatous reactions are well recognized to beryllium and zirconium, with similar responses having been seen in tattoos containing chromium and cobalt. The histologic differential diagnosis includes sarcoid, but the patient lacked clinical or laboratory findings to suggest that disorder. It is known that the monofilament stainless steel sternotomy wire has a chromium content of 17% to 19% and a nickel content of 13% to 15%. Biopsy tissue samples were stained with Giemsa, carbol chromotrope, and dimethylglyoxine, with a positive control used in the form of a nickel standard solution provided by the Ethicon analytic laboratory. All three stains were negative for nickel on the biopsy samples. It is likely that these techniques are not sufficiently sensitive to detect the true quantity likely to be eluted from the wire. X-ray spectrophotographic analysis would be the definitive investigation to establish the cause of the granulomas. Samitz and Katz [7] have shown nickel release from stainless steel prostheses (including 316 monofilament sternotomy wires) by the action of sweat and physiologic saline solution in animal experiments. Although we did not perform scanning electron microscopy on an unused sternotomy wire, we would still hypothesize that the pitting of the wire demonstrated by electron microscopy represents erosion of the stainless steel (and release of materials contained therein, ie, nickel) producing subsequent granuloma formation. Irrespective of whether this was in response to nickel or another component of the wire, it is a logical assumption that dissolution took place and in the process nickel was released. The resolution of the eczema after removal of the wire further supports this hypothesis.
Our experience suggests that when implants are considered in strongly nickel sensitive patients it is prudent to avoid, if possible, nickel-containing prostheses. As an alternative to stainless steel wire for closing the sternum in patients with preexisting hypersensitivity reactions to nickel or chromium, the manufacturers, Ethicon, would recommend braided polybutylate-coated polyester.
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Acknowledgments
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We acknowledge the contribution of Mr Evan Cameron, Consultant Cardiothoracic Surgeon, Royal Infirmary of Edinburgh NHS Trust, for removing the sternal sutures and performing the parasternal biopsies.
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Footnotes
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Address reprint requests to Dr Gordon, University Department of Dermatology, Royal Infirmary of Edinburgh NHS Trust, Level 4, Lauriston Building, Edinburgh EH3 9YW, Scotland.
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References
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- Weber LD, Peters RW. Delayed chest wall complications of median sternotomy. South Med J 1986;79:723–7.[Medline]
- Carlsson AS, Magnusson B, Moller H. Metal sensitivity in patients with metal-to-plastic total hip arthroplasties. Acta Orthop Scand 1980;51:57–62.[Medline]
- Deutman R, Mulder TJ, Brian R, Nater JP. Metal sensitivity before and after total hip arthroplasty. J Bone Joint Surg 1977;59:862–5.[Abstract/Free Full Text]
- Burrows D. Is systemic nickel important? J Am Acad Dermatol 1992;26:632–5.[Medline]
- Fine PG, Karwande SK. Sternal wire-induced persistent chest pain: a possible hypersensitivity reaction. Ann Thorac Surg 1990;49:135–6.[Abstract]
- Weber LD, Nashel DJ, Peters RW. Persistent chest pain due to sternal wire sutures: a complication of coronary artery bypass surgery. South Med J 1985;78:1018–9.[Medline]
- Samitz MH, Katz SA. Nickel dermatitis hazards from prostheses-in vivo and in vitro solubilization studies. Br J Dermatol 1975;92:287–90.[Medline]
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M. A. Norgaard, T. C. Andersen, M. J. Lavrsen, and S. Borgeskov
The outcome of sternal wire removal on persistent anterior chest wall pain after median sternotomy.
Eur. J. Cardiothorac. Surg.,
June 1, 2006;
29(6):
920 - 924.
[Abstract]
[Full Text]
[PDF]
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