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  • Title: MELISA® Pre-Testing prior to surgery
  • Subtitle: Melisa®
  • Content text:

    MELISA testing for patients with planned surgery - important consideration


    MELISA tests for Type IV hypersensitivity, which is mediated by T-cell memory. This immune response requires prior sensitization - meaning that if the immune system has never encountered a particular metal, it will not have developed a memory response to it. However, complete avoidance of metal exposure is nearly impossible, as metals are present in everyday environments, including food, and cosmetics. Some patients may not realise they are already exposed via dental metals when undergoing pre-testing for orthopedic implants. From an immunological perspective, metals may provoke the same Type IV response, regardless of whether they are used in dental or orthopedic applications.

    MELISA can be used for metal hypersensitivity testing prior to surgery if there are indicators that an allergy may be present. For instance, skin reactions to metals, previous failed surgery and repeated unexplained infections following surgery using metal devices, pins or plates.

    There are recommendations available on managing patients with potential metal hypersensitivity prior to undergoing joint arthroplasty or implantation surgery. Schalock et al. (1) recommend that patients who report cutaneous metal allergy should be tested prior to device implantation. Granchi et al. (2) also recommend patch testing for any patient with previous signs or symptoms of metal allergy. Granchi et al. further add that patients with positive skin reactions should not have an implant containing the metal allergen if possible (2).

    Some orthopaedic surgeons who suspect that a patient may have problems with metals, for instance, nickel, will pre-test for a whole panel of metals.  Titanium was traditionally thought of as bio-inert, but there are increasing reports that it may cause problems in hypersensitive patients (3). Studies show that in vitro blood lymphocyte transformation tests such as MELISA are better suited for diagnosing possible metal sensitivity than patch testing (4, 5, 6). Also, the relationship between skin hypersensitivity and systemic hypersensitivity is ill-defined. Lymphocyte transformation test sensitivity is higher than patch testing and provides quantifiable data and is highly reproducible (7).

    However, even in a paper that recommends using pre-operative allergy testing in patients with self-reported metal allergy, there are limitations in testing. The authors report that the frequency of allergy increases after the operation (2). The magnitude of exposure differs significantly - a large orthopedic implant introduces a substantially higher and more prolonged exposure than dietary or cosmetic sources of titanium. Granchi et al. say that the frequency of positive tests increases post-operatively, especially in those patients with failing implants or metal-on-metal devices.

    The immune system is dynamic, and sensitivity may develop over time with increased exposure. Testing provides a snapshot of immune reactivity at a specific moment but cannot predict how the immune system will respond to prolonged or intensified exposure in the future. Therefore, the MELISA test cannot guarantee that an allergy will not develop during in vivo, long-term, high-level metal exposure post-surgery.
  • List item:
    • List title: References, List content:

      1. Schalock PC, Menne T, Johansen JD, Taylor JS, Maibach HI, Liden C, Bruze M, Thyssen JP. Hypersensitivity reactions to metallic implants-diagnostic algorithm and suggested patch test series for clinical use. Contact Dermatitis. 2012;66:4–19.
      2. Granchi D, Cenni E, Giunti A, Baldini N. Metal hypersensitivity testing in patients undergoing joint replacement: a systematic review. J Bone Joint Surg Br. 2012;94:1126–1134.
      3. Wood, MM, and E Warshaw. 2015. “Hypersensitivity reactions to titanium: diagnosis and management.” Dermatitis 26:7-25.
      4. Carossino, AM, C Carulli, and S Ciuffi. 2016. “Hypersensitivity reactions to metal implants: laboratory options.” BMC Musculoskelet Disord 17:486.
      5. Hallab, NJ. 2004. “Lymphocyte transformation testing for quantifying metal-implant-related hypersensitivity responses.” Dermatitis. 15(2):82-90.
      6. Ständer, S, E Oppel, P Thomas, and B Summer. 2017. “Evaluation of lymphocyte transformation tests as compared with patch tests in nickel allergy diagnosis.” Contact Dermatitis ;76(4):228-234. doi:10.1111/cod.12751.
      7. Saccomanno, M. F., Sircana, G., Masci, G., Cazzato, G., Florio, M., Capasso, L., Passiatore, M., Autore, G., Maccauro, G., Pola, E., 2019. Allergy in total knee replacement surgery: Is it a real problem? World J Orthop. 10, 63-70.
  • Title: MELISA Pre-Testing prior to surgery
  • Subtitle: Melisa
  • Intro text editor:

    MELISA can be used for metal hypersensitivity testing prior to surgery if there are indicators that an allergy may be present. For instance, skin reactions to metals, previous failed surgery and repeated unexplained infections following surgery using metal devices, pins or plates.

    There are recommendations available on managing patients with potential metal hypersenstivity prior to undergoing joint arthroplasty or implantation surgery. Schalock et al. (1) recommend that patients who report cutaneous metal allergy should be tested prior to device implantation. Granchi et al. (2) also recommend patch testing for any patient with previous signs or symptoms of metal allergy. Granchi et al further add that patients with positive skin reaction should not have an implant containing the metal allergen if possible (2).

    Some orthopaedic surgeons who suspect that a patient may have problems with metals for instance, nickel, will pre-test for a whole panel of metals. Titanium was traditionally thought of as bio-inert but there are increasingly reports that it may cause problems in hypersensitive patients (3). Studies show that in vitro blood lymphocyte transformation tests such a MELISA are better suited for diagnosing possible metal sensitivity than patch testing (4, 5, 6). Implant-related hypersensitivity reactions are mediated by sensitized T cells and the relationship between skin hypersensitivity and systemic hypersensitivity is ill-defined. Lymphocyte transformation test sensitivity is higher than patch testing and provides quantifiable data and is highly reproducible (7).

    However, even in a paper that recommends using pre-operative allergy testing in patients with self-reported metal allergy there are limitations in testing. The authors report that the frequency of allergy increases after the operation (2). Granchi et al say that the frequency of positive tests increases post-operatively, especially in those patients with failing implants or a metal-on-metal devices. Therefore, the MELISA test cannot guarantee that an allergy will not develop during in vivo, long-term, high-level metal exposure post-surgery.
  • References:

    References

    1. Schalock PC, Menne T, Johansen JD, Taylor JS, Maibach HI, Liden C, Bruze M, Thyssen JP. Hypersensitivity reactions to metallic implants-diagnostic algorithm and suggested patch test series for clinical use. Contact Dermatitis. 2012;66:4–19.
    2. Granchi D, Cenni E, Giunti A, Baldini N. Metal hypersensitivity testing in patients undergoing joint replacement: a systematic review. J Bone Joint Surg Br. 2012;94:1126–1134.
    3. Wood, MM, and E Warshaw. 2015. “Hypersensitivity reactions to titanium: diagnosis and management.” Dermatitis 26:7-25.
    4. Carossino, AM, C Carulli, and S Ciuffi. 2016. “Hypersensitivity reactions to metal implants: laboratory options.” BMC Musculoskelet Disord 17:486.
    5. Hallab, NJ. 2004. “Lymphocyte transformation testing for quantifying metal-implant-related hypersensitivity responses.” Dermatitis. 15(2):82-90.
    6. Ständer, S, E Oppel, P Thomas, and B Summer. 2017. “Evaluation of lymphocyte transformation tests as compared with patch tests in nickel allergy diagnosis.” Contact Dermatitis ;76(4):228-234. doi:10.1111/cod.12751.
    7. Saccomanno, M. F., Sircana, G., Masci, G., Cazzato, G., Florio, M., Capasso, L., Passiatore, M., Autore, G., Maccauro, G., Pola, E., 2019. Allergy in total knee replacement surgery: Is it a real problem? World J Orthop. 10, 63-70.

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  • Title: Select testing
  • Subtitle: Melisa
  • Content text:

    MELISA testing is best used to check if any ongoing metal exposure is causing unexplained symptoms. It can be chronic long term symptoms or new symptoms that appeared after surgery. Generally, all ongoing exposure should be considered, even if the symptoms started after, for example, placement of an implant. The reason being that galvanic effects between different metal alloys can lead to increased corrosion and release of metal ions, which can fuel symptoms. Also, removing dental fillings or crowns are usually preferable to removing implants.

    MELISA can also check pre-operatively for specific metal allergy in patients presenting with a history of suspected metal allergy (e.g. dermal reactions to jewellery, contact dermatitis, etc.) to ensure the biocompatibility of the new implant. Studies have shown patients who reacted to a
    single metal have an increased chance of co-sensitization to another metal, so self-reported nickel allergy may indicate hypersensitivity to other metals. However, it is crucial to understand that increased metal exposure after implant-placement may lead to a stronger immune response (metal reactivity). For more information, see Pre-testing.

    You may need to check with your healthcare professional for the exact metal content of a device or implant.

    To decide what to test for in MELISA consider the following:

    Do you have any dental restorations; silver/amalgam fillings, crowns, bridges, implants and orthodontic braces/retainer?

    Do you have any orthopaedic devices; knee, hip, shoulder replacements, pins and plates?

    Do you have any cardio and vascular devices: embolization coils, stents, septal occluders, implanted defibrillators and pacemakers?

    What about environmental or occupational exposure; jewellery, cell phones, coins, certain foods and medications etc.

    A detailed overview of metals found in frequently used dental and orthopaedic restorations as well as an overview of metals present in our environment can be found at Metal exposure.

    Please see Testing panels for more information on what metals can be tested in MELISA.
  • Title: Select testing
  • Subtitle: Melisa
  • Content text in two columns instead of list:

    MELISA testing is best used to check if any ongoing metal exposure is causing unexplained symptoms. It can be chronic long term symptoms or new symptoms that appeared after surgery. Generally, all ongoing exposure should be considered, even if the symptoms started after, for example, placement of an implant. The reason being that galvanic effects between different metal alloys can lead to increased corrosion and release of metal ions, which can fuel symptoms. Also, removing dental fillings or crowns are usually preferable to removing implants.

    MELISA can also check pre-operatively for specific metal allergy in patients presenting with a history of suspected metal allergy (e.g. dermal reactions to jewellery, contact dermatitis, etc.) to ensure the biocompatibility of the new implant. Studies have shown patients who reacted to a
    single metal have an increased chance of co-sensitization to another metal, so self-reported nickel allergy may indicate hypersensitivity to other metals. However, it is crucial to understand that increased metal exposure after implant-placement may lead to a stronger immune response (metal reactivity). For more information, see Pre-testing.

    You may need to check with your healthcare professional for the exact metal content of a device or implant.

    To decide what to test for in MELISA consider the following:

    Do you have any dental restorations; silver/amalgam fillings, crowns, bridges, implants and orthodontic braces/retainer?

    Do you have any orthopaedic devices; knee, hip, shoulder replacements, pins and plates?

    Do you have any cardio and vascular devices: embolization coils, stents, septal occluders, implanted defibrillators and pacemakers?

    What about environmental or occupational exposure; jewellery, cell phones, coins, certain foods and medications etc.

    A detailed overview of metals found in frequently used dental and orthopaedic restorations as well as an overview of metals present in our environment can be found at Metal exposure.

    Please see Testing panels for more information on what metals can be tested in MELISA.

Layout 2 - heading on the left, content on the right

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