SCIENTIFIC ARTICLE
A Delayed Allergic Reaction to Polypropylene Suture Used in Flexor Tendon Repair: Case Report Mohammad M. Al-Qattan, MBBS,* Hala Kfoury, MD*
We report a patient who developed a delayed hypersensitivity reaction to a polypropylene suture used in flexor pollicis longus repair. We also review the literature and aim to increase the awareness of hand surgeons to the presentation, diagnosis, and management of these rare cases. (J Hand Surg Am. 2015;40(7):1377e1381. Copyright Ó 2015 by the American Society for Surgery of the Hand. All rights reserved.) Key words Suture, allergy, flexor tendon.
T
WO DIFFERENT TYPES OF REACTIONS are known to occur in response to sutures and devices used in flexor tendon repair: early foreign body and delayed hypersensitivity (allergic) reactions. At the histological level, foreign body reactions to sutures occur in 100% of cases and are characterized by an inflammatory zone around the suture and the presence of multinucleated giant cells.1 This is generally considered as a “normal” body reaction to any foreign material at any site and is not specific for flexor tendons. In most cases, the foreign body reaction has no clinical importance, although severe reactions may be symptomatic and present as discharging skin sinuses (with aseptic drainage) at the site of flexor tendon repair.2 Experimentally, authors quantify this microscopic reaction either by measuring the width of inflammatory zone (WIZ) or by counting giant cells per high-power field.1 Generally, foreign body reactions to absorbable sutures such as polyglactin are more intense than reactions to nonabsorbable sutures.2 Esenyel et al1 studied the early foreign body reaction to various nonabsorbable sutures used in Achilles tendon repair. This early reaction was severe
From the *Departments of Surgery and Pathology, King Saud University, Riyadh, Saudi Arabia. Received for publication January 23, 2015; accepted in revised form March 3, 2015. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: M. M. Al-Qattan, MBBS, PO Box 18097, Riyadh 11415, Saudi Arabia; e-mail: [email protected]. 0363-5023/15/4007-0014$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2015.03.004
with braided polyester, moderate with polypropylene, and relatively mild with polyethylene. Esenyel et al1 considered a mean WIZ of less than 2 mm as mild, 2 to 6 mm as moderate, and more than 6 mm as severe. Delayed hypersensitivity reactions to sutures are rare and occur late. Furthermore, the presentation is variable and the patient does not usually have a history of an allergic reaction to sutures. Hence, the diagnosis is usually delayed or missed. This entity has not received much attention in the hand surgery literature.3 We report a patient who developed a delayed hypersensitivity reaction to a polypropylene suture used in flexor pollicis longus repair. We also aim to review the literature on this entity and increase the awareness of hand surgeons to the presentation, diagnosis, and management of these rare cases. CASE REPORT A 30-year-old man sustained a glass laceration resulting in zone I injury of the flexor pollicis longus tendon. Repair was done at his local hospital with a polypropylene core suture. No peripheral sutures were used, and the skin was closed with polyglactin sutures. The postoperative course was uneventful with recovery of 0 to 50 of motion at the interphalangeal (IP) joint of the thumb. Two and a half months later, the patient noted a slowly growing diffuse subcutaneous swelling at the site of tendon repair, and the range of motion at the IP joint decreased to 0 to 40 despite home exercises. The patient obtained medical advice from several hand surgeons (including the original surgeon), and he was given the clinical diagnosis of
Ó 2015 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
1377
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SUTURE REACTION
FIGURE 1: Clinical pictures. A Intraoperative picture following digital block. Note the mass (arrow) at the site of the tendon repair. B The thin white pseudocapsule surrounding the tendon repair site. C This layer was incised, and the suture was removed. Note the gelatin-like material. Only biopsies were taken, and no attempt was made to completely excise the mass. D Complete resolution of symptoms one month following removal of the tendon suture.
FIGURE 2: Histopathological pictures. A Low power (hematoxylin-eosin stain; magnification 40) shows chronic inflammatory cells in a myxoid background (arrow) and no granuloma formation. B High power (hematoxylin-eosin stain; magnification 400) shows plasma cells (arrow).
excessive fibrosis. Advice was given to do daily massage and continue exercises. The patient presented to the senior author (M.A.-Q.) at 14 weeks postrepair (Fig. 1). The diffuse subcutaneous swelling measured 2 1 cm and was slightly tender on palpation. There was no overlying erythema or blistering. The active range of motion at the IP joint was 0 to 25 . There were no constitutional symptoms (such as fever), no lymphadenopathy, and no other abnormalities on systemic examination. Complete blood count showed mild lymphocytosis (4,100/mL) and the erythrocyte sedimentation rate (ESR) was 20 mm/h. X-ray of the thumb showed no bony abnormalities or soft tissue calcifications. Surgical exploration was done under a digital block. Upon elevation of the skin, a thin white J Hand Surg Am.
pseudocapsule was seen surrounding the tendon repair site (Fig. 1). The pseudocapsule was incised, revealing gelatin-like material surrounding the blue polypropylene suture. The suture was removed and biopsies were taken for bacterial, fungal, and mycobacterial cultures and for histopathological examination. No attempt was made to completely remove the mass because the diagnosis was still unclear and because of the potential risk of tendon rupture. The skin was closed using polyglactin sutures, and no orthosis was used. No antibiotics were given. The postoperative recovery was uneventful, and all cultures were negative. Histopathological examination showed chronic inflammatory cells (foamy histiocytes, lymphocytes, and plasma cells) in a myxoid background (Fig. 2). There were only few r
Vol. 40, July 2015
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SUTURE REACTION
TABLE 1.
Presentation of Allergic Reactions to Sutures, Prostheses, and Devices Used in Hand Surgery
Suture, Prosthesis, or Device
Presentation
Reported Cases
Polypropylene, polyamide, stainless steel, and polyethylene sutures
In flexor tendons: slowly growing solid mass In skin closure (retained skin suture): chronic skin eczema
A reaction to polypropylene in the current case. Reactions to polyethylene were only reported in Achilles tendon repair.15
Braided polyester sutures
Solid or cystic mass
One case in the hand8 and another in the subscapularis tendon9
Stainless steel and other metal prostheses and plates
Pain, swelling, and bone resorption. An overlying skin rash may be present. Rarely, an acute anaphylactic reaction may occur.
This is the most common with several cases reported in the orthopedic literature.3 Two cases of reactions to trapeziometacarpal prostheses were reported.17 One patient with a metacarpal fracture who had a history of anaphylaxis to the cobalt component of stainless steel was reported.18
Mitek anchor
Mass at the repair site as well as osteolysis at the bony insertion
One case in the hand19
polymorphonuclear cells. There was no evidence of granuloma formation or foreign body giant cell reaction. The findings were consistent with an allergic reaction and not a foreign body reaction. After an informed consent, a 4-0 blue polypropylene suture was sutured into the skin of the back of the patient. An intense erythematous reaction with vesicles was seen at 48 hours, confirming an allergic response. The dermatologist recommended further skin testing to determine if the allergy was to polypropylene or to the blue dye (phtalocyanine) of the suture, but the patient declined further testing. The swelling in the thumb gradually resolved within 1 month (Fig. 1), and the range of motion improved to 0 to 40 at the IP joint at final follow-up 3 months later. A repeat blood test showed a normal blood count, and the ESR was 5 mm/h.
also present as a slowly growing mass of the nasal tip4 or the conjunctiva.5,6 The initial diagnosis at the time of presentation of these cases was as an abscess,4 a giant papillary growth,5 or a malignant tumor.6 Polypropylene is also commonly used in skin closure. Delayed allergic reaction to polypropylene within the skin presents as a chronic eczematous reaction or erythema with vesicles, and this has been documented in cases of retained polypropylene sutures7 within the skin and in skin testing for polypropylene allegy.4 Delayed hypersensitivity reactions secondary to other sutures have also been reported. Braided polyester is commonly used for flexor tendon repair. Pabari et al8 reported a case of a delayed reaction to braided polyester 4 months following repair of a flexor tendon in zone III. The presentation was painless cystic swelling. Histological examination showed histiocytes and lymphocytes; the symptoms resolved following suture removal. A similar reaction to braided polyester was described following the repair of the subscapularis tendon.9 Polyamide is also widely used for flexor tendon repair. Our literature search did not reveal delayed allergic reactions to polyamide in flexor tendon repair. However, allergic reactions to polyamide have been reported following its use in eye surgery.10 Raap et al11 reported on a case of a delayed allergic reaction to polyamide suture following its use in skin closure. Skin testing revealed that the allergy was to the dye of the suture and not to the polyamide. Although silk is not used for flexor tendon repair, recent literature suggests that braided spider silk sutures resist cyclic loading and, hence, could be suitable for use in flexor tendon repair.12 The silk “fibroin” may
DISCUSSION We document an allergic reaction to a polypropylene suture used in flexor tendon repair. The presentation was a slowly growing mass, and blood tests showed mild lymphocytosis and a mildly elevated ESR. The diagnosis was confirmed by histological examination and skin testing. There was no need to completely excise the chronic inflammatory mass, which would risk tendon rupture. Spontaneous resolution of symptoms was expected following removal of the suture. Polypropylene sutures are synthetic nonabsorbable monofilament sutures available as colorless or dyed. Our case presented with a slowly growing mass, and the diagnosis was delayed. A review of the literature noted that delayed allergic reactions to polypropylene J Hand Surg Am.
r
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SUTURE REACTION
rarely induce an immunoglobulin Eemediated hypersensitivity.13 Finally, polyethylene is commonly used in Achilles tendon repair and is gaining popularity in flexor tendon repair. Polyethylene debris is able to incite a delayed cell-mediated reaction,14 and this presents clinically as a slowly growing mass within the sutured flexor tendon.15 There has been a recent interest in the use of stainless steel in flexor tendon repair. Although we found no cases of stainless steel allergy in flexor tendons, metal allergy to stainless steel is not as rare as allergy to nonmetallic sutures.16 Several cases of stainless steel allergy have been reported following the use of stainless steel prostheses or plates in orthopedic surgery.16 Manifestations include eczematous or bullous reactions in the overlying skin and loosening of the implant. In the hand, Smith et al17 reported 2 cases of metal allergy to trapeziometacarpal prostheses. Both patients developed swelling and pain 2 to 4 months after surgery, and skin testing confirmed allergy to cobalt. Symptoms resolved after removal of the prostheses. Stainless steel contains nickel, cobalt, and chromium, but nickel is the most common ion implicated in metal allergies. It is also important to note that some allergic patients develop a systemic anaphylactic reaction to any of the components of stainless steel, and this has implications in hand surgery. Haas and Savage18 reported on the management of an oblique metacarpal fracture in a patient with a history of anaphylaxis to the cobalt component of stainless steel. A large dose of corticosteroid was given during bone drilling. Fixation of the fracture was then done using interosseous polyamide sutures instead of screws or K-wires. Currently, many hand plating systems have titanium implants (with only trace levels of nickel) that could be used instead of stainless steel in patients with implant allergy.3 Suture anchors are a common repair technique for flexor profundus tendon avulsions. Giannikas et al19 reported on a case of distal zone I flexor tendon laceration repaired with Mitek anchor (Depuy Synthes, Raynham, MA). Several months later, a subcutaneous mass appeared at the site of the anchor. The mass kept growing and an ulcer appeared. X-ray showed osteolysis around the anchor. Complete resolution of symptoms and signs occurred following the removal of anchor. Similar delayed reactions were reported following the use of Mitek anchors in shoulder surgery.20 Thomopoulos et al21 studied the use of a magnesiumbased bone adhesive to enhance the tensile strength of flexor tendonetoebone healing in the management of flexor digitorum profundus avulsion injuries. The J Hand Surg Am.
tensile properties at time zero were higher in the adhesive group than in the control group. However, the tensile strength and bone density became significantly lower at the 3-week interval because of a delayed allergic response to the adhesive. Hence, the use of such adhesives was not recommended for clinical use. The hand surgeon should be aware of the rare entity of delayed allergic reactions to sutures and devices used in flexor tendon repair. The presentation and the number of cases reported in hand surgery are summarized in Table 1. The diagnosis should be confirmed by histology and skin testing. Management is based on removal and avoiding the causative agent. We stress the proper diagnosis and management of hypersensitivity as opposed to recommending the use of specific materials in flexor tendon repair. ACKNOWLEDGMENT The work was funded by the College of Medicine Research Center, Deanship of Scientific Research, King Saud University, Riyadh, Saudi Arabia. REFERENCES 1. Esenyel CZ, Demirham M, Kiliçoglu O, et al. Evaluation of soft tissue reactions to three non-absorbable suture materials in a rabbit model [in Turkish]. Acta Orthop Traumatol Turc. 2009;43(4): 366e372. 2. Bekler H, Beyzadeoglu T, Gökçe A, Servet E. Aseptic drainage associated with polglactin sutures used for repair of Achilles tendon ruptures [in Turkish]. Acta Orthop Traumatol Turc. 2008;42(2): 135e138. 3. Mahmood B, Hammert WC. Metal implant allergy. J Hand Surg Am. 2015 Jan 29. Epub ahead of print. 4. Teymoortash A, Fasunla JA, Pfutzner W, Steinbach-Hundt S. Nasal tip abscess due to adverse skin reaction to Prolene: an unusual long term complication of rhinoplasty. J Laryngol Otol. 2013;127(1): 76e79. 5. Skrypuch OW, Willis NR. Giant papillary conjunctivitis from an exposed prolene suture. Can J Ophthalmol. 1986;21(5):189e192. 6. Chung HS, Feder RS, Weston BC, Bryar PJ. Suture reaction masquerading as a conjunctival malignancy. Can J Ophthalmol. 2006;41(2):207e209. 7. Ascherman JA, Hunter CJ, Bickers DR. Refractory eczematous dermatitis associated with retained suture material. Ann Plast Surg. 2006;56(2):205e207. 8. Pabari A, Iyer S, Branford OA, Armstrong AP. Palmar granuloma following flexor tendon repair suing Ticron: a case for absorbable suture material? J Plast Reconstr Aesthet Surg. 2011;64(3): 409e411. 9. Warme WJ, Burroughs RF, Ferguson T. Late foreign body reaction to Ticron sutures following inferior capsular shift: a case report. Am J Sport Med. 2004;32(1):232e236. 10. Schechter RJ. Nylon suture toxicity after vitrectomy surgery. Ann Ophthalmol. 1990;22(9):352e353. 11. Raap U, Wieczorek D, Kapp A, Wedi B. Allergic contact dermatitis to acid blue 158 in suture material. Contact Dermatitis. 2008;59(3): 192e193.
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17. Smith E, Mehta AJ, Statham BN. Metal sensitivity to Elektra prostheses—two cases from a metal on metal implant for hand joint replacement. Contact Dermatitis. 2009;60(5):298. 18. Haas SB, Savage RC. Metacarpal fracture fixations with interosseous nylon suture in a patient with metal allergies. J Hand Surg Am. 1989;14(1):107e110. 19. Giannikas D, Athanaselis E, Matzaroglou C, Saridis A, Tyllianakis M. An unusual complication of Mitek suture anchor use in primary treatment of flexor distorum profundus tendon laceration: a case report. Cases J. 2009;2:9319. 20. Park HB, Keyurapan E, Gill HS, Selhi HS, McFarland EG. Suture anchors and tacks for shoulder surgery, part II: the prevention and treatment of complications. Am J Sports Med. 2006;34(1): 136e144. 21. Thomopoulos S, Zampiakis E, Das R, et al. Use of magnesium-based bone adhesive for flexor tendon-to-bone healing. J Hand Surg Am. 2009;34(6):1066e1073.
12. Hennecke K, Redeker J, Kuhbier W, et al. Bundles of spider silk, braided into suture, resist basic cyclic tests: potential use for flexor tendon repair. PLoS One. 8(4):e61100. 13. Kurosaki S, Otsuka H, Kunimoto M, et al. Fibroin allergy. IgE mediated hypersensitivity to silk suture materials. Nihon Ika Daigaku Zasshi. 1999;66(1):41e44. 14. Catelas I, Huk OL, Petit A, Zukor DJ, Marchand R, Yahia L. Flow cytometric analysis of macrophage response to ceramic and polyethylene particles: effects of size, concentration, and composition. J Biomed Mater Res. 1998;41(4):600e607. 15. Ollivere BJ, Bosman HA, Bearcroft PW, Robinson AH. Foreign body granulomatous reaction associated with polyethylene (Fiberwire) suture material used in Achilles tendon repair. Foot Ankle Surg. 2014;20(2):e27ee29. 16. Basko-Plluska JL, Thyssen JP, Schalock PC. Cutaneous and systemic hypersensitivity reactions to metallic implants. Dermatitis. 2011;22(2): 65e79.
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A Delayed Allergic Reaction to Polypropylene Suture Used in Flexor Tendon Repair: Case Report Mohammad M. Al-Qattan, MBBS,* Hala Kfoury, MD*
We report a patient who developed a delayed hypersensitivity reaction to a polypropylene suture used in flexor pollicis longus repair. We also review the literature and aim to increase the awareness of hand surgeons to the presentation, diagnosis, and management of these rare cases. (J Hand Surg Am. 2015;40(7):1377e1381. Copyright Ó 2015 by the American Society for Surgery of the Hand. All rights reserved.) Key words Suture, allergy, flexor tendon.
T
WO DIFFERENT TYPES OF REACTIONS are known to occur in response to sutures and devices used in flexor tendon repair: early foreign body and delayed hypersensitivity (allergic) reactions. At the histological level, foreign body reactions to sutures occur in 100% of cases and are characterized by an inflammatory zone around the suture and the presence of multinucleated giant cells.1 This is generally considered as a “normal” body reaction to any foreign material at any site and is not specific for flexor tendons. In most cases, the foreign body reaction has no clinical importance, although severe reactions may be symptomatic and present as discharging skin sinuses (with aseptic drainage) at the site of flexor tendon repair.2 Experimentally, authors quantify this microscopic reaction either by measuring the width of inflammatory zone (WIZ) or by counting giant cells per high-power field.1 Generally, foreign body reactions to absorbable sutures such as polyglactin are more intense than reactions to nonabsorbable sutures.2 Esenyel et al1 studied the early foreign body reaction to various nonabsorbable sutures used in Achilles tendon repair. This early reaction was severe
From the *Departments of Surgery and Pathology, King Saud University, Riyadh, Saudi Arabia. Received for publication January 23, 2015; accepted in revised form March 3, 2015. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: M. M. Al-Qattan, MBBS, PO Box 18097, Riyadh 11415, Saudi Arabia; e-mail: [email protected]. 0363-5023/15/4007-0014$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2015.03.004
with braided polyester, moderate with polypropylene, and relatively mild with polyethylene. Esenyel et al1 considered a mean WIZ of less than 2 mm as mild, 2 to 6 mm as moderate, and more than 6 mm as severe. Delayed hypersensitivity reactions to sutures are rare and occur late. Furthermore, the presentation is variable and the patient does not usually have a history of an allergic reaction to sutures. Hence, the diagnosis is usually delayed or missed. This entity has not received much attention in the hand surgery literature.3 We report a patient who developed a delayed hypersensitivity reaction to a polypropylene suture used in flexor pollicis longus repair. We also aim to review the literature on this entity and increase the awareness of hand surgeons to the presentation, diagnosis, and management of these rare cases. CASE REPORT A 30-year-old man sustained a glass laceration resulting in zone I injury of the flexor pollicis longus tendon. Repair was done at his local hospital with a polypropylene core suture. No peripheral sutures were used, and the skin was closed with polyglactin sutures. The postoperative course was uneventful with recovery of 0 to 50 of motion at the interphalangeal (IP) joint of the thumb. Two and a half months later, the patient noted a slowly growing diffuse subcutaneous swelling at the site of tendon repair, and the range of motion at the IP joint decreased to 0 to 40 despite home exercises. The patient obtained medical advice from several hand surgeons (including the original surgeon), and he was given the clinical diagnosis of
Ó 2015 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
1377
1378
SUTURE REACTION
FIGURE 1: Clinical pictures. A Intraoperative picture following digital block. Note the mass (arrow) at the site of the tendon repair. B The thin white pseudocapsule surrounding the tendon repair site. C This layer was incised, and the suture was removed. Note the gelatin-like material. Only biopsies were taken, and no attempt was made to completely excise the mass. D Complete resolution of symptoms one month following removal of the tendon suture.
FIGURE 2: Histopathological pictures. A Low power (hematoxylin-eosin stain; magnification 40) shows chronic inflammatory cells in a myxoid background (arrow) and no granuloma formation. B High power (hematoxylin-eosin stain; magnification 400) shows plasma cells (arrow).
excessive fibrosis. Advice was given to do daily massage and continue exercises. The patient presented to the senior author (M.A.-Q.) at 14 weeks postrepair (Fig. 1). The diffuse subcutaneous swelling measured 2 1 cm and was slightly tender on palpation. There was no overlying erythema or blistering. The active range of motion at the IP joint was 0 to 25 . There were no constitutional symptoms (such as fever), no lymphadenopathy, and no other abnormalities on systemic examination. Complete blood count showed mild lymphocytosis (4,100/mL) and the erythrocyte sedimentation rate (ESR) was 20 mm/h. X-ray of the thumb showed no bony abnormalities or soft tissue calcifications. Surgical exploration was done under a digital block. Upon elevation of the skin, a thin white J Hand Surg Am.
pseudocapsule was seen surrounding the tendon repair site (Fig. 1). The pseudocapsule was incised, revealing gelatin-like material surrounding the blue polypropylene suture. The suture was removed and biopsies were taken for bacterial, fungal, and mycobacterial cultures and for histopathological examination. No attempt was made to completely remove the mass because the diagnosis was still unclear and because of the potential risk of tendon rupture. The skin was closed using polyglactin sutures, and no orthosis was used. No antibiotics were given. The postoperative recovery was uneventful, and all cultures were negative. Histopathological examination showed chronic inflammatory cells (foamy histiocytes, lymphocytes, and plasma cells) in a myxoid background (Fig. 2). There were only few r
Vol. 40, July 2015
1379
SUTURE REACTION
TABLE 1.
Presentation of Allergic Reactions to Sutures, Prostheses, and Devices Used in Hand Surgery
Suture, Prosthesis, or Device
Presentation
Reported Cases
Polypropylene, polyamide, stainless steel, and polyethylene sutures
In flexor tendons: slowly growing solid mass In skin closure (retained skin suture): chronic skin eczema
A reaction to polypropylene in the current case. Reactions to polyethylene were only reported in Achilles tendon repair.15
Braided polyester sutures
Solid or cystic mass
One case in the hand8 and another in the subscapularis tendon9
Stainless steel and other metal prostheses and plates
Pain, swelling, and bone resorption. An overlying skin rash may be present. Rarely, an acute anaphylactic reaction may occur.
This is the most common with several cases reported in the orthopedic literature.3 Two cases of reactions to trapeziometacarpal prostheses were reported.17 One patient with a metacarpal fracture who had a history of anaphylaxis to the cobalt component of stainless steel was reported.18
Mitek anchor
Mass at the repair site as well as osteolysis at the bony insertion
One case in the hand19
polymorphonuclear cells. There was no evidence of granuloma formation or foreign body giant cell reaction. The findings were consistent with an allergic reaction and not a foreign body reaction. After an informed consent, a 4-0 blue polypropylene suture was sutured into the skin of the back of the patient. An intense erythematous reaction with vesicles was seen at 48 hours, confirming an allergic response. The dermatologist recommended further skin testing to determine if the allergy was to polypropylene or to the blue dye (phtalocyanine) of the suture, but the patient declined further testing. The swelling in the thumb gradually resolved within 1 month (Fig. 1), and the range of motion improved to 0 to 40 at the IP joint at final follow-up 3 months later. A repeat blood test showed a normal blood count, and the ESR was 5 mm/h.
also present as a slowly growing mass of the nasal tip4 or the conjunctiva.5,6 The initial diagnosis at the time of presentation of these cases was as an abscess,4 a giant papillary growth,5 or a malignant tumor.6 Polypropylene is also commonly used in skin closure. Delayed allergic reaction to polypropylene within the skin presents as a chronic eczematous reaction or erythema with vesicles, and this has been documented in cases of retained polypropylene sutures7 within the skin and in skin testing for polypropylene allegy.4 Delayed hypersensitivity reactions secondary to other sutures have also been reported. Braided polyester is commonly used for flexor tendon repair. Pabari et al8 reported a case of a delayed reaction to braided polyester 4 months following repair of a flexor tendon in zone III. The presentation was painless cystic swelling. Histological examination showed histiocytes and lymphocytes; the symptoms resolved following suture removal. A similar reaction to braided polyester was described following the repair of the subscapularis tendon.9 Polyamide is also widely used for flexor tendon repair. Our literature search did not reveal delayed allergic reactions to polyamide in flexor tendon repair. However, allergic reactions to polyamide have been reported following its use in eye surgery.10 Raap et al11 reported on a case of a delayed allergic reaction to polyamide suture following its use in skin closure. Skin testing revealed that the allergy was to the dye of the suture and not to the polyamide. Although silk is not used for flexor tendon repair, recent literature suggests that braided spider silk sutures resist cyclic loading and, hence, could be suitable for use in flexor tendon repair.12 The silk “fibroin” may
DISCUSSION We document an allergic reaction to a polypropylene suture used in flexor tendon repair. The presentation was a slowly growing mass, and blood tests showed mild lymphocytosis and a mildly elevated ESR. The diagnosis was confirmed by histological examination and skin testing. There was no need to completely excise the chronic inflammatory mass, which would risk tendon rupture. Spontaneous resolution of symptoms was expected following removal of the suture. Polypropylene sutures are synthetic nonabsorbable monofilament sutures available as colorless or dyed. Our case presented with a slowly growing mass, and the diagnosis was delayed. A review of the literature noted that delayed allergic reactions to polypropylene J Hand Surg Am.
r
Vol. 40, July 2015
1380
SUTURE REACTION
rarely induce an immunoglobulin Eemediated hypersensitivity.13 Finally, polyethylene is commonly used in Achilles tendon repair and is gaining popularity in flexor tendon repair. Polyethylene debris is able to incite a delayed cell-mediated reaction,14 and this presents clinically as a slowly growing mass within the sutured flexor tendon.15 There has been a recent interest in the use of stainless steel in flexor tendon repair. Although we found no cases of stainless steel allergy in flexor tendons, metal allergy to stainless steel is not as rare as allergy to nonmetallic sutures.16 Several cases of stainless steel allergy have been reported following the use of stainless steel prostheses or plates in orthopedic surgery.16 Manifestations include eczematous or bullous reactions in the overlying skin and loosening of the implant. In the hand, Smith et al17 reported 2 cases of metal allergy to trapeziometacarpal prostheses. Both patients developed swelling and pain 2 to 4 months after surgery, and skin testing confirmed allergy to cobalt. Symptoms resolved after removal of the prostheses. Stainless steel contains nickel, cobalt, and chromium, but nickel is the most common ion implicated in metal allergies. It is also important to note that some allergic patients develop a systemic anaphylactic reaction to any of the components of stainless steel, and this has implications in hand surgery. Haas and Savage18 reported on the management of an oblique metacarpal fracture in a patient with a history of anaphylaxis to the cobalt component of stainless steel. A large dose of corticosteroid was given during bone drilling. Fixation of the fracture was then done using interosseous polyamide sutures instead of screws or K-wires. Currently, many hand plating systems have titanium implants (with only trace levels of nickel) that could be used instead of stainless steel in patients with implant allergy.3 Suture anchors are a common repair technique for flexor profundus tendon avulsions. Giannikas et al19 reported on a case of distal zone I flexor tendon laceration repaired with Mitek anchor (Depuy Synthes, Raynham, MA). Several months later, a subcutaneous mass appeared at the site of the anchor. The mass kept growing and an ulcer appeared. X-ray showed osteolysis around the anchor. Complete resolution of symptoms and signs occurred following the removal of anchor. Similar delayed reactions were reported following the use of Mitek anchors in shoulder surgery.20 Thomopoulos et al21 studied the use of a magnesiumbased bone adhesive to enhance the tensile strength of flexor tendonetoebone healing in the management of flexor digitorum profundus avulsion injuries. The J Hand Surg Am.
tensile properties at time zero were higher in the adhesive group than in the control group. However, the tensile strength and bone density became significantly lower at the 3-week interval because of a delayed allergic response to the adhesive. Hence, the use of such adhesives was not recommended for clinical use. The hand surgeon should be aware of the rare entity of delayed allergic reactions to sutures and devices used in flexor tendon repair. The presentation and the number of cases reported in hand surgery are summarized in Table 1. The diagnosis should be confirmed by histology and skin testing. Management is based on removal and avoiding the causative agent. We stress the proper diagnosis and management of hypersensitivity as opposed to recommending the use of specific materials in flexor tendon repair. ACKNOWLEDGMENT The work was funded by the College of Medicine Research Center, Deanship of Scientific Research, King Saud University, Riyadh, Saudi Arabia. REFERENCES 1. Esenyel CZ, Demirham M, Kiliçoglu O, et al. Evaluation of soft tissue reactions to three non-absorbable suture materials in a rabbit model [in Turkish]. Acta Orthop Traumatol Turc. 2009;43(4): 366e372. 2. Bekler H, Beyzadeoglu T, Gökçe A, Servet E. Aseptic drainage associated with polglactin sutures used for repair of Achilles tendon ruptures [in Turkish]. Acta Orthop Traumatol Turc. 2008;42(2): 135e138. 3. Mahmood B, Hammert WC. Metal implant allergy. J Hand Surg Am. 2015 Jan 29. Epub ahead of print. 4. Teymoortash A, Fasunla JA, Pfutzner W, Steinbach-Hundt S. Nasal tip abscess due to adverse skin reaction to Prolene: an unusual long term complication of rhinoplasty. J Laryngol Otol. 2013;127(1): 76e79. 5. Skrypuch OW, Willis NR. Giant papillary conjunctivitis from an exposed prolene suture. Can J Ophthalmol. 1986;21(5):189e192. 6. Chung HS, Feder RS, Weston BC, Bryar PJ. Suture reaction masquerading as a conjunctival malignancy. Can J Ophthalmol. 2006;41(2):207e209. 7. Ascherman JA, Hunter CJ, Bickers DR. Refractory eczematous dermatitis associated with retained suture material. Ann Plast Surg. 2006;56(2):205e207. 8. Pabari A, Iyer S, Branford OA, Armstrong AP. Palmar granuloma following flexor tendon repair suing Ticron: a case for absorbable suture material? J Plast Reconstr Aesthet Surg. 2011;64(3): 409e411. 9. Warme WJ, Burroughs RF, Ferguson T. Late foreign body reaction to Ticron sutures following inferior capsular shift: a case report. Am J Sport Med. 2004;32(1):232e236. 10. Schechter RJ. Nylon suture toxicity after vitrectomy surgery. Ann Ophthalmol. 1990;22(9):352e353. 11. Raap U, Wieczorek D, Kapp A, Wedi B. Allergic contact dermatitis to acid blue 158 in suture material. Contact Dermatitis. 2008;59(3): 192e193.
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17. Smith E, Mehta AJ, Statham BN. Metal sensitivity to Elektra prostheses—two cases from a metal on metal implant for hand joint replacement. Contact Dermatitis. 2009;60(5):298. 18. Haas SB, Savage RC. Metacarpal fracture fixations with interosseous nylon suture in a patient with metal allergies. J Hand Surg Am. 1989;14(1):107e110. 19. Giannikas D, Athanaselis E, Matzaroglou C, Saridis A, Tyllianakis M. An unusual complication of Mitek suture anchor use in primary treatment of flexor distorum profundus tendon laceration: a case report. Cases J. 2009;2:9319. 20. Park HB, Keyurapan E, Gill HS, Selhi HS, McFarland EG. Suture anchors and tacks for shoulder surgery, part II: the prevention and treatment of complications. Am J Sports Med. 2006;34(1): 136e144. 21. Thomopoulos S, Zampiakis E, Das R, et al. Use of magnesium-based bone adhesive for flexor tendon-to-bone healing. J Hand Surg Am. 2009;34(6):1066e1073.
12. Hennecke K, Redeker J, Kuhbier W, et al. Bundles of spider silk, braided into suture, resist basic cyclic tests: potential use for flexor tendon repair. PLoS One. 8(4):e61100. 13. Kurosaki S, Otsuka H, Kunimoto M, et al. Fibroin allergy. IgE mediated hypersensitivity to silk suture materials. Nihon Ika Daigaku Zasshi. 1999;66(1):41e44. 14. Catelas I, Huk OL, Petit A, Zukor DJ, Marchand R, Yahia L. Flow cytometric analysis of macrophage response to ceramic and polyethylene particles: effects of size, concentration, and composition. J Biomed Mater Res. 1998;41(4):600e607. 15. Ollivere BJ, Bosman HA, Bearcroft PW, Robinson AH. Foreign body granulomatous reaction associated with polyethylene (Fiberwire) suture material used in Achilles tendon repair. Foot Ankle Surg. 2014;20(2):e27ee29. 16. Basko-Plluska JL, Thyssen JP, Schalock PC. Cutaneous and systemic hypersensitivity reactions to metallic implants. Dermatitis. 2011;22(2): 65e79.
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