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OCR for page 814
Environmental Medicine: Integrating a Missing Element into Medical Education Contact Dermatitis in Surgeons from Methylmethacrylate Bone Cement BY IAN BLAIR FRIES, M.D.*, ALEXANDER A.FISHER, M.D.†, AND EDUARDO A.SALVATI, M.D.*, NEW YORK, N.Y. From the Hospital for Special Surgery Affiliated with the New York Hospital- Cornell University Medical College, New York City In 1956, Fisher identified methylmethacrylate monomer as the cause of allergic dermatitis in four dentists and dental laboratory technicians who had come in repeated contact with acrylic denture materials, and this was also reported in one orthopaedic surgeon handling bone cement2. Methylmethacrylate monomer does diffuse through intact surgical rubber gloves2. An allergic eruption on the hands of one of the authors (I.B.F.) stimulated us to investigate the allergenic effects of bone cement. Case Report In 1972, I.B.F. frequently participated as assistant surgeon in cases of total joint replacements. Often this required that he mix and handle methylmethacrylate cement. Routinely the operation was done with two pain of gloves, the outer pair being chanced frequently. Often it was changed just prior to handling the cement. A mild pruritis in the fingers first developed the night following operations, but no treatment was sought. Some paresthesias also developed which were attributed to over-tight gloves. However, larger gloves did not alleviate the symptoms. At the end of 1972, he performed two joint-replacement procedures. Following the first he experienced pruritis, swelling, and erythema of the right and left index fingers and the right long finger. This subsided spontaneously in a few days. After the second operation, a week later, the same symptoms reappeared, this time associated with a localized vesicular eruption. Overnight incapacitating deep tenderness developed in these fingers, making it impossible for him to operate for three weeks. Extensive patch tests were performed with a number of suspected contactants, but the only positive patch test was to methylmethacrylate monomer. The dermatitis was successfully treated with topical steroid ointment. The skin of the affected fingers remained atrophic and scaling for about three weeks, and deep tenderness and parethesias lasted for about two months. After this episode, recurrence of the dermatitis was prevented by avoiding contact with bone cement, that is, the cement was handled by other members of the surgical team. We collected thirteen cases of dermatitis in handlers of bone cement, including nine in active orthopaedic surgeons. Of these, seven demonstrated patch-test sensitivity to methylmethacrylate monomer (10 per cent in olive oil). We consider these seven to be cases of true allergic contact dermatitis characterized by itching, erythema, edema, and vesiculation followed by eczematization (Fig. 1). Three of * 535 East 70th Street, New York, N.Y. 10021. † University Hospital, New York University Medical Center, New York N.Y. Reprinted with permission from Journal of Bone and Joint Surgery 57-A(4):547–9, Copyright 1975, Journal of Bone and Joint Surgery.
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Environmental Medicine: Integrating a Missing Element into Medical Education FIG. 1 the subjects showed complete resolution of their eruption with careful avoidance of the monomer, but did not demonstrate a positive patch test. We do not consider their reactions to be allergic. The dermatitis was marked by the presence of dryness and fissuring of the finger tips, but without pruritis and vesicle formation. Three of the patients were identified through correspondence and have not yet been fully characterized as allergic. The observations of Pegum and Medhurst led us to examine different types of surgical gloves in the hope of finding one that would successfully isolate the surgeon’s hands from the monomer. Glove fingers were cut off intact gloves and filled with small amounts of powdered polymer. The tips of these filled glove fingers were immersed in glass vials containing monomer. A test period of twenty minutes was chosen as the maximum time a surgeon might be in cedure. After twenty minutes the filled glove fingers were removed from the monomer and the contents were excontact with the bone cement during any one operative proamined. In all cases partial to complete polymerization of the powdered polymethylmethacrylate was noted, indicating that monomer had diffused directly through the gloves. The majority of the gloves also showed evidence of direct attack by the monomer. One type of glove completely disintegrated. The vinyl glove tips were markedly affected, and most latex rubber gloves showed wrinkling and brittleness. In many of the trials the monomer solution was discolored by leaching of dye from the gloves. In approximately one-third of the samples the polymerized cement also took on coloration from contact with the gloves (Table I). The unique and consistent feature of the dermatitis from bone cement was paresthesia. Deep tenderness was also common and outlasted the duration of the eruption. Methylmethacrylate monomer is a lipid solvent. The irritant effect of the monomer is probably due to its ability to degrease the skin and penetrate the subcutaneous tissue. Apparently some surgeons with a mild sensitivity are able to avoid the dermatitis by using three layers of gloves during handling of the cement, and then immediately removing the outer two, or possibly all three gloves. Multiple gloves tend TABLE I GLOVE TESTS Type of Glove Polymerization after 20 Min. Glove Damage Monomer Discolored Polymer Discolored Abbott—Latex Surgeon’s +++ ++ + − Arbrook Micro-touch, Latex Medical ++ + − − Arbrook Micro-touch, Vinyl Medical +++ ++ − + Arlin Poly-Version (Polyethylene) + + − − Bard-Parker, Thru-touch Vinyl +++ ++ ++ + Danpren Elastren * ++++ + * Dart Industries “Seamless” Limber Latex Surgeon’s ++ + − − Dart Industries “Seamless” Original Brown Milled Surgeon’s +++ ++ +++ +++ Dow Silastic Sheet +++ ++ − − Fisher Polygloves (Polyethylene) + − − − Parke-Davis Eudermic Surgeon’s +++ − − − Parke-Davis Examination +++ +++ − ++ Parke-Davis “Spectra” Surgeon’s +++ + + − Perry Latex Surgeon’s +++ + + + Perry Latex Surgeon’s Orthopaedic ++ + + − Pioneer ++ + − − Tomac Latex Exam +++ − + + Tomac “Thin-tip” +++ + + − *No polymerization, glove disintegrated.
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Environmental Medicine: Integrating a Missing Element into Medical Education to retard and reduce diffusion, proportionally to the number of layers. However, diffusion is not prevented and the monomer tends to be kept in contact with the skin. Merely painting methylmethacrylate monomer on the skin of a sensitive subject has been shown not to cause an allergic reaction because the monomer evaporates so rapidly. However, if the monomer is applied under an exclusive or semiocclusive dressing, a reaction will ensue in the sensitive subject. Synthetic gloves are currently under development that we hope will be impervious to methylmethacrylate monomer. References 1. FISHER, A.A.: Allergic Sensitization of the Skin and Oral Mucosa to Acrylic Denture Materials. J. Prosth. Dent., 6:593–602, 1956. 2. PEGUM, J.S., and MEDHURST, E.A.: Contact Dermatitis from Penetration of Rubber Gloves by Acrylic Monomer. British Med. J., 2:141–143, 1971.
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