melisa test for titanium allergy

However, it indeed seems titanium allergy had a significant role in her abdominal discomfort owing to her positive allergy test results further proving titanium hypersensitivity in this patient. In many ways, implants function like natural teeth. The skin patch test has not yet been developed as the valid standardized test for titanium allergy. Medically Reviewed By Colgate Global Scientific Communications. 2021, 2022 OsseoNews, Inc. All rights reserved. aseptic osteolysis. Oral saliva usualy "buffers" reaction. allergic reaction to bio oss is it possible. It is important to establish which metals are contained in your device prior to testing. WebThis test is used to determine whether titanium dental implants, metal bridges,crowns and over dentures or amalgam fillings are causing allergic reactions within the body. M. Tu and Y. Wu, Multiple allergies to metal alloys, Dermatologica Sinica, vol. Wood MW, Warshaw EM. The patient started having another episode of intermittent right lower quadrant (RLQ) pain starting in January 2020. The body does not uptake B 12 via tablets or injections. National Library of Medicine 2. Alas, such is not the case. This test is also available in the US. We thank Dr. Guirguis, Department of Radiology, and Williamson Medical Center for their contributions in this case report. Patch testing to metals planned but patient is receiving steroids with chemotherapy every two weeks and cannot stop. Our goal at OsseoNews.com is to help expand knowledge of dental implants and related dental fields by offering interactive online education and communication tools. Zirkonia crowns or bridge, and be cemented. Metal sensitivity in patients with orthopaedic implants: a prospective study. Moreover, the patient was under multiple specialists care and had many hospitalizations and a history of various medication intake, including antibiotics and painkillers. Trouble is in the United States there are NO approved dental materials (metals and other) patch tests and most allergists will not help you w/o that. I am sending you a link (copied below) to a study employing delayed hypersensitivity testing to detect metal allergy. This will improve the patients quality of life and prevent serious complications. Is there any other material used as an alternate to titanium in the implant fixtures? Dental implant surgery is performed in stages, requiring adequate healing time after each one. Reduction of metal exposure in the FM patients was achieved by replacement of dental metal restorations and by the avoidance of known sources of metal exposure. On the contrary, IFN-gamma, IL-2, IL-4, IL-10, and IL-12 production to the ELISpot, patch test results, sensitization against other metals, and atopy score did not significantly discriminate between sensitization with and without allergy. WebMELISA test for the minimization or complete elimination of health problems in patients with conrmed hypersensitiv-ity to metals. Over his thirty-year career, Dr. Schroeder has encountered numerous cases involving neuromuscular and other systemic symptoms (fibromyalgia, chronic fatigue syndrome, Lupus & RA symptoms, brain fog, migraines, etc) that have dramatically improved or resolved once the offending metal was removed. The patient had delayed hypersensitivity reaction to nickel in the past with erythematous rash formation and severe itching. WebTitanium, Whole Blood TEST: 792620 CPT: 83018 Print Share Include LOINC in print Expected Turnaround Time 3 - 7 days Turnaround time is defined as the usual number of Due to another foot problem requiring surgery, he returned to his surgeon Dr Schroeder, who noticed swelling over the areas the screws were placed and recommended removal of the screws. This started at 45 minutes per day but the periodic paralysis progressed to 10-12 hours per day of immobility. This is an open access article distributed under the, Memory lymphocyte immunostimulation assay, Endoscopic retrograde cholangiopancreatography. I have copied the question and our response below. Once you heal from the implant surgery, a crown is attached to the part of the implant that protrudes through the gumline. 201207, 2012. This may start an immune reaction. The MELISA test a scientifically-proven test which can objectively test for the presence of titanium hypersensitivity and measure its severity. Blood based testing may give an more accurate measurement of titanium reactions than patch testing. Suspecting systemic contact dermatitis to metal buttons and I have been asked to evaluate. Mediators of Inflammation. Six metal surgical clips removed from the RUQ via fluoroscopic guidance. Review our cookies information for more details. I am severely allergic to many metals..confirmed nickel was "off the charts"..worst case they'd ever seen which I'd know obviously for my entire life. The authors conclude: Standardizing allergy tests as part of the pre-operation checklist can prove to be an inexpensive way to eliminate such post-surgical complications. Oral Health, Dental Conditions & Treatments, Erythema (skin redness, in this case, in the tissues around the implant), Urticaria (hives that may be seen on the skin or gum surface), Eczema (itchy inflammation of the skin or gum tissue), Necrosis (death of cells or tissue, in this case, around the implant), Toxic reactions in other tissues, causing yellow nail syndrome (which can also affect the lungs and airways). Mnchen, Germany. Metal allergies are becoming more recognized within the surgical field. The patient also started having low-grade fever, nausea, vomiting, joint pain, diffuse rash, and fatigue. The patient has allergic symptoms reported from IV contrast, nickel, titanium, iodine, metoclopramide, and oxalate. "MELISAan in vitro tool for the study of metal allergy." Moreover, titanium has been described to activate macrophages through phagocytosis to cause the release of pro- and anti-inflammatory cytokines [9]. 18, no. Antifungal activity of Ag:hydroxyapatite thin films synthesized by pulsed laser deposition on Ti and Ti modified by TiO2 nanotubes substrates. Question posted to Ask the Expert website 4/25/2012: Nickel allergy signs and symptoms include: Rash or bumps on the skin Itching, which may be severe Redness or changes in skin color Dry patches of skin that may resemble a burn Blisters and draining fluid in severe cases When to see a doctor If you have a skin rash and don't know how you got it, talk to your doctor. I had a hip replaced with titanium. coating disolves over the years. Correction on the last thread last word should read capsules, not injections. Our case is about a 28-year-old female presenting with a spectrum of abdominal symptoms with a complicated medical history. For almost 6 years, this was his life. of weight loss in only four months of duration. Moreover, the increase in the percentage of patients who tested positive for metal sensitivity 1 year post-implantation suggests the possibility of prosthesis-induced sensitization. In a pilot study, 20 patients also underwent both patch testing and a lymphocyte transformation test (LTT-MELISA) for the same metals. 2/12/2021 Thank you for submitting a question to Ask the Expert. She reported extensive health issues such as skin rash, hair loss, memory loss, difficulty concentrating, severe shortness of breath, hot and cold flashes, metallic taste in the mouth, abdominal bloating, joint and body aches, muscle pain and tightness, insomnia and more. It is important to diagnose RFB promptly and remove it as soon as possible due to life-threatening complications such as gastrointestinal bleeding, intestinal obstruction, and perforation [13]. d. most literature continue to recommend patch testing as the standard, possibly with the exception of titanium due to potential occurrence of false negative patch skin test results. V. Vijayaraghavan, A. V. Sabane, and K. Tejas, Hypersensitivity to titanium: a less explored area of research, J Indian Prosthodont Soc., vol. W. S. Towers and K. Kurtom, Rare systemic response to titanium spinal fusion implant: case report, Cureus, vol. Please enable it to take advantage of the complete set of features! But the good news is that there are other options available to you. Fowler, Joseph F., and Matthew J. Zirwas. I also had titanium screws inserted into my mouth giving me alot of pain. Retained foreign bodies (RFB) are also possible complications of any surgical procedure. Did you have any skin reaction on one of those products containig Titaniumoxides ? With her history of allergy to other metals in the past, a titanium allergy was suspected at this visit, and the patient promptly underwent a titanium skin patch test that turned out positive. 26 Its usefulness may be improved if patients are tested with chemicals relevant to their problem. Therefore, objective determination of metal sensitivity at preoperative assessment should be considered in planning arthroplasty intervention, as it would help the surgeon in selecting the most appropriate prosthesis for the patient and could benefit implant performance. Concerned this may give false negative results with patch testing. Metal hypersensitivity is a well-documented factor in the failure of implants, and the need for testing in sensitive patients is well recognized by both implant manufacturers and by surgeons alike. zirconia has never osseointegrated to bone as titanium or titanium alloys can do. This study is aimed at proving the clinical benefit of the MELISA test in the minimization or complete elimination of health problems in patients with confirmed 12, no. i. Dermatitis overlying the implant Six patients did not follow the recommendation, and from these, only one patient reported an improvement in his health problems. Making this recommendation on a test that is not generally accepted is difficult, but you may wish to document a shared decision making discussion regarding this controversy. Implant failed right after placement. Even low grade allergies are causing significant symptoms. Dear Richard Hughes, DDS,FAAID, FAAIP.DABOI v. Positive in vitro test to metals Then the titanium-alluminium-vanadium alloy gets exposed. ", I had transplants in September 2009 December 16th 2009 very sick and have never been allergic to anything and now 5th time to almost die and surgeon contacted today 25th Jan 2010 going tomorrow morning I have not been in pain other than swelling tongue not breathing and and almost dead We will see wish me luck. Reference: My B12 was normal. 4143, 2011. See MoreSee Less, Metal hypersensitivity and pro-inflammatory cytokine production in patients with failed orthopedic implants: A case-control study, Valentine-Thon E, Schiwara HW. See this image and copyright information in PMC. These stages include removing the damaged tooth, bone grafting (if needed), dental implant placement, abutment placement, and the placement of your artificial tooth (crown). Vaelentin-Thon E, Mller K, Guzzi G et al. Journal of Biomedical Materials Research PART A. I hope this information is of help to you and your practice. The MELISA test may be used in two ways for orthopaedic patients. The .gov means its official. 4/25/2017: Lymphocyte Transformation testing and Metal ion testing C. Shi, Y. Xi, B. 1, pp. Percentage of patients in individual intervals of the stimulation index: green 2.0, yellow = 2.14, orange = 4.110.0, and red 10.1; comparison of the initial with the follow-up values of the stimulation indexmetals with nonsignificant differences. 2022 Nov 23;10(12):716. doi: 10.3390/toxics10120716. These metals ions bind to proteins in the body. For those who react, the bodys immune system will attack this new protein/metal structure. This may start an immune reaction. The MELISA test a scientifically-proven test which can objectively test for the presence of titanium hypersensitivity and measure its severity. G. Tawil, P. Tawil, and C. Irani, Zirconium implant as an alternative to titanium implant in a case of type IV titanium allergy: case report, The International Journal of Oral & Maxillofacial Implants, vol. I am skeptical that the in vitro testing would facilitate a better alloy than titanium. Questionnaire data was processed, and the follow-up MELISA test results were compared with the results of the initial MELISA tests. MELISA also discovered he was HIGHLY allergic to palladium; the 2 white gold crowns in his mouth contained 26% palladium! It is used worldwide by healthcare professionals to help determine whether patients are hypersensitive to metals Faster and more secure then Zirkonia implants. Good Luck! 78, p. 1135, 1999. Sun et al., Suspected allergy to titanium after anterior cervical discectomy and fusion using a Zero-P device: a case report, British Journal of Neurosurgery, pp. doi: 10.1016/j.apsusc.2013.12.029. However, THA subjects (Groups 3a & b) were >3 fold more reactive to Cr (p < 0.04), than were controls (Groups 1a & b) or OA subjects (Groups 2a & b). Carol: keep an eye on the situation and as you already have consult with your physician. She was tested for Clostridium difficile infection and showed positive toxin B results confirming the diagnosis. I've had 2 titanium implant procedures with 2 diffenrent surgeons and both implants didn't take which caused me tremendous pain. Background: Sensitization to orthopaedic implant materials is an unpredictable event that might affect implant performance. government site. sharing sensitive information, make sure youre on a federal However, the skin-patch test is still not the best diagnostic modality due to failure in positive reaction to most titanium allergy cases [3]. YYYY Colgate-Palmolive Company. The patients past surgical history includes a tonsillectomy, an appendectomy, and cholecystectomy. iii. Valentine-Thon E, Mller K, Guzzi G, Kreisel S, Ohnsorge P, Sandkamp M. Neuro Endocrinol Lett. Find out how to recognize those symptoms and when to approach your dentist for a complete diagnosis. LTT-MELISA is clinically relevant for detecting and monitoring metal sensitivity. Usualy allergic response is seen on epidermis. Accessibility FOIA Lisa: It's interesting that you have these symptoms! A case by Little et al. The reference to which I sent the link will give you some perspective on false-positive and false-negative tests using delayed hypersensitivity testing. A dental professional can help you treat your titanium allergy and ensure that you fill the gap in your mouth with a treatment that works for you! OA subjects with a history of metal sensitivity (Group 2b) were more metal reactive to Ni than any other group, as expected (66% incidence and Stimulation Index >20). i. Among different RFB, sponges are one of the most common retained foreign bodies in the abdomen, pelvis, and retroperitoneal cavities [13]. Dermatitis 26;2015:1-25. J. S. Gammie, M. C. Banks, C. R. Fuhrman et al., The pigtail catheter for pleural drainage: a less invasive alternative to tube thoracostomy, JSLS., vol. v. Postoperative testing may help in determining if metal allergy is responsible; The test itself, that is, the lymphocyte transformation test, is a validated means of testing for delayed hypersensitivity, the type of hypersensitivity that results in contact dermatitis. Testing for titanium Therfore a immediate or a delayed immediate response can be excluded. Fishers textbook on contact dermatitis provides a summary of the state of the art for in vitro lymphocyte proliferation (2): The patient has been recommended to do a close follow-up for a few months to monitor her progress. Would you like email updates of new search results? The lymphocyte transformation test has several issues: Hypersensitivity to titanium: clinical and laboratory evidence. Titanium is a known metal used widely in the medical field and can cause allergic reactions with complications. Parallel to this, in vitro hyperreactivity to titanium disappeared. PMC Simply cut, peel, & apply to protect wounds, & more! Could I have an allergy to titanium? 40% of patients with failing implants had hypersensitivity reactions to a metal present in their implant. This may be the situation you are facing. All of her symptoms were initially suspected due to the infections mentioned above, and she was placed on various antibiotic therapy regimens consisting of ciprofloxacin, amoxicillin/clavulanate potassium, and sulfamethoxazole/trimethoprim. 5761, 1999. 155162, 1999. -, Erakovi S., Jankovi A., Ristoscu C., et al. viii. Bookshelf Second, post-surgery, MELISA can be used to identify if metal hypersensitivity is responsible for any of the symptoms that have developed. Due to ongoing chronic symptoms, CT scan incidentally revealed a portion of a lodged pigtail catheter in the cecum. Titanium is a transition metal and thus may function as a hapten and trigger cellular hypersensitivity. The patient initially presented to the clinic with an intermittent right upper quadrant (RUQ) pain in 2016. Only osteolytic THA subjects demonstrated increased cytokine responses with >two-fold (p <0.05) increases in soluble interferon- (IFN-) and interleukin-2 (IL-2) levels in response to Cr challenge. I would recommend though that you take a clifford test first on Zircon Oxide due to your allergic component. Phil Lieberman, M.D. 6. de Graaf, Niels PJ, et al. c. most 3rd party payers do not cover this testing which is not FDA approved and has limited validation data other than from a single European site (3); All but one clip was removed and the patient reported resolution of most symptoms within one week of surgery. The use of low-dose naltrexone (LDN) is also discussed. Fage, Simon W., et al. Before MELISA Foundation, etc. Metal hypersensitivity and Goolge Titanium allergy test and I'm sure you will find it. Very much looking forward to the launch of the first ever podcast dedicated to the adverse effects of metals on health! For statistical analysis, the Fisher's exact test and paired T-test were used. If you have any questions, call the Drug Allergy Clinic at (615) 936-2727, 8 a.m.-4:30 p.m. Monday through Thursday or 8 The MELISA Medica Foundation, which conducts the MELISA test for metal sensitivities, estimates that as many as 4% of the population could be allergic to titanium. A test was developed in Europe to detect and measure Titanium allergies. WebMELISA is a blood test to aid the diagnosis of metal hypersensitivity. A 72- and 96-hour reading is provided. Hallab N J, Mikecz K, Jacobs J J. How lymphocyte-mediated metal sensitivity affects orthopaedic implant performance remains poorly understood. Unable to load your collection due to an error, Unable to load your delegates due to an error. Validity of MELISA for metal sensitivity testing. a. Fonacier L, Bernstein D, Pacheco K et al. I usually suspect angry back if you have more than 5 positive patch tests. We've been working on metal free implants in my clinic since 2005, so we have mid term results showing the amazing results on our patients. "A retrospective study on titanium sensitivity: Patch test materials and manifestations." STUPID is that there is no sure fire way to know AHEAD of time if you will have a reaction..to me this is unacceptable..especially considering costs. The catheter was removed surgically which resolved the patients RLQ abdominal pain and accompanying symptoms. Fisher's Contact Dermatitis. Int J Implant Dent. and transmitted securely. The criteria for postimplant metal hypersensitivity are: Thus interpreting these tests is much like interpreting the immediate hypersensitivity skin tests and tests for serum-specific IgE. 2008 Sep;38(9):1468-75. doi: 10.1111/j.1365-2222.2008.02970.x. 3. The https:// ensures that you are connecting to the You may be dealing with angry back syndrome from the start. In the following years, the patient went through an ERCP procedure multiple times due to her sphincter of Oddi dysfunction followed by laparoscopic rectopexy for a rectal prolapse. Since titanium, in the form of titanium dioxide (E171), is used as white pigment in toothpaste, cosmetics and medication, the latent sensitization of susceptible individuals is possible. This site uses cookies. 3. This causes type IV hypersensitivity reaction through sensitization of T lymphocytes and macrophages. Mller-Heupt LK, Schiegnitz E, Kaya S, Jacobi-Gresser E, Kmmerer PW, Al-Nawas B. Int J Implant Dent. There are zyrconia implants like White Sky, that are monoblock type implants, and that are a real option for you.Also Rocksolid from straumann is a combination that may also help you 2004 Orthopaedic Research Society. I strongly recommend zircon implants. Objective: The aim of this study was to prove whether cellular in vitro tests are predictive of chromium allergy. Unauthorized use of these marks is strictly prohibited. This information is for educational purposes only. Patch testing gave no reactions to titanium nor to nickel, chromium, or cobalt. They are real and they manifest themselves over time. a. viable lymphocytes are required therefore logistical issues of shipping often complicate testing; The Mayo Clinic had diagnosed him with Stiff Person Syndrome. One year post-implantation (72 patients), 5 patients who had initially tested negative for a metal allergy became positive for at least one or more metal constituents of the prosthesis on at least one or the other test. Zimmer dental, former Sulzer-Calcitek, stil have HA-(hydroxylapatit) coated implants. Overnight, Jeske went from being paralyzed 10-12 hours a day down to 3 hours a day. WebMELISA is a simple blood test which can separate those individuals which may suffer side-effects from metal exposure and those that will not. Dana Jeske, a mechanical engineer living near Seattle, experienced intermittent paralysis for five years, before regaining his ability to walk and move his b "Metal hypersensitivity testing should be offered to patients before surgery to minimize the risk of implant failure", concluded this study from Charles University, Prague; "especially those with autoimmune diseases, asthma, and/or allergies." WebThe MELISA test has been known to be a more sensitive test to metal allergy but lacks specificity in the proliferation of lymphocytes [ 3 ]. In the study, 35 patients with failed orthopedic implants and 15 patients scheduled for orthopedic implant surgery were tested for metal hypersensitivity using the MELISA test. Have new referral 62 year-old female smoker with focal seizure in 2017 - evaluation showed brain tumor confirmed to be malignant with primary in lung. In vitro testing with metal ions in solution mixed with lymphocytes from affected subjects has been suggested as means to overcome the reduced reactivity of specific metals or the reduced penetration of the metal through the keratin layer of the skin. Contact dermatitis 79.2 (2018): 85-90. Ask the Colgate Chatbot! During the cholecystectomy, six titanium surgical clips were placed in the RUQ. Applied Surface Science. 2023 American Academy of Allergy, Asthma & Immunology. We obtained written informed consent from the patient for the publication of this case report and accompanying images. Patients who report anorexia and fatigue over a long duration after the initial post-operative period may be diagnosed with depression rather than a systemic response to spinal metallic instrumentation. I would have a few questions about this case It's simple, cheap, and reliable. Present left knee joint contains several metals positive with patch testing. In our case, the pigtail catheter was found as a retained surgical body lodged in the patients cecum. Traces of nickel (0.03%) may be found even in commercially pure titanium due to the production process. Just wondering. WebThe only current blood test for titanium allergy, a test called the MELISA(R) test, is available through Breakspear. However, all the symptoms were resolved after the removal of the offending agent [57]. Safe for patients with metal allergies Zirconia implants are a viable option for patients who have an allergy to titanium or adhere to holistic dental principles. Just some thoughts. You should get titanium implants bc you probably don't have an allergy to it or you can just get a zirconia based implant and have it fracture shortly after due to a reaction with fluids/water, then have someone remove it, place another, then removed, place another, etc. please note that there are many brands of implants which are used to titanium alloys in making implants so i agree with whose are believe in allergist consultation. An exact breakdown, which includes trace amounts of metals present, is needed prior to testing, but below is a guideline. THA subjects with moderate vs mild osteolysis (Group 3b vs 3a) were more reactive to Co (43% vs 0% incidence). I had bone tumor & metal rods placed in my femor a 1 yr & 6 months ago .. Contact dermatitis: A practice updateUpdate 2015. e.g. 2, pp. Therapy resistant dermatitis T. Okamura, M. Morimoto, D. Fukushima, and G. Yamane, A skin patch test for the diagnosis of titanium allergy, Journal of Dental Research, vol. If all of the positive tests are metals, you may be dealing with irritant reactions, usually pustules and follicular lesions, more common to metals and more likely in atopic individuals, perhaps due to skin barrier issues. Careers. 6, p. 630, 2014. Conclusions: Given the discrepancies between the information obtained while taking patient histories and test results, preoperative history-taking alone appears to be insufficient for identifying patients with metal sensitivity. say. We report on a patient in whom impaired fracture healing and eczema localized to the perioperative area developed upon titanium-based osteosynthesis. There is also no risk of allergic reactions, galvanic shock, or battery effects with ceramic like there is with metal implants. By postoperative day 6, the patients symptoms of abdominal distension resolved and her RLQ pain also diminished. The authors declare that they have no conflict of interest associated with this work. She had to be hospitalized with strict isolation to wait for her medication regimen to work along with the infusion of IV fluids. In the study, 35 patients with failed orthopedic implants and 15 patients scheduled for orthopedic implant surgery were tested for metal hypersensitivity using the MELISA test. They were clinically examined, and peripheral blood samples were taken to perform follow-up MELISA tests. 2. A team has devised a blood test to determine allergies to nickel and is working on developing blood tests for other allergens such as cobalt and the bone cement that is used in most implants. In: StatPearls [Internet]. WebThe MELISA test a scientifically-proven test which can objectively test for the presence of titanium hypersensitivity and measure its severity. The results of a MELISA test came back negative for a titanium allergy but revealed Peters is allergic to nickel. (SOURCE Lymphocyte responses in patients with total hip arthroplasty, JOURNAL of ORTHOPEDIC RESEARCH 23(2), 384-391, 2005). Effect of blood component coatings of enosseal implants on proliferation and synthetic activity of human osteoblasts and cytokine production of peripheral blood mononuclear cells. Was the patch test removed at 48 hours and what was the reading at that time? The patient tolerated the procedure well with no postoperative complications. 15, 2020. A pigtail catheter is a universal drain used to remove fluids or abscesses from organs, ducts, or body cavities. 3, pp. Arakelyan M, Spagnuolo G, Iaculli F, Dikopova N, Antoshin A, Timashev P, Turkina A. They work even in a periodontic compromised oral situations. Abstract A decision was made to remove all the metal surgical clips laparoscopically via fluoroscopic guidance (Figure 1). The pigtail catheter in the cecum was removed carefully, and the foreign body was measured 10.0cm in length and 0.3cm in diameter. iv. See MoreSee Less, Stiff Person Syndrome Paralysis Goes Away, "Metal hypersensitivity testing should be offered to patients before surgery to minimize the risk of implant failure", concluded this study from Charles University, Prague; "especially those with autoimmune diseases, asthma, and/or allergies." The patients past medical history consists of depression, polycythemia vera, hypothyroidism, mitral valve prolapse, chronic back pain, and deep vein thrombosis of nonextremity and acute cholecystitis. After removal of the titanium material, fracture healing was achieved and the eczema cleared. I also think this form of dentistry s/b considered and covered as MEDICAL. Concentrations of J Biomed Mater Res 2000: 53: 480489. Many will have seen the devastating news that singer Celine Dion has been diagnosed with Stiff Person Syndrome. As with all tests, there are false-positives and false-negatives, and the diagnosis of contact allergy remains a clinical diagnosis in which tests are used to add additional evidence of its existence to a specific agent. However, in the lymphocyte transformation test, the patient's lymphocytes showed markedly enhanced proliferation in vitro totitanium. Sarah, a potential dental implant patient, asks:I am allergic to titanium. doi: 10.1002/jbm.a.34721. WebTitanium allergy and lymphocyte transformation test 2/12/2021 Have new referral 62 year-old female smoker with focal seizure in 2017 - evaluation showed brain tumor 4. The additional cost of titanium implant may be judged reasonable in light of the financial and personal cost in a knee or hip implant.