Pseudotumor in Ceramic-on-Ceramic Total Hip Arthroplasty: A Case Report

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Abstract

Pseudotumors are a rare complication of total hip arthroplasty (THA), arising from local soft tissue reactions. These reactions can lead to painful joint effusions and prosthetic loosening, often necessitating revision surgery. Metal-on-metal and metal-on-polyethylene prostheses are particularly prone to this complication due to the accumulation of metal debris from prosthetic wear, which represents a significant drawback. In contrast, ceramic-on-ceramic (CoC) prostheses are considered a superior alternative, offering lower wear rates and avoiding complications related to metal debris. This case report presents a rare instance of pseudotumor formation in a CoC THA. A 57-year-old patient underwent a cementless CoC THA in 2010. Despite developing a pulmonary embolism, the patient experienced no prosthetic-related complications until 2021, when they presented to the Royal Orthopaedic Hospital with concerns about a deep vein thrombosis. MRI and ultrasound scans of the hip revealed a complex collection involving the iliopsoas bursa and a small joint effusion, prompting a biopsy. Histopathology confirmed a pseudotumor with tissue necrosis, macrophages, neutrophils, and ceramic debris. In 2024, the patient underwent revision arthroplasty with excision of the pseudotumor. The original prosthesis was well-fixed, with minimal damage to the ceramic head and acetabular liner, and there were no signs of infection or metallosis. Following the revision, the patient’s pain resolved, and they were satisfied with the outcome of the surgery.

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Total hip arthroplasties: what are the reasons for revision?

Helle Ulrich, Michael Mont, Javad Parvizi … (2008)

Primary total hip arthroplasties have reported success rates of greater than 95% in many series with a longer than 10-year follow-up. Revision total hip arthroplasty due to such factors as increased high-activity levels, younger patients undergoing the procedure and increasing life expectancy has become more prevalent. An understanding of the mechanisms and timing of total hip arthroplasty failure can direct efforts aimed at reducing revision rates. This study was conducted to evaluate the indications for revision hip arthroplasty and relate these to the time after the index primary hip arthroplasty. A review of all revision hip arthroplasties at two centres over a 6-year time period identified 225 patients who underwent 237 revisions. The overall mean time to revision was 83 months (range: 0-360 months). The cause of failure was aseptic loosening in 123 hips (51.9%), instability in 40 hips (16.9%) and infection in 37 hips (5.5%). When stratified into two groups (less than 5 years, more than 5 years after the index primary hip arthroplasty), 118 of 237 (50%) revisions occurred in less than 5 years, with 33% due to instability and 24% resulting from infection. The majority of the causes of failure within 5 years in these early revisions were instability and deep infection. The success of hip arthroplasty is likely to be compromized if technical aspects of the surgery for appropriate component positioning and critical protocols to minimise complications such as infection are not given the proper attention.

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Histological Features of Pseudotumor-like Tissues From Metal-on-Metal Hips

Pat Campbell, Edward Ebramzadeh, Scott Nelson … (2010)

Background Pseudotumor-like periprosthetic tissue reactions around metal-on-metal (M-M) hip replacements can cause pain and lead to revision surgery. The cause of these reactions is not well understood but could be due to excessive wear, or metal hypersensitivity or an as-yet unknown cause. The tissue features may help distinguish reactions to high wear from those with suspected metal hypersensitivity. Questions/purposes We therefore examined the synovial lining integrity, inflammatory cell infiltrates, tissue organization, necrosis and metal wear particles of pseudotumor-like tissues from M-M hips revised for suspected high wear related and suspected metal hypersensitivity causes. Methods Tissue samples from 32 revised hip replacements with pseudotumor-like reactions were studied. A 10-point histological score was used to rank the degree of aseptic lymphocytic vasculitis-associated lesions (ALVAL) by examination of synovial lining integrity, inflammatory cell infiltrates, and tissue organization. Lymphocytes, macrophages, plasma cells, giant cells, necrosis and metal wear particles were semiquantitatively rated. Implant wear was measured with a coordinate measuring machine. The cases were divided into those suspected of having high wear and those suspected of having metal hypersensitivity based on clinical, radiographic and retrieval findings. The Mann-Whitney test was used to compare the histological features in these two groups. Results The tissues from patients revised for suspected high wear had a lower ALVAL score, fewer lymphocytes, but more macrophages and metal particles than those tissues from hips revised for pain and suspected metal hypersensitivity. The highest ALVAL scores occurred in patients who were revised for pain and suspected metal hypersensitivity. Component wear was lower in that group. Conclusions Pseudotumor-like reactions can be caused by high wear, but may also occur around implants with low wear, likely because of a metal hypersensitivity reaction. Histologic features including synovial integrity, inflammatory cell infiltrates, tissue organization, and metal particles may help differentiate these causes. Clinical Relevance Painful hips with periprosthetic masses may be caused by high wear, but if this can be ruled out, metal hypersensitivity should be considered.

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Pseudotumours associated with metal-on-metal hip resurfacings.

H Gill, Brendan D. Murray, S Ostlere … (2008)

We report 17 patients (20 hips) in whom metal-on-metal resurfacing had been performed and who presented with various symptoms and a soft-tissue mass which we termed a pseudotumour. Each patient underwent plain radiography and in some, CT, MRI and ultrasonography were also performed. In addition, histological examination of available samples was undertaken. All the patients were women and their presentation was variable. The most common symptom was discomfort in the region of the hip. Other symptoms included spontaneous dislocation, nerve palsy, a noticeable mass or a rash. The common histological features were extensive necrosis and lymphocytic infiltration. To date, 13 of the 20 hips have required revision to a conventional hip replacement. Two are awaiting revision. We estimate that approximately 1% of patients who have a metal-on-metal resurfacing develop a pseudotumour within five years. The cause is unknown and is probably multifactorial. There may be a toxic reaction to an excess of particulate metal wear debris or a hypersensitivity reaction to a normal amount of metal debris. We are concerned that with time the incidence of these pseudotumours may increase. Further investigation is required to define their cause.

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Author and article information

Journal

Journal ID (nlm-ta): Cureus

Journal ID (iso-abbrev): Cureus

Journal ID (issn): 2168-8184

Title: Cureus

Publisher: Cureus (Palo Alto (CA) )

ISSN (Electronic): 2168-8184

Publication date (Electronic, pub): 15 October 2024

Publication date (Electronic, collection): October 2024

Volume: 16

Issue: 10

Electronic Location Identifier: e71518

Affiliations

[1 ] Trauma and Orthopedics, Queen Elizabeth Hospital, Birmingham, GBR

[2 ] Trauma and Orthopedics, University Hospitals Birmingham NHS Foundation Trust, Birmingham, GBR

[3 ] Orthopedic Surgery, Royal Orthopaedic Hospital, Birmingham, GBR

[4 ] Trauma and Orthopedics, Royal Orthopaedic Hospital, Birmingham, GBR

Author notes

Danielle Piper daniellecpiper@ 123456gmail.com

Article

DOI: 10.7759/cureus.71518

PMC ID: 11563772

PubMed ID: 39553120

SO-VID: 0ca14dd2-0d34-498d-8796-fd8d6ca7fb9b

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This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 4.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

History

Date accepted : 15 October 2024

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Pseudotumor in Ceramic-on-Ceramic Total Hip Arthroplasty: A Case Report

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Most cited references 17

Total hip arthroplasties: what are the reasons for revision?

Histological Features of Pseudotumor-like Tissues From Metal-on-Metal Hips

Pseudotumours associated with metal-on-metal hip resurfacings.

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