Massive Pseudotumor in a 28mm Ceramic-Polyethylene Revision THA: A Case Report

  • Edward McPherson, M.D., FACS
  • Matthew Dipane, BA
  • Sherif Sherif, MD

Abstract

This report reviews the findings of a massive pseudotumor detected pre-operatively in a 13-year-old revision total hip arthroplasty. The case is unique in that the bearing involved was a 28mm zirconia ceramic head on a polyethylene liner. We propose that the pseudotumor arose from ultrafine titanium particles liberated from the proximal porous coating of the femoral stem. We suspect that the osteolysis produced from polyethylene wear exposed the proximal porous coating and, via a process of mechanical abrasion with the surrounding soft tissues, liberated ultrafine titanium particles. We believe the pseudotumor formed because the patient was pre-sensitized to metal debris based upon a pre-operative lymphocyte T-cell proliferation test (LTT). Based upon this unique case, we feel that pseudotumors more likely form when there is a high rate of ultrafine metal particles generated in a pre-sensitized patient. Finally, we introduce what we believe are the main biologic wear responses in THA. Further research is needed to validate this proposed model.

Keywords: pseudotumor, ceramic, polyethylene, osteolysis, THA, bearing wear eesponse, titanium debris

Level of Evidence:  AAOS Therapeutic Study Level IV

References

Bourghli A, Fabre T, Tramond P, et al. Total hip replacement pseudotumoral osteolysis. Orthopaedics & Traumatology: Surgery&Research. 2010; 96: 319-22.

Caicedo MS, Pennekamp PH, Hallab NJ, et al. Soluble ions more than particulate cobalt-alloy implant debris induce monocyte costimulatory molecule expression and release of proinflammatory cytokines critical to metal-induced lymphocyte reactivity. J Biomed Mater Res A. 2010; 93(4): 1312-21.

Campbell P, Ebramzadeh E, Nelson S, et al. Histological features of pseudotumor-like tissues from metal-on-metal hips. Clin Orthop Relat Res. 2010; 468(9): 2321-7.

Clyburn TA. Pseudotumor in metal-on-polyethylene total hip arthroplasty. Reconstructive Review. 2013; 3(1): 18-22.

Cooper HJ, Ranawat AS, Potter HG, et al. Early reactive synovitis and osteolysis after total hip arthroplasty. Clin Orthop Rel Res. 2010; 468(12): 3278-85.

Daniel J, Holland J, Quigley L, et al. Pseudotumor associated with total hip arthroplasty. J Bone Joint Surg Am. 2012; 94-A(1): 86-93.

Glyn-Jones S, Pandit H, Kwon YM, et al. Risk factors for inflammatory pseudotumor formation following hip resurfacing. J Bone Joint Surg Br. 2009; 91(12): 1566-74.

Griffiths HJ, Burke J, Bonfiglio TA. Granulomatous pseudotumor in total joint replacement. Skeletal Radiol. 1987; 16(2): 146-52.

Hallab NJ, Anderson S, Stafford T, et al. Lymphocyte response in patients with total hip arthroplasty. J Orthop Res. 2005; 23(2): 384-91.

Hallab NJ, Caicedo M, Finnegan A. Th I type lymphocyte reactivity to metals in patients with total hip arthroplasty. Journal of Orthopaedic Surgery and Research. 2008; 3: 6.

Hallab NJ, Mikecz K, Jacobs JJ. A triple assay technique for the evaluation of Metal-induced, delayed type hypersensitivity response in patients with or receiving total joint arthroplasty. Journal of Biomedical Materials Research. 2000; 53(5): 480-9.

Hallab NJ. Metal sensitivity in patients with Orthopaedic implants. Journal of Clinical Rheumatology. 2001; 7(4): 215-8.

Hsu AR, Gross CE, Levine BR. Pseudotumor from modular neck corrosion after ceramic-on-polyethylene total hip arthroplasty. Am J Orthop. 2012; 41(9): 422-6.

Hsu AR, Kim JD, Fabi D, et al. Adverse Reactions in Metal-on-Metal hip arthroplasty: two cases presenting as pseudoseptic acetabular component loosening. Am J Orthop. 2011; 40(10): 509-13.

Issack PS. Formation of a large rice body-containing cyst following total hip arthroplasty. BMC Research Notes. 2012; 5: 294.

Jacobs JJ, Hallab NJ. Loosening and osteolysis associated with metal-on-metal bearing: a local effect of metal hypersensitivity? J Bone Joint Surg Am. 2006; 88: 1171-2.

Kang PD, Pei FX, Shen B, et al. Extra-articular inflammatory pseudotumor after well-fixed metal-polyethylene total hip arthroplasty. Chinese Journal of Orthopaedics. 2012; 32(6): 526-32.

Kwon YM, Glyn-Jones S, Simpson DJ, et al. Analysis of wear of retrieved metal-on-metal hip resurfacing implants revised due to pseudotumours. J Bone Joint Surg Br. 2010; 92(3): 356-61.

Kwon YM, Thomas P, Summer B, et al. Lymphocyte proliferation responses in patients with pseudotumors following metal-on-metal hip resurfacing arthroplasty. J Orthop Res. 2010; 28(4): 444-50.

Langton DJ, Joyce TJ, Jameson SS, et al. Adverse reaction to metal debris following hip resurfacing: the influence of component type, orientation and volumetric wear. J Bone Joint Surg Br. 2011; 93(2): 164-71.

Leigh W, O’Grady P, Lawson EM, et al. Pelvic Pseudotumor: an unusual presentation of an extra-articular granuloma in a well-fixed total hip arthroplasty. J Arthroplasty. 2008; 23(6): 934-8.

Mahendra G, Pandit H, Kliskey K, et al. Necrotic and inflammatory changes in metal-on-metal resurfacing hip arthroplasties. Acta Orthop. 2009; 80(6): 653-9.

Mao X, Tay GH, Godbolt DB, et al. Pseudotumor in a well fixed metal-on-polyethylene uncemented hip arthroplasty. J Arthroplasty. 2012; 27(3): 493.e13-e17. Available from: American Association of Hip and Knee Surgeons, Rosemont, Ill. Accessed January 21, 2014.

Matthies AK, Skinner JA, Osmani H, et al. Pseudotumors are common in well-positioned low-wearing metal-on-metal hips. Clin Orthop Relat Res. 2011; 470(7): 1895-906.

Mavrogenis AF, Nomikos GN, Sakellarious VI, et al. Wear debris pseudotumor following total knee arthroplasty: a case report. Journal of Medical Case Reports. 2009; 3: 9304.

Olsen RV, Munk PL, Lee MJ, et al. Metal artifact reduction sequence: early clinical applications. Radiographics. 2000; 20: 699-712.

Pandit H, Glyn-Jones S, McLarky-Smith P, et al. Pseudotumors associated with metal-on-metal hip resurfacings. J Bone Joint Surg Br. 2008; 90-B(7): 847-51.

Park YS, Lim SJ, Kim JH, et al. Thigh mass associated with polyethylene wear-induced osteolysis after cementless total hip arthroplasty. Arch Orthop Trauma Surg. 2010; 130(9): 1097-101.

Polyzois I, Nikolopoulos D, Michos I, et al. Local and systemic toxicity of nanoscale debris particles in total hip arthroplasty. J Appl Toxicol. 2012; 32(4): 255-69.

Potter HG, Nestor BJ, Sofka CM. Magnetic resonance imaging after total hip arthroplasty: evaluation of periprosthetic soft tissue. J Bone Joint Surg Am. 2004; 86: 1947-54.

Scully WF, Teeny SM. Pseudotumor associated with metal-on-polyethylene total hip arthroplasty. Orthopedics. 2013; 36(5): e666-70.

Singh C, Kaplan A, Pambuccian SE. Necrotic granulomatous pseudotumor following metal-on-metal hip arthroplasty: A potential mimic of sarcoma on fine needle aspiration cytology. Diagnostic Cytopathology. 2012; 40(S2): E104-E108. Available from: Wiley Online Library, Malden, MA. Accessed January 28, 2014.

Sugimoto H, Hirose I, Miyaoka E. Low field strength MR imaging of failed hip arthroplasty: association of femoral periprosthetic signal intensity with radiographic, surgical, and pathologic findings. Radiology. 2003; 229: 718-23.

Sunderman FW Jr, Hopfer SM, Swift T, et al. Cobalt, chromium, and nickel concentrations in body fluids of patients with porous-coated knee or hip prostheses. J Orthop Res. 1989; 7(3): 307-15.

Svensson O, Mathiesen EB, Reinholt FP, et al. Formation of a fulminant soft-tissue pseudotumor after uncemented hip arthroplasty. A case report. J Bone Joint Surg Am. 1988; 70(8): 1238-42.

Walsh AJ, Nikolaou VS, Antoniou J. Inflammatory Pseudotumor Complicating Metal-On-Highly Cross-Linked Polyethylene Total Hip Arthroplasty. J Arthoplasty. 2012; 27(2): 324e5-e8.

Waters TS, Cardona DM, Menon KS, et al. Aseptic lymphocyte-dominated vasculitis-associated lesion, a clinicopathologic review of an underrecognized cause of prosthetic failure. Am J Clin Pathol. 2010; 134: 886-93.

Williams DH, Greidanus NV, Masri BA, et al. Prevalence of pseudotumor in asymptomatic patients after metal-on-metal hip arthroplasty. J Bone Joint Surg Am. 2011; 93(23): 2164-71.

Yadav J, Samelko L, Hallab NJ, et al. Osteoclasts lose innate inflammatory reactivity to metal and polymer implant debris compared to monocyte/macrophages. The Open Orthopaedic Journal. 2013; 7: 605-13.

Published
2014-03-31
How to Cite
McPherson, M.D., FACS, E., Dipane, BA, M., & Sherif, MD, S. (2014). Massive Pseudotumor in a 28mm Ceramic-Polyethylene Revision THA: A Case Report. Reconstructive Review - Open Access Orthopaedic Journal of Reconstructive Arthroplasty, 4(1). https://doi.org/10.15438/rr.v4i1.53
Section
Case Report