Intrapelvic Pseudotumor Causing Neuropathy and Vascular Obstruction After Revision Total Hip Arthroplasty: A Case Report
DOI:
https://doi.org/10.15438/rr.11.1.285Keywords:
Pseudotumor, Total Hip Arthroplasty, THA, Pelvic Mass, Adverse Local Tissue Reaction, Femoral Nerve NeuropathyAbstract
Background:
There is a growing body of recent literature regarding the occurrence of pseudotumors associated with modular junctions and various bearing surfaces after total hip arthroplasty (THA). Revision surgery is often technically challenging and high complication rates have been reported. The optimal management of these patients and outcomes after operative treatment remain poorly understood.
Methods:
We report the case of a 77-year-old male with progressive unilateral lower extremity swelling, pain, and neuropathy 9 years after revision THA for polyethylene liner wear. Imaging and biopsy confirmed a massive intrapelvic pseudotumor exerting compressive effects. Radiographs demonstrated extensive femoral and pelvic osteolysis without evidence of component loosening. Debulking of the intrapelvic portion of the pseudotumor was performed via the lateral window of the ilioinguinal approach with component retention.
Results:
Debulking of the intrapelvic mass resulted in resolution of symptoms. One year postoperatively the patient reported pain free ambulation using a walker and no recurrence of symptoms. Radiographs demonstrated stable THA components in comparison with preoperative films.
Discussion and Conclusion:
This case demonstrates a rare finding of intrapelvic pseudotumor causing neurovascular compression after revision THA. Clinicians should be aware of intrapelvic pseudotumor as a possible cause of limb swelling and neuropathy, and that debulking of the mass is a potential treatment option in the setting of well-fixed implants.
References
McGrory BJ, Jacobs JJ, Kwon YM, Fillingham Y. Standardizing terms for tribocorrosion-associated adverse local tissue reaction in total hip arthroplasty. Arthroplast Today. 2020;6(2):196-200. doi:10.1016/j.artd.2020.01.008
Kwon Y-M, della Valle CJ, Lombardi A v, Garbuz DS, Berry DJ, Jacobs JJ. Risk Stratification Algorithm for Management of Head-Neck Taper Tribocorrosion in Patients with Metal-on-Polyethylene Total Hip Arthroplasty: Consensus Statement of the American Association of Hip and Knee Surgeons, the American Academy of Orthopaedic Surgeons, and The Hip Society. J Bone Joint Surg Am. 2021;103(5):e1-9. doi:10.2106/JBJS.20.01837
Plummer DR, Berger RA, Paprosky WG, Sporer SM, Jacobs JJ, della Valle CJ. Diagnosis and Management of Adverse Local Tissue Reactions Secondary to Corrosion at the Head-Neck Junction in Patients With Metal on Polyethylene Bearings. J Arthroplasty. 2016;31(1):264-268. doi:10.1016/j.arth.2015.07.039
Daniel J, Holland J, Quigley L, Sprague S, Bhandari M. Pseudotumors associated with total hip arthroplasty. J Bone Joint Surg Am. 2012;94(1):86-93. doi:10.2106/JBJS.J.01612
Hall DJ, Pourzal R, Jacobs JJ. What Surgeons Need to Know About Adverse Local Tissue Reaction in Total Hip Arthroplasty. J Arthroplasty. 2020;35(6):S55-S59. doi:10.1016/j.arth.2020.01.016
Pandit H, Glyn-Jones S, Mclardy-Smith P, et al. Pseudotumours associated with metal-on-metal hip resurfacings. J Bone Joint Surg Br. 2008;90(7):847-851. doi:10.1302/0301-620X.90B7
Bolognesi MP, Ledford CK. Metal-on-Metal Total Hip Arthroplasty: Patient Evaluation and Treatment. J Am Acad Orthop Surg. 2015;23(12):724-731. doi:10.5435/JAAOS-D-14-00183
Yoshihara Y, Shiromoto Y, Tatsumi M, Hirano M, Kawano T, Arino H, Osako M, Nemoto K. Backflow from a Metallosis-Induced Intrapelvic Mass into a Revision Hip Arthroplasty. JBJS Case Connect. 2013;3(3):e66. doi:10.2106/jbjs.cc.l.00201
Swiontkowski M, Resnick L. Pseudotumors After Non-MoM Hip Replacements. JBJS Case Connect. 2014;4(1):e27. doi:10.2106/jbjs.cc.n.00023
Hjorth MH, Mechlenburg I, Soballe K, Roemer L, Jakobsen SS, Stilling M. Higher Prevalence of Mixed or Solid Pseudotumors in Metal-on-Polyethylene Total Hip Arthroplasty Compared With Metal-on-Metal Total Hip Arthroplasty and Resurfacing Hip Arthroplasty. J Arthroplasty. 2018;33(7):2279-2286. doi:10.1016/j.arth.2018.02.011
Wiley KF, Ding K, Stoner JA, Teague DC, Yousuf KM. Incidence of pseudotumor and acute lymphocytic vasculitis associated lesion (ALVAL) reactions in metal-on-metal hip articulations: A meta-analysis. J Arthroplasty. 2013;28(7):1238-1245. doi:10.1016/j.arth.2013.03.027
Williams DH, Greidanus N v., Masri BA, Duncan CP, Garbuz DS. Prevalence of pseudotumor in asymptomatic patients after metal-on-metal hip arthroplasty. J Bone Joint Surg Am. 2011;93(23):2164-2171. doi:10.2106/JBJS.J.01884
Weber MA, Snyder MJ, Workman KK, et al. Comparison of Asymptomatic and Symptomatic Adverse Local Tissue Reaction in Patients With Head-Neck Taper Corrosion. J Arthroplasty. Published online September 17, 2020. doi:10.1016/j.arth.2020.09.014
Almousa SA, Greidanus N v., Masri BA, Duncan CP, Garbuz DS. The natural history of inflammatory pseudotumors in asymptomatic patients after metal-on-metal hip arthroplasty. Clin Orthop Relat Res. 2013;471(12):3814-3821. doi:10.1007/s11999-013-2944-4
Persson A, Eisler T, Bodén H, Krupic F, Sköldenberg O, Muren O. Revision for symptomatic pseudotumor after primary metal-on-polyethylene total hip arthroplasty with a standard femoral stem. J Bone Joint Surg Am. 2018;100(11):942-949. doi:10.2106/JBJS.17.00616
Bosker BH, Ettema HB, van Rossum M, Boomsma MF, Kollen BJ, Maas M, Verheyen CCPM. Pseudotumor formation and serum ions after large head metal-on-metal stemmed total hip replacement. Risk factors, time course and revisions in 706 hips. Arch Orthop Trauma Surg. 2015;135(3):417-425. doi:10.1007/s00402-015-2165-2
Wang J-W, Lin C-C, Wang W. Pelvic Mass Caused by Polyethylene Wear After Uncemented Total Hip Arthroplasty Case Report. J Arthroplasty. 1996;11(5):626-628.
Hattrup S, Richard B, Gaffey T, Stanhope R. Pelvic mass causing vesical compression after total hip arthroplasty. Case report. Clin Orthop Relat Res. 1988;227:184-189.
Shilt JS, Rozencwaig R, Wilson MR. Pelvic Mass Secondary to Polyethylene and Titanium Alloy Wear Debris Resulting in Recurrent Deep Vein Thrombosis. J Arthroplasty. 1997;12(8):946-949.
Fischer SR, Christ DJ, Roehr BA. Sciatic Neuropathy Secondary to Total Hip Arthroplasty Wear Debris. Vol 14.; 1999.
Jeanrot C, Ouaknine M, Anract P, Forest M, Tomeno B. Massive pelvic and femoral pseudotumoral osteolysis secondary to an uncemented total hip arthroplasty. Int Orthop. 1999;23(1):37-40. doi:10.1007/s002640050300
Mak KH, Wong TK, Poddar NC. Wear debris from total hip arthroplasty presenting as an intrapelvic mass. J Arthroplasty. 2001;16(5):674-676. doi:10.1054/arth.2001.23726
Nazarian DG, Zeni JA. Management of a pelvic mass following a worn uncemented total hip arthroplasty. J Arthroplasty. 2012;27(2):323.e17-323.e20. doi:10.1016/j.arth.2011.03.023
Allen Butler R, Barrack RL. Total Hip Wear Debris Presenting as Lower Extremity Swelling. A Report of Two Cases. J Bone Joint Surg Am. 2004;86(1):142-145.
Lencioni A, Ellis B, Dean CS, Lendrum J, Hogan CA. Metal-on-metal total hip arthroplasty adverse local tissue reaction with intermittent unilateral vascular claudication. Arthroplast Today. 2019;5(4):389-393. doi:10.1016/j.artd.2019.08.012
Grote CW, Cowan PC, Anderson DW, Templeton KJ. Pseudotumor from Metal-on-Metal Total Hip Arthroplasty Causing Unilateral Leg Edema: Case Presentation and Literature Review. Biores Open Access. 2018;7(1):33-38. doi:10.1089/biores.2017.0035
Harvie P, Giele H, Ansorge O, Ostlere S, Gibbons M, Whitwell D. The treatment of femoral neuropathy due to pseudotumour caused by metal-on-metal resurfacing arthroplasty. Hip Int. 2008;18(4):313-320.
Kawakita K, Shibanuma N, Tei K, Nishiyama T, Kuroda R, Kurosaka M. Leg Edema Due to a Mass in the Pelvis After a Large-Diameter Metal-On-Metal Total Hip Arthroplasty. J Arthroplasty. 2013;28(1):197.e1-197.e4. doi:10.1016/j.arth.2012.04.016
Fokter SK, Repše-Fokter A, Takač I. Case report: Femoral neuropathy secondary to total hip arthroplasty wear debris. Clin Orthop Relat Res. 2009;467(11):3032-3035. doi:10.1007/s11999-009-0894-7
Leung P, Kudrna JC. Growth of an intrapelvic pseudotumor associated with a metal-on-metal total hip arthroplasty after revision arthroplasty causing a femoral nerve neuropathy. Arthroplasty Today. 2016;2(3):105-109. doi:10.1016/j.artd.2016.07.001
Abdel-Hamid H, Miles J, Carrington RWJ, Hart A, Loh A, Skinner JA. Combined Vascular and Orthopaedic Approach for a Pseudotumor Causing Deep Vein Thrombosis after Metal-on-Metal Hip Resurfacing Arthroplasty. Case Rep Orthop. 2015;2015:1-4. doi:10.1155/2015/926263
Parfitt DJ, Wood SN, Chick CM, Lewis P, Rashid MH, Evans AR. Common Femoral Vein Thrombosis Caused By a Metal-On-Metal Hip Arthroplasty-Related Pseudotumor. J Arthroplasty. 2012;27(8):1581.e9-1581.e11. doi:10.1016/j.arth.2012.01.024
Memon AR, Galbraith JG, Harty JA, Gul R. Inflammatory Pseudotumor Causing Deep Vein Thrombosis After Metal-On-Metal Hip Resurfacing Arthroplasty. J Arthroplasty. 2013;28(1):197.e9-197.e12. doi:10.1016/j.arth.2012.02.014
Maurer-Ertl W, Friesenbichler J, Liegl-Atzwanger B, Kuerzl G, Windhager R, Leithner A. Noninflammatory pseudotumor simulating venous thrombosis after metal-on-metal hip resurfacing. Orthopedics. 2011;34(10):e678-681. doi:10.3928/01477447-20110826-32
Hananouchi T, Saito M, Nakamura N, Yamamoto T, Yonenobu K. Huge pelvic mass secondary to wear debris causing ureteral obstruction. J Arthroplasty. 2005;20(7):946-949. doi:10.1016/j.arth.2004.11.005
Kilicoglu ZG, Kilicoglu OI, Simsek MM. Total hip arthroplasty-related pelvic pseudotumor: Unusual presentation with hydronephrosis. Acta Orthop Traumatol Turc. 2016;50(4):470-472. doi:10.1016/j.aott.2016.05.001
Regis D, Sandri A, Costa A, Mazzilli G, Bartolozzi P. Recurrent femoral deep vein thrombosis: Rare complication of a pelvic mass induced by polyethylene wear debris following total hip arthroplasty. A case report. Thromb Res. 2008;121(4). doi:10.1016/j.thromres.2007.05.024
Leigh W, O’Grady P, Lawson EM, Hung NA, Theis JC, Matheson J. Pelvic Pseudotumor. An Unusual Presentation of an Extra-Articular Granuloma in a Well-Fixed Total Hip Arthroplasty. J Arthroplasty. 2008;23(6):934-938. doi:10.1016/j.arth.2007.08.003
Lin KHB, Lo NN. Failure of Polyethylene in Total Hip Arthroplasty Presenting as a Pelvic Mass. J Arthroplasty. 2009;24(7):1144.e13-1144.e15. doi:10.1016/j.arth.2008.06.029
Adelman S, Urquhart A, Biermann J, Freiberg A. Polyethylene wear debris presenting as a retroperitoneal tumor. Surgery. 1998;123(1):111-112.
Hisatome T, Yasunaga Y, Takahashi K. Hidden Intrapelvic Granulomatous Lesions Associated with Total Hip Arthroplasty: A Report of Two Cases. J Bone Joint Surg Am. 2003;85(4):708-710. https://journals.lww.com/jbjsjournal
Madan S, Jowett R, Goodwin M. Recurrent intrapelvic cyst complicating metal-on-metal cemented total hip arthroplasty. Arch Orthop Trauma Surg. 2000;120:508-510.
Kohn D, Pape D. Extensive Intrapelvic Granuloma Formation Caused by Ceramic Fragments After Revision Total Hip Arthroplasty. J Arthroplasty. 2007;22(2):293-296. doi:10.1016/j.arth.2006.01.030
Tamaki Y, Goto T, Tsutsui T, Takasago T, Wada K, Sairyo K. Compression of the Femoral Vessels by a Pseudotumor after Metal-on-Metal Total Hip Arthroplasty. Case Rep Orthop. 2017;2017:1-5. doi:10.1155/2017/2594902
McPherson, M.D., FACS E, Dipane, BA M, Sherif, MD S. Massive Pseudotumor in a 28mm Ceramic-Polyethylene Revision THA: A Case Report. Reconstructive Review. 2014;4(1):11-17. doi:10.15438/rr.v4i1.53
Serrano PM, Rodrigues C, S. Silva M, Coelho R, Cardoso P, Oliveira V. Pseudotumor complicating a well-fixed ceramic-on-polyethylene total hip arthroplasty. Clin Case Rep. 2018;6(9):1756-1760. doi:10.1002/ccr3.1720
Svensson O, Mathiesen EB, Reinholt FP, Blomgren G. Formation of a fulminant soft-tissue pseudotumor after uncemented hip arthroplasty. A case report. J Bone Joint Surg Am. 1988;70(8):1238-1242.
Murgatroyd SE. Pseudotumor Presenting as a Pelvic Mass: A Complication of Eccentric Wear of a Metal on Polyethylene Hip Arthroplasty. Journal of Arthroplasty. 2012;27(5):820.e1-820.e4. doi:10.1016/j.arth.2011.09.008
Ollivere B, Wimhurst JA, M. Clark I, Donell ST. Current concepts in osteolysis. J Bone Joint Surg Br. 2012;94-B(1). doi:10.1302/0301-620X.94B1.28047
Desai BR, Sumarriva GE, Chimento GF. Pseudotumor recurrence in a post-revision total hip arthroplasty with stem neck modularity: A case report. World Journal of Orthopaedics. 2020;11(2):116-122. doi:10.5312/wjo.v11.i2.116
Kwon YM, Rossi D, MacAuliffe J, Peng Y, Arauz P. Risk Factors Associated With Early Complications of Revision Surgery for Head-Neck Taper Corrosion in Metal-on-Polyethylene Total Hip Arthroplasty. J Arthroplasty. 2018;33(10):3231-3237. doi:10.1016/j.arth.2018.05.046
Waterson HB, Whitehouse MR, Greidanus N v, Garbuz DS, Masri BA, Duncan CP. Revision for adverse local tissue reaction following metal-on-polyethylene total hip arthroplasty is associated with a high risk of early major complications. doi:10.1302/0301-620X.100B6
Bonner B, Arauz P, Klemt C, Kwon YM. Outcome of Re-Revision Surgery for Adverse Local Tissue Reaction in Metal-on-Polyethylene and Metal-on-Metal Total Hip Arthroplasty. J Arthroplasty. 2020;35(6):S284-S288. doi:10.1016/j.arth.2020.02.006
Grammatopoulos G, Pandit H, Kwon Y-M, Gundle R, Mclardy-Smith P, Beard DJ, Murray DW, Gill HS. Hip resurfacings revised for inflammatory pseudotumour have a poor outcome. J Bone Joint Surg Br. 2009;91(8):1019-1024. doi:10.1302/0301-620X.91B8
Published
How to Cite
Issue
Section
License
Copyright (c) 2021 Matthew C. Sweet, MD, Tyler Snoap, MD, Bernard A. Roehr, MD, Jason W. Roberts, MD
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
Copyright and License Agreement:
Authors who publish with the Reconstructive Review agree to the following terms:
- Authors retain copyright and grant the journal right of first publication with the work. Reconstructive Review follows the Creative Commons Attribution-NonCommercial CC BY-NC. This license allows anyone to download works, build upon the material, and share them with others for non-commercial purposes as long as they credit the senior author, Reconstructive Review, and the Joint Implant Surgery & Research Foundation (JISRF). An example credit would be: "Courtesy of (senior author's name), Reconstructive Review, JISRF, Chagrin Falls, Ohio". While works can be downloaded and shared they cannot be used commercially.
- Authors are able to enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgement of its initial publication in this journal.
- Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work.
