Pseudotumour Complicated by Implant Loosening One Year After revision Ceramic on Metal Total Hip Arthroplasty: A Case Report

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1 Cse Report Journl of Orthopedic Cse Reports 2017 Jn Fe: 7(1):82 86 Pseudotumour Complicted y Implnt Loosening One Yer After revision Cermic on Metl Totl Hip Arthroplsty: A Cse Report Devendr Lkhoti 1, Prshnt Kumr 2 Wht to Lern from this Article? Erly intervention for metllosis of implnt cn prevent rpid progression of cup loosening. Astrct Introduction: Pseudotumor is not n uncommon compliction fter totl hip rthroplsty (THA). This cn occur in reltionship to different ering surfces of hed nd liner rnging from soft to hrd rticultion. There is wide spectrum of presenttion from symptomtic to implnt filure. Cse Report: We report cse of pseudotumor formtion with cetulr cup septic loosening fter revision cermic on metl hip rthroplsty. The ptient underwent pseudotumor excision nd re-revision complex rthroplsty procedure using treculr metl shell nd uttress with cermic on polyethylene THA. Conclusion: The surgeon should wre of this compliction during presenttion in revision cses to prevent rpid progression of cup loosening, nd to intervene erly to void complex rthroplsty procedures. Keywords: Arthroplsty, cermics, metls, polyethylene. Introduction Pseudotumor is norml periprosthetic soft tissue rection [1] developed in reltion to oth metl-on-polyethylene totl hip rthroplsty (THA) due to polyethylene deris [2] nd metl-on-metl (MoM) THA due to metl deris [3,4]. These lesions re non-neoplstic lesions elieve to worsen progressively nd resulted in oth one nd soft tissue extensive destruction [1]. Pseudotumor is incresingly ssocited to THA with recent studies incidence rnging from 0.27% to 5% [5, 6]. To overcome the dverse issue of metl ion relese of MoM, other hrd erings with improved qulity were introduced such s cermic-on-cermic (CoC) nd cermic-on-metl (CoM) couples to minimize ering surfce wer. CoM hve hd limited clinicl dt with short durtion of follow-up with high vrition in the wer performnce [7, 8, 9]. We report cse of pseudotumor formtion one yer fter revision CoM THA. At the time of initil presenttion, the ptient hs mild discomfort with well-fixed implnts. The ptient underwent pseudotumor formtion nd rpid septic loosening, nd mnged with complex re-revision rthroplsty with pseudotumor excision. On the sis of clinicl findings, Author s Photo Gllery Access this rticle online Wesite: Dr. Devendr Lkhoti Dr. Kumr Prshnt DOI: Deprtment of Orthopedics, Institute for Medicl Sciences nd Reserch Centre, Jipur Ntionl University, Jgtpur, Jipur, Rjsthn, Indi, 2 Deprtment of Orthopedics, Trum Centre, Bnrs Hindu University, Vrnsi, Uttr Prdesh, Indi. Address of Correspondence Dr. Devendr Lkhoti, Deprtment of Orthopedics, Institute for Medicl Sciences nd Reserch Centre, Jipur Ntionl University, Jgtpur, Jipur, Rjsthn, Indi. E-mil: drdevendr.ortho@gmil.com Copyright 2017 y Journl of Orthpedic Cse Reports Journl of Orthopedic Cse Reports pissn eissn Aville on doi: /jocr This is n Open Access rticle distriuted under the terms of the Cretive Commons Attriution Non Commercil License ( nc/3.0) which permits unrestricted non commercil use, distriution, nd reproduction in ny medium, provided the originl work is properly cited. 82

2 imging studies, increse serum metl ions, intropertive findings of metllosis nd histopthology, we elieved pseudotumor formtion in this cse of revision CoM THA. The ptient informed consent ws tken for the purpose of puliction of the cse. Cse Report 83 A 50-yer-old femle, deprtment store slesperson y profession, with idiopthic ilterl vsculr necrosis, underwent primry left hip THA in 2003 t n outside institution 3 yers efore evlution t our hospitl presented with worsening right hip pin. Rdiogrphs demonstrted secondry osteorthritis right hip for which cementless cermic on polyethylene (CoP) THA ws done. On the left side, there ws well functioning THA without evidence of ny loosening. Review of opertive record identified components s cementless metl-on-polyethylene (MoP) THA on left side. The posterolterl incision t left hip ws well heled with no evidence of ny infection. In 2011, the ptient strted grdul onset of pin in the left hip. Rdiogrphs nd computed tomogrphy (CT) scn demonstrted polyethylene wering with septic loosening of oth cetulr nd femorl components. The ptient underwent revision cementless CoM THA left side in 2011 using 54 mm pinncle cetulr shell, colt chromium metl liner, 36 mm Biolox delt cermic hed, S-ROM titnium lloy femorl stem with titnium sintered proximl sleeve (Depuy, Jhonson nd Jhonson co., Wrsw, IN). On the cetulr side llo chip one grft ws used for osteolytic lesions, encirclge wiring done for greter trochnter. Intropertive findings were loosening of femorl stem nd cetulr cup long with mild metllosis on cetulum nd femorl side. Postopertive period ws eventless with sustntil improvement in function. Acetulr cup inclintion nd nteversion ngle were 45 nd 20 respectively estimted from plin rdiogrph. Femorl nterversion ws 15 with norml stem lignment. At 6-week follow-up, the ptient ws mde prtil weight ering incresing to full weight ering with n ssistive device nd ctive duction over 6-week period. After 1 yer of follow-up in 2012, ptient complint of mild discomfort in the groin in the left inguinl region. On exmintion soft swelling, non-tender, 2 cm 3 cm size with no signs of inflmmtion ws present in inguinl region. Rdiogrphs showed norml lignment nd position of hip prosthesis with no signs of loosening (Fig. 1). Ultrsonogrphy suggestive of cystic lesion in illiopsos re in the left nterior hip (3.76 cm 3.12 cm 2.95 cm) suspected to e iliopsos ursitis. Serum inflmmtory mrkers nd complete lood counts were within norml limits. Clinicl exmintion showed pinless norml rnge of motion t left hip. The ptient ws kept under oservtion fter refusl for ultrsonogrphy-guided spirtion. After one month, she complins left groin nd thigh pin, limping followed y impired multion in few dys. The ptient showed n increse in size of iliopsos cystic lesion. Follow-up rdiogrphs showed signs of cetulr cup superior nd lterl migrtion, incresed inclintion ngle with evidence of loosening nd well-fixed femorl stem (Fig. 1). CT scn showed well circumscried cystic lesion round the left hip with n expnsion of in iliopsos region (Fig. 2). CT scn lso showed the superior segmentl defect in the cetulum long with loosening Figure 1: ( nd ) Anteroposterior rdiogrph of left hip. () 1 yer fter revision cementless cermic-on-metl hip rthroplsty demonstrting with well ligned nd fixed implnts. () 1 month fter the initil presenttion of mild discomfort, rdiogrph showed cetulr cup superior nd lterl migrtion with well-fixed femorl stem. Figure 2: The xil computed tomogrphy scn of oth hips shows spce occupying lesion in iliopsos region in communiction with left hip joint (rrow). of cetulr cup. Positive rdioisotope one scn indictes cetulr loosening. Serum C-rective protein ws 0.6 mg/dl, nd erythrocyte sedimenttion rte ws 28 mm/h. Her complete lood count ws norml. Serum colt nd chromium ws significntly rised (serum Co = 2.4 µg/l, serum Cr = 22.5 µg/l). Given the clinicl nd imging findings, comined with history of CoM THA, it ws felt tht ptients symptoms were likely septic loosening of cetulr cup with locl soft tissue response due to elevted serum metl ions. Surgicl explortion with revision THA for loosened implnt ws discussed with ptient. The ptient underwent revision surgery using posterolterl pproch. The pseudotumor nd surrounding inflmed synovitis sc ws excised. The cystic soft tissue extended to hip joint ws stined with fetures suggestive of metllosis (Fig. 3). Hip ws dislocted nd loosened cetulr cup long with colt-chromium liner ws removed. There is corrosive wer t the metl liner with lrge lck stripe cross the top of retrieved cermic femorl hed (Fig. 4). The proximl femorl sleeve nd the femorl tper showed no corrosion

3 Figure 3: ( nd ) Intropertive photogrph demonstrting cermic hed nd metl liner with metl stining s well metllosis of soft tissue. Figure 5: Postopertive nteroposterior rdiogrph fter second stge revision with treculr metl cup nd uttress with hed nd liner exchnged. c d Figure 4: Removed components nd metl stined soft tissue. or wer. The femorl stem with proximl sleeve ws well fixed with no evidence of corrosion. The intropertive frozen section of mss showed less thn 5 polymorphonucler leukocytes per high-power field in ll the three specimens. Intropertive drk gry colored fluid nlysis ws done with 58% polymorphonucler, 39% lymphocytic, nd 3% mononucler cells. After ggressive deridement of metllic nd necrotic tissue, cetulr cvitry defects were filled with mixed utogenous one grft nd llogrft one chips. On the cetulr side, the ptient ws revised with 52 mm treculr metl shell (52 mm) with metl uttress (Fig. 5) to ddress the superior one defect (zimmer, wrsw, Indin, USA). Highly crosslinked polyethylene liner ws pplied with 32 mm iolox delt cermic femorl hed (Depuy, Jhonson nd Jhonson co., Wrsw, IN). Opertive cultures for soft tissue nd fluid were oth negtive for infection. Histopthology ws consistent with metllosis. For ech tissue frgment, sections were routinely stined with hemtoxylin nd eosin nd exmined with light microscopy. On microscopic exmintion, the inner surfce covered with eosinophilic firinoid mteril with locl firotic tissue. The histopthology nlysis supports morphology consistent with the metllosis s n inflmmtory response to metl prticles. It reveled undnt lymphocytes, histiocytes, occsionl plsm cells, foreign ody type gint cells, nd lck metl prticles (Fig. 6-d). After 6 weeks of prtil weight ering, the ptient ws fully moilized with full weight ering over 6-week period. At 6 month repet serum metl ion nlysis showed decrese level with colt nd chromium Figure 6: (-d) Histologicl sections. () Chronic inflmmtion with lck pigments with pseudotumor perivsculr lymphocytes (H nd E, LM 40). () Necrotic deris with firosis, firin mteril lymphocytes (H nd E, 100). (c) Photomicrogrph demonstrting histiocytes infiltrtion with grey nd lck metl prticles in the tissue surrounding the grnulom (H nd E, 400). (d) High power mgnifiction demonstrting histiocytes nd foreign ody type gint cells contining lck metllic prticles (H nd E, 400). levels of 1.3, 2.54 µg/l, respectively. The recent colt nd chromium mesurements were 0.66 nd 0.42 µg/l, respectively. The ptient with continued improvements in function with full weight ering wlking t lst follow-up with Hrris hip score of 87 compred with 58 preopertively. Discussion The use of MoM ering is ssocited with elevted levels of serum metl ions [3, 10] with locl effects (metllosis nd locl soft tissue rection) [6] nd systemic effects [11]. The use of MoM rticultions hs decresed, nd other hrd on hrd erings such s CoC nd CoM hve een incresingly used. Although CoC is ssocited with low wer rtes ut rekge nd squeking re still concern. The in vitro studies showed reduce in wer in CoM ering surfce [12, 13]. At the sme time, there is difference in literture etween wer nd metl ion relese in CoM with limited clinicl 84

4 dt [8, 9, 14]. Few reports showed reltion etween hed - neck, modulr neck, nd stem-sleeve corrosion with the incresed incidence of metl hypersensitivity rections [15, 16]. Ptient-relted fctor like femle [17] nd surgeon relted fctor like suoptiml component positioning [18] more often involved in the pseudotumor. However, ll the three hrd ering (CoC, CoM, MoM) showed incresed wer with edge loding, CoM erings demonstrted lower wer compred with MoM [12]. Two cse reports descrie the pseudotumor formtion round the CoM ering fter primry rthroplsty with norml cetulr cup positioning [19, 20]. To est of our knowledge, our cse report is first to descrie pseudotumor formtion with rpid loosening, fter well ligned nd positioned revision CoM THA; nd mnged with complex re-revision rthroplsty. Initil presenttion of symptoms in our cse occurred one yer fter the revision surgery. This durtion is short in comprison to soft tissue rection in MoP ering rnging from 3 to 26 yers [21]. However, we oserved excessive cetulr inclintion, superior nd lterl migrtion of cup, nd loosening correlted with the increse symptoms of pin nd increse of soft tissue swelling in inguinl region. We oserved superior cetulr segmentl defect in CT scn. The inititing fctor in our cse would e pseudotumor followed y rpid loosening. After loosening there ws n increse in edge loding. The symptoms increse rpidly followed y incresed in size of pseudotumor indicting vicious cycle of rpid loosening nd metllosis. In the mngement of pseudotumor, non-metl ering is indicted during revision surgery [5] nd we revised our cse with CoP. But still, the presence of modulr titnium lloy stem with sleeve, porous treculr metl shell nd metl uttress [22], ptient with the serum metl ions need close follow-up. This CoM ering needs to e studied more thoroughly nd testing with emphsis on design nd mteril of the ering surfce. The clinicl dt with component position nd serum metls level in the long-term follow-up re necessry. Conclusion Pseudotumor is not n uncommon compliction fter THA. This cn occur in reltionship to different ering surfces of hed nd liner. Treting physicin should e wre of this condition so tht prompt dignosis nd tretment cn e crried out. Ptients with index revision surgery due to septic loosening my require susequent re-revision due to loosening. Loosening in such cses will increse edge loding, hence more severe metllosis nd rpid loosening requiring complex rthroplsty procedure. Clinicl Messge Even mild signs nd symptoms of soft tissue rection should e ggressively investigted for metllosis of implnt in the sence of ny rdiogrphic loosening. The surgeon should wre of this compliction during presenttion in revision cses to prevent rpid progression of cup loosening. 85 References 1. Dniel J, Hollnd J, Quigley L, Sprgue S, Bhndri M. Pseudotumors ssocited with totl hip rthroplsty. 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5 JBJS Cse Connect 2012;2(2):e Koper MC, Mthijssen NM, vn Rvenswy HH, Witt F, Morlock MM, Vehmeijer SB. Pseudotumor fter ilterl cermicon-metl totl hip rthroplsty-a cse report JBJS Cse Connect 2014;4:e Crli A, Reuven A, Zukor DJ, Antoniou J. Adverse soft-tissue rections round non-metl-on-metl totl hip rthroplsty - A systemtic review of the literture. Bull NYU Hosp Jt Dis 2011;69 Suppl 1:S47-S Potter HG, Ho ST, Altchek DW. Mgnetic resonnce imging of the elow. Semin Musculoskelet Rdiol 2004;8(1):5-16. Conflict of Interest: Nil. Source of Support: None How to Cite this Article Lkhoti D, Prshnt K. Pseudotumour Complicted y Implnt Loosening One Yer After revision Cermic on Metl Totl Hip Arthroplsty: A Cse Report. Journl of Orthopedic Cse Reports 2017 Jn-Fe;7(1):