Rev. bras. ortop. vol.50 número6

w w w . r b o . o r g . b r

Case

report

Formation

of

a

pseudotumor

in

total

hip

arthroplasty

using

a

tribological

metal–polyethylene

pair

夽

Lorenzo

Fagotti

_,

_José

_Ricardo

_Negreiros

_Vicente

,

Helder

Souza

Miyahara

,

Pedro

Vitoriano

de

Oliveira

_,

_Antônio

_Carlos

_Bernabé

_,

_Alberto

_Tesconi

_Croci

a_{InstitutodeOrtopediaeTraumatologia,HospitaldasClínicas,FaculdadedeMedicina,UniversidadedeSãoPaulo(USP),SãoPaulo,SP,}

Brazil

b_{InstitutodeQuímica,UniversidadedeSãoPaulo(USP),SãoPaulo,SP,Brazil}

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Articlehistory:

Received4September2014 Accepted14October2014 Availableonline19October2015

Keywords:

Granulomaofplasmacells Hiparthroplasty

Orthopedics

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Theaimherewastoreportacaseofayoungadultpatientwhoevolvedwithtumor forma-tionintheleftthigh,14yearsafterrevisionsurgeryonhiparthroplasty.Daviesin2005made thefirstdescriptionofthisdiseaseinpatientsundergoingmetal-on-metalhiparthroplasty. Overthelastdecade,however,pseudotumorsaroundmetal-on-polyethylenesurfaceshave becomemoreprevalent.Ourpatientpresentedwithincreasedvolumeoftheleftthigh8 yearsafterhiparthroplastyrevisionsurgery.Twoyearsbeforethearisingofthetumorin thethigh,anoduleintheinguinalregionwasinvestigatedtoruleoutamalignant neoplas-ticprocess,buttheresultswereinconclusive.Themainpreoperativecomplaintswerepain, functionallimitationandmarkedreductionintherangeofmotionofthelefthip.Plain radiographsshowedlooseningofacetabularandfemoral,andalargemassbetweenthe muscleplaneswasrevealedthroughmagneticresonanceimagingoftheleftthigh.The sur-gicalprocedureconsistedofresectionofthelesionandremovalofthecomponentsthrough lateralapproach.Inrespectoftotalhiparthroplasty,pseudotumorsarebenignneoplasms inwhichthebearingsurfaceconsistsofmetal-on-metal,buttheycanalsooccurindifferent tribologicalpairs,aspresentedinthiscase.

©2015SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.Allrightsreserved.

夽

StudycarriedoutatInstitutodeOrtopediaeTraumatologia,HospitaldasClínicas,FaculdadedeMedicina,UniversidadedeSãoPaulo (USP),SãoPaulo,SP,Brazil.

∗ _{Correspondingauthor.}

E-mail:rrnegreiros@gmail.com(J.R.N.Vicente). http://dx.doi.org/10.1016/j.rboe.2015.10.006

plasmáticas

Artroplastiadequadril Ortopédica

descreveuestaafecc¸ãoempacientessubmetidosa artroplastiadequadrilcompar tri-bológicometal–metal,masnaúltimadécadaépossívelacharrelatosdepseudotumores emsuperfíciemetal–polietileno.Opacienteiniciouqueixadeaumentodevolumedacoxa esquerdaapósoitoanosdacirurgiaderevisãodaartroplastiadoquadril.Doisanosantesdo aparecimentodatumorac¸ãodacoxa,ainvestigac¸ãoparadescartarumprocessoneoplásico malignodeumnóduloemregiãoinguinalfoiinconclusiva.Suasprincipaisqueixas pré-operatóriaseramdor,limitac¸ãofuncionalemarcadareduc¸ãodaamplitudedemovimento doquadrilesquerdo.Asradiografiasdomembroacometidoevidenciavamsolturados com-ponentesacetabularefemoral,eumagrandemassaentreosplanosmuscularesserevelou àressonânciamagnéticadacoxaesquerda.Aabordagemcirúrgicaconsistiuderessecc¸ão intralesionaldacoxaesquerda,seguidadaretiradadoscomponentespelavialateraldireta. Noâmbitodacirurgiadeartroplastiadequadril,ospseudotumoressãoneoplasiasbenignas cujopartribológicoconsisteemmetal-metal,maspodemtambémocorreremdiferentes parestribológicos,comonestecaso.

©2015SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Todososdireitosreservados.

Introduction

Total hip replacement is an established procedure in the context of orthopedicsurgery. However, as inany surgical procedure, it is not free of complications. An uncommon complicationistheappearanceofpseudotumors,ascitedby Pandittin2008,whichconsistsintheformationofstructures (solidmasses,cysts,nodules) inthe peri-prosthetic tissues withoutinfection ormalignancycharacteristics.Thisentity wasoriginallyassociatedwiththemetal–metalinterface,1–3 buttheappearanceofpseudotumorshasalsobeendescribed in the case of metal–polyethylene4–8 _{and metal–ceramic}9 interfaces.Thisisaveryundesirablecomplicationforboththe surgeonandthepatient,asitcancauseseverepain,restricting therangeofmotionandeventuallycompressing neurovascu-larstructures.Inaddition,italsorepresentsamajorconcern inrelationtothehypothesisofapossibleneoplasia.

Case

report

Male patient, 45 years old, former smoker with no other comorbidities,wastreatedbytheHipGroupandthe Orthope-dicOncologyGroup.Hereportedpainandprogressivebulging inthemedialregionoftheleftthighsinceapproximately2 yearsago.At14years ofage, thepatient hadafracture of the left femoralneckand was treated withosteosynthesis andcannulatedscrewsinanotherservice.Fouryearsafterthe surgery,atage18,hewasadmittedtoanotherhospitalforthe treatmentofposttraumaticosteonecrosisofleftfemoralhead. Onthatoccasionheunderwentaleft totalhiparthroplasty (THA),ofwhichtribological pairconsistedofametalhead

andpolyethyleneinsert,withuncementedfemoralstemand uncementedacetabulum.Thirteenyears aftertheTHA, the patientsufferedanautomobileaccidentandhada peripros-theticfracture,whichwastreatedwithrevisionoftheprimary arthroplasty.Ananatomical,uncementedfemoralcomponent wasused,withporouscoating(PCAHowmedica®_),metalhead

and polyethylene insert. Five years after this surgery, the patientdevelopedanoduleintheleftgroinarea.Abiopsyof thelesionhadinconclusiveresults.Twoyearslater,hestarted tofeelleftlegweaknessandpainworseningintheinguinal region,mainlywhenheremainedinthesittingpositionfor morethan30min.Healsohaddifficultydrivingbecauseof thepainhefeltwhenusingthecarclutch.Thepatient devel-opedprogressivehardeningandincreasedvolumeoftheleft thigh. Venous Dopplerultrasound ofthe lower limbs diag-nosedvenousthrombosisoftheleftthigh.Thepatientwas treatedwithfullanticoagulationfor6months,with throm-bosisresolution,butthenoduleinthegroinpersisted,which graduallyincreasedinvolume.

Fig.1–Clinicalimageoftheleftthighanteromedialand proximalregions.Blackarrow,neurovascularbundle. Whitearrow,tumorofcysticconsistencynexttotheregion oftheleftgroin,with9cmofdiameter×5cmheight.

(Fig.2).Thearteriographyshowedthatthetumorwaslocated medially to the neurovascular bundle. This, in turn, was anterolaterallydisplacedatthemagneticresonanceimaging. Surgicaltreatmentofthelesionwaschosen,whichconsisted intheintralesionalresectionofthepseudotumor,collecting thematerialforinfectiousandanatomopathologicalanalysis andremovaloftheprostheticimplant.Surgicalaccesswas initiallycarriedoutthroughmedialaccessof4cminlengthat theapexofthelesion,fromanterosuperiortoposteroinferior direction.Duetothepresenceoftumormassthatwasdeeper andmoredistaltothecysticlesion,additionallya posteroinfe-riorandmedialaccessmeasuring5cmperformedtofacilitate theemptyingofthefluidmaterial(Fig.3).

Thepatientwas placedinthe supineposition withthe aidofacushiononthebackoftheleftthigh. Throughthe twomedialaccessroutes,itwaspossibletoachievethe emp-tyingof alarge amount of darkyellowish-green secretion, withoutdistinctiveodororpurulent aspect,withorganized lumps(Fig.4).Aftertheemptyingofthe cysticcontents,it waspossibletoidentifythepseudotumorcapsulewithmore precision(Fig.5).Thisstructurewaspreservedanditsclosure wascarriedoutbyapproximationwithspacedstitchesand Mononylon4.0TM_{.Then,withthepatientstillinthesupine}

Fig.2–MRIaxialviewoftheproximalregionoftheleft thighweightedinT1.Whitearrow,hyposignaland expansiveformationinmuscleplanesintheanteromedial regionoftheleftthigh.Blackarrow,adjacentcystwith presenceoffluidcollectionandthickcontentanddebris inside.

Fig.3–Clinicalpictureofthemedialregionoftheleft thigh.Blackarrow,outliningofthetumormassinthe proximalregionoftheleftthigh.Whitearrows,surgical planningthroughtwomedialaccessroutes.

Fig.4–(a)Emptyingofthepseudotumorshowinglargeamountsofdarkgreenfluid;(b)presenceoflumpsofthesamecolor withoutcharacteristicodorand(c)approximatedimageoflumpsandliquidcontentsinthesyringethatwassentfor laboratoryanalysis.

collected 3monthsaftersurgery,whichalso measuredthe metalratiowithurinarycreatinine.Theabsolutevaluewas 13.9␮g/Landtherelativevalueof6.7␮gCr/gofcreatinine,a slightly increasedlevel. Thepatient was alsosubmitted to theHarrisHipScorequestionnairebeforeandaftersurgery, whichshowedanincreaseofninepoints2weeksaftersurgery (54–63);thepatientiscurrentlyasymptomaticandthesurgical woundhasagoodaspect.Theleukocytecount,ESRandCRP valuesarewithinthenormalrange(Figs.4and5).

Discussion

Pseudotumorsthatoccurafteratotalhiparthroplasty usu-ally affect the population aged >50 years old3–11 _{and this} canbepartlyexplainedbythefactthatarthroplastyis

per-Fig.5–Intraoperativeimageofpseudotumorcapsuleafter emptyingofthefluidcontents.Thedarkaspectofitsinner wallcanbeobserved.

formed more often in elderly individuals. In the study by Davies,12_{samplesoftissuearoundtheimplantwerecollected} inpatientsundergoingTHArevision,andthissurgeryis usu-allyperformedinolderpatients.However,pseudotumorsmay alsooccurinyoungerpatients.13,14

Usually, the clinical picture reported by patients con-sists ofpainintheaffected hip,particularlywhenwalking, whichshowsprogressiveworseningandmakesambulation difficult.5,9,10 _{In somecases, symptoms can occur inmore} remote locations of the hip joint, which requires greater attention of the orthopedist in relation to the differential diagnosis.6,11 _{Apalpablemassisnotalwayspresentand,in} this sense,the imagingexaminationsare ofutmost impor-tance forthediagnosis.Hipplainradiographyusuallydoes not showsigns ofacetabularand femoralloosening.5,9,11,15 Computedtomographyofthepelvis,inturn,allowsthe identi-ficationofsignsofpelvicosteolysis14_{andcysticmassadjacent} totheimplant.2,6,11,14 _{Incaseswheretheprevioustestsare} normal,theMRIoftheoperatedhipcanbeuseful.10

Laboratoryanalysisusuallycharacterizesanon-infectious processwithnormalinflammatorymarkers.4–6,9,10,15,16_Incase ofelevatedinflammatorymarkers,5,11,13_{theinvestigationof} rheumatic diseases should be considered.8 _{Theeosinophil} increase is also described, but only as a finding in the leukogram.5,10 _{Lymphohistiocytic infiltrate, multinucleated} giant cells and necrotic fibrous-connective tissue are com-mon findings at the histological analysis of pseudotumor afterTHA.4,6,7,13_{Theunderstandingofdelayed} hypersensitiv-ityreactionstometalisnecessary, astheycharacterizethe immunologyofthesepatientsandcanoccurinseveraltypes ofcontactsurface.AsepticLymphocyticVasculitis-Associated Lesions (ALVAL) and perivascular lymphocytic infiltration (PVLI)maybehistologicallyassociatedandpresentin arthro-plastysurgeries.15,17

thepresenceofapseudotumorshouldalsobeconsidered.A decreaseinvolumeandeventhecompletedisappearanceof thetumormasscanjustifytheconservativetreatment.7

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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metal-on-polyethylenetotalhiparthroplasty.Orthopedics. 2013;36(5):e666–70.

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13.ShahrdarC.Pseudotumorinlarge-diametermetal-on-metal totalhiparticulation.JArthroplasty.2011;26(4):665.e21–3. 14.BourghliA,FabreT,TramondP,DurandeauA.Totalhip

replacementpseudotumoralosteolysis.OrthopTraumatol SurgRes.2010;96(3):319–22.

15.MaoX,TayGH,GodboltDB,CrawfordRW.Pseudotumorina well-fixedmetal-on-polyethyleneuncementedhip arthroplasty.JArthroplasty.2012;27(3):493.e13–7. 16.LeeJH,LeVH,SteinhoffA,HoangBH.Vasculartumorin

metal-on-polyethyleneTHArequiringhemipelvectomy. Orthopedics.2013;36(7):e974–7.