Rev. bras. ortop. vol.49 número5

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

Case

Report

Pelvic

pseudotumor

following

total

hip

arthroplasty

–

case

report

夽,夽夽

Nelson

Franco

Filho

,

Alexandre

de

Paiva

Luciano

,

Bruno

Vierno

a_{DepartmentofMedicine,UniversidadedeTaubaté(UNITAU),Taubaté,SP,Brazil}

b_{OrthopedicsandTraumatologyService,UniversityHospitalofTaubaté,Taubaté,SP,Brazil}

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t

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Articlehistory:

Received18September2013 Accepted7October2013

Availableonline18September2014

Keywords:

Plasmacellgranuloma Hiparthroplasty Pelvicneoplasms

a

b

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Looseningisawell-knowncomplicationoftotalhiparthroplasty.Theaccumulationof detri-tusresultingfrommechanicalwearformsinflammatorycellsthathavethefunctionof phagocytizingthisdebris.Overthelongterm,thesecellsmaygiverisetoalocal granulo-matousreaction.Here,wepresentareportonacaseofpelvicpseudotumorsubsequent tototalhiparthroplasty,whichisconsideredrareintheliterature.Thepatientwasa 48-year-oldblackmanwhostartedtobefollowedupmedicallyeightmonthsearlierbecause ofuncharacteristicabdominalpains,dysuriaandpollakiuria.Hehadundergonelefttotal hiparthroplasty17 yearspreviously.Throughclinicalinvestigation andcomplementary examinations,anextra-articulargranulomatousmasswasdiagnosed,constitutingapelvic pseudotumor.

©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.Allrightsreserved.

Pseudotumor

de

pelve

pós-artroplastia

total

do

quadril

–

relato

de

caso

Palavras-chave:

Granulomadecélulasplasmáticas Artroplastiadequadril

Neoplasiaspélvicas

r

e

s

u

m

o

Asoltura éumacomplicac¸ãobemconhecidanasartroplastiastotaisdoquadril.O acú-mulodedetritosresultantedodesgastemecânicoformacélulasinflamatóriasquetêma func¸ãodefagocitaressesdetritosepodem,emlongoprazo,gerarumareac¸ãogranulomatosa

local. A seguir, apresentamos um relato de caso de pseudotumor de pélvis

pós-artroplastiatotaldoquadril,consideradoraronaliteraturaconsultada.Trata-sedepaciente

夽

Pleasecitethisarticleas:FrancoFilhoN,dePaivaLucianoA,ViernoB.Pseudotumordepelvepós-artroplastiatotaldoquadril–relato decaso.RevBrasOrtop.2014;49(5):543–9.

夽夽

WorkdevelopedintheDisciplineofOrthopedicsandTraumatology,DepartmentofMedicine,UniversidadedeTaubaté,andinthe OrthopedicsandTraumatologyService,UniversityHospitalofTaubaté,Taubaté,SP,Brazil.

∗ _{Correspondingauthor.}

E-mail:alexandrepaiva76@ig.com.br(A.dePaivaLuciano).

http://dx.doi.org/10.1016/j.rboe.2013.10.001

544

de48anos,masculino,negro,queiniciouseguimentomédicopordoresabdominais incar-acterísticas,disúriaepolaciúriahaviaoitomeses.Apresentavaartroplastiatotaldoquadril esquerdohavia17anos.Apósinvestigac¸ãoclínicaepormeiodeexamescomplementares, diagnosticou-seumamassagranulomatosaextra-articular,pseudotumordepélvis.

©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Todososdireitosreservados.

Introduction

Looseningisawell-knowncomplicationoftotalhip

arthro-plasty.Theaccumulationofdetritusfrom mechanicalwear

formsinflammatorycellsthathavethefunctionof phagocy-tizingthisdetritus.However,overthelongterm,formationof thesecellsmayresultinagranulomatousreaction.Thishas theeffectofcreatinganabnormaladditionaljointmassand mayleadtoatypicaljointorabdominalsymptoms.

Inthefollowing,wereportacaseoflooseningofan unce-mentedprosthesisinwhichanextra-articulargranulomatous masscomprisingapelvicpseudotumordeveloped.Inthe lit-erature,thisconditionisconsideredtoberare.

Description

of

the

clinical

condition

The patient was a 48-year-old black man who started to

undergomedicalfollow-upbecauseofabdominalpain irra-diatinguncharacteristicallytothelefthip,alongwithdysuria andpollakiuria,whichhehadhadforeightmonths.Hehad undergonetotalhiparthroplasty17yearsearlier.

Fig.1–Radiographsofthelefthipinanteroposteriorandobliqueviews(December27,2010)showingtotalarthroplasty performed17yearsearlier.

At a consultationwith an urologist, no irregularities or alterationswerefoundthroughdigitalrectalexamination.The patientunderwentaprostatebiopsy,whichdidnotshowany neoplasticalterations.

Intheorthopedicphysicalexaminationonadmission,the patientpresentedthefollowing:

• Inspection:nogaitabnormalities;presenceofasurgicalscar

intheposterolateralregionofthelefthip;

• Bonepalpation:nopainintheleftorrighthip;

• Rangeofmotionofthelefthip:flexionof90◦_,extensionof 20◦_{,abductionof25}◦_{,adductionof15}◦_{,internalrotationof} 20◦_{andexternalrotationof15}◦_;

• Sensitivitypresentandnoalterationstothelowerlimbs;

• MusclestrengthofgradeVinbothlowerlimbs;

• Peripheralpulsepresentandfullinthelowerlimbs;

• Aftertheorthopedicclinicalexamination,aninvestigation

usingimagingexaminationswasconducted(Figs.1–3).

Withtheaidoftheimagingexaminations,surgical treat-mentwasthenproposed,withinterventionbytwospecialists

Fig.2–Echographicimagesoftheurinarytractandprostateshowingmassofcysticappearanceclosetothebladder.

546

Tensor fasciae latae

Gluteus maximus muscle

Gluteus medius muscle Vastus lateralis muscle

C

A

B

Fig.4–Detailofthesurgicalprocedureforrevisionoftotalhiparthroplastyandresectionofthetumoralmass.

performdecompressionandresectionofthemass;andfrom the joint reconstruction group to perform revision of the left-side total hip arthroplasty. These surgical procedures werecarriedoutinFebruary2011(Figs.4and5).

Afterthesurgicalresectiondescribedabove,thediagnosis

wasconfirmedbymeansofanatomopathological

examina-tion,whichshowedthepresenceofgranulomatoustissuewith absenceofneoplasticorinfectiouscells.

Eightmonthsaftertheoperation,controlradiographsof therevisionoftheleft-sidetotalhiparthroplastyin anteropos-teriorandlateralviewsandcontrolechographsoftheurinary tractandprostatewereproduced.Thesewerewithinnormal patternsanddemonstratedthattherehadnotbeenany recur-renceofthecyst(Figs.6and7).

Discussion

Clinical and radiographic signs of induced osteolysis are

frequently seen in relation to hip prostheses, and these

complicationsarewell-knownamonghipsurgeons.However,

a less commoncomplication may accompanysuchevents:

presenceofamassofsymptomaticsofttissue.Inourcase, thepatientpresentedinitialsymptomsrelatingtourological alterations,withoutsignsorsymptomsinthehipjoint.

Detritusresultingfromlooseningorwearisusually

phago-cytized bymacrophagesand inflammatorycells.In certain

situations,anaggressivegranulomatousreactionmayoccur, with the characteristics ofa foreign body. Thisreaction is characterized clinically by formation of progressive cysts

that generate symptomatic masses in the pelvis.1,2

San-tavirta et al.3 _{suggested that this granulomatosis would}

involve decouplingofthenormalsequence of

“monocytes-macrophages-clearance”,mediatedbyforeignmaterialsand

tissue detritus, which is normally followed by fibroblasts. SchmalzriedandCallaghan4_{reportedthatthisaggressivelysis} couldoccuratanypointalongthespaceofthehipjoint.A defectinthejointcapsuleorabonedefectmayresultin her-niationorinpropagationofthisspacetotheextra-articular

ESQ

ESQ

ESQ

ESQ

Fig.6–Postoperativecontrolradiographsinanteroposteriorandlateralviews,producedeightmonthsafterrevisionofthe left-sidetotalhiparthroplasty.

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Table1–Summaryofdiagnosesandmanagementofsimilarcases.

Authors Age Typeof prosthesis

Numberof yearsuntil revision

Symptoms Diagnosis Cyst management Prosthesis management Numberof incisions Hartrup etal.7

59 Cemented

revisiondue toinfection

7yearssince revision Dysuriaand nocturia Acetabular loosening and migration Laparotomy withcyst excision Revisionof totalhip prosthesis 2 Reigstadand Rokkum8 78 Cemented revi-sion/loosening

6yearssince revision

Massinright iliacfossa

Migrationof acetabulum insidepelvis

Extraperitoneal excisionofthe cyst Revisionof totalhip prosthesis 2 DeFrang etal.9

57 Uncemented 3years Edemaand

paininlower limb

Wearon polyethylene

Ilioinguinal excisionofthe cyst Revisionone yearsafter totalhip prosthesis 2 Matsumoto etal.10

58 Cemented 21years Ileocecalpain

andmass Loosening and migrationof acetabulum Retroperitoneal excision Revisionof totalhip prosthe-sis+bone grafting

2

Fischer etal.11

84 Uncemented 5years Painand

weaknessin lowerlimb

Compression ofsciatic nerve

Debridement Revisionof

totalhip prosthesis

1

Madanetal.12 _{83 Cemented}

revi-sion/loosening

14yearssince revision

Acutepain andedemain hip Compression offemoral arteryand vein Inguinal excisionand subsequent retroperitoneal Revisionand graftingin totalhip prosthesis 3 Hisatome etal.13

46 Cemented

Charnley

16years Hippain Acetabular

defect Resectionof mass Acetabular revision 1 Hisatome etal.13

46 Bipolar

arthroplasty

15years Right-side

inguinal mass Acetabular osteolysis Resectionof mass Cemented revisionof totalhip prosthesis 1 Korkalaand Syrjanen14

56 Cemented 10years Right-side

inguinal mass Acetabular osteolysis Aspirationof cyst Revisionand graftingin acetabulum 1 Wangand Lin15 50 Uncemented revision

5yearssince revision Left-side inguinal mass Defectof acetabular wall Debridementof mass Revisionand graftingin acetabulum 1

TranslatedandadaptedfromLeighW,O’GradyP,LawsonEM,HungNA,TheisJC,MathesonJ.Pelvicpseudotumor:anunusualpresentationof anextra-articulargranulomainawell-fixedtotalhiparthroplasty.JArthroplasty.2008;23(6):934–8.

region.5,6 _{Inourpatient,thismasswasconcentratedinthe} extra-articularspace.Granulomatousmassesofthisnaturein

thepelvismaybesymptomaticorasymptomatic.Theymay

beidentifiedduringroutineinvestigationsforotherreasons ormaybecomeevidentduringthepreoperativeinvestigations forhiprevisionsurgery.7_{Inourpatient,revisionofthe} pros-thesiswasindicatedonlyforremovalofthecyst.Thelesion

may causesymptoms, resulting from pressureon adjacent

structures,whichdidnotoccurinthispatient.Inthiscase,

thepelvicmasscausedabdominalpainswith

uncharacter-isticirradiationtothelefthip,accompaniedbydysuriaand pollakiuria.

Forthepurposesofmakingcomparisonswiththepresent case,Table1showsasummaryofdiagnosesandmanagement approachesusedinsimilarcases.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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2.JacobsJJ,ShanbhagA,GlantTT,BlackJ,GalanteJO.Wear debrisintotaljointreplacements.JAmAcadOrthopSurg. 1994;2(4):212–20.

3.SantavirtaS,KonttinenYT,BergrothV,EskolaA,TallrothK, LindholmTS.Aggressivegranulomatouslesionsassociated withhiparthroplasty:immunopathologicalstudies.JBone JointSurgAm.1990;72(2):252–8.

4.SchmalzriedTP,CallaghanJJ.Wearintotalhipandknee replacements.JBoneJointSurgAm.1999;81(1):115–36.

5.MakKH,WongTK,PoddarNC.Weardebrisfromtotalhip arthroplastypresentingasanintrapelvicmass.J Arthroplasty.2001;16(5):674–6.

6.MorrisonKM,ApelgrenKN,MahanyBD.Backpain,femoral veinthrombosis,andaniliopsoascyst:unusualpresentation ofaloosetotalhiparthroplasty.Orthopedics.1997;20(4):347–8.

8. ReigstadA,RøkkumM.Anintrapelvicgranulomainducedby acetabularcuploosening.ActaOrthopScand.

1992;63(4):465–6.

9. DeFrangRD,GuyerWD,PorterJM,DuweliusPJ.Synovialcyst formationcomplicatingtotalhiparthroplasty:acasereport. ClinOrthopRelatRes.1996;(325):163–7.

10.MatsumotoK,HukudaS,NishiokaJ,FujitaT.Iliopsoasbursal distensioncausedbyacetabularlooseningaftertotalhip arthroplasty:ararecomplicationoftotalhiparthroplasty. ClinOrthopRelatRes.1992;(279):144–8.

11.FischerSR,ChristDJ,RoehrBA.Sciaticneuropathysecondary tototalhiparthroplastyweardebris.JArthroplasty.

1999;14(6):771–4.

12.MadanS,JowettRL,GoodwinMI.Recurrentintrapelviccyst complicatingmetal-on-metalcementedtotalhip

arthroplasty.ArchOrthopTraumaSurg.2000;120(9):508–10.

13.HisatomeT,YasunagaY,IkutaY,TakahashiK.Hidden intrapelvicgranulomatouslesionsassociatedwithtotalhip arthroplasty:areportoftwocases.JBoneJointSurgAm. 2003;85A(4):708–10.

14.KorkalaO,SyrjänenKJ.Intrapelviccystformationafterhip arthroplastywithacarbonfibre-reinforcedpolyethylene socket.ArchOrthopTraumaSurg.1998;118(1/2):113–5.