Vascular tumor in metal-on-polyethylene THA requiring hemipelvectomy

Abstract

Total hip arthroplasty with metal-on-polyethylene implants and metal-on-metal articulations have been an area of recent interest. This article describes a patient with a persistent small soft tissue mass on the anterior groin following total hip arthroplasty with negative findings on infection workup, including blood work and aspiration. Subsequent biopsy findings were consistent with organizing thrombus and necrosis. It then developed into an expansile soft tissue groin mass with significant femoral and pelvic bony destruction and soft tissue infiltration. Metallosis, the formation of a pseudocapsule, and aseptic lymphocyte vasculitis-associated lesions have also been an area of interest following adult hip reconstruction. Occasionally, the formation of subsequent lesions make revision surgery impossible to perform due to bony destruction and soft tissue limitations. Although few in number, most studies or cases that have linked metal-on-metal implants to pseudotumors have been treated with revision surgery and replacement of articulating surfaces. This case highlights a metal-on-polyethylene total hip arthroplasty with a mass presenting with pseudotumor-like characteristics. However, final histology demonstrated fibroadipose tissue with fat necrosis and fibrosis, thickened vascular vessels, and diffuse chronic inflammation with lymphocytic infiltrates, which are more consistent with an atypical inflammatory vascular tumor. The current case illustrates treatment difficulties and provides surgical options for when this event occurs. Although aseptic lymphocyte vasculitis-associated lesions have been observed with metal-on-polyethylene articulations, the multiorgan involvement in this case is unique. In this case, radical excision with hemipelvectomy and complex flap closure was a last resort treatment solution that staved off the prospect of patient mortality.