Pseudotumor from ceramic-on-ceramic total hip arthroplasty

Abstract

Introduction and importance: Total hip arthroplasty is one of the most performed surgical interventions in the world. Adverse local tissue reactions and pseudotumors are infrequent but dangerous eventualities, which are often related with metal-on-metal or metal-on-polyethylene implants. This study wants to highlight how adverse local tissue reactions and pseudotumors must be taken into consideration during the diagnostic process.

Case presentation: We report the case of a patient with ceramic-on-ceramic modular total hip arthroplasty with titanium neck. 12 years after surgery, he complained of pain and swelling on the hip. Diagnostic tests revealed the presence of a bulky pseudotumor. During the revision surgery biopsy samples were taken and microscopical analysis revealed the presence of fibrous tissue, fibrin hemorrhagic collections, histiocytes and chronic inflammation due to foreign body, with dark refractive material of an exogenous nature.

Clinical discussion: The possible formation of pseudotumor and metallosis reactions in hip prostheses with metal-on-metal coupling or in couplings with polyethylene is known. Many cases of pseudotumor are reported after revision of prostheses due to the breakage of ceramic components, but we did not observe any damage or corrosion of the prosthetic elements; on the other hand, we noticed an excessive retroversion of the femoral neck. It may be possible that an accurate microscopic analysis could clarify the failure of this implant.

Conclusion: To date ceramic-ceramic coupling remains the gold standard in terms of resistance and durability for hip arthroplasty but there is still a gap of knowledge in the field of tribology and individual immune response mechanisms.

Keywords: Ceramic; Hip arthroplasty; Metallosis; Pseudotumor.

Fig. 1

Preoperative X-rays (anteroposterior and lateral view) - bone resorption around the left femoral stem.

Fig. 2

Preoperative MRI, Adverse Local Tissue Reaction and pseudotumor - bone resorption around the left femoral stem, left ilium and the acetabulum; protein/hemorrhagic subsolid collection of 7 cm in diameter inside the proximal part of the quadriceps muscle, which involved also the iliopsoas bursa and extended to the pelvis.

Fig. 3

Intra-operative images: through the Enneking approach and the detachment of the gluteal muscles from the ileum, the pseudotumor was removed.

Fig. 4

Explanted components, the femoral stem through Wagner's trans-femoral access, the acetabular cup with the help of gauges.

Fig. 5

Post-operative result; Burch Schneider cage with screws and filler cement, Muller II cemented cup (Smith & Nephew), 225 mm monolithic Wagner SL Revision Hip Stem (Zimmer Biomet) with a 32 mm femoral head, two cerclages.

Fig. 6

Microscopic analysis. A. Red arrow, exogenous material refracting at light microscopy. Black arrow, fibrin-hematous material. H&E, 20× magnification. B. Red arrow, granulomatous reaction with foamy hystiocytes. Pigmented macrophages can be seen scattered around this formation. H&E, 20× magnification. C. Black arrows, hystiocytes wall surrounding fibrin-hematous material (top right). Red arrow, a giant multi-nucleated cell. H&E, 20× magnification. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)