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Combined Vascular and Orthopaedic Approach for a Pseudotumor Causing Deep Vein Thrombosis after Metal-on-Metal Hip Resurfacing Arthroplasty


Abstract and Figures

. Metal-on-metal (MoM) hip resurfacings have been associated with a variety of complications resulting from adverse reaction to metal debris. Pseudotumors have rarely been reported to cause deep venous thrombosis (DVT). Study Design . A case report and a review of the literature. Case Presentation . A 75-year-old female who had left metal-on-metal hip resurfacing 6 years ago presented with left groin pain associated with unilateral lower limb edema and swelling. By duplex and MRI studies, our patient had an extensive soft tissue necrosis associated with a large pelvic mass causing extensive DVT of the lower limb secondary to mechanical compression of the left iliac vein. Results . Our case was initially treated for DVT followed by dual surgical approach. The pseudotumor was excised through a separate iliofemoral approach and revision of the hip implant was undertaken through a posterior approach in the same setting. An inferior vena cava (IVC) filter was inserted to minimise the perioperative risks of handling the iliac veins. Conclusion . A combined approach with vascular surgeons is required. Combined resection of the pseudotumor and revision of the metal bearing surfaces is essential, in order to achieve a good surgical outcome in this rare complication.
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Case Report
Combined Vascular and Orthopaedic Approach for
a Pseudotumor Causing Deep Vein Thrombosis after
Metal-on-Metal Hip Resurfacing Arthroplasty
Hossam Abdel-Hamid, Jonathan Miles, Richard W. J. Carrington, Alister Hart,
Alex Loh, and John A. Skinner
Correspondence should be addressed to Hossam Abdel-Hamid; dr sam
Received  May ; Accepted August 
Academic Editor: Paul E. Di Cesare
Copyright ©  Hossam Abdel-Hamid et al. is is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
Introduction. Metal-on-metal (MoM) hip resurfacings have been associated with a variety of complications resulting from adverse
reaction to metal debris. Pseudotumors have rarely been reported to cause deep venous thrombosis (DVT). Study Design.Acase
report and a review of the literature. Case Presentation. A -year-old female who had le metal-on-metal hip resurfacing
years ago presented with le groin pain associated with unilateral lower limb edema and swelling. By duplex and MRI studies,
our patient had an extensive so tissue necrosis associated with a large pelvic mass causing extensive DVT of the lower limb
secondary to mechanical compression of the le iliac vein. Results. Our case was initially treated for DVT followed by dual surgical
approach. e pseudotumor was excised through a separate iliofemoral approach and revision of the hip implant was undertaken
through a posterior approach in the same setting. An inferior vena cava (IVC) lter was inserted to minimise the perioperative
risks of handling the iliac veins. Conclusion. A combined approach with vascular surgeons is required. Combined resection of
the pseudotumor and revision of the metal bearing surfaces is essential, in order to achieve a good surgical outcome in this rare
1. Introduction
Metal-on-metal (MoM) hip resurfacing was popularised in
adverse local tissue reactions (ALTRs), have been reported
tissue necrosis or possibly hypersensitivity reactions.
We present a case of large pelvic pseudotumor associated
with MoM hip resurfacing resulting in deep vein thrombosis
(DVT). Such cases have been described in association with
polyethylene debris but rarely reported with resurfacing hip
2. Case Presentation
A -year-old female presented to our hospital in April 
with le groin pain associated with unilateral lower limb
She had previously had le hip resurfacing arthroplasty
in , using Cormet prosthesis (Corin, Cirencester, United
levels were within the normal range recommended by MHRA
(Cobalt . ppb, chromium . ppb). A metal artifact reduc-
tion sequence (MARS) MRI scan of both hips was also per-
formed one year ago. is showed a cystic lesion measuring
 mm × mm in size. Our patient was asymptomatic with
regard to both hips and mobilizing independently and was
fully active prior to the onset of recent symptoms.
On examination, the le leg was swollen from thigh to
ankle. She had generalized tenderness starting from the groin
and the lateral aspect of the thigh radiating down her leg.
Her hip arthroplasty wound was well healed, and there were
no inammatory changes. Her hip was painful on all move-
ments, but worse with rotation in exion. Patient also showed
signs of psoas irritation.
Hindawi Publishing Corporation
Case Reports in Orthopedics
Volume 2015, Article ID 926263, 4 pages
Case Reports in Orthopedics
F : Anteroposterior X-ray pelvis showing right THR and le
hip resurfacing.
On abdominal examination, there was fullness in the le
iliac fossa with tenderness on deep palpation. Her right hip
examination was normal.
Investigations revealed an elevated erythrocyte sedimen-
tation rate (ESR) of  mm/hour and C-reactive protein
(CRP) of  mg/L (normal: – mg/L). Her white blood cell
count was . (.–). Metal ion levels were within the
normal range, cobalt . ppb and chromium . ppb.
She was admitted to hospital. A plain radiograph of her
pelvis showed satisfactory positioning of right uncemented
total hip replacement with  mm metal-on-metal articu-
lation (Corail/Pinnacle) and le hip resurfacing, without
adverse features (Figure ).
Duplex ultrasound of the le leg venous system showed a
distended occluded le common femoral vein which failed
to respond to respiratory excursions. ere was extensive
induration and oedema of the skin overlying the thigh which
hampers good visualisation of the deep veins within the thigh.
Also, ultrasound showed an  mm × mm le sided psoas
collection which extends from just about the level of the
femoral head to the level of the lesser trochanter distally. is
collection was compressing the le iliac vein.
MARS MRI scan of both hips and pelvis showed le
retroperitoneal pelvic cystic lesion ( mm × mm) previ-
ously noted anteriorly and now extending into the iliopsoas
bursa. It was thin walled and contained low signal linear
debris. e external iliac vessels were displaced and attened.
Further, a smaller cystic lesion was also noted around the
greater trochanter ( mm in length ×mm in width)
(Figure ).
Our patient was anticoagulated with low molecular
weight heparin (LMWH) and warfarin. e swelling im-
proved rapidly with treatment and rest. Revision surgery was
planned but delayed for months pending treatment of DVT.
Prior to surgery, a temporary IVC lter was inserted to
minimise the risks of intraoperative pulmonary emboli and
CT angiography performed before surgery (Figure ).
At surgery, pseudotumor was resected aer mobilisation
of the iliac veins, via an extraperitoneal iliofemoral approach
the patient placed in the right lateral decubitus position for
revision of the le hip resurfacing to total hip replacement
via a posterior approach.
Intraoperatively, the external iliac vessels lie closely
related to the external wall/capsule of the pseudotumor. e
periarticular tissues at the le hip were abnormal and dull
grey in colour. Samples were sent for histopathology and
microbiology examination. Cultures were sterile aer  days
of incubation. Histologically, the tissue consisted of brous
and brohyalinized tissue with evidence of acute inam-
mation, predominantly macrophages with only occasional
lymphocytes. ere were small areas of synovial hyperplasia
and focal necrosis. is suggested an adverse reaction to
metal debris.
Subsequently, she also completed her course of anticoag-
ulants, and a repeat sonogram revealed patent deep venous
system. Her symptoms have signicantly improved. She is
able to carry out most of her daily activities and has an Oxford
score of  out of  nine months aer surgery.
3. Discussion
Metal-on-metal hip resurfacing was introduced in the s
with the hope that wear rates would be lower for the harder
bearing surfaces, that larger head sizes would reduce the rate
of dislocation, and that subsequent revision surgery would
benet from bone preservation of the femoral neck [].
Although there is less wear in MoM bearing compared
with metal-on-polyethylene bearings, the particle size in
MoM hips is small and may induce greater biological reac-
tivity [].
Excellent results have been reported aer MoM hip resur-
facing, but concern regarding abnormal reaction to metal
debris in some patients persists. Pandit et al. rst described
neither malignant nor infective cystic and solid masses asso-
ciated with metal-on-metal resurfacing and introduced the
term pseudotumor. ey reported that pseudotumor may be
the result of a toxic eect on cells due to particulate wear
debris or an idiosyncratic response to the release of metal
particles [].
By -year follow-up, the incidence of pseudotumors aer
hip resurfacing arthroplasty has been described at .% to
.% [–]. According to Pandit et al., the overall incidence
of pseudotumors in MoM resurfacing arthroplasty is % at
years [].
tumors are female sex, bilateral resurfacing arthroplasties,
excessive cup anteversion, cup inclination of more than ,
and higher metal ion levels and some prosthesis types [, ].
Pseudotumors may be asymptomatic. Various complica-
tions associated with pseudotumors include persistent pain,
femoral or sciatic nerve palsy, rash, and ureteral obstruction
[, ]. Although the DVT from a pseudotumor caused by
metal-on-polyethylene hip arthroplasty has been described
in the literature [, ], only very few cases were described
in relation to the large MoM resurfacing arthroplasty.
Our patient had bilateral MoM bearing hips. She
remained asymptomatic for years. She developed a pseudo-
tumor that caused local compression of the iliac veins. is is
Case Reports in Orthopedics
F : MARS MRI showing a le retroperitoneal cystic mass lesion ( mm × mm) noted anteriorly and extending into the iliopsoas
F : CT angiography showing a large cystic mass compressing the le iliac vessels.
Only four cases of such tumors causing DVT aer MoM
have been described before. One case had a revision surgery
and excision of the pseudotumor using the same approach
[]. Another case was deemed to be inoperable and only
revision of the implant was done []. e third case had only
marginal resection of the cystic lesion but ten months later the
patient developed recurrent swelling and underwent revision
surgery of the implant []. e fourth case underwent
resection of the pseudotumor only [].
DVT followed by interval resection of the pseudotumor with
IVC lter insertion to minimise the perioperative risks of
revised to a non-metal bearing (ceramic-on-polyethylene)
total hip replacement, which removes the metal ion/particle
generating force. Nine months aer surgery, the patient
reported complete relief of groin pain and good function and
is case report is the rst, to our knowledge, to describe
a dual surgical approach for management of pseudotumor
causing deep venous thrombosis due to mass eect. e
external iliac vessels and femoral neurovascular bundles were
at risk and lie closely related to the external wall/capsule of
the pseudotumor. is study highlights the importance of
two surgical specialties working together to reduce the risk
of harm to these structures.
Conflict of Interests
e authors declare that there is no conict of interests
regarding the publication of this paper.
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... Pseudotumor masses typically present with hip pain and gait disturbance but can also cause intrapelvic lesions with compression of local soft tissue structures. Previous case reports on lower extremity swelling and deep vein thrombosis (DVT) as a result of venous compression, urinary symptoms, and hydronephrosis, as well as vague abdominal fullness and groin pain, have been published in the literature [3][4][5][6][7][8]. Additionally, femoral and sciatic nerve palsies have been reported due to compression or encasement by pseudotumor [9]. ...
... Multiple reports detail compression of the iliac vein secondary to pseudotumor, resulting in lower extremity swelling and/or deep vein thrombosis (DVT) [3][4][5]. A common aspect of treatment in patients with iliac vein compression, particularly in the setting of DVT, is the placement of an IVC filter [3][4][5]. ...
... Multiple reports detail compression of the iliac vein secondary to pseudotumor, resulting in lower extremity swelling and/or deep vein thrombosis (DVT) [3][4][5]. A common aspect of treatment in patients with iliac vein compression, particularly in the setting of DVT, is the placement of an IVC filter [3][4][5]. The IVC filter is thought to reduce the risk of pulmonary emboli while handling the iliac vein during decompression [4]. ...
Full-text available
A 58-year-old male who underwent left total hip arthroplasty in 1988 for post-traumatic arthritis after an operatively-treated acetabular fracture presented with progressive left hip pain, lower extremity swelling, urinary urgency, constipation, and tenesmus (the feeling of needing to pass stool despite having an empty colon). Imaging demonstrated massive pseudotumor causing iliac vein compression and significant displacement of the rectum and bladder requiring decompression in combination with general surgery followed by revision hip arthroplasty four months later. This case highlights a unique constellation of symptoms due to pseudotumor after total hip arthroplasty, as well as the severity to which pseudotumor can progress, requiring staged decompression with general surgery before revision.
... Patients with MACC may present with a variety of symptoms including pain, weakness, and gross instability in the hip, thigh, groin, or buttock or other vague lower extremity complaints. In rare instances, lower extremity edema due to an ALTR has been described [4,5], although primarily with MoM implants [6][7][8][9][10][11][12][13]. Here we present a case of MACC occurring in a patient with a MoP modular hip prosthesis who presented with unilateral lower extremity swelling that resolved with revision to a ceramic-on-polyethylene (CoP) construct, which, to our knowledge, is the first description of documented vascular compromise due to an ALTR in a patient with an MoP hip. ...
... Until recently, ALTRs, including the presence of cystic masses and fluid collections, have been more commonly associated with MoM hip prostheses and MoM hip resurfacing, although vascular compromise even in this population appears to be rare. Our review of the literature revealed 7 case reports describing unilateral leg swelling in patients with ipsilateral MoM total hip prosthesis [6][7][8][9][10][11][12] and 4 cases in cohort studies of leg swelling in MoP THAs [4,5]. As discussed by Grote et al, the patients in the MoM cases are usually female, with evidence of DVT present in 50% of cases and presence of a cystic mass causing vascular compression present in all cases [9]. ...
... These results are similar to those described in the previously mentioned case reports of lower extremity vascular compromise in the setting of MoM total hip implants, in which all patients eventually had improvement or resolution of vascular symptoms after revision to ceramic-on-ceramic (CoC) or CoP total hip components [6][7][8][9][10][11][12]. Of note, in the case described by Maurer-Ertl et al [6], the patient was first treated with partial resection of inflamed, necrotic tissue and developed a recurrence of swelling that permanently subsided after revision to CoC THA. ...
Full-text available
Mechanically assisted crevice corrosion in modular total hip replacements may lead to an adverse local tissue reaction (ALTR) with a variety of sequelae. Although an ALTR is most commonly recognized with metal-on-metal modular hip constructs, tribocorrosion at the head-neck junction of metal-on-poly- ethylene (MoP) total hip arthroplasties may also lead to an ALTR. We present a case of a 79-year-old woman with a history of MoP total hip arthroplasty who presented with unilateral leg swelling, joint pain, and stiffness and subsequently underwent revision for an ALTR secondary to mechanically assisted crevice corrosion. This unique case of lower extremity vascular compromise resulting from an ALTR is important because clinicians should consider corrosion-related ALTRs when treating patients with an MoP hip prosthesis presenting with new-onset lower extremity swelling.
... Historically, this was termed pseudotumor but is referred to as adverse local soft-tissue reaction (ALTR). ALTRs can also lead to persistent pain, femoral or sciatic nerve palsy, rash, and ureteral obstruction [3][4][5][6]. ...
... The variability of individual response to these metal ions makes it difficult to predict which patient is more likely to require revision surgery after a MoM primary THA or resurfacing [2]. Metal ions carry their own adverse reactions including persistent pain, rash, and ureteral obstruction [3][4][5][6]. Systemic findings can include cognitive, auditory, and visual symptoms along with cardiac pathology, tremor, neuropathy, and depression [13]. Many studies have attempted to develop a critical serum metal ion (Co and Cr) to predict symptomatic ALTR or need for revision surgery. ...
... According to our vascular surgery colleagues, his vascular claudication symptoms and cramping were secondary to femoral venous occlusion from adjacent soft-tissue swelling resulting in symptomatic intermittent venous insufficiency. Eight previous reports of MoM primary or resurfacing THAs have been reported to have ALTR with associated unilateral leg swelling [3,[18][19][20][21][22][23][24]. However, to our knowledge, this is the only case reported with intermittent vascular claudication as a primary complaint. ...
Full-text available
Osteolysis and adverse local soft-tissue reactions are well-documented complications of metal-on-metal prosthetic implants. This case report describes a 68-year-old man who presented to the clinic 10 years after staged bilateral metal-on-metal total hip arthroplasty revisions with the primary complaint of groin pain, intermittent right leg pain, swelling, and muscle cramping while ambulating that resolved with rest. A complete workup was negative for deep venous thrombosis and infection. His symptoms were found to be secondary to an iliopsoas bursal mass externally compressing the femoral vasculature resulting in vascular claudication. He was treated with revision arthroplasty and drainage of the fluid within the iliopsoas bursal effusion with symptomatic resolution. Keywords: Metallosis, Metal-on-metal, Total hip arthroplasty, THA, Revision arthroplasty, Adverse local tissue reaction, Pseudotumor, Mechanically assisted crevice corrosion
... A review of the literature identified six published case reports that describe unilateral leg swelling after MoM THA. [26][27][28][29][30][31] The result of each case is summarized in Table 1. Unfortunately, no other higher level studies or reviews are available; thus, no definitive statements can be made regarding patients with this condition. ...
... Parfitt et al. in 2012 published the first report of unilateral leg swelling related to a pseudotumor from an MoM THA; this is also the only case report published that described a male patient. 27 As with the patients described by Memon et al. 29 and Abdel-Hamid et al., 31 this patient was found to have a DVT and was treated with anticoagulation and inferior vena cava filter before surgical intervention for the pseudotumor. In addition, Abdel-Hamid et al. reported involving vascular surgery in the treatment paradigm. ...
... The vascular surgeons assisted in mobilization of the external iliac artery and vein and excision of the pseudotumor via a separate ilioinguinal approach. 31 Our proposed diagnostic workup for patients with symptomatic MoM THA and ipsilateral leg swelling is similar to that published by Bolognesi and Ledford,5 with the addition of a vascular surgery consult and Doppler ultrasound to rule out DVT. As with THA of any type, complete workup of symptomatic MoM THA would include laboratory values to exclude infection, such as ESR, CRP, and CBC with differential. ...
Full-text available
Metal-on-metal (MoM) total hip arthroplasty (THA) can be associated with adverse metal reactions, including pseudotumors. This case report describes a 58-year-old female with an MoM THA-related pseudotumor that caused unilateral leg edema from compression of her external iliac vein. After thorough preoperative workup to rule out infection and deep vein thrombosis and consultation with a vascular surgeon, the patient underwent revision THA and excision of her pseudotumor. She had complete resolution of her swelling at 4 years after surgery. Review of all available case reports for this rare complication revealed that almost all patients were female. All patients underwent revision THA, with resolution of their symptoms. Literature review demonstrates that women are disproportionally affected by complications associated with MoM THA. We recommend close monitoring of patients with MoM THA, particularly women, for development of adverse metal reactions.
... Pseudotumors associated with THA may be asymptomatic, and identification may occur during routine investigations for another reason. While unexplained pain is typically the presenting symptom, unilateral limb swelling [25][26][27]29,45], sciatic nerve neuropathy [21], femoral nerve neuropathy [28,30,31], venous thrombosis [32][33][34][35], and ureteral obstruction [36,37] have been reported in several case reports. ...
Full-text available
Background: There is a growing body of recent literature regarding the occurrence of pseudotumors associated with modular junctions and various bearing surfaces after total hip arthroplasty (THA). Revision surgery is often technically challenging and high complication rates have been reported. The optimal management of these patients and outcomes after operative treatment remain poorly understood. Methods: We report the case of a 77-year-old male with progressive unilateral lower extremity swelling, pain, and neuropathy 9 years after revision THA for polyethylene liner wear. Imaging and biopsy confirmed a massive intrapelvic pseudotumor exerting compressive effects. Radiographs demonstrated extensive femoral and pelvic osteolysis without evidence of component loosening. Debulking of the intrapelvic portion of the pseudotumor was performed via the lateral window of the ilioinguinal approach with component retention. Results: Debulking of the intrapelvic mass resulted in resolution of symptoms. One year postoperatively the patient reported pain free ambulation using a walker and no recurrence of symptoms. Radiographs demonstrated stable THA components in comparison with preoperative films. Discussion and Conclusion: This case demonstrates a rare finding of intrapelvic pseudotumor causing neurovascular compression after revision THA. Clinicians should be aware of intrapelvic pseudotumor as a possible cause of limb swelling and neuropathy, and that debulking of the mass is a potential treatment option in the setting of well-fixed implants.
... Anesthesia of the orthopedic surgery can slow down the venous flow rate, formating a hypercoagulable state of blood, and after surgery the patients need limb immobilization for recovering, which is also an important cause of postoperative DVT (2,3). The incidence of DVT after orthopedic surgery has been reported to be between 1% and 25% (4). Therefore, prevention of postoperative thrombosis is very important, the use of anticoagulant drugs can prevent the formation of new thrombus and dredge the vein that has formed thrombus, in addition, some physical therapies can help to inhibit the growth of thrombus, such as leg elevation, intermittent compression inflation, plantar venous pump, and compression elastic stockings (5). ...
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Background: To investigate the preventive effect of elastic stockings on deep vein thrombosis (DVT) after orthopedic surgery by literature search and meta-analysis. Methods: PubMed, Embase and Cochrane were selected as the search database platforms to search the literature of randomized controlled trials related to elastic stockings and DVT published from 2008 to date. Revman 5.3.5 software was used for statistical analysis of the data to obtain forest and funnel plots. Results: In this study, 90 studies were initially screened and 7 were finally included, covering a total of 3,116 patients. Meta-analysis showed that the 7 studies had statistical heterogeneity (I2=32%, P=0.18), so a random effect model was used. The obtained statistic was [odds ratio (OR) =0.59, 95% confidence interval (CI): (0.34, 1.03)], the statistical effect size was Z=1.84, P=0.07, and the difference was not statistically significant, so a stepwise sensitivity analysis was performed by the exclusion method. One study was excluded, and the remaining 6 showed homogeneity (I2=0%, P=0.46). They were analyzed by subgroup according to the type of operation: ankle surgery or hip and knee arthroplasty. The internal literatures of each subgroup were homogeneous: ankle surgery subgroup (I2=0%, P=0.43), hip and knee arthroplasty subgroup (I2=0%, P=0.88). Therefore, fixed effect mode analysis was used, and the effect size of elastic stockings after ankle surgery was Z=3.65, P=0.0003, while the effect size of elastic stockings in the hip and knee arthroplasty subgroup was Z=1.23, P=0.22. Discussion: Elastic stockings had an obvious preventive effect on DVT in patients undergoing ankle surgery, but not in patients undergoing lumbar, knee or spinal surgery. It is necessary to combine anticoagulant drugs and other physical therapies to prevent DVT.
... However, when implanted in the human body, metal on metal implants failed as they release metal ions and wear debris due to the long-term contact with the corrosive physiological solution. Further, the released metal ions cause an allergic reaction called metal hypersensitivity [10], or metallosis [11,12] and are also associated with the formation of pseudotumors [13][14][15]. In contrast to the metal on metal implants, ceramics were found to exhibit low wear rate, nevertheless, the sudden fracture, squeaking noise and the high cost of ceramics implants also have raised concerns about their usage [16,17]. ...
Developing coatings for various applications is an uttermost important area of research, to protect surfaces from severe damage by improving wear and corrosion resistance of the materials. Recently, there have been increasing interests in ceramic coatings for the biomedical application, as the surface may become more inert in nature for the biological reactions and potentially increase the lifespan of the implants and minimize the side effects on the patients. Hence this study is focused on the tribocorrosion behavior of the ceramic coatings for the hip implant application on commonly used implant titanium alloy. The three types of the ceramic coatings are, conventional monolithic micron alumina (IDA), micron alumina-40wt% yttria-stabilized zirconia (YSZ) composite coating (IDAZ) and by-layer nanostructured alumina-13wt% titania/YSZ (IDZAT) on Ti-6Al-4V alloy. A series of tests, under free potential and potentiostatic mode, using a hip simulator tribocorrosion setup under simulated joint fluid, (Bovine calf serum with protein concentration 30g/L). The tribological conditions, are pin-on-ball contact with a load of 16N (contact pressure of 50MPa), the frequency of 1Hz (walking frequency) and with an amplitude of 30o. The tribocorrosion studies clearly revealed that the coatings have better wear and corrosion resistance and predominantly damage mechanism was mechanical wear than corrosion. Among the coatings, the IDZAT shows enhanced tribocorrosion performance by exhibiting more positive OCP, no induced current and lower coefficient of friction.
... Recent studies show that the incidence of pseudotumors is comparable with other THA systems such as cobalt on polyethylene and metal on polyethylene [4,5]. MoM THA-induced pseudotumors can cause compression of the neurovascular bundle [6,7]. This had also been described for conventional THA, although this pseudotumor compression was associated with a broken or worn-out inlay, which induces a MoM reaction [8,9]. ...
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Objective: Pseudotumors, a well-known complication of metal-on-metal total hip arthroplasty (MoM THA), are well identified on metal artifact-reducing sequences magnetic resonance imaging (MARS-MRI). Several MRI grading systems are described in the orthopedic literature, but their validity is unknown in large clinical studies. Our study was undertaken to describe the classification of pseudotumors in a preselected cohort divided into high- and low-risk patients, using three pseudotumor grading systems applied on MARS-MRI, and to determine the interobserver reliability of the grading systems. Patients and methods: A retrospective study was performed on 377 consecutive patients (240 MRI scans) treated with an M2a-38 and Taperloc stem combination (Biomet, Warsaw, IN, USA). Patients were divided into a high-risk and a low-risk group based on previous published risk factors. Two observers determined the presence of pseudotumors using three different pseudotumor grading systems for classifying MARS-MRI results. Results: The prevalence of pseudotumors as determined with MARS-MRI was 59% in our high-risk group, 0% in the low-risk group and 43% in the control group. Serum cobalt values were increased in the high-risk group. The kappa values of the Anderson, Hauptfleisch and Matthies grading system scores were 0.43, 0.44, and 0.49 respectively. Conclusions: High-risk patients are at a high risk for pseudotumor development. No pseudotumor development was found in low-risk patients. Interobserver reliability scored best with the Matthies system, but all three grading systems showed only a moderate agreement.
... Deep vein thrombosis (DVT) is a type of venous thromboembolism disease that is common in the clinic and typically occurs following surgery for lower extremity bone trauma and other diseases, including diabetes and gestational hypertension (1,2). The incidence of DVT is >0.1% and has increased in recent years (3). The primary pathological characteristic of lower extremity venous thrombosis is abnormal blood coagulation in the lower extremity deep vein that obstructs the lumen and causes venous reflux obstacles (4). ...
The present study aimed to investigate the role and mechanism of action of microRNA (miR)‑26a in deep vein thrombosis (DVT). Peripheral blood was collected from 45 patients with DVT and 40 healthy controls. Levels of miR‑26a, chemokine C‑C motif ligand (CCL)2 mRNA and CCL7 mRNA were detected using reverse transcription‑quantitative polymerase chain reaction and the value of miR‑26a in the clinical diagnosis of DVT was assessed using receiver operating characteristic curve analysis. The correlation of miR‑26a with CCL2 and CCL7 levels was analyzed using Spearman's rank correlation. In addition, miR‑26a and protein kinase C δ (PRKCD) were overexpressed in human umbilical vein endothelial cells (HUVECs) and PRKCD expression was knocked down by small interfering (si)RNA. Western blotting was conducted to detect the expression of PRKCD and p65. Furthermore, a dual‑luciferase reporter gene assay was performed. The results of the current study demonstrated that the expression of miR‑26a was significantly downregulated in the peripheral blood of patients with DVT compared with healthy controls (P<0.05) and negatively correlated with CCL2 and CCL7 levels (P<0.05). Furthermore, it was demonstrated that miR‑26a markedly inhibited the expression of PRKCD, significantly decreased levels of CCL2 and CCL7 mRNA (P<0.05) and inhibited activation of the NF‑κB signaling pathway. Overexpression of PRKCD in HUVECs inhibited the effects of miR‑26a and markedly upregulated the phosphorylation of p65. The present study indicated that miR‑26a directly targets PRKCD mRNA and that miR‑26a may be a useful biomarker in the clinical diagnosis of DVT. Thus, the present findings suggest that miR‑26a regulates the NF‑κB signaling pathway by binding to PRKCD mRNA, inhibits the expression of CCL2 and CCL7 and reduces the risk of DVT.
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Total hip arthroplasty (THA) is a common treatment for osteoarthritis and is also performed for other conditions, such as secondary arthritis due to developmental dysplasia of the hip. Various THA types may be complicated by osteolysis and an inflammatory pseudotumor due to an adverse reaction to metal debris. Rarely, THA has been associated with malignant tumors, but their causality remains unclear. In this case report, we describe a female patient with developmental dysplasia of the hip. She had undergone left metal-onpolyethylene THA, acetabular revision of the THA, and left total knee arthroplasty. In addition, she had a history of dyslipidemia and telangiectasia of the eyes, anemia, hiatal hernia, and pleuritis. A THA-associated mass (suspected to be a pseudotumor) had been detected during a previous hospital admission due to pleuritis. She was hospitalized due to swelling in her left lower limb, fatigue, and bruises. A clinical examination revealed anemia, thrombocytopenia, and growth of the suspected pseudotumor. Within 6 weeks, she presented with bleeding of the oral mucosa, hemoptysis, melena, severe thrombocytopenia that did not respond to treatment, elevated D-dimer and C-reactive protein levels, severe pain, increased osteolysis, and fractures around the THA. Infection or malignancy was suspected, but two trocar biopsies suggested an inflammatory pseudotumor. Since her anemia and thrombocytopenia were considered to have been caused by an inflammatory process within the suspected pseudotumor, her suspected pseudotumor and all THA components were surgically removed. However, she developed severe alveolar hemorrhaging and hypoxia and died 2 weeks after her surgery. Histopathological analysis of her surgical and autopsy samples revealed highly malignant angiosarcoma. Although individual cases of malignancies associated with THA have been reported, the literature lacks a clear association between THA and increased cancer risk. Most pseudotumors are non-malignant. The patient’s case presented in this report exemplifies the challenges to the differential diagnosis of a THA-associated pseudotumor and rare angiosarcoma. Atypically rapid tumor growth, severe osteolysis, and deterioration in the general wellbeing suggest a malignant disease.
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Despite the increasing interest and subsequent published literature on hip resurfacing arthroplasty, little is known about the prevalence of its complications and in particular the less common modes of failure. The aim of this study was to identify the prevalence of failure of hip resurfacing arthroplasty and to analyse the reasons for it. From a multi-surgeon series (141 surgeons) of 5000 Birmingham hip resurfacings we have analysed the modes, prevalence, gender differences and times to failure of any hip requiring revision. To date 182 hips have been revised (3.6%). The most common cause for revision was a fracture of the neck of the femur (54 hips, prevalence 1.1%), followed by loosening of the acetabular component (32 hips, 0.6%), collapse of the femoral head/avascular necrosis (30 hips, 0.6%), loosening of the femoral component (19 hips, 0.4%), infection (17 hips, 0.3%), pain with aseptic lymphocytic vascular and associated lesions (ALVAL)/metallosis (15 hips, 0.3%), loosening of both components (five hips, 0.1%), dislocation (five hips, 0.1%) and malposition of the acetabular component (three hips, 0.1%). In two cases the cause of failure was unknown. Comparing men with women, we found the prevalence of revision to be significantly higher in women (women = 5.7%; men = 2.6%, p < 0.001). When analysing the individual modes of failure women had significantly more revisions for loosening of the acetabular component, dislocation, infection and pain/ALVAL/metallosis (p < 0.001, p = 0.004, p = 0.008, p = 0.01 respectively). The mean time to failure was 2.9 years (0.003 to 11.0) for all causes, with revision for fracture of the neck of the femur occurring earlier than other causes (mean 1.5 years, 0.02 to 11.0). There was a significantly shorter time to failure in men (mean 2.1 years, 0.4 to 8.7) compared with women (mean 3.6 years, 0.003 to 11.0) (p < 0.001).
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Early failure associated with adverse reactions to metal debris is an emerging problem after hip resurfacing but the exact mechanism is unclear. We analysed our entire series of 660 metal-on-metal resurfacings (Articular Surface Replacement (ASR) and Birmingham Hip Resurfacing (BHR)) and large-bearing ASR total hip replacements, to establish associations with metal debris-related failures. Clinical and radiological outcomes, metal ion levels, explant studies and lymphocyte transformation tests were performed. A total of 17 patients (3.4%) were identified (all ASR bearings) with adverse reactions to metal debris, for which revision was required. This group had significantly smaller components, significantly higher acetabular component anteversion, and significantly higher whole concentrations of blood and joint chromium and cobalt ions than asymptomatic patients did (all p < 0.001). Post-revision lymphocyte transformation tests on this group showed no reactivity to chromium or cobalt ions. Explants from these revisions had greater surface wear than retrievals for uncomplicated fractures. The absence of adverse reactions to metal debris in patients with well-positioned implants usually implies high component wear. Surgeons must consider implant design, expected component size and acetabular component positioning in order to reduce early failures when performing large-bearing metal-on-metal hip resurfacing and replacement.
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We report the incidence of pseudotumours in a single-surgeon consecutive series of 670 metal-on-metal hip resurfacings performed in the last ten years, with a minimum follow-up of one year. Two cases of pseudotumours have been found and are discussed in detail including metrology and wear analyses of the explanted components. The first was a painless, large synovial cyst in the thigh, secondary to aseptic femoral cup loosening 8 years following hip resurfacing. The second was a painful collection of wear debris in the psoas region at one year post surgery caused by impingement, resulting in eccentric edge wearing. In the first case it was decided to retain the bearing surface; in the second case, conversion to a metal-on-polyethylene hip replacement was performed. In our experience the risk of pseudotumours is low (0.15%) and can be fully explained. In selected cases the bearing surface can be retained.
This case report details the presentation, imaging results, and operative findings of a pseudotumor associated with a press-fit metal-on-polyethylene total hip arthroplasty (THA). An 80-year-old man presented approximately 7 years after undergoing THA with worsening right groin and lateral hip pain with an associated proximal thigh mass. Physical examination demonstrated a tender, large anterolateral thigh mass that was also evident on metal artifact reduction sequence magnetic resonance imaging. An exploratory operative procedure revealed extensive tissue necrosis involving nearly the entire hip capsule, short external rotators, and tendinous portion of the gluteus medius muscle. In addition, marked surface corrosion was discovered about the taper at the head-neck junction of the prosthetic femoral component and the trunnion within the femoral head. The press-fit THA components were solidly fixed. The metallic head was replaced with a ceramic component, and the polyethylene liner was exchanged. The patient had complete resolution of his preoperative symptoms but had persistent problems with dislocations. Although reports of pseudotumor and local soft tissue reactions associated with metal-on-metal THAs have become increasingly ubiquitous in the literature, similar reports involving metal-on-polyethylene THA implants are less common.
We report the case of a patient with leg edema after large-diameter metal-on-metal total hip arthroplasty. At 1 year and 2 months after primary left large-diameter metal-on-metal total hip arthroplasty, the patient complained of left leg edema. At first, we suspected deep venous thrombosis. However, deep venous thrombosis was not detected by venous ultrasonographic examination. Computed tomography imaging revealed a mass in front of the iliac fossa. The mass compressed the left iliac artery and vein. We therefore believed that this lesion was the cause of the leg edema and performed resection of the mass. The resected mass consisted of necrotic tissue infiltrating inflammation cells, so it was diagnosed as pseudotumor. Unilateral leg edema disappeared gradually after the resection.
Metal-on-metal hip resurfacings have recently been associated with a variety of complications resulting from adverse reaction to metal debris. We report a case of extensive soft tissue necrosis associated with a huge pelvic mass causing extensive deep vein thrombosis of the lower limb secondary to mechanical compression of the iliac vein. This is a rare and unusual cause of deep vein thrombosis after metal-on-metal hip resurfacing arthroplasty.
We present a case of a pseudotumor causing a deep femoral vein thrombosis 16 months after undergoing a metal-on-metal total hip arthroplasty. There is increasing concern over the effect of metal ions that are produced by wear in metal-on-metal hip arthroplasty systems. Recently, a number of articles have reported the development of an inflammatory pseudotumor causing a number of different problems early on in the lifespan of the implant necessitating revision surgery. This case reports the first presentation of a pseudotumor causing a serious venous thrombosis due to pressure effect and indicates further possible evidence for caution when considering metal-on-metal bearing hip arthroplasty.
Metal-on-metal hip resurfacing has become a widespread procedure, especially in young, physically active patients. Pseudotumor is a new complication that can occur after hip resurfacing and metal-on-metal total hip arthroplasty (THA). This article presents a case of a 37-year-old woman who underwent metal-on-metal resurfacing of the left hip for symptomatic osteoarthritis. Twelve months following implantation, the patient reported painless swelling of the left lower leg. There was no clinical evidence of a deep venous thrombosis. Ultrasound and computed tomography showed a solid cystic lesion in the iliopsoas muscle, which communicated with the hip joint and compressed the external iliac vein. As a consequence, the cystic lesion was resected marginally. A few months later, the patient reported some discomfort in the groin and symptoms of instability, metallic clicking, and a restricted range of motion. Clinical and radiological examination revealed normal findings. Determining the serum concentration of cobalt and chromium revealed high increased levels of these metal ions. Ten months following excision of the pseudotumor, the patient reported recurrent swelling of the left lower leg. Computed tomography of the affected area showed a lobulated cystic formation; therefore, a relapse was suspected. At the second revision, the mass was excised and the implant was revised to a conventional ceramic-on-ceramic THA. At 30-month follow-up, the patient was doing well and there were no signs of local recurrence. Additionally, the metal ion levels of cobalt and chromium in the blood had significantly decreased.
We present a patient with unilateral, spontaneous, late leg swelling that developed 4 years after total hip arthroplasty. The etiology was the compression of the internal iliac vein by a voluminous iliopsoas bursitis caused by polyethylene debris. The expansive lesion was detected by ultrasound, arthrography, and magnetic resonance imaging. An ultrasound-guided aspiration provided transient relief of the patient's symptoms. The patient later required surgical excision through an abdominal approach. A second recurrence was detected and treated with revision surgery. We present the diagnosis and the treatment of this rare cause of late, unilateral leg swelling after total hip arthroplasty together with a review of the literature.
Metal-on-metal resurfacing arthroplasty of the hip has been used increasingly in Europe over the last ten years for the treatment of osteoarthritis of the hip in younger (<65 years of age), active patients. In 2005, 6,153 procedures were performed in England and Wales1. Marketing of the Birmingham hip replacement for resurfacing arthroplasty was approved by the United States Food and Drug Administration in May 2006. Metal-on-metal resurfacing of the hip is known to be associated with elevated concentrations of metal ions within the hip joint and systemically, but, to our knowledge as of this writing, no adverse effects of this process have been identified. However, the United Kingdom Medicines and Healthcare Products Regulatory Agency (MHRA) issued an alert in June 2007 about the Ultima metal-on-metal bearing total hip arthroplasty prosthesis (DePuy International, Leeds, United Kingdom) following reports of the need for early revision due to periprosthetic soft-tissue necrosis2. The bearing in question was a cobalt-chromium-molybdenum alloy similar to that used in the Birmingham hip replacement. We report the development of an ipsilateral mass associated with markedly elevated intralesional cobalt and chromium levels and a femoral nerve palsy in a patient who underwent a Birmingham metal-on-metal resurfacing arthroplasty of the hip one year previously. Our patient was informed that data concerning the case would be submitted for publication, and she consented. A sixty-three-year-old woman presented to another institution with painful idiopathic osteoarthrosis of the right hip. She had undergone a total abdominal hysterectomy, oophorectomy, and lysis of bowel adhesions five years previously but had no other contributory medical history. She underwent metal-on-metal resurfacing arthroplasty of the hip with the Birmingham hip replacement (Smith and Nephew Orthopaedics, Warwick, United Kingdom) in June 2005 (Fig. 1). The surgery and the early postoperative recovery were uncomplicated. Fig. 1 Pelvic radiograph made one …