The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 94, Issue 1

Current Concepts Review | January 04, 2012

Pseudotumors Associated with Total Hip Arthroplasty

Joseph Daniel, FRCS, MS(Orth)¹; James Holland, FRCS, FRCS(Orth)²; Laura Quigley, MSc³; Sheila Sprague, MSc⁴; Mohit Bhandari, MD, PhD, FRCSC⁴

¹ Hip and Knee Reconstruction, The McMinn Centre, 25 Highfield Road, Edgbaston, Birmingham, B15 3DP, United Kingdom
² Department of Orthopaedic Surgery, Freeman Hospital, Freeman Road, Newcastle-upon-Tyne, NE7 7DN United Kingdom
³ Faculty of Medicine, University of Toronto, 219 Fort York Boulevard, Unit 3608, Toronto, ON M5V 1B1, Canada
⁴ Department of Clinical Epidemiology & Biostatistics (S.S., M.B.), Division of Orthopaedic Surgery, Department of Surgery (M.B.), McMaster University, 293 Wellington Street North, Suite 110, Hamilton, ON L8L 8E7, Canada. E-mail address for M. Bhandari: bhandam@mcmaster.ca

View Disclosures and Other Information

Disclosure statement for author(s): PDF

Investigation performed at the Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada

Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of an aspect of this work. In addition, one or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

J Bone Joint Surg Am, 2012 Jan 04;94(1):86-93. doi: 10.2106/JBJS.J.01612

5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case

Article

Comments (0)

text A A A

Abstract

Pseudotumors are a rare but important complication occurring with all types of hip replacements.

The true prevalence of pseudotumors is debated.

Potential causes of pseudotumors may include foreign-body reaction, hypersensitivity, and wear debris.

The conduct of clinical trials on the incidence, causes, and treatments of pseudotumors has been inadequate as few investigators have used a randomized controlled design to compare various implant types.

Figures in this Article

Introduction

Several terms have been used to describe the spectrum of conditions resulting from abnormal periprosthetic soft-tissue reactions in total hip replacement (Figs. 1 and 2). The term pseudotumor was originally used to describe solid granulomatous masses related to prosthetic wear debris in metal-on-polyethylene implants and leading to pressure effects or extensive tissue necrosis^1,2.The term pseudotumor in reference to lesions related to metal-on-polyethylene implants is less common now as the causes of metal-on-polyethylene wear, implant loosening, and cell-mediated osteolysis are further understood. Currently, the term pseudotumor is used primarily in reference to metal-on-metal arthroplasty implants, although agreement on the exact definition of the term is unclear. Langton et al. identified that there is no clear consensus in the literature defining the boundaries of the terms metallosis, aseptic lymphocyte-dominated vasculitis-associated lesions (ALVAL), and pseudotumors and used the term adverse reactions to metal debris to describe arthroplasty failures associated with pain, a large sterile effusion, and/or macroscopic necrosis or metallosis³. There is no evidence to suggest that all effusions eventually develop into granulomatous masses or lead to extensive necrosis with time. For the purposes of this review, the umbrella term pseudotumor is used in reference to both metal-on-polyethylene and metal-on-metal implants.

Pseudotumors are often a granulomatous lesion or a destructive cystic lesion, neither infective nor neoplastic, which develops in the vicinity of a total hip replacement and resembles a tumor. They can be small or large, solid or fluid-filled masses with or without a communication to the joint. Once this reaction has developed, it is believed to worsen progressively, resulting in pain, pressure effects, and bone and soft-tissue destruction requiring revision arthroplasty to halt the process. Pseudotumors have been reported to develop in patients who have received conventional metal-on-polyethylene bearing hip replacements¹. More recently, pseudotumors have been reported in relation to metal-on-metal bearing hip replacements^4-7.

Pseudotumors have been reported to occur around both cemented and cementless metal-on-polyethylene total hip replacements^1,2,8-10, and have been described as rapidly growing lesions with extensive bone loss^1,8-10. Early reports have described a histiocytoma, which mimics an infection, in relation to a cemented femoral stem in a conventional total hip replacement¹¹. These pseudotumors are often associated with discomfort, pain, or osseous erosion¹² or with pressure effects on vital structures in the vicinity, including veins¹³, nerves¹⁴, and ureters¹⁵. A common factor in most patients has been increased implant wear either due to a wear-prone bearing or to suboptimal component positioning¹⁶.

The recent focus on pseudotumors associated with metal-on-metal bearings indicates that pseudotumors are associated not only with a soft-tissue mass and osseous changes of osteolysis and erosions but also with damage to the periarticular soft tissue. The damage may lead to soft-tissue and muscle necrosis, osseous denudation, pathological fractures, and hip dislocations. The problem of hypersensitivity to metal in patients with metal-on-metal bearings^17,18 has been suspected, investigated, and debated^19,20 for over thirty years.

We review the literature to understand the current evidence of the incidence, symptoms, causes, and treatment of pseudotumors following total hip arthroplasty. Case reports were excluded from review (see Appendix).

Fig. 1

The diagram shows the causes and local adverse effects of excess metal debris, which have been described in association with all types of hip replacements and are not exclusive to metal-on-metal bearing replacements.

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 2

The wide spectrum of clinical problems associated with excess metal debris. ALVAL = aseptic lymphocyte-dominated vasculitis-associated lesions, and AVN = avascular necrosis.

View Large | Download Slide(.ppt)
Add to My JBJS

Incidence and Prevalence of Pseudotumors

Tallroth et al. found that 4.6% of their patients who had revision hip arthroplasty had radiographic evidence of pseudotumors associated with metal-on-polyethylene bearings⁹. Howie et al. found that 5.8% (seven) of 121 patients who had revision of a Wagner hip replacement had a bursal mass²¹.

Pseudotumors in association with metal-on-metal hip resurfacing have also been reported; however, the true incidence and prevalence are unknown²². An Australian national review of failures after 3497 metal-on-metal hip resurfacings performed during a five-year period reported only one failure due to a presumed metal hypersensitivity that led to a revision²³. In a more recent review of approximately 1500 hip-resurfacing procedures performed by three surgeons, four hips (0.27%) that needed revision for persistent groin pain were reported²⁴. Malviya and Holland, in a study of 670 consecutive metal-on-metal Birmingham hip resurfacings performed over a ten-year period, found two hips (0.3%) with pseudotumors, one secondary to femoral component loosening (noninvasive effusion and normal wear) and another due to impingement (locally destructive debris mass and excess wear)²⁵. Grammatopolous et al. identified fifty-three hips with metal-on-metal hip resurfacing that required revision at a mean of 1.59 years postoperatively. Of those, sixteen were revised for pseudotumors²⁶.

Pandit et al. assessed the prevalence of pseudotumors in 1300 hips that had metal-on-metal resurfacing⁷. They reported that 1% (twelve hips) had cystic or solid masses and, in some cases, semiliquid contents associated with soft-tissue necrosis, pathological fractures, and dislocations within five years after implantation. All twelve patients were women, which raises the possibility that preoperative sensitization to metal may be a factor. Kwon et al. also investigated subjects who had undergone hip resurfacings and were asymptomatic, to assess for the prevalence of asymptomatic pseudotumors²⁷. They performed ultrasonography or magnetic resonance imaging (MRI) and found that 5% of these asymptomatic patients had pseudotumors²⁷.

Presenting Symptoms

Whether related to a metal-on-metal or a conventional bearing replacement, patients with pseudotumors often present with pain, discomfort, a palpable swelling, or symptoms from a distal pressure effect⁵. The patient may have compression symptoms that can include neuropathy and venous compression or thrombosis or compression of other vital structures^11-14. Tallroth et al. found that the first clinical sign of a pseudotumor was usually pain, which led to radiographic examination and detection of lesions around the prosthetic stem⁹. Some studies have identified osteolytic areas as a precursor to pseudotumors^9,28. In one study, nine of fifteen patients had discrete ovoid lucencies in or around the calcar or on the medial aspect of the shaft of the femoral component¹. In patients with these adverse features on radiographs, a high index of suspicion for potential pseudotumors is warranted¹.

In studies of patients who have had total hip arthroplasty with metal-on-metal bearings, cysts have been described⁶. Some of these were highly destructive²⁹, and the presenting symptoms included pain, rash, pathological fractures²⁹, spontaneous dislocations, femoral nerve palsy¹⁴, and the presence of a lump⁷. Pandit et al. found that the most common presenting symptom was discomfort in the groin or lateral aspect of the hip or in the buttock⁷.

Excessive Wear Debris

Wear debris is potentially important in understanding the cause of pseudotumors. Keegan et al. reviewed the exposure, uptake, dissemination, and biological activity of metals released from orthopaedic materials³⁰. They found that wear debris is generated by mechanical wear, surface corrosion, or a combination of both, and consists of both particulate and soluble forms. Metal-on-metal articulations generate approximately 6.7 × 10¹² to 2.5 × 10¹⁴ particles every year, which is 13,500 times the number of polyethylene particles produced from a typical metal-on-polyethylene bearing. Despite this finding, the actual volumetric wear of a metal-on-metal articulation is lower because of the very small size of the particles (generally <50 nm) compared with polyethylene particles, which are rarely <0.1 μm³⁰. Reducing the clearance between the femoral and acetabular components reduces the amount of wear debris²². Patients with joint replacement, especially those with metal-on-metal articulations, are likely to experience elevated metal levels throughout the life of the prosthesis³⁰.

Excessive wear debris is the cause of pseudotumors in patients with metal-on-polyethylene components as well. Howie et al. explored bursal masses (Fig. 3) and identified excessive wear of the polyethylene component as the cause of the masses²¹. Santavirta et al. and Austin and Stoney recognized excessive polyethylene debris as the primary factor in the causation of granulomatous reactions^31-33. Willert et al. also found that polyethylene wear products alone can cause massive osteolysis by triggering foreign-body granuloma formation at the bone-cement interface³⁴. Nygaard et al. compared three bearing materials (polyethylene on zirconia, CoCr on CoCr, and alumina on alumina) and found that granulomatous inflammation is a common finding around implants that are not loose as early as twelve months after the arthroplasty³⁵. The study did not demonstrate a difference in macrophages and granuloma formation with the various bearing materials³⁵.

Fig. 3

Arthrogram of a so-called pseudoabscess in relation to a metal-on-polyethylene hip resurfacing and a photomicrograph showing small polyethylene particles (arrows) contained in macrophages and large polyethylene particles surrounded by multinucleate giant cells²¹. (Reproduced and adapted, with permission and copyright of the British Editorial Society of Bone and Joint Surgery, from Howie DW, Cain CMJ, Cornish BL. Pseudo-abscess of the psoas bursa in failed double-cup arthroplasty of the hip. J Bone Joint Surg Br. 1991;73:29-32.)

View Large | Download Slide(.ppt)
Add to My JBJS

Foreign-Body Reaction

Because the pathological reaction to polyethylene debris and metal debris appears fundamentally different, the pathogenetic mechanisms of pseudotumors in these different bearings are likely to be different. Pseudotumors may be caused by a foreign-body reaction to methylmethacrylate, polyethylene, or metal adjacent to a total joint implant¹. Polyethylene debris is taken up by macrophage giant cells that release prostaglandin E₂, which resorbs bone, causing the implant to loosen and leading to a vicious cycle of wear and loosening. Santavirta et al. suggested that immunopathological responses to loose components do not depend on the chemical nature of the irritant, but rather represent a nonspecific foreign-body reaction³¹. Often there is the formation of a synovium-like biomembrane with the capacity to produce collagenase, interleukin-1, and tumor necrosis factor, which may mediate the absorption of bone¹⁶.

Elevated metal-ion levels following metal-on-metal total hip arthroplasty have been well documented, but the effects of these levels are not yet clearly understood²². Additionally, there is controversy about the contribution of the bearing diameter to metal-ion levels. The published evidence includes only studies on metal-on-metal hip resurfacing arthroplasty and may not be truly reflective of metal-on-metal total hip arthroplasty, in which the head-neck ratio is different²². The cytotoxicity of the high concentration of metal nanoparticles phagocytosed by macrophages located in the periprosthetic tissues has been postulated as a cause of pseudotumors in patients with metal-on-metal hip resurfacing. Hart et al. demonstrated the predictive role of blood metal-ion analysis, metal-artifact-reduction MRI sequences, and measurement of component position to aid in the detection of a periprosthetic mass and to help in determining the most appropriate treatment for patients presenting with pain at the site of metal-on-metal hip resurfacing³⁶.

Metal Hypersensitivity

Metal hypersensitivity reaction has been identified as one potential cause of resurfacing failures and of pseudotumor development. There is an ongoing debate on whether the immune-mediated response is an adaptive response to excessive debris from high wear and is dose-dependent, or whether it is an innate hypersensitivity response, which is independent of dosage and is initiated at low levels of wear.

Willert et al. found radiolucent lines in five hips and osteolysis in seven hips of nineteen patients undergoing revision of metal-on-metal hip replacements³⁷. At revision, both components were well fixed in nine patients. Fourteen had the metal device revised to a nonmetal articulation, while five received a second all-metal total hip arthroplasty. The former group had permanent relief of pain after revision, while the latter group had persistent pain, suggesting the possibility of a metal hypersensitivity reaction according to Koch's postulates³⁷. Histological analysis of the tissue specimens in the study by Willert et al. revealed an active cellular reaction with diffuse and perivascular infiltrates of lymphocytes and plasma cells, increased endothelial venules, fibrin exudation, accumulation of macrophages with drop-like inclusions, and infiltrates of eosinophilic granulocytes and necrosis³⁷. These histological findings were described as ALVAL. Only a few metal particles were detected. The report does not include a retrieval analysis to establish the possibility of excessive wear. Pandit et al. believed that multiple factors led to the development of pseudotumors in patients with metal-on-metal bearings³⁸. They found that necrotic granulomatous response and inflammatory infiltrate is typically seen in the context of a delayed hypersensitivity reaction and suggested that a type-IV immune response plays a role in pseudotumor pathogenesis.

Some other studies have found wear debris to be the prime factor in the development of pseudotumors^4,26,39. Investigators have suggested that wear debris generation is the primary cause of the histopathological changes, rather than an inherent genetically determined hypersensitivity to metal³⁹. Several other factors, including those related to the implant, surgeon, and patient, have been shown to contribute toward pseudotumor development.

Implant and Surgeon-Related Factors (Component Design and Component Malposition)

There are a few reports of a high incidence of pseudotumors that are implant-specific and are related to specific component factors, including their metallurgy or design characteristics. With metal-on-metal total hip replacements in which a low-carbon component is used as one or both of the bearing surfaces, the incidence of metallosis and revisions for periprosthetic effusions is high. Nolan et al. reported that sixty (9.3%) of 643 metal-on-metal hip replacements had revisions over a nine-year period: thirteen were for periprosthetic fracture and forty-seven, for extensive symptomatic periarticular soft-tissue changes with one specific metal-on-metal total hip replacement with demonstrated excess stem corrosion of the Ultima TPS stem (DePuy Johnson & Johnson, Leeds, United Kingdom)²⁹. Pathological analysis showed mixed lymphocytic and fibroblastic infiltrate with soft-tissue necrosis in a majority of revised hip replacements. There are distinct differences between different metal-on-metal combinations in terms of both their metallurgy and corresponding revision rate. Daniel et al. found different revision rates when double heat treatments were introduced into the manufacture of resurfacing components, leading to carbide depletion and excess wear, which resulted in higher revision rates⁴⁰. This finding, in particular, points out the importance of not generalizing all metal-on-metal implants to the same category, especially in terms of revision rates.

Relatively high incidences of pseudotumors in patients with metal-on-metal resurfacings have been reported from two centers by Glyn-Jones et al. and Langton et al.^41,42. These experiences, in which the procedures were performed by a single experienced surgeon, demonstrated that the failures were most likely device-related, with pseudotumors found in 3.4% (seventeen) of 500 patients after resurfacing with an articular surface replacement (ASR; Johnson & Johnson DePuy), while no failures occurred with Birmingham Hip Resurfacing (BHR; Smith & Nephew, Warwickshire, United Kingdom)⁴². The ASR failures were associated with effusions with extensive associated damage involving muscle necrosis and severe bone changes. In the study by Glyn-Jones et al., in which the procedures were reportedly performed by multiple surgeons, pseudotumors were found in 1.8% (twenty-six) of 1419 hips that had resurfacing⁴¹. Four different types of resurfacing systems were used: the Birmingham Hip Resurfacing (BHR, Smith & Nephew), the Conserve Plus (C+; Wright Medical Technology, Memphis, Tennessee), Recap (Biomet, Swindon, United Kingdom), and the Cormet (Corin, Cirencester, United Kingdom).

Following revision, a retrieval analysis was performed on the explanted components from these patients⁴³. The components were grouped together with components revised for other causes such as fracture and infection, and the tribologist who performed the tests was blinded to the cause of revision. All of the components revised for pseudotumors showed signs of edge-loading, suggestive of a pattern of excess runaway wear. Furthermore, no explant without evidence of edge-loading had failed through a pseudotumor⁴³.

Combining the observations at the two centers, it is clear that edge-loading of components either because of component malposition or poor component design is the underlying problem leading to excessive wear and local debris-related soft-tissue problems. Malposition is often due to excessive acetabular cup inclination but can also be due to excessive anteversion of the cup or an excessive combined anteversion of the cup and femoral neck⁴⁴. Any of these positions can reduce the effective coverage of the femoral head. Furthermore, an inclination that is too low or a coverage angle of the cup that is too wide can also lead to impingement and subluxation of the femoral head and excess wear³. Abnormal cup inclination and excess combined anteversion of the cup and femoral neck can also lead to posterior impingement of the femoral neck on the edge of the acetabular component and excess wear (Fig. 4)³. If femoral neck anteversion is between 20° and 45°, it can be compensated for by reducing cup anteversion. Femoral neck anteversion in excess of 45° is unsuitable for resurfacing unless it is combined with a preplanned derotation subtrochanteric femoral osteotomy⁴⁴. Component malposition cannot be ruled out unless femoral neck anteversion also is taken into account. Malviya and Holland also believed that edge wear and impingement are responsible for pseudotumors²⁵. Conversely, Pandit et al. claimed that several implants in their study were apparently well positioned, but metal wear particles were detected in every case examined histologically⁷. The absence of data on femoral neck anteversion may render the assessment of component position incomplete in this study.

Fig. 4

A fifty-five-year-old woman with mild hip dysplasia who underwent a hip resurfacing arthroplasty and later developed a periprosthetic effusion at ten years after surgery. Thin arrows show signs of impingement at the superior margin of the femoral neck and femoral neck thinning. Thick arrows show the multislice computed tomography (CT) scan demonstrating the pseudotumor. The cup inclination (35°) and anteversion (27°) measured from multislice CT images were reasonable, but the combined cup and femoral neck anteversion (not shown) was excessive (57°).

View Large | Download Slide(.ppt)
Add to My JBJS

Langton et al. reported that all resurfacings are not the same and that their overall results for the fourth-generation ASR cup were due to increased debris³. The failure rate was 3.4% (seventeen of 500 patients) in the group that had ASR resurfacings, whereas no debris-related adverse reactions occurred in the group that had the BHR resurfacing, confirming the fact that factors related to the component play a significant role in pseudotumor development. The high prevalence of pseudotumors in the group that had the ASR device was reported to be due to its reduced articulation angle, which makes it less tolerant to major or minor component malposition, especially in the smaller-diameter bearings³. The absence of this failure pattern in the group that had the BHR component was due to its greater coverage angle, which makes it more forgiving toward minor malposition³.

Furthermore, the ASR is a thinner cup and has reduced diametral clearance^45,46. It is possible that reduced clearance and in vivo component deformation may lead to higher friction⁴⁷. The Australian National Registry also confirmed the increased revision rate of the ASR and other resurfacings, although it did not specify the reasons for revision⁴⁸.

Patient-Related Factors

Previous research on pseudotumors in patients after hip-resurfacing arthroplasty has shown that pseudotumors develop more often in women than in men⁴⁹. The reason for the high prevalence in women is not entirely clear. It has sometimes been attributed to preoperative sensitization of women through the use of costume jewelry⁴¹. There might be other reasons too. A common etiological reason for premature arthritis in women is minor hip dysplasia. This is often associated with excess femoral torsion, which needs to be taken into account and compensated for during placement of the cup⁴⁴. Furthermore, the naturally small component sizes required in women provide a smaller coverage angle and also leave a smaller margin of error in component positioning³.

Whatever the underlying mechanism for high wear, evidence is beginning to emerge from the leading retrieval centers that the final common pathway in pseudotumors or adverse reactions to metal debris is a wear-debris-induced response leading to osseous and soft-tissue lesions. The occurrence of true hypersensitivity, whereby an exaggerated response develops in the presence of low wear, is likely rare^3,39.

Investigations for Pseudotumors

Unexplained groin pain, the most common symptom of pseudotumors following hip resurfacing⁷, can result from a number of causes. Local soft-tissue problems, such as psoas tendinitis or bursitis, and referred pain from intra-abdominal or intrapelvic pathology, inguinal hernias, and spinal conditions should be excluded.

Campbell et al. outlined a practical list of the steps necessary to diagnose the cause of groin and hip pain²⁴. This includes radiographs to exclude aseptic implant loosening, femoral neck stress fracture or collapse of the femoral head, and femoroacetabular impingement. Components can be assessed for cup orientation with use of EBRA software (Einzel-Bild-Roentgen-Analyse; University of Innsbruck, Innsbruck, Austria), to rule out excessive cup inclination or anteversion⁵⁰.

Multislice computed tomography scanning is necessary to allow assessment of femoral neck anteversion. MRI (with metal artifact-reducing sequences) is useful in the assessment of soft-tissue masses or fluid collections²⁴. Hematologic testing and microbiological assessment of joint aspirate is needed to rule out infection²⁴. Positive radioisotope bone scan studies can indicate infection or implant loosening.

In the past, skin patch testing was used in the assessment of contact dermatitis for metal hypersensitivity. The value of patch testing is limited²⁴. Two other in vitro tests that have been used in the assessment of metal hypersensitivity include the lymphocyte transformation test and the leukocyte migration-inhibition factor test²⁴. The lymphocyte transformation test involves measuring the proliferative response of lymphocytes following activation by the metal.

Patients with persistent hip or groin pain, a mass, or a fluid collection following total hip arthroplasty should be carefully evaluated, especially for the presence of infection. The histological characteristics of an infection are distinctly different from those of an adverse immune reaction or an inflammatory foreign-body response; thus, a biopsy and tissue analysis allows an appropriate diagnosis of these reactions. At this time, there is no reliable blood or other screening test that offers a high predictive value for subsequent pseudotumor development⁴⁹. Assuming some patients are more sensitive to metals, the ultimate prognostic benefit from in vitro testing would be the development of a sensitive and reliable screening test that would preoperatively diagnose whether a person has a genetic predisposition to hypersensitivity to a specific metal or group of metals. That knowledge would enable a patient and his or her clinician to make an informed decision regarding the choice of bearing material for hip arthroplasty.

Treatment

Treatment for pseudotumors in patients with metal-on-polyethylene implants varies. Pseudotumors in patients with a cemented total hip replacement can be satisfactorily treated with a cementless revision prosthesis combined with cancellous bone-grafting^9,10. Surgeons can proceed to revision arthroplasty using techniques appropriate for aseptic loosening²¹. Wirta et al. suggested that pseudotumors can be well treated with revision and a new cemented total hip replacement; however, the risk of recurrence remains²⁸. These authors also considered the use of an uncemented prosthesis and bone-grafting for revision.

When a metal-on-metal bearing hip replacement fails from a pseudotumor or a debris-induced local adverse reaction, there is growing support for an early revision to a non-metal-on-metal bearing hip arthroplasty^24,51. Harvie et al., who performed a revision in two patients with metal-on-metal resurfacings after they developed pseudotumors and nerve palsies, advocated prompt revision in the presence of a neurological deficit¹⁴. Willert et al. and Campbell et al. observed that when patients develop a debris-related effusion or have failure of a metal-on-metal bearing hip replacement, they may have revision to a non-metal-on-metal bearing hip replacement, with the expectation of a good result if the soft tissue has remained intact^24,51.

When patients with pain related to a metal-on-metal hip replacement had revision to another metal-on-metal articulation, lack of improvement in symptoms has been reported⁵¹. Grammatopolous et al. reported poor outcomes in patients following revision to a non-metal-on-metal total hip replacement because of pseudotumor²⁶. There was a high rate of serious complications including recurrent dislocations, nerve palsies, and femoral artery stenosis. They compared the revisions of hip resurfacings related to pseudotumors with resurfacings revised for other reasons, such as femoral neck fractures, and found that the hip function scores for patients who had revision for pseudotumors were significantly worse than those for patients who had revision for other reasons. Furthermore, the hip function after revisions because of a pseudotumor was worse than that before the primary resurfacing operation. Finally, they reported a high prevalence of repeat revision in patients who had revision for pseudotumors.

Need for Evidence

The results in this review are based on studies with a generally lower level of evidence, namely case series, which limits the ability to make recommendations for or against various types of implants for total hip arthroplasty (Grade-C recommendation). The term pseudotumor is not clearly defined in the literature from an anatomical, structural, or histological standpoint. The term pseudotumor has been used to describe lesions in patients with metal-on-polyethylene and metal-on-metal replacements in the literature, for solid or fluid collections, and for a variety of failure mechanisms. Future research should adequately define the bearing and the local pathological process. Only when the device and surgeon-related factors are excluded can the true biological characteristics of these masses be investigated.

Many important questions remain: (1) What is the prevalence of pseudotumors after the use of well-positioned components among different designs of prostheses? (2) Are pseudotumors purely a consequence of metal, ceramic, or polyethylene debris or can these lesions result from associated particulate debris such as polymethylmethacrylate? (3) Is it an adaptive immune response to excess metal and is there a threshold level of debris that leads to the development of pseudotumors? (4) In addition to careful patient selection and meticulous surgical technique and component positioning, what potential strategies would reduce the development of pseudotumors? (5) Should national joint registries be used more effectively for surveillance of these problems and to assess the association between the device and/or unit revision rate? Improvements in implant design and alternative materials are being bench-tested in laboratories around the world for potential use in hip arthroplasty. The introduction of these devices should be accompanied with high-quality cohort studies with use of validated, patient-centered outcome measures and periodic monitoring with clinical, radiographic, and ion-level assessments in order to determine the risks and benefits of these newer devices. The prevalence of systemic and local adverse effects should be specifically assessed. Further studies to elucidate the causes and effects of pseudotumors and prevention strategies are certainly needed.

Appendix

A list of case reports excluded from the review is available with the online version of this article as a data supplement at jbjs.org.

Griffiths HJ; Burke J; Bonfiglio TA. Granulomatous pseduotumors in total joint replacement. Skeletal Radiol. 1987;16:146-52.

Harris WH; Schiller AL; Scholler JM; Freiberg RA; Scott R. Extensive localized bone resorption in the femur following total hip replacement. J Bone Joint Surg Am. 1976;58:612-8.

Langton DJ; Jameson SS; Joyce TJ; Hallab NJ; Natu S; Nargol AV. Early failure of metal-on-metal bearings in hip resurfacing and large-diameter total hip replacement: a consequence of excess wear. J Bone Joint Surg Br. 2010;92:38-46.

Boardman DR; Middleton FR; Kavanagh TG. A benign psoas mass following metal-on-metal resurfacing of the hip. J Bone Joint Surg Br. 2006;88:402-4.

Counsell A; Heasley R; Arumilli B; Paul A. A groin mass caused by metal particle debris after hip resurfacing. Acta Orthop Belg. 2008;74:870-4.

Madan S; Jowett RL; Goodwin MI. Recurrent intrapelvic cyst complicating metal-on-metal cemented total hip arthroplasty. Arch Orthop Trauma Surg. 2000;120:508-10.

Pandit H; Glyn-Jones S; McLardy-Smith P; Gundle R; Whitwell D; Gibbons CL; Ostlere S; Athanasou N; Gill HS; Murray DW. Pseudotumours associated with metal-on-metal hip resurfacings. J Bone Joint Surg Br. 2008;90:847-51.

Jacobs JJ; Urban RM; Wall J; Black J; Reid JD; Veneman L. Unusual foreign-body reaction to a failed total knee replacement: simulation of a sarcoma clinically and a sarcoid histologically. A case report. J Bone Joint Surg Am. 1995;77:444-51.

Tallroth K; Eskola A; Santavirta S; Konttinen YT; Lindholm TS. Aggressive granulomatous lesions after hip arthroplasty. J Bone Joint Surg Br. 1989;71:571-5.

Eskola A; Santavirta S; Konttinen YT; Hoikka V; Tallroth K; Lindholm TS. Cementless revision of aggressive granulomatous lesions in hip replacements. J Bone Joint Surg Br. 1990;72:212-6.

Rabin DN; Smith C; Kubicka RA; Rabin S; Ali A; Charters JR; Rabin H. Problem prostheses: the radiologic evaluation of total joint replacement. Radiographics. 1987;7:1107-27.

Svensson O; Mathiesen EB; Reinholt FP; Blomgren G. Formation of a fulminant soft-tissue pseudotumor after uncemented hip arthroplasty. A case report. J Bone Joint Surg Am. 1988;70:1238-42.

Beksaç B; Tözün R; Baktiroglu S; Sener N; Gonzalez Della Valle A. Extravascular compression of the femoral vein due to wear debris-induced iliopsoas bursitis: a rare cause of leg swelling after total hip arthroplasty. J Arthroplasty. 2007;22:453-6.

Harvie P; Giele H; Fang C; Ansorge O; Ostlere S; Gibbons M; Whitwell D. The treatment of femoral neuropathy due to pseudotumour caused by metal-on-metal resurfacing arthroplasty. Hip Int. 2008;18:313-20.

Hananouchi T; Saito M; Nakamura N; Yamamoto T; Yonenobu K. Huge pelvic mass secondary to wear debris causing ureteral obstruction. J Arthroplasty. 2005;20:946-9.

Harper GD; Bull T; Cobb AG; Bentley G. Failure of the Ring polyethylene uncemented acetabular cup. J Bone Joint Surg Br. 1995;77:557-61.

Benson MK; Goodwin PG; Brostoff J. Metal sensitivity in patients with joint replacement arthroplasties. Br Med J. 1975;4:374-5.

Elves MW; Wilson JN; Scales JT; Kemp HB. Incidence of metal sensitivity in patients with total joint replacements. Br Med J. 1975;4:376-8.

Brown GC; Lockshin MD; Salvati EA; Bullough PG. Sensitivity to metal as a possible cause of sterile loosening after cobalt-chromium total hip-replacement arthroplasty. J Bone Joint Surg Am. 1977;59:164-8.

Christiansen K; Holmes K; Zilko PJ. Metal sensitivity causing loosened joint prostheses. Ann Rheum Dis. 1980;39:476-80.

Howie DW; Cain CM; Cornish BL. Pseudo-abscess of the psoas bursa in failed double-cup arthroplasty of the hip. J Bone Joint Surg Br. 1991;73:29-32.

Malviya A; Ramaskandhan J; Holland JP; Lingard EA. Metal-on-metal total hip arthroplasty. J Bone Joint Surg Am. 2010;92:1675-83.

Shimmin AJ; Back D. Femoral neck fractures following Birmingham hip resurfacing: a national review of 50 cases. J Bone Joint Surg Br. 2005;87:463-4.

Campbell P; Shimmin A; Walter L; Solomon M. Metal sensitivity as a cause of groin pain in metal-on-metal hip resurfacing. J Arthroplasty. 2008;23:1080-5. Epub 2008 Mar 14.

Malviya A; Holland JP. Pseudotumours associated with metal-on-metal hip resurfacing: 10-year Newcastle experience. Acta Orthop Belg. 2009;75:477-83.

Grammatopolous G; Pandit H; Kwon YM; Gundle R; McLardy-Smith P; Beard DJ; Murray DW; Gill HS. Hip resurfacings revised for inflammatory pseudotumour have a poor outcome. J Bone Joint Surg Br. 2009;91:1019-24.

Kwon YM; Ostlere S; Mclardy-Smith P; Gundle R; Whitwell D; Gibbons CLM; Taylor A; Pandit H; Glyn-Jones S; Athanasou N; Beard D; Gill HS; Murray DW. Asymptomatic pseudo-tumours in patients with metal-on-metal hip resurfacing: prevalence and metal ion study. J Bone Joint Surg Br. 2010;92 Suppl III:390.

Wirta J; Eskola A; Santavirta S; Tallroth K; Konttinen YT; Lindholm S. Revision of aggressive granulomatous lesions in hip arthroplasty. J Arthroplasty. 1990;5 Suppl:S47-52.

Nolan JF; Darrah C; Donell ST; Wimhurst J; Toms A; Marshall T; Barker T; Case CP; Peters C; Tucker JK. Metal on metal hip replacement. J Bone Joint Surg Br. 2007;90 Suppl III:531.

Keegan GM; Learmonth ID; Case CP. Orthopaedic metals and their potential toxicity in the arthroplasty patient: a review of current knowledge and future strategies. J Bone Joint Surg Br. 2007;89:567-73.

Santavirta S; Konttinen YT; Hoikka V; Eskola A. Immunopathological response to loose cementless acetabular components. J Bone Joint Surg Br. 1991;73:38-42.

Austin RT; Stoney PJ. Granulomatosis of bone from high density polyethylene. Injury. 1982;13:414-8.

Santavirta S; Hoikka V; Eskola A; Konttinen YT; Paavilainen T; Tallroth K. Aggressive granulomatous lesions in cementless total hip arthroplasty. J Bone Joint Surg Br. 1990;72:980-4.

Willert HG; Bertram H; Buchhorn GH. Osteolysis in alloarthroplasty of the hip. The role of ultra-high molecular weight polyethylene wear particles. Clin Orthop Relat Res. 1990;25.

Nygaard M; Elling F; Bastholm L; Søballe K; Borgwardt A. No difference in early cellular response of the pseudo-synovial membrane after total hip arthroplasty: comparison of 3 combinations of bearing materials. Acta Orthop. 2006;77:402-12.

Hart AJ; Sabah S; Henckel J; Lewis A; Cobb J; Sampson B; Mitchell A; Skinner JA. The painful metal-on-metal hip resurfacing. J Bone Joint Surg Br. 2009;91:738-44.

Willert HG; Buchhorn GH; Göbel D; Köster G; Schaffner S; Schenk R; Semlitsch M. Wear behavior and histopathology of classic cemented metal on metal hip endoprostheses. Clin Orthop Relat Res. 1996;329 Suppl:S160-86.

Pandit H; Vlychou M; Whitwell D; Crook D; Luqmani R; Ostlere S; Murray DW; Athanasou NA. Necrotic granulomatous pseudotumours in bilateral resurfacing hip arthoplasties: evidence for a type IV immune response. Virchows Arch. 2008;453:529-34. Epub 2008 Sep 4.

Shahrdar C; Campbell P; Mirra J; Dorr LD. Painful metal-on-metal total hip arthroplasty. J Arthroplasty. 2006;21:289-93.

Daniel J; Ziaee H; Kamali A; Pradhan C; Band T; McMinn DJ. Ten-year results of a double-heat-treated metal-on-metal hip resurfacing. J Bone Joint Surg Br. 2010;92:20-7.

Glyn-Jones S; Pandit H; Kwon YM; Doll H; Gill HS; Murray DW. Risk factors for inflammatory pseudotumour formation following hip resurfacing. J Bone Joint Surg Br. 2009;91:1566-74.

Langton DJ; Jameson SS; Joyce TJ; Webb J; Nargol AV. The effect of component size and orientation on the concentrations of metal ions after resurfacing arthroplasty of the hip. J Bone Joint Surg Br. 2008;90:1143-51.

Kwon YM; Glyn-Jones S; Simpson DJ; Kamali A; McLardy-Smith P; Gill HS; Murray DW. Analysis of wear of retrieved metal-on-metal hip resurfacing implants revised due to pseudotumours. J Bone Joint Surg Br. 2010;92:356-61.

Daniel J; Pradhan C; Ziaee H; McMinn DJW. Management of complex anatomy. In: McMinn DJW, editor. Modern hip resurfacing. London: Springer; 2009. p 333-47.

Lin ZM; Meakins S; Morlock MM; Parsons P; Hardaker C; Flett M; Isaac G. Deformation of press-fitted metallic resurfacing cups. Part 1: experimental simulation. Proc Inst Mech Eng H. 2006;220:299-309.

Yew A; Jin ZM; Donn A; Morlock MM; Isaac G. Deformation of press-fitted metallic resurfacing cups. Part 2: finite element simulation. Proc Inst Mech Eng H. 2006;220:311-9.

Ziaee H; Daniel J; Pradhan C; McMinn DJW. Clinico-radiological and metal ion study with a low clearance surface replacement hip arthroplasty. J Bone Joint Surg Br. 2010;92 Suppl III:400.

Australian Orthopaedic Association National Joint Replacement Registry. Annual Report. Adelaide: AOA; 2009.

Mont MA; Schmalzried TP. Modern metal-on-metal hip resurfacing: important observations from the first ten years. J Bone Joint Surg Am. 2008;90 Suppl 3:3-11.

Langton DJ; Sprowson AP; Mahadeva D; Bhatnagar S; Holland JP; Nargol AV. Cup anteversion in hip resurfacing: validation of EBRA and the presentation of a simple clinical grading system. J Arthroplasty. 2010;25:607-13. Epub 2009 Dec 21.

Willert HG; Buchhorn GH; Fayyazi A; Flury R; Windler M; Köster G; Lohmann CH. Metal-on-metal bearings and hypersensitivity in patients with artificial hip joints. A clinical and histomorphological study. J Bone Joint Surg Am. 2005;87:28-36.

Topics

hip replacement arthroplasty ; pseudotumor ; hip bearing surface, metal-on-metal ; hip bearing surface, metal-on-polyethylene ; metal debris from medical device

Username

Password

Access for Patients

Forgot Password?

Have a subscription to the print edition?

Not a Subscriber?

Buy this Article

Get online access for 30 days for $35

New to JBJS?

Subscribe to the online edition for 30 days for $75

Register for a FREE limited account to get full access to all CME activities, to comment on public articles, or to sign up for alerts.

Have a subscription to the print edition?

Current subscribers to The Journal of Bone & Joint Surgery in either the print or quarterly DVD formats receive free online access to JBJS.org.

Activate your online account now

Forgot your password?

Enter your username and email address. We'll send you a reminder to the email address on record.

Username:*

Email Address:*

Forgot your username or need assistance? Please contact customer service at subs@jbjs.org. If your access is provided
by your institution, please contact you librarian or administrator for username and password information. Institutional
administrators, to reset your institution's master username or password, please contact subs@jbjs.org

References

Accreditation Statement

These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.

CME Activities Associated with This Article

Submit a Comment

Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
Comments are moderated and will appear on the site at the discretion of JBJS editorial staff.

* = Required Field

Comment Author(s) * (if multiple authors, separate names by comma)

Example: John Doe

Affiliation & Institution*

Disclosure

Comment Title*

Comment*

Cancel

Print
PDF
Email

Recipient(s) will receive an email with a link (good for 5 days) to 'Pseudotumors Associated with Total Hip Arthroplasty'.
Your Name:*
Example: John Doe

Email Address:* CC Me:
Enter your valid email address. Example: jdoe@example.com

Recipient's Email Address:*

Separate multiple email address with semi-colons (up to 5).

Subject:* 's The Journal of Bone & Joint Surgery: 'Pseudotumors Associated with Total Hip Arthroplasty'
Subject for your email.

Message:

(Optional, message will truncate at 1000 characters)

Processing your request... Please Wait...

Copyright © in the material you requested is held by The Journal of Bone & Joint Surgery, Inc. (unless otherwise noted). This email ability is provided as a courtesy, and by using it you agree that that you are requesting the material solely for personal, non-commercial use, and that it is subject to Journal of Bone & Joint Surgery, Inc.'s Terms of Use. The information provided in order to email this topic will not be used to send unsolicited email, nor will it be furnished to third parties. Please refer to The Journal of Bone & Joint Surgery Inc.'s Privacy Policy for further information.

Copyright © The Journal of Bone & Joint Surgery Inc. All rights reserved.
Share
Get Citation

Joseph Daniel, James Holland, Laura Quigley, Sheila Sprague, Mohit Bhandari; Pseudotumors Associated with Total Hip Arthroplasty. The Journal of Bone & Joint Surgery. 2012 Jan;94(1):86-93.

Download citation file:

RIS (Zotero)

EndNote

BibTex

Medlars

ProCite

RefWorks

Reference Manager

Copyright © The Journal of Bone and Joint Surgery, Inc.
Rights & Permissions
Article Alerts

Processing your request... Please Wait.
Submit a Comment
Supplemental Content