Pseudotumor as adverse local tissue reaction due to implant corrosion

Ognjen B.  Vukadin; Jelena M.  Džudović; Aleksandra M.  Repić; Zoran Lj.  Baščarević

doi:10.2298/VSP220620092V

Ognjen B. Vukadin Institute for Orthopedic Surgery “Banjica”, Belgrade, Serbia
Jelena M. Džudović Military Medical Academy, National Poison Control Center, Belgrade, Serbia
Aleksandra M. Repić Institute of Forensic Medicine, Belgrade, Serbia
Zoran Lj. Baščarević Institute for Orthopedic Surgery “Banjica”, Belgrade, Serbia

DOI: https://doi.org/10.2298/VSP220620092V

Keywords: arthroplasty, replacement, hip, chromium, cobalt, long term adverse effects, prostheses and implants, tissues

Abstract

Introduction. The term adverse local tissue reactions (ALTRs) is used to describe pathologic tissue conditions appearing after total joint replacement, and it includes osteolysis, bone necrosis, muscle necrosis, cystic lesions, excessive fluid collections, soft tissue masses, pseudotumors, metal sensitivity, metallosis, and chronic inflammatory lesions. ALTRs are rarely described in the literature after the breakage of the ceramic components of the hip prosthesis. Case report. We present a case of a patient with massive fluid collections filled with metallic and tissue detritus, along with signs of systemic cobalt (Co) and chromium (Cr) intoxication. Symptoms developed after revision of the acetabular component with the application of a metal-on-polyethylene coupling. Previously, several revisions were made due to breakage of the ceramic components of the endoprosthesis and instability of the hip. After removal of pseudotumor masses and revision of all components of the endoprosthesis with implantation of a coupling between the ceramic head and the polyethylene insert, there was a significant drop in the serum values of Co and Cr. Conclusion. Trunnion damage should be assessed during revision procedures, and if present, both prosthetic components should be replaced to prevent disastrous effects of metallic corrosion, ALTRs, and systemic metallic ions intoxication. Measurement of serum levels of Co and Cr in patients after joint replacement could identify patients at risk for the development of ALTRs and metallosis.

References

1. Hjorth MH, Mechlenburg I, Soballe K, Roemer L, Jakobsen SS, Stilling M. Higher prevalence of mixed or solid pseudotumors in metal-on-polyethylene total hip arthroplasty compared with metal-on-metal total hip arthroplasty and resurfacing hip arthroplasty. J Arthroplasty 2018; 33(7): 2279‒86.

2. Williams DH, Greidanus NV, Masri BA, Duncan CP, Garbuz DS. Prevalence of pseudotumor in asymptomatic patients after metal-on-metal hip arthroplasty. J Bone Joint Surg Am 2011; 93(23): 2164‒71.

3. Hsu AR, Gross CE, Levine BR. Pseudotumor from modular neck corrosion after ceramic-on-polyethylene total hip arthroplasty. Am J Orthop (Belle Mead NJ 2012; 41(9): 422‒6.

4. Istanbullu OB, Akdogan G. A Simulation Study of Galvanic Corrosion Potential on the Surface of Implantable Biometallic Couples. J Bio Tribo Corros 2021; 7: 25.

5. 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(8): 1238‒42.

6. Mahendra G, Pandit H, Kliskey K, Murray D, Gill HS, Athanasou N. Necrotic and inflammatory changes in metal-on-metal resurfacing hip arthroplasties. Acta Orthop 2009; 80(6): 653‒9.

7. Campbell PA, Kung MS, Hsu AR, Jacobs JJ. Do retrieval analysis and blood metal measurements contribute to our understanding of adverse local tissue reactions? Clin Orthop Relat Res 2014; 472(12): 3718‒27.

8. Bravo D, Wagner ER, Larson DR, Davis MP, Pagnano MW, Sierra RJ. No Increased Risk of Knee Arthroplasty Failure in Patients With Positive Skin Patch Testing for Metal Hypersensitivity: A Matched Cohort Study. J Arthroplasty 2016; 31(8): 1717‒21.

9. Plummer DR, Berger RA, Paprosky WG, Sporer SM, Jacobs JJ, Della Valle CJ. Diagnosis and Management of Adverse Local Tissue Reactions Secondary to Corrosion at the Head-Neck Junction in Patients With Metal on Polyethylene Bearings. J Arthroplasty 2016; 31(1): 264‒8.

10. Matharu GS, Pandit HG, Murray DW, Judge A. Adverse reactions to metal debris occur with all types of hip replacement not just metal-on-metal hips: a retrospective observational study of 3340 revisions for adverse reactions to metal debris from the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man. BMC Musculoskelet Disord 2016; 17(1): 495.

11. MHRA. Medical Device Alert: MDA/2017/018: All Metal-on-Metal (MoM) hip Replacements—Updated Advice for Follow-up of Patients. Available from: https://www.gov.uk/drug-device-alerts/all-metal-on-metal-mom-hip-replacements-updated-advice-for-follow-up-of-patients [accessed on 2022 June].

12. Nousiainen T, Palosaari S, Peräniemi S, Tervahauta A, Niinimäki J, Leppilahti J, et al. Retention of metals in periprosthetic tissues of patients with metal-on-metal total hip arthroplasty is reflected in the synovial fluid to blood cobalt transfer ratio in the presence of a pseudotumour. BMC Musculoskelet Disord 2020; 21(1): 610.

13. Xing D, Yang C, Li R, Hou Y, Kou B, Li H, et al. Severe Wear and multiple Pseudotumor formation due to revision for ceramic head breakage after ceramic-on-ceramic Total hip arthroplasty: a case report. BMC Musculoskelet Disord 2019; 20(1): 332.