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Al-Khatib Y, Tyas B, Kalson NS, Agni N, Bhutani P, Petheram T, Carluke I, Partington P. Quantification and severity grading of femoral vessel compression by adverse reactions to metal debris in metal-on-metal total hip arthroplasty. Hip Int 2024; 34:215-220. [PMID: 37545332 DOI: 10.1177/11207000231190738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
INTRODUCTION Metal-on-metal (MoM) total hip arthroplasty (THA) may cause adverse reactions to metal debris (ARMD). ARMD causing femoral vessel compression with serious complications has been described in case reports, but the rate of compression by ARMD is not known. This study aims to investigate the rate, and quantify the severity, of femoral vessel compression in MoM hips with ARMD lesions. METHODS Patients under surveillance for MoM THA investigated with MRI were studied. In patients with confirmed ARMD, femoral artery (FA) and vein (FV) diameters were measured at the point of maximal compression and compared to contralateral vessels. The primary outcome measure was presence or absence of compression. Cases were then classified by compression ratios. Secondary outcome measures were rates of deep vein thrombosis, revision surgery and time to ARMD from index procedure. RESULTS MRI scans for 436 patients with MoM THA were screened. Of these, 211/436 (48.4%) showed evidence of ARMD. Measurements were obtained on 133/211 (63.0%) patients. The FV was compressed in 102/133 (76.7%) and FA in 58/133 (43.6%), while 31/133 (23.3%) patients had no compression. In FVs, 42 demonstrated mild compression, 39 moderate and 21 severe. In FAs, none were severely compressed, 6 were moderate and 52 showed mild compression. There were 3 DVT cases, 2 in patients with moderate FV compression and 1 in patients without FV compression. Revision rates were highest in patients with severe FV compression (14/21, 66.7%). The mean time for MRI-diagnosed ARMD from index procedure was 8 years and 1 month (range 11 months-14.5 years). CONCLUSIONS Extra-luminal compression of the femoral vessels was found in >75% of patients with ARMD. Although it is not clear whether revision for femoral vessel compression is required, quantification of FV compression may be useful for surgeons and radiologists considering revision for ARMD.
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Affiliation(s)
| | - Ben Tyas
- Trauma and Orthopaedics, Health Education North East, Newcastle Upon Tyne, UK
| | - Nicholas S Kalson
- Department of Orthopaedics, Northumbria Healthcare NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Nickil Agni
- Department of Orthopaedics, Northumbria Healthcare NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Priyesh Bhutani
- Department of Radiology, Northumbria Healthcare NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Timothy Petheram
- Department of Orthopaedics, Northumbria Healthcare NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Ian Carluke
- Department of Orthopaedics, Northumbria Healthcare NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Paul Partington
- Department of Orthopaedics, Northumbria Healthcare NHS Foundation Trust, Newcastle Upon Tyne, UK
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Systemic Metal Ion Concentrations in Patients With Hip and Knee Megaprostheses: A Prospective Cohort Study. Arthroplast Today 2022; 18:191-201.e1. [PMID: 36561551 PMCID: PMC9764025 DOI: 10.1016/j.artd.2022.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 07/03/2022] [Accepted: 08/09/2022] [Indexed: 12/13/2022] Open
Abstract
Background Local tissue and serum metal ions have been shown to be elevated in some metal-on-metal and metal-on-polyethylene joint replacements. Local elevations have been linked to adverse local tissue reactions in some patients, and systemic elevation has been less commonly implicated cardiac and neurologic issues. Using a prospective study design, we aimed to identify the changes in serum metal ion levels after hip or knee megaprosthesis reconstruction. Furthermore, we will evaluate the occurrence of adverse effects and complications, possibly linked to metal ion elevation. Methods Fourteen consecutive patients receiving a Modular Universal Tumor Revision System megaprosthesis were enrolled. Blood samples were collected preoperatively and postoperatively to determine the serum ion concentrations of aluminum, chromium, cobalt, and silver. To evaluate the safety of the megaprostheses and the subsequently possible related (elevated) serum metal ion concentrations, all adverse effects and complications were registered until last outpatient clinic visit at the time of this study. Results Compared to the preoperative median serum concentrations, the postoperative median serum concentrations of chromium, silver, and cobalt increased 11-fold, 62-fold, and 64-fold, respectively. The median serum concentration of aluminum increased with 16%. Elevations were primarily noted in patients with knee prostheses. Eight patients had no adverse effects or complications during the period between preoperative and postoperative blood sampling. One adverse effect directly related to the serum metal ion concentrations, namely argyria, was observed. Conclusions This study documents significantly elevated concentrations of the metal ions, but only one adverse effect directly related to the metal ion concentrations was observed. Future studies are needed to further assess the impact of elevated metal ion levels after megaprostheses, specifically knee implants, which are metal-on-metal.
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Filer JL, Berstock J, Hughes-Roberts Y, Foote J, Sandhu H. Haemorrhagic Pseudotumour Following Metal-on-Metal Hip Replacement. Cureus 2021; 13:e15541. [PMID: 34277167 PMCID: PMC8269998 DOI: 10.7759/cureus.15541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2021] [Indexed: 11/17/2022] Open
Abstract
We present a unique report of a spontaneous haemorrhage into a pseudotumour five years following revision surgery for failed metal-on-metal hip arthroplasty. The patient sustained no trauma, was not taking anticoagulants and had no bleeding disorder. Rapid progression in the size of the pseudotumour caused significant symptoms and functional impairment. Surgical excision was recommended by a national specialist centre, but with conservative management, significant regression of the pseudotumour was noted, with complete resolution of symptoms. This case is the first report of haemorrhage into a pseudotumour, which is an important differential and can be managed non-operatively.
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Affiliation(s)
- Joshua L Filer
- Trauma and Orthopaedics, Royal United Hospitals Bath, Bath, GBR
| | - James Berstock
- Trauma and Orthopaedics, Royal United Hospitals Bath, Bath, GBR
| | | | - Julian Foote
- Trauma and Orthopaedics, Royal United Hospitals Bath, Bath, GBR
| | - Harvey Sandhu
- Trauma and Orthopaedics, Royal United Hospitals Bath, Bath, GBR
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Jabbouri S, Lee G, Stonecipher T, Nawalany M. Intrapelvic Pseudotumor Presenting with Deep Vein Thrombosis After Hip Replacement with Metal-on-Metal Bearing Surface Implant: A Case Report. JBJS Case Connect 2021; 11:01709767-202106000-00063. [PMID: 35102006 DOI: 10.2106/jbjs.cc.20.00866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
CASE A 61-year-old woman with an asymptomatic hip presented acutely with a swollen lower limb 15 years after a metal bearing surface total hip replacement (THR). A large intrapelvic pseudotumor was discovered compressing her femoral and iliac vessels. Collaboration between an orthopaedic and vascular surgeon led to a 2-stage surgical procedure with resection of the pseudotumor, followed by revision of the THR implant 3 months later. CONCLUSION This case demonstrates the importance of long-term follow-up of patients with metal bearing surface implants, early recognition of an unusual presentation of a common problem, and the utility of collaboration between orthopaedic and vascular surgeons.
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Affiliation(s)
- Sahir Jabbouri
- Washington State University Elson S. Floyd College of Medicine, Spokane, Washington
| | - Gina Lee
- Washington State University Elson S. Floyd College of Medicine, Spokane, Washington
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Mechanically Assisted Crevice Corrosion in a Metal-on-Polyethylene Total Hip Presenting With Lower Extremity Vascular Compromise. Arthroplast Today 2020; 6:445-450. [PMID: 32637514 PMCID: PMC7327377 DOI: 10.1016/j.artd.2020.04.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 04/18/2020] [Accepted: 04/23/2020] [Indexed: 11/22/2022] Open
Abstract
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-polyethylene (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.
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6
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Lencioni A, Ellis B, Dean CS, Lendrum J, Hogan CA. Metal-on-metal total hip arthroplasty adverse local tissue reaction with intermittent unilateral vascular claudication. Arthroplast Today 2019; 5:389-393. [PMID: 31886377 PMCID: PMC6920729 DOI: 10.1016/j.artd.2019.08.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Revised: 08/14/2019] [Accepted: 08/26/2019] [Indexed: 12/05/2022] Open
Abstract
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.
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Affiliation(s)
- Alex Lencioni
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Byron Ellis
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Chase S Dean
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO, USA
| | - James Lendrum
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Craig A Hogan
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO, USA
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Eltit F, Wang Q, Wang R. Mechanisms of Adverse Local Tissue Reactions to Hip Implants. Front Bioeng Biotechnol 2019; 7:176. [PMID: 31417898 PMCID: PMC6683860 DOI: 10.3389/fbioe.2019.00176] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 07/08/2019] [Indexed: 12/11/2022] Open
Abstract
Adverse Local Tissue Reactions (ALTRs) are one of the main causes of hip implant failures. Although the metal release from the implants is considered as a main etiology, the mechanisms, and the roles of the released products are topics of ongoing research. The alloys used in the hip implants are considered biocompatible and show negligible corrosion in the body environment under static conditions. However, modularity and its associated mechanically assisted corrosion have been shown to release metal species into the body fluids. ALTRs associated with metal release have been observed in hip implants with metal-on-metal articulation initially, and later with metal-on-polyethylene articulation, the most commonly used design in current hip replacement. The etiological factors in ALTRs have been the topics of many studies. One commonly accepted theory is that the interactions between the metal species and body proteins and cells generate a delayed type IV hypersensitivity reaction leading to ALTRs. However, lymphocyte reactions are not always observed in ALTRS, and the molecular mechanisms have not been clearly demonstrated. A more accepted mechanism is that cell damage generated by metal ions may trigger the secretion of cytokines leading to the inflammatory reactions observed in ALTRs. In this inflammatory environment, some patients would develop hypersensitivity that is associated with poor outcomes. Concerns over ALTRS have brought significant impact to both the clinical selection and development of hip implants. This review is focused on the mechanisms of ALTRs, specifically, the metal release process and the roles of the metal species released in the etiology and pathogenesis of the disease. Hopefully, our presentation and discussion of this biological process from a material perspective could improve our current understanding on the ALTRs and provide useful guidance in developing preventive solutions.
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Affiliation(s)
- Felipe Eltit
- Department of Materials Engineering, University of British Columba, Vancouver, BC, Canada.,School of Biomedical Engineering, University of British Columba, Vancouver, BC, Canada.,Centre for Hip Health and Mobility, Vancouver, BC, Canada
| | - Qiong Wang
- Department of Materials Engineering, University of British Columba, Vancouver, BC, Canada.,School of Biomedical Engineering, University of British Columba, Vancouver, BC, Canada.,Centre for Hip Health and Mobility, Vancouver, BC, Canada
| | - Rizhi Wang
- Department of Materials Engineering, University of British Columba, Vancouver, BC, Canada.,School of Biomedical Engineering, University of British Columba, Vancouver, BC, Canada.,Centre for Hip Health and Mobility, Vancouver, BC, Canada
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Grote CW, Cowan PC, Anderson DW, Templeton KJ. Pseudotumor from Metal-on-Metal Total Hip Arthroplasty Causing Unilateral Leg Edema: Case Presentation and Literature Review. Biores Open Access 2018; 7:33-38. [PMID: 29607251 PMCID: PMC5870059 DOI: 10.1089/biores.2017.0035] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Caleb W Grote
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Paul C Cowan
- Department of Orthopedic Surgery, Drisko, Fee and Parkins, Kansas City, Missouri
| | - David W Anderson
- Department of Orthopedic Surgery, Kansas City Joint Replacement at Menorah Medical Center, Overland Park, Kansas
| | - Kimberly J Templeton
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
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9
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Sassoon AA, Barrack RL. Pseudotumour formation and subsequent resolution in metal-on-metal total hip arthroplasty following revision: Instructional review and an illustrative case report with revision using a dual mobility design. Bone Joint J 2017; 98-B:736-40. [PMID: 27235513 DOI: 10.1302/0301-620x.98b6.36908] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 01/26/2016] [Indexed: 12/13/2022]
Abstract
The use of large-diameter metal-on-metal (MoM) components in total hip arthroplasty (THA) is associated with an increased risk of early failure due to adverse local tissue reaction to metal debris (ARMD) in response to the release of metal ions from the bearing couple and/or head-neck taper corrosion. The aim of this paper was to present a review of the incidence and natural history of ARMD and the forms of treatment, with a focus on the need for and extent of resection or debulking of the pseudotumour. An illustrative case report is presented of a patient with an intra-pelvic pseudotumour associated with a large diameter MoM THA, which was treated successfully with revision of the bearing surface to a dual mobility couple and retention of the well-fixed acetabular and femoral components. The pseudotumour was left in situ Resolution of the intra-pelvic mass and normalisation of metal ion levels was observed seven months post-operatively. Cite this article: Bone Joint J 2016;98-B:736-40.
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Affiliation(s)
- A A Sassoon
- University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - R L Barrack
- Washington University, 4921 Parkview Place, St. Louis, MO 63110, USA
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10
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Davis DL, Morrison JJ. Hip Arthroplasty Pseudotumors: Pathogenesis, Imaging, and Clinical Decision Making. J Clin Imaging Sci 2016; 6:17. [PMID: 27195183 PMCID: PMC4863402 DOI: 10.4103/2156-7514.181493] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Accepted: 04/14/2016] [Indexed: 12/13/2022] Open
Abstract
Pseudotumors are a complication of hip arthroplasty. The goal of this article is to review the clinical presentation, pathogenesis, histology, and the role of diagnostic imaging in clinical decision making for treatment, and surveillance of pseudotumors. We will discuss the multimodal imaging appearances, differential diagnosis, associated complications, treatment, and prognosis of pseudotumors, as an aid to the assessment of orthopedic prostheses at the hip.
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Affiliation(s)
- Derik L Davis
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - James J Morrison
- Dotter Interventional Institute, Oregon Health and Science University, Portland, OR, USA
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Combined Vascular and Orthopaedic Approach for a Pseudotumor Causing Deep Vein Thrombosis after Metal-on-Metal Hip Resurfacing Arthroplasty. Case Rep Orthop 2015; 2015:926263. [PMID: 26457216 PMCID: PMC4592736 DOI: 10.1155/2015/926263] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 08/24/2015] [Indexed: 12/12/2022] Open
Abstract
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. 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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12
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Singh V, Shon WY, Lakhotia D, Kim JH, Kim TW. A Rare Case of Femoral Neuropathy Associated with Ilio-Psoas Bursitis After 10 Years of Total Hip Arthroplasty. Open Orthop J 2015; 9:270-3. [PMID: 26312109 PMCID: PMC4541316 DOI: 10.2174/1874325001509010270] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2014] [Revised: 04/19/2015] [Accepted: 05/18/2015] [Indexed: 11/26/2022] Open
Abstract
We describe a case of femoral nerve palsy caused due to non-infective large iliopsoas bursitis after 10 years of cementless ceramic-on-metal THA. Bursectomy and exploration of femoral nerve were done to relieve the compressive symptoms of femoral nerve. Patient neurological symptoms were recovered within six months. Iliopsoas bursitis after THA can lead to anterior hip pain, lump in inguinal area or abdomen, limb swelling due to venous compression or more rarely neurovascular compressive symptoms depending on size and extension. Treating physician should be aware of this rare condition after THA in the absence of any radiographic findings so that prompt diagnosis and treatment can be carried out.
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Affiliation(s)
- Vivek Singh
- Department of Orthopaedic Surgery, Korea University College of Medicine, Guro Hospital, 97 Gurodong-gil, Guro-gu, Seoul, 152-703, Korea
| | - Won Yong Shon
- Department of Orthopaedic Surgery, Korea University College of Medicine, Guro Hospital, 97 Gurodong-gil, Guro-gu, Seoul, 152-703, Korea
| | - Devendra Lakhotia
- Department of Orthopaedic Surgery, Korea University College of Medicine, Guro Hospital, 97 Gurodong-gil, Guro-gu, Seoul, 152-703, Korea
| | - Jong Hoon Kim
- Department of Orthopaedic Surgery, Korea University College of Medicine, Guro Hospital, 97 Gurodong-gil, Guro-gu, Seoul, 152-703, Korea
| | - Tae Wan Kim
- Department of Orthopaedic Surgery, Korea University College of Medicine, Guro Hospital, 97 Gurodong-gil, Guro-gu, Seoul, 152-703, Korea
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13
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[Histopathological particle algorithm. Particle identification in the synovia and the SLIM]. Z Rheumatol 2015; 73:639-49. [PMID: 24821089 DOI: 10.1007/s00393-013-1315-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND In the histopathological diagnostics of synovitis and the synovium-like interface membrane (SLIM) the identification of crystals and crystal-like deposits and the associated inflammatory reactions play an important role. The multitude of endogenous crystals, the range of implant materials and material combinations, and the variability in the formation process of different particles explain the high morphological particle heterogeneity which complicates the diagnostic identification of diagnostic particles. STUDY DESIGN AND METHODS A simple histopathological particle algorithm has been designed which allows methodological particle identification based on (1) conventional transmitted light microscopy with a guide to particle size, shape and color, (2) optical polarization criteria and (3) enzyme histochemical properties (oil red staining and Prussian blue reaction). These methods, the importance for particle identification and the differential diagnostics from non-prosthetic materials are summarized in the so-called histopathological particle algorithm. RESULTS A total of 35 cases of synovitis and SLIM were analyzed and validated according to these criteria. Based on these criteria and a dichotomous differentiation the complete spectrum of particles in the SLIM and synovia can be defined histopathologically. CONCLUSION For histopathological diagnosis a particle score for synovitis and SLIM is recommended to evaluate (1) the predominant type of prothetic wear debris with differentiation between microparticles, and macroparticles, (2) the presence of non-prosthesis material particles and (3) the quantification of particle-association necrosis and lymphocytosis. An open, continuously updated web-based particle algorithm would be helpful to address the issue of particle heterogeneity and include all new particle materials generated in a rapidly changing field.
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Self-reported neurological clinical manifestations of metal toxicity in metal-on-metal hip arthroplasty. Hip Int 2014; 24:568-74. [PMID: 25096449 DOI: 10.5301/hipint.5000179] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/16/2014] [Indexed: 02/04/2023]
Abstract
Adverse reactions to metal particle debris have been increasingly reported as a complication following large head metal-on-metal (MoM) hip arthroplasty. Elevated metal ion levels are a cause for concern. The aim of this study is to evaluate whether exposure to cobalt is associated with patient characteristics and symptoms of neuropathy, representing nervous system dysfunction. A cross-sectional study was conducted comparing patients with a MoM total hip arthroplasty and patients with a conventional hip arthroplasty. They received three questionnaires, one to assess neurotoxic complaints and two standardised self-administered questionnaires to identify symptoms that are suggestive of peripheral neuropathy. Current and historical data were available for whole blood cobalt levels in all patients. We analysed potential predictive factors for cobalt based on five different cut-off levels (0-2, 2-4, 4-10, 10-20, >20 µg/L). We performed 723 MoM total hip arthroplasties in 643 patients in our clinic. The response rate was 89%. Male-female ratio was 236/280, median age 63.6 years (30-72) with a mean follow-up of 50.6 months (20-86). We also sent the questionnaires to 98 patients in the control group. An increase in the incidence of reported symptoms was not consistent with higher serum cobalt levels. Female gender was the only consistent predictive factor for serum cobalt at different cobalt cut-off levels in the multivariate analysis. The study population did not show an increase in reported symptoms with elevated cobalt levels. Neurotoxic symptoms and whole blood cobalt levels did not show a consistent relationship with different dichotomised levels of cobalt exposure.
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15
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Serum metal ion concentrations in paediatric patients following total knee arthroplasty using megaprostheses. BIOMED RESEARCH INTERNATIONAL 2014; 2014:817257. [PMID: 25276819 PMCID: PMC4172978 DOI: 10.1155/2014/817257] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Revised: 07/17/2014] [Accepted: 08/11/2014] [Indexed: 11/18/2022]
Abstract
The purpose of this study was to determine the concentrations of cobalt, chromium, and molybdenum in the serum of paediatric tumour patients after fixed hinge total knee arthroplasty. Further, these metal ion levels were compared with serum metal ion levels of patients with other orthopaedic devices such as hip and knee prostheses with metal-on-metal or metal-on-polyethylene articulation to find differences between anatomical locations, abrasion characteristics, and bearing surfaces. After an average follow-up of 108 months (range: 67 to 163) of 11 paediatric patients with fixed hinge total knee arthroplasty, the mean concentrations for Co and Cr were significantly increased while Mo was within the limits compared to the upper values from the reference laboratory. Furthermore, these serum concentrations were significantly higher compared to patients with a standard rotating hinge device (P = 0.002 and P < 0.001) and preoperative controls (P < 0.001). On the other hand, the serum levels of patients following MoM THA or rotating hinge arthroplasty using megaprostheses were higher. Therefore, periodic long-term follow-ups are recommended due to the rising concerns about systemic metal ion exposure in the literature. Upon the occurrence of adverse reactions to metal debris the revision of the fixed hinge implant should be considered.
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Mokka J, Junnila M, Seppänen M, Virolainen P, Pölönen T, Vahlberg T, Mattila K, Tuominen EKJ, Rantakokko J, Aärimaa V, Kukkonen J, Mäkelä KT. Adverse reaction to metal debris after ReCap-M2A-Magnum large-diameter-head metal-on-metal total hip arthroplasty. Acta Orthop 2013; 84:549-54. [PMID: 24171688 PMCID: PMC3851668 DOI: 10.3109/17453674.2013.859419] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Accepted: 09/06/2013] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE The clinical findings of adverse reaction to metal debris (ARMD) following large-diameter-head metal-on-metal total hip arthroplasty (LDH MoM THA) may include periarticular fluid collections, soft tissue masses, and gluteal muscle necrosis. The ReCap-M2a-Magnum LDH MoM THA was the most commonly used hip device at our institution from 2005 to 2012. We assessed the prevalence of and risk factors for ARMD with this device. METHODS 74 patients (80 hips) had a ReCap-M2a-Magnum LDH MoM THA during the period August 2005 to December 2006. These patients were studied with hip MRI, serum chromium and cobalt ion measurements, the Oxford hip score questionnaire, and by clinical examination. The prevalence of ARMD was recorded and risk factors for ARMD were assessed using logistic regression models. The mean follow-up time was 6.0 (5.5-6.7) years. RESULTS A revision operation due to ARMD was needed by 3 of 74 patients (3 of 80 hips). 8 additional patients (8 hips) had definite ARMD, but revision was not performed. 29 patients (32 hips) were considered to have a probable or possible ARMD. Altogether, 43 of 80 hips had a definite, probable, or possible ARMD and 34 patients (37 hips) were considered not to have ARMD. In 46 of 78 hips, MRI revealed a soft tissue mass or a collection of fluid (of any size). The symptoms clicking in the hip, local hip swelling, and a feeling of subluxation were associated with ARMD. INTERPRETATION ARMD is common after ReCap-M2a-Magnum total hip arthroplasty, and we discourage the use of this device. Asymptomatic patients with a small fluid collection on MRI may not need instant revision surgery but must be followed up closely.
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Affiliation(s)
- Jari Mokka
- Department of Orthopaedics and Traumatology , Turku University Hospital, Turku , Finland
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Krenn V, Kretzer JP, Thomas P, Thomsen M, Usbeck S, Scheuber L, Boettner F, Rüther W, Schulz S, Zustin J, Huber M. Update on endoprosthesis pathology: Particle algorithm for particle identification in the SLIM. ACTA ACUST UNITED AC 2013. [DOI: 10.1053/j.sart.2014.01.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Kawakita K, Shibanuma N, Tei K, Nishiyama T, Kuroda R, Kurosaka M. Leg edema due to a mass in the pelvis after a large-diameter metal-on-metal total hip arthroplasty. J Arthroplasty 2013; 28:197.e1-4. [PMID: 22704029 DOI: 10.1016/j.arth.2012.04.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Accepted: 04/17/2012] [Indexed: 02/01/2023] Open
Abstract
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.
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Affiliation(s)
- Kohei Kawakita
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-2 Chuo-ku Kusunokicho, Kobe, Japan
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Algarni AD, Huk OL, Pelmus M. Metallosis-induced iliopsoas bursal cyst causing venous obstruction and lower-limb swelling after metal-on-metal THA. Orthopedics 2012; 35:e1811-4. [PMID: 23218642 DOI: 10.3928/01477447-20121120-30] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The formation of iliopsoas bursal cystic lesions after total hip arthroplasty is an infrequently reported condition. This article describes an unusual complication of a current-generation metal-on-metal total hip arthroplasty.A woman presented with unilateral spontaneous lower-limb swelling that developed 5 years postoperatively. It occurred secondary to venous obstruction by a metallosis-induced iliopsoas bursal cyst associated with markedly elevated intralesional cobalt and chromium levels. Metal artifact reduction sequence magnetic resonance imaging showed that the bursal cyst was communicating with the hip joint and that it severely compressed the common femoral vein. Based on the findings of high local tissue metal ions and vertical cup positioning causing edge loading, the authors proposed an inflammatory reaction to metal debris that tracked into the iliopsoas bursa and formed a cyst. The patient underwent revision of the excessively vertical acetabular component and conversion to a ceramic-on-ceramic bearing interface, drainage of the bursal cyst, and synovectomy. No signs existed of local recurrence at 1-year follow-up.To the authors' knowledge, the occurrence of metallosis-induced iliopsoas bursitis with secondary pressure effects after contemporary metal-on-metal total hip arthroplasty has not been reported. When treating hip dysplasia, one must avoid maximizing cup-host bone contact at the risk of oververticalization. Iliopsoas bursal cystic lesions can lead to severe vascular compressive symptoms with no ominous radiographic findings. Physicians and orthopedic surgeons should be aware of the possibility of this complication in patients with unexplained unilateral lower-limb swelling.
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Affiliation(s)
- Abdulrahman D Algarni
- Arthroplasty Division, Department of Orthopedic Surgery, Jewish General Hospital, McGill University, Montreal, Quebec, Canada.
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Bosker BH, Ettema HB, Boomsma MF, Kollen BJ, Maas M, Verheyen CCPM. High incidence of pseudotumour formation after large-diameter metal-on-metal total hip replacement: a prospective cohort study. ACTA ACUST UNITED AC 2012; 94:755-61. [PMID: 22628588 DOI: 10.1302/0301-620x.94b6.28373] [Citation(s) in RCA: 149] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Peri-articular soft-tissue masses or 'pseudotumours' can occur after large-diameter metal-on-metal (MoM) resurfacing of the hip and conventional total hip replacement (THR). Our aim was to assess the incidence of pseudotumour formation and to identify risk factors for their formation in a prospective cohort study. A total of 119 patients who underwent 120 MoM THRs with large-diameter femoral heads between January 2005 and November 2007 were included in the study. Outcome scores, serum metal ion levels, radiographs and CT scans were obtained. Patients with symptoms or an identified pseudotumour were offered MRI and an ultrasound-guided biopsy. There were 108 patients (109 hips) eligible for evaluation by CT scan at a mean follow-up of 3.6 years (2.5 to 4.5); 42 patients (39%) were diagnosed with a pseudotumour. The hips of 13 patients (12%) were revised to a polyethylene acetabular component with small-diameter metal head. Patients with elevated serum metal ion levels had a four times increased risk of developing a pseudotumour. This study shows a substantially higher incidence of pseudotumour formation and subsequent revisions in patients with MoM THRs than previously reported. Because most revision cases were identified only after an intensive screening protocol, we recommend close monitoring of patients with MoM THR.
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Affiliation(s)
- B H Bosker
- Isala Klinieken, Department of Orthopaedic Surgery and Traumatology, Groot Wezenland 20, 8011 JW Zwolle, The Netherlands
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Meneghini RM, Hallab NJ, Jacobs JJ. Evaluation and treatment of painful total hip arthroplasties with modular metal taper junctions. Orthopedics 2012; 35:386-91. [PMID: 22588392 DOI: 10.3928/01477447-20120426-03] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Modern primary total hip arthroplasty femoral components have evolved to include modular necks. Subsequently, the additional taper junction provides another interface as a potential source for mechanically assisted crevice corrosion, which is a complex process involving fretting and crevice corrosion. Furthermore, it is becoming evident that an adverse local tissue reaction may result in some patients due to the mechanically assisted crevice corrosion. This article details the clinical, radiographic, and laboratory evaluation of patients with these components who present with persistent pain. The relevant surgical strategies and techniques to address this pathology in symptomatic patients are addressed.
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Affiliation(s)
- R Michael Meneghini
- Indiana University Health Physicians, Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana 46037, USA.
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