Foreign Body Reaction Mimicking Lymph Node Metastasis is Not Rare After Lung Cancer Resection

BACKGROUND

 Mediastinal lymphadenopathies with high 18-fluorodeoxyglucose uptake in patients previously operated on for lung cancer are alarming for recurrence and necessitate invasive diagnostic procedures. Peroperative placement of oxidized cellulose to control minor bleeding may lead to a metastasis-like image through a foreign body reaction within the dissected mediastinal lymph node field at postoperative examinations. In this study, we investigated clinicopathological features and the frequency of foreign body reaction mimicking mediastinal lymph node metastasis.

METHODS

 Patients who underwent surgery for lung cancer between January 2016 and August 2021 and who were subsequently evaluated for mediastinal recurrence with endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) were included. Patients were grouped according to the results of EBUS-TBNA as metastasis, foreign body, and reactive. Clinicopathological features of these patients were compared and characteristics of patients in the foreign body group were scrutinized.

RESULTS

 EBUS-TBNA was performed on a total of 34 patients during their postoperative follow-up due to suspicion of mediastinal recurrence. EBUS-TBNA pathological workup revealed metastasis in 18 (52.9%), foreign body reaction in 10 (29.4%) and reactive lymph nodes in 6 (17.6%) patients. Mean maximum standardized uptake value (SUVMax) for metastasis group and foreign body group were 9.39 ± 4.69 and 5.48 ± 2.54, respectively (p = 0.022). Time interval between the operation and EBUS-TBNA for the metastasis group was 23.72 ± 10.48 months, while it was 14.90 ± 12.51 months in the foreign body group (p = 0.015).

CONCLUSION

 Foreign body reaction mimicking mediastinal lymph node metastasis is not uncommon. Iatrogenic cause of mediastinal lymphadenopathy is related to earlier presentation and lower SUVMax compared with metastatic lymphadenopathy.

Foreign Body Reaction Due to a Forgotten Rubber Band on the Neck of a Toddler Girl

ABSTRACT

In the presence of an unhealed granulation tissue-like wound, a possibility of abuse and neglect along with a foreign body should come to mind. However, it may be difficult to recognize a foreign body in patients with atypical clinical presentations. We demonstrated delayed diagnosis of a rubber band embedded into subcutaneous tissue in a 2½-year-old girl who presented with a circumferential scar with 2 granulation tissue-like wounds on her neck due to a foreign body reaction developed over years. With this rare case presentation, we remind the possibility of abuse/neglect along with foreign bodies in neck lesions of children.

Characterization of the T-cell response to polypropylene mesh in women with complications

BACKGROUND

Polypropylene mesh is used widely for surgical treatment of pelvic organ prolapse and stress urinary incontinence. Although these surgeries demonstrate favorable functional and anatomic outcomes, their use has been limited by complications, the 2 most common being exposure and pain. Growing evidence suggests that T lymphocytes play a critical role in the regulation of the host response to biomaterials.

OBJECTIVE

The purpose of this study was to define and characterize the T-cell response and to correlate the response to collagen deposition in fibrotic capsules in mesh tissue complexes that are removed for the complications of pain vs exposure.

STUDY DESIGN

Patients who were scheduled to undergo a surgical excision of mesh for pain or exposure at Magee-Women's Hospital were offered enrollment. Forty-two mesh-vagina tissue complexes were removed for the primary complaint of exposure (n=24) vs pain (n=18). Twenty-one patients agreed to have an additional vaginal biopsy away from the site of mesh that served as control tissue. T cells were examined via immunofluorescent labeling for cell surface markers CD4+ (T_h), CD8+ (cytotoxic) and foxp3 (T-regulatory cell). Frozen sections were stained with hematoxylin-eosin for gross morphologic condition and picrosirius red for collagen fiber analysis. Interrupted sodium-dodecyl sulfate gel electrophoresis was used to quantify the content of collagens type I and III, and the collagen III/I ratio. Transforming growth factor-β and connective tissue growth factor, which are implicated in the development of fibrosis, were measured via enzyme-linked immunosorbent assays. Data were analyzed with the Student's t tests, mixed effects linear regression, and Spearman's correlation coefficients.

RESULTS

Demographic data were not different between groups, except for body mass index, which was 31.7 kg/m² for the exposure group and 28.2 kg/m² for pain (P=.04). Tissue complexes demonstrated a marked, but highly localized, foreign body response. We consistently observed a teardrop-shaped fibroma that encapsulated mesh fibers in both pain and exposure groups, with the T cells localized within the tip of this configuration away from the mesh-tissue interface. All 3 T-cell populations were significantly increased relative to control: CD4⁺ T helper (P<.001), foxp3⁺ T regulatory (P<.001), and CD8⁺ cytotoxic T cell (P=.034) in the exposure group. In the pain group, only T-helper (P<.001) and T-regulatory cells (P<.001) were increased, with cytotoxic T cells (P=.520) not different from control. Picrosirius red staining showed a greater area of green (thin) fibers in the exposure group (P=.025) and red (thick) fibers in the pain group (P<.001). The ratio of area green/(yellow + orange + red) that represented thin vs thick fibers was significantly greater in the exposure group (P=.005). Analysis of collagen showed that collagen type I was increased by 35% in samples with mesh complications (exposure and pain) when compared with control samples (P=.043). Strong correlations between the profibrosis cytokine transforming growth factor-β and collagen type I and III were found in patients with pain (r≥0.833; P=.01) but not exposure (P>.7).

CONCLUSION

T cells appear to play a critical role in the long-term host response to mesh and may be a central pathway that leads to complications. The complexity of this response warrants further investigation and has the potential to broaden our understanding of mesh biology and clinical outcomes.

Buried umbilicus with inflammation due to retained rubber foreign body after liposuction: A case report

INTRODUCTION

Liposuction is one of the most widely performed aesthetic surgeries. It is mainly used for the correction of deep and superficial fat accumulations and remodeling of the body contour.

CASE PRESENTATION

We present a rare case of unusual rubber foreign body found within the periumbilical area during the reconstruction of buried umbilicus after liposuction.A 61-year-old female had undergone a liposuction surgery 10 years ago. Last year, she experienced signs of inflammation around the periumbilical area. The patient was treated with antibiotics and daily dressing at a local clinic. However, her symptoms did not improve with treatment.After admission, we decided to reconstruct the umbilicus and explore the previous operative site. During reconstruction of umbilicus, we finally discovered a rubber foreign body in the periumbilical area and buried umbilicus.

CONCLUSION

Retained surgical foreign body can clinically manifest as acute reaction, such as an inflammatory response, infection, or abscess within days or weeks after the operation. Patients may complain of pain and discomfort, even months or years after the procedure.Our patient had suffered from delayed inflammation due to retained surgical foreign body after liposuction surgery. We emphasize the need for excellent communication within the surgical team to prevent the incidence of retained surgical bodies.

Blood Metal Ion Thresholds to Identify Patients with Metal-on-Metal Hip Implants at Risk of Adverse Reactions to Metal Debris: An External Multicenter Validation Study of Birmingham Hip Resurfacing and Corail-Pinnacle Implants

BACKGROUND

The authors of recent studies have reported newly devised implant-specific blood metal ion thresholds to predict adverse reactions to metal debris (ARMD) in patients who have undergone unilateral or bilateral metal-on-metal (MoM) hip arthroplasty. These thresholds were most effective for identifying patients at low risk of ARMD. We investigated whether these newly devised blood metal ion thresholds could effectively identify patients at risk of ARMD after MoM hip arthroplasty in an external cohort of patients.

METHODS

We performed a validation study involving 803 MoM hip arthroplasties (323 unilateral Birmingham Hip Resurfacing [BHR], 93 bilateral BHR, and 294 unilateral Corail-Pinnacle implants) performed in 710 patients at 3 European centers. All patients underwent whole-blood metal ion sampling, and were divided into 2 groups: those with ARMD (leading to revision or identified on imaging; n = 75) and those without ARMD (n = 635). Previously devised implant-specific blood metal ion thresholds (2.15 μg/L of cobalt for unilateral BHR; 5.5 μg/L for the maximum of either cobalt or chromium for bilateral BHR; and 3.57 μg/L of cobalt for unilateral Corail-Pinnacle implants) were applied to the validation cohort, and receiver operating characteristic curve analysis was used to establish the discriminatory characteristics of each threshold.

RESULTS

The area under the curve, sensitivity, specificity, and positive and negative predictive values for the ability of each implant-specific threshold to distinguish between patients with and without ARMD were, respectively, 89.4% (95% confidence interval [CI] = 82.8% to 96.0%), 78.9%, 86.7%, 44.1%, and 96.9% for unilateral BHR; 89.2% (CI = 81.3% to 97.1%), 70.6%, 86.8%, 54.5%, and 93.0% for bilateral BHR; and 76.9% (CI = 63.9% to 90.0%), 65.0%, 85.4%, 24.5%, and 97.1% for unilateral Corail-Pinnacle implants. Using the implant-specific thresholds, we missed 20 patients with ARMD (2.8% of the patients in this series). We missed more patients with ARMD when we used the fixed thresholds proposed by regulatory authorities: 35 (4.9%) when we used the U.K. threshold of 7 μg/L for both cobalt and chromium (p = 0.0003), 21 (3.0%) when we used the U.S. threshold of 3 μg/L for both cobalt and chromium (p = 1.0), and 46 (6.5%) when we used the U.S. threshold of 10 μg/L for both cobalt and chromium (p < 0.0001).

CONCLUSIONS

This external multicenter validation study confirmed that patients with blood metal ion levels below new implant-specific thresholds have a low risk of ARMD after MoM hip arthroplasty. Using these implant-specific thresholds, we missed fewer patients with ARMD compared with when the thresholds currently proposed by regulatory authorities were used. We therefore recommend using implant-specific blood metal ion thresholds when managing patients who have undergone MoM hip arthroplasty.

LEVEL OF EVIDENCE

Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Aseptic Lymphocytic-Dominated Vasculitis-Associated Lesions Scores Do Not Correlate With Metal Ion Levels or Unreadable Synovial Fluid White Blood Cell Counts

BACKGROUND

Failed metal-on-metal (MoM) bearings are being increasingly encountered with little information to guide evaluation for aseptic lymphocytic-dominated vasculitis-associated lesions (ALVAL). It is often assumed that elevated metal ion levels correlate with the occurrence of ALVAL. Our purpose was to determine the utility of the erythrocyte sedimentation rate, C-reactive protein, synovial white blood cell count, differential (%PMN), and serum metal ion levels in diagnosing ALVAL.

METHODS

We identified 80-failed MoM total hip arthroplasties. Tissue was examined under light microscopy and graded on a scale of ALVAL severity. Mean laboratory values were compared between groups and receiver operating curves generated with an area under the curve to determine test performance and optimal cutoffs.

RESULTS

ALVAL scores were graded as low in 30 (37.5%), moderate in 39 (49%), and severe in 8 (10%), with 3 being unreadable. No clear cutoff values for erythrocyte sedimentation rate, C-reactive protein, or synovial white blood cell count could be determined to reliably diagnose moderate or severe ALVAL. Furthermore, serum metal levels had no correlation with ALVAL score. The best test to diagnose ALVAL was the synovial fluid monocyte percentage with an optimal cutoff value of 39% and area under the curve of 69% (moderate testing performance).

CONCLUSION

The diagnosis of ALVAL remains challenging, with most of the screening tests being unreliable. Although serum metal ion levels are typically elevated in failed MoM bearings, higher levels do not appear to correlate with ALVAL grade. Elevated synovial fluid monocytes may provide diagnostic utility for ALVAL, suggesting a possible delayed-type hypersensitivity reaction.

Injectable silicon oils - complications

There have been reports of the use of silicone oils in injectable form for cosmetic purposes since the 1940s. With the popularization of the use of this technique in the mid-60s, there have been a wide range of adverse effects reported. We report a 32-year-old woman, who had intramuscular injections of an unknown substance, which led to serious complications.

Perforating gout of the ear

Gout is the most common cause of inflammatory arthritis in men over 40 [1]. The prevalence of gout in the US is approximately 3.9%. Tophus is a characteristic sign of gout and results when monosodium urate deposits at the joint, skin, or cartilage. Tophi develop in 12-35% of patients who are diagnosed with gout [2]. We report a case of a 70-year-old man who was diagnosed with squamous cell carcinoma of the helix via shave biopsy. During Mohs micrographic surgery, a vigorous foreign-body reaction was noted. Review of the initial biopsy slides identified crystals with pseudoepitheliomatous hyperplasia (PEH) rendering a diagnosis of gout. This case emphasizes the importance of recognizing causes of PEH and the predilection for tophi to form on the ear.

Retained strabismus suture material masquerading as nonspecific orbital inflammation

We report a case of orbital myositis of the superior rectus muscle-levator complex masquerading as nonspecific orbital inflammation but corresponding in location to a known braided polyester "chicken suture" placed 20 years earlier during strabismus surgery. The orbital inflammation was refractory to oral steroids but resolved promptly on surgical removal of the suture material. Although suture material is known to cause foreign body granulomatous reactions, to our knowledge this is the first reported case of a deep, diffuse orbital inflammation attributable to chicken suture placed during strabismus surgery.

Evaluation of p53 Polymorphism in Patients with Pannus-Derived Prosthetic Dysfunction

BACKGROUND AND AIM OF THE STUDY

Prosthetic valve dysfunction (PVD) due to pannus formation is considered to occur due to a bioreaction to prosthetic material. The p53 gene plays a critical role in apoptosis and cell proliferation. p53 Arg72Pro polymorphism has been found to be associated with coronary stent restenosis, but has not yet been studied in prosthetic heart valve dysfunction. The study aim was to evaluate the association between pannus-derived PVD and p53 G72C(Arg72Pro) polymorphism.

METHODS

This single-center, prospective study included 25 patients (20 females, five males; mean age 45.6 +/- 12.5 years; group 1) who underwent redo valve surgery due to PVD, and 49 age- and gender-matched control patients (44 females, five males; mean age 47.3 +/- 12.2 years; group 2) with normofunctional prostheses. The prostheses were examined using transthoracic and transesophageal echocardiography. Analyses of p53 G72C(Arg72Pro) polymorphism were performed using Roche LightCyler 2.0 Real-time polymerase chain reaction.

RESULTS

The most common location of replaced valves was the mitral position in both groups (88% and 89.8%, respectively). In group 1, normal alleles (GG) were observed in 12 patients (48%), while one patient (4%) showed a homozygous mutation (GC) and 12 patients (48%) showed a heterozygous mutation (CC). In group 2, 21 patients (42.9%) had normal alleles (GG), while four (8.2%) had a homozygous mutation (CC) and 24 (48.9%) had a heterozygous mutation (GC). No significant difference was observed between the groups with regards to p53 Arg72Pro polymorphism (p = 0.769).

CONCLUSION

In patients with prosthetic valves, the underlying mechanism behind pannus formation is unrelated to p53 Arg72Pro polymorphism.

Common bile duct injury by fibrin glue: Report of a rare complication

Fibrin glue is widely used in clinical practice and plays an important role in reducing postoperative complications. We report a case of a 65-year-old man, whose common bile duct was injured by fibrin glue, with a history of failed laparoscopic cholecystectomy and open operation for uncontrolled laparoscopic bleeding. In view of the persistent liver dysfunction, xanthochromia and skin itching, the patient was admitted to us for further management. Ultrasound, computed tomography, and magnetic resonance cholangiopancreatography (MRCP) revealed multiple stones in the common bile duct, and liver function tests confirmed the presence of obstructive jaundice and liver damage. Endoscopic retrograde cholangiopancreatography was unsuccessfully performed to remove choledocholithiasis, but a small amount of tissue was removed and pathologically confirmed as calcified biliary mucosa. This was followed by open surgery for suspicious cholangiocarcinoma. There was no evidence of cholangiocarcinoma, but the common bile duct wall had a defect of 8 mm × 10 mm at Calot’s triangle. A hard, grid-like foreign body was removed, which proved to be solid fibrin glue. Subsequently, the residual choledocholithiasis was removed by a choledochoscopic procedure, and the common bile duct deletion was repaired by liver round ligament with T-tube drainage. Six months later, endoscopy was performed through the T-tube fistula and showed a well-repaired bile duct wall. Eight months later, MRCP confirmed no bile duct stenosis. A review of reported cases showed that fibrin glue is widely used in surgery, but it can also cause organ damage. Its mechanism may be related to discharge reactions.

Foreign Body Gingivitis

Foreign body gingivitis (FBG) is a non-plaque induced chronic inflammatory process involving the marginal and/or attached gingiva. It results from the introduction of foreign particulate material, primarily dental prophylaxis paste and restorative dental materials, into the gingival tissues. Clinical presentation varies from an erythematous to vesiculoerosive-like process that may mimic a localized form of desquamative gingivitis or an erosive lichenoid process. Rarely, it may also present with a granular appearance. We describe the clinical presentation, differential diagnosis and clinical management of a 52-year-old Woman who presented with localized chronic inflammation of the maxillary anterior and left posterior gingiva secondary to the presence of foreign material.

How do absorbable sutures absorb? A prospective double-blind randomized clinical study of tissue reaction to polyglactin 910 sutures in human skin

OBJECTIVE

To compare the tissue reaction produced by 2 gauges of implanted polyglactin 910(Vicryl) suture material in human skin.

METHODS

A prospective, double masked, parallel randomized IRB approved clinical trial. Consecutive patients with involutional entropion and horizontal eyelid laxity were randomly allocated to 5/0 or 7/0 gauge test suture groups. Symptoms were alleviated during the wait for definitive surgery by placement of eyelid everting sutures. After 28 days, surgical entropion correction including eyelid wedge excision was achieved. Histological analysis was carried out, masked to the suture gauge used, on the excised eyelid containing one of the temporary everting sutures. Both patient and analyst were masked to the suture group. The four primary outcome measurements were granuloma outer diameter, central cellular diameter, giant cell number and area of fibrous coat and a statistical comparison made between suture gauge groups.

RESULTS

21 patients were allocated to each group, and histological analysis was possible in 36 patients. Significant suture-related granulomatous inflammatory reactions were found in all specimens. Medians of the measurements for 5/0 and 7/0 gauge sutures, respectively, were 0.855 mm versus 0.387 mm granuloma outer diameter (p = 0.0001); 0.464 mm versus 0.250 mm central cellular element diameter (p = 0.0003); 0.194 mm(2) versus 0.053 mm(2) fibrous coat area (p = 0.0009) and 0.8 versus 1.2 giant cell number (p = 0.7511).

CONCLUSIONS

Polyglycolic acid sutures elicit a significant foreign body inflammatory response proportional to suture gauge. This reaction may be minimized by early suture removal. The study validates a novel and ethical approach to the examination of human skin response to implanted suture material.

Foreign body reaction after PLC reconstruction caused by a broken PLLA screw

Foreign body reactions may occur in patients who receive bioabsorbable implants during orthopedic surgery for fractures and ligament repair. The authors describe a 34-year-old man who presented with a palpable tender mass on the lateral aspect of the left knee of 1 month's duration. He underwent posterior cruciate ligament and posterolateral corner reconstruction 3 years earlier. Physical examination showed a 1×1-cm soft, nontender mass without localized warmth on the lateral epicondyle of the distal femur. Magnetic resonance imaging showed a broken screw fragment surrounded by a cyst-like mass. Under general anesthesia, the surgeon excised the screw fragment and the fibrotic mass, enclosing it in the subcutaneous tissue at the lateral epicondyle, the site at which a poly-L-lactic acid bioabsorbable screw had been inserted to fix the graft for posterolateral corner reconstruction. Histologic evaluation showed a foreign body reaction to the degraded screw particles. To the authors' knowledge, this report is the first description of a patient presenting with a delayed foreign body reaction to a broken poly-L-lactic acid bioabsorbable screw at the lateral femoral epicondyle after posterolateral corner reconstruction. Because delayed foreign body reactions can occur at any site of poly-L-lactic acid bioabsorbable screw insertion, care should be taken to avoid screw protrusion during ligament reconstruction because it can lead to screw breakage and delayed foreign body reaction.

Adverse reaction to metal debris after ReCap-M2A-Magnum large-diameter-head metal-on-metal total hip arthroplasty

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.

Imaging of cosmetic facial implants and grafts

SUMMARY

A wide variety of implants and grafts have been used for cosmetic facial surgery, including forehead, nose, cheek, lip, and chin augmentation. Some of the implant materials include silicone, expanded polytetrafluoroethylene (Gore-Tex), hydroxylapatite, and porous polyethylene (Medpor). Grafts include bone and cartilage, which can be prepared as "Turkish Delight" for rhinoplasty. Imaged facial implants and grafts can be encountered incidentally or purposely to evaluate complications. Many of these materials have distinct radiologic imaging features and should not be misinterpreted as pathology. Conversely, implant complications should be appropriately recognized by using a focused imaging approach. The purpose of this article was to review the different types of cosmetic facial implants and grafts with an emphasis on their expected and complicated radiologic imaging appearances.

[Classification and clinical observation of rhinoliths in the adult patients]

This paper reports 3 cases of rhinoliths 20, 14, and 45 years in duration respectively observed during the last 3 years. Rhinoliths caused difficulty of nasal breathing on the side of their localization accompanied by serous discharge from the nose and atrophy of turbinate bones; moreover, they provoked the development of maxilloethmoidal sinusitis, nasal polyps, and deviation of the nasal septum. The surgical removal of the rhinoliths promoted elimination of these complications. A new classification of rhinoliths distinguishing between 4 groups of these stone-like structures is proposed.

Role of endoscopic sonography in the diagnosis of a fish bone perforation of the gastric wall resulting in a submucosal pseudotumor

We report the case of a 72-year-old woman with a fish bone-induced granulation tissue in the gastric wall that was initially diagnosed as a submucosal tumor by panendoscopy. High-frequency endoscopic ultrasonography identified the linear calcified fish bone embedded in a heterogeneous mass.

"A dropped call"

We present an interesting case of tracheobronchial foreign body aspiration. A 29-year-old healthy female, with no history of pulmonary disease, presented on multiple occasions to healthcare providers with wheezing and cough. She was repeatedly diagnosed and treated for asthma with acute exacerbations. Upon further evaluation, the patient was subsequently found to have a tracheobronchial foreign body causing her symptoms. This case report highlights a clinical approach to wheezing illnesses and reviews the diagnosis and management of tracheobronchial foreign body aspiration.

Large foreign body reaction to tension-free vaginal tape masquerading as inguinal hernia

We report a case of a 73-year-old woman who presented to general surgery with a tender lump in the groin 5 years after insertion of a tension-free vaginal tape. The lesion was thought to be an incarcerated inguinal hernia. Emergency surgical exploration revealed a 7 × 5 × 4 cm soft tissue mass which was adherent to the external inguinal ring, emanating from the end of the tension-free vaginal tape at the level of the symphysis pubis. Resection and histological examination revealed a central track of granulation tissue with a surrounding foreign body inflammatory response. The surgery was complicated by an infected seroma requiring surgical drainage and antibiotic therapy, following which the patient made a full recovery. Large foreign body reaction is a rare but an important complication of tension-free vaginal tapes and may be mistaken for a groin hernia or lymphadenopathy.

Adverse soft-tissue reactions around non-metal-on-metal total hip arthroplasty - a systematic review of the literature

Adverse local soft-tissue reactions have been associated with severe osteolysis and implant failure in metal-on-metal total hip arthroplasty (THA). Such a causal relationship has not often been associated with non metal-on-metal bearing surfaces. The purpose of this study was to assess the literature for cases of adverse soft-tissue reactions in non-metal-on-metal bearings in order to determine if a consistent histological diagnosis existed and if it was bearing-specific.

METHODS

A systematic review was performed in Medline and Embase databases, utilizing keyword searches to target reports of soft tissue complications following THA. Strict exclusion criteria were applied to retrieved studies in order to ensure that analyzed papers involved non-metal-on-metal bearing surfaces, had a final histological diagnosis, and had no previous history of periprosthetic infection or neoplastic process. Presenting symptoms, diagnostic work-up, histological diagnosis, and operative treatment were recorded for all reports retained for analysis.

RESULTS

Twenty-seven reports representing 31 cases of adverse soft-tissue reactions for non-metal-on-metal THAs met the criteria for analysis. In the majority of cases, patients presented with painful, limited motion in the affected hip, and radiological evidence of severe osteolysis. Histological examination often revealed a cystic mass, denoted by a granulomatous reaction comprised of histiocytes and giant cells, but few plasma cells. Revision of loose components was the most common successful therapeutic strategy utilized.

CONCLUSION

The present analysis revealed that similar adverse soft-tissue reactions have been described for both metal-on-polyethylene and ceramic bearing surfaces. When encountering such reactions in patients, a comprehensive diagnostic workup, including computed tomography (CT) scanning, lesion biopsy, and revision planning to alternate bearing surfaces should be considered.

Gossypiboma: a rare abdominal lesion of women after cesarean section, usually misdiagnosed as a neoplasm

The case of a 20-year-old pregnant woman with a history of one previous cesarean section (CS) who developed a tumorous mass in the area of the CS scar is presented. The clinical diagnosis of endometriosis or fibromatosis was made but the histologic findings were confusing and the pathological diagnosis of an inflammatory type of liposarcoma was made. The case was referred to our Laboratory for re-evaluation and the diagnosis of gossypiboma was made based on histopathological features, the patient's age, her medical history and the exact location of the lesion. Gossypiboma is a foreign body-related inflammatory pseudotumor caused by retained non-resorbable or even resorbable substances, such as glue, surgical gause or sutures. It is an obscure lesion ignored by doctors of all specialties studying the differential diagnosis of a postoperative mass.

Concomitant infection and local metal reaction in patients undergoing revision of metal on metal total hip arthroplasty

Total hip arthroplasty (THA) with conventional polyethylene bearings is traditionally the standard operative treatment for endstage arthritis of the hip. This design has excellent survivorship in most populations, with a low occurrence of infection and other associated complications. Due to concern over increased wear in younger, more active populations, other bearing surfaces have been evaluated, particularly metal-on-metal with wear rates theorized to be lower than conventional THA. Unique to metal-on-metal THA, however, is the possibility of local soft tissue reactions that can mimic infection, making proper diagnosis and treatment difficult. We present a case series of nine hips in eight patients undergoing revision of metal-on-metal THA for local soft tissue reactions, three of which were also found to be concomitantly infected. The laboratory and hip aspirate data described show significant overlap between the infected and non-infected cases. Care must be taken when evaluating patients with failed metal-on-metal THA as there may be an increased incidence of co-infection in this group of patients.

A novel tongue implant for tongue advancement for obstructive sleep apnea: feasibility, safety and histology in a canine model

Obstructive sleep apnea (OSA) is a sleep related breathing disorder caused by partial or complete collapse of the upper airway during sleep. The disease is linked with important cardiovascular and cerebrovascular morbidity and mortality. Tongue base collapse is a major cause of upper airway occlusion in OSA and present surgical procedures to prevent this are invasive and inefficient. A novel implantable system to stabilize the tongue was evaluated in a canine model for feasibility, safety and histology. Successful implantation of the Advance System was performed in 21 canines and follow-up evaluations were performed at 30, 60, 90, 120 and 150 days. No technical or clinical adverse events were seen during the procedure. Minor clinical adverse events at some of the follow-up evaluations were treated successfully. Histologic evaluation of the implant was performed at different time points during follow-up and showed good biocompatibility, stability and osteointegration. The outcome of this study resulted in an implant for adjustable tongue advancement in humans with OSA.

Joint and long-bone gunshot injuries

Gunshot wounds remain a major clinical problem, with the number of nonfatal gunshot wounds reported as 60,000 to 80,000 per year in the United States. Bone or joint injuries comprise a major portion of gunshot wound injuries. It is paramount for orthopaedic surgeons to be thorough in their treatment of patients with these injuries. Intra-articular injuries remain a source of significant clinical morbidity because of joint stiffness, arthritis, and the risk of infection. Treatment of long-bone fractures is a challenging clinical problem, and further studies are needed to investigate modern treatment methods. Lead toxicity is a potential risk for patients with gunshot injuries, particular for those with joint injuries. The clinician's recognition of the signs and symptoms of lead toxicity is important to achieve the best care for these patients.

Intra-abdominal gossypiboma: a report of two cases and a review of literature

Post operative foreign body in the abdominal cavily, though rare continues to occur in surgical practice. Symptoms may start early with abdominal pain but usually have a varying course, ofter leading 10 the formation of gossypiboma. This is usually a great source of embarrassment to the surgeon and the centre, and of serious detrimental effect to the patient. A case report of a 27-year-old trader with intra-abdominal foreign body is presented to highlig at the similarity in presentation with abdominal lymphoma and the need to explore carefully masses in the abdominal cavity especially in patients who have had surgery in the past. A high index of suspicious is required on the part of the clinician in addition to appropriate radiological and sonologic assessment. Prompt diagnosis and treatment ameliorates the patients suffering and brings them back to life.

Endobronchial Actinomycosis Secondary to a Tooth Aspiration

We report a middle aged smoker with recurrent pneumonia caused by endobronchial actinomycosis secondary to a tooth aspiration. Unlike previously reported cases, our patient was not chronically debilitated. The case suggests that a follow-up bronchoscopy is beneficial after the initiation of antibiotic therapy for endobronchial actinomycosis.

Inguinal vasal obstruction following polypropylene mesh repair

Inguinal vasal obstruction following hernia repair is related to either direct injury to vas or ischemic injury leading to delay stricture. Not much has been described regarding the long term impact of synthetic mesh as far as integrity of the cord structure is concerned. Here, we report a case that underwent mesh explantation for posthernioplasty inguinodynia as well as recurrence and found to have total occlusion of the lumen of vas segment adherent to the explanted mesh on microscopic examination.