Elusive Differential of a Painful Unstable Total Knee Arthroplasty – Metal on Cement Disease

Abstract

Particle disease from the release of metal, cement, ceramic, or polyethylene particles is a rare condition in total knee replacement. Wear, fracture, or corrosion of the components leads to foreign body reaction in the joint, followed by pain, swelling, limited motion, difficulty in walking, functional disability, and occasional systemic disease. This paper presents two cases of metal-on-cement disease as an etiology for the implant failure wherein the metal particles were shed off from the implant, along with cement and polyethylene particles, leading to a complex foreign body reaction in the failed total knee. We have coined this phenomenon as "cementallosis." Initial symptoms and signs from implant failure in both patients were mild, intermittent mediolateral knee pain that was aggravated after walking but no pain at rest or at night. The pain was associated with a 'buckling' sensation, recurrent knee swelling, and gradually worsening knee range of motion. Clinical examination in both cases was suggestive of a wellhealed anterior midline surgical scar, mild to moderate effusion, mild diffuse tenderness over the entire joint, limited functional range of motion, grade 1+ laxity throughout the range of motion, and intact distal neurovascular status. Routine blood and synovial fluid workup were inconclusive for identifying the exact etiology of the patient's symptoms. Radiographs, computed tomography (CT) scans, as well as bone scans, were negative for prosthetic joint infection, component malalignment, polyethylene wear, maltracking, or loosening of the components but showed mild to moderate effusions, synovial hypertrophy, and mild scattered periprosthetic osteolysis. Intraoperatively, there was significant synovial hypertrophy with dark pigment deposition and apparent dissociation of the femoral and tibial components from the underlying cement mantle, although the cement was well-adhered to the underlying bone. Synovial fluid and multiple tissue specimens were suggestive of complex foreign body granulomas with metal, cement, and polyethylene particles. These patients had undergone surgery by the same surgery team in the community using the same implant. These cases demonstrate the failure of a total knee arthroplasty implant at the metal-cement interface with features of adverse local tissue reactions that resemble a pseudotumor from the metal-on-metal disease in the knee joint. We have compared and contrasted the clinical presentations, laboratory, imaging, histopathological, and intraoperative study findings in these cases. Knowing what to look for will aid in early diagnosis, ordering necessary investigations, better surgery planning, reducing operative time, as well as improving outcomes and cost of care. The aim of this paper is to educate the audience about this new phenomenon as a cause of knee prosthesis failure produced by a complex pseudotumor-like foreign body reaction that involves metal, cement, and polyethylene particles.

Two Cases of Polyethylene Granuloma After Distal Femoral Endoprosthesis With All-Polyethylene Tibia

“…In joint arthroplasty, it is well recognized that accumulation of wear debris from prosthetic hardware can cause macrophagedriven foreign body reaction, which in turn leads to periprosthetic osteolysis [6][7][8][9][10]. Specifically, polyethylene particulate debris created by chronic abrasive wear of polyethylene components can cause massive periprosthetic osteolysis in arthroplasties of the hip and knee [6][7][8][9][10].…”

“…In joint arthroplasty, it is well recognized that accumulation of wear debris from prosthetic hardware can cause macrophagedriven foreign body reaction, which in turn leads to periprosthetic osteolysis [6][7][8][9][10]. Specifically, polyethylene particulate debris created by chronic abrasive wear of polyethylene components can cause massive periprosthetic osteolysis in arthroplasties of the hip and knee [6][7][8][9][10]. In some cases, foreign body reaction to polyethylene can also lead to the formation of a tumor-like softtissue mass, termed polyethylene granuloma or pseudotumor, often detectable by conventional imaging modalities such as plain radiograph and CT [6][7][8][9][10].…”

“…Specifically, polyethylene particulate debris created by chronic abrasive wear of polyethylene components can cause massive periprosthetic osteolysis in arthroplasties of the hip and knee [6][7][8][9][10]. In some cases, foreign body reaction to polyethylene can also lead to the formation of a tumor-like softtissue mass, termed polyethylene granuloma or pseudotumor, often detectable by conventional imaging modalities such as plain radiograph and CT [6][7][8][9][10]. This is particularly notable in total hip arthroplasty where the formation of polyethylene granuloma on the femoral side has been more commonly reported [9][10][11][12][13][14].…”

“…However, in contrast to knee arthroplasty with polyethylene components, which may lead to the formation of polyethylene granuloma or pseudotumor [5][6][7][8], such complication of polyethylene granuloma after a DFR was not seemingly reported to date. The formation of polyethylene granuloma is driven by mechanical wear of polyethylene and periprosthetic accumulation of wear debris, which trigger macrophage-driven foreign body reaction [5][6][7][8]. This results in chronic lymphohistiocytic inflammation, which in turn leads to periprosthetic osteolysis [5,7,8].…”

FDG-Avid Periprosthetic Particle Disease Mimicking Osteosarcoma Recurrence

“…3 Particle disease is a type of surgical complication after arthroplasty, which is caused by the accumulation of attrition particles and the granulomatous reaction incited by macrophage mediation. [4][5][6][7][8][9][10][11] It is more often seen with total hip arthroplasties. [4][5][6][7] Particle disease commonly manifests as a lytic and sometimes expansile osseous abnormality located near the prosthesis, occasionally associated with a soft tissue mass.…”