Pseudotumor Caused by Titanium Particles From a Total Hip Prosthesis

Abstract

A 77-year-old woman underwent metal-on-polyethylene total hip arthroplasty for osteoarthritis of the right hip at another institution. During surgery, the greater trochanter was broken and internal fixation was performed with a trochanteric cable grip reattachment. Although postoperative recovery was uneventful, approximately 6 years later, the patient had severe right hip pain with apparent swelling, and she was referred to the authors' institution. Plain radiographs showed evidence of severe osteolysis in the proximal femur and cable breakage; however, preoperative aspiration culture findings were negative for bacterial growth. Magnetic resonance imaging showed a well-circumscribed mass, presumed to be a pseudotumor. Serum cobalt and chromium levels were within normal limits, and the serum titanium level was high. During surgery, the mass was excised and removal of the cable system revealed a sharp deficit in the bare femoral stem. Gross surgical findings showed no obvious evidence of infection and no corrosion at the head-neck junction; therefore, all components were retained besides the cable system, which resulted in clinical recovery. All of the cultures from specimens were negative for bacterial growth, and histologic findings were compatible with a pseudotumor, such as histiocytes containing metal particles, abundant plasma cells, and CD8-positive cells. Quantitative analysis by inductively coupled plasma atomic emission spectrometry showed that the main source of metal debris in the pseudotumor was the femoral stem, which was made of titanium alloy, not the broken cable, which was made of cobalt-chromium alloy. The findings suggest that titanium particles can form symptomatic solid pseudotumors.

A Case of Titanium Pseudotumor and Systemic Toxicity After Total Hip Arthroplasty Polyethylene Failure

“…They concluded that a chronic host inflammatory response and a delayed foreign-body hypersensitivity response were both integral to titanium pseudotumor formation. Despite being unable to perform atomic spectrometry for our samples, intraoperative pathology obtained from our patient's pseudotumor was consistent with that of Sakamoto et al, who reported the presence of many inflammatory cells (CD3-, CD4-, and CD8-positive lymphocytes; plasma cells; and histiocytes) and metal debris [23].…”

Blood titanium level as a biomarker of orthopaedic implant wear

“…Soluble and particulate titanium disturbs the delicate balance between the two cell types, resulting in bone loss and implant loosening, which often necessitates a redo surgery (revision surgery) [35,41,56,[59][60][61]. Formation of large inflammatory masses (pseudotumours) in the vicinity of the implant, originally thought to be an immune response unique to CoCr alloy, was recently linked to titanium release [62][63][64]. The pathogenesis of pseudotumor formation is unknown, but it is thought to involve both a chronic inflammatory response and a delayed hypersensitivity response to ultrafine titanium particles [62].…”

“…Formation of large inflammatory masses (pseudotumours) in the vicinity of the implant, originally thought to be an immune response unique to CoCr alloy, was recently linked to titanium release [62][63][64]. The pathogenesis of pseudotumor formation is unknown, but it is thought to involve both a chronic inflammatory response and a delayed hypersensitivity response to ultrafine titanium particles [62]. It follows that individuals with a pre-existing titanium sensitivity might be at a greater risk of this particular complication [64].…”

Titanium for Orthopedic Applications: An Overview of Surface Modification to Improve Biocompatibility and Prevent Bacterial Biofilm Formation

“…This oxide layer, while offering corrosion resistance, is quite thin and offers little protection in potential for the release of titanium wear particles into the adjacent tissue ( Li et al., 2010 ). Wear particles pose a serious problem for orthopedic implant success, and several rejected arthroplasties recovered have found wear particles in the surrounding tissue ( Grosse et al., 2015 ; de Pasquale et al., 2018 ; Hall et al., 2019 ; Sakamoto et al., 2016 ). Furthermore, titanium debris has been found to distribute throughout the body, with traces found in the liver, spleen, and lymphatic system ( Urban et al., 2000 ).…”