Two-Stage Treatment of a Large Pelvic Cystic Pseudotumor in a Metal-On-Metal Total Hip Arthroplasty

Abstract

The authors report a case of a huge cystic pseudotumor, surrounding a failed metal-on-metal total hip arthroplasty (THA). The cyst surrounded the hip anteriorly, occupied part of the anterior portion of the thigh, and extended to the anterolateral aspect of the abdomen. The case was treated by a two-stage procedure. The first stage consisted of a percutaneous drainage of the fluid content of the cyst (∼1,200 mL). This procedure reduced the risk of tearing the cyst capsule spreading the liquid in the tissues surrounding the THA, and in the abdomen. Thanks to this simple procedure, the second stage treatment consisted of a relatively usual THA revision. The patient recovered completely from the treatment and returned to pain-free full activities of daily living.

Metallosis following hip arthroplasty: two case reports

“…Unfortunately, significant extension, including into the pelvis, can occasionally occur with large lesions, and there remain no well-defined criteria to guide the required extent of excision [ 5 , 12 – 14 ]. Although patients with pseudotumors may be asymptomatic, there have been reports of these intrapelvic lesions resulting in abdominal pain resulting in admission under a general surgery service, gynecologic issues including uterovaginal prolapses with initial presentation to a gynecology service, urinary retention with hydronephrosis, compression of the external iliac vasculature or femoral vasculature from a mass extending anteriorly along the iliopsoas tendon, and femoral nerve palsy [ 5 , 6 , 11 – 15 ]. Patients with a femoral vein compression syndrome may present with only unilateral leg swelling with preserved distal pulses [ 6 , 14 , 15 ].…”

“…However, these components ultimately were found to have significantly higher revision rates up to three times those of contemporary hip implants with a resultant significant decline in their use [ 2 – 4 ]. A majority of these failures are attributed to the production of metal debris resulting in adverse local tissue reactions (ALTRs), a term used to describe a broad spectrum of pathological changes including extensive tissue necrosis, osteolysis, and large sterile hip effusions, as well as periprosthetic solid and cystic masses known as pseudotumors [ 1 – 3 , 5 , 6 ]. Although originally felt to be the result of the MoM articulation itself, there has been increasingly implication of these nonmalignant and noninfectious masses and ALTRs in other THA articulations, including metal-on-polyethylene (MoP) and ceramic-on-polyethylene (CoP) bearings, likely the result of metal ion release from the modular junctions [ 1 , 2 , 5 , 7 – 10 ].…”

“…A majority of these failures are attributed to the production of metal debris resulting in adverse local tissue reactions (ALTRs), a term used to describe a broad spectrum of pathological changes including extensive tissue necrosis, osteolysis, and large sterile hip effusions, as well as periprosthetic solid and cystic masses known as pseudotumors [ 1 – 3 , 5 , 6 ]. Although originally felt to be the result of the MoM articulation itself, there has been increasingly implication of these nonmalignant and noninfectious masses and ALTRs in other THA articulations, including metal-on-polyethylene (MoP) and ceramic-on-polyethylene (CoP) bearings, likely the result of metal ion release from the modular junctions [ 1 , 2 , 5 , 7 – 10 ]. Although patients may be asymptomatic, pseudotumors may result in pain, swelling, extensive destruction to surrounding hip soft tissues, and compression syndromes on neurovascular, gastrointestinal, and genitourinary structures [ 1 , 2 , 5 , 6 , 11 – 15 ].…”

“…Although originally felt to be the result of the MoM articulation itself, there has been increasingly implication of these nonmalignant and noninfectious masses and ALTRs in other THA articulations, including metal-on-polyethylene (MoP) and ceramic-on-polyethylene (CoP) bearings, likely the result of metal ion release from the modular junctions [ 1 , 2 , 5 , 7 – 10 ]. Although patients may be asymptomatic, pseudotumors may result in pain, swelling, extensive destruction to surrounding hip soft tissues, and compression syndromes on neurovascular, gastrointestinal, and genitourinary structures [ 1 , 2 , 5 , 6 , 11 – 15 ]. As reports of extensile pseudotumors requiring multidisciplinary excision are limited, we present two cases of pseudotumor following hip arthroplasties that involved vascular and intrapelvic structures that were excised through a combination approach.…”

Selective arterial embolization as neoadjuvant treatment in hip pseudotumors

“…Main therapeutic approaches include one or two-stage revision procedures in association to excision of PT. [9,18,19] In addition, new methods have been proposed to facilitate PT surgeries and prevent recurrence. For example, a titanium sleeve was used in association to the cup to prevent PT formation, while short-term results were not successful.…”