Pelvic Pseudotumor: An Unusual Presentation of an Extra-Articular Granuloma in a Well-Fixed Total Hip Arthroplasty

doi:10.1016/j.arth.2007.08.003

The Journal of Arthroplasty

Volume 23, Issue 6, September 2008, Pages 934-938

https://doi.org/10.1016/j.arth.2007.08.003 Get rights and content

Abstract

A 76-year-old woman developed a pelvic mass and abdominal pain 12 years after cementless total hip arthroplasty. The mass was a cystic granuloma that communicated with the hip joint via a soft tissue herniation under the inguinal ligament. There was no acetabular lysis or defects. The shell and femoral component were well fixed, the polyethylene was worn, and a liner exchange was undertaken. The cyst was debrided, and follow-up computed tomography demonstrated resolution of the granuloma and no recurrence of the cyst. Removal of the source of the particle wear debris via liner exchange or revision surgery combined with cyst debridement via a single incision is recommended.

Section snippets

Case Report

A 76-year-old woman underwent an uncemented right total hip arthroplasty in 1992. She had symptomatic osteoarthritis of her hip and had failed conservative management. A porous-coated anatomical (Howmedica, Rutherford, NJ) system was used, with a size 4 E series femur, with a 32-mm head and a 52 shell with a polyethylene liner. She made an uneventful recovery and remained well for 11 years.

She noticed a gradual onset of right groin discomfort over the following year but did not seek medical

Discussion

Wear-induced osteolysis is a well-recognized complication of total joint arthroplasty. The presence of a symptomatic soft tissue mass in response to PWD is less common. Wear debris are phagocytosed by macrophages and inflammatory cells. In certain situations, an aggressive granulomatous reaction may occur, with features of a foreign body–type reaction, which is characterized clinically by progressive cyst formation and osteolysis 1, 2, 3. Santavirta et al [4] suggested that this granulomatosis

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Cited by (48)

A 58-year-old woman with clinical deterioration, severe anemia and a periprosthetic mass 14 years after hip arthroplasty
2021, Medicina Clinica Practica
Growth of an intrapelvic pseudotumor associated with a metal-on-metal total hip arthroplasty after revision arthroplasty causing a femoral nerve neuropathy
2016, Arthroplasty Today
Citation Excerpt :
Some authors advocate for complete cyst excision to directly decompress the nerve, which may necessitate either a staged procedure or an extensile surgical approach. Others support debriding as much of the pseudotumor as possible through the same surgical approach as the revision arthroplasty and indirectly decompressing the cyst [12,13]. In our case, the patient presented with a subacute femoral neuropathy with mild motor and sensory symptoms, and thus, we opted to perform a single-staged revision arthroplasty with debridement of the pseudotumor through the same posterior surgical approach.
The development of pseudotumors is not uncommon with metal-on-metal total hip arthroplasty. Pseudotumors that dissect into the retroperitoneal space can cause symptoms of nerve compression. We describe a case of a 53-year-old male with a metal-on-metal total hip arthroplasty who developed mild symptoms of a femoral nerve neuropathy 6 years postoperatively. Revision arthroplasty to a ceramic-on-polyethylene articulation and debridement of the pseudotumor was performed. Postoperatively, the patient's femoral neuropathy progressed and a repeat magnetic resonance imaging showed an increase in size of the pseudotumor despite the removal of the offending metal-on-metal articulation. The patient subsequently underwent a laparoscopic excision of the retroperitoneal pseudotumor. By 17 months post laparoscopic excision of the pseudotumor, the patient's motor deficits resolved, however, sensory deficits persisted in the anteromedial thigh.
Total hip arthroplasty-related pelvic pseudotumor: Unusual presentation with hydronephrosis
2016, Acta Orthopaedica et Traumatologica Turcica
Citation Excerpt :
Clinical presentation of pseudotumors is dependent on their size and localization. While they may appear as incidental lesions without pain or failure of arthroplasty, various clinical symptoms and signs have been described in the literature, including gynecologic symptoms,10 femoral vein compression syndrome11,12 and femoral nerve palsy,13 as well as complaints involving the urinary system.8,14,15 Urinary retention caused by pseudotumors were also reported previously.8,15
Clinical Surveillance of UHMWPE Using Radiographic Methods
2016, UHMWPE Biomaterials Handbook: Ultra High Molecular Weight Polyethylene in Total Joint Replacement and Medical Devices: Third Edition
As recounted in Chapter 4, ultra-high molecular weight polyethylene (UHMWPE) has been the primary bearing material used in total hip arthroplasty since its introduction by Charnley in 1962. UHMWPE is used to create the acetabular component of the reconstruction, and in most cases is coupled with a femoral head made of a cobalt chromium alloy, though other materials such as ceramic femoral heads have also been used. The original UHMWPE acetabular components were cemented into the acetabular bed of the pelvis. This design is still in use today along with a modular design consisting of a metal shell, which can be fixed to the skeleton with either bone cement or by biological fixation.
Clinical Surveillance of UHMWPE Using Radiographic Methods
2015, UHMWPE Biomaterials Handbook: Ultra High Molecular Weight Polyethylene in Total Joint Replacement and Medical Devices
As recounted in Chapter 4, ultra-high molecular weight polyethylene (UHMWPE) has been the primary bearing material used in total hip arthroplasty since its introduction by Charnley in 1962. UHMWPE is used to create the acetabular component of the reconstruction, and in most cases is coupled with a femoral head made of a cobalt chromium alloy, though other materials such as ceramic femoral heads have also been used. The original UHMWPE acetabular components were cemented into the acetabular bed of the pelvis. This design is still in use today along with a modular design consisting of a metal shell, which can be fixed to the skeleton with either bone cement or by biological fixation.
Formation of a pseudotumor in total hip arthroplasty using a tribological metal-polyethylene pair
2015, Revista Brasileira de Ortopedia
Relatar o caso de um paciente adulto jovem que evoluiu com tumoração na coxa esquerda após 14 anos de uma cirurgia de revisão de artroplastia do quadril. Davies em 2005 descreveu esta afecção em pacientes submetidos a atroplastia de quadril com par tribológico metal‐metal, mas na última década é possível achar relatos de pseudotumores em superfície metal‐polietileno. O paciente iniciou queixa de aumento de volume da coxa esquerda após oito anos da cirurgia de revisão da artroplastia do quadril. Dois anos antes do aparecimento da tumoração da coxa, a investigação para descartar um processo neoplásico maligno de um nódulo em região inguinal foi inconclusiva. Suas principais queixas pré‐operatórias eram dor, limitação funcional e marcada redução da amplitude de movimento do quadril esquerdo. As radiografias do membro acometido evidenciavam soltura dos componentes acetabular e femoral, e uma grande massa entre os planos musculares se revelou à ressonância magnética da coxa esquerda. A abordagem cirúrgica consistiu de ressecção intralesional da coxa esquerda, seguida da retirada dos componentes pela via lateral direta. No âmbito da cirurgia de artroplastia de quadril, os pseudotumores são neoplasias benignas cujo par tribológico consiste em metal ‐metal, mas podem também ocorrer em diferentes pares tribológicos, como neste caso.
The aim here was to report a case of a young adult patient who evolved with tumor formation in the left thigh, 14 years after revision surgery on hip arthroplasty. Davies in 2005 made the first description of this disease in patients undergoing metal‐on‐metal hip arthroplasty. Over the last decade, however, pseudotumors around metal‐on‐polyethylene surfaces have become more prevalent. Our patient presented with increased volume of the left thigh eight years after hip arthroplasty revision surgery. Two years before the arising of the tumor in the thigh, a nodule in the inguinal region was investigated to rule out a malignant neoplastic process, but the results were inconclusive. The main preoperative complaints were pain, functional limitation and marked reduction in the range of motion of the left hip. Plain radiographs showed loosening of acetabular and femoral, and a large mass between the muscle planes was revealed through magnetic resonance imaging of the left thigh. The surgical procedure consisted of resection of the lesion and removal of the components through lateral approach. In respect of total hip arthroplasty, pseudotumors are benign neoplasms in which the bearing surface consists of metal‐on‐metal, but they can also occur in different tribological pairs, as presented in this case.

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Case ReportPelvic Pseudotumor: An Unusual Presentation of an Extra-Articular Granuloma in a Well-Fixed Total Hip Arthroplasty

Abstract

Section snippets

Case Report

Discussion

J Arthroplasty

Orthop Clin North Am

J Arthroplasty

J Arthroplasty

Patterns of osteolysis around total hip components inserted with and without cement

J Bone Joint Surg

Osteolysis of the pelvis: evaluation and treatment

Clin Orthop Relat Res

Wear debris in total joint replacements

J Am Acad Orthop Surg

Aggressive granulomatous lesions associated with hip arthroplasty. Immunopathological studies

J Bone Joint Surg Am

Current concepts review—wear in total hip and knee replacements

J Bone Joint Surg Am

Back pain, femoral vein thrombosis, and an iliopsoas cyst: unusual presentation of a loose total hip arthroplasty

Orthopaedics

Case Report
Pelvic Pseudotumor: An Unusual Presentation of an Extra-Articular Granuloma in a Well-Fixed Total Hip Arthroplasty