Malignomrn podoben vnetni (jseudotumor: redek zaplet popolne artroi)lastilce Icolka
Inflammatory pseuootu mor ^imulatii^ c| malignancsy: a rare complication after total hip ^rthro i)lasty
Avtor / Author
Ustanova / Institute
Al(£ìnke ^?epšl£ì~Foktuìr1, SMamo Karl Fokterd
1Splošnabolnišnica Celje, Oddelekza patologijo incitologijo,Celje, Slovenija 2Splošna bolnišnica Celje, Oddelek za ortopedijo in športne poškodbe, Celje, Slovenia
Ključne besede:
totalna artroplastika kolka, nekrotični drobir, medenični tumor, reakcija tujkovega tipa. Key words:
total hip arthroplasty, intrapelvic mass, wear debris, foreign body reaction.
Članek prispel / Received
04.07.2009
Članek sprejet / Accepted
28.10.2009
Naslov za dopisovanje / Correspondence
Doc. dr. Samo K. Fokter, dr. med., spec. ortoped
Splošna bolnišnica Celje, Oddelek za ortopedijo in športne poškodbe, Oblakova 5, 3000 Celje, Slovenija Telefon: +3863 423 3300 Fax: +3863 491 5621 E-pošta: samo.fokter@guest.arnes.si
Izvleček
Namen: Tujkov drobir, ki nastaja po vstavitvi popolne kolčne endoproteze, povzroča neželene lokalne odgovore gostitelja. Prispevek poroča o izraziti obliki takšnega odgovora bolnika, pri katerem je po popolni artroplastiki levega kolka prišlo do naraščajoče ste-genske bolečine, izgube mišične moči in odrevenelosti.
Metode: Računalniška tomografija spodnjega dela trebuha in medenice bolnika je pokazala veliko cistično tvorbo. Ocenili smo jo kot maligni tumor. Z aspiracijsko biopsijo ciste smo dobili sivo-zeleno tekočino, s citološko preiskavo je bil ugotovljen nekrotični drobir brez malignih celic. Z biopsijo smo potrdili nekroze in obilno granu-lacijsko tkivo tujkovega tipa z drobirjem, ki je pod polarizacijskim mikroskopom značilno lomil svetlobo. Rezultati: Med kirurško odstranitvijo cistične tvorbe smo opazili defekt kostnine notranje stene kolčnice. Po uspešni revizijski artroplastiki in
Abstract
Purpose: Particulate debris created by accelerated polyethylene wear in totally replaced hips causes adverse local reactions. We report an extreme form of such a reaction in a patient who developed progressive thigh pain, weakness and numbness after total arthroplasty of his left hip. Methods: An abdominopelvic computed tomogram showed a large in-trapelvic cystic mass interpreted as a malignant tumor. Dark grayish-green fluid was aspirated from the cyst and cytopathologic examination showed necrotic debris without malignant cells. Biopsy revealed necrosis and abundant foreign body granulation tissue with polarizable debris. Results: During surgical removal of the cyst a defect of the inner acetabular wall was noted. After successful revision arthroplasty with allograft bone the clinical symptoms improved. Conclusion: A foreign-body reaction to wear debris may produce an
uporabi homolognih kostnih presadkov so bolnikove težave izzvenele.
Zaključki: Vnetna reakcija tujkovega tipa na obrabne delce endoproteze lahko povzro~i rast medeni~nega tumorja in posledi~ne simptome. Citolo{ka in histolo{ka preiskava tumorja ali njegove teko~e vsebine lahko pomaga razložiti klinično sliko in izvide slikovnih diagnosti~nih preiskav.
intrapelvic mass and corresponding symptoms. Cytologic and histologic examination of the mass or fluid may aid in interpreting the clinical picture and imaging studies.
INTRODUCTION
Inflammatory processes have to be kept in mind when considering the differential diagnosis of a pelvic mass. Following total hip arthroplasty (THA), accelerated polyethylene wear is often associated with periprosthetic osteolysis, which may be asymptomatic, present with groin pain, or even produce compression symptoms including urinary obstruction, venous thrombosis, and neuropathy [1, 2]. We present a case in which a large mass containing wear debris originating from a failed THA mimicked malignancy and produced intrapelvic compression of the femoral nerve.
Case report
tures of the fluid were negative. These findings were believed to be consistent with malignancy. However, cytopathologic examination showed necrotic debris without malignant cells (Figigure 2).
During surgical removal of the cystic mass, a defect was noted on the medial acetabular wall. Histologi-cally, the cyst wall consisted of hyalinized fibrous and foreign-body granulation tissue without epithelial elements, and the mass was believed to represent a foreign body reaction to polyethylene wear debris originating from a failed THA (Figure 3). The hip was treated surgically 4 weeks later. On incising the pseudocapsule, large, thick, black masses were found around the neck of prosthesis (Figure 4). The polyethylene liner was fractured and the articular surface of the titanium alloy socket was burnished. The
A 58-year-old male had undergone a left uncemented THA in 1994 because of osteoarthritis. Nine years later he experienced pain in the left groin and thigh. Over the next 4 years he noted loss of strength in his left thigh. On physical examination, diminished quadriceps motor function, hypoesthesia in the anterome-dial aspect of the thigh, and an absent patellar reflex on the left side were noted. Plain films of the left hip showed the eccentric location of the femoral head. An electromyogram (EMG) demonstrated a lesion of the left lumbosacral plexus with denervation predominantly of muscles innervated by the femoral nerve. An abdominopelvic computed tomogram (CT) scan showed a large intrapelvic cyst (Figure 1). Percutaneous aspiration of the fluid was performed and a total of 80 mL of thick, grayish-green fluid was removed. Cul-
Figure 1. Abdominopelvic CT showing a large cyst
Figure 2. Cytopathologic examination of the cyst aspirate showing necrotic debris without malignant cells
Figure 4. Thick black masses found during revision surgery around the neck of the prosthesis
acetabular shell, the modular neck and the head of the prosthesis were replaced. Histological analysis of the resected tissue revealed foreign-body giant cells within hyperplastic synovium. Abundant foreign-body granulation tissue containing coarse granular black pigment, an unusually large number of his-tiocytes and polarizable polyethylene particles were noted (Figure 5).
The pain from the femoral nerve irritation improved postoperatively. Ten months later, follow-up EMG demonstrated neurophysiologic improvement without any significant denervation. On X-ray the pros-
thesis remained securely stable at the 12-month follow-up examination.
DISCUSSION
Particulate debris from total joint implants extending well beyond bone can simulate malignancies owing to mass effects and pressure on adjacent tissues [3]. However, malignant tumors can arise a long time after bone surgery [4]. Therefore, each case of such a mass needs surgical removal and thorough histopathological examination.
Figure 3. Hyalinized fibrous tissue of the cyst wall (HE, x100)
Figure 5. Foreign-body granulation tissue containing coarse granular black pigment (HE, x100)
Characteristic osseous and soft tissue reactions caused by release of polyethylene particles into periarticular tissue as well as the differential diagnosis, including infectious and malignant conditions, are discussed in a paper by Olesen Schaarup and Var-marken [5]. Parwani et al. described the cytopatho-logic findings of particle disease in an unusual case in which an ultrasound-guided aspiration produced hypercellular smears consisting predominantly of proliferating mesenchymal cells, foamy macrophag-es, inflammatory cells and background acellular debris [6]. Numerous multinucleated giant cells were also observed. Their differential diagnosis included primary or metastatic clear-cell tumors.
A delayed onset of nerve palsy after THA is rare. In a meta-analysis of the English literature on in-trapelvic complications after THA failure, Bach et al. identified 50 cases of injury, including three cases of sciatic nerve injury and two cases involving in-trapelvic mass formation [7]. In a thorough recent
report, Hananouchi et al. described a huge pelvic mass causing severe ureteral obstruction and found 18 additional cases of pelvic masses caused by particle debris after THA [8]. With regard to wear debris masses and femoral nerve palsy after THA, we are aware of only two previous reports [9, 10].
CONCLUSION
In this case a large mass containing particulate wear debris originating from a failed THA mimicked malignancy and produced intrapelvic compression of the femoral nerve. We suggest looking carefully for mass effect symptoms and signs in addition to osteolysis during follow-up examinations of THA patients. Cytologic examination of the mass or fluid may aid in interpreting the clinical picture and imaging studies. Moreover, thorough histopathological examination of such lesions is highly important to exclude malignant tumor.
REFERENCES
1.
2.
3.
4.
Clayton RA, Beggs I, Salter DM, Grant MH, Patton JT, Porter DE. Inflammatory pseudotumor associated with femoral nerve palsy following metal-on-metal resurfacing of the hip. A case report. J Bone Joint Surg Am 2008; 90: 1988-93. Maloney WJ, Smith RL. Periprosthetic osteolysis in total hip arthroplasty: the role of particulate wear debris. Instr Course Lect 1996; 45:171-82. Brand RA, Marsh JL. Particulate debris osteolysis simulating malignant tumor. Iowa Orthop J 2004; 24; 111-4.
Machinami R, Nishida K, Ishida T, Matsumoto S, Kuroda K, Kobayashi M, Takeuchi K, Ishikawa Y. Carcinosarcomatous malignancy, osteosarcoma and squamous cell carcinoma, in giant cell tumor of the right distal femur. Pathol Res Pract 2008; 204: 583-8.
Olesen Schaarup S, Varmarken JE. Intrapelvic mass in a young woman with an uncemented hip arthro-
6.
7.
8.
plasty. Acta Orthop Belg 2002; 68: 546-50. Parwani AV, Yang B, Clark DP, Ali SZ. Particle disease: cytopathologic findings of an unusual case. Diagn Cytopathol 2004; 31: 259-62. Bach CM, Steingruber E, Ogon M, Maurer H, Nogler M, Wimmer C. Intrapelvic complications after total hip arthroplasty failure. Am J Surg 2002; 183: 75-9.
Hananouchi T, Saito M, Nakamura N, Yamamoto T, Yonenobu K. Huge pelvic mass secondary to wear debris causing ureteral obstruction. J Arthroplasty 2005; 20: 946-9.
Leinung S, Schönfelder M, Würl P. Inflammatory phantom tumour in the left ileopsoas muscle with a paresis of the femoral nerve caused by excessive abrasion of a metal hip endoprosthesis. Chirurg 2002; 73: 725-8.
10. Schuh A, Werber S, Zeiler G, Craiovan B. Femoral nerve palsy due to excessive granuloma in aseptic cup loosening in cementless total hip arthroplasty. Zentralbl Chir 2004; 129: 421-3.
9.