Massive pelvic and femoral pseudotumoral osteolysis secondary to an uncemented total hip arthroplasty

Abstract

A 51 year-old man developed an extensive osteolytic response to wear debris in an uncemented porous-coated total hip arthroplasty, with metal/polyethylene interface, which had been implanted eighteen years previously. This reaction, which involved the upper femur and the ilium, produced a mass which compressed the pelvic viscera. IntroductionOsteolysis is a frequent complication which affects the outcome of total hip arthroplasty. Since Charnley's first description concerning a cemented prosthesis in 1968 [5], osteolysis has been described as occurring around loose and well-fixed femoral and acetabular implants of cemented and cementless prostheses. This complication results from an inflammatory foreign body reaction to the different prosthetic components and wear debris from the articulating surfaces and the interfaces has been implicated as a causative factor [1]. Polymethylmethacrylate cement, polyethylene, metal and more recently ceramic [27] debris may be the cause of osteolytic response, although polyethylene debris is considered to be the most damaging. Phagocytosis of debris by macrophages releases the mediators of osteolysis. Lack of bone ingrowth in uncemented implants or defective fixation at the bone-cement interface in cemented prostheses play a role in producing particles and activating the reaction [1,10,27]. Once radiologically identified, the majority of the osteolytic lesions remain stable over many years or else evolve slowly [15,18,25,26,28]. A minority progress, mimicking a tumour [3, 10, 12-14, 17, 19-21, 27]. These massive osteolyses constitute a real clinical problem, because of the eventual failure of the implant and technical difficulties at revision due to bone loss. We report an unusual case of an aggressive pelvic and femoral osteolysis secondary to an uncemented hip prosthesis which had been implanted eighteen years previously. Case reportIn March 1995, a black male aged 51 years was admitted into our Department of Orthopaedic Surgery with pain and swelling affecting the proximal third of the left thigh. He had the sequelae of neonatal cerebral palsy (Little's syndrome) and had started to walk with an aid at the age of seven years. In December 1977, at the age of 34 years, he was treated in another hospital for a femoral neck non-union which occurred two years after a femoral neck fracture. Replacement arthroplasty was undertaken using an uncemented

Rapidly Progressive Osteolysis and a Large Cystic Lesion that Destroyed the Inner Table of the Iliac Bone Following Cementless Total Hip Arthroplasty: A Case Report

“…Osteolysis surrounding prosthesis has been defined as a complication that is caused by wear debris, and affects the clinical outcome of THA [1]. There are many reports of osteolysis and accompanying enlargement of the cyst [2][3][4][5][6][7], but few reports present pathological findings [2,3]. The pathological findings of our case indicated that there were polyethylene particle-like substances in abundant macrophages, and hemosiderin was present in the interstitium of the tissue.…”

“…Thus, the findings of this case (presence of polyethylene particles and hemosiderin) do not contradict the causative factors in the rapidly progressive periprosthetic osteolysis and cystic lesion. It is important that we make an early diagnosis of progressive osteolysis after THA, because there may be severe complications in cases where hematoma and hemosiderin deposits coexist in osteolysis, such as cystic tumor increase, urinary obstruction disorder, femoral nerve paralysis, sciatic nerve paralysis and abdominal organ pressure [2,3,5,7]. It is often difficult to predict the progression of osteolysis because most cases are asymptomatic [10].…”

“…In general, polyethylene wear debris causes the formation of a soft tissue mass as a result of an inflammatory reaction. Some cases with cystic or tumorous lesions have also been reported [2][3][4][5][6], and it has been suggested that cystic lesions after THA may be an early sign of wear debris [7]. We report an unusual case of a rapidly progressive osteolysis and a cystic lesion that destroyed the inner table of the iliac bone and occurred secondary to a cementless total hip arthroplasty (THA) 12 years after surgery.…”

Compression of the Sciatic Nerve by Wear Debris Following Total Hip Replacement: A Report of Three Cases

“…Problems due to accumulation of wear debris are rare, although several cases have been reported. 6,7 Fischer, Christ and Roehr 8 described a patient with sciatic neuropathy following compression by an intrapelvic mass of wear debris.…”

Bone disease

“…(Jeanrot et al 1999), as shown in Fig. Norian); surgeons are therefore reluctant to use cements in pathological fractures in bone that may heal after the fracture has been stabilised.…”