Metallosis-Induced Iliopsoas Bursal Cyst Causing Venous Obstruction and Lower- Limb Swelling After Metal-On-Metal THA

n Case Report THA

Metallosis-induced Iliopsoas Bursal Cyst Causing Venous Obstruction and Lower- limb Swelling After Metal-on-metal THA

Abdulrahman D. Algarni, MD, SSC(Ortho), ABOS; Olga L. Huk, MD, MSc, FRCS(C); Manuela Pelmus, MD, PhD, FRCP(C) abstract Full article available online at Healio.com/Orthopedics. Search: 20121120-30

The formation of iliopsoas bursal cystic lesions after total hip arthroplasty is an infre- quently reported condition. This article describes an unusual complication of a current- generation metal-on-metal total hip arthroplasty.

A woman presented with unilateral spontaneous lower-limb swelling that developed 5 years postoperatively. It occurred secondary to venous obstruction by a metallosis- Figure: Clinical photograph of metal-stained tissue. induced iliopsoas bursal cyst associated with markedly elevated intralesional cobalt and chromium levels. Metal artifact reduction sequence magnetic resonance imaging showed that the bursal cyst was communicating with the hip joint and that it severely compressed the common femoral vein. Based on the findings of high local tissue metal ions and vertical cup positioning causing edge loading, the authors proposed an inflammatory reaction to metal debris that tracked into the iliopsoas bursa and formed a cyst. The patient underwent revision of the excessively vertical acetabular component and conversion to a ceramic-on-ceramic bearing interface, drainage of the bursal cyst, and synovectomy. No signs existed of local recurrence at 1-year follow-up.

To the authors’ knowledge, the occurrence of metallosis-induced iliopsoas bursitis with secondary pressure effects after contemporary metal-on-metal total hip arthroplasty has not been reported. When treating hip dysplasia, one must avoid maximizing cup−host bone contact at the risk of oververticalization. Iliopsoas bursal cystic lesions can lead to severe vascular compressive symptoms with no ominous radiographic findings. Physicians and orthopedic surgeons should be aware of the possibility of this complication in patients with unexplained unilateral lower-limb swelling.

Dr Algarni is from King Saud University, Riyadh, Saudi Arabia; Drs Algarni and Huk are from the Arthroplasty Division, Department of Orthopedic Surgery; and Dr Pelmus is from the Department of Pathology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada. Drs Algarni, Huk, and Pelmus have no relevant financial relationships to disclose. The authors thank their arthroplasty coordinator, Maricar Alminiana, for her assistance in the prep- aration of this article. Correspondence should be addressed to: Abdulrahman D. Algarni, MD, SSC (Ortho), ABOS, Arthroplasty Division, Department of Orthopedic Surgery, Jewish General Hospital, McGill University, 3755 Cote-St Catherine Rd, Room E-003, Montreal, Quebec, Canada, H3T 1E2 ([email protected]). doi: 10.3928/01477447-20121120-30

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he formation of iliopsoas bursal In June 2011, she presented with pro- cystic lesions after total hip arthro- gressive unilateral limb swelling that wors- Tplasty (THA) is a rare and infre- ened with walking. Clinical examination quently reported condition.1-6 Iliopsoas revealed an edematous limb that measured bursal cystic lesions develop in response to 4 cm greater in diameter than the contra- intra-articular derangement and increased lateral limb at the mid-calf level. Hip ex- intra-articular pressure due to particulate amination revealed a nontender, firm mass wear debris with or without component in the right groin. Neurovascular exami- loosening or osteolysis.1-6 Iliopsoas bursal nation revealed intact motor and sensory cystic lesions may be detected incidental- function with palpable distal pulses. ly or can present as pain or a groin mass. Duplex ultrasonography showed no ve- 1 Rarely, they present as lower-limb swell- nous thrombosis up to the common femoral ing from severe vascular compression.1-5,7 vein. Plain radiographs of the hip showed no Figure 1: Anteroposterior pelvis radiograph showing an excessively vertical cup (59°) and otherwise Vascular compression and limb swell- interval changes from previous radiographs well-fixed components. ing have been described with metal-on- or signs of loosening. The cup inclination polyethylene THA due to iliopsoas bursal and anteversion angles were 59° and 20°, re- lesions.1-5 It has also been reported due spectively, as measured by the Einzel-Bild- Metal artifact reduction sequences to pseudotumors with metal-on-metal Roentgen-Analyse software (EBRA-CUP/ showed an iliopsoas bursal cyst measuring resurfacing.7 One report described this SP2, Innsbruck, Austria) (Figure 1). 9 cm in length34 cm in transverse34 cm lesion in an old-generation cemented Blood workup revealed an erythro- in anteroposterior dimension, with some McKee-Farrar metal-on-metal prosthesis cyte sedimentation rate of 5 mm/h and a debris in the collection. The iliopsoas cys- (Howmedica, London, United Kingdom); C-reactive protein of 2.4 mg/L. Ultrasound tic lesion was communicating with the hip however, it was due to an intrapelvic cyst examination of the groin demonstrated an joint and compressed the common femo- containing cement debris that communi- 8.233.834-cm heterogeneous collection ral vein (Figure 2). cated with the hip joint through an ace- lateral to the right femoral neurovascular Based on the findings of high local tabular medial wall defect and occurred in bundle, which was aspirated and yielded tissue metal ions and vertical cup posi- response to acetabular component loosen- 40 cc of greenish-black material. The as- tioning causing edge loading, the authors ing.8 pirate showed no organisms on staining or proposed an inflammatory reaction to This article describes a case of venous culture, including that for acid-fast bacilli metal debris that tracked into the iliopsoas compression leading to a groin mass and and fungi. Determination of metal ions bursa, forming a cyst that secondarily significant lower-limb swelling follow- concentration of the aspirate revealed high compressed the common femoral vein and ing metal-on-metal THA. To the authors’ levels of chromium and cobalt (cobalt, resulted in limb swelling. knowledge, this is the first report that de- 17ug/g [standard, 0-0.5 ug/g]; chromium, The authors removed the implicated scribes an iliopsoas bursal cystic lesion 83 ug/g [standard, 0-1.9 ug/g]). source of metal debris through revision with a current-generation metal-on-metal articulation without component loosening or osteolysis. The patient gave informed consent for data concerning her case to published.

Case Report In March 2006, a 54-year-old woman underwent an uneventful right metal-on-metal THA for symptomatic arthritis secondary to hip dysplasia. The components were an S-ROM stem with a 28-mm head and a press-fit acetabular component (DePuy, 2A 2B Warsaw, Indiana) and an Ultamet metal lin- Figure 2: Coronal (A) and axial (B) T1-weighted metal artifact reduction sequence magnetic resonance er (Pinnacle 100; DePuy). She made a good images showing the iliopsoas bursal cyst (white arrow) displacing and compressing the common femoral recovery and remained well for 5 years. vein (black arrow).

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3 4A 4B Figure 3: Clinical photograph of metal-stained tissue. Figure 4: Photographs of the histopathological slides showing periprosthetic tissue with diffuse peri- vascular lymphocytic infiltrate and histiocytic reaction (hematoxylin-eosin stain, original magnification 3100) (A). Metal debris containing macrophages with giant cell features (hematoxylin-eosin, original of the malpositioned acetabular compo- magnification3 400) (B). nent and conversion of the metal-on-metal bearing to ceramic-on-ceramic. At revision surgery, the same direct Discussion In addition to contributing to osteoly- lateral approach was used as for the Metal-on-metal bearings of the hip are sis and aseptic loosening, polyethylene index operation. The iliopsoas bursa, associated with elevated concentrations wear debris has induced inflammatory which was in communication with the of metal ions in the hip joint and systemi- reactions that might track to the iliopsoas joint, was drained of copious amounts cally.9 The deposition of metal ions and bursa.1-6 Walsh et al15 reported polyethyl- of milky, gray fluid. The synovium debris in periprosthetic tissue may cause ene debris–induced pseudotumor forma- was highly inflamed and metal stained an adverse reaction to metal debris,9,10 tion following a metal-on-highly-cross- (Figure 3). No evidence existed of cor- which may result in fluid or mass forma- linked polyethylene bearing THA with rosion at the head–neck junction or of tion.7 Adverse reactions to metal debris histopathologic changes analogous to that gross liner wear. After fluid drainage, an includes a spectrum of inflammatory reac- seen with metal-on-metal bearings. aggressive synovectomy and partial bur- tions to metal debris, including metallosis, Limb swelling due to occlusive iliopsoas sal excision were performed. aseptic lymphocytic vasculitis−associated cyst is not exclusive for metal-on-metal The acetabular component was re- lesions, and pseudotumors.11 bearings and has been reported in metal- moved, and a new Biolox Delta Ceramic Adverse reaction to metal debris cas- on-polyethylene articulations.1-5 Some re- component with a ceramic-on-ceramic es appear to develop more frequently in ports described isolated compressive symp- bearing interface (DePuy) was implanted women implanted with metal-on-metal ar- toms1,3-5; however, others described it in at 40° of inclination and 20° of antever- ticulation with a wide spectrum of clinical association with osteolysis or component sion. presentations, ranging from small asymp- loosening.2 The histological examination of Histopathology showed evidence of tomatic lesions to massive local infiltrat- the retrieved cysts demonstrated multinucle- aseptic lymphocytic vasculitis−associ- ing lesions causing severe symptoms. The ar giant cells containing fine polyethylene ated lesions and classic foreign-body exact etiology of these soft tissue reac- particles consistent with a foreign-body re- reaction. Areas were dense with perivas- tions is unknown. However, the consensus action. cular lymphocytic infiltrate, and other is that they are reactions to high levels of Component malposition with metal- areas were characteristic for foreign- particulate or ionic debris that result in on-metal bearings is less forgiving than body reaction of metal debris–contain- cellular cytotoxicity, metal hypersensitiv- that with metal-on-polyethylene bearings. ing macrophages and giant cell infiltrate ity, or both.12,13 Vertical cup position of more than 50° (Figure 4). Amstutz et al14 reported that the cellu- leads to edge loading and excessive ion Postoperatively, the patient had com- lar effects of metal particles vs metal ions production.16 Higher wear rates were also plete resolution of limb swelling within differ. Particles cause a foreign-body re- associated with cup inclination greater than 6 months. Duplex ultrasounds were response with activation of macrophages. In 50° when using metal-on-polyethylene17 peated twice and showed no evidence of the absence of gross metallosis, metal ions or ceramic-on-ceramic bearings.18 venous thrombosis. stimulate lymphocytes, resulting in the ac- The iliopsoas bursa is the largest bur- At 1-year follow-up, the patient was tivation of the immune system in what is sa in the body that overlies the hip joint doing well, and no signs existed of local thought to result in a type IV hypersensi- capsule posterior to the iliopsoas tendon recurrence. tivity reaction. and lateral to the femoral vessels.6,19

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Although the iliopsoas bursa commu- lesion. In the current patient, the cyst was 8. Madan S, Jowett RL, Goodwin MI. Recur- rent intrapelvic cyst complicating metal-on- nicates anatomically with the hip joint debrided through the same approach, and metal cemented total hip arthroplasty. Arch in 15% of cases,20 it is unclear whether the limb swelling resolved in the absence Orthop Trauma Surg. 2000; 120(9):508-510. surgical trauma or inflammation due to of continued stimulation from metal debris. 9. Korovessis P, Petsinis G, Repanti M, Repan- wear debris could lead to communica- tis T. Metallosis after contemporary metal- on-metal total hip arthroplasty. Five to nine- tion. However, increased intra-articular Conclusion year follow-up. J Bone Joint Surg Am. 2006; pressure takes the path of least resistance When treating hip dysplasia, one must 88(6):1183-1191. into the iliopsoas bursa with secondary aim for an average cup inclination of 40° 10. Willert HG, Buchhorn GH, Fayyazi A, et al. accumulation of the synovial fluid.8 A and avoid maximizing cup–host bone con- Metal-on-metal bearings and hypersensitivity in patients with artificial hip joints. A clinical 1-way communication from the hip joint tact at the risk of oververticalization. and histomorphological study. J Bone Joint to the bursal cyst has been suggested, Iliopsoas bursal cystic lesions can lead to Surg Am. 2005; 87(1):28-36. with possible herniation of the effective severe vascular compressive symptoms in 11. Haddad FS, Thakrar RR, Hart AJ, et al. Metal- on-metal bearings: the evidence so far. J joint space under the inguinal ligament the absence of ominous radiographic find- Bone Joint Surg Br. 2011; 93(5):572-579. 1,6 into the pelvis. ings. Physicians and orthopedic surgeons 12. Campbell P, Ebramzadeh E, Nelson S, Taka- In the current patient, magnetic reso- should be aware of the possibility of this mura K, De Smet K, Amstutz HC. Histologi- nance imaging showed that the bursa complication in patients with unexplained cal features of pseudotumor-like tissues from metal-on-metal hips. Clin Orthop Relat Res. communicated with the hip joint. The au- unilateral lower-limb swelling. 2010; 468(9):2321-2327. thors propose that edge-loading from the 13. Langton DJ, Joyce TJ, Jameson SS, et al. Ad- vertical cup position that generated exces- References verse reaction to metal debris following hip resurfacing: the influence of component type, sive metal debris, combined with a direct 1. Yang SS, Bronson MJ. Cystic enlargement of orientation and volumetric wear. J Bone Joint the iliopsoas bursa causing venous obstruc- route of access from the joint to the psoas Surg Br. 2011; 93(2):164-171. tion as a complication of total hip arthro- bursa, contributed to the pathogenesis of plasty. A case report. J Arthroplasty. 1993; 14. Amstutz HC, Campbell P, McKellop H, et al. this lesion. 8(6):657-661. 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