Centre Hospitalier Universitaire d’Ambroise Paré, Department of Orthopaedics and Traumatology, Mons, Hainaut, Belgium.
*Corresponding Author: Jérôme Valcarenghi
Department of Orthopaedics and Traumatology, CHU Ambroise Paré, Boulevard John Fitzgerald Kennedy 2, 7000 Mons, Belgium.
Email: [email protected]
Received : Oct 07, 2021
Accepted : Nov 23, 2021
Published : Nov 30, 2021
Archived : www.jcimcr.org
Copyright : © Valcarenghi J (2021).
We report a rare case of symptomatic adverse local tissue reaction in a patient with a ceramic-on-ceramic total hip bearing surface. Probably, ceramic wear debris are not entirely inert and may lead to adverse local tissue reactions.
Keywords: ceramic-on-ceramic; pseudotumor; revision total hip arthroplasty; osteolysis; ALTR.
Outside of cobalt-chromium alloy articulations, the development of adverse local tissue reaction (ALTR) after total hip arthroplasty (THA) is uncommon but remains a significant complication . ALTR is used to describe a granulomatous or destructive cystic lesion that develops around a THA [1,2]. The patient often describes the first sign of the development of ALTR and pseudotumor formation as discomfort and pain. ALTR causes soft tissue mass, osteolysis, bone erosion, and significant damage to periarticular soft tissues, leading to total joint failure and instability . In THA, ALTR may develop around metal-onpolyethylene implants due to taper corrosion and around metal-on-metal (MoM) bearing surfaces [3-6].
To our knowledge, just one case reported of a pseudotumor related to a ceramic-on-ceramic (CoC) THA . In this view, we present this uncommon case of a pseudotumor in a CoC THA.
In 2009, a 61-year-old man underwent a right THA for symptomatic hip osteoarthritis. Given the patient’s relatively young age for the procedure, the surgeon selected a cementless arthroplasty with CoC articulation. The patient received a 54 mm acetabular component (Horizon II® - Amplitude) with a modular 36 mm alumina ceramic liner and a 0 mm alumina ceramic head. The femoral component placed was a 4-size stem with a hydroxyapatite proximal coating (Integrale® - Amplitude). The patient’s postoperative course was unremarkable and reportedly without infectious complications. Postoperative radiographs showed both components were in recommended position.
In March 2020, then 72 years old, the patient evaluated a painful total hip. Physical examination revealed a full range of motions. When compared with immediate postoperative radiographs showed a suspicious lytic lesion on the proximal femur (Figure 1,2,3). CT-scan imaging showed a 6 X 2 X 2 cm heterogeneous fluid collection consistent with the appearance of a cyst and severe osteolysis of the proximal femur. The three-phase bone scintigraphy supported the proposal to loosen the femoral stem. The C-reactive protein was slightly increased while the rest were within normal limits. Chromium and cobalt levels were obtained, and both were found to be normal at <0.1 ppb. The patient denied systemic symptoms. The surgical wound was clean with no erythema, swelling, or drainage. After discussing the risks of the procedure, the patient elected to have the CoC articulation revised.
A pseudotumor was found protruding from the joint space. It contained caseous appearing material. The liquid and the pseudotumor were tied off and sent to pathology for examination. All Cultures, including fungal and acid-fast cultures, were negative. No abnormal markings or discoloration were present on the femoral head, trunnion, ceramic head, or acetabular component. There were no signs of impingement on the neck of the prosthesis or rim of the acetabular shell. The loosening femoral stem and the modular ceramic liner were removed.
After thorough irrigation, a Uption® reconstruction stem (Biomet, Indiana, USA) and a 36-mm Biolox® delta head (CeramTec GmbH, Plochingen, Germany) was placed. Due to bone loss in the greater trochanter, a bone graft and hook plate were used for femur reconstruction (Figure 4,5,6,7). The hip stability and range of motion were tested.
Pathology revealed a large synovial-lined cyst-like structure with histiocytes and lymphocytes in the perivascular stroma. The fibrovascular stroma was thick with a lot of pigmented macrophages. The fibrovascular stroma was thick with a lot of pigmented macrophages. In addition, it showed rare microscopic ceramic particles.
The patient’s postoperative course was unremarkable. Rehabilitation was started on postoperative day one, and he was discharged home on the fourth postoperative day. The rehabilitation proceeded without any complications. The patient remained free of symptoms and complications at the 12-month follow-up.
ALTR and pseudotumor formation are well described in MoM-bearing surfaces . There is no consensus on the exact cause of the process, and histological appearances widely vary . In MoM articulation, the formation of pseudotumors and ALTR was initially 1-4% . However, new data show a prevalence of 36-61% in well-functioning hips [8,9].
Not all pseudotumors are symptomatic, and not all require immediate treatment. However, their presence should be closely monitored, both clinically and radiographically. Almousa et al., in a case series study of the natural history of pseudotumor formation, showed that only six patients had increased size at the two-year follow-up . For four patients, the pseudotumor decreased in size or resolved over the same period . Hart et al. showed that the incidence of pseudotumor formation does not significantly differ in symptomatic or asymptomatic MoM hips .
Concerns with CoC articulations primarily center around fracture of the ceramic head or liner, which is an uncommon occurrence ( 0.01–0.15%) [1,10]. It is well known that CoC articulations are less tolerant of component misplacement; this can lead to posterior edge loading . When cups are placed in excessive abduction, wear rates increased .
Despite the mostly benign characteristics, ceramic wear debris is not entirely inert. Mochida et al. showed a predominantly macrophage response to ceramic debris; this was confirmed with immunohistochemical staining [1,12]. In vitro studies have shown that macrophage injection of ceramic debris will increase proinflammatory cytokine production . While macrophage apoptosis was more extensive after alumina particle ingestion than polyethylene particles of the same size [1,13], CoC generated less wear debris than polyethylene articulations, leading to less response . In ceramic-on-polyethylene and non MoM articulations in THA, ATLR and pseudotumor formation are primarily due to trunnion or modular neckwear [1,4,15-17].
To the authors’ knowledge, this is only the second case of such an ALTR/pseudotumor seen in CoC articulation with the absence of a CoCr stem, femoral head, sleeve, or source of Co ions or Co alloy corrosion debris. In the absence of any other cause (metal in the articulation, lack of elevated Co or Cr ions, and lack of exposed porous coating), it is reasonable to assume that the ATLR/pseudotumor was in reaction to wear debris from the CoC articulation.
This paper presents the case of symptomatic adverse local tissue reaction in a patient with a CoC total hip bearing surface. It occurred in the absence of a source of metal debris and without elevation of either chromium or cobalt. The case illustrates that ceramic wear debris are probably not entirely inert. It may lead to adverse local tissue reaction with possible ATLR/pseudotumor formation.
• Ceramic wear debris are probably not entirely inert.
• Even if it’s rare, CoC THA may lead to adverse local tissue reaction with possible ATLR/pseudotumor formation.
• Long-term follow-up and careful analysis of x-rays or Ct-scan after CoC THA should be recommended.
Conflicts of interests: The authors declared no potential conflicts of interest concerning this article's research, authorship, and/or publication.
Funding Acknowledgement: The authors received no financial support for this article's research, authorship, and/or publication.