Advertisement

International Orthopaedics

, Volume 43, Issue 6, pp 1321–1328 | Cite as

Aggressive granulomatosis of the hip: a forgotten mode of aseptic failure

  • Pablo Ariel Isidoro SlullitelEmail author
  • Rodrigo Brandariz
  • Jose Ignacio Oñativia
  • German Farfalli
  • Fernando Comba
  • Francisco Piccaluga
  • Martin Buttaro
Original Paper
  • 93 Downloads

Abstract

Purpose

It has been acknowledged that implant wear correlates with the risk for periprosthetic osteolysis, being aggressive granulomatosis the worst expression of bone resorption. We sought to determine the clinical, radiological, and histological features of aggressive granulomatosis after primary total hip arthroplasty (THA).

Methods

We included nine cases with aggressive granulomatosis of the hip around cemented stems. Indications for revision THA consisted of progressive signs of extensive bone resorption or implant loosening. Mean follow-up since revision THA was 143 months (SD ± 59.4). We analysed clinical outcomes, component loosening and gross as well as histological characteristics of the granulomatous lesions.

Results

Overall mean time between primary THA and revision surgery was 81 months (SD ± 20.8). All of the cases evidenced multiple ovoid tumour-like lesions around the stem with extensive bone loss. Only one case reported thigh pain before revision surgery, with radiological evidence of stem loosening; the remaining cases were asymptomatic with well-fixed implants. Gross anatomy findings revealed metallosis in the femoral canal and inside the cystic lesions. Pathology analysis showed monocyte-macrophage-dominated adverse foreign-body-type tissue reaction with fibroblastic reactive zones and granulomatous inflammation.

Conclusions

We found a prevalence of 1% of this aseptic mode of implant failure. Since most of the retrieved stems were not loose, we did not find any alarming clinical symptoms anticipating implant failure. In this scenario, surgeons should be aware of the rapidly progressive nature of this entity and propose a revision THA in a timely fashion.

Keywords

Aggressive granulomatosis Total hip arthroplasty Osteolysis 

Notes

Compliance with ethical standards

Conflicts of interest

Each author certifies that he has no commercial associations (e.g., consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article. No funding/grant was received for the development of this research. On behalf of all authors, the corresponding author states that there is no conflict of interest. Each author certifies that his institution has approved the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research.

References

  1. 1.
    Harris WH (1994) Osteolysis and particle disease in hip replacement. A review. Acta Orthop Scand 65:113–123.  https://doi.org/10.3109/17453679408993734 CrossRefGoogle Scholar
  2. 2.
    Jones LC, Hungerford DS (1987) Cement disease. Clin Orthop Relat Res 225:192–206Google Scholar
  3. 3.
    Pajarinen J, Gallo J, Takagi M, Goodman SB (2018) Particle disease really does exist: an evidence based rebuttal to Dr. Mjöberg’s opinion letter. Acta Orthop 89:133–136.  https://doi.org/10.1080/17453674.2017.1402463 CrossRefGoogle Scholar
  4. 4.
    Jiranek WA, Machado M, Jasty M et al (1993) Production of cytokines around loosened cemented acetabular components. Analysis with immunohistochemical techniques and in situ hybridization. J Bone Joint Surg Am 75:863–879.  https://doi.org/10.15713/ins.mmj.3 CrossRefGoogle Scholar
  5. 5.
    Ries MD, Link TM (2012) Monitoring and risk of progression of osteolysis after total hip arthroplasty. J Bone Joint Surg Am 94:2097–2105.  https://doi.org/10.1016/j.jhse.2007.02.052 Google Scholar
  6. 6.
    Harris WH, Schiller AL, Scholler JM et al (1976) Extensive localized bone resorption in the femur following total hip replacement. J Bone Joint Surg Am 58:612–618CrossRefGoogle Scholar
  7. 7.
    Goldring SR, Schiller AL, Roelke M et al (1983) The synovial-like membrane at the bone-cement interface in loose total hip replacements and its proposed role in bone lysis. J Bone Joint Surg Am 65:575–584.  https://doi.org/10.15713/ins.mmj.3 CrossRefGoogle Scholar
  8. 8.
    Tallroth K, Eskola A, Santavirta S et al (1989) Aggressive granulomatous lesions after hip arthroplasty. J Bone Joint Surg Br 71:571–575CrossRefGoogle Scholar
  9. 9.
    Santavirta S, Konttinen YT, Bergroth V et al (1990) Aggressive granulomatous lesions associated with hip arthroplasty. Immunopathological studies. J Bone Joint Surg Am 72:252–258CrossRefGoogle Scholar
  10. 10.
    Santavirta S, Hoikka V, Eskola A et al (1990) Aggressive granulomatous lesions in cementless total hip arthroplasty. J Bone Joint Surg Br 72:980–984CrossRefGoogle Scholar
  11. 11.
    Hartofilakidis G, Stamos K, Karachalios T et al (1996) Congenital hip disease in adults. Classification of acetabular deficiencies and operative treatment with acetabuloplasty combined with total hip arthroplasty. J Bone Joint Surg Am 78:683–692CrossRefGoogle Scholar
  12. 12.
    Saleh KJ, Kassim R, Yoon P, Vorlicky LN (2002) Complications of total hip arthroplasty. Am J Orthop (Belle Mead NJ) 31:485–488Google Scholar
  13. 13.
    DeLee JG, Charnley J (1976) Radiological demarcation of cemented sockets in total hip replacement. Clin Orthop Relat Res 121:20–32Google Scholar
  14. 14.
    Gruen TA, McNeice GM, Amstutz HC (1979) “Modes of failure” of cemented stem-type femoral components: a radiographic analysis of loosening. Clin Orthop Relat Res 141:17–27Google Scholar
  15. 15.
    Aribindi R, Barba M, Solomon MI et al (1998) Bypass fixation. Orthop Clin North Am 29:319–329CrossRefGoogle Scholar
  16. 16.
    Engh CA, Massin P, Suthers KE (1990) Roentgenographic assessment of the biologic fixation of porous-surfaced femoral components. Clin Orthop Relat Res 257:107–128Google Scholar
  17. 17.
    D’Aubigné RM, Postel M (1954) Functional results of hip arthroplasty with acrylic prosthesis. J Bone Joint Surg Am 36–A:451–475CrossRefGoogle Scholar
  18. 18.
    Buttaro MA, Comba F, Piccaluga F (2009) Proximal femoral reconstructions with bone impaction grafting and metal mesh. Clin Orthop Relat Res 467:2325–2334.  https://doi.org/10.1007/s11999-009-0777-y CrossRefGoogle Scholar
  19. 19.
    Korovessis P, Repanti M (1994) Evolution of aggressive granulomatous periprosthetic lesions in cemented hip arthroplasties. Clin Orthop Relat Res 300:155–161Google Scholar
  20. 20.
    Moholkar K, Tamblyn P (2001) Aggressive granulomatous lesion presenting as tumor in cementless long stem total hip arthroplasty. J Arthroplast 16:404–407.  https://doi.org/10.1054/arth.2001.23365 CrossRefGoogle Scholar
  21. 21.
    Sebecić B, Japjec M, Dojcinović B et al (2013) Aggressive granulomatosis after cementless total hip arthroplasty as a result of inflammatory reaction to metal debris: case report. Acta Clin Croat 52:492–496Google Scholar
  22. 22.
    Eskola A, Santavirta S, Konttinen YT et al (1990) Cementless revision of aggressive granulomatous lesions in hip replacements. J Bone Joint Surg Br 72:212–216CrossRefGoogle Scholar
  23. 23.
    Willert H-G, Buchhorn GH, Fayyazi A et al (2005) Metal-on-metal bearings and hypersensitivity in patients with artificial hip joints. A clinical and histomorphological study. J Bone Joint Surg Am 87:28–36.  https://doi.org/10.2106/JBJS.A.02039pp CrossRefGoogle Scholar
  24. 24.
    Daniel J, Holland J, Quigley L et al (2012) Pseudotumors associated with total hip arthroplasty. J Bone Joint Surg Am 94:86–93.  https://doi.org/10.2106/JBJS.J.01612 CrossRefGoogle Scholar
  25. 25.
    Nawabi DH, Gold S, Lyman S et al (2014) MRI predicts ALVAL and tissue damage in metal-on-metal hip arthroplasty. Clin Orthop Relat Res 472:471–481.  https://doi.org/10.1007/s11999-013-2788-y CrossRefGoogle Scholar
  26. 26.
    Nich C, Hamadouche M (2011) Cup loosening after cemented Metasul® total hip replacement: a retrieval analysis. Int Orthop 35:965–970.  https://doi.org/10.1007/s00264-010-1061-1 CrossRefGoogle Scholar
  27. 27.
    Santavirta S (2003) Compatibility of the totally replaced hip. Reduction of wear by amorphous diamond coating. Acta Orthop Scand Suppl 74:1–19.  https://doi.org/10.1080/00016470310018108 CrossRefGoogle Scholar
  28. 28.
    Santavirta S, Lappalainen R, Konttinen YT (2004) Materials for artificial joints. Duodecim 120:2020–2026Google Scholar
  29. 29.
    Joshi RP, Eftekhar NS, McMahon DJ, O a N (1998) Osteolysis after Charnley primary low-friction arthroplasty. A comparison of two matched paired groups. J Bone Joint Surg Br 80:585–590.  https://doi.org/10.1302/0301-620X.80B4.7361 CrossRefGoogle Scholar
  30. 30.
    Clauss M, Ilchmann T, Zimmermann P, Ochsner PE (2010) The histology around the cemented Müller straight stem. J Bone Joint Surg Br 92–B:1515–1521.  https://doi.org/10.1302/0301-620X.92B11.25342 CrossRefGoogle Scholar
  31. 31.
    Yamako G, Janssen D, Hanada S et al (2017) Improving stress shielding following total hip arthroplasty by using a femoral stem made of β type Ti-33.6Nb-4Sn with a Young’s modulus gradation. J Biomech 63:135–143.  https://doi.org/10.1016/j.jbiomech.2017.08.017 CrossRefGoogle Scholar
  32. 32.
    Santavirta S, Takagi M, Gómez-Barrena E et al (1999) Studies of host response to orthopedic implants and biomaterials. J Long-Term Eff Med Implants 9:67–76Google Scholar
  33. 33.
    Mitchelson AJ, Wilson CJ, Mihalko WM et al (2015) Biomaterial hypersensitivity: is it real? Supportive evidence and approach considerations for metal allergic patients following total knee arthroplasty. Biomed Res Int 2015:137287.  https://doi.org/10.1155/2015/137287 CrossRefGoogle Scholar
  34. 34.
    Guenther D, Thomas P, Kendoff D et al (2016) Allergic reactions in arthroplasty: myth or serious problem? Int Orthop 40:239–244.  https://doi.org/10.1007/s00264-015-3001-6 CrossRefGoogle Scholar
  35. 35.
    Hood RW, Wright TM, Burstein AH (1983) Retrieval analysis of total knee prostheses: a method and its application to 48 total condylar prostheses. J Biomed Mater Res 17:829–842.  https://doi.org/10.1002/jbm.820170510 CrossRefGoogle Scholar

Copyright information

© SICOT aisbl 2018

Authors and Affiliations

  1. 1.Hip Surgery Unit, Italian Hospital of Buenos AiresInstitute of Orthopaedics “Carlos E. Ottolenghi”Buenos AiresArgentina
  2. 2.Division of Orthopaedic Surgery, The Ottawa HospitalOttawaCanada
  3. 3.Division of Musculoskeletal Oncology, Italian Hospital of Buenos AiresInstitute of Orthopaedics “Carlos E. Ottolenghi”Buenos AiresArgentina

Personalised recommendations