Doctor of Philosophy, Fellowship of the Royal College of Surgeons, Health, Hip Replacement, iliopsoas bursitis, Magnetic resonance imaging, Medicine, metallosis, New York City, Physician, science, surgery, Total Hip Arthroplasty
Metallosis-induced Iliopsoas Bursal Cyst Causing Venous Obstruction and Lower-limb Swelling After Metal-on-metal THA
December 2012 – Volume 35 · Issue 12: e1811-e1814
The formation of iliopsoas bursal cystic lesions after total hip arthroplasty is an infrequently 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-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.
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 preparation 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@example.com).
The formation of iliopsoas bursal cystic lesions after total hip arthroplasty (THA) is a rare and infrequently reported condition.1–6 Iliopsoas bursal cystic lesions develop in response to intra-articular derangement and increased intra-articular pressure due to particulate wear debris with or without component loosening or osteolysis.1–6 Iliopsoas bursal cystic lesions may be detected incidentally or can present as pain or a groin mass. Rarely, they present as lower-limb swelling from severe vascular compression.1–5,7
Vascular compression and limb swelling have been described with metal-on-polyethylene THA due to iliopsoas bursal lesions.1–5 It has also been reported due to pseudotumors with metal-on-metal resurfacing.7 One report described this lesion in an old-generation cemented McKee-Farrar metal-on-metal prosthesis (Howmedica, London, United Kingdom); however, it was due to an intrapelvic cyst containing cement debris that communicated with the hip joint through an acetabular medial wall defect and occurred in response to acetabular component loosening.8
This article describes a case of venous compression leading to a groin mass and significant lower-limb swelling following metal-on-metal THA. To the authors’ knowledge, this is the first report that describes an iliopsoas bursal cystic lesion 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.
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