Arthroplasty Today 2 (2016) 105e109

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Arthroplasty Today
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Case report

Growth of an intrapelvic pseudotumor associated with a metal-on-metal

total hip arthroplasty after revision arthroplasty causing a femoral
nerve neuropathy
Patrick Leung, MD a, *, James C. Kudrna, MD, PhD b
a
b

Department of Orthopedic Surgery, University of Chicago, Chicago, IL, USA

Department of Orthopedic Surgery, NorthShore Medical Group, University of Chicago Pritzker School of Medicine, Glenview, IL, USA

a r t i c l e i n f o

a b s t r a c t

Article history:
Received 10 May 2016
Received in revised form
2 July 2016
Accepted 11 July 2016
Available online 21 August 2016

The development of pseudotumors is not uncommon with metal-on-metal total hip arthroplasty.
Pseudotumors that dissect into the retroperitoneal space can cause symptoms of nerve compression. We
describe a case of a 53-year-old male with a metal-on-metal total hip arthroplasty who developed mild
symptoms of a femoral nerve neuropathy 6 years postoperatively. Revision arthroplasty to a ceramic-onpolyethylene articulation and debridement of the pseudotumor was performed. Postoperatively, the
patient's femoral neuropathy progressed and a repeat magnetic resonance imaging showed an increase
in size of the pseudotumor despite the removal of the offending metal-on-metal articulation. The patient
subsequently underwent a laparoscopic excision of the retroperitoneal pseudotumor. By 17 months post
laparoscopic excision of the pseudotumor, the patient's motor decits resolved, however, sensory decits
persisted in the anteromedial thigh.
2016 The Authors. Published by Elsevier Inc. on behalf of The American Association of Hip and Knee
Surgeons. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).

Keywords:
Pseudotumor
Femoral nerve neuropathy
Metal-on-metal total hip arthroplasty

Introduction
The development of pseudotumors is a known complication
associated with metal-on-metal total hip arthroplasty (MoM THA).
Metallic-wear debris is believed to result in a chronic inammatory
process and a type IV delayed hypersensitivity response from the
immune system leading to local tissue necrosis [1]. The prevalence
of pseudotumors after MoM THA is estimated to be 0%-6.5% [2].
However, a recent single surgeon magnetic resonance imaging
(MRI) review of patients who underwent MoM THA showed that
the percentage of patients with detectable pseudotumors could be
as high as 68.6% [3]. Pseudotumors often remain subclinical, but
they can cause extensive local tissue necrosis often affecting the
hip abductors, short external rotators, and exors. In addition,

One or more of the authors of this paper have disclosed potential or pertinent
conicts of interest, which may include receipt of payment, either direct or indirect,
institutional support, or association with an entity in the biomedical eld which
may be perceived to have potential conict of interest with this work. For full
disclosure statements refer to http://dx.doi.org/10.1016/j.artd.2016.07.001.
* Corresponding author. 5841 S. Maryland Ave, MC 3079, Chicago, IL 60637, USA.
Tel.: 1 908 334 1917.
E-mail address: [email protected]

there are a number of case reports of large pseudotumors causing

compression of intraabdominal structures [4-7].
Compressive neuropathies of the femoral nerve by large pseudotumors have been reported [8-10]. The pseudotumor typically
dissects along the iliopsoas bursa into the retroperitoneal space and
can result in compression of the femoral neurovascular bundle.
Treatment involves revision arthroplasty to address the wear debris
generated by the MoM articulation. The cyst can either be excised
or decompressed to alleviate the compressive symptoms [4]. To the
best of our knowledge, no one has identied cases in which a
pseudotumor continues to increase in size even after the removal of
the offending MoM arthroplasty. We report the case of a patient
with a known pseudotumor and femoral nerve palsy 6 years after
undergoing a MoM THA, who subsequently had enlargement of the
pseudotumor along with a worsening femoral nerve neuropathy
despite a revision to a ceramic-on-polyethylene bearing.

Case history
A 53-year-old Caucasian male presented to us with symptomatic
left hip osteoarthritis nonresponsive to conservative management.
His medical history was unremarkable and had no known metal

http://dx.doi.org/10.1016/j.artd.2016.07.001
2352-3441/ 2016 The Authors. Published by Elsevier Inc. on behalf of The American Association of Hip and Knee Surgeons. This is an open access article under the CC BY-NCND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

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allergies. His body mass index was 23. The patient underwent a left
THA with a cementless Summit stem, cementless Pinnacle
acetabular shell, and Ultamet MoM 36-mm bearing (DePuy,
Warsaw, IN). The patient's recovery was uneventful.
Six years postoperatively, the patient presented with left leg
weakness and anteromedial thigh numbness and paresthesias. His
clinical exam revealed decreased sensation in L2 and L3 dermatome
distributions along with 4/5 strength in the iliopsoas and quadriceps. Cobalt and chromium levels were elevated at 76.4 and 75.6
ppb, respectively. An AP hip radiograph did not demonstrate signs
of component loosening (Fig. 1).
Metal artifact reduction MRI of the left hip revealed 2 heterogeneous lesions. One lesion was isolated within the iliacus and
extended into the iliopsoas, measuring 8.8  4.7  9.3 cm and
displaced the femoral neurovascular structures. The second was
located posterolateral to the proximal femur measuring 7.8  2.2 
5.7 cm (Fig. 2). Nerve conduction studies revealed no abnormalities; however, electromyography demonstrated decreased
recruitment in the vastus medialis and iliopsoas.
In the presence of a large pseudotumor, elevated serum cobalt
and chromium levels, and symptoms of a compressive neuropathy,
a revision arthroplasty with debridement and head and liner exchange was performed. Upon exposure through a posterior surgical
approach, the joint capsule appeared uctuant and was decompressed, returning 60 milliliters of blood tinged uid. In addition,
there was diffuse synovial staining and the presence of several
visible pseudotumors, which were thoroughly debrided (Fig. 3).
Intraoperatively, the acetabular cup and femoral stem were well
xed. Examination of the femoral head and taper revealed minimal
corrosion and fretting at the head-stem junction. The acetabular
shell did not show any signs of wear. The modularity of the Summit
stem and Pinnacle Acetabular cup allowed for a head and liner
exchange with a BIOLOX delta ceramic femoral head with a titanium sleeve and a moderately crosslinked polyethylene liner

(DePuy). Pathology review of the specimen revealed brous tissue

with marked histiocytic inltrates and abundant metallic staining
of the tissue.
Ten months postrevision arthroplasty, the patient continued to
experience progressive numbness and paresthesias in the medial
thigh at the level of knee, further instability of the knee with
ambulation, and difculty ascending and descending stairs. A cane
and double-upright drop lock knee brace were required for
ambulation. Clinically, mild quadriceps atrophy along with
decreased sensation in the L2 and L3 dermatomes were present. In
addition, a large abdominal mass could now be palpated in the left
lower quadrant. Repeat sampling of serum cobalt and chromium
ion levels 6 and 10 months post revision revealed a progressive
downward trend in ion levels (Fig. 4).
Due to the progression of motor and sensory decits postrevision arthroplasty and the presence of a palpable abdominal
mass, a repeat MRI of the left hip was performed demonstrating a
persistent pseudotumor within the iliopsoas and proximal femur.
The size of the pseudotumor within the iliopsoas had signicantly
increased in size, now measuring 9.1  10.2  13.4 cm, with further
displacement of the femoral neurovascular bundle (Fig. 5). In light
of the progressive neurological decits, the decision was made to
surgically excise the retroperitoneal pseudotumor.
One-year post revision left THA, the patient underwent a laparoscopic removal of the retroperitoneal pseudotumor. Intraoperatively, the cyst was identied and dissected free from the
sigmoid colon. The contents of the cyst were excised and consisted
of dark viscous uid and brown caseous tissue (Fig. 6a and b).
Four months postsurgical excision, symptoms remained unchanged, with quadriceps weakness on ambulation and paresthesias in the anteromedial thigh. Clinical exam revealed mild
quadriceps atrophy, and motor strength remained at 4/5 in iliopsoas and 3/5 in quadriceps. Decreased sensation to sharp touch was
present in the L3-L4 dermatomes. Nerve conduction studies
revealed absent saphenous nerve conduction, and electromyography demonstrated abnormal vastus lateralis and rectus femoris
response. Repeat MRI revealed interval resolution of the pseudotumor within the iliopsoas (not shown).
Twelve months after excision of the pseudotumor, quadriceps
strength had improved and there was partial return of sensation
over the anteromedial thigh. At 17 months post pseudotumor
excision, motor decits resolved and assistive devices for ambulation were discontinued; however, paresthesias in the anteromedial
thigh persisted. The patient was able to resume normal functional
and recreational activities. At 35 months post pseudotumor excision, the patient continued to have residual paresthesias in the
anteromedial thigh.
Discussion

Figure 1. Anteroposterior (AP) hip radiograph performed 6 years postimplantation

with metal-on-metal prosthesis in appropriate alignment without signs of loosening,
osteolysis, or hardware failure.

MoM THA have 2- to 3-fold increased rates of revision due to the

inammatory reaction to metal debris leading to the development
of macroscopic necrosis, osteolysis, large sterile hip effusions, and
pseudotumors [11]. The pathogenesis of this local response to
MoM-wear debris has not been fully characterized; however it has
been theorized to involve both a cytotoxic and delayed hypersensitivity reaction.
The development of gross instability and need for revision surgery is not the only complications associated with the local tissue
response to metallic-wear debris. A number of literature reports
describe cases in which pseudotumors associated with MoM
arthroplasty cause clinically signicant compressive neuropathies
involving either the femoral or sciatic nerve [12]. In these instances,
prompt revision arthroplasty is advocated [8,9]. The evidence for
surgical excision of the pseudotumor is not clear. Some authors

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107

Figure 2. (a) Coronal, (b) sagittal, and (c) axial T1 MRI images of the left hip prior to revision demonstrated a heterogeneous mixed signal lesion within the substance of the left
iliacus and iliopsoas muscle (asterisk). The lesion has a mass effect on the surrounding structures and displaces the external iliac and femoral artery (arrow).

Figure 3. Intraoperative photo of the initial revision arthroplasty with head and liner
exchange through a posterior approach to the hip. Upon dissection through the gluteus
maximus, diffuse synovial staining was seen in the surrounding tissues.

advocate for complete cyst excision to directly decompress the

nerve, which may necessitate either a staged procedure or an
extensile surgical approach. Others support debriding as much of the
pseudotumor as possible through the same surgical approach as the
revision arthroplasty and indirectly decompressing the cyst [12,13].
In our case, the patient presented with a subacute femoral neuropathy with mild motor and sensory symptoms, and thus, we opted to
perform a single-staged revision arthroplasty with debridement of
the pseudotumor through the same posterior surgical approach.
With the removal of the source of metallic-wear debris, it was
thought that the pseudotumor would stabilize or regress in size.
We are not aware of any reports of a pseudotumor associated
with a MoM articulation continuing to increase in size after the
removal of the offending source. In this instance, the pseudotumor
continued expand in size and caused a clinically progressive femoral
nerve compressive neuropathy with both motor and sensory decits.
We theorize that the increase in size of the pseudotumor can be
in part explained by the cytotoxic effects of cobalt and chromium
ions. In high concentrations, both metal ions induced necrosis of

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100
Chromium

90

Cobalt
80

Parts Per Billion (ppb)

70
60
50
40
30
20
10
0
0

10

20

30

40

50

60

70

80

90

100

110

Months Post- THA

Figure 4. Serum cobalt and chromium levels measured at various intervals following
metal-on-metal THA. Revision arthroplasty to ceramic-on-polyethylene bearing was
performed 86 months after the primary surgery (black arrow). The retroperitoneal
lesion was excised laparoscopically 99 months following the index arthroplasty
procedure (white arrow).

macrophages cultured in vitro [14]. The induction of necrosis leads to

disruption of the cellular membrane and release of intracellular
contents including cytokines, lysosmal enzymes, and phagocytosed
metallic-wear debris. The continued presence of inammatory mediators will again induce macrophage recruitment, phagocytosis of
metallic-wear debris, and cell death. This cycle of inammation
within the pseudocyst can lead to continued growth of the pseudotumor [15].
The neuropathy in our patient could have also worsened secondary to a direct effect of metallic-wear debris on the nerve itself.
Harvie et al. described 2 cases of a pseudotumor associated with
MoM resurfacing arthroplasty causing a dense femoral nerve palsy.
In each instance, revision arthroplasty and femoral nerve neurolysis
were performed. Intraoperative examination of the femoral nerve
revealed a pale attened appearance that was partially encased
within the pseudotumor. Femoral nerve biopsy demonstrated
absence of axons and myelin sheaths and large dystrophic calcications in place of axons [8]. In our case, we did not directly visualize the femoral nerve as it was deeply encased in the
pseudotumor making it difcult to grossly examine laparoscopically. Since the patient's symptoms did improve with removal of the
cyst, this suggests that compression of the femoral nerve was likely
the resulting cause of the femoral neuropathy; however, other
direct effects cannot be discounted.

Figure 5. Representative (a) coronal, (b) sagittal, and (c) axial T1 MRI images 1-year post revision revealed a large lesion in the iliopsoas muscle that has increased in size compared
to prior MRI (asterisk). Signicant displacement of the femoral neurovascular bundle is again demonstrated (arrow). An increase in the uid component is also noted.

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109

Figure 6. (a) Intraoperative laparoscopic nding of a retroperitoneal pseudotumor which has been dissected free from adjacent sigmoid colon. (b) The pseudotumor consisted of a
rm brous capsule and contained both cystic areas lled with thick brown uid and regions of necrotic tissue. All contents of the cyst and the capsule were removed
laparoscopically.

Summary
The treatment decision for addressing pseudotumors can be
difcult since they have been detected in both symptomatic and
asymptomatic patients [3]. Bolognesi et al. proposed an algorithm
providing a framework for the evaluation and treatment of patients
with MoM THA. This risk stratication algorithm enables orthopaedic surgeons to make objective decisions and reduces the
overreliance on just one diagnostic tool [11]. In conjunction with
this algorithm, we suggest intrapelvic pseudotumors associated
with MoM THA should be closely monitored for symptoms of
compressive neuropathies. If symptoms do arise, revision arthroplasty should be considered. There are conicting reports on
whether the pseudotumor needs to be surgically excised in its
entirety. The decision on how to address the pseudotumor is case
dependent and varies based on factors including degree of nerve
compression and ease of accessibility of the pseudotumor. If the
pseudotumor is not completely excised one must be cognizant to
the possibility that the cyst can continue to grow and cause worsening compressive symptoms. Thus, the presence of a retroperitoneal pseudotumor warrants continued observation even if
revision arthroplasty has already been performed.

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