A metal-on-metal pseudotumor, also known as aseptic lymphocyte-dominant vasculitis-associated lesion (ALVAL), is a mass-forming tissue reaction around a metal-on-metal hip or knee replacement.
Metal-on-metal pseudotumors are large focal solid or semiliquid masses around the hip (or knee) prostheses. The pseudotumors mimic local effects of neoplasia or infection in the absence of either of these. The principal symptom is pain. There may be restricted range of movement with large pseudotumors.
The incidence of symptomatic pseudotumors following metal-on-metal hip arthroplasty is in the region of 5%.
Patients with bilateral resurfacing total hip replacement who develop a pseudotumor in one hip have a 1 in 3 chance of having a lesion on the contralateral side.
Pseudotumors are more common in females.
The pathophysiology is poorly understood. Metal-on-metal pseudotumors are sterile inflammatory lesions.
Excessive wear is considered the initiating process, leading to the release of particles (nanometer sized). These are cytotoxic to macrophages once phagocytosed, therefore leading to necrosis within the lesions.
Reactive masses are related to high serum and joint fluid ion levels, and a delayed type IV hypersensitivity reaction has been implied.
Sonographic features are non-specific but may show:
- mass of heterogenous echogenicity
- without internal power or color Doppler signal
- fluid components
- located at posterolateral aspect of the joint, often in continuity with the greater trochanter
- typically cystic in nature
- frequently with layering of contents, and a low signal intensity wall
- foci of susceptibility artefact due to metal content
- representing extension through posterior capsular defects (typical surgical approach in hip arthroplasty
- less common
- typically involving the iliopsoas bursa
- solid components are more likely
- typical: contiguous with the joint capsule (representing distension of the iliopsoas bursa)
- may more definitively reveal a connection between the periprosthetic collection and the joint space
- aspiration of the collection will reveal elevated cobalt and chromium ion levels (may be elevated in serum as well)
- T C+ (Gd): and generally show no enhancement 5
Imaging differential diagnosis in MRI
There are two important diagnostic alternatives.
- less well defined than pseudotumors
- lack of a low signal intensity rim
Soft-tissue edema can be seen with both infection or pseudotumor. Extensive perifascial fluid is more suggestive of infection.
Abductor tendon avulsion-associated fluid collections
- pure fluid signal
- lack of a low signal intensity rim
- typical: location at the site of abductor avulsion
Pseudotumors can coexist with abductor tendon avulsion following hip arthroplasty.
- 1. Kwon YM, Ostlere SJ, McLardy-Smith P et-al. "Asymptomatic" pseudotumors after metal-on-metal hip resurfacing arthroplasty: prevalence and metal ion study. J Arthroplasty. 2011;26 (4): 511-8. doi:10.1016/j.arth.2010.05.030 - Pubmed citation
- 2. Campbell P, Ebramzadeh E, Nelson S et-al. Histological features of pseudotumor-like tissues from metal-on-metal hips. Clin. Orthop. Relat. Res. 2010;468 (9): 2321-7. Clin. Orthop. Relat. Res. (full text) - doi:10.1007/s11999-010-1372-y - Free text at pubmed - Pubmed citation
- 3. Hart AJ, Satchithananda K, Liddle AD et-al. Pseudotumors in association with well-functioning metal-on-metal hip prostheses: a case-control study using three-dimensional computed tomography and magnetic resonance imaging. J Bone Joint Surg Am. 15;94 (4): 317-25. doi:10.2106/JBJS.J.01508 - Pubmed citation
- 4. Williams DH, Greidanus NV, Masri BA et-al. Prevalence of pseudotumor in asymptomatic patients after metal-on-metal hip arthroplasty. J Bone Joint Surg Am. 07;93 (23): 2164-71. doi:10.2106/JBJS.J.01884 - Pubmed citation
- 5. Davis DL, Morrison JJ. Hip Arthroplasty Pseudotumors: Pathogenesis, Imaging, and Clinical Decision Making. (2016) Journal of clinical imaging science. 6: 17. doi:10.4103/2156-7514.181493 - Pubmed