Formation of a large rice body-containing cyst following total hip arthroplasty
© Issack; licensee BioMed Central Ltd. 2012
Received: 10 April 2012
Accepted: 14 June 2012
Published: 14 June 2012
There are several well-described causes of a painful mass following total hip arthroplasty including polyethylene and metal wear debris, infection, expanding hematoma, dislocation, and synovial cysts. In addition to causing pain, these lesions, when large enough, may cause neurologic and vascular compromise. Rapid growth of the mass may clinically and radiographically resemble a sarcoma. Here, we report a case of a large painful hip mass which developed after total hip arthroplasty. The well-circumscribed mass was overlying and extending into the hip joint containing thousands of highly organized fibrin-containing “rice bodies”. To our knowledge, this is the first report of a large, highly organized (rice-body-containing) cyst complicating total hip arthroplasty.
A 55-year old Caucasian woman developed a large, slowly enlarging, painful hip mass 2 1/2 years after primary total hip arthroplasty. Clinically and radiographically, the lesion resembled a soft tissue sarcoma. Surgical removal identified a well-circumscribed mass extending into the hip joint containing thousands of highly organized fibrin-containing “rice bodies”.
Identification and excision of this “pseudotumor” following hip arthroplasty is important for obtaining a definitive diagnosis, ruling out malignancy or infection and relieving any potential compression on surrounding neurovascular structures.
The differential diagnosis of a painful mass in the hip following total hip arthroplasty includes polyethylene and metal wear debris [1–5], infection , hematoma [7, 8], dislocation , malignancy such as synovial sarcoma, and malignant fibrous histiocytoma [10–12], synovial cyst [2, 4], and iliopsoas bursitis .
We report here a case of a 55-year old woman who developed a large painful hip mass 2 1/2 years after primary total hip arthroplasty. The mass slowly increased in size and in clinical and radiographic presentation, resembled a soft tissue sarcoma on imaging. Surgical exploration identified a well-circumscribed mass overlying and extending into the hip joint containing thousands of highly organized fibrin-containing “rice bodies”. To our knowledge, this is the first report of a large, highly organized (rice-body-containing) cyst complicating total hip arthroplasty.
There are several well-described causes of a painful mass following total hip arthroplasty. Many of the more common causes have characteristic physical exam, radiographic or serologic findings which make diagnosis relatively straightforward. For examples, following polyethylene and metal wear debris, hip arthroplasties have characteristic radiographic features including eccentric polyethylene wear, osteolysis [1–3, 5], or a radiolucency outlining the effective joint space termed the “bubble sign” . Infection can present with a mass if there is an infected hematoma or a large abscess [6, 15]. In these situations, there may be prolonged wound drainage, radiographic changes, if the infection is chronic, or abnormal serology (elevated C-reactive protein and erythrocyte sedimentation rates) and positive cultures on joint aspiration [6, 16]. An expanding hematoma may present with increasing size, correlating with a drop in the hematocrit and progressive sciatic nerve compression and palsy [7, 8]. A periprosthetic dislocation would be readily identified on plain radiographs .
Rarer causes of painful hip masses following total hip arthroplasty have been described. Malignancies such as synovial sarcoma , osteosarcoma  and malignant fibrous histiocytoma  have been observed following total hip arthroplasty. Synovial cysts arising either from the hip joint capsule or from an expansion of the iliopsoas bursae following total hip arthroplasty are extremely rare, and there are only scattered case reports in the literature describing these [2–5, 13]. In these cases, the leukocyte count, hemoglobin levels, hematocrit, erythrocyte sedimentation rate, and C-reactive protein levels were all within normal limits. In some cases, vascular compression by the cyst was what prompted exploration and surgical excision of the compressive mass [2, 4, 5]. In most of these cases, pathologic examination of these synovial cysts demonstrated fluid within the cyst with synovial cells on the inner surface of the cavity. Many of the specimens contained polyethylene debris suggesting that a hypersensitivity reaction to wear particles may be responsible for cyst formation [2, 4, 5]. In one case report, an allergic reaction to the cobalt-chromium molybdenum hip prosthesis was implicated in the development of a large firm soft tissue mass characterized by metallic debris and necrosis. Progessive sciatic nerve palsy resulting from compression by the mass prompted surgical excision .
The case reported here differs from those previously described in the literature in that the contents of the mass associated with the hip arthroplasty were highly organized. The mass contained numerous granules of fibrin or “rice-bodies” (Figure 2b). There was no evidence of polyethylene or metallic wear debris. There is one published report in the literature of a 83-year-old man who developed a large synovial cyst in his pelvis. The lesion was identified on computed tomography scanning and magnetic resonance imaging in the presacral area of the pelvic cavity. Surgical excision was performed. The cyst contained numerous fibrin-composed rice bodies. The cyst wall was composed of synovial tissue. The patient did not have a history of hip arthroplasty . While rice bodies have been historically associated with rheumatoid arthritis and tuberculosis, this patient, similar to the one presented in this report, did not have evidence for either disease.
While synovial cyst formation or iliopsoas bursitis complicating hip arthroplasties have been described in the literature, to our knowledge, this is the first report documenting the formation of a highly-organized fibrin-containing lesion following hip replacement. The growth and imaging characteristics of this lesion can resemble a soft tissue sarcoma. Thus, identification and excision of this “pseudotumor” is important for obtaining a definitive diagnosis and ruling out malignancy or infection. Furthermore, excision relieves the potential compressive effect of the mass on surrounding neurovascular structures including, as in this case, the sciatic nerve.
Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Series Editor of this journal.
PI performed the surgery and drafted the manuscript. All authors read and approved the final manuscript.
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