Clinical Orthopaedics and Related Research®

, Volume 471, Issue 12, pp 3814–3821 | Cite as

The Natural History of Inflammatory Pseudotumors in Asymptomatic Patients After Metal-on-metal Hip Arthroplasty

  • Sulaiman A. Almousa
  • Nelson V. Greidanus
  • Bassam A. Masri
  • Clive P. Duncan
  • Donald S. Garbuz
Symposium: 2012 International Hip Society Proceedings



Although pseudotumors have been reported in 32% of asymptomatic metal-on-metal hips, the natural history of asymptomatic pseudotumors is unknown.


The purpose of this study was to assess changes over time in asymptomatic pseudotumors and the effect of revision on pseudotumor mass.


Followup ultrasound was performed a mean of 25.8 months (range, 21–31 months) after the detection of 15 pseudotumors and five isolated fluid collections in a cohort of 20 asymptomatic patients (13 metal-on-metal, three metal-on-polyethylene, and four hip resurfacings) [42]. Changes in pseudotumors and fluid collections size and nature, and serum ion levels were determined.


Among the 15 nonrevised patients, pseudotumors increased in size in six (four solid and two cystic) of 10 patients, three of which had clinically important increases (13–148 cm3; 28–74 cm3; 47–104 cm3). Three pseudotumors (one solid and two cystic) disappeared completely (the largest measured 31 cm3). One solid pseudotumor decreased in size (24 to 18 cm3). In five revised patients, pseudotumors completely disappeared in four patients. The fifth patient had two masses that decreased from 437 cm3 to 262 cm3 and 43 cm3 to 25 cm3. All revision patients had a reduction of chromium (40.42 μ/L to 2.69 μ/L) and cobalt ions (54.19 μ/L to 0.64 μ/L). Of five isolated fluid collections, four completely disappeared (two metal-on-metal and two metal-on-polyethylene) and one (metal-on-metal) increased from 26 cm3 to 136 cm3.


Our observations suggest pseudotumors frequently increase in size in asymptomatic patients with occasional remission of small masses. Revision resulted in remission of pseudotumors.

Level of Evidence

Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.



We thank Diana Korlaet CRGS, PDDipAppSci (Medical Ultrasound), for performing the ultrasound scans; and Daphné Savoy BA, for her assistance in the preparation of the manuscript.


  1. 1.
    Amstutz HC, Su EP, Le Duff MJ. Surface arthroplasty in young patients with hip arthritis secondary to childhood disorders. Orthop Clin North Am. 2005;36:223–230.PubMedCrossRefGoogle Scholar
  2. 2.
    Amstutz HC, Thomas BJ, Jinnah R, Kim W, Grogan T, Yale C. Treatment of primary osteoarthritis of the hip. A comparison of total joint and surface replacement arthroplasty. J Bone Joint Surg Am. 1984;66:228–241.PubMedGoogle Scholar
  3. 3.
    Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). Available at: Accessed January 5, 2013.
  4. 4.
    Beaulé PE, Kim PR, Hamdi A, Fazekas A. A prospective metal ion study of large-head metal-on-metal bearing: a matched-pair analysis of hip resurfacing versus total hip replacement. Orthop Clin North Am. 2011;42:251–257.PubMedCrossRefGoogle Scholar
  5. 5.
    Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt LW. Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. J Rheumatol. 1988;15:1833–1840.PubMedGoogle Scholar
  6. 6.
    Berton C, Girard J, Krantz N, Migaud H. The Durom large diameter head acetabular component: early results with a large-diameter metal-on-metal bearing. J Bone Joint Surg Br. 2010;92:202–208.PubMedGoogle Scholar
  7. 7.
    Boardman DR, Middleton FR, Kavanagh TG. A benign psoas mass following metal-on-metal resurfacing of the hip. J Bone Joint Surg Br. 2006;88:402–404.PubMedGoogle Scholar
  8. 8.
    Campbell P, Ebramzadeh E, Nelson S, Takamura K, De Smet K, Amstutz HC. Histological features of pseudotumor-like tissues from metal-on-metal hips. Clin Orthop Relat Res. 2010;468:2321–2327.PubMedCrossRefGoogle Scholar
  9. 9.
    Canadian Hip Resurfacing Study Group. A survey on the prevalence of pseudotumors with metal-on-metal hip resurfacing in Canadian academic centers. J Bone Joint Surg Am. 2011;93(Suppl 2):118–121.Google Scholar
  10. 10.
    Clayton RA, Beggs I, Salter DM, Grant MH, Patton JT, Porter DE. Inflammatory pseudotumor associated with femoral nerve palsy following metal-on-metal resurfacing of the hip. A case report. J Bone Joint Surg Am. 2008;90:1988–1993.PubMedCrossRefGoogle Scholar
  11. 11.
    Counsell A, Heasley R, Arumilli B, Paul A. A groin mass caused by metal particle debris after hip resurfacing. Acta Orthop Belg. 2008;74:870–874.PubMedGoogle Scholar
  12. 12.
    Cuckler JM, Moore KD, Lombardi AVJ, McPherson E, Emerson R. Large versus small femoral heads in metal-on-metal total hip arthroplasty. J Arthroplasty. 2004;19(Suppl 3):41–44.PubMedCrossRefGoogle Scholar
  13. 13.
    Daniel J, Pynsent PB, McMinn DJ. Metal-on-metal resurfacing of the hip in patients under the age of 55 years with osteoarthritis. J Bone Joint Surg Br. 2004;86:177–184.PubMedCrossRefGoogle Scholar
  14. 14.
    Davies AP, Willert HG, Campbell PA, Learmonth ID, Case CP. An unusual lymphocytic perivascular infiltration in tissues around contemporary metal-on-metal joint replacements. J Bone Joint Surg Am. 2005;87:18–27.PubMedCrossRefGoogle Scholar
  15. 15.
    DePuy Synthes. Available at: Accessed July 2012.
  16. 16.
    Dowson D, Hardaker C, Flett M, Isaac GH. A hip joint simulator study of the performance of metal-on-metal joints. Part II: design. J Arthroplasty. 2004; 19(Suppl 3):124–130.Google Scholar
  17. 17.
    Dunstan E, Ladon D, Whittingham-Jones P, Carrington R, Briggs TW. Chromosomal aberrations in the peripheral blood of patients with metal-on-metal hip bearings. J Bone Joint Surg Am. 2008;90:517–522.PubMedCrossRefGoogle Scholar
  18. 18.
    Ebreo D, Khan A, El-Meligy M, Armstrong C, Peter V. Metal ion levels decrease after revision for metallosis arising from large-diameter metal-on-metal hip arthroplasty. Acta Orthop Belg. 2011;77:777–781.PubMedGoogle Scholar
  19. 19.
    Garbuz DS, Tanzer M, Greidanus NV, Masri BA, Duncan CP. The John Charnley Award: metal-on-metal hip resurfacing versus large-diameter head metal-on-metal total hip arthroplasty: a randomized clinical trial. Clin Orthop Relat Res. 2010;468:318–325.PubMedCrossRefGoogle Scholar
  20. 20.
    Glyn-Jones S, Roques A, Taylor A, Kwon YM, McLardy-Smith P, Gill HS, Walter W, Tuke M, Murray D. The in vivo linear and volumetric wear of hip resurfacing implants revised for pseudotumor. J Bone Joint Surg Am. 2011;93:2180–2188.PubMedCrossRefGoogle Scholar
  21. 21.
    Grammatopolous G, Pandit H, Kwon YM, Gundle R, McLardy-Smith P, Beard DJ, Murray DW, Gill HS. Hip resurfacings revised for inflammatory pseudotumour have a poor outcome. J Bone Joint Surg Br. 2009;91:1019–1024.PubMedGoogle Scholar
  22. 22.
    Gruber FW, Böck A, Trattnig S, Lintner F, Ritschl P. Cystic lesion of the groin due to metallosis: a rare long-term complication of metal-on-metal total hip arthroplasty. J Arthroplasty. 2007;22:923–927.PubMedCrossRefGoogle Scholar
  23. 23.
    Hart AJ, Satchithananda K, Liddle AD, Sabah SA, McRobbie D, Henckel J, Cobb JP, Skinner JA, Mitchell AW. 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. 2012;94:317–325.PubMedCrossRefGoogle Scholar
  24. 24.
    Heilpern GN, Shah NN, Fordyce MJ. Birmingham hip resurfacing arthroplasty: a series of 110 consecutive hips with a minimum five-year clinical and radiological follow-up. J Bone Joint Surg Br. 2008;90:1137–1142.PubMedGoogle Scholar
  25. 25.
    Information for Orthopaedic Surgeons about Metal-on-Metal Hip Implant Surgery. Available at: Accessed July 2012.
  26. 26.
    Kim PR, Beaulé PE, Dunbar M, Lee JK, Birkett N, Turner MC, Yenugadhati N, Armstrong V, Krewski D. Cobalt and chromium levels in blood and urine following hip resurfacing arthroplasty with the Conserve Plus implant. J Bone Joint Surg Am. 2011;93(Suppl 2):107–117.PubMedCrossRefGoogle Scholar
  27. 27.
    Kwon YM, Ostlere SJ, McLardy-Smith P, Athanasou NA, Gill HS, Murray DW. ‘Asymptomatic’ pseudotumors after metal-on-metal hip resurfacing arthroplasty: prevalence and metal ion study. J Arthroplasty. 2011;26:511–518.PubMedCrossRefGoogle Scholar
  28. 28.
    Lavigne M, Ganapathi M, Mottard S, Girard J, Vendittoli PA. Range of motion of large head total hip arthroplasty is greater than 28 mm total hip arthroplasty or hip resurfacing. Clin Biomech (Bristol, Avon). 2011;26:267–273.Google Scholar
  29. 29.
    MacDonald SJ, McCalden RW, Chess DG, Bourne RB, Rorabeck CH, Cleland D, Leung F. Metal-on-metal versus polyethylene in hip arthroplasty: a randomized clinical trial. Clin Orthop Relat Res. 2003;406:282–296.PubMedCrossRefGoogle Scholar
  30. 30.
    Mao X, Wong AA, Crawford RW. Cobalt toxicity—an emerging clinical problem in patients with metal-on-metal hip prostheses? Med J Aust. 2011;194:649–651.PubMedGoogle Scholar
  31. 31.
    McMinn DJ, Daniel J, Ziaee H, Pradhan C. Results of the Birmingham Hip Resurfacing dysplasia component in severe acetabular insufficiency: a six- to 9.6-year follow-up. J Bone Joint Surg Br. 2008;90:715–723.PubMedGoogle Scholar
  32. 32.
    Murray DW, Grammatopoulos G, Gundle R, Gibbons CL, Whitwell D, Taylor A, Glyn-Jones S, Pandit HG, Ostlere S, Gill HS, Athanasou N, McLardy-Smith P. Hip resurfacing and pseudotumour. Hip Int. 2011;21:279–283.PubMedCrossRefGoogle Scholar
  33. 33.
    National Joint Registry (NJR) for England and Wales. Available at: Accessed January 5, 2013.
  34. 34.
    Pandit H, Glyn-Jones S, McLardy-Smith P, Gundle R, Whitwell D, Gibbons CL, Ostlere S, Athanasou N, Gill HS, Murray DW. Pseudotumours associated with metal-on-metal hip resurfacings. J Bone Joint Surg Br. 2008;90:847.PubMedGoogle Scholar
  35. 35.
    Pandit H, Vlychou M, Whitwell D, Crook D, Luqmani R, Ostlere S, Murray DW, Athanasou NA. Necrotic granulomatous pseudotumours in bilateral resurfacing hip arthroplasties: evidence for a type IV immune response. Virchows Arch. 2008;453:529–534.PubMedCrossRefGoogle Scholar
  36. 36.
    Peters CL, McPherson EJ, Jackson JD, Erickson JA. Reduction in early dislocation rate with large-diameter femoral heads in primary total hip arthroplasty. J Arthroplasty. 2007;22:140–144.PubMedCrossRefGoogle Scholar
  37. 37.
    Stuchin SA. Anatomic diameter femoral heads in total hip arthroplasty: a preliminary report. J Bone Joint Surg Am. 2008;90(Suppl 3):52–56.PubMedCrossRefGoogle Scholar
  38. 38.
    Tower SS. Arthroprosthetic cobaltism: neurological and cardiac manifestations in two patients with metal-on-metal arthroplasty: a case report. J Bone Joint Surg Am. 2010;92:2847–2851.PubMedCrossRefGoogle Scholar
  39. 39.
    van der Weegen W, Smolders JM, Sijbesma T, Hoekstra HJ, Brakel K, van Susante JL. High incidence of pseudotumours after hip resurfacing even in low risk patients; results from an intensified MRI screening protocol. Hip Int. 2012 Dec 11. doi:  10.5301/hipint.5000004 [Epub ahead of print].
  40. 40.
    Vendittoli PA, Amzica T, Roy AG, Lusignan D, Girard J, Lavigne M. Metal ion release with large-diameter metal-on-metal hip arthroplasty. J Arthroplasty. 2011;26:282–288.PubMedCrossRefGoogle Scholar
  41. 41.
    Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care. 1992;30:473–483.PubMedCrossRefGoogle Scholar
  42. 42.
    Williams DH, Greidanus NV, Masri BA, Duncan CP, Garbuz DS. Prevalence of pseudotumor in asymptomatic patients after metal-on-metal hip arthroplasty. J Bone Joint Surg Am. 2011;93:2164–2171.PubMedCrossRefGoogle Scholar
  43. 43.

Copyright information

© The Association of Bone and Joint Surgeons® 2013

Authors and Affiliations

  • Sulaiman A. Almousa
    • 1
    • 2
  • Nelson V. Greidanus
    • 1
  • Bassam A. Masri
    • 1
  • Clive P. Duncan
    • 1
  • Donald S. Garbuz
    • 1
  1. 1.Department of OrthopaedicsUniversity of British ColumbiaVancouverCanada
  2. 2.Department of OrthopedicsUniversity of DammamDammamSaudi Arabia

Personalised recommendations