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Anterior Subluxation of a Metal-on-Metal Total Hip Arthroplasty Resulting in Erosion and Metal Debris.

Introduction: Total hip arthroplasty (THA) is a commonly performed and highly successful surgical procedure. Metal-on-metal (MoM) THA implants were introduced two decades ago and subsequently recalled due to high early revision rates. Acetabular cup erosion and fragmentation secondary to chronic edge loading causing delayed instability are rare but devastating complications of MoM THA warranting expeditious revision surgery. Case Presentation: We report a 70-year-old male with a history of bilateral MoM THA who presented with left hip instability. In addition to the radiographic and clinical features of hip instability, macroscopic examination at revision surgery revealed extensive erosion and fragmentation of the antero-superior margin of the implanted cup, osteolysis, and widespread metallosis of the periarticular soft tissues. Discussion: This case highlights a significant adverse complication of MoM THA. Despite the industry's wide discontinuation and recall of these implants, MoM hip arthroplasty implants are present in many patients, who are all at risk of developing similar complications. Guidelines for the surveillance and treatment of both symptomatic and asymptomatic MoM THAs have been reported, although ambiguity remains in the optimal approach for managing patients with existing MoM THA. Conclusion: Failure of MoM hip arthroplasty is most commonly the result of adverse reaction to metal debris. We present a novel mechanism of failure in a patient presenting with late instability due to asymmetric wear of the MoM bearing surface.. While it is uncertain whether early intervention in this patient may have prevented this complication, arthroplasty surgeons should be aware of the various modes of failure for MoM hip implants, as expeditious revision surgery is often required.

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Periprosthetic Joint Infection Occurring Following a Femoral Subcutaneous Cyst: A Rare Complication Post-Total Knee Arthroplasty.

Herein, we present a rare case of periprosthetic joint infection (PJI) which was triggered by an infection with a latent subcutaneous cyst on the thigh and occurred in a strange course following total knee arthroplasty (TKA). An 87-year-old female underwent right TKA followed by left TKA 5 months later. Six weeks after left TKA, a painful subcutaneous induration appeared in the left medial thigh. Magnetic resonance imaging revealed a 30∗50-mm multifocal mass. The cystic fluid was brown and cloudy, indicating an infected cyst. Oral antimicrobial therapy was initiated for 7 days. Nine weeks after the left TKA, a left calcaneal fracture occurred. Subsequently, edema of the lower extremities and pain in the left knee gradually developed. Arthrocentesis was performed twice: joint fluid Gram staining and culture examination were negative. However, at 12.5 weeks, an alpha-defensin test of the synovial fluid was positive. Therefore, PJI was diagnosed. DAIR was performed, followed by multiantibiotic therapy. The infection subsided gradually. Edema of the lower limbs was treated with oral diuretics, lymphatic massage, and compression stockings. Consequently, the lower limb edema also improved. In this case, infection of a latent subcutaneous cyst in the thigh occurred and spread around the prosthesis due to leg edema, which was associated with loss of lower limb motion due to a calcaneal fracture. The presence of a potential thigh subcutaneous cyst is a risk factor for PJI. Moreover, lower extremity edema occurs by decreasing lower extremity motion, such as after a calcaneal fracture, and it increases the risk of extending extra-articular infection to the PJI. Potential thigh subcutaneous cysts and lower extremity edema are risk factors for the development of PJI. Orthopedic surgeons need to be aware of these facts during follow-up after TKA.

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