Periprosthetic Fluid Collections Research Articles

Metal artifact reduction sequence-MRI abnormalities in asymptomatic patients with dual-mobility hip prostheses.

Modular dual-mobility (DM) articulations are increasingly used during total hip arthroplasty (THA). However, concerns remain regarding the metal liner modularity. This study aims to correlate metal artifact reduction sequence (MARS)-MRI abnormalities with serum metal ion levels in patients with DM articulations. A total of 45 patients (50 hips) with a modular DM articulation were included with mean follow-up of 3.7 years (SD 1.2). Enrolled patients with an asymptomatic, primary THA and DM articulation with over two years' follow-up underwent MARS-MRI. Each patient had serum cobalt, chromium, and titanium levels drawn. Patient satisfaction, Oxford Hip Score, and Forgotten Joint Score-12 (FJS-12) were collected. Each MARS-MRI was independently reviewed by fellowship-trained musculoskeletal radiologists blinded to serum ion levels. Overall, two patients (4.4%) had abnormal periprosthetic fluid collections on MARS-MRI with cobalt levels > 3.0 μg/l. Four patients (8.9%) had MARS-MRI findings consistent with greater trochanteric bursitis, all with cobalt levels < 1.0 μg/l. A seventh patient had a periprosthetic fluid collection with normal ion levels. Of the 38 patients without MARS-MRI abnormalities, 37 (97.4%) had cobalt levels < 1.0 μg/l, while one (2.6%) had a cobalt level of 1.4 μg/l. One patient (2.2%) had a chromium level > 3.0 μg/l and a periprosthetic fluid collection. Of the 41 patients with titanium levels, five (12.2%) had titanium levels > 5.0 μg/l without associated MARS-MRI abnormalities. Periprosthetic fluid collections associated with elevated serum cobalt levels in patients with asymptomatic DM articulations occur infrequently (4.4%), but further assessment is necessary due to implant heterogeneity.

Case of Mycobacterium bovis Prosthetic Joint Infection from Intravesicular BCG

An 89-year-old man was seen for worsening left hip pain. He had a history of bladder cancer status post-transurethral resection of bladder tumor followed by intravesicular instillations of bacillus Calmette-Guérin (BCG). About one year later, he developed worsening pain in his left prosthetic hip that continued to worsen over the next three months. A computed tomography scan of the hip revealed loosening hardware and periprosthetic fluid collection. Aspiration and operative cultures revealed Mycobacterium bovis BCG. Susceptibility testing revealed resistance to pyrazinamide. The patient underwent a surgical washout with retention of hardware. Treatment with isoniazid, rifampin, ethambutol, and pyridoxine was initiated. This case highlights an extremely rare and delayed complication of intravesicular BCG leading to prosthetic joint infection.

METAL ARTIFACT REDUCTION SEQUENCE MRI ABNORMALITIES IN ASYMPTOMATIC PATIENTS WITH DUAL MOBILITY HIP PROSTHESES

Modular dual mobility (DM) articulations are increasingly utilized during total hip arthroplasty (THA). However, concerns remain regarding the metal liner modularity. This study aims to correlate metal artifact reduction sequence (MARS) magnetic resonance imaging (MRI) abnormalities with serum metal ion levels in patients with DM articulations.All patients with an asymptomatic, primary THA and DM articulation with &gt;2-year follow-up underwent MARS-MRI of the operative hip. Each patient had serum cobalt, chromium, and titanium levels drawn. Patient satisfaction, Oxford Hip Score, and Forgotten Joint Score-12 (FJS-12) were collected. Each MARS-MRI was independently reviewed by fellowship-trained musculoskeletal radiologists blinded to serum ion levels.Forty-five patients (50 hips) with a modular DM articulation were included with average follow-up of 3.7±1.2 years. Two patients (4.4%) had abnormal periprosthetic fluid collections on MARS-MRI with cobalt levels &gt;3.0 μg/L. Four patients (8.9%) had MARS-MRI findings consistent with greater trochanteric bursitis, all with cobalt levels &lt; 1.0 μg/L. A seventh patient had a periprosthetic fluid collection with normal ion levels. Of the 38 patients without MARS-MRI abnormalities, 37 (97.4%) had cobalt levels &lt;1.0 μg/L, while one (2.6%) had a cobalt level of 1.4 μg/L. One patient (2.2%) had a chromium level &gt;3.0 μg/L and a periprosthetic fluid collection. Of the 41 patients with titanium levels, five (12.2%) had titanium levels &gt;5.0 μg/L without associated MARS-MRI abnormalities.Periprosthetic fluid collections associated with elevated serum cobalt levels in patients with asymptomatic dual mobility articulations occur infrequently (4.4%), but further assessment of these patients is necessary.Level of Evidence: Level IV

Breast Implant Capsule-Associated Squamous Cell Carcinoma during Pregnancy: A Mimicker of Breast Implant-Associated Anaplastic Large-Cell Lymphoma.

Breast Implant Capsule-Associated Squamous Cell Carcinoma during Pregnancy: A Mimicker of Breast Implant-Associated Anaplastic Large-Cell Lymphoma.

Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL)

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a distinct type of T-cell lymphoma, developing around implants, that can occur 2 to 25 years (median 8 years) post-implantation. Most patients present with a swelling of the breast, which is usually associated with pain and fluid collecting around the implant. Less commonly, a lump in the breast and/or in the axilla can be present. A periprosthetic fluid collection (> 1 year post-implantation) should be investigated with ultrasound and fine needle aspiration. Immunohistochemistry confirms the diagnosis BIA-ALCL with CD30+ and ALK- expression. In most patients with disease localized to the periprosthetic fluid, surgery alone usually is curative. A total capsulectomy and bilateral implant removal should be performed. Before surgical intervention, international recommendations state that a PET-CT scan should be done to exclude disseminated disease. The international profile registry (www.thepsf.org/profile) collects all confirmed cases.

Ultrasound evaluations and guided procedures of the painful joint arthroplasty.

The purpose of this article is to describe the use of ultrasound for the diagnosis and treatment of painful joint arthroplasty. Ultrasound plays a crucial role in the diagnosis of the painful joint arthroplasty, especially given its unique dynamic capabilities, convenience, and high resolution. Ultrasound guidance is also instrumental for procedures in both diagnosing and in select cases, treating the painful joint arthroplasty. Topics to be discussed in this article include trends in arthroplasty placement, benefits of the use of ultrasound overall, and ultrasound evaluation of periprosthetic joint infections. We will also review the sonographic findings with dissociated/displaced components and adverse reaction to metallic debris including metallosis, trunnionosis, and metal-on-metal pseudotumors. Additionally, we will discuss ultrasound evaluation of tendon pathologies with arthroplasties, including dynamic maneuvers to evaluate for tendon impingement/snapping. Finally, we will cover ultrasound-guided joint arthroplasty injection indications and precautions. KEY POINTS: • Ultrasound is preferred over MRI in patients with joint arthroplasty and plays a crucial role in diagnosis, especially given its unique dynamic capabilities, convenience and high resolution. • It is especially beneficial for US-guided aspiration in periprosthetic joint infections; effectively used to evaluate periprosthetic fluid collections, facilitating differentiation between abscesses and aseptic collections, and tracking sinus tracts. • Recently, the diagnosis of periprosthetic joint infections has shifted focus to biomarkers in the periprosthetic fluid, specifically α-defensin, which has a high sensitivity and specificity for diagnosing infection. • Cutibacterium acnes is a major pathogen responsible for shoulder arthroplasty infections, often presenting with normal laboratory values and since slow growing, must be kept for a minimum of 14days.

Breast Implant-associated Anaplastic Large Cell Lymphoma Affecting a Neosubpectoral Pocket

The complications associated with breast implants are under perpetual scrutiny to maximize patient safety. In this era of plastic surgery, a new concern being addressed is breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). Patients with BIA-ALCL most commonly present several years after implant placement with a periprosthetic fluid collection. The body of literature and reports of BIA-ALCL continues to grow with additional nuances in proposed causes as well as management. Most recently, this has led to a recall of breast implants manufactured utilizing a specific texturing. We describe here the time course, diagnosis, and management of BIA-ALCL in a 52-year-old patient who underwent submuscular implant-based reconstruction and subsequent revision of that reconstruction with the creation of a neosubpectoral pocket. The patient was managed in accordance with current guidelines under the supervision of a multidisciplinary team. In our review of the literature, several case reports, case series, and guideline publications were identified. Current guidelines for management are based on the staging of BIA-ALCL at diagnosis and span from only surgical with implant removal, excision of the lymphoma, and excision of the surrounding fibrous capsule to addition of chemotherapeutic regimens or radiation for distant and locally advanced disease.

Radiological Imaging Evaluation of the Failing Total Hip Replacement.

Total hip replacements (THR) have been performed in the UK from the 1960s and since then we have seen surgical techniques, the design of implants, and imaging modalities rapidly develop. This paper will aim to review the different complications and imaging appearance which help to evaluate each problem. As for all investigations for bone and joints, a radiograph is the first imaging to be performed for any patient with a THR and can detect a majority of complications. CT is relatively low-cost, simple to perform and easily available making it an excellent tool to supplement radiographs when trying to evaluate a hip prosthesis. Single photon emission computed tomography with CT (SPECT-CT) is an emerging modality which has shown to combine the sensitivity that bone scintigraphy offers with the high specificity of CT. SPECT imaging also has the advantage of showing the bone's metabolic activity and is less prone to metal artifact than Magnetic resonance imaging (MRI). MRI has evolved to become an important diagnostic tool for the evaluation of THR in the post-operative period. Optimized pulse sequences and metal artifact reduction techniques have made MRI a useful tool in diagnosis of soft tissue abnormalities and is particularly useful in identifying adverse local tissue reactions in metal on metal implants. CT and MRI are accurate in identifying the diagnosis of most causes of THR complications except infection. Research confirms that leukocyte-marrow scintigraphy is the modality of choice for accurately diagnosing prosthetic joint infection and reassures us of its superiority over other nuclear medicine imaging. However, due to the limited availability and increased costs when performing leukocyte-marrow scintigraphy, CT and SPECT-CT would be a more preferred option when suspecting prosthesis infection. Ultrasound (US) has a limited role in the assessment of most THR complications but can be useful to identify peri-prosthetic fluid collections and the presence of soft tissue sinus tracts. Being aware of the imaging modalities that are available to orthopedic surgeons, and discussing these challenging cases with specialist radiologists will enable optimal management of THR complications.

Ultrasound-based decision making following metal-on-metal hip arthroplasty

BackgroundMetal-on-Metal (MoM) total hip arthroplasty (THA) represents a very controversial procedure because of the possibility of postoperative adverse local tissue reaction (ALTR). This study investigates the reliability of the ultrasound scan as a diagnostic tool to quantify a clinically useful threshold in the level of periprosthetic fluid collection to suggest implant revision. MethodsThis study includes 116 patients (123 implants) who received an Articular Surface Replacement XL (ASRTMXL, De Puy Synthes, USA) MoM THA. The study group included 56 males and 60 females with a mean age of 66.6 years (range, 15–86 years). All patients were clinically and radiologically annually evaluated (according to the Harris Hip Score) up to a mean follow-up of 7.5 years (min. 1.4 – max. 10.3 years) from the primary surgery: all patients underwent standard ultrasound evaluation of the affected hip and Cobalt/Chromium blood detection testing according to a custom-made diagnostic algorithm for MoM THA revision. ResultsAt final follow-up, 51 (43.1%) of 117 implants underwent revision after a mean of 6 years (1.79–9.26) from the primary ASR implant. The authors found a statistically significant correlation between Cr (p = 0.015) and Co (p = 0.009) blood values and different ultrasound grades. Statistical analysis showed a significant association between periprosthetic fluid collection and revision surgery (p < 0.0001) and the final revision risk was estimated to be 7 times greater in patients with ultrasound grade ≥ 2 (peri-prosthetic collection ≥ 20 mm). ConclusionsThis study confirms the reliability of ultrasound evaluation in detecting clinically significant peri-prosthetic joint effusions: a new diagnostic algorithm for MoM THA revision is here presented. Longer follow up studies are mandatory to better understand the potential advantages of this diagnostic protocol.

Patient Registry and Outcomes for Breast Implants and Anaplastic Large Cell Lymphoma Etiology and Epidemiology (PROFILE): Initial Report of Findings, 2012-2018.

In January of 2011, the US Food and Drug Administration released a safety communication regarding the potential association between breast implants and anaplastic large cell lymphoma (ALCL). In August of 2012, the American Society of Plastic Surgeons, The Plastic Surgery Foundation, and the Food and Drug Administration signed a cooperative research and development agreement to develop a patient registry entitled the "Patient Registry and Outcomes for Breast Implants and Anaplastic Large Cell Lymphoma Etiology and Epidemiology" (PROFILE). The first report of the registry findings is presented here. From August of 2012 to March of 2018, a total of 186 distinct cases of breast implant-associated ALCL (BIA-ALCL) in the United States were reported to PROFILE. At the time of this present analysis, complete detailed case report forms have been received for 89 (48%) cases. Median time from implantation of any device to BIA-ALCL diagnosis was 11.0 years (range = 2-44 years; n = 89). At the time of presentation, 96% of cases had local symptoms and 9% had concurrent systemic symptoms. The most common local symptom was a periprosthetic fluid collection seen in 86% of patients. All patients had a history of a textured device; there were no patients who had a smooth-only device history. At the time of initial case report submission, 3 deaths were reported. The PROFILE Registry has shown to be an essential tool in unifying the collection of data pertaining to BIA-ALCL. These data have broadened our understanding of the disease and emphasize the critical importance of detailed tracking of BIA-ALCL cases.

Validation of a CD30 Enzyme-Linked Immunosorbant Assay for the Rapid Detection of Breast Implant-Associated Anaplastic Large Cell Lymphoma.

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is an uncommon type of non-Hodgkin lymphoma occurring in the fluid or capsule adjacent to textured breast implants. Diagnosis of BIA-ALCL of symptomatic patients requires demonstration of large anaplastic cells with uniform expression of CD30 protein on immunohistochemistry. The authors investigated a novel, rapid, office-based, and economic in-situ enzyme-linked immunosorbent assay (ELISA) for screening BIA-ALCL patients. A commercially available in-situ ELISA was standardized and validated for patients with confirmed BIA-ALCL diagnosis with clinical isolates. A panel of 9 pathologically confirmed BIA-ALCL patients was screened by serum, plasma, and periprosthetic effusion specimens and compared against serum, plasma, and nonneoplastic delayed seromas in 7 control patients. Statistical analysis demonstrated assay consistency and reliability. All BIA-ALCL effusions demonstrated CD30 ELISA detection at full and all serial concentrations. BIA-ALCL serum specimens and all control specimens were negative at full concentration and serial dilutions (1:100, 1:250, 1:500, and 1:1000). BIA-ALCL plasma specimens were weakly positive at full concentration and revealed no activity with serial dilution. This is the first study to demonstrate a viable alternative to CD30 immunohistochemistry for the screening of BIA-ALCL. Our study demonstrates 100% sensitivity in seroma fluid with no detectable CD30 in benign seroma samples. A CD30 ELISA represents a novel, low-cost screening test, which may be used to screen suspicious aspirations of delayed periprosthetic fluid collections in an office-based setting.

Anaplastic Large Cell Lymphoma Associated with Double-Lumen Breast Implants: A Case Report and Review of the Literature

Background: Breast implant-associated anaplastic large cell lymphoma (ALCL) is commonly associated with diagnostic delay due to the insidious nature of presentation with late periprosthetic fluid collection, mass or locoregional adenopathy. Case Presentation: A 75-year-old woman with a remote history of right breast cancer treated with modified radical mastectomy and immediate reconstruction with a double-lumen silicone implant presented 13 years later with volume asymmetry. The implant was removed and a saline implant was placed. Five years later, she presented with acute onset of right breast enlargement and pain. Ultrasound revealed an associated periprosthetic fluid accumulation. Cytology showed anaplastic lymphoma kinasenegative, CD30-positive ALCL without associated systemic disease. The patient was treated with implant removal and total capsulectomy. Conclusion: Due to the insidious presentation of ALCL, a high index of clinical suspicion must be maintained when evaluating patients for delayed presentation of volumetric discrepancy. Treatment typically entails implant removal. Indications for additional systemic treatment include extracapsular spread of ALCL or presence of a periprosthetic tumour.

Inflammatory pseudotumor of the hip: a complication of arthroplasty to be recognized by the radiologist.

Soft tissue complications following hip arthroplasty may occur either in cases of total hip arthroplasty or in hip resurfacing, a technique that has become popular in cases involving young patients. Both orthopedic and radiological literatures are now calling attention to these symptomatic periprosthetic soft tissue masses called inflammatory pseudotumors or aseptic lymphocytic vasculites-associated lesions. Pseudotumors are associated with pain, instability, neuropathy, and premature loosening of prosthetic components, frequently requiring early and difficult reoperation. Magnetic resonance imaging plays a relevant role in the evaluation of soft tissue changes in the painful hip after arthroplasty, ranging from early periprosthetic fluid collections to necrosis and more extensive tissue damage.

MRI Findings Following Metal on Metal Hip Arthroplasty and Their Relationship With Metal Ion Levels and Acetabular Inclination Angles

Following the global recall of all ASR metal on metal hip products, our aim was to correlate MRI findings with acetabular inclination angles and metal ion levels in patients with these implants. Both cobalt and chromium levels were significantly higher in the presence of a periprosthetic fluid collection. There was no association between the presence of a periprosthetic mass, bone marrow oedema, trochanteric bursitis or greater levels of abductor muscle destruction for cobalt or chromium. There was no association between the level of periprosthetic tissue reaction and the acetabular inclination angle with any of the pathologies identified on MRI. The relationship between MRI pathology, metal ion levels and acetabular inclination angles in patients with ASR implants remains unclear adding to the complexity of managing patients.

Diagnosis of Periprosthetic Joint Infection

Diagnosis of Periprosthetic Joint Infection

Aorto-enteric fistulas: A physiopathological approach and computed tomography diagnosis

Infection of an abdominal aortic prosthesis with an enteroprosthetic fistula is a very serious, life-threatening complication, leading sometimes to severe functional consequences, the most serious being amputation. Since the symptoms, if there are any, are often rather non-specific, diagnosis is frequently difficult and has always to be based on a whole series of justifications. Early diagnosis is essential and this fistula should be the first possibility considered in a patient with an abdominal aortic prosthesis who is presenting rectorrhagia or melaena (even if only to a slight degree), sepsis and/or abdominal pain. Although rare, the clinical existence of hypertrophic osteoarthropathy may assist diagnosis. A CT scan is the examination of choice, the criteria providing evidence of a fistula being the presence of gaseous images in a periprosthetic fluid collection, thickening and/or retraction of the intestinal walls in contact, the existence of a false aneurysm, and finally, very rarely, extravasation of contrast agent into the intestinal lumen. The differential diagnoses that may mimic a fistula need to be well known, and can include retroperitoneal fibrosis, an infectious aneurysm, inflammatory or infectious aortitis, and above all, a 'simple' prosthesis infection without fistulisation.

CT of the Hip Prosthesis: Appearance of Components, Fixation, and Complications

Multidetector computed tomography (CT) is an excellent way to supplement the radiographic evaluation of problematic hip prostheses. Multidetector CT is well suited for assessing periprosthetic bone, determining precise acetabular cup position, and evaluating periprosthetic fluid collections or ossified masses. Metal implants pose a number of challenges in the performance and interpretation of CT examinations. However, metal artifacts can be minimized by decreasing the detector collimation and pitch, increasing the kilovolt peak and milliampere-seconds, and using appropriate reconstruction algorithms and section thickness. Image interpretation requires a basic understanding of hip reconstruction and hip implants, as well as use of a systematic method of analysis that incorporates prior radiographic findings and CT findings. Radiologists must be familiar with the normal and abnormal CT appearances of hip prostheses and be able to recognize common complications on CT scans.

MRI of Aseptic Lymphocytic Vasculitis–Associated Lesions in Metal-on-Metal Hip Replacements

The aim of this review is to describe the clinical, histopathologic, and MRI features of aseptic lymphocytic vasculitis-associated lesions in total hip replacements. The introduction of modern metal-on-metal hip arthroplasty has been accompanied by a newly described disease, aseptic lymphocytic vasculitis-associated lesions, which is characterized histologically by bland necrosis and dense perivascular lymphocytic infiltrates. Conventional radiographic findings are often normal, but the typical MRI findings include periprosthetic fluid collections, soft-tissue masses, gluteal tendon avulsion, bone loss, periosteal stripping, neurovascular involvement, and periprosthetic fractures. The severity of the histologic and MRI appearances can be graded according to defined published criteria.

Magnetic resonance imaging of painful total hip replacement: detection and characterisation of periprosthetic fluid collection and interobserver reproducibility

The purpose of our study was to demonstrate the diagnostic value of magnetic resonance imaging (MRI) when measuring and characterising periprosthetic fluid collections in patients with painful hip prosthesis and to provide an estimation of interobserver reproducibility. Nineteen patients (mean age 59±13 years) with painful total hip replacement and clinical suspicion of infection underwent MRI. Images were reviewed blindly by two musculoskeletal radiologists with different levels of experience who evaluated the presence/absence of soft tissue oedema or fluid collection (when present, three-plane maximal diameters were measured; involvement of skin/subcutaneous/deep tissues or prosthesis were estimated; fluid was classified as serous/purulent/haematic according to signal behaviour). Interobserver agreement was calculated (Cohen's ). A total of 26 MRI studies were carried out (three patients underwent two and two patients underwent three MRI examinations). Both readers detected soft tissue oedema (13/26, 50%) or fluid collection (21/26, 81%) and characterised the fluid as serous (9/21, 43%), purulent (8/21, 38%) or haematic (4/21, 19%). The collection involved skin/subcutaneous tissues (16/21, 76%), deep soft tissues (19/21, 91%) or the implant (12/21, 57%). For all evaluations, interobserver agreement was complete (=1). No significant differences were found between the measurements of the collections (p>0.258). MRI is highly reproducible in detection, localisation, quantification, and characterisation of fluid collections when the presence of implant infection is clinically suspected.

Managing Late Periprosthetic Fluid Collections (Seroma) in Patients with Breast Implants: A Consensus Panel Recommendation and Review of the Literature

The goal of this consensus is to establish an algorithm for the management of patients who develop a late or delayed periprosthetic fluid collection. A work group of practicing plastic surgeons and device industry physicians met periodically by teleconference and discussed issues pertinent to the diagnosis and management of late periprosthetic fluid collections in patients with breast implants. Based on these meetings, treatment recommendations and a treatment algorithm were prepared in association with an editorial assistant. The work group participants discussed optimal care approaches developed in their private practices and from evidence in the literature. The consensus algorithm and treatment and management recommendations represent the consensus of the group. The group concluded that late periprosthetic fluid collection (arbitrarily defined as occurring ≥ 1 year after implant) is an infrequently reported occurrence (0.1 percent) after breast implant surgery and that, at a minimum, management should include clinically indicated ultrasound-guided aspiration of fluid, with appropriate cultures and cytologic testing. Further evaluation and additional treatment is recommended for recurrence of periprosthetic fluid collection after aspiration, or clinical suspicion of infection or neoplasia.