Aim

What is the fate of revision total joint arthroplasty, when conventional tissue sample culture (TSC) is negative and sonication fluid culture (SFC) is positive, in terms of re-revision?

Introduction: There are ongoing concerns regarding metal wear debris following the use of metal-on-metal (MonM) bearings for hip surface and total arthroplasty. A Type IV Hypersensitivity reaction to MonM articulations has previously been identified (aseptic lymphocyte dominated vasculitis associated lesion, ALVAL) but little is known of its incidence, diagnosis or management. Persisting groin pain in MonM patients may be undiagnosed ALVAL. At our single centre we have reviewed and compared three types of MonM articulations to examine the incidence of ALVAL and to identify trends.

Methods: The resurfacing group comprised 250 patients with the ASR prosthesis. In the resurfacing hybrid total hip replacement (THR) group there were 86 patients implanted with an ASR head on a stem. The final group comprised of 625 patients with a MonM THR using a 36mm Pinnacle head. Both the S-ROM and the Corail stems were used in the THR groups. Patients with persisting and activity-restricting groin pain had tests for infection. Patients were counselled and revision was offered if ALVAL was suspected from the clinical picture, blood results and the aspiration result. Specimens for microbiological and histological analysis were taken at the time of revision.

Results: We found 5 cases of histologically proven ALVAL in the absence of infection in 961 patients. The incidence was: 1.2% in the resurfacing group, 2.3% of Resurfacing Hybrid THR group and 0 in the 36 mm THR group. All 5 cases were in female patients. Only 1 case had any radiological abnormality. One patient was initially revised from a resurfacing to a 36mm MonM THR without clinical success. All patients have now been revised to ceramic-on-ceramic bearings with improvements in outcome.

Discussion: ALVAL may be under-diagnosed. The 5 patients we describe showed good clinical recovery following their primary procedure. However, activity levels decreased and pain increased at 6–12 months post-op. All described non-specific systemic symptoms. On examination, a painful straight leg raise was a characteristic finding. This may result from the significant effusion found around the hip at each revision. Fluid aspirated from these hips was of a characteristic colour (green grey) and viscosity. The failure of the revision of a resurfacing to a smaller MonM bearing highlights the problem of sensitisation to the metal debris. Any subsequent revision to a MonM bearing is unlikely to improve clinical outcome. This finding is consistent with previous reports in the literature. Our results suggest the incidence of ALVAL may be higher that previously thought. We suggest all patients with significant groin pain should have inflammatory markers tests and a hip aspiration performed. In the absence of infection, revision to an alternative bearing surface may be indicated.