title: Aseptic lymphocyte-dominated vasculitis-associated lesion: a clinicopathologic review of an underrecognized cause of prosthetic failure.
abstract: It is estimated that 35% of total hip arthroplasties (THAs) involve a second-generation metal-on-metal (MOM) prosthesis. A novel complication has appeared in a subset of patients with MOM THAs that is described as an aseptic, lymphocyte-dominated vasculitis-associated lesion (ALVAL). The clinical features of ALVAL are nonspecific, but patients complain of pain and may develop "pseudotumors." It is hypothesized that metal ions are released from the prosthesis and form haptens with native proteins that elicit a type IV hypersensitivity response in the local soft tissues. Histopathologic descriptions of ALVAL are similar to those of failed arthroplasty in general, with the addition of a dense perivascular inflammatory infiltrate that is the hallmark of ALVAL. We report 3 cases of ALVAL with clinical, radiographic, and histologic findings. Accurate assessment is crucial because an intraoperative diagnosis of chronic inflammation suggestive of ALVAL will necessitate a replacement of the prosthetic component surfaces.
authors.affiliation: Division of Orthopaedic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA.
authors.forename: Tyler Steven
authors.initials: TS
authors.lastname: Watters
authors.forename: Diana M
authors.initials: DM
authors.lastname: Cardona
authors.forename: K Sunil
authors.initials: KS
authors.lastname: Menon
authors.forename: Emily N
authors.initials: EN
authors.lastname: Vinson
authors.forename: Michael P
authors.initials: MP
authors.lastname: Bolognesi
authors.forename: Leslie G
authors.initials: LG
authors.lastname: Dodd
mesh_terms: D000368:Aged; D019644:Arthroplasty, Replacement, Hip / Q000009:adverse effects / Q000295:instrumentation*; D005260:Female; D006241:Haptens; D006621:Hip Joint / Q000000981:diagnostic imaging / Q000601:surgery; D006622:Hip Prosthesis; D006801:Humans; D006967:Hypersensitivity / Q000209:etiology / Q000473:pathology; D008214:Lymphocytes / Q000473:pathology*; D008297:Male; D008670:Metals / Q000009:adverse effects*; D008875:Middle Aged; D010146:Pain / Q000139:chemically induced / Q000473:pathology; D011474:Prosthesis Design; D011475:Prosthesis Failure / Q000209:etiology*; D011859:Radiography; D014657:Vasculitis / Q000139:chemically induced / Q000473:pathology*
chemical_list: D006241:Haptens; D008670:Metals