title: Aseptic Lymphocytic-Dominated Vasculitis-Associated Lesions Scores Do Not Correlate With Metal Ion Levels or Unreadable Synovial Fluid White Blood Cell Counts.
abstract: Failed metal-on-metal (MoM) bearings are being increasingly encountered with little information to guide evaluation for aseptic lymphocytic-dominated vasculitis-associated lesions (ALVAL). It is often assumed that elevated metal ion levels correlate with the occurrence of ALVAL. Our purpose was to determine the utility of the erythrocyte sedimentation rate, C-reactive protein, synovial white blood cell count, differential (%PMN), and serum metal ion levels in diagnosing ALVAL.
  
  
  
  We identified 80-failed MoM total hip arthroplasties. Tissue was examined under light microscopy and graded on a scale of ALVAL severity. Mean laboratory values were compared between groups and receiver operating curves generated with an area under the curve to determine test performance and optimal cutoffs.
  
  
  
  ALVAL scores were graded as low in 30 (37.5%), moderate in 39 (49%), and severe in 8 (10%), with 3 being unreadable. No clear cutoff values for erythrocyte sedimentation rate, C-reactive protein, or synovial white blood cell count could be determined to reliably diagnose moderate or severe ALVAL. Furthermore, serum metal levels had no correlation with ALVAL score. The best test to diagnose ALVAL was the synovial fluid monocyte percentage with an optimal cutoff value of 39% and area under the curve of 69% (moderate testing performance).
  
  
  
  The diagnosis of ALVAL remains challenging, with most of the screening tests being unreliable. Although serum metal ion levels are typically elevated in failed MoM bearings, higher levels do not appear to correlate with ALVAL grade. Elevated synovial fluid monocytes may provide diagnostic utility for ALVAL, suggesting a possible delayed-type hypersensitivity reaction.
authors.affiliation: Department of Orthopaedic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio.
authors.forename: Darren R
authors.initials: DR
authors.lastname: Plummer
authors.affiliation: Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California.
authors.forename: Paul H
authors.initials: PH
authors.lastname: Yi
authors.affiliation: Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois.
authors.forename: Joshua J
authors.initials: JJ
authors.lastname: Jacobs
authors.affiliation: Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois.
authors.forename: Robert M
authors.initials: RM
authors.lastname: Urban
authors.affiliation: Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois.
authors.forename: Mario M
authors.initials: MM
authors.lastname: Moric
authors.affiliation: Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois.
authors.forename: Craig J
authors.initials: CJ
authors.lastname: Della Valle
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D019644:Arthroplasty, Replacement, Hip; D001799:Blood Sedimentation; D002097:C-Reactive Protein / Q000032:analysis; D005260:Female; D005549:Foreign-Body Reaction / Q000097:blood / Q000175:diagnosis* / Q000276:immunology; D006622:Hip Prosthesis / Q000009:adverse effects*; D006801:Humans; D007958:Leukocyte Count; D008297:Male; D008670:Metals / Q000009:adverse effects / Q000097:blood; D008875:Middle Aged; D011475:Prosthesis Failure / Q000009:adverse effects*; D013582:Synovial Fluid / Q000166:cytology* / Q000276:immunology; D014657:Vasculitis / Q000276:immunology / Q000473:pathology
chemical_list: D008670:Metals; D002097:C-Reactive Protein
keywords: ALVAL; adverse local tissue reaction; aseptic lymphocytic-dominated vasculitis-associated lesions; failed metal-on-metal bearing; metal ion levels