Total Hip Arthroplasty Complicated by a Malignant Fibrous Hisfiocytoma A Case Report M i c h a e l I. S o l o m o n , M B , C h B , a n d R o n a l d S e k e l , F R C S ( E d n ) , F R A C S ( O r t h )
Abstract: Tumors associated with total hip arthroplasty are uncommon. The authors report the eighth case of a malignant fibrous histiocytoma associated with a total joint arthroplasty and discuss its etiology and significance. Key words: total hip arthroplasty, malignant fibrous histiocytoma.
Malignancies associated with total joint arthroplasties are rare occurrences. We report a case of a total hip arthroplasty (THA) complicated by the subsequent growth of a malignant fibrous histiocytoma (MFH).
formed. Histological sections of the femoral head showed no evidence of lymphoma. Seven years post THA she again presented with hip pain. There was no evidence of loosening of the prosthesis, and the bone-prosthesis relationship had not changed. A bone scan, however, revealed increased uptake of technitium 99m in the greater trochanter as well as in the proximal third of the femur. The trochanter was percutaneously biopsied using a craig needle. Histological diagnosis confirmed the presence of a MFH. A revision THA was performed using a custommade stem. The proximal third of the femur was resected and the abductors were attached to the prosthesis. The patient mobilized well with two canes. Two and one half years following the revision procedure, a recurrence of the MFH occurred. It was localized to the soft tissue around the hip joint, distending but not penetrating the skin. A hindquarter amputation was performed, excising all malignant tissue and a 5 cm margin of healthy tissue. Resected lymph nodes showed no evidence of tumor, and at the time of this report, the patient is 2 years post surgery with no clinical or radiologic evidence of recurrence.
Case Report A'48-year-old woman presented with a painful right hip. On clinical examination the hip joint was normal, however, an erosive lesion in the femoral head was suspected on plain radiographs. A bone scan confirmed this lesion. The greater trochanter was noted as normal. On general examination an abdominal mass was palpated, and following further investigation a provisional diagnosis of lymphoma was made. Staging laperotomy confirmed a histiocytic non-Hodgkin's lymphoma. A course of radiotherapy (3,500 R) to the hip joint was initiated. The patient also had a course of chemotherapy. Six months after initial presentation her hip pain worsened and she developed an antalgic gait. Repeat radiographs showed a flattening of the femoral head. A right cemented Chamley-Muller THA was per-
Discussion
Front the Orthopaedic Skills Laboratory, The St. George Hospital Sydney, Australia.
This report appears to be the eighth case of MFH associated with total joint arthroplasty reviewed by the literature. ~'3"7"9o~0
Reprint requests: Ronald Sekel, OrthopaedicSkills Laboratory, The St. George Hospital, BelgraveStreet, Kogarah, NSW 2217, Australia.
549
550
The Journal of Arthroplasty Vol. 7 No. 4 December 1992
M a n y past reports h a v e tried to link the appearance of a t u m o r with the materials of the prosthetic implants or cement, 5"8 but no uniformly conclusive results h a v e p r o v e n this association. 4 Bone necrosis and ischemia, however, are factors agreed u p o n by most authorities to be predisposing causes. T M This patient demonstrates several factors k n o w n to contribute to the development of a MFH, including the late effects of radiotherapy to soft tissue. Weiss and Enzinger reported MFH associated with various hematopoietic diseases, including n o n - H o d g k i n ' s 1ymphoma. l 1 The incidence of MFH associated with THA appears to be exceedingly low. Malignancy adjacent to a THA should be considered in the differential diagnosis of localized pain and swelling a r o u n d the replaced joint, especially w h e n these s y m p t o m s and signs occur a n u m b e r of years following joint arthroplasty. Paget's disease, hamatopoietic malignancies, and even steroid therapy have b e e n s h o w n to be predisposing causes ofMFH, z and one should be suspicious in patients with these underlying conditions.
References 1. Bago-Granell J, Aguirre-Canyadell M, Nardi J, Tallada N: Malignant fibrous histiocytoma of bone at the site of a total hip arthroplasty: a case report. J Bone Joint Surg 66B:38, 1984
2. Dahzin DC, Krishnan KU, Matsuno T: Malignant (fibrous) histiocytoma of bone: fact or fancy? Cancer 39: 1508, 1977 3. Haag M, Adler CP: Malignant fibrous histiocytoma in association with hip replacement. J Bone Joint Surg 71B:701, 1989 4. Hamblen DL, Carter RL: Sarcoma and joint replacement: editorial. J Bone Joint Surg 66B:625, 1984 .5. Laskin DM, Robinson IB, Weinmann JP: Experimental production of sarcomas by methylmethacrylate implants. Proc Soc Exp Biol Med 87:329, 1954 6. Mirra JM et al: Malignant fibrous histiocytoma and osteosarcoma in association with bone infarction: report of four cases, two in caisson workers. J Bone Joint Surg 56A:932, 1974 7. Swann M: Malignant soft-tissue tumour at the site of a total hip replacement. J Bone Joint Surg 66B:629, 1984 8. Swanson SAV, Freeman MAR, Heath JC: Laboratory tests on total joint replacement prostheses. J Bone Joint Surg 55B:759, 1973 9. Tait NP, Hacking PM, Malcolm AJ: Malignant fibrous histiocytoma occurring at the site of a previous total hip replacement. Br J Radiol 61:73, 1988 10. Troop JT, Mallory TH, Fisher DA, Vaughn BK: Malignant fibrous histiocytoma after total hip arthroplasty: a case report. Clin Orthop 253:297, 1990 I1. Weiss W, Enzinger FM: Malignant fibrous histiocytoma: an analysis of 200 cases. Cancer 41:2250, 1978
Abstract: Tumors associated with total hip arthroplasty are uncommon. The authors report the eighth case of a malignant fibrous histiocytoma associated with a total joint arthroplasty and discuss its etiology and significance. Key words: total hip arthroplasty, malignant fibrous histiocytoma.
Malignancies associated with total joint arthroplasties are rare occurrences. We report a case of a total hip arthroplasty (THA) complicated by the subsequent growth of a malignant fibrous histiocytoma (MFH).
formed. Histological sections of the femoral head showed no evidence of lymphoma. Seven years post THA she again presented with hip pain. There was no evidence of loosening of the prosthesis, and the bone-prosthesis relationship had not changed. A bone scan, however, revealed increased uptake of technitium 99m in the greater trochanter as well as in the proximal third of the femur. The trochanter was percutaneously biopsied using a craig needle. Histological diagnosis confirmed the presence of a MFH. A revision THA was performed using a custommade stem. The proximal third of the femur was resected and the abductors were attached to the prosthesis. The patient mobilized well with two canes. Two and one half years following the revision procedure, a recurrence of the MFH occurred. It was localized to the soft tissue around the hip joint, distending but not penetrating the skin. A hindquarter amputation was performed, excising all malignant tissue and a 5 cm margin of healthy tissue. Resected lymph nodes showed no evidence of tumor, and at the time of this report, the patient is 2 years post surgery with no clinical or radiologic evidence of recurrence.
Case Report A'48-year-old woman presented with a painful right hip. On clinical examination the hip joint was normal, however, an erosive lesion in the femoral head was suspected on plain radiographs. A bone scan confirmed this lesion. The greater trochanter was noted as normal. On general examination an abdominal mass was palpated, and following further investigation a provisional diagnosis of lymphoma was made. Staging laperotomy confirmed a histiocytic non-Hodgkin's lymphoma. A course of radiotherapy (3,500 R) to the hip joint was initiated. The patient also had a course of chemotherapy. Six months after initial presentation her hip pain worsened and she developed an antalgic gait. Repeat radiographs showed a flattening of the femoral head. A right cemented Chamley-Muller THA was per-
Discussion
Front the Orthopaedic Skills Laboratory, The St. George Hospital Sydney, Australia.
This report appears to be the eighth case of MFH associated with total joint arthroplasty reviewed by the literature. ~'3"7"9o~0
Reprint requests: Ronald Sekel, OrthopaedicSkills Laboratory, The St. George Hospital, BelgraveStreet, Kogarah, NSW 2217, Australia.
549
550
The Journal of Arthroplasty Vol. 7 No. 4 December 1992
M a n y past reports h a v e tried to link the appearance of a t u m o r with the materials of the prosthetic implants or cement, 5"8 but no uniformly conclusive results h a v e p r o v e n this association. 4 Bone necrosis and ischemia, however, are factors agreed u p o n by most authorities to be predisposing causes. T M This patient demonstrates several factors k n o w n to contribute to the development of a MFH, including the late effects of radiotherapy to soft tissue. Weiss and Enzinger reported MFH associated with various hematopoietic diseases, including n o n - H o d g k i n ' s 1ymphoma. l 1 The incidence of MFH associated with THA appears to be exceedingly low. Malignancy adjacent to a THA should be considered in the differential diagnosis of localized pain and swelling a r o u n d the replaced joint, especially w h e n these s y m p t o m s and signs occur a n u m b e r of years following joint arthroplasty. Paget's disease, hamatopoietic malignancies, and even steroid therapy have b e e n s h o w n to be predisposing causes ofMFH, z and one should be suspicious in patients with these underlying conditions.
References 1. Bago-Granell J, Aguirre-Canyadell M, Nardi J, Tallada N: Malignant fibrous histiocytoma of bone at the site of a total hip arthroplasty: a case report. J Bone Joint Surg 66B:38, 1984
2. Dahzin DC, Krishnan KU, Matsuno T: Malignant (fibrous) histiocytoma of bone: fact or fancy? Cancer 39: 1508, 1977 3. Haag M, Adler CP: Malignant fibrous histiocytoma in association with hip replacement. J Bone Joint Surg 71B:701, 1989 4. Hamblen DL, Carter RL: Sarcoma and joint replacement: editorial. J Bone Joint Surg 66B:625, 1984 .5. Laskin DM, Robinson IB, Weinmann JP: Experimental production of sarcomas by methylmethacrylate implants. Proc Soc Exp Biol Med 87:329, 1954 6. Mirra JM et al: Malignant fibrous histiocytoma and osteosarcoma in association with bone infarction: report of four cases, two in caisson workers. J Bone Joint Surg 56A:932, 1974 7. Swann M: Malignant soft-tissue tumour at the site of a total hip replacement. J Bone Joint Surg 66B:629, 1984 8. Swanson SAV, Freeman MAR, Heath JC: Laboratory tests on total joint replacement prostheses. J Bone Joint Surg 55B:759, 1973 9. Tait NP, Hacking PM, Malcolm AJ: Malignant fibrous histiocytoma occurring at the site of a previous total hip replacement. Br J Radiol 61:73, 1988 10. Troop JT, Mallory TH, Fisher DA, Vaughn BK: Malignant fibrous histiocytoma after total hip arthroplasty: a case report. Clin Orthop 253:297, 1990 I1. Weiss W, Enzinger FM: Malignant fibrous histiocytoma: an analysis of 200 cases. Cancer 41:2250, 1978
