Recurrent arthrocele and sterile sinus tract formation due to ceramic wear as a differential diagnosis of periprosthetic joint infection — a case report

A 63-year-old female patient with total hip arthroplasty (THA) presented at our clinic with a massive swelling of the right hip joint. 13 years ago, cementless THA with an alumina ceramic-on-ceramic bearing (Biolox forte, CeramTec GmbH, Plochingen, Germany) had been performed due to advanced osteoarthritis.

In the first years after THA, the patient had been symptom-free. The patient then complained of a swelling when sitting. MRI and CT showed a fluid-filled tumor of the right hip joint expanding into the gluteal muscle. Laboratory infection parameters were normal (C-reactive protein: not detectable; leucocytes: 7.1 G/L).

The patient was twice bursectomized elsewhere 12 years after the THA and histopathological examination pointed to a granulomatous disease. Various differential diagnoses such as rheumatoid arthritis, sarcoidosis, tuberculosis and rare causes such as brucellosis, toxoplasmosis, echinococcosis and mycosis as well as an adverse local tissue reaction (ALTR) due to abrasive wear particles were considered.

As further diagnostic procedures including QuantiFERON test and chest radiography showed no signs of tuberculosis and sarcoidosis, we performed an open synovial biopsy 10 months later to search for abrasive wear particles and to exclude periprosthetic joint infection (PJI). The dorsal hip joint capsule and the arthrocele were completely resected. Histology showed granulomas of the foreign body type and very sparse birefringent wear particles. In 5 of 8 tissue samples, the histological criteria for PJI according to Krenn et al. (20179) were not met. The microbiological culturing of tissue samples and synovial fluid over 14 days remained sterile. As the arthrocele recurred, revision THA was performed another 2 months later with suspicion of ALTR to wear particles and the acetabular cup, which was firmly integrated into the bone, was exchanged (Allofit IT, Zimmer, Warsaw, IN, USA). No macroscopic abnormalities of the head–neck junction or the connection between ceramic liner and acetabular cup were observed. A new aluminum-zirconium composite ceramic head and acetabular liner (Biolox delta, CeramTec GmbH) was implanted. Particle analysis of tissue samples by CytoViva dark-field microscopy (CytoViva Inc, Auburn, AL, USA) indicated intracellular particles (Figure 1).