Systemic Lupus Erythematosus Induced by Adjuvants After Metal-on-Polyethylene Total Hip Arthroplasty
Total hip arthroplasty (THA) is a common surgical procedure aimed at alleviating pain and restoring function in patients with severe hip osteoarthritis. While the procedure is generally successful, complications can arise, including osteolysis, infection, dislocation, or fracture. However, a less commonly discussed complication is the potential for immune disorders induced by the materials used in the prosthesis. This article presents a case of systemic lupus erythematosus (SLE) induced by adjuvants following a metal-on-polyethylene THA, highlighting the complexities and potential risks associated with prosthetic materials.
The patient, a 36-year-old Chinese woman, underwent THA due to hip osteoarthritis. The acetabular component of the prosthesis was composed of a titanium, cobalt, and molybdenum alloy, fitted with an ultra-high molecular weight polyethylene liner. The surgery was initially successful, and the patient experienced relief from her symptoms. However, eight months post-surgery, she developed myalgia and pain in her right thigh, which was managed with oral non-steroidal anti-inflammatory drugs. Two months later, she presented with a rash over her entire body, accompanied by a fever of 38°C. The rash and fever were controlled with dexamethasone treatment.
Following this episode, the patient experienced symptoms of dryness of the mouth, thirst, fatigue, anorexia, and right upper abdominal discomfort. She was diagnosed with gastritis and prescribed omeprazole, which she continued to take for the next 18 months. Blood tests revealed an increased erythrocyte sedimentation rate and neutropenia. Thirty months after the hip replacement, she was diagnosed with Felty syndrome, characterized by rheumatoid arthritis, splenomegaly, and neutropenia. Additionally, she developed painful ulceration in the scar over her right hip. Cultures from the scar ulcers were negative, and no cause for the ulceration was identified. The ulcers recurred intermittently for 16 months.
Radiographs showed no evidence of osteolysis or implantation failure. To rule out infection, 99mTc-methylenediphosphonate-labeled triphase isotope scintigraphy and bacterial culture were performed, both of which were negative. Pathological findings from debridement material revealed chronic inflammation and fibrous tissue hyperplasia, with the presence of T lymphocytes. Sixty months after the implantation, the patient was diagnosed with SLE, presenting with a typical “butterfly rash” and high titers of anti-Ro/SS-A, anti-La/SS-B, and anti-nuclear antibodies. She also exhibited lymphocytopenia and neutropenia.
Given the persistent symptoms and the diagnosis of SLE, the decision was made to replace the titanium alloy prosthesis with a new cemented prosthesis 66 months after the initial surgery. Nine months following the revision surgery, all the previously observed abnormalities had resolved. The final diagnosis was an inflammatory mass related to adjuvants, suggesting that the immune disorder was induced by the materials used in the initial prosthesis.
The case underscores the potential for immune disorders as a serious complication of THA. While failure of artificial joint replacement is typically associated with mechanical issues or infection, metal prostheses can also cause metal allergies, leading to autoimmune or autoinflammatory syndromes. The concept of Autoimmune/Autoinflammatory Syndrome Induced by Adjuvants (ASIA), also known as Shoenfeld syndrome, has been proposed to describe such conditions. In this case, the titanium-molybdenum alloy used in the prosthesis may have acted as an adjuvant, triggering an immune response that led to the development of SLE.
The patient’s history and clinical findings highlight the multifactorial pathogenesis of implant failures. Metal-induced inflammation can be a significant risk factor, particularly in patients with metal allergies. Conventional diagnostic methods, including serological tests, imaging, and laboratory analyses, were employed to rule out periprosthetic infection. However, the absence of infection and the resolution of symptoms following the replacement of the prosthesis suggest that the immune disorder was directly related to the prosthetic materials.
This case also raises important considerations for the selection of materials in prosthetic implants. While titanium alloys are widely used due to their biocompatibility and mechanical properties, they can still elicit immune responses in certain individuals. The potential for metal hypersensitivity and its role in exacerbating or inducing autoimmune conditions like SLE should be carefully considered in patients undergoing THA.
In conclusion, immune disorders represent a significant but underrecognized complication of THA. The case presented here illustrates the potential for metal prostheses to induce autoimmune conditions such as SLE through mechanisms involving adjuvants. Clinicians should be aware of the possibility of ASIA in patients with persistent or atypical symptoms following joint replacement surgery. Further research is needed to better understand the relationship between prosthetic materials and immune responses, with the aim of improving patient outcomes and reducing the risk of such complications.
doi.org/10.1097/CM9.0000000000000897
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