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Aseptic lymphocyte-dominated vasculitis-associated lesion: a clinicopathologic review of an underrecognized cause of

Tyler Steven Watters1, Diana M Cardona, K Sunil Menon

  • 1Division of Orthopaedic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA.

American Journal of Clinical Pathology
|November 20, 2010
PubMed

Insights

Metal-on-metal hip replacements can cause a rare complication called aseptic, lymphocyte-dominated vasculitis-associated lesion (ALVAL). Early diagnosis of ALVAL is vital for effective treatment and to prevent further complications.

Area of Science:

  • Orthopedic Surgery
  • Immunology
  • Biomaterials Science

Background:

  • Metal-on-metal (MOM) total hip arthroplasties (THAs) are used in an estimated 35% of cases.
  • A subset of patients with MOM THAs develop a novel complication known as aseptic, lymphocyte-dominated vasculitis-associated lesion (ALVAL).

Observation:

  • ALVAL presents with nonspecific clinical features, including pain and potential pseudotumor formation.
  • Histopathology reveals findings similar to general arthroplasty failure, but with a characteristic dense perivascular inflammatory infiltrate.

Findings:

  • Metal ions released from MOM prostheses may form haptens with proteins.
  • This is hypothesized to trigger a type IV hypersensitivity response in local soft tissues.
  • Three cases of ALVAL are presented with detailed clinical, radiographic, and histologic findings.

Implications:

  • Accurate and timely diagnosis of ALVAL is crucial for patient outcomes.
  • Intraoperative identification of chronic inflammation suggestive of ALVAL necessitates replacement of prosthetic component surfaces.
  • Understanding the immunologic response to MOM THAs can inform future implant design and patient selection.

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