Small-diameter cemented Metasul® cups have been previously identified to be at high risk of early loosening. We asked whether this particular mode of failure was associated with a specific histological feature. Periprosthetic tissues were obtained at the time of revision of two aseptically loose cemented Metasul® cups. Each tissue sample was processed for routine histological analysis. A slight metallosis was visible microscopically in all tissue samples. Metallic wear-debris particles were present both extracellularly and within the cytoplasm of macrophages. We noted a perivascular infiltration of lymphocytes accompanied by mature plasma cells. Our observations are compatible with the hypersensitivity-like reaction previously reported, described as an aseptic lymphocytedominated vasculitis-associated lesion (ALVAL). Although wear was within normal reported range limits, this tissue reaction appeared as a consequence of continuous release of metallic ions from the prosthetic articulation. We hypothesise that ALVAL was involved in acetabular component failure, although acetabular loosening may have been initiated by high mechanical stress.
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