OSTEOLYSIS and ASEPTIC LOOSENING THA

OSTEOLYSIS & ASEPTIC

LOOSENING
March 13, 2017
THA Complications
Aseptic Loosening of implants is caused by osteolysis. It is most
significant factor limiting longevity of THA. Revision for
loosening is 4x higher than next leading cause (dislocation at
13.6%), and its particularly problematic in younger patients [2].

Osteolysis is bone resorption caused by the body’s response to

particulate debris generated as the THA implant wears out.
Motion between any two components of the prosthesis (ie the
femoral head and the acetabuluar liner, the head-neck junction of
the femoral stem, or the liner and shell of the acetabulum)
generates debris that floats around the joint. This debris
stimulates a host response. Particles of metal, poly, or cement can
all cause osteolysis, albeit different types of reaction. Osteolysis
is important because it leads to implant loosening and/or
periprosthetic fractures.

While osteolysis is the primary cause of loosening, infection must

be part of the differential diagnosis.

Historical Perspective: Osteolysis was first described by Harris in

1976 and it was attributed to “cement disease” [3], because it was
observed around the femoral component, and this was what started
the drive for cementless implants. Yet after significant R&D, and
development of cementless implants, osteolysis was still seen
around the implants [4], and the histology was similar between
cemented [5] and cementless implants [6]. Surgeons then looked
for another cause of osteolysis and recognized that it was
produced by wear particles.
STAGES OF OSTEOLYSIS

1) Debris production (ie poly wear) is the initial stage (we talk
about metal debris in a separate section because it behaves totally
differently, see section). Particulate debris in THA is produced by
Abrasive and Adhesive wear (whereas the TKA produces
delaminating wear: small fissures form within the poly).

▪ Adhesive wear is two surfaces bonding together causing the

softer material to “peel” off as a thin film onto the harder surface
during motion.

Volumetric wear is a specific type of adhesive wear, and it occurs

as the femoral head articulates with the cup liner, and the amount
of wear is proportional to the femoral head radius squared
(therefore larger femoral head = more wear..this is why the initial
Charnley implants, which used conventional poly, used a size 22
femoral head). Linear wear is caused by focused stress on a
isolated part of the poly due to abnormal loading.

▪ Abrasive wear occurs when a harder surface (which is never

completely smooth) cuts or ploughs through a softer surface, like a
cheese grater. Both cause particle formation. Most wear occurs
superiorly in the cup (or at the rim in cases of impingement).

The conventional PE wear from articulating with a Cobalt-chrome

head is 0.10 mm/year. The ultramolecular weight poly (UMWPE,
also known as highly-crosslinked poly) wear is about 0.02
mm/year. What is the difference between conventional and
UMWPE? The quality of PE depends on the consolidation of PE
(the shape is formed using compression molding), the preparation
(irradiation causes extensive cross-linking which decreases
susceptibility to oxidation and wear), and the packaging (poly is
sterilized in inert gas to prevent free-radical formation…although
it can oxidize over time within the body, which is the reason some
poly contains Vit. E,, which theoretically eats up the free radicals
generated with oxidation) [7] [8].
The debris then travels in the joint fluid and reacts with any area
of bone that is in contact with the fluid (this is an important
concept when considering whether to place acetabular screws as
this hardware effectively increases the surface area of bone in
contact with synovial fluid…referred to as the “effective joint
space” [5], this concept also highlights the value of
circumferential porous coating in the femoral stem, because it
reduces the effective joint space by causing bone ingrowth and
blocking the path of joint fluid around the implant).

2) Immune Reaction & Bone Loss. Poly debris activates

macrophages to initiate an inflammatory response by releasing the
standard cytokines (ie TNF-alpha, RANKL, IL-6, and IL-1) that
stimulate osteoclast activity, inhibit osteoblast activity, and
promote progressive bone loss around the prosthesis. Osteolysis
is typically progressive. Its often asymptomatic until catastrophic
failure, which occurs in the form of sudden implant loosening or
an acute periprosthetic fracture (due to severe bone loss, the bone
breaks under minimal stress).

Because osteolysis is a chronic issue that causes acute

complications, it must be monitored with serial radiographs for
progressive changes every 3 to 6 months. Signs of large lytic
lesions, significant progression, or loose implants are the
indications for revision surgery (even in the absence of
symptoms).

clinical correlate: Plain x-rays typically underestimate the size of

osteolytic lesions, with lytic lesion only visible on x-ray once 20-
30% of acetabular bone loss has occurred [9].

3) Implant Loosening. There is no universal definition of

loosening. Many consider x-ray evidence (progressive
radiolucency or implant migration) sufficient to diagnose
loosening, while many require clinical decline to be included for
diagnosis. Lets consider the clinical and radiographic signs.

clinical correlate: Loosening is considered when patients report

“start-up” pain (pain with their first steps, which gradually
resolves, suggesting that the implant moves, then settles into a
stable position during weight bearing).

X-ray. The femur and pelvis have been divided into zones called
Gruen Zones, which help to identify areas of osteolysis. The inter-
oberver reliability is somewhat suspect and therefore, these zones
are mainly for academic purpose and less useful clinically. In
general serial x-rays are performed,and changes in implant
positioning, such as stem subsidence, provides the best evidence.
The accepted diagnostic criteria for loosening is progressive
radiolucency or implant migration.

Radiolucent lines that progress >2 years after surgery, or new

radiolucent lines over 1 mm are significant signs of loosening.
Thinning is not the only sign to look for. Focal areas of high
cortical density (radiopaque lines), especially around the collar or
at the end of the stem, indicate non-uniform stress (ie pedestal
formation at the calcar), which suggest loosening [10][11]. But
remember that not all cortical thinning is osteolysis (age-related
thinning, or stress shielding also cause thinning). Also, in a
cementless implant, a “spot weld” found at the distal end of the
stem is a sign of stable fixation. In the acetabulum there are 3
zones of radiolucency, however, radiolucencies isolated to one or
two zones is less specific. Leopold et al found nonprogressive
lucencies in over 50% of revised components that were
performing well clinically.

Migration. Femoral component migration is best evaluated by

comparing the position of the stem relative to the calcar on serial
x-rays. Acetabular component migration (superior or medial)
should similarly be examined. A loose acetabulum may also
demonstrate changes in version or inclination.

Cement Implants. In cemented implants debonding or cement

fracture will precede loosening (cement implants can loosen by
fatigue fracture where cracks propagate into pre-existing pores of
the cement mantle). However debonding doesn’t always cause
loosening. For example, a supero-lateral lucency around the stem
< 2 mm does not indicate loosening. Different with cemented
implants. Changes at the bone-cement interface can just be
remodeling rather than loosening, however, radiolucency at the
implant-cement interface is loosening. If there is rapid osteolysis
or bone disintegration then be suspicious of infection.

Look for complete radiolucent line and implant migration. An

incomplete radiolucent line of 50-99% implant is only possibly
loose. Progressive radiolucent line around cement-bone interface
is probably loose. If radiolucency is <50% is unlikely loose if
nonprogressive. The loosening rates for a cemented femur are
impressively low, going back to the Charnley stem, survivorship
at 20 years was over 95%, at 25 years about 89% and at 30 years
about 82%.

Press-Fit Implants. many demonstrate some level of subsidence

from initial position, and early subsidence < 5 mm usually leads to
integration without problem, and the proximal taper allows for
stable fit. The acetabular component should have circumferential
radiolucent line >2 mm or implant migration.
TREATMENT.

The decision to operate and the type of revision surgery is

controversial. Does all osteolysis need surgery? A loose implant
should be revised. Symptomatic osteolysis should be revised. But
the need for surgical intervention for osteolysis around a stable
implant in an asymptomatic patient is less clear. The decision to
operate on a hip depends on a few variables: rate of progression
(delta); location of osteolysis, type of implant, activity level and
age of the patient.

Studies examining the timing for surgical intervention [12 - 15]

offer some guidelines. Even a few small areas of integration can
keep a cup stable and thus patients remain asymptomatic despite
expansile lesions [12] [15]. Yet progressive osteolysis will
continue to reduce the area of integration until failure inevitably
occurs. Thus, in general, lesions that progress over 3-6 month
period should be revised. Femoral osteolyisis similarly remains
asymptomatic until extensive synovitis occurs or impending
fracture.
FEMORAL IMPLANT REVISION.

Osteolysis causes different degrees of bone loss. The Paprosky

Classification was established to grade the severity of bone loss,
which in turn guides treatment (different grades of bone loss
require different implants to achieve stability).

Proxmially coated stems (primary implants) can be used if

sufficient metaphyseal bone stock for ingrowth. Fully-coated
stems (cylindrical monoblock) are used for deficient metaphyseal
bone stock but decent diaphyseal bone (type 2, type 3A), however,
there were high failure rates if used in cases with notable
deficiency in diaphyseal bone stock. Fluted, Tapered Stems
(Wagner-type) either monoblock or modular are successful for
type 3B, and some type 4. Modular Wagner-type stems have
grown in popularity because adjustments can be made if the final
implant subsides more than the trial implant. Oncology prosthesis
are often needed in type 4 implants when the bone stock is
deficient past the isthmus of the femur.

ACETABULAR IMPLANT REVISION.

Asymptomatic acetabular osteolysis maybe be treated

with a) implant revision or b) implant retention with bone grafting
of the defect and head/liner exchange; or c) no surgery, close
monitoring. Symptomatic acetabular osteolysis and gross
loosening of the cup is treated with full component revision.

Similar to the femoral side, there is a Paprosky Classification for

Acetabular Osteolysis, which grades the severity of bone loss and
guides implant choices. Different grades of bone loss require
different implants to achieve stability.

Head/liner exchange: considered if the components are well

aligned [16]. Yet despite well aligned components there is still a
10% re-revision rate for liner exchange [17] vs. 2% re-revision
rate after the cup is revised [18]. Yet other studies have found less
significant differences in revision rates when the implants are well
positioned [19]. In cases of malpositioned components, which
may be accelerating wear, complete implant revision is probably
indicated.

Cup Revision: Many surgeons will fully revise a cup with

significant osteolysis, but all surgeons will revise a malpositioned
cup with osteolysis and any loose cup. The cup is loose if there is
>2 mm of migration observed on serial x-ray, or if there are any
signs of rotational changes, any screw breakage, or a radiolucent
line (>1 mm) seen in all 3 zones [20] [21].

If the rim is supportive (type 1) or partially supportive (type 2

- over 2/3 rim intact, 50% contact with bone), then a standard cup
can be used (consider multi-hole or high porous metal for better
scratch fit). Augments or cement + rebar can be incorporated to
improve stability.

Special implants (i.e. Triflange cup, or cup-cage) are needed when

the rim is unsupportive (type 3) causing the implant to rock up and
roll out posteriorly (type 3A) or roll up and in causing a superior
medial defect (type 3b).

REFERNECES

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