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PubMed2003

Spinal implant debris-induced osteolysis.

STUDY DESIGN: Generally, implant-induced osteolysis is a manifestation of an adverse cellular response to phagocytosable particulate wear and corrosion debris. Initially termed "cement disease," particle-induced loosening was recognized by Charnley in the early 1960s. Despite the plethora of information gained over the last 40 years on the basic science of periprosthetic bone loss, much remains unanswered. The effect of unintended debris resulting from wear and corrosion (e.g., micromotion between the interconnection mechanisms in spinal implants) remains a clinical concern. The current study highlights what is known of particle-induced osteolysis and how the presence of spinal implant particulate debris deleteriously influences osseointegration of posterolateral bone graft or disrupts an established posterolateral fusion mass. Tissue explant, animal, and cell culture studies have revealed the complexity of cellular reactivity involved in aseptic particle-induced osteolysis. OBJECTIVES: The objectives of this study are twofold: 1) to highlight the dominant cellular participants in total joint arthroplasty particle induced osteolysis, which are purportedly the macrophage, osteoblast, fibroblast, and osteoclast and several of the dominant chemical mediators have been identified as well, which include prostaglandin E2, tumor necrosis factor-alpha, interleukin-1, and interleukin-6; and 2) to demonstrate the potential deleterious effects of spinal implant debris using animal models and analysis of soft tissue surrounding spinal implants in symptomatic patients. METHODS: There are a growing number of proinflammatory and anti-inflammatory cytokines, prostenoids, and enzymes that have been shown to play important roles in the pathology of particle-induced osteolysis. Reports that aseptic granulomatous inflammation typical of that associated with corrosion debris appear to correlate with the complexity of the implant. Titanium particulate material was used to induce effects in 34 New Zealand White rabbits where analysis included serological quantification of systemic cytokines. Postmortem microradiographic, immunocytochemical, and histopathologic assessment of the intertransverse fusion mass quantified the extent of osteolysis, local proinflammatory cytokines, osteoclasts and inflammatory infiltrates. Clinical analysis of 12 patients more than 0.4 years after spinal implants (mean 4.03, range 0.4 to 11 years) presented with late operative site pain. RESULTS: Currently the etiology of this inflammation around spinal implants resembles particle-induced osteolysis around joint arthroplasties where there typically is a self-perpetuating fibroinflammatory zone adjacent to the implant, where macrophage exhaustion, reactive oxygen intermediates, and pro-inflammatory cytokines affect a host of local cell types and induce a widening zone of soft tissue damage and inflammation. Animal model analysis indicated increased levels of local inflammatory cytokines typically associated with osteolysis-tumor necrosis factor-alpha. Osteoclast cell counts and regions of osteolytic resorption lacunas were higher in the titanium-treated versus autograft-alone groups (P < 0.05), and the extent of cellular apoptosis was markedly higher in the titanium-treated sites at both time intervals. Electron microscopy indicated definitive evidence of phagocytized titanium particles and foci of local, chronic inflammatory changes in the titanium-treated sites. CLINICAL CASES: 11 of 12 clinical cases demonstrated elevated tumor necrosis factor-alpha levels and an increased osteoclastic response in the vicinity of wear debris caused by dry frictional wear particles of titanium or stainless steel. Resection of the wear debris and surrounding fibroinflammatory zone resolved clinical symptoms in all 12 cases. CONCLUSIONS: More basic science and clinical research is needed to develop novel strategies for gaining knowledge, and developing effective evaluation and treatment of patients with implant debris related osteolysis. Titanium debris simulating that produced by spinal implants introduced at the level of a spinal arthrodesis elicits an inflammatory cytokine mediated particulate-induced response through increased expression of intracellular TNF-alpha, increased osteoclastic activity and cellular apoptosis. This study highlighted the association between spinal implants particulate wear debris and increased potential for osteolysis. Aseptic osteolysis is among the primary reasons for failure of orthopedic implants. Increased awareness of this destructive process is becoming more important with the growing popularity of total disc arthroplasty and highly modular spinal implants.

Adult↗
PubMed2004

Retroacetabular osteolysis: when to operate?

Polyethylene liner exchange for retroacetabular osteolysis should be done before the shell becomes loose. The purpose of this study was to determine the radiographic quantity of osteolysis that will predict impending loosening of the cementless shell. Between 1992 and 2002, 46 cementless shells were revised at our institution for aseptic osteolysis. Radiographs and a computer-assisted technique were used to quantify osteolysis. Implant stability was confirmed intraoperatively. Of 26 stable and 20 loose shells, the average area of osteolysis on anteroposterior radiographs showed no significant difference, whereas lateral radiographs showed a difference. The percentage of shell circumference with associated osteolysis seen on anteroposterior and lateral radiographs showed a significant difference. Diagnostic criterion of 50% shell circumference associated with osteolysis on lateral films has a sensitivity of 0.84 and a specificity of 0.54, and on anteroposterior views, a sensitivity of 1.0 and a specificity 0.27 for predicting shell loosening. Percent of shell circumference with surrounding osteolysis seems to be more predictive of loosening than the area of osteolysis. When 50% of the shell circumference has osteolysis evident on anteroposterior or lateral radiographs, but preferably anteroposterior radiographs, liner exchange should be considered so that the exchange procedure is still possible, rather than allowing the osteolysis to increase and compromise shell fixation.

Acetabulum↗
PubMed2006

Cross-linked N-telopeptide of type I collagen (NTx) in urine as a predictor of periprosthetic osteolysis.

Periprosthetic osteolysis is often nonsymptomatic and hard to visualize by conventional radiography. Cross-linked N-telopeptide of type I collagen (NTx), a marker of osteoclast mediated bone resorption, has been suggested to evaluate local particulate-induced osteolysis in patients operated on with a total hip prosthesis. Urine specimens were sampled after hip joint replacement in 160 patients. NTx was analyzed by a commercially available ELISA kit. Osteolysis was identified in the acetabulum and confirmed at operation. Using analysis of covariance to correct for differences in age, gender, and time after operation, NTx (mean SD) was 36+/-12 BCE/nM creatinine in patients with osteolysis (n=33) and 27+/-13 BCE/nM creatinine in patients without osteolysis (n=127) (p=0.003). Eighteen hips of 38 (47%), demonstrating an annual wear of more than 0.2 mm and an NTx value above 29 BCE/nM creatinine, had been revised due to osteolysis. The osteolysis prevalence in this group was increased 10 times (CI 4-23, p<0.05). Indeed, NTx release and annual wear were both associated with increased prevalence of osteolysis, however, independently of each other. NTx seems a feasible marker of periprosthetic osteolysis. A preoperative baseline NTx level is likely needed for its use as a predictor of periprosthetic osteolysis in individual cases.

Adult↗
PubMed2006

Periprosthetic osteolysis: an immunologist's update.

PURPOSE OF REVIEW: Inflammation-induced osteolysis is a problem in both inflammatory arthritis and total joint arthroplasty. New drug therapies have been shown to slow, halt, or even reverse the osteolysis associated with inflammatory arthritis. Unfortunately, similar advances in the medical treatment of periprosthetic osteolysis have not occurred. This review will update the state of periprosthetic osteolysis. RECENT FINDINGS: Preliminary results with phase I and II clinical trials with AMG-162, a human IgG2 that binds receptor activator of nuclear factor kappaB (RANK) ligand, have been reported. Based on these results AMG-162 appears to be safe and to have a potent effect on osteoclast function. Based on animal studies, it is expected that regents such as AMG-162 that block RANK-ligand/RANK interaction will have activity in inflammation-induced osteolysis. Volumetric three-dimensional and magnetic resonance imaging scans for detecting and quantifying periprosthetic osteolysis have been validated in cadaver studies. Lymphocytic infiltrates and positive skin tests to cobalt have been found in patients with periprosthetic osteolysis after second generation metal-on-metal prostheses. These findings again raise the question of whether metal allergy may contribute to implant failure in these patients. A new subset of T helper cells that are neither Th1 nor Th2, but secrete a unique pattern of cytokines including IL-17, has recently been discovered. The importance of these cells in modifying particle-induced osteolysis remains to be determined. SUMMARY: There have been significant advances in our understanding of periprosthetic osteolysis, imaging technology to quantify osteolysis, and drug development. The time now seems ripe to translate these advances in clinical trials.

Antibodies, Monoclonal↗
PubMed2000

Characterization of long-term femoral-head-penetration rates. Association with and prediction of osteolysis.

BACKGROUND: We examined the relationship between long-term femoral-head-penetration patterns and osteolysis in a ten-year follow-up study of a well controlled patient population. The purposes of this study were to characterize the linearity of long-term head-penetration patterns over time, to describe the relationship between ten-year true wear rates and osteolysis, and to determine whether the occurrence of osteolysis at ten years could be predicted by penetration data obtained prior to five years. METHODS: Temporal femoral-head-penetration patterns were examined at a minimum of ten years after forty-eight primary total hip arthroplasties. The arthroplasties were performed with the use of an Arthropor acetabular cup (Joint Medical Products) and a thirty-two-millimeter-diameter cobalt-chromium femoral head (DePuy). Using a computer-assisted radiographic technique, we evaluated two-dimensional head penetration on serial annual radiographs. Linear regression analysis modeled penetration-versus-time data as a line for each patient. The slope of the regression line indicated the true wear rate for each patient. In a subgroup of thirty-four hips for which three annual radiographs had been made less than five years after the arthroplasty, we compared early head-penetration patterns with the later occurrence of osteolysis. RESULTS: For all forty-eight hips, the true wear rate averaged 0.18 millimeter per year (range, 0.01 to 0.44 millimeter per year) and temporal head-penetration patterns tended to be linear (mean r2 = 0.91 +/- 0.16). Osteolysis at ten years was strongly associated with increasing true wear rates (p < 0.001). Osteolysis did not develop in any of the nine hips with a true wear rate of less than 0.1 millimeter per year. However, osteolysis developed in nine (43 percent) of twenty-one hips with a rate between 0.1 and less than 0.2 millimeter per year, in eight of ten hips with a rate between 0.2 and 0.3 millimeter per year, and in all eight hips with a rate of greater than 0.3 millimeter per year. Evaluation of early true wear rates as a predictor of late osteolysis showed a similar relationship. CONCLUSIONS: This study demonstrates that true wear rates tend to be constant and that increased true wear is significantly associated with osteolysis at ten years after the operation. A similar relationship was also found at the early follow-up interval, indicating that early true wear rates (determined from serial radiographs) might enable orthopaedists to predict if patients are at risk for the development of osteolysis. CLINICAL RELEVANCE: On the basis of these findings, we use temporal femoral-head-penetration data in our practice to evaluate polyethylene inserts in asymptomatic patients, to estimate the time to component wear-through, and to adjust the frequency of follow-up evaluations for monitoring the development of osteolytic lesions in at-risk patients.

Adult↗
PubMed2002

Osteolysis in failed total knee arthroplasty: a comparison of mobile-bearing and fixed-bearing knees.

BACKGROUND: Osteolysis is an important complication associated with total knee arthroplasty. The purpose of this study was to compare the prevalence of osteolysis after failed total knee arthroplasty with a mobile-bearing prosthesis and after failed arthroplasty with a fixed-bearing prosthesis. METHODS: Eighty revision total knee arthroplasties performed between 1995 and 1998 were included in this study. All had radiographic evidence of advanced polyethylene wear. The mobile-bearing group consisted of thirty-four knees with a Low Contact Stress implant, and the fixed-bearing group included forty-six knees. The average time (and standard deviation) from the primary operation to the revision was 102.8 +/- 26.5 months in the mobile-bearing group and 96.0 +/- 30.1 months in the fixed-bearing group. The prerevision radiographs and operative findings were reviewed. RESULTS: The prevalence of osteolysis was significantly higher in the mobile-bearing group (47%; sixteen of thirty-four knees) than in the fixed-bearing group (13%; six of forty-six knees) (p = 0.003). The distal part of the femur was involved in thirteen knees in the mobile-bearing group and in four knees in the fixed-bearing group. Seventeen knees had osteolysis in the posterior aspect of the femoral condyle, which was the most common site of osteolysis; however, twelve of them had no evidence of osteolysis on prerevision radiographs. CONCLUSIONS: The prevalence of osteolysis was higher in the knees with a mobile-bearing prosthesis than in those with a fixed-bearing prosthesis. The osteolysis was predominantly on the femoral side, adjacent to the posterior aspect of the condyle. Radiographic evaluation of osteolysis in the distal part of the femur may not be reliable and usually leads to an underestimation of the degree of osteolysis.

Aged↗
PubMed2001

T1-weighted MR imaging for distinguishing large osteolysis of Paget's disease from sarcomatous degeneration.

OBJECTIVE: To report five symptomatic patients, four with unequivocal Paget's disease and large areas of osteolysis and one patient with presumed osteolytic Paget's disease, evaluated by MR imaging to confirm or exclude a sarcoma. DESIGN AND PATIENTS: Four men and one woman (median age 74 years) presented with new symptoms of pain. Four of these patients had unequivocal Paget's disease with large areas of osteolysis; one patient presented with large focal osteolysis and no other finding. MR imaging was performed in each case to exclude malignancy in the area of osteolysis. RESULTS: Two patients whose MR images showed a low signal abnormality on the T1-weighted sequence corresponding to osteolysis on the radiograph were found to have malignant degeneration. Three patients with osteolytic lesions on T1-weighted MR imaging showed preservation of fat signal in the areas of osteolysis, were not biopsied and have been free of malignant disease for from 12 months to 2 1/2 years. One patient had one area of osteolysis in the iliac bone which showed malignancy and another area of osteolysis which showed preservation of fat signal on the T1-weighted sequence. CONCLUSIONS: The information obtained from T1-weighted MR imaging sequences performed on patients with Paget's disease who have new symptoms and large areas of osteolysis could reliably be used in the clinical decision-making process between conservative follow-up and biopsy.

Aged↗
PubMed2001

Rapid repair of titanium particle-induced osteolysis is dramatically reduced in aged mice.

Aseptic loosening is the most common cause of orthopaedic implant failure. This process is thought to be due to osteolysis induced by implant-derived wear particles. Teitelbaum and colleagues have recently developed a promising murine calvarial model of wear particle-induced osteolysis. However, prior to this study, this model had only been assessed qualitatively. We now report a reproducible, quantitative version of the calvarial model of wear particle-induced osteolysis, in which the extent of osteolysis (and repair) of entire parietal bones is assessed by histomorphometry of contact microradiographs. Using this model, we found that the osteolytic response is transient and rapidly repaired in one month old mice. The extent of osteolysis peaks 7 days after particle implantation and returns to baseline levels by 13 days. A similar amount of osteolysis and even more extensive repair is observed when particles are implanted repeatedly. In contrast, aged mice develop progressive osteolysis with no detectable repair. As a result, 26 month old mice have approximately 17-fold more osteolysis than one month old mice 21 days after particle implantation. Skeletally mature, adult mice (4-16 months old) show an intermediate pattern of response. Osteolysis in these mice peaks at 7 days after particle implantation but it is repaired more slowly than in the one month old mice. Taken together, these results underscore the role of an imbalance between bone resorption and bone formation in the development of aseptic loosening and suggest that agents that stimulate bone formation maybe useful in prevention or treatment of aseptic loosening.

Aging↗
PubMed2003

Osteolysis of the pelvis: evaluation and treatment.

Osteolysis of the pelvis is a common and well-recognized complication associated with total hip arthroplasty. The diagnosis and treatment of osteolysis of the pelvis is a challenging and controversial problem. Osteolysis of the pelvis often is asymptomatic and does not present with symptoms until considerable bone loss and loosening of the acetabular socket occur. Radiographs are the most common way to detect and monitor osteolysis around an implant. However, lesions viewed radiographically usually are underestimations of the lesions found intraoperatively. Moreover, some advocate computed tomography scanning to evaluate these lesions. The indications for treatment of osteolysis with cemented acetabular components are defined more clearly than with a cementless component. If the cemented or cementless acetabular component is loose, then revision is necessary. However, it is less clear when to intervene surgically with a well-fixed cup with osteolysis. Many early reports advocated the removal of a well-fixed socket during revision surgery for osteolysis and polyethylene wear. However, the removal of a well-fixed socket has the potential for significant damage and loss of the surrounding bone resulting in loss of integrity of a column or pelvic discontinuity, which may compromise placing another acetabular component. Recently, a new treatment strategy of retaining a well-fixed socket, exchanging the liner, and grafting lesions has proven successful. Without the removal of the acetabular shell, different techniques are needed to graft the osteolytic lesions. Osteolysis is a difficult problem; however, with radiographic surveillance to monitor patients for lesions, proper indications, and good surgical techniques, the treatment of osteolysis of the pelvis can result in a well-functioning total hip arthroplasty.

Algorithms↗
PubMed2003

Variation in the TNF gene promoter and risk of osteolysis after total hip arthroplasty.

UNLABELLED: Genetic factors may influence implant failure caused by osteolysis after THA. In an association study of 481 subjects after THA, we found that carriage of the TNF-238A allele was associated with an increased incidence of osteolysis versus noncarriage (odds ratio, 1.7) and was independent of other risk factors. Genetic and environmental factors influence implant survival after THA. INTRODUCTION: Tumor necrosis factor (TNF) is thought to play a role in osteolysis, the major cause of implant failure after total hip arthroplasty (THA). Natural sequence variations at -238 and -308 in the TNF gene promoter are associated with differences in susceptibility to several TNF-mediated diseases. We tested whether these polymorphisms are associated with osteolysis after THA. MATERIALS AND METHODS: A total of 481 whites (214 with failed versus 267 with intact implants) were recruited 11.7 +/- 4 years after cemented THA. Genomic DNA was extracted from peripheral blood and genotyped for the -238 and -308 polymorphisms using the Taqman 5' nuclease method. Healthy controls (n = 500) from the background population were also genotyped to establish the local prevalence of these alleles. RESULTS: The carriage of -238A was 8.8% in the background population and 10.9% in the THA controls (p > 0.05). Carriage of -238A in the osteolysis group was 17.3% (odds ratio, 1.7; 95% CI, 1.0-2.9). Carriage was highest (20.5%) in patients with more widespread osteolysis (OR, 2.1; 1.2-3.8). The association of -238A with osteolysis was independent of other risk factors for osteolysis (logistic regression analysis: OR, 1.8; 1.0-3.2). Carriage of -308A was not associated with osteolysis. CONCLUSION: Genetic, as well as environmental factors, influence implant failure after THA. Whether the TNF-238 polymorphism causes a biological change that predisposes to loosening or is in linkage disequilibrium with such a locus is not yet known.

Aged↗
PubMed1998

Osteolysis in association with a total hip arthroplasty with ceramic bearing surfaces.

The results of 103 total hip arthroplasties performed with insertion of a ceramic femoral head and acetabular component in ninety-six patients were reviewed to determine the radiographic prevalence of osteolysis. After a mean duration of follow-up of ninety-two months (range, sixty to 125 months), femoral osteolysis was observed in twenty-three hips (22 per cent), in one of two distinct patterns: linear osteolysis (twelve hips) or scalloping expansile-type osteolysis (eleven hips). The most common locations of osteolysis in the femur were in zones I and VII as described by Gruen et al. Serial radiographs demonstrated that the extent of the osteolysis progressed over time. Osteolysis of the pelvis, noted in forty-nine hips, was always associated with migration of the acetabular socket. No focal osteolysis was observed in association with the stable sockets. Ten patients (ten hips) had a revision because of loosening and migration of the acetabular component. In three of these patients, the femoral stem also was revised. Gross examination revealed evidence of wear of the ceramic bearing surface in all ten patients. Scanning electron microscopy showed cracking and wear marks on the weight-bearing surface. Histological evaluation of the tissue in the periprosthetic membrane demonstrated abundant ceramic wear particles. The interface membrane was composed of a vascularized fibrous connective tissue with macrophages. Ultrastructurally, the macrophages contained numerous phagosomes of various sizes, with electron-dense material within the cytoplasm of the cell. The mean size of the ceramic particles, as determined with scanning electron microscopy, was 0.71 micrometer (range, 0.13 to 7.20 micrometers). This study supports the concept that ceramic wear particles can stimulate a foreign-body response and periprosthetic osteolysis.

Acetabulum↗
PubMed1999

Effect of circumferential plasma-spray porous coating on the rate of femoral osteolysis after total hip arthroplasty.

BACKGROUND: Osteolysis of the femur has been a serious problem associated with some designs of total hip-replacement implants; it frequently leads to failure of the femoral component. We evaluated the effect of a circumferential plasma-spray porous coating on the rate of osteolysis in a study that included two groups of hips, each of which received an implant with the same design except for the extent of the porous coating. Our goal was to determine the possible role of circumferential porous coating in protecting the bone-implant interface from osteolysis. METHODS: A series of consecutive primary total hip replacements performed with insertion of the Mallory-Head implant without cement was divided into two study groups. The first 126 hips (Group 1) were treated with a femoral stem that had a noncircumferential plasma-spray porous titanium coating. The next ninety hips (Group 2) were treated with a circumferentially coated stem of the same design. The average duration of radiographic follow-up was 7.8 years in Group 1 and 7.5 years in Group 2. RESULTS: The average rate of polyethylene wear was similar for the two groups (0.187 millimeter per year in Group 1 and 0.189 millimeter per year in Group 2). The prevalence of osteolysis in Group 1 (40 percent; fifty of 126 hips) was significantly higher than that in Group 2 (10 percent; nine of ninety hips) (p < 0.001). Osteolysis remote from the joint space (distal to zones 1 and 7) was found in 11 percent (fourteen) of the hips in Group 1 but in none of those in Group 2 (p = 0.0004). The average total area of osteolysis in Group 1 (5.0 square centimeters) was significantly larger than that in Group 2 (2.9 square centimeters) (p < 0.05). CONCLUSIONS: A circumferential plasma-spray titanium porous coating on the femoral component of a total hip-replacement prosthesis inserted without cement appears to provide an effective barrier preventing wear debris from gaining access to the endosteal surface of the femur and the greater trochanter. This finding supports the hypothesis of the so-called effective joint space, which predicts that wear debris from the joint bearing can migrate, driven by intracapsular pressures, to all areas to which joint fluid has access and thus can result in osteolysis. The reduction of the prevalence of osteolysis and the elimination of osteolysis from the zones remote from the joint space by the use of a circumferential plasma-spray porous coating indicates that the femur was effectively sealed off from the joint space. We believe that the durability and longevity of the femoral component should be enhanced by the use of such a coating.

Coated Materials, Biocompatible↗
PubMed2000

Collagen crosslinked N-telopeptides as markers for evaluating particulate osteolysis: a preliminary study.

The purpose of this study was to determine whether a marker of bone resorption could be used noninvasively to diagnose and assess treatment of periprosthetic osteolysis. The crosslinked N-telopeptide marker of osteoclast-mediated bone resorption potentially has the sensitivity to detect periprosthetic osteolysis. Second-morning urine specimens were obtained from (a) seven age-matched controls, (b) eight patients who had a hip arthroplasty, hybrid implants at least 1 year after surgery, and no osteolysis, (c) 11 patients who had a hip arthroplasty and osteolysis, and (d) 10 patients who had a hip arthroplasty and with osteolysis before and after 6 weeks of oral Fosamax (alendronate) treatment. The Fosamax treatment consisted of one 10-mg dose per day for 6 weeks. Men and young women (less than 40 years old) were chosen for this study to avoid bone resorption enhanced after menopause as a possible confounder. An enzyme-linked immunosorbent assay technique for quantifying crosslinked N-telopeptides of type-I collagen was performed on all specimens. The patients with osteolysis had significantly elevated levels of N-telopeptide compared with the implant control group. In addition, levels of N-telopeptide were significantly lowered after Fosamax treatment. These findings indicate that a systemic bone-resorption marker (N-telopeptide) can be used to evaluate local particulate-induced osteolysis and its treatment. The study also provides clinical evidence that osteolysis is associated with increased osteoclast-mediated bone resorption and that this locally induced bone resorption can be suppressed by certain bisphosphonates (Fosamax). These insights have potential value in the understanding and clinical management of aseptic loosening.

Adult↗
PubMed1994

Osteolysis of the distal femur after total knee arthroplasty.

An 11.1% incidence of femoral osteolysis (30 cases in 28 patients) was identified in a series of 271 primary total knee arthroplasties. Two minimally constrained total knee designs (Synatomic [Depuy, Warsaw, IN] and Porous-Coated Anatomic [PCA, Howmedica, Rutherford, NJ] were used in this patient population. Femoral osteolysis was observed in 26 Synatomic and 4 PCA knees. The average follow-up period was 52 months (range, 24-96 months). Osteolytic lesions were identified radiographically, adjacent to the nonporous-coated (smooth) regions of the anterior and posterior flanges of the Synatomic and PCA femoral components. The average time to the diagnosis of femoral osteolysis was 31 months (range, 7-96 months). The average patient age at the time of primary total knee arthroplasty was 63 years (range, 43-83 years) and the average weight was 180 lb. (range, 107-278 lb.). Sixteen of the 30 cases were in men. All of the cases with femoral osteolysis had cementless implantation. Tissue specimens were obtained from the 18 cases requiring revision. Implants remained in situ an average of 66 months (range, 15-96 months) prior to revision. In 16 of the 18 cases revised, the femoral component was clinically and radiographically stable. Six of 18 cases were revised for severe osteolysis. The remaining 12 cases were revised for failed metal-backed patellae, failed cementless tibial fixation, or advanced polyethylene wear. Wear of the thin tibial inserts and patellar components were the two sources of particulate polyethylene. Polyethylene debris was observed in all tissue specimens. In cases with failed metal-backed patellae or impingement of the tibial locking pin-and-clip, fine metallic debris was also noted in tissue specimens. Microscopic evaluation of the osteolytic tissue revealed a florid histiocytic response with occasional giant cells. Intracellular submicron particulate polyethylene was identified with polarized light microscopy and oil-red-O staining techniques. In the study population, statistically significant factors associated with femoral osteolysis included male gender (P < .05), younger age (P < .05), increased patient weight (P < .05), positive tibial osteolysis (P < .001), osteoarthritis (P < .07), and length of time in situ (P < .001). In addition, patients with a Synatomic prosthesis were at increased risk for osteolysis compared to patients with a PCA device (P < .02). The authors postulate that histiocytic granuloma gained access to the proximal femur primarily via the unbonded interface between the smooth metal and bone.

Adult↗
PubMed2006

Magnetic resonance imaging with metal suppression for evaluation of periprosthetic osteolysis after total knee arthroplasty.

Osteolysis around total knee arthroplasty (TKA) can be difficult to identify and quantitate on plain radiographs. This study reports on magnetic resonance imaging (MRI) with metal suppression for the evaluation of suspected periprosthetic osteolysis around TKA. We retrospectively reviewed 11 patients referred for MRI with suspected periprosthetic osteolysis. Radiographic and MRI findings and findings at revision arthroplasty were correlated. The presence of osteolysis was identified or suspected radiographically in all of the 11 patients. Osteolysis was confirmed in 10 patients by MRI. In 9 of 11 patients, the extent of osteolysis was greater on MRI than estimated radiographically. In 5 of 11 patients, MRI demonstrated additional osteolytic lesions which were radiographically occult. In one case, the amount of osteolysis on MRI was less than on initial radiographs, and in one case, osteolysis was felt to be present radiographically but was not confirmed on MRI. In all 7 of 11 patients subsequently treated with revision TKA, MRI findings were confirmed at revision.

Adult↗
PubMed1996

Natural history of femoral focal osteolysis with proximal ingrowth smooth stem implant.

Focal femoral osteolysis has become a prominent cause of failure of total hip arthroplasty. Femoral focal osteolysis is studied in 185 hips with a patched porous-coated titanium femoral stem. Seventy-two hips had osteolysis and 113 did not. Seventy-one percent of osteolysis is evident on radiographs by 6 months to 5 years after surgery. The location is most commonly seen on an anteroposterior radiograph, with proximal osteolysis most common and the initial size of defects being greatest in zones 2, 3, 5, and 6. Progression of size is slow, with each focal defect averaging 0.89 mm/y. Progression of bone loss occurs more commonly with the occurrence of new defects rather than extension of an existing defect. Focal osteolysis was directly correlated with the amount of polyethylene wear. Osteolysis is more likely when linear polyethylene wear exceeds 0.2 mm/y or volumetric wear exceeds 150 mm3/y or when the patient is below age 60. Accelerated wear and osteolysis occur most often when the fixation of the arthroplasty is poor.

Adult↗
PubMed2001

Efficacy of etanercept for wear debris-induced osteolysis.

A major limitation of total joint arthroplasty is that up to 20% of patients require revision surgery to correct prosthetic loosening. Aseptic loosening is believed to result from the phagocytosis of wear debris particles by macrophages, which secrete proinflammatory cytokines that stimulate osteolysis. Tumor necrosis factor alpha (TNF-alpha) has been shown to be one of the prominent cytokines in this cascade and to be involved critically in the generation of particle-induced osteolysis. Etanercept is a soluble inhibitor of TNF-alpha, which is widely used for the treatment of rheumatoid arthritis. Here, we show this agent's ability to prevent wear debris-induced osteolysis. In vitro we show that Etanercept can inhibit directly osteoclastic bone resorption in a bone wafer pit assay, as well as cytokine production from titanium (Ti)-stimulated macrophages. Using a quantitative in vivo model of wear debris-induced osteolysis, we show that Etanercept prevents bone resorption and osteoclastogenesis. In mice treated with Etanercept at the time of osteolysis induction, bone resorption and osteoclast numbers were reduced to background levels in both normal and human TNF-alpha (hTNF-alpha) transgenic mice. In an effort to evaluate its effect on established osteolysis, Etanercept was administered 5 days after Ti implantation, and we observed that further osteolysis was prevented. These data support the concept that TNF-alpha is involved critically in osteoclastogenesis and bone resorption during periprosthetic osteolysis and suggest that soluble TNF-alpha inhibitors may be useful as therapeutic agents for the treatment of prosthetic loosening in humans.

Animals↗
PubMed2004

Osteolysis: medical and surgical approaches.

Osteolysis is defined as the process of progressive destruction of periprosthetic bony tissue, characterized on serial radiographs as progressive radiolucent lines and/or cavitation at the implant-bone or cement-bone interface. Without proper treatment, osteolysis may progress to aseptic loosening and catastrophic failure of the implant. Osteolysis is a multifactorial process stemming from host, prosthesis, and surgical factors. Billions of submicron wear particles are generated at material interfaces that cause osteolysis. Wear particles are dispersed along the effective joint space, into bone, and throughout the adjacent soft tissues. Initially, patients may have no clinical symptoms despite radiographic evidence of osteolysis and can remain completely asymptomatic, even in the presence of substantial bone loss. Symptoms usually do not occur until the bone loss has reached the point of causing implant loosening, implant failure (fracture), or periprosthetic fracture. Radiographic images and standard examination provide limited information and almost always underestimate the amount of bone loss. Three-dimensional computed tomography is more sensitive and can monitor the volume of the lesion, however the trade-offs are its high cost and radiation exposure. The timing for treatment of periprosthetic osteolysis is controversial and the medical decision-making is debatable. Medical treatment seems to be attractive but there is no proven or approved drug therapy to prevent or inhibit periprosthetic osteolysis. We reviewed the medical and surgical options that are available for treatment of periprosthetic osteolysis.

Algorithms↗