Osteolysis around total knee arthroplasty: A review of pathogenetic mechanisms

Abstract

Aseptic loosening and other wear-related complications are one of the most frequent late reasons for revision of total knee arthroplasty (TKA). Periprosthetic osteolysis (PPOL) predates aseptic loosening in many cases indicating the clinical significance of this pathogenic mechanism. A variety of implant-, surgery-, and host-related factors have been delineated to explain the development of PPOL. These factors influence the development of PPOL due to changes in mechanical stresses within the vicinity of the prosthetic device, excessive wear of the polyethylene liner, and joint fluid pressure and flow acting on the peri-implant bone. The process of aseptic loosening is initially governed by factors such as implant/limb alignment, device fixation quality, and muscle coordination/strength. Later large numbers of wear particles detached from TKAs trigger and perpetuate particle disease, as highlighted by progressive growth of inflammatory/granulomatous tissue around the joint cavity. An increased accumulation of osteoclasts at the bone-implant interface, an impairment of osteoblast function, mechanical stresses, and an increased production of joint fluid contribute to bone resorption and subsequent loosening of the implant. In addition, hypersensitivity and adverse reactions to metal debris may contribute to aseptic TKA failure but should be determined more precisely. Patient activity level appears to be the most important factor when the long-term development of PPOL is considered. Surgical technique, implant design, and material factors are the most important preventative factors because they influence both the generation of wear debris and excessive mechanical stresses. New generations of bearing surfaces and designs for TKA should carefully address these important issues in extensive preclinical studies. Currently, there is little evidence that PPOL can be prevented with pharmacological interventions.

How Does Wear Rate Compare in Well-functioning Total Hip and Knee Replacements? A Postmortem Polyethylene Liner Study

“…This comparison entailed adjusting the wear rates to a patient age of 70 years to account for age dependence, and included only active patients. Given that wear particles from tibial wear tend to be larger than those from acetabular liners made from historical PE, approximately by a factor of three [33], the lower wear rate for knees suggests that the number of submicron particles generated from knee wear could be more than an order magnitude lower than for hips, consistent with the lower incidence of wear-induced osteolysis reported for knees [11,12].…”

“…This ratio is for active patients and excludes delaminated tibial liners. The lower TKR wear rate and assumed subsequent lower particle burden is in line with the lower incidence of osteolysis in TKRs compared with THRs [11,12]. Although we used components made from historical PE in this study, the approach we used to evaluate wear of tibial inserts also can be applied to contemporary retrieved tibial inserts.…”

“…Although infection and instability are dominant reasons for early failure, aseptic loosening accompanied by periprosthetic osteolysis becomes the primary revision cause of TKR after 5 years in situ [11]. Wear debris from UHMWPE has been identified as a major contributor to the occurrence of periprosthetic osteolysis.…”

Wear Tests of a Potential Biolubricant for Orthopedic Biopolymers

“…The majority of these hip and knee prostheses consist of a hard metal or ceramic component which articulates against a polyethylene counterface. However, a small number of these implants do need to be revised and in the majority of cases this is due to wear induced osteolysis [2,3]. Here the polyethylene wear debris provokes a negative cascade of events within the body eventually leading to osteolysis and a revision operation.…”

Allergy in Total Knee Replacement. Does It Exist?

“…While it is likely that allergies to metal or cement can trigger clinical symptoms and Multilayer coated -might ultimately lead to revision, allergies have not been associated with implant loosening [23]. Although a positive patch test shows a strong correlation, no causal relationship has been established between dermal reactions and implants failure [62].…”