J Am Acad Orthop Surg, Vol 16, No suppl_1, July 2008, S20-S25.
© 2008 the American Academy of Orthopaedic Surgeons
What are the guidelines for the surgical and nonsurgical treatment of periprosthetic osteolysis?
Bernard N. Stulberg, MD and
Alejandro González Della Valle, MD
Dr. Stulberg is Director, Center for Joint Reconstruction, Cleveland Orthopaedic and Spine Hospital at Lutheran, Cleveland Clinic Health System, Cleveland, OH. Dr. González Della Valle is Assistant Attending Orthopaedic Surgeon, Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY.
*The Implant Wear Symposium 2007 Clinical Work Group included John J. Callaghan, MD, John M. Cuckler, MD, Jorge O. Galante, MD, DMSc, Alejandro González Della Valle, MD, Stuart B. Goodman, MD, PhD, James I. Huddleston, MD, Lynne C. Jones, PhD, David G. Lewallen, MD, Henrik Malchau, MD, PhD, William Maloney, MD, Amanda Marshall, MD, Wayne Paprosky, MD, Hollis G. Potter, MD, Michael D. Ries, MD, Aaron Rosenberg, MD, Thomas P. Sculco, MD, Bernard N. Stulberg, MD, Audrey K. Tsao, MD, and Timothy Wright, PhD.
Dr. Stulberg or a member of his immediate family has received research or institutional support from Stryker, and is a consultant to or an employee of Styker and Exactech. Neither Dr. González Della Valle nor a member of his immediate family has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the subject of this article.
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Abstract
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Periprosthetic osteolysis is most often diagnosed by plain radiographs. Because these radiographs routinely underestimate the extent of the lesion, three-dimensional imaging should be used early in the evaluation process to confirm the presenting extent of disease. If the osteolytic process is asymptomatic, scheduled regular follow-up should be instituted until the lesion can be confirmed to be stable or until the decision is made to proceed with surgery. Nonsurgical management with pharmacologic agents has not proved to be effective. If surgery is contemplated, a three-dimensional evaluation with magnetic resonance imaging or helical computed tomography can assist in preoperative planning. Surgical intervention requires complete débridement of the lesional membrane and removal of the wear-generator—with or without component removal and with or without bone grafting, depending on the individual circumstances. A standardized follow-up evaluation mechanism for all patients should be a part of total joint arthroplasty management.
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Initial Diagnosis and Assessment of Osteolysis
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The identification of osteolysis is initially accomplished through the use of radiographs (standard anteroposterior [AP] and cross-table lateral for the hip; weight-bearing AP, lateral, and patellar views for the knee). Full-length standing AP and lateral radiographs as well as fluoroscopic interface views may be useful for some total knee patients. Identification of radiographic osteolysis should lead the orthopaedic surgeon to institute a thorough diagnostic evaluation and a plan for therapeutic intervention. Because osteolysis can progress without symptoms until considerable periprosthetic bone loss has occurred, patient and payer education on the need for follow-up radiographs is critical to ensure early identification.
For both total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients, plain radiographic evaluation substantially underestimates the extent of involvement in the bone and the soft tissue, and it may inaccurately portray the location of the lesions.1-3 Therefore, the diagnosis of osteolysis should be confirmed by a three-dimensional imaging study in an attempt to quantitatively estimate the extent of the lesion or lesions. Helical computed tomography and new magnetic resonance imaging sequences with artifact minimization allow three-dimensional evaluation of the lesions around the metallic devices.3-5 The protocols and sequences of both types of studies are available. As part of delineating a treatment plan, the orthopaedic surgeon should have this information available soon after the initial diagnosis of osteolysis has been made.
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Treatment Strategies for Osteolysis
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Osteolysis can be managed nonsurgically or surgically. The choice should be determined by the severity of symptoms and the extent of bone loss identified on the three-dimensional assessments. The patient and the treating physician must understand that the ultimate goals of management are to minimize the effect of the osteolytic process (the "osseous lesion") and to negate the effect of the articulation or interface that is stimulating the process (the "wear generator"). Wear-induced osteolysis is a progressive phenomenon that is best treated ultimately by surgical intervention. In an asymptomatic patient, the lesion can be managed nonsurgically until either the patient becomes sufficiently symptomatic to require intervention or the risk-benefit equation favors a surgical intervention before catastrophic failure occurs. Therefore, the treatment strategies employed must encompass the likelihood that lesion size and thus, the risk of structural compromise, can increase with time—even in the absence of symptoms.
The presence of osteolysis around hard-on-hard bearings (eg, metal-on-metal, ceramic-on-ceramic) indicates that wear-induced failure is occurring at a fast pace.6,7 These cases are commonly associated with severe soft-tissue and bone lesions; therefore, revision of these components should be considered at an earlier stage.
Nonsurgical
Nonsurgical treatment strategies involve frequent surveillance through clinical and radiographic follow-up and may include the use of pharmacologic agents. Initially, the orthopaedic surgeon and the patient should commit to follow-up evaluation every 3 to 6 months. Stability of clinical and radiographic assessments can allow subsequent intervals to be extended to as long as 12 months. Thorough patient education and the repeat use of a quantitative measure at 1- to 2-year intervals are appropriate. Satisfactory results of nonsurgical intervention would be the stabilization of bone loss accompanied by absence of symptoms. Treatment with anti-inflammatory agents and bisphosphonates have some theoretic benefit in the early stages of nonsurgical management, but their efficacy is difficult to determine because of the absence of quantitative measures to evaluate the treatment effect. The clinical efficacy of these drugs has been questionable.8
In THA, the interface behavior of cementless and cemented implant components will be different. Carefully crafted nonsurgical intervention strategies require an understanding of failure mechanisms as well as identification of devices and/or interfaces that might be associated with accelerated deterioration. The identification of devices at particular risk of progression of osteolysis (eg, precoated femoral stems) will be useful in determining frequency of follow-up and the criteria for surgical intervention.9-15
In the patient who has had TKA, evaluation of all components (tibial, femoral, patellar) should include careful assessment of the bone support of the implants and the impact of bone loss on component fixation. Nonsurgical strategies for the knee also require an understanding of failure mechanisms of specific types of interfaces and behavior characteristics of various implant designs.16 TKA instability can be associated with increased wear of components and should be diagnosed early, followed closely, and treated when appropriate. Progressive instability requires a more vigilant follow-up. Loss of alignment and instability may occur early on, contributing to early wear and osteolysis. Physical therapy, activity modification, and bracing can be employed to manage symptoms and control limb function until the risk-benefit ratio favors surgical intervention.
Surgical
Goals and Options
Few intraoperative measures are available for quantitative assessment of lesion size. Most reports of surgical intervention describe qualitative measures to address treatment, including mechanical stabilization of new devices and augmentation of bone deficiency where necessary. A contemporary grading system for bone loss should be used to guide the revision arthroplasty and to characterize deficiencies appropriately for clinical and research purposes. The general goals of surgical intervention for wear-induced osteolysis are to remove all debris and restore bone stock (address the osseous lesion) as needed, while providing a mechanically sound reconstruction, and to remove the source of wear debris particles (the wear generator).
For THA, surgical intervention could include either exchange of bearing surfaces, with or without local bone grafting measures to restore host bone, or revision of one or both components with direct grafting of bone-deficient areas. The role of proper identification of prosthetic components that are at risk of failure cannot be overemphasized. Detection of early failure of some prosthetic components associated with rapidly progressive osteolysis, such as cemented femoral stems with a rough surface finish,17-21 should prompt early surgical intervention. For TKA, surgical intervention could include exchange of the polyethylene insert, with or without revision of an isolated component; single-component revision; or complete revision of components with graft/implant augmentation to address bone deficiencies and soft-tissue compromise22,23 (Figure 1).
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Figure 1 A, Anteroposterior (AP) view of stemmed (revision) total knee arthroplasty (TKA) in a 77-year-old man 10 years after initial revision. Arrows denote areas of possible osteolysis around the femoral component. The patient was asymptomatic at the time of this radiograph. B, AP view of stemmed TKA almost 11 years after revision, with obvious osteolysis of the femur (arrows). The patient is currently symptomatic. C, Intraoperative view of the distal femur. Extensive osteolysis from ultra-high–molecular-weight polyethylene wear is seen and is greater than anticipated on plain radiographs. D, Postoperative AP radiograph demonstrating revision components and bone grafting. A varus-valgus constrained implant and modular buildups were used to improve implant fixation and knee stability.
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Revision Surgery in an Asymptomatic Patient
An asymptomatic patient under surveillance for osteolysis may require revision surgery when progression of osteolysis is demonstrated on serial radiographs or other ancillary quantitative surveillance imaging studies. The recommendation for revision surgery is further supported in the patient who has a long life expectancy when excessive polyethylene wear is evident on the radiographs. Polyethylene wear is related to the development of osteolysis. It is important that the surgeon recognize that some THA and TKA implants have a prevalent, well-defined mechanism of failure. Such mechanisms can be seen in components with known poor polyethylene wear properties, such as ultra-high–molecular-weight polyethylene (UHMWPE) products that are sterilized by gamma irradiation in air or those experiencing a long shelf life before implantation,24,25 known acetabular component designs with poor liner-to-shell conformity26-28 or inferior locking mechanisms,13 and components with suboptimal sintering of the ingrowth surface.15 When clinical or radiographic signs of impending mechanical failure are detected, revision surgery should be considered on an urgent basis to avoid catastrophic failure.14 During preoperative assessment, multiple radiographic projections or quantitative imaging studies can assist preoperative planning. Identification of the precise cause of failure and degree of bone loss is important as the surgeon may need to consider, and be prepared for, several options of management for the same problem in the revision procedure.1,2
Revision surgery in the asymptomatic patient requires performing a complete synovectomy (including the removal of biologically active granuloma), addressing the bone loss, and exchanging worn bearing surfaces. The potential complications associated with revision THA and TKA surgery (eg, infection, dislocation, arthrofibrosis) should be weighed against the consequences of osteolysis-related failure when recommending surgery in a patient without symptoms.
Due to the worldwide trend to cementless acetabular fixation and a relatively higher prevalence of revision for osteolysis in cementless acetabular components for THA, we will focus on the guidelines for their surgical treatment.
Surgical Alternatives for Acetabular Osteolysis
The trend to cementless acetabular fixation and to a relatively higher prevalence of revision for osteolysis in cementless acetabular components for THA benefits from guidelines for their surgical treatment when osteolysis is diagnosed. The surgeon can choose to retain or revise a well-fixed socket when retroacetabular osteolysis is present.29,30 The decision is not always clear. Historically, revision of well-fixed cementless sockets was associated with bone loss to a varied extent, particularly in the medial wall. Current revision instrumentation that uses cup diameter and head-size–specific curved osteotomes to articulate with the liner have made revision of a well-fixed socket expeditious and technically easy, with minimal or no bone loss in most instances.31
The ideal conditions to preserve a well-fixed socket in the presence of retroacetabular osteolysis exist when the socket has good orientation, most of the fixation area remains unaffected by osteolysis, and bone grafting can be safely performed. In addition, the presence of both a socket with a good locking mechanism and available low-wear UHMWPE inserts favors socket retention.
Preservation of the socket should not preclude meticulous removal of the biologically active granuloma and packing of bone graft/bone substitute in the osteolytic lesion. Generally, small lesions behind sockets with multiple holes can be efficiently débrided and grafted. Some large osteolytic lesions in sockets with a limited number of holes may require an ancillary window to be made in an area of the iliac bone that does not jeopardize the bone structure or the socket support; in some cases, formal socket revision is required (Figure 2).
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Figure 2 Anteroposterior (AP) radiographs demonstrating progressive retroacetabular osteolysis that developed over the course of 6 years (A, 1996; B, 1999; C, 2002) in an active man who underwent primary total hip arthroplasty at age 42 years. Loosening and migration of a central dome plug of the socket allows particle access to the retroacetabular space. The patient was revised with débridement and grafting of the lesion through a small anterosuperior window in the iliac bone. The shell was well-fixed. D, Radiograph taken 6 weeks following revision surgery demonstrating placement of a new liner and retention ring. The extensive retroacetabular osteolysis was grafted without removing the well-fixed shell.
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The second decision to be made when attempting preservation of the metallic shell relates to the fixation of the new liner. The surgeon may need to decide between a liner exchange using the socket’s current locking mechanism or cementing a liner into the socket. The decision should be based on the particular design characteristics and track record of the acetabular component. Liner exchange should be avoided in discontinued cup designs with poor long-term results, extensive areas of unsupported UHMWPE, and a locking mechanism that is compromised.32 In addition, the UHMWPE insert should have a short shelf life and excellent wear characteristics.
The ideal conditions for cementing a polyethylene liner into a well-fixed cementless metallic shell are the presence of multiple holes in the shell and a diameter sufficiently large that a minimum 2-mm-thick cement mantle can be achieved without sacrificing polyethylene insert thickness. The technicalities associated with cementing a liner in a well-fixed shell have been described in detail.33-35
The socket should be removed when there is a risk of periprosthetic fracture (eg, loss of the medial wall of the pelvis), when fixation of the socket has been compromised by osteolysis, and when the socket is malpositioned, damaged, or nonmodular.36 Furthermore, the socket should be removed when the conditions for preserving it either by liner exchange or cementing a new liner are not met.
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Limitations of Current Treatment Options
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The surgical treatment options for osteolysis are predictable but are usually not employed until symptoms or bone loss are substantial. The efficacy of nonsurgical approaches cannot be easily measured; therefore, the timing and use of nonsurgical interventions remain unproved. Consistent surveillance to limit symptoms and bone loss remains the mainstay of nonsurgical treatment.
The importance of several factors related to wear-induced osteolysis and its treatment has led to recommendations that remain appropriate,37 including the importance of early diagnosis and the need for diligent longitudinal imaging surveillance for the asymptomatic, well-functioning THA or TKA as well as for symptomatic arthroplasties. With the introduction of materials and designs with improved wear resistance, the incidence of osteolysis may be decreasing, but the overall prevalence of osteolysis may be the same or greater because of the increasing number of arthroplasties performed each year. Our understanding of devices at particular risk of failure continues to improve. The treatment goals, however, remain the same—preservation of bone stock, reduction of the risk of catastrophic failure, and restoration of the articulation with materials with improved wear resistance.
The expanding use of helical computed tomography and magnetic resonance imaging in determining lesion size and location and the introduction of extraction devices to make removal and direct débridement of osteolytic lesions a safe option are important advancements in the treatment of osteolysis. However, the lack of consistent methodologies for assessing bone graft usage or incorporation and for providing nonsurgical (pharmacologic) measures to manage osteolytic lesions remains a problem.
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Future Directions for Research
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Guidelines for the treatment of periprosthetic osteolysis would benefit from further research to (1) develop clinically usable quantitative measurements of periprosthetic osteolysis; (2) standardize methods for the evaluation of graft incorporation and viability around implants revised for osteolysis; (3) develop new approaches to measure in vivo wear of TKA and of hard-on-hard bearing surfaces for THA; (4) standardize criteria for determination of a therapeutic effect of nonsurgical interventions for osteolysis; and (5) implement joint registries for primary and revision total joint arthroplasties based on an expanded definition of failure in the updated ICD-9 codes.
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Figures
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References
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Abstract
Initial Diagnosis and Assessment...
