This article discusses the causes, diagnosis and treatment options for osteolysis around well-fixed acetabular components in total hip arthroplasty.

MOHAMMAD HUTAIF, EMIAL

INTRODUCTION

 

Particle-induced osteolysis from cement, polyethylene, or metal debris is a common complication after total hip arthroplasty resulting in revision surgery (1,2,3,4,5,6,7). Rapid linear polyethylene wear, greater than 0.2 mm/year, is the most significant cause of osteolysis (8,9). Osteolysis is a resorptive disorder of bone mediated by particle induced macrophage release of bone resorbing cytokines and subsequent osteoclast activation (10,11). Elevated intra-articular fluid pressure pushes wear particles into the available space around the implant resulting in progressive bone loss and aseptic loosening (12,13). Osteolysis is initially asymptomatic but eventually results in pain, instability, fracture, and/or implant loosening (14,15,16,17,18).

Osteolysis progressively destroys the cement-bone interface circumferentially around cemented acetabular components leading to loosening (14). Bone ingrowth can stabilize uncemented acetabular components despite significant acetabular osteolysis (Fig. 31-1) (19). Osseointegrated uncemented acetabular components eventually fail if the wear debris and progressive osteolysis are not surgically addressed (15).

When faced with the problem of significant acetabular osteolysis in association with a well-fixed uncemented acetabular component, the surgeon has two choices: (a) remove the acetabular component and perform an acetabular reconstruction or (b) debride the lytic lesion(s) with or without bone grafting and perform a polyethylene liner exchange.

 

A classification system has been developed to direct this treatment decision (Table 31-1) (20,21). A type I acetabular component is well fixed and can undergo lesion debridement and polyethylene liner exchange. A type II acetabular component is well fixed but should be removed prior to acetabular reconstruction. A type III acetabular component is unstable and necessitates acetabular reconstruction.

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TABLE 31-1 Modified Algorithm for Well-Fixed Uncemented Acetabular Components (20,21)

 

FIGURE 31-1 A: Anterior-to-posterior view of a painful uncemented total hip arthroplasty demonstrating asymmetric polyethylene wear. B: An iliac oblique view reveals a major osteolytic lesion of the posterior column and a well-fixed acetabular component.

 

Type I		Type II	Type III
Radiographically	Stable	Stable	Unstable
	Focal	Focal osteolysis	Component
	osteolysis		migration
			Circumferential
			lucency
Mandatory criteria for	(1) Well fixed	One or more of the mandatory criteria	—
head-liner exchange	(2) Well	for head-liner exchange are NOT
	positioned	present
	(3) Modular
	component
	(4)
	Undamaged
	(5) Adequate
	liner
	available
	(6) Good
	track record

Treatment

Component

retention Head-liner exchange

± Defect grafting

Liner cementationa Acetabular revision

± Defect grafting

Acetabular

revision

± Defect grafting

aLiner cementation with or without bone grafting in sockets that are well fixed but do not have an adequate liner for the shell in place is a modification to the original Maloney, Rubash and Paprosky algorithm (20,21). Note that liner cementation cannot compensate for malposition or poor component track record and is subject to sockets that reliably accept cement (49).

 

 

 

 

 

 

INDICATIONS

Six criteria are required for a type I acetabular component and surgical consideration of lesion debridement followed by polyethylene liner exchange: (a) well fixed, (b) well positioned, (c) a modular uncemented acetabular component with a good clinical track record, (d) an undamaged acetabular component or one capable of accepting a new liner, (e) an available highly cross-linked polyethylene liner for the acetabular component, and (f) uninfected (20,22,23). Acetabular component retention is more predictable with a three-dimensional ingrowth surface, like tantalum, fibermesh, or chrome-cobalt beads. An ongrowth surface, like titanium plasma spray, has a higher loosening rate in the presence of acetabular osteolysis (24,25,26,27,28,29).

An anterior-to-posterior radiograph of the pelvis and a cross-table lateral radiograph of the hip are critical to assess the fixation (Table 31-2). Radiographic signs of loosening for uncemented acetabular components include radiolucent lines that initially appeared or progress after 2 years, a continuous radiolucent line in all three DeLee and Charnley zones, a radiolucent line greater than 2 mm in any DeLee and Charnley zone, or component migration more than 2 mm (30,31,32,33). Peripheral, noncontinuous, nonprogressive radiolucent lines are common with uncemented acetabular components and do not indicate loosening (33). The absence of radiolucent lines and the presence of a superolateral buttress, medial stress shielding, radial trabeculae, and an inferomedial buttress are signs of acetabular component ingrowth (34). Ninety-seven percent of the uncemented acetabular components with three or more radiographic signs of fixation were well fixed at the time of revision surgery, while 83% of the uncemented acetabular components with two or fewer radiographic signs of fixation were loose at the time of revision surgery (34). No combination of radiographic signs has a 100% positive predictive value for fixation or a 100% negative predictive value for loosening, so stability of the acetabular component must be assessed intraoperatively.

Radiographs tend to underestimate the size of osteolytic lesions. Computed tomography (CT) scans provide the most accurate information regarding the size and location of osteolytic lesions (35,36,37). An anterior-to-posterior radiograph of the pelvis alone detected only 39% of osteolytic lesions, adding an iliac oblique improved detection to 52%, but using a CT scan was the most sensitive detecting 87% of lesions (38,39).

Asymptomatic osteolysis is present in 48% of uncemented acetabular components evaluated by CT scan (40).

Careful preoperative radiographic assessment of the acetabular and femoral component position is essential. The postoperative dislocation rate after polyethylene liner exchange has been reported as high as 25% (41,42). This may be related to the rapid recovery of polyethylene liner exchange patients as well

 

TABLE 31-2 Radiographic Signs of Fixation and Loosening for Uncemented Acetabular Components (30,31,32,33,34)

 

as their relative lack of adherence to posterior hip precautions. At surgery, femoral offset should be restored and leg lengths equalized when appropriate. Serious consideration should be given to revising the acetabular component if the position is suboptimal (43). Larger femoral head sizes, lateralized and phase changing liners, as well as increasing femoral neck lengths should be considered to reduce the incidence of dislocation (44). If the acetabular component and/or locking mechanism is damaged, consideration should be given to revision or cementation of a liner into the compromised component (45). Biomechanical testing and clinical data support cementation of a texturized polyethylene liner into an unpolished acetabular component with screw holes (46,47). This provides similar stability to most locking mechanisms (46,48). If failures occur, it is usually at the cement-liner interface, so care should be taken to adequately texturize the inner surface of the metal component and the outer surface of the polyethylene liner. Note that texturizing the polyethylene liner will decrease the polyethylene thickness available for the articulation. Polished nontextured acetabular components without screw holes fail at the cement-implant interface (49). In this situation, either the polished nontextured acetabular component should be revised or a metal cutting burr should be used to roughen the inner surface of the polished nontextured acetabular component. When cementing a liner, it should fully seat within the acetabular component, since a proud liner may be at risk for impingement and loosening. Selecting a polyethylene liner with an outer diameter 1 to 2 mm less than the inner diameter of the acetabular component will help avoid this issue and provide a reasonable cement mantle.

 

Loose	Fixed
Progressive radiolucent lines	No radiolucent lines
Continuous radiolucent line in all zones	Superolateral buttress
Radiolucent line >2 mm in any zone	Inferomedial buttress
Component migration >2 mm	Medial stress shielding
	Radial trabeculae

 

 

 

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CONTRAINDICATIONS

The absolute contraindications to polyethylene liner exchange in the setting of acetabular osteolysis include severe medical comorbidity precluding surgery, infection, acetabular component loosening, component malposition affecting stability, an acetabular component with a poor track record, a cemented acetabular component, lack of an available highly cross-linked polyethylene liner, or lack of an available femoral head for a modular femoral component. The relative contraindication to polyethylene liner exchange in the setting of acetabular osteolysis includes locking mechanism damage and a well-fixed acetabular component with a two-dimensional ongrowth surface (24,25,26,27,28,29).

Acetabular components regardless of radiographic fixation should be tested intraoperatively after removal of the liner and screws. If there is motion, the component is not osseointegrated and the component should be revised (50). Additionally, if the damage to the acetabular component is too severe to support cementation

 

or there is component malposition affecting stability, it should be revised.

Several types of acetabular components perform poorly after polyethylene liner exchange. Ongrowth fixation surfaces like titanium plasma spray or hydroxyapatite coating are predisposed to continued loosening and failure after revision surgery in the presence of a large acetabular defect (25,26,27,28,29). The Acetabular Cup System (Depuy, Warsaw, IN) has a high incidence of locking mechanism failure after polyethylene liner exchange and should be revised (24,25). Harris-Galante (Zimmer, Warsaw, IN) acetabular components also have a greater than 50% re-revision rate at 2 years after polyethylene liner exchange because of a poor locking mechanism (51). We recommend cementing a liner for this type of acetabular component. Osseointegration of the acetabular component and inspection of the supporting bone as well as an intact locking mechanism with a good track record after head-liner exchange are prerequisites for durable implant fixation and survival after head-liner exchange (25,51).

 

 

POLYETHYLENE LINER EXCHANGE TECHNIQUE

A direct anterior, anterolateral, direct lateral, or posterior approach may be used to expose the pelvis and gain access to the hip (52,53,54). In complex cases, an extended trochanteric osteotomy, trochanteric slide, or standard trochanteric osteotomy may be required to facilitate femoral or acetabular exposure. The authors prefer the miniposterior approach because of its extensile nature and preservation of the abductor insertion (54). The patient is placed in the lateral decubitus position with boney prominences and peripheral nerves protected.

Intravenous prophylactic antibiotics are administered prior to incision unless deep cultures are planned. A 10-cm incision centered over the middle of the greater trochanter and extended distally over the femoral shaft and curving proximally toward the posterior superior iliac spine. Previous surgical incisions should be incorporated, if possible. The leg is abducted to relax the abductor and gluteal musculature. The gluteus maximus fascia is incised, and fibers of the gluteus maximus muscle are split bluntly from distal to proximal exposing the posterior edge of the greater trochanter. If necessary, the fascia lata is incised from proximal to distal in line with the femur to aid exposure. Care should be taken to elevate a full-thickness flap of posterior pseudocapsule off the greater trochanter. Protecting this flap for repair during closure reduces the dislocation rate of the posterior approach

(54). An inside-out debridement of visible granulomatous tissue is performed with the hip reduced. The hip is dislocated with gentle traction and internal rotation. After dislocation, a modular femoral head can be removed with an impactor. Care should be taken to protect the femoral trunnion upon disimpaction and after removal of the femoral head. This can be accomplished with the fingertip of a glove or specialized device. If the femoral component or femur is obstructing acetabular visualization, anterior femoral mobilization of the femur will enhance the exposure. First, create a subperiosteal space over the anterior column with a Cobb elevator to tuck the femoral trunnion when the femur is retracted anteriorly and externally rotated. Additional femoral mobilization can be accomplished with partial or complete release of the gluteus maximus insertion. Care should be taken to leave a small cuff of tendon for repair. Note that the first perforating branch of the profunda femoris artery is just deep to the gluteus maximus insertion. If additional femoral mobilization is required for adequate exposure of the acetabulum, a trochanteric osteotomy or removal of the femoral component may be required. The goal is sufficient anterior femoral mobilization to allow circumferential acetabular exposure (52,55,56). Osteophytes and overhanging bone are removed with curettes, osteotomes, rongeurs, and/or a high-speed burr to facilitate visualization of the acetabular component rim.

 

 

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After proper circumferential acetabular exposure, the polyethylene liner is removed. The polyethylene liner should be removed without damaging the acetabular component. It may be removed with the appropriate extraction tool. If this is not available, a screw technique is useful. A 3.2-mm drill bit is used to pierce the

polyethylene liner and a 6.5-mm cancellous screw is used to engage the polyethylene liner and back it out of the

acetabular component. A second screw can be used as well. Care should be taken to ensure the drill engages the metal component and not a screw hole. If the screw technique fails, the polyethylene liner will need to be removed in fragments utilizing reamers, osteotomes, and/or a high-speed burr. Damage to the locking mechanism or acetabular component may necessitate removal and revision. Once the polyethylene liner has been removed, any screws should be removed from the acetabular component and the intraoperative stability of the acetabular component should be assessed with a Kocher clamp, heavy needle driver, bone tamp, Cobb elevator, or acetabular component inserter (20,21,57,58). Gross visualization of bone ingrowth can be reassuring as well. If there is gross motion of the acetabular component at the implant-bone interface, the acetabular component is not osseointegrated and should be revised.

Once the stability of the acetabular component has been visually confirmed, the granulomatous tissue from behind the acetabular cup may be removed. This is accomplished through the access channels used by the particulate debris (i.e., periphery of the acetabular component, screw holes, central hole in acetabular component). A cortical window or trap door may be made in the superior or posterior acetabulum, but care must be taken to preventing acetabular component destabilization and consideration should be given to limited weight bearing postoperatively if this technique is chosen. Care should be taken not to disrupt any pods of bone ingrowth that are providing acetabular stability. Allograft bone, demineralized bone matrix, or bone graft substitute is used to fill the debrided defects. Specifically designed trumpets with a plunger may facilitate graft placement (59). Defects in the anterior column and pubis are not usually grafted because of limited access. After meticulous trialing for stability, a new liner is impacted or cemented into position based on intraoperative hip stability, liner availability, femoral head availability, acetabular component type, and damage to the locking mechanism or acetabular component. If cementing, care should be taken to adequately texturize the inner surface of the acetabular component and the outer surface of the polyethylene liner. Undersize the outer diameter of the polyethylene liner by 2 mm from the inner diameter of the acetabular component to facilitate cementation. The cemented liner should fully seat within the metal shell, since a proud liner may be at risk for impingement. A larger femoral head, lateralized and phase changing liners, and increasing femoral neck lengths should be considered to reduce the incidence of dislocation (44). Finally, the femoral head is impacted into position for modular stems, the hip is reduced with traction and external rotation, and closure is performed in a routine fashion with particular attention paid to the repair of the posterior soft tissue flap back to the greater trochanter. Postoperatively, patients are allowed to bear weight as tolerated. Despite sparse evidence for the use of an abductor brace, the authors still prefer to use one for 6 to 8 weeks while the patient is ambulatory in conjunction with an abductor pillow while in bed (60,61). Rigorous posterior hip precautions should be observed for at least 3 months.

 

RESULTS

Head and liner exchange is a reliable treatment for pelvic osteolysis when the acetabular component is well fixed, well positioned, undamaged, and has a good clinical track record (20,21). Using the criteria from Table 31-1, type I components remain radiographically stable at 6 years of mean follow-up (21,62).

Regardless of the choice to bone graft, 1/3 of the osteolytic defects resolved completely and 2/3 decrease in size (Fig. 31-2) (21,53,57,63). Additionally, type II components that were radiographically stable but revised because they did not meet the appropriate criteria for head-liner exchange remained radiographically stable after revision and a mean follow-up of almost 4 years (Fig. 31-3) (21). Wear rates decline after head-liner exchange by half, from 0.4 mm/year to 0.2 mm/year (62). Several small series document a low rate of subsequent acetabular component loosening after liner exchange ranging from 0% to 10% (41,42,57,62,63,64). Data from the Norwegian Arthroplasty Registry evaluated 1,649 revision total hip arthroplasties performed between 1987 and 2005 with 60 different types of uncemented acetabular

 

 

components (65). 318 revisions were liner exchanges, 396 revisions had fixed acetabular components, and 933 had loose acetabular components. The risk of re-revision after liner exchange was almost double the re-revision risk for a fixed or loose acetabular component (65). Reasons for re-revision included instability (28%), pain (12%), aseptic loosening (11%), infection (9%), and wear (8%) (65). The risk of re-revision for pain was five times less when a well fixed acetabular component was revised compared to liner exchange (65).

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These registry data support the fact that head and liner exchange performs well under ideal circumstances and adherence to the modified criteria set forth in Table 31-1 is paramount.

 

 

 

FIGURE 31-2 Retention of a well-fixed acetabular component with major associated osteolysis requires access to the lesions through either (A) the screw holes or (B) a cortical window. Care must be taken not to disrupt any pods of bony ingrowth. After debridement and an assessment of acetabular component stability, osteolytic lesions are grafted through the same screw holes or cortical window and a head and liner exchange performed. C: Anterior-to-posterior view of a painful uncemented total hip arthroplasty demonstrating a large osteolytic lesion superior to a well-fixed acetabular component. D: Anterior-to-posterior view 1 year after debridement, bone grafting, and liner exchange total hip arthroplasty

demonstrating reconstitution of the superior defect.

Postoperative hip instability remains a major concern after head and liner exchange. The dislocation rate is as high as 25% (41,42). Patients should have a posterior capsular closure and observe strict posterior hip precautions, if the posterior approach to the hip is used. Additionally, consideration must be given to alternative approaches to the hip with lower dislocation rates (52,53,54). Component position must be scrutinized for impingement and malposition on the preoperative radiographs and intraoperatively.

 

Consideration should be given to larger femoral head, lateralized and phase changing liners, and increasing femoral neck lengths (44). Lipped liners and skirted femoral heads should be avoided, if possible, as they can result in impingement and reduce stability (66).

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FIGURE 31-3 A: Anterior-to-posterior view of a painful uncemented total hip arthroplasty demonstrating multiple large osteolytic lesions superior and medial to the acetabular component. B: A cross-table lateral view reveals near complete involvement of the posterior column. C: Anterior-to-posterior view 2 years after revision of the acetabular component, filling of the defect with bone graft, and multiple screws demonstrating a well-fixed uncemented revision acetabular component and reconstitution of the superior and medial defects. D: A cross-table lateral view reveals reconstitution of the posterior column.

 

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57. Maloney WJ, Herzwurm P, Paprosky W, et al.: Treatment of pelvic osteolysis associated with a stable acetabular component inserted without cement as part of a total hip replacement. J Bone Joint Surg Am 79(11): 1628-1634, 1997.

     

     

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osteolysis

acetabular component

total hip arthroplasty

revision surgery

bone grafting

cementless