Updated: 9/11/2018

THA Aseptic Loosening

Topic
Review Topic
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Questions
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Evidence
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https://upload.orthobullets.com/topic/12304/images/asl1.jpg
https://upload.orthobullets.com/topic/12304/images/asl2.jpg
https://upload.orthobullets.com/topic/12304/images/asl3.jpg
Introduction
  • Macrophage-induced inflammatory response resulting in bone loss
    • Steps in the process include    
      • prosthesis micromotion
      • particulate debris formation
      • macrophage activated osteolysis 
    • see wear and osteolysis basic science for full description 
Presentation
  • Symptoms
    • pain
      • location
        • groin pain
        • thigh pain
        • knee pain
      • aggrevating factors
        • often activity related
  • Physical exam
    • may have minimal pain with ROM
    • increased pain with weight bearing
Imaging
  • Radiographs
    • recommended views
      • AP
      • lateral
    • findings (xrays are not sensitive for osteolysis and typically underestimate extent of involvement)
      • lucency > 2 mm at cement-bone or metal-bone interface
      • component motion with stress views
      • femoral component
        • subsidence > 1 cm
        • fracture of cement mantle
        • change in peg-neck angle
          • can also represent femoral head necrosis/collapse, femoral neck fracture
        • decreased distance from tip of peg to lateral femoral cortex
          • can also represent femoral head necrosis/collapse
        • narrowing of femoral neck after 3 years or > 10%
          • can also represent impingement
      • acetabular component
        • migration or change in position/inclination
        • wearing of polyethylene liner
          • leads to asymmetric superior location of femoral head within acetabular cup
Studies
  • Serum labs
    • ESR will be normal
    • CRP will be normal
Treatment
  • Nonoperative
    • observation
      • indications
        • stable implant with minimal symptoms
  • Operative
    • revision THA
      • Indications  
        • pain due to aseptic loosening
        • pain with evidence of osteolysis 
        • extensive osteolysis that would compromise revision surgery in the future.
 

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Questions (7)
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(OBQ13.164) Figure A and B are radiographs of a 77-year-old patient presenting with right hip and upper thigh pain for the past 3 months. He is an avid golfer and plans to travel south for 6 months on a golf tour. He denies fever, chills or weight loss. His past medical history includes hypertension and a right total hip replacement 15 years ago. Physical examination reveals minimal pain with range of motion. ESR=10 (normal range 0-20) and CRP=4 (normal range 0-10). He does not want any further surgery. The patient is at the highest risk of which complication with non-operative care? Review Topic

QID: 4799
FIGURES:
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1

Infection

0%

(16/3675)

2

Pseudotumour formation

1%

(28/3675)

3

Periprosthetic femoral fracture

94%

(3451/3675)

4

Periprosthetic acetabular fracture

0%

(13/3675)

5

Dislocation

4%

(139/3675)

L 1

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SUBMIT RESPONSE 3
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(SAE07HK.99) Which of the following statements best describes results that have been reported with roentgen stereophotogrammetric analysis (RSA)? Review Topic

QID: 6059
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1

Cemented total hip stems do not migrate.

0%

(0/222)

2

Well-fixed total hip stems (cemented or cementless) migrate approximately 3 degrees and 5 mm in the first year.

12%

(26/222)

3

Any early migration (ie, greater than 0 mm less than 6 months after surgery) portends failure of the component.

8%

(18/222)

4

Migration greater than 1 mm to 2 mm in the first year is associated with a higher risk of loosening.

61%

(135/222)

5

The system has been proven to not be as accurate as claimed and has been abandoned.

18%

(40/222)

L 3

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(SAE07HK.30) Figure 17 shows the AP radiograph of a 75-year-old man with right hip pain. The femoral component is loose. The mechanism of loosening is most likely secondary to Review Topic

QID: 5990
FIGURES:
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1

osteolysis.

56%

(80/142)

2

fatigue failure of the implant.

4%

(5/142)

3

failure of bone ingrowth.

34%

(48/142)

4

wear debris from cerclage wire.

1%

(2/142)

5

trochanteric impingement.

4%

(6/142)

L 4

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Topic COMMENTS (5)
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