Updated: 8/6/2018

Wear & Osteolysis Basic Science

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Introduction
  • Osteolysis represents a histiocytic response to wear debris.   
  • Steps in the process include (see below)
    1. particulate debris formation
    2. macrophage activated osteolysis 
    3. prosthesis micromotion
    4. particulate debris dissemination
  • Evaluation
    • radiostereometric analysis
      • is the most accurate and precise technique to evaluate polyethylene wear 
      • uses radiopaque tantalum beads planted in the bone to follow the position of the components relative to the beads on radiographs.
Step 1: Particulate Debris Formation
  • Types of wear
    • adhesive wear
      • most important in osteolytic process
      • microscopically PE sticks to prosthesis and debris gets pulled off
    • abrasive wear
      • cheese grater effect of prosthesis scraping off particles
    • third body wear
      • particles in joint space cause abrasion and wear
    • volumetric wear
      • main determinant of number of particles created
      • directly related to square of the radius of the head
      • volumetric wear more or less creates a cylinder
        • V=3.14rsquaredw
        • V is volumetric wear, r is the radius of head, w is linear head wear
        • head size is most important factor in predicting particles generated
    • linear wear
      • is measured by the distance the prosthesis has penetrated into the liner
  • Wear leads to particulate debris formation
    • wear rates by material
      • polyethylene
        • non-cross linked UHMWPE wear rate is 0.1-0.2 mm/yr
          • linear wear rates greater than 0.1 mm/yr has been associated with osteolysis and subsequent component loosening  
        • highly-cross linked UHMWPE generates smaller wear particles and is more resistant to wear (but has reduced mechanical properties compared to conventional non-highly cross-linked)   
          • factors increasing wear in THA
          • thickness < 6mm
          • malalignment of components
          • patients < 50 yo
          • men
          • higher activity level
        • femoral head size between 22 and 46mm in diameter does not influence wear rates of UHMWPE
      • ceramics
        • ceramic bearings have the lowest wear rates of any bearing combination (0.5 to 2.5 µ per component per year)  
        • ceramic-on-polyethylene bearings have varied, ranging from 0 to 150 µ.
        • has a unique complication of stripe wear occurring from lift-off separation of the head gait 
        • recurrent dislocations or incidental contact of femoral head with metallic shell can cause "lead pencil-like" markings that lead to increased femoral head roughness and polyethylene wear rates.
      • metals
        • metal-on-metal produces smaller wear particles as well as lower wear rates  than those for metal-on-polyethylene bearings (ranging from 2.5 to 5.0 µ per year) 
        • titanium used for bearing surfaces has a high failure rate because of a poor resistance to wear and notch sensitivity. 
        • metal-on-metal wear stimulates lymphocytes 
        • metal-on-metal serum ion levels greater with cup abduction angle >55 degrees and smaller component size 
  • Particulate Type
    • UHMWPE
      • most common
    • PMMA
    • Co-Cr
    • Ti
    • third-body
  • Particulate size
    •  is < 1 micron 
Step 2: Macrophage Activated Osteoclastogenesis and Osteolysis
  • Macrophage activation
    • results in macrophage activation and further macrophage recruitment 
    • macrophage releases osteolytic factors (cytokines) including  
      • TNF- alpha
      • osteoclast activating factor
      • oxide radicals
      • hydrogen peroxide
      • acid phosphatase
      • interleukins (Il-1, IL-6) 
      • prostaglandins
  •  Osteoclast activation and osteolysis
    • increase of TNF- alpha increases RANK
    • increase of VEGF with UHMWPE  inhances RANK and RANKL activation
      • RANKL mediated bone resorption 
        • an increase in production of RANK and RANKL gene transcripts leads to osteolysis 
Step 3: Prosthesis Micromotion 
  • Osteolysis surrounding the prosthesis leads to micromotion
    • micromotion leads to increase particle wear and further prosthesis loosening 
    • N-telopeptide urine level is a marker for bone turnover and are elevated in osteolysis 
Step 4: Debris Dissemination 
  • Increase in hydrostatic pressure leads to dissemination of debris into effective joint space
    • increased hydrostatic pressure is result of  inflammatory response
    • dissemination of debris into effective joint space further propagates osteolysis
    • circumferentially coated prosthesis limits osteolysis in the distal femur 
 

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Questions (31)
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(OBQ08.245) Which type of inflammatory cell is thought to be involved in the activation of the biological response to metal-on-metal particulate debris? Review Topic

QID: 631
1

Neutrophil

1%

(37/2870)

2

Giant cell

1%

(35/2870)

3

Macrophage

26%

(755/2870)

4

Eosinophil

2%

(46/2870)

5

Lymphocyte

69%

(1990/2870)

ML 3

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(OBQ12.117) Which of the following molecules is associated with macrophage induced osteolysis surrounding orthopaedic implants? Review Topic

QID: 4477
1

BMP-7

2%

(68/3628)

2

IL-10

9%

(343/3628)

3

SOX-9

2%

(88/3628)

4

Osteoprotegrin

6%

(224/3628)

5

IL-1

79%

(2876/3628)

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(OBQ10.259) A design surgeon has created a new polyethlyene acetabular liner for total hip arthroplasty. Early clinical outcomes are comparable to conventional total hip arthroplasty. At 4 year follow-up, radioisometric analysis reveals 0.05 mm of annual wear in the surgeon's trial patients. Which of the following statements can be made from this data? Review Topic

QID: 3311
1

Osteolysis and subsequent component loosening will be minimal if the wear rate continues

70%

(1640/2358)

2

Osteolysis and subsequent component loosening will be greater than conventional hip arthroplasty if the wear rate continues

19%

(449/2358)

3

Component positioning should have no effect on wear rates of these bearings

10%

(227/2358)

4

All total hip arthroplasties should use this new polyethylene

1%

(21/2358)

5

Patient satisfaction will be greater at 10 year follow up

0%

(8/2358)

ML 3

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PREFERRED RESPONSE 1

(OBQ05.146) A 75-year-old man underwent total hip arthroplasty 10 years ago. He now reports mild groin pain which has been increasing lately. What is the most likely explanation for the finding in Figure A indicated with the arrows? Review Topic

QID: 1032
FIGURES:
1

Osteosarcoma

0%

(4/2004)

2

Galvanic corrosion of the modular components

5%

(91/2004)

3

Polyethlene wear particles tracking through the effective joint space

93%

(1863/2004)

4

Joint sepsis

1%

(21/2004)

5

Occult fracture

1%

(17/2004)

ML 1

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(OBQ11.191) A 56-year-old man reports progressively worsening left knee pain after undergoing total knee arthroplasty 6 years ago. He was initially very happy with his progress, but 18 months after surgery he began to have knee pain. Radiographs are shown in Figures A and B. Laboratory values reveal a C-reactive protein of 0.1 mg/dL (normal 0.0-0.6 mg/dL) and an erythrocyte sedimentation rate of 3 mm/h (normal 0-15 mm/h). An aspiration of the knee reveals 157 leukocytes/ml with 18% polymorphonucleocytes. What is the most appropriate next step in management? Review Topic

QID: 3614
FIGURES:
1

One-stage revision

91%

(2349/2575)

2

Irrigation and debridement with polyethylene spacer exchange

2%

(55/2575)

3

Antibiotic impregnated cement spacer placement

1%

(17/2575)

4

Two-stage revision

5%

(130/2575)

5

Broad-spectrum, empiric oral antibiotics

1%

(14/2575)

ML 1

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PREFERRED RESPONSE 1

(OBQ04.196) A 69-year-old female 16 years status post total knee arthroplasty complains of knee pain. A radiograph is provided in Figure A. Which of the following is true regarding the pathogenesis of the bony abnormality seen in the distal femur? Review Topic

QID: 1301
FIGURES:
1

It is related to the toughness of the polyethylene liner

2%

(48/2018)

2

It is more likely to occur with highly cross-linked polyethylene compared to conventional polyethylene

1%

(30/2018)

3

It is caused by macrophage activation by polyethylene particles

94%

(1897/2018)

4

It is most frequently caused by infection

1%

(14/2018)

5

It occurs more frequently in patients taking immunosuppressive medications.

1%

(24/2018)

ML 1

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(OBQ12.246) A 72-year-old female underwent an uncomplicated primary total hip replacement 18 years ago. Current radiographs reveal the abnormality shown in Figure A. Which of the following cell types (Figures B-F) is implicated in the process shown by the arrow? Review Topic

QID: 4606
FIGURES:
1

Figure B

9%

(262/2830)

2

Figure C

10%

(297/2830)

3

Figure D

6%

(179/2830)

4

Figure E

2%

(69/2830)

5

Figure F

71%

(2002/2830)

ML 3

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PREFERRED RESPONSE 5

(OBQ09.180) Osteoprotegrin (OPG) binds to what structure to inhibit particle-induced osteolysis? Review Topic

QID: 2993
1

RANK

18%

(420/2377)

2

RANK-ligand

75%

(1792/2377)

3

OPG-receptor

6%

(145/2377)

4

CD7

0%

(6/2377)

5

CD10

0%

(10/2377)

ML 2

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PREFERRED RESPONSE 2

(OBQ12.177) Which of the following variables is associated with elevated serum metal ion levels following metal-on-metal hip resurfacing arthroplasty? Review Topic

QID: 4537
1

Smaller implant diameter

40%

(1134/2864)

2

Smaller acetabular cup abduction angle

28%

(798/2864)

3

Higher postoperative functional scores

24%

(681/2864)

4

Severe preoperative osteoarthritis

2%

(70/2864)

5

Anteversion of acetabular cup between 10 and 20 degrees

6%

(161/2864)

ML 4

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PREFERRED RESPONSE 1

(OBQ12.196) A patient undergoes a primary total hip arthroplasty with a highly cross-linked ultra-high molecular weight (UHMW) polyethylene acetabular liner. In comparison to a 28mm femoral head, a 32mm femoral head will provide which of the following? Review Topic

QID: 4556
1

Increased risk of dislocation

3%

(110/3868)

2

Decreased range of motion

10%

(375/3868)

3

Decreased risk of osteolysis

21%

(807/3868)

4

Equivalent wear rate of the polyethylene acetabular liner

63%

(2446/3868)

5

Increased risk of periprosthetic fracture

2%

(95/3868)

ML 4

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(OBQ10.116) A new biomaterial has been designed for hard on soft bearings in total hip arthroplasty. The implant company claims this new material has a lower wear rate and greater toughness than highly cross linked polyethylene. Which of the following studies would most accurately evaluate wear between the two materials? Review Topic

QID: 3210
1

Retrospective review of each material with immediate post-operative radiographs compared to annual follow-up radiographs

1%

(15/1928)

2

Prospective trial comparing each material with radiostereometric analysis

84%

(1618/1928)

3

Prospective trial comparing each material with annual CT scans

2%

(47/1928)

4

Prospective trial comparing each material with computer-assisted edge-detection radiographs

12%

(237/1928)

5

Retrospective trial comparing each material with computer-assisted edge-detection radiographs

0%

(7/1928)

ML 2

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(OBQ12.68) Which of the following is indicative of type 1 collagen breakdown and can be utilized as a marker of bone turnover? Review Topic

QID: 4428
1

Increased urinary N-telopeptide

71%

(2873/4044)

2

Increased urinary cAMP and phosphate

13%

(542/4044)

3

Increased urinary phosphoethanolamine

6%

(223/4044)

4

Increased urinary Bence Jones proteins

3%

(111/4044)

5

Increased serum bone sialoprotein

7%

(263/4044)

ML 3

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PREFERRED RESPONSE 1

(OBQ05.63) When comparing conventional polyethylene liners to the newer highly cross-linked polyethylene liners, all of the following are true EXCEPT for one. Which of these statements about conventional poly liners is incorrect? Review Topic

QID: 949
1

Higher steady-state femoral head penetration rate

6%

(67/1113)

2

More susceptible to adhesive wear

10%

(115/1113)

3

Generate smaller wear particle size

61%

(679/1113)

4

Increased fracture toughness

13%

(142/1113)

5

Increased tensile strength

10%

(108/1113)

ML 3

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PREFERRED RESPONSE 3

(OBQ10.39) A 45-year-old male, with a history of avascular necrosis, undergoes a total hip arthroplasty using a metal-on-metal bearing. Which of the following statements regarding the use of metal-on-metal bearings is true? Review Topic

QID: 3127
1

Produce lower serum metal ion concentrations than metal-on-cross linked polyethylene bearings

0%

(11/2554)

2

Have a decreased volumetric wear rate compared to metal-on-ceramic bearings

11%

(270/2554)

3

Have smaller wear particles compared to metal-on-cross linked polyethylene bearings

79%

(2014/2554)

4

Have a higher incidence of early soft-tissue sarcoma compared to all other bearing surfaces.

6%

(156/2554)

5

The wear rate significantly increases after the first year of use.

4%

(96/2554)

ML 2

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PREFERRED RESPONSE 3

(OBQ08.116) All of the following are risk factors for wear-related failure in total knee arthroplasty when using a polyethylene liner that underwent sterilization via gamma irradiation in air EXCEPT? Review Topic

QID: 502
1

Increasing shelf age of polyethylene liner

7%

(68/965)

2

Younger age of patient

1%

(14/965)

3

Male gender

10%

(94/965)

4

Posterior cruciate retaining knee design

74%

(717/965)

5

Use of a rough tibial baseplate

7%

(66/965)

ML 3

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PREFERRED RESPONSE 4

(OBQ06.46) Figure A shows a ceramic head removed during a total hip revision. The component shows damage to the femoral head which was most likely caused by which of the following? Review Topic

QID: 157
FIGURES:
1

Third body debris

18%

(190/1052)

2

Chronic infection

0%

(5/1052)

3

Impingement of the femoral stem neck on the acetabular socket

18%

(191/1052)

4

Lift-off separation of the femoral head during hip range of motion

58%

(611/1052)

5

Insertion of the head on the femoral stem at time of initial surgery

5%

(52/1052)

ML 3

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(OBQ07.236) Ultra-high-molecular-weight polyethylene (UHMWPE) particles have been associated with osteoclastogenesis, a key component of osteolysis in total joint replacement. Which of the following accurately describes the expression of vascular endothelial growth factor (VEGF) and receptor activator of nuclear factor kappa-B ligand (RANKL) during UHWMPE induced osteolysis? Review Topic

QID: 897
1

RANKL expression is increased and VEGF is unchanged or mildly decreased

13%

(232/1745)

2

VEGF expression is increased and RANKL is decreased

5%

(79/1745)

3

VEGF expression is increased and RANKL expression is unchanged

3%

(55/1745)

4

Expression of both VEGF and RANKL is increased

77%

(1346/1745)

5

Expression of both VEGF and RANKL is decreased

2%

(28/1745)

ML 1

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(OBQ06.220) Which of the following interventions reduces osteolysis around distal portion of the femoral stem when performing a total hip arthroplasty? Review Topic

QID: 231
1

Use of an extended offset femoral neck component

2%

(15/871)

2

Use of a proximal circumferentially coated ingrowth stem

67%

(580/871)

3

Use of a collared stem

3%

(28/871)

4

Use of a long femoral stem

1%

(11/871)

5

Ensuring that the stem fills the diaphysis of the femur

27%

(233/871)

ML 3

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PREFERRED RESPONSE 2

(OBQ07.11) Figure A is a photograph of a femoral head removed during revision of a ceramic on ceramic total hip arthroplasty. Which of the following is the most likely indication for this revision total hip arthroplasty? Review Topic

QID: 672
FIGURES:
1

Prosthetic infection

0%

(5/1283)

2

Recurrent dislocations

83%

(1059/1283)

3

Leg length discrepancy

2%

(21/1283)

4

Ceramic bearing fracture

11%

(142/1283)

5

Aseptic lymphocytic-vasculitis-associated lesion (ALVAL)

4%

(52/1283)

ML 2

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PREFERRED RESPONSE 2

(OBQ07.145) Highly cross-linked ultra-high-molecular-weight polyethylene (UHMWPE) liners used in total hip arthroplasty have which of the following characteristics compared to conventional UHMWPE liners? Review Topic

QID: 806
1

Increased average wear particle size

3%

(64/2057)

2

Increased resistance to abrasive wear

79%

(1629/2057)

3

Increased number of wear particles generated

5%

(94/2057)

4

Increased resistance to fatigue crack propogation

9%

(194/2057)

5

Increased ductility

3%

(71/2057)

ML 2

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(OBQ07.205) Highly cross-linked ultra high molecular weight polyethylene has which of the following characteristics as compared to conventional polyethylene? Review Topic

QID: 866
1

Improved ductility

1%

(23/2598)

2

Increased fracture toughness

1%

(34/2598)

3

Increases the elongation to break

1%

(13/2598)

4

Improved resistance to crack propagation

1%

(34/2598)

5

Improved wear resistance

96%

(2489/2598)

ML 1

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