Review Question - QID 7643

This patient has evidence of severe periarticular osteolysis around a previous total knee arthroplasty. He is symptomatic and would benefit from revision total knee arthroplasty (TKA).

Osteolysis is one of the leading causes for late reoperation in patients who undergo TKA. Osteolysis occurs as the result of a foreign body response to particulate wear debris from the prosthetic joint. These particles consist of polyethylene, polymethylmethacrylate cement, and metal, all of which have been shown to elicit a distinct inflammatory response. Once the particles are generated from and around the implant, they become phagocytosed by macrophages and giant cells in the synovial or periprosthetic tissue. These cells, in turn, become activated and can directly or indirectly cause osteolysis. The femur is prone to osteolysis in the region of the femoral condyles and near the attachments of the collateral ligaments of the femur. Osteolysis around the tibia tends to occur along the periphery of the component or along the access channels to the cancellous bone.

Maloney & Rosenberg reviewed the management and outcome of periprosthetic osteolysis around hip and knee implants. They recommended surgical intervention for periprosthetic osteolysis around a TKA with (1) first-time presentation of advanced osteolysis in the presence of an identifiable cause of wear particle production or in the presence of associated bone loss that places the structural integrity of the bone or fixation of the components at risk, (2) bearing surface wear in the presence of impending wear-through or related mechanical symptoms, (3) progressive osteolysis in an active individual, and (4) symptoms of wear debris-related synovitis that are refractory to conservative treatment.

Griffin et al. evaluated the results of isolated polyethylene exchange for wear and/or osteolysis in 68 press-fit condylar TKAs from four centers. At a minimum of 24 months after polyethylene exchange surgery, there were 11 failures (16.2%).

Gupta et al. discuss the etiology, diagnosis, contributing factors, and management of osteolysis as it relates to TKAs. They recommend that if the patient is asymptomatic with minimal osteolysis on plain radiographs, regular follow-up at 6 months to 1 year with medical management including calcium and bisphosphonates would be adequate. If the patient becomes symptomatic or the osteolysis is progressive, then early liner exchange with or without tibial baseplate exchange is considered.

Figure A & B are AP and lateral radiographs of severe periarticular osteolysis. Illustration A is an AP and lateral radiograph of the revision TKA.

Incorrect Answers:
Answer 1: Protecting this patients weight bearing will not address the underlying cause of their pain, which is osteolysis and should be addressed with revision TKA.
Answer 3: Bisphosphonate therapy has not been shown to decrease the amount of osteolysis once generated.
Answer 4: Observation for 1 year is not advised because the amount of osteolysis is extensive.
Answer 5: The patient is symptomatic (i.e., pain and instability) and has evidence of severe osteolysis on x-ray. Liner exchange and bone grafting would not adequately address this degree of osteolysis as the components are likely loose.