The pathology of total joint arthroplasty - II. Mechanisms of implant failure

Although the clinical results of total joint arthroplasty are usually excellent, some implants develop loosening and require revision. Implants usually fail by a combination of mechanisms, but different basic designs tend to show differ ent dominant mechanisms of failure. Infection causes failure of about 1-5% of cases of primary arthroplasty. Clues to the presence of infection include clinical signs, a periosteal reaction, a positive culture of aspirated joint fluid, and acute inflammation identified in tissue around the implant. There are several different mechanisms and modes of implant wear, and perhaps the most important cause of aseptic loosening is an inflammatory reaction to particles of wear debris. Abrasive, adhesive, and fatigue wear of polyethylene, metal and bone cement produces debris particles that induce bone resorption and implant loosening. Particles can cause linear, geographic, or erosive patterns of bone resorption (osteolysis), the distributions of which are influenced by the implant design. Micromotion of implants that did not achieve adequate initial fixation is another important mechanism of loosening. Fatigue failure at the bone/cement and bone/implant interface may cause aseptic loosening, and may be especially important for implants with relatively smooth surfaces. Stress shielding can influence local bone density, but is rarely an isolated cause of implant loosening. Elevated hydrodynamic pressure has been associated with bone resorption in the absence of implants, and may also play a role in implant loosening.