Diagnosis and management of implant debris-associated inflammation

ABSTRACT

Introduction: Total joint replacement is one of the most common, safe, and efficacious operations in all of surgery. However, one major long-standing and unresolved issue is the adverse biological reaction to byproducts of wear from the bearing surfaces and modular articulations. These inflammatory reactions are mediated by the innate and adaptive immune systems.

Areas covered: We review the etiology and pathophysiology of implant debris-associated inflammation, the clinical presentation and detailed work-up of these cases, and the principles and outcomes of non-operative and operative management. Furthermore, we suggest future strategies for prevention and novel treatments of implant-related adverse biological reactions.

Expert opinion: The generation of byproducts from joint replacements is inevitable, due to repetitive loading of the implants. A clear understanding of the relevant biological principles, clinical presentations, investigative measures and treatments for implant-associated inflammatory reactions and periprosthetic osteolysis will help identify and treat patients with this issue earlier and more effectively. Although progressive implant-associated osteolysis is currently a condition that is treated surgically, with further research, it is hoped that non-operative biological interventions could prolong the lifetime of joint replacements that are otherwise functional and still salvageable.

KEYWORDS:

• Joint replacement
• joint arthroplasty
• hip
• knee
• wear
• particles
• osteolysis

Article highlights

• The generation of byproducts from joint replacements will always occur, due to repetitive cyclic loading of the bearing surfaces and modular junctions during use.

• byproducts of wear activate the innate immune system, and in some cases (especially with metallic debris and ions), the adaptive immune system.

• progressive inflammation and osteolysis are generally addressed by surgical revision.

• non-operative biological interventions might be possible in the future, and could prolong the lifetime of joint replacements that are otherwise functional and still salvageable.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) of the National Institute of Health, grant numbers [R01AR055650, R01AR063717, R01AR073145, R01AR072613] and the Ellenburg Chair in Surgery. One of the authors (J.G.) was supported in his work by the Ministry of Health of the Czech Republic, grant number (VES16-31852A).