Laboratory Studies

Laboratory evaluation prior to any surgical intervention should include a complete blood count (CBC), coagulation studies, and routine chemistries. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are useful, especially in excluding indolent infection. In cases where infection is a serious consideration, preoperative aspiration may also prove helpful in further evaluation.

Radiography

Standard anteroposterior (AP) hip and pelvis views and frog-leg lateral views are central to the evaluation of acetabular wear in total hip arthroplasty (THA). Most information can be gathered from these views. Serial radiography over time confers additional information regarding wear and prosthetic loosening.

In the setting of significant osteolysis, additional views may be helpful in defining the extent of these lesions and the extent of any bony deficiencies. These include Judet oblique views to evaluate the integrity of both the anterior and posterior columns and the false profile view and sitting lateral view.

Derbyshire et al described a two-dimensional (2D) radiographic wear measurement system that enables the low wear of highly cross-linked polyethylene cups to be accurately measured from standard pelvis radiographs.^[23]

Computed Tomography

Computed tomography (CT) may provide supplemental information regarding the pelvis and help differentiate contained bony deficiencies from significant pelvic discontinuity.

Devane et al described a computer-assisted method that uses models of the patient's bones and components built from a single CT scan to measure migration and polyethylene wear.^[24]

Bone Scanning

Although bone scintigraphy has been available for more than 30 years, it plays a limited role in the evaluation of a painful hip prosthesis. The main determinants of technetium (Tc)-99m methylene diphosphate (MDP) tracer uptake in bone are blood flow and metabolic bone activity. Increased tracer uptake may be observed for 12-24 months after implantation of a total hip prosthesis because of bone remodeling.

The appearance of abnormal uptake surrounding a painful prosthesis has been used to differentiate loosening from infection. Loose prostheses tend to show increased uptake in the trochanters, at the stem tip, and possibly the acetabular shell. Bone scintigraphy is sensitive for infection but lacks specificity.^[25]

Gallium scanning may be useful in the assessment of infection. Gallium binds to serum transferrin and carries an accuracy of 75% in detecting a periprosthetic infection. It has more intense uptake than Tc-99m MDP, and combining these tests may be effective in the evaluation of a painful prosthesis.

Indium-labeled white blood cells (WBCs) accumulate in the region of infection because of chemotaxis. Mixed WBC lines are used in the preparation and may account for the similar sensitivity for acute and chronic infections of 82%.

Treatment & Management

Charnley J. Long-term results of low-friction arthroplasty. Hip. 1982. 42-9. [Medline].
Charnley J. Total hip replacement by low-friction arthroplasty. Clin Orthop Relat Res. 1970 Sep-Oct. 72:7-21. [Medline].
Charnley J. Arthroplasty of the hip. A new operation. Lancet. 1961 May 27. 1 (7187):1129-32. [Medline].
Lampropoulou-Adamidou K, Georgiades G, Vlamis J, Hartofilakidis G. Charnley low-friction arthroplasty in patients 35 years of age or younger. Results at a minimum of 23 years. Bone Joint J. 2013 Aug. 95-B (8):1052-6. [Medline].
Bhatt H, Goswami T. Implant wear mechanisms--basic approach. Biomed Mater. 2008 Dec. 3 (4):042001. [Medline].
Cipriano CA, Issack PS, Beksac B, Della Valle AG, Sculco TP, Salvati EA. Metallosis after metal-on-polyethylene total hip arthroplasty. Am J Orthop (Belle Mead NJ). 2008 Feb. 37 (2):E18-25. [Medline].
Schmalzried TP, Callaghan JJ. Wear in total hip and knee replacements. J Bone Joint Surg Am. 1999 Jan. 81 (1):115-36. [Medline].
Dorr LD, Wan Z, Longjohn DB, Dubois B, Murken R. Total hip arthroplasty with use of the Metasul metal-on-metal articulation. Four to seven-year results. J Bone Joint Surg Am. 2000 Jun. 82 (6):789-98. [Medline].
McKellop HA, Campbell P, Park SH, Schmalzried TP, Grigoris P, Amstutz HC, et al. The origin of submicron polyethylene wear debris in total hip arthroplasty. Clin Orthop Relat Res. 1995 Feb. (311):3-20. [Medline].
McCalden RW, MacDonald SJ, Rorabeck CH, Bourne RB, Chess DG, Charron KD. Wear rate of highly cross-linked polyethylene in total hip arthroplasty. A randomized controlled trial. J Bone Joint Surg Am. 2009 Apr. 91 (4):773-82. [Medline].
Martell JM. Clinical wear assessment. Callaghan JJ, Rosenberg AG, Rubash HE, et al, eds. The Adult Hip: Hip Arthroplasty Surgery. 3rd ed. Philadelphia: Wolters Kluwer; 2016. Vol 1: 268-77.
Sychterz CJ, Engh CA Jr, Yang A, Engh CA. Analysis of temporal wear patterns of porous-coated acetabular components: distinguishing between true wear and so-called bedding-in. J Bone Joint Surg Am. 1999 Jun. 81 (6):821-30. [Medline].
Sychterz CJ, Engh CA Jr, Young AM, Hopper RH Jr, Engh CA. Comparison of in vivo wear between polyethylene liners articulating with ceramic and cobalt-chrome femoral heads. J Bone Joint Surg Br. 2000 Sep. 82 (7):948-51. [Medline].
O'Dwyer Lancaster-Jones O, Williams S, Jennings LM, Thompson J, Isaac GH, Fisher J, et al. An in vitro simulation model to assess the severity of edge loading and wear, due to variations in component positioning in hip joint replacements. J Biomed Mater Res B Appl Biomater. 2018 Jul. 106 (5):1897-1906. [Medline].
Willert HG, Semlitsch M. Reactions of the articular capsule to wear products of artificial joint prostheses. J Biomed Mater Res. 1977 Mar. 11 (2):157-64. [Medline].
Charnley J. Postoperative infection after total hip replacement with special reference to air contamination in the operating room. Clin Orthop Relat Res. 1972 Sep. 87:167-87. [Medline].
Harris WH, Schiller AL, Scholler JM, Freiberg RA, Scott R. Extensive localized bone resorption in the femur following total hip replacement. J Bone Joint Surg Am. 1976 Jul. 58 (5):612-8. [Medline].
Jasty MJ, Floyd WE 3rd, Schiller AL, Goldring SR, Harris WH. Localized osteolysis in stable, non-septic total hip replacement. J Bone Joint Surg Am. 1986 Jul. 68 (6):912-9. [Medline].
Anthony PP, Gie GA, Howie CR, Ling RS. Localised endosteal bone lysis in relation to the femoral components of cemented total hip arthroplasties. J Bone Joint Surg Br. 1990 Nov. 72 (6):971-9. [Medline].
Corten K, Bourne RB, Charron KD, Au K, Rorabeck CH. Comparison of total hip arthroplasty performed with and without cement: a randomized trial. A concise follow-up, at twenty years, of previous reports. J Bone Joint Surg Am. 2011 Jul 20. 93 (14):1335-8. [Medline].
Livermore J, Ilstrup D, Morrey B. Effect of femoral head size on wear of the polyethylene acetabular component. J Bone Joint Surg Am. 1990 Apr. 72 (4):518-28. [Medline].
Oonishi H, Kadoya Y, Masuda S. Gamma-irradiated cross-linked polyethylene in total hip replacements--analysis of retrieved sockets after long-term implantation. J Biomed Mater Res. 2001. 58 (2):167-71. [Medline].
Derbyshire B, Barkatali B. Validation of a new 2-D technique for radiographic wear measurement of cemented, highly cross-linked polyethylene acetabular cups. Med Eng Phys. 2017 Sep. 47:159-166. [Medline].
Devane PA, Horne JG, Foley G, Stanley J. Measuring the migration of the components and polyethylene wear after total hip arthroplasty: beads and specialised radiographs are not necessary. Bone Joint J. 2017 Oct. 99-B (10):1290-1297. [Medline].
Merkel KD, Brown ML, Fitzgerald RH Jr. Sequential technetium-99m HMDP-gallium-67 citrate imaging for the evaluation of infection in the painful prosthesis. J Nucl Med. 1986 Sep. 27 (9):1413-7. [Medline].
Narkbunnam R, Amanatullah DF, Electricwala AJ, Huddleston JI 3rd, Maloney WJ, Goodman SB. Outcome of 4 Surgical Treatments for Wear and Osteolysis of Cementless Acetabular Components. J Arthroplasty. 2017 Sep. 32 (9):2799-2805. [Medline].
Yang CC, Kim RH, Dennis DA. The squeaking hip: a cause for concern-disagrees. Orthopedics. 2007 Sep. 30 (9):739-42. [Medline].
Keurentjes JC, Kuipers RM, Wever DJ, Schreurs BW. High incidence of squeaking in THAs with alumina ceramic-on-ceramic bearings. Clin Orthop Relat Res. 2008 Jun. 466 (6):1438-43. [Medline].
Mai K, Verioti C, Ezzet KA, Copp SN, Walker RH, Colwell CW Jr. Incidence of 'squeaking' after ceramic-on-ceramic total hip arthroplasty. Clin Orthop Relat Res. 2010 Feb. 468 (2):413-7. [Medline]. [Full Text].
Molloy D, Jack C, Esposito C, Walter WL. A mid-term analysis suggests ceramic on ceramic hip arthroplasty is durable with minimal wear and low risk of squeak. HSS J. 2012 Oct. 8 (3):291-4. [Medline]. [Full Text].
Brockett CL, Harper P, Williams S, Isaac GH, Dwyer-Joyce RS, Jin Z, et al. The influence of clearance on friction, lubrication and squeaking in large diameter metal-on-metal hip replacements. J Mater Sci Mater Med. 2008 Apr. 19 (4):1575-9. [Medline].
Kim RH, Dennis DA, Carothers JT. Metal-on-metal total hip arthroplasty. J Arthroplasty. 2008 Oct. 23 (7 Suppl):44-6. [Medline].
Moroni A, Savarino L, Cadossi M, Baldini N, Giannini S. Does ion release differ between hip resurfacing and metal-on-metal THA?. Clin Orthop Relat Res. 2008 Mar. 466 (3):700-7. [Medline].
Passuti N, Terver S. [Metal on metal bearing surfaces in total hip arthroplasty: a survey of material incidents]. Rev Chir Orthop Reparatrice Appar Mot. 2007 May. 93 (3):288-312. [Medline].
Jacobsson SA, Djerf K, Wahlström O. A comparative study between McKee-Farrar and Charnley arthroplasty with long-term follow-up periods. J Arthroplasty. 1990 Mar. 5 (1):9-14. [Medline].
Jacobs JJ, Skipor AK, Patterson LM, Hallab NJ, Paprosky WG, Black J, et al. Metal release in patients who have had a primary total hip arthroplasty. A prospective, controlled, longitudinal study. J Bone Joint Surg Am. 1998 Oct. 80 (10):1447-58. [Medline].
Visuri T, Pukkala E, Paavolainen P, Pulkkinen P, Riska EB. Cancer risk after metal on metal and polyethylene on metal total hip arthroplasty. Clin Orthop Relat Res. 1996 Aug. (329 Suppl):S280-9. [Medline].
Lewis PM, Al-Belooshi A, Olsen M, Schemitch EH, Waddell JP. Prospective randomized trial comparing alumina ceramic-on-ceramic with ceramic-on-conventional polyethylene bearings in total hip arthroplasty. J Arthroplasty. 2010 Apr. 25 (3):392-7. [Medline].
Choy WS, Kim KJ, Lee SK, Bae KW, Hwang YS, Park CK. Ceramic-on-ceramic total hip arthroplasty: minimum of six-year follow-up study. Clin Orthop Surg. 2013 Sep. 5 (3):174-9. [Medline]. [Full Text].
Yoo JI, Ha YC, Kim DH, Lee YK, Koo KH. Total Hip Arthroplasty Using Hybrid Ceramic Bearing: A Minimum 10-Year Followup Study. Indian J Orthop. 2019 Sep-Oct. 53 (5):637-640. [Medline]. [Full Text].
Geerdink CH, Grimm B, Vencken W, Heyligers IC, Tonino AJ. Cross-linked compared with historical polyethylene in THA: an 8-year clinical study. Clin Orthop Relat Res. 2009 Apr. 467 (4):979-84. [Medline].
McCalden RW, MacDonald SJ, Rorabeck CH, Bourne RB, Chess DG, Charron KD. Wear rate of highly cross-linked polyethylene in total hip arthroplasty. A randomized controlled trial. J Bone Joint Surg Am. 2009 Apr. 91 (4):773-82. [Medline].
Jacobs CA, Christensen CP, Greenwald AS, McKellop H. Clinical performance of highly cross-linked polyethylenes in total hip arthroplasty. J Bone Joint Surg Am. 2007 Dec. 89 (12):2779-86. [Medline].
Wroblewski BM, Siney PD, Dowson D, Collins SN. Prospective clinical and joint simulator studies of a new total hip arthroplasty using alumina ceramic heads and cross-linked polyethylene cups. J Bone Joint Surg Br. 1996 Mar. 78 (2):280-5. [Medline].
Jacobs CA, Christensen CP, Greenwald AS, McKellop H. Clinical performance of highly cross-linked polyethylenes in total hip arthroplasty. J Bone Joint Surg Am. 2007 Dec. 89 (12):2779-86. [Medline].
Geerdink CH, Grimm B, Vencken W, Heyligers IC, Tonino AJ. Cross-linked compared with historical polyethylene in THA: an 8-year clinical study. Clin Orthop Relat Res. 2009 Apr. 467 (4):979-84. [Medline].
Lanting BA, Springer BD. Catastrophic wear in total hip arthroplasty. Complete wear-through of a metal-backed acetabular component: case report. Orthop Clin North Am. 2012 Nov. 43 (5):e63-5. [Medline].
Stambough JB, Pashos G, Bohnenkamp FC, Maloney WJ, Martell JM, Clohisy JC. Long-Term Results of Total Hip Arthroplasty with 28-Millimeter Cobalt-Chromium Femoral Heads on Highly Cross-Linked Polyethylene in Patients 50 Years and Less. J Arthroplasty. 2016 Jan. 31 (1):162-7. [Medline].
Min BW, Cho CH, Son ES, Lee KJ, Lee SW, Song KS. Highly Cross-Linked Polyethylene in Total Hip Arthroplasty in Patients Younger Than 50 Years With Osteonecrosis of the Femoral Head: A Minimum of 10 Years of Follow-Up. J Arthroplasty. 2020 Mar. 35 (3):805-810. [Medline].
Jassim SS, Patel S, Wardle N, Tahmassebi J, Middleton R, Shardlow DL, et al. Five-year comparison of wear using oxidised zirconium and cobalt-chrome femoral heads in total hip arthroplasty: a multicentre randomised controlled trial. Bone Joint J. 2015 Jul. 97-B (7):883-9. [Medline].

Media Gallery

Acetabular wear in total hip arthroplasty. Cementless total hip arthroplasty in a 60-year-old woman with osteoarthritis.
Acetabular wear in total hip arthroplasty. Woman who underwent cementless total hip arthroplasty for osteoarthritis at age 60 years, 6 years following the index arthroplasty. This image demonstrates eccentric polyethylene wear, osteolysis, and a protrusio defect. The stem appears to be well fixed.
Acetabular wear in total hip arthroplasty. Lateral radiograph of the left hip of woman who underwent cementless total hip arthroplasty for osteoarthritis at age 60 years, 6 years following the index arthroplasty. She has eccentric polyethylene wear, osteolysis, and a protrusio defect. The stem is well fixed.
Acetabular wear in total hip arthroplasty. Intraoperative photograph of retrieved specimens at the time of revision arthroplasty. The specimens demonstrate both mode 1 and mode 2 wear.
Acetabular wear in total hip arthroplasty. Intraoperative photograph of retrieved specimens at the time of revision arthroplasty. The specimens demonstrate both mode 1 and mode 2 wear.

of 5

Author

Hari P Bezwada, MD Staff Physician, Department of Orthopedic Surgery, Drexel University College of Medicine

Hari P Bezwada, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Pennsylvania Orthopaedic Society

Disclosure: Nothing to disclose.

Coauthor(s)

David G Nazarian, MD Assistant Clinical Professor, Department of Orthopedic Surgery, University of Pennsylvania School of Medicine

David G Nazarian, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Robert E Booth, Jr, MD Medical Director of Total Knee Replacement and Revision, Jefferson Health 3B Orthopaedics

Robert E Booth, Jr, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, The Knee Society

Disclosure: Received consulting fee from Zimmer for consulting. for: Zimmer Biomet.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

B Sonny Bal, MD, JD, PhD, MBA CEO and President, SINTX Technologies, Salt Lake City, UT

B Sonny Bal, MD, JD, PhD, MBA is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: SINTX Technologies.

Chief Editor

William L Jaffe, MD Clinical Professor of Orthopedic Surgery, New York University School of Medicine; Vice Chairman, Department of Orthopedic Surgery, New York University Hospital for Joint Diseases

William L Jaffe, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American College of Surgeons, Eastern Orthopaedic Association, New York Academy of Medicine

Disclosure: Received consulting fee from Stryker Orthopaedics for speaking and teaching.

Additional Contributors

Jegan Krishnan, MBBS, FRACS, PhD Professor, Chair, Department of Orthopedic Surgery, Flinders University of South Australia; Senior Clinical Director of Orthopedic Surgery, Repatriation General Hospital; Private Practice, Orthopaedics SA, Flinders Private Hospital

Jegan Krishnan, MBBS, FRACS, PhD is a member of the following medical societies: Australian Medical Association, Australian Orthopaedic Association, Royal Australasian College of Surgeons

Disclosure: Nothing to disclose.