Osteolysis can have a number of etiologies including infection, tumors, and inflammatory reactions related to particulate debris. In joint replacement, non-infection-related osteolysis is most commonly caused by reactions to polyethylene debris, cement debris, or metal debris or metal ions.

Osteolysis may be asymptomatic or may lead to pain and decreased function (typically due to the associated particle generated synovitis), loosening of the femoral and/or acetabular component, and periprosthetic fracture.

In many cases, periprosthetic acetabular osteolysis can be treated with component retention in the case of a well-fixed acetabular shell with the benefit of reduced surgical time, blood loss, cost, and avoidance of additional bone loss.

Surgical treatment of osteolysis is recommended when there is imminent wear-through of the acetabular polyethylene, progressive expansile lesions that may cause implant loosening, or periprosthetic fracture.

Prior imaging, over the lifetime of the arthroplasty, is helpful for comparative purposes to evaluate for changes in osteolysis and radiolucent or reactive lines.

The formation of particulate debris or corrosion products from total hip implants leads to an inflammatory response and macrophage activation that leads to osteolysis.

The particulate debris can be formed from any type of wear of the total hip arthroplasty (THA) implants. Particulate debris can be formed from polyethylene (particularly non-cross-linked polyethylene), either at the bearing surface or on the back side of the polyethylene. Cement debris may be created from a loosened cemented implant (due to abrasion of the cement by implant or bone). Metal wear particles may be created from metal-on-metal bearings. Additionally, modular metal junctions maybe subject to taper corrosion in which mechanically assisted crevice corrosion leads to release of cobalt and chromium ions that lead to osteolysis and tissue necrosis through other pathways.

It is important to first rule out infection in the setting of osteolysis as both may have similar presenting clinical pictures in regard to bone loss. This can be done with laboratory workup of erythrocyte sedimentation rate, C-reactive protein, and aspiration if warranted and intraoperative cultures.

Lateral decubitus position

The operative approach is at the discretion of the surgeon and may be chosen based on the location of the osteolysis and the planned operative intervention.

For many cases the authors prefer the posterior approach as it may easily be made extensile if needed. Additionally, posterior column osteolysis is more readily approached posteriorly.

The senior author reserves the anterolateral approach in those with severe abductor damage seen at time of exposure or for cases in which cup retention is planned and there is relatively less prosthetic cup anteversion present.

The direct anterior approach, in expert hands, is useful for a minority of revision hip arthroplasties, but extensile exposure is more difficult.

Periodic screening of all patients with THA is recommended; more frequent screening is appropriate for patients who are young and active or have components known to be poor performers. This should be performed with anteroposterior (AP) pelvis, AP and lateral hip, and potentially Judet view radiographs.

Plain radiographs may inadequately detect the extent of osteolysis; however, there is increased sensitivity with computed tomography (CT) (and sometimes magnetic resonance imaging [MRI]). These modalities may be recommended in cases in which there is progressive wear and/or symptoms with little radiographic evidence of lysis. However, advanced imaging is not cost-effective for screening. Additionally, in settings of massive osteolysis or if pelvic discontinuity is suspected, CT may help the surgeon further investigate and perhaps plan further surgical intervention.

CT is more effective in assessing bone loss in the pelvis; however, MRI is particularly useful in assessing soft tissue reactions especially in situations of osteolysis in conjunction with metal reaction and soft tissue mass.

It is an important exercise to classify osteolytic bone loss in the setting of revision THA, as the classification systems may help guide treatment.