Current Concepts Review Wear in Total Hip and Knee Replacements

Before the advent of total joint replacement, patients who had end-stage arthritis of the lower extremities had unremitting pain and a greatly decreased functional capacity. In addition, they often were confined to a wheelchair and were dependent on the care of others. Today, the outcomes of primary total hip and knee replacement are predictable and usually excellent. Prosthetic joint replacement has dramatically improved the lives of millions of people worldwide. As the fixation of total joint implants has become more reliable and durable and as the technology of total joint replacement has been applied to younger and more active patients, the current limitations of total joint arthroplasty are related to the wear of the components. Wear is the removal of material, with the generation of wear particles, that occurs as a result of the relative motion between two opposing surfaces under load. In complex mechanical-biological systems such as total hip and knee replacements, there can be many types of wear. Although the mechanical consequences of wear, such as progressive thinning of polyethylene components, can limit the functional life of a joint replacement, the clinical problems from wear more frequently are due to the release of an excessive number of wear particles into a biological environment. When particles within a certain size-range are phagocytized in sufficient amounts, the macrophages enter into an activated state of metabolism, releasing substances that can result in periprosthetic bone resorption. Progressive loss of periprosthetic bone can necessitate a reoperation, which is the definitive measure of clinical failure of a joint arthroplasty.