Mechanisms of Disease: molecular insights into aseptic loosening of orthopedic implants


Despite the success of treating rheumatic disorders with biologic therapies, joint replacement surgery still remains the final treatment option in many cases. Approximately 1.5 million joint arthroplastic operations are performed annually worldwide. Implant failure due to massive bone loss and aseptic loosening of prostheses, however, is a major complication of joint replacement, which can lead to high socioeconomic burdens both for the individual patient and for health-care systems. To date, there is no approved drug therapy to prevent or inhibit periprosthetic osteolysis, and aseptic loosening of prostheses can only be overcome by surgical revision. Research during the past decade, however, has unravelled much of the pathogenesis of aseptic prosthesis loosening and preclinical studies have identified potential targets for pharmaceutical treatments. This article highlights the importance of a cooperative interaction between rheumatologists and orthopedic surgeons, and presents novel insights into the molecular mechanisms behind aseptic loosening of prostheses. In addition, we outline potential perspectives for the development of future therapeutic strategies for this devastating complication.

Key Points

  • Prosthesis loosening without concurrent infection or trauma is called aseptic loosening

  • Over 10% of implants require surgical revision within 15 years of the initial operation, mostly because of aseptic prosthesis loosening

  • The pathogenesis of aseptic loosening shows substantial overlap with the pathogenesis of inflammatory disorders of the joint, such as rheumatoid arthritis; similarities include histopathology (i.e. the periprosthetic membrane) and the molecular signaling pathways involved

  • Key cells in bone destruction include multinucleated osteoclasts, macrophages and mesenchymal cells (prosthesis-loosening fibroblasts)

  • Preclinical studies have identified molecular targets that might lead to potential pharmaceutical therapies for aseptic prosthesis loosening

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Figure 1: Immunogold–silver staining of wear debris particles
Figure 2: Wear debris induces interplay between prosthesis-loosening fibroblasts, multinucleated osteoclasts and macrophages
Figure 3: Signaling pathways involved in aseptic prosthesis loosening


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Correspondence to Philipp Drees.

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Drees, P., Eckardt, A., Gay, R. et al. Mechanisms of Disease: molecular insights into aseptic loosening of orthopedic implants. Nat Rev Rheumatol 3, 165–171 (2007).

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