Abstract
Only a little over a decade ago the vast majority of primary total hip replacements performed in North America, and indeed globally, employed a conventional polyethylene insert, either in a modular version or in a cemented application. Beginning in the early 2000's there was an explosion in technology and options available for the bearing choice in total hip arthroplasty.
Highly cross-linked polyethylene was introduced in 1998, and within a few short years the vast majority of polyethylene inserts performed in North America were manufactured from this material. Globally there was a mixed picture with variable market penetration. Surgeons had seen historically poor results with attempts at “improving” polyethylene in the past and many were hesitant to use this new technology. Many randomised clinical trials have been performed and all have shown to a greater or lesser degree, that indeed the highly cross-linked polyethylene insert has undergone less linear and volumetric wear than its more conventional counterpart. This replicates well the hip simulator data. The challenge, however, is as we approached mid-term results, orthopaedic manufacturers began altering the polyethylene to improve wear and improve mechanical strength. Therefore while ten-year and greater data will ultimately be published, the actual polyethylene in use at that time will be a different material. Additionally while wear rates are undoubtedly lower, we are still waiting for long-term results of actual osteolytic lesion development and the effect that highly cross-linked polyethylene will have on this clinical scenario. That being said, with over a decade of clinical experience, unquestionably highly cross-linked polyethylene has truly been a revolution in design, essentially eliminating polyethylene wear as an early failure mode.
The question still remains as to the best material for the femoral ball. Essentially two options exist – cobalt chrome (CoCr) and ceramic. There are theoretically advantages to ceramic heads; however, they come at a cost premium:
To date there have been no published reports that demonstrate any improved clinical outcomes with the use of ceramic heads. In fact, the Australian registry demonstrates that the cumulative revision rate is lowest with CoCr heads (at 10 years, 4.3% with CoCr on XLPE and 4.6% with ceramic on XLPE).
Costs continue to be significantly higher for ceramic heads. A price premium of 2–4x higher cost for ceramic over CoCr heads exists in most global markets.
Trunnion issues. An emerging concern is corrosion at the head neck junction in THA. Ceramic heads should theoretically have a lower incidence of taper corrosion. To date this is unproven, as is the actual incidence of this as a significant clinical problem.
