Ceramic-on-ceramic total hip replacements (THRs) have shown low wear volumes in standard gait hip simulator studies. 1. However clinical reports have indicated a variation in wear rates and formation of stripe wear on the ceramic femoral heads. 2. The aim of this study was to investigate the influence of different clinical conditions such as cup inclination angle and microseparation (head offset deficiency) on the wear of ceramic-on-ceramic THRs. The six station Leeds II hip joint simulator was used to investigate the wear of size 28mm ceramic-on-ceramic bearing couples. The alumina matrix composite ceramic material (AMC, Biolox Delta, CeramTec AG, Germany) was used in this study. The lubricant used was 25% bovine serum. The study was carried out for a total of five million cycles; the first two million cycles under standard gait conditions and a further three million cycles under microseparation conditions. During microseparation, a lateral movement of 0.5mm was applied to the cup relative to the head during the swing phase of the gait cycle. 3. Three of the cups were mounted to provide a clinical angle of 55°, which is referred to as the ‘standard’ condition; and the other three cups were mounted to provide a clinical angle of 65°, which is referred to as the ‘steep angle’ condition. These combinations provided four different testing conditions: standard, steep cup angle, microseparation, and combination of steep cup angle and microseparation conditions. Volumetric wear was determined gravimetrically and statistical analysis was performed using One Way ANOVA (significance at p< 0.05). Increasing the cup inclination angle from 55° to 65° had no significant effect on the wear rate in Biolox Delta ceramic-on-ceramic THRs under both standard (p> 0.42) and microseparation (p> 0.55) conditions. Under standard gait conditions, the mean wear rate for both cup inclination angles was very low at 0.05 mm3/million cycles. The introduction of microseparation to the standard gait cycle significantly increased the mean wear rates (p< 0.01) to 0.13 mm3/ million cycles for the ‘standard’ cup inclination angle of 55° and 0.11 mm3/million cycles for the ‘steep’ cup inclination angle of 65°. A stripe of wear on the head also formed, with corresponding superior rim wear on the cup. For comparison, the steady state wear rate of HIPed third generation alumina ceramic (Biolox Forte) under microseparation conditions was 1.3 mm3/million cycles [. 4. ]. In conclusion, increasing the cup inclination angle by 10° had no influence on the wear rate of Biolox Delta ceramic-on-ceramic bearings. The introduction of microseparation conditions significantly increased the wear rate and resulted in stripe-like wear on the femoral head, which has previously been observed on retrieved ceramic prosthesis. However, these wear rates were still low, and were ten times lower than those previously reported for Biolox Forte

The angle of acetabular inclination is an important measurement in total hip replacement (THR) procedures. Determining the acetabular component orientation intra-operatively remains a challenge. An increasing number of innovators have described techniques and devices to achieve it. This paper describes a mechanical inclinometer design to measure intra-operative acetabular cup inclination. Then, the mechanical device is tested to determine its accuracy. The aim was to design an inclinometer to measure inclination without existing instrumentation modification. The device was designed to meet the following criteria: 1. measure inclination with acceptable accuracy (+/− 5o); 2. easy to use intra-operatively (handling & visualization); 3. adaptable and useable with majority of instrumentation kits without modification; 4. sterilizable by all methods; 5. robust/reusable. The prototype device was drafted by computer aided design (CAD) software. Then a prototype was constructed using a 3D printer to establish the final format. The final device was CNC machined from SAE 304 stainless steel. The design uses an eccentrically weighted flywheel mounted on two W16002-2RS ball bearings pressed into symmetrical housing components. The weighted wheel is engraved with calibrated markings relative to its mass centre. Device functioning is dependent on gravity maintaining the weighted wheel in a fixed orientation while the housing can adapt to the calibration allowing for determining the corresponding measurement. The prototype device accuracy was compared to a digital device. A digital protractor was used to create an angle. The mechanical inclinometer (user blinded to digital reading) was used to determine the angle and compared to the digital reading. The accuracy of the device compared to the standard freehand technique was assessed using a saw bone pelvis fixed in a lateral decubitus position. 18 surgeons (6 expert, 6 intermediate, 6 novice) were asked to place an uncemented acetabular cup in a saw bone pelvis to a target of 40 degrees. First freehand then using the inclinometer. The inclination was determined using a custom-built inertial measurement unit with the user blinded to the result. Comparison between the mechanical and digital devices showed that the mechanical device had an average error of −0.2, a standard deviation of 1.5, and range −3.3 to 2.6. The average root mean square error was 1.1 with a standard deviation of 0.9. Comparison of the inclinometer to the freehand technique showed that with the freehand component placement 50% of the surgeons were outside the acceptable range of 35–45 degrees. The use of the inclinometer resulted all participants to achieve placement within the acceptable range. It was noted that expert surgeons were more accurate at achieving the target inclination when compared to less experienced surgeons. This work demonstrates that the design and initial testing of a mechanical inclinometer is suitable for use in determining the acetabular cup inclination in THR. Experimental testing showed that the device is accurate to within acceptable limits and reliably improved the accuracy of uncemented cup implantation in all surgeons

Background. Cup inclination is a major factor in the success of a total hip replacement. An open cup position can lead to dislocation or increased wear from rim loading and a closed cup position lead to impingement against the femoral neck or psoas. Although the ideal inclination for cup position is recommended as between 40 and 45 degrees, accurate positioning of the implant might be influenced by pelvic flexion and movement of the patient's pelvis during the procedure. We wanted to examine if the transvers acetabular ligament (TAL) could be used to determine cup inclination intra-operatively. Methods. 16 hips from 9 cadaveric specimens were used for the study. A computer navigation system (Brain lab) was used to measure and document the exact inclination and version of the acetabular trial component in three positions: flush with the transvers acetabular ligament (TAL), with the rim of the cup 5 mm from the TAL in a cranial direction and with the rim of the cup 5 mm caudally displaced. Statistical analysis of the results was performed by the Department of Biostatistics. Findings. With the cup positioned flush with the TAL, the average version was 43 degrees (range 37 to 47 degrees.) When there was a 5 mm gap between the TAL and the cup the average inclination was 28 degrees (21 to 35 degrees.) When the cup was opened so it covered the TAL by 5 mm the average inclination increased to 64 degrees (55 to 75 degrees.) The average anteversion angle was 18 degrees (range 15 to 25 degrees.). Conclusion. We found the transverse acetabular ligament to be an accurate landmark for positioning of the femoral implant as far as version and inclination was concerned. We recommend positioning the acetabular component flush with the TAL as cup inclination was shown to be ideal in all cases when we adhered to that principle. NO DISCLOSURES

INTRODUCTION. Retrieval and clinical studies of metal-on-metal (MoM) bearings have associated increased wear. 1. and elevated patient ion levels. 2. with steep cup inclination angles and edge loading conditions. The University of Leeds have previously developed a hip simulator method that has been validated against retrievals and shown to replicate clinically relevant wear rates and wear mechanisms. 3,4. This method involves introducing lateral microseparation to represent adverse joint laxity and offset deficiency. This study aimed to investigate the effect of microseparation representing translational malpostion, and increased cup inclination angle, representing rotational malposition, in isolation and combined on the wear of different sizes (28 and 36mm) MoM bearing in total hip replacement (THRs). MATERIALS AND METHODS. The wear of size 28mm and 36mm MoM THRs bearings was determined under different in vitro conditions using the Leeds II hip simulator. For each size bearing, two clinical cup inclination angles were considered, 45° (n=3) and 65° (n=3). The first three million cycles were run under standard gait conditions and subsequently three million cycles were run under microseparation conditions. Standard gait cycles included a twin peak load (300N–3000N), extension/flexion (−15°/+30°) and internal/external rotation (±10°). Microseparation. 4. was achieved by applying a 0.4–0.5mm medial displacement to the cup relative to the head during the swing phase of the standard gait cycle resulting in edge loading at heel strike. The lubricant was 25% (v/v) new-born calf serum. The wear volume was determined through gravimetric analysis every million cycles. One way ANOVA was performed (significance: p<0.05), and 95% confidence limits were calculated. RESULTS. Under standard gait conditions, the 28mm MoM bearing showed head-rim contact and increased wear rate with increased cup inclination angle but the 36mm bearing did not show any increase in wear. Microseparation and edge loading increased the wear rate of MoM bearings for all cup inclination angle conditions and bearing sizes (Figure 1). DISCUSSION. With the larger size bearings, head-rim contact occurred at a steeper cup inclination angle (>65°) providing an advantage over smaller bearings. Under standard gait conditions, where head-rim contact did not occur, wear was low, due to mixed lubrication and wear reduction through a protein boundary film. However, edge loading of the cup, with elevated stress, caused excess damage and wear. This effect was more dominant with microseparation conditions to that of head-rim contact due to increased cup inclination angle alone. Under microseparation conditions, there were no significant differences in the wear rates of the 28mm and the 36mm size bearings. However, the wear rates obtained in this study for 28mm and 36mm bearings were significantly lower than those obtained for size 39mm surface replacement MoM bearings (8.99 mm. 3. /million cycles) tested under the same adverse conditions. 5. . CONCLUSION. This study shows the importance of acetabular cup design and correct surgical positioning of the femoral head and acetabular cup and restoration of offset and cup centre. ACKNOWLEDGEMENT. This study was supported by the Furlong Research Charitable Foundation (FRCF) and the National Institute of Health Research (NIHR) as part of a collaboration with the Leeds Musculoskeletal Biomedical Research Unit (LMBRU). The components were custom made specifically for this project by Corin Ltd

The purpose of this study was to examine the utility of the acetabular component introducer as a tool to intra-operatively predict implant inclination in total hip arthroplasty. This study investigated (1) the correlation between intra-operative photographic assessment of cup inclination using the acetabular introducer and that measured on post-operative radiograph; and (2) the accuracy of intra-operative prediction of abduction angle. For this study, we prospectively recruited 56 patients scheduled to receive primary hip arthroplasty from one of two senior surgeons. During the procedure, the lead surgeon provided a prediction of the abduction angle based on the alignment of the impactor attached to the cup in its final seated position. A standardized anteroposterior (AP) photograph was then taken of the acetabular impactor in situ. Abduction angles were measured by two observers on the photographs and post-operative AP pelvis radiographs. Linear regression was used to determine the correlation between the angle of the guide measured on the photographs and the actual position of the implant measured on the radiograph. Descriptive statistics were further used to analyze the accuracy of the intra-operative prediction as compared with the abduction angle measured on the photographs. Measurements of cup position made from post-operative radiographs were significantly correlated with the measurements as assessed by intra-operative photographs (r = 0.34, p = 0.00). Our findings demonstrate that radiological abduction angles tend to be greater than that assessed by intra-operative photographs by a mean of 5.6 degrees (SD = 6.6 degrees; 95% CI = 7.3 to 3.9 degrees). Conversely, surgeon prediction of cup inclination based on the acetabular introducer differed from the radiographic measurements by a mean of 6.8 degrees (SD = 8.7 degrees). There was good agreement between the two observers in both photographic and radiographic measurement (k = 0.95, k = 0.96, respectively). In conclusion, we found that the intra-operative photographic assessment of acetabular cup inclination by acetabular impactor alignment tends to underestimate the abduction angle by a mean of approximately 5 degrees. In addition, intra-operative surgeon estimation of acetabular inclination did not appear accurate in this study demonstrating that cup position should rely on additional visual cues beyond that captured in the anteroposterior view of the cup introducer

Introduction: Hip resurfacing is a successful pain-relieving procedure which restores function in young patients. However, some patients have persisting pain. We suggest that load characteristics in relation to position of the cup may influence these symptoms. We aimed to determine the effect of acetabular cup inclination angle on pain following hip resurfacing. Methods: 92 consecutive hips in 81 patients were resurfaced with the ASR prosthesis. The average age was 56.5 years (35–72). 33 were female hips. Harris Hip Scores (HHS) and UCLA activity scores were recorded pre-operatively and at last follow-up. Patient satisfaction was recorded. Acetabular cup inclination angle was measured. An acceptable angle for hip replacement is 45 degrees +/− 5 degrees. We therefore grouped cups into those above 50 degrees and those below. Average follow-up was 17.9 months (8–31). There were 39 hips with an angle less than 50 degrees (A), and 53 greater than 50 (B). Patients in each group were comparable for age, sex, follow-up and BMI. Results: In group A HHS improved from 53.4 to 98.7 and UCLA activity score improved from 4.2 to 7.5. All patients were extremely or very pleased. In group B HHS improved from 49.0 to 94.0 and UCLA activity score improved from 3.9 to 7.1. 48 of 53 patients were extremely or very pleased. At follow up 37 of 39 (95%) of patients in group A had no pain. In group B 35 of 53 had no pain (66%). This is a statistically significant difference when analysed with Fisher’s exact test (p< 0.05). Discussion: This study shows that an excessively open acetabular cup may contribute to persisting pain and patient dissatisfaction. This may be a result of excessive eccentric wear and metal ion deposition, and may lead to early failure of the prosthesis

Introduction. Wear plays a key role in the clinical outcome of total hip replacements (THR). In addition, increased frictional moment can stress the implant interfaces which may lead to high torsional loadings in the intermodular taper junction (fretting) and cup loosening and to the development of noise (squeaking). Against the background of larger head diameters (increased range of motion and decreased risk of dislocation), the friction induced by the joint articulation is of particular interest. As of now, the investigation of friction with the use of relevant joint kinematics and loadings are limited to numerical studies. Experimental approaches use simplified models which do not take into consideration complex activities. Thus, with the aim of this study is the identification of articular frictional moments that consider critical in vivo loading conditions and kinematics as well as the clinical cup inclination, head size and clearance of ceramic-on-ceramic hip bearings. Materials and Methods. A standard hip simulator (Minibionix 852 with 4 DOF Hip setup, MTS, Eden Prairie, USA) was modified in order to allow for high-precision friction measurements during head-insert articulation in all 6 DOF (MC2.5D-500, AMTI, Boston, USA). Disturbing systemic effects have been minimized by using quasi frictionless aerostatic lateral force compensation (Eitzenberger, Wessobrunn, Germany) and cross talk compensation. Beside the standard protocoll for in vitro wear assessment (ISO 14242-1), more complex profiles from in vivo patient data (Heidelberg Motion Lab and Orthoload database) have been used: normal walking with different walking speeds and patient's weights, stairs up/down and start-stop conditions. All-ceramic bearings (Biolox delta, Ceramtec, Plochingen, Germany) have been orientated in clinically relevant cup inclinations (30, 45, 60 and 75 deg). For each head diameter (28, 36 and 48 mm) n=8 specimens have been devided in two groups: small and large clearance according to the manufacturer's specification. All tests were run at 37°C in diluted bovine serum (20 g/l protein content). Results and Discussion. For all continuously running activities (normal walking, stairs up/down and ISO standard), increased resulting frictional moments have been measured with larger head diameters and smaller clearances in a range of less than 6 Nm. This data corresponds well to the results of a well-lubricated ceramic-on-ceramic bearing from numerical studies. In addition, the initial breakaway torque after a short resting period (start-stop initiation) was increased, where the highest maximal moments have been measured with increasing resting durations and larger head diameters (large clearance: up to 11 Nm, small clearance: up to 20 Nm). Interestingly enough, not in all cases a negative effect on the resulting moment was seen with increasing cup inclination, even though no subluxation was induced. For any figures or tables, please contact authors directly (see Info & Metrics tab above).

Introduction. A high inclination angle has been linked to an increased dislocation rate, liner fracture, and increased wear. The aim of this study was to compare the operative (OI) with the radiological inclination (RI) angle and determine the influence of patient morphology on pelvic tilt and cup inclination angle. Methods. In the first cohort of 100 patients undergoing uncemented primary total hip arthroplasty, the cup was inserted freehand. In the second cohort of 100 patients, the OI was measured with the aid of a digital inclinometer. RI and pelvic tilt in lateral decubitus were measured. Results. The mean RI in the freehand group was similar to the protractor group (38.5 SD 7.0 and 38.3 SD 4.7; p=0.83) with a significantly greater variance in the freehand group (range 22°-60° versus 27°-51°; p=0.0001) and more outliers for the inclination safe zone (24 versus 10; p=0.01). The mean difference between the RI and OI (ΔRI-OI) in the protractor group was 12.3° SD 4.2 (range 3.8°-19.8°). The mean pelvic tilt was 4.0° (SD 3.5) of adduction. Linear regression analysis demonstrated that RI was positively correlated with OI (r. 2. =0.44, p<0.0001). Hip circumference was negatively correlated with pelvic tilt (r. 2. =0.20, p=0.002) and ΔRI-OI (r. 2. =0.37, p=0.0001). There was a significant reduction in the number of inclination outliers over time in the second cohort (6 versus 2 versus 1 versus 1; p=0.04). Discussion. The mean ΔRI-OI was 12.3°. In patients with a larger hip circumference there was less pelvic tilt in the frontal plane and less ΔRI-OI. Surgeons using the posterior approach in lateral decubitus should aim for a lower OI in order to achieve an acceptable RI, especially in patients with a smaller hip circumference. Conclusion. In our hands, taking into account patient morphology and using a digital protractor intraoperatively has significantly reduced the number of inclination outliers

The orientation of the acetabular component is influenced by the orientation at which the surgeon implants the component and the orientation of the pelvis at the time of implantation. When operating with the patient in the lateral decubitus position, pelvic orientation can be highly variable. The goal of this study was to examine the effect of two different pelvic supports on cup orientation. In this prospective study, 200 consecutive patients undergoing uncemented primary THA in the lateral decubitus position were included. In the control group a single support over the pubic symphysis (PS) was used. In the study group, a single support over the ipsilateral anterior superior iliac spine (ASIS) was used. In every patient, the cup was inserted and the angle of the cup introducer relative to the floor (apparent operative inclination; OIa) was measured with the aid of a digital inclinometer. The radiographic inclination (RI) was measured on anteroposterior pelvic radiographs at 6 weeks postoperatively. The target zone for cup inclination was 35–45°. In both cohorts the cups were implanted close to the target OIa with an absolute difference with the OIa of 0.86° SD 0.82 in the PS cohort and 1.03° SD 0.99 in the ASIS cohort (p=0.18). The difference between the RI and OIa was higher in the PS cohort 12.2° SD 4.1 compared with 7.5° SD 3.7 in the ASIS cohort (p<0.0001) with also a bigger variance (p=0.04) in the PS cohort. The mean RI was 38.5° SD 4.4 compared with 39.2° SD 4.1 (p=0.26) respectively. There were more cups outside the RI target zone in the PS cohort compared with the ASIS cohort (respectively 26 versus 15; p<0.05). In this study the mean difference between the RI and OIa (the angle of the cup introducer during surgery) was significantly less when using a support over the ASIS compared with a support over the pubic symphysis. Apparently using a support over the ASIS causes less pelvic motion during surgery compared with a support over the pubic symphysis. This resulted in less variance and inclination outliers when using a tight target zone of 35–45°

INTRODUCTION. Ceramic-on-ceramic hip replacements have generated great interest in recent years due to substantial improvements in manufacturing techniques and material properties. 1. Microseparation conditions that could occur due to several clinical factors such as head offset deficiency, medialised cup combined with laxity of soft tissue resulting in a translation malalignment, have been shown to cause edge loading, replicate clinically relevant wear mechanisms. 2,3. and increase the wear of ceramic-on-ceramic bearings. 3,4. The aim of this study was to investigate the influence of increasing the femoral head size on the wear of ceramic-on-ceramic bearings under several clinically relevant simulator conditions. MATERIALS AND METHODS. The wear of size 28mm and 36mm ceramic-on-ceramic bearings (BIOLOX® Delta, CeramTec, Germany) was determined under different in vitro conditions using the Leeds II hip simulator. For each size bearing, two clinical cup inclination angles were considered, 55° (n=3) and 65° (n=3) for the 28mm bearing and 45° (n=3) and 65° (n=3) for the 36mm bearing. The first two (28mm study) or three (36mm study) million cycles ran under standard gait conditions and a subsequent three million cycles ran under microseparation conditions. A standard gait cycle included a twin peak load (300N–3000N), extension/flexion (−15°/+30°) and internal/external rotation (±10°). Microseparation. 3. was achieved by applying a 0.4–0.5mm medial displacement to the cup relative to the head during the swing phase of the standard gait cycle resulting in edge loading at heel strike. The lubricant was 25% (v/v) new-born calf serum which was changed approximately every 333,000 cycles. The wear volume was ascertained through gravimetric analysis every million cycles. One way ANOVA was performed (significance: p<0.05), and 95% confidence limits were calculated. RESULTS AND DISCUSSION. The mean wear rate under standard gait conditions was 0.05mm. 3. / million cycles for the 28mm bearings and significantly lower (p=0.003) for the 36mm bearings (Figure 1) which could be due to improved lubrication regime. The wear of ceramic-on-ceramic bearings was not influenced by the increase in cup inclination angle for either bearing size (Figure 1). The introduction of microseparation into the gait cycle resulted in stripe wear on the femoral head with a corresponding wear area at the rim of the acetabular cup and significantly higher wear rates of the ceramic-on-ceramic bearings (Figure 2). The wear rate of BIOLOX® Delta bearings under microseparation conditions was still low (<0.25mm. 3. /million cycles) compared to the third generation alumina ceramic-on-ceramic bearings (1.84mm. 3. /million cycles). 4. under the same adverse conditions. Under microseparation conditions, the wear rate of size 36mm bearings was significantly higher (p=0.004) than that for size 28mm bearings. This was thought to be due to the larger contact area for the larger bearings and deprived lubrication under edge loading conditions. For both bearing sizes, the combination of both steep cup inclination angles and microseparation conditions did not increase the wear rates any further compared to microseparation conditions alone (Figure 3). This study shows the importance of surgical positioning of the femoral head and acetabular cup and the importance of testing new bearing materials and designs using these adverse simulator methods. ACKNOWLEDGEMENT. This study was supported by the Furlong Research Charitable Foundation (FRCF) and the National Institute of Health Research (NIHR) as part of a collaboration with the Leeds Musculoskeletal Biomedical Research Unit (LMBRU)

Metal-on-metal (MOM) hip arthroplasty, including resurfacing, has become the subject of recent research and debate. There is the perceived benefit of improved wear rates of bearing surfaces leading to superior durability and performance of these types of implant. An associated feature of MOM bearing surfaces is the generation of metal ions. These can have local and systemic cytotoxic effects. An immunoloigical response has been suggested, however, metal wear debris may cause direct damage to cellular DNA. Studies have shown that release of these ions is related to bearing diameter and component alignment. However, little is known about the relationship between metal ion levels and implant survivorship. The MHRA has published guidelines on the follow-up of patients with MOM implants including measurement of serum ion levels and cross sectional imaging. Between February 2001 and November 2009, 135 patients (164 hips) had MOM resurfacing arthroplasty at our institution. We report a retrospective analysis of the data generated by review of these patients. Of the 135 patients, 91 were identified for clinical review. Each patient had serum metal ion levels measured, plain AP radiographs of the pelvis examined and, in the presence of raised metal ions, a Metal Artefact Reduction Sequence (MARS) MRI performed. 27 patients (35 hips) had raised metal ion levels (Cobalt and Chromium). Patients with raised metal ion levels had a mean acetabular cup inclination of 52.7 degrees compared with a mean inclination of 48.6 degrees in patients with normal ion levels (p<0.05). MARS MRI in the raised ion group revealed 9 patients with appearances suggestive of ALVAL. A number of these patients had hip revision surgery with the remainder awaiting potential revision. These findings reflect current evidence suggesting a relationship between sub-optimal component position and raised metal ion levels and an increased rate of ALVAL

Achieving the correct inclination angle for the acetabular component in total hip arthroplasty (THR) can be technically challenging. The aim of this study is to validate the use of a simple, laser-guided system to address the acetabular cup inclination angle intraoperatively and quantify its accuracy and repeatability across users. A simple inclinometer system was manufactured, consisting of a laser that snaps into both the inclinometer and the handle of a standard trial cup impacter. The system functions as follows:. desired inclination angle is set on the inclinometer,. inclinometer is positioned on the acetabulum,. laser beam is projected onto and marked on a screen outside of the surgical exposure,. the impacter is reoriented in the acetabulum until the laser beam aligns with the recorded mark on the screen. A validation study was performed on this system using intact cadavers (N=4). A THR-specific. Trial acetabular components were installed unilaterally in each donor using both the laser inclinometer system with an in-line mounted intraoperative navigation system (NaviVision, Vector Vision Hip 3.1, BrainLab) serving as the measurement standard. Three orthopaedic surgeons participated in the study, two experienced with the device (“experts”) and one “novice”, and each surgeon performed two sequential validation experiments:. 10 trials at a set device inclination angle, and. 5 trials of matching the trial cup placement to this set angle. Using the laser-guided system, the inclination angle of the trial cup deviated from the desired orientation by 1.1±0.9° (mean st. dev; range: 0–3°) for all specimens across all operators. The corresponding error in anteversion angle was 1.4±1.3° (range: 0–5°). There was no difference in inclination angle between expert and novice surgeons (1.0±0.8° versus 1.1±1.2°, respectively; p> 0.10 for unpaired t-test). To set the desired inclination angle on the trial cup, original and final laser target positions were within 4.1±2.5 cm at 1 m screen placement. Results suggest that the laser-guided system has sufficient accuracy and repeatability for use intra-operatively. Inclination angles differed from prescribed angles by 1° on average, and malalignment in anteversion was subclinical, ≤5° for all cases. Furthermore, the tolerance for laser re-alignment sufficiently large (5–10 cm) to make the device functional intraoperatively. Future work will focus on expanding the sample size and correcting simple design limitations in the device

Introduction: There is increasing interest in the use of ceramic on ceramic bearings for hip replacement, due to recognition of their extremely low wear and biocompatibility of the wear debris [. 1. ]. The aim of this study was to investigate the influence of cup inclination angle and head position on the wear of ceramic-on-ceramic total hip replacements. Methods: The wear of Biolox Delta alumina matrix composite ceramic (CeramTec AG, Germany) was investigated using the six station Leeds II Physiological Anatomical hip joint simulator, using 25% bovine serum as a lubricant. Three ceramic-on-ceramic bearings were mounted with the cup providing a clinical angle of 55o (representing the standard condition) and three were mounted to provide a clinical angle of 65o (representing the steep cup angle condition). Simulator studies were carried out under standard gait conditions for 2 million cycles, and under micro-separation conditions for a further 3 million cycles. Micro-separation and dynamic lateralisation of the position of the head replicate head/cup rim contact at heel strike and simulate stripe wear on a ceramic femoral head as found on ceramic-on-ceramic retrievals [. 2. ]. Volumetric wear was determined gravimetrically and statistical analysis was performed using One Way ANOVA. Results: There was no difference in the wear rates under standard gait conditions for the standard and steep cup angles, with a wear rate of 0.05 mm3/million cycles. Under micro-separation conditions the wear rates increased significantly to 0.13 and 0.11 mm3/million cycles for the standard and steep cup angles respectively. However, there was no significant difference between the standard and steep cup angle groups. Discussion: Micro-separation and dynamic lateralisation of the position of the head during gait simulation significantly increased wear. However, the inclination of the cup in ceramic-on-ceramic THRs did not have a significant effect on the wear under either standard gait or micro-separation conditions

Introduction

In total hip arthroplasty, a high radiographic inclination angle (RI) of the acetabular component has been linked to short- and long-term complications. There are several factors that lead to RI outliers including cup version, pelvic orientation and angle of the cup introducer relative to the floor. The primary aim of this study was to analyse what increases the risk of having a cup with an RI outside the target zone when controlling cup orientation with a digital inclinometer.

Introduction

Radiological inclination (RI) is determined in part by operative inclination (OI), which is defined as the angle between the cup axis or handle and the sagittal plane. In lateral decubitus the theatre floor becomes a surrogate for the pelvic sagittal plane.

Critically at the time of cup insertion if the pelvic sagittal plane is not parallel to the floor either because the upper hemi pelvis is internally rotated or adducted, RI can be much greater than expected. We have developed a simple Pelvic Orientation Device (POD) to help achieve a horizontal pelvic sagittal plane.

The POD is a 3-sided square with flat footplates that are placed against the patient's posterior superior iliac spines following initial positioning (figure 1). A digital inclinometer is then placed parallel and perpendicular to the patient to give readings of internal rotation and adduction, which can then be corrected.

Background: Metal-on-metal bearing hip replacements release between three and nine times more cobalt and chromium ions than a metal on polyethylene bearing hip replacement. We do not fully understand the cause for the variability of ion levels after metal on metal hip replacement. The factors that determine an individual’s levels of metal ions include: firstly, patient factors (renal failure, patient weight, high activity); secondly, manufacture factors (head size (and fluid film lubrication), carbide density, surface finish) and lastly study factors (bilateral implants, time from operation). Biomechanical studies suggest that component position, in particular acetabular inclination, is important for wear rate but there is no published correlation from clinical studies.

Aim: To investigate the relationship between acetabular inclination angle and metal ion levels of patients with Birmingham Hip resurfacings.

Methods: Using standardised radiographs, we measured the inclination angle (using UTHSCSA image tool) of the acetabular components in thirty-one patients (mean age 54 years) who underwent unilateral Birmingham hip resurfacing (mean time post operation of 22 months). We also measured peripheral whole blood chromium and cobalt ion concentrations using inductively coupled mass spectrometry. All components were well fixed.

Results: There was a positive correlation between the inclination angle (range 28 degrees – 55 degrees) of the acetabular component and whole blood concentration of Cobalt (range 2.3 – 7 mcg/L), Chromium (range 0.56 – 4.3 mcg/L) and total metal ion levels (range 3.1 – 10.3 mcg/L). This finding was statistically significant, with a Pearson correlation coefficient of 0.46 (95% CI 0.13-0.70) and a p-value of 0.00398.

Conclusion: Acetabular inclination angle is likely to be a factor in determining an individual’s metal ion levels in patients with metal on metal resurfacing. We also iden-tified a threshold level of 50 degrees inclination, after which the metal ion levels rise dramatically. We describe the possible biomechanical mechanisms to explain these results. We recommend surgeons implant the metal socket at an inclination angle of less than 50 degrees.

Aims. The aim of this study was to identify the optimal lip position for total hip arthroplasties (THAs) using a lipped liner. There is a lack of consensus on the optimal position, with substantial variability in surgeon practice. Methods. A model of a THA was developed using a 20° lipped liner. Kinematic analyses included a physiological range of motion (ROM) analysis and a provocative dislocation manoeuvre analysis. ROM prior to impingement was calculated and, in impingement scenarios, the travel distance prior to dislocation was assessed. The combinations analyzed included nine cup positions (inclination 30-40-50°, anteversion 5-15-25°), three stem positions (anteversion 0-15-30°), and five lip orientations (right hip 7 to 11 o’clock). Results. The position of the lip changes the ROM prior to impingement, with certain combinations leading to impingement within the physiological ROM. Inferior lip positions (7 to 8 o’clock) performed best with cup inclinations of 30° and 40°. Superior lip positions performed best with cup inclination of 50°. When impingement occurs in the plane of the lip, the lip increases the travel distance prior to dislocation. Inferior lip positions led to the largest increase in jump distance in a posterior dislocation provocation manoeuvre. Conclusion. The lip orientation that provides optimal physiological ROM depends on the orientation of the cup and stem. For a THA with stem anteversion 15°, cup inclination 40°, and cup anteversion 15°, the optimal lip position was posterior-inferior (8 o’clock). Maximizing jump distance prior to dislocation while preventing impingement in the opposite direction is possible with appropriate lip positioning. Cite this article: Bone Joint Res 2023;12(9):571–579

We have previously reported on the improved all-cause revision and improved revision for instability risk in lipped liner THAs using the NJR dataset. These findings corroborate studies from the Australian (AOANJRR) and New Zealand (NZOA) joint registries. The optimal orientation of the lip in THAs utilising a lipped liner remains unclear to many surgeons. The aim of this study was to identify impingement-free optimal liner orientations whilst considering femoral stem version, cup inclination and cup version. A cementless THA kinematic model was developed using a 20 degree XLPE liner. Physiological ROM and provocative dislocation manoeuvre analyses were performed. A total of 9 cup positions were analysed (inclination 30–40–50 degrees, anteversion 5-15-25 degrees) and combined with 3 stem positions (anteversion 0-15-30 degrees) and 5 lip orientations (right hip 11 to 7 o'clock). Some lip orientation/component position combinations lead to impingement within the physiological ROM range. Using a lipped liner increases the femoral head travel distance prior to dislocation when impingement occurs in the plane of the lip. In THAs with a cup inclination of 30 and 40 degrees, inferior lip orientations (7–8 o'clock for a right hip) performed best. Superior lip orientation performed best with a cup inclination of 50 degrees. Femoral stem version has a significant effect on the range of movement prior to impingement and hence the preferred lip orientation. The optimal orientation of the lip in lipped liner THA is dependent on the position of both the acetabular and femoral components. In the common component orientation combination of stem anteversion 15, cup inclination 40 and cup anteversion 15, the optimal lip orientation was postero-inferiorly (8 o'clock for a right hip). Preventing impingement during physiological ROM is possible with appropriate lip liner orientation

Aims. Custom triflange acetabular components (CTACs) play an important role in reconstructive orthopaedic surgery, particularly in revision total hip arthroplasty (rTHA) and pelvic tumour resection procedures. Accurate CTAC positioning is essential to successful surgical outcomes. While prior studies have explored CTAC positioning in rTHA, research focusing on tumour cases and implant flange positioning precision remains limited. Additionally, the impact of intraoperative navigation on positioning accuracy warrants further investigation. This study assesses CTAC positioning accuracy in tumour resection and rTHA cases, focusing on the differences between preoperative planning and postoperative implant positions. Methods. A multicentre observational cohort study in Australia between February 2017 and March 2021 included consecutive patients undergoing acetabular reconstruction with CTACs in rTHA (Paprosky 3A/3B defects) or tumour resection (including Enneking P2 peri-acetabular area). Of 103 eligible patients (104 hips), 34 patients (35 hips) were analyzed. Results. CTAC positioning was generally accurate, with minor deviations in cup inclination (mean 2.7°; SD 2.84°), anteversion (mean 3.6°; SD 5.04°), and rotation (mean 2.1°; SD 2.47°). Deviation of the hip centre of rotation (COR) showed a mean vector length of 5.9 mm (SD 7.24). Flange positions showed small deviations, with the ischial flange exhibiting the largest deviation (mean vector length of 7.0 mm; SD 8.65). Overall, 83% of the implants were accurately positioned, with 17% exceeding malpositioning thresholds. CTACs used in tumour resections exhibited higher positioning accuracy than rTHA cases, with significant differences in inclination (1.5° for tumour vs 3.4° for rTHA) and rotation (1.3° for tumour vs 2.4° for rTHA). The use of intraoperative navigation appeared to enhance positioning accuracy, but this did not reach statistical significance. Conclusion. This study demonstrates favourable CTAC positioning accuracy, with potential for improved accuracy through intraoperative navigation. Further research is needed to understand the implications of positioning accuracy on implant performance and long-term survival. Cite this article: Bone Jt Open 2024;5(4):260–268

Introduction. Variations in component position can lead to dynamic separation and edge loading conditions. In vitro methods have been developed to simulate edge loading conditions and replicate stripe wear, increased wear rate, and bimodal wear debris size distribution, as observed clinically [1, 2]. The aim of this study was to determine the effects of translational and rotational positioning on the occurrence of dynamic separation and severity of edge loading, and then investigate the wear rates under the most severe separation and edge loading conditions on an electromechanical hip joint simulator. Materials and Methods. A hip joint simulator (ProSim EM13, Simulation Solutions, UK) was set up with 36mm diameter ceramic-on-ceramic (BIOLOX®delta, PINNACLE®, DePuy Synthes, UK) hip replacements. Three axes of rotation conditions (ISO 14242-1 [3]) was applied to the femoral head. This study was in two parts. I) A biomechanical test was carried out at 45° (n=3) and 65° (n=3) cup inclination angles with 1, 2, 3 and 4 (mm) medial-lateral translational mismatch between the centres of the head and cup. The amount of dynamic separation displacement between the head and cup was measured using a position sensor. The severity of edge loading was determined from the area under the axial force and medial-lateral force outputs during the time of separation [4]. II) A wear test was carried out at 45° (n=6) and 65° (n=6) cup inclination angles for three million cycles with translational mismatch of 4mm between the head and cup. The lubricant used was diluted new-born calf serum (25% v/v). Volumetric wear measurements were undertaken at one million cycle intervals and mean wear rates were calculated with 95% confidence limits. Statistical analysis was carried out using ANOVA and a t-test with significance levels taken at p<0.05. Results. Dynamic separation increased significantly with 3mm (p<0.01) and 4mm (p<0.01) translational mismatch at a 45° cup inclination angle (Figure 1). At 65° the separation increased significantly as the translational mismatch increased from 1mm to 4mm (p<0.01). The most severe edge loading conditions occurred at a 65° cup inclination angle with 4mm of translational mismatch (p<0.01, Figure 2). Mean wear rates were greater at a 65° cup inclination angle compared with a 45° cup inclination angle (p<0.01, Figure 3). Conclusion. Different levels of rotational and translational mismatch affected the separation between the head and cup during gait. Higher levels of translational mismatch and a steeper cup inclination angle may lead to more severe edge loading conditions and increased wear of ceramic-on-ceramic bearings in vivo. A new preclinical testing approach was developed to study the effects of edge loading due to variations in rotational and translational surgical positioning under ISO loading and angular displacement conditions. The first stage comprised of biomechanical tests to determine the occurrence and severity of edge loading in a range of component positions. The second stage investigated the tribological performance of the bearing surface under the worst case edge loading conditions