As there are many reports describing avascular reactions to metal debris (ARMD) after Metal-on-Metal Hip Arthroplasty (MoMHA), the use of MoMHA, especially hip resurfacing, is decreasing worldwide. In cases of ARMD or a rise of metal ion blood levels, revision is commended even in pain free patients with a well integrated implant. The revision of a well integrated implant will cause bone loss. As most of the patients with a hip resurfacing are young and a good bone stock is desirable for further revision surgeries, the purpose of this study was to evaluate the stability of a cemented polyethylene cup in a metal hip resurfacing cup. Two different hip resurfacing systems were investigated in this study (ASR™, DePuy Orthopaedics, Leatherhead, UK; Cormet™, Corin Group, Cirencester, UK). Six different groups were formed according to the treatment and preparation of the cement-cup-interface (table 1). Before instilling cement in groups 1, 3, 5 the surface, which was contaminated with blood, was cleaned just using a gauze bandage. In groups 2, 4, 6 saline, polyhexanid and a gauze were used to clean the surface prior to the cement application. In group one and two the polyethylene cup (PE) was cemented either into Cormet™ or ASR™, just the ASR™ was further investigated in group three to six. A monoaxial load was applied while the cup was fixed with 45 degrees inclination (group 1–4) and 90 degrees inclination (group 5, 6: rotatory stability) and the failure torque was measured. In contrast to group 1 and 2, the cement penetrated the peripheral groove of the ASR™ in groups 3–6. The mean failure torque of five tests for each group was compared between the groups and the implants. The ASR™ showed mean failure torque of 0.1 Nm in group one, of 0.14 Nm in group two, of 56.9 Nm in group three, of 61.5 Nm in group four, of 2.96 Nm in group five and of 3.04 Nm in group six. The mean failure torque of the Cormet™ was 0.14 Nm both in groups one and two (table 2). In groups 1–6 there were no significant differences between the different preparations of the interface. Furthermore, in groups 1 and 2 there were no significant differences between the Cormet™ and the ASR™. The mean failure torque of group 4 was significant increased compared to group 3 (p=0.008). We saw an early failure of the cement fixation due to the smooth surface of the Cormet™ and the ASR™ components in groups 1, 2, 5, 6. In contrast to other hip resurfacing cups the ASR™ has a peripheral groove, which was not cemented except in groups 3 and 4 and therefore the lever-out failure torque was significant increased in these groups. Nevertheless, the groove did not provide stability of the cement-PE compound in case of rotatory movements. In conclusion we do not recommend the use of these methods in clinical routine. The complete removal of hip resurfacing components seems to be the most reasonable procedure

Aims. Highly cross-linked polyethylene (HXLPE) greatly reduces wear in total hip arthroplasty, compared to conventional polyethylene (CPE). Cross-linking is commonly achieved by irradiation. This study aimed to compare the degree of cross-linking and in vitro wear rates across a cohort of retrieved and unused polyethylene cups/liners from various brands. Methods. Polyethylene acetabular cups/liners were collected at one centre from 1 April 2021 to 30 April 2022. The trans-vinylene index (TVI) and oxidation index (OI) were determined by Fourier-transform infrared spectrometry. Wear was measured using a pin-on-disk test. Results. A total of 47 specimens from ten brands were included. The TVI was independent of time in vivo. A linear correlation (R. 2. = 0.995) was observed between the old and current TVI standards, except for vitamin E-containing polyethylene. The absorbed irradiation dose calculated from the TVI corresponded to product specifications for all but two products. For one electron beam-irradiated HXLPE, a mean dose of 241% (SD 18%) of specifications was determined. For another, gamma-irradiated HXLPE, a mean 41% (SD 13%) of specifications was determined. Lower wear was observed for higher TVI. Conclusion. The TVI is a reliable measure of the absorbed irradiation dose and does not alter over time in vivo. The products of various brands differ by manufacturing details and consequently cross-linking characteristics. Absorption and penetration of electron radiation and gamma radiation differ, potentially leading to higher degrees of cross-linking for electron radiation. There is a non-linear, inverse correlation between TVI and in vitro wear. The wear resistance of the HXLPE with low TVI was reduced and more comparable to CPE. Cite this article: Bone Joint Res 2024;13(11):682–693

Revision hip surgery is reportedly rising inexorably yet not all units report this phenomenon. The outcome of 1143 consecutive Corin TaperFit primary hip arthroplasties (957 patients) performed between 1995 and 2010 is presented. The implants were cemented under pressurisation and combined the TaperFit stem with Ogee flanged cups. Data was gathered from local arthroplasty database and case note review of revised joints. 13 hips have been revised (1.1%). Cumulative prosthesis survival is 0.99 +/− 0.0. Two femoral stems were revised (0.2%); one at 6 months for sepsis, one at 14 days after dislodgment during reduction of dislocation. No revisions were undertaken for aseptic loosening of the stem or cup, nor for thigh pain. 32 patients (32 hips) ≥15 year follow up, 13 survive today and none have been revised (0%). Of the 471 with ≥10 year follow up, 38 were aged ≤50 at time of surgery and 1/38 has been revised to date (PLAD for dislocation). The strong population stability in this region, supported by independent investigation by Scottish Arthroplasty Project, endorses the accuracy of the data quoted. The low incidence of revision in this cohort, and absence of revision for aseptic loosening (mean follow up 8.03 years +/− SD 3.94; range 18 months to 16yrs 2 months), substantially supports the longevity and use of cemented, double-taper, polished, collarless femoral stems in combination with cemented polyethylene cups in primary hip arthroplasty in all patient age groups

Between January 1990 and October 2000, 108 total hip arthroplasties using a cemented polished titanium stem and a cemented ultra-high molecular weight polyethylene (UHMWP) cup were performed at our hospital. Because during routine follow-up visits we noted instances of resorption of the calcar, we decided to assess whether this was a problem. We were able to assess 85 of the original 108 hips. Calcar resorption was observed in 43 hips. The extent of calcar resorption varied from 1 mm to over 15 mm. In one patient a biopsy showed typical polyethylene granuloma. Because there is a risk of long-term failure, we concluded that it is inadvisable to use a cemented polished titanium stem when UHMWP is one of the bearing surfaces

Trabecular metal (TM) augments are designed to support an uncemented socket in revision surgery when adequate rim fit is not possible. We have used TM augments in an alternative arrangement, to contain segmental defects to facilitate impaction bone grafting (IBG) and cementation of a cemented socket. However, there is a paucity of literature supporting the use of this technique. We present one of the largest studies to date, reporting early outcomes of patients from a tertiary centre.

A single-centre retrospective analytical study of prospectively collected data was performed on patients who had undergone complex acetabular reconstruction using TM augments, IBG and a cemented cup. All patients operated between 2015 and 2019 were included. We identified 105 patients with a mean age of 74yrs. The mean follow-up was 2.3 years(1–5.5yrs). Our primary outcome measure was all-cause revision of the construct. The secondary outcome measures were, Oxford hip score (OHS), radiographic evidence of cup migration/loosening and post-op complications.

Eighty-four out of 105 patients belonged to Paprosky grade IIb, IIc or IIIa. Kaplan-Meier survivorship for all-cause revision was 96.36% (CI, 90.58–100.00) at 2 years with 3 failures. Two were due to early infection which required two-stage re-revision. The third was due to post-operative acetabular fracture which was then re-revised with TM augment, bone graft and large uncemented cup. Pre-op and post-op matched OHS scores were available for 60 hips(57%) with a mean improvement of 13 points. Radiographic analysis showed graft incorporation in all cases with no evidence of cup loosening. The mean vertical cup migration was 0.5mm (Range −5 to 7mm). No other complications were recorded.

This study shows that reconstruction of large acetabular defects during revision THA using a combination of TM augments to contain the acetabulum along with IBG to preserve the bone stock and a cemented socket is a reliable and safe technique with low revision rates and satisfactory clinical and radiographic results. Long term studies are needed to assess the possibility of preservation and regeneration of bone stock.

Introduction: In a pioneer study Oonishi et al (1988) found reduced socket wear with the use of polyethylene subjected to high radiation doses. This observation has stimulated the development of a new generation polyethylene. In addition to high radiation doses the plastic is also subjected to various types of heat treatment to reduce the amount of free radicals. The purpose of the present study is to evaluate one of the new highly cross-linked polyethylenes in a randomized controlled study of cemented THA. The hypothesis is that the improved wear resistance will reduce the prevalence of osteolytic lesions with long-term follow-up.

Methods and materials: Patients in clinical and radiographic need of a THR with non-inflammatory osteoarthritis of the hip were randomized in two groups. Group 1 received a cemented Weber cup (Sulzer®, Switzerland) made of highly cross-linked (WIAM) polyethylene, group 2 got a conventional cup. All patients received a cemented Spectron (Smith & Nephew, USA) with a 28mm cobalt-chromium head.

So far 15 patients, (6 male and 9 females) with a median age of 55 years (range 42–62) have been evaluated in group 1 and 14 (9 male and 5 females) with a median age of 55 years (range 45–70) in group 2. The penetration of the femoral heads has so far been measured postoperatively (all hips supine), after 3 month (17 hips supine and standing) and after 6 month (11 hips supine and standing) using radiostereometry.

Results: The median proximal and three-dimensional (3-D) penetration (total wear) 0–6 month (supine position) was almost equal in the two groups. Group 1 had a proximal penetration of 0.08 mm (range 0.00–0.17) and a total penetration of 0.11 mm (range 0.06–0.14). The corresponding values for group 2 were 0,10 mm (0.05–0.21) for proximal penetration and 0.13 mm (0.10–0.16) for total penetration. Between 3 and 6 month the penetration (median values) was 0.04 mm/0.10 mm (proximal/3-D) for group 1 and 0.07 mm/0.12 mm for group 2. With the patients standing we found a proximally migration of the socket (0–6 month) in group 1 of 0,08 mm (−0.07 – 0.21) and 0.12 mm (0.1–0.13) in group 2.

Discussion: Use of a highly cross-linked polyethylene in the socket did not influence the early penetration rate after THR. Early creep of the material is possible explanation.

1-year follow-up on approximately 50% of the patients will be presented at the meeting.

Purpose: Wear of prosthetic implants, especially the metal-polyethylene head-cup couple, and dissemination of wear particles throughout the organisms the dominant long-term complication of total hip arthroplasty. We determined serum concentrations of chromium, cobalt, nickel, and molybdenum in patients bearing a total hip prosthesis with a chromium-cobalt metal-poly-ethylene head-cup couple. The purpose of our work was first to compare the levels observed with those found in a control population and then to study variations in these levels as a function of clinical and radiological signs commonly searched for during the follow-up of patients with a total hip arthroplasty.

Material and methods: During a period of 30 months, a total hip arthroplasty (PVL®) was implanted in 53 patients suffering from degenerative hip disease. Forty-eight patients were assessed at a minimum follow-up of 32 months with physical examination and standard x-rays as well as serum assay of the specified metals using mass spectrometry on whole blood samples. The control group was composed of 56 patients scheduled for total hip arthroplasty.

Results: At a mean follow-up of 44 months, 17% of the patients had a fair or poor functional score and 37% had radiological signs suggestive of femoral stem loosening. There was a significant increase in the serum level of cobalt compared with the control group. This increase was greater in patients with radiological signs of loosening.

Discussion: The metal-on-metal couple does not appear to be the only couple which increases serum metal levels. Serum metal assay could be a diagnostic tool useful for following patients with total hip prostheses.

A consensus on total hip arthroplasty (THA) concluded that the major remaining issues of concern included the long-term fixation of the joint replacement, osteolysis due to poluethylene (PE) wear debris which often leads to aseptic loosening. Alumina ceramics had been extensively used in medicine, and we started using the alumina ceramic for THA bearing surface in hopes to reduce the PE debris. It was because alumina ceramics is advantageous for precision machining compared with metal materials, and its hardness is higher than that of metal materials. Also, to augment cement–bone bonding, we interposed hydroxyl apatite (HA) granules at the cement–bone interface, so called “Interface Bioactive Bone Cement (IBBC) technique”. HA granules (2–3 g) were smeared on the bone surface of the acetabulum and femur just before cementing. In this study, we evaluated 19–22 years clinical results of THA with alumina ceramic head combined with PE cup fixated IBBC technique.

Total 285 joints (212 patients) were implanted by one senior surgeon from January 1986 to December 1988, and 265 joints (192 patients) were traceable. Alumina ceramic femoral head of 28 mm in diameter and acetabular cup of the conventional PE sterilized with ethylene oxide gas were used in all patients. The PE cup and stem were fixed with IBBC technique in all cases. The presence of radiolucent line, loosening and osteolysis were observed using radiograph of the traceable cases. The locations of radiolucent lines were identified according to the zones described by DeLee and Charnley for acetabular cups and the zones described by Gruen et al. for femoral stems. The in vivo wear of 21 PE acetabular cups for 19.0–21.9 years (mean 20.3 years) was measured from the latest radiographs using computer assistant technique with Vector Works 10.5 software.

Features of the clinical radiograph images of the IBBC case were classified as follows: the radiolucent line represented “gap” between the HA layer and the cement; the loosening represented “opening” between the HA layer and the cement. For the quantitative analysis, we divided the surrounding bones of the THA into several zones as done in the previous studies. The “gap” appeared in zone 4 in three joints (1.4 %), in zone 3 in two joints (0.9 %) of acetabular cup. In femoral side, in zone 1 in four joints (1.8 %) in zone 7 in one joint (0.4 %). The “opening” appeared in three acetabular cup (1.4 %). Since no opening was appeared in zone 3 or zone 4, however, no re-operation was needed. Images of osteolysis were seen one in zone 1 (0.5 %), and one in zone 2 (0.5 %) in acetabular side and two in zone 1 (0.9 %) of the femur. The mean linear wear rate of PE acetabular cups was 0.13 mm/year.

The fixation to the bone by the IBBC technique has been maintained for long term. We think that the result was brought by the biological integration between bone and HA granules. In conclusion, this study has shown satisfactory results of the cemented THA with ceramic head combined with PE cup for 19–22 years.

Aims

Limited implant survival due to aseptic cup loosening is most commonly responsible for revision total hip arthroplasty (THA). Advances in implant designs and materials have been crucial in addressing those challenges. Vitamin E-infused highly cross-linked polyethylene (VEPE) promises strong wear resistance, high oxidative stability, and superior mechanical strength. Although VEPE monoblock cups have shown good mid-term performance and excellent wear patterns, long-term results remain unclear. This study evaluated migration and wear patterns and clinical and radiological outcomes at a minimum of ten years’ follow-up.

Different types of highly cross-linked polyethylene (HXLPE) have been introduced widely in acetabular cups in hip prostheses to reduce the incidence of wear debris-induced osteolysis. Also, we reported that HXLPE cups with 28-mm alumina ceramic femoral head exhibited lower wear than conventional PE cups. Recently, the combination of HXLPE cup and larger diameter femoral head is used widely to prevent dislocation. In this study, we examined the wear of HXLPE with 32-mm alumina ceramic femoral head and compared it with the wear of HXLPE with 28-mm alumina ceramic femoral head.

The in vivo wear of 60 HXLPE cups (Aeonian; Kyocera Corp., Kyoto, Japan, currently Japan Medical Materials Corp., Osaka, Japan) with 28-mm alumina ceramic femoral head with clinical use for 3.1–9.1 years (mean 7.4 years) and eight HXLPE cups with 32-mm alumina ceramic femoral head used for 2.3–3.2 years (mean 2.8 years) were examined by radiographic analysis.

The early wear rate for the first year of HXLPE cups with 28-mm and 32-mm alumina ceramic femoral head were 0.24±0.10 mm/year and 0.29±0.12 mm/year respectively. There was no significant difference in both femoral head groups (p>0.05). The steady wear rate after 1 year were 0.001±0.03 mm/year and −0.03±0.10 mm/year respectively. There was no significant difference either in both femoral head groups (p>0.05).

These findings from this radiographic analysis suggest that the early wear rate in the first 1 year probably represents the creep deformation in bedding-in stage; and the steady wear rate after 1 year probably represents mainly the wear than of the creep deformation. By the radiographic analysis, HXLPE cups in both femoral head groups exhibited low steady wear rate.

In conclusion, we expect that the combination of HXLPE cup and 32-mm diameter alumina ceramic femoral head has favorable wear properties with possibility of prevention of dislocation in long-term clinical use.

One of important issues of concern in total hip arthroplasty (THA) is osteolysis due to wear debris of ultra-high molecular weight polyethylene (PE), and it often leads to aseptic loosening. Reduction of PE wear debris is essential to prevent osteolysis, and different bearing interfaces as well as improvement of the bearing material itself have been attempted. Alumina ceramics as the bearing material for THA was introduced in Europe and Japan in the 1970s in aim to reduce the PE wear debris. The clinical results have proved the superiority of ceramic on PE couples to metal on PE couples in wear resistance. PE materials cross-liked by irradiation have also demonstrated a significant low wear by in vitro studies. Several types of highly cross-linked polyethylene (CLPE), with the irradiation dose of 50 to 105 kGy, have been developed and extensively used since 1998. In this study, the in vivo wear and oxidation of CLPE acetabular cup combined with ceramic femoral head were evaluated using retrieved cups.

Eight retrieved CLPE acetabular cups (Aeonian; Kyocera Corp., Kyoto, Japan, currently Japan Medical Materials Corp., Osaka, Japan) with clinical use for 3–80 months (mean 34 months) were examined. All cups were used against alumina or zirconia ceramic femoral heads. The linear wear of the retrieved CLPE cups was measured using a three-dimensional coordinate measurement machine. The worn surfaces of retrieved CLPE cups were observed by a scanning electron microscope (SEM). Oxidative degradation of the retrieved CLPE cups was expressed in terms of an oxidation index which was calculated from microscopic Fourier transformed infrared spectroscopy analysis, according to ASTM F2102.

The linear wear rate of retrieved CLPE cups was in 0.006–0.08 mm/year range, which was similar to the results reported by the previous radiographic study. In the worn surface of the CLPE cup retrieved after clinical use shorter than 39 months, machine marks were observed. In contrast, those retrieved after clinical use of 70 and 80 months were smooth. Oxidation indices of retrieved CLPE cups were: 0.12–0.37 in worn surface and 0.13–0.34 in unworn surface, respectively. There was no difference in the oxidation indices between the worn surface and unworn surface.

The retrieved CLPE acetabular cups in this study showed low and stable wear rates. The results showed a notable reduction in wear of the CLPE cups compared to that of conventional PE cups in the previous studies. And also, the oxidation indices of the retrieved CLPE cups were the same level as conventional PE cups. These findings from this retrieval study showed that there is neither progressive wear in the clinical use for 3–80 months, material failures due to wear, delamination nor cracks. The lower wear rate and smooth surface of the CLPE acetabular cup suggest the possibility of reduced wear debris from those cups articulated against the ceramic femoral head. We expect that the CLPE acetabular cup has favorable wear properties in long-term clinical use.

In total hip arthroplasty (THA), one of concerned issues is osteolysis due to wear debris of ultra-high molecular weight polyethylene (PE) which often leads to aseptic loosening. Reduction of PE wear debris is essential to prevent osteolysis, and different bearing combination as well as improvement of the bearing material itself have been attempted. Hence alumina ceramics was introduced for THA, aiming to reduce PE wear debris. Ceramic on PE couple showed good results in clinical wear compared with metal on PE couples. Highly cross-linked PE (HXLPE) with gamma-ray or electron-beam irradiation followed by thermal treatment has also demonstrated a remarkably low wear in the previous in vitro studies. In in vivo studies, the wear of HXLPE acetabular cups against alumina ceramic femoral head was evaluated to compare with that of conventional PE cups against alumina ceramic femoral head.

The in vivo wear of 61 HXLPE cups (Aeonian; Kyocera Corp., Kyoto, Japan, currently Japan Medical Materials Corp., Osaka, Japan) against alumina ceramic femoral head of 28 mm in diameter with clinical use for 2.1–7.1 years (mean 5.6 years) and eight conventional PE cups against an alumina ceramic femoral head of 28 mm in diameter used for 18.7–23.3 years (mean 20.4 years) were examined by radiographic analysis with Vector Works 10.5. The in vivo wear of eight retrieved HXLPE cups with clinical use for 0.9–6.7 years (mean 2.9 years) and 14 retrieved conventional PE cups used for 16.0–28.0 years (mean 22.0 years) were examined by using a three-dimensional coordinate measuring machine. The worn surfaces of retrieved HXLPE and conventional PE cups were observed by a scanning electron microscope.

In the radiographic study, penetration rate of alumina head into HXLPE and conventional PE for the first 1 year were 0.24 mm/year and 0.34 mm/year respectively. One year later, the HXLPE showed significant lower penetration rate of 0.001 mm/year than the conventional PE penetration rate of 0.12 mm/year (p< 0.01). By the retrieval analysis, the mean penetration of retrieved HXLPE and conventional PE cups were 0.11 and 2.97 mm, and they were similar to the results by radiographic analysis. In the worn surface of the retrieved HXLPE cups used for around 1 year, machine marks were observed. In contrast, the worn surface of the retrieved HXLPE cups used for more than five years were smooth, and furthermore, in high magnification observation they had wear morphology different from conventional PE. These findings from this retrieval study suggest the penetration in the first 1 year detected by radiographic measurement was probably caused by creep deformation in bedding-in stage; and 1 year after, the penetration was probably caused mainly by wear.

By the radiographic analysis, HXLPE cups against alumina ceramic femoral head has a 99 % lower wear rate compared with conventional PE cups. Also, retrieved HXLPE cups against alumina ceramic femoral head exhibited lower wear compared with conventional PE cups. In conclusion, we expect that the HXLPE cup used with alumina ceramic femoral head has favorable wear properties in long-term clinical use.

Abstract. Cemented total hip arthroplasty (THA) in the younger patient has historically been associated with higher wear and revision rates. We carried out a retrospective study of a prospectively collected database of patients at Wrightington hospital undergoing cemented THA under 55 years of age to determine acetabular wear and revision rates. Between August 2005 and December 2021 a cohort of 110 patients, 56 males and 54 females, underwent Cemented Total Hip Replacement through a posterior approach. Mean age at operation was 50yrs (35–55). The mean follow up was 6 years 9 months (0–16 years). 3 patients were lost to follow-up. Of the remaining 107 patients, Conventional and cross lined polyethylene were used in 54 and 53 patients respectively. Ceramic heads were used in 102 patients. 22.225mm and 28mm heads were used in 60 and 47 patients respectively. Clinical outcomes were assessed by Merle d'Aubigne and Postel scores which showed significant functional improvement. Linear wear was measured on plain radiographs using TRAUMA CAD and cup loosening was assessed by classification of Hodgkinson et al. No cases were revised during the observed follow up period. The mean wear rate in conventional and crosslinked polyethylene cups were 2.31mm (0.1–4.6) and 1.02mm (0.1–2.6) respectively. Cemented THA with both conventional and crosslinked polyethylene provides excellent survival rates in adults under the age of 55 years and crosslinked polyethylene may further improve these results due to improved wear rates

Scapular notching is a common problem following reverse shoulder arthroplasty (RSA). This is due to impingement between the humeral polyethylene cup and scapular neck in adduction and external rotation. Various glenoid component strategies have been described to combat scapular notching and enhance impingement-free range of motion (ROM). There is limited data available detailing optimal glenosphere position in RSA with an onlay configuration. The purpose of this study was to determine which glenosphere configurations would maximise impingement free ROM using an onlay RSA prosthesis. A three-dimensional (3D) computed tomography (CT) scan of a shoulder with Walch A1, Favard E0 glenoid morphology was segmented using validated software. An onlay RSA prosthesis was implanted and a computer model simulated external rotation and adduction motion of the virtual RSA prosthesis. Four glenosphere parameters were tested; diameter (36mm, 41mm), lateralization (0mm, 3mm, 6mm), inferior tilt (neutral, 5 degrees, 10 degrees), and inferior eccentric positioning (0.5mm, 1.5mm. 2.5mm, 3.5mm, 4.5mm). Eighty-four combinations were simulated. For each simulation, the humeral neck-shaft angle was 147 degrees and retroversion was 30 degrees. The largest increase in impingement-free range of motion resulted from increasing inferior eccentric positioning, gaining 15.0 degrees for external rotation and 18.8 degrees for adduction. Glenosphere lateralization increased external rotation motion by 13. 6 degrees and adduction by 4.3 degrees. Implanting larger diameter glenospheres increased external rotation and adduction by 9.4 and 10.1 degrees respectively. Glenosphere tilt had a negligible effect on impingement-free ROM. Maximizing inferior glenosphere eccentricity, lateralizing the glenosphere, and implanting larger glenosphere diameters improves impingement-free range of motion, in particular external rotation, of an onlay RSA prosthesis. Surgeons’ awareness of these trends can help optimize glenoid component position to maximise impingement-free ROM for RSA. Further studies are required to validate these findings in the context of scapulothoracic motion and soft tissue constraints

We investigated the revision rates of primary total hip replacement (THR) reported in the National Joint Registry (NJR) by types of bearing surfaces used. We analysed THR procedures across all orthopaedic units in England and Wales. Our analyses estimated all-cause and cause-specific revision rates. We identified primary THRs with heads and monobloc cups or modular acetabular component THRs with head and shell/liner combinations. We used flexible parametric survival models to estimate adjusted hazard ratios (HR). A total of 1,026,481 primary THRs performed between 2003–2019 are included in the primary analysis (Monobloc: n=378,979 and Modular: n=647,502) with 20,869 (2%) of these primary THRs subsequently undergoing a revision episode (Monobloc: n=7,381 and Modular: n=13,488). Compared to implants with a cobalt chrome head and highly crosslinked polyethylene (HCLPE) cup, the all-cause risk of revision for monobloc acetabular implant was higher for patients with cobalt chrome or stainless steel head and non-HCLPE cup. The risk of revision was lower for patients with a delta ceramic head and HCLPE cup implant, at any post-operative period. Compared to patients with a cobalt chrome head and HCLPE liner primary THR, the all-cause risk of revision for modular acetabular implant varied non-constantly. THRs with a delta ceramic or oxidised zirconium head and HCLPE liner had a lower risk of revision throughout the entire post-operative period. The all-cause and indication-specific risk of prosthesis revision, at different time points following the initial implantation, is lower for implants with a delta ceramic or oxidised zirconium head and a HCLPE liner/cup than commonly used alternatives such as cobalt chrome heads and HCLPE liner/cup

Introduction: Hip simulator tests, analyses of retrieved components as well as radiostereometric measurements revealed that cups made of highly linked polyethylene show a much better wear performance than cups of conventional polyethylene. However, to the best of our knowledge, histomorphological studies of tissues from the surrounding of highly cross – linked polyethylene components have not been reported yet. The aim of this study was to examine such tissues for particles, released from highly cross – linked polyethylene cups and to compare the findings with those of conventional polyethylene. Material and methods: So far, periprosthetic tissues retrieved at revisions of 11 total hip endoprostheses with highly cross – linked polyethylene cups could be analysed. The revisions became necessary 3 to 50 months after implantation because of cup loosening (4), stem loosening (1), infection (3), periprosthetic fracture of the femur (1), multiple dislocations (1) and periarticular ossification (1). The findings were compared with those of 5 artificial joints (2 ABG, 2 Müller Cup older design, 1 Metalback pressfit) with conventional polyethylene cups and 54 to 231 months of function. 5 μm sections were made from the tissues and conventionally stained with HE and van Gieson. Morphometric measurements were done using objectives 10 and 40 of an Olympus microscope and the ‘Analysis’ program of Soft Ware Imaging GmbH. In the Durasul TM – cases, the total amount and the total area of particles were ascertained while in the cases used for comparison only random CX 40 samples could be measured because of the much higher content of particles. Results: The DurasulTM cases showed in contrast to the cases with conventional polyethylene cups, no distinct foreign body reaction. In four of the DurasulTM cases no particles could be detected at all and in the remaining seven particles could be found only in a few areas. Their number per section was between 6 and 1208, their total area per mm. 2. section ranged between 0,03 and 6,99 × 10 5.mm. 2. In the conventional polyethylene cases the number of particles per section was between 2832 and 71447, their total area per mm. 2. section ranged between 1,06 and 25,91 × 10 3mm. 2. ! The average size of the DurasulTM particles was clearly bigger than the size of the conventional Polyethylene. Discussion: The measurements in tissues of early revisions show that DurasulTM releases much less particles into the surrounding than PE and cause rather no foreign body reaction. Accordingly, the burden of the tissue with polyethylene debris is much lower while the particle size is bigger with DurasulTM than with PE

Hip bearing surfaces materials are typically broadly reported in national registry (metal-on-polyethylene, ceramic-on-ceramic etc). We investigated the revision rates of primary total hip replacement (THR) reported in the National Joint Registry (NJR) by detailed types of bearing surfaces used. We analysed THR procedures across all orthopaedic units in England and Wales. Our analyses estimated all-cause and cause-specific revision rates. We identified primary THRs with heads and monobloc cups or modular acetabular component THRs with detailed head and shell/liner bearing material combinations. We used flexible parametric survival models to estimate adjusted hazard ratios (HR). A total of 1,026,481 primary THRs performed between 2003–2019 were included in the primary analysis (Monobloc cups: n=378,979 and Modular cups: n=647,502) with 20,869 (2%) of these primary THRs subsequently undergoing a revision episode (Monobloc: n=7,381 and Modular: n=13,488). Compared to implants with a cobalt chrome head and highly crosslinked polyethylene (HCLPE) cup, the overall risk of revision for monobloc acetabular implant was higher for patients with cobalt chrome or stainless steel head and non-HCLPE cup. The risk of revision was lower for patients with a delta ceramic head and HCLPE cup implant, at any post-operative period. Compared to patients with a cobalt chrome head and HCLPE liner primary THR, the overall risk of revision for modular acetabular implant varied non-constantly. THRs with a delta ceramic or oxidised zirconium head and HCLPE liner had a lower risk of revision throughout the entire post-operative period. The overall and indication-specific risk of prosthesis revision, at different time points following the initial implantation, is reduced for implants with a delta ceramic or oxidised zirconium head and a HCLPE liner/cup in reference to THRs with a cobalt chrome head and HCLPE liner/cup

Unlike conventional radiographic methods, the newly introduced EOS system provides simultaneously-synchronized anteroposterior (AP) and true-lateral (LAT) x-ray images. EOS offers considerable potential for calculating parameters such as true femoral and acetabular angular positioning, impingement sites, and also for measuring wear in polyethylene cups. In this study we used THA wear-simulation fixtures to assess 3D-wear in polyethylene cups using EOS algorithms. Material and methods. A validated phantom apparatus was used to simulate values of three-dimensional wear, controlled in the 3 directions (antero-posterior, medio-lateral, cranio-caudal) using micrometers. (Figure 1). 24 simulations of wear with controlled amplitudes and directions were imaged using the biplane EOS slot-scanning system. Wear amplitudes were between 0 and 3464 μm. Using dedicated software, wear was measured by a 2D/3D matching of 3D spheres onto the 2D frontal and lateral radiographs, allowing the determination of the 3D coordinates of both the cup and femoral head centers and thus the calculation of a 3D wear vector. (Figure 2). Measured wear vector were compared to real wear vectors in terms of amplitude and direction.3D wear vectors were measured twice by 3 independent observers (for a total of 144 measurements) in order to evaluate intra- and inter-observer reliability. Results. There was a strong correlation between the measured wear amplitude and the real wear amplitude (Pearson's r = 0,99). Mean error when comparing wear measurement amplitude with real wear amplitude was 356 μm (SD = 127 μm). None of the 144 measurements presented an error over 1 mm. The accuracy of wear direction evaluation was highly correlated with wear amplitude (Spearman's rho = 0,98), the measurement of 3D wear direction presenting an accuracy better than 15° for wear amplitudes over 1,5 mm. Intra-observer errors for wear amplitude were between 138 μm and 221 μm depending on the observer. Inter-observer error for wear amplitude was 333 μm. Conclusion. EOS imaging is a promising technology for measuring 3D-wear in polyethylene cups. Further works are underway to compare the EOS algorithms with conventional methods

Different studies have shown that gamma-irradiated polyethylene generally results in degradation by oxidation. On the other hand, we clinically used ultra-high molecular weight polyethylene sterilized by gamma-irradiation of 1,000kGy dose in the air (100Mrad cross-link polyethylene) for total hip prostheses from 1970 to 1978, and excellent clinical results extending for 30 years were shown. In the present study, the wear characteristics were evaluated by hip simulator on 100Mrad cross-link polyethylene cups which were available after shelf-aging for extremely long term (about 30 years). The results are compared with those ofthe explanted cup after 30 years of clinical use as well as the cups aged by acceleration in order to review the influence of aging environments and themechanism of degradation. The 100Mrad polyethylene cups were manufactured by Mizuho Medical Instruments in the 1970s and they have been in stock on the shelf in air-containing package or without being packed for 30 years. These cups were tested with alumina heads (36mm in diameter) by the AMTI hip-joint simulator. The 100Mrad polyethylene cup aged for 30 years without a package showed considerable initial wear. In case of the same cup aged in an air-containing package, however, a significant reduction of wear was observed even with the presence of the oxidized surface layer. This observation agreed with the low wear of explanted 100Mrad polyethylene after 30 years of clinical use. These results suggest that wear properties of this gamma-irradiated polyethylene are significantly affected by the environmental conditions it was kept for long period of time

Cemented total hip arthroplasty yields reliable results in short to medium term studies, but aseptic loosening remains a problem in long-term follow up, especially in young and active patients. Aseptic loosening has been related to wear, and in order to minimize wear various alternatives to the traditional metal on polyethylene have been proposed. Both ceramic on polyethylene (COP) and metal on metal (MOM) have been shown to produce less wear than metal on polyethylene (MOP). In order to study the effect of the bearing, we have utilized identical stems and cups while comparing the different bearings. Methods and material. 396 hips were randomized to MOP, COP or MOM using a cemented triple tapered polished stem (MS-30; Sulzer Orthopedics) with a cemented polyethylene cup (Weber; Sulzer, Orthopedics) and a 28 millimeter head. For the MOP and COP articulations, a all-polyethylene cup was used with a Protasul™ metal head or a Sulox™ alumina head, whereas a polyethylene cup with metal insert was used for the MOM articulations (Weber Polyethylene Cup with Metasul™ Insert) with a Metasul™ metal head. Harris Hip Score (HHS) and radiological evaluation was performed after two, five and seven years. Ethical approval was obtained. Results. HHS was available for 338 hips after seven years. The HHS in the MOP group (116 hips) was 93.7 (SD 9.0), 93.5 in the COP group (112 hips) (SD 8.8), and 91.0 (SD 13.4) in the MOM group (110 hips). Radiographic evaluation was available for 335 hips. Radiolucencies around the stem larger than one millimeter were found in five of 115 MOP hips, seven of 111 COP hips and in seven of 110 MOM hips. Periacetabular radiolucencies identified as larger than one millimeter were found in none of the 116 MOP hips, five of the 112 COP hips and in 19 of the 110 MOM hips. Ten revisions were performed. In the MOP group there were three revisions (infection, dislocation, pain); one in the COM group (infection), and six in the MOM group (three infections, two aseptic loosening and one septic loosening). Discussion. Clinically, the three bearing types perform equally well at seven years, and there are few signs of impending failure for the stem. However, there are an alarmingly high proportion of cups showing signs of loosening. Two hips have been revised in the MOM group for aseptic loosening as opposed to none in the two other groups, which adds to the concern. The MOM articulation used in this study should be monitored closely for signs of aseptic loosening