Aims. Leg length discrepancy (LLD) is a common pre- and postoperative issue in total hip arthroplasty (THA) patients. The conventional technique for measuring LLD has historically been on a non-weightbearing anteroposterior pelvic radiograph; however, this does not capture many potential sources of LLD. The aim of this study was to determine if long-limb EOS radiology can provide a more reproducible and holistic measurement of LLD. Methods. In all, 93 patients who underwent a THA received a standardized preoperative EOS scan, anteroposterior (AP) radiograph, and clinical LLD assessment. Overall, 13 measurements were taken along both anatomical and functional axes and measured twice by an orthopaedic fellow and surgical planning engineer to calculate intraoperator reproducibility and correlations between measurements. Results. Strong correlations were observed for all EOS measurements (r. s. > 0.9). The strongest correlation with AP radiograph (inter-teardrop line) was observed for functional-ASIS-to-floor (functional) (r. s. = 0.57), much weaker than the correlations between EOS measurements. ASIS-to-ankle measurements exhibited a high correlation to other linear measurements and the highest ICC (r. s. = 0.97). Using anterior superior iliac spine (ASIS)-to-ankle, 33% of patients had an absolute LLD of greater than 10 mm, which was statistically different from the inter-teardrop LLD measurement (p < 0.005). Discussion. We found that the conventional measurement of LLD on AP pelvic radiograph does not correlate well with long leg measurements and may not provide a true appreciation of LLD. ASIS-to-ankle demonstrated improved detection of potential LLD than other EOS and radiograph measurements. Full length, functional imaging methods may become the new gold standard to measure LLD. Cite this article: Bone Jt Open 2022;3(12):960–968

We assessed leg length discrepancy and hip function in 90 patients undergoing primary total hip arthroplasty before surgery and at three and 12 months after. Function was measured using the Oxford hip score (OHS). After surgery the mean OHS improved by 26 points after three months and by 30 points after 12. After operation 56 (62%) limbs were long by a mean of 9 mm and this was perceived by 24 (43%) patients after three months and by 18 (33%) after 12. The mean OHS in patients who perceived true lengthening was 27% worse than the rest of the population after three months and 18% worse after 12. In 55 (98%) patients, lengthening occurred in the femoral component. Appropriate placement of the femoral component could significantly reduce a patient’s perception of discrepancy of length

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This study aimed to investigate the incidence of ≥ 5 mm asymmetry in lower and whole leg lengths (LLs) in patients with unilateral osteoarthritis (OA) secondary to developmental dysplasia of the hip (DDH-OA) and primary hip osteoarthritis (PHOA), and the relationship between lower and whole LL asymmetries and femoral length asymmetry.

Aims. The purpose of this study was to compare the clinical, radiological, and patient-reported outcome measures (PROMs) in the first 100 consecutive patients undergoing total hip arthroplasty (THA) via a direct superior approach (DSA) with a matched group of patients undergoing THA by the same surgeon, using a posterolateral approach (PLA). Methods. This was a retrospective single surgeon study comparing the first 100 consecutive DSA THA patients with a matched group of patients using a standard PLA. Case notes were examined for patient demographics, length of hospital stay, operating time, intra- and postoperative complications, pain score, satisfaction score, and Oxford Hip Score (OHS). Leg length discrepancy and component positioning were measured from postoperative plain radiographs. Results. The DSA patients had a shorter length of hospital stay (mean 2.09 days (SD 1.20) DSA vs 2.74 days (SD 1.17) PLA; p < 0.001) and shorter time to discharge from the inpatient physiotherapy teams (mean 1.44 days (SD 1.17) DSA vs 1.93 days (SD 0.96) PLA; p < 0.001). There were no differences in operating time (p = 0.505), pain levels up to postoperative day 1 (p = 0.106 to p =0.242), OHS (p = 0.594 to p = 0.815), satisfaction levels (p = 0.066 to p = 0.299), stem alignment (p = 0.240), acetabular component inclination (p < 0.001) and anteversion (p < 0.001), or leg length discrepancy (p = 0.134). Conclusion. While the DSA appears safe and was not associated with a significant difference in PROMs, radiological findings, or intraoperative or postoperative complications, a randomized controlled trial with functional outcomes in the postoperative phase is needed to evaluate this surgical approach formally. Cite this article: Bone Joint J 2021;103-B(3):500–506

Aims. Achieving accurate implant positioning and restoring native hip biomechanics are key surgeon-controlled technical objectives in total hip arthroplasty (THA). The primary objective of this study was to compare the reproducibility of the planned preoperative centre of hip rotation (COR) in patients undergoing robotic arm-assisted THA versus conventional THA. Methods. This prospective randomized controlled trial (RCT) included 60 patients with symptomatic hip osteoarthritis undergoing conventional THA (CO THA) versus robotic arm-assisted THA (RO THA). Patients in both arms underwent pre- and postoperative CT scans, and a patient-specific plan was created using the robotic software. The COR, combined offset, acetabular orientation, and leg length discrepancy were measured on the pre- and postoperative CT scanogram at six weeks following surgery. Results. There were no significant differences for any of the baseline characteristics including spinopelvic mobility. The absolute error for achieving the planned horizontal COR was median 1.4 mm (interquartile range (IQR) 0.87 to 3.42) in RO THA versus 4.3 mm (IQR 3 to 6.8; p < 0.001); vertical COR mean 0.91 mm (SD 0.73) in RO THA versus 2.3 mm (SD 1.3; p < 0.001); and combined offset median 2 mm (IQR 0.97 to 5.45) in RO THA versus 3.9 mm (IQR 2 to 7.9; p = 0.019). Improved accuracy was observed with RO THA in achieving the desired acetabular component positioning (root mean square error for anteversion and inclination was 2.6 and 1.3 vs 8.9 and 5.3, repectively) and leg length (mean 0.6 mm vs 1.4 mm; p < 0.001). Patient-reported outcome measures were comparable between the two groups at baseline and one year. Participants in the RO THA group needed fewer physiotherapy sessions postoperatively (median six (IQR 4.5 to 8) vs eight (IQR 6 to 11; p = 0.005). Conclusion. This RCT suggested that robotic-arm assistance in THA was associated with improved accuracy in restoring the native COR, better preservation of the combined offset, leg length correction, and superior accuracy in achieving the desired acetabular component positioning. Further evaluation through long-term and registry data is necessary to assess whether these findings translate into improved implant survival and functional outcomes. Cite this article: Bone Joint J 2024;106-B(4):324–335

Aims. To develop a core outcome set of measurements from postoperative radiographs that can be used to assess technical skill in performing dynamic hip screw (DHS) and hemiarthroplasty, and to validate these against Van der Vleuten’s criteria for effective assessment. Methods. A Delphi exercise was undertaken at a regional major trauma centre to identify candidate measurement items. The feasibility of taking these measurements was tested by two of the authors (HKJ, GTRP). Validity and reliability were examined using the radiographs of operations performed by orthopaedic resident participants (n = 28) of a multicentre randomized controlled educational trial (ISRCTN20431944). Trainees were divided into novice and intermediate groups, defined as having performed < ten or ≥ ten cases each for DHS and hemiarthroplasty at baseline. The procedure-based assessment (PBA) global rating score was assumed as the gold standard assessment for the purposes of concurrent validity. Intra- and inter-rater reliability testing were performed on a random subset of 25 cases. Results. In total, 327 DHS and 248 hemiarthroplasty procedures were performed by 28 postgraduate year (PGY) 3 to 5 orthopaedic trainees during the 2014 to 2015 surgical training year at nine NHS hospitals in the West Midlands, UK. Overall, 109 PBAs were completed for DHS and 80 for hemiarthroplasty. Expert consensus identified four ‘final product analysis’ (FPA) radiological parameters of technical success for DHS: tip-apex distance (TAD); lag screw position in the femoral head; flushness of the plate against the lateral femoral cortex; and eight-cortex hold of the plate screws. Three parameters were identified for hemiarthroplasty: leg length discrepancy; femoral stem alignment; and femoral offset. Face validity, content validity, and feasibility were excellent. For all measurements, performance was better in the intermediate compared with the novice group, and this was statistically significant for TAD (p < 0.001) and femoral stem alignment (p = 0.023). Concurrent validity was poor when measured against global PBA score. This may be explained by the fact that they are measuring difference facets of competence. Intra-and inter-rater reliability were excellent for TAD, moderate for lag screw position (DHS), and moderate for leg length discrepancy (hemiarthroplasty). Use of a large multicentre dataset suggests good generalizability of the results to other settings. Assessment using FPA was time- and cost-effective compared with PBA. Conclusion. Final product analysis using post-implantation radiographs to measure technical skill in hip fracture surgery is feasible, valid, reliable, and cost-effective. It can complement traditional workplace-based assessment for measuring performance in the real-world operating room . It may have particular utility in competency-based training frameworks and for assessing skill transfer from the simulated to live operating theatre. Cite this article: Bone Joint Open 2020;1-9:594–604

Aims. The aims of this study were to compare clinically relevant measurements of hip dysplasia on radiographs taken in the supine and standing position, and to compare Hip2Norm software and Picture Archiving and Communication System (PACS)-derived digital radiological measurements. Methods. Preoperative supine and standing radiographs of 36 consecutive patients (43 hips) who underwent periacetabular osteotomy surgery were retrospectively analyzed from a single-centre, two-surgeon cohort. Anterior coverage (AC), posterior coverage (PC), lateral centre-edge angle (LCEA), acetabular inclination (AI), sharp angle (SA), pelvic tilt (PT), retroversion index (RI), femoroepiphyseal acetabular roof (FEAR) index, femoroepiphyseal horizontal angle (FEHA), leg length discrepancy (LLD), and pelvic obliquity (PO) were analyzed using both Hip2Norm software and PACS-derived measurements where applicable. Results. Analysis of supine and standing radiographs resulted in significant variation for measurements of PT (p < 0.001) and AC (p = 0.005). The variation in PT correlated with the variation in AC in a limited number of patients (R. 2. = 0.378; p = 0.012). Conclusion. The significant variation in PT and AC between supine and standing radiographs suggests that it may benefit surgeons to have both radiographs when planning surgical correction of hip dysplasia. We also recommend using PACS-derived measurements of AI and SA due to the poor interobserver error on Hip2Norm. Cite this article: Bone Joint J 2021;103-B(11):1662–1668

Aims. Traditionally, acetabular component insertion during total hip arthroplasty (THA) is visually assisted in the posterior approach and fluoroscopically assisted in the anterior approach. The present study examined the accuracy of a new surgeon during anterior (NSA) and posterior (NSP) THA using robotic arm-assisted technology compared to two experienced surgeons using traditional methods. Methods. Prospectively collected data was reviewed for 120 patients at two institutions. Data were collected on the first 30 anterior approach and the first 30 posterior approach surgeries performed by a newly graduated arthroplasty surgeon (all using robotic arm-assisted technology) and was compared to standard THA by an experienced anterior (SSA) and posterior surgeon (SSP). Acetabular component inclination, version, and leg length were calculated postoperatively and differences calculated based on postoperative film measurement. Results. Demographic data were similar between groups with the exception of BMI being lower in the NSA group (27.98 vs 25.2; p = 0.005). Operating time and total time in operating room (TTOR) was lower in the SSA (p < 0.001) and TTOR was higher in the NSP group (p = 0.014). Planned versus postoperative leg length discrepancy were similar among both anterior and posterior surgeries (p > 0.104). Planned versus postoperative abduction and anteversion were similar among the NSA and SSA (p > 0.425), whereas planned versus postoperative abduction and anteversion were lower in the NSP (p < 0.001). Outliers > 10 mm from planned leg length were present in one case of the SSP and NSP, with none in the anterior groups. There were no outliers > 10° in anterior or posterior for abduction in all surgeons. The SSP had six outliers > 10° in anteversion while the NSP had none (p = 0.004); the SSA had no outliers for anteversion while the NSA had one (p = 0.500). Conclusion. Robotic arm-assisted technology allowed a newly trained surgeon to produce similarly accurate results and outcomes as experienced surgeons in anterior and posterior hip arthroplasty. Cite this article: Bone Jt Open 2021;2(6):365–370

Aims. Improvements in functional results and long-term survival are variable following conversion of hip fusion to total hip arthroplasty (THA) and complications are high. The aim of the study was to analyze the clinical and functional results in patients who underwent conversion of hip fusion to THA using a consistent technique and uncemented implants. Methods. A total of 39 hip fusion conversions to THA were undertaken in 38 patients by a single surgeon employing a consistent surgical technique and uncemented implants. Parameters assessed included Harris Hip Score (HHS) for function, range of motion (ROM), leg length discrepancy (LLD), satisfaction, and use of walking aid. Radiographs were reviewed for loosening, subsidence, and heterotopic ossification (HO). Postoperative complications and implant survival were assessed. Results. At mean 12.2 years (2 to 24) follow-up, HHS improved from mean 34.2 (20.8 to 60.5) to 75 (53.6 to 94.0; p < 0.001). Mean postoperative ROM was flexion 77° (50° to 95°), abduction 30° (10° to 40°), adduction 20° (5° to 25°), internal rotation 18° (2° to 30°), and external rotation 17° (5° to 30°). LLD improved from mean -3.36 cm (0 to 8) to postoperative mean -1.14 cm (0 to 4; p < 0.001). Postoperatively, 26 patients (68.4%) required the use of a walking aid. Complications included one (2.5%) dislocation, two (5.1%) partial sciatic nerve injuries, one (2.5%) deep periprosthetic joint infection, two instances of (5.1%) acetabular component aseptic loosening, two (5.1%) periprosthetic fractures, and ten instances of HO (40%), of which three (7.7%) were functionally limiting and required excision. Kaplan-Meier Survival was 97.1% (95% confidence interval (CI) 91.4% to 100%) at ten years and 88.2% (95% CI 70.96 to 100) at 15 years with implant revision for aseptic loosening as endpoint and 81.7% (95% CI 70.9% to 98.0%) at ten years and 74.2% (95% CI 55.6 to 92.8) at 15 years follow-up with implant revision for all cause failure as endpoint. Conclusion. The use of an optimal and consistent surgical technique and cementless implants can result in significant functional improvement, low complication rates, long-term implant survival, and high patient satisfaction following conversion of hip fusion to THA. The possibility of requiring a walking aid should be discussed with the patient before surgery. Cite this article: Bone Joint J 2021;103-B(7 Supple B):129–134

Aims. The direct anterior approach (DAA) for total hip arthroplasty (THA) has potential advantages over other approaches and is most commonly performed with the patient in the supine position. We describe a technique for DAA THA with the patient in the lateral decubitus position and report the early clinical and radiological outcomes, the characteristics of the learning curve, and perioperative complications. Methods. All primary DAA THAs performed in the lateral position by a single surgeon over a four-year period from the surgeon’s first case using the technique were identified from a prospectively collected database. Modified Harris Hip Scores (mHHS) were collected to assess clinical outcome, and routine radiological analysis was performed. Retrospective review of the medical records identified perioperative complications, the characteristics of the learning curve, and revisions. Results. A total of 257 patients were included in the study. Their mean age was 60 years (SD 9.0). A total of 164 (64%) were female. The mean mHHS improved significantly from 52.1 (SD 16.2) preoperatively to 94.4 (SD 11) at a follow-up of one year (p < 0.001), with 212 of 225 patients (94%) achieving a minimal clinically important difference (MCID) (> 8 points). Radiological evaluation showed a mean leg length discrepancy of 2.6 mm (SD 5.9) and a mean difference in femoral offset of 0.2 mm (SD 4.9). A total of 234/243 acetabular components (96.3%) were positioned within Lewinnek’s safe zone. Analysis of operating time, blood loss, the position of the components, and complications did not identify a learning curve. A total of 14 patients (5.4%) had a major perioperative complication and three (1.2%) required revision THA. There were no major neurovascular complications and no dislocations. Conclusion. We have described and analyzed a surgical technique for undertaking DAA THA in the familiar lateral decubitus position using a routine operating table, positioning devices, and instrumentation, and shown that it can be performed safely and effectively under these circumstances. Cite this article: Bone Joint J 2021;103-B(7 Supple B):53–58

Aims. Our retrospective analysis reports the outcome of patients operated for slipped capital femoral epiphysis using the modified Dunn procedure. Results, complications, and the need for revision surgery are compared with the recent literature. Methods. We retrospectively evaluated 17 patients (18 hips) who underwent the modified Dunn procedure for the treatment of slipped capital femoral epiphysis. Outcome measurement included standardized scores. Clinical assessment included ambulation, leg length discrepancy, and hip mobility. Radiographically, the quality of epiphyseal reduction was evaluated using the Southwick and Alpha-angles. Avascular necrosis, heterotopic ossifications, and osteoarthritis were documented at follow-up. Results. At a mean follow-up of more than nine years, the mean modified Harris Hip score was 88.7 points, the Hip Disability and Osteoarthritis Outcome Score (HOOS) 87.4 , the Merle d’Aubigné Score 16.5 points, and the UCLA Activity Score 8.4. One patient developed a partial avascular necrosis of the femoral head, and one patient already had an avascular necrosis at the time of delayed diagnosis. Two hips developed osteoarthritic signs at 14 and 16 years after the index operation. Six patients needed a total of nine revision surgeries. One operation was needed for postoperative hip subluxation, one for secondary displacement and implant failure, two for late femoroacetabular impingement, one for femoroacetabular impingement of the opposite hip, and four for implant removal. Conclusion. Our series shows good results and is comparable to previous published studies. The modified Dunn procedure allows the anatomic repositioning of the slipped epiphysis. Long-term results with subjective and objective hip function are superior, avascular necrosis and development of osteoarthritis inferior to other reported treatment modalities. Nevertheless, the procedure is technically demanding and revision surgery for secondary femoroacetabular impingement and implant removal are frequent. Cite this article: 2020;1-4:80–87

Aims. The aims of this study were to examine the rate at which the positioning of the acetabular component, leg length discrepancy and femoral offset are outside an acceptable range in total hip arthroplasties (THAs) which either do or do not involve the use of intra-operative digital imaging. Patients and Methods. A retrospective case-control study was undertaken with 50 patients before and 50 patients after the integration of an intra-operative digital imaging system in THA. The demographics of the two groups were comparable for body mass index, age, laterality and the indication for surgery. The digital imaging group had more men than the group without. Surgical data and radiographic parameters, including the inclination and anteversion of the acetabular component, leg length discrepancy, and the difference in femoral offset compared with the contralateral hip were collected and compared, as well as the incidence of altering the position of a component based on the intra-operative image. Results. Digital imaging took a mean of five minutes (2.3 to 14.6) to perform. Intra-operative changes with the use of digital imaging were made for 43 patients (86%), most commonly to adjust leg length and femoral offset. There was a decrease in the incidence of outliers when using intra-operative imaging compared with not using it in regard to leg length discrepancy (20% versus 52%, p = 0.001) and femoral offset inequality (18% versus 44%, p = 0.004). There was also a difference in the incidence of outliers in acetabular inclination (0% versus 7%, p = 0.023) and version (0% versus 4%, p = 0.114) compared with historical results of a high-volume surgeon at the same centre. Conclusion. The use of intra-operative digital imaging in THA improves the accuracy of the positioning of the components at THA without adding a substantial amount of time to the operation. Cite this article: Bone Joint J 2018;100B(1 Supple A):36–43

Aims. Studying the indications for revision total hip arthroplasty (THA) may enable surgeons to change their practice during the initial procedure, thereby reducing the need for revision surgery. The aim of this study was to identify and describe the potentially avoidable indications for revision THA within five years of the initial procedure. Patients and Methods. A retrospective review of 117 patients (73 women, 44 men; mean age 61.5 years (27 to 88)) who met the inclusion criteria was conducted. Three adult reconstruction surgeons independently reviewed the radiographs and medical records, and they classified the revision THAs into two categories: potentially avoidable and unavoidable. Baseline demographics, perioperative details, and quality outcomes up to the last follow-up were recorded. Results. A total of 60 revision THAs (51.3%) were deemed potentially avoidable and 57 (48.7%) were deemed unavoidable. The following were identified as avoidable factors: suboptimal positioning of the acetabular component (29; 48%), intraoperative fracture or a fracture missed on an intraoperative radiograph (20; 33%), early (less than two weeks) aseptic loosening (seven; 11.7%), and symptomatic leg length discrepancy of > 1 cm (four; 6.7%). Conclusion. A surprisingly large proportion of acute revision THAs are potentially avoidable. Surgeons must carefully evaluate the indications for revision THAs in their practice and identify new methods to address these issues. Cite this article: Bone Joint J 2019;101-B(6 Supple B):97–103

Aims. There is no consensus about the best method of achieving equal leg lengths at total hip arthroplasty (THA) in patients with Crowe type-IV developmental dysplasia of the hip (DDH). We reviewed our experience of a consecutive series of patients who underwent THA for this indication. Patients and Methods. We retrospectively reviewed 78 patients (86 THAs) with Crowe type-IV DDH, including 64 women and 14 men, with a minimum follow-up of two years. The mean age at the time of surgery was 52.2 years (34 to 82). We subdivided Crowe type-IV DDH into two major types according to the number of dislocated hips, and further categorised them into three groups according to the occurrence of pelvic obliquity or spinal curvature. Leg length discrepancy (LLD) and functional scores were analysed. Results. Type-I included 53 patients with unilateral dislocation, in which 25 (category A) had no pelvic obliquity or spinal deformity, 19 (category B) had pelvic obliquity with a compensated spinal curvature and nine (category C) had pelvic obliquity and decompensated spinal degenerative changes. Type-II included 25 patients with one dislocated and one dysplastic hip, in which there were eight of category A, 15 of category B and two of category C. Pre-operatively, there were significant differences between the anatomical and functional LLD in type-IB (p = 0.005) and -IC (p < 0.001), but not in type-IA, -IIA or -IIB. Post-operatively, bony LLD increased significantly in types-IB, -IC and -IIB, whereas functional LLD decreased significantly in each type except for IIA. The mean functional LLD decreased from 30.7 mm (standard deviation (. sd. ) 18.5) pre-operatively to 6.2 mm (. sd. 4.4) post-operatively and the mean anatomical LLD improved from 35.8 mm (. sd. 19.7) pre-operatively to 12.4 mm (. sd. 8.3) post-operatively. Conclusion. Pelvic and spinal changes are common in patients with Crowe type-IV DDH and need to be taken into consideration when planning THA, in order to obtain equal leg lengths post-operatively. The principal subdivisions of Crowe type-IV DDH which we describe proved effective in achieving equal leg lengths and satisfactory outcomes. Cite this article: Bone Joint J 2017;99-B:872–9

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The Birmingham Hip Resurfacing (BHR) arthroplasty has been used as a surgical treatment of coxarthrosis since 1997. We present 20-year results of 234 consecutive BHRs performed in our unit.

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When performing revision total hip arthroplasty using diaphyseal-engaging titanium tapered stems (TTS), the recommended 3 to 4 cm of stem-cortical diaphyseal contact may not be available. In challenging cases such as these with only 2 cm of contact, can sufficient axial stability be achieved and what is the benefit of a prophylactic cable? This study sought to determine, first, whether a prophylactic cable allows for sufficient axial stability when the contact length is 2 cm, and second, if differing TTS taper angles (2° vs 3.5°) impact these results.

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Dislocation remains a leading cause of failure following revision total hip arthroplasty (THA). While dual-mobility (DM) bearings have been shown to mitigate this risk, options are limited when retaining or implanting an uncemented shell without modular DM options. In these circumstances, a monoblock DM cup, designed for cementing, can be cemented into an uncemented acetabular shell. The goal of this study was to describe the implant survival, complications, and radiological outcomes of this construct.

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The aims of the study were to report for a cohort aged younger than 40 years: 1) indications for HRA; 2) patient-reported outcomes in terms of the modified Harris Hip Score (HHS); 3) dislocation rate; and 4) revision rate.

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United Classification System (UCS) B2 and B3 periprosthetic fractures in total hip arthroplasties (THAs) have been commonly managed with modular tapered stems. No study has evaluated the use of monoblock fluted tapered titanium stems for this indication. This study aimed to evaluate the effects of a monoblock stems on implant survivorship, postoperative outcomes, radiological outcomes, and osseointegration following treatment of THA UCS B2 and B3 periprosthetic fractures.

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In metal-on-metal (MoM) hip arthroplasties and resurfacings, mechanically induced corrosion can lead to elevated serum metal ions, a local inflammatory response, and formation of pseudotumours, ultimately requiring revision. The size and diametral clearance of anatomical (ADM) and modular (MDM) dual-mobility polyethylene bearings match those of Birmingham hip MoM components. If the acetabular component is satisfactorily positioned, well integrated into the bone, and has no surface damage, this presents the opportunity for revision with exchange of the metal head for ADM/MDM polyethylene bearings without removal of the acetabular component.