Aims. The aim of this study was to determine whether there is a difference in the rate of wear between acetabular components positioned within and outside the ‘safe zones’ of anteversion and inclination angle. Patients and Methods. We reviewed 100 hips in 94 patients who had undergone primary total hip arthroplasty (THA) at least ten years previously. Patients all had the same type of acetabular component with a bearing couple which consisted of a 28 mm cobalt-chromium head on a highly crosslinked polyethylene (HXLPE) liner. A supine radiostereometric analysis (RSA) examination was carried out which acquired anteroposterior (AP) and lateral paired images. Acetabular component anteversion and inclination angles were measured as well as total femoral head penetration, which was divided by the length of implantation to determine the rate of polyethylene wear. Results. The mean anteversion angle was 19.4° (-15.2° to 48°, . sd. 11.4°), the mean inclination angle 43.4° (27.3° to 60.5°, . sd. 6.6°), and the mean wear rate 0.055 mm/year (. sd. 0.060). Exactly half of the hips were positioned inside the ‘safe zone’. There was no difference (median difference, 0.012 mm/year; p = 0.091) in the rate of wear between acetabular components located within or outside the ‘safe zone’. When compared to acetabular components located inside the ‘safe zone’, the wear rate was no different for acetabular components that only achieved the target anteversion angle (median difference, 0.012 mm/year; p = 0.138), target inclination angle (median difference, 0.013 mm/year; p = 0.354), or neither target (median difference, 0.012 mm/year; p = 0.322). Conclusion. Placing the acetabular component within or outside the ‘safe zone’ did not alter the wear rate of HXLPE at long-term follow-up to a level that risked osteolysis. HXLPE appears to be a forgiving bearing material in terms of articular surface wear, but care must still be taken to position the acetabular component correctly so that the implant is stable. Cite this article: Bone Joint J 2018;100-B:891-7

We examined the behaviour of alumina ceramic heads in 156 cemented total hip arthroplasties, at a minimum follow-up of eight years. They were divided into three groups according to the size of the femoral head; 22, 26, and 28 mm. We measured polyethylene wear radiologically using a computer-aided technique. The linear wear rate of polyethylene sockets for the 28 mm heads was high (0.156 mm/year), whereas those for the 22 and 26 mm heads were relatively low (0.090 and 0.098 mm/year, respectively). Moreover, the surface roughness data of retrieved femoral heads clearly showed maintenance of an excellent surface finish of the current alumina. We conclude that the alumina ceramic femoral heads currently used are associated with a reduced rate of polyethylene wear

We have studied the influence of weight-bearing on the measurement of wear of the polyethylene acetabular component in total hip arthroplasty using two techniques. The measured vertical wear was significantly greater when radiographs were taken weight-bearing rather than with the patient supine (p = 0.001, method 1; p = 0.007, method 2). Calculations of rates of linear wear of the acetabular component were significantly underestimated (p < 0.05) when radiographs were taken supine. There are two reasons for this. First, a change in pelvic orientation when bearing weight ensures that the thinnest polyethylene is brought into relief, and secondly, the head of the femoral component assumes the position of maximal displacement along its wear path. Interpretation of previous studies on both linear and volumetric polyethylene wear in total hip arthroplasty should be reassessed in the light of these findings

Aims. Vitamin E-diffused, highly crosslinked polyethylene (VEPE) and porous titanium-coated (PTC) shells were introduced in total hip arthroplasty (THA) to reduce the risk of aseptic loosening. The purpose of this study was: 1) to compare the wear properties of VEPE to moderately crosslinked polyethylene; 2) to assess the stability of PTC shells; and 3) to report their clinical outcomes at seven years. Patients and Methods. A total of 89 patients were enrolled into a prospective study. All patients received a PTC shell and were randomized to receive a VEPE liner (n = 44) or a moderately crosslinked polyethylene (ModXLPE) liner (n = 45). Radiostereometric analysis (RSA) was used to measure polyethylene wear and component migration. Differences in wear were assessed while adjusting for body mass index, activity level, acetabular inclination, anteversion, and head size. Plain radiographs were assessed for radiolucency and patient-reported outcome measures (PROMs) were administered at each follow-up. Results. In total, 73 patients (82%) completed the seven-year visit. Mean seven-year linear proximal penetration was -0.07 mm (. sd. 0.16) and 0.00 mm (. sd. 0.22) for the VEPE and ModXLPE cohorts, respectively (p = 0.116). PROMs (p = 0.310 to 0.807) and radiolucency incidence (p = 0.330) were not different between the polyethylene cohorts. The mean proximal shell migration rate was 0.04 mm per year (. sd. 0.09). At seven years, patients with radiolucency (34%) demonstrated greater migration (mean difference: 0.6 mm (. sd. 0.2); p < 0.001). PROMs were lower for patients with radiolucency and greater proximal migration (p = 0.009 to p = 0.045). No implants were revised for aseptic loosening. Conclusion. This is the first randomized controlled trial to report seven-year RSA results for VEPE. All wear rates were below the previously reported osteolysis threshold (0.1 mm per year). PTC shells demonstrated acceptable primary stability through seven years, as indicated by low migration and lack of aseptic loosening. However, patients with acetabular radiolucency were associated with higher shell migration and lower PROM scores. Cite this article: Bone Joint J 2019;101-B:760–767

We have followed up for a period of seven to nine years 100 consecutive arthroplasties of the hip in which an entirely HA-coated implant had been used. The clinical results were excellent and bony incorporation was extensive in all components. No stem became loose or subsided but five cups were revised because of loosening after 3.8 to 5.5 years, having functioned painlessly and shown radiological ingrowth. Revision procedures because of excessive polyethylene wear have been performed on 18 hips and are planned for six more. Two eroded metal backings with worn-through polyethylene were exchanged; six hips showed metallosis without polyethylene wear-through. There were two cases of granulomatous cysts in the groin and 66 hips had osteolysis located periarticularly, in the greater trochanter or in the acetabulum

Objectives

The accuracy and precision of two new methods of model-based radiostereometric analysis (RSA) were hypothesised to be superior to a plain radiograph method in the assessment of polyethylene (PE) wear.

We selected randomly a consecutive series of 162 patients requiring hip replacement to receive either a cementless, hemispherical, modular, titanium acetabular cup or a cemented, all-polyethylene cup. These replacements were performed by two surgeons in four general hospitals. The same surgical technique was used and a 26 mm metal-head femoral component was used in every case.

After exclusions, 115 hips were studied for differences in rates of wear and osteolysis. The mean clinical follow-up was eight years and the mean radiological follow-up, 6.5 years. The cementless cups wore at a mean rate of 0.15 mm per year and the cemented cups at 0.07 mm per year. This difference was significant (p < 0.0001).

Our findings in this mid-term study suggest that cementless cups wear more than cemented cups.

It has been suggested that the wear of ultra-high molecular weight polyethylene (UHMWPE) in total hip replacement is substantially reduced when the femoral head is ceramic rather than metal. However, studies of alumina and zirconia ceramic femoral heads on the penetration of an UHMWPE liner in vivo have given conflicting results.

The purpose of this study was to examine the surface characteristics of 30 alumina and 24 zirconia ceramic femoral heads and to identify any phase transformation in the zirconia heads. We also studied the penetration rate of alumina and zirconia heads into contemporary UHMWPE liners. The alumina heads had been implanted for a mean of 11.3 years (8.1 to 16.2) and zirconia heads for a mean of 9.8 years (7.5 to 15).

The mean surface roughness values of the explanted alumina heads (Ra 40.12 nm and Rpm 578.34 nm) were similar to those for the explanted zirconia heads (Ra 36.21 nm and Rpm 607.34 nm). The mean value of the monoclinic phase of two control zirconia heads was 1% (0.8% to 1.5%) and 1.2% (0.9% to 1.3%), respectively. The mean value of the monoclinic phase of 24 explanted zirconia heads was 7.3% (1% to 26%).

In the alumina group, the mean linear penetration rate of the UMWPE liner was 0.10 mm/yr (0.09 to 0.12) in hips with low Ra and Rpm values (13.22 nm and 85.91 nm, respectively). The mean linear penetration rate of the UHMWPE liner was 0.13 mm/yr (0.07 to 0.23) in hips with high Ra and Rpm values (198.72 nm and 1329 nm, respectively). This difference was significant (p = 0.041).

In the zirconia head group, the mean linear penetration rate of the UHMWPE liner was 0.09 mm/yr (0.07 to 0.14) in hips with low Ra and Rpm values (12.78 nm and 92.99 nm, respectively). The mean linear penetration rate of the UHMWPE liner was 0.12 mm/yr (0.08 to 0.22) in hips with high Ra and Rpm values (199.21 nm and 1381 nm, respectively). This difference was significant (p = 0.039).

The explanted zirconia heads which had a minimal phase transformation had similar surface roughness and a similar penetration rate of UHMWPE liner as the explanted alumina head.

Large ceramic femoral heads offer several advantages that are potentially advantageous to patients undergoing both primary and revision total hip replacement. Many high-quality studies have demonstrated the benefit of large femoral heads in reducing post-operative instability. Ceramic femoral heads may also offer an advantage in reducing polyethylene wear that has been reported in vitro and is starting to become clinically apparent in mid-term clinical outcome studies. Additionally, the risk of taper corrosion at a ceramic femoral head–neck junction is clearly lower than when using a metal femoral head. With improvements in the material properties of both modern ceramic femoral heads and polyethylene acetabular liners that have reduced the risk of mechanical complications, large ceramic heads have gained popularity in recent years.

Cite this article: Bone Joint J 2013;95-B, Supple A:63–6.

Aims. Vitamin E-infused highly crosslinked polyethylene (VEPE) has been introduced into total hip arthroplasty (THA) with the aim of further improving the wear characteristics of moderately and highly crosslinked polyethylenes (ModXLPE and HXLPE). There are few studies analyzing the outcomes of vitamin E-infused components in cemented arthroplasty, though early acetabular component migration has been reported. The aim of this study was to measure five-year polyethylene wear and acetabular component stability of a cemented VEPE acetabular component compared with a ModXLPE cemented acetabular component. Methods. In a prospective randomized controlled trial (RCT), we assessed polyethylene wear and acetabular component stability (primary outcome) with radiostereometric analysis (RSA) in 68 patients with reverse hybrid THA at five years follow-up. Patients were randomized to either a VEPE or a ModXLPE cemented acetabular component. Results. Mean polyethylene wear in the proximal direction was 0.17 mm (SD 0.15) for the VEPE group and 0.20 mm (SD 0.09) for the ModXLPE group (p = 0.005) at five years. Annual proximal wear rates were 0.03 mm/year (VEPE) and 0.04 mm/year (ModXLPE). Total 3D wear was 0.21 mm (SD 0.26) and 0.23 mm (SD 0.10) for the VEPE and ModXLPE groups, respectively (p = 0.009). Total 3D cup translation was 0.72 mm (SD 0.70) (VEPE) and 0.50 mm (SD 0.44) (ModXLPE) (p = 0.409). Conclusion. At five years, there was less polyethylene wear in the VEPE group than in the ModXLPE group. Both VEPE and ModXLPE cemented components showed low annual wear rates. Component stability was similar in the two groups and remained constant up to five years. Whether these results will equate to a lower long-term revision rate is still unknown. Cite this article: Bone Joint J 2020;102-B(12):1646–1653

Aims. Highly cross-linked polyethylene (HXLPE) has greatly improved the durability of total hip arthroplasty (THA) in young patients because of its improved wear characteristics. Few studies have followed this population into the second decade, and therefore the purpose of this investigation was to evaluate the clinical outcome for THA patients 50 years of age and younger at a minimum of 15 years postoperatively. The second purpose was to evaluate the radiological findings secondary to wear or mechanical failure of the implant. Methods. Between October 1999 and December 2005, 105 THAs were performed in 95 patients (53 female, 42 male) aged 50 years and younger (mean 42 years (20 to 50)). There were 87 patients (96 hips) that were followed for a minimum of 15 years (mean 17.3 years (15 to 21)) for analysis. Posterior approach was used with cementless fixation with a median head size of 28 mm. HXLPE was the acetabular bearing for all hips. Radiographs were evaluated for polyethylene wear, radiolucent lines, and osteolysis. Results. Clinical outcomes showed significant improvement of mean Harris Hip Scores from 52.8 (SD 13.5) preoperatively to 94.8 (SD 7.6) postoperatively. One hip was revised for recurrent instability, and there were no infections. No hips were revised for mechanical loosening or osteolysis. Mean polyethylene linear wear was 0.04 mm/year and volumetric wear was 6.22 mm. 3. /year, with no significant differences between head size or material. Osteolysis was not present in any of the hips. Conclusion. The use of HXLPE in THA for patients aged 50 years and younger has performed exceptionally well without evidence of significant wear causing mechanical loosening or necessitating revision. The radiolucent lines of the acetabular component must be followed to determine the prognostic significance. This investigation represents the longest clinical follow-up of a large, consecutive cohort of patients aged 50 years or younger with THA using HXLPE. This long-term analysis found negligible polyethylene wear, no incidence of aseptic loosening, and excellent clinical outcomes at and beyond 15 years of follow-up. Cite this article: Bone Joint J 2021;103-B(7 Supple B):78–83

Aims. The aim of this study was to evaluate the performance of first-generation annealed highly cross-linked polyethylene (HXLPE) in cementless total hip arthroplasty (THA). Methods. We retrospectively evaluated 29 patients (35 hips) who underwent THA between December 2000 and February 2002. The survival rate was estimated using the Kaplan-Meier method. Hip joint function was evaluated using the Japanese Orthopaedic Association (JOA) score. Two-dimensional polyethylene wear was estimated using Martell’s Hip Analysis Suite. We calculated the wear rates between years 1 and 5, 5 and 10, 10 and 15, and 15 and final follow-up. Results. The mean follow-up period was 19.1 years (SD 0.6; 17.3 to 20.1). The 19-year overall survival rate with the end point of all-cause revision was 97.0% (95% confidence interval (CI) 91 to 100). The mean JOA score improved from 43.2 (SD 10.6; 30 to 76) before surgery to 90.2 (SD 6.4; 76 to 98) at the final follow-up (p < 0.001). There was no osteolysis or loosening of the acetabular or femoral components. The overall steady-state wear rate was 0.013 mm/year (SD 0.012). There was no hip with a steady-state wear rate of > 0.1 mm/year. There was no significant difference in wear rates for each period. We found no significant correlation between the wear rate and age, body weight, BMI, or cup inclination. Conclusion. First-generation annealed HXLPE shows excellent wear resistance and no acceleration of wear for approximately 20 years, with low all-cause revision rates. Cite this article: Bone Joint J 2022;104-B(2):200–205

Aims. We aimed to investigate if the use of the largest possible cobalt-chromium head articulating with polyethylene acetabular inserts would increase the in vivo wear rate in total hip arthroplasty. Methods. In a single-blinded randomized controlled trial, 96 patients (43 females), at a median age of 63 years (interquartile range (IQR) 57 to 69), were allocated to receive either the largest possible modular femoral head (36 mm to 44 mm) in the thinnest possible insert or a standard 32 mm head. All patients received a vitamin E-doped cross-linked polyethylene insert and a cobalt-chromium head. The primary outcome was proximal head penetration measured with radiostereometric analysis (RSA) at two years. Secondary outcomes were volumetric wear, periacetabular radiolucencies, and patient-reported outcomes. Results. At two years, 44 patients in each group were available for RSA assessment. The median total two-year proximal head penetration was -0.02 mm (IQR -0.09 to 0.07; p = 0.548) for the largest possible head and -0.01 mm (IQR -0.07 to 0.10; p = 0.525) for 32 mm heads. Their difference was not statistically significant (p = 0.323). Neither group demonstrated a bedding-in period. The median steady-state volumetric wear rates were 6.1 mm. 3. /year (IQR -59 to 57) and 3.5 mm. 3. /year (-21 to 34) respectively, and did not differ between the groups (p = 0.848). There were no statistically significant differences in periacetabular radiolucencies or patient-reported outcomes. Conclusion. The use of the largest possible metal head did not increase vitamin E-doped cross-linked polyethylene wear compared with 32 mm heads at two years. Linear wear was negligible and volumetric wear rates were very low in both head size groups. There was a tendency towards higher values of volumetric wear in large heads that warrants longer-term evaluation before any definite conclusions about the association between head size and wear can be drawn. Cite this article: Bone Joint J 2021;103-B(7):1206–1214

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. Methods. This prospective observational study investigated 101 cases of primary THA over a mean duration of 129 months (120 to 149). At last follow-up, 57 cases with complete clinical and radiological outcomes were evaluated. In all cases, the acetabular component comprised an uncemented titanium particle-coated VEPE monoblock cup. Patients were assessed clinically and radiologically using the Harris Hip Score, visual analogue scale (pain and satisfaction), and an anteroposterior radiograph. Cup migration and polyethylene wear were measured using Einzel-Bild-Röntgen-Analyze software. All complications and associated treatments were documented until final follow-up. Results. Clinical assessment showed persistent major improvement in all scores. On radiological assessment, only one case showed a lucent line (without symptoms). At last follow-up, wear and migration were below the critical thresholds. No cup-related revisions were needed, indicating an outstanding survival rate of 100%. Conclusion. Isoelastic VEPE cups offer high success rates and may prevent osteolysis, aseptic loosening, and the need for revision surgeries in the long term. However, longer follow-up is needed to validate our findings and confirm the advantages offered by this cup. Cite this article: Bone Jt Open 2024;5(10):825–831

We report the five-year outcome of a randomised controlled trial which used radiostereometric analysis (RSA) to assess the influence of surface oxidised zirconium (OxZr, Oxinium) on polyethylene wear in vivo. A total of 120 patients, 85 women and 35 men with a mean age of 70 years (59 to 80) who were scheduled for primary cemented total hip arthroplasty were randomly allocated to four study groups. Patients were blinded to their group assignment and received either a conventional polyethylene (CPE) or a highly cross-linked (HXL) acetabular component of identical design. On the femoral side patients received a 28 mm head made of either cobalt-chromium (CoCr) or OxZr. . The proximal head penetration (wear) was measured with repeated RSA examinations over five years. Clinical outcome was measured using the Harris hip score. . There was no difference in polyethylene wear between the two head materials when used with either of the two types of acetabular component (p = 0.3 to 0.6). When comparing the two types of polyethylene there was a significant difference in favour of HXLPE, regardless of the head material used (p < 0.001). . In conclusion, we found no advantage of OxZr over CoCr in terms of polyethylene wear after five years of follow-up. Our findings do not support laboratory results which have shown a reduced rate of wear with OxZr. They do however add to the evidence on the better resistance to wear of HXLPE over CPE. Cite this article: Bone Joint J 2015;97-B:1463–9

We investigated the rate of polyethylene wear of a cementless acetabular component at different periods of follow-up in order to test the hypothesis than an irrecoverable deformation process (creep) was followed by an initially low, but gradually increasing wear rate. We studied prospectively 93 uncemented total hip arthroplasties in 83 patients (mean age 50 years (22 to 63)) with a mean follow-up of 8.2 years (3 to 12). We measured the penetration of the femoral head from radiographs taken immediately after surgery at three, six and nine years, or at the latest follow-up. The median wear rate was 0.17 mm per year in the first three years, a finding which we considered to be caused by creep. Thereafter, the rate of wear declined to 0.07 mm per year (four- to six-year period) and then increased to 0.17 mm per year (seven to nine years) and 0.27 mm per year (more than nine years), which we considered to be a reflection of genuine polyethylene wear. After the nine-year follow-up the wear rates were higher in patients with marked osteolysis. We found no relationship between the inclination angle of the acetabular component or femoral head orientation and the rate of wear. No acetabular component required revision

We compared the five- to seven-year clinical and radiological results of the metal-on-metal Birmingham hip resurfacing with a hybrid total hip arthroplasty in two groups of 54 hips, matched for gender, age, body mass index and activity level. Function was excellent in both groups, as measured by the Oxford hip score, but the Birmingham hip resurfacings had higher University of California at Los Angeles activity scores and better EuroQol quality of life scores. The total hip arthroplasties had a revision or intention-to-revise rate of 8%, and the Birmingham hip resurfacings of 6%. Both groups demonstrated impending failure on surrogate end-points. Of the total hip arthroplasties, 12% had polyethylene wear and osteolysis under observation, and 8% of Birmingham hip resurfacings showed migration of the femoral component. Polyethylene wear was present in 48% of the hybrid hips without osteolysis. Of the femoral components in the Birmingham hip resurfacing group which had not migrated, 66% had radiological changes of unknown significance

We compared the medium-term clinical and radiological results of hybrid total hip replacement (THR) with metal-on-metal Birmingham hip resurfacing (BHR) in two groups of 54 young patients matched for age, gender, body mass index and pre-operative levels of activity. The clinical outcome was assessed by the University of California, Los Angeles (UCLA) activity score, the Oxford Hip Score (OHS) and the EuroQol scores. Radiologically, all hips were assessed for migration and osteolysis, the hybrid THRs for polyethylene wear and the BHRs for a pedestal sign. The mean follow-up of the patients with a hybrid THR was ten years and for those with a BHR, nine years. Four patients with a hybrid THR and one with a BHR had died. In each group five were lost to follow-up. The revision rate of the hybrid THRs was 16.7% (9 of 54) and of the BHRs 9.3% (5 of 54) (p = 0.195). Radiographs of a further eight hybrid THRs demonstrated wear and osteolysis, and they await revision (p = 0.008). Of the unrevised BHRs 90% had radiological changes, of which approximately 50% had progressed over the previous four years. All hybrid THRs demonstrated linear polyethylene wear with a mean of 1.24 mm (0.06 to 3.03). The BHRs recorded superior OHS (p = 0.013), UCLA (p = 0.008), and EuroQol visual analogue scores (p = 0.009). After nine years, patients with BHRs remained more active and had a lower rate of revision than those with hybrid THRs. Both groups demonstrated progressive radiological changes at medium-term follow-up

We have evaluated the results of total hip replacement in patients with congenital hip disease using 46 cemented all-polyethylene Charnley acetabular components implanted with the cotyloplasty technique in 34 patients (group A), and compared them with 47 metal-backed cementless acetabular components implanted without bone grafting in 33 patients (group B). Patients in group A were treated between 1988 and 1993 and those in group B between 1990 and 1995. The mean follow-up for group A was 16.6 years (12 to 18) and the mean follow-up for group B was 13.4 years (10 to 16). Revision for aseptic loosening was undertaken in 15 hips (32.6%) in group A and in four hips (8.5%) in group B. When liner exchange was included, a total of 13 hips were revised in group B (27.7%). The mean polyethylene wear was 0.11 mm/yr (0.002 to 0.43) and 0.107 mm/yr (0 to 0.62) for groups A and B, respectively. Polyethylene wear in group A was associated with linear osteolysis, and in group B with expansile osteolysis. In patients with congenital hip disease, when 80% cover of the implant can be obtained, a cementless acetabular component appears to be acceptable and provides durable fixation. However, because of the type of osteolysis arising with these devices, early exchange of a worn liner is recommended before extensive bone loss makes revision surgery more complicated

Aims. This paper describes the methodology, validation and reliability of a new computer-assisted method which uses models of the patient’s bones and the components to measure their migration and polyethylene wear from radiographs after total hip arthroplasty (THA). Materials and Methods. Models of the patient’s acetabular and femoral component obtained from the manufacturer and models of the patient’s pelvis and femur built from a single computed tomography (CT) scan, are used by a computer program to measure the migration of the components and the penetration of the femoral head from anteroposterior and lateral radiographs taken at follow-up visits. The program simulates the radiographic setup and matches the position and orientation of the models to outlines of the pelvis, the acetabular and femoral component, and femur on radiographs. Changes in position and orientation reflect the migration of the components and the penetration of the femoral head. Validation was performed using radiographs of phantoms simulating known migration and penetration, and the clinical feasibility of measuring migration was assessed in two patients. Results. Migration of the acetabular and femoral components can be measured with limits of agreement (LOA) of 0.37 mm and 0.33 mm, respectively. Penetration of the femoral head can be measured with LOA of 0.161 mm. Conclusion. The migration of components and polyethylene wear can be measured without needing specialised radiographs. Accurate measurement may allow earlier prediction of failure after THA. Cite this article: Bone Joint J 2017;99-B:1290–7