In almost all countries performing Total Hip Replacement (THR), dislocation is one of the major reasons for revision. Hence, in the last years the trend to larger bearings has been observed, following an improve in the bearing materials, the operation technique, and fixation techniques of stem and shell. Larger bearings allow for more range of motion and higher stability than conventional 28 mm bearing couples, leading to a better postoperative mobility. On the other hand, size limitations on the acetabular side are given by the anatomy of the human pelvic bone as well as the deformation and fracture behaviour of the used artificial materials. Therefore, the best solution to be achieved provides a maximum physiological outcome along with a minimised risk of intraoperative and in-vivo failures. Investigating the wall thickness of the metal shell which is press-fitted in the human pelvic bone, the general trend towards a smaller wall thickness yielding an increased compliance can be observed with larger bearing diameters. This may lead to deformations of the metal shell making it difficult for the surgeon to properly introduce the insert. Hence, taking into account that a proper seating of the insert is absolutely necessary when using a ceramic insert in order to avoid point loads, operation time may strongly increase especially when minimal invasive surgery technique is used. With decreasing overall wall thickness of the acetabular components the volumetric stresses increase by definition. Therefore, an optimal component coupling between insert and metal shell is necessary in order to avoid point loads and resulting stress concentrations. With pre-assembled systems, this optimal coupling is reached by the force-controlled insertion of the insert in the metal shell without any prior deformation of the shell. This procedure enables to design acetabular components with a much lower overall wall thickness than conventional systems. As an example, in the case of the DELTA motion system, this overall wall thickness has been decreased to 5 mm allowing e.g. for a usage of a 36 mm bearing couple together with a 46 mm outer diameter of the metal shell. Additionally, the coating of the metal shell allows for direct bone ingrowth. Problems involved with larger bearing diameters may also arise from higher wear rates inducing possibly osteolysis and aseptic loosening. Investigations concerning the wear behaviour of large ceramic bearings have shown that there is no increase in the wear volume with increasing diameter

Introduction. Acetabular cup orientation has been shown to be a factor in edge-loading of a ceramic-on-ceramic THR bearing. Currently all recommended guidelines for cup orientation are defined from static measurements with the patient positioned supine. The objectives of this study are to investigate functional cup orientation and the incidence of edge-loading in ceramic hips using commercially available, dynamic musculoskeletal modelling software that simulates each patient performing activities associated with edge-loading. Methodology. Eighteen patients with reproducible squeaking in their ceramic-on-ceramic total hip arthroplasties were recruited from a previous study investigating the incidence of noise in large-diameter ceramic bearings. All 18 patients had a Delta Motion acetabular component, with head sizes ranging from 40 – 48mm. All had a reproducible squeak during a deep flexion activity. A control group of thirty-six patients with Delta Motion bearings who had never experienced a squeak were recruited from the silent cohort of the same original study. They were matched to the squeaking group for implant type, acetabular cup orientation, ligament laxity, maximum hip flexion and BMI. All 54 patients were modelled performing two functional activities using the Optimized Ortho Postoperative Kinematics Simulation software. The software uses standard medical imaging to produce a patient-specific rigid body dynamics analysis of the subject performing a sit-to-stand task and a step-up with the contralateral leg, Fig 1. The software calculates the dynamic force at the replaced hip throughout the two activities and plots the bearing contact patch, using a Hertzian contact algorithm, as it traces across the articulating surface, Fig 2. As all the squeaking hips did so during deep flexion, the minimum posterior Contact Patch to Rim Distance (CPRD) can then be determined by calculating the smallest distance between the edge of the contact patch and the true rim of the ceramic liner, Fig 2. A negative posterior CPRD indicates posterior edge-loading. Results. The mean CPRD was significantly less in the squeaking group than the control group, −2.5mm and 2.9mm respectively, (p < 0.001), Fig 3. The mean pelvic tilt in the flexed seated position was 12.6° (range −13.5° to 30.3°) for the squeaking group and 5.1° (−9.8° to 26.4°) for the control group. Consequently, the mean functional cup anteversion at seat-off was significantly less in the squeaking group than the control group, 8.1° (−10.5° to 36.0°) and 21.1° (−1.9° to 38.4°) respectively (p < 0.001), Fig 3. There were 67% (12) of patients in the squeaking group that showed posterior edge-loading in the simulation compared to only 28% (10) in the control group that exhibited posterior edge-loading in the simulation. Conclusions. Acetabular cup orientation during activities associated with edge-loading are likely very different from those measured when supine. Patients with large anterior pelvic tilts during deep flexion activities might be more susceptible to posterior edge-loading and squeaking in ceramic-on-ceramic bearings, as a consequence of a significant decrease in cup anteversion. If these patients can be identified preoperatively, cup orientation and bearing choice could be customised accordingly to accommodate these individual motion patterns

Introduction. The Delta Motion device (developed by Finsbury Orthopaedics, Leatherhead, United Kingdom, now manufactured by DePuy, Leeds, United Kingdom) is a pre-assembled factory fitted cup. It has been introduced to overcome some of the concerns relating to intra-operative assembly with improper seating of the liner and chipping. This device has a thinner shell and liner in comparison with other cups, allowing the use of larger sized heads which should help reduce the risk of impingement and dislocation. A drawback of the pre-assembled design is the inability to use supplementary screws to achieve stability and the difficulty in obtaining primary stability compared with a thin titanium shell. To date we are not aware of any publications reviewing the outcomes of these devices. Methods. 206 DeltaMotion cups were implanted in 195 patients, between Dec 2008 to Dec 2009 by the three senior authors. All the hips had the same stem (Osteonics) and a ceramic head was used. Data was prospectively collected and we reflect on our two year results. Results. A total of 206 cups (123 F: 83 M) were implanted in 195 patients. The mean age at implantation was 69 years (range 38–93). 11 patients had bilateral hips (6M:5F). Complications were 1 pulmonary embolism, 2 femoral stem subsidence, 1 dislocation, 2 femoral fractures, 13 squeaking hips (9F:4M). The squeaking hips had a mean age of 65 years. Discussion. The main complication was ‘benign’ squeaking. This was more common in younger (mean age 64 years) females. This cohort has a squeaking rate of 6.3% which is higher than 3.1% previously reported by our unit. There was no squeaking when 36 mm heads were used. The risk of squeaking dramatically increased when cup sizes 60 mm and above were used with 48 mm heads. Although squeaking seems to have increased with this device, none of the patients required revision

The June 2014 Hip & Pelvis Roundup³⁶⁰ looks at: Modular femoral necks: early signs are not good; is corrosion to blame for modular neck failures; metal-on-metal is not quite a closed book; no excess failures in fixation of displaced femoral neck fractures; noise no problem in hip replacement; heterotopic ossification after hip arthroscopy: are NSAIDs the answer?; thrombotic and bleeding events surprisingly low in total joint replacement; and the elephant in the room: complications and surgical volume.