The number one reason to consider large heads in total hip arthroplasty (THA) is for increased stability. Large diameter femoral heads substantially increase stability by virtue of increased range of motion and increased jump distance, which is the amount of displacement required to sublux the head out of the socket. Prevention is the best means for reducing dislocation, with requisites for stability being appropriate component position, restoration of leg length, and restoration of offset. In a review from our center studying the frequency of dislocation with small diameter femoral heads (≤32 mm) in 1262 patients (1518 hips) who underwent primary THA performed via a direct lateral approach, we observed a dislocation rate of 0.8% (12 of 1518). In a subsequent study of 1748 patients (2020 hips) who underwent primary THA at our center with large diameter heads (mean 43 mm, range 36–60 mm), we observed a substantially lower 0.04% frequency of dislocation (one of 2010) at a mean followup of 2.6 years. Our findings have been echoed in studies from several other centers. Howie et al. reported a prospective controlled trial of 644 low risk patients undergoing primary or revision THA randomised to receive either a 36 mm or 28 mm metal head articulated on highly crosslinked polyethylene. They observed significantly lower frequency of frequency of dislocation with 36 mm heads both overall (1.3%, 4 of 299 versus 5.4%, 17 of 216 with 28 mm heads, p=0.012) and in primary use (0.8%, 2 of 258 versus 4.4%, 12 of 275 with 28 mm heads, p=0.024), and a similar trend in their smaller groups of revision patients (5%, 2 of 41 versus 12%, 5 of 41 with 28 mm heads, p=0.273). Lachiewicz and Soileau reported on early and late dislocation with 36- and 40 mm heads in 112 patients (122 hips) at presumed high risk for dislocation who underwent primary THA. Risk factors were age >75 for 80 hips, proximal femur fracture for 18, history of contralateral dislocation for 2, history of alcohol abuse in 2, large acetabulum (>60 mm) in 6, and other reasons in 14. Early dislocation (<1 year) occurred in 4% (5 of 122), all with 36 mm heads. Late dislocation (>5 years) did not occur in any of the 74 patients with follow up beyond 5 years. Stroh et al. compared 225 patients (248 hips) treated with THA using small diameter heads (<36 mm) to 501 patients (559 hips) treated with THA using large diameter heads (≥36 mm). There were no dislocations with large diameter heads compared with 1.8% (10 of 559) with small diameter heads. Allen et al. studied whether or not large femoral heads improve functional outcome after primary THA via the posterior approach in 726 patients. There were 399 done with small heads (<36 mm), 254 with medium heads (36 mm), and 73 with large heads (>36 mm), analyzed preoperatively, at 6 months, and at 12 months. The authors could not find a correlation between increasing head size and improved function at one year, but observed that dislocation was reduced with large diameter heads. Optimization of hip biomechanics via proper surgical technique, component position, and restoration of leg length and offset are mandatory in total hip arthroplasty. Large heads enhance stability by increasing range of motion prior to impingement and enhancing jump stability

Introduction & aims. Total hip replacement is an excellent treatment option for people with late stage degenerative hip disease. In addition to marked reduction in pain and improvement in sleep, most people regain range of motion, physical ability and quality of life. This study aimed at the functional outcomes of large diameter heads in THR patients. Method. This study is an analysis of a cohort of patients undergoing total hip replacement performed at our hospital from November 2011 to July 2013. A total of 70 hips, 40 males and 30 females, were operated upon with large diameter femoral heads. The mean age was 50.38 years (range 40–59 years). In our cohort, 32 patients had AVN of femur head, 19 had post traumatic secondary degeneration, 10 had RA, 6 had AS and 3 patients had OA of hip. The follow-up data included local complications, Harris Hip Score, medical complications, readmission, activity status and use of a walking aid. Results. Harris hip score at final follow up was, 33 cases had excellent, 26 cases had good result. None of the patient had fair or poor result. Two cases of superficial infection were observed. One case of dislocation was observed in post operative period which was reduced under GA and patient was given abduction brace. The mean follow up was 16.31 months ranging from 6 to 32 months. During the follow up, we had mortality of two patients. One died at 14 months due to myocardial infarction and the cause of other died due to CVA at 10 months follow up. Conclusions. Lower dislocation rate and better range of motion in majority of cases reinforces the advantage of large diameter head in THR in young and active patients. For any figures or tables, please contact authors directly (see Info & Metrics tab above).

Introduction:. Large diameter femoral heads have been used successfully to prevent dislocation after Total Hip Arthroplasty (THA). However, recent studies show that the peripheral region of contemporary femoral heads can directly impinge against the native soft-tissues, particularly the iliopsoas, leading to activity limiting anterior hip pain. This is because the spherical articular surface of contemporary prosthesis overhangs beyond that of the native anatomy (Fig. 1). The goal of this research was to develop an anatomically shaped, soft-tissue friendly large diameter femoral head that retains the benefits of contemporary implants. Methods:. Various Anatomically Contoured femoral Head (ACH) designs were constructed, wherein the articular surface extending from the pole to a theta (θ) angle, matched that of contemporary implants (Fig. 2). However, the articular surface in the peripheral region was moved inward towards the femoral head center, thereby reducing material that could impinge on the soft-tissues (Fig. 1 and Fig. 2). Finite element analysis was used to determine the femoroacetabular contact area under peak in vivo loads during different activities. Dynamic simulations were used to determine jump distance prior to posterior dislocation under different dislocation modes. Published data was used to compare the implant articular geometry to native anatomy (Fig. 3). These analyses were used to optimize the soft-tissue relief, while retaining the load bearing contact area, and the dislocation resistance of conventional implants. Results:. The resulting ACH prosthesis retained the large diameter profile of contemporary implants over an approximately hemispherical portion (Fig. 2). Beyond this, the peripheral articular surface was composed of smaller convex radii. With this design, the jump distance under posterior and anterior dislocation modes, and the femoroacetabular contact area under loads corresponding to walking, deep knee bend and chair sit, remained identical to that of contemporary implants. Additionally, while contemporary prosthesis extended beyond the native articular surface in the distal-medial and proximal-lateral regions (shaded grey), the ACH implant remained within the margins of the native anatomy (Fig. 3). Conclusion:. A novel large diameter anatomically contoured femoral head prosthesis was developed, to mitigate the soft-tissue impingement with contemporary prosthesis. The ACH retained the large diameter profile of contemporary implants over a hemispherical portion. However, in the peripheral region, the ACH had a smaller profile to reduce soft-tissue impingement

Introduction: Dislocation rates with THA vary from 3% to 15%. One specialist centre reported a 6.4% early dislocation rate with a 28mm ceramic on polyethylene THA in young patients (mean age 56 years) in a single surgeon series. Although young patients have the advantage of better soft tissues, their greater mobility demands increase dislocation risk. Dislocation rates in large headed metal-on-metal resurfacings are extremely low. However, many patients are unsuitable for resurfacing and need a replacement. In such cases, it is attractive to transfer the large-headed metal-metal bearing advantage to replacement arthroplasty in order to reduce wear and dislocation rates. Does large diameter metal-metal total hip replacement really reduce the early dislocation rate?. Methods: 206 consecutive primary metal-metal THRs (189 patients) were included. The device consists of an uncemented cup, a matching modular cobalt chrome head (head diameter ranged 38 – 58mm) fixed on a stem through a 12/14 cone. Cemented stems were used in 107 procedures and 99 were proximal-porous uncemented stems. Age at operation ranged from 37 to 83 years. Thirty patients were 55 years or under, eighty one were 56 – 65 years and ninety five were over 65 years. There were 122 females and 67 males. Posterior approach was used in all. Results: There were no dislocations in these 206 consecutive procedures. Discussion: Metal-metal hips have lower dislocation rates than hips containing polyethylene (0.9% against 6.4% in a matched series). This is attributed to the suction-fit effect of metal-metal bearings. Large diameter bearings have the additional benefit of having to translate a greater jump distance before a dislocation. This dual advantage leading to extremely low dislocation rates was first noted in metal-metal resurfacings. In large headed metal-metal THRs, the head-neck ratio is even more favourable and these devices appear to eliminate early dislocation as a major complication

INTRODUCTION. The risk of dislocation in large diameter metal on metal hip replacement is significantly lower than in standard THR. This is due to the increased primary arc, increased jump distance and possibly a suction effect. Our unit has performed over 1500 of these cases with an overall revision rate of <1%. We report a case series of dislocations in 5 large diameter metal on metal hips undertaken at our unit. METHOD. All cases were reduced closed and investigated for cause of dislocation. Radiological investigation included plain film radiographs and CT to exclude component mal-position and MRI to document soft tissue deficiency. Metal ion levels were measured and microbiological investigation was undertaken. RESULTS. In all cases component positioning was acceptable. Metal ion levels were significantly elevated with levels comparable to published work. MRI showed significant soft tissue defects in all patients. At revision all were found to have necrotic areas associated with a large turbid effusion. Histology confirmed metal related inflammatory change and microbiology specimens confirmed the absence of infection. DISCUSSION. The local detrimental effects of metal debris are well documented. We believe this is the first series with a proven link between these soft tissue problems and dislocation. Every case of large diameter metal on metal hip in our unit that has dislocated has been proven to be associated with metallosis and has required revision

The extension of THR to younger and more demanding patients implies the need of bearings enhancing the implants survival, raising the interest on hard-on-hard bearings (metal-on-metal and ceramic-on-ceramic). The standard bearing diameters in THR range from 7/8in (22,225 mm) to 32 mm. Larger diameter bearings were used by McKee-Farrar and Ring THR a solution that was abandoned after the success of Charnley Low Friction Arthroplasty that offered the advantage of much lower torques at the implant-bone interface, due also to the state-of-the-art of the cementation in the early 1960s. Increasing the diameter of THR bearings offers several advantages in terms of increased stability of the joint, as a larger displacement is necessary to produce the joint subluxation, and for a given neck diameter the risk of impingement is reduced while the prosthesis range of motion is increased. The reduced wear of metal-on-metal and ceramic-on-ceramic bearings has led recently to revitalise the design concept of the early THR designs, and large diameter joints today are available in sizes ranging from 36 to 52 mm. Large metal-on-metal bearings are used mostly in resurfacing prostheses. This surgery, which requires a specific surgical training, is indicated for patients performing physical activity, as those patients are relatively young, and have a long life expectation. This raises-some concerns, as increased cobalt and chromium concentrations were measured in the blood and urine of patients having Metal on Metal bearings and the effect of such high metal concentration in the long time is still unknown, as it is controversial if the metal ions are originated by wear debris of by the corrosion of the implant. Recently 36 mm ceramic on ceramic bearings were introduced in THR as a solutions to overcome many of the problems of metal-on-metal joints. Ceramic-on-ceramic bearings have a 35-year clinical history in THR. The extremely low wear of these joints is well assessed , as well as the extreme biocompatibil-ity of the material and the absence of local and systemic negative reaction to ceramic debris. Besides the enhanced safety of the design of the 36 mm heads, the development of thin ceramic inserts allowed to limit the overall diameter of the cup. It is expected that the use of the new alumina matrix composites will allow to further enhance the performances of large diameter ceramic THR bearings

Purpose of the study: The tribologic characteristics of the metal-on-metal bearing enabled the introduction of large-diameter femoral heads on a conventional stem with the aim of improving implant stability. Our work was designed to determine whether the short-term outcomes corroborate this hypothesis and identify any specific complications. Material and methods: This was a comparative study of two series of non-cemented total hip arthroplasties (THA) with a high-carbon content metal-on-metal bearing: 250 25 mm arthroplasties implanted from August 2001 to April 2004; 250 large-diameter arthroplasties implanted from August 2003 to December 2006. The two series were comparable regarding age, gender, BMI, aetiology, Devane and Harris scores preoperatively (r2=0.98; p< 0.001). Patients were reviewed at mean 5 years 5 months (28mm) and 3 years 1 months (large diameter). Results: The analysis was possible for 224 implants in the 28 mm series and 242 in the large diameter series. Clinically, the Merle-d’Aubigné et Harris scores were highly comparable between the series; the activity item on the UCLA score revealed better results in the anatomic head series (6.09 versus 6.81; p< 0.0039). Regarding complications: There was one cases of implant migration in the large diameter series with preservation of the good outcome and no revision. For dislocations: anatomic head (n=1, 0.4% with revision); 28 mm head (n=7, 2.8% with four revisions). One particular case of one patient with a large diameter head presented two episodes of localised recurrent cellulitis under regular surveillance. Metal ion assays (medians): Cr.− 1.55μg/l for 28mm; 2.21μg/l for large diameter; Co. − 1.10μg/l for 28mm; 1.92μg/l for large diameter. Discussion: Our results provide objective evidence of the improvement in the stability of the prosthesis joint and in the functional outcome, confirming the few results published to date. Conversely, while we did have less technical failures than published series, we did find significantly higher metal ion levels in the large diameter series, in contrast with prior data. The neck length being modulated with the intermediary piece, the potential corrosion might be the only cause of this difference

Large diameter metal-metal bearings possess several clinical advantages over small bearings including greater joint stability, improved range of motion, and lower wear due to improved lubrication. Simulator wear tests were conducted to assess the effects of thermal processing on the wear behavior of large diameter metal-metal hip bearings. Three groups of high carbon, cast 54 mm hip bearings with different thermal processing histories were tested. Two groups of bearings were manufactured to identical specifications and subjected to either no heat treatment(as-cast) or to typicall thermal processing prior to testing. The third group was comprised of commercially available as castbearing systems. Wear tests were performed on a Shore Western orbital bearing wear test machine. A simulated gait profile (triple-peak Paulprofile) with a maximum force of 2000N was applied to the bearings at a frequency of 1 Hz. The bearings were tested in the inverted position (headabove, shell below). The general wear behavior of all three groups of bearing couples was similar to that previously reported for metal-metal bearings. All couples exhibited a run-in wear phase followed by a low-wear steady-state phase. For all bearing couples tested the heads demonstrated more wear than the shells. The appearance of the worn surfaces of all the bearing couples tested in this study were consistent with that of previously reported in-vitro wear testing as well as metal-metal hip bearing retrieval studies. There was no statistical difference among the three groups tested in the run-in or steady-state wear rates, although the heat treated bearings tended to wear less on average. The results of this study indicate that thermal processing has no adverse effect on the wear of large diameter metal-metal hip bearings

Dislocation is a major concern following total hip replacement (THR) for fractured neck of femur. The aim of this prospective study was to investigate the use of large diameter femoral head uncemented THR to treat fractured neck of femur, and to demonstrate if the improved stability seen in previous clinical situations with these designs, can be used to benefit this difficult subgroup of patients that are particularly prone to dislocation. Forty-six consecutive independent, active and mentally alert patients with displaced intracapsular fractured neck of femur underwent large diameter head uncemented THR. The mean age of patients was 72.1 years. The outcome measures used were the dislocation rate, reoperation and revision rate, Oxford hip score (OHS), Euroqol (EQ-5D) and residential status. Clinical and radiological data were available on all 46 patients. At a mean follow-up of 12.5 months there were no dislocations. The reoperation, revision and infection rate were all 0%. Two patients died (4.3%) from unrelated causes. Mean pre- and postoperative OHS were 12.1 and 17.9 respectively. The mean pre- and postoperative EQ-5D index scores were 0.97 and 0.83 respectively. The mean postoperative walking distance was 2.5 miles and there were no changes in residential status. This is the first published series utilising a 36-mm diameter metal-on-metal THR for the treatment of fractured neck of femur in mobile, independent patients. We have demonstrated that it affords patients excellent stability with no recorded dislocations

Dislocation is a major concern following THR for fractured neck of femur. The aim of this prospective study was to investigate the use of large diameter femoral head uncemented THR to treat fractured neck of femur, and to demonstrate if the improved stability seen in previous clinical situations with these designs, can be used to benefit this difficult subgroup of patients that are particularly prone to dislocation. Forty-six consecutive independent, active and mentally alert patients with displaced intracapsular fractured neck of femur underwent large diameter head uncemented THR. The mean age of patients was 72.1 years. The outcome measures used were the dislocation rate, reoperation and revision rate, Oxford hip score (OHS), EuroQol (EQ-5D) and residential status. Clinical and radiological data were available on all 46 patients. At a mean follow-up of 12.5 months there were no dislocations. There were no reoperations, revisions or infections. Two patients died (4.3%) from unrelated causes. Mean pre- and postoperative OHS were 12.1 and 17.9 respectively. The mean pre- and postoperative EQ-5D index scores were 0.97 and 0.83 respectively. The mean postoperative walking distance was 2.5 miles and there were no changes in residential status. This is the first published series utilising a 36-mm diameter metal-on-metal THR for the treatment of fractured neck of femur in mobile, independent patients. We have demonstrated that it affords patients excellent stability with no recorded dislocations

Introduction. Large diameter femoral heads provide increased range-of-motion and reduced dislocation rates compared to smaller diameter femoral heads. However, several recent studies have reported that contemporary large head prostheses can directly impinge against the local soft tissues leading to anterior hip pain. To address this we developed a novel Anatomically Contoured large diameter femoral Head (ACH) that maintains the profile of a large diameter femoral head over a hemispherical portion and then contours inward the distal profile of the head for soft-tissue relief. We hypothesized that the distal contouring of the ACH articular surface would not affect contact area. The impact of component placement, femoral head to acetabular liner radial clearance, and joint loading during different activities was investigated. Methods. A finite element model was used to assess the femoroacetabular contact area of a 36 mm diameter conventional head and a 36 mm ACH (Fig. 1). It included a rigid acetabular shell, plastically deformable UHMWPE acetabular liner, rigid femoral head and rigid femoral stem. The femoral stem was placed at 0°, 10° and 20° of anteversion. The acetabular shell and liner were placed in 20°, 40° and 60° of abduction and 0°, 20° and 40° of anteversion. The femoral head to acetabular liner radial clearances modeled were 0.06 mm, 0.13 mm and 0.5 mm. Three loading cases corresponding to peak in vivo loads during walking, chair sit and deep-knee bend were analyzed (Fig. 2). This allowed a range of component positions and maximum joint loads to be studied. Results. Under all tested conditions there was no difference between the two implants (Fig. 3). The contact area for both prosthesis depended on the radial clearance between the head and liner. The conventional head contact area (standard deviation) in mm. 2. for 0.5 mm, 0.13 mm and 0.06 mm of radial clearance was 230.5 (70.2), 419.8 (48.7) and 575.4 (60.1) respectively. Similarly, for the ACH these were 230.5 (70.4), 420.1 (48.7) and 575.9 (59.4). The average data for a head and radial clearance combination included all component placements and load conditions completed. A student T-Test (p = 0.05) confirmed that the ACH had the same contact area as the conventional head for all radial clearances. Conclusion. This study showed that, as intended, an anatomically contoured large diameter femoral head designed to provide soft-tissue relief maintained the load bearing articular contact area of a conventional implant. The novel ACH prosthesis could mitigate the risk of soft-tissue impingement with contemporary large head implants while retaining their benefits of additional stability and range-of-motion

Introduction. Acetabular revision surgery is challenging due to severe bone defects. Burch-Schneider anti-protrusion cages (BS cage: Zimmer-Biomet) is one of the options for acetabular revision, however higher dislocation rate was reported. A computed tomography (CT)-based navigation system indicates us the planned direction for implantation of a cemented acetabular cup during surgery. A large diameter femoral head is also expected to reduce the dislocation rate. The purpose of this study is to investigate short-term results of BS cage in acetabular revision surgery combined with the CT-based navigation system and the use of large diameter femoral head. Methods. Sixteen hips of fifteen patients who underwent revision THA using allografts and BS cage between September 2013 and December 2017 were included in this study with the follow-up of 2.7 (0.1–5.0) years. There were 12 women and three men with a mean age of 78.6 years (range, 59–61 years). The cause of acetabular revision was aseptic loosening in all hips. The failed acetabular cup was carefully removed, and acetabular bone defect was graded using the Paprosky classification. Structural allografts were morselized and packed for all medial or contained defects. In some cases, solid allograft was implanted for segmental defects. BS cage was molded to optimize stability and congruity to the acetabulum and fixed with 6.5 mm titanium screws to the iliac bone. The inferior flange was slotted into the ischium. The upside-down trial cup was attached to a straight handle cup positioner with instrumental tracker (Figure 1) and placed on the rim of the BS cage to confirm the direction of the target angle for cement cup implantation under the CT-based navigation system (Stryker). After removing the cement spacer around the X3 RimFit cup (Stryker) onto the BS cage for available maximum large femoral head, the cement cup was implanted with confirming the direction of targeting angle. Japanese Orthopedic Association score (JOA score) of the hip was used for clinical assessment. Implant position, loosening, and consolidation of allograft were assessed using anterior and lateral radiographies of the pelvis. Results. Fifteen hips had a Paprosky IIIB defect, and one hip had a pelvic discontinuity. JOA score significantly improved postoperatively. No radiolucent lines and no displacement of BS cage could be found in 9 of 15 hips. Consolidation of allografts above the protrusion cage was observed in these patients. Displacement of BS cage (>5mm) was observed in 6 hips and displacement was stopped with allograft consolidation in 5 of 6 hips. The other patient showed lateral displacement of BS cage and underwent revision surgery. Average cup inclination and anteversion angles were 37.7±5.0 degree and 24.6±7.2 degree, respectively. 12 of 16 patients were included in Lewinnek's safe zone. One patient with 32 mm diameter of the femoral head had dislocation at 17 days postoperatively. All patients who received ≥36mm diameter of femoral head showed no dislocation. Conclusions. CT-based navigation system and the use of large femoral head may influence the prevention of dislocation in the acetabular revision surgery with BS cage for severe acetabular bone defects

Purpose of study There is renewed scientific interest in the use of metal-metal bearings for hip replacements. Such bearings have lower volumetric wear rates compared to metal or ceramic on polyethylene bearings. They permit the use of large diameter bearings which potentially have the benefit of reduced dislocation. They also allow the use of thin components without the risk of fracture associated with similar ceramic-ceramic components. However, there remain concerns about the long-term effects of nanometre sized debris and the release of metal ions. It is therefore critical to understand which parameters are important in minimising the amount of debris generated. This study investigated the effect of design and materials on the wear rates in a hip simulator. Methods Wear studies were carried out in a 10 station ProSim hip simulator in 25% newborn calf serum. A Paul type load curve was applied (maximum load 3000N, minimum 300N) in an anatomical configuration. The extent of a fluid film between the bearing surfaces was determind by measuring the voltage drop between the components. Test samples were made from low-carbon (< 0.05%) and high-carbon (> 0.20%) CoCrMo alloys in various conditions. These samples had bearing surface diameters of 16–54.5mm. The diametral clearance between the femoral head and acetabular cups were from 50–300um. Results The results of this study were that the low-carbon material wears more than high-carbon materials, there is no significant difference in wear performance of the various forms of high-carbon material tested (wrought, cast, and cast and heat treated), and wear decreased with reduced clearances and increased component diameter. Voltage changes indicated that reduced clearances resulted in component separation and fluid film lubrication. Conclusions These results are consistent with the hypothesis that large diameter metal-on-metal bearings with optimized bearing surface geometry operate in the mixed and/or fluid film lubrication regime

Introduction. Current literature supports the use of total hip replacement (THR) for the treatment of displaced intra-capsular proximal femoral fractures (DIPFF). Case series of patients receiving this treatment show dislocation rates higher than that of patients who have THR to treat osteoarthritis. Large diameter THR have mechanical advantages in terms of dislocation and their role in PFF has yet to be assessed. Objectives. To assess the role of large-diameter total hip replacements on the rate of dislocation when used to treat displaced intra-capsular proximal femoral fractures. Design: Single surgeon, case series. Setting: Level I trauma centre. Inclusion criteria:. Displaced intra-capsular proximal femoral fracture (Garden III & IV). Independently mobile pre-operatively for distances greater than a mile, with no more than 1 stick as a mobility aid. Abbreviated mental test score of 9/10 or greater. Exclusion criteria:. Patient under 60. Pathological fractures. Additional fractures of the femur. Outcomes. Mortality. Morbidity (Including dislocation). Oxford Hip Score. SF12. Patients/Participants: Retrospective study to assess patients who presented between May 2006 and December 2008 and met the requirements had a CPTÒ (Zimmer) cemented femoral stem, using 3. rd. generation cementation techniques, and large diameter Duronò (Zimmer) head and cup (uncemented) inserted as a primary procedure via a modified Hardinge technique. Follow up was via routine clinic appointments, letter to GP and phone conversation with patient. Results. 67 patients were selected (49 female) average age was 74.6 (67–87). Follow-up was for an average of 14 months (3–39 months). No dislocations or deaths were recorded for this period of time. Conclusions. This study suggests that the high rates of dislocation associated with THR for PPF can be limited by the use of large diameter components. This study should be followed up by a multi-centre multi-surgeon study

High failure rates have been associated with large diameter metal-on-metal total hip replacements (MoM THR). However there is limited literature describing the outcomes following the revision of MoM THR for adverse local tissue reaction (ALTR). A total of 98 large diameter MoM THRs underwent revision for ALTR at our institution. The data was obtained from the clinical records and included the demographics, intra-operative findings of ALTR and post-operative complications. Any subsequent procedures and re-revision for any reason was analysed in detail. The clinical outcome was measured using functional outcome scores using the Oxford hip score (OHS), Western Ontario and McMaster Universities osteo-arthritis index (WOMAC) score and Short Form (SF12). The mean age of the patients at the time of revision was 58.2 yrs. At a mean follow-up of 3.9 years (1.0 to 8.6) from revision for ALTR, there were 15 hips (15.3 %) with post-operative complications and 8 hips (8 %) requiring re-revision. The Kaplan–Meier five-year survival rate for ALTR revision was 91 % (95% confidence interval 78.9 to 98.0). There were no statistically significant predictors of re-revision. The rate of postoperative dislocation following revision was 9.2% (9 hips). The post-operative functional outcome depends on the intra-operative findings of tissue destruction secondary to ALTR. The short term results following revision of large diameter MoM THR for ALTR are comparable with other reports in the literature. The use of constrained liners reduces the incidence of post-operative dislocation. There is an increased risk of postoperative instability following revision THR for ALTR. Early identification and intervention seems to be the logical approach in the management of patients with ALTR

Introduction. Fatigue and wear at the head/stem modular junction of large diameter total hip replacements can be exacerbated as a result of the increase in frictional torque. In vivo, a “toggling,” anterior-posterior (A-P) movement of the head taper on the trunnion may facilitate corrosion in the presence of physiological fluids, leading to increased metal ion release. Clinically, metal ion release has been linked to the formation of pseudo tumours and tissue necrosis [1]. Aims. In this investigation, a large diameter metal on metal THR was tested on a rig designed to recreate the toggling motion at the head/stem junction. Post-test analyses are conducted to look for evidence of mechanical and corrosive damage. Methods and Materials. A 58 mm diameter metal head (12/14 taper) was assembled onto a sectioned Freeman stem affixed to custom designed rig that enabled both, axial loads and a frictional torque (for the AP toggle load) about the rotation of the femoral head to be applied as shown in Figure 1. A linear variable differential transformer (LVDT), which had a minimum resolution of 0.5 microns, was positioned in contact with the neck directly under the modular head to track A-P movements at the junction. An axial load of 150N with toggle loads varying between 100 (± 50N) and 200N (± 50N) at 1 Hz were run on 4 taper assemblies, 2 dry and 2 wet (incorporating a physiological fluid at the junction) between 400,000 and 600,000 cycles. Movement at the junction was recorded, followed by visual inspection and RedLux® surface profile analysis of the taper and trunnion. Results and Conclusion. The LVDT could successfully record movement at the junction. Initially (∼1000 cycles), the movement at the junction was found to be variable and between 5–10 microns, which can be attributed to the taper “bedding-in” on to the trunnion. The movement was then found to steadily increase before stabilising. The dry tapers recorded motion ranging between 5–15 microns, and between 10–20 microns for the wet taper. Visual inspection post testing showed minimal or no damage on the trunnion or taper surfaces on the dry tests. However, the trunnion and taper on the wet samples displayed marks and scratches on the surface (Figure 2). In addition, there was visible surface discolouration on both wet taper assemblies but none observed on the dry assemblies. This was further corroborated by Redlux topography measurements that also showed that material had been removed from both surfaces. The pilot study showed that A-P toggle movements at the junction could be produced by incorporating torque about the rotation of the head. Damage was evident on both the trunnion and taper surfaces, and discoloration was observed at the junction when fluid was introduced

Large diameter metal-on-metal (MOM) bearings are becoming increasingly popular for young, active patients. Clearance is a particularly important consideration for designing MOM implants, considering historical experience of equatorial contact and high frictional torque. Lubrication theory predicts increasing the clearance will result in diminished lubrication, resulting in increased friction and wear. Clinical cases of transient squeaking in patients with resurfacing bearings have been noted in recent years, with some reporting an incidence of up to 10% between 6 months and 2 years post-implantation. This study aimed to investigate the impact of increasing clearance on the lubrication, friction and squeaking of a large diameter metal-on-metal resurfacing bearing through frictional studies. Clinical-grade MOM implants of 55mm diameter and 100μm diametric clearance, and custom-made, 55mm bearings with diametric clearances of approximately 50μm and 200μm (DePuy International Ltd) were tested in a friction simulator. Components were inverted with a flexion-extension of ±25o applied to the head and lubricated with 25% and 100% newborn bovine serum. A peak load of 2kN, with swing-phase loads of 25N, 100N and 300N were applied. Sound data was recorded during each friction test using a MP3 recorder and pre-amplifier. A microphone was set up at a distance of 50mm from the implant, and data recorded over a minimum of 10 seconds where sound was generated. Sound data was assessed through narrow band analysis on Frequency Master software (Cirrus Research, UK). Lubrication was assessed by directly measuring the separation between the head and cup during the test cycle by ultrasonic methods (Tribosonics, UK). An ultrasound sensor was bonded to the back of the cup and reflection measurements were taken during the friction tests with a sampling rate of 100Hz. Using equations which related reflection coefficient to lubricant properties and thickness, values for the film thickness were calculated. The surface replacement with the largest clearance yielded the highest friction factor for each test condition. The difference between the large clearance bearing and the smaller clearance samples was statistically significant in 25% bovine serum, the more clinically relevant lubricant (ANOVA, p< 0.05). The 50μm clearance group yielded similar results to the 100μm clearance bearing, although a slight increase in friction was observed. Squeaking occurred during every test in the large clearance group. There was a reduced incidence of squeaking in the smaller clearances, with the lowest incidence observed in the 100μm clearance group. The smallest separation of the head and cup was observed within the large clearance bearings. The best lubrication condition measured ultrasonically was observed within the 100μm clearance bearing. There appeared to be good correlation between friction, lubrication and the incidence of squeaking. This study suggests a large diametric clearance results in reduced lubrication, increased friction and an increased incidence of squeaking. However, there is a minimum diametric clearance that can be tolerated, as clearance must accommodate the manufacturing tolerance

Summary Statement. The frictional torque of ceramic-on-ceramic bearings tended to increase with increasing the bearings size (32, 48, 56mm). However, the frictional torque was significantly lower than that measured on metal-on-metal bearings under well positioned and well lubricated conditions. Introduction. Larger head size in total hip replacement theoretically provides increased range of motion and enhanced stability. However, there are potential clinical concerns regarding increased frictional torques with large diameter metal-on-metal bearings causing loosening of the acetabular cups and corrosion at the taper. The aim of this study was to determine the frictional torques of large diameter BIOLOX® delta ceramic-on-ceramic bearings. Materials and Methods. The single-station pendulum friction simulator (SimSol, UK) was used to determine the frictional torque of three ceramic-on-ceramic bearing sizes: 32mm and 48mm (DeltaMotion®, DePuy Synthes Joint Reconstruction, Leeds, UK) and a 56mm prototype design. Four repeats were tested for each bearing size using 100% new-born calf serum, 25% new-born calf serum and water as lubricants. The input profiles were a simplified loading regime with a peak of 2kN and an angular motion of ±25° [1]. The frictional torque was determined under swing phase loads of 25N, 100N or 300N. The bearings were tested under standard conditions where the cup was positioned so the face was horizontal to the loading axis and at an inclination angle equivalent to 65° in vivo. Results. When lubricated with 100% serum, size 48mm bearings showed similar frictional toque to the 32mm bearings (1.5Nm and 1.7Nm respectively, p=0.28), however, the frictional torque of the 56mm prototype design bearings was significantly higher (2.2Nm, p=0.01). When using 25% serum, there was a trend of increased frictional torque (p=0.016) with increased head size; increasing from 1.2 Nm to 1.5 Nm to 1.9 Nm for the 32mm, 48mm, and 56mm bearings respectively. The frictional torque significantly decreased when water was used compared to using new-born calf serum as lubricant. There was no significant difference in the frictional torque between all bearings sizes with water as lubricant, however, there was a trend of increased frictional torque with increased swing phase load. Changing the swing phase load had no influence on the frictional torques obtained for all bearing sizes when using 100% or 25% new-born calf serum. Under a steep inclination angle, the frictional torque for all bearing sizes did not significantly change compared to the flat cup condition. Discussion and Conclusion. The frictional torque tended to increase with increased head size. The highest frictional torque measured in this study was 2.5Nm for the 56mm ceramic-on-ceramic bearing (25% serum, steep cup) compared to 5.3Nm maximum torque measured using the same method for well-positioned and well lubricated 54mm metal-on-metal bearings. The frictional torque for all ceramic-on-ceramic bearing sizes (32mm, 48mm, and 56mm) decreased as the concentration of protein decreased. This was consistent with previous work done on 28mm bearings and the understanding that for ceramic-on-ceramic bearings the adherence of proteins to the surface reduces the effectiveness of lubricant film thickness, thus resulting in higher frictional torques due to the force required to shear the proteins

Dislocation remains among the most common complications of, and reasons for, revision of both primary and revision total hip arthroplasties in the United States. Hence, there is great interest in maximising stability to prevent this complication. Highly cross-linked polyethylene has allowed us to increase femoral head size, without a clinically important increase in wear. Head size has long been recognised to have a strong influence on the risk of dislocation postoperatively. As femoral head size increases, stability is augmented, secondary to a decrease in component-to-component impingement, which is theoretically eliminated at head sizes greater than 36mm in diameter (however osseous impingement can still occur). Larger head sizes also greatly increase the “jump distance” required for the head to dislocate (in an appropriately positioned cup) and eliminate the need for skirts. Level one studies support the use of larger diameter heads as decreasing the risk of dislocation following primary and revision THA. Larger diameter heads do, however, have negatives with the most recent concern being larger forces imparted upon the trunnion, which may contribute to adverse local tissue reactions (ALTR) which have recently been reported in patients with a metal on polyethylene bearing. However, in the series by Cooper et al, 32mm was the most common head size identified with no head sizes >36mm in this series. This suggests that the cause of ALTR is probably multifactorial and while femoral head size may be a contributor, the trunnion itself may be more important including its diameter, length and modulus of elasticity as well as the specific finish of the taper. Finally, when larger femoral head sizes are used in smaller acetabular components, the result is a thinner polyethylene liner, which may increase the risk of liner breakage. Larger diameter bearings may also increase the risk of squeaking in ceramic on ceramic bearing couples. Hence, the decision on femoral head size probably should include a balance between patient risk factors for instability and the risks of increased head size. Hence for revision procedures, and in primary cases where the risk of dislocation is known to be high, the risk of a larger femoral head is probably outweighed by the benefits of enhanced stability if a larger femoral head is utilised

Introduction. Large diameter metal on metal cups have been used in total hip arthroplasty advocating superior results with respect to dislocation rates, range of motion and long term survival. The Durom cup used as part of the Durom hip resurfacing system has been incriminated with poor short term results sometimes correlated to incorrect positioning of either the femoral or acetabular component. Our objective was to evaluate short term results of the Durom cup used in conjunction with standard stems. Methods. We prospectively followed all patients with a large diameter metal-on-metal articulation (Durom) and a standard stem operated upon between 9/2004 and 9/2008. Patients were seen at follow-up for a clinical (Harris hip score=HHS, UCLA scale and patient satisfaction), radiographic and questionnaire assessment. Results. 89 primary THAs in 80 patients (74% men) with a mean age of 52 (±12) years were included. Main diagnoses were primary osteoarthritis in 47% and aseptic necrosis in 35%. An uncemented stem was used in 79%. Overall, 80 THAs were controlled at a mean follow-up of 39 months (range 16–67 months), 4 patients were lost to follow-up and 5 patients refused or were unable to attend the visit. However, none of the 5 underwent revision. Overall, 8 THAs (8/85, 9.4%) were revised in mean 28 months (range 8–60) after the operation. One additional patient was awaiting revision for aseptic loosening of both cup and stem. The reasons for revision were aseptic loosening in three cases, presence of a granuloma (histological diagnosis of ALVAL) in three, deep infection in one and impingement in one case. Radiographic analysis revealed linear (n=2) and focal (n=3) osteolysis as well as early cup migration (n=2). In 5 revised patients no radiographic changes were found. 56 (70%) of the 80 patients with follow-up had a HHS between 80 and 100. Among those who were not revised, the mean HHS improved from 55.2 to 88.4 (mean increase 33.2, 95% CI 27.7; 38.7). The mean activity level (UCLA scale) at follow-up was 6.4 (±1.8). Overall, mild to severe pain was reported in 14 cases and occasional pain in 22. Groin pain was present in 18 patients (22.5%), 7 of them belonged to the revised group. 61 (76.3%) of the 80 patients with follow-up were satisfied. Mean patient satisfaction on the VAS scale among those who were not revised was 9.0 (±1.3). Conclusion. This study confirms the increased short-term revision rate of the large diameter metal-on-metal couple (Durom) reported by others. In all revision cases the retrieved cups showed no osteo-integration and were removed easily. The operative indication for revision was based upon groin pain and patient dissatisfaction. Radiographic signs of implant loosening were not always present even though in all revised cases except for one the cup was found loose