We report the results of our continued review of 11 hip arthroplasties using 22.225mm alumina ceramic femoral heads (CCH) on a Charnley flanged stem articulating with a chemically cross-linked polyethylene (XLPE) cup. The initial bedding-in of up to 0.41mm, which was reached within about 2 years, has not progressed further with a follow up to 18.1 years. The mean total penetration of the XLPE cup for this group of patients is 0.31mm (0 – 0.41) and a penetration rate of 0.019 mm/year (mean 0 – 0.026). One patient with CCH/XLPE arthroplasty on the left side and a conventional metal on ultra high molecular weight polyethylene (UHMWPE) on the right side, has a ten fold difference in total penetration: 0.41mm compared with 4.1mm and a year shorter follow-up.

The mean age of the 9 patients (11 hips) attending was 47.2 years (26–58) at the operation and is now 64 years (42–73). Clinical results remain excellent with freedom from pain and normal activity level appropriate to their age and gender.

Radiographically none of the cups or stems show evidence of loosening or osteolysis and there have been no problems that could have been attributed to the materials or the design used.

Triple-tapered cemented polished C-Stem has evolved from the study of long-term results of the Charnley low-frictional torque arthroplasty when the first fractured stem and then proximal strain shielding of the femur and stem loosening were identified as the continuation of the same process: lack or loss of proximal stem support.

The C-Stem, by the concept, design and the surgical technique, caters for a limited slip of the stem within the cement mantle transferring the load more proximally. With a follow-up past 10 years and 3299 primary procedures there have been no revisions for aseptic stem loosening and no stem is radiologically loose.

Four hundred and forty eight patients had 500 LFAs using the C-Stem with the longest follow-up: 256 women and 192 men; 52 patients had bilateral LFAs. The patients’ mean age at surgery was 55.5 years (range 17–89 years) and at a mean follow-up of 5.2 years.

There was an overall improvement in the clinical outcome graded according to d’Aubigne and Postel for pain, function and movement from 3.1, 2.9 and 2.8 to 5.9, 5.7 and 5.5 respectively.

A good quality proximal femur had been maintained in 56.8% and improved in 21.8%.

The results are encouraging and support the concept but place a demand on the understanding of the technique and its execution at surgery.

With the demand for total hip arthroplasty continuing it is essential that the longest follow-up cases remain under continuous review.

Fifty one of the primary Charnley low-frictional torques arthroplasties have passed 30 years follow-up: mean 31 years (30–36): 42 are women and 9 men. Their mean age at surgery was 47 years (24–64). At the latest follow-up two have had a late deep infection, three a dislocation, nine a radiologically loose cup, two a loose stem and one had had a fracture of the shaft of the femur, and one a fractured stem, with only the fractured stem coming to revision.

Clinical results remain satisfactory. Wear and loosening of the cup remains the long term problem. Further improvement and even longer follow-up and successful results of the Charnley LFA will come from materials which offer the greatest resistance to wear.

Previous studies have confirmed a very strong correlation between penetration depth and the incidence of cup loosening due to impingement of the neck of the stem on the rim of the cup. The Charnley stem has been consistently manufactured in stainless steel – originally in EN58J then 316L. Introduction of the high nitrogen content stainless steel (ORTRON) allowed the reduction of the diameter of the neck from 12.5mm to 10mm. A prospective study was set up to establish the value of the reduced diameter neck in the context of the long-term survivorship of the cup revisions for wear and aseptic loosening. The benefit of the reduced diameter neck was clear from theoretical considerations – our objective was to establish the level of that benefit.

We compared the results where the 12.5mm diameter neck had been used with patients where the reduced 10mm diameter neck was used. We have analysed the correlation between the depth of cup penetration (mm) and the incidence of radiograph cup loosening as well as revision for aseptic cup loosening. The two groups comprised 1047 and 387 hips with a mean follow-up of 16.6 years (1–36) and 12.7 years (1–20) respectively.

When there was no measurable cup penetration, not only were there no revisions for aseptic cup loosening, but none of the cups were radiologically loose. At 1mm the decrease is 5% (from 9.4% to 4.4%), at 5mm the decrease is nearly 35% (from 56.7% to 22.2%). The effect on the reduction of the revision rate was nearly 3% at 1mm to nearly 8% at 5mm. The overall “gain” in the UHMWPE thickness is about 1mm which does suggest 10 years extra at a mean of 0.1mm penetration per year.