Aims. The survival of humeral hemiarthroplasties in patients with relatively intact glenoid cartilage could theoretically be extended by minimizing the associated postoperative glenoid erosion. Ceramic has gained attention as an alternative to metal as a material for hemiarthroplasties because of its superior tribological properties. The aim of this study was to assess the in vitro wear performance of ceramic and metal humeral hemiarthroplasties on natural glenoids. Methods. Intact right cadaveric shoulders from donors aged between 50 and 65 years were assigned to a ceramic group (n = 8, four male cadavers) and a metal group (n = 9, four male cadavers). A dedicated shoulder wear simulator was used to simulate daily activity by replicating the relevant joint motion and loading profiles. During testing, the joint was kept lubricated with diluted calf serum at room temperature. Each test of wear was performed for 500,000 cycles at 1.2 Hz. At intervals of 125,000 cycles, micro-CT scans of each glenoid were taken to characterize and quantify glenoid wear by calculating the change in the thickness of its articular cartilage. Results. At the completion of the wear test, the total thickness of the cartilage had significantly decreased in both the ceramic and metal groups, by 27% (p = 0.019) and 29% (p = 0.008), respectively. However, the differences between the two were not significant (p = 0.606) and the patterns of wear in the specimens were unpredictable. No significant correlation was found between cartilage wear and various factors, including age, sex, the size of the humeral head, joint mismatch, the thickness of the native cartilage, and the surface roughness (all p > 0.05). Conclusion. Although ceramic has better tribological properties than metal, we did not find evidence that its use in hemiarthroplasty of the shoulder in patients with healthy cartilage is a better alternative than conventional metal humeral heads. Cite this article: Bone Joint J 2024;106-B(11):1273–1283

Aims. Metal and ceramic humeral head bearing surfaces are available choices in anatomical shoulder arthroplasties. Wear studies have shown superior performance of ceramic heads, however comparison of clinical outcomes according to bearing surface in total shoulder arthroplasty (TSA) and hemiarthroplasty (HA) is limited. This study aimed to compare the rates of revision and reoperation following metal and ceramic humeral head TSA and HA using data from the National Joint Registry (NJR), which collects data from England, Wales, Northern Ireland, Isle of Man and the States of Guernsey. Methods. NJR shoulder arthroplasty records were linked to Hospital Episode Statistics and the National Mortality Register. TSA and HA performed for osteoarthritis (OA) in patients with an intact rotator cuff were included. Metal and ceramic humeral head prostheses were matched within separate TSA and HA groups using propensity scores based on 12 and 11 characteristics, respectively. The primary outcome was time to first revision and the secondary outcome was non-revision reoperation. Results. A total of 4,799 TSAs (3,578 metal, 1,221 ceramic) and 1,363 HAs (1,020 metal, 343 ceramic) were included. The rate of revision was higher for metal compared with ceramic TSA, hazard ratio (HR) 3.31 (95% confidence interval (CI) 1.67 to 6.58). At eight years, prosthesis survival for ceramic TSA was 98.7% (95% CI 97.3 to 99.4) compared with 96.4% (95% CI 95.2 to 97.3) for metal TSA. The majority of revision TSAs were for cuff insufficiency or instability/dislocation. There was no significant difference in the revision rate for ceramic compared with metal head HA (HR 1.33 (95% CI 0.76 to 2.34)). For ceramic HA, eight-year prosthetic survival was 92.8% (95% CI 86.9 to 96.1), compared with 91.6% (95% CI 89.3 to 93.5) for metal HA. The majority of revision HAs were for cuff failure. Conclusion. The rate of all-cause revision was higher following metal compared with ceramic humeral head TSA in patients with OA and an intact rotator cuff. There was no difference in the revision rate for HA according to bearing surface. Cite this article: Bone Joint J 2024;106-B(5):482–491

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The aim of this study was to evaluate the incidence of liner malseating in two commonly used dual-mobility (DM) designs. Secondary aims included determining the risk of dislocation, survival, and clinical outcomes.

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The aim of our study was to investigate the effect of asymmetric crosslinked polyethylene liner use on the risk of revision of cementless and hybrid total hip arthroplasties (THAs).

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The aim of this study was to identify the effect of the manufacturing characteristics of polyethylene acetabular liners on the survival of cementless and hybrid total hip arthroplasty (THA).

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

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The primary aim of this study was to compare the wear properties of vitamin E-diffused, highly crosslinked polyethylene (VEPE) and one formulation of moderately crosslinked and mechanically annealed ultra-high molecular weight polyethylene (ModXLPE) in patients five years after primary total hip arthroplasty (THA). The secondary aim was to assess the clinical results of patients treated with VEPE by evaluating patient-reported outcome measures (PROMs), radiological evidence of fixation, and the incidence of mechanical failure.

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Instability continues to be a troublesome complication after total hip arthroplasty (THA). Patient-related risk factors associated with a higher dislocation risk include the preoperative diagnosis, an age of 75 years or older, high body mass index (BMI), a history of alcohol abuse, and neurodegenerative diseases. The goal of this study was to assess the dislocation rate, radiographic outcomes, and complications of patients stratified as high-risk for dislocation who received a dual mobility (DM) bearing in a primary THA at a minimum follow-up of two years.

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Our aim was to report survivorship data and lessons learned with the Corail/Pinnacle cementless total hip arthroplasty (THA) system.

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To report our experience with trunnion corrosion following metal-on-polyethylene total hip arthroplasty, in particular to report the spectrum of presentation and determine the mean time to presentation.

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.

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To present a surgically relevant update of trunnionosis.

The long term biological effects of wear products following total hip arthroplasty (THA) are unclear. However, the indications for THA are expanding, with increasingly younger patients undergoing the procedure.

This prospective, randomised study compared two groups of patients undergoing THA after being randomised to receive one of two different bearing surfaces: metal-on-polyethylene (MoP) n = 22 and metal-on-metal (MoM) n = 23. We investigated the relationship between three variables: bearing surface (MoP vs MoM), whole blood levels of chromium (Cr) and cobalt (Co) and chromosomal aberrations in peripheral lymphocyte pre-operatively and at one, two and five years post-surgery.

Our results demonstrated significantly higher mean cobalt and chromium (Co and Cr) blood levels in the MoM group at all follow-up points following surgery (p < 0.01), but there were no significant differences in the chromosomal aberration indices between MoM and MoP at two or five years (two years: p = 0.56, p = 0.08, p = 0.91, p = 0.51 and five years: p = 0.086, p = 0.73, p = 0.06, p = 0.34) for translocations, breaks, loss and gain of chromosomes respectively. Regression analysis showed a strong linear relationship between Cr levels and the total chromosomal aberration indices in the MoM group (R² = 0.90016), but this was not as strong for Co (R² = 0.68991). In the MoP group, the analysis revealed a poor relationship between Cr levels and the total chromosomal aberration indices (R² = 0.23908) but a slightly stronger relationship for Co (R² = 0.64292). Across both groups, Spearman’s correlation detected no overall association between Co and Cr levels and each of the studied chromosomal aberrations. There remains no clear indication which THA bearing couple is the most biocompatible, especially in young active patients. While THA continues to be very successful at alleviating pain and restoring function, the long-term biological implications of the procedure still require further scrutiny.

Cite this article: Bone Joint J 2015;97-B:1183–91.

We compared the rate of revision for instability after total hip replacement (THR) when lipped and non-lipped acetabular liners were used. We hypothesised that the use of a lipped liner in a modular uncemented acetabular component reduces the risk of revision for instability after primary THR. Using data from the New Zealand Joint Registry, we found that the use of a lipped liner was associated with a significantly decreased rate of revision for instability and for all other indications. Adjusting for the size of the femoral head, the surgical approach and the age and gender of the patient, this difference remained strongly significant (p < 0.001).

We conclude that evidence from the New Zealand registry suggests that the use of lipped liners with modular uncemented acetabular components is associated with a decreased rate of revision for instability after primary THR.

Cite this article: Bone Joint J 2014;96-B:884–8.

Several radiological methods of measuring anteversion of the acetabular component after total hip replacement (THR) have been described. These studies used different definitions and reference planes to compare methods, allowing for misinterpretation of the results. We compared the reliability and accuracy of five current methods using plain radiographs (those of Lewinnek, Widmer, Liaw, Pradhan, and Woo and Morrey) with CT measurements, using the same definition and reference plane. We retrospectively studied the plain radiographs and CT scans in 84 hips of 84 patients who underwent primary THR. Intra- and inter-observer reliability were high for the measurement of inclination and anteversion with all methods on plain radiographs and CT scans. The measurements of inclination on plain radiographs were similar to the measurements using CT (p = 0.043). The mean difference between CT measurements was 0.6° (-5.9° to 6.8°).

Measurements using Widmer’s method were the most similar to those using CT (p = 0.088), with a mean difference between CT measurements of -0.9° (-10.4° to 9.1°), whereas the other four methods differed significantly from those using CT (p < 0.001).

This study has shown that Widmer’s method is the best for evaluating the anteversion of the acetabular component on plain radiographs.

Cite this article: Bone Joint J 2014; 96-B:597–603.

In a randomised study, 28 patients with a mean age of 62.2 years (32 to 81) with osteoarthritis or avascular necrosis of the hip received either a ceramic-on-ceramic or a metal-on-metal total hip replacement. Apart from the liners the acetabular and femoral components were made of Ti-Al-Nb alloy. The serum aluminium and cobalt levels were measured before, and at one year after surgery.

The 15 patients in the ceramic-on-ceramic group had a median pre-operative aluminium level of 1.3 μg/l (0.25 to 8.4) and a cobalt level below the detection limit. At one year the aluminium level was 1.1 μg/l (0.25 to 2.3) and the cobalt level was 0.4 μg/l (0.15 to 0.7). The 13 patients in the metal-on-metal group had a median pre-operative aluminium level of 1.9 μg/l (0.25 to 4.4) and a cobalt level below the detection limit. At one year the median aluminium level was 0.9 μg/l (0.25 to 3.9) whereas the cobalt level was 1.4 μg/l (0.5 to 10.5). This increase in the cobalt level at one year was significant (p < 0.001).

Our findings indicate that ceramic-on-ceramic bearings do not cause elevated levels of serum aluminium in the first post-operative year.

Total hip replacement for developmental hip dysplasia is challenging. The anatomical deformities on the acetabular and femoral sides are difficult to predict. The Crowe classification is usually used to describe these cases – however, it is not a very helpful tool for pre-operative planning. Small acetabular components, acetabular augments, and modular femoral components should be available for all cases. Regardless of the Crowe classification, the surgeon must be prepared to perform a femoral osteotomy for shortening, or to correct rotation, and/or angulation.

Cite this article: Bone Joint J 2013;95-B, Supple A:31–6.

The debate whether to use cemented or uncemented components in primary total hip replacement (THR) has not yet been considered with reference to the cost implications to the National Health Service.

We obtained the number of cemented and uncemented components implanted in 2009 from the National Joint Registry for England and Wales. The cost of each component was established. The initial financial saving if all were cemented was then calculated. Subsequently the five-year rates of revision for each type of component were reviewed and the predicted number of revisions at five years for the actual components used was compared with the predicted number of revisions for a cemented THR. This was then multiplied by the mean cost of revision surgery to provide an indication of the savings over the first five years if all primary THRs were cemented.

The saving at primary THR was calculated to be £10 million with an additional saving during the first five years of between £5 million and £8.5 million. The use of cemented components in routine primary THR in the NHS as a whole can be justified on a financial level but we recognise individual patient factors must be considered when deciding which components to use.

A variety of radiological methods of measuring version of the acetabular component after total hip replacement (THR) have been described. The aim of this study was to evaluate the reliability and validity of six methods (those of Lewinnek; Widmer; Hassan et al; Ackland, Bourne and Uhthoff; Liaw et al; and Woo and Morrey) that are currently in use. In 36 consecutive patients who underwent THR, version of the acetabular component was measured by three independent examiners on plain radiographs using these six methods and compared with measurements using CT scans. The intra- and interobserver reliabilities of each measurement were estimated. All measurements on both radiographs and CT scans had excellent intra- and interobserver reliability and the results from each of the six methods correlated well with the CT measurements. However, measurements made using the methods of Widmer and of Ackland, Bourne and Uhthoff were significantly different from the CT measurements (both p < 0.001), whereas measurements made using the remaining four methods were similar to the CT measurements. With regard to reliability and convergent validity, we recommend the use of the methods described by Lewinnek, Hassan et al, Liaw et al and Woo and Morrey for measurement of version of the acetabular component.

This multicentre study analysed 12 alumina ceramic-on-ceramic components retrieved from squeaking total hip replacements after a mean of 23 months in situ (11 to 61). The rates and patterns of wear seen in these squeaking hips were compared with those seen in matched controls using retrieval data from 33 ‘silent’ hip replacements with similar ceramic bearings. All 12 bearings showed evidence characteristic of edge-loading wear. The median rate of volumetric wear was 3.4 mm³/year for the acetabular component, 2.9 mm³/year on the femoral heads and 6.3 mm³/year for head and insert combined. This was up to 45 times greater than that of previously reported silent ceramic-on-ceramic retrievals. The rate of wear seen in ceramic components revised for squeaking hips appears to be much greater than in that seen in retrievals from ‘silent’ hips.