Aims

Dual-mobility (DM) components are increasingly used to prevent and treat dislocation after total hip arthroplasty (THA). Intraprosthetic dissociation (IPD) is a rare complication of DM that is believed to have decreased with contemporary implants. This study aimed to report incidence, treatment, and outcomes of contemporary DM IPD.

Aims. Radiostereometric analysis (RSA) is the most accurate radiological method to measure in vivo wear of highly cross-linked polyethylene (XLPE) acetabular components. We have previously reported very low wear rates for a sequentially irradiated and annealed X3 XLPE liner (Stryker Orthopaedics, USA) when used in conjunction with a 32 mm femoral heads at ten-year follow-up. Only two studies have reported the long-term wear rate of X3 liners used in conjunction with larger heads using plain radiographs which have poor sensitivity. The aim of this study was to measure the ten-year wear of thin X3 XLPE liners against larger 36 or 40 mm articulations with RSA. Methods. We prospectively reviewed 19 patients who underwent primary cementless THA with the XLPE acetabular liner (X3) and a 36 or 40 mm femoral head with a resultant liner thickness of at least 5.8 mm. RSA radiographs at one week, six months, and one, two, five, and ten years postoperatively and femoral head penetration within the acetabular component were measured with UmRSA software. Of the initial 19 patients, 12 were available at the ten-year time point. Results. The median proximal, 2D, and 3D wear rates calculated between one and ten years were all less than 0.005 mm/year, with no patient recording a proximal wear rate of more than 0.021 mm/year. Importantly, there was no increase in the wear rate between five and ten years. Conclusion. The very low wear rate of X3 XLPE liners with larger articulations remains encouraging for the future clinical performance of this material. Cite this article: Bone Jt Open 2023;4(11):839–845

Aims

Proximal femoral endoprosthetic replacements (PFEPRs) are the most common reconstruction option for osseous defects following primary and metastatic tumour resection. This study aimed to compare the rate of implant failure between PFEPRs with monopolar and bipolar hemiarthroplasties and acetabular arthroplasties, and determine the optimum articulation for revision PFEPRs.

Aims

Uncemented metal acetabular components show good osseointegration, but material stiffness causes stress shielding and retroacetabular bone loss. Cemented monoblock polyethylene components load more physiologically; however, the cement bone interface can suffer fibrous encapsulation and loosening. It was hypothesized that an uncemented titanium-sintered monoblock polyethylene component may offer the optimum combination of osseointegration and anatomical loading.

Abstract. Objectives. Hip instability following total hip arthroplasty in treatment of intracapsular neck of femur fractures is reported at 8–11%. Utilising the principle of a small articulation to minimize the problems of wear coupled with a large articulation, dual-mobility total hip arthroplasty prostheses stabilise the hip further than conventional fixed-bearing designs. The aim of this study is to compare the rate of dislocation and complication between standard fixed-bearing and dual-mobility prostheses for the treatment of intracapsular neck of femur fractures. Methods. A four-year retrospective review in a large district general hospital was completed. All cases of intracapsular neck of femur fractures treated with total hip arthroplasty were identified through the theatre logbooks. Patient's operative and clinical notes were retrospectively reviewed to collect data. Results. A total of 91 patients underwent total hip arthroplasty for intracapsular neck of femur fracture in the four-year period. 61.5% were dual-mobility design versus 28.5% had fixed-bearing implants. There were no statistical differences between patient group characteristics. Choice of implant was dependent on surgeon preference. There was a 0.0% dislocation rate in the dual-mobility group versus 8.6% in the fixed-bearing prosthesis group. All dislocations occurred in patients who underwent total hip arthroplasty with 36.0mm fixed-bearing prosthesis via posterior surgical approach. There was no statistical difference in mortality between both groups. Conclusion. There was an increasing trend of towards the use of dual-mobility prosthesis for fractured neck of femur within this department with excellent outcomes. Dual-mobility designs provide reduced dislocation rates in total hip arthroplasty in intracapsular neck of femur fractures compared to standard fixed-bearing designs at this institution. The authors recommend that all orthopaedic staff consider the use of dual-mobility prostheses in suitable patients and ensure trainees are suitably trained in use of dual-mobility designs. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Aims. Dislocation is the most common indication for further surgery following total hip arthroplasty (THA) when undertaken in patients with a femoral neck fracture. This study aimed to assess the complication rates of THA with dual mobility components (THA-DMC) following a femoral neck fracture and to compare outcomes between THA-DMC, conventional THA, and hemiarthroplasty (HA). Methods. We performed a systematic review of all English language articles on THA-DMC published between 2010 and 2019 in the MEDLINE, EMBASE, and Cochrane databases. After the application of rigorous inclusion and exclusion criteria, 23 studies dealing with patients who underwent treatment for a femoral neck fracture using THA-DMC were analyzed for the rate of dislocation. Secondary outcomes included reoperation, periprosthetic fracture, infection, mortality, and functional outcome. The review included 7,189 patients with a mean age of 77.8 years (66.4 to 87.6) and a mean follow-up of 30.9 months (9.0 to 68.0). Results. THA-DMC was associated with a significantly lower dislocation rate compared with both THA (OR 0.26; 95% CI 0.08 to 0.79) and HA (odds ratio (OR) 0.27; 95% confidence interval (CI) 0.15 to 0.50). The rate of large articulations and of intraprosthetic dislocation was 1.5% (n = 105) and 0.04% (n = 3) respectively. Conclusion. THA-DMC when used in patients with a femoral neck fracture is associated with a lower dislocation rate compared with conventional arthroplasty options. There was no increase in the rates of other complication when THA-DMC was used. Future cost analysis and prospective, comparative studies are required to assess the potential benefit of using THA-DMC in these patients. Cite this article: Bone Joint J 2020;102-B(7):811–821

Aims

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.

Aims

The purpose of this study was to compare two different types of metal-on-metal (MoM) bearing for total hip arthroplasty (THA): one with a large femoral head (38 mm to 52 mm) and the other with a conventional femoral head (28 mm or 32 mm). We compared clinical outcome, blood metal ion levels, and the incidence of pseudotumour in the two groups.

The selection of an acetabular component for primary hip arthroplasty has narrowed significantly over the past 10 years. Although monoblock components demonstrated excellent long-term success the difficulty with insertion and failure to fully appreciate full coaptation of contact with the acetabular floor has led to almost complete elimination of its utilization. Modular acetabular components usually with titanium shells and highly crosslinked polyethylene are by far the most utilised today. This is particularly true with mid-term results demonstrating excellent wear rates and extremely low failure rates and the concern of possible mechanical failure of highly crosslinked polyethylene not being a clinical problem. Ceramic liners are also used but problems with squeaking articulations and liner chipping have made highly crosslinked polyethylene the preferred liner material. Metal-on-metal except in surface replacement arthroplasty is rarely used in primary hip arthroplasty. With instability in total hip replacement still being a significant and the leading cause of revision hip replacement the dual mobility articulation has emerged as an increasingly used acetabular component. This is composed of either a monoblock cobalt chrome socket articulating with a large polyethylene liner into which the femoral head is constrained. The polyethylene liner becomes essentially a larger femoral head articulation and hip stability is significantly improved. A modular dual mobility can also be utilised with a titanium shell and a cobalt chrome liner inserted into the shell and then a dual mobility articulation. In a recent series of 182 dual mobility cups, all monoblock ADM, in high risk patients undergoing primary total hip replacement there was 1 interprosthetic dislocation which occurred during reduction of a dislocation. Average follow up was 4.4 years with a range of 2–6.6 years

Aims. The increased in vivo resistance to wear of highly crosslinked polyethylene (HXLPE) in total hip arthroplasty (THA) has led to an increased use of larger articulations which have been shown to reduce the incidence of early dislocation. To date, there are few reports of the wear of larger articulations using second generation HXLPE liners. Our prospective cohort study measured the bedding-in and early wear of large (36 mm and 40 mm diameter) articulations involving a second generation X3 HXLPE liner and compared our findings with previous clinical and in vitro studies of the same material. Patients and Methods. The proximal penetration of the femoral head five years post-operatively was measured for 15 patients using radiostereometric analysis (RSA). Results. The median proximal bedding-in within the first post-operative year was 0.022 mm (interquartile range (IQR) -0.050 to 0.091). The median proximal rate of wear between one and five years was -0.004 mm/year (IQR -0.021 to 0.022). The rates of proximal, medial, 2D or 3D wear between one and five years post-operatively of the X3 HXLPE liner did not increase with larger articulations compared with our previous study of 32 mm articulations. Conclusion. Although reassuring, the use of larger articulations requires continued monitoring to determine whether the low wear observed in the short-term continues to the mid- to long-term. Cite this article: Bone Joint J 2016;98-B:1604–10

Aims

Long-term clinical outcomes for ceramic-on-ceramic (CoC) bearings are encouraging. However, there is a risk of squeaking. Guidelines for the orientation of the acetabular component are defined from static imaging, but the position of the pelvis and thus the acetabular component during activities associated with edge-loading are likely to be very different from those measured when the patient is supine. We assessed the functional orientation of the acetabular component.

Large femoral heads have become popular in total hip replacement (THR) as a method of reducing the risk of dislocation. However, if large heads are used in ceramic-on-ceramic THR, the liner must be thinner, which may increase the risk of fracture. To compare the rates of ceramic fracture and dislocation between 28 mm and 32 mm ceramic heads, 120 hips in 109 patients (51 men and 58 women, mean age 49.2 years) were randomised to THR with either a 28 mm or a 32 mm ceramic articulation. A total of 57/60 hips assigned to the 28 mm group and 55/60 hips assigned to the 32 mm group were followed for at least five years. No ceramic component fractures occured in any patient in either group. There was one dislocation in the 32 mm group and none in the 28 mm group (p = 0.464). No hip had detectable wear, focal osteolysis or prosthetic loosening. In our small study the 32 mm ceramic articulation appeared to be safe in terms of ceramic liner fracture.

Cite this article: Bone Joint J 2014;96-B:1459–63.

Background:. Dual mobility components in total hip arthroplasty have been successfully in use in Europe for greater than 25 years. However, these implants have only recently obtained FDA approval and acceptance among North American arthroplasty surgeons. Both decreased dislocation rate and decreased wear rates have been proposed benefits of dual mobility components. These components have been used for primary total hip arthroplasty in patients at high risk for dislocation, total hip arthroplasty in the setting of femoral neck fracture, revision for hip instability, and revision for large metal-on-metal (MoM) hip articulation. The literature for the North American experience is lacking. Purpose:. We report indications, short term outcomes, and complications of a series of subjects who received dual mobility outcomes at one institution. Study Design:. Consecutive subjects who received dual mobility total hip arthroplasty components from February 2010 and April 2013 were identified. Charts were retrospectively reviewed for surgical indications, comorbidities, component sizes, and perioperative complications including infection, dislocation, mechanical failure, and reoperation. Results:. 86 hips in 83 subjects underwent total hip arthroplasty or revision total hip arthroplasty using dual mobility components. There were 56 primary total hips and 30 revision total hips. Indications included small acetabular components in the setting of AVN (13 hips), DDH (12 hips) or severe inflammatory arthritis (5 hips), femoral neck fracture (5 hips), intraoperative instability (6 hips), recurrent postoperative instability (5 hips), and revision of large MoM articulations in the setting of failed hip resurfacing (10 hips) or failed MoM total hip arthroplasty (6 hips). Mean follow up was 1 year (3 months to 3.3 years). There were no complications in the primary total hip group. In the revision total hip group, only one hip dislocated and this was in a patient with familial dysautonomia and insensitivity to pain. One subject underwent reoperation for acute prosthetic joint infection. No other complications were encountered. Overall dislocation rate was 1.1% and overall complication rate was 2.2%. Conclusions:. These results closely mirror that of the European literature. Dual mobility articulations in total hip arthroplasty have a low short term complication rate in this cohort and provide a simple solution to difficult cases. Indications for these implants include primary and revision total hip arthroplasty in patients at high risk for instability and revision of large MoM implants including hip resurfacing

Purpose. Total disc replacement (TDR) devices have been restricted to designs with large, congruent articulations due to the limited wear properties of available materials. TDRs with more natural motion could be designed if materials were available which could resist the higher wear conditions. A novel TriLobe TDR design is self-centering and energetically stable, emulating the natural motion of the intact motion segment, but is not feasible using traditional materials due to small incongruent articulating surfaces. The objective of this study was to compare the wear properties of a medical grade polycrystalline diamond with wear properties of cobalt chrome (CoCr) and ultrahigh molecular weight polyethylene (UHMWPE) in aggressive high wear conditions. Methods. A modified pin-on-disc, crossing-path wear test was used to measure the wear rates of PCD-on-PCD, CoCr-on-CoCr, and CoCr-on-UHMWPE. The discs were placed in the inferior position on an oscillating plate, moving in a 10mm by 5mm figure-eight pattern. Pins had an initial 11.5mm radius and were loaded at 133N normal to the disc. In a typical pin-on-disc test, a wear flat develops on the pin and the wear rate is reduced as the contact area increases. The TriLobe design uses three lobes sliding in three non-conforming lenses which prevents wear flats from developing. To approximate this condition, the fixture holding the disc was placed on an air bearing and was allowed to rock in concert with movement of the load. The test was conducted in 25% bovine serum at a speed of less than two Hertz. Two sets of each material were tested, one set to 2.0 million cycles and the other set to 14.0 million cycles. Wear rates on the rocking-discs were measured using a high resolution coordinate measuring machine because the wear in the PCD specimens was not detectable gravimetrically. Results. The diamond specimen averaged 0.0036mm. 3. /MC of wear over the first 2 million cycles. The CoCr-on-CoCr specimens averaged 1.4mm. 3. /MC and the CoCr-on-UHMWPE averaged 4.7mm. 3. /MC over 2 million cycles. The PCD specimen taken to 14 million cycles had and average wear of 0.0022mm. 3. /MC compared to 2.4mm. 3. /MC and 9.5mm. 3. /MC for CoCr-on-CoCr and CoCr-on-UHMWPE respectively. Conclusions. Using the pin-on-rocking-disc test to approximate small, non-congruent articulating surface wear, both CoCr-on-CoCr and CoCr-on-UHMWPE wore at rates that were orders of magnitude greater than medical grade PCD. At two million cycles, CoCr-on-CoCr had worn nearly 400 times more than PCD and CoCr-on-UHMWPE wore more than 1300 times greater. During the last 12 million cycles the wear in non-diamond specimen accelerated, while the diamond wear rate decreased. At the end of 14 million cycles CoCr on itself and on UHMWPE specimens had worn at more than 1100 times and nearly 4300 times greater than PCD, respectively. Coupled with the inherent biocompatibility, high strength and toughness, and ultra low friction of diamond, the performance of PCD makes it an attractive material for TDR applications. PCD could be used in current designs to alleviate concern over wear debris and ion release and to increase the space for the next generation of TDR devices

Surface arthroplasty or resurfacing represents a significant development in the evolution of hip replacement. A hip resurfacing arthroplasty (HRA) is a bone conserving alternative to total hip arthroplasty (THA) that restores normal joint biomechanics and load transfer and ensures joint stability. Metal-on-metal (MoM) bearings have been preferred for these large diameter articulations because of their lower volumetric wear and smaller particulate debris compared to metal-on-poly-ethylene bearings. Of the many engineering factors which have contributed to the success of the MoM bearing, the metallurgy, diametral clearance, sphericity and surface finish were thought to be most important. More recently, adverse reactions to metal particles and ions generated by wear and corrosion of the metal surfaces have focused the attention on the importance of coverage angle and cup positioning. Currently, the scientific consensus is that cup coverage angle, diametral clearance and metallurgy have their importance in that order. Precise understanding of manufacturing variables is imperative in obtaining clinical consistency and safety in the patient. It is important to examine femoral fixation, bone remodelling, and wear of MoM implants. For the second and third generation MoM HRA various designs and biomaterials have been used. We have conducted a randomised, controlled trial comparing 9 different hip resurfacing prostheses. Clinical and radiographic outcome and whole blood, serum and urine metal ion levels are evaluated at 6 months, 1 year and 2 years in 180 patients with 9 different HRA designs and the differences are analyzed. Besides, the design quality of the 9 different metal-on-metal prostheses and their accessory instruments have been judged during the operation. The Durom with its Metasul history may claim a metallurgic advantage, and in combination with the highest coverage angle of all cups, it may be the best wear couple, as suggested by low ion measurements. However, as discussed above, an optimal bearing alone is not sufficient to achieve a successful hip resurfacing

We present our experience with a double-mobility acetabular component in 155 consecutive revision total hip replacements in 149 patients undertaken between 2005 and 2009, with particular emphasis on the incidence of further dislocation. The mean age of the patients was 77 years (42 to 89) with 59 males and 90 females. In all, five patients died and seven were lost to follow-up. Indications for revision were aseptic loosening in 113 hips, recurrent instability in 29, peri-prosthetic fracture in 11 and sepsis in two. The mean follow-up was 42 months (18 to 68). Three hips (2%) in three patients dislocated within six weeks of surgery; one of these dislocated again after one year. All three were managed successfully with closed reduction. Two of the three dislocations occurred in patients who had undergone revision for recurrent dislocation. All three were found at revision to have abductor deficiency. There were no dislocations in those revised for either aseptic loosening or sepsis.

These results demonstrate a good mid-term outcome for this component. In the 29 patients revised for instability, only two had a further dislocation, both of which were managed by closed reduction.

Large articulations are increasingly being used to reduce dislocation, the most common early complication following THR. However, potential benefits of large articulations in reducing dislocation have not been proven in a well-controlled clinical trial. The aim of our randomised controlled trial was to compare the one-year incidence of dislocation between 36 and 28 mm metal on highly cross-linked polyethylene articulations. Patients were excluded if they had a high risk of dislocation due to, for example, abnormal anatomy, neuromuscular disease, previous infection or dislocation. Eligible patients were stratified according to a number of other factors which may influence dislocation risk, including primary or revision THR and, if primary THR, by surgeon, age, diagnosis, sex and Charnley grade. Patients were randomised intra- operatively to either a 28 or 36 mm articulation. Dislocation incidence was determined using a hip instability questionnaire and a hospital visit questionnaire. A dislocation was diagnosed if there was radiological evidence and reduction by a doctor was required. Six-hundred-and-forty-four patients undergoing primary or revision THR were entered into the study. Overall, the incidence of dislocation at one year following THR was 5.4% with a 28 mm articulation and 1.3% with a 36 mm articulation (p=.004). Incidence in primary THR patients was 4.4% with a 28 mm articulation, compared to 0.8% with a 36 mm articulation (p=.007). Incidence in revision THR patients was 12.2% and 4.9% with 28 and 36 mm articulations, respectively. For both primary and revision THR patients, sex distribution, age and BMI of patients who dislocated were similar to those of the total samples of primary or revision patients. This large randomised study unequivocally shows for the first time that, compared to a 28 mm articulation, a 36 mm articulation in THR is efficacious in reducing the incidence of dislocation in the first year following THR

We report the findings of an independent review of 230 consecutive Birmingham hip resurfacings (BHRs) in 213 patients (230 hips) at a mean follow-up of 10.4 years (9.6 to 11.7). A total of 11 hips underwent revision; six patients (six hips) died from unrelated causes; and 13 patients (16 hips) were lost to follow-up. The survival rate for the whole cohort was 94.5% (95% confidence interval (CI) 90.1 to 96.9). The survival rate in women was 89.1% (95% CI 79.2 to 94.4) and in men was 97.5% (95% CI 92.4 to 99.2). Women were 1.4 times more likely to suffer failure than men. For each millimetre increase in component size there was a 19% lower chance of a failure. The mean Oxford hip score was 45.0 (median 47.0, 28 to 48); mean University of California, Los Angeles activity score was 7.4 (median 8.0, 3 to 9); mean patient satisfaction score was 1.4 (median 1.0, 0 to 9). A total of eight hips had lysis in the femoral neck and two hips had acetabular lysis. One hip had progressive radiological changes around the peg of the femoral component. There was no evidence of progressive neck narrowing between five and ten years.

Our results confirm that BHR provides good functional outcome and durability for men, at a mean follow-up of ten years. We are now reluctant to undertake hip resurfacing in women with this implant.

Early revision is an important risk factor for repeated revision and poor results after primary total hip replacement and instability is a major cause of early revision. Larger articulations with cross-linked polyethylene are proposed as a solution, but these are not without risk, including fracture of the thin polyethylene rim of the liner. The aim of our study was to examine implant-related revisions among primary total hip replacement patients with up to six year follow-up in a randomized controlled trial which compared 28 mm and 36 mm metal on highly cross-linked polyethylene articulations in total hip replacement. 557 patients undergoing primary total hip replacement were included in this study. Risk factors for dislocation and wear were controlled by stratification and patients were then randomized intra-operatively to either a 28 or 36 mm articulation. To date, 10 hips have been revised for implant-related problems following primary total hip replacement. Seven hips with a 28 mm articulation were revised to a larger articulation because of instability. Four of these were for recurrent dislocation, one for an irreduceable first dislocation and two for subluxation. In contrast, only one patient who had undergone total hip replacement with a 36 mm articulation was revised for recurrent dislocation. One hip with a 36 mm articulation in a well-positioned cup was revised to a 32 mm articulation because of elevated lip liner fracture. Another 36 mm articulation hip was revised for acetabular component loosening. This study shows that a 36 mm metal on highly cross-linked polyethylene articulation reduces the need for early revision for instability after primary total hip replacement. However, these benefits need to be weighed against the potential risks associated with these articulations, including rare fracture of the relatively thin poly-ethylene liner

Large articulations using cross-linked polyethylene and other alternate bearings are increasingly being used to reduce the incidence of dislocation, the most common early complication following total hip replacement. While indirect evidence has suggested the potential benefits of a large articulation in reducing dislocation risk, this has not been proven in a well-controlled clinical trial. The primary objective of our multi-centre international randomized controlled trial was to compare the one-year incidence of dislocation between a 36 mm and 28 mm metal on highly cross-linked polyethylene articulation in primary and revision total hip replacement. 644 patients were entered into the study. Patients were stratified according to a number of factors which may influence dislocation risk, including primary or revision total hip replacement, age, sex, Charnley grade, diagnosis and stem type. Patients were randomized intra-operatively to either a 28 or 36 mm articulation. The 12-month incidence of dislocation was statistically significantly lower in patients undergoing total hip replacement with a 36 mm articulation than in those with a 28 mm articulation (1.3% vs 5.2%, p< .05). A total of 6 dislocations occurred in the 4 patients who dislocated with a 36 mm articulation, compared to a total of 36 dislocations in the 17 patients who dislocated with a 28 mm articulation. When primary and revision THR were examined separately, the 12-month incidence of dislocation was statistically significantly lower in patients undergoing primary total hip replacement with a 36 mm articulation than in those with a 28 mm articulation (0.7% vs 4.2%, p< .05). A total of 4 dislocations occurred in two patients with a 36 mm articulation, compared to a total of 19 dislocations in 12 patients with a 28 mm articulation. The incidence of dislocation after revision total hip replacement with a 36 mm articulation was 4.8%, compared to 11.1% with a 28 mm articulation. This large randomized study unequivocally shows for the first time that, compared to a 28 mm articulation, a 36 mm articulation in total hip replacement is efficacious in reducing the incidence of dislocation in the first year following hip replacement