Fracture of a Cross-Linked Polyethylene Liner: A Multifactorial Issue

doi:10.1016/j.arth.2010.07.009

The Journal of Arthroplasty

Volume 26, Issue 4, June 2011, Pages 666.e5-666.e8

https://doi.org/10.1016/j.arth.2010.07.009 Get rights and content

Abstract

A limited number of reports have detailed the cause of fracture of a highly cross-linked polyethylene liner. Typically, the fractures have occurred in a region of thin and/or unsupported polyethylene, in association with superiorly directed edge loading conditions secondary to an excessively inclinated acetabular component. This case report details an unusual fracture mechanism of a 5-mrad cross-linked liner caused by horizontal loading conditions. The report details several factors that were felt to be etiologic including the specific liner locking mechanism. The treatment options are discussed.

Section snippets

Case Report

A 71-year-old man with a body mass index of 43.2 (height, 68 in; weight, 284 lb) underwent bilateral hip hemiarthroplasties performed for osteoarthritis, on the right in 1984 and on the left in 1986. In 2001, he was referred and diagnosed with bilateral superior hemiarthroplasty migration (right Paprosky IIIA, left IIA/IIIA), with osseointegrated cementless femoral components. The patient underwent bilateral conversions to total hip arthroplasties performed at separate surgeries (right

Analysis of the Retrieved Liner

The fracture in the polyethylene followed a curved path between 2 notches on the external surface of the liner (Fig. 3). These notches were intended to provide access for placement of either push pins or screws into the acetabular shell to prevent rotation of the liner. The portion of the fragment that had been part of the face of the liner (Fig. 3, center left) was plastically deformed and polished; and the inner surface of the fragment also was polished, consistent with repetitive anterior

Discussion

The clinical performance to date of most 5-Mrad remelted polyethylene acetabular components has indicated that these design parameters represented an appropriate balance between the requirements of reducing wear and preserving strength. For example, in the 5-year minimum clinical follow-up by Leung and colleagues [6], the wear rate of 5-Mrad remelted polyethylene averaged about 95% lower than that of non–cross-linked polyethylene (ie, gas-plasma sterilized). Similarly, Bitsch and colleagues [17]

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Cited by (44)

Excellent 20-Year Results of Total Hip Arthroplasty With Highly Cross-Linked Polyethylene on Cobalt-Chromium Femoral Heads in Patients ≤50 Years
2024, Journal of Arthroplasty
Highly cross-linked polyethylene (HXLPE) acetabular bearing surfaces have appeared to offer excellent wear resistance, low incidence of wear-related osteolysis, and high implant survivorship at 10-year to 15-year follow-up. However, concerns over potential performance deterioration at longer-term follow-up remain — particularly in younger patients — and outcome data into the third decade have not been available.
We retrospectively assessed 62 patients (68 hips) who underwent primary total hip arthroplasty (THA) at age ≤50 years with a single manufacturer’s cementless components, remelted HXLPE liner, and small diameter (26 and 28 millimeter) cobalt-chromium (CoCr) femoral heads at minimum 18-year follow-up. We assessed clinical outcomes (modified Harris Hip score, University of California Los Angeles Activity Score, polyethylene wear rates, radiographic findings (osteolysis, component loosening), and implant survivorship.
At 20.6-year mean follow-up (range, 18 to 23 years) modified Harris Hip scores for surviving hips remained an average of 41 points above preoperative baseline (49 versus 90, P < .001) and UCLA scores 2.8 points above baseline (3.7 versus 6.4, P < .001). Wear analysis revealed a population linear wear rate of 0.0142 mm/y (standard deviation (SD), 0.0471) and volumetric wear rate of 10.14 mm³/y (SD, 23.41). Acetabular lysis was noted in 2 asymptomatic hips at 16.6 and 18.4 years. No components were radiographically loose. Survivorship free from wear-related revision was 100% at 20 years (97% free from any revision).
The HXLPE-CoCr bearing couple with small femoral heads continues to be extremely effective 20 years after primary THA in the younger patient population.
Instability After Primary Total Hip Arthroplasty: Dual Mobility Versus Jumbo Femoral Heads
2022, Journal of Arthroplasty
The use of dual mobility (DM) articulations has grown substantially over the last decade to help minimize dislocation risk. The purpose of this study is to compare the results of DM articulations to jumbo femoral heads of equivalent sizes as they relate to postoperative dislocation.
This is a retrospective cohort study of primary total hip arthroplasties (THAs) performed at a single institution between 2005 and 2018. DM articulations and large-diameter metal-on-metal femoral heads were included. Patients were followed with Harris Hip Scores and standard radiographs. Complications were prospectively recorded. Statistical analyses included chi-squared and Brown-Forsythe tests.
In total, 1,288 Magnum femoral head THAs and 365 Active Articulation DM THAs were included for analysis. The same monoblock cup was implanted via a posterior approach in all cases. Age, gender, body mass index, and diagnosis were similar between groups. Average follow-up in the DM group was 49 months, and 126 months in the jumbo head group. The average head sizes in the DM and jumbo head groups were 50 mm. There were no dislocations in the DM hips and only 2 (0.2%) in the jumbo femoral head group. Both groups had significant improvements in Harris Hip Score from their preoperative baseline.
Our study found similarly low dislocation rates in DM and jumbo femoral heads in primary THA. No evidence currently exists showing a benefit of the DM articulation beyond that of the large effective head size, and we recommend making every attempt at maximizing head size prior to using DM articulations.
Pairing 40-mm Femoral Heads With the Smallest Compatible Acetabular Components in Total Hip Arthroplasty: Mid-Term Outcomes in 177 Cases
2022, Journal of Arthroplasty
Citation Excerpt :
In this series of 177 primary THAs with 40-mm femoral heads and acetabular components ≤56 mm with HXLPE, there were no liner failures, cumulative incidence of dislocation was modest, and cumulative incidences of any revision or any reoperation were low at mid-term follow-up. Liner fracture or dissociation is a rare occurrence but theoretically at greatest risk in implant combinations utilizing the thinnest acetabular liners [7–9]. Despite acetabular liner rim thickness as thin as 3 mm in some implant systems included in this study, there were no instances of mechanical liner failures including fracture or dissociation.
Contemporary total hip arthroplasty (THA) often employs larger femoral heads to optimize hip stability. However, pairing 40-mm femoral heads with the smallest compatible acetabular components poses a potential risk for implant failure. The purpose of this study is to evaluate the outcomes of primary THAs using 40-mm femoral heads and the smallest compatible acetabular components.
Between 2007 and 2018, 177 primary THAs involving 40-mm femoral heads and acetabular components ≤56 mm with highly cross-linked polyethylene liners were identified. Mean age was 61 years, 56% were females, and mean body mass index was 32 kg/m². Cumulative incidences of dislocation, any revision, and any reoperation were determined utilizing a competing risk model. Osteolysis and femoral head penetration were assessed at minimum 8-year follow-up (n = 16). Mean follow-up was 6 years.
There were no cases of liner fractures or dissociations. The 10-year cumulative incidences of dislocation, any revision, and any reoperation were 3.6%, 4.2%, and 6.8%, respectively. Mean linear femoral head penetration was 0.01 mm/y and mean volumetric wear rate was 50 mm³/y. One THA demonstrated stable, asymptomatic periacetabular radiolucent lines at most recent follow-up.
In 177 primary THAs pairing 40-mm femoral heads with the smallest compatible acetabular components, there were no liner fractures or dissociations. The cumulative incidence of dislocation was modest at 10 years. The cumulative incidences of any revision and any reoperation were low at mid-term.
IV.
Survivorship and Clinical Outcomes of Constrained Acetabular Liners in Primary and Revision Total Hip Arthroplasty: A Systematic Review
2021, Journal of Arthroplasty
Citation Excerpt :
Despite that, a significant reduction in dislocation rate after revision THA was noted with large diameter femoral heads (36 mm or 40 mm) compared with smaller ones (32 mm), 1.1% and 8.7% respectively [63]. However, large diameter femoral heads have raised multiple concerns regarding potential downsides including increased volumetric wear, increased stress within a thinner polyethylene liner and at the trunnion-head junction leading to potential mechanical failure, local tissue reactions related to fretting corrosion when large metal heads are used, and potential impingement with the iliopsoas tendon [64–69]. CALs are currently used in multiple settings, and the most common indications are recurrent dislocation, inadequate soft tissue envelop with abductor mechanism deficiency, and neuromuscular disorders.
Several studies have evaluated the survivorship and clinical outcomes of constrained acetabular liners (CALs) in complex primary and revision total hip arthroplasty with hip instability; however, there remains no consensus on the overall performance of this constrained implant. We therefore performed a systematic review of the literature to examine survivorship and complication rate of CAL usage.
A systematic review of the literature in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed. A comprehensive search of PubMed, MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews was conducted for English articles using various combinations of keywords.
In all, 37 articles met the inclusion criteria. A total of 4152 CALs were implanted. The all-cause reoperation-free survivorship was 79.9%. The overall complication rate was 22.2%. Dislocation was the most common complications observed and the most frequent reason for reoperation with an incidence of 9.4% and 9.2%, respectively. Infection after CAL placement had an incidence of 4.6%. The reoperation rate for aseptic acetabular component loosening was 2.9%. Overall, patients had improved outcomes as documented by postoperative hip scores.
CALs usage have a relatively high complication rate, particularly when compared with current bearing alternatives (dual mobility cups and large diameter femoral heads), however, it remains a valuable salvage procedure in complex patients affected by recurrent dislocation and implant instability. Newer designs have shown reduced impingement and higher survivorship free from dislocation. However, CALs should only be used when the reasons of instability have been correctly recognized and optimized.
The Lawrence D. Dorr Surgical Techniques & Technologies Award: Using Big Heads and Small Acetabular Components With Highly Cross-Linked Polyethylene in Total Hip Arthroplasty: Is It Safe?
2021, Journal of Arthroplasty
Contemporary total hip arthroplasty (THA) employs larger femoral heads to optimize hip stability. However, the combination of large femoral heads and comparatively small acetabular components poses a potential risk for implant failure secondary to polyethylene (PE) liner fracture or dissociation. The purpose of this study was to evaluate the incidence of liner fracture or dissociation, implant survivorship, and PE wear rates in primary THAs using large femoral heads and small acetabular components.
Between 2000 and 2017, we retrospectively identified 882 primary THAs with 36 mm femoral heads and acetabular components ≤52 mm with highly cross-linked polyethylene liners. Mean age was 66 years, 88% were females, and mean body mass index was 30 kg/m². We evaluated the cumulative incidences of dislocation, any revision, and any reoperation utilizing a competing risk model. Osteolysis and femoral head penetration were assessed with a validated radiographic technique at minimum 10-year follow-up (n = 18). Mean follow-up was 4 years.
There were no liner fractures or dissociations in the entire cohort. The 10-year cumulative incidences of dislocation, any revision, and any reoperation were 3.2%, 5.6%, and 9.3%, respectively. Mean linear femoral head penetration was 0.042 mm/y and mean volumetric wear rate was 44 mm³/y. No THAs demonstrated evidence of osteolysis or component loosening at long-term follow-up.
In a large cohort of primary THAs pairing large femoral heads with small acetabular components, there was no evidence of liner fracture or dissociation. Cumulative incidences of dislocation, any revision, and any reoperation were low at mid-term.
IV.
Modern Dual-Mobility Cups in Revision Total Hip Arthroplasty: A Systematic Review and Meta-Analysis
2018, Journal of Arthroplasty
The purpose of this systematic review is to analyze the outcomes of dual-mobility (DM) cups in revision total hip arthroplasty (THA). Specifically, we evaluated the following: (1) all-cause and aseptic survivorship rates; (2) dislocation rates; (3) complications; and (4) clinical outcomes reported using validated health status measures.
A comprehensive literature search included studies that reported the following: (1) re-revision rates, (2) complications, and (3) clinical outcomes following DM use in revision THA. The following exclusion criteria were used: (1) studies that did not stratify their analysis between primary and revision THA, (2) studies that utilized off-label techniques, (3) review articles, (4) case studies, (5) basic science articles, (6) non–English language reports, and (6) reports on patients who underwent surgery before 2010, in order to reflect modern DM implants use and technology. A total of 9 studies were included in our final analysis.
Aseptic and all-cause survivorship rates were 97.7% and 94.5%. Prevalence of dislocation was 2.2%, and 0.3% for intraprosthetic dislocation. Meta-analysis comparing DM to fixed-bearing prostheses demonstrated a significantly lower odds of dislocation in the DM cohort (odds ratio 0.24, P = .002). Complications occurred in 7.4% of revision THAs with DM cups, while infection rates totaled to 3.3% of cases. Studies comparing outcomes using Harris Hip Scores did not demonstrate a statistically significant difference in improved postoperative scores (P > .05).
DM cups have demonstrated excellent survivorship, low dislocation, and overall complication rates. Therefore, it can be considered a safe and effective option, particularly in the high-risk patients who undergo revision THA.

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: No benefits or funds were received in support of the study.

: Investigation performed at the Sutter Medical Center, Sacramento, CA, and the J Vernon Luck Sr, MD, Orthopaedic Research Center, Los Angeles, CA.

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Case ReportFracture of a Cross-Linked Polyethylene Liner: A Multifactorial Issue

Abstract

Section snippets

Case Report

Analysis of the Retrieved Liner

Discussion

Biomaterials

J Orthop Res

J Arthroplasty

J Arthroplasty

Biomaterials

The pathology of failed total joint arthroplasty

Clin Orthop Relat Res

Periprosthetic bone loss in total hip arthroplasty. Polyethylene wear debris and the concept of the effective joint space

J Bone Joint Surg Am

Development of an extremely wear-resistant ultra high molecular weight polyethylene for total hip replacements

J Orthop Res

Case Report
Fracture of a Cross-Linked Polyethylene Liner: A Multifactorial Issue