Recommendation None
Question 3: Has the advent of HCLPE resulted in a decrease in the prevalence of osteolysis
after THA?
Case clarification
The 55 year old women receiving a THA can realistically expect to live another 20–25 years. Over this period of time the THA is more likely to fail due to osteolysis than any other failure mechanism.
C H A P T E R 1 5 Highly Crosslinked Polyethylene in Total Hip Arthroplasty
• Mechanical properties of HCLPE are negatively affected by crosslinking
• Clinical reports of implant failure are rare
Conclusion
The exposure of UHMWPE to radiation creates a material that behaves differently both on the hip simulator and in the patient. In every study there has been a significant reduction in wear and—even more encouraging—there is a reduction in the number and size of osteolytic lesions.
This is not the final story, as the longest follow-up in the best methodological studies is only 6 years. There remains the risk that wear rates could dramatically increase with longer follow-up. Despite the reported liner failures in case series,37,38 there have been no liner-associated complica- tions in any of the studies presented in this chapter. Caution must be exerted when using larger head sizes, as there is one RSA RCT that shows there is no effect after only 2 years.22 At present, there is enough reported evidence to support the continued use of HCLPE in THA patients.
References
1. Canadian Institute for Health Information. Hip and Knee Replacements in Canada—Canadian Joint Replacement Registry 2008–2009 Annual Report. Canadian Institute for Health Information Ottawa, 2009)
2. Dumbleton JH, Manley MT, Edidin AA. A literature review of the association between wear rate and osteolysis in total hip arthroplasty. J Arthroplasty 2002;17(5):649–61.
3. Muratoglu OK, Bragdon CR, O’Connor DO, Jasty M, Harris WH. A novel method of cross-linking ultra-high-molecular- weight polyethylene to improve wear, reduce oxidation, and retain mechanical properties. Recipient of the 1999 HAP Paul Award. J Arthroplasty 2001;16(2):149–60.
4. Bragdon CR, Jasty M, Muratoglu OK, Harris WH. Third-body wear testing of a highly cross-linked acetabular liner: the effect of large femoral head size in the presence of particulate poly(methyl-methacrylate) debris. J Arthroplasty 2005;20(3):
379–85.
5. Laurent MP, Johnson TS, Crowninshield RD, Blanchard CR, Bhambri SK, Yao JQ. Characterization of a highly cross-linked ultrahigh molecular-weight polyethylene in clinical use in total hip arthroplasty. J Arthroplasty 2008;23(5):751–61.
6. Ito H, Maloney CM, Crowninshield RD, Clohisy JC, McDonald DJ, Maloney WJ. In vivo femoral head damage and its effect on polyethylene wear. J Arthroplasty 2009;25(2):302–8.
7. Livermore J, Ilstrup D, Morrey B. Effect of femoral head size on wear of the polyethylene acetabular component. J Bone Joint Surg Am 1990;72(4):518–28.
8. Devane PA, Bourne RB, Rorabeck CH, Hardie RM, Horne JG.
Measurement of polyethylene wear in metal-backed acetabular cups. I. Three-dimensional technique. Clin Orthop Relat Res 1995;319:303–16.
Current opinion
Increasing the crosslinking in UHMWPE does have a measurable effect on mechanical properties; specifically, fatigue properties, crack propagation, and toughness are all decreased.
Finding the evidence
• PubMed (www.ncbi.nlm.nih.gov/pubmed/) clinical queries search/ systematic reviews: “crosslinked” OR
“cross-linked” AND “polyethylene” AND “mechanical properties”
° Found 10 articles
• PubMed (www.ncbi.nlm.nih.gov/pubmed/) -sensitiv- ity search using keywords “crosslinked” OR “cross-linked”
AND “polyethylene” AND “mechanical properties”
° Retrieved 91 articles with 28 potentially relevant
Quality of the evidence
Level III
• 5 retrospective studies Level IV
• 1 case series Level V
• 4 case reports and expert opinion Nonclinical
• 18 basic science
Findings
The creation of HCLPE results in unfavorable changes with ultimate tensile strength, ductility, modulus, toughness, and crack propagation resistance.35,36 Cases of liner failures are reported in the literature, but some of the failures were likely related to implant design.37
Recommendations
• Mechanical properties of HCLPE are negatively affected by crosslinking [overall quality: high]
• Clinical reports of implant failure are rare [overall quality: moderate]
Summary of recommendations
• HCLPE has been demonstrated to decrease wear rates in vitro and in vivo compared to UHMWPE
• The use of larger femoral head components with HCLPE does not appear to increase wear rates in short- term studies
• HCLPE reduces the risk of osteolysis at short-term follow up compared to UHMWPE
23. Glyn-Jones S, Isaac S, Hauptfleisch J, McLardy-Smith P, Murray DW, Gill HS. Does highly cross-linked polyethylene wear less than conventional polyethylene in total hip arthroplasty? A double-blind, randomized, and controlled trial using roentgen stereophotogrammetric analysis. J Arthroplasty 2008;23(3):337–43.
24. Ayers DC, Hays PL, Drew JM, Eskander MS, Osuch D, Bragdon CR. Two-year radiostereometric analysis evaluation of femoral head penetration in a challenging population of young total hip arthroplasty patients. J Arthroplasty 2009;24(6 Suppl):9–14.
25. Rohrl SM, Li MG, Nilsson KG, Nivbrant B. Very low wear of non-remelted highly cross-linked polyethylene cups: an RSA study lasting up to 6 years. Acta Orthop 2007;78(6):739–45.
26. Estok DM, 2nd, Burroughs BR, Muratoglu OK, Harris WH.
Comparison of hip simulator wear of 2 different highly cross- linked ultra high molecular weight polyethylene acetabular components using both 32- and 38-mm femoral heads. J Arthroplasty 2007;22(4):581–9.
27. Lachiewicz PF, Heckman DS, Soileau ES, Mangla J, Martell JM.
Femoral head size and wear of highly cross-linked polyethylene at 5 to 8 years. Clin.Orthop.Relat.Res 2009;467(12):3290–6.
28. Bragdon CR, Kwon YM, Geller JA, Greene ME, Freiberg AA, Harris WH, et al. Minimum 6-year followup of highly cross-linked polyethylene in THA. Clin.Orthop.Relat.Res. 2007;465:122–7.
29. Harris WH. The problem is osteolysis. Clin.Orthop.Relat.Res 1995; 311:46–53.
30. Engh CA, Jr, Stepniewski AS, Ginn SD, Beykirch SE, Sychterz- Terefenko CJ, Hopper RH, Jr, et al. A randomized prospective evaluation of outcomes after total hip arthroplasty using cross- linked marathon and non-cross-linked Enduron polyethylene liners. J.Arthroplasty 2006;21(6 Suppl 2):17–25.
31. Illgen RL,2nd, Forsythe TM, Pike JW, Laurent MP, Blanchard CR.
Highly crosslinked vs. conventional polyethylene particles—an in vitro comparison of biologic activities. J Arthroplasty 2008;23(5):721–31.
32. Illgen RL, 2nd, Bauer LM, Hotujec BT, Kolpin SE, Bakhtiar A, Forsythe TM. Highly crosslinked vs. conventional polyethylene particles: relative in vivo inflammatory response. J Arthroplasty 2009;24(1):117–24.
33. Ries MD, Scott ML, Jani S. Relationship between gravimetric wear and particle generation in hip simulators: conventional compared with cross-linked polyethylene. J Bone Joint Surg Am 2001;83(Suppl 2 Pt 2):116–22.
34. Sethi RK, Neavyn MJ, Rubash HE, Shanbhag AS. Macrophage response to cross-linked and conventional UHMWPE.
Biomaterials 2003;24(15):2561–73.
35. Pruitt LA. Deformation, yielding, fracture and fatigue behavior of conventional and highly cross-linked ultra high molecular weight polyethylene. Biomaterials 2005;26(8):905–15.
36. Bradford L, Baker D, Ries MD, Pruitt LA. Fatigue crack propaga- tion resistance of highly crosslinked polyethylene. Clin Orthop Relat Res 2004; 429:68–72.
37. Tower SS, Currier JH, Currier BH, Lyford KA, Van Citters DW, Mayor MB. Rim cracking of the cross-linked longevity polyeth- ylene acetabular liner after total hip arthroplasty. J Bone Joint Surg Am 2007;89(10):2212–17.
38. Bradford L, Kurland R, Sankaran M, Kim H, Pruitt LA, Ries MD.
Early failure due to osteolysis associated with contemporary highly cross-linked ultra-high molecular weight polyethylene. A case report. J Bone Joint Surg Am 2004;86(5):1051–6.
9. Martell JM, Berdia S. Determination of polyethylene wear in total hip replacements with use of digital radiographs. J Bone Joint Surg Am 1997;79(11):1635–41.
10. Bragdon CR, Estok DM, Malchau H, Karrholm J, Yuan X, Bourne R, et al. Comparison of two digital radiostereometric analysis methods in the determination of femoral head penetration in a total hip replacement phantom. J Orthop Res 2004;22(3):
659–64.
11. Bragdon CR, Malchau H, Yuan X, Perinchief R, Karrholm J, Borlin N, et al. Experimental assessment of precision and accu- racy of radiostereometric analysis for the determination of poly- ethylene wear in a total hip replacement model. J Orthop Res 2002;20(4):688–95.
12. Dorr LD, Wan Z, Shahrdar C, Sirianni L, Boutary M, Yun A.
Clinical performance of a Durasul highly cross-linked polyeth- ylene acetabular liner for total hip arthroplasty at five years. J Bone Joint Surg Am 2005;87(8):1816–21.
13. Manning DW, Chiang PP, Martell JM, Galante JO, Harris WH.
In vivo comparative wear study of traditional and highly cross- linked polyethylene in total hip arthroplasty. J Arthroplasty 2005;20(7):880–6.
14. Digas G, Karrholm J, Thanner J, Herberts P. 5-year experience of highly cross-linked polyethylene in cemented and uncemented sockets: two randomized studies using radiostereometric analy- sis. Acta Orthop 2007;78(6):746–54.
15. Calvert GT, Devane PA, Fielden J, Adams K, Horne JG. A double- blind, prospective, randomized controlled trial comparing highly cross-linked and conventional polyethylene in primary total hip arthroplasty. J Arthroplasty 2009;24(4):505–10.
16. Engh CA, Jr., Stepniewski AS, Ginn SD, Beykirch SE, Sychterz- Terefenko CJ, Hopper RH, Jr., et al. A randomized prospective evaluation of outcomes after total hip arthroplasty using cross- linked marathon and non-cross-linked Enduron polyethylene liners. J Arthroplasty 2006;21(6 Suppl 2):17–25.
17. Garcia-Rey E, Garcia-Cimbrelo E, Cruz-Pardos A, Ortega- Chamarro J. New polyethylenes in total hip replacement: a pro- spective, comparative clinical study of two types of liner. J Bone Joint Surg Br 2008;90(2):149–53.
18. Martell JM, Verner JJ, Incavo SJ. Clinical performance of a highly cross-linked polyethylene at two years in total hip arthroplasty:
a randomized prospective trial. J Arthroplasty 2003;18(7 Suppl 1):55–9.
19. Triclot P, Grosjean G, El Masri F, Courpied JP, Hamadouche M.
A comparison of the penetration rate of two polyethylene acetabular liners of different levels of cross-linking. A prospec- tive randomised trial. J Bone Joint Surg Br 2007;89(11):1439–45.
20. McCalden RW, MacDonald SJ, Rorabeck CH, Bourne RB, Chess DG, Charron KD. Wear rate of highly cross-linked polyethylene in total hip arthroplasty. A randomized controlled trial. J Bone Joint Surg Am 2009;91(4):773–82.
21. Geerdink CH, Grimm B, Ramakrishnan R, Rondhuis J, Verburg AJ, Tonino AJ. Crosslinked polyethylene compared to conven- tional polyethylene in total hip replacement: pre-clinical evalu- ation, in-vitro testing and prospective clinical follow-up study.
Acta Orthop 2006;77(5):719–25.
22. Bragdon CR, Greene ME, Freiberg AA, Harris WH, Malchau H.
Radiostereometric analysis comparison of wear of highly cross- linked polyethylene against 36- vs. 28-mm femoral heads. J Arthroplasty 2007;22(6 Suppl 2):125–9.
Hip Resurfacing vs. Metal-on-Metal Total Hip Arthroplasty
Sanket R. Diwanji, Pascal-André Vendittoli, and Martin Lavigne
Hospital Maisonneuve Rosemont, Montreal, QC, Canada
Case scenario
A 40 year old active man with no past medical history presents to your clinic complaining of right groin pain of 6 months’ duration. He has restricted right hip motion and a mild limp. Radiography of the pelvis shows advanced osteoarthritis in the right hip with cystic changes in the femoral head.
Relevant anatomy
Precise knowledge of the vascular supply of the femoral head is important when considering surgical procedures around the femoral head and neck junction. The blood supply to the femoral head epiphysis has been studied in the past, with emphasis on the critical role of the deep branch of the medial femoral circumflex artery (traveling under the short rotators) and the lateral retinacular vessels (traveling along the posterolateral femoral neck).1–5 Since the femoral component of hip resurfacing is supported in part by the femoral head epiphysis, it seems intuitive that damage to the blood supply could eventually jeopardize component fixation. None the less, clinical evidence has not confirmed this assumption as most surgeons use a poste- rior surgical approach without significant occurrence of femoral head collapse/failure.
Clarke described the femoral neck shape as being not circular but more of an ovoid shape with its larger diameter oriented from 2 o’clock to 8 o’clock.6 Thus, head–neck offset (distance between head equator and femoral neck surface) is not constant around the head/neck circumference. To replicate natural hip range of motion and avoid femoral neck impingement on the acetabular component, surgeons
performing hip resurfacing must make every effort to reproduce or restore the natural femoral head/neck offset all around the femoral neck.7,8 A detailed understanding of the relation between femoral neck diameter and femoral component diameter with the amount of acetabular bone resection and resultant range of motion is critical to opti- mize success of hip resurfacing.
Importance of the problem
Total hip arthroplasty (THA)* continues to be the gold standard for treatment of degenerative hip disorders.
Although it has demonstrated satisfactory clinical outcome in elderly patients, concerns still exist regarding its longev- ity in young patients.9 Among male patients receiving a primary hip arthroplasty in the last decade, the group of patients between 45–54 years of age has grown rapidly, at a rate of 140% compared to the 36% rate seen in older (65–74 years) age group.10 The concern about the durability of hip arthroplasty in young adults, along with recent improvements in metal-on-metal bearing designs, has led to resurgence of metal-on-metal hip resurfacing (HR).
Since the introduction of metal-on-metal HR devices in the 1990s, over 300,000 procedures have been performed worldwide.11 While HR is being performed with increasing frequency in the US, Canada and the UK,10,12,13 it is not quite as popular in Scandinavia14 and its use in Australia is on the decline.15 HR accounted for 7.6% of all primary total
Evidence-Based Orthopedics, First Edition. Edited by Mohit Bhandari.
© 2012 Blackwell Publishing Ltd. Published 2012 by Blackwell Publishing Ltd.
16
* Throughout this chapter, THA means 28 or 32 mm THA (where the diameter of the prosthetic femoral head is 28 or 32 mm). The term
“LDH (large-diameter head)-THA” is specifically used for studies where diameter of the head is larger than 36 mm.
Question 1: What are the differences relating