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Are Hooded, Crosslinked Polyethylene Liners Associated with a Reduced Risk of Revision After THA?

Bauze, Adrian, MBBS, FRACS, FAOrthA; Agrawal, Somen, MBBS; Cuthbert, Alana, BMathSc (Hons); de Steiger, Richard, MBBS, PhD, FRACS, FAOrthA

Clinical Orthopaedics and Related Research®: June 2019 - Volume 477 - Issue 6 - p 1315–1321
doi: 10.1097/CORR.0000000000000710

Background Hooded acetabular liners and head sizes ≥ 32 mm have both shown to have a beneficial effect on the revision rate for dislocation in THA. Experience with noncrosslinked polyethylene (nonXLPE) raised concerns regarding the risk of impingement damage, loosening, and osteolysis with hooded liners; however, the evidence for this in crosslinked polyethylene (XLPE) is inconclusive. The interaction between different femoral head sizes and hooded liners is not well understood, and it is unclear whether hooded XLPE liners have a beneficial effect on overall long-term survivorship.

Questions/purposes We analyzed a large national joint registry to ask: (1) Is the use of hooded XLPE liners associated with a reduced revision rate for dislocation compared with nonhooded liners? (2) Is there a difference in the revision rate for aseptic loosening/osteolysis? (3) Is head size associated with any difference in the revision rate between hooded and nonhooded liners?

Methods The Australian Orthopaedic Association National Joint Replacement Registry longitudinally maintains data on all primary and revision joint arthroplasties with nearly 100% capture. We analyzed all conventional primary THAs performed from registry inception in September 1999 until December 31, 2016 in patients with a diagnosis of osteoarthritis who had nonhooded or hooded XLPE bearings in a cementless acetabular shell. The study group included 192,659 THA procedures with XLPE liners, of which 67,904 were nonhooded and 124,755 were hooded. The mean age of patients receiving nonhooded liners was 70 years (range, 11-100 years); 44% were males. This was similar to the patients with hooded liners, who had a mean age of 70 years (range, 16-100 years); 45% were males. The main outcome measure was the cumulative percent revision at 15 years of the THA using Kaplan-Meier estimates of survivorship. We examined reasons for revision and and performed multivariable analysis to control for the confounding factors of three head size groups (< 32mm, 32mm, and > 32mm) and for the method of femoral fixation.

Results There was a higher revision rate for dislocation for patients with nonhooded liners at all times to 15 years (HR, 1.31; 95% CI, 1.17–1.47; p < 0.001). There was a higher revision rate for the diagnosis of aseptic loosening/osteolysis with patients with nonhooded liners compared with hooded liners (HR, 1.19; 95% CI, 1.05–1.34; p = 0.006). Head sizes of 32 mm or larger were independently associated with a lower comparative revision rate between hooded and nonhooded liners, but this was not apparent for head sizes smaller than 32 mm. It appeared that the main driver of the finding in larger heads was a reduced dislocation risk with hooded liners for 32 mm heads (HR, 1.50; 95% CI, 1.23–1.80; p < 0.001) and for heads larger than 32 mm (HR, 1.50; 95% CI, 1.20–1.89; p < 0.001).

Conclusions Prior research has suggested that hooded acetabular liners may be associated with impingement, loosening, and osteolysis; however, in this large, registry-based report we found that XLPE hooded liners are not associated with an increased revision rate for aseptic loosening/osteolysis. Although there are many potential confounding variables in this registry analysis, if anything, surgeons using larger femoral heads and hooded liners likely did so in patients with a higher perceived dislocation risk. Patients with larger heads and XLPE hooded liners were, however, less likely to experience revision for dislocation. These liners therefore appear reasonable to use in primary THA at the surgeon’s discretion.

Level of Evidence Level III, therapeutic study.

A. J. Bauze, Sportsmed, University of Adelaide, Stepney, South Australia, Australia

S. Agrawal, Sportsmed, Stepney, South Australia, Australia

A. Cuthbert, South Australian Health and Medical Research Institute, North Terrace, Adelaide, South Australia, Australia

R. N. de Steiger, Department of Surgery, Epworth Healthcare, University of Melbourne, Richmond, Victoria, Australia, Australian Orthopaedic Association National Joint Replacement Registry, Adelaide, Australia

A. Bauze, Sportsmed Orthopaedic Division, 32 Payneham Rd, Stepney, South Australia, Australia, Email:

Each author certifies that he or she has no commercial associations (eg consultancies, stock ownership, equity interest, patent/licensing arrangements etc) that might pose a conflict of interest in connection with the submitted article.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

Clinical Orthopaedics and Related Research® neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA approval status, of any drug or device before clinical use.

Each author certifies that his or her institution approved the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research.

This work was performed at the Australian Orthopaedic Association National Joint Replacement Registry.

Received September 22, 2018

Accepted February 12, 2019

© 2019 Lippincott Williams & Wilkins LWW
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