Michael C Wyatt1,2, Michael R Whitehouse3,4, David C Kieser5, Chris M A Frampton5, Gary J Hooper5. 1. M. C. Wyatt, Department of Trauma and Orthopaedic Surgery, Midcentral District Health Board, Palmerston North Hospital, 50 Ruahine Street, Palmerston North, Manawatu, New Zealand. 2. M. C. Wyatt, Massey University, Palmerston North, Manawatu, New Zealand. 3. M. R. Whitehouse, Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, Southmead Hospital, Bristol, UK. 4. M. R. Whitehouse, National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK. 5. D. C. Kieser, C. M. A. Frampton, G. J. Hooper, Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago, Christchurch, New Zealand.
Abstract
BACKGROUND: Recurrent dislocation after THA remains a serious complication that carries with it a high risk of revision surgery. Previous studies have shown reduced dislocation rates with the use of lipped polyethylene (PE) liners in modular uncemented acetabular components, but there may be increased wear because of impingement, which may lead to aseptic loosening in the longer term; whether the aggregate benefit of lipped PE liners outweighs the risks associated with their use remains controversial. QUESTIONS/PURPOSES: We used data from the New Zealand Joint Registry to (1) compare Kaplan-Meier survival rates, (2) rates of revisions for dislocation between neutral and lipped PE liners, and (3) revision rates for aseptic loosening for the four most commonly used modular uncemented cups. METHODS: We used data from the New Zealand Joint Registry (NZJR) to identify 31,247 primary THAs using the four most commonly used uncemented modular acetabular implants from January 1, 1999 to December 31, 2018. The lipped liner group comprised 49% males (9924 of 20,240) compared with 42% (4669 of 11,007) in the neutral group (p < 0.001); 96% (19,382 of 20,240) of patients in the liner group had OA versus 95% (10,450 of 11,007) in the neutral group (p < 0.001). There was no difference in other patient characteristics such as age (mean 66.9 years), BMI (mean 29 ± 6 kg/m) and American Society of Anesthesiologists grade. The mean follow-up was 5.1 years (SD 3.9) and longest follow-up 19.3 years. The NZJR has more than 96% capture rate and data entry is a mandatory requirement of members of the New Zealand Orthopaedic Association. Kaplan-Meier survival rates were compared between 20,240 lipped and 11,007 neutral PE liners. Highly cross-linked polyethylene was used in 99% of lipped liner cups and 85% of neutral liner cups. Associated hazard ratios were calculated using a Cox regression analysis with a Kaplan-Meier revision-free estimates plot. RESULTS: The Kaplan-Meier survival at 10 years for lipped PE liners was 96% (95% confidence interval 95.4 to 96.2) and for neutral liners 95% (95% CI 94.7 to 95.9). After controlling for age, gender approach, femoral head size, and the use of image guidance, the all-cause revision risk was greater for neutral PE liners than that for lipped PE liners (HR 1.17 [95% CI 1.06 to 1.36]; p = 0.032). There was a higher risk of revision for dislocation in those with neutral PE liners than in those with lipped liners (HR 1.84 [95% CI 1.41 to 2.41]; p < 0.001) but no difference in the revision rate for aseptic acetabular component loosening (HR 0.85 [95% CI 0.52 to 1.38]; p = 0.511). CONCLUSIONS: The use of a lipped PE liner is not associated with a higher rate of aseptic loosening in patients who undergo primary THA compared with a neutral PE liner. Lipped PE liners are associated with lower rates of dislocation and lower all-cause revision rates without any increased association with revision rates for wear and aseptic loosening. LEVEL OF EVIDENCE: Level III, therapeutic study.
BACKGROUND: Recurrent dislocation after THA remains a serious complication that carries with it a high risk of revision surgery. Previous studies have shown reduced dislocation rates with the use of lipped polyethylene (PE) liners in modular uncemented acetabular components, but there may be increased wear because of impingement, which may lead to aseptic loosening in the longer term; whether the aggregate benefit of lipped PE liners outweighs the risks associated with their use remains controversial. QUESTIONS/PURPOSES: We used data from the New Zealand Joint Registry to (1) compare Kaplan-Meier survival rates, (2) rates of revisions for dislocation between neutral and lipped PE liners, and (3) revision rates for aseptic loosening for the four most commonly used modular uncemented cups. METHODS: We used data from the New Zealand Joint Registry (NZJR) to identify 31,247 primary THAs using the four most commonly used uncemented modular acetabular implants from January 1, 1999 to December 31, 2018. The lipped liner group comprised 49% males (9924 of 20,240) compared with 42% (4669 of 11,007) in the neutral group (p < 0.001); 96% (19,382 of 20,240) of patients in the liner group had OA versus 95% (10,450 of 11,007) in the neutral group (p < 0.001). There was no difference in other patient characteristics such as age (mean 66.9 years), BMI (mean 29 ± 6 kg/m) and American Society of Anesthesiologists grade. The mean follow-up was 5.1 years (SD 3.9) and longest follow-up 19.3 years. The NZJR has more than 96% capture rate and data entry is a mandatory requirement of members of the New Zealand Orthopaedic Association. Kaplan-Meier survival rates were compared between 20,240 lipped and 11,007 neutral PE liners. Highly cross-linked polyethylene was used in 99% of lipped liner cups and 85% of neutral liner cups. Associated hazard ratios were calculated using a Cox regression analysis with a Kaplan-Meier revision-free estimates plot. RESULTS: The Kaplan-Meier survival at 10 years for lipped PE liners was 96% (95% confidence interval 95.4 to 96.2) and for neutral liners 95% (95% CI 94.7 to 95.9). After controlling for age, gender approach, femoral head size, and the use of image guidance, the all-cause revision risk was greater for neutral PE liners than that for lipped PE liners (HR 1.17 [95% CI 1.06 to 1.36]; p = 0.032). There was a higher risk of revision for dislocation in those with neutral PE liners than in those with lipped liners (HR 1.84 [95% CI 1.41 to 2.41]; p < 0.001) but no difference in the revision rate for aseptic acetabular component loosening (HR 0.85 [95% CI 0.52 to 1.38]; p = 0.511). CONCLUSIONS: The use of a lipped PE liner is not associated with a higher rate of aseptic loosening in patients who undergo primary THA compared with a neutral PE liner. Lipped PE liners are associated with lower rates of dislocation and lower all-cause revision rates without any increased association with revision rates for wear and aseptic loosening. LEVEL OF EVIDENCE: Level III, therapeutic study.
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