Metal-on-conventional Polyethylene Total Hip Arthroplasty Bearing Surfaces Have a Higher Risk of Revision Than Metal-on-highly Crosslinked Polyethylene: Results From a US Registry

Background Although studies have reported lower radiological wear in highly crosslinked polyethylene (HXLPE) versus conventional polyethylene in total hip arthroplasty (THA), there is limited clinical evidence on the risk of revision of these polyethylene THA bearing surfaces.

Questions/purposes We asked: (1) Do primary THAs with a metal-on-conventional polyethylene bearing surface have a higher risk of revision (all-cause or aseptic) than metal-on-HXLPE? (2) Is the risk of revision (all-cause or aseptic) higher for conventional polyethylene versus HXLPE when the effect of femoral and acetabular components is controlled for in prosthesis-specific analyses?

Methods The Kaiser Permanente’s Total Joint Replacement Registry was used to identify metal-on-conventional polyethylene and metal-on-HXLPE primary THAs (N = 26,823) performed between April 2001 and December 2011. The registry has 95% voluntary participation and 8% were lost to followup during the 10-year study period. Endpoints of interest were all-cause and aseptic revisions. Descriptive statistics and marginal Cox regression models with propensity score adjustments were applied to compare risk of revision for metal-on-conventional polyethylene versus metal-on-HXLPE THAs and to evaluate two specific manufacturers’ hip implant designs while controlling for femoral and acetabular components. Of the 26,823 THAs included in the study, 1815 (7%) were metal-on-conventional polyethylene and 25,008 (93%) were metal-on-HXLPE.

Results At 7 years followup, the cumulative incidence of revision was 5.4% (95% confidence interval [CI], 4.4%-6.7%) for metal-on-conventional and 2.8% (95% CI, 2.6%-3.2%) for metal-on-HXLPE. There was a higher adjusted risk of all-cause (hazard ratio [HR], 1.75; 95% CI, 1.37-2.24; p < 0.001) and aseptic (HR, 1.91; 95% CI, 1.46-2.50; p < 0.001) revisions among metal-on-conventional polyethylene bearing surface hips compared with metal-on-HXLPE. Results were similar within manufacturer hip designs with the same femoral and acetabular components. Conclusions Metal-on-conventional polyethylene THA bearing surfaces have a higher risk of revision compared with metal-on-HXLPE bearing surfaces. Clinicians should consider the use of HXLPE when using a polyethylene bearing in THA.

Level of Evidence Level II, cohort study.