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      Polyethylene liner dissociation with the Pinnacle acetabular component: should we be concerned?

      case-report
      Author(s): , MBBS, MCh, FRCS ∗ , , MA, FRCS, FRACS (Orth)
      Publication date (Electronic):
      Journal: Arthroplasty Today
      Publisher: Elsevier
      Keywords: Pinnacle, Liner dissociation, Acetabular cup

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          Abstract

          Between 2007 and 2018, 535 total hip arthroplasties using the uncemented Pinnacle acetabular component (DePuy Synthes, Warsaw, IN) and polyethylene liner were implanted in our unit. Of these, 6 patients presented acutely with liner polyethylene dissociation, giving a rate of liner dissociation of 1.11%. All dissociations were atraumatic. Failure occurred at mean 37 months (range 4.5 to 130 months). Radiologically, all acetabular components were within safe zone of abduction and mean anteversion was 10 degrees (range 2-20). In one case, there was posterior impingement against the femoral neck due to femoral malalignment. All patients underwent head and liner exchange with no repeat failures. Despite excellent long-term results, the frequency of dissociated polyethylene liners is a cause of concern with the Pinnacle acetabular component.

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          Rim cracking of the cross-linked longevity polyethylene acetabular liner after total hip arthroplasty.

          Stephen Tower, John H Currier, Barbara Currier … (2007)
          Studies have suggested that cross-linked polyethylene bearings reduce wear rates from 40% to 100% compared with conventional polyethylene. However, the reduced mechanical properties of highly cross-linked polyethylene have the potential to be a limiting factor in device performance. We reviewed a series of retrieved acetabular liners with a fracture of the superior rim to assess the factors that played a role in their failure. Four Longevity acetabular bearings, which had been retrieved from two patients after seven to twenty-seven months in vivo, were visually examined for clinical damage, were assessed with use of Fourier transform infrared spectroscopy to determine the level of oxidation, and were analyzed for mechanical properties and fracture surface characterization. Control data were obtained from never-implanted devices and from global reference ultrahigh molecular weight polyethylene bar stock as an industry calibration material. All four retrieved liners demonstrated articular surface wear modes, which in most cases were rated as moderate, and none were rated as severe. All showed cracking or rim failure of the liner at the superior aspect along the groove in the polyethylene that engages the locking ring of the shell. The retrieved liners had no measurable oxidation, and the mechanical properties were comparable with those of never-implanted material. There was no notable in vivo degradation of the retrieved liners. Important factors related to failure appear to be thin polyethylene at the cup rim, relatively vertical cup alignment, and the material properties of the highly cross-linked polyethylene that are decreased relative to conventional polyethylene. The critical dimension with respect to rim failure in modular liners appears to be the minimum thickness at the equatorial region.
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            Independent predictors of failure up to 7.5 years after 35 386 single-brand cementless total hip replacements: a retrospective cohort study using National Joint Registry data.

            S. Jameson, P N Baker, Jeffrey J Mason … (2013)
            The popularity of cementless total hip replacement (THR) has surpassed cemented THR in England and Wales. This retrospective cohort study records survival time to revision following primary cementless THR with the most common combination (accounting for almost a third of all cementless THRs), and explores risk factors independently associated with failure, using data from the National Joint Registry for England and Wales. Patients with osteoarthritis who had a DePuy Corail/Pinnacle THR implanted between the establishment of the registry in 2003 and 31 December 2010 were included within analyses. There were 35 386 procedures. Cox proportional hazard models were used to analyse the extent to which the risk of revision was related to patient, surgeon and implant covariates. The overall rate of revision at five years was 2.4% (99% confidence interval 2.02 to 2.79). In the final adjusted model, we found that the risk of revision was significantly higher in patients receiving metal-on-metal (MoM: hazard ratio (HR) 1.93, p < 0.001) and ceramic-on-ceramic bearings (CoC: HR 1.55, p = 0.003) compared with the best performing bearing (metal-on-polyethylene). The risk of revision was also greater for smaller femoral stems (sizes 8 to 10: HR 1.82, p < 0.001) compared with mid-range sizes. In a secondary analysis of only patients where body mass index (BMI) data were available (n = 17 166), BMI ≥ 30 kg/m(2) significantly increased the risk of revision (HR 1.55, p = 0.002). The influence of the bearing on the risk of revision remained significant (MoM: HR 2.19, p < 0.001; CoC: HR 2.09, p = 0.001). The risk of revision was independent of age, gender, head size and offset, shell, liner and stem type, and surgeon characteristics. We found significant differences in failure between bearing surfaces and femoral stem size after adjustment for a range of covariates in a large cohort of single-brand cementless THRs. In this study of procedures performed since 2003, hard bearings had significantly higher rates of revision, but we found no evidence that head size had an effect. Patient characteristics, such as BMI and American Society of Anesthesiologists grade, also influence the survival of cementless components.
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              Dislodgment of polyethylene liners in first and second-generation Harris-Galante acetabular components. A report of eighteen cases.

              P Ruzo, T Sculco, Shiqing Li … (2001)
              Dislodgment of the polyethylene liner is an increasingly common complication following total hip arthroplasty. The purposes of this study are to present the results in a series of patients with this complication and to analyze the mode of failure. Between November 1995 and January 2001, eighteen patients who had had a total hip arthroplasty presented with dislodgment of the polyethylene liner from a Harris-Galante metal acetabular shell. The medical records, radiographs, operative notes, and retrieved components were reviewed. In addition, scanning electron microscopy was used to study the fractured surfaces in a shell that had four broken tines. The components had been in situ for an average of seven years (range, three to eleven years). Seventeen components were second generation, and one was first generation. Symptoms developed spontaneously in sixteen patients, during sexual intercourse in one, and following a fall on the hip in one. Radiographs showed eccentric positioning of the head in all of the hips and broken tines in six. All of the shells were well fixed. Treatment consisted of revision of the shell in four patients, exchange of the liner in four, cementation of a new liner into the shell in seven, and cementation of an all-polyethylene cup in three. The liners had severe damage of the rim. Scanning-electron microscopy of the fractured surfaces of four tines revealed a fatigue pattern. We believe that, as the liner wears and becomes loose because of an inadequate locking mechanism, progressive micromotion occurs and the load increases on the polyethylene rim until it deforms and/or fractures. Subsequently, nothing prevents the liner from rotating out of the shell. As this mechanism of failure appears to include fatigue failure of the locking tines and wear of the liner, this complication is likely to increase as the components age in situ.
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                Author and article information

                Contributors
                Adeel R. Memon: Role: Arthroplasty Fellow
                David Gwynne-Jones: Role: Consultant Orthopaedic Surgeon
                Journal
                Journal ID (nlm-ta): Arthroplast Today
                Journal ID (iso-abbrev): Arthroplast Today
                Title: Arthroplasty Today
                Publisher: Elsevier
                ISSN (Print): 2352-3441
                ISSN (Electronic): 2352-3441
                Publication date PMC-release: 09 January 2020
                Publication date Collection: March 2020
                Publication date (Electronic): 09 January 2020
                Volume: 6
                Issue: 1
                Pages: 5-8
                Affiliations
                [1]Department of Trauma and Orthopaedics, Dunedin Hospital Dunedin, Dunedin, New Zealand
                Author notes
                [∗ ]Corresponding author. Dunedin Hospital, Great King street Dunedin, Otago, New Zealand. Tel.: +64 3 4740999. adeelmemon@ 123456rcsi.ie
                Article
                Publisher ID: S2352-3441(19)30162-1
                DOI: 10.1016/j.artd.2019.12.001
                PMC ID: 7083726
                PubMed ID: 32211467
                SO-VID: 11ffbb17-5e3d-46e4-8156-f0e739e54279
                Copyright © © 2019 The Authors
                License:

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

                History
                Date received : 12 June 2019
                Date revision received : 14 November 2019
                Date accepted : 2 December 2019
                Categories
                Subject: Case Report

                Keywords: pinnacle,liner dissociation,acetabular cup
                Data availability:
                Keywords: pinnacle, liner dissociation, acetabular cup

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