Highly Cross-Linked Polyethylene Reduces Wear and Revision Rates in Total Hip Arthroplasty: A 10-Year Double-Blinded Randomized Controlled Trial

J Bone Joint Surg Am. 2017 Oct 18;99(20):1703-1714. doi: 10.2106/JBJS.16.00878.


Background: Highly cross-linked polyethylene (XLPE) was developed to address the problem of wear and osteolysis associated with metal-on-conventional ultra-high molecular weight polyethylene (UHMWPE) bearing surfaces. The purpose of this study was to compare in vivo wear rates and clinical and radiographic outcomes between XLPE and UHMWPE in a prospective double-blinded randomized controlled trial with a minimum of 10 years of follow-up.

Methods: We randomized 122 patients to receive either a conventional UHMWPE liner (Enduron; DePuy) or an XLPE liner (Marathon; DePuy). Ninety-one patients were assessed clinically and radiographically at a minimum of 10 years (range, 10.08 to 12.17 years). Oxford Hip Scores and Short Form-12 Health Survey scores were collected. The radiographs were analyzed for osteolysis and for 2-dimensional (2-D), 3-dimensional (3-D), and volumetric wear using validated software.

Results: All 122 patients were accounted for at the 10-year follow-up evaluation. Twelve patients had undergone revision surgery, 21 patients had died (1 of whom had previously undergone revision surgery), and 2 patients were unable to return for follow-up, leaving 91 patients available for clinical and radiographic evaluation. At a minimum of 10 years, 3-D wear rates were significantly lower (p < 0.001) in the XLPE group (mean, 0.03 mm/yr) than in the conventional UHMWPE group (mean, 0.27 mm/yr). The prevalence of osteolysis was also significantly lower in the XLPE group (38% versus 8%, p < 0.005), as was the revision rate (14.6% versus 1.9%, p = 0.012), with 10 of the 12 revisions being in the Enduron group. There was no significant difference between the clinical scores of the 2 groups.

Conclusions: XLPE liners have significantly reduced wear and are associated with a greater implant survival rate at 10 years compared with conventional UHMWPE liners.

Level of evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Publication types

  • Randomized Controlled Trial

MeSH terms

  • Aged
  • Arthroplasty, Replacement, Hip / instrumentation*
  • Arthroplasty, Replacement, Hip / statistics & numerical data
  • Cross-Linking Reagents
  • Double-Blind Method
  • Female
  • Follow-Up Studies
  • Hip Prosthesis*
  • Humans
  • Kaplan-Meier Estimate
  • Male
  • Middle Aged
  • Osteoarthritis, Hip / diagnostic imaging
  • Osteoarthritis, Hip / surgery*
  • Polyethylene*
  • Prospective Studies
  • Prosthesis Design*
  • Prosthesis Failure*
  • Reoperation / statistics & numerical data*
  • Treatment Outcome


  • Cross-Linking Reagents
  • Polyethylene