Oxidized zirconium versus cobalt-chrome femoral heads in total hip arthroplasty: a multicentre prospective randomized controlled trial with ten years' follow-up

Bone Joint J. 2022 Jul;104-B(7):833-843. doi: 10.1302/0301-620X.104B7.BJJ-2021-1673.R1.


Aims: This study reports the ten-year wear rates, incidence of osteolysis, clinical outcomes, and complications of a multicentre randomized controlled trial comparing oxidized zirconium (OxZr) versus cobalt-chrome (CoCr) femoral heads with ultra-high molecular weight polyethylene (UHMWPE) and highly cross-linked polyethylene (XLPE) liners in total hip arthroplasty (THA).

Methods: Patients undergoing primary THA were recruited from four institutions and prospectively allocated to the following treatment groups: Group A, CoCr femoral head with XLPE liner; Group B, OxZr femoral head with XLPE liner; and Group C, OxZr femoral head with UHMWPE liner. All study patients and assessors recording outcomes were blinded to the treatment groups. The outcomes of 262 study patients were analyzed at ten years' follow-up.

Results: Patients in Group C were associated with increased mean liner wear rates compared to patients in Group A (0.133 mm/yr (SD 0.21) vs 0.031 mm/yr (SD 0.07), respectively; p < 0.001) and Group B (0.133 mm/yr (SD 0.21) vs 0.022 mm/yr (SD 0.05), respectively; p < 0.001) at ten years' follow-up. Patients in Group C were also associated with increased risk of osteolysis and aseptic loosening requiring revision surgery, compared with patients in Group A (7/133 vs 0/133, respectively; p = 0.007) and Group B (7/133 vs 0/135, respectively; p = 0.007). There was a non-statistically significant trend towards increased mean liner wear rates in Group A compared with Group B (0.031 mm/yr (SD 0.07) vs 0.022 mm/yr (SD 0.05), respectively; p = 0.128). All three groups were statistically comparable preoperatively and at ten years' follow-up when measuring normalized Western Ontario and McMaster Universities Osteoarthritis Index (p = 0.410), 36-Item Short Form Health Survey (p = 0.465 mental, p = 0.713 physical), and pain scale scores (p = 0.451).

Conclusion: The use of UHMWPE was associated with progressively increased annual liner wear rates after THA compared to XLPE. At ten years' follow-up, the group receiving UHMWPE demonstrated an increased incidence of osteolysis and aseptic loosening requiring revision surgery compared to XLPE. Femoral heads composed of OxZr were associated with trend towards reduced wear rates compared to CoCr, but this did not reach statistical significance and did not translate to any differences in osteolysis, functional outcomes, or revision surgery between the two femoral head components. Cite this article: Bone Joint J 2022;104-B(7):833-843.

Keywords: Aseptic loosening; Bearing surface; Cobalt–chrome; Highly-crosslinked polyethylene; Oxidized zirconium; Randomized Controlled Trial; Total hip arthroplasties (THAs); Ultra-high molecular weight polyethylene; cobalt-chrome; femoral heads; highly cross-linked polyethylene; osteolysis; revision surgery; ultra-high molecular weight polyethylene (UHMWPE); zirconium.

Publication types

  • Multicenter Study
  • Randomized Controlled Trial

MeSH terms

  • Arthroplasty, Replacement, Hip* / adverse effects
  • Chromium Alloys
  • Cobalt
  • Femur Head / surgery
  • Follow-Up Studies
  • Hip Prosthesis* / adverse effects
  • Humans
  • Osteolysis* / surgery
  • Polyethylene
  • Prospective Studies
  • Prosthesis Design
  • Prosthesis Failure
  • Zirconium


  • Chromium Alloys
  • Cobalt
  • Polyethylene
  • Zirconium