Thin highly cross-linked polyethylene liners combined with large femoral heads in primary total hip arthroplasty show excellent survival and low wear rates at a mean follow-up of 12.8 years

Bone Joint J. 2023 Jan;105-B(1):29-34. doi: 10.1302/0301-620X.105B1.BJJ-2022-0812.R1.


Aims: Several short- and mid-term studies have shown minimal liner wear of highly cross-linked polyethylene (HXLPE) in total hip arthroplasty (THA), but the safety of using thinner HXLPE liners to maximize femoral head size remains uncertain. The objective of this study was to analyze clinical survival and radiological wear rates of patients with HXLPE liners, a 36 mm femoral head, and a small acetabular component with a minimum of ten years' follow-up.

Methods: We retrospectively identified 55 patients who underwent primary THA performed at a single centre, using HXLPE liners with 36 mm cobalt-chrome heads in acetabular components with an outer diameter of 52 mm or smaller. Patient demographic details, implant details, death, and all-cause revisions were recorded. Cox regression and Kaplan-Meier survival was used to determine all-cause and liner-specific revision. Of these 55 patients, 22 had a minimum radiological follow-up of seven years and were assessed radiologically for linear and volumetric wear.

Results: Overall survival rate for all-cause revision was 94.5% (95% confidence interval (CI) 81.7% to 97.2%) at a mean follow-up of 12.8 years (10.9 to 18.7). Three patients were revised, none for liner wear, fracture, or dissociation. A total of 22 patients were included in the radiological analysis (mean follow-up 9.9 years (7.5 to 13.7)). Mean linear liner wear was 0.085 mm (95% CI -0.086 to 0.257) and the volumetric wear rate was 11.097 mm3/year (95% CI -6.5 to 28.7).

Conclusion: Using HXLPE liners with 36 mm heads in 52 mm acetabular components or smaller is safe, with excellent survival and low rates of linear and volumetric wear at medium-term follow-up. Patients did not require revision surgery for liner complications such as fracture, dissociation, or wear. Our results suggest that the advantages of using larger heads outweigh the potential risks of using thin HXLPE liners.Cite this article: Bone Joint J 2023;105-B(1):29-34.

Keywords: Cox regression model; Highly cross-linked polyethylene; Radiological outcome; Survivorship; Total hip arthroplasty; Wear; acetabular components; cobalt-chrome heads; femoral heads; highly cross-linked polyethylene (HXLPE); larger femoral heads; osteolysis; primary total hip arthroplasty; revision surgery; total hip arthroplasty (THA).

MeSH terms

  • Arthroplasty, Replacement, Hip* / methods
  • Femur Head / surgery
  • Follow-Up Studies
  • Hip Prosthesis*
  • Humans
  • Polyethylene
  • Prosthesis Design
  • Prosthesis Failure
  • Retrospective Studies


  • Polyethylene