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Implants & Biomaterials

Femoral stem coatings and acetabular bearing surfaces in THA, focusing on HXLPE and HA coatings to minimize wear and optimize biological fixation.

Overview

Long-term fixation of cementless hip components demonstrates durability across diverse porous-coated designs. Proximally HA-coated tapered titanium femoral components remained well-fixed and asymptomatic at 15 years [1], while extensively porous-coated components maintained fixation through 20-year follow-up despite revisions for wear in young populations [7]. Calcium phosphate-coated stems exhibit ingrowth stability and migration patterns comparable to hydroxyapatite-coated stems [20]. Although metal-carbon fiber composite femoral stems showed promising early results with clinical outcomes similar to all-metal stems at ten years [5], cementless acetabular revision using third-generation porous-coated components yields results that are acceptable but inferior to earlier generations [2]. Both porous-coated acetabular implants studied demonstrated successful long-term fixation despite low ingrowth amounts [4].

The durability of the prosthesis-bone interface for uncemented anatomic total hip prostheses requires further study [9], and continued investigation of 3D-printed acetabular implants is necessary to understand their long-term impact [3]. Porous tantalum osteonecrosis implants require close monitoring of design, surgical technique, and clinical characteristics [6]. In the knee, success of cementless unicompartmental arthroplasty is device-specific; three of four devices exceeded 95% survivorship at five years, and three of five achieved at least 92% survivorship after 10 years [13]. For very young children, a resurfaced allograft-prosthesis composite offers an alternative to preserve bone stock and achieve good function, though success is limited by a high risk of complications [8].

Anatomy & Pathophysiology

Osseous

The functional orientation of the acetabular component during activities associated with posterior edge-loading differs from those measured when supine due to patient-specific pelvic kinematics [35]. Significant sex-specific differences in acetabular anteversion and inclination were revealed by a reliable and accurate methodology for determining three-dimensional acetabular orientation [62]. The position of the acetabular component can influence the femoral head penetration of modern highly cross-linked polyethylenes (HXLPEs) [39], and the best predictor of change in bone mineral density at five years in the trochanteric area was acetabular component inclination [55]. A mismatch exists between the proximal femoral anatomy of a relevant proportion of adult hips and the implant geometry of the most common femoral component in total hip arthroplasty [45]. Current classification of borderline hip dysplasia based solely on lateral center edge angle is insufficient, and the focus must shift to assessing hip instability to better predict treatment outcomes and the need for bony realignment [69].

Ligamentous

The anterior and posterior surgical approaches differentially affect postoperative biomechanical function of the capsular ligaments [66]. Hips showing continuous migration are at risk for early failure, but this seems to be unrelated to cement type, rather to cementing technique [72].

Kinematics

Acetabular cup position in the anteversion and abduction planes improved between manual and navigation groups, indicating that an imageless navigation system provides a more controlled and reproducible technique of performing total hip arthroplasty [64]. Electrical resistance and reactance of the limbs did not change significantly after total hip arthroplasty [68].

Implant Interface

Scanning electron microscopy (SEM) analysis of a specific modular neck total hip system design revealed corrosion at the additional junction of modularity [73].

Classification

Implant Longevity & Fixation: At 15 years, all 143 proximally HA-coated tapered titanium femoral components remained well fixed and clinically asymptomatic [1]. Cementless acetabular revision using a third-generation porous-coated component yielded results that are acceptable but inferior to those of series using earlier generation implants [2]. Variable amounts of ingrowth of bone were observed after revision to porous-coated prostheses without bone cement in a canine model, though further study is needed to determine whether adequate ingrowth occurs [25].

Material & Design Characteristics: Technologic advances in implant materials, design, amputee care, and imaging continue to drive improvements in patient care and outcomes [10]. 3D-printed implants are designed to be significantly more porous than some conventional components while exhibiting the same shape and size [42]. Surface properties create a higher frictional resistance, thereby providing better inherent stability for implants featuring novel surface morphology [46]. Mechanically, all four artificial joint replacement types analyzed in the finite element analysis of porously punched prosthetic short stems are stabilized in quantity [47]. Early retrieved highly cross-linked polyethylene acetabular liners had not failed clinically as a result of wear [11].

Bearing Surface & Debris Profiles: Metal-on-metal bearings are well suited for hip resurfacing arthroplasty when a well-designed device is properly implanted [23]. The pattern and type of inflammation seen in periprosthetic tissues obtained from hips with metal-on-metal implants are very different from those with metal-on-polyethylene implants [54]. Particulate prosthetic debris in tissues around failed femoral components inserted without cement constitutes a class of particles predominantly less than one micrometer in size and present in amounts exceeding one billion particles per gram of tissue [43]. The composition of the implant and the size of the modular femoral head were most strongly related to the concentration of debris in tissue around failed total hip implants [60].

Specialized Applications: A resurfaced allograft-prosthesis composite could be an alternative surgical option to preserve bone stock and achieve good functional outcomes in very young children, although its success may be limited owing to a high risk of complications [8]. Continued investigations of unused 3D-printed acetabular hip implants are necessary, as is examining those in vivo and retrieved to understand their long-term impact on patients and the effects of certain features [3]. The implant design, surgical technique, application, and clinical characteristics of candidates for porous tantalum osteonecrosis implants should continue to be monitored closely [6].

Other Considerations: The evidence base highlights the necessity for ongoing monitoring of specific implant designs and patient populations, particularly regarding long-term outcomes of 3D-printed components and porous tantalum osteonecrosis implants.

Clinical Presentation

Long-term fixation of porous-coated and tapered titanium femoral components remains durable, with 143 proximally HA-coated tapered femoral components staying well-fixed and asymptomatic at 15 years [1]. Extensively porous-coated components maintained fixation through 20-year follow-up in young patients despite revisions for wear-related complications [7]. Cementless acetabular revision using third-generation porous-coated components yielded acceptable but inferior results compared to earlier generations [2], whereas both porous-coated acetabular implants studied achieved successful outcomes and long-term fixation despite low ingrowth amounts [4]. Highly cross-linked polyethylene liners with wear and surface cracking have not failed clinically due to wear [11].

Implant-Specific Behaviors: Porous tantalum: Design, surgical technique, application, and clinical characteristics of candidates for porous tantalum osteonecrosis implants require close monitoring [6]. The trabecular metal monoblock acetabular cup system demonstrated excellent early clinical and radiographic behavior [14]. Metal-carbon fiber composites: These femoral stems showed promising early results with clinical outcomes similar to all-metal stems at ten-year follow-up [5]. Resurfaced allograft-prosthesis composites: This option may preserve bone stock and achieve good functional outcomes in very young children, though success is limited by a high risk of complications [8]. Modular dual mobility: Corrosion occurs at the interface between modular dual mobility liners and shells, associated with local tissue reactions and potential long-term clinical importance [33].

Corrosion and Adverse Reactions: Metallic debris may form a fibrous membrane around implants, acting as a conduit for polyethylene debris and contributing to osteolysis and loosening [16]. Corrosion at the acetabular liner taper requires close monitoring for signs of adverse reaction to corrosion by-products [29]. A systematic risk stratification algorithm is recommended to optimize management, as early recognition of adverse local tissue reactions due to mechanically assisted crevice corrosion is critical to prevent soft-tissue damage [32]. Other surgical, implant, and patient factors must be considered when determining failure mechanisms of large diameter metal-on-metal hip arthroplasties [15]. The material presented provides a strong background on taper corrosion diagnosis and treatment, though methods will advance as more information becomes available [28].

Systemic and Long-Term Considerations: Systemic distribution of metallic and polyethylene wear particles is common in patients with both failed and primary total joint prostheses [30]. Continued investigations of 3D-printed acetabular hip implants, including in vivo and retrieved samples, are necessary to understand their long-term impact and the effects of specific features [3]. Technologic advances in implant materials, design, amputee care, and imaging continue to drive improvements in patient care and outcomes [10]. Clinical results of the S-ROM-A femoral prosthesis showed good fixation without osteolysis or loosening [31]. At an average of 127 months follow-up, no significant differences were found in clinical, radiographic, or survival results regarding the presence or absence of HA/TCP coating on cementless femoral stems [12].

Investigations

Plain radiography: Cementless acetabular revision using third-generation porous-coated components yields acceptable but inferior results compared to earlier generations [2]. Extensively porous-coated components demonstrate durable fixation through 20-year follow-up despite revisions for wear-related complications in young populations [7]. While long-term fixation was successful with low ingrowth observed, further study is required to determine the durability of the prosthesis-bone interface for uncemented porous-coated anatomic total hip prostheses [4, 9]. The extent of porous coating influences bone remodeling in the distal periprosthetic region rather than the proximal region [27]. For aseptic loosening of the acetabular cup after cementless total hip arthroplasty, imaging does not rely on postoperative baseline or serial follow-up radiographs and can accurately determine the specific location of loosening [51]. Surgeons utilizing modular hip systems with a titanium stem and cobalt-chromium neck should employ annual radiographic follow-up [74].

MRI: Most patients with metal-on-metal total hip replacements who do not undergo early revision present with normal MRI scans [49]. However, the relationship between MRI pathology, metal ion levels, and acetabular inclination angles in patients with ASR implants remains unclear [56]. Magnetic resonance imaging indicates that the donor site following autologous osteochondral mosaicplasty for cartilaginous lesions of the elbow joint is resurfaced with fibrous tissue [38]. MRI is indicated for modular hip systems with a titanium stem and cobalt-chromium neck as clinically indicated [74].

CT: In CTAC implants, bone removal is minimal, and implant-bone apposition is more evenly distributed between the residual acetabulum and the outer cortex of the pelvis [58].

Other Considerations: Technologic advances in implant materials, design, amputee care, and imaging continue to drive improvements in patient care and outcomes [10]. Metallic debris may facilitate the formation of a fibrous membrane around implants, potentially acting as a conduit for polyethylene debris and contributing to osteolysis and loosening [16]. Bone resorption occurs in association with macrophages laden with polyethylene debris, regardless of radiographic appearance or anatomical origin [44]. Observed rates of volumetric wear in total hip arthroplasty suggest that these hips may require revision in the future [24]. The Trabecular Metal Monoblock Acetabular Cup System demonstrated excellent early clinical and radiographic behavior [14]. Promising early results for trabecular metal acetabular components used at revision total hip arthroplasty have been reported with radiostereometry follow-up [67]. Osteoconductivity was confirmed in 71% of screw sites for self-reinforced poly–levo (96%)/dextro (4%)–lactide/β-tricalcium phosphate biocomposite interference screws, with nearly complete or complete filling in 33% [70]. At 15 years, all 143 implants remained well fixed and clinically asymptomatic [1].

Treatment

Non-Operative

Promising and established treatment modalities for osteonecrosis include nonweightbearing, pharmacological treatments, extracorporeal shock wave therapy, pulsed electromagnetic fields, core decompression surgery, and cellular therapies [65]. Treatment options for hallux rigidus and osteoarthrosis of the first metatarsophalangeal joint range from non-operative measures to various surgical procedures including cheilectomy, arthroplasty, and arthrodesis, with selection depending on disease stage and patient factors [63].

Operative

Indications: Candidates for porous tantalum osteonecrosis implants require close monitoring of design, surgical technique, application, and clinical characteristics [6]. A resurfaced allograft-prosthesis composite serves as an alternative surgical option to preserve bone stock and achieve good functional outcomes in very young children, although its success may be limited by a high risk of complications [8].

Implant Selection: At 15 years, all 143 proximally HA-coated tapered titanium femoral components remained well fixed and clinically asymptomatic [1]. At an average of 127 months follow-up, no significant differences were found in clinical results, radiographic results, and survival distributions regarding the presence or absence of HA/TCP coating on cementless femoral stems [12]. The survival of non-hydroxyapatite-coated stems was similar to hydroxyapatite-coated stems, and hydroxyapatite coating did not seem to have an advantageous effect in terms of fixation and survival of the stem [34]. Calcium phosphate-coated stems are safe implants in terms of ingrowth stability, with migration patterns comparable to hydroxyapatite-coated stems [20]. Metal-carbon fiber composite femoral stems showed promising results at early follow-up, with clinical outcomes similar to all-metal stems at ten-year follow-up [5]. Metal-on-metal hybrid hip resurfacing arthroplasty is a viable concept when a well-designed device is properly implanted [23].

Revision: Cementless acetabular revision using a third-generation porous-coated component yielded results that are acceptable but inferior to those of series using earlier generation implants [2]. Despite revisions for wear-related complications in a relatively young patient population, fixation achieved with extensively porous-coated components remained durable through 20-year follow-up [7]. Revision total hip arthroplasty without cement using a curved, long-stem, non-circumferentially porous-coated femoral component is associated with an unacceptable rate of subsidence [53]. Although implant stabilization was achieved with the short global tissue-sparing hip stem, excellent long-term survival similar to that of the Taperloc stem should not be inferred [40].

Adjuncts: Treatment with 1000 centigrays of radiation decreased the strength of fixation of porous-coated implants at two weeks, but not at four or eight weeks, while 500 centigrays had no significant effect [41]. Both porous-coated acetabular implants studied had successful outcomes and long-term fixation despite the observation of low amounts of ingrowth [4]. Continued investigations of unused 3D-printed acetabular hip implants and those retrieved in vivo are necessary to understand their long-term impact on patients and the effects of certain features [3]. Early retrieved highly cross-linked polyethylene acetabular liners had not failed clinically as a result of wear [11].

Other Considerations: Success in cementless unicompartmental knee arthroplasty was device specific, with three of four devices exceeding 95% survivorship within five years and three of five achieving at least 92% survivorship after 10 years [13]. Three described methods of managing intraoperative nondisplaced calcar fractures demonstrated little radiographic stem subsidence, but the risk of reoperation was much higher than expected [59]. Using implant-specific blood metal ion thresholds missed fewer patients with adverse reactions to metal debris (ARMD) compared with thresholds currently proposed by regulatory authorities [37].

Complications

Polyethylene wear: Long-term analysis of total hip arthroplasty using highly cross-linked polyethylene in patients aged 50 years and younger found negligible polyethylene wear, no incidence of aseptic loosening, and excellent clinical outcomes at and beyond 15 years of follow-up [18]. At 10-year follow-up, cross-linked polyethylene demonstrated superior survivorship with 100% survivorship compared to 94.7% for non-cross-linked liners when using revision for wear-related complications as an endpoint [19]. Minimum 10-year follow-up demonstrated durable fixation and reduced wear with contemporary acetabular components and cross-linked polyethylene compared to historical controls in patients aged 50 and under [26].

Aseptic loosening: At 15 years, all 143 proximally HA-coated tapered titanium femoral components remained well fixed and clinically asymptomatic [1]. Despite revisions for wear-related complications in a relatively young patient population, fixation with extensively porous-coated components remained durable through 20-year follow-up [7]. Both porous-coated acetabular implants studied demonstrated successful outcomes and long-term fixation despite the observation of low amounts of ingrowth [4]. Cementless acetabular revision using a third-generation porous-coated component yielded results that were acceptable but inferior to those of series using earlier generation implants [2]. Hydroxyapatite coating survival was duration-dependent, and given sufficient duration of follow-up, it would be better than porous coating for survival [22]. Further study is necessary to determine the long-term durability of the prosthesis-bone interface for the porous-coated anatomic total hip prosthesis inserted without cement [9].

Other Considerations: Metal-carbon fiber composite femoral stems showed promising results at early follow-up, with clinical outcomes similar to all-metal stems at ten-year follow-up [5]. Ceramic-on-metal bearing is safe and reliable at long-term follow-up in association with short stems arthroplasty if the implant is correctly positioned [21]. The extent of porous coating affects bone-remodeling in the distal periprosthetic region rather than in the proximal region after cementless total hip arthroplasty [27]. Continued investigations of unused 3D-printed acetabular hip implants and those retrieved in vivo are necessary to understand their long-term impact on patients and the effects of certain features [3]. The design, surgical technique, application, and clinical characteristics of candidates for porous tantalum osteonecrosis implants should continue to be monitored closely [6]. Further studies with long-term follow-up are needed to determine whether the grafted area in autologous matrix-induced chondrogenesis will maintain structural and functional integrity over time [17]. Resurfaced allograft-prosthesis composites for proximal humerus reconstruction in children with bone tumors may have limited success owing to a high risk of complications [8]. Despite major primary complications and a high incidence of radiographic signs of degenerative changes after 8.8 years, mainly good clinical results were achieved with Judet's bipolar prosthesis for radial head arthroplasty [61].

Recovery

Light activity (weeks): Evidence regarding specific timelines for light activity, such as desk work or driving, is not explicitly quantified in the provided L1 evidence base. While studies confirm clinical asymptomatic status and successful fixation at long-term intervals (e.g., 15 years) [1], and early follow-up outcomes for metal-carbon fiber stems are promising [5], no data points define the specific week ranges for resumption of light activities.

Full activity (months): The provided evidence does not contain specific month ranges for the return to manual work, sport, or full range of motion. Long-term survivorship data exists for cementless unicompartmental knee arthroplasty devices, with three of four exceeding 95% survivorship within five years [13] and three of five achieving at least 92% survivorship after 10 years [13]. Similarly, total hip arthroplasty using highly cross-linked polyethylene in patients aged 50 and younger demonstrated excellent clinical outcomes at and beyond 15 years [18], but these metrics reflect implant durability rather than a defined timeline for full functional activity resumption.

Complete recovery / outcome plateau (months): Long-term analysis indicates that clinical outcomes for total hip arthroplasty using highly cross-linked polyethylene stabilize with negligible wear and no aseptic loosening at and beyond 15 years of follow-up [18]. Cementless acetabular revision using a third-generation porous-coated component yielded acceptable results, though these were inferior to series using earlier generation implants [2]. For cementless femoral stems, no significant differences were found in clinical results, radiographic results, and survival distributions regarding the presence or absence of HA/TCP coating at an average of 127 months follow-up [12]. Hydroxyapatite coating survival was duration-dependent, and if given sufficient duration of follow-up, hydroxyapatite coating would be better than porous coating for survival [22].

Rehabilitation protocol: The provided evidence does not specify rehabilitation protocols, including PT phasing, immobilisation duration, weight-bearing progression, or sling/brace removal timing. While investigations into unused 3D-printed acetabular hip implants and retrieved in vivo components are necessary to understand long-term impacts [3], and further study is needed to determine the long-term durability of the prosthesis-bone interface for porous-coated anatomic total hip prostheses inserted without cement [9], no procedural rehabilitation guidelines are detailed.

Functional milestones: Validated PROM trajectories or specific outcome-measure benchmarks are not explicitly reported in the provided evidence. However, ceramic-on-metal bearing is safe and reliable at long-term follow-up in association with short stems arthroplasty if the implant is correctly positioned [21]. Minimum 10-year follow-up demonstrated durable fixation and reduced wear compared to historical controls in patients aged 50 and under using contemporary acetabular components and cross-linked polyethylene [26]. At 10-year follow-up, cross-linked polyethylene demonstrated superior survivorship with 100% survivorship compared to 94.7% for non-cross-linked liners when using revision for wear-related complications as an endpoint [19].

Other Considerations: Continued investigations of unused 3D-printed acetabular hip implants and those retrieved in vivo are necessary to understand their long-term impact on patients and the effects of certain features [3]. Further study is necessary to determine the long-term durability of the prosthesis-bone interface for the porous-coated anatomic total hip prosthesis inserted without cement [9]. Further studies with long-term follow-up are needed to determine whether the grafted area in autologous matrix-induced chondrogenesis will maintain structural and functional integrity over time [17]. Both porous-coated acetabular implants studied demonstrated successful outcomes and long-term fixation despite low amounts of ingrowth [4]. Variable amounts of ingrowth of bone were observed after revision to porous-coated prostheses without bone cement in a canine model, and further study is needed to determine whether adequate ingrowth of bone occurs in this model [25].

Key Evidence

  • [L3] At 15 years, all 143 implants remained well fixed and clinically asymptomatic. (10.1007/s11999-008-0550-7)
  • [L3] The results of this series are acceptable but inferior to those of series using earlier generation implants. (10.1016/j.arth.2008.11.037)
  • [L4] Therefore, it is necessary for continued investigations of unused implants, but perhaps more significantly, examining those in vivo and retrieved to understand their long-term impact on patients and the effects of certain features. (10.1530/eor-23-0182)
  • [L4] Both implants studied had successful outcomes and long-term fixation despite the observation of low amounts of ingrowth. (10.1016/j.arth.2020.03.036)
  • [L2] The implant showed promising results at the time of early follow-up, and the clinical outcomes were similar to those of an all-metal stem at the time of a ten-year follow-up. (10.2106/jbjs.m.01542)
  • [L4] The implant design, the surgical technique, its application, and the clinical characteristics of candidates for this procedure should continue to be monitored closely. (10.2106/jbjs.f.00847)
  • [L3] Despite revisions for wear-related complications in this relatively young patient population, the fixation achieved with these extensively porous-coated components remained durable through 20-year follow-up. (10.1016/j.arth.2006.12.088)
  • [L4] Although its success may be limited owing to a high risk of complications, a resurfaced allograft-prosthesis composite could be an alternative surgical option in order to preserve the bone stock and achieve good functional outcomes in very young children. (10.1097/corr.0000000000002969)
  • [L2] Further study is necessary to determine the long-term durability of the prosthesis-bone interface. (10.2106/00004623-199301000-00011)
  • [L4] These devices had not failed clinically as a result of wear. (10.2106/00004623-200406000-00021)
  • [L1] At an average of 127 months follow-up, no significant differences were found in clinical results, radiographic results, and survival distributions with regard to the presence or absence of HA/TCP coating. (10.1016/j.arth.2006.06.005)
  • [L4] Success was device specific, with three of four cementless UKA devices exceeding 95% survivorship within five years and three of five achieving at least 92% survivorship after 10 years. (10.1016/j.arth.2026.01.019)
  • [L4] The implant showed excellent early clinical and radiographic behavior. (10.1016/j.arth.2008.09.027)
  • [L3] Other surgical, implant and patient factors should be considered when determining the mechanisms of failure of large diameter metal-on-metal hip arthroplasties. (10.1302/0301-620x.98b7.36554)
  • [L5] Metallic debris may be instrumental in the formation of a fibrous membrane around implants, potentially acting as a conduit for polyethylene debris and contributing to osteolysis and loosening. (10.2106/00004623-199306000-00005)
  • [L4] However, further studies with long-term follow-up are needed to determine whether the grafted area will maintain structural and functional integrity over time. (10.1007/s00167-010-1042-3)
  • [L3] This long-term analysis found negligible polyethylene wear, no incidence of aseptic loosening, and excellent clinical outcomes at and beyond 15 years of follow-up. (10.1302/0301-620x.103b7.bjj-2020-2443.r1)
  • [L1] At 10-year follow-up, cross-linked polyethylene demonstrated superior survivorship with 100% survivorship compared to 94.7% for non-cross-linked liners (P = .003) when using revision for wear-related complications as an endpoint. (10.1016/j.arth.2012.03.048)
  • [L1] Our data show that the calcium phosphate-coated stem is a safe implant in terms of ingrowth stability, and with migration patterns comparable to a hydroxyapatite-coated stem. (10.1186/s42836-025-00324-z)
  • [L4] Ceramic-on-metal bearing is safe and reliable at long term follow-up in association to short stems arthroplasty, if the implant is correctly positioned. (10.1186/s12891-022-05077-3)
  • [L1] The HHS and survival was duration-dependent—if given the sufficient duration of follow-up, hydroxyapatite coating would be better than porous coating for the survival. (10.1186/s13018-015-0161-4)
  • [L3] HRA is a viable concept; metal-on-metal bearings are well suited for this procedure when a well-designed device is properly implanted. (10.1302/0301-620x.100b11.bjj-2017-1459.r2)
  • [L4] The observed rates of volumetric wear suggest that the hips may require revision in the future. (10.2106/00004623-199505000-00014)
  • [L5] Although variable amounts of ingrowth of bone were observed after the revision to the porous-coated prostheses without bone cement, further study is needed to determine whether adequate ingrowth of bone occurs in this model. (10.2106/00004623-198870080-00011)
  • [L2] The extent of porous coating affects bone-remodeling in the distal periprosthetic region rather than in the proximal region. (10.2106/00004623-200010000-00009)
  • [L5] The material presented provides a strong background about taper corrosion for the practicing orthopedic surgeon and practical information about diagnosis and treatment, though methods will advance as more information becomes available. (10.1016/j.arth.2018.07.008)
  • [L4] Systemic distribution of metallic and polyethylene wear particles was a common finding in patients with both failed and primary total joint prostheses. (10.2106/00004623-200004000-00002)
  • [L4] Clinical results showed good implant fixation without evidence of osteolysis or loosening. (10.1016/j.arth.2009.03.009)
  • [L5] A systematic approach to evaluation based on a risk stratification algorithm is recommended to optimize patient management, as early recognition and diagnosis of adverse local tissue reactions due to mechanically assisted crevice corrosion is critical to prevent soft-tissue damage and poorer outcomes. (10.2106/jbjs.20.01837)
  • [L4] Corrosion occurs at the interface between MDM liners and shells and can be associated with reactions in the local tissues, suggesting continued concern that this problem may become clinically important with longer-term use of these implants. (10.1302/0301-620x.103b7.bjj-2020-0221.r1)
  • [L1] The survival of non-hydroxyapatite-coated stems was similar to hydroxyapatite-coated stems, and hydroxyapatite coating did not seem to have an advantageous effect in terms of fixation and survival of the stem. (10.1016/j.arth.2007.11.007)
  • [L3] The functional orientation of the acetabular component during activities associated with posterior edge-loading differs from those measured when supine due to patient-specific pelvic kinematics. (10.1302/0301-620x.98b7.37062)
  • [L3] Using these implant-specific thresholds, we missed fewer patients with ARMD compared with when the thresholds currently proposed by regulatory authorities were used. (10.2106/jbjs.16.01568)
  • [L4] However, magnetic resonance imaging indicates that the donor site is resurfaced with fibrous tissue. (10.1177/0363546507306465)
  • [L3] The position of the acetabular component can influence the femoral head penetration of modern HXLPEs. (10.1302/0301-620x.107b5.bjj-2024-1083.r1)
  • [L1] Although implant stabilization was achieved, excellent long-term survival similar to that of the Taperloc stem should not be inferred. (10.1302/0301-620x.102b6.bjj-2019-1026.r2)
  • [L5] Treatment with 1000 centigrays of radiation decreased the strength of fixation of porous-coated implants at two weeks, but not at four or eight weeks, while 500 centigrays had no significant effect. (10.2106/00004623-199072100-00015)
  • [L5] 3D-printed implants are designed to be significantly more porous than some conventional components while exhibiting the same shape and size. (10.1186/s13018-020-01665-y)
  • [L4] Particulate prosthetic debris in tissues around failed femoral components inserted without cement constitutes a class of particles predominantly less than one micrometer in size and present in amounts exceeding one billion particles per gram of tissue. (10.2106/00004623-199509000-00002)
  • [L4] Bone resorption occurs in association with macrophages laden with polyethylene debris, regardless of radiographic appearance or anatomical origin. (10.2106/00004623-199274060-00006)
  • [L4] The present study revealed a mismatch between proximal femoral anatomy of a relevant proportion of adult hips and implant geometry of the most common femoral component in total hip arthroplasty. (10.1016/j.arth.2016.02.015)
  • [L5] Mechanically, all four artificial joint replacement types are stabilized in quantity. (10.1186/s12891-017-1651-9)
  • [L4] Most patients with a metal-on-metal total hip replacement who do not undergo early revision have normal MRI scans. (10.1302/0301-620x.95b8.31377)
  • [L4] This approach does not rely on postoperative baseline radiographs or serial follow-up radiographs and can accurately determine the specific location of prosthetic loosening. (10.1186/s12891-025-08607-x)
  • [L3] The data indicate that revision with use of a curved, long-stem, non-circumferentially porous-coated femoral component without cement is associated with an unacceptable rate of subsidence. (10.2106/00004623-199508000-00012)
  • [L4] The pattern and type of inflammation seen in periprosthetic tissues obtained from hips with metal-on-metal and metal-on-polyethylene implants are very different. (10.2106/jbjs.c.00949)
  • [L2] The best predictor of change in BMD at five years in the trochanteric area was acetabular component inclination. (10.1016/j.arth.2012.09.012)
  • [L4] In CTAC implants, the amount of bone removed is minimal, while the implant-bone apposition is more evenly distributed between the residual acetabulum and the outer cortex of the pelvis. (10.1302/0301-620x.106b5.bjj-2023-0852.r1)
  • [L3] The three described methods of managing intraoperative nondisplaced calcar fractures demonstrated little radiographic stem subsidence; however, the risk of reoperation was much higher than expected. (10.1016/j.arth.2024.03.049)
  • [L4] The composition of the implant and the size of the modular femoral head were most strongly related to the concentration of debris in tissue. (10.2106/00004623-199608000-00014)
  • [L4] Despite major primary complications and high incidence of radiographic signs of degenerative changes after 8.8 years, mainly good clinical results were achieved with Judet's bipolar prosthesis. (10.1016/j.jse.2010.05.022)
  • [L4] The study developed a reliable and accurate methodology for determining three-dimensional acetabular orientation, revealing significant sex-specific differences in anteversion and inclination that were not observed in previous studies with smaller samples or coarser resolution. (10.2106/jbjs.l.01141)
  • [L5] Treatment options range from non-operative measures to various surgical procedures including cheilectomy, arthroplasty, and arthrodesis, with selection depending on disease stage and patient factors. (10.2106/00004623-199806000-00015)
  • [L3] Acetabular cup position in the anteversion and abduction planes improved between manual and navigation groups, indicating that an imageless navigation system provides a more controlled and reproducible technique of performing THAs. (10.1016/j.arth.2008.01.004)
  • [L5] Promising and established treatment modalities for osteonecrosis include nonweightbearing, pharmacological treatments, extracorporeal shock wave therapy, pulsed electromagnetic fields, core decompression surgery, and cellular therapies. (10.1016/j.arthro.2021.08.032)
  • [L5] The anterior and posterior approach differentially affect postoperative biomechanical function of the capsular ligaments. (10.1302/0301-620x.101b4.bjj-2018-1321.r1)
  • [L1] The study reports promising early results for trabecular metal acetabular components used at revision total hip arthroplasty, followed with radiostereometry. (10.1302/0301-620X.99B7.BJJ-2016-1241.R1)
  • [L4] Electrical resistance and reactance of the limbs did not change significantly after THA. (10.1186/s12891-023-06893-x)
  • [L5] The authors argue that current classification of borderline hip dysplasia based solely on lateral center edge angle is insufficient and that the focus must shift to assessing hip instability to better predict treatment outcomes and the need for bony realignment. (10.1016/j.arthro.2023.10.023)
  • [L4] Osteoconductivity was confirmed in 71% of screw sites, with nearly complete or complete filling in 33%. (10.1016/j.arthro.2015.08.037)
  • [L1] Hips showing continuous migration are at risk for early failure, but this seems to be unrelated to cement type, rather to cementing technique. (10.1302/0301-620x.98b10.37116)
  • [L4] Surgeons using modular hip systems with a titanium stem and cobalt-chromium neck should be vigilant about annual follow-up with radiographs, and use of MRIs as indicated. (10.2106/jbjs.l.01625)

References

[1] Late Remodeling Around a Proximally HA-coated Tapered Titanium Femoral Component. Clinical Orthopaedics & Related Research. 2009. DOI: 10.1007/s11999-008-0550-7

[2] Cementless Acetabular Revision Using a Third Generation Porous-Coated Component: Evaluation at 5 to 11-Year Follow up. The Journal of Arthroplasty. 2009. DOI: 10.1016/j.arth.2008.11.037

[3] Characterisation of 3D-printed acetabular hip implants. EFORT Open Reviews. 2024. DOI: 10.1530/eor-23-0182

[4] Porous Coatings in Retrieved Acetabular Components. The Journal of Arthroplasty. 2020. DOI: 10.1016/j.arth.2020.03.036

[5] Metal-Carbon Fiber Composite Femoral Stems in Hip Replacements. The Journal of Bone and Joint Surgery-American Volume. 2014. DOI: 10.2106/jbjs.m.01542

[6] Histopathologic Retrieval Analysis of Clinically Failed Porous Tantalum Osteonecrosis Implants. The Journal of Bone & Joint Surgery. 2008. DOI: 10.2106/jbjs.f.00847

[7] Outcome of Total Hip Arthroplasty Using Extensively Porous-Coated Components at 20-Year Follow-Up. The Journal of Arthroplasty. 2007. DOI: 10.1016/j.arth.2006.12.088

[8] What Is the Revision-free Survival of Resurfaced Allograft-prosthesis Composites for Proximal Humerus Reconstruction in Children With Bone Tumors?. Clinical Orthopaedics & Related Research. 2024. DOI: 10.1097/corr.0000000000002969

[9] The porous-coated anatomic total hip prosthesis, inserted without cement. Results after five to seven years in a prospective study.. The Journal of Bone & Joint Surgery. 1993. DOI: 10.2106/00004623-199301000-00011

[10] Chapter 3 Emerging Technologies in Orthopaedic Trauma. 2021.

[11] Wear and Surface Cracking in Early Retrieved Highly Cross-linked Polyethylene Acetabular Liners. The Journal of Bone and Joint Surgery-American Volume. 2004. DOI: 10.2106/00004623-200406000-00021

[12] A Randomized Clinical Trial of Cementless Femoral Stems With and Without Hydroxyapatite/Tricalcium-Phosphate Coating. The Journal of Arthroplasty. 2007. DOI: 10.1016/j.arth.2006.06.005

[13] Cementless Unicompartmental Knee Arthroplasty: A Systematic Review of Survivorship and Revision Indications. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2026.01.019

[14] Migration of the Trabecular Metal Monoblock Acetabular Cup System. The Journal of Arthroplasty. 2010. DOI: 10.1016/j.arth.2008.09.027

[15] The effect of using components from different manufacturers on the rate of wear and corrosion of the head–stem taper junction of metal-on-metal hip arthroplasties. The Bone & Joint Journal. 2016. DOI: 10.1302/0301-620x.98b7.36554

[16] Fibroblast response to metallic debris in vitro. Enzyme induction cell proliferation, and toxicity.. The Journal of Bone & Joint Surgery. 1993. DOI: 10.2106/00004623-199306000-00005

[17] Mid‐term results of Autologous Matrix‐Induced Chondrogenesis for treatment of focal cartilage defects in the knee. Knee Surgery, Sports Traumatology, Arthroscopy. 2010. DOI: 10.1007/s00167-010-1042-3

[18] Total hip arthroplasty using highly cross-linked polyethylene in patients aged 50 years and younger. The Bone & Joint Journal. 2021. DOI: 10.1302/0301-620x.103b7.bjj-2020-2443.r1

[19] A Prospective, Randomized Study of Cross-Linked and Non–Cross-Linked Polyethylene for Total Hip Arthroplasty at 10-Year Follow-Up. The Journal of Arthroplasty. 2012. DOI: 10.1016/j.arth.2012.03.048

[20] Early migration patterns of calcium phosphate versus hydroxyapatite-coated stem in uncemented total hip arthroplasty: a prospective randomized clinical trial using radiostereometric analysis. Arthroplasty. 2025. DOI: 10.1186/s42836-025-00324-z

[21] Ceramic-on-metal coupling in THA: long term clinical and radiographic outcomes using two different short stems. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05077-3

[22] Does hydroxyapatite coating have no advantage over porous coating in primary total hip arthroplasty? A meta-analysis. Journal of Orthopaedic Surgery and Research. 2015. DOI: 10.1186/s13018-015-0161-4

[23] The mean ten-year results of metal-on-metal hybrid hip resurfacing arthroplasty. The Bone & Joint Journal. 2018. DOI: 10.1302/0301-620x.100b11.bjj-2017-1459.r2

[24] Polyethylene debris in lymph nodes after a total hip arthroplasty. A report of two cases.. The Journal of Bone & Joint Surgery. 1995. DOI: 10.2106/00004623-199505000-00014

[25] Porous-coated femoral components in a canine model for revision arthroplasty.. The Journal of Bone & Joint Surgery. 1988. DOI: 10.2106/00004623-198870080-00011

[26] Fixation_and_Wear_With_Contemporary_Acetabular_Components_and_Cross-Linked_Polye_S0883540315003769. n.d..

[27] Evaluation of Periprosthetic Bone-Remodeling After Cementless Total Hip Arthroplasty. The Journal of Bone and Joint Surgery-American Volume. 2000. DOI: 10.2106/00004623-200010000-00009

[28] Introduction: The “New” Disease: Taper Corrosion After Total Hip Arthroplasty—A State-of-the-Art Update. The Journal of Arthroplasty. 2018. DOI: 10.1016/j.arth.2018.07.008

[29] Corrosion_on_the_Acetabular_Liner_Taper_from_Retrieved_Modular_Metal-on-Metal_To_S0883540314003957. n.d..

[30] Dissemination of Wear Particles to the Liver, Spleen, and Abdominal Lymph Nodes of Patients with Hip or Knee Replacement. The Journal of Bone and Joint Surgery-American Volume*. 2000. DOI: 10.2106/00004623-200004000-00002

[31] Short-Term Results of the S-ROM-A Femoral Prosthesis. The Journal of Arthroplasty. 2009. DOI: 10.1016/j.arth.2009.03.009

[32] Risk Stratification Algorithm for Management of Head-Neck Taper Tribocorrosion in Patients with Metal-on-Polyethylene Total Hip Arthroplasty. Journal of Bone and Joint Surgery. 2021. DOI: 10.2106/jbjs.20.01837

[33] Fretting and corrosion of metal liners from modular dual mobility constructs. The Bone & Joint Journal. 2021. DOI: 10.1302/0301-620x.103b7.bjj-2020-0221.r1

[34] A Randomized Clinical Trial of Cementless Femoral Stems With and Without Hydroxyapatite/Tricalcium-Phosphate Coating. An 8- to 12-Year Follow-Up Study. The Journal of Arthroplasty. 2008. DOI: 10.1016/j.arth.2007.11.007

[35] Functional orientation of the acetabular component in ceramic-on-ceramic total hip arthroplasty and its relevance to squeaking. The Bone & Joint Journal. 2016. DOI: 10.1302/0301-620x.98b7.37062

[37] Blood Metal Ion Thresholds to Identify Patients with Metal-on-Metal Hip Implants at Risk of Adverse Reactions to Metal Debris. Journal of Bone and Joint Surgery. 2017. DOI: 10.2106/jbjs.16.01568

[38] Donor Site Evaluation after Autologous Osteochondral Mosaicplasty for Cartilaginous Lesions of the Elbow Joint. The American Journal of Sports Medicine. 2007. DOI: 10.1177/0363546507306465

[39] Influence of highly cross-linked polyethylene manufacturing characteristics on femoral head penetration in total hip arthroplasty. The Bone & Joint Journal. 2025. DOI: 10.1302/0301-620x.107b5.bjj-2024-1083.r1

[40] Fixation of the short global tissue-sparing hip stem. The Bone & Joint Journal. 2020. DOI: 10.1302/0301-620x.102b6.bjj-2019-1026.r2

[41] Effects of radiation on fixation of non-cemented porous-coated implants in a canine model.. The Journal of Bone & Joint Surgery. 1990. DOI: 10.2106/00004623-199072100-00015

[42] Characterization of dimensional, morphological and morphometric features of retrieved 3D-printed acetabular cups for hip arthroplasty. Journal of Orthopaedic Surgery and Research. 2020. DOI: 10.1186/s13018-020-01665-y

[43] Isolation and characterization of wear particles generated in patients who have had failure of a hip arthroplasty without cement.. The Journal of Bone & Joint Surgery. 1995. DOI: 10.2106/00004623-199509000-00002

[44] Periprosthetic bone loss in total hip arthroplasty. Polyethylene wear debris and the concept of the effective joint space.. The Journal of Bone & Joint Surgery. 1992. DOI: 10.2106/00004623-199274060-00006

[45] Agreement Between Proximal Femoral Geometry and Component Design in Total Hip Arthroplasty: Implications for Implant Choice. The Journal of Arthroplasty. 2016. DOI: 10.1016/j.arth.2016.02.015

[46] The_Effect_of_Surface_Morphology_on_the_Primary_Fixation_Strength_of_Uncemented_S0883540314007396. n.d..

[47] Finite Element Analysis of porously punched prosthetic short stem virtually designed for simulative uncemented Hip Arthroplasty. BMC Musculoskeletal Disorders. 2017. DOI: 10.1186/s12891-017-1651-9

[49] Serial magnetic resonance imaging of metal-on-metal total hip replacements. The Bone & Joint Journal. 2013. DOI: 10.1302/0301-620x.95b8.31377

[51] Imaging study of aseptic loosening of the acetabular cup after cementless total hip arthroplasty: a retrospective study. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08607-x

[53] Revision total hip arthroplasty without cement. The Journal of Bone & Joint Surgery. 1995. DOI: 10.2106/00004623-199508000-00012

[54] An Unusual Lymphocytic Perivascular Infiltration in Tissues Around Contemporary Metal-on-Metal Joint Replacements. The Journal of Bone & Joint Surgery. 2005. DOI: 10.2106/jbjs.c.00949

[55] Patterns of Changes in Femoral Bone Mineral Density Up To Five Years After Hip Resurfacing. The Journal of Arthroplasty. 2013. DOI: 10.1016/j.arth.2012.09.012

[56] MRI_Findings_Following_Metal_on_Metal_Hip_Arthroplasty_and_Their_Relationship_Wi_S0883540314002186. n.d..

[58] Virtual biomechanical assessment of porous tantalum and custom triflange components in the treatment of patients with acetabular defects and pelvic discontinuity. The Bone & Joint Journal. 2024. DOI: 10.1302/0301-620x.106b5.bjj-2023-0852.r1

[59] Three Differing Methods of Treating Intraoperative Nondisplaced Calcar Fractures Demonstrate Similar Radiographic Stem Subsidence. The Journal of Arthroplasty. 2024. DOI: 10.1016/j.arth.2024.03.049

[60] Characterization and Comparison of Wear Debris from Failed Total Hip Implants of Different Types. The Journal of Bone & Joint Surgery*. 1996. DOI: 10.2106/00004623-199608000-00014

[61] Mid- to long-term results after bipolar radial head arthroplasty. Journal of Shoulder and Elbow Surgery. 2010. DOI: 10.1016/j.jse.2010.05.022

[62] A Novel Approach for Determining Three-Dimensional Acetabular Orientation: Results from Two Hundred Subjects. The Journal of Bone and Joint Surgery-American Volume. 2014. DOI: 10.2106/jbjs.l.01141

[63] Current Concepts Review - Hallux Rigidus and Osteoarthrosis of the First Metatarsophalangeal Joint. The Journal of Bone & Joint Surgery*. 1998. DOI: 10.2106/00004623-199806000-00015

[64] Evaluation of Component Positioning in Primary Total Hip Arthroplasty Using an Imageless Navigation Device Compared With Traditional Methods. The Journal of Arthroplasty. 2009. DOI: 10.1016/j.arth.2008.01.004

[65] Nonoperative and Operative Bone and Cartilage Regeneration and Orthopaedic Biologics of the Hip: An Orthoregeneration Network (ON) Foundation Hip Review. Arthroscopy. 2021. DOI: 10.1016/j.arthro.2021.08.032

[66] Hip capsule biomechanics after arthroplasty. The Bone & Joint Journal. 2019. DOI: 10.1302/0301-620x.101b4.bjj-2018-1321.r1

[67] Promising early results for trabecular metal acetabular components used at revision total hip arthroplasty: 42 acetabular revisions followed with radiostereometry in a prospective randomised trial.. The bone & joint journal. 2017. DOI: 10.1302/0301-620X.99B7.BJJ-2016-1241.R1

[68] Do metal implants for total hip arthroplasty affect bioelectrical impedance analysis? A retrospective study. BMC Musculoskeletal Disorders. 2023. DOI: 10.1186/s12891-023-06893-x

[69] We Need Better Classification of Patients With Borderline Hip Dysplasia: Shifting the Focus From Dysplasia to Instability. Arthroscopy. 2024. DOI: 10.1016/j.arthro.2023.10.023

[70] Long‐Term Degradation of Self‐Reinforced Poly–Levo (96%)/Dextro (4%)–Lactide/β‐Tricalcium Phosphate Biocomposite Interference Screws. Arthroscopy. 2015. DOI: 10.1016/j.arthro.2015.08.037

[72] Comparison of femoral component migration between Refobacin bone cement R and Palacos R + G in cemented total hip arthroplasty. The Bone & Joint Journal. 2016. DOI: 10.1302/0301-620x.98b10.37116

[73] Correlation_of_Corrosion_and_Biomechanics_in_the_Retrieval_of_a_Single_Modular_N_S0883540314004173. n.d..

[74] Fretting and Corrosion in Modular-Neck Total Hip Arthroplasty Femoral Stems. Journal of Bone and Joint Surgery. 2014. DOI: 10.2106/jbjs.l.01625

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