Acetabulum Liner
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haminatrafAcetabulum Liner
Uploaded by
haminatrafACETABULUM LINER
January 6, 2017
THA Implants
The current acetabular implant is a cementless 2-component cup. A metal
shell for bony ingrowth + a liner to articulate with femoral head. We
discuss the LINER.
Polyethylene liner (ie "poly") is the most common material type for the
acetabular liner, however, ceramic or metal are also available. The
Acetabular Shell provides the base for bony ingrowth, while the liner clips
into the shell and articulates directly with the Femoral Head.
The Liner Size refers to its inner diameter = the Femoral Head Size. The
poly must be at the very minimum 6 mm in thickness to prevent fracture.
The Femoral Head Size + Liner Thickness = Acetabular Shell size. Liners
come in varying thickness. For example a Size 32 Femoral Head can fit into
an Acetabular Cup Size 48, 50, 52 etc etc because you can get a 16 mm, 18
mm, 20 mm etc thickness poly. Importantly, there is variability in sizing
between manufacturers.
Chart Showing Size of Femoral Heads that Fit Size of Acetabular Shells
POLYETHYLENE
Poly is a long-chain polymer that’s a tough biocompatible material, and the
first iteration, polytetrafluoroethylene (aka Teflon), was introduced to THA
by Dr. Charnley. The original poly demonstrated high wear rates (about 0.2
mm/year) that lead to loosening from osteolysis. There was minimal poly
cross-linking, and it was sterilized in air (leading to high free radical
production).
Interestingly, this loosening was initially attributed to cement failure,
termed “cement disease”, and this misconception drove advances in press-fit
technology. Once the etiology of aseptic loosening was correctly attributed
to conventional poly, poly was then seen as the leading barrier to long-term
THA survival and thus multiple alternatives were developed, particularly
the now notorious metal-on-metal implants.
Yet advances in poly have continued over the decades. The poly material
improved to high-density polyethylene (HDPE) in the 1970s (wear 0.10
mm/year), and then to ultrahigh molecular weight polyethylene
(UHMWPE) in the early 2000s, which has progressively demonstrated
significantly less wear (<0.02 mm/year).
UHMWPE. There is a process to manufacturing UHMWPE. The poly is
subjected to higher radiation (5-10 Mrads) that breaks poly bonds and
creates free radicals that bond with other free radicals on neighboring chains
to form cross-links. This is how cross-linking occurs.
The process initially creates instability, which can be problematic if the
environment isn't closely regulated, for example, if there is oxygen lying
around, then free radicals don't bond with each other to form cross-links but
rather combine with oxygen, which propagates further free radical
formation, and ultimately breaks down the poly to create "Oxidized PE".
Therefore, radiation is performed in the setting of inert gas to prevent
oxidation of the poly. Irradiating the PE in inert gas accomplishes two
things: 1) it reduces wear by forming cross-links; and 2) it sterilizes the PE.
There are techniques to sterilize the PE without cross-linking using ethylene
oxide gas or gas plasma spray.
After the poly undergoes radiation in an inert gas, it is heated (via remelting,
or annealing) to quench the remaining free radials (the heating allows free
radicals form stable carbon-carbon covalent bonds). This process has the
side effect of decreasing the crystallinity, thus decreasing toughness and
tensile strength of the poly.
Some second generation UHMWPE liners are impregnated with
antioxidants (such as Vit. E) to further decrease free radical breakdown after
implantation.
Up to this point the poly is prepared as a solid tube of plastic. It then needs
to be shaped into the poly insert that’s implanted during surgery. There are a
few techniques, although direct compression molding (implant made from a
mold, no machining involved) creates the lowest wear.
In summary, its believed that the summation of advancements in poly
manufacturing have decreased wear by 95% compared to conventional PE.
LINER DESIGN TYPES.
The standard poly liner is a neutral face hemispherical design to allow
maximal range of motion (the goal is to provide a large implant ROM so
that the THA falls within the motion circle allowed by native hip anatomy.
The poly can have a 10, 15, or 20° lip liner depending on the manufacturer.
The “lip” is placed in the region with the greatest risk for dislocation, to
provide an additional few millimeters of clearance needed for the jump
distance. The poly can also be lateralized by 4 mm. In this scenario, the
liner has more material on the medial side, as opposed to the apex, thereby
“lateralizing” the center of rotation of the hip. This is the same as
increasing offset, only it occurs on the acetabular side as opposed to the
"high offset" stem. This usually also results in adding length but it is
negligible. This liner can be used in cases of protrusio or revision cases
when the goals are to increase stability by restoring tension on the soft
tissues (particularly the abductor complex).
There are also liners used in revision cases when there is a higher risk of
dislocation. This includes a dual-mobility and a constrained liner. Dual-
mobility is essentially a bipolar head (as used in some hemi cases) within a
cup. A constrained liner occurs when the femoral head gets locked into the
poly.
