Association of polyethylene type with revision and dislocation risk following primary total hip arthroplasty: a population-based cohort study from the Danish Hip Arthroplasty Register
DOI:
https://doi.org/10.2340/17453674.2026.46487Keywords:
Arthroplasty, Aseptic loosening, Dislocation, Highly Cross-linked Polyethylene, HipAbstract
Background and purpose: Highly cross-linked polyethylene (HXLPE) has been widely adopted to address wear in total hip arthroplasty (THA), yet population-based evidence remains limited. We aimed to evaluate the long-term risk of all-cause revision, dislocation, and cause-specific revision according to polyethylene type in primary THA.
Methods: We conducted a population-based cohort study using data from the Danish Hip Arthroplasty Register and the Danish National Patient Register, including 48,618 patients undergoing primary THA for osteoarthritis from 2000 to 2016. Patients were followed until revision, dislocation, death, year 10, or December 2021. We compared HXLPE with non-HXLPE for patients receiving implants with 28 mm, 32 mm, and 36 mm femoral heads. We estimated standardized risk differences using targeted maximum likelihood estimation comparing polyethylene type stratified by femoral head size and standardized to age, sex, fixation, and Charlson Comorbidity Index.
Results: Standardized risk differences showed favorable results for HXLPE regarding all-cause revision (–3.1%, 95% confidence interval [CI] –4.5 to –1.6), dislocation (–1.9%, CI –3.1 to –0.6), revision due to dislocation (–1.3%, CI –1.9 to –0.7), and revision due to infection (–0.9%, CI –1.3 to –0.4) for 36 mm heads, and for dislocation (–1.4%, CI –2.6 to –0.2) and revision due to aseptic loosening (–0.8%, CI –1.1 to –0.5) for 32 mm heads. There was no difference between HXLPE and non-HXPLE for any outcomes for the 28 mm group.
Conclusion: Among 36 mm implants, HXLPE was associated with lower risk of dislocation, all-cause revision, and revision due to infection and dislocation. Among 32 mm implants, HXLPE was associated with lower risk of dislocation and aseptic loosening revision. These findings may suggest potential advantages of HXLPE, though caution is warranted given the observational design.
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Atkins G J, Haynes D R, Howie D W, Findlay D M. Role of polyethylene particles in peri-prosthetic osteolysis: a review. World J Orthop 2011; 2(10): 93-101. doi: 10.5312/wjo.v2.i10.93.
Zhu Y H, Chiu K Y, Tang W M. Review article: Polyethylene wear and osteolysis in total hip arthroplasty. J Orthop Surg (Hong Kong) 2001; 9(1): 91-9. doi: 10.1177/230949900100900117.
Danish Hip Arthroplasty Register [Internet]. National Annual Report 2024. Available from: https://www.sundk.dk/media/fz0bgm2m/dhr_aarsrapport_2024_udgivet_2025_offentliggjort-version.pdf
Ingham E, Fisher J. The role of macrophages in osteolysis of total joint replacement. Biomaterials 2005; 26(11): 1271-86. doi: 10.1016/j.biomaterials.2004.04.035.
Kahlenberg C A, Swarup I, Krell E C, Heinz N, Figgie M P. Causes of revision in young patients undergoing total hip arthroplasty. J Arthroplasty 2019; 34(7): 1435-40. doi: 10.1016/j.arth.2019.03.014.
Sluis-Cremer T, Shimmin A J. Arthroplasty options for the young arthritic hip. Ann Joint 2020; 5: 31. doi: 10.21037/aoj.2020.02.05.
Kurtz S M, Gawel H A, Patel J D. History and systematic review of wear and osteolysis outcomes for first-generation highly crosslinked polyethylene. Clin Orthop Relat Res 2011; 469(8): 2262-77. doi: 10.1007/s11999-011-1872-4.
Mutimer J, Devane P A, Adams K, Horne J G. Highly crosslinked polyethylene reduces wear in total hip arthroplasty at 5 years. Clin Orthop Relat Res 2010; 468(12): 3228-33. doi: 10.1007/s11999-010-1379-4.
Tsukamoto M, Mori T, Ohnishi H, Uchida S, Sakai A. Highly cross-linked polyethylene reduces osteolysis incidence and wear-related reoperation rate in cementless total hip arthroplasty compared with conventional polyethylene at a mean 12-year follow-up. J Arthroplasty 2017; 32(12): 3771-6. doi: 10.1016/j.arth.2017.06.047.
de Steiger R, Lorimer M, Graves S E. Cross-linked polyethylene for total hip arthroplasty markedly reduces revision surgery at 16 years. J Bone Joint Surg Am 2018; 100(15): 1281-8. doi: 10.2106/JBJS.17.01221.
Langlois J, Hamadouche M. What have we learned from 20 years of using highly crosslinked PE in total hip arthroplasty? Orthop Traumatol Surg Res 2023; 109(1S): 103457. doi: 10.1016/j.otsr.2022.103457.
Schmidt M, Schmidt S A, Sandegaard J L, Ehrenstein V, Pedersen L, Sørensen H T. The Danish National Patient Registry: a review of content, data quality, and research potential. Clin Epidemiol 2015; 7: 449-90. doi: 10.2147/CLEP.S91125.
RECORD statement. Available from: https://www.record-statement.org/
Hermansen L L, Viberg B, Overgaard S. Development of a diagnostic algorithm identifying cases of dislocation after primary total hip arthroplasty-based on 31,762 patients from the Danish Hip Arthroplasty Register. Acta Orthop 2021; 92(2), 137-42. doi: 10.1080/17453674.2020.1868708.
Rytgaard H C W, Eriksson F, van der Laan M J. Estimation of time-specific intervention effects on continuously distributed time-to-event outcomes by targeted maximum likelihood estimation. Biometrics 2023; 79(4): 3038-49. doi: 10.1111/biom.13856.
Rytgaard H C W, van der Laan M J. Targeted maximum likelihood estimation for causal inference in survival and competing risks analysis. Lifetime Data Anal 2024; 30(1): 4-33. doi: 10.1007/s10985-022-09576-2.
Chen D. concrete: Continuous-time competing risks estimation using Targeted Minimum Loss-Based Estimation (TMLE); 2023. R package version 1.0.5. available from: https://cran.r-project.org/src/contrib/Archive/concrete (accessed Feb 14, 2026).
Yoon B H, Park J W, Lee Y K, Koo K H, Chang C B. Long-term wear-related complications of cross-linked versus conventional polyethylene after total hip arthroplasty: a meta-analysis. J Arthroplasty 2022; 37(11): 2308-15.e2. doi: 10.1016/j.arth.2022.05.013.
Lewis P L, Gill D R, McAuliffe M J, McDougall C, Stoney J D, Vertullo C J, et al. Hip, Knee and Shoulder Arthroplasty: 2024 Annual Report, Australian Orthopaedic Association National Joint Replacement Registry. Adelaide, South Australia: AOA; 2024. https://doi.org/10.25310/GLOL7776
Parilla F W, Ince D C, Pashos G E, Maloney W J, Clohisy J C. Long-term follow-up of conventional polyethylene in total hip arthroplasty in young patients: heightened wear-related complications are observed at the beginning of the third decade. J Arthroplasty 2022; 37(9): 1816-21. doi: 10.1016/j.arth.2022.04.011.
Garvin K L, White T C, Dusad A, Hartman C W, Martell J. Low wear rates seen in THAs with highly crosslinked polyethylene at 9 to 14 years in patients younger than age 50 years. Clin Orthop Relat Res 2015; 473(12): 3829-35. doi: 10.1007/s11999-015-4422-7.
Paxton E, Cafri G, Havelin L, Stea S, Pallisó F, Graves S, et al. Risk of revision following total hip arthroplasty: metal-on-conventional polyethylene compared with metal-on-highly cross-linked polyethylene bearing surfaces: international results from six registries. J Bone Joint Surg Am 2014; 96(Suppl 1): 19-24. doi: 10.2106/JBJS.N.00460.
Wu M, Bukowski B R, Fruth K M, Trousdale R T, Abdel M P, Mabry T M. Should we use the largest femoral head with the smallest acetabular component in primary total hip arthroplasty? J Arthroplasty 2025; 40(9S1): S290-S296.e3. doi: 10.1016/j.arth.2025.05.078.
Muratoglu O K, Bragdon C R, O’Connor D, Perinchief R S, Estok D M 2nd, Jasty M, et al. Larger diameter femoral heads used in conjunction with a highly cross-linked ultra-high molecular weight polyethylene: a new concept. J Arthroplasty 2001; 16(8 Suppl 1): 24-30. doi: 10.1054/arth.2001.28376.
Girard J. Femoral head diameter considerations for primary total hip arthroplasty. Orthop Traumatol Surg Res 2015; 101(1 Suppl): S25-9. doi: 10.1016/j.otsr.2014.07.026.
Jameson S S, Lees D, James P, Serrano-Pedraza I, Partington P F, Muller S D, et al. Lower rates of dislocation with increased femoral head size after primary total hip replacement: a five-year analysis of NHS patients in England. J Bone Joint Surg Br 2011; 93(7): 876-80. doi: 10.1302/0301-620X.93B7.26657.
Ashkanfar A, Toh S M S, English R, Langton D J, Joyce T J. The impact of femoral head size on the wear evolution at contacting surfaces of total hip prostheses: a finite element analysis. J Mech Behav Biomed Mater 2024; 153: 106474. doi: 10.1016/j.jmbbm.2024.106474.
Lachiewicz P F, Heckman D S, Soileau E S, Mangla J, Martell J M. Femoral head size and wear of highly cross-linked polyethylene at 5 to 8 years. Clin Orthop Relat Res 2009; 467(12): 3290-6. doi: 10.1007/s11999-009-1038-9.
Banche G, Bracco P, Allizond V, Bistolfi A, Boffano M, Cimino A, et al. Do crosslinking and vitamin E stabilization influence microbial adhesions on UHMWPE-based biomaterials? Clin Orthop Relat Res 2015; 473(3): 974-86. doi: 10.1007/s11999-014-4024-9.
Tsikandylakis G, Mohaddes M, Cnudde P, Eskelinen A, Kärrholm J, Rolfson O. Head size in primary total hip arthroplasty. EFORT Open Rev 2018; 3(5): 225-31. doi: 10.1302/2058-5241.3.170061.
Hermansen L L, Iversen T F, Iversen P, Viberg B, Overgaard S. The “true” 1-year incidence of dislocation after primary total hip arthroplasty: validation of an algorithm identifying dislocations in the Danish National Patient Register based on 5,415 patients from the Danish Hip Arthroplasty Register. Acta Orthop 2024; 95: 380-5. doi: 10.2340/17453674.2024.41064.
Karim M E, Lei Y. How effective are machine learning and doubly robust estimators in incorporating high-dimensional proxies to reduce residual confounding? Pharmacoepidemiol Drug Saf 2025; 34(5): e70155. doi: 10.1002/pds.70155.
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