Does the presence of a lipped highly crosslinked polyethylene liner affect the survival of total hip arthroplasty implants? - A registry-based retrospective cohort study

Sep 29, 2026

Large-scale registry data evaluate whether lipped highly crosslinked polyethylene (HXLPE) liners (LL) change long-term implant survival after primary total hip arthroplasty (THA) compared with flat liners (FL). Analysis covers 15,222 THAs in 13,989 patients treated between 2000 and 2021 using Kaplan-Meier survival and multivariable Cox regression. Overall revision rates show no significant difference, yet LL increases dislocation and aseptic acetabular loosening, with higher mechanical-complication–linked revision hazard. Outcomes emphasize careful positioning and patient-specific selection.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages9

Reading Time23 min

AccessFree to download

Aims

Methods

Study design and population

Outcomes and statistical analysis

Results

Overall revision and long-term survival

Mechanical complications

Multivariable findings

Conclusion

Take home message

Introduction

Methods

Does the presence of a lipped highly crosslinked polyethylene liner affect the survival of total hip arthroplasty implants? A registry-based retrospective cohort study From University of Bologna, and IRCCS-Istituto Ortopedico Rizzoli, Bologna, Italy Correspondence should be sent to A. Di Martino albertocorrado.dimartino@ [ior.it](ior.it) Cite this article: Bone Jt Open 2026;7(1): 19–27. DOI: 10. 1302/2633-1462 . 71.BJO-2025-0243.R1 A. Di Martino,1,2 M. Morandi Guaitoli,1 C. D'Agostino,1 B. Bordini,3 C. Faldini1,2 1 1st Department of Orthopedics and Traumatology, IRCCS-Istituto Ortopedico Rizzoli, Bologna, Italy 2Department of Biomedical and Neuromotor Sciences-DIBINEM, University of Bologna, Bologna, Italy 3Medical Technology Laboratory, IRCCS-Istituto Ortopedico Rizzoli, Bologna, Italy Aims This study aimed to evaluate the effect of lipped liners (LL) on implant survival in primary total hip arthroplasty (THA), focusing on mechanical complications such as dislocation and aseptic loosening. Given the conflicting evidence on LL performance, we conducted a large-scale registry analysis to clarify their long-term safety and effectiveness compared to flat liners (FL) . Methods We analyzed 15,222 primary THAs performed in 13,989 patients between 1 January 2000 and 31 December 2021, using data from the Emilia-Romagna Registry of Orthopaedic Prosthetic Implants (RIPO) . Patients were allocated into two groups: 7,619 received FL and 7,603 received LL. The primary outcome was implant survival, with mechanical complications as key endpoints. Kaplan-Meier survival analysis and multivariate Cox regression were employed to assess therevision risk, adjusted for age, sex, type of stem fixation, femoral head material, and liner design. Results Overall, no significant difference in revision rates was observed comparing groups when all the causes of revisions were considered (log-rank p = 0.088); at 15 years, cumulative implant survival was 96.9% for FL and 96.4% for LL. Revisions for dislocation (28.2% vs 19.0%) and aseptic acetabular loosening (19.2% vs 13.8%) were more frequent in the LL group. When considering mechanical complications alone, 15-year survival was 98.9% for FL versus 98.1% for LL; a similar trend was observed at 20 years (98.9% vs 96.2%; p = 0.002) . In multivariable analysis, LL use was independently associated with an increased hazard of revision (HR 1.53, 95% CI 1.05 to 2.23; p = 0.026) . Conclusion LL use in THA is linked to a higher risk of mechanical complications and implant revision compared to FL. Although LL may provide enhanced stability in select cases, optimal outcomes depend on patient-specific factors and precise implant positioning, warranting a cautious approach to their widespread use. Take home message • The use of lipped liners in primary total hip arthroplasty is associated with a higher overall risk of revision—specifically due to mechanical complications such as dislocation, aseptic loosening, and polyethylene wear—when compared with flatliners (HR = 1.53,(95% CI 1.05 to to 2.23); p = 0 .026) . Does the presence of a lipped HXLPE liner affect the survival of total hip arthroplasty implants? 19 A. Di Martino, M. Morandi Guaitoli, C. D'Agostino, B. Bordini, C. Faldini Introduction Total hip arthroplasty (THA) has often been described as the“operation of the century” due to its notable clinical success and cost-effectiveness.1 Despite this success, projections indicate a substantial rise in revision procedures, with an estimated 19% increase—potentially reaching up to 40%—by 2050 to 2060.2,3 Instability after THA remains a critical issue, with reported dislocation rates ranging from 0.2% to 10% and accounting for up to 22.5% of all revisions.4,5 Moreover, patients undergoing revision for instability face a significant risk of recurrent dislocation.6 The success of a THA implant is contingent upon many variables—including patient-specific factors, surg

FAQs

What was the study’s primary goal regarding lipped liners in primary THA?

To evaluate whether lipped liners (LL) affect implant survival in primary THA, with emphasis on mechanical complications such as dislocation and aseptic loosening.

How were patients and liner types compared in the registry analysis?

Patients with primary THA were grouped by liner type: 7,619 received flat liners (FL) and 7,603 received lipped liners (LL), using registry data from 2000 to 2021.

Did lipped liners significantly change overall revision rates compared with flat liners?

No. Considering all revision causes, no significant difference was found (log-rank p = 0.088), with similar cumulative survival at 15 years.

What mechanical complications were more frequent with lipped liners?

Revisions for dislocation and aseptic acetabular loosening were more frequent in the LL group, and LL use was independently associated with a higher hazard of revision.

Sep 29, 2026

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