Vitamin E-blended highly cross-linked polyethylene liners in total hip arthroplasty: a randomized, multicenter trial using virtual CAD-based wear analysis at 5-year follow-up

  • André BuschEmail author
  • Marcus Jäger
  • Stefan Klebingat
  • Josef Baghdadi
  • Thilo Flörkemeier
  • Felix Hütter
  • Thomas M. Grupp
  • VITAS-Group
  • Marcel Haversath
Orthopaedic Surgery



Progressive oxidation of highly cross-linked ultra-high molecular weight (UHMPWE-X) liners is considered to be a risk factor for material failure in THA. Antioxidants such as vitamin E (alpha-tocopherol) (UHMWPE-XE) were supplemented into the latest generation of polyethylene liners. To prevent inhomogenous vitamin E distribution within the polymer, blending was established as an alternative manufacturing process to diffusion. The purpose of the present study was to investigate the in vivo wear behavior of UHMWPE-XE in comparison with conventional UHMWPE-X liners using virtual CAD-based radiographs.


Until now, 94 patients from a prospective, randomized, controlled, multicenter study were reviewed at 5-year follow-up. Of these, 51 (54%) received UHMWPE-XE and 43 (46%) UHMWPE-X liners. Anteroposterior pelvic radiographs were made immediately after surgery and at 1 and 5 years postoperatively. The radiographs were analyzed using the observer-independent analysis software RayMatch® (Raylytic GmbH, Leipzig, Germany).


The mean wear rate was measured to be 23.6 μm/year (SD 13.7; range 0.7–71.8 μm). There were no significant differences between the two cohorts (UHMWPE-X: 23.2 μm/year vs. UHMWPE-XE: 24.0 μm/year, p = 0.73). Cup anteversion significantly changed within the 1st year after implantation independent from the type of polyethylene liner [UHMWPE-X: 18.2–23.9° (p = 0.0001); UHMWPE-XE: 21.0–25.5° (p = 0.002)]. No further significant changes of cup anteversion in both groups were found between year 1 and 5 after implantation [UHMWPE-X (p = 0.46); UHMWPE-XE (p = 0.56)].


The present study demonstrates that the addition of vitamin E does not adversely affect the midterm wear behavior of UHMWPE-X. The antioxidative benefit of vitamin E is expected to become evident in long-term follow-up. Cup anteversion increment by 5° within the 1st year is likely a result of the released hip flexion contracture resulting in an enhanced posterior pelvic tilt. Therefore, a reassessment of target values in acetabular cup placement might be considered.


Total hip arthroplasty CAD-based wear analysis UHMWPE-XE Particle-induced osteolysis 


Author contribution

All authors ensured that they had furnished a substantial contribution to the article and that they are in agreement with form and contents of the manuscript.


The study is financially supported by B. Braun-Aesculap AG, Germany; Trial registration: NCT01713062. This study was supported by B. Braun Melsungen (AAG-G-H-1113).

Compliance with ethical standards

Ethics approval and consent to participate

The study was approved by the local ethics committee (11-4845-BO). The study was registered on The trial registration number is NCT01713062.

Consent to publish

All patients consented to publish personal data in an anonymised form.

Conflict of interest

The authors declare they have no conflict of interest.

Patient confidentiality

Data were protected according to the U.S. Health Insurance Portability and Accountability Act (HIPAA).


  1. 1.
    Beaulé PE, Campbell P, Mirra J, Hooper JC, Schmalzried TP (2001) Osteolysis in a cementless, second generation metal-on-metal hip replacement. Clin Orthop Relat Res 386:159–165CrossRefGoogle Scholar
  2. 2.
    Muratoglu OK, Kurtz S (2002) Alternate bearing surfaces in hip replacement. In: Sinha R (ed) Hip replacement. Current trends and controversies. CRC Press, New York, pp 1–46Google Scholar
  3. 3.
    Oral E, Wannomae KK, Rowell SL, Muratoglu OK (2007) Diffusion of vitamin E in ultra-high molecular weight polyethylene. Biomaterials 28(35):5225–5237 (Epub 2007 Sep 19) CrossRefGoogle Scholar
  4. 4.
    Kawakage NOS, Ogihara T (1997) Poly (vinyl alcohol)-clay and poly (ethylene oxide)-clay blends prepared using water as solvent. J Appl Polym Sci 66:573–581CrossRefGoogle Scholar
  5. 5.
    Digas G, Karrholm J, Thanner J, Malchau H, Herberts P (2004) Highly cross-linked polyethylene in total hip arthroplasty: randomized evaluation of penetration rate in cemented and uncemented sockets using radiostereometric analysis. Clin Orthop. 429:16CrossRefGoogle Scholar
  6. 6.
    Nivbrant B, Roerhl S, Hewitt B, Li M. In vivo wear and migration of high cross linked poly cups: a RSA study. In: 49th Annual Orthopaedic Research Society; 2003; New Orleans; 2003. p. 358Google Scholar
  7. 7.
    MacDonald D, Sakona A, Ianuzzi A et al (2011) Do first-generation highly crosslinked polyethylenes oxidize in vivo? Clin Orthop Relat Res 469:2278–2285CrossRefGoogle Scholar
  8. 8.
    Oral E, Christensen S, Malhi A, Wannomae K, Muratoglu O (2006) Wear resistance and mechanical properties of highly crosslinked UHMWPE doped with vitamin E. J Arthroplasty 21(4):580–591CrossRefGoogle Scholar
  9. 9.
    Bracco P, Oral E (2011) Vitamin E-stabilized UHMWPE for total joint implants: a review. Clin Orthop Relat Res 469:2286–2293CrossRefGoogle Scholar
  10. 10.
    Oral E, Wannomae KK, Hawkins N, Harris WH, Muratoglu OK (2004) Tocopheroldoped irradiated UHMWPE for high fatigue resistance and low wear. Biomaterials 25:5515–5522CrossRefGoogle Scholar
  11. 11.
    Grupp TM, Holderied M, Mulliez MA, Streller R, Jäger M, Blömer W, Utzschneider S (2014) Biotribology of a vitamin E-stabilized polyethylene for hip arthroplasty—influence of artificial ageing and third-body particles on wear. Acta Biomater 10(7):3068–3078. 2014 Mar 12) CrossRefPubMedGoogle Scholar
  12. 12.
    Oral E, Godleski Beckos C, Malhi AS, Muratoglu OK (2008) The effects of high dose irradiation on the cross-linking of vitamin E-blended ultrahigh molecular weight polyethylene. Biomaterials 29(26):3557–3560. 2008 Jun 2) CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Xu JZ, Wannomae KK, Muratoglu OK, Oral E (2018) Increased oxidative protection by high active vitamin E content and partial radiation crosslinking of UHMWPE. J Orthop Res 36(7):1860–1867. 2018 Jan 3) CrossRefPubMedGoogle Scholar
  14. 14.
    Oral E, Ghali BW, Rowell SL, Micheli BR, Lozynsky AJ, Muratoglu OK (2010) A surface crosslinked UHMWPE stabilized by vitamin E with low wear and high fatigue strength. Biomaterials 31(27):7051–7060. 2010 Jun 25) CrossRefPubMedGoogle Scholar
  15. 15.
    Oral E, Muratoglu OK (2011) Vitamin E diffused, highly crosslinked UHMWPE: a review. Int Orthop 35(2):215–223. 2010 Dec 1) CrossRefPubMedGoogle Scholar
  16. 16.
    Parth M, Aust N, Lederer K (2002) Studies on the effect of electron beam radiation on the molecular structure of ultra-high molecular weight polyethylene under the influence of alpha-tocopherol with respect to its application in medical implants. J Mater Sci Mater Med 13(10):917–921CrossRefGoogle Scholar
  17. 17.
    Oral E, Greenbaum E, Malhi A, Muratoglu O (2005) Characterization of blends of α-Tocopherol with UHMWPE. Biomaterials 26:6657–6663CrossRefGoogle Scholar
  18. 18.
    Oral E, Neils AL, Rowell SL, Lozynsky AJ, Muratoglu OK (2013) Increasing irradiation temperature maximizes vitamin E grafting and wear resistance of ultrahigh molecular weight polyethylene. J Biomed Mater Res B Appl Biomater 101(3):436–440. 2012 Oct 31) CrossRefPubMedGoogle Scholar
  19. 19.
    Ayers DC, Greene M, Snyder B et al (2015) Radiostereometric analysis study of tantalum compared with titanium acetabular cups and highly cross-linked compared with conventional liners in young patients undergoing total hip replacement. J Bone Joint Surg Am 97:627–634CrossRefGoogle Scholar
  20. 20.
    Selvik G (1989) Roentgen stereophotogrammetry. A method for the study of the kinematics of the skeletal system. Acta Orthop Scand 232:1–51CrossRefGoogle Scholar
  21. 21.
    Bottner F, Su E, Nestor B, Azzis B, Sculco TP, Bostrom M (2005) Radiostereometric analysis: the hip. HSS J. 1(1):94–99. CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Stilling M, Kold S, de Raedt S, Andersen NT, Rahbek O, Søballe K (2012) Superior accuracy of model-based radiostereometric analysis for measurement of polyethylene wear: a phantom study. Bone Joint Res. 1(8):180–191. 2012 Aug) CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Troelsen A, Greene ME, Ayers DC, Bragdon CR, Malchau H (2015) A Novel method for assessment of polyethylene liner wear in radiopaque tantalum acetabular cups: clinical validation in patients enrolled in a randomized controlled trial. J Arthroplasty 30(12):2354–2359. 2015 Jul 2) CrossRefPubMedGoogle Scholar
  24. 24.
    Langton DJ, Sprowson AP, Mahadeva D, Bhatnagar S, Holland JP, Nargol AV (2010) Cup anteversion in hip resurfacing: validation of EBRA and the presentation of a simple clinical grading system. J Arthroplasty 25(4):607–613. 2009 Dec 21) CrossRefPubMedGoogle Scholar
  25. 25.
    Biedermann R, Krismer M, Stöckl B, Mayrhofer P, Ornstein E, Franzén H (1999) Accuracy of EBRA-FCA in the measurement of migration of femoral components of total hip replacement. Einzel-Bild-Röntgen-Analyse-femoral component analysis. J Bone Joint Surg Br. 81(2):266–272CrossRefGoogle Scholar
  26. 26.
    Krismer M, Bauer R, Tschupik J, Mayrhofer P (1995) EBRA: a method to measure migration of acetabular components. J Biomech 28(10):1225–1236CrossRefGoogle Scholar
  27. 27.
    Callary SA, Solomon LB, Holubowycz OT et al (2017) Accuracy of methods to measure femoral head penetration within metal-backed acetabular components. J Orthop Res 35:988–996CrossRefGoogle Scholar
  28. 28.
    Haversath M, Klebingat S, die VITAS-Gruppe, Jäger M (2018) Endoprosthetic wear analysis using virtual CAD-based radiographs. Orthopade. 47(10):811–819. in German) CrossRefPubMedGoogle Scholar
  29. 29.
    Jäger M, Van Wasen A, Warwas S et al (2014) A multicenter approach evaluating the impact of vitamin e-blended polyethylene in cementless total hip replacement. Orthop Rev (Pavia) 6:5285CrossRefGoogle Scholar
  30. 30.
    Dowd JE, Sychterz CJ, Young AM, Engh CA (2000) Characterization of long-term femoral-head-penetration rates. Association with and prediction of osteolysis. J Bone Joint Surg Am. 82(8):1102–1107CrossRefGoogle Scholar
  31. 31.
    Scemama C, Anract P, Dumaine V, Babinet A, Courpied JP, Hamadouche M (2017) Does vitamin E-blended polyethylene reduce wear in primary total hip arthroplasty: a blinded randomised clinical trial. Int Orthop 41(6):1113–1118. 2016 Nov 4) CrossRefPubMedGoogle Scholar
  32. 32.
    Salemyr M, Muren O, Ahl T, Bodén H, Chammout G, Stark A, Sköldenberg O (2015) Vitamin-E diffused highly cross-linked polyethylene liner compared to standard liners in total hip arthroplasty. A randomized, controlled trial. Int Orthop. 39(8):1499–1505. 2015 Jan 29) CrossRefPubMedGoogle Scholar
  33. 33.
    Nebergall AK, Greene ME, Laursen MB, Nielsen PT, Malchau H, Troelsen A (2017) Vitamin E diffused highly cross-linked polyethylene in total hip arthroplasty at five years: a randomised controlled trial using radiostereometric analysis. Bone Joint J. 99(5):577–584. CrossRefPubMedGoogle Scholar
  34. 34.
    Galea VP, Connelly JW, Shareghi B, Kärrholm J, Sköldenberg O, Salemyr M, Laursen MB, Muratoglu O, Bragdon C, Malchau H (2018) Evaluation of in vivo wear of vitamin E-diffused highly crosslinked polyethylene at five years: a multicentre radiostereometric analysis study. Bone Joint J. 100(12):1592–1599. CrossRefPubMedGoogle Scholar
  35. 35.
    Shareghi B, Johanson PE, Kärrholm J (2017) Wear of vitamin E-infused highly cross-linked polyethylene at five years. J Bone Joint Surg Am 99(17):1447–1452. CrossRefPubMedGoogle Scholar
  36. 36.
    Sillesen NH, Greene ME, Nebergall AK, Huddleston JI, Emerson R, Gebuhr P, Troelsen A, Malchau H (2016) 3-year follow-up of a long-term registry-based multicentre study on vitamin E diffused polyethylene in total hip replacement. Hip Int. 26(1):97–103. 2015 Dec 11) CrossRefPubMedGoogle Scholar
  37. 37.
    Beckmann NA, Jaeger S, Janoszka MB, Klotz MC, Bruckner T, Bitsch RG (2018) Comparison of the primary stability of a porous coated acetabular revision cup with a standard cup. J Arthroplasty 33(2):580–585. 2017 Sep 20) CrossRefPubMedGoogle Scholar
  38. 38.
    O’Rourke D, Al-Dirini RM, Taylor M (2018) Primary stability of a cementless acetabular cup in a cohort of patient-specific finite element models. J Orthop Res 36(3):1012–1023. 2017 Sep 12) CrossRefPubMedGoogle Scholar
  39. 39.
    Saka G, Altun G, Burc H, Aydogan M (2019) A new radiographic acetabular cup anteversion measurement method in total hip arthroplasty: a clinical study. Eur J Orthop Surg Traumatol. ahead of print) CrossRefPubMedGoogle Scholar
  40. 40.
    Muir JM, Vincent J, Schipper J, Govindarajan M, Paprosky WG (2018) Evaluation of tilt-correction of anteversion on anteroposterior pelvic radiographs in total hip arthroplasty. Cureus 10(5):e2647. CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Tiberi JV III, Antoci V, Malchau H, Rubash HE, Freiberg AA, Kwon YM (2015) What is the fate of total hip arthroplasty (THA) acetabular component orientation when evaluated in the standing position? J Arthroplasty 30:1555–1560CrossRefGoogle Scholar
  42. 42.
    Hassan DM, Johnston GH, Dust WN, Watson LG, Cassidy D (1995) Radiographic calculation of anteversion in acetabular prostheses. J Arthroplasty 10:369–372CrossRefGoogle Scholar
  43. 43.
    Sillesen NH, Greene ME, Nebergall AK, Nielsen PT, Laursen MB, Troelsen A, Malchau H (2015) Three year RSA evaluation of vitamin E diffused highly cross-linked polyethylene liners and cup stability. J Arthroplasty 30:1260–1264CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2020

Authors and Affiliations

  1. 1.Department of Orthopaedics, Trauma and Reconstructive Surgery Marienhospital Mülheim an der RuhrChair of Orthopaedics and Trauma Surgery University of Duisburg–EssenEssenGermany
  2. 2.Institut für Medizintechnik und Forschungscampus STIMULATEOtto-von-Guericke-Universität MagdeburgMagdeburgGermany
  3. 3.Department of Orthopaedic SurgeryHannover Medical SchoolHannoverGermany
  4. 4.Department für Orthopädie, Unfall- und WiederherstellungschirurgieUniversitätsklinikum Halle (Saale)Halle (Saale)Germany
  5. 5.Department of Orthopaedics and Trauma SurgeryElisabeth-Klinikum OlsbergOlsbergGermany
  6. 6.Aesculap AG, Research and DevelopmentTuttlingenGermany
  7. 7.Department of Orthopaedic Surgery, Physical Medicine and Rehabilitation, Campus GrosshadernLudwig Maximilians University MunichMunichGermany

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