JOA - 2026-09-21 - Journal Article
There Is No One-Size-Fits-All: Surgical Approach Dictates Optimal Bearing Surface Configuration Choice in 30,000 Total Hip Arthroplasties Over 25 Years.
Cochrane NH, Panos JA, Khela MS, Mabry TM, Perry KI, Pagnano MW, Taunton MJ, Wyles CC, Abdel MP
Topics
Key Takeaway
In 30,246 primary THAs over 25 years, 10-year dislocation-free survivorship was 96% posterior, 98% anterolateral, and 99% direct anterior, with bearing surface choice significantly modifying dislocation risk only in posterior and anterolateral approaches.
Summary Depth
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Summary
This study stratified 30,246 primary THAs by surgical approach and bearing surface configuration to determine approach-specific dislocation risk. In posterior approach THA, dual-mobility constructs reduced dislocation risk (RR <0.5); in anterolateral THA, elevated rim liners doubled dislocation risk (RR 2.0) compared to flat/neutral PE; in direct anterior THA, bearing surface configuration had no significant effect on dislocation risk. Ten-year dislocation-free survivorship was 96%, 98%, and 99% for posterior, anterolateral, and direct anterior approaches, respectively.
Key Limitation
Surgeon and era selection bias in bearing surface assignment is uncontrolled—dual-mobility use increased over the 25-year study period and was disproportionately applied to higher-risk patients, potentially confounding the risk reduction attributed to DM constructs in the posterior approach group.
Original Abstract
INTRODUCTION
Dislocation remains a consequential complication following primary total hip arthroplasty (THA). Both surgical approach and bearing surface configuration individually influence dislocation risk. This study assessed the dislocation risk stratified by both surgical approach and bearing surface configuration to develop approach-specific recommendations for bearing selection.
METHODS
We identified 30,246 primary THAs performed from 1998 to 2022 at a single academic institution. Hips were stratified by bearing surface configuration, including flat/neutral polyethylene (PE) liners, elevated rim/face-changing (elevated) PE liners, and dual-mobility (DM) constructs. There were 14,611 posterior hips (8,587 flat/neutral, 5,207 elevated, and 816 DM), 8,968 antero-lateral (AL, 7,433 flat/neutral, 1,358 elevated, and 171 DM), and 6,667 direct anterior (DA, 6,541 flat/neutral, 91 elevated, and 35 DM). The mean age was 65 years (range, 18 to 100), the mean body mass index was 30 (range, 13 to 66), and 52% were women. The mean follow-up was six years (range, two to 26).
RESULTS
The survivorship free of dislocation at 10 years in the posterior, AL, and DA approach THAs were 96, 98, 99%, respectively. In posterior THAs, DM constructs reduced the relative risk of dislocation (RR [risk ratio] < 0.5, P < 0.01). In AL THAs, flat/neutral PE liners had a 99% survivorship free of dislocation, whereas elevated PE liners had double the relative risk of dislocation (RR 2, P < 0.01). In DA THAs, the bearing surface configuration had no discernible impact on the relative risk of dislocation.
CONCLUSION
A one-size-fits-all approach to bearing surface configuration is not supported, and a surgical approach should guide bearing selection in primary THAs. For posterior approach THA, DM constructs should be considered in high-risk cases. For the AL approach THA, flat/neutral PE liners had the lowest absolute dislocation risk. Direct anterior THA had the lowest risk of dislocation risk, regardless of bearing selection.