Clinical and Patient Reported Outcomes of Vitamin E Diffused Highly Cross-Linked Polyethylene Liner Versus Moderately Cross-Linked Polyethylene Liner in Total Hip Arthroplasty: A Meta-Analysis


Introduction: In the modern era of Medicine, total hip arthroplasty (THA) is found to last longer than ever before due to the fact that there has been improved bearing surfaces and materials available. Despite these modern approaches, failure caused by polyethylene wear, aseptic loosening, instability and mispositioning and even infection could affect THA survival. In the course of addressing anti-wear characteristics of the conventional polyethylene surface various approaches have been made. To date, there are very limited studies done in which polyethylene liner is better.

General Objective: To compare the effects of vitamin E diffused highly cross-linked polyethylene liner versus moderately cross-linked polyethylene liner in THA.

Methodology: Meta-analysis research design was used in this study. The primary investigators conducted a comprehensive literature search from Medline, Cochrane Library, PubMed, Elsevier, Google Scholar, Embase and as electronic database. All randomized controlled trials comparing the effects of vitamin E diffused highly cross-linked polyethylene liner versus moderately cross-linked polyethylene liner in THA were included in the review.

Conclusions: The investigation disclosed no statistical significance between moderately cross-linked polyethylene liner and vitamin E diffused highly cross-linked polyethylene liner in terms of migration, head penetration and wear on mediolateral, longitudinal and anteroposterior axes after 2 and 5 years of undergoing THA. Moreover, the data pertaining to patient reported outcomes and clinical outcomes measure also indicated no statistical significance between moderately cross-linked polyethylene liner and vitamin E diffused highly cross-linked polyethylene liner. This indicates that vitamin E diffused highly cross-linked polyethylene liner is comparable with the conventional moderately cross-linked polyethylene liner. Vitamin E-infused highly cross-linked polyethylene ( VEPE) showed an almost similar stability with regard to the wear rates and the component showed similar stability with that of moderately cross-linked polyethylene liner.

Keywords: Moderately Cross-linked Polyethylene Liner, Vitamin E Diffused Highly Cross-linked Polyethylene Liner, Total Hip Arthroplasty

  1. Barbour KE, Helmick CG, Boring M, Brady TJ. Vital signs: Prevalence of doctor-diagnosed arthritis and arthritis-attributable activity limitation — United States, 2013–2015. MMWR Morb Mortal Wkly Rep [Internet]. 2017;66(9):246–53. Available from: 

  2. Zhang Y, Jordan JM. Epidemiology of osteoarthritis. Clin Geriatr Med [Internet]. 2010;26(3):355–69. Available from:

  3. Jordan JM, Helmick CG, Renner JB, Luta G, Dragomir AD, Woodard J, et al. Prevalence of hip symptoms and radiographic and symptomatic hip osteoarthritis in African Americans and Caucasians: The Johnston County Osteoarthritis Project. J Rheumatol [Internet]. 2009;36(4):809–15. Available from:

  4. Felson DT. Preventing knee and hip osteoarthritis. Bull Rheum Dis [Internet]. 1998;47(7):1–4. Available from:

  5. Murphy NJ, Eyles JP, Hunter DJ. Hip osteoarthritis: Etiopathogenesis and implications for management. Adv Ther [Internet]. 2016;33(11):1921–46. Available from: 

  6. Lespasio MJ, Sultan AA, Piuzzi NS, Khlopas A, Husni ME, Muschler GF, et al. Hip osteoarthritis: A primer. Perm J [Internet]. 2018;22(1). Available from: 

  7. Osteoarthritis: Care and management: Guidance [Internet]. [cited 2017 Aug 11]. Available from:

  8. da Costa BR, Reichenbach S, Keller N, Nartey L, Wandel S, Jüni P, et al. Effectiveness of non-steroidal anti-inflammatory drugs for the treatment of pain in knee and hip osteoarthritis: a network meta-analysis. Lancet [Internet]. 2017;390(10090):e21–33. Available from:

  9. Jahan MS, King MC, Haggard WO, Sevo KL, Parr JE. A study of long-lived free radicals in gamma-irradiated medical grade polyethylene. Radiat Phys Chem Oxf Engl 1993 [Internet]. 2001;62(1):141–4. Available from: 

  10. McKellop H, Shen F-W, Lu B, Campbell P, Salovey R. Development of an extremely wear ‐ resistant ultra high molecular weight polythylene for total hip replacements. J Orthop Res [Internet]. 1999 [cited 2023 Nov 14];17(2):157–67. Available from: 

  11. Oral E. α-Tocopherol-doped irradiated UHMWPE for high fatigue resistance and low wear. Biomaterials [Internet]. 2004;25(24):5515–22. Available from: 

  12. Oral E, Muratoglu OK. Vitamin E diffused, highly crosslinked UHMWPE: a review. Int Orthop [Internet]. 2011;35(2):215–23. Available from: 

  13. Elbardesy H, Yadav H, Rabea M, Guerin S, Harty J. Femoral head penetration in Vitamin-E polyethylene liner versus conventional liners in total hip arthroplasty: systematic review and meta-analysis of randomised control trials. SICOT J [Internet]. 2021;7:47. Available from: 

  14. Vadei L, Kieser DC, Frampton C, Hooper G. Survivorship of total hip joint replacements following isolated liner exchange for wear. J Arthroplasty [Internet]. 2017;32(11):3484–7. Available from: 

  15. Hall A, Eilers M, Hansen R, Robinson BS, Maloney WJ, Paprosky WG, et al. Advances in acetabular reconstruction in revision total hip arthroplasty: Maximizing function and outcomes after treatment of periacetabular osteolysis around the well-fixed shell. J Bone Joint Surg Am [Internet]. 2013;95(18):1709–18. Available from: 

  16. Karachalios T, Komnos G, Koutalos A. Total hip arthroplasty: Survival and modes of failure. EFORT Open Rev [Internet]. 2018;3(5):232–9. Available from: 

  17. Kurtz SM, Gawel HA, Patel JD. History and systematic review of wear and osteolysis outcomes for first-generation highly crosslinked polyethylene. Clin Orthop Relat Res [Internet]. 2011;469(8):2262–77. Available from:

  18. Harris WH. Conquest of a worldwide human disease: particle-induced periprosthetic osteolysis. Clin Orthop Relat Res [Internet]. 2004;(429):39–42. Available from:

  19.   Kurtz SM. UHMWPE Biomaterials Handbook. Third ed. Oxford: Elsevier, 2015:293–304.

  20. Sköldenberg OG, Rysinska AD, Chammout G, Salemyr M, Mukka SS, Bodén H, et al. A randomized double-blind noninferiority trial, evaluating migration of a cemented vitamin E-stabilized highly crosslinked component compared with a standard polyethylene component in reverse hybrid total hip arthroplasty. Bone Joint J [Internet]. 2019;101-B(10):1192–8. Available from: 

  21. Yamamoto K, Tateiwa T, Takahashi Y. Vitamin E-stabilized highly crosslinked polyethylenes: The role and effectiveness in total hip arthroplasty. J Orthop Sci [Internet]. 2017;22(3):384–90. Available from: 

  22. Lindalen E, Thoen PS, Nordsletten L, Høvik Ø, Röhrl SM. Low wear rate at 6-year follow-up of vitamin E-infused cross-linked polyethylene: a randomised trial using 32- and 36-mm heads. Hip Int [Internet]. 2019;29(4):355–62. Available from: 

  23. Galea VP, Rojanasopondist P, Laursen M, Muratoglu OK, Malchau H, Bragdon C. Evaluation of vitamin E-diffused highly crosslinked polyethylene wear and porous titanium-coated shell stability: a seven-year randomized control trial using radiostereometric analysis. Bone Joint J [Internet]. 2019;101-B(7):760–7. Available from: 

  24. Wyatt MC, Roberton A, Foxall-Smi M, Beswick AD, Kunutsor SK, Whitehouse MR. Does vitamin E highly-crosslinked polyethylene convey an advantage in primary total hip replacement? A systematic review and meta-analysis. Hip Int [Internet]. 2020;30(5):598–608. Available from: 

  25. Röhrl SM, Nivbrant B, Snorrason F, Kärrholm J, Nilsson KG. Porous-coated cups fixed with screws: a 12-year clinical and radiostereometric follow-up study of 50 hips. Acta Orthop [Internet]. 2006;77(3):393–401. Available from: 

  26. Dumbleton JH, Manley MT, Edidin AA. A literature review of the association between wear rate and osteolysis in total hip arthroplasty. J Arthroplasty [Internet]. 2002;17(5):649–61. Available from: 

  27. Digas G, Kärrholm J, Thanner J, Malchau H, Herberts P. The Otto Aufranc Award. Highly cross-linked polyethylene in total hip arthroplasty: randomized evaluation of penetration rate in cemented and uncemented sockets using radiostereometric analysis. Clin Orthop Relat Res . 2004;(429):6–16.

  28. Thoen PS, Nordsletten L, Pripp AH, Röhrl SM. Results of a randomized controlled trial with five-year radiostereometric analysis results of vitamin E-infused highly crosslinked versus moderately crosslinked polyethylene in reverse total hip arthroplasty. Bone Joint J [Internet]. 2020;102-B(12):1646–53. Available from: 

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