Acetabular options: notes from the other side

The socket remains the weakest link of primary total hip arthroplasty (THA). The revision rates of the socket are higher than those of the stem, with aseptic loosening and polyethylene wear being the most frequent indications for revision THA. Both cemented all-polyethylene cups and cementless sockets have benefited from stepwise improvements in surgical techniques and designs. In many countries, cementless sockets have replaced cemented cups during primary THA, with >90% of the acetabular components using a cementless fixation mode. The long-term prospective data of cementless sockets from high-volume centers show excellent and equivalent survivorship to cemented implants, but the insertion technique is easier and quicker. In addition, cementless sockets are more versatile than cemented all-polyethylene cups. With cementless sockets there is a move to increased porosity of the ingrowth surface, tri-bearing options, and enhanced locking mechanisms. There is a role for well-conducted randomized controlled trials to assess these new designs because data from various national registries show that the socket remains the weakest link of primary THA. Factors like sex, age, diagnosis, and bearing couples have a different and significant influence on the intermediate to long-term survivorship of contemporary cemented and cementless THA.