The Journal of Arthroplasty Vol. 27 No.

8 2012

Reliability of a PowerPoint Method for Wear

Measurement After Total Hip Arthroplasty
A Retrieval Study Using 3-Dimensional Laser Scanning
Ho Hyun Yun, MD,* Won Yong Shon, MD, PhD,y Jung Ro Yoon, MD,*
Jae-Hyuk Yang, MD,* and Deuk-Soo Lim, MD*

Abstract: The purpose of this study was to evaluate the reliability of the PowerPoint (PP) (2007
Version; Microsoft, Redmond, Wash) method for measuring polyethylene liner wear after total
hip arthroplasty. Seventeen retrieved polyethylene liners were included in this study. Wear
volumes were calculated using the PP, the Dorr and Wan, and 3-dimensional (3D) laser
scanning methods. Spearman correlation coefficients for wear volume results indicated strong
correlations between the PP and 3D laser scanning methods (range, 0.89-0.93). On the other
hand, Spearman correlation analysis revealed only moderate correlations between the Dorr and
Wan and 3D laser scanning methods (range, 0.67-0.77). The PP method can be used to monitor
linear wear after total hip arthroplasty and could serve as an alternative method when
computerized methods are not available. Keywords: hip, total hip arthroplasty, wear, wear
measurement, PowerPoint method.
© 2012 Elsevier Inc. All rights reserved.

Liner wear after total hip arthroplasty (THA) is deter-
mined using manual [1-5], computer-assisted [6,7],
radiostereometric [8,9], or 3-dimensional (3D) computed
tomographic (CT) [10,11] methods. Manual methods
have been validated for conventional polyethylene (PE)
[1-5]. However, the validity of manual methods has been
questioned in recent retrieval studies [12,13], and they are
now considered to be less accurate than computer-assisted
methods [14,15]. Thus, manual methods have largely
been replaced by computer-assisted methods [6,7,16,17].
However, computer-assisted methods require high-qual-
ity images, more expensive equipment, and a level of
computational data processing that may not be available
in clinical situations. Radiostereometric analysis (RSA)
methods are considered to be the most accurate method
[8,9], but the RSA technique is invasive and expensive
and requires prospective study designs, which are
From the *Department of Orthopaedic Surgery, Seoul Veterans Hospital,
Seoul, Korea; and yDepartment of Orthopaedic Surgery, Guro Hospital, Korea
University School of Medicine, Seoul, Korea.
Submitted April 4, 2011; accepted December 23, 2011.
The Conflict of Interest statement associated with this article can be
found at doi:10.1016/j.arth.2011.12.025.
Reprint requests: Won Yong Shon, MD, PhD, Department of
Orthopaedic Surgery, Guro Hospital, Korea University School of
Medicine, #80, Guro-Dong, Guro-Gu, Seoul 152703, Korea.
© 2012 Elsevier Inc. All rights reserved.
0883-5403/2708-0019$36.00/0
doi:10.1016/j.arth.2011.12.025
normally not available in the clinical setting. Three-
dimensional CT-based (3D CT) methods can be used for
both 2D and 3D wear measurements [10,11,18], but they
expose patients to high doses of radiation, and the images
are prone to metal artifacts that can be problematic when
interpreting results. The accuracy of in vivo wear mea-
surement methods is mainly determined by retrieval
studies [5,6,11,18-22]. In vitro methods for determining
the wear volumes of retrieved PE liners include direct
measurement [5,22,23], shadowgraphs [12,22,24,25],
volumetric measurement [13,19,21], and 3D CT scans
[11,18,26]. Direct methods based on fluid displacement
[22,23] or digital caliper measurements [5] are simple and
require less time-consuming procedures. However, de-
termining minimum thickness by probing with a digital
caliper can affect accuracy. Several fill materials are used
for the shadowgraph method [12,22,24,25], and wear
volumes are calculated using mathematical equations.
However, the large number of parameters involved re-
quires complicated mathematics, which can ultimately
lead to computational errors [12,13,24]. Volumetric
methods are performed using coordinate-measuring
machines [13,19,21]. The disadvantage of volumetric
methods is that they require contact with the object being
scanned, which could modify or damage the object. In
addition, they are slower than other methods. Three-
dimensional CT scans are known to be more accurate and
repeatable and are applicable to retrieved PE liners

1530
 Reliability of a PP Method for Wear Measurement After THA  Yun et al
[11,18,20,26]. However, the quality of surface recon-
struction depends on CT slice thickness, which can pro-
duce stepped surfaces and cause errors.
Because of the pitfalls of in vivo wear measurement
methods, a new manual wear measurement method
was developed that is referred to as the PowerPoint-
based (PP) method [27]. The PP method is reported to
have improved repeatability and reproducibility and is
better able to detect differences in radiographs than
previously established manual wear measurement
methods [3,4]. In this study, the PP method [27] and
the Dorr and Wan method [4] were used to calculate
the PE liner wear volume. The wear volumes of re-
trieved PE liners calculated from the 3D laser scanning
method were compared with each method. This study
hypothesized that the wear volume calculated by the PP
method would correlate well with the wear volume
measured by 3D laser scanning method.
Materials and Methods
Between March 2004 and June 2009, 22 PE liners
from 20 patients were collected during revision THA.
Exclusion criteria included (1) missing an early primary
postoperative radiograph or prerevision radiograph, (2)
evidence of acetabular loosening or migration according
to the guidelines of Callaghan et al [28], (3) existence of
significant mismatch between early primary postopera-
tive radiograph and prerevision radiographs on vertical
axis, and (4) liner wear-through. After applying these
exclusion criteria, 17 retrieved PE liners from 16 patients
were included in this study.
The male-to-female ratio was 11:5, and the mean
patient age was 43 ± 11.17 years (range, 22-66 years).
The mean implantation time was 134 ± 37.71 months
(range, 92-211 months). All components were manu-
factured by one company (Zimmer, Warsaw, Ind), and
all acetabular cups were uncemented. There were 10
Harris-Galante porous cups and 7 Harris-Galante cups.
Mean acetabular cup diameter was 50 ± 8.32 mm (range,
44-58 mm). For femoral stems, 8 Versys cemented stems,
5 Centrealign precoat stems, and 4 Zimmer Versys
beaded midcoat stems were used. All femoral heads
were 28 mm in diameter and composed of cobalt-
chromium. All PE liners were made by ultrahigh-
molecular-weight PE and were sterilized by γ-irradiation
in air [29]. The most frequent PE liner size was size E
(8 cases), and sizes ranged from size C to J.
The Dorr and Wan method [4] was used for com-
parison. Digitalized images of prerevision non–weight-
bearing hip anteroposterior radiographs were acquired
with a picture archiving and communication system
(PACS) (Infinite, Seoul, South Korea) and exported into
PowerPoint (2007 Version; Microsoft, Redmond, Wash).
After magnifying the images to 400% in PowerPoint,
the radiographs were printed, and measurements were
taken using a handheld ruler.
1531
Before taking to measurements, PP templates (acetab-
ular and head-centering templates) were designed in
Microsoft PowerPoint. The acetabular template was
designed using 15 concentric circles in different colors
to improve visual contrast at diameters increasing in
increments of 2.5 mm from the femoral head diameter
(28 mm). These circles were then fixed as a group so that
they moved as a single unit. Diameter increments of
2.5 mm were found to be most convenient after exam-
ining various combinations of sizes. When concentric
circles were drawn at increments of 2.5 mm, the dis-
tance between circles was 1.25 mm, or 5 mm on 400%
magnified images. A head-centering template was
designed by drawing a circle with a femoral head
diameter (28 mm). Images of early primary postopera-
tive (6 weeks) and prerevision non–weight-bearing hip
anteroposterior radiographs were acquired using PACS.
These images were opened in Microsoft Office Picture
Manager (2007 Version; Microsoft) and then rotated in
increments of 1° using MS Office Picture Manager and a
screen ruler (MB-Ruler, open-source software; www.
markus-bader.de) until both ischial tuberosities were
parallel. The area of interest (complete hip joint, tear
drop, ischial tuberosity, greater tuberosity, and proximal
shaft of femur) was then labeled, cropped, and saved.
These images were then exported into a PowerPoint
template. Images from 6 weeks postoperation were
positioned on the left side of the PowerPoint slide, and
prerevision images, on the right. To ensure correct mag-
nification, the center of the femoral head was matched
with the head-centering template, and the grouping
function was used to fix the overlapped circles. The
center of the acetabular template was aligned with the
center of the femoral head circle on the early primary
postoperative radiograph, and the circle that most
closely matched the outline of the acetabular cup was
selected. Taking note of the overlay pattern on the left
side, the acetabular template was moved to the prerevi-
sion radiograph on the right side. A circle of the same
color was then matched with the margin of the
acetabular cup up to the closest accuracy of the image
on the left side (Fig. 1). Wear measurements were taken
on a 17-in (1280 × 1024 Pixel value) LCD monitor
(Syncmaster; Samsung, Seoul, South Korea) using a
PowerPoint window magnified to 400% and a handheld
ruler (Fig. 2). The margin of the head-centering template
(in black) was identified, and then the maximum
direction in which it had moved from the innermost
circle of the acetabular template (in green) was noted.
The movement of the margin was calculated to
determine the movement of the center of the femoral
head. The innermost circle of the acetabular template (in
green) was defined as large zone (LZ) 0, the next coded
circle was 30.5 mm in diameter and defined as LZ 1 (in
white), the next circle was defined as LZ 2 (in pink), and
so on. As mentioned above, the distance between the
1532 The Journal of Arthroplasty Vol. 27 No. 8 September 2012
Fig. 1. Early postoperation (left side) and prerevision (right side) radiographs. Taking note of the overlay pattern on the left side, try to
move the other set of acetabular templates to the right side, and match the same-colored circle to the margin of the acetabular cup on
the left side.
color-coded circles was 1.25 mm. The number of large
zones moved was determined by the number of times
the margin of the black circle crossed the periphery of
the corresponding acetabular circles. The distance
between the corresponding acetabular circles was
divided into 5 small zones, each equivalent to 1.25/5
mm = 0.25 mm. If the distance between the correspond-
ing acetabular circles lay between 2 ruler markings, a
reading of 0.125 mm was noted. Linear wear was
calculated using the equation: W (wear in millimeters) =
(LZ × 1.25 + SZ × 0.25), where LZ (large zone) is the
maximum distance penetrated by the femoral head
between the color-coded circles and SZ (small zone) is
the distance penetrated by the femoral head between
2 adjacent circles.
Measurements were performed by 3 independent
observers who were unaware of the study design. All 3
observers had extensive experience measuring liner
wear using the PP and Dorr and Wan methods, and thus,
training was unnecessary. All radiographs were reeval-
uated in random order by all observers individually
4 weeks after the first evaluation to determine intra-
observer agreement. Wear volumes were calculated
using the cylinder equation [25]: W (wear volume in
cubic millimeters) = πr 2 × linear wear.
Seventeen retrieved PE liners and 7 unused serial PE
liners (size C to J) were scanned using a triangulation 3D
laser scanner (Rexcan III; Solutionix, Seoul, South
Korea). Three-dimensional laser technique involves
using a camera to determine the location of a laser on
the object [30]. Three-dimensional laser scans are
high resolution (2.0 megapixels) and high precision
(b0.01 mm). The mean scan time was 30 minutes
(range, 25-34 minutes). Each 3D laser scan produced
30 to 60 megabytes of data and was recorded on a
separate CD-ROM. Qualify imaging processing software
(Geomagic, Morrisville, NC,) was used to generate 3D
reconstruction images (Fig. 3). The interior volumes of
the PE liners were calculated using the surface rendering
function in Geomagic. The wear volume of each re-
trieved PE liner was measured by subtracting the interior
volume of an unused PE liner from the interior volume
 Reliability of a PP Method for Wear Measurement After THA  Yun et al 1533

Fig. 2. Early postoperation (left side) and prerevision (right side) radiographs. The black circle has moved up to the yellow circle
(right side), such that it has moved 3 LZ and 0 SZ. Hence, wear = (3 × 1.25 + 0 × 0.25) mm = 3.75 mm.

of a retrieved PE liner of the same size. Two sets of
measurements were taken.
For statistical analysis, Cronbach α value was used to
assess agreement between unused PE liners and the
interior volumes of PE liners determined by the 3D laser
scan of the retrieved PE liners. Spearman correlation
coefficients were used to evaluate the differences
between the PP, the Dorr and Wan, and the 3D laser
scanning methods. Intraclass correlation coefficients
(ICCs) were used to determine interobserver and
intraobserver variations and reliability. Wilcoxon signed
rank test was used to assess whether the mean wear
volume determined by the PP method and the Dorr and
Wan method differed from values determined by the 3D

Fig. 3. Three-dimensional reconstructed images of 17 retrieved PE liners and an unused size E PE liner (the most common PE
liner size).
1534 The Journal of Arthroplasty Vol. 27 No. 8 September 2012

laser scanning method. The experimental design
achieved an any-pair power of 0.43 using Wilcoxon
signed rank test with a target familywise error rate of
0.05. All analyses were performed using Statistical
Package for the Social Sciences version 12 (SPSS,
Chicago, Ill).
Results
The mean interior volumes of the 17 retrieved PE
liners measured by 2 sets of 3D laser scan were
9172.19 ± 574.70 mm 3 (range, 8344.88-10480.71
mm 3) and 9151.62 ± 576.47 mm 3 (range, 8344.88-
10419.42 mm 3). The mean interior volumes of the
7 unused PE liners measured by 2 sets of 3D laser
scan were 8016.23 ± 0.13 mm 3 (range, 8016.03-
8016.43 mm 3 ) and 8016.37 ± 0.42 mm 3 (range,
8016.04-8016.65 mm 3). The individual wear volumes
of the 17 retrieved PE liners measured by 3D laser
scanning methods are shown in Table 1. The mean wear
volume by 3D laser scanning methods was 1146.72 ±
576.59 mm 3 (range, 339.51-2464.69 mm 3). Cronbach
α values for the 17 retrieved PE liners and 7 unused PE
liners were .976 and .996, respectively. Mean linear
wear measured by the PP and the Dorr and Wan
methods were 2.40 ± 1.06 mm (range, 0.50-4.82 mm)
and 2.46 ± 1.18 mm (range. 0.11-4.96 mm), respec-
tively. The individual wear volume of the 17 retrieved
PE liners as determined by 3D laser scan, PP, and Dorr
and Wan methods are shown in Table 1. The mean
wear volumes of the PP and the Dorr and Wan methods
were 1342.48 ± 600.43 mm 3 (range, 276.95-2669.76
mm 3 ) and 1369.57 ± 654.93 mm 3 (range, 63.08-
2746.65 mm 3), respectively. Spearman correlation co-
efficient results between the PP and 3D laser scanning
methods revealed that the 2 methods are strongly
correlated (range, 0.89-0.93) (Table 2). Similarly,
Spearman correlation coefficient results between the
PP method (range, 0.93-1.00) and the Dorr and Wan
method (range, 0.91-0.98) showed that these 2 methods
are also strongly correlated (Table 2). On the other hand,
Spearman correlation coefficient results between the
Dorr and Wan and 3D laser scanning methods revealed
only moderate correlations (range, 0.67-0.77) (Table 2).
The ICC values of wear measurements determined by
the PP method (range, 0.95-1.00) and the Dorr and Wan
method (range, 0.88-0.96) showed excellent correla-
tions (Table 2). Wilcoxon signed rank test showed that
mean wear volumes determined using the PP and Dorr
and Wan methods were significantly different from 3D
laser scanning methods–determined values (P N .05).
Discussion
The accuracies of in vivo wear measurement methods
are mainly determined by retrieval studies [5,6,11,18-
22]. The present study hypothesized that, in a retrieval
study, the PP method would be correlated well with 3D
laser scanning method. Study results show that wear
volumes determined by the PP method are strongly
correlated (Spearman correlation coefficients, range,
0.89-0.93) with volumes determined using 3D laser
scan with excellent ICC values (range, 0.95-1.00)
(Table 2). In this study, Cronbach α values for the
interior volume of 17 retrieved PE liners and 7 unused
PE liners were 0.976 and 0.996, respectively. The
mean wear volume determined by the PP method
(1342.48 mm 3) was larger than the mean wear vol-
ume determined by 3D laser scanning method (1146.72
mm 3); compared with the 3D laser scanning method, it

Table 1. Individual Wear Volume (mm 3) of 17 Retrieved Polyethylene Liners Measured by 3D Laser Scanning Method, the
PowerPoint Method, and the Dorr and Wan Method
3D Laser Scan (Scan 1/Scan 2) PowerPoint Method (A-1/A-2/B-1/B-2/C-1/C-2) Dorr and Wan Method (A-1/A-2/B-1/B-2/C-1/C-2)
1 1554/1450 2077/2077/2077/2077/2007/2077 1667/1512/1677/1506/1601/1627
2 1142/1092 1730/1800/1800/1800/1730/1800 1509/1512/1558/1537/1601/1767
3 928/928 953/953/953/953/953/953 63/286/415/123/607/261
4 339/339 415/484/484/484/346/484 315/377/677/426/238/666
5 988/988 1038/1315/969/1246/1038/1246 330/718/658/870/664/733
6 1864/1864 1923/2200/1923/2200/1923/2338 1698/2126/2030/1732/2043/1821
7 328/328 276/553/276/553/276/553 404/512/166/310/541/650
8 992/956 1077/938/1008/1008/1077/1008 2160/2140/2195/2089/2348/2157
9 785/785 1038/1107/1107/1107/969/1038 1144/1127/826/1141/1246/1015
10 747/683 915/707/984/707/846/638 1211/1689/1531/1589/1711/1764
11 1845/1845 2077/2007/2077/2077/2077/2077 1787/1997/1513/1717/2221/1860
12 1149/1149 1453/1453/1523/1523/1523/1453 1749/1790/1755/2106/2114/1892
13 2464/2403 2531/2115/2600/2600/2462/2669 2317/2498/2734/1729/2342/2746
14 689/689 1177/1177/1107/1107/1107/1107 1241/1178/1263/1201/1303/1390
15 1417/1417 1515/1307/1446/1307/1446/1238 1326/1330/1307/1530/1277/1369
16 1645/1645 1723/1723/1723/1723/1723/1653 1801/1832/1915/1980/2024/2106
17 771/771 815/815/815/815/746/746 733/773/840/875/692/875
Mean 1156/1137 1337/1337/1345/1370/1354/1354 1262/1376/1356/1321/1445/1453
A indicates observer A; B, observer B; C, observer C.
 Reliability of a PP Method for Wear Measurement After THA  Yun et al 1535

1.00/0.97

1.00 (0.99-1.00)/0.96
appears that the PP method overestimated the mean

C1/C2

Interobserver C/A
wear volume by 16.1%. It is believed that 3D laser scans
are more accurate than radiograph-derived linear wear

(0.88-0.98)
measurement methods because they reflect the real

0.91/0.71

1.00/0.95
direction of wear and peripheral wear in impingement

B2/C2
cases. Derbyshire [31] showed that the formula to
C2

calculate 3D wear volume derived by Kabo et al [25]

was incorrect and suggested that 3D wear volume

0.97/0.93

0.99 (0.98-1.00)/0.92
B2/C1 calculations could not be used. Devane et al [16]

Interobserver B/C
concluded that it is impossible to measure 3D wear
volume directly. They suggested that only radiologic

CI indicates confidence interval; Scan, 3D laser scan; PP, PowerPoint method; Dorr, Dorr and Wan method; A, observer A; B, observer B; C, observer C.
(0.78-0.97)
0.91/0.72

0.94/0.95

techniques could be used in vivo and these remain

B1/C2

useful in clinical setting, although the interpretation of

C1

radiologic measurements of liner wear must be per-

formed judiciously in a clinical setting. The maximum
0.98/0.91

depth of linear wear can be measured using a digital

1.00 (0.99-1.00)/0.94
B1/C1

caliper [5], a coordinate-measuring machine [11], or

Interobserver A/B

by 3D CT scan [20], but, as mentioned above, they all

Spearman Correlation Coefficients (Scan and PP/Scan and Dorr)

have weaknesses.
(0.85-0.98)
0.93/0.67

0.95/0.92

Wear measurements on clinical radiographs are

Table 2. Correlation Results and Intraobserver and Interobserver Reliability Evaluated By ICC With 95% CI

B1/B2

affected by many factors [9,17] such as radiograph qua-

B2

Spearman Correlation Coefficients (PP/Dorr)

lity, rotational differences, loosening of implants, inter-

position of soft tissue, joint laxity, creep, and sagittal
1.00/0.97

wear. The PP method depends on the ability to clearly

A2/C2

ICC (PP/Dorr with 95% CI)

identify the edges of the femoral head and metal shell,

and thus, its exclusion criteria are similar to those of
computer-assisted methods. The number of exclusions
0.95/0.98

0.97 (0.91-0.99)/0.94

can be reduced through use of Microsoft Office Picture

A2/C1

Manager software to correct for rotational differences and

Intraobserver C

use of the PACS system to optimize contrast. Considering

(0.84-0.98)
0.89/0.74

0.99/0.93

the interposition of soft tissue and joint laxity, radio-

A2/B2

graphs taken 6 weeks postoperatively are defined as early

B1

primary postoperative radiographs. Polyethylene liner

deformation is caused by a combination of wear and
0.93/0.94

creep, and creep can reach 0.14 mm over a 10-year

A2/B1

period [32]. In this study, a combination of wear and

creep is labeled as wear. The use of sagittal radiographs
may improve results and make it easier to calculate 3D
0.96/0.97

0.97 (0.93-0.99)/0.88

wear, but the variable quality of sagittal radiographs and

A1/C2

difficulty of detecting the edges of the femoral head

Intraobserver B

on metal backed cups on sagittal radiographs limit their

(0.70-0.95)

use for THA wear measurement [9,17].

0.90/0.75

1.00/0.94

This study has several limitations. The minimum wear

A1/C1

indication for the PP method is 0.125 mm. Theoretically,

A2

this could be further reduced to 0.0025 mm if a digital

caliper with a resolution of 0.01 mm was used. How-
0.97/0.91

0.95 (0.88-0.98)/0.96 (0.91-0.99)

ever, wear measurement with a digital caliper may be

A1/B2

erroneous because of the inaccuracy of human eye

measurement compared with a digital image analyzer
0.98/0.92

[33]. Another limitation of this study is the small sam-

A1/B1

ple size. In addition, the retrieved PE liners did not

Intraobserver A

represent low-wear situations, in which linear wear

amounts are less than 1 mm. A previous study [27]
0.91/0.77

0.95/0.96

showed that the PP method has acceptable repeatability

A1/A2

and reproducibility and that it detects differences well in

A1

low-wear situations. It may seem questionable to

1536 The Journal of Arthroplasty Vol. 27 No. 8 September 2012
measure wear in the non–weight-bearing state
[10,19,34], but several studies have demonstrated no
difference between wear measured on supine and
standing radiographs [9,17,35,36].
The PP method [27] is similar to method of Livermore
et al [3], which also uses a transparent template of
concentric circles. However, the PP method makes it
possible to work at 400% magnification, correct for
rotation around the vertical axis, and use the grouping
function. The PowerPoint grouping function allows
circles to be fixed after satisfactory overlap has been
achieved and, thus, reduces the risk of errors and in-
creases accuracy. In a previous study [27], the PP
method was shown to have improved repeatability and
reproducibility and is better able to identify differences
between radiographs when compared with the method
of Livermore et al [3]. Because of the similarity between
the PP method and the method of Livermore et al, the
PP method was compared with the Dorr and Wan
method in this study [4]. The Dorr and Wan method is a
simple, clinically effective wear measurement method.
However, it can only measure wear in one direction at
the superolateral corner and is unable to measure wear
in the maximal direction. On the other hand, the PP
method can measure the wear in the maximal wear
direction. Pollock et al [5] developed a template-based
manual wear measurement method, but it requires
different templates for different types of implants. The
PP method is versatile in this respect because templates
can easily be made using PowerPoint and the inner-
most diameter of the acetabular template and the diam-
eter of the head-centering template are easily changed
by changing the diameter of a circle to match femoral
head sizes.
The accuracy of wear measurements depends on the
measuring device used, the environment, the mea-
surement process, and observer skill [37]. It is
unreasonable to expect that any method of wear
measurement based on the use of clinical radiographs
could be error free. Errors of manual wear measure-
ment methods will be higher, compared to computer-
assisted methods [6,7] and RSA methods [8,9]. At the
study institute, x-ray digitalization was available from
March 2004; the older low-quality scanned postoper-
ative radiographic images did not match the latest
high-quality digitalized radiographic images and some-
times made it difficult to use a computer-assisted
method. Future studies should compare the PP method
to computer-assisted methods using digital radiographs
with initial postoperative digital radiographic images
captured after March 2004. RSA methods [8,9] require
prospective study designs because retrospective studies
are limited by the fact that radiography protocols are
not standardized. The edges of femoral heads and
metal shells must be clear for computer-assisted
methods to work [6,7], and thus, the accuracy of
these methods depends on the image quality and
accuracy of distances determined using pixel values on
screens. Wan et al [38] showed that computer-assisted
methods are inaccurate when wear is below 1 mm
because they produce too many negative wear
measurement numbers. Collier et al [39] used a
novel method to determine the accuracy and repro-
ducibility of computer-assisted methods [6,7] using the
same set of radiographs, which simulated zero wear.
They reported that mean linear and volumetric wear
values from 2 computer-assisted methods were 0.26 to
0.40 mm and 78 to 126 mm 3 when there was no
actual wear.
The PP method is an efficient tool for the sequential
radiologic follow-up of patients after THA. The PP
method can be used to monitor linear wear after THA
and could serve as an alternative method when com-
puterized methods are not available.
References
1. Callaghan JJ, Pedersen DR, Olejniczak JP, et al. Radio-
graphic measurement of wear in 5 cohorts of patients
observed for 5 to 22 years. Clin Orthop Relat Res 1995;
317:14.
2. Charnley J, Halley DK. Rate of wear in total hip
replacement. Clin Orthop Relat Res 1975;112:170.
3. Livermore J, Ilstrup D, Morrey B. Effect of femoral head
size on wear of the polyethylene acetabular component.
J Bone Joint Surg Am 1990;72:518.
4. Dorr LD, Wan Z. Ten years of experience with porous
acetabular components for revision surgery. Clin Orthop
Relat Res 1995;319:191.
5. Pollock D, Sychterz CJ, Engh CA. A clinically practical
method of manually assessing polyethylene liner thick-
ness. J Bone Joint Surg Am 2001;83:1803.
6. Yamaguchi M, Bauer TW, Hashimoto Y. Three-dimen-
sional analysis of multiple wear vectors in retrieved ace-
tabular cups. J Bone Joint Surg Am 1997;79:1539.
7. Shaver SM, Brown TD, Hillis SL, et al. Digital edge-
detection measurement of polyethylene wear after total
hip arthroplasty. J Bone Joint Surg Am 1997;79:690.
8. Glyn-Jones S, Isaac S, Hauptfleisch J, et al. Does highly
cross-linked polyethylene wear less than conventional
polyethylene in total hip arthroplasty? A double-blind,
randomized, and controlled trial using roentgen stereo-
photogrammetric analysis. J Arthroplasty 2008;23:337.
9. Bragdon CR, Kwon YM, Geller JA, et al. Minimum 6-year
followup of highly cross-linked polyethylene in THA. Clin
Orthop Relat Res 2007;465:122.
10. Vandenbussche E, Saffarini M, Hansen U, et al. Mea-
surement of femoral head penetration in polyethylene
using a 3-dimensional CT-scan technique. Acta Orthop
2010;81:563.
11. Jedenmalm A, Noz ME, Olivecrona H, et al. A new
approach for assessment of wear in metal-backed acetab-
ular cups using computed tomography: a phantom study
with retrievals. Acta Orthop 2008;79:218.
 Reliability of a PP Method for Wear Measurement After THA  Yun et al
12. Barrack RL, Lavernia C, Szuszczewicz ES, et al. Radio-
graphic wear measurements in a cementless metal-backed
modular cobalt-chromium acetabular component. J
Arthroplasty 2001;16:820.
13. Ebramzadeh E, Sangiorgio SN, Lattuada F, et al. Accuracy
of measurement of polyethylene wear with use of radio-
graphs of total hip replacements. J Bone Joint Surg Am
2003;2378:85.
14. Sychterz CJ, Young AM, Engh CA. Effect of radiographic
quality on computer-assisted head penetration measure-
ments. Clin Orthop Relat Res 2001;386:150.
15. Dorr LD, Wan Z. Comparative results of a distal modular
sleeve, circumferential coating, and stiffness relief using
the Anatomic Porous Replacement II. J Arthroplasty 1996;
11:419.
16. Devane PA, Bourne RB, Rorabeck CH, et al. Measurement
of polyethylene wear in metal-backed acetabular cups. I.
Three-dimensional technique. Clin Orthop Relat Res 1995;
319:303.
17. Martell JM, Berdia S. Determination of polyethylene wear
in total hip replacements with use of digital radiographs.
J Bone Joint Surg Am 1997;79:1635.
18. Bowden AE, Kurtz SM, Edidin AA. Validation of a micro-
CT technique for measuring volumetric wear in retrieved
acetabular liners. J Biomed Mater Res B Appl Biomater
2005;75:205.
19. Raimondi MT, Sassi R, Pietrabissa R. A method for the
evaluation of the change in volume of retrieved acetabular
cups. Proc Inst Mech Eng H 2000;214:577.
20. Jedenmalm A, Nilsson F, Noz ME, et al. Validation of a 3D
CT method for measurement of linear wear of acetabular
cups. Acta Orthop 2011;82:35.
21. Gallo J, Havranek V, Cechova I, et al. Wear measurement of
retrieved polyethylene ABG 1 cups by universal-type mea-
suring microscope and x-ray methods. Biomed Pap Med Fac
Univ Palacky Olomouc Czech Repub 2006;150:321.
22. Chuter GS, Cloke DJ, Mahomed A, et al. Wear analysis of
failed acetabular polyethylene: a comparison of analytical
methods. J Bone Joint Surg Br 2007;89:273.
23. Walker PS, Blunn GW, Lilley PA. Wear testing of materials
and surfaces for total knee replacement. J Biomed Mater
Res 1996;33:159.
24. Jasty M, Goetz DD, Bragdon CR, et al. Wear of
polyethylene acetabular components in total hip arthro-
plasty. An analysis of one hundred and twenty-eight
components retrieved at autopsy or revision operations.
J Bone Joint Surg Am 1997;79:349.
25. Kabo JM, Gebhard JS, Loren G, et al. In vivo wear of
polyethylene acetabular components. J Bone Joint Surg Br
1993;75:254.
26. Thomsen M, Burandt C, Gortz A, et al. An optical method
for determining deformation and form changes in poly-
1537
ethylene surfaces of explanted acetabular cups of hip
endoprostheses. Biomed Tech (Berl) 1999;44:247.
27. Yun HH, Jajodia NK, Myung JS, et al. Use of slide pre-
sentation software as a tool to measure hip arthroplasty
wear. J Arthroplasty 2009;24:1210.
28. Callaghan JJ, Dysart SH, Savory CG. The uncemented
porous-coated anatomic total hip prosthesis. Two-year
results of a prospective consecutive series. J Bone Joint
Surg Am 1988;70:337.
29. Jacobs CA, Christensen CP, Greenwald AS, et al. Clinical
performance of highly cross-linked polyethylenes in
total hip arthroplasty. J Bone Joint Surg Am 2007;
2779:89.
30. Thibault S, Borra EF. Telecentric three-dimensional sensor
with a liquid mirror for large-object inspection. Appl Opt
1999;38:5962.
31. Derbyshire B. The estimation of acetabular cup wear
volume from two-dimensional measurements: a compre-
hensive analysis. Proc Inst Mech Eng H 1998;212:281.
32. Isaac GH, Dowson D, Wroblewski BM. An investigation
into the origins of time-dependent variation in penetration
rates with Charnley acetabular cups—wear, creep or
degradation? Proc Inst Mech Eng H 1996;210:209.
33. Bould M, Barnard S, Learmonth ID, et al. Digital image
analysis: improving accuracy and reproducibility of radio-
graphic measurement. Clin Biomech (Bristol, Avon) 1999;
14:434.
34. Digas G, Karrholm J, Thanner J, et al. Highly cross-linked
polyethylene in cemented THA: randomized study of 61
hips. Clin Orthop Relat Res 2003;417:126.
35. Moore KD, Barrack RL, Sychterz CJ, et al. The effect of
weight-bearing on the radiographic measurement of the
position of the femoral head after total hip arthroplasty.
J Bone Joint Surg Am 2000;82:62.
36. Digas G, Karrholm J, Thanner J, et al. The Otto
Aufranc Award. Highly cross-linked polyethylene in
total hip arthroplasty: randomized evaluation of pene-
tration rate in cemented and uncemented sockets using
radiostereometric analysis. Clin Orthop Relat Res 2004;
429:6.
37. Saikko V, Calonius O, Keranen J. Wear of conventional
and cross-linked ultra-high-molecular-weight polyethyl-
ene acetabular cups against polished and roughened CoCr
femoral heads in a biaxial hip simulator. J Biomed Mater
Res 2002;63:848.
38. Wan Z, Boutary M, Dorr LD. Precision and limitation of
measuring two-dimensional wear on clinical radiographs.
Clin Orthop Relat Res 2006;449:267.
39. Collier MB, Kraay MJ, Rimnac CM, et al. Evaluation of
contemporary software methods used to quantify poly-
ethylene wear after total hip arthroplasty. J Bone Joint
Surg Am 2003;2410:85.