A
Use of ceramic femoral heads
B
Polyethylene wear debris leading to osteolysis
C
Use of cemented stems
D
Small femoral head size
Explanation:Polyethylene wear debris generated from the articulation between the femoral head and acetabular liner can trigger a macrophage-mediated inflammatory response. Activated macrophages release cytokines and enzymes that stimulate osteoclast activity, leading to periprosthetic bone resorption known as osteolysis. Progressive osteolysis can ultimately result in loosening of the acetabular component. Improvements in highly cross-linked polyethylene have significantly reduced wear rates and thereby decreased the incidence of osteolysis in modern arthroplasty practice. Reference: Harris WH, 'Osteolysis and particle disease in hip replacement', Clinical Orthopaedics and Related Research (1994).