Large head ceramic-on-ceramic bearing in primary total hip arthroplasty: average 3-year follow-up of a multicentre study

Lower Revision Rates and Improved Stability With a Monoblock Ceramic Acetabular Cup

BACKGROUND

Monoblock ceramic cups are designed to accommodate large-diameter femoral heads. This has the potential to offer the advantages of an increased range of motion and enhanced joint stability. These features could benefit younger and high-demand patients in need of total hip arthroplasty. The aim of this study was to assess the survival rate and the reasons for revision of the DeltaMotion cup.

METHODS

Data from the AOANJRR were analyzed for all patients who had undergone a primary conventional THA performed between January 1, 2001 and December 31, 2021. Only prostheses with ceramic/ceramic, ceramic/XLPE, metal/XLPE, or CM/XLPE bearing surfaces were included. The primary outcome measure was the cumulative percent revision for all causes. Secondary outcome measures were revision for dislocation/instability, ceramic breakage, or noise. A subanalysis for cup size was also performed.

RESULTS

There were 486,946 primary conventional THA procedures undertaken for any reason. Of these, 4,033 used the DeltaMotion cup and 482,913 were modular designs. The DeltaMotion cup had the lowest CPR for all diagnoses compared to the modular bearings at all time points, had a significantly lower revision rate for prosthesis dislocation and no revisions for squeaking compared to other modular bearings. There were 175 ceramic breakages recorded in the modular bearing group and 1 ceramic breakage in the DeltaMotion group.

CONCLUSIONS

The DeltaMotion cup had a low rate of all-cause revision, and for dislocation, ceramic breakage, and noise. Although this cup is no longer manufactured, ongoing follow-up of newer monoblock ceramic cups will determine their suitability for younger and more active patients.

Liner dissociation in a large-diameter ceramic-bearing acetabular component: a report of five cases

Background

Ceramic-on-ceramic (CoC) bearings for total hip arthroplasty (THA) have been offering very favorable results and survivorship since their introduction. In order to increase range of movement (ROM) and decrease dislocation rates, some manufacturers have introduced larger diameter head (LDH) CoC bearings. This has been achieved with the use of preassembled cup designs, in which the ceramic liner is already fitted into the metal backing and implanted as a monoblock component by the surgeon. In this report we present data from a series of 5 patients with ceramic liner dissociation from a monoblock cup.

Case presentation

All cases were overweight men with acetabular components of 56 or 58 mm. After a mean of 5.5 (range, 3.5-6.7) years, all patients reported sudden pain and audible noise when performing activities of daily living. Liner displacement was suspected on plain radiographs and confirmed by Ct-scan. Pneumarthrosis was present in all cases. Taper modular junction wear and corrosion signs were observed in the four revised patients.

Conclusion

Although one of our case is still treated conservatively, implant revision is probably inevitable. Further LDH CoC implant design should take in consideration this potential complication by avoiding bearing diameters over 40mm and/or improving locking mechanism or by providing a real monoblock acetabular implant.

Catastrophic intraoperative failure of a ceramic femoral head

Approximately 17 years after a primary metal-on-metal total hip arthroplasty, a 59-year-old female developed pain, swelling, and weakness in her right hip accompanied by laboratory findings and imaging suggestive of an adverse local tissue reaction. Acetabular revision was performed to upsize the femoral head and improve hip stability. Upon impaction of the new, non-option ceramic femoral head onto the unsleeved retained stem, the head split into two pieces without fragmentation. The surgery was completed using a cobalt-chromium head, which was impacted without issue onto the stem’s taper. Although BIOLOX delta femoral heads do not require titanium sleeves, we believe that careful consideration should be given to their use in revision total hip arthroplasty with ceramic heads, regardless of the extent of trunnion damage noted intraoperatively.

Ceramic-on-ceramic total hip arthroplasty is superior to metal-on-conventional polyethylene at 20-year follow-up: A randomised clinical trial

BACKGROUND

Metal-on-conventional polyethylene (MoPc) bearing wear-related biological reactions in total hip arthroplasty (THA) continue to raise concerns among young, active patients. Ceramic-on-ceramic (CoC) bearings may offer improved outcomes in this patient population.

QUESTIONS/PURPOSES

The aim of this study was to determine if, more than 20years postoperatively, there is a difference between MoPc and CoC THA in terms of (1) survivorship, (2) related complications, (3) radiographic signs of wear, and (4) functional scores.

HYPOTHESIS

CoC bearing THAs have superior clinical results compared to MoPc THAs.

PATIENTS AND METHODS

A total of 140 hips in 116 patients with a mean age of 42years were randomised to receive CoC or MoPc THA between 1996 and 2001. Sixty-nine hips in 58 patients received MoP and 71 hips in 68 patients received CoC. Revision rate, WOMAC score, and radiological signs of osteolysis and loosening were compared at last follow-up.

RESULTS

After a mean follow-up of 21years (19-23), 40 patients (48 THAs; 34%) had died and 6 patients (6 THAs; 4%) were lost to follow-up. Aseptic revision rate was significantly higher in the MoPc group (17/69; 24.6%) versus CoC (2/71; 2.8%; p<0.001). Kaplan-Meier survivorship estimator with revision for aseptic reasons was 73.6% (95% CI: 63.3-84.9%) for MoPc and 96.9% (95% CI: 92.8-100%) for CoC (p<0.001). On radiographic evaluation, 13% (3/23) MoPc were considered loose versus no CoC, and 61% (14/23) MoPc versus 6% (2/33) CoC showed osteolytic signs (p<0.001). CoC had better mean WOMAC scores than MoPc (11.0 vs. 19.4; p=0.048). No ceramic fracture was observed.

CONCLUSION

In this RCT, CoC bearings provided excellent results and were safer than MoPc bearings at more than 20-year follow-up. The long-term in vivo behaviour of CoC bearing makes it a great THA option for middle-aged patients and should be compared to newer polyethylene bearings.

LEVEL OF EVIDENCE

I.

Ceramic-on-Ceramic Total Hip Arthroplasty with Large Diameter Heads: A Systematic Review

Ceramic-on-ceramic (COC) total hip arthroplasties (THAs) with large heads (>36 mm) were introduced to reduce dislocation rates and restore the hip anatomy as closely as possible to the native one. To date, the literature is scarce and fragmented; a review is desirable to point out the outcomes and the possible specific complications (noise, groin pain, and taperosis). A systematic review about large-diameter COC THAs was conducted according to the PRISMA guidelines. The PubMed and Cochrane databases were searched using the terms "large", "big", "head", "hip", and "ceramic." The methodological quality of the papers was assessed using the MINORS (Methodological Index for Nonrandomized Studies) score. Seven papers (level of evidence: 5 case series and 2 case-control studies) met the inclusion criteria. Clinical outcomes were excellent in >90% of the patients. Groin pain was reported in only 1 article (7%). Radiological outcomes were positive. Minimal revision rates (<2%) were reported at short- to mid-term follow-ups. Dislocation rates were usually <1%. No bearing surfaces failed. No case of trunnionitis was reported. Noise occurred in up to 30% of the patients, mostly squeaking. The noise did not influence clinical outcomes or patients' satisfaction. Noise was inconstantly associated with component positioning, younger age, high articular excursions, and larger sizes. Large-diameter heads in COC THAs (≥40 mm) showed promising clinical and radiological outcomes with minimal revision rates. Noise is a cause of concern and should be carefully evaluated at longer follow-ups and in larger, prospective, and specifically designed case series.

Arthroscopic evaluation and treatment of a squeaking hip. A case report

Background

Squeaking of ceramic-on-ceramic total hip arthroplasty is an unexpected complication which occurs in 1- 30% of patients. Revision surgery is required in 0.2% of the cases, when a ceramic fracture is suspected, or in case of severe malposition of the implants, subluxation, or impingement. Hip arthroscopy may be a useful diagnostic and therapeutic option in squeaking hips.

Case presentation

A patient presenting with a pain-free squeaking underwent hip arthroscopy to examine the sliding surfaces and the rim of the acetabulum, and to search for signs of impingement. Thorough lavage and debridement of hip synovitis and fibrous tissue was performed. The squeaking noise immediately disappeared after the surgery. The patient was allowed to fully weight bear as tolerated with 2 crutches for 2 weeks. Two years after the arthroscopy, the patient remained symptom-free.

Conclusions

The potential reasons for hip squeaking in our patient are discussed. Hip arthroscopy may prove useful as a diagnostic and therapeutic option for some patients presenting with a squeaking ceramic-on ceramic hip replacement.

Global diversity in bearings in primary THA

Choice of articulating materials, head size and the design of the articulation will become decisive for the long-term performance of a total hip arthroplasty (THA) and especially in terms of risk for dislocation and wear-related problems. Here we account for common alternatives based on available studies and the evidence that can be derived from them.Metal or ceramic femoral heads articulating against a liner or cup made of highly cross-linked polyethylene and ceramic-on-ceramic articulations have about similar risk for complications leading to revision, whereas the performance of metal-on-metal articulations, especially with use of big heads, is inferior. The clinical significance of problems related to ceramic-on-ceramic articulations such as squeaking remains unclear. With use of current technology ceramic fractures are rare.Large femoral heads have the potential to increase the range of hip movement before impingement occurs and are therefore expected to reduce dislocation rates. On the other hand, issues related to bearing wear, corrosion at the taper-trunnion junction and groin pain may arise with larger heads and jeopardize the longevity of THA. Based on current knowledge, 32-mm heads seem to be optimal for metal-on-polyethylene bearings. Patients with ceramic-on-ceramic bearings may benefit from even larger heads such as 36 or 40 mm, but so far there are no long-term reports that confirm the safety of bearings larger than 36 mm.Assessment of lipped liners is difficult because randomized studies are lacking, but retrospective clinical studies and registry data seem to indicate that this liner modification will reduce the rate of dislocation or revision due to dislocation without clear evidence of clinically obvious problems due to neck-liner impingement.The majority of studies support the view that constrained liners and dual mobility cups (DMC) will reduce the risk of revision due to dislocation both in primary and revision THA, the latter gaining increasing popularity in some countries. Both these devices suffer from implant-specific problems, which seem to be more common for the constrained liner designs. The majority of studies of these implants suffer from various methodological problems, not least selection bias, which calls for randomized studies preferably in a multi-centre setting to obtain sufficient power. In the 2020s, the orthopaedic profession should place more effort on such studies, as has already been achieved within other medical specialties, to improve the level of evidence in the choice of articulation when performing one of the most common in-hospital surgical procedures in Europe. Cite this article: EFORT Open Rev 2020;5:763-775. DOI: 10.1302/2058-5241.5.200002.