Early to mid-term results of ceramic-on-ceramic total hip replacement: analysis of bearing-surface-related complications

Factors Influencing Noise Following Primary Ceramic-on-Ceramic Total Hip Arthroplasty

BACKGROUND

The noise associated with ceramic-on-ceramic (CoC) total hip arthroplasty (THA) has been a concerning issue, while its underlying causes remain unclear.

METHODS

We conducted a retrospective analysis of 119 patients (174 primary CoC THAs) who had a mean follow-up of 28 months (range, 12 to 106). A questionnaire was designed to collect information on nature, frequency, onset, duration, and impact of the noise. Postoperative x-rays were evaluated. Clinical evaluations, including Harris and Oxford hip scores, were documented at follow-up time points (6 weeks, 3 months, 6 months, and 1 year).

RESULTS

Of the 174 hips, 31.6% reported noise, including 26 popping (14.9%), 24 clicking (12.1%), and 5 grinding (2.9%). No patients reported squeaking. Noisy hips had lower age (P = .009) and body mass index (P = .019). Among patients with developmental dysplasia of the hip, 17 of 55 hips reported noise associated with smaller cup anteversion angle (P = .004), greater body height (P = .022), and larger acetabular cup size (P = .049). Noise typically began at a mean of 193 days (range, 1 to 2,598) after surgery and disappeared spontaneously in 50.9% of hips before final follow-up, with an average disappearance time of 211 days (range, 60 to 730). Noise did not affect daily life in 74.5% of patients, while 26.9% of patients who had popping reported painful sensations. One patient experienced joint dislocation, and another experienced a ceramic liner fracture during follow-up. No statistical difference was observed in outcome scores between noise and silent groups at 4 follow-up time points.

CONCLUSIONS

Incidence of noise after primary CoC THA is relatively high. Smaller cup anteversion and larger acetabular cup size were associated with noise production in patients who had developmental dysplasia of the hip.

5 year follow up of a hydroxyapatite coated short stem femoral component for hip arthroplasty: a prospective multicentre study

Short stem, uncemented femoral implants for hip arthroplasty are bone conserving achieving stability through initial metaphyseal press-fit and biological fixation. This study aimed to evaluate the survivorship, mid-term function and health related quality of life outcomes in patients who have undergone total hip arthroplasty (THA) with a fully hydroxyapatite coated straight short stem femoral component with up to 5 years follow-up. 668 patients were recruited to a multicentre study investigating the performance of the cementless Furlong Evolution® stem for THA. 137 patients withdrew at various time points. The mean follow-up was 49 months. Clinical (Harris Hip Score (HHS), radiographic and patient-reported outcome measures-Oxford Hip Score (OHS) and EuroQol 5D (EQ-5D), were recorded pre-operatively and at 6 weeks, 6 months, 1 year, 3 year and 5 year follow ups. At 5-year follow-up, 12 patients underwent revision surgery, representing a cumulative revision rate of 1.8%. Median OHS, HHS and EQ5D scores improved significantly: OHS improved from a pre-operative median of 21 (IQR 14-26) to 47 (IQR 44-48) (p < 0.001). HHS improved from 52 (IQR 40-63) to 98 (IQR 92-100) (p < 0.001) and EQ5D improved from 70 (IQR 50-80) to 85 (IQR 75-95) (p < 0.001). This fully HA-coated straight short femoral stem implant demonstrated acceptable mid-term survivorship and delivered substantial improvements in function and quality of life after THA.

Ceramic Bearings Are Associated With a Significantly Reduced Revision Rate in Primary Hip Arthroplasty: An Analysis From the National Joint Registry for England, Wales, Northern Ireland, and the Isle of Man

BACKGROUND

Prosthetic joint infection (PJI) is a devastating complication. Studies have suggested reduction in PJI with the use of ceramic bearings.

METHODS

Adult patients who underwent total hip arthroplasty (THA) using an uncemented acetabular component with ceramic-on-ceramic (CoC), ceramic-on-polyethylene (CoP), or metal-on-polyethylene (MoP) bearing surfaces between 2002 and 2016 were extracted from the National Joint Registry for England, Wales, Northern Ireland, and the Isle of Man. A competing risk regression model to investigate predictors of each revision outcome was used. Time-to-event was determined by duration of implantation since primary surgery with competing risks being death or revision. The results were adjusted for age, gender, American Association of Anaesthesiologists grade, body mass index, surgical indication, intraoperative complications, and implant data.

RESULTS

In total, 456,457 THAs (228,786 MoP, 128,403 CoC, and 99,268 CoP) were identified. Multivariable modeling showed that the risk of revision for PJI was significantly lower with CoC (risk ratio 0.748, P < .001) and CoP (risk ratio 0.775, P < .001) compared to MoP. Significant reduction in risk of aseptic and all-cause revision was also seen. The significant protective effect of ceramic bearing was predominantly seen 2 years after implantation. Aseptic revision beyond 2 years reduced by 18.1% and 24.8% for CoC and CoP (P < .001), respectively. All-cause revision rate beyond 2 years reduced by 21.6% for CoC and 27.1% for CoP (P < .001) CONCLUSION: This study demonstrates an association between the use of ceramic as part of the bearing, with lower rates of revision for all causes, revision for infection, and revision for aseptic causes, supporting ceramic bearings in THA.

Alumina ceramic-on-ceramic hybrid total hip arthroplasty. A median of 15 years follow-up

INTRODUCTION

The optimum choice of bearing surfaces in total hip replacement (THR) in the younger and active patient remains controversial. The aim of this study was to report the 10 year clinical outcomes, and a median of 15 year implant survival and incidence of complications in a series of Alumina ceramic-on-ceramic THRs utilising an uncemented shell and cemented stem.

METHODS

From January 2004 to December 2007, 175 consecutive patients (195 hips) underwent primary THR. The acetabular components was Trident Peripheral Self Locking (Stryker Orthopaedics) with a third-generation ceramic head and liner (Alumina ceramic, Stryker Orthopaedics). The stem utilised was an Exeter V-40 (Stryker Orthopaedics). Data were collated on demographics, surgical factors, clinical outcomes, radiographic outcomes and revision.

RESULTS

23 patients (27 THRs) died during the follow-up period at a median of 7.8 (3.8 to 9.0) years post-operatively due to causes unrelated to the THR. Median age at time of surgery was 55 (interquartile range 48-60) years. Median follow-up for surviving patients was 15.2 years. Survivorship for all-cause revision was 97.2%. Increasing patient age at time of surgery was associated with a higher OHS at 10 years (p = 0.022). 32 mm head diameter had an improved OHS at 3 months (p = 0.014) and 10 years (p = 0.030). Posterior surgical approach had a statistically significant better OHS at 3 months (p = 0.015) and 1 year (p < 0.001), but the effect was not significant at 10 years (p = 0.440).

CONCLUSION

The findings of this study support excellent long-term outcomes and survivorship of Alumina ceramic-on-ceramic bearing in a hybrid THR in a younger population. Surgical factors leading to a more favourable outcome were the use of a 32 mm femoral head and a posterior approach. Increasing age at surgery demonstrated the most sustained improvement in 10 year clinical outcomes.

Prevention of infection in primary THA and TKA

Rates of peri-prosthetic joint infection (PJI) in primary total hip and total knee arthroplasty range between 0.3% and 1.9%, and up to 10% in revision cases. Significant morbidity is associated with this devastating complication, the economic burden on our healthcare system is considerable, and the personal cost to the affected patient is immeasurable.

The risk of surgical site infection (SSI) and PJI is related to surgical factors and patient factors such as age, body mass index (BMI), co-morbidities, and lifestyle. Reducing the risk of SSI in primary hip and knee arthroplasty requires a multi-faceted strategy including pre-operative patient bacterial decolonization, screening and avoidance of anaemia, peri-operative patient warming, skin antisepsis, povidone-iodine wound lavage, and anti-bacterial coated sutures.

This article also considers newer concepts such as the influence of bearing surfaces on infection risk, as well as current controversies such as the potential effects of blood transfusion, laminar flow, and protective hoods and suits, on infection risk.

Cite this article: EFORT Open Rev 2020;5:604-613. DOI: 10.1302/2058-5241.5.200004

Squeaking in fourth-generation ceramic-on-ceramic total hip replacement and the relationship with prosthesis brands: meta-analysis and systematic review

Background

Postoperative squeaking in patients who applied the fourth-generation ceramic bearing in primary hip replacement has not been reported systematically; we aim to study the squeaking incidence in the fourth-generation ceramic bearing and related risk factors for squeaking, and we also attempt to explore the relationship between squeaking and prosthetic brands.

Methods

The PubMed, Embase, and Cochrane library were searched, and 14 articles were finally included. Patients’ demographic data, surgical-related information, and prosthesis data were extracted. The occurrence rate of squeaking was calculated by meta-analysis, and subgroup analysis was performed based on prosthetic brands and follow-up time. Regression analysis was further applied to investigate the relationship between various risk factors and squeaking.

Results

The squeaking incidence in patients with the fourth-generation ceramic bearing was 3%. Age, gender, body mass index, and abduction and anteversion angles of acetabular cup might have no influence on squeaking. The squeaking incidence was significantly high with the presence of Delta Motion cup (DePuy, Warsaw, Indiana) and Secure-Fit stem (Stryker, Kalamazoo, MI), and the overall incidence of DePuy femoral stem was relatively small except for the Summit femoral stem. And there was no significant difference of squeaking incidence between less than 5-year and more than or equal to 5-year follow-up subgroups.

Conclusions

In our study, squeaking in the fourth-generation ceramic bearing occurred at a rate of 3%; occurrence rate was high when the Delta Motion cup was applied. We hope for more relevant researches to focus on this issue.

Electronic supplementary material

The online version of this article (10.1186/s13018-018-0841-y) contains supplementary material, which is available to authorized users.

3rd generation ceramic-on-ceramic cementless total hip arthroplasty: a minimum 10-year follow-up study

INTRODUCTION

3^rd generation ceramic bearings were introduced in total hip arthroplasty (THA) with the potential to have better mechanical strength and wear properties than their predecessors. At present, there are few studies looking at the long-term results of this latest generation of ceramic bearings. The purpose of our study was to investigate the long-term clinical and radiographic results of 3^rd generation ceramic-on-ceramic THA and the incidence of ceramic specific complications such as squeaking and bearing surface fracture.

METHODS

The database of the senior author (J.D.W.) was reviewed. A total of 126 hip replacements performed in 108 patients (average age 39.6 years) with an average follow-up of 12.1 years (10-16 years) was identified. Clinical notes and plain radiographs were reviewed. To measure function, patients were contacted and an Oxford Hip Questionnaire was completed. Patients were also directly questioned about the presence of squeaking or any other sounds from the hip. Radiographs were evaluated for signs of wear, osteolysis, loosening and heterotopic ossification. The abduction angle of the acetabular component was measured.

RESULTS

The average Oxford Hip Score was 39.8 out of 48. Survivorship at 10 years was 94.6% (95% CI) with revision for any cause as the endpoint. There was 1 femoral head fracture, no osteolysis, no squeaking and no detectable wear.

CONCLUSIONS

The good clinical and radiographic results for this series of patients are similar to other recent long-term studies looking at 3^rd generation ceramic-on-ceramic THA. The results compare favourably with other bearing surfaces. The lack of osteolysis associated with this articulation is encouraging and may also make it a good choice for younger patients requiring total hip replacement.

A comparison of two different navigated hip replacement techniques on leg length discrepancy

We hypothesised that a femoral array placed into bone or an external (pinless) reference marker made no difference to leg length discrepancy in patients undergoing navigated total hip arthroplasty. Consecutive patients undergoing navigated total hip arthroplasty. 162 patients. No statistical difference between preoperative leg length discrepancy (p = 0.524). Mean intraoperative change was 3.7 mm and 4.6 mm (p = 0.262). The mean change in leg length measure post operatively was 4.2 mm and 4.1 mm (p = 0.656). No significant difference in leg length discrepancy between a pinless reference markers and a femoral array placed into the bone.

3rd generation ceramic-on-ceramic cementless total hip arthroplasty: a minimum 10-year follow-up study

INTRODUCTION

3rd generation ceramic bearings were introduced in total hip arthroplasty (THA) with the potential to have better mechanical strength and wear properties than their predecessors. At present, there are few studies looking at the long-term results of this latest generation of ceramic bearings.The purpose of our study was to investigate the long-term clinical and radiographic results of 3rd generation ceramic-on-ceramic THA and the incidence of ceramic specific complications such as squeaking and bearing surface fracture.

METHODS

The database of the senior author (J.D.W.) was reviewed. A total of 126 hip replacements performed in 108 patients (average age 39.6 years) with an average follow-up of 12.1 years (10-16 years) was identified. Clinical notes and plain radiographs were reviewed. To measure function, patients were contacted and an Oxford Hip Questionnaire was completed. Patients were also directly questioned about the presence of squeaking or any other sounds from the hip. Radiographs were evaluated for signs of wear, osteolysis, loosening and heterotopic ossification. The abduction angle of the acetabular component was measured.

RESULTS

The average Oxford Hip Score was 39.8 out of 48. Survivorship at 10 years was 94.6% (95% CI) with revision for any cause as the endpoint. There was 1 femoral head fracture, no osteolysis, no squeaking and no detectable wear.

CONCLUSIONS

The good clinical and radiographic results for this series of patients are similar to other recent long-term studies looking at 3rd generation ceramic-on-ceramic THA. The results compare favourably with other bearing surfaces. The lack of osteolysis associated with this articulation is encouraging and may also make it a good choice for younger patients requiring total hip replacement.

Early performance-based and patient-reported outcomes of a contemporary taper fit bone-conserving short stem femoral component in total hip arthroplasty

Aims

The aim of this study was to compare early functional and health related quality of life outcomes (HRQoL) in patients who have undergone total hip arthroplasty (THA) using a bone conserving short stem femoral component and those in whom a conventional length uncemented component was used. Outcome was assessed using a validated performance based outcome instrument as well as patient reported outcome measures (PROMs).

Patients and Methods

We prospectively analysed 33 patients whose THA involved a contemporary proximally porous coated tapered short stem femoral component and 53 patients with a standard conventional femoral component, at a minimum follow-up of two years. The mean follow-up was 31.4 months (24 to 39). Patients with poor proximal femoral bone quality were excluded. The mean age of the patients was 66.6 years (59 to 77) and the mean body mass index was 30.2 kg/m2 (24.1 to 41.0). Outcome was assessed using the Oxford Hip Score (OHS) and the University College Hospital (UCH) hip score which is a validated performance based instrument. HRQoL was assessed using the EuroQol 5D (EQ-5D).

Results

There were no major peri-operative complications. There was no difference in the mean post-operative OHS, EQ-5D or function subscale of the UCH hip scores between the two groups. The mean pre-operative OHS and EQ-5D scores improved significantly (all p <  0.001). The mean functional component of the UCH hip score at final follow-up was 42.5 and 40.6 in the short stem and conventional stem groups, respectively. There was no statistically significant difference between the groups (p = 0.42). A total of seven patients (21.2%) in the short stem group and nine (16.98%) in the conventional group achieved a ceiling effect using the OHS; none did using the function subscale of the UCH hip score.

Conclusion

The proximally porous coated tapered short stem femoral component achieves comparable short-term functional outcomes when compared with a conventional longer stem uncemented femoral component when THA is undertaken in patients with good bone quality. Cite this article: Bone Joint J 2017;99-B(4 Supple B):49–55.

High prevalence of noise following Delta ceramic-on-ceramic total hip arthroplasty

Aims

We evaluated the short-term functional outcome and prevalence of bearing-specific generation of audible noise in 301 patients (336 hips) operated on with fourth generation (Delta) medium diameter head, ceramic-on-ceramic (CoC) total hip arthroplasties (THAs).

Patients and Methods

There were 191 female (63%) and 110 male patients (37%) with a mean age of 61 years (29 to 78) and mean follow-up of 2.1 years (1.3 to 3.4). Patients completed three questionnaires: Oxford Hip Score (OHS), Research and Development 36-item health survey (RAND-36) and a noise-specific symptom questionnaire. Plain radiographs were also analysed. A total of three hips (0.9%) were revised.

Results

There were 52 patients (54 hips, 17%) who reported noise, and in 25 (48%) of them the noise was frequently heard. In the multiple regression analysis, the only independent risk factor for noise was a specific THA brand, with a threefold increased risk (95% confidence intervals 1.39 to 6.45, p = 0.005) of noise compared with the reference THA brand. Patients with noisy hips had lower median OHS (43 versus 46.5, p = 0.002) and their physical functioning (p = 0.021) subscale in RAND-36 was reduced.

Conclusion

Noise was surprisingly common in this population. Cite this article: Bone Joint J 2017;99-B:44–50.

The choice between hip prosthetic bearing surfaces in total hip replacement: a protocol for a systematic review and network meta-analysis

BACKGROUND

Prosthetic hip implants have many combinations of bearing surface materials, sizes, and fixation techniques, which can determine the quality of life of patients after primary total hip replacement (THR) and the likelihood of needing revision surgery. When an implant fails, patients require revision THR, which is distressing to the patient and expensive for the health care payer. Primary THR is one of the most common elective procedures performed worldwide, with over 300,000 performed annually in the USA and over 80,000 in England and Wales. It is important to review all available randomised controlled trial (RCT) evidence to determine which implant bearing surface materials, size, and fixation technique are most effective for patients.

METHODS/DESIGN

This is a protocol for a systematic review and meta-analysis of RCTs comparing outcomes of hip implant bearing surfaces, size, and fixation techniques used in THR. Implant combinations compared in the literature include four bearing surface combinations (metal-on-polyethylene, metal-on-metal, ceramic-on-polyethylene, and ceramic-on-ceramic); two femoral head sizes (large vs small heads); and four fixation techniques (uncemented, cemented, hybrid, and reverse hybrids). The primary outcome will be revision surgery. We will also collect data on patient characteristics, mortality, quality of life, and other outcomes. In network meta-analysis, we will estimate the relative effectiveness of every implant bearing surface, head size (large vs small), and fixation permutation, using evidence where implants have been compared directly in an RCT and indirectly through common comparators in different RCTs.

DISCUSSION

There has been much debate about materials used for prosthetic implants in THR. Different combinations of prosthetic materials, sizes, and fixation, can vary widely in cost and fail at different rates for different patient groups. Given the number of THRs performed yearly, and the increasing use of expensive implants, it is important to review evidence to inform surgeons, patients, and health care providers of optimal implant bearing combinations for given patient characteristics. This review will inform a cost-effectiveness model that will include evidence from other sources, to determine the most effective and cost-effective implant bearing combination for patients.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015019435.

Midterm results of 36 mm metal-on-metal total hip arthroplasty

BACKGROUND

Despite the many perceived benefits of metal-on-metal (MoM) articulation in total hip arthroplasty (THA), there have been growing concerns about metallosis and adverse reaction to metal debris (ARMD). Analysis of size 36 mm MoM articulation THAs is presented. These patients were evaluated for patient characteristics, relationship between blood metal ions levels and the inclination as well as the version of acetabular component, cumulative survival probability at final followup and functional outcome at final followup.

MATERIALS AND METHODS

288, size 36 mm MoM THAs implanted in 269 patients at our institution from 2004 to 2010 were included in this retrospective study. These patients were assessed clinically for hip symptoms, perioperative complications and causes of revision arthroplasty were analysed. Biochemically, blood cobalt and chromium metal ions level were recorded and measurements of acetabular inclination and version were examined. Radiological evaluation utilizing Metal Artefact Reduction Sequence (MARS) MRI was undertaken and implant cumulative survivorship was evaluated.

RESULTS

The mean followup was 5 years (range 2-7 years), mean age was 73 years and the mean Oxford hip score was 36.9 (range 5-48). Revision arthroplasty was executed in 20 (7.4%) patients, of which 15 patients underwent single-stage revision THA. The causes of revision arthroplasty were: ARMD changes in 6 (2.2%) patients, infection in 5 (1.9%) patients and aseptic loosening in 5 (1.9%) patients. Three (1.1%) patients had their hips revised for instability, 1 (0.3%) for raised blood metal ions levels. The implant cumulative survival rate, with revision for any reason, was 68.9% at 7 years.

CONCLUSIONS

Although medium-sized MoM THA with a 36 mm head has a marginally better survivorship at midterm followup, compared to larger size head MoM articulating THA, our findings nonetheless are still worryingly poor in comparison to what has been quoted in the literature. Furthermore, ARMD-related revision remains the predominant cause of failure in this cohort with medium-sized MoM articulation. No correlation was found between blood metal ions levels and the inclination as well as the version of acetabular component.

A new method of registration in navigated hip arthroplasty without the need to register the anterior pelvic plane

A prospective clinical study of 50 patients was conducted to validate a new method of imageless computer navigated hip arthroplasty. The new method enables the surgeon to acquire all registration points with the patient positioned and draped in lateral decubitus position. The final component orientation was measured from post-operative CT scans. The mean error in component position was -1.1° (SD 3.1°) for inclination and 0.9° (SD 4.3°) for anteversion. This compared favourably with the error of -1.8° (SD 1.8°) for inclination and -4.8° (SD 2.7°) for anteversion when using the traditional APP registration. Results show that one can expect the acetabular component to be within a safe zone of ±10° in 99.8% for inclination and 97.7% for anteversion when using the new lateral registration method. Level of Evidence Level II, Prognostic study.

Meta-analysis of the Incidence and Risk Factors for Squeaking after Primary Ceramic-on-ceramic Total Hip Arthroplasty in Asian Patients

Purpose

The purpose of this study was to assess the squeaking incidence and risk factors after primary ceramic-on-ceramic total hip arthroplasty (THA) in Asian patients using meta-analysis.

Materials and Methods

We performed a meta-analysis of published data on the squeaking incidence and risk factors from 2000 to 2013. Eight studies in Asians were analyzed for both squeaking incidence and risk factors and 25 studies in Western patients were analyzed for squeaking incidence. The data collected were: patient factors, surgical factors and implantation factors.

Results

The overall incidence of hip squeaking was 2.7% in Asians and 3.1% in Westerners. This difference was not statistically significant. The only significant risk factor was an increase in the acetabular cup abduction angle. Of the factors, the cup abduction angle was the only significant risk factor for the occurrence rate of squeaking, and the occurrence rate tended to increase with increasing angle.

Conclusion

The incidence of squeaking in Asians after primary ceramic-on-ceramic THA is 2.7% and is similar to that in Westerners. The increased cup abduction angle is associated with squeaking; therefore, surgeons should be careful not to implant the cup at a too steep abduction angle.

An estimation of the incidence of squeaking and revision surgery for squeaking in ceramic-on-ceramic total hip replacement: a meta-analysis and report from the Australian Orthopaedic Association National Joint Registry

Squeaking arising from a ceramic-on-ceramic (CoC) total hip replacement (THR) may cause patient concern and in some cases causes patients to seek revision surgery. We performed a meta-analysis to determine the incidence of squeaking and the incidence of revision surgery for squeaking. A total of 43 studies including 16,828 CoC THR that reported squeaking, or revision for squeaking, were entered into the analysis. The incidence of squeaking was 4.2% and the incidence of revision for squeaking was 0.2%. The incidence of squeaking in patients receiving the Accolade femoral stem was 8.3%, and the incidence of revision for squeaking in these patients was 1.3%.

Ceramic-on-ceramic bearings in young patients

We report the clinical and radiological outcomes of a series of contemporary cementless ceramic-on-ceramic total hip replacements (THRs) at ten years in patients aged ≤ 55 years of age. Pre- and post-operative activity levels are described. A total of 120 consecutive ceramic cementless THRs were performed at a single centre in 110 patients from 1997 to 1999. The mean age of the patients at operation was 45 years (20 to 55). At ten years, four patients had died and six were lost to follow-up, comprising ten hips. The mean post-operative Harris hip score was 94.7 (55 to 100). Radiological analysis was undertaken in 90 available THRs of the surviving 106 hips at final review: all had evidence of stable bony ingrowth, with no cases of osteolysis. Wear was undetectable. There were four revisions. The survival for both components with revision for any cause as an endpoint was 96.5% (95% confidence interval 94.5 to 98.7). The mean modified University of California, Los Angeles activity level rose from a mean of 6.4 (4 to 10) pre-operatively to 9.0 (6 to 10) at the ten-year post-operative period.

Alumina ceramic-on-ceramic bearings in cementless primary THR in this series have resulted in good clinical and radiological outcomes with undetectable rates of wear and excellent function in the demanding younger patient group at ten years.

Cite this article: Bone Joint J 2013;95-B:1603–9.

Ceramic-on-ceramic total hip arthroplasty: incidence and risk factors of bearing surface-related noises in 125 patients

The ceramic-on-ceramic bearing surface has high wear resistance and good biocompatibility in total hip arthroplasty (THA). However, the postoperative noise problem has been an important issue. The purpose of this retrospective study was to determine the incidence and risk factors of bearing surface-related noises in patients with third-generation ceramic-on-ceramic THAs. One hundred twenty-five patients (143 hips) with ceramic-on-ceramic THAs were included in the study and followed to obtain noise and functional results. Patient factors, including sex, age, height, weight, body mass index, diagnosis, and postoperative range of motion, and surgical factors, including cup inclination, ceramic head size and length, and size of cup related to noises, were recorded. Mean follow-up was 4.2 years (range, 2-10 years). Mean Harris Hip Score was 94 points (range, 68-100 points) at latest follow-up. One (0.8%) patient had radiological evidence of osteolysis, and 4 (3.2%) patients had hip dislocation. No hip sustained a fracture of the ceramic component. Eight (6.4%) patients developed noise at their hips, including clicking in 4, grinding in 2, and snapping in 2. No patient developed squeaking hips or underwent revision surgery because of noisy hips. Younger patients (P=.01), a diagnosis of osteonecrosis (P=.014), a 28-mm ceramic head (P=.042), and a higher hip range of motion postoperatively (P=.001) were related to noise in ceramic-on-ceramic THAs. The study showed third-generation ceramic-on-ceramic THAs had a low incidence of noise problems. However, long-term follow-up is necessary to determine the clinical relevance.

Advantages and disadvantages of ceramic on ceramic total hip arthroplasty: a review

BACKGROUND

Ceramic on ceramic (COC) total hip arthroplasty (THA) was developed to reduce wear debris and accordingly, the occurrence of osteolysis and aseptic loosening especially in younger patients. Based on the excellent tribological behavior of current COC bearings and the relatively low biological activity of ceramic particles, significant improvement in survivorship of these implants is expected.

METHODS

We used manual search to identify all relevant studies reporting clinical data on COC THAs in PubMed. The objective was to determine whether current COC THA offers a better clinical outcome and survivorship than non-COC THA.

RESULTS

Studies with early generation ceramic bearings yielded 68% to 84% mean survivorship at 20 years follow-up which is comparable with the survivorship of non-COC THAs. Studies on current ceramic bearings report a 10-year revision-free interval of 92% to 99%. These outcomes are comparable to the survivorship of the best non-COC THAs. However, there are still concerns regarding fracture of sandwich ceramic liners, squeaking, and impingement of the femoral neck on the rim of the ceramic liner leading to chipping, especially in younger and physically active patients.

CONCLUSION

Current COC THA leads to equivalent but not improved survivorship at 10 years follow-up in comparison to the best non-COC THA. Based on this review, we recommend that surgeons weigh the potential advantages and disadvantages of current COC THA in comparison to other bearing surfaces when considering young very active patients who are candidates for THA.

Ceramic-Ceramic Bearing: Too Unpredictable to Use it Regularly

BACKGROUND

Ceramic-on-ceramic (CoC) bearings have excellent tribologic properties because of the smoothness, hardness, and wettability of the material. Therefore, their use has been proposed in younger, active patients who may wear out a traditional metal-on-polyethylene bearing. The same material properties that are beneficial to tribology may also create problems, however. For example, squeaking and fracture of the bearing materials have been reported to occur.

PURPOSE

The purpose of this paper was to investigate the literature reporting the complications of ceramic bearings and attempt to provide insight into their implications.

METHODS

The US National Library of Medicine Database (PubMed) was searched using the terms "ceramic-ceramic total hip replacement," "complications," "squeaking," and "fracture." Only clinical studies with a clear reporting of the incidence of these complications were included.

RESULTS

The literature reports that squeaking of the CoC bearing occurs in a certain percentage of patients and is likely indicative of edge loading and excessive wear. Other factors, such as patient height, weight, range of motion, and implant design, may contribute to the propensity for squeaking. Fracture is a unique risk of the CoC articulation that requires revision surgery. Though improvements in manufacturing techniques have reduced the fracture risk to a very low percentage, the ceramic material remains susceptible to this complication by impingement and component malposition.

CONCLUSIONS

Because of these possible negative outcomes associated with the ceramic material, the CoC bearing is too unpredictable to use regularly, and its use should be limited to patients who would benefit the most from it.