Primary Total Hip Arthroplasty With Fourth-Generation Ceramic-on-Ceramic: Analysis of Complications in 939 Consecutive Cases Followed for 2-10 Years

Long-term follow-up of total hip arthroplasty using polyethylene-ceramic composite (sandwich) liner

INTRODUCTION

Ceramic-on-ceramic bearings have been widely used since their introduction in the 1970s. First-generation ceramics have very high fracture (breakage) rates. To overcome this, in the 1990s, modular cotyloid insert designs were developed, consisting of a ceramic and polyethylene composite (sandwich-type) liner; however, high implant fracture rates were observed in the medium term. We aimed to estimate the cumulative incidences of revision surgery (implant failure) and implant failure due to fractures, survival rates (time-to-revision surgery and time-to-fracture), and the long-term clinical and radiological outcomes in our series.

METHODS

This was an observational, longitudinal, ambispective, single-centre study based on patients who underwent primary total hip arthroplasty (THA) using a sandwich-type liner (Cerasul), only available in our tertiary hospital between January 1999 and December 2002. Cumulative incidences were estimated and the 95% confidence interval (95% CI) was calculated. The Kaplan-Meier method was used to assess the time-to-revision surgery and time-to-fracture.

RESULTS

54 patients (49 men) were included, accounting for 59 sandwich-type linear implants. The mean (range) age was 47.4 (22-57) years. The primary THA indications were osteoarthritis (28 patients), osteonecrosis (14), childhood pathology sequelae (11), and inflammatory arthritis (6). The cumulative incidence of revision surgery by implants was 8.5% (5/59, 95% CI, 3.5-19.2%), 9.3% by patients (5/54, 95% CI, 4.0-19.9%), and 5.1% by implant fractures (3/59, 95%CI, 1.7-13.9%). The median (Interquartile Range, IQR) time-to-revision surgery was 158 (72.5-161) months, and the time to fracture was 182 (138-215) months. All primary THAs had good clinical and long-term survival outcomes. All implants had signs of solid fixation.

CONCLUSIONS

After a 20-year follow-up period, the polyethylene-ceramic sandwich-type liner showed a long survival rate and low cumulative incidence of implant fracture; however, implant fractures remain the main complication. Orthopaedic surgeons should be aware that some patients still have this type of prosthesis and must be capable of responding quickly if a fracture occurs.

Outcomes of Ceramic-On-Ceramic Bearing Total Hip Arthroplasty: A Minimum 10-Year Follow-Up Study

BACKGROUND

Although the fourth generation of ceramics has demonstrated excellent clinical results 5 to 6 years postoperatively, concerns over ceramic fracture and squeaking persist and longer-term follow-up (minimum 10 years) studies are warranted. Our study aimed to evaluate the minimum 10-year clinical outcomes and bearing-specific complications of ceramic-on-ceramic (CoC) total hip arthroplasties.

METHODS

We retrospectively evaluated all patients who underwent primary delta CoC total hip arthroplasty in our institution between January 2004 and February 2013. Demographics, surgical techniques, complications, patient-reported outcomes, and radiographic outcomes were collected and analyzed. For continuous variables, the comparison between groups was conducted using a one-way analysis of variance. Of all 235 patients included in the study, 70.5% were women (190 hips). The mean follow-up period was 12 years (range, 10 to 18). The femoral head sizes of 28- mm, 32 mm, and 36 mm were used in 50, 26, and 197 cases, respectively. Mean acetabular inclination and anteversion angles were 39.2 ± 7.1° and 14.9 ± 3.5°.

RESULTS

There were 5 hips revised at a mean 4.6 years (range, 0.1 to 7.1). One revision was squeaking-related. Squeaking was also reported by 8 other patients, but did not require revision. Other reasons for revision were early infection in 2 cases, stem loosening in 1 case, and stem fracture in 2 cases. The survival analysis for any causes for revision as an endpoint was 96.7% (95% confidence interval 0.313%-2.57%).

CONCLUSION

We report excellent mean 12-year follow-up results regarding the complications and survivorship of the fourth generation CoC bearings.

A Nomogram That Characterizes a Patient's Odds of Developing Squeaking After Fourth-generation Ceramic-on-ceramic THA

BACKGROUND

Although ceramic-on-ceramic (CoC) bearings result in the lowest wear rate of any bearing combination, postoperative squeaking remains worrisome. However, data concerning squeaking in long-term follow-up studies are still lacking, especially for fourth-generation CoC THA.

QUESTIONS/PURPOSES

(1) After keeping the prosthesis in place for 10 years, what percentage of patients treated with fourth-generation CoC THA implants report squeaking, and are there points in time when squeaking occurs more frequently? (2) What are the characteristics, association with hip function, and factors associated with squeaking? (3) Can we create a nomogram that characterizes a patient's odds of experiencing squeaking based on the factors associated with it?

METHODS

Between January 2009 and December 2011, 1050 patients received primary THAs at our institution, 97% (1017) of whom received fourth-generation CoC THAs because this was the preferred bearing during this period. Of the 1017 eligible patients, 5% (54) underwent THAs performed by low-volume surgeons, 3% (30) were implanted with cemented prostheses, 2% (22) died, 1% (10) were immobile, 1% (six) underwent revision surgery, and 17% (169) were lost to follow-up before 10 years, leaving 726 patients for analysis here at a mean of 11 ± 1 years. In the study cohort, 64% (464) were male and 36% (262) were female, with a mean age of 44 ± 13 years at primary THA. We extracted data about articular noise from follow-up records in our institutional database and used a newly developed questionnaire to ascertain the percentage of patients who reported squeaking at the latest follow-up interval. Although not validated, the questionnaire was modeled on previous studies on this topic. The longitudinal pattern for squeaking was explored to find timepoints when squeaking occurs more frequently. Based on the questionnaire data, we calculated the percentages of frequent, reproducible, and avoidable squeaking. Hip function was evaluated with the Harris Hip Score and WOMAC score and compared between the squeaking and nonsqueaking groups. Factors associated with squeaking, which were examined in a multivariate analysis, were used to develop a nomogram.

RESULTS

At 10 years, 16% (116 of 726) of patients reported squeaking. Two squeaking peaks were determined, at 0 to 1 year and 8 to 10 years. Frequent, reproducible, and avoidable squeaking accounted for 42% (36 of 86), 20% (17 of 86), and 41% (35 of 86), respectively. The mean Harris Hip Score (93 ± 4 versus 94 ± 5; p = 0.81) and WOMAC score (16 ± 13 versus 15 ± 13; p = 0.23) did not differ between patients with squeaking and those without. After controlling for potential confounding variables such as etiology and head offset, we found that patients younger than 46 years (odds ratio 2.5 [95% confidence interval 1.5 to 5.0]; p < 0. 001), those who were male (OR 2.0 [95% CI 1.1 to 3.5]; p = 0.04), those having a total flexion and extension arc of less than 50° (OR 2.0 [95% CI 1.2 to 3.3]; p = 0.02), and those with the Corail hip implant (OR 4.1 [95% CI 2.1 to 7.7]; p < 0. 001) were more likely to report squeaking. We created a nomogram that can be used at the point of care that can help clinicians identify patients at a higher risk of experiencing squeaking; this nomogram had good performance (area under the receiver operating characteristic curve of 77%).

CONCLUSION

As a potential late complication, squeaking after fourth-generation CoC THA is of concern and may be related to increased stripe wear. We recommend that surgeons use this nomogram to assess the odds of squeaking before selecting a bearing, especially in patients at high risk, to facilitate shared decision-making and improve patient satisfaction. Future external validation of the model is still needed to enhance its applicability.Level of Evidence Level III, therapeutic study.

Ten to 13-Year Results of Delta Ceramic-on-Ceramic Total Hip Arthroplasty in Patients Less Than 30 Years Old

BACKGROUND

We previously reported mid-term results of total hip arthroplasty (THA) using Delta ceramic-on-ceramic (CoC) bearings in 72 patients (86 hips) who were <30 years old. Noise was noted in 8 (9.3%) of the hips, no osteolysis or loosening was detected, and no patient required reoperation. The purpose of this study was to assess clinical and radiographic outcomes, complications, and survivorship at >10 years after THA using Delta CoC bearings in patients who were <30 years old.

METHODS

Cementless THA with a Delta CoC bearing was performed between March 2008 and January 2012 in 91 hips of 76 patients who were <30 years old. Eighty-five hips in 71 patients (44 men and 27 women) with a mean age of 25.9 years (range, 16 to 29 years) at surgery were followed for a mean of 10.9 years (range, 10 to 13 years).

RESULTS

No ceramic bearings fractured. The incidence of squeaking increased to 5.9% (5 of 85), but the squeaking was not reproducible within individual patients. Periprosthetic osteolysis developed in 3 hips (3 patients): around the stem in 2 and around the metal shell in 1. The stem in 1 hip underwent revision because of a Vancouver type-B2 periprosthetic femoral fracture. One patient with systemic lupus erythematosus underwent irrigation and debridement for periprosthetic joint infection. Survivorship free of reoperation for any reason was 92.4% (95% confidence interval, 82.4% to 100%) at 13 years.

CONCLUSIONS

The long-term results and survivorship of Delta CoC THA in patients <30 years old were favorable.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

A 10- to 12-year follow-up study of delta ceramic-on-ceramic total hip arthroplasty

BACKGROUND

We previously reported five-to-seven-year results of total hip arthroplasty (THA) with the use of delta ceramic-on-ceramic (CoC) bearing. We conducted an extension study with a CT scan at a minimum of 10 years after surgery.

METHODS

From March 2009 to March 2011, 273 patients (310 hips) received cementless THA with delta CoC bearing, porous-coated cup and hydroxyapatite-coated stem. In this extended study, 252 patients (144 men and 108 women) (288 hips) with a mean age of 49.7 years (16-83) at surgery were followed for a mean of 10.4 years (10-12) with CT scans in 133 hips (46.2%, 133/288). Clinical and radiographic evaluations were made at each follow-up and Kaplan-Meier survival analysis was performed with revision and reoperation as endpoints.

RESULTS

There were no more ceramic fractures. Compared to mid-term results, the incidence of squeaking and RLLs increased to 3.1% (9/288) and 19.4% (56/288), respectively. The RLL progressed to focal osteolysis in 3 hips (5.4%, 3/56). No hip had detectable wear or prosthetic loosening. Two hips were reoperated due to periprosthetic joint infection and periprosthetic femoral fracture in each. The survivorship decreased to 98.3% (96.7-99.9%) at 12 years.

CONCLUSION

During the extended follow-up, no additional ceramic fracture occurred, and the incidence of squeak increased by 0.7%. The long-term survivorship of Delta CoC THA was encouraging. However, focal osteolysis occurred around the hydroxyapatite-coated stem in 1% (3/288).

LEVEL OF EVIDENCE

II (Prospective cohort study).

Primary Total Hip Arthroplasty with Ceramic-on-Ceramic Articulations: Analysis of a Single-center Series of 1,083 Hips at a Minimum of 10-Year Follow-Up

BACKGROUND

There are limited long-term results of using ceramic-on-ceramic bearings (COC) in total hip arthroplasty (THA) in a large number of patient cohorts. The purpose of this study was to evaluate the minimum 10-year clinical and radiological outcomes and survivorship in a single surgeon series of CoC-THA.

METHODS

Among the 1,039 patients (1,391 hips) who underwent primary THA at our institution between 2008 and 2011, 49 patients (69 hips) experienced paralysis or death, and 194 patients (239 hips, 19%) were lost to follow-up. The remaining 796 patients (1,083 hips) were assessed at a mean of 11 years (range, 10 to 13 years) using the modified Harris hip score (mHHS), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and a questionnaire on articular noises. Survival analysis was used to estimate the survivorship. Radiological evaluation was performed on 869 hips at the final follow-up.

RESULTS

Survivorship at 11 years was 98.3% for revision or aseptic loosening, and 98.2% for re-operation. At the final follow-up, the mean mHHS and WOMAC scores were 93 (range, 12 to 100) and 14.4 (range, 3 to 66), respectively. There were 131 (12%) hips experienced squeaking, but no patient required revision. No fracture of the ceramic was observed. Radiological evaluation at the final follow-up revealed that three (0.3%) hips exhibited loosening, two (0.2%) had femoral osteolysis, 81(9.3%) acquired radiolucencies, and 35 (4%) showed heterotopic ossification.

CONCLUSION

This ceramic-on-ceramic bearing for THA had a high survivorship and excellent functional outcomes for at least 10 years.

Long-Term Results of Delta Ceramic-on-Ceramic Total Hip Arthroplasty

Background

Ceramic-on-ceramic (COC) bearings in total hip arthroplasty (THA) have long been considered the coupling with the lowest overall wear. However, concerns about complications such as ceramic breakage and noise, combined with the improved performance of polyethylene, have limited its use in the United States. This postapproval follow-up reports long-term (10 years) results of Delta COC in THA patients primarily enrolled in an Investigational Device Exemption study.

Methods

Patients received Delta COC THA in a prospective multicenter study with either 28-mm (N = 105 hips in 104 patients) or 36-mm (N = 81) articulations. Annual clinical and radiographic evaluations were performed for years 5 to 10, and study patients were asked about hip noises and reproducibility.

Results

There have been 4 additional reports of noise in 4 patients (COC 28, n = 3; COC 36, n = 1). The cumulative incidence rate for squeaking or noise at 10 years is 5.9% for COC 28 and 13.5% for COC 36. There have been 2 additional reports of dislocation in 2 patients (COC 28, n = 1; COC 36, n = 1). The cumulative incidence rate for dislocation at 10 years is 3.7% for COC 28 and 3.5% for COC 36. At 10 years, there were greater than 40 hips available for follow-up. At mean 10-year follow-up, there were a total of 3 ceramic liner fractures, but none since the previous report. There were no revisions in the 28-mm cohort, and 2 revisions in the 36-mm cohort (1 for recurrent dislocation and 1 for pain and noise). Overall Kaplan-Meier survivorship was 95.96% at 10.5 years (28 mm: 97.68% at 10.2 years; 36 mm: 94.11% at 10.4 years.)

Conclusions

At 10-year follow-up, we report excellent results in regard to survivorship, with one patient revised for pain with associated squeaking.

Outcomes of Ceramic Composite in Total Hip Replacement Bearings: A Single-Center Series

Despite the fact that total hip replacement is one of the most successful surgical procedures for treatment of a variety of end-stage hip diseases, the process of osteolysis and implant loosening remains a significant problem, especially in young and high-demand patients. More than 40 years ago, ceramic bearings were introduced due to their mechanical advantage in order to obtain a reduction in wear debris, and due to the conviction that it was possible to minimize friction and wear owing to their mechanical hardness, high chemical stability, surface lubrication by fluids and low friction coefficient. Together with excellent mechanical properties, ceramics have a biological inertness: eventual ceramic debris will lead to a reactive response with a high predominance of fibrocystic cells, rather than macrophagic cells, and absence of giant cells, which is ideal from a biological perspective. As a consequence, they will not trigger the granulomatous reaction necessary to induce periprosthetic osteolysis, and this clearly appears to be of great clinical relevance. In recent years, tribology in manufacturing ceramic components has progressed with significant improvements, owing to the development of the latest generation of ceramic composites that allow for an increased material density and reduced grain size. Currently, ceramic-on-ceramic bearings are considered the attractive counterparts of ceramic- or metal-on-polyethylene ones for patients with a long life expectancy. The aim of this paper is to report the results of total hip replacements performed with a ceramic-on-ceramic articulation made from a ceramic composite in a single center, focusing on its usefulness in specific preoperative diagnosis.

Articular Noise After THA Using Delta CoC Bearings Has Little Impact on Quality of Life

BACKGROUND

To report clinical outcomes and survival at a minimum of 10 years of a consecutive series of uncemented total hip arthroplasty (THA) with fourth-generation ceramic-on-ceramic (CoC) bearings and determine the incidence of articular noises, their risk factors, and impact on quality of life (QoL).

METHODS

From a series of 456 CoC THAs, there were 25 revisions, 38 deceased, and 36 lost to follow-up. The remaining 357 hips were assessed at 11.1 ± 0.7 years (range, 10-14) using the Forgotten Joint Score, Oxford Hip Score, and a questionnaire on articular noises. Kaplan-Meier survival was calculated, and multivariable analysis was performed to determine associations between articular noise and patient/surgical factors.

RESULTS

The 10-year survival was 96.3% for the cup, 96.5% for the stem, and 94.2% for all components. The Forgotten Joint Score was 79 ± 26 (range, 0-100), and Oxford Hip Score was 16 ± 7 (range, 12-60). The mean impact of articular noises on QoL was 1.8 ± 2.9 (range, 0-9): considered negligible in 60 hips (16%), moderate in 27 hips (7%), and severe in only 13 hips (4%). Multivariable analyses revealed that the incidence of articular noise decreased with age (odds ratio [OR], 0.94; P = .001), body mass index (OR, 0.85; P = .001), and in hips implanted with 32-mm (vs 36 mm) heads (OR, 0.18; P = .030).

CONCLUSION

Of 100 hips (28%) that reported some articular noises 10 years after CoC THA, the impact of articular noises on QoL was negligible for most patients. Although larger heads can improve mobility and reduce risks of dislocations, surgeons must be aware that increasing head size could also increase risks of articular noises, notably in young and active patients.

Impingement Between the Metal Stem and the Ceramic Liner in Total Hip Arthroplasty: The Neck Is Not the Only Place Where Impingement Occurs

BACKGROUND

It is assumed that impingement between the ceramic liner and the stem increases the possibility of a liner fracture in total hip arthroplasty with a ceramic-on-ceramic bearing. The purpose of this study was to analyze the pattern of the impingement by evaluating the notches (U-shaped indented wear scars engraved on the stem) on radiographs to determine when and where impingement develops and to analyze the factors affecting its occurrence.

METHODS

Among the primary total hip arthroplasty cases using a ceramic-on-ceramic bearing performed from November 1997 to December 2003, 244 cases of 197 patients (123 male patients and 74 female patients) that had follow-up of ≥15 years were included. All of the radiographs were examined with special regard to the notches and the cup positions.

RESULTS

Notches were detected at 77 sites of 57 cases (23.4%) for the first time between 8 months and 14.8 years after the surgical procedure. They were located on the neck or the shoulder of the stem. Shoulder notches were detected only in the cases with a short-neck head. Shoulder notches were found in 29 cases (20.0% of short-neck cases). Cup inclination was lower (p = 0.01) and anteversion was higher (p = 0.01) in the group with notches than the group without notches. There were 5 cases of ceramic head fracture. One of them experienced another ceramic liner fracture, assumed to be caused by prosthetic shoulder impingement, after the revision surgical procedure.

CONCLUSIONS

The results of this study suggest that impingement between the stem and the ceramic liner occurs in a considerable proportion of patients who underwent total hip arthroplasty not only on the neck but also on the shoulder of the stem. Forceful and abrupt impingement on the stem shoulder can cause ceramic liner fracture. Impingement between the stem shoulder and the ceramic liner should be considered in designing a stem. It seems to be prudent to recommend that patients avoid squatting or sitting cross-legged on the floor as much as possible.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Mid-term outcomes of the R3™ delta ceramic acetabular system in total hip arthroplasty

Background

Whilst bony fixation of hip replacement has stable solutions, there remains controversy over which bearing best optimizes longevity and function. Ceramic-on-ceramic (CoC) bearing combinations are associated with lower risk of revision due to aseptic loosening and dislocation. Evidence for long-term functional outcomes of modern, 4th generation CoC bearings is limited. The aim of this study was to analyze outcomes and complications of the R3™ Acetabular System (Smith & Nephew, Inc., Cordova, TN, USA) in combination with BIOLOX® Delta ceramic femoral head in patients undergoing primary total hip arthroplasty (THA).

Methods

Between June 2009 and May 2011, 175 patients (178 hips) were enrolled into a prospective, study at 6 sites in Europe and prospectively followed-up at 3 months and 1, 3, 5, and 7 years postoperative.

Results

Total WOMAC score improved from 63 (range, 22–91) preoperative to 8 (range, 0–8) at 1-year follow-up and remained unchanged at 7-year follow-up. Modified Harris hip score improved from 45 (range, 10–87) preoperative to 83 (range, 25–100) at 3 months, 91 (range, 42–100) at 1 year, and 92 (range, 46, 100) at 7 years. UCLA Activity Rating Scale score improved from 3.3 (range, 1–8) preoperative to 6.2 (range, 2–8) at 1 year; it marginally declined to 5.8 (range, 3–8) at 7-year follow-up. There were 4 trochanteric fractures and 5 patients died of unrelated reasons. Three hips were revised (2 periprosthetic fractures and 1 subluxation). The 7-year cumulative survival rate was 98.3%.

Conclusion

Clinical and functional improvements of THA with CoC bearing are maintained at 7 years postoperative.

Trial registration

ClinicalTrials.Gov, NCT03566082, Registered 10 January 2018—retrospectively registered,

Third generation delta ceramic-on-ceramic bearing for total hip arthroplasty at mid-term follow-up

Purpose

to evaluate the results of Delta ceramic-on-ceramic (CoC) for total-hip-arthroplasty (THA).

Methods

261 THA using Delta-CoC, retrospectively analyzed. A 36 mm head was used in 189 cases and a 32/40 mm in the others. The series have been compared to a group of 89 THA with Forte-CoC.

Results

The Harris-Hip-Score improved from 49.1 ± 14.3 to 92.0 ± 8.9 (P < 0.001). In the Delta group there were one ceramic fracture and 2 dislocations. Two hips underwent revision. There were one revision in the Forte group for instability and one squeaking hip.

Conclusions

The new ceramic bearings provides a safe bearing for THA, with rare complications.

Mixed ceramic combinations in primary total hip arthroplasty achieved reassuring mid-to-longterm outcomes

INTRODUCTION

Ceramic-on-ceramic couplings demonstrated to be reliable bearings in primary total hip arthroplasty (THA), with long-term remarkable results. Like-on-like configurations were widely described. On the contrary, mixed material combinations from the same manufacturer, Delta-on-Forte or Forte-on-Delta, were poorly studied. In particular, it is unknown whether mixed ceramic combinations are more at risk of ceramic fractures. Thus, a registry study was conducted to investigate the long-term survival rates and reasons for revision of mixed ceramic combinations. A comparison with Delta-on-Delta couplings was also performed.

MATERIALS AND METHODS

The regional arthroplasty registry RIPO was enquired about three cohorts of ceramic bearings (head-on-liner: Delta-on-Forte, Forte-on-Delta, Delta-on-Delta). Demographics, survival rates and reasons for revision were evaluated and compared.

RESULTS

In total, 346 (1.5%) implants had a Delta-on-Forte coupling (mean follow-up: 6.4 years). In total, 1163 (5%) THAs had a Forte-on-Delta articulation (mean follow-up: 8.2 years). Delta-on-Delta surfaces were implanted in 21,874 (93.5%) hips (mean follow-up: 3.9 years). Mixed material combinations were implanted between 2003 and 2007. The survival rates of the three cohorts were similar and were higher than 95% at 10 years. In Forte-on-Delta group, four liners failed (0.3% of the implants), whereas ceramic fractures occurred in 15 cases (0.1%) in Delta-on-Delta couplings (3 heads and 12 liners). Considering ceramic fracture as endpoint, there was no significant difference between the three survival rates.

CONCLUSIONS

Mixed ceramic bearing configurations from the same manufacturer in primary THA showed mid-to-longterm dependable outcomes, not inferior to the most recent like-on-like ceramic bearings. No additional risks of ceramic fractures were evident. Thus, closer follow-ups are not required.

[Research progress of total hip arthroplasty for patients with sequelae of suppurative hip arthritis]

Objective

To summarize the research progress of total hip arthroplasty (THA) in treatment of sequelae of suppurative hip arthritis.

Methods

The relevant literature was systematically searched and the operation timing, treatments of acetabular and femoral sides, and prosthesis selection in THA for sequelae of suppurative hip arthritis were summarized.

Results

THA is an effective way to treat the sequelae of suppurative hip arthritis. In order to avoid the recurrence of infection, THA is recommended to be performed after 10 years of resting period of hip septic infection. These patients may have acetabulum dysplasia and poor coverage of acetabulum. When performing THA, high position acetabulum, osteotomy of the medial acetabular wall, structural bone graft, Cage, tantalum augment, or three-dimensional printing prosthesis can be chosen. The femoral side may has small medullary cavity, increased femoral neck anteversion, increased femoral neck-stem angle, extend trochanter, and poor bone mass. When performing THA, the femoral osteotomy and appropriate prosthesis can be selected for treatment. The patients with sequelae of suppurative hip arthritis are mostly young, cementless THA is preferred for a better long-term survivorship.

Conclusion

THA is an effective method for the sequelae of suppurative hip arthritis, but the operation is difficult and has relative high complication rate. Surgeons should have full understanding.

Midterm outcome of fourth-generation ceramic-on-ceramic bearing surfaces in revision total hip arthroplasty

PURPOSE

The purpose of this study is to evaluate the clinical and radiologic outcomes after revision total hip arthroplasty (THA) using fourth-generation ceramic-on-ceramic (CoC) bearing surfaces.

METHODS

A total of 52 revision THAs (28 men and 19 women) using the fourth-generation CoC bearing surfaces were retrospectively evaluated. Both acetabular cup and femoral stem were revised in all cases. The mean follow-up period was 7.3 years (range, 4.0-9.9 years). The clinical results with Harris hip score (HHS), Western Ontario McMaster Osteoarthritis Index (WOMAC), and radiologic outcomes were evaluated.

RESULTS

At the final follow-up examination, the average HHS was 90.4 (range, 67-100). The average WOMAC pain and physical function score were 2.8 (range, 0-12) and 16.4 (range, 0-42), respectively. Complications were observed in 10 hips (19.2%). However, there were no bearing surface-related complications, and no cases of dislocation and squeaking. Retroacetabular pelvic osteolysis without cup loosening was observed in one hip at the final follow-up. However, no hip showed radiographic signs of cup loosening, vertical or horizontal acetabular cup migrations, and changes of inclinations during the follow-up period.

CONCLUSION

Our data showed that clinical and radiologic outcomes after revision THA using fourth-generation CoC bearing were favorable. Hence, revision THA with the use of CoC bearing surfaces can be preferentially considered. Further studies with long-term follow-up data are warranted.

Delta-on-Delta Ceramic Bearing Surfaces in Revision Hip Arthroplasty

BACKGROUND

Fourth-generation ceramic-on-ceramic couplings were developed to improve ceramic toughness and strength. Encouraging outcomes in primary total hip arthroplasty were reported. This coupling was proposed as an attractive option even in the case of revision procedures, particularly in younger patients with a longer life expectancy. However, the pertinent literature is scarce. Thus, a registry study was conducted to investigate the midterm survival rates and reasons for re-revision of the fourth-generation ceramic-on-ceramic bearing surfaces in revision hip arthroplasties.

METHODS

A total of 327 revision implants (all the components were exchanged) with BIOLOX Delta couplings were investigated using the regional orthopedic registry RIPO. The demographics, the survival rates, and the reasons for re-revision were assessed. Revisions with bearings other than Delta were compared.

RESULTS

Delta bearings achieved a survival rate of 90.5% at 7 years, with stable results. Twenty-six (8%) re-revisions occurred at a mean follow-up of 4.1 years. And 2.8% of the re-revisions were due to recurrent dislocations; 1.5% of the cases were due to cup aseptic loosening. Septic loosening occurred in 1.6% of the cases. No ceramic fractures were reported. When compared to revisions with bearings other than Delta-on-Delta, Delta coupling cohort achieved similar performances at 5 and 7 years. Lower, nonsignificant rates of aseptic and septic loosening were reported in Delta cohort.

CONCLUSION

Delta-on-Delta couplings demonstrated to be reliable bearing surfaces in revision settings at a midterm follow-up. Clinical studies and longer follow-ups are required to investigate potential adverse effects, like squeaking and fractures, and confirm these preliminary findings.

LEVEL OF EVIDENCE

Level III, therapeutic study.

A focused update on preventing ceramic fractures in hip arthroplasty

Ceramic bearings have several desirable properties, such as resistance to wear, hardness, and biocompatibility, that favour it as an articulating surface in hip arthroplasty. However, ceramic fracture remains a concern. We have reviewed the contemporary literature, addressing the factors that can influence the incidence of ceramic bearing surface fracture.

Cite this article: Bone Joint J 2019;101-B:897–901.

Component positioning and ceramic damage in cementless ceramic-on-ceramic total hip arthroplasty

BACKGROUND

In ceramic-on-ceramic (CoC) total hip arthroplasty (THA), component positioning demonstrated to influence the bearing damage: however the connection between angles and clinical outcomes at long-term follow-ups is currently lacking. Aims of this study were: the computer tomography (CT) assessment of component positioning in CoC THAs; the correlation analysis between positioning and ceramic damage; the identification of safe zones.

METHODS

91 consecutive post-operative CT scans including two types of CoC implants, with a mean follow-up of 12 ± 4.4 years, were evaluated. III generation (74.2%) and IV generation (25.8%) CoC surfaces were included. The angle measurements (cup abduction, anteversion, cup tilt, stem antetorsion, sacral slope) were automated using a CT-based software. The combined anteversion was assessed as well as the cup-neck position at -15°, 0°, 45° and 90° of flexion. Ceramic damage was diagnosed using synovial fluid analyses and radiological criteria.

RESULTS

63.7% of THAs was inside the cup abduction target 30°-45° and 68.1% was inside the cup anteversion target 5°-25°. 19 patients (20.9%) showed signs of ceramic damage. High cup abduction and high cup-neck 45° minimum angle (which stood for high abduction and extreme combined version) significantly correlated with ceramic damage. No demographical features apart III generation ceramic bearings influenced the results. No safe zones could be detected.

CONCLUSIONS

In CoC THA, no safe zones can be described. However it is important to avoid cup inclination over 45° and a combination of steep cup and extreme combined version.

Results of 200 Consecutive Ceramic-on-Ceramic Cementless Hip Arthroplasties in Patients Up To 50 Years of Age: A 5-24 Years of Follow-Up Study

BACKGROUND

Ceramic-on-ceramic (CoC) bearings due to their mechanical properties can be used in primary total hip arthroplasty (THA) especially in young patients requiring a long-lasting implant. The goal of this study is to analyze the results of a series of 200 consecutive CoC THAs in patients aged 50 years or less at the time of surgery.

METHODS

A retrospective study was conducted on the first 200 consecutive CoC arthroplasties performed using the direct lateral approach on 105 females and 81 males (14 bilateral cases) with an average age of 44.2 (16-50) years. The diagnosis was primary or post-traumatic osteoarthritis in 94 cases, avascular necrosis of the femoral head in 47, displaced intracapsular femoral neck fracture in 29, osteoarthritis secondary to developmental dysplasia of the hip/Legg-Calvè-Perthes disease/slipped capital femoral epiphysis in 20, and rheumatic diseases in 10 cases. The preoperative Harris Hip Score was 32.5 on average (range 15-55). All the implants were cementless. In 177 THAs the coupling was alumina-on-alumina, and in 23 cases the coupling was AMC-on-AMC (alumina matrix composite).

RESULTS

Twenty-five patients with 28 THAs were lost at the final follow-up, 2 stems were revised due to subsidence, 1 cup was revised due to malposition, 1 femoral head was changed because of impingement, and 1 THA was revised for periprosthetic infection. Three patients sustained a Vancouver B1 periprosthetic femoral fracture. At the final follow-up (mean 14.9 years; minimum 5 years to maximum 24 years), 172 THAs were eligible for clinical and radiographic evaluation: none was revised for wear and/or breakage of the ceramic components. Harris Hip Score rose up to a mean value of 90.1 (52-100).

CONCLUSION

The present report demonstrates that CoC coupling offers excellent long-term results in THA performed in young patients with very low wear and no adverse effects caused by the material.

Quality of life and health status after Girdlestone resection arthroplasty in patients with an infected total hip prosthesis

Introduction: The Girdlestone resection arthroplasty (GRA) is a salvage procedure for a recurrent or persistent prosthetic joint infection of the hip. This procedure negatively impacts the functional outcome and presumably also diminishes health status (HS) and quality of life (QOL). However, studies investigating the QOL after GRA are lacking. This cross-sectional study compares patients with a Girdlestone situation after an infected total hip prosthesis with a normative population with regard to HS and QOL.

Methods: Patients with a permanent GRA were suitable to be enrolled in the study. Subjects completed the World Health Organization Quality of life (WHOQOL-BREF) and the EuroQol 5 dimension 3 level version (EQ-5D-3L). Scores were compared with data from the normal population, from patients with a lower limb amputations and data from patients with a myocardial infarction.

Results: Sixty-three patients who underwent GRA between January 2000 and March 2017 completed the questionnaire. The median time between the GRA and competing the questionnaire was 48 months (4 -436). All WHOQOL-BREF domain scores were significantly lower in GRA patients compared to the normative data (p<0.001), patients with myocardial infarction or lower limb amputation. EQ-5D-3L results showed that HS was significantly impaired in GRA patients when compared to normative data (p<0.001) and also impaired when compared to data from lower limb amputations and myocardial infarctions.

Conclusion: HS and QOL scores in patients with a permanent Girdlestone situation after an infected hip prosthesis are significantly lower than Dutch normative scores. Patients with a permanent Girdlestone situation scored even lower on HS than patients with a lower limb amputation or a myocardial infarction.

Total Hip Arthroplasty Using Hybrid Ceramic Bearing: A Minimum 10-Year Followup Study

BACKGROUND

Contemporary ceramic articulation in total hip arthroplasty (THA) has shown successful clinical and radiologic outcomes at mid-to-long term. Delta ceramic, which includes 24% zirconia, has been developed to reduce the rate of ceramic fracture. However, the phase transformation of the zirconia that might cause surface roughness, ceramic wear, and subsequent osteolysis remains a concern. The purpose of this study was to evaluate clinicoradiological outcomes, ceramic-related complications, and survivorship of THA with the use of hybrid ceramic bearing; BIOLOX delta liner-on-BIOLOX forte head articulation at a minimum followup of 10 years.

MATERIALS AND METHODS

One hundred cementless THAs (85 patients) were performed with the use of 36-mm hybrid ceramic bearing. The thickness of the delta ceramic liner was 4-6 mm. Four patients (4 hips) were lost and six patients (6 hips) died within 10 years after the operation. Thus, the remaining 75 patients (90 hips) were followed up for 10-12 years. There were 43 men and 32 women. The mean age of these patients at the index operation was 58 years (21-78 years).

RESULTS

There were no fractures of ceramic liner or head. There was no measurable ceramic wear, and neither pelvic nor femoral osteolysis was identified. All acetabular and femoral components were bone-ingrown. Three (3/90, 3.3%) patients noted noise of clicking sound. The mean Harris hip score was 87 points (range 72-99 points) at the time of final followup. THA survivorship with revision surgery as an endpoint was 97.8% (95% confidence interval: 91.4%-99.8%).

CONCLUSIONS

The long term result of cementless THA with the use of a large BIOLOX forte head on the BIOLOX delta liner showed an encouraging result. Wear or osteolysis associated with composite of 24% zirconia in the fourth-generation ceramic was not observed at a minimum followup of 10 years.

A minimum 20-year outcome of 100 consecutive alumina-on-alumina arthroplasties performed by a single surgeon

BACKGROUND:

Ceramic-on-ceramic (CoC) is currently a viable bearing combination in primary total hip arthroplasty (THA) and, due to its mechanical properties, it can be used in young patients requiring a long-lasting implant. The aim of this study is to report the results of a series of CoC THAs at a minimum 20 years follow-up.

METHODS:

A retrospective study was conducted on the 1st 100 consecutive alumina-on-alumina arthroplasties performed by a single surgeon on 51 females and 40 males with an average age of 60.7 years. The mean preoperative Harris Hip Score was 35. The press-fit cup consisted of a pure titanium core with a titanium alloy mesh. Both the inlay and the head were made of dense polycrystalline surgical-grade alumina. The 32-mm femoral head was anchored on 3 different femoral components.

RESULTS:

19 patients with 22 THAs were died or lost, 2 anatomic cementless stems were revised due to sinking, 1 THA was revised for periprosthetic infection. 2 patients sustained a Vancouver B1 periprosthetic femoral fracture. None of the 78 THAs eligible for this study were revised for wear, breakage, noise of the ceramic components. None of the cups, none of the cemented stems, none of the cementless straight stems failed. HHS raised up to a mean value of 95.

CONCLUSIONS:

The present report demonstrates that CoC coupling offers minimal wear at a long-term follow-up. Further studies are needed to evaluate whether the modern ceramic composites will confirm such excellent results in total hip replacement.

Primary total hip arthroplasty with fourth-generation ceramic bearings: Clinical and survival results with a minimum follow-up of 5 years

OBJECTIVE

To evaluate the clinical results and survival of primary hip prosthesis with ceramic delta bearings (C-C) with a minimum follow-up of 5years.

MATERIAL AND METHOD

A total of 205 primary hip arthroplasties performed between 2008 and 2012 were studied. The clinical results, pre-surgical and at 5years of follow-up were evaluated using the Harris Hip Score (HHS), the Short Form-36 (SF-36), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and the visual analogue scale (VAS). The position of the prosthetic components, periprosthetic osteolysis, loosening of the prosthetic components and ruptures of the ceramic components were studied radiologically. The adverse events related to bearings were recorded according to their diameter, paying special attention to prosthetic dislocations and the presence of noise. Survival with an endpoint of prosthetic revision for any cause was estimated using the Kaplan-Meier method.

RESULTS

Significant improvements were obtained in the HHS (88.7% of good/excellent results), SF36, WOMAC and EVA, P<.001. There were 19 adverse events related to the prosthesis (4 periprosthetic fractures, 4 dislocations, 2 superficial infections, 1 mobilization of the cup, 2 noises, 4 aseptic loosenings and 2 breaks of the prosthetic neck); 47.3% needed revision. The cumulative survival of the prostheses was 97.5% (95%CI: 96.4-98.5). No differences were found in survival, prosthetic adverse events, noise incidence or dislocations and clinical results among the different diameters used.

CONCLUSIONS

Primary hip prostheses with fourth-generation ceramic bearings showed good survival in the medium term, and good clinical results.

Clinical Outcomes and Bearing-Specific Complications Following Fourth-Generation Alumina Ceramic-on-Ceramic Total Hip Arthroplasty: A Single-Surgeon Series of 749 Hips at a Minimum of 5-Year Follow-Up

BACKGROUND

The purpose of this study is to evaluate the minimum 5-year outcomes and bearing-specific complications in a single surgeon series of fourth-generation alumina ceramic-on-ceramic total hip arthroplasties (THAs).

METHODS

We retrospectively analyzed 667 patients (749 hips) who underwent primary THAs by a single surgeon using fourth-generation alumina ceramic bearings. There were 315 men and 352 women with a mean age of 54.2 years. The surgeon used cementless prostheses with an identical design and BIOLOX Delta ceramics in all hips, using a 36-mm head in 472 hips (63%) and a 32-mm head in 227. The mean follow-up duration was 6.5 years (range, 5 to 8 years).

RESULTS

The mean Harris hip score improved from 45.6 points preoperatively to 91.3 points at final follow-up. All but 1 acetabular cup and all femoral stems were well fixed. No radiographic evidence of osteolysis was identified at final follow-up. There were 2 (0.3%) ceramic liner fractures and no ceramic head fractures. A total of 48 hips (6.4%) exhibited audible noise (29 clickings and 19 squeakings), but no patient required revision. Other complications were 1 dislocation, 1 deep infection, 3 iliopsoas tendonitis, and 6 periprosthetic femoral fractures. Kaplan-Meier survivorship for revision for any reason was 98.6% (95% confidence interval, 97.7-99.5) at 6.5 years.

CONCLUSION

Delta ceramic-on-ceramic THAs had a high rate of survivorship without radiographic evidence of osteolysis at 6.5-year follow-up. However, we found 0.3% ceramic liner fractures and 6.4% audible noises associated with the use of Delta ceramics.

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.

Bearing surfaces in primary total hip arthroplasty

Total hip arthroplasty (THA) is widely considered one of the most successful surgical procedures in orthopaedics. It is associated with high satisfaction rates and significant improvements in quality of life following surgery. On the other hand, the main cause of late revision is osteolysis and wear, often a result of failure of bearing surfaces.Currently, several options are available to the surgeon when choosing the bearing surface in THA (ceramic-on-ceramic (CoC), ceramic-on-polyethylene (CoPE), metal-on-polyethylene (MoPE)), each with advantages and drawbacks.Very few studies have directly compared the various combinations of bearings at long-term follow-up. Randomized controlled trials show similar short- to mid-term survivorship among the best performing bearing surfaces (CoC, CoXLPE and MoXLPE). Selection of the bearing surface is often 'experience-based' rather than 'evidence-based'.The aim of this paper is therefore to evaluate the main advantages and drawbacks of various types of tribology in THA, while providing practical suggestions for the surgeon on the most suitable bearing surface option for each patient. Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.180300.

Total Hip Arthroplasty Using Ceramic-on-ceramic Bearing Surfaces: Long-term Assessment of Squeaking Sounds

Purpose

This study was performed to characterize the natural history of squeaking sounds that occur following total hip arthroplasty (THA) using ceramic-on-ceramic bearing surfaces and its potential correlation with clinical and/or radiological results.

Materials and Methods

This study included 47 patients who underwent THA between April 1999 and April 2005, and had at least 10 years of follow up from the time of the operation. Squeaking sounds were detected in 10 out of the 47 cases (21.3%). Squeaking-associated factors (i.e., cause, time of onset, inducing motions, and continuity of the sound) were assessed.

Results

Squeaking sounds: i) were detected an average of 46.2 months after operation, ii) occurred more frequently in patients with a high body mass index (BMI) compared to those with low BMI, and iii) most frequently detected when deep flexion of hip joint followed extension. In all 10 cases, the squeaking sound remained through the follow up period; 6 cases experienced no change in frequency and pitch, 4 cases experienced a decrease in frequency and pitch over time. The cause(s) of changes to squeaking sounds could not be determined.

Conclusion

The frequency and pitch of the squeaking sounds changed over time in a subset of patients. The squeaking sound did not appear to correlate with clinical results or survival of the prosthesis.

Challenges in Total Hip Arthroplasty in the Setting of Developmental Dysplasia of the Hip

BACKGROUND

Developmental dysplasia of the hip (DDH) is a recognized cause of secondary arthritis, which may eventually lead to total hip arthroplasty (THA). An understanding of the common acetabular and femoral morphologic abnormalities will aid the surgeon in preparing for the complexity of the surgical case.

METHODS

We present the challenges associated with acetabular and femoral morphologies that may be present in the dysplastic hip and discuss surgical options to consider when performing THA. In addition, common complications associated with this population are reviewed.

RESULTS

The complexity of THA in the DDH patient is due to a broad range of pathomorphologic changes of the acetabulum and femur, as well as the diverse and often younger age of these patients. As such, THA in the DDH patient may offer a typical primary hip arthroplasty or be a highly complex reconstruction. It is important to be familiar with all the subtleties associated with DDH in the THA population. The surgeon must be prepared for bone deficiency when reconstructing the acetabulum and should place the component low and medial (at the anatomic hip center), and avoid oversizing the acetabular component. Femoral dysplasia is also complex and variable, and the surgeon must be prepared for different stem choices that allow for decoupling of the metaphyseal stem fit from the implanted stem version. In Crowe III and IV dysplasia, femoral derotation/shortening osteotomy may be required. Many complications associated with THA in the DDH patient may be mitigated with careful planning and surgical technique.

CONCLUSION

Performed correctly, THA can yield excellent results in this complex patient population.

Cobalt Intoxication Heart Failure after Revision Total Hip Replacement for Ceramic Head Fracture: A Case Report

In 1960s, toxic heart failure due to cobalt poisoning was firstly reported from Canadian industrial worker. Following development of bearing materials in hip arthroplasties, using cobalt-chrome alloy in bearing surface, there were rarely reported of systemic affect toxic cobaltism include toxic heart failure due to articulation wear in Western countries. It could be happened more easily by third body wear from ceramic particle especially revision total hip replacement (THR) surgery using cobalt-chrome alloy following ceramic articulation breakage which index surgery performed by ceramic on ceramic bearing. In Korea, due to many surgeons prefer ceramic on ceramic bearing in THR compared to Western countries, it might be more important issue within a time. However in our knowledge, there was no previous report about cobalt poisoning heart failure in Korea. It is still very rare and hard to diagnose cobalt intoxication heart failure after THR, so we report a case of fatal heart failure caused by cobalt intoxication after revision THR in 53-year old man who successfully underwent re-revision THR.