What every surgeon should know about Ceramic-on-Ceramic bearings in young patients

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.

Ceramic fragmentation after total hip arthroplasty: two case reports and literature review

Background

Ceramic fragmentation is a rare but serious complication after total hip arthroplasty (THA). We reviewed the PubMed literature from 1990 to 2023 and found only 31 case reports of ceramic fragmentation after THA. Our case reports help to expand understanding of this rare complication. We shared our surgical experience and identified an ideal material for revision surgery, which can serve as a useful reference for other orthopedic surgeons to perform ceramic fragmentation revision surgery in the future. We also analyzed the possible causes, diagnosis, and treatment opinions of ceramic fragmentation.

Case presentation

This study presents two cases of ceramic fragmentation after THA. One patient had ceramic head fragmentation 10 years after the primary THA, and one patient had ceramic liner fragmentation 5 years after the primary THA. Both patients presented with pain, and one patient also reported a clicking sound in the hip. The two patients described here had BMIs of 23.7 and 23.1, respectively. Both patients' ceramic fragmentation were due to aseptic loosening, not periprosthetic joint infections, as confirmed by negative microbiological cultures. Radiographic examinations of both patients revealed radio-opaque wear debris around the hip joint prostheses and we describe the surgical protocols and intraoperative findings in both cases in detail.

Conclusion

Our cases and the literature suggest that ceramic fragmentation can occur at any time after THA. The most immediate symptoms are pain and noise, but some patients may be asymptomatic. Ceramic on polyethylene bearings is recommended for revision surgery whenever possible; metal bearings should be avoided.

Updates on Biomaterials Used in Total Hip Arthroplasty (THA)

One of the most popular and effective orthopedic surgical interventions for treating a variety of hip diseases is total hip arthroplasty. Despite being a radical procedure that involves replacing bone and cartilaginous surfaces with biomaterials, it produces excellent outcomes that significantly increase the patient's quality of life. Patient factors and surgical technique, as well as biomaterials, play a role in prosthetic survival, with aseptic loosening (one of the most common causes of total hip arthroplasty failure) being linked to the quality of biomaterials utilized. Over the years, various biomaterials have been developed to limit the amount of wear particles generated over time by friction between the prosthetic head (metal alloys or ceramic) and the insert fixed in the acetabular component (polyethylene or ceramic). An ideal biomaterial must be biocompatible, have a low coefficient of friction, be corrosion resistant, and have great mechanical power. Comprehensive knowledge regarding what causes hip arthroplasty failure, as well as improvements in biomaterial quality and surgical technique, will influence the survivability of the prosthetic implant. The purpose of this article was to assess the benefits and drawbacks of various biomaterial and friction couples used in total hip arthroplasties by reviewing the scientific literature published over the last 10 years.

Third and fourth generation ceramic-on-ceramic total hip arthroplasty at a minimum of ten years

BACKGROUND

Ceramic on Ceramic bearings in Total Hip Arthroplasty (THA) afford a low friction coefficient, low wear rates and extreme hardness. Significant complications include hip squeak, ceramic fracture and poor polyethylene performance in revision procedures due to imbedding of abrasive microscopic ceramic fragments. We report on the results of this bearing at a minimum of 10 years.

METHODS

A single-centre retrospective review of 449 THAs was performed. Primary outcome measures included aseptic revision and all-cause revision rates at a minimum of 10 years post operatively. Evaluation of functionality was performed with WOMAC and SF-36 scores which were performed pre-operatively and at intervals of 6 months, one year, 2 years, 5 years and 10 years post operatively.

RESULTS

There was a 6.2% (n = 28) all-cause and 5.3% (n = 24) aseptic revision rate for ceramic on ceramic total hip arthroplasty at minimum of 10 years with a mean time to revision 4.8 years (range 2 months-11.6 years). Notably, there were 2 revisions for ceramic head fracture, one for ceramic liner fracture, 3 for aseptic loosening and 3 revisions for squeaking. Pain of unknown origin was the most common reason for revision. There was an improvement in postoperative WOMAC scores from a mean of 59.8 (range 15-95) pre-operatively to a mean of 15.6 (range 0-78) at 10 years.

CONCLUSION

This study showed good functional outcomes but high revision rates for CoC THA at a minimum of 10 years. Our rates of ceramic fracture were consistent with other studies.

Personalized Hip Joint Replacement with Large Diameter Head: Current Concepts

Hip arthroplasty is a common procedure in elective orthopaedic surgery that has excellent outcomes. Hip replacement surgery aims to create a “forgotten” joint, i.e., a pain-free joint akin to a native articulation. To achieve such goals, hip arthroplasty must be personalised. This is achieved by restoring: the centre of rotation of the native hip; leg length equality; femoral offset; femoral orientation; soft tissue tension; joint stability with an unrestricted hip range of motion; and having appropriate stress transfer to the bone. In addition, the whole pathway should provide an uneventful and swift postoperative recovery and lifetime implant survivorship with unrestricted activities. At our institution, the preferred option is a personalized total hip arthroplasty (THA) with a large diameter head (LDH) using either monobloc or dual-mobility configuration for the acetabular component. LDH THA offers an impingement-free range of motion and a reduced risk of dislocation. The larger head-neck offset allows for a supraphysiologic range of motion (ROM). This can compensate for a patient’s abnormal spinopelvic mobility and surgical imprecision. Additionally, LDH bearing with a small clearance exerts a high suction force, which provides greater hip micro-stability. With appropriate biomechanical reconstruction, LDH THA can restore normal gait parameters. This results in unrestricted activities and higher patient satisfaction scores. We use LDH ceramic on ceramic for our patients with a life expectancy of more than 20 years and use LDH dual mobility bearings for all others.

Surgeons’ Awareness and Impaction Technique of a Ceramic Liner into a Metal Shell

Background

In ceramic-on-ceramic total hip arthroplasty, firm locking is necessary between a ceramic liner and an acetabular metal shell to prevent dissociation of the liner from the metal shell. We evaluated surgeons’ awareness of the technique for inserting the ceramic liner and measured the impaction force applied by surgeons during the insertion of the ceramic liner.

Methods

To evaluate the awareness, we conducted a survey using a questionnaire including techniques for ceramic liner insertion. The impaction force was measured using an impaction simulator in 224 surgeons.

Results

Most surgeons answered that they cleaned and dried up the inner surface of the metal shell before inserting a ceramic liner (96.4% and 86.2%, respectively), and 74.6% checked the correct seating of the ceramic liner. However, only 23.2% correctly answered that a minimum of 2kN (a light strike) was necessary to obtain a sufficient fit between the metal shell and the ceramic liner. The impaction force was weaker than 2 kN in 9.4% of the surgeons.

Conclusions

Education about the adequate impaction force to obtain a firm fit of the ceramic liner is necessary for surgeons who perform total hip arthroplasty using ceramic-on-ceramic bearings.

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.

Total hip arthroplasty for sickle cell osteonecrosis: guidelines for perioperative management

The prognosis of sickle cell disease (SCD) has greatly improved in recent years, resulting in an increased number of patients reporting musculoskeletal complications such as osteonecrosis of the femoral head. Total hip arthroplasty (THA) can be utilized to alleviate the pain associated with this disease.

Although it is well known that hip arthroplasty for avascular necrosis (AVN) in SCD may represent a challenge for the surgeon, complications are frequent, and no guidelines exist to prevent these complications. Because patients with SCD will frequently undergo THA, we thought it necessary to fulfil the need for guidance recommendations based on experience, evidence and agreement from the literature.

For all these reasons this review proposes guidelines that provide clinicians with a document regarding management of patients with SCD in the period of time leading up to primary THA. The recommendations provide guidance that has been informed by the clinical expertise and experience of the authors and available literature.

Although this is not a systematic review since some papers may have been published in languages other than English, our study population consisted of 5,868 patients, including 2,126 patients with SCD operated on for THA by the senior author in the same hospital during 40 years and 3,742 patients reported in the literature.

Cite this article: EFORT Open Rev 2020;5:641-651. DOI: 10.1302/2058-5241.5.190073

[Total hip arthroplasty in young patients : Bearings and custom-made prostheses]

BACKGROUND

Carefully and correctly implanted components are the prerequisite for the lifespan of a prosthesis. Whether higher levels of activity lead to prior failure of total hip arthroplasty in young patients is controversially discussed. The right choice of bearings is still of great relevance.

BEARINGS

Ceramic-on-ceramic as well as polyethylene-on-ceramic bearings achieve comparable results, although ceramic-on-ceramic bearings should be avoided in patients with high demands on their range of motion. Polyethylene-on-metal bearings also show good clinical results, if corrosion between head and stem is absent. Metal-on-metal bearings lead to adverse systemic effects due to metal wear and should be implanted in individual cases only, e. g. as hip resurfacing. Alternative bearings have to give proof of effectivity first. Custom-made prostheses constitute an option for young patients with special conditions of hip anatomy. Planning and study results of these prostheses are elucidated in this review article.

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.

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.

Ceramic prosthesis surfaces induce an inflammatory cell response and fibrotic tissue changes

Aims

Early evidence has emerged suggesting that ceramic-on-ceramic articulations induce a different tissue reaction to ceramic-on-polyethylene and metal-on-metal bearings. Therefore, the aim of this study was to investigate the tissue reaction and cellular response to ceramic total hip arthroplasty (THA) materials in vitro, as well as the tissue reaction in capsular tissue after revision surgery of ceramic-on-ceramic THAs.

Patients and Methods

We investigated tissue collected at revision surgery from nine ceramic-on-ceramic articulations. we compared our findings with tissue obtained from five metal-on-metal THA revisions, four ceramic-on-polyethylene THAs, and four primary osteoarthritis synovial membranes. The latter were analyzed to assess the amount of tissue fibrosis that might have been present at the time of implantation to enable evaluation, in relation to implantation time, of any subsequent response in the tissues.

Results

There was a significant increase in tissue fibrosis with implantation time for all implant types tested. Interestingly, the tissue fibrosis in ceramic-on-ceramic THAs was significantly increased compared with metal-on-metal and ceramic-on-polyethylene. Additionally, we found ceramic wear particles in the periprosthetic tissue of ceramic implants. Fibroblasts responded with expression of cytokines when cultured on alumina-toughened zirconia (ATZ) and zirconia-toughened alumina (ZTA) ceramic surfaces. This response was more pronounced on ATZ ceramics compared with ZTA ceramics. The same inflammatory response was observed with peripheral blood mononuclear cells (PBMCs) cultured on ZTA and ATZ.

Conclusion

Our findings therefore, corroborate the previous findings that ceramic-on-ceramic periprosthetic revision tissue is fibrous and offer an explanation for this observation. We detected a long-term inflammatory response of PBMCs and an inflammatory response of fibroblasts to ATZ and ZTA ceramic. These findings partially explain the fibrotic tissue change in periprosthetic tissue of ceramic-on-ceramic bearings. Cite this article: Bone Joint J 2018;100-B:882–90.