Ten-Year Follow-Up of Patients Younger Than 50 Years With Modern Ceramic-on-Ceramic Total Hip Arthroplasty

TTen-Year Follow-Up of PatientsYounger Than 50 Years With ModernCeramic-on-Ceramic Total Hip ArthroplastyJason E. Hsu, MD,* Stuart D. Kinsella, BA, Jonathan P. Garino, MD, andGwo-Chin Lee, MD*Recent technologic advances in total hip arthroplasty (THA) have focused on improving thelongevity and wear characteristics of bearing surfaces that can withstand the high demandsof younger and more active patients. Recent reports of early failures of metal-on-metal THAhave introduced doubts to its ability to be a viable long-term hard-on-hard bearing surfacefor hip arthroplasty. Like metal-on-metal, ceramic-on-ceramic (COC) bearing surfaces haveexcellent in vitro wear characteristics, but there is little information about their long-termtrack record in vivo, particularly in those patients who are younger and more active. Thepurpose of this study is to evaluate the long-term outcomes of COC THA in active patientsyounger than 50 years of age. We retrospectively reviewed 82 consecutive THAs in 64patients performed by a single surgeon from 1997 to 2000. There were 42 men and 22women with an average age of 38.6 years. Of the 82 THAs, 39 were performed for avascularnecrosis of the hip, 30 for osteoarthritis, 8 for developmental dysplasia, and 5 for inam-matory or posttraumatic arthritis. Clinical outcomes were evaluated using the Harris hipscore, and serial radiographs were evaluated for signs of component loosening. The meanfollow-up period was 10.1 (range, 10.0-12.3) years. One patient died, and another was lostto follow-up. The mean Harris hip score was 89.8. There were no implants with subsidenceor circumferential radiolucent lines. Two patients required revision surgery of their THA fora ceramic liner fracture. One patient complained of squeaking that required revision. Therewere no cases of revision for ceramic head fracture, instability, or aseptic loosening. At aminimum 10-year follow-up, the survivorship of the COC THA was 96.3%. Modern COCTHA in active patients younger than 50 years of age is durable at a minimum 10-yearfollow-up; however, patients should be advised of the small chance of squeaking andceramic fracture.Semin Arthro 22:229-233 2011 Elsevier Inc. All rights reserved.KEYWORDS ceramic-on-ceramic, total hip arthroplasty, alternative bearing, THA in young,survivorship*Department of Orthopaedic Surgery, University of Pennsylvania, Philadel-phia, PA.University of Pennsylvania School of Medicine, Philadelphia, PA.Pennsylvania Orthopedic Center, Main Line Health, Malvern, PA.J.P.G receives royalties from Smith and Nephew; consultant from CeramTec,DePuy, Smith and Nephew. G.C.L receives institutional support fromZimmer, Smith and Nephew; consulting fees from Covidien and DePuy(less than 1000); speaker/teaching: from Salient Surgical (one timeagreement).Address reprint requests to Gwo-Chin Lee, MD, Department of OrthopaedicSurgery, University of Pennsylvania, 1 Cupp Pavilion, 39th and MarketStreets, Philadelphia, PA 19104. E-mail: Gwo-Chin.L1045-4527/11/$-see front matter 2011 Elsevier Inc. All rights reserved.doi:10.1053/j.sart.2011.09.003otal hip arthroplasty (THA) is a durable and reliabletreatment of end-stage arthritis and has been shown tohave survival rates of more than 90% of patients at 10years.1-3 However, the majority of these studies have fo-cused on the results of conventional metal-on-polyethyl-ene THA, and in elderly patients. Long-term results ofTHA in younger patients are not as well described in theliterature, with some registry studies showing a lowerlong-term survival rate for younger, more active pa-tients.2,4,5 Recent technologic advances in THA have fo-cused on improving the longevity and wear characteristicsof bearing surfaces that can withstand the high demands ofthese younger and more active patients.229230Table 1 Patient DemographicsAge (Mean)GenderMaleFemaleEtiologyOsteonecrosisOsteoarthritisDevelopmental dysplasiaPost-traumaticFollow-up38.6 Years422239308310.1 Years16.3-48.961%39%46%42%7%5%10.0-12.3J.E. Hsu et alexcept in those at high risk for venous thromboembolism ora contraindication to aspirin. In these high-risk patients,Coumadin with a goal INR of 1.8-2.2 was used.Clinical evaluation of each patient was performed at regu-lar intervals: 2 weeks, 6 weeks, 3 months, 6 months, 12months, 24 months, and then every other year thereafter.Clinical outcomes were evaluated using the Harris hip scoreat each postoperative visit.16 In addition, each patient wasasked about any issues regarding the presence, nature, andfrequency of noise from the hip prosthesis, or any other com-plication to the hip prosthesis. Radiographic outcomes wereAlternative bearings, such as metal-on-metal (MOM) andceramic-on-ceramic (COC) THA, have been the subject ofmuch debate in recent years. Although both bearings haveexcellent in vitro wear characteristics, reports of delayed-typehypersensitivity and early osteolysis of MOM THA have in-troduced doubts to its ability to be a viable long-term hard-on-hard bearing surface for THA.6 Furthermore, increasedprevalence of other related complications including groinpain after MOM THA and total hip resurfacing has beenreported as well.7,8Recent experience with COC THA has shown successfullong-term outcomes, with a low wear rate and minimal in-ammatory response.9-13 Early concerns with componentfracture have been tempered by newer designs and betterquality ceramic.14,15 However, there has been a paucity ofdata on the success of these implants long-term in young,active patients who are theoretically at increased risk of ear-lier wear-related failure and loosening. Therefore, the objec-tive of this study was to evaluate the long-term outcomes ofCOC THA in patients younger than 50 years of age.MethodsBetween 1997 and 2000, 82 consecutive primary COC THAswere performed in 64 patients younger than 50 years of age.All patients in this study were prospectively followed as partof an investigational device exemption evaluation. Of the 64patients initially enrolled into the study, 42 were male and 22were female, with an average age of 38.6 years (range, 16.3-48.9 years) (Table 1). Of the 82 COC THAs, 39 were per-formed for avascular necrosis of the hip, 30 for osteoarthritis,8 for developmental dysplasia, and 5 for inammatory orposttraumatic arthritis. The data were prospectively collectedand retrospectively reviewed for all patients with a minimumof 10 years of follow-up. The study was approved and con-ducted in accordance with the guidelines set forth by ourinstitutional review board.All primary THAs were performed by one surgeon usingone specic COC hip design, the Transcend/Perfecta system(Wright Medical Technology, Arlington, TN). The femoralstem components were cemented designs, whereas acetabu-lar components were uncemented cup designs. All THAswere implanted using a posterolateral approach. Patientswere allowed immediate full weight-bearing postoperatively,and aspirin was used for thromboprophylaxis in all patients,determined by evaluation of serial radiographs of the hip,including AP pelvis, AP hip, and lateral hip. Specic radio-graphic outcomes included the presence of any radiolucentlines, calcar resorption, osteolysis, component fracture, orloosening.17-19 A KaplanMeier survival analysis was per-formed with the end point being revision of any implant orreoperation for any reason.ResultsThe minimum follow-up was 10 years with an average fol-low-up of 10.1 (range, 10.0-12.3) years. One patient died ofmedical reasons unrelated to this THA, and one patient waslost to follow-up. This left 80 COC THAs in 62 patients fornal analysis.At latest follow-up, the mean Harris hip score was 89.8 (SD14.0). Three patients required revision of their COC implant.Two patients had a ceramic liner fracture that occurred 7 and10 years postoperatively, following trauma (Fig. 1). One pa-tient complained of squeaking of the hip prosthesis after theFigure 1 Fracture of the ceramic liner in a patient after a fall.Ceramic arthroplasty under 50 231Figure 2 KaplanMeier survivorship curve for 108 hips with implant revision for any reason as the end point.operation that required a revision at 1 year after the opera-tion. This patient was satised after the revision operation.Final radiographic evaluation revealed no implants with sub-sidence, acetabular or femoral radiolucent lines, osteolysis, orcement fracture.KaplanMeier survivorship analysis based on 80 hips at risk,with implant revision for any reason as the end point, revealed acumulative survival rate of 96.3% at 10 years (Fig. 2).DiscussionCOC bearing surfaces have demonstrated the lowest in vivowear rates to date of any bearing combination and have afavorable wear prole for use in younger, more active pa-tients. Ceramics provide better wettability than other bearingsurfaces, including MOM and metal-on-polyethylene. Thisresults in lower friction and maximizes wear performance.Recent reports have suggested that ceramics have better bio-compatibility than metal alloys, increasing enthusiasm foruse of COC in younger patients. This study supports thisfavorable long-term prole of COC bearing surfaces inyounger patients with a 10-year survival rate of 96.3% forTHA in patients younger than 50 years of age.The literature pertaining to total hip replacement in young,active patients using conventional metal-on-polyethylene hasmixed results, with some studies noting an acceptable sur-vival rate at 10 years,5,20 whereas others have noted an unac-ceptably high rate of complications related to polyethylenewear.21,22 In a study by McAuley et al5 of 561 hip replace-ments done on patients younger than 50 years of age , 10-year survival rates were 89% at 10 years and 60% at 15 years,although the group of patients aged 40 years or younger hadinferior results, with 85% at 10 years and 54% at 15 years. Anumber of reports have also reported on an unacceptablyhigh rate of complications related to polyethylene wear inyounger patients. Dowdy et al reported on 41 THAs in pa-tients younger than 50 years of age; at an average of 5.3 years,they found evidence of polyethylene wear in 49% of hips,with the majority of these showing signicant acetabular os-teolysis.21 Dunkley similarly reported an unacceptably highrate of excessive polyethylene wear at a mean of 7 yearsrequiring liner exchange in 11% of patients.22 These resultshave prompted investigation into alternative bearings as op-tions for younger patients.Recent reports on the long-term survival for COC THAhave been more favorable than metal-on-polyethylene THA.Lusty et al9 and Lee et al10 reported a 99.0% survivorship at 7and 10 years, respectively, and Park et al reported a 95.3%survivorship at 10 years.11 Our results in patients youngerthan 50 years of age are comparable with these reports inolder populations. Studies with even longer follow-up of 20years have reported an acceptable survival rate. At a mini-mum 18.5 years of follow-up, Hamadouche et al reported an85.6% survivorship of cementless cups and 87.3% for ce-232mented stems.12 Petsatodis et al recently reported on a min-imum 20-year follow-up and noted a survival rate of 84.4% at20.8 years with an average patient age of 46 years at time ofsurgery.13 Although presumed to have superior wear proper-ties compared to other bearing surfaces, COC THAs are stillsusceptible to wear-related osteolysis, and improper designand implantation leading to edge-loading and neck-socketimpingement can accelerate this process.23 Longer-termstudies of modern COC THA are needed to continue deter-mining whether osteolysis affects the long-term durability ofnewer ceramic materials and designs.Component fracture in ceramic bearings is more commonbecause of their low fracture strength and was observed in 2 hips(2.5%) in our cohort. Although early reports of catastrophicfailure in the 1970s tempered the initial enthusiasm for use ofCOC bearing surfaces, improved design and quality since rst-generation ceramics have greatly decreased the prevalence ofceramic bearing fractures from rates as high as 13.4% before1990 to relatively rare events currently.14,15 Hannouche et alretrospectively reported on 5500 alumina components thatwere implanted between 1977 and 2001, with only 13 fracturedcomponents. Willmann reported a fracture rate of 0.004% forthird-generation Biolox femoral heads.15 Some recent investiga-tions concerning COC THA have noted a number of ceramiccomponent fractures.10,24,25 Although fracture of modern COCmaterials and designs is now considered an infrequent event,patients must still be warned about the possibility of cata-strophic failure of these components.The occurrence of acoustic emissions is a concerning phe-nomenon for both surgeons and patients when choosing COCbearing surfaces. The prevalence of squeaking has ranged any-where from below 1% in some series to as high as 20% inothers.26-30 We found a relatively low rate in our series (1.3%),with only one patient complaining of squeaking. This patient,however, thought the squeaking was bothersome enough toaffect quality of life and opted for revision of components. Var-ious factors have been associated with noise production, includ-ing acetabular and femoral component position and design, aswell as various patient demographics,19,31-33 but the exact etiol-ogy of squeaking in COC designs remains elusive. Sexton et alfound a signicant association between higher activity levels andsqueaking hips, which would be of concern in younger, moreactive patients.32 However, the incidence of squeaking in ourcohort of young patients was relatively low.Our study shows an acceptable survival rate (96.3%) of COCTHA in a cohort of patients younger than 50 years of age, andthis rate is comparable with that in other series of COC THA inolder populations reported in the literature. The strengths ofthis study include the long-term follow-up and the high fol-low-up rate (97.6%). The major weakness of our study is thatwe did not obtain preoperative Harris hip scores in our pa-tients, although our nal average Harris hip score results arecomparable with those of other reports of COC THA in theliterature.9,10,29 Longer-term survival analysis at 20 years andbeyond in our group of patients will determine whether thereis a survival benet in COC design over conventional metal-on-polyethylene and other alternative bearing designs inyounger, more active patients.J.E. Hsu et alReferences1. Mkel KT, Eskelinen A, Pulkkinen P, et al: Total hip arthroplasty forprimary osteoarthritis in patients fty-ve years of age or older. Ananalysis of the Finnish arthroplasty registry. J Bone Joint Surg Am90:2160-2170, 20082. Corbett KL, Losina E, Nti AA, et al: Population-based rates of revision ofprimary total hip arthroplasty: A systematic review. PLoS ONE5:e13520, 20103. Garellick G, Malchau H, Herberts P: Survival of hip replacements. 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