Causes of Failure of Ceramic-on-Ceramic and Metal-on-Metal Hip Arthroplasties

Abstract

Background Few large series of hard bearing surfaces have reported on reasons for early failure. A number of unique mechanisms of failure, including fracture, squeaking, and adverse tissue reactions, have been reported with these hard bearing surfaces. However, the incidence varies among the published studies. Questions/purposes To confirm the incidences, we identified the etiologies of early failures of hard-on-hard bearing surfaces for ceramic-on-ceramic and metal-onmetal THAs. Methods We retrospectively reviewed records of 2907 THAs with hard-on-hard bearing surfaces implanted between 1996 and 2009; 1697 (58%) had ceramic-onceramic and 1210 (42%) had metal-on-metal bearing surfaces. We recorded bearing-related complications and compared them to nonspecific reasons for revision THA. The minimum followup of the ceramic-on-ceramic and metal-on-metal cohorts was 6 months (mean, 48 months; range, 6-97 months) and 24 months (mean, 60 months; range, 24-178 months), respectively. Results The overall revision rate for ceramic-on-ceramic THA was 2.2% (38 of 1697), with aseptic loosening accounting for 55% of revisions (femur or acetabulum). The bearing accounted for 13% of the revisions in the ceramic-on-ceramic THA cohort. The overall metal-onmetal revision rate was 5.4% (65 of 1210), 17 involving adverse tissue reactions related to the metal-on-metal bearing surface (17 of 1210, 1.4% of cases; 17 of 65, 26% of revisions). Conclusions Twenty-six percent of the revisions from metal-on-metal and 13% of ceramic-on ceramic were bearing related. The overall short-to medium-term revision rate was 2.2% and 5.4% for ceramic-on-ceramic and metalon-metal, respectively. The most common etiology of failure was loosening of the femoral or acetabular components.

Do the Reasons for Ceramic-on-ceramic Revisions Differ From Other Bearings in Total Hip Arthroplasty?

“…The fixation of CoC cementless cups has been improved using modern porous coatings [4,13,14,30] but remains a weak point of this bearing, particularly when considering the low rate of osteolysis that, contrary to MoP, did not contribute to cup loosening. Our results differ from the study by Porat et al [27] that identified femoral loosening as the main reason for revision of CoC THA (13 of 38 [34%]). After revisions for infection (n = 39), revisions directly related to ceramic use (including impingement, squeaking, ceramic breakage, and incorrect ceramic insertion) were the third most common reason for revision in our study (n = 37) ( Table 2).…”

“…This is an important finding because the time to revision of CoC THA was not mentioned in previous studies [27] or easy to extract from registries (the Australian register mentioned 2109 of 65,114 CoC THA revisions [3.2%] but not the revision rate before 5 years) [32]. Our results are in accordance with the Danish register indicating that 63 of 71 (88%) CoC THAs were revised before 5 years of followup [35].…”

“…These infections were observed in our study despite the CoC population being younger and more active than the MoP group. Iliopsoas irritation was a common indication for CoC revision (18 of 238 [8%]; OR, 4.95 [2.69-9] versus MoP) as reported by Yeung et al [37] (three of nine [33%]), but not by Porat et al [27] (one of 38 [3%]). This was a paradoxical finding because the revisions for iliopsoas irritation were performed in cups with a smaller diameter and in bearings whose diameter was comparable to other CoC revisions.…”

“…The rate of ceramic breakage has diminished with the introduction of better components and is currently estimated to be below one in 5000 [1,20,28]. However, with more frequent use of ceramics, other concerns such as squeaking have emerged with a frequency of 0.5% to 20% [2,5,6,18,27]. All these limitations expose CoC THAs to reoperation with the 10-year survival rate ranging from 62% to 97% [12][13][14][15][16][17].…”

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

“…that require revision surgery and that are not prevented by simple choice of bearing surface (Table 3). Even aseptic loosening cannot be completely resolved using one specific bearing surface because of its multifactorial etiology 32 . On the other hand, the rate of osteolysis was diminished as a direct consequence of using ceramic bearings.…”