Lee v. Padgett: Ceramic-Ceramic Bearings in Patients <60 Assures Longevity

So why not ceramics for everybody? It’s less forgiving. Potential squeaking. Risk of fracture and risk of cost prevent wide adoption.

Head fractures have been eliminated with improved materials. Understanding proper taper handling; not mismatching tapers. Liner fractures remain at a relatively low rate. Problems are largely related to intra-operative events, surgical technique and poor instrumentation.

Squeaking hips have also been reduced with the removal of certain implant designs from the market and revision for squeaking is quite low. But it’s also important to remember that crosslinked polyethylene can also break. Polyethylene bearings can also make noise. All mechanical devices can make noise.

If you want to do total hip arthroplasty in the young patient with polyethylene, there is literature supporting that, but only if you use 28mm heads. I think we need to make patient-specific choices that are clinically sound but most importantly economically responsible. Highly crosslinked polyethylene may be winning the battle at this point, but I think that in the long term you may lose the war.

In summary, recognition that there is a role and place for ceramic-on-ceramic articulation in total hip arthroplasty should exist and modern ceramic-on-ceramic hip arthroplasty should be the standard in young, active patients considering total hip arthroplasty.

Dr. Padgett: The long-term success in total hip arthroplasty really resides in two things. Number one, avoid short-term problems such as instability and infection. Number two, ensure long-term fixation and address concerns about bearing wear and osteolysis.

I’d like to take you back in time to eight years ago—this is the venue—it’s the HSS alumni meeting—and at that time I was challenged to defend the possibility of the use of metal- or ceramic-on-polyethylene. The number one public enemy at that time was osteolysis. The question at the time was what was the optimal bearing in the young patient.

My opponents were two—one of my partners Ed Su who made a very recent case for metal-on-metal at the time, looking at hydrodynamic fluid film lubrication, essentially becoming an almost wear-less type of articulation. Improved manufacturing was suggested, including a better understanding of radial clearance. More problematic on the metal-metal side though was my concerns about metal ion release and the potential secondary affects and organ tumor induction—hypersensitivity—again the timeframe is 2008.

My opponent on the ceramic side was none other than my mentor, Chit Ranawat. Chit gave a very reasoned approach to the use of alumina-on- alumina with very low wear rates. And again, the advantages were due to wetability, low friction, and scratch resistance.

In 2008, the arguments about ceramic were the following: noise—approximately 20% in almost all series and they fell into two types: clickers and squeakers. The clickers were due to micro-separation and it was a common phenomenon. Squeakers? Again, an article from the front page of The New York Times, “That Must Be Bob. I Hear His New Hip Squeaking” and I was quoted as saying “There is something amiss here.”

More specific and more concerning events dealt with fractures. An early series reported approximately 1 in 1,000. Causes were attributed to large grain size; ceramic impurities; and trunnion mismatches. There were some improvements in decreasing grain size, reducing impurities, and reducing fracture rates—which were estimated to be about 1 in 25,000—but still not zero.

From our retrieval lab we looked at the effect of marginal impingement, chipping in several instances. We were concerned about metal transfer onto the surface as a result of this impingement.

And finally we looked at ceramic mal-seating. While none were associated with any squeaking we were concerned about the long-term consequences of this.

I was left at this point to defend the role of crosslinked polyethylene with three studies at 3 and 5 years (Digas, Dorr and Martel), looking at a 50-60% reduction in wear rates. And that was the basis of my argument.

Well, the year now is 2016. Donald Trump is the president. The Cubs won the World Series. And quite frankly, let me give you an update…metal-on-metal total hip is dead. Hip resurfacing on life support. I think we can stop that.

What about ceramic-on-ceramic in 2016? There’s a slow, but steady, decrease in its use in Europe. The issues with ceramic-on-ceramic…we’ve got more data; newer data and the latest—345 Delta-Delta ceramic hips with a mean follow-up of 5.3 years, looking specifically at clinical outcomes, noise and fracture rates from Bill Hamilton’s group (J Arthroplasty 2015). Three fractured ceramic liners and a 7.5% reported incidence of ceramic squeaking.