This week’s Orthopaedic Crossfire® debate was part of the 34th Annual Current Concepts in Joint Replacement® (CCJR®), Winter 2017 meeting, which took place in Orlando. This week’s topic is “Trousdale v. Engh: Ceramic Heads Should Be Used in all Patients” For isRobert T. Trousdale, M.D., Mayo Clinic, Rochester, MinnesotaOpposing isC. Anderson Engh Jr., M.D., Anderson Orthopaedic Research Institute, Alexandria, Virginia.Moderating is Thomas S. Thornhill, M.D., Brigham and Women’s Hospital, Boston, Massachusetts.
Dr. Trousdale: This debate is going to involve the use of ceramic vs. cobalt chrome heads in total hip replacement. I’ll say instead of all patients, I use and argue for the fact that ceramic heads should be used in the majority of our patients. As you all know we’ve got a lot of options for our bearing surface and, again, Andy and I are going to discuss the role of ceramic versus cobalt chrome and we’ll limit it to highly crosslinked polyethylene as I’m sure that’s the majority of the polyethylene used throughout the world.
In my practice today, I’ll use a different bearing option in a 12-year-old with avascular necrosis who needs bilateral total replacements compared to a 78-year-old with end stage right hip arthritis
If you look at ceramic versus cobalt chrome on highly crosslinked polyethylene you’d look at wear, durability, corrosion, cytotoxicity, and cost so there are pros and cons to each of the options.
I would argue that wear is a wash. The wear of ceramic versus highly crosslinked polyethylene compared to cobalt chrome versus crosslinked polyethylene is very close. I’m going to give durability, at least now, a slight nod to ceramic. Corrosion …the big advantage of ceramic over cobalt chrome has to do with corrosion. I give cytotoxicity a slight nod to ceramic and cost I give a slight nod to ceramic.
Here’s a bit of data to justify those statements.
So how about wear? I would argue there is no significant clinical difference in the wear of ceramic versus cobalt chrome on highly crosslinked polyethylene.
In data from our colleagues in New York City (Gaudiani et al, J Arthroplasty2018), the linear wear rates were a a little bit better with ceramics. If you look at volumetric wear, the data showed a little better wear with the ceramic versus cobalt chrome but not significantly different. I think Andy’s going to show you the data that he generated (Sychterz et al, JBJS-Br2000). He states in his article that despite differences in the wear rates and head penetration, there is no clinical relevance, no increase in osteolysis between the two groups.
How about durability, endpoint to revision?
The recent data from the Australian Joint Registry demonstrates, up to 15 years, a slight advantage with ceramic and highly crosslinked poly versus cobalt chrome on highly crosslinked poly. Same data from the Dutch Registry, the ceramic on highly crosslinked polyethylene does a little bit better than the metal on highly crosslinked poly for the cumulative incidence of revision, at 5 years and 9 years.
