Walter v. MacDonald: Ceramic-Ceramic: Articulations of Longevity for the Young Active Patient

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 Ceramic-Ceramic: Articulations of Longevity for the Young Active”. For is William L. Walter, M.D., F.R.A.C.S., Ph.D., Sydney Hip & Knee Surgeons, Waverton, Australia.Opposing is Steven J. MacDonald, M.D., F.R.C.S.(C), University of Western Ontario, London, Ontario, Canada. Moderating is Thomas S. Thornhill, M.D., Brigham and Women’s Hospital, Boston, Massachusetts.

Dr. Walter: I’m here to talk to you about ceramic-on-ceramic bearings.

Around the world, ceramic-on-ceramic bearings are used more frequently than they are in this country. In the United States, ceramic-on-ceramic is used less than 5% of the time but worldwide it’s higher. In Australia, it’s about 1 in 4 hips are ceramic-on-ceramic.

Ceramic-on-ceramic bearing use in Australia, according to data from our registry, is increasing although the most common is still polyethylene on the acetabular side. In terms of revisions by bearing surface in all ages, ceramic-on-ceramic bearings perform well at 15 years and the registry data shows less than a 10% revision rate at 20 years.

When we look at the younger patients, conventional polyethylene has a higher failure rate while ceramic-on-ceramic has good data out to 15 years. Fifteen-year data for patients under 55 years with ceramic-on-ceramic had a 6.6% revision rate. And ceramic-on-crosslinked polyethylene is a 5.1% revision rate at ten years.

So, we know that younger patients have a higher revision rate than all the patients and the under 55-year age group experienced the highest revision rate of all age groups. The Australian registry data shows 9.9% revision at 15 years for the under 55-year age group as compared to 6.3% for the over 75-year group.

Younger patients have 1.4 times higher risk for revision compared to the 75-year-old or older patient.

We’ve done a lot of work in our own practice with midterm results and are currently looking at the 15-year results of the first 300 ceramic-on-ceramic bearings. We’ve done over 5,500 arthroplasty surgeries with 4,000 ceramic-on-ceramic hip surgeries.

We’ve had 55 retrievals. Most were revisions due to aseptic loosening of the cup or for femoral and pelvic fracture. We had very few revisions in our 4,000 ceramics for bearing failure—two for squeaking and a couple of broken ceramics.

We analyzed those 55 retrievals. One patient was a 47-year-old female who had a hip replacement and had psoas tendon irritation at 33 months post-op. We went in to release the psoas tendon and at the same time retrieve the bearing. On the retrieved bearing we saw the characteristic stripe wear or edge lining wear on the edge of the cup and a long stripe on the head. Using the RedLux machine we’ve analyzed a large number of these bearings now and measured the rate of median head wear. It is 0.2 mm³per year, so it’s a very low volume.

We also measured the acetabular component position and related that to wear and found that wear is related to cup position. So, if you have high anteversion and high inclination you’ll have anterosuperior wear. If you have low anteversion and low inclination, you’ll have posterior edge loading and posterior wear. In our patients, compared to the conventional polyethylene, we’ve had a dramatic reduction in osteolysis.