A recent randomized trial showed no revisions for polyethylene wear and osteolysis in ceramic-on-ceramic patients at 15 years (Atrey, et al., JOA, 2017).
Even in patients with very small heads—28mm heads on highly crosslinked polyethylene—have higher rates of osteolysis compared to ceramic-on-ceramic articulations (Higuchi Y, et al., JOA, 2016).
Meta-analysis of the results out there in the literature shows that if you use longevity and durability as a potential endpoint, ceramic-on-ceramic wins this argument every single time (Hu, et al., J Orthop Surg Res, 2015).
So, why not in everybody? In my opinion it’s probably the risk of squeaking and cost. Head fractures are rare. Liner chips and fractures during insertion are a problem, but better instrumentation is coming online (Lee, et al., JOA, 2016). If you look at squeaking, if you basically exclude certain manufacturer’s designs the overall rate of squeaking is actually relatively low and certainly even lower revisions for overall squeaking (Owen, et al., Bone Joint J, 2014).
If you want to do conventional bearings on highly crosslinked polyethylene, use 28mm ball heads. That is supported by the literature (Garvin, et al., Clin Orthop Relat Res, 2014). If you’re going to use larger ball heads, you should consider ceramic-on-ceramic.
In the United States we haven’t really adopted the use of ceramic-on-ceramic, maybe because of the reasons mentioned previously (Heckmann, et al., JOA, 2018). But in countries like Korea where they treat a lot of young patients (Yoon, et al., Clin in Orthop Surg, 2016) with avascular necrosis, the use of ceramic-on-ceramics is actually almost 80% of total hips.
In summary, in a young and active patient where a ball head greater than 32mm on thin polyethylene is planned, ceramic-on-ceramic is the best guarantee against wear and osteolysis.
Dr. MacDonald: I will actually agree and concede that it is your articulation of choice for the young patient…IF you want a bearing with higher failure rates, a substantial price premium and unique and unresolved complications.
Let’s face it. There is no perfect bearing, and I think we all agree with that. I believe, however, that the best choice for the young patient is a ceramic head on a highly crosslinked polyethylene insert.
Regarding longevity, we need to look at large numbers and that’s the beauty of registry data.
The Australian Registry captured data for more than 300,000 total hips. And the data is presented in a very easy and reproducible manner. The 15-year cumulative revision rate – all comers to begin with. What’s the best performing bearing? It’s ceramic-on-highly crosslinked polyethylene with a 5.1%, 15-year cumulative revision rate.
What do you think is second? That’s actually cobalt chrome-on-highly crosslinked polyethylene with 1 percentage point more, 6.3%. And then coming in third is ceramic-on-ceramic. So, that’s all comers. That’s 7.2%. We could debate whether that’s relevant or not. But I think once you get 2-3% it becomes relevant.
Ceramic-on-ceramic is definitely NOT the bearing of choice if you plan on living 15 years or more. Ceramic-on-highly crosslinked polyethylene is. That’s the Australian Registry.
In the New Zealand Joint Registry recently published data—106,139 primary hips. What’s their conclusion? Ceramic-on-highly crosslinked polyethylene couples have the lowest all cause revision rate. And ceramic-on-highly crosslinked polyethylene was the most durable and successful coupling used in primary hip, irrespective of age, gender, and head size (Sharplin, et al., Hip Int, 2018).
I am 57 years old. I’ve been active in sports and outdoor activities all my life. I have had three orthopedic surgeon tell me I need a hip replacement because it is bone on bone. I have stopped running because of the pain. I still work out on an eliptical. I am considering as hip replacement using ceramic on ceramic. I live in southern Missouri about 4 hours South of St.Louis. Are there any surgeons relatively close to me that use the ceramic on ceramic material? I’ve seen on surgeon in New York, that uses ceramic on ceramic, but that’s a long way from home.
Thanks,
Darrell Brewer