Lee v. MacDonald: Ceramic-Ceramic: Pricey Longevity for the Young Active Patient?

This week’s Orthopaedic Crossfire® debate was part of the 19th Annual Current Concepts in Joint Replacement® (CCJR®), Spring meeting, which took place in Las Vegas. This week’s topic is “Ceramic-Ceramic: Articulations of Longevity for the Young Active Patient.” For is Gwo-Chin Lee, M.D. – University of Pennsylvania, Philadelphia, Pennsylvania. Opposing is Steven J. MacDonald, M.D., F.R.C.S.(C) – University of Western Ontario, London, Ontario, Canada. Moderating is Daniel J. Berry, M.D. – Mayo Clinic, Rochester, Minnesota.

Dr. Lee: I recommend and will discuss the use of ceramic-on-ceramic in patients if they are under the age of 55. I believe ceramic-on-ceramic properties are optimized for larger heads in active patient populations.

A fear of instability and dislocations has driven the use of larger heads. Data from the American Joint Replacement Registry (AJRR Annual Report-2014) shows that the 36mm ball heads have been used in greater than 50% of the patients undergoing total hip arthroplasty. And that number has since increased.

Patients under age 55 are at significantly greater risk of revision—because of wear and osteolysis—as shown on the Australian Registry (AOANJRR Annual Report 2017)—with a revision rate of about 10% at 16 years.

The data on crosslinked polyethylene is great, but only if you use 28 and 32mm ball heads. And that’s not really what’s going in young patients in 2018. Instead many receive 50mm, 52mm, 54mm cups.

And there’s data that supports that the use of large heads and thin poly can potentially exceed the 0.1mm per year osteolysis threshold (Selvarajah, et al., Bone Joint J, 2015).

Crosslinked polyethylene wears over time (Snir, et al, JOA, 2014). The concern is volumetric wear, which accelerates in large head sizes (Lachiewicz, et al., Clin Orthop Relat Res, 2016). Small osteolytic lesions are visible at 10 to 12 years.

The question really is; can these bearings last 20, 30, even 40 years in a young patient?

The Australian Registry, albeit non-crosslinked polyethylene, shows a higher revision rate in patients with heads larger than 32mm.

Younger (under 55) female revision rates are highest probably because they receive thinner poly, larger heads and smaller shaped cups.

You may see information from my opponent which shows that ceramic-on-polyethylene, or even metal-on-crosslinked polyethylene implants have lower revision rates compared to ceramic-on-ceramic.

But if you delve into the data, ceramic-on-ceramic patients actually have a 7.3% revision rate which is lower than the cumulative 10% for that patient population—and these are young patients, not all comers.

We all agree that wear characteristics are important (Sentuerk, et al., Bone Joint J, 2016). Ceramic-on-ceramic wear characteristics are actually optimized with the use of large heads. Fracture rates decrease and lubrication rises as head size increases.

Ceramic-on-ceramic total hip clinical results have been excellent worldwide. Excellent survivorship in the very young patient (Kim, et al., JBJS, 2012).

If the question is whether ceramic-on-ceramic will outperform conventional bearings at 10 years (Beaupre, et al., JOA, 2016), I think I’ll lose that argument every single time, but this is not the debate. Patients who are 55 or under expect their hips to last more than 20-30 years.

But even in studies that show no significant difference in revision rates comparing ceramic-on-crosslinked polyethylene and ceramic-on-ceramic bearing surfaces, a different mode of failure in ceramic-on-ceramic total hip arthroplasties is reported (Epinette, et al., JOA, 2014). Ceramic-on-ceramic simply does not wear or loosen compared to conventional bearings.