Thirty years of experience with alumina-on-alumina bearings in total hip arthroplasty

Alumina-on-alumina bearings in total hip arthroplasty have been developed in an attempt to minimise debris and the occurrence of osteolytic lesions. The outstanding tribological properties of this bearing system are explained by low surface roughness, high hardness for major scratch resistance, and high wettability. Since the 1970s, technological improvements in the manufacturing process of alumina components together with a better understanding of Morse taper technology have provided a surgical grade material with high density, high purity and small grains. Published studies on the outcome of total hip arthroplasty performed with this new generation of implants showed high survivorship especially in young and active patients, with survival rates free of revision of 90.8% to 97.4% at ten years. However, concern remains over ceramic liner fracture and squeaking, which has been noted recently with increasing prevalence. This review will discuss the current knowledge on the use of alumina-on-alumina bearings.     

Alumina ceramic bearings for total hip arthroplasty

This article presents an experience with alumina ceramic bearings involving the use of improved ceramic materials as well as new design considerations. The alumina-alumina ceramic hard bearing is a safe option for the younger, more active patient.     

Mid-term result of ceramic bearings in total hip arthroplasty

Purpose

The purpose of this study was to evaluate our clinical experience with ceramic-on-ceramic cementless total hip arthroplasty (THA) and complications after an average follow-up of more than eight years.

Methods

From January 2001 to December 2008, 540 THA with ceramic-on-ceramic bearings were performed in 448 patients (92 bilateral, 54 of which were operated simultaneously) with a mean age 49.9 years (range 18–84) by a senior surgeon. Pre-operative aetiological reasons were developmental dysplasia of the hip (DDH) in 205 hips, degenerative arthritis in 157 hips, avascular necrosis in 51 hips, rheumatoid diseases in 40 hips, posttraumatic arthritis in 40 hips, other reasons in 25 hips and revision surgery in 22 hips. Patients were evaluated with Harris hip score (HSS), and radiological findings of acetabular and femoral component loosening or osteolysis with ceramic bearing related complications like squeaking, liner and head fractures were recorded.

Result

The average duration of follow-up time was 8.2 years (range, five to 13.2). The main Harris hip score increased from 42.4 points preoperatively to 94.9 points at the time of last follow-up. We had one fracture of the ceramic head, 11 clicking and four squeaking; one of them was revised because of terrible squeaking due to acetabular liner fracture, the other three were seldom audible from the outside and followed conservatively. We did not observed loosening or osteolysis due to ceramic bearings at the time of the final follow-up.

Conclusion

Our study has demonstrated that ceramic-on-ceramic bearings can be used safely in different etiological problems. Incidences of noisy hips are becoming less frequent.     

Ceramic failure after total hip arthroplasty with an alumina-on-alumina bearing

BACKGROUND: The mechanical properties of alumina ceramic, now in its third generation, have been markedly improved through the evolution of design features and manufacturing processes and the introduction of proof-testing. Nonetheless, because of the lack of ductility of alumina ceramic, there is concern regarding the risk of fracture during insertion or in vivo use. The purpose of the present study was to present a multicenter review of primary total hip arthroplasties performed with use of a polyethylene-ceramic composite liner combined with a ceramic femoral head, with particular attention to failure of the ceramic bearing. METHODS: We evaluated 357 primary total hip arthroplasties that had been performed in 319 patients with use of a contemporary alumina-on-alumina bearing design incorporating a polyethylene-ceramic composite liner within a titanium-alloy shell coupled with a 28-mm-diameter ceramic femoral head. The procedures were performed at four participating centers from 1998 to 2001. Ceramic failure without trauma occurred in six hips (1.7%). All of these hips were revised, and the retrieved alumina implants were examined by means of visual inspection and scanning electron microscopy equipped with energy-dispersive x-ray spectrometry. RESULTS: Two femoral heads fractured during the first postoperative year, and four alumina liners fractured after an average of 36.8 months in vivo. All four of the explanted alumina liners revealed evidence of rim contact with the metal neck of the femoral component. Composition analysis confirmed that surface-stain materials were titanium particles transferred from the femoral component. CONCLUSIONS: Despite the theoretical improvement in the fracture toughness of a polyethylene-alumina composite liner, a relatively high rate of catastrophic ceramic bearing surface failure was still observed at the time of short-term follow-up. This finding prompted us to discontinue the use of this type of alumina bearing design.     

Ceramic-on-ceramic bearings in total hip arthroplasty

The ideal bearing surface for total hip arthroplasty still is being sought. This bearing would be durable, cost-effective, easy to implant, inert, and produce minimal wear debris. Ceramic-on-ceramic bearings have continued to evolve and have enjoyed success in many European centers throughout the past 3 decades. A limited number of early reports from the United States discouraged widespread acceptance and use of ceramic-on-ceramic total hip arthroplasty. Once critically analyzed most of the failures from the early reports are attributable to design and material specific flaws. Vast improvements have been made in ceramic manufacturing leading to even more superior wear characteristics and higher burst strengths. The case for alumina-on-alumina ceramic bearings is becoming stronger as data accumulate clinically and in vitro. In a multicenter, prospective and randomized study, an alumina-on-alumina ceramic bearing is compared with a cobalt chrome-on-polyethylene bearing. After as many as 48 months there has been no significant difference in clinical performance between the two study groups. No ceramic head fracture or ceramic bearing failure has occurred. Therefore, this new alumina-on-alumina ceramic bearing is a safe option for total hip arthroplasty and may provide a more durable prosthesis especially in young and active patients.     

Ceramic/ceramic total hip arthroplasty

Alumina-on-alumina total hip arthroplasty has been used for 30 years, mainly in Europe. The theoretical advantages of this combination are represented by its remarkable sliding characteristics, its very low wear debris generation, and its sufficient fracture toughness. These advantages are achieved if the material is properly controlled with high density, high purity, and small grains. The authors summarize the results obtained with ceramic/ceramic total hip arthroplasty. Information is provided about in vivo behavior regarding wear debris characterization and quantification, and histological tissue examinations for inflammatory reactions, which were not encountered except when alumina debris was mixed with metal or cement. Modification of socket fixation resulted in improved clinical outcomes. With a press-fit metal shell and an alumina liner utilized for 10 years, the results are excellent especially in a young and active population. Alumina-on-alumina seems at the moment to be one of the best choices when a total hip arthroplasty has to be performed in young and active patients. Received: March 22, 2000     

Long-term results of alumina-on-alumina hip arthroplasty for osteonecrosis

Alumina-on-alumina bearings in THR may, in theory, provide an effective answer to osteolysis in young patients with ON of the femoral head. The purpose of this retrospective study was to report the long-term results of a series of 52 consecutive alumina THAs (41 patients) done for ON. The mean age of the patients at surgery was 41 years (range, 22-79 years). Cemented femoral stems with a 32-mm alumina head were used. Plain alumina cups were used and were either cemented (39 hips) or press-fit (13 hips). No patients were lost to followup. Sixteen hips have been revised. Aseptic loosening of the socket was the main cause of failure. At an average 16-year followup (range, 11-23.65 years), 26 hips were rated excellent and one hip was rated good. No osteolysis was observed and wear was undetectable. If revision for aseptic loosening was the end point, the rate of survival was 88.5% at 10 years for the socket and 100% at 10 years for the stem. With the alumina-on-alumina hip replacement done for ON, absence of osteolysis can be expected for as many as 24 years after the operation. New methods of socket fixation now are being explored.     

Excellent results with cementless total hip arthroplasty and alumina-on-alumina pairing: minimum ten-year follow-up

Ceramic-on-ceramic coupling is thought to be a durable alternative to metal- or alumina-on-polyethylene pairing. No evidence exists suggesting superior clinical and radiological results for hydroxyapatite-coated stems versus uncoated stems. The aim of this study is to report the performance of an alumina-on-alumina bearing cementless total hip arthroplasty and to compare stems with a tapered design with and without hydroxyapatite coating. We prospectively analysed the results of cementless tapered femoral stems (40 hydroxyapatite-coated versus 22 uncoated stems), a metal-backed fibre mesh hydroxyapatite-coated socket and alumina-on-alumina pairing. Of 75 hips studied, 62 were available for follow-up (mean of 10.5 years after surgery). The average Harris hip score was 90. Only one hydroxyapatite-coated stem was revised for aseptic loosening. One instance of non-progressive osteolysis was detected around a screw of a cup. All other components showed radiographic signs of stable ingrowth. Hydroxyapatite coating of the stem had no significant impact on the clinical or radiological results. Total hip arthroplasty with the presented implant and pairing provides a durable standard for all patients requiring hip joint replacement against which all newer generations of cementless implants should be judged.     

Alumina-on-alumina ceramic versus metal-on-highly cross-linked polyethylene bearings in total hip arthroplasty: a comparative study

The aim of the study was to evaluate the reliability and durability of alumina-on-alumina ceramic in comparison to metal-on-highly cross-linked polyethylene (CoCr/HXLPE) bearing couples. This prospective randomised study involved 150 patients (157 hips). All patients (mean age: 54.7 years) obtained an identical fibre metal midcoat femoral stem and fibre metal-coated acetabular shell. In 78 patients (82 hips) we used alumina, while in 72 patients (75 hips) metal-polyethylene bearing couples were used. During a mean 50.4-month follow-up period (51 ± 8 alumina and 50 ± 8.9 metal-polyethylene) no statistically significant changes in clinical and radiographic parameters were noted between the two groups. There was no ceramic breakage and no need for revision surgery due to the ceramic liner. The alumina bearing couples proved to be as reliable as CoCr/HXLPE.     

Anatomic cementless total hip arthroplasty with ceramic bearings and modular necks: 3 to 5 years follow-up

Reported here are the results obtained for 216 prosthetic implants in which cementless arthroplasty and a modular neck were used. The advantages to using this method are related to the fact that it may be adapted to a variety of anatomical conditions.     

陶瓷-陶瓷全髋关节置换术治疗年龄<40岁患者的疗效观察

目的探讨陶瓷-陶瓷全髋关节置换术(THA)治疗年龄40岁髋关节疾病患者的疗效。方法回顾性分析52例年龄40岁因髋关节疾病采用陶瓷-陶瓷THA治疗患者的临床资料。临床疗效评估重点观察手术前后Harris评分;影像学评估重点观察术后脱位率、骨溶解及陶瓷碎裂发生率等。结果 52例均获得随访,时间8~16(12.1±3.7)年。Harris评分由术前9~68(49.3±9.7)分提高到末次随访时68~98(95.1±6.7)分(P0.05)。除1例(1.9%)在术后7 d出现髋关节后脱位外,其余患者均无脱位。2例(3.8%)随访中出现关节异响,1例(1.9%)术后8年出现陶瓷碎裂。至末次随访,未出现假体松动及假体周围骨溶解。结论采用陶瓷-陶瓷THA治疗年龄40岁髋关节疾病患者可以获得满意的临床疗效。     

Clinical experience with primary cemented total hip arthroplasty.

Results obtained with 433 cemented prostheses with original design, implanted at Exeter since 1969, are presented. Clinical and radiographic findings were evaluated on 88% of cases at 7,4-13, 4-16, 4 follow-ups. Average age at surgery was 66,7 years. Sixty-two (14,3%) prostheses have been revised. Stem loosening was evident in 13 (3%) cases, of which 11 were revised. Socket loosening was evident in 21 patients (4,9%), all revised. Due to sepsis 7 prosthetic were explanted (Girdlestone) were done. Stem sinking > 2 mm into the cement mantle was observed at 16,4 years follow-up in 15% of cases, with no relation to pain. None of the patients showed a complete radiolucent line around the stem. The biomechanical relevance of the tapered design of a smooth and collarless stem for the cemented implant is discussed.     

Clinical experience with primary cementless total hip arthroplasty.

One hundred-eleven patients (121 hips) treated with cementless total hip arthroplasty (Harris-Galante, Zimmer) were clinically and radiographically reviewed at an average follow-up of 67 months (55-79). 9,1% of the stems presented signs of loosening and 5 stems (4,1%) had to be revised. None of the acetabula required revision surgery for loosening. One socket was revised due to recurrent dislocation. Clinical results were evaluated according to Harris protocol: excellent 75,2%, good 12,4%, fair 5%, poor 3,3%. Ten (7,9%) intraoperative fractures of the proximal femur were observed: in 2 cases stem instability consequently occurred. Endosteal cortical erosions, not clinically evident, were observed in 8,3% of stable stems. A foreign body biological reaction to polyethylene or metallic debris is supposed as cause of erosions.