Primary Ceramic-on-ceramic Total Hip Arthroplasty Using a 32-mm Ceramic Head With a Titanium-alloy Sleeve

Background Modern ceramic-on-ceramic bearings have become attractive alternatives to conventional polyethylene in total hip arthroplasty (THA) as a result of their low wear and minimal particle production. However, 28-mm heads in ceramic-on-ceramic bearing couples have been associated with ceramic fracture. To address these issues, 32-mm and larger ceramic heads with a titanium-alloy sleeve have been introduced, although limited data are available on their durability and clinical outcomes.

Questions/purposes We determined (1) the survivorship of the primary ceramic-on-ceramic THA using a 32-mm ceramic head with a titanium-alloy sleeve at a minimum followup of 5 years; (2) Harris hip scores; (3) the incidence of ceramic fracture and noisy hip; and (4) the proportion of hips showing radiographic evidence of osteolysis.

Methods From November 2005 to August 2009, we performed 301 ceramic-on-ceramic THAs using a 32-mm ceramic head with a titanium-alloy sleeve in 270 patients. Of these, 12 patients (12 hips [4%]) died from problems unrelated to surgery and 13 patients (15 hips [5%]) were lost during followup before a minimum of 5 years had been reached, leaving 245 patients who had 274 THAs with a minimum followup of 5 years (mean, 6.5 years; range, 5-9 years) in this retrospective analysis. During the study period, 30% (301 of 997 hips) were performed with this articulation based on the operating surgeon’s discretion. The mean patient age at the time of surgery was 55 years (range, 16-82 years). All operations were performed at a single center. All of the ceramic implants were hot isostatic-pressed, laser-marked, proof-tested third-generation alumina. We determined the implant survival, Harris hip scores, incidence of ceramic fracture or noisy hips (based on a questionnaire), and presence of osteolysis.

Results The survival rate of ceramic-on-ceramic bearings in primary THA using a 32-mm ceramic head with a titanium-alloy sleeve was 98% (95% confidence interval, 96%-100%) at 9 years. The Harris hip score improved from a mean of 47 points preoperatively to 93 points at last followup. One ceramic head fractured at 6 years postoperatively. No ceramic liners fractured. Audible hip clicking and squeaking were identified in four hips and one hip, respectively. Osteolysis was detected in three hips, but none had symptoms.

Conclusions Primary ceramic-on-ceramic THA using a 32-mm ceramic head with a titanium-alloy sleeve has a survivorship of 98% at 9-year followup. Nevertheless, surgeons should be aware of the potential risks of ceramic fracture, noise, and osteolysis associated with the use of a ceramic head with a titanium-alloy sleeve.

Level of Evidence Level IV, therapeutic study.