Recommendation None
Question 7: Is a CC articulation less likely to require revision than a conventional
replacement? For any patient contemplating a ceramic hip replacement, what options are available should the bearings fail at any stage?
Case clarification
Because of her relatively young age, the patient has con- cerns about the need for further surgery in the future. She has read about squeaking and also fracture in ceramic hips.
She asks what options are available to her should this occur.
Relevance
Although there are some undisputable advantages to ceramic bearings, consideration must be made of the poten- tial for failure and need for revision within the lifetime of a younger patient.
Table 17.1 Revision surgery (values <1 favor ceramic-on-ceramic, >1 favor control)
N Events RR 95% CI
CC Control
CC vs. CP 475 2/226 7/249 0.309 0.063–1.502
CC vs. MP 1036 14/744 16/292 0.331 0.159–0.687 CC vs. all 1511 16/970 23/541 0.378 0.198–0.721 CC, ceramic-on-ceramic; CP, ceramic-on-polyethylene; MP, metal-on- polyethylene; RR, relative risk of revision with CC compared to alternatives.
C H A P T E R 1 7 The Role of Ceramic in Total Hip Arthroplasty cobalt–chrome or ceramic head. A revision following frac- ture is not therefore a simple undertaking, requiring an extensive revision and not simply a head and liner exchange.13 Even without previous fracture, revision of a previous ceramic articulation will be susceptible to retained ceramic wear particles, potentially limiting longevity.
Recommendations
With regard to revision for a failed ceramic hip replace- ment, evidence suggests:
• With maximum mean follow-up of 8 years CC hips have a lower risk of revision in comparison to alternatives in currently available level I studies [overall quality: high]
• Following ceramic fracture, revision total hip arthro- plasty has a poorer survival than following conventional hip replacements [overall quality: low]
• Following ceramic fracture complete component revi- sion is required due to damage to trunnions and cups by the exceptionally hard fragments [overall quality: low]
• Total synovectomy is required during any ceramic revision to reduce the amount of highly abrasive wear debris from the previous articulation [overall quality:
low]
• Caution should be used before considering the use of any “soft” bearing such as polyethylene or stainless steel with risk of deformation, accelerated wear, and failure from retained abrasive third-body wear [overall quality: low]
Summary of recommendations
• Ceramics are exceptionally hard, wettable, and chemi- cally inert, but they are brittle and, unlike metal compo- nents, prone to fracture
• Zirconia undergoes phase transformation, limiting its safety as an orthopedic device
• There has been an improvement in the purity, produc- tion techniques, and overall quality of ceramics between early-generation ceramics and current options
• Ceramic may be used as a conventional hard-on-soft bearing with a ceramic femoral head articulating against polyethylene, or as a hard-on-hard CC or CM bearing
• There is less modularity with ceramic bearings as compared to metal and polyethylene implants, limiting the available options for optimizing leg lengths and stability
• Patients can expect disease-specific and quality of life outcome score improvement at least equivalent to a con- ventional hard-on-soft total hip replacement at mid-term follow-up
• Wear with CC articulations is significantly reduced in comparison to conventional hard-on-soft polyethylene replacements
reduced overall risk of revision was identified in the ceramic group (RR 0.331, 95% CI 0.159–0.687). Follow-up in these studies was 2 years (N = 61), mean 35.2 months (N = 500) and a mean of 8 years (N = 475). Taking all CC articulations and comparing with all of the controls reveals a relative risk of revision of 0.378 (N = 1511, 95% CI 0.198–
0.721) for the CC option.
Revision of any hip replacement is a complex undertak- ing. Ideally the use of ceramic articulations during primary surgery would remove the need for a future revision hip replacement. If ultimately one is required, “the absence of osteolysis facilitates revision surgery”41 avoiding the need for bone graft.40 Unfortunately, however, the use of any bearing will produce wear. Although the quantity is reduced with a ceramic bearing, what is produced is excep- tionally hard and a potentially damaging third body for any subsequent articulation. Worse, if revision is required following fracture there will be extensive third-body debris within the effective joint space, damaging exposed femoral trunnions and acetabular shells. Any delay will cause further damage and soft tissue contamination and revision is therefore an urgent undertaking. The revision will likely require exchange of all components due to this damage with subsequent bearings likely exposed to macro- and microscopic particles of ceramic, limiting longevity.
Level I evidence reviewing this issue is difficult to obtain, but observational and retrospective evidence is available.
Allain has published a case report and a study on a large series of head fractures.53,54 The case report was of a 54 year old patient who sustained a traumatic fracture of their femoral head 5 years after implantation.53 This was revised to a stainless steel on polyethylene liner. Subsequently at 11 months the patient developed pain and then at 18 months required a second revision. Intraoperatively the stainless steel femoral head was deformed and severe met- allosis was noted. Histologically, fragments of both stain- less steel and alumina ceramic were noted in the soft tissue.
A multicenter review by the same author54 reviewed 105 revisions for ceramic head fractures: 31% went on to require at least one repeat revision with an overall 5 year survival rate of only 63%. This rate is worse than most revision series and in all likelihood due to retained ceramic particles.13 Allain’s review is the most extensive review available in the literature and makes a number of recom- mendations.54 Factors influencing results included whether the cup was changed (57% required re-revision without, 21% with exchange), extent of synovectomy (re-revision in 67% with partial synovectomy, 19% with complete syn- ovectomy) and patient age (54 years in those requiring revision and 63 in those who did not (p = 0.02)). Although definitive conclusions could not be made as to whether the femoral component required exchange, this paper does conclude that any revision following ceramic fracture should include cup exchange, total synovectomy, and a
ments are challenging. Exceptionally hard retained wear and fracture debris often necessitates complete component revision with the potential to compromise the long-term survival of the revised hip.
References
1. NHS National Institute of Clinical Excellence: Guidance on the Selection of Prostheses for Primary Total Hip Replacement.
NICE, London, 2000.
2. Wright T, Goodman S. Implant Wear: the Future Of Joint Replacement. American Academy of Orthopaedic Surgeons, Rosemont, IL, 1995.
3. Schmalzried TP, Szuszczewicz ES, Northfield MR, et al.
Quantitative assessment of walking activity after total hip and knee replacement. J Bone Joint Surg Am 1998;80:54. 417.
4. Wrolbewski BM, Siney PD, Flemming PA. Charnley low-frictional torque arthroplasty in patients under the age of 51 years. Follow up to 33-years. J Bone Joint Surg Br 2002;84:540–3.
5. Bozic KJ, Kurtz SM, Lau E, Ong K, Vail TP, Berry DJ. The epide- miology of revision total hip arthroplasty in the United States. J Bone Joint Surg Am 2009;91:128–33.
6. Willmann G. Alumina ceramic components for total hip arthro- plasty. Orthopaedics 1997;4:269–76.
7. Feder BJ. That must be Bob. I hear his new hip squeaking. New York Times, May 11, 2008.
8. Mittelmeier H. Report on the first decennium of clinical experi- ence with a cementless ceramic total hip replacement. Acta Orthop Belg 1985;51(2–3):367–76.
9. Miller E. Self bearing, uncemented alumina ceramic total hip replacement arthroplasty. AAOS Instructional Course 1986;35:
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10. Nizard RS et al. Ten-year survivorship of cemented ceramic- ceramic total hip prosthesis. Clin Orthop Relat Res 1992;282:
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11. Ceramtec. Current perspective on the use of ceramics in total hip arthroplasty. Biolox. January 13, 2007.
12. Skinner HB. Ceramic bearing surfaces. Clin Orthop Relat Res.
1999;369:83–91.
13. Barrack RL, Burak C, Skinner HB. Concerns about ceramics in THA. Clin Orthop Relat Res 2004;429:73–9.
14. Bierbaum BE, Nairus J, Kuesis D, Morrison JC, Ward D. Ceramic- on-ceramic bearings in total hip arthroplasty. Clin Orthop Relat Res 2002;405:158–63.
15. Mundy GM, Esler CNA, Harper WM. Primary hip replacement in young osteoarthritic patients: current practices in one UK region. Hip 2005;15:159.
16. Pandit H, Glyn-Jones S, McLardy-Smith P, et al. Pseudotumours associated with metal-on-metal hip resurfacings. J Bone Joint Surg Br 2008;90:847–51.
17. Zhou ZK, Li MG, Börlin N, Wood DJ, Nivbrant B. No increased migration in cups with ceramic-on-ceramic bearing: an RSA study. Clin Orthop Relat Res 2006;448:39–45.
18. Lewis PM, Al-Belooshi A, Olsen M, Schemitsch EH, Waddell JP.
Prospective randomised trial comparing alumina ceramic on ceramic with ceramic on conventional polyethylene bearings in total hip arthroplasty. J Arthroplasty 2010;25(3):392–7.
• Stripe wear is an occasional cause of severe wear in CC articulations
• With maximum mean follow-up of 8 years CC hips have a lower risk of revision in comparison to alternatives in currently available level I studies
• Using CM articulations may reduce the overall amount of wear and the incidence of stripe wear
• Any articulation, including a ceramic type, which pro- duces excessive particulate wear, is likely to cause osteolysis
• A modern well-fixed CC bearing, without impingement, reduces the risk of mid to long-term osteolysis compared to a comparable MP articulation
• Improvements in manufacturing and components have reduced the risk of fracture of ceramic components
• Risk of fracture may be increased in the young, heavier, active male
• Care must be taken on insertion of ceramic liners to avoid the risk of insertional chips; this remains an issue even with modern materials and components
• Squeaking is unique to hard-on-hard bearings
• The overall incidence squeaking may be under-reported
• Ideal component positioning may reduce the risk of squeaking
• The risk of a squeaking articulation may be increased in the younger, heavier, and taller patient
• Following ceramic fracture, revision total hip arthro- plasty has a poorer survival than following conventional hip replacements
• Following ceramic fracture, complete component revi- sion is required due to damage to trunnions and cups by the exceptionally hard fragments
• Total synovectomy is required during any ceramic revi- sion to reduce the amount of highly abrasive wear debris from the previous articulation
• Caution should be used before considering the use of any “soft” bearing such as polyethylene or stainless steel during a ceramic hip revision, with risk of deformation, accelerated wear and failure from retained abrasive third- body wear
Conclusions
The use of modern ceramic bearings has become signifi- cantly safer than when they were first introduced over 30 years ago. With improved manufacture and testing tech- niques, the risk of catastrophic failure through fracture has improved. A patient receiving a CC total hip arthroplasty can expect a low-wear articulation, outcome scores equiva- lent to a conventional hip replacement, and a low risk of long-term osteolysis. Fracture does, however, remain a risk, as does squeaking, which may be an under-reported issue.
Revision procedures following failed ceramic hip replace-
C H A P T E R 1 7 The Role of Ceramic in Total Hip Arthroplasty
36. Sedel L, Nizard R, Bizot P. Letters to the editor. Clin Orthop Relat Res 1998;349:273–4.
37. Murali R, Bonar SF, Kirsh G, Walter WK, Walter WL. Osteolysis in third-generation alumina ceramic-on-ceramic hip bearings with severe impingement and titanium metallosis. J Arthroplasty 2008;23(8):1240.
38. Sedel L. Total hip arthroplasty using a ceramic prosthesis. Clin Orthop Relat Res 2000;379:3–11.
39. Greene JW, Malkani AL, Kolisek FR, Jessup NM, Baker DL.
Ceramic-on-ceramic total hip arthroplasty. J Arthroplasty 2009;24(6 Suppl):15–18.
40. Hannouche D, Hamadouche M, Nizard R, Bizot P, Meunier A, Sedel L. Ceramics in total hip replacement. Clin Orthop Relat Res 2005;430:62–71.
41. Sedel L. Evolution of alumina-on-alumina implants: a review.
Clin Orthop Relat Res 2000;379:48–54.
42. Willmann G. Ceramic femoral head retrieval data. Clin Orthop 2000;379:22–8.
43. Higuchi F, Shiba N, Inoue A, Wakeve I. Case report. Fracture of an alumina ceramic head in total hip arthroplasty. J Arthroplasty 1995;10(6)851–4.
44. Torán MM, Cuenca J, Martinez AA, Herrera A, Thomas JV.
Fracture of a ceramic femoral head after ceramic-on-ceramic total hip arthroplasty. J Arthroplasty 2006;21(7):1072–3.
45. Jarrett CA, Ranawat AS et al. The squeaking hip phenomenon of ceramic on ceramic total hip arthropplasty. J Bone Joint Surg Am 2009;91:1344–9.
46. Buchanan JM. Ceramic on ceramic bearings in total hip arthro- plasty. Key Eng Mater 2003;240(2):793–6.
47. Ebied A, Journeaux SF, Pope JA. Hip resurfacing arthroplasty:
the Liverpool experience. Read at the International Conference:
Engineers and Surgeons—Joined at the Hip, June 13–15, 2002, London, UK.
48. Eickmann TH, Clarke IC, Gustafson GA. Squeaking in ceramic on ceramic total hip. In: Zippel H, Dietrich M, eds. Ceramics in Orthopaedics. Bioceramics in Joint Arthroplasty: 8th BIOLOX Symposium Proceedings, March 28–29, 2003, pp. 187–92.
Steinkopf Verlag, Darmstadt, 2003.
49. Morlock M, Nassutt R, Janssen R, Willmann G, Honl M.
Mismatched wear couple zirconium oxide and aluminum oxide in total hip arthroplasty. J Arthroplasty 2001;16:1071–4.
50. Keurentjes JC, Kuipers RM, Wever DJ, Schreurs BW. High inci- dence of squeaking in THAs with alumina ceramic-on-ceramic bearings. Clin Orthop Relat Res 2008; 466(6):1438–43.
51. Walter WL, O’Toole GC, Walter WK, Ellis A, Zicat BA. Squeaking in ceramic-on-ceramic hips: the importance of acetabular com- ponent orientation. J Arthroplasty 2007;22(4):496–503.
52. D’Antonio J, Capello W, Manley M, Bierbaum B. New experi- ence with alumina-on-alumina ceramic bearings for total hip arthroplasty. J Arthroplasty 2002;17(4):390–7.
53. Allain J, Goutallier D, Voisin Mc, Lemouel S, Failure of a stainless-steel femoral head of a revision total hip arthroplasty performed after a fracture of a ceramic femoral head. A case report. J Bone Joint Surg Am 1998;80:1355–60.
54. Allain J, Roudot-Thoraval F, Delecrin J, Anract P, Migaud H, Goutallier D. Revision total hip arthroplasty performed after fracture of a ceramic femoral head. A multicenter survivorship study. J Bone Joint Surg Am 2003;85:825–30.
19. D’Antonio J, Capello W, Manley M, Naughton M, Sutton K.
Alumina ceramic bearings for total hip arthroplasty: five-year results of a prospective randomized study. Clin Orthop Relat Res 2005;436:164–71.
20. D’Antonio JA, Capello WN, Manley MT, Naughton M, Sutton K. A titanium-encased alumina ceramic bearing for total hip arthroplasty: 3- to 5-year results. Clin Orthop Relat Res 2005;441:
151–8.
21. Capello WN, D’Antonio JA, Feinberg JR, Manley MT, Naughton M. Ceramic-on-ceramic total hip arthroplasty: update. J Arthroplasty 2008;23(7 Suppl):39–43.
22. Sonny Bal B, Aleto TJ, Garino JP, Toni A, Hendricks KJ. Ceramic- on-ceramic versus ceramic-on-polyethylene bearings in total hip arthroplasty: Results of a multicenter prospective randomized study and update of modern ceramic total hip trials in the United States. Hip Int 2005;15:129–35.
23. Aldrian S, Nau T, Gillesberger F, Petras N, Ehall R. Medium-term analysis of modern ceramic-on-ceramic bearing in THA. Hip Int 2009;19(1):36–40.
24. Restrepo C, Parvizi J, Kurtz SM, Sharkey PF, Hozack WJ, Rothman RH. The noisy ceramic hip: is component malposition- ing the cause? J Arthroplasty 2008;23(5):643–9.
25. Nizard R, Sedel L, Hannouche D, Hamadouche M, Bizot P.
Aspects of current management. Alumina pairing in total hip replacement. J Bone Joint Surg Br 2005;87:755–8.
26. Clarke I, Gustafson A. Clinical and hip simulator comparisons of ceramic on polyethylene and metal on polyethylene wear.
Clin Orthop Relat Res 2000;379:34–40.
27. Kraay MJ, Thomas RD, Rimnac CM, Fitzgerald SJ, Goldberg VM.
Zirconia versus Co-Cr femoral heads in total hip arthroplasty:
early assessment of wear. Clin Orthop Relat Res 2006;453:
86–90.
28. Kim YH. Comparison of polyethylene wear associated with cobalt-chromium and zirconia heads after total hip replacement.
A prospective, randomized study. J Bone Joint Surg Am 2005;87(8):1769–76.
29. Palm L, Olofsson J, Aström SE, Ivarsson I. No difference in migration or wear between cemented low-profile cups and standard cups : a randomized radiostereographic study of 53 patients over 3 years. Acta Orthop 2007;78(4):479–84.
30. Walter A. On the material and tribology of alumina-alumina couplings for hip joint prostheses. Clin Orthop 1992; 282:
31–4647.
31. Williams S, Schepers A, Isaac G, Hardaker C, Ingham E, van der Jagt D, et al. The 2007 Otto Aufranc Award. Ceramic-on-metal hip arthroplasties: a comparative in vitro and in vivo study. Clin Orthop Relat Res 2007;465:23–32.
32. Affatato S, Spinelli M, Squarzoni S, Traina F, Toni A. Mixing and matching in ceramic-on-metal hip arthroplasty: An in-vitro hip simulator study. J Biomech 2009;42(15):2439–46.
33. Yoon TR, Rowe SM, Jung ST, Seon KJ, Maloney WJ. Osteolysis in association with a total hip arthroplasty with ceramic bearing surfaces. J Bone Joint Surg Am 1998;80(10):1459–68.
34. Orthopaedic forum. Osteolysis and ceramic bearing surfaces. J Bone Joint Surg Am 2000;10:1518–21.
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Minimally Invasive Techniques in Total Hip Arthroplasty
Amre Hamdi and Paul E. Beaulé
University of Ottawa, Ottawa, ON, Canada
Case scenario
A 53 year old woman who is otherwise healthy presents with left-sided groin pain that was first noticed 2 years ago and has been getting progressively worse over the last 3 months. Currently, she cannot walk for more than 30 minutes but does not use any walking aids. She has tried various anti-inflammatories and physiotherapy with no improvement. On clinical examination, she walks with an antalgic gait. Range of motion shows flexion of 100° with no internal and external rotation respectively in 90° of hip flexion. She has 5° of fixed flexion contracture, and leg lengths are equal . Motor power is 5/5 in flexion, abduction and extension. Her radiographs show a severely arthritic hip joint.
Importance
Total hip arthroplasty (THA) is one the most successful surgeries in modern era because of the overall marked improvement of the patient’s function and quality of life.1 Once a surgical intervention has achieved a certain stand- ard of efficacy and reproducibility, further developments can be placed on minimizing the morbidity of the interven- tion. Less invasive surgical techniques as well as multimo- dal pain management have also evolved over the last decade in the field of joint replacements, especially THA, enabling patients to potentially recover faster as well as optimize their overall function by avoiding excessive muscle dissection.2 As with any new surgical technique, initial enthusiasm was based on high patient expectations3 as well as surgeon enthusiasm but, as is all too common in
surgery, over enthusiasm lead to some serious complica- tions.4 In this chapter we review the current techniques as well as clinical results and future of minimally invasive (MIS) hip replacement surgery.
One of the reasons total hip replacement (THR) surgery has been so successful is the standardization as well as reproducibility of the surgical approaches. As one would expect, different areas of the world will favor certain approaches because of history as well as available instru- mentation, with the classic approaches in the literature for primary THR being posterior, lateral, anterolateral, and anterior (Table 18.1). To discuss how each of them evolved as well and became part of daily practice is not the purpose of this chapter; however, certain basic principles are common to those approaches for performing a successful THR:
• proper visualization and access to bony interfaces
• low risk of neurovascular injury
• minimal to no significant compromise on patient function.
The two-incision technique is probably the approach that brought the new MIS THR surgical technique to the fore- front, with its optimization of pain management protocols as well as a rapid discharge program.2 This also led to decreasing the length of the skin incision (6–10 cm) com- pared to standard surgical approaches such as the posterior and lateral approaches.5
Anatomy and surgical approaches
With respect to surgical approaches, we now briefly discuss the different techniques based on patient positioning and identified in the literature as MIS.
Evidence-Based Orthopedics, First Edition. Edited by Mohit Bhandari.
© 2012 Blackwell Publishing Ltd. Published 2012 by Blackwell Publishing Ltd.
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C H A P T E R 1 8 Minimally Invasive Techniques in Total Hip Arthroplasty
ant to hold it.14 Recent multicenter data has shown this approach to be safe and reproducible.15
The two-incision approach for THA uses a small direct anterior approach for acetabular exposure and component placement, and a small posterior approach for femoral preparation and femoral implant insertion.2 This approach is less and less used because of a high initial complication rate16 as well as significant damage to the gluteus minimus muscle.17
Finding the evidence
Since the evidence in the literature is lacking, it is difficult to critically analyze and formulate well-founded answers to the key clinical questions. We therefore present all the available evidence within MIS THR first, followed by attempts to answer the clinical questions.
• Cochrane Database, with search term “minimally inva- sive total hip replacement,” “minimally invasive total hip arthroplasty”
• PubMed (www.ncbi.nlm.nih.gov/pubmed/) clinical queries search/systematic reviews, “minimally invasive total hip replacement,” “minimally invasive total hip arthroplasty”
° 8208 hits
• MEDLINE search identifying the population (“hip”
AND “minimally invasive total hip replacement”
° 10,230 hits
• PubMed (www.ncbi.nlm.nih.gov/pubmed/), sensitivity search using keywords “minimally invasive total hip replacement”
° 10,300 hits and, after review, 230 potentially relevant articles
Quality of the evidence
• Level I: 30
• Level II: 50
• Level III: 34 retrospective studies
• Level V: 19 case reports and expert opinion Lateral decubitus position
For both posterior and lateral approaches the patient is placed in the lateral decubitus position with the hip flexed 45–60° and adducted 10°. For the posterior approach an oblique incision is placed near the tip of the trochanter. The deep dissection splits the fascia over the gluteus maximus muscle and proceeds posterior to the gluteus medius and minimus muscle into the hip joint .The posterior approach generally requires transection of the piriformis tendon and at least a portion of the short external rotators down to the quadratus femoris muscle.6 Penenberg et al.7 recently reported on a technique which uses percutaneous portals for acetabular preparation and component insertion per- mitting only release of the piriformis tendon.
For the lateral approach, the skin incision is similar to that described for the posterior approach, with the incision placed obliquely over the greater trochanter, generally starting 1–2 cm above the tip of the trochanter and proceed- ing distally. For the anterolateral approach(Roetinger/
Watson-Jones)8,9 the superficial dissection is between the tensor and gluteus medius and deep dissection between gluteus minimus and rectus femoris. An alternative is the standard lateral approach is splitting the anterior portion of the gluteus medius tendon in a continuous sleeve with the vastus lateralis and gluteus minimus in one layer with the hip capsule.8–10 The main downside to these approaches is that they are not truly intervnervous and damage to the gluteus minimus is common either during the exposure or femoral preparation.
Supine position
The direct anterior approach or Hueter approach repre- sents the only truly internervous approach to the hip passing through the sheath of the tensor fascia lata muscle (superior gluteal nerve) with the sartorius muscle medially (femoral nerve).11 The deeper plane is between rectus femoris and gluteus minimus.12,13 In order to facilitate access to the femur the leg can be placed in a “figure 4”
position or by using an orthopedic positioning table per- mitting extension of the leg without the need for an assist-
Table 18.1 Advantages and disadvantages of different MIS surgical approaches
Posterior Anterior Lateral Two-incision
Advantages Excellent exposure Preserving the abductors
Excellent exposure to acetabulum Internervous plane
Very good exposure Less risk of dislocation
Smaller incision
Disadvantages Release of short external rotators Increase risk of dislocation
Difficult exposure to femur Neuropraxia of lateral femoral cutaneous nerve
Violating the abductors Chronic limp
Difficult exposure Damage to abductors