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Essay: Outcome of Ceramic-on-Ceramic (CoC) Total Hip Replacement (THR) in Young Adult Patients

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Introduction: Ceramic-on-ceramic (CoC) Total Hip Replacement(THR) was developed to minimize debris and osteolytic reaction. Yet the major concern is its brittleness. This study evaluated the outcome of THR in young adult patients with CoC articulation.
Methods : 11 patients, 13 THR procedures totally, were followed up 6 months after implantation of CoC THR in Cipto Mangunkusumo Hospital. Patients were evaluated clinically using Harris Hip Score (HHS), Visual Analog Scale (VAS), patients’ complaint, and Short Form ‘ 36 (SF-36). We also measured the acetabular (lateral inclination and anteversion) and femoral component (femoral anteversion) from radiograph. All of the data was analyzed using SPSS 20.
Results: The patients were 33.64??11.66 years average and 54.55% were female. Systemic lupus erythematosus is the main background. The average VAS, pre and post operative, was 5.00 and 1.00 respectively. The average pre and post operative HHS increased significantly from 25.23 to 92.02 (p=0.003, 95%CI). The SF-36 health and mental status increased significantly (p=0.003, 95%CI). Squeaking was found only in 9.09% (1 patient).The mean acetabular inclination and anteversion were 37.100 and 15,000 respectively. Mean femoral anteversion was 19,500. There was no correlation between acetabular and femoral component and squeaking incidence.
Conclusions: Outcome of ceramic on ceramic THR are encouraging for young adult patient. . Combined with proper indications, CoC THR ensures good clinical outcomes .
Keywords: total hip replacement, ceramic-on-ceramic, outcome , young adult patient
Total hip replacement (THR) is among the successful orthopaedic surgical procedures and has regained popularity during the last decade. The rapidly developing operating techniques and excellent quality of the implants minimizes the complexity of procedure and provides rapid recovery of patients. 1 All of these has provided this procedure as a treatment of choice, even in young adult patients. In the United States, THR is carried out closer to a million in a year(population 308 million).In Australia, over 30 000 metal-on-metal hip replacements were carried out between 1999 and 2010 (population 21.5 million).Similarly, about 60 000 such operations have been carried out in England and Wales since 2003 (population 54.4 million).2
Metal-on-polyethylene (MoP) is the most commonly implanted articulation nowadays, while metal-on-metal (MoM) and ceramic-on-ceramic (CoC) are less frequently used. MoP couplings is proven to be associated with debris particles that can induce preprosthetic inflammation and osteolysis, all of these reaction lead to implant failure. Then, MoM couplings has also proven to elevate serum level of metal ion in the body . This may lead to renal toxicity or chromosomal aberrations.There has been no reported increase in the risk of cancer after THR with conventional MoP or first generation MoM implants.1,2,3
Nowadays, CoC articulations increasingly applied in THR with satisfatory long term outcome. Its special features include the high resistant to scratch, high wettability, inert, and smooth surface. All of them minimize the risk of wear and periprosthetic osteolysis. We could predict more and more application of CoC articulation in THR.3,4
Yet, the major concern is its brittleness. Ceramic material could just minimally withstand the plastic deformation. The loads will induce the micro fracture leading to potentially implant failure.5,6,7,8 In addition, there is a consideration of transient squeaking sound. This problem was elusive and likely to be multifactorial in nature. Hannouche et al found that there was no association between squeaking and the implant component.3Synder et al stated that 12 year survival for the whole prosthesis with COC articulation is 86,36%. Yeung et al observed that the overallsurvival rate of the implants was 98% at ten years with average Harris Hip Score 94 points.3,5,9,10
The purpose of this study is to evaluate the outcome, incidence of squeaking complication, and its relation to implant component in young adults undergone THR with COC couplings
This descriptive-analytic study included young adultspatients who had undergone THR with COC couplings at our Orthopaedic and Traumatology Department in Cipto Mangunkusumo Hospital. We investigated 13 THR with COC performed in 11 patients with minimum 6 months of follow up. This study was composed of 5 men and 6 women with variants of the underlying disease. All of these THR operations was carried out by single orthopaedic surgeon. The implant was supplied by 3 health instrument provider; Johnson and Johnson, Zimmer, and United.
We evaluated the clinical signs and symptoms by patient and examiner assessment at preoperative and 6 months follow up. Examiner assessment was carried out using Harris Hip Score. Harris Hip score was determined preoperatively and at 6 months follow up. Harris Hip Scale score of 90 points or more was categorized as an excellent outcome; 80-89 points, a good outcome; 70-79 points, a fair outcome; less than 70 points, a poor outcome.
Patient assessment was carried out using Short Form ‘ 36 (SF-36). We interviewed the patients using SF-36 preoperatively and at 6 months follow up. Average score >50 was defined as the the lowest point of being average in each of physical health category and mental category.
Other way to evaluate patients was by using Visual Analog Scale. We determined the pain level by asking and showing the pain step ladder picture, and asked the patients to point out which was the best suited for them. We evaluated this preoperatively and at 6 months follow up. At last, we evaluated the complaints at the 6 months follow up.
We also evaluated the acetabular component by measuring the lateral inclination angle and anteversion angle from the post operation radiograph. In addition, we got the femoral anteversion angle from the post operation hip axial radiograph. All of these data were collected and analyzed using SPSS version 20.
At the follow up of 6 months, 13 hips in 11 patients were available for clinical examination and were the subject of this descriptive study. Hereby, we described the characteristics of our patients
Age (years)
Mean 33.64
Std. Deviation 11.664
Table 1. Age. Number of patients undergone THR COC at Cipto Mangunkusumo Hospital according to age at operation.
Fig 1. Age proportion. Most of the patients were at the range of 20-30 years old.
According to table 1 and figure 1, the average age of patients undergone THR COC at Cipto Mangunkusumo Hospital is 33.64??11.66 years old with the range of age 17-59 years old.
Table 2. Gender. Number of patients undergone THR COC at Cipto Mangunkusumo Hospital according to gender.
Frequency Percent
Female 6 54.5
Male 5 45.5
Total 11 100.0
Fig 2. Gender proportion. THR COC was applied at more female patients.
According to table 2 and figure 2, 54.5% patients undergone THR COC at Cipto Mangunkusumo Hospital are female.
Table 3. Underlying disease. Number of patients undergone THR COC according to the underlying disease
Disease Frequency Percent
Ankylosing spondilitis (AS) 1 9,09
Systemic Lupus Erithematosus (SLE) 5 45,45
Osteoarthritis (OA) 3 27,27
Tuberculosis (TBC) 2 18,18
Total 11 100.0
Figure 3. Underlying disease. Most of patients undergone THR COC had Systemic Lupus Erythematosus
According to table 3 and figure 3, 45.45% of patients undergone THR COC at Cipto Mangunkusumo Hospital had Systemic Lupus Erythematosus(SLE), 27.27% of patients had osteoarthritis(OA) of hip, and 18.18% of patients had Tuberculosis (TBC) of hip, and 9.1% of patients had ankylosing spondilitis(AS) of hip.
Table 4. Harris Hip Scale. The Harris Hip Scale in patients undergone THR COC at before and after 6 months surgery.
Harris Hip Scale Pre surgery 6 months follow up
Mean 25.23 85.71
Median 25.25 92.02
Standard deviation 18.82 15.34
Minimum 1.55 42.67
Maximum 48.75 97.03
Shapiro-Wilk significance 0.069 0.000
Wilcoxon Signed Rank Test significance 0.003
Before surgery, the Harris Hip Scale was 25.23 (range 1.55-48.75), while at the 6 months follow up it was 92.02 (range 42.67-97.03). With Wilcoxon Signed Rank Test, significance was 0.003 (p<0.05, 95%CI).
Table 5. Harris Hip Scale Category.
Category Frequency Percent
Poor 1 9.1
Fair 1 9.1
Good 3 27.3
Excellent 6 54.5
The Harris Hip Scale before surgery was 100% poor, while after surgery, 9.1% was poor; 9.1% was fair; 27.3% was good; and 54.5% was excellent.
Table 6. SF-36 Physical Status. The SF-36 physical status in patients undergone THR COC before and after 6 months surgery.
SF-36 Physical Status Pre surgery 6 months follow up
Mean 22.90 53.81
Median 21.00 54.00
Standard deviation 7.44 3.18
Minimum 16.00 50.00
Maximum 43.00 59.00
Shapiro-Wilk significance 0.003 0.122
Wilcoxon Signed Rank Test significance 0.003
Before surgery, the SF-36 physical status was 21.00 (range 16.00-43.00), while at the 6 months follow up it was 53.81 (range 50.00-59.00). With Wilcoxon Signed Rank Test, significance was 0.003 (p<0.05, 95% CI)
Table 7. SF-36 Mental status. The SF-36 mental status in patients undergone THR COC before and after 6 months surgery.
SF-36 Mental Status Pre surgery 6 months follow up
Mean 38.72 56.63
Median 38.00 56.00
Standard deviation 5.25 2.01
Minimum 28.00 54.00
Maximum 47.00 60.00
Shapiro-Wilk significance 0.309 0.393
Paired t-test significance 0.000
Before surgery, the SF-36 mental status was 38.72 ?? 5.25,while at the 6 months follow up it was 56.63 ?? 2.01. With paired t-test, significance was 0.000 (p<0.05, 95%CI).
Table 8. Visual Analog Scale. The Visual Analog Scale in patients undergone THR COC before and after 6 months surgery.
Visual Analog Scale Pre surgery 6 months follow up
Mean 5.00 1.00
Median 5.00 1.00
Standard deviation 0.63 0.89
Minimum 4.00 0.00
Maximum 6.00 2.00
Shapiro-Wilk significance 0.008 0.008
Wilcoxon Signed Rank Test Significance 0.003
Before surgery, the Visual Analog Scale (VAS) was 5.00 (range 4.00-6.00), while at the 6 months follow up it was 1.00 (range 0.00-2.00). With Wilcoxon signed rank test, significance was 0.003 ((p<0.05, 95%CI).
Figure 4. Complaint. Only one patient complained about squeaking sound.
Table 9. Acetabular component. The lateral inclination of acetabular cup in patients undergone THR CoC
Acetabular component Lateral inclination Anteversion
Mean 37,10 19,50
Median 39,00 15,00
Standard deviation 6,74 11,16
Minimum 30,00 10,00
Maximum 48,00 40,00
Shapiro-Wilk significance 0,06 0,01
Spearman’s correlation with squeaking incidence 0,341 0,442
In patients undergone THR CoC at Cipto Mangunkusumo Hospital, the lateral inclination of acetabular cup was 37,100 ?? 6,740 while the anteversion of the acetabular cup was 15,000 (10,000-40,000). With Spearman correlation test, there was no correlation between lateral inclination, anteversion of acetabulum and incidence of squeaking.
Table 10. Femoral component. The femoral anteversion in patients undergone THR CoC
Femoral component Femoral anteversion
Mean 19,50
Median 19,50
Standard deviation 5,62
Minimum 10,00
Maximum 27,00
Shapiro-Wilk significance 0,74
Spearman’s correlation with squeaking incidence 0,116
In patients undergone THR CoC at Cipto Mangunkusumo Hospital, the femoral anteversion was 19,500 (10,000-27,000). With Spearman correlation test, there was no correlation between the femoral anteversion and squeaking incidence.
In our study, we found that THR COC was carried out in patients with the average age of 33.64 years old. These young adults cases was due to the underlying diseases in our cases, avascular necrosis (AVN) with Systhemic Lupus Erithematosus (SLE) and Tuberculosis which attacked young adult patients. It was similar to Synder et al and Kazutaka et al study that the mean age at operation was 44.5 and 50 years old respectively. Synder et al stated that 70% THR surgery was carried out in under 50 years old patients. It was related to the high survival rates free of revision of 90.8 ‘ 97.4% at ten years.1,6
THR COC was applied in more female than male patients. It was similar with Synder et al study (101 female and 87 male) and Kazutaka et al study (78 female and 14 male). 1,6 Our patients mostly had avascular necrosis(AVN) of hip with SLE as the underlying cause while Kazutaka et al study found that most of the patients had secondary osteoarthritis due to developmental dysplasia of the hip. OA of the hip was found as the second most underlying disease at his study. Synder et al also found that the most underlying disease was dysplastic hip in childhood.1 It was due to the small number of patients in our study and low screening rate for congenital dislocation of the hip as well as high usage of long term steroid drugs for SLE treatment that we got different results from them. In addition, the dislocation rate is found significantly more frequent in AVN than in OA patients according to Ortiguera et al because AVN patients unfortunately due to the less stiffness could gain larger range of motion that made them prone to dislocation. 11 Berry et al studied that AVN cases had a more than 2 fold greater cumulative risk for dislocation than osteoarthritis cases. 12Millar et al. stated that eventhough non cemented CoC THR was applied, osteoarthritis patients had better clinical outcome than osteonecrosis patients..13
The Visual Analog Scale decreased significantly while The Harris Hip Scale was found significantly increased. It was equal with Yeung et al study that the average Harris Hip Scale was 94 points in 301 THR alumina-on-alumina ceramic bearings. We also found that 81.8% patients had an excellent or good result which was similar to Yeung et al that 95% of the patients having an excellent of good result. Synder et al found that 83.1% patients had excellent and good results by having THR COC.1Solarino et al found that Harris Hip Scale was 90.7 ?? 5,8 points and 96.7% had excellent and good results.7The SF-36, both physical and mental status was found significantly increased at 6 months follow up. Harris Hip Scale was assessed objectively by the pyhsician by interviewing and providing some motion to the patients’ hip while SF-36 was assessed subjectively by the patients by answering the questions. These both tools provided both clinical assessment from the physician and patient side. These significance increasing was thought due to the low friction, high wear resistance and low rate of osteolysis.
Studies in recent years have demonstrated that osteolytic processes around the endoprosthesis are associated with systemic reaction to the substances, released in the course of endoprosthesis wear. These microcomponents, released during friction of artificial joint surfaces, induce biological systemic reactions, leading to a release of proinflammatory cytokines from cells, surrounding the endoprosthetic elements. These cells additionally stimulate the secretion of metalloproteinases and influence osteoclasts, exerting a significant effect on the osteolytic processes. The activation of osteoclasts by cytokines, such as interleukin 6 (IL-6), or the stimulation of their differentiation by tumour necrosis factor alpha (TNF-??) enhances osteolysis around the implant. It seems that these reactions depend on the size and number of particles released from endoprosthetic surface friction.1,2,3 Affatato et alstated that the polyethylene abrasion rate is 0.01’0.3 mm/year, while it is merely 0.13’78 ??m for ceramic joints.14 Fewer particles from implant surface abrasion means smaller phagocytic reactions around the implant and a reduced incidence of endoprosthetic stem migrations, thus extending the endoprosthesis life span.
Squeaking as patient’s complaint was found in 9.09% patients. McDonnell et al found that 13% patient had reproducible squeaking after THR patients undergone THR COC had reproducible squeaking as their complaint.5 Squeaking was thought multifactorial and no definite conclusion can be drawn from the reported serieshad multifactorial reason without any conclusion. Taylor et al. demonstrated that squeaking was encountered in association with stripe wear and occurred during subluxation of the head across the insert edge once the stripe wear began to form.9 Walter et alsuggested that squeaking may result from resonance of one or other or both of the metal components especially when there is a mismatch between the shell and the liner during edge loading, which may cause the liner to tilt out of the shell.15We found that the incidence of squeaking was not associated with the acetabular cup anterversion and lateral inclination also the femoral anteversion. This was equal with Restrepo et al and Hannouche et al that the implant position was equal between the squeaking and the non-squeaking.16Despite the surprisingly high incidence of squeaking, all patients remain satisfied with their hip replacement.
6 months follow up of total hip replacement using ceramic on ceramic couplings are fairly encouraging. The Harris Hip Scale and SF-36 increased significantly while VAS markedly decreased. Squeaking was found in 1 patient and was not associated with acetabular lateral inclination and anterversion as well as femoral anteversion. Combined with proper indications, THR COC ensures good clinical outcomes . Long term follow up should be carried out to evaluate application of this implant.
1. Synder M, Drobniewski M, Sibinski M. Long-term results of cementless hip arthroplasty with ceramic-on-ceramic articulation. Int Orthop. 2012 Nov;36(11):2225-9.
2. Sugano N, Takao M, Sakai T, Nishii T, Miki H, Ohzono K. Eleven to 14 year follow up results of cementless total hip arthroplasty using a third generation alumina ceramic on ceramic bearing. J Arthroplasty. 2012 May;27(5):736-41.
3. Hannouche D, Zaoui A, Nizard R. Thirty years of experience with alumina-on-alumina bearings in total hip arthroplasty. Int Orthop. 2011 Feb;35(2):207-13.
4. Yeung E, Bott PT, Chana R, Jackson MP, Holloway I, Walter WL et al. Mid-term results of third-generation alumina-on-alumina ceramic bearings in cementless total hip arthroplasty: a ten-year minimum follow up. J Bone Joint Surg Am. 2012 Jan;94(2): 138-44.
5. McDonnell SM, Boyce G, Bare J, Young D, Shimmin AJ. The incidence of noise generation arising from the large diameter Delta Motion ceramic total hip bearing. Bone Jont J. 2013 Feb;95-B(2): 160-5.
6. Kazutaka S, Kumiko T, Haruhiko A. Good short-term outcome of primary total hip arthroplasty with cementless bioactive glass ceramic bottom-coated implants. Acta Orthop. 2012 Dec;83(6):399-603.
7. Solarino G, Piazzolla A, Moretti B. Long-term results of 32-mm alumina-on-alumina THA for avascular necrosis of the femoral head. J Orthop Traumatol. 2012 Mar;13(1):21-7.
8. D’Antonio JA, Capello WN, Naughton M. Ceramic bearings for total hip arthroplasty have high survivorship at 10 years. Clin Orthop Relat Res. 2012 Feb;470(2):373-81.
9. Taylor S, Manley MT, Sutton K. The role of stripe wear in causing acoustic emissions from alumina ceramic-on-ceramic bearings. J Arthroplasty. 2007;22:47’51.
10. Chevillotte C, Pibarot V, Carret JP, Bejui-Hugues J, Guyen O. Hip squeaking: a 10 year follow up study. J Arthroplasty. 2012 Jun;27(6):1008-13.
11. Ortiguera CJ, Pulliam IT, Cabanela ME. Total hip arthroplasty for osteonecrosis: matched pair analysis of 188 hips with long-term follow-up. J Arthroplast. 1999;14:21’28. doi: 10.1016/S0883-5403(99)90197-3.
12. Berry DJ, Harmsen WS, Cabanela ME, Morrey BF. Twenty-five-year survivorship of two thousand consecutive primary Charnley total hip replacements: factors affecting survivorship of acetabular and femoral components. J Bone Joint Surg.2002;84A:171’177.
13. Millar NL, Halai M, McKenna R, McGraw IW, Millar LL, Hadidi M. Uncemented ceramic-on-ceramic THA in adults with osteonecrosis of the femoral head. Orthopaedics.2010;33(11):795.
14. Affatato S, Traina F, Toni A. Microseparation and stripe wear in alumina-on-alumina hip implants. Int J Artif Organs.2011;34:506’512.
15. Walter WL, Insley GM, Walter WK, Tuke MA. Edge loading in third generation alumina ceramic-on-ceramic bearings: stripe wear. J Arthroplasty. 2004;19:402’413.
16. Resrepo C, Matar WY, Parvizi J, Rothman RH, Hozack WJ. Natural History of Squeaking After Total Hip Arthroplasty. Clin Orthop Relat Res. 2010;468:2340-2345.

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