The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 84, Issue 1

Scientific Article | January 01, 2002

Alumina-on-Alumina Total Hip Arthroplasty : A Minimum 18.5-Year Follow-up Study

Moussa Hamadouche, MD, PhD; Pierre Boutin, MD; Jacques Daussange, MD; Mark E. Bolander, MD; Laurent Sedel, MD

Investigation performed at the Orthopaedic Research Laboratory, Université D. Diderot Paris, Paris, France

Moussa Hamadouche, MD, PhD
Laboratoire de Recherches Orthopédiques, Faculté de Médicine Lariboisière St. Louis, Université D. Diderot Paris VII, UPRES A CNRS 7052, 10, avenue de Verdun, 75010 Paris, France. E-mail address for M. Hamadouche: moussah@club-internet.fr

Laurent Sedel, MD
Service de Chirurgie Orthopédique, Hôpital Lariboisière, 2, rue Ambroise Paré, F-75475 Paris CEDEX 10, France

Pierre Boutin, MD
Deceased

Jacques Daussange, MD
Clinique Marzet, 40 boulevard Alsace Lorraine, 64000 Pau, France

Mark E. Bolander, MD
Orthopaedic Research Laboratory, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905

In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from Ceraver Osteal, Roissy, France. In addition, one or more of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity (Ceraver Osteal, Roissy, France). Also, a commercial entity (Ceraver Osteal, Roissy, France) paid or directed, or agreed to pay or direct, benefits to a research fund, foundation, educational institution, or other charitable or nonprofit organization with which one or more of the authors are affiliated or associated.

A commentary is available with the electronic versions of this article, on our web site (www.jbjs.org) and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).

J Bone Joint Surg Am, 2002 Jan 01;84(1):69-77

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Abstract

Background: The purpose of this retrospective study was to report the results, after a minimum of 18.5 years of follow-up, in a consecutive series of total hip arthroplasties performed with an alumina-on-alumina combination.

Methods: One hundred and eighteen consecutive total hip arthroplasties were performed in 106 patients between 1979 and 1980. The prostheses combined a 32-mm alumina head and an all-alumina socket. Both components were cemented in eighty-five hips, both components were implanted without cement in twenty-nine, and only the stem was cemented in four. The mean age of the patients at the time of the index arthroplasty was 62.2 years (range, thirty-two to eighty-nine years).

Results: At the 18.5 to 20.5-year follow-up evaluation, forty-five patients (fifty-one hips) were alive and had not had a revision, twenty-five patients (twenty-five hips) had undergone revision of one or both components, twenty-seven patients (thirty hips) had died, and nine patients (twelve hips) had been lost to follow-up. The mean Merle d’Aubigné hip score (and standard deviation) was 16.2 ± 1.8 points at the latest follow-up evaluation. The rate of survival at twenty years, with revision for any reason as the end-point, was 85.6% for the cementless cups compared with 61.2% for the cemented cups and 84.9% for the cementless stems compared with 87.3% for the cemented stems. Wear of the prosthetic components was undetectable on plain radiographs. Periprosthetic cystic or scalloped lesions requiring the use of allograft bone during revision were present in three of the twenty-five revised hips. In addition, seven hips had moderate acetabular osteolysis treated with a 4-mm-larger cup. No fracture of the alumina socket or head was recorded. The mean acetabular wear rate in this series was <0.025 mm/yr.

Conclusion: With the alumina-on-alumina total hip arthroplasty, minimal wear rates and limited osteolysis can be expected up to twenty years after the operation, provided that sound acetabular component fixation is obtained.

Figures in this Article

Introduction

Introduction | Materials and Methods | Results | Discussion | References

Metal-on-polyethylene bearings remain the most widely used combination for total joint replacements. However, a number of studies have demonstrated that osteolysis induced by polyethylene wear debris remains the main long-term complication of total hip arthroplasty^1-5. Therefore, there have been efforts to develop alternate bearing surfaces to eliminate or reduce complications related to polyethylene wear debris. An alumina-on-alumina combination was introduced as an attractive alternative in the early 1970s. The short to mid-term results of procedures performed with this friction couple were encouraging, with rates of survival free of revision of 94.6% and 88.6% at six and ten years, respectively^6-9.

In the current study, a consecutive series of patients in whom an alumina-on-alumina total hip arthroplasty had been performed were followed for a minimum of 18.5 years. The purpose of this retrospective study was to evaluate the rates of clinical and radiographic survival of these prostheses, with special emphasis on wear and osteolysis. Factors likely to influence the final functional and radiographic outcomes as well as survival of the artificial hip were analyzed.

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Fig. 1-A:: Figs. 1-A and 1-B The Ceraver Osteal alumina-on-alumina total hip replacement. Fig. 1-A Prosthesis designed for cemented fixation of both components.

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Fig. 1-B:: Figs. 1-A and 1-B The Ceraver Osteal alumina-on-alumina total hip replacement. Fig. 1-B Prosthesis designed for cementless fixation of both components. The acetabular component has three pegs and concentric grooves.

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Fig. 2-A:: Figs. 2-A and 2-B Loosening of a cemented alumina-on-alumina total hip replacement. Fig. 2-A Postoperative anteroposterior radiograph.

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Fig. 2-B:: Figs. 2-A and 2-B Loosening of a cemented alumina-on-alumina total hip replacement. Fig. 2-B Acute debonding at the alumina cup-cement interface resulted in a tilt of the socket nine years after the index arthroplasty.

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Fig. 3-A:: Actuarial survival curves, with failure defined as revision for any reason at the time of follow-up, for the acetabular (Fig. 3-A) and femoral (Fig. 3-B) components.

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Fig. 3-B:: Actuarial survival curves, with failure defined as revision for any reason at the time of follow-up, for the acetabular (Fig. 3-A) and femoral (Fig. 3-B) components.

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Fig. 4:: Actuarial survival curve, with failure defined as radiographic loosening at the time of follow-up, for the acetabular components.

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TABLE I: Initial Diagnosis

Underlying Disease	No. of Hips
Primary osteoarthritis	?75 (64%)
Congenital hip dysplasia	?24 (20%)
Femoral neck fracture	??9 (8%)
Avascular necrosis	??8 (7%)
Posttraumatic osteoarthritis	??1 (0.8%)
Slipped capital femoral epiphysis	??1 (0.8%)
Total	118 (100%)

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TABLE I: Initial Diagnosis

Underlying Disease	No. of Hips
Primary osteoarthritis	?75 (64%)
Congenital hip dysplasia	?24 (20%)
Femoral neck fracture	??9 (8%)
Avascular necrosis	??8 (7%)
Posttraumatic osteoarthritis	??1 (0.8%)
Slipped capital femoral epiphysis	??1 (0.8%)
Total	118 (100%)

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TABLE II: Demographic Data According to the Final Status of the Patient and Replacement

*The n values refer to the number of hips. †The numbers are given as the mean and the standard deviation, with the range in parentheses.

	Alive, Unrevised (N = 51*)	Deceased (N = 30*)	Lost to Follow-up (N = 12*)	Revised (N = 25*)
Duration of follow-up† (yr)	19.7 1.2 (18.5 to 20.5)	?5.8 3.8 ?(0 to 13)	2.8 2.9 (0 to 9)	10.3 4.7 (2.3 to 19.5)
Age at index op.† (yr)	?58.5 10.1 ?(37 to 78)	71.3 9.4 (49 to 89)	67.7 12.9 (42 to 81)	?56.1 10.1 (32 to 75)
Women/men	31/14	14/13	6/3	19/6

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TABLE II: Demographic Data According to the Final Status of the Patient and Replacement

*The n values refer to the number of hips. †The numbers are given as the mean and the standard deviation, with the range in parentheses.

	Alive, Unrevised (N = 51*)	Deceased (N = 30*)	Lost to Follow-up (N = 12*)	Revised (N = 25*)
Duration of follow-up† (yr)	19.7 1.2 (18.5 to 20.5)	?5.8 3.8 ?(0 to 13)	2.8 2.9 (0 to 9)	10.3 4.7 (2.3 to 19.5)
Age at index op.† (yr)	?58.5 10.1 ?(37 to 78)	71.3 9.4 (49 to 89)	67.7 12.9 (42 to 81)	?56.1 10.1 (32 to 75)
Women/men	31/14	14/13	6/3	19/6

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TABLE III: Survival of the Replacement at Twenty Years with Revision as the End Point

*The n values refer to the number of hips. †The size of the cup could not be determined for twenty-one of the 118 hips.

	Cumulative Survival Rate (%)	P Value
Age at index op.*
50 yr (n = 93)	71.1 (59.2 to 83.0)	0.5334
<50 yr (n = 25)	61.1 (39.2 to 83.0)
Gender*
Female (n = 79)	67.5 (55.3 to 79.7)	0.3806
Male (n = 39)	69.3 (47.7 to 91.0)
Abduction angle of cup*
<45Â° (n = 60)	79.3 (66.2 to 92.4)	0.0220
45Â° (n = 58)	58.6 (42.0 to 75.2)
Size of cup*†
<48 mm (n = 13)	33.0 (0 to 81.5)	0.0051
48 mm (n = 84)	70.0 (57.2 to 82.8)

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TABLE III: Survival of the Replacement at Twenty Years with Revision as the End Point

*The n values refer to the number of hips. †The size of the cup could not be determined for twenty-one of the 118 hips.

	Cumulative Survival Rate (%)	P Value
Age at index op.*
50 yr (n = 93)	71.1 (59.2 to 83.0)	0.5334
<50 yr (n = 25)	61.1 (39.2 to 83.0)
Gender*
Female (n = 79)	67.5 (55.3 to 79.7)	0.3806
Male (n = 39)	69.3 (47.7 to 91.0)
Abduction angle of cup*
<45Â° (n = 60)	79.3 (66.2 to 92.4)	0.0220
45Â° (n = 58)	58.6 (42.0 to 75.2)
Size of cup*†
<48 mm (n = 13)	33.0 (0 to 81.5)	0.0051
48 mm (n = 84)	70.0 (57.2 to 82.8)

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

Patients

Between December 1979 and December 1980, the senior author (P.B.) performed 118 total hip replacements in 106 patients (seventy women [seventy-nine hips] and thirty-six men [thirty-nine hips]). The average age (and standard deviation) of the patients at the time of the index arthroplasty was 62.2 ± 11.9 years (range, thirty-two to eighty-nine years). The mean body mass index was 25.9 ± 4.0 (range, 17.5 to 39.1). The right hip was operated on in fifty-four patients, the left hip was operated on in forty, and a bilateral replacement was performed in twelve. The initial diagnoses are summarized in Table I. Nine of the 118 hips had been operated on before the index arthroplasty: a femoral hemiarthroplasty had been performed for the treatment of a femoral neck fracture in three hips, a shelf procedure with use of an autogenous bone graft from the iliac crest had been done for the treatment of acetabular dysplasia in three hips, a previous total hip replacement had been done for the treatment of primary osteoarthritis in two hips, and an intra-articular arthrodesis had been performed for the treatment of a slipped capital femoral epiphysis in one hip. The index total replacement was performed through a lateral approach with a trochanteric osteotomy in seventeen hips, through a lateral approach without a trochanteric osteotomy in sixty-two, and through a posterolateral approach in thirty-nine.

Prosthesis

An alumina-on-alumina combination (Ceraver Osteal, Roissy, France) was used in all patients. The collared femoral component was made of titanium alloy (Ti-Al6-V4) and was available in both a cemented and a cementless configuration (Figs. 1-A and 1-B). The acetabular component and the 32-mm femoral head were made of dense polycrystalline surgical-grade alumina (Al2O3). The all-alumina socket could be either cemented or inserted without cement; the cementless design had concentric grooves and three pegs to increase rotational stability (Figs. 1-A and 1-B). Special reamers were available for the implantation of components without cement. Cementing of the femoral components was performed with a first-generation technique with use of Simplex bone cement (Howmedica, Rutherford, New Jersey). The femoral head was secured to the femoral stem with a Morse taper. In all patients, the femoral head and cup were a matched pair to reduce the clearance between the two components to about 50 m.

Thirty-three of the 118 acetabular components were cementless, and eighty-five were cemented. Twenty-nine of the 118 femoral stems were cementless, and eighty-nine were cemented. The arthroplasties were performed with cementing of both components in eighty-five hips, were hybrid (only the stem cemented) in four, and were cementless in twenty-nine.

Postoperative Rehabilitation

Passive motion exercises of the involved joint were performed immediately postoperatively. Patients were free to walk using two crutches after three days. Full weight-bearing was allowed six weeks after the cementless and hybrid arthroplasties, whereas it was allowed immediately after the replacements with cementing of both components.

Clinical and Radiographic Follow-up Evaluation

All patients had been evaluated preoperatively, and most of them had been followed at regular intervals. Attempts were made to interview, or contact the families of, all 106 patients in the initial series. The surviving patients were asked to return for clinical and radiographic evaluation. Those who were unable to return were asked to have radiographs made locally and then sent to us. All of the living patients were evaluated clinically or interviewed by telephone by the same independent observer (M.H.). Members of the families of the patients who had died were interviewed to determine the function of the hip at the time of death. Hip functional results were rated according to the Merle d’Aubigné¹⁰ grading system. The hip score was then classified as excellent (18 points), very good (17 points), good (16 points), fair (15 points), poor (14 points), or bad (£13 points).

Serial anteroposterior radiographs of the pelvis were analyzed by the same independent observer (M.H.). The position of the socket relative to the horizontal and vertical teardrop lines, the inclination angle of the cup, and the presence and progression of radiolucent lines according to the zones described by DeLee and Charnley¹¹ were evaluated on the pelvic side. Loosening of the socket was defined as cup migration exceeding 3 mm, angular rotation exceeding 3Â°, or a continuous radiolucent line wider than 2 mm (reflecting the observer’s confidence in his ability to detect radiolucent lines on plain radiographs). Linear wear of the acetabular component was determined by measuring the change in the shortest distance between the center of the femoral head and the periphery of the acetabular component as seen on the immediate postoperative radiograph compared with that seen on the radiograph made at the latest follow-up evaluation, as described by Livermore et al.¹². Measurements were made with calipers that had an accuracy of 0.5 mm. Correction for magnification was performed on the basis of the radius of the femoral head. Parameters investigated on the femoral side included progression of radiolucent lines according to the seven zones described by Gruen et al.¹³, calcar resorption, and subsidence of the stem. Loosening of the stem was defined as a migration exceeding 3 mm or a continuous radiolucent line wider than 2 mm.

Periprosthetic cystic or scalloped lesions exceeding 2 mm in diameter that had not been present on the immediate postoperative radiograph were defined as osteolysis^14,15.

A survivorship analysis according to the actuarial method was performed with revision for any reason as one end point and with radiographic loosening of either component at the time of follow-up as the other end point. The survival curve was derived from the cumulative survival rate over time, as calculated from the actuarial life table¹⁶. The standard error, given as a percentage, and the 95% confidence intervals were calculated from the data in the life table. The log-rank test was used for the statistical comparison of the survivorship-analysis groups¹⁷.

Statistical analysis was performed with use of nonparametric tests. Significance was defined as a p value of <0.05 (StatView 5.0 Statistical Software; SAS Institute, Cary, North Carolina).

Results

Introduction | Materials and Methods | Results | Discussion | References

At the time of follow-up, forty-five patients (fifty-one hips) were alive and had not had either acetabular or femoral revision. Twenty-five patients (twenty-five hips) had undergone revision of either component or both components. Twenty-seven patients (thirty hips) had died from unrelated causes, and nine patients (twelve hips) had been lost to follow-up; these forty-two hips were functioning well at the time of the last follow-up. Thus, the status of 106 (90%) of the original 118 hips was known at the last follow-up examination. The duration of follow-up and the demographic data according to the patients’ final status are summarized in Table II. Of the forty-five patients (fifty-one hips) who were still alive and had not had a revision, forty (forty-six hips) were evaluated both clinically and with use of an anteroposterior radiograph of the pelvis made at a minimum of 18.5 years after the index arthroplasty. The remaining five patients (five hips) were unable to return for a clinical evaluation for reasons not related to the result of the arthroplasty, and they were evaluated on the basis of a telephone interview only.

Complications

Complications included a common peroneal nerve palsy in two patients. One patient had a deep vein thrombosis without pulmonary embolism, and one patient had a nonfatal pulmonary embolism. There was one deep hematoma, which was treated with débridement with no additional complications. One patient died within the first postoperative day from myocardial infarction. An intraoperative femoral fracture occurred in one patient during the implantation of a stem without cement. The fracture was fixed with screws, and it healed within three months. A fracture of a peg of the cementless socket occurred in two hips during implantation, with no subsequent component migration over a twenty-year follow-up period. No patient had an infection, a dislocation, or a fracture of the femoral head or acetabular component.

Revisions

Twenty-five patients (twenty-five hips in nineteen women and six men) had a revision of either component or both components. The mean duration (and standard deviation) until the revision was 10.3 ± 4.7 years (range, 2.3 to 19.5 years). Of the twenty-five revision procedures, eight were performed on both the acetabular and the femoral side; fifteen, on the acetabular side only; and two, on the femoral side only. Nineteen of the eighty-five cemented sockets and four of the thirty-three cementless sockets were revised, at a mean of 9.9 ± 4.4 years (range, 2.3 to 18.9 years) and 11.7 ± 7.9 years (range, 3.6 to 19.5 years), respectively. The difference was not significant (Mann-Whitney U test, p = 0.72).

All of the revisions of the cemented sockets were done because of acute debonding at the cup-cement interface leading to a tilt of the component (Figs. 2-A and 2-B). The patients experienced sudden pain and a limp, and each had a revision within three months to avoid major wear or fracture of a prosthetic component that was functioning under poor mechanical conditions. Loosening of the cemented cup was associated with minor bone loss in ten of the nineteen hips, and this required the use of either a revision component that was 4 mm larger than the index component (seven hips) or reconstruction of the bone defect with allograft bone (three hips). No osteolysis was observed at the revisions of the remaining nine hips. Associated femoral revision was performed in five of the nineteen hips. In one additional hip, an isolated revision of a cemented stem without revision of the socket was performed because of stem migration and cement fracture associated with a poor initial cement mantle.

Four cementless acetabular components were revised because of progressive superior and medial migration with subsequent loss of hip function. The mean Merle d’Aubigné functional score prior to revision was 13.3 ± 1.7 points. In three of these four acetabular revisions, the femoral component also was revised because it had subsided. In one additional hip, an isolated revision of a cementless stem was performed because of subsidence.

Clinical Results

The clinical results were assessed for the forty-five patients (fifty-one hips) who were alive and had not had a revision at the time of the last follow-up evaluation. There were thirty-one women and fourteen men. The mean age at the time of the index arthroplasty in this group was not significantly different from the mean age of the patients who had a revision (Table II). The mean age at the time of the last follow-up was 78.1 ± 9.9 years (range, 57.2 to 98.5 years). Twenty-five of the arthroplasties were performed without cement on either side, and twenty-six were done with cement on both sides. The mean Merle d’Aubigné functional hip score increased from 10.3 ± 2.2 points preoperatively to 16.2 ± 1.8 points at the time of the last follow-up (Wilcoxon rank test, p < 0.001). The hip score was not significantly different according to the type of fixation of the prosthetic components (Mann-Whitney U test, p = 0.31). Nine hips (eight patients) were rated as excellent; twenty-nine hips (twenty-six patients), as very good; seven hips (five patients), as good; three hips (three patients), as fair; and three hips (three patients), as poor. Thirty-five patients (thirty-seven hips) had no pain in the involved joint, nine patients (thirteen hips) had moderate pain that did not restrict their activity level, and one patient (one hip) had pain that limited the duration for which he was able to walk to less than twenty minutes. Twenty-five patients (twenty-eight hips) had a normal gait, eleven patients (fourteen hips) needed one cane for walking a long distance, eight patients (eight hips) had a marked limp and frequently used a cane, and one patient (one hip) had a severe limp that required the use of two canes. The range of flexion was >90Â° in twenty-six hips, 75Â° to 85Â° in eighteen, 55Â° to 70Â° in five, and 30Â° to 50Â° in two. The mean range of flexion in the series was 85Â° ± 17Â° (range, 50Â° to 120Â°).

Radiographic Results

The mean abduction angle of the socket was 41Â° ± 7Â° (range, 28Â° to 60Â°). The mean distance from the most medial point of the socket to the vertical teardrop line was 2.8 ± 2.8 mm (range, 0 to 12 mm), and the mean distance from the lowest point of the cup to the horizontal teardrop line was 5.9 ± 5.5 mm (range, 0 to 23 mm). None of the fifty-one unrevised hips had a lytic lesion (cystic or scalloped) on either the femoral or the acetabular side. Calcar resorption always measured <0.5 mm. Uncemented stems were associated with proximal osteopenia, which was probably related to stress-shielding of the proximal part of the femur. On the acetabular side, fifteen hips had no radiolucent line; fifteen had a radiolucent line in zone I; eighteen, in zone III; two, in zones I and III; and one had a complete radiolucent line. On the femoral side, twenty-five hips had no radiolucent line; six had a radiolucent line in zone IV; eighteen, in zones II and IV; and two, in zones IV, V, and VI. The radiolucent lines were always <1 mm thick. In addition to the four revised cementless acetabular components, four cementless cups were loose according to the criteria described previously. None of the unrevised femoral components were loose.

Wear, as measured on plain anteroposterior radiographs of the pelvis, was always <0.5 mm (the accuracy of the calipers) at the latest follow-up evaluation. The rate of wear of the acetabular component was therefore <0.025 mm/yr. These values were identical for the revised and unrevised acetabular components.

Survivorship Analysis

With revision of either component for any reason as the end point, the cumulative survival rate at twenty years was 68.3% (95% confidence interval, 57.7% to 78.9%). With revision for any reason as the end point, the survival rate at twenty years was 85.6% (95% confidence interval, 72.2% to 99.0%) for the thirty-three cementless cups (Fig. 3-A), 61.2% (95% confidence interval, 46.8% to 75.6%) for the eighty-five cemented cups (Fig. 3-A) (p = 0.0162 for cemented versus cementless cups, log rank test), 84.9% (95% confidence interval, 71.1% to 98.8%) for the twenty-nine cementless stems (Fig. 3-B), and 87.3% (95% confidence interval, 77.4% to 97.1%) for the eighty-nine cemented stems (Fig. 3-B) (p = 0.86 for cemented versus cementless stems, log rank test). Among the variables studied in this series, factors significantly associated with a higher risk of revision were an initial abduction angle of the cup of 45Â° (p = 0.0220) and a cup diameter of <48 mm (p = 0.0051), as summarized in Table III.

With radiographic loosening as the end point, the survival rate at twenty years (Fig. 4) was 50.7% (95% confidence interval, 21.8% to 79.5%) for the cementless cups compared with 61.2% (95% confidence interval, 46.8% to 75.6%) for the cemented cups (none of the unrevised cemented sockets were loose) (log rank test, p = 0.1343).

Discussion

Introduction | Materials and Methods | Results | Discussion | References

The first alumina-on-alumina total hip arthroplasty was performed in April 1970 by Boutin¹⁸. Until 1977, the alumina head was either glued with an epoxy resin or screwed to the femoral stem. However, this method of fixation led to an unacceptable rate of head-stem dissociation, with forty-five (5.7%) of 791 hip replacements performed between 1970 to 1977 complicated by such dissociation¹⁹. Moreover, the quality of the alumina ceramic was not optimal, with a large grain size and a broad grain-size distribution combined with a low purity. All of these adverse factors were responsible for the fractures of the alumina components (six heads and four sockets) that occurred in ten (1.3%) of the 791 hip replacements¹⁹. In 1977, notable progress was made with the introduction of a Morse taper locking mechanism for attachment of the alumina head to the titanium stem together with an improvement in the material manufacturing process leading to the production of surgical-grade dense alumina ceramic²⁰.

The theoretical advantages of alumina ceramic are related to exceptional tribologic properties due to high scratch resistance and wettability of the material, both of which reduce third-body and adhesive wear²¹. The linear wear rate of alumina ceramic articulating against alumina ceramic has been shown to be 4000 times lower than that of metal articulating against polyethylene²². The reported European experience with the alumina-on-alumina combination showed a mean wear rate of 0.025 m/yr and limited osteolysis up to ten years after the arthroplasty^7,22-25. These favorable results were also observed in a young and active population^8,9. Because only a small amount of wear particles was produced, the subsequent biologic reaction to ceramic wear debris was assumed to be moderate. Recently, Bohler et al.²⁶ showed that the concentrations of wear particles in the periprosthetic tissues around alumina-on-alumina bearings were two to twenty-two times lower than those previously observed around metal-on-polyethylene articulations. However, we are not aware of any report evaluating alumina bearings after follow-up periods of greater than ten years.

In the current study, of the original 106 patients, forty-five with fifty-one hips followed for a median of 19.8 years were available for evaluation. Clinical results were reliably maintained over time, with 75% excellent or very good results. Moreover, wear was undetectable on plain radiographs and was therefore assumed to be less than what could be measured accurately with the calipers. In addition, no massive osteolysis was observed. Only three of the twenty-five revisions of the acetabular components required the use of allograft bone. No bone loss on the femoral side was recorded. Minimal acetabular osteolysis occurred in association with the loose cemented acetabular components, whereas no osteolysis occurred in association with the cementless sockets. Osteolysis has seldom been reported after alumina-on-alumina total hip arthroplasty, and the few cases were usually associated with the use of a Mittelmeier total hip system^27-29. The alumina material of this prosthesis had a large grain size, a low density, and a high porosity, all of which could have led to the production of a large amount of debris. In addition, this prosthesis had a poor socket design that was responsible for a rate of failure as high as 27% by the time of a twenty-six-month follow-up³⁰. In our series, there were no fractures of the head or socket after a minimum of 18.5 years of follow-up of fifty-one hips; this finding supports the assumption that the risk of fracture of alumina is minimal when appropriate materials are used. Although alumina is a relatively brittle material, the risk of fracture is mainly related to a cone-trunion mismatch or to alumina of poor quality and structure. Willmann³¹ reported the risk of fracture to be 0.02% on the basis of more than 1.5 million femoral heads used since 1974. This value was confirmed by Heck et al.³², who reported, on the basis of a survey of the entire membership of the American Association of Hip and Knee Surgeons, that twenty-two of 10,000 ceramic heads had fractured over a five-year period.

It should be acknowledged that the twenty-year cumulative survival rate in the current series was notably lower than the survival rates that have been reported for the Charnley hip system (usually >80% at twenty years) with revision as the end point^33-39. However, survival of the titanium stems in our series, with either revision or radiographic loosening as the end point, was comparable with the survival of the Charnley low-friction prostheses³⁶. The high failure rate observed in our series was related to issues other than the bearings per se. The main reason for revision was aseptic loosening of the acetabular component (the reason for twenty-three [92%] of the twenty-five revision procedures). The pattern of loosening differed between the cemented and cementless sockets. Loosening of the cemented sockets was always an acute event related to the debonding of the alumina cup from the bone cement, whereas there was progressive migration of the cementless sockets. The latter performed significantly better (p = 0.0162), with a rate of survival free of revision of 85.6% ± 6.9% at twenty years. On the basis of our observations made over a twenty-year period, the process of loosening of alumina sockets can be assumed to be different from that reported for polyethylene cups. Indeed, long-term studies of Charnley arthroplasties revealed a substantial correlation between the rate of acetabular wear and the prevalence of revision because of aseptic loosening^33,40,41. Furthermore, Wroblewski et al.^39,42 showed a notable relationship between the depth of penetration of the polyethylene socket and the percentage of cases of socket migration. Joshi et al.¹⁴ specifically evaluated osteolysis at a minimum of ten years after Charnley primary low-friction arthroplasty and found that osteolysis was substantially associated with a high wear rate (>2 mm at ten years) and with socket migration. As no measurable wear of the components was recorded in the current series, it is highly probable that loosening of alumina cups is not caused by biologic reactions to wear particles.

Alumina ceramic has a Young modulus that is 300 times greater than that of bone and 190 times greater than that of cement. Therefore, the process of loosening of alumina sockets is probably a mechanical phenomenon due to a stiffness mismatch between the alumina cup and either the bone or the cement. Our study showed that minimal wear rates together with limited osteolysis can be expected up to twenty years after the arthroplasty, provided that sound fixation of the acetabular component is obtained. The weak link was the fixation of the alumina acetabular component, which sometimes led to loosening and subsequent revision. We believe that the socket fixation still needs to be improved. This could be achieved through the use of either a titanium shell with an alumina modular insert⁴³ or a bioactive material as a coating on the alumina to enhance primary fixation⁴⁴.

Note: The authors are grateful to Miguel E. Cabanela, MD, and Daniel J. Berry, MD (Mayo Clinic, Rochester, MN) for their comments.

References

Introduction | Materials and Methods | Results | Discussion | References

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Topics

aluminum oxide ; femur ; follow-up ; hip joint ; osteolysis ; prostheses and implants ; arthroplasty ; hip replacement arthroplasty

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Moussa Hamadouche, Pierre Boutin, Jacques Daussange, Mark E. Bolander, Laurent Sedel; Alumina-on-Alumina Total Hip Arthroplasty A Minimum 18.5-Year Follow-up Study. The Journal of Bone & Joint Surgery. 2002 Jan;84(1):69-77.

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