title: Do the Reasons for Ceramic-on-ceramic Revisions Differ From Other Bearings in Total Hip Arthroplasty?
abstract: BACKGROUND
  Despite widespread use of ceramic-on-ceramic (CoC) in total hip arthroplasty (THA) during the past 10 years, little is known about why revisions are performed in hips with this bearing or the time elapsed before revision.
  
  
  OBJECTIVE
  The purposes of this study were: (1) Do the reasons for first revision differ between CoC bearings and other bearing couples? (2) Does the time to revision differ between CoC and other bearing couples? (3) Are there unique reasons for revisions of CoC bearings?
  
  
  METHODS
  All members of the Société Française de Chirurgie Orthopédique et Traumatologique (SoFCOT) who performed ≥ 30 revisions per year were invited to participate in this multicenter, prospective, observational study. Our data represent 12% of the revision procedures performed in France. A total of 2107 first revisions of THA (from January 2010 to December 2011) were done in 2107 patients (1201 females [57%] and 906 males [43%]; median age, 73 years; age range, 17-104 years) at the time of surgery after a median of 11 years (range, 0 day-42 years) after the primary THA. There were 238 of 2107 (11%) CoC, 148 of 2107 (7%) metal-on-metal (MoM), and 1721 of 2017 (82%) metal-on-polyethylene (MoP) bearings.
  
  
  RESULTS
  The reasons for reoperation differed according to the bearing component: (1) for the MoP reference bearing (odds ratio [OR]; 95% confidence interval), cup loosening occurred in 698 of 1721 hips (41%), periprosthetic fracture in 220 of 1721 hips (13%), and osteolysis in 213 of 1721 hips (12%); (2) for CoC, cup loosening occurred in 41 of 238 hips (17%) (OR, 0.31 [0.22-0.43; p < 0.001), infection in 39 of 238 hips (16%) (OR, 1.63 [1.12-2.37]; p = 0.01), and dislocation in 23 of 238 hips (10%) (OR, 0.9 [0.57-1.42]; p = 0.9); (3) for MoM, cup loosening occurred in 28 of 148 hips (19%) (OR, 0.34 [0.22-0.52]; p < 0.001), adverse reaction to metallic debris in 26 of 148 hips (18%) (OR, 18.12 [9.84-33.4]; p < 0.001), and infection in 16 of 148 hips (11%) (OR, 1 [0.59-1.73]; p = 0.9). In comparison with MoP, osteolysis was rarely the reason for revision in CoC (four of 238 hips [2%]; OR, 0.12 [0.05-0.33]; p < 0.001), but this bearing was frequently revised because of iliopsoas irritation (18 of 238 hips [8%]; OR, 4.9 [2.7-9]; p < 0.001). The time elapsed before revision differed between bearings: median of 3 years (range, 3 days to 28 years) for CoC and 4 years (range, 14 days to 37 years) for MoM versus a median 13 years (range, 0 day to 42 years) for MoP (p < 0.001). Thirty-seven of the 238 revisions (16%) were directly related to ceramic use (ceramic breakage [n = 23], squeaking [n = 6], impingement [n = 7], incorrect ceramic insert insertion [n = 1]). No factors were identified that contributed to breakage of the 12 bulk ceramic components (eight heads, four inserts, four of 12 Delta ceramic). No factors were associated with squeaking, iliopsoas irritation, or impingement, but component orientation was not assessed.
  
  
  CONCLUSIONS
  The reasons and time to first revision differed between CoC and other bearings. CoC THAs are revised earlier and are sensitive to mechanical problems such as impingement, squeaking, and ceramic rupture that did not disappear with introduction of Delta ceramics and large-diameter (≥ 36 mm) bearings. CoC was rarely revised for osteolysis, but a high rate of iliopsoas irritation requires further investigation.
  
  
  METHODS
  Level III, therapeutic study.
authors.affiliation: Hôpital Salengro, Lille University Hospital, Place de Verdun, 59037, Lille, France. hemigaud@nordnet.fr.
authors.forename: Henri
authors.initials: H
authors.lastname: Migaud
authors.affiliation: Hôpital Salengro, Lille University Hospital, Place de Verdun, 59037, Lille, France.
authors.forename: Sophie
authors.initials: S
authors.lastname: Putman
authors.affiliation: Hôpital Salengro, Lille University Hospital, Place de Verdun, 59037, Lille, France.
authors.forename: Grégory
authors.initials: G
authors.lastname: Kern
authors.affiliation: Hôpital Salengro, Lille University Hospital, Place de Verdun, 59037, Lille, France.
authors.forename: Ronald
authors.initials: R
authors.lastname: Isida
authors.affiliation: Hôpital Salengro, Lille University Hospital, Place de Verdun, 59037, Lille, France.
authors.forename: Julien
authors.initials: J
authors.lastname: Girard
authors.affiliation: Department of Biostatistics, CERIM, Université Lille Nord de France, Lille, France.
authors.forename: Nassima
authors.initials: N
authors.lastname: Ramdane
authors.affiliation: Clinique de l'Yvette, Longjumeau, France.
authors.forename: Christian P
authors.initials: CP
authors.lastname: Delaunay
authors.affiliation: Hospital Cochin, University of Paris, Paris, France.
authors.forename: Moussa
authors.initials: M
authors.lastname: Hamadouche
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D019644:Arthroplasty, Replacement, Hip / Q000009:adverse effects* / Q000295:instrumentation*; D001696:Biomechanical Phenomena; D002516:Ceramics; D016009:Chi-Square Distribution; D005260:Female; D005602:France; D006621:Hip Joint / Q000503:physiopathology / Q000601:surgery*; D006622:Hip Prosthesis; D006801:Humans; D008297:Male; D061825:Metal-on-Metal Joint Prostheses; D008875:Middle Aged; D016017:Odds Ratio; D020959:Polyethylene; D011183:Postoperative Complications / Q000175:diagnosis / Q000209:etiology / Q000601:surgery*; D011446:Prospective Studies; D011474:Prosthesis Design; D012086:Reoperation; D012307:Risk Factors; D013997:Time Factors; D055815:Young Adult
chemical_list: D020959:Polyethylene