Higher risk of 2-year cup revision of ceramic-on-ceramic versus ceramic-on-polyethylene bearing: analysis of 33,454 primary press-fit total hip arthroplasties registered in the Dutch Arthroplasty Register (LROI)

Background and purpose: The influence of bearing on short-term revision in press-fit total hip arthroplasty (THA) remains under-reported. The aim of this study was to describe 2-year cup revision rates of ceramic-on-ceramic (CoC) and ceramic-on-polyethylene (CoPE). Patients and methods: Primary press-fit THAs with one of the three most used cups available with both CoC or CoPE bearing recorded in the Dutch Arthroplasty Register (LROI) were included (2007–2019). Primary outcome was 2-year cup revision for all reasons. Secondary outcomes were: reasons for revision, incidence of different revision procedures and use of both bearings over time. Results: 2-year Kaplan-Meier cup revision rate in 33,454 THAs (12,535 CoC; 20,919 CoPE) showed a higher rate in CoC (0.67% [95% CI, 0.54–0.81]) compared to CoPE (0.44% [95% CI, 0.34–0.54]) ( p = 0.004). Correction for confounders (age, gender, cup type, head size) resulted in a hazard ratio (HR) of 0.64 [95%CI, 0.48–0.87] ( p = 0.019). Reasons for cup revision differed only by more cup revision due to loosening in CoC (26.2% vs.1 3.2%) ( p = 0.030). For aseptic loosening a revision rate of 0.153% [95% CI, 0.075–0.231] was seen in CoC and 0.058% [95%CI 0.019–0.097] in CoPE ( p = 0.007). Correction for head size resulted in a HR of 0.475 [95% CI, 0.197–1.141] ( p = 0.096). Incidence of different revision procedures did not differ between bearings. Over time the use of CoPE has increased and CoC decreased. Conclusions: A higher 2-year cup revision rate in press-fit THA was observed in CoC compared to CoPE. Cup loosening was the only significantly different reason for revision and seen more often in CoC and mostly aseptic. Future randomised controlled trials need to confirm causality, since the early cup revision data provided has the potential to be useful when choosing the bearing in press-fit THA, when combined with other factors like bone quality and patient and implant characteristics.

What Factors Reduce the Incidence of Early Dislocations in Aseptic Total Hip Revisions with Stem Retention?

It is unclear which factors are the most important protectors for early postoperative dislocation in aseptic total hip arthroplasty (THA) revisions with stem retention. Therefore, we sought to determine what factors reduce the incidence of dislocations among these patients. Single institution retrospective review was made of 83 consecutive aseptic THA revisions of the head/liner and/or cup performed by five surgeons between 2017 and 2020. Periprosthetic infections and femoral component revisions were excluded. Demographics, preoperative diagnosis, revision type, surgical approach, use of dual mobility systems, length of stay, skin-to-skin time, transfusions, complications, and dislocations were assessed. Pearson correlation/logistic regression analyses were used to determine association/independent predictors of dislocation; α was set at 0.05. The overall dislocation rate was 12%. In Pearson correlation, only preoperative diagnosis (instability vs. other, −0.241, p = 0.028) and revision type (only liner vs. cup, −0.304, p = 0.005) were significantly associated with dislocations. In logistic regression, only preoperative diagnosis other than instability (odds ratio [OR] = 0.235, p = 0.038) and cup revision (OR = 0.130, p = 0.014) were found significant protectors against dislocation. Surgical approach and dual mobility systems were not independent predictors of dislocations (p = 0.184 and p = 0.083, respectively). Dislocation rates were significantly different between those cases that had the cup revised (4.0%) and those that did not (24.2%; p = 0.012). Preoperative diagnosis other than instability and cup revision seemed to be protective against early dislocation. Revision of the cup, in particular, seemed to be the most important factor to avoid dislocations while use of dual mobility liners per se did not significantly reduce that risk. The role of isolated liner exchanges in revision THA continues to evolve and should be reserved for appropriately selected patients.

Ceramic-on-ceramic articulation in press-fit total hip arthroplasty as a potential reason for early failure, what about the survivors: a ten year follow-up

Purpose In press-fit total hip arthroplasty (THA), primary stability is needed to avoid micromotion and hereby aseptic loosening, the main reason for early revision. High aseptic loosening revision rates of the seleXys TH+ cup (Mathys Medical) with Ceramys ceramic-on-ceramic (CoC) bearing are seen in literature. Since CoC is presumed to overcome long-term wear-related revisions, the reason for early failure of this cup is important to clarify. The aim is to investigate its ten year outcomes and differentiate between potential causes and identify risk factors for aseptic loosening. Methods Retrospective screening of a prospectively documented series of 315 THAs was performed. Primary outcome was cumulative incidence of cup revision due to aseptic loosening. Secondary outcomes were component revision and reoperation. Additionally, potential predictive factors for aseptic loosening were evaluated. Results At the median follow-up of 9.7 years [IQR 4.4; 10.3], 48 TH+ (15.2%) were revised due to aseptic loosening. Competing risk analysis showed a ten year cumulative incidence of cup revision due to aseptic loosening of 15.6% (95% CI 12.0–20.2). Stabilization of early revision rates was observed, following a high rate of respectively 81.3% (n = 39) and 95.8% (n = 46) within the first two and three years. No significant predictive factors for aseptic loosening were found. Conclusion The ten year results of seleXys TH+ cup with Ceramys CoC bearing showed an unacceptable high aseptic loosening rate, which stabilized over time after a high early failure incidence. This could be attributed to a problem with osseointegration during the transition of primary to definitive stability.

High risk of hip dislocation following polyethylene liner exchange in total hip arthroplasty—is cup revision necessary?

Purpose Polyethylene (PE) wear remains a common reason for revision surgery following total hip arthroplasty (THA). An established treatment method is isolated liner exchange in a well-fixed acetabular cup and entails a known high risk of hip dislocation after revision surgery. The purpose of this retrospective study was to determine the rate of hip dislocation after liner exchange. Methods Patients were included if (1) the PE liner was removable, (2) the acetabular shell was stable with acceptable orientation, (3) no osteolysis around the acetabular cup was found and (4) no dislocation of the THA occurred before revision surgery. We reviewed medical histories and performed radiological measurements using Einzel-Bild-Röntgen-Analyse (EBRA) software. EBRA measurements and statistical investigations were performed by two independent investigators. Results A total of 82 patients were included in our study. Mean follow-up was six (range: 3.6–9.9) years. In 13 (15.8%) patients THA dislocations occurred at a mean postoperative period of 20.2 (range: 1–44) weeks after revising the PE liner. This is equivalent to an absolute risk increase of 16% after revision surgery, which results in a number needed to harm of 6. This means that every sixth patient with isolated liner exchange can expect to experience dislocation due to wear. Conclusion In conclusion, isolated exchange of the polyethylene liner because of wear showed a high risk of dislocation and further cup revision. Our results suggest that the threshold for revising well-fixed components in the case of liner wear should be lowered. Trial Registration number and date of registration Number: 20140710-1012 and Date: 2016-03-09.

Customised three-dimensional printed revision acetabular implant for large defect after failed triflange revision cup

Aseptic loosening is the most common cause for total hip arthroplasty revision. Acetabular cup revision is a significant challenge in the presence of a large bone defect. One of the options for cup revision in the presence of a large bone defect is the recently introduced customised three-dimensional (3D)-printed reconstruction. We present the case of a 68-year-old woman successfully treated with a customised revision acetabular implant for the failure of triflange cup in the presence of large acetabular defect. The modern orthopaedic surgeon must have full knowledge of customised 3D-printed reconstruction to have as a reserve solution for difficult hip revision surgery.