Outcome analysis of various bearing surface materials used in ...

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2158-5849/2020/10/301/013doi:10.1166/mex.2020.1651

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Outcome analysis of various bearing surfacematerials used in total hip replacementLong Chen1,†, Fei Xing2,†, Yuanzheng Wang1,†, Rui He3, Jingming He1, Yunwen Xu4, Cheng Wang5,Zhuhai Li6, Zeyu Sun1, Yankun Li1, Jiaqi Yang1, Lingchao Kong1, Yangyang Li1, and Li Sun1,∗

1Department of Orthopedics, Guizhou Provincial People’s Hospital, Guiyang, Guizhou 550000, China2Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, Sichuan 610000, China3Department of Orthopedics, The Fifth People’s Hospital of Wuhu, Wuhu, Anhui 241000, China4Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore MD 21205, USA5School of Clinical Medicine, Guizhou Medical University, Guiyang, Guizhou 550000, China6Department of Orthopedics, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning,Guangxi 530000, China

ABSTRACT

Since the first total hip replacement (THR) in 1938 by Philip Wiles, prosthesis materials and THR surgicaltechnologies have developed rapidly. In this review, we use internationally-published research to synthesizea comprehensive analysis of the specific characteristics and clinical outcomes of different bearing surfacesused in THR. Polyethylene, metallic alloys, and ceramic have become the three most commonly used hipprosthesis bearing surfaces after decades of hip implant development. Different bearing surface types havevarying characteristics that offer specific benefits and risks of complication. A thorough understanding of theunique properties and possible complications of each type of bearing surface is critical to surgeons tasked withselecting appropriate implant materials for total hip replacement.

Keywords: Total Hip Replacement, Prosthesis Materials, Bearing Surfaces, Polyethylene, Metallic Alloys,Ceramic.

CONTENTS1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3012. Ideal Bearing Surface . . . . . . . . . . . . . . . . . . . . . . . . . . . 3053. Characteristics of Different Kinds of Bearing Surfaces . . . . . . 305

3.1. Metal-on-Polyethylene . . . . . . . . . . . . . . . . . . . . . . . 3053.2. Metal on Metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3063.3. Ceramic-on-Ceramic . . . . . . . . . . . . . . . . . . . . . . . . 3063.4. Ceramic-on-Polyethylene . . . . . . . . . . . . . . . . . . . . . 306

4. Clinical Outcomes of Different Bearing Surfaces . . . . . . . . . 3074.1. Metal-on-Polyethylene . . . . . . . . . . . . . . . . . . . . . . . 3074.2. Metal-on-Metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3074.3. Ceramic-on-Ceramic . . . . . . . . . . . . . . . . . . . . . . . . 3084.4. Ceramic-on-Polyethylene . . . . . . . . . . . . . . . . . . . . . 309

∗Author to whom correspondence should be addressed.Email: sunlisy@hotmail.com

†These three authors contributed equally to this work.

5. Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309References and Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . 309

1. INTRODUCTIONThe hip joint is a ball-and-socket type of synovial jointthat is capable of supporting a load about three timesan individual’s body weight during common activitiessuch as walking and climbing stairs [1]. Not long afterthe first total hip replacement (THR) surgery (PhilipWiles, 1938), prosthesis materials and surgical technol-ogy related to THR have developed rapidly [2]. THR wasa landmark surgical innovation in the twentieth centuryand proved remarkably successful as a medical treatment

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Materials ExpressOutcome analysis of various bearing surface materials used in total hip replacement

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Long Chen associate chief physician of the Guizhou Provincial People’s Hospital, focus onthe researches of regenerative medicine and biomaterials in orthopedics.

Fei Xing focus on the researches about bone and articular cartilage repair.

Yuanzheng Wang chief physician of the Guizhou Provincial People’s Hospital, mainlyspecializes in complex extremities fractures, pelvic acetabulum fracture, bone nonunion,bone infection (osteomyelitis), and other disease.

Rui He chief physician of the Fifth People’s Hospital of Wuhu, mainly specializes in com-plex extremities fractures, pelvic acetabulum fracture.

Jingming He attending doctor of the Guizhou Provincial People’s Hospital, focus on theresearches of stem cell and biomaterials.

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Materials ExpressOutcome analysis of various bearing surface materials used in total hip replacementChen et al.

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Yunwen Xu is a biostatistician at Johns Hopkins University, providing data managementand statistical supports to the Chronic Kidney Disease in Children (CKiD) cohort study.She obtained a bachelor of medicine from Fudan University, and a master of health sciencedegree in epidemiology from Johns Hopkins Bloomberg School of Public Health.

Cheng Wang Medical student of Clinical Medical College in Guizhou Medical University.

Zhuhai Li served on Department of Orthopedics, The People’s Hospital of Guangxi ZhuangAutonomous Region, and engaged in the surgical treatment of cervical spondylosis, lumbardisc herniation and other degenerative diseases of the spine.

Zeyu Sun resident physician of the Guizhou Provincial People’s Hospital.

Yankun Li resident physician of the Guizhou Provincial People’s Hospital.

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Jiaqi Yang resident physician of the Guizhou Provincial People’s Hospital.

Lingchao Kong attending physician, mainly engaged in orthopaedic trauma and jointsurgery.

Yangyang Li attending physician, mainly engaged in orthopaedic trauma and joint surgery.

Li Sun chief physician of the Guizhou Provincial People’s Hospital, is known for his workengineering novel materials for regenerative medicine and orthopedic applications.

for osteonecrosis, end-stage osteoarthritis, rheumatoidarthritis, and femoral neck fracture [3]. Despite the suc-cesses of THR in successfully improving life qualityfor many patients with hip diseases, revision surgeriesare necessary when periprosthetic osteolysis occurs [4].Periprosthetic osteolysis caused by polyethylene weardebris poses the most risk to the long-term life of hipprosthesis, especially for young patients with hip dis-ease [5]. There have been many joint surface innova-tions involving new combinations of different materials

to reduce the harmfulness of polyethylene wear parti-cles [6]. Over decades of hip implant development, threekinds of bearing surfaces: polyethylene, metallic alloys,and ceramic have become the primary hip prosthesismaterials used in total hip replacement (Scheme 1) [7].Despite significant advances in the designs and com-ponents of bearing surfaces, choosing bearing surfacesstill remains controversial. Therefore, our study aims toreview different kinds of bearing surfaces in vitro andin vivo.

Review

Scheme 1. Various bearing surface materials used in total hipreplacement.

2. IDEAL BEARING SURFACEThe bearing surface of the hip prosthesis affects the life-time of the prosthesis in vivo. The ideal bearing surfaceshould have the following characteristics. a. The materialcan endure corrosion by body fluids for a long time andis chemically stable. b. Debris produced from wear doesnot produce a host immune response. c. Low interfacialfriction. d. The bearing surface can bear the patient’s ownweight and exercise load. e. The large-enough diameter ofthe femoral head prosthesis lowers the risk of the occur-rence of a hip dislocation. f. The risk of material fractureis small.

3. CHARACTERISTICS OF DIFFERENTKINDS OF BEARING SURFACES

3.1. Metal-on-PolyethyleneMetal-on-polyethylene bearing surfaces (Fig. 1(A)) arecurrently the most widely used in THR [8, 9]. Bedardet al. reported the prevalence of different kinds of hipimplants in 28,504 primary THA procedures from 2007through 2015. The results demonstrated that the metal-on-polyethylene is the most popular type of hip pros-thesis [10]. However, the durability and longevity ofmetal-on-polyethylene implants are limited by compli-cations, including aseptic loosening and periprostheticalosteolysis [11, 12]. In addition, aseptic loosening asso-ciated with polyethylene wear debris often cause THRimplant failure [13–15]. Highly cross-linked polyethylene,which is produced when standard polyethylene is irra-diated at 50 to 100 kGy, had lower rates of wear thanstandard polyethylene in 10 year post-operative follow-ups [16–18]. The occurrence and prevalence of wearparticles produced by bearing surfaces of hip prosthe-ses are closely related to risk of periprosthetic osteoly-sis and prosthesis loosening [19, 20]. There are fewer,smaller sized wear particles produced by highly cross-linked polyethylene compared to standard polyethylene,which may reduce the occurrence of periprosthetic osteol-ysis [21, 22]. Highly cross-linked polyethylene is preparedby irradiating polyethylene with ultra-high doses of �-raysor electronic beams to increase the amount of crosslinkingof the molecular structure [23, 24]. However, ultra-high

A B C D

Fig. 1. Bearing surfaces for total hip replacement. (A) Metal-on-polyethylene bearing (Reprinted with permission from [3], Mellon,S.J., et al., 2013. Hip replacement: Landmark surgery in modernmedical history. Maturitas, 75(3), pp.221–226. Copyright@Elsevier);(B) metal-on-metal bearing (Reprinted with permission from [95],Higuchi, Y., et al., 2018. 32-mm ceramic-on-ceramic total hip arthro-plasty versus 28-mm ceramic bearings: 5- to 15-year follow-up study.Hip International, 29(1), pp.65–71. Copyright@SAGE Publications);(C) ceramic-on-ceramic bearing (Reprinted with permission from [100],Lim, S.J., et al., 2018. Clinical outcomes and bearing-specific compli-cations following fourth-generation alumina ceramic-on-ceramic totalhip arthroplasty: A single-surgeon series of 749 hips at a minimum of5-year follow-up. Journal of Arthroplasty, 33(7), pp.2182–2186. Copy-right@Elsevier); (D) ceramic-on-polyethylene bearing (Reprinted withpermission from [107], Li, H., et al., 2017. Medium-term results ofceramic-on-polyethylene Zweymüller-plus total hip arthroplasty. HongKong Medical Journal, 23(4), pp.333–339. Copyright@Smith&NephewOrthopaedics AG).

doses of radiation can reduce the fatigue resistance of pros-theses and produces more free radicals, which can dam-age surrounding cells and tissues [25, 26]. Production offirst-generation cross-linked polyethylene bearings for hiparthroplasty involved annealing and re-melting prosthesesto reduce the level of free radicals [27]. However, afterlong periods of observation, oxidation and edge stratifica-tion were observable at the edge of the annealed prosthe-ses [28]. Therefore, vitamin E, an antioxidant, was addedto the second-generation polyethylene bearings for hiparthroplasty [29]. As an effective antioxidant in the humanbody, Vitamin E reacts with free radicals on cell sur-faces to destroy oxidized chains of polyunsaturated fattyacids and reduce oxidation-related degradation of polyun-saturated fatty acids. The mechanism of polyethylene oxi-dation is similar to that of polyunsaturated fatty acidsin vivo and vitamin E can effectively prevent the oxida-tion of polyethylene [30]. The addition of vitamin E topolyethylene did not cause toxic reactions to the surround-ing tissues of hip prostheses [31]. Compared to virginhighly cross-linked polyethylene particles, the expressionlevels of important osteolytic mediators, including tumornecrosis factor-alpha (TNF-�), interleukin 1� (IL-�), IL-6,and IL-8 were appreciably lowered in peripheral bloodmononuclear cells stimulated with particles derived fromvitamin E-treated highly cross-linked polyethylene [32].However, long-term clinical outcomes of highly cross-linked polyethylene treated by vitamin E still remainsunclear.

Chen et al.

3.2. Metal on MetalFirst described in the 1960s, metal-on-metal (MoM) hipprostheses (Fig. 1(B)) became significantly utilized in thelate 1990s [33]. MoM surface bearing has been used intotal hip replacement worldwide for about sixty years.MoM hip implants have three parts: the ball, the stem,and the shell, all of which are predominantly composedof cobalt and chromium. MoM hip implants consist of atrimmed femoral head covered by a metal as a cap [34].Metal-on-metal bearing surfaces offer a large femoral headdiameter to increase hip stability and optimize range ofmotion, making MoM prosthesis the most ideal choicefor younger patients [14]. Scratches to the metal surfacesself-heal and metal-on-metal bearing surfaces effectivelydecrease volumetric wear [35].However, compared to other hip implants options, MoM

hip implants have a higher revision rate. This mightbe caused by the metal debris particles produced bywear [36, 37]. Compared to polyethylene wear particles,metal wear particles are smaller and more biologicallyactive [38]. However, one needs to consider that compli-cations may happen, as adverse reactions in response tometal debris following the total hip arthroplasty using largediameter head metal-on-metal do exist. As a unique com-plication of MoM surface bearing, adverse reactions tometal debris (ARMD) include elevated serum metal ion,pseudotumors, and soft tissue damage. These are all symp-toms that increase the risk of prosthesis loosening andkidney damage [39]. The treatment of ARMD caused byMoM surface bearing often need revision surgeries. Highlevel of metal ion released from MoM surface bearingmight damage different kinds of organs and tissue in vivo.A previous study reported the case of a patient experi-encing progressive cardiomyopathy following a metal-on-metal (MOM) total hip arthroplasty due to high bloodlevels of cobalt [40]. At present, there are many meth-ods of detecting metal ions in blood, but there is no goldstandard. However, it is very necessary to detect the bloodmetal ions regularly in patients who received a MoM hipprosthesis. As granulomatous, destructive cystic or solidlesions develop adjacent to THR implants, pseudotumorsare neither neoplastic or infectious [41]. Histological sec-tioning of such pseudotumors reveals large abundance ofmacrophages and T lymphocytes, accompanied by exten-sive necrosis [42]. Currently, the diagnosis of pseudo-tumors mainly depends on magnetic resonance imaging.However, the mechanism of pseudotumor development isstill unclear.

3.3. Ceramic-on-CeramicCeramic-on-ceramic hip prostheses (Fig. 1(C)) have beengrowing their popularity as a promising choice for hipreplacement. Alumina is one type of oxide ceramic andit consists of pure metal oxides [43]. As one of the ear-liest ceramics used in hip prosthesis, alumina ceramics

have good resistance to wear. Many previous studies havedemonstrated that the wear rate of ceramic-on-ceramicbearing surfacing are low both in vivo and in vitro [44, 45].Additionally, alumina is hydrophilic and contains manyionic bonds [43]. The wetting angle of a material isone aspect that can affect the surface lubrication of hipprostheses. Compared to other kinds of bearing surfaces,alumina ceramics have lower wetting angles, which cancontribute to decreased surface lubrication [46]. Due to itshigh oxidative state, alumina ceramics also exhibit goodchemical stability and corrosion resistance in vivo andin vitro [47].Ceramic-on-ceramic hip implants also pose many

unsolved problems. Implant fracture still remains a dan-gerous complication for such bearing surfaces. Clinicalfollow-ups of early ceramic prostheses are not optimisticdue to defective prosthesis design, unstable fixation of theprosthesis, and prosthesis fracture [48]. Innovations in alu-mina ceramic manufacturing technology have effectivelyimproved the fragility of ceramics [43]. Stripe wear, a nar-row area of wear formed by contacts and frictions on thebearing surfaces, between the femoral head of the prosthe-sis and the edge of the ceramic liner, is unique to ceramic-on-ceramic hip implants [49]. Surgical error, such as steepcup angles, may have contributed to the formation of stripewear in first and second-generation ceramic-on-ceramicbearing surfacing [43]. However, despite improvementsto surgical techniques and implant materials, bearing sur-face stripe wear continued with third-generation ceramicsimplants [50]. Stripe wear in third-generation ceramicsimplants might be related to loading of the posterior edgewhen patients move from a flexed to un-flexed position,such when as climbing stairs [43]. Hip squeaking is onepost-operative complication in ceramic-on-ceramic bearingsurfaces. However, the reasons for this transient squeak-ing still remain unclear. There was speculation that micro-separations may lead to stripe wear [51].

3.4. Ceramic-on-PolyethyleneThe conventional metal-on-polyethylene bearing surfaces(Fig. 1(D)) might generate particulate debris over time,resulting in periprosthetic osteolysis and implant fail-ure [52]. Ceramic-on-polyethylene systems consists ofceramic femoral heads and polyethylene acetabular lin-ers. Comparing to metal-on-polyethylene total hip replace-ments, the ceramic-on-polyethylene rendered a lower wearrate for the polyethylene [53, 54]. In addition, progressof ceramic manufacturing technology could decrease therate of facture and wear, resulting in increasing the use ofceramic-on-polyethylene bearings [55]. Heckmann et al.investigated 2,460,640 THA discharges from 2007 to2014 in the United States and reported that ceramic-on-polyethylene bearing surfaces became more and more pop-ular and finally outperformed all other bearing surfacetypes in popularity [56]. Considering the cost, ceramic-on-polyethylene is much cheaper than ceramic-on-ceramic.

Review

Currently, ceramic-on-polyethylene are commonly used inurban nonteaching and rural hospitals [57]. However, thedebris of polyethylene wear is still a challenge of patientsundergoing total hip replacement.

4. CLINICAL OUTCOMES OF DIFFERENTBEARING SURFACES

4.1. Metal-on-PolyethyleneBetween 2005 and 2006, mechanical loosening accountedfor about 20% of all hip revision surgeries in UnitedStates. Polyethylene wear particles are prone to causeaseptic loosening and thus a higher occurrence rate of hiparthroplasty with impaired functions. Highly cross-linkedpolyethylene has demonstrated substantial reductions inwear in vitro compared to conventional polyethylene.A randomized control study found that highly cross-linkedpolyethylene had lower penetration rates compared to con-ventional polyethylene at 2, 3, and 5 year follow-ups [19].A retrospective study found that the annual linear wear ofhighly cross-linked polyethylene (0.031 mm) was greatlylower than that of polyethylene (0.141 mm) during follow-ups 7.5 years after placement [58]. Additionally, a random-ized study found that the penetration rate at steady state ofthe femoral head was much lower in polyethylene linersthat were highly cross-linked comparing to those that werenot (conventional PE) at follow-ups a minimum of 5 yearsafter placement [59]. Geraint and coworkers also did arandomized study to investigate differences in steady-statewear rate between polyethylene with a high cross-linkingdensity and polyethylene with an ultra-high molecularweight [60]. The results indicated that the former held alower steady-state wear rate. Johanson conducted a ran-domized study to investigate the difference between highlycross-linked polyethylene cups and polyethylene cupscombined with a cemented stem [61]. The results indi-cated that the three-dimensional wear rate of highly cross-linked polyethylene cups were significantly lower than thatof polyethylene cups between 2 and 10 years after place-ment. One factor that significantly influences polyethy-lene wear is patient activity levels. Battenberg et al.conducted a retrospective study to investigate the rela-tionship between patient activity level and wear rate [62].The results showed that greatest patient activity and wearoccurred over the first 5 post-operative years. Additionally,the rate of bearing surface wear decreased over time due todecreased walking speed and gait cycles as patients aged.In addition, D’Antonio et al. found that the wear rate andoccurrence of complication of second-generation of highlycross-linked polyethylene were significant lower than first-generation [63]. Fawsitt et al. created a Markov modelto compare the cost-effectiveness of different kinds ofhip implants, including metal-on-polyethylene, metal-on-metal, ceramic-on-ceramic implants. The results demon-strated that small-head cemented metal-on-polyethylene

implants were the most cost-effective for men and womenolder than 65 years [64].The polyethylene particles generated from hip implants

are associated with the occurrence of periprosthetic oste-olysis, which is a significant cause of aseptic looseningand late implant failure of THR [65]. A previous studyreported that the occurrence of periprosthetic osteolysiswith highly cross-linked polyethylene was significantlylower than with conventional polyethylene [66]. In addi-tion, Leung et al. found that incidence and volume ofpelvic osteolysis is highly decreased with the use of highlycross-linked polyethylene as compared to when standardpolyethylene is used [67]. Peters et al. identified 209,912primary THR procedures, in the Netherlands in the period2007–2016, and concluded that the revision rate of highlycrosslinked polyethylene was significantly lower than con-ventional polyethylene [68].

4.2. Metal-on-MetalMetal-on-metal hip implants have a history of applica-tion for over seven decades. In 1988, Weber reintroducedmetal-on-metal articulation in total hip replacement [69].A second-generation product was designed and manufac-tured in the 2000s with the goal of prolonging implantlongevity and reducing occurrence of dislocation [70].A previous study found that the survival rate of metal-on-metal THR was 84.4% in a 20-year follow-up [71].A retrospective study reported that the cumulative survivalrates of 38-mm metal-on-metal hip implants at a 10 and13 years follow-up were 98% and 74%, respectively [72].Ridon et al. conducted a retrospective study to investigatethe survival time of metal-on-metal hip implants from a10 year follow-up [73]. The results showed that ten-yearsurvival rate was 67.1% [73]. Steiger et al. conducted astudy investigating long-term revision rates between small-head and large-head metal-on-metal bearing surfaces [74].The results showed that the revision rate of small-headimplants (8.5%) was significantly lower than that of large-head ones (27.4%) at a 15 year follow-up.Metal-on-Metal (MoM) THR has been under debate

primarily because metal ions can be release from thewear. Increases in cobalt and chromium concentrationsin synovial joint fluid are associated with aseptic lesionresponses dominated by lymphocytes and/or vasculi-tis [75]. The presence of metal-on-metal hip implantswould dramatically increase cobalt level and chromiumlevel in plasma [76]. Additionally, previous studies havereported that these released cobalt ions can damageone’s ability to hear high frequencies, but there lacksa clear dose-response relationship [77]. Besides, Vazet al. reported incidences in which patients with metal-on-metal hip replacements developed rarely seen autoim-mune/autoinflammatory syndrome induced by adjuvants(ASIA), that was likely caused by an aberrant autoimmuneresponse to the released ions as an adjuvant trigger [78].

Chen et al.

Lodge et al. reported a positive correlation between theincrease in left ventricular volume, the increase in leftatrial volume, and the decline in renal function, with anelevated blood level of cobalt in patients implanted metal-on-metal hips [79]. Charette and coworkers reported acase in which one patient (male, age 46) developed severecardiomyopathy following an arthroplasty using bilateralmetal-on-metal hips, that finally ended up with implan-tation of a left ventricular assist device [80]. Cardiacfunction was improved after revision of the total hiparthroplasty [80]. Additionally, Wyles found that themyocardial cobalt abundance locally in patients carry-ing metal-on-metal hip replacements were significantlyhigher than that of patients without history of metalimplants [81]. Shapira et al. has shown a rather extremecase, in which one patient (female, age 54) suffered fromsystemic cobaltism following the hip replacements andpresented black discoloration of the tongue and metal-lic gustation. A surgical procedure was prescribed toremove the metal implant, debride thoroughly in the localtissues, and replacing a ceramic-on-polyethylene hip inposition. The symptoms presented by the patient werefinally resolved [82]. Sangaletti et al. conducted a 10-yearprospective study evaluating the release profile of ionsfrom metal-on-metal hip implants [83]. It was concludedby this study that hematic concentrations of chromiumand cobalt at 6 months post-operative were significantlyhigher than before the implant was placed. Additionally,the concentration of cobalt increased significantly between60 months and 120 months post-operative [83]. However,it was also found that ionic blood concentrations are notpredictive of revision or adverse reaction to metals.Pseudotumor formation in patients with hips replaced

by metal-on-metal implants is not an uncommon post-operative complication and would likely results in implantrevision surgeries. Additionally, patients with thick-walledcystic and solid lesions were more likely to develop symp-tomatic pseudotumor and undergo revision [84]. Con-cerns are rising about adverse reactions to debris frommetal associated with metal-on-metal hip implants hav-ing a small head diameter. A previous study found thatpseudotumors were observed in 26 patients out of atotal of 91 patient hips treated with small-head metal-on-metal total hip replacement at an average follow-up yearof 20 [85]. Therefore, adverse reaction to metal debrisshould be considered even in the case of small-head MoMarthroplasty.

4.3. Ceramic-on-CeramicCeramic-on-ceramic bearing surfaces were found to havelow surface wear rates during the long history of theirpractical uses [86, 87]. Results from an analysis of patientoutcomes during post-operative follow-ups for at least20 years also strengthens the claim that this kind ofmaterials has a low wear rate [88]. Higuchi et al. con-ducted a retrospective case control study and found that

the occurrence of periprosthetic osteolysis caused byceramic-on-ceramic hip replacements was lower than thatof metal-on-metal hip replacements, as examined in afollow-up at post-operative 8th year [89]. In a consecu-tive series of 301 primary cement-less ceramic-on-ceramictotal hip replacement, the survival rate of the ceramic-on-ceramic hip implants was 98% at 10 years. Addition-ally, there was no occurrence of ceramic fractures in thisstudy [90]. Another study also found that the survivalrate of ceramic-on-ceramic hip implants was 97% at a10 year follow-up [91]. In a consecutive series of 100 pri-mary cement-less total hip arthroplasties, the survival ofthe third-generation alumina-on-alumina bearing surfaceswas 99% [92].Additionally, a retrospective study including

300 patients who had total hip arthroplasty using ceramic-on-ceramic supported an overall revision rate of 93.2%after 13 to 18 years follow-up [93]. Hernigou et al. [94]investigated the occurrence of periprosthetic femoral frac-tures in 327 patients with bilateral total hip replacement(placing ceramic–ceramic on one side and ceramic–polyethylene on the contralateral side) after a 40 yearfollow-up. This study found the occurrence rate of post-operative fractures on the PE side was 30 times higherthan that of the ceramic-on-ceramic bearing side [94].The fewer periprosthetic femoral fractures occurrencescould be attributed to the differences in the mechanicalproperties between these two kinds of materials and/orabsence of wear and osteolysis. Higuchi et al. [95] wenton a retrospective review to investigate outcome differ-ences between 32-mm ceramic-on-ceramic and 28-mmceramic-on-ceramic hip replacement implants. This studyfound that during a 5 to 15-year follow-up period, Harriship scores and ranges of hip motion were better in groupswith 32-mm ceramic-on-ceramic implants. There was nonoticeable differences between the two groups in termsof the wear rate [95]. Based on the results from a dataanalysis on 223,362 bearings from 111,681 primary casesthat had ceramic-on-ceramic as the materials in a total hipreplacement procedure (National Joint Registry in UnitedKingdom), the risk of ceramic bearing fracture was highif the femoral head size was too small, or the patient helda high BMI number [96].Post-operative complications of ceramic-on-ceramic

prosthetics includes ceramic fracture, squeaking, and oste-olysis. A previous study done in 2003 reported the frac-ture rate of alumina-on-alumina bearing surfaces rangedfrom 0.005% to 0.02% [97]. In the early 2000s, a fourth-generation alumina ceramic, delta ceramic, was man-ufactured by incorporating zirconia into the aluminamatrix [98]. Aiming to reduce post-operative complica-tions, delta ceramic significantly improved the tough-ness of the bearing surface in vitro [99]. Additionally,the delta ceramic allowed for larger femoral heads andthinner acetabular liners to improve post-operative hip

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function [99]. In a retrospective study, delta ceramicshowed high survival rates in a 6.5 year follow-up [100].Although some previous studies have reported low preva-lence of delta ceramic fractures, there are no long-term,large-scale clinical studies of delta ceramic fractures [101,102]. An important contributing factor to consider is thatsurgical technical errors can increase the occurrence ofceramic fractures [102]. Therefore, surgeons should avoidexcessive inclination of the cup and excessive angulationof the acetabular fixation screws to ensure the insert isseated inside the cup.Recently, there have been rises in the percentages of

younger patient populations receiving total joint replace-ments. Previous studies have predicted that half of total hipreplacements are on patients younger than 65 [103]. There-fore, it is very important to conduct long-term follow-ups on younger patients to track the clinical outcomesof the surgical materials used over years. A retrospec-tive study of 200 consecutive ceramic-on-ceramic totalhip replacements on patients who were 50 or lower yearsold found that ceramic-on-ceramic offers good hip func-tionality without adverse effects after a follow-up ofmean 14.9 years post-operatively [104]. Another retrospec-tive study of 239 consecutive patients (324 hips total)younger than 50 years of age also demonstrated good clin-ical outcomes of ceramic-on-ceramic hip implants duringfollow-ups of 15.6 years [105]. Segura et al. investigateddifferences in clinical outcomes between patients whowere treated with ceramic-on-ceramic total hip replace-ment with an average age of 37.2 years and older onesaged on average of 64.7 years [106]. They did not observemajor differences in the 10-year post-operative follow-upin terms of the effectiveness and complications examinedwithin each group [106].

4.4. Ceramic-on-PolyethyleneAs a good total hip replacement material choice fora long time, the polyethylene wear rates of ceramic-on-polyethylene was lower comparing to metal-on-polyethylene total hip replacements [53, 54]. Li et al.carefully reviewed the clinical records of 207 con-secutive total hip replacements that used ceramic-on-polyethylene as the bearing surfaces. After a follow-upfor at least 12.4 years, the percentage survival of hipimplants was 99.03% [107]. Another randomized trialwas carried out by Atrey et al. to investigate if there isany difference in clinical outcomes of Alumina ceramic-on-ceramic and ceramic-on-polyethylene. After a follow-up period for at least 15 years, the survival rates andfunctional evaluation results of the two bearing groupswere similar [108]. In addition, another systematic reviewof 13 randomized trials also revealed that the HarrisHip Score appeared to be similar between groups ofceramic-on-ceramic and ceramic-on-polyethylene bearingsurfaces [109].

5. SUMMARYTHR has long been one of the most effective treat-ment options for hip joint diseases. Bearing surface mate-rial choice significantly affects the survival time of hipimplants. Over decades of tribology development in hipimplants, the bearing surfaces used in total hip replacementmainly includes polyethylene, metallic alloys, and ceram-ics. Polyethylene that is highly cross-linked was shownto result in substantially reduced wear in comparison toconventional polyethylene. However, the problems of oste-olysis and aseptic loosening caused by polyethylene parti-cles still need further study to be appropriately addressed.Metal-on-metal bearing surfaces that offer a large femoralhead diameter increase hip stability and optimize rangeof motion, but downsides include metal ion release andaseptic lymphocyte-dominated vasculitis-associated lesionresponse. Ceramic-on-ceramic bearing surfaces usually donot cause surface wear, thus rendering a long survival time;however, post-operative complications of such surfacesinclude ceramic fracture and squeaking. When choosingthe most suitable weight-bearing interface for individualhip joints, critical factors for consideration include age,sex, body mass index, activity, type of work, and eco-nomic benefit. Additionally, good surgical technique iscritical to reducing occurrence of bearing surface-relatedcomplications.

Acknowledgments: The project was supported bythe National Natural Science Foundation of China(Nos. 81960404 and 81960401), Guizhou Province Sci-ence and Technology Project ([2019]1429), Scientific andTechnological Research Project for Traditional ChineseMedicine and Folk Medicine of Guizhou ProvincialAdministration of Traditional Chinese Medicine (QZYY-2018-003), Doctoral Fund of Guizhou Provincial Peo-ple’s Hospital (Grant No. GZSYBS [2017] 04) and KeyScientific Research Projects for Medicine and Health ofGuangxi (Grant No. Emphasis 2010029).

References and Notes1. Mann, R.W., 2002. Comment on: Hip contact forces and gait

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109. Si, H.B., Zeng, Y., Cao, F., Pei, F.X. and Shen, B., 2015.Is a ceramic-on-ceramic bearing really superior to ceramic-on-polyethylene for primary total hip arthroplasty? A systematicreview and meta-analysis of randomised controlled trials. Hip Inter-national, 25(3), pp.191–198.

Received: 29 July 2019. Accepted: 25 August 2019.

Outcome analysis of various bearing surface materials used in ...

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