Results of Cementless Total Hip Arthroplasty Using Third-Generation Ceramic-on-Ceramic Bearings: A Minimum 15-Year Follow-up.

Abstract

The third-generation ceramic-on-ceramic (CoC) total hip arthroplasty (THA) offers excellent wear resistance and biocompatibility, but is associated with unique complications such as ceramic fracture and squeaking. While fourth-generation ceramics have become the standard, long-term outcomes of third-generation bearings remain clinically relevant, especially in patients still living with these implants. We retrospectively reviewed 533 hips in 417 patients who underwent primary alumina-on-alumina THA using ceramic bearings with a minimum 15-year follow-up (mean 17.4 years). After excluding deaths and losses to follow-up, 317 hips in 234 patients were analyzed. Kaplan-Meier analysis assessed implant survivorship, and multivariate logistic regressions identified risk factors for ceramic fractures, reoperations, and audible joint noises. The 20-year implant survivorship was 85.2% when considering reoperation for any cause and 94.4% when limited to ceramic fracture. Most fractures (11 of 12) occurred after 10.9 years postoperatively. Significant risk factors for ceramic fracture included men (odds ratio (OR) = 6.94, P = 0.022), higher body mass index (exponential β = 1.22, P = 0.035), short-neck heads (OR = 9.17, P = 0.020), sandwich liners (OR = 17.41, P = 0.007), and prior audible noise (OR = 6.03, P = 0.013). Squeaking and clunking were particularly associated with increased fracture and reoperation risk. Despite these complications, average patient-reported outcome measures remained within acceptable ranges. A gradual decline in survivorship was observed beyond 15 years in third-generation CoC THAs, with a notable incidence of late-onset ceramic fractures. Risk factors included men, higher BMI, short-neck heads, sandwich liners, and articular noises. The use of 28-mm heads, even with medium necks, should be avoided when possible in favor of 32-mm or larger heads. For patients who have previously had a 28-mm implant, annual follow-up is recommended to monitor for late complications.