Total hip arthroplasty (THA) continues to be one of the most successful surgical procedures in the medical field. However, over the last two decades, the use of modularity and alternative bearings in THA has become routine. Given the known problems associated with hard-on-hard bearing couples, including taper failures with more modular stem designs, local and systemic effects from metal-on-metal bearings, and fractures with ceramic-on-ceramic bearings, it is not known whether in aggregate the survivorship of these implants is better or worse than the metal-on-polyethylene bearings that they sought to replace.
Have alternative bearings (metal-on-metal and ceramic-on-ceramic) and implant modularity decreased revision rates of primary THAs?
In this systematic review of MEDLINE and EMBASE, we used several Boolean search strings for each topic and surveyed national registry data from English-speaking countries. Clinical research (Level IV or higher) with ≥ 5 years of followup was included; retrieval studies and case reports were excluded. We included registry data at ≥ 7 years followup. A total of 32 studies (and five registry reports) on metal-on-metal, 19 studies (and five registry reports) on ceramic-on-ceramic, and 20 studies (and one registry report) on modular stem designs met inclusion criteria and were evaluated in detail. Insufficient data were available on metal-on-ceramic and ceramic-on-metal implants, and monoblock acetabular designs were evaluated in another recent systematic review so these were not evaluated here.
There was no evidence in the literature that alternative bearings (either metal-on-metal or ceramic-on-ceramic) in THA have decreased revision rates. Registry data, however, showed that large head metal-on-metal implants have lower 7- to 10-year survivorship than do standard bearings. In THA, modular exchangeable femoral neck implants had a lower 10-year survival rate in both literature reviews and in registry data compared with combined registry primary THA implant survivorship.
Despite improvements in implant technology, there is no evidence that alternative bearings or modularity have resulted in decreased THA revision rates after 5 years. In fact, both large head metal-on-metal THA and added modularity may well lower survivorship and should only be used in select cases in which the mission cannot be achieved without it. Based on this experience, followup and/or postmarket surveillance studies should have a duration of at least 5 years before introducing new alternative bearings or modularity on a widespread scale.
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We thank Kay Daugherty, Campbell Foundation medical editor, for her aid in preparing this manuscript.
One of the authors (WMM) receives royalty payments, during the study period, an amount of USD 10,000 to USD 100,000 from B Braun/Aesculap Inc (Center Valley, PA, USA) and less than USD 10,000 from Elsevier Inc (Philadelphia, PA, USA); receives USD 10,000 to USD 100,000 as a consultant for B Braun/Aesculap Inc and less than USD 10,000 from Medtronic Inc (Memphis, TN, USA); receives research funding, during the study period, an amount of less than USD 10,000 from B Braun/Aesculap Inc and less than USD 10,000 Stryker Inc (Mahwah, NJ, USA); and serves on the editorial boards for the Journal of Arthroplasty, The Knee, the International Journal of Orthopaedics, and The Journal of Long Term Effects of Medical Implants. One of the authors (MAW) receives institutional funding in the amount of less than USD 10,000 from Biomet, Inc (Warsaw, IN, USA), USD 10,000 to USD 100,000 from CeramTec GmbH (Lauf, Germany), and material support from Zimmer Inc (Warsaw, Inc, USA) and B Braun/Aesculap AG. He is an unpaid consultant for Endolab GmbH and a paid consultant receiving an amount of less than USD 10,000 from Irwing Fritche Urquhart & Moore LLC (New Orleans, LA, USA). One of the authors (MPL) owns Zimmer Holdings, Inc stock but received no payments during the study period.
All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research ® editors and board members are on file with the publication and can be viewed on request.
Clinical Orthopaedics and Related Research ® neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA-approval status, of any drug or device prior to clinical use.
This work was performed at Rush University, Chicago, IL, USA; and Campbell Clinic/University of Tennessee, Memphis, TN, USA.
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Mihalko, W.M., Wimmer, M.A., Pacione, C.A. et al. How Have Alternative Bearings and Modularity Affected Revision Rates in Total Hip Arthroplasty?. Clin Orthop Relat Res 472, 3747–3758 (2014). https://doi.org/10.1007/s11999-014-3816-2
- Revision Rate
- Australian Registry
- Registry Report
- Alternative Bearing
- High Revision Rate