Long-Term Results of Alumina Ceramic-On-Ceramic Bearings in Cementless Total Hip Arthroplasty: A 20-Year Minimum Follow-Up

Published:November 26, 2021DOI:https://doi.org/10.1016/j.arth.2021.11.028



      Alumina ceramic-on-ceramic bearings are used in total hip arthroplasty (THA) because of their wear-resistant and inert properties. In this study, we assessed the clinical and radiographic outcomes of patients undergoing primary cementless ceramic-on-ceramic THA at a minimum follow-up of 20 years.


      A series of 301 consecutive primary THAs in 283 patients were assessed. Clinically, patients were assessed with the modified Harris Hip Score (HHS) and pain questionnaires. Anteroposterior radiographs of the pelvis and lateral radiographs of the hip were used to radiologically assess the implant. Patients were classified as lost to follow-up if they could not be contacted on multiple occasions or did not wish to participate further in this study.


      At twenty years after operation, 60 patients had died of a cause unrelated to surgery, 16 had experienced complications requiring reoperation, and 100 hips had both clinical assessments and radiographs at a minimum of 20 years of follow-up. The average HHS improved from 56.1 (range: 17-89) before THA to 92.5 (range: 63-100) at the latest follow-up. The classification of the HHS was good or excellent in 96.4% of patients. Only 1.8% of patients still had moderate residual pain at the thigh or groin. Radiographically, all patients demonstrated bony ingrowth but no clinical symptoms of loosening. The overall survival rate of the implants was 94.2% at 20 years with revision for any reason as the end point.


      Long-Term follow-up in our series showed excellent implant survival, excellent functional outcomes, and minimal late complications. There was no significant radiographic evidence of failure at a minimum of 20 years after THA.

      Level of evidence

      Therapeutic Level IV.


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        • Boutin P.
        Arthroplasit totale de la hanche par prostheses en alumine fritte.
        Reparatrice Appar Mot. 1972; 58: 230-246
        • Capello W.N.
        • D'Antonio J.A.
        • Feinberg J.R.
        • Manley M.T.
        • Naughton M.
        Ceramic-on-ceramic total hip arthroplasty: update.
        J Arthroplasty. 2008; 23: 39-43
        • Yoon H.J.
        • Yoo J.J.
        • Yoon K.S.
        • Koo K.H.
        • Kim H.J.
        Alumina-on-alumina THA performed in patients younger than 30 years: a 10-year minimum followup study.
        Clin Orthop Relat Res. 2012; 470: 3530-3536
        • Sugano N.
        • Takao M.
        • Sakai T.
        • Nishii T.
        • Miki H.
        • Ohzono K.
        Eleven- to 14-year follow-up results of cementless total hip arthroplasty using a third-generation alumina ceramic-on-ceramic bearing.
        J Arthroplasty. 2012; 27: 736-741
        • Solarino G.
        • Piazzolla A.
        • Notarnicola A.
        • Moretti L.
        • Tafuri S.
        • De Giorgi S.
        • et al.
        Long-term results of 32-mm alumina-on-alumina THA for avascular necrosis of the femoral head.
        J Orthop Traumatol. 2012; 13: 21-27
        • Lee G.-C.
        • Knox D.E.
        • Garino J.P.
        Long-term results of hybrid alumina-on-alumina total hip arthroplasty: 10–14-Year results.
        Semin Arthroplasty. 2013; 24: 202-205
        • Kim Y.H.
        • Choi Y.
        • Kim J.S.
        Cementless total hip arthroplasty with ceramic-on-ceramic bearing in patients younger than 45 years with femoral-head osteonecrosis.
        Int Orthop. 2010; 34: 1123-1127
        • Kang B.J.
        • Ha Y.C.
        • Ham D.W.
        • Hwang S.C.
        • Lee Y.K.
        • Koo K.H.
        Third-generation alumina-on-alumina total hip arthroplasty: 14 to 16-year follow-up study.
        J Arthroplasty. 2015; 30: 411-415
        • Yeung E.
        • Bott P.T.
        • Chana R.
        • Jackson M.P.
        • Holloway I.
        • Walter W.L.
        • et al.
        Mid-term results of third-generation alumina-on-alumina ceramic bearings in cementless total hip arthroplasty: a ten-year minimum follow-up.
        J Bone Joint Surg Am. 2012; 94: 138-144
        • Johnston R.C.
        • Fitzgerald R.H.
        • harris W.H.
        • poss R.
        • muller M.E.
        • sledge C.B.
        Clinical and radiographic evaluation of total hip replacement.
        J Bone Joint Surg Am. 1990; 72: 161-168
        • Hatton A.
        • Nevelos J.E.
        • Nevelos A.A.
        • Banks R.E.
        • Fisher J.
        • Ingham E.
        Alumina-alumina artificial hip joints. Part I: a histological analysis and characterisation of wear debris by laser capture microdissection of tissues retrieved at revision.
        Biomaterials. 2002; 23: 3429-3440
        • Tippera J.L.
        • Hatton A.
        • Nevelos J.E.
        • Ingham E.
        • Doyle C.
        • Streicherd R.
        • et al.
        Alumina-alumina artificial hip joints.Part II: characterisation of the wear debris from in vitro hip joint simulations.
        Biomaterials. 2002; 23: 3441-3448
        • Yoon T.R.
        • Rowe S.M.
        • Jung S.T.
        • Seon J.K.
        • Maloney W.J.
        Osteolysis in association with a total hip arthroplasty Yoon.
        J Bone Joint Surg Am. 1998; 80-A: 1459-1468
        • Murali R.
        • Bonar S.F.
        • Kirsh G.
        • Walter W.K.
        • Walter W.L.
        Osteolysis in third-generation alumina ceramic-on-ceramic hip bearings with severe impingement and titanium metallosis.
        J Arthroplasty. 2008; 23: 1240.e13-9
        • Molloy D.
        • Jack C.
        • Esposito E.
        • Walter W.L.
        A Mid-term analysis suggesting ceramic on ceramic hip arthroplasty is durable with minimal wear and low risk of squeak.
        HSS J. 2012; 8: 291-294
        • Lusty P.J.
        • Tai C.C.
        • Sew-Hoy R.P.
        • Walter W.L.
        • Walter W.K.
        • Zicat B.A.
        Third-generation alumina-on-alumina ceramic bearings in cementless total hip arthroplasty.
        J Bone Joint Surg Am. 2007; 12: 2676-2683
        • Kang B.J.
        • Ha Y.C.
        • Hwang S.C.
        • Lee Y.K.
        • Koo K.H.
        Midterm results of large diameter Biolox forte ceramic head on Delta ceramic liner articulation in total hip arthroplasty.
        J Arthroplasty. 2014; 29: 2412-2414
        • Walter W.L.
        • O’toole G.C.
        • Walter W.K.
        • Zicat B.A.
        Squeaking in Ceramic-on-Ceramic hips, the importance of acetabular component orientation.
        J Arthroplasty. 2007; 22: 496-503
        • Restrepo C.
        The Noisy ceramic hip: is component malpositioning the cause?.
        J Arthroplasty. 2008; 23: 633-639
        • Restrepo C.
        • Post Z.D.
        • Kai B.
        • Hozack W.J.
        The effect of stem design on the prevalence of squeaking following ceramic-on-ceramic bearing total hip arthroplasty.
        J Bone Joint Surg Am. 2010; 92: 550-557
        • Kim Y.H.
        • Park J.W.
        • Kulkarni S.S.
        • Kim Y.H.
        A randomised prospective evaluation of ceramic-on-ceramic and ceramic-on-highly cross-linked polyethylene bearings in the same patients with primary cementless total hip arthroplasty.
        Int Orthop. 2013; 37: 2131-2137
        • D'Antonio J.A.
        • Capello W.N.
        • Naughton M.
        High survivorship with a titanium-encased alumina ceramic bearing for total hip arthroplasty.
        Clin Orthop Relat Res. 2014; 472: 611-616
        • Petsatodis G.E.
        • Papadopoulos P.P.
        • Papavasiliou K.A.
        • Hatzokos I.G.
        • Agathangelidis F.G.
        • Christodoulou A.G.
        Primary cementless total hip arthroplasty with an alumina ceramic-on-ceramic bearing: results after a minimum of twenty years of follow-up.
        J Bone Joint Surg Am. 2010; 92: 639-644
        • Hamadouche M.
        • Boutin P.
        • Daussange J.
        • Bolander M.
        • Sedel L.
        Alumina-on-aluminatotal hip arthroplasty.
        J Bone Joint Surg Am. 2002; 84A: 69-77
        • Synder M.
        • Drobniewski M.
        • Sibinski M.
        Long-term results of cementless hip arthroplasty with ceramic-on-ceramic articulation.
        Int Orthop. 2012; 36: 2225-2229
        • Hannouche D.
        • Zaoui A.
        • Zadegan F.
        • Sedel L.
        • Nizard R.
        Thirty years of experience with alumina-on-alumina bearings in total hip arthroplasty.
        Int Orthop. 2011; 35: 207-213
        • Al-Hajjar M.
        • Jennings L.M.
        • Begand S.
        • Oberach T.
        • Delfosse D.
        • Fisher J.
        Wear of novel ceramic-on-ceramic bearingsunder adverse and clinically relevant hip simulator conditions.
        J Biomed Mater Res B Appl Biomater. 2013; 101B: 1456-1462
        • Dalla Pria P.
        • Zagra L.
        • Esopi P.
        • Masoni D.
        Breakage and noises in ceramic on ceramic couplings.
        Eur Orthop Traumatol. 2010; 1: 53-59
        • Bal B.S.
        • Garino J.
        • Ries M.
        • Rahman M.N.
        A review of ceramic bearing materials in total joint arthroplasty.
        Hip Int. 2007; 17: 21-30
        • Garino J.P.
        The reliability of modern alumina bearings in total hip arthroplasty—update to a 2006 report.
        Semin Arthroplasty. 2013; 24: 193-201