Ceramic-on-ceramic THA associated with fewer dislocations and less muscle degeneration by preserving muscle progenitors.

Background: Dislocation is a common complication after total hip arthroplasty (THA). Although the etiology of dislocation is multifactorial, longer-term changes in muscle such as atrophy may influence the risk of prosthetic dislocation. Biological differences in wear products generated by different bearing surfaces may influence differences in the appearance of periarticular muscle after THA; however, such bearing-associated differences to our knowledge have not been studied in vivo, and few studies have evaluated bearing-associated differences in dislocation risk.

Questions/purposes: (1) Is there a correlation between the postoperative risk of dislocation at revision and the bearing surfaces of the primary arthroplasty? (2) Is there a higher extent of fatty muscle atrophy on CT scan in hips with osteolysis (polyethylene hips) as compared with hips without osteolysis (ceramic-on-ceramic hips)? (3) Are these two abnormalities (bone osteolysis and fatty atrophy) associated with a decrease of mesenchymal stem cells (MSCs) in bone and in muscle?

Methods: We retrospectively evaluated 240 patients (240 hips) who had a THA revision (98% of which, 235 of the 240, were isolated acetabular revisions) and a normal contralateral hip. All patients had received the same implants for the primary arthroplasty (32-mm head) except for bearing surfaces (80 hips with ceramic-on-ceramic, 160 with polyethylene). No differences were noted between the groups in terms of age, sex, body mass index, proportion of patients who had a dislocation after the index arthroplasty but before the revision, and proportion of the patients with stem loosening in addition to acetabular loosening. Indications for revision generally were cup loosening. The revisions in the hips with polyethylene bearings generally had more acetabular bone loss, but the position of the center of the cup and the orientation of the cup were similar after reconstruction in the two groups. Before revision, osteolysis, muscle atrophy, and fatty degeneration were evaluated on CT scan and compared with the contralateral side. Bone muscle progenitors were evaluated by bone marrow MSCs and satellite cells for muscle. At revision, all the hips received the same implants with the same head diameter (32 mm) and a standard liner. Revisions were performed between 1995 and 2005. The followup after revision was at a mean of 14 years (range, 10-20 years) for ceramic revision and 12 years (range, 10-20 years) for polyethylene hips, and there was no differential loss to followup between the groups.

Results: More hips with polyethylene liners at the time of index arthroplasty dislocated after revision than did hips with ceramic liners (18% [29 of 160] compared with 1% [one of 80]; odds ratio, 17.5; 95% confidence interval, 2.3363-130.9100; p = 0.005). For the 80 hips with ceramic-on-ceramic, no osteolysis was detected before revision; there was no muscle fatty degeneration of the gluteus muscles on CT scan or histology. For the 160 hips with polyethylene liners, osteolytic lesions on the acetabulum and femur were observed in 100% of the hips. The increased atrophy of the gluteus muscles observed on CT scan correlated with the increase of osteolysis (r = 0.62; p = 0.012). The surgical limbs in the patients with polyethylene hips as compared with ceramic-on-ceramic hips demonstrated a greater reduction in cross-sectional area (respectively, 11.6% compared with 3%; odds ratio, 3.82; p < 0.001) and radiological density (41% [14.1/34.1] compared with 9%; odds ratio, 6.8; p = 0.006) of gluteus muscles when compared with the contralateral normal side. (41% compared with 9%; odds ratio, 6.8; p = 0.006).

Conclusions: Ceramic bearing surfaces were associated with fewer dislocations after revision than polyethylene bearing surfaces. The reasons of the lower rate of dislocation with ceramic-on-ceramic bearings may be related to observed differences in the periarticular muscles (fat atrophy or not) with the two bearing surfaces.

Level Of Evidence: Level III, therapeutic study.