Fourth-Generation Ceramic-on-Ceramic THA in Patients with Ankylosing Spondylitis: A Minimum 10-Year Follow-Up

To report the long-term outcomes of total hip arthroplasty (THA) with fourth-generation ceramic-on-ceramic (CoC) bearing in patients with ankylosing spondylitis (AS).

We retrospectively identified 180 primary THAs performed in 110 patients with AS, including 100 (90.9%) men and 10 women (9.1%), from 2009 to 2011.The mean age of the patients at surgery was 33 years (range, 16 to 65 years). Cementless prostheses with fourth-generation CoC bearings were used in all patients. Survivorship of the implants and postoperative complications were calculated. Functional improvement was assessed by the hip flexion-extension range of motion (ROM) and Harris hip score (HHS). A special noise assessment questionnaire was performed at the last follow-up. The cumulative incidence of noise was calculated by the Kaplan-Meier method with 95% confidence intervals (CIs). Clinical characteristics and functional outcomes were compared in the hips with noise to those without noise.

The mean follow-up was 11 years (range, 10 to 12 years), and survivorship of the implants was 99.4% at the most recent follow-up. The complications included dislocation (one hip, 0.6%), periprosthetic joint infection (one hip, 0.6%), mild to moderate pain (five hips, 2.8%), heterotopic ossification (12 hips, 6.7%), and noise (52 hips, 28.9%). The flexion-extension ROM improved significantly with a median from 10° (range, 0 ~ 130°) to 100° (30 ~ 130°) after THA (p < 0.001), and the HHS increased significantly from 41 ± 20 to 90 ± 8 (p < 0.001). The cumulative incidence of noise at 0.5, 5, and 10 years was 6.1% (95% CI, 2.6 ~ 9.6), 16.7% (95% CI, 11.2 ~ 22.1), and 28.9% (95% CI, 22.2 ~ 35.5), respectively, and that of squeaking at 0.5, 5, and 10 years was 4.4% (95% CI, 1.4 ~ 7.4), 13.3% (95% CI, 8.4 ~ 18.3), and 23.9% (95% CI, 17.6 ~ 30.1), respectively. None of the patients with noise generation in the hip reported it affecting daily activities or causing dissatisfaction. No differences in age, sex, BMI, disease duration, bilateral THA, the frequency of bony ankylosis, the proportion of using a 36-mm-diameter femoral head, pre/postoperative flexion-extension ROM, or pre/postoperative HHS were found between hips with noise and those without noise (p > 0.05).

THAs with fourth-generation CoC bearings exhibit excellent long-term survival and clinical outcomes in patients with AS, with a very low dislocation rate. The incidence of noise associated with CoC bearings in THA performed in patients increases over time, but it does not affect postoperative hip function or daily activities.