Alternative Bearings, Meaning and Truth: What Patients Understand (2012)

Introduction Are there really ‘conventional’ bearings, offering more security and less risk than the ‘alternative’ bearings that feature in the programme? Alternative, when used as an adjective has 2 meanings: offering or expressing a choice, as in several alternative plans different from or functioning outside the usual or conventional: eg alternative newspaper, alternative rock music, alternative medicine This paper reviews the elements that make up the bearing couples available today in the developed world, and tests each bearing against these meanings. Materials what are the alternatives? The materials available today fall into the following broad families: Metals Stainless Steel and Cobalt-Chromium Alloy, are the dominant metals available. There is no variation in the Steel, but the characterisation of the Co-Cr does vary. Several manufacturers use different carbide content for the femoral and acetabular components, and different processes. One has been withdrawn from the market, and others may be at risk of this, although it is not the material itself that seems to be the main issue. Ceramics include alumina and zirconia ceramics. Alumina has been available unchanged for over 40 years, although delta ceramic (a zirconia toughened alumina) has only been available unchanged since 2001, making in available for 10 years. Polymers a huge range of polyethylenes are now available, with different individual claims. All claim superior wear resistance, and oxidation resistance. More than 20 unique products are available in the EU, each with a proprietary formula giving individual characteristics. Coatings and surface treatments these are now available today from many companies, who either ceramicise the surface of cobalt chrome or titanium with titanium nitride, or use oxinium (a proprietary product from a single company). Bearing couples what are the alternatives Symmetric and Asymmetric bearings are currently offered. Symmetric bearings are available for Ceramic on Ceramic and Metal on Metal bearings only. Asymmetric bearings are available with metals, including metal on poly, and metal on peek. Ceramics can couple with metal or polymers. Bearing Sizes Larger than 32mm should be considered ‘alternative’. The larger metal bearings have seen the start of crevice corrosion at the taper between titanium and Co-Cr, and even between different Co-Cr alloys. This new class of complication seems to be unique to metal femoral heads. Bearing-stem compatibility Larger metal on metal head bearings have brought an entirely new world of complications. The choices of trunion are mainly twofold: the 12/14 tapers which differ significantly between products, and the V40 taper still used by one manufacturer. Neither was designed for use with a larger diameter head. Conclusions The use of the word ‘alternative’ implies a ‘standard’ or conventional bearing. Ceramic bearings have changed least, have been immune from the metallosis and crevice corrosion seen with large ball Metal head whether bearing on metal or polyethylene. They also have reassuring long term results. In 2011 they should be considered the standard bearing for the young and active patient. The large diameter metal on highly cross-linked poly bearings should now be considered ‘alternative’.