O R I G I N A L R E S E A R C H

Body mass index as a risk factor for mis-seating of ceramic liners in total hip arthroplasty
Mitchell Winemakerabc, Kirsteen Burtonad, Karen Finlayace, Danielle Petruccellibc and Justin de Beerabc
were more than two times more likely to suffer mis-seating than those who were underweight, of normal weight, or obese. Keywords ceramic liner, mis-seating, risk, radiographic review, total hip arthroplasty

ABSTRACT
Background A retrospective radiographic review was undertaken to determine the prevalence of mis-seated ceramic liners in primary total hip arthroplasty and the association between body mass index and mis-seating risk. Methods Patients with primary implantation of the Trident (Stryker, Mahwah, NJ) uncemented ceramic acetabular component were identied from a prospective database of 2227 primary total hip arthroplasties and radiographically reviewed. All procedures were performed at one center between 1999--2006. The mis-seating angle and location were determined. The risk of mis-seating by body mass index was calculated using logistic regression models. Results A total of 411 primary total hip arthroplasties were identied. Mis-seating occurred in 81 patients (19.7%). Of the 411 total hip arthroplasties, 83 (20.2%) were performed in patients with a body mass index of less than 25.0 dened as underweight to normal, 133 (32.4%) in patients who were overweight with a body mass index between 25.0--29.9, and 195 (47.4%) in patients who were obese with a body mass index of over 30.0. Adjustment for case mix revealed a signicant association between body mass index and risk of mis-seating of ceramic components. Patients who were overweight at the time of total hip arthroplasty (body mass index 25.0--29.9) were at increased risk of mis-seating (adjusted odds ratio 2.52, 95% condence interval (1.24-5.12, P 0.01). Conclusions Mis-seating of ceramic acetabular systems in total hip arthroplasty was a frequent occurrence. Patients who were overweight

INTRODUCTION
he implication of mis-seated ceramic liners has yet to be determined, and at present seems to be a radiographic abnormality without an effect on clinical outcome in the short term.1,2 The purpose of the current study was to examine the prevalence of mis-seated ceramic liners in primary total hip arthroplasty (THA) at our institution and to determine the association between body mass index (BMI) and the presence of mis-seated ceramic liners in THA. Based on our clinical perception and support for difcult surgical exposure in obese patients, we hypothesized that greater BMI would be associated with a greater risk of mis-seated ceramic liners in primary THA.

MATERIALS AND METHODS

A retrospective radiographic review of primary THA procedures using the Trident uncemented ceramic acetabular component (Stryker, Mahwah, NJ) was undertaken (Figure 1). All primary THA cases implanted with the Trident acetabular system were abstracted from a prospectively tabulated arthroplasty database of 2227 cementless primary hips performed at one center, either by or under the direct supervision of one of six high-volume arthroplasty surgeons between 1999 and 2006. The Trident acetabular components are comprised of a metal-backed shell that is xed to the acetabular bone. The liner that ts into the metal-backed shell is comprised of a ceramic component that is manufactured within a metal casing (metal-ceramic composite) that locks into the metal back shell through a morse taper principle (i.e. the locking mechanism is a metal-metal interface). This locking mechanism differs from the inner ceramic bearing surface that mates with a ceramic head. The ceramic-ceramic interface is where the normal hip motion occurs. The locking mechanism, which is the metal-metal interface is purely designed to house the ceramic liner against the metal backed shell. This metal-metal interface is where mis-seating can occur and is the subject of this current study. It should be noted that the ceramic liner in this second generation of the Trident shell was designed this way to avoid having surgeons impact a pure ceramic liner against metal, which has more potential Current Orthopaedic Practice

McMaster University, Hamilton, Ontario, Canada Hamilton Arthroplasty Group, Hamilton, Ontario, Canada c Hamilton Health Sciences Henderson Hospital, Hamilton, Ontario, Canada d Radiologist-Scientist Training Program, University of Toronto, Department of Medical Imaging, Toronto, Ontario, Canada e Diagnostic Radiology, McMaster University, Hamilton, Ontario, Canada Correspondence to Danielle Petruccelli, MLIS, MSc, Hamilton Arthroplasty Group, Hamilton Health Sciences Henderson Hospital, 711 Concession St., Hamilton, Ontario, Canada L8 V 1C3 Tel: 905 527 4322, ext. 42296; fax: 905 389 5617; e-mail: petrucce@hhsc.ca None of the authors (or members of their immediate families) have a nancial interest or other relationship with a commercial company related directly or indirectly with the scientic material presented in this manuscript.
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radiograph and this assessment was used to resolve the disagreement. Kappa coefcient calculations were used to assess the inter-rater reliability of the proportion of misseated ceramic liners. Patient demographics, including gender, age and BMI recorded at the time of preoperative assessment were abstracted from the arthroplasty database to determine correlation with mis-seating. Implant cup size also was abstracted to determine the relationship to mis-seating. Outcomes measured included the prevalence of mis-seated ceramic liners, and the risk of BMI category including; underweight to normal (BMI < 25.0), overweight (BMI 25.0--29.9), and obese (BMI Z 30.0), as it relates to ceramic liner mis-seating. Chi-square tests and Pearsons correlation coefcients were used to assess baseline differences between patient groups as well as unadjusted clinical outcomes between patient groups. Logistic regression analyses were used to identify only the factors associated with an increased risk of mis-seated ceramic liners while adjusting for patient baseline characteristics.

RESULTS
FIGURE 1. Arrows show a properly seated metal-ceramic liner.

for fracture of the ceramic material. In addition, it was thought that by recessing the ceramic liner within a metal casing, there would be less risk of neck impingement on ceramic during range of motion, which was again designed to reduce the incidence of ceramic rim fractures. Three authors, including one orthopaedic surgeon, one radiologist, and one radiology resident, blindly and independently reviewed most recent postoperative hip radiographs to identify mis-seated liners (Figure 2). Two reviewers (KB and JDB) assessed each radiograph. If the two reviewers agreed that mis-seating existed, then a third review of the radiograph was not required. However, if the two reviewers disagreed, then a third reviewer (KF) was asked to assess the

FIGURE 2. Mis-seated metal-ceramic liner.

A total of 426 patients with primary cementless THA using the Trident uncemented acetabular component were abstracted from the arthroplasty database of 2227 cementless primary hips. Of these, radiographs were unavailable for 15 patients and thus were excluded from the study. The study sample was comprised of a total of 411 patients implanted with the Trident uncemented acetabular components. Implants included Stryker Omnit, Securt, or Accolade femoral stem (Stryker, Mahwah, New Jersey). Femoral head sizes were 28, 32 or 36 mm. Radiographic review was conducted at a mean follow-up of 18.8 months postoperatively (SD 16.2). The mean age of the study group receiving primary ceramic-on-ceramic THA was 55 years (SD 9.2), with 52% being men. The preoperative diagnosis was osteoarthritis in 89.4% of patients, rheumatoid arthritis in 6% and avascular necrosis in 4.6% of patients. THA liner mis-seating occurred in 80 patients (19.5%). Inter-observer agreement as to the presence of mis-seated ceramic liners was moderate (kappa 0.43--0.52). Of the 80 mis-seated liners, 40 were in men and 40 were in women. There was no correlation between sex and misseating (r 0.018; P 0.717). Of the 411 THAs, 83 (20.2%) were performed in patients with BMIs that were dened as underweight to normal (BMI < 25.0), 133 (32.4%) in patients who were overweight (BMI 25.0--29.9), and 195 (47.4%) in patients who were obese (BMI Z 30.0). In comparison with patients who did not have a misseated liner, patients who did incur a mis-seated liner did not have a signicantly different trend in BMI (w2 trend, P 0.09). However, adjustment for case mix, THA femoral component type, surgeon and year of the procedure revealed a signicant association between BMI and risk of mis-seating. Patients who were overweight at the time of THA (BMI 25.0--29.9) were at increased risk of liner misseating (adjusted odds ratio [OR] 2.52, 95% condence interval [CI], 1.24-5.12, P 0.01; Table 1).

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TABLE 1. Metal-ceramic liner mis-seating risk

Crude Mis-seated THA BMI BMI < 25.0 BMI 25.0-29.9 BMI Z 30.0 OR (95% CI) 1.00 2.00 (1.06-3.76) 1.28 (0.71-2.30) P-value 0.03 0.42 OR (95% CI) 1.00 2.52 (1.24-5.12) 1.21 (0.64-2.26) Adjusted P-value 0.01 0.56

Model adjusted for age, gender, clinical diagnosis, surgeon, and procedure year. BMI indicates body mass index; CI, condence interval; OR, odds ratio; THA, total hip arthroplasty.

Intraoperative characteristics differed signicantly according to THA mis-seating status. Univariate analysis revealed that liner mis-seating was more likely to occur in procedures performed by certain surgeons (w2 trend, P 0.01) and procedures performed in more recent years (w2 trend, P 0.02). Mean cup size for the mis-seated liner group was 53 mm (SD 3.5) and 52 mm (SD 12.9) for the well-seated group; the mean difference was neither clinically signicant nor clinically relevant. Mis-seating was not signicantly correlated with the cup size (r 0.058, P 0.247).

DISCUSSION
Modular ceramic liners in primary THA are widely used to permit exible intraoperative component selection and possibly allow for more limited future revision.2,3 Modularity does, however, introduce the possibility of component dissociation and backside wear.4,5 In addition, with modularity there is the potential for mis-seating of the liner within the outer shell.1 Results of this study show that mis-seating of acetabular ceramic-ceramic liners is a frequent occurrence (19.5%) using the Trident acetabular implant in primary THA. The longterm outcomes of this nding are unknown and need to be followed. Thus far, no mis-seated liners have dislodged in our series. There may be some concern regarding the revisability of a cold-welded poorly seated liner. No experience is available on whether one will be able to do a limited liner exchange revision into a shell that was previously cold-welded from poor seating of the liner. Intuitively, every effort should be made to reduce the incidence of mis-seated liners. To the best of our knowledge, this is the rst study of its kind to link ceramic liner mis-seating to patient BMI. Inferior clinical outcomes and increased complications in THA have been attributed to an excessive BMI.6,7 This is a controversial issue and some authors disagree.8,9 Technical misadventure related to obesity is poorly documented in the literature to our knowledge; however, most surgeons agree that surgical exposure can be more difcult in obese patients. Obesity has been linked to increased dislocations, infections and poorer function, but not to component malposition specically.6,7 It was interesting to note that the year of THA procedure and surgeon differed signicantly between the mis-seated and well-seated liners. Surgeon experience as implied by volume of THAs performed did not correlate with misseating in our study. More mis-seated liners in recent years (2005--2006) may be due to a perceived trend toward smaller surgical exposures in our hospital stemming from an interest

in less invasive surgery. This was not something we were able to evaluate in a retrospective manner. An observation that would endorse this as a possible contributing factor is that mis-seating invariably occurs at the inferior margin of the cup, which is the most difcult area of the rim to see at the time of surgery. We were informed by the manufacturer that implant tolerances and specications did not change in this study period, which could have been another source for potential mis-seating. We had hypothesized that obese patients (BMI Z 30) would be at increased risk of mis-seated liners, but instead found that the overweight group (BMI 25--29.9) were at higher risk. We would conclude that mis-seating is related to inadequate exposure of the periphery of the metal-ceramic liner during seating. It may be that the surgeons were more likely to enlarge incisions in morbidly obese patients, but were more prepared to struggle in overweight patients by avoiding larger incisions, inadvertently contributing to misseating. This may further be exacerbated by the overweight patients being more muscular rather than fat, which may hinder exposure of the cup more than in the obese group. We would emphasize the importance of full exposure of the outer shell at the time of liner insertion, and in this respect, adequate surgical exposure is key. We acknowledge that there may be other confounding variables that were not captured in our study that might contribute to ceramic liner mis-seating. Langdown et al.1 and Squire et al.10 have suggested that there is deformation of the outer acetabular shell in hard bone contributing to liner mis-seating. It may also be that incomplete seating of acetabular screws contributed to mis-seating of liners. We suggest the following technical advice to reduce the risk of metal-ceramic liner mis-seating: (1) ensure adequate circumferential exposure of the acetabular outer shell; (2) clear osteophytes and soft tissue from the margin of the outer acetabular component; (3) ensure that acetabular screws are fully countersunk into the outer acetabular component before liner seating; (4) under-ream by only 1 mm in hard bone as compared to the recommended 2 mm with the current implant used in this study to reduce potential for acetabular shell deformation during impaction into the native socket; (5) ensure the metal-ceramic liner is seated square with the outer shell before impaction so the two metals do not engage or cold--weld eccentrically; (6) always conrm the locking of the two metal components by stressing the junction with a Cobb elevator in two locations that are 50% the diameter of the cup apart.

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In conclusion, there is an increased risk of ceramic liner mis-seating in primary THA among patients who are considered overweight with respect to BMI classication. Surgeons should be aware of this potential problem and should recognize and limit the incidence, particularly in this at risk population. The long-term effects of mis-seated liners remain to be determined. REFERENCES
1. Langdown AJ, Pickard RJ, Hobbs CM, et al. Incomplete seating of the liner with the Trident acetabular system: a cause for concern? J Bone Joint Surg. 2007; 89(B):291--295. 2. Miller AN, Su EP, Bostrom MP, et al. Incidence of ceramic liner malseating in Trident acetabular shell. Clin Orthop Relat Res. 2009; 467:1552--1556. 3. Blaha JD. Well-xed acetabular component retention or replacement: the whys and the wherefores. J Arthroplasty. 2002; 17(4 suppl 1):157--161.

4. Barrack RL. Concerns with cementless modular acetabular components. Orthopedics. 1996; 19:741--743. 5. Huk OL, Bansal M, Betts F, et al. Polyethylene and metal debris generated by non-articulating surfaces of modular acetabular components. J Bone Joint Surg. 1994; 76(B): 568--574. 6. Grant JA, Viens N, Bolognesi MP, et al. Two-year outcomes in primary THA in obese male veterans administration medical center patients. Rheumatol Int. 2008; 28:1105--1109. 7. Vincent HK, Weng JP, Vincent KR. Effect of obesity on inpatient rehabilitation outcomes after total hip arthroplasty. Obesity. 2007; 15:522--530. 8. Parvizi J, Trousdale RT, Sarr MG. Total joint arthroplasty in patients surgically treated for morbid obesity. J Arthroplasty. 2000; 15:1003--1008. 9. Haverkamp D, de Man FH, de Jong PT, et al. Is the long-term outcome of cemented THA jeopardized by patients being overweight? Clin Orthop Relat Res. 2008; 466:1162--1168. 10. Squire M, Grifn WL, Mason JB, et al. Acetabular component deformation with press-t xation. J Arthroplasty. 2006; 21 (6 suppl 2):72--77.