Aims

In 2015, we published the results of our ceramic-on-metal (CoM) total hip arthroplasties (THAs) performed between October 2007 and July 2009 with a mean follow-up of 34 months (23 to 45) and a revision rate of 3.1%. The aim of this paper is to present the longer-term outcomes.

The October 2024 Hip & Pelvis Roundup³⁶⁰ looks at: Does the primary surgical approach matter when choosing the approach for revision total hip arthroplasty?; Time to achieve the minimal clinically important difference in primary total hip arthroplasty: comparison of anterior and posterior surgical approaches; To scope or not to scope: arthroscopy as an adjunct to PAO does not provide better clinical outcomes at one year than PAO alone; Re-exploring horizons in hip resurfacing: two-year results of a ceramic-on-ceramic hip resurfacing; Association between tranexamic acid and decreased periprosthetic joint infection risk in patients undergoing total hip and knee arthroplasty; Octogenarians fare well: in revision for infection age is not a bar.

Ceramic-on-ceramic (CoC) articulations in total hip arthroplasty (THA) have low wear, but the unique risk of fracture. After revision for CoC fracture, ceramic third bodies can lead to runaway wear of cobalt chrome (CoCr) causing extremely elevated blood cobalt. We present five cases of ceramic liner fractures revised to a CoCr head associated with the rapid development of severe cobalt toxicity. We identified 5 cases of fractured CoC THA treated with revision to CoCr on highly cross-linked polyethylene (HXLPE) – three to conventional bearings and two to modular dual mobility bearings (CoCr acetabular liner, CoCr femoral head, and HXLPE). Mean follow up was 2.5 years after CoCr/HXLPE re-revision. Symptoms of cobalt toxicity occurred at average 9.5 months after revision for ceramic fracture (range 6–12). All patients developed vision and hearing loss, balance difficulties, and peripheral neuropathy. Several had cardiomyopathy, endocrinopathy, and local skin discoloration. Two reported hip pain. Re-revision for cobalt toxicity occurred at an average of 22 months (range 10–36) after revision for ceramic fracture. Average serum cobalt level at re-revision was 991 μg/L (range 734–1302, normal <1 μg/L). All CoCr heads exhibited massive wear with asphericity; deep tissues exhibited prominent metallosis. Treatment consisted of debridement and revision to a ceramic head with HXLPE. Serum cobalt improved to an average of 25 μg/L at final follow up. All patients reported partial improvement in vision and hearing; peripheral neuropathy and balance did not recover. Systemic cobalt toxicity is a rare but devastating complication of ceramic fracture in THA treated with cobalt-alloy bearings. Cobalt alloy bearings should be avoided in this setting. The diagnosis of systemic cobalt toxicity requires a high index of suspicion and was typically delayed following systemic symptoms. Debridement and revision to a ceramic-on-HXLPE leads to improvement but not resolution of cobalt toxicity complications

Ceramic bearing fracture is a rare complication following implantation using modern day ceramic bearing materials. Revision bearing options in such cases is debated, with the choice between ceramic-on-ceramic and ceramic-on-polyethylene bearings. Revision to a hard on soft bearing raises concerns about potential catastrophic wear secondary to a third-body reaction caused by the fractured ceramic particles. Data was collected retrospectively from the NJR, electronic patient records, revision database and picture archiving and communication system. Templating software was used to determine linear wear between first post-operative radiograph and the latest available follow up. Univariate analysis was used to examine patient demographics and the wear rates for revision of ceramic bearing fractures to ceramic on polyethylene components. The intra and inter-rater reliability of wear measurements was calculated. There were twelve patients identified as meeting the inclusion criteria. The average age at revision was 62 years (54–72). There were 6 liner and 6 head fractures revised to delta ceramic heads and cross-linked polyethylene acetabular components. The most frequently used head size was 32mm. At mean follow up of 3.8 years (0.5 6.1 years), median 4.4 years, linear wear rate was calculated at 0.08± 0.06 mm/year. Both intra-rater and inter-rater reliability was excellent with ICC scores of 0.99 at all timepoints. Revision to ceramic on polyethylene (CoP) bearings following ceramic fracture does not cause early catastrophic wear at early follow up. It appears safe to use this hard on soft bearing combination, given that wear rates are comparable to what is expected in a primary hip replacement setting. Longer follow up is required to establish if this trend persists

Ceramic bearing fractures are rare events, but mandate revision and implantation of new bearings. Revisions using metal heads have been reported to lead to gross volumetric head wear (due to abrasive retained ceramic micro-debris), cobalt toxicity, multi-organ failure and death. Such complications are widely published (50+ reports), yet we know that patients continue to be put at risk. Using data from the NJR and AOANJRR, this study seeks to compare the risk of re-revision and death by revision bearing combination following a ceramic bearing fracture. Data were extracted from the NJR and AOANJRR, identifying revisions for ceramic bearing fracture. Subsequent outcomes of survival, re-revision and death were compared between revision bearing combinations (ceramic-on-ceramic, ceramic-on-polyethylene, and metal-on-polyethylene). 366 cases were available for analysis from the NJR dataset (MoP=34, CoP=112, CoC=221) and 174 from the AOANJRR dataset (MoP=17, CoP=44, CoC=113). The overall incidence rate of adverse outcome (revision or death) was 0.65 for metal heads and 0.23 for ceramic head articulations (p=0.0012) across the whole time period (NJR). Kaplan-Meir survival estimates demonstrate an increased risk of both re-revision and death where a metal head has been used vs a ceramic head following revision for ceramic fracture. There are few decisions in arthroplasty surgery that can lead to serious harm or death for our patients, but revision using a metal head following ceramic bearing fracture is one of them. This study enhances the signal of what is already known but previously only reported as inherently low-level evidence (case reports and small series) due to event rarity. Use of a metal head in revision for ceramic fracture represents an avoidable patient safety issue, which revision guidelines should seek to address

Introduction and Objective. Ceramic on Ceramic bearings in Total Hip Arthroplasty (THA) afford a low friction coefficient, low wear rates and extreme hardness. Significant complications include hip squeak, ceramic fracture and poor polyethylene performance in revision procedures due to imbedding of abrasive microscopic ceramic fragments. We report on the results of this bearing at a minimum of 10 years. Materials and Methods. A single-centre retrospective review of 449 THAs was performed. Primary outcome measures included aseptic revision and all-cause revision rates at a minimum of 10 years post operatively. Evaluation of functionality was performed with WOMAC and SF-36 scores which were performed pre-operatively and at intervals of 6 months, one year, 2 years, 5 years and 10 years post operatively. Results. There was a 6.2% (n=28) all-cause and 5.3% (n=24) aseptic revision rate for ceramic on ceramic total hip arthroplasty at minimum of 10 years with a mean time to revision 4.8 years (range 2 months − 11.6 years). Notably, there were 2 revisions for ceramic head fracture, one for ceramic liner fracture, 3 for aseptic loosening and 3 revisions for squeaking. Pain of unknown origin was the most common reason for revision. There was an improvement in postoperative WOMAC scores from a mean of 59.8 (range 15–95) pre-operatively to a mean of 15.6 (range 0–78) at 10 years. Conclusions. This study showed good functional outcomes but high revision rates for CoC THA at a minimum of 10 years. The role for CoC bearings in THA has been called into question in recent years and may continue to decline in popularity, even in younger patients. Further large scale studies are important to assess the long-term outcomes of this bearing surface

Fracture risks are the most common argument against the use of Ceramic on ceramic (CoC) hip implants. Question: is ceramic material at risk in case of severe local trauma?. Over a long period, we tried to identify patients with a CoC prosthesis (Ceraver Osteal°)who did sustain a trauma. This was conducted in three different institutions. Eleven patients were found: 9 males and 2 females aged 17 to 70 years at time of index surgery. Accident occurred 6 months to 15 years after index: one car accident, five motorcycle accident, five significant trauma after a fall, including one ski board accident. Consequences of these trauma were: six fractures of the acetabulum with socket loosening in 4 that needed revision, two femoral shaft fracture, one orifed and one stem exchanged, one traumatic hip dislocation associated to loosening of the socket revised at 10 years, and one traumatic loosening of the socket. Ten had no consequence on ceramic integrity. One experienced a fracture of the patella from a dashboard trauma, a liner shipping was discovered during socket revision 2 years later. This is the only case of possible relation between trauma and ceramic fracture. In a more recent longitudinal study on 1856 CoC prosthesis performed from 2010 to 2021, 29 severe traumas were identified with no consequence on Ceramic material. From this limited case study, it can be assumed that Pure Alumina Ceramic well designed and manufactured, will not break after a significant trauma

Aims

The Exeter V40 cemented femoral stem was first introduced in 2000. The largest single-centre analysis of this implant to date was published in 2018 by Westerman et al. Excellent results were reported at a minimum of ten years for the first 540 cases performed at the designer centre in the Exeter NHS Trust, with stem survivorship of 96.8%. The aim of this current study is to report long-term outcomes and survivorship for the Exeter V40 stem in a non-designer centre.

Aims

In patients with a “dry” aspiration during the investigation of prosthetic joint infection (PJI), saline lavage is commonly used to obtain a sample for analysis. The aim of this study was to investigate prospectively the impact of saline lavage on synovial fluid analysis in revision arthroplasty.

Introduction & aims. Apparently well-orientated total hip replacements (THR) can still fail due to functional component malalignment. Previously defined “safe zones” are not appropriate for all patients as they do not consider an individual's spinopelvic mobility. The Optimized Positioning System, OPS. TM. (Corin, UK), comprises preoperative planning based on a patient-specific dynamic analysis, and patient-specific instrumentation for delivery of the target component alignment. The aim of this study was to determine the early revision rate from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) for THRs implanted using OPS. TM. . Method. Between January 4. th. 2016 and December 20. st. 2017, a consecutive series of 841 OPS. TM. cementless total hip replacements were implanted using a Trinity acetabular cup (Corin, UK) with either a TriFit TS stem (98%) or a non-collared MetaFix stem (2%). 502 (59%) procedures were performed through a posterior approach, and 355 (41%) using the direct superior approach. Mean age was 64 (range; 27 to 92) and 51% were female. At a mean follow-up of 15 months (range; 3 to 27), the complete list of 857 patients was sent to the AOANJRR for analysis. Results. There were 5 revisions: . a periprosthetic femoral fracture at 1-month post-op in a 70F. a ceramic head fracture at 12-months post-op in a 59M. a femoral stem loosening at 7-months post-op in a 58M. a femoral stem loosening at 16-months post-op in a 64M. an anterior dislocation in a 53M, that was revised 9 days after the primary procedure. CT analysis, prior to revision surgery, revealed acetabular cup orientation of 46°/31° (inclination/anteversion) and femoral stem anteversion of 38°. Conclusions. These preliminary findings suggest the OPS. TM. dynamic planning and delivery system provides good early results, with a low rate of revision for dislocation. Limitations of the study will be discussed

The disadvantage of removing a well-fixed femoral stem are multiple (operating time, risk of fracture, bone and blood loss, recovery time and post-op complications. Ceramic heads with titanium adapter sleeves (e.g. BIOLOX®OPTION, Ceramtec) are a possibility for putting a new ceramic head on slightly damaged used tapers. ‘Intolerable’ taper damages even for this solution are qualitatively specified by the manufacturers. The aim of this study was to determine the fracture strength of ceramic heads with adapter sleeves on stem tapers with such defined damage patterns. Pristine stem tapers (Ti-6Al-4V, 12/14) were damaged to represent the four major stem taper damage patterns specified by the manufacturers: . -. ‘Truncated’: Removal of 12.5% of the circumference along the entire length of the stem taper at a uniform depth of 0.5mm parallel to the taper slope. -. ‘Slanted’: Removal of 33.3% of the proximal diameter perimeter with decreasing damage down to 3.7mm from the proximal taper end. -. ‘Cut’: Removal of the proximal 25% (4mm) of the stem taper. -. ‘Scratched’: Stem tapers from a previous ceramic fracture test study with a variety of scratches and crushing around the upper taper edge from multiple ceramic head fractures. -. The ‘Control’ group consisted of three pristine tapers left undamaged. BIOLOX®OPTION heads (Ø 32mm, length M) with Ti adapter sleeves were assembled to the damaged stem tapers and subjected to ISO7206-10 ultimate compression strength testing. The forces required to fracture the head were high and caused complete destruction of the ceramic heads in all cases. The ‘Truncated’ group showed the lowest values (136kN ± 4.37kN; Fig. 3). Forces were higher and similar for the ‘Cut’ (170kN ± 8.89kN), ‘Control’ (171.8 ± 16.5kN) and ‘Slanted’ (173kN ± 21.9kN) groups, the ‘Scratched’ group showed slightly higher values (193kN ± 11.9kN). The Ti adapter sleeves were plastically deformed but did not fail catastrophically. The present study suggests that manufacturer's recommendations for removal of a well fixed femoral stem could be narrowed down to the ‘Truncated’ condition. Even this might not be necessary since the fracture load is still substantially higher than the ASTM standard requires. Surgeons should consider to keep stems with larger taper damages as previously thought and spare the patient from stem revision. The greatest reservation regarding adapter sleeves is the introduction of the new metal-on-metal interface between stem and sleeve, which could possibly facilitate fretting-corrosion, which is presently one of the major concerns for modular junctions (3). Clinically such problems have not been reported yet. Ongoing FE-simulations are performed to investigate whether micromotions between stem and head taper are altered by the investigated damages

Ceramic bearings have several desirable properties, such as resistance to wear, hardness, and biocompatibility, that favour it as an articulating surface in hip arthroplasty. However, ceramic fracture remains a concern. We have reviewed the contemporary literature, addressing the factors that can influence the incidence of ceramic bearing surface fracture. Cite this article: Bone Joint J 2019;101-B:897–901

Aims

This study reports the mid-term results of total hip arthroplasty (THA) performed using a monoblock acetabular component with a large-diameter head (LDH) ceramic-on-ceramic (CoC) bearing.

This was a retrospective study of registry data from a National Orthopaedic Hospital for all THRs with 10-year follow-up data. Inclusion criteria were all THRs with a minimum of 10-year follow-up data. All metal-on-metal (MoM) THRs and MoM resurfacings were excluded from the analysis due to the high rate of revision associated with these bearings. Univariate and multivariate analyses controlling for confounding variables were performed to compare outcomes. A total of 1,697 THRs were performed in 1,553 patients. The four significant predictors for revision were fixation type (p<0.01), surface bearing type (p<0.01), age (P<0.05) and head size (p<0.05). Gender, BMI and approach had no effect on revision rates. The lowest 10-year all-cause revision rates were seen in cemented THRs at 1.7%. Ceramic-on-poly bearings had the lowest revision rate at only 1.2%. Metal-on-poly bearings had a 1.7% revision rate. Ceramic on ceramic bearings had a 7.1% revision rate with 1 revision for squeak and 1 revision for ceramic head fracture. The causes for revision in order of decreasing frequency were as follows: Infection (n=13, 0.7%), dislocation (n=7, 0.4%), periprosthetic fracture (n=3, 0.2%) and aseptic loosening (n=2, 0.1%). There were 2 re-revisions at 10 years in total. The smaller 22.225mm head sizes had a significantly lower revision rate than other head sizes (p<0.05). Ceramic-on-poly bearings, cemented fixation and smaller head sizes perform better in the experience of this registry. However, with multivariate analysis, these differences were shown to be insignificant

Introduction. Long term results of Total Hip Arthroplasty (THA) are affected by wear of articulation. Ceramic on ceramic articulation have been used especially for young patients because of its low wear and bio-inert property. However, because of its hardness, it is concerned that ceramic fracture, chipping, or squeaking might happen with ceramic on ceramic articulation. Objective. The purpose of this study was to investigate over 10-years clinical and radiographic results of ceramic bearing cementless THA. Methods. Evaluation was performed in 60 patients (68 joints) who underwent primary cementless THA from May 2003 to April 2007. Mean age at surgery was 59 years. Mean follow up period was 11.2 years. Forty-nine patients were female. Mean BMI at surgery was 24.0 kg/m. 2. Fifty-one patients had osteoarthrosis, 6 patients had osteonecrosis, 2 patients had rheumatoid arthraitis, and 1 patient had PSS. A 28mm-size femoral head was used in all patients. Clinical evaluation was performed with Japanese Orthopaedic Association Hip Score (JOA score). Radiographic results were evaluated with standard bilateral hip radiograph in supine position. Results. Mean clinical score at surgery was 45 (pain: 13/40, ROM: 12/20, gait: 9/20, ADL: 12/20). Mean clinical score at final follow up was 92 (pain: 39/40, ROM: 17/20, gait: 17/20, ADL: 18/20). Pain score was dramatically improved from 13 to 39 (maximum pain score: 40). One stem was revised because of recurrent dislocation. Two other patients experienced one time dislocation during follow up. One stem showed 5mm of subsidence. ALL cups and stems showed bone ingrowth at final follow up. Cortical hypertrophy was seen in 17 joints. However, there was no patient complained thigh pain. Stress shielding was seen in 55 joints (81%). First, second and third degree of stress shielding were seen in 12, 40, and 3 joints, respectively. Most of the female patients who had surgery at the age over 60 years showed second and third degree of stress shielding. There was no measurable wear. No osteolysis was found around the implants. There were no ceramic fracture, chipping, and squeaking. Conclusion. This study demonstrated excellent clinical and radiographic results of ceramic bearing cementless THA. Excellent long term results will be expected with this system

We report a case of fatal heart failure caused by cobalt intoxication after revision THR in the patient who successfully underwent re-revision THR. 53-year old male presented to emergency room in our hospital with progressive shortness of breath. Symptom was started about 6 months ago so he visited local hospital. He worked up for worsening dyspnea. Simple chest radiograph and enhanced heart MRI study were performed and they showed bilateral pericardial and pleural effusion. There was no evidence of ischemic change. Transthoracic echocardiogram showed the evidence of heart failure, left ventricular ejection fraction(EF) was 40%. He was admitted at local hospital and started on vasopressors but urine output was decreased and follow-up echocardiogram showed a 25% of EF. Patient recommended heart transplantation and transferred our hospital emergency room. He underwent sequential bilateral total hip arthroplasties using CoP bearing surfaces. At 12 years postoperatively, he presented to the other hospital with acute onset of left hip pain. He was diagnosed ceramic head fracture on his left hip. Head and liner change revision surgery was performed using Cobalt-Chrome alloy 28mm metal head and Protruded cross-linked polyethylene liners. In our hospital, the patient admitted cardiovascular department of internal medicine. Patient complained nonspecific fatigue and general weakness but had no other symptoms such as visual and hearing loss, cognitive dysfuction. During work-up, patient presented progressive left hip pain and complaint of discomfort for the mass on the left groin. He also complained Left leg weakness and numbness. Simple radiograph and enhanced CT study was done. Simple radiograph image shows radiodense area around the hip joint and radiologist suspected heterotopic ossification. The cardiovascular department consulted orthopedic department. In the image findings showed huge mass combined hemorrhagic component lining acetabular component extending psoas compartment and eccentric wear on cobalt-chrome alloy metal head. Also highly radiodense material was seen around neck inferor portion and severly deformed metal head was seen. It was highly suspected that metal related granuloma, which means severe metallosis. Performed heavy metals screen, cobalt levels were 397,800 μg/Land chrome levels were 236,000 μg/L suggesting cobalt toxicity. Hip joint aspiration was done for decompression as radiologic intervention and EDTA (ethylenediamine tetraacetate) chelation therapy started immediately. After 10 cycle chelating therapy, metal level was lowered cobalt levels by 255.2μg/L and chrome levels by 39.5 μg/L. When hospital day after 134, Medical condition of the patient was getting improved, we underwent revision surgery using ceramic on ceramic bearing surface. The patient discharged postoperative 79 days. Final heavy metals screen results were 27.79μg/L on cobalt and 22.17μg/L on chrome. Although there were also reported a good clinical result of revision surgery using MoP bearing, and some surgeons reluctant to use CoC articulation because of concerns about re-fracture of ceramic. But take into account like this devastating complication after cobalt-chrome wear caused by remained ceramic particles, we should carefully select which bearing is safer

The purpose of this study was to compare the effect of femoral head material (delta ceramic versus metal) on polyethylene wear in a consecutive prospective randomized series of low friction total hip arthroplasty. A total of 110 patients with a mean age of 60.6 ± 9.3 (34–75) years were randomized (power of 90%, alpha of 5%) to receive either a metal (55 hips) or a delta ceramic (55 hips) femoral head. The polyethylene socket was moderately cross-linked (3 Mrads of gamma radiation in nitrogen) and annealed at 130°C in all hips. All other parameters were identical in both groups. The primary criterion for evaluation was linear head penetration measurement using the Martell system, performed by an investigator blinded to the material of the femoral head. Creep and steady state wear values were calculated. At the minimum of 3-year follow-up, complete data were available for analysis in 38 hips at a median follow-up of 4.4 years (3.0 to 5.7), and in 42 hips at a median follow-up of 4.0 years (3.0 to 5.4) in the metal and delta ceramic groups, respectively. The mean creep, measured as the linear head penetration at one year follow-up, was 0.42 ± 1.0 mm in the metal group versus 0.30 ± 0.81 mm in the delta ceramic group (Mann and Whitney test, p = 0.56). The mean steady state penetration rate from one year onwards measured 0.17 ± 0.44 mm/year (median 0.072) in the metal group versus 0.074 ± 0.44 mm/year (median 0.072) in the delta ceramic group (Mann and Whitney test, p = 0.48). No case of delta ceramic femoral head fracture was recorded, and no hip had signs of periprosthetic osteolysis. This study demonstrated that up to 5-year follow-up, delta ceramic femoral head did not significantly influence creep neither wear of a contemporary annealed polyethylene. Longer follow-up is necessary to further evaluate the potential clinical benefits of delta ceramic

The fourth generation Delta ceramic, in which zirconia is incorporated into the alumina matrix, was developed to provide improved fracture toughness and wear characteristics. The purpose of this study was to evaluate the minimum 5-year outcomes and bearing-specific complications in a single surgeon series of Delta ceramic-on-ceramic total hip arthroplasties (THAs). We retrospectively analysed 667 patients (749 hips) who underwent cementless THAs using Delta ceramic-on-ceramic bearings by a single surgeon. There were 315 men and 352 women with mean age of 55 years (range, 16 to 88 years) at the time of index surgery. Acetabular and femoral components were cementless in all hips. A 36 mm head was used in 472 hips and a 32 mm head was used in 227 hips. The mean duration of follow-up was 6.3 years (range, 5 to 8 years). The mean Harris hip score improved from 47.6 points preoperatively to 91.1 points at the time of final follow-up. All but one acetabular components were well-fixed, and all but one femoral components were well-fixed. No radiographic evidence of osteolysis was identified at the time of final follow-up. There were 2 (0.27%) ceramic liner fractures and no ceramic head fracture. A total of 48 hips (6.4%) exhibited an audible noise (29 clickings and 19 squeakings), but no patient required revision. Kaplan-Meier survivorship with an end point of revision for any reason was 98.7% at 6.3 years. Delta ceramic-on-ceramic THAs provide excellent clinical outcomes without osteolysis at the minimum 5-year follow-up. However, we also found 0.27% ceramic liner fractures and 6.4% audible noises associated with the use of Delta ceramic-on-ceramic bearings

Aims

To evaluate the outcomes of cemented total hip arthroplasty (THA) following a fracture of the acetabulum, with evaluation of risk factors and comparison with a patient group with no history of fracture.