A standard is defined as something established by authority, custom, or general consent. Clearly that does not exist for ceramic on ceramic total hip replacement. A better question is: Is there any indication for a ceramic on ceramic total hip. The answer to that question should when possible be based on clinical outcome data including the value added (or not) with this more expansive technology. Ceramic on ceramic has been popularised based on its low wear. Is this clinically relevant? Probably not, based on currently available data. Both metal on highly crosslinked polyethylene and ceramic on highly crosslinked polyethylene have very low clinically documented wear rates with excellent outcomes in multiple studies. In addition, ceramic on ceramic bearings are more sensitive to implant position. Whereas polyethylene may tolerated edge loading and impingement, ceramic bearings are less likely to do so. Dislocation remains one of if not the top reason for early revision. Even with newer ceramics, there are still less options to fine tune hip stability with ceramic on ceramic bearing surfaces. When looking at the overall, risk of revision, Bozic et al concluded that hard bearings provided no benefit in terms of risk reduction of revision. Considering their higher cost, they questioned the use of these products especially in the 65 and older age group. Looking at the Australian Registry, the cumulative percent revision for ceramic-ceramic THA was 5.7% at 11 years compared to 5.1% for metal on crosslinked poly. The hazard ratio (adjusted for age and gender) was 1.09 in favor of ceramic on poly and the difference was highly significant (p=0.012). When one take into account the increased cost of ceramic on ceramic bearings, it is hard to make a case for ceramic on ceramic bearings. Any use of ceramic on ceramic bearings would have to be based on the hypothesis that in the long run in young active patients they may provide an advantage. This is a hypothesis with no data to support it currently

The use of hard-on-hard bearings, including ceramics peaked in the mid 2000's and has seen rapid decline since that time. Ceramics are not new to the market place but have had a 40 year history outside the U.S. The basis for renewed enthusiasm for ceramics included improved manufacturing, improved taper tolerances, higher strength, and lower wear. In spite of the major improvements concerns have been expressed with new generation ceramics by the experts and thought leaders in the field. The major concerns included complications related to modularity, continued problems with fracture and consequences of fracture, limited surgical options, and squeaking and impingement. The conclusion of one review article was that “although ceramics show promise as a lower wear articulation, manufacturing and design modifications and improvements will continue in an attempt to address the substantial concerns that persist”. Modifications have indeed occurred. The question is rather all of these concerns have been addressed and the answer is no. One proposed solution was a hybrid material of Alumina and Zirconia (Delta Ceramic). The advantages included higher strength, lower wear, more options and possibly less squeaking. Unfortunately the modest material improvements did not begin to overcome the obstacles to adopting this technology. High on this list is the problem with cost with the current health care environment unwilling to pay for expensive new technology that does not have proven value. A 2nd major issue is new technology must account for variability in surgeon performance in maximising margin for error. The medical legal environment is unforgiving of failure of new unproven options. Most of the old issues with ceramics have not been completely resolved. Delta Ceramic in particular, has increased cost with no demonstrated benefit. A major problem is there is no known problem with metal or ceramic against cross-linked polyethylene bearing in terms of wear or osteolysis in the 10–15 year time frame. Among all the bearing articulations, metal-on-cross-linked performs the best. The persistent vexing problems with ceramics include impingement, liner breakage, and squeaking. Ceramic components do not tolerate component malposition which increases wear and squeaking. The problem is that a substantial percentage of hip replacements are put in outside of the ideal radiographic zone even at specialty centers. Breakage continues to be a problem especially with liners. There is also a need for complete rim exposure for concentric placement with impaction of liners which makes ceramics less compatible with small incision surgery. The problem of squeaking has not been solved by Delta Ceramic. Originally a case report appeared in the literature of squeaking with Delta Ceramic. Since that time a large scale study has showed that only 69% of Delta Ceramic hips were silent with up to 13% being associated with reproducible squeaking. While a new generation of ceramics are better than the earlier generation and have lowered the fracture risk and increased intraoperative options, the current generation ceramics still provide far fewer options than a standard metal-on-cross-linked total hip. The current generation metal-on-cross-linked total hips have 10–15 year results that cannot be improved upon in terms of wear and osteolysis. Other unsolved problems include breaking, chipping and squeaking. Ceramic-on-ceramic is less tolerant of suboptimal position which leads to impingement, edge loading, and an increased incidence of squeaking. Until all of these problems are successfully addressed, ceramic-on-ceramic cannot be advocated for widespread use

A ceramic is currently considered as the most ideal articulation in primary THA. The authors evaluated clinicoradiographic results and complications of cementless THA with 3rd generation of ceramic bearing. From April 2001 to January 2008, 310 primary THAs were performed in 300 patients using 3rd generation of ceramic bearing. In results, Harris hip score at last follow up was improved to an average of 95.4 points from 51.6 points preoperatively. In all cases, fixations around implants were stable and there was no osteolysis. Complications were dislocations, squeaking, ceramic femoral head and liner fracture. Our outcomes using cementless THA with 3rd generation of ceramic articulation were satisfactory, but more clinical study and investigation will be necessary to reduce complications

BACKGROUND CONTEXT. Ceramic bearings are widely used in total hip arthroplasty (THR) along with metal and polyethylene bearings. There were several studies in past few years evaluating the advantage of one over the other. The young population with high activity levels has an increased risk of wear debris production at bearing surface and subsequent implant failure. Recently, interest and use of a ceramics with high wear resistance has been growing. Early reports on ceramic on ceramic THR have demonstrated excellent clinical and radiological results. PURPOSE. To evaluate clinical, functional and radiological outcomes of cement-less ceramic on ceramic primary total Hip Replacement (THR) in young patients (<50 years age) with diagnosis of avascular necrosis femoral head. STUDY DESIGN. Single - centre, prospective comparative study of prospectively collected outcomes, with a minimum of 12 month follow-up. PATIENT SAMPLE. 30 patients who underwent cement-less ceramic on ceramic primary THR in young patients (< 50 years age) for avascular necrosis of femoral head. OUTCOME MEASURES. For clinical evaluation, Harris hip scores was measured pre-operatively and post-operatively at predefined intervals. For radiological evaluation, Post- operative radiographs were checked for alignment of femoral stem, loosening of stem, presence of heterotopic ossification, loosening of acetabular component at predefined regular intervals. METHOD. This study included 30 patients, who underwent cement-less ceramic on ceramic primary THR in young patients (< 50 years age) for avascular necrosis of femoral head between July 2013 to April 2015 with a minimum of 12 month follow –up. RESULTS. The mean Harris hip score in our study increased from 32.73 pre-operatively to 87.8 post-operatively at the latest follow up with 90% hips having good to excellent results. This improvement was statistically significant (p<0.005). On evaluation of alignment of femoral stem 27 stems were central (90%) and 3 stems found to be in valgus (10%) and none to be in varus position. There was no significant correlation between stem alignment and clinical outcome based on Harris hip score. Not a single case of focal osteolysis, stem loosening or heterotopic ossification was seen in our study till latest follow-up. None of the major complication was noticed during evaluation of our cases except minor chronic hip pain in one patient which did not restricted his daily living activities. CONCLUSION. In our study, we found better results of ceramic on ceramic THR for younger patients(<50 years age) comparable to previous studies with no serious complication found in any patient. Based on our study, we recommend ceramic on ceramic THR for younger patients in the age group of less than 50 years of age. We need a study of large sample size with long term follow up to further confirm the findings of our study

Background. Complications of metal-on-metal hip resurfacing, leading to implant failure, include femoral notching, neck fracture, and avascular necrosis. Revision arthroplasty options include femoral-only revision with a head, however mis-matching radial clearance could accelerate metal ion release. Alternatively, revision of a well-fixed acetabular component could lead to further bone loss, complicating revision surgery. We have developed a ceramic hip resurfacing system with a titanium-ceramic taper junction; taking advantage of the low frictional torque and wear rates that ceramic affords. Taking a revision scenario into account, the ceramic head has a deep female taper for the resurfacing stem, but also a superficial tapered rim. Should revision to this resurfacing be required, any femoral stem with a 12/14 taper can be implanted, onto which a dual taper adaptor is attached. The outer diameter of the taper adaptor then becomes the male taper for the superficial taper of the ceramic head; ultimately allowing retention of the acetabular component. In an in-vitro model, we have compared the fretting corrosion of this taper adaptor to existing revision taper options: a titanium-cobalt chrome (Ti-CoCr) taper junction, and a titanium-titanium sleeve-ceramic (Ti-Ti-Cer) taper junction. Methods. To simulate gait, sinusoidal cyclical loads between 300N-2300N, at a frequency of 3Hz was applied to different neck offsets generating different bending moments and torques. Bending moment and frictional torque were tested separately. An electrochemical assessment using potentiostatic tests at an applied potential of 200mV, was used to measure the fretting current (μA) and current amplitude (μA). In a short term 1000 cycle test with bending moment, four neck lengths (short to x-long) were applied. For frictional torque, four increments of increasing torque (2-4-6-8Nm) were applied. In a long-term test using the taper adaptor, the combination of worst-case scenario of bending and torque were applied, and fretting currents measured every million cycles, up to 10 million cycles. Results. Short-term test: When adjusting bending moment the taper adaptor displayed equivalent fretting currents for the short and medium neck lengths. Using the long neck the taper adaptor displayed a higher fretting current, though this was not significant (Kruskal-Wallis test). However, using the X-Long adaptor the fretting current was significantly higher than the other tapers (Fig. 1). Across the range of frictional torques, the taper adaptor displayed equivalent fretting currents to the Ti-CoCr single taper. The Ti-Ti-Cer displayed the lowest fretting currents but this was not significant when compared to the other combinations (Fig. 2). Long-term test: combining the worst case bending (X-Long) and torque (8Nm) showed consistent fretting currents and current amplitudes across 10 million cycles, with no significant variance of the median values (Fig. 3). Conclusion. Electro-chemical testing has highlighted caution if revision arthroplasty is performed using the X-Long taper adaptor. However for shorter neck lengths, fretting corrosion is comparable to existing revision tapers. The LIMA ceramic resurfacing arthroplasty is an integrated system and can be safely revised to a conventional hip system using a dual taper head, and taper adaptor

Aims. Excision of chronic osteomyelitic bone creates a dead space which must be managed to avoid early recurrence of infection. Systemic antibiotics cannot penetrate this space in high concentrations, so local treatment has become an attractive adjunct to surgery. The aim of this study was to present the mid- to long-term results of local treatment with gentamicin in a bioabsorbable ceramic carrier. Methods. A prospective series of 100 patients with Cierny-Mader Types III and IV chronic ostemyelitis, affecting 105 bones, were treated with a single-stage procedure including debridement, deep tissue sampling, local and systemic antibiotics, stabilization, and immediate skin closure. Chronic osteomyelitis was confirmed using strict diagnostic criteria. The mean follow-up was 6.05 years (4.2 to 8.4). Results. At final follow-up, six patients (six bones) had recurrent infection; thus 94% were infection-free. Three infections recurred in the first year, two in the second year, and one 4.5 years postoperatively. Recurrence was not significantly related to the physiological class of the patient (1/20 Class A (5%) vs 5/80 Class B (6.25%); p = 0.833), nor was it significantly related to the aetiology of the infection, the organisms which were cultured or the presence of nonunion before surgery (1/10 with nonunion (10%) vs 5/90 without nonunion (5.6%); p = 0.570). Organisms with intermediate or high-grade resistance to gentamicin were significantly more likely in polymicrobial infections (9/21; 42.8%) compared with monobacterial osteomyelitis (7/79 (8.9%); p < 0.001). However, recurrence was not significantly more frequent when a resistant organism was present (1/16 for resistant cases (6.25%) vs 5/84 in those with a microbiologically sensitive infection (5.95%); p = 0.958). Conclusion. We found that a single-stage protocol, including the use of a high-delivery local antibiotic ceramic carrier, was effective over a period of several years. The method can be used in a wide range of patients, including those with significant comorbidities and an infected nonunion. Cite this article: Bone Joint J 2022;104-B(9):1095–1100

Young patients have been reported to have a higher risk of revision following total hip arthroplasty than older cohorts. This was attributed to the higher activity level which led to increased wear, osteolysis, and component fracture. We prospectively assessed the clinical results, wear and osteolysis, the incidence of squeaking, and the survivorship of ceramic on ceramic THA in patients younger than 50 years (mean age of 42 [18–50] years). The series included 425 THAs in 370 patients with 368 hips followed for a minimum of 2 years (mean 7.1 years, range 2–14 years). All patients received uncemented acetabular components with flush-mounted acetabular liners using an 18 degree taper. No osteolysis was observed in any uncemented construct. There was osteolysis around one loose cemented femoral component. The survivorship for reoperation for implant revision was 96.7%. There were only two acetabular liner fractures (0.47%) and one femoral head fracture (0.24%). Two of the three fractures involved a fall from a significant height. There were no hip dislocations. Five patients (1.17%) noted rare or occasional squeaking. None had reproducible squeaking. In summary, the current study shows that ceramic-on-ceramic THAs in the young patient population are extremely reliable with a very low revision rate and an absence of wear-induced osteolysis. In addition, it shows that both bearing fracture in this young patient population typically occurs with polytrauma and squeaking issues that have been raised relative to ceramic bearings occur very rarely with the flush-mounted ceramic liner design used in this study

Introduction. Metallic resurfacing systems have been widely used until pseudotumors and ALTR have been clinically found and related to excessive wear of these metal-on-metal hip systems. Hence, surgeons widely abandoned the use of resurfacing systems. Meanwhile, there is a ceramic on ceramic (CoC) resurfacing system (Embody, London, UK) made of zirconia toughened alumina (BIOLOX. ®. delta, CeramTec, Plochingen, Germany) in a clinical safety study. Even though conventional CoC hip systems are known for their excellent wear behavior, it has to be ensured that intraoperative and in-vivo deformations of the ceramic acetabular cup do not infringe the proper functionality of the system. The method of determining the minimum clearance of such a system will be presented here. Materials and Methods. Combined experimental and numerical results were used to determine the deformation of the ceramic shell. In a cadaver lab, the resulting deformations after impaction of generic metal shells have been measured, see e.g. [1] for the method of measurement. The maximum deformation has been chosen for further calculation. Additionally, the stiffness of both generic metal and ceramic shells has been measured using ISO 7206–12. The deformation of the ceramic shells were then calculated by the equation. where u. c. and u. m. are the deformations of the ceramic and the metal shell, respectively, and K. m. and K. c. are the respective stiffnesses. Additionally, in a finite element simulation, the resulting deformation of the ceramic shell under in-vivo conditions was calculated and superposed with u. c. The resulting deformation was used as the minimum value of the clearance for the ceramic resurfacing system. Results. The average value of the maximum deformation of the 8 generic metal shells was 177 µm (StD. 68 µm). Using the stiffness values for the ceramic and the metal shells, a maximum deformation for the ceramic shells (with the smallest and the largest outer diameter) were calculated to 56 µm and 74 µm, respectively. The superposition with the results from the FE studies led to deformation values of 69 µm (smallest shell) and 87 µm (largest shell), respectively. These values were chosen as the minimum values for the realization of the minimum clearance. Discussion. The above described minimum clearance results from a worst-case scenario for the long-term deformation of the ceramic shells. The values from the experimental measurements were taken ten minutes after impaction in the cadaveric hips, when first relaxation already took place. Any other bone remodeling in the long-term, leading to further relaxation of the ceramic shell, has not been taken into account. The maximum deformations resulting from the numerical investigations have been superposed to the experimental values, assuming that both maximum deformations are acting in the same direction. In reality, this is most likely not the case because the line-of-action of the in-vivo forces acting on the hip are not collinear with the direction where the maximum deformation during intra-operative impaction takes place. Additionally, the experimentally chosen underreaming (1 mm) can also be considered as a worst-case. Hence, the calculated minimum clearances are representing the maximal deformation that in the long-term may take place in-vivo

Aim. Excision of chronic osteomyelitis (cOM) creates a dead space which must be managed to avoid early recurrence of infection. Systemic antimicrobials cannot penetrate this space in high concentration so local therapy has become an attractive adjunct to surgery. This study presents the mid- long-term results of local therapy with gentamicin in a bioabsorbable ceramic carrier. Method. A prospective series of 100 patients with Cierny & Mader Types III and IV cOM, affecting 105 bones, were treated with a single stage procedure, including debridement, deep tissue sampling, local and systemic antimicrobials, stabilization and immediate skin closure. cOM was confirmed with strict diagnostic criteria. Patients were followed up for a mean of 6.05 years (range 4.2–8.4 years). Results. At final follow-up, 6 patients had evidence of recurrent infection (94% infection-free). 3 infections recurred in the first year, with 2 in the second year and one at 4.5 years after surgery. Recurrence was not dependent on host physiological class (1/20 Class A; 5% vs 5/80 Class B; 6.25%. p=0.833). Nor was it related to aetiology of the infection, microbial culture or the presence of an infected non-union before surgery (1/10 with non-union; 10% vs 5/90 without non-union; 5.6%. p=0.57). Organisms which demonstrated intermediate or high-grade resistance to gentamicin were more likely in polymicrobial infections (9/21; 42.8%) compared to single isolate osteomyelitis (7/79; 8.9%)(p<0.001). However, recurrence was not more frequent when a resistant organism was present (1/16; 6.25% for resistant cases vs 5/84; 5.95% in sensitive culture infection) (p=0.96). Conclusions. This study shows that the single stage protocol, including a high delivery local antibiotic ceramic, was effective over several years. The method can be applied to a wide range of patients, including those with significant comorbidities and infected non-union

Introduction. The successful performance of ceramic on ceramic bearings in today's THA can mainly be addressed to the excellent tribological behaviour and the minimal wear of ceramic bearings. The clearance between head and shell plays a major role in this functionality of artificial hip joints. Knowledge about the deformation behaviour of the shell during implantation but also under daily loads is essential to be able to define a minimum clearance of the system. The aim of this work is to establish a tool for determining maximum ceramic shell deformation in order to predict minimum necessary clearance between heads and monolithic ceramic shells. Materials and Methods. In order to determine the minimum clearance the following in vivo, in vitro and in silico tests were taken into account:. Eight generic metal shells were implanted into cadaveric pelvises of good quality bone realizing an underreaming of 1 mm. Maximum deformation of the metal shells (u. m. ) after implantation were determined using an validated optical system. The deformations were measured 10 min. after implantation. The stiffnesses of the metal shells (C. m. ) were experimentally determined within a two-point-loading frame acc. to ISO 7206-12. The stiffness of a monolithic ceramic shell (C. c. ) representing common shell designs (outer diameter 46 mm, 3 mm constant wall thickness) were determined acc. to ISO 7206-12 using Finite-Element-Method (FEM). Maximum deformation for the ceramic shells (u. c,dl. ) under daily loading, represented by jogging (5kN, Bergmann et. al), was determined applying FEM. Press-fit forces (F. pf. = u. m. C. m. ) can be calculated with the results of test 1 and 2 considering linear elastic material behaviour. Assuming force equilibrium and applying the evaluated stiffness from test 3 the deformation of the ceramic shell (u. c. ) occurring after implantation can be estimated (u. c. = u. m. C. m. /C. c. ). For minimum clearance calculation of a monolithic ceramic shell (u. c,lt. ) in vivo deformation (u. c,dl. ) has to be considered additionally (u. c,lt. = u. c. + u. c,dl. ). Results. An average deformation of 177 µm was measured for the metal shells (average shell stiffness of 4368 N/mm). From the FEM the stiffness of the monolithic ceramic shell was calculated to be 9510 N/mm (46 mm). Deformation of 13 µm need to be considered from in-vivo relevant loading. The calculation of the minimum clearance for a generic monolithic ceramic shell (46 mm; 3 mm constant wall thickness) would result in 94 µm. Discussion. The above described method can be taken as a worst-case approach as long-term bone relaxation has deliberately been not taken into account, intra-operative and post-operative deformation has been superposed and a 1 mm underreaming represents an upper limit for good bone quality. More intra-operative shell deformation values would improve the power of the approach. The new tool can be used to define a necessary minimum clearance for a customer specific monolithic ceramic shell

Numerous studies have shown highly cross-linked polyethylene (XLPE) to be an extremely low wear bearing surface for total hip arthroplasty (THA) at intermediate term follow-up. Wear rates and the incidence of osteolysis for CoCr femoral heads on XLPE liners appears to be considerably less than what is observed for conventional polyethylene (PE). This has been demonstrated even in younger, more active patients. Nevertheless, polyethylene wear and associated osteolysis are still a concern, since the indications for THA have been expanded to include younger and more active patients. Both wear simulator and clinical data suggest that ceramic femoral heads can reduce bearing surface wear of conventional PE. There is, however, extremely limited evidence supporting any advantage of ceramic femoral heads over CoCr femoral heads with regards to bearing surface wear of XLPE. This is perhaps due to the relative difficulty in measuring the low wear rates of XLPE bearings in general, regardless of material composition of the femoral head. Although ceramic femoral heads are more scratch resistant and less susceptible to third body wear, their current clinical use to reduce wear of XLPE bearings is, in reality, based on the unproven assumption that use of ceramic femoral heads will have a similar effect on wear reduction as is seen with ceramic on conventional PE bearing couples. Nevertheless, the use of ceramic femoral heads has become common in younger, more active patients. Recently, corrosion at the head neck junction of modular THA (trunnionosis), has been determined to be the possible source of metal debris and metal ions associated with adverse local tissue reactions (ALTR or ARMD) in THA, including ALVAL and pseudotumors. There is general agreement that trunnionosis results from mechanically assisted crevice corrosion (fretting) of the modular junctions common to nearly all contemporary THA designs. Several design, material and patient factors have been implicated as contributors to this problem including larger diameter femoral heads (>36 mm), reduced femoral neck and taper geometry, flexural rigidity of the taper, and patient body weight and activity level. Data from our multicenter implant retrieval program has shown that corrosion at the head-neck junction of contemporary modular THAs may be reduced with use of ceramic femoral heads. The use of ceramic femoral heads also eliminates the potential for release of cobalt and chromium ions from the taper junctions of titanium alloy stems. In younger patients, the long term effects of cobalt ions released from corrosion at the modular neck junction are still unknown. Although the surgeon's selection of a ceramic femoral head in combination with a XLPE acetabular liner is likely based on the desire to minimise PE wear, the impact of femoral head composition on taper neck corrosion and ALTR is perhaps more of a concern in 2015. Until the problem of taper neck corrosion is more thoroughly understood and effectively addressed by implant manufacturers, the use of ceramic femoral heads in THA should be considered in the younger or more active patient. The increased cost of ceramic femoral heads creates a dilemma in defining who is “young” enough and “active” enough to be considered an appropriate candidate for a ceramic femoral head in our current environment of bundled care payments, value based purchasing and concern about providing cost-effective health care to our patients

Introduction. Advantages of ceramic materials for hip joint prosthesis are recognized to be high hardness, scratch resistance, improved wettability, lower friction and lower wear than CoCr surfaces. Recent studies suggest the use of ceramic femoral head reduce fretting corrosion at stem taper junction compared to metal-on-metal taper junction[1]. Continuous improvement of ceramic materials for orthopedic lead to the development of a resurfacing ceramic-on-ceramic hip joint prosthesis. The main differences of resurfacing heads respect to standard heads are their anatomical dimension and the empty shape suitable to cover the femoral bone and to connect with the resurfacing stem. Ceramic is essentially a brittle material and its strength is influenced by the minimum thickness in the stressed area. Ceramic resurfacing head minimum thickness is comparable with ceramic revision head already on the market. The aim of this study is to develop a mechanical pre-clinical analysis verification process for the newly developed system. Materials and methods. The empty shape of the ceramic resurfacing head may influence its strength in a crush loading scenario. Although this is not a physiological condition this test represents the most severe loading for a resurfacing head. Also comparative analysis can be done considering the yield point of conventional metal resurfacing heads reported by the FDA Center for Devices and Radiological Health. For this reason a static unsupported head strength test is performed by applying a compressive load perpendicular to the head axis along the equatorial plane[2](Fig.1). Resurfacing ceramic head made in ZTA is suitable both for a resurfacing stem and an adaptor to be coupled with a standard stem. Mechanical test was performed on worst case resurfacing head size both with resurfacing stem and standard stem based and on FE non linear analysis performed in ANSYS 17.2 according the following material properties: ZTA ceramic (modulus of elasticity E, Poisson ratio ν and density ρ of 348GPa, 0.23 and 4.25g/cm. 3. respectively), and Ti6Al4V (E=114GPa, ν=0.33 and ρ=4.43g/cm. 3. ). For comparison purposes unsupported test was performed on standard head Ø28#S both in Biolox®Delta and Biolox®Forte ceramic. At least three components were used for each test and the average values was compared with predicates[2]. Static compressive load was applied with MTS hydraulic actuators with load cell of 100kN. Results. FE analysis indicated the larger resurfacing head as the worst case size in the size range(Fig.2). Static unsupported head strength test was performed on resurfacing ceramic head Ø57 coupled both with resurfacing stem and standard stem, Biolox®Delta head Ø28#S, Biolox®Forte head Ø28#S and respectively reached a strength value of 53±7kN, 90±3kN, 78±27kN, 49±1kN. Equivalent test were reported in literature for DeltaSurf® Ø58 and BHR. TM. , and respectively reached a strength of 26kN and 5.6kN. Discussion and Conclusion. LIMA ceramic resurfacing head and Biolox Forte Ø28#S showed equivalent unsupported head burst strength. LIMA ceramic resurfacing head showed higher unsupported head burst strength respect to DeltaSurf® and BHR. TM. highlighting its potential in clinical use. For any figures or tables, please contact the authors directly

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

Improvements in ceramic materials, component design, and surgical technique have made ceramic bearing complications increasingly rare. However, when it happens, a fractured ceramic component can cause significant pain and morbidity following total hip arthroplasty (THA). The hard and sharp particulate debris from fractured ceramic components can cause damage to the existing hip prosthesis and jeopardise subsequent revision THA results due to third body wear. Patients with ceramic fractures can present with sudden onset of pain and dysfunction. Often, the patient will report a noisy hip articulation. Radiographs can range from subtle densities surrounding the hip implant to complete disintegration and loss of sphericity of the femoral head or acetabular liner. Ceramic component fractures should be treated expeditiously. Revision options for failed ceramic components depend on existing component fixation, position, and locking mechanism and femoral trunnion integrity. In order to retain the implants, the components must be well-fixed, in good position, and have tapers and locking mechanisms that can accept new modular components. Additionally, an extensile exposure and complete synovectomy are necessary to remove as much of the sharp particulate debris. Finally, a new ceramic ball head with a titanium inner sleeve should be used in revisions for fractured ceramics due to their hardness and scratch resistance. Early results for revision surgery for fractured ceramic components were inconsistent. Allain et al. reported on a series of 105 revisions performed for ceramic head fractures and found that the survivorship at 5 years was only 63%. The authors reported a high reoperation rate and also worse survivorship when the acetabular component was retained, a metal head was used for revisions, age younger than 50 years, and when a complete synovectomy was not performed at the time of revision. More recently, Sharma and colleagues reported on a series of 8 ceramic fractures revised to a metal-on-polyethylene articulation performed with a complete synovectomy. At 10-year follow-up, the authors reported on failures; increased wear; or lesser function compared to 6 matched patients undergoing revision using similar implants for other diagnoses. Others have also reported catastrophic failures when revising fractured ceramic components using metal ball heads. In summary, ceramic bearing complications in THA are rare but catastrophic events. A systematic approach to evaluation and management is necessary to ensure a safe return

INTRODUCTION. Young patients (< 50 years old) have been reported to have a higher risk of revision following total hip arthroplasty (THA) than older patient cohorts, possibly to due higher activity, a higher incidence of deformity and greater probability of prior surgery. Ceramic-on-ceramic bearing surfaces have been proposed for use in young and active individuals due to their low wear, low risk of adverse biologic reaction, and long-term survivorship. We assessed the clinical results and long-term survivorship of uncemented ceramic-on-ceramic THA in a young patient population. METHODS. Between August 1999 and December 2007, 220 total hip arthroplasties in 191 patients under 50 years of age at the time of surgery were performed using alumina ceramic-ceramic bearings as part of a prospective, non-randomized study. All patients received uncemented acetabular components with flush-mounted acetabular liners using an 18 degree taper, and uncemented femoral components. The average patient age at the time of surgery was 42.1 ±7.2 years (range: 17.4 years to 49.9 years), and the average time to follow-up was 10.1 ±2.4 years (range: 4.2 years to 15.2 years). We evaluated implant-related complications and performed Kaplan-Meier analyses to determine survivorship of the THA components with revision for any reason as the endpoint. RESULTS. There were no dislocations or failures due to osteolysis or aseptic loosening. There was one patient death not related to the THA procedure. Through 15-years, the Kaplan-Meier survivorship of all components was 94.9% (CI: ±8.0) with 8 revisions (3.6%) of either the cup, the stem, or both. For the acetabular component, the 15-year survivorship was 97.0% (CI: ±6.1) and included 4 revisions (1.8%), and 98.1% (CI: ±1.9) for the femoral component including 4 revisions (1.8%). One patient had both the femoral and acetabular components revised. There were two liner fractures (0.59%) and one head fracture (0.3%), two of which were sustained as a result of a fall from significant height. There were three failures of osseointegration (1.3%), and one acetabular component dislodged (0.4%) immediately following surgery. Two patients reported non-reproducible squeaking. One hip was revised at an outside institution for unknown reasons. Using the National Institutes for Health and Clinical Excellence (NICE) guidelines, our results are well within the 1% per year acceptable failure rate for this young patient population (acetabular components: 0.1% per year, femoral components: 0.1% per year, all revisions: 0.2% per year). From our experience, ceramic-on-ceramic THA in patients less than 50 years of age is very reliable with a low revision rate and absence of wear-related osteolysis. Component fracture typically occurs with high-energy trauma, and squeaking occurrence is rare in the flush-mounted ceramic liners used in our study. CONCLUSION. Total hip arthroplasty in young patients demonstrates excellent survivorship when uncemented titanium implants are coupled with ceramic-ceramic bearings

Purpose. The results of ceramic-on-ceramic (CoC) bearing surfaces in primary total hip arthroplasty (THA) were well known. However, it was not known in revision THA. The purpose of this study is to report the results of revision THA with ceramic articulation. Materials and Methods. 112 revision THAs with ceramic articulation were evaluated. The mean age at the time of surgery was 58.3 years (28 to 97). The mean duration of the follow-up periods was 6.4 years (2 to 11.8 years). Results. The Harris hip scores improved from an average of 79.0 at the index surgery to an average of 91.1 at the last follow-up. (P<0.001) None of hips showed osteolysis or ceramic head fracture. One hip shows aseptic loosening in the acetabular components with squeaking that caused a re-revision. There were nine cases of dislocation. The overall survival rate of the implants was 85.1% (95% confidence interval, 61.7% to 94.0%) at ten years with revision for any reason as the end point. Conclusion. The ceramic articulation is one of good bearing options for revision THA in patients with a long life expectancy

INTRODUCTION. Ceramic hip components are known for their superior material properties and longevity. In comparison to other materials commonly used, ceramics have a very low friction coefficient and a high fracture load. However, even though in-vivo fractures of ceramic ball heads are a relatively rare occurrence compared to other reasons for revision, they are of concern to the surgeon using ceramic components. The goal of this work was to evaluate the most probable causes for fracture and to quantify the influence of the metal taper contamination and shell deformation, respectively. METHODS. An experimental set-up imitating the in-vivo loading situation was used to analyze different scenarios that may lead to the fracture of the ball heads, such as dynamic loading, edge loading and the metal taper contamination. 58 ceramic ball heads made of pure alumina were loaded until fracture under various conditions. Parameters under investigation were the inclination of the insert, the loading velocity, and the contamination of the interface between taper and ball head. RESULTS. The behavior of the ball heads for the different scenarios showed a large variation. If the inclination of the insert equaled 45°, it is not possible to break the ceramic ball head prior to the failure of the metal taper due to high plastic deformation. In case of edge loading, due to the reduction of load transfer area, the load required to fracture dropped significantly. The loading rate had no measurable influence on this value. The largest effect on the fracture load had a contamination with osseous tissue and a damage of the metal taper. The fracture load decreases to approximately 20% compared to the value measured without the contamination. DISCUSSION. Contamination of the interface with osseous tissue or damages on the metal taper lead to a minimum fracture load in the range of the maximum forces ever measured in vivo. According to these findings, diligence is recommended during the implantation of the ceramic hip components in order to avoid disturbances or contamination of this interface. Because the reduction of the friction and the damage or contamination of the ceramic/metal interface results in a reduction of the fracture load, the presence of any material on the component tapers should be avoided

INTRODUCTION. Experience with Metal on Metal (MoM) hip resurfacing devices has shown adequate cementation of the femoral head is critical for implant survival. Bone necrosis can be caused by the temperature change in the peri-prosthetic bone whilst the cement cures during implantation. This can lead to implant loosening, head/neck fracture and implant failure. During the implantation it is known that implants change shape potentially altering joint clearance and causing loosening. Given the history of Metal on Metal implant failure due adverse tissue reactions from Cobalt and Chromium particles we sought to test a novel Ceramic on Ceramic (CoC) bearing which may mitigate such problems. AIM. We set out to compare the behaviour of a novel ceramic femoral head component to a standard metal component in a hip resurfacing system after cemented implantation in a physiological warmed cadaveric model. Our first aim was to perform heat transfer analysis: To document time to, and extent of, maximum temperature change on the metal/ceramic surface and inside the resurfaced femoral head bone. Our second aim was to perform a dimensional analysis: To document any resulting deformation in the metal/ceramic femoral head bearing diameter during cementation. METHODS. Femurs were removed from four fresh frozen cadavers and placed into a vice. One surgeon with extensive experience in hip resurfacing surgery (JH) prepared all the femoral heads for implantation. Cadaveric warming was performed using a thermostatic silicone heating element to achieve near physiological conditions (28–32°C). The femur components were then implanted onto the femur head using Simplex P (Stryker) low viscosity bone cement. We used four ceramic (ReCerf™) and four metal implants (ADEPT®) of equal and varying size. (2 × (42mm, 46mm, 48mm, 50mm). Temperature change was measured using a thermometer probe placed into femur neck and head from the lateral side with position check using an image intensifier. Implant surface temperature was measured using a calibrated infrared thermometer at a standard 30cm distance. Head bearing surface diameter was measured using a micro-meter. Measurements were taken 2mins pre-implantation and sequentially at 1, 5, 10, 15, 20, 25 and 30 minutes after implantation. RESULTS. The bone temperature change for both metal and ceramic implants fell after implantation and then increased. The implant surface temperature increased and then stabilised for both implants. There was no significant difference in the bone or surface temperature change between metal and ceramic implants. The bearing surface diameter change was greater in the metal implants, although this was not significant. All implants returned to within one µm of initial surface diameter at 30 minutes. CONCLUSIONS. The femoral head component of a ceramic resurfacing has similar properties for surface temperature change following implantation to conventional MOM resurfacing. The periprosthetic bone is not at risk of significant heat necrosis during cementation (max temp 32°C). The deformation following implantation was similar for both metal and ceramic components. All implants returned to near initial diameter. The deformation and temperature changes following implantation of a ceramic resurfacing are similar to a metal implant

INTRODUCTION. Ceramic-on-ceramic hip resurfacing offers a bone conserving treatment for more active patients without the potential metal ion risks associated with resurfacing devices. The Biolox Delta ceramic material has over 15 years of clinical history with low wear and good biocompatibility but has been limited previously in total hip replacement to 48mm diameter bearings [1]. Further increasing the diameter for resurfacing bearings and removing the metal shell to allow for direct fixation of the ceramic cup may increase the wear of this material and increase the risk of fracture. METHODS. Eighteen implants (ReCerf™, MatOrtho, UK; Figure1) were wear tested; six were ⊘40mm (small) and twelve ⊘64mm (large). All small and six large implants were tested under ISO 14242 standard conditions for 5 million cycles (mc) at 30° inclination (45° clinically). The six remaining large implants were tested under microseparation conditions in which rim contact was initiated during heel strike of the gait cycle for 5mc. Cups were orientated at 45° inclination (60° clinically) to allow for separation of the head and cup with a reduced 50N swing phase load and a spring load applied to induce a 0.5mm medial-superior translation of the cup. Wear was determined gravimetrically at 0.5mc, 1mc and every mc after. RESULTS. Wear was low in both standard and microseparation tests, less than 1mm. 3. cumulatively over 5mc (Figure 2). Standard conditions showed a run-in wear phase over the first mc followed by negligible wear in both diameters. The run-in wear significantly increased from 0.2mm. 3. /mc in the 40mm diameter bearings to 0.5mm. 3. /mc with the larger diameter implants. Under microseparation conditions, there was low wear over the first mc, increasing to 0.28mm. 3. /mc between 1–3mc. The wear rate reduced to 0.11mm. 3. /mc from 3=5mc. Stripe wear was evidenced on the microseparated components. There were no incidences of fracture or squeaking. DISCUSSION. Biolox Delta is known for its low wear rates but published results have only reported testing up to ⊘36mm [2]. Increasing the diameter to 64mm showed increased wear compared to smaller diameters but this was only significant over the first mc suggesting similar performance long term. Microseparation testing of these large sized bearings doubled the cumulative wear produced over 5mc but wear measured was still much lower than other bearing combinations. Wear of metal-on-metal resurfacing implants under these high angle, microseparation conditions has been reported up to 10.5mm. 3. /mc [3], significantly higher than any wear rate reported in the current study. Despite the 3mm wall thickness, no fracture of the cup occurred but stripe wear was observed in the ceramic components. SIGNIFICANCE. Biolox Delta ceramic is appropriate for use in larger diameters without excessive wear or damage to the bearings. The improved biocompatibility of the material may allow for hip resurfacing to be offered to more patients than currently available. For any figures or tables, please contact the authors directly

Trunnionosis in modular hip arthroplasty has recently been recognised to be clinically important. Gaining an understanding of how the material interface at the head-trunnion affects the tribology at the modular junctions has current clinical implications as well as an implication on future implant selection and material choice. This matched-cohort study aims to compare tribocorrosion between ceramic and cobalt-chromium trunnions and to investigate other factors that contribute to the difference in tribocorrosion if present. All hip prostheses retrieved between 1999 and 2015 at one centre were reviewed. Fifty two ceramic heads were retrieved, and these were matched to a cobalt-chromium cohort according to taper design, head size, neck length and implantation time in that order. The two cohorts were similar in male:female ratio (p=0.32) and body mass index (p=0.15) though the ceramic group was younger than the cobalt-chromium group (56.6 (+/−)13.5 years for ceramic group vs 66.3 (+/−14.4) years for cobalt-chromium group; p=0.001). There was no significant difference in the reasons for revision between the two groups (p=0.42). The femoral head trunnions were examined by two independent observers using a previously published 4-point scoring technique. The trunnions were divided into three zones: apex, middle and base. The observers were blinded to clinical and manufacturing data where possible. Ceramic head trunnions demonstrated a lower median fretting and corrosion score at the base zone (p<0.001), middle zone (p<0.001) and in the combined score (p<0.001). In a subgroup analysis by head size, ceramic heads had a lower fretting and corrosion score at 28mm head diameter (p<0.001). Within the ceramic group, taper design had a significant effect on fretting and corrosion in the apex zone (p=0.04). Taper design also had a similar effect in the cobalt-chromium group in the apex zone (p=0.03). For the ceramic trunnions, the largest effect was contributed by the difference between the 11/13 taper and the 12/14 taper. For the cobalt-chromium trunnions, the largest effect was contributed by the difference between the 5 degree 38′ 37″ taper and type 1 taper. Ceramic head trunnions showed a significantly lower fretting and corrosion score as compared to cobalt-chromium trunnions. Ceramic heads had a lower score than cobalt-chromium heads at 28mm head diameter. Taper design had an effect on fretting and corrosion within each cohort