Fracture of a ceramic component in total hip replacement is a rare but potentially catastrophic complication. The incidence is likely to increase as the use of ceramics becomes more widespread. We describe such a case, which illustrates how inadequate initial management will lead to further morbidity and require additional surgery. We present the case as a warning that fracture of a ceramic component should be revised to another ceramic-on-ceramic articulation in order to minimise the risk of further catastrophic wear

We analysed 54 alumina ceramic-on-ceramic bearings from total hip replacements retrieved at one centre after a mean duration of 3.5 years (0.2 to 10.6) in situ. These implants were obtained from 54 patients (16 men and 38 women) with a mean age of 67 years (33 to 88) who underwent revision for a variety of reasons. Posterior edge loading was found in the majority of these retrievals (32 out of 54). Anterosuperior edge loading occurred less often but produced a higher rate of wear. Stripe wear on the femoral heads had a median volumetric wear rate of 0.2 mm. 3. /year (0 to 7.2). The wear volume on the femoral heads corresponded to the width of edge wear on the matching liner. Anteversion of the acetabular component was found to be a more important determinant than inclination for wear in ceramic bearings. Posterior edge loading may be considered to be a normal occurrence in ceramic-on-ceramic bearings, with minimal clinical consequences. Edge loading should be defined as either anterosuperior or posterior, as each edge loading mechanism may result in different clinical implications

The leading indication for revision total hip arthroplasty (THA) remains aseptic loosening owing to wear. The younger, more active patients currently undergoing THA present unprecedented demands on the bearings. Ceramic-on-ceramic (CoC) bearings have consistently shown the lowest rates of wear. The recent advances, especially involving alumina/zirconia composite ceramic, have led to substantial improvements and good results in vitro. Alumina/zirconia composite ceramics are extremely hard, scratch resistant and biocompatible. They offer a low co-efficient of friction and superior lubrication and lower rates of wear compared with other bearings. The major disadvantage is the risk of fracture of the ceramic. The new composite ceramic has reduced the risk of fracture of the femoral head to 0.002%. The risk of fracture of the liner is slightly higher (0.02%). Assuming that the components are introduced without impingement, CoC bearings have major advantages over other bearings. Owing to the superior hardness, they produce less third body wear and are less vulnerable to intra-operative damage. The improved tribology means that CoC bearings are an excellent choice for young, active patients requiring THA. Cite this article: Bone Joint J 2016;98-B(1 Suppl A):14–17

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

To compare complications, survivorship and results in 2 groups of Furlong-HAP Active, one with ceramic-ceramic and the other with metal-XLPE friction pair. Prospective, non-randomized, comparison of 2 series of JRI uncemented prosthesis, implanted with identical protocol by 1 surgeon in 1 hospital from 2006 to 2014. Friction pair was ceramic (Biolox Forte or Delta) in 35 patients of 53.7+/−10.6 years (25–69) (21 males, 60%), and CrCo-XLPE in 65 cases of 69.0+/−8.9 years (42–81) (36 males, 55%); there were significant differences in age (p<0.00001) but not in sex (p=0.6565). Head diameter: Ce-Ce with 19 of 28mm, 9 of 32 and 7 of 36mm; Me-PE with 63 of 28mm, 1 of 32 and 1 of 36. Follow-up averaged 10.5+/−3.1 years (1–15) in ceramic and 9.8+/−3.8 years (2–15) in XLPE group. Pearson, Fisher, Kolmogorov-Smirnov, Student, Mann-Whitney, calculated with the informatic tools Microsoft Excel 2007 and . https://www.socscistatistics.com/tests/. . Complications in ceramic joints: 2 late infections (Fisher exact test=0.6101) (1 DAIR, 1 one-stage exchange); 1 dislocation (Fisher exact test=0.2549) (closed reduction); 1 Vancouver C fracture (ORIF) (Fisher exact test=0.6548). Complications in Me-XLPE joints: 2 late infections (Fisher=0.6101) (1 DAIR, 1 two-stage exchange); 7 dislocations (Fisher=0.2549) (2 early, open reduction) (5 late: 3 closed reduction, 1 cup revision, 1 constrained cup); 4 Vancouver B fractures (Fisher=0.6548) (2 intraoperative, cerclages; 2 late, exchange). Final follow-up: Harris Hip Score averaged 93.2+/−13.7 (23–100) in ceramic and 94.3+/−8.7 (65–100) in XLPE joints (p=0.64552). Wear: 0.06+/−0.38mm (0–1.5) in ceramic and 0.16+/−0.5mm (0–2) in Me-PE THAs (p=0.30302). Osteolysis in Charnley-De Lee zones: 8 zones (6 patients) (17%) in ceramic cups, 25 zones (15 patients) (23%) in XLPE cups (p=0.980127). Survivorship without any surgery or closed reduction after 15 years: 91.0% in ceramic joints, 83.8% in Me-XLPE joints. Survivorship without component exchange after 15 years: 93.9% in ceramic joints, 93.6% in Me-XLPE joints. At least after 10 years follow-up of Furlong-HAP Active, metal-XLPE and ceramic-ceramic joints present no significant differences in complications, clinical score, wear, acetabular osteolysis, or survivorship without component exchange. On the contrary, survivorship without any surgery or closed reduction is different because of the high rate of dislocation in 28mm metal-poly joints

Objectives. The use of ceramic femoral heads in total hip arthroplasty (THA) has increased due to their proven low bearing wear characteristics. Ceramic femoral heads are also thought to reduce wear and corrosion at the head-stem junction with titanium (Ti) stems when compared with metal heads. We sought to evaluate taper damage of ceramic compared with metal heads when paired with cobalt chromium (CoCr) alloy stems in a single stem design. Methods. This retrieval study involved 48 total hip arthroplasties (THAs) with CoCr V40 trunnions paired with either CoCr (n = 21) or ceramic (n = 27) heads. The taper junction of all hips was evaluated for fretting/corrosion damage and volumetric material loss using a roundness-measuring machine. We used linear regression analysis to investigate taper damage differences after adjusting for potential confounding variables. Results. We measured median taper material loss rates of 0.210 mm. 3. /year (0.030 to 0.448) for the metal head group and 0.084 mm. 3. /year (0.059 to 0.108) for the ceramic group. The difference was not significant (p = 0.58). Moreover, no significant correlation between material loss and implant or patient factors (p > 0.05) was found. Conclusions. Metal heads did not increase taper damage on CoCr trunnions compared with ceramic heads from the same hip design. The amount of material released at the taper junctions was very low when compared with available data regarding CoCr/Ti coupling in metal-on-metal bearings. Cite this article: A. Di Laura, H. Hothi, J. Henckel, I. Swiatkowska, M. H. L. Liow, Y-M. Kwon, J. A. Skinner, A. J. Hart. Retrieval analysis of metal and ceramic femoral heads on a single CoCr stem design. Bone Joint Res 2017;6:–350. DOI: 10.1302/2046-3758.65.BJR-2016-0325.R1

Aims. Early evidence has emerged suggesting that ceramic-on-ceramic articulations induce a different tissue reaction to ceramic-on-polyethylene and metal-on-metal bearings. Therefore, the aim of this study was to investigate the tissue reaction and cellular response to ceramic total hip arthroplasty (THA) materials in vitro, as well as the tissue reaction in capsular tissue after revision surgery of ceramic-on-ceramic THAs. Patients and Methods. We investigated tissue collected at revision surgery from nine ceramic-on-ceramic articulations. we compared our findings with tissue obtained from five metal-on-metal THA revisions, four ceramic-on-polyethylene THAs, and four primary osteoarthritis synovial membranes. The latter were analyzed to assess the amount of tissue fibrosis that might have been present at the time of implantation to enable evaluation, in relation to implantation time, of any subsequent response in the tissues. Results. There was a significant increase in tissue fibrosis with implantation time for all implant types tested. Interestingly, the tissue fibrosis in ceramic-on-ceramic THAs was significantly increased compared with metal-on-metal and ceramic-on-polyethylene. Additionally, we found ceramic wear particles in the periprosthetic tissue of ceramic implants. Fibroblasts responded with expression of cytokines when cultured on alumina-toughened zirconia (ATZ) and zirconia-toughened alumina (ZTA) ceramic surfaces. This response was more pronounced on ATZ ceramics compared with ZTA ceramics. The same inflammatory response was observed with peripheral blood mononuclear cells (PBMCs) cultured on ZTA and ATZ. Conclusion. Our findings therefore, corroborate the previous findings that ceramic-on-ceramic periprosthetic revision tissue is fibrous and offer an explanation for this observation. We detected a long-term inflammatory response of PBMCs and an inflammatory response of fibroblasts to ATZ and ZTA ceramic. These findings partially explain the fibrotic tissue change in periprosthetic tissue of ceramic-on-ceramic bearings. Cite this article: Bone Joint J 2018;100-B:882–90

Large ceramic femoral heads offer several advantages that are potentially advantageous to patients undergoing both primary and revision total hip replacement. Many high-quality studies have demonstrated the benefit of large femoral heads in reducing post-operative instability. Ceramic femoral heads may also offer an advantage in reducing polyethylene wear that has been reported in vitro and is starting to become clinically apparent in mid-term clinical outcome studies. Additionally, the risk of taper corrosion at a ceramic femoral head–neck junction is clearly lower than when using a metal femoral head. With improvements in the material properties of both modern ceramic femoral heads and polyethylene acetabular liners that have reduced the risk of mechanical complications, large ceramic heads have gained popularity in recent years. Cite this article: Bone Joint J 2013;95-B, Supple A:63–6

We investigated the wear characteristics and clinical performance of four different total hip joint articulations in 114 patients. Wear and migration was measured by roentgenstereophotogrammetric analysis at five years or at the last follow-up. The mean annual wear was 0.11 mm for a stainless steel/Enduron articulation, 0.34 mm for stainless steel/Hylamer cup, 0.17 mm for zirconium oxide ceramic/Enduron and 0.40 mm for zirconium oxide ceramic/Hylamer. The difference between the groups was significant (p < 0.008) except for stainless steel/Hylamer vs zirconium oxide ceramic/Hylamer (p = 0.26). At present, 12 patients have undergone a revision procedure, four at five years and eight thereafter. No patient who received a stainless steel/Enduron articulation at their primary replacement required revision. Conflicting results have been reported about the performance of the zirconium oxide ceramic femoral head, but our findings suggest that it should not be used with a polymethylmethacrylate acetabular component. Hylamer has already been withdrawn from the market

The practice of removing a well-fixed cementless femoral component is associated with high morbidity. Ceramic bearing couples are low wearing and their use minimises the risk of subsequent further revision due to the production of wear debris. A total of 165 revision hip replacements were performed, in which a polyethylene-lined acetabular component was revised to a new acetabular component with a ceramic liner, while retaining the well-fixed femoral component. A titanium sleeve was placed over the used femoral trunnion, to which a ceramic head was added. There were 100 alumina and 65 Delta bearing couples inserted. . The mean Harris hip score improved significantly from 71.3 (9.0 to 100.0) pre-operatively to 91.0 (41.0 to 100.0) at a mean follow up of 4.8 years (2.1 to 12.5) (p < 0.001). No patients reported squeaking of the hip. There were two fractures of the ceramic head, both in alumina bearings. No liners were seen to fracture. No fractures were observed in components made of Delta ceramic. At 8.3 years post-operatively the survival with any cause of failure as the endpoint was 96.6% (95% confidence interval (CI) 85.7 to 99.3) for the acetabular component and 94.0% (95% CI 82.1 to 98.4) for the femoral component. The technique of revising the acetabular component in the presence of a well-fixed femoral component with a ceramic head placed on a titanium sleeve over the used trunnion is a useful adjunct in revision hip practice. The use of Delta ceramic is recommended. Cite this article: Bone Joint J 2013;95-B:333–8

Aims. Modular dual-mobility constructs reduce the risk of dislocation after revision total hip arthroplasty (THA). However, questions about metal ions from the cobalt-chromium (CoCr) liner persist, and are particularly germane to patients being revised for adverse local tissue reactions (ALTR) to metal. We determined the early- to mid-term serum Co and Cr levels after modular dual-mobility components were used in revision and complex primary THAs, and specifically included patients revised for ALTR. Patients and Methods. Serum Co and Cr levels were measured prospectively in 24 patients with a modular dual-mobility construct and a ceramic femoral head. Patients with CoCr heads or contralateral THAs with CoCr heads were excluded. The mean age was 63 years (35 to 83), with 13 patients (54%) being female. The mean follow-up was four years (2 to 7). Indications for modular dual-mobility were prosthetic joint infection treated with two-stage exchange and subsequent reimplantation (n = 8), ALTR revision (n = 7), complex primary THA (n = 7), recurrent instability (n = 1), and periprosthetic femoral fracture (n = 1). The mean preoperative Co and Cr in patients revised for an ALTR were 29.7 μg/l (2 to 146) and 21.5 μg/l (1 to 113), respectively. Results. Mean Co and Cr levels were 0.30 μg/l and 0.76 μg/l, respectively, at the most recent follow-up. No patient had a Co level ≥ 1 μg/l. Only one patient had a Cr level ≥ 1 μg/l. That patient’s Cr level was 12 μg/l at 57 months after revision THA for ALTR (and decreased ten-fold from a preoperative Cr of 113 μg/l). Conclusion. At a mean of four years, no patient with a modular dual-mobility construct and ceramic femoral head had elevated Co levels, including seven patients revised specifically for ALTR. While further studies are required, we support the selective use of a modular dual-mobility construct in revision and complex primary THAs for patients at high risk for instability. Cite this article: Bone Joint J 2019;101-B(6 Supple B):57–61

Aims. Our aim in this study was to describe a continuing review of 11 total hip arthroplasties using 22.225 mm Alumina ceramic femoral heads on a Charnley flanged femoral component, articulating against a silane crosslinked polyethylene. Patients and Methods. Nine patients (11 THAs) were reviewed at a mean of 27.5 years (26 to 28) post-operatively. Outcome was assessed using the d’Aubigne and Postel, and Charnley scores and penetration was recorded on radiographs. In addition, the oxidation of a 29-year-old shelf-aged acetabular component was analysed. Results. The mean clinical outcome scores remained excellent at final follow-up. The mean total penetration remained 0.41 mm (0.40 to 0.41). There was no radiographic evidence of acetabular or femoral loosening or osteolysis. There was negligible oxidation in the shelf-aged sample despite gamma irradiation and storage in air. Conclusion. These results highlight the long-term stability and durability of this type of crosslinked, antioxidant containing polyethylene when used in combination with a small diameter alumina ceramic femoral head. Cite this article: Bone Joint J 2017;99-B:1286–9

Symptomatic cobalt toxicity from a failed total hip replacement is a rare but devastating complication. It has been reported following revision of fractured ceramic components, as well as in patients with failed metal-on-metal articulations. Potential clinical findings include fatigue, weakness, hypothyroidism, cardiomyopathy, polycythaemia, visual and hearing impairment, cognitive dysfunction, and neuropathy. We report a case of an otherwise healthy 46-year-old patient, who developed progressively worsening symptoms of cobalt toxicity beginning approximately six months following synovectomy and revision of a fractured ceramic-on-ceramic total hip replacement to a metal-on-polyethylene bearing. The whole blood cobalt levels peaked at 6521 µg/l. The patient died from cobalt-induced cardiomyopathy. Implant retrieval analysis confirmed a loss of 28.3 g mass of the cobalt–chromium femoral head as a result of severe abrasive wear by ceramic particles embedded in the revision polyethylene liner. Autopsy findings were consistent with heavy metal-induced cardiomyopathy. We recommend using new ceramics at revision to minimise the risk of wear-related cobalt toxicity following breakage of ceramic components. Cite this article: Bone Joint J 2013;95-B:31–7

Although there is some clinical evidence of ceramic bearings being associated with a lower infection rate after total hip arthroplasty (THA), available data remains controversial since this surface is usually reserved for young, healthy patients. Therefore, we investigated the influence of five commonly-used biomaterials on the adhesion potential of four biofilm-producing bacteria usually detected in infected THAs. In this in-vitro research, we evaluated the ability of S. aureus, S. epidermidis ATCC 35984, E. coli ATCC 25922 and P. aeruginosa to adhere to the surface of solid biomaterials, including a 28mm cobalt-chromium metal head, a 28mm fourth-generation ceramic head, a 48mm fourth-generation ceramic insert, a 48mm highly-crossed linked polyethylene insert and a 52mm titanium porous-coated acetabular component. After an initial vortex step, a bacterial separation from the surface of each specimen was done until no remaining attached bacteria were observed by digital optical microscope. The colony-forming units were counted to determine the number of viable adherent bacteria and the bacterial density. We found no differences on global bacterial adhesion between the different surfaces. E. coli presented the least adherence potential among the analysed pathogens (p<0.001). The combination of E. coli and S. epidermidis generated an antagonist effect over the adherence potential of S. epidermidis individually (58±4% vs. 48±5%; p=0.007). The combination of P. aeruginosa and S. aureus presented a trend to an increased adherence of P. aeruginosa independently, suggesting an agonist effect (71% vs. 62%; p=0.07). In this study, ceramic bearings appeared not to be related to a lower bacterial adhesion than other biomaterials. However, different adhesive potentials among bacteria may play a major role on infection's inception

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

We aimed to demonstrate the clinical safety of a novel anatomic cementless ceramic hip resurfacing device. Concerns around the safety of metal on metal arthroplasty have made resurfacing less attractive, while long term function continues to make the concept appealing. Biolox Delta ceramic is now used in more than 50% of all hip arthroplasties, suggesting that it's safety profile is acceptable. We wondered if a combination of these concepts might work?. The preclinical testing of anatomic hip resurfacing device developed by our group was presented last year. A twenty patient safety study was designed. Patients had to be between the ages of 18 and 70. The initial size range was restricted to femoral heads between 46 and 54, representing the common sizes of hip resurfacing. The primary outcomes were clinical safety, PROMs and radiological control. Secondary outcomes include CTRSA and metal ion levels. 20 patients were recruited, aged 30–69. 7 were women and 13 were men. There were no operative adverse events in their operations undertaken between September 2017 and February 2018. One patient had a short episode of atrial fibrillation on the second postoperative day, and no other complications. At three months the median oxford hip score had risen from 27 (range 14–38) to 46 (31–48). Cobalt and chromium levels were almost undetectable at 3 months. Fixation appeared satisfactory in all patients, with no migration detected in either component. CTRSA is in process. The initial safety of a novel cementless ceramic resurfacing device is demonstrated by this data. The 10 year, 250 case efficacy study will continue in 5 other European centres

Hip resurfacing remains a safe and effective option according to registry data. Results in women were less reliable, in part owing to soft tissue impingement. Biolox Delta ceramic bearing couples are now in widespread use with very low complication rates. We set about merging these three elements to develop a novel hip resurfacing arthroplasty. Contours of both acetabular and femoral components were generated from biometric data, adapted to the constraints of ceramic machining, to ensure that radii blended from the bearing surface avoiding any sharp boundaries. Plasma spray coating with titanium and hydroxyapatite direct onto ceramic was developed and tested using shear, tensile and taber abrasion testing. Wear testing was carried out to 5 million cycles according to the ASTM. Destructive testing was carried out in a variety of test conditions and angles. Cadaveric testing demonstrated stability using a single use disposable instruments for both conventional and patient specific procedures. Very low dose CT enabled the entire interface to be observed as the Ceramic is radiolucent, enhancing migration analysis, which will be undertaken at 4 intervals to confirm stability. Functional scores and gait analysis will be used in the safety study. The CE study recruitment is underway, with first in human trials starting in summer 2017. PMA submission will follow the safety study. Commercial release of the device in Europe is unlikely before 2019, and in the USA may not be until 2027. The path to novel device development in 2017 is very costly in time and money

Introduction. Ceramic heads are used in hip revision surgery to mitigate corrosion concerns. Manufacturers recommend using a pristine titanium sleeve in conjunction with a well-fixed metal stem to prevent early failure of the ceramic head. However, the influence of impact force, head size, and sleeve offset on pull-off strength and seating displacement of a revision head assembly is not fully understood. Therefore, the purpose of this study was to investigate the pull-off strength and displacement of commercially available revision ceramic heads and titanium taper sleeve offsets (BIOLOX OPTION, CeramTec GmbH, Plochingen, Germany) while covering a range of clinically relevant impaction forces. Methods. Two head sizes (28 mm, n = 12 and 36 mm, n = 12) and two taper adapter sleeve offsets (small, n = 12 and extra-large, n = 12) were tested in this study. A dynamic impaction rig was constructed to seat the head, sleeve, and stem assembly (Fig. 1). Consistent impaction forces were achieved by dropping a hammer fixed to a lever arm from a pre-determined height onto a standard impactor instrumented with a piezoelectric force sensor (PCB Piezotronics Inc.). Axially applied forces of 2 kN and 6 kN were used to cover a range of typical impaction forces. Three non-contact differential variable reluctance transducers (LORD Sensing Systems) were used to track the displacement of the head relative to the stem. Subsequently, samples were transferred to a servo hydraulic testing machine, and a pull-off test was carried out per ISO 7206–10 to measure the disassembly force. Results. For all head and sleeve combinations assembled at 6 kN, pull-off forces and assembly displacements were over two times the values measured at 2 kN. As expected, an increased assembly force resulted in increased pull-offs and displacements. Head size did not play a significant role on measured outcomes. Regarding sleeve offsets, at assembly of 6 kN mean pull-off forces for extra-large sleeves were reduced by approximately 25% relative to small sleeves (Fig 2). However, at a 2 kN assembly, sleeve offsets did not appear to influence pull-off forces. Discussion. This study assessed the effect of impact assembly force, head size, and sleeve offset on pull-off strength and seating displacement of revision ceramic heads. The data suggests assembly force and sleeve offset may influence the pull-off strength and seating displacement of modular heads used in revision hip arthroplasty. Mean pull-off forces for revision heads were comparable in magnitude and trend to previous studies assessing the linear relationship between assembly force and pull-off force in primary heads (Krull et al., 2017, Rehmer et al., 2012). Lower pull-off forces were observed for extra-large sleeves when compared to small sleeves, indicating, decreased contact at the sleeve and stem interface for extra-large offsets may play a role in reducing pull-off forces. Acknowledgment:. The authors would like to thank CeramTec GmbH (Plochingen, Germany) for providing the head, sleeve, and stem implants. For any figures or tables, please contact authors directly

Prosthetic joint infections (PJI) are a devastating consequence in total hip arthroplasties (THA) with both significant morbidity and sometimes mortality, posing a significant health economic burden. Studies, both clinical and in-vitro have suggested possible reduction in PJI with the use of ceramic bearings. We have investigated the relationship of ceramic-on-ceramic (CoC), ceramic-on-polyethylene (CoP) or metal-on-polyethylene (MoP) bearing surface in affecting outcome of revision surgery after primary THA using data collected from National Joint Registry for England and Wales, Northern Ireland and the Isle of Man between 2002 and 2016. We used a competing risk regression model to investigate predictors of each revision outcome, such as infection, dislocation, aseptic revision and all cause revisions. The results were adjusted for age, gender, ASA grade, BMI, indication for surgery, intraoperative complications and implant data. We identified 456,457 THA (228,786 MoP, 128,403 CoC and 99,268 CoP). In a multivariable model, the adjusted risk of revision for PJI was lower with CoC (OR-0.748, p<0.001) and CoP (OR-0.775, p<0.001) when compared to MoP bearing. Additionally there was also a significant reduction in the risk of all cause revision for CoC (OR-0.918, p=0.002) and CoP (0.806, p<0.001), bearings as compared with MoP. The protective effect of ceramic bearing was predominantly seen after two years of implantation with a significant (p<0.0001) reduction of revision for PJI in both CoC (by 42.8%) and CoP (by 41.3%) group. Similarly significant effect was seen for aseptic revision beyond two years and overall all cause revision rate beyond two years reduced by 21.6% for CoC and 27.1% for CoP (p<0.001). Within the limits of registry analysis, this study has demonstrated an association between the use of ceramic bearing and lower rates of revision for all cause revisions especially infection and aseptic loosening. This finding supports the use of ceramic bearings in THA

It has been suggested that the wear of ultra-high molecular weight polyethylene (UHMWPE) in total hip replacement is substantially reduced when the femoral head is ceramic rather than metal. However, studies of alumina and zirconia ceramic femoral heads on the penetration of an UHMWPE liner in vivo have given conflicting results. The purpose of this study was to examine the surface characteristics of 30 alumina and 24 zirconia ceramic femoral heads and to identify any phase transformation in the zirconia heads. We also studied the penetration rate of alumina and zirconia heads into contemporary UHMWPE liners. The alumina heads had been implanted for a mean of 11.3 years (8.1 to 16.2) and zirconia heads for a mean of 9.8 years (7.5 to 15). The mean surface roughness values of the explanted alumina heads (Ra 40.12 nm and Rpm 578.34 nm) were similar to those for the explanted zirconia heads (Ra 36.21 nm and Rpm 607.34 nm). The mean value of the monoclinic phase of two control zirconia heads was 1% (0.8% to 1.5%) and 1.2% (0.9% to 1.3%), respectively. The mean value of the monoclinic phase of 24 explanted zirconia heads was 7.3% (1% to 26%). In the alumina group, the mean linear penetration rate of the UMWPE liner was 0.10 mm/yr (0.09 to 0.12) in hips with low Ra and Rpm values (13.22 nm and 85.91 nm, respectively). The mean linear penetration rate of the UHMWPE liner was 0.13 mm/yr (0.07 to 0.23) in hips with high Ra and Rpm values (198.72 nm and 1329 nm, respectively). This difference was significant (p = 0.041). In the zirconia head group, the mean linear penetration rate of the UHMWPE liner was 0.09 mm/yr (0.07 to 0.14) in hips with low Ra and Rpm values (12.78 nm and 92.99 nm, respectively). The mean linear penetration rate of the UHMWPE liner was 0.12 mm/yr (0.08 to 0.22) in hips with high Ra and Rpm values (199.21 nm and 1381 nm, respectively). This difference was significant (p = 0.039). The explanted zirconia heads which had a minimal phase transformation had similar surface roughness and a similar penetration rate of UHMWPE liner as the explanted alumina head