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

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

Background. Theoretically, improved material properties of new alumina matrix composite (AMC) material, Delta ceramics, are expected to decrease concerns associated with pure alumina ceramics and allow manufacturing thinner liners and consequent larger heads. However, limited short-term clinical results are available and mid-term results of these effects are unclear. Questions/Purposes. (1) Does AMC material decrease the rate of ceramic fracture and noise, concerns of previous-generation ceramics, following change of material properties? (2) Does the possible use of larger heads consequent to manufacturing thinner liners decrease dislocation rate and affect inguinal pain? (3) Do any other complications associated with the use of AMC ceramics occur?. Materials and Methods. One-hundred cementless primary total hip arthroplasties (THAs) using AMC ceramic bearings were performed consecutively by single surgeon. The mean follow-up period was 5.4 years (range, 5.0 to 5.7) and average age at the time of arthroplasty was 54.7 years. Prostheses with identical design and Biolox® Delta ceramics were used in all patients. Clinical evaluation included the occurrence of inguinal pain and noise which was classified into squeaking, clicking, grinding and popping. Ceramic fracture, dislocation and any other complications associated with the use of AMC ceramics were also investigated. Result. No ceramic fracture occurred and noise was reported in three patients (3.2%); three subjective clicking, but no squeaking. Single event of perioperative dislocation due to incompliance occurred in one hip (1.1%) and inguinal pain was reported in two hips (2.1 %); neither evidence of iliopsoas tendinitis on ultrasonography, nor association with ceramic head size (p>0.05). Liner dissociation following initial square seating was shown immediately after surgery in one hip (1.1%) and underwent revision THA. Conclusion. Improved material properties combined with the possible use of larger-diameter head make AMC ceramics a promising alternative bearing option with reduced risk of ceramic fracture, squeaking and dislocation. In spite of these encouraging results, however, meticulous technical precautions such as square seating and proper impaction in particular, should be taken during whole process of liner insertion

Introduction. Modern ceramic-on-ceramic bearings have become attractive alternatives to conventional polyethylene due to their low wear and minimal particle production. However, ceramic-on-ceramic implants have been associated with ceramic fracture and squeaking. To address these issues, large ceramic heads with a titanium-alloy sleeve have been introduced although limited data are available on their clinical outcomes. The purpose of this study was to report the midterm results of primary total hip arthroplasty using a 32mm with a titanium-alloy sleeve. Materials & Methods. We reviewed 245 patients who had 274 total hip arthroplasties with a 32 mm ceramic head with a titanium-alloy sleeve and had been followed for more than 5 years (average, 6.5 years; range, 5–9 years). The mean patient age at the time of surgery was 55.1 years (range, 16–82 years). All operations were performed at a single center. All of the ceramic implants were hot isostatic pressed, laser-marked, proof-tested third-generation alumina (Fig. 1). We determined the implant survival, Harris hip scores, incidence of ceramic fracture or noisy hips, and presence of osteolysis. Results. The survival rate of ceramic-on-ceramic bearings in primary total hip arthroplasty using 32 mm ceramic head with titanium-alloy sleeve was 97.5% at 9 years (Fig. 2). The Harris hip score improved from mean of 47 preoperatively to 93 at last follow-up. One ceramic head fractured at 6 years postoperatively. No ceramic liners were seen to fracture. Audible hip noise was identified in five hips (1.8%); clicking in four and squeaking in one. Osteolysis was detected in four hips (1.5%), but all had no symptom (Fig. 3). Other complications included three deep infections, two dislocations, and one peroneal nerve palsy. Conclusions. Primary ceramic-on-ceramic total hip arthroplasty using a 32 mm ceramic head with a titanium-alloy sleeve has a high survival rate of 97.5% at a 9-year follow-up. Nevertheless, surgeons should be aware of the potential risks of ceramic fracture, noise, and osteolysis associated with the use of ceramic head with a titanium-alloy sleeve

Ceramic bearing complications are rare but 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 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

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

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

Purpose. The fourth generation ceramic, in which zirconia is incorporated into the alumina matrix, was developed to reduce the risk of ceramic fractures. The purpose of this study was to evaluate the survivorship, clinical and radiographic results, and bearing-related failures associated with total hip arthroplasty using zirconia-toughened alumina ceramic-on-ceramic bearings over a minimum follow-up of 5 years. Materials and methods. We retrospectively analysed 135 patients (151 hips) who underwent cementless total hip arthroplasty using zirconia-toughened alumina ceramic-on-ceramic bearings. There were 58 men and 77 women with mean age of 55.9 years (range, 20 to 82 years) at index surgery. Acetabular and femoral components were cementless in all hips. A 36 mm head was used in 81 of 151 hips and a 32 mm head was used in 70 hips with smaller acetabular shells. The mean duration of follow-up was 6.1 years (range, 5 to 6.8 years). Results. Kaplan-Meier survival analysis with an end point of revision for any reason was 100% at 6.8 years. All acetabular and femoral components showed bony ingrowth. No radiographic evidence of osteolysis was identified. No ceramic fracture occurred. There were 4 (2.6%) noisy hips (1 squeaking and 3 clickings), but no patient could reproduce the noise and required revision. Other complications included one iliopsoas tendonitis and one dislocation. Conclusions. The minimum 5-year results of total hip arthroplasties performed using 32 mm or 36 mm zirconia-toughened alumina ceramic-on-ceramic bearings were encouraging with excellent survivorship. However, it was also found that the risk of noise development remains even for the newest generation of ceramics

Introduction. The optimal bearing for hip arthroplasty is still a matter of debate. in younger and more active patients ceramic-on-polyethylene (CoP) bearings are frequently chosen over metal-on-polyethylene (MoP) bearings to reduce wear and increase biocompatibility. However, the fracture risk of ceramic heads is higher than that of metal heads. This can cause serious issue, as ceramic fractures pose a serious complication often necessitating major revision surgery – a complication more frequently seen in ceramic-on-ceramic bearings. To date, there are no long-term data (> 20 years of follow-up) reporting fracture rates of the ceramic femoral heads in CoP bearings. Patients and Methods. We retrospectively evaluated the clinical and radiographic results of 348 cementless THAs treated with 2nd generation Biolox® Al2O3 Ceramic-on-Polyethylene (CoP) bearings, which had been consecutively implanted between January 1985 and December 1989. At implantation the mean patient age was 57 years. The cohort was subsequently followed for a minimum of 20 years. At the final follow-up 111 patients had died, and 5 were lost to follow-up (Fig. 1). A Kaplan-Meier survivorship analysis was used to estimate the cumulative incidence of ceramic head fractures over the long-term. Results. (Figs. 2, 3):. After 22-years the cumulative incidence of ceramic head fracture was estimated at 0.3% (95%-CI, 0–2.4%; 38 hips at risk). No impending failures could be noted on radiographic analysis at final follow-up. Discussion. The fracture rate of second-generation ceramic heads using a CoP articulation remains very low into the third decade after cementless THA; ceramic heads appear to be a safe alternative to metal femoral heads. Summary. This study evaluates the long-term (20–25 year) survivorship of cement on polyethylene bearings in uncemented THA

Introduction. Wear performances and fracture toughness of the alumina-matrix composite (AMC) Biolox-delta(r) are pointed out in the literature. This study is a prospective monocentric evaluation of 32 and 36 mm AMC/AMC bearing surfaces. Material and methods. 141 THA were included prospectively since 2006 in 127 patients. (62 females, 65 males, mean age 62, 2 years, mean BMI 25, 5). 134 cases were primary implantations. Mean follow-up is 40.9 months (29.8-53.4). In all patients we used the same cementless stem and cup. Clinical and radiological data were evaluated with a special attention for ceramic fracture and squeaking. Results. At follow-up mean HHS is 95.4. We faced current problems in this series (2 post-op.dislocations in non compliant patients, 1 hematoma, 3 early septic complications in immunodepressed patients). Intraoperative events were 3 non relevant femur fractures and 1 partial acetabular fracture. 4 cases needed a revision (1 cup and 1 stem loosening, 1 painful stem, 1 limb length discrepancy). No abnormal wear, osteolysis or implants migration could be detected in the other cases. No ceramic head fracture or liner chipping occurred. No patient reported squeaking. Discussion and conclusion. In this monocentric report the Delta COC articulation provides similar functional scores and survivorship as previously published ceramic on ceramic series. We did not observe ceramic fracture. Unusual rates of liner chipping have been described in an other multicentric study. According to our experience and despite the short follow-up, we suggest that those complications could be related to cup design rather than to the ceramic material

Osteolysis is one of a major cause of failure that affect long term survival rate in THA. Hard-on-hard bearing surface were developed to reduce wear and osteolysis, such as ceramic-on-ceramic which is the lowest wear rate was introduced but it still has squeaking and ceramic fracture. Metal-on-metal bearing surface significantly reduce wear rate but it still release metal ion which affect local tissue reaction. Then ceramic-on-metal is another choice of bearing with combine the advantage of reduce wear rate, metal ion release, no stripe wear, no squeaking and no ceramic fracture. However after clinical use ALTRs may occur and disturb the longevity of THA. During January 2009 to December 2009 we performed 98 THR with the same femoral stem and acetabular cup with difference bearing which were 87 cases of metal on cross-linked PE, 8 cases of ceramic on metal and 5 cases of metal on metal. Routinely postoperative care were done with clinical evaluation, plain x-rays and Harris hip score. After 5 years follow up there are clinical problems in ceramic on metal THA with decrease clinical score and progressive osteolysis in radiographic finding in 2 cases then we investigated to find the cause of this problem and revise the components. We preformed magnetic resonance imaging and collect blood sample for ESR, CRP and Cobalt and Chromium level. We revised 2 cases of ceramic on metal THA, during surgery we collected tissue for bacterial and AFB and histopathology. All retrieval components were studied for wear pattern. First patient have thigh pain and progressive osteolysis after year 4. th. of follow up. She had normal ESR and CRP with high level of cobalt and chromium level. We revised both components and tissue histopathology showed metallosis with chronic inflammation. Another patient had failure due to ALTRs with mixed solid-cystic mass at trochanteric bursa but component is stable then only bearing surface were change. Wear pattern at femoral head was in weight bearing area with corresponding to apical center wear of metal liner. Our study showed that only in group of ceramic-on-metal THA that have 5 years follow up have early reoperation due to osteolysis and tissue reaction. We routinely stop to use this bearing since 2010. But we have small number of cases in our study to conclude that is bearing are not suitable for clinical usage

Ceramic bearing complications are rare, but can be a catastrophic complication following total hip arthroplasty (THA). Particulate debris from fractured ceramics can cause damage to the hip prosthesis and jeopardise subsequent revision THA. 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 type. In order to retain the implants, the components must be well fixed, appropriately positioned, and have tapers that are undamaged and can accept current femoral heads. Additionally, an extensile exposure and complete synovectomy are necessary to remove the sharp ceramic particulate debris. Finally, a ceramic ball head should be used to revise a fractured ceramic THA. Newer, alumina composite ceramic ball heads are harder, reliable, and more scratch resistant compared to metal ball heads. However, when retaining the femoral component, a ceramic ball head with a titanium sleeve should be used to prevent subsequent failures. In summary, ceramic bearing complications are rare but catastrophic events. A systematic approach to evaluation and management is necessary to ensure a safe return

Ceramic bearing complications are a rare, but can be catastrophic, complication following total hip arthroplasty (THA). Particulate debris from these failed bearings can cause damage the underlying femoral and acetabular components and/or cause further damage to future hip implants. Failure to recognise and appropriately manage these events can lead to significant morbidity. Ceramic component fractures should be treated expeditiously. Delays in diagnosis and treatment can result in destructive damage of the underlying hip prosthesis caused by sharp, abrasive wear of ceramic particles. Patients with ceramic fractures 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. As with any other causes of failed joint arthroplasty, a systematic evaluation and workup for failure is mandatory prior to revision surgery. Revision options for failed ceramic components depend on component fixation, position, and type. In order to retain existing implants, the components must be well fixed, appropriately positioned, and have tapers that are undamaged and can accept current femoral heads. If these conditions are not met, then revision of components should be performed to optimise outcomes. Additionally, an extensile exposure is necessary in order to perform a complete synovectomy in order to remove as much of the ceramic particulate debris. Finally, the question of optimal bearing choice following component revision remains an area of debate. Newer, alumina composite ceramic ball heads are harder and more scratch resistant that metal ball heads and therefore preferred in my personal practice. In summary, ceramic bearing complications are rare but catastrophic events. A systematic approach to evaluation and management is necessary to ensure a safe return

Background/Purpose. Total hip arthroplasties (THAs) with ceramic bearings are widely performed in young, active patients and thus, long-term outcome in these population is important. Moreover, clinical implication of noise, in which most studies focused on ‘squeaking’, remains controversial and one of concerns unsolved associated with the use of ceramic bearings. However, there is little literature regarding the long-term outcomes after THAs using these contemporary ceramic bearings in young patients. Therefore, we performed a long-term study with a minimum follow-up of . 1. 5 years after THAs using contemporary ceramic bearings in young patients with osteonecrosis of the femoral head (ONFH) less than fifty. Materials and Methods. Among sixty patients (71 hips) with a mean age of 39.1 years, 7 patients (7 hips) died and 4 patients (4 hips) were lost before 15-year follow-up. The remaining 60 hips were included in this study with an average follow-up period of 16.3 years (range, 15 to 18). All patients underwent cementless THA using a prosthesis of identical design and a 28-mm third-generation alumina head by single surgeon. The clinical evaluations included the modified Harris hip score (HHS), history of dislocation and noise around the hip joint: Noise was classified into squeaking, clicking, grinding and popping and evaluated at each follow-up. Snapping was excluded through physical examination or ultrasonography. Radiographic analysis was performed regarding notching on the neck of femoral component, loosening and osteolysis. Ceramic fracture and survivorship free from revision were also evaluated. Results. The mean Harris hip score improved from 55.3 to 95.5 points (range, 83 to 100) at the time of the final follow-up. Seventeen patients (34.7%) reported noise around the hip joint: “squeaking” in one and “clicking” in 16 patients. Notching on the neck of femoral component suggesting impingement between neck and ceramic liner was demonstrated in 9 hips (15%) at average of 6.9 years postoperatively and located at 2 to 3.5 mm distal to edge of ceramic head. Although no chip fracture of ceramic ‘liner’ occurred, notching was associated with “clicking” sound (p<0.01). One patient who reported clicking sound underwent a revision THA because of ceramic ‘head’ fracture. Loosening, osteolysis or dislocation was not observed in any hip and survivorship free from revision at 5 years was 98%. Conclusion. Cementless THAs using 28-mm contemporary alumina ceramic head demonstrated excellent long-term outcome in young, active patients with ONFH. Despite this encouraging result, however, we remain concerned about ‘clicking’ sound, because we did observe it associated with notching on the neck of stem. Acknowledgement. This work was supported by Institute for Information & communications Technology Promotion (IITP) grant funded by the Korea government (MSIP) (#B0101-14-1081)

Introduction:. Ceramic head with titanium-alloy sleeve offers a modular ceramic head solution for the damaged taper in revision total hip arthroplasty (THA). It can also be used in primary THA to reduce the risk of ceramic head fracture. The purpose of the present study was to report the intermediate-term outcomes of primary ceramic-on-ceramic THA with use of ceramic head with titanium-alloy sleeve. Materials & Methods:. We evaluated 244 patients (271 hips) who had undergone primary ceramic-on-ceramic THA with use of BIOLOX® forte 32 mm ceramic head with titanium-alloy sleeve between November 2005 and August 2009. There were 158 males (175 hips) and 86 female (96 hips) patients with a mean age of 55.5 years. Clinical and radiographic evaluation was performed at a mean of 4.6 years (range, 2–7 years) postoperatively. Results:. Mean Harris hip score improved from 46 points (range, 7–77 points) preoperatively to 91 points (range, 45–100 points) postoperatively. One (0.4%) ceramic heads fractured at 6 years postoperatively, which was treated with isolated cup revision and ceramic head exchange. Periprosthetic osteolysis was detected in 3 hips (1.1%), but not symptomatic in all patients. One patient (0.4%) complained of clicking in his operated hip. There was no aseptic loosening of the acetabular cup. Two (0.7%) out of 271 hips sustained aseptic loosening of the femoral stem (both were 14×9 mm small stem). Other complications included 3 (1.1%) deep infections, 2 (0.7%) dislocations, and 1 (0.4%) periprosthetic femoral fracture. Conclusions:. The intermediate-term outcomes of primary ceramic-on-ceramic THA with use of BIOLOX® forte 32 mm head with titanium-alloy sleeve was encouraging. However, it is concerning that ceramic head fractures still occur, even in a very low incidence rate (0.4%). Additionally, long-term observation is required for periprosthetic osteolysis whether it comes from corrosion/fretting between taper and sleeve

Age is often used as a surrogate for activity. However, it has been demonstrated that BMI has a stronger correlation to post-operative activity than age. The fundamental exercise in choosing a bearing is maximizing the benefit-to-risk ratio. The following question should be addressed on a patient by patient basis: what available bearing is most likely to meet the needs of this patient, with an acceptable risk of revision surgery during their lifetime, is accepted in my community, and with a justifiable cost?. The risk of ceramic fracture is very low with Biolox® Delta, and that risk decreases with increasing head size. However, concerns of taper corrosion, not wear and osteolysis, have driven the increase in utilization of ceramic heads. More research is needed into the etiology of taper corrosion, especially surgeon variability in taper assembly. Crosslinked polyethylene has substantially reduced wear, osteolysis, and revision rates compared to non-crosslinked polyethylene, regardless of the countersurface. In the AOA National Joint Replacement Registry, ceramic/ceramic, metal/XLPE, ceramic/XLPE, and ceramicised metal/XLPE are the most commonly used bearing surfaces. With 12–15 year follow-up, there is no difference in the cumulative percent revision of these four bearings in patients aged <55. Ceramic heads are variably more expensive. The ability to recoup the increased cost of ceramic heads through a diminished lifetime revision cost is dependent on the price premium for ceramic and the age of the patient. A wholesale switch to ceramic bearings regardless of age or cost differential could result in an economic burden to the health system. One measure of “standard” is simply “the most frequently used”. In this regard, market data alone makes the determination of “standard” without regard to clinical or economic outcomes. However, longer follow-up, including financial data, is necessary to better assess the relative value (benefit-to- risk ratio) of all the available bearing couples

Introduction. From a tribological point of view and clinical experience, a ceramic-on-ceramic bearing represents the best treatment option after rare cases of ceramic component fracture in total hip arthroplasty (THA). Fractured ceramic components potentially leave small ceramic fragments in the joint capsule which might become embedded in PE acetabular liners. Purpose. This in vitro study compared for the first time the wear behaviour of femoral ball heads made of ceramic and metal tested with PE liners in the presence of ceramic third-body debris. The contamination of the test environment with third-body ceramic debris, insertion of ceramic fragments into the PE liners and implementation of continuous subluxation simulated a worst-case scenario after revision of a fractured ceramic component. Materials and Methods. Ceramic femoral ball heads (ϕ 32 mm) made of alumina matrix composite (AMC; BIOLOX® delta, CeramTec, Germany) were tested in combination with PE and cross-linked liners and compared to metal femoral ball heads (CoCrMo) of the same diameter. All PE liners were fixed into Ti-6Al-4V metal shells by conical fixation as intended for clinical use. The tests were performed based on ISO 14242-1 utilizing a hip simulator (EndoLab, Germany). Alumina ceramic debris (BIOLOX® forte, CeramTec, Germany) of about 2 mm diameter (maximum 5 mm) were inserted into the PE liners in predefined specific points corresponding to the main load transfer area before the test. The acetabular liners were tested at an inclination of 45° in the medial-lateral plane with the specimens placed in an anatomically correct position. During the test, additional alumina ceramic debris was introduced into the articulation area as a part of the test fluid (calf serum) used in the simulator test chambers. All specimens were tested up to 5 million cycles. Damages to the surfaces of the materials were assessed visually. The wear of the femoral ball heads was measured gravimetrically. Results. High wear rates were found for metal femoral ball heads, being 1,010 times higher when compared to ceramic femoral ball heads tested with XPE liners and 560 times higher when compared to ceramic femoral ball heads tested with conventional PE liners. The conventional and crosslinked PE liners used in combination with metal femoral ball heads clearly exhibited a scratched surface, whereas the surface of the liners tested with ceramic femoral ball heads exhibited significantly less scratching. Discussion and Conclusion. This study demonstrates that apart from the recommended ceramic-on-ceramic option also ceramic-on-PE and ceramic-on-crosslinked PE bearing couples may be a viable treatment option after fracture of a ceramic component. The use of a ceramic femoral ball head after fracture of a ceramic articulation component minimizes wear and wear-related complications caused by third-body wear. Based on the results of this in vitro study and clinical findings, the use of a metal femoral ball head in articulation with any PE liner after a ceramic fracture is contraindicated

INTRODUCTION. Patients less than 60 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. For the six year period from May 1999 to March 2005, 278 hip replacements in 244 patients less than 60 yeas of age at the time of surgery were performed using alumina ceramic-ceramic bearings. All hips had uncemented titanium femoral and acetabular components. The ceramic liner was fixed to the shell with an 18-degree flush-mounted taper design. Patients were followed clinically and radiographically. Attempts were made to contact all patients who had not been seen in the prior 3 years. Of the 278 hips, 17 hips (16 patients) remain lost to follow-up, leaving 261 hips (228 patients; 155 hips in men, 106 hips in women) for assessment. Mean age of the patients was 46.2 years at the time of surgery (range 17.8 to 59.9 years). 17% of hips had at least one previous hip surgery. Mean time following surgery was 9.75 years (range 2 to 16.8 years). RESULTS. At mean 9.75 year follow-up, none of these 261 hips experienced early or late deep infection or dislocation. Four patients died of causes unrelated to their arthroplasty at a mean of 6.1 years, all with well functioning constructs. Nine hips (3%) were revised: 2 stems and 2 cups failed to osseointegrate; 1 modular neck component sustained a modular neck fracture; and ceramic fracture occurred in 1 femoral head and 3 liners. Three of the 4 patients with fracture sustained severe trauma from life-threatening injuries. CONCLUSION. Total hip arthroplasty in young patients demonstrates excellent survivorship when uncemented titanium implants are coupled with ceramic-ceramic bearings

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

Purpose. Ceramic-on-ceramic bearings in total hip arthroplasty (CoC THA) have theoretical advantages of wear resistance and favorable biocompatibility of ceramic particles to the surrounding bony and soft tissue. Long-time durability of CoC THA has been expected, however, clinical results over 10 years after operation were scarcely reported. In the present study, clinical results at follow of 10 years were examined for CoC THAs with a changeable femoral neck which allowed correction of anteversion of the femoral component in cases with abnormal femoral anteversion in dysplastic hips. Methods. During 1997 and 2000, 203 cementless CoC THAs in 158 patients were conducted in our hospital. Six patients died because of unrelated causes and 5 patients were lost to followup, and the remaining 188 hips in 147 patients were analyzed at the mean followup period of 10.8 years (3.7 to 13.5). There were 24 men and 123 women, and the average age at operation was 54 years (26 to 73). The hip diseases for operation were osteoarthritis in 165 hips, osteonecrosis of the femoral head in 21 hips and failure of hemiarthroplasty in 2 hips. The operation was performed in the lateral position through the posterior approach without trochanteric osteotomy. The articulation was composed of Biolox forte alumina liner fitted into beads-coated hiemispherical titanium shell, and a 28-mm Biolox forte alumina femoral head (Cremascoli). The femoral component was either AnCA stem or custom-designed stem, coupled with a modular neck allowing selection of 5 variable offsets and anteversions (Cremascoli). Clinical and radiological findings, and complications during the followup period were analyzed. Results. During the follow-up, 8 hips were revised, due to repeated dislocation (2 hips), periprosthetic fracture (1 hips), cup loosening (1 hip), fracture of ceramic liner rim (2 hips), and cup loosening along with ceramic liner rim fracture (2 hips). Cup abduction angle of the 4 cases with ceramic liner rim fracture were high at 49 degrees or more, as compared with the mean cup abduction angle of 41 degrees in the other hips without ceramic fracture. The survival rate at 10 years was 96.0 % when failure was revision. In the hips other than the revised cases, 6 hips showed cup loosening and no hip showed stem loosening on radiographs. Osteolysis was seen in 3 hips around the cup and 4 hips around the stem. Nineteen patients (10%) complained of abnormal noises around the hip, but most of the noises were click sound. Discussion. The 10-year results of cementless CoC THAs with a modular neck were favorable with few cases of osteolysis. However, relatively high frequency of cup loosening may be a concern, since increased cup abduction angle associated with cup loosening may cause ceramic liner fracture