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

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. We conducted a prospective study of a delta ceramic total hip arthroplasty (THA) to determine the rate of ceramic fracture, to characterise post-operative noise, and to evaluate the mid-term results and survivorship. Patients and Methods. Between March 2009 and March 2011, 274 patients (310 hips) underwent cementless THA using a delta ceramic femoral head and liner. At each follow-up, clinical and radiological outcomes were recorded. A Kaplan-Meier analysis was undertaken to estimate survival. Results. Four patients (four hips) died and 18 patients (20 hips) were lost to follow-up within five years. The remaining 252 patients (286 hips) were followed for a mean of 66.5 months (60 to 84). There were 144 men (166 hips) and 108 women (120 hips) with a mean age of 49.7 years (16 to 83) at surgery. The mean pre-operative Harris Hip Score of 47.1 points improved to 93.8 points at final follow-up. Six patients reported squeaking in seven hips; however, none were audible. Radiolucent lines involving Gruen zones one and/or seven were seen in 52 hips (18.2%). No hip had detectable wear, focal osteolysis or signs of loosening. One hip was revised because of fracture of the ceramic liner, which occurred due to an undetected malseating of the ceramic liner at the time of surgery. One hip was revised for a periprosthetic fracture of the femur, and one hip was treated for periprosthetic joint infection. The six-year survivorship with re-operation for any reason as the endpoint was 99.0% (95% confidence interval 97.8% to 100%). Discussion. The rate of delta ceramic fracture was 0.3% (one of 286). While ceramic head fracture was dominant in previous ceramic-on-ceramic THA, fracture of the delta ceramic liner due to malseating is a concern. Cite this article: Bone Joint J 2017;99-B:741–8

Large femoral heads have become popular in total hip replacement (THR) as a method of reducing the risk of dislocation. However, if large heads are used in ceramic-on-ceramic THR, the liner must be thinner, which may increase the risk of fracture. To compare the rates of ceramic fracture and dislocation between 28 mm and 32 mm ceramic heads, 120 hips in 109 patients (51 men and 58 women, mean age 49.2 years) were randomised to THR with either a 28 mm or a 32 mm ceramic articulation. A total of 57/60 hips assigned to the 28 mm group and 55/60 hips assigned to the 32 mm group were followed for at least five years. No ceramic component fractures occured in any patient in either group. There was one dislocation in the 32 mm group and none in the 28 mm group (p = 0.464). No hip had detectable wear, focal osteolysis or prosthetic loosening. In our small study the 32 mm ceramic articulation appeared to be safe in terms of ceramic liner fracture. . Cite this article: Bone Joint J 2014;96-B:1459–63

Aims. Ceramic-on-ceramic (CoC) bearings in total hip arthroplasty (THA) are commonly used, but concerns exist regarding ceramic fracture. This study aims to report the risk of revision for fracture of modern CoC bearings and identify factors that might influence this risk, using data from the National Joint Registry (NJR) for England, Wales, Northern Ireland and the Isle of Man. Patients and Methods. We analysed data on 223 362 bearings from 111 681 primary CoC THAs and 182 linked revisions for bearing fracture recorded in the NJR. We used implant codes to identify ceramic bearing composition and generated Kaplan-Meier estimates for implant survivorship. Logistic regression analyses were performed for implant size and patient specific variables to determine any associated risks for revision. Results. A total of 222 852 bearings (99.8%) were CeramTec Biolox products. Revisions for fracture were linked to seven of 79 442 (0.009%) Biolox Delta heads, 38 of 31 982 (0.119%) Biolox Forte heads, 101 of 80 170 (0.126%) Biolox Delta liners and 35 of 31 258 (0.112%) Biolox Forte liners. Regression analysis of implant size revealed smaller heads had significantly higher odds of fracture (chi-squared 68.0, p < 0.001). The highest fracture risk was observed in the 28 mm Biolox Forte subgroup (0.382%). There were no fractures in the 40 mm head group for either ceramic type. Liner thickness was not predictive of fracture (p = 0.67). Body mass index (BMI) was independently associated with revision for both head fractures (odds ratio (OR) 1.09 per unit increase, p = 0.031) and liner fractures (OR 1.06 per unit increase, p = 0.006). . Conclusions. We report the largest independent study of CoC bearing fractures to date. The risk of revision for CoC bearing fracture is very low but previous studies have underestimated this risk. There is good evidence that the latest generation of ceramic has greatly reduced the odds of head fracture but not of liner fracture. Small head size and high patient BMI are associated with an increased risk of ceramic bearing fracture. Cite this article: Bone Joint J 2017;99-B:1012–19

Aims

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

A moderator and panel of five experts led an interactive session in discussing five challenging and interesting patient case presentations involving surgery of the hip. The hip pathologies reviewed included failed open reduction internal fixation of subcapital femoral neck fracture, bilateral hip disease, evaluation of pain after metal-on-metal hip arthroplasty, avascular necrosis, aseptic loosening secondary to osteolysis and polyethylene wear, and management of ceramic femoral head fracture.

Aims

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

Aims

We evaluated the short-term functional outcome and prevalence of bearing-specific generation of audible noise in 301 patients (336 hips) operated on with fourth generation (Delta) medium diameter head, ceramic-on-ceramic (CoC) total hip arthroplasties (THAs).

We report the clinical and radiological outcomes of a series of contemporary cementless ceramic-on-ceramic total hip replacements (THRs) at ten years in patients aged ≤ 55 years of age. Pre- and post-operative activity levels are described. A total of 120 consecutive ceramic cementless THRs were performed at a single centre in 110 patients from 1997 to 1999. The mean age of the patients at operation was 45 years (20 to 55). At ten years, four patients had died and six were lost to follow-up, comprising ten hips. The mean post-operative Harris hip score was 94.7 (55 to 100). Radiological analysis was undertaken in 90 available THRs of the surviving 106 hips at final review: all had evidence of stable bony ingrowth, with no cases of osteolysis. Wear was undetectable. There were four revisions. The survival for both components with revision for any cause as an endpoint was 96.5% (95% confidence interval 94.5 to 98.7). The mean modified University of California, Los Angeles activity level rose from a mean of 6.4 (4 to 10) pre-operatively to 9.0 (6 to 10) at the ten-year post-operative period.

Alumina ceramic-on-ceramic bearings in cementless primary THR in this series have resulted in good clinical and radiological outcomes with undetectable rates of wear and excellent function in the demanding younger patient group at ten years.

Cite this article: Bone Joint J 2013;95-B:1603–9.

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.

This systematic review of the literature summarises the clinical experience with ceramic-on-ceramic hip bearings over the past 40 years and discusses the concerns that exist in relation to the bearing combination. Loosening, fracture, liner chipping on insertion, liner canting and dissociation, edge-loading and squeaking have all been reported, and the relationship between these issues and implant design and surgical technique is investigated. New design concepts are introduced and analysed with respect to previous clinical experience.

A number of studies have reported satisfactory results from the isolated revision of an acetabular component. However, many of these studies reported only the short- to intermediate-term results of heterogeneous bearing surfaces in a mixed age group.

We present our experience of using a ceramic-on-ceramic (CoC) bearing for isolated revision of an uncemented acetabular component in 166 patients (187 hips) who were under the age of 50 years at the time of revision. There were 78 men and 88 women with a mean age of 47.4 years (28 to 49). The most common reason for revision was polyethylene wear and acetabular osteolysis in 123 hips (66%), followed by aseptic loosening in 49 hips (26%).

We report the clinical and radiological outcome, complication rate, and survivorship of this group. The mean duration of follow-up was 15.6 years (11 to 19).

The mean pre-operative Harris hip score was 33 points (1 to 58), and improved to a mean of 88 points (51 to 100) at follow-up. The mean pre-operative total Western Ontario and McMaster Universities Osteoarthritis Index score was 63.2 (43 to 91) and improved to 19.8 points (9 to 61) post-operatively. Overall, 153 of 166 patients (92%) were satisfied with their outcome. Kaplan–Meier survivorship analysis, with revision or radiological evidence of implant failure (13 patients, 8%) as end-points, was 92% at 15 years (95% confidence interval 0.89 to 0.97).

Isolated revision of a cementless acetabular component using a CoC bearing gives good results in patients under 50 years of age.

Cite this article: Bone Joint J 2015;97-B:1197–1203.

A modular layered acetabular component (metal-polyethylene-ceramic) was developed in Japan for use in alumina ceramic-on-ceramic total hip replacement. Between May 1999 and July 2000, we performed 35 alumina ceramic-on-ceramic total hip replacements in 30 consecutive patients, using this layered component and evaluated the clinical and radiological results over a mean follow-up of 5.8 years (5 to 6.5). A total of six hips underwent revision, one for infection, two for dislocation with loosening of the acetabular component, two for alumina liner fractures and one for component dissociation with pelvic osteolysis. There were no fractures of the ceramic heads, and no loosening of the femoral or acetabular component in the unrevised hips was seen at final follow-up. Osteolysis was not observed in any of the unrevised hips. The survivorship analysis at six years after surgery was 83%. The layered acetabular component in our experience, has poor durability because of unexpected mechanical failures including alumina liner fracture and component dissociation.

Dislocation is a common reason for revision following total hip replacement. This study investigated the relationship between the bearing surface and the risk of revision due to dislocation. It was based on 110 239 primary total hip replacements with a diagnosis of osteoarthritis collected by the Australian Orthopaedic Association National Joint Replacement Registry between September 1999 and December 2007. A total of 862 (0.78%) were revised because of dislocation. Ceramic-on-ceramic bearing surfaces had a lower risk of requiring revision due to dislocation than did metal-on-polyethylene and ceramic-on-polyethylene surfaces, with a follow-up of up to seven years. However, ceramic-on-ceramic implants were more likely to have larger prosthetic heads and to have been implanted in younger patients. The size of the head of the femoral component and age are known to be independent predictors of dislocation. Therefore, the outcomes were stratified by the size of the head and age.

There is a significantly higher rate of revision for dislocation in ceramic-on-ceramic bearing surfaces than in metal-on-polyethylene implants when smaller sizes (≤ 28 mm) of the head were used in younger patients (< 65 years) (hazard ratio = 1.53, p = 0.041) and also with larger (> 28 mm) and in older patients (≥ 65 years) (hazard ratio = 1.73, p = 0.016).

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.