Aims Osteolysis from polythene debris contributes to loosening of total hip components. Will ceramic/ceramic bearings in conjunction with Hydroxyapatite Ceramic Coated Hips (HAC) survive any better?. Material. Hydroxyapatite Ceramic Coated Hips were first used in Sunderland, U.K. in May 1988. More than 2400 HAC hips have been inserted. There are 521 hips in 441 patients with ceramic/ceramic bearings. I am reporting this consecutive series. These hips are generally inserted into patients with a 20+ year life expectancy. This ranges from 18 to 74. Mean age is 52.4 years. These young patients are mostly active and many are working. Amongst the indications were osteoarthritis 297, hip dysplasia 76, and ankylosing spondylitis 18. Thirty eight had had previous childhood hip disorders, and 19 had rheumatoid arthritis. The series also includes 43 with AVN and 7 revisions from cemented hip replacement. All the patients are assessed using the Harris Hip Score before and after surgery. They are assessed annually. Post operative scores show 22 patients with Harris Hip Scores of less than 80, but only 9 patients have problems attributable to HAC hip surgery. These include 2 patients with infection, 3 fractured ceramic acetabular liners, two broken heads and 2 patients with loose cups, one from aseptic loosening. Apart from this one case, aseptic loosening has not been a problem. Discussion. The results have been rewarding. There are 2400+ HAC hips in the whole series. This sub group of 521 ceramic/ceramic HAC hips is small with a maximum follow up of 14 years. However, there have been few failures which could be attributed to the HA coated device. The broken ceramic components are a concern. It is probable that third body inclusions between the modular components led to stress concentrations. It is also possible that acetabular impingement was a problem and the hips may have been subluxing a few microns with every step and not just gliding with every step. This might overload the alumina implants leading to their failure. All the earlier prostheses are alumina/alumina but 55 hips inserted since august, 2005 have an alumina/zirconia compound head (Biolox Delta®). There have been no cases of periprosthetic osteolysis. Conclusions. Hydroxy Apatite bony bonding secures the implants. No cement or polyethylene is used which can contribute to osteolysis. Wear in ceramic bearings will be negligible. Third body inclusions must be avoided to prevent wear or fracture. The femoral spigot must not impinge on the acetabular margin causing subluxation which may lead to fracture. The ceramic material has to be supported to prevent fracture. The outcome of the patients in this sub-group has been rewarding. Alumina/alumina hip arthroplasty should be considered where life expectancy is substantial

Purpose: Ceramic/ceramic bearing surfaces have the advantage of significantly decreased wear and high biocompatibility compared to CoCr/PE or ceramic/PE. The purpose of this randomized, controlled, multi-center, prospective study was to evaluate the clinical and roentgenographic results of 469 ceramic/ceramic versus 321 ceramic/PE THA at a 2 to 7 year follow-up. Methods: The ceramic/ceramic THA had a polished alumina femoral head articulating with a polished alumina acetabular liner seated into the metal acetabular shell designed to avoid any impingement of the ceramic liner on the femoral component. Evaluations were completed preoperatively, at 6 months and yearly postoperatively. Results: Mean age of the 790 patients was 59 years, with slightly more females. There were no significant demographic differences between the two groups. The main diagnoses were OA in 74% and osteonecrosis in 19%. Preoperatively the mean Harris Hip Score (HHS) and WOMAC scores were 44 and 41, respectively, and did not differ significantly between the two groups. At follow-up, the mean HHS was 93 for the ceramic/ ceramic THA and 93 for the ceramic/PE THA. The mean WOMAC scores showed no differences at follow-up. Roentgenographic analysis revealed one acetabular cup migration with a PE liner. One ceramic liner fractured upon insertion that was not properly positioned prior to impaction. Otherwise, there were no revisions or complications related to either bearing surface. Conclusions: This short-term study has demonstrated efficacy and safety of a ceramic/ceramic bearing surface compared to the standard ceramic/PE surface currently used in clinical practice, with no failures or complications related to the bearing surface. Further follow-up is indicated to determine the long-term outcome. Funding: Commerical funding. Funding Parties: Encore Orthopaedics

Introduction: Ceramics appear to be good material for bearing surfaces due to their extreme hardness. We present the follow up results on 726 Total Hip Replacements using ceramics done in an institution over 19 years. Patients and methods: This is a single surgeon series of 836 total hip replacements using ceramic as a bearing surface, performed since 1981. 283 of these were ceramic on ceramic whereas 408 were ceramic on polyethylene, most inserted without cement. 726 (86.9%) of these patients were either examined (546) or assessed with a questionnaire (149). 31 patients had died and their dates of death were taken as the point in time when their hips were surviving. These three groups are included in the analysis. 43 of the hips were revised. A survivorship analysis – using the life table technique – of the two groups was performed using revision as the end point. Results: 31 total ceramics, and 12 ceramic-on-polyethylene hips required revision. The survivorship illustrated a superior performance of the ceramic-on-polyethylene implants. Discussion: The patients in the total ceramic group were considerably younger (average age 34.7) compared to the ceramic on polyethylene group (average age 59.2). Seven patients with failed implants from the ceramic-on-ceramic group had been subjected to previous surgery compared to only one in the other group. The majority of the ceramic-on-ceramic group had a primary pathology more likely to cause a distorted anatomy of the hip joint. In general the patients in the total ceramic group were at higher risk of failure for technical reasons. The follow up period – mean 9.23 years for the total ceramic group, and 8.22 years for the ceramic-on-polyethylene group – is relatively short, and future years will further clarify the situation

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

Hydroxyapatite Ceramic Coated Hips (HAC) were first used in Sunderland, U.K. in May 1988. More than 1725 HAC hips have been inserted. There are 264 hips in 237 patients with ceramic/ceramic (alumina) bearings. These hips are inserted into patients with a 20+ year life expectancy. Their mean age is 50.5 years. All patients are assessed using the Harris Hip Score pre. and postoperatively. There are 14 patients with Harris Hip Scores of less than 80, but only 8 patients have problems attributable to HAC hip surgery. These include 1 patient with infection, 3 fractured ceramic acetabular liners, one broken ceramic head, 2 with aseptic loosening and 1 patient who chronically dislocated her hip. Amongst the indications were osteoarthritis 136, hip dysplasia 44, and ankylosing spondylitis 13. Twenty six had had previous childhood hip disorders, and 16 had rheumatoid arthritis. The series also includes 4 revisions from cemented hip replacement. The results have been rewarding. There are 1700+ HAC hips in the whole series. This sub group of 264 ceramic/ceramic HAC hips is small and follow up is relatively short. There have been few failures which could be attributed to the HA coated device. However, there are 4 broken ceramic components. Conclusion: Hydroxy Apatite bony bonding secures the implants. No polyethylene is used which can contribute to debris disease. Wear in ceramic bearings will be negligible. Third body inclusions must be avoided. The femoral spigot must not impinge on the acetabular margin. The ceramic material has to be supported to prevent fracture

At ten years, alumina ceramic bearings are functioning well with low complication rates and a fewer number of revisions than the control cohort. Alumina ceramic bearings have proven superior wear resistance, lubrication, and scratch resistance, without carrying the risk of metal ion release. In 1996 a U.S. IDE clinical trial was initiated utilizing newly improved alumina ceramic materials and implant design. The purpose of this multi-center, prospective, randomized study is to prove comparable safety and efficacy of alumina-alumina ceramic to a control cobalt chrome-polyethylene bearing. Four hundred fifty two patients (475 hips) are followed in this study. Subjects include ceramic on ceramic, with either porous coated cup or arc deposited cup, or control group with metal on polyethylene with porous coated cup. Average age of subject at time of surgery was 53 years with 82% diagnosis of OA. The average Harris Hip Score was 96 and 94% of hips had little to no pain. Kaplan-Maier survivorship at 10 years, component revision for any reason, was 95.9% for ceramic bearings compared to 91.3% for metal on polyethylene control. There have been nine hips requiring revision of one or both components for any reason. Data was recently collected on the subjects that participated in either the IDE or Continued Access arms of the ABC. ®. and Trident. ®. study. Data collection included revisions, complications, and noise. Out of 930 hips (848 patients) there were nine incidences of squeaking noise reported, no wear/osteolysis issues, and only two insert fractures (0.2%). At ten years ceramic bearings show no wear, inconsequential lysis, minimal breakage, and occasion noise. Clinically, alumina ceramic bearings perform as well as the metal-on-polyethylene, with fewer revisions and less osteolysis, suggesting that they are a safe, viable option for younger, more active patients

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

Current CoC hip bearing ranges are typically from 28mm to 36mm diameter, but to improve stability and range of motion, a novel large diameter hip bearing is introduced, with bearing diameter from 32mm to 48mm. To minimise acetabular bone loss, a low profile acetabular component is required and achieved with a ceramic wall thickness of 3.5mm and metal shell thickness of 1.5mm at the acetabular rim. This paper presents some of the testing required to develop this novel design. Finite element (FE) modelling was performed to simulate the standard 46kN burst loading of the acetabular cup for 5 different geometries of ceramic liner and metal (titanium) shell. By smoothing the facets on the back of the ceramic and thinning the metal shell, the stresses in the ceramic were reduced by 20% and failure was not predicted for the burst test. Reducing the thickness of the metal shell increased the stresses in the metal, but these were kept below the yield strength of the material. When assembled, the hoop stresses in the titanium shell caused a greater volume of the ceramic to be in compression and the strength of the assembled cup was therefore increased. To assess the effect of fatigue loading on the ceramic/titanium taper-lock, cups were loaded at 45° to the horizontal for 10,000 cycles in Ringer’s solution at 37°C. The load required to push the ceramic from the metal shell were recorded after the test and compared to the push out load of unloaded specimens. There was no significant decrease in the push-out load (mean 2kN) indicating that the taper lock retains its strength during fatigue loading. The new CoC acetabular cup design is assembled under controlled conditions before packaging. To demonstrate the effectiveness of this, the new device was compared to a commercially available intraoperatively assembled Ti/ceramic device which had a metal shell thickness of 5mm. The cups were placed in reamed cavities of polyurethane foam and the rims impacted with increasing impact energy until the ceramic came loose from the metal shell. An average impact energy of 4J (1kg dropped from 400mm) was necessary to separate the ceramic from the metal liner of the new design compared to 2J for the commercially available design. The thicker titanium wall thickness and intraoperative assembly method of the commercially available design limited the amount of shell deformation/hoop stress generated, and therefore limited the ‘grip’ of the Ti/ceramic interface. The thinner titanium shell (1.5mm) and controlled assembly load of the new design allowed greater shell deformation/hoop stress which produced a two-fold improvement in interface strength. Further effects of assembly in vivo, in particular the effects of periprosthetic or lavage fluids, remain to be investigated. In any case, incomplete ceramic liner seating has been reported in 16% of procedures in vivo (Lang-down, JBJS Br 2007) and the preassembled design therefore represents a notable and necessary improvement to current technology

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

The purpose of this study is to analyze clinical and radiological results of total hip arthroplasty using the 3rd generation ceramic on ceramic articular surface. Between July 1999 and May 2005, 339 hips of 250 patients had primary cementless total hip arthroplasty with the 3rd generation ceramic on ceramic bearing implants. And 325 hips of 236 patients were followed up over 3 years. Male were 168 patients(237 hips) and female were 68 patients(88 hips). The mean age at the time of operation was 47.3(range, 25~76) years old and the mean follow up period was 62.4(range, 36~107.6) months. The preoperative diagnoses were osteonecrosis of the femoral head (ONFH) in 250 hips, secondary osteoarthritis in 55 hips(dysplasia in 35, infection sequalae in 12, LCP in 2, CDH in 2), hemophilic arthropathy in 9 hips, ankylosing spondylitis in 7 hips etc. We used Bicontact system(Aesculap, Germany) in 65 hips, Secur-FitTM(Stryker Howmedica Osteonics, USA) in 206 hips, Trilogy ABTM (Zimmer, USA) in 54 hips. Clinically, Harris Hip Score, thigh pain, squeaking and other complications were evaluated. Radiologically, the serial radiographs were analyzed. Clinically, the Harris hip score was improved from preoperative 66.0(19~91) to 96.2(58~100) at the last follow-up. Radiologically, there was no loosening of implants and visible wear and osteolysis. Heterotopic ossifications were noted in 5 cases. In complications, there was dislocation in one case, periprosthetic fracture in 2 cases and thigh pain in 9 cases. Intermittent squeaking sound has occurred in 8 cases(2.5%). Among these, one case of loud squeaking which happened after fall down had revision surgery. There was no infection and fracture of ceramic implant. Our midterm results of THA with the 3rd generation ceramic bearing system were very satisfactory and demonstrated that the 3rd generation ceramic bearings remain as an excellent bearing choice because of their superior wear characteristics. However, the results of this study suggests that the squeaking would be one of strong potential risk factors for failure of ceramic on ceramic total hip arthroplasty and we must be very cautious to prevent squeaking

Squeaking in ceramic total hip joint replacements has become a controversial topic. This study aims to document the incidence of squeaking and other noise generation in a single surgeon series for ceramic on ceramic total hip joint replacements. Possible aetiological for squeaking causes are explored. All patients from public and private who received ceramic on ceramic total hip joint replacements (Stryker trident-accolade) from 2002 to 2007 were identified via the New Zealand Joint registry. Following ethics approval all patients were contacted for a phone interview to question as to whether they had noted any noise generation. Patients who demonstrated noise generation were reviewed in clinic for full history and examination. Data including age, sex, weight, primary diagnosis, head size and cup size were obtained from clinical notes. Post operative x-rays were reviewed to analyse cup abduction and version. Forty one ceramic total hip joint replacements in a total of thirty seven patients were reviewed via telephone interviews. Three patients complained of squeaking in the ceramic bearing while one patient complained of a grinding and one other of clicking. Two of the three who had recognised the squeaking were both able to reproduce the squeaking in the clinic room. The third patient was noted to have crepitus from anterior patello-femoral osteoarthritis. There was no statistical difference in age, weight, primary diagnosis or head size. In terms of abduction and version of the acetabular cups that squeaked, one had twenty seven degrees of ante-version and forty seven degrees of abduction and the other fifteen degrees of anteversion and thirty degrees of anteversion. Four cups lay outside the recommended fifteen-thirty five degrees of anteversion and thirty five-fifty five degrees of abduction yet showed no squeaking. Neither patient is troubled by the squeaking and neither would seek revision surgery. The incidence of squeaking in ceramic on ceramic total hip joint replacements appears to be around five percent with a similar number of patients experiencing other noises. The position of the acetabular cup does not appear to be the sole contributor to the noise and other aetiological causes need to be further investigated

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

A major challenge for total hip arthroplasty is to minimize wear and osteolysis in young, active patients. Alumina ceramic bearings have shown superior wear resistance and lubrication and do not carry the risk of ion release. In a prospective randomized study (ABC), 514 hips were implanted. All patients (average age, 53 years) received the same press-fit hydroxyapatite coated femoral stem; two thirds (345 hips) received alumina ceramic bearings, and one third (169 hips) received a cobalt-chrome-on-polyethylene bearing. A fourth arm (Trident) was included involving use of a metal-backed acetabular component implanted in 209 patients. At a mean follow-up of 35.2 months (range, 24–48 months), there was no significant difference in clinical performance between the patient cohorts. The cohort of patients included in the ABC, Trident, and extended access portion of the study represents a population of 2313 patients with no device related failures attributable to the ceramic on ceramic articulation used in these patients. This new experience involves the use of improved ceramic materials and new design considerations that eliminate the risks and complications of past experiences with ceramic implants and provides a safe bearing option for young patients

Background: Squeaking in hip arthroplasty is a phenomenon that was described decades ago, but has only been brought back to attention recently. It occurs predominantly in ceramic on ceramic bearings, and has a reported incidence from less than 1% to 21%. The cause and the implication of squeaking are still unknown and many factors have been suggested to contribute. This study has looked into the patient factors to investigate if any clinical features are associated with an increased risk of squeaking. Methods: All primary total hip arthroplasties with ceramic on ceramic bearing that were performed at our unit were reviewed and all squeaking hips presented are included in the study. Patient demographics and clinical outcome data were analysed and compared with matched controls from the silent hips. Results: Between 1997 and 2008, 3375 primary hip arthroplasties in 3182 patients with ceramic on ceramic bearing were performed in our unit. Seventy one hips (2.1%) presented with squeaking on direct questioning and self reporting. Those patients were found to be taller, heavier and younger. They also have a significantly higher post-operative range of hip motion and higher Harris hip score when compared to matched controls. There was no difference in the satisfaction score. Only 4 patients (5.6%) presented with pain as well as squeaking, and 2 (2.8%) resulted in revision surgery for problematic squeaking. Conclusions: We present the largest series of squeaking primary hip arthroplasties with ceramic on ceramic bearing to date. A number of patient factors were found to be associated with squeaking. The taller, heavier and younger patients with more flexible and functional hips were at a higher risk, presumably because these patients put greater mechanical demands on their hips. Majority of the patients with squeaking are pain free and there is only a small risk of requiring revision surgery

Aim: Alumina ceramic on ceramic bearings have gained popularity in hip arthroplasty due to the properties of low wear, low friction and chemically inert wear debris. In a previous study, we reported the excellent clinical results of a series of cementless ceramic on ceramic primary total hip arthroplasties at a minimum of 5 years. We now present the follow up results at 10 years. Method: Between June 1997 and February 1999, 301 consecutive, primary cementless hip arthroplasties were performed on 283 patients in our unit. The mean age of the patients was 57.8 years, with 145 (51%) being female. All of the hips received the same implant: (Osteonic ABC cup and Secure-Fit or Secure-Fit Plus stem; Stryker Orthopaedics). A third generation alumina ceramic on ceramic bearing (Biolox Forte; CeramTec) was used for articulation in all cases. All the operations were performed through a posterior approach with enhanced posterior repair, and the post-operative protocols were the same for all the patients. The clinical and radiographic outcome at 10 years were analysed. Results: At 10 years, 7.3% had died of unrelated cause and 3% were revised. The average Harris Hip score was 94.3 points at the last follow up. Ninety six percent of patients scored an excellent or good result, with less than 3% have moderate residual pain. Radiographically, all patients assessed had evidence of stable bony ingrowth. There were nine revisions in all, four stem revisions due to periprosthetic fracture, one secondary to aseptic loosening and one to facilitate a femoral shortening osteotomy. There was one cup revision for psoas tendonitis and one for cup repositioning. This same patient subsequently underwent further revision due to acetabular osteolysis with metallosis and some ceramic wear. Overall, the survival rate of the implants was 96% at 10 years. The retrieved femoral heads showed a median wear rate of 0.2 cubic millimeters per year. Conclusions: Alumina ceramic on ceramic bearings in cementless primary total hip arthroplasty had been shown to have good survival rate at 10 years with good function, low wear rate and no adverse radiographic changes. The one case of osteolysis may be due to ceramic wear debris or may be due to metal wear debris from the neck to rim impingement

Total joint arthroplasty of the first metatarsophalangeal joint is an acceptable modality of treatment for hallux rigidus. We set out to evaluate the early outcome of ceramic/ceramic (MOJE) prosthesis, in the treatment of painful hallux rigidus. Between March 2000 and June 2002, 13 patients (14 implants) with painful hallux rigidus were treated with ceramic/ceramic (MOJE) prosthesis. The hallux meta-tarsophalangeal-interphalangeal scoring scale, by the American Orthopaedic Foot and Ankle Society, was used to assess these patients, pre-operatively and at follow up. A total score of 100 is possible in a patient with no pain, full range of MTP joint movement and good alignment. The average follow up was for 12 months. At six months, 12 patients had no pain post operatively. The average AOFAS score pre-operatively was 43.07, compared to 95.28 post-operatively (p= 0.0001). Ten of the patients subjectively described the out come of the procedure as excellent. Two patients described it as satisfactory. One patient with significant hallux valgus pre-operatively, developed subluxation of the prosthesis at 6 months. At revision, the prosthesis was noted to be loose and a distraction arthrodesis was carried out. Pre-operatively, all patients had a combined dorsiflexion and plantarflexion range of between 30 and 74 degrees. Post operatively this was improved to greater than 75 degrees in 10 patients. Seven out of the eight female patients were able to wear fashionable foot shoes with high heels comfortably. Twelve of the patients experienced audible squeaking, which improved after six months. One patient developed a superficial infection, which was treated successfully. The ceramic/ceramic (MOJE) total arthroplasty gave excellent results in 77% of patients. Patients were happy with the fact that they could continue wearing fashionable shoes. The early outcome is encouraging, with a statistically significant improvement in the AOFAS scoring system

Ceramics are used in hip prostheses in approximately 40% of the implants (ce/ce and ce/pe). The increase of the diameters (32 and 36 mm) in order to improve the stability and the Range of Motion of the prostheses is now the topic. Research and development has allowed creating new alumina inserts with smaller out diameter (39 mm for the 32 mm bearing and of 44 mm for the 36 mm ones). The new alumina matrix composite has allowed the realization of ceramic revision ball-heads. This system, made of 28 or 32 mm ball-heads with a titanium slivers (12714 internal cone), will allow applications of the ceramic ball-head on an in situ damaged taper. Beyond S, M and L lengths, will be available also an XL version. A femoral knee component, still in phase of study, has shown advanced resistances of 5, 8 and 15 times the body-weight in different load configurations. Have been carry out some tests in order to estimate the adhesion between the ceramic and the cement of different thickness and have been caught up values of 6,17 MPa (2 mm) and 14,90 MPa (0,7mm)

Hallux rigidus is a common condition involving the first Metatarsophalyngeal (MTP) joint. Total joint arthroplasty is an acceptable modality of treatment. A number of different prosthesis have been used. Our study aims to evaluate the outcome of uncemented ceramic on ceramic (MOJE) prosthesis, in the treatment of painful hallux rigidus. Between March 2000 and June 2005, 38 patients (53 feet) with painful hallux rigidus were treated with uncemented ceramic on ceramic (MOJE) prosthesis. There were 30 female and 8 male patients. The hallux meta-tarsophalangeal-interphalangeal scoring scale, by the American Orthopaedic Foot and Ankle Society, was used to assess these patients, pre-operatively and at follow up. A total score of 100 is possible in a patient with no pain, full range of MTP joint movement and good alignment. The average follow up was for 34 months (range 12–68 months). Three revisions were carried out in three patients, 2 for deep infection, and 2 for persisting pain. Five patients showed radiological signs of osteolysis but had no symptoms. There was one late subluxation after 32 months. One patient developed a superficial infection, which was treated successfully. The average AOFAS score pre-operatively was 45, compared to 91 post-operatively (p< 0.05). 23 patients (36 feet) classed the outcome as excellent to good. Ten of the patients subjectively described the out come of the procedure as excellent. The preop range of movement (combined dorsiflex-ion and plantarflexion) was improved from a mean of 22 degrees to 68 degrees postoperatively. The ceramic/ceramic (MOJE) total arthroplasty gave excellent results in 77% of patients. The early outcome is encouraging. We ewcommend continued use of this prosthesis for painful hallux rigidus

Introduction: With ceramic on ceramic bearing surfaces in total hip arthroplasty audible noise is a frequently documented problem. With increasing head size, there is less chance of component-on-component impingement and therefore a decreased risk of chipping, breaking and maybe noise occurrence. Material and Methods: Prospective multicentre follow-up study of n=149 cases (91 males and 58 females). All patients were treated with either 32 or 36mm ceramic on ceramic articulation (Bionit. ®. ) in combination with the non-cemented modular pressfit cup seleXys. ®. (Mathys Ltd Bettlach, Switzerland). There were n=4 patients with bilateral surgery. 56 patients received a 32mm head whereas 93 patients were treated with a 36mm head. In the group with 32 mm head diameter 79% were women, whereas in the 36 mm group only 16% were women. Patients were operated between December 2005 and January 2007. The mean age at surgery was 67.2 years (range, 46.3 – 86.4 years). Mean body mass index was 28.0 kg/m2 (range, 17.1 – 45.4 kg/m2). Patients were followed clinically and radiographically at three and six months, then after one and two years. Results: 5 patients died and 2 patients were lost to follow-up. Only one patient reported squeaking noise immediately after the operation. At the one year follow-up the patient reported a feeling of subluxation and the noise turned into a clicking. The patient had to be revised after 14 months with a polyethylene inlay. No other revisions had taken place. Patients with femoral heads of 32 mm and 36 mm diameter had excellent clinical results after 2 years follow-up for flexion angle, range of motion and Harris Hip Score. The Harris Hip Score increased from a pre-operative mean of 48.7 points to 93.5 points. Hip flex-ion increased from 91° to 113°. The Visual Analogue Scale for pain decreased from 6.7 to 0.9 and VAS for satisfaction increased from 3.2 to 9.3. Conclusion: Compared to other studies the occurrence of noise and resulting revision procedures is very low. We assume that the insertion of bigger heads may reduce this problem and simultaneously allow the patient a better range of motion. The non-cemented modular cup combined with a ceramic inlay and a ceramic femoral head is a safe implant with excellent clinical results after two years

In 2020 almost 90% of femoral heads for total hip implants in Germany were made of ceramic. Nevertheless, the cellular interactions and abrasion mechanisms in vivo have not been fully understood until now. Metal transfer from the head-neck taper connection, occurring as smear or large-area deposit, negatively influences the surface quality of the articulating bearing. In order to prevent metal transfer, damage patterns of 40 Biolox delta ceramic retrievals with CoC and CoPE bearings were analysed. A classification of damage type and severity for each component (n=40) was done according to an established scoring system. To investigate the physical properties, the surface quality was measured using confocal microscopy, quantitative analysis of phase composition were performed by Raman spectroscopy and qualitative analysis of metal traces was done by scanning electron microscopy (SEM) with energy dispersive X-ray spectroscopy (EDX). The periprosthetic tissue was analysed for abrasion particles with SEM and EDX. Both bearing types show different damage patterns. Dotted/ drizzled metal smears were identified in 82 % of CoC (n=16) and 96 % of CoPE (n=24) bearings. Most traces on the ceramic heads were identified in the proximal area while they were observed predominantly in the distal area for the ceramic inlays. The identified marks are similar to those of metallic bearings. Metallic smears lead to an increase of up to 30 % in the monoclinic crystalline phase of the ceramic. The roughness increases by up to six times to Ra=48 nm. Ceramic and metallic wear particles from the articulating surfaces or head neck taper junctions were found in the periprosthetic tissue. Damage patterns on CoC hip implants seem to be similar to those of metallic implants. More detailed analysis of CoC implants are needed to understand the described damage patterns and provide advice for prevention