Aims. The aims of this study were to evaluate wear on the surface of cobalt-chromium (CoCr) femoral components used in total knee arthroplasty (TKA) and compare the wear of these components with that of ceramic femoral components. Methods. Optical profilometry was used to evaluate surface roughness and to examine the features created by the wear process in a knee wear simulator. We developed a method of measuring surface changes on five CoCr femoral components and quantifying the loss of material from the articular surface during the wear process. We also examined the articular surface of three ceramic femoral components from a previous test for evidence of surface damage, and compared it with that of CoCr components. Results. We found that the surface roughness of CoCr components rapidly increased during the first 1,000 wear cycles, then reached a steady state, but material loss from the surface continued at a rate of 1,778,000 μm. 3. per million cycles as carbides were removed from its matrix. These carbides formed third-body wear particles, leading to the formation of new scratches even as older scratches were worn away. In contrast, no scratching, loss of material, or other surface damage, when evaluated with one nanometer resolution, was found on the surface of the ceramic components after a 15 M wear cycle test. Conclusion. This study showed wear and loss of CoCr material from scratching and microabrasive wear in TKA. The material loss from the surface continued in a linear relationship with increasing cycles. We also found the absence of scratching and roughening of ceramic femoral components in simulated wear, suggesting an advantage in wear rate and avoiding metal sensitivity. This may have implications in the management of persistent pain after TKA. Cite this article: Bone Joint J 2021;103-B(6 Supple A):94–101

Ceramic bearings have several desirable properties, such as resistance to wear, hardness, and biocompatibility, that favour it as an articulating surface in hip arthroplasty. However, ceramic fracture remains a concern. We have reviewed the contemporary literature, addressing the factors that can influence the incidence of ceramic bearing surface fracture. Cite this article: Bone Joint J 2019;101-B:897–901

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

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

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

Aims. Metal and ceramic humeral head bearing surfaces are available choices in anatomical shoulder arthroplasties. Wear studies have shown superior performance of ceramic heads, however comparison of clinical outcomes according to bearing surface in total shoulder arthroplasty (TSA) and hemiarthroplasty (HA) is limited. This study aimed to compare the rates of revision and reoperation following metal and ceramic humeral head TSA and HA using data from the National Joint Registry (NJR), which collects data from England, Wales, Northern Ireland, Isle of Man and the States of Guernsey. Methods. NJR shoulder arthroplasty records were linked to Hospital Episode Statistics and the National Mortality Register. TSA and HA performed for osteoarthritis (OA) in patients with an intact rotator cuff were included. Metal and ceramic humeral head prostheses were matched within separate TSA and HA groups using propensity scores based on 12 and 11 characteristics, respectively. The primary outcome was time to first revision and the secondary outcome was non-revision reoperation. Results. A total of 4,799 TSAs (3,578 metal, 1,221 ceramic) and 1,363 HAs (1,020 metal, 343 ceramic) were included. The rate of revision was higher for metal compared with ceramic TSA, hazard ratio (HR) 3.31 (95% confidence interval (CI) 1.67 to 6.58). At eight years, prosthesis survival for ceramic TSA was 98.7% (95% CI 97.3 to 99.4) compared with 96.4% (95% CI 95.2 to 97.3) for metal TSA. The majority of revision TSAs were for cuff insufficiency or instability/dislocation. There was no significant difference in the revision rate for ceramic compared with metal head HA (HR 1.33 (95% CI 0.76 to 2.34)). For ceramic HA, eight-year prosthetic survival was 92.8% (95% CI 86.9 to 96.1), compared with 91.6% (95% CI 89.3 to 93.5) for metal HA. The majority of revision HAs were for cuff failure. Conclusion. The rate of all-cause revision was higher following metal compared with ceramic humeral head TSA in patients with OA and an intact rotator cuff. There was no difference in the revision rate for HA according to bearing surface. Cite this article: Bone Joint J 2024;106-B(5):482–491

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

Aims. The survival of humeral hemiarthroplasties in patients with relatively intact glenoid cartilage could theoretically be extended by minimizing the associated postoperative glenoid erosion. Ceramic has gained attention as an alternative to metal as a material for hemiarthroplasties because of its superior tribological properties. The aim of this study was to assess the in vitro wear performance of ceramic and metal humeral hemiarthroplasties on natural glenoids. Methods. Intact right cadaveric shoulders from donors aged between 50 and 65 years were assigned to a ceramic group (n = 8, four male cadavers) and a metal group (n = 9, four male cadavers). A dedicated shoulder wear simulator was used to simulate daily activity by replicating the relevant joint motion and loading profiles. During testing, the joint was kept lubricated with diluted calf serum at room temperature. Each test of wear was performed for 500,000 cycles at 1.2 Hz. At intervals of 125,000 cycles, micro-CT scans of each glenoid were taken to characterize and quantify glenoid wear by calculating the change in the thickness of its articular cartilage. Results. At the completion of the wear test, the total thickness of the cartilage had significantly decreased in both the ceramic and metal groups, by 27% (p = 0.019) and 29% (p = 0.008), respectively. However, the differences between the two were not significant (p = 0.606) and the patterns of wear in the specimens were unpredictable. No significant correlation was found between cartilage wear and various factors, including age, sex, the size of the humeral head, joint mismatch, the thickness of the native cartilage, and the surface roughness (all p > 0.05). Conclusion. Although ceramic has better tribological properties than metal, we did not find evidence that its use in hemiarthroplasty of the shoulder in patients with healthy cartilage is a better alternative than conventional metal humeral heads. Cite this article: Bone Joint J 2024;106-B(11):1273–1283

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