Introduction and Objective. Ceramic on Ceramic bearings in Total Hip Arthroplasty (THA) afford a low friction coefficient, low wear rates and extreme hardness. Significant complications include hip squeak, ceramic fracture and poor polyethylene performance in revision procedures due to imbedding of abrasive microscopic ceramic fragments. We report on the results of this bearing at a minimum of 10 years. Materials and Methods. A single-centre retrospective review of 449 THAs was performed. Primary outcome measures included aseptic revision and all-cause revision rates at a minimum of 10 years post operatively. Evaluation of functionality was performed with WOMAC and SF-36 scores which were performed pre-operatively and at intervals of 6 months, one year, 2 years, 5 years and 10 years post operatively. Results. There was a 6.2% (n=28) all-cause and 5.3% (n=24) aseptic revision rate for ceramic on ceramic total hip arthroplasty at minimum of 10 years with a mean time to revision 4.8 years (range 2 months − 11.6 years). Notably, there were 2 revisions for ceramic head fracture, one for ceramic liner fracture, 3 for aseptic loosening and 3 revisions for squeaking. Pain of unknown origin was the most common reason for revision. There was an improvement in postoperative WOMAC scores from a mean of 59.8 (range 15–95) pre-operatively to a mean of 15.6 (range 0–78) at 10 years. Conclusions. This study showed good functional outcomes but high revision rates for CoC THA at a minimum of 10 years. The role for CoC bearings in THA has been called into question in recent years and may continue to decline in popularity, even in younger patients. Further large scale studies are important to assess the long-term outcomes of this bearing surface

Introduction. The identification of biological markers associated to implant failure in THA (total hip arthroplasty) patients remains a challenge in orthopedic surgery. In this search, previous studies have been mainly focused on typical mediators associated to bone metabolism and inflammation. Our group has evaluated changes in serum levels of insulin-like growth factor binding protein-1 (IGFBP-1), a protein which is not directly related to bone homeostasis, in patients undergoing THA. Method. We assessed IGFBP-1 levels in serum obtained from 131 patients (58% female, 42 % male; age: 68 ± 13 years) who underwent THA in the Orthopedic Surgery and Traumatology Department of our institution. In this cohort, 57% of patients had metal on polyethylene (MoP) as hip-bearing surface combination, 17 % had ceramic on ceramic (CoC) and 26% of them did not have any prosthesis. A test based on an enzyme-linked immunosorbent assay (ELISA) was used to determine IGFBP-1 levels in serum obtained from these patients. Result. Our results showed a significant increase in IGFBP- 1 levels in MoP group as compared to CoC and control groups, in which no differences in quantified levels were detected. Further analysis revealed no significant differences in IGFBP-1 between cemented and non-cemented MoP bearings. We performed a ROC curve to evaluate the accuracy of serum IGFBP-1 in discriminating MoP from the rest of patients (area under the curve: 0.7; 95% confidence interval: 0,6-0.8; p<0.05) and established a cut-off value of 10.2 ng/ml, according to the Youden´s Index. Logistic regression analysis showed that patients with MoP bearing surfaces had a higher risk of increased IGFBP- 1 levels in serum (p<0.05, Odds Ratio: 6.7, 95% Confidence Interval 3.1 to 14.8). Conclusion. IGFBP- 1 levels are significantly elevated in THA patients with MoP bearing surfaces, suggesting that this protein might be a reliable biomarker for the outcome of patients implanted with MoP

Introduction and Objective. Despite pure alumina have shown excellent long-term results in patients undergoing total hip arthroplasty (THA), alumina matrix composites (AMCs) composed of alumina and zirconium oxide are more commonly used. There are no comparative studies between these two different ceramics. We performed a retrospective case-control study to compare results and associated complications between AMC from two manufacturers and those with pure alumina from another manufacturer. Materials and Methods. 480 uncemented THAs with ceramic on ceramic (CoC) bearing surfaces (288 men and 192 women; mean age of 54.1 ± 12.4 years), were implanted from 2010 to 2015. Group 1: 281 THAs with pure alumina; Group 2A: 142 with AMC bearing in a trabecular titanium cup. Group 2B: 57 hips with AMC bearing with a porous-coated cup. Results. The mean follow-up was 7.3 years. There was one late infection in group 1, eight dislocations, three in group 1 (1.1%), three in group 2A (2.1%), all with a 36 mm femoral head, and two in group 2C (3.5%). Liner malseating was found in one hip in group 1, and in five hips in group 2C, of these, there were four liner fractures (7.0%). Four cups were revised for iliopsoas impingement (three in group 1 and one in group 2B). Two cups were revised for aseptic loosening, one in group 1 and one in group 2A, and four revised femoral stems in group 2A, three for subsidence and another for postoperative periprosthetic B. 2. fracture. The mean preoperative Harris Hip Score was 48.6 ± 3.3 in the whole series and 93.9 ± 7.2 at the end of follow-up. The survival rate of revision for any cause was 98.2% (95% Confidence Interval: 96.6–99.8) at ten years for group 1, 95.8% (95% CI: 92.1–99.5) for group 2A, and 91.1% (95% CI: 83.7–98.5) for group 2B (log-rank 0.030). Conclusions. Outcome of uncemented CoC THA in young patients was satisfactory at mid-term in all three groups. However, liner fractures were frequent in group 2B. All dislocated hips in group 2A had a 36 mm femoral head diameter, and revision due to any cause was less frequent in group 1. Pure alumina CoC THA can be used as a benchmark for comparison with newer CoC THAs

Background. The R3 cementless acetabular system (Smith & Nephew, Memphis, Tennessee, United States) is a modular titanium shell with an asymmetric porous titanium powder coating. It supports cross-linked polyethylene, metal and ceramic liners with several options for the femoral head component. The R3 cup was first marketed in Australia and Europe in 2007. Two recent papers have shown high failure rates of the MoM R3 system with up to 24% (Dramis et al 2014, Hothi et al 2015). There are currently no medium term clinical papers on the R3 acetabular cup. Objectives. The aim of the study is to review our results of the R3 acetabular cup with a minimum of 5 year follow up. Study Design & Methods. Patients who were implanted with the R3 acetabular cup were identified from our centre”s arthroplasty database. Our centre started implanting the R3 acetabular cup in August 2009. For this study, we only included patients with a minimum of 5 year follow up (until June 2011). Over this time period, 293 consecutive THAs were performed in 286 patients, of which 7 were bilateral staged total hip arthroplasties. The primary outcome was revision. The secondary outcomes were the Oxford hip scores and radiographic evaluation. Results. The mean age of the patients was 69.4 years (range 20–100 years). There were 117 males and 169 females in our series. The majority of the total hip arthroplasties in our series were cementless (n=283, 97%) and the rest were hybrid (n=10, 3%). The articulation bearings were as follows: ceramic on ceramic (n=167; 57%), Ceramic on Poly XLPE (n=97; 33%), Oxinium-Poly XLPE (n=19; 6.5%), stainless steel- Poly XLXE (n=10; 3.5%). The mean pre-operative Oxford Hip Score was 23 (range 10–34) and the mean Oxford Hip Score was 40 (range 33–48) at the final follow-up. Radiological evaluation showed an excellent ARA-score in all patients at five years. None of the R3 cups showed osteolysis at final follow up. There were 3 revisions in our series, of which two R3 cup were revised. The risk of revision was 0.28% at 5 years. Using Weibull analysis, it gives a 10-year estimate of 98.8% survival for the R3 cup (95%CI 95.0 to 99.6). Conclusions. Our experience at a district general hospital using the R3 acetabular system with conventional bearings showed high survivorship and is consistent with the allocated Orthopaedic Data Evaluation Panel (ODEP) rating of 5A* as rated in 2015 in the United Kingdom

This was a retrospective study of registry data from a National Orthopaedic Hospital for all THRs with 10-year follow-up data. Inclusion criteria were all THRs with a minimum of 10-year follow-up data. All metal-on-metal (MoM) THRs and MoM resurfacings were excluded from the analysis due to the high rate of revision associated with these bearings. Univariate and multivariate analyses controlling for confounding variables were performed to compare outcomes. A total of 1,697 THRs were performed in 1,553 patients. The four significant predictors for revision were fixation type (p<0.01), surface bearing type (p<0.01), age (P<0.05) and head size (p<0.05). Gender, BMI and approach had no effect on revision rates. The lowest 10-year all-cause revision rates were seen in cemented THRs at 1.7%. Ceramic-on-poly bearings had the lowest revision rate at only 1.2%. Metal-on-poly bearings had a 1.7% revision rate. Ceramic on ceramic bearings had a 7.1% revision rate with 1 revision for squeak and 1 revision for ceramic head fracture. The causes for revision in order of decreasing frequency were as follows: Infection (n=13, 0.7%), dislocation (n=7, 0.4%), periprosthetic fracture (n=3, 0.2%) and aseptic loosening (n=2, 0.1%). There were 2 re-revisions at 10 years in total. The smaller 22.225mm head sizes had a significantly lower revision rate than other head sizes (p<0.05). Ceramic-on-poly bearings, cemented fixation and smaller head sizes perform better in the experience of this registry. However, with multivariate analysis, these differences were shown to be insignificant

Aluminia ceramic on ceramic (COC) bearing surfaces have been used for 35 years in total hip arthroplasty (THA). Studies report 85% survival at a minimum follow-up of 18.5 years. Nonetheless, an audible noise is a finding associated with COC bearings with incidence rates of 2–10%. This study aims to determine the prevalence of noise and evaluate its effect on patients. All patients who had a COC THA from August 2003 to December 2010 were contacted and asked to complete a standardised questionnaire. This asked about the presence and characteristics of a noise and if associated with activities, pain and whether this phenomenon should be mentioned preoperatively. Four consultant surgeons performed 282 consecutive primary COC THAs in 258 patients. (Male=122, Female=136 mean age 68.5; age range 28–88). In all cases, the same brand of ceramic acetabular component and stems were implanted. 11.0% had a noise, of which 5.5% had a squeak. Pain was experienced in 38.7% of patients in hips that made a noise. There was no trauma and one dislocation in this group. In this study, 85% of noises occur during weight-bearing although no patients have reduced daily activities as a result of the noises. Of all the patients, 55.0% stated they would have preferred to have known about a noisy hip possibility before consenting but none would have refused consent. Squeaking has not been a problem here despite the prevalence being higher than most in the literature. The authors recommend that squeaking should be discussed preoperatively. A checklist for Orthopaedic Trainees is being drafted to enable trainees to counsel patients appropriately, allowing patients a better opportunity to give informed consent

Wear particles produced by alumina ceramic-on-ceramic (CoC) bearings cause a minimal immunological response with low cytotoxicity and inflammatory potential. 1, 2. However, more comprehensive immunological studies are yet to be completed for the composite CoC (zirconia-toughened, platelet reinforced alumina) hip replacements due to difficulties in isolating the very low volume of clinically relevant wear debris generated by such materials in vitro. The aim of this study was to compare the cytotoxic effects of clinically relevant cobalt chromium (CoCr) nano-particles with commercial composite ceramic particles. Composite ceramic particles (commercial BIOLOX® delta powder) were obtained from CeramTec, Germany and clinically relevant CoCr wear particles were generated using a six station pin-on-plate wear simulator. L929 fibroblast cells were cultured with 50µm. 3. of CoCr wear debris or composite ceramic particles at low to high volumes ranging from 500µm. 3. –0.5µm. 3. per cell and the cyctotoxic effects of the particles were assessed over a period of 6 days using the ATP-Lite™ cell viability assay. The composite ceramic particles were bimodal in size (0.1–2µm & 30–100nm) and showed mild cytotoxic effects when compared with equivalent particle volumes (50µm. 3. ) of clinically relevant CoCr nano-particles (10–120nm). The CoCr nano-particles had significant cytotoxic effects from day 1, whereas the composite ceramic particles only showed cytotoxic effects at particle concentrations of 50 and 500µm. 3. after 6 days. The increased cytotoxicity of the clinically relevant CoCr nano-particles may have been attributed to the release of Co and Cr ions. This study demonstrated the potential cytotoxic effects of model ceramic particles at very high volume concentrations, but it is unlikely that such high particle volumes will be experienced routinely in vivo in such low wearing bearing materials. Future work will investigate the longer-term effects on genotoxicity and oxidative stress of low volumes of clinically-relevant generated BIOLOX® delta ceramic wear particles

We examined stainless-steel, cobalt-chrome, titanium and alumina and zirconia ceramic femoral heads retrieved at revision surgery. All the heads had articulated against ultra-high-molecular-weight-polyethylene (UHMWPE) acetabular cups. We studied the simulation of third-body damage and the wear of UHMWPE against the various materials used for the heads. The surfaces of the retrieved heads were analysed using a two-dimensional contacting profilometer. Third-body damage was characterised by the mean height of the scratches above the mean line (R. pm. ). The alumina ceramic and zirconia ceramic retrieved heads were found to have significantly less damage. In laboratory studies the ceramics were also more resistant to simulated third-body damage than the metal alloys. We studied the wear of UHMWPE against the damaged counterfaces in simple configuration tests. The damaged ceramics produced less polyethylene wear than the damaged metal counterfaces. The wear factor of UHMWPE against the damaged materials was dependent on the amount of damage to the counterface (R. p. ). Our study has shown the benefit of using the harder and more damage-resistant ceramic materials for femoral heads

Objectives

Our study aimed to examine not only the incidence but also the impact of noise from two types of total hip replacement articulations: ceramic-on-ceramic and ceramic-on-polyethylene.