See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/319078636

Ceramics in total hip arthroplasty

Article · August 2017

DOI: 10.1302/0301620X.99B8.BJJ20170771

CITATIONS READS
2 91

2 authors, including:

John A Skinner
University College London
363 PUBLICATIONS 10,092 CITATIONS

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Spinal Implant Retrieval View project

Retrieval Analysis of Beyond Compliance Implants (LIRC) View project

All content following this page was uploaded by John A Skinner on 25 July 2019.

The user has requested enhancement of the downloaded file.

  EDITORIAL
Ceramics in total hip arthroplasty
A BEARING SOLUTION?

J. A. Skinner, The use of ceramic femoral heads in total hip tion. High body mass index (BMI) and some
F. S. Haddad arthroplasty is increasing.1 This is partly a component designs are also risk factors. Walter
result of good wear characteristics when artic- et al12 found a correlation between squeaking
From The British ulated against ceramic or highly crosslinked and acetabular positioning outside the Lewin-
Editorial Society of polyethylene (PE) liners, and because modern neks safe zone of 45° +/-10° inclination and
Bone and Joint ceramics allow the use of larger femoral heads 25° +/-10° anteversion. This may be due to the
Surgery, London, without increased friction and wear, and with- increased risk of edge loading outside this ori-
United Kingdom out major taper issues.2-5 entation. Stripe wear secondary to edge-load-
A reduction in wear and osteolysis, in the ing is a consistent finding in retrieved
cumulative long-term risk of dislocation, in squeaking implants. As yet, clinical studies
muscle atrophy, and in head-neck corrosion have not shown adverse effects of squeaking
have all been reported following the use of with regard to osteolysis or implant fail-
ceramic-on-ceramic (CoC) bearings. Hernigou ure.13,14
et al reported that for hips with PE liners, the Bearing fractures have been described in
cumulative risk of a first-time dislocation was crosslinked PE liners and in both ceramic
2% rising to 13% at 30 years for patients who heads and liners. Fracture rates of up to 13.4%
were alive and had not had a revision by that were reported for early generation ceramic
time. For hips with ceramic liners, the cumula- heads manufactured prior to 1990.15 However,
tive risk of a first-time dislocation was 2% at with improved manufacturing techniques,
one year and then did not change at 20 years or improvements in materials with reduced grain
at 30 years for patients who were alive and had size and increased density, the rate of fracture
not had a revision by that time.6-8 fell significantly.16
Careful surgical technique is required when Across the world, most ceramic bearings are
assembling any head-stem junction, including manufactured by Ceramtec (Plochingen, Ger-
 J. A. Skinner, MBBS, those involving ceramic heads. This includes many). The third generation Biolox Forte is
FRCS(Eng), FRCS(Orth),
Consultant Orthopaedic
using clean gloves, removing any bone or tissue Alumina (aluminium oxide) and the fourth
Surgeon, Institute of debris, washing and drying the morse taper generation Biolox Delta is Zirconia toughened
Orthopaedics
Royal National Orthopaedic
and then using sufficient impaction to seat the alumina composite (82% alumina and 17%
Hospital, Brockley Hill, head on the taper.9 This force must be in the zirconia). Fourth-generation alumina compos-
Stanmore, Middlesex, HA7 4LP,
UK.
axis of the taper and using a nylon or polyeth- ite ceramics with smaller grain size, increased
ylene impactor. A metallic hammer should not bending strength and toughness have further
 F. S. Haddad, BSc MD (Res),
FRCS (Tr&Orth), Professor of be used to impact the ceramic head, as this reduced the risk of fracture by introducing zir-
Orthopaedic Surgery, Editor-in- causes metal transfer to the bearing. conium particles and strontium oxide platelets
Chief
The Bone & Joint Journal, 22 There are still concerns about the best tech- that help the prevent the initiation and propa-
Buckingham Street, London, nique for implantation of ceramic hips to avoid gation of cracks.
WC2N 6ET and NIHR University
College London Hospitals fracture and squeaking. Noises can emanate Peter Howard et al’s study in this month’s
Biomedical Research Centre, from prosthetic bearings.10 journal17 confirms that revision for fracture of
UK.
Squeaking is a phenomenon seemingly a ceramic bearing is rare, occurring in 0.16%
Correspondence should be sent
to F. S. Haddad; email:
unique to hard-on-hard bearings and more of patients in a large study. It is apparent that
[email protected] common with CoC than with metal-on-metal fractures of liners are now more common
©2017 The British Editorial
bearings. It is reported to occur in approxi- (0.126%) than fractures of the head (0.009%)
Society of Bone & Joint mately 2.4% (0.7% to 20%) of hips with CoC with the latest generation Biolox Delta
Surgery
doi:10.1302/0301-620X.99B8.
bearings.11 It is potentially an indication for Ceramic.
BJJ-2017-0771 $2.00 revision. Squeaking is not well understood but These authors report that the incidence of
Bone Joint J
may be associated with poor lubrication,12 fractures of the head is reduced by increasing
2017;99-B:993–5. edge-loading, third body debris or subluxa- its size (ceramic thickness) and using better

VOL. 99-B, No. 8, AUGUST 2017 993

994 J. A. SKINNER, F. S. HADDAD

material (Biolox Delta). This is not the case for liners, metal artefact reduction MRI in order to identify those
which suggests that there may be a different mechanism of patients at greatest risk and offer them early revision sur-
fracture. With earlier ceramics, the taper angle between the gery. Revision of bearings with cobalt chromium related
acetabular shell and ceramic liner was 18°. In order to problems have a better outcome if identified early than
allow surgeons to choose polyethylene, ceramic or metal those not under surveillance.23
bearing liners for the same shell, some manufacturers have This is an interesting consequence of reporting popula-
changed the taper angle to 10°.18 This may affect the ease tion data from National Registries. When such outcomes
with which surgeons can reliably seat the liners. It is possi- are identified and therefore a population that is potentially
ble that incomplete seating or prominent screw heads may “at risk” is confirmed, whose responsibility is it to inform
contribute to this differential rate of fracture. It would be the patient, their surgeon and their hospital? Whose duty is
interesting to see if some acetabular designs are more prone it to organise appropriate clinical assessment and investiga-
to ceramic fracture than others. tions? And who pays? These issues are complex, and have
It is important that revision bearings after fracture of a organisational and financial ramifications, but surely must
ceramic component should not contain cobalt chromium. be considered to be in the best interests of patients.
The highest blood metal ion levels reported in the literature, Ceramic bearings are perfoming well globally, and their
do not occur with metal-on-metal bearings but with the use use is increasing. They are prone to bearing noise in a
of cobalt chromium following ceramic fracture.19,20 It is minority, and various patient, implant and surgical factors
likely that very hard ceramic debris is left in the articulation have been identified as risk factors for this. The noise
after revision surgery and becomes embedded in the bearing remains unexplained in many cases, however. As a result of
to erode the softer metal femoral head. With the metal ion this, ceramic-on-polyethylene combinations are becoming
levels reported in this context, significant toxic systemic more popular than CoC, in many countries.
effects have been observed.19,21,22 Fracture of a ceramic bearing is becoming increasingly
In Howard et al’s study,17 the resulting bearing combina- rare. If it occurs, safe revision surgery is needed, and cobalt
tions following revision for ceramic component fracture and chromium should be avoided in the revision bearing in
were known for 161 of 178 revisions (90%). It is reassuring order to avoid the risks of ARMD and toxicity. If a bearing
that CoC or ceramic-on-polyethylene bearings were chosen containing cobalt or chromium is used, then there is enough
in 126 patients (78.3%). These are safe revision options. evidence to recommend that those patients should be iden-
Following ceramic fracture, the risk of retained ceramic tified and offered enhanced follow up and surveillance.24-26
particles in the joint or in the neosynovium, even after
debridement and extensive synovectomy, is high. Extremely References
hard ceramic particles will produce third-body abrasive 1. No authors listed. National Joint Registry for England, Wales, Northern Ireland and
the Isle of Man. 13th annual report. NJR:2016. http://www.njrcentre.org.uk (date last
wear if a softer cobalt chromium metal head is used. The accessed 21 June 2017).
best bearing surfaces are CoC but ceramic-on-polyethylene 2. Senturk U, von Roth P, Perka C. Ceramic on ceramic arthroplasty of the hip: new
may also be used. In this case, the possible microscopic materials confirm appropriate use in young patients. Bone Joint J 2016;98-B
(1_Suppl_A):14–17.
ceramic debris will be embedded in the liner, forming a
3. Kim YH, Park JW, Kim JS. Isolated revision of an acetabular component to a
ceramic-polyethylene composite that the ceramic head can ceramic-on-ceramic bearing in patients under 50 years of age. Bone Joint J 2015;97-
articulate with, without being damaged. B:1197–1203.
Following revision surgery for ceramic bearing fracture, 4. Panagiotidou A, Meswania J, Osman K, et al. The effect of frictional torque and
bending moment on corrosion at the taper interface: an in vitro study. Bone Joint J
24 patients (14.9%) in this study have metal-on- 2015;97-B:463–472.
polyethylene bearings, five (3.1%) have ceramic-on-metal 5. Del Balso C, Teeter MG, Tan SC, Lanting BA, Howard JL. Taperosis: Does head
bearings, five have metal-on-metal bearings (3.1%) and length affect fretting and corrosion in total hip arthroplasty? Bone Joint J 2015;97-B
911–916.
one (0.6%) has a metal-on-ceramic bearing. This amounts
6. Hernigou P, Zilber S, Filippini P, Poignard A. Ceramic-ceramic bearing decreases
to 35 patients after ceramic fracture who have potentially osteolysis: a 20-year study versus ceramic-polyethylene on the contralateral hip. Clin
vulnerable bearings and 17 patients whose bearing combi- Orthop Relat Res 2009;467:2274–2280.
nation is unknown. 7. Hernigou P, Homma Y, Pidet O, Guissou I, Hernigou J. Ceramic-on-ceramic
bearing decreases the cumulative long-term risk of dislocation. Clin Orthop Relat Res
While not all of these patients will run into problems, 2013;471:3875–3882.
some may. The registries collating this information should 8. Hernigou P, Roussignol X, Delambre J, Poignard A, Flouzat-Lachaniette CH.
make every effort to identify these patients and offer them Ceramic-on-ceramic THA associated with fewer dislocations and less muscle degen-
eration by preserving muscle progenitors. Clin Orthop Relat Res 2015;473:3762–3769.
the safety net of enhanced assessment and follow up. They
9. Pandorf T. How important it is to use clean taper fixations? [abstract]. Procs 13th
are at risk of adverse reactions to metal debris (ARMD) and International BIOLOX Symposium: Bioceramics and Alternative Bearings in Joint
possible metal toxicity. Arthroplasty, Edinburgh, 2009.
The Medicines and Healthcare related products Regula- 10. Pierrepont JW, Feyen H, Miles BP. Functional orientation of the acetabular com-
ponent in ceramic-on-ceramic total hip arthroplasty and its relevance to squeaking.
tory Agency guidance on metal-on-metal bearings recom- Bone Joint J 2016;98-B:910–916.
mend clinical assessment, blood cobalt and chromium ion 11. Stanat SJ, Capozzi JD. Squeaking in third- and fourth-generation ceramic-on-
measurement and possible cross sectional imaging with ceramic total hip arthroplasty: meta-analysis and systematic review. J Arthroplasty
2012;27:445–453.

THE BONE & JOINT JOURNAL

 CERAMICS IN TOTAL HIP ARTHROPLASTY 995

12. Walter WL, O’Toole GC, Walter WK, Ellis A, Zicat BA. Squeaking in ceramic-on- 20. Whittingham-Jones P, Mann B, Coward P, Hart AJ, Skinner JA. Fracture of a
ceramic hips: the importance of acetabular component orientation. J Arthroplasty ceramic component in total hip replacement. J Bone Joint Surg [Br] 2012;94-B:70–73.
2007;22:496–503.
21. Cheung AC, Banerjee S, Cherian JJ, et al. Systemic cobalt toxicity from total hip
13. Chevillotte C, Pibarot V, Carret JP, Bejui-Hugues J, Guyen O. Hip squeaking: a arthroplasties: review of a rare condition Part 1 - history, mechanism, measurements,
10-year follow-up study. J Arthroplasty 2012;27:1008–1013. and pathophysiology. Bone Joint J 2016;98-B:6–13.
14. Restrepo C, Matar WY, Parvizi J, Rothman RH, Hozack WJ. Natural history of 22. Zywiel MG, Cherian JJ, Banerjee S, et al. Systemic cobalt toxicity from total hip
squeaking after total hip arthroplasty. Clin Orthop Relat Res 2010;468:2340–2345. arthroplasties: review of a rare condition Part 2. measurement, risk factors, and step-
15. Knahr K, Böhler M, Frank P, Plenk H, Salzer M. Survival analysis of an unce- wise approach to treatment. Bone Joint J 2016;98-B:14–20.
mented ceramic acetabular component in total hip replacement. Arch Orthop Trauma 23. Matharu GS, Judge A, Pandit HG, Murray DW. Which factors influence the rate
Surg 1987;106:297–300. of failure following metal-on-metal hip arthroplasty revision surgery performed for
16. Willmann G. Ceramic femoral head retrieval data. Clin Orthop Relat Res adverse reactions to metal debris? Bone Joint J 2017;99-B:1020–1027.
2000;379:22–28.
24. Jeffers JR, Walter WL. Ceramic-on-ceramic bearings in hip arthroplasty: state of
17. Howard D, Wall P, Fernandez M, Parsons H, Howard P. Ceramic-on-ceramic the art and the future. J Bone Joint Surg [Br] 2012;94-B:735–745.
bearing fractures in total hip arthroplasty: an analysis of data from the National Joint
Registry. Bone Joint J 2017;99-B:1012–1019. 25. Hannouche D, Zaoui A, Zadegan F, Sedel L, Nizard R. Thirty years of experience
with alumina-on-alumina bearings in total hip arthroplasty. Int Orthop 2011;35:207–
18. Lee YK, Ha YC, Yoo JI, et al. Mid-term results of the BIOLOX delta ceramic-on- 213.
ceramic total hip arthroplasty. Bone Joint J 2017;99-B:741–748.
26. Kuntz M. Validation of a new high performance alumina matrix composite for use in
19. Rizzetti MC, Liberini P, Zarattini G, et al. Loss of sight and sound. Could it be the
total joint replacement. Semin Arthroplasty 2006;17:141–145.
hip? Lancet 2009;373:1052.

VOL. 99-B, No. 8, AUGUST 2017

View publication stats