The Bearing Surface: Ceramic on Ceramic
Michael A. Mont, MD
Historically, controversy has always existed around which bearing surface was the most appropriate for total hip arthroplasty. Early metal-on-metal designs, such as the McKee-Farrar, were plagued by manufacturing problems that led to inappropriate wear with these implants, and consequently the Charnley soft-on-hard bearing surface was utilized by a majority of surgeons. As younger and more patients began receiving total hip replacement, however, implant longevity became a concern with these hard-on-soft bearing surfaces, and hard-on-hard bearings had a resurgence. Recently, however, metal-on-metal bearings have been the subject of mass media recognition, product recalls, and devastating complications related to adverse local tissue reactions.
In light of this, ceramic-on-ceramic is a “hard-on-hard” bearing that may be an alternative to metal bearings in the young, active patient when implant longevity is a concern. The purpose of this presentation will be to educate the attendee regarding: (1) the historical origins and development of modern alumina bearing surfaces; (2) Potential advantages of ceramic bearings; (3) Potential disadvantages of ceramic bearings; (4) Clinical outcomes of these bearings; and (5) give an overview of ceramic-on-metal: the best of both worlds, or an unfeasible combination??
Historical Origins and Development of Modern Alumina Bearing Surfaces
- Early implants designed in Europe in early 1970’s with monolithic cementless ceramic acetabular components1-4
- — Poor results (<80% 10 year survivorship) due mainly to failure of monolithic cups5-8
- — High incidence of component fracture9
- — Material property problems resulting in uneven wear patterns and early failures10
- Zirconia ceramic 11-16
- — Introduced in the early 1980s in an effort to improve the fracture-resistance of the implants
- — This material was abandoned because of 32 to 63% implant survivorship at 5 to 8 year follow-up
- Modern alumina ceramic
- — Survival rates reported between 94 and 97% at 7 to 10 year follow-up17-24. o Current ceramic used in most ceramic bearing surfaces
- — More stable, more fracture-resistance, and improved wear characteristics. However, there are disadvantages to its use, which will be outlined below.
- Low wear rates25
- — Wear rates are typically three orders of magnitude lower than those observed for traditional metal-on-polyethylene bearings, and comparable to metal-on-metal bearing surfaces
- — Believed to be a result of the extreme hardness inherent in alumina’s material properties, combined with the lubrication that occurs due to ceramic’s natural hydrophilic properties, and improved manufacturing techniques
- High biocompatibility, with low osteolysis rates20,26,27.
- — This can be a devastating complication due to the brittle nature of ceramic. When this does occur, revisions are technically difficult due to the numerous fracture particles that are present in the joint
- — Certain designs were more susceptible to fracture than others, with one design in particular having its fractures attributable to poor tolerances between the taper fit of the metal femoral component and ceramic femoral head31
- — Chipping can occur during implant placement, or post-operatively, which can lead to excessively high wear rates
- — Post-operatively can be attributed to point-loading of the component at the time of dislocation of the hip, closed reduction, femoral head prosthesis subluxation, or neck component on the liner
- — Ensure careful prosthesis placement, optimal component alignment, and appropriate joint stability to minimize these complications
- Audible Squeaking 38-42.
- — Incidence ranges from 0.5 to 21%
- — Exact etiology is unknown, but is believed to be due to third-body wear
- — Questionable clinical relevance outside of an inconvenience or irritation to the patient
- Improved wear when compared to metal-on-metal articulations in hip simulator studies43
- Lower serum metal-ion levels compared to traditional metal articulations
- Allows for the use of larger ceramic femoral heads with thinner metal acetabular shells compared to ceramic-on-ceramic bearings
- Only preliminary clinical data exists; this bearing still needs further clinical assessment
Potential Advantages of Modern Alumina Ceramic Bearing Surfaces
Potential Disadvantages of Modern Alumina Ceramic Bearing Surfaces
Ceramic-on-metal: the best of both worlds or an unfeasible combination??
1. Boutin, P.: [Alumina and its use in surgery of the hip. (Experimental study)]. Presse Med, 79(14): 639-40, 1971.
2. Griss, P.; Werner, E.; Buchinger, R.; and Heimke, G.: [The Mannheimer oxide ceramic-metal composite hip prostheses (author’s transl)]. Arch Orthop Unfallchir, 87(1): 73-84, 1977.
3. Mittelmeier, H.: [New development of wear-resistant ceramic and metal composite prostheses with ribbed support shafts for cement-free implantation]. Hefte Unfallheilkd, (126): 333-6, 1975.
4. Salzer, M.; Locke, H.; Engelhardt, H.; and Zweymuller, K.: [Ceramic endoprostheses of the upper extremities]. Z Orthop Ihre Grenzgeb, 113(4): 458-61, 1975.
5. Huo, M. H.; Martin, R. P.; Zatorski, L. E.; and Keggi, K. J.: Cementless total hip arthroplasties using ceramic-on-ceramic articulation in young patients. A minimum 5-year follow-up study. J Arthroplasty, 11(6): 673-8, 1996.
6. O’Leary, J. F.; Mallory, T. H.; Kraus, T. J.; Lombardi, A. V., Jr.; and Lye, C. L.: Mittelmeier ceramic total hip arthroplasty. A retrospective study. J Arthroplasty, 3(1): 87-96, 1988.
7. Petsatodis, G. E.; Papadopoulos, P. P.; Papavasiliou, K. A.; Hatzokos, I. G.; Agathangelidis, F. G.; and Christodoulou, A. G.: Primary cementless total hip arthroplasty with an alumina ceramic-on- ceramic bearing: results after a minimum of twenty years of follow-up. J Bone Joint Surg Am, 92(3): 639-44, 2010.
8. Mahoney, O. M., and Dimon, J. H., 3rd: Unsatisfactory results with a ceramic total hip prosthesis. J Bone Joint Surg Am, 72(5): 663-71, 1990.
9. Winter, M.; Griss, P.; Scheller, G.; and Moser, T.: Ten- to 14-year results of a ceramic hip prosthesis. Clin Orthop Relat Res, (282): 73-80, 1992.
10. Boutin, P.; Christel, P.; Dorlot, J. M.; Meunier, A.; de Roquancourt, A.; Blanquaert, D.; Herman, S.; Sedel, L.; and Witvoet, J.: The use of dense alumina-alumina ceramic combination in total hip replacement. J Biomed Mater Res, 22(12): 1203-32, 1988.
11. Hummer, C. D., 3rd; Rothman, R. H.; and Hozack, W. J.: Catastrophic failure of modular zirconia- ceramic femoral head components after total hip arthroplasty. J Arthroplasty, 10(6): 848-50, 1995.
12. Masonis, J. L.; Bourne, R. B.; Ries, M. D.; McCalden, R. W.; Salehi, A.; and Kelman, D. C.: Zirconia femoral head fractures: a clinical and retrieval analysis. J Arthroplasty, 19(7): 898-905, 2004.
13. Fukatsu, K.; Pezzotti, G.; Hayaishi, Y.; and Sugano, N.: Evaluation of phase stability in zirconia femoral heads from different manufacturers after in vitro testing or in vivo retrieval. J Arthroplasty, 24(8): 1225-30, 2009.
14. Haraguchi, K.; Sugano, N.; Nishii, T.; Miki, H.; Oka, K.; and Yoshikawa, H.: Phase transformation of a zirconia ceramic head after total hip arthroplasty. J Bone Joint Surg Br, 83(7): 996-1000, 2001.
15. Hayaishi, Y.; Miki, H.; Yoshikawa, H.; and Sugano, N.: Phase transformation of a new generation yttria-stabilized zirconia femoral head after total hip arthroplasty. Mod Rheumatol, 18(6): 647-50, 2008.
16. Maccauro, G.; Piconi, C.; Burger, W.; Pilloni, L.; De Santis, E.; Muratori, F.; and Learmonth, I. D.: Fracture of a Y-TZP ceramic femoral head. Analysis of a fault. J Bone Joint Surg Br, 86(8): 1192-6, 2004.
17. Kawanabe, K.; Tanaka, K.; Tamura, J.; Shimizu, M.; Onishi, E.; Iida, H.; and Nakamura, T.: Effect of alumina femoral head on clinical results in cemented total hip arthroplasty: old versus current alumina. J Orthop Sci, 10(4): 378-84, 2005.
18. D’Antonio, J.; Capello, W.; Manley, M.; Naughton, M.; and Sutton, K.: Alumina ceramic bearings for total hip arthroplasty: five-year results of a prospective randomized study. Clin Orthop Relat Res, (436): 164-71, 2005.
19. Bizot, P.; Hannouche, D.; Nizard, R.; Witvoet, J.; and Sedel, L.: Hybrid alumina total hip arthroplasty using a press-fit metal-backed socket in patients younger than 55 years. A six- to 11-year evaluation. J Bone Joint Surg Br, 86(2): 190-4, 2004.
20. Murphy, S. B.; Ecker, T. M.; and Tannast, M.: Two- to 9-year clinical results of alumina ceramic-on- ceramic THA. Clin Orthop Relat Res, 453: 97-102, 2006.
21. Capello, W. N.; D’Antonio, J. A.; Feinberg, J. R.; Manley, M. T.; and Naughton, M.: Ceramic-on- ceramic total hip arthroplasty: update. J Arthroplasty, 23(7 Suppl): 39-43, 2008.
22. Garino, J. P.: Modern ceramic-on-ceramic total hip systems in the United States: early results. Clin Orthop Relat Res, (379): 41-7, 2000.
23. Yoo, J. J.; Kim, Y. M.; Yoon, K. S.; Koo, K. H.; Kim, J. W.; Nam, K. W.; and Kim, H. J.: Contemporary alumina-on-alumina total hip arthroplasty performed in patients younger than forty years: a 5-year minimum follow-up study. J Biomed Mater Res B Appl Biomater, 78(1): 70-5, 2006.
24. Yoo, J. J.; Kim, Y. M.; Yoon, K. S.; Koo, K. H.; Song, W. S.; and Kim, H. J.: Alumina-on-alumina total hip arthroplasty. A five-year minimum follow-up study. J Bone Joint Surg Am, 87(3): 530-5, 2005.
25. Oonishi, H.; Clarke, I. C.; Good, V.; Amino, H.; and Ueno, M.: Alumina hip joints characterized by run-in wear and steady-state wear to 14 million cycles in hip-simulator model. J Biomed Mater Res A, 70(4): 523-32, 2004.
26. Lusty, P. J.; Tai, C. C.; Sew-Hoy, R. P.; Walter, W. L.; Walter, W. K.; and Zicat, B. A.: Third- generation alumina-on-alumina ceramic bearings in cementless total hip arthroplasty. J Bone Joint Surg Am, 89(12): 2676-83, 2007.
27. Kim, Y. H.; Choi, Y.; and Kim, J. S.: Cementless total hip arthroplasty with ceramic-on-ceramic bearing in patients younger than 45 years with femoral-head osteonecrosis. Int Orthop, 2009.
28. Allain, J.; Goutallier, D.; Voisin, M. C.; and Lemouel, S.: Failure of a stainless-steel femoral head of a revision total hip arthroplasty performed after a fracture of a ceramic femoral head. A case report. J Bone Joint Surg Am, 80(9): 1355-60, 1998.
29. Allain, J.; Roudot-Thoraval, F.; Delecrin, J.; Anract, P.; Migaud, H.; and Goutallier, D.: Revision total hip arthroplasty performed after fracture of a ceramic femoral head. A multicenter survivorship study. J Bone Joint Surg Am, 85-A(5): 825-30, 2003.
30. Kempf, I., and Semlitsch, M.: Massive wear of a steel ball head by ceramic fragments in the polyethylene acetabular cup after revision of a total hip prosthesis with fractured ceramic ball. Arch Orthop Trauma Surg, 109(5): 284-7, 1990.
31. D’Antonio, J. A., and Sutton, K.: Ceramic materials as bearing surfaces for total hip arthroplasty. J Am Acad Orthop Surg, 17(2): 63-8, 2009.
32. Clarke, I. C.: Role of ceramic implants. Design and clinical success with total hip prosthetic ceramic- to-ceramic bearings. Clin Orthop Relat Res, (282): 19-30, 1992.
33. Hamilton, W. G.; McAuley, J. P.; Dennis, D. A.; Murphy, J. A.; Blumenfeld, T. J.; and Politi, J.: THA with Delta ceramic on ceramic: results of a multicenter investigational device exemption trial. Clin Orthop Relat Res, 468(2): 358-66, 2010.
34. Hasegawa, M.; Sudo, A.; Hirata, H.; and Uchida, A.: Ceramic acetabular liner fracture in total hip arthroplasty with a ceramic sandwich cup. J Arthroplasty, 18(5): 658-61, 2003.
35. Hwang, S. K.; Oh, J. R.; Her, M. S.; Shim, Y. J.; Cho, T. Y.; and Kwon, S. M.: Fracture-dissociation of ceramic liner. Orthopedics, 31(8): 804, 2008.
36. Popescu, D.; Gallart, X.; Garcia, S.; Bori, G.; Tomas, X.; and Riba, J.: Fracture of a ceramic liner in a total hip arthroplasty with a sandwich cup. Arch Orthop Trauma Surg, 128(8): 783-5, 2008.
37. Schuh, A.; Mittelmeier, W.; Zeiler, G.; Behrend, D.; Kircher, J.; and Bader, R.: Severe damage of the femoral head after dislocation and difficult reduction maneuvers after total hip arthroplasty. Arch Orthop Trauma Surg, 126(2): 134-7, 2006.
38. Jarrett, C. A.; Ranawat, A. S.; Bruzzone, M.; Blum, Y. C.; Rodriguez, J. A.; and Ranawat, C. S.: The squeaking hip: a phenomenon of ceramic-on-ceramic total hip arthroplasty. J Bone Joint Surg Am, 91(6): 1344-9, 2009.
39. Keurentjes, J. C.; Kuipers, R. M.; Wever, D. J.; and Schreurs, B. W.: High incidence of squeaking in THAs with alumina ceramic-on-ceramic bearings. Clin Orthop Relat Res, 466(6): 1438-43, 2008.
40. Mai, K.; Verioti, C.; Ezzet, K. A.; Copp, S. N.; Walker, R. H.; and Colwell, C. W., Jr.: Incidence of ‘squeaking’ after ceramic-on-ceramic total hip arthroplasty. Clin Orthop Relat Res, 468(2): 413-7, 2010.
41. Restrepo, C.; Parvizi, J.; Kurtz, S. M.; Sharkey, P. F.; Hozack, W. J.; and Rothman, R. H.: The noisy ceramic hip: is component malpositioning the cause? J Arthroplasty, 23(5): 643-9, 2008.
42. Walter, W. L.; O’Toole G, C.; Walter, W. K.; Ellis, A.; and Zicat, B. A.: Squeaking in ceramic-on- ceramic hips: the importance of acetabular component orientation. J Arthroplasty, 22(4): 496-503, 2007.
43. Firkins, P. J.; Tipper, J. L.; Ingham, E.; Stone, M. H.; Farrar, R.; and Fisher, J.: A novel low wearing differential hardness, ceramic-on-metal hip joint prosthesis. J Biomech, 34(10): 1291-8, 2001.