| Avoiding Pitfalls in Primary Total Hip Arthroplasty (V)- Index

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


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.