Sage Journals: Discover world-class research

Abstract

Purpose:

The purpose of this study is to evaluate the clinical and radiologic outcomes after revision total hip arthroplasty (THA) using fourth-generation ceramic-on-ceramic (CoC) bearing surfaces.

Methods:

A total of 52 revision THAs (28 men and 19 women) using the fourth-generation CoC bearing surfaces were retrospectively evaluated. Both acetabular cup and femoral stem were revised in all cases. The mean follow-up period was 7.3 years (range, 4.0–9.9 years). The clinical results with Harris hip score (HHS), Western Ontario McMaster Osteoarthritis Index (WOMAC), and radiologic outcomes were evaluated.

Results:

At the final follow-up examination, the average HHS was 90.4 (range, 67–100). The average WOMAC pain and physical function score were 2.8 (range, 0–12) and 16.4 (range, 0–42), respectively. Complications were observed in 10 hips (19.2%). However, there were no bearing surface-related complications, and no cases of dislocation and squeaking. Retroacetabular pelvic osteolysis without cup loosening was observed in one hip at the final follow-up. However, no hip showed radiographic signs of cup loosening, vertical or horizontal acetabular cup migrations, and changes of inclinations during the follow-up period.

Conclusion:

Our data showed that clinical and radiologic outcomes after revision THA using fourth-generation CoC bearing were favorable. Hence, revision THA with the use of CoC bearing surfaces can be preferentially considered. Further studies with long-term follow-up data are warranted.

Keywords

bearing surface ceramic-on-ceramic fourth generation revision total hip arthroplasty

Introduction

Despite recent advancements in implant design and surgical technique for total hip arthroplasty (THA), the incidence of revision THA has increased, and its burden has not improved over the last several decades.¹ Osteolysis around the prosthesis and aseptic loosening are the important causes of revision THA due to the wear of the conventional polyethylene (PE).² To minimize osteolysis induced by the wear of PE, ceramic-on-ceramic (CoC) bearing was developed and used in THA as a substitute bearing surface.³ Since its first inception, the mechanical property and design of ceramic bearing have evolved. Although the third-generation alumina ceramics (Biolox forte; CeramTec, Plochingen, Germany) have superior mechanical properties as well as better quality than its predecessor,⁴ substantial concerns remained regarding CoC bearing, including stripe wear, limited sizing options, squeaking, and ceramic fracture. To overcome these concerns, the fourth-generation ceramic (Biolox delta; CeramTec) was introduced in the 2000s. The fourth-generation ceramic is alumina matrix composite consisting of alumina (81.6%), zirconia (17%), and other mixed oxides, which exhibit even more toughness, resistance to fracture, and provide a large head and a thin liner.⁵ Several studies showed favorable clinical outcomes using the fourth-generation CoC bearing in primary and isolated acetabular revision THAs.^6,7 However, due to the habitual characteristics of the Asian population, such as squatting and crossed-leg sitting postures, the incidences of wear, pelvic osteolysis, and impingement are relatively higher, and the possibility of subsequent revisions is also higher.⁸ Moreover, CoC THAs are sensitive to mechanical problems, such as impingement, squeaking, and ceramic breakage.⁹ The chances of impingement, dislocation, and long-term wear are likely to be increased due to the difficulty in obtaining optimal implant position in cases of revision THA.¹⁰ Thus, we evaluated the clinical and radiologic outcomes in revision THA that revised both the cup and stem using the fourth-generation CoC bearing couples in Asian patients.

Materials and methods

We retrospectively evaluated the clinical and radiologic outcomes in 52 revision THAs (47 patients; 28 men and 19 women), which were performed using cementless cups with fourth-generation Biolox delta CoC bearing surfaces between January 2008 and December 2013 and were consecutively enrolled in this study. Patients were excluded from this study if the revision was performed using cemented cups or reinforced rings. Those with pelvic deformity or hips with pelvic discontinuity were also excluded. All enrolled revision THAs in this study were performed using an imageless navigation (VectorVision; BrainLab, Heimstetten, Germany) with the concept of combined anteversion of Widmer by a single surgeon using the posterolateral approach for the hip. This study was approved by our regional institutional review board, and informed consent was obtained from each participant whose anonymity was preserved.

The mean age at the time of revision THA was 57.2 ± 10.4 years (range, 42–75 years). The mean weight and height were 62.5 ± 4.8 kg (range, 51–74 kg) and 159.8 ± 13.5 cm (range, 141–182 cm), with the average body mass index being 22.9 ± 3.6 kg/m² (range, 18.2–31.5 kg/m²). The mean interval from primary to revision THA was 9.7 years (range, 3.5–15.9 years). The mean follow-up period was 7.3 years (range, 4.0–9.9 years). The preoperative diagnosis for primary THA was osteonecrosis of the femoral head (ONFH) in 34 hips, neglected femoral neck fracture in 6 hips, rheumatoid arthritis in 4 hips, degenerative osteoarthritis in 4 hips, pyogenic arthritis in 2 hips, and tuberculosis arthritis in 2 hips.

Indications for revision surgery were aseptic loosening in 23 hips (stem loosening in 10, cup loosening in 9, both stem and cup loosening in 4), infection with/without loosening in 10 hips, retroacetabular osteolysis in 9 hips, dissociation of PE liner in 7 hips, periprosthetic fracture with loosening in 2 hips, and fracture of third-generation ceramic liner in 1 hip (Table 1). The extent and location of pelvic osteolysis were evaluated on preoperative radiographs, and acetabular bone deficiency was categorized according to the American Academy of Orthopedic Surgeons (AAOS) classification. The cups were well fixed in 37 hips (71%) and the stems in 26 hips (50%). Osteolysis around the stem was observed in 23 hips (44%), of which, 11 showed well-fixed stems. Retroacetabular pelvic osteolysis was observed in 26 hips (50%). The mean width and length of the areas of osteolysis were 25.4 ± 11.1 mm (range, 7–63 mm) and 41.8 ± 20.3 mm (range, 7–112 mm), respectively. Among the 26 hips with retroacetabular pelvic osteolysis, 14 (54%) showed type IIB bone deficiency, 5 showed type III, 3 showed type IA, 2 showed type IB, and 2 showed type IIA. The linear wear of PE liners was measured by the method of Livermore and colleagues; the average wear rate was 0.16 mm/year (range, 0.00–0.69 mm/year).

Table 1.

Causes of revision THA.

Aseptic loosening
• Loosening of stem	10
• Loosening of cup	9
• Loosening of cup and stem	4
Infection	10
Retroacetabular osteolysis	9
Dissociation of PE liner	7
Periprosthetic fracture with loosening	2
Fracture of third generation ceramic liner	1

THA: total hip arthroplasty; PE: polyethylene.

Thirty-four Harris-Galante II cups (Zimmer, Warsaw, Indiana, USA), six Harris-Galante I cups (Zimmer), four AML cups (DePuy, Warsaw, Indiana, USA), three Cementless Mittelmeier Ceramic cups (Osteo AG, Selzach, Switzerland), three PCA (Howmedica, Rutherford, New Jersey, USA), and two Trident cups (Stryker, Mahwah, New Jersey, USA) were retrieved. The average cup size was 54.9 mm (range, 44–62 mm), and the average number of screws used was 1.8. Among the retrieved stem types, there were 17 Anatomic (Zimmer), 10 Harris-Galante (Zimmer), 9 cemented Centralign (Zimmer), 7 cemented Osteonics (Osteonics, Allendale, New Jersey, USA), 6 ABG (Howmedica International, Staines, UK), and 3 PCA (Howmedica).

For acetabular cup revision, Pinnacle cups (DePuy) were used in 22 cases, EP-FIT Plus cups (Plus Orthopedics, Rotkreuz, Switzerland) were used in 18 cases, while Bencox cups (Corentec, Korea) were used in 12 cases. All femoral heads and acetabular liners were Biolox delta ceramics (Figures 1 and 2). The average cup size was 57.1 mm (range, 52–66 mm), and the femoral head diameter was 36 mm in all hips. Stems were revised in all hips: Wagner stems (Wagner SL revision stem, Protek AG, Bern, Switzerland) in 24 hips, SL Plus Long stems (Plus Orthopedics) in 14, S-ROM stems (DePuy) in 6, Arcos revision stems (Biomet, Warsaw, Indiana, USA) in 5, Revitan revision stems (Zimmer GmbH, Winterthur, Switzerland) in 2, and 1 Benfix long stem (Corentec). Extended trochanteric osteotomy was required in 35 hips, and greater trochanteric advancement was performed in 6 hips. Bone grafting was performed in 25 hips (48%), in which morsellized allograft was used in 18 hips, cortical strut allograft in 4 hips, and autograft in 3 hips.

Figure 1.

Anteroposterior radiograph obtained 23 years after primary THA, of the right hip in a 50-year-old man, showing diffuse pelvic osteolysis with loosening of the acetabular cup and fracture of right inferior ramus. Revision surgery was performed using the fourth-generation CoC bearing surface. THA: total hip arthroplasty; CoC: ceramic-on-ceramic.

Figure 2.

Anteroposterior radiograph obtained 22 years after THA, of the left hip in a 54-year-old woman, showing diffuse pelvic osteolysis with loosening of the acetabular cup due to tuberculosis infection. Two-stage revision THA was performed using the fourth-generation CoC bearing surface. THA: total hip arthroplasty; CoC: ceramic-on-ceramic.

The follow-up protocol included clinical and radiological evaluation at 6 weeks, 3 months, and 6 months after surgery, and annually thereafter. At the final follow-up examinations, the clinical outcomes, including Harris hip score (HHS), Western Ontario McMaster Osteoarthritis Index (WOMAC), and complications, were assessed. Postoperative inclination of the cup was evaluated on the standard anteroposterior view of the radiograph, and postoperative anteversion of the cup and femoral stem was evaluated on the CT scan. The goal of revision THA implants positioned in the “safe zone” was defined as follows: 40 ± 10° for a cup inclination and 37 ± 10° for a combined anteversion of the cup and femoral stem using Widmer’s equation. All changes in prosthesis inclination were documented radiographically. The presence of radiolucent lines, vertical or horizontal migration of the acetabular cup (>2 mm), and osteolysis were also evaluated.

We used IBM SPSS statistics for Windows version 23 for all statistical analyses. Because HHS and WOMAC scores did not fit a normal distribution, the postoperative values of these were compared with the preoperative values using Wilcoxon signed-rank test.

Results

The average HHS was improved, from 64.3 (range, 17–87) preoperatively to 90.4 (range, 67–100; p = 0.001) postoperatively. The average WOMAC pain and physical function score were also improved, from 8.9 (range, 2–18) to 2.8 (range, 0–12; p = 0.001) and from 36.8 (range, 2–64) to 16.4 (range, 0–42; p = 0.001), respectively. The mean inclination, anteversion of the cup, and combined anteversion after revision THA were 43.1 ± 3.0° (range, 31.9–48.2°), 24.9 ± 2.8° (range, 17.0–29.5°), and 36.4 ± 3.3° (range, 27.5–42.9°), respectively (Table 2). Therefore, no outliers were observed after the revision surgery regarding the position of the implants relative to the “safe zone.”

Table 2.

Clinical and radiologic results before and after revision THA.

	Before revision THA	After revision THA	p Value
Clinical parameters
• HHS	64.3 (range, 17–87)	90.4 (range, 67–100)	<0.001
• WOMAC pain score	8.9 (range, 2–18)	2.8 (range, 0–12)	<0.001
• WOMAC function score	36.8 (range, 2–64)	16.4 (range, 0–42)	<0.001
Radiologic parameters
• Inclination of cup		43.1 ± 3.0° (range, approximately 31.9–48.2°)
• Anteversion of cup		24.9 ± 2.8° (range, approximately 17.0–29.5°)
• Combined anteversion		36.4 ± 3.3° (range, approximately 27.5–42.9°)

THA: total hip arthroplasty; WOMAC: Western Ontario McMaster Osteoarthritis Index; HHS: Harris hip score.

Complications were observed in 10 hips (19.2%): 6 heterotrophic ossifications, 2 periprosthetic fractures, and 2 late infections. Hips with late infection were treated with retention of the prosthesis by applying antibiotic-loaded cement beads after irrigation and meticulous debridement. One hip with periprosthetic fracture occurred during the operation, and the other one occurred 3 years postoperatively. These fractures were well healed after treatment with internal fixation. There were no complications related to acetabular cup and bearing surface. There were no cases of dislocation and squeaking. Radiolucent line around the stem was observed in five hips at the final follow-up. Among them, there was no case with radiolucent line measured greater than 2 mm in width and more than 2 mm of stem subsidence. No cases required any further management including revision surgery. Radiolucent line of less than 2 mm around the cup was observed in six hips and retroacetabular pelvic osteolysis without cup loosening was observed in one hip at the final follow-up. However, all acetabular cups had radiographic evidence of bone ingrowth at the latest follow-up and no hip showed radiographic signs of cup loosening, vertical or horizontal acetabular cup migrations, and changes of inclinations during the follow-up period. Wear of bearing surface was not measurable. In all 25 hips with bone graft, incorporation of graft was observed radiographically at the final follow-up examination.

Discussion

Various causes for revision THA have been revealed to date, including aseptic loosening of implant, osteolysis, dislocation, and infection.¹¹ Aseptic loosening and osteolysis induced by the wear of PE are the main causes of revision THA.² In Asian patients, induction of osteolysis from wear has been more particularly problematic than in Western patients due to cultural and habitual differences, such as squatting and crossed-leg sitting in Asian populations.⁸ Moreover, THA has been performed in relatively young patients with ONFH, and the incidence of revision THA has also been increased in the relatively younger populations in Asia.^8,12 In the current study, the average age of patients undergoing revision THA was 57.2 years (range, 42–75 years), which is also relatively younger when considering the average age of those undergoing revision THA from previous epidemiological studies.^10,13 Because younger patients are usually more active, demanding, and have a different lifestyle as compared with older individuals, osteolysis due to wear of PE could be more problematic.¹⁴ Therefore, when revision THA is planned for relatively younger, more active group of patients, the chance of subsequent revision should be considered. The choice of bearing surface for avoiding early repeat failures and ensuring better longevity is also important; the bearing surface should have superior characteristics with respect to wear and should be durable, bio-inert, cost-effective, and easy to implant. In this respect, ceramic bearing should be considered as an alternative bearing surface for relatively younger and active group of patients in revision THA for its following characteristics: extreme hardness, scratch resistance, biocompatibility, low coefficient of friction, superior lubrication, and lowest wear rates in comparison to all other bearings.

The Biolox delta ceramic was developed to address some of the drawbacks of the third-generation alumina designs using nano-sized yttria-stabilized zirconia particles (17%), which are dispersed in the alumina matrix (81.6%) along with strontium (1%) in the form of a platelet to inhibit crack propagation, providing more strength. The addition of zirconia greatly increases the fracture toughness; and the addition of chromium oxide recaptures the hardness of the basic alumina matrix. The mechanical properties of the alumina matrix composite, Biolox delta, compared with medical grade alumina are significantly improved: fracture toughness increased 150%, burst strength increased 160%, and four-point bending strength improved 210%.¹⁵ Due to increased fracture toughness and burst strength, the occurrence of fractures would be significantly reduced in the fourth-generation, when compared with the third-generation ceramic implants (0.004%–0.015%).¹⁶ In this study, there was no case of ceramic head or liner fracture after revision THA. However, cup placement with outside the optimal range of cup anteversion and neck to cup impingement could cause ceramic liner fracture; thus, more attention should be paid to the exact cup positioning to prevent impingement.¹⁷ For optimal implant placement, we utilized a navigation system with the concept of combined anteversion to position the acetabular and femoral components in a relatively safe zone for impingement-free range of motion in the current study. Consequentially, no outliers were observed after the revision surgery with respect to the position of the implants relative to the safe zone in this study. One of the reasons of ceramic liner fracture is related to the design of ceramic liners. Some investigators reported high incidence of fracture in the third-generation sandwich ceramic PE liners.^18,19 In our cases, there was only one case with the third-generation sandwich ceramic liner fracture that was treated via extensive synovectomy and revision THA with the fourth-generation CoC bearing (Figure 3). According to a systematic review, CoC bearing is considered as a viable option for reducing the risk of a third-body wear of the revised implants.²⁰ During the follow-up periods, there were no signs of a third-body wear, as well as no other complications, such as significant osteolysis and squeaking in our case of sandwich ceramic liner fracture.

Figure 3.

Anteroposterior radiograph obtained 8 years after primary THA, of the right hip in a 53-year-old man, showing fracture on the third-generation sandwich ceramic PE liner. Revision surgery was performed using the fourth-generation CoC bearing surface. During the follow-up period, there was no sign of a third-body wear. THA: total hip arthroplasty; CoC: ceramic-on-ceramic; PE: polyethylene.

Dislocation after primary THA has been reported to be in the range of 2–7% and may even reach 25% after revision surgery.²¹ Dislocation after THA is the second most common cause for revision hip arthroplasty.²² There were several reports for low incidence of dislocation in primary THA using large-head fourth-generation ceramics.^23,24 In a previous study on revision THA using the third-generation ceramics, two dislocations with 28 mm heads occurred,¹² while none in the current study. In this study, the size of the femoral head in all cases was 36 mm. Large-sized femoral heads favor impingement-free range of motion, as well as increased stability by increasing the jump distance.²⁵ However, this improved jump distance is dependent on a well-positioned acetabular component,²⁶ which emphasizes the importance of surgical technique in maximizing stability. Therefore, application of combined anteversion concept during implant positioning would reduce dislocation and impingement through the impingement-free range of motion by proper positioning of the acetabular and femoral components. However, given that anterior hip and groin pain related to anterior soft tissue impingement by large diameter femoral heads may occur,²⁷ delicate clinical observation would be necessary during the follow-up period. Moreover, this limitation can be overcome by a recently introduced “anatomically contoured heads.”²⁸

Recently, Iamthanaporn et al. reported periprosthetic joint infection (PJI) as the most common cause for revision THA within the first 5 years of surgery.²⁹ In our current study, there were 10 cases (19%) of infection as a cause for revision. Kurtz et al. reported that the relative incidence of PJI has increased and the increased demand for joint arthroplasty will be the economic burden of prosthetic infections.³⁰ In addition, revision THA in cases of infected hip can cause disastrous complications and higher chance of recurrence. Hence, selecting the right bearing surface, while considering revision for PJI, is very important. Corrosion products of metal particles can induce profound derangements and necrosis of the local tissue, and PE debris causes a distinctive foreign body reaction.³¹ On the other hand, ceramic debris is less bio-reactive with minimal occurrence due to the lower wear rate of ceramic bearing.⁴ Bozic et al. reported that metal-on-metal bearings were associated with a higher adjusted risk of PJI than CoC bearing,³² and Pitto and Sedel reported that CoC bearings were associated with a lower risk of revision for deep infection when compared with other bearing surfaces.³³ In the current study, there were two cases of late infection following revision THA. The causes for revision THA were infection in one case and aseptic loosening accompanied with osteolysis in another case. The time interval between prior revision THA and the diagnosis of infection in the two cases was 75 months and 37 months, respectively. In general, the standard treatment method for infected THAs is known as the two-stage reimplantation with insertion of antibiotic-loaded cement spacer or beads. In our two infected cases, although the implants were well fixed, the soft tissue and bone stock were in seriously poor condition due to multiple prior surgeries. Hence, we tried to treat these two cases with meticulous debridement and antibiotic-loaded cement beads with retention of well-fixed prostheses, based on our previous experience.³⁴ The femoral head and acetabular liner were intraoperatively changed with the fourth-generation CoC bearing couple. Microorganism-specific intravenous antibiotics were administered for 6 weeks. The follow-up period after the last surgery for the two cases was 41 months and 73 months, respectively. At the final follow-up examination, there were no signs of infection, and the implants were well maintained with no signs of loosening.

With the introduction of the fourth-generation ceramic bearings, the reported incidence of squeaking has also decreased considerably, suggesting that ceramic bearings should be the choice of bearings in patients undergoing primary THA, especially in young and active patients. Wang et al. reported a 1.1% squeaking rate,²⁴ while Cai et al. reported a 3.9% (two patients) squeaking rate in their respective study.²³ However, we found no cases of squeaking in our current study. Parvizi et al. suggested that squeaking is likely related to the design of prosthesis, which can cause neck impingement on the elevated titanium rim.³⁵ Moreover, Restrepo et al. reported that the more flexible stem material and more slender neck design of the femoral component may contribute to squeaking by amplifying the vibrations generated by CoC articulation.³⁶ In all of our cases, the acetabular components with a ceramic liner that seats flush with the acetabular shell were used. Walter et al. suggested that weight, height, and cup position may be the factors that contribute to squeaking sound.³⁷ Chen et al. reported no squeaking in their study of 413 hips in the Asian population.³⁸ They suggested that relatively low height and weight compared with Western patients and optimal cup positioning may be related to the absence of squeaking. In our study, the average height and weight were also relatively low, and no outliers were observed after the revision THA regarding the position of the implants relative to the “safe zone.” We believe that the various factors described above contributed to the absence of squeaking in our cases.

In this study, although the femoral stem was revised in all 52 hips, including the 26 hips with well-fixed stems, none of them was revised solely to allow the use of an alternative bearing surface, such as a CoC surface. In the 26 hips, 15 had severe osteolysis, 5 had leg length discrepancies, 1 had hip joint laxity, and 5 had an old Morse taper that could not be reused. In revision THA with well-fixed stem which had Morse taper with or without damage, using Biolox Option head (CeramTec) with retained stem showed favorable results, including marked improvement in pain and function, no squeaking or ceramic bearing fracture.³⁹

This study has several limitations. First, this study was a retrospective study with a relatively small number of patients in a single institution. Second, this was not a comparative study, lacking a control group. Finally, this was a midterm follow-up study (mean follow-up 7.3 years).

Conclusion

This study showed favorable clinical and radiologic outcomes after revision THA using the fourth-generation CoC bearing surface. Our data support the use of CoC bearing surfaces in revision THA. We believe that the fourth-generation ceramics will have an impact on the results of revision THA as well as primary THA. Nonetheless, further studies with long-term follow-up data and comparison data for other new bearing surfaces are warranted.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

References

Bozic

Kamath

Ong

. Comparative epidemiology of revision arthroplasty: failed THA poses greater clinical and economic burdens than failed TKA. Clin Orthop Relat Res 2015; 473(6): 2131–2138.

Amstutz

Campbell

Kossovsky

. Mechanism and clinical significance of wear debris-induced osteolysis. Clin Orthop Relat Res 1992; 276: 7–18.

Oonishi

Clarke

Good

. 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 2004; 70(4): 523–532.

Sterner

Schutze

Saxler

. Effects of clinically relevant alumina ceramic, zirconia ceramic and titanium particles of different sizes and concentrations on TNF-alpha release in a human macrophage cell line. Biomed Tech (Berl) 2004; 49: 304–344.

Massin

Lopes

Masson

. Does Biolox^® Delta ceramic reduce the rate of component fractures in total hip replacement? Orthop Traumatol Surg Res 2014; 100(suppl 6): S317–S321.

Buttaro

Zanotti

Comba

. Primary total hip arthroplasty with fourth-generation ceramic-on-ceramic: analysis of complications in 939 consecutive cases followed for 2–10 years. J Arthroplasty 2017; 32(2): 480–486.

Jack

Molloy

Walter

. The use of ceramic-on-ceramic bearings in isolated revision of the acetabular component. Bone Joint J 2013; 95(3): 333–338.

Chang

Lee

Hur

. Revision total hip arthroplasty in hip joints with metallosis: a single-center experience with 31 cases. J Arthroplasty 2005; 20: 568–573.

Migaud

Putman

Kern

. Do the reasons for ceramic-on-ceramic revisions differ from other bearings in total hip arthroplasty? Clin Orthop Relat Res 2016; 474(10): 2190–2199.

10.

Jolles

Zangger

Leyvraz

. Factors predisposing to dislocation after primary total hip arthroplasty: a multivariate analysis. J Arthroplasty 2002; 17: 282–288.

11.

Jacobs

Roebuck

Archibeck

. Osteolysis: basic science. Clin Orthop Relat Res 2001; 393: 71–77.

12.

Chang

Kamdar

Yoo

. Third-generation ceramic-on-ceramic bearing surfaces in revision total hip arthroplasty. J Arthroplasty 2009; 24: 1231–1235.

13.

Gwam

Mistry

Mohamed

. Current epidemiology of revision total hip arthroplasty in the United States: national inpatient sample 2009 to 2013. J Arthroplasty 2017; 32(7): 2088–2092.

14.

Silva

Shepherd

Jackson

. Average patient walking activity approaches 2 million cycles per year: pedometers under-record walking activity. J Arthroplasty 2002; 17(6): 693–697.

15.

Kuntz

. Validation of a new high performance alumina matrix composite for use in total joint replacement. Semi Arthroplast 2006; 17: 141–145.

16.

Huet

Sakona

Kurtz

. Strength and reliability of alumina ceramic femoral heads: review of design, testing, and retrieval analysis. J Mech Behav Biomed Mater 2011; 4: 476–483.

17.

Traina

De Fine

Bordini

. Risk factors for ceramic liner fracture after total hip arthroplasty. Hip Int 2012; 22(6): 607–614.

18.

Lopes

Philippeau

Passuti

. High rate of ceramic sandwich liner fracture. Clin Orthop Relat Res 2012; 470(6): 1705–1710.

19.

Viste

Chouteau

Desmarchelier

. Fractures of a sandwich ceramic liner at ten year follow-up. Int Orthop 2012; 36(5): 955–960.

20.

Traina

De Fine

Di Martino

. Fracture of ceramic bearing surfaces following total hip replacement: a systematic review. Biomed Res Int 2013; 2013: 157247.

21.

Pattyn

De Haan

Kloeck

. Complications encountered with the use of constrained acetabular prostheses in total hip arthroplasty. J Arthroplasty 2010; 25: 287–294.

22.

Thomas

Marwin

. A unique failure mechanism of a constrained total hip arthroplasty: a brief review of the literature. J Arthroplasty 2008; 23(2): 293–298.

23.

Cai

Xie

. Large-diameter Delta ceramic-on-ceramic versus common-sized ceramic-on-polyethylene bearings in THA. Orthopedics 2012; 35(9): 1307–1313.

24.

Wang

Guo

Yue

. Fourth-generation ceramic-on-ceramic total hip arthroplasty in patients of 55 years or younger: short-term results and complications analysis. Chin Med J 2014; 127(12): 2310–2315.

25.

Bartz

Nobel

Kadakia

. The effect of femoral component head size on posterior dislocation of the artificial hip joint. J Bone Joint Surg Am 2000; 82:1300–1307.

26.

Sariali

Lazennec

Khiami

. Mathematical evaluation of jumping distance in total hip arthroplasty: influence of abduction angle, femoral head offset, and head diameter. Acta Orthop 2009; 80: 277–282.

27.

Browne

Polga

Sierra

. Failure of larger diameter metal-on-metal total hip arthroplasty resulting from anterior iliopsoas impingement. J Arthroplasty 2011; 26(6): 978, e5–e8.

28.

Varadarajan

Duffy

Zumbrunn

. A new anatomically contoured large diameter femoral head to alleviate soft tissue impingement in hip arthroplasty. Bone Joint J 2013; 95–B(suppl 34): 408.

29.

Iamthanaporn

Chareancholvanich

Pornrattanamaneewong

. Revision primary total hip replacement: causes and risk factors. J Med Assoc Thai 2015; 98(1): 93–99.

30.

Kurtz

Lau

Watson

. Economic burden of periprosthetic joint infection in the United States. J Arthroplasty 2012; 27: 61–66.

31.

Esposito

Maclean

Campbell

. Periprosthetic tissues from third generation alumina-on-alumina total hip arthroplasties. J Arthroplasty 2013; 28(5): 860–866.

32.

Bozic

Lau

Ong

. Comparative effectiveness of metal-on-metal and metal-on-polyethylene bearings in Medicare total hip arthroplasty patients. J Arthroplasty 2012; 27(suppl 8): 37–40.

33.

Pitto

Sedel

. Periprosthetic joint infection in hip arthroplasty: is there an association between infection and bearing surface type? Clin Orthop Relat Res 2016; 474(10): 2213–2218.

34.

Chang

Kim

Lee

. Acute delayed or late infection of revision total hip arthroplasty treated with debridement/antibiotic-loaded cement beads and retention of the prosthesis. Hip Pelvis 2017; 29(1): 35–43.

35.

Parvizi

Adeli

Wong

. A squeaky reputation: the problem may be design-dependent. Clin Orthop Relat Res 2011; 469(6): 1598–1605.

36.

Restrepo

Post

Kai

. The effect of stem design on the prevalence of squeaking following ceramic-on-ceramic bearing total hip arthroplasty. J Bone Joint Surg Am 2010; 92(3): 550–557.

37.

Walter

O’Toole

Walter

. Squeaking in ceramic-on-ceramic hips: the importance of acetabular cup orientation. J Arthroplasty 2007; 22: 496–503.

38.

Chen

. No significant squeaking in total hip arthroplasty: a series of 413 hips in the Asian people. J Arthroplasty 2012; 27(8): 1575–1579.

39.

Fritz

Manoon

Satit

. Early results of revision hip arthroplasty using a ceramic revision ball head. Semin Arthro 2011; 22: 284–289.

Midterm outcome of fourth-generation ceramic-on-ceramic bearing surfaces in revision total hip arthroplasty

Abstract

Purpose:

Methods:

Results:

Conclusion:

Keywords

Introduction

Materials and methods

Results

Discussion

Conclusion

Footnotes

Declaration of conflicting interests

Funding

References