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Issue # 22022

Clear Trends Are Favoring Ceramics

Dr. Alessandro Alan Porporati

Director Medical and Scientific Affairs CeramTec GmbH, Germany

The latest figures speak for themselves. According to the six most important national registries, the use of ceramic components in arthroplasty is on the rise. In 2020, 48.8% of all primary total hip replacements registered in the NJR*, around 60% in the AOA NJRR*, 89.3% in the EPRD*, 61% in the NZJR*, around 26% in the SAR*, and 71.1% in the AJRR* were performed with ceramic femoral heads. This accounts for an increase of more than 3.8% in the NJR, about 2% in the AOA NJRR, 0.4% in the EPRD and 2.1% for the AJRR compared to the previous year. The use of ceramic-on-polyethylene (CoP) bearings has generally increased in 2020. According to the NJR, hybrid CoP figures have grown in particular, making this the most often utilized construct in 2020. Correspondingly, the use of metal femoral heads has again declined in 2020.


Recurrent dislocation, infection, periprosthetic fracture and aseptic loosening are still the main complications with these products leading to revision. On the other hand, according to the NJR, revision rates for CoP bearings remain consistently low or equivalent to other bearings across all fixation types for up to ten years. The NJR shows that good results were obtained with CoC and CoP bearings in young patients. The AOA NJRR also shows that CoXLPE has a lower rate of revision compared to MoXLPE after the first two weeks. According to the EPRD, CoC shows the lowest short- and mid-term failure rates among all bearing surfaces. Obviously, the good clinical results support the observed trends.


We can say that statistics show more than promising figures for ceramic bearings. New applications such as dual mobility can benefit from the excellent biocompatibility and extraordinary wear resistance of advanced ceramics. The number of dual mobility bearings implanted has steadily increased over the years. According to the AJRR, the use of dual mobility in primary and revision hip replacements has continued to increase and in 2020 accounted for 10.5 percent of all bearings used in elective primary surgeries and for more than 25 percent of all revision procedures. The NJR is currently the only registry reporting the use of ceramic heads with dual mobility constructs, and nearly one-third of the total dual mobilities implanted in a primary procedure in 2020 had a ceramic head. The Australian registry reports a lower revision rate for dislocation with this solution, in comparison with all other acetabular prostheses.


AJRR: The American Joint Replacement Registry

NJR: The National Joint Registry, which covers England, Wales, Northern Ireland, the Isle of Man and the States of Guernsey

AOA NJRR: The Australian Orthopaedic Association National Joint Replacement Registry

EPRD: Endoprothesenregister Deutschland

NZJR: The New Zealand Joint Registry

SAR: The Swedish Arthroplasty Register


Analysing registry data can be complex due to differences in the definitions used, which are dependent on the culture, healthcare systems, response patterns, priorities, and needs. The International Society of Arthroplasty Registries (ISAR) is working on the harmonisation of definitions, data collection and reporting across registries. The aggregation of data for procedures recorded by different registries aims to enable international comparisons and to identify issues with medical devices.

This CeraNews issue extracts and summarizes the data and trends related to the usage of bearing materials and especially ceramic bearings, and the reasons for revision and trends in total hip replacement using the data on hip procedures from the annual reports 2021 of six registries selected for their historical perspective and data collection.

The analysis is limited to the most commonly used materials, i.e. ceramic and metal (cobalt chrome) for femoral heads; (cross-linked) polyethylene and ceramic for inserts. The bearing types considered are therefore ceramic-on-ceramic, ceramic-on-polyethylene and metal- on-polyethylene.

Ceramic - No differentiation between the ceramic materials

The only registry that differentiates between ceramic materials is the AOA NJRR which in its analysis examines only the newest generation materials, mixed ceramic and cross-linked polyethylene. Therefore, the following analysis was generalized to ceramic without distinguishing between alumina and mixed ceramics.

Polyethylene – The classification according to the irradiation dose is not harmonised across the registries

The only registry that differentiates polyethylene according to irradiation dose is the German registry, whereas, at the other extreme, the NJR makes no differentiation at all. This summary tries to reflect the results of modern prosthetics as closely as possible.

Dual Mobility – Increasing attention by registry annual reports

Dual mobility constructs were until recently sparsely used. They have gained increasing interest in the last decade and most registries considered reporting their use, but only the AOA NJRR and NJR annual reports show revision rates. NJR is the only registry that differentiates between dual mobility constructs by head material (i.e. CoCr and ceramic).

Outcomes Research

Bearings and Hip Procedures: Comparative Analysis

What can we learn from the latest Annual Reports? Hip replacement registries worldwide reflect a continuing overall trend toward uncemented and especially hybrid fixation. Larger head sizes and dual mobility are obviously seen as viable answers to instability problems and are also gaining in popularity. One trend is especially obvious and has been going on for years: metal femoral heads are more and more supplanted by ceramic components.

Outcomes Research

Failure Modes in THA: an International Comparison

Discounting the use of slightly different terminologies, the most common reasons for hip revision are very similar throughout national registries. Only the ranking seems to show some differences between countries. Loosening, infection, dislocation and periprosthetic fractures are found at the top of the lists in varying order. The use of ceramic components seems to be linked to lower revision rates.

Outcomes Research

PROMs and Trends: More Patient Centricity?

Revision surgery is the traditional endpoint of registries. Until recently, other outcomes that are relevant for patients were less considered. Indeed, national orthopaedic arthroplasty registries increasingly report PROMs, which measure functional improvement. In addition registries contribute to identify trends in implant choice such as the increasing use of dual mobility.

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