CeraNews | To The Point

Our goal is to support you with an overview of relevant current research – brief and to the Point! CeraNews is structured around the following key topics:

  • Implant Material

  • Outcomes Research

  • Health Economics & Policy

We trust that you will find the selected summaries both relevant and valuable.

CeraNews – to the Point is published twice per year. Ideally, we can contribute in this way to the ongoing debate on important topics in orthopedics, and beyond. Ultimately, working towards improved patient outcomes and long-term cost reductions in health care is our mutual motivation and strong link, regardless of our individual role or location. 


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CeramTec is committed to selecting and bringing to interested parties relevant articles on bioceramics related topics. The presented authors’ views and opinions are solely those of the authors of these publications. It is the focus and intent of CeraNews that CeramTec presents and comments on the authors’ views and opinions in a specific context. Such comments and editorials therefore solely express CeramTec’s views and opinions and not necessarily those of the quoted authors.

Issue # 22020


Guest Editor

Prof. Francesco Traina – Rizzoli Orthopaedic Institute Bologna, Italy

Dear colleagues,

The Corona pandemic has affected our lives and our work severely. Elective surgeries have been postponed, with a massive negative impact on orthopaedic care in general and also on the financial situation of many hospitals. We still do not know when we can return to something that resembles normality. Nevertheless, our professional focus as surgeons has not changed. Under any circumstances, our goal will be further to increase benefits for the patient. Arthroplasty is not only about pain relief but also about performance, long-term success (lifelong if possible), and cost efficiency. In the field of revision, 3D printing and customization offer new chances adequately to treat even the most difficult cases. Advanced bearing materials allow us to achieve long-term survival. As the number of primary and revision procedures keeps increasing continuously, we must be aware that we are riding a tiger!

In revision cases, the choice of implant is especially crucial. In my department, we have been using ceramic femoral heads exclusively for all our patients for more than 20 years.

Our clinical results with BIOLOX®forte ceramic bearings at Rizzoli were excellent compared to other materials1, showing very good results even in difficult cases like DDH, Poliomyelitis or Legg-Calvé-Perthes disease, Slipped Capital Femoral Epiphysis (SCFE)2–5. Our regional hip registry (RIPO) documents twenty years of long-term results with a very low rate of ceramic failure in ceramic-on-ceramic. The rare cases of failure were mostly related to mishandling6–9.

With the next generation of ceramics, BIOLOX®delta introduced in 2003, new geometries became possible. The possibility to reduce the thickness of the acetabular liner and increase the diameter of the head was, in my mind, a true game-changer in our clinical practice. The introduction of sleeved ceramic heads for revision gave us an additional treatment option.


Bearing distribution according to the thickness of the acetabular component

See graphic in PDF

Ceramics is the second hardest material after diamond. It is also very tough. Only punctual and local stresses can lead to damage under extreme circumstances. Small metal elevations on the worn surface of the metal taper or micro-movements between head and taper may lead to the fracture of a ceramic component.


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However, this risk is extremely low when we compare the fracture risk of a ceramic head with the risk of polyethylene wear or instability due to a small head diameter. This is clearly shown by the evidence we collected over the years. And if I have to choose between a material releasing toxic ions, compromising the immune system of already weakened patients on the one hand and ceramics on the other, my choice will clearly be for the second. A fractured ceramic component can be revised. Damage by metal intoxication cannot.


Ceramics in Revision – Treatment Algorithm

In revision, I usually choose the largest head diameter (>36mm) available to increase implant stability, and to date I can report very good clinical outcomes. Furthermore, large heads increase positive proprioceptive sensations for the patients10. I have never faced any cases of trunnionosis related to a large ceramic head, and I am not aware of any clinical studies or case reports stating the opposite11.


In our recently published study, Delta-on-Delta bearings showed reliable outcomes in revision at mid-term, with no fractures12. These outcomes were confirmed also in smaller case series involving total hip revisions or isolated acetabular revisions, and even in specific cases as metal-on-metal revisions13.


At Rizzoli, we have very few cases of patients with noise issues. None of them had to be revised and therefore, squeaking is not rated as a risk factor in our institution. In my opinion, the only true limit for ceramics in revision surgery is set by the cases in which good implant stability cannot be achieved. Implant manufacturers strongly advise the use of a titanium sleeve on the damaged taper, in order to recreate the pristine trunnion and still allow a uniform distribution of the stresses on the ceramic head.


In finite-element simulations the fracture strength of Delta heads strongly decreased on tapers showing small metal elevations14. On the other hand, the fracture strength of sleeved heads did not decrease significantly on severely damaged tapers15.


In conclusion, our extensive clinical experience supported by the data collected in the RIPO regional registry demonstrates that the use of Delta-on-Delta ceramic bearings in revision surgery shows very promising results at a mid-term follow-up. The Australian registry suggests that the use of prostheses with improved performance has a positive impact on the incidence of revision. At Rizzoli, we observed that even the number of re-revisions decreases with the use of ceramic bearings. As revisions have a strong impact on patients’ quality of life and also on the healthcare system, implants with proven outcomes should be considered as best practice and as a valuable strategy to reduce healthcare expenditures in the long term.


Health Economics & Policy

Burden of Disease: Can the Curve Be Flattened?

The growing number of hip arthroplasty procedures requires solutions and adequate planning to reduce the future burden of disease and its economic consequences. As revision has a severe impact on the patient’s quality of life and the healthcare economy, implant solutions with proven superior outcomes should be regarded as best practice.

Outcomes Research

Excellent Outcomes with BIOLOX®delta in Revision: Don't Forget the Sleeve

Introduced to the market over 15 years ago, BIOLOX®delta ceramic hip implants have been widely used in primary THA ever since. Recent studies support their value as a reliable solution in hip revision, too. Placing a BIOLOX®delta head on a retained stem without an adapter is a matter of risk mitigation. Stay on the safe side by using a sleeved femoral head.

Implant Material

Sleeved Ceramic Heads: Versatile, Essential and Proven

In hip revision, the metal taper of an otherwise intact and well-fixed stem can exhibit varying types of damage which may be attributed to assembly or disassembly damage as well as black debris indicating fretting or even corrosion. Depending on the grade of the taper damage, the use of a sleeved ceramic head can offer a possibility to retain a well-fixed stem.

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References Editorial

[1] C.I. Esposito, T.M. Wright, S.B. Goodman, D.J. Berry, B. Clinical, T.B.W. Bioengineering Study Groups from Carl, What is the trouble with trunnions?, Clin Orthop Relat Res 472(12) (2014) 3652-8.

[2] D.R. Sumner, R. Ross, E. Purdue, Are there biological markers for wear or corrosion? A systematic review, Clin Orthop Relat Res 472(12) (2014) 3728-39.

[3] E.M. Greenfield, Do Genetic Susceptibility, Toll-like Receptors, and Pathogen-associated Molecular Patterns Modulate the Effects of Wear?, Clin Orthop Relat Res 472(12) (2014) 3709-17.

[4] B.K.J. Kilb, A.P. Kurmis, M. Parry, K. Sherwood, P. Keown, B.A. Masri, C.P. Duncan, D.S. Garbuz, Frank Stinchfield Award: Identification of the At-risk Genotype for Development of Pseudotumors Around Metal-on-metal THAs, Clin Orthop Relat Res 476(2) (2018) 230-241.

[5] P. Campbell, E. Ebramzadeh, S. Nelson, K. Takamura, K. De Smet, H.C. Amstutz, Histological features of pseudotu- mor-like tissues from metal-on-metal hips, Clin Orthop Relat Res 468(9) (2010) 2321-7.

[6] E. Ebramzadeh, P. Campbell, T.L. Tan, S.D. Nelson, S.N. Sangiorgio, Can wear explain the histological variation around metal-on-metal total hips?, Clin Orthop Relat Res 473(2) (2015) 487-94.

[7] C.M. Arnholt, D.W. MacDonald, G.R. Klein, H.E. Cates, C.M. Rimnac, S.M. Kurtz, C. Implant Research Center Writing, S. Kocagoz, A.F. Chen, What Is the Incidence of Cobalt-Chromium Damage Modes on the Bearing Surface of Contem- porary Femoral Component Designs for Total Knee Arthroplasty?, J Arthroplasty 33(10) (2018) 3313-3319.

[8] C.M. Arnholt, J.B. White, J.A. Lowell, M.R. Perkins, W.M. Mihalko, S.M. Kurtz, Postmortem Retrieval Analysis of Metallosis and Periprosthetic Tissue Metal Concentrations in Total Knee Arthroplasty, J Arthroplasty In Press (2019) https://doi.org/10.1016/j.arth.2019.08.038.

[9] P. Bisseling, B.W. de Wit, A.M. Hol, M.J. van Gorp, A. van Kampen, J.L. van Susante, Similar incidence of peripros- thetic fluid collections after ceramic-on-polyethylene total hip arthroplasties and metal-on-metal resurfacing arthro- plasties: results of a screening metal artefact reduction sequence-MRI study, The bone & joint journal 97-B(9) (2015) 1175-82.

[10] M.F. Koff, C. Esposito, P. Shah, M. Miranda, E. Baral, K. Fields, T. Bauer, D.E. Padgett, T. Wright, H.G. Potter, MRI of THA Correlates With Implant Wear and Tissue Reactions: A Cross-sectional Study, Clin Orthop Relat Res 477(1) (2019) 159-174.

[11] D. Xing, C. Yang, R. Li, Y. Hou, B. Kou, H. Li, J. Lin, Severe Wear and multiple Pseudotumor formation due to revi- sion for ceramic head breakage after ceramic-on-ceramic Total hip arthroplasty: a case report, BMC Musculoskelet Dis- ord 20(1) (2019) 332.

[12] S.B. Kocagoz, R.J. Underwood, D.W. MacDonald, J.L. Gilbert, S.M. Kurtz, Ceramic Heads Decrease Metal Release Caused by Head-taper Fretting and Corrosion, Clin Orthop Relat Res 474(4) (2016) 985-94.

[13] A. Krull, M.M. Morlock, N.E. Bishop, The Influence of Contamination and Cleaning on the Strength of Modular Head Taper Fixation in Total Hip Arthroplasty, J Arthroplasty 32(10) (2017) 3200-3205.