Delayed diagnosis of low-symptomatic ceramic acetabular liner fracture in ceramic-on-ceramic total hip arthroplasty

Effect of Alumina Particles on the Osteogenic Ability of Osteoblasts

Biomaterials are used as implants for bone and dental disabilities. However, wear particles from the implants cause osteolysis following total joint arthroplasty (TJA). Ceramic implants are considered safe and elicit a minimal response to cause periprosthetic osteolysis. However, few reports have highlighted the adverse effect of ceramic particles such as alumina (Al2O3) on various cell types. Hence, we aimed to investigate the effect of Al2O3 particles on osteoprogenitors. A comparative treatment of Al2O3, Ti, and UHMWPE particles to osteoprogenitors at a similar concentration of 200 μg/mL showed that only Al2O3 particles were able to suppress the early and late differentiation markers of osteoprogenitors, including collagen synthesis, alkaline phosphatase (ALP) activity and mRNA expression of Runx2, OSX, Col1α, and OCN. Al2O3 particles even induced inflammation and activated the NFkB signaling pathway in osteoprogenitors. Moreover, bone-forming signals such as the WNT/β-catenin signaling pathway were inhibited by the Al2O3 particles. Al2O3 particles were found to induce the mRNA expression of WNT/β-catenin signaling antagonists such as DKK2, WIF, and sFRP1 several times in osteoprogenitors. Taken together, this study highlights a mechanistic view of the effect of Al2O3 particles on osteoprogenitors and suggests therapeutic targets such as NFĸB and WNT signaling pathways for ceramic particle-induced osteolysis.

Third-generation pure alumina and alumina matrix composites in total hip arthroplasty: What is the evidence?

Wear, corrosion and periprosthetic osteolysis are important causes of failure in joint arthroplasty, especially in young patients.

Ceramic bearings, developed 40 years ago, are an increasingly popular choice in hip arthroplasty. New manufacturing procedures have increased the strength and reliability of ceramic materials and reduced the risk of complications.

In recent decades, ceramics made of pure alumina have continuously improved, resulting in a surgical-grade material that fulfills clinical requirements.

Despite the track record of safety and long-term results, third-generation pure alumina ceramics are being replaced in clinical practice by alumina matrix composites, which are composed of alumina and zirconium.

In this review, the characteristics of both materials are discussed, and the long-term results with third-generation alumina-on-alumina bearings and the associated complications are compared with those of other available ceramics.

Cite this article: EFORT Open Rev 2018;3:7-14. DOI: 10.1302/2058-5241.3.170034

Noise production in ceramic-on-ceramic total hip arthroplasty is associated with lower patient satisfaction and hip scores

Background

Ceramic-on-ceramic total hip arthroplasties (THA) are commonly implanted. We investigated the incidence of noise in ceramic-on-ceramic and determined any association with patient satisfaction and hip scores.

Methods

We recruited 140 THA. Questionnaires were completed to assess the incidence and frequency of noise, and satisfaction level. Hip and SF-12 scores were recorded.

Results

Forty-two patients (30%) were aware of noise production. Patients with noise production had lower satisfaction, mean hip and SF-12 scores than those with silent hips.

Conclusion

Given the high incidence of noise in ceramic-on-ceramic THA, patients should be counselled on this risk pre-operatively.

Imaging of ceramic liner fractures in total hip arthroplasty: the value of CT

Fracture of a ceramic liner of a total hip arthroplasty is rare and is radiographically occult if not displaced. We report on two patients in whom ceramic liner fracture was radiographically occult but was diagnosed on subsequent CT scan through appropriate windowing.

Wear Debris Characterization and Corresponding Biological Response: Artificial Hip and Knee Joints

Wear debris, of deferent sizes, shapes and quantities, generated in artificial hip and knees is largely confined to the bone and joint interface. This debris interacts with periprosthetic tissue and may cause aseptic loosening. The purpose of this review is to summarize and collate findings of the recent demonstrations on debris characterization and their biological response that influences the occurrence in implant migration. A systematic review of peer-reviewed literature is performed, based on inclusion and exclusion criteria addressing mainly debris isolation, characterization, and biologic responses. Results show that debris characterization largely depends on their appropriate and accurate isolation protocol. The particles are found to be non-uniform in size and non-homogeneously distributed into the periprosthetic tissues. In addition, the sizes, shapes, and volumes of the particles are influenced by the types of joints, bearing geometry, material combination, and lubricant. Phagocytosis of wear debris is size dependent; high doses of submicron-sized particles induce significant level of secretion of bone resorbing factors. However, articles on wear debris from engineered surfaces (patterned and coated) are lacking. The findings suggest considering debris morphology as an important parameter to evaluate joint simulator and newly developed implant materials.

Ceramic liner fatigue fracture: 3-D CT findings in a late recurrent THA dislocation

Dislocation is one of the most common complications of total hip arthroplasty (THA). To the authors' knowledge, late recurrent dislocation of a THA with a ceramic-on-ceramic coupling secondary to fatigue fracture of the ceramic liner has never been described. A 76-year-old woman with right hip osteoarthritis underwent cementless modular THA with a ceramic-on-ceramic coupling. Approximately 10 years postoperatively, she experienced right hip pain with no trauma, which resolved in 14 days. Family members reported that the patient had shown a progressive cognitive and muscular decline in the previous months. Six months later, the patient was admitted for THA dislocation, which was immediately reduced. Computed tomography revealed that the right acetabular component had a retroversion of 4° and an inclination angle of 45°. An orthopedic brace was applied, but dislocation recurred 2 days after discharge. A 3-dimensional CT reconstruction showed a fracture of the ceramic liner in the posterolateral region. The patient underwent revision surgery, and the ceramic liner breakage was confirmed. After removal of the acetabular components, a cemented polyethylene cup was implanted. The stability of the stem was verified. The existing modular neck was replaced with a chromium-cobalt neck, and a new ceramic head was applied. At 7-month follow-up, the patient had good functional recovery with no hip instability. Fatigue failure of a ceramic liner should be considered as responsible for late dislocation after ceramic-on-ceramic THA. As part of the diagnostic strategy, 3-dimensional CT reconstruction should be used to evaluate ceramic liner breakage.

Hip squeaking: a 10-year follow-up study

The aim of the study was to analyze the incidence of squeaking with ceramic-on-ceramic total hip arthroplasty (THA) after 10 years of follow-up and the potential complications that could occur related to this phenomenon. One hundred THAs implanted between November 1999 and December 2000 were evaluated. Incidence of squeaking was investigated clinically with a questionnaire. Implant positioning was analyzed on x-rays and computer tomography. Of the 100 THAs, 5 patients presented with squeaking. All of them were active, sporty, and heavy men. Functional scores were comparable with nonsqueaking patients. There was no malpositioning on the x-ray analysis, no wear, and no loosening. We could not demonstrate any relation between squeaking and ceramic fracture. Squeaking noise appeared at a mean of 66 months postsurgery. It appears to be an isolated phenomenon without any consequences at 10-year follow-up.

Nine years follow-up of 100 ceramic-on-ceramic total hip arthroplasty

The aim of this study was to evaluate the first 100 cementless ceramic-on-ceramic total hip arthroplasty (THA) performed at our institution with more than nine years of follow-up. Clinical evaluation was performed using Harris hip score. Radiological evaluation was performed by two surgeons. Four patients were lost to follow-up. Harris hip score significantly improved at latest follow-up. Radiological analysis showed calcar osteolysis for 75 patients and one cup loosening. One patient required a revision five years postoperatively for cup loosening. Based on these results and the routine use of a navigation system to optimise positioning of the implants, we advocate the use of uncemented hydroxyapatite coated ceramic-on-ceramic THA in young and active patients in our current practice.