Ceramic-on-ceramic bearings have very low wear rates compared to other bearing surfaces like metal-on-metal and polyethylene. Modern ceramics have improved strength and toughness through advances like high purity materials, hot isostatic pressing, and proof testing. However, ceramic components can still fracture if there is impingement or asymmetric loading. Registry data shows ceramic fracture rates are lower with newer zirconia ceramics like Biolox Delta compared to earlier alumina ceramics, but liner fractures remain a concern. Long term follow up shows ceramic bearings can function well in hip replacements for decades.

1. Ceramic on Ceramic
Total Hip Arthroplasty-
Recent update
Joint Replacement Surgeon
Dr Naveen Thiyagu
ALPHA ORTHO CLINIC
Pondicherry ,India

2. WHAT IS CERAMIC ?
Ceramic is any of the various hard, brittle, heat-
resistant and corrosion-resistant materials made by
shaping and then firing a nonmetallic mineral, such as
clay, at a high temperature.
Common examples are earthenware,
porcelain, and brick.
The word "ceramic" comes from the Greek
word κεραμικός (keramikos), "of pottery" or
"for pottery"

4. Structure
• Evolution
• Surgical tips
• Registry (American and Australian )
• Journal
• Case
• Take home message

5. ● Strength
● Strength is the material ability to withstand stress
● Toughness
● Toughness is the indication of the ability of the
material to
dissipate fracture energy
● Plastic deformation is a way to dissipate energy
before fracture

6. Weak
Strong
ToughBrittle

7. Toughness (kl / m2)
0.001 0.01 0.1 1 10 100
Brittle Tough
Strength(MPa)
0.1
1
10
1,000
100
10,000
WeakStrong
Rubbers
FoamWood
and wood
products
Polymers
Metal
and
alloys
Composites
Porous
ceramics
Concrete Brick
Glasses
Ceramics
Zirconia
Silicon
Carbide
Alumina

8. FATHER OF CERAMIC
BUTIN
1970
27 YRS POST-OP

9. First Generation of Ceramics
■ Started in Europe and
Japan
■ It was monolithic
acetabular component,
fabricated from alumina
ceramics(Al2O3)
■ Femoral head was
ceramic, fitting with
tapered interlock to the
metallic femoral stem

10. ■ Failure due to : ( combine failure 35%).
• Lack of fixation
• Migration, tilting of compontent
• Edge loading, accelerated wear and impingement
• In vivo fracture of acetabular component
Still minimal wear

11. Second Generation Ceramics
■ Modular acetabular
component with metal
backing with some type of
biological coating-
improved fixation.
■ Mixed result.
■ 3 years follow up-high
vertical migration.
Ceramic fracture

12. Evolution of ceramics for THR bearings
1970
Boutin’s
THR
1988
High Purity
Powders
1994
HIP
Proof Testing
1998
Colloidal
Processing
1975:
Mg-PSZ
1987
ZTA
1985:
???
Y-TZP
2000
ZPTA
Alumina
Zirconia
Alumina matrix Composites

15. Weak
Strong
ToughBrittle
Z

16. In August 2001, the unexpected high fracture rate
in two batches of zirconia ball heads
made by the largest YTZP manufacturer
led to the worldwide product recall

17. Maccauro et al., JBJS 2004

19. ● High purity starting
materials
● Hot isostatic pressing (HIP)
● Quality assurance
1978 1996
420 MPa
620 MPa 650 MPa
850 MPa
σ Fracture
(3p bending test)

20. ■ The feared fracture of ceramic component, most notable
the ball components, successfully disappeared.
■ Two technological achievement :
• Introduction of individual testing of every ceramic
component before is it shipped and sold to surgeon.
(1993)
• Hot Isostatic Pressing(HIPping)
so alumina ceramics are produced in very dense
fine grain alimina and with very limited grain boundries
and inclusions.

21. 0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
XLPE MOM Forte
Wearmm3
/Mc
Nevelos et al Mat in Med 2001, Galvin 2004

22. ● Very low wear rate approximately 0.5 to 1 mm3/ year
● Stripe wear on the femoral head commonly observed
● Stripe wear mechanism → grain boundary fracture/surface roughening
● Simulated in vitro by introducing micro-separation
Nevelos et al., Biomaterials 1999

23. Hydrophilic Nature
■ Ceramics also attract fluid on their surfaces to the coupling made
of ceramics have low friction resistance.
■ Wettable (hydrophilic): Contact angle<50º .
■ Highly conforming fluid film reduces contact stresses.
■ The ionic nature will allow wetting of the surface.
which may reduce adhesive wear.

24. More hydrophilic then Co-Cr
■ Improved wettability of
ceramics contributes to lower
friction than CoCr when
articulated against UHMWPE
under physiological loading
and lubrication conditions.
■ It ensures that the synovial
fluid-film is uniformly
distributed over the whole
bearing surface areas.

26. ■ These pistoning
movements are
small between
0.8 to 5
■ Seen in MOP
and COC , not
in MOM designs.

27. ■ Due to these movement
pressure concentrates in
one area and wear
increases.
Studies demonstrated that these noises
from
ceramic total hips are associated with
faulty
position of the ceramic cup( Walter 2007)

28. ■ Still modern ceramic material are
very sensitive to asymmetric
loading and impingement by the
femoral neck
■ Less accurate position of the ceramic
cup may increase considerably the
wear of the ceramic components.

29. 0
0.5
1
1.5
2
Forte Standard Forte
Microseparation
Wearmm3
/Mc
4-fold
increase

30. Hatton et al., Biomaterials 2003
0
2
4
6
8
COC
Microseparation
XLPE
FBA
•Forte wear particles can
cause production of
cytokines associated with
osteolysis
•However, unlikely to due
to low wear volumes,
unlikely this threshold will
be reached

31. Material combinations in total hip joints( Heisel
2003).
Young pt and physical activity

32. DEVELOPMENT OF CERAMIC
PROPERTY ALUMINA 1970’s ALUMINA 1980’s
ALUMINA
1990’s
GRAIN SIZE 7.2 um 7.5 1.8
LASER MARKING NO YES YES
HOT ISOSTATIC PRESSED NO NO YES
PROOF TESTED NO NO YES
FRACTURE RATE 0.026% 0.014% 0.004%

33. Disadvantage of the modern alumina
ceramic is lower toughness in spite of
the impressive test figures.
Zirconia Toughened Alumina (ZTA) ceramic

34. Pros
● Optimum biocompatibility
● Good mechanical strength
● Cons
● Brittle fracture mechanics
● Limitation in device design

35. ● Increase in strength
● Increase in toughness
● High hardness
● High biocompatibility
● Low wear

37. 0
200
400
600
800
1000
1200
1400
Forte Zirconia Delta
Strength(MPa)
0
2
4
6
8
10
12
Forte Zirconia Delta
Toughness(MPa)
Strength Toughness

38. 0
500
1000
1500
2000
2500
Forte Zirconia Delta
Microhardness(HV)

39. SURGICAL TIPS
Full seating
Eccentric seating

40. Avoid Head-Neck inpingement
■ Hips with
Lateral opening<30, >50
a high neck shaft angle
Risk of neck/shaft
impingement
High wear rate as a result
of stress concentration
in the very stiff ceramic
material

41. Weak
Strong
ToughBrittle
Z

42. 0
0.5
1
1.5
2
Standard Microseparation
Wearrate(mm3
/Mc)
Forte
Delta
Stewart et al., J Biomed Mat Res, B, 2003

43. ● PROS
● VERY LOW WEAR
● NO METAL IONS
● CONS
● CAN BREAK
● SQEEKING
● STRIPE WEAR
● EXPENSIVE

44. Figure 2.11: Cumulative Percent Revision for Diameter of Femoral Heads for
Elective Primary Total Hip Arthroplasty in Patients ≥65 Years of Age with
Primary Osteoarthritis, 2012-2019

45. Figure 2.16: Composition of Femoral Heads for All
Elective Primary Total Hip Arthroplasty Procedures
Excluding Dual Mobility by Age Group, 2012-2019
(N=533,256)

46. Figure 2.17: Elective Primary Total Hip Arthroplasty
Bearing Surface Materials by Year, 2012-2019
(N=502,862)

51. The rate of ceramic fracture In the present study, the
rate of ceramic fracture was 0.5% (0.9/1000 patient-
years) in the forte group vs 0.2% (0.5/1000 patient-
years) in the delta group.

52. It is our hypothesis that these insertional liner fractures, and
possibly even the postoperative liner fractures, are a consequence
of either leaving the liner asymmetrically seated in the cup or failure
to impact the liner forcibly and lock the liner in its taper …believe
that this may implicate the insertional technique and emphasizes
the importance of careful attention when seating the liner. The
squeaking that is reported in this study remains a concern, and at
this time there is no consensus as to cause.

53. It seems to be that use of the Biolox Delta decreased the rate of
ceramic head fracture but not the rate of ceramic liner fracture
• Howard D.P. Wall P.D.H. Fernandez M.A. Parsons H. Howard P.W.
• Ceramic-on-ceramic bearing fractures in total hip arthroplasty: an analysis of data from the National Joint Registry.
Bone Joint J. 2017; 99–B: 1012-1019

54. • Garcia P. Leal D. Kimura O. Freitas E. Fernandes M.
• Results and complications of total hip arthroplasty with ceramic-ceramic.
Hip Int. 2016; 26: S72-S73
“As the head diameter increases, the liner becomes thinner,
which might increase the risk of liner fracture “

55. Case 1

56. “ceramic has been part of
our life from the beginning”
“from the datas that come up it would be
part of our body at least for a century “

57. Joint Replacement Surgeon
Dr Naveen Thiyagu
ALPHA ORTHO CLINIC
Pondicherry ,India
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I welcome u for
fellowship in
joint replacement
at our centre