The Bisurface Total Knee Replacement: A Unique Design for Flexion Four-to-Nine-Year Follow-up Study* Prospective multi-centre study on a composite ceramic femoral component in total knee arthroplasty: Five-year clinical and radiological outcomes. Ceramic-on-ceramic total hip arthroplasty: update. Clinical results of posterior cruciate ligament retaining TKA with alumina ceramic condylar prosthesis: comparison to Co–Cr alloy prosthesis Total knee arthroplasty with an oxidised zirconium femoral component: ten-year survivorship analysis. Excellent results with cementless total hip arthroplasty and alumina-on-alumina pairing: minimum ten-year follow-up The squeaking hip: a phenomenon of ceramic-on-ceramic total hip arthroplasty. A randomized trial of ceramic-on-ceramic bearing versus ceramic-on-crossfire-polyethylene bearing in total hip arthroplasty: five-year outcomes. Staged bilateral mobile-bearing and fixed-bearing total knee arthroplasty in the same patients: a prospective comparison of a posterior-stabilized prosthesis THA With Delta Ceramic on Ceramic: Results of a Multicenter Investigational Device Exemption Trial Comparison of surgical outcomes and implant wear between ceramic-ceramic and ceramic-polyethylene articulations in total hip arthroplasty.
Background : The Bisurface knee prosthesis was design ed in 1989 to improve knee flexion without affecting the durability of the prosthesis . The prosthesis has a unique ball- and -socket joint in the midposterior portion of the femoral and tibial components , which functions as a posterior stabilizing cam mechanism and causes femoral rollback . The femoral component was made of alumina ceramic . The purpose of this study was to review the clinical results of the first 223 arthroplasties performed with this prosthesis in order to assess whether this new implant had achieved its design objectives . Methods : From December 1989 to May 1994 , all patients who were scheduled for primary total knee arthroplasty were enrolled in a prospect i ve study of the Bisurface knee . The patients were evaluated clinical ly according to The Hospital for Special Surgery knee-rating system and with a self-administered question naire , and they were evaluated radiographically according to the system of the Knee Society . Kaplan-Meier survivorship analysis was performed with revision of the knee or recommendation for revision as the end point . Results : One hundred and sixty-six patients treated with a total of 223 consecutive primary total knee arthroplasties were enrolled in the study , and 182 knees were followed for 3.9 to 9.0 years ( mean , 5.8 years ) . Preoperatively , the mean Hospital for Special Surgery knee score was 44.5 points . At the time of latest follow-up , the mean knee score was 86.3 points . The mean preoperative and postoperative ranges of flexion were 119 and 124 degrees , respectively . The patients , even those with a good preoperative range of motion , rarely lost deep flexion of the knee after the procedure . A revision operation was performed in eight knees ( because of infection in five , instability in two , and breakage of the peg of the patellar component in one ) . Two knees had recurrent medial-lateral subluxations of the femorotibial articulation , which were treated nonoperatively . No prosthesis had loosened aseptically and no alumina ceramic femoral component had broken by the time of latest follow-up . The rate of survival of the implant was 94 percent ( 95 percent confidence interval , 90 to 98 percent ) at six years . According to the patient question naires , 20 percent of the knees sometimes felt loose in daily living activities , which prompted us to improve the intrinsic stability of the prosthesis by improving the congruity of the ball- and -socket joint . Conclusions : Total knee arthroplasty with the Bisurface prosthesis result ed in an excellent range of motion and a high level of satisfaction with the operation ; the durability of the prosthesis is promising BACKGROUND Enhanced wear resistance of ceramics in general and improved mechanical characteristics of composite ceramics in terms of strength and resistance meet the dem and s for application in TKA . The aim of this prospect i ve international multi-centre study was to evaluate the 5-year clinical and radiological outcomes of an unconstrained TKA with a composite ceramic femoral component . METHODS A total of 107 patients ( 109 knees ) underwent TKA with the MULTIGEN-PLUS Ceramic Knee at seven centres in three European countries .  Clinical and radiological assessment s were performed preoperatively and postoperatively at 3 , 12 , 24 and 60 months , using HSS , WOMAC , SF-36 and st and ardised radiographs . RESULTS Mean HSS and WOMAC increased significantly from 55.1±11.5 ( 21 - 83 ) and 48.1±16.6 ( 3 - 90 ) preoperatively to 85.6±9.6 ( 49 - 98 ) and 73.3±20.4 ( 17 - 100 ) at 60 months . Mean SF-36 showed significant improvements in patients ' quality of life ( 49.1±17.6 ( 12 - 96 ) preoperatively versus 67.7±23.1 ( 12 - 100 ) at 60 months ) . Non-progressive radiolucent lines ( < 1 mm ) were observed around the femoral component in four cases . Neither implant migration nor loosening were registered . Kaplan-Meier survivorship was 96.0 % at 60 months ( 92.1 - 100 % , CI 95 % ) . CONCLUSIONS Five-year implant survival rate of the ceramic knee is comparable to other metallic and ceramic unconstrained TKA systems . Although the assessment of long-term implant survivorship is still pending , the ceramic implants represent a promising solution for patients with allergies against metallic components and furthermore for the general osteoarthritis population due to enhanced wear resistance This prospect i ve , r and omized , multicenter study of alumina ceramic-on-alumina ceramic bearing couples includes 452 patients ( 475 hips ) . Their average age was 53 years with approximately two thirds men and 82 % with osteoarthritis . At an average 8-year follow-up , clinical results were excellent and cortical erosions significantly less than in the conventional polyethylene-on-metal bearing group . Nine hips have undergone revision of one or both components for any reason . Of the 380 ceramic liners , 2 ( 0.5 % ) have fractured requiring reoperation , and 3 ( 0.8 % ) ceramic patients reported a transient squeaking sound , one of which had a head and liner change due to groin pain secondary to psoas tendinitis at 5 years . With no revisions for aseptic loosening and minimal cortical erosions , alumina-ceramic bearing couples are performing in a manner superior to the polyethylene-on-metal bearing in this young , active patient population In a prospect i ve study , 194 knees undergoing total knee arthroplasty ( 110 knees with alumina ceramic prostheses ; 84 knees with Co – Cr alloy prostheses )  were clinical ly and radiologically evaluated . Average follow-up period was 66 months ( 36–124 months ) . Average age at the time of surgery was 66 years . In the ceramic prostheses , two revision surgeries were performed because of breakage of the tibial tray and late infection , whereas two revisions of the Co – Cr alloy prostheses were carried out due to loosening and late infection . In the other patients , there were no significant differences in clinical parameters ( HSS knee score and range of motion ) between the two prostheses . In radiological evaluation , we could not find any radiolucent lines around the femoral ceramic component while radiolucency was present in three knees ( 3.6 % ) around the Co – Cr femoral component . Beneath the tibial tray , three knees ( 2.7 % ) showed a radiolucent line around the former prosthesis while eight knees ( 9.5 % ) demonstrated a radiolucent line around the latter prosthesis . Chi-square tests showed a significant difference in the occurrence of radiolucent line around both of the femoral and tibial prosthesis . This study demonstrated that clinical results of the alumina ceramic PCL retaining total knee prosthesis are comparable to the st and ard Co – Cr alloy PCL retaining total knee prosthesis . Although we could not draw any conclusions regarding the superiority of the ceramic prosthesis with respect to UHMWPE wear and long-term survivorship , this report encouraged a long-term follow-up study on ceramic prostheses AIMS Oxidised zirconium was introduced as a material for femoral components in total knee arthroplasty ( TKA ) as an attempt to reduce polyethylene wear . However , the long-term survival of this component is not known . METHODS We performed a retrospective review of a prospect ively collected data base to assess the ten year survival and clinical and radiological outcomes of an oxidised zirconium total knee arthroplasty with the Genesis II prosthesis . The Western Ontario and McMaster Universities Osteoarthritis Index ( WOMAC ) , Knee Injury and Osteoarthritis Outcome Score ( KOOS ) and a patient satisfaction scale were used to assess outcome . RESULTS A total of 303 consecutive TKAs were performed in 278 patients with a mean age of 68 years ( 45 to 89 ) . The rate of survival ten years post-operatively as assessed using Kaplan-Meier analysis was 97 % ( 95 % confidence interval 94 to 99 ) with revision for any reason as the endpoint . There were no revisions for loosening , osteolysis or failure of the implant . There was a significant improvement in all components of the WOMAC score at final follow-up ( p < 0.001 ) . The mean individual components of the KOOS score for symptoms ( 82.4 points ; 36 to 100 ) , pain ( 87.5 points ; 6 to 100 ) , activities of daily life ( 84.9 points ; 15 to 100 ) and quality of life ( 71.4 points ; 6 to 100 ) were all at higher end of the scale . DISCUSSION This study provides further supportive evidence that the oxidised zirconium TKA gives comparable rates of survival with other implants and excellent functional outcomes ten years post-operatively . TAKE HOME MESSAGE Total knee arthroplasty with an oxidised zirconium femoral component gives comparable long-term rates of survival and functional outcomes with conventional implants Ceramic-on-ceramic coupling is thought to be a durable alternative to metal- or alumina-on-polyethylene pairing . No evidence exists suggesting superior clinical and radiological results for hydroxyapatite-coated stems versus uncoated stems . The aim of this study is to report the performance of an alumina-on-alumina bearing  cementless total hip arthroplasty and to compare stems with a tapered design with and without hydroxyapatite coating . We prospect ively analysed the results of  cementless tapered femoral stems ( 40 hydroxyapatite-coated versus 22 uncoated stems ) , a metal-backed fibre mesh hydroxyapatite-coated socket and alumina-on-alumina pairing .  Of 75 hips studied , 62 were available for follow-up ( mean of 10.5 years after surgery ) . The average Harris hip score was 90 . Only one hydroxyapatite-coated stem was revised for aseptic loosening . One instance of non-progressive osteolysis was detected around a screw of a cup . All other components showed radiographic signs of stable ingrowth .  Hydroxyapatite coating of the stem had no significant impact on the clinical or radiological results . Total hip arthroplasty with the presented implant and pairing provides a durable st and ard for all patients requiring hip joint replacement against which all newer generations of cementless implants should be judged BACKGROUND Early reports on modern  ceramic-on-ceramic total hip replacements  have demonstrated excellent clinical and radiographic results with few cases of catastrophic failure , which , in the case of earlier design s , often had been caused by implant fracture . Several reports , however , have noted the presence of audible squeaking . The purpose of the present study was to determine the incidence of squeaking in association with the use of this bearing couple . METHODS During the period from March 2003 to May 2005 , three surgeons performed 159 total hip arthroplasties in 143 patients with use of a ceramic-on-ceramic bearing . One hundred and forty-nine hips ( 131 patients ) were available for review after at least one year of follow-up . These patients were followed prospect ively with use of the modified Hospital for Special Surgery hip score and a patient-administered question naire . Additionally , a control group of sixty hips ( forty-eight patients ) with a metal-on-polyethylene bearing  was matched to the ceramic group on the basis of age , sex , and body mass index to compare the incidence of squeaking and other noises . Radiographic evaluations were performed according to previously established criteria . RESULTS Fourteen ( 10.7 % ) of 131 patients described an audible squeak during normal activities . However , squeaking was reproducible clinical ly in only four patients , and only one patient complained of squeaking before being presented with the question naire . The average Hospital for Special Surgery score improved from 19.8 preoperatively to 38.4 at the time of the latest follow-up , indicating excellent clinical results . Ninety-five percent of the patients had a satisfaction score of > or = 8 of 10 . Three hips dislocated . One of those three hips squeaked and was revised because of recurrent dislocations . One patient was considering revision because of squeaking . In the matched metal-on-polyethylene cohort , there were no cases of squeaking . CONCLUSIONS The squeaking hip is a phenomenon that is unique to total hip replacements with hard-on-hard bearings . The incidence of squeaking in association with ceramic-on-ceramic bearings may be higher than previously reported as < 1 % of the patients in the present study reported this finding before being queried . The causes and implication s of squeaking are yet to be determined . The use of hard-on-hard bearings offers many advantages in terms of wear reduction , especially for young and active patients . Nonetheless , patients considering ceramic-on-ceramic bearings should be counseled with regard to this phenomenon This study determined how ceramic-on-ceramic bearing THA affected joint-specific pain , function and stiffness in the first five postoperative years compared with ceramic-on-highly-crosslinked-polyethylene bearing THA .  Subjects less than 61 years of age were r and omized  to ceramic-on-ceramic ( CERAMIC ) [ n = 48 ] or ceramic-on-highly-crosslinked-polyethylene ( POLYETHYLENE ) [ n = 44 ] bearing THA . Subjects were assessed using the Western Ontario McMaster Osteoarthritis Index ( WOMAC ) and the R AND 12-Item Health Survey ( R AND -12 ) preoperatively , and at one and five years postoperatively . 92 subjects(50 ( 54 % ) males ; average age = 52 ( SD 6.6 ) years ) were enrolled . 78 ( 85 % ) subjects returned five years postoperatively . All subjects reported improvements at one and five years in all measured indices with no group differences detected . Seven ( 8 % ) subjects experienced postoperative THA complications , none related to bearing surfaces ; two subjects ( POLYETHYLENE ) required revision for instability . Both bearing surfaces provided excellent short-term results in younger subjects Mobile-bearing total knee arthroplasty ( TKA ) has several theoretical advantages over fixed-bearing TKA . We conducted a prospect i ve r and omized trial to compare the results of mobile-bearing and fixed-bearing posterior-stabilized TKA in the same patients using the same femoral component design of a mobile-bearing prosthesis in one knee and a fixed-bearing prosthesis in the other knee in 25 patients with osteoarthritis . The mean follow-up was 40 months . No significant differences were found in the mobile-bearing and fixed-bearing knees in terms of clinical and radiographic results . No osteolysis , loosening , or revision occurred . One knee with a mobile-bearing prosthesis had a dislocation of the rotating bearing ; however , spontaneous reduction occurred and the dislocation did not recur . Satisfactory early results can be achieved in both mobile-bearing and fixed-bearing knees . We could not demonstrate an advantage of a mobile-bearing TKA Although the published studies on the outcomes of  total hip arthroplasty (  THA ) performed with currently available ceramic components show high survivorship and low bearing wear at midterm followup , concern over ceramic fracture and squeaking persist . For these reasons , the use of ceramic is limited . Recently , a new alumina matrix composite material ( Delta ceramic ) with improved material properties was developed to address these concerns . We report the early outcomes and complications of a prospect i ve , r and omized , multicenter trial of 263 patients ( 264 hips ) at eight centers , comparing a Delta ceramic-on-ceramic ( COC ) articulation with a Delta ceramic head-crosslinked polyethylene bearing combination ( COP ) . There were 177 COC hips and 87 COP hips . Complications  were reported for all patients , whereas  clinical and radiographic results were provided for the 233 patients with minimum 2-year followup ( average , 31.2 months ; range , 21–49 months ) . The Harris hip scores and clinical , radiographic , and survivorship outcomes were similar in both groups . There were four ( 2 % ) revisions in the COC group and two ( 2 % ) in the COP group . We encountered three intraoperative ceramic liner-related events . In addition , one patient receiving the COC underwent revision for chipping of the ceramic liner , and a second had ceramic fragmentation on followup radiographs but has not undergone revision . These liner related complications remain a concern . No patient reported squeaking in either group ; this leaves us hopeful the new material will lessen the frequency of squeaking . In the short term , the Delta COC articulation provided similar functional scores and survivorship and complication rates with the ceramic head mated with crosslinked polyethylene . Level of Evidence : Level I , therapeutic study . See Guidelines for Authors for a complete description of levels of evidence The results of a prospect i ve multicenter trial comparing 357 hips r and omized to total hip arthroplasty with either ceramic-ceramic or ceramic-polyethylene couplings  are presented . No statistically significant difference in clinical outcomes scores between the ceramic-ceramic and ceramic-polyethylene groups was observed at any time interval . The mean linear rate was statistically lower ( P < .001 ) in the ceramic-ceramic group ( 30.5 μm/year ) when compared with the ceramic-polyethylene group ( 218.2 μm/year ) . The rates of ceramic implant fracture ( 2.6 % ) and audible component-related noise ( 3.1 % ) were statistically higher in the ceramic-ceramic group when compared with the ceramic-polyethylene group ( P < .05 ) . Lastly , there was no statistically significant difference in the dislocation or revision rate between the groups at the time of last clinical follow-up
Overall , there was a notable enhancement of joint function after the procedure , with a satisfactory mid- and long-term survival of the ceramic components , which is comparable to that of the conventional alloy components reported previously .
However , revision due to aseptic loosening , wear , and component fracture appeared to be rare , demonstrating the safety of in vivo use of ceramic bearings in the TKA procedure .
Conclusions Ceramic TKA implants show similar post-operative clinical results and survival rate compared to their conventional metallic counterparts .
Our results confirmed the safety of in vivo use of ceramic bearings in TKA , with rare implant breakage and aseptic loosening .
Purpose Ceramic bearings have been widely used in total hip arthroplasty ( THA ) , which result ed in satisfactory clinical outcomes due to the excellent tribological characteristics of the implants .
However , ceramic components are not commonly used in total knee arthroplasty ( TKA ) because of brittleness .
This study aim ed to gather and analyze information regarding the clinical outcomes ( including survival without revision , causes of revision , functional outcome , and incidence of loosening ) and reach a definitive conclusion about the use of ceramic femoral components in total knee arthroplasty .