CERAMIC TOTAL HIPS

What are the ceramic hips?:

The term "ceramic total hips" is sometimes used for two, widely different,
models of total hip joints.

The upper picture:

The ceramic on ceramic total hips are true ceramic total hips

They have the ceramic cup that articulates with the ceramic ball
component. Both components are made from alumina ceramic
(aluminum oxide ceramic).

GO TO CERAMIC TOTAL HIPS

____________________________

(Click on
the icon
for a full
size The lower picture:
picture)
The ceramic-on-polyethylene total hips

have a ball component made from ceramic material that articulates

against a polyethylene cup. The right term for these total hips is
"ceramic-on-polyethylene total hips".

GO TO CERAMIC ON POLYETHYLENE TOTAL HIPS

2
Why ceramic total hip?

In a ceramic total hip the ceramic ball moves inside the ceramic cup. This
bearing combination produces (in laboratory tests) the lowest quantity of wear
particles of all known combinations materials used for manufacture of total hip
joints. This is so because the modern medical grade ceramic is very hard and
scratch resistant material.

Volumes of wear particles produced by different bearing

material combinations in total hip joints. (Heisel 2003).

Bars in the diagram show the annual production of wear

particles in cubic millimeters. The metallic ball articulating
on a polyethylene cup produces 57 cubic millimeters of
polyethylene wear particles, whereas the ceramic ball
articulating on the same polyethylene cup produces only 17
(Click on the icon
cubic millimeters of such particles. The lowest rate of wear
for a full size
particles, 0,04 cubic millimeters of ceramic wear particles
picture)
annually produces the ceramic total hip.

Note that ceramic total hip produces (57/0.04)= 1425 times

less wear particles than the metal on polyethylene total hip
and (17/0.04) = 425 times less wear particles than the
ceramic on polyethylene total hip.

Moreover, laboratory studies also demonstrated that ceramic wear particles

entice less cell reaction than polyethylene or metal particles produced by other
total hip systems (Warashina 2003).

The current theory maintains that the risk of total hip joint failure is directly
dependent on the volume of wear particles produced inside the total hip joint.
The less wear particle production the less the risk of developing failure of the
total hip.

From this viewpoint, (and based on laboratory results only), the ceramic total hip
joints should have the lowest risk of loosening and failure. Look at the results of
ceramic total hips.

Because physical activity increases the production of wear particles, the ceramic
total hips should be especially suitable for young patients who are physically
active and have a long active life before them.
During their long and physically active lifespan the young patients with ceramic
total hips would produce the lowest volume of wear particles of all studied total
hip systems.

Note please, that as yet there are no long-term results of modern ceramic total
hips available to substantiate the laboratory results; this is so because the
modern ceramic total hips came into use in 1995's.

The outline of a ceramic-on-ceramic total hip joint

The modern ceramic hips have both the femoral ball and the cup components
made from medical grade alumina ceramic. (For information about the material
properties please see the chapter Ceramic for total joints)

The alumina ceramic is very hard. This fact has important consequences.

• First, the bone tissue cannot endure direct contact with the hard ceramic; thus
the ceramic cup must be enshrouded in a metallic cover (sleeve) to
prevent bone tissue from direct contact with ceramic material.
• Second, although alumina ceramic is very hard it is also very brittle if a blow
strikes against a small area of its surface. The blow at the rim of a ceramic
cup engages a very small area only and produces high stress
concentration in the material. Such blow may chip off a small piece of the
ceramic material and produce a thin fracture line. The edge of the modern
ceramic cup must be thus protected against unintentional blows.
• Third, the ceramic ball is attached to the femoral stem through a metallic
conus. This attachment produces stresses in the ball. The alumina made
ball must have a certain minimal diameter (28 millimeters) to contain these
stresses.

These conditions influence the construction of a modern ceramic total hip device.

The cup (A) of the ceramic total hip is composed of at

Picture: Outline of least two layers: The inner layer is the ceramic cup proper,
the modern also called ceramic liner, that articulates directly with the
ceramic-on-ceramic ceramic bal. The outer layer is a metallic sleeve (back-up)
 total hip joint that is in direct contact with the bone tissue of the hip
socket.
The ceramic ball (B) is fixed to the metallic femoral stem
(Click on the icon through the Morse taper. The metallic cone of the taper is
for a full size put into a hole in the ceramic ball under pressure. Such
picture) construction produces always stresses in the ceramic
material (red arrows). (For details see the chapter Morse
taper).

The ceramic cups with extra protection against impingement

The construction of some modern ceramic total hip includes arrangements that
will protect the edge of the ceramic cup against unintentional blows/strikes.
These strikes may happen during surgery, when the surgeon puts the ceramic
inlayer into its metallic back-up. Most often, however, occur these strikes during
extreme hip movements and are called "impingements". See details on
Impingement mechanism.

These modern ceramic cups are three-layered constructions. Their ceramic liner
is placed in an additional protective sleeve at the factory.

Picture:(Click on the icon for a full size picture)

The ceramic cup composed of three layers:

On the upper picture is Trident TH, Stryker model. It has

a composite ceramic liner that was preassembled at
factory ; the titanium overrides the ceramic cup's rim and
thus protects it from impingements.

Click on the icon for a You see on the photography (and on the schematic small
full size picture cross section picture below) the ceramic ball that
articulates directly with the ceramic inlay. Around the
CeramicTH_Cup.jpg ceramic inlay is firmly attached

a metallic sleeve (intermediate layer). The metallic inlay

slightly over-rides the ceramic inlay's rim and thus
protects it from blows / impingements. The ceramic cup
and the metallic sleeve are preassembled in the factory.
The surgeons obtains them as one component.
 The third layer is the metallic back-up cup that lies
outermost. At operation the surgeon attaches the free
metallic back-up in the prepared hip socket first and then
carefully puts the preassembled ceramic cup (inside its
protective slide) into the metallic back-up. It is fixed there
with a Morse taper.

The lowermost picture shows the Hedrocel TM

(Implex/Zimmer) composite ceramic cup. The ceramic
inlayer is enshrouded into a protective layer of
polyethylene. The polyethylene layer overrides the
ceramic cup's rim and thus protects it against
impingements. The assembled ceramic-polyethylene
layers are placed in a back-up made of porous metal.

The constructions with interposed polyethylene layer are

also called "sandwiched" cups. (Zimmer).

The cup models with interposed soft polyethylene layer

were developed because some surgeons feared that the
ceramic on ceramic coupling was too "rigid" ("armchair"
science probably). The sandwiched polyethylene layer
should reduce this "rigidity". Instead the polyethylene
layer proved to be a weak link (Park 2007). See later
under Complications - Fractures of sandwiched ceramic
cups.

Femoral shaft component construction

On the femoral shaft component's side, a thin neck is advantageous, because it

makes possible greater range of motion without the risk of impingement of the
neck against the rim of the cup.

Thin and thick neck- shaft components

(Click on the icon for a full size picture)
Click on
the icon
for a full To avoid impingement of the cup component's rim, the engineers had
size
picture to diminish the neck's size relative to the ball diameter:

1) the upper row pictures:

they designed a thin neck on the shaft component, as you see on the
total hip model on the left side of the picture. The shaft component of
this hip model has a thin, conically narrowing neck and a relatively
large ceramic ball (Trident TM, Stryker). The ball's diameter is 3,4
times larger than the cross-section of the neck.

The total hip model on the right half of the picture shows a total hip
model (Corail TM, DePuy) that has a relatively thick neck part which
has a cylindrical form as well. The ball's diameter is "only" 2.3 times
greater than the neck's cross-section.

2) lower row pictures:

the engineers kept the neck diameter constant and increase the ball
component's diameter instead from 28 to 40 (Furlong Biolox delta).
The range of movement increases from 123 to 150 degrees.

At operation, the surgeon places first the metallic back-up cup into the prepared
hole in the acetabulum (hip socket), blowing and pushing it in place (a method
called press-fit fixation). (For more information on this technique please visit the
chapter Cemented and cementless THP).

When the metallic back-up is sitting firmly in place, the surgeon places very
tenderly the ceramic cup with its protective sleeve into it. This is a tricky part of
operation because the rim of the ceramic may chip off during this part of surgery.
The metallic or polyethylene sleeve around the ceramic cup proper should help
to avoid damage to the rim of the delicate ceramic cup.

There are, however, also cup models where all three layers are put together by
the manufacturer. Even this manufacturing trick cannot, however, exclude
disassembly of the cup, the ceramic liner may still dislocate and fracture
(Hedrocel TM cup, Poggie 2007)

The ceramic ball has a conical bore hole that accommodates to a conical
trunnion (conus) protruding from the prosthetic shaft. The length of the hole in the
ball regulates the length of the neck of the prosthesis; the longer the hole in the
ball, the shorter will be the resulting neck of the femoral component. See also the
chapter The mechanics of Morse taper.

The surgeon thus can regulate the length of the neck and the tension of the soft
tissues around the new total hip directly during the operation.

CERAMIC TOTAL HIPS: THE RESULTS

What is a failure?

Every time the surgeon is forced to operate again on the total hip and change
one or both components of the total hip joint is a failure; the causes of the failure
may be very different, infection, dislocation, and loosening are the most frequent
ones.

The published results thus give the percentage of failures. In the following there
are these failures given as annual failure rates. This annual failure rate shows
how many percent of all ceramic total hips failed every year during the
postoperative period.

The present results:

At present, four large scientific studies are being performed in the United States
with totally more than 2000 operations with ceramic total hips enrolled. The
studies enclose Transcend and Lineage total hip (both Wright Medical
Technologies), ABC System, and Trident System (both Stryker Howmedica
Osteonics). These studies are presented on the following diagram..

Annual failure rates for ceramic total hip systems (USA study)

The horizontal line in the diagram represents the benchmark for cemented metal
on polyethylene total hip with annual failure rate of 0.5%.( the data from the
Swedish National Hip Register, Malchau)

The picture shows that the annual rate of failures of ceramic total hips in this
study varies from 0.6% (Transcend and ABC System), over 0.9% (Trident), to
1.4% (Lineage). (Data from Lusty 2007, Heisel 2003, Wright, and Stryker.).

One should note in the diagram that the cemented polyethylene-on-metal total
hip models in the Swedish National Hip Register have had the annual failure rate
of 0.5%, which is lower than all compared ceramic total hip systems. This
difference is without clinical significance

The results of sandwiched ceramic cups

Published reports of sandwiched ceramic cup show rather high failure rates of
some of these systems. See more in Complications / Fractures Sandwiched
systems.

Some authors maintain that the cause of these failures is the combination of the
"soft" polyethylene with the hard "ceramic". The soft polyethylene eventually
disintegrates and the ceramic cup loses its support. The alumina ceramic is then
exposed to excessive pressures and fails. It is the wrong construction, not the
wrong ceramic that is the culprit.

Complications of ceramic TH

There are some failures that are specific for ceramic total hips;

6A Impingement
In extreme hip joint positions, such as during too much bending, the neck of the
femoral component may strike, impinge, against the rim of the cup component.
This is called impingement of the total hip joint.

See the mechanism of impingement:

On the upper picture the patients makes the knee-to-
chest exercise, she bends forcefully the thigh against the
chest. In her ceramic total hip the neck of femoral stem
impinges against the rim of the ceramic cup.

On the lower picture you see this situation in more detail

(schematically):
Impingement of the
ceramic total hip.
The metallic collum (neck) of the femoral stem strikes
(impinges) against the rim of the ceramic cup (yellow).
Ceramic cup of this total hip model has a metallic back up Click on the icon for a
(blue) that is, however, level with the edge of the ceramic full size picture
cup. Therefore, the metallic back-up does not protect the
ceramic cup against the strike from the collum (neck) of
the stem component.

With every such extreme movement the edge of the ceramic cup receives a
blow. The chipped off ceramic cup is a weak ceramic cup. Eventually, continuing
blows / impingements fracture the cup which splinters into many fragments.

Do never such extreme movements and exercises!

The risk of impingement increases with faulty position of the cup, with the
extreme movement in the hip, with some constructions of total hips (with the
"thickness" of the neck).

There are thus some ways how to diminish the risk of impingement:

One is more precise placement of the cup during the surgery. Recent reports
demonstrate that use of computer navigated insertion of components reduces the
risk of faulty position of the cup and diminishes the risk of impingement (Sugano
2007).

The second is patient's awareness of risks of extreme movements in the ceramic

total hips. There are computer programs that construct the range of movements
from x-ray pictures. These programs then demonstrate which hip movements
produce danger of impingement. After such analysis the surgeon may may warn
and instruct the patient which hip movements to avoid. (Toni 2006).

6B

Fracture of ceramic components.

This is the complication that still scares both patients and surgeons from the use
of ceramic total hips. For history of this complication see the chapter History of

Fractures of modern ceramic balls

are very rare. That is so because the modern medical
grade ceramic has very fine structure , is produced by
a special HIP procedure (see the chapter Ceramic
material), and is individually tested before use with
weights 60 times greater than the patient body weight
(60 times 77 kg). This process produces very reliable
Picture of fractured ceramic ball components. The reported fracture rate of
ceramic ball modern ceramic balls is exceedingly small: 0.004% or
(From Greenwald 2001) 4 in 100 000. (Heisel 2003).

Even in modern times the fracture of the ceramic ball is

a serious complication. For details why read the
chapter Ceramic Ball Fracture.

Ceramic total joints.

 Ceramic Liner fractures

Picture of in sandwiched total hip systems occur relatively often. The

fractured ceramic three last reports demonstrated 1.1% (4/357) (Park 2006);
liner inside its 5.7% (2/35) (Hasegava 2006); and (4.4%) (Poggie 2007) of
polyethylene such fractures, respectively.
protective sleeve.
(From Park
2006) The fracture often starts as a failure of the binding between
polyethylene sleeve and ceramic liner which is caused by
impingement of the neck against the rim of the liner.

Early diagnosis of ceramic cup /ceramic liner fracture

Ceramic liner fractures may present from the beginning as hair-fine fracture lines.
These fractures are often caused by repeated small traumas (impingement) and
the right diagnosis is often made too late. In rare cases, one can see small
fragments of ceramic on x-ray picture. Another sign are noises from the hip
during walking. Only when the whole liner eventually splinters (upper picture) the
patient perceives pain.

If the surgeon has suspicion of ceramic liner fracture he /she may take the joint
fluid from the ceramic hip for analysis of small ceramic particles. If the joint fluid
contains greater quantity of ceramic particles revision operation should be
considered (Toni 2006).

Loosening of ceramic components

has been reported for 0.5% of components in the Lineage System.

Postoperative infection of ceramic hips

has been reported for 0.7% of operations with ceramic total hips in the USA
study. This rate is like the rates of postoperative infection observed in operations
with other total hip systems.

Dislocation of ceramic hips

Has been reported for 2.4% of ABC systems and for 1% of the Transcend and
Lineage systems. The rates of dislocations for other total hip systems varies from
0 up to 7%, so that the dislocation rates of ceramic hips are not specially low, but
not exceptionally high either.

Possible concerns with ceramic total hips

8A

Noises from ceramic total hips

Many patients feel clicking or squeaking noises in their new total hips. Usually,
these sounds are not followed by pain. These sounds usually occur when the
patient changes the position in the hip joint. They may irritate the patient.
According to some investigators the squeaking noises occur more often in
patients with ceramic total hips. (see Stryker website)

The surgeons have two explanations for this sound phenomenon:

First, The clicking noises may be caused by a tendon or scar tissue streak that
glides over the protruding portion of the new total hip joint. When you can put
your hand (or the surgeon can do it) over the jerking tendon or scar tissue the
diagnosis is clear, otherwise it is only a conjecture. When these clickings cause
no pain or other problems you should not br bothered.

Second, the clicking noises may be caused by very small "pistoning"

movements of the ball components in the polyethylene cup. The patients
sometimes also feel small jerks in the total hip with change of the position.

X-ray studies of patients with total hip joints demonstrated that the ball
component separates from the center of the cup component during gait.

When the operated on leg swings out during the gait cycle (the hip is not loaded)
the ball component moves out of the centre of the cup and comes in contact with
the rim of the cup. The ball separates from the cup.

When the leg then comes back in contact with the floor (the leg takes the body's
weight) the ball returns to the close contact with the whole cup. The body weight
presses the ball in the centre of the cup.

Thus, during the gait cycle the ball component moves from the center of the cup
to the outside of the cup and then backs to the centre again like a piston. The
"pistoning" movements are small, between 0.8 to 5 millimeters. Studies showed
that these "pistoning" movements occur in total hips where the metallic ball
articulates with polyethylene cup (Dennis 2001) and in total hips with ceramic
bearing surfaces. The "pistoning" movements were not observed in metal on
metal total hips (Komistek 2002).

Left side: During stance phase when the

Picture: "Pistoning" (piston-like)
movements of the ball
component
operated leg is in contact with the floor, the
ball component is in close contact with the
inside of the cup component. The body weight
pushed the ball into the centre of the ball.
Right side: during the swing phase of the gait,
when the leg is swinging in the air, the total
hip is not loaded with the body weight. The
ball component moves out of the centre of the
cup and comes in contact with the peripheral
rim side of the polyethylene cup component.
The tonus (springiness) of the muscles around
the hip pushes the ball upward. The ball is in
contact with only the rim of the cup.

Click on the icon for a full size
picture
When the patient then tramps with full weight
on the limb, the ball glides forcibly back to the
centre of the cup. Thus, the ball makes piston-
like movements out of and back into the
centre of the cup during gait.

The pressure during this movements is

concentrated to a small area of the cup and
the wear in this area increases. The surgeons
speak about "stripe wear". The patients may
feel "pistoning" movements and hear clicking
sounds.
The clicking, pistoning movements may be more pronounced during rising from
the chair or negotiating stairs.

It is important to realize that these piston-like movements are very small, only
about some millimeters, although the patients feels / hears them very distinctly.

Simulation of the "pistoning" motion of the ball inside the cup in laboratory
produced loud squeaking noises. (Stewart 2003)

What is the practical importance of this small pistoning movement?

Studies demonstrated that these noises from ceramic total hips are associated
with faulty position of the ceramic cup (Walter 2007)

Stripe wear

Stripe wear is the term used to describe the long, rather narrow area of wear
damage seen on some femoral balls retrieved from alumina ceramic-on-ceramic
hip-bearing couples. This unusual shape of the damage is the result of line
contact between the head and the edge of the liner. Stripe wear has been
reported in first- and second-generation alumina bearings and has been
associated with steep cup component position in young patients. Again, the
problem lies in the faulty position of the cup, not in the ceramic itself.

This picture shows the ceramic ball removed because of

osteolysis from a patient with ceramic-on-ceramic total hip. The
violet color was first smeared on the whole ball and the excess
was then wiped out. The color stayed fixed only to the area of
stripe wear, marked with blue arrows.
Click on the icon for The black lines (white arrow) are titanium metal transferred
a full size picture from cup's metallic sleeve during operation. ( During the
removal of the ball out from the cup the surgeon scratched it on
the sleeve's cup).

It was hoped that with improved material properties of the ceramic and better
operation technique the edge loading wear of the ceramic could be prevented.
However, recent reports of stripe wear in the third-generation alumina ceramic-
on-ceramic bearings with well fixed and well positioned acetabular components
suggest that another phenomenon is occurring, and this led to a second theory
for the cause of the stripe wear.

Researchers have proposed that micro-separation of the bearing centers occurs

during the swing phase of normal walking and that the subsequent edge loading
with heel strike causes the stripe]. Studies on patients using video fluoroscopy
have shown that pistoning (or microseparation) of hip bearings can occur during
walking gait and cause stripe wear. See also the chapter Life with a TH / sounds

The real importance of this special form of wear that may occur in up to 50% of
all ceramic components is unknown at present (Walter 2004).

Bad results of revision operations of failed fractured ceramic total hips

Although rare, the revision operation for a fractured ceramic component carries a
high risk of failure. The splintered fragments of the ceramic device are hard and
sharp. If left in the wound these fragments would act as a grinding paste and
would quickly grind down and destroy the new total hip. Revision operation for a
fractured ceramic component is thus difficult, because the surgeon must remove
carefully not only all visible splinters of the fractured ceramic component but also
all soft tissues together with the rest of the total joint component. This is a major
surgery and the failure rate of these operations has been up to 31% (Allain
2003).

_____________________________________________________

References:

Dennis DA et al. J Biomech 2001; 34: 623-29

Komistek L et al.: J Bone Joint Surg Am 2002; 84-A: 1836 -41

Lombardi AV et al. J Arthroplasty 2000; 15: 702- 9

Stewart TD et al. J Arthroplasty 2003; 18: 726 – 34

Stryker: www.stryker.com/orthopaedics/sites/trident/healthcare/ceramictech.php
Walter WL et al.: J Arthroplasty 2004, 19: 402-13

Walter WL, et al.: Squeaking in Ceramic-on-Ceramic Hips The Importance of

Acetabular Component Orientation. J Arthroplasty. 2007 Jun;22:496-
503 Revised August 2007

CERAMIC BALL COMBINED WITH POLYETHYLENE CUP

In this total hip system the ceramic ball component articulates against the
conventional polyethylene cup component.

Ceramic balls produce 2 - 3 times less wear particles when articulating against
polyethylene cup than a metallic ball. (See Diagram)

Three sorts of ceramic are used for manufacture of these ceramic balls

alumina ceramic,

zirconia ceramic,

oxidized zirconium metal (Oxinium TM).

Total hip systems with balls made out of alumina:

Have been in use since 1970’s. The long-term results, published recently, with
such old ceramic total hips operated on with old cementing techniques still
demonstrate the annual failure rates of 1% only (Urban 2001).

The modern polyethylene on ceramic systems show one of the lowest annual
failure rates. A multi-centre study conducted by Austrian surgeons on 800
patients operated on with the Alloclassic cementless total hip system and
followed for seven years demonstrated an annual failure rate of only 0.21%!

See also the chapter Ceramic for total joints

7B

Total hip systems with balls made out of zirconia ceramic.

Zirconia is a high-strength ceramics suitable for medical use, two to three times
stronger than alumina. It also produces less wear particles when it articulates
against polyethylene in a total hip system (in laboratory tests). See the Zirconia
ball picture

Zirconia ceramic balls were introduced into use in 1985 in Europe and approved
by the FDA in the USA in 1989.

Unfortunately, the crystal formation of zirconia ceramic is unstable and must be

stabilized with another ceramic –yttrium oxide. See the chapter Ceramic for total
joints

The published results of total hip systems with zirconia balls are an enigma.

Despite the fact that zirconia ceramic balls were in use eighteen years and more
than 400 000 were sold by only one of the many manufacturers, there exist only
two clinical studies showing good results with total hip systems with zirconia
balls; the rest of the reports shows bad results with zirconia ceramic in these hip
systems (Clarke 2003).

The statement from Smith & Nephew is revealing:

"Although ceramic total hip systems may extend the life of hip implants by
reducing the wear, a major recall of ceramic ball components by the French
manufacturer Saint-Gobain Desmarquest in 2001 reinforced surgeon concerns
that some ceramic implants may be prone to fracture inside patients. As a result,
only ten-percent of (total hip) procedures now involve the use of ceramic
implants."

7A

Oxinium - Total hip systems with balls made out of oxidized zirconium
metal.

Zirconium metal is biocompatible and strong enough to be used for manufacture

of ball components. One manufacturer exploited this fact for production of a ball
component made from Zirconia metal (actually an alloy of Zirconia and Yttrium).

In a special process the surface of the ball is then oxidized. This process creates
a thin layer of zirconia ceramic on the surface of the Zirconia ball. See more in
the chapter Ceramics for total hips).

This product thus should have the smoothness and low

wear characteristics of zirconia ceramic, whereas the ball
itself would not be not brittle because it is made from metal.
Thus, this ball will not be at risk for a fracture. The Smith &
Nephew Company introduced recently the oxidized
zirconium ball on the market under the name of Oxinium
total hip system (http://www.strongasanox.com).
Note that the oxidized Zirconium femoral ball is black and
articulates with polyethylene cup.

Oxinium total hip Note also that the cup component is placed in a metallic
Click on the icon for sleeve. This sleeve is made from cobalt chrome. Cobalt
a full size picture chrome alloy is twice as hard as the "soft" zirconium alloy
from which is made the ball component.Under normal
circumstances these two metals do not come in contact
and thus the hardness discrepancy is not a problem.

If the hip would dislocate, the soft Oxinium head would

come in contact with twice as hard metallic back up of the
cup This would lead to problems. See under
Complications.

At a hip dislocation, the Oxinium cup comes into contact with the metallic rim of
the sleeve of the cup: The harder metal of the sleeve produces deep scratches
on the surface of the softer ball. The cup component made from the soft
polyethylene then articulates with the rasping surface of the damaged Oxinium
ball. The scratches on the hard ball surface are effective in destructing the very
soft (in comparison) polyethylene cup.

Dislocated Oxinium TM ball

A - x-ray picture of the dislocated Oxinium ball that is in

contact with the metallic sleeve on the outside of the cup.
The contours of the Oxinium ball and the metallic back -up
are artificially blue.

Only the metallic sleeve is x-ray opaque and is depicted,

the soft polyethylene cup is not seen.
Damage of the
dislocated
OxiniumTM ball. B - the deep scratches on the surface of the dislocated
Click on the icon for Oxinium ball. This ball is depicted on the upper x-ray
a full size picture picture.

The ball was removed at subsequent surgery.

( Both pictures from Evangelista 2007)

C- the Oxinium cup with intact surface layer of black

zirconium oxide for comparison. (Smith&Nephew)

Thus, for patients with dislocated Oxinium total hip the surgeon must open the
total hip, remove and replace the scratched ball with all risks and problems that
follow such a revision operation. (Evangelista 2007)

Dislocation of a total hip is in the majority of patients with other total hip systems
usually managed by reposition on the emergency room without need of an
operation. For patients with Oxinium TM total hip the dislocation becomes a
serious problem needing an extended surgery with all possible risks. Because of
this risk some surgeons now say that they will not use the Oxinium total hip until
this problem is solved.

Hardening of the total joint surfaces by diffusion of gases is nothing new in the
history of total joints. Nitrogen diffusion was once used for hardening of titanium
made ball components; the laboratory results were splendid, the clinical results
were a fiasco.

Reference: Evangelista GT et al.: Surface damage to an Oxinium femoral head...

J Bone Joint Surg-Br 2007; 89-B: 535 - 7.

Ceramic ball articulating with metallic cup

Such total hip joints are under clinical testing by a team from DePuy
manufacturer and the University of Leeds, England, headed by professor John
Fischer from Leeds.