Download PDF, 2.4 MB - CeramTec

CeraNewsThe Orthopaedic Landscape Information JournalIssue 1/2012Ceramics in OrthopaedicsEditorial 2Focus on Quality AssuranceInterview with Klaus-Peter Günther, MD, PhD 2ScienceWhat’s New in Hip Arthroplasty? 5ScienceWhat’s New in Total Knee Arthroplasty? 7New Model of Quality Assurancein GermanyInterview with Wolfram Mittelmeier, MD, PhD 8Klaus-Peter Günther, MD, PhDEuropean Highlights12 th EFORT Congress 2011 10Chinese Highlights6 th International Congress of the Chinese 21Orthopaedic Association 2011AwardHeinz Mittelmeier Research Award 2011 for Hip Revision 24Call for Papers – 2012 25A Perfect MatchBIOLOX ® Symposium and CCJR meet in Las Vegas 26Update in TribologyA book review by Miquel Pons, MD 28

EditorialInterviewFocus on QualityAssuranceCeraNews 1/2012Dear Reader,Dieter Burkhardt,Director Salesand MarketingJoint Registry data summarize important and neutralfindings about the success rates of THA andTKA. Even though we keep seeing many countrieswithout a registry, there are several initiatives to setup regional registries.After many years of discussion, the German arthroplastyregistry will finally be set up in 2012. It is animportant, but by no means the only initiative aimedat making arthroplasty even better and safer. Thisis because, in view of the constantly rising numbersof cases, we cannot be satisfied even with successrates way above 90 percent. The small remainingpercentage of problem cases means that a sizeablenumber of patients are affected here and now.Reducing this number is the most important goalof all our efforts to achieve even higher quality andimplant safety. It means we must look at the complexprocess of arthroplasty as a whole. The trainingof surgeons and surgical personnel plays a crucialrole here. The Arbeitsgemeinschaft Endoprothetik(Arthroplasty Association, AE) has developed andput into practice a number of exemplary concepts inthis area. AE chairman Klaus-Peter Günther explainswhat this involves – among other things – in theinterview opposite.These initiatives have one thing in common: theyare based on the close and trusting collaboration ofdoctors and implant industry. The highest possiblequality of arthroplasty is our common concern."Sharing of the best practice": This is the mottoof the 14 th BIOLOX ® symposium – Bearing SurfaceOptions in Total Joint Replacement – The Expertsprovide the Evidence. This one and half-day eventsponsored by CeramTec is being held in conjunctionwith the Current Concepts in Joint Replacement(CCJR) – Spring meeting at the ARIA at City-Center in Las Vegas, Nevada, USA, May 19–20.The opportunity to attend both events will realize aunique learning experience. I’m looking forward towelcome you in Las Vergas.Sincerely yours,Dieter Burkhardt* AE – www.ae-germany.comKlaus-Peter Günther, MD, PhD, holds theChair for Orthopaedics in the Carl GustavCarus Medical School at Dresden TechnicalUniversity and is Medical Director of theOrthopaedic Clinic and Outpatient Centerat the University Hospital. As Chairmanof the Portal Steering Committee, he is amember of the EFORT Executive Committee.Since 2011, he has been President ofthe German Arbeitsgemeinschaft Endoprothetik(Arthroplasty Asso ciation, AE) * . Hisscientific work focuses on issues relatedto clinical efficiency and quality.Recent media coverage gives the impression thatarthroplasty is a field dominated by problems. Whatcould have given rise to such a lopsided public perception?Expectations have been raised which cannot alwaysbe met. For example, in their marketing, someimplant manufacturers give unrealistic depictionsof what postoperative activities will be possible.Surgeons in Germany are also confronted with acompetitive environment and some try to positionthemselves with "major successes" from procedureswhich have only recently been introduced. Finally,many patients tend to have unrealistic expectations.They assume that there are procedures whichpermit unlimited demands to be placed on theimplants with maximum safety and a minimal risk.However, even with the most cautious approach,the risk of an early revision after arthroplasty is 2to 4%. Another factor is the media, which occasionallyseize on isolated cases with poor outcomesand depict them in a sensationalist manner. Becausethere is no completely safe procedure in medicine,undue expectations turn the overall great successof arthroplasty into something quite the opposite inthe eyes of the public.Let's take a look at professional training. Does it doenough in its current form to keep arthroplasty at ahigh level and further reduce the incidence of complications?Germany does have regulations for specialty trainingas part of the continuing medical education,thanks to which we have a robust process andadequate general conditions, such as those stipulatingthe number of surgeries which a prospectivespecialist must have performed as a prerequisite forformal qualification as an orthopaedic and traumasurgeon. However, more and more hospitals are2

What is is the motive behind the latter?Klaus-Peter Günther,MD, PhDBoth physicians and industry must learn how tohandle incidents effectively. The aviation industry,for example, is somewhat ahead of us in thisrespect. They regard the incident primarily as anopportunity to improve the process. In the field ofarthroplasty, joint initiatives have been launched bymanufacturers, scientists, and surgeons. It is, afterall, essential for incidents to be recorded in a systematicmanner, which is why standardized requirementsare necessary. Physicians are often unsurehow to handle implant retrievals. While there arelegal requirements, physicians are often not sufficientlyaware of them.pulling out of advanced training because they donot get paid for it. As a result, something which issensibly regulated in theory is getting ever more difficultto implement in practice.How do you see the situation with regard to continuingeducation itself?The problem is ensuring consistently high qualityand creating appropriate general conditions. Weshould bear in mind that colleagues performingarthroplasties have to meet certain conditions. Itshould be ensured that they are constantly undergoingcontinuing education and that this is monitoredregularly. That is also the goal of the EndoCert initiative** for the establishment of certified arthroplastycenters. It would be a condition of certification thatthe clinic conducts continuing medical educationbased on structured plans and that its staff demonstrablymake regular use of the continuing medicaleducation offerings.Continuing medical education of this type is offeredin German-speaking countries by the AE, of whichyou are President. What is the goal?The primary goal of the AE is to ensure high qualitytraining and continuing medical education inthe field of arthroplasty. For this purpose, it offersa structured system of courses for physicians andoperating room personnel. In so doing, the AEdiffers significantly from other specialist societieswhich generally either focus on a single joint, suchas the hip societies, or on specific procedures, suchas the societies for arthroscopy. Our scope extendsfrom joint preserving procedures to complex revision,and includes all joints. Our other quality assuranceactivities include involvement in the Germanarthroplasty registry and EndoCert, as well as ourown initiative aimed at optimizing failure analysis.Should surgeons be obligated to undergo implantspecifictraining, the key idea being "no train, nouse"?A new product should only be used if physiciansand OR personnel have received the applicabletraining. This is a clear criterion for certificationunder the EndoCert initiative we talked aboutpreviously.What role can an arthroplasty registry play?Arthroplasty registries are of no help when analyzingindividual incidents. However, they can provideearly indications of the failure of one or more contributingfactors – e.g., a faulty implant or an applicationmistake – if problems occur frequently. Fortunately,an arthroplasty registry is now also beingestablished in Germany.What is your experience with the increasing timepressure in the German healthcare system, aboutwhich physicians are complaining? Does this haveany impacts on clinical practice?There is already a high degree of time pressureassociated with the introduction of new implants,not only from the manufacturer, but also on thepart of physicians. While the introduction of newimplants satisfies formal conditions, I would like tosee a stepwise process required for substantiallychanged or novel implants. This should start withtesting in selected arthroplasty centers, and onlythereafter should the implants be released for themarket. Outside the field of arthroplasty, we arealso facing increasing problems, with significantlyhigher strain on everyone involved to find the timefor the necessary internal and external continuingmedical education programs.** EndoCert – See also interview withMittelmeier, MD, PhD, on page 8CeraNews 1/20123

Interview (continued)What are the reasons?Increasing time pressure is an international problem,but in terms of its particularly acute nature itis typically German . With service-based funding forsurgical procedures in general, but to a particularlylarge extent in the field of arthroplasty, there isincreasing pressure to obtain funding based on casenumbers. Thus, Germany has seen an increase incase numbers since the introduction of the DRGs *** .In countries with other funding systems, such asScandinavia, which adopt a more general societybasedapproach, time pressure and case numbersare significantly lower. In addition to the demandsof growing output, job profiles are changing in Germany,leading to an increasing administrative overloadfor physicians. This brings us back to adequatecontinuing medical education: while this should bepart of the working day, experience shows us thatit is by necessity taking place increasingly outsidework hours.How could this problem be solved?In my opinion, in addition to attending conferencesand courses, e-learning is increasingly playinga significant role. It allows quick access toinformation about techniques during work hoursand provides an opportunity to assure oneself ofcertain processes before performing surgical procedures.E-learning should provide information whichis quick to retrieve, succinct, and valid, as well asproviding an opportunity for personnel to devotetheir attention to medical science information ata time of their choosing. The only disadvantage isthe lack of personal interaction. For me, the idealcontinuing medical education and advanced trainingin the future will combine practical exercises incourses which feature personal interaction with aninformation tool based primarily on e-learning. Bothin EFORT and the AE, we are working on new conceptslike this for communicating knowledge.Does time pressure also have an impact on surgicalprocedures or the choice of implants?Of course. For example, time savings also played arole in the introduction of less invasive procedures.However, I think that is legitimate. For any procedure,it makes sense to consider how the totalexpense can be reduced for everyone involved. Optimizingprocedures includes improving the complicationprofile, simplifying use, and increasing safety.Otherwise, we will not be able in future to satisfythe upturn in demand for arthroplasty resultingfrom an increasingly ageing society. The problem isthat we are frittering away the advantage by startingoff a vicious cycle: our payment system is forcingus to use time-saving procedures to generate highercase numbers in order to keep financial returns ata given level. This leads to workflows being consolidatedwithout there being any discernible positivechange in terms of the time factor.Doesn't that influence quality sooner or later?In principle, streamlined processes and quality donot need to be mutually exclusive. We know fromindustrial production that a high degree of standardizationsimultaneously increases quality and efficiency.That is also our goal in certifying arthroplastycenters. However, if surgeons attempt on monetarygrounds to perform more arthroplasty proceduresin the time available without optimizing their processes,they will run the risk of losing quality. Allfactors should be viewed as related: improving quality,achieving greater standardization, utilizing clinicalpathways, optimizing workflows, and shorteningtreatment times and rehabilitation. It will onlywork as a whole process.*** DRGs – Diagnosis Related GroupsCeraNews 1/20124

ScienceWhat’s New in Hip Arthroplasty?Advantages and long-term results of CoC THAExperts discussed clinical outcomes of CoC THA at the SICOT, ISTA, SOFCOTand SIOT congresses 2011.Laurent Sedel (France) reported on advantages of ceramic bearings and hisclinical results of alumina CoC THA with an overall survivorship of 88% at 20years. Ceramic bearings have demonstrated the lowest in-vivo wear rates todate of any bearing combination. They have an excellent biocompatibility, abetter wettability and a greater hardness than metal.The advantages of ceramic-on-ceramic are great. This coupledoes not present any biological adverse effects, no allergicresponse, no elevation of chromium or cobalt in the blood andno problems regarding pregnancy or renal insufficiency.10-year results with CoC THA- Laurent Sedel, MDIn: Researchers tout the advantages of ceramic-on-ceramic hip bearings.ORTHOSuperSite; http://www.orthosupersite.com/view.aspx?rid=90278Delta ceramic has especially gained increasing use asimprovement of the ceramic material allows larger femoralheads and reduces the risk of ceramic fracture dramatically.Prof. Sedel’s data are stimulating the use of this hard-on-hardbearing articulation, which is now accepted worldwide asmaterial with optimal wear characteristics to achieve excellentlong-term clinical results.- Karl Knahr, MDIn: Researchers tout the advantages of ceramic-on-ceramic hip bearings. Perspective.ORTHOSuperSite; http://www.orthosupersite.com/view.aspx?rid=902786–11-year results with CoC THAJérôme Essig et al. (France) reported on clinical andradiographic results of 232 consecutive cementlessalumina CoC THA (BIOLOX ® forte) in 224 patients.The mean age was 58 (22–78) years. A 28mm femoralball head was used in 99% of all cases. Indicationswere osteoarthritis (81%) and osteonecrosis(13%). The mean follow-up was 9.2 (6–11) years.Squeaking was noted in 16 patients (6%) and disappearedin 10 patients. 6 hips were revised. Patientshad to be revised for septic loosening (4), periprostheticfracture (4) and dislocation (1). Ceramic fractureswere not observed. No acetabular or femoralosteolysis could be detected at the latest follow-up.The survival rate was 96.6% at 10 year follow-up,revision for any reason taken as endpoint.This series shows that alumina CoC THA in youngand active patients avoids the risk of osteolysis andimproves implant longevity, the authors concluded.3-year results with larger CoC THASuk Kyu Choo et al. (Korea) evaluated clinical andradiographic results of 43 CoC THA (BIOLOX ® forte,BIOLOX ® delta) in 40 patients. The average age was56 (28–82) years. The indication was osteonecrosisin 21 cases. A 36mm femoral ball head was used.The minimum follow-up was 3 years. Squeaking wasobserved in 3 patients. The authors reported that 1patient had a dislocation after an accident one weekafter surgery. There was no ceramic fracture.No osteolysis or aseptic loosening could be observedat the latest follow-up.Cementless CoC THA – More stabilitywith screws?Simon Tilley et al. (Australia) evaluated the clinical and radiographic outcomeof 120 consecutive alumina CoC THA (BIOLOX ® forte) in 110 patients. Theaverage age was 45 (20–55) years. 4 patients died and 6 were lost to followup.There were no postoperative ceramic fractures. There was an intraoperativeceramic liner chipping in 1 case. The authors reported that the liner waschanged without any complication. Squeaking was reported in 2 cases.No acetabular or femoral osteolysis could be observed at the latest follow-up.Wear rates were undetectable. The survival rate was 97.5% at 10 year followup,revision for any reason taken as endpoint.Alumina ceramic-on-ceramic bearings in cementless primaryTHA in this series have resulted in good clinical and radiographicoutcomes with low wear rates and excellent function in thedemanding younger patient group at 10 years.* Jäger M et al. Migration pattern of press fit cups in the presence of stabilizing screws.Abstract F 240, EFORT, Madrid, 2–5 June 2010- Simon Tilley, MDIn the 2/2010 issue of CeraNews we reportedon findings of a prospective study by a Germanresearch group * confirming that the stabilityof pressfit cups is not enhanced by the use ofscrews.Now, Christophe Chevillotte et al. (France) presented10-year results of 51 CoC THA without screwfixation and 49 CoC THA with the use of screwfixation. The aim of this retrospective study was toevaluate acetabular implant migration, osteolysis,radiolucent lines and ossifications in order to answerthe question whether screws are useful for the fixationof the acetabular component in cementless primaryCoC THA. Patient demography and implantsizes were comparable. The clinical and radiographicresults in this series did not show any superiority ofthe screw fixation of pressfit cups (p>0.05).The authors concluded that a ceramic-on-ceramicbearing can be used reliably with a pressfit fixationwithout additional screws.CeraNews 1/20125

What’s New in Total Knee Arthroplasty?Metal hypersensitivity in patients with TKADomenico Tigani et al. (Italy) evaluated the prevalence of hypersensitivityto metals in patients with TKA in a retrospective case control study. Theycompared the results of 20 individuals with no implants, 27 patients with astable TKA and 47 patients with a failed TKA. The prevalence of positive patchtesting was significantly higher in patients with TKA. No differences wereobserved between patients with stable or failed TKA. The authors reportedthat 15% of the individuals with no implants showed a positive patch testingfor at least one metal. Patients with a stable TKA showed a higher prevalenceof positive patch testing for vanadium compared to individuals with noimplants. The authors reported that these findings confirm a higher prevalenceof positive patch testing in patients with TKA compared to the normalpopulation. They pointed out that the presence of symptoms of metalhypersensitivity in patients before surgery should be taken into account as apotential risk factor for TKA failure.The authors concluded that ceramics may be a solution for such patients.Ceramics therefore may be a solution for patients withallergies to implant materials and may have an improvedresistance to wear, followed by reduced aseptic looseningrates.- Domenico Tigani, MD1-year minimum results with a ceramicfemoral componentAlso Francesco Benazzo et al. (Italy) reported onclinical and radiographic outcomes of TKA with theBIOLOX ® delta femoral component * . 110 TKA wereperformed in 108 patients (81 females, 29 males)with an average age of 67.7 ± 5.9 years in 7 Europeancentres. The minimum follow-up was 12 months. Thefunctional scores improved significantly compared tothe situation before surgery. No implant-related complicationsor failures were observed.The authors concluded that these short-term clinicaland radiographic outcomes in the use of theBIOLOX ® delta femoral component in TKA are verypromising.The introduction of alternative materials,as ceramic, is important because it allowsthe reduction of polyethylene wear … andrepresents a solution for the growing problemof metals hypersensitivity.- Francesco Benazzo, MD1-year results with a ceramic femoral componentMario Manili et al. (Italy) evaluated the PE wear in cemented TKA with aBIOLOX ® delta femoral component * . Between 2007 and 2010, 10 patientsreceived this implant. The average follow-up was 12 months. All patientsshowed an increase of the functional scores. No radiolucent lines were observedat the interfaces (ceramic-cement, cement-bone). The CT analysis showed nosigns of scratches or gaps in the PE. There were no implant-related complicationsor revisions.The radiographic and CT results in this short follow-up period demonstratedthat cemented TKA with a BIOLOX ® delta femoral component * constitute anexcellent solution to wear problems, the authors concluded.Intraoperative view of the BIOLOX ® delta femoral component * .Source: With kind permission of Francesco Benazzo, MD, ClinicaOrthopedica e Traumatologica, Università degli Studi di Pavia FoundazioneIRCCS, Policlinico San Matteo (Italy)References:Benazzo F et al. Preliminary results of a ceramic femoral component in total knee arthroplasty. J Orthopaed Traumatol 2011,12(Suppl 1):S137Carfagni A et al. Large diameter metal-on-metal in total hip replacement: are there indications for this type of implant yet? J Orthopaed Traumatol 2011,12(Suppl 1):S107–108Choo SK et al. Short Term Result of 36mm Femoral Head Ceramic on Ceramic Total Hip Athroplasty. Poster 34, ISTA, 24 th Annual Congress, Bruges (Belgium), 20–23 September 2011Chevillotte C et al. Usefulness of fixation screws for press-fit ceramic-on-ceramic bearings: retrospective analysis at 10 years. Abstract 275, SOFCOT, Paris, 5–10 November 2011Essig J et al. Alumina ceramic bearing for total hip arthroplasty: a consecutive series with nine years minimum follow-up. Abstract 274, SOFCOT, Paris, 5–10 November 2011Klingenstein G et al. Long-Term Survivorship and Wear Rates of Ceramic and Metal Femoral Heads on Conventional Polyethylene in Young Patients: A Matched Pair Analysis. Abstract 620, ISTA,24 th Annual Congress, Bruges (Belgium), 20–23 September 2011Manili M et al. CT evaluation of polyethylene wear in total knee arthroplasty with a ceramic femoral component. J Orthopaed Traumatol 2011,12(Suppl 1):S120Olmeda A et al. Ceramic-on-ceramic bipolar head in partial hip replacement: a mid-term experience. J Orthopaed Traumatol 2011,12(Suppl 1):S154–S155Tigani D et al. Metal hypersensitivity in patients with total knee arthroplasty. J Orthopaed Traumatol 2011,12(Suppl 1):S127Tilley S et al. Third Generation Alumina-on-Alumina Ceramic Bearings in Cementless Total Hip Arthroplasty in Patients 55 Years and Younger: A 10 Year Follow-Up. Poster 282, ISTA, 24 th AnnualCongress, Bruges (Belgium), 20–23 September 2011Further references:Olmeda A et al. Preliminary Experience with Ceramic Biarticular Cups. In:Cobb JP (ed.).Modern Trends in THA Bearings. Springer-Verlag Berlin, Heidelberg 2010:221–225* Multigen Plus Total Knee System (Lima Corporate)CeraNews 1/20127

InterviewSetting far-reaching quality standardsGermany could soon have new quality assurance steps aimedat providers of joint replacement. In addition to the arthroplastyregistry, a tool used for the continuous monitoring of the qualityof outcomes, EndoCert, the certification program of the specialistsocieties for orthopaedic surgery, is aimed at establishing anotherpillar in quality assurance.The EndoCert process could be used to ensure certified processand structural quality for arthroplasty centers. In this respect,it is the declared goal of the specialist societies to promote thecertification of arthroplasty centers on a voluntary basis withan established quality standard and thus to achieve further improvementin patient care. This will involve analyzing the entirecare process, defining the qualifications for users and structuralquality for medical institutions, and following tried and testedstandards.Wolfram Mittelmeier, MD,PhD, is the Director of theOrtho paedic Clinic and OutpatientCenter at RostockUniversity as well as beingPresident of the GermanSociety for Orthopaedicsand Orthopaedic Surgery(DGOOC) for 2012 and ofthe German Society forOrtho paedics and TraumaSurgery (DGOU) for 2012.CeraNews 1/2012CeraNews spoke with Wolfram Mittelmeier, MD, PhD, President of theDGOOC and the DGOU for 2012, and one of the founders of the initiative,about his goals for the coming year and his ideas on quality assurancewithin the field.What are your goals for your term as president?The central theme on which we want to focus in conjunction with my colleaguesChristoph Josten, MD, PhD (German Society of Traumatology, DGU),and Andreas Gassen, MD (Professional Association of Orthopaedics and Traumatology,BVOU), in 2012 is the immanent conflict of the principles of quality,ethics and efficiency. The problem lies in substantially increasing quality,especially in the perioperative and early post-op periods, in a reproducible mannerthroughout Germany to achieve strict conformity and without short-termchanges to the legal framework.Thus, for musculoskeletal trauma, a formidable trauma network based in particularon structural quality is already being established. This will certainly resultin valuable approaches to the continued improvement of trauma care.The EndoCert initiative was developed to establish a quality assurance modelfor arthroplasty similar, for example, to the one which already exists for tumorcenters. The quality of care will be assured and improved based on the qualityof structures, process, and outcomes. It is essential that this should help us toachieve benefits for the patients.What will that look like in practice?It starts with a catalog of minimum structural requirements for a clinic practicingmajor joint arthroplasty. Interaction between the surgery unit and otherdepartments such as anaesthesia and radiology must follow clearly definedquality conventions. For example, findings must be evaluated within strictlydefined time frames and x-ray imaging must really meet certain criteria so thatthe quality of the implantation procedure can also be verified reliably. Standardsare being developed for a large number of subprocesses, ranging from documentationto follow-up. However, the standards will become simpler and moretransparent for those involved thanks to the standard.It cannot be the goal that every clinic needs to develop its own processes toensure high-quality workflows. In future, standards could be agreed which simplifyworkflows, increase safety, reduce administrative costs, and create transparency– for everyone involved.Does the qualification of physicians and OR staffhave a role to play?Of course. Medical devices and technologies mustonly be used if training has demonstrably beenprovided in handling them. The motto "no train,no use" applies to everyone, from the surgeon tothe OR nurse. But this must not mean only applyto the usual, one time demonstration of an implantsystem. A valid, good "training status" must beattained and maintained, comparable to an athlete.It cannot be that a surgeon only performs arthroplastiesvery rarely. We rely on a minimum numberof arthroplasties which the participating clinics willcommit themselves to observe. A surgeon acting asa lead physician responsible for a procedure must,for example, perform at least 50 hip or knee arthroplastiesper year. Those performing revisions mustdemonstrate that they perform 100 arthroplastiesper year for the joint concerned. These are what wecall Lead Surgeons. They must be clearly appointedand associated with the center.Your clinic and some others have already tested thisprocess in the pilot phase. What have been yourexperiences?We started the first pilot run at Rostock Universityin 2007 and were then able to get the participantsfrom the Conference of Tenured Professors ofOrthopaedics and the DGOOC to assist in furtherdeveloping the system. An expert panel from theGerman Society for Orthopaedics and OrthopaedicSurgery coordinated by K.-P. Günther, MD, PhD,has been examining the further development ofquality criteria since 2009 and is also engaged ina Germany-wide review of the system at what areknown as the pilot clinics. A certification board (H.8

EFORTHighlights of the 12 th EFORT CongressMore than 6,500 physicians and scientists from 90 countriestook part in the 12 th EFORT Congress, held June 1–4, 2011 inCopen hagen. After last year's success, another "Tribology Day"reflected the great importance attached to tribology. Karl Knahr,MD, PhD (Vienna) once again acted as chairman. Tribology continuesto be one of the most frequently discussed topics in thefield of arthroplasty. As patients are becoming younger andlife expectancy is increasing, calls for bearing couple materialswhich are resistant to wear and tear are getting louder. In theirpresentations, experts repeatedly stressed in this respect thatalongside parameters such as design, wear characteristics andhead diameters, the correct implantation technique also plays adecisive role for the quality of outcomes.Source: CeramTecCeraNews 1/2012Tribology overviewTheofilos Karachalios (Greece) reported on theproblem of wear and the bearing couple materialspolyethylene (PE), crosslinked polyethylene (XPE),metal and ceramics. Karachalios voiced the criticismthat despite an abundance of research resultsrelated to tribology problems, long-term clinicalresults are lacking. Therefore, constant critical scrutinyis necessary to ascertain whether data fromthe laboratory can be applied as-is to actual clinicalpractice. He raised the concern that the use of newmaterials and procedures results in new biologicalproblems, something which is discussed primarilyin the context of resurfacing and the trend towardlarger diameter ball heads. It cannot be denied thatthere is a certain amount of pressure from industryto introduce new products, while the cost effectivenessof modern implants in the context of limitedhealthcare system budgets is not yet proven. Whilethere is also a need for modern bearing couples forelderly patients, patients must also be provided withrealistic information about all treatment optionsand the sensible use of the implant.In-vitro findings do not always translate intoclinical success.- Theofilos Karachalios, MDCrosslinked polyethylene (XPE)While conventional PE has proven itself in clinicalpractice, it is subject to load-dependent wear.Crosslinked polyethylene has resulted in a furthersignificant reduction of wear and has thus pavedthe way for implantation in young, active patients.A variety of XPEs based on different manufacturingprocesses are now on the market and aim to strikea balance between strength, resistance to wear andelasticity. The addition of antioxidants is a new andhighly promising approach to prolonging survivaltime. There are conflicting results regarding the biologicalactivity of the wear particles in the nanometerrange, which are smaller than those from conventionalPE. On the one hand, in-vitro studies showthat small XPE particles cause mild bone resorption,while other studies have concluded that XPE particlesexhibit the same biological activity as PE particles.Other studies came to the conclusion thatmacrophages are primarily stimulated by XPE wearparticles and that more inflammatory mediators arereleased than with conventional PE. Furthermore,biological reactions to wear particles vary a greatdeal from individual to individual. Karachalios indicatedthat some experts are critical in their evaluationof the mechanical characteristics of XPE. Thesecharacteristics could make XPE inserts more susceptibleto fractures, which have been reported in publications.Therefore, the use of thin-walled XPE insertsand constrained inserts as well as malpositionedcomponents must be avoided. While conventionalPE has remained a "forgiving" material, when usingXPE it must be ensured that implants are correctlypositioned. Most of the clinical results involving XPEhave been reported in conjunction with metal femoralball heads, while only a few results are availablefor ceramic femoral ball heads.Metal-on-metal (MoM)MoM bearing couples exhibit differences in termsof their material, macrogeometry (diameter andclearance), microgeometry (surface topography)10

and fluid film formation. While larger diameterfemoral ball heads result in less wear, metal wear isbiologically active, with potential consequences assignificant as apoptosis. Local tissue damage due tometal reactivity was evident, primarily when malpositioningcaused excessive wear; on the other hand,metal sensitivity occured regardless of the quantityof particles. The latter manifested itself in the formof lymphocyte stimulation with subsequent boneloss. Particularly with resurfacing, pseudo-tumorformation is marked and is under scrutiny. Knownsystemic effects include elevated serum and urinemetal ion levels and deposition in organs. A potentialcarcinogenic risk cannot ultimately be assessed.Existing study data for modern MoM implants arenot conclusive due to limited patient numbers anddue to the fact that in most cases the follow-upperiod was less than 10 years. In view of the factthat the latency period for tumors is more than 20years, longer follow-up studies with large patientpopulations are required to permit an evaluationof the risk of carcinogenicity. The umbrella termARMD (Adverse Reaction to Metallic Debris) coversmetallosis, pseudo-tumors and ALVAL (Aseptic LymphocyticVasculitis Associated Lesions).Ceramic-on-ceramic (CoC)The CoC bearing couple exhibited the leastamount of wear. It is characterized by its low levelof surface roughness, its hardness and excellentfluid film formation. The result is a high level ofwear resistance. Correct implant positioning isnecessary to avoid any negative impact on theclinical outcome. In this respect, Karachaliospointed out the "chipping" problem, which mayoccur during surgery when positioning ceramicinserts. Noise only occurred in fewer than 1% ofcases. It has many reasons, but they have nowbeen identified. Impingement, edge loading anddisrupted fluid film associated with malpositioningplay a role, as does the vibration behavior ofthe stem, in which case there is evidence that thisis a design-specific problem. Karachalios statedthat the BIOLOX ® delta 4 th generation ceramicshave largely consigned implant fractures as acomplication to history. However, great cautionneeds to be exercised both when handling theceramic components during surgery and implantingthe acetabular cup in the correct position.If these principles are followed, ceramics is thematerial of the future.If these principles are followed, ceramics is the materialof the future.Oxinium *Karachalios remarked that hip simulator resultswith Oxinium femoral ball heads in combinationwith PE and XPE exhibit less wear than the MoPbearing couple. However, there have only beena few clinical results thus far. He reported on thefirst results from his own prospective, randomizedstudy with Oxinium femoral ball heads (28mm,32mm), which exhibited lower wear rates thanCoP or CoXPE. On the other hand, there have beenreports of severe damage to Oxinium femoral ballheads in patients who have experienced recurrentdislocations.Ceramic-on-metal ** (CoM)CoM bearing couples also have only preliminary,short-term clinical results available, albeit with arobust body of experimental data. Clinical studiesare currently in process to evaluate the performanceof the CoM bearing couple.- Theofilos Karachalios, MD* Oxinium is a trademark ofSmith&Nephew** CoM-articulation, Pinnacle ®CoMplete Acetabular HipSystem, DePuy Orthopaedics Inc.Focus on bearing couplesJohn Fisher (UK) spoke about the effect of femoralball head size and material on the onset of wear. Heasserted that hard-on-hard bearings (CoC, MoM)exhibit less wear with increasing head diameter. Inthe hip simulator, the 4 th generation CoC bearingcouple (BIOLOX ® delta) clearly exhibited the lowestlevel of wear, with a volume 50 times lower thanwas observed with the MoXPE bearing couple. TheCoM bearing couple ** still has critical metal wearcompared with the CoC bearing. However, he considersthe possibility of combining a large ceramicfemoral ball head (36mm) with a relatively smallmetal acetabular cup in Asian patients of smallbuild to be an advantage. Nevertheless, the primarygoal must be optimal function and prolongedlongevity. In any case, this requires an optimal positioningof the acetabular cup. Otherwise, the wearrate will be drastically increased.Karl Knahr (Austria) highlighted the risk of fracturesand noise associated with CoC bearing couples.Thanks to developments in the materials used inCeraNews 1/201211

10-year results with CoC THA due toosteonecrosis of the femoral headKyung-Hoi Koo (South Korea) pointed out thatosteonecrosis of the femoral head is the most commondiagnosis for hip replacement in Asia. Becauseit is mainly younger patients who are affected bythis condition, particular attention must be paid toimplant longevity. He reported on the initial resultsfrom his own study in which he followed up on 124BIOLOX ® delta CoC bearing couples (with a totalof 210 THA – 32mm, and 99 THA – 36mm). Therewere no fractures and no cases of squeaking over a16 month follow-up period. There were reports of 3dislocations and 2 cases of clicking noises.In his own personal experience, there is no perfectbearing couple, but the CoC articulation is the leastproblematic bearing.Ceramics seems to be the least bad articulation.- Kyung-Hoi Koo, PhDOther papersMoM hip resurfacing (MoM HR)At this year's EFORT Congress, much attentionwas devoted to hip resurfacing. There wasspirited discussion of findings with regard toclinical practice and fundamental research.Andrew G. Cobb (UK) and Thomas Poulsen (Denmark)reported on basics and the latest scientificfindings for MoM HR. Clinical outcomes in termsof quality of mobility, activity and longevity aregood. Revision rates have been cut from 13% to2% in recent years due to improvements in identifyingthe indication for HR and better implantationtechniques. The speakers mentioned tworecent groundbreaking publications. 1 Unfavorablepredictors included secondary osteoarthritis associatedwith dysplasia or osteonecrosis of the femoralhead, a small acetabulum, female gender and anage of over 65 years for men and over 55 years forwomen. In view of the known flat learning curve,the increased incidence of femoral neck fractures,and the increased metal wear in case of malpositioning,MoM HR should only be performed bysurgeons who are conversant with the procedure.Until the mechanisms behind ARMD are explainedthese implants will remain under close scrutiny. Inaddition, due to the fact that there are significantdifferences between the implants offered by variousmanufacturers, registry data should be trackedclosely.The correct positioning of components is a criticaldeterminant for ensuring optimal contact betweenbearing surfaces and lubrication conditions in orderto limit wear.The correct implant orientation will help to ensure thatwear occurs within the bearing surfaces, maintaining anoptimal lubrication regime and low wear.Darren Ebreo (UK) reported on a series of 22MoM HRs performed by one surgeon with an averagefollow-up of 3.2 (2.4–5) years. The average ageof the patients (12 male, 10 female) was 56 (44–69) years. In the group of 11 patients with a cupinclination of over 50° there was evidence of significantlyelevated serum chromium (146 nmol/L)and cobalt (245 nmol/L) ion levels versus the groupof 11 patients with a cup inclination of under 50°(92 nmol/L for chromium and 110 nmol/L forcobalt).It is precisely because high levels of metals in thebody have a toxic effect and could trigger immunologicalreactions, the effects of which remainindeterminate, that care must be taken to ensure asuitable inclination.- Azad Hussain, MDThere have thus far been few MoM HR studiesinvestigating implant orientation and itspotential impact on linear wear.Azad Hussain (UK) was analyzing the linear wearin relation to acetabular orientation (inclination oranteversion) in 70 MoM HR implants post retrieval.The acetabular cups which displayed morphologicalsigns of edge loading exhibited 20 times moremetal wear, with significantly increased cup inclination(54° vs. 45°) and anteversion (22° vs. 15°).Arne Borgwardt (Denmark) studied a randomizedgroup of 60 patients who had undergone cementlessCoC THA (alumina ceramic), had been given acementless MoM bearing couple (large diameter),or had undergone an MoM HR, for allergic reactivityfor up to 3 years after implantation. To thisend, elaborate serum level testing was performed todetect metal ions and immune response cytokines inthe body. Significantly higher metal ion levels weremeasured in patients with large diameter MoMimplants. One of these patients exhibited a hyper-1Corten K et al. Hip resurfacingarthroplasty: current status andfuture perspectives. Eur Cell Mater.2011;15(21):243–58Carrothers AD et al. Birmingham hipresurfacing: the prevalence of failure.J Bone Joint Surg [Br] 2010;92-B:1344–50.CeraNews 1/201213

EFORT (continued)sensitivity reaction of unclear origin to metal after 3years accompanied by relatively high serum metalion levels.Gill Harinderjit (UK) explained the many negativepredictors for MoM HR. A multivariate analysisinvolving 206 patients (124 male, 82 female) and a3 year follow-up was performed to identify majorfactors related to high wear rates and thus a highand potentially harmful level of metal exposure ofthe body. The EBRA method was used for radiologicalassessment of implant position.The study concluded that the selection of an excessivelysmall femoral ball head resulting in a smallhead/neck ratio, as well as an acetabular cup inclinationoutside the recommended range of 40° ±10°, had the greatest influence on metal wear. Inorder to preserve acetabular bone, there is a tendencyto select smaller components. However,this results in a low head/neck ratio and thus in anexcessively restricted range of motion, impingement,edge loading and increased wear.According to Harinderjit, cobalt ions have a moretoxic effect than do chromium ions.Harinderjit cited the results from another study toshow that there is a positive correlation betweennarrowing of the femoral neck by more than 10%after MoM HR and the tendency to select smallercomponents, and that there is thus also a positivecorrelation with female gender and increasedmetal wear.214 patients with an average age of 54.1 (13–73years) who had had MoM HR mainly due to primaryosteoarthritis underwent follow-up after anaverage of 4.3 (2–10) years. 6 different MoM HRimplants were used. Patients with higher wearrates for cobalt and chromium exhibited narrowingof the femoral neck of over 10% significantlymore frequently. Overall, narrowing of the femoralneck occurred in 75% of all cases, while narrowingin excess of 10% occurred in 6% of cases. Therewere multiple reasons for this, including impingement,osteolysis, impaired perfusion and evenchanges in tissue pressure in the environment surroundingthe implant.Therefore, if there is evidence of bone loss in thefemoral neck region upon follow-up, this can beinterpreted as an indicator of increased metal wearand such cases require close monitoring.Large diameter MoM bearing couplesMegan Hadley (UK) reported on new hip simulatorprotocols for the in-vitro measurement of metalwear. Frequently, in-vitro wear measurements arenot reproducible in vivo since testing in the laboratoryis performed under optimal conditions.A hip simulator test was used to analyze 4 groupsof a 36mm MoM bearing couple which varied interms of cup inclination and motion patterns versusa 28mm MoM bearing couple under standardconditions. Both an increase in inclination angleand the use of different gait patterns resulted in significantlylower gravimetric mass loss in the 36mmMoM bearing couple than in the 28mm MoM couple.Hence, even under extreme conditions, a largerhead diameter may significantly reduce the amountof wear.It has yet to be adequately explained whetherrevision of a symptomatic MoM large diameterimplant is followed by a reduction in metal ionlevels (chromium and cobalt) or whether theamount of residual metal debris in the tissueremains at the same level over a prolongedperiod.Darren Ebreo (UK) presented new findings in thisrespect. He started by explaining that the advantagesof large diameter metal ball heads, such aslow wear rate, anatomical reconstruction, protectionagainst dislocation and a high degree of mobility,contrast with the disadvantage of a large numberof metal particles, which have been blamed forhypersensitivity reactions, tissue toxicity, osteolysis,aseptic loosening and carcinogenicity.44 revisions of large diameter MoM implants(38mm THA, HR) were subjected to histologicalanalysis due to presumed metallosis after a meansurvival time of 4.8 (1.4–7) years. In 42 cases, ametal allergy, metal toxicity, or a foreign body reactionwere identified. A return of serum metal ionlevels to within normal limits was observed withinone year after revision.It was shown for the first time that serum metalion levels fall after revision of a symptomatic largediameter MoM implant.CeraNews 1/201214

10-year results with MoM THAin 1,121 patientsFabian von Knoch (Switzerland) reported on radiologicaland clinical results from 1,270 MoM THA(28mm, high carbon).Between 1994 and 2004, 1,121 patients (57%male, 43% female) underwent surgery mainly totreat primary osteoarthritis (80%) in one institution.After a mean follow-up of 6.8 years, theprobable survival rate was determined (using theKaplan-Meier method). This was 91% after 10years for the acetabular cup and 96% for thefemoral stem. The reasons for revision includedaseptic loosening in 63 cases (5%), infections in 8cases, periprosthetic fractures in 8 cases, dislocationin 8 cases, pain of unclear origin in 7 cases andacetabular cup fractures in 4 cases. The study didnot identify any significant influence on longevityfrom demographic factors, implantation factors, orsurgi cal techniques.Von Knoch concluded that the second generationMoM bearing couple does not offer any majoradvantages over other bearing couples, but is associatedwith the risk of potentially harmful metal ionlevels and can therefore only be recommended withprovisos.Ultrasound diagnostics for MoMbearing couples with ARMDFor a conversant user, ultrasound is a reliable, noninvasiveand cost effective method for the detectionof ARMD.According to Singisetti, diagnostic ultrasound isused routinely in his clinic as a screening methodfor patients with complaints of an unclear natureafter MoM implantation.8.5-year results with MoM, MoP andCoC bearing couples in a hip systemIngrid Milosev (Slovenia) reported on results withMoM (low carbon), MoP and CoC (BIOLOX ® forte)bearing couples implanted in 474 patients in 487THA performed between 01/2000 and 12/2002.The modular acetabular cup and femoral stem wereidentical in all cases. After a mean follow-up of 8.5(6.9–9.9) years, the overall revision rate was 3.7%.The revision rate was 8.7% for MoM, 4.1% for CoCand 1.5% for MoP. The MoM group had the highestrevision rate due to aseptic loosening.In the CoC group, patients mainly experiencedsecondary insert fractures due to improper handlingwhen the liner was inserted into the cup.To conclude, the MoP bearing couple can be recommendedas a solution for older, less active patients,while the CoC couple is recommended for youngeractive patients.It was noted from the audience that the CoC THAused in this study was one with a sandwich design.Various diagnostic imaging procedures areused to investigate complaints of an unclearnature after MoM implantation. The efficacyof diagnostic ultrasound in cases of ARMDhas been demonstrated for the first time in arecent study.Kiran Singisetti (UK) started by explaining theproblems associated with ARMD. The complexpathogenetic mechanisms require further research,but diagnostic assessment also presents difficulties.Ultrasound diagnostics was evaluated in a studywhich involved 35 patients in whom ARMD wasconfirmed clinically and histologically after MoMbearing couple implantation. Extra-articular fluidaccumulation was present in 33 (94.3%) of thepatients; in most cases this was found in combinationwith iliopsoas and trochanteric bursitis. Extraarticularechogenic responses were detected in 31(88.6%) of the patients. Over a period of severalmonths, progression of the changes was observedin 5 patients, while 1 patient was found to haveconverted from non-echogenic to echogenic jointeffusion.Immunological reactions: comparisonof MoM and CoP bearing couplesHypersensitivity reactions to metal wear arereported as a cause of osteolysis associated withMoM bearing couples. Evidence-based data fora correlation of this nature remains insufficientfor low-carbon MoM bearing couples.In this respect, studies of retrieved implants conductedby Thomas Repantis (Greece) have providednew findings. He analyzed retrieved implantsfrom 20 MoM bearing couples (low carbon) and 13CoP bearing couples for a hypersensitivity immuneresponse in the periprosthetic tissue. The reason forall of the revisions was aseptic loosening. Controlsamples from primary implantations and tissue samplesfrom the revisions were subjected to histologicaland immunohistochemical analysis.The 13 CoP bearing couples did not exhibit anyparti cular reactions.The 20 MoM bearing couples (low carbon) exhibitedextensive necrotic areas and fibrin exudates,which were not to be found in either the CoP bearingcouples or the control samples. Diffuse perivas-CeraNews 1/201215

EFORT (continued)cular lymphocytic infiltration was significantly morepronounced than was the case with the CoP bearingcouples. There were more T cells detected thanB cells.Thus, there is a demonstrable correlation in patientswith MoM bearing couples (low carbon) betweenhypersensitivity reactions to metal wear and osteolysiswith resultant implant loosening.7-year results with CoP,MoP and MoM THAKristian Bjorgul (Norway) randomized 396cemented THA with CoP, MoP or MoM (high carbon)bearing couples and a 28mm femoral ballhead. An alumina ceramic femoral ball head wasused for the CoP bearing couple. A full PE acetabularcup was used for the MoP and the CoP THA.After 7 years, there had been 10 revisions, of which6 occurred in the MoM group (3 infections, 2 casesof aseptic loosening, 1 case of septic loosening), 3in the MoP group (infection, dislocation, pain) and1 in the CoP group (infection). Radiologic findingswere available for 335 hips. Periacetabular radiolucentlines measuring over 1mm were detected in19 of 110 MoM hips and 5 of 112 CoP hips, whilenone were detected at all in the MoP group. Onlyin the MoM group did 2 patients need to undergorevision surgery for acetabular cup loosening.Bjorgul concluded that the MoM group shouldtherefore be monitored closely for signs of asepticloosening.Clinical results with ceramics15-year results with CoC THAJames Buchanan (UK) reported on a series of 626CoC THA (28mm, with a total of 467 BIOLOX ® forteand 169 BIOLOX ® delta) with HA coated components,with more than 15 years of follow-up forthe BIOLOX ® forte implants. The patients underwentannual clinical and radiologic follow-ups.Aseptic loosening was only observed in 3 of theTHA (2 stems, 1 cup). Dislocation occurred in 6 ofthe THA due to malpositioning. Ceramic fracturesoccurred in 3 femoral ball heads and 2 inserts fromBIOLOX ® forte, but none occurred in BIOLOX ® deltaimplants. Neither osteolysis nor any form of particlerelateddisease were observed. At the time of thefinal follow-up 91% of the patients had an HHSof at least 90 points. Lower scores were primarilyattributable to other medical problems.It was hoped that ceramic implants would offer ahard-on-hard bearing couple with a high degree ofwear resistance without the metal-associated problemsof MoM bearing surfaces. The expectation wasconfirmed in this study, while the potential hazardof fractures was significantly reduced with the 4 thgeneration ceramics (BIOLOX ® delta).8.5-year results with CoC THAin patients < 60 yearsJérôme Essig (France) conducted a retrospectivestudy involving a consecutive series of 265 cementlessCoC THA (BIOLOX ® forte) with a mean followupof 8.5 (5–11) years. The average age of thepatients was 58 (22–78) years. 28mm femoral ballheads were used in 99% of the cases. Continuousclinical and radiological follow-up was possible in224 patients (232 hips).The survival rate with the endpoint of all revisionswas 96.6% after 10 years. Infections were identifiedin 4 cases, a periprosthetic femoral fracture in4 cases and dislocation in 1 case. Aseptic looseningand ceramic fractures were not observed. Nowear, osteolysis, or other particle-related diseasescould be detected. The mean HHS was 97.3 points.A noise phenomenon (squeaking) occurred in 16cases (6%) without there being any malpositioning.In 10 cases, the noise disappeared over time.Essig concluded that the wear-resistant CoC bearingcouple in this series proved itself effective in ayounger patient population.CeraNews 1/2012Ceramic-on-ceramic is a reliable selection of bearingsurfaces in patients of any age and either sex.- James Buchanan, MDThis series demonstrates that the implantationof an ana tomic cementless HAarthroplasty with an alumina bearing ina young and active patient prevents therisk of wear and osteo lysis and improvesdurability over time.- Jérôme Essig, MD16

COAHighlights of the 6 th InternationalCongress of the Chinese OrthopaedicAssociation (COA) in Beijing (China)December 1–4, 201111,357 orthopaedic surgeons from 48 countries attended themeeting which is the second largest orthopaedic congress inthe world. 10,897 of them were from China. The educationalprogram included 1,796 presentations in Chinese, 403 in Englishand 2,777 poster presentations.Source: OrthonlineYan Wang, MD, Presidentof the ChineseOrthopaedic Association(COA), on the OpeningCeremony of the 6 thInternational Congressof the COAThe COA invited the presidents and senior expertsfrom almost 100 foreign academic organizationsand medical institutions such as the AAOS, APAS,CSOS, EFORT, HSS, ISAKOS, SICOT, SRS etc. Theguests shared a very high level of academic lecturesand discussions with their Chinese counterparts.The 13th Annual Meeting of the Asia-Pacific ArthroplastySociety (APAS) was also held during the congressin Beijing.The most important topics in the area of hip arthroplastyincluded the following:• The choice of the bearing surface• Long-term results with different bearing surfaces• Large bearing diameters• Adverse reactions to metal debris (ARMD)• Failure analysis in MoM THA and hip resurfacingRichard Rothman (USA) discussed the currentsituation and future trends in THA. ChitranjanRanawat (USA) reported on modern trends in THAbearings. Luigi Zagra (Italy) gave an overview onEuropean experiences with THA bearings. PhilippeHernigou (France) presented excellent clinicalresults with the CoC bearing couple in decreasingthe cumulative long-term risk of dislocation. LaurentSedel (France) reported extensively on theexcellent biocompatibility and the comprehensive40-year clinical experience that is now available forCoC bearings. In his view the CoC bearing couple isthe best option for young patients.5–10-year results with CoP vs. MoP THAZhanjun Shi et al. (China) presented the clinicaland radiographic results of alumina ceramic femoralball heads (BIOLOX ® forte) and metal femoral ballheads in combination with conventional PE liners.142 THA (116 patients) were performed between1997 and 2002. The average age was 51.1 years. Allpatients were treated with the same hip system. 57patients (72 THA) were followed up. The mean follow-upwas 7.2 (5–10) years. The mean wear rate forthe CoP group and the MoP group were 0.09mm/yand 0.12mm/y, respectively. There were no revisionsat the latest follow-up.2–4-year results of CoC THABolong Kou et al. (China) reported on clinicaland radiographic results of 102 alumina CoC THA(28mm, 32mm, BIOLOX ® forte). From 2006 to 2011,76 patients (56 male, 20 female) were treated witha CoC bearing couple. 26 patients received a bilateralTHA treatment. The mean age was 43.58 ± 10.30(27–61) years. Diagnoses were mainly avascularfemoral head necrosis (55 hips), femoral neck fracture(10 hips), DDH (3 hips) and others (8 hips). Themean follow-up was 25.8 (3–57) months.No dislocation or migration occurred. There were noceramic fractures. No acetabular or femoral osteolysiswas observed at the latest follow-up.Failure analysis of MoM THAOpening Ceremony of the COA Congress 2011Source: OrthonlineQi Wang et al. (China) evaluated reasons for failuresof 505 MOM THA which were performedbetween 2007 and 2010. 7 failures of MoM THAwere observed. The reasons for revision were infection(2), periprosthetic facture (2), and acetabularcomponent loosening (3). In the cases of cup loosening,one case showed severe osteoporotic bonearound the acetabulum. In another case the patienthad an extremely hard bone at the bony acetabularring. Consistent groin pain due to cup migrationwas seen in one patient. The authors concludedCeraNews 3/ 201121

COA (continued)Source: OrthonlineBeijing Declaration: The International President Forum at the COA 2011 Beijing Congress is committed to work on a globalstrategy and technology to unite the resources and musculoskeletal expertise around the world to meet the challenge of anaging population and the rampant threat of road trauma epidemic, natural disaster and emerging infection.The specific areas of focus are: Cooperation, Advocacy, Research, Education, Patient CARE.that at this short follow-up time, no revisions forosteolysis, soft tissue damage or pseudotumor wereobserved in this series. Longer follow-up is neededto evaluate the long-term performance of theseMoM THA.Cementless CoC THA for Crowe IVdysplastic hipsThere are still only very few reports on CoC bearingsimplanted in dysplastic hips.The report by Yonggang Zhou et al. (China)focused on clinical experience with cementless aluminaCoC THA (BIOLOX ® forte) in dysplastic hips. In32 patients with Crowe IV DDH, 43 implantationswere performed between January 2007 and October2010. The mean age was 31.44 ± 7.86 (22–49)years. In 41 cases CoC was used, in 2 cases a PEliner was implanted. The patients were treated witha 28mm ceramic femoral ball head. The mean follow-upwas 25.81 ± 9.72 (13–59) months.In the CoC group acetabular fracture occurred inone case, but the fracture healed and the acetabularcomponent was stable at the latest follow-up.In the observation period no implant-related failurewas observed.The authors concluded that in most patients withCrowe IV DDH a treatment with CoC THA (28mm)is possible. CoC THA in this series achieved in goodclinical and radiographic outcomes. Long-termresults are necessary to confirm these promisingresults.43-year-old female with Crowe IV DDH, post-op X-ray after surgery.Both hip joints were treated simultaneously with a cementless CoCTHA (28mm, BIOLOX ® forte), stabilized with screws.Source: Yonggang Zhou, MD, Surgeon-in-chief, Department of Orthopaedics,The Chinese General Hospital of the People’s Liberation Army, Beijing (China)CeraNews 1/201222Post-op X-ray 4 years after surgery: Cup and stem werestable and well osteointegrated, with no signs of radiolucentlines or osteolysis. The patient was fully satisfiedwith the clinical outcome.Source: Yonggang Zhou, MD, Surgeon-in-chief, Department ofOrthopaedics, The Chinese General Hospital of the People’s LiberationArmy, Beijing (China)

EventLevels of metal ions after MoM THAYi Zeng et al. (China) investigated 51 large diameterMoM THA which were performed in 42 patientsbetween June and August 2007. The mean followupwas 4 years. The radiographic analysis revealedno radiolucent lines or osteolysis. There was nodislocation, migration or implant loosening. Theauthors determined the levels of cobalt and chromiumin serum and urine using inductively coupledplasma mass spectrometry (ICP-MS).They observed that metal ion concentrations dramaticallyincreased after surgery, with a peak at1 year postoperatively. They found median serumlevels of cobalt and chromium of 51.56 nmol/Land 70.2 nmol/L respectively. The metal ionconcen trations of cobalt and chromium in urinealso signifi cantly increased to 81.25 nmol/L and58.72 nmol/L respectively. The authors reportedthat after the peak the metal ion levels in serum andurine decreased slowly.Concern remains, however, regarding possible biologicaleffects of the metal ions that these bearingsrelease. Metal ion levels in serum and urine andpossible long-term side-effects have to be monitored,the authors concluded. Longer follow-up isneeded to evaluate the long-term performance ofMoM THA in this series.The use of ceramics in Turkeyis increasing exponentiallyOn the occasion of the 22 nd Turkish National Congress ofOrthopaedics and Traumatology which was held in Antalya(Turkey) on October 31–5 November, 2011, CeramTecinvited leading experts in the field of arthroplasty to around-table meeting.The discussion was focused on bearing couples and theuse of ceramic bearing surfaces in THA in Turkey. MazharTokgozoglu, MD (Hacettepe University of Ankara), chairmanof the round-table meeting, emphasized that there isa known fact that the use of ceramics in THA in Turkey isincreasing exponentially.Mazhar Tokgozoglu, MD,Hacettepe University Facultyof Medicine, Departmentof Orthopaedics and Traumatology,Ankara (Turkey)References:Kou BL et al. Clinical results of CoC THA in 102 cases. Abstract 12865(Chinese), COA, Beijing, 1–4 December 2011Shi ZJ et al. Mid-term results of the cementless Zweymüller hip system.Abstract 4570 (Chinese), COA, Beijing, 1–4 December 2011Wang Q et al. Causes of failed MoM THA. Abstract 7811 (Chinese),COA, Beijing, 1–4 December 2011Zeng Y et al. Clinical outcome of large diameter MoM THA. Abstract13570 (Chinese), COA, Beijing, 1–4 December 2011Zhou YG et al. The necessity and possibility of CoC THA for Crowe IVDDH patients. Abstract 8354 (Chinese), COA, Beijing, 1–4 December 2011In this context, Remzi Tözün, MD (Acibadem Maslak HospitalIstanbul) presented his comprehensive clinical experienceof nearly 791 cases in which he used different typesof ceramics.Remzi Tözün, MD, AcibademMaslak Hospital, Directorof the Department of Orthopaedics,Traumatology andArthroplasty, Istanbul (Turkey)Tribology in hip and knee arthroplasty will also be amongthe highlight topics of the 14 th EFORT Congress * which willbe held June 5–8, 2013, in Istanbul.In the next issue of CeraNews (2/2012) we will givea detailed report on the role of ceramics, arthroplastytrends and “hot topics” of discussion in THAin Turkey.* http://www.efort.org/communications/statements_08.aspxCeraNews 1/201223

AwardHeinz Mittelmeier Research Award for Hip RevisionAt the German Congress for Orthopaedics and Trauma Surgery(DKOU) held in Berlin in October 2011, the German Society forOrthopaedics and Orthopaedic Surgery (DGOOC) awarded theHeinz Mittelmeier Research Award for Hip Revision to FritzThorey, MD, PhD, Assoc. Professor (ATOS Clinic Heidelberg).He earned this distinction for his retrospective study entitled"Early results of revision hip arthroplasty using a ceramic revisionball head." The prize, which is endowed with an award of5,000 euros, was donated by CeramTec.Fritz Thorey, MD, PhD, Assoc. Professorwas Assistant Medical Director of theDepartment for Reconstruction and Arthroplastyin the Orthopaedic Clinic at HanoverMedical School from 2009 to 2011.Since July 1, 2011 he has been Head forHip Arthroplasty and Reconstruction ofthe ATOS Clinic Heidelberg. He continuesto have close scientific links with HanoverMedical School and is involved in variouship arthroplasty and hip reconstructionprojects. He is a member of the AmericanAcademy of Orthopaedic Surgeons(AAOS), the German Society for Orthopaedicsand Orthopaedic Surgery (DGOOC)and the German Arthroplasty Association(AE). He is also an instructor in minimallyinvasive hip arthroplasty, revision arthroplasty,and hip arthroscopy, providing trainingin these specialist fields to colleagueson the national and international level.Fritz Thorey, MD, PhD, Assoc. Professorhas delivered approximately 140 lecturesat international conferences and has publishedover 50 specialist papers.Fritz Thorey, MD, PhD, and colleagues analyzed the radiological findings fromhip revisions performed using the BIOLOX ® OPTION ceramic revision ball headin a substantial series comprising 91 patients. The average patient age was64 years. The indications were primarily acetabular cup loosening, as well asinfection, noises, instability, and ceramic fractures. The revisions involved theimplantation of a CoC articulation for 58 patients and a CoP articulation for 33patients. In all cases, a 32mm femoral ball head was used. All of the patientsexhibited significant improvements in pain and functional scores. No signs ofloosening, noises or ceramic fractures were identified. No implant related revisionsoccurred.The study provided convincing results using the ceramic revision ball head ina relatively large patient population after an average follow-up of 2 years. Allpatients remain under observation for the purpose of obtaining long-termresults.Bibliography:CeraNews 1/2012Contact:Fritz Thorey, MD, PhDCenter for Hip, Knee and FootSurgery, Sports TraumatologyATOS Clinic HeidelbergBismarckstr. 9–1569115 HeidelbergGermanyPhone: +49 6221 983 190Fax: +49 6221 983 199e-mail fritz.thorey@atos.dewww.zentrum-hueft-knie-fusschirurgie.deProf. Fritz-Uwe Niethard (German Society for Orthopaedics and Trauma Surgery),Fritz Thorey, MD, PhD, Assoc. Professor, and Heinrich Wecker (CeramTec) after theaward ceremony (left to right)Thorey F 1 , Sakdinakiattikoon M 2 , Thiengwittayaporn S 2 , Windhagen H 3 .Early results of revision hip arthroplasty using a ceramic revision ball head.Seminars in Arthroplasty 2011;22(4):284–2891Center for Hip, Knee and Foot Surgery, Sports Traumatology ATOS Clinic Heidelberg2Department for Orthopaedics, Bangkok Metropolitan General College, Bangkok/Thailand3Orthopaedic Clinic at Hanover Medical School24

Read CeraNews online: www.ceranews.comCall for papersThe German Society for Orthopaedics andOrthopaedic Surgery (DGOOC) will also beawarding the Heinz Mittelmeier ResearchAward together with a 5,000 euro endowmentin 2012. The research prize, which is donatedby CeramTec GmbH, is awarded to clinicians,engineers or scientists up to 40 years old foroutstanding contributions to research anddevelopment in the field of bioceramics andproblems associated with arthroplasty wearand tear, as well as with regard to clinicalresults from ceramic implants.Submissions to the DGOOCmust be postmarked August 31, 2012or before.The prize will be awarded at the German Congressfor Orthopaedics and Trauma Surgery(DKOU), to be held October 23–26, 2012 inBerlin.For further details on theapplication process:Deutsche Gesellschaft für Orthopädieund Orthopädische Chirurgie e.V. (DGOOC)Langenbeck-Virchow-HausLuisenstr. 58/5910117 BerlinGermanyPhone: +49 3084 71 21 31Fax: +49 3084 71 21 32e-mail: info@dgooc.dewww.dgooc.deDownload the BIOLOX ®app on your smartphoneor tablet! *You can use the new BIOLOX ® app to accessinformation on BIOLOX ® implants quickly andfrom anywhere. What needs to be borne inmind when handling and implanting ceramiccomponents? Which bearing couple can beused in the rare event of a ceramic fracture?With this app, you can find the answers toquestions like these and lots of further information.The BIOLOX ® app can be downloaded for freefrom the App Store.Category: MedicineVersion: 3Size: 369 MBLanguage: English* Compatible with iPhone 3GS, iPhone 4, iPhone 4S, iPod Touch(3 rd generation), iPod Touch (4 th generation) and iPad. RequiresIOS 4.0 or later.Apple, the Apple Logo, iPhone and iPad are trademarks of Apple Inc.Registered in the U.S. and other countries.CeraNews 1/201225

14 th BIOLOX ® Symposium 2012A Perfect MatchBIOLOX ® Symposium and CCJRmeet in Las VegasCeramTec Medical Products would like to invite the readers ofCeraNews to participate in the 14 th BIOLOX ® Symposium (BearingSurface Options in Total Joint Replacement: The ExpertsProvide the Evidence) in Las Vegas, USA, on May 19–20, 2012.For the first time ever the Symposium will be held immediatelyprior and in the same venue as the Current Concepts in JointReplacement (CCJR) Spring Meeting (May 20–23, 2012) allowingparticipants the benefit of participating in both meetings.Javad Parvizi, MDA. Seth Greenwald,D. Phil. (Oxon)CeraNews 1/2012In order to give our readers more insight into theSymposium, we sat down with the SymposiumPresident, Javad Parvizi, MD (Director of Researchat the Rothman Institute), and the Chairman of theScientific Committee, A. Seth Greenwald, D. Phil.(Director of the Current Concepts in Joint ReplacementMeetings), and asked them some questions:Where did the idea of combining the BIOLOX ® Symposiumand the CCJR Meeting come from?Javad Parvizi:In my mind it is very clear that both meetings havethe same focus. They offer a learning experience tothe surgeon interested in providing his/her patientswith the best standard of care. I have followed theevolution of both meetings and thought that thepracticing orthopaedic surgeon needs more claritybased on scientific data when it involves the bearingsurface options of today. In my mind combining thetwo meetings would serve this purpose well.What was your reaction when Dr. Parvizi contactedyou and presented the idea of holding both meetingsin a single venue?A. Seth Greenwald:First of all, I thought it a novel idea and one whichoffered immediate synergies. The CCJR Meeting isfocused on clinically relevant issues facing the surgeon.When you couple this with the surgeon’sneed to gain contemporary scientific knowledge inthe area of bearing surface options and choices, itwas clear to me that the alignment of these eventswas excellent.What is your point of view on the two meetingsbeing held in one venue?Javad Parvizi:The two events are a perfect match. At the CCJRMeeting orthopaedic surgeons and healthcare professionalsare provided updates on important topicsrelevant to hip, knee and shoulder reconstruction.By arriving just one day earlier, participantsalso acquire a great insight into bearing surfaceoptions in total joint arthroplasty. Any overlapbetween the two meetings only serves as reenforcement.The two meetings have a somewhat different faculty.In the CCJR Meeting the majority of participants areorthopaedic surgeons from the USA whereas in theBIOLOX ® Symposium the faculty is mostly interdisciplinaryand with a stronger international influence.Do you see this as a challenge?A. Seth Greenwald:I personally see this as an opportunity since it is myhope that the interaction between surgeons, scientistsand engineers, who work in the field of orthopaedicsurgery will add a further dimension to theoverall meeting.Javad Parvizi:The BIOLOX ® Symposium is a globally recognizedinterdisciplinary meeting with a very clear directionof bringing together the latest informationon bearing surfaces. Combining this with a wellestablishedand recognized educational forum likethe CCJR Meeting offers a unique opportunity forthe participants to enhance their knowledge onan important, contemporary aspect of total jointarthroplasty.Why was the CCJR Spring Meeting in Las Vegasselected?Javad Parvizi:We both agree that one of our goals was that wewould select a venue that enhanced participation ofinternational surgeons and scientists. The Las Vegaslocation and the hotel facilities are such that we willbe able to attract surgeons from North and SouthAmerica, Asia, Australia and Europe.26

Save the date!As the Symposium President do you plan to includesatellite events in the program?Javad Parvizi:We are certainly looking at every opportunity toprovide participants attending both events with avery complete learning experience. It is our hope toinclude a hard bound book of the proceedings andoverlap with the live surgery and workshop offeringsof the CCJR Meeting.When will the program be finalized and available fordistribution?A. Seth Greenwald:As the Chairman of the Scientific Committee I amreviewing the offerings that have been submittedand graded. It is my hope to develop the final programshortly after the notification of acceptance ofthe abstracts to be included in the program. Thisshould take place by February 2012.14 th BIOLOX ® SymposiumBearing Surface Options inTotal Joint Replacement:The Experts Provide the Evidence.May 19–20, 2012in conjunction withCurrent Concepts in Joint ReplacementSpring 2012May 20–23, 2012The ARIA at CityCenter, Las Vegas, NevadaFor further information please contact theBIOLOX ® Symposium Conference SecretariatCeramTec Phone: (+49) 7153 611 513CeramTec Fax: (+49) 7153 611 16 513email: bioloxsymposium@ceramtec.dewww.biolox-symposium.comCurrent Concepts InstituteDorothy L. Granchi, MBA,Course CoordinatorPhone: (+1) 216 295 1900Fax: (+1) 216 295 9955email: info@ccjr.comwww.ccjr.comCeraNews 1/201227