INTRODUCTIONCorrosion of modular tapers is increasingly recognized as a source of adverse tissue reaction (ALTR) and revision surgery in total hip arthroplasty (THA). The incidence of corrosion and rate of revision for ALTR may differ among different types of implants.OBJECTIVEThe objective of this study was to determine if a difference exists in rate of THA revision for corrosion and ALTR with tapered broach only stems compared to ream-broach femoral stems.METHODSWe reviewed the results of 3741 primary THA performed over a 5 year period at our institution using 2 different implants by the same manufacturer, a tapered proximally coated cementless titanium stem inserted via a broach only technique (Group A) and dual tapered proximally coated cementless titanium stem inserted via a ream and broach technique (Group B).RESULTSOf 1567 THA in group A, 964 were combined with a chrome cobalt metal head, while 603 were ceramic. Of 2174 THA in group B, 1302 were metal and 872 were ceramic. Head sizes used were simi...

Background Deep vein thrombosis (DVT) and pulmonary emboli (PE), known together as venous thromboembolic (VTE) disease remain major complications following elective hip and knee surgery. This study compares three chemoprophylactic regimens for VTE following elective primary unilateral hip or knee replacement, one of which was designed to minimize risk of post-operative bleeding. Methods Patients were randomized and stratified for hip vs. knee to receive A: variable dose warfarin (first dose on the night preceding surgery with subsequent target INR 2.0–2.5), B: 2.5 mg fondaparinux daily starting 6–18 h postoperatively, or C: fixed 1.0 mg dose warfarin daily starting 7 days preoperatively. All treatments continued until bilateral leg venous ultrasound day 28 ± 2 or earlier upon a VTE event. The study examined primary endpoints including leg DVT, PE or death due to VTE and secondary endpoints including effects on D-dimer, estimated blood loss (EBL) at surgery and hemorrhagic complications. Results Three hundred fifty-five patients were randomized. None was lost to follow-up. Taking 1.0 mg warfarin for seven days preoperatively did not prolong the prothrombin time (PT). Two patients in Arm C had asymptomatic distal DVT. One major bleed occurred in Arm B and one in Arm C (ischemic colitis). Elevated d-dimer did not predict delayed VTE for one year. Conclusions Fixed low dose warfarin started preoperatively is equivalent to two other standards of care under study (95 % CI: -0.0428, 0.0067 for both) as VTE prophylaxis for the patients having elective major joint replacement surgery. Trial registration ClinicalTrials.gov identifier # NCT00767559 FDA IND: 103,716

Wear simulator studies suggest low wear rates of Alumina ceramic femoral heads with polyethylene total hip bearings. Short-term wear and clinical data of ceramic/highly crosslinked ultra-high molecular weight polyethylene (UHMWPE) couples are under reported in the literature. A retrospective review was performed to determine and compare the wear rate for hips implanted with an Alumina ceramic femoral head and X3® poly-ethylene insert to the acceptable polyethylene wear rate in the literature. We evaluated 70 primary total hip replacements performed at one institution, by two surgeons, from February 2006 through June 2007. At a minimum 2 year follow-up, calculated annual wear for the ceramic/X3 ® polyethylene articulations showed a significant decrease compared to literature reports of 0.1mm/year or greater for conventional polyethylene. Radiographic and clinical outcomes show no loose implants, dislocations, ceramic fractures or revision surgeries at last follow-up. These early findings suggest that ceramic/X3 ® bearing couples may serve as an acceptable choice for the younger, active patient.

While alumina ceramic-ceramic THA has been performed in the US for more than 12 years, the phenomenon of frequent, clinically reproducible squeaking is relatively new. The current study investigates the influence of implant design on the incidence of squeaking. We reviewed implant information on 1275 consecutive revision THAs performed from 10/2002 through 10/2007 to identify any patients who had complained of squeaking or grinding. We also identified, 2778 consecutive primary ceramicceramic THA. Of these, we reviewed the clinical records of 1,039 patients (37%) to date. Any patient complaint of squeaking or grinding at the time of an office visit or by phone interview was recorded. Hips were divided into group 1: flush mounted ceramic liner; group 2a: recessed ceramic liner mated with a stem made of TiAlV and using a 12/14 neck taper; and group 2b: recessed ceramic liner mated with a stem made of a beta titanium alloy comprised of 12% molybdenum, 6% Zirconium, and 2% Iron and using a neck taper smaller than a 12/14 taper. Of the revision THAs, 5 hips (0.4%) were in patients who had complained of squeaking or grinding. All 5 hips had a recessed, metal-backed ceramic liner and evidence of metallosis. In primary THAs, Group 2b had statistically significantly (p=0.04) more squeaking (7.6%) than group 2a (3.2%) which had statistically significantly (p=0.002) more squeaking than group 1 (0.6%). Squeaking following ceramic-ceramic THA is associated with use of a recessed metal-backed ceramic liner in combination with a femoral component made of a betatitanium alloy and using a relatively small head-neck taper. Since all revised hips in our study had metallosis, it is possible that metal debris is adversely affecting the bearing and that the elevated metal rim combined with a small head neck taper and the beta-titanium alloy contribute to this problem. Use of bearings with a flush-mounted ceramic liner mated with femoral components made of TiAlV and using a 12/14 taper appears to be prudent.

Purpose: Dislocation is one of the most common complications following total hip arthroplasty (THA), with rates reported between 1% and 3%, but as high as 6% using a posterior approach with metal on polyethylene bearing surfaces. The purpose of this study was to assess the dislocation rates in ceramic-on-ceramic THAs. Method: Primary ceramic-on-ceramic (Stryker Orthopaedics) THAs performed at 9 institutions from October 1996 through July 2005 were included in the study (1635 hips in 1485 patients). Sixty-one percent were male. The average age was 52 years (range 15–83). Osteoarthritis was the leading reason for surgical intervention (86%). A posterior approach and 32 mm or 36 mm femoral head was used in the majority of patients (90%). Patients returned for routine clinical examination or were contacted by telephone to assess for dislocations at a minimum of one year (average three years) after surgery. Results: Of the 1635 ceramic-on-ceramic THAs performed, there were 18 dislocations (1.1%). Of these, 15 were 32 mm femoral heads; 3 were 28 mm; none were 36 mm. The majority of dislocations occurred within 3 months after surgery (72%). Closed reduction was successful in 17 hips with one requiring a revision. Conclusion: A low rate of dislocations in ceramic-on-ceramic THAs occurred in this study (1.1%). Compared with reported metal-on-polyethylene bearing surfaces, the ceramic-on-ceramic articulation design appears to have fewer dislocations. Other factors associated with this low dislocation rate may be decreased femoral neck diameters and/or larger average femoral head size in patients receiving the ceramic-on-ceramic design. These results will need to be compared with contemporary THA using different articular surfaces.

BACKGROUND:Delirium is a serious postoperative condition for which few pharmacologic prevention trials have been conducted.OBJECTIVE:The authors tested the efficacy of perioperative olanzapine administration to prevent postoperative delirium in elderly patients after joint-replacement surgery.METHOD:The authors conducted a randomized, double-blind, placebo-controlled, prophylaxis trial at an orthopedic teaching hospital, enrolling 495 elderly patients age ≥65 years, who were undergoing elective knee- or hip-replacement surgery; 400 patients received either 5 mg of orally-disintegrating olanzapine or placebo just before and after surgery. The primary efficacy outcome was the incidence of (DSM-III-R) delirium.RESULTS:The incidence of delirium was significantly lower in the olanzapine group than in the placebo group; this held true for both knee- and hip-replacement surgery. However, delirium lasted longer and was more severe in the olanzapine group. Advanced age, a high level of medical comorbidity, an abnormal albumin level, and having knee-replacement surgery were independent risk factors for postoperative delirium (Clinicaltrials.gov Identifier: NCT000699946).CONCLUSION:Administration of 10 mg of oral olanzapine perioperatively, versus placebo, was associated with a significantly lower incidence of delirium. These findings suggest that olanzapine prophylaxis of postoperative delirium may be an effective strategy.

Alumina ceramic-ceramic bearings have the benefit of very low wear and studies showing the complete absence of osteolysis during the first decade of close study. However, good results depend on several critical factors including surgical exposure, surgical technique, component placement, and choice of component design. The following abstract discusses our experience with several of these factors. Initially, there were concerns that the use of ceramic-ceramic bearings would lead to a higher incidence of hip dislocation since the bearings have fewer femoral head-length choices and the absence of lipped-liners. In our prospective study of 418 hips the incidence of hip dislocation at 1 to 10 year followup is 0.5% (2/418). This experience suggests that the use of alumina ceramic-ceramic bearings is not associated with an increased incidence of dislocation. More recently, concerns about squeaking of alumina ceramic-ceramic bearings have been reported, particularly from centers in the United States. To investigate this issue, we reviewed information on 1275 consecutive revision THAs and 1039 consecutive primary ceramic-ceramic THA that had been performed at two institutions between 1996 and 2007. To identify the influence of the implant design on the incidence of squeaking we divided the primary hips into three groups with group 1: flush mounted ceramic liner; group 2a: recessed ceramic liner mated with a stem made of TiAlV; and group 2b: recessed ceramic liner mated with a stem made of a beta titanium alloy comprised of 12% molybdenum, 6% Zirconium, and 2% Iron. Analysis of the 1275 revision hips revealed 5 alumina ceramic-ceramic hips in patients who complained of squeaking or grinding. All 5 hips were designs that included a ceramic liner that was recessed inside of an elevated metal rim. All 5 hips also demonstrated metallosis at the time of revision. In primary THA, Group 2b had statistically significantly more squeaking (9 of 118) than group 2a (10 of 321) which had statistically significantly more squeaking than group 1 (6 of 700). In addition, the severity of squeaking between the groups was qualitatively different. Patients in Group 2b who complained of squeaking would often experience squeaking frequently throughout the day and could be demonstrated in the physician’s office. By contrast, patients in Group 1 who noted squeaking stated that the hip squeaked once a day to once a year. No patient in Group 1 complained of frequent squeaking or could demonstrate squeaking in the physicians’ office. Further, joint fluid analysis from a patient in Group 2b who complained of squeaking revealed metal from both the femoral (Molybdenum) and acetabular (Aluminum) components. As reported in another abstract at this meeting, 10 year survivorship of flush-mounted alumina ceramic-ceramic THA is 98.4% (95% confidence interval 97.1–100%) and no patient in that prospective clinical studies demonstrated radiographic evidence of osteolysis or wear. These experiences demonstrate that THA using alumina ceramic-ceramic is extremely reliable with low revision and dislocation rates and an absence of osteolysis. Significant squeaking is not associated with flush-mounted alumina ceramic liners and is clearly associated with elevated metal rims and metallosis. Finally, squeaking is statistically significantly associated with femoral components made of a beta titanium alloy consisting of Titanium, Molybdenum, Aluminum, and Iron.

This study reports revision and complication rates of a single cementless double-wedged tapered stem with an alumina-alumina bearing over 10 years since the beginning of premarket clinical trials. Of 930 hips (848 patients) implanted by 9 surgeons, there were 19 revisions at mean follow-up of 5.9 years compared to 10 revisions in the 123 hips implanted with the polyethylene control group at mean 7.8 years. The ongoing safety of alumina-alumina bearings is demonstrated through excellent (96.8%) survivorship at 10 years. Twenty-one patients reported 23 incidences of noise described as clicking, squeaking, popping, or creaking. Eight patients with 9 hips described the noise as squeaking, most occurring rarely and only 1 occurring frequently in a patient subsequently revised for a reason aside from the squeaking.

The delayed Gadolinium-Enhanced Magnetic Resonance Imaging of Cartilage (dGEMRIC) method allows for both qualitative and quantitative measurement of the spatial distribution of glycosaminoglycan [GAG] in excised cartilage. The objective of this study was to determine the effect of paraformaldehyde fixation on dGEMRIC measurements. Five bovine and seven human cartilage pieces were punched into 5-mm plugs, fixed for 18 h in 4% paraformaldehyde solution, and washed. The magnetic resonance imaging (MRI) parameter T1 was measured prior and post fixation in cartilage without (T1(0)) and with (T1(Gd)), the ionically charged MRI contrast agent Gd(DTPA)(2-). Images of tissue before and after fixation were qualitatively very similar. The ratios of T1(0), T1(Gd), and calculated [GAG] after fixation, relative to before fixation, were near or slightly higher than 1 for both bovine cartilage (1.01 +/- 0.01, 1.04 +/- 0.02, 1.05 +/- 0.03, respectively) and for human cartilage (0.96 +/- 0.11, 1.03 +/- 0.05, 1.09 +/- 0.13). Thus, these data suggest that dGEMRIC can be used on previously fixed samples to assess the three dimensional spatial distribution of GAG.

Background The purpose of this retrospective study was to examine if physical therapy intervention initiated on the same day as total hip arthroplasty reduces length of stay in the acute care hospital and increases the number of patients discharged to home rather than a rehabilitation facility. Methods We retrospectively reviewed 40 patients to evaluate the effect of physical therapy intervention on the day of surgery compared with first postoperative day. Results Length of stay for the day of surgery group was 4 days and 4.7 days for the postoperative day 1 group. Sixty percent of day of surgery patients were discharged to home compared with 50% for postoperative day 1 patients. Conclusions Our results may support the feasibility of a larger, prospective study to examine the effect of physical therapy intervention on the day of surgery for all total joint replacement surgeries.

Previous studies have shown that, compared with standard electrocautery, a bipolar sealer reduces tissue damage and smoke production during surgery. We conducted a multicenter, prospective, randomized study to compare a bipolar sealer with standard electrocautery for hemostasis. Sixty-nine primary total knee arthroplasties were performed. Cohorts were evaluated for intraoperative and postoperative blood loss, blood transfusion requirements, postoperative hemoglobin and pain levels, length of hospital stay, range of motion, and Knee Society scores. Amount of blood loss and decrease in postoperative hemoglobin were significantly lower in the bipolar sealer group than in the standard electrocautery group. Need for autologous blood transfusions was decreased in the bipolar sealer group compared with the electrocautery group. There were no between-groups differences in clinical knee scores. The bipolar sealer was an effective coagulation alternative for total knee arthroplasties in reducing blood loss and transfusion requirements without affecting clinical outcome.

OBJECTIVE:Our previous study suggested that growth arrest and DNA damage-inducible protein 45beta (GADD45beta) prolonged the survival of hypertrophic chondrocytes in the developing mouse embryo. This study was undertaken, therefore, to investigate whether GADD45beta plays a role in adult articular cartilage. METHODS:Gene expression profiles of cartilage from patients with late-stage osteoarthritis (OA) were compared with those from patients with early OA and normal controls in 2 separate microarray analyses. Histologic features of cartilage were graded using the Mankin scale, and GADD45beta was localized by immunohistochemistry. Human chondrocytes were transduced with small interfering RNA (siRNA)-GADD45beta or GADD45beta-FLAG. GADD45beta and COL2A1 messenger RNA (mRNA) levels were analyzed by real-time reverse transcriptase-polymerase chain reaction, and promoter activities were analyzed by transient transfection. Cell death was detected by Hoechst 33342 staining of condensed chromatin. RESULTS:GADD45beta was expressed at higher levels in cartilage from normal donors and patients with early OA than in cartilage from patients with late-stage OA. All chondrocyte nuclei in normal cartilage immunostained for GADD45beta. In early OA cartilage, GADD45beta was distributed variably in chondrocyte clusters, in middle and deep zone cells, and in osteophytes. In contrast, COL2A1, other collagen genes, and factors associated with skeletal development were up-regulated in late OA, compared with early OA or normal cartilage. In overexpression and knockdown experiments, GADD45beta down-regulated COL2A1 mRNA and promoter activity. NF-kappaB overexpression increased GADD45beta promoter activity, and siRNA-GADD45beta decreased cell survival per se and enhanced tumor necrosis factor alpha-induced cell death in human articular chondrocytes. CONCLUSION:These observations suggest that GADD45beta might play an important role in regulating chondrocyte homeostasis by modulating collagen gene expression and promoting cell survival in normal adult cartilage and in early OA.

Objectives: To examine patient characteristics and outcomes of total knee replacement (TKR) in orthopaedic specialty hospitals. Methods: We performed a retrospective cohort study in the US Medicare population. We defined specialty hospitals for TKR as centers: (1) that performed >75 TKRs in Medicare recipients in 2000; (2) in which TKR accounted for >7% of all Medicare discharges; and (3) that had <300 beds. We divided specialty hospitals into those with ≤100 beds and those with 101–299 beds. We compared preoperative characteristics and complications among patients undergoing TKR in specialty and nonspecialty centers. We stratified patients according to risk of complications and performed stratum-specific analyses. Results: A total of 2417 patients received TKA in 19 specialty hospitals, accounting for 3% of all TKRs in 2000. The specialty hospitals had fewer patients with poverty level income. The smaller "boutique" specialty hospitals had lower complication rates than the larger specialty hospitals and the nonspecialty centers (P value for trend = 0.001). In analyses that adjusted for patient age and sex, low-risk patients had similar outcomes across all hospital categories. However, high-risk patients had statistically significantly greater benefit from treatment in smaller specialty hospitals, with the risk of any adverse event ranging from 1.4% (95% CI, 0%–3.5%) in smaller specialty hospitals to 4.9% (95% CI, 4.4%–5.5%) in low-volume centers. Conclusions: Smaller specialty hospitals have low complication rates and are especially beneficial for high-risk patients. Further work should address functional outcomes, costs, and satisfaction in these specialty centers, and evaluate strategies to manage more high-risk patients in specialty centers.

Osteoclast and their mononuclear cell precursors are present within the bone microenvironment at sites of physiologic and pathologic bone resorption. Analysis of tissues from sites of bone resorption reveal that cells expressing the full morphological and functional properties of mature osteoclasts are restricted to the immediate bone surface. We hypothesize that in addition to cytokines, components of the bone matrix and specific cell surface receptors on osteoclasts and their precursors play an essential role in determining the genetic profile and functional properties of fully differentiated resorbing osteoclasts. We have employed expression profiling, with an in vitro model of matrix-dependent osteoclast differentiation, to identify the molecular pathways by which bone matrix-interactions induce terminal osteoclast differentiation and activation. In preliminary studies, we have identified unique genes and transcriptional pathways that are induced by interaction of osteoclast precursors with specific components of the mineralized bone matrix. The authenticity of the gene profiles, as markers of osteoclast differentiation and activation, have been provisionally validated using an in vivo animal bone implantation model and by examination of tissues from patients with specific forms of pathologic osteoclast-mediated bone resorption. The ultimate goal of our studies is to identify new molecular targets for inhibiting osteoclast-mediated bone loss in disorders of pathologic bone loss.

Consecutive patients having elective total hip arthroplasty were prescribed 1 mg of warfarin for 7 days preceding surgery, variable doses while in hospital (target international normalized ratio, 1.5-2.0), and discharged to rehabilitation center or home taking 1 mg daily until 4-week to 6-week follow-up visit. Lower leg pneumatic compression was used postoperatively and elastic compression stockings after discharge. Hospital and clinic charts plus auxiliary sources were reviewed for evidence of thromboembolic diseases (TED). Of 1003 consecutive patients studied, 3 (0.3%, 95% CI 0.0-0.6%) had symptomatic TED, including 2 with deep venous thrombosis and 1 with nonfatal pulmonary embolus. Follow-up rate was 99.1%. Complications from warfarin were minimal. Very–low-dose warfarin coupled with lower leg compression is effective prophylaxis against TED after elective hip arthroplasty when prescribed as described.

We sought to determine if a generalized relationship between the dGEMRIC index ( T 1 Gd relaxation time) and compressive stiffness of articular cartilage could be defined across multiple samples. Osteochondral blocks were cut from 12 human tibial plateaus, six from cadaveric sources and six from total knee replacement surgeries. Each block contained submeniscal (“covered”) and extrameniscal (“uncovered”) cartilage regions. At ∼18 sites per block, a pulse indentation was applied and local dGEMRIC index was determined using dGEMRIC MRI. No correlation was found between stiffness and full cartilage depth dGEMRIC index. When averaged over the depth comparable to the indentation, good correlations were found between stiffness and the dGEMRIC index whether all data were combined, or whether each sample/region was considered independently. However, the standard error of the estimate for predicting stiffness from the local dGEMRIC index was improved when the uncovered and covered regions were considered separately. Further improvement in predictive capacity was obtained if, rather than predict absolute stiffness, differences in the dGEMRIC index across a region were used to predict difference in stiffness. The dGEMRIC index is highly correlated to mechanical stiffness. A generalized relationship was found to provide good correspondence across sources and regions. Use of the dGEMRIC index as a predictive measure of stiffness is possible, depending on the application's acceptable error. © 2007 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 25:904–912, 2007

Wear debris from metal-on-polyethylene articulation in conventional total hip arthroplasty can limit the implant's longevity. Modern ceramic material with high wear resistance and low fracture risk has the potential to extend the lifetime of total hip arthroplasty, which makes the procedure potentially more suitable for young, active patients. Concerns with brittle ceramic material include fracture risk, the "squeak" phenomenon, and potentially a higher dislocation rate secondary to limited neck lengths and liner options. We therefore determined the early dislocation rate in modern ceramic-on-ceramic total hip arthroplasty. In 1635 total hip arthroplasties performed over the 9-year period (1996-2005), we observed three anterior and 15 posterior dislocations (1.1%). All were treated successfully, one with a revision and 17 with closed reduction under general anesthesia. Ceramic-on-ceramic total hip arthroplasty can be a good alternative bearing surface with a low dislocation rate.

Type C bone, as described by Dorr, exhibits both cellular and structural compromise, which presents a challenge for fixation of a total hip arthroplasty (THA). We evaluated the performance of the Omnifit® HA stem, a hydroxyapatite-coated titanium alloy stem, by retrospectively reviewing the clinical and radiographic data of 15 patients with femoral Type C bone who received the stem during primary THA between 1991 and 1994. The patients were followed a minimum of 9 years (mean, 11.5 years; range, 9-14 years). The average age at surgery was 54 years and the average body mass index was 28. Eight of the patients were men. The median Harris hip score was 94.5 points. Radiographically, two independent reviewers identified all patients as Type C bone. The average canal to calcar isthmus ratio was 0.74 (range, 0.65-0.95). At most recent followup, four patients demonstrated proximal osteolysis. Using plain radiography we detected no patients with distal osteolysis or subsidence. At 9 to 14 years, the stem has performed well in a selected series of patients with poor bone quality and the outcomes compare favorably with previously reported findings using this design of stem in other bone types. These results support the decision to use a hydroxyapatite-coated stem in patients with Type C bone.Level of Evidence: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Prosthetic wear debris-induced peri-implant osteolysis is a major cause of aseptic loosening after total joint replacement. In this condition, wear particles released from the implant components induce a granulomatous inflammatory reaction at the interface between implant and adjacent bone, leading to progressive bone resorption and loss of fixation. The present study was undertaken to characterize definitively the phenotype of osteoclast-like cells associated with regions of peri-implant focal bone resorption and to compare the phenotypic features of these cells with those of mononucleated and multinucleated cells associated with polyethylene wear particles. Peri-implant tissues were obtained from patients undergoing hip revision surgery for aseptic loosening after total joint replacement. Cells were examined for the expression of several markers associated with the osteoclast phenotype using immunohistochemistry, histochemistry, and/or in situ hybridization. CD68 protein, a marker expressed by multiple macrophage lineage cell types, was detected in mononucleated and multinucleated cells associated with polyethylene particles and the bone surface. Cathepsin K and tartrate-resistant acid phosphatase were expressed highly in both mononucleated and multinucleated cells associated with the bone surface. Levels of expression were much lower in cells associated with polyethylene particles. High levels of beta3 integrin protein were detected in cells in contact with bone. Multinucleated cells associated with polyethylene particles exhibited faint positive staining. Calcitonin receptor mRNA expression was detected solely in multinucleated cells present in resorption lacunae on the bone surface and was absent in cells associated with polyethylene particles. Our findings provide further evidence that cells expressing the full repertoire of osteoclast phenotypic markers are involved in the pathogenesis of peri-implant osteolysis after total joint replacement. They also demonstrate that foreign body giant cells, although believed to be phenotypically and functionally distinct from osteoclasts, express many osteoclast-associated genes and gene products. However, the levels and patterns of expression of these genes in the two cell types differ. We speculate that, in addition to the role of cytokines and growth factors, the substrate with which these cells interact plays a critical role in their differential phenotypic and functional properties.

Compared with alternative bearings, alumina ceramics are extremely hard and scratch resistant, have a lower coefficient of friction, and superior wear resistance. Four hundred seventy-five hips were implanted as part of a multicenter prospective study comparing alumina-on-alumina ceramic bearings with a control chrome cobalt-on-polyethylene bearing. At 4- to 9-year follow-up, the alumina ceramic bearings have significantly higher survivorship than the metal-on-polyethylene cohort when revision for any reason is evaluated. No ceramic fracture or alumina ceramic device failures have occurred out to 9 years. Alumina ceramic bearings provide a safe option for the younger and more active patient.