import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' **Location**: Exits pelvis through greater sciatic notch below piriformis, runs 2cm posterior to short external rotators, lies posterior to hip joint **Protection**: Tag and retract piriformis/conjoint tendons anteriorly, use retractors carefully during posterior capsulotomy, avoid deep posterior retractors, ensure NO excessive limb traction or manipulation **Location**: Exits pelvis above piriformis through greater sciatic notch, enters gluteus medius/minimus 3-5cm proximal to greater trochanter **Protection**: Limit proximal dissection to <5cm above GT, avoid superior retractor placement above muscle split, ensure muscle split follows fibers in line with superior gluteal nerve **Location**: Anterior to hip in femoral triangle - nerve lateral, artery central, vein medial, 2-3cm medial to anterior capsule **Protection**: Anterior approach requires careful dissection, avoid medial retractors penetrating deep, protect with Hohmann retractors on bone, ensure NO forced manipulation **Location**: Runs under inguinal ligament 1-2cm medial to ASIS, in superficial fascia over sartorius **Protection**: Anterior approach incision 2cm lateral and distal to ASIS (away from nerve), dissect deep to fascia lata, avoid superficial retractors medially **Location**: Thin bone separating acetabulum from intrapelvic structures (iliac vessels, bladder, rectum) - only 2-4mm thick at quadrilateral plate **Protection**: Ream medially to TRUE floor (transverse ligament landmark), avoid excessive medial force, measure screw length carefully (max 20-25mm), NO anteroinferior screws ## Ideal Candidate Profile **Age and Life Expectancy**: - Primary target: <65 years with life expectancy >30 years - Ceramic ultra-low wear (0.001-0.004 mm/year) prevents osteolysis over decades - Cost-benefit analysis: 2-3x bearing cost justified by avoiding early revision - Registry data (AOANJRR): Similar revision rates to metal-on-HXLPE in young patients at 10 years (>95% survival) **Activity Level Requirements**: - MUST accept lifelong LOW-IMPACT activities only - Encouraged: Walking, swimming, cycling, golf, dancing, light hiking, elliptical - PROHIBITED: Running, jumping, basketball, tennis, skiing, contact sports, high-impact aerobics - Falls prevention critical - neuromuscular disorders or high fall risk are relative contraindications **Physical Characteristics**: - Normal BMI preferred (<35) - obesity increases component loads and fracture risk - Excellent bone quality - ceramics require stable rigid fixation without subsidence - Normal hip anatomy - dysplasia or major deformity increases malposition risk - Intact acetabular rim - 360° contact essential for ceramic liner stability **Specific Indications**: 1. Primary osteoarthritis in young patient 2. Inflammatory arthritis (RA, AS) in young patient requiring THR 3. Post-traumatic arthritis from acetabular fracture (if bone stock adequate) 4. Avascular necrosis of femoral head 5. Metal allergy or hypersensitivity (documented or suspected) 6. Patient preference for lowest wear option after counseling ## Ceramic Types and Properties **Alumina Ceramics (First Generation)**: - Pure aluminum oxide (Al₂O₃) - hardness similar to diamond - Historical fracture rate 0.4% (1970s-1980s) - improved to 0.05% by 1990s - Higher squeak rate (5-10%) due to friction characteristics - Largely superseded by composite ceramics **Alumina-Zirconia Composite (Modern Standard)**: - BIOLOX Delta: 82% alumina, 17% zirconia, 1% chromium oxide/strontium oxide - Increased strength +250%, increased toughness +150% vs pure alumina - Fracture rate reduced to 0.004-0.013% in recent registries - Lower squeak rate (1-3%) due to superior tribology - Current gold standard ceramic material **Ceramic-on-Ceramic vs Ceramic-on-Polyethylene**: ## Preoperative Templating **Imaging Requirements**: - AP pelvis with femurs included - magnification marker (25mm ball) at GT level - Lateral hip (cross-table or frog-leg) - assess femoral offset and version - CT scan if dysplasia or deformity - assess bone stock and acetabular version - Ensure NO overlying bowel gas or soft tissue obscuring landmarks **Acetabular Templating**: - Template cup size to achieve 70-80% host bone contact - Target position: 40-45° inclination (radiographic), 15-20° anteversion - Mark anatomic landmarks: tearoom (superior roof), medial wall, anterior/posterior columns - Plan screw positions if needed - posterosuperior quadrant only (10-2 o'clock) - Measure hip center to medial wall - screw length calculation (max 20-25mm) **Femoral Templating**: - Template stem size to achieve metaphyseal fit (cementless) or canal fill (cemented) - Measure offset - restore anatomic offset or increase slightly for stability - Measure neck length - restore leg length or correct preoperative discrepancy - Plan stem version - 10-15° anteversion standard (combine with cup for total 30-35°) **Component Selection**: - Ceramic head size: 32-36mm most common (balance dislocation vs squeak/torque) - Larger heads (36-40mm): Lower dislocation, higher torque/squeak risk - Smaller heads (28-32mm): Lower squeak, higher dislocation risk - Ceramic liner thickness: Minimum 4-6mm to prevent fracture - Verify cup-liner compatibility - manufacturer-specific pairing (NOT interchangeable) - Verify stem taper type - usually 12/14 standard taper but confirm with manufacturer - ORDER BACKUP components: Metal head and polyethylene liner in case ceramic unsuitable intraoperatively ## Posterior Approach (Moore/Southern) - Most Common **Patient Positioning**: - Lateral decubitus position with affected side up - Beanbag or pegboard fixation for pelvis - RIGID positioning essential - Anterior pelvic posts at ASIS and pubis, posterior support at sacrum - Ensure pelvis perpendicular to floor - verify with level or fluoroscopy - Contralateral hip/knee flexed, ipsilateral leg draped free - Prepare full circumferential leg draping for manipulation **Skin Incision**: - Centered on greater trochanter - identify GT by palpation - Curved or straight 10-15cm incision from 5cm proximal to GT extending distally along femoral shaft - Shorter incision possible for minimally invasive approach (8-10cm) if experienced **Deep Dissection**: 1. Incise fascia lata along skin incision 2. Split gluteus maximus fibers bluntly along fiber direction (proximal 2/3 to distal 1/3 fiber transition) 3. Identify greater trochanter and short external rotators insertion 4. CRITICAL: Identify sciatic nerve - runs 2cm posterior to rotators - protect throughout 5. Tag short external rotators (piriformis, superior/inferior gemelli, obturator internus conjoint) with stay sutures 6. Release rotators 1cm from GT insertion - leave cuff for later repair 7. Perform T-shaped posterior capsulotomy - tag capsule with sutures for repair 8. Place retractors: Anterior (over femoral neck), posterior (protecting sciatic nerve), inferior (acetabular floor) **Hip Dislocation**: - Flex hip 90°, adduct across table, internal rotate - posterior dislocation - If tight, release more capsule or external rotators - Once dislocated, place femoral head corkscrew and remove head with twisting motion - Send for culture, pathology, and microbiologic analysis - Perform 360° capsulectomy to improve exposure and reduce impingement risk ## Anterior Approach (Smith-Petersen Modified) - Alternative **Patient Positioning**: - Supine on standard OR table or specialized orthopedic table - Perineal post if using traction table - Bump under ipsilateral buttock to internally rotate hip - Both legs draped to allow comparison **Skin Incision**: - 8-10cm incision starting 2cm lateral and 2cm distal to ASIS - Extend distally along line toward lateral patella **Deep Dissection**: 1. Incise fascia lata - identify interval between sartorius (medial) and TFL (lateral) 2. Internervous plane: Sartorius (femoral nerve) vs TFL (superior gluteal nerve) 3. CRITICAL: Lateral femoral cutaneous nerve runs superficial - protect by staying deep 4. Incise deep fascia between muscles - develop interval bluntly 5. Identify ascending branch of lateral femoral circumflex artery - ligate/cauterize 6. Retract rectus femoris medially - may release reflected head from anterior capsule 7. Anterior capsulotomy - T-shaped or extended along femoral neck 8. Place retractors around femoral neck **Hip Dislocation**: - Flex hip, externally rotate, apply anterior force - anterior dislocation - May require release of iliopsoas or capsule if tight - Remove head, perform anterior capsulectomy ## Acetabular Exposure **Retractor Placement (Critical for Ceramic Liner Visualization)**: - Anterior retractor: Hohmann over anterior wall at 3 o'clock (right hip) or 9 o'clock (left hip) - Posterior retractor: Hohmann over posterior wall at 9 o'clock (right) or 3 o'clock (left) - Inferior retractor: Broad retractor (Cobra) at 6 o'clock on floor/transverse ligament - Superior exposure: Remove labrum, clear soft tissue **Landmarks**: - Transverse ligament: Inferior landmark - marks TRUE floor (do not ream below) - Fovea centralis: Central landmark - Anterior/posterior walls: Orientation guides - Horseshoe: Subchondral bone U-shape - marks acetabular rim ## Reaming Philosophy for Ceramics **Why Precision Matters**: - Ceramic bearings are UNFORGIVING of malposition - Edge loading from malposition causes: 1. Stripe wear (linear wear pattern on head/liner) 2. Increased friction and squeaking (up to 30% if malpositioned) 3. Accelerated bearing failure 4. Patient dissatisfaction - Target: Lewinnek safe zone 40-45° inclination, 15-20° anteversion - Malposition (outside safe zone) increases dislocation 4x AND squeak 6-10x **Reaming Technique**: 1. **Initial Reaming**: Start 4-6mm smaller than templated size, ream to bleeding subchondral bone 2. **Incremental Reaming**: Advance in 2mm increments, assess rim contact after each reamer 3. **Orientation Control**: - Inclination: Reference pelvic position (perpendicular), aim 40-45° lateral opening - Anteversion: Reference transverse ligament (inferior), anterior/posterior walls, aim 15-20° anterior opening - Use fluoroscopy or navigation if available - ceramics worth extra verification 4. **Medial Reaming**: Ream medially to anatomic floor (transverse ligament) - NOT lateral high hip center 5. **Rim Assessment**: Final reamer must achieve 360° uniform contact - NO gaps or defects 6. **Bone Quality**: Ensure excellent subchondral bone - osteoporotic or deficient bone may preclude ceramic liner **Final Reamer Size**: - Typically 54-60mm for average patient - Measure actual reamed size - cup will be 1-2mm larger for press fit - Confirm 360° bleeding bone rim with no defects - If rim defects present, consider augments or switch to polyethylene liner ## Cup Insertion - Positioning Critical **Cup Selection**: - Uncemented metal cup (titanium) with porous coating for osseointegration - Size 1-2mm LARGER than final reamer (56mm cup for 54mm reamer) for press fit - Manufacturer-specific ceramic liner compatibility - verify cup model matches available liners **Cup Orientation**: - Use cup inserter aligned to target angles - CRITICAL: 40-45° inclination (radiographic angle from horizontal) - CRITICAL: 15-20° anteversion (rotation from coronal plane) - Cross-check with: 1. Pelvic landmarks (ASIS anteriorly, sacrum posteriorly) 2. Transverse ligament inferiorly 3. Fluoroscopy C-arm if available (AP and lateral views) 4. Computer navigation if available - ceramics are worth the technology **Impaction Technique**: 1. Position cup in reamed acetabulum with inserter at target angles 2. Initial press with manual pressure 3. Sequential controlled mallet strikes - start periphery, work to center 4. Listen for pitch change - dull (seating) to sharp (fully seated) 5. Avoid excessive force - risk rim fracture or cup deformation 6. Confirm fully seated - NO gap between cup rim and bone rim, 360° contact **Stability Assessment**: - Remove cup inserter, reattach, attempt to toggle cup - Cup should be ABSOLUTELY stable with no micromotion - If any instability, use supplemental screw fixation **Supplemental Screw Fixation**: - RECOMMENDED for ceramic liners - reduces liner micromotion (reduces squeak/fracture risk) - Use 2-3 screws in POSTEROSUPERIOR quadrant (10-2 o'clock position) - AVOID anteroinferior screws (3-5 o'clock) - risk to external iliac vessels - Measure screw length carefully - distance from cup rim to medial wall (typically 20-25mm max) - Drill through screw holes, measure depth, insert screws 2-4mm shorter than depth - Confirm NO medial wall penetration with fluoroscopy if available ## Ceramic Liner Insertion - Handle with Extreme Care **Ceramic Liner Properties**: - Brittle material - fractures with point loads or impact - Even microscopic cracks propagate to catastrophic failure under load - CANNOT be removed after seating - must get it right first time **Cup Preparation (CRITICAL STEP)**: 1. Remove ALL debris from metal cup - blood, bone particles, soft tissue 2. Irrigate cup copiously with saline 3. Dry cup completely with lint-free gauze - NO fluid or blood 4. Inspect cup - ensure no scratches or damage to liner seating surface 5. Re-dry immediately before liner insertion **Liner Inspection**: - Remove liner from sterile packaging carefully - Inspect entire surface under good lighting - Look for ANY chips, cracks, scratches, or defects - REJECT liner if ANY defect found - even microscopic damage will propagate - Verify liner size matches cup size exactly (manufacturer-specific pairing) **Liner Insertion Technique**: 1. Identify orientation markers on liner and cup (anteversion reference) 2. Align liner to cup - markers should match 3. Position liner at cup opening 4. Press liner into cup with steady FIRM hand pressure 5. Manufacturer-specific technique: - Some liners press-fit by hand only - Some allow gentle impaction with plastic-tipped device - Some have locking rings or snap-fit mechanisms 6. NEVER strike ceramic liner directly with metal mallet - will microfracture 7. Continue pressure until fully seated **Seating Verification**: - Visual inspection: 360° circumferential contact between liner and cup - NO GAPS - Tactile: Run finger around liner-cup junction - should be flush, no step-off - Attempt to remove liner by hand - should be IMPOSSIBLE - Verify locking mechanism engaged if present (snap or click) - If not fully seated, remove (if possible), clean cup again, re-insert - If gap persists, REJECT ceramic liner and switch to polyethylene backup ## Femoral Exposure and Preparation **Femoral Exposure**: - Place femoral elevator to lift proximal femur into wound - Circumferential soft tissue release from metaphysis - Identify anatomic landmarks: greater trochanter, lesser trochanter, calcar **Entry Point**: - STRAIGHT stems: Piriformis fossa (medial to GT tip) - ANATOMIC stems: Lateral to piriformis fossa (GT tip) - Entry point determines stem alignment - medial entry risks varus **Box Chisel**: - Orient chisel with handle LATERAL (prevents varus stem positioning) - Remove cancellous bone from metaphysis - create space for broach - Preserve calcar integrity - important for stem stability **Broaching Technique**: 1. Start with smallest broach (typically size 1-3 depending on templating) 2. Handle lateral, gentle mallet strikes, advance down femoral canal 3. Version control: Aim 10-15° anteversion (reference lesser trochanter - should be posterior-medial) 4. Avoid varus - keep handle lateral, check with fluoroscopy if available 5. Progressive broach sizes - typically advance 1-2 sizes at a time 6. Stop when broach achieves: - Cortical contact (firm feel, pitch change) - No toggle or rotation - Flanges at calcar level (fully seated) 7. Final broach size determines stem size **Critical for Ceramics**: - Stem MUST be perfectly stable - subsidence changes head-liner relationship and causes edge loading - In young patients with good bone: Cementless standard (press fit) - In elderly or osteoporotic bone: Consider CEMENTED stem for immediate rigid fixation - Ceramics cannot tolerate subsiding stem - cemented may be better despite patient age ## Trial Reduction with Metal Components **Trial Components**: - NEVER trial with ceramic components - risk damage - Use METAL trial stem (size of final broach) and METAL trial head - Trial head sizes: 28mm, 32mm, 36mm (have range available) - Trial neck lengths: Standard, +4mm, +8mm **Reduction Technique**: 1. Place trial stem in femoral canal 2. Attach trial head - typically start with standard neck length, templated head size 3. Reduce hip carefully with traction, rotation, leverage 4. Confirm head in liner visually and with fluoroscopy **Stability Testing**: 1. **Anterior stability**: Extend hip fully, externally rotate 40° - should remain stable 2. **Posterior stability**: Flex hip 90°, internally rotate 40°, adduct - should remain stable 3. **Full ROM**: Flexion 110-120°, extension 0°, abduction, adduction, rotation 4. **Impingement check**: Feel for hard stops during ROM - indicates bony or component impingement **Leg Length Assessment**: 1. Overlapping patellae method - legs straight, compare patella heights 2. ASIS to medial malleolus measurement - compare sides 3. Fluoroscopy: Lesser trochanter to ischial tuberosity distance - compare to preop 4. Target: Within 1cm equality (small lengthening acceptable, shortening avoided) **Adjustments**: - If unstable: Try larger head size, longer neck, reposition cup, augment soft tissue repair - If leg length discrepancy: Change neck length, change cup position (rare) - If impingement: Identify source (cup position, stem position, bone), correct before proceeding **CRITICAL Decision Point**: - If ANY instability that cannot be corrected with component changes or soft tissue optimization: DO NOT use ceramic bearing - Ceramics CANNOT be used with: - Constrained liners (require polyethylene) - Dual mobility systems (require polyethylene) - Locking mechanisms (most require polyethylene) - If instability present: Switch to polyethylene liner (backup) and use larger head or dual mobility ## Final Femoral Stem Implantation **Cementless Stem**: 1. Remove trial components, clean femoral canal (irrigation, suction) 2. Insert final stem (same size as final broach, same version) 3. Press fit with progressive controlled strikes 4. Advance until stem fully seated: - Flanges at calcar level - No step-off or gap - Firm endpoint feel 5. Confirm stability - no toggle, no subsidence with pressure **Cemented Stem (if chosen for elderly/poor bone)**: 1. Clean canal thoroughly - pulsatile lavage 2. Dry canal - lap sponges 3. Place cement restrictor 1-2cm distal to templated stem tip 4. Retrograde cementation with cement gun - fill canal from distal to proximal 5. Pressurize cement with pressurizer or thumb 6. Insert stem during doughy phase (no longer liquid, not yet rubbery) 7. Hold stem in correct position (version, depth) until cement hardens (5-10 minutes) 8. Remove excess cement carefully - especially posterior (sciatic nerve protection) ## Ceramic Femoral Head Impaction - MOST CRITICAL STEP **Why This Step Matters**: - Improper technique causes ceramic fracture (0.004-0.05% but catastrophic if occurs) - Taper fretting/corrosion from incomplete seating causes late head dissociation - This is the HIGHEST risk step for preventable ceramic complications **Ceramic Head Inspection**: 1. Remove from sterile packaging carefully - avoid dropping or striking 2. Inspect ENTIRE surface under good lighting 3. Look for ANY chips, cracks, scratches, or defects 4. REJECT head if ANY defect found 5. Verify head size matches trial (from prior stability testing) 6. Verify head taper matches stem taper: - Standard 12/14 taper most common - Some stems use V40 or other tapers - Mismatch causes fretting and dissociation **Stem Taper Preparation (CRITICAL)**: 1. Clean taper with lint-free gauze soaked in saline 2. Wipe thoroughly - remove ALL blood, bone debris, cement, soft tissue 3. Inspect taper under good lighting - should be shiny metal, no debris visible 4. Dry taper completely with clean dry lint-free gauze 5. NO blood, fluid, or debris on taper surface 6. Re-clean and re-dry immediately before head placement if any contamination **Head Impaction Technique**: 1. Position hip in accessible position for impaction 2. Hold ceramic head with hand, position over stem taper 3. Align head version to stem version (should match - typically 10-15° anteversion) 4. Seat head onto taper with gentle hand pressure initially 5. Use plastic-tipped head impactor (or metal impactor with plastic/rubber tip) 6. Apply 2-3 FIRM strikes with mallet - First strike: Moderate force - Second strike: Firm force - Third strike (if needed): Final seating force 7. Listen for pitch change - dull (seating) to sharp/high-pitched (fully seated) 8. Stop when fully seated - excessive strikes can fracture **Seating Verification**: 1. Visual inspection: No gap visible between head and stem neck/shoulder 2. Attempt to rotate head manually - should be IMPOSSIBLE to move 3. If head rotates or wobbles: NOT fully seated - apply additional impaction strikes 4. If still unstable after multiple strikes: Taper mismatch or damaged - REJECT head and stem **Critical Errors to Avoid**: - Debris on taper - causes incomplete seating, point loading, fracture - Insufficient impaction - causes taper fretting, dissociation, fracture - Excessive impaction - can fracture head - Striking ceramic with metal mallet directly - microfractures - Wrong taper size - will not seat properly - Wrong head size - cannot change after impaction (stuck on taper) ## Hip Reduction and Stability Assessment **Reduction Technique with Ceramic Components**: - GENTLE manipulation - avoid forceful wrenching (ceramic fracture risk) - Apply longitudinal traction - Flex hip slightly, rotate to align head with liner - Ease head into liner with controlled pressure - Confirm reduction visually and by feel **Post-Reduction Stability Testing**: - Repeat SAME stability tests as with metal trials - Anterior stability: Extension + 40° ER - Posterior stability: 90° flexion + 40° IR + adduction - Full ROM check: Flexion, extension, abduction, adduction, rotation - Stability should be IDENTICAL to trialing - If DIFFERENT: Something wrong (component malposition, soft tissue interposition, head size error) - Must identify and correct before closure **Range of Motion Assessment**: - Flexion: Should achieve 110-120° without impingement - Extension: Full extension to 0° or slight hyperextension - Abduction: 40-50° - Adduction: 20-30° (limited by opposite leg) - Rotation: Internal and external rotation in flexion and extension **Impingement Testing (CRITICAL for Ceramics)**: - Move hip through full ROM in all planes - Feel for hard stops (bony or component impingement) - Impingement causes: 1. Edge loading on ceramic bearing 2. Stripe wear 3. Increased friction and SQUEAKING 4. Accelerated wear - If impingement identified: - Check cup position (most common cause) - Check stem position - Remove osteophytes (femoral neck, acetabular rim) - Adjust components if needed **Fluoroscopy Confirmation**: - AP view: Cup inclination 40-45°, head centered in liner - Lateral view: Cup anteversion 15-20° - Assess for component malposition, femoral fracture, wire/screw placement ## Irrigation and Hemostasis **Irrigation**: - Copious irrigation with 3-6 liters warm normal saline - Remove ALL ceramic particles, bone debris, blood, soft tissue - Ceramic particles cause third-body wear if retained - Consider pulsatile lavage for deep areas - Final inspection of hip joint - should be clean **Hemostasis**: - Identify and cauterize/ligate bleeding vessels - Bone bleeding: Bone wax (use sparingly) or thrombin-soaked gelfoam - Soft tissue bleeding: Electrocautery or ligature - Ensure NO active bleeding before closure - Consider tranexamic acid (topical 2-3g in 100ml saline for 5 minutes) to reduce blood loss ## Soft Tissue Repair **Posterior Approach Repair**: 1. **Posterior Capsule**: Heavy absorbable suture (0 or 1 Vicryl/PDS) - Repair capsule to capsule in figure-of-8 or interrupted sutures - Or repair capsule to short external rotator cuff - Capsular repair reduces dislocation rate 3-4x (from 5-8% to 1-2%) 2. **Short External Rotators**: Repair to greater trochanter - Transosseous tunnels in GT (preferred - strongest repair) - Or repair to soft tissue cuff left on GT - Heavy absorbable suture (0 or 1 Vicryl) - Ensure adequate tension - slack repair increases dislocation 3. **Gluteus Maximus Fascia**: Close with running absorbable suture (1 Vicryl) **Anterior Approach Repair**: 1. Repair anterior capsule with absorbable suture 2. Reattach reflected head of rectus femoris to anterior capsule or bone 3. Close interval between sartorius and TFL (fascia lata) **Universal Closure**: 1. **Deep fascia**: Running absorbable suture (1 Vicryl) 2. **Subcutaneous**: Interrupted or running absorbable suture (2-0 or 3-0 Vicryl) 3. **Skin**: Staples, running subcuticular suture, or tissue adhesive **Drain Placement**: Optional - Pros: Reduces hematoma, allows monitoring - Cons: Infection risk, patient discomfort - If used: Remove at 24-48 hours or when output <30ml/8hr ## Post-operative Protocol **Immediate Post-operative (Day 0-1)**: - Recovery room: Monitor vitals, neurovascular status, drain output - Abduction pillow between legs to prevent dislocation - DVT prophylaxis: LMWH (enoxaparin 40mg SC daily) or DOAC (apixaban, rivaroxaban) - Multimodal analgesia: Acetaminophen, NSAIDs (if no contraindication), opioids as needed - Consider spinal morphine or local infiltration analgesia for superior pain control **Mobilization**: - Sit edge of bed Day 0 (day of surgery) or Day 1 - Stand and walk with physiotherapy Day 1 - Weight bearing as tolerated (WBAT) - both cemented and modern cementless stems - Gait aids: Walker or crutches initially, progress to cane, then independent **Hip Precautions (6 weeks for posterior approach)**: - NO hip flexion >90° (avoid low chairs, bending to floor) - NO adduction across midline (keep abduction pillow, avoid crossing legs) - NO internal rotation (avoid pigeon-toed walking) - Sleep with abduction pillow - Use elevated toilet seat, shower chair - Anterior approach: Often NO formal precautions (surgeon-dependent) **Activity Guidance - CRITICAL for Ceramics**: - **Encouraged LOW-IMPACT activities**: - Walking (unlimited - excellent for hip) - Swimming, aqua aerobics (after wound healing) - Cycling (stationary or road - avoid mountain biking) - Golf (after 3 months) - Dancing, ballroom dancing - Light hiking on even terrain - Elliptical trainer, rowing machine - Pilates, yoga (modified to respect ROM limits) - **PROHIBITED HIGH-IMPACT activities (LIFELONG)**: - Running, jogging (high repetitive loads increase fracture risk) - Jumping, basketball, volleyball - Contact sports (football, rugby, hockey, martial arts) - Tennis, squash, racquetball (high twisting loads) - Skiing, snowboarding (high fall risk) - High-impact aerobics, CrossFit - Heavy lifting >25kg repetitively - **Falls Prevention**: - Home safety assessment - Remove tripping hazards, improve lighting - Avoid alcohol excess, ensure vision correction - Neuromuscular disorders (Parkinson's, stroke) require extra precautions **Radiographic Follow-up**: - Immediate post-operative: AP pelvis and lateral hip (confirm position, rule out fracture) - 6 weeks: AP pelvis and lateral hip (assess early subsidence, osseointegration) - 1 year: AP pelvis (assess for wear, osteolysis, loosening) - Lifelong surveillance: Every 2-3 years (ceramics require long-term monitoring) - Assess cup position, stem position, head-liner wear, osteolysis, heterotopic ossification **Monitoring for Ceramic-Specific Complications**: 1. **Squeaking**: Ask at every visit - When: Walking, stairs, rising from chair, specific positions - Severity: Occasional vs constant, bothersome vs tolerable - If severe: Investigate with X-rays, CT, gait analysis - may need revision 2. **Ceramic Fracture**: Rare but catastrophic - Symptoms: SUDDEN pain, grinding sensation, inability to bear weight, may hear 'crack' - Investigation: X-rays show fractured head or liner, ceramic fragments - Management: URGENT revision - remove all ceramic particles, revise to metal/ceramic-on-polyethylene - Prevention: Activity restrictions, falls prevention, proper component positioning ## References 1. Hamilton WG, McAuley JP, Dennis DA, et al. THA with Delta ceramic on ceramic: results of a multicenter investigational device exemption trial. *Clin Orthop Relat Res.* 2010;468(2):358-366. doi:10.1007/s11999-009-1091-4 - Level I evidence: Prospective multicenter FDA IDE trial of 475 THRs with alumina-zirconia composite ceramic-on-ceramic. 5-year survivorship 98.8%, wear rate 0.004 mm/year, squeak 2.7%, no fractures. Demonstrates safety and ultra-low wear of modern composite ceramics. 2. Traina F, De Fine M, Di Martino A, Faldini C. Fracture of ceramic bearing surfaces following total hip replacement: a systematic review. *Biomed Res Int.* 2013;2013:157247. doi:10.1155/2013/157247 - Systematic review of ceramic fracture: Alumina head fracture rate 0.004-0.05% with modern materials (down from 0.4% historical). Causes: trauma, malposition, liner malseating. Emphasizes prevention through proper technique and patient selection. 3. Sexton SA, Yeung E, Jackson MP, et al. The role of patient factors and implant position in squeaking of ceramic-on-ceramic total hip replacements. *J Bone Joint Surg Br.* 2011;93(4):439-442. doi:10.1302/0301-620X.93B4.25707 - Case-control study of 135 ceramic THRs: Squeak rate 10.7%. Cup malposition (outside Lewinnek safe zone) associated with 6x increased squeak risk. Component position most important modifiable factor for squeak prevention. 4. Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). *Hip, Knee & Shoulder Arthroplasty: 2023 Annual Report.* Adelaide: AOA, 2023. - National registry data: Ceramic-on-ceramic revision rate 5.2% at 10 years for osteoarthritis (similar to metal-on-HXLPE 4.8%). Lower wear-related revision than metal-on-metal (historical). Main reasons for ceramic revision: dislocation, fracture, squeak, and infection (similar to standard bearings except squeak). 5. Lewinnek GE, Lewis JL, Tarr R, Compere CL, Zimmerman JR. Dislocations after total hip-replacement arthroplasties. *J Bone Joint Surg Am.* 1978;60(2):217-220. - Classic study defining safe zone for cup position: 40° ± 10° inclination, 15° ± 10° anteversion (ranges 30-50° and 5-25°). Dislocation rate 1.5% within safe zone vs 6.1% outside. Essential reference for ceramic bearing positioning (tighter target 40-45°/15-20° for ceramics to prevent edge loading). 6. Lusty PJ, Watson A, Tuke MA, et al. Wear and acetabular component orientation in third generation alumina-on-alumina ceramic bearings: an analysis of 33 retrievals. *J Bone Joint Surg Br.* 2007;89(9):1158-1164. doi:10.1302/0301-620X.89B9.19282 - Retrieval study of 33 ceramic bearings: Median wear rate 0.003 mm/year (ultra-low). Stripe wear pattern in 45% associated with edge loading from malposition. Demonstrates importance of precise positioning for optimal ceramic wear performance. 7. Hwang KT, Kim YH, Kim YS, Choi IY. Is second-generation ceramic-on-ceramic bearing as good as the current bearing in primary total hip arthroplasty? *J Arthroplasty.* 2013;28(10):1861-1865. doi:10.1016/j.arth.2013.03.034 - Comparison of pure alumina vs alumina-zirconia composite: Composite had lower squeak rate (1.9% vs 6.3%), no fractures vs 0.7% with pure alumina. Modern composites (BIOLOX Delta) superior to historical pure alumina for clinical outcomes. 8. Capello WN, D'Antonio JA, Feinberg JR, Manley MT, Naughton M. Ceramic-on-ceramic total hip arthroplasty: update. *J Arthroplasty.* 2008;23(7 Suppl):39-43. doi:10.1016/j.arth.2008.06.003 - Long-term outcomes review: 15-year survivorship 94% with ceramic-on-ceramic. Minimal osteolysis due to ultra-low wear. Squeak rate 3-5% in well-positioned cups. Supports ceramic bearings for young patients requiring long implant survival. 9. Jarrett CA, Ranawat AS, Bruzzone M, Blum YC, Rodriguez JA, Ranawat CS. The squeaking hip: a phenomenon of ceramic-on-ceramic total hip arthroplasty. *J Bone Joint Surg Am.* 2009;91(6):1344-1349. doi:10.2106/JBJS.F.00970 - Prospective study of 143 ceramic THRs: Squeak rate 10.7% at mean 3.5 years. All squeaks painless and benign - no wear acceleration or loosening. Most patients tolerated squeak. No revisions performed for squeak alone. Reassuring data that squeak is usually benign phenomenon. 10. Baek SH, Kim SY. Cementless total hip arthroplasty with alumina bearings in patients younger than fifty with femoral head osteonecrosis. *J Bone Joint Surg Am.* 2008;90(6):1314-1320. doi:10.2106/JBJS.G.00594 - Long-term outcomes of ceramic-on-ceramic THR in young patients (mean age 37 years, mean follow-up 11 years): Survivorship 95% at 10 years, minimal osteolysis (2%), squeak 4%, no fractures. Excellent durability for young active patients with proper technique and selection.

Total Hip Replacement with Ceramic Bearing Surfaces

Total Hip Replacement with Ceramic Bearing Surfaces