Background

Metastatic bone patients who require surgery needs to be evaluated in order to maximise quality of life and avoiding functional impairment, minimising the risks connected to the surgical procedures. The best surgical procedure needs to be tailored on survival estimation. There are no current available tool or method to evaluate survival estimation with accuracy in patients with bone metastasis. We recently developed a clinical decision support tool, capable of estimating the likelihood of survival at 3 and 12 months following surgery for patients with operable skeletal metastases. After making it publicly available on www.PATHFx.org, we attempted to externally validate it using independent, international data.

Foreword

Silver coatings, used in many surgical devices, have demonstrated good antimicrobial activity and low toxicity. Oncological musculoskeletal surgery have an high risk of infection, so in the last decades, silver coated mega-prostheses have been introduced and are becoming increasingly widespread.

Introduction

The number of total hip arthroplasties in young patients is continuosly increasing. Nowdays, the study of the materials wear, with the goal of improving the survivorship of implants, represents a fundamental subject in this kind of surgery. The role of ceramic materials in the valutation of types of wear is particularly known.

Introduction: It is noted that infections make up the most feared complications of prostheses’ surgery in orthopaedic implants after resection of primary or secondary cancer of limb bones. The causes must be attributed to the entity of the skeletal resection and of surrounding soft tissues sacrifice, to the duration of surgery and to the pre-operative cycle of chemotherapy or radiotherapy. Infections of prostheses in oncology are caused mainly by bacteria present either in isolated strains or in poly-microbic associations, and most recently fungus infections have begun to be found, in immunodepressed patients. Candidemia makes up an important cause of systemic infections in immuno-compromised oncological patients, who received high doses of chemotherapy; moreover candidemia represents a high risk of hospital sepsis. It is noted that the behaviour of the Candida is interpreted through the production of a biofilm and then the inhibition of the production of the biofilm itself is translated into a potential antifungal effect. From the analysis of the literature a protective role carried out by the silver coating of the tumoural prostheses towards the bacterial infections is deduced. It is noted, in fact, the antimicrobiotic effect of medical devices coated in silver; in particular in studies conducted in animals favourable results were demonstrated on bacterial adherence of titanium devices coated with silver. The aim of the study was to evaluate in vitro the inhibition of the production of biofilm by different strains of Candida in the presence of titanium and titanium coated with silver.

Materials and Methods: Six strains of Candida were analyzed: 2 strains of C. albicans, 2 of C. tropicalis and 2 of C. parapsilosis. The fungal strains were stratified on discs of pure titanium, a material in which implants of tumoural prostheses are made, and furthermore on discs of titanium coated in silver, and the ability of the fungus to produce protective biofilm on different substratum was evaluated. All of the studies were conducted 3 times. The adherence to the biofilm was measured by semi-quantitative, colormetric and spettrophotometric methods according to standardized protocols.

Results: The spettrophotometric analysis demonstrated a statistically significant reduction of the production of biofilm by fungus strains that came in contact with titanium coated in silver compared to pure titanium in all of the strains that were examined, attested by the fact that the silver creates a micro-environment unfavourable for fungus growth.

Conclusion: The analysis of the results demonstrated that the Silver coating of the oncological prosthesis made an unfavourable micro-environment not only for bacteria, as has already been widely established, but also for fungus. For this reason we maintain that this coating constitutes a valid opportunity in oncological resections for those patients who, being treated with chemotherapy, radiotherapy and to long hospitalitations present an elevated risk of fungal infection in oncological resections. From the studies we conducted it appeared how fundamental the use of silver in tumoural prosthesis is in order to prevent contamination by fungal strains and how this use must be taken more and more into consideration to improve life expectancy of a particular and sensitive category of patients, especially oncological.

Aims: The innovative surgical procedure of humeral resurfacing emiarthroplasty is currently used for the treatment of younger patients, in need of a bone-preserving implant, affected by primary gleno-humeral osteoarthritis and rheumatoid arthritis, secondary degenerative joint disease, post-traumatic arthritis or mal-unions of the humeral head, loss of articular cartilage, joint incongruity and stiffness, avascular osteonecrosis of the humeral head, combined loss of the gleno-humeral joint surface and rotator cuff loss of function and pain unresponsive to nonoperative measures. Published reports have indicated a large variation in the benefits of this procedure. The aim of this study is to analyse the clinical results obtained by the authors in a preliminary report of a two-years experience in the surgical actuation of this procedure, that represents one of the most innovative options in the field of the shoulder arthroplasty.

Materials and Methods: The authors report the outcomes of their experience in humeral head surface replacement emiarthroplasty. In the last two years 25 selected patients have been treated according to the surgical implantation of the “bone sparing” Global Cap conservative anatomic prosthesis (DePuy). The mean age of the patients was 52 years (range, 34 to 76 years). They have been followed for a mean of 8 months, (range, 4 to 16 months).

Preoperative diagnoses were: osteoarthritis, rheumatoid arthritis, psoriasic arthritis, osteonecrosis and post traumatic arthritis. 8 patients underwent contextual cuff tear repair.

Results: Constant score for the whole group improved from a mean preoperative score of 22 to 60 at the last follow-up. Periprosthetic osteolisys was seen in 3 cases. One case of stiffness required narcosis mobilization at 5 months after surgery. Our results are comparable to those obtained with others modern R.R.H. and are similar to Copeland’s own series.

Conclusions: The preliminary results of our study show how some pre-operative factors appear to influence the functional improvement and the personal satisfaction rate of the patients after humeral resurfacing emiarthroplasty. The most important are represented by: the presence of erosions in the glenoid cartilage, possible previous shoulder surgery and associated cuff tears. The gender of the patients doesn’t appear a discriminating factor. The age appears to influence only boundedly the clinical post-operative outcomes. In our opinion, the initial diagnoses is determinant: patients affected by systemic pathology, like rheumatoid arthritis, or by cuff tear obtain the least functional improvement and satisfaction; on the contrary, patients affected by primary and secondary degenerative joint diseases, post-traumatic cartilage lesions and avascular osteonecrosis of the humeral head obtain better results.

Aims: Reconstruction of bone continuity after wide resections for malignant tumours has always been a big problem in orthopaedic surgery. During the growing age the problem of reconstruction is harder because of the arrest of growing referring to the scheletal segment involved.

Authors present their experience with different surgical methods.

The choice of surgery depends on the age of the growing child and on the site of the neoplasm.

Methods: The personal series of the authors refer to nine osteogenic sarcomas (five of the distal femur, and four of the proximal tibia) and four Ewing’s sarcomas of the femoral diaphysis. The age of the patients was between nine and sixteen years.

Females were eight and males were five. After ten years only ten patients were disease free (seven osteogenic sarcomas and three Ewing’s sarcomas).

Results and conclusion: In four cases of osteogenic sarcoma the patients were under ten years of age and the surgical choice of Authors was dependent to the exention of the surgical resection including the growing cartilage and the normal growing of the controlateral scheletal segment. For this reason authors employed a conservative method using the association of the Ilizarov external fixator with a final arthrodesis employing a long intramedullary nail.

In five cases of o.s. the age of the patients was over fourteen years, the remaining growing period was limited and for this reason a mechanical growing prosthesis was employed.

In the four cases of diaphyseal Ewing’s sarcoma the reconstruction was performed in two cases employing an autologous graft taken from the iliac crest and in two cases a microvascularized fibular graft.

Functional results of the affected limb, in the surviving patients, depend on the sacrifice of the joint (arthro-dhesis) or in the use of a modular prosthesis that, in AA. experience have a follow-up of 12 years; in diaphyseal reconstruction an anatomical result was obtained either with the mcrovascularized fibular graft or with the autologous graft from the iliac crest, the only difference between these two methods depending on the time of bone healing.

Introduction: Antegrade intramedullary locked nailing is a reliable method for the treatment of humeral shaft fractures. There is a still debate on the functional effect due to a possible damage during surgical approach of the rotator cuff, but in the Literature few paper deal with the analysis of tendons in these patients. Ultrasonography is still considered a reliable method in evaluating rotator cuff tendons. The aim of this study is to evaluate if antegrade intramedullary nailing may induce a possible damage on rotator cuff.

Methods: Between May 2002 to December 2005 42 patient suffering of humeral shaft fractures were surgically treated with Unreamed Humeral Nail. Of them 21 (13 males and 8 female) were followed (average follow-up 22,9 months). All the fractures were traumatic except 1 due to bone metastasis of carcinoma. Follow up was clinical with Constant Score, radiographic in 3 projection (neutral, internal and external), and ultrasonographic, evaluating tendon of m. Sovraspinosus.

Results: Healing of fractures was obtained after 2 month from surgery in all cases; Constant Score’s average was 77,0. Three cases of impingement syndrome due to excessive length of nail were observed, healed after the nail removal. Ultrasonography showed that in 13 cases rotator cuff was normal. In 5 cases we have found a signicative hyperecogen area, related to the scarf. We have never had a damage of tendon in all its tickness.

Conclusion: Our study confirms that antegrade intra-medullary nail is a reliable method for the treatment humeral shaft fractures, not adversely influenced shoulder tendons. Damage of rotator cuff observed in few cases is not related to surgical technique, but depends on surgical pitfall with an excessively long nail and then impingement syndrome.

The choice to use alumina in the manufacture of a low-wear THR bearing made by Boutin and its co-workers has proven its effectiveness in almost 35 years of clinical use. A continuous development process aimed to improve mechanical properties led to today’s materials that exhibit extreme high reliability.

The recent introduction in clinical use of alumina matrix composites represents the latest evolution of alumina that thanks to high hardness, toughness, and bending strength allow to manufacture new design of ceramic components. Composites obtained introducing zirconia in the alumina matrix, known as Zirconia Toughened Alumina (ZTA) are candidate for use in THA bearings from a long time. A real breakthrough was represented by alumina ceramics toughened both by zirconia both by platelets nucleated in-situ during sintering (Zirconia-Platelet Toughened Alumina - ZPTA).

The chemical composition and the microstructure of ZPTA were optimised to achieve a ceramic material joining strength of more than 1200MPa, Vickers hardness 1975, fracture toughness of 6,5 MPa m-1/2, andextremely low wear also in the most severe simulator tests performed in microseparation mode The paper reviews the improvements introduced in the technology of ceramic for arthoplasty, and their effects on the microstructural properties and on the performances of the past and actual generation of ceramic for THR bearings, and summarise the results obtained in the development of alumina matrix composites.

Lateral unstable fractures of the femoral neck represent a controversial problem for the surgical treatment, due to the difficulty in achieving an adequate mechanically stable bone-devices system. Compression hip screw alone has proven to be inadequate, while in association with the trochanteric stabilizing plate (TSP) it offers better results. The authors analyse functional results and complications of a series of 87 lateral unstable fractures of the femoral neck (type A2 and A3 of the AO classification). Weight bearing was allowed 48 hours after surgery. The most important complications reported were: persistent trochanteric pain (12 cases) shaft medialization and device mobilization (2 cases) shortening of more than 2cm (3 cases). All complications were reported in A3 type fractures. Our data confirm the efficacy of the TSP the treatment of lateral unstable fractures of the femoral neck (type A2) because it stabilizes the lateral cortex. In A3 type fractures, intramedullary devices offers better results than compression hip screw and TSP in terms of complications rate and stability.

Primitive malignant neoplasms affecting the distal third of the tibia are altogether rare. The authors describe the diagnostic procedure and surgical strategy of limb salvage in a case of malignant fibrous histiocytoma in this region, in a 50-year-old male. In this anatomic region, considering the limb salvage surgery, there are different reconstructive possibilities, as ankle prosthesis and arthrodesis with or without vascolarized fibula. The Authors underline the infective and mechanic problems of these surgical solutions, proposing a different arthrodesis. The surgical treatment consisted in resection of the distal third of the tibia and fibula. The restoration of the skeletal continuity has been obtained by a locked nail. The mechanical resistance of the system has been obtained by acrylic cement. A vascularized myocutaneous flap allowed the cover of the resection area. About 28 months after surgical intervention, the patient is now able to walk without the aid of the knee stabilizer nor the sticks; without signs of local recurrence of the disease, metastases, with no implant failure, nor of the cement. The very favourable outcome of the clinical case previously described should make this method be looked at as one of the available surgical options in treating these lesions.

It is well known that wide resection and reconstruction with modular or composite prostheses is the treatment of choice in high chondrosarcoma of metasepiphyseal bone. Nevertheless there is a debate concerning the treatment of low grade chondrosarcoma, a locally aggressive tumour, similar also histologically to benign lesion. Two different therapeutic options are reported in these lesions: wide resection and intralesion curettage. Between 1995 and 2003 the Authors analysed a series of 37 cases of low grade chondrosarcoma of long bone treated with curettage and local adjuvant, like liquid nitrogen and acrylic cement, if necessary associated with synthesis. The least follow-up was two years. The authors observed 3 local recurrences within the first 12 months from the surgical treatment; and, in every case, an increased grade of malignity was observed at histology. The Authors confirmed that the aggressive intralesional treatment with the use of the local adjuvant like liquid nitrogen and cement, is a valid therapeutic possibility in these lesions, but they confirm that it’s necessary an accurate preoperative diagnosis with also open biopsy for an efficacy treatment.

Elastofibroma dorsi is a rare benign unencapsulated tumour characterized by a elastic fibres proliferation in a collagen stroma with adipose tissue. Lesion is often asymptomatic, monolateral and localized at the tip of the scapular. It is slow-growing. It mainly occurs in adult females. At now some controversies concerning diagnosis and modality of treatment are reported in the literature. Authors report clinicopathological features of elastofibroma dorsi analysing 8 cases from 2001 to 2005, and revise the literature. Seven females and 1 adult male were observed, often dedicated to manual labour. Six symptomatic patients underwent marginal excision of tumour, and the remaining asymptomatic 2 patients were only followed. No local recurrences were observed in operated patients.

On the basis of these data Authors evidenced limits of different instrumental methodologies of diagnosis (ultasonography, computer tomography and magnetic resonance imaging) and suggested a algorithm for diagnosis and treatment remarking that marginal excision constitutes effective treatment of symptomatic patients.

Aim. Ceramic-ceramic coupling is currently used in Orthopaedics in younger patients with longer life expectance, for the high biocompatibility of these materials. More recently new ceramic materials have been developed with better mechanical properties in comparison to Alumina, as the Alumina Matrix Composites by Transformation Toughened and in situ Plateled Reinforcement (ZPTA). The aim of the study was to analyze the biological properties of this material in comparison to Alumina and Zirconia. Materials and methods. Cylinders of different ceramic materials were inserted into surgical created defect of proximal metaepiphysis of New Zealand White adult rabbits to analyze the bone response to ceramics. Percentage of bone ceramic contact was measured. Massive inflammatory response was analyzed by intraarticullar injection of powders of different materials; while chronic low grade response as the one observed in long term well functioning implants was tested by implantation of low cohesive ceramic pellets under patellar tendons of rabbits: thank to leg movements few particles were released in time. Systemic host response was tested analyzing peripheral organs of animals. Results. Connective tissue was present at bone ceramic interface whatever materials used: no statically differences were observed in term of bone ceramic contact among Alumina, Zirconia and ZPTA. Inflammatory response with new vessels was observed around powders, especially with small diameter; while low cohesive pellets did not elicited inflammatory response neither systemic toxicity. Discussion and conclusion. Our results confirm that Alumina Matrix Composites by Transformation Toughened and in situ Plateled Reinforcement, as well as Alumina and Zirconia ceramics, induces a low inflammatory reaction in periprosthetic tissues without any systemic toxicity, due to massive or chronic release. So thank to its higher mechanical properties than Alumina and Zirconia, it should be indicated for ceramic to ceramic coupling in Orthopaedic Surgery.

Pain is the main symptom of acetabular osteolysis and is frequently associated with pathologic fractures. Surgical procedures requiring an aggressive approach, and as a consequence high morbidity, are rarely indicated. The minimally invasive approach may be effective in treating tumours and is capable of reducing the mechanical pain. PMMA has been widely used in neoplastic and spinal surgery as a bone filler because of its mechanical and biologic behaviours. Recently percutaneous injection of PMMA was proposed for the treatment of neoplastic acetabular osteolysis.

The technique was tested in four patients affected by secondary ostheolytic lesions. The patients were evaluated clinically (HHS, Womac, SF-12) and radiographically (X-ray and CT) at 18 months.

All the patients demonstrated a durable and significant improvement in terms of pain and restoration of function. The radiographic examinations (X-ray and CT) confirm these results. Complications (temporary increase in pain and fever) were only observed in one patient.

The preliminary results demonstrate the reliability and effectiveness of this procedure. Clinical results showed a significant reduction in pain and the capability of restoring function. The indications can be extended also to the acetabular lesion at a distance from the weight-bearing zone, reducing pain and the risk of pathologic fractures.

The technique was demonstrated to be effective and showed only minor and self-resolving complications. It is useful in patients in whom major surgery is contraindicated and clinical improvement is necessary to improve the quality of life.

In order to improve hydroxyapatite (Ha) quality as a bone substitute, two types of Ha were developed based on a new and original technique: Ha with graduated porosity (G-Ha) and porous “carbonated” Ha (C-Ha). Ha cylinders were implanted into the femoral diaphysis of NZW rabbits. Before implantation the materials were characterised by XRD, porosimetry, SEM and thermic and mechanical analysis. Macroscopic, radiographic and histologic analysis were performed on the specimens at standard intervals after surgery (1-3-6- and 12 months).

G-Ha proved to be morphologically more similar to bone tissue because of the graduated porosity that mimes the two natural components of bone (cortical-scarce porosity and spongious-high porosity). The C-Ha was chemically more similar to bone because of the CO₃- substitution, which is a normal substitute in natural bone.

Both materials achieved good mechanical strength, in particular the pseudo-cortical portion of G-Ha. Interconnected porosity was also observed in both materials. Newly formed bone appeared earlier in C-Ha (1–3 months). At 1 year C-Ha demonstrated quiescent bone and significant degradation. The G-Ha was scarcely reabsorbed but showed active osteogenesis in the surrounding living bone. Graduated porosity improved the mechanical interaction with bone over time, while the carbonation improved the temporal interaction and Ha resorption.

Porous Ha was found to be a promising bone substitute and also a reliable drug-delivery carrier.

Aims: Yttria-stabilised Zirconia (Y-TZP) ball heads were introduced into the market in 1985. Since then these components have had wide diffusion in hip replacements, due to their good mechanical performance and reliability. Namely, only a few papers were published up to now reporting failures of Y-TZP ball heads. The worldwide recall in August 2001 of some Y-TZP batches changed this situation. The recall was due to an high number of fractures, that were somehow linked to the spontaneous phase transition in Y-TZP. The revision surgery of a zirconia head belonging to the batches in above that fractured 34 months after implant gave us the opportunity to retrieve the fragments for analysis, and to draw some conclusions about the cascade of events that led to the ball head fracture.

Methods: The retrieved specimens were submitted to visual inspection by optical microscopy to analyze the fracture pattern, then selected samples were cut and analysed by FEG-SEM equipped with backscattered CEN-TAURUSA8 detector. Specimen were analysed without any coating. Grain size were measured by SEM-coupled computerized image analysis on thermally etched samples. Phase composition was investigated by XRD. Density was determined by the Archimedes’ method. Periprosthetic tissue membrane collected at revision surgery was observed by light and Scanning Electron Microscopy coupled with EDAX.

Results: XRD showed that maximum of about 60% monoclinic phase was present in the inner cone near the chamfer, while in the outer polished surface only 3% monoclinic phase was present. SEM demonstrated that the zone near to the surface of the taper, in the core of the ball head, consisted of an inhomogeneous structure formed by dense agglomerates of Y-TZP grains, about 10 mm in diameter, within a matrix of lower density. A crack network originated from the above mentioned inhomogeneous zone, and extended through the outer part of the sample which consists of well densified material. Histologic sections showed the presence of many metal particles in a poor in vessels stroma; ceramic appeared as polygonal shape granules of different dimension, ranging from 2 to 10 B5m.

Conclusions: The Authors demonstrated that the likely initiator of the failure is to be sought in subcritical crack growth of the defects due the uncontrolled densification during sintering, enhanced by the wet environment and by cyclic loading. The hydrothermal stability of the material had only a secondary role in the fracture.

Aims: PMMA is currently used as grouting agent of arthroprostheses and for filling of bone cavities after bone curettage. It is moreover used as a carrier of antibiotics in the local treatment of bone infections and it has been proposed as a carrier of antiblastic drugs in the local treatment of bone metastases. The aim of this study is to analyse the biological properties and compressive strenght of PMMA-Methotrexate mixture to be used for the local treatment of bone metastases.

Methods: Cylinders of PMMA containing Methotrexate in different concentrations were manufactured according to ASTM F-451. Cylinders of PMMA were used as control. The porosity of the cylinders was characterised by SEM. Drug elution rate in saline solution was measured by HPLC. The biological activity of Methotrexate was analysed on human breast cancer cells using MTT test at different time (from 5 minutes to 30 days). Compressive tests was performed in conformity to ASTM F-451 on PMMA- Methotrexate samples and control as-made and after 30 days of aging in saline

Results: SEM analysis showed the presence of granules of Methotrexate on the surface of as-made cylinders that can be readily released from PMMA cylinders. The release occurred in large amount within 24 hours after immersion. We observed a relative release rate is more sustained in samples containing the drug in lower concentration. Also the biological activity was time dependent: cell death decreased progressively from 60% at 24 hours to 10% at 30 days.

Compressive tests showed no statistical differences between PMMA cylinders containing Methotrexate and controls before and after aging in saline.

Conclusions: The results show that PMMA-Metho-trexate may be considered an interesting option in the treatment of bone metastases because cement allows mechanical resistance after bone curettage or resection and Methotrexate improves locally anticancer activity.

We studied factors contributing to the initiation of fracture and failure of a zirconia ceramic femoral head. The materials retrieved during a revision total hip replacement were submitted to either visual, stereomicroscopic and scanning electron microscopy (SEM) or SEM and energy-dispersive x-ray analysis. X-ray diffraction was performed in order to investigate the extent of tetragonal to monoclinic phase transition. Histological examination was performed on the periprosthetic tissues.

The results showed that failure was due to the propagation during clinical use of defects which may have been introduced into the material during the processing of the ceramic, rather than those intrinsic to zirconia. The literature relating to previous failures of zirconia components is reviewed.

In primary malignant bone tumours, the “en – block” excision with the sacrifice of soft tissues causes a functional deficit of the interested limb. There are many possibilities for reconstruction after a wide resection of the proximal humerus. The Authors report their experience using megaprostheses, focusing to soft tissue reconstruction, in order to obtain a good and fast functional recovery of the involved limb. 13 megaprostheses of the proximal humerus were employed. All patients were affected of primary malignant bone tumors with different histology. The tumor was staged according to Enneking’s system. 8 cases were classified as IIB and the remaining as IIA. All the tumors were treated with an intrarticular resection. Soft tissues reconstruction was performed, in 8 cases, using a mesh (Trevira tube), dressed all along the prosthesis, with a high resistance to traction. Radio and/or chemotherapy were employed referring to the histology.

At a medium follow – up of two years, for the surviving patients, we have obtained excellent functional results in 1 case, good in seven cases, fair in three cases and poor in two cases. The size of the resection is a main factor in order to obtain a good functional recovery of the joint motion. A wide excision (below deltoid insertion) with the sacrifice of large muscular masses and of the osteoarticular structures can represent a functional amputation causing the loss of muscles that are important to have an acceptable joint movement.

In our experience we retain that the use of modular prostheses in reconstructive orthopaedic surgery is advantageous because of its versatility and of its quick implantation, despite of other reconstructive systems. Moreover the use of a device, as that described, for an easy anchorage of the myotendinous structures, allows a quick functional recovery offering the patients considerable advantages for their social life.

Zirconia has considered a good material for manufacturing of ball heads in total hip replacement due to high mechanical properties of this ceramic material. However in the literature the problem of heads biocompatibility is still debated. The Authors reported their experience in ten years of research on the biological properties of this material. In vitro tests were performed onto materials in form of powders, analyzing the inhibitory effects on human lymphocyte mitogenesis, and in form of plates measuring adhesion and spreading of 3T3 fibroblasts. A mutagenic test was also performed. In vivo tests were performed by injection of powders in mice and evaluating the survival of animals according to ASTM F – 750. We also inserted ceramic in form of cylinders into proximal tibial metaphysis of NZW rabbits and analysed local and systemic reaction due to material diffusion. We also developed a system of production of Zirconia particles by inserting ceramics under patellar tendon of NZW rabbits.

In vitro tests showed that Zirconia powders and plates induced a similar effect of Alumina ones; no mutagenic effect were observed using our samples, demonstrating that Zirconia has no carginogenic effects. In any case the diffusion of particles didn’t show modifications into internal organs (lung, kidney, liver, spleen) of mice and rabbits. In time (one year after operation) the connective tissue present at bone ceramic interface is transformed into lamellar bone.

Our experience demonstrates that Zirconia may be considered a good material for prosthetic implants.