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Zirconia in Zirconia toughened alumina ceramic hip replacements exists in an unstable state and can transform in response to stress giving the material improved fracture toughness. Phase transformation also occurs under hydrothermal conditions such as exist in vivo. To predict the hydrothermal aging that will occur in vivo accelerated aging procedures have been used, but validation of these models requires the study of retrieved hip joints. Here 26 retrievals are analysed to determine the degree of phase transformation in vivo. These were compared with virgin heads, heads that had undergone the accelerated aging process and heads wear tested to 5 million cycles in a hip simulator. Monoclinic content and surface roughness were measured using Raman spectroscopy and white light interferometry respectively. The monoclinic content for retrieved heads was 28.5% ± 7.8, greater than twice that in virgin, aged, or wear tested heads and did not have a significant correlation with time, contrary to the predictions of the hydrothermal aging model. The surface roughness for retrieved heads in the unworn area was not significantly different to that in virgin, aged, or unworn areas of wear tested heads. However in worn areas of the retrieved heads, the surface roughness was higher than observed in wear simulator testing. These results indicate that current testing methodologies do not fully capture the operational conditions of the material and the real performance of future new materials may not be adequately predicted by current pre‐clinical testing methods. © 2017 The Authors. Journal of Orthopaedic Research Published by Wiley Periodicals, Inc. on behalf of Orthopaedic Research Society 35:2781–2789, 2017.

Background and purpose — Knee and hip replacement are common and increasing procedures, and an optimized care process that could be implemented in different settings would be useful. The PROMISE trial investigates whether a new care process works equally in different German settings and how the results compare with current non-standardized care. Patients and methods — This multi-center prospective mixed-method study includes 2,000 German patients receiving arthritis-related hip or knee endoprostheses. An interdisciplinary and cross-sectoral care process was developed and implemented in 3 German hospitals with different levels of care, and corresponding rehabilitation centers were included to bridge the gap after acute care. Duration and outcome — The PROMISE trial recruited patients between May 2018 and March 2020. Follow-up will end in February 2021. Assessments are performed at: examination on clinical indication, 1 week before surgery, on the day of surgery, at the end of hospitalization, end of the rehabilitation program, and 3 months, 6 months, and 12 months after surgery. Outcomes include patient-reported outcomes, medical examination findings, and routinely collected data regarding the surgery and complications. Guideline-based interviews are conducted with selected patients and care partners. The primary endpoint is the presence of chronic pain at 12 months after surgery. Secondary endpoints are the number of recognized pre-existing conditions, physical activity at 12 months after surgery, use of medical services, quality of life, and interactions between care partners. Trial registration — The trial is registered with the German Clinical Trials Register ( https://www.drks.de ; DRKS00013972; March 23, 2018).