Fracture and Squeaking in Ceramic-on-Ceramic Bearings: Is It Really a Concern?



With an increasing demand for endoprosthetic treatment of patients leading an active and demanding lifestyle, the need for optimizing tribological properties of implants has arisen. Minimum wear rates are required in order to secure longevity of the implants.

In comparison to metal-on-polyethylene, ceramic-on-polyethylene or metal-on-metal bearings, ceramic-on-ceramic bearings show the lowest wear rates. The linear wear has been measured at 0.005 mm/year, and the volumetric wear at 0.04 mm3/year. Furthermore, the minimum risk of ionization of ceramic particles guarantees excellent biocompatibility. Excellent clinical results with a reported survival rate of more than 85% in cementless fixation at long-term follow-up of a mean 19.7 years have been documented [22].

However, ceramics still have a reputation of being unreliable due to first generation ceramics, which have been linked to an increased risk of fracture of ceramic components with reported fracture rates of up to 13.4%. Consequently, an uncertainty amongst surgeons developed, and other bearings were thus favoured. However, with the introduction of improved manufacturing processes and designs, the fracture rates could be dropped dramatically. The fracture rate reported for contemporary ceramic heads ranges from 0.002% to 0.2% propagated by the manufacturer (Source: Ceramtec™) to 0.004% and 1.4% in clinical reports, and the risk for liner fracture is assumed to be as low as 0.01–2%.

Ceramic-on-ceramic bearings have shed the stigma of high fracture rates and are nowadays acknowledged to be the material of choice for the high-demand, young and active patient.

Recently, numerous reports on audible phenomena generated by ceramic-on-ceramic bearings have been published and caused new concern. A distinct squeaking noise has been reported in between 0.3% and 10.7%.

Various other noises like clicking, grinding or grating can reach an incidence of 32.8%.

Up to date, the aetiology is still unclear and most likely multifactorial. Multiple studies have linked it to prosthetic design, malpositioning of components, edge loading, stripe wear, bone stock and patient activity levels.


Acoustic Emission Fracture Rate Acetabular Component Lower Wear Rate Ceramic Component 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

11.1 Historical Development of Ceramic-on-Ceramic Bearings

Alumina ceramics have been in use since the 1970s. Initially, components were made of pure alumina oxide (Al2O3). After their introduction by Boutin in France [5], they were applied in Germany and Austria by Griss, Mittelmeier and Salzer [21, 36, 44, 56]. The fracture rate for the first generation of ceramics was comparatively high with reported fracture rates of up to 13.4% [47]. This was due to a combination of material-, design- and surgical-related factors. First-generation ceramic was of low purity and density and large grain size distribution. Unfavourable designs like skirt heads or mushroom heads as well as missing bony ongrowth on cups led to increased fracture and high loosening rates. Furthermore, some retrievals showed unpredictable complex high wear rates [10]. Monobloc designs associated with loosening were soon abandoned. However, the occurrence of catastrophic failures and reports on occasional high wear rates were disquieting [4]. The reputation of ceramic as being a brittle and unsafe material in total hip arthroplasty was established (Figs. 11.1 and 11.2).
Fig. 11.1

Implant failure of first-generation ceramic heads

Fig. 11.2

Implant failure of first-generation ceramic cups

Further advances in technology led to the introduction of third-generation ceramics under the trade name Biolox forte (Ceramtec, Plöchingen). According to its manufacturer, it is the most widely used ceramic material for hip arthroplasty in the world. It is produced of synthetic, fine-grained high-purity alumina with minor amounts of sintering aids. Enhancements in the production process as well as quality management like hot isostatic pressing and laser etching as well as adjustments in quality management by proof testing of all components resulted in a significant increase in mechanical strength. The fracture rate could be reduced to about 0.02% [32]. The resulting higher quality alumina featured decreased grain size, inclusions and grain boundaries and had a significantly greater burst strength than previous ceramics.

In order to create even higher mechanical-load bearing capability, Biolox delta ceramic was developed and became available in 2002. It consists of a zirconia-toughened alumina (ZTA) and contains 75 vol.% Al2O3, 24 vol.% ZrO2 and mixed oxides (1 vol.% CrO2 and SrO). The added zirconia has the benefit of increased crack resistance. It has been proven to have twice the strength of Biolox forte and lower wear rates even under adverse conditions of microseparation [32, 48] (Table 11.1, Figs. 11.3 and 11.4). The fracture rate is reported to be as low as 0.002% (Source Ceramtec TM).
Table 11.1

Comparison of properties for different generations of ceramics



BIOLOX® (since 1974)

BIOLOX® forte (since 1995)

BIOLOX® delta (since 2004)






















Other oxides















Grain size Al2O3








4-Point bending strengtha
















Fracture toughness K IC b

MPa m1/2







Hardness HV1





Source: Ceramtec™

aAverage values measured for BIOLOX® delta from 2006

bFracture toughness refers to the capacity of a material to resist crack propagation; K IC is the ­corresponding characteristic value

Figs. 11.3 and 11.4

Comparison of properties and burst strength for Biolox, Biolox forte and Biolox delta (Source: Ceramtec™)

11.2 Survival of Ceramic-on-Ceramic Bearings

Long-term results for ceramic-on-ceramic bearings are very promising. Petsatodis et al. conducted a retrospective analysis of a series of 100 consecutive patients (109 hips). He reported a cumulative rate of survival of 84.4% at 20.8 years. All revisions were due to aseptic loosening of the cup [40]. Even better results at intermediate-term follow-up have been published recently. Lusty et al. found a 99% rate of survival at 7 years postoperatively with a median wear rate of the femoral head measured at 0.2 mm3 per year. He therefore encourages the use of third-generation ceramics for primary total hip arthroplasty particularly in young and more active patients [34]. Another report found similar results at 10-year follow-up in 88 hips treated with third-generation alumina-on-alumina bearings [33].

11.3 Tribological Properties of Ceramics

Ceramics show a number of tribological advantages as compared to other bearings. Most important is the significantly lowest wear rate and friction [17, 38, 39]. Aseptic loosening due to wear is still one of the main indications for revision surgery in total hip arthroplasty [15, 41]. Volumetric wear for alumina-on-alumina bearings has been reported to be 2,000–4,000 times less than for metal-on-polyethylene combinations. Ceramic wear particles are bioinert and feature superior corrosion resistance due to the minimum risk of ionization [7]. These factors lead to the established excellent biocompatibility of ceramic components.

Furthermore, Ceramic is hydrophilic and therefore features superior lubrication conditions. Alumina is one of the hardest materials and is therefore resistant to scratching. However, alumina ceramics are brittle and have no way to deform without breakage. The introduction of zirconia-toughened alumina has significantly increased crack resistance [32, 48].

11.4 Fracture Rate for Ceramic-on-Ceramic Bearings

First-generation ceramics made from pure alumina were associated with high failure rates. They showed unpredictable and inferior results with fracture rates of up to 13% [58]. Reasons were mostly a problem of inferior quality of the alumina as well as implant-related factors like missing bony ongrowth and dislocation of the acetabular component as well as mushroom or skirt designs of the head [4]. First- and second-generation Biolox ceramics were reported to have a fracture rate of 0.026% and 0.014%, respectively [25].

Enhancements in the production process led to a significant decrease in fractures. Willmann et al. reported a fracture rate for third-generation ceramics (Biolox femoral head) of 0.004% [58]. The rate for femoral head fractures with fourth-generation Biolox delta is even lower and is estimated at 0.002%. According to Schmalzried, it is therefore far lower than the risk of a fractured stem (0.27%) [45]. However, fractures still occur (Table 11.2). In a large study by Capello et al., a fracture rate of 0.008% for ceramic inserts and 0.017% for femoral heads in 52.000 ceramic implants used since 2003 was reported [8]. In a multicenter study by Murphy et al., 1,709 hips in 1,484 patients were evaluated, and a fracture rate of 0.27% for ceramic liners was identified [37]. Walter et al. reported one case of ceramic liner fracture in 2,503 alumina ceramic-on-ceramic bearings implanted between 1997 and 2004 [53].
Table 11.2

Overview of in vivo fracture rates for Biolox forte standard inserts (Source: Ceramtec™)

Other studies reported not a single case of ceramic fracture at long-term follow-up. Toni et al. reported on a consecutive series of 147 patients. No osteolysis or fracture could be detected at 17-year follow-up [52]. Similar findings were published by Kim et al. for young patients and dysplastic hips [30].

Hannouche et al. conclude, that ceramic liner fracture caused by impact force during normal life is unlikely to occur in vivo [24].

11.5 Risk Factors for Ceramic Fracture

A number of potential risk factors for ceramic head fracture have been identified. A mismatch between head and taper with unpredictable stress loads, damage to the metal taper at initial surgery, use of a new ball on a previously damaged taper in revision surgery, entrapped debris on the contact area between head and taper, continuing use of the original head at revision surgery and manufacturing problems like autoclave and shock cooling of the head have been identified as potential risk factors [12, 26] (Fig. 11.5).
Fig. 11.5

Fracture of ceramic head

With regards to fracture of the acetabular liner, positioning of the acetabular component, impingement, contact of head and cup during repositioning as well as a position change of the liner after initial improper insertion have been related to failure [14] (Fig. 11.6).
Fig. 11.6

Fracture of ceramic liner

11.6 Revision Strategies Following Ceramic Fracture

Although ceramic fracture is rare in contemporary ceramic implants, revision surgery can be challenging. Ceramic debris can contaminate the joint area. In a multicenter retrospective study of 105 patients, who had underwent revision surgery for ceramic head fracture, the importance of total synovectomy could be clearly documented. Only 19% of patients required repeat revision following total synovectomy as opposed to 67%, who had only received partial synovectomy. Allain et al. further propagate cup exchange in any case of ceramic fracture because microscopic ceramic particles might be embedded in it [2].

The exchange to a new ceramic head or insertion of a cobalt-chromium head have both shown satisfactory results [2]. However, the use of stainless-steel heads in revision surgery is not recommended and has led to catastrophic wear of the head related to ceramic debris [1, 2]. If the trunnion shows sign of macroscopic damage, the exchange to a cobalt-chrome head or revision head with a titanium sleeve (see Fig. 11.7) is advisable. Otherwise, peak stress loads might lead to repeat fracture if a new ceramic head is used [2, 31].
Fig. 11.7

Revision system Biolox option (Ceramtec™, Plöchingen)

11.7 Squeaking

With the problems of ceramic fractures sufficiently addressed by third- and fourth-generation ceramic bearings, reports on audible emissions emerged. General interest was sparked in 2006, when various publications reported a squeaking sensation emanating from ceramic-on-ceramic bearings. The incidences varied widely, ranging from 0.3% to 10.7% [28, 34] (Tables 11.3 and 11.4).
Table 11.3

Overview of incidences of squeaking


1/301 Secur-Fit, or Secur-Fit Plus, + Osteonics ABC cup [34]


17/2397 ABG II system, Osteonics THR, ABG II stem  +  Duraloc option cup, various combinations [55]


3/452 Omnifit stem  +  4 groups: ABC insert, porous-coated shell, arc-deposited-HA-coated shell and Trident cup [8]


30/1056 Omnifit or Accolade stem  +  Trident cup [42]


18/175 Stryker ABG II stem  +  cup [20]


14/131 Accolade TMZF stem  +  Trident PSC cup [28]

Table 11.4

Overview of incidences of hip noise


36/175 [20]

ABG II stem and cup


9/43 [29]

ABG II stem Trident cup


43/131 [28]

Accolade TMZF stem  +  Trident PSC cup

11.7.1 Influencing Factors for Development of Squeaking

Numerous factors have been reported as the cause for this phenomenon. Generally, all publications agree that the aetiology is multifactorial.

Prosthetic Design and Material

Recent reports emphasize the importance of prosthetic design and material. Squeaking is caused by oscillations of the implant due to vibrations. Experimental analysis by Weiss et al. [57] has shown that these vibrations are generated by an instability of the relative motion of the components with respect to each other. Some stems were found to be more susceptible than others.

But also in clinical analysis, some implant designs and materials seem to favour the spreading of vibrations. Restrepo et al. demonstrated the importance of the femoral stem component. He found an increased incidence of squeaking in patients managed with a thinner stem component with a V-40 taper neck and a stem made of titanium-molybdenum-zirconium-iron alloy, thus indicating that the femoral stem plays a vital role in the development of acoustic phenomena [43].

Furthermore, the design of the cup seems to play a key role. Numerous reports on acoustic emissions from THAs with a cup design consisting of a metal rim on a ceramic liner can be found. The possible impingement between the metal rim and the neck of the prosthesis, especially in designs with a short neck, might lead to increased edge loading or wear of the bearings or even to third-body wear, which in turn can damage the surface of any bearing and cause stripe wear. Swanson et al. found a high incidence of squeaking of up to 35.6% for those ensleeved designs [49]. 11.1% of patients experienced an audible sensation at least once a week. Short femoral neck length seemed to favour the occurrence.

Fluid Film Disruption

Chevilotte et al. conducted in vitro testing of 32-mm heads and inserts in varying conditions [9]. Interestingly, squeaking was reproducible in all dry conditions, especially with increased loading, stripe wear and metal transfer. Furthermore, in case of material transfer, squeaking could be even found in lubricated conditions, whereas in the other settings, squeaking ­disappeared when lubrication was introduced. Therefore, the authors concluded that a disruption of the lubrication layer is the underlying cause for the squeaking phenomenon.


Another closely linked factor to these findings seems to be microseparation of the components. Nevelos et al. and Glaser et al. demonstrated microseparation for all bearings during normal gait [18, 38, 39]. This seems to be aggravated by a general joint laxity. Microseparation in turn leads to edge loading and increased wear of the components [10, 11]. The so-called stripe wear is formed. In an area of such wear, increased amounts of friction might be generated, thus leading to vibration.

Component Orientation

Initial reports on squeaking attribute a major role to anteversion and inclination of the acetabular component. W. Walter evaluated 2,716 THAs with ceramic-on-ceramic bearings and found an increased variance in cup anteversion for squeaking hips leading to a recommendation for positioning of the acetabular component within 10° of a target of 25° operative anteversion and operative inclination of 45°. Outside this range, he determined an increased possibility of 29% for squeaking [54, 55]. In contrast, Restrepo et al. could not verify a correlation between cup anteversion or inclination and the occurrence of squeaking [43]. This finding is supported by various other reports [46].

Patient-Related Factors

Walter et al. described a correlation between patient age, BMI and activity level and occurrence of squeaking, which could be found more frequently in the overweight, young and active patient [55].

Grimm et al. reported evidence that periprosthetic bone can play a role in the generation of acoustic emissions by influencing resonance [19].

11.8 Author’s Clinical Experience

Until increasing literature coverage of the squeaking sensation, we were unaware of patient reports of acoustic phenomena. Therefore, we started an analysis of our ceramic-on-ceramic total hip arthroplasties in 2008.

11.8.1 Materials and Method

To investigate the occurrence of acoustic emissions in our patients, we conducted a ­retrospective study of a consecutive series of patients, who had all received the same prosthesis system (Zimmer™ Alloclassic Variall®) in combination with ceramic-on-ceramic bearings. The aim was to evaluate the nature of the noise, duration and clinical consequence. First introduction of the Alloclassic® hip system was conducted in 1979. After some modifications, the Alloclassic Variall ® system emerged and has been in use at our department since 1998. This cementless design features a rectangular titanium stem of Protasul titanium alloy TiAlNb, which creates a diaphyseal press fit. Secondary stability is achieved by bone ongrowth onto the grist-blasted surface. The conical acetabular component is threaded into the bone and gains long-term stability by bone ongrowth on its rough titanium surface. This hip system was combined with 28-mm heads of alumina ceramic-on-ceramic Cerasul® bearing available by Zimmer™. Cerasul® is a third-generation ­aluminium oxide (Al2O3) hot-isostatic-pressed ceramic, first implanted in Europe in 1998. It is available in three head sizes: small, medium and large. The alumina Cerasul® gamma inlays were used. To date, no fracture of Cerasul® gamma inlays has been reported to Zimmer™. The fracture rate for the Cerasul® heads ranges around 1:6, 2,000 (0.01%) (Source: Zimmer™) (Fig. 11.8).
Fig. 11.8

Zimmer™ Alloclassic Variall® system

Between 1998 and 2003, a consecutive series of 327 patients received 337 cementless Zimmer™ Alloclassic Variall implants at our department. This secured a minimum ­follow-up period of 5 years.

Patients were operated by different surgeons of the same department using the standard lateral transgluteal (Bauer) approach. In order to conduct a retrospective analysis of the occurrence of audible sensations, patients received a detailed questionnaire via mail, ­including questions on the first occurrence of squeaking, information on the kind of noise, duration of the phenomenon and possible negative subjective evaluation on behalf of the patient. In case of a positive reply, the patient was invited to a clinical exam and radiographic evaluation. In addition, a specialized audiography was conducted in patients, who reported audible sensations. Occurrence of noise was tested walking, bending and on clinical exam.

11.8.2 Results

Two hundred twenty-nine patients returned the questionnaire, 21 were deceased and 46 could not be contacted due to change of address or refused to participate in this study. Only one patient (0.4%), a 52-year-old female, reported a distinct squeaking, which first occurred 98 months after implantation. Initially, it was not associated with pain, but soon aggravated. However, only the questionnaire sent by mail caused her to seek contact. She reported a squeaking occurring with every movement, which did not keep her from being physically active but was perceived as disturbing. On clinical exam, movement was painful. The subsequent X-ray showed implant failure with pelvic protrusion of the acetabular.

Thirty-one (13.5%) patients reported to have experienced varying other types of noises like clicking, creaking, grinding or combinations of noises. In three cases (9.7%), a snapping of the iliotibial band could be identified. The mean onset of noise was 45.6 months postoperatively.

The majority of patients (83.9%) experienced the noise with specific movements like getting up from a seated position or bending. Four patients (13.9%) reported the onset after a period of prolonged walking, and one patient (3.2%) felt a clicking noise with every movement.

In some cases (16%), noise was self-limiting. Other patients could avoid the occurrence by adapting specific positions (29%). In order to validate impingement as a possible cause, we evaluated the neck length of the component. However, we could not find a significant difference between hips-emitting noises and silent hips. Demographic analysis showed no significant difference in gender, age or BMI between patients with noisy and silent hips.

Ceramic fracture could not be detected in any case.

11.8.3 Revisions

More than half of the patients (52%) who reported audible sensations felt disturbed by the noise, with one patient seeking revision surgery for this cause. She felt increasingly limited by clicking noises emanating from the hip implant.

In addition, two further patients required revision surgery. One 56-year-old male patient reported a creaking sensation, which started 108 months postoperatively and was later associated with pain. Another 53-year-old female patient perceived a clicking sensation associated with pain. Ceramic components were analysed by Ceramtec™ (Figs. 11.9 and 11.10). Analysis of the retrievals showed areas of increased wear corresponding to episodes of edge loading as occurring in subluxation. In addition, a distinct area of metal transfer could be found on one of the ceramic inserts corresponding to impingement.

This resulted in a total rate of revision for noise of 1.7% (four patients).
Figs. 11.9 and 11.10

Area of stripe wear on retrieval liner and head

11.9 Revision Strategies for Hip Noise

Toni et al. have recently published guidelines on treatment of hip noise associated with ceramic-on-ceramic bearings. If a patient reports acoustic emissions and clinical examination confirms the findings, then radiologic evaluation by means of X-ray or CT scan should be conducted. If ceramic fragments are radiologically documented, revision surgery is indicated. Should radiologic evaluation prove negative, Toni et al. suggest a needle aspiration of synovial fluid. In case of ceramic fragments in the aspiration fluid, revision surgery is recommended if ­fragments measure >5 ym. If fragments are smaller than 5 ym, close follow-up is advisable [51].

In case of positive clinical examination, but negative radiologic findings as well as negative aspiration results, normal follow-up is thought sufficient.

In cases where increased joint laxity might lead to subluxation and increased edge loading and therefore to increased wear, an exchange of the head to a larger neck size might be indicated.

In cases where no obvious reasons for squeaking can be detected, an exchange to a metal-on-highly cross-linked polyethylene bearing has demonstrated promising results and eliminated hip noise [35]. However, there are yet no long-term results available, and adverse effects from switching from a hard-hard to a hard-soft bearing with destruction of the metal head through undetectable ceramic debris might be possible.

11.10 Safe Handlings of Ceramic Components

Ceramics in THA have proven to be a reliable bearing surface. However, fractures of ceramic components still occur. This is mainly due to false handling of the components or wrong positioning of implants. Therefore, safe handling of ceramic components is crucial to a satisfactory outcome. It is important to ensure that no damage to the articular surface occurs during insertion of the liner and that the liner is placed correctly in the shell. We ensure this by using a suction device, which allows safe and exact positioning of the liner (see Figs. 11.11 and 11.12).
Figs. 11.11 and 11.12

Suction device for handling of ceramic liner

To avoid intraoperative damage to the taper, it is important to remove the protective head immediately prior to insertion of the femoral head (see Fig. 11.13)
Fig. 11.13

Avoiding damage to the taper

If required, trial repositioning should be conducted by using the trial head. It is necessary to ensure a clean and dry taper. Debris on the interface between taper and head has been associated with an increased risk of ceramic fractures due to areas of increased stress in loading zones. After the correct head size has been identified, the original ceramic head is inserted. Extreme care during reposition is crucial in order to avoid damage to the articulating surface. Therefore, a special device named “shoehorn” is used to ensure safe repositioning at our institution (see Fig. 11.14).
Fig. 11.14

Use of a shoehorn minimizes risk of damage to ceramic head

11.11 Discussion

New generation of ceramics are a reliable bearing with outstanding tribological qualities. They show the lowest wear rate of all bearings and feature superior biocompatibility and are therefore recommended for the young and active patient [17, 38, 39].

Intermediate and long-term studies report survival rates of 85–99% [33, 34, 40].

Due to improved materials and production methods, ceramic fractures are nowadays a rare phenomenon with incidences of 0.02–0.002%. When handled carefully with regards to surgical technique, it is a safe bearing and should by now have shed its unrightful ­reputation of being prone to fracture.

Studies, which describe high incidences of squeaking or other acoustic phenomena from ceramic-on-ceramic bearings, often deal with the same specific implant groups, which seem to favour the development of acoustic emissions because of their design [28,34, 56].

Generally, audible sensations are not limited to ceramic-on-ceramic bearings. They were first mentioned as soon as the 1950s for the Judet acrylic hemiarthroplasty. Later on, Holzmann reported a clicking noise for metal-on-metal bearings for 18 of 117 hips [27]. A transient squeaking was described by Brockett et al. for large diameter metal-on-metal bearings as well as by Back et al. in a metal-on-metal resurfacing hip [3, 6]. Recent ­publications by Glaser et al. and Clarke et al. indicate that all kinds of bearings can cause acoustic sensations [10, 18]. Further reports on the emission of noises for metal-on-metal bearings and hip resurfacings support these findings [13, 16]. In general, “noisy hips” are more frequent than expected, though they hardly require intervention. But noise can be the first sign of an underlying serious problem like implant failure, malpositioning, impingement and advanced wear and can adversely affect patient satisfaction [31]. Toni et al. reported the occurrence of noise as an early clinical sign of liner chipping or fracture or stripe wear of the head [51]. This is in line with our findings of a case of squeaking in the presence of failure of the acetabular component. We found a very low incidence of audible sensations for ceramic bearings in combination with the Alloclassic Variall® system. Therefore, we conclude that the generation of noise seems to be affected by choice of prosthetic design. High incidences linked to other implant systems are supporting this assumption and show in vivo that the generation of noises is a complex interaction between bearing and implant.

The development of the new delta ceramic might be a further improvement to target the squeaking phenomenon as well as ceramic fracture. The delta ceramic consists of a combination of 82% alumina and 17% zirconia as well as 0.5% chromium oxide and 0.3% strontium. This combination improves wear characteristics and makes the bearing less prone to fracture by diffusing crack energy [32]. Delta ceramics show superior performance even under adverse conditions like microseperation in simulator studies [48].

One recent report by Hamilton et al. of a prospective, randomized, multicenter trial of 218 patients (264 hips) could not detect any case of squeaking for this type of ceramic bearing [23]. However, long-term data is still pending.

Should revision of a ceramic-on-ceramic implant due to squeaking become necessary, recent data has shown that a change to metal-on-highly cross-linked polyethylene eliminates squeaking and shows promising results [35]. But long-term results are missing and possible adverse effects due to change from a hard-hard to a hard-soft bearing could soccur.

In any case, if a ceramic component is used, safe primary handling of the rather delicate ceramics is crucial and is the key to a satisfactory outcome.


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Copyright information

© EFORT 2012

Authors and Affiliations

  1. 1.Orthopaedic Hospital Vienna-SpeisingViennaAustria

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