Preventing ceramic liner fracture after Delta ceramic-on-ceramic total hip arthroplasty

Ceramic fragmentation after total hip arthroplasty: two case reports and literature review

Background

Ceramic fragmentation is a rare but serious complication after total hip arthroplasty (THA). We reviewed the PubMed literature from 1990 to 2023 and found only 31 case reports of ceramic fragmentation after THA. Our case reports help to expand understanding of this rare complication. We shared our surgical experience and identified an ideal material for revision surgery, which can serve as a useful reference for other orthopedic surgeons to perform ceramic fragmentation revision surgery in the future. We also analyzed the possible causes, diagnosis, and treatment opinions of ceramic fragmentation.

Case presentation

This study presents two cases of ceramic fragmentation after THA. One patient had ceramic head fragmentation 10 years after the primary THA, and one patient had ceramic liner fragmentation 5 years after the primary THA. Both patients presented with pain, and one patient also reported a clicking sound in the hip. The two patients described here had BMIs of 23.7 and 23.1, respectively. Both patients' ceramic fragmentation were due to aseptic loosening, not periprosthetic joint infections, as confirmed by negative microbiological cultures. Radiographic examinations of both patients revealed radio-opaque wear debris around the hip joint prostheses and we describe the surgical protocols and intraoperative findings in both cases in detail.

Conclusion

Our cases and the literature suggest that ceramic fragmentation can occur at any time after THA. The most immediate symptoms are pain and noise, but some patients may be asymptomatic. Ceramic on polyethylene bearings is recommended for revision surgery whenever possible; metal bearings should be avoided.

Outcomes of Ceramic-On-Ceramic Bearing Total Hip Arthroplasty: A Minimum 10-Year Follow-Up Study

BACKGROUND

Although the fourth generation of ceramics has demonstrated excellent clinical results 5 to 6 years postoperatively, concerns over ceramic fracture and squeaking persist and longer-term follow-up (minimum 10 years) studies are warranted. Our study aimed to evaluate the minimum 10-year clinical outcomes and bearing-specific complications of ceramic-on-ceramic (CoC) total hip arthroplasties.

METHODS

We retrospectively evaluated all patients who underwent primary delta CoC total hip arthroplasty in our institution between January 2004 and February 2013. Demographics, surgical techniques, complications, patient-reported outcomes, and radiographic outcomes were collected and analyzed. For continuous variables, the comparison between groups was conducted using a one-way analysis of variance. Of all 235 patients included in the study, 70.5% were women (190 hips). The mean follow-up period was 12 years (range, 10 to 18). The femoral head sizes of 28- mm, 32 mm, and 36 mm were used in 50, 26, and 197 cases, respectively. Mean acetabular inclination and anteversion angles were 39.2 ± 7.1° and 14.9 ± 3.5°.

RESULTS

There were 5 hips revised at a mean 4.6 years (range, 0.1 to 7.1). One revision was squeaking-related. Squeaking was also reported by 8 other patients, but did not require revision. Other reasons for revision were early infection in 2 cases, stem loosening in 1 case, and stem fracture in 2 cases. The survival analysis for any causes for revision as an endpoint was 96.7% (95% confidence interval 0.313%-2.57%).

CONCLUSION

We report excellent mean 12-year follow-up results regarding the complications and survivorship of the fourth generation CoC bearings.

Ten to 13-Year Results of Delta Ceramic-on-Ceramic Total Hip Arthroplasty in Patients Less Than 30 Years Old

BACKGROUND

We previously reported mid-term results of total hip arthroplasty (THA) using Delta ceramic-on-ceramic (CoC) bearings in 72 patients (86 hips) who were <30 years old. Noise was noted in 8 (9.3%) of the hips, no osteolysis or loosening was detected, and no patient required reoperation. The purpose of this study was to assess clinical and radiographic outcomes, complications, and survivorship at >10 years after THA using Delta CoC bearings in patients who were <30 years old.

METHODS

Cementless THA with a Delta CoC bearing was performed between March 2008 and January 2012 in 91 hips of 76 patients who were <30 years old. Eighty-five hips in 71 patients (44 men and 27 women) with a mean age of 25.9 years (range, 16 to 29 years) at surgery were followed for a mean of 10.9 years (range, 10 to 13 years).

RESULTS

No ceramic bearings fractured. The incidence of squeaking increased to 5.9% (5 of 85), but the squeaking was not reproducible within individual patients. Periprosthetic osteolysis developed in 3 hips (3 patients): around the stem in 2 and around the metal shell in 1. The stem in 1 hip underwent revision because of a Vancouver type-B2 periprosthetic femoral fracture. One patient with systemic lupus erythematosus underwent irrigation and debridement for periprosthetic joint infection. Survivorship free of reoperation for any reason was 92.4% (95% confidence interval, 82.4% to 100%) at 13 years.

CONCLUSIONS

The long-term results and survivorship of Delta CoC THA in patients <30 years old were favorable.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Damage analysis of retrieved BioloxⓇdelta components used in hard and soft bearings

This retrieval study included 43 Biolox delta explants (18 CoC, 25 CoP). Implants were examined macroscopically, whereby damage was evaluated using a semi quantitative scoring system. Confocal microscopy was used to examine wear related damage patterns of the articulating surfaces. Scanning electron microscopy (SEM) with energy-dispersive X-ray spectroscopy (EDS) was used to analyze wear marks on the implant surface and wear debris in periprosthetic tissue samples. Raman spectroscopy and X-ray diffraction (XRD) were used to quantify monoclinic zirconia fractions. On all components, in vivo wear resulted predominantly in different damage patterns caused by metal transfer. In CoC bearings stripe wear was additionally detected, and some implants underwent severe damage due to component breakage. The wear scores were higher for CoC components, with no differences between the scores for CoC heads and liners. Wear features caused comparable roughening on implants from CoC and CoP bearings. SEM studies demonstrated that most wear marks were caused by metal debris released from implant components. Grain pull-out was observed in stripe wear regions. Monoclinic phase shift was observed in a similar quantity on components from CoP and CoC bearings. The increase of monoclinic zirconia content around metal deposits was minimal and was more pronounced in areas of stripe wear. The results of this study indicate, that ZTA components in general undergo minimal wear in both, CoC and CoP bearings, however, it is more pronounced in the former. Metal deposits, as the most common wear feature, have no significant effect on monoclinic phase transition. STATEMENT OF SIGNIFICANCE: In this paper, we classify all damage patterns macroscopically according to an established scoring system and assess them regarding surface roughness (confocal microscopy) and monoclinic phase content (Raman spectroscopy) in order to derive the severity for patients. We compare hard-hard and hard-soft bearings and relate damage patterns with metal transfer based on SEM/EDS examinations. Furthermore, we work out correlations between patient-specific data, cause of revision and the physical condition of each individual sample Our cohort consists of 43 Biolox delta retrievals, a comparatively large quantity. In addition, we address current topics such as metal transfer and, based on the classification of damage patterns, provide incentives and/or meaningful focal points for further research.

A 10- to 12-year follow-up study of delta ceramic-on-ceramic total hip arthroplasty

BACKGROUND

We previously reported five-to-seven-year results of total hip arthroplasty (THA) with the use of delta ceramic-on-ceramic (CoC) bearing. We conducted an extension study with a CT scan at a minimum of 10 years after surgery.

METHODS

From March 2009 to March 2011, 273 patients (310 hips) received cementless THA with delta CoC bearing, porous-coated cup and hydroxyapatite-coated stem. In this extended study, 252 patients (144 men and 108 women) (288 hips) with a mean age of 49.7 years (16-83) at surgery were followed for a mean of 10.4 years (10-12) with CT scans in 133 hips (46.2%, 133/288). Clinical and radiographic evaluations were made at each follow-up and Kaplan-Meier survival analysis was performed with revision and reoperation as endpoints.

RESULTS

There were no more ceramic fractures. Compared to mid-term results, the incidence of squeaking and RLLs increased to 3.1% (9/288) and 19.4% (56/288), respectively. The RLL progressed to focal osteolysis in 3 hips (5.4%, 3/56). No hip had detectable wear or prosthetic loosening. Two hips were reoperated due to periprosthetic joint infection and periprosthetic femoral fracture in each. The survivorship decreased to 98.3% (96.7-99.9%) at 12 years.

CONCLUSION

During the extended follow-up, no additional ceramic fracture occurred, and the incidence of squeak increased by 0.7%. The long-term survivorship of Delta CoC THA was encouraging. However, focal osteolysis occurred around the hydroxyapatite-coated stem in 1% (3/288).

LEVEL OF EVIDENCE

II (Prospective cohort study).

Proportion of stable femoral neck fracture types in different age groups: a population-based study

OBJECTIVE

The treatment and incidence of femoral neck fracture (FNF) in older patients is controversial. We investigated the new AO (Arbeitsgemeinschaft für Osteosynthese) classification in patients with FNF by age to determine the proportions of stable fracture and change trends according to patients' age.

METHODS

We divided patients with FNF hospitalized in Xi'an Honghui Hospital from 2018 to 2020 into five groups according to age: young (<50 years), middle-aged (50-59 years), young-elderly (60-69 years), middle-elderly (70-79 years), and very elderly (≥80 years) groups. We retrospectively collected data of patients' sex, admission date, fracture side, mechanism of injury, and new AO classification.

RESULTS

In total, 2071 patients were included for analysis, with 1329 women (64.2%); 1106 patients (53.4%) had left-side fracture. The main mechanism of injury was falling. In the young-elderly, middle-elderly, and very-elderly groups, 33.3%, 29.2%, and 24.1% had stable fracture type, respectively). The proportion of patients with FNF did not show a change trend by age during the 3-year investigation period.

CONCLUSION

In our study, the proportion of older patients with FNF did not increase, and as many as a third of patients with FNF aged 50 to 70 years had stable fracture.

Liner dissociation in a large-diameter ceramic-bearing acetabular component: a report of five cases

Background

Ceramic-on-ceramic (CoC) bearings for total hip arthroplasty (THA) have been offering very favorable results and survivorship since their introduction. In order to increase range of movement (ROM) and decrease dislocation rates, some manufacturers have introduced larger diameter head (LDH) CoC bearings. This has been achieved with the use of preassembled cup designs, in which the ceramic liner is already fitted into the metal backing and implanted as a monoblock component by the surgeon. In this report we present data from a series of 5 patients with ceramic liner dissociation from a monoblock cup.

Case presentation

All cases were overweight men with acetabular components of 56 or 58 mm. After a mean of 5.5 (range, 3.5-6.7) years, all patients reported sudden pain and audible noise when performing activities of daily living. Liner displacement was suspected on plain radiographs and confirmed by Ct-scan. Pneumarthrosis was present in all cases. Taper modular junction wear and corrosion signs were observed in the four revised patients.

Conclusion

Although one of our case is still treated conservatively, implant revision is probably inevitable. Further LDH CoC implant design should take in consideration this potential complication by avoiding bearing diameters over 40mm and/or improving locking mechanism or by providing a real monoblock acetabular implant.

The Wear Rate and Survivorship in Total Hip Arthroplasty Using a Third-generation Ceramic Head on a Conventional Polyethylene Liner: A Minimum of 15-year Follow-up

Purpose

Materials and Methods

Results

Conclusion

Mid-term outcomes of the R3™ delta ceramic acetabular system in total hip arthroplasty

Background

Whilst bony fixation of hip replacement has stable solutions, there remains controversy over which bearing best optimizes longevity and function. Ceramic-on-ceramic (CoC) bearing combinations are associated with lower risk of revision due to aseptic loosening and dislocation. Evidence for long-term functional outcomes of modern, 4th generation CoC bearings is limited. The aim of this study was to analyze outcomes and complications of the R3™ Acetabular System (Smith & Nephew, Inc., Cordova, TN, USA) in combination with BIOLOX® Delta ceramic femoral head in patients undergoing primary total hip arthroplasty (THA).

Methods

Between June 2009 and May 2011, 175 patients (178 hips) were enrolled into a prospective, study at 6 sites in Europe and prospectively followed-up at 3 months and 1, 3, 5, and 7 years postoperative.

Results

Total WOMAC score improved from 63 (range, 22–91) preoperative to 8 (range, 0–8) at 1-year follow-up and remained unchanged at 7-year follow-up. Modified Harris hip score improved from 45 (range, 10–87) preoperative to 83 (range, 25–100) at 3 months, 91 (range, 42–100) at 1 year, and 92 (range, 46, 100) at 7 years. UCLA Activity Rating Scale score improved from 3.3 (range, 1–8) preoperative to 6.2 (range, 2–8) at 1 year; it marginally declined to 5.8 (range, 3–8) at 7-year follow-up. There were 4 trochanteric fractures and 5 patients died of unrelated reasons. Three hips were revised (2 periprosthetic fractures and 1 subluxation). The 7-year cumulative survival rate was 98.3%.

Conclusion

Clinical and functional improvements of THA with CoC bearing are maintained at 7 years postoperative.

Trial registration

ClinicalTrials.Gov, NCT03566082, Registered 10 January 2018—retrospectively registered,