Revision total hip arthroplasty for ceramic head fracture: a long-term follow-up

Material-Intrinsic NIR-Fluorescence Enables Image-Guided Surgery for Ceramic Fracture Removal

Hip arthroplasty effectively treats advanced osteoarthritis and is therefore entitled as "operation of the 20th century." With demographic shifts, the USA alone is projected to perform up to 850 000 arthroplasties annually by 2030. Many implants now feature a ceramic head, valued for strength and wear resistance. Nonetheless, a fraction, up to 0.03% may fracture during their lifespan, demanding complex removal procedures. To address this, a radiation-free, fluorescence-based image-guided surgical technique is presented. The method uses the inherent fluorescence of ceramic implant materials, demonstrated through chemical and optical analysis of prevalent implant types. Specifically, Biolox delta implants exhibited strong fluorescence around 700 nm with a 74% photoluminescence quantum yield. Emission tails are identified extending into the near-infrared (NIR-I) biological transparency range, forming a vital prerequisite for the label-free visualization of fragments. This ruby-like fluorescence could be attributed to Cr within the zirconia-toughened alumina matrix, enabling the detection of even deep-seated millimeter-sized fragments via camera-assisted techniques. Additionally, fluorescence microscopy allowed detection of µm-sized ceramic particles, enabling debris visualization in synovial fluid as well as histological samples. This label-free optical imaging approach employs readily accessible equipment and can seamlessly transition to clinical settings without significant regulatory barriers, thereby enhancing the safety, efficiency, and minimally invasive nature of fractured ceramic implant removal procedures.

Ceramic-on-Ceramic or Metal-on-Polyethylene: The Bearing of Choice after Ceramic Component Fracture in Total Hip Arthroplasty along with Concise Follow-Up of the Previous Cohort

OBJECTIVE

We previously reported the questionable result of reoperation using metal-on-polyethylene (MoP) bearing after the fracture of the ceramic component. After the report, we abandoned the use of MoP; instead, we used ceramic-on-ceramic (CoC) bearing. This report aimed to present the outcome of reoperation to CoC bearing after ceramic component failures along with the longer-term outcome of the previously reported cohort with an MoP bearing.

RESULTS

The mean follow-up of the MoP cohort was extended from 4.3 years to 8.8 years. Metallosis had occurred in three of nine patients of the previous cohort, which all required re-reoperations. Two hips from 11 patients with revision to CoC had re-reoperations due to ceramic liner fracture and non-union of the osteotomized fragment, respectively. No metallosis and wear occurred in the cohort revised with CoC articulation. Otherwise, there were no adverse changes in radiographs and no impairment in functions.

METHODS

We conducted an extended prospective evaluation of a previous cohort consisting of six head fractures and three liner fractures. In this cohort, the patients underwent a bearing change to metal-on-polyethylene. Additionally, we retrospectively analyzed 11 cases of third-generation ceramic bearing fractures, comprising nine head fractures and two liner fractures. These cases were subsequently treated with a bearing change to fourth-generation CoC. We assessed clinical and radiological outcomes, including complication rates, in both groups.

CONCLUSION

We recommend the latest CoC as the bearing of choice in reoperation after the fracture of ceramic components. In the case of an MoP bearing after the ceramic component fracture, the risk of metallosis seemed high in the early postoperative period.

Revision total hip arthroplasty by a ceramic bearing surface after a third- and fourth-generation ceramic head or liner fracture

PURPOSE

Although rare, fractures of ceramic components are difficult to revise, mainly due to the presence of residual ceramic debris that can cause catastrophic wear of the replacement components. Modern ceramic-on-ceramic bearings are suggested to improve outcomes of revision total hip arthroplasty (THA) for ceramic fractures. However, there are few published reports of mid-term outcomes of revision THA using ceramic-on-ceramic bearings. We evaluated clinical and radiographic outcomes of 10 patients who received ceramic-on-ceramic bearings during revision THA for ceramic fractures.

METHODS

All patients but one received fourth-generation Biolox Delta bearings. Clinical evaluation was performed using the Harris hip score at latest follow-up, and all patients received a radiographic evaluation to analyze the fixation of the acetabular cup and of the femoral stem. Osteolytic lesions and the presence of ceramic debris were noted.

RESULTS

After a mean follow-up of 8.0 years, there were no complications or implant failures, and all patients reported satisfaction with their implant. The average Harris hip score was 90.6. There was neither osteolysis nor loosening, but despite our extensive synovial debridement, ceramic debris was noted in the radiographs of five patients (50%).

CONCLUSION

We report excellent mid-term outcomes, with no implant failures after eight years despite ceramic debris being found in a significant proportion of patients. We conclude that modern ceramic-on-ceramic bearings are an advantageous option for the revision of THA due to the fracture of initial ceramic components.

Incidence, Risk Factors, and Outcome of Ceramic-On-Ceramic Bearing Breakage in Total Hip Arthroplasty

BACKGROUND

Ceramic-on-ceramic bearing breakage is a rare but significant complication of total hip arthroplasty. This study aimed to identify risk factors for breakage and to determine the outcome of different revision options.

METHODS

All ceramic-on-ceramic primary total hip arthroplasty procedures reported to the Australian Joint Replacement Registry from September 1999 to December 2019 were included. Procedures were subdivided into alumina or mixed ceramic (alumina/zirconia). All breakages were identified. The association between ceramic type and head size was assessed. Subsequent revision rates were compared and cause of revision assessed.

RESULTS

There were 23,534 alumina and 71,144 mixed ceramic procedures. Breakage was the reason for 1^st revision in 84 alumina (5.27% of all revisions and 0.36% of procedures) and 56 mixed ceramic procedures (2.46% of all revisions; 0.08% of procedures). Alumina had a higher breakage rate than mixed ceramic (HR 2.50 (95% CI 1.75, 3.59), P < .001), and breakage was higher for 36-38mm head sizes using alumina (HR 2.84 (1.52, 5.31), P = .001). 17.8% of 2^nd revisions occur by 3 years, due to dislocation, infection, metal-related pathology, and loosening. A neck adapter sleeve did not reduce 2^nd revisions. Numbers were too low to compare revision bearing surface options.

CONCLUSION

Ceramic breakage has reduced with mixed ceramics but has a 0.79/1000 incidence at 15-year follow-up. It is unclear what the risk factors are for modern ceramics with increasing head size a risk for alumina only. Risk of 2^nd revision is high and occurs early. The optimal revision option is unknown.

Femoral Head Perforation After Primary Hip Arthroplasty: Unseen Complication of Ceramic-on-Ceramic Interface: A Case Report

CASE

A 33-year-old woman, who underwent bilateral ceramic-on-ceramic total hip arthroplasty 3 years previously, presented with right groin pain and mechanical grinding without a history of trauma. Radiographs revealed luxation of the femoral head, and computerized tomography showed perforation of the ceramic femoral head. The patient underwent revision with a metal-on-polyethylene articulation and retained femoral stem. Two years of follow-up yielded good clinical outcome with no evidence of osteolysis or polyethylene wear.

CONCLUSION

The perforation of a ceramic femoral head should be kept in mind as one of the possible implant failure mechanisms after primary hip arthroplasty.

Pushing Ceramic-on-Ceramic in the most extreme wear conditions: A hip simulator study

BACKGROUND

Hip revision surgery for fractured ceramic components may represent the worst-case wear scenario due to the high risks of recurrent dislocations, instability, and third body wear. The ideal bearing choice for the new prosthetic articulation is still subject of debate, while alumina matrix composite (AMC) articulations offer theoretical superior performances; the present work was designed to test the wear behaviour of ceramic on ceramic articulations (liner and head) in a worst-case scenario by adding ceramic third-body particles to the test lubricant with combined walking and subluxation cycles in a hip joint simulator. Therefore, we performed an in vitro study aiming to assess how does AMC articulation perform with 1) third-body particles added to the test environment and 2) under subluxation stresses.

HYPOTHESIS

We hypothesised that AMC articulations offer superior performances in such worst conditions.

MATERIALS AND METHODS

A hip simulator test was designed to analyse how AMC articulation performs with third-body particles added to the test environment and under subluxation stresses. Two different load patterns including level walking and subluxation of the ceramic liner were applied. The test fluid lubricant was contaminated by adding coarse ceramic particles during the first 2 million cycles and fine ceramic particles from 2 to 4 million cycles. Group 1 consisted of an alumina matrix composite articulation (liner and head); group 2 consisted of an alumina liner and an alumina matrix composite head. A control group consisting of an alumina ceramic liner articulated against an alumina matrix composite head was provided and only axially loaded. The liners of groups 1 and 2 were tested at an in vivo angle of 45° in the medial lateral plane (inclinationangle), which corresponds to an angle L=30° relative to the ISO standard fixated position used for in vitro testing. All mass measurements were performed using a high precision balance (Sartorius BP211D). During each examination, images on dedicated location of the bearing surfaces were taken using a digital microscope.

RESULTS

Mean cumulative wear of 0.09mg per million cycles between 2 and 4 million cycles was detected in group 2, and this value was significantly lower (p=0.016) in comparison with the average value in group 1 (0.21mg per million cycle). This result can be explained in light of a possible transformation phase of zirconia in AMC liners, probably due to excessive stress during subluxation cycles. However, wear levels observed are close to the gravimetric measurement detection limit of the Sartorious Balance (about 0.1-0.2mg); therefore, wear can be considered negligible in all groups.

CONCLUSION

Our results confirm that AMC couplings perform very well even in the worst-case wear scenario. Since AMC articulations revealed 25% lower cumulative wear respect to AMC on cross linked polyethylene in same simulator setup, AMC articulations should be considered the bearing of choice in revision surgery in light of the high risk of recurrent dislocations, instability, and third body wear.

LEVEL OF EVIDENCE

III, prospective case-control study, in vitro.

Early Short-Term Postoperative Mechanical Failures of Current Ceramic-on-Ceramic Bearing Total Hip Arthroplasties

Although ceramic-on-ceramic (CoC) bearings have been shown to produce the smallest amount of wear volume in vitro as well as in vivo studies when used for total hip arthroplasties (THA), concerns about the failure of these bearing surfaces persist due to early failures observed after short postoperative time. In this study, an exhaustive analysis of the early failure occurred on the new generation of ceramic bearings, consisting of a composite alumina matrix-based material reinforced with yttria-stabilized tetragonal zirconia (Y-TZP) particles, chromium dioxide, and strontium crystals, was performed. For this study, 118 CoC bearings from 117 patients were revised. This article describes a group of mechanical failure CoC-bearing BIOLOX THA hip prosthesis patients without trauma history. The retrieved samples were observed under scanning electron microscopy (SEM), composition was analyzed with energy dispersive X-ray spectroscopy (EDX), and damaged surfaces were analyzed by grazing-incidence X-ray diffraction (GI-XRD) and white light interferometry. In the short term, CoC articulations provided similar mechanical behavior and functional outcome to those in XLPE cases. However, 5% more early mechanical failures cases were observed for the ceramic components. Although the fracture rate of third generation CoC couples is low, the present study shows the need to further improve the third generation of CoC-bearing couples for THA. Despite the improved wear compared to other materials, stress concentrators are sources of initial crack propagation, such as those found in the bore-trunnion areas. Moreover, in view of the evidence observed in this study, the chipping observed was due to the presence of monoclinic phase of the Y-TZP instead of tetragonal, which presents better mechanical properties. The results showed that total safety after receiving a THA is still a goal to be pursued.

Role of computed tomography in determining the choice of treatment for delayed ceramic acetabular liner fracture: A case report

Ceramic acetabular liner fracture is a rare complication and requires early revision surgery to avoid abrasive damaging of metal components by ceramic particles. Chromium-cobalt femoral head can be used in revision surgery if only fractured ceramic particles are completely removed because the abrasive effect of ceramic debris is more pronounced on metal head compared to ceramic head. In this article, we report a 50-year-old male patient of delayed acetabular liner fracture in which we used a ceramic head that is more resistant to residue ceramic particles. We assessed the patient by using computed tomography (CT) to locate the ceramic particles. By using CT imaging, we can detect which ceramic particles pose high morbidity risk for debridement.

Severe Wear and multiple Pseudotumor formation due to revision for ceramic head breakage after ceramic-on-ceramic Total hip arthroplasty: a case report

Background

Head breakage is a serious complication following total hip arthroplasty when using Ceramic on Ceramic bearings surfaces. There is still in controversy about the selection of bearing surfaces when conducting revision surgery.

Case presentation

We describe the case of a fifty-year-old man who had undergone right total hip arthroplasty (THA) with ceramic-on-ceramic prostheses in 2011. After a fall 6 years after the primary procedures, radiographs suggested a ceramic head breakage for revision THA with exchange of metal-on-polyethylene bearing. However, 8 months later, severe metallosis and multiple pseudotumor was confirmed in pelvis and surrounding hip after re-revision THA with ceramic-on-polyethylene prostheses. Analysis of the serum metal ion indicated massive wear of the metal head and erosion of the stem neck and taper.

Conclusions

This case vividly demonstrates metal bearings should be avoided and revision with complete synovectomy and thorough debridement should be performed whenever possible for a fractured ceramic bearing.

High risk of complications using metal heads after ceramic fracture in total hip arthroplasty

BACKGROUND

There is some uncertainty about the bearing to be used to substitute a broken ceramic. Using metal components (head or liner) may lead to catastrophic wear of the metal.

AIM

The purpose of this article is to describe the long-term follow-up result of ceramic fracture replaced with metal-on-polyethylene (MoP).

METHODS

We report 3 cases of ceramic head fracture after ceramic-on-ceramic (CoC) total hip arthroplasty (THA) in which the broken ceramic was replaced with MoP.

RESULTS

All cases developed severe complications due to gross wear of the metal head: one developed a pseudotumour after a few months while the other 2 had significant local metallosis and toxic blood metal levels.

CONCLUSIONS

When there is a fracture of a ceramic component, we advise caution with the use of metal heads, as small ceramic fragments can cause 3rd-body wear with massive metal debris and severe local and general complications.

Heart transplant secondary to cobalt toxicity after hip arthroplasty revision

INTRODUCTION

Cobalt toxicity in patients with hip arthroplasty is a rare complication, but it should be considered in those patients who, after a ceramic fracture, were implanted with a metal-on-polyethylene prosthesis. The complete removal of ceramic particles during revision surgery can be complicated. If the bearing surface is replaced with a metal-on-polyethylene prosthesis, these residual ceramic particles may wear down the chrome-cobalt head, producing localised metallosis. This can trigger blood metal ion levels to rise, causing systemic toxicity. Visual and auditory alterations, cognitive deterioration, hypothyroidism, neuropathy, cardiomyopathy, anorexia, fatigue, diabetes, polycythemia, and respiratory and cutaneous symptoms are some of the clinical manifestations of prosthetic cobaltism.

CASE DESCRIPTION

A young patient presented with multiorgan failure secondary to cobalt toxicity after a ceramic fracture and revision with a metal-on-polyethylene prosthesis; his serum cobalt and chromium levels were 652 μg/L and 270 μg/L, respectively. The patient needed a heart transplant after presenting with cobalt-induced cardiogenic shock.

CONCLUSIONS

In a patient with a ceramic fracture who is subjected to revision surgery with a metal-on-polyethylene bearing, it is necessary to rule out the possibility of cobalt intoxication. Serum cobalt levels > 20 μg/L are inadmissible; in these cases, surgical treatment should be considered in the short term. A wide synovectomy and replacement of components should be performed with hard friction options, preferably with a ceramic-on-ceramic prosthesis.

Revision total hip arthroplasty with metal on metal bearing for ceramic bearing fractures

BACKGROUND

Due to concern of potential metallosis caused by residual microscopic ceramic particles, metal-on-metal (MoM) bearing is deemed undesirable in revision total hip arthroplasty (THA) for ceramic bearing fracture. We determined whether MoM bearing is suitable to be used in revision THA for ceramic fractures and also evaluated whether this treatment increases serum iron levels compared with MoM bearing revision THA for polyethylene failure.

METHODS

Between 2006 and 2012, 22 patients underwent revision surgery using MoM bearing (28 mm femoral head in 18 hips and 32 mm in 4 hips) for ceramic bearing fracture and followed average 52.1 months. We assessed radiological parameter and functional outcome using Harris hip score (HHS) and WOMAC score. Also, serum cobalt (Co) and chromium (Cr) blood tests were performed and compared with the result obtained from age, sex- and follow-up duration-matched patients with MoM revision THA for failed polyethylene bearing.

RESULTS

The mean HHS improved from 60.6 preoperatively to 90.3 at final follow-up. There were no changes in cup position, progression of osteolytic lesions, and measurable wear of MoM bearing articulation at final follow-up radiographs. There was one case of recurrent dislocation after surgery, which was treated with greater trochanter distal advancement and one case of deep infection, which underwent two-stage revision. Mean serum Co level (1.7 vs. 1.4 μg/dl; p = 0.211) and Cr level (0.70 vs. 1.01 μg/dl; p = 0.327) showed no significant difference.

CONCLUSIONS

MoM articulation with liner cementation into the acetabular cup along with total synovectomy can be chosen in revision surgery for ceramic fracture with good midterm follow-up. However, the use of MoM bearing is indicated when the stem and metal shell can be retained and ceramic on ceramic or ceramic on polyethylene bearing cannot be selected. Also long-term outcome needs to be further evaluated.

Chromium-Cobalt Intoxication with Intense Systemic Complications following Total Hip Revision after Per-Operative Ceramic Fracture

Introduction

Heavy metal intoxication after arthroplasty is extremely rare but could be lethal. Case Report. We report the case of a 69-year-old woman, who presented intense systemic symptoms of chromium-cobalt intoxication after revision of per-operative fractured ceramic components with metal-on-polyethylene. Systemic toxicity occurred a year after surgery and expressed brutally with mostly central neurological symptoms. Chelation associated with revision surgery allowed rapid regression of all symptoms.

Conclusion

Revision of fractured ceramic, even per-operatively, should not be done with metal-on-polyethylene components, in order to avoid potentially lethal metal intoxication.

Revision Total Hip Arthroplasty after Ceramic Bearing Fractures in Patients Under 60-years Old; Mid-term Results

Purpose

Although advances in technology have reduced the risk of ceramic implant fractures in total hip arthroplasty, these injuries do occur and their treatment remains challenging. There is a lack of studies reporting on the effectiveness of ceramic components in revision hip arthroplasty after ceramic bearing fracture. The aim of this study is to evaluate clinical and radiologic outcomes of revision surgery with ceramic-on-ceramic components after ceramic bearing fractures in young (i.e., under 60 years old) and active patients.

Materials and Methods

Eight patients who, from May 2004 to November 2011, underwent ceramic-on-ceramic revision surgery following a ceramic component fracture and had more than 6 years follow up were enrolled in this study. All eight patients were male with mean ages at first and revision surgeries of 39 years (range, 31–50 years) and 43.8 years (range, 33–60 years), respectively. There were 6 and 2 cases of ceramic liner and ceramic head fractures, respectively. The average time from the first operation to revision surgery was 54.3 months (range, 9–120 months), and the average follow up period was 9.7 years (range, 6–13.3 years).

Results

At the last follow up, all patients showed improvement in Harris hip score and pain relief and there were no cases of loosening or osteolysis.

Conclusion

Revision total hip arthroplasty using ceramic-on-ceramic components after ceramic component fracture is a feasible and appropriate surgical option in young and active patients.

Fatal Cobalt Toxicity after a Non-Metal-on-Metal Total Hip Arthroplasty

This case illustrates the potential for systemic cobalt toxicity in non-metal-on-metal bearings and its potentially devastating consequences. We present a 71-year-old male with grinding sensations in his right hip following ceramic-on-ceramic total hip arthroplasty (THA). After diagnosing a fractured ceramic liner, the hip prosthesis was revised into a metal-on-polyethylene bearing. At one year postoperatively, X-rays and MARS-MRI showed a fixed reversed hybrid THA, with periarticular densities, flattening of the femoral head component, and a pattern of periarticular metal wear debris and pseudotumor formation. Before revision could take place, the patient was admitted with the clinical picture of systemic cobalt toxicity, supported by excessively high serum cobalt and chromium levels, and ultimately died. At autopsy dilated cardiomyopathy as cause of death was hypothesized. A third body wear reaction between ceramic remnants and the metal femoral head very likely led to excessive metal wear, which contributed systemic cobalt toxicity leading to neurotoxicity and heart failure. This case emphasizes that fractured ceramic-on-ceramic bearings should be revised to ceramic-on-ceramic or ceramic-on-polyethylene bearings, but not to metal-on-polyethylene bearings. We aim to increase awareness among orthopedic surgeons for clinical clues for systemic cobalt intoxication, even when there is no metal-on-metal bearing surface.

Revision Total Hip Arthroplasty for Fractured Ceramic Bearings: A Review of Best Practices for Revision Cases

BACKGROUND

Total hip arthroplasty revision for a fractured ceramic bearing is rare but offers unique challenges. The purpose of this review was to provide a summary of existing literature on fractured ceramic bearings.

METHODS

Two authors performed a literature search of the MEDLINE OVID and PubMed databases with the following search terms: ceramic, fracture, total hip arthroplasty, and revision.

RESULTS

The search identified 228 articles of which 199 were selected for review.

CONCLUSIONS

It is mandatory to perform a complete synovectomy and thorough debridement of the fractured ceramic fragments. A well-fixed acetabular component should be removed if either the locking mechanism is damaged or the component is malpositioned. If the femoral stem taper is damaged, the femoral stem should be removed. However, if minimal damage is present, the femoral stem may be retained and revised using a fourth generation ceramic head with a titanium sleeve. Metal bearings should be avoided and revision with ceramic bearings should be performed whenever possible.

Adverse local tissue reaction after 2 revision hip replacements for ceramic liner fracture: A case report

INTRODUCTION

In younger patients, ceramic-on-ceramic (CoC) bearing surfaces are usually recommended for total hip replacement (THR) because of their low wear rate and longer expected functional life. Although technical advancements have reduced the risk of ceramic bearings fracture, this complication remains a major concern.

CASE DESCRIPTION

We present the case of a 56-year-old patient undergoing 3 revision hip arthroplasties of the right hip due to ceramic liner fractures. Initial THR (2008) was performed with a CoC bearing, followed by liner fracture due to trauma a year later. The acetabular component and liner were replaced, with a minor incongruence between the old head and new insert. The 2nd ceramic insert fractured 3.5 years later, following minor trauma. Upon revision, the bearing surface was changed to metal-on-polyethylene (MoP). The performed retrieval analysis demonstrated stripe and rim wear, and evidence of adhesive wear. The patient was referred to us a month later, with a fistula on the lateral side of the hip, discharging black, petroleum-like liquid. Radiology showed well-fixed implants, no dislocation and no apparent polyethylene wear. Microbiological assessment of the discharge showed no infection. Intraoperatively massive metallosis was noticed, with stable acetabular and femoral components. The metal femoral head was heavily abraded, with almost 1% volumetric wear. Hematoxylin and eosin stained frozen tissue samples showed muscular and adipose tissue necrosis, while polarized light microscopy highlighted metal, polyethylene, and ceramic particles.

CONCLUSION

The present case is yet another report showing the adverse outcomes of using MoP bearings for revision after ceramic liner fracture in THR.

Long Term Survivorship of a Severely Notched Femoral Stem after Replacing the Fractured Ceramic head with a Cobalt-Chromium Head

Background:

Although ceramic head fracture occurs infrequently today, in the event of a fracture, the resulting revision surgery can prove very challenging, since the ceramic particles lodge into the surrounding soft tissue and can cause rapid implant failure

Case Presentation:

A case of long term survivorship of a severed notched femoral stem after replacing the fractured femoral head with a cobalt-chromium one is reported in a 40-year old woman with hip dysplasia who underwent an uncomplicated total hip arthroplasty. The incident of ceramic femoral head fracture occurred 14 months postoperatively without reporting any significant trauma. Intraoperative findings at revision were a multifragmented femoral head and a damaged polyethylene insert along with diffuse metallosis and excessive wear of the cone of the stem. Both the stem and the acetabular component were stable. After removal of ceramic fragments, metallotic tissue excision and careful lavage of the joint, the inlay was replaced by a similar one and a cobalt-chromium femoral head was placed to the existing notched taper of the firmly incorporated stem. At the 13^th year follow up examination, the patient had no pain, used no walking aids, and had normal activity with no signs of wearing or loosening in the plain x-rays.

Conclusion:

Despite current recommendations of using ceramic femoral heads in cases of fracture or to revise the severely damaged stems we were able to provide a long term survivorship up to 13 years postoperatively of a cobalt-chromium femoral head applied to a severe damaged stem.

Cobalt Intoxication Heart Failure after Revision Total Hip Replacement for Ceramic Head Fracture: A Case Report

In 1960s, toxic heart failure due to cobalt poisoning was firstly reported from Canadian industrial worker. Following development of bearing materials in hip arthroplasties, using cobalt-chrome alloy in bearing surface, there were rarely reported of systemic affect toxic cobaltism include toxic heart failure due to articulation wear in Western countries. It could be happened more easily by third body wear from ceramic particle especially revision total hip replacement (THR) surgery using cobalt-chrome alloy following ceramic articulation breakage which index surgery performed by ceramic on ceramic bearing. In Korea, due to many surgeons prefer ceramic on ceramic bearing in THR compared to Western countries, it might be more important issue within a time. However in our knowledge, there was no previous report about cobalt poisoning heart failure in Korea. It is still very rare and hard to diagnose cobalt intoxication heart failure after THR, so we report a case of fatal heart failure caused by cobalt intoxication after revision THR in 53-year old man who successfully underwent re-revision THR.

Revision of ceramic fracture with ceramic-on-polyethylene in total hip arthroplasty: Medium-term results

There is no consensus on the bearing of choice in revision for ceramic fracture after total hip arthroplasty (THA). The aim of this study was to evaluate the outcomes using ceramic-on-polyethylene (CoP) articulation in revision for ceramic breakage. Twelve patients who underwent revision hip surgery between 2002 and 2013 were followed-up. Appropriate surgical technique, including accurate synoviectomy, was used. The cup and the head were changed in four patients and only the liner and the head were replaced in the remaining eight patients. At the final follow-up there were no cases of re-revision due to tribological reasons, and only one case of polyethylene (PE) wear and osteolysis was scheduled for a new revision because of clear cup malposition. Complications were four cases of dislocation, one case of loosening and one case of infection. Revision of fractured ceramic is a challenging situation with a high risk of early complications. Using CoP liners with accurate synoviectomy and correction of misalignment can be considered a valuable bearing option at medium-term follow-up.

Systemic effects of cobalt toxicity after revision hip replacement can manifest in intermediate to long term follow-up

INTRODUCTION

Metal toxicity from metal-on-metal hip replacements is now well documented and several large series have reported local reactions. Although less common, there are reports of similar reactions from failed ceramic liners. Systemic effects documented in literature have been grouped into cardiac, neuro-ocular and thyroid signs.

METHODS AND RESULTS

We report a case of a patient who had revision for fractured ceramic liner to metal on polyethylene. Third body effect of the ceramic particles led to wear through of the poly liner and the head directly articulating with metal shell. He developed cardiac and neurological features of cobalt toxicity in addition to extensive soft tissue destruction. Revision of the bearing surfaces and synovectomy led to clinical improvement and fall in metal ion levels.

CONCLUSIONS

We recommend 2-stage revision in such situations and close monitoring of all these patients.

Results of revision of total hip arthroplasty for alumina ceramic-on-ceramic bearing fracture

PURPOSE

The purpose of this study was to compare the results of revision total hip arthroplasty after fracture of primary ceramic components using different type of revision bearing surfaces.

METHODS

We analysed the results of 16 patients with a follow-up more than 3 years after first revision. 6 were revised to ceramic-on-ceramic (CoC) bearing, 9 to metal-on-polyethylene (MoP) and 1 to ceramic-on-cross-linked polyethylene (CoXLP) bearing.

RESULTS

The mean follow-up was 87 months. Patients with revision to CoC had higher Harris Hip Score (HHS) of 89 points in comparison to the patients with revision to MoP with 84 points. Radiographic examinations revealed visible eccentric polyethylene wear with osteolysis in 3 out of 9 patients revised to MoP. There were no detrimental x-ray changes in patients revised to CoC components.

CONCLUSIONS

We consider CoC as the best option at revision operation for ceramic component fracture.

Is a ceramic-on-ceramic bearing really superior to ceramic-on-polyethylene for primary total hip arthroplasty? A systematic review and meta-analysis of randomised controlled trials

INTRODUCTION

The outcomes of using a ceramic-on-ceramic (CoC) vs ceramic-on-polyethylene (CoP) bearing surface for primary total hip arthroplasty (THA) are much debated. We performed a systematic review and meta-analysis of randomised controlled trials (RCTs) to compare and evaluate the outcomes of these 2 bearing surfaces.

MATERIALS AND METHODS

Electronic databases (PubMed/Medline, CENTRAL, Embase and Web of Science) were systematically searched for RCTs investigating the association between bearing surfaces and outcomes following primary THA. Two investigators independently reviewed studies for eligibility, assessed the risk of bias, extracted and analysed the data.

RESULTS

In total, 13 RCTs including a total of 2,488 THAs were identified. The Harris Hip Score appeared to be similar between CoC and CoP THAs. The acetabular liner wear rate was lower in CoC than CoP THA, but the meta-analysis showed that the incidence of component-related noise and overall ceramic fracture in CoC group were 14.73 times and 6.02 times higher than CoP THA, respectively. There were no statistically significant differences in rates of radiolucent line formation (&gt;1 mm), osteolysis, loosening, revision with follow-up ≥ 5 years, intraoperative femoral fracture, dislocation, deep infection, deep venous thrombosis and leg length discrepancy between CoC and CoP THAs.

CONCLUSIONS

There appears to be no clear evidence favouring the use of either a CoC or CoP bearing surfaces in primary THA, further studies with high-quality and longer term follow-up to provide more evidence on this topic are still required.

Bearing Change to Metal-On-Polyethylene for Ceramic Bearing Fracture in Total Hip Arthroplasty; Does It Work?

We evaluated the short-term to midterm results of reoperation with bearing change to metal-on-polyethylene (MoP) after ceramic bearing fracture in ceramic-on-ceramic total hip arthroplasty. Nine third-generation ceramic bearing fractures (6 heads and 3 liners) were treated with bearing change to MoP. Mean age at reoperation was 52.7 years. Mean follow-up was 4.3 years. During follow-up, 2 of 3 liner-fractured hips and 1 of 6 head-fractured hips showed radiologic signs of metallosis and elevated serum chromium levels. Re-reoperation with bearing rechange to a ceramic head was performed for the hips with metallosis. One liner-fractured hip had periprosthetic joint infection. Dislocation occurred in 3 hips. From our experience, bearing change to MoP is not a recommended treatment option for ceramic bearing fracture in total hip arthroplasty.

Cobalt toxicity after revision to a metal-on-polyethylene total hip arthroplasty for fracture of ceramic acetabular component

Cobalt metallosis after revision metal-on-polyethylene total hip arthroplasty for catastrophic failure of ceramic components is uncommon but a potentially devastating complication. Common findings associated with heavy metal toxicity include cardiomyopathy, hypothyroidism, skin rashes, visual disturbances, hearing changes, polycythemia, weakness, fatigue, cognitive deterioration, and neuropathy. We report a case of a 57-year-old woman who presented with complaints of progressively worsening hip pain, fatigue, memory loss, lower extremity sensory loss, persistent tachycardia, and ocular changes 5 years after synovectomy and revision of a failed ceramic-on-ceramic total hip arthroplasty to metal-on-polyethylene components. A cobalt level of 788.1 ppb and chromium level of 140 ppb were found on presentation and subsequently decreased to 468.8 ppb and 105.9 ppb, respectively, 2 weeks after revision to a ceramic-on-polyethylene total hip arthroplasty. Improvement of symptoms accompanied this decrease in cobalt and chromium levels. Revision of failed ceramic arthroplasties with later-generation ceramics to avoid this potential complication is recommended.

Ceramic liner fracture and impingement in total hip arthroplasty

BACKGROUND

Ceramic-on-ceramic bearing surfaces were developed to provide an alternate to metal-on-polyethylene to decrease wear-induced osteolysis in total hip arthroplasty patients. In an effort to decrease the risk of ceramic acetabular component fracture or damage during implantation, a raised metal rim was added.

QUESTIONS/PURPOSES

How many fractures or impingements have occurred in our population of patients with ceramic liners with raised rims?

METHODS

With IRB-approved consent, a case series was reviewed from a single center registry and 4 of 169 patients were identified who had revision hip surgery with the ceramic liner with a raised metal rim: one for ceramic liner fracture and three for metallosis, pain, and squeaking. Implant alignment and operative findings were reviewed.

RESULTS

One ceramic liner fracture and three cases of metallosis from impingement of the femoral neck on the posterior elevated metal rim of the acetabular liner were observed at revision. The femoral neck in each patient had a divot that corresponded to a divot in the posterosuperior liner rim. Three of the four patients had audible squeaking or clicking prior to revision. A total of 3% of patients in this series had clinically significant impingement with this implant type.

CONCLUSION

Acoustic phenomenon in a ceramic on ceramic bearing surface should be investigated with a cross-table lateral radiograph to evaluate component position. If symptomatic impingement is demonstrated, revision should be considered to avoid failure from metallosis or fracture.

Treatment of failures related to articulation material in THA. A comprehensive algorithm of surgical options and open questions

Total hip arthroplasty is considered one of the greatest advances in health care of the last century. More than one million THAs are estimated to be performed annually and an increasing number of revisions are expected in the future. Osteolysis and loosening are still the main reasons for failure, justifying the use of low-wear bearings.The aim of this paper is to describe the mode of failure of the different couplings (polyethylene, cross-linked PE, metal, ceramic) and the options of treatment considering the various scenarios that the surgeon has to face nowadays in the case of failure related to articulation material. A comprehensive algorithm of treatment strategies is proposed based on the best current evidence and on the authors' experience.Periodical follow-up, indications for early revision, selection of proper surgical techniques and tribology are suggested. Nowadays, few rules are strongly recommended: trying to avoid any metal in case of failure of metal-on-metal; to avoid metal in fracture of ceramic; never to mix metals or ceramics from different manufactures. We aim to address a great number of open questions. There is still need for further research and evidences in this essential field of orthopaedic surgery.

Unusual prosthetic femoral head fracture in total hip arthroplasty: ceramic on polyethylene articulation

A 68-year-old man with a previous right total hip arthroplasty presented with acute pain in the right hip, and no associated trauma was reported. The previous hybrid arthroplasty consisted of a ceramic femoral head articulating on an ultra-high-molecular-weight polyethylene liner. The unusual diagnosis of fractured ceramic femoral head was made and an urgent revision arthroplasty was performed to remove the ceramic bearing as well as all implants that may have come into contact with the ceramic. This case report highlights the material properties of ceramics in total hip arthroplasties as well as the importance of regular follow-up in these patients.

Revision of ceramic head fracture after third generation ceramic-on-ceramic total hip arthroplasty

We performed 24 revisions of fractures of third generation ceramic heads. The stem was not changed in 20 revisions; a new ceramic-on-ceramic bearing was used in four and a metal-on-polyethylene bearing in 16. The stem was changed in four revisions; a new ceramic-on-ceramic bearing was used in three and a metal-on-polyethylene bearing in one. During the follow-up of 57.5 months, complications occurred in five hips among the 20 stem retained revisions: a fracture of the new ceramic head in two, metallosis with pseudocyst in two, and femoral osteolysis with stem loosening in one. However, there were no complications in the four revisions where the stem was changed. Revision surgery after ceramic head fracture shows high rates of early complications. We recommend stem revision in cases of THA failure due to fracture of a modern ceramic head.

In vivo stimulation of bone formation by aluminum and oxygen plasma surface-modified magnesium implants

A newly developed magnesium implant is used to stimulate bone formation in vivo. The magnesium implant after undergoing dual aluminum and oxygen plasma implantation is able to suppress rapid corrosion, leaching of magnesium ions, as well as hydrogen gas release from the biodegradable alloy in simulated body fluid (SBF). No released aluminum is detected from the SBF extract and enhanced corrosion resistance properties are confirmed by electrochemical tests. In vitro studies reveal enhanced growth of GFP mouse osteoblasts on the aluminum oxide coated sample, but not on the untreated sample. In addition to that a small amount (50 ppm) of magnesium ions can enhance osteogenic differentiation as reported previously, our present data show a low concentration of hydrogen can give rise to the same effect. To compare the bone volume change between the plasma-treated magnesium implant and untreated control, micro-computed tomography is performed and the plasma-treated implant is found to induce significant new bone formation adjacent to the implant from day 1 until the end of the animal study. On the contrary, bone loss is observed during the first week post-operation from the untreated magnesium sample. Owing to the protection offered by the Al2O3 layer, the plasma-treated implant degrades more slowly and the small amount of released magnesium ions stimulate new bone formation locally as revealed by histological analyses. Scanning electron microscopy discloses that the Al2O3 layer at the bone-implant interface is still present two months after implantation. In addition, no inflammation or tissue necrosis is observed from both treated and untreated implants. These promising results suggest that the plasma-treated magnesium implant can stimulate bone formation in vivo in a minimal invasive way and without causing post-operative complications.

Fracture of ceramic bearing surfaces following total hip replacement: a systematic review

Ceramic bearing surfaces are increasingly used for total hip replacement, notwithstanding that concern is still related to ceramic brittleness and its possible mechanical failure. The aim of this systematic review is to answer three questions: (1) Are there risk factors for ceramic component fracture following total hip replacement? (2) Is it possible to perform an early diagnosis of ceramic component failure before catastrophic fracture occurs? (3) Is it possible to draw guidelines for revision surgery after ceramic components failure? A PubMed and Google Scholar search was performed and reference citations from publications identified in the literature search were reviewed. The use of 28 mm short-neck femoral head carries an increased risk of fracture. Acetabular component malposition might increase the risk of ceramic liner fractures. Synovial fluid microanalysis and CT scan are promising in early diagnosis of ceramic head and liner failure. Early revision is suggested in case of component failure; no consensus exists about the better coupling for revision surgery. Ceramic brittleness remains a major concern. Due to the increased number of ceramic on ceramic implants, more revision surgeries and reports on ceramic components failure are expected in the future. An algorithm of diagnosis and treatment for ceramic hip failure is proposed.

Clinical failure analysis of contemporary ceramic-on-ceramic total hip replacements

The present study investigates the performance of ceramic-on-ceramic total hip replacements by combining a retrieval analysis with a survivorship analysis to elucidate mechanisms that led to clinical failure. Semiquantitative surface damage assessment, contact profilometry, contour measurements, and scanning electron microscopy were performed to characterize the types and quantify the extent of surface damage on the retrieved ceramic components. The implantation period was positively correlated with both damage scores of the femoral heads (R = 0.573, p < 0.001) and the acetabular cups (R = 0.592, p < 0.001). Increased maximal out-of-roundness values of the femoral heads correlated with both increased metal transfer damage score (R = 0.384, p = 0.023) and increased stripe damage score (R = 0.729, p ≤ 0.001) of the acetabular liners. The damage rate (damage score/year) for both the retrieved heads and acetabular liners was at least 2.2-fold greater at inclination angles of >45° than the damage rate at inclination angles of ≤45°. For the retrieved femoral heads only, the linear wear rate of 25.5 ± 21.3 µm/year at inclination angles of >45° was 6-fold greater than the linear wear rate of 4.2 ± 2.3 µm/year at inclination angles of ≤45°. Metal transfer on the ceramic bearing surface could possibly contribute to fluid-film starvation and, in combination with an increased inclination angle, may facilitate an adhesive wear mechanism associated with stripe surface damage. At our institution, the clinical survivorship of ceramic-on-ceramic total hip replacements was 98.9% (a total of 9 out of 815 patients were revised within 10 years after total hip arthroplasty) with revision as the end point, suggesting their safe use in younger patients.

Severe metallosis leading to femoral head perforation

This article describes a case of severe metallosis in a 67-year-old woman who initially underwent primary total hip arthroplasty with a ceramic-on-ceramic articular bearing. This was subsequently revised to a metal-on-polyethylene articulation due to ceramic liner fracture. She presented with severe hip pain and a pelvic mass. Infective workup was negative. Perforation of the cobalt-chrome femoral head was observed intraoperatively. In addition, signs of extensive metallosis, including embedded ceramic debris from the primary procedure, were observed. To the authors' knowledge, this is the first report of a ceramic fracture that led to cobalt-chrome femoral head perforation after subsequent revision total hip arthroplasty. The patient underwent successful revision surgery with a ceramic-on-ceramic coupling. Ceramic materials are increasingly being used in total hip arthroplasty in younger patients. They have excellent tribological properties. However, they also have a lower elasticity and plasticity, which makes them susceptible to sudden material failure. Ceramic fracture is an uncommon yet problematic complication of total hip arthroplasty. Previous authors have reported the importance of performing thorough synovectomy following ceramic liner fracture. Revision surgery using couplings that have a lower hardness, such as metal-on-polyethylene, are best avoided due to their susceptibility to undergo abrasive wear from remaining ceramic particles. The authors advocate revision with ceramic-on-ceramic couplings after ceramic liner fracture.

Fatal cardiomyopathy after revision total hip replacement for fracture of a ceramic liner

Symptomatic cobalt toxicity from a failed total hip replacement is a rare but devastating complication. It has been reported following revision of fractured ceramic components, as well as in patients with failed metal-on-metal articulations. Potential clinical findings include fatigue, weakness, hypothyroidism, cardiomyopathy, polycythaemia, visual and hearing impairment, cognitive dysfunction, and neuropathy. We report a case of an otherwise healthy 46-year-old patient, who developed progressively worsening symptoms of cobalt toxicity beginning approximately six months following synovectomy and revision of a fractured ceramic-on-ceramic total hip replacement to a metal-on-polyethylene bearing. The whole blood cobalt levels peaked at 6521 µg/l. The patient died from cobalt-induced cardiomyopathy. Implant retrieval analysis confirmed a loss of 28.3 g mass of the cobalt–chromium femoral head as a result of severe abrasive wear by ceramic particles embedded in the revision polyethylene liner. Autopsy findings were consistent with heavy metal-induced cardiomyopathy.

We recommend using new ceramics at revision to minimise the risk of wear-related cobalt toxicity following breakage of ceramic components.

Cite this article: Bone Joint J 2013;95-B:31–7.

Revision total hip arthroplasty in younger patients: indications, reasons for failure, and survivorship

Increasing numbers of total hip arthroplasty (THA) procedures are being performed on younger patients, and the incidence of revision THA in this population is also increasing. The goals of our retrospective study were to survey the surgical indications and reasons for failure and survivorship of revision THA in patients aged < 50 years. We identified 139 cases of revision THA performed over a 6-year period in patients aged < 50 years. The most common reason for revision was aseptic loosening, followed by acetabular liner wear with or without osteolysis. We found an overall 10-year survivorship of 76%. When survivorship was stratified by the indication for revision surgery, revision for wear demonstrated the best 10-year survivorship, while revision for instability or infection exhibited poor survivorship.

Traumatic ceramic femoral head fracture: an initial misdiagnosis

Background and Purpose:

Ceramic heads are widely used in modern total hip arthroplasty (THA). Although a rare complication, fractures of ceramic heads are described in the literature, evoking uncertainties regarding the in vivo stability of this material, especially when impaction of a fractured ceramic head can lead to disastrous results.

Methods:

In this case report, we present a fracture of a ceramic head after trauma. A misinterpretation of the initial radiographs led to severe fragmentation of the ceramic head two weeks after the incident, later resulting in complete destruction of the arthroplasty.

Results and Interpretation:

Remarkably, radiographs obtained more than one year after the trauma led to this delayed diagnosis. A single radiographic evaluation, especially in patients with persistent pain after major trauma, with a ceramic head in a THA, seems to be insufficient

Synovial fluid microanalysis allows early diagnosis of ceramic hip prosthesis damage

The first clinical sign of ceramic hip prosthesis failure is hip noise. We therefore investigated whether isolation, observation at scanning electron microscopy, and chemical identification with microanalysis of particles from synovial fluid of "noisy hip" could be predictive of ceramic damage. Firstly, the level of "physiological wear" of well functioning ceramic-on-ceramic hip prostheses was assessed with this method, then the test was validated as diagnostic method for liner fracture. Twelve asymptomatic patients were enrolled to demonstrate the first aim; 39 cases of noisy hip (GROUP 1), and 7 cases of pending failure not related to ceramic (GROUP 2) were enrolled for the second aim. The analysis of the synovial fluid of the 12 asymptomatic patients allowed to set the "physiological wear" threshold. The analysis of GROUP 1 hips demonstrated the presence of ceramic particles (2 physiological, 12 mild, and 25 strong). The analysis of GROUP 2 showed a physiological presence of ceramic particles in all cases. Revision surgery in GROUP 1 was performed in 16 hips out 25 with strong ceramic particle presence and 2 out of 12 with mild ceramic particle presence. Failure of the ceramic component was evident in all but one of these cases, while the integrity of components was demonstrated in all seven hips of GROUP 2. Synovial fluid microanalysis can be a useful surrogate in predicting ceramic failure particularly when a strong presence of ceramic particles is observed. On the contrary there is not enough evidence to predict ceramic failure in presence of mild positivity.

A polyethylene liner scratch after revision hip arthroplasty performed to repair ceramic fracture

A 61-year-old man who had undergone revision total hip arthroplasty in 2000 was evaluated at our clinic in 2008, 1 day after feeling an abnormal clicking sensation in his left hip. Radiographs showed a fracture of the alumina ceramic liner of his acetabular component. A second revision total hip arthroplasty was performed with a 28-mm highly crosslinked polyethylene acetabular liner and an alumina femoral head. Sixteen months after the second revision, the patient experience sudden-onset hip pain. Radiographs revealed a fatigue fracture of the neck of a displaced stem. Analysis by scanning electron microscopy of the surface of the retrieved alumina ceramic femoral head revealed no scratches or wear, but analysis of the highly crosslinked polyethylene socket revealed third-body wear, scratches, irregularly shaped dips, and white ceramic particles. Elemental analysis of the white particles by an x-ray microanalyzer revealed the presence of aluminum and oxygen.

Causes of failure of ceramic-on-ceramic and metal-on-metal hip arthroplasties

BACKGROUND

Few large series of hard bearing surfaces have reported on reasons for early failure. A number of unique mechanisms of failure, including fracture, squeaking, and adverse tissue reactions, have been reported with these hard bearing surfaces. However, the incidence varies among the published studies.

QUESTIONS/PURPOSES

To confirm the incidences, we identified the etiologies of early failures of hard-on-hard bearing surfaces for ceramic-on-ceramic and metal-on-metal THAs.

METHODS

We retrospectively reviewed records of 2907 THAs with hard-on-hard bearing surfaces implanted between 1996 and 2009; 1697 (58%) had ceramic-on-ceramic and 1210 (42%) had metal-on-metal bearing surfaces. We recorded bearing-related complications and compared them to nonspecific reasons for revision THA. The minimum followup of the ceramic-on-ceramic and metal-on-metal cohorts was 6 months (mean, 48 months; range, 6-97 months) and 24 months (mean, 60 months; range, 24-178 months), respectively.

RESULTS

The overall revision rate for ceramic-on-ceramic THA was 2.2% (38 of 1697), with aseptic loosening accounting for 55% of revisions (femur or acetabulum). The bearing accounted for 13% of the revisions in the ceramic-on-ceramic THA cohort. The overall metal-on-metal revision rate was 5.4% (65 of 1210), 17 involving adverse tissue reactions related to the metal-on-metal bearing surface (17 of 1210, 1.4% of cases; 17 of 65, 26% of revisions).

CONCLUSIONS

Twenty-six percent of the revisions from metal-on-metal and 13% of ceramic-on ceramic were bearing related. The overall short- to medium-term revision rate was 2.2% and 5.4% for ceramic-on-ceramic and metal-on-metal, respectively. The most common etiology of failure was loosening of the femoral or acetabular components.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the Guidelines for Authors for a complete description of level of evidence.

Thirty years of experience with alumina-on-alumina bearings in total hip arthroplasty

Alumina-on-alumina bearings in total hip arthroplasty have been developed in an attempt to minimise debris and the occurrence of osteolytic lesions. The outstanding tribological properties of this bearing system are explained by low surface roughness, high hardness for major scratch resistance, and high wettability. Since the 1970s, technological improvements in the manufacturing process of alumina components together with a better understanding of Morse taper technology have provided a surgical grade material with high density, high purity and small grains. Published studies on the outcome of total hip arthroplasty performed with this new generation of implants showed high survivorship especially in young and active patients, with survival rates free of revision of 90.8% to 97.4% at ten years. However, concern remains over ceramic liner fracture and squeaking, which has been noted recently with increasing prevalence. This review will discuss the current knowledge on the use of alumina-on-alumina bearings.