Revision total hip arthroplasty performed after fracture of a ceramic femoral head. A multicenter survivorship study

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.

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.

Сomparative analysis of large diameter bearing ceramic monoblock acetabular components

Introduction

The goal of total hip arthroplasty (THA) is to provide ease to patients with persistent and exhausting pain. Durability is the main challenge associated with any tribological pair, with the aim of minimizing wear and thus avoiding problems with aseptic loosening of components and osteolysis. When polyethylene inserts are used in young patients, we should always consider their disadvantages, e.g., increased wear of the interacting components. Proper selection of friction pairs allows prolonged implant life. Ceramic-on-ceramic (CoC) friction pairs should provide long-term wear of the friction components.

Objectives

To evaluate the mid-term results of using the monoblock Maxera Cup (Zimmer Biomet) acetabular system in cementless THA.

Methods

We operated on 151 patients using the monoblock Maxera Cup (Zimmer Biomet) acetabular system. The mean follow-up duration was 6 years (73.8 ± 11.7 months). Fifty-seven women and 94 men aged 19-64 years were surgically treated. All 170 THA cases in 151 patients were divided into 3 groups according to the diameters of the CoC friction pairs used (40, 44, and 48 mm). As a control group, we have taken 50 patients who received 50 THA using a standard 36 mm CoC friction pair. The achieved functional results were evaluated using the HHS scale, WOMAC scale, and SF36 scale. We also evaluated the mean duration of surgical intervention and blood loss.

Results

When assessing long-term results, the average HHS significantly increased from 34.10 (before surgery) to 87.50 (postoperation) points in the 1st group, from 46.24 to 96.5 points in the 2nd group, and from 38.70 to 92.10 points in the 3rd group. From preoperative examination to 1 year after surgery, there was a 2.4-fold improvement in the functional results in group 1 and 1,8 and 2.9 -fold improvement in groups 2 and 3, indicating excellent treatment results. Inconsistent creaking in the implanted joint was noted in only 2.6% of cases in which a CoC friction pair with a diameter of 44 mm was used. We did not observe any complications associated with aseptic or septic loosening of the components either clinically or radiologically during the 7-year follow-up period after surgery in the entire patient population.

Conclusions

1Use of the CoC monoblock allowed us to expect an increase in the life cycle of the implant and provided good joint function and perception by the patient.2Monoblock cups provided good joint function and perception by the patient.3Acoustic effects, in the form of minor creaking, did not affect the functional results.

Long-Term Results of Delta Ceramic-on-Ceramic Total Hip Arthroplasty

Background

Ceramic-on-ceramic (COC) bearings in total hip arthroplasty (THA) have long been considered the coupling with the lowest overall wear. However, concerns about complications such as ceramic breakage and noise, combined with the improved performance of polyethylene, have limited its use in the United States. This postapproval follow-up reports long-term (10 years) results of Delta COC in THA patients primarily enrolled in an Investigational Device Exemption study.

Methods

Patients received Delta COC THA in a prospective multicenter study with either 28-mm (N = 105 hips in 104 patients) or 36-mm (N = 81) articulations. Annual clinical and radiographic evaluations were performed for years 5 to 10, and study patients were asked about hip noises and reproducibility.

Results

There have been 4 additional reports of noise in 4 patients (COC 28, n = 3; COC 36, n = 1). The cumulative incidence rate for squeaking or noise at 10 years is 5.9% for COC 28 and 13.5% for COC 36. There have been 2 additional reports of dislocation in 2 patients (COC 28, n = 1; COC 36, n = 1). The cumulative incidence rate for dislocation at 10 years is 3.7% for COC 28 and 3.5% for COC 36. At 10 years, there were greater than 40 hips available for follow-up. At mean 10-year follow-up, there were a total of 3 ceramic liner fractures, but none since the previous report. There were no revisions in the 28-mm cohort, and 2 revisions in the 36-mm cohort (1 for recurrent dislocation and 1 for pain and noise). Overall Kaplan-Meier survivorship was 95.96% at 10.5 years (28 mm: 97.68% at 10.2 years; 36 mm: 94.11% at 10.4 years.)

Conclusions

At 10-year follow-up, we report excellent results in regard to survivorship, with one patient revised for pain with associated squeaking.

Outcome after Two Sequential Revision Hip Arthroplasties for CoC Bearing Fracture with 10 Years Follow-up: A Case Report

Introduction

Revisions due to the fracture of ceramic-on-ceramic (CoC) bearing are rare, however when they occur, they represent a major challenge to an orthopedic surgeon for ensuring safe and long-term survival of the replaced bearing.

Case Report

We present a case of fractured ceramic liner of total hip prosthesis that underwent revision to a metal-on-polyethylene (MoP) bearing couple, with consequent huge periprosthetic metallosis. Shortly after, the second revision operation followed using the third bearing couple of ceramic-on-polyethylene (CoP). At 10 years follow-up after the operation due to ceramic fracture, the patient is now pain free with full range of motion of the revised hip.

Conclusion

Establishment of diagnostic routes and recommended protocols for CoC bearing fracture would allow easier recognition of potential fracture and diminish its consequences for the patients.

Fracture of a 40-mm BIOLOX Delta Femoral Head

Ceramic bearing surfaces have gained popularity in total hip arthroplasty as a result of the favorable mechanical properties and low wear rates. Despite the recognition as an attractive articulation, problems such as ceramic head fracture persist. Smaller heads and higher body mass indices are touted as risk factors for ceramic head fracture and are often associated with antecedent trauma. We present a case report of an 83-year-old male with a body mass index of 26.7 kg/m² who suffered a fracture of a 40-mm ceramic femoral head. This occurred atraumatically 5 years from his index surgery. This patient underwent revision total hip arthroplasty which included debridement of ceramic debris and alteration of the bearing surface with femoral head and polyethylene liner exchange.

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.

Early low complication rate of ceramic-on-ceramic total hip arthroplasty by direct anterior approach

Introduction: Ceramic-on-ceramic couplings are an alternative bearing surface to reduce the problems related to polyethylene wear and debris. However, ceramic articulations have their own risk of unique complications: fracture, squeaking, or dislocation. Few studies have assessed the outcomes of ceramic-on-ceramic total hip arthroplasties (THA) by direct anterior approach (DAA). The aim was to evaluate the early complications and revision rate of ceramic-on-ceramic THA by DAA. Material: A retrospective single-center study of 116 consecutive THAs was performed by DAA (106 patients) with ceramic-on-ceramic bearing from January 2015 to February 2018 with a minimum 24 months of follow-up. No patients were lost to follow-up. The mean age was of 55.3 years ± 11.3. The same cementless acetabular shell with a Biolox Delta ceramic insert and head were used. The complication and revision rates were collected at the last follow-up. The positioning of the acetabular implant was assessed on standard radiographs. Postoperative clinical outcomes were assessed by the Harris Hip Score. Results: At a mean follow-up of 31.9 months ± 5.5, no THA was revised. Five patients had late complications: 3 squeaking (2.6%) and 2 psoas impingements (1.7%) and were managed conservatively. All patients had satisfactory bony ingrowth of acetabular component, with no radiolucent lines and no osteolysis. Eight patients (6.9%) had an anterior overhang of the cup. The mean overhang for these patients was 4.1 mm. 111 hips (96%) were perceived as forgotten or having no limitations. Conclusion: This ceramic-on-ceramic coupling and shell by DAA produced excellent clinical outcomes and implant survival rate at a minimum two-year follow-up study. No serious complication was observed during the follow-up.

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.

What Is the Frequency of Fracture of Ceramic Components in THA? Results from the Norwegian Arthroplasty Register from 1997 to 2017

BACKGROUND

Ceramic bearings in THA have been used to reduce wear and, more recently, to avoid metals in the bearing because of the risk of metal ions adverse effects. Potential disadvantages to ceramic bearings are their brittleness and the ceramic fracture risk, which may lead to revision surgery. The frequency of revision for a fracture ceramic bearing, however, has not been thoroughly studied.

QUESTIONS/PURPOSES

(1) What is the frequency of revision for a fractured ceramic bearing in ceramic-on-polyethylene (CoP) and ceramic-on-ceramic (CoC) THAs, and is there any difference between alumina ceramics and alumina matrix composites (AMC)? (2) What are the factors associated with this complication? (3) To what extent did the patients who underwent revision for a fractured ceramic bearing undergo subsequent revisions, and for what reason?

METHODS

The Norwegian Arthroplasty Register has collected data on hip arthroplasty since 1987 and has a completeness of reporting of 97.3% for primary THAs and 93.3% for revision. From 1997 to 2017, 146,171 primary THAs were registered in the Norwegian Arthroplasty Register. Of these, 31,479 had a CoP articulation and 5790 had a CoC articulation. Two manufacturers produced ceramic heads; one produced 25,678 alumina heads and the other made 2465 alumina heads. All 7901 AMC heads were made by the same manufacturer. Patients who underwent CoP THA were a median (range) of 63 years old (11 to 98) and CoC THA were a median (range) 61 years old (17 to 95); 38% (11,833 of 31,479) of the patients who underwent CoP THA and 41% (2379 of 5790) of the patients who underwent CoC THA were males. Femoral heads made of alumina (n = 28,143), zirconia (n = 1225), and AMC (n = 7901) ceramics were used. To assess revision frequency, we identified patients who underwent revision because of fracture of a ceramic head and/or liner, and calculated the Kaplan-Meier survivorship free of revision for fracture in CoC and CoP articulations. Alumina ceramics and AMC were compared. In terms of factors potentially associated with revision, patient factors (age, sex, and diagnosis), type of articulation (CoP or CoC), femoral head size, and femoral head/neck length were evaluated with Cox regression models to evaluate any association with ceramic fracture and a Poisson regression to compare alumina and AMC head fractures. To evaluate subsequent revisions, hips that were revised for ceramic fracture were evaluated for any further revisions; Kaplan-Meier survivorship free of further revisions was calculated, and revision causes were identified.

RESULTS

Survivorship free from revision for ceramic fracture was 99.9% (95% CI 99.9 to 99.9) for CoP bearings, and 99.8% (95% CI 99.6 to 100) for CoC bearings at 10 years, with 7467 and 1884 hips at risk in the two groups, respectively. The hazard ratio for ceramic head fracture was 3.6 (95% CI 1.7 to 7.6) for CoC compared with CoP. The risk of fracture was greater for alumina ceramics than for AMC heads (adjusted HR 14.1 [95% CI 4.2 to 47.0]; p < 0.001). Factors that were associated with revision for fracture of a ceramic head were male sex (HR 5.2 [95% CI 2.6 to 10.4]; p < 0.001), a CoC articulation compared with CoP (HR 3.6 [95% CI 1.7 to 7.6]; p = 0.001), a 28-mm femoral head compared with a 32-mm head (HR 2.7 [95% CI 1.1 to 6.4]; p = 0.02), and short head/neck length compared with a medium head/neck length (HR 2.5 [95% CI 1.1 to 5.3]; p = 0.03). Five of 50 patients undergoing revision for ceramic fracture underwent further revisions, resulting in a 5-year survivorship free from re-revision of 86% (95% CI 74.4 to 98.0). The reasons for re-revision were infection (n = 2), another ceramic head fracture (n = 2), and cup loosening (n = 1).

CONCLUSIONS

Fracture of a ceramic THA bearing is rare and seems to affect about one in 1000 patients who receive such a bearing. To minimize the risk of this complication, surgeons should avoid small femoral heads (< 32 mm) and the shortest head/neck lengths. Surgeons should also know that the risk is increased in CoC articulations and in males. Bearings made of AMC appear to be at lower risk than those made from alumina ceramics. However, the long-term clinical wear performance of AMC bearings has not been extensively studied and should be studied further.

LEVEL OF EVIDENCE

Level III, therapeutic study.

High survivorship of highly cross-linked polyethylene in revision Total hip Arthroplasty: a minimum 10-year follow-up study

Purpose

Highly cross-linked polyethylene has been introduced to decrease osteolysis secondary to polyethylene wear debris generation. However, few long-term data on revision total hip arthroplasty (THA) using highly cross-linked polyethylene liners are available. The objective of this study was to determine long-term outcomes of a highly cross-linked polyethylene liner in revision THA.

Materials & methods

We evaluated 63 revision THAs performed in 63 patients using a highly cross-linked polyethylene liner between April 2000 and February 2005. Of these, nine died and four were lost to follow-up. Thus, the final study cohort consisted of 50 patients (50 hips), including 26 males and 24 females with a mean age of 53 years (range, 27–75 years). Mean follow-up was 11 years (range, 10–14 years).

Results

The mean Harris hip score improved from 44 points preoperatively to 85 points at the final follow-up. No radiographic evidence of osteolysis was found in any hip. The mean rate of polyethylene liner wear was 0.029 mm/year (range, 0.003 to 0.098 mm/year). A total of 5 hips (10%) required re-revision arthroplasty, including one cup loosening, one recurrent dislocation, and three deep infections. Kaplan-Meier survivorship with an end point of re-revision for any reason was 91.1% and for aseptic cup loosening was 97.9% at 11 years.

Conclusion

At a minimum of 10 years, the highly cross-linked polyethylene liners showed excellent clinical performance and implant survivorship, and were not associated with osteolysis in our patients with revision THAs.

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.

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.

Liner dissociation leading to catastrophic failure of an Oxinium femoral head

Oxinium is an alternative bearing surface designed to emulate the superior wear and scratch properties of ceramic femoral heads in total hip arthroplasty while minimizing the risk for brittle fracturing. However, recent studies have indicated that hip dislocation following total hip arthroplasty may be a risk factor for catastrophic failure of the femoral head. Here, we report on a novel case of a catastrophic Oxinium head and polyethylene liner failure in the absence of previous hip dislocation or trauma and review the probable failure mechanism. This report underscores the need to be vigilant about proper acetabular cup and liner seating, particularly in the setting of Oxinium femoral head use. In the event of Oxinium head failure, metallosis may compromise stabilizing soft tissues including the abductors. Dual-mobility articulation, which was successful in this case, is one option to consider when the risk for chronic redislocation is elevated.

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.

The use of polycarbonate-urethane as an acetabular shell bearing surface: a 5-year prospective study

AIM

To evaluate the clinical performance of a polycarbonate-urethane liner as a bearing material inside a cobalt-chrome acetabular shell.

METHODS

Between December 2007 and July 2011, this material combination was used in 27 total hip replacement patients, most of whom had an indication of osteoarthritis. This report focuses on the first 5-year results of the clinical use of this material combination in the TriboFit® Hip System.

RESULTS

Mean Harris Hip Score showed significant improvement from 40 to 86 after 5 years, similar to studies in the literature. No adverse events - revisions or complications - or disadvantages that have been reported for other total hip materials were observed over the 5-year period. The radiographs showed no signs of wear, migration or loosening of the implants.

CONCLUSIONS

These early results indicate this new material combination offers promise as a safe and effective alternative bearing material for use in total hip systems. Further clinical trials are necessary to reconfirm these findings.

Mid-term results of the BIOLOX delta ceramic-on-ceramic total hip arthroplasty

Aims

We conducted a prospective study of a delta ceramic total hip arthroplasty (THA) to determine the rate of ceramic fracture, to characterise post-operative noise, and to evaluate the mid-term results and survivorship.

Patients and Methods

Between March 2009 and March 2011, 274 patients (310 hips) underwent cementless THA using a delta ceramic femoral head and liner. At each follow-up, clinical and radiological outcomes were recorded. A Kaplan-Meier analysis was undertaken to estimate survival.

Results

Four patients (four hips) died and 18 patients (20 hips) were lost to follow-up within five years. The remaining 252 patients (286 hips) were followed for a mean of 66.5 months (60 to 84). There were 144 men (166 hips) and 108 women (120 hips) with a mean age of 49.7 years (16 to 83) at surgery. The mean pre-operative Harris Hip Score of 47.1 points improved to 93.8 points at final follow-up. Six patients reported squeaking in seven hips; however, none were audible. Radiolucent lines involving Gruen zones one and/or seven were seen in 52 hips (18.2%). No hip had detectable wear, focal osteolysis or signs of loosening. One hip was revised because of fracture of the ceramic liner, which occurred due to an undetected malseating of the ceramic liner at the time of surgery. One hip was revised for a periprosthetic fracture of the femur, and one hip was treated for periprosthetic joint infection. The six-year survivorship with re-operation for any reason as the endpoint was 99.0% (95% confidence interval 97.8% to 100%).

Discussion

The rate of delta ceramic fracture was 0.3% (one of 286). While ceramic head fracture was dominant in previous ceramic-on-ceramic THA, fracture of the delta ceramic liner due to malseating is a concern. Cite this article: Bone Joint J 2017;99-B:741–8.

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.

Correlation of Cup Inclination Angle with Liner Wear for Metal-on-polyethylene in Hip Primary Arthroplasty

OBJECTIVES

The relationship between cup inclination angle and liner wear is controversial. Most authors in the published literature agree that the ideal cup inclination is associated with lower inner wear; however, some disagree. All previous studies did not control for femoral head diameter and inclination, so it is difficult to assess the relative or synergistic effects of cup angle on outcomes.

METHODS

We retrospectively reviewed 154 patients (171 hips) with primary total hip arthroplasties performed from 2001 to 2004. All surgeries had been performed by the same physician team. A posterior approach was applied in all patients. All prostheses were non-cemented cups with a 28-mm metal head. Inclusion criteria included that the radiographic material was not completed or lost for primary or last follow up. Patients were divided into four groups according to different cup inclination angle. There were 108 hips with inclination angles below 50°; 35 hips with angles between 50° and 55°; 17 hips with angles between 55° and 60°; and 11 hips with angles greater than 60°. An immediate postoperative radiograph was compared with a follow-up radiograph. Clinical and radiographic data were collected on standardized hip evaluation forms preoperatively, 6 months after surgery and at yearly follow-up visits. Radiographs were digitized and enlarged 100%. After the radiographs were digitized, polyethylene wear rates and acetabular cup abduction were measured on all patients with Cavas 15.0 software. The results were analyzed using Student's two-tailed paired t-test with SPSS 11.5.

RESULTS

The preoperative mean Harris hip score improved from 45.36 to 93.5 points 10 years after surgery. No acetabular component was revised for aseptic loosening. Three patients (three hips) had to undergo bone grafting and a lined arthroplasty for severe osteolysis around the acetabular component. The rate of implant survival at 10 years with respect to loosening was 100%. The mean liner wear rate was 0.135 mm/year in cups with inclination angles below 50°, 0.144 mm/year between 50° and 55°, 0.260 mm/year between 55° and 60°, and 0.403 mm/year when the angle was greater than 60°. Liner wear increased when the cup angle was larger than 55° (P < 0.05).

CONCLUSIONS

For metal-on-polyethylene prostheses, liner wear correlates with cup inclination angle larger than 55°. The ideal abduction angle for metal-on-polyethylene prostheses is less than 55°.

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.

Alumina Delta-on-Alumina Delta Bearing in Cementless Total Hip Arthroplasty in Patients Aged <50 Years

BACKGROUND

There are limited studies to evaluate long-term clinical and radiographic outcomes of alumina delta ceramic-on-ceramic bearings in cementless total hip arthroplasty (THA). The purpose of this study was to evaluate the clinical and radiographic results, prevalence of osteolysis, squeaking, and fracture of ceramic material associated with the use of the alumina delta ceramic-on-alumina delta ceramic bearing in cementless THA in patients aged <50 years.

METHODS

We reviewed the cases of 277 patients (334 hips) who underwent a cementless THA using alumina delta ceramic-on-alumina delta ceramic when they were 50 years or younger at the time of surgery. Demographic data; Harris Hip Score; Western Ontario McMaster Universities Osteoarthritis Index; and University of California, Los Angeles activity score were recorded. Radiographic and computerized tomographic evaluations were used to evaluate implant fixation and osteolysis. Squeaking sound and ceramic fracture were documented. The mean follow-up was 7.8 years (range, 6-9).

RESULTS

The mean postoperative Harris Hip Score, Western Ontario and McMaster Universities Osteoarthritis Index score, University of California, Los Angeles activity score were 93 points, 15 points, and 8.6 points, respectively. Two patients had thigh pain (grade 7 points). All acetabular components and all but 2 femoral components were well fixed. Thirty-three hips (10%) exhibited clicking sound, and 2 hips (0.6%) exhibited squeaking sound. No hip had osteolysis or ceramic head or liner fracture.

CONCLUSION

Our minimum 6-year follow-up results with the use of alumina delta ceramic-on-alumina delta ceramic bearings in patients aged <50 years suggest that cementless THA provides a high rate of survivorship without evidence of osteolysis or fracture of ceramic material.

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.

Inflammatory pseudotumor after ceramic-on-ceramic total hip arthroplasty

We present a unique case of a symptomatic adverse local tissue reaction in a patient with a ceramic-on-ceramic total hip bearing surface. To our knowledge, this pathological finding has not yet been described in a ceramic-on-ceramic articulation without a cobalt-chromium alloy trunnion or modular neck component as a source of metal wear. We conclude that despite its mechanical mostly benign wear characteristics, ceramic wear debris is not entirely inert and may lead to the development of adverse local tissue reaction.

Alumina Delta-on-Highly Crosslinked-Remelted Polyethylene Bearing in Cementless Total Hip Arthroplasty in Patients Younger than 50 Years

BACKGROUND

The purpose of this retrospective study was to determine the clinical and radiographic results, prevalence of polyethylene wear and osteolysis, and fracture of alumina delta ceramic femoral head or highly crosslinked, remelted polyethylene (HXLPE) liner associated with the use of alumina delta ceramic femoral head-on-HXLPE bearing in cementless total hip arthroplasty in patients younger than 50 years.

METHODS

We reviewed the cases of 119 patients (130 hips) who underwent a cementless total hip arthroplasty using alumina delta ceramic-on-HXLPE bearing when they were 50 years or younger at the time of surgery. The most common diagnoses were osteonecrosis (51%) and osteoarthritis secondary to developmental dysplastic hip (39%). Osteolysis and polyethylene wear rates were evaluated with use of radiography and computed tomography. In addition, prevalence of fracture of alumina delta ceramic head and polyethylene line was documented. The mean follow-up was 8.3 years (range, 7-9 years).

RESULTS

The mean Harris hip score, Western Ontario and McMaster Universities Osteoarthritis Index score, University of California, Los Angeles activity score were 94 points, 14 points, and 8.1 points, respectively, at the final follow-up. No patient had thigh pain. All acetabular components and all but one femoral components were well fixed. The mean annual penetration rate of femoral head was 0.022 ± 0.003 mm/year. No hip had osteolysis or ceramic head or HXLPE liner fracture.

CONCLUSION

Our average 8.3-year results with the use of alumina delta ceramic-on-HXLPE bearing in the patients younger than 50 years suggest that cementless acetabular and femoral components provide a high survival rate without evidence of osteolysis or ceramic head or AXLPE liner fracture.

Delayed diagnosis of catastrophic ceramic liner failure with resultant pelvic discontinuity and massive metallosis

With newer-generation ceramic components used in total hip arthroplasty, component fracture is a rare complication. However rare, when ceramic component fracture does occur, prompt identification and revision is necessary as delay can lead to dramatic failure with resultant metallosis as the extremely hard ceramic debris abrades remaining components. We present a case of a 70-year-old woman with ceramic liner fracture and an estimated 10-year delay in intervention with failure resulting in pelvic discontinuity and massive metallosis with associated cutaneous manifestation. She was treated with a complex revision and reconstruction and is 2 years postrevision without major complication.

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.

Do the Reasons for Ceramic-on-ceramic Revisions Differ From Other Bearings in Total Hip Arthroplasty?

BACKGROUND

Despite widespread use of ceramic-on-ceramic (CoC) in total hip arthroplasty (THA) during the past 10 years, little is known about why revisions are performed in hips with this bearing or the time elapsed before revision.

QUESTIONS/PURPOSES

The purposes of this study were: (1) Do the reasons for first revision differ between CoC bearings and other bearing couples? (2) Does the time to revision differ between CoC and other bearing couples? (3) Are there unique reasons for revisions of CoC bearings?

METHODS

All members of the Société Française de Chirurgie Orthopédique et Traumatologique (SoFCOT) who performed ≥ 30 revisions per year were invited to participate in this multicenter, prospective, observational study. Our data represent 12% of the revision procedures performed in France. A total of 2107 first revisions of THA (from January 2010 to December 2011) were done in 2107 patients (1201 females [57%] and 906 males [43%]; median age, 73 years; age range, 17-104 years) at the time of surgery after a median of 11 years (range, 0 day-42 years) after the primary THA. There were 238 of 2107 (11%) CoC, 148 of 2107 (7%) metal-on-metal (MoM), and 1721 of 2017 (82%) metal-on-polyethylene (MoP) bearings.

RESULTS

The reasons for reoperation differed according to the bearing component: (1) for the MoP reference bearing (odds ratio [OR]; 95% confidence interval), cup loosening occurred in 698 of 1721 hips (41%), periprosthetic fracture in 220 of 1721 hips (13%), and osteolysis in 213 of 1721 hips (12%); (2) for CoC, cup loosening occurred in 41 of 238 hips (17%) (OR, 0.31 [0.22-0.43; p < 0.001), infection in 39 of 238 hips (16%) (OR, 1.63 [1.12-2.37]; p = 0.01), and dislocation in 23 of 238 hips (10%) (OR, 0.9 [0.57-1.42]; p = 0.9); (3) for MoM, cup loosening occurred in 28 of 148 hips (19%) (OR, 0.34 [0.22-0.52]; p < 0.001), adverse reaction to metallic debris in 26 of 148 hips (18%) (OR, 18.12 [9.84-33.4]; p < 0.001), and infection in 16 of 148 hips (11%) (OR, 1 [0.59-1.73]; p = 0.9). In comparison with MoP, osteolysis was rarely the reason for revision in CoC (four of 238 hips [2%]; OR, 0.12 [0.05-0.33]; p < 0.001), but this bearing was frequently revised because of iliopsoas irritation (18 of 238 hips [8%]; OR, 4.9 [2.7-9]; p < 0.001). The time elapsed before revision differed between bearings: median of 3 years (range, 3 days to 28 years) for CoC and 4 years (range, 14 days to 37 years) for MoM versus a median 13 years (range, 0 day to 42 years) for MoP (p < 0.001). Thirty-seven of the 238 revisions (16%) were directly related to ceramic use (ceramic breakage [n = 23], squeaking [n = 6], impingement [n = 7], incorrect ceramic insert insertion [n = 1]). No factors were identified that contributed to breakage of the 12 bulk ceramic components (eight heads, four inserts, four of 12 Delta ceramic). No factors were associated with squeaking, iliopsoas irritation, or impingement, but component orientation was not assessed.

CONCLUSIONS

The reasons and time to first revision differed between CoC and other bearings. CoC THAs are revised earlier and are sensitive to mechanical problems such as impingement, squeaking, and ceramic rupture that did not disappear with introduction of Delta ceramics and large-diameter (≥ 36 mm) bearings. CoC was rarely revised for osteolysis, but a high rate of iliopsoas irritation requires further investigation.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Alumina Delta-on-Alumina Delta Bearing in Cementless Total Hip Arthroplasty in Patients Aged <50 Years

BACKGROUND

There are limited studies to evaluate long-term clinical and radiographic outcomes of alumina delta ceramic-on-ceramic bearings in cementless total hip arthroplasty (THA). The purpose of this study was to evaluate the clinical and radiographic results, prevalence of osteolysis, squeaking, and fracture of ceramic material associated with the use of the alumina delta ceramic-on-alumina delta ceramic bearing in cementless THA in patients aged <50 years.

METHODS

We reviewed the cases of 277 patients (334 hips) who underwent a cementless THA using alumina delta ceramic-on-alumina delta ceramic when they were 50 years or younger at the time of surgery. Demographic data; Harris Hip Score; Western Ontario McMaster Universities Osteoarthritis Index; and University of California, Los Angeles activity score were recorded. Radiographic and computerized tomographic evaluations were used to evaluate implant fixation and osteolysis. Squeaking sound and ceramic fracture were documented. The mean follow-up was 13.1 years (range, 10-14).

RESULTS

The mean postoperative Harris Hip Score, Western Ontario and McMaster Universities Osteoarthritis Index score, University of California, Los Angeles activity score were 93 points, 15 points, and 8.6 points, respectively. Two patients had thigh pain (grade 7 points). All acetabular components and all but 2 femoral components were well fixed. Thirty-three hips (10%) exhibited clicking sound, and 2 hips (0.6%) exhibited squeaking sound. No hip had osteolysis or ceramic head or liner fracture.

CONCLUSION

Our minimum 10-year follow-up results with the use of alumina delta ceramic-on-alumina delta ceramic bearings in patients aged <50 years suggest that cementless THA provides a high rate of survivorship without evidence of osteolysis or fracture of ceramic material.

Metallosis after Exchange of the Femoral Head and Liner following Ceramic Acetabular Liner Dissociation in Total Hip Arthroplasty with a Modular Layered Acetabular Component

The type of bearing material that should be used in revision surgery after the failure of ceramic-on-ceramic total hip arthroplasty (THA) remains controversial. In the case of ceramic fracture, the residual ceramic particles can cause consequent metallosis when metal implants are used for revision THA. On the other hand, in the case of THA failure without ceramic fracture, revision THA with a metal femoral head provides satisfactory results. We report an unusual case of progressive osteolysis due to metallosis that developed after revision THA for ceramic liner dissociation without a liner fracture performed using a metal femoral head and polyethylene liner. The residual metal debris and abnormal pumping motion of the polyethylene liner due to the breakage of the locking system or the aspherical metal shell being abraded by the ceramic head seemed to be the cause of the progressive osteolysis.

Tribocorrosion: Ceramic and Oxidized Zirconium vs Cobalt-Chromium Heads in Total Hip Arthroplasty

BACKGROUND

This matched-cohort study aims to compare tribocorrosion between matched ceramic and cobalt-chromium femoral head trunnions and between matched Oxinium and cobalt-chromium femoral head trunnions. Secondary objectives were to investigate whether taper design, depth of trunnion, implantation time, age, body mass index, and gender have an effect on fretting and corrosion.

METHODS

All hip prostheses retrieved between 1999 and 2015 at one center were reviewed, giving a total of 52 ceramic heads. These were matched to a cobalt-chromium cohort according to taper design, head size, neck length, and implantation time. The trunnions were examined by 2 observers using a 4-point scoring technique and scored in 3 zones: apex, middle, and base. The observers were blinded to clinical and manufacturing data where possible. A separate matched-cohort analysis was performed between 8 Oxinium heads and 8 cobalt-chromium heads, which were similarly scored.

RESULTS

Ceramic head trunnions demonstrated a lower median fretting and corrosion score at the base zone (P < .001), middle zone (P < .001), and in the combined score (P < .001). Taper design had a significant effect on fretting and corrosion in the apex zone (P = .04) of the ceramic group, as well as the cobalt-chromium group (P = .03). Between Oxinium heads and cobalt-chromium heads, there was no significant difference in the fretting and corrosion score across all 3 zones (base: P = .22; middle: P = .92; and apex: P = .71) and for the combined score (P = .67).

CONCLUSION

This study shows that ceramic head confers an advantage in trunnion fretting and corrosion. Taper design and implantation time were also significant factors for fretting and corrosion.

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.

Revision for taper corrosion at the head-neck junction: pearls and pitfalls

Modular hip replacement components offer numerous advantages, and the modular femoral component has become standard for contemporary total hip implants. Recent reports of mechanically assisted crevice corrosion (MACC) at the head-neck junction, and associated adverse local tissue reactions (ALTRs), have renewed concerns for complications attributed to modularity. This manuscript describes the diagnosis, prognosis, and treatment options for MACC and highlights how appropriate pre-revision evaluation and planning, in conjunction with meticulous surgical technique, should be followed to avoid complications and achieve optimal surgical outcomes. Future directions for research include biomechanical, clinical, and retrieval studies.

The Epidemiology and National Trends of Bearing Surface Usage in Primary Total Hip Arthroplasty in Korea

Background

We analyzed the data for primary total hip arthroplasty (THA) in the Korean nationwide database to assess (1) the epidemiology and national trends of bearing surface usage in THAs and (2) the prevalence of each type of bearing surface according to age, gender, hospital type, primary payer, and hospital procedure volume.

Methods

A total of 30,881 THAs were analyzed using the Korean Health Insurance Review and Assessment Service database for 2007 through 2011. Bearing surfaces were sub-grouped according to device code for national health insurance claims and consisted of ceramic-on-ceramic (CoC), metal-on-polyethylene (MoP), ceramic-on-polyethylene (CoP), and metal-on-metal (MoM). The prevalence of each type of bearing surface was calculated and stratified by age, gender, hospital type, primary payer, and procedure volume of each hospital.

Results

CoC was the most frequently used bearing surface (76.7%), followed by MoP (11.9%), CoP (7.3%), and MoM (4.1%). The proportion of THAs using a CoC bearing surface increased steadily from 71.6% in 2007 to 81.4% in 2011, whereas the proportions using CoP, MoP, and MoM bearing surfaces decreased. The order of prevalence was identical to that in the general population regardless of age, gender, hospital type, primary payer, and hospital procedure volume.

Conclusions

The trends and epidemiology of bearing surface usage in THAs in Korea are different from those in other countries, and the CoC bearing surface is the most prevalent articulation. In future, the results of a large-scale study using nationwide data of THAs involving a CoC bearing surface will be reported in Korea.

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.

Oxidized zirconium head on crosslinked polyethylene liner in total hip arthroplasty: a 7- to 12-year in vivo comparative wear study

BACKGROUND

Osteolysis resulting from wear debris production from the bearing surfaces is a major factor limiting long-term survival of hip implants. Oxidized zirconium head on crosslinked polyethylene (XLPE) is a modern bearing coupling. However, midterm in vivo wear data of this coupling are not known.

QUESTIONS/PURPOSES

The purpose of this study was to investigate in vivo whether the combination of an oxidized zirconium femoral head on XLPE produces less wear than a ceramic head on XLPE or a ceramic head on conventional polyethylene (CPE) couplings and whether any of these bearing combinations results in higher hip scores.

METHODS

Between 2003 and 2007, we performed 356 total hip arthroplasties in 288 patients; of those, 199 (69.1%) patients (199 hips) were enrolled in what began as a randomized trial. Unfortunately, after the 57(th) patient, the randomization process was halted because of patients' preference for the oxidized zirconium bearing instead of the ceramic after (as they were informed by the consent form), and after that, alternate allocation to the study groups was performed. Hips were allocated into four groups: in Group A, a 28-mm ceramic head on CPE was used; in Group B, a 28-mm ceramic head on XLPE; in Group C, a 28-mm Oxinium head on XLPE; and in Group D, a 32-mm Oxinium head on XLPE. The authors prospectively collected in vivo wear data (linear wear, linear wear rate, volumetric wear, and volumetric wear rate) using PolyWare software. Preoperative and postoperative clinical data, including Harris and Oxford hip scores, were also collected at regular intervals. Of those patients enrolled, 188 (95%) were available for final followup at a minimum of 7 years (mean, 9 years; range, 7-12 years).

RESULTS

All bearing surfaces showed a varying high bedding-in effect (plastic deformation of the liner) up to the second postoperative year. At 5 years both oxidized zirconium on XLPE groups showed lower (p < 0.01) volumetric wear (mean ± SD mm(3)) and volumetric wear rates (mean ± SD mm(3)/year) (Group C: 310 ± 55-206 ± 55 mm(3)/year, Group D: 320 ± 58-205 ± 61 mm(3)/year) when compared with ceramic on CPE (Group A: 791 ± 124-306 ± 85 mm(3)/year) and ceramic on XLPE (Group B: 1420 ± 223-366 ± 88 mm(3)/year) groups. For those patients who had completed 10 years of followup (20 patients [44.5%] of Group A, 21 [45.7%] of Group B, 23 [47.9%] of Group C, and 22 [44.9%] of Group D), at 10 years, both oxidized zirconium on XLPE groups also showed lower (p < 0.01) volumetric wear (mean ± SD mm(3)) and volumetric wear rates (mean ± SD mm(3)/year) (Group C: 356 ± 64 to 215 ± 54 mm(3)/year, Group D: 354 ± 50 to 210 ± 64 mm(3)/year) when compared with ceramic on CPE (Group A: 895 ± 131 to 380 ± 80 mm(3)/year) and ceramic on XLPE (Group B: 1625 ± 253 to 480 ± 101 mm(3)/year) groups. When wear rates of both oxidized zirconium groups were compared, no differences were found at any time interval with the numbers available. Two hips (one from Group A and one from Group B) are scheduled for revision as a result of wear and osteolysis. There were no differences in hip scores among the groups with the numbers available.

CONCLUSIONS

In this study, in vivo wear parameters were lower when the combination of an oxidized zirconium head on XLPE liner was used at an average of 9 years (range, 7-12 years) followup. Further larger-scale clinical studies should confirm these findings and evaluate osteolysis and revision rates in association with the use of this bearing coupling.

LEVEL OF EVIDENCE

Level II, therapeutic study.

Atraumatic Fracture of a BIOLOX Delta Ceramic Femoral Head Articulating with a Polyethylene Liner: A Case Report

CASE

We describe the case of a forty-one-year-old man who underwent total hip arthroplasty with a 32-mm BIOLOX delta ceramic head articulating with a polyethylene liner. The patient did not suffer any trauma postoperatively, and his only symptom was of a "clicking" noise from the operatively treated hip. At his six-week postoperative review, fracture of the femoral head was diagnosed.

CONCLUSION

Fracture of a ceramic femoral head is a rare but catastrophic complication. This case report highlights the importance of vigilance on the part of the surgeon when reviewing patients after hip arthroplasty with ceramic-on-polyethylene bearing couples, even with limited symptoms associated with the hip and no reported trauma.

Midterm Results of Delta Ceramic-on-Ceramic Total Hip Arthroplasty

This study reports mid-term results of Delta ceramic on ceramic (COC) in total hip arthroplasty (THA). Subjects received Delta COC THA in a prospective multi-center study with either 28 mm (n=177) or 36 mm (n=168) articulations. Annual clinical and radiographic evaluations were performed, and patients were asked about hip noises. At mean 5.3-year follow-up there were 3 (0.9%) post-operative liner fractures. Nine revisions were performed (2 liner fracture, 4 stem loosening, 3 deep infection). Kaplan-Meier survivorship at 6 years was 96.9% (94.0-98.4). Twenty-six (7.5%) subjects reported squeaking, of whom none were revised. One (0.3%) subject could reproduce a sound in clinic. More patients reported squeaking with a 36 mm bearing (28 mm: 7/177, 36 mm: 19/168, P=0.013).

The influence of stem taper re-use upon the failure load of ceramic heads

Ceramic components are frequently used in total hip replacement due to their good tribological properties. In revision of broken ceramic heads clinical uncertainties arise, whether the taper of the stem can be re-used with a new ceramic head, especially if the stem is well fixed. Ceramic is a brittle material. Even small damage on the male stem taper can lead to stress concentrations causing premature failure of a new ceramic head. As a consequence, manufactures strictly prohibit stem taper re-use for ceramic heads. The aim of this study was to determine the fracture strength of ceramic heads assembled to re-used male stem tapers, which were subjected to prior head fracture. Five 12/14 Ti6Al4V male tapers and 15 Al2O3 ceramic heads (BIOLOX forte(®); ∅ 28 mm, L) were used for three consecutive fracture tests. Before and after every fracture test, all components were inspected visually and the surface geometry was analyzed. Mean fracture force (52.5 kN) did not decrease with the number of taper re-uses (p ≥ 0.77) but the range increased significantly from initially 4.1 kN to 31.8 kN for the first and 52.6 kN for the second re-use due to some components failing at very low loads. Visual inspection was not sufficient to predict the reduced failure loads. Ceramic heads should therefore not be put on used male tapers without metal adapter sleeves.

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.

Two-year follow-up of revision total hip arthroplasty using a ceramic revision head with a retained well-fixed femoral component: a case series

Introduction

It is known that a well-fixed stem can be left in situ when only the acetabular component and femoral head have to be changed. However, in a revision case, the use of a ceramic head on an existing taper is not recommended. Slight damages of the taper may increase the risk of a ceramic fracture. Until now in a revision case a primary ceramic-on-ceramic or ceramic-on-polyethylene pairing was changed to a metal-on-polyethylene pairing or the well-fixed stem was removed as well. During the past several years, a ceramic head with a metallic sleeve has been introduced as an option for revisions with a stem left in situ. We report short-term results of a ceramic revision head in this clinical setting.

Methods

Eight patients with a ceramic revision head were clinically and radiologically followed up two years after revision surgery. Their Harris Hip Score and visual analogue scale scores for pain and satisfaction were recorded, and their radiographs were checked for osteolysis and heterotopic ossifications.

Results

The mean Harris Hip Score increased from 46.5 points before surgery to 88.3 points 2 years after surgery. The mean visual analogue scale score for pain improved from 6.7 to 1.1, and the mean visual analogue scale for satisfaction rose from 5.1 to 8.3. The radiological results did not show osteolysis in any of the patients. Grade I heterotopic ossification according to the Brooker classification system was seen in one patient.

Conclusions

The early clinical and radiological results in this case series are in agreement with previously published studies. Ceramic revision heads with a metallic sleeve are a promising approach in the revision of a ceramic head with a well-fixed stem which can be left in situ. This solution avoids an unnecessary exchange of a well-fixed stem and thereby shortens the surgical time of the revision and may reduce the peri-operative complications.

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.

Implants for total hip arthroplasty

This article is a comprehensive review of the published literature on total hip replacement design. It seeks to provide a nonbiased view of the technology related to total hip implants and bearing surfaces. Implant designs and fixation methods are discussed with summaries of their respective long-term outcome studies. Fixation methods include cemented, cementless and hybrid techniques and are explained and presented with current outcome data and their respective failure modes that have promoted new technological development. The current data point toward cementless acetabular fixation as being superior to cemented fixation. As for stem fixation, there are good data to suggest that either method of fixation is acceptable in the proper setting. Also included in this article is a brief review of bearing surfaces and hip biomechanics.

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.

The incidence of implant fractures after total hip arthroplasty

PURPOSE

Implant fractures after total hip arthroplasty (THA) are considered as rare in clinical practice. Nevertheless they are relevant complications for patients, physicians, and the public health system leading to high socioeconomic burdens. The aim of this study was to assess the incidence of fractures after THAs in a comparative analysis of clinical studies and worldwide arthroplasty register datasets.

METHODS

We calculated the pooled incidence of revision operations after fractures of THAs in a comparison of clinical studies published in Medline-listed journals and annual reports of worldwide arthroplasty registers in a structured literature analysis based on a standardised methodology.

RESULTS

Included clinical studies (sample-based datasets) were mono-centre trials comprising a cumulative number of approximately 70,000 primary implantations whereas worldwide national arthroplasty register datasets referred to 733,000 primary implantations, i.e. approximately ten times as many as sample-based datasets. In general, sample-based datasets presented higher revision rates than register datasets with a maximum deviation of a 14.5 ratio for ceramic heads, respectively. The incidence of implant fractures in total hip arthroplasty in pooled worldwide arthroplasty register datasets is 304 fractures per 100,000 implants. In other words, one out of 323 patients has to undergo revision surgery due to an implant fracture after THA in their lifetime.

CONCLUSIONS

Implant fractures in total hip arthroplasty occur in a relevant number of patients. The authors believe that comprehensive arthroplasty register datasets allow more general evaluations and conclusions on that topic in contrast to clinical studies.