Fracture of a Ceramic-on-Ceramic Total Hip Implant
When a 62-year-old male presents with severe squeaking 3 years after a THA with a ceramic-on-ceramic implant, the authors discover that the implant has fractured and a revision procedure is necessary.
Antonia F. Chen, MD, MBA, and Javad Parvizi, MD, FRCS
The authors have no disclosures relevant to this article.
Ceramic-on-ceramic (CoC) implants were initially introduced as an optimal bearing surface for total hip arthroplasty (THA) because they generate the least amount of wear particles and have long survivorship.  It is an ideal bearing surface for young and active patients, as ceramic particles have relatively low biological activity, unlike metal particles generated from metal-on-metal implants.
One potential complication of CoC implants, however, is squeaking. A study from our institution demonstrated 6% rate of squeaking following THA with a CoC implant. . A meta-analysis from the Australian National Joint Registry reported 4.2% rate of squeaking; the incidence of revision for squeaking was 0.2% in that registry. 
Another potential complication of THA with a CoC implant is ceramic fracture. Ceramic liner fractures can occur when inserting the component or after trauma secondary to impingement.  Ceramic head fractures often occur after trauma.
However, there have been reported cases in which CoC implant fractures have occurred atraumatically.  This article presents one such case of CoC implant failure without any known trauma, as well as a method of surgically revising these cases.
A healthy 62-year-old male presented to the clinic with asymptomatic squeaking with ambulation. He had undergone an uneventful left THA with a CoC implant 3 years earlier. The patient had no history of trauma, no pain with ambulation, no other systemic symptoms, and no prior symptoms of prolonged squeaking. The constant squeaking of the implant was having a negative impact on his quality of life.
- Male patient, 6 feet tall, weight 198 pounds (26.9 kg/m2)
- Well-healed lateral incision
- Equal limb lengths
- Full hip range of motion (ROM); no pain with hip ROM
- Reproducible squeaking sound when ambulating (Video 1)
- Intact neurovascularly
- No clinical evidence of infection
- Figure 1 shows radiographic evaluation of the left hip in the immediate postoperative period 3 years prior to presentation.
- Figure 2 shows radiographic evaluation of the left hip 3 years after surgery; fractured ceramic fragments are visible.
Figure 1. Postoperative radiograph showing the original total hip arthroplasty performed in 2010 with a ceramic-on-ceramic implant.
Figure 2. Preoperative radiographs from 2013 showing the original hip implant with fractured ceramic pieces within the hip capsule. Anteroposterior view, left, and lateral view, right.
- Failure of the CoC implant secondary to fracture and squeaking
The patient had a negative workup for infection, with a normal erythrocyte sedimentation rate and a normal C-reactive protein. A revision THA was recommended and he agreed to undergo the procedure.
- When the hip was exposed, extensive ceramic fragments were noted within the hip capsule, the result of fracture of the ceramic femoral head and ceramic acetabular liner.
- A complete synovectomy was performed to carefully remove all ceramic fragments.
- Extensive irrigation was performed in multiple steps to remove small ceramic debris.
- Once all fragments had been removed, along with the remaining femoral head and acetabular liner, the acetabulum was exposed.
- The existing, well-fixed cup was only able to accept a ceramic liner. Although CoC implant fractures have been revised with another CoC implant,  it was determined that this patient should be revised with a ceramic-on-polyethylene (CoP) implant to provide a bearing surface with a much lower risk of squeaking.
- The well-fixed acetabular component was removed with minimal bone loss, successive reaming was performed, and a larger acetabular component that could take a polyethylene liner was inserted.
- The trunnion was inspected and was noted to have minimal damage (Figure 3). Thus, it was determined that a Delta ceramic femoral head designed for revision (Biolox option) could be impacted directly onto the existing trunnion.
- The hip was reduced and had stability in all ranges of motion. Limb lengths were equal.
- The patient had an uneventful postoperative course in the hospital.
- At 1.5 years postoperatively, the patient has had no further complications, no pain, and no squeaking.
Figure 3. Minimal wear noted on the existing femoral trunnion.
There are multiple risk factors that can contribute to the need for revision of CoC hip implants. A retrieval analysis study demonstrated that a longer implantation period, higher acetabular abduction angles (greater than 45°), and metal transfer of the bearing surface facilitate adhesive wear are some of the most frequent factors that leads to subsequent need to revise CoC implants. [7,8]
Squeaking – most often associated with ambulating – is a well-reported phenomenon after THA with a CoC implant, with the incidence ranging from 1.9% to 10.7%. [2,3,9,10] This squeaking can be asymptomatic or it may be constant. This latter situation can lead to revision surgery, as reported in the Australian Registry (0.02%).
Ceramic fracture is another complication of CoC implants that may be secondary to trauma, may occur intraoperatively during component insertion, or may occur atraumatically. Revision surgery is indicated in cases of clinically fractured components in order to remove the ceramic fragments and implant new components.
Care must be taken to remove all fractured ceramic fragments. If these fragments are left within the joint, they can cause third body wear that could accelerate wear of the new components and lead to subsequent re-revision surgery. When all fracture fragments are removed, revision after a CoC implant failure generally has a low re-revision rate.
After a complete debridement is performed, ensure that the revised hip is stable in all ranges of motion. If instability persists, an elevated liner or a constrained liner may be considered, depending on the patient.
With regard to the new bearing surface, various studies have supported the use of another CoC implant or a CoP implant. In these revision cases, it is not recommended to implant a metal head, as there exists the possibility of small ceramic particles still being present in the surgical site. These small particles could become embedded in the polyethylene insert and damage the metal head.
The femoral stem should be closely evaluated. If the stem is firmly fixed onto the surrounding bone, a careful evaluation of the stem taper condition must be carried out. If the stem taper is previously used and largely undamaged, a ceramic revision head should be used. If the stem taper is highly damaged, the femoral stem may have to be revised.
- Revision surgery is recommended as promptly as possible once a ceramic fracture has been identified to minimize damage to other implanted components.
- A complete synovectomy should be performed to ensure that all ceramic fragments have been removed, as third body particles can damage the new bearing surface..
- Multiple irrigation steps of the surgical site allows for any small ceramic debris to float to the surface where it can be easily removed with suction.
- To evaluate whether an acetabular shell can remain in place, it is critical to carefully remove the existing ceramic liner using a specially designed removal instrument. If there is any damage to the inner taper, the shell must be removed and a new acetabular shell designed for either a ceramic or a polyethylene insert should be implanted.
- In these CoC revision cases, it is important to carefully assess the stem and the insert taper surfaces. If the stem taper is highly damaged, the femoral stem should be revised, as it will affect the reliability of the replacement head.
- The femoral component does not need to be changed if minimal damage is noted on the trunnion of the existing femoral component. The use of a ceramic head designed for revision is recommended.
Adult Reconstruction Section Editor, Rothman Institute Grand Rounds
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