Non-Traumatic Fracture of a Fourth-Generation Ceramic Femoral Head
Following primary total hip arthroplasty with a ceramic-on-polyethylene articulation, a 59-year-old man sustains a rare fracture of the ceramic femoral head following minimal trauma after stepping down from a curb.
Robert Pivec, MD, and Gregory K. Deirmengian, MD
Ceramic fracture following total hip arthroplasty (THA) is a rare complication that has steadily decreased following iterative generational improvements in ceramic design. [1,2] The introduction of fourth-generation ceramics in 2003 (BIOLOX delta, CeramTec; Phlochingen, Germany) has resulted in improved fracture resistance compared with third-generation ceramics that were introduced in 1994 (BIOLOX forte, CeramTec; Phlochingen, Germany).  The decrease in the fracture rate with the newer ceramic femoral heads has been observed in the manufacturer’s own data (0.009% vs 0.04%),  registry studies from the United Kingdom (0.009% vs 0.12%),  and clinical outcome studies in France (0.001% vs 0.18%). 
Subgroup analysis of registry data from the United Kingdom has allowed for further risk stratification based on patient- and implant-related factors. Howard et al  analyzed 212,296 primary THAs and observed that only femoral head size and body mass index (BMI) were significant risk factors. Specifically, 28-mm femoral heads were identified as a risk factor, but not 32-mm or 36-mm heads. However, these fractures were exclusively observed in third-generation 28-mm ceramic heads (0.38% fracture rate), not fourth-generation 28-mm heads (0.0% fracture rate). 
BMI was the only other independent predictor, with an odds ratio for failure of 1.09 per unit BMI increase. Thus, a patient with BMI of 40 was reported to have 2.46 increased odds of fracture compared with a patient with BMI of 30. 
Complications following ceramic head fracture are primarily a consequence of macroscopic and microscopic wear. Early revision is necessary to prevent catastrophic wear-through of the intact trunnion and maintain normal hip motion and biomechanics. [2,6] Exchange of the femoral head must always be to a new ceramic head, as microscopic ceramic debris will cause eburnation of metal heads, leading to severe systemic metallosis.
Numerous recent case reports have detailed the catastrophic effects of improper head exchange (ceramic to metal), including central neurologic symptoms (blindness and hearing loss), cardiac toxicity, multiple organ failure, pseudotumors, and rapid anorexia, many of which are irreversible even after revision and complete synovectomy. [7–10]
In this article, we present a unique case of a delta ceramic femoral head fracture following minimal trauma that required revision to a new ceramic liner, as well as removal of a well-fixed femoral stem due to trunnion damage.
A 59-year-old male patient with no significant past medical history presents to the emergency department with right hip pain following a step down from a sidewalk curb that was not associated with a fall. Six years earlier, he had undergone primary THA with a ceramic-on-polythyelene bearing, which had been functioning well with no pain, squeaking, or difficulty ambulating.
- Height: 6 feet, 0 inches; weight: 250 pounds; BMI: 34
- Well-healed lateral incision
- Shortened extremity
- Hip range of motion unable to be evaluated
- Normal distal lower extremity motor and sensory exam
- Palpable pedal pulses
- Serum white blood cell count: 9.5
- Serum creatinine: 0.9
- Erythrocyte sedimentation rate: Within normal limits
- C-reactive protein level: Within normal limits
- Intraoperative culture: Negative
The patient was initially triaged and evaluated by an emergency department physician, during which post-injury imaging, including plain radiographs of the affected hip (Figure 1) and a CT scan (Figure 2), were obtained. Review of the medical record showed the hip prosthesis in situ following the index operation (Figure 3).
Figure 1. Immediate post-injury radiograph demonstrates limb shortening, femoral head distal migration, and small radiopaque foreign bodies adjacent to greater trochanter.
Figure 2. Post-injury axial CT shows the ceramic femoral head fracture with dissociation from the trunnion (left) and multiple large fragments (right) present within the acetabular shell.
Figure 3. Anteroposterior radiograph following the index right total hip arthroplasty show a ceramic-on-polyethylene bearing in situ.
- Acute ceramic femoral head fracture with trunnion damage and well-fixed femoral and acetabular components
In this situation, treatment should consist of revision THA, with several considerations for management:
- How long has the femoral head been fractured and is there wear through the polyethyene? Although the polyethylene will be exchanged in all cases, damage to the acetabular shell, as well as its stability, must be assessed.
- Is the femoral stem well fixed and is there trunnion damage? A damaged trunnion will necessitate removal of the stem, even if it is well fixed, as trunnion corrosion could lead to future metallosis.
- What are the risks with conversion to a metal-on-polyethylene bearing?
We had an extensive discussion with the patient about the proposed surgical treatment, including the need for a revision to a new ceramic femoral head, rather than a metal head, and the possibility that either the femur or acetabulum, or both, may need to be revised. We also discussed implant factors (femoral head size) and patient factors (elevated BMI) as they related to the risk of future fracture.
The implant that had initially been utilized (TaperLoc, Zimmer-Biomet; Warsaw, Indiana) appeared to be well fixed radiographically. The femoral head (BIOLOX delta) had a large diameter (36 mm) and was offset (3.5 mm), both of which are protective against head fracture, according to registry data.
With the above in mind, we planned to perform a thorough debridement and synovectomy with removal of all ceramic debris. The stability of all components would be assessed, and close inspection of the trunnion would be performed. In the absence of trunnion corrosion, a head/liner exchange to the same dimension ceramic head would also be performed. If we found trunnion damage, the femoral stem would be exchanged as well.
This technique, as described by the senior surgeon (GKD), would:
- Prevent ceramic-debris associated metallosis
- Conserve bone stock
- Allow immediate weight bearing
- Utilizing the prior incision, dissection was carried down and deep to the fascia.
- A communication to the joint was discovered through the gluteus medius, in which we found small ceramic debris.
- The capsule was noted to be disrupted and several large femoral head fragments were clearly visible (Figure 4).
- The femoral head fragments (Figure 5) and acetabular liner were removed, and a thorough debridement and synovectomy was performed.
- The femoral stem and acetabular cup were noted to the well fixed.
- However, marked damage to the trunnion was noted (Figure 6) and the decision was made to revise the femoral stem with a ream-and-broach style system (Trabecular Metal, Zimmer-Biomet; Warsaw, Indiana).
- A prophylactic cable was placed around the calcar to decrease the risk of intraoperative periprosthetic fracture.
Figures 4-6. Intraoperative photographs show the initial position of the fractured femoral head during approach (top) and the midline fracture of the femoral head (bottom left). The trunnion exhibited extensive damage (bottom right).
- A new ceramic femoral head with a titanium sleeve (BIOLOX delta; 36 mm +3.5) was placed and satisfactory limb length and stability were achieved.
- The immediate postoperative radiograph is shown in Figure 7.
Figure 7. Immediate postoperative radiograph following debridement and head/stem/liner exchange to a new ceramic head. A prophylactic cable was placed around the calcar.
- In the immediate postoperative period, the patient was made weight-bearing as tolerated with a walker for 4 to 6 weeks. Posterior hip precautions were instituted.
- At the initial postoperative visit, the patient was ambulating with an assistive device as instructed. He had a well-healed incision and minimal pain.
- The patient will be monitored with a 6-month follow-up and thereafter with yearly follow-up.
- Fractured ceramic heads must be replaced with new ceramic heads, never metal.
- Trunnion damage will necessitate removal of the femoral stem, even if it is well fixed.
- Larger femoral heads and plus heads have a lower incidence of fracture. Small (28-mm) and minus heads should be avoided.
- The patient’s BMI plays a role in ceramic head fracture risk: A BMI less than 30 is protective.
Robert Pivec, MD, and Gregory K. Deirmengian, MD, are from The Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.
Adult Reconstruction Section Editor, Rothman Institute Grand Rounds
Disclosures: The authors have no disclosures relevant to this article.
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