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Abstract:
Fracture of the ceramic head component is a well known and
described complication in total hip arthroplasty (THA). We
report a case of a 75 year old man who received a THA on both
hips. 2 years after primary surgery THA the ceramic head of the
femoral stem broke on the right and consequently a revision
surgery was done. In this revision surgery the ceramic head was
replaced by a new ceramic head. Only 8 months after revision
surgery the ceramic head component fractured again. Again a
revision surgery was performed and finally a metal head was
implanted. This case reports shows that reimplantation of a
ceramic head in a revision surgery seems to be a surgical
failure. To the authors knowledge only few cases of two
consecutive fractures of the ceramic head have been described in
orthopedic literature before.
J.Orthopaedics 2007;4(4)e22
Keywords:
Total hip arthroplasty; ceramic head fracture; revision
surgery;
Case Report:
A 68 year old man with bilateral osteoarthritis in the hip
underwent a total hip arthroplasty (THA) on the left side in
1998. A cemented stem (Link, Hamburg, Germany, conus: 12/14,)
Lubinus SP II model with a ceramic head (Bionit 2, Mathys,
Bettlach, Bern, Swiss, diameter: 28 millimetre (mm)), and a
Duraloc (Johnson & Johnson, New Brunswick, New Jersey, USA)
acetabular cup size 52 were implanted. In February 2003 the
patient received a THA on the opposite side with a cemented
Lubinus SP II standard normal stem, a cemented ARTOS (Johnson &
Johnson, 56 (mm)) cup and a medium ceramic head (Bionit,
diameter: 28 (mm)). Both procedures were performed in our
hospital through an anterolateral transgluteal approach. The
moblisation after THA on the right side started on the first
postoperative day.
The patient showed no complications. Recovery was normal and the
patient was discharged 10 days after surgery. The following
rehabilitation was uneventfull. A radiographic follow up six
weeks postoperatively showed an intact implant. In April 2005
the patient the patient slipped and fell to the ground. He
noticed pain and less range of motion in the right hip and went
to a local trauma clinic. There, radiographs showed that the
ceramic head was broken. Consequently this was revised in that
institution and the ceramic fragments were removed. The femoral
component was left in situ and a new ceramic head (Link,
diameter:28 mm) was attached to the stem. Recovery after this
revision was uneventful as well.
In December 2005 the now 75 year old patient presented at our
hospital with pain in the revised hip and again less range of
motion. A radiograph revealed again fragmentation of the ceramic
head. (Figure 1) The revision was performed through an
anterolateral transgluteal approach. An extensive excission of
the newly formed capsule as well as removal of periarticular
scar-tissue, and all non muscular soft tissue was performed in
order to remove as many ceramic splinters as possible. The
taper of the stem looked macroscopically good and therefore the
stem was left in situ. The macroscopically damaged cup was
replaced by a new cup (ARTOS size: 56) in an attempt to remove
polyethylene – embedded ceramic fragments. All visible ceramic
fragments were removed (Figure 2). Additionally a extensive
lavage with a pulsatile lavage system (Bionit) with 4.5 liter
of saline solution was done. A 28 mm metall head (Mathys) with
was placed on the neck of the femural implant.
The histologic
examination of the soft tissue showed reactive modified tissue
with unspecific debris reaction. The patient had a good recovery
and left hospital 13 days after surgery. Follow ups 6 weeks and
1 year after surgery showed excellent radiopgraphical and
clinical results, the patient had no pain and was able to walk
without any crutches.
Discussion :
Alumina ceramic materials demonstrate an excellent compression
strength but a poor bending strength.1 These components have no
way to deform without breakage. This is the reason for the
brittleness of these components. Nethertheless fracture of the
ceramic femoral head is a rare complication of THA, varying from
0.22% 2 to 3,5% 3 of all cases. Many factors have been described
as cause of the fracture of the head such as obesity, trauma,
less physical activity, component mismatch, small diameter of
the femoral head, malfunction of the material and implantation
failures. 6,8 Attention should also be paid to surgical details.
Surgeons guidelines should be carried out such as preventing the
presence of any foreign body between the cone and the ceramic
head. Furthermore a strong impaction of the head on the cone is
essential and the cone should be protected from damage during
surgery.4
The consequences of the fracture are massive osteolytic lesions,
the dramatic wear of implants which results in an early
loosening of the implant, 4 followed by extensive revision
surgerys.5
In our case the cause of the first fracture of the femoral head
was due to the accident. The cause of the second fracture may be
more difficult to explain. Some authors report that the risk of
a fracture of a new ceramic head stuck on a used stem is low.6
Yet, no prove from literature is given to support this
assumption. If a new ceramic femoral head is used and the stem
is left in situ, the change in the geometry of the Morse taper
may lead to a maladjustment between trunnion of the femoral stem
and the of the ceramic head. This can create stress conditions
and may be the reason for a refracture of the femoral ceramic
head.5 In our case this scenario could be an explanation for the
refracture of the femoral head. Although only few such cases
have been reported in the literature. It might be concluded that
a ceramic femoral head should not be placed on a femoral stem
left in situ in revision arthroplasty but should be replaced by
a metal head.2,3 However, there is a considerable risk for
increased wear of a new metallic head and metallosis if ceramic
fragments are left.7 Although surgical guidelines for revision
surgery have been exactly executed in the second revision
arthroplasty, some microscopic ceramic particles may be still
remaining in the joint cavity. These particles may lead to quick
and essential wear of stainless steel.7 In our opinion a ceramic
femoral head is a good component for primary THA. Fracture of
the femoral ceramic head is a very rare but a serious
complication in THA, leading to extensive revision procedures.
Changes in the geometry of the Morse taper can lead to a
refracture of the femoral head. Therefore, the reimplantation of
a ceramic head on existing femoral taper in revision surgery
should be avoided.
Fig.1
X – ray showing ragmentation of the right femoral head
before the second revision surgery; 12/05
Fig.2
Picture showing removed fragmetns of the broken femoral head
after the second revision surgery
Reference :
1. Pulliam I, Trousdale R. Fracture of a ceramic femoral
head after a revision operation. A case report. J Bone Joint
Surg Am 1997;79: 118-121.
2. Barrack R, Burak C, Skinner HB. Concerns about ceramics in
THA. Clin Orthop Relat Res 2004; 429: 73-79.
3. Callaway G, Flynn W, Ranawat C, Sculco T. Fracture of the
femoral head after ceramic-on-polyethylene total hip
arthroplasty. J Arthroplasty 1995; 10: 855-859.
4. Fritsch E, Gleitz M. Ceramic femoral head fractures in total
hip arthroplasty. Clin Orthop Relat Res 1996, 328: 129-136:
5. Willmann G. Ceramic femoral head retrieval data Clin Orthop
Relat Res 2000; 379: 22-8.
6. Fritsch E, Gleitz M. Ceramic femoral head fractures in total
hip arthroplasty. Clin Orthop Relat Res 1996; 328: 129-136.
7. Allain J, Goutallier D, Voisin MC, Lemouel S. Failure of a
stainless-steel femoral head of a revision total hip
arthroplasty performed after a fracture of a ceramic femoral
head. A case report. J Bone Joint Surg Am 1998; 80: 1355-1360.
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