Ceramic Liner Fatigue Fracture: 3-D CT Findings in a Late Recurrent THA Dislocation

Abstract

Dislocation is one of the most common complications of total hip arthroplasty (THA). To the authors' knowledge, late recurrent dislocation of a THA with a ceramic-on-ceramic coupling secondary to fatigue fracture of the ceramic liner has never been described. A 76-year-old woman with right hip osteoarthritis underwent cementless modular THA with a ceramic-on-ceramic coupling. Approximately 10 years postoperatively, she experienced right hip pain with no trauma, which resolved in 14 days. Family members reported that the patient had shown a progressive cognitive and muscular decline in the previous months. Six months later, the patient was admitted for THA dislocation, which was immediately reduced. Computed tomography revealed that the right acetabular component had a retroversion of 4° and an inclination angle of 45°. An orthopedic brace was applied, but dislocation recurred 2 days after discharge. A 3-dimensional CT reconstruction showed a fracture of the ceramic liner in the posterolateral region. The patient underwent revision surgery, and the ceramic liner breakage was confirmed. After removal of the acetabular components, a cemented polyethylene cup was implanted. The stability of the stem was verified. The existing modular neck was replaced with a chromium-cobalt neck, and a new ceramic head was applied. At 7-month follow-up, the patient had good functional recovery with no hip instability. Fatigue failure of a ceramic liner should be considered as responsible for late dislocation after ceramic-on-ceramic THA. As part of the diagnostic strategy, 3-dimensional CT reconstruction should be used to evaluate ceramic liner breakage.

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

“…Frank grinding or crunching sensations are highly concerning; however, other clinical signs such as audible sounds must also be investigated. A creaking or squeaking sound is suggestive of articular malposition and initial failure whereas a duller clicking sound has been suggested to indicate rupture [25], [26]. Any audible sounds can represent a major complication; Malem [27] et al in 2013 report a case in which a patient with a CoC total hip presented with a squeaking hip 5 years post-operatively and was found to have catastrophic failure at revision.…”

“…Any audible sounds can represent a major complication; Malem [27] et al in 2013 report a case in which a patient with a CoC total hip presented with a squeaking hip 5 years post-operatively and was found to have catastrophic failure at revision. Other less specific symptoms include limited range of motion and hip pain [26]. Radiographic analysis can also prove challenging.…”

“…Small cracks in the ceramic liner can be difficult to identify with conventional radiology, and the assessment of joint fluid to investigate the presence of ceramic particles has been suggested [28]. Additionally, the use of 3-dimensional computed tomography reconstruction has been suggested to be more sensitive (maybe add the sensitivity number from the study) for identification of ceramic liner failure [26]. Even with early identification and intervention, revision arthroplasty for fractured ceramic component is complex and carries a significant risk of failure as ceramic debris and fragments are sharp and extremely hard.…”

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

“…[11] However, plain X-ray imaging is not sufficient for delayed acetabular liner fractures since particles might spread until the time of diagnosis. For avoiding misinterpretation and detecting the exact locations of the particles at the hip joint, we need assistance from three-dimensional imaging like CT. Computed tomography scan can be used for early diagnosis at occult ceramic liner fractures, [12] contemporarily to ascertain the presence of ceramic fragments eventually not visible with traditional X-ray. [6] Also, CT can show concomitant bone defects around the implants.…”

Development of a femoral stem providing strong anchorage and facilitated removal

“…Dale et al showed a 5.3% increase risk of revision due to infection when comparing 1987-1992 to 2003-2007 (30). Second, there can be a failure of other parts of the total hip replacement, i.e., the caput or acetabular component (85,86). When there is a fracture in a ceramic caput component, the taper of the femoral component is at a high risk of damage and therefore necessitates a replacement (Figure 15).…”