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A Case Of Two Consecutive Fractures Of Ceramic Heads In Total Hip Arthroplasty

 Thaler M *,  Nogler M.*,  Auckenthaler T*,  Behensky H  ,Mayr E

* Department for Orthopedic Surgery,Medical University Innsbruck,Anichstr. 35,A-6020 Innsbruck

Address for Correspondence:

Martin Thaler MD
Department for Orthopedic Surgery
Medical University Innsbruck
Anichstr. 35
A-6020 Innsbruck
Phone: +43-512-504-80851
Fax: +43-512-504-22701



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.


This is a peer reviewed paper 

Please cite as : Thaler M : A Case Of Two Consecutive Fractures Of Ceramic Heads In Total Hip Arthroplasty

J.Orthopaedics 2007;4(4)e22





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