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Bearing Change to Metal-On-Polyethylene for Ceramic Bearing Fracture in Total Hip Arthroplasty; Does It Work?
The Journal of Arthroplasty xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
The Journal of Arthroplasty journal homepage: www.arthroplastyjournal.org
Bearing Change to Metal-On-Polyethylene for Ceramic Bearing Fracture in Total Hip Arthroplasty; Does It Work? Soong Joon Lee, MD a, Hong Suk Kwak, MD a, Jeong Joon Yoo, MD, PhD a, Hee Joong Kim, MD, PhD a,b a b
Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea Medical Research Center, Seoul National University, Seoul, Republic of Korea
a r t i c l e
i n f o
Article history: Received 27 April 2015 Accepted 7 August 2015 Available online xxxx Keywords: ceramic bearing fracture total hip arthroplasty metallosis ceramic failure bearing change
a b s t r a c t We evaluated the short-term to midterm results of reoperation with bearing change to metal-on-polyethylene (MoP) after ceramic bearing fracture in ceramic-on-ceramic total hip arthroplasty. Nine third-generation ceramic bearing fractures (6 heads and 3 liners) were treated with bearing change to MoP. Mean age at reoperation was 52.7 years. Mean follow-up was 4.3 years. During follow-up, 2 of 3 liner-fractured hips and 1 of 6 head-fractured hips showed radiologic signs of metallosis and elevated serum chromium levels. Re-reoperation with bearing rechange to a ceramic head was performed for the hips with metallosis. One liner-fractured hip had periprosthetic joint infection. Dislocation occurred in 3 hips. From our experience, bearing change to MoP is not a recommended treatment option for ceramic bearing fracture in total hip arthroplasty. © 2015 Elsevier Inc. All rights reserved.
A ceramic bearing fracture is one of the most serious complications in total hip arthroplasty (THA) with ceramic-on-ceramic (CoC) bearing [1]. The current consensus on reoperation after a ceramic bearing fracture includes immediate reoperation after diagnosis of the ceramic fracture and complete synovectomy during the reoperation [2-5]. However, there is controversy about the method of reoperation after a ceramic bearing fracture, including the selection of a new bearing surface or the replacement of well-fixed implants with damaged tapers [5,6]. In a ceramic bearing fracture, the cone of the stem or the inner surface of the cup may be damaged by fractured ceramic particles or direct contact [4]. Insertion of a new ceramic bearing on a damaged taper surface might increase the risk of ceramic refracture [7-9]. Hence, change of the implant is recommended regardless of firm fixation of the implant [5,7]. However, concerns remain regarding the removal and replacement of well-fixed cementless stems or cups due to technical difficulties with removing well-fixed implants, potential damage to the bone stock during removal, and longevity of the revised implant [10,11]. In contrast, by changing the bearings to metal-on-polyethylene bearings (MoP), well-fixed implants can be retained without concerns about ceramic refracture [10]. However, there is controversy regarding the results of reoperation with MoP bearings after ceramic bearing fractures [2,3]. Favorable long-term results were reported after MoP bearing replacement combined with complete synovectomy [3]. However,
No author associated with this paper has disclosed any potential or pertinent conflicts which may be perceived to have impending conflict with this work. For full disclosure statements refer to http://dx.doi.org/10.1016/j.arth.2015.08.039. Reprint requests: Jeong Joon Yoo, MD, PhD, Department of Orthopedic Surgery, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, Republic of Korea 110-744.
massive metallosis due to third body wear by remnant ceramic particles remains a concern [12]. In addition, fatal systemic complications related to cobalt or chrome intoxication by metallosis have been reported after MoP bearing replacement due to ceramic bearing fractures [13]. We retrospectively reviewed the short-term to midterm results of reoperation after ceramic head and liner fractures treated with MoP bearing replacement with a minimum follow-up period of 2 years. We evaluated the clinical and radiologic outcomes of reoperation with MoP bearings for ceramic bearing fractures, especially in terms of the occurrence of metallosis and complications, as well as the necessity for re-reoperation. Materials and Methods Between November 1999 and December 2013, 11 reoperations were performed for ceramic bearing fractures in our institution. During the reoperation for ceramic fracture, the type of bearing surface was determined according to the damage in the morse taper at the stem or the inner surface of the cup. When the taper at the stem was damaged significantly, a metal head was inserted. A polyethylene (PE) liner was inserted with new metal heads or in cases with significant damage to the inner surface of the cup. In a patient with ceramic liner fracture, morse taper was not damaged, but inner surface of cup was damaged. She was treated with reoperation with bearing change to ceramic-on-polyethylene (CoP) and followed up for 14 years without osteolysis, loosening, ceramic refracture, or other complications. In a patient with ceramic head fracture, morse taper showed mild damage on surface, and inner surface of cup was intact. He was treated with reoperation with bearing change to new CoC and followed up for 7.3 years without ceramic refracture or other complications. Excluding these 2 patients with new ceramic
http://dx.doi.org/10.1016/j.arth.2015.08.039 0883-5403/© 2015 Elsevier Inc. All rights reserved.
Please cite this article as: Lee SJ, et al, Bearing Change to Metal-On-Polyethylene for Ceramic Bearing Fracture in Total Hip Arthroplasty; Does It Work?, J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.08.039
MoP changed Cup + MoP change 5 mo 10 d No DAL 7.3 2.0 Liner Liner 32/S 28/M Osteonics (Secur-fit/Accolade) Zimmer (Trilogy/Versys)b Male DA Female FNF 70.7 56.8 8 9
Abbreviations: ONFH, osteonecrosis of femoral head; FNF, femoral neck fracture; DA, degenerative arthritis; S, short; M, medium; DAL, daily activity of living; TA, traffic accident; X-PE, highly cross-linked polyethylene. a Sandwich-type liner. b Cemented stem. c Accompanied with posterior hip dislocation. d Cemented liner fixation. e Metal-sleeved ceramic head.
CoP changed CoC change 3.9 7.3
Death (leukemia) Death (unknown) No complication No complication Metallosis, dislocation Recurrent dislocation Recurrent periprosthetic joint infection Metallosis, dislocation Metallosis 2.7 3.6 2.0 2.4 6.0 6.4 4.8
PE PE PE PE PE PE Zimmer Trilogy cup + X-PE X-PE Zimmer Trilogy cup + X-PE MoP change MoP change MoP change MoP change MoP change MoP change Cup + MoP change 6d 1d 4d 1 mo 1d 1d 7 mo DAL TAc No Slip downc DAL DAL No 3.4 4.2 14.3 10.1 11.3 2.9 6.4 Head Head Head Head Head Head Liner 28/S 28/S 28/S 28/S 28/S 28/S 28/M Aesculap (Plasma/BiContact) Aesculap (Plasma/BiContact) Aesculap (Plasma/BiContact) Aesculap (Plasma/BiContact) Aesculap (Plasma/BiContact) DePuy (Duraloc/AML) Lima (SPH/C2)a ONFH ONFH ONFH ONFH ONFH ONFH FNF 54.5 36.9 67.2 47.2 53.5 22.5 65.1 1 2 3 4 5 6 7
Male Male Male Female Male Female Female
Follow- Results (Cause) Up (y) New Cup or Liner of Reoperation Type of Reoperation Duration of Symptom From THA Event to Ceramic Fracture (y) Location of Fracture Head (Size/ Length of Neck) Etiology Company of Implant for THA (Name of Cup/Stem) Age at Sex reoperation (y) Patient No.
Table Reoperation With Bearing Change to MoP for Ceramic Bearing Fracture.
CoP changed,e Closed reduction Repeated debridement
S.J. Lee et al. / The Journal of Arthroplasty xxx (2015) xxx–xxx
Re-Reoperation
2
heads, 9 reoperations in 9 patients for 6 ceramic head fractures and 3 ceramic liner fractures were included in the present study. During follow-up, 2 patients died. One patient died due to leukemia. The cause of death for the other patient is unknown because contact with his family was lost. Follow-up for the 2 patients lasted for 2.7 and 3.6 years after reoperation, respectively, and they are included in the present study. The mean age at reoperation for all patients was 52.7 ± 15.4 years (22.5-70.7 years), with 5 male and 4 female patients. Primary THA was performed at the mean age of 45.8 ± 21.9 years (19.6-63.4 years). Etiology of primary THA was osteonecrosis in 6 patients, femoral neck fracture in 2 patients, and degenerative arthritis in the remaining patient. In 5 hips, Plasma cups (Aesculap AG, Tuttlingen, Germany) with BiContact Stems (Aesculap AG) were implanted. The other 4 patients underwent THAs with Duraloc cup (DePuy, Leeds, UK) with AML stem (DePuy), SPH contact cup (LimaLto, Udine, Italy) with C2 stem (Lima-Lto), Secur-fit cup (Osteonics, Allendale, NJ) with Accolade stem (Osteonics), and Trilogy cup (Zimmer, Warsaw, IN) with Versys cemented stem (Zimmer). All ceramic heads and liners were made of third-generation alumina ceramic (Biolox Forte; CeramTec, Plochingen, Germany). There was 1 sandwichtype liner in a patient with a Lima implant. The Table shows feature of primary THA. Ceramic fracture was diagnosed at mean 6.9 ± 4.2 years (2.0-14.3 years) after primary THA. Six heads and 3 liners were fractured (Figs. 1A and 2A). Of the 6 patients with ceramic head fracture, 2 had a history of definite trauma accompanied by posterior hip dislocation. The remaining patients with head fracture had an abrupt onset of pain with daily activities of living or without any specific prior events. With the exception of 1 patient, reoperation was performed for all patients with ceramic head fracture within 6 days after pain or discomfort developed. Diagnosis of the fracture was delayed in the last patient because she took a bed rest at home for a month after the injury. Two patients with liner fracture had periods of discomfort for more than 5 months without any prior events. The other patient with liner fracture had 10 days of discomfort, which occurred after daily activity. The mean interval between symptom onset and reoperation for ceramic fracture was 7.2 days (1 day to 1 month) with ceramic head fractures and 4.1 months (10 days to 7 months) with ceramic liner fractures. The Table also shows feature of ceramic bearing fracture. Reoperation was planned and performed immediately after diagnosis of ceramic fracture. During reoperation, macroscopic ceramic particles were removed, and synovectomy was performed as thoroughly as possible (Fig. 1B). All stems were securely fixed, but all cones of the stems with ceramic head fractures were damaged by ceramic particles or direct contact. All stems were retained during reoperation. In 2 patients with liner fracture, the cup was removed and revised for complete removal of ceramic particles. Finally, the 28-mm metal head made of cobalt-chrome alloy and the PE liner were inserted. For all 3 liner fractures, PE liners made of highly cross-linked PE were inserted, and for all 6 head fractures, PE liners were made of conventional PE because highly cross-linked PE liners are not available for the cups. In 1 patient with ceramic liner fracture of a Secur-fit cup, a highly cross-linked PE liner was fixed with cement because no PE liner is available for the cup. The Table shows feature of reoperation for ceramic bearing fracture. Patients were followed up at postoperative 6 weeks, 3 months, 6 months, and 1 year. After postoperative 1 year, patients were followed up annually. For clinical evaluation, the patients were asked about clinical symptoms of pain or limping. The occurrence of complications was recorded. Mean follow-up of patients was 4.3 ± 1.9 years (2.0-7.3 years). For radiographic evaluation, standard anteroposterior radiograph and cross-table lateral radiograph were checked before and immediately after the operation and at each visit to the clinics. Using radiographs obtained at each visit to the clinic, the presence of osteolysis, loosening, or metallosis was evaluated [14-16]. We also checked serum chromium (Cr) level in patients with suspicious findings of metallosis.
Please cite this article as: Lee SJ, et al, Bearing Change to Metal-On-Polyethylene for Ceramic Bearing Fracture in Total Hip Arthroplasty; Does It Work?, J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.08.039
S.J. Lee et al. / The Journal of Arthroplasty xxx (2015) xxx–xxx
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Fig. 1. (A) At 2 years after THA with CoC bearing, x-ray shows ceramic liner fracture that occurred in 56-year-old female patient during daily activity. (B) Retrieved ceramic liner shows severe fragmentation. (C) Seven months after reoperation using MoP bearing, x-ray shows bubble sign of metallosis (arrows) and serum chromium (Cr) level was elevated to 34.6 μg/L. (D) Six years after re-reoperation using CoC bearing, x-ray shows no sign of metallosis or ceramic refracture. Serum Cr level decreased to 1.9 μg/L.
Results In radiologic evaluation, there was no sign of osteolysis or loosening during the follow-up period. However, 3 hips with 1 head fracture and 2 liner fractures showed suspicious findings of metallosis at 6.9 month, 3.1 years, and 5.7 years after reoperation, respectively (Figs. 1C and 2B and C) In the laboratory tests, serum Cr level was elevated to 13.2, 27.8, and 34.6 μg/L, respectively (mean serum Cr level, 25.2 ± 10.9 μg/L; reference level, 0-3 μg/L). Re-reoperation was performed for the patients with suspicious findings of metallosis. During re-reoperation, metallosis was confirmed with black-colored fluid and pigmented soft tissue. Cups and stems of all patients were securely fixed, but the retrieved metal heads had scratches on their surfaces from remnant ceramic particles
(Fig. 2E). Cups and stems were retained. However, after synovectomy, the bearing was changed to ceramic-on-polyethylene in 2 patients and to CoC in 1. In 1 of the 3 cases, 32-mm metal-sleeved ceramic heads (Biolox Option; CeramTec) were inserted, and a highly cross-linked PE liner was fixated with cement because 32-mm PE liners were not available for cups. After re-reoperation, the patients were followed up for 3 months, 10 months, and 6.2 years, respectively. During follow-up, there was no evidence of the recurrence of metallosis, and serum Cr levels decreased gradually. Fig. 3 shows the flowchart for ceramic bearing fractures treated with MoP bearing replacement after ceramic head and liner fractures in our series. As for complications, an acute periprosthetic joint infection occurred in 1 patient with liner fracture of a sandwich-type liner, which was
Fig. 2. (A) At 11 years after THA with CoC bearing, ceramic head fracture occurred in 53-year-old male patient during daily activity. (B and C) Five years after reoperation using MoP bearing, x-ray shows sign of metallosis (arrow). (D) In the retrieved polyethylene liner, a tiny ceramic particle was embedded on the surface (arrow). (E) The retrieved metal head had scratches (arrow) on the surface.
Please cite this article as: Lee SJ, et al, Bearing Change to Metal-On-Polyethylene for Ceramic Bearing Fracture in Total Hip Arthroplasty; Does It Work?, J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.08.039
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S.J. Lee et al. / The Journal of Arthroplasty xxx (2015) xxx–xxx
Fig. 3. Flowchart of ceramic bearing fracture treated with MoP bearing replacement. *Metal-sleeved ceramic head with highly cross-linked PE liner fixated with cement.
treated with irrigation and debridement with implant retention. Periprosthetic joint infection recurred 3 years after reoperation and was treated with repeated irrigation and debridement. She was followed up for 4.8 years with no signs of metallosis. There were 3 posterior hip dislocations during follow-up. There was a recurrent dislocation in a patient with head fracture. The inclination angle of the cup after primary THA was measured as more than 55°, but the cup was retained during reoperation because it was fixed stably. At the most recent follow-up, the patient complained about mild discomfort due to instability. Two other dislocations occurred in patients with metallosis. In 1 patient with metallosis, posterior dislocation occurred 10 months after re-reoperation. In the other patient, posterior dislocation occurred 2 weeks before re-reoperation for metallosis. There were no other complications. The Table shows results and complications of reoperation for ceramic bearing fracture. Discussion Reoperation with MoP bearing replacement after ceramic bearing fracture had catastrophic results with the occurrence of metallosis, especially for liner fractures. Ceramic liner fractures have a few
differences from ceramic head fractures. For ceramic head fractures, a 28-mm head with a short neck is a well-known risk factor [6,17]. The short distance from the outer surface to the inner surface of the head with a 28-mm short neck makes it prone to fracture [17] (Fig. 4B). Ceramic head fracture occurs with a few pieces of fractured fragments [17] (Fig. 4C). Once ceramic head fracture occurs, the neck of the stem, which is cross-sectionally tapered and trapezoid, makes direct contact with the inner surface of the liner, resulting in loss of congruity in the bearing surface (Fig. 4D). Hip function is subsequently impaired abruptly and completely. In contrast, ceramic liner fracture occurs gradually by repeated impingement (Fig. 4F and G), and the intact spherical ceramic head can create a secondary bearing surface with the inner shell of the metal cup (Fig. 4H). Because of the secondary bearing, impairment of hip function in liner fractures can be less significant than in head fractures. Ceramic liner fracture results in severe fragmentation of fractured liner particles due to repeated damage by further movement of the hip joint after ceramic liner fracture. In addition, once ceramic head fracture occurs, fractured ceramic head particles remain in the joint space by the intact ceramic liner (Fig. 4D). In contrast, with ceramic liner fractures, fractured ceramic liner particles could be embedded in the
Fig. 4. Schematics of ceramic head fracture and liner fracture.
Please cite this article as: Lee SJ, et al, Bearing Change to Metal-On-Polyethylene for Ceramic Bearing Fracture in Total Hip Arthroplasty; Does It Work?, J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.08.039
S.J. Lee et al. / The Journal of Arthroplasty xxx (2015) xxx–xxx
acetabular side through the screw hole of the cup (Fig. 4G and H). Delayed diagnosis of ceramic liner fracture, severe fragmentation of fractured ceramic liner particle, and embedding of ceramic particle through screw holes lead to difficulties with complete removal of the ceramic particles after ceramic liner fracture. Remnant fractured ceramic liner particles cause catastrophic results of metallosis after reoperation with MoP bearing replacement. However, metallosis did not occur in 1 patient with periprosthetic infection after ceramic liner fracture of a sandwich-type liner. Intact PE liner behind the ceramic surface may have prevented embedding of ceramic particles through the screw hole. In addition, repeated irrigation and debridement for periprosthetic joint infection might have played a positive role in preventing the occurrence of metallosis in the present study. The outcome of reoperation with MoP bearing replacement after ceramic head fracture was doubtful with the occurrence of metallosis in 1 hip. Fragments from ceramic head fractures are fewer in number than those from ceramic liner fractures. Good long-term results have been achieved from bearing change to MoP after ceramic head fracture with complete synovectomy [3]. However, in the case with metallosis after ceramic head fracture in the present study, a tiny ceramic particle was embedded in the surface of the PE liner (Fig. 2D). A tiny ceramic particle can lead to severe damage of the metal head, resulting in metallosis (Fig. 2E). Complete removal of fractured ceramic particles seems impossible, and even 1 tiny remaining ceramic particle has the potential to cause significant metallosis. During follow-up after reoperation with bearing change to MoP for ceramic fracture, metallosis should be carefully evaluated. However, there is no consensus on protocol of follow-up for reoperation after ceramic bearing fracture, except for careful examination of bubble sign on serial radiograph. In some cases, metallosis could be identified during revision THA without bubble sign in preoperative radiograph [18]. In our study, we checked the presence of bubble sign in serial x-ray follow-up, and serum Cr level was evaluated in patients with suspicious finding of metallosis. For the earlier case with ceramic liner fracture, we checked ultrasound before reoperation; however, no definite abnormal finding was detected except for joint effusion. For the latter 2 cases with ceramic bearing fracture, computed tomography (CT) with metal artifact reduction was checked before reoperation, and CT scan showed sign of metallosis with soft tissue lesion or distension of joint capsule with high-attenuation rim. For detection of metallosis, evaluation of bubble sign on serial x-ray and identification of elevated serum metal ion level should be performed. In addition, CT scan with metal artifact reduction could be helpful for confirmation of metallosis. Further study with specific protocol should be necessitated. Our study has several limitations. First, the number of patients is small. Ceramic bearing fracture is a rare complication after THA with CoC bearings, especially in those made of third- or fourth-generation alumina ceramic [4,6]. Although our institution has a high volume of hip arthroplasty and we performed more than 2000 THAs with CoC bearings during the study period, there were only a small number of cases with ceramic bearing fractures. Second, the follow-up period was short. Despite the short follow-up period, the present study showed the catastrophic results of reoperation after ceramic liner fracture. For the results of reoperation after ceramic head fracture, further study with a longer follow-up period would be necessary. Third, the results of reoperation with other types of bearing surfaces were not compared with those of bearing change to MoP. From our study, implantation of metal heads should not be performed after ceramic bearing fracture. To insert new ceramic heads, revision of the stem is required [5,10]. However, metal-sleeved ceramic heads (Biolox Option; CeramTec) have recently become available for revision THAs with stem retention [4]. For the retention of well-fixed stems, metal-sleeved ceramic heads could be a good treatment option for reoperation, with less concern about ceramic refracture even in conditions with damaged morse tapers. However, there might be more specific concerns regarding the corrosion of damaged taper-neck junctions
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with metal sleeves. Further study on the result of revision THA with metal-sleeved ceramic head should be necessary. As for fractures at the cup, the selection of ceramic or PE liners should be determined based on damage to the inner surface of the cup. Ceramic liners can be implanted in cups with less damaged inner surfaces [4]. Polyethylene liners should be implanted in securely fixed cups with significantly damaged inner surfaces [4]. Severely damaged cups can sometimes result in damage to the locking mechanism of PE liners or PE liners may not be available for specific cups. We believe that PE liner with cement fixation accompanied with ceramic head may be a treatment option in these situations without the revision of well-fixed cups. However, there might be more specific concerns regarding excessive third-body PE wear due to remnant ceramic particles. Further study on the result of revision THA with PE liner with ceramic head is necessary. Conclusions Reoperation with MoP bearing replacement after ceramic liner fracture showed catastrophic results with the occurrence of metallosis. Reoperation with MoP bearing replacement after ceramic head fracture had doubtful outcomes, and concerns about metallosis remained. Reoperation with MoP bearing should not be performed for ceramic bearing fractures. Further studies with more patients and a longer follow-up period would be necessary to support our findings. Acknowledgement This work was supported by Seoul National University Hospital Research Fund (grant no. 06-03-063). References 1. Barrack RL, Burak C, Skinner HB. Concerns about ceramics in THA. Clin Orthop Relat Res 2004(429):73. 2. Allain J, Roudot-Thoraval F, Delecrin J, et al. Revision total hip arthroplasty performed after fracture of a ceramic femoral head. A multicenter survivorship study. J Bone Joint Surg Am 2003;85-a(5):825. 3. Sharma V, Ranawat AS, Rasquinha VJ, et al. Revision total hip arthroplasty for ceramic head fracture: a long-term follow-up. J Arthroplast 2010;25(3):342. 4. Traina F, Tassinari E, De Fine M, et al. Revision of ceramic hip replacements for fracture of a ceramic component: AAOS exhibit selection. J Bone Joint Surg Am 2011; 93(24), e147. 5. Koo KH, Ha YC, Kim SY, et al. Revision of ceramic head fracture after third generation ceramic-on-ceramic total hip arthroplasty. J Arthroplast 2014;29(1):214. 6. Traina F, De Fine M, Di Martino A, et al. Fracture of ceramic bearing surfaces following total hip replacement: a systematic review. BioMed Res Int 2013;2013:157247. 7. Bierbaum BE, Nairus J, Kuesis D, et al. Ceramic-on-ceramic bearings in total hip arthroplasty. Clin Orthop Relat Res 2002(405):158. 8. Pulliam IT, Trousdale RT. Fracture of a ceramic femoral head after a revision operation. A case report. J Bone Joint Surg Am 1997;79(1):118. 9. Weisse B, Affolter C, Stutz A, et al. Influence of contaminants in the stem-ball interface on the static fracture load of ceramic hip joint ball heads. Proc Inst Mech Eng H J Eng Med 2008;222(5):829. 10. Yoo JJ, Kim YM, Yoon KS, et al. Alumina-on-alumina total hip arthroplasty. A five-year minimum follow-up study. J Bone Joint Surg Am 2005;87(3):530. 11. Barrack RL, Folgueras AJ. Revision total hip arthroplasty: the femoral component. J Am Acad Orthop Surg 1995;3(2):79. 12. Allain J, Goutallier D, Voisin MC, et al. 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(9):1355. 13. Zywiel MG, Brandt JM, Overgaard CB, et al. Fatal cardiomyopathy after revision total hip replacement for fracture of a ceramic liner. Bone Joint J 2013;95-b(1):31. 14. Joshi RP, Eftekhar NS, McMahon DJ, et al. Osteolysis after Charnley primary lowfriction arthroplasty. A comparison of two matched paired groups. J Bone Joint Surg Br 1998;80(4):585. 15. Martell JM, Pierson III RH, Jacobs JJ, et al. Primary total hip reconstruction with a titanium fiber-coated prosthesis inserted without cement. J Bone Joint Surg Am 1993; 75(4):554. 16. Su EP, Callander PW, Salvati EA. The bubble sign: a new radiographic sign in total hip arthroplasty. J Arthroplast 2003;18(1):110. 17. Koo KH, Ha YC, Jung WH, et al. Isolated fracture of the ceramic head after thirdgeneration alumina-on-alumina total hip arthroplasty. J Bone Joint Surg Am 2008; 90(2):329. 18. Kwak HS, Yoo JJ, Lee YK, et al. The result of revision total hip arthroplasty in patients with metallosis following a catastrophic failure of a polyethylene liner. Clin Orthop Surg 2015;7(1):46.
Please cite this article as: Lee SJ, et al, Bearing Change to Metal-On-Polyethylene for Ceramic Bearing Fracture in Total Hip Arthroplasty; Does It Work?, J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.08.039
Contents lists available at ScienceDirect
The Journal of Arthroplasty journal homepage: www.arthroplastyjournal.org
Bearing Change to Metal-On-Polyethylene for Ceramic Bearing Fracture in Total Hip Arthroplasty; Does It Work? Soong Joon Lee, MD a, Hong Suk Kwak, MD a, Jeong Joon Yoo, MD, PhD a, Hee Joong Kim, MD, PhD a,b a b
Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea Medical Research Center, Seoul National University, Seoul, Republic of Korea
a r t i c l e
i n f o
Article history: Received 27 April 2015 Accepted 7 August 2015 Available online xxxx Keywords: ceramic bearing fracture total hip arthroplasty metallosis ceramic failure bearing change
a b s t r a c t We evaluated the short-term to midterm results of reoperation with bearing change to metal-on-polyethylene (MoP) after ceramic bearing fracture in ceramic-on-ceramic total hip arthroplasty. Nine third-generation ceramic bearing fractures (6 heads and 3 liners) were treated with bearing change to MoP. Mean age at reoperation was 52.7 years. Mean follow-up was 4.3 years. During follow-up, 2 of 3 liner-fractured hips and 1 of 6 head-fractured hips showed radiologic signs of metallosis and elevated serum chromium levels. Re-reoperation with bearing rechange to a ceramic head was performed for the hips with metallosis. One liner-fractured hip had periprosthetic joint infection. Dislocation occurred in 3 hips. From our experience, bearing change to MoP is not a recommended treatment option for ceramic bearing fracture in total hip arthroplasty. © 2015 Elsevier Inc. All rights reserved.
A ceramic bearing fracture is one of the most serious complications in total hip arthroplasty (THA) with ceramic-on-ceramic (CoC) bearing [1]. The current consensus on reoperation after a ceramic bearing fracture includes immediate reoperation after diagnosis of the ceramic fracture and complete synovectomy during the reoperation [2-5]. However, there is controversy about the method of reoperation after a ceramic bearing fracture, including the selection of a new bearing surface or the replacement of well-fixed implants with damaged tapers [5,6]. In a ceramic bearing fracture, the cone of the stem or the inner surface of the cup may be damaged by fractured ceramic particles or direct contact [4]. Insertion of a new ceramic bearing on a damaged taper surface might increase the risk of ceramic refracture [7-9]. Hence, change of the implant is recommended regardless of firm fixation of the implant [5,7]. However, concerns remain regarding the removal and replacement of well-fixed cementless stems or cups due to technical difficulties with removing well-fixed implants, potential damage to the bone stock during removal, and longevity of the revised implant [10,11]. In contrast, by changing the bearings to metal-on-polyethylene bearings (MoP), well-fixed implants can be retained without concerns about ceramic refracture [10]. However, there is controversy regarding the results of reoperation with MoP bearings after ceramic bearing fractures [2,3]. Favorable long-term results were reported after MoP bearing replacement combined with complete synovectomy [3]. However,
No author associated with this paper has disclosed any potential or pertinent conflicts which may be perceived to have impending conflict with this work. For full disclosure statements refer to http://dx.doi.org/10.1016/j.arth.2015.08.039. Reprint requests: Jeong Joon Yoo, MD, PhD, Department of Orthopedic Surgery, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, Republic of Korea 110-744.
massive metallosis due to third body wear by remnant ceramic particles remains a concern [12]. In addition, fatal systemic complications related to cobalt or chrome intoxication by metallosis have been reported after MoP bearing replacement due to ceramic bearing fractures [13]. We retrospectively reviewed the short-term to midterm results of reoperation after ceramic head and liner fractures treated with MoP bearing replacement with a minimum follow-up period of 2 years. We evaluated the clinical and radiologic outcomes of reoperation with MoP bearings for ceramic bearing fractures, especially in terms of the occurrence of metallosis and complications, as well as the necessity for re-reoperation. Materials and Methods Between November 1999 and December 2013, 11 reoperations were performed for ceramic bearing fractures in our institution. During the reoperation for ceramic fracture, the type of bearing surface was determined according to the damage in the morse taper at the stem or the inner surface of the cup. When the taper at the stem was damaged significantly, a metal head was inserted. A polyethylene (PE) liner was inserted with new metal heads or in cases with significant damage to the inner surface of the cup. In a patient with ceramic liner fracture, morse taper was not damaged, but inner surface of cup was damaged. She was treated with reoperation with bearing change to ceramic-on-polyethylene (CoP) and followed up for 14 years without osteolysis, loosening, ceramic refracture, or other complications. In a patient with ceramic head fracture, morse taper showed mild damage on surface, and inner surface of cup was intact. He was treated with reoperation with bearing change to new CoC and followed up for 7.3 years without ceramic refracture or other complications. Excluding these 2 patients with new ceramic
http://dx.doi.org/10.1016/j.arth.2015.08.039 0883-5403/© 2015 Elsevier Inc. All rights reserved.
Please cite this article as: Lee SJ, et al, Bearing Change to Metal-On-Polyethylene for Ceramic Bearing Fracture in Total Hip Arthroplasty; Does It Work?, J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.08.039
MoP changed Cup + MoP change 5 mo 10 d No DAL 7.3 2.0 Liner Liner 32/S 28/M Osteonics (Secur-fit/Accolade) Zimmer (Trilogy/Versys)b Male DA Female FNF 70.7 56.8 8 9
Abbreviations: ONFH, osteonecrosis of femoral head; FNF, femoral neck fracture; DA, degenerative arthritis; S, short; M, medium; DAL, daily activity of living; TA, traffic accident; X-PE, highly cross-linked polyethylene. a Sandwich-type liner. b Cemented stem. c Accompanied with posterior hip dislocation. d Cemented liner fixation. e Metal-sleeved ceramic head.
CoP changed CoC change 3.9 7.3
Death (leukemia) Death (unknown) No complication No complication Metallosis, dislocation Recurrent dislocation Recurrent periprosthetic joint infection Metallosis, dislocation Metallosis 2.7 3.6 2.0 2.4 6.0 6.4 4.8
PE PE PE PE PE PE Zimmer Trilogy cup + X-PE X-PE Zimmer Trilogy cup + X-PE MoP change MoP change MoP change MoP change MoP change MoP change Cup + MoP change 6d 1d 4d 1 mo 1d 1d 7 mo DAL TAc No Slip downc DAL DAL No 3.4 4.2 14.3 10.1 11.3 2.9 6.4 Head Head Head Head Head Head Liner 28/S 28/S 28/S 28/S 28/S 28/S 28/M Aesculap (Plasma/BiContact) Aesculap (Plasma/BiContact) Aesculap (Plasma/BiContact) Aesculap (Plasma/BiContact) Aesculap (Plasma/BiContact) DePuy (Duraloc/AML) Lima (SPH/C2)a ONFH ONFH ONFH ONFH ONFH ONFH FNF 54.5 36.9 67.2 47.2 53.5 22.5 65.1 1 2 3 4 5 6 7
Male Male Male Female Male Female Female
Follow- Results (Cause) Up (y) New Cup or Liner of Reoperation Type of Reoperation Duration of Symptom From THA Event to Ceramic Fracture (y) Location of Fracture Head (Size/ Length of Neck) Etiology Company of Implant for THA (Name of Cup/Stem) Age at Sex reoperation (y) Patient No.
Table Reoperation With Bearing Change to MoP for Ceramic Bearing Fracture.
CoP changed,e Closed reduction Repeated debridement
S.J. Lee et al. / The Journal of Arthroplasty xxx (2015) xxx–xxx
Re-Reoperation
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heads, 9 reoperations in 9 patients for 6 ceramic head fractures and 3 ceramic liner fractures were included in the present study. During follow-up, 2 patients died. One patient died due to leukemia. The cause of death for the other patient is unknown because contact with his family was lost. Follow-up for the 2 patients lasted for 2.7 and 3.6 years after reoperation, respectively, and they are included in the present study. The mean age at reoperation for all patients was 52.7 ± 15.4 years (22.5-70.7 years), with 5 male and 4 female patients. Primary THA was performed at the mean age of 45.8 ± 21.9 years (19.6-63.4 years). Etiology of primary THA was osteonecrosis in 6 patients, femoral neck fracture in 2 patients, and degenerative arthritis in the remaining patient. In 5 hips, Plasma cups (Aesculap AG, Tuttlingen, Germany) with BiContact Stems (Aesculap AG) were implanted. The other 4 patients underwent THAs with Duraloc cup (DePuy, Leeds, UK) with AML stem (DePuy), SPH contact cup (LimaLto, Udine, Italy) with C2 stem (Lima-Lto), Secur-fit cup (Osteonics, Allendale, NJ) with Accolade stem (Osteonics), and Trilogy cup (Zimmer, Warsaw, IN) with Versys cemented stem (Zimmer). All ceramic heads and liners were made of third-generation alumina ceramic (Biolox Forte; CeramTec, Plochingen, Germany). There was 1 sandwichtype liner in a patient with a Lima implant. The Table shows feature of primary THA. Ceramic fracture was diagnosed at mean 6.9 ± 4.2 years (2.0-14.3 years) after primary THA. Six heads and 3 liners were fractured (Figs. 1A and 2A). Of the 6 patients with ceramic head fracture, 2 had a history of definite trauma accompanied by posterior hip dislocation. The remaining patients with head fracture had an abrupt onset of pain with daily activities of living or without any specific prior events. With the exception of 1 patient, reoperation was performed for all patients with ceramic head fracture within 6 days after pain or discomfort developed. Diagnosis of the fracture was delayed in the last patient because she took a bed rest at home for a month after the injury. Two patients with liner fracture had periods of discomfort for more than 5 months without any prior events. The other patient with liner fracture had 10 days of discomfort, which occurred after daily activity. The mean interval between symptom onset and reoperation for ceramic fracture was 7.2 days (1 day to 1 month) with ceramic head fractures and 4.1 months (10 days to 7 months) with ceramic liner fractures. The Table also shows feature of ceramic bearing fracture. Reoperation was planned and performed immediately after diagnosis of ceramic fracture. During reoperation, macroscopic ceramic particles were removed, and synovectomy was performed as thoroughly as possible (Fig. 1B). All stems were securely fixed, but all cones of the stems with ceramic head fractures were damaged by ceramic particles or direct contact. All stems were retained during reoperation. In 2 patients with liner fracture, the cup was removed and revised for complete removal of ceramic particles. Finally, the 28-mm metal head made of cobalt-chrome alloy and the PE liner were inserted. For all 3 liner fractures, PE liners made of highly cross-linked PE were inserted, and for all 6 head fractures, PE liners were made of conventional PE because highly cross-linked PE liners are not available for the cups. In 1 patient with ceramic liner fracture of a Secur-fit cup, a highly cross-linked PE liner was fixed with cement because no PE liner is available for the cup. The Table shows feature of reoperation for ceramic bearing fracture. Patients were followed up at postoperative 6 weeks, 3 months, 6 months, and 1 year. After postoperative 1 year, patients were followed up annually. For clinical evaluation, the patients were asked about clinical symptoms of pain or limping. The occurrence of complications was recorded. Mean follow-up of patients was 4.3 ± 1.9 years (2.0-7.3 years). For radiographic evaluation, standard anteroposterior radiograph and cross-table lateral radiograph were checked before and immediately after the operation and at each visit to the clinics. Using radiographs obtained at each visit to the clinic, the presence of osteolysis, loosening, or metallosis was evaluated [14-16]. We also checked serum chromium (Cr) level in patients with suspicious findings of metallosis.
Please cite this article as: Lee SJ, et al, Bearing Change to Metal-On-Polyethylene for Ceramic Bearing Fracture in Total Hip Arthroplasty; Does It Work?, J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.08.039
S.J. Lee et al. / The Journal of Arthroplasty xxx (2015) xxx–xxx
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Fig. 1. (A) At 2 years after THA with CoC bearing, x-ray shows ceramic liner fracture that occurred in 56-year-old female patient during daily activity. (B) Retrieved ceramic liner shows severe fragmentation. (C) Seven months after reoperation using MoP bearing, x-ray shows bubble sign of metallosis (arrows) and serum chromium (Cr) level was elevated to 34.6 μg/L. (D) Six years after re-reoperation using CoC bearing, x-ray shows no sign of metallosis or ceramic refracture. Serum Cr level decreased to 1.9 μg/L.
Results In radiologic evaluation, there was no sign of osteolysis or loosening during the follow-up period. However, 3 hips with 1 head fracture and 2 liner fractures showed suspicious findings of metallosis at 6.9 month, 3.1 years, and 5.7 years after reoperation, respectively (Figs. 1C and 2B and C) In the laboratory tests, serum Cr level was elevated to 13.2, 27.8, and 34.6 μg/L, respectively (mean serum Cr level, 25.2 ± 10.9 μg/L; reference level, 0-3 μg/L). Re-reoperation was performed for the patients with suspicious findings of metallosis. During re-reoperation, metallosis was confirmed with black-colored fluid and pigmented soft tissue. Cups and stems of all patients were securely fixed, but the retrieved metal heads had scratches on their surfaces from remnant ceramic particles
(Fig. 2E). Cups and stems were retained. However, after synovectomy, the bearing was changed to ceramic-on-polyethylene in 2 patients and to CoC in 1. In 1 of the 3 cases, 32-mm metal-sleeved ceramic heads (Biolox Option; CeramTec) were inserted, and a highly cross-linked PE liner was fixated with cement because 32-mm PE liners were not available for cups. After re-reoperation, the patients were followed up for 3 months, 10 months, and 6.2 years, respectively. During follow-up, there was no evidence of the recurrence of metallosis, and serum Cr levels decreased gradually. Fig. 3 shows the flowchart for ceramic bearing fractures treated with MoP bearing replacement after ceramic head and liner fractures in our series. As for complications, an acute periprosthetic joint infection occurred in 1 patient with liner fracture of a sandwich-type liner, which was
Fig. 2. (A) At 11 years after THA with CoC bearing, ceramic head fracture occurred in 53-year-old male patient during daily activity. (B and C) Five years after reoperation using MoP bearing, x-ray shows sign of metallosis (arrow). (D) In the retrieved polyethylene liner, a tiny ceramic particle was embedded on the surface (arrow). (E) The retrieved metal head had scratches (arrow) on the surface.
Please cite this article as: Lee SJ, et al, Bearing Change to Metal-On-Polyethylene for Ceramic Bearing Fracture in Total Hip Arthroplasty; Does It Work?, J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.08.039
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S.J. Lee et al. / The Journal of Arthroplasty xxx (2015) xxx–xxx
Fig. 3. Flowchart of ceramic bearing fracture treated with MoP bearing replacement. *Metal-sleeved ceramic head with highly cross-linked PE liner fixated with cement.
treated with irrigation and debridement with implant retention. Periprosthetic joint infection recurred 3 years after reoperation and was treated with repeated irrigation and debridement. She was followed up for 4.8 years with no signs of metallosis. There were 3 posterior hip dislocations during follow-up. There was a recurrent dislocation in a patient with head fracture. The inclination angle of the cup after primary THA was measured as more than 55°, but the cup was retained during reoperation because it was fixed stably. At the most recent follow-up, the patient complained about mild discomfort due to instability. Two other dislocations occurred in patients with metallosis. In 1 patient with metallosis, posterior dislocation occurred 10 months after re-reoperation. In the other patient, posterior dislocation occurred 2 weeks before re-reoperation for metallosis. There were no other complications. The Table shows results and complications of reoperation for ceramic bearing fracture. Discussion Reoperation with MoP bearing replacement after ceramic bearing fracture had catastrophic results with the occurrence of metallosis, especially for liner fractures. Ceramic liner fractures have a few
differences from ceramic head fractures. For ceramic head fractures, a 28-mm head with a short neck is a well-known risk factor [6,17]. The short distance from the outer surface to the inner surface of the head with a 28-mm short neck makes it prone to fracture [17] (Fig. 4B). Ceramic head fracture occurs with a few pieces of fractured fragments [17] (Fig. 4C). Once ceramic head fracture occurs, the neck of the stem, which is cross-sectionally tapered and trapezoid, makes direct contact with the inner surface of the liner, resulting in loss of congruity in the bearing surface (Fig. 4D). Hip function is subsequently impaired abruptly and completely. In contrast, ceramic liner fracture occurs gradually by repeated impingement (Fig. 4F and G), and the intact spherical ceramic head can create a secondary bearing surface with the inner shell of the metal cup (Fig. 4H). Because of the secondary bearing, impairment of hip function in liner fractures can be less significant than in head fractures. Ceramic liner fracture results in severe fragmentation of fractured liner particles due to repeated damage by further movement of the hip joint after ceramic liner fracture. In addition, once ceramic head fracture occurs, fractured ceramic head particles remain in the joint space by the intact ceramic liner (Fig. 4D). In contrast, with ceramic liner fractures, fractured ceramic liner particles could be embedded in the
Fig. 4. Schematics of ceramic head fracture and liner fracture.
Please cite this article as: Lee SJ, et al, Bearing Change to Metal-On-Polyethylene for Ceramic Bearing Fracture in Total Hip Arthroplasty; Does It Work?, J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.08.039
S.J. Lee et al. / The Journal of Arthroplasty xxx (2015) xxx–xxx
acetabular side through the screw hole of the cup (Fig. 4G and H). Delayed diagnosis of ceramic liner fracture, severe fragmentation of fractured ceramic liner particle, and embedding of ceramic particle through screw holes lead to difficulties with complete removal of the ceramic particles after ceramic liner fracture. Remnant fractured ceramic liner particles cause catastrophic results of metallosis after reoperation with MoP bearing replacement. However, metallosis did not occur in 1 patient with periprosthetic infection after ceramic liner fracture of a sandwich-type liner. Intact PE liner behind the ceramic surface may have prevented embedding of ceramic particles through the screw hole. In addition, repeated irrigation and debridement for periprosthetic joint infection might have played a positive role in preventing the occurrence of metallosis in the present study. The outcome of reoperation with MoP bearing replacement after ceramic head fracture was doubtful with the occurrence of metallosis in 1 hip. Fragments from ceramic head fractures are fewer in number than those from ceramic liner fractures. Good long-term results have been achieved from bearing change to MoP after ceramic head fracture with complete synovectomy [3]. However, in the case with metallosis after ceramic head fracture in the present study, a tiny ceramic particle was embedded in the surface of the PE liner (Fig. 2D). A tiny ceramic particle can lead to severe damage of the metal head, resulting in metallosis (Fig. 2E). Complete removal of fractured ceramic particles seems impossible, and even 1 tiny remaining ceramic particle has the potential to cause significant metallosis. During follow-up after reoperation with bearing change to MoP for ceramic fracture, metallosis should be carefully evaluated. However, there is no consensus on protocol of follow-up for reoperation after ceramic bearing fracture, except for careful examination of bubble sign on serial radiograph. In some cases, metallosis could be identified during revision THA without bubble sign in preoperative radiograph [18]. In our study, we checked the presence of bubble sign in serial x-ray follow-up, and serum Cr level was evaluated in patients with suspicious finding of metallosis. For the earlier case with ceramic liner fracture, we checked ultrasound before reoperation; however, no definite abnormal finding was detected except for joint effusion. For the latter 2 cases with ceramic bearing fracture, computed tomography (CT) with metal artifact reduction was checked before reoperation, and CT scan showed sign of metallosis with soft tissue lesion or distension of joint capsule with high-attenuation rim. For detection of metallosis, evaluation of bubble sign on serial x-ray and identification of elevated serum metal ion level should be performed. In addition, CT scan with metal artifact reduction could be helpful for confirmation of metallosis. Further study with specific protocol should be necessitated. Our study has several limitations. First, the number of patients is small. Ceramic bearing fracture is a rare complication after THA with CoC bearings, especially in those made of third- or fourth-generation alumina ceramic [4,6]. Although our institution has a high volume of hip arthroplasty and we performed more than 2000 THAs with CoC bearings during the study period, there were only a small number of cases with ceramic bearing fractures. Second, the follow-up period was short. Despite the short follow-up period, the present study showed the catastrophic results of reoperation after ceramic liner fracture. For the results of reoperation after ceramic head fracture, further study with a longer follow-up period would be necessary. Third, the results of reoperation with other types of bearing surfaces were not compared with those of bearing change to MoP. From our study, implantation of metal heads should not be performed after ceramic bearing fracture. To insert new ceramic heads, revision of the stem is required [5,10]. However, metal-sleeved ceramic heads (Biolox Option; CeramTec) have recently become available for revision THAs with stem retention [4]. For the retention of well-fixed stems, metal-sleeved ceramic heads could be a good treatment option for reoperation, with less concern about ceramic refracture even in conditions with damaged morse tapers. However, there might be more specific concerns regarding the corrosion of damaged taper-neck junctions
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with metal sleeves. Further study on the result of revision THA with metal-sleeved ceramic head should be necessary. As for fractures at the cup, the selection of ceramic or PE liners should be determined based on damage to the inner surface of the cup. Ceramic liners can be implanted in cups with less damaged inner surfaces [4]. Polyethylene liners should be implanted in securely fixed cups with significantly damaged inner surfaces [4]. Severely damaged cups can sometimes result in damage to the locking mechanism of PE liners or PE liners may not be available for specific cups. We believe that PE liner with cement fixation accompanied with ceramic head may be a treatment option in these situations without the revision of well-fixed cups. However, there might be more specific concerns regarding excessive third-body PE wear due to remnant ceramic particles. Further study on the result of revision THA with PE liner with ceramic head is necessary. Conclusions Reoperation with MoP bearing replacement after ceramic liner fracture showed catastrophic results with the occurrence of metallosis. Reoperation with MoP bearing replacement after ceramic head fracture had doubtful outcomes, and concerns about metallosis remained. Reoperation with MoP bearing should not be performed for ceramic bearing fractures. Further studies with more patients and a longer follow-up period would be necessary to support our findings. Acknowledgement This work was supported by Seoul National University Hospital Research Fund (grant no. 06-03-063). References 1. Barrack RL, Burak C, Skinner HB. Concerns about ceramics in THA. Clin Orthop Relat Res 2004(429):73. 2. Allain J, Roudot-Thoraval F, Delecrin J, et al. Revision total hip arthroplasty performed after fracture of a ceramic femoral head. A multicenter survivorship study. J Bone Joint Surg Am 2003;85-a(5):825. 3. Sharma V, Ranawat AS, Rasquinha VJ, et al. Revision total hip arthroplasty for ceramic head fracture: a long-term follow-up. J Arthroplast 2010;25(3):342. 4. Traina F, Tassinari E, De Fine M, et al. Revision of ceramic hip replacements for fracture of a ceramic component: AAOS exhibit selection. J Bone Joint Surg Am 2011; 93(24), e147. 5. Koo KH, Ha YC, Kim SY, et al. Revision of ceramic head fracture after third generation ceramic-on-ceramic total hip arthroplasty. J Arthroplast 2014;29(1):214. 6. Traina F, De Fine M, Di Martino A, et al. Fracture of ceramic bearing surfaces following total hip replacement: a systematic review. BioMed Res Int 2013;2013:157247. 7. Bierbaum BE, Nairus J, Kuesis D, et al. Ceramic-on-ceramic bearings in total hip arthroplasty. Clin Orthop Relat Res 2002(405):158. 8. Pulliam IT, Trousdale RT. Fracture of a ceramic femoral head after a revision operation. A case report. J Bone Joint Surg Am 1997;79(1):118. 9. Weisse B, Affolter C, Stutz A, et al. Influence of contaminants in the stem-ball interface on the static fracture load of ceramic hip joint ball heads. Proc Inst Mech Eng H J Eng Med 2008;222(5):829. 10. Yoo JJ, Kim YM, Yoon KS, et al. Alumina-on-alumina total hip arthroplasty. A five-year minimum follow-up study. J Bone Joint Surg Am 2005;87(3):530. 11. Barrack RL, Folgueras AJ. Revision total hip arthroplasty: the femoral component. J Am Acad Orthop Surg 1995;3(2):79. 12. Allain J, Goutallier D, Voisin MC, et al. 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(9):1355. 13. Zywiel MG, Brandt JM, Overgaard CB, et al. Fatal cardiomyopathy after revision total hip replacement for fracture of a ceramic liner. Bone Joint J 2013;95-b(1):31. 14. Joshi RP, Eftekhar NS, McMahon DJ, et al. Osteolysis after Charnley primary lowfriction arthroplasty. A comparison of two matched paired groups. J Bone Joint Surg Br 1998;80(4):585. 15. Martell JM, Pierson III RH, Jacobs JJ, et al. Primary total hip reconstruction with a titanium fiber-coated prosthesis inserted without cement. J Bone Joint Surg Am 1993; 75(4):554. 16. Su EP, Callander PW, Salvati EA. The bubble sign: a new radiographic sign in total hip arthroplasty. J Arthroplast 2003;18(1):110. 17. Koo KH, Ha YC, Jung WH, et al. Isolated fracture of the ceramic head after thirdgeneration alumina-on-alumina total hip arthroplasty. J Bone Joint Surg Am 2008; 90(2):329. 18. Kwak HS, Yoo JJ, Lee YK, et al. The result of revision total hip arthroplasty in patients with metallosis following a catastrophic failure of a polyethylene liner. Clin Orthop Surg 2015;7(1):46.
Please cite this article as: Lee SJ, et al, Bearing Change to Metal-On-Polyethylene for Ceramic Bearing Fracture in Total Hip Arthroplasty; Does It Work?, J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.08.039