Alternative bearing surfaces for total hip arthroplasty (THA), such as ceramic couplings, have gained increasing popularity in recent years for their low-wear properties. Clinical outcomes have been excellent; however, these bearings have disadvantages, such as noise and catastrophic failure. To the authors’ knowledge, this is the first report of severe metallosis resulting in cobalt–chrome head perforation in a patient who previously underwent primary THA with a ceramic-on-ceramic coupling that was revised with a metal-on-polyethylene articulation because of cement liner fracture.
A 67-year-old woman was referred to the authors’ institution reporting right hip pain after a revision THA performed 3 years previously. Eight years previously, she underwent primary THA using a ceramic-on-ceramic system for osteoarthritis. The hip was revised due to a fracture of the ceramic liner without a precipitating event. The liner and head were revised to polyethylene-on-cobalt-chrome at another hospital.
She presented to the current authors reporting pain and a right pelvic mass. Ultrasound and computed tomography (CT) scan (Figure 1) of the pelvis were performed. Images showed a complex loculated fluid collection in the right hemipelvis arising from the right hip, suggesting possible infection, although no history of systemic symptoms was found and inflammatory markers were normal. A CT-guided aspiration showed granulomatous tissue. Radiographs showed heterotopic ossification with radiodensity around the cup, ischial tuberosity, and proximal femoral metaphysis with a deformed femoral head (Figure2).
Figure 1: Axial computed tomography scan showing an isodense multilocular lesion in the right hemipelvis with a hyperdense wall (white arrow.)
Figure 2: Preoperative anteroposterior radiograph showing eccentric deformation of the femoral head (black arrow) with heterotopic ossification (white arrow) and radiodensity around the cup, ischium, and proximal femur.
Revision was undertaken using a trochanteric slide technique. Dark fluid indicating severe metallosis was present as the trochanteric osteotomy was performed. The metal head was perforated (Figure 3A). The liner showed eccentric wear superiorly with embedded ceramic debris (Figure 3B). After the liner was removed, curetting the cup holes caused dark fluid to gush out, accentuated by pressing on the abdomen. A large defect was found in the ischium, but no pelvic discontinuity was found.
Figure 3: Photographs showing complete perforation of the superior aspect of the femoral head (white arrow) (A) and metallic debris embedded within the cup (white arrow) and worn liner along with an inferior view of perforated femoral head (black arrow) (B).
A 62-mm TM cup (Zimmer, Ltd, Mississauga, Canada) with 3 screws was implanted after allografting the ischium. The stem was well fixed and not revised. A 40-mm ceramic head was used.
Eighteen months postoperatively, the patient was asymptomatic and mobilizing without aid.
Ceramic materials are increasingly being used in THA in younger patients. They have excellent tribological properties, including corrosion resistance and biocompatibility. However, they also have a lower elasticity and plasticity, which makes them susceptible to sudden material failure. Ceramic fracture is an uncommon yet problematic complication of THA. To the authors’ knowledge, this is the first reported case where ceramic fracture led to perforation of a cobalt–chromium femoral head after subsequent revision THA.
A multicenter trial of 105 patients who underwent revision surgery with different bearing surfaces to treat ceramic fracture showed that revision with ceramic femoral heads were at least as durable as the original implants at short-term follow-up.1 Cobalt–chrome heads provided satisfactory results; however, stainless steel heads showed excessive wear, and the authors advised against their use.1
Severe wear of the cobalt–chromium head was also reported after ceramic failure in 6 bipolar cases.2 However, a series of 8 patients with more than 10 years of survivorship with metal-on-polyethylene after revision THA for ceramic fracture was reported after thorough synevectomy, highlighting its importance.3
Metallosis may present on radiographs with an appearance similar to heterotopic ossification.4 Elimination of all ceramic particles is impossible. The higher wear of cobalt–chromium and stainless steel femoral heads used in revision surgery following ceramic fracture may be explained due to their having a lower hardness level than ceramics. Materials with a lower hardness level are susceptible to more abrasive wear when they come into contact with those with a greater hardness level.5 Because microscopic ceramic particles are going to remain from the primary procedure, they can cause more abrasive wear to these materials if they are used in revision surgery.
The authors advocate replacing the cup at revision, even if it appears macroscopically normal, because microscopic ceramic particles may be embedded.1 They further advise that ceramic-on-ceramic articulation be used after previous ceramic fracture to prevent further catastrophic failure, in accordance with other authors.6,7
- Allain J, Roudot-Thoraval F, Delecrin J, Anract P, Migaud H, Goutallier D. Revision total hip arthroplasty performed after fracture of a ceramic femoral head. A multicenter survivorship study. J Bone Joint Surg Am. 2003; 85(5):825–830.
- Matsuda Y, Yamamuro T. Metallosis due to abnormal abrasion of the femoral head in bipolar hip prosthesis. Implant retrieval and analysis in six cases. Med Prog Technol. 1994; 20(3–4):185–189.
- Sharma V, Ranawat AS, Rasquinha VJ, Weiskopf J, Howard H, Ranawat CS. Revision total hip arthroplasty for ceramic head fracture: a long-term follow-up. J Arthroplasty. 2010; 25(3):342–347. doi:10.1016/j.arth.2009.01.014 [CrossRef]
- Khan RJ, Wimhurst J, Foroughi S, Toms A. The natural history of metallosis from catastrophic failure of a polyethylene liner in a total hip. J Arthroplasty. 2009; 24(7): e1141–e1144. doi:10.1016/j.arth.2008.09.002 [CrossRef]
- Dearnley PA. A review of metallic, ceramic and surface-treated metals used for bearing surfaces in human joint replacements. Proc Inst Mech Eng H. 1999; 213(2):107–135. doi:10.1243/0954411991534843 [CrossRef]
- Hashiguchi T, Hirano T, Shindo H, Baba K. Wear of alumina ceramics prosthesis. Arch Orthop Trauma Surg. 1999; 119(1–2):30–34. doi:10.1007/s004020050350 [CrossRef]
- Matziolis G, Perka C, Disch A. Massive metallosis after revision of a fractured ceramic head onto a metal head. Arch Orthop Trauma Surg. 2003; 123(1):48–50.