The Journal of Arthroplasty Vol. 25 No. 3 2010

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Total HipArthroplasty for Ceramic Head Fracture

A Long-Term Follow-Up

Vineet Sharma, MD, Amar S. Ranawat, MD, Vijay J. Rasquinha, MD,JoAnne Weiskopf, R-PAC, Holly Howard, BA, and Chitranjan S. Ranawat, MD

Abstract: The results of revision total hip arthroplasty (THA) for ceramic head fracture havegenerally been disappointing, largely due to third body wear after incomplete synovectomy. Wehave followed 8 patients who sustained ceramic head fractures and were subsequently revised to ametal-on-polyethylene articulation. There were no revisions for osteolysis or aseptic loosening at amean follow-up of 10.5 years. The yearly wear rates of each of 5 of these THAs after revision werecompared with 6 matched metal-on-polyethylene THAs; there were no significant differences inwear rates. Greater than 10-year survivorship with a metal-on-polyethylene bearing couple ispossible after revision THA for a ceramic head fracture if a complete and thorough synovectomy canbe performed. Our technique of synovectomy will be described. Keywords: ceramic fracture,revision total hip, wear rate.© 2010 Elsevier Inc. All rights reserved.

Alumina ceramics have been used in total hip arthro-plasty (THA) since the early 1970s [1]. More than1.5 million ceramic femoral heads have been implantedsince their introduction [2]. Despite having the lowestwear rates among currently available hip bearingsurfaces, the occurrence of fractures with ceramics hasprevented their widespread use [3-7]. The reportedfracture rate of first-generation and second-generationceramics is between 0% and 13% [8-15]. Fractures havealso been described with third-generation ceramics[16-18]. The fracture rate with third-generation ceramicsis thought to be around 1 in 5000 based on reportedfractures to Ceramtec, Inc, over units sold.The recommended treatment for ceramic head fracture

is urgent revision THA with complete synovectomy. Athorough synovectomy is technically difficult in thissituation because the ceramic head fragments intomultiple pieces of varying sizes These ceramic particlescan then penetrate into all the surrounding tissues of the

he Ranawat Orthopaedic Center, Lenox Hill Hospital, New York,.tted April 5, 2008; accepted January 13, 2009.ts or funds were received in partial or total support of thematerial described in this article. These benefits or supporteived from the following sources: C S Ranawat and A Sare paid consultants with Stryker and Depuy.t requests: Amar S. Ranawat, MD, Ranawat Orthopaedicenox Hill Hospital, William Black Hall, 11th Floor, 130 EastNew York, NY 10021.0 Elsevier Inc. All rights reserved.403/09/2503-0002$36.00/0.1016/j.arth.2009.01.014

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hip [19,20]. The results of revision THA done for ceramichead fracture with various bearing surfaces have beendisappointing [19-23]. Most failures can be attributed toincomplete synovectomy and residual ceramic particles.These ceramic particles in turn lead to accelerated thirdbody wear and osteolysis.The aim of this study is to report on the long-term

results of revision THA done for ceramic head fractureusing a metal-on-polyethylene bearing couple at thetime of initial revision. We also report on ourtechnique of performing a complete synovectomy inthese cases, which we hope will prove helpful to thepracticing orthopedic surgeon who is faced with thiscatastrophic complication.

Materials and MethodsBetween 1990 and 1992, the senior author (XXX)

performed 87 THAs with ceramic-on-polyethylene bear-ing surfaces at the XXX Hospital. The femoral stem usedin all these cases was a cementless, proximally plasma-sprayed “8311” femoral component (The Dana Center forOrthopedic Implants, HSS, New York, NY), which issimilar in stem design to the commercially availableRanawat-Burstein prosthesis (Biomet, Warsaw, IN). Thefemoral head used in all cases was a 28-mm short-neckBiolox aluminum oxide bearing (Feldmuhle Aktienge-sellschaft, now Cerasiv GmbH, Plochingen, Germany).The acetabular component used in all cases was anuncemented Harris-Galante II titanium shell (Zimmer,Warsaw, IN) with a corresponding polyethylene liner.

Fig. 2. Lateral radiograph of left hip of 54-year-old man with

Revision THA for Ceramic Head Fracture � Sharma et al 343

There were 8 cases of fracture of a ceramic head (Figs. 1and 2). The operative findings of 3 of these cases havebeen described in an earlier publication by the seniorauthor [6]. Of the 8 patients, there were 7 males and 1female. The preoperative diagnosis was osteoarthritis in 6patients, developmental dysplasia of hip in 1, andjuvenile rheumatoid arthritis in 1. The average patientage at the time of index revision surgery was 50.6 years(range, 29-62). Average patient weight was 191 lb(range, 165-215 lb).The incidence of ceramic head fracture in this series was

9.2%. The mean time to fracture was 33.8 months(range, 3-96 months). There were 2 peaks observed inthe occurrence of fracture. Of the 8 fractures, 4 occurredwithin the first year of surgery, at an average of5.2 months (range, 3-8 months). Another 4 fracturesoccurred late at an average of 62 months after surgery(range, 48-96 months).All of these fractures occurred during normal daily

activities, and there was no history of trauma. All of thepatients underwent an urgent revision THA. A thoroughanterior and posterior synovectomy through a singleposterior incision was done in all cases. In 7 cases, therevision consisted of head and liner exchange within48 hours of fracture. In 1 patient, the stem was alsorevised because the trunion was severely damaged due toa 3 week delay in presentation. In all cases, a cobalt-

Fig. 1. Anteroposterior of left hip of 54 year old male withfractured ceramic head.

fractured ceramic head.

chromium femoral head and a polyethylene acetabularliner were placed.The patients were followed annually for the first

3 years and then at 5, 7, and 10 years after revision. Onepatient was lost to follow-up and was not included inthe study. One patient refused to participate in thestudy. One patient developed an infection 12 monthsafter revision THA and underwent a 2-stage reimplanta-tion. This patient was excluded from the study becausehe had more than 1 synovectomy. Another patientunderwent revision of the femoral stem for a traumaticperiprosthetic fracture 8.5 years after revision. Thefracture was unrelated to wear or periprostheticosteolysis (Figs. 3 and 4).At each follow-up visit, Harris Hip Scores (HHS) were

obtained, a clinical examination was performed, andradiographs were reviewed. Radiographs were criticallyreviewed for evidence of excessive wear and osteolysiscompared to the immediate postoperative radiographs.Finally, wematched each of the 5 ceramic head fracture

patients with 6 other patients who had a primary THA(metal-on-polyethylene bearing) during the same period;these other patients were matched for length of follow-up, age, sex, and body mass index. The control group wasselected to see if the wear rate after revision THA forceramic head fracture is greater than the wear rate inpatients after a primary THA. The control group consisted

Fig. 3. Anteroposterior radiograph of 52-year-old man withperiprosthetic fracture of femur after a fall. There is no evidenceof osteolysis.

344 The Journal of Arthroplasty Vol. 25 No. 3 April 2010

of a total of 30 primary metal-on-polyethylene THAs in30 patients. Twenty patients in the control group weremale, and 10 were female. The mean age in this groupwas 54.8 years (range, 34-62). The average body massindex was 27.7 (range, 16.3-44.9). Wear rates weremeasured in both groups using Martell's software [24].

Fig. 4. Lateral radiograph of 52-year-old man with peripros-thetic fracture of femur after a fall. There is no evidenceof osteolysis.

Technique of the Complete Anterior andPosterior SynovectomyThe goal of the complete anterior and posterior

synovectomy is to excise the entire pseudocapsule andthe synovium from around the hip joint. The hip joint isexposed with an extensive posterolateral exposure asdescribed previously [25]. The gluteus maximus insertionon the femur is released almost completely. The joint isentered after taking the short external rotators down fromthe greater trochanter and performing a capsulotomy. Allthe macroscopic ceramic particles are excised first.A soft tissue plane is then developed between the short

external rotators and hip pseudocapsule. All of thesmaller ceramic particles lodged posteriorly that cannotbe seen with the naked eye are removed by thistechnique. Next, the hip joint is dislocated, and thefemur is elevated with a bone hook. An anterior capsularrelease is performed with a knife from the anterior aspectof the femur from the insertion of the iliopsoas medially

to the trochanter laterally. This allows for adequatemobilization of the proximal femur.Damage to the trunion is assessed when deciding

whether to retain the femoral component. Occasionally,modular sleeves are available to protect newmetal heads.If minimal damage is noted, a pocket is made to accept thetrunion near the anterior inferior iliac spine by removingthe pseudocapsule and retained gluteus minimus. Theacetabulum is exposed with a C-retractor anteriorlyunder the anterior inferior iliac spine, an Aufrancretractor inferiorly in the obturator foramen, a benthohmann retractor posteriorly in the ischial spine, and aSteinman pin superiorly in the ilium. The hip is flexedapproximately 30°, and the knee is bolstered. This shouldprovide a wide exposure of the acetabulum. All accessiblepseudocapsule and synovium are excised from thesuperior, posterior, and inferior aspects of the hip joint,and the liner is removed from the acetabular shell.Damage to the shell is assessed when deciding whether toretain the acetabular component. The surgeon must keepin mind that cementing a polyethylene liner into adamaged shell is often a reasonable compromise, asopposed to removing a well-fixed shell. A trial head andliner are inserted next, and the hip joint is reduced.Anterior exposure of the hip joint is done next through

a modified Hardinge approach through the same

Fig. 5. Anteroposterior radiograph at 15 years follow-up of thepatient in Figs. 1 and 2. There is very little polyethylene wearand no osteolysis.

Fig. 6. Lateral radiograph at 15 years follow-up.

Revision THA for Ceramic Head Fracture � Sharma et al 345

posterolateral skin incision and fascial incision [26]. Theanterior quarter of the vastus lateralis and the anteriorquarter of the gluteus medius are taken down against thebone as 1 single sleeve. After exposing the hip joint in thisfashion, the trial head is dislocated anteriorly. Anteriorcapsular releases are completed from the acetabular side.The femoral stem is retracted posteriorly, and all theanterior and inferior pseudocapsule and synovium areexcised. Meticulous irrigation is done to ensure that noceramic particles are left behind. The final acetabular linerand femoral head are inserted, and the wound is closedfrom the front and the back using nonabsorbable suturesthru drill holes in the trochanter.

Statistical AnalysisThe independent samples t test was used to compare the

patients revised for a ceramic head fracturewith the controlgroups with regard to yearly wear rates at 10 years follow-up. Significance was established at P b .05.

ResultsThe mean follow-up for the 5 patients was 126 months

(range, 84-180 months). The mean HHS at the lastfollow-up was 95 (range, 85-99). The mean follow-upfor the control group was 121.6 months (range, 96-168

months). The mean HHS at the last follow-up was 93.6(range, 85-98).The average yearly linear wear rate after revision as

measured by Martell's software in these 5 patients was0.11 mm/y (range, 0.8-0.14). The average wear rate inthe control group of patients was 0.14 mm/y (range,−0.11 to 0.67). The difference was not statisticallysignificant (P = .634). Each ceramic fracture revisionpatient was found to have a yearly wear rate at 10 yearsfollow-up that was within 1 SD of the wear ratedistribution of the respective control group.There have been no revisions to date in any patient in

either group for wear, osteolysis, or aseptic loosening.There have been no cases of progressive, expansileosteolysis or evidence of implant loosening in any patientin either group (Figs. 5 and 6).

DiscussionThere are multiple case reports of ceramic head

fractures in the literature with all generations of ceramic[8,10,13,14,17,18,27,28]. The incidence has declinedover the years, and the incidence with the newerceramics is estimated at around 1 in 5000 (0.02%) [29].Ceramic heads have been used with both ceramic as wellas polyethylene acetabular liners, and ceramic headfractures have been reported with both bearing surfaces,although the incidence of ceramic head fracture with

346 The Journal of Arthroplasty Vol. 25 No. 3 April 2010

ceramic-on-ceramic bearings is slightly higher than withceramic-on-polyethylene couples [9].The factors related to an increased fracture risk can be

related to the implant, surgical errors, or trauma. Thegrain size of ceramic is a well-known factor related to theincidence of fracture. Implant malpositioning has alsobeen implicated as a cause of fracture due to edge loadingand impingement [9,11]. Direct trauma and impact sportshave been reported to lead to fracture but never provenconclusively [9,12,14,16,30]. Surgical factors include amismatch between the trunion and the head creatingundue hoop stresses in the ceramic head [11,31]. Inaddition, impacting the ceramic head on the trunion withexcessive force leads to very high stresses in the head andcan lead to fracture.Fractures have been reported in the literature both at

short-term and long-term follow-up after THA. It hasbeen postulated that the first peak in incidence is due tomismatch between the head and the trunion, and thesecond peak is related to repetitive stress and fatiguefailure of the ceramic material.There are several reports on catastrophic wear and

osteolysis after revision for ceramic head fracture [19-23].Most of these have reported catastrophic failure ofstainless steel and cobalt-chromium heads after revision[6,19-22]. The main reason for failure in most of thesereports is an inadequate synovectomy and failure toremove all ceramic particles. When a ceramic fractureoccurs, it fragments into multiple particles of varying size[19]. The larger fragments are easy to remove, but thesmaller fragments are embedded into the soft tissuesaround the hip. Because these particles may not be visibleto the naked eye, removing them completely is verydifficult [20]. Moreover, trying to do an adequate anteriorsynovectomy via a posterior approach and vice versa isvery difficult technically. The importance of a thoroughsynovectomy has previously been stressed by multipleauthors, but none have described their technique.The only larger series on the results of revision THA for

ceramic head fracture was a multicenter retrospectivereview of 105 cases [22]. The results in the series weredissappointing due to a high rerevision rate. Overallsurvivorship was 63% at 5 years. There was a highrevision rate due to implant loosening (20 cases), asepticloosening (8 cases), infection (4 cases), and refracture of aceramic head (1 case). In addition, there was radiographicevidence of cup loosening and stem loosening in 21% ofpatients. Overall, 27.6% of revisions in this series couldbe directly attributed to ceramic head fracture andsubsequent inadequate synovectomy. There was also acase of 1 refracture of ceramic reported in the same series.This was attributed to putting a new ceramic head on adamaged trunion creating uneven force distributionwithin the ceramic material. Overall, the authorsreported the best results with a cobalt-chromium headand the worst results with a stainless steel head. There are

very few case reports showing a good outcome afterrevision THA for ceramic head fracture [16]. Moreover,the follow-up in these reports is very short.Our study has a few limitations. The number of patients

with head fracture is very small; this is because the veryincidence of ceramic head fracture is very low. Theselection of the control group may not be ideal, but wehave tried to match the patient and implant variables inboth groups as much as possible. The validity of ourmatching has been confirmed by a biostatistician.Although the excellent results that we are reporting

for revision of a ceramic head fracture with a metal onpolyethylene bearing surface is in contrast to mostreports on this subject in the literature, we believe thatthere may be better options at the present time. Ingeneral, the preference should be to put in a hardermaterial at the time of revision surgery compared to theinitial bearing. In that case, even if some ceramicparticles are inadverantly left behind, the newer bearingsurface will be more resistant to wear. Newer ceramics(biolox delta) against a similar ceramic acetabularsurface will be the ideal bearing surface for revision ofa fractured ceramic component made of biolox forte.Other options include the availability of newer ceramicheads with a built-in metal sleeve. It is now possible toreplace a broken ceramic head with a newer ceramicone with a sleeve, whereas this is ill-advised in anyother circumstance.It should be noted that a metal-on-metal bearing

surface is not an ideal choice for revision for ceramichead fracture because the hardness differential may posea risk of runaway metal wear and ion production.To our knowledge, this is the first study reporting on

the long-term results of revisions done for ceramichead fracture in the literature. We conclude thatrevision using a CrCo head on polyethylene with acomplete and thorough anterior and posterior syno-vectomy at the time of revision surgery can yieldfavorable results. It must be emphasized, however, thatthe key to the long-term success of any revision for aceramic head fracture is performing a thorough ante-rior and posterior synovectomy.

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