Revision Total Hip Arthroplasty for fractured ceramic bearings: a review of best practices for revision cases
- R. Rambani, D.M. Kepecs, T.J. Mäkinen, O.A. Safir, A.E. Gross, P.R. Kuzyk; United Lincolnshire Hospital UK &
University of Toronto, Canada
- The Journal of Arthroplasty (2017), doi: 10.1016/j.arth.2016.12.050. Article in press.
- Level of Evidence
- Not applicable (review).
Rambani et al. searched the available literature for the terms ceramic, fracture, total hip arthroplasty and revision and selected based on evidence level, bias and quality 199 articles out of 228 for their review. Alumina ceramic heads fractured after trauma but also during daily activities; most fractures occurred with 28mm diameter short necks. Ceramic liners had a different fracture mechanism compared to the femoral heads. Malalignment of the acetabular component and/or liner malpositioning were identified as the 2 risk factors for ceramic liner fracture. Only a very small number of fractures has been reported if alumina matrix composite heads were used.
Patients with fractured femoral heads usually present with impaired hip function, possible crunching noise and pain in the groin area. If the diagnosis of ceramic component fracture is confirmed revision should be performed urgently. According to the authors it is the key decision whether to retain or replace well-fixed implant components. This decision should be made taking into account all available factors, e.g. mechanism of fracture, component position, state of the metal components, etc. In any case a complete synovectomy should be performed to remove as many ceramic fragments as possible. If there is damage to the locking mechanism, general significant damage to the metal shell or if the component position is unacceptable, it should be revised. If the stem taper is significantly damaged it should also be revised. The use of a ceramic component with a titanium sleeve (BIOLOX®OPTION) should be reserved to cases with only moderate damage of the trunnion.
Regarding the right choice of bearing surface for revision after ceramic component fracture there is no consensus in the literature, though bearings with metal heads have been shown to be associated with poorer results and even death. Ceramic-on-ceramic and ceramic-on-polyethylene bearings seem to reduce the risk of third body wear as the most recent publications have shown, with no evidence of superiority yet.
Rambani et al. concluded that revision for a fractured ceramic component is a challenging operation and a complete synovectomy and thorough debridement is mandatory. Femoral and acetabular components should rather be removed if there is damage to the components or if they are malpositioned. For revision ceramic-on-ceramic or ceramic-on-polyethylene bearings should be used due to concerns with third body wear and adverse reactions to metal particles and ions. If the femoral stem is retained a fourth-generation ceramic head with titanium sleeve should be used. Whenever possible metal head bearings should be avoided.
- Review article, summary of current knowledge.
- Several outdated articles using old technology included.
- No differentiation between various generations of ceramics.
- Revision THA for a fractured ceramic component is challenging and a complete synovectomy is mandatory.
- Extremely low number of head fractures with alumina matrix composite to date.
- Femoral and acetabular metal components should be removed if they are damaged or malpositioned. Whenever possible bearings with ceramic components should be used.