Abstract
Introduction
Alumina Ceramic liners are increasingly used in patients undergoing Total Hip Replacement (THR). The rate of fracture of ceramic liner is decreasing with improved manufacturing techniques from 1st to 3rd generation alumina-ceramic liners. We report the first case of a fracture of a modern, 4th generation alumina bearing ceramic liner, which incorporates a metal sheath to help avoid fracture. Our case is a 60 years old female presenting two years and three months after a bilateral total hip replacement using Stryker Trident cup, securfit stem and alumina on alumina bearing ceramic liner. Ceramic liners are commonly used, especially in young patients because of their excellent biocompatibility, low wear rate and superior tribology. Although fracture of ceramic liner is a less common complication of modern total hip arthroplasty, it is a major concern with the use of ceramic on ceramic THR, the reason being brittleness of ceramic. Cases of 3rd generation ceramic liner fracture have been reported which might be associated with impingement due to excessive anteversion of the socket in Asian patients who habitually squat. Habitual squatting, sitting cross legged and kneeling were not characteristic of this case.
Methods
The patient presented with complains of mechanical grinding in left hip. She also reported a past history of clicking sound from left hip on extension of left hip and long stride gait. There was no history of trauma or fall. On examination she had a nonantalgic gait and left hip had audible and palpable crepitations. The range of motion on left hip was intact with no subluxation. Right hip was symptom free and examination did not detect any abnormalities.
Evaluation & Results
Radiographs of left hip revealed eccentric positioning of the head [Fig. 1] within the socket and excessive anteversion of the socket, which likely caused edge-loading in extension, leading to catastrophic failure in form of fracture of ceramic liner on left hip. She was treated with revision surgery using polyethylene liner with metal head. Intra-operative findings confirmed the ceramic liner fracture [Fig. 2] and revealed impingement of the metal neck against the metal rim of the liner.
Discussion & Conclusion
Although ceramic on ceramic hips have excellent wear properties, it is subject to fracture due to its brittle nature. This can lead to catastrophic failure with edge loading. In this case, the alumina-ceramic liner fractured; despite of being surrounded by a metal rim to prevent fracture. It fractured at the anterior edge, which is where it was loaded in extension. We believe that careful attention must be paid not only to inclination, but version of the socket, so as to avoid this complication. Other factors which might lead to such complication are obesity, high activity level, improper manufacturing teachniques for ceramic liners and entrapment and impingement of a micromm sized foreign body between ceramic liner and prosthetic head which initiates wear.
