Adverse local tissue reaction after 2 revision hip replacements for ceramic liner fracture: A case report

Abstract

Introduction: In younger patients, ceramic-on-ceramic (CoC) bearing surfaces are usually recommended for total hip replacement (THR) because of their low wear rate and longer expected functional life. Although technical advancements have reduced the risk of ceramic bearings fracture, this complication remains a major concern.

Case description: We present the case of a 56-year-old patient undergoing 3 revision hip arthroplasties of the right hip due to ceramic liner fractures. Initial THR (2008) was performed with a CoC bearing, followed by liner fracture due to trauma a year later. The acetabular component and liner were replaced, with a minor incongruence between the old head and new insert. The 2nd ceramic insert fractured 3.5 years later, following minor trauma. Upon revision, the bearing surface was changed to metal-on-polyethylene (MoP). The performed retrieval analysis demonstrated stripe and rim wear, and evidence of adhesive wear. The patient was referred to us a month later, with a fistula on the lateral side of the hip, discharging black, petroleum-like liquid. Radiology showed well-fixed implants, no dislocation and no apparent polyethylene wear. Microbiological assessment of the discharge showed no infection. Intraoperatively massive metallosis was noticed, with stable acetabular and femoral components. The metal femoral head was heavily abraded, with almost 1% volumetric wear. Hematoxylin and eosin stained frozen tissue samples showed muscular and adipose tissue necrosis, while polarized light microscopy highlighted metal, polyethylene, and ceramic particles.

Conclusion: The present case is yet another report showing the adverse outcomes of using MoP bearings for revision after ceramic liner fracture in THR.

Figure 1

Timeline of interventions and outcomes.

Figure 2

(A) Lateral aspect of the right hip, showing a healed postoperative scar with a fistula in its middle part, discharging a black, petroleum-like liquid. (B) Intraoperative aspect of the right hip after incision of the deep fascia – metallosis was confirmed by the presence of a black colored fluid and darkly pigmented soft tissues around the hip. (C) The retrieved femoral head and some of the ceramic fragments. The metal femoral head shows multiple scratches and is severely abraded. (D) Intraoperative aspect of the right hip showing a stable acetabular component.

Figure 3

(A) Preoperative antero-posterior radiograph of the pelvis, showing adequately aligned, well-fixed components, no signs of wear or loosening, but evident “bubble sign” (deposited metallic debris outlining the joint space, creating bubble-like hyperdensities). (B) Follow-up antero-posterior radiograph of the pelvis at 7 months postoperatively showing good implant alignment and no sign of loosening or metallosis. (C) Antero-posterior radiograph of the pelvis at 31 months postoperatively showing stable components and no signs of osteolysis, loosening, or metallosis.

Figure 4

(A) Foreign body granuloma: inflammatory focus with a central multinucleated giant cell with intracytoplasmic polyethylene (white arrow) and ceramic particles (colored in black, black arrow). The same particles are also found in the surrounding macrophages (hematoxylin and eosin [HE], ×200). (B) Blackish interstitial deposits of ceramic particles (black arrows) without birefringence in polarized light microscopy compared to the neighboring birefringent polyethylene particles (white arrow) (HE, ×200, polarized light). (C) Ischemic necrosis lesions of striated muscle surrounded by granulation tissue containing rare macrophages. Intracytoplasmic blackish ceramic particles (black arrows) can be identified in the macrophages (HE, ×40).