Symptomatic cobalt toxicity from a failed total
hip replacement is a rare but devastating complication. It has been reported
following revision of fractured ceramic components, as well as in
patients with failed metal-on-metal articulations. Potential clinical
findings include fatigue, weakness, hypothyroidism, cardiomyopathy,
polycythaemia, visual and hearing impairment, cognitive dysfunction,
and neuropathy. We report a case of an otherwise healthy 46-year-old
patient, who developed progressively worsening symptoms of cobalt
toxicity beginning approximately six months following synovectomy
and revision of a fractured ceramic-on-ceramic total hip replacement
to a metal-on-polyethylene bearing. The whole blood cobalt levels
peaked at 6521 µg/l. The patient died from cobalt-induced cardiomyopathy.
Implant retrieval analysis confirmed a loss of 28.3 g mass of the
cobalt–chromium femoral head as a result of severe abrasive wear
by ceramic particles embedded in the revision polyethylene liner.
Autopsy findings were consistent with heavy metal-induced cardiomyopathy. We recommend using new ceramics at revision to minimise the risk
of wear-related cobalt toxicity following breakage of ceramic components. Cite this article: Bone Joint J 2013;95-B:31–7.

Fatal cardiomyopathy after revision total hip replacement for fracture of a ceramic liner

AimsCeramic-on-ceramic (CoC) bearings in total hip arthroplasty (THA) are commonly used, but concerns exist regarding ceramic fracture. This study aims to report the risk of revision for fracture of modern CoC bearings and identify factors that might influence this risk, using data from the National Joint Registry (NJR) for England, Wales, Northern Ireland and the Isle of Man.Patients and MethodsWe analysed data on 223 362 bearings from 111 681 primary CoC THAs and 182 linked revisions for bearing fracture recorded in the NJR. We used implant codes to identify ceramic bearing composition and generated Kaplan-Meier estimates for implant survivorship. Logistic regression analyses were performed for implant size and patient specific variables to determine any associated risks for revision.ResultsA total of 222 852 bearings (99.8%) were CeramTec Biolox products. Revisions for fracture were linked to seven of 79 442 (0.009%) Biolox Delta heads, 38 of 31 982 (0.119%) Biolox Forte heads, 101 of 80 170 (0.126%) B...

Ceramic on ceramic bearing fractures in total hip arthroplasty : an analysis of data from the national joint registry

Ceramic on ceramic (CoC) bearings in total hip arthroplasty (THA) are commonly used but concerns exist regarding ceramic fracture. This study aims to report the risk of revision for fracture of modern CoC bearings and identify factors that might influence this risk, using data from the National Joint Registry.We analysed data on 111,681 primary CoC THA's and 182 linked revisions for bearing fracture recorded in the National Joint Registry of England, Wales, Northern Ireland and the Isle of Man (NJR). We used implant codes to identify ceramic bearing composition and generated Kaplan-Meier estimates for implant survivorship. Logistic regression analyses were performed for implant size and patient specific variables to determine any associated risks for revision.99.8% of bearings were CeramTec Biolox® products. Revisions for fracture were linked to 7 of 79,442 (0.009%) Biolox® Delta heads, 38 of 31,982 (0.119%) Biolox® Forte heads, 101 of 80,170 (0.126%) Biolox® Delta liners and 35 of 31,258 (0.112%) Biolox®...

Ceramic-on-ceramic bearing fractures in total hip arthroplasty: an analysis of data from the national joint registry

Hydroxyapatite Ceramic Coated Hips (HAC) were first used in Sunderland, U.K. in May 1988. More than 1725 HAC hips have been inserted. There are 264 hips in 237 patients with ceramic/ceramic (alumina) bearings. These hips are inserted into patients with a 20+ year life expectancy. Their mean age is 50.5 years. All patients are assessed using the Harris Hip Score pre. and postoperatively. There are 14 patients with Harris Hip Scores of less than 80, but only 8 patients have problems attributable to HAC hip surgery. These include 1 patient with infection, 3 fractured ceramic acetabular liners, one broken ceramic head, 2 with aseptic loosening and 1 patient who chronically dislocated her hip. Amongst the indications were osteoarthritis 136, hip dysplasia 44, and ankylosing spondylitis 13. Twenty six had had previous childhood hip disorders, and 16 had rheumatoid arthritis. The series also includes 4 revisions from cemented hip replacement. The results have been rewarding. There are 1700+ HAC hips in the whole series. This sub group of 264 ceramic/ceramic HAC hips is small and follow up is relatively short. There have been few failures which could be attributed to the HA coated device. However, there are 4 broken ceramic components. Conclusion: Hydroxy Apatite bony bonding secures the implants. No polyethylene is used which can contribute to debris disease. Wear in ceramic bearings will be negligible. Third body inclusions must be avoided. The femoral spigot must not impinge on the acetabular margin. The ceramic material has to be supported to prevent fracture.

Ceramic on ceramic bearings in total hip arthroplasty

The use of ceramic femoral heads in total hip arthroplasty is increasing.[1][1] This is partly a result of good wear characteristics when articulated against ceramic or highly crosslinked polyethylene (PE) liners, and because modern ceramics allow the use of larger femoral heads without increased

Ceramics in total hip arthroplasty: a bearing solution?

Fracture of a ceramic component in total hip replacement is a rare but potentially catastrophic complication. The incidence is likely to increase as the use of ceramics becomes more widespread. We describe such a case, which illustrates how inadequate initial management will lead to further morbidity and require additional surgery. We present the case as a warning that fracture of a ceramic component should be revised to another ceramic-on-ceramic articulation in order to minimise the risk of further catastrophic wear.

P. Coward

Papers

Fracture of a ceramic component in total hip replacement