Fourth-generation Ceramic Head Fracture in Total Hip Arthroplasty: A Case Report and Literature Review

Abstract

Ceramics are used in total hip arthroplasty due to inherent wettability and low wear rates, but fracture risk is a known complication. Rates as high as 13.4% were reported in the past, yet as low as 0.02% in newer generations. Howard et al. reported a fracture rate of 0.009% for fourth-generation ceramic heads. We present a case report of a 69-year-old male with a BMI of 40.01 kg/m² who suffered a fracture of a 36-mm ceramic femoral head with pseudoacetabular involvement of the polyethylene liner. This occurred 2 years and 3 months after his primary surgery after a 4-foot fall off of a ladder. The patient underwent revision of his total hip arthroplasty with arthroplasty of the polyethylene liner and femoral head component without stem explantation.

Introduction

Bearing choice is a crucial aspect of total hip arthroplasty (THA), consisting of 4 configurations: (1) metal-on-polyethylene, (2) metal-on-metal, (3) ceramic-on-ceramic, and (4) ceramic-on-polyethylene. Ceramic bearings were introduced to reduce wear, limit osteolysis, and improve longevity of hip arthroplasties [1,2]. First-generation fracture rates were up to 13.4%, while fourth-generation ceramics rates were as low as 0.001% [[3], [4], [5], [6]]. Named the BIOLOX Delta ceramic (CeramTec, Plochingen, Baden-Württemberg, Germany), this fourth-generation ceramic commercialized in 2000 is composed of alumina, zirconia, strontium oxide, and chromium oxide [[7], [8], [9], [10]].

With advancements in material composition and manufacturing techniques, each subsequent generation of the BIOLOX system has aimed to enhance wear resistance, fracture toughness, and minimize overall complications. First-generation implants were characterized by larger material grains and less refined manufacturing processes. The introduction of hot isostatic pressing, along with a reduction in grain size in third-generation implants, resulted in a significant decrease in implant fracture rates and an almost 100% 10-year survival rate. The latest generation, BIOLOX Delta, incorporates a zirconia-alumina composite, further refining the design and performance of the implant [11,12].

Despite these improvements, fourth-generation ceramic femoral head fractures, albeit rare, still occur and can result in damage to the trunnion, acetabular shell, or femoral stem. The main risk factors for ceramic head fractures are obesity, high activity level, trauma, small ball diameter, poor manufacturing techniques, and poor surgical technique [13].

This case report describes a traumatic fracture of a BIOLOX Delta ceramic femoral head 2 years and 3 months after the index surgery. The intent to publish was discussed with the patient and written informed consent was obtained.

Case history

A 67-year-old male underwent left primary THA for severe hip osteoarthritis. The patient had several medical comorbidities including obesity (body mass index 39.3 kg/m²), chronic obstructive pulmonary disease, history of deep vein thrombosis, hypertension, and Parkinson’s disease. Left THA was performed via a posterior approach without complications. The implants consisted of a BIOLOX Delta ceramic femoral head with 36 mm diameter and 5 mm length, Stryker polyethylene 36 mm liner, Stryker Accolade II size 7 127^o stem, and a Stryker Trident 56 mm acetabular shell (Stryker Corporation, Kalamazoo, MI, 49002; www.stryker.com). At 2 years and 3 months after the index procedure, the patient sustained a 4-foot traumatic fall from a ladder onto the contralateral hip and buttock. He presented to his family practitioner 1 week later complaining of back pain and ambulating with a limp. Radiographs demonstrated ceramic head fracture with several fragments extruded to the region of the greater trochanter, read as an “atypical appearance involving the femoral head component which may be related to revision or hardware failure” (Fig. 1). On radiographs, the femoral stem and acetabular component remained in acceptable position without evidence of osteolysis or failure. He presented to an outside hospital emergency department that same day for low back pain and was subsequently discharged with a diagnosis of lumbar radiculopathy.

Figure 1.

AP left hip showing obvious deformity of the femoral head, well-positioned acetabular cup, and stable appearing femoral stem. AP, anteroposterior.

It was not until the initial surgeon (senior author, M. S. K.) was contacted by the patient’s primary care physician that the severity of the condition was recognized, prompting the patient’s admission to our hospital, 9 days after the injury. Physical examination revealed intact neurovascular status and a well-healed posterior approach surgical scar without signs of infection. The patient denied pain with passive range of motion of the hip, antecedent hip or thigh pain, clicking, or stiffness; no other injuries were present. He was kept nonweight-bearing on the affected side and indicated for revision surgery.

Surgical exposure of the hip revealed 2 large fragments of the ceramic femoral head in the acetabular cup. Several smaller fragments of ceramic material extruded from a defect in the capsule into the greater trochanteric bursal area with surrounding areas of metallosis (Fig. 2). All detected fragments were removed and the hip was thoroughly irrigated with copious sterile saline solution, mineral oil, ultrasound gel, and dilute betadine solution to aid in removal of fragments (Fig. 3). An extensive synovectomy was performed to remove any remaining fragments and prevent the risk of third body wear.

Figure 2.

Intraoperative photograph demonstrating metallosis and scattered debris.

Figure 3.

The femoral head was broken into 2 major fragments with several smaller pieces. The polyethylene liner was being eroded by the exposed trunnion but remained intact.

After the particles were removed, the polyethylene liner and acetabular cup were evaluated. The polyethylene liner showed signs of damage from weight-bearing, with the exposed trunnion articulating directly with the liner, effectively acting as a pseudoacetabulum. The acetabular metal shell remained intact. Appearing as a small, slightly angled protrusion at the head-neck interface, the trunnion, alongside the femoral stem, showed no visible defects. Given the stability and proper positioning of the stem, along with the potential morbidity associated with explanting it, the femoral stem was not revised. Provided this increased risk, and no macroscopic damage but unknown microscopic trunnion damage, conservative measures were taken by placing a BIOLOX taper sleeve trunnion adapter alongside a new polyethylene liner was inserted and was implanted with a BIOLOX Delta 36 mm (−2.5 mm length) ceramic head. The hip was reduced, concentric and stable without impingement. The patient’s wound was irrigated and closed. Patient was weight-bearing as tolerated, transferred to the floor, and discharged home the following morning. Postoperative radiographs were satisfactory (Fig. 4). The patient had an uneventful recovery, evaluated at 2 and 6 weeks postoperatively.

Figure 4.

AP pelvis radiograph postoperative day. AP, anteroposterior.

Follow-up

The patient was lost to follow-up initially after the postoperative timeframe but was seen more than 3 years later. At this time, he reports no complications or complaints from the procedure and has been ambulating since his postoperative recovery period. Physical examination reveals full range of motion with no associated pain. Radiographs indicated revision hardware positioning to be well maintained with no evidence of loosening or recurrence of implant fracturing (Fig. 5).

Figure 5.

AP pelvis and lateral left hip radiographs at 3 years of follow-up show components have maintained adequate positioning and no evidence of hardware loosening. AP, anteroposterior.

Discussion

Ceramic bearing fractures are a known but rare complication. One of the first reported BIOLOX Delta ceramic femoral head fractures reported in the literature occurred in a 45-year-old female after a traumatic event [14]. This case report adds to the existing literature of ceramic head fractures, as described in Table 1 [[14], [15], [16],[18], [19], [20],23], with a ceramic femoral head fracture 2 years postoperatively, reporting a detailed description, photographs of intraoperative findings, and management.

Table 1.

Prior case reports demographics, index, and revision procedures.

					Index procedure						Revision procedure
Authors	Year	Age	Sex	BMI	Reason for index surgery	Approach	Articulation	Acetabular components	Head size (mm)	Femoral components	Time from index surgery (mo)	Activity leading to revision	Articulation	Head size (mm)	Revision components	Retained components
Hungerford et al. [15]	2023	68	F	NR	NR	NR	CoC	48 mm acetabular shell, 18.8o anteversion, 66o inclination	28	Stryker stem, size #7	204	Atraumatic	NR	NR	Stryker BIOLOX dual mobility vitt E 42 mm/28 mm/E	NR
Patetta et al. [16]	2022	45	M	NR	Avascular necrosis	Posterolateral	NR	MDM, 28 mm inner diameter, 48 mm outer diameter, cobalt-chromium liner, 54 mm titanium acetabular shell	28	Stryker Accolade 2 stem, size #6, 132o neck angle	54	Ground-level fall	CoP	28	BIOLOX delta 28 + 0, Stryker universal titanium taper adapter, restoration MDM poy liner	NR
Duensing et al. [17]	2021	83	M	26.7	Primary hip osteoarthritis	Standard posterior	NR	56 mm Trident PSL shell, 32o inclination	40	Stryker Accolade 2 stem, size #6, varus neck angle	60	Atraumatic community ambulation	NR	NR	Modular splined-tapered revision stem (RECLAIM Modular revision stem, DePuy)	NR
Valentini et al. [18]	2020	58	M	NR	Revision for metallosis and foreign body reaction after primary total hip replacement for hip osteoarthritis	NR	CoP	36 mm inner diameter, 54 mm acetabular shell, 32o anteversion, 44o inclination	36	DePuy S-ROM total hip system	72	Skiing	NR	NR	NR	NR
Rankin et al. [19]	2019	52	M	26	Primary hip osteoarthritis	NR	CoP	32 mm inner diameter, 52 mm Trident Tritanium shell	32	Stryker cemented V40 Exeter stem, size #1, 50 mm offset	8	Traumatic fall with unremarkable radiographs, 1 month later he noticed a sudden sharp pain and sensation of grinding following swimming	CoC	32	Cement-in-cement revision with a new 50 mm offset, no. 1 Exeter stem	Metal shell
Kocadal et al. [20]	2019	52	F	34.3	Hx femoral osteotomy 35 years prior from developmental dysplasia	NR	CoC	52 mm Trident Tritanium shell, 14o anteversion, 43o inclination	32	NR	192	Atraumatic	CoC	32	NR	Cup, stem, and the ceramic liner
Pomeroy et al. [21]	2015	41	M	26.6	Primary hip osteoarthritis	Anterolateral	CoP	54 mm G7 high wall shell	32	Biomet Taperloc 13 × 146 high offset type 1	< 1	Atraumatic. Reported to 6-week f/u appointment and radiographs showed fracture of the ceramic head	CoC	32	NR	Stem and cup
Tucker and Acharya [22]	2014	68	M	NR	Primary hip osteoarthritis	Posterior	CoP	28 mm inner diameter, 58 mm Zimmer acetabular shell	28	Zimmer CPT size #3, 7 mm neck, 6o taper	168	Atraumatic	CoC	36	Zimmer CPT size #1 stem, 36 mm femoral head, 60 mm/36 mm BIOLOX shell	NR
Heiner and Mahoney [14]	2014	45	F	NR	Osteoarthritis secondary to femoral dysplasia	NR	CoP	35 mm inner diameter, 52 mm Pinnacle AltrX acetabular shell	36	DePuy S-ROM total hip system	18	Bicycle accident occurred 2 months prior to presentation	CoP	NR	Same company, design, and size as index	NR

BMI, body mass index; CoC, ceramic-on-ceramic; CoP, ceramic-on-polyethylene; F, female; f/u, follow-up; M, male; NR, not reported; MDM, modular dual mobility.

Prior case reports and series have shown traumatic and atraumatic fracturing of BIOLOX ceramic heads over time, ranging from immediately following a ground-level fall to degeneration over the course of years [16,19,23]. In a similar case study, a patient with a THA fitted with a 32 mm BIOLOX ceramic head fell at 8 months postoperatively; he ambulated immediately afterward and imaging obtained by his surgeon within 1 week of the fall were unremarkable [19]. One month later, the patient returned to the emergency department unable to ambulate due to sharp pain, resulting in a revision THA to replace the multifragmented head [19]. Similarly, a 45-year-old female suffered a bicycle accident 2 months prior to presentation, resulting in fracture of the 36 mm BIOLOX head [14]. These cases of delayed ceramic head fragmentation are demonstrative of “slow crack growth” or “subcritical crack growth” phenomena [14,19].

As the generations of ceramic femoral implants continue to become more well refined, its associated benefits over that of its metallic counterparts become apparent. With decreased wear of the polyethylene liner and high wettability creates a favorable wear environment; therefore, utilization of a ceramic head was chosen over that of a metal head implant [11]. With the primary concern surrounding metal femoral head implants being that of debris generation from the articular surface resulting in joint failure [12,24].

The patient in the current case had a unique mechanism of injury. He fell off a ladder approximately 4 feet and landed on the contralateral hip. Another case of unusual impact occurred with a revision THA using a 40 mm BIOLOX head; the head split in 2 upon a single blow of impaction, hypothesized to be the result of unseen trunnion damage or trunnionosis [23]. Patetta et al. reported a case of a 28 mm BIOLOX head fracture following a ground-level fall [16]. The patient had an uncomplicated right THA and developed insidious onset of right hip pain 28 months after surgery and did not follow-up for a period of 4.5 years. At which point, he fell and was unable to ambulate [16]. Other cases demonstrated head fragmentation 1 and 2 decades postoperatively following the sudden onset of atraumatic hip pain, hypothesized to have resulted from acetabular cup angulation or hybrid articulation [5,15].

Prior review articles examining ceramic head implants with associated patient demographics, component compositions, accompanying complications, and reasons for revision are noted in Table 2, Table 3, Table 4. Lucchini et al., in a multicenter retrospective study of 29,495 THA, reported only 2 ceramic femoral head fractures at a fracture rate of 0.007%, within the range (0.001%-0.009%) reported in the literature for fourth-generation ceramics [26,54]. These 2 fractures occurred with 36 mm BIOLOX Delta femoral head components. Due to the multifragmentation, a centralized fracture origin could not be determined. However, the authors hypothesized that these occurred in a multistage crack growth mechanism from damage sustained to the head-neck interface, presenting a potential area of redesign for future ceramic implantation generations [54]. Howard et al. reported the largest independent study of CoC fractures to date, noting a 0.009% fracture rate, with smaller fractured heads and patients with high body mass index [42]. These associated patient and implant parameters can be used to evaluate overall risk and likelihood of a ceramic fracture in the future as well as develop a differential diagnosis for postoperative THA patients with hip pain.

Table 2.

Prior large review papers on ceramic total hip arthroplasty–patient demographics.

Authors	Year	Type of study	Articulation	Total # of hips	Patients (M/F/total)	Age (y) Mean ± SD [minimum-maximum]	BMI Mean ± SD [minimum-maximum]	Follow-up (mo) Mean ± SD [minimum-maximum]
Park et al. [25]	2023	Prospective therapeutic, level II	CoC	85	44/27/71	25.9 [16-29]	22.9 [17-38.8]	123.6 [2-156]
Lucchini et al. [26]	2022	Multicenter retrospective	CoC	29,495	11,432/14,969/26,401	65.8 [11-96]	NR	62.4 [1.2-187.2]
Blumenfeld et al. [27]	2022	Randomized control trial	CoC 28	104	57/47/104	56.9 ± 8.99	30.7 ± 6.6	117.6 ± 15.48
			CoC 36	81	40/41/81	59.5 ± 9.35	29.1 ± 5.9	124.8 ± 8.52
Logroscino et al. [28]	2022	Retrospective	COM Proxima Stem	19	10/9/19	71.97 ± 9.39	27.91 ± 6.5	97 ± 16.15
			COM Metha	25	17/8/25	64 ± 9.51	27.78 ± 3.2	131.6 ± 10.05
Alshammari et al. [29]	2023	Retrospective	CoC	273	69/165/243	50 [14-71]	NR	144 [120-216]
McCarthy et al. [11]	2022	Retrospective	Fourth-generation CoC	117	NR	NR	NR	NR
			Mixed-generation CoC	3	NR	NR	NR	NR
Van Loon et al. [30]	2021	Retrospective	CoP	27	6/21/27	64.2	27.6	NR
			CoC	34	12/22/34	55.7	26.9	NR
Kim et al. [31]	2021	Multicenter retrospective, level III	CoC	54	28/26/54	62 ± 15.8	24 ± 14.2	76 ± 14.2
Davis et al. [32]	2021	Multicenter prospective	CoC	178	60/115/175	63.4 ± 9 [27-75]	28.3 ± 5 [19-44.4]	84
Castagnini et al. [33]	2020	Multicenter retrospective	Delta head, Forte liner	346	163/183/346	65.4	NR	76.8
			Delta head, Delta liner	21,874	9384/12,490/21,874	66	NR	46.8
Hallan et al. [6]	2020	Multicenter retrospective	CoP	5912	NR	63 [11-98]	NR	NR
			CoC	1989	NR	61 [17-95]	NR	NR
Henri Bauwens et al. [34]	2020	Retrospective	CoC	116	55/51/106	55.3 ± 11.3 [23.3-76.8]	25.8 ± 4.4 [17.7-39.3]	31.9 ± 5.5 [24-42.5]
Lee and Yoon [35]	2020	Retrospective	CoC	133	83/50/129	55.5 ± 11.3	23.8 ± 3.8	50.4 ± 22.8
Lee et al. [36]	2019	Prospective	CoC	86	44/28/72	25.9 [16-29]	22.6 [13-38.8]	NR
Cho et al. [37]	2019	Retrospective	CoC	263	175/67/242	53.6 [23-84]	23.8 [16.6-32.2]	62.4 [24-78]
Kim et al. [38]	2019	Multicenter retrospective	CoC	292	123/111/234	50.5 [18-83]	23.5 [16.8-37.9]	66 [60-88.8]
Solarino et al. [39]	2019	Retrospective	CoC	23	NR	NR	NR	NR
Blakeney et al. [40]	2018	Retrospective	CoC	276	96/150/246	53.8 ± 10.3 [16-73]	27.2 ± 4.9 [16.2-41.7]	66.5 ± 6.9 [48-78.5]
Lim et al. [41]	2018	Retrospective	CoC	749	315/352/667	54.2 ± 14.7 [16-88]	24.2 ± 3.2 [15.4-37.7]	78 [60-84]
Howard et al. [42]	2017	Multicenter retrospective	CoC	79,442	NR	NR	NR	NR
Kim et al. [43]	2017	Retrospective	CoC	334	143/134/227	48.2 ± 11.3	28.9 ± 10 [27.2-34.6]	157.2 [120-168]
Salo et al. [44]	2017	Retrospective	CoC	336	110/191/301	61 [29-78]	28.5 [19-53]	25.6 [16-41]
Lee et al. [45]	2017	Prospective	CoC	286	144/108/252	49.7 [16-83]	24.6 [17-37.7]	66.5 [60-84]
Hamilton et al. [46]	2015	Randomized control trial	CoC 28	177	90/87/177	56.4 ± 10.6	30 ± 6.3	62.4 ± 19.2
			CoC 36	168	91/77/168	57.3 ± 11	29 ± 6.4	64.8 ± 15.6
Baek et al. [47]	2015	Retrospective	CoC	100	47/44/91	55 ± 14	23 ± 3	60 ± 3.6 [60-72]
Tai et al. [48]	2015	Retrospective	CoC	206	77/118/195	69 [38.1-93]	NR	NR
Varnum et al. [49]	2015	Multicenter retrospective	CoC	1773	938/835/1773	NR	NR	NR
McDonnell et al. [50]	2013	Retrospective	CoC	208	67/141/208	59 [22-84]	27.5 [19-50]	21 [12-35]
Cai et al. [51]	2012	Randomized control trial	CoC	51	25/18/43	42.1 ± 10.5 [21-60]	24.6 ± 3.9 [17.9-33.1]	39.7 [36-44]
			CoP	62	27/23/50	42 ± 10.6 [20-59]	24.8 ± 4.1 [18.1-36.7]	40.3 [36-45]
Hamilton et al. [52]	2010	Multicenter randomized control trial	CoC	177	90/87/177	56.4	NR	31.1 [21-49]
			CoP	87	47/40/87	57.3	NR	31.5 [21-49]
Lombardi et al. [53]	2010	Randomized control trial	CoC	64	35/29/64	57 [33-76]	29.9	73 [26-108]

BMI, body mass index; CoC, ceramic-on-ceramic; CoP, ceramic-on-polyethylene; F, female; M, male; NR, not reported; SD, standard deviation.

Table 3.

Prior large review papers on ceramic total hip arthroplasty–preoperative diagnosis and implant information.

Authors	Year	Articulation	Total # of hips	Preoperative diagnosis	Approach	Femoral head	Femoral stem	Acetabular cup	Inclination (o) Mean ± SD [minimum-maximum]	Anteversion (o) Mean ± SD [minimum-maximum]
Park et al. [25]	2023	CoC	85	Osteonecrosis: 55 Femoral neck fracture: 2 Secondary arthritis: 26 Tumor: 2	Posterolateral: 85	NR	S-ROM: 1 Corail: 64 Bencox II: 3 Bencox ID: 2 Taperloc: 15	Pinnacle: 67 ABT Exceed: 15 Bencox: 3	40.8 [29-49]	25 [11-39]
Lucchini et al. [26]	2022	CoC	29,495	Osteoarthritis: 21,472 Rheumatoid arthritis: 206 Osteonecrosis: 1593 Dysplasia: 22,121 Femoral neck fracture: 3746 Other: 265	NR	NR	NR	NR	NR	NR
Blumenfeld et al. [27]	2022	CoC 28	104	Osteoarthritis: 94 Osteonecrosis: 2 Post-traumatic arthritis: 4 Other: 4	NR	BIOLOX Delta 28: 104	NR	Pinnacle: 104	NR	NR
		CoC 36	81	Osteoarthritis: 76 Osteonecrosis: 1 Post-traumatic arthritis: 1 Other: 3	NR	BIOLOX Delta 36: 81	NR	Pinnacle: 81	NR	NR
Logroscino et al. [28]	2022	COM Proxima Stem	19	Osteoarthritis: 18 Dysplasia: 1	Posterolateral – 19	BIOLOX Delta 36: 19	Proxima – 19	Pinnacle – 19	47.91 [40.2-60.1]	13.98 [4.42-22.33]
		COM Metha	25	Osteoarthritis: 17 Dysplasia: 8	Direct lateral: 25	BIOLOX Delta 36: 25	NR	Pinnacle: 25	52.14 [42.1-58.2]	6.49 [0.82-17.08]
Alshammari et al. [29]	2022	CoC	273	Osteoarthritis: 190 Congenital hip dislocation: 29 Rheumatoid arthritis: 13 Osteonecrosis: 17 JRA: 6 Other: 18	Direct lateral: 175 Posterior: 98	BIOLOX Delta 28: 50 BIOLOX Delta 32: 26 BIOLOX Delta 36: 197	TRI-Lock: 171 S-ROM: 64 Prodigy: 20 Corail: 15 Summit: 3	Pinnacle: 273	39.2 ± 7.1 [20.6-58.1]	14.9 ± 3.5 [5.9-24.3]
McCarthy et al. [11]	2022	Fourth-generation CoC	117	NR	NR	NR	S-ROM: 80 Corail: 35 Charnley: 2	Pinnacle: 116 Duraloc: 1	NR	NR
		Mixed-generation CoC	3	NR	NR	NR	S-ROM: 1 Charnley: 1 Exeter: 1	Trident: 2 Plasmacup-SC: 1	NR	NR
Van Loon et al. [30]	2021	CoP	27	Osteoarthritis: 23 Other: 4	NR	NR	NR	NR	NR	NR
		CoC	34	Osteoarthritis: 19 Other: 15	NR	NR	NR	NR	NR	NR
Kim et al. [31]	2021	CoC	54	Osteoarthritis: 14 Osteonecrosis: 18 Femoral neck fracture: 14 Other: 9	Direct lateral: 8 Anterolateral: 8 Posterolateral: 38	NR	NR	NR	NR	NR
Davis et al. [32]	2021	CoC	178	Osteonecrosis: 150 Osteonecrosis: 17 Dysplasia: 11	Anterolateral: 70 Posterolateral: 64 Posterior: 44	NR	R3: 178	R3: 178	NR	NR
Castagnini et al. [33]	2020	Delta head, Forte liner	346	NR	NR	NR	NR	NR	NR	NR
		Delta head, Delta liner	21,874	NR	NR	NR	NR	NR	NR	NR
Hallan et al. [6]	2020	CoP	5912	NR	NR	NR	NR	NR	NR	NR
		CoC	1989	NR	NR	NR	NR	NR	NR	NR
Henri Bauwens et al. [34]	2020	CoC	116	Osteoarthritis: 105 Dysplasia: 5 Femoral neck fracture: 4 Septic hip sequelae: 2	Anterior: 116	NR	Targos: 116	Cargos HAP: 116	44.9 ± 5 [30.6-60]	16.4 ± 3.7 [9-30]
Lee and Yoon [35]	2020	CoC	133	Osteoarthritis: 16 Rheumatoid arthritis: 6 Osteonecrosis: 75 Dysplasia: 14 Femoral neck fracture: 13 LCP Sequelae: 15 AS: 3	Direct lateral: 133	BIOLOX Delta 36: 133	TRI-Lock: 50 Summit: 83	NR	42.3 ± 5.3	24.2 ± 12
Lee et al. [36]	2019	CoC	86	Osteonecrosis: 55 Femoral neck fracture: 2 Secondary arthritis: 27 Other: 2	Posterolateral: 86	NR	NR	NR	NR	NR
Cho et al. [37]	2019	CoC	263	Osteoarthritis: 59 Osteonecrosis: 166 Femoral neck fracture: 25 Septic hip sequelae: 7 LCP sequelae: 6	Posterolateral: 79 Modified 2 incision: 184	NR	M/L Taper: 126 Fitmore: 137	Continuum: 263	37.39 [20.6-49.5]	20.7 [4.8-36.1]
Kim et al. [38]	2019	CoC	292	Osteoarthritis: 54 Rheumatoid arthritis: 9 Osteonecrosis: 155 Dysplasia: 47 Septic hip sequelae: 8 LCP sequelae: 12 Post-traumatic arthritis: 5 AS: 2	NR	BIOLOX Delta 32: 43 BIOLOX Delta 36: 249	Bencox: 292	Bencox: 292	42.1 ± 6.5 [28-58]	16.2 ± 6 [4-37]
Solarino et al. [39]	2019	CoC	23	NR	Direct lateral: 23	BIOLOX Delta 32: 3 BIOLOX Delta 36: 18 BIOLOX Delta 40: 1	NR	NR	NR	NR
Blakeney et al. [40]	2018	CoC	276	Osteoarthritis: 222 Osteonecrosis: 16 Dysplasia: 21 LCP sequelae: 7 Post-traumatic arthritis: 4 Inflammatory arthritis: 6	NR	NR	NR	NR	NR	NR
Lim et al. [41]	2018	CoC	749	Osteoarthritis: 325 Osteonecrosis: 369 Femoral neck fracture: 35 Inflammatory arthritis: 20	Anterolateral: 749	BIOLOX Delta 32: 227 BIOLOX Delta 36: 472	Bencox: 749	Bencox: 749	NR	NR
Howard et al. [42]	2017	CoC	79,442	NR	NR	NR	NR	NR	NR	NR
Kim et al. [43]	2017	CoC	334	Rheumatoid arthritis: 4 Osteonecrosis: 124 Dysplasia: 115 Femoral neck fracture: 6 Septic hip sequelae: 15 Ethanol associated: 69 Idiopathic steroid use: 44	Posterolateral: 277	BIOLOX Delta 32: 51 BIOLOX Delta 36: 283	Proxima: 334	Pinnacle: 344	42 [35-47]	21 [17-25]
Salo et al. [44]	2017	CoC	336	Osteoarthritis: 287 Dysplasia: 17 Post-traumatic arthritis: 26 Other: 6	Posterior: 336	BIOLOX Delta 32: 12 BIOLOX Delta 36: 222 BIOLOX Delta 40: 102	S-ROM: 13 Corail: 16 Summit: 101 M/L Taper: 184 Bimetric: 8 Anthology: 6 CDH: 3	Pinnacle: 130 ABT Exceed: 11 Continuum: 184 R3: 6	NR	NR
Lee et al. [45]	2017	CoC	286	Osteoarthritis: 28 Rheumatoid arthritis: 1 Osteonecrosis: 165 Femoral neck fracture: 6 AS: 6 Secondary arthritis: 80	Modified 2 incision: 286	BIOLOX Delta 32: 247 BIOLOX Delta 36: 39	Corail: 286	Pinnacle: 286	41.5 ± 4.1 [25-54]	26.4 ± 7.2 [10-46]
Hamilton et al. [46]	2015	CoC 28	177	Osteoarthritis: 155 Osteonecrosis: 12 Dysplasia: 5 Post-traumatic arthritis: 5 Other: 2	NR	NR	NR	Pinnacle: 286	NR	NR
		CoC 36	168	Osteoarthritis: 147 Osteonecrosis: 13 Dysplasia: 4 Post-traumatic arthritis: 2	NR	NR	NR	Pinnacle: 168	NR	NR

AS, Ankylosing spondylitis; CoC, ceramic-on-ceramic; CoP, ceramic-on-polyethylene; JRA, Juvenile rheumatoid arthritis; LCP, Legg-Calve-Perthes disease; NR, not reported; SD, standard deviation.

Table 4.

Prior large review papers on ceramic total hip arthroplasty–complications and revisions.

Authors	Year	Articulation	Total # of hips	Reason for revisions	Complications
Park et al. [25]	2023	CoC	85	Infection: 1 Periprosthetic fracture: 1	NR
Lucchini et al. [26]	2022	CoC	29,495	NR	Ceramic head fracture: 2
Blumenfeld et al. [27]	2022	CoC 28	104	NR	NR
		CoC 36	81	NR	NR
Logroscino et al. [28]	2022	COM Proxima Stem	19	NR	NR
		COM Metha	25	NR	NR
Alshammari et al. [29]	2022	CoC	273	Squeaking: 1 Infection: 2 Stem loosening: 1 Stem fracture: 2	NR
McCarthy et al. [11]	2022	Fourth-generation CoC	117	NR	NR
		Mixed-generation CoC	3	NR	NR
Van Loon et al. [30]	2021	CoP	27	NR	NR
		CoC	34	NR	NR
Kim et al. [31]	2021	CoC	54	NR	NR
Davis et al. [32]	2021	CoC	178	Total revision: 3	NR
Castagnini et al. [33]	2020	Delta head, Forte liner	346	NR	NR
		Delta head, Delta liner	21,874	NR	Ceramic head fracture: 3
Hallan et al. [6]	2020	CoP	5912	NR	NR
		CoC	1989	NR	NR
Henri Bauwens et al. [34]	2020	CoC	116	NR	Psoas impingement: 2 Squeaking: 3 Greater trochanter fracture: 3 Femoral stem wrong way: 1
Lee and Yoon [35]	2020	CoC	133	NR	NR
Lee et al. [36]	2019	CoC	86	NR	NR
Cho et al. [37]	2019	CoC	263	Infection: 1 Stem loosening: 1 Liner fracture: 1 Recurrent dislocation: 1	NR
Kim et al. [38]	2019	CoC	292	Stem loosening: 2 Periprosthetic fracture: 2	Dislocation: 1
Solarino et al. [39]	2019	CoC	23	NR	NR
Blakeney et al. [40]	2018	CoC	276	Infection: 1 Periprosthetic fracture: 1 Acetabular migration: 1	Sciatic neuropathy: 1
Lim et al. [41]	2018	CoC	749	NR	NR
Howard et al. [42]	2017	CoC	79,442	NR	Ceramic head fracture: 7
Kim et al. [43]	2017	CoC	334	Recurrent dislocation: 1	NR
Salo et al. [44]	2017	CoC	336	Infection: 1 Recurrent dislocation: 1 Periprosthetic fracture: 1	NR
Lee et al. [45]	2017	CoC	286	Liner fracture: 1 Periprosthetic fracture: 1	NR
Hamilton et al. [46]	2015	CoC 28	177	Infection: 2 Liner fracture: 1 Stem loosening: 2	Dislocation: 6
		CoC 36	168	Infection: 1 Liner fracture: 1 Stem loosening: 2	Dislocation: 3
Baek et al. [47]	2015	CoC	100	NR	NR
Tai et al. [48]	2015	CoC	206	Periprosthetic fracture: 2	Pulmonary embolism: 1 Dislocation: 1
Varnum et al. [49]	2015	CoC	1773	NR	Ceramic head fracture: 1
McDonnell et al. [50]	2013	CoC	208	NR	Dislocation: 1
Cai et al. [51]	2012	CoC	51	Infection: 1 Recurrent dislocation: 1	NR
		CoP	62	Recurrent dislocation: 1 Leg length discrepancy: 1 Acetabular migration: 1	NR
Hamilton et al. [52]	2010	CoC	177	Total revision: 4	Insertional chipped liner: 2 Femoral component loosening: 3 Intraoperative femur fracture: 5 Fracture: 2 Wound problem: 9 Deep infection: 2 Acetabular liner fracture: 2 Nerve damage: 1 Dislocation: 5
		CoP	87	Total revision: 2	Intraoperative femur fracture: 1 Wound problem: 2 Dislocation: 4
Lombardi et al. [53]	2010	CoC	64	NR	Ceramic head fracture: 1

CoC, ceramic-on-ceramic; CoP, ceramic-on-polyethylene; NR, not reported.

There is sparse literature on the optimal treatment strategy for this rare complication, but general treatment strategies include evaluating the acetabular cup and stem for damage and loosening, trunnion for wear and abrasion, osteolysis from metallosis, and debridement. Further follow-up for similar cases is recommended, as complete removal of microscopic debris cannot be fully guaranteed, potentially increasing the risk of wear. However, thorough debridement during revision surgery can help minimize this risk in the postoperative period.

Several factors may have impacted this patient’s clinical course. Compared to prior cases, this patient was morbidly obese with multiple comorbidities and arthroplasties.

Summary

Although ceramic head failure via fracture was more common in the original generation, the newer generation can still fracture. These fractures are important to recognize and develop a systematic approach in the operating room to addressing these mechanical undersides.

Conflicts of Interest

M. Karadsheh is a Stryker educational consultant; all other authors declare no potential conflicts of interest.

For full disclosure statements refer to https://doi.org/10.1016/j.artd.2025.101614.

Informed patient consent

The author(s) confirm that written informed consent has been obtained from the involved patient(s) or if appropriate from the parent, guardian, power of attorney of the involved patient(s); and, they have given approval for this information to be published in this case report (series).

CRediT authorship contribution statement

Clark Yin: Writing – review & editing, Writing – original draft, Supervision, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Lauren Eberhardt: Writing – review & editing, Writing – original draft, Resources, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Matthew Cederman: Writing – review & editing, Writing – original draft, Visualization, Resources, Formal analysis, Data curation. Henry Haley: Writing – review & editing, Visualization, Supervision, Project administration, Methodology, Conceptualization. Andrew Steffenmeier: Writing – review & editing, Supervision, Project administration, Methodology, Conceptualization. Mark Karadsheh: Writing – review & editing, Supervision, Project administration, Conceptualization.

Appendix A. Supplementary data

Conflict of Interest Statement for Henry