The hole story: a case report of a ceramic implant’s unexpected journey

Abstract

Introduction and importance:

Catastrophic failure of ceramic-on-polyethylene (CoP) total hip arthroplasty (THA) is a rare but severe complication. While ceramics offer superior wear resistance, polyethylene liner degradation can progress silently over decades, culminating in component failure, metallosis, and functional decline.

Presentation of case:

We report the case of a 66-year-old female who presented with pain and mechanical symptoms 20 years after a CoP “DURALOC” Exeter THA. Imaging revealed eccentric polyethylene wear and acetabular osteolysis. Intraoperatively, the ceramic femoral head was found to have eroded through the polyethylene liner and acetabular shell, accompanied by gross metallosis and joint subluxation. Revision surgery involved full component exchange, debridement, and successful reconstruction.

Clinical discussion:

This case highlights the potential for catastrophic failure in long-standing CoP implants and emphasizes the importance of long-term surveillance. Despite the durability of ceramic components, polyethylene wear remains a critical factor in implant longevity.

Conclusion:

Early detection of polyethylene wear is essential to prevent catastrophic failure. Regular follow-up and prompt revision can result in excellent postoperative outcomes, even after severe implant degradation.

Introduction and importance

Total hip arthroplasty (THA) is one of the most successful and durable procedures in orthopedic surgery, offering long-term pain relief and functional restoration for patients with end-stage joint disease^[1–10]. While ceramic-on-polyethylene (CoP) bearings have demonstrated lower wear rates compared to metal-on-polyethylene and metal-on-metal systems due to the superior hardness and wettability of ceramics, they are not immune to catastrophic failure^[3]. In particular, the polyethylene component remains the mechanical weak link in these constructs, especially in the setting of long-term use, suboptimal implant positioning, or high patient activity levels^[1–3].

Polyethylene wear in THA can lead to osteolysis, aseptic loosening, and, in rare cases, catastrophic failure where the femoral head penetrates the polyethylene liner and metal shell^[4,5]. While several case reports have detailed such occurrences, most describe either late detection of wear or failure to follow up, contributing to progressive joint damage and metallosis^[6–10]. These events are particularly concerning given the theoretical wear resistance of ceramic components. Nevertheless, contributing factors such as a thin liner, oxidized polyethylene from gamma sterilization in air, malalignment, and high cup inclination can significantly accelerate wear^[2,4,9].

HIGHLIGHTS

• Rare case of complete ceramic head migration through both polyethylene liner and acetabular shell, 20 years post ceramic-on-polyethylene total hip arthroplasty, despite a well-fixed femoral stem.

• Successful revision involved upsizing the acetabular shell, multi-screw fixation, and full component exchange, with excellent recovery.

• Silent progression of polyethylene wear underscores the need for routine long-term radiographic surveillance.

• Review of 10 comparable cases highlights key risk factors, including thin liners, excessive cup inclination (>55°), and outdated sterilization methods.

With consent, this case report presents a rare instance of complete polyethylene wear-through in a 66-year-old female with a 20-year-old CoP “DURALOC” Exeter THA. The ceramic femoral head had polished through the polyethylene liner and migrated beyond the acetabular shell, resulting in gross metallosis and subluxation. This failure occurred despite a well-fixed femoral component and the absence of significant femoral osteolysis, emphasizing the progressive yet silent nature of polyethylene wear in well-functioning THAs. The case also highlights the surgical challenges in managing such failures and the favorable outcomes that can be achieved with timely revision. This work has been reported in line with the SCARE criteria^[11].

Presentation of the case

This case details a 66-year-old female who underwent elective revision arthroplasty of her right hip in March 2025. She had a CoP “DURALOC” Exeter right hip replacement in 2004 and was doing well until 20 years later, in January 2025, when she developed pain, a limp, and feelings of “movement” within her right hip.

Background medical history included rheumatoid arthritis, hypothyroidism, hypertension, and gastroesophageal reflux. Surgically, she also had a right total knee replacement, tonsillectomy, and varicose vein ligation. She was independent with her activities of daily living and lived with her partner in a two-story house.

On examination in January 2025, she had a well-healed surgical scar, significant pain on internal and external rotation of her right hip, and obvious shortening. An AP pelvic X-ray confirmed significant eccentric polyethylene wear with osteolysis on the acetabular side in Gruen zones 1–3. On the femoral side, her implant appeared well fixed with relatively very little osteolysis Figure 1. Inflammatory markers were normal.

Figure 1.

AP Pelvic X-Ray of worn prosthesis.

The patient underwent revision of her right total hip replacement in March 2025. A spinal anesthetic was performed. Patient was placed in the lateral decubitus position, and was incised through her existing incision. Metallosis was immediately evident. Abductors were degenerative, and her hip had subluxed.

Clearly apparent was the ceramic head, which had been polished over time to reveal its metal coating Figure 2. The ceramic head had migrated through the polyethylene “DURALOC” liner and was sitting outside of the acetabular shell Figure 3.

Figure 2.

View on Surgical Approach.

Figure 3.

Worn Acetabular Liner.

The liner was removed without issue, and the femoral head and stem were taken out en bloc. This revealed the acetabular shell, which was worn through Figure 4. The granulomatous tissue and metal debris were extensively debrided. The acetabular shell was increased by 2 millimeters, and three screws were employed to improve primary stability. The ceramic head and liner were also replaced, along with a new stem. Intravenous antibiotics were administered for 48 hours after the procedure.

Figure 4.

Worn Acetabulum.

The patient was permitted to fully weight-bear. The muscle strength and function were grossly in line with preoperative function at the 6-week check-up. Plain radiographs of the pelvis showed the ideal size and position of the prosthesis Figure 6. Pain was relieved at 2 weeks of follow-up, and the patient returned to normal life 8 weeks postoperatively.

Figure 6.

Catastrophic THA Failure-Case Summary.

Clinical discussion

Catastrophic failure of the acetabular component in CoP THA is a rare but increasingly reported complication, typically arising years after primary implantation. A literature review was conducted across PubMed, CINAHL, and Embase databases, identifying ten relevant case studies reporting catastrophic failure in CoP THA over the last 30 years Figure 5. Our multi-case synthesis underscores that polyethylene wear-through, metallosis, and structural component failure remain significant risks even in ceramic-coupled systems.

Figure 5.

Post Operative AP Pelvic X-ray.

Mechanisms and risk factors

The ten published cases highlighted a consistent pathophysiologic pattern^[1–10]. That is, gradual wear of the polyethylene liner, resulting in direct contact between the ceramic femoral head and the metal acetabular shell, frequently accompanied by periprosthetic metallosis, osteolysis, and later implant instability or dislocation^[1–10].

Notably, complete liner wear was observed in both standard and HXLPE materials, indicating that advanced processing alone does not eliminate long-term wear risks under biomechanical stress.

Several modifiable risk factors were frequently observed Figure 7. Among the most prevalent were component malposition and thin polyethylene liners <4 mm in thickness, both reported in 6 of the 10 papers. Several patients had acetabular component inclination angles that exceeded 55°, which increased the possibility of impingement and stress concentration on the superior liner side^[1,8].

Figure 7.

Frequency of Risk Factors in Ceramic-on-Polyethylene THA Failure.

Additional factors have been implicated in the pathogenesis of catastrophic failure in CoP THA. The use of gamma-sterilized polyethylene liners stored in atmospheric conditions has been shown to accelerate oxidative degradation and subsequent embrittlement of the material, increasing susceptibility to mechanical wear and fracture, as supported by cases reported by Needham et al and Manzano et al^[1,10].

Moreover, high levels of patient activity, particularly in younger individuals, impose increased cyclical loading on the bearing surfaces, potentially expediting the wear process. Compounding these risks is the absence of routine postoperative follow-up, which was identified in 7 of the 10 papers. This lack of surveillance often leads to a delayed recognition of early warning signs such as eccentric femoral head positioning or subtle osteolytic changes, allowing wear to progress unchecked toward catastrophic failure.

Interestingly, all ceramic heads remained structurally intact, reinforcing their resistance to third-body wear and fracture but simultaneously emphasizing the mechanical vulnerability of polyethylene liners as the weakest interface component.

Clinical and systemic manifestations

Metallosis presented with discolored periprosthetic tissue, suspected pseudotumor formation, and significant bone resorption. Tarpada et al^[2] described a dramatic case of titanium toxicity with serum levels 100 times above normal, followed by weariness, headaches, and visual abnormalities. Such findings caution that systemic metal ion monitoring should be considered in patients with unexplained symptoms and radiographic signs of implant degradation.

Moreover, unique radiographic signs like the “bubble sign,” Malizos et al^[6], may assist early diagnosis of metallosis even in the absence of clinical symptoms. Similarly, serum titanium or cobalt levels can be used as surrogate indicators of mechanical abrasion in failed THA, especially when conventional radiographs underestimate debris loads.

Timing and outcomes of revision

Failure occurred between 1 and 16 years post-op across reviewed cases^[1–10]. Although HXLPE is known for durability, early failures have been reported, often due to surgical issues such as poor implant positioning rather than flaws in the material itself^[7,9]. Li and Zhang^[9], for instance, described early failure linked to malalignment and high cup inclination. This highlights the importance of surgical technique and follow-up, even with modern materials. Successful outcomes were generally reported, though functional recovery was often contingent on early diagnosis and intervention.

Implications for practice

This analysis underscores several critical considerations for clinical practice. First, routine radiographic surveillance remains essential for all patients following THA, particularly in younger or more physically active individuals, even in the absence of symptoms.

Early identification of subtle radiographic changes such as eccentric femoral head positioning or biochemical abnormalities, including elevated serum metal ion levels, should prompt timely investigation and, if necessary, intervention.

Intraoperatively, surgeons should aim to minimize polyethylene-related complications by selecting appropriately thick liners, utilizing modern oxidation-resistant sterilization techniques, and ensuring optimal component alignment.

Lastly, comprehensive patient education regarding the recognition of symptoms and the importance of adhering to long-term follow-up schedules plays a pivotal role in preventing the progression of wear-related complications to catastrophic implant failure.

Conclusion

This case underscores the potential for catastrophic failure in long-standing CoP THA, even in the absence of early clinical warning signs. Despite the known wear resistance of ceramic components, polyethylene liners remain susceptible to gradual degradation, which may ultimately lead to complete mechanical failure, metallosis, and significant functional impairment.

Routine long-term surveillance of THA patients, including radiographic follow-up and clinical review, is critical for identifying progressive eccentric wear before it results in irreversible damage. Timely surgical intervention can enable successful reconstruction and return to function, as demonstrated in this case. Surgeons should remain vigilant for subtle signs of liner wear, particularly in patients approaching the second decade post-implantation.

Ethical approval

Exempt from ethical approval, Royal College of Surgeons of Ireland.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Sources of funding

None.

Author contributions

Study concept and design: A.O.; data collection: A.O.; data analysis and interpretation: A.O.; writing – original draft: A.O.; writing – review and editing: S.G.; supervision (senior clinical oversight, surgical guidance, or final approval): S.G.

Conflicts of interest disclosure

The authors received no financial support for this research, authorship, and/or publication of this article.

Research registration unique identifying number (UIN)

Not applicable.

Guarantor

Amanda O’Halloran.

Provenance and peer review

Not applicable.

Data availability statement

Not applicable.

Declaration of generative AI and AI-assisted technologies in the writing process

During the preparation of this work, the author used Scholar GPT to aid in analyzing comparable case reports and formatting references as per the journal’s specific referencing request. It helped synthesize the author’s clinical insights into a cohesive manuscript. After using this service, the author reviewed and edited the content and takes full responsibility for the publication.