Mode I and II Wear in Ceramic on Ceramic Total Hip Arthropla
A 68-year-old man presented to the Emergency Department with a 3-week history of left hip pain, clicking, and difficulty weight-bearing, with no antecedent trauma. This occurred on a background history of an ipsilateral ceramic on ceramic (CoC) uncemented total hip arthroplasty implanted 10 years previously, with a complicated immediate post-operative course involving a dislocation requiring closed reduction. He suffered from no further complications and was asymptomatic up to this presentation. His background history was significant for a right uncemented CoC total hip arthroplasty 6 years previously, type-2 diabetes, and chronic venous disease. On examination, the patient displayed an antalgic gait with no obvious leg length discrepancy. Inspection revealed no evidence of infection at the previous total hip arthroplasty incision. The patient suffered from pain on both active and passive movement at the hip, with an audible clicking sound throughout. There was no associated neurovascular deficit.

Plain radiographic evaluation revealed superolateral subluxation of the ceramic femoral head in relation to the ceramic acetabular component with no associated periprosthetic fracture or dislocation. Serological evaluation revealed normal infectious markers, consistent with clinical assessment showing no evidence of infection. Further imaging using computerized tomography revealed a superolateral deficiency of the acetabular component, with a diagnosis of ceramic acetabular component fracture presumed to be the mechanism behind the patient’s symptoms. Following initial inpatient management, the patient’s symptoms improved, but nevertheless, he continued to suffer from discomfort and limitation of his activities of daily living (ADL’s). Following outpatient re-evaluation by a specialist revision arthroplasty orthopedic surgeon, a shared decision was made to proceed to revision total hip arthroplasty, with the intended goal to address the presumed ceramic acetabular component fracture.

This was undertaken to utilize the anterolateral incision from the index total hip arthroplasty procedure. Inspection during exposure of the hip joint revealed no obvious macroscopic evidence of infection, osteolysis, or destruction of surrounding articular tissue. Tissue samples were taken using an aseptic technique and sent for culture and sensitivity; these identified no underlying microscopic infective cause for the patient’s symptoms.

Assessment of the implanted femoral components was unremarkable, revealing a well-fixed proximally coated uncemented femoral component with no evidence of loosening or osteolysis and an intact articulating ceramic femoral head. Evaluation of the acetabular component was, however, more significant, revealing evidence of gross wear of the superior ceramic acetabular liner, with a resultant Mode II wear articulation of the ceramic head with the underlying titanium acetabular shell. There was no evidence of associated ceramic component particulate debris or fracture as had been suspected preoperatively.

The native acetabular liner and shell were thus removed and revised to a titanium alloy externally-coated acetabular shell and corresponding fourth-generation alumina-ceramic composite liner. The native femoral stem was left in situ as it was well fixed, with the ceramic femoral head being replaced by a corresponding fourth-generation ceramic head. Post-operatively, the patient was treated with both antibiotic and thromboprophylaxis and allowed to fully- weigh bear. At the 9-month postoperative interval, the patient has had a successful outcome, with complete resolution of his pre-operative symptoms as well as a return to all routine ADL’s.