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Ceramic Liner Fractures Presenting as Squeaking After Primary Total Hip Arthroplasty
Matthew P. Abdel, MD1; Thomas J. Heyse, MD1; Marcella E. Elpers, BS1; David J. Mayman, MD1; Edwin P. Su, MD1; Paul M. Pellicci, MD1; Timothy M. Wright, PhD1; Douglas E. Padgett, MD1
1 Adult Reconstruction and Joint Replacement Division (M.P.A., T.J.H., D.J.M., E.P.S., P.M.P., and D.E.P.) and Department of Biomechanics (M.E.E. and T.M.W.), Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for D.E. Padgett: padgettd@hss.edu
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Investigation performed at the Hospital for Special Surgery, New York, NY

Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2014 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2014 Jan 01;96(1):27-31. doi: 10.2106/JBJS.M.00737
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Squeaking after ceramic-on-ceramic total hip arthroplasty is a relatively uncommon phenomenon. It usually does not require treatment in the absence of pain, mechanical symptoms, and/or relentless squeaking. The purpose of this investigation was to report on four patients who presented with hip pain and squeaking due to fractured ceramic liners after ceramic-on-ceramic total hip arthroplasty.


Four patients with painful squeaking after ceramic-on-ceramic total hip arthroplasty were seen at our institution. One patient had a revision for suspected loosening and excessive anteversion of the cup noted on radiographs and magnetic resonance imaging (MRI). The remaining three patients had a revision for audible squeaking with progressive pain.


Intraoperatively, the ceramic liners of all four patients were fractured.


Squeaking after ceramic-on-ceramic total hip arthroplasty rarely is a functional issue. However, painful squeaking without notable trauma may indicate fracture of the ceramic liner. Painful squeaking is difficult to evaluate by conventional imaging. When painful squeaking occurs, exploration via surgical revision is recommended in selected patients, as ceramic liner fractures may go unnoticed on radiographs and/or MRI and thus their actual prevalence may be higher than estimated.

Level of Evidence: 

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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    Matthew P. Abdel, MD, Thomas J. Heyse, MD, Marcella E. Elpers, BS, David J. Mayman, MD, Edwin P. Su, MD, Paul M. Pellicci, MD, Timothy M. Wright, PhD, and Douglas E. Padgett, MD
    Posted on January 28, 2014
    Response to comment by Kamath et al. entitled “Computed tomography for ceramic liner fracture diagnosis”
    Hospital for Special Surgery (HSS), New York, NY, USA

    We appreciate the comments by Kamath et al. entitled “Computed tomography for ceramic liner fracture diagnosis” in regard to our original article entitled “Ceramic Liner Fractures Presenting as Squeaking After Primary Total Hip Arthroplasty” by Abdel et al. (2014;96: 27-31). While we respect the authors’ analysis and their reservations about our observations and conclusions, we stand firmly by our findings and recommendations. Although the goal of our study was not intended to present a diagnostic algorithm, one inherently developed when analyzing these patients. Briefly, we described a retrospective series of 4 patients from our institution. All patients presented with an implant-specific complication that was previously unknown in the literature. As clearly noted in the manuscript, only one of the 4 patients was evaluated with a MRI. We did not recommend MRI as the advanced imaging of choice for ceramic liner fractures, but simply noted that in our experience, “ceramic liner fractures may go unnoticed on radiographs and/or MRI.” Our recommendations are clear, and we think few can argue with our concluding algorithm: “In treating a patient presenting with a squeaking ceramic-on-ceramic total hip replacement that is painless and without mechanical symptoms, and for which imaging is unremarkable, it is reasonable to reassure the patient and schedule routine follow-up visits. However, when squeaking is associated with increasing pain, we recommend a more thorough investigation of the ceramic components, as well as ruling out infection by serological tests and an aspiration if necessary.” As the reader can see, MRI is not recommended in our diagnostic algorithm.

    Second, we raise issue with the comment by Kamath et al. that “CT has been used effectively in the accurate diagnosis of ceramic liner fractures.” The current published literature does not support this statement. In the single case report by Trevillin et al., which Kamath et al. cite, the authors report on a ceramic rim fracture after late recurrent dislocations [1]. Rim fracture should have been suspected upon closer inspection of the plain radiographs, which demonstrate what appears to be ceramic particles at the neck of the implant. In addition, this rim fracture was not noted on the initial CT, but rather on a subsequent three-dimensional reconstruction. However, our series reports on the occurrence of dome fractures that were minimally displaced (see Fig. 1-B and Fig. 2 from our original manuscript). While we did not obtain CT scans as part of the investigation, it is unclear whether CT imaging would have been capable of showing a ceramic fracture contained within a metallic shell with less than 1 millimeter of displacement between the fragments.

    Finally, while we respect the concern of Kamath et al. over our recommendation for considering revision surgery in patients who presents with new onset painful squeaking, in the final analysis we feel that this may be the most prudent course of action. Given that optimal imaging and diagnostic testing for these patients have not been fully elucidated, there is a high likelihood that this unique cohort of patients with new onset painful squeaking has a fractured bearing. Multiple studies (including one from our institution) have emphasized the importance of a “joint exploration”, thorough removal of all ceramic debris, an extensive synovectomy, and a bearing exchange [2-4]. Based upon our experience, new onset painful squeaking in a patient with this particular ceramic-on-ceramic bearing surface potentially represents bearing failure and should be treated accordingly.

    1. Trivellin G, Sandri A, Bizzotto N, Marino MA, Mezzari S, Sambugaro E, Regis D. Ceramic liner fatigue fracture: 3-D CT findings in a late recurrent THA dislocation. Orthopedics 2013;36-1:e101-4.
    2. Sharma V, Ranawat AS, Rasquinha VJ, Weiskopf J, Howard H, Ranawat CS. Revision total hip arthroplasty for ceramic head fracture: a long-term follow-up. The Journal of arthroplasty 2010;25-3:342-7.
    3. Allain J, Goutallier D, Voisin MC, Lemouel S. Failure of a stainless-steel femoral head of a revision total hip arthroplasty performed after a fracture of a ceramic femoral head. A case report. The Journal of bone and joint surgery. American volume 1998;80-9:1355-60.
    4. Allain J, Roudot-Thoraval F, Delecrin J, Anract P, Migaud H, Goutallier D. Revision total hip arthroplasty performed after fracture of a ceramic femoral head. A multicenter survivorship study. The Journal of bone and joint surgery. American volume 2003;85-A-5:825-30.

    Atul Kamath, MD, Christian W. A. Pfirrmann, MD, MBA, Michael Leunig, MD
    Posted on January 18, 2014
    Computed tomography for ceramic liner fracture diagnosis
    Schulthess Klinik, Zurich, Switzerland

    We read with interest the case series “Ceramic Liner Fractures Presenting as Squeaking After Primary Total Hip Arthroplasty” by Abdel et al. (2014;96: 27-31). As total hip arthroplasty (THA) technology evolves, the authors are commended for sharing their experience with a particular failure pattern of a specific ceramic-on-ceramic THA (Biolox forte, R3, Smith & Nephew, Memphis, Tennessee). While the authors provide an adequate overview of the clinical presentation and operative management of this manufacturer-specific implant design, we disagree with the diagnostic algorithm as presented.

    The authors fail to discuss the role of computed tomography (CT) in the evaluation of this subset of symptomatic patients. While the authors cite a prior study [1] which used CT to assess for potential sources of impingement, there is no further mention of the role of CT in the diagnosis and identification of liner fractures. Beyond impingement analysis, the study by Toni et al. [1] also discusses the “macro fragments” as CT-based evidence of liner fracture; however, this is not reviewed in the above case series.

    In the setting of plain radiographs that do not demonstrate a liner fracture, it would appear to the readership, based on the authors’ described diagnostic work-up, that magnetic resonance imaging (MRI) of the involved hip follows sequentially. We disagree with this choice of advanced imaging for further evaluation of ceramic-ceramic couples for several reasons. The authors correctly point out that liner fractures may be missed on MRI imaging, even with newest generation metal artifact reduction sequences (MARS). While MRI has gained an increasing role in the management of failed metal-on-metal articulations [2], it is unlikely to represent the first-line cross-sectional imaging modality when there exists suspicion of a liner fracture. Fractures of the ceramic liners are often very thin, similar to capillary cracks. For the detection of these subtle fracture lines, high-resolution images are necessary. The resolution of CT images is considerably higher than that of MRI, especially with regard to the slice thickness. A slice thickness of 1 mm and smaller is routinely available on a standard CT scanner. This resolution is almost impossible to achieve with current MRI of the hip, especially with MARS. Further study is needed to characterize the specific diagnostic parameters and utility of CT versus MRI in ceramic articulations. Based on our own institutional experience, CT has been used effectively in the accurate diagnosis of ceramic liner fractures. We present here a supportive case report of a 51-year-old male status post bilateral ceramic-on-ceramic THA. The implanted prostheses were from the same company as described by Abdel et al.: R3 ceramic liners (Biolox forte), 36 mm ceramic heads (Biolox forte), and Polarstem femoral components (Smith & Nephew, Memphis, Tennessee). The patient presented with a two-month history of squeaking and insecurity of his left hip; he had done well for the initial three years after index surgery. Plain radiographs demonstrated no obvious hardware failure (Figure 1), and femoral and acetabular components were deemed to be in an acceptable position. Computed tomography identified failure of the ceramic liner, with a fracture at the liner dome (Figure 2) in a pattern similar to that found by the above authors. The patient underwent left hip arthroplasty revision of the ceramic inlay (Biolox delta) and of the femoral head (Biolox delta), and liner fracture was confirmed at the time of surgery (Figure 3). This utility of CT has been confirmed in other study [3].

    Finally, we must disagree with the authors’ concluding statement: “In conclusion, painful squeaking following ceramic-on-ceramic total hip arthroplasty is difficult to evaluate by traditional imaging, including radiographs and MRI. A joint exploration during surgical revision is warranted in patients who are unresponsive to conservative treatment.” We would caution against the authors’ suggestion of "joint exploration" in the setting of negative radiographs and MRI scan alone. Computed tomography may offer an important adjunctive imaging measure. It is likely that the diagnosis of liner fracture could have been confirmed pre-operatively in the authors’ published series if CT imaging, rather than or in addition to MRI, were obtained prior to surgical exploration.

    1. Toni A, Traina F, Stea S, Sudanese A, Visentin M, Bordini B, Squarzoni S. Early diagnosis of ceramic liner fracture. Guidelines based on a twelve-year clinical experience. J Bone Joint Surg Am. 2006 Dec;88(Suppl 4):55-63.
    2. Kwon YM, Lombardi AV, Jacobs JJ, Fehring TK, Lewis CG, Cabanela ME. Risk Stratification Algorithm for Management of Patients with Metal-on-Metal Hip Arthroplasty: Consensus Statement of the American Association of Hip and Knee Surgeons, the American Academy of Orthopaedic Surgeons, and The Hip Society. J Bone Joint Surg Am. 2014 Jan 1;96(1):e4
    3. Trivellin G, Sandri A, Bizzotto N, Marino MA, Mezzari S, Sambugaro E, Regis D. Ceramic liner fatigue fracture: 3-D CT findings in a late recurrent THA dislocation. Orthopedics. 2013 Jan;36(1):e101-4.

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