Ceramic head and liner fractures in total hip arthroplasty.

The ceramic-on-ceramic (CoC) bearing is preferred in total hip arthroplasty (THA) in young patients since it has virtually no wear or peri-prosthetic osteolysis. However, it exposes patients to a rare but serious risk of head or liner fracture. These fractures are multifactorial in origin and involve parameters related to the material, implant geometry, interface characteristics (angle and length of the taper junction), surgical technique (impaction, positioning), joint kinematics, and to a lesser extent, patient factors. According to registries and manufacturers, the head fracture rate has significantly decreased between the 3rd (2 per 1000) and 4th (2 per 100,000) generations of ceramics. However, the liner fracture rate remained stable at around 2-3 per 10,000. These fractures occur suddenly through high-speed propagation of an intragranular crack. The diagnosis may be obvious on standard radiographs or more difficult, requiring CT imaging or even joint aspiration. Reoperation is not urgent but must be planned rapidly and performed meticulously. After retrieving the surgical data on the current implants, synovectomy and lavage must be performed with removal of ceramic fragments that could cause third-body wear in the subsequent arthroplasty. The revision modalities depend on the fractured component (femoral head and/or liner) and the condition and position of the implants. The preferred new bearing is CoC with a revision head diameter of 36 mm if possible, to reduce the risk of instability. Alternatively, the ceramic-on-polyethylene (CoPE) bearing may be used. This revision carries significant risks of instability and re-revision. However, a well-defined surgical strategy has contributed to improving the prognosis of this rare but formidable complication. LEVEL OF EVIDENCE: > V: expert opinion.