Delayed diagnosis of low-symptomatic ceramic acetabular liner fracture in ceramic-on-ceramic total hip arthroplasty

Alumina ceramics in total hip arthroplasty (THA) have been used in Europe since 1970. Over the years, ceramic-on-ceramic coupling became a valid option in THA because of excellent biocompatibility and tribological properties. The major disadvantages are possible squeaking and risk of breakage, usually disclosed by pain and functional impairment. Squeaking is an audible noise arising from ceramic-on-ceramic bearings, the incidence of which is reported to range from 1% to 7% of THAs. Component positioning, stripe wear, and edge loading have all been implicated. Clicking sounds and scratching have also been anecdotally described. Breakage of a ceramic component due to brittleness of the material is a rare complication. Trauma, high activity level, and obesity may increase the risk of fracture. Defective ceramic manufacture, inadequate implant design, and errors in surgical technique may contribute to breakage. Asian population lifestyle, including squatting, kneeling, and sitting cross-legged, has been correlated to liner rim impingement and fracture. Additional reports concerning failure of various ceramic liners have recently been described.