A 51-year-old man with a history of left total hip arthroplasty in 2014 reports chronic atraumatic hip pain for five years, worsening acutely over three weeks. Despite walking unaided, he describes a "clicking" sensation and has a notable limp. X-rays reveal gas in the soft tissues around the hip.
According to you what could be the causes of this kind of complication? What is your diagnosis and how would you treat this patient?
"I graduated summa cum laude from both my Bachelor of Science degree and master’s degree in biomedical engineering programs at Ben-Gurion University of the Negev in Israel, where I later graduated as valedictorian of my medical class.
After an orthopedic surgery residency here at the Hospital for Joint Diseases—now NYU Langone Orthopedic Hospital—I completed a fellowship in adult reconstruction and total joint replacement surgery at Brigham and Women’s Hospital, a major teaching hospital of Harvard Medical School.
My practice at NYU Langone focuses specifically on caring for people with hip and knee conditions. I have a particular interest in degenerative joint disease of the hips and knees. Other areas of focus include treatment for people with developmental hip dysplasia, avascular necrosis, posttraumatic arthritis, rheumatoid arthritis, and complex revision surgery.
I have had the privilege to train and learn from the founders of the field of joint replacement surgery. I have gained a vast amount of experience in performing complex and revision hip and knee surgery, partial knee replacement, ligament-sparing knee surgery, hip resurfacing, and hip fracture surgery. I helped develop and use robotics and advanced technology for hip and knee replacement. I pioneered minimally invasive surgical techniques such as the STAR approach for hip and robotic knee replacements. My goal is to help my patients maintain their lifestyle and activity levels.
Dr Schwarzkopf is the director of the Research Center for the Adult Reconstruction Division. Dr. Schwarzkopf’s research interests include both clinical and basic science. He has published over 800 peer reviewed studies on topics ranging from hip fracture fixation to outcomes of total joint replacements. Dr. Schwarzkopf has received multiple grants throughout his career including the TriOrg, FARE, OREF and knee and hip society research grants. Dr. Schwarzkopf is a member of both the prestigious North American Hip Society and Knee Society; he serves on the board of the hip society and the American Association of Hip and Knee Surgeons."
Dr Schwarzkopf is married to Aude, and father to Matan, Yaelle and Mia. His hobbies include running, snowboarding, Scuba diving and skydiving.
- 51 year-old man
- Left THA in 2014
- Atraumatic chronic left hip pain for approximately 5 years that acutely exacerbated three weeks ago.
- States that the left hip has been “clicking” for years and has gradually worsened.
- XRs ordered by his PCP showed “gas within the hip's soft tissues.”
- Able to ambulate without an assistive device, but is limping
Pre-Op X-rays 6/7/2024
Pertinent CT 6/10/2024
What is your diagnosis ?
- ✔️Ceramic liner fracture
Ceramic liner fracture is a rare complication, found in only 0.22% of the implanted implants of this kind.
D'Antonio J, Capello W, Manley M, Bierbaum B. New experience with alumina-on-alumina ceramic bearings for total hip arthroplasty. J Arthroplasty. 2002;17(4):390–397. doi: 10.1054/arth.2002.32183.
What are the possible causes of this kind of complication typical of the type of implants used in this patient?
- ✔️Dislocation
- ✔️Impingement
- ✔️Microseparation
- ✔️Trauma with implantation
- ✔️Malposition
D'Antonio J, Capello W, Manley M, Bierbaum B. New experience with alumina-on-alumina ceramic bearings for total hip arthroplasty. J Arthroplasty. 2002;17(4):390–397. doi: 10.1054/arth.2002.32183.
Nevelos J, Ingham E, Doyle C, et al. Microseparation of the centers of alumina-alumina artificial hip joints during simulator testing produces clinically relevant wear rates and patterns. J Arthroplasty. 2000;15(6):793–795. doi: 10.1054/arth.2000.8100.
Could this complication already be suspected in 2019?
- ✔️Yes
The 2019 x rays already show signs in the soft tissue that there was probably already fractured liner parts.
What treatment would you propose for this patient?
- ✔️Acetabulum revision with a ceramic-polyethylene friction torque
- ✔️Acetabulum revision with a ceramic-ceramic friction torque
When a ceramic fracture occurs, numerous small ceramic fragments may remain in the joint, even after thorough cleaning. These fragments are extremely hard and abrasive. If a metal head is used during the revision, the friction between these fragments and the metal head can lead to accelerated wear of the metal head and the liner
Olmedo-Garcia NI, Zagra L. High risk of complications using metal heads after ceramic fracture in total hip arthroplasty. Hip Int. 2019 Jul;29(4):373-378. doi: 10.1177/1120700018813978. Epub 2018 Dec 3. PMID: 30501527.
Per-op images
Post-op X-rays
