When Ceramics Shatter: Unmasking Cutaneous Metallosis after Total Hip Arthroplasty Failure

Abstract Background: Total hip arthroplasty (THA) using ceramic components is favoured for its excellent wear characteristics and biocompatibility. However, fracture of ceramic inserts—though rare—can initiate a cascade of implant failure mechanisms, including third-body wear and subsequent metallosis. A particularly underrecognised manifestation is cutaneous metallosis, characterised by grey-to-black skin discolouration overlying the affected joint. This review aims to synthesise current literature on this rare phenomenon, assess pathophysiological mechanisms and provide clinical guidance for diagnosis and management. Objectives: To systematically review the literature on cutaneous metallosis following ceramic insert fracture in THA, with a focus on clinical presentation, diagnostic challenges, surgical management and patient outcomes. Materials and Methods: A comprehensive search of PubMed, Scopus, EMBASE, Google Scholar and Web of Science was conducted for articles published between 2000 and 2024. Studies were included if they reported cutaneous manifestations of metallosis secondary to ceramic liner fracture in THA. Data from case reports, case series and retrospective studies were extracted and qualitatively synthesised. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed to ensure methodological rigour. Results: A total of 24 studies comprising 47 patients were included. Most patients had a history of ceramic-on-ceramic or ceramic-on-polyethylene THA and presented with skin hyperpigmentation over the lateral hip, thigh or gluteal region. In nearly all cases, the source was undetected or retained ceramic debris leading to abrasion of metallic components and subsequent dermal metal deposition. Diagnostic delays were common due to misinterpretation of skin changes. Serum metal ion levels were elevated in 80% of cases, and imaging (when performed) revealed ceramic fragments and soft-tissue damage. Surgical outcomes were variable, with persistent pigmentation noted in 40% of cases post-revision. Conclusion: Cutaneous metallosis is a visible but underrecognised indicator of severe prosthetic failure following ceramic liner fracture in THA. Delayed recognition, incomplete synovectomy and inappropriate implant choices can result in persistent tissue damage. Clinicians should maintain high suspicion in patients with a history of ceramic implants and unexplained skin discolouration. Early diagnosis, complete debridement and avoidance of metal-on-polyethylene articulation in the presence of ceramic debris are key to favourable outcomes.