Different Bearing Options in THA – What hip surgeons should consider

Background: Total hip arthroplasty (THA) demonstrates high long-term survivorship, yet aseptic loosening remains a primary cause of late revision. This failure is frequently driven by polyethylene wear debris and subsequent macrophage-mediated osteolysis. While various bearing surfaces have been developed to mitigate these complications, clinical selection remains complex due to the distinct mechanical and biological profiles of each material combination.

Objective: This review evaluates current bearing surface options in THA, analyzing the clinical performance, advantages, and complications associated with polyethylene, ceramic, and metal articulations.

Key Points: Highly cross-linked polyethylene (XLPE) significantly reduces linear penetration compared to conventional ultra-high molecular weight polyethylene, with antioxidant-doped variants further resisting in vivo oxidation. Ceramic-on-ceramic (CoC) bearings provide optimal wear resistance and biocompatibility, though they are associated with risks of component fracture and audible squeaking. The adoption of larger femoral head diameters (>32 mm) has improved joint stability without compromising the wear rates of XLPE or ceramic liners. Conversely, metal-on-metal bearings have been largely discontinued due to adverse reactions to metal debris. Recent evidence suggests that ceramic femoral heads may reduce the incidence of trunnionosis at the modular head-neck junction compared to metallic alternatives. Registry data indicate a global trend toward increased utilization of XLPE and ceramic components.

Conclusion: Optimal bearing selection requires balancing wear resistance against mechanical stability. CoC is recommended for young, high-demand patients, while XLPE provides a reliable, versatile option for older populations. Ultimately, precise surgical positioning and component handling are as critical to long-term prosthesis survival as the material properties of the bearing surface.