Should Ceramic-on-Ceramic or Ceramic-on-Polyethylene Bearings Be Preferred in Revision Total Hip Arthroplasty After Ceramic Head or Liner Fracture? A Retrospective Multicenter Case-Control Study of 33 Cases.

Introduction: Fracture of ceramic components in total hip arthroplasty (THA), although rare, remains a major concern. The optimal bearing choice in revision surgery following such fractures is still debated. Few studies have specifically compared ceramic-on-polyethylene (CoP) to ceramic-on-ceramic (CoC) in this context. Therefore we built up a retrospective comparative study aiming to compare the two bearing surfaces regarding: (1) complication rates, (2) implant survival, and (3) functional outcomes.

Hypothesis: The use of CoP with a monoblock (single-mobility) design is associated with fewer complications than CoC bearings in revision THA for ceramic component fracture.

Materials and methods: A retrospective multicenter analysis was conducted on 33 patients treated for ceramic component fractures (17 femoral heads, 16 liners), which occurred at a mean of 6 years and 8 months (range, 2 months to 25 years) after the index procedure. Sixteen patients received CoC bearings and 17 received CoP bearings. Patients were assessed at a mean follow-up of 8 years and 10 months (range, 1-21 years).

Results: At a mean follow-up of 8.9 years, the CoC group (mean follow-up 9.1 years) experienced significantly more complications than the CoP group (mean follow-up 8.7 years): 10/16 cases (62.5%) in the CoC group versus 3/17 cases (17.6%) in the CoP group (p = 0.013). Complications in the CoC group included: 5 dislocations (31%), 2 cases of squeaking (13%), 2 recurrent ceramic head fractures (13%), and 1 infection (6%). In the CoP group, complications included 2 dislocations (12%) and 1 aseptic loosening (6%). Mean Oxford Hip Scores at final follow-up were 21.7/60 (range, 12-47) for the CoP group and 23.1/60 (range, 12-45) for the CoC group, with no significant difference (p = 0.5).

Discussion: The strength of this study lies in the direct comparison of CoC and CoP bearing surfaces, with a significantly lower complication rate observed in the CoP group. However, these results should be confirmed in larger cohorts to help standardize current practices, which are often guided by expert opinion rather than scientific evidence. CoC bearings did not prevent dislocations, squeaking, or recurrent fractures. CoP monoblock constructs may offer both durability and a reduced complication profile in these high-risk revision scenarios.

Level of evidence: III; Retrospective comparative study.