Ceramic-on-ceramic versus polyethylene-based bearings in total hip arthroplasty: a meta-analysis

Bearing surface selection is a key determinant of long-term performance in total hip arthroplasty (THA), yet comparative evidence across modern ceramic and polyethylene-based couples remains inconsistent. This meta-analysis provides a comprehensive comparative evaluation of ceramic-on-ceramic (CoC) bearings versus metal-on-polyethylene (MoP), metal-on-highly cross-linked polyethylene (MoHXLPE), ceramic-on-polyethylene (CoP), and ceramic-on-highly cross-linked polyethylene (CoHXLPE).

A systematic search of four databases identified randomized controlled trials and comparative observational studies evaluating CoC bearings against alternative articulations in primary THA. Thirty-three studies were included (over 120,000 THAs). Outcomes included implant survivorship, revision, dislocation, wear, osteolysis, functional scores, radiographic findings, and postoperative complications. Pooled analyses were performed using fixed-effect or random-effects models according to heterogeneity.

Across all comparisons, revision rates, aseptic loosening, and periprosthetic fracture were similar between CoC and polyethylene-based bearings; periprosthetic joint infection was also comparable (all p > 0.05), except that a lower pooled PJI rate was observed with CoC versus MoHXLPE (RR 0.42, p < 0.00001). CoC demonstrated reduced prosthetic hip dislocation compared with MoP (RR 0.39, p = 0.05) and MoHXLPE (RR 0.77, p = 0.004), and lower osteolysis relative to MoP (RR 0.26, p = 0.02) and MoHXLPE (RR 0.48, p = 0.004). Squeaking was consistently more frequent with CoC, particularly versus MoP (RR 2.14, p = 0.002), CoP (RR 8.60, p = 0.04), and CoHXLPE (RR 5.98, p = 0.0007). Functional outcomes were broadly equivalent, although in the CoC vs MoHXLPE subgroup CoC showed modestly better Harris Hip Score (MD 1.78, p = 0.0009) and lower WOMAC scores (MD -6.16, p = 0.005). Kaplan-Meier survivorship was excellent in the CoC vs MoP and CoC vs MoHXLPE comparisons, with a small but consistent numerical advantage favoring CoC, frequently remaining above 95% at long-term follow-up.

Modern bearing surfaces provide generally comparable safety and survivorship in THA. CoC bearings offer specific benefits, including reduced dislocation risk and lower osteolysis, balanced against a higher incidence of squeaking. These findings support individualized bearing selection based on patient age, activity level, and tolerance for ceramic-specific complications.