Total Hip Replacement with Ceramic Bearing Surfaces

Indication. A young, active patient (typically less than 65 years old) with end-stage hip arthritis and a life expectancy greater than 30 years, in whom the ultra-low wear of a ceramic-on-ceramic bearing is the whole point: minimising particle generation and osteolysis over decades so the implant outlives the patient and bone stock is preserved for any future revision. The ideal candidate sits at the intersection of three requirements:

Specific indications include primary osteoarthritis in a young patient, inflammatory arthritis (rheumatoid, ankylosing spondylitis) in a young patient, post-traumatic arthritis after acetabular fracture (if bone stock is adequate), avascular necrosis of the femoral head, documented or suspected metal allergy, and the informed patient's preference for the lowest-wear option after counselling. Consent must be ceramic-specific: the 1–10 percent squeak rate (usually benign but may be unacceptable to a high-functioning patient), the small but catastrophic ceramic fracture risk, the lifelong prohibition on high-impact activity, and the fact that ceramic cannot be combined with constrained or dual-mobility liners — so if instability develops later, revision options are constrained. Setup. Lateral decubitus with the affected side up and a rigidly fixed pelvis (this is non-negotiable — pelvic roll corrupts cup orientation). General or regional anaesthesia, full circumferential leg draping for manipulation, prophylactic cefazolin within one hour of incision, and intra-operative fluoroscopy or navigation available — for ceramics the extra verification of position is worth it.

The goal is to reconstruct a painless, stable, mobile hip with the bearing positioned so precisely that the ceramic articulates on its intended surfaces only. The workhorse exposure is the posterior (Moore/Southern) approach — described in depth on the posterior approach to the hip page — laid out as the first steps below. The anterior (Smith-Petersen) approach is a valid alternative noted at the end.

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Rehabilitation | Phase | Timing | Weight-bearing and precautions | Therapy and activity | |-------|--------|--------------------------------|----------------------| | 1 | Day 0–2 | Abduction pillow; weight-bearing as tolerated (modern cementless and cemented stems) | Sit out day 0–1; stand and walk with physiotherapy and a walker or crutches | | 2 | 2–6 weeks | Posterior precautions: no flexion beyond 90 degrees, no adduction past midline, no internal rotation | Progress gait aids toward a cane; wound care | | 3 | 6–12 weeks | Wean gait aids | Abductor strengthening, normal gait, scar mobility | | 4 | 3 months onward | Lifelong low-impact activity only | Return to low-impact sport; surveillance radiographs | Start DVT prophylaxis on day 0 (enoxaparin 40 mg subcutaneously daily or a DOAC) and use multimodal analgesia. Encouraged lifelong: walking (unlimited), swimming, cycling, golf after three months, dancing, light hiking, elliptical and rowing. Prohibited for life: running, jumping, basketball and volleyball, contact sport, tennis and squash, skiing, high-impact aerobics, and heavy repetitive lifting greater than 25 kg. Radiographic follow-up is at 6 weeks, 1 year, then every 2–3 years for life to monitor wear, osteolysis, loosening and heterotopic ossification, and to ask specifically about squeaking. Complications

Why the lowest wear matters. The entire rationale for a ceramic-on-ceramic bearing is that osteolysis is particle-driven: the fewer and smaller the wear particles, the slower the bone loss, and the longer the implant (and the bone stock for any future revision) lasts. Ceramic-on-ceramic articulations wear at 0.001–0.004 mm/year — about 10–20 times less than metal-on-highly-cross-linked polyethylene — which is why they are reserved for the young patient who needs 30-plus years of service. Ceramic materials. First-generation pure alumina (aluminium oxide) had a historical in-vivo fracture rate around 0.4 percent in the 1970s–1980s (improved to about 0.05 percent by the 1990s with better manufacturing) and a higher squeak rate (5–10 percent), and is largely superseded. The current gold standard is the alumina-zirconia composite (e.g. BIOLOX delta: roughly 82 percent alumina, 17 percent zirconia, 1 percent chromium oxide and strontium oxide), with about 250 percent greater strength and 150 percent greater toughness than pure alumina, a fracture rate down to 0.004–0.013 percent in recent registries, and a lower squeak rate (1–3 percent) from superior tribology.

Registry and long-term evidence. National joint registries (AOANJRR Australia; the NJR of England, Wales, Northern Ireland and the Isle of Man; the Swedish and Nordic arthroplasty registers) consistently show ceramic-on-ceramic revision rates broadly comparable to ceramic- or metal-on-highly-cross-linked-polyethylene in younger patients, with a cumulative percent revision of roughly 5–6 percent at 15–20 years and very low wear- or osteolysis-related revision. The principal reasons for ceramic-on-ceramic revision are dislocation, infection, periprosthetic fracture, ceramic fracture and squeak. Retrieval studies report median wear around 0.003 mm/year with a stripe-wear pattern in roughly 45 percent from edge loading, and single-surgeon series in patients under 30 years old report greater than 95 percent survival at 10–15 years with minimal osteolysis — validating ultra-low-wear bearings to protect bone stock in exactly the young, high-demand population they are designed for. Registries are cited here as global evidence rather than any single country's practice.