Clinical Orthopaedics and Related Research ®

A Publication of The Association of Bone and Joint Surgeons ®

Is There a Difference in Revision Risk Between Metal and Ceramic Heads on Highly Crosslinked Polyethylene Liners?

Guy Cafri PhD, MStat, Elizabeth W. Paxton MA, Rebecca Love MPH, RN, Stefano A. Bini MD, Steven M. Kurtz PhD



The most common bearing surface used among primary THAs worldwide is a metal or ceramic femoral head that articulates against a highly crosslinked ultrahigh-molecular-weight polyethylene (HXLPE) acetabular liner. Despite their widespread use, relatively little is known about the comparative effectiveness of ceramic versus metal femoral heads with respect to risk of revision and dislocation as well as the role of head size in this relationship.


The purpose of this study was to evaluate the risk of (1) all-cause revision in metal versus ceramic femoral heads when used with an HXLPE liner, including an evaluation of the effect of head size; and (2) dislocation in metal versus ceramic femoral heads when used with an HXLPE liner as well as an assessment of the effect of head size.


Data were collected as part of the Kaiser Permanente Total Joint Replacement Registry between 2001 and 2013. Patients in this study were on average overweight (body mass index = 29 kg/m), 67 years old, mostly female (57%), and had osteoarthritis (93%) as the primary indication for surgery. The material of the femoral head (metal, ceramic) was crossed with head size (< 32, 32, 36, > 36 mm), yielding eight device groupings. Only uncemented devices were evaluated. The primary outcome was all-cause revision (n = 28,772) and the secondary outcome was dislocation within 1 year (n = 19,623). Propensity scores were used to adjust for potential confounding at the implant/patient level using between-within semiparametric survival models that control for surgeon and hospital confounding and adjust estimates for the within-cluster correlation among observations on the response.


For all-cause revision, there was no difference between ceramic versus metal (reference) heads in combination with an HXLPE liner (hazard ratio [HR] = 0.82 [0.65–1.04], p = 0.099). Smaller metal head sizes of < 32 mm were associated with increased risk of revision relative to 36 mm (HR = 1.66 [1.20–2.31], p = 0.002, adjusted p = 0.025). For dislocation, ceramic heads increased risk relative to metal at < 32 mm only (HR = 4.39 [1.72–11.19], p = 0.002, adjusted p = 0.020). Head sizes < 32 mm were associated with increased risk of dislocation relative to 36 mm for metal (HR = 2.99 [1.40–6.39], p = 0.005, adjusted p = 0.047) and ceramic heads (HR = 15.69 [6.07–40.55], p < 0.001, adjusted p < 0.001).


The results did not provide evidence for use of one femoral head material over another when used with HXLPE liners for the outcome of revision, but for dislocation, metal performed better than ceramic with < 32-mm heads. Overall, the findings suggest increased risk of revision/dislocation with head sizes < 32 mm.

Level of Evidence

Level III, therapeutic study.

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