Hip Replacement Bearing Surfaces: Which Is Best for You?

What I use, and why

A ceramic head on a highly cross-linked polyethylene liner. For every patient.

That is not a hedge or a default. It is the combination with the best durability record available, and the others on the menu were each tried seriously and each set aside for reasons worth understanding — because you may well have read about one of them.

What a bearing surface actually is

A hip replacement has two moving parts that meet: the head — the ball that sits on top of the stem in your femur — and the liner, which sits inside the socket implanted in your pelvis. Those two surfaces slide against each other every step you take.

The pair is called the bearing, and it is named head-first: a ceramic head on a polyethylene liner is “ceramic on poly.” This single choice does more to determine how long your hip lasts than almost anything else about the implant.

Ceramic on polyethylene — the one I use

A ceramic ball articulating against a liner of highly cross-linked polyethylene, which is a specially processed plastic that replaced the older conventional material.

The polyethylene is the part that changed everything. Older conventional plastic did wear, and that wear generated particles which caused bone loss around the implant — for years, that was the thing that ended a hip replacement's life. Highly cross-linked polyethylene largely solved it. Liner wear is no longer what limits a modern hip.

For the broader durability picture, see how long a hip replacement lasts.

Metal on metal — abandoned

A metal head against a metal liner. The appeal was that it allowed very large heads, which lowers dislocation risk.

The problem is that metal articulating against metal sheds cobalt and chromium particles, and those do not stay put. In a proportion of patients the debris provokes an adverse reaction: inflammation in the surrounding tissue, damage to tendon and muscle, bone loss around the components, and sometimes a fluid collection called a pseudotumor.

Metal-on-metal total hips are effectively gone — some recalled, others quietly withdrawn, and many simply abandoned by surgeons who had watched them fail. I have written about this at length in the context of hip resurfacing, which uses the same metal-on-metal bearing — and which is the reason I counsel patients against that operation.

Ceramic on ceramic — abandoned too

This is the one patients ask about most, usually having read that it is the premium option. The theory was genuinely attractive: two extremely hard surfaces that would barely wear at all.

Three problems ended it.

The squeaking is the one patients find hardest to believe until they meet someone who has it. It is not a minor cosmetic issue — a hip that announces itself across a quiet room affects how someone lives.

There was a period when ceramic on ceramic was used in very young patients, on the theory that they most needed a bearing that would never wear out. That reasoning has been overtaken: cross-linked polyethylene wears so little that the problem it was solving has largely gone away.

Metal on polyethylene

A metal head on a polyethylene liner. This is a widely used and perfectly reasonable modern bearing, and many excellent hips have been done with it — it is not in the same category as the two above.

I prefer a ceramic head because ceramic is harder and more scratch-resistant, so the surface running against the liner stays smoother over decades, and because it introduces no metal at the articulation at all. If you already have a metal-on-poly hip that is working well, there is no cause for concern in anything on this page.

What about dislocation?

The strongest argument for metal on metal was head size — bigger heads dislocate less, and metal bearings allowed the biggest heads.

That argument has largely lost its force. A muscle-sparing direct anterior approach addresses dislocation risk directly, by not detaching the muscles that stabilise the hip in the first place. My patients get no positional precautions afterwards — no 90-degree rule, no restrictions on crossing legs or bending. Head sizes in a modern ceramic-on-poly construct are generous, and the approach handles the rest.

In other words: you do not have to accept a metal-debris problem to get a stable hip. See the direct anterior approach and why I don't use the 90-degree rule.

Partial hip replacement — a different operation

Patients sometimes ask whether they can have a partial hip instead. It is worth clearing up, because it is not a bearing choice at all.

A partial hip replacement — a hemiarthroplasty — replaces the ball but leaves your own socket in place. It is used mainly for displaced femoral neck fractures in older patients, frequently those with poor muscle tone, neurologic conditions, or limited mobility, where a smaller operation is the right answer.

It is not an option for arthritis. Arthritis affects both sides of the joint, so leaving the arthritic socket in place leaves the pain in place. If you are asking about a partial hip for an arthritic joint, the honest answer is that you are asking about the wrong operation.

The bottom line

You are unlikely to be offered a menu. Most surgeons have settled on a construct they trust and use it consistently, and that is the right way to practise — familiarity with one system produces better positioning than dabbling across several.

But it is entirely reasonable to ask what you are getting, and why. If the answer involves a metal-on-metal bearing, that is worth a longer conversation. If it involves ceramic on ceramic, ask about squeaking. If it is ceramic on highly cross-linked polyethylene, you are getting the combination with the longest and best record we have.