A 63 year old lady, fit and well apart from osteoarthritis in her right hip, fell whilst on holiday in Devon. She had previously seen an Orthopaedic Surgeon in her home town, and was on a waiting list for a metal on metal resurfacing replacement of her right hip.

She sustained a valgus impacted subcapital fracture of her right femoral neck in the fall (Fig 1). In view of the pre existing symptomatic hip arthritis, after discussion with the patient, a total hip replacement was advised.

In view of her young age and high activity level, a hybrid THR was performed, with a press fit Trident cementless HA coated acetabular component, and a cemented Exeter stem (Figs 2 & 3). A cementless acetabular component was selected to allow for a hard on hard bearing couple with alumina ceramic on ceramic.

Despite the impressive in-vitro evidence to support ceramic on ceramic as a bearing couple, there is limited long term clinical data available of the use of ceramic in combination with contemporary acetabular components. A randomised controlled trial is therefore underway in Exeter, in patients under 65 years of age undergoing THR. This is investigating the long term clinical outcome of hybrid ceramic on ceramic versus a metal on cemented polyethylene bearing couple (the current gold standard).

In Exeter we do not currently recommend metal on metal resurfacing in view of the concerns with femoral neck fracture, metal ion release, the poor historical track record and the lack of long term results with current designs.