Clinicians › Hip

Bearing surfaces and wear

125 citationsUpdated Sep 2026

Overview

Total joint replacement articulations invariably produce wear, typically manifesting as the degradation of softer materials by harder counterparts [132]. This process is accelerated by surface roughening, such as scratching, or the interposition of third bodies like cement fragments [132]. While bearings are categorized as hard-on-soft (e.g., metal-on-polyethylene) or hard-on-hard (e.g., ceramic-on-ceramic) [132], the selection of the optimal bearing surface remains a challenge, particularly for young, active patients where no single couple is definitively established as the most biocompatible [49, 31]. Consequently, bearing surface choice is often experience-based rather than evidence-based due to limited long-term direct comparisons [6].

Metal-on-metal bearings have been largely abandoned due to higher failure rates associated with cobalt and chrome debris production, which triggers soft tissue inflammatory responses and pseudotumors [132, 2, 57]. Registry analyses confirm that patients receiving metal-on-metal total hip arthroplasty or hip resurfacing face a greater risk for revision compared to those with other bearing combinations [10]. In elderly patients, hard-on-hard bearings offer no demonstrable benefits and may increase short-term complication risks [20]. Therefore, metal-on-metal surfaces should be used with caution due to increased complications, cost, and adverse medical consequences [32].

Modern bearing surfaces aim to minimize wear particle generation to optimize prosthesis survival and reduce periprosthetic osteolysis [5, 8]. Metal-on-highly cross-linked polyethylene is considered the preferred surface for conventional total hip arthroplasty, demonstrating excellent results over the first 10 to 15 years [67]. Although contemporary alternatives are not a panacea and require further comparative studies [3], their use is recommended to avoid wear-related revisions [7]. Patient-specific wear rates correlate with gait patterns [1], and while ceramic-on-ceramic bearings may be preferentially considered for revision in young patients [15], the decision to revise metal-on-metal implants remains multifactorial and must rely on documented, objective clinical indications [26].

Anatomy & Pathophysiology

Joint Anatomy and Biomechanics

The hip is a multiaxial joint formed by the articulation between the pelvis and femur, connecting the axial skeleton and the lower extremity [86]. The hemipelvis comprises the ilium, ischium, and pubis, which unite at the triradiate cartilage within the concave acetabulum [86]. The acetabulum consists of an articular crescent-moon-shaped lunate surface and a nonarticular central fossa that serves as the attachment point for the ligamentum teres [86]. The acetabular labrum is a fibrocartilaginous ring attached to the rim of the acetabulum that extends the articulating surface area and increases femoral head coverage [86]. The femoral head forms two-thirds of a sphere, with a small depression at its center from which the ligamentum teres extends to connect to the acetabular notch [86].

The neck-shaft angle of the femur averages 125° [86], while normal version, defined as the head-neck angle in the frontal plane, averages 15 to 20° [86]. The hip joint is inherently stable due to its relatively rigid ball-and-socket configuration and high conformity [128]. The hip functions as a fulcrum, resulting in a state of equilibrium between body weight and the opposing abductor muscles [128]. An increase in femoral offset correlates with a decreased requirement of abductor force to produce a constant net hip moment, thereby decreasing joint reaction forces [128]. Conversely, a decrease in the abductor muscle force disrupts joint stability, triggering a reactive neuromuscular mechanism that increases muscular cocontraction and joint reaction forces [128]. Increasing the joint reaction force at the hip may increase the wear rate of the implant [128].

Peak contact forces vary with activity: walking generates approximately 2.5 times body weight [128], the push-off phase in running generates approximately 5.2 times body weight [128], and descending stairs produces the highest calculated forces and torques across the hip joint [128].

Ligamentous Support and Capsule

The iliofemoral ligament, also known as the Y ligament of Bigelow, is the thickest and strongest of the three main ligaments supporting the hip [86]. It functions to limit external rotation, while its lateral arm limits extension of the joint [86]. The ischiofemoral ligament provides support posteriorly and restricts internal rotation motion [86]. The pubofemoral ligament acts to limit abduction of the joint [86]. Deep fibers from the iliofemoral, ischiofemoral, and pubofemoral ligaments merge to form the zona orbicularis, which circumvents the femoral neck [86].

The hip capsule attaches anteriorly and posteriorly along the periphery of the acetabulum outside the labrum [87]. On the femur, it attaches anteriorly along the intertrochanteric crest, while on the posterior side it attaches only partially, leaving the basicervical region of the femoral neck and intertrochanteric region extracapsular [87]. The iliofemoral ligament becomes taut in full extension, preventing anterior dislocation and hyperextension of the hip [87]. The twisted orientation of the hip ligaments provides a screw mechanism for the hip in full extension [87]. The ligamentum teres originates in the cotyloid fossa and attaches on the fovea of the femoral head [87].

Osseous Morphology and Kinematics

The acetabulum is normally anteverted 15 degrees and obliquely oriented in the coronal plane 45 degrees caudally [92]. The posterosuperior articular surface of the acetabulum is thickened to accommodate weight bearing [92]. The inferior surface of the acetabulum contains the acetabular (cotyloid) notch, which is bound by the transverse acetabular ligament [92]. The femoral neck is normally anteverted approximately 14 degrees in relation to femoral condyles, with a range of 1 to 40 degrees [92]. The femoral neck-shaft angle averages 127 degrees [92].

The average range of motion of a normal hip includes approximately 120° of flexion, 30° of extension, 45° of abduction, 20° to 30° of adduction, 35° of internal rotation, and 45° of external rotation [94]. Normal gait function requires hip flexion of 30°, hyperextension of 10°, abduction and adduction of 5°, and internal and external rotation of 5° [94].

Muscular Function

Primary Flexors: The iliopsoas, rectus femoris, and sartorius muscles [94]. Primary Extensors: The gluteus maximus and hamstring muscles [94]. Abductors: Predominantly the gluteus medius and minimus muscles, which function together to maintain and abduct the femur during the stance phase of gait [94]. External Rotators: The obturator internus and externus, superior and inferior gemelli, quadratus femoris, and piriformis muscles [94]. Internal Rotators: The most consistent internal rotators are the gluteus medius and tensor fascia latae muscles [94].

Vascular & Neural Anatomy

The sacrospinous and sacrotuberous ligaments create the boundaries of the greater and lesser sciatic foramina [87]. The piriformis muscle and the sciatic nerve exit from the greater sciatic foramen [87]. The short external rotator muscles exit from the lesser sciatic foramen [87].

The superior gluteal nerve and artery exit the pelvis above the piriformis muscle [94]. The pudendal nerve, internal pudendal artery, nerve to the obturator internus, posterior femoral cutaneous nerve, sciatic nerve, inferior gluteal nerve, inferior gluteal artery, and nerve to the quadratus femoris exit the pelvis below the piriformis [94]. In 10% of cases, the common peroneal component of the sciatic nerve can pass through the division in the piriformis [94].

The medial femoral circumflex artery is the main blood supply to the femoral head in adulthood [100]. From birth to approximately 4 years of age, the major blood supply to the femoral head comes from the medial and lateral femoral circumflex arteries, with major contributions from the artery of the ligamentum teres [100]. From the age of 4 years to adulthood, the posterosuperior and posteroinferior retinacular arteries from the medial circumflex artery are the major blood supply to the femoral head [100].

The common femoral vessels are the most commonly reported extrapelvic vascular structures injured during total hip arthroplasty [100]. The most common mechanism of injury to the common femoral vessels during total hip arthroplasty is errant retractor placement anterior to the acetabulum [100]. The profundus or deep femoral artery arises from the lateral aspect of the common femoral artery approximately 3.5 cm below the inguinal ligament [100]. The lateral circumflex artery arises from the lateral side of the proximal profundus femoris artery [100]. The medial circumflex artery most commonly comes from the posteromedial profundus femoris artery and traverses between the pectineus and psoas muscles [100]. The superior gluteal vessels are branches of the posterior division of the internal iliac artery and are closest to the hip as they exit from the sciatic notch [100]. The inferior gluteal vessels and internal vessels are branches of the anterior division of the internal iliac artery and exit the pelvis between the piriformis and coccygeus muscles [100].

Wear Mechanisms and Tribology

Tribology is the science and technology of friction, lubrication, and wear in interacting surfaces in relative motion [44]. Wear is defined as the removal of surface material by mechanical motion [82], caused by friction, motion, and loading of an interface between materials [82]. Wear damage is defined as the change in surface texture or morphology caused by the action of the wear mechanisms [14]. Lubrication mechanisms act to reduce friction and wear [82].

Wear Types: * Abrasive wear: Occurs when a rougher, harder surface moves against a softer surface, generating particulate debris from the softer surface [82]. It also occurs when a rough femoral head surface causes mechanical scratching of the polyethylene surface with loss of polyethylene material [105]. * Adhesive wear: Results between two moving objects in contact whereby a thin layer of material is transferred from one surface to another [82]. Wear occurs in the material which donates the film during adhesive wear [82]. Adhesive wear predominates in the metal-on-polyethylene bearings used in total hip arthroplasty [44] and is the most important process that generates submicron-sized polyethylene particles [105]. * Third-body wear: Results when an additional particle is present between the two main bearing surfaces, leading to friction and loss of material at the contact surface [82]. Third-body particles within the joint space get between the head and polyethylene cup, causing abrasion and removal of polyethylene from the cup surface [105]. Sources of third-body particles include cement debris, metal debris shed from the cup or stem, and metal debris from metal corrosion at modular metal-metal interfaces [105]. * Fatigue and Delamination: Delamination, abrasion, and adhesive wear are commonly seen with total knee arthroplasty [44]. The classical wear mechanisms that apply to prosthetic joints include adhesion, abrasion, and fatigue [14].

Wear Modes: * Mode 1: Occurs when the two bearing surfaces are articulating against each other in the manner intended by the implant designer [14]. * Mode 2: Occurs when a bearing surface articulates against a non-bearing surface [14]. * Mode 3: Occurs when third-body abrasive particles have become entrapped between the two bearing surfaces [14]. * Mode 4: Occurs when two non-bearing surfaces are wearing against each other [14]. The least wear occurs in Mode 1, whereas severe wear typically occurs in Modes 2, 3, and 4 [14].

Friction between two sliding surfaces depends on the applied load, not the area of contact or speed of movement [96]. Normal human joints possess coefficients of friction that are about ten times lower than those of various combinations of prosthesis-bearing materials [96]. Metal on ultra-high molecular weight polyethylene produces a better coefficient of friction than other combinations, which is improved further if the metal is replaced by a ceramic such as alumina or zirconium [96]. Synovial fluid reduces the coefficient of friction by forming a fluid film lubrication layer or a molecular-width coating for boundary lubrication [96]. Wear is proportional to the load and distance of movement between the two surfaces [96]. Causes of wear between surfaces include abrasion, adhesion, and debris trapped between articulating surfaces causing third-body wear [96].

Polyethylene wear comes from bearing wear at the head-cup articulation and backside wear where the polyethylene insert rubs against the metal shell [105]. Backside wear occurs because the polyethylene locking mechanism does not completely inhibit polyethylene micromotion against the metal shell [105]. The more backside micromotion allowed, the more polyethylene debris is generated [105]. Billions of particles are generated by polyethylene bearings [105]. Submicron-sized particles shed by the polyethylene bearing are responsible for eliciting the osteolysis reaction [105]. Osteolysis is more likely when the number of polyethylene particles exceeds 10 billion particles per gram of tissue [105]. Osteolysis is rarely observed at a linear wear rate of less than 0.1 mm per year, termed the "osteolysis threshold" [105].

Metal wear particles may cause local inflammation, scarring, and occasionally a toxic or allergic reaction [96]. Metal wear particles may cause implant loosening following their uptake by macrophages and subsequent activation of osteoclastic bone resorption [96]. Metal wear particles may provoke a lymphocyte-dominated vasculitis-associated reaction locally [96]. The presence of metal wear particles has been demonstrated in lymph nodes and other organs far distant from the implant [96].

Tribochemical reactions play an important role in the wear of metal-on-metal joints [61]. The generated tribomaterial, which forms by mechanical mixing of the uppermost nanocrystalline zone of the metal surface with proteins from the synovial fluid, governs the wear rate and influences the corrosive behavior of the bearing [61]. Nanometer-sized wear particles in metal-on-metal joints may initially originate from the passivation layer covering the implant surface and then detach from this tribolayer [61]. The tribolayer appears to have beneficial effects on the wear of metal-on-metal bearings [61]. The inflammatory response observed surrounding metal-on-metal implants appears to be lower than that around metal-on-polyethylene implants [61]. Metallic byproducts from metal-on-metal implants can complex with proteins and lead to a T lymphocyte-mediated hypersensitivity response [61]. Wear and tribocorrosion remain important causes of failure in joint arthroplasty, with metal-on-metal bearings and taper tribocorrosion being prominent clinical concerns due to associated soft tissue inflammatory responses [2]. Fretting and corrosion damage occurs at a variety of modular component interfaces in contemporary metal-on-metal total hip arthroplasties [195].

Hip and knee joint simulators are the accepted means for obtaining preclinical test data on wear performance [44]. Hip and knee joint simulators have been shown to produce wear particles of similar size and shape to those observed in vivo [44]. Wear is measured periodically and gravimetrically on the basis of the small amount of weight that a material loses during its use [44]. One million cycles of test use is equal to 1 year of clinical use, although recent literature has shown that some patients experience nearly 2 million cycles of activity per year [44].

Most design parameters influencing wear of contemporary bearings under idealized conditions are well understood, but major confounding considerations arise in vivo from suboptimal component positioning and third-body debris [11]. Neither patient-specific factors nor estimated hip contact force have a major influence on annual wear in DuraLoc cups [39]. The future of hip bearing development needs to be focused on performance issues with the entire total hip arthroplasty construct rather than on the abrasive wear resistance of the bearing couple per se [75].

The findings suggest that a likely cause of squeaking in hip arthroplasty is adverse tribological conditions caused by suboptimal lubrication [71]. Differing audible sounds were detected in total hip arthroplasties with variable bearing surfaces, likely related to differing bearing materials or variable hip kinematic patterns [137]. The study represents the first attempt to establish baseline acoustic characteristics for total hip prostheses with various bearing surfaces and to correlate in vivo sound with femoral head separation [188].

Deformed acetabular shells produced higher frictional torque than spherical shells [166]. It is likely that impaction deformation with consequent friction, wear, and micromotion contributed to the early failure of the Durom acetabular component [167]. Other surgical, implant, and patient factors should be considered when determining the mechanisms of failure of large diameter metal-on-metal hip arthroplasties [158]. Current technology or design of some total hip arthroplasty systems that make use of a large-diameter femoral head may not yet allow the use of modular large heads with a metal-on-metal articulation, especially in young, active male patients [177].

An acetabular component inclination of 50° and an anteversion of 25° allowed the most physiologic range of hip motion in metal-on-metal hip resurfacing [131]. High ion levels were associated with an abduction angle of more than 45° and repetitive extreme hip motion in revision metal-on-metal cases [163]. Acetabular inclination angle is not a meaningful determinant of metal ion levels in ASR arthroplasties [196]. Anterior iliopsoas impingement caused by large-diameter metal-on-metal femoral heads is a potential failure mechanism resulting in persistent groin pain [197].

The battery-powered, handheld impaction system provides consistent and sufficient force to loosen modular taper junctions of dual mobility or metal-on-metal liners without damaging the well-fixed acetabular shell [180]. The dual mobility hip with sequentially crosslinked polyethylene was highly wear resistant under all test conditions [176]. This uncemented acetabular component and this particular XLPE had low rates of linear and volumetric wear [193]. This acetabular component and XLPE with large

Classification

Wear Modes: The classification of wear in prosthetic joints is defined by the interaction between surfaces and the presence of third-body particles. Wear Mode 1 occurs when two bearing surfaces articulate against each other in the manner intended by the implant designer [14]. This mode results from motion between the intended primary bearing surfaces, such as the prosthetic femoral head against the polyethylene acetabular bearing surface [70]. Wear Mode 2 occurs when a bearing surface articulates against a non-bearing surface [14]. Specifically, this refers to a primary bearing surface moving against a secondary surface that is not intended to move against it [70]. Wear Mode 3 occurs when third-body abrasive particles become entrapped between two bearing surfaces [14]. This mode involves primary surfaces with the interposition of third-body particles [70]. Wear Mode 4 occurs when two non-bearing surfaces wear against each other [14]. This refers to two nonprimary surfaces rubbing together, such as impingement of the prosthetic femoral neck on the rim of the acetabular component [70].

Wear Mechanisms and Damage: Classical wear mechanisms applicable to prosthetic joints include adhesion, abrasion, and fatigue [14]. Wear damage is defined as the change in surface texture or morphology caused by the action of these wear mechanisms [14]. The least wear occurs in Wear Mode 1, whereas severe wear typically occurs in Modes 2, 3, and 4 [14].

Other Considerations: Metal debris generated from taper junctions appears to have a different morphology and composition than debris generated from bearing surfaces [147].

Clinical Presentation

General Wear and Osteolysis

Clinical experience prior to the year 2000 documented rates of wear and osteolysis ranging from 10% to as high as 70% at 7- to 14-year follow-up [19]. The greatest patient activity and wear occurred during the first 5 years [21]. Impingement provides a potent mechanism for third-body access to wear-critical central areas of the bearing surface, potentiating accelerated or outlier wear and heightened osteolysis propensity [22]. Early detection of severe polyethylene wear may permit revision of only the femoral head and liner to prevent catastrophic outcomes [29]. Regular long-term patient follow-up is needed to detect evidence of occult polyethylene wear at the earliest opportunity [50].

Metal-on-Metal Specific Presentation

Patients who receive metal-on-metal total hip arthroplasty and hip resurfacing are at greater risk for revision than patients who receive total hip arthroplasty using a different bearing surface combination [10]. The rate of groin pain was 15% with metal-on-metal THA and 18% with total hip resurfacing, compared to 7% after THA with conventional bearing surfaces [27]. Younger patients were more likely to report groin pain postoperatively and more likely to have metal-on-metal bearing surfaces [27]. Sterile soft tissue lesions appear to be present in a sizeable proportion (N50%) of unexplained painful MOM hips [23]. Wasting of the glutei or short external rotators was present almost universally in the population of unexplained painful MOM hips [23]. Pseudotumors, masses, and enlarged bursae have been reported in hips with M-M bearings associated with pain and swelling [114]. Histological features support the formation of pseudotumors from both wear and hypersensitivity reactions [114]. Increased bearing articulation wear and serum metal ion concentrations in cases with taper interface corrosion support the hypothesis that increased friction in the joint articulation is one of the factors responsible for simultaneous articulation and taper damage [60]. A lesion on MARS MRI is not synonymous with the need for intervention [23]. Ultrasound examination provides sensitive screening of soft tissue reactions around metal-on-metal bearings and may be useful in monitoring progression and defining treatment for periarticular soft tissue abnormalities [51]. Current worldwide guidance for metal-on-metal hip patients is neither evidence-based nor financially sustainable, with most protocols lacking the sensitivity to detect asymptomatic adverse reaction to metal debris lesions [24]. In cases of painful metal-on-metal hip arthroplasty with elevated inflammatory markers, revision and reorientation of the acetabular component with conversion to a non-metal-on-metal bearing can address both mechanical subluxation and metal hypersensitivity when infection is not confirmed [133]. Following 8 dislocations and visible wear, a patient with a metal-on-metal hip prosthesis suffered no additional complications such as osteolysis or black tissues [134].

Ceramic Bearing Specific Presentation

The larger 'bedding-in' head penetration in contemporary dual mobility heads may be due to the additional convex bearing surface, creating 2 surfaces for deformation/wear [30].

Diagnostic and Surveillance Findings

Diagnosis and surveillance of wear-related problems should include measurement of wear and imaging methods such as radiographic edge detection, spiral CT, MRI, and radiostereometric analysis to assess the extent and progression of osteolysis [53]. The migration of components and polyethylene wear can be measured without needing specialised radiographs [28]. While three-dimensional analysis detected 10% more wear than two-dimensional analysis, its repeatability was four times worse, resulting in higher patient enrollment requirements for wear detection [52]. Technologies such as whole genome screening and proteomics show great promise for identifying biomarkers exclusively associated with wear-induced osteolysis, but standardized protocols and methods to distinguish these markers from non-wear-related pathologies are needed [122]. Increased patient age, higher BMI, inflammatory arthritis diagnosis, and ceramic femoral heads were associated with decreased wear rates [129].

Investigations

Wear Measurement and Surveillance

Plain radiography: Conventional radiographs remain critical in the initial imaging evaluation of the hip [46]. Close radiographic monitoring with determination of linear wear rates is recommended to assess the risk of osteolysis [142]. Multiple radiographic views and determination of linear wear rate are recommended, while CT scans may be needed only when surgical intervention is considered [140]. A single prerevision radiograph appears to be sufficient to assess 2-dimensional in vivo wear [168]. Radiographic wear data on conventional polyethylene are consistent with laboratory studies showing that radiation-induced cross-linking has a beneficial effect on wear resistance [150].

CT: A clinically available high-resolution CT scanner can estimate 3D displacement of 0.026 ± 0.101 mm, indicating it is a clinically relevant tool for measuring polyethylene wear in total hip arthroplasty [80]. Three-dimensional analysis detected 10% more wear than two-dimensional analysis, but its repeatability was four times worse [52].

Other Considerations: The use of PolyWare and Hip Analysis Suite imaging techniques for measurement of polyethylene wear in the clinical setting appears to be acceptable, provided that their limitations are understood [74]. Patient-specific polyethylene wear rates are associated with patients' gait patterns [1].

Metal-on-Metal Surveillance

MRI: Metal artifact reduction MRI is advised in all patients with metal-on-metal hip arthroplasties [173]. Most patients with a metal-on-metal total hip replacement who do not undergo early revision have normal MRI scans [157]. Wasting of the glutei or short external rotators was present almost universally in a population of unexplained painful MOM hips [23].

Laboratory: Metal ion levels are not sufficient as a screening measure for adverse reactions in metal-on-metal hip arthroplasties [173]. The consensus statement recommends safety assessment for all patients with metal-on-metal bearings, with closer follow-up for large head bearings and resurfacing involving x-rays and metal ion measurement [165].

Imaging Modalities

MRI: MRI is the modality of choice for patients suspected of soft tissue or intra-articular pathology, given its superior sensitivity and specificity [104]. MRI is helpful in assessing complications of conventional and resurfacing hip arthroplasties, particularly those with metal-on-metal bearing systems [118]. Major findings that help predict histologic ALVAL scores include synovial thickening, synovitis, synovial volume, abductor disruption, and soft-tissue edema [118].

CT: CT scans are effective for examining cortical and cancellous bone and can be used to create three-dimensional reconstructions of the hip for use in surgical planning [104].

Ultrasonography: Ultrasonography can be an effective modality to identify musculotendinous disruptions, effusions associated with intra-articular pathology, or inflammatory conditions, such as bursitis [104].

Wear Determinants and Mechanisms

Other Considerations: The orientation of the acetabular component affects polyethylene wear, with abduction angles of ≥45° associated with a 40% increase in mean linear polyethylene wear compared to angles <45° [68]. The hip center of rotation can be moved superiorly and/or medially to permit cup inclination below 45° with correct cup coverage [17]. Impingement provides a potent mechanism for third-body access to wear-critical central areas of the bearing surface, thus potentiating accelerated/outlier wear and heightened osteolysis propensity [22]. One should consider replacement of all heads in a failed closed reduction, and those patients successfully reduced should at least be monitored for excessive wear [79].

Treatment

Non-Operative

Nonoperative management is advocated for patients with mild and transient symptoms of trunnionosis, negative MRI findings, and inconclusive metal ion levels, managed by interval 6-month re-evaluation [43]. Patients with mild trunnionosis symptoms should abstain from high-impact activities to decrease force load on the prosthesis [43].

Operative

Indications: Indications for modular bearing change include a symptomatic patient with polyethylene wear, significant linear polyethylene wear associated with progressive radiographic osteolysis with concern for impending catastrophic failure, and recurrent instability and/or mechanical symptoms of subluxation [108]. For patients with confirmed trunnionosis on imaging and laboratory investigations, the next appropriate step is consideration of revision total hip arthroplasty [43].

Surgical Approach / Technique: Isolated liner exchange is a viable treatment option in the patient with radiographically demonstrated polyethylene wear in which the acetabular component is well-fixed [59]. Implants must be well fixed to bone and adequately positioned for isolated liner exchange; loose implants should be revised [108]. Both the liner and the head must be exchanged during modular bearing change [108]. Bone grafting of osteolytic lesions behind the cup is performed with particulate graft through cup holes or a small iliac trap door [108]. Cementing of a polyethylene bearing into a fixed porous cup is indicated when there is a damaged or worn locking mechanism or the replacement polyethylene bearing is not available [108]. Technique requirements for cementing a polyethylene liner include optimization of polyethylene cup position to avoid neck impingement, deep seating of the polyethylene liner into the metal cup, roughening of the back side of the polyethylene liner insert, and roughening of the inside surface of the metal cup shell [108]. Preoperative planning for trunnionosis revision includes careful evaluation of radiographs and MRI images to evaluate prosthetic alignment and the extent of soft tissue involvement [43]. Operative exposure allows for the most accurate evaluation of the extent of local soft tissue damage, particularly if there is any abductor or other muscle deficiency [43]. Any necrotic soft tissue should be appropriately excised during revision for trunnionosis [43]. Revision of adverse wear related failure had an excellent outcome using limited debridement and a stable large metal bearing placed in the correct position [171].

Implant Selection: Ceramic-on-ceramic bearings have superior wear resistance when compared with all other available alternative bearing surfaces, providing an excellent alternative for young and very active patients [66]. The use of modern bearings is recommended to avoid wear-related complications and revisions, considering their superior performance [7]. Intermediate-term follow-up data suggest that the prevalence and severity of osteolysis may be reduced with alternative bearing materials compared with conventional metal-on-polyethylene bearing surface couples [34]. Both ceramic-on-ceramic and ceramic-on-crossfire-polyethylene bearing surfaces performed well out to 10 years in subjects who were <61 years at time of surgery [16]. Both oxidized zirconium and cobalt chrome articulations demonstrated polyethylene wear rates well below the threshold for osteolysis at 10 years [36]. The alumina matrix composite femoral head on an alumina liner provided high survivorship and performed as well as the control device in terms of reoperation, and clinical and radiographic outcome [192]. The four to seven-year experience with the Metasul metal-on-metal articulation indicates that clinical results are similar to those of total hip replacements with a metal-on-polyethylene articulation [9]. The long-term experiences with metal-on-metal total hip arthroplasty make this combination of implant material the conservative choice for success [77]. Bearing surface choice in primary total hip arthroplasty has changed tremendously from 2007 to 2015, with metal-on-metal bearing use decreasing as a result of adverse effects [4]. The authors consider that the use of large-head metal-on-metal total hip arthroplasty should be discontinued [135]. Gender factors, potentially hormonal, anatomic, or functional, influence the success of metal-on-metal total hip arthroplasty, leading to expanded contraindications to avoid this device in female patients [130].

Other Considerations: Wear and tribocorrosion remain important causes of failure in joint arthroplasty, with metal-on-metal bearings and taper tribocorrosion currently being prominent clinical concerns due to associated soft tissue inflammatory responses [2]. There was no difference in the rate of rerevision comparing different types of the initial revision and comparing different bearing surfaces used for the first revision of hip resurfacing arthroplasty [35]. Clinical experience before the year 2000 included rates of wear and osteolysis from 10% to as high as 70% at 7- to 14-year follow-up [19]. Severe acetabular bone defects were predicted by an increased wear rate and increased patient height, while femoral bone defects were predicted by increased wear rate and placement of the cup outside of the true acetabulum [37]. Articulating components should minimise the generation of wear particles in order to optimize long-term survival of the prosthesis [5]. The clinical outcome of an uncemented total hip arthroplasty can be considered comparable to other uncemented total hip arthroplasties, with a mean polyethylene wear of 1.8 mm and an annual wear rate of 0.15 mm/y [138]. The most common postoperative complication of isolated head and liner exchange for polyethylene wear is dislocation [108]. Postoperative physical therapy for isolated acetabular liner exchange allows immediate and full weight-bearing [59]. Postoperative precautions for isolated acetabular liner exchange include not crossing legs, not flexing the hip >90°, not internally or externally rotating the operated leg, and avoiding low seats for at least 6 weeks [59]. A hinged hip abduction orthosis restricting motion to <90° of flexion may be used for 6 weeks in patients with questionable intraoperative stability [59]. There are four modes of wear: (1) between primary bearing surfaces as intended by the designer; (2) between one bearing surface and a nonbearing surface; (3) third-body wear; and (4) between two nonbearing surfaces [44]. Hip and knee joint simulators are the accepted means for obtaining preclinical test data on wear performance and have been shown to produce wear particles of similar size and shape to those observed in vivo [44]. Wear is measured periodically and gravimetrically on the basis of the small amount of weight that a material loses during its use, with 1 million cycles of test use equal to 1 year of clinical use [44]. Recent literature has shown that some patients experience nearly 2 million cycles of activity per year [44]. Wear damage can best be defined as the change in surface texture or morphology that is caused by the action of the wear mechanisms [14]. Fatigue, wear, and corrosion are the three major types of failures that can occur in joint replacement components [48]. By reducing abrasion, surface structuring could be used to extend the life of prostheses and minimise the number of revisions [191].

Complications

Wear and Osteolysis

Polyethylene wear: Highly cross-linked polyethylene maintains wear resistance despite surface changes occurring during the first year of in vivo service [73]. Linear penetration measurements differ significantly between AP pelvis and AP hip radiographs, with lower rates recorded using AP pelvis views [38]. Polyethylene wear and dislocation can occur with an average time from initial arthroplasty to dislocation of 9 years (range, 5 to 20 years) [154]. Catastrophic failure of a polyethylene liner can lead to metallosis, characterized by asymmetric polyethylene wear, femoral head migration, and heterotopic ossification [155].

Ceramic bearings: Survivorship and function of alumina ceramic-on-ceramic and ceramic-on-conventional polyethylene bearing groups remain comparable at 15 years, while polyethylene wear and osteolysis may represent issues in the future [65].

Metal-on-Metal Specific Complications

Revision risk: Patients who receive metal-on-metal total hip arthroplasty and hip resurfacing are at greater risk for revision than are patients who receive total hip arthroplasty using a different bearing surface combination [10]. Bearing surface choice in primary THA has changed tremendously from 2007 to 2015, with metal-on-metal bearing use decreasing as a result of adverse effects [4]. Hard-on-hard bearings used in elderly THA patients are associated with no demonstrable benefits and possibly an increased risk of complications at short-term follow-up [20].

Aseptic loosening: Aseptic loosening was the major reason for failure of Sikomet metal-on-metal prostheses after a mean duration of follow-up of seven years [78]. Poor implant survivorship and frequent complications were observed at a median of 10 years after metal-on-metal hip resurfacing revision [141].

Soft tissue reactions: Sterile soft tissue lesions appear to be present in a sizeable proportion (>50%) of unexplained painful metal-on-metal hips [23]. Wasting of the glutei or short external rotators was present almost universally in a population of unexplained painful metal-on-metal hips [23]. A lesion on MARS MRI is not synonymous with the need for intervention, as asymptomatic soft tissue lesions similar in appearance to symptomatic lesions have been identified [23].

Mechanical and ion-related factors: High cup inclination and large femoral head size have been shown to increase metal ion production secondary to edge loading [56]. The presence of abnormal noise after hard-on-hard bearing implantation necessitates periodical follow-up and searching for mechanical complications [169]. Bilateral simultaneous metal inlay dissociation from the polyethylene liner of a metal-on-metal hip replacement has been reported [169].

Long-term surveillance: No unexplained pain or other complication attributable to wear debris or the metal-on-metal articulation was observed in minimum 5-year results of modular metal-on-metal total hip arthroplasty [25]. Additional follow-up is necessary to determine any possible long-term deleterious effects associated with metal-on-metal articulation in patients less than fifty years old [63]. It will take decades of close clinical observation to determine if the benefits of metal-on-metal bearings outweigh the associated risks [64].

Resurfacing-specific outcomes: Hip resurfacing arthroplasty is associated with lower metal ion levels and revision risk compared with large-head metal-on-metal total hip arthroplasty [152]. In hip resurfacing for osteonecrosis, the main reason for revision was femoral loosening (8.7% of hips) [153]. In hip resurfacing for ankylosing spondylitis, the main reason for revision was femoral-neck fracture (5.2% of hips) [153].

Other Considerations

General complication rates: The risk of short-term complication (including dislocation) and revision THA were similar among appropriately matched Medicare THA patients regardless of bearing surface [139].

Tribology and noise: A likely cause of squeaking in hip arthroplasty is adverse tribological conditions caused by suboptimal lubrication [71].

Ceramic-on-metal performance: Although both ceramic-on-metal and metal-on-metal bearings performed well at short-term followup, the ceramic-on-metal bearing group had no wear-related revisions and maintained consistently low metal levels [13].

Recovery

Other Considerations: The provided evidence base for this section consists exclusively of long-term implant survivorship, wear characteristics, and comparative clinical outcomes. It does not contain data regarding post-operative rehabilitation protocols, weight-bearing restrictions, immobilisation durations, or specific timelines for the return to light or full activity. Consequently, the fields for Light activity (weeks), Full activity (months), Complete recovery / outcome plateau (months), Rehabilitation protocol, and Functional milestones are omitted as no genuine recovery-timeline evidence exists in the source material.

The following clinical observations regarding bearing surface performance and survivorship are reported at various follow-up intervals and serve as outcome benchmarks rather than recovery timelines:

Contemporary alternative bearing surfaces are not a panacea, and detailed comparative clinical studies are required to determine factors associated with implant performance and survivorship [3]. Bearing surface choice in primary total hip arthroplasty changed tremendously from 2007 to 2015 [4], with metal-on-metal bearing use decreasing during this period as a result of adverse effects [4]. Long-term data regarding the performance of alternative bearing materials are presently unavailable [34].

Regarding specific articulations, clinical results of the Metasul metal-on-metal articulation at four to seven years are similar to those of total hip replacements with a metal-on-polyethylene articulation [9]. The ceramic-on-metal bearing group had no wear-related revisions at short-term follow-up [13] and maintained consistently low metal levels at short-term follow-up [13]. Both ceramic-on-ceramic and ceramic-on-crossfire-polyethylene bearing surfaces performed well out to 10 years in subjects who were younger than 61 years at the time of surgery [16]. No unexplained pain or other complication attributable to wear debris or the metal-on-metal articulation was observed in a minimum 5-year follow-up of modular metal-on-metal total hip arthroplasty [25].

Groin pain rates vary by bearing surface: the rate was 7% after total hip arthroplasty with conventional bearing surfaces [27], 15% after metal-on-metal total hip arthroplasty [27], and 18% after total hip resurfacing [27]. Survivorship and function of alumina ceramic-on-ceramic and ceramic-on-conventional polyethylene bearing groups remain comparable at 15-year follow-up [65], although polyethylene wear and osteolysis may represent issues in the future for ceramic-on-conventional polyethylene bearings [65]. Clinical and radiographic results of second-generation metal-on-metal bearings continue to be comparable with the results observed for other hard-on-hard bearings [72]. Long-term experiences with metal-on-metal total hip arthroplasty make this combination of implant material the conservative choice for success [77].

In revision and resurfacing contexts, Delta-on-Delta couplings demonstrated to be reliable bearing surfaces in revision settings at a midterm follow-up [144]. The functional outcome of hip resurfacing in patients 40 years old and younger was excellent [145], yet overall survival of hip resurfacing in this demographic was unsatisfactory with a 7-year survival of 90.5% [145]. The 5-year survivorship of metal-on-metal hybrid hip resurfacing was 95.2% with no failures in hips implanted since 2002 [149]. A specific metal-on-metal total hip implant with a modular titanium adapter demonstrated more favorable mid-term to long-term survivorship compared to other designs [156].

Key Evidence

• [L3] Patient-specific wear rates are associated with patients' gait patterns. [1] (10.1007/s11999-017-5293-x)
• [L5] Wear and tribocorrosion remain important causes of failure in joint arthroplasty, with metal-on-metal bearings and taper tribocorrosion currently being prominent clinical concerns due to associated soft tissue inflammatory responses. [2] (10.1007/s11999-014-3610-1)
• [L5] Contemporary alternative bearing surfaces are not a panacea, and detailed comparative clinical studies are required to determine the factors associated with implant performance and survivorship. [3] (10.2106/jbjs.f.00453)
• [L3] Bearing surface choice in primary THA has changed tremendously from 2007 to 2015, with metal-on-metal bearing use decreasing as a result of adverse effects. [4] (10.1016/j.arth.2017.07.044)
• [L5] Articulating components should minimise the generation of wear particles in order to optimize long-term survival of the prosthesis. [5] (10.1302/2058-5241.1.000004)
• [L5] Selection of the bearing surface is often 'experience-based' rather than 'evidence-based' due to limited direct comparisons at long-term follow-up. [6] (10.1302/2058-5241.3.180300)
• [L3] Considering the superior performance of modern bearings, their use is recommended to avoid wear-related complications and revisions. [7] (10.1186/s42836-026-00408-4)
• [L4] Alternative bearing surfaces with lower wear rates and less particulate debris formation may have the potential to improve total joint arthroplasty survivorship by decreasing periprosthetic osteolysis, especially in younger, high-demand patients. [8] (10.5435/00124635-199807000-00001)
• [L4] The four to seven-year experience with this articulation surface indicates that the clinical results are similar to those of total hip replacements with a metal-on-polyethylene articulation. [9] (10.2106/00004623-200006000-00005)
• [L2] Analyses conducted on objective patient-oriented outcomes by two joint registries indicate that, overall, patients who receive metal-on-metal total hip arthroplasty and hip resurfacing are at greater risk for revision than are patients who receive total hip arthroplasty using a different bearing surface combination. [10] (10.5435/jaaos-20-06-402)
• [L5] Most design parameters influencing wear of contemporary bearings under idealized conditions are well understood, but major confounding considerations arise in vivo from suboptimal component positioning and third-body debris. [11] (10.5435/00124635-200800001-00020)
• [L3] Ceramic bearing surfaces were associated with fewer dislocations after revision than polyethylene bearing surfaces. [12] (10.1007/s11999-015-4378-7)
• [L1] Although both bearings performed well at short-term followup, the CoM bearing group had no wear-related revisions and maintained consistently low metal levels. [13] (10.1007/s11999-015-4424-5)
• [L5] [14] (10.1016/j.biomaterials.2007.07.040)
• [L4] Ceramic-on-ceramic bearing surfaces can be preferentially considered for revision THA, especially in young patients. [15] (10.1016/j.arth.2009.04.016)
• [L1] Both bearing surfaces performed well out to 10 years in subjects who were <61 years at time of surgery. [16] (10.1016/j.arth.2015.11.043)
• [L3] The hip center of rotation can be moved superiorly and/or medially to permit cup inclination below 45° with correct cup coverage. [17] (10.1016/j.arth.2007.06.008)
• [L3] Caution should be exercised when choosing bearing surfaces for adverse reaction to metal debris revisions. [18] (10.1302/0301-620x.96b12.33473)
• [L4] Clinical experience before the year 2000 included rates of wear and osteolysis from 10% to as high as 70% at 7- to 14-year follow-up. [19] (10.5435/00124635-200800001-00003)
• [L3] Hard-on-hard bearings used in elderly THA patients are associated with no demonstrable benefits and possibly an increased risk of complications at short-term follow-up. [20] (10.1016/j.arth.2012.03.031)
• [L3] The greatest patient activity and wear occurred during the first 5 years. [21] (10.1007/s11999-012-2497-y)
• [L4] This corroborates other recent modalities of evidence that impingement provides a potent mechanism for third-body access to wear-critical central areas of the bearing surface, thus potentiating accelerated/outlier wear and heightened osteolysis propensity. [22] (10.1097/blo.0b013e31815c5a7b)
• [L4] [23] (10.1016/j.arth.2009.11.008)
• [L5] Current worldwide guidance for metal-on-metal hip patients is neither evidence-based nor financially sustainable, with most protocols lacking the sensitivity to detect asymptomatic adverse reaction to metal debris lesions. [24] (10.1016/j.arth.2015.03.009)
• [L3] No unexplained pain or other complication attributable to wear debris or the metal-on-metal articulation was observed. [25] (10.1016/j.arth.2011.07.002)
• [L5] The decision to perform revision hip arthroplasty of a metal-on-metal implant is multifactorial and should be based on documented, objective clinical indications. [26] (10.5435/jaaos-d-14-00183)
• [L4] [27] (10.1007/s11999-010-1356-y)
• [L4] The migration of components and polyethylene wear can be measured without needing specialised radiographs. [28] (10.1302/0301-620x.99b10.bjj-2016-1169.r1)
• [L5] Early detection of severe polyethylene wear may permit revision of only the femoral head and liner to prevent catastrophic outcomes. [29] (10.1007/s00402-009-0843-7)
• [L4] The larger 'bedding-in' head penetration may be due to the additional convex bearing surface, creating 2 surfaces for deformation/wear. [30] (10.1016/j.arth.2018.02.061)
• [L3] Determining the optimal bearing surface for extremely young patients continues to be a challenge for orthopedic surgeons as they weigh the risks and benefits of each. [31] (10.1016/j.arth.2016.01.061)
• [L1] Due to the lack of superiority, increased complications, greater cost, and potential adverse medical consequences, these bearing surfaces should be used with caution. [32] (10.1016/j.arth.2012.05.023)
• [L4] Intermediate-term follow-up data suggest that the prevalence and severity of osteolysis may be reduced with alternative bearing materials compared with conventional metal-on-polyethylene bearing surface couples, but long-term data are presently unavailable and future performance awaits clinical validation. [34] (10.5435/00124635-200800001-00008)
• [L3] There was no difference in the rate of rerevision comparing different types of the initial revision and comparing different bearing surfaces used for the first revision. [35] (10.1007/s11999-015-4215-z)
• [L3] Both bearing combinations demonstrated wear rates well below the threshold for osteolysis. [36] (10.1016/j.arth.2022.02.099)
• [Paper] Severe acetabular bone defects were predicted by an increased wear rate and increased patient height, while femoral bone defects were predicted by increased wear rate and placement of the cup outside of the true acetabulum. [37] (10.1007/s00264-009-0731-3)
• [L3] There was a significant difference in linear penetration measurements between AP pelvis and AP hip radiographs, with lower rates recorded using AP pelvis. [38] (10.1016/j.arth.2013.07.034)
• [L4] Neither patient-specific factors nor estimated hip contact force have a major influence on annual wear in DuraLoc cups. [39] (10.1016/j.arth.2017.07.027)
• [L4] [43] (10.1016/j.arth.2018.05.035)
• [L2] There remains no clear indication which THA bearing couple is the most biocompatible, especially in young active patients. [49] (10.1302/0301-620x.97b9.34824)
• [L5] The authors emphasize the need for regular long-term patient follow-up to detect evidence of occult polyethylene wear at the earliest opportunity. [50] (10.1007/s00402-009-0979-5)
• [L4] Ultrasound examination provides sensitive screening of soft tissue reactions around metal-on-metal bearings and may be useful in monitoring progression and defining treatment for periarticular soft tissue abnormalities. [51] (10.1016/j.arth.2011.09.015)
• [L4] While three-dimensional analysis detected 10% more wear, its repeatability was four times worse than that of the two-dimensional technique and, as a consequence, patient enrollment requirements for wear detection were higher. [52] (10.2106/00004623-200306000-00020)
• [L5] Diagnosis and surveillance of wear-related problems should include measurement of wear and imaging methods such as radiographic edge detection, spiral CT, MRI, and radiostereometric analysis to assess the extent and progression of osteolysis. [53] (10.5435/00124635-200800001-00005)
• [L5] [56] (10.1016/j.arth.2020.01.011)
• [L4] The routine use of metal-on-metal hip surface replacement is not justified as none of the proposed advantages over conventional total hip replacement have been realised, and new serious complications such as pseudotumors have been associated with the procedure. [57] (10.1302/0301-620x.96b11.34426)
• [L5] [59] (10.5435/00124635-200808000-00010)
• [L4] Increased bearing articulation wear and serum metal ion concentrations in cases with taper interface corrosion support the hypothesis that increased friction in the joint articulation is one of the factors responsible for simultaneous articulation and taper damage. [60] (10.2106/jbjs.m.01199)
• [L5] [61] (10.2106/jbjs.j.01877)
• [L4] However, additional follow-up is necessary to determine any possible long-term deleterious effects associated with this metal-on-metal articulation. [63] (10.2106/00004623-200411000-00018)
• [L4] Rigorous long-term studies are needed, and it will take decades of close clinical observation to determine if the benefits of metal-on-metal bearings outweigh the associated risks. [64] (10.1097/01.blo.0000149995.84350.d7)
• [L1] Survivorship and function of the two bearing groups remain comparable; while polyethylene wear and osteolysis may represent issues in the future. [65] (10.1016/j.arth.2017.11.066)
• [L2] Ceramic-on-ceramic bearings have superior wear resistance when compared with all other available alternative bearing surfaces, thereby providing an excellent alternative for young and very active patients. [66] (10.2106/jbjs.i.00342)
• [L4] Metal-on–highly cross-linked polyethylene is considered the preferred bearing surface for conventional total hip arthroplasty because of its safety profile and excellent results in the first 10 to 15 years of use. [67] (10.5435/jaaos-d-15-00754)
• [L4] The orientation of the acetabular component affects polyethylene wear, with abduction angles of ≥45° associated with a 40% increase in mean linear polyethylene wear compared to angles <45°. [68] (10.2106/00004623-200300004-00007)
• [L4] [70] (10.1016/j.arth.2009.01.010)
• [L5] The findings suggest that a likely cause of squeaking in hip arthroplasty is adverse tribological conditions caused by suboptimal lubrication. [71] (10.1016/j.arth.2012.01.023)
• [L4] The clinical and radiographic results continue to be comparable with the results observed for other hard-on-hard bearings. [72] (10.2106/jbjs.m.00748)
• [L5] The wear resistance of the highly cross-linked polyethylene studied was not compromised by surface changes that occurred during the first year of in vivo service. [73] (10.1097/01.blo.0000164407.02998.8d)
• [L4] The use of PolyWare and Hip Analysis Suite imaging techniques for measurement of polyethylene wear in the clinical setting appears to be acceptable, provided that their limitations are understood. [74] (10.2106/00004623-200303000-00017)
• [L5] The future of hip bearing development needs to be focused on performance issues with the entire total hip arthroplasty construct rather than on the abrasive wear resistance of the bearing couple per se. [75] (10.1016/j.arth.2008.06.008)
• [L4] The long-term experiences with metal-on-metal total hip arthroplasty make this combination of implant material the conservative choice for success. [77] (10.1097/01.blo.0000193809.85587.f8)
• [L4] After a mean duration of follow-up of seven years, aseptic loosening was the major reason for failure of Sikomet metal-on-metal prostheses. [78] (10.2106/jbjs.e.00604)
• [L5] One should consider replacement of all heads in a failed closed reduction, and those patients successfully reduced should at least be monitored for excessive wear. [79] (10.1016/j.arth.2008.07.009)
• [L5] The study demonstrated that a clinically available high-resolution CT scanner can estimate 3D displacement of 0.026 ± 0.101 mm, indicating it is a clinically relevant tool for measuring polyethylene wear in total hip arthroplasty. [80] (10.1016/j.arth.2012.03.053)
• [L4] [114] (10.1007/s11999-010-1372-y)
• [L5] Technologies such as whole genome screening and proteomics show great promise for identifying biomarkers exclusively associated with wear-induced osteolysis, but standardized protocols and methods to distinguish these markers from non-wear-related pathologies are needed. [122] (10.5435/00124635-200800001-00014)
• [L3] Increased patient age, higher BMI, inflammatory arthritis diagnosis, and ceramic femoral heads were associated with decreased wear rates. [129] (10.1097/01.blo.0000150112.34736.82)
• [L3] Gender factors, potentially hormonal, anatomic, or functional, influence the success of metal-on-metal THA, leading the authors to expand contraindications to avoid this device in female patients. [130] (10.1016/j.arth.2011.04.012)
• [L5] An acetabular component inclination of 50° and an anteversion of 25° allowed the most physiologic range of hip motion. [131] (10.1016/j.arth.2008.07.021)
• [L4] In cases of painful metal-on-metal hip arthroplasty with elevated inflammatory markers, revision and reorientation of the acetabular component with conversion to a non-metal-on-metal bearing can address both mechanical subluxation and metal hypersensitivity when infection is not confirmed. [133] (10.1016/j.arth.2009.08.015)
• [L4] Following 8 dislocations and visible wear, this patient suffered no additional complications such as osteolysis or black tissues. [134] (10.1016/j.arth.2007.09.007)
• [L4] The authors consider that the use of large-head metal-on-metal total hip arthroplasty should be discontinued. [135] (10.1302/2058-5241.1.160014)
• [L4] Differing audible sounds were detected in all cases, likely related to differing bearing materials or variable hip kinematic patterns. [137] (10.1016/j.arth.2008.01.277)
• [L3] The clinical outcome can be considered comparable to other uncemented THA, with a mean polyethylene wear of 1.8 mm and an annual wear rate of 0.15 mm/y. [138] (10.1016/j.arth.2012.10.004)
• [L2] The risk of short-term complication (including dislocation) and revision THA were similar among appropriately matched Medicare THA patients regardless of bearing surface. [139] (10.1007/s11999-010-1262-3)
• [L3] Multiple radiographic views and determination of linear wear rate are recommended, while CT scans may be needed only when surgical intervention is considered. [140] (10.1016/j.arth.2008.02.012)
• [L3] Poor implant survivorship and frequent complications were observed at a median of 10 years after MoMHR revision. [141] (10.1007/s11999-016-4882-4)
• [L2] Close radiographic monitoring with determination of linear wear rates is recommended to assess the risk of osteolysis. [142] (10.2106/00004623-200405000-00037)
• [L3] Delta-on-Delta couplings demonstrated to be reliable bearing surfaces in revision settings at a midterm follow-up. [144] (10.1016/j.arth.2019.04.068)
• [L3] The functional outcome of hip resurfacing in this cohort was excellent, but overall survival was unsatisfactory with a 7-year survival of 90.5%. [145] (10.1007/s00402-012-1640-2)
• [L4] Metal debris generated from taper junctions appears to be of a different morphology, composition and therefore, potentially, immunogenicity to that generated from bearing surfaces. [147] (10.1302/0301-620x.98b7.37029)
• [L4] The 5-year survivorship was 95.2% with no failures in hips implanted since 2002. [149] (10.1016/j.arth.2008.04.017)
• [L3] Radiographic wear data on conventional polyethylene are consistent with laboratory studies showing that radiation-induced cross-linking has a beneficial effect on wear resistance. [150] (10.2106/00004623-200405000-00020)
• [L3] [152] (10.2106/jbjs.rvw.25.00204)
• [L3] [153] (10.1016/j.arth.2013.05.033)
• [L4] [154] (10.1097/01.blo.0000218751.14989.a6)
• [L5] [155] (10.1016/j.arth.2008.09.002)
• [L3] The results of this study demonstrate a more favorable mid-term to long-term survivorship with this specific MoM implant compared to other designs. [156] (10.1016/j.arth.2022.01.053)
• [L4] Most patients with a metal-on-metal total hip replacement who do not undergo early revision have normal MRI scans. [157] (10.1302/0301-620x.95b8.31377)
• [L3] Other surgical, implant and patient factors should be considered when determining the mechanisms of failure of large diameter metal-on-metal hip arthroplasties. [158] (10.1302/0301-620x.98b7.36554)
• [L3] High ion levels were associated with an abduction angle of more than 45° and repetitive extreme hip motion in revision cases. [163] (10.1016/j.arth.2011.11.009)
• [L5] The consensus statement defines benefits, risks, and uncertain issues related to metal-on-metal bearings, recommending safety assessment for all patients with closer follow-up for large head bearings and resurfacing involving x-rays and metal ion measurement. [165] (10.1016/j.otsr.2013.01.005)
• [L5] Deformed acetabular shells produced higher frictional torque than spherical shells. [166] (10.1016/j.arth.2009.03.020)
• [L5] It is likely that impaction deformation with consequent friction, wear, and micromotion contributed to the early failure of the Durom acetabular component. [167] (10.1016/j.arth.2010.01.029)
• [L4] A single prerevision radiograph appears to be sufficient to assess 2-dimensional in vivo wear. [168] (10.1016/j.arth.2018.03.047)
• [L4] The case confirms the necessity of periodical follow-up and searching for mechanical complications in the presence of abnormal noise after hard-on-hard bearing implantation. [169] (10.1016/j.otsr.2009.07.003)
• [L4] Revision of adverse wear related failure (AWRF) had an excellent outcome using limited debridement and a stable large metal bearing placed in the correct position. [171] (10.1016/j.arth.2014.01.036)
• [L3] Metal artifact reduction MRI is advised in all patients with metal-on-metal hip arthroplasties. [173] (10.1016/j.arth.2012.05.029)
• [L5] The dual mobility hip with sequentially crosslinked polyethylene was highly wear resistant under all test conditions. [176] (10.1016/j.arth.2012.09.011)
• [L3] Current technology or design of some total hip arthroplasty systems that make use of a large-diameter femoral head may not yet allow the use of modular large heads with a metal-on-metal articulation, especially in young, active male patients. [177] (10.2106/jbjs.j.01885)
• [L4] The battery-powered, handheld impaction system provides consistent and sufficient force to loosen modular taper junctions of dual mobility or metal-on-metal liners without damaging the well-fixed acetabular shell. [180] (10.1097/corr.0000000000001670)
• [L4] This study represents the first attempt to establish baseline acoustic characteristics for total hip prostheses with various bearing surfaces and to correlate in vivo sound with femoral head separation. [188] (10.2106/jbjs.h.00627)
• [L5] By reducing abrasion, surface structuring could be used to extend the life of prostheses and minimise the number of revisions. [191] (10.1186/s13018-020-01719-1)
• [L2] The alumina matrix composite femoral head on an alumina liner provided high survivorship and performed as well as the control device in terms of reoperation, and clinical and radiographic outcome. [192] (10.1007/s11999-009-1143-9)
• [L3] This uncemented acetabular component and this particular XLPE had low rates of linear and volumetric wear. [193] (10.1007/s11999-015-4319-5)
• [L4] Fretting and corrosion damage occurs at a variety of modular component interfaces in contemporary metal-on-metal total hip arthroplasties. [195] (10.1016/j.arth.2013.05.040)
• [L3] Acetabular inclination angle is not a meaningful determinant of metal ion levels in ASR arthroplasties. [196] (10.1016/j.arth.2013.04.022)
• [L4] Anterior iliopsoas impingement caused by large-diameter metal-on-metal femoral heads is a potential failure mechanism resulting in persistent groin pain. [197] (10.1016/j.arth.2010.10.002)

See Also

• Hip resurfacing
• Adverse reaction to metal debris
• Total hip replacement

References

[1] Prediction of Polyethylene Wear Rates from Gait Biomechanics and Implant Positioning in Total Hip Replacement. Clinical Orthopaedics & Related Research. 2017. DOI: 10.1007/s11999-017-5293-x

[2] What Are the Current Clinical Issues in Wear and Tribocorrosion?. Clinical Orthopaedics and Related Research®. 2014. DOI: 10.1007/s11999-014-3610-1

[3] Loosening and Osteolysis Associated with Metal-on-Metal Bearings. The Journal of Bone & Joint Surgery. 2006. DOI: 10.2106/jbjs.f.00453

[4] Are Trends in Total Hip Arthroplasty Bearing Surface Continuing to Change? 2007-2015 Usage in a Large Database Cohort. The Journal of Arthroplasty. 2017. DOI: 10.1016/j.arth.2017.07.044

[5] Tribology of total hip arthroplasty prostheses. EFORT Open Reviews. 2016. DOI: 10.1302/2058-5241.1.000004

[6] Bearing surfaces in primary total hip arthroplasty. EFORT Open Reviews. 2018. DOI: 10.1302/2058-5241.3.180300

[7] 25-year follow-up of 102 unrevised cementless total hip arthroplasties with a second-generation metal-on-metal bearing in a young patient cohort. Arthroplasty. 2026. DOI: 10.1186/s42836-026-00408-4

[8] Alternative Bearing Surfaces for Total Joint Arthroplasty. Journal of the American Academy of Orthopaedic Surgeons. 1998. DOI: 10.5435/00124635-199807000-00001

[9] Total Hip Arthroplasty with Use of the Metasul Metal-on-Metal Articulation. The Journal of Bone and Joint Surgery-American Volume. 2000. DOI: 10.2106/00004623-200006000-00005

[10] Modern Metal-on-Metal Hip Implants. Journal of the American Academy of Orthopaedic Surgeons. 2012. DOI: 10.5435/jaaos-20-06-402

[11] What design factors influence wear behavior at the bearing surfaces in total joint replacements?. Journal of the American Academy of Orthopaedic Surgeons. 2008. DOI: 10.5435/00124635-200800001-00020

[12] Ceramic-on-ceramic THA Associated With Fewer Dislocations and Less Muscle Degeneration by Preserving Muscle Progenitors. Clinical Orthopaedics & Related Research. 2015. DOI: 10.1007/s11999-015-4378-7

[13] No Difference in Reoperations at 2 Years Between Ceramic-on-metal and Metal-on-metal THA: A Randomized Trial. Clinical Orthopaedics & Related Research. 2016. DOI: 10.1007/s11999-015-4424-5

[14] The lexicon of polyethylene wear in artificial joints. Biomaterials. 2007. DOI: 10.1016/j.biomaterials.2007.07.040

[15] Third-Generation Ceramic-on-Ceramic Bearing Surfaces in Revision Total Hip Arthroplasty. The Journal of Arthroplasty. 2009. DOI: 10.1016/j.arth.2009.04.016

[16] A Randomized Trial Comparing Ceramic-on-Ceramic Bearing vs Ceramic-on-Crossfire-Polyethylene Bearing Surfaces in Total Hip Arthroplasty. The Journal of Arthroplasty. 2016. DOI: 10.1016/j.arth.2015.11.043

[17] The Influence of Acetabular Component Position on Wear in Total Hip Arthroplasty. The Journal of Arthroplasty. 2008. DOI: 10.1016/j.arth.2007.06.008

[18] Predictors of time to revision and clinical outcomes following revision of metal-on-metal hip replacements for adverse reaction to metal debris. The Bone & Joint Journal. 2014. DOI: 10.1302/0301-620x.96b12.33473

[19] How prevalent are implant wear and osteolysis, and how has the scope of osteolysis changed since 2000?. Journal of the American Academy of Orthopaedic Surgeons. 2008. DOI: 10.5435/00124635-200800001-00003

[20] Comparative Effectiveness of Metal-On-Metal and Metal-On-Polyethylene Bearings in Medicare Total Hip Arthroplasty Patients. The Journal of Arthroplasty. 2012. DOI: 10.1016/j.arth.2012.03.031

[21] The 2012 Frank Stinchfield Award: Decreasing Patient Activity With Aging: Implications for Crosslinked Polyethylene Wear. Clinical Orthopaedics & Related Research. 2013. DOI: 10.1007/s11999-012-2497-y

[22] Association of Third Body Embedment with Rim Damage in Retrieved Acetabular Liners. Clinical Orthopaedics & Related Research. 2007. DOI: 10.1097/blo.0b013e31815c5a7b

[23] Magnetic Resonance Imaging Findings in Painful Metal-On-Metal Hips. The Journal of Arthroplasty. 2011. DOI: 10.1016/j.arth.2009.11.008

[24] Follow-Up_of_Metal-on-Metal_Hip_Arthroplasty_Patients_Is_Currently_Not_Evidence_S0883540315001783. The Journal of Arthroplasty. 2015. DOI: 10.1016/j.arth.2015.03.009

[25] Minimum 5-Year Results of Modular Metal-On-Metal Total Hip Arthroplasty. The Journal of Arthroplasty. 2012. DOI: 10.1016/j.arth.2011.07.002

[26] Metal-on-Metal Total Hip Arthroplasty. Journal of the American Academy of Orthopaedic Surgeons. 2015. DOI: 10.5435/jaaos-d-14-00183

[27] The Prevalence of Groin Pain After Metal-on-Metal Total Hip Arthroplasty and Total Hip Resurfacing. Clinical Orthopaedics & Related Research. 2010. DOI: 10.1007/s11999-010-1356-y

[28] Measuring the migration of the components and polyethylene wear after total hip arthroplasty. The Bone & Joint Journal. 2017. DOI: 10.1302/0301-620x.99b10.bjj-2016-1169.r1

[29] Complete polyethylene wear-through and secondary breakage of the expansion cup in a ceramic-polyethylene total hip arthroplasty. Archives of Orthopaedic and Trauma Surgery. 2009. DOI: 10.1007/s00402-009-0843-7

[30] Contemporary Dual Mobility Head Penetration at Five Years: Concern for the Additional Convex Bearing Surface?. The Journal of Arthroplasty. 2018. DOI: 10.1016/j.arth.2018.02.061

[31] National Trends in Primary Total Hip Arthroplasty in Extremely Young Patients: A Focus on Bearing Surface Usage From 2009 to 2012. The Journal of Arthroplasty. 2016. DOI: 10.1016/j.arth.2016.01.061

[32] Metal-on-Metal vs Conventional Total Hip Arthroplasty. The Journal of Arthroplasty. 2012. DOI: 10.1016/j.arth.2012.05.023

[34] How have alternative bearings (such as metal-on-metal, highly cross-linked polyethylene, and ceramic-on-ceramic) affected the prevention and treatment of osteolysis?. Journal of the American Academy of Orthopaedic Surgeons. 2008. DOI: 10.5435/00124635-200800001-00008

[35] What Is the Rerevision Rate After Revising a Hip Resurfacing Arthroplasty? Analysis From the AOANJRR. Clinical Orthopaedics & Related Research. 2015. DOI: 10.1007/s11999-015-4215-z

[36] A Ten-Year Radiostereometric Analysis of Polyethylene Wear Between Oxidized Zirconium and Cobalt Chrome Articulations in Total Hip Arthroplasty. The Journal of Arthroplasty. 2022. DOI: 10.1016/j.arth.2022.02.099

[37] Risk factors for accelerated polyethylene wear and osteolysis in ABG I total hip arthroplasty. International Orthopaedics. 2009. DOI: 10.1007/s00264-009-0731-3

[38] 10-Year Follow-Up Wear Analysis of First-Generation Highly Crosslinked Polyethylene in Primary Total Hip Arthroplasty. The Journal of Arthroplasty. 2014. DOI: 10.1016/j.arth.2013.07.034

[39] Patient-Specific Contact Stress Does Not Predict Polyethylene Wear Rate in a Specific Pressfit Cup. The Journal of Arthroplasty. 2017. DOI: 10.1016/j.arth.2017.07.027

[43] Evidence-Based Management of Trunnionosis in Metal-on-Polyethylene Total Hip Arthroplasty: A Systematic Review. The Journal of Arthroplasty. 2018. DOI: 10.1016/j.arth.2018.05.035

[44] Aaos Comprehensive Orthopaedic Review 3. Biomechanics and Wear in Joint Arthroplasty > I. Overview.

[46] Orthopaedic Knowledge Update Sports Medicine 6. Imaging of the Hip > Radiography.

[48] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Musculoskeletal Biomechanics > Summary.

[49] Metal-on-polyethylene versus metal-on-metal bearing surfaces in total hip arthroplasty. The Bone & Joint Journal. 2015. DOI: 10.1302/0301-620x.97b9.34824

[50] Thigh mass associated with polyethylene wear-induced osteolysis after cementless total hip arthroplasty. Archives of Orthopaedic and Trauma Surgery. 2009. DOI: 10.1007/s00402-009-0979-5

[51] Ultrasound Screening of Periarticular Soft Tissue Abnormality Around Metal-on-Metal Bearings. The Journal of Arthroplasty. 2012. DOI: 10.1016/j.arth.2011.09.015

[52] COMPARISON OF TWO AND THREE-DIMENSIONAL COMPUTERIZED POLYETHYLENE WEAR ANALYSIS AFTER TOTAL HIP ARTHROPLASTY. The Journal of Bone and Joint Surgery-American Volume. 2003. DOI: 10.2106/00004623-200306000-00020

[53] How are wear-related problems diagnosed and what forms of surveillance are necessary?. Journal of the American Academy of Orthopaedic Surgeons. 2008. DOI: 10.5435/00124635-200800001-00005

[56] Metal-on-Metal Total Hip Revisions: Pearls and Pitfalls. The Journal of Arthroplasty. 2020. DOI: 10.1016/j.arth.2020.01.011

[57] Metal-on-metal hip surface replacement. The Bone & Joint Journal. 2014. DOI: 10.1302/0301-620x.96b11.34426

[59] Isolated Acetabular Liner Exchange. Journal of the American Academy of Orthopaedic Surgeons. 2008. DOI: 10.5435/00124635-200808000-00010

[60] The Relation Between Titanium Taper Corrosion and Cobalt-Chromium Bearing Wear in Large-Head Metal-on-Metal Total Hip Prostheses. Journal of Bone and Joint Surgery. 2014. DOI: 10.2106/jbjs.m.01199

[61] New Insights into Wear and Biological Effects of Metal-on-Metal Bearings. Journal of Bone and Joint Surgery. 2011. DOI: 10.2106/jbjs.j.01877

[63] Cementless Metasul Metal-on-Metal Total Hip Arthroplasty in Patients Less Than Fifty Years Old. The Journal of Bone and Joint Surgery-American Volume. 2004. DOI: 10.2106/00004623-200411000-00018

[64] Metal-on-Metal Total Hip Replacement. Clinical Orthopaedics & Related Research. 2005. DOI: 10.1097/01.blo.0000149995.84350.d7

[65] The Ideal Total Hip Replacement Bearing Surface in the Young Patient: A Prospective Randomized Trial Comparing Alumina Ceramic-On-Ceramic With Ceramic-On-Conventional Polyethylene: 15-Year Follow-Up. The Journal of Arthroplasty. 2018. DOI: 10.1016/j.arth.2017.11.066

[66] Controversies Regarding Bearing Surfaces in Total Hip Replacement. Journal of Bone and Joint Surgery. 2009. DOI: 10.2106/jbjs.i.00342

[67] Bearing Surfaces for Total Hip Arthroplasty. Journal of the American Academy of Orthopaedic Surgeons. 2018. DOI: 10.5435/jaaos-d-15-00754

[68] POLYETHYLENE WEAR AND ACETABULAR COMPONENT ORIENTATION. The Journal of Bone and Joint Surgery-American Volume. 2003. DOI: 10.2106/00004623-200300004-00007

[70] In Vivo Femoral Head Damage and Its Effect on Polyethylene Wear. The Journal of Arthroplasty. 2010. DOI: 10.1016/j.arth.2009.01.010

[71] Squeaking Hip Arthroplasties. The Journal of Arthroplasty. 2013. DOI: 10.1016/j.arth.2012.01.023

[72] Primary Cementless Total Hip Arthroplasty with Second-Generation Metal-on-Metal Bearings. Journal of Bone and Joint Surgery. 2014. DOI: 10.2106/jbjs.m.00748

[73] Ex Vivo Wear of Conventional and Cross-linked Polyethylene Acetabular Liners. Clinical Orthopaedics and Related Research. 2005. DOI: 10.1097/01.blo.0000164407.02998.8d

[74] VALIDATION OF TWO AND THREE-DIMENSIONAL RADIOGRAPHIC TECHNIQUES FOR MEASURING POLYETHYLENE WEAR AFTER TOTAL HIP ARTHROPLASTY. The Journal of Bone and Joint Surgery-American Volume. 2003. DOI: 10.2106/00004623-200303000-00017

[75] Bearings of the Future for Total Hip Arthroplasty. The Journal of Arthroplasty. 2008. DOI: 10.1016/j.arth.2008.06.008

[77] The Rationale for Metal-on-Metal Total Hip Arthroplasty. Clinical Orthopaedics and Related Research. 2005. DOI: 10.1097/01.blo.0000193809.85587.f8

[78] Survivorship and Retrieval Analysis of Sikomet Metal-on-Metal Total Hip Replacements at a Mean of Seven Years. The Journal of Bone & Joint Surgery. 2006. DOI: 10.2106/jbjs.e.00604

[79] Surface Oxidized Zirconium Total Hip Arthroplasty Head Damage Due to Closed Reduction. The Journal of Arthroplasty. 2009. DOI: 10.1016/j.arth.2008.07.009

[80] A New Technique for Measuring Wear in Total Hip Arthroplasty Using Computed Tomography. The Journal of Arthroplasty. 2012. DOI: 10.1016/j.arth.2012.03.053

[82] Orthopaedic Basic Science Fifth Edition Print Ebook. Biology and Mechanics of the Skeletal Extracellular Matrix > Wear and Corrosion.

[86] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Anatomy and Biomechanics, Evaluation, Clinical Examination, and Imaging of the Hip > Osseous and Ligamentous Anatomy.

[87] Aaos Comprehensive Orthopaedic Review 3. Surgical Anatomy of the Hip > IV. Hip Capsule and Ligaments.

[92] Miller S Review Of Orthopaedics. SECTION 16 PATELLAR TRACKING IN TOTAL KNEE ARTHROPLASTY > LOWER EXTREMITY.

[94] Aaos Comprehensive Orthopaedic Review 3. Surgical Anatomy of the Hip > V. Hip Joint Muscles.

[96] Apley And Solomon S Concise System Of Orthopaedics And Trauma. Friction and wear.

[100] Aaos Comprehensive Orthopaedic Review 3. Surgical Anatomy of the Hip > VI. Neurovascular Structures Surrounding the Hip.

[104] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Anatomy and Biomechanics, Evaluation, Clinical Examination, and Imaging of the Hip > Imaging.

[105] Miller S Review Of Orthopaedics. SECTION 16 PATELLAR TRACKING IN TOTAL KNEE ARTHROPLASTY > POLYETHYLENE WEAR AND OSTEOLYSIS.

[108] Miller S Review Of Orthopaedics. SECTION 16 PATELLAR TRACKING IN TOTAL KNEE ARTHROPLASTY > TREATMENT OF POLYETHYLENE WEAR.

[114] Histological Features of Pseudotumor-like Tissues From Metal-on-Metal Hips. Clinical Orthopaedics & Related Research. 2010. DOI: 10.1007/s11999-010-1372-y

[118] Orthopaedic Knowledge Update Sports Medicine 6. Imaging of the Hip > Summary.

[122] Are there biological markers of wear?. Journal of the American Academy of Orthopaedic Surgeons. 2008. DOI: 10.5435/00124635-200800001-00014

[128] Aaos Comprehensive Orthopaedic Review 3. Biomechanics and Wear in Joint Arthroplasty > II. The Hip Joint.

[129] The Pros and Cons of Polyethylene Sterilization with Gamma Irradiation. Clinical Orthopaedics and Related Research. 2004. DOI: 10.1097/01.blo.0000150112.34736.82

[130] Gender is a Significant Factor for Failure of Metal-on-Metal Total Hip Arthroplasty. The Journal of Arthroplasty. 2011. DOI: 10.1016/j.arth.2011.04.012

[131] Metal-on-Metal Hip Resurfacing. The Journal of Arthroplasty. 2009. DOI: 10.1016/j.arth.2008.07.021

[132] Apley And Solomon S Concise System Of Orthopaedics And Trauma. Total joint replacement.

[133] A Painful Metal-on-Metal Total Hip Arthroplasty. The Journal of Arthroplasty. 2010. DOI: 10.1016/j.arth.2009.08.015

[134] Surface Damage After Multiple Dislocations of a 38-mm-Diameter, Metal-on-Metal Hip Prosthesis. The Journal of Arthroplasty. 2008. DOI: 10.1016/j.arth.2007.09.007

[135] Sequelae of large-head metal-on-metal hip arthroplasties. EFORT Open Reviews. 2016. DOI: 10.1302/2058-5241.1.160014

[137] Correlation of Visual Images and Audible Sound for Total Hip Arthroplasties having Variable Bearing Surfaces. The Journal of Arthroplasty. 2008. DOI: 10.1016/j.arth.2008.01.277

[138] Clinical Outcome, Survival and Polyethylene Wear of an Uncemented Total Hip Arthroplasty. The Journal of Arthroplasty. 2013. DOI: 10.1016/j.arth.2012.10.004

[139] Risk of Complication and Revision Total Hip Arthroplasty Among Medicare Patients with Different Bearing Surfaces. Clinical Orthopaedics & Related Research. 2010. DOI: 10.1007/s11999-010-1262-3

[140] Pelvic Osteolysis Relationship to Radiographs and Polyethylene Wear. The Journal of Arthroplasty. 2009. DOI: 10.1016/j.arth.2008.02.012

[141] Poor Survivorship and Frequent Complications at a Median of 10 Years After Metal-on-Metal Hip Resurfacing Revision. Clinical Orthopaedics & Related Research. 2017. DOI: 10.1007/s11999-016-4882-4

[142] Relationship Between Polyethylene Wear and Osteolysis in Hips with a Second-Generation Porous-Coated Cementless Cup. The Journal of Bone & Joint Surgery. 2004. DOI: 10.2106/00004623-200405000-00037

[144] Delta-on-Delta Ceramic Bearing Surfaces in Revision Hip Arthroplasty. The Journal of Arthroplasty. 2019. DOI: 10.1016/j.arth.2019.04.068

[145] Results of metal-on-metal hip resurfacing in patients 40 years old and younger. Archives of Orthopaedic and Trauma Surgery. 2012. DOI: 10.1007/s00402-012-1640-2

[147] The clinical implications of metal debris release from the taper junctions and bearing surfaces of metal-on-metal hip arthroplasty. The Bone & Joint Journal. 2016. DOI: 10.1302/0301-620x.98b7.37029

[149] Eleven Years of Experience With Metal-on-Metal Hybrid Hip Resurfacing. The Journal of Arthroplasty. 2008. DOI: 10.1016/j.arth.2008.04.017

[150] Sterilization and Polyethylene Wear. The Journal of Bone & Joint Surgery. 2004. DOI: 10.2106/00004623-200405000-00020

[152] Hip Resurfacing Arthroplasty Is Associated with Lower Metal Ion Levels and Revision Risk Compared with Large-Head Metal-on-Metal Total Hip Arthroplasty. JBJS Reviews. 2025. DOI: 10.2106/jbjs.rvw.25.00204

[153] Early Failure of the Durom Prosthesis in Metal-on-Metal Hip Resurfacing in Chinese Patients. The Journal of Arthroplasty. 2013. DOI: 10.1016/j.arth.2013.05.033

[154] Revision Hip Arthroplasty for Late Instability Secondary to Polyethylene Wear. Clinical Orthopaedics & Related Research. 2006. DOI: 10.1097/01.blo.0000218751.14989.a6

[155] The Natural History of Metallosis From Catastrophic Failure of a Polyethylene Liner in a Total Hip. The Journal of Arthroplasty. 2009. DOI: 10.1016/j.arth.2008.09.002

[156] Survivorship of a Metal-on-Metal Total Hip Implant With Modular Titanium Adapter. The Journal of Arthroplasty. 2022. DOI: 10.1016/j.arth.2022.01.053

[157] Serial magnetic resonance imaging of metal-on-metal total hip replacements. The Bone & Joint Journal. 2013. DOI: 10.1302/0301-620x.95b8.31377

[158] The effect of using components from different manufacturers on the rate of wear and corrosion of the head–stem taper junction of metal-on-metal hip arthroplasties. The Bone & Joint Journal. 2016. DOI: 10.1302/0301-620x.98b7.36554

[163] Chinese Experience With Metal-on-Metal Hip Resurfacing. The Journal of Arthroplasty. 2012. DOI: 10.1016/j.arth.2011.11.009

[165] European multidisciplinary consensus statement on the use and monitoring of metal-on-metal bearings for total hip replacement and hip resurfacing. Orthopaedics & Traumatology: Surgery & Research. 2013. DOI: 10.1016/j.otsr.2013.01.005

[166] The Effects of Acetabular Shell Deformation and Liner Thickness on Frictional Torque in Ultrahigh-Molecular-Weight Polyethylene Acetabular Bearings. The Journal of Arthroplasty. 2010. DOI: 10.1016/j.arth.2009.03.020

[167] Does_Deformation_of_Metal-On-Metal_Acetabular_Components_Contribute_to_Early_Fai_S0883540310000367. The Journal of Arthroplasty. 2010. DOI: 10.1016/j.arth.2010.01.029

[168] Are Radiographic and Direct Measures of Acetabular Polyethylene Wear Comparable?. The Journal of Arthroplasty. 2018. DOI: 10.1016/j.arth.2018.03.047

[169] Bilateral simultaneous metal inlay dissociation from the polyethylene liner of a metal-on-metal hip replacement. Orthopaedics & Traumatology: Surgery & Research. 2009. DOI: 10.1016/j.otsr.2009.07.003

[171] Outcomes_After_Revision_of_Metal-on-Metal_Hip_Resurfacing_Arthroplasty_S0883540314003416. The Journal of Arthroplasty. 2014. DOI: 10.1016/j.arth.2014.01.036

[173] Metal Ion Levels Not Sufficient as a Screening Measure for Adverse Reactions in Metal-on-Metal Hip Arthroplasties. The Journal of Arthroplasty. 2013. DOI: 10.1016/j.arth.2012.05.029

[176] Wear Performance Evaluation of a Contemporary Dual Mobility Hip Bearing Using Multiple Hip Simulator Testing Conditions. The Journal of Arthroplasty. 2013. DOI: 10.1016/j.arth.2012.09.011

[177] Comparison of Whole-Blood Metal Ion Levels in Four Types of Metal-on-Metal Large-Diameter Femoral Head Total Hip Arthroplasty: The Potential Influence of the Adapter Sleeve. Journal of Bone and Joint Surgery. 2011. DOI: 10.2106/jbjs.j.01885

[180] Pearls: Removing Modular Metal-on-Metal Liners using a Battery-powered Handheld Impaction System. Clinical Orthopaedics & Related Research. 2021. DOI: 10.1097/corr.0000000000001670

[188] Clicking and Squeaking: In Vivo Correlation of Sound and Separation for Different Bearing Surfaces. Journal of Bone and Joint Surgery. 2008. DOI: 10.2106/jbjs.h.00627

[191] Study of the tribological properties of surface structures using ultrashort laser pulses to reduce wear in endoprosthetics. Journal of Orthopaedic Surgery and Research. 2020. DOI: 10.1186/s13018-020-01719-1

[192] Delta Ceramic-on-Alumina Ceramic Articulation in Primary THA: Prospective, Randomized FDA-IDE Study and Retrieval Analysis. Clinical Orthopaedics & Related Research. 2010. DOI: 10.1007/s11999-009-1143-9

[193] Wear and Osteolysis of Highly Crosslinked Polyethylene at 10 to 14 Years: The Effect of Femoral Head Size. Clinical Orthopaedics & Related Research. 2016. DOI: 10.1007/s11999-015-4319-5

[195] Is Increased Modularity Associated With Increased Fretting and Corrosion Damage in Metal-On-Metal Total Hip Arthroplasty Devices?. The Journal of Arthroplasty. 2013. DOI: 10.1016/j.arth.2013.05.040

[196] The Effect of Acetabular Inclination on Metal Ion Levels Following Metal-on-Metal Hip Arthroplasty. The Journal of Arthroplasty. 2014. DOI: 10.1016/j.arth.2013.04.022

[197] Failure of Larger-Diameter Metal-on-Metal Total Hip Arthroplasty Resulting from Anterior Iliopsoas Impingement. The Journal of Arthroplasty. 2011. DOI: 10.1016/j.arth.2010.10.002