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Dual-mobility bearings:
areview of the literature
Expert Rev. Med. Devices 9(1), 2331 (2012)

D Alex Stroh,
Qais Naziri,
Aaron J Johnson and
Michael A Mont*
Center for Joint Preservation and
Replacement, Rubin Institute for
Advanced Orthopedics, Sinai Hospital
of Baltimore, Baltimore, MD, USA
*Author for correspondence:
Tel.: +1 410 601 8500
Fax: +1 410 601 8501
mmont@lifebridgehealth.org
Dislocation after total hip arthroplasty remains a major problem and hip instability is the most
common reason for revision. These complications are costly to both patients and the healthcare
system, and efforts to reduce them have had varied degrees of success. Although there are well
documented patient and surgical risk factors for dislocation, the typical surgical solutions offered
(constrained liners, large femoral heads) have the drawbacks of reduced range-of-motion and
high rates of revision. Dual-mobility prostheses (unconstrained tripolar prostheses) are hip design
solutions to dislocation that aim to provide a greater stability with an increased range-of-motion,
along with potentially reduced wear. The mean overall dislocation rate from multiple combined
studies using dual-mobility prostheses was 0.1% for primary total hip arthroplasty and 3.5%
for revisions, compared with 27% for standard primary total hip arthroplasties and up to 16%
for revisions. Dual-mobility prostheses offer a viable option for treating recurrent dislocation as
well as for primary and revision arthroplasty.

Keywords : dislocation dual mobility jump distance review total hip arthroplasty

Dislocation remains a difficult problem for
patients undergoing primary total hip arthro-
plasty and is the primary reason for revision
arthroplasty [1] . Presently, the risk of dislocation
rises from 2% in the first postoperative year to
7% after 25years for primary arthroplasties [2] ,
and is over 7% at 16years for revision arthro-
plasties [3] . This has remained unchanged since
a large series of over 10,000 arthroplasties at
the Mayo Clinic was reviewed showing a dis-
location incidence of 3% [4] . Each dislocation
has been estimated to carry a hospital cost of
nearly US$2500 for closed reductions and nearly
US$14,000 if revision is required, although
present costs are likely to be much higher [5] . The
biomechanics of dislocation are a well-studied
area of ongoing research supported by clinical
reports and computational models [616] , and
this has led to multiple recent advances in hip
implant design and technique.
Various implant designs have been used in
an attempt to reduce the rate of dislocation.
Locking rim liners, constrained tripolar pros-
theses, large femoral head designs and dual-
mobility bearing prostheses (also called uncon-
strained tripolar prostheses) were all created
with this purpose, and have been shown to have
lowered dislocation rates compared with stand-
ard hip arthroplasty [1621] . Experience with
dual-mobility bearing hip prostheses is limited
in the USA, though they have been used more
extensively in Europe.
The purpose of this review is to describe the
origin and evolution of dual-mobility bearing
prostheses, provide a brief biomechanical back-
ground for evaluating dislocation of total hip
arthroplasties, summarize the outcomes of clini-
cal studies performed using the dual-mobility
bearings and compare these outcomes to other
available prosthetic designs developed specifically
to reduce dislocation.
Literature search strategy
The PubMed and Web of Science databases were
searched for potentially relevant articles pertain-
ing to dual-mobility prostheses, dislocation of
total hip arthroplasty, constrained liners and
large femoral heads using the initial search string
in Box1. The results of this search yielded several
additional articles not originally returned, and
these were searched further for pertinent refer-
ences. The initial search contained 341reports
and eight other pertinent articles were identified
in four review articles. Studies were excluded if
they met any of the following criteria: reports
from conference proceedings in cases where
only summary data was available; reports of the
same or similar patient cohorts from the same
time period in different journals; articles writ-
ten in languages other than English, French or

www.expert-reviews.com 10.1586/ERD.11.57 2012 Expert Reviews Ltd ISSN 1743-4440 23

 Review Stroh, Naziri, Johnson & Mont
Box1. PubMed and Web of Science
database searches.
dual-mobility (ti) or dual mobility (ti) or mobile bearing (ti) Dcines, France). A diagrammatic representation of the compo-
or unconstrained tripolar (ti) or bousquet (ti) nents of a dual-mobility prosthesis is shown in Figure1. Designs
or
dislocation (ti)
or
constrained liner (ti) or large femoral head (ti) or big femoral with between 50 and 70 of movement, while the articulation
head (ti) or lateralized liner (ti) or femoral offset (ti)
and
total hip arthroplasty or total hip replacement overall range-of-motion for a dual-mobility implant with typical
ti: Title field of PubMed search feature.
German; articles not pertaining to clinical outcomes that repeated
or reinforced clinical findings or risk factors for dislocation; and
technical articles not related to the implantation of dual-mobility
prostheses. Review articles that contained separate reports of the
authors experience were analyzed. Articles with only abstracts
available were reviewed but the lack of access to a full text was
noted and observations were restricted only to data reported in the
abstract. We excluded 293reports based on these criteria, leaving
53articles for review.
Origins & evolution
The concept of dual-mobility bearings was developed by Gilles
Bousquet in the early 1970s. It has been noted that inspiration
for the idea came from Tor Christiansen who had developed a
novel, trunnion bearing prosthesis in 1964 that utilized a femo-
ral component with a cylindrical neck, upon which was seated
a ringflange system that contacted the femoral head compo-
nent [22] . This design created an extra joint between the stem
and femoral head piece, providing presumed increased mobility.
Unfortunately, the Christiansen design was found to have a revi-
sion rate that was eight-times that of the Charnley hip arthroplasty
[23] , a problem that was attributed to both the prosthetic design
and the choice of materials. Nevertheless, the concept of additional
degrees of mobility for total hip arthroplasty had begun.
Dual-mobility designs involve a femoral head component that
is mobile within a polyethylene liner with a raised rim, creating a
soft-on-hard articulation. This entire construct is mobile within a
metal acetabular component. The aim of the design was to reduce
both articular instability and wear. The first aim is achieved with
a low-friction metal-polyethylene interface between the poly
ethylene liner and a standard femoral head (typically 22.2mm).
The polyethylene liner expands the effective head diameter and
articulates with a metal acetabular component, recreating the
effects of a large femoral head component that increases stability.
A retentive rim on the liner may also be added to aid in stabilizing
the prosthesis. The early acetabular components for this system
used no fixation and were gradually replaced with a cemented
24
design, and finally cementless fixation with either three-point
screw/stud or press-fit systems became available. The original
prosthesis was the Novae Tripod design (Serf Dedienne sant,
offered by various manufacturers in the USA and Europe are
listed in Table1.
The dual-mobility hip arthroplasty system allows for a range
of motion that surpasses traditional implants, while maintaining
implant stability. The articulation between the femoral compo-
nent and the polyethylene liner allows for a cone of mobility
between the polyethylene liner and the acetabular component
allows for a cone with between 120 and 140 of movement.
Fessy [24] extrapolated the work of Harkess [25] to determine the
size and positioning to be 126 in abduction/adduction, 186 in
flexion/extension and 220 in rotation. These estimated ranges
surpass most conventional implants.
Epidemiology, risk factors & biomechanics of
dislocation
Various studies have identified many risk factors that place
patients at greater risk for dislocation. Some of these include:
older age at the time of surgery, previous hip surgery, female
gender, pathologic muscle weakness (either neuromuscular or
traumatic), altered hip joint anatomy (developmental dyspla-
sia of the hip), neurodegenerative diseases or cognitive deficits
(Alzheimers disease, Parkinsons disease, cerebral palsy), high
alcohol intake and a high American Society for Anesthesiologists
score [26,27] . Among the indications for total hip arthroplasty,
post-traumatic arthritis places patients at particularly high risk
for dislocation [3] , although this has improved over time. Use
of the posterior approach to access the hip joint was previously
thought to be a risk factor for posterior dislocation; however,
with proper soft-tissue repair this is less of a concern [28] . Owing
to the anatomy of the hip joint, the most common mechanism
of dislocation of the femoral head is to move posteriorly out of
the acetabulum, with anterior and lateral dislocations being less
common. While late dislocation may be the result of stretching
of the surrounding capsular tissues of the hip or gradual wear of
the components, the etiology of early dislocation is less clear in
the absence of component malposition [29] .
The biomechanical requirements for dislocation of the hip joint
can be explained using the concept of jump distance, which is
defined as the lateral distance the center of femoral head must
traverse in order to escape the acetabulum. Because cups are never
seated without some degree of version and rotation, this distance
varies based on the expected direction of dislocation (e.g., the
posterior-horizontal dislocation distance is the jump distance
required for posterior dislocation). The exact mechanism for dis-
location can be variable, with pure linear displacement being rare.
More commonly, prosthesis impingement between the neck and
liner, or between the femur and pelvis, acts as a lever to unseat
the femoral head. The femoral component must also overcome
Expert Rev. Med. Devices 9(1), (2012)
 Dual-mobility bearings: a review of the literature Review

the force of the surrounding soft tissue and musculature holding

the head in place. This force has a greater effect when a longer
moment arm exists between the center of the acetabular shell
and the center of the femoral head. This femoral offset has been
shown to improve both abductor muscle strength and range-of-
motion before impingement [30] . Thus, prosthetic design (femoral
head size, liner design) and implantation (degree of anteversion
or rotation) critically affect the jump distance.
Prosthetic design modifications act through different mecha-
nisms to reduce dislocation. Constrained liners physically lock
the femoral head into the acetabular component with the addi-
tion of either a metal locking ring or another articulating liner to
the standard polyethylene liner. These adjustments come at the
price of a decreased range-of-motion, an increased wear rate and
increased chance of failure [31] . Lateralized liners and femoral-
neck lengthening increase femoral offset and increase soft-tissue
tension holding the femoral head in place. Large femoral heads
increase the available range-of-motion before the stem impinges
on the acetabular component and increase the jump distance.
This design decreases wear if metal-on-metal components are
used; however, this is accompanied by possible increased metal
ion release. Bipolar and tripolar (both constrained and uncon-
strained/dual-mobility) implants allow for motion to occur at
multiple bearing surfaces, increasing the range-of-motion avail-
able to a patient before the femoral head begins to impinge and Figure1. Diagrammatic view of dual-mobility prosthesis,
dislodge. demonstrating articulation between the acetabular
component and liner, and between the liner and the
Retrieval & invitro studies femoral head. Both of these articulations allow mobility at
each interface.
The original goals of the dual-mobility design decreased wear
and increased stability have been suggested in various invitro
studies. Adam etal. analyzed 40 retrieved polyethylene liners from femoral head cups (48-mm) using a novel computer model. The
dual-mobility prostheses for evidence of wear. The mean duration posterior horizontal dislocation distance was calculated at 30,
of implantation was 8years (range: not available) and at removal, 45 and 60 of inclination, and 0, 10 and 20 of anteversion for
a mean total volumetric wear of 54.3mm3/year was noted, which simulated standing and chair rise activities. Standard and large
was of the same order as the amount of wear of conventional femoral head cups had higher dislocation distances at almost
metal-on-polyethylene prostheses of the same size [32] . The volu- every position as the inner diameter increased. The anatomic
metric wear rate was similar between the convex and concave dual-mobility bearing had the highest jump distance in all posi-
surfaces of the polyethylene insert (28.9 vs 25.5mm3/year) and no tions and activities. These results suggest that component posi-
mention of uneven wear at either articulation was noted. No study tioning is an important consideration for cups of any design,
of periprosthetic osteolysis, which might
be an expected outcome of polyethylene
Table1. Dual-mobility implants by manufacturer.
wear, was performed. Advantages in terms
of range-of-motion have also been reported. Manufacturer (location) Design
Guyen etal. studied dual-mobility implants Aston Medical (Saint Etienne, France) Tregor Medial Cup
with both 22.2- and 28-mm femoral head
Zimmer GmbH (Winterthur, Switzerland) Stafit Cup
sizes that were mounted on an automated
hip simulator. They found that the dual- Amplitude (Neyron, France) Saturne Cup
mobility designs conferred an extra 30.5 Wright Medical France (Crteil, France) Collgia Cup
in flexion, 15.4 in abduction and 22.4 Smith & Nephew Orthopaedics AG (Rotkreuz, Switzerland) POLARCUP
in external rotation when compared with
conventional implants [33] . Stryker Orthopaedics (Mahwah, NJ, USA) Anatomic Dual-Mobility X3
A recent study [34] performed at our Modular Dual-Mobility X3
institution compared the stability of a Biomet Orthopedics (Warsaw, IN, USA) Active Articulation E1
dual-mobility cup to both standard cups
(28- and 36-mm inner diameter) and large Serf Dedienne sant (Dcines, France) Novae Series Cups

www.expert-reviews.com 25
 Review Stroh, Naziri, Johnson & Mont
and that dual-mobility prostheses have greater stability than
standard and large femoral head cups based on measurements
of jump distance.
Experience in primary arthroplasty
Clinical studies have also reported low dislocation rates, excellent
survivorship, and excellent clinical outcomes for dual-mobility
prostheses used in primary total hip arthroplasty. Vielpeau
etal. described their experience with 389patients (437 hips)
who had a mean age of 61years (range: 2587years), and who
underwent total hip arthroplasty with a first generation dual-
mobility implant [35] . At a mean follow-up of 16.5years (range:
not given), there were five dislocations (1.1% dislocation rate)
and survivorship was 84.4%. This low survivorship was attrib-
uted to the younger age and higher activity level of patients who
eventually developed aseptic loosening and required revision.
The first generation designs used cemented acetabular compo-
nents, and these were associated with osteolysis at the cement
interface and resultant cup displacement leading to migration
and a slightly higher dislocation rate. This prompted adoption of
press-fit and anchoring screw techniques in the 1980s. Philippot
etal. reported on a large series of 384primary dual-mobility
prostheses in 384 patients who had a mean age of 56 years
(range: 2387years) [36] . At a mean follow-up of 15years (range:
1220years), no dislocations had occurred, the mean dAubigne
hip score was 16.3points (range: not given) and overall survivor-
ship was 96.7%. However, it was noted that 14patients (3.6%)
experienced intraprosthetic dislocation, where the femoral head
dislocates from the polyethylene liner and comes into contact
with the metal cup. It is primarily due to excessive liner wear at
the interface between the headneck junction and the polyethyl-
ene liner, which directly erodes the retentive barrier of the insert.
This can lead to metalloid release if any prolonged contact is
permitted between the two metal surfaces. There are currently
no studies that have measured serum ion levels in patients with
dual mobility prostheses. Given the current concerns over met-
allosis and the potential for non-bearing metal-on-metal wear
with these implants, future studies might consider evaluating
serum ion levels in patients with intractable pain. Owing to
the mobility of the polyethylene liner, the occurrence of pros-
thetic impingement may allow contact between the metal femo-
ral neck and the metal acetabular shell, leading to metallosis.
Bouchet etal. performed primary total hip arthroplasty with
dual-mobility prostheses in 105patients (105 hips) who had
a mean age of 77years (range: 5393years) [37] . At a mean
follow-up of 4.3years (range: 3.25.6years), there had been no
dislocations and survivorship was 100%. These were compared
with a matched group of patients who received conventional
implants during the same period, who experienced five dislo-
cations (4.6% dislocation rate; p=0.0597) and one revision.
Tarasevicius etal. demonstrated the versatility of dual-mobility
prostheses by reporting on 42 patients (42 hips) who had a
mean age of 75years (standard deviation10years) and who
were treated exclusively for femoral neck fractures [38] . At 1 year,
this group experienced no dislocations and no revisions, while a
26
demographically similar group of 56patients who received con-
ventional implants experienced eight dislocations. A summary
of clinical studies that used modern dual-mobility designs for
primary total hip arthroplasty is provided in Table2 .
Notably, the age distribution of these studies on dual-mobility
designs in primary total hip arthroplasty falls into two categories,
with several studies reporting on patients who had a mean age of
less than 60years and other studies involving patients who had a
mean age of 70years or greater. This separation did not correlate
with a difference in dislocation rate or survivorship, as might
have been expected.
These studies report a total of two dislocations in 1314 hips
(0.15% dislocation rate). There were a total of 1292patients who
had a mean age (based on the studies that reported age) of 65years
(range: 2197years) and the mean follow-up for all patients was
8years (range: 1 20years). The overall mean survivorship was
97.5% (range: 95.4100%).
Experience in revision arthroplasty
Dual-mobility prostheses have also shown excellent clinical out-
comes and reduced dislocations rates for revision total hip arthro-
plasty (Table3) . Leiber-Wackenheim etal. reported on revision
dual-mobility arthroplasty in 59patients (59 hips) who had a
mean age of 68years (range: 47 88years) [39] . At a mean follow-
up of 8years (range: 611years), this group had one dislocation
(1.7% dislocation rate), a mean Harris Hip Score of 87points
(range: 4999points), a mean dAubigne hip score of 17points
(range: 1218 points) and a survivorship of 98%. Langlais etal.
reviewed the results of 82patients (88 hips) who had a mean age
of 72years (range: 6586years) and who received revision hip
arthroplasty with dual-mobility prostheses [40] . At a mean follow-
up of 3years (range: 25years), there was one dislocation (1.2%
dislocation rate), 3.5% of patients showed radiographic evidence
of loosening, the mean dAubigne hip score was 16 points and
survivorship was 94.6%. Guyen etal. performed a revision total
hip arthroplasty with dual-mobility prostheses on 54patients
(54 hips) who had a mean age of 67years (range: 3699years)
[41] . At a mean follow-up of 3.9years (range: 2.26years), there
were three dislocations (5.5% dislocation rate), the mean Harris
Hip score was 83.7points (range: 50100) and survivorship was
91%. This last report is one of the few that demonstrates a high
dislocation rate and low survivorship at short-term follow-up,
which was attributable to three patients who experienced peripros-
thetic joint infections. Massin and Besnier performed acetabular
revision using press-fit dual-mobility components on 23patients
(23 hips) who had a mean age of 68years (range: 4390years)
[42] . At a mean follow-up of 4.5years (range: 210years), two
patients experienced dislocation (8.7% of patients), the mean
dAubigne hip score was 15points (range: 718) and survivorship
was 95.7%. It was noted, however, that one of the patients who
suffered a dislocation was particularly complicated, having under-
gone five previous revision procedures and requiring bone allo-
graft to complete the acetabular revision with the dual-mobility
component. With this patient excluded, the dislocation rate was
4.3%, which is more in line with other reports.
Expert Rev. Med. Devices 9(1), (2012)
 Dual-mobility bearings: a review of the literature Review

Altogether, these studies report a total 20 dislocations in

Dislocation Radiographic Clinical score Survivorship Ref.

[45]

[46]

[47]

[48]

[36]

[37]

[38]

[35]
565hips (3.5% dislocation rate). There were 559patients who
had a mean age (based on studies that reported age) of 69years
(range: 3499years). The mean follow-up time for these patients
was 4.0years (range: 1.111years) and the overall mean survivor-
96.4 ship was 95.6% (range: 90.8100%). It should be noted that these
95.4

99.6
PMA: 16.3 (NA) 96.7
PMA: 17.1 (NA) 97.4
97.0
(%)

100
100
results are comparable to those studies that have been reported
using large metal-on-polyethelene articulations [6,19,20,31,43] . The
added surgical complexity and cost of dual-mobility prostheses
HHS: 83.4

should be accounted for when the surgeon is developing a pre-

(25100)

operative plan for revision and might be reserved for only the
most complicated cases where the risks for recurrent dislocations
NA
NA

NA
NA

NA
are highest.
loosening (%
of patients)

Comparison to other surgical technologies

Compared to constrained liners and large femoral head prosthe-
3.90

ses, dual-mobility prostheses appear to have equivalent or lower

4.4

0.0
NA

NA

NA
NA

NA

dislocation rates, greater range of motion and lower rates of revi-

sion. Constrained liners are typically implanted as a salvage opera-
0.7 (1/144)

15.3 (1220) 0 (0/384)

rate (%)

6.2 (3.37.1) 0 (0/150)

Posterolateral (100) 4.3 (3.25.6) 0 (0/105)

0 (0/105)

0 (0/231)
0 (0/167)
1 (1/100)

tion for recurrent dislocation, and they have reported a dislocation

rate of between 2.4 and 18% depending on whether they were
used for primary or revision procedures [17,18,21] . Ranges of motion
for constrained liners have been reported between 72 and 137 of
Posterolateral (100) 6.4 (011.8)
Follow-up

3.4 (25.4)

flexion [8,44] , compared with a reported flexion extension range

(range),

5.2 (NA)
1 (11)

of motion in dual mobility prostheses of greater than 180 [24,25] .

5 (NA)
years

Shapiro etal. reviewed 87revisions using constrained liners in

84patients who had a mean age of 75years (range not given)
Anterolateral (60);

Pnterolateral (100)
Posterolateral (40)

[17] . At a mean follow-up of 58months (range: 3689months),

Male/ Approach (%)

two patients experienced repeated dislocation (2.4% dislocation

Posterior (100)

Posterior (100)

rate) and three hips required revision of the acetabular component

(96.5% survivorship). Berend etal. reported their experience with
720patients (755 hips) who had a mean age of 67years (range:
Table2. Dual-mobility prostheses for primary arthroplasty.

NA

198/186 NA

2199years) and who underwent primary insertion or revision

with a constrained liner for prosthetic dislocation [21] . At a mean
female

99/122
Values are reported as system mean (range) as stated in the original manuscript.
99/64
66/69

45/60
61/89

11/33

follow-up of approximately 12years (range: 1018years), 117hips

NA

experienced repeat dislocation (17.5% dislocation rate) and the

HHS: Harris Hip Score; NA: Not available; PMA: Postel and Merle DAubigne.

overall long-term failure rate was 42%. This study provides good
384 (384) 55.8 (2387)
105 (105) 76.6 (5393)
150 (150) 69.0 (4091)
127 (135) 63.0 (2789)

221 (231) 74.0 (3892)

163 (167) 72.0 (2197)
Level of Patients Mean age

long-term follow-up on the use of constrained liners for both

100 (100) 54.1 (NA)

75.010
(range),

primary insertion and revision for a variety of reasons, and rein-

years

(NA)

forces the knowledge that constrained liners should only be used

with extreme caution. Additionally, these liners confer a reduced
range-of-motion that limits the functionality of the prosthesis
42 (42)
evidence (hips)

dislocation rates in primary and revision procedures involving

large femoral heads (range: 04%) [16,19,20] but have higher rates
of revision when compared with conventional implants [43] . Sikes
etal. reported on the use of large femoral head, metal-on-metal
prostheses (diameter: 3854mm) in 41patients (52hips) who
IV
IV
IV

IV
Philippot etal. (2009) IV

IV
III
III

had a mean age of 52years (range: 3084years) [16] . There were

no dislocations or revisions in this group; however, a matched
Vielpeau etal. (2011)
Bouchet etal. (2011)
Bauchu etal. (2008)
Aubriot etal. (1993)
Farizon etal. (1998)
Guyen etal. (2007)

group of patients who received conventional sized, metal-on-

Tarasevicius etal.

polyethylene implants experienced two dislocations. Smith etal.

Study (year)

performed arthroplasty with large femoral head (38mm), metal-

on-metal implants on 327patients (377hips) who had a mean
(2010)

age of 56years [19] . In the early postoperative period (mean fol-

low-up 4months) there were no dislocations. Tarasevicius etal.

www.expert-reviews.com 27
28
Table3. Dual-mobility prostheses for revision arthroplasty.
Study Level of Patients Mean age Male/ Approach (%) Follow-up, Dislocation Radiographic Clinical score Survivorship Ref.
(year) evidence (hips) (range), female years (range) rate (%) loosening (%)
Review

years (% of patients)
Leclercq etal. IV 13 (13) 73 (5884) 13/3 NA 2.5 (NA) 0 (0/13) NA NA NA [49]
(1995)
Beguin etal. IV 42 (42) NA (NA) NA Posterolateral (100) NA (NA) 4.75 (2/42) NA NA NA [50]
(2002)
Leiber- IV 59 (59) 68 (4788) 27/32 Posterolateral (100) 8 (611) 1.7 (1/49) 0.0 HHS: 86.7 98.0 [51]
Wackenheim (4999); PMA:
etal. (2007) 16.5 (1218)
Guyen etal. IV 45 (45) 67 (3648) 17/28 NA 2.1 (NA) 4.4 (2/45) NA NA 95.5 [52]
(2008)
Langlais etal. IV 82 (88) 72 (6586) NA Posterior (45); 3 (25) 1.2 (1/85) 3.5 PMA: 16.1 (NA) 94.6 [40]
(2008) trochanteric slide (36);
Stroh, Naziri, Johnson & Mont

extended trochanteric
slide (19)
Philippot IV 163 (163) 69 (3492) 60/103 Posterolateral (85); 5.0 (1.5) 3.7 (6/163) 3.10 PMA: 14.8 (NA) 96.1 [53]
etal. (2009) anterolateral (10);
transgluteal (5)
Guyen etal. IV 54 (54) 67 (3699) 35/19 Posterolateral (76); 3.9 (2.26) 5.5 (3/54) 0.0 HHS: 83.7 90.8 [41]
(2009) anterolateral (24) (50100)
Hamadouche IV 51 (51) 71 (4192) 39/12 Transtrochanteric (61); 4.3 (2.16.4) 4.3 (2/47) 2.0 PMA: 15.8 96.0 [54]
etal. (2010) posterolateral (33); (918)
lateral (6)
Gtze etal. IV 27 (27) 68 (4091) 13/14 Lateral (100) 1.7 (1.12.4) 3.7 (1/27) 0.0 HHS: 66.8 100 [55]
(2010) (17.4 89.9)
Massin and IV 23 (23) 68 (4390) 7/16 Posterolateral (100) 4.5 (210) 8.7 (2/23) 0.0 PMA: 15.0 95.7 [42]
Besnier (718)
(2010)

Values are reported as system mean (range).
HHS: Harris Hip Score; NA: Not available; PMA: Postel and Merle DAubigne.

Expert Rev. Med. Devices 9(1), (2012)

 Dual-mobility bearings: a review of the literature Review

reviewed the results of 1720 hip replacements performed with
either a 22 or 32-mm femoral head [43] . Over a follow-up period
ranging 920years, they found that patients treated with the
large femoral head had a 2.8-times greater risk of revision com-
pared with those who received the conventional implant. In this
study, the large femoral head group had a mean age of 71years,
compared with 59years in the conventional head group, which
the authors suggested should have led to a lower risk of revision
in the large femoral head group. The authors of this study sug-
gested that increased femoral head diameter led to greater release
of polyethylene particles from the liner, which eventually led to
prosthetic loosening over time.
Expert commentary & five-year view
Dual-mobility prostheses have been used as an effective solution
to reduce dislocation in total hip arthroplasty since the 1970s.
Although primarily used in Europe, they are becoming more
utilized worldwide as many device manufacturers have begun to
develop at least one type of dual-mobility designs. The develop-
ment and background of this design combines the low-friction
principle of the conventional Charnley hip with an effective large
femoral head as suggested by McKee to make an implant with
excellent range-of-motion, increased stability and low wear. This
design has proven effective in clinical studies for both primary
and revision total hip arthroplasty. Indications for the use of
dual-mobility systems for primary arthroplasty include any fac-
tor that predisposes to dislocation (neurological deficit, abductor
weakness, altered joint anatomy and so on). The implant is also
well suited as an option for revision arthroplasty for recurrent
dislocation owing to its superior stability or may be used to pro-
vide improved range: of motion. While dislocation can still occur
with this prosthesis (between either of the two bearing surfaces),
the rate is much lower than that of conventional components and
is equivalent to, or better than, that of constrained liners and
large femoral head prostheses. Modern ceramic tripolar designs
were not considered in the present study. Other disadvantages
of the system include a high polyethylene wear rate, especially
in younger, active patients. Earlier designs showed high rates of
aseptic loosening that were corrected with the use of press-fit com-
ponents. As clinical studies of their use in the USA are reported,
we expect that, over the next 5years, these prostheses will become
more popular. Greater use will lead to improved designs from
product manufacturers, and further reductions in dislocation rate
or failure will occur. We recommend the use of such dual-mobility
prostheses in cases of recurrent dislocation or for patients at high
risk of dislocation in primary arthroplasty. We look forward to
future large, randomized control trials comparing dual mobility
prostheses to 2632mm metal on cross-linked polyethylene to
justify its use in the general population.
Financial & competing interests disclosure
MA Mont is a consultant for Stryker Orthopaedics and Wright Medical
Technologies, and receives royalties from Stryker Orthopaedics. The authors
have no other relevant affiliations or financial involvement with any organi-
zation or entity with a financial interest in or financial conflict with the
subject matter or materials discussed in the manuscript apart from those
disclosed.
No writing assistance was utilized in the production of this manuscript.

Key issues
Dual-mobility bearings have been in use since the 1970s, primarily in Europe.
Dual-mobility designs combine the low-friction principle with an effective large femoral head. Age, gender, mental status, body
habitus, muscle strength and underlying diagnosis leading to joint arthroplasty all contribute to the risk of dislocation. Surgical factors
contributing to dislocation include neck length, femoral head size, liner design and degree of version.
Jump distance is a quantifiable criterion for dislocation and an understanding of this parameter can help explain the etiologies of
dislocation and methods for prevention.
Compared to constrained liners and large femoral head prostheses, dual-mobility prostheses have an equivalent or better recurrent
dislocation rate and survivorship for both primary and revision arthroplasty.
Clinical studies have demonstrated that dual-mobility prostheses have a mean overall dislocation rate of 0.1% at 8years for primary
arthroplasty. The mean overall dislocation rate was 3.5% at 4years for revision arthroplasty.

References
Papers of special note have been highlighted as:
of interest
of considerable interest
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 Review Stroh, Naziri, Johnson & Mont
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31
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