The Journal of Arthroplasty Vol. 23 No. 7 Suppl.

1 2008

Bearings of the Future for Total Hip Arthroplasty

Michael T. Manley, FRSA, PhD, and Kate Sutton, MA, ELS

Abstract: In the last decade or so, newer hip bearings such as ceramic-on-ceramic,
metal-on-metal, and metal-on-highly cross-linked polyethylene were introduced
into clinical practice in attempts to reduce the debris load released to the tissues after
total hip arthroplasty. Present clinical evidence suggests that these newer bearings
reduce both abrasive wear and the incidence of osteolysis at up to 10 years clinical
follow-up. As further efforts to reduce abrasive wear may meet decreasing returns,
we suggest that other bearing issues remain unresolved. These include mechanical
failure, impingement or joint laxity, bearing noise, and stress shielding of supporting
structures. We present a brief review of the current status of bearing technology and
summarize potential areas for further research. Key words: total hip arthroplasty,
alternative bearings, stress shielding, wear, ceramic, polyethylene.
© 2008 Published by Elsevier Inc.

Adoption of newer bearings, such as highly cross-
linked polyethylene bearings for total hip arthro-
plasty, has been rapid and widespread. In the United
States, it is estimated that cross-linked polyethylene
acetabular bearings are used in about 70% of the
approximately 315 000 primary and revision hip
arthroplasties now performed annually [1]. The
average age of a primary total hip arthroplasty
patient is decreasing [2], and younger, more active
patients require hip implants that will last for
decades. It is now imperative to understand the
biological limits on lifespan of a total hip arthro-
plasty, whether these limits were due to the release
of debris, chemicals, and ions; to the stress shielding
of tissue by implant components; to implant fixation
From the Homer Stryker Center for Orthopaedic Education and
Research, Mahwah, New Jersey.
Submitted May 12, 2008; accepted June 10, 2008.
Benefits or funds were received in partial or total support of
the research material described in this article. These benefits or
support were received from the following sources: Stryker
Orthopaedics.
Reprint requests: Michael T. Manley, FRSA, PhD, Homer
Stryker Center, 325 Corporate Drive, Mahwah, NJ 07430.
© 2008 Published by Elsevier Inc.
0883-5403/08/2307-0013$34.00/0
doi:10.1016/j.arth.2008.06.008
issues; or to patient tolerance to aspects of the
mechanical performance of the implant itself.
In this brief review, we examined distinctions
among the different hip bearing combinations
currently available. We suggest potential next steps
in development that perhaps are not related directly
to abrasive wear resistance but to other factors that
may compromise the long-term performance of
the bearings.
Hard-on-Hard Bearings
Ceramic-on-Ceramic
Low friction, high wear resistance, and good
biocompatibility make alumina ceramic-on-alumina
bearings an attractive choice for the long-term.
Clinical results reported for alumina-on-alumina
bearings indicate that they are an excellent choice
for young and active patients because they exhibit
significantly greater survivorship and significantly
less osteolysis (P b .001) than metal-on-conven-
tional polyethylene controls at more than 10 years
clinical follow-up [3]. A clinical study comparing
ceramic-on-ceramic bearings and highly cross-
linked bearings would be valuable.

47
48 The Journal of Arthroplasty Vol. 23 No. 7 Suppl. 1 October 2008
Complications with alumina-on-alumina bear-
ings include chipping during insertion, unantici-
pated bearing fracture, and bearing noise. The
incidence of unanticipated alumina bearing fracture
is rare, 0.004% for femoral heads manufactured
after 1994 [4]. The fracture of a ceramic component
requires the careful removal of ceramic fragments in
the soft tissues during revision. Any remaining
ceramic fragments have the potential to facilitate
third body wear in the replaced bearing, particularly
if a softer replacement bearing material is chosen.
Depending on the type of fracture, a surgeon may
prefer to replace a failed ceramic bearing with a new
bearing of the same material. Current ceramic
technology allows a fractured head to be replaced
by a new ceramic head with an inbuilt metal thimble
and fractured acetabular bearings to be replaced by
an insert contained in a metal shell.
Occurrences of noise from ceramic bearings
(usually clicking and squeaking) have been reported
with rates that vary from 0.48% to 10% [5,6].
Clinical observations of a wear stripe (dulling of the
polished bearing surface) on retrieved ceramic
bearing components led to the suggestion that
wear stripes are formed during edge loading during
flexion or extension. In a lax hip, microseparation
and subsequent impact reseating of the head during
gait may also lead to a wear stripe. It is suggested that
noise occurs either during the edge loading event or
during congruent articulation as motion under load
occurs along the long axis of the wear stripe [7,8].
Not all bearings with wear stripes squeak, and not all
pristine bearings are silent. There is also no evidence
to date to suggest that bearing noise is an early
precursor of ceramic bearing failure.
Developments in ceramic bearings are leading to
new material formulations such as zirconia-tough-
ened alumina and to new bearing couples such as
ceramic-on-metal. Because it is unlikely that these
new ceramic bearings can be shown to further
substantially reduce clinical production of wear
debris, their adoption will depend on their capability
of solving more pragmatic needs, such as large heads
and thin shells.
Metal-on-Metal
First-generation cobalt-chromium alloy metal-
on-metal bearings were introduced in the 1960s
[9] with second-generation designs [10] introduced
in the late 1980s. Wear rates of second generation
metal-on-metal bearings have been reported to be
20 to 100 times lower than that of metal-on-
conventional polyethylene [11]. We are unaware
of any studies comparing metal-on-metal to highly
cross-linked polyethylene. It appears that the
requirements for low wear with this bearing couple
are determined primarily by bearing geometry, and
strict tolerances in roundness, clearance, and surface
roughness are required for success [12]. In simulator
studies, occasional ‘runaway’ wear associated with
release of large amounts of metal debris that blacken
the joint lubricant has been reported [13]. The
metal-on-metal bearing couple currently is experi-
encing widespread clinical use in both hip resurfa-
cing and total hip arthroplasty. The material
properties allow the use of large heads in thin
acetabular shells and leads to the promise of a
reduced incidence of hip dislocation in younger and
more active patients.
Despite the biomechanical advantages of metal-
on-metal bearings, metal ion release over time and
the potential deleterious effects of accumulated
metal ions in the body remains a concern [14,15].
Dermal hypersensitivity to metals occurs in about
10% to 15% of the general population, with
double the incidence in patients with hip pros-
theses [12]. Tissue around metal-on-metal bearings
is reported to sometimes show a diffuse and
perivascularity oriented lymphocytic infiltration
[16] and early inflammation with pain [17]. Metal
wear debris is considered to be more biologically
reactive when compared with ceramic or polyethy-
lene debris [12].
The long-term acceptance of metal-on-metal
bearing couples may require surface coatings or
films that reduce the amount of debris and metal
ions generated by the articulation while maintaining
the attributes of a large head and a thin shell that
makes this bearing combination desirable.
Hard-on-Soft Bearings
Metal-on-Highly Cross-Linked Polyethylene
Because of its good, long-term clinical history,
conventional polyethylene is considered to be the
standard to which wear testing for other bearing
articulations are compared. The eventual occur-
rence of osteolysis appears likely at a polyethylene
wear rate of more than 0.1 mm per year but is
uncommon at a wear rate of less than 0.05 mm per
year [18].
Cross-linking of polyethylene molecules by
gamma radiation or electron beams are now
known to substantially reduce wear of polyethylene
bearings, with wear reduction proportional to the
amount of cross-linking achieved [19]. The first
generation of cross-linked polyethylenes made
 Bearing of the Future for Total Hip Arthroplasty  Manley and Sutton
available commercially are all associated with
clinical results that suggest that wear reduction in
the hip was achieved as predicted [20,21]. The issue
of thermal treatment (annealing or remelting),
subsequent free radicals, and oxidation has also
been discussed in the literature [22], as the choice of
thermal treatment has an effect on the crystalloid
and mechanical properties of the polymer. Remelt-
ing reduces key mechanical properties of the
polymer [23], although annealing leaves free
radicals and susceptibility to oxidation. Second-
generation highly cross-linked polyethylenes such
as X3 (Stryker Orthopaedics, Mahwah, NJ) that uses
a sequential annealing process to help saturate free
radicals and EPoly (Biomet, Warsaw, IN) that uses
vitamin E as a free radical scavenger have been
released. Clinical results with these second-genera-
tion devices are not yet available.
What Next in Hip Bearings?
The current generation of hard-on-soft and hard-
on-hard hip bearings exhibit extremely low wear
when compared to the traditional cobalt-chromium
alloy-on-conventional polyethylene bearing couple.
At more than 10 years clinical follow-up for hard-
on-hard bearings and more than 5 years follow-up
for highly cross-linked polyethylenes, particle-
mediated osteolysis now seems to be such a rare
event that it will be difficult to show the advantages
of further reduction in abrasive wear in clinical
populations [20,21]. Issues other than wear remain.
Alumina-on-alumina bearings are sensitive to cup
position and edge loading and, in rare instances, can
fracture or squeak. Metal-on-metal bearings allow
the use of large heads in thin shells but are sensitive
to cup position and edge loading also. Inflammation
and the long-term biological effects of the metal ions
released from these bearings are unknown. Metal-
on-highly cross-linked polyethylene bearings seem
more forgiving than hard-on-hard bearings with
regard to technique. However, edge loading due to
joint laxity or component malposition will increase
wear with this couple without emitting any detect-
able noise. High contact stresses in the polymer due
to very thin liners or edge loading may lead to
component fracture.
All contemporary hip bearings are supported by
femoral stems and acetabular shells that are very stiff
when compared to adjacent bone. In the acetabulum,
it has been shown that the presence of a stiff shell can
lead to retroacetabular bone loss in patient populations
[24]. Recent finite element analysis (Fig. 1, available
online at www.arthroplastyjournal.org) suggests that
49
acetabular stress shielding and bone loss are inevitable
with hemispherical acetabular shells and that stress
shielding is not affected by the thickness of the cup
wall [25]. Results with a horseshoe-shaped all poly-
mer (polyethylene bearing surface, carbon fiber
reinforced polybutyleneterphthalate shell, and hydro-
xylapatite coating) Cambridge Cup (Howmedica,
Staines, UK) showed an early reduction in bone loss
with this flexible design and the recovery in bone
density in the weight bearing region of the acetabulum
at 2 years follow-up [26]. A second generation
horseshoe-shaped design, the so-called MITCH™
PCR Cup (Stryker SA, Montreux, Switzerland), has
both a structure and bearing surface of carbon fiber/
polyetheretherketone composite and is fixed to bone
with a hydroxylapatite coating. The femoral head is
alumina ceramic. Finite element analyses of the
MITCH™ PCR Cup in bone show superior loading of
the acetabular dome compared to a traditional
hemispherical design (Fig. 1C, available online at
www.arthroplastyjournal.org). Clinical trials of the
Mitch PCR now are underway (Fig. 2, available online
at www.arthroplastyjournal.org).
Summary
Midterm clinical results with newer bearings
suggest that efforts to reduce hip bearing wear is
indeed leading to a reduction in osteolysis and thus
to a reduction in the need for revision because of this
complication. At the same time, a younger, more
active, heavier, and longer-lived patient population
is placing other demands on the performance of
bearings and on the structures that support them.
Increased range of motion and enhanced implant
stability have their own design and material pro-
blems as does the need to preserve the bone stock
supporting the bearing during very long implant
survivorship. Component placement and joint laxity
can both play a role in edge loading, wear, bearing
damage, and hip longevity. The success of this recent
era of wear reduction now suggests that the future of
hip bearing development needs to be focused on
performance issues with the entire total hip arthro-
plasty construct rather than on the abrasive wear
resistance of the bearing couple per se.
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Appendix A
Supplementary figures

Fig. 1. The maximum compressive stress looking into the acetabulum for an intact hip (A), a hip with a hemispherical metal
acetabular shell (B), and a hip with a MITCH carbon fiber/polyetheretherketone “horseshoe” shell calculated in a finite
element model (C). It is assumed both shells are fully fixed to bone. The stress shielding in the dome caused by a
hemispherical shell is apparent. The Mitch shell restores some of the stresses to the area of the dome.

Fig. 2. The MITCH acetabular shell in clinical use. Inset

FEA model of the Mitch cup (Clinical radiograph courtesy
of Richard Field FRCS).