Orthopaedic Advances

The Use of Dual-mobility

Components in Total Hip
Arthroplasty
Abstract
Paul F. Lachiewicz, MD
Tyler Steven Watters, MD

From the Department of

Orthopaedic Surgery, Duke
University Medical Center, Durham,
NC (Dr. Lachiewicz and
Dr. Watters), the Durham VA
Medical Center, Durham, NC
(Dr. Lachiewicz), and Chapel Hill
Orthopedics Surgery and Sports
Medicine, Chapel Hill, NC
(Dr. Lachiewicz).
Dr. Lachiewicz or an immediate
family member is a member of a
speakers bureau or has made paid
presentations on behalf of Cadence,
serves as a paid consultant to or is
an employee of the Gerson
Lehrman Group and Guidepoint
Global Advisors, has received
research or institutional support from
Zimmer, and serves as a board
member, owner, officer, or
committee member of the Hip
Society, the Orthopaedic Surgery &
Trauma Society, and the Southern
Orthopaedic Association. Neither
Dr. Watters nor any immediate
family member has received
anything of value from or owns
stock in a commercial company or
institution related directly or
indirectly to the subject of this
article.
J Am Acad Orthop Surg 2012;20:
481-486
http://dx.doi.org/10.5435/
JAAOS-20-08-481
Copyright 2012 by the American
Academy of Orthopaedic Surgeons.

August 2012, Vol 20, No 8

Dual-mobility hip components provide for an additional articular

surface, with the goal of improving range of motion, jump distance
(ie, vertical or inferior head displacement required for dislocation),
and stability of the total hip arthroplasty. A large polyethylene head
articulates with a polished metal acetabular component, and an
additional smaller metal head is snap-fit within the polyethylene.
New components have recently been released for use in North
America. Although these devices are routinely used in some
European centers for primary hip arthroplasty, their greatest utility
may be to manage recurrent dislocation in the setting of revision
hip arthroplasty. Several small retrospective series have shown
satisfactory results for this indication at short- to midterm follow-up.
Polyethylene wear and intraprosthetic dislocation are concerns, as
is the lack of long-term data. Caution is thus advised in the routine
use of dual-mobility components in primary and revision total hip
arthroplasty.

islocation is a serious and frequent complication following

primary and revision total hip arthroplasty (THA). A review of the
National Inpatient Sample database
of revision THAs performed from
October 1, 2005, through 2006
found hip instability to be the most
common cause of revision, accounting for 22.5% of the 51,345 revision
arthroplasties performed.1
In an effort to reduce the risk of
dislocation after THA, a surgeon
may use a large femoral head (eg, 36,
38, and 40 mm) that articulates with
highly cross-linked polyethylene.2
Constrained acetabular components
have been used in specific circumstances, such as in patients with cognitive disorders or with abductor
muscle insufficiency, and when larger
femoral heads have been unsuccess-

ful.3 A specific concern with these

constrained devices is the risk of failure of different locking mechanisms
and the increased stress produced at
the implant-bone interface, leading
to increased wear and loosening.
Although dual-mobility components
have been used in Europe for >25
years, interest has been renewed recently in the United States in the use of
new dual-mobility components for difficult primary hip arthroplasty, revision
of failed large-head metal-on-metal hip
arthroplasty, and revision for recurrent
hip instability.

Design Concepts of Dualmobility Articulations

The concept of a dual-mobility THA
was first developed by Bousquet in

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The Use of Dual-mobility Components in Total Hip Arthroplasty

Figure 1

A and B, Photographs of the dual-mobility component designed by

Bousquet. A 22.25-mm metal femoral head (not shown) was inserted into the
polyethylene head. (Courtesy of Serf, Orthopaedic Implants, France.)

1974.4,5 This was an uncemented

hemispherical acetabular component
with a plasma-sprayed alumina coating (porosity, 50 to 100 m) and a
highly polished stainless steel inner
bearing surface. For mechanical fixation, the component was equipped
with an upper anchor clip through
which a 4.5-mm screw was inserted
into the ilium. Additionally, two
stainless steel pins were pressed into
two holes in the socket. This metal
acetabular component was attached to a modular 22.25-mm
femoral head (following the model of
the Charnley low-friction arthroplasty prosthesis) using a bipolar retention polyethylene connecting
piece (Figure 1). In a consecutive series of 144 primary THAs, 5 were removed for infection, 3 were revised
for a fractured femoral stem, and 1
was revised early for dislocation. In
the 135 cups available for follow-up,
this dual-mobility component had a
reported survival of 95.37% (95%
confidence interval [CI], 91.95% to
98.79%) at 10 to 12 years, with 85
hips surviving to 10 years.4 Two revisions were performed to address recurrent dislocation, one in the second year for acetabular component
retroversion and one at 10 years be-

482

cause of polyethylene wear. Three

patients had groin pain resulting
from radiographic loosening/migration, and 12 had notable radiolucent
lines, with likely loose components.
A second report from the same institution provided data on 384 primary THAs (79 titanium and 305
stainless steel acetabular components) with a mean follow-up of 15.3
years (range, 12 to 20 years).5 There
were 13 aseptic loose acetabular
components (3.3%), 14 intraprosthetic dislocations (3.6%), and 7
revisions for polyethylene wear
(1.8%), for a total failure rate of
8.7%. Intraprosthetic dislocation occurred between the small femoral
head and the mobile polyethylene insert, usually as the result of severe inner polyethylene wear. Of the 14 intraprosthetic dislocations, 9 were
pure (presumably due to wear), 2
were associated with loosening of the
acetabular component, and 3 were
related to fibrosis and jamming of
the second articulation. The mean
time to intraprosthetic dislocation
was 8.9 years (range, 4 to 16 years).
Using surgical revision for aseptic
loosening as the end point, the survival rate was 96.7% (95% CI,
94.6% to 98.8%) at 15 years and

95.9% (95% CI, 93.5% to 98.2%)

at 18 years.5 To our knowledge, this
particular implant was never used in
North America.
The current generation of THA
components has been referred to alternately as dual-mobility sockets,
unconstrained tripolar cups, and
mobile-bearing hips. These devices
have a large polyethylene head that
articulates with a polished acetabular component, with an additional
smaller femoral head that is snap-fit
into the polyethylene. Currently,
three North American manufacturers
produce these devices. Multiple
other designs are available only in
Europe.
The ADM (Anatomic Dual Mobility, Stryker Orthopaedics, Mahwah,
NJ) has a chrome-cobalt alloy acetabular shell that is coated with
both plasma spray titanium and hydroxyapatite. The shell ranges in size
from 46 to 64 mm. There are anterior psoas tendon and inferior obturator foramen cutouts, and the inner
surface is polished. No adjunctive
fixation of the shell is possible.
This dual-mobility component has a
28-mm cobalt-chromium alloy or ceramic femoral head. On a back table
and using a bearing press, the femoral head is introduced into a large
(40- to 58-mm), highly cross-linked
polyethylene liner (X3, Stryker) that
articulates with the polished shell
(Figure 2).
The MDM (Modular Dual Mobility, Stryker) component has an acetabular shell with titanium plasma
spray coating and multiple holes for
adjuvant screw fixation. Shells range
in size from 42 to 64 mm. A modular polished cobalt-chromium alloy
articular surface component fits into
the shell and articulates with a large
(36- to 58-mm), highly cross-linked
(X3) polyethylene liner that has a
28-mm metal or ceramic femoral
head within it (Figure 3). In both the
ADM and the MDM components,

Journal of the American Academy of Orthopaedic Surgeons

Paul F. Lachiewicz, MD, and Tyler Steven Watters, MD

Figure 2

Photograph of the Anatomic Dual

Mobility component (Stryker
Orthopaedics, Mahwah, NJ).

the large polyethylene ball is reduced

into the metal acetabular articular
surface.
The E1 Active Articulation device
(Biomet, Warsaw, IN) has a onepiece, high-carbon, cobalt-chromium
alloy acetabular component with titanium porous plasma spray coating
and rim fixation fins. No adjuvant
screw fixation is possible. Using a
bearing press, a 28-mm femoral head
is introduced into the highly crosslinked, vitamin Estabilized polyethylene bearing (E1, Biomet), which is
then reduced into the metal shell
(Figure 4).
The goal with these devices is to
provide for greater range of motion
and jump distance (ie, vertical or inferior head displacement required for
dislocation) than is possible with a
single-piece large femoral head. The
inability for adjuvant screw fixation
with some of these designs makes
their use in revision hip arthroplasty
problematic. However, a metal dualmobility component without screw
holes could be cemented into a wellfixed retained acetabular shell.
Surgeons also have the option of constructing a different unconstrained tripolar component intraoperatively. A
standard or enhanced porous-surface
August 2012, Vol 20, No 8

Figure 3

Photograph of the Modular Dual

Mobility component (Stryker
Orthopaedics, Mahwah, NJ).

Figure 4

Photograph of the E1 Active

Articulation dual-mobility
component (Biomet, Warsaw, IN).

Figure 5

Illustration of an unconstrained tripolar component. (Adapted with permission

from Levine BR, Della Valle CJ, Deirmengian CA, et al: The use of a tripolar
articulation in revision total hip arthroplasty: A minimum of 24 months followup. J Arthroplasty 2008;23[8]:1182-1188.)

modular acetabular component receives a 40-mm highly cross-linked

polyethylene liner.6 This articulates
with a 40-mm outer-diameter hip
fracturetype bipolar component
with a 22-, 26-, or 28-mm inner-

diameter femoral head (Figure 5).

However, there are two major disadvantages of this construct. First, the
inner polyethylene bearing is fabricated of conventional polyethylene.
Second, this inner bearing is much

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The Use of Dual-mobility Components in Total Hip Arthroplasty

Table 1
Results of Dual-mobility and Tripolar Components for Recurrent Dislocation Following Total Hip Arthroplastya
Implant Type

No. of Hips

No. Revised for

Instability (%)

Mean Age in Years

(range)

Levine et al6
Guyen et al15
Hamadouche et al16
Leiber-Wackenheim
et al17
Langlais et al13
Grigoris et al18
Philippot et al14

UTP
DM
DM
DM

30
51
47
50

14 (47)
51 (100)
47 (100)
50 (100)

65 (4589)
67 (3699)
71 (4192)
68 (4788)

DM
UTP
DM

85
8
156

5 (5.9)
8 (100)
26 (16)

72 (6586)
55 (2975)
68 (3492)

Beaul et al19

UTP

11

11 (100)

59 (2984)

Study

DM = dual mobility, UTP = unconstrained tripolar

a
Hips followed for <2 years were excluded from this analysis.
b
Infection, fracture, or loosening
c
Denotes number of subset originally revised for instability in a larger series

thinner than in the dual-mobility designs.

Biomechanical Analysis
There is a paucity of independent (ie,
non-industry) basic science studies of
dual-mobility components. In vitro
range of motion to impingement of one
tripolar hip implant in an automated
hip simulator has been evaluated and
compared with in vitro range of motion to impingement with conventional
implants.7,8 Tripolar components with
22.2- and 28-mm femoral heads provided increased flexion, adduction, and
external rotation compared with conventional 22.2- and 28-mm femoral
heads.7 At 90 of flexion and 40 of adduction, there was an increase of 45.2
in internal rotation with the tripolar
components compared with the conventional 22.2-mm femoral head and
of 27.5 compared with the conventional 28-mm femoral head.
A potential biomechanical disadvantage of dual-mobility devices is
that excessive motion may result in
impingement of the femoral neck or
the femoral component itself against
the large outer polyethylene bearing,

484

resulting in motion at the second articulation site. This could lead to increased polyethylene wear and intraprosthetic dislocation. It is also
unclear whether, after fibrous tissue
replacement of the hip hematoma
postoperatively, motion will continue
to occur at both articulations or at
only the larger outer polyethylenemetal surface.
To our knowledge, no publication
in the English-language literature has
reported the wear rate of a large
polyethylene head against a polished
metal surface. This new construct is
the opposite of what THA surgeons
have used with current bearing technology, in which the harder surface
is the femoral head and the softer
surface is the acetabular component.
Such flipping of the bearing surfaces,
as in dual-mobility devices, may result in increased wear rates. This is a
notable concern.

Indications and Results

Primary THA
The original designer of the first
dual-mobility THA apparently used

this device in all primary THAs.4,5 A

more recent study reports on the use
of the POLARCUP Dual Mobility
System (Smith & Nephew Orthopaedics AG, Rotkreuz, Switzerland),
which has recently become available
in the United States.9 This system has
a stainless steel cup with hydroxyapatite coating and a 22- or 28-mm inner femoral head. One study reported no dislocations in 150
primary hips managed with this device at a mean follow-up of 6.2
years.9 However, two cups were revised for loosening.
It has been suggested that any
dual-mobility component is indicated only in patients at high risk for
dislocation, that is, in patients aged
>75 years, in women aged >70 years,
after prior hip surgery, in patients
with neuromuscular disorders or
cognitive dysfunction, and in those
with preoperative American Society
of Anesthesiologists scores 3.10 One
nonrandomized retrospective study
compared the rate of dislocation of
dual-mobility cup THA with conventional THA in patients treated for
femoral neck fracture via a posterior
approach.11 At 1-year follow-up,

Journal of the American Academy of Orthopaedic Surgeons

Paul F. Lachiewicz, MD, and Tyler Steven Watters, MD

Table 1 (continued)
Results of Dual-mobility and Tripolar Components for Recurrent Dislocation Following Total Hip Arthroplastya
No. of Dislocations (%)

No. of Re-revisions for

Dislocation (%)

No. of Other Revisionsb

(%)

3 (24)
4 (27)
4 (26)
8 (611)

3 (10)
3 (5.9)
2 (4.3)
1 (2)

2 (6.7)
2 (3.9)
2 (4.3)
None

1 (3.3)
3 (5.9)
1 (2.1)
2 (4)

3 (25)
4 (26)
5 (29)

1 (1.2)
None
6 (3.8)
Nonec
1 (10)

1 (1.2)
None
None
Nonec
1 (10)

5 (5.9)
None
11 (7.1)

Mean Follow-up
in Years (range)

7 (312)

4 (40)

DM = dual mobility, UTP = unconstrained tripolar

a
Hips followed for <2 years were excluded from this analysis.
b
Infection, fracture, or loosening
c
Denotes number of subset originally revised for instability in a larger series

there were 8 dislocations in 56 patients with conventional hips (28and 32-mm heads) compared with
no dislocations in 42 consecutive patients treated with the dual-mobility
component. However, this study was
limited because posterior capsular repair was not performed in either
group, and the cohorts were consecutive rather than randomized.
Hamadouche et al12 recently reported on a retrospective review of
168 consecutive primary hips with a
dual-mobility socket after a minimum 5-year follow-up. Four hips
were revised for intraprosthetic dislocation resulting from fatigue damage and wear of the mobile insert at
the capture area (2.4%).

Revision THA
The greatest utility for dual-mobility
components may be revision THA,
in particular, revision for recurrent
dislocation. Two studies have evaluated the prevention of dislocation
with a dual-mobility design after revision THA performed for a variety
of reasons, including recurrent dislocation.13,14 One study retrospectively
evaluated 85 revisions (including five
August 2012, Vol 20, No 8

hips with recurrent dislocation) with

substantial acetabular bone loss,
which was defined as segmental in
21 hips, combined segmental and
cavitary in 50 hips, severe segmental
in 14 hips, and pelvic discontinuity
in 3 hips.13 Using a cemented dualmobility component with a 22-mm
inner head and a polyethylene head
40 mm, there was only one dislocation at a mean follow-up of 3 years
(range, 2 to 5 years).
A different study retrospectively reviewed 163 revisions performed for
various reasons, including recurrent
dislocation in 26 hips and reimplantation after infection in 33 hips.14
Four different types of dual-mobility
components were implanted. There
were six early dislocations (3.7%),
all of which were successfully managed with closed reduction without
recurrence. No dislocations occurred
in patients who underwent revision
for recurrent dislocation. The mean
follow-up was 5 years (range, 2 to 9
years). The overall rate of revision
was 6.7%.
Three European studies have evaluated the results of dual-mobility
components used specifically to man-

age recurrent dislocation,15-17 and

three North American studies have
evaluated unconstrained tripolar
components (ie, metal bipolar heads
reduced into polyethylene acetabular
liners) used in the management of recurrent dislocation6,18,19 (Table 1).
The European studies included 51,15
47,16 and 5017 patients managed for
recurrent dislocation with a different
dual-mobility component in each
study, with a mean follow-up of 4,
4.3, and 8 years, respectively. The
success rate (ie, no dislocation) was
94.5%,15 96%,16 and 98.3%.17 The
three North American studies are
much smaller, with 30,6 8,18 and 1119
unconstrained tripolar components,
with mean follow-ups of 3.2, 4.2,
and 6.5 years, respectively. In the
largest series, there were three dislocations, two of which required rerevision, for an overall success rate
of 93.3%.6 There were no reported
problems of loosening of the acetabular component or of excessive polyethylene wear in all three North
American studies, but the follow-up
times were relatively short. No randomized studies have compared the
results of dual-mobility or uncon-

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The Use of Dual-mobility Components in Total Hip Arthroplasty

strained tripolar components with

those of large femoral heads articulating with highly cross-linked polyethylene components.

Summary
Dual-mobility components have
been used in Europe for more than
two decades, and interest in this concept has been renewed recently in
North America. Dual-mobility components offer an additional articulating surface, with the goal of improving range of motion and stability of
THA. The fabrication of several
types of highly cross-linked polyethylene has permitted large polyethylene femoral heads to articulate with
a polished inner surface acetabular
component. There are no data published to date on the wear of these
components, which is of great
concern because of the reports of
intraprosthetic dislocation. Dualmobility components may have their
greatest utility in revision THA, especially in cases of revision for recurrent dislocation. The early rates of
success of older dual-mobility components used to manage recurrent
dislocation are encouraging, ranging
from 90% to 98% at short- to midterm follow-up. These components
may be an alternative to constrained
components in select patients with
recurrent dislocation. Because there
are no long-term studies or registry
data on these new dual-mobility
components, caution is advised in
their routine use in primary and revision THA.

Acknowledgment

9.

References
Evidence-based Medicine: Levels of
evidence are described in the table of
contents. In this article, all references
are level IV studies.
References printed in bold type are
those published within the past 5
years.
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2.

3.

4.

5.

6.

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8.

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13.

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Hamadouche M, Biau DJ, Huten D,

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Leiber-Wackenheim F, Brunschweiler B,
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The authors would like to thank

Mr. Stephen Perlman for his assistance with the literature search.

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Journal of the American Academy of Orthopaedic Surgeons