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Recent updates for biomaterials used in total hip arthroplasty



Total hip arthroplasty (THA) is probably one of the most successful surgical interventions performed in medicine. Through the revolution of hip arthroplasty by principles of low friction arthroplasty was introduced by Sir John Charnley in 1960s. Thereafter, new bearing materials, fixation methods, and new designs has been improved. The main concern regarding failure of THA has been the biological response to particulate polyethylene debris generated by conventional metal on polyethylene bearing surfaces leading to osteolysis and aseptic loosening of the prosthesis. To resolve these problems, the materials of the modern THA were developed since then.


A literature search strategy was conducted using various search terms in PUBMED. The highest quality articles that met the inclusion criteria and best answered the topics of focus of this review were selected. Key search terms included ‘total hip arthroplasty’, ‘biomaterials’, ‘stainless steel’, ‘cobalt-chromium’, ‘titanium’, ‘polyethylene’, and ‘ceramic’.


The initial search retrieved 6921 articles. Thirty-two articles were selected and used in the review.


This article introduces biomaterials used in THA and discusses various bearing materials in currentclinical use in THA as well as the newer biomaterials which may even further decrease wear and improve THA survivorship.


Total hip arthroplasty (THA) is one of the most popular surgical procedures performed worldwide. In England, the National Joint Registry recorded that more than 790,000 THAs were performed between 2003 and 2015 [1]. As of 2003, more than 200,000 THA operations were performed annually in the USA, about 2.5 million people are living with a hip replacement [2]. This number is expected to reach 572,000 by 2030 [3]. In Korea, the Health Insurance Review and Assessment Service informed that more than 60,000 THAs were performed between 2010 and 2017, and incidence was increasing over time [4].

Current developments in the field of artificial hip joints are focused on mechanical strength, biocompatibility [5,6,7,8], bioactivity [9,10,11,12,13,14,15,16,17,18] and materials that impart better wear resistance and mechanical reliability [19,20,21,22,23,24,25,26,27,28]. When an implant fails, patients may endure severe pain and disability and require revision surgery. Periprosthetic osteolysis is the primary cause of failure that is the result of activation of an innate immune response caused by wear of bearing materials in THA. Taken up by macrophages and multinucleated giant cells, the presence of wear debris particles may cause the release of cytokines, thereby resulting in inflammation that further activates osteoclasts and finally leading to implant loosening.

The functional goal of joint arthroplasty is to return a patient to activities of daily living and range of motion in the absence of pain. Thus, various biomaterials have been used and are constantly being developed. The purpose of this review was to provide an update on the development status of various materials in THA.

History of development of Total hip arthroplasty

Metal on metal (MoM) bearings were made using large ball diameters during 1955–1965 [29]. However, the use of MoM bearings declined in the 1970s for some years after Sir John Charnley introduced a THA device based on metal on polyethylene (MoP) composed of a small metal ball and a cemented polyethylene (PE) cup in a 1960s [30]. Long term survival of these early implants was good, with around 77–81% of success rate 25 years after primary THA [31]. With the increasing use of THA in younger and more active patients, the revision rate becomes higher [32], and there has been concerns about the role of PE wear particles in osteolysis and loosening [31]. New materials have been introduced to prevent wear and osteolysis.

Pierre Boutin, a French surgeon who anticipated the problem of “polyethylene disease”, began using alumina ceramic on ceramic (CoC) hip implants in a 1970s [33]. CoC implants have been used in THA and these developments also created ceramic on polyethylene (CoP) combinations as competitive bearing alternative along with MoM and CoC over 1963–1973 (Fig. 1).

Fig. 1

Early bearing materials used in THA (a) MoM Mckee-Farrer THA from 1960 (b) MoP combinations, Thompson prosthesis in a 1960s (c) CoC hip implants in a 1970s (d) CoP combinations over 1963–1973

Stainless steel was the first class of alloy introduced for orthopedic implants [34]. However, since some corrosion was inevitable, it has been recommended that stainless steel only be used for short duration purposes [35]. Currently, the most frequently used artificial hip joints are composed of an acetabular cup, liner, head and stem. The main materials for THAs were titanium, cobalt-chromium, PE, and ceramic, respectively.

Supporting metallic materials

Stainless steel

Stainless steels are iron-carbon based alloys. In general, these alloys contain Cr, Ni, Mo, Mn and C. The austenitic (316 series) alloys are typically used in fracture-fixation devices. The resistance to oxidation coupled with relative ease of machining, forming, and hardening makes stainless steel a strong candidate for material choice. Stainless steel is rarely used for THA material nowadays, because of poor biocompatibility, though stainless steel devices remain available in other countries (particularly the United Kingdom).

Cobalt-chromium (co-Cr) alloys

Co-Cr alloys which was used in dentistry, are now one of the major materials used for hip prostheses. The favorable strength, corrosion, and wear characteristics make alloys of Co-Cr one of the main choice as an implant material. It is mainly used as cement type femoral stem material because the Young’s modulus is larger than titanium alloys and articulating head due to wear resistance.

Titanium alloys

Titanium and its alloys are popular metallic implant biomaterials used in THA. Commercially, α + β titanium alloys, such as titanium-6Al-4 V have been the most commonly used alloys for stem and acetabular cementless components of THA, because of its comparatively low density, high mechanical strength, excellent corrosion resistance, and biocompatibility with bone [36].

However, Titanium alloys are not used for manufacturing of femoral head due to their poor wear resistance.

During the last two decades, vanadium free titanium alloys such as α + β titanium-6Al-7Nb alloy with improved biocompatibility have been developed by incorporating biocompatible elements such as Niobium [5,6,7,8]. Many researches have been devoted to the development of bulk metallic materials that have lower Young’s modulus, among which β titanium alloys have attracted significant attention.

Alloy surface modifications

Classic implants are fabricated using traditional materials (sintered beads, fiber metal, plasma spray) which have several inherent biomaterial limitations. In order to achieve an effective osseointegration with a vital bone implant contact and reduce risk of loosening, the use of porous metals andcoatingswere developed [37]. In general, compared to stainless steels and Co-Cr alloys, titanium, some of its alloys and tantalum are the more suitable porous metallic materials used for orthopaedic applications.

Hydroxyapatite has been used in order to achieve the permanent mechanical fixation of an implant in the bone bed to involve the process of osseointegration [38]. Porous metal has been also introduced to obtain biological fixation and improve longevity of orthopedic implants [39]. The new generation of porous metal has intriguing characteristics that allows bone healing and high osteointegration of the metallic implants [40].

Materials used in bearing surface


UltraHigh molecular weight polyethylene (UHMWPE)

UHMWPE was first introduced in 1962 as the bearing for the Charnley hip prosthesis. He developed the low-friction arthroplasty consisting of cemented fixation with a bearing surface of a 22.25-mm metallic femoral head andan all-PE cup [41].

Conventional PE is sterilized by gamma irradiation in air. This process offers the benefits of molecular crosslinking but can also produce free radicals that is oxidized in the presence of air [42]. Oxidation decreases resistance of the biomaterial, resulting in degradation and brittle PE, and thus may increase wear [43]. PE wear is multifactorial: among the different factors associated with wear are a patient’s higher activity level, a big femoral-head diameter or thin PE liners, vertical orientation of the acetabular cup, or the use of modular uncemented cups [44, 45]. UHMWPE wear debris mediated osteolysis is widely recognized as one of the most serious challenges in hip arthroplasty [46, 47].

High crosslinked UHMWPE (XLPE)

The developmentof new XLPE is aimed at improving UHMWPE in both cemented and uncemented implants. In order to decrease PE wear, research has attempted to improve wear resistance while maintaining mechanical properties and eliminating the oxidation process [48].

Crosslinking is accomplished by using either gamma radiation or electron beam radiation to break the molecular bonds. All manufacturers produce XLPE based on three processes: crosslinking, heat treatment, and sterilization while avoiding exposure to air. Higher crosslinking density is obtained using gamma irradiation or electron beams at a dose between 50 and 100 kGy to increase wear resistance. Heat treatment is aimed at eliminating free radicals that appear after crosslinking; this thermal treatment applies temperature above (remelting) or below (annealing) the melting transition temperature of the polymer (137 °C).

In vivo studies, Manning et al. reported 95% wear rate reduction, and Martell et al. showed 42% to 50% wear rate reduction using XLPE compared to conventional PE [49, 50]. Biologic activity of the wear debris was also reduced and osteolysis has been dramatically decreased [49,50,51,52,53,54].

Antioxidant doped polyethylene

In efforts to improve oxidation resistance without compromising mechanical properties through thermal treatments, XLPE is stabilized by the addition of antioxidants like vitamin E, to prevent oxidation of free radicals with the intention of increased wear resistance [19, 20, 55]. Although initial results are promising, longterm clinical results of this second generation PEs are not yet available.

Poly (2-methacryloyloxyethyl phosphorylcholine) (PMPC)

Kyomoto et al. made a great progress in tribological aspect of XLPE [21]. XLPE has been surface-treated on the articulating surface, covering the surface with a chemically thin layer (100–200 nm) to improve abrasion resistance. Poly (2-methacryloyloxyethyl phosphorylcholine) (PMPC), which is formed by photo-induced graft polymerization, creates a super-lubricious layer that mimicks articular cartilage [22]. A recent hip simulator study reported that MPC polymer grafted on the XLPE surface dramatically reduced the wear up to 70 million cycles [56].



Alumina has been used as a bearing surface in total hips since the 1970s [57]. Alumina ceramics have biocompatibility, high wear resistance, and chemical durability. Wear was as low as a few microns for a 15-year period in use, which is 2000 times less than a regular MoP sliding couple and 100 times less than a MoM prosthesis [58].

Although alumina ceramics have shown better wear characteristics than MoP, alumina has historically had a high incidence of fracture [59]. This high incidence of fracture led to improved manufacturing processes which was possible by decreasing grainsize and porosity, and by tempering process for the increase of toughness [60].

With the improvements made in alumina material properties, the incidence of fracture has declined dramatically in recent years. The decreased incidence of fracturing of alumina components has made ceramics a more feasible option, especially for younger, more active patients [59].


Zirconia femoral heads were introduced in Europe in 1985 and later introduced into the USA in 1989 [61]. The move from alumina to zirconia as a femoral head component was because of the high incidence of fractures of alumina heads and the increased fracture toughness of zirconia compared to alumina [62]. Zirconia also had a historically higher bending strength than alumina [63].

However, in view of the recently reported potential for zirconia ceramics to undergo monoclinic phase transformation in vivo, with resultant increased fracture risk and degradation of wear properties [64, 65]. Unfortunately, the largest manufacturer of zirconia femoral heads recalled their products in 2001, because of problems with the thermal processing associated with those batches [61]. Since the recall, use of zirconia stabilized with yttria has declined, but a trend toward developing alumina-zirconia composites to improve performance of ceramic bearings has emerged [66].

Alumina-zirconia composites

Despite the long clinical history of alumina and zirconia in THA, both materials had drawbacks. Attempts to overcome the weaknesses of these materials by combining alumina’s hardness with zirconia’s toughness have led to the development of zirconia-toughened alumina (ZTA), which was first commercialized by CeramTec under the trade name of BIOLOX® Delta in around 2000. ZTA is an alumina matrix composite containing 75% fine grained alumina of 0.5–0.6 μm in diameter and 25% Y-TZP with a grain size of 1 μm or smaller to obtain a flexural strength of 1200 MPa and a fracture toughness of 6.5 MPa√m [66]. The base alumina matrix ensures high hardness of the materials, and the addition of zirconia particles promotes resistance to crack propagation [62]. ZTA also slows down the kinetics of hydrothermal aging, which is a potential advantage over monolithic zirconia.

Silicon nitride

Silicon nitride is a non-oxide ceramic material with high strength and toughness and has been used as bearings, turbine blades for more than 50 years. In the medical field, since 2008, it has been used in cervical spacer and spinal fusion devices, with few adverse reports among 25,000 implanted spinal cages [67, 68]. Silicon Nitride has been recently regarded as a bearing material for artificial hips due to its high biocompatibility, moderate Vickers hardness of 12–13 GPa, Young’s modulus of 300 GPa, high fracture toughness of 10–12 MPa√m and flexural strength of 1 GPa, with a typical grain size of 0.6 μm after alloying with small amounts of yttria and alumina [69]. Mechanical testing has shown higher fracturetoughness, higher flexural strength, higher resistance to hydrothermal degradation. Biocompatibility tests haveshown that Si3N4 does not produce any adverse reactions behaving similar to alumina [70].

Recent hip simulator studies show that self-mated silicon nitride couples exhibit up to 3 million cycles of wear compared to self-mated alumina; however, some self-mated silicon nitride couples show increased wear at the end of 5 million cycles compared to alumina CoC [71]. Further long term clinical studies of retrieved heads of silicon nitride and hip simulator studies by others may be necessary.

Hybrid Design of Oxide Ceramic Layer on metal (Oxinium™)

A new zirconium alloy (Zr-2.5Nb) was introduced to hip arthroplasty in 2003 [68]. When heated in an air environment, the surface of the metal zirconium converts to a black zirconium oxide which is approximately 4 to 5 μm thick [60, 72, 73]. This oxidized zirconium femoral head commercialized as Oxinium™ (OxZr; Smith & Nephew, Memphis, TN, USA) is not a coating, but a surface transformation by oxygen diffusion hardening process, which is expected to provide improved resistance under load bearing. It is a relatively new material used as an alternative to alumina or zirconia ceramics, demonstrating increased hardness and decreased surface roughness similar to zirconia, but possessing inherently high fracture toughness and fatigue strength because of the metal substrate [74].

In a simulator study, it was observed that Oxinium™ heads produced 45% less wear than did smooth Co-Cr heads, and, when the heads were roughened, the difference was much greater, with oxinium producing 61% less wear. Lewis et al. compared 50 Co-Cr and 50 oxinium heads and observed the clinical outcome to be equivalent at 2 years of follow-up [75].

Despite the clinical use of OxZr’s head for more than eight years, we need more reliable data about long term outcomes.

Ultra-hard coatings on metals

While Co-Cr alloy in self-mated configuration or the alloy heads sliding against PE or XLPE are frequently used in THA, over 50% of failed artificial hipjoints are mainly due to osteolysis mediated aseptic loosening in addition to metal ion allergies overa long term period [76]. A frequent used alternative hybrid approach is to coat metal alloys with very hard, biocompatible surface layers such as diamond-like carbon (DLC, 5000 HV) [77] or titanium nitride (TiN 2100 HV) [78].

This approach ensures that the original properties of high strength metallic substrate are retained while: (a) supporting a bearing surface; and (b) avoiding the release of toxic metal ions from the underlying the Ti alloy substrate. However, there are several problems such as local delamination, crevice corrosion, third body wear [78, 79]. Another method is to deposit pure diamond on the metal head. In this regard, coating of ultra nanocrystalline diamond (UND) with grain size of 3–100 nm was directly applied to Ti and Co-Cr alloy using microwave plasma CVD [80, 81]. UND coatings possess high hardness (56–80 GPa) and low surface roughness, high wear resistance to third-body wear particles [82]. Nevertheless, large compressive stresses are retained in the UND coating due to impurities at the grain boundaries, affecting the adhesion to the substrate [83]. In short, further enhancements to these coating techniques are needed to meet the high wear resistance, mechanical reliability and adhesive requirements for prolonged THA.

Clinical aspects of bearing surface

Bearing couples should have a low coefficient of friction, high surface hardness with lowductility and scratch resistance, and generate a low volume of wear particles. Moreover, surfaces exposed to tissues should be non-cytotoxic, biocompatible, and bioinert [84]. There are several bearing materials that are commonly used in clinical practice (Fig. 2).

Fig. 2

Recent bearing materials used in THA (a) MoP bearing (b) Large head MoM bearing (c) Small head MoM bearing (d) CoC articulation (e) CoP articulation

MoP articulation


MoP composed of a small metal ball and a cemented PE cup in 1963 [85]. Over the last few decades, one of the most acceptable bearing surface couple in a prosthetic hip is a Co-Cr femoral head articulating with a UHMWPE acetabular component in view of the excellent Long term results available. Tsukamoto M et al. reported that XLPE group presented a significantly reduced wear rate compared with the conventional PE group (XLPE groups, 0.035 mm/yr.; conventional PE group, 0.118 mm/yr) [86]. This bearing surface couple remains the one of the standards to which wear testing for other bearing articulations are compared. MoP bearing surface, a bearing surface with good long term results in elderly patients, once was taken as gold standard for THA [87].


It became clear that PE liner wear debris generated with time was associated with the occurrence of osteolysis which leads to subsequent loosening and eventual implant failure (Fig. 3). This osteolysis appears tooccur more commonly at wear rates of more than 0.1 mm/yr. and is uncommon when wear rate is less than 0.05 mm/yr. [88, 89]. It has been reported that the osteolysis rate of MoP is as high as 26%, and aseptic loosening rate is 3% at 10-year follow up [90].

Fig. 3

A 62-year-old male patient with right total hip arthroplasty using MoP bearing (a) Radiograph illustrating liner wear and metalosis (b) Severe metalosis and osteolysis (c) Radiographs after revision surgery including excising mass, changing to metasul liner and metal head after cementing

During the past decade, different manufacturers have begun to develop new biomaterials in order to decrease PE wear, such as XLPE, Antioxidant Doped Polyethylene and PMPC. Brach et al. reported better performance by this newer XLPE than with conventional or even first-generation XLPE [91]. The other strategy is to introduce vitamin E, the antioxidant alpha-tocopherol, into UHMWPE prior toconsolidation to help prevent the oxidative degradative reaction. This would avoid the deleterious effect of the melting process that decreases the mechanical properties of PE. Oral et al. reported good wear and improved mechanical and fatigue properties [92]. However, these new technology whose success and impact will be determined in the longer term. Analysis of retrieved components and clinical results will continue to inform us on the effects of wear problems [93].

Wear mechanism

Adhesive features have been found on the surface of PE cups matched with a metallic ball [94]. Welding between the cup and ball generates fibrils on the surface of the polymeric material. These fibrils may become torn off and pulled away as loose particles. Without sufficient lubrication, bigger fragments may be transferred from counterbody to body and vice versa. Such particles may introduce abrasion in the form of two or three body abrasion resulting in scratches on the surface.

MoM articulation


Proposed advantages included the reduction in wear, improved range of movement and a lower dislocation rate [95, 96] and MoM bearings have wear rates that are 20 to 100 times lower than metal-on-conventional polyethylene [97]. MoM THA using a 28 mm head has shown favorable results compared with large head MoM THA. Small head MoM showed a relatively low rate of aseptic loosening at a mean follow up of 20 years [98]. Yoon et al. reported that good clinical results with no complicationsin THAs with MoM bearing even with chronic renal failure [99]. Small head MoM bearing seems to have good results, relatively.


The problems with large bead MoM began to appear in 2005. With increasing clinical experience, the national joint registries have recently reported the failure rate of THA with MoM bearings to be 2–3 fold higher than contemporary THA with non MoM bearings [100, 101] associated with local bone and softtissue necrosis, with pseudotumor formation comprising a predominantly lymphocytic inflammatory reaction [102, 103] and, wear particles in the form of cobalt and chromium ions have been detected throughout the body [104]. Although granuloma have been found in both the liver and spleen [105] and increased chromosomal translocation has been found within lymphocytes [106], there is currently no hard evidence that this leads to neoplasia [107].

Furthermore, midterm studies demonstrated increased rates of osteolysis and implant.

Failure (Fig. 4), raising concerns about the longevity and safety of this bearing surface [108,109,110]. Korovessis et al. followed 217 patients who underwent a primary THA using a second-generation, large diameter MoM bearing surface for an average of 77 months [108]. During this follow up period, 14 THAs (6.5%) were revised and found to have concerning signs of metallosis and lymphocytic infiltrates raising concerns about this bearing surface. Park et al. followed 169 hips who underwent THA using a second-generation MoM bearing surface for a minimum of 24 months and noted 10 hips (5.9%) had early osteolysis [110]. The poor performance associated with large head MoM bearing surfaces led the Food and Drug Administration to remove several second-generation MoM THA systems from the market, effectively ushering out the era of this bearing surface [111].

Fig. 4

A 68-year-old male patient with right total hip arthroplasty using large head MoM bearing (a) Preoperative radiograph of acetabular aseptic loosening (b) Large head MoM bearing (c) Radiographs after acetabular revision using CoC bearing

Wear mechanism

The dominant wear mechanism is determined to be mild surface fatigue. Surface fatigue is introduced by direct solid contact of surface asperities or by foreign and/or system inherent third bodies, which repeatedly slide or roll within the wear track. Although these third bodies contribute to fatigue related wear loss, this wear is several orders of magnitude smaller than would be introduced by adhesion. Tribochemical reactions also comprise an important wear mechanism in MoM hip joints. They might be triggered by the synergistic interaction of wear and corrosion and can influence the tribosystem in a positive or negative manner.

CoC articulation


In the late 60s, CoC bearings were first introducedin hip arthroplasty by Boutin [112]. They have undergone many generations of changes since then during which the susceptibility to fracture (a problem in early generation ceramics) has been overcome. Since ceramics are harder than metals, are biologically inert and have better lubrication properties leading to low wear rates [113], CoC bearings make an attractive choice for ensuring long term survival of hip prosthesis. The minimal wear particles released from CoC bearings are also biologically relatively inert and at nanometric size, significantly reducing the osteolysis produced due to PE wear particles. In addition, CoC bearing combination also has lesser coefficient of friction, higher wettability with biologically inert wear particles [114]. Clinical results have confirmed higher survivorship, lesser wear and low osteolysis making these bearings an excellent choice for young and active individuals [115]. Yoon et al. reported no case of osteolysis after 3rdgeneration of CoC bearing THA [116] and lower rate of osteolysis has been confirmed by many other studies [117, 118].

Hernigou et al. investigated wear and osteolysis in bilateral arthroplasties (one CoC and the contralateral CoP) of patients who had survived 20 years without revision and without loosening of either hip [119]. The number of lesions was higher on the side with Cop couple. Hai-bo Si et al. reviewed several articles that wear rate was also lower in CoC than CoP THA [120].

CoP articulations also reportedly have reduced wear rates compared to metal heads on PE in THA [121].


Though the ceramics are the new preferred bearing surface, especially in the young, they are not without their share of complications which include squeaking noises, stripe wear, a rare bearing surface fracture or chipping during insertion. Complications have been more commonly associated with acetabular component malposition (more vertical cups), smaller femoral heads and non-adherence to meticulous surgical technique [122, 123]. Fracture of a ceramic head and/or liner remains a major disadvantage for this bearing combination compared with MoP or MoM (Fig. 5). Earlier generations of alumina ceramic heads had a reported risk for fracture until 13.4%, however for newer implants (Biolox Forte and Delta) the reported fracture rate is much lower at 0 to 3.2% [124, 125].

Fig. 5

A 34-year-old male patient with right total hip arthroplasty using CoC articulation (Forte) (a) Radiograph with fractured ceramic head and liner (b) The fractured ceramic head and liner (c) Radiographs after revision surgery changing the ceramic liner and fractured head to metasul liner and metal head after cementing

Another concern remains squeaking of ceramic bearings. This potentially affects the patient’s quality of lifeand survivorship of the implant due to revision of the squeaky hip. Noises emanating from ceramic bearings (usually clicking and squeaking) have been reported with rates that vary from 0 to 33%. Fortunately clinically the problem is often minor in themajority of patients and revision surgery is indicated onlyoccasionally. Yoon et al. also reported low incidence of squeaking (1.5%), and there were no complications to limit daily life and no revision [126]. Despite these shortcomings, CoC articulation seems to be the best recently.

Wear mechanism

The dominating wear mechanism is mild surface fatigue maintaining a polished appearance in most areas of the articulating surfaces. The grain structure of the material can be easily identified in such polished areas. Sometimes, fine scratches originating from the initial polishing procedure during manufacturing are still visible indicating a very mild wear process. Abrasive scratches can be observed, however to a much lower extent than in other systems. No tribochemical reaction layers have been reported.

Ceramic on PE (CoP) articulation


CoP as a bearing couple currently accounts for around one in seven hip replacements in the UK [127]. Potentially this keeps the advantages of the softer, less rigid PE surface and utilises the advantages of the smooth, hard ceramic surface.

Over the period examined, CoP bearing surfaces steadily increased in popularity to become the most popular bearing surface type. Although concerns about fracturing of the femoral head [128] and increased costs had decreased usage of ceramic heads in the 1980s and 1990s, the advent of large ceramic heads with low fracture rates, low wear rates, and multiple neck length options over the past decade had increased the use of CoP bearings [129].

It is also apparent from the literature that CoC hips have lower wear rates compared with CoP hips, however, the mid-term studies utilising newer alumina ceramic with newer PEs show no difference in osteolysis or patient satisfaction at five years [130].


Theoretically, the limitations of CoP bearing surfaces involves the risk of alumina head fracture, the resultant difficult revision surgery [131], metal transfer which can increase surface roughness, and third body wear leading to increased PE wear [132]. With the advent of delta ceramic, the rate of fracture decreased dramatically. There has been no reports yet, about the clinically significant problem coming from metal transfer (Table 1).

Table 1 Advantages and disadvantages of bearing surfaces

Wear mechanism

It may be similar to MoP articulation. Wear mechanism is surface fatigue where the PE part is usually by far more affected than the hard counterbody. Surface fatigue is associated with repetitive loading and generates wear features such as pitting and delamination [133, 134]. The most common wear appearance in PE cups is polishing.

Unlike in MoM articulation, no tribochemical reactions have yet been reported for polymer cups. But, this does not preclude their existence. PE transfer films on the hard counter parts have been reported [135].

Orthopedic wear debris

Wear debris is formed at prosthetic joint articulations, at modular interfaces, at areas of impingement, and at nonarticulating interfaces due to abrasion with the surrounding bone, or debris [136].

Cells in the periprosthetic environment are exposed to a continuous production of wear particles. The biologic response to particle wear debris complex and drives the process toward periprosthetic tissue destruction and implant loosening. Although most of the studies have focused on UHMWPE particles, particles generated from other sources may induce an inflammatory reaction and subsequent osteolysis [137, 138]. For example, silicate and stainless steel particles, as possible containments from drilling and reaming tools, may elicit an aggressive cellular response. Although they may participate in initiating and/or instigating an inflammatory process, their role is considered minor. Alumina ceramic is a material commonly described as bio-inert [139]. However, submicron-sized particulates of alumina and zirconia may elicit a similar but less intense reaction to those seen with submicron-sized polymers and metal debris.


THA remains a highly successful procedure providing good pain relief and improvement of activity levels. Despiteits success, the expectations continue to increase with more and more young patients undergoing hip replacement and most of them seeking higher activity level (higher range ofmotion and stability in those ranges) as well as longevity of the prosthesis. Besides, the fixation method for the prosthesis, good surgical approach, bearing surfaces remain the most important determinant of longevity of the hip prosthesis.

Newer bearing surfaces incurrent clinical practice have shown promising clinical outcomes. With success of these wear reducing bearing surfaces, the scientific community will need to focus on not only further reducing abrasive wear but on reducing stress shielding as well by newer materials as well as designs. Ongoing research and the future of biomaterials in the hip are anticipated.



ceramic on ceramic




ceramic on polyethylene


diamond-like carbon


metal on metal


metal on polyethylene




poly (2-methacryloyloxyethyl phosphorylcholine)


total hip arthroplasty


titanium nitride


ultra high molecular weight polyethylene


ultra nanocrystalline diamond


high crosslinked UHMWPE


zirconia-toughened alumina


  1. 1.

    National Joint Registry for England. Wales, Northern Ireland and the Isle of Man. 13th AnnualReport. Accessed 2016.

  2. 2.

    Maradit Kremers H, Larson DR, Crowson CS, et al. Prevalence of TotalHip and knee replacement in the United States. J Bone Joint Surg Am. 2015;97:1386–97.

    Article  Google Scholar 

  3. 3.

    Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and kneearthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007;89:780–5.

    Google Scholar 

  4. 4.

    Health Insurance Review & Assessment Service, Korea Healthcare Bigdata Hub. Accessed 14 Sept 2018.

  5. 5.

    Miura K, Yamada N, Hanada S, Jung TK, Itoi E. The bone tissue compatibility of a new Ti-Nb-Sn alloywith a low Young’s modulus. Acta Biomater. 2011;7:2320–6.

    CAS  Article  Google Scholar 

  6. 6.

    Guo S, Bao ZZ, Meng QK, Hu L, Zhao XQ. A novel metastable Ti-25Nb-2Mo-4Sn alloy with high strength and low Young’s modulus. Metall Mater Trans A Phys Metall Mater Sci. 2012;43:3447–51.

    CAS  Article  Google Scholar 

  7. 7.

    Niinomi M, Hattori T, Morikawa K, Kasuga T, Suzuki A, Fukui H, Niwa S. Development of lowrigidity beta-type titanium alloy for biomedical applications. Mater Trans. 2002;43:2970–7.

    CAS  Article  Google Scholar 

  8. 8.

    Okazaki Y. A new Ti-15Zr-4Nb-4Ta alloy for medical applications. Curr Opin Solid State Mater Sci. 2001;5:45–53.

    CAS  Article  Google Scholar 

  9. 9.

    Bai X, Sandukas S, Appleford MR, Ong JL, Rabiei A. Deposition and investigation of functionallygraded calcium phosphate coatings on titanium. Acta Biomater. 2009;5:3563–72.

    CAS  Article  Google Scholar 

  10. 10.

    Bai X, Sandukas S, Appleford MR, Ong JL, Rabiei A. Antibacterial effect and cytotoxicity of Ag-doped functionally graded hydroxyapatite coatings. J Biomed Mater Res Part B Appl Biomaterials. 2012;100:553–61.

    Article  CAS  Google Scholar 

  11. 11.

    Chen W, Liu Y, Courtney HS, Bettenga M, Agrawal CM, Bumgardner JD, Ong JL. In vitro anti-bacterial and biological properties of magnetron co-sputtered silver-containing hydroxyapatite coating. Biomaterials. 2006;27:5512–7.

    CAS  Article  Google Scholar 

  12. 12.

    Ong JL, Lucas LC, Lacefield WR, Rigney ED. Structure solubility and bond strength of thin calcium-phosphate coatings produced by ion-beam sputter deposition. Biomaterials. 1992;13:249–54.

    CAS  Article  Google Scholar 

  13. 13.

    Yang YZ, Kim KH, Ong JL. Review on calcium phosphate coatings produced using a sputtering process—an alternative to plasma spraying. Biomaterials. 2005;26:327–37.

    CAS  Article  Google Scholar 

  14. 14.

    Kim HM, Miyaji F, Kokubo T, Nakamura T. Preparation of bioactive Ti and its alloys via simple chemical surface treatment. J Biomed Mater Res. 1996;32:409–17.

    CAS  Article  Google Scholar 

  15. 15.

    Kim HM, Miyaji F, Kokubo T, Nishiguchi S, Nakamura T. Graded surface structure of bioactive titanium prepared by chemical treatment. J Biomed Mater Res. 1999;45:100–7.

    CAS  Article  Google Scholar 

  16. 16.

    Kim HM, Takadama H, Miyaji F, Kokubo T, Nishiguchi S, Nakamura T. Formation of bioactivefunctionally graded structure on Ti-6Al-4V alloy by chemical surface treatment. J Mater Sci Mater Med. 2000;11:555–9.

    CAS  Article  Google Scholar 

  17. 17.

    Kizuki T, Takadama H, Matsushita T, Nakamura T, Kokubo T. Preparation of bioactive Ti metal surface enriched with calcium ions by chemical treatment. Acta Biomater. 2010;6:2836–42.

    CAS  Article  Google Scholar 

  18. 18.

    Kokubo T, Pattanayak DK, Yamaguchi S, Takadama H, Matsushita T, Kawai T, Takemoto M, Fujibayashi S, Nakamura T. Positively charged bioactive Ti metal prepared by simple chemical and heat treatments. J R Soc Interface. 2010;7:503–13.

    Article  CAS  Google Scholar 

  19. 19.

    Oral E, Christensen SD, Malhi AS, Wannomae KK, Muratoglu OK. Wear resistance and mechanical properties of highly cross-linked, ultrahigh-molecular weight polyethylene doped with vitamin E. J Arthroplast. 2006;21:580–91.

    Article  Google Scholar 

  20. 20.

    Oral E, Muratoglu OK. Vitamin E diffused, highly crosslinked UHMWPE: a review. Int Orthop. 2011;35:215–23.

    Article  Google Scholar 

  21. 21.

    Kyomoto M, Moro T, Konno T, Takadama H, Yamawaki N, Kawaguchi H, Takatori Y, Nakamura K, Ishihara K. Enhanced wear resistance of modified cross-linked polyethylene by grafting with poly(2-methacryloyloxyethyl phosphorylcholine). J Biomed Mater Res Part A. 2007;82(1):10–7.

    Article  CAS  Google Scholar 

  22. 22.

    Kyomoto M, Moro T, Iwasaki Y, Miyaji F, Kawaguchi H, Takatori Y, Nakamura K, Ishihara K. Superlubricious surface mimicking articular cartilage by grafting poly(2-methacryloyloxyethyl phosphorylcholine) on orthopaedic metal bearings. J Biomed Mater Res Part A. 2009;91:730–41.

    Article  CAS  Google Scholar 

  23. 23.

    Clarke IC, Manaka M, Green DD, Williams P, Pezzotti G, Kim YH, Ries M, Sugano N, Sedel L, Delauney C, et al. Current status of zirconia used in total hip implants. J Bone Joint Surg Am. 2003;85:73–84.

    Article  Google Scholar 

  24. 24.

    Begand S, Oberbach T, Glien W. Investigations of the mechanical properties of an alumina toughened zirconia ceramic for an application in joint prostheses. Key Eng Mater. 2005;284:1019–22.

    Article  Google Scholar 

  25. 25.

    Al-Hajjar M, Jennings LM, Begand S, Oberbach T, Delfosse D, Fisher J. Wear of novel ceramic-on-ceramic bearings under adverse and clinically relevant hip simulator conditions. J Biomed Mater Res Part B Appl Biomater. 2013;101:1456–62.

    Article  CAS  Google Scholar 

  26. 26.

    Hobbs LW, Rosen VB, Mangin SP, Treska M, Hunter G. Oxidation microstructures and interfaces in the oxidized zirconium knee. Int J Appl Ceram Technol. 2005;2:221–46.

    CAS  Article  Google Scholar 

  27. 27.

    Good V, Ries M, Barrack RL, Widding K, Hunter G, Heuer D. Reduced wear with oxidized zirconium femoral heads. J Bone Joint Surg Am. 2003;85:105–10.

    Article  Google Scholar 

  28. 28.

    Burger W, Richter HG. High strength and toughness alumina matrix composites by transformationtoughening and ‘in situ’ platelet reinforcement (ZPTA)—the new generation of bioceramics. Key Eng Mater. 2000;192–5:545–8.

    Article  Google Scholar 

  29. 29.

    McKee GK, Watson-Farrar J. Replacement of arthritic hips by the McKee-Farrar prosthesis. J Bone Joint Surg Br. 1966;48(2):245–59.

    CAS  Article  Google Scholar 

  30. 30.

    Triclot P. Metal-on-metal: history, state of the art. Int Orthop. 2011;35(2):201-6.

  31. 31.

    Learmonth ID, Young C, Rorabeck C. The operation of the century: total hip replacement. Lancet. 2007;370:1508–19.

    Article  Google Scholar 

  32. 32.

    Berry DJ, Harmsen WS, Cabanela ME, Morrey BF. Twenty-five-year survivorship of two thousand consecutive primary Charnley total hip replacements: factors affecting survivorship of acetabular and femoral components. J Bone Joint Surg Am. 2002;84–A:171–7.

    Article  Google Scholar 

  33. 33.

    Boutin P. Total arthroplasty of the hip by fritted alumina prosthesis. Experimental study and 1st clinical applications. Orthop Traumatol Surg Res. 2014;100:15–21.

    CAS  Article  Google Scholar 

  34. 34.

    Howmedica I. Strength for Life : The Vitallium Alloy Story. Rutherord: Howmedica Inc.; 1995.

    Google Scholar 

  35. 35.

    Bronzino JD. The Biomedical Engineering Handbook. 2nd ed: CRC Press; 1999.

  36. 36.

    Head WC, Bauk DJ, Emerson RH. Titanium as the material of choice for cementless femoral components in total hip arthroplasty. Clin Orthop Relat Res. 1995;311:85–90.

    Google Scholar 

  37. 37.

    Branemark PI, George AZ, Tomas A. Tissue-integrated prostheses: osseointegration in clinical dentistry. Chicago: Quintessence; 1985. p. 1–76.

  38. 38.

    Landor I, Vavrik P, Sosna A, Jahoda D, Hahn H, Daniel M. Hydroxyapatite porous coating and the osteointegration of the total hip replacement. Arch Orthop Trauma Surg. 2007;127(2):81–9.

    Article  Google Scholar 

  39. 39.

    Balla VK, Bodhak S, Bose S, Bandyopadhyay A. Porous tantalum structures for bone implants: fabrication, mechanical and in vitrobiological properties. Acta Biomater. 2010;6(8):3349–59.

    CAS  Article  Google Scholar 

  40. 40.

    Matassi F, Botti A, Sirleo L, Carulli C, Innocenti M. Porous metal for orthopedics implants. Clin Cases Miner Bone Metab. 2013;10(2):111–5.

    Google Scholar 

  41. 41.

    Charnley J. Arthroplasty of the hip: a new operation. Lancet. 1961;1:1129–32.

    CAS  Article  Google Scholar 

  42. 42.

    Hopper RH Jr, Young AM, Orishimo KF, Engh CA Jr. Effect of terminal sterilization with gas plasma or gammaradiation on wear of polyethylene liners. J Bone Joint Surg Am 2003;85:464–468.

    Article  Google Scholar 

  43. 43.

    McKellop H, Shen FW, Lu B, Campbell P, Salovey R. Effect of sterilization method and other modifications on the wearresistance of acetabular cups made of ultra-high molecular weightpolyethylene. A hip-simulator study. J Bone Joint Surg Am. 2000;82:1708–25.

    Article  Google Scholar 

  44. 44.

    Devane PA, Horne JG, Martin K, Coldham G, Krause B. Three-dimensional polyethylene wear of a press-fit titaniumprosthesis. Factors influencing generation of polyethylene debris. J Arthroplasty. 1997;12:256–66.

    CAS  Article  Google Scholar 

  45. 45.

    Young AM, Sychterz CJ, Hopper RH Jr, Engh CA. Effectof acetabular modularity on polyethylene wear and osteolysis intotal hip arthroplasty. J Bone Joint Surg Am 2002; 84:58–63.

    Article  Google Scholar 

  46. 46.

    Harris WH. The problem is osteolysis. Clin Orthop Relat Res. 1995;311:46–53.

    Google Scholar 

  47. 47.

    Kim YH, Kim JS, Park JW, Joo JH. Periacetabular osteolysis is the problem in contemporary total hip arthroplasty in young patients. J Arthroplast. 2012;27:74–81.

    Article  Google Scholar 

  48. 48.

    Digas G, Kärrholm J, Thanner J, Malchau H, Herberts P. Highly cross-linked polyethylene in total hip arthroplasty: randomizedevaluation of penetration rate in cemented and uncementedsockets using radiostereometric analysis. Clin Orthop Relat Res. 2004;429:6–16.

    Article  Google Scholar 

  49. 49.

    Manning DW, Chiang PP, Martell JM, et al. In vivo comparative wear study of traditional and highly cross-linked polyethylene in total hip arthroplasty. J Arthroplast. 2005;20(7):880–6.

    Article  Google Scholar 

  50. 50.

    Martell JM, Verner JJ, Incavo SJ. Clinical performance of a highly cross-linked polyethylene at two years in total hip arthroplasty: a randomized prospective trial. J Arthroplast. 2003;18(7 suppl 1):55–9.

    Article  Google Scholar 

  51. 51.

    Collier JP, Currier BH, Kennedy FE, et al. Comparison of cross-linked polyethylene materials for orthopaedic applications. Clin Orthop Relat Res. 2003;414:289–304.

    Article  Google Scholar 

  52. 52.

    Muratoglu OK, Bragdon CR, O’Connor DO, et al. Unified wear model for highly cross-linked ultra-high molecular weight polyethylenes (UHMWPE). Biomaterials. 1999;20(16):1463–70.

    CAS  Article  Google Scholar 

  53. 53.

    Chiesa R, Tanzi MC, Alfonsi S, et al. Enhanced wear performance of highly crosslinked UHMWPE for artificial joints. J Biomed Mater Res. 2000;50(3):381–7.

    CAS  Article  Google Scholar 

  54. 54.

    Muratoglu OK, Greenbaum ES, Bragdon CR, et al. Surface analysis of early retrieved acetabular polyethylene liners: A comparison of conventional and highly crosslinked polyethylene. J Arthroplasty. 2004;19(1):68–77.

    Article  Google Scholar 

  55. 55.

    Dumbleton JH, D’Antonio JA, Manley MT, Capello WN, Wang A. The basis for a second-generation highly cross-linked UHMWPE. Clin Orthop Relat Res. 2006;453:265–71.

    Article  Google Scholar 

  56. 56.

    Ishihara K. Highly lubricated polymer interfaces for advanced artificial hip joints through biomimetic design. Polym J. 2015;47:585–97.

    CAS  Article  Google Scholar 

  57. 57.

    Hannouche D, Hamadouche M, Nizard R, et al. Ceramics in total hip replacement. Clin Orthop Relat Res. 2005;430:62–71.

    Article  Google Scholar 

  58. 58.

    Clarke IC, Good V, Williams P, Schroeder D, Anissian L, Stark A, Oonishi H, Schuldies J, Gustafson G. Ultra-low wear rates for rigid-on-rigid bearings in total hip replacements. Proc Inst Mech Eng H. 2000;214:331–47.

    CAS  Article  Google Scholar 

  59. 59.

    Jeffers JR, Walter WL. Ceramic-on-ceramic bearings in hip arthroplasty: state of the art and the future. J Bone Joint Surg Br. 2012;94(6):735–45.

    CAS  Article  Google Scholar 

  60. 60.

    Kurtz SM. UHMWPE Biomaterials Handbook. 2nd ed. Boston, mass: Academic Press; 2009.

    Google Scholar 

  61. 61.

    Masonis JL, Bourne RB, Ries MD, et al. Zirconia femoral head fractures: A clinical and retrieval analysis. J Arthroplasty. 2004;19(7):898–905.

    Article  Google Scholar 

  62. 62.

    De Aza AH, Chevalier J, Fantozzi G, et al. Crack growth resistance of alumina, zirconia and zirconia toughened alumina ceramics for joint prostheses. Biomaterials. 2002;23(3):937–45.

    CAS  Article  Google Scholar 

  63. 63.

    Allain J, Le Mouel S, Goutallier D, et al. Poor eight-year survival of cemented zirconia-polyethylene total hip replacements. J bone Joint Surg Br. 1999;81(5):835–42.

    CAS  Article  Google Scholar 

  64. 64.

    Masonis JL, Bourne RB, Ries MD, McCalden RW, Salehi A, Kelman DC. Zirconia femoral head fractures: a clinical and retrieval analysis. J Arthroplast. 2004;19:898–905.

    Article  Google Scholar 

  65. 65.

    Santos EM, Vohra S, Catledge SA, McClenny MD, Lemons J, Moore KD. Examination of surface and material properties of explantedzirconia femoral heads. J Arthroplast. 2004;19(7Suppl 2):30–4.

    Article  Google Scholar 

  66. 66.

    Chevalier J. What future for zirconia as a biomechanical? Biomaterials. 2006;27(4):535–43.

    CAS  Article  Google Scholar 

  67. 67.

    Bal BS, Rahaman MN. Orthopedic applications of silicon nitride ceramics. Acta Biomater. 2012;8:2889–98.

    CAS  Article  Google Scholar 

  68. 68.

    McEntire BJ, Bal BS, Rahaman MN, Chevalier J, Pezzotti G. Ceramics and ceramic coatings in orthopaedics. J Eur Ceram Soc. 2015;35:4327–69.

    CAS  Article  Google Scholar 

  69. 69.

    Chen FC, Ardell AJ. Fracture toughness of ceramics and semi-brittle alloys using a miniaturized disk-bend test. Mater Res Innov. 2000;3:250–62.

    CAS  Article  Google Scholar 

  70. 70.

    Bal BS, et al. Fabrication and testing of silicon nitride bearingsin total hip arthroplasty. J Arthroplast. 2009;24(1):110–6.

    Article  Google Scholar 

  71. 71.

    McEntire BJ, Lakshminarayanan R, Ray DA, Clarke IC, Puppulin L, Pezzotti G. Silicon nitride bearings for total joint arthroplasty. Lubricants. 2016;4:35.

    Article  Google Scholar 

  72. 72.

    Tribe H, Malek S, Stammers J, et al. Advanced wear of an Oxinium™ femoral head implant following polyethylene liner dislocation. Ann R Coll Surg Engl. 2013;95(8):133–5.

    Article  Google Scholar 

  73. 73.

    Hernigou P, Mathieu G, Poingnard A, et al. Oxinium, a new alternative femoral bearing surface option for hip replacement. Eur J Orthop Surg Traumatol. 2007;17(3):243–6.

    Article  Google Scholar 

  74. 74.

    Kop AM, Whitewood C, Johnston DJ. Damage of Oxinium femoral heads subsequent to hip arthroplasty dislocation: Three retrieval case studies. J Arthroplasty. 2007;22(5):775–9.

    Article  Google Scholar 

  75. 75.

    Lewis PM, Moore CA, Olsen M, Schemitsch E, Waddell JP. Comparison of mid-term clinical outcomes following primarytotal hip arthroplasty with Oxinium versus cobalt chromefemoral heads. Orthopedics. 2008;31(12Supppl2).

  76. 76.

    Abu-Amer Y, Darwech I, Clohisy JC. Aseptic loosening of total joint replacements: mechanisms underlying osteolysis and potential therapies. Arthritis Res Ther. 2007;9:S6.

    Article  CAS  Google Scholar 

  77. 77.

    Narayan RJ. Nanostructured diamondlike carbon thin films for medical applications. Mater Sci Eng C. 2005;25:405–16.

    Article  CAS  Google Scholar 

  78. 78.

    Pappas MJ, Makris G, Buechel FF. Titanium nitride ceramic film against polyethylene: A 48-million cycle wear test. Clin Orthop Relat Res. 1995;317:64–70.

    Google Scholar 

  79. 79.

    Hauert R, Falub CV, Thorwarth G, Thorwarth K, Affolter C, Stiefel M, Podleska LE, Taeger G. Retrospective lifetime estimation of failed and explanted diamond-like carbon coated hip joint balls. Acta Biomater. 2012;8:3170–6.

    CAS  Article  Google Scholar 

  80. 80.

    Catledge SA, Vohra YK. Effect of nitrogen addition on the microstructure and mechanical properties of diamond films grown using high-methane concentrations. J Appl Phys. 1999;86:698–700.

    CAS  Article  Google Scholar 

  81. 81.

    Catledge SA, Vaid R, Diggins P, Weimer JJ, Koopman M, Vohra YK. Improved adhesion of ultra-hard carbon films on cobalt-chromium orthopaedic implant alloy. J Mater Sci Mater Med. 2011;22:307–16.

    CAS  Article  Google Scholar 

  82. 82.

    Papo MJ, Catledge SA, Vohra YK. Mechanical wear behavior of nanocrystalline and multilayer diamond coatings on temporomandibular joint implants. J Mater Sci Mater Med. 2004;15:773–7.

    CAS  Article  Google Scholar 

  83. 83.

    Vila M, Amaral M, Oliveira FJ, Silva RF, Fernandes AJS, Soares MR. Residual stress minimum in nanocrystalline diamond films. Appl Phys Lett. 2006;89:093109.

    Article  CAS  Google Scholar 

  84. 84.

    Kumar N, Arora GN, Datta B. Bearing surfaces in hip replacement-evolution and likely future. Med J Armed Forces India. 2014;70(4):371–6.

    Article  Google Scholar 

  85. 85.

    Charnley J, Kamangar A, Longfield MD. The optimum size of prosthetic heads in relation to wear of plastic sockets in total replacement of hip. Med Biol Eng. 1969;7:31–9.

    CAS  Article  Google Scholar 

  86. 86.

    Tsukamoto M, Mori T, Ohnishi H, Uchida S, Sakai A. Highly cross-linked polyethylene reduces Osteolysis incidence and Wear-related reoperation rate in Cementless Total hip arthroplasty compared with conventional polyethylene at a mean 12-year follow-up. J Arthroplast. 2017;32(12):3771–6.

    Article  Google Scholar 

  87. 87.

    Vendittoli PA, Riviere C, Lavigne M, Lavoie P, Alghamdi A, Duval N. Aluminaon alumina versus metal on conventional polyethylene: a randomizedclinical trial with 9 to 15 years follow-up. Acta Orthop Belg. 2013;79:181–90.

    Google Scholar 

  88. 88.

    Green TR, Fisher J, Stone M, Wroblewski BM, Ingham E. Polyethylene particles of a ‘critical size’ are necessary for theinduction of cytokines by macrophages in vitro. Biomaterials. 1998;19:2297–302.

    CAS  Article  Google Scholar 

  89. 89.

    Dumbleton JH, Manley MT, Edidin AA. A literature review ofthe association between wear rate and osteolysis in total hiparthroplasty. J Arthroplast. 2002;17:649–61.

    Article  Google Scholar 

  90. 90.

    D’Antonio JA, Capello WN, Naughton M. Ceramic bearings for total hiparthroplasty have high survivorship at 10 years. Clin Orthop Relat Res. 2012;470:373–81.

    Article  Google Scholar 

  91. 91.

    Brach del Prever EM, Bistolfi A, Bracco P, Costa L. UHMWPE for arthroplasty: past or future? J Orthop Traumatol. 2009;10:1–8.

    Article  Google Scholar 

  92. 92.

    Oral E, Christensen SD, Malhi AS, Wannomae KK. MuratogluOK. Wear resistance and mechanical properties of highlycross-linked, ultrahigh-molecular weight polyethylene dopedwith vitamin E. J Arthroplast. 2006;21:580–91.

    Article  Google Scholar 

  93. 93.

    Bragdon CR, Doerner M, Martell J, Jarrett B, Palm H, Malchau H. The 2012 John Charnley award: clinical multicenter studies of the wear performance of highly crosslinked remelted polyethylene in THA. Clin Orthop Relat Res. 2013;471:393–402.

    Article  Google Scholar 

  94. 94.

    McKellop HA, Campbell P, Park SH, Schmalzried TP, Grigoris P, Amstutz HC, Sarmiento A. The origin of submicron polyethylene wear debris in total hip arthroplasty. Clin Orthop Relat Res. 1995;311:3–20.

    Google Scholar 

  95. 95.

    McMinn D, Daniel J. History and modern concepts in surface replacement. Proc lnst Mech EngH. 2006;220:239–51.

    CAS  Google Scholar 

  96. 96.

    Daniel J, Pynsent PB, McMinn DJ. Metal-on-metal resurfacing of the hip inpatients under the age of 55 years with osteoarthritis. J Bone Joint Surg Br. 2004;86:177–84.

    CAS  Article  Google Scholar 

  97. 97.

    Mauricio S, Christian H, Thomas P. Metal-on-Metal Total Hip Replacement. Clin Orthop Relate Res. 2005;430:53–61.

  98. 98.

    Moon JK, Kim Y, Hwang KT, Yang JH, Oh YH, Kim YH. Long-term outcomes after metal-on-metal Total hip arthroplasty with a 28-mm head: a 17- to 23-year follow-up study of a previous report. J Arthroplast. 2018.

    Article  Google Scholar 

  99. 99.

    Hur CI, Yoon TR, Cho SG, Song EK, Seon JK. Serum ion level after metal-on-metal THA in patients with renal failure. Clin Orthop Relat Res. 2008;466(3):696–9.

    Article  Google Scholar 

  100. 100.

    National Joint Registry for England. Wales, Northern Ireland and the Isle of Man. 5th Annual Report. Accessed 2008.

  101. 101.

    Australian Orthopaedic Association National Joint Replacement Registry Annual Report. Asscessed 2008.

  102. 102.

    Willert HG, Buchhorn GH, Fayyazi A, et al. Metal-on-metal bearings and hypersensitivity in patients with artificial hip joints. A clinical and histomorphologicalstudy. J Bone Joint Surg Am. 2005;87:28–36.

    Article  Google Scholar 

  103. 103.

    Jacobs JJ, Hallab NJ. Loosening and osteolysis associated with metal-on-metalbearings: a local effect of metal hypersensitivity? J Bone Joint Surg Am. 2006;88:1171–2.

    Google Scholar 

  104. 104.

    Brodner W, Bitzan P, Meisinger V, Kaider A, Gottsauner-Wolf F, Kotz R. Elevated serum cobalt with metal-on-metal articulating surfaces. J Bone Joint Surg Br. 1997;79(2):316–21.

    CAS  Article  Google Scholar 

  105. 105.

    Urban RM, Jacobs JJ, Tomlinson MJ, Gavrilovic J, Black J, Peoc’h M. Dissemination of wear particles to the liver, spleen, and abdominal lymph nodes of patients with hip or knee replacement. J Bone Joint Surg Am. 2000;82:457–76.

    CAS  Article  Google Scholar 

  106. 106.

    Case CP. Chromosomal changes after surgery for joint replacement. J Bone Joint Surg Br. 2001;83(8):1093–5.

    CAS  Article  Google Scholar 

  107. 107.

    Smith AJ, Dieppe P, Porter M, Blom AW. National Joint Registry of England and Wales Risk of cancer in first seven years after metal-on-metal hip replacement compared with other bearings and general population: linkage study between the National Joint Registry of England and Wales and hospital episode statistics. BMJ. 2012;344:e2383.

    Article  Google Scholar 

  108. 108.

    Korovessis P, Petsinis G, Repanti M, Repantis T. Metallosis after contemporarymetal-on-metal total hip arthroplasty. Five to nine-year follow-up. J BoneJoint Surg Am. 2006;88:1183–91.

    CAS  Article  Google Scholar 

  109. 109.

    Milosev I, Trebse R, Kovac S, Cor A, Pisot V. Survivorship and retrieval analysisof Sikomet metal-on-metal total hip replacements at a mean of seven years. J Bone Joint Surg Am. 2006;88:1173–82.

    Article  Google Scholar 

  110. 110.

    Park YS, Moon YW, Lim SJ, Yang JM, Ahn G, Choi YL. Early osteolysisfollowing second-generation metal-on-metal hip replacement. J Bone Joint Surg Am. 2005;87:1515–21.

    Article  Google Scholar 

  111. 111.

    Administration FAD. List of Device Recalls. … fda. gov/medicaldevices/safety/ListofRecalls/default …; 2014; Accessed 06 Feb 2018.

  112. 112.

    Boutin P. Total arthroplasty of the hip by fritted aluminum prosthesis. Experimental study and 1st clinical applications. Rev Chir Orthop Reparatrice Appar Mot. 1972;58:229–46.

    CAS  Google Scholar 

  113. 113.

    Jonathan PG. Ceramic hip replacement history. Semin Arthroplast. 2011;22(4):214–7.

    Article  Google Scholar 

  114. 114.

    Kurtz SM, Ong K. Contemporary total hip arthroplasty: Hard-on hard bearings and highly crosslinked UHMWPE. In: Kurtz SM, editor. UHMWPE Biomaterials Handbook. 2nd ed. Burlington: Academic(Elsevier); 2009. p. 55–79.

    Chapter  Google Scholar 

  115. 115.

    Williams S, Schepers A, Isaac G, Hardaker C, Ingham E, van der Jagt D, Breckon A, Fisher J. The 2007 Otto Aufranc award. Ceramic-on-metalhip arthroplasties: a comparative in vitro and in vivo study. Clin Orthop Relat Res. 2007;465:23–32.

    Google Scholar 

  116. 116.

    Park KS, Seon JK, Yoon TR. The survival analysis in third-generation ceramic-on-ceramic Total hip arthroplasty. J Arthroplast. 2015;30(11):1976–80.

    Article  Google Scholar 

  117. 117.

    Lewis PM, Al-Belooshi A, Olsen M, Schemitch EH, Waddell JP. Prospective randomized trial comparing alumina ceramic-on-ceramic with ceramic-on-conventional polyethylene bearings in total hip arthroplasty. J Arthroplasty. 2010;25(3):392–7.

    Article  Google Scholar 

  118. 118.

    Kubo T, Sawada K, Hirakawa K, Shimizu C, Takamatsu T, Hirasawa Y. Histiocyte reaction in rabbit femurs to UHMWPE, metal, and ceramicparticles in different sizes. J Biomed Mater Res. 1999;45(4):363–9.

    CAS  Article  Google Scholar 

  119. 119.

    Hernigou P, Zilber S, Filippini P, Poignard A. Ceramic-ceramic bearing decreases osteolysis: a 20-year study versus ceramic-polyethylene on the contralateral hip. Clin Orthop Relat Res. 2009;467:2274–80.

    Article  Google Scholar 

  120. 120.

    Si HB, Zeng Y, Cao F, Pei FX, Shen B. Is a ceramic-on-ceramic bearing really superiorto ceramic-on-polyethylene for primary total hiparthroplasty? A systematic review and meta-analysisof randomised controlled trials. Hip Int. 2015;25(3):191–8.

    Article  Google Scholar 

  121. 121.

    Glaser D, Komistek RD, Cates HE, Mahfouz MR. Clicking and squeaking:in vivo correlation of sound and separation for different bearingsurfaces. J Bone Joint Surg Am. 2008;90(Suppl(4):112–20.

    Article  Google Scholar 

  122. 122.

    Yang CC, Kim RH, Dennis DA. The squeaking hip: a cause for concern-disagrees. Orthopedics. 2007;30:739.

    Google Scholar 

  123. 123.

    Ranawat AS, Ranawat CS. The squeaking hip: a cause for concern-agrees. Orthopedics. 2007;30:738.

    Google Scholar 

  124. 124.

    Lusty PJ, Tai CC, Sew-Hoy RP, Walter WL, Walter WK, Zicat BA. Third-generation alumina-on-alumina ceramic bearings incementless total hip arthroplasty. J Bone Joint Surg Am. 2007;89:2676–83.

    CAS  Article  Google Scholar 

  125. 125.

    Hamilton WG, McAuley JP, Dennis DA, Murphy JA, Blumenfeld TJ, Politi J. THA with Delta ceramic on ceramic: results of a multicenter investigational device exemption trial. Clin Orthop Relat Res. 2010;468:358–66.

    Article  Google Scholar 

  126. 126.

    Haq RU, Park KS, Seon JK, Yoon TR. Squeaking after third-generation ceramic-on-ceramic total hip arthroplasty. J Arthroplast. 2012;27(6):909–15.

    Article  Google Scholar 

  127. 127.

    Lancaster JG, Dowson D, Isaac GH, Fisher J. The wear of ultra-high molecular weight polyethylene sliding on metallic and ceramic counterfaces representative of current femoral surfaces in joint replacement. Proc Inst Mech Eng H. 1997;211(1):17–24.

    CAS  Article  Google Scholar 

  128. 128.

    Callaway GH, Flynn W, Ranawat CS, Sculco TP. Fracture of the femoral headafter ceramic-on-polyethylene total hip arthroplasty. J Arthroplast. 1995;10:855–9.

    CAS  Article  Google Scholar 

  129. 129.

    Lehil MS, Bozic KJ. Trends in total hip arthroplasty implant utilization in theUnited states. J Arthroplast. 2014;29:1915–8.

    Article  Google Scholar 

  130. 130.

    Rieger W. Ceramics in orthopaedics - 30 years of evolution and experience. In: Reiker CB, Oberholzer S, Wyss U, editors. World tribology forum in arthroplasty. Berne: Hans Huber Verlag; 2001.

    Google Scholar 

  131. 131.

    Heisel C, Silva M, Schmalzried TP. Bearing surface options fortotal hip replacement in young patients. Instr Course Lect. 2004;53:49–65.

    Google Scholar 

  132. 132.

    Della Valle AG, Doty S, Gradl G, Labissiere A, Nestor BJ. Wear ofa highly cross-linked polyethylene liner associated with metallicdeposition on a ceramic femoral head. J Arthroplast. 2004;19(4):532–6.

    Article  Google Scholar 

  133. 133.

    Magnissalis EA, Eliades G, Eliades T. Multitechnique characterization of articular surfaces of retrieved ultrahigh molecular weight polyethylene acetabular socket. J Biomed Mater Res. 1999;48(3):365–73.

    CAS  Article  Google Scholar 

  134. 134.

    Collier JP, Bargmann LS, Currier BH, Mayor MB, Currier JH, Bargmann BC. An analysis of hylamer and polyethylene bearings from retrieved acetabular components. Orthopedics. 1998;21(8):865–71.

    CAS  Google Scholar 

  135. 135.

    Crockett R, Roba M, Naka M, Gasser B, Delfosse D, Frauchiger V, Spencer ND. Friction, lubrication, and polymer transfer between UHMWPE and CoCrMo hip-implant materials: a fluorescence microscopy study. J Biomed Mater Res A. 2009;89(4):1011–8.

    Article  CAS  Google Scholar 

  136. 136.

    McKellop HA. The lexicon of polyethylene wear in artificial joints. Biomaterials. 2007;28(34):5049–57.

    CAS  Article  Google Scholar 

  137. 137.

    Berger RA, Jacobs JJ, Quigley LR, Rosenberg AG, Galante JO. Primary cementless acetabular reconstruction in patients younger than 50 years old. 7- to 11-year results. Clin Orthop Relat Res. 1997;344:216-226.

    Article  Google Scholar 

  138. 138.

    Devane PA, Bourne RB, Rorabeck CH, MacDonald S, Robinson EJ. Measurement of polyethylene wear in metal-backed acetabular cups. II Clinical application. Clin Orthop Relat Res. 1995;319:317–26.

    Google Scholar 

  139. 139.

    Lusty PJ, Tai CC, Sew-Hoy RP, Walter WL, Walter WK, Zicat BA. Third-generation alumina-on-alumina ceramic bearings in cementless total hip arthroplasty. J Bone Joint Surg Am. 2007;89:2676–83.

    CAS  Article  Google Scholar 

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Correspondence to Taek-Rim Yoon.

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Hu, C.Y., Yoon, TR. Recent updates for biomaterials used in total hip arthroplasty. Biomater Res 22, 33 (2018).

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  • Hip
  • Arthroplasty
  • Biomaterials
  • Stainless steel
  • Cobalt-chromium alloy
  • Titanium alloy
  • Polyethylene
  • Ceramic