Metal-on-Metal Total Hip Arthroplasty: Current Recommendations and Lessons Learned


  • Jonathan Liu Texas A&M HSC
  • Dr. Alister Hart Royal National Orthopaedic Hospital
  • Brendan Holderread Texas A&M College of Medicine
  • Dr. Terry Clyburn Houston Methodist Hospital



metal-on-metal, total hip arthroplasty, clinical management, literature review, lessons learned


Metal-on-metal (MoM) hip arthroplasty was re-popularized in the 1990s to resolve osteolysis and wear associated with metal-on-polyethylene products. Despite early success, registries began reporting high failure rates due to adverse reactions to metal debris (ARMD), manifesting as pseudotumors, hip effusions and osteolysis. Evaluation includes clinical exam, advanced imaging, and blood metal ions and infectious markers. This review provides physicians with an evidence-based update on the 1) clinical workup and management of patients with existing MoM implants, 2) risk and prognostic factors associated with suboptimal results and 3) the precipitating events and lessons learned applicable to future orthopedic prosthesis.

Author Biographies

Dr. Alister Hart, Royal National Orthopaedic Hospital

Department of Orthopedic Surgery, Adult Reconstruction

Dr. Terry Clyburn, Houston Methodist Hospital

Department of Orthopedics, Adult Reconstruction


Kovochich M, Fung ES, Donovan E, Unice KM, Paustenbach DJ, Finley BL. Characterization of wear debris from metal-on-metal hip implants during normal wear versus edge-loading conditions. J Biomed Mater Res - Part B Appl Biomater. 2018;106(3):986-996. doi:10.1002/jbm.b.33902

Liow MHL, Kwon YM. Metal-on-metal total hip arthroplasty: risk factors for pseudotumours and clinical systematic evaluation. Int Orthop. 2017;41(5):885-892. doi:10.1007/s00264-016-3305-1

Amstutz HC, Grigoris P. Metal on metal bearings in hip arthroplasty. Clin Orthop Relat Res. 1996;(329 SUPPL.). doi:10.1097/00003086-199608001-00003

Kovochich M, Finley BL, Novick R, et al. Understanding outcomes and toxicological aspects of second generation metal-on-metal hip implants: a state-of-the-art review. Crit Rev Toxicol. 2018;48(10):853-901. doi:10.1080/10408444.2018.1563048

Eltit F, Wang Q, Wang R. Mechanisms of adverse local tissue reactions to hip implants. Front Bioeng Biotechnol. 2019;7(JUL). doi:10.3389/fbioe.2019.00176

Granchi D, Savarino LM, Ciapetti G, Baldini N. Biological effects of metal degradation in hip arthroplasties. Crit Rev Toxicol. 2018;48(2):170-193. doi:10.1080/10408444.2017.1392927

Bradberry SM, Wilkinson JM, Ferner RE. Systemic toxicity related to metal hip prostheses. Clin Toxicol. 2014;52(8):837-847. doi:10.3109/15563650.2014.944977

Bolognesi MP, Ledford CK. Metal-on-Metal Total Hip Arthroplasty: Patient Evaluation and Treatment. J Am Acad Orthop Surg. 2015;23(12):724-731. doi:10.5435/JAAOS-D-14-00183

Kwon YM, Lombardi A V., Jacobs JJ, Fehring TK, Lewis CG, Cabanela ME. Risk stratification algorithm for management of patients with metal-on-metal hip arthroplasty: Consensus statement of the American association of hip and knee surgeons, the American academy of orthopaedic surgeons, and the hip society. J Bone Jt Surg - Ser A. 2014;96(1). doi:10.2106/JBJS.M.00160

Langton DJ, Joyce TJ, Jameson SS, et al. Adverse reaction to metal debris following hip resurfacing: The influence of component type, orientation and volumetric wear. J Bone Jt Surg - Ser B. 2011;93 B(2):164-171. doi:10.1302/0301-620X.93B2.25099

Nakano N, Volpin A, Bartlett J, Khanduja V. Management guidelines for metal-on-metal hip resurfacing arthroplasty: A strategy on followup. In: Indian Journal of Orthopaedics. Vol 51. Medknow Publications; 2017:414-420. doi:10.4103/ortho.IJOrtho_230_17

Hart AJ, Sabah S, Henckel J, et al. The painful metal-on-metal hip resurfacing. J Bone Jt Surg - Ser B. 2009;91(6):738-744. doi:10.1302/0301-620X.91B6.21682

Hart AJ, Sabah SA, Bandi AS, et al. Sensitivity and specificity of blood cobalt and chromium metal ions for predicting failure of metal-on-metal hip replacement. J Bone Jt Surg - Ser B. 2011;93 B(10):1308-1313. doi:10.1302/0301-620X.93B10.26249

Martin JR, Odum SM, Springer BD, Griffin WL. Initial metal ion levels predict risk of elevation in metal on metal total hip arthroplasty. HIP Int. July 2019:112070001986154. doi:10.1177/1120700019861544

All metal-on-metal (MoM) hip replacements: updated advice for follow-up of patients - GOV.UK. Accessed March 4, 2020.

Mehzer M. MHRA Updates Alert on Metal-on-Metal Hip Implants | RAPS. Regulatory Focus. Published 2017. Accessed January 11, 2020.

Information about Soft Tissue Imaging and Metal Ion Testing | FDA. Accessed January 11, 2020.

Kiran M, Armstrong C, Shivarathre D, Peter VK. Blood Metal Ion Levels Have Limited Utility in the Surveillance of Asymptomatic Large-Head Metal-on-Metal Total Hip Arthroplasties. J Arthroplasty. 2017;32(12):3685-3688. doi:10.1016/j.arth.2017.07.015

Gillam MH, Pratt NL, Inacio MCS, et al. Heart failure after conventional metal-on-metal hip replacements: A retrospective cohort study. Acta Orthop. 2017;88(1):2-9. doi:10.1080/17453674.2016.1246276

Sabah SA, Moon JC, Jenkins-Jones S, et al. The risk of cardiac failure following metalon-metal hip arthroplasty. Bone Jt J. 2018;100B(1):20-27. doi:10.1302/0301-620X.100B1.BJJ-2017-1065.R1

Zywiel MG, Cherian JJ, Banerjee S, et al. Systemic cobalt toxicity from total hip arthroplasties. Bone Jt J. 2016;98B(1):14-20. doi:10.1302/0301-620X.98B1.36712

Matharu GS, Judge A, Eskelinen A, Murray DW, Pandit HG. What is appropriate surveillance for metal-on-metal hip arthroplasty patients? A clinical update. Acta Orthop. 2018;89(1):29-39. doi:10.1080/17453674.2017.1398011

Asaad A, Hart A, Khoo MMY, et al. Frequent Femoral Neck Osteolysis With Birmingham Mid-head Resection Resurfacing Arthroplasty in Young Patients. Clin Orthop Relat Res. 2015;473(12):3770-3778. doi:10.1007/s11999-015-4348-0

Drummond J, Tran P, Fary C. Metal-on-Metal Hip Arthroplasty: A Review of Adverse Reactions and Patient Management. J Funct Biomater. 2015;6(3):486-499. doi:10.3390/jfb6030486

Apostu D, Lucaciu O, Berce C, Lucaciu D, Cosma D. Current methods of preventing aseptic loosening and improving osseointegration of titanium implants in cementless total hip arthroplasty: a review. J Int Med Res. 2018;46(6):2104-2119. doi:10.1177/0300060517732697

Siddiqui IA, Sabah SA, Satchithananda K, et al. A comparison of the diagnostic accuracy of MARS MRI and ultrasound of the painful metal-on-metal hip arthroplasty. Acta Orthop. 2014;85(4):375-382. doi:10.3109/17453674.2014.908345

Chalmers BP, Perry KI, Taunton MJ, Mabry TM, Abdel MP. Diagnosis of adverse local tissue reactions following metal-on-metal hip arthroplasty. HIP. doi:10.1007/s12178-016-9321-3

Matharu GS, Mansour R, Dada O, Ostlere S, Pandit HG, Murray DW. Which imaging modality is most effective for identifying pseudotumours in metal-on-metal hip resurfacings requiring revision. Bone Jt J. 2016;98B(1):40-48. doi:10.1302/0301-620X.98B1.36746

Pandit H, Glyn-Jones S, McLardy-Smith P, et al. Pseudotumours associated with metal-on-metal hip resurfacings. J Bone Jt Surg - Ser B. 2008;90(7):847-851. doi:10.1302/0301-620X.90B7.20213

Hart AJ, Satchithananda K, Liddle AD, et al. Pseudotumors in association with well-functioning metal-on-metal hip prostheses: A case-control study using three-dimensional computed tomography and magnetic resonance imaging. J Bone Jt Surg - Ser A. 2012;94(4):317-325. doi:10.2106/JBJS.J.01508

Berber R, Khoo M, Cook E, et al. Muscle atrophy and metal-on-metal hip implants. Acta Orthop. 2015;86(3):351-357. doi:10.3109/17453674.2015.1006981

Amstutz HC, Le Duff MJ. Effects of physical activity on long-term survivorship after metal-on-metal hip resurfacing arthroplasty: is it safe to return to sports? Bone Joint J. 2019;101-B(10):1186-1191. doi:10.1302/0301-620X.101B10.BJJ-2018-1535.R2

Esposito CI, Wright TM, Goodman SB, Berry DJ. What is the Trouble With Trunnions? Clin Orthop Relat Res. 2014;472(12):3652-3658. doi:10.1007/s11999-014-3746-z

Del Balso C, Teeter MG, Tan SC, Howard JL, Lanting BA. Trunnionosis: Does Head Size Affect Fretting and Corrosion in Total Hip Arthroplasty? J Arthroplasty. 2016;31(10):2332-2336. doi:10.1016/j.arth.2016.03.009

Meftah M, Haleem AM, Burn MB, Smith KM, Incavo SJ. Early corrosion-related failure of the Rejuvenate modular total hip replacement. J Bone Jt Surg - Ser A. 2014;96(6):481-487. doi:10.2106/JBJS.M.00979

Weiser MC, Lavernia CJ. Trunnionosis in Total Hip Arthroplasty. J Bone Jt Surg - Am Vol. 2017;99(17):1489-1501. doi:10.2106/JBJS.17.00345

Silverman EJ, Ashley B, Sheth NP. Metal-on-metal total hip arthroplasty: is there still a role in 2016? Curr Rev Musculoskelet Med. 2016;9(1):93-96. doi:10.1007/s12178-016-9323-1

Hart AJ, Muirhead-Allwood S, Porter M, et al. Which factors determine the wear rate of large-diameter metal-on-metal hip replacements? Multivariate analysis of two hundred and seventy-six components. J Bone Jt Surg - Ser A. 2013;95(8):678-685. doi:10.2106/JBJS.J.01447

Madanat R, Hussey DK, Donahue GS, et al. Early Lessons From a Worldwide, Multicenter, Followup Study of the Recalled Articular Surface Replacement Hip System. Clin Orthop Relat Res. 2016;474(1):166-174. doi:10.1007/s11999-015-4456-x

Amstutz HC, Le Duff MJ, Bhaurla SK. Risk factors for wear-related failures after hip resurfacing in patients with a low contact patch to rim distance. Bone Jt J. 2017;99B(7):865-871. doi:10.1302/0301-620X.99B7.BJJ-2016-1369.R1

Matharu GS, Eskelinen A, Judge A, Pandit HG, Murray DW. Revision surgery of metal-on-metal hip arthroplasties for adverse reactions to metal debris. Acta Orthop. 2018;89(3):278-288. doi:10.1080/17453674.2018.1440455

Liow MHL, Dimitriou D, Tsai TY, Kwon YM. Preoperative Risk Factors Associated With Poor Outcomes of Revision Surgery for “Pseudotumors” in Patients With Metal-on-Metal Hip Arthroplasty. J Arthroplasty. 2016;31(12):2835-2842. doi:10.1016/j.arth.2016.05.034

Matharu GS, Berryman F, Dunlop DJ, et al. No Threshold Exists for Recommending Revision Surgery in Metal-on-Metal Hip Arthroplasty Patients With Adverse Reactions to Metal Debris: A Retrospective Cohort Study of 346 Revisions. J Arthroplasty. 2019;34(7):1483-1491. doi:10.1016/j.arth.2019.03.022

García-Rey E, García-Cimbrelo E. Abductor Biomechanics Clinically Impact the Total Hip Arthroplasty Dislocation Rate. A Prospective Long-Term Study. J Arthroplasty. 2016;31(2):484-490. doi:10.1016/j.arth.2015.09.039

Colacchio ND, Wooten CJ, Martin JR, Masonis JL, Fehring TK. Dual Mobility for Monoblock Metal-on-Metal Revision—Is It Safe? J Arthroplasty. 2020;35(2):508-512. doi:10.1016/j.arth.2019.09.028

METAL DEBRIS DISEASE CASE ONE: Bilateral abductor atrophy — Complex Hip Surgery. Accessed March 5, 2020.

METAL DEBRIS DISEASE CASE TWO: Osteolysis Secondary to Metalosis — Complex Hip Surgery. Accessed March 5, 2020.

METAL DEBRIS DISEASE CASE FOUR: Trunnionosis — Complex Hip Surgery. Accessed March 5, 2020.

Wyles CC, Van Demark RE, Sierra RJ, Trousdale RT. High rate of infection after aseptic revision of failed metal-on-metal total hip arthroplasty. Clin Orthop Relat Res. 2014;472(2):509-516. doi:10.1007/s11999-013-3157-6

Lombardi A V., Barrack RL, Berend KR, et al. The Hip Society: Algorithmic approach to diagnosis and management of metal-on-metal arthroplasty. J Bone Jt Surg - Ser B. 2012;94 B(11 SUPPL.A):14-18. doi:10.1302/0301-620X.94B11.30680

Fisher J, Hu XQ, Stewart TD, et al. Wear of surface engineered metal-on-metal hip prostheses. J Mater Sci Mater Med. 2004;15(3):225-235. doi:10.1023/B:JMSM.0000015482.24542.76

Jacobs JJ, Wimmer MA. An important contribution to our understanding of the performance of the current generation of metal-on-metal hip replacements. J Bone Jt Surg - Ser A. 2013;95(8). doi:10.2106/JBJS.M.00137

Hart AJ, Sabah SA, Henckel J, Lloyd G, Skinner JA. Lessons learnt from metal-on-metal hip arthroplasties will lead to safer innovation for all medical devices. HIP Int. 2015;25(4):347-354. doi:10.5301/hipint.5000275

Tucker K, Gregg P, Kay P, et al. Monitoring the introduction and performance of a joint replacement: the United Kingdom metal-on-metal alert. J Bone Joint Surg Am. 2011;93 Suppl 3:37-42. doi:10.2106/JBJS.K.01107

Howard JJ. Balancing innovation and medical device regulation: the case of modern metal-on-metal hip replacements. 2016. doi:10.2147/MDER.S113067

Berber R, Skinner J, Board T, et al. International metal-on-metal multidisciplinary teams: DO we manage patients with metal-on-metal hip arthroplasty in the same way? An analysis from the international specialist centre collaboration on mom hips (ISCCOMH. Bone Jt J. 2016;98B(2):179-186. doi:10.1302/0301-620X.98B2.36201




How to Cite

Liu, J., Hart, A., Holderread, B., & Clyburn, T. . (2021). Metal-on-Metal Total Hip Arthroplasty: Current Recommendations and Lessons Learned. Reconstructive Review, 11(1).