Different generations of dual mobility cup: from beginning to contemporary systems| Lo Scalpello - Journal

Abstract

Dual mobility cups (DMCs) were introduced in the 1970s to combine the low-friction concept of small femoral heads with the increased stability provided by larger articulations. Over the past five decades, DMCs have undergone substantial evolution in terms of design, materials, fixation methods, and polyethylene technology. This review analyzes the historical development of DMCs through three generations, focusing on the major complications encountered during their clinical use, including iliopsoas impingement, cup loosening, dislocation, intraprosthetic dislocation, accelerated wear, and infection. For each complication, the design modifications and technological advances introduced to improve implant performance are discussed. Contemporary third-generation systems have demonstrated excellent survivorship and low complication rates, while recent highly porous 3D-printed titanium designs may represent the beginning of a new generation of dual mobility implants. The continuous evolution of DMC technology has contributed to improved stability, fixation, and longevity, making these implants a valuable option in both primary and revision total hip arthroplasty.

Introduction

Dual mobility total hip arthroplasty (THAs) is considered a good alternative to traditional implants in patients with a high risk of instability after primary and revision procedures. Currently available literature indicates that a dual mobility implant is becoming a leading treatment option for patients with fixed spinopelvic alignment, neuromuscular disorders, femoral neck fractures, age above 75 years, previous hip surgery and failed fixation of previously sustained proximal femoral fractures ^1-5. These expectancies have been confirmed by some European registries which have documented a constant increase of dual mobility (DM) implantation during the last decades ⁶ as well as a lower risk of revision in general and due to dislocation particularly for hip fractures ^7-9. The DM concept was developed in the early 1970s with the particular aim of improving the patient’s original range of motion and reducing wear ¹⁰. Gilles Bousquet, Head of the orthopedic and Trauma surgery department of Saint-Étienne, Jean Rieu, professor at Ecole des Mines in Saint-Étienne, and André Rambert, engineer and founder of Serf company, developed the concept of dual mobility cup (DMC) in THA ¹¹.

The revolutionary idea of dual mobility in hip replacement surgery was to combine three principles already present at the time:

1. the “low friction” principle of THA popularized by Charnley thanks to the small diameter of the femoral head (22.2 mm) 12;
2. the Mckee-Farrar concept of using a larger diameter femoral head to enhance implant stability ¹³;
3. and the Christiansen hip notion, which allows mobility of the head, that in the development of the inventors of the DM solution, three degrees of liberty ¹⁴.

DM design consists of two concentric articulations, a smaller joint that is enclosed in a second, larger joint. The advantage of the small articulation between the femoral head and mobile insert is to prevent multidirectional wear ¹², whereas the large articulation between the mobile insert and cup increases the range of motion but at the same time let to the implant a reduction of the dislocation risk by increasing the jump distance ¹⁵.

In accordance with Caton et al. ¹⁶ at the beginning of 1979, two different models of cup have been implanted: the Novae^™, called Bousquet cup and the Lithia^™ cup developed by a young assistant of Prof. Buosquet, Dr Daniel Noyer. Both implants were settled by SERF, a France-based orthopedics company in Décines (France) and were made of forged stainless steel (316L).

Since then, numerous innovations have been developed to deal with complex primary or revision cases as well as to solve emergent problems that occur during clinical use.

During this evolution process, it is possible to differentiate three periods of time, called generations. Consistent with Neri et al. ¹⁷, the first generation covers the time frame from the creation of the original DMC in 1974 by Bousquet until the expiration of the exclusive right of the project in 1996 (Fig. 1).

The second generation was introduced during the next decade (1996-206), when changes were made to the cup and liner. This period was also important for the correct interpretations of the rule of stem, and particularly of the femoral neck surface (D. Noyer) and thickness.

The third generation starts in 2006 until the present; new coatings have been used on the outside of the metal cup. Particularly the bi-coating of hydroxyapatite – titanium has become the standard external surface of the cup ^18,19. Numerous papers have been published on the results of DM arthroplasty, highlighting the benefit in terms of increased stability without compromising clinical outcomes and implant longevity ²⁰.

However, as with conventional arthroplasties, dual mobility systems are not free from complications, both generic and exclusive to the system itself, as Hernigou has clearly highlighted ²¹. The aim of our paper was to analyze the evolution of the DM during the half-century through the study of one’s own complications, highlighting the solutions applied from time to time to try to resolve them. Starting from the study of Hernigou et al., we can list the complications observed in the literature as follows:

1. mechanical conflict with the iliopsoas tendon;
2. cup loosening;
3. dislocation;
4. intraprosthetic dislocation;
5. accelerated wear;
6. infection.

Mechanical conflict with the iliopsoas tendon

A mechanical conflict of the acetabular cup with the iliopsoas (IPI) tendon has been reported as a cause of persistent pain after THA, with an incidence of 4.3% of patients with pain ²². The impingement of the IPI tendon could be a consequence of the prominence of the anterior cup rim at the ilio-psoas notch and can cause bursitis and tendon lesion ²³. Although IPI is not a complication exclusively related to DM, in the 2009 symposium, it was reported in 2.1 % of cases of first-generation Bouschet cups ²¹. It seems rather that large acetabular cups, which are typically used in revision THA with their greater surface area, have more potential to cause psoas impingement. In the study by Odri et al. ²⁴ who compared the size difference between the native femoral head and the implanted cup, it was reported that patients with cups larger than 6 mm of the native femoral head had a significant increase in groin pain after THA. Finally, as psoas tendonitis appears to be related to the amount of anterior overhang of the cup rim beyond the physiologic or anatomic bony rim, both cup size and implant position can affect the risk of psoas tendonitis. The study of Reis et al. ²⁵ in human cadavers using CT imaging to construct 3D models of the pelvis and soft tissue clearly demonstrated that cup anteversion has a direct effect on the risk of psoas impingement, while cup inclination has a less significant relationship.

The original Busquet (first generation) featured a prominent, cylindric-spherical rim to enhance stability and prevent dislocation. If its geometry was chamfered in the lower (inferior) zone, most of the surface resulted in an 8 mm overhang extending from the equator of the hemisphere. This overhang mechanically irritated the iliopsoas tendon, especially during hip flexion (like climbing stairs or getting up), causing pain and inflammation. To relieve IPI, newer generations of DM cups were introduced at the end of the 1990s, including hemispherical designs that lack the aggressive rim. Some companies maintained the cylindric-spherical configuration but reduced the cylindrical extension of the metallic rim to 3 mm instead of 8 mm. Most opted for the press fit solution and grid blasted, or porous-coated surface, while others maintained the original tripod fixation ²⁶. Some companies have retained Buschet’s original design, “Hat Configuration” (casquette in French), while embracing the concept of press-fit fixation followed by bone ingrowth. The term “casquette” describes the outer appearance or configuration where the inner liner sits within the metal shell, like a cap. Finally, other companies designed left and right anatomical cup shapes that incorporate a psoas cut-out to allow for relief between the acetabular shell rim and the iliopsoas tendon ²⁷. Contextually, the distal profile of the liner was reduced in order to mitigate soft tissue impingement without affecting mechanical performance ²⁸. Recently, in a retrospective multicenter study of treatment outcomes for IPI in THA, Batailler et al. ²⁹ found the incidence of IPI was approximately double for standard cups compared to DM: 63% compared to 37%. With the second generation of DM, the cobalt-chromium alloy was introduced for the first time as a bearing surface for the shell ³⁰.

Cup loosening

In 1977, the principle of DM was clearly defined. Such a system combines both the large head articulation and low-friction arthroplasty concepts. In a DM articulation, the interposition of a mobile ultra-high molecular weight polyethylene (UHMWPE) component between the prosthetic head and the highly polished inner surface of an outer metal shell provides two bearings. At beginning of 1979, the French orthopedics company SERF was able to introduce on the market two different models of DMC: the Novae cup (Fig. 1), also called the Bousquet cup, and the Lithia cup, developed by a young assistant of Prof. Bousquet, Dr. Daniel Noyer, adding macrostructure on the back of the cup which was secured by two iliac flanges. The Novae cup had a single external fixation flange on the acetabular rim and two anchoring pegs in the pubis anteriorly at the ischium posteriorly. The design was a spherical cylinder shaped with a cut-out at its inferior area, which gives the implant the form of a hat (forme à casquette). Both shells were forged from stainless steel and coated with alumina on the external surface.

The idea to use ceramic materials for hip replacement comes from the French surgeon Pierre Boutin. In 1970, he implanted a cemented ceramic cup combined with a ceramic head for the first time. In 1974, Peter Griss and Heinz Mittelmeier introduced the regular use of ceramic heads and cups in Germany. Concurrently in the same years, an Italian Austrian collaboration led to the development of a new THA for implantation without bone cement. This prosthesis consists of a ceramic socket and a titanium femoral component with a non-modular ceramic ball for articulation with the socket.

It is therefore evident that there was interest and strong expectations in those years for ceramics. Ceramic was then used with surface coating with the intent of improving the biological anchoring to the bone or as monolithic or bloc cups entirely made of alumina. The advantage of using ceramics in hip joint replacement is that laboratory experiments showed ceramics to be bioinert. The material does not corrode; it is well tolerated by the surrounding tissue and produces significantly less wear than current alternative materials of ultra-high molecular weighted polyethylene (UHMWPE) and titanium aluminum vanadium TiAlV ^31,32. Ceramic demonstrated good bio-inert characteristics and high corrosion resistance, but poor osteo-integration. A fibrous tissue was frequently found between the implant and bone, leading to migration and loosening. Therefore, the results in the early era of ceramic hip implants had been poor. In the DM implants, the delamination of the alumina layer coated on a grit-blasted surface jeopardized the fixation of the initial design. This was a major issue as an incidence of cup loosening superior to 4% was observed. In general, it occurred about 9 years after the operation, and in 2016, Neri et al. ²⁰ published an observational retrospective study of 212 implants with more than 25 years of follow-up. At the final follow-up, there were 17 cases (8.02%) of isolated aseptic loosening. Only the acetabular component was changed in these patients. The failures were attributable to delamination of alumina coating surface. Nowadays, we know that alumina is inert and it is impossible to allow osteointegration. The first modification consisted of the substitution of the alumina with hydroxyapatite, which was initially coated on grit-blasted surfaces. At the same time, tripod fixation was often converted to a press-fit fixation and eventually secured with additional extra-acetabular screws.

Dislocation

Dislocation following total hip arthroplasty remains a major complication. The reported dislocation rate ranges from 0.2% to 7% after primary procedures, and up to 21% in revision surgery, representing a second reason for revision at any time, and the first cause for early reoperation ⁸. Several known risk factors for THA dislocation have been identified, including patient-, surgeon-, and implant-related factors ^33-34. DM gained attention as a potential solution for preventing and managing instability in both primary and revision THA procedures ^35-36 due to the use of large diameter prosthetic heads and its increment of jump distance in comparison with standard systems ³⁷. Long-term studies of the first-generation DMC confirmed that this implant was an excellent solution to the problem of postoperative dislocation. In 2012, Boyer et al. reported no cases of dislocations at the 22-year follow-up in 240 THAs using a DMC ³⁸. Another study with second-generation implants compared the results of DMC in patients aged less than 55 years and in patients aged more than 55 years. They found no dislocation cases independently of the age of the patients ³⁹. In a comparative study with a second generation DM, the dislocation rate was compared with a press-fit stainless steel metal back and hydroxyapatite coating deposited by plasma spray. The incidence of dislocation with DMC was 0.9%, while it was 12.9% when a standard cementless press fit cup was used; the same cemented Charnley-type stem was used for both arms ¹⁵. Bouschet et al. also showed that even using a posterior approach and in older patients, DMC increase stability with no postoperative dislocations: there were no dislocations in the DM series and five early dislocations (before the third month) in the Standard series for a rate of 4.63% ⁴⁰. Finally, third-generation DMCs provide excellent dislocation prevention, with clinical data even outside France, confirming their low rates, often making them a preferred choice for complex hip in both primary and revision cases ^41-42.

Intraprosthetic dislocation and accelerated wear

Intraprosthetic dislocation (IPD) and accelerated wear will be discussed together, as the wear of polyethylene may represent the same mechanism of failure. Before describing the characteristics of the lesion in detail, it is essential to differentiate between IPD, which corresponds to wear of the liner’s retention mechanism, from acute trauma in which the femoral head exists from the cup (large articulation). The latter is a rare event, but it is the most reported in the recent literature ^43-45. IPD is a specific failure mode observed exclusively in DM cups and occurs when the small joint head and the polyethylene mobile liner dissociate due to wear of the liner retention rim or due to design imperfection ⁴⁶. Lecuire et al. described IPD for the first time in 2004. They reported seven cases in which the femoral head escaped from the polyethylene insert due to wear. This complication occurred, on average, at 10 years after implantation. All patients had a large-sized neck femoral stems. On X-ray, the classical aspect was represented by loss of the concentric head metal cup configuration. The head was applied against the upper wall of the metal cup. Since then, Philippot et al. ⁴⁶ have described three types of IPD: type 1, pure IPD without arthrofibrosis or cup loosening; type 2, secondary to blocking of the liner; and type 3, associated with cup loosening. These three types of IPD have mean postoperative onset times of 11, 8, and 9 years, respectively. They prospectively followed all 1960 revisions performed on 1850 patients who had DM prostheses implanted between January 1985 and December 1998. During that time, 81 (80 patients) of the 1960 hips subsequently had an IPD (4%).

In 2001, Noyer conducted a study of the results of the DMC implant and demonstrated the importance of the design of the femoral stem neck in this type of prosthesis. In this study, implants with a rough neck had an IPD rate of 9.2%, compared with 4.5% for smooth/polished neck implants. The author also described his observation of a more rapid onset of IPD in roughneck implants and coined the term “third joint” to describe the neck-polyethylene contact area ⁴⁷. The data in Noyer’s study were confirmed by the series reported by Lautridou et al. ⁴⁸ where the first-generation DMC paired with a Charnley-like stem with a thin polished neck produced a limited incidence of IPD.

Once the second-generation DMC was introduced, IPD was almost eliminated, with only occasional observations reported in the literature ^30,49-50. This improvement can be explained, first, by the introduction of the quality of the fabrication of polyethylene and the different modalities of sterilization. Consequently, optimization of the chamfer of the polyethylene, and change to a polished neck that is trapezoid, elliptical or circular in shape has reduced the contact stresses between the polythene and the femoral neck. This observation has been confirmed by the latest studies of third-generation implants, in which no IPD was reported ^10,51.

Infection

Recently, a study by the Nordic Arthroplasty Register Association (NARA) reported an increased risk of revision due to deep infection in the DMC cohort ⁵². They identified only primary THAs performed because of osteoarthritis with a DMC or with a standard cup with a MoP or CoP bearing: 2,277 hips with a DMC and 179,822 with a MoP or CoP bearing were eligible for propensity score matching. The data of this study were in line with another French multicentric study where all patients who underwent partial or complete revision THA underwent a preoperative and short-term (3 months) postoperative evaluation ⁵³. The last trial was a multicenter study (30 centers) sponsored by SOFCOT, which reported the results of first revisions of primary THA during the period January 1, 2010, and December 31, 2011. In both studies, it was noted that the increased infection rate might be associated with patient selection rather than the implant itself. Observing that the increased risk may be due to confounding by indication, because the DMCs were used in patients with greater frailty, who are at increased risk for infection. This suspicion was further supported by the study of Prudhon et al. ⁵⁴, which used the same source, the multicentric study of French Society of Orthopedics and Traumatology in 2010 and 2011. The authors believed a matching process allowed a closer analysis of all the reasons leading to revision. The two cohorts, including 231 patients in each group, were then strictly comparable in terms of age, gender, and etiology, but particularly for ASA score, comorbidity, and BMI. They concluded that the DM cup procedure was not associated with an increased risk of revision for infection compared to the standard implants. More recently, Assi et al. ⁵⁵ in a meta-analysis demonstrated that the use of DMC reduces the risk of post-operative infection in revision THA and a similar lower infection trend for primary THA compared with standard cups.

Discussion and conclusions

The DM concept was developed in the early 1970s and has now exceeded 50 years of use. Since then, numerous innovations have been developed regarding DMC design and implementation of materials in order to meet the needs of complex primary or revision

cases and to solve emerging problems observed using the implant. This evolution can be divided into distinct time periods, corresponding to three generations of DMCs.

Long-term studies of the first-generation DMC have confirmed that this implant is an excellent solution to the problem of postoperative dislocation. In the series of 240 THAs, Boyer et al. 38 observed no cases of dislocations at the 22-year follow-up. However, the same study highlighted an 8.3% incidence of aseptic cup loosening after 11 years and a 4.1% rate of retentive failure after 10 years. Contextually, a specific complication, such as IPD, appeared as a consequence of wear at the retentive rime of the polyethylene. In the paper by Boyer et al. ³⁸, it was reported that 240 hips with a first-generation device, followed for nine years and 11 months, had an IPD. Incidence of 4.1%. A similar incidence (4%) was reported by Philippot et al. ⁵⁶ among 1960 primary THAs with a mean follow-up of 14 years.

According to the above problems that occurred with the first generation of implants, since 1996, a new design of the cup, as well as different material surface coatings, have been introduced. Most of the second-generation cup designs ceased to use tripod fixation in favor of press-fit fixation. The Avantage system (Biomet) was the first press-fit implant of this new era; it was introduced commercially in 1998. Originally, the Avantage shell was coated by a layer of hydroxyapatite (HA), but it has quickly been replaced by a double-layer coating of HA and titanium ⁵⁷. Other manufacturers used molded cobalt-chromium (CoCr) instead of SS (e.g., the Evora cup [Aston/Sem] and the Quattro cup [GroupeLépine]). The majority of second-generation DMCs were also plasma-sprayed with HA to improve cup osseointegration. In the Novae second-generation cup (Novae E), the metallic shell, always made of SS, was covered with a dual layer of HA and alumina ceramic. The shell design was modified to be hemispherical, and the anterior and posterior metallic flanges reduced to 3 mm, allowing a regular cylindric-hemispherical configuration. To provide a better press-fit, the polar region was modified to be flatter. Finally, the polyethylene insert also has a retentive portion with a chamfer to decrease contact stress between the polyethylene and the stem neck (the so-called third joint).

Second-generation DMCs showed excellent long-term outcomes, significantly better than first-generation cups, with high revision-free survival rates for aseptic loosening ^57-58. With second-generation, IPD was virtually eliminated (0% to 0.1%) ^3,49. This reduction can be explained by the increase in the molecular weight of the polyethylene liner and its better” sterilization and storage process which maintains material integrity. Consequently, the optimization of the contact between the prosthetic neck with the introduction of a chamfered edge and retaining ring, as well as the optimization of the neck that is thin, trapezoid, elliptical, or circular in shape and highly polished, completed the improvement process over the time.

The third generation of DMCs is currently ongoing and has seen the use of new coatings and designs. There are several third-generation implant options on the market, each with an improved cup fixation interface intended for osseointegration or cementation, and a smooth inner surface for articulation with the polyethylene liner. The implant material matches that of the previous generations and consists of SS or CoCr, mainly owing to the ability to produce a highly polished, smooth inner surface using these materials.

In the third generation DMCs, the polyethylene insert has further evolved, improving the retentive ring and chamfering of the liner and introducing the possibility to use vitamin E and highly cross-linked UHMWPE liners ^2,7,36. Clinical studies of the use of third generation DMCs in THA have reported unanimously excellent mid-term results, with survival rates of nearly 100% and dramatically reduced incidences of aseptic cup loosening, dislocation, and IPD ^59,19,42. A recent meta-analysis, which included 119 studies with 30,016 primary and revision THA procedures using current DMC implants, reported incidences following primary THA of 0.9%, 0.6%, and 0.8% for aseptic loosening, extra-articular dislocation, and IPD, respectively ⁶⁰. Moreover, this study also identified younger age as a risk factor for implant failure following primary THA. A potential limitation in standard DMC implants is the lack of additional screw fixation options, as in other conventional metal-backed acetabular shells, and the impossibility to appreciate the acetabular floor during impacting procedures. In the last 15 years, several modular implants have been introduced ⁶¹. There is now the possibility to use a multihole acetabular component, allowing numerous screw fixation points for primary or revision surgery. However, this requires an additional metal liner, which has its own potential disadvantages in terms of reducing the internal size for the same external diameter compared with a conventional DMC, leading to a decreased jump distance, and, therefore, a theoretically increased risk of dislocation ^37,61. One advantage of modular DM constructs is the surgeon’s familiarity with a standard press-fit titanium cup and its option for supplementary screw fixation. Low rates of revision and procedure-related complications have been reported for modular DM implants at early follow-up, along with good clinical and patient-reported outcomes after primary THA ^62,63 and revision THA ⁶⁴. Nevertheless, the current use of modular DM constructs is raising some concerns about fretting corrosion, metal ion release, and the potential for adverse local tissue reactions ⁶⁵.

As the evolution of cementless metal-backed acetabular cups has mainly involved the cup-bone fixation interface, the evolution of DMCs has proceeded likewise. Improvements in the fixation interface have been based on the principle of enhancement of initial cup press-fit and secondary cup stability by increasing the capacity for durable osseointegration. A new cementless DMC was recently developed and introduced to the market. This implant features a cancellous bone-like, highly porous structure on the non-articular surface that is additively manufactured by selective laser melting with Ti-6Al-4V titanium alloy powder in a one-step process, together with the cup

The cup is fully 3D-printed with a titanium alloy for powder bed fusion. Its design has a polar flattened hemispherical profile with a flat cup opening plane. The articular surface is coated with titanium niobium nitride to allow articulation against the polyethylene mobile head ⁶⁶. A highly porous titanium DMC may further reduce aseptic cup loosening (especially in high-risk patients with suboptimal acetabular bone quality), prevent periprosthetic adverse reactios due to Co, Cr, or Ni ion release throughout the life of the implant, and facilitate radiographic assessment of the implant ⁶⁷.

In conclusion, DMCs have a 50-year history in which helped to reduce the incidence of instability

hip dislocation. Through continuous updating it has allowed us to resolve the problems encountered in terms of design, materials during this long evolution time.

Nowadays new technologies have led to profound design change from past DM generations and might be a landmark for the beginning of a new generation of highly porous DMs.

Conflict of interest statement

The Authors declare no conflict of interest

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors

Authors’ contributions

The Authors contributed equally to the work.

Ethical consideration

This article is a narrative review of previously published studies and does not involve human participants, patient data, animal experimentation, or identifiable personal information. Therefore, approval from an Institutional Review Board or Ethics Committee was not required. The authors conducted the review in accordance with the ethical principles of scientific research and publication.

History

Received: March 7, 2026

Accepted: May 15, 2026

Published online: June 12, 2026

Figures and tables

Fig. 1.First Generation of DM cup: cylindro-spherical design.

Figure 2.Second generation of DM cup maintaining the Tripode fixation.

Figure 3.Second generation of DM cup. Pressfit fixation with alumina and hydroxyapatite coating.

Figure 4.The Acorn Traser cup (Permedica Orthopedics) is a cementless dual mobility cup, additively manufactured with a titanium alloy. The cup has a highly porous trabecular structure (Traser) on the bone-cup surface and a TiNbN ceramic coating on the articular side to improve the tribological behavior of the titanium shell against the mobile liner (A). Scanning electron micrograph of the Traser structure, which is 3-dimensionally printed by selective laser melting without a continuity solution with the shell. Traser has 70% permeable porosity with a mean pore size of 520 μm (B). (Image courtesy of Permedica Orthopaedics).

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