SYMPOSIUM: PAPERS PRESENTED AT THE 2009 CLOSED MEETING OF THE INTERNATIONAL
The Use of a Cemented Dual Mobility Socket to Treat Recurrent
Moussa Hamadouche MD, PhD, David J. Biau MD,
Denis Huten MD, Thierry Musset MD,
Franc ¸ois Gaucher MD
Published online: 8 June 2010
? The Association of Bone and Joint Surgeons1 2010
total hip arthroplasty remains challenging. Dual mobility
sockets have been associated with a low rate of dislocation
but it is not known whether they are useful for treating
cemented dual mobility socket would (1) restore hip sta-
bility following recurrent dislocation; (2) provide a pain-
The treatment of recurrent dislocation after
free and mobile hip; and (3) show durable radiographic
We retrospectively reviewed 51 patients treated
with a cemented dual mobility socket for recurrent dislo-
cation after total hip arthroplasty between August 2002 and
June 2005. The mean age at the time of the index procedure
of was 71.3 years. Of the 51 patients, 47 have had complete
clinical and radiographic evaluation data at a mean fol-
lowup of 51.4 months (range, 25–76.3 months).
The cemented dual mobility socket restored
complete stability of the hip in 45 of the 47 patients (96%).
The mean Merle d’Aubigne ´ hip score was 16 ± 2 at the
latest followup. Radiographic analysis revealed no or
radiolucent lines less than 1 mm thick located in a single
acetabular zone in 43 of 47 hips (91.5%). The cumulative
survival rate of the acetabular component at 72 months
using revision for dislocation and/or mechanical failure as
the end point was 96% ± 4% (95% confidence interval,
A cemented dual mobility socket was able
to restore hip stability in 96% of recurrent dislocating hips.
However, longer-term followup is needed to ensure that
dislocation and loosening rates will not increase.
Level of Evidence
Level IV, therapeutic study. See
Guidelines for Authors for a complete description of levels
THA is associated with high levels of function, relatively
low complication rates, and high survival. However,
despite surgical technique and implant design improve-
ments, dislocation continues to be a matter of concern with
an incidence of around 3% [6, 42] and with important
One or more of the authors (TM, FG) has received funding (royalties)
from Aston Medical. MH is a nonpaid consultant for Aston-Medical.
Each author certifies that his or her institution has approved or waived
approval for the human protocol of this investigation and that all
investigations were conducted in conformity with ethical principles of
This work was performed at The Clinical Orthopaedic Research
Centre, Department of Reconstructive and Orthopaedic Surgery,
Universite ´ Rene ´ Descartes, Ho ˆpital Cochin (AP-HP), Paris France;
the Department of Orthopaedic Surgery and Traumatology,
University Hospital, Rennes, France; The Clinique du Ter, Ploemeur,
France; and The Centre Hospitalier de Pont l’Abbe ´, France.
M. Hamadouche (&), D. J. Biau
The Clinical Orthopaedic Research Centre, Department of
Reconstructive and Orthopaedic Surgery, Service A, Centre
Hospitalo-Universitaire Cochin-Port Royal, Universite ´ Rene ´
Descartes, Ho ˆpital Cochin (AP-HP), 27 Rue du Faubourg St
Jacques, 75014 Paris, France
Department of Orthopaedic Surgery and Traumatology,
University Hospital, Rennes, France
The Clinique du Ter, Ploemeur, France
The Centre Hospitalier de Pont l’Abbe ´, Pont l’Abbe ´, France
Clin Orthop Relat Res (2010) 468:3248–3254
functional and financial consequences [9, 43]. Among the
patients presenting with an episode of dislocation,
approximately one-third may experience recurrence after
nonoperative treatment . The outcomes of reoperation
for recurrent dislocation have been variable with approxi-
mately one-third of patients experiencing redislocation
despite a number of proposed methods of surgical treat-
ment [6, 11].
Perhaps the most common option for treating recurrent
dislocation in the United States is revision with a con-
strained acetabular component . Two basic designs of
constrained components are available: the locking ring
system and the constrained tripolar device. Tripolar con-
strained devices reportedly provide 90% survival at 10-
year followup with revision for redislocation or mechanical
failure of the constraining mechanism as the end point .
However, other reports show lower rates of reducing
recurrent dislocation even in the short-term, pointing out
specific mechanisms of failure at each interface [10, 13, 20]
and rates of actual or potential loosening of 12% after less
than 3-year followup [26, 45, 49]. Another concept intro-
duced in the late 1970s by Bousquet  to deal with these
complex situations is an unconstrained tripolar device, a
so-called dual mobility socket. Since this early period, a
number of cemented and cementless designs have emerged
in Europe, and some have been recently Food and Drug
Administration-approved. Several studies have assessed the
outcome of such devices in the prevention of dislocation in
both primary and revision THAs [3, 14, 22, 28, 29, 37–40]
and reported very low dislocation rates. Only two studies
have assessed a dual mobility socket in the treatment of
recurrent dislocation [21, 30]. These studies that concerned
mainly a cementless design showed residual hip instability
in 0 and 3.7%, respectively.
We therefore asked whether a cemented dual mobility
socket would (1) restore hip stability following recurrent
dislocation; (2) provide a pain-free and mobile hip; and (3)
show durable radiographic fixation.
Patients and Methods
After a minimum 2-year followup, we retrospectively
reviewed 51 patients (51 hips) presenting with recurrent
dislocation after primary or revision THA and treated with
a cemented dual mobility socket between August 2002 and
June 2005 at four tertiary centers. All patients gave
informed consent for participation in the study. During this
time we treated five patients with recurrent dislocation
using other approaches. The indications for use of the dual
mobility socket were patients (1) in whom no identifiable
cause for dislocation could be identified or corrected; (2) in
whom education and a spica cast or surgical attempts at
stabilization failed; and (3) with a marked deficiency of the
hip abductors. All patients were evaluated preoperatively
and returned for followup visit at 6 weeks, 3 months,
6 months, 1 year, and annually thereafter. Of the 51
patients, two died before the minimal 2-year followup. One
patient living in a foreign country was evaluated by his
local physician, but we could not obtain his followup
radiograph. One patient was lost to followup. The
remaining 47 patients have had complete adequate clinical
and radiographic evaluation at a minimum of 2-year fol-
lowup with a mean followup of 51.4 ± 1.4 months (range,
There were 39 females and 12 males with a mean age at
the time of the index procedure of 71.4 ± 11.5 years
(range, 41.1–91.8 years). The mean body mass index was
26.4 ± 6.5 kg/m2(range, 17.6–36.6 kg/m2). The mean
number of dislocation was 3.3 ± 1.4 (median, 4; range, 2–
9). All patients had been initially treated nonoperatively,
including education and a spica-type cast for a minimum of
6 weeks. Three patients had additionally been treated with
trochanteric advancement and five with liner augmentation.
The initial diagnosis was primary osteoarthritis in 35 hips,
congenital hip dysplasia in five hips, inflammatory arthritis
in three hips, posttraumatic osteoarthritis in three hips,
femoral neck fracture in three hips, and osteonecrosis of
the femoral head in two hips. An average 2.0 ± 1.3 (range,
1–6) previous surgical procedures had been performed on
these 51 hips. The dislocating hip was a primary
arthroplasty in five patients, a first revision in 20, a second
revision in 13, a third revision in seven, a fourth revision in
five, and a fifth revision in one. Four hips had been pre-
vious infected although at the time of the index surgery the
infections were controlled. Eleven hips had a Kerboull
acetabular reinforcement device  that was used in
conjunction with allograft in eight hips. The acetabular and
the femoral components were loosened in six and four hips,
The Medial Cup1 (Aston Medical, Saint Etienne,
France) cemented dual mobility socket was used in all hips.
This device (Fig. 1) consists of a spherocylindrical
M30NW stainless steel outer shell with a peripheral rim
and concentric grooves for cement fixation with a highly
polished inner surface. This shell articulates with a com-
pression-molded GUR 1050 ultrahigh-molecular-weight
polyethylene mobile component sterilized with 2.5 Mrad of
gamma radiation in a vacuum atmosphere. The opening
diameter of the all-polyethylene mobile component is 6%
smaller than that of the femoral head, and its minimal
thickness ranges from 6.3 mm to 13 mm for 46 and 62 mm
outer diameter shells, respectively. The femoral head is
captured in the polyethylene component using a snap-fit-
type mechanism, the latter acting as a large unconstrained
head inside the metal cup. This principle creates two
Volume 468, Number 12, December 2010Cemented Dual Mobility Sockets3249
articulations: an inner bearing between the femoral head
and the insert and an outer bearing between the insert and
the shell. The thickness of the metal shell is 1.7 mm at the
apex and 3.4 to 4.2 mm at the equator. This medializes the
center of rotation of the polyethylene insert approximately
5 mm when compared with the center of rotation of the
metal shell, increasing the stability of the device (Fig. 2).
No locking ring or other means of constraint was associ-
ated. This device is available for use with either a 22.2- or
28 mm-diameter femoral head. In the current series, only a
22.2-mm femoral head were used, and the mean size of the
shell was 51.2 ± 4.2 mm (range, 46–60 mm).
The operative approach for the index operation was
transtrochanteric (standard, modified, or extended) in 31
hips, posterolateral in 17 hips, and lateral without a tro-
chanteric osteotomy in the remaining three hips. The
femoral component was revised in 20 hips, and only the
femoral head was exchanged in two hips. Femoral com-
ponent revision was associated with femoral bone stock
reconstruction in three hips, using proximal femoral allo-
graft in two hips, and morselized bone grafting in one hip.
The 16 well-fixed cemented femoral components were
revised for ease of the acetabular revision. In these hips, a
cement-in-cement procedure was performed on the femoral
side. On the acetabular side, the socket was systematically
removed, and fibrous tissue was completely excised. Bone
loss then was assessed and when judged necessary by the
operating surgeon, bony reconstruction was performed
using a Kerboull acetabular reinforcement device in 22
hips in association with allograft in 13 hips, hydroxyapatite
in one hip, autograft in one hip, and cement in the
remaining seven hips. Moreover, in an additional hip,
allograft was used without a reinforcement device to treat a
cavitary defect. The cavity then was washed using pulsatile
lavage and dried, and the shell was cemented with CMW
Type 3 bone cement loaded with gentamycin (DePuy 3;
DePuy, Exeter, Devon, UK) that was mixed in air and
hand-packed. The mobile all-polyethylene component was
snapped on the femoral head using a specifically designed
power press and placed into the metal shell.
Postoperatively, patients received systemic antibiotics
for 48 hours, nonsteroidal anti-inflammatory drugs (keto-
profen; 100 mg/day) for 5 days to prevent heterotopic
ossification, and anticoagulation therapy (enoxaparin;
40 mg/day) for 5 weeks. Immediately after the operation,
passive motion exercises of the involved joint were begun
with the assistance of a therapist and were continued until
active motion of the hip was possible. The patients were
free to walk with two supports after 3 days. Full weight-
bearing was allowed after 6 weeks for patients operated on
through a transtrochanteric approach, and allowed imme-
diately as tolerated in the remaining patients. No specific
measures were undertaken to prevent redisolocation,
including restrictions to mobility, use of an abduction
brace, or a hip spica cast.
Fig. 1 Photograph of the Medial Cup1 tripolar unconstrained
acetabular component (Aston Medical) consisting of, from inside
out, a spherical mobile polyethylene insert that accepts a 22.2- or 28-
mm femoral head and is not constrained into a spherocylindrical
Fig. 2 Diagram of the Medial cup1 design indicating the medial-
ization (1) of the center of rotation of the polyethylene insert (a) when
compared with the center of rotation of the metal shell (b), the
spherocylindrical design of the metal shell decreasing stresses at the
periphery of the shell (2) and the good congruity between the femoral
neck and the polyethylene rim (3).
3250Hamadouche et al. Clinical Orthopaedics and Related Research1
Hip functional results were rated according to the Merle
d’Aubigne ´  grading system by independent observers
(DJB, DH, NB). Instability of the hip was defined as a
dislocation or a subluxation. Subluxation was defined as
perception by the patient of an abnormal hip movement
accompanied by an audible thud or clunk of the hip often
associated with pain.
Serial anteroposterior radiographs of the pelvis were
analyzed by three independent observers (DJB, DH, NB).
The inclination angle of the cup and the presence and
progression of radiolucent lines according to the zones
described by De Lee and Charnley  were evaluated on
the pelvic side. Loosening of the socket was defined as cup
migration exceeding 3 mm, angular rotation exceeding 3?,
or a continuous radiolucent line wider than 2 mm
(reflecting the observer’s confidence in his ability to detect
radiolucent lines on plain radiographs). Parameters inves-
tigated on the femoral side included progression of
radiolucent lines according to the seven zones described
by Gruen et al.  and subsidence of the stem. Loosen-
ing of the stem was defined according to the criteria of
Barrack et al. . Definite, probable, and potential evi-
dence of loosening were considered in this study. Peripros-
thetic cystic or scalloped lesions exceeding 2 mm in
diameter that had not been noted on the immediate post-
operative radiograph were defined as osteolysis (we are
unaware of studies of interobserver variability to make this
We performed a survivorship analysis according to the
actuarial method on the entire cohort using revision for
redislocation and/or mechanical failure of the acetabular
component and redislocation at the time of followup as
the end points. The survival curve was derived from the
cumulative survival rate over time as calculated from the
actuarial life table . We calculated the SE, given as a
percentage, and the 95% confidence intervals from the
data in the life table . Comparison of preoperative and
last followup clinical parameters was performed using the
Wilcoxon rank test. We performed analyses with Stat-
View statistical software (Version 5.0; SAS Institute,
The cemented dual mobility socket restored stability of the
hip in 45 of the 47 patients (95.7%). Two patients (4.3%)
had further episodes of posterior dislocation. These
occurred between the polyethylene insert and the metal
shell in one hip, whereas the other occurred between the
femoral head and the mobile polyethylene insert 32 and
72 months after the index arthroplasty, respectively. The
dislocation that occurred between the mobile insert and the
shell was related to a technical error with a highly abducted
socket. The intraprosthetic dislocation occurred in an
active patient and was due to wear and fatigue deformation
of the capturing area. Both hips underwent revision to a
new dual mobility socket. With redislocation as the end
point, the cumulative survival rate at 36 months was
97.8% ± 3.8% (95% confidence interval, 93.7%–100%).
The mean Merle d’Aubigne ´ functional hip score
increased from 13.4 ± 4.1 (median, 14; range, 8–18) pre-
operatively to 15.8 ± 2.2 (median, 16; range, 9–18) points
at the time of the last followup (p = 0.0003). Twenty
patients had no pain in the involved joint, fifteen patients
had moderate pain that did not restrict their activity level,
and twelve patients had pain that limited the duration for
which they were able to walk to less than thirty minutes.
The range of flexion was greater than 90? in 43 hips and
75? to 85? in four hips. At the latest followup, the mean
range of flexion of the series was 101.7? ± 12.6? (median,
100?; range, 70?–130?).
The mean abduction angle of the socket was 47? ± 8?
(median, 45?; range 31?–63?). Of the 47 acetabular com-
ponents, 35 (75%) had no radiolucent line; four (9%) had
a radiolucent line in Zone I, three (6%) in Zone III, and
four (9%) in Zones I and III (Fig. 3). In all these hips, the
radiolucent lines were less than 1 mm in thickness and
were nonprogressive. One hip (2%) had a complete and
progressive radiolucent line thicker than 2 mm associated
with a migrated acetabular component. This patient had a
revision procedure pending at the time of the last fol-
lowup. On the femoral side, no component was loose or
had been revised during the followup period. None of the
47 hips had a lytic lesion (cystic or scalloped) on either
the femoral or the acetabular side. With revision for
redislocation and/or mechanical failure of the acetabular
component as the end point, the cumulative survival rate
at 72 months was 95.7% ± 4.6% (95% confidence inter-
To date, the most widely used surgical option for recurrent
instability after THA in the absence of a correctable
identified cause is likely the constrained acetabular com-
ponents [6, 46]. However, this type of device has a
complex design involving a number of parts, and several
specific failure modes have been described in the literature
[5, 10, 12, 15, 20, 24, 32, 34, 47]. The concept of dual
mobility introduced in France over 30 years ago combines
a low friction inner bearing and an ultralarge effective
femoral head. This concept proved effective in the pre-
vention of dislocation following primary and revision
THA, even in patients at risk for dislocation [3, 14, 22, 28,
Volume 468, Number 12, December 2010 Cemented Dual Mobility Sockets3251
29, 37–40]. However, dual mobility in the treatment of hip
instability has been reported only twice in the literature
[21, 30]. Both studies used mostly a cementless design
which fixation can be changeling in revision surgery. Our
aim was to evaluate the ability of a cemented dual mobility
socket to restore stability to the recurrently unstable THA,
grant a pain-free and mobile hip, and provide durable
There are several limitations of our study. First, owing
to the retrospective design the group of patients was het-
erogeneous as it included isolated acetabular revision (with
and without bone deficiency) and revision of both com-
ponents. However, this limitation is inherent to all revision
series for recurrent dislocation due to the multifactorial
causes that contribute to THA instability. Second, ours is a
relatively short-term followup study. The time is adequate
for identifying most patients with recurrent dislocation
after the procedure, but not to determine long-term sur-
vival. However, with similar followup, other designs have
proved unsatisfactory in terms of redislocation prevention
 or worrisome in terms of actual or potential mechanical
failures, including constraint mechanism breakage or
radiographic loosening [26, 45].
We found a dual mobility socket provided complete
restoration of hip stability in 45 of the 47 hips (96%).
These results are comparable to those obtained with tri-
polar constrained components, and appear far better when
compared with bipolar constrained components at similar
followup (Table 1). Our results are in accordance with
those of Guyen et al.  who reported on a series of 54
patients with unstable THA treated with a current design of
dual mobility socket (cementless in 43 hips). Of the 54
patients, one patient had a single episode of dislocation at
the metal-polyethylene insert interface, and two required
revision because of dislocation at the inner bearing. Dis-
location of the femoral head from the mobile polyethylene
component inside the metal shell (so-called intraprosthetic
dislocation) represents a specific complication of dual
mobility socket . This phenomenon can occur through
impingement of the femoral neck or varus tilting of the
mobile component leading to rim fatigue damage and wear
Fig. 3A–D A 66-year-old man presented with recurrent dislocation
after revision THA of the right hip. (A) The patient had a THA for
posttraumatic osteoarthritis 15 years after a posterior column acetab-
ular fracture that was operated on. He experienced recurrent
dislocations that were unsuccessfully treated with trochanteric
advancement and augmentation of the acetabular liner. (B) A third
revision was performed using a Kerboull acetabular reinforcement
device with allograft and trochanteric advancement fixed with wires
and a claw plate. (C) Although trochanteric consolidation was
obtained, and no component malposition was noted, the patient
continued to experience dislocation. (D) The patient underwent
revision to a cemented tripolar unconstrained acetabular component.
He described episodes of transient instability during stair climbing but
is otherwise not limited in his daily activities. Fifty-one months
postoperatively, the radiograph shows no radiolucent line and no sign
of loosening or impingement.
Table 1. Main published results of constrained acetabular compo-
nents and dual mobility in the treatment of recurrent dislocation
Anderson et al.  18 31290%
Berend et al.  138 12828.9 NA
Goetz et al.  561227% 4%
Goetz et al.  5664 4%NA
Khan et al.  3432 3% 11.8
Shapiro et al. 8758 2.8 8.2
Shrader et a. 110351.8% 14%
Guyen et al.  54483.7% 0%
Leclercq et al.  134 0%NA
Hamadouche et al.
51 514% 2%
NA = not available.
3252Hamadouche et al. Clinical Orthopaedics and Related Research1
of the capturing area of the polyethylene insert . To
reduce the consequences of the femoral neck to mobile
insert impingement (so-called third articulation), it is rec-
ommended to use a highly polished surface and thin
femoral neck below the Morse taper, and a high head to
neck ratio. Also, the use of skirted heads should be
avoided. In addition, various design factors of the dual
mobility socket can play a role in the occurrence of
intraprosthetic dislocation including thickness of the
polyethylene at the capturing area, shape of the rim of the
metal shell and eccentric rotation center of the metal shell
and mobile insert. In the current study, a medialized dual
mobility socket has been used to avoid varus tilting of the
mobile polyethylene component, this design resulting in a
counterbalancing valgus moment as been demonstrated
in vitro with a bipolar prosthesis . We are not aware of
any study evaluating the advantage of one design over
another in clinical practice.
Only 35 of our 47 patients had no to moderate pain at
the latest followup, reflecting the complexity of this pop-
ulation that had multiple operations about the hip. The
mean range of flexion of the current series of 101? is in
accordance with the in vitro results obtained by Guyen
et al.  and higher than the results obtained with con-
strained acetabular component .
Radiographic analysis revealed no or radiolucent lines
less than 1 mm thick located in a single acetabular zone in
43 of 47 hips (91.5%), and one socket that was considered
loosened with a complete and progressive radiolucent line.
Although cemented metal sockets have provided high
loosening rates in some reports [8, 23, 41], we did not
observe this complication. This might be related to the fact
that with a dual mobility device, most of the motion occurs
within the inner bearing , avoiding overstressing the
cement-metal and the bone-cement interfaces. These
results appear better when compared to recent studies
providing detailed radiographic analysis of constrained
acetabular components at less than 3-year followup
The use of a cemented dual mobility socket has pro-
vided restoration of hip stability in 96% of patients
presenting with recurrent dislocation, with less mechanical
complication and loosening rates than have been reported
with constrained systems. However, longer-term followup
is needed to ensure dislocation and loosening rates will not
increase. We believe this device should be limited to the
prevention of dislocation in high risk patients and to the
treatment of THA instability with abductor mechanism
disruption, or in patients in whom no identifiable cause for
dislocation could be identified or corrected.
Langlais, MD. We thank O. Chaix, MD, and Jean Pierre Courpied,
We dedicate this paper to the memory of Frantz
MD, for contributing patients and Nicolas Barba, MD, for help in
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3254Hamadouche et al.Clinical Orthopaedics and Related Research1