George McKee of Norwich, England, was the first to use metal-on-metal articulation with modified Thompson stems and a one-piece cobalt chrome socket combination in THR in 1953. The design was primitive, but many lasted for more than 14 years. In 1986, August et al. reviewed 657 total hip arthroplasties performed by McKee and Farrar. The combined survival rate of the hip and stem at fourteen years was 84.3%. Loosening was cited as the main cause of failure, and bone cement was cited as the main culprit. The authors never implicated metal-on-metal articulation as a reason for complications in their paper.5 Although metal wear was detected in devices that were revised, McKee did not observe any undesirable effects of that debris on the soft tissues or the bone.6 The early history of metal-on-metal devices, including Dr. Amstutz ' experience with the McKee device in New York, has been previously published.7-9 

More than four decades have elapsed since the widespread adoption of total hip arthroplasty for the treatment of arthritic disorders of the hip joint. The treatment has proved to be one of the most important surgical developments of the 20th century, providing substantial pain relief and improved quality of life for chronic arthritic conditions in elderly patients. In recent years, as with many areas of medicine, substantial research has been undertaken in an attempt to optimise both materials and design of hip replacement devices.

The very early days of hip arthroplasty centred around use of metal-on-metal bearings, developed largely in England. These produced widely varying clinical results, due primarily to vagaries in design and manufacturing capabilities. By the mid-1970’s, metal-on-metal arthroplasty was all but abandoned as Sir John Charnley’s technique for low friction hip arthroplasty, using metal-on-polyethylene bearings, became widely accepted.

The primary cause of failure of conventional metal-on-polyethylene total hip arthroplasty is component loosening. In many cases this loosening phenomenon is associated with an osteolytic reaction, caused by the body’s response to particles of polyethylene debris released from the bearing surface. Inevitably, with the younger more active patient group, this process is accelerated, potentially leading to earlier failure of the implant and the consequent need for a difficult revision procedure. As younger, more active patients presented with osteo-arthritic hip conditions, the determination of how to treat this potentially high risk group of patients became more important. Once again, metal-on-metal hip arthroplasty came back into consideration.