The enduring success of the low-friction arthroplasty advanced by Sir John 2000, more than 270,000 hip arthroplasties were performed in the United States. Over the last three decades, patient profiles have changed substantially, resulting in demands for a greater service life of ultra-high molecular weight polyethylene (UHMWPE) hip components. Material failure, often leading to an osteolytic response, is increasingly associated with younger, more active patients. In this context, the low-friction solution has become a problem, limiting in vivo system longevity and initiated a reexamination of alternative bearing surfaces. This presentation summarizes current clinical solutions to long-term bearing articulation involving metal-polyethylene, metal-metal, ceramic-polyethylene and ceramic-ceramic alternatives. Clinical and laboratory evidences are presented which describe the efficacy and concerns of these bearing couples as well as their current availability through the FDA regulatory process.