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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 14  |  Issue : 2  |  Page : 126-133

Dual mobility cup in total hip replacements: a single center experience


1 Department of Orthopaedics, Command Hospital Air Force Station, Bengaluru, Karnataka, India
2 Department of Orthopaedics, INHS Asvini, Mumbai, Maharashtra, India
3 Department of Orthopaedics, Army Hospital R&R, New Delhi, India
4 Department of Orthopaedics, Military Hospital Kirkee, Pune, Maharashtra, India

Date of Submission25-Oct-2021
Date of Acceptance30-Oct-2022
Date of Web Publication30-Dec-2022

Correspondence Address:
Dr. Munish Sood
Department of Orthopaedics, INHS Asvini, Mumbai - 400 005, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jotr.jotr_108_21

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  Abstract 


Objective: Prosthetic joint dislocation remains a significant cause of revision following total hip replacement (THR). To prevent this complication, emphasis has been on choosing the optimum surgical approach, accurate implant alignment, bigger femoral head size, and implementing postoperative hip precautions. In the last decade, a newer acetabular design concept; the “Dual Mobility cup” (DM cup) was introduced to reduce the prosthetic dislocation. Although the concept of the use of such a device is well accepted, there remains apprehension regarding its precise indications, the outcome in terms of wear and ability to decrease the incidence of prosthetic dislocation. We reviewed the early results of a particular DM cup design. Materials and Methods: This study shares a single center experience of using a monoblock DM cup (Captiv DM, Evolutis, Briennon, France) in THR. It is a prospective cohort study that looked at indications, handling issues, complications including prosthetic dislocations at 24 months follow-up. Results: We followed up results of uncemented and cemented DM cup used in 129 patients who underwent primary THR or revision THR (RTHR). There was one (1.6%) prosthetic dislocation amongst primary THR and 2 (3%) in the RTHR group. There were handling issues with monoblock uncemented DM cups of occasional improper seating and acetabular rim fracture. Three cases in which revision was performed, were due to component to component impingement and resulted due to inappropriate acetabular version. Conclusion: The use of DM cups while performing THR or RTHR significantly decreased the incidence of instability. While placing DM cups an attempt should be made to maintain the native version of the acetabular cup to decrease the risk of component impingement and instability. Level of Evidence: Level III, therapeutic study.

Keywords: Dual mobility cup, early outcomes, indications, prosthetic dislocations, technique


How to cite this article:
Kumar S, Kulshrestha V, Sood M, Datta B, Mittal G. Dual mobility cup in total hip replacements: a single center experience. J Orthop Traumatol Rehabil 2022;14:126-33

How to cite this URL:
Kumar S, Kulshrestha V, Sood M, Datta B, Mittal G. Dual mobility cup in total hip replacements: a single center experience. J Orthop Traumatol Rehabil [serial online] 2022 [cited 2023 Jan 31];14:126-33. Available from: https://www.jotr.in/text.asp?2022/14/2/126/365821




  Introduction Top


Prosthetic dislocation is a dreaded complication following total hip replacement (THR). It is observed in up to 4% of patients after primary THR and the incidence rises exponentially after revision THR (RTHR; 10%–40%).[1],[2] It is one of the most frequent causes of revision and re-revision surgery after THR,[3],[4] and constant efforts are being made to minimize its incidence. Some of the accepted strategies are the use of larger diameter femoral heads, modified hip approaches to preserve hip stabilizers, optimizing implant positioning with navigations aids, and ensuring secure soft tissue closure.[1],[5] With all these efforts, there has been a significant decrease in the incidence of prosthetic hip dislocations after primary THR, which is seen in most recent studies (2%–4%).[6],[7] In spite of this, a subset of patients like those with neuromuscular weakness, elderly with poor compliance to hip precautions, spinal disease with fixed pelvic obliquity, severe joint deformities with polyarticular involvement like rheumatoid disease, hip fractures, and those undergoing RTHR remain susceptible to hip instability.[6],[8] Prosthetic dislocation remains a concern in these cases and choosing an implant design, which may offer additional protection against dislocation, may be of significant advantage. Dual mobility (DM) cups for THR were introduced in our Joint Replacement Center in the year 2013 when it was made available in our country. Our study is a review of prospectively collected the data of THR and RTHR using the posterior approach in which a monoblock DM cup was used (Captiv DM, Evolutis, Briennon, France). Our study aimed to look at the indications for which we used DM cup in patients undergoing THR, its preoperative handling issues, complications, and early outcome.


  Materials and Methods Top


Patients selection and baseline data

This study was conducted at a high-volume Joint Replacement Center co-located with a military tertiary care research and referral hospital. The center performs more than 1600 arthroplasties of the hip and knee annually, of which 4%–8% are revision surgeries. A team led by two senior fellowship-trained joint replacement surgeons performed all the surgeries. The institutional review board approved our prospective cohort study which consecutively enrolled patients undergoing primary or revision hip arthroplasty in whom uncemented or cemented DM cup was used from January 2014 to December 2017. The patient details were recorded on a per forma designed to capture, demographics, patient profile, indication of THR, the choice of bearing surface and acetabular design used (reasons for use), the intraoperative technical details relating to the handling of DM cups, and the postoperative complications till date. Being a prospective study, careful record was maintained of the indication for which the DM cup was chosen over the other conventional designs when being used in a primary THR and RTHR. In RTHR where a DM cup was used exact details of the construct like a DM cup cemented into an ultraporous cup or a cup cage construct or uncemented DM directly impacted into host bone was recorded. Careful surgical notes were filled up regarding any handling issues or per-operative difficulties faced by the surgical team.

Details of implant

The DM cups used, were solid mono-block titanium porous and hydroxyapatite-coated shell with equatorial oversizing. It has macro-interlock with serrations at the rim and dome spikes for primary stability. DM cup, a brainchild of Gilles Bosquet and Andre Rambert, was a merger of concepts of classical low friction arthroplasty by the father of arthroplasty with McKee–Farrar's principles of enhanced jump distance by greater head-neck ratio was designed in a pursuit to combat nightmares of prosthetic instability associated with hip replacement surgeries.[9] Resurgence from waning earlier generations DM cups was plausible only with an improved understanding of its designs primarily in terms of robust highly crosslinked polyethylene bearing surface which abridged risks of poly-wear, intra-prosthetic dissociation, and resultant metallosis ensuing better survivability of these implants both in primary and revision arthroplasty.[10] Further, the adding porous coating to enhance cup and host bone integration, the inclusion of screw holes in the cup to allow visualization of native acetabular floor and also providing additional primary cup stability, provisioning of the retentive chamber in the poly and subtle improvisation on neck thickness is the other major contributing factors for minimizing the drawbacks of initial designs.[11]

The DM cup used in our center was the classical model akin to first-generation cups, with equatorial press-fit monolithic porous titanium and hydroxyapatite dual coating on the outer surface with three layers of anchoring teeth along with four dome spikes allowing better docking in the native acetabular bone. The inner surface is a highly polished forged stainless steel that articulates with mediumly cross-linked ultrahigh molecular weight polyethylene. The inner articulation accommodated either a 22.2 or 28 mm metallic/ceramic head inside with a positive excentration design of larger poly liner, limiting the contact and wear at the “third articulation” level.

Surgical protocol

DM cup was used for THR and RTHR in both elective and emergent situations like proximal femoral fractures and prosthetic dislocations. In elective surgery preoperative risk mitigation and comorbidity, optimization was achieved using a standard institutional protocol. In all emergent cases, aggressive preoperative co-management of comorbidities was initiated with the physician. All patients were risk assessed for Deep vein thrombosis (DVT) and started on mechanical and chemical prophylaxis as per risks. On the day of surgery, the patient was started preoperatively on multimodal pain protocol, patient received injectable steroid (injection dexamethasone 8 mg), injection tranexamic acid 1 g and broad-spectrum antibiotics within an hour before the incision. All surgeries were done using posterior approach and the extent of the approach varied depending upon primary THR or RTHR. Adequate all-around exposure of acetabulum was achieved using pins and retractors. Using anatomical landmarks, the acetabular bed was prepared trial cup was used to check optimal implant position. The Monoblock DM cup we used has serrations along the equator and spikes which are in each quadrant more polar in position. In our cup preparation, depending on host bone quality, frequently we over-reamed the rim of the acetabulum to try and bottom out the cup. As there was no way to confirm whether the cup bottomed out, all efforts were made to ensure proper cup seating by judging with the rim of acetabulum all around. In very poor bone stock, like in elderly especially in cases of fracture neck of femur, we required to shift to the cemented option of the DM cup as we felt the uncemented cup would require additional screw augmentation and the option of which was not available with the DM cup design we used.

Patient follow-up

Patients were followed up as per the standard protocol, we looked at procedure-related and systemic complications and compared Oxford Hip Score,[12] Forgotten Joint Score,[13] to evaluate the outcome of surgery and EQ 5D quality of life index [Figure 1].[14]
Figure 1: CONSORT diagram of the study

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  Results Top


Monoblock DM cup was used in 142 patients out of 824 hip replacements (650 primary and 174 revision surgeries). One hundred and twenty-nine patients were available at the final follow-up. The mean age of the patients was 64.86 years [Table 1]. There were 60 males and 69 females. The mean BMI was 26.79 (range 21.46–36.89). Most of the patients had comorbidities with an average Functional Comorbidity Index of 0.94. Thirty-eight percent of patients had hypertension and 17.8% had diabetes. 4.6% of the patients had chronic obstructive lung disease and 10% had ischemic heart disease. Five patients had a BMI of more than 40. The mean preoperative hemoglobin was 11.92 (range 8.5–15.5). Sixty-five percent of the patients were accepted in ASA grade II while 21% were in Grade III, 11% were Grade I, and the rest 3% were Grade IV.
Table 1: Patient demographics and baseline characteristics and indications for surgery

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Out of 129 patients available for 2 years follow-up, in 64 patients primary DM fixation was performed while in 65 cases revision surgery was the indication [Table 1]. In primary THR, the usage of DM cup was 10% (70 out of 650) and in revision surgery 41% (72 out of 174). In 93 cases, an uncemented DM cup was used (primary 60/revision 33), and in 36 cases, a cemented cup was used (primary 4/revision 32). In all revision cases in which cemented, DM cup was used it was cemented into the acetabular shell with or without a cage. The indications for surgery in the primary THR group included intracapsular or extracapsular fracture neck of femur in 66% patients, failed osteosynthesis of extra or intracapsular neck fracture in 20%, and primary OA in rest 14% [Figure 2] and [Figure 3]. Out of the 65 patients in the RTHR group, the reason for revision surgery was aseptic loosening in 43%, the second stage of septic hip revision in 31%, 15% of the revisions were for hip instability, and 10% for the periprosthetic fractures [Figure 3]. While using uncemented cups in 20 cases (22%) on postoperative radiograph, there was radiolucency at the medial pole of the cup and indirect evidence of peripheral seating, but in none of these patients, there was any mechanical loosening or obvious adverse outcome noticed at 2 years follow-up. In most of the cases, the radiolucent line at the medial pole disappeared over 2 years of follow-up with new bone formation indicating good integration. Disprin was used as a prophylaxis for deep-vein thrombosis in 22 patients and low-molecular-weight heparin in 107 patients.
Figure 2: Dual mobility hip replacement performed for fracture neck femur. (a) Preoperative 2. (b) Postoperative X-ray. Dual mobility hip replacement performed for failed osteosynthesis. (c) Pre-operative. (d) Postoperative X-ray

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Figure 3: Dual mobility hip replacement performed for post-operative failed instability. (a) Preoperative. (b) Postoperative X-ray. Dual mobility hip replacement performed in revision scenario. (c) Preoperative. (d) Postoperative X-ray

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At 2-year follow-up, the mean Oxford hip score was 35.77 (range 19–46), while based on EQ5D 69 patients were better, 46 were same and 15 were worse from preoperative levels [Table 2]. At 2 years' follow-up, 14 complications were noted [Table 2]. There was one prosthetic dislocation in the primary THR group (case of intertrochanteric fracture who underwent THR) and two in RTHTR. One patient had an acetabular fracture while inserting an uncemented DM cup but did not require an additional procedure. One patient had an intra-operative pelvic fracture. Periprosthetic femoral fractures were observed in 03 patients. Two patients had surgical site infection, in one of the patients, symptoms subsided after regular dressings and antibiotics while the other patients required wound debridement. One patient had aseptic loosening which required revision of the implant. One patient had pulmonary embolism which required ICU care. There were two mortalities in this group that occurred within 90 days of surgery; both were due to pulmonary events.
Table 2: Patient-reported activity, function, and performance at final follow-up and complication seen

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  Discussion Top


Over the last two decades, use of larger prosthetic femoral heads, ensuring secure posterior capsular repair and optimizing component alignment has significantly reduced dislocation rates.[2],[6],[8] In spite of the above measures, prosthetic dislocation rates post THR in a specific subgroup of patients remains an important reason for revision.[6],[8] DM cup which was being used by the French surgeons for more than 40 years with good results was introduced into the global market only a decade back after FDA approval in 2009.[15] Its use has dramatically increased all over the world, especially in difficult hip reconstructions including revision hip surgeries. In our country, the device came into use in the early half of the current decade. Till recently, only one manufacturer had its monoblock design in the Indian market (CaptivR DM, Evolutis, France). With its increasing usage, now newer designs with modular options from other manufacturers have been introduced. Our study brought out the clinical utility of DM in our practice significantly influencing patient outcomes in a subset of patients undergoing primary THR and RTHR.

Half of the enrolled patients in our study were primary THR majority done for proximal femoral fractures (66%) which was significantly higher to the ones found in studies by Boyer et al.[16] (4%), Hamadouche et al.[17] (6.5%), Combes et al.,[10] Prudhon et al.[18] (4%), and Caton et al.[19] (3%). In most of the published studies, the major indications for use of DM cups in primary THR were primary OA Hip; Boyer et al.[16] (78.5%), Hamadouche et al.[17] (72%), Combes et al.[10] (89.6%), Leclercq et al.[20] (93%), Prudhon et al.[21] (93%), and Caton et al.[19] (93%) [Table 3].
Table 3: Comparison with various other studies

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The other major indication in our primary THR cases was failed osteosynthesis in proximal femoral fractures (18%). Boyer et al.[16] and Combes et al.[10] in their series had 9% and 18% dysplastic hips where THR was performed using a DM cup, wherein our series seven out of nine primary OA hip patients were also short statured with radiologically perceivable dysplasia accounting for just 3% of all primaries. Our series was devoid of patients with neurological conditions undergoing primary THR with a DM cup unlike 8% of the patients in Hamadouche et al.[17] study. In contrast to published studies, proximal femur fracture or failed osteosynthesis of proximal femur fracture was the major indications (>80%) of using a DM cup in a primary THR. These patients are known to carry a high risk of prosthetic dislocation following THR which prompted the use of DM cups in our study.[22]

Amongst 64 cases of RTHR in our series, aseptic revisions dominated (46%) over septic revisions (30%), compared to 50% and 20% of Simian et al.[23] and 39% and 34% of Schmidt et al.[24] correspondingly. DM was used in[10] (15%) of our RTHR cases for dislocated primaries, contrasting to studies published by Simian et al.[23] and Proudhon et al.[18] which was in 31% and 27% for instability, respectively. Usage of DM in periprosthetic fractures by Proudhon et al.[18] (30%) was nearly three times of our series which was merely 10%. However, the key indications for DM cups in revisions amongst Simian et al.,[23] Schmidt et al.[24] and Prudhon et al.[18] were similar to our study in terms of aseptic loosening, instability/dislocations, and septic RTHR. RTHR in itself is a high-risk situation for prosthetic dislocation; hence, we used DM cups in almost half of the revisions done during the time of the study.

In our study, out of a cohort of 129 patients in whom monoblock cemented or uncemented DM cup (CaptivR DM, Evoluits, France) was used in primary THR, there was only one case of instability at 4 weeks postop which was managed by closed reduction and when used for revision surgeries the prosthetic dislocation rate was <3% (02 cases). Our study compares well with results found by work from Simian et al.[23] Schmidt et al.[24], and Prudhon et al.[18] 1, 7 and 1%, respectively. Like many other studies, our study also showed that the use of DM cup reduced the incidence of instability. In spite of being used in patients at high risk of postoperative dislocation (fracture neck of femur/failed osteosynthesis of proximal femur fracture) in primary THR our dislocation rate was 1.6%. Moreover, in RTHR, at 3% it was much less than the lowest incidence of prosthetic dislocation reported in recent literature (10%).[25]

In our study, there were some handling difficulties encountered during the use of the monoblock DM cup of the specified design that it was difficult to ensure complete seating of the uncemented cup to the floor of the prepared acetabulum and the same was difficult to confirm on the table as there were no screw holes in the cup. But that did not seem to affect the outcome. The cup seating required peripheral over reaming from time to time as per bone stock and size of the cup specially to accommodate the equatorial splines and serrations found on the brim of the cup. In spite of this, there was only one case in which during impaction there was an acetabular rim crack detected which was incomplete and did not require additional procedure and stability of the cup was found acceptable. No such handling issues were found while using a cemented version of the DM cup. Akin to our study, few studies reported periprosthetic fractures; Wegrzyn et al.[26] one case, Bloemheuvel et al.[27] eight cases, Leclercq et al.[20] one case, and Prudhon et al.[18] in two cases. These could be due to handling issues. We did not come across any intra-prosthetic dislocations of the DM cup in our case series which was unlike 4 recorded by Hamadouche et al.[17] and 7 by Combes et al.[10] in their study. Three cases in which the DM hip dislocated were one primary and two revision hip surgeries done one for aseptic loosening of a cemented DM and the other one done in septic revision and periprosthetic fracture-dislocation. When we revised the three hips, we found that there was evidence of impingement of the neck of the femoral component over the posterior edge of the DM acetabular cup (implant on implant impingement). In all three cases, we had used modular hip stem hence we could adjust the version of the femoral body to avoid impingement and did not have to change the cup. When we analyzed the cases using computed tomography scan, we found that in all three cases the cup anteversion was 10°–15° more than the native side. Although we cannot categorically state, it was felt that it is prudent to maintain the native cup version while implanting the DM acetabular cup as an increased permissible range of movement of dual bearing also entails a greater risk of impingement if the cup overhangs. Out of the other complications which could be attributed to the design or surgical technique was a case of aseptic loosening of the uncemented DM shell which presented at 3 months of follow-up and was revised at 6 months. In this case, we revised it to a cemented DM shell, we found that the cup was loose and there was no integration with the host bone. Infection was ruled out as per MSIS criterion[28] and the aseptic loosening could be related to poor primary fit achieved at index surgery or lack of osseointegration of the cup by on growth or ingrowth of new bone.

As seen in our study, we had to switch to a cemented option of the cup few times when we were not able to achieve good primary stability and fit of the monoblock DM cup due to compromised quality and quantity of bone both in primary and revision hip replacement surgeries, this could have been minimized if we had the option of a modular design with the ability to use screws. With the recent introduction of modular uncemented DM cups, it is likely to increase the use of the uncemented option. However, in revision setting with the cup in a cup or cup cage construct the utility of cemented option is inescapable. Most of the primary series have used sphero-cylindrical CoCr metal-backed press-fit HA with or without titanium-coated cups whose secondary fixation enhancement included either anchorage pegs which may Boyer et al.,[16] S. Leclercq et al.[20] or may not Caton et al.,[19] Hamadouche et al.,[17] have additional screw fixation options, DM cups used by Prudhon et al.[18] had equatorial fins in addition to anchorage spikes. Flexible options have been exercised with prudence in revision series as horses for courses while deploying DM cups either with metal-backed cementless designs[18],[24] by supplementary fixation augmentation with screws, spikes or superior screw blades or by cementing DM cup in the DM/TM shells with or without cages.[17],[26],[29]

The limitation of our study was that in all our cases we used a particular design of monoblock DM cup of cobalt-chromium alloy, and our findings may not be completed applicable to now available modular DM cups (Titanium alloy shell with cobalt-chromium liner). However, it is still one of the most frequently used cups worldwide. Although the handling difficulties reported may pertain to the monoblock design the impact of the cup in the reduction of cases of hip instability can be extrapolated to even modular cup design which offers the same biomechanical advantages. The implant to implant impingement resulting in dislocation due to increased range of hip movements reported by our study in cases with increased anteversion of the acetabular cup can also affect hip stability in modular designs. Our study only looked at the handling of the device and its contribution to the reduction of instability we could not evaluate the function as compared to baseline as many cases were done in patients with hip fractures. The follow-up of patients is limited and we need mid- and long-term studies to look at complications and survival over an extended period of time. Another limitation of our study is the lack of statistical analysis. As our study is purely descriptive observation study. Our finding is exploratory in nature. Hence, it does not have any statistically power to prove or disprove any hypothesis.

The strength of our study is the meticulous prospective data keeping of a single centre large cohort operated by the same surgical team who could elucidate handling issues and analyze the advantages and the shortcomings of the specified cup design.


  Conclusion Top


Ours was a case series that evaluated the handling, safety, and efficacy of monoblock DM cup. We found that the use of DM cup in primary total hip arthroplasty done in a subset of patients who were considered prone for instability resulted in an acceptable incidence of instability (1.6%) at 2 years of follow-up. When used for revision total hip arthroplasty, the rate of dislocation at 2 years was only 3% which is remarkably less than that reported in contemporary literature.

Ethical approval

Ethical approval of the institutional ethical committee was obtained.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Zampelis V, Ornstein E, Franzén H, Atroshi I. A simple visual analog scale for pain is as responsive as the WOMAC, the SF-36, and the EQ-5D in measuring outcomes of revision hip arthroplasty. Acta Orthop 2014;85:128-32.  Back to cited text no. 14
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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