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Survivorship of a contemporary highly porous titanium hemispherical acetabular cup in primary and revision total hip arthroplasty
, Young Dong Songa, Allina A. Nocona, Alberta V. Carlia, Peter K. Sculcoa
⁎Corresponding author: Troy D. Bornes. troy.bornes@gmail.com
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Received: ,
Accepted: ,
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.
Abstract
Abstract
Cementless acetabular cups are widely used in total hip arthroplasty (THA). Highly porous metal cups were introduced with the goal of enhancing osseointegration and survivorship of these components. The purpose of this study was to investigate survivorship and failure mechanisms of a contemporary highly porous metal cup in primary and revision THA.
There were 154 patients treated with a highly porous metal (OsseoTi) cup during primary THA (71) or revision THA (83) from 2016 to 2022. Chart review was performed to collect demographic information, surgical information, implant specifics, survivorship, and failures of these components. Descriptive statistics and survival probability were calculated, and a log-rank test was used to identify differences between curves. Radiographic review was performed to evaluate for radiographic evidence of loosening.
Mean age was 64.4 ± 14.3 years, 108 (70.1%) were women, and mean BMI was 28.0 ± 6.3 kg/m2. Mean clinical follow-up was 37.8 ± 18.3 months. Liner types included 106 dual mobility (68.8%), 28 high wall (18.2%), and 20 neutral (13.0%). Overall survivorship free from acetabular revision at 4 years was 88.2% (CI 45.2-98.0%). Acetabular survivorship at 4 years was 100% in primary THA versus 79.0% (CI 44.3-100%) in revision THA (p = 0.21). There were 2 failures (1.3%) for aseptic loosening that occurred at 2- and 41-months following revision THA. Radiographic review of one year postoperative radiographs demonstrated possible acetabular component loosening in 1 primary THA patient (2.2%) and 2 revision THA patients (3.8%).
We reported good 4-year survivorship of a highly porous metal cup after primary and revision THA, with two failures for aseptic loosening. This survivorship was supported by low rates of radiographic evidence of loosening. Future studies are encouraged to investigate outcomes and survivorship of highly porous shells with follow up at longer intervals.
1 Introduction
Cementless acetabular cups are the most widely used acetabular components in total hip arthroplasty (THA). While cementless acetabular cups may lead to favorable radiographic and clinical outcomes, component failures in THA remain problematic, particularly with conventional cups.1 Highly porous metal acetabular cups were introduced with the goals of optimizing osseointegration, reducing risk of aseptic loosening and migration, and improving implant longevity.2–6 These highly porous metal acetabular cups provide several advantages, including reduced stress shielding and increased stability of the interference fit with improved friction coefficient.7,8 It is anticipated that these advantages yield improved outcomes. Several studies have reported high survivorship and low failure rates following THA with highly porous metal cups.5,6,9–12 However, some studies have demonstrated that there is a high radiographic incidence of radiolucent lines following implantation with these components, and their association with future revision risk remains unknown.11–13 At present, there is a relative paucity of literature investigating outcomes and survivorship of highly porous metal cup in primary and revision THA.
Several types of highly porous metal cups exist, and these vary in terms of design and materials used. One recent development, The G7 OsseoTi® Porous Metal Technology shell (Zimmer Biomet, Warsaw, IN, USA), received Food and Drug Administration (FDA) clearance for use in THA in December 2014. This cup uses a novel porous titanium coating (PTC), OsseoTi, with a consistent porosity of 475 μm.14 This highly porous metal consists of Ti-6Al-4V alloy that is manufactured with three-dimensional (3D) printing, utilizing a structure that mimics human cancellous bone and enhances osseointegration.14 While other types of highly porous metal cups have been shown to improve outcomes following THA, only one prior study has investigated THA outcomes using the OsseoTi cup.12 While prior literature has investigated the incidence of radiolucent lines associated with OsseoTi shell implantation following primary THA, clinical outcomes of this shell following both primary and revision THA remain uncharacterized.12 The objective of the present study was to (1) assess survivorship of OsseoTi cup in primary and revision THA, (2) assess the radiographic fixation and radiolucency of the failure mechanism, and (3) assess the clinical outcomes and reoperation rate.
2 Methods
2.1 Patient selection
Ethical approval for this single-center retrospective study was obtained from the hospital's institutional review board.
Within an institutional arthroplasty registry of an academic center with a high volume of hip and knee arthroplasty, patients treated with THA using a highly porous metal cup (OsseoTi) were identified and verified using medical records. The following inclusion criteria were used: (1) primary or revision THA performed during the period of September 1, 2016, and January 31, 2022; (2) use of a G7 OsseoTi acetabular component in reconstruction of the acetabulum.
2.2 Data collection and variables of interest
A chart review was conducted to obtain demographics and surgical variables including date of surgery, primary diagnosis, and implants used. Liner types evaluated included neutral, high wall, and dual mobility. Duration from surgery to last follow-up in medical records, need for revision, and reason for revision were evaluated. Failure was defined as aseptic acetabular component failure treated with subsequent revision surgery to address aseptic loosening of the cup, instability, metallosis/adverse local tissue reaction (ALTR) related to the acetabular component (OsseoTi cup (titanium) paired with a dual mobility liner (Cobalt chrome), polyethylene wear, and osteolysis related to polyethylene wear. Clinical outcome measurement was performed using Hip disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS JR) at preoperative and at postoperative 1-year timepoint.
2.3 Radiographic review
Standing pelvic radiographs performed at (1) 6-week, (2) 1-year, and (3) the most recent follow-up were evaluated by two graders (one orthopaedic surgeon [YS] and one resident [RR]). The graders were blinded to clinical outcomes and were not involved in clinical care for the patients. Each radiograph was reviewed for presence of radiolucent and radiosclerotic lines around the OsseoTi acetabular component. The cut-off value for radiolucent line (RLL) presence was 1.0 mm. When radiolucent/radiosclerotic lines were identified, the location was described using DeLee and Charnley acetabular zones.15 In cases in which there was disagreement between reviewers, a third reviewer (an orthopaedic surgeon [DD]) served as a tie breaker. All of the radiogrpahic results were confirmed by the principle investigator [PS]. Interobserver reliability was calculated for reviewer ability to agree on number of DeLee zones with RLL (either 0, 1, 2, or 3) for each patient at each timepoint.
2.4 Study population
Mean age at time of index surgery was 64.4 ± 14.3 years, 108 (70.1%) were women, and mean BMI was 28.0 ± 6.3 kg/m2. Mean clinical follow-up was 26.7 ± 17.7 months.
2.5 Data analyses
Data analysis was performed using SAS version 9.3 (Cary, NC). Descriptive statistics were reported as mean ± standard deviation (SD). Survival probability was calculated using the Kaplan-Meier method with the 95% confidence interval (CI) reported. Log-rank test was used to identify differences between curves.
Pearson correlation coefficient was calculated to evaluate whether the presence of RLL in 2 or more DeLee zones at 6 weeks postoperatively was associated with presence of RLL in 2 or more DeLee zones at 1 year postoperatively. Fisher's exact test was used to compare determine whether there was a difference in proportion of patients with RLL in 2 or more DeLee zones in the primary and revision cohorts.
All data analyses were performed using SPSS Software (SPSS, Chicago, IL). Significance was noted when P < 0.05.
3 Results
3.1 Surgical details
Baseline demographic and surgical variables are shown in Table 1. There were 154 patients who had OsseoTi acetabular components implanted; 71 patients (46.1%) underwent primary THA and 83 patients (53.9%) underwent revision THA. Liners inserted within the shell included 106 dual mobility (68.8%), 28 high wall (18.2%), and 20 neutral (13.0%) liners (Table 1).
| Variable | All cases (n = 154) | Primary cases (n = 71) | Revision cases (n = 83) |
| Age (years), mean ± SD | 64.4 ± 14.3 | 66.5 ± 13.1 | 62.6 ± 15.0 |
| Women, sex, n (%) | 108 (70.1) | 55 (77.5) | 53 (63.9) |
| BMI (kg/m2), mean ± SD | 28.0 ± 6.3 | 28.4 ± 6.6 | 27.6 ± 6.0 |
| ASA Class, n (%) | |||
| 1 | 3 (1.9) | 2 (2.8) | 1 (1.2) |
| 2 | 115 (74.7) | 55 (77.4) | 60 (72.2) |
| 3 | 33 (21.4) | 12 (16.9) | 21 (25.3) |
| 4 | 2 (1.3) | 1 (1.4) | 1 (1.2) |
| 5 | 0 (0.0) | 0 (0.0) | 0 (0.0) |
| Cup diameter, mean ± SD | 53.9 ± 4.8 | 51.0 ± 4.0 | 56.4 ± 4.0 |
| Augment, n (%) | 6 (3.9) | 2 (2.8) | 4 (4.8) |
| Liner type, n (%) | |||
| Dual mobility | 105 (69.1) | 41 (57.7) | 65 (78.3) |
| High wall | 26 (17.1) | 14 (19.7) | 14 (16.9) |
| Neutral | 20 (13.2) | 16 (22.5) | 4 (4.8) |
Acetabular bone loss for patients undergoing revision THA was collected intraoperatively at the time of revision(Table 2). In revision THA, augments were used in the acetabular reconstruction in 6 patients (3.9%) (see Table 3).
| Paprosky Class | N (%) |
| I | 19 (22.9) |
| IIA | 19 (22.9) |
| IIB | 17 (20.5) |
| IIC | 7 (8.4) |
| IIIA | 4 (4.8) |
| IIIB | 3 (3.6) |
| Not reported | 14 (16.9) |
| Primary Cases | After 6 weeks (N = 71) | After 1 year (N = 46) | Latest follow up (N = 29) |
| Gap (>1 mm) | 8 (11.3%) | 3 (6.5%) | 1 (3.6%) |
| Zone 1 | 0 | 0 | 0 |
| Zone 2 | 8 (11.3%) | 3 (6.5%) | 1 (3.6%) |
| Zone 3 | 2 (2.8%) | 1 (2.2%) | 1 (3.6%) |
| Revision Cases | After 6 weeks (N = 83) | After 1 year (N = 55) | Latest follow up (N = 42) |
| Gap (>1 mm) | 10 (12.0%) | 7 (12.7%) | 5 (11.9%) |
| Zone 1 | 2 (2.4%) | 0 | 0 |
| Zone 2 | 3 (3.6%) | 2 (3.6%) | 2 (4.8%) |
| Zone 3 | 8 (9.6%) | 5 (9.1%) | 4 (9.5%) |
3.2 Survivorship
There were no acetabular component failures in patients who underwent primary THA with OsseoTi acetabular component. There were two patients who required repeat revision THA due to aseptic loosening after index revision THA with OsseoTi acetabular component (1.3%; Table 4). Both patients who sustained aseptic loosening after revision THA with the highly porous metal cup underwent index revision THA for treatment of aseptic loosening of previously implanted acetabular components (see Table 5).
| Failure type | All cases (%) | Primary cases (%) | Revision cases (%) |
| Aseptic loosening | 2 (1.3%) | 0 (0.0%) | 2 (2.4%) |
| Instability | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) |
| Metallosis/adverse local tissue reaction | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) |
| Polyethylene wear | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) |
| Osteolysis related to polyethylene wear | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) |
| Failure type | All cases (%) | Primary cases (%) | Revision cases (%) |
| Infection | 4 (2.6%) | 0 (0.0%) | 4 (4.8%) |
| Periprosthetic femoral fracture | 4 (2.6%) | 4 (5.6%) | 0 (0.0%) |
| Periprosthetic acetabular fracture | 1 (0.6%) | 0 (0.0%) | 1 (1.2%) |
| Femoral component fracture | 1 (0.6%) | 0 (0.0%) | 1 (1.2%) |
| Scar tissue formation | 1 (0.6%) | 0 (0.0%) | 1 (1.2%) |
| Leg length discrepancy | 1 (0.6%) | 1 (1.4%) | 0 (0.0%) |
One patient who experienced aseptic loosening of the OsseoTi component after revision THA had history of a metal-on-metal arthroplasty with substantial metallosis and adverse local tissue reaction that was revised with another component; the patient then sustained an acetabular fracture and a repeat revision was performed with an OsseoTi cup and augmentation using a bone graft. In this patient, failure due to aseptic loosening occurred 41 months after OsseoTi cup implantation.
A second patient who experienced aseptic loosening of the OsseoTi acetabular component after revision THA had a history of juvenile rheumatoid arthritis with primary THA performed at age 9 and then developed subsequent aseptic loosening of the previously implanted cup with significant superolateral bone loss 11 years after the primary procedure. A revision THA using an OsseoTi cup was performed. Failure occurred within 2 months of the revision THA.
There were no revisions required for instability, metallosis/ALVAL, polyethylene wear, or osteolysis in any patient.
Overall reoperation rate for the cohort was 9.1% (14 patients; Table 4). There were 5 primary THA patients (7.0%) who underwent reoperation and 9 revision THA patients (10.8%) who underwent subsequent reoperation.
Overall survivorship free from acetabular revision at 4 years was 88.2% (CI, 45.2-98.0%) (Fig. 1). Acetabular survivorship at 4 years was 100% in primary THA versus 79.0% (CI 44.3-100%) in revision THA (p = 0.21). In the evaluation of acetabular component failure based on type of liner used, one aseptic loosening involved a cup containing a neutral liner and the second aseptic loosening involved a cup containing a high wall liner. In the revision group, survivorship of shells containing dual mobility liners was 100% while 4-year survivorship shells containing neutral or high wall liners was 94.1% (CI, 82.9-100%; p = 0.03). There were no failures attributed to the liners specifically. There were no failures resulting from polyethylene wear or osteolysis related to polyethylene wear. In dual mobility components, there were no failures resulting from metallosis or adverse local tissue reaction (ALTR).
3.3 Radiographic review
For primary THA patients, evaluation of 1-year postoperative pelvic radiographs demonstrated RLL in 1 or more DeLee zones in 3 patients (6.7%) and RLL in 2 or more DeLee zones in one patient (2.2%). For revision THA patients, evaluation of 1-year postoperative pelvic radiographs demonstrated RLL in 1 or more DeLee zones in 8 revision THA patients (15.4%) and RLL in 2 or more DeLee zones in one patient (3.8%). No patients in either group with available 1-year postoperative radiographs demonstrated RLL in all three DeLee zones.
Intraclass correlational coefficients (ICC) for agreement among observers for number of DeLee zones with RLL at 6 week postoperative were moderate to good (k = 0.65 for primary THA, k = 0.85 for revision THA). ICC for 1 year postoperative radiographs were excellent (k = 0.96 for primary THA, k = 0.98 for revision THA). ICC for 2 year postoperative radiographs were moderate (k = 0.65 for primary THA, k = 0.70 for revision THA).
Presence of 2 or more RLL at 6 weeks postoperatively did have a significant low positive correlation with presence of RLL at one year postoperative (r = 0.31, P = 0.04 for primary THA; r = 0.47, P = 0.0004 for revision THA). There were no differences between the primary and revision THA groups in regards to frequency of RLL presence in 2+ DeLee zones in at 1 year postoperative (P = 1.0) and 2 years postoperative (P = 1.0).
3.4 Clinical outcome
Total of 67 (43.5%) patients had filled out the preoperative HOOS JR, and 87 (56.4%) of patients had filled out the postoperative 1-year HOOS JR. The average preoperative HOOS JR for primary THA was 46.0 (13.7), and average preoperative HOOS JR for revision THA was 45.8 (13.8). The average postoperative 1-year HOOS JR for primary THA was 71.2 (11.5), and average postoperative 1-year HOOS JR for revision THA was 70.8 (12.1). The delta change of HOOS JR for primary THA was 29.1 (17.1), and delta change of HOOS JR for revision THA was 28.3 (17.6) [Table 6].
| n (%) | Primary THA (mean, SD) | Revision THA (mean, SD) | |
| Preoperative HOOS JR | 67 (43.5) | 46.0 (13.7) | 45.8 (13.8) |
| Postoperative 1-year HOOS JR | 87 (56.4) | 71.2 (11.5) | 70.8 (12.1) |
| Δ HOOS JR | 29.1 (17.1) | 28.3 (17.6) |
4 Discussion
Our findings represent the first in the literature to report on survivorship and radiographic evaluation of the OsseoTi highly porous titanium hemispherical acetabular cup at short-to medium-term follow-up following primary and revision THA. The OsseoTi cup demonstrated good 4-year survivorship for both primary THA (100%) and revision THA (79%). There were two aseptic fixation failures, both of which occurred following implantation of the highly porous metal cup in revision THA for treatment of aseptic loosening of the acetabular component. We did not observe any failures due to instability, metallosis/ALTR, or polyethylene wear/osteolysis during the study period. This study also examined several different liner types used within the highly porous cup, and we did not observe any failures or complications specifically related to the liners. Radiographic evaluation of the components demonstrated low rates of developing radiolucent lines in two or more DeLee acetabular zones at 1-year after surgery (2.2% for primary THA and 3.8% for revision THA).
To our knowledge, only one prior study (Tamaki et al.) has examined clinical and radiographic outcomes of the OsseoTi cup following primary THA.12 The authors reported excellent clinical outcomes using the Japanese Orthopaedic Association (JOA) score. For radiographic review, Tamaki et al. used a cut-off of 0.5 mm for determining presence of RLL; at one year postoperative, they noted 20.8% presence of RLL in one or more DeLee zones and 10.9% presence of RLL in two or more DeLee zones. However, when the cut-off for RLL was increased to 1.0 mm in the Tamaki study, they reported 5.0% presence of RLL in one or more DeLee zone and 4.0% presence of RLL in two or more DeLee zones. These rates are comparable to the findings of the current study (5.0% vs 6.7% and 4.0% vs 2.2%). In the Tamaki et al. study, none of the cases with radiolucent lines required revision for aseptic loosening. The prior study only reported outcomes following primary THA and reported a mean follow-up in of 26.5 months in the OsseoTi group. This study was also limited to the use of highly cross-linked polyethylene (HXLPE) liners and ceramic femoral heads in every case. The current study is more comprehensive than the Tamaki et al. study as both primary and revision THA patients as well as different liners are included.
Several other studies have examined clinical outcomes and failures of various highly porous metal cups. One article by Castagnini et al. used registry data to assess survivorship between one type of highly porous titanium cup (Fixa Ti-Por, Adler Ortho, Milan, Italy) and all other uncemented cups.6 The Ti-Por cup had significantly higher survivorship at 7 years follow-up (98.7% vs. 97.9%, p = 0.005) when compared to all other uncemented cups, and a significantly lower incidence of aseptic loosening (p < 0.01). The highly porous cup also achieved noninferior survivorship when ceramic-on-polyethylene and ceramic-on-ceramic bearings were compared with those in other cups. Another study reported survivorship using the Delta TT Acetabular Cup (Lima Corporate, Udine, Italy) in 58 cases of revision THA, in which the main reasons for re-revision THA were recurrent dislocation (N = 3, 5.2%), deep infection (N = 2, 3.4%), and aseptic loosening (N = 1, 1.7%).10.10 They also reported a survivorship of 89.7% at 48.3 months mean follow-up,10 which is comparable to our assessment of overall survivorship at 4 years follow-up. Two other studies reported excellent survivorship (100% and 98.2%) of the Trident acetabular cup at a mean follow-up of 3 and 4.24 years, respectively.13,16 However, there remains concern regarding the long-term survivorship of highly porous acetabular cups, particularly related to the incidence of radiolucent lines and revision for aseptic loosening. Three studies identified the risk of radiolucent line development and subsequent revision THA for aseptic loosening in patients who received a highly porous acetabular cup.11,13,17 However, one of these studies was a case series of 5 patients who underwent revision THA for aseptic loosening,17 and the other 2 studies reported revision rates for aseptic loosening lower than 2%.11,13 Thus, longer-term follow up is needed to better characterize the association between radiolucent line development and survivorship of these components, particularly with the OsseoTi cup.
The present study addresses some of the gaps in previous literature regarding survivorship and outcomes of highly porous cups in THA. Our report is the first to examine various mechanisms of failure of the OsseoTi cup in a large cohort, with medium-term survivorship data. Additionally, we reported the use of several liner types including dual mobility, whereas previous studies were limited to conventional polyethylene or ceramic liners.6,12,13,17 Dual mobility liners have shown promise in reducing instability after primary and revision THA,18,19 which is a potential explanation for our reported low instability rates, as the majority (69.1%) of liners in our study were dual mobility. One anticipated complication associated with dual mobility liners is metallosis and ALTR,20,21 however we did not encounter any revisions due to this complication. Thus, the use of dual mobility liners with the OsseoTi highly porous acetabular component appear to be safe option to reduce dislocation risk after rTHA without associated ALVAL failure at mid-term follow-up. In addition, cases of titanium metallosis related to highly porous metal cups are rare, with only one case report in the literature citing metallosis in a patient due to ceramic-on-polyethylene wear through a highly porous titanium cup.22,23 However, this case report involved a conventional polyethylene liner, and we do not anticipate polyethylene wear and metallosis to be a significant complication with the use of HXLPE liners.
Our study is the first, to our knowledge, to report survivorship and radiographic evaluation of OsseoTi in revision THA at short to mid-term follow up. OsseoTi6.2% at 4 years. In the present study, the only failures included two complex cases in which aseptic loosening occurred following revision THA using an OsseoTi cup in the context of previous aseptic loosening of the cup and acetabular bone loss. Aseptic loosening has been documented following implantation with highly porous metal cups.6,10,13,17 The revision rate in our study was comparable to that of other studies.6,10,11,13 Future studies at longer term follow up will be helpful to understand OsseoTi survivorship.
This study is not without limitations. First, this is retrospective study and the conclusions may be limited relative to those of a prospective study. Also, mean clinical follow-up was 27 months, which is insufficient to characterize long-term survivorship. Finally, in regards to our radiographic review, we did use a cutoff of 1.0 mm, which is more permissive than 0.5 mm which has been used in a prior study of OsseoTi. One could argue that we therefore may be underreporting the number of patients with radiolucent lines around OsseoTi components. However, a 1.0 mm is frequently used in other studies of radiolucency around acetabular components and is arguably more easily identified using current radiographic review techniques.
In conclusion, we report good overall survivorship (88%) of the OsseoTi acetabular component in primary and revision THA. Our findings regarding survivorship and radiographic follow-up after primary THA are consistent with those reported in one previous study (100% in both),12 and we presented the first survivorship data for the OsseoTi cup in revision THA. Our findings regarding development of RLL in primary THA are consistent with prior studies and we presented the first data regarding presence of RLL following revision THA with OsseoTi. Both cases of component failure were attributed to aseptic loosening following revision THA with the OsseoTi acetabular components in patients who had a prior revision THA for aseptic loosening and both were associated with significant acetabular bone loss. We did not report any other complications or revisions due to instability, metallosis/ALTR, or polyethylene wear and osteolysis demonstrated the efficacy of both the dual mobility and XLPE articulations in limiting wear related particle reactions. The lack of these complications in the short-to medium-term follow-up is promising in the context of dual mobility liner use with this cup as no ALVAL related revision occurred. Future studies are encouraged to report on long-term clinical outcomes, survivorship of highly porous metal cups, and clinical significance of radiolucency development on long term outcomes.
Patient consent
There was no guardian/patient consent needed since it was not a clinical trial nor prospective study.
Credit author statement
Troy D. Bornes MD, PhD, MPH1,2∗: Writing – Original draft, Data curation, Formal analysis.
Robert Ricotti MS1,3: Writing – original draft, data curation, formal analysis.
Daniel A. Driscoll MD1: Writing – original draft, formal analysis.
Jonggu Shin, MD1: Writing – original draft, formal analysis.
Young Dong Song MD, PhD1: Formal analysis, Writing – original draft.
Allina A. Nocon PhD1: Methodology.
Alberta V. Carli MD, MSc1: Writing – review & Editing.
Peter K. Sculco MD1: Conceptualization, Writing – review & Editing, Funding acquisition.
Ethics
All procedures were performed in compliance with relevant laws and institutional guidelines and have been approved by the Institutional Review Board (IRB).
Funding
There was no funding for this manuscript.
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