Highly Porous Titanium Acetabular Components in Primary and Revision Total Hip Arthroplasty: A Systematic Review

doi:10.1016/j.arth.2020.01.052

The Journal of Arthroplasty

Volume 35, Issue 6, June 2020, Pages 1737-1749

https://doi.org/10.1016/j.arth.2020.01.052 Get rights and content

Abstract

Background

A number of papers have been published reporting on the clinical performance of highly porous coated titanium acetabular cups in primary and revision total hip arthroplasty (THA). However, no systematic review of the literature has been published to date.

Methods

The US National Library of Medicine (PubMed/MEDLINE), Embase, and the Cochrane Database of Systematic Reviews were queried for publications utilizing the following keywords: “tritanium” OR “highly-porous” AND “titanium” OR “acetabular” AND “trabecular” AND “titanium”.

Results

Overall, 16 studies were included in this review (11,366 cases; 60% females, 2-7 years mean follow-up). The overall survival rate of highly porous titanium acetabular components in primary cases was 99.3% (10,811 of 10,886 cases), whereas the rate of aseptic loosening was 0.1%. The overall survival rate of the highly porous titanium acetabular components in revision THA cases was 93.5% (449 of 480 cases), whereas the rate of aseptic loosening was 2.1%.

Conclusion

There was moderate quality evidence to show that the use of highly porous titanium acetabular components in primary and revision THA cases is associated with satisfactory clinical outcomes in the short- and medium-term, without showing any evidence of cup migration or radiolucency. Taking into consideration that there is no evidence yet regarding the long-term survivorship of these components, we feel that further research of higher quality is required to generate more evidence-based conclusions regarding the longevity of highly porous titanium acetabular implants compared with conventional titanium counterparts.

Section snippets

Search Criteria

Inclusion and Exclusion Criteria

The inclusion criteria were (1) clinical trials investigating the outcome of primary or revision THA using highly porous titanium

Search Results

The literature search identified 281 abstracts related to the use of highly porous titanium acetabular components in THA (Fig. 1). Among those, 79 duplicate articles were identified and removed from the search. After the removal of duplicate articles, 202 articles remained and were subject to application of the predetermined inclusion and exclusion criteria. After application of these criteria, 19 articles were subject to a full-text screening process. Ultimately, 16 articles were included for

Highly Porous Titanium Cups in Primary THA

The key finding of this systematic review is that highly porous titanium cups used in primary THA cases were associated with a high survivorship (99.3%) and low rate of complications in the short- to mid-term follow-up. Specifically, in the primary THA setting (10,886 cases), highly porous titanium acetabular components had a minimal rate of aseptic loosening (0.1%), instability (0.2%), and periprosthetic joint infection (0.2%).

According to the study with the largest patient cohort by far (9864

Conclusions

There was moderate quality evidence to show that the use of highly porous titanium acetabular components in primary THA cases is associated with satisfactory clinical outcomes in the short and medium term, with a 0.7% revision rate and 0.1% rate of aseptic loosening. Furthermore, highly porous titanium acetabular components were also effective in revision THA cases with acetabular bone loss, without showing any evidence of cup migration or radiolucency. The increased radiolucency observed with

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Early aseptic loosening of the Tritanium primary acetabular component with screw fixation
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Comparison of a highly porous titanium cup (Tritanium) and a conventional hydroxyapatite-coated porous titanium cup: a retrospective analysis of clinical and radiological outcomes in hip arthroplasty among Japanese patients
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Total hip arthroplasty after acetabular fracture is associated with lower survivorship and more complications
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Trabecular Titanium^TM cups and augments in revision total hip arthroplasty: clinical results, radiology and survival outcomes
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Highly porous titanium cup in cementless total hip arthroplasty: registry results at eight years

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Cited by (31)

Patient-reported and radiographic outcomes of a porous-coated acetabular cup in robotic assisted total hip arthroplasty at 2-year follow up
2023, Journal of Orthopaedics
Several implant manufacturers have developed ultra-porous metal substrate acetabular components recently. Despite this, data on clinical and radiographic outcomes remain limited. Our study evaluated postoperative patient-reported outcome measures (PROMs) and radiographic analyses in patients fitted with a novel acetabular porous-coated component.
A total of 152 consecutive patients underwent a total hip arthroplasty by a single orthopaedic surgeon. All patients underwent surgery utilizing the same CT-scan based robotic-assisted device with the same porous cementless acetabular shell. They received standardized postoperative physical therapy, rehabilitation, and pain protocols. Preoperatively, first postoperative visit, 6-months, 1-year, and 2-years, patients were evaluated based on Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain, physical function, and total scores; 2) Patient-Reported Outcomes Measurement Information System (PROMIS)-10 physical and mental scores; 3) Hip Disability and Osteoarthritis Outcome Score (HOOS)-Jr scores; as well as 4) acetabular component positions and 5) evidence of acetabular component loosening.
Significant improvements were observed by 6 months in WOMAC pain, physical function, and total scores (p < 0.05), maintained at 1 and 2 years. PROMIS-10 physical scores also improved significantly from preoperative to 6 months postoperative and remained so at 1 and 2 years postoperative (p < 0.05). No significant changes were found in PROMIS-10 mental scores. HOOS-Jr scores significantly improved from preoperative to 6 months postoperative and remained so through 2 years (p < 0.05). At 6 months, slight changes were noted in abduction angle and horizontal and vertical offset. Radiolucencies, initially found in 3 shells, reduced to 1 shell with 2 new radiolucencies by 6 months, and remained stable with no subsequent operative interventions. At 1 year and 2 years, no radiographic abnormalities were noted, including complete resolution of prior radiolucencies as well as stable components.
This porous cementless acetabular shell, implanted with CT-scan-based robotic-assisted techniques, demonstrated excellent postoperative PROMs at 2 years. Stable radiolucencies suggest good component stability. The early stable clinical and radiographic results suggest promising long-term outcomes with this device.
III (retrospective cohort study)
Comparative Survival of Contemporary Cementless Acetabular Components Following Revision Total Hip Arthroplasty
2023, Journal of Arthroplasty
The advent of highly porous ingrowth surfaces and highly crosslinked polyethylene has been expected to improve implant survivorship in revision total hip arthroplasty. Therefore, we sought to evaluate the survival of several contemporary acetabular designs following revision total hip arthroplasty.
Acetabular revisions performed from 2000 to 2019 were identified from our institutional total joint registry. We studied 3,348 revision hips, implanted with 1 of 7 cementless acetabular designs. These were paired with highly crosslinked polyethylene or dual-mobility liners. A historical series of 258 Harris-Galante-1 components, paired with conventional polyethylene, was used as reference. Survivorship analyses were performed. For the 2,976 hips with minimum 2-year follow-up, the median follow-up was 8 years (range, 2 to 35 years).
Contemporary components with adequate follow-up had survivorship free of acetabular rerevision of ≥95% at 10-year follow-up. Relative to Harris-Galante-1 components, 10-year survivorship free of all-cause acetabular cup rerevision was significantly higher in Zimmer Trabecular Metarevision (hazard ratio (HR) 0.3, 95% confidence interval (CI) 0.2-0.45), Zimmer Trabecular MetaModular (HR 0.34, 95% CI 0.13-0.89), Zimmer Trilogy (HR 0.4, 95% CI 0.24-0.69), DePuy Pinnacle Porocoat (HR 0.24, 95% CI 0.11-0.51), and Stryker Tritanium revision (HR 0.46, 95% CI 0.24-0.91) shells. Among contemporary components, there were only 23 rerevisions for acetabular aseptic loosening and no rerevisions for polyethylene wear.
Contemporary acetabular ingrowth and bearing surfaces were associated with no rerevisions for wear and aseptic loosening was uncommon, particularly with highly porous designs. Therefore, it appears that contemporary revision acetabular components have dramatically improved upon historical results at available follow-up.
Custom Triflange Acetabular Components For Catastrophic Bone Loss: Minimum 5-Year Results
2023, Journal of Arthroplasty
Custom acetabular components are an increasingly utilized reconstructive option in total hip arthroplasty for catastrophic bone loss and acetabular failure. The purpose of this study was to determine the survivorship of such components for reconstruction due to catastrophic bone loss at a minimum 5-year follow-up.
From August 2003 to July 2016, 64 patients (66 hips) underwent acetabular reconstruction with custom triflange components. All hips were classified as Paprosky 3B or 3C. Harris hip scores were analyzed. Overall survivorship was determined by survival analysis.
Seventeen patients (18 hips) died prior to returning for 5-year follow-up. One presumed living patient was lost to contact, yielding a cohort of 46 patients (47 hips) who had minimum 5-year follow-up. The mean age was 65 years (range, 46 to 85), mean body mass index was 29.4 (range, 18 to 45), and 72% were women. Mean follow-up was 8 years (range, 5 to 16). There were 3 revisions of the triflange device (6.4%) due to infection. Survivorship to end point of triflange removal for any reason was 94.1% (95% confidence interval: ±3.4%) at a mean of 16 years. In the overall series (n = 66), there were 9 (13.6%) additional reoperations as follows: 5 incision and debridements, one open reduction internal fixation, two stem revisions for periprosthetic femoral fracture, and one head revision. Harris hip scores improved significantly from a mean of 41 points preoperatively to 64 points postoperatively.
Custom acetabular triflange components represent a highly effective tool in a surgeon’s armamentarium. These devices are extremely helpful in managing catastrophic bone loss and have a good mean 16-year survival.
Femoral Head Autograft Can Reliably Reconstruct Dysplastic Acetabula Through the Direct Anterior Approach for Total Hip Arthroplasty
2022, Arthroplasty Today
Citation Excerpt :
In the present series, there was radiographic evidence of graft incorporation in all patients at a mean time of 6.5 months, which is comparable to alternative surgical approaches [3,4], with no evidence of component loosening or graft collapse. Although the underlying etiology of higher survival rates of FHA in recent literature is unknown, it could be speculated to be from several technical factors including (1) initial graft and cup stability through press-fitting the cup and placement of vertical screws through the cup to capture both graft and host bone; (2) graft orientation such that the subchondral portion of the graft was in maximum contact with the acetabular defect [47]; (3) use of highly porous-coated titanium cups to enhance initial component stability and facilitate bone ingrowth [48]; (4) restoration of the anatomic hip center to allow for a more physiological load transfer to the implant-bone interface [5]. The maximum graft size and extent of host bone coverage has been debated, with some authors recommending >60% [15] or >70% [49] of host bone coverage; however, we found the initial mean percent coverage of the acetabular component by host bone to be 54.4% with satisfactory results.
Bone deficiencies in dysplastic acetabula create technical difficulties during total hip arthroplasty (THA). Bulk femoral head autograft (FHA) is one method to increase cup coverage and bone stock of the true acetabulum; however, only limited data exist on its efficacy through a direct anterior approach (DAA). This study aimed to evaluate the outcomes of FHA during THA via a DAA in dysplastic hips.
Retrospective review of 34 patients (41 hips) with hip dysplasia (Crowe I-III) who underwent primary THA via a DAA with FHA at a single institution was performed. Surgical procedures were performed on a traction table with intraoperative fluoroscopy and highly porous-coated cup placement in the true acetabulum. Patients were assessed clinically and radiographically at a minimum of 2 years postoperatively (range, 2 to 7).
The average modified Harris Hip Score improved from 31.9 ± 10.8 to 94.1 ± 5.8, Merle d'Aubigné Hip Score from 7.5 ± 2.8 to 16.6 ± 1.1, and visual analog pain score from 7.9 ± 2.7 to 1.4 ± 1.4 (all P < .001). All hips had an “anatomic” inferomedial cup position postoperatively, with an average increase in horizontal coverage of 43.4%. Mean postoperative limb-length discrepancy improved from 21.8 ± 16.1 mm to 1.6 ± 5.7 mm (P < .001). There were no cases of revision THA, nor complications such as dislocation, infection, or osteolysis.
Reconstructing dysplastic acetabula (Crowe I-III) with FHA during THA can be successfully accomplished via the DAA with increased acetabular bone stock and accurate correction of limb-length discrepancy.
Trabecular metal versus non-trabecular metal acetabular components for acetabular revision surgery: A systematic review and meta-analysis
2022, International Journal of Surgery
Citation Excerpt :
Consistent with this, in the short term, TM cup survivorship following acetabular revision surgery for any reason has been estimated at 92% [28]. Specifically, the use of a TM shell provided good radiological and clinical outcomes, and the mean 10-year follow-up overall survival rate of acetabular components was 92.5% after THA revisions for hips (n = 53) with acetabular bone defects [14], and a systematic review showed that the use of porous titanium acetabular components in primary and revision THA can achieve satisfactory clinical results in the short- and medium-term with no evidence of loosening [35]. Few studies have compared clinical outcomes with TM cups and other frequently used designs in acetabular revision surgery.
The objective of this study was to compare cup survival and the incidence of adverse events associated with the use of trabecular metal (TM) and non-TM cups for acetabular revision surgery.
The MEDLINE, EMBASE, and Cochrane Library databases were searched for comparative studies that reported cup survival and the incidence of adverse events associated with the use of TM and non-TM cups for acetabular revision surgery. Primary outcomes included cup survival, aseptic loosening, dislocation, and infection.
The meta-analysis included 6 studies that involved 13,864 total hip arthroplasty (THA) revisions who underwent acetabular revision surgery with TM (n = 5,619) or non-TM (n = 8,245) cups. The meta-analysis demonstrated no significant difference in cup survival using re-revision for any reason or aseptic loosening as the endpoint following acetabular revision surgery with TM or non-TM cups (HR = 0.96; [95% CI, 0.84–1.09]; HR = 1.29; [95% CI, 0.70–2.38]). Pooled data indicated that the overall incidence of adverse events for TM or non-TM cups was 6.8% (382/5,289) and 9.0% (725/8,083), respectively, and not significantly different (OR = 0.91; [95% CI, 0.80–1.04]). The incidence of aseptic loosening and infection were significantly lower (OR = 0.75; [95% CI, 0.58–0.96]; OR = 0.70; [95% CI, 0.54–0.90]) and the incidence of dislocation was significantly higher (OR = 1.53; [95% CI, 1.22–1.91]) for TM compared to non-TM cups.
This review was the first to use reconstructed time-to-event data to find that there was no difference in survival of TM and non-TM cups in acetabular revision surgery. Overall, fewer adverse events were associated with the use of TM compared to non-TM cups, but the difference was not significant. The incidence of aseptic loosening and infection were significantly lower and the incidence of dislocation was significantly higher for TM compared to non-TM cups. This information is expected to guide orthopedic surgeons in the selection of appropriate acetabular components for THA revision.
Revision for Aseptic Loosening of Highly Porous Acetabular Components in Primary Total Hip Arthroplasty: An Analysis of 20,993 Total Hip Replacements
2022, Journal of Arthroplasty
Highly porous-coated titanium acetabular components have a high coefficient of friction and ultraporous surfaces to enhance bone ingrowth and osseointegration in total hip arthroplasty (THA). There have been concerns with the development of early radiolucent lines and aseptic loosening of highly porous acetabular components. It is unclear whether these concerns relate to a specific implant or the entire class. The aim of this study is to compare the revision rates for aseptic loosening of highly porous acetabular combinations in primary THA using data from a large joint replacement registry.
Data were retrieved from the Australian Orthopedic Association National Joint Replacement Registry for the study period September 1999 to December 2019. All primary THA procedures recorded and performed for osteoarthritis using the most common combinations for each highly porous acetabular component with highly cross-linked polyethylene and a 32-mm or 36-mm femoral head were included. The primary outcome measure was revision for aseptic loosening of the acetabular component. Results were adjusted for patient age and gender.
There were 20,993 primary THA procedures performed for osteoarthritis using a highly porous acetabular component across 6 combinations. Relative to the POLARSTEM/R3 (StikTite), the Exeter V40/Tritanium had a significantly higher risk of revision for aseptic loosening of the acetabular component (hazard ratio 0.21, 95% confidence interval 0.06-0.74, P = .014). There was no difference between any other highly porous acetabular component combination and no late revisions for aseptic loosening.
Highly porous-coated titanium acetabular components have low rates of aseptic loosening with long-term follow-up. A difference between components may exist.
Level III.

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: One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to https://doi.org/10.1016/j.arth.2020.01.052.

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Systematic Review & Meta-AnalysisHighly Porous Titanium Acetabular Components in Primary and Revision Total Hip Arthroplasty: A Systematic Review

Abstract

Background

Methods

Results

Conclusion

Section snippets

Search Criteria

Inclusion and Exclusion Criteria

Search Results

Highly Porous Titanium Cups in Primary THA

Conclusions

Arthroplasty Today

J Orthopaedic Sci

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Mech Behav Biomed Mater

J Arthroplasty

J Arthroplasty

Total hip arthroplasty after acetabular fracture is associated with lower survivorship and more complications

Clin Orthopaedics Relat Res

Trabecular TitaniumTM cups and augments in revision total hip arthroplasty: clinical results, radiology and survival outcomes

HIP Int

Highly porous titanium cup in cementless total hip arthroplasty: registry results at eight years

Int Orthopaedics

Additive manufacturing of Trabecular Titanium orthopedic implants

MRS Bull

Preparation and characterization of newly developed trabecular structures in titanium alloy to optimize osteointegration

Int J Medical Heal Pharm Biomed Eng

Systematic Review & Meta-Analysis
Highly Porous Titanium Acetabular Components in Primary and Revision Total Hip Arthroplasty: A Systematic Review

Trabecular Titanium^TM cups and augments in revision total hip arthroplasty: clinical results, radiology and survival outcomes