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. 2022 Dec 29;13(1):81. doi: 10.3390/jpm13010081

Is Cemented Dual-Mobility Cup a Reliable Option in Primary and Revision Total Hip Arthroplasty: A Systematic Review

Gianluca Ciolli 1,2, Guillaume Mesnard 1,*, Etienne Deroche 1, Stanislas Gunst 1,3, Cécile Batailler 1,3, Elvire Servien 1,4, Sébastien Lustig 1,3
Editor: Günther Maderbacher
PMCID: PMC9867154  PMID: 36675742

Abstract

Background: Instability is a common complication following total hip arthroplasty (THA). The dual mobility cup (DMC) allows a reduction in the dislocation rate. The goal of this systematic review was to clarify the different uses and outcomes according to the indications of the cemented DMC (C-DMC). Methods: A systematic review was performed using the keywords “Cemented Dual Mobility Cup” or “Cemented Tripolar Cup” without a publication year limit. Of the 465 studies identified, only 56 were eligible for the study. Results: The overall number of C-DMC was 3452 in 3426 patients. The mean follow-up was 45.9 months (range 12–98.4). In most of the cases (74.5%) C-DMC was used in a revision setting. In 57.5% DMC was cemented directly into the bone, in 39.6% into an acetabular reinforcement and in 3.2% into a pre-existing cup. The overall dislocation rate was 2.9%. The most frequent postoperative complications were periprosthetic infections (2%); aseptic loosening (1.1%) and mechanical failure (0.5%). The overall revision rate was 4.4%. The average survival rate of C-DMC at the last follow-up was 93.5%. Conclusions: C-DMC represents an effective treatment option to limit the risk of dislocations and complications for both primary and revision surgery. C-DMC has good clinical outcomes and a low complication rate.

Keywords: hip arthroplasty, dual mobility cup, cemented dual mobility, dislocation, instability, hip revision

1. Introduction

The use of the dual mobility cup (DMC) is an established practice in hip replacement surgery, which could ensure higher implant stability, physiological mobility of the hip joint and reduce wear. DMC is considered one of the major current strategies to prevent and treat hip instability, which is the first reason for total hip arthroplasty (THA) revision. The excellent long-term results of DMC justify their steady increase in recent years, both in primary complex cases and in recurrent hip instability after THA [1,2,3,4,5].

DMC can be used as the first implant surgery in complex cases of osteoarthritis (OA), including obese patients or those with neuromuscular or neurological diseases; and in fractures, such as acetabular fractures, femoral neck fractures (FNF), or pathological fractures [6,7,8,9]. Another common use of DMC is in revision surgery of total or partial hip arthroplasties or following the failure of a previous osteosynthesis [10,11].

In complex cases, including bone defects, DMC can be cemented directly into the bone or acetabular brace, such as primary or revision surgery [12,13]. While many reviews in the literature investigate and describe DMC [14,15], there is no specific analysis of cemented DMC (C-DMC).

The study aims to provide a systematic review concerning the C-DMC and a specific analysis of its application, in terms of complications, clinical results, survivorship rate, and radiographic findings. Secondary objectives are to describe the outcomes of primary and revision surgery and with or without acetabular reinforcement.

2. Materials and Methods

2.1. Search Strategy and Design

A systematic literature review was performed following the 2009 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. The following online electronic databases were used: Cochrane Database of Systematic Reviews, PubMed, EMBASE and Google Scholar. The search strategy had no data limit and was conducted until 31 December 2021. The following keywords, and their MeSH terms in any possible combination, were used: “Cemented Dual Mobility Cup” OR “Cemented Tripolar Cup”. A minimum mean follow-up of 1 year was considered to allow the evaluation of all early complications and outcomes.

2.2. Eligibility Criteria

Inclusion criteria were (1) patients undergoing C-DMC for any reason; (2) all levels of evidence; (3) full-text articles in indexed journals; (4) studies in English; (4) human studies; (5) mean follow-up of at least 12 months. Exclusion criteria were (1) nonoperative studies; (2) studies using different types of cups; (3) studies in which C-DMC was been used in less than 10% of cases; (4) studies in which DMC data were not specifically described; (5) reviews; (6) surveys or case reports; (7) book chapters; (8) congress abstract; (9) surgical technical reports; (10) expert opinions or letters to the editor; (11) cadaveric or animal studies.

2.3. Study Selection

The study selection was conducted by two independent reviewers (C.G. and M.G.). Articles were identified based on the title and abstract. If necessary, full-text articles were obtained to screen. After excluding the unacceptable studies, the full texts of the remaining studies were assessed. Any disagreements between reviewers were resolved through discussion with a third author (D.E.). Finally, the included articles’ references have been evaluated to highlight further relevant items useful for the search. In the case of multiple studies involving the same case series with different follow-ups, only the manuscript with the longest follow-up was selected.

2.4. Data Extraction and Analysis

A standard data extraction form was used which included the following: (1) study details: author, year, country, study design, level of evidence; (2) study population: cohort, population size, gender, age at the time of surgery, body mass index (BMI); (3) follow-up information: patients at follow-up, mean follow-up, patients lost to follow-up; (4) surgical approach to the hip; (5) C-DMC information: number, implant, cement, graft, primary or revision procedure, “cup-in-cup” technique, acetabular reinforcement; (6) outcomes: preoperative and postoperative Harris Hip Score (HSS), postoperative Postel Merle d’Aubigné (PMA); (7) postoperative complications: mechanical failures, aseptic loosening, infections, dislocations, intra-prosthetic dislocations (IPD); (8) radiographic complications: peri-acetabular radiolucent lines (RLLs), Brooker heterotopic ossification (HO); (9) survivorship rate. In the presence of comparative studies, in which the C-DMC are compared with different treatment techniques, only the C-DMC data were obtained for the study; while in the presence of overall values with the other different cups, these values were not taken into consideration for the statistics.

2.5. Methodological Quality Assessment

The study quality of all included studies was evaluated using the MINORS (Methodological Index for Non-Randomized Studies) criteria. Each item was scored from 0 to 2, with maximum scores of 16 for non-comparative studies and 24 for comparative studies. Each study included was scored by 2 authors (C.G. and M.G.).

2.6. Statistical Analysis

The kappa (k) value was used to evaluate consensus among reviewers in item selection. The agreement was classified as poor when k < 0.30, partial 0.30 < k < 0.60 and total with k > 0.60. Given the high heterogeneity among the studies, a meta-analysis was not performed; however, indirect comparisons were made.

3. Results

3.1. Literature Search and Study Characteristics

The initial search found 465 studies. After removing the duplicates, the remaining items were screened based on the title and abstract. The full texts of the remaining 86 articles were examined. Finally, according to the eligibility criteria, 56 articles were included in the systematic review [12,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68] (Figure 1).

Figure 1.

Figure 1

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Prisma Flowchart from the identification to the inclusion.

Among the reviewers, there was excellent agreement involving the title (k = 0.90; 95% CI, 0.88 to 0.92), the abstract (k = 0.91; 95% CI, 0.89 to 0.93), and the full text (k = 0.93; 95% CI, 0.92 to 0.94). Of the selected articles published between 2008 and 2021, ten reports are comparative studies (17.9%).

Most of the studies were retrospective (n = 44, 78.6%), while the remaining were prospective (n = 12, 21.4%). Forty-two (75%) studies were level IV evidence, 12 (21.4%) studies were level III, and two (3.6%) studies were level I.

The mean MINORS score was 11 (range 10–14) and 20 (range 17–24), for the non-comparative and comparative studies, respectively.

Most of the studies were conducted in France (28.1%), Egypt and the United States (both 10.7%) (Table 1).

Table 1.

Characteristics of studies included in the review.

Author Year Nationality Type Level of Evidence Number of Patiens Males Females Mean Age (SD) [Range] BMI (kg/m2) (SD) [Range] Cemented DMC Patients at
Follow-Up		 Follow-up (Months) (SD) [Range] MINORS
Langlais 2008 france Retrospective IV 82 / / 72 [65–86] / 88 79 36 [24–60] 12
Philippot 2009 france Retrospective IV 51 / / 68.7 [34–92] / 51 51 60.4 (±17.6) [24–112] 12
Tarasevicius 2010 Sweden Retrospective comparative III 42 / / 75 (±10) 42 42 12 19
Schneider 2011 France Retrospective IV 96 25 71 69.9 [34–95] / 96 77 41 (±29) [1–101] 11
Civinini 2012 Italy Prospective IV 24 / / 69 [51.3–82.4] / 24 24 39.6 [24–60] 14
Hailer 2012 Sweden Retrospective IV 200 / / / / 200 200 24 10
Pattyn 2012 Belgium Retrospective IV 36 16 20 70.4 [46–93] / 37 36 16 [6–27] 11
Mukka 2013 Sweden Retrospective IV 34 13 21 75.7 [58–90] / 34 34 18 [6–36] 11
Toro-Ibarguen 2014 Spain Retrospective IV 14 / / 67.8 [29–90] / 14 14 64.8 10
Wegrzyn 2014 france Prospective IV 61 29 32 67 (±10) 26 (±9) 61 61 89 (±23) [60–138] 10
Haen 2015 France Retrospective IV 64 / / 79.8 (±11.1) [40–95] / 66 42 50.4 12
Simian 2015 France Retrospective IV 47 / / 67.9 (±9.3) [38–90] / 47 47 87.6 [60–137] 11
van Heumen 2015 The Netherlands Retrospective IV 46 / / 67 [32–90] 27.2 [16.6–43.0] 46 46 29 [12–66] 11
Carulli C 2016 Italy Retrospective IV 11 13 18 75.4 [71–86] / 11 11 45.6 [24–84] 11
Luthra 2016 Oman Retrospective IV 63 35 30 61 [23–91] / 63 63 60 [18–72] 11
Plummer 2016 USA Retrospective IV 11 / / 64 (42–87) 28.6 [20.8–43.6] 11 11 28.8 [24–48] 12
Hamadouche 2017 France Retrospective IV 51 12 39 71.4 (±11.5) [41.1–91.8] 26.4 (±6.5) [17.6–56.6] 51 30 98.4 [60–156] 10
Lebeau 2017 France Retrospective IV 62 20 42 70.5 (±11.1) [36–94] 27.2 (±4.8) [19.5–43] 62 62 76.8 [60–108] 10
Mohaddes 2017 Sweden Retrospective comparative III 436 154 282 75 (±9) / 436 436 37.2 20
Nabil 2017 Egypt Prospective IV 12 / / 56.6 [34–63] / 12 12 24 20
Stambough 2017 USA Retrospective IV 8 / / 60.6 [51–71] / 8 8 34.8 [24–63.6] 12
Bruggemann 2018 Sweden Retrospective comparative III 69 34 35 67 [35–88] / 69 44 58.8 [6–106.8] 17
Chalmers 2018 USA Retrospective IV 18 6 12 64 [37–81] 28 [19–47] 18 18 36 [24–60] 12
Evangelista 2018 USA Retrospective IV 18 9 9 62 [30–86] 29 [19–37] 18 16 36 [25–56] 11
Hipfl 2018 Germany Retrospective IV 15 / / 70 [42–85] 26 [17–38] 15 15 47 [25–84] 11
Kavcic 2018 Slovenia Retrospective IV 174 47 127 76.8 [54–98] / 174 156 92.4 [60–120] 11
Ozden 2018 Turkey Prospective IV 14 3 11 64.5 [33–89] 28.8 (±5.2) [18.7–36.2] 15 14 38.1 [24–98] 13
Rashed 2018 Egypt Prospective IV 31 16 15 66.4 (± 5.9) / 32 31 12 13
Spaans 2018 The Netherlands Retrospective comparative III 96 38 58 73.1 (±8.5) 26.3 (4.5) 102 96 27.6 [3–84] 19
Stucinskas 2018 Lithuanian Retrospective IV 236 96 151 72 (±12) / 236 236 24 10
Tabori-Jensen 2018 Denmark Prospective comparative III 56 10 46 76.5 (42–93) / 56 56 36 19
Wegrzyn 2018 France Prospective IV 126 48 78 64 (±13) 24 (±4) 131 126 33 (±17) 12
Assi 2019 Lebanon Retrospective comparative III 16 3 13 69.2 (±14.8) / 16 16 72.9 (±40.5) 20
Dikmen 2019 Turkey Prospective IV 30 3 27 66.1 [33–89] 26.8 (±7.2) [19.7–36.2] 30 30 42.2 [24.6–75.1] 12
Fathy 2019 Egypt Prospective IV 20 12 8 66.8 [55–80] / 20 20 24 14
Gabor 2019 USA Retrospective IV 38 18 20 62.7 (±9.7) 29.7 (±7.0) 38 38 17.9 10
Giunta 2019 France Retrospective IV 27 23 4 68.5 (±8.1) [60–84] / 27 25 48 [12–84] 12
Plummer 2019 USA Retrospective IV 19 / / 64 [48–81] 27.9 [18.5–38] 19 13 24 12
Schmidt-Braekling 2019 Germany Retrospective IV 79 24 55 68.5 [41–87] 26.8 [18.6–41.5] 79 71 63.6 [24–122.4] 12
Wheelton 2019 England (UK) Retrospective IV 54 12 42 78 [49–97] / 54 54 22.8 [6–60] 11
de l’Escalopier 2020 France Retrospective III 76 23 58 71 [31–90] 25.2 [17.2–38] 76 63 76.8 [36–144] 10
Lannes 2020 Switzerland Retrospective comparative III 26 15 11 78 (±6) [66–88] / 26 25 12 [1–96] 19
Lavignac 2020 France Retrospective IV 71 27 64 62 (±10.5) [38–88] / 71 71 28.2 (±2.9) [0.3–124.8] 10
Mahmoud 2020 Egypt Prospective IV 20 11 9 65.85 (±5.58) [58–78] / 20 20 24 14
Sayac 2020 France Retrospective IV 74 24 50 70 (±11.3) [34–88] / 77 39 128.4 [25.2–194.4] 12
Schmidt 2020 France Retrospective comparative IV 59 / / 69 (±13.2) [19–92] 26.5 (±5.1) [17–46] 59 59 24 [12–141.6] 20
Tabori-Jensen 2020 Denmark Prosective randomized trial I 29 14 15 75 [70–82] 28 [23–39] 29 29 24 24
Wegrzyn 2020 Switzerland Retrospective IV 28 17 11 82 [74–93] 25 [20–39] 28 28 42 [24–60] 12
Bellova 2021 Germany Retrospective IV 33 / / 78.6 (±7.1) [63–93] / 33 19 28.5 (±17.3) [3–64] 10
Bozon 2021 france Retrospective comparative III 23 12 11 67 (±10) 24 (±3) 23 23 108 (±12) 18
Elkhadrawe 2021 Egypt Prospective IV 31 16 15 66.6 (±6.3) / 32 30 12 13
Lamo Espinosa 2021 Spain Retrospective IV 68 15 53 81.7 (± 6.4) / 68 68 49 (±22.6) 12
Moreta 2021 Spain Retrospective IV 10 / / 79.2 [71–87] 27.5 [19–34] 10 10 42 [24–72] 12
Rashed 2021 Egypt Prospective I 31 16 15 66.38 [63.9–68.7] / 31 30 12 23
Unter Ecker 2021 Germany Retrospective III 216 96 120 69 (±9) 29 (±7) 216 216 69 [60–110] 10
Uriarte 2021 Spain Retrospective comparative IV 44 13 31 76.3 (±6.7) 25.8 (±4.1) 44 44 49.2 20
Totals and proportions 3426 1018 (37.1%) 1729 (62.9%) Mean: 26.8 kg/m2 3452 3239 (94.5%)
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3.2. Overall Demographic Data

The overall number of patients was 4675 (4701 hips). Finally, 3452 C-DMC in 3426 patients were found. The patients who reached the last follow-up and who were evaluated for clinical and radiographic outcomes are 3162 (92.3%).

Females are more represented (62.9%) than males (37.1%). The mean age at the time of surgery was of 71.5 years (mean range 67–82), only one study doesn’t have the mean age value. The mean follow-up was 45.9 months (range 12–98.4). The mean BMI was 26.8 kg/m2 (range 24–29.7) (Table 1, Table 2 and Table 3).

Table 2.

Cemented dual mobility cup: surgical information.

Author Year Cemented DMC Posterior Approach Lateral Approach Anterior Approach Extensile Approach Avantage (Zimmer Biomet) Polarcup (Smith and Nephew) Ecofit (Implantcast) Tornier ADM (Stryker) MDM (Stryker) Medial Cup (Aston Medical) SaturneTM (Amplitude) Novae (SERF) Symbol Cup DM (Dedienne santé) Quattro (Lepine) Apogee (Biotechni Inc.) ADES (ZimmerBiomet) DMS (SEM) Cement Palacos R+G (Heraeus) CMW Type 3 with Gentamycin (DePuy) Antibiotic-Loaded Cement Simplex (Stryker) Graft AutoGraft AlloGraft Synthetic Graft
Langlais 2008 88 40 0 0 48 0 0 0 0 0 0 88 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Philippot 2009 51 / / / / 0 0 0 0 0 0 0 0 51 0 0 0 0 0 / / / / / / /
Tarasevicius 2010 42 42 0 0 0 42 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Schneider 2011 96 96 0 0 0 0 0 0 0 0 0 0 0 96 0 0 0 0 0 0 0 0 91 0 0 0
Civinini 2012 24 / / / / 24 0 0 0 0 0 0 0 0 / / / 0 0 1 0 0 30 0 30 0
Hailer 2012 200 / / / / 200 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Pattyn 2012 37 37 0 0 0 0 0 0 0 0 0 0 0 0 0 0 37 0 0 1 0 0 0 0 0 0
Mukka 2013 34 34 0 0 0 34 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Toro-Ibarguen 2014 14 / / / / 0 14 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Wegrzyn 2014 61 61 0 0 0 0 0 0 0 0 0 0 61 0 0 0 0 0 0 1 0 0 61 0 61 0
Haen 2015 66 66 0 0 0 0 0 0 0 0 0 0 66 0 0 0 0 0 0 1 0 0 3 1 2 0
Simian 2015 47 47 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 47 0 0 0 23 0 23 0
van Heumen 2015 46 46 0 0 0 46 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 6 0 0 0
Carulli C 2016 11 0 11 0 0 11 0 0 0 0 0 0 0 0 0 0 0 0 0 / / / / / / /
Luthra 2016 63 65 0 0 0 63 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0
Plummer 2016 11 10 0 0 1 0 3 0 0 6 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Hamadouche 2017 51 17 3 0 31 0 0 0 0 0 0 51 0 0 0 0 0 0 0 0 1 0 15 1 13 1
Lebeau 2017 62 62 0 0 0 0 0 0 0 0 0 0 0 0 0 62 0 0 0 1 0 0 58 0 58 0
Mohaddes 2017 436 283 0 140 0 436 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Nabil 2017 12 0 12 0 0 / / / / / / / / / / / / / / 0 0 0 1 0 1 0
Stambough 2017 8 8 0 0 0 0 0 0 0 2 6 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0
Bruggemann 2018 69 0 69 0 0 69 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 16 0 0 0
Chalmers 2018 18 11 0 7 0 0 0 0 0 18 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Evangelista 2018 18 0 0 0 0 0 18 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Hipfl 2018 15 0 0 0 0 0 15 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 15 0 15 0
Kavcic 2018 174 0 0 174 0 174 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Ozden 2018 15 15 0 0 0 0 15 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5 0 0 0
Rashed 2018 32 32 0 0 0 0 0 32 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Spaans 2018 102 102 0 0 0 102 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 102 0 102 0
Stucinskas 2018 236 236 8 3 0 227 0 0 0 0 0 0 0 0 0 9 0 0 0 0 0 0 0 0 0 0
Tabori-Jensen 2018 56 56 0 0 0 0 0 0 0 0 0 0 56 0 0 0 0 0 0 1 0 0 0 0 0 0
Wegrzyn 2018 131 131 0 0 0 0 0 0 0 0 0 0 0 131 0 0 0 0 0 1 0 0 0 0 0 0
Assi 2019 16 16 0 0 0 / / / / / / / / / / / / / / 0 0 0 16 0 0 0
Dikmen 2019 30 30 0 0 0 0 30 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 14 0 0 0
Fathy 2019 20 0 20 0 0 20 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4 0 0 0
Gabor 2019 38 27 11 0 0 0 38 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 18 0 18 0
Giunta 2019 27 27 0 6 0 0 0 0 27 0 0 0 0 0 0 0 0 0 0 0 0 0 6 6 0 0
Plummer 2019 19 19 0 0 0 0 0 0 0 0 19 0 0 0 0 0 0 0 0 0 0 0 19 0 0 19
Schmidt-Braekling 2019 79 / / / / 60 0 19 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Wheelton 2019 54 0 0 0 0 / / / / / / / / / 0 0 0 0 0 0 0 0 0 0 0 0
de l’Escalopier 2020 76 0 0 0 76 0 0 0 0 0 0 76 0 0 0 0 0 0 0 0 1 0 39 0 39 0
Lannes 2020 26 26 0 0 0 0 0 0 0 0 0 0 0 0 26 0 0 0 0 0 0 0 0 0 0 0
Lavignac 2020 71 0 0 0 0 / / / / / / / / / 0 0 0 0 0 0 0 0 0 0 0 0
Mahmoud 2020 20 0 20 0 0 / / / / / / / / / 0 0 0 0 0 0 0 0 0 0 0 0
Sayac 2020 77 77 0 0 0 0 0 0 0 0 0 0 0 77 0 0 0 0 0 0 0 0 0 0 0 0
Schmidt 2020 59 59 0 0 0 0 0 0 0 0 0 0 0 0 0 59 0 0 0 0 0 0 0 0 0 0
Tabori-Jensen 2020 29 29 0 0 0 29 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0
Wegrzyn 2020 28 28 0 0 0 0 0 0 0 0 0 0 0 0 28 0 0 0 0 1 0 0 0 0 0 0
Bellova 2021 33 33 0 0 0 0 29 4 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0
Bozon 2021 23 23 0 0 0 0 0 0 23 0 0 0 0 0 0 0 0 0 0 0 0 0 21 0 21 0
Elkhadrawe 2021 32 32 0 0 0 / / / / / / / / / / / / / / 0 0 0 0 0 0 0
Lamo Espinosa 2021 68 0 0 68 0 6 0 0 0 0 0 0 0 51 0 0 0 11 0 0 0 0 0 0 0 0
Moreta 2021 10 4 0 6 0 0 0 0 0 0 0 0 0 10 0 0 0 0 0 0 0 0 0 0 0 0
Rashed 2021 31 31 0 0 0 0 0 31 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Unter Ecker 2021 216 216 0 0 0 216 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Uriarte 2021 44 0 0 0 0 0 0 0 0 0 0 0 0 44 0 0 0 0 0 0 1 0 0 0 0 0
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Table 3.

Cemented dual mobility cup: surgical setting.

Author Year Cemented DMC Primary Setting Revision Setting No Acetabular Reinforcement Acetabular Reinforcement Cup-in-Cup
Langlais 2008 88 0 88 7 81 0
Philippot 2009 51 0 51 0 51 0
Tarasevicius 2010 42 42 0 42 0 0
Schneider 2011 96 0 96 0 96 0
Civinini 2012 24 0 24 0 24 0
Hailer 2012 200 0 200 / / 0
Pattyn 2012 37 0 37 0 37 0
Mukka 2013 34 9 25 34 0 0
Toro-Ibarguen 2014 14 0 14 0 14 0
Wegrzyn 2014 61 0 61 0 61 0
Haen 2015 66 32 34 66 0 0
Simian 2015 47 0 47 24 23 0
van Heumen 2015 46 0 46 46 0 0
Carulli C 2016 11 0 11 11 0 0
Luthra 2016 63 30 33 63 0 0
Plummer 2016 11 0 11 0 11 0
Hamadouche 2017 51 0 51 29 22 0
Lebeau 2017 62 0 62 0 62 0
Mohaddes 2017 436 0 436 436 0 0
Nabil 2017 12 12 0 11 1 0
Stambough 2017 8 0 8 0 0 8
Bruggemann 2018 69 0 69 0 69 0
Chalmers 2018 18 0 18 0 0 18
Evangelista 2018 18 0 18 0 0 18
Hipfl 2018 15 0 15 0 15 0
Kavcic 2018 174 173 1 174 0 0
Ozden 2018 15 0 15 6 9 0
Rashed 2018 32 32 0 32 0 0
Spaans 2018 102 0 102 102 0 0
Stucinskas 2018 236 0 236 236 0 0
Tabori-Jensen 2018 56 56 0 56 0 0
Wegrzyn 2018 131 131 0 0 131 0
Assi 2019 16 0 16 0 16 0
Dikmen 2019 30 0 30 11 19 0
Fathy 2019 20 0 20 20 0 0
Gabor 2019 38 0 38 27 11 0
Giunta 2019 27 27 0 4 23 0
Plummer 2019 19 19 0 0 19 0
Schmidt-Braekling 2019 79 0 79 0 79 0
Wheelton 2019 54 0 54 54 0 0
de l’Escalopier 2020 76 0 76 23 53 0
Lannes 2020 26 26 0 0 26 0
Lavignac 2020 71 71 0 0 71 0
Mahmoud 2020 20 15 5 20 0 0
Sayac 2020 77 0 77 0 77 0
Schmidt 2020 59 0 59 0 59 0
Tabori-Jensen 2020 29 29 0 29 0 0
Wegrzyn 2020 28 0 28 0 0 28
Bellova 2021 33 0 33 0 0 33
Bozon 2021 23 0 23 0 23 0
Elkhadrawe 2021 32 32 0 32 0 0
Lamo Espinosa 2021 68 68 0 68 0 0
Moreta 2021 10 0 10 0 0 10
Rashed 2021 31 31 0 31 0 0
Unter Ecker 2021 216 0 216 NA NA NA
Uriarte 2021 44 44 0 44 0 0
Totals and proportions 3452 879 (25.5%) 2573 (74.5%) 1738 (57.2%) 1183 (39%) 115 (3.8%)
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3.3. Operative Technique and Implants

Overall, 3452 C-DMCs are included. The posterolateral approach was the most used surgical approach (75.3%). The anterior approach was used in 14% of cases, the lateral approach in 5.3% of cases, and an extensive approach was used in 5.4% of cases. The most used implant was the Avantage dual mobility cup (Zimmer Biomet©, Warsaw, IN, USA), used in 17 studies and 54.2% of all cases, followed by the DM Novae cemented cup (Serf©, Décines-Charpieux, France) (7 studies, 14.2%) (Table 2 and Table 3).

3.4. Complications and Cup Survival Rate

The overall dislocation rate from 51 studies was 3.1%. The systematic review reported 7 cases of IPD, in four different studies. The overall IPD rate is 0.2%. The most frequent postoperative complications were periprosthetic infections (3%); aseptic loosening (1.3%) and mechanical failure (0.5%). A total of 138 revisions are reported (revision rate of 4%), in 48 studies reporting data eligible for the study. The average survival rate of the DMC at the last follow-up was evaluated in 43 studies (76.8%). At 45.9 months follow-up, the overall survival rate was 93.5% (range 83.1–100) (Table 4).

Table 4.

Cemented dual mobility cup: complications.

Author Year C-DMC Dislocations Intra-Prosthetic Dislocations Infection Aseptic Loosening Mechanical Failure Revisions Cup-Survivorship
Langlais 2008 88 0 1 2 0 0 3 100%
Philippot 2009 51 6 0 3 2 1 / 86.8%
Tarasevicius 2010 42 0 0 0 0 0 0 87%
Schneider 2011 96 11 0 5 1 2 4 96%
Civinini 2012 24 0 0 1 0 0 1 100%
Hailer 2012 200 3 0 4 4 2 10 /
Pattyn 2012 37 2 0 1 0 1 2 97%
Mukka 2013 34 2 0 3 0 0 0 91.2%
Toro-Ibarguen 2014 14 1 0 / / / / 91.2%
Wegrzyn 2014 61 0 0 0 0 1 0 96%
Haen 2015 66 0 0 0 1 0 1 100%
Simian 2015 47 1 0 6 0 0 / 100%
van Heumen 2015 46 0 0 2 1 0 3 100%
Carulli C 2016 11 0 0 0 0 0 0 /
Luthra 2016 63 1 0 1 0 0 1 /
Plummer 2016 11 1 0 2 0 2 4 98%
Hamadouche 2017 51 1 2 2 2 0 7 93%
Lebeau 2017 62 1 0 7 5 0 8 75.2%
Mohaddes 2017 436 7 0 15 2 2 10 89%
Nabil 2017 12 0 0 0 0 0 0 100%
Stambough 2017 8 2 0 0 0 0 / 98.5%
Bruggemann 2018 69 1 0 0 2 0 2 94.6%
Chalmers 2018 18 2 1 0 0 0 2 92.3%
Evangelista 2018 18 0 0 0 0 0 0 /
Hipfl 2018 15 1 0 2 0 0 / 91.9%
Kavcic 2018 174 0 0 2 0 0 0 98%
Ozden 2018 15 0 0 0 2 0 2 100%
Rashed 2018 32 0 0 1 0 0 1 96%
Spaans 2018 102 3 0 1 4 0 5 /
Stucinskas 2018 236 5 0 5 1 0 11 /
Tabori-Jensen 2018 56 1 0 0 1 0 / 100%
Wegrzyn 2018 131 3 0 4 0 0 0 93%
Assi 2019 16 0 0 0 0 0 0 98.80%
Dikmen 2019 30 1 0 1 2 0 3 /
Fathy 2019 20 1 0 0 0 0 0 96.80%
Gabor 2019 38 1 0 1 0 0 1 93.75
Giunta 2019 27 3 0 0 0 0 0 /
Plummer 2019 19 0 0 2 0 0 1 72.1%
Schmidt-Braekling 2019 79 2 0 5 4 0 9 90%
Wheelton 2019 54 0 0 1 0 0 1 95.8%
de l’Escalopier 2020 76 2 3 2 1 0 / /
Lannes 2020 26 2 0 2 0 0 2 85%
Lavignac 2020 71 1 0 10 4 6 / 83.10%
Mahmoud 2020 20 0 0 0 0 0 0 100%
Sayac 2020 77 7 0 2 3 0 6 85%
Schmidt 2020 59 4 0 / / / 13 95.6%
Tabori-Jensen 2020 29 0 0 0 0 0 0 100%
Wegrzyn 2020 28 0 0 0 0 0 0 /
Bellova 2021 33 2 0 1 0 1 2 97.3%
Bozon 2021 23 1 0 3 2 0 2 93%
Elkhadrawe 2021 32 0 0 1 0 0 1 98%
Lamo Espinosa 2021 68 0 0 0 1 0 1 /
Moreta 2021 10 1 0 0 0 0 1 92.2%
Rashed 2021 31 0 0 1 0 0 0 /
Unter Ecker 2021 216 24 0 0 0 0 17 100%
Uriarte 2021 44 0 0 2 0 0 1 /
Totals and proportions 3452 107 (3.1%) 7 (0.2%) 103 (3%) 45 (1.3%) 18 (0.5%) 138 (4%) Mean: 93.5%
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3.5. Radiographic Outcomes

Among the systematic review, 36 studies (64.3%) showed radiological information about peri-acetabular radiolucent lines (RLLs), and only 26 studies (46.4%) investigated Brooker HO. The rate of periacetabular RLLs was 3.2%, while the HO rate was 6.7% (Table 5).

Table 5.

Cemented dual mobility cup: radiographic and functional outcomes.

Author Patiens Patients at Follow-Up Acetabular
Components
Radiolucent Lines		 Brooker Heterotopic
Ossification		 Pre-Operative HHS Post-Operative HHS Pre-Operative PMA Post-Operative PMA
Langlais 82 79 2 / 26.2 87.4 ± 12.1 / /
Philippot 51 51 / / / 59.4 ± 22.2 (29–91) / /
Tarasevicius 42 42 3 / / 82 ± 18 (40–100) 11 ± 3 15.5 ± 3 (11–18)
Schneider 96 77 0 / / 77 (25–100) / /
Civinini 24 24 3 4 / / / /
Hailer 200 200 0 / 47 (37–60) 81 (62–98) / /
Pattyn 36 36 15 / 48 (32–68) 86 (66–95) / /
Mukka 34 34 0 / / / 12.9 (5–18) 16.3 (10–18)
Toro-Ibarguen 14 14 / / 42.8 ± 6.7 (34–60) 87.3 ± 5.8 (75–98) / /
Wegrzyn 61 61 / / / / / /
Haen 64 42 0 2 / 92.6 ± 11.1 / /
Simian 47 51 / / 46 (40–79) 65 (41–97) / /
van Heumen 46 46 1 / 40 (23–44) 86 (79–96) / /
Carulli C 11 11 0 / 50 (35–78) 78 (49–95) / /
Luthra 63 63 / / / 70.4 ± 23 (24–90) / 14.3 ± 4.2 (7–18)
Plummer 11 11 3 0 / / / 15.5 ± 1.9 (9–18)
Hamadouche 51 30 0 0 / / / /
Lebeau 62 62 9 / / / 13.5 ± 4.0 (8–18) 16.3 ± 1.6 (13–18)
Mohaddes 436 436 0 / 30 (15–51) 71 (40–89) / /
Nabil 12 12 0 0 31.7 (20–81) 84.5 (32–100) / /
Stambough 8 12 / / / / 10.31 15.61
Bruggemann 69 44 3 / / / / 16.1
Chalmers 18 18 0 6 / 72.36 ± 11.65 / /
Evangelista 18 16 / / / / / /
Hipfl 15 15 2 / 49 ± 16 (17–90) 73 ± 21 (24–99) 11 ± 3 (3–18) 14.4 ± 3.6 (3–18)
Kavcic 174 156 0 0 / / / /
Ozden 14 14 / / 25.95 ± 9.91 (14–44) 92.45 ± 2.74 (88–98) / /
Rashed 31 31 / / / / / /
Spaans 96 96 0 0 49.3 (33–62) 71.3 (22–91) 10.1 12.8
Stucinskas 236 236 / / / 67 (±14) / /
Tabori-Jensen 56 56 / 0 39.4 87.6 / /
Wegrzyn 126 25 0 0 42 86 (49–93) / /
Assi 16 16 / / / / / /
de l’Escalopier 76 63 0 0 45 90 / /
Dikmen 30 30 0 0 34 (27–41) 82 (66–95) / /
Fathy 20 20 2 0 / 92.8 (88.2–97.4) / /
Gabor 38 38 0 2 / 92.8 (SD 11.1) / /
Giunta 27 25 0 0 39.95 (6–84) / 8.05 (3–16) /
Moreta 10 10 4 29 39.5 ± 9.6 [37–43] 71.3 ± 14 8.1 ± 2.5 [7–9] 15.3 ± 2.2 [15–16]
Plummer 19 13 / / / / / /
Sayac 74 39 / / / 73.0 (24–99) / /
Schmidt 59 59 6 17 / / 9.6 ± 3.06 (2–16) 15.5 ± 2.32 (7–18)
Schmidt-Braekling 79 71 3 0 / 80.4 ± 12.9 (51–98) / 15.2 ± 2 (11–18)
Wheelton 54 54 / / / / / /
Lannes 26 25 / / / / / /
Lavignac 71 91 / / / / / /
Mahmoud 20 20 0 0 56 (±12) 92 (8.7) / /
Rashed 31 30 9 7 / 78.8 (31–100) / /
Tabori-Jensen 29 29 / / / / / /
Wegrzyn 28 28 / / / / 5.48 (SD 2.41) 10.5 (SD 3.82)
Bellova 33 19 4 16 / 76.9 (16.8) / 13.1 (3.3)
Bozon 23 23 0 0 / / / /
Elkhadrawe 31 30 3 0 53 ± 19 79 ± 13 / /
Lamo Espinosa 68 68 0 0 37 ± 8 84 ± 7 / /
Unter Ecker 216 216 0 0 71 (69–74) 88 (82–95) / /
Uriarte 44 44 / 0 / / / /
Totals and proportions 3426 3162 (92.3%) 72 (3.2%) 83 (6.7%) Mean: 43 Mean: 76.7 Mean: 10.4 Mean: 14.7
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3.6. Functional Outcomes

The preoperative level of function was assessed with the HHS in 22 studies (59.3%). The mean preoperative HHS value was on average 43. The mean postoperative HHS value, evaluated in 34 studies (60.7%), was 76.7 (Table 5). The mean pre-operative PMA was 10.4 in 10 studies (17.9%). Instead, the post-operative PMA was 14.7, in 14 studies (25%) (Table 5).

3.7. Cemented Dual Mobility Cups in the Primary Setting

C-DMCs were used in 25.5% of cases as the primary setting, in 19 different studies (33.9%). In 40.5% of those cases, C-DMCs were used for the treatment of FNF, in 27.9% of cases as a treatment of OA complex cases, in 25.2% of cases as a treatment of pathological lesions (all cases of peri-acetabular metastasis cases except one case of pathological femur fracture) [59].

Finally, in 6.4% of the cases, a C-DMC was used in the treatment of acetabular fractures (Table 6).

Table 6.

Cemented dual mobility cup in the primary setting.

Author Year C-DMC Primary Setting Primary (FNF) Primary (AO) Primary (Oncology) Primary (Acetabular Fracture) No Acetabular Reinforcement Acetabular Reinforcement Dislocations Intra-Prosthetic Dislocations Revisions Mechanical Failure Aseptic Loosening Infection Posterior Approach Lateral Approach Anterior Approach Cup-Survivorship
Tarasevicius 2010 42 42 0 0 0 42 0 0 0 0 0 0 0 42 0 0 100%
Mukka 2013 9 0 9 0 0 9 0 2 0 0 0 0 3 9 0 0 94.1%
Haen 2015 32 12 20 0 0 32 0 0 0 1 0 1 0 32 0 0 98% [94–100]
Luthra 2016 30 9 18 0 3 30 0 1 0 1 0 0 1 30 0 0 98%
Nabil 2017 12 0 12 0 0 11 1 0 0 0 0 0 0 0 12 0 100%
Kavcic 2018 173 88 85 0 0 173 0 0 0 0 0 0 2 0 0 173 100%
Rashed 2018 32 32 0 0 0 32 0 0 0 1 0 0 1 32 0 0 93.75%
Tabori-Jensen 2018 56 56 0 0 0 56 0 / 0 / 0 1 0 56 0 0 /
Wegrzyn 2018 131 0 0 131 0 0 131 3 0 0 0 0 4 131 0 0 /
Giunta 2019 27 0 0 0 27 4 23 3 0 0 0 0 0 27 0 6 /
Plummer 2019 19 0 0 19 0 0 19 0 0 1 0 0 2 19 0 0 /
Lannes 2020 26 0 0 0 26 0 26 2 0 2 0 0 2 26 0 0 92.3%
Lavignac 2020 71 0 0 71 0 0 71 1 0 / 6 4 10 / / / /
Mahmoud 2020 15 10 4 1 0 15 0 0 0 0 0 0 0 0 15 0 100%
Tabori-Jensen 2020 29 0 29 0 0 29 0 0 0 0 0 0 0 29 0 0 100%
Elkhadrawe 2021 32 32 0 0 0 32 0 0 0 1 0 0 1 32 0 0 100%
Lamo Espinosa 2021 68 0 68 0 0 68 0 0 0 1 0 1 0 0 0 68 98.5%
Rashed 2021 31 31 0 0 0 31 0 0 0 0 0 0 1 31 0 0 /
Uriarte 2021 44 44 0 0 0 44 0 0 0 1 0 0 2 / / / 97.3% [93.5–100]
Totals and proportions 879 356 (40.5%) 245 (27.9%) 222 (25.2%) 56 (6.4%) 608 (69.2%) 271 (30.8%) 12 (1.5%) 0 9 (1.2%) 6 (0.7%) 7 (0.8%) 29 (8.1%) 496 (64.4%) 27 (3.5%) 247 (32.1%) Mean: 98.5 %
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3.8. Cemented Dual Mobility Cups in the Revision Setting

In 74.5% of cases, a C-DMC was used in the revision setting, such as the revision of previous THA or fixation failures. The use of C-DMC in revision cases was described in 42 studies (75%) (Table 7).

Table 7.

Cemented dual mobility cup in the revision setting.

Author Year C-DMC Revision Setting No Acetabular Reinforcement Acetabular Reinforcement Cup-in-Cup Posterior/Posterolateral Approach Lateral Approach Anterior/Anterolateral Approach Extensile Approach Graft Complications (Dislocations) Complications (IPD) Complications (Revisions) Complications (Mechanical Failure) Complications (Aseptic Loosening) Complications (Infection) Cup-Survivorship
Langlais 2008 88 7 81 0 40 0 0 48 0 0 1 3 0 0 2 94.6%
Philippot 2009 51 0 51 0 / / / / / 6 0 / 1 2 3 98.8%
Schneider 2011 96 0 96 0 96 0 0 0 91 11 0 4 2 1 5 95.6% (95% CI, 93.3–97.7%)
Civinini 2012 24 0 24 0 / / / / 30 0 0 1 0 0 1 97% (95% CI, 82–98%)
Hailer 2012 200 / / 0 / / / / 0 3 0 10 2 4 4 93% (95% CI, 90–97%)
Pattyn 2012 37 0 37 0 37 0 0 0 0 2 0 2 1 0 1 /
Mukka 2013 25 25 0 0 25 0 0 0 0 2 0 0 0 0 3 94.11%
Toro-Ibarguen 2014 14 0 14 0 / / / / 0 1 0 / / / / /
Wegrzyn 2014 61 0 61 0 61 0 0 0 61 0 0 0 1 0 0 98%
Haen 2015 34 34 0 0 34 0 0 0 3 0 0 1 0 1 0 98% (95% CI, 94–100%)
Simian 2015 47 24 23 0 47 0 0 0 23 1 0 / 0 0 6 90% (95% CI, 84–95%)
van Heumen 2015 46 46 0 0 46 0 0 0 6 0 0 3 0 1 2 93% (95% CI, 79–98%)
Carulli C 2016 11 11 0 0 0 11 0 0 / 0 0 0 0 0 0 100%
Luthra 2016 33 33 0 0 33 0 0 0 0 1 0 1 0 0 1 98%
Plummer 2016 11 0 11 0 10 0 0 1 0 1 0 4 2 0 2 /
Hamadouche 2017 51 29 22 0 17 3 / 31 15 1 2 7 0 2 2 75.2 ± 9.3% (95% CI, 56.9–93.5%)
Lebeau 2017 62 0 62 0 62 0 0 0 58 1 0 8 0 5 7 91.9%
Mohaddes 2017 436 436 0 0 285 / 140 / 0 7 0 10 2 2 15 96%
Stambough 2017 8 0 0 8 8 0 0 0 1 2 0 / 0 0 0 85%
Bruggemann 2018 69 0 69 0 0 69 0 0 16 1 0 2 0 2 0 96% (95% CI, 90–100%)
Chalmers 2018 18 0 0 18 11 0 7 0 0 2 1 2 0 0 0 /
Evangelista 2018 18 0 0 18 / / / / 0 0 0 0 0 0 0 100%
Hipfl 2018 15 0 15 0 / / / / 15 1 0 / 0 0 2 89 (72–96)
Ozden 2018 15 6 9 0 15 0 0 0 5 0 0 2 0 2 0 93% (95% CI, 88–98.7%)
Spaans 2018 102 102 0 0 102 0 0 0 102 3 0 5 0 4 1 95.8% (3 months–7 years) (95% CI, 91.7–99.9%)
Stucinskas 2018 236 236 0 0 / / / / 0 5 0 11 0 1 5 95.14%
Assi 2019 16 0 16 0 16 0 0 0 16 0 0 0 0 0 0 100%
de l’Escalopier 2019 76 23 53 0 0 0 0 76 39 2 3 / 0 1 2 91.2 ± 3.8%
Dikmen 2019 30 11 19 0 30 0 0 0 14 1 0 3 0 2 1 91.2% (95% CI, 81.6–100%)
Fathy 2019 20 20 0 0 0 20 0 0 4 1 0 0 0 0 0 100%
Gabor 2019 38 27 11 0 27 11 0 0 18 1 0 1 0 0 1 /
Moreta 2019 10 0 0 10 4 0 6 0 0 1 0 1 0 0 0 /
Sayac 2019 77 0 77 0 77 0 0 0 0 7 0 6 0 3 2 92.2%
Schmidt 2019 59 0 59 0 59 0 0 0 0 4 0 13 / / / 72.1%
Schmidt-Braekling 2019 79 0 79 0 / / / / 0 2 0 9 0 4 5 85%
Wheelton 2019 54 54 0 0 / / / / 0 0 0 1 0 0 1 /
Mahmoud 2020 5 5 0 0 0 5 0 0 0 0 0 0 0 0 0 100%
Wegrzyn 2020 28 0 0 28 28 0 0 0 0 0 0 0 0 0 0 100%
Bellova 2021 33 0 0 33 33 0 0 0 0 2 0 2 1 0 1 86.8%
Bozon 2021 23 0 23 0 23 0 0 0 21 1 0 2 0 2 3 87% (95% CI, 94.7–72.3)
Unter Ecker 2021 216 / / / 216 0 0 0 0 24 0 17 0 0 0 96%
Totals and proportions 2572 1129 (52.4%) 912 (42.3%) 115 (5.3%) 1442 (77.1%) 119 (6.4%) 153 (8.2%) 156 (8.3%) 538 (21.4%) 97 (3.8%) 7 (0.3%) 131 (5.1%) 12 (0.5%) 39 (1.5%) 78 (3%) 93.6%
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3.9. Acetabular Reinforcement

In most cases (57.5%), the C-DMCs were used without acetabular reinforcement, cementing the acetabular component directly on the bone resulting in a low loosening rate and good cup survivorship, between 93 and 100% at the last followup (Table 8).

Table 8.

Cemented DMC without acetabular reinforcement.

Author Year C-DMC without Acetabular Reinforcement Primary Setting Revision Setting Graft Dislocations IPD Mechanical Failure Aseptic Loosening Infection Revisions Cup-Survivorship
Tarasevicius 2010 42 42 0 0 0 0 0 0 0 0 100%
Mukka 2013 34 9 25 0 2 0 0 0 3 3 94.1%
Carulli C 2015 11 0 11 / 0 0 0 0 0 0 100%
Haen 2015 66 32 34 3 0 0 0 1 0 1 98%
Simian 2015 24 0 24 / / 0 0 0 / / /
van Heumen 2015 46 0 46 6 0 0 0 1 2 3 93%
Luthra 2016 63 30 33 0 0 0 0 0 1 1 98%
Hamadouche 2017 29 0 29 / / / 0 / / / /
Mohaddes 2017 436 0 436 0 7 0 2 2 15 10 96%
Nabil 2017 11 11 0 1 0 0 0 0 0 0 100%
Kavcic 2018 174 173 1 0 0 0 0 0 2 0 100%
Ozden 2018 6 0 6 / 0 0 0 / 0 / /
Rashed 2018 32 32 0 0 0 0 0 0 1 1 93.75%
Spaans 2018 102 0 102 102 3 0 0 4 1 5 95.8%
Stucinskas 2018 236 0 236 0 5 0 0 1 5 11 94.9%
Tabori-Jensen 2018 56 56 0 0 1 0 0 1 0 / /
de l’Escalopier 2019 23 0 23 / / / 0 / / / /
Dikmen 2019 11 0 11 / / 0 0 / / / /
Fathy 2019 20 0 20 4 1 0 0 0 0 0 100%
Gabor 2019 27 0 27 / / 0 0 0 / / /
Wheelton 2019 54 0 54 0 0 0 0 0 1 1 100%
Mahmoud 2020 20 15 5 0 0 0 0 0 0 0 100%
Rashed 2020 31 31 0 0 0 0 0 0 1 0 96.8%
Tabori-Jensen 2020 29 29 0 0 0 0 0 0 0 0 100%
Elkhadrawe 2021 32 32 0 0 0 0 0 0 1 1 100%
Lamo Espinosa 2021 68 68 0 0 0 0 0 1 0 1 98.5%
Uriarte 2021 44 44 0 0 0 0 0 0 2 1 93.3%
Totals and proportions 1727 604 (35%) 1123 (65%) 116 (7.3%) 19 (1.2%) 0 2 (0.1%) 11 (0.7%) 35 (2.2%) 39 (2.5%) Mean: 96.9%
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In 39.6% of the total cases, in 30 studies, a DMC was cemented into an acetabular reinforcement.

The most common AR used were the Kerboull cross-plates and Burch–Schneider Cage (Table 9).

Table 9.

Cemented DMC with acetabular reinforcement.

Author Year C-DMC with
Acetabular Reinforcement		 Acetabular
Reinforcement		 Primary Setting Revision Setting Graft Dislocations Intra-Prosthetic Dislocations Mechanical Failure Aseptic Loosening Infection Revisions Cup-Survivorship
Langlais 2008 81 Kerboull Cross-Plate 0 81 0 0 1 0 0 2 3 94.6%
Philippot 2009 51 7 Novae Arm cage/Kerboull cross (44) 0 51 / 6 0 1 2 3 / 98.80%
Schneider 2011 96 70 Kerboull cross-plate, 6 Burch-Schneider antiprotrusio cage, 20 custom-fit Novae ARM cage 0 96 91 11 0 2 1 5 4 95.6%
Civinini 2012 24 Contour acetabular ring (Smith & Nephew, London, UK) 0 24 30 0 0 0 0 1 1 97%
Pattyn 2012 37 35 Ganz ring (Zimmer Inc., Warsaw, IN, USA), 2 Burch Schneider ring (Zimmer Inc., Warsaw, IN, USA) 0 37 0 2 0 1 0 1 2 /
Toro-Ibarguen 2014 14 15 Protrusio cage [DePuy Orthopaedics, Inc, Warsaw, IN], 22 Contour [Smith and Nephew Richards, Memphis, TN, USA] 0 14 0 1 0 / / / / /
Wegrzyn 2014 61 Kerboull Cross-Plate 0 61 61 0 0 1 0 0 0 98%
Simian 2015 23 Ganz Reinforcement Ring (Zimmer, Warsaw, IN, USA) 0 23 / / 0 0 0 / / /
Plummer 2016 11 / 0 11 0 1 0 2 0 2 4 /
Hamadouche 2017 22 Kerboull acetabular reinforcement 0 22 / / / 0 / / / /
Lebeau 2017 62 47 Müller ring, 8 Burch-Schneider ring, 4 Link reinforcement 0 62 58 1 0 0 5 7 8 91.9%
Bruggemann 2018 69 / 0 69 16 1 0 0 2 0 2 96%
Hipfl 2018 15 titanium acetabular cage (Zimmer Biomet) 0 15 15 2 0 0 0 2 / 89%
Ozden 2018 9 Contour Acetabular Reinforcement Ring (Smith & Nephew) 0 9 / 0 0 0 / 0 / /
Wegrzyn 2018 131 Kerboull cross-plate or Burch-Schneider anti-protrusio cage 131 0 0 3 0 0 0 4 0 /
Assi 2019 16 Kerboull cross-plate 0 16 16 0 0 0 0 0 0 100%
Dikmen 2019 19 Contour Acetabular Reconstruction Ring (Smith & Nephew) 0 19 / / 0 0 / / / /
Gabor 2019 11 / 0 11 / / 0 0 0 / / /
Giunta 2019 23 Kerboull cross-plate 23 0 6 3 0 0 0 0 0 /
Plummer 2019 19 triflange titanium acetabular cage (Restoration GAP Acetabular Cup; Stryker) 19 0 19 0 0 0 0 2 1 /
Schmidt-Braekling 2019 79 Burch–Schneider Cage (Zimmer, Warsaw, IN, USA) 0 79 0 2 0 0 4 5 9 85%
de l’Escalopier 2020 53 Kerboull acetabular reinforcement device (KARD, Zimmer-Biomet, Warsaw, IN, USA) 0 53 / / / 0 / / / /
Lannes 2020 26 Ganz ring (Zimmer-Biomet®, Warsaw, IN, USA) 26 0 0 2 0 0 0 2 2 92.3%
Lavignac 2020 71 Kerboull cross-plate, Muller ring, Burch-Schneider cage 71 0 0 1 0 6 4 10 / /
Sayac 2020 77 Kerboull cross-plate, Burch-Schneider antiprotrusio cage, custom-fit Novae ARM cage 0 77 0 7 0 0 3 2 6 92.2%
Schmidt 2020 59 Kerboull cross-plate, Burch-Schneider ring, or jumbo metal-back 0 59 0 4 0 / / / 13 72.1%
Bozon 2021 23 Kerboull reinforcement device (316 L, Aston Medical, Saint-Étienne, France) 0 23 21 1 0 0 2 3 2 87%
Totals and proportions 1182 270 (22.8%) 912 (77.2%) 333 (33.5%) 48 (4.5%) 1 (0.09%) 13 (1.2%) 23 (2.3%) 51 (5.2%) 57 (6.4%) Mean: 91.7%
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3.10. Cup-in-Cup Technique

DMC was cemented into a pre-existing cup following the “cup-in-cup” technique, in 106 cases (3.1%) (Table 3). In all cases, this procedure was used as a revision setting after the failure of a previous THA (Table 10).

Table 10.

Cemented DMC: cup-in-cup technique.

Author Year Cemented DMC Dislocations IPD Revisions Mechanical Failure Aseptic Loosening Infections Acetabular Components RLLs Brooker HO Preoperative HHS Postperative HHS Preoperative PMA Postoperative PMA Revisions Posterior Approach Lateral Approach Anterior Approach Follow-up (Months) (SD) [Range] Cup-Survivorship
Stambough 2017 8 2 0 2 0 0 1 / / / / / 8 8 0 0 34.8 [24–63.6] 85%
Chalmers 2018 18 2 1 2 0 0 0 0 / 47 [37–60] 81 [62-98] / / 18 11 0 7 36 [24–60] /
Evangelista 2018 18 0 0 0 0 0 0 / / 46 [40–79] 65 [41–97] / / 18 0 0 0 36 [25–56] 100%
Wegrzyn 2020 28 0 0 0 0 0 0 0 0 71 [69–74] 88 [82–95] / / 28 28 0 0 42 [24–60] 100%
Bellova 2021 33 2 0 2 1 0 1 / / / 59.4 (±22.2) [29–91] / / 33 33 0 0 28.5 (±17.3) [3–64] 86.8%
Moreta 2021 10 1 0 1 0 0 0 0 0 49.3 [33–62] 71.3 [22–91] 10.1 12.8 10 4 0 6 42 [24–72] /
Totals and proportions 115 4.7% 0.9% 4.7% 0.9% 0% 0.9% 0% 0% Mean: 56.4 Mean: 74.8 Mean: 10.1 Mean: 12.8 100% 86.6% 0% 13.4% Mean: 35.7 Mean: 93.6%
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3.11. Acetabular Bone Grafting

In the current study, the use of bone grafting was observed in 22 (39.3%) manuscripts. Overall, acetabular bone grafting has been used in 16.3% of C-DMC. In most cases, it was an allograft (93.2%), while in a minor part it was a synthetic graft (4.9%) or autograft (1.9%).

Acetabular bone grafting was used in 3% of the primary C-DMC setting and in 19% of the revision C-DMC setting. In cases where an acetabular reinforcement was utilized, acetabular bone grafting was used in 24.2% of cases, while only in 9.8% of cases in the absence of acetabular reinforcement (Table 2).

4. Discussion

This review allowed us to appreciate the satisfactory results of C-DMC. Dislocation rates found are low and the survivorship of the implants in both primary and revision surgery is satisfactory. Clinically, the improvement of the functional outcomes is significant, and radiologically, RLLs are rare.

The clinical and radiographic outcomes of cementless DMCs are excellent at medium and long follow-ups with an overall survivorship of 95% at 10-year follow-ups and demonstrated low revision and dislocation rates, without major polyethylene wear concerns [16,68,69,70,71,72,73,74,75,76,77,78,79,80].

4.1. Cemented Dual Mobility Cup in the Setting of Primary Surgery

In the present study, was observed the use of C-DMC in a primary setting in about a quarter of the surgeries (25.5%). C-DMC is an established treatment of hip OA, especially in association with other comorbidities that could increase the risk of dislocation and loosening, such as acetabular deficiency, abductor deficiency, prior acetabular fracture fixation or high-demanding physical activity patients [32].

Tabori-Jensen et al. [61] in a randomized controlled study in elderly osteoarthrosis patients with 2 years’ follow-up comparing cementless DMC with C-DMC have demonstrated that cemented fixation of the Avantage DMC seems safer in elderly patients, with less implant migration.

Moreover, C-DMC represents an option in the management of FNF. In those cases, Tarasevicius et al. [15] reported a 100% survival rate one year after treatment of 42 patients with C-DMC. Lamo-Espinosa et al. [67], in a series of 69 elderly (>75 years) and frail patients with a high risk of instability with a median follow-up time of 49.04 months, reported only one case of revision due to aseptic loosening.

Another well-recognized use of C-DMC is in cases of pathological fractures. Lavignac et al. [58] used DMC in the treatment of peri-acetabular metastasis, but although the rate of complications and revisions is low, the mean patient survivorship was 19.5 months due to the progression of the primary disease. Similarly, Wegrzyn et al. [46], in a continuous series of 131 cases of periacetabular metastatic disease treated using a DMC cemented into an acetabular reinforcement device, observed an improvement in the postoperative functional outcome and pain relief, no mechanical failure or aseptic loosening of the acetabular reconstruction and a dislocation rate of 2%.

Finally, in some cases of acetabular fractures, C-DMC could be used. In those cases, it is associated with the combined treatment of fracture reduction and fixation. As reported by Giunta et al. [38], primary C-DMC for acetabular fracture in the elderly population might be a good therapeutic option that allows a return to previous daily life activity. Lannes et al. [57] found that DMC combined with internal fixation, also known as the combined hip procedure (CHP), could be an efficient procedure in selected elderly patients, with a lower level of revision rate compared to the ORIF group alone. In the CHP group, internal fixation was performed before the hip replacement. When the anterior column was involved, a suprapectineal quadrilateral buttress plate was used through a modified Stoppa approach; otherwise, a Kocher-Langenbeck approach was performed with a posterior column or wall osteosynthesis [81,82].

These findings are important and demonstrate that primary surgery with C-DMC is an excellent treatment in complex cases of OA, FNF, acetabular fractures or periacetabular metastases in terms of survival and reduced number of complications.

4.2. Cemented Dual Mobility Cup in the Setting of Revision Surgery

As demonstrated by the results of the study, the most frequent use of C-DMC is in revision settings (74.5%).

In cases of failure of a previous THA, C-DMC has shown an excellent role in avoiding further failures and reducing the number of complications. In fact, from the Swedish Hip Arthroplasty Register, Hailer, et al. [18] revealed in a series of 228 patients that DMCs for revision due to instability are associated with a low rate (8%) of re-revisions due to dislocation.

In patients with first-time revision hip arthroplasty due to dislocation, Mohaddes et al. [31] found better short to mid-term implant survival for C-DMC compared with cemented polyethylene cups at four years of follow-up. Stucinskas et al. [44], from the Lithuanian arthroplasty register, observed a significantly lower short-term re-revision rate for dislocations at five-year follow-up, in patients treated with C-DMC (2%) compared to different surgical concepts (9%) when used for first-time hip revisions due to recurrent dislocations.

As emerges from the results of the current review, C-DMC is a valid option in a revision setting with a dislocation rate of 3% and a survival rate of approximately 95% (with a mean follow-up of 49.6 months).

4.3. Cemented Dual Mobility Cup into an Acetabular Reinforcement

In the present study, DMC was cemented in an acetabular reinforcement in the revision setting in 83.6%, while in the primary setting only in 16.4% of the cases.

Neri et al. [74] suggested the use of DMC cemented into a reinforcement cage (Kerboull cross-plate or custom reinforcement cage) in cases of acetabular defects 2C or more according to Paprosky’s classification. In a single-center continuous series of 62 patients, Lebeau et al. [30] evidenced that DMC cemented into an acetabular reinforcement at a minimum FU of five years presented good outcomes (PMA 14, HHS score 73) and only 2 cases of dislocation, while Brüggemann et al. [35], in a case series of 69 patients, demonstrated a 4-year survival of 96% and only one case of dislocation.

4.4. Cemented Dual Mobility Cup into a Pre-Existing Cup

Among the studies, a minor part (3.2%) of the DMCs was cemented into a pre-existing cup following the surgical technique described by Blumenfeld [83], known as the “Cup-in-cup” technique. This technique, developed for the treatment of acetabular defects, in the current study showed good results in terms of fewer complications and guaranteed a survival rate of 93.6% at a mean follow-up of 35.7 months (Table 10).

4.5. Bone Grafting

In the current study, the use of bone grafting was observed in 16.3% of C-DMC. In most cases, bone grafting was used in a revision setting, in combination with acetabular reinforcement, using an allograft. Bone grafting could help the surgeon in cases of loss of acetabular bone stock and unstable components fixation and can be easily combined with cemented fixation of the DMC [84].

4.6. C-DMC Complications and Outcomes

In the current review, the overall dislocation rate was 2.9%, and at 45.9 months follow-up, the overall survival rate was 93.5%. These data are similar to the mean rates of dislocation and medium-term survival of single-mobility THA or cementless DMC [25,85,86]. These results must be considered even more due to the use of the C-DMC especially in complex cases or in revision settings.

The overall IPD rate was 0.2%. First described in 2004 by Lecuire [87], intra-prosthetic dislocation (IPD) is a specific complication of DMC. IPD is defined as excessive “wear” of the head-liner interface which induces the separation of the head from the polyethylene, but the present systematic review reported only 7 cases of IPD, showing that this complication is now extremely rare.

Overall, C-DMC demonstrates to be a valid treatment in primary complex cases, such as in revision settings, in terms of survival and reduced number of complications.

The greatest strength of the article is to represent the only systematic review specifically focused on the C-DMC present in the literature. Moreover, over three thousand C-DMCs are considered in the systematic review. Limitations of the study are represented by the low average level of evidence, most of the studies have a level IV of evidence. Furthermore, the nature of the inclusion criteria may have minimally altered the results, due to the wide heterogeneity of the patients included. However, it is assumed that in such a large case series, this possible bias could be minimized.

5. Conclusions

The use of C-DMCs is an option used mainly in THA revision surgery, although it also exists in a primary setting. It represents an effective treatment option with good clinical outcomes. The complication rate remains moderate, with a low rate of dislocation in both primary and revision surgery. The loosening and revision rates are also low. These results can be observed whether the implant is cemented directly into the bone or cemented in acetabular reinforcement or a previous well-fixed cup. An acetabular reinforcement was used in almost 40% of cases.”

Author Contributions

G.C. and G.M. wrote the manuscript. G.C., G.M., E.D. and S.G. collected the data. C.B. provided data analysis. E.S. and S.L. are the senior authors who designed the study and reviewed the manuscript. The authors approved the submitted version. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

The authors confirm that the data supporting the findings of this study are available within the article.

Conflicts of Interest

G.C., G.M., E.D., S.G. and C.B.: No conflict of interest. E.S.: institutional research support from Corin. S.L.: Consultant for Stryker, Smith and Nephew, Heraeus, Depuy Synthes. Institutional research support to Lepine and Amplitude. Editorial Board for Journal of Bone and Joint Surgery (Am).

Funding Statement

This research received no external funding.

Footnotes

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Associated Data

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Data Availability Statement

The authors confirm that the data supporting the findings of this study are available within the article.

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