Risk Factors and Modes for Implant Failure in the Modern Dual Mobility Implant. A Systematic Review and Meta-analysis&nbsp;

doi:10.21203/rs.3.rs-109503/v1

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Risk Factors and Modes for Implant Failure in the Modern Dual Mobility Implant. A Systematic Review and Meta-analysis

https://doi.org/10.21203/rs.3.rs-109503/v1

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Background

The aims of this meta-analysis were to: (1) validate the outcome of modern dual mobility (DM) designs in patients who had undergone primary and revision total hip arthroplasty (THA) procedures and (2) to identify factors that affect the outcome.

Methods

We searched for studies that assessed the outcome of modern DM-THA in primary and revision procedures that have been conducted between January, 2000 to August, 2020 on PubMed, MEDLINE, Cochrane Reviews and Embase. The pooled incidence of common failure modes and functional scores were evaluated in patients who have received: (1) primary THA, (2) revision THA for all causes or (3) for recurrent dislocation. A meta-regression analysis was performed for each parameter to determine the association with the outcome.

Results

A total of 120 studies (N= 30016 DM-THAs) were included for analysis. The mean follow-up duration was 47.3 months. The overall implant failure rate was 4.2% (primary: 2.3%, revision for all causes: 5.5%, recurrent dislocation: 6.0%). The most common failure modes were aseptic loosening (primary: 0.9%, revision for all causes: 2.2%, recurrent dislocation: 2.4%), septic loosening (primary:0.8%, revision for all causes: 2.3%, recurrent dislocation: 2.5%), extra-articular dislocation (primary:0.6%, revision for all causes:1.3%, recurrent dislocation:2.5%), intra-prosthetic dislocation (primary:0.8%, revision for all causes:1.0%, recurrent dislocation:1.6%) and periprosthetic fracture (primary:0.9%, revision for all causes:0.9%, recurrent dislocation:1.3%). The multi-regression analysis identified younger age (β=-0.04, 95% CI -0.07 – -0.02) and female patients (β=3.34, 95% CI 0.91–5.78) were correlated with higher implant failure rate. Age, gender, posterolateral approach and body mass index (BMI) were not risk factors for extra-articular or intra-prosthetic dislocation in this cohort. The overall Harris hip score and Merle d’Aubigné score were 84.87 and 16.36, respectively.

Conclusion

Modern dual-mobility designs provide satisfactory mid-term implant survival and clinical performance. Younger age and female patients might impact the outcome after DM-THA.

Orthopedics

Dislocation

dual mobility

implant failure

instability

outcome

revision total hip arthroplasty

risk factor

total hip arthroplasty

Dislocation has been one of the most common cause of implant failure after total hip arthroplasty (THA).(1) The reported dislocation rate after primary THAs is 0.3-10%(2-4) and is much higher after revision THAs (5-30%).(5-7) Dislocation can be multifactorial, including both surgeon and patient related factors.(8-18) Several design changes have been made on the prosthesis to resolve this. Currently, dual mobility (DM) THA is one of the most successful designs to reduce the risk of dislocation.(19) The concept of DM was invented by Gilles Bousquet and Andrè Rambert in France in 1973.(19) The design included Charnley’s low-friction principle and the theory of McKee and Watson-Farrar, which increased the femoral head-to-neck ratio, extending the “jumping” distance in order to prevent dislocations.(20-23) The first generation DM design was associated with higher aseptic loosening and intra-prosthetic dislocation (IPD) rate, which resulted from polyethylene wear, suboptimal fixation and surface coating of the acetabular component.(24-30) In the late 1990’s, a newer DM design was introduced with several modifications including modular design, shape, surface coating and highly cross-linked polyethylene to reduce the rate of aseptic loosening and IPD.(31-34)

Compared with the fixed-bearing THA, several meta-analyses have validated a lower dislocation rate using DM articulation in both primary(35-37) and revision THA procedures.(36-39) Despite the established efficacy of DM articulation in preventing dislocation, it is with clinical importance to validate the overall implant survival and failure modes of this unique design. To our knowledge, the most recent and comprehensive systematic review discussing the outcome after DM-THA was conducted by Darrith et al.(40) The authors reviewed studies published from 2007 to 2016, including 54 studies with 14345 primary and revision THA procedures. They reported the overall failure rate (primary: 2.0%, revision: 3.4%) and incidence of common failure modes including aseptic loosening (primary: 1.3%, revision: 1.4%), extra-articular dislocation (primary: 0.46%, revision: 2.2%) and intra-prosthetic dislocation (primary: 1.1%, revision: 0.3%). However, this review involves a mixture of the 1^st generation and modern (2^nd and 3^rd generations) DM designs. Some important modes of implant failure such as septic loosening and periprosthetic fracture were not analyzed in this review. Moreover, the number of articles regarding the outcome of modern DM-THA from 2016 to 2020 have doubled since 2016.(41-115) Therefore, an up-to-date meta-analysis is essential to validate the outcome of modern DM-THA. Our primary objective was to identify the overall implant failure rate and several common failure modes including aseptic loosening, septic loosening, extra-articular dislocation, intra-prosthetic dislocation and periprosthetic fracture. The secondary objective was to determine risk factors predisposing to implant failure and functional outcome.

We completed a comprehensive search on PubMed, MEDLINE, Cochrane Reviews and Embase for studies that reported outcome in patients who had undergone dual mobility total hip arthroplasty (DM-THA) published from the earliest record to August, 2020. We conducted the search according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement. The following terms were used in variable combinations: total hip arthroplasty, total hip replacement and dual mobility. Two authors (xxx, xxx) independently searched and screened the titles and abstracts for relevant studies. If there was disagreement, a third author (xxx) was consulted for a consensus. The search strategy is shown in Figure 1.

We included original articles written in English that validated the outcome in patients who had undergone DM-THA for all kinds of indications including primary THA, revision THA or recurrent dislocation. We excluded review articles, letter to the editor, expert opinion, biomechanical studies, articles not written in English, study period earlier than 2000 or studies in which data were not obtainable. For comparative studies (e.g. hemiarthroplasty or THA vs DM-THA), we extracted data from the DM-THA group if possible. If there was uncertainty regarding the data from the study, we contacted the authors for clarifications.

Two authors (xxx, xxx) examined all relevant studies and extracted data using a predetermined form. The primary aim was to determine the overall implant failure rate and failure modes including aseptic loosening, septic loosening, extra-articular dislocation, intra-prosthetic dislocation and periprosthetic fracture. We further validated these rates stratified by indications including primary THA, revision THA for all causes or for recurrent dislocation. The secondary aim was to identify risk factors for implant failures and to evaluate the functional outcome using Harris hip score(116) and Merle d’Aubigné score(117). We recorded the first author, year, study design, number of THA procedures, indications, age, follow-up duration, implant brand and outcome parameters in Table 1.

Two authors (xxx, xxx) independently evaluated the methodological quality of the included studies using the NIH Quality Assessment Tool for Case Series Studies(118). The highest score on this scale is 9. A score between 7 and 9, 4 and 6, less than 4 were defined as “good”, “fair” and “poor”, respectively. If there were disagreement, we consulted a third author (xxx). (Table 2)

Statistical analysis

A meta-analysis of proportions was conducted using the Freeman-Tukey analysis under random-effects model to determine pooled estimates with a 95% confidence interval (CI). A random-effects model was used for differences among studies such as age, sex, surgical approaches, body mass index, indications for THA procedure, implant brand and methodology. A standard multivariate linear regression analysis (β) was performed to determine potential factors for implant failure or improved functional outcome. We completed all analyses with the Comprehensive Meta-Analysis (CMA) software, version 3 (Biostat, Englewood, New Jersey, USA) and significance was defined as p < 0.05.

We identified 1123 studies according to our search strategy. We removed 714 duplicate records and 231 studies after reading the title and abstract. Another 58 studies were excluded after reading the full text as the studies did not meet the inclusion criteria: studies on different outcome domains (n=21), mixed etiologies (n=12), 1st generation DM designs (n=10), cemented liner to cup (n=9), cadaveric or in vitro studies (n=3), studies not written in English (n=3). After exclusion, a total of 120 studies were included (41-115, 119-163) (Figure 1).

Baseline characteristics

We included 30016 patients who had undergone DM-THA for primary and revision THA procedures. The mean age was 71.9 years (range, 19.2 to 87.6) and 63.2% of the patients were female. Mean follow-up duration in overall, primary, revision and recurrent dislocation group were 47.29 months (range, 3 to 152.4), 40.86 months (range, 3 to 152.4), 61.82 months (range, 6 to 87.6), and 35.23 months (range, 24 to 55), respectively. DM-THA was used in 19819 primary THA procedures, 9411 revision THA procedures and 786 revision THA procedures for recurrent dislocation.

Aseptic loosening

A total of 105 studies, including 28980 DM-THA procedures, have reported aseptic loosening rates. The overall pooled rate was 1.6% (95% CI 0.008 – 0.032). The aseptic loosening rates in primary THA, revision THA and revision THA for recurrent dislocation were 0.9%, 2.2% and 2.4%, respectively (Table 3, Figure S1). A multivariate regression analysis revealed that a revision THA procedure for all causes (β=1.30, 95% CI 0.71 – 1.89), or for recurrent dislocation (β=1.18, 95% CI 0.26 – 2.10), carried a higher risk of aseptic loosening compared with a primary THA procedure (Table 4).

Septic loosening

A total of 105 studies, including 28980 DM-THA procedures, have reported septic loosening rates. The overall pooled rate was 1.6% (95% CI 0.007 – 0.037). The septic loosening rates in primary THA, revision THA and revision THA procedure for recurrent dislocation were 0.8%, 2.3% and 2.5%, respectively (Table 3, Figure S2). A multivariate regression analysis showed that both revision THA for all causes (β=1.85, 95% CI 1.26 – 2.44) and for recurrent dislocation (β=1.40, 95% CI 0.45 – 2.36) were at a higher risk of septic loosening, compared with a primary THA procedure (Table 4).

Extra-articular dislocation

A total of 113 studies, including 20447 DM-THA procedures, have validated the extra-articular dislocation rates. The overall pooled rate was 1.2% (95% CI 0.006 – 0.025). The extra-articular dislocation rates in primary THA, revision THA and revision THA for recurrent dislocation were 0.6%, 1.3% and 2.5%, respectively (Table 3, Figure S3). Compared with a primary THA procedure, risk of dislocation was higher after revision THA procedures (β=1.02, 95% CI 0.30 – 1.73) (Table 4).

Intra-prosthetic dislocation

A total of 113 studies, including 20447 DM-THA procedures, have reported the intra-prosthetic dislocation rates. The overall pooled rate was 1.0% (95% CI 0.007 – 0.015). The intra-prosthetic dislocation rates in primary THA, revision THA and revision THA for recurrent dislocation were 0.8%, 1.0% and 1.6%, respectively (Table 3, Figure S4). None of the factors including age, female sex, posterolateral approach, BMI or indication have led to intra-prosthetic dislocation (Table 4).

Periprosthetic fracture

A total of 100 studies, including 27731 DM-THA procedures, have recorded the periprosthetic fracture rates. The overall pooled rate was 0.9% (95% CI 0.008 – 0.011). The periprosthetic fracture rates in primary THA, revision THA and revision THA for recurrent dislocation were 0.9%, 0.9% and 1.3%, respectively (Table 3, Figure S5). Revision THA procedure for all causes (β=0.93, 95% CI 0.23 – 1.62) was a risk factor for periprosthetic fracture (Table 4).

Overall implant failure

A total of 105 studies, including 27873 DM-THA procedures, have recorded the implant failure rates. The overall pooled rate was 4.2% (95% CI 0.021 – 0.081) at a mean follow-up of 45.8 months. The implant failure rates in primary THA, revision THA and revision THA for recurrent dislocation were 2.3%, 5.5% and 6.0%, respectively (Table 3, Figure S6). Younger age (β=-0.04, 95% CI -0.07 – -0.02), female sex (β=3.34, 95% CI 0.91 – 5.78), revision THA procedure for all causes (β=1.48, 95% CI 0.93 – 2.03) and for recurrent dislocation (β=1.08, 95% CI 0.24 – 1.92) were risk factors for implant failures (Table 4).

Functional outcome

We included 49 (N= 7086) and 21 (N= 2764) studies that have evaluated functional outcome using Harris hip score and Merle d’Aubigné score. The pooled Harris hip score and Merle d’Aubigné score were 84.87 (95% CI 78.99 – 90.76) and 16.36 (95% CI 15.20 – 17.53), respectively (Table 3, Figure S7, S8). Revision THA procedure for all causes (β=-9.44, 95% CI -15.17 – -3.72) and female sex (β=-4.10, 95% CI -8.17 – -0.03) were associated with lower functional scores. (Table 4).

In this meta-analysis, we included 120 studies with 30016 primary and revision THA procedures using the modern DM design. At a mean follow-up of 47.3 months, the overall failure rate of modern dual mobility design was 4.2%. The most common failure modes include aseptic loosening (primary: 0.9%, revision for all causes: 2.2%, revision for recurrent dislocation: 2.4%), septic loosening (primary: 0.8%, revision for all causes: 2.3%, revision for recurrent dislocation: 2.5%), extra-articular dislocation (primary: 0.6%, revision for all causes: 1.3%, revision for recurrent dislocation: 2.5%), intra-prosthetic dislocation (primary: 0.8%, revision for all causes: 1.0%, revision for recurrent dislocation: 1.6%) and periprosthetic fracture (primary: 0.9%, revision for all causes: 0.9%, revision for recurrent dislocation: 1.3%). The multi-regression analysis revealed that revision THA procedures were associated with a higher risk of aseptic loosening, septic loosening, extra-articular dislocation, periprosthetic fracture, overall implant failure and lower Harris Hip scores. But interestingly, several risk factors that have been identified for THA dislocation such as advanced age, female sex, posterolateral approach and increased BMI were not risk factors for extra-articular dislocation. Younger and female patients were associated with higher risk of implant failure. In terms of functional outcome, the patients were satisfied with their postoperative function based on the improved Harris hip score and Merle d’Aubigné score.

Dislocation is one of the common causes of THA implant failure and can be caused by many factors.(8) In current literature, the known risk factors include advanced age, female patients,(9, 10) obesity,(11, 12) previous hip surgeries,(13) posterolateral surgical approach,(14, 15) THA for acute fractures, patients with neurological diseases,(16) and patients with abductor weakness.(17, 18) The dual mobility design increases femoral head-to-neck ratio and jumping distance to improve stability.(20-23) Therefore, we can anticipate decreased dislocation rates for the DM design in primary and revision THA. Even after revision THA due to recurrent instability, the dislocation rate was only 2.5%, which was much lower than the reported dislocation rate after primary THAs and revision THAs, which ranged from 0.3% to 10%(2-4) and 5% to 30%(5-7), respectively. In addition, a multivariate analysis revealed that older age, female patients, posterolateral approach and BMI were not risk factors for dislocation after DM-THA. Based on the difference in risk factors for dislocations, we can assume that the DM design can effectively overcome some of the shortcomings of previous THA designs. Nevertheless, optimization of component position and restoration of soft tissue tension are paramount to prevent dislocation in both primary and revision THA procedures.

Despite these improvements, there are still some concerns with the DM design, including increased wear of the acetabular liner(164), increased risk of aseptic loosening(30) and intra-prosthetic dislocation.(30)

The two-articulation design creates two surfaces for plastic deformation and wear, which theoretically leads to a higher wear rate than fixed-bearing THA. The inner, small articulation dominates the majority of movement and follows the Charnley’s low-friction principle with a small-diameter head to reduce wear.(20) The motion between the outer shell and acetabular component occurs in extreme angle when femoral neck abuts the PE liner and creates a homogenous wear over the liner.(40) Using plain radiographs or implant retrieval analysis, several studies aimed to assess the volumetric difference in wearing of DM articulations and fixed-bearing THA.(165-172) Interestingly, the wear rate of ultra-high molecular weight polyethylene (UHMWPE) bearing in the 1^st generation DM cup was less than 40 mm³/year, which was similar to wear rate of UHMWPE in fixed-bearing THAs (30–80 mm³/year at 15 to 21 year follow up).(165-169) In vitro simulation study for modern generation DM cup, using highly cross-linked polyethylene (HXLPE), reported lower wear rate in DM cup compared to fixed-bearing THA (1.2 vs. 2.7 mm³/million cycles, respectively).(170) In another study performed by Laende et al., the wear rate of modern generation DM cups with HXLPE at 3 years follow-up was 0.02 mm/year in DM cup, which was similar to non-dual mobility constructs (0.00 to 0.06 mm/year).(69, 171) In contrast, Deckard et al. recorded the wear rate was two times higher for modern-generation DM cup with HXLPE than the fixed-bearing THA (0.27mm/year and 0.11 mm/year, respectively).(172) The in vitro simulation or retrieval studies have validated reasonable wear rates of DM articulation using either UHMWPE or HXLPE.(165-170) The results from studies using plain radiographs to estimate the wear rate were controversial, which is considered less accurate than the retrieval or simulation studies.(171, 172) Currently, there is limited evidence regarding the increased PE wear of modern DM articulation.

The non-porous alumina-coated surface, tripod anchoring system of acetabular component and polyethylene wear have been associated with a higher aseptic loosening rate in the first-generation DM implants.(24, 29, 31) Several changes have been made in modern dual mobility designs, including (1) to replace UHMWPE with HXLPE to reduce wear(33, 34); (2) to add bevelled edges (or chamfer) in polyethylene (PE) inserts to lower femoral neck impingement and wear(32); (3) press-fit fixation by bilayer coating of porous titanium and hydroxyapatite to enhance osseointegration on the outer surface(31); (4) modular metal liner design to facilitate supplementary screw fixation. The long-term overall survival and aseptic loosening rate of the primary THAs using 1^st generation DM implants were 85-95.4% and 3-8.3%, respectively.(24-28) In this study, the primary THAs using modern generations DM implants are associated with a better overall survival (97.7%) and a lower aseptic loosening rate (0.9%). This pooled aseptic loosening rate was comparable to that of primary, fixed-bearing THA from several registries, which ranged from 0.7-1.1% at 5 to 16 years.(1, 173, 174)

The modern, modular design has an additional cobalt-chromium (CoCr) liner inserted into a titanium acetabular component allowing supplementary screw fixation to enhance primary stability. However, the metal-on-metal interface between CoCr liner and titanium cup is at risk of fretting corrosion and remains a concern.(175-177) Metal ions can further lead to advance local tissue reaction (ALRT) and implant loosening.(178) The first study regarding metal ions was conducted by Matsen Ko et al., which revealed 21% of the patient had elevated serum chromium levels.(179) Other studies reported that serum ion levels (cobalt, chromium or titanium) was elevated in 9.3-23% of the patients.(47, 111) On the other hand, some studies have noted that this elevation was not associated with clinical adverse events including instability, loosening or need of revision.(64, 67, 72) In summary, the current evidence suggests there is a slight elevation of serum ion level but this does not negatively affect the implant survival.

Intra-prosthetic dislocation (IPD) is a rare complication of DM design, which occurs as a result of retentive failure of the inner articulation. Long-term, homogenous PE wear or impingement at extreme range of motion between neck and PE liner leads to loss of PE retentive rim and IPD.(180, 181) The incidence of IPD ranged from 0.7%-4.3% in first generation of DM cup and(29, 30) modifications have been made to the 2^nd generation DM implants. These changes include a thinner, more polished femoral neck to reduce impingement with the liner and the use of HXLPE to reduce wear during contact.(32) In our pooled study for modern DM cup, IPD rate in primary THA and revision THA was 0.8% and 1.0% respectively, which is much lower than the 1^stgeneration.(29, 30) Another form of IPD has been observed in modern generation DM implants, which often occurs in the short-term. This form of IPD results from a secondary decapsulation of the liner followed by reduction for dislocation.(182) During close reduction of a dislocated DM-THA, impingement occurs between PE liner and posterior edge of the acetabular component. The excessive loading during reduction maneuver may “decapsulate” the femoral head from PE liner. Therefore, the reduction should be performed gradually under general anesthesia with completely relaxed muscle.(29)

Our meta-analysis showed that the mid-term revision rates in primary and revision DM-THA were 2.3% and 5.5-6.0%, respectively. These results were comparable to the reported outcome of primary or revision, fixed-bearing THA.(1, 38, 39, 60, 73, 98, 108, 183, 184) In primary fixed-bearing THA, the mid-term and long-term revision rate ranged from 1.2-4.0% and 12.1-14.3%, respectively.(1, 38, 60, 73, 98, 108, 183) In revision fixed-bearing THA, the mid-term and long-term revision rates can be up to 5.3-13% and 27-45%, respectively.(39, 184)

This meta-analysis revealed promising mid-term outcomes and a reduction in dislocation rate, but the long-term implant survival of modern DM-THA is still lacking. In addition, the regression analysis showed that revision THA procedures, younger age and female patients were associated with a higher risk of implant failure. Younger patients have been established as a risk factor for failure after primary THAs. However, whether female sex is a risk factor remains controversial.(185-188) This can be attributed to the representativeness of the study cohort, follow-up duration and type of implant. Although female patients have been associated with increased risk of dislocation, aseptic loosening, periprosthetic fracture and overall implant failure after primary THA(187, 188), the same was not seen in DM-THA aside from overall implant failure. Potential confounders and inadequate follow-up duration are important considerations when interpreting this result.

We should recognize several limitations. First, we included only studies written in English. In addition, due to the nature of our research question, the level of evidence of the included studies was low (III or IV). Furthermore, we included studies that reported outcome of modern DM (the 2^nd and 3^rd generation) implants over a time span of 12 years between 2008 to 2020. We could only analyze factors that were clearly described in the studies, including age, sex, surgical approach, BMI and indication for hip arthroplasty. Factors such as surgeons’ experience, patient activity level or implant designs could have affected the outcome but were unavailable could not be analyzed. Nonetheless, this review provides an updated information about the outcome of modern DM implants and factors that might affect the outcome.

In conclusion, the mid-term implant survival of modern dual-mobility designs was satisfactory. Aseptic loosening continued to be the most common failure mode after DM-THA. Younger age and female sex were correlated with implant failure.

Dual mobility (DM); total hip arthroplasty (THA); body mass index (BMI); intra-prosthetic dislocation (IPD); Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA); confidence interval (CI); Comprehensive Meta-Analysis (CMA); ultra-high molecular weight polyethylene (UHMWPE); highly cross-linked polyethylene (HXLPE); polyethylene (PE); cobalt-chromium (CoCr); advance local tissue reaction (ALRT)

Ethics approval and consent to participate

Not applicable

Consent for publication

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Availability of data and materials

All data generated or analysed during this study are included in this published article [and its supplementary information files]

Competing interests

The authors declare that they have no competing interests

Funding

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Authors' contributions

FYP and SWT were responsible for conception and design, publication screening, acquisition of data, analysis and interpretation, and drafting and revising the manuscript. HHM and TFAC were initial analysis and prepared tables. TWH and KCH prepared figures. CFC and WMC were responsible for reviewing and revising the manuscript. All authors were involved with interpretation of the data. All authors discussed the results and commented on the manuscript. The author(s) read and approved the final manuscript.

Acknowledgements

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Authors' information

¹Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan; ²Department of Orthopaedics, School of Medicine, National Yang-Ming University, Taipei, Taiwan; ³Chang Gung University College of Medicine, Taoyuan, Taiwan; ⁴Department of Orthopaedic Surgery, Chang-Gung Memorial Hospital, Chiayi, Taiwan

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Sanders RJ, Swierstra BA, Goosen JH. The use of a dual-mobility concept in total hip arthroplasty patients with spastic disorders: no dislocations in a series of ten cases at midterm follow-up. Arch Orthop Trauma Surg. 2013;133(7):1011-6.
Prudhon JL, Ferreira A, Verdier R. Dual mobility cup: dislocation rate and survivorship at ten years of follow-up. International orthopaedics. 2013;37(12):2345-50.
Hamadouche M, Arnould H, Bouxin B. Is a cementless dual mobility socket in primary THA a reasonable option? Clinical orthopaedics and related research. 2012;470(11):3048-53.
Hailer NP, Weiss RJ, Stark A, Karrholm J. Dual-mobility cups for revision due to instability are associated with a low rate of re-revisions due to dislocation: 228 patients from the Swedish Hip Arthroplasty Register. Acta Orthop. 2012;83(6):566-71.
Civinini R, Carulli C, Matassi F, Nistri L, Innocenti M. A dual-mobility cup reduces risk of dislocation in isolated acetabular revisions. Clinical orthopaedics and related research. 2012;470(12):3542-8.
Adam P, Philippe R, Ehlinger M, Roche O, Bonnomet F, Mole D, et al. Dual mobility cups hip arthroplasty as a treatment for displaced fracture of the femoral neck in the elderly. A prospective, systematic, multicenter study with specific focus on postoperative dislocation. Orthopaedics & traumatology, surgery & research : OTSR. 2012;98(3):296-300.
Schneider L, Philippot R, Boyer B, Farizon F. Revision total hip arthroplasty using a reconstruction cage device and a cemented dual mobility cup. Orthopaedics & traumatology, surgery & research : OTSR. 2011;97(8):807-13.
Bouchet R, Mercier N, Saragaglia D. Posterior approach and dislocation rate: a 213 total hip replacements case-control study comparing the dual mobility cup with a conventional 28-mm metal head/polyethylene prosthesis. Orthopaedics & traumatology, surgery & research : OTSR. 2011;97(1):2-7.
Tarasevicius S, Busevicius M, Robertsson O, Wingstrand H. Dual mobility cup reduces dislocation rate after arthroplasty for femoral neck fracture. BMC Musculoskelet Disord. 2010;11:175.
Hamadouche M, Biau DJ, Huten D, Musset T, Gaucher F. The use of a cemented dual mobility socket to treat recurrent dislocation. Clinical orthopaedics and related research. 2010;468(12):3248-54.
Guyen O, Pibarot V, Vaz G, Chevillotte C, Bejui-Hugues J. Use of a dual mobility socket to manage total hip arthroplasty instability. Clinical orthopaedics and related research. 2009;467(2):465-72.
Langlais FL, Ropars M, Gaucher F, Musset T, Chaix O. Dual mobility cemented cups have low dislocation rates in THA revisions. Clinical orthopaedics and related research. 2008;466(2):389-95.
Goldman AH, Thompson JC, Berry DJ, Sierra RJ. Tripolar Articulations as a "High Stability Bearing" for Revision Total Hip Arthroplasty: Success Rates and Risk Factors for Failure. J Arthroplasty. 2020.
Bauchu P, Bonnard O, Cypres A, Fiquet A, Girardin P, Noyer D. The dual-mobility POLARCUP: first results from a multicenter study. Orthopedics. 2008;31(12 Suppl 2).
Pattyn C, Audenaert E. Early complications after revision total hip arthroplasty with cemented dual-mobility socket and reinforcement ring. Acta Orthop Belg. 2012;78(3):357-61.
Vasukutty NL, Middleton RG, Matthews EC, Young PS, Uzoigwe CE, Minhas TH. The double-mobility acetabular component in revision total hip replacement: the United Kingdom experience. The Journal of bone and joint surgery British volume. 2012;94(5):603-8.
Snir N, Park BK, Garofolo G, Marwin SE. Revision of Failed Hip Resurfacing and Large Metal-on-Metal Total Hip Arthroplasty Using Dual-Mobility Components. Orthopedics. 2015;38(6):369-74.
Gaudin G, Ferreira A, Gaillard R, Prudhon JL, Caton JH, Lustig S. Equivalent wear performance of dual mobility bearing compared with standard bearing in total hip arthroplasty: in vitro study. International orthopaedics. 2017;41(3):521-7.
Geringer J, Boyer B, Farizon F. Understanding the dual mobility concept for total hip arthroplasty. Investigations on a multiscale analysis-highlighting the role of arthrofibrosis. Wear. 2011;271(9):2379-85.
Imbert L, Geringer J, Boyer B, Farizon F. Wear analysis of hip explants, dual mobility concept: Comparison of quantitative and qualitative analyses. Proceedings of the Institution of Mechanical Engineers, Part J: Journal of Engineering Tribology. 2012;226(10):838-53.
Boyer B, Neri T, Geringer J, Di Iorio A, Philippot R, Farizon F. Long-term wear of dual mobility total hip replacement cups: explant study. International orthopaedics. 2018;42(1):41-7.
Boyer B, Neri T, Geringer J, Di Iorio A, Philippot R, Farizon F. Understanding wear in dual mobility total hip replacement: first generation explant wear patterns. International orthopaedics. 2017;41(3):529-33.
Boyer B, Neri T, Di Iorio A, Geringer J, Philippot R, Farizon F. The linear penetration rate is not relevant for evaluating wear of dual mobility cups: an explant study. International orthopaedics. 2017;41(3):599-603.
Loving L, Herrera L, Banerjee S, Heffernan C, Nevelos J, Markel DC, et al. Dual mobility bearings withstand loading from steeper cup-inclinations without substantial wear. J Orthop Res. 2015;33(3):398-404.
Callary SA, Solomon LB, Holubowycz OT, Campbell DG, Munn Z, Howie DW. Wear of highly crosslinked polyethylene acetabular components. Acta Orthop. 2015;86(2):159-68.
Deckard ER, Azzam KA, Meneghini RM. Contemporary Dual Mobility Head Penetration at Five Years: Concern for the Additional Convex Bearing Surface? J Arthroplasty. 2018;33(7S):S280-S4.
Australian Orthopaedic Association National Joint Replacement Registry. Annual report 2019. 2019;https://aoanjrr.sahmri.com/annual-reports-2019 Accessed September 13, 2020.
National Joint Registry for England W, Northern Ireland, and the Isle of Man. National Joint Registry for England, Wales, Northern Ireland, and the Isle of Man 16th annual report, 2019. 2019;https://reports.njrcentre.org.uk/downloads Accessed September 13, 2020.
Tarity TD, Koch CN, Burket JC, Wright TM, Westrich GH. Fretting and Corrosion at the Backside of Modular Cobalt Chromium Acetabular Inserts: A Retrieval Analysis. J Arthroplasty. 2017;32(3):1033-9.
Hothi HS, Ilo K, Whittaker RK, Eskelinen A, Skinner JA, Hart AJ. Corrosion of Metal Modular Cup Liners. J Arthroplasty. 2015;30(9):1652-6.
Kolz JM, Wyles CC, Van Citters DW, Chapman RM, Trousdale RT, Berry DJ. In Vivo Corrosion of Modular Dual-Mobility Implants: A Retrieval Study. J Arthroplasty. 2020.
Wiley KF, Ding K, Stoner JA, Teague DC, Yousuf KM. Incidence of pseudotumor and acute lymphocytic vasculitis associated lesion (ALVAL) reactions in metal-on-metal hip articulations: a meta-analysis. J Arthroplasty. 2013;28(7):1238-45.
Matsen Ko LJ, Pollag KE, Yoo JY, Sharkey PF. Serum Metal Ion Levels Following Total Hip Arthroplasty With Modular Dual Mobility Components. J Arthroplasty. 2016;31(1):186-9.
D'Apuzzo MR, Koch CN, Esposito CI, Elpers ME, Wright TM, Westrich GH. Assessment of Damage on a Dual Mobility Acetabular System. J Arthroplasty. 2016;31(8):1828-35.
Neri T, Boyer B, Geringer J, Di Iorio A, Caton JH, PhiIippot R, et al. Intraprosthetic dislocation of dual mobility total hip arthroplasty: still occurring? International orthopaedics. 2019;43(5):1097-105.
De Martino I, D'Apolito R, Waddell BS, McLawhorn AS, Sculco PK, Sculco TP. Early intraprosthetic dislocation in dual-mobility implants: a systematic review. Arthroplast Today. 2017;3(3):197-202.
Evans JT, Evans JP, Walker RW, Blom AW, Whitehouse MR, Sayers A. How long does a hip replacement last? A systematic review and meta-analysis of case series and national registry reports with more than 15 years of follow-up. Lancet. 2019;393(10172):647-54.
Van Eecke E, Vanbiervliet J, Dauwe J, Mulier M. Comparison of Constrained Acetabular Components and Dual Mobility Cups in Revision Total Hip Arthroplasty: A Literature Review. Hip Pelvis. 2020;32(2):59-69.
Wright EA, Katz JN, Baron JA, Wright RJ, Malchau H, Mahomed N, et al. Risk factors for revision of primary total hip replacement: results from a national case-control study. Arthritis Care Res (Hoboken). 2012;64(12):1879-85.
Prokopetz JJ, Losina E, Bliss RL, Wright J, Baron JA, Katz JN. Risk factors for revision of primary total hip arthroplasty: a systematic review. BMC Musculoskelet Disord. 2012;13:251.
Inacio MC, Ake CF, Paxton EW, Khatod M, Wang C, Gross TP, et al. Sex and risk of hip implant failure: assessing total hip arthroplasty outcomes in the United States. JAMA Intern Med. 2013;173(6):435-41.
Karachalios T, Komnos G, Koutalos A. Total hip arthroplasty: Survival and modes of failure. EFORT Open Rev. 2018;3(5):232-9.

Table 1 Characteristics of included studies

Author, Year

Study design

No. of THA procedure

Indications

Mean age(yrs)

Follow up duration (m)

Implant type

2020 Tabori-jensen

Prospective series

Primary

2020 Schmidt

Retrospective series

184

Revision

2, 3

2020 Rashed

Prospective series

Primary

66.4

2020 Nessler

Retrospective series

Primary

65.5

32.4

2020 Laende

Retrospective series

Primary

2020 Klemt

Retrospective series

Revision

1, 5, 6, 10, 13

2020 Hoggett

Retrospective series

Recurrent dislocation

3, 7

2020 Favreau

Retrospective series

Revision

2020 Dubin

Retrospective series

664

Primary

61.7

5, 6

2020 Dubin (Arthroplasty Today)

Retrospective series

142

Primary

68.4

2020 de l’Escalopier

Retrospective series

Revision

65.3

8, 9

2020 Colacchio

Retrospective series

Revision

61.4

6, 10

2020 Civinini

Retrospective series

Revision

63.7

61.2

2020 Ait Mokhtar

Retrospective series

148

Primary

2020 Abdel

Retrospective series

126

Revision

43.2

2019 Ukaj

Prospective series

Primary

78.1

2019 Tabori-jensen, Arch

Retrospective series

997

Primary

80.5

64.8

1, 11

2019 Schmidt-braekling

Retrospective series

Revision

68.5

63.6

1, 4

2019 Nonne

Retrospective series

Primary

87.6

28.3

2019 Neil Wheelton

Retrospective series

Revision

22.8

2019 Nam

Prospective series

Primary

52.6

2019 Markel

Prospective series

Primary

61.7

2019 Li

Retrospective series

Revision

63.6

37.8

2019 Kreipke

Retrospective series

2277

Primary

75.5

35.9

1, 11, 13

2019 Jones

Retrospective series

151

Primary

43.2

2019 Jobory

Retrospective series

4520

Primary

25.2

1, 11, 13

2019 Iorio

Retrospective series

Primary

2019 Huang

Retrospective series

315

Revision

65.8

39.6

2019 Huang

Retrospective series

107

Recurrent dislocation

65.8

39.6

2019 Gaillard

Retrospective series

138

Primary

152.4

2019 Fessy

Retrospective series

541

Primary

73.6

103.2

2019 Fahad

Retrospective series

Primary

69.3

2019 Dubin

Retrospective series

287

Primary

67.8

34.3

2019 Dubin

Retrospective series

287

Primary

67.9

34.3

2019 Dikmen

Prospective series

Revision

66.1

42.24

2019 Cypres

Retrospective series

244

Primary

63.8

142.8

2019 Chalmers

Retrospective series

Revision

2019 Canton

Retrospective series

Primary

76.7

67.2

2019 Boulat

Retrospective series

Primary

2019 Bloemheuvel

Retrospective series

3038

Primary

1, 2, 11, 13, 14

2019 Bloemheuvel

Retrospective series

4637

Revision

1, 2, 11, 13, 14

2019 Assi
(J Arthroplasty)

Retrospective series

125

Primary

78.1

61.2

1, 2

2019 Assi
(Int Orthop)

Retrospective series

Revision

69.2

72.9

2019 Assi
(Hip Int.)

Retrospective series

229

Primary

1, 2

2019 Addona

Retrospective series

107

Primary

5; 15

2019 Addona

Retrospective series

Revision

5; 15

2018 Tabori-Jensen

Retrospective series

124

Primary

74.7

33.6

2018 Stucinskas

Retrospective series

247

Revision

1; 2

2018 Spaans

Retrospective series

102

Recurrent dislocation

73.1

27.6

2018 Rashed

Prospective series

Primary

66.4

2018 Perrin

Prospective series

Revision

79.5

2018 Ozden

Retrospective series

Revision

64.5

38.1

2018 Marie-hardy

Retrospective series

Primary

69.6

2018 Lange

Retrospective series

Recurrent dislocation

5; 6

2018 Kim

Retrospective series

Primary

73.1

21.7

2018 Kavcic

Retrospective series

173

Primary

76.8

92.4

2018 Kasparek

Retrospective series

Revision

5; 6

2018 Hwang

Prospective series

167

Primary

2018 Harwin

Retrospective series

Revision

2018 Hartzler

Retrospective series

126

Revision

2018 Diamond

Retrospective series

Revision

65.5

38.6

2018 Chalmers

Retrospective series

Recurrent dislocation

2018 Boukebous

Retrospective series

Primary

77.8

25.9

16, 17

2018 Assi

Retrospective series

Primary

54.9

1; 2; 19

2017 Viste

Retrospective series

334

Revision

2017 Tarasevicius

Retrospective series

620

Revision

63.2

1; 2

2017 Sutter

Retrospective series

Revision

2017 Rowan

Retrospective series

136

Primary

48.5

38.4

5; 6

2017 Puch

Prospective series

103

Primary

49.9

132

2017 Puch

Prospective series

217

Primary

72.3

149

2017 Ochi

Retrospective series

Primary

15.8

2017 Nam

Prospective series

Primary

52.8

2017 Martz

Retrospective series

Primary

129.8

2017 Lebeau

Retrospective series

Revision

75.5

2 (1st-gen)

2017 Hernigou

Retrospective series

Revision

2, 21

2017 Henawy

Prospective series

Primary

2017 Hamadouche

Retrospective series

Revision

71.4

2017 Graversen

Retrospective series

Primary

2017 Gonzalez

Prospective series

150

Revision

13; 22

2017 Ferreira

Retrospective series

553

Primary

71.2

2017 Ferreira

Retrospective series

Primary

81.7

2017 Epinette

Retrospective series

321

Primary

48.1

32.4

5, 6

2017 Chalmers

Retrospective series

Revision

2017 Batailler

Retrospective series

302

Primary

2, 23

2016 Nich

Retrospective series

Primary

86.7

23.8

6; 24

2016 Morin

Retrospective series

Primary

19.2

2016 Jauregui

Retrospective series

Revision

2016 Homma

Retrospective series

Primary

75.6

5; 6

2016 Haughom

Retrospective series

Primary

50.2

2016 Griffin

Prospective series

Primary

>60

2016 Chughtai

Retrospective series

410

Primary

2016 Carulli

Retrospective series

Recurrent dislocation

75.4

45.6

2015 Wegrzyn

Retrospective series

994

Revision

87.6

2015 Vigdorchik

Retrospective series

485

Primary

2015 Vermersch

Prospective series

Primary

2015 van Heumen

Retrospective series

Recurrent dislocation

2015 Snir

Retrospective series

Revision

50.6

26.5

5; 6; 10

2015 Simian

Retrospective series

Revision

67.9

87.6

17; 18; 25

2015 Mohammed

Retrospective series

Primary

70.8

2015 Mohammed

Retrospective series

Revision

76.4

2015 Epinette

Prospective series

143

Primary

70.6

2015 Bel

Retrospective series

Primary

2014 Wegrzyn

Prospective series

Revision

2014 Prudhon

Prospective series

Revision

62.5

2014 Jakobsen

Retrospective series

Recurrent dislocation

2014 Epinette

Prospective series

437

Primary

74.2

2014 Caton

Retrospective series

105

Primary

120

2014 Bensen

Retrospective series

175

Primary

75.2

21.7

2013 Tarasevicius

Retrospective series

Primary

2013 Saragaglia

Retrospective series

Recurrent dislocation

75.6

1; 3; 20; 24

2013 Sanders

Retrospective series

Primary

2013 Prudhon

Retrospective series

105

Primary

2012 Vasukutty

Retrospective series

143

Revision

2012 Pattyn

Retrospective series

Revision

2012 Hamadouche

Retrospective series

119

Primary

2012 Hailer

Retrospective series

228

Recurrent dislocation

2012 Civinini

Prospective series

Revision

2012 Adam

Prospective series

214

Primary

2011 Schneider

Retrospective series

Revision

69.9

2011 Bouchet

Retrospective series

105

Primary

76.6

1; 3; 20; 24

2010 Tarasevicius

Retrospective series

Primary

2010 Hamadouche

Retrospective series

Recurrent dislocation

71.3

51.4

2009 Guyen

Retrospective series

Recurrent dislocation

66.5

2008 Langlais

Retrospective series

Revision

2008 Bauchu

Retrospective series

121

Primary

74.4

A: aseptic loosening; B; septic loosening or PJI; C: extra-dislocation; D: Intra-dislocation; E: Periprosthetic fracture; F: implant failure; G; HHS; H: Merle D’Aubigne scores

1: Avantage (Zimmer Biomet, Warsaw, Indiana, USA); 2: Quattro (Groupe Lépine, Genay, France ); 3. Novae cup or Novae Sunfit cup (Serf, Décines, France); 4. EcoFit 2M cup (Ecofit, implantcast, Buxtehude, Germany); 5. Stryker MDM (Stryker, Mahwah, New Jersey, USA); 6. Stryker ADM (Stryker, Mahwah, New Jersey, USA); 7. ADES (Zimmer Biomet, Warsaw, Indiana, USA); 8. Medial cup (Aston Medical, Saint-Étienne, France); 9. Tregor cup (Aston Medical, Saint-Étienne, France); 10. Biomet Active Articulation E1 (Biomet Orthopedics, Warsaw, Indiana, USA); 11. Saturne (Amplitude, Valence, France); 12. Dualis acetabular cup(Gruppo Bioimpianti, Peschiera Borromeo, Milano, Italy); 13. Polarcup (Smith & Nephew AG, Aarau, Switzerland); 14. SeleXys DS cup (Mathys European Orthopaedics, Bettlach, Switzerland); 15. G7 DM (Zimmer Biomet, Warsaw, Indiana, USA); 16. Galiléa (SEM, Créteil, France); 17. Evora (SEM, Créteil, France); 18. DMS (SEM, Créteil, France); 19. Hip’n Go dual mobility (FH orthopedics, Mulhouse, France); 20. Gyros cup (Depuy, Warsaw, IN, USA); 21. Ceraver DM device (Ceraver Osteal, Roissy, France); 22. Versafit DM cup (Medacata international, Castel San Pietro, Switzerland); 23. Tornier DM cup (Tornier, Montbonnot-Saint-Martin, France); 24. Stafit (Zimmer, Etupes, France); 25. Mobilite (Tornier, Montbonnot-Saint-Martin, France); 26. Apogee DM socket (Biotechni Inc., Marseille, France)

Table 2. Study Assessment based on Quality Assessment Tool for Case Series Studies.

Criteria	2020 Tabori-jensen et al.	2020 Schmidt et al.	2020 Rashed et al.	2020 Nessler et al.	2020 Laende et al.	2020 Klemt et al	2020 Hoggett et al.	2020 Favreau et al.	2020 Dubin et al.	2020 Dubin (Arthroplasty Today) et al.
1. Was the study question or objective clearly stated?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
2. Was the study population clearly and fully described, including a case definition?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
3. Were the cases consecutive?	N	Y	N	N	Y	Y	Y	N	N	N
4. Were the subjects comparable?	Y	Y	Y	N	N	Y	Y	N	Y	N
5. Was the intervention clearly described?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
6. Were the outcome measures clearly defined, valid, reliable and implemented consistently across all study participants?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
7. Was the length of follow-up adequate?	Y	Y	N	Y	Y	Y	Y	Y	Y	Y
8. Were the statistical methods well-described?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
9. Were the results well-described?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
Quality of the cohort study (score)	8	9	7	7	8	9	9	7	8	7

Y= Yes, N= No; The maximum possible score on this scale is 9. “Good” was defined as a total score of 7-9; “fair” as a score 4-6, and “poor” as a score of less than 4.

Criteria	2020 de l’Escalopier et al.	2020 Colacchio et al.	2020 Civinini et al.	2020 Ait Mokhtar et al	2020 Abdel et al	2019 Ukaj et al.	2019 Tabori-jensen et al.	2019 Schmidt-braekling et al.	2019 Nonne et al.
1. Was the study question or objective clearly stated?	Y	Y	Y	Y	Y	Y	Y	Y	Y
2. Was the study population clearly and fully described, including a case definition?	Y	Y	Y	Y	Y	Y	Y	Y	Y
3. Were the cases consecutive?	Y	N	N	Y	N	N	Y	Y	N
4. Were the subjects comparable?	N	N	N	N	Y	Y	N	N	Y
5. Was the intervention clearly described?	Y	Y	Y	Y	Y	Y	Y	Y	Y
6. Were the outcome measures clearly defined, valid, reliable and implemented consistently across all study participants?	Y	Y	Y	Y	Y	Y	Y	Y	Y
7. Was the length of follow-up adequate?	Y	Y	Y	Y	Y	Y	Y	Y	Y
8. Were the statistical methods well-described?	Y	Y	Y	N	N	Y	Y	Y	Y
9. Were the results well-described?	Y	Y	Y	Y	Y	Y	Y	Y	Y
Quality of the cohort study (score)	8	7	7	7	7	8	8	8	8

Y= Yes, N= No; The maximum possible score on this scale is 9. “Good” was defined as a total score of 7-9; “fair” as a score 4-6, and “poor” as a score of less than 4.

Criteria	2019 Neil Wheelton et al.	2019 Nam et al.	2019 Markel et al.	2019 Li et al.	2019 Kreipke et al.	2019 Jones et al.	2019 Jobory et al.	2019 Iorio et al.	2019 Huang et al.	2019 Gaillard et al.	2019 Fessy et al.
1. Was the study question or objective clearly stated?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
2. Was the study population clearly and fully described, including a case definition?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
3. Were the cases consecutive?	Y	N	N	Y	N	Y	N	N	Y	Y	Y
4. Were the subjects comparable?	N	N	N	Y	Y	N	Y	Y	N	N	N
5. Was the intervention clearly described?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
6. Were the outcome measures clearly defined, valid, reliable and implemented consistently across all study participants?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
7. Was the length of follow-up adequate?	N	Y	Y	Y	Y	Y	Y	N	Y	Y	Y
8. Were the statistical methods well-described?	N	Y	Y	Y	Y	N	Y	Y	Y	Y	Y
9. Were the results well-described?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
Quality of the cohort study (score)	6	7	7	9	8	7	8	7	8	8	8

Y= Yes, N= No; The maximum possible score on this scale is 9. “Good” was defined as a total score of 7-9; “fair” as a score 4-6, and “poor” as a score of less than 4.

Criteria	2019 Fahad et al.	2019 Dubin et al.	2019 Dikmen et al.	2019 Cypres et al.	2019 Chalmers et al.	2019 Canton et al.	2019 Boulat et al.	2019 Bloemheuvel et al.	2019 Assi (J Arthroplasty) et al.	2019 Assi (Int Orthop) et al.
1. Was the study question or objective clearly stated?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
2. Was the study population clearly and fully described, including a case definition?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
3. Were the cases consecutive?	N	N	Y	N	N	N	N	N	N	N
4. Were the subjects comparable?	Y	Y	N	N	N	N	N	Y	N	Y
5. Was the intervention clearly described?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
6. Were the outcome measures clearly defined, valid, reliable and implemented consistently across all study participants?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
7. Was the length of follow-up adequate?	N	Y	Y	Y	Y	Y	Y	Y	Y	Y
8. Were the statistical methods well-described?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
9. Were the results well-described?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
Quality of the cohort study (score)	7	8	8	7	7	7	7	8	7	8

Y= Yes, N= No; The maximum possible score on this scale is 9. “Good” was defined as a total score of 7-9; “fair” as a score 4-6, and “poor” as a score of less than 4

Criteria	2019 Assi (Hip Int.) et al.	2019 Addona et al.	2018 Tabori-Jensen et al.	2018 Stucinskas et al.	2018 Spaans et al.	2018 Rashed et al.	2018 Perrin et al.	2018 Ozden et al.	2018 Marie-hardy et al.	2018 Lange et al.	2018 Kim et al.
1. Was the study question or objective clearly stated?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
2. Was the study population clearly and fully described, including a case definition?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
3. Were the cases consecutive?	N	Y	Y	N	N	N	N	Y	Y	N	Y
4. Were the subjects comparable?	N	N	Y	Y	Y	N	Y	N	N	N	Y
5. Was the intervention clearly described?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
6. Were the outcome measures clearly defined, valid, reliable and implemented consistently across all study participants?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
7. Was the length of follow-up adequate?	Y	N	Y	Y	Y	N	N	Y	Y	Y	N
8. Were the statistical methods well-described?	Y	N	Y	Y	Y	Y	Y	Y	N	Y	Y
9. Were the results well-described?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
Quality of the cohort study (score)	7	6	9	8	8	6	7	8	7	7	8

Y= Yes, N= No; The maximum possible score on this scale is 9. “Good” was defined as a total score of 7-9; “fair” as a score 4-6, and “poor” as a score of less than 4

Criteria

2018 Kavcic
et al.

2018 Kasparek
et al.

2018 Hwang
et al.

2018 Harwin
et al.

2018 Hartzler
et al.

2018 Diamond
et al.

2018 Chalmers
et al.

2018 Boukebous
et al.

2018 Assi
et al.

2017 Viste
et al.

2017 Tarasevicius
et al.

2017 Sutter
et al.

1. Was the study question or objective clearly stated?

2. Was the study population clearly and fully described, including a case definition?

3. Were the cases consecutive?

4. Were the subjects comparable?

5. Was the intervention clearly described?

6. Were the outcome measures clearly defined, valid, reliable and implemented consistently across all study participants?

7. Was the length of follow-up adequate?

8. Were the statistical methods well-described?

9. Were the results well-described?

Quality of the cohort study (score)

Y= Yes, N= No; The maximum possible score on this scale is 9. “Good” was defined as a total score of 7-9; “fair” as a score 4-6, and “poor” as a score of less than 4

Criteria	2017 Rowan et al.	2017 Puch et al.	2017 Ochi et al.	2017 Nam et al.	2017 Martz et al.	2017 Lebeau et al.	2017 Hernigou et al.	2017 Henawy et al.	2017 Hamadouche et al.	2017 Graversen et al.	2017 Gonzalez et al.
1. Was the study question or objective clearly stated?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
2. Was the study population clearly and fully described, including a case definition?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
3. Were the cases consecutive?	N	Y	N	N	N	N	N	Y	N	N	Y
4. Were the subjects comparable?	Y	N	Y	N	N	N	Y	N	N	N	Y
5. Was the intervention clearly described?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
6. Were the outcome measures clearly defined, valid, reliable and implemented consistently across all study participants?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
7. Was the length of follow-up adequate?	Y	Y	N	N	Y	Y	Y	N	Y	N	Y
8. Were the statistical methods well-described?	Y	Y	Y	Y	Y	Y	Y	N	Y	Y	Y
9. Were the results well-described?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
Quality of the cohort study (score)	8	8	7	6	7	7	8	6	7	6	9

Y= Yes, N= No; The maximum possible score on this scale is 9. “Good” was defined as a total score of 7-9; “fair” as a score 4-6, and “poor” as a score of less than 4

Criteria

2017 Ferreira
et al.

2017 Epinette
et al.

2017 Chalmers
et al.

2017 Batailler
et al.

2016 Nich
et al.

2016 Morin
et al.

2016 Jauregui
et al.

2016 Homma
et al.

2016 Haughom
et al.

2016 Griffin
et al.

2016 Chughtai
et al.

2016 Carulli
et al.

1. Was the study question or objective clearly stated?

2. Was the study population clearly and fully described, including a case definition?

3. Were the cases consecutive?

4. Were the subjects comparable?

5. Was the intervention clearly described?

6. Were the outcome measures clearly defined, valid, reliable and implemented consistently across all study participants?

7. Was the length of follow-up adequate?

8. Were the statistical methods well-described?

9. Were the results well-described?

Quality of the cohort study (score)

Y= Yes, N= No; The maximum possible score on this scale is 9. “Good” was defined as a total score of 7-9; “fair” as a score 4-6, and “poor” as a score of less than 4

Criteria	2015 Wegrzyn et al.	2015 Vigdorchik et al.	2015 Vermersch et al.	2015 van Heumen et al.	2015 Snir et al.	2015 Simian et al.	2015 Mohammed et al.	2015 Epinette et al.	2015 Bel et al.	2014 Wegrzyn et al.	2014 Prudhon et al.
1. Was the study question or objective clearly stated?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
2. Was the study population clearly and fully described, including a case definition?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
3. Were the cases consecutive?	N	N	Y	Y	Y	N	N	N	Y	N	Y
4. Were the subjects comparable?	N	N	N	N	N	N	N	Y	Y	N	N
5. Was the intervention clearly described?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
6. Were the outcome measures clearly defined, valid, reliable and implemented consistently across all study participants?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
7. Was the length of follow-up adequate?	Y	Y	Y	Y	N	Y	N	Y	Y	Y	Y
8. Were the statistical methods well-described?	N	Y	Y	Y	N	Y	N	Y	Y	Y	Y
9. Were the results well-described?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
Quality of the cohort study (score)	6	7	8	8	6	7	5	8	9	7	8

Y= Yes, N= No; The maximum possible score on this scale is 9. “Good” was defined as a total score of 7-9; “fair” as a score 4-6, and “poor” as a score of less than 4

Criteria	2014 Jakobsen et al.	2014 Epinette et al.	2014 Caton et al.	2014 Bensen et al.	2013 Tarasevicius et al.	2013 Saragaglia et al.	2013 Sanders et al.	2013 Prudhon et al.	2012 Vasukutty et al.	2012 Pattyn et al.
1. Was the study question or objective clearly stated?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
2. Was the study population clearly and fully described, including a case definition?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
3. Were the cases consecutive?	Y	Y	Y	Y	N	N	Y	Y	Y	N
4. Were the subjects comparable?	N	Y	Y	Y	Y	N	N	N	N	N
5. Was the intervention clearly described?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
6. Were the outcome measures clearly defined, valid, reliable and implemented consistently across all study participants?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
7. Was the length of follow-up adequate?	Y	Y	Y	Y	N	Y	Y	Y	Y	N
8. Were the statistical methods well-described?	Y	Y	Y	Y	Y	N	Y	Y	Y	N
9. Were the results well-described?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
Quality of the cohort study (score)	8	9	9	9	7	6	8	8	8	5

Y= Yes, N= No; The maximum possible score on this scale is 9. “Good” was defined as a total score of 7-9; “fair” as a score 4-6, and “poor” as a score of less than 4

Criteria	2012 Hamadouche et al.	2012 Hailer et al.	2012 Civinini et al.	2012 Adam et al.	2011 Schneider et al.	2011 Bouchet et al.	2010 Tarasevicius et al.	2010 Hamadouche et al.	2009 Guyen et al.	2008 Langlais et al.	2008 Bauchu et al.
1. Was the study question or objective clearly stated?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
2. Was the study population clearly and fully described, including a case definition?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
3. Were the cases consecutive?	N	N	N	N	N	Y	Y	N	N	N	Y
4. Were the subjects comparable?	N	N	N	N	N	Y	Y	N	N	N	N
5. Was the intervention clearly described?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
6. Were the outcome measures clearly defined, valid, reliable and implemented consistently across all study participants?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
7. Was the length of follow-up adequate?	Y	Y	Y	N	Y	Y	N	Y	Y	Y	Y
8. Were the statistical methods well-described?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	N
9. Were the results well-described?	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
Quality of the cohort study (score)	7	7	7	6	7	9	8	7	7	7	7

Y= Yes, N= No; The maximum possible score on this scale is 9. “Good” was defined as a total score of 7-9; “fair” as a score 4-6, and “poor” as a score of less than 4

Table 3 Pooled event rate and clinical performance stratified by indications.

Rate or Mean Value

95% CI

Aseptic loosening

Primary THA

Revision THA

Recurrent dislocation

Overall

0.009

0.022

0.024

0.016

0.007-0.012

0.016-0.030

0.013-0.045

0.008-0.032

Septic loosening

Primary THA

Revision THA

Recurrent dislocation

Overall

0.008

0.023

0.025

0.016

0.006-0.011

0.017-0.032

0.013-0.049

0.007-0.037

Extra-articular dislocation

Primary THA

Revision THA

Recurrent dislocation

Overall

0.006

0.013

0.025

0.012

0.005-0.008

0.009-0.017

0.014-0.043

0.006-0.025

Intra-prosthetic dislocation

Primary THA

Revision THA

Recurrent dislocation

Overall

0.008

0.010

0.016

0.010

0.006-0.010

0.007-0.015

0.008-0.031

0.007-0.015

Periprosthetic fracture

Primary THA

Revision THA

Recurrent dislocation

Overall

0.009

0.013

0.009

0.007-0.011

0.006-0.012

0.006-0.025

0.008-0.011

Implant failure

Primary THA

Revision THA

Recurrent dislocation

Overall

0.023

0.055

0.060

0.042

0.018-0.030

0.042-0.073

0.034-0.103

0.021-0.081

Harris Hip score

Primary THA

Revision THA

Recurrent dislocation

Overall

89.47

81.89

82.65

84.87

87.62-91.33

78.96-84.83

77.41-87.89

78.99-90.76

Merle d’Aubigné score

Primary THA

Revision THA

Recurrent dislocation

Overall

17.08

15.45

16.57

16.36

16.85-17.30

15.07-15.83

15.85-17.28

15.20-17.53

THA: total hip arthroplasty.

Table 4 Multivariate Linear Regression Analysis.

Independent Variable

-Coefficient

95% Confidence Interval

P Value

Aseptic loosening

Age

Female Sex

Posterolateral approach (ref to others)

BMI

Indication (ref to primary THA)

Revision THA

Recurrent dislocation

-0.02

0.55

0.18

-0.07

1.30

1.18

-0.05 – 0.01

-2.08– 3.17

-0.59 – 0.94

-0.19 – 0.06

0.71 – 1.89

0.26 – 2.10

0.269

0.683

0.654

0.302

<0.001

0.012

Septic loosening

Age

Female Sex

Posterolateral approach (ref to others)

BMI

Indication (ref to primary THA)

Revision THA

Recurrent dislocation

-0.02

1.39

0.34

-0.09

1.85

1.40

-0.05 – 0.01

-1.54 – 4.32

-0.42 – 1.10

-0.20 – 0.02

1.26– 2.44

0.45 – 2.36

0.226

0.353

0.384

0.125

<0.001

0.004

Extra-articular dislocation

Age

Female Sex

Posterolateral approach (ref to others)

BMI

Indication (ref to primary THA)

Revision THA

Recurrent dislocation

0.01

1.18

-0.39

-0.10

1.02

0.78

-0.03 – 0.05

-1.82 – 4.18

-1.20 – 0.41

-0.24 – 0.03

0.30 – 1.73

-0.49 – 2.04

0.741

0.440

0.338

0.126

0.006

0.230

Intra-prosthetic dislocation

Age

Female Sex

Posterolateral approach (ref to others)

BMI

Indication (ref to primary THA)

Revision THA

Recurrent dislocation

0.00

1.30

-0.31

-0.05

0.52

0.88

-0.05 – 0.04

-2.04 – 4.64

-1.19 – 0.56

-0.18 – 0.08

-0.24 – 1.28

-0.19 – 1.94

0.829

0.444

0.482

0.473

0.180

0.107

Periprosthetic fracture

Age

Female Sex

Posterolateral approach (ref to others)

BMI

Indication (ref to primary THA)

Revision THA

Recurrent dislocation

-0.02

0.81

0.21

-0.07

0.93

0.42

-0.06– 0.02

-2.47 – 4.08

-0.70 – 1.12

-0.22 – 0.08

0.23 – 1.62

-0.93 – 1.77

0.340

0.629

0.651

0.364

0.009

0.542

Implant failure

Age

Female Sex

Posterolateral approach (ref to others)

BMI

Indication (ref to primary THA)

Revision THA

Recurrent dislocation

-0.04

3.34

0.34

-0.06

1.48

1.08

-0.07 – -0.02

0.91 – 5.78

-0.32 – 1.01

-0.16 – 0.05

0.93 – 2.03

0.24 – 1.92

0.002

0.007

0.309

0.273

<0.001

0.012

Harris Hip score

Age

Female Sex

Posterolateral approach (ref to others)

BMI

Indication (ref to primary THA)

Revision THA

Recurrent dislocation

-0.01

3.66

-1.71

0.58

-9.44

-6.81

-0.34 – 0.32

-15.82 – 23.15

-8.11 – 4.69

-0.48 – 1.64

-15.17 – -3.72

-15.42 – 1.80

0.964

0.713

0.601

0.285

0.001

0.121

Merle d’Aubigné score

Age

Female Sex

Posterolateral approach (ref to others)

BMI

Indication (ref to primary THA)

Revision THA

Recurrent dislocation

0.03

-4.10

0. 23

0.14

-0.38

-0.37

-0.03 – 0.09

-8.17 – -0.03

-0.64 – 1.11

-0.03 – 0.31

-1.45 – 0.69

-1.81 – 1.07

0.378

0.049

0.600

0.109

0.487

0.617

BMI: body mass index; ref: reference; THA: total hip arthroplasty

1027FigureS1asepticloosening.jpg
Figure S1. Forest plot of the pooled aseptic loosening rate among included studies.
1027FigureS1asepticloosening.jpg
Figure S1. Forest plot of the pooled aseptic loosening rate among included studies.
1027FigureS1asepticloosening.jpg
Figure S1. Forest plot of the pooled aseptic loosening rate among included studies.
1027FigureS2septicloosening.jpg
Figure S2. Forest plot of the pooled septic loosening rate among included studies.
1027FigureS2septicloosening.jpg
Figure S2. Forest plot of the pooled septic loosening rate among included studies.
1027FigureS2septicloosening.jpg
Figure S2. Forest plot of the pooled septic loosening rate among included studies.
1027FigureS3extradislocation.jpg
Figure S3. Forest plot of the pooled extra-articular dislocation rate among included studies.
1027FigureS3extradislocation.jpg
Figure S3. Forest plot of the pooled extra-articular dislocation rate among included studies.
1027FigureS3extradislocation.jpg
Figure S3. Forest plot of the pooled extra-articular dislocation rate among included studies.
1027FigureS4IPD.jpg
Figure S4. Forest plot of the pooled intra-prosthetic dislocation rate among included studies.
1027FigureS4IPD.jpg
Figure S4. Forest plot of the pooled intra-prosthetic dislocation rate among included studies.
1027FigureS4IPD.jpg
Figure S4. Forest plot of the pooled intra-prosthetic dislocation rate among included studies.
1027FigureS5Periprostheticfx.jpg
Figure S5. Forest plot of the pooled periprosthetic fracture rate among included studies.
1027FigureS5Periprostheticfx.jpg
Figure S5. Forest plot of the pooled periprosthetic fracture rate among included studies.
1027FigureS5Periprostheticfx.jpg
Figure S5. Forest plot of the pooled periprosthetic fracture rate among included studies.
1027FigureS6implantfailure.jpg
Figure S6. Forest plot of the pooled implant failure rate among included studies.
1027FigureS6implantfailure.jpg
Figure S6. Forest plot of the pooled implant failure rate among included studies.
1027FigureS6implantfailure.jpg
Figure S6. Forest plot of the pooled implant failure rate among included studies.
1027FigureS7HHS.jpg
Figure S7. Forest plot of the pooled Harris hip score among included studies.
1027FigureS7HHS.jpg
Figure S7. Forest plot of the pooled Harris hip score among included studies.
1027FigureS7HHS.jpg
Figure S7. Forest plot of the pooled Harris hip score among included studies.
1027FigureS8MerleDAubigne.jpg
Figure S8. Forest plot of the pooled Merle d’Aubigné score among included studies.
1027FigureS8MerleDAubigne.jpg
Figure S8. Forest plot of the pooled Merle d’Aubigné score among included studies.
1027FigureS8MerleDAubigne.jpg
Figure S8. Forest plot of the pooled Merle d’Aubigné score among included studies.

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Editorial decision: Major revision
03 Feb, 2021
Reviews received at journal
02 Feb, 2021
Reviewers agreed at journal
19 Jan, 2021
Reviews received at journal
28 Dec, 2020
Reviewers agreed at journal
12 Dec, 2020
Reviewers invited by journal
22 Nov, 2020
Editor assigned by journal
20 Nov, 2020
Editor invited by journal
20 Nov, 2020
Submission checks completed at journal
19 Nov, 2020
First submitted to journal
16 Nov, 2020

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Risk Factors and Modes for Implant Failure in the Modern Dual Mobility Implant. A Systematic Review and Meta-analysis

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