Evaluation of short-term clinical and imaging outcomes of porous coated trabecular titanium cup manufactured with electron beam melting technique in primary total hip arthroplasty: prospective study of 236 cases

doi:10.21203/rs.3.rs-2761302/v1

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Research Article

Evaluation of short-term clinical and imaging outcomes of porous coated trabecular titanium cup manufactured with electron beam melting technique in primary total hip arthroplasty: prospective study of 236 cases

https://doi.org/10.21203/rs.3.rs-2761302/v1

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Background

The previous acetabular surface manufacturing technology provides a suitable surface for bone ingrowth into cementless cups, but there were already some literatures reporting failure cases due to sintered titanium beads and titanium fiber mesh. Electron beam melting (EBM) technology has been used in manufacturing trabecular titanium acetabular cups with high porosity, pore size suitable for bone ingrowth, low elastic modulus and high friction coefficient. Objectives We study and evaluate the clinical and imaging outcomes of porous coated trabecular titanium cup manufactured with electron beam melting technique with a relatively large sample, in order to provide evidence-based basis for its clinical application.

Methods

Two hundred and thirty-six patients who underwent primary total hip arthroplasty using porous coated trabecular titanium cup from January 2019 to June 2021 in the Department of Joint Surgery of our hospital were selected. General date, imaging information, functional scores and complications were collected to evaluate the early clinical efficacy of the cup.

Results

All patients were followed up for 17–46 months, with an average of (26.2 ± 9.2) months. At the last follow-up, the preoperative HSS score increased from 43.7 ± 6.8 to 85.6 ± 9.3 points with statistical significance (P < 0.01). The preoperative WOMAC score improved from 59.2 ± 5.8 to13.1 ± 3.5 points, with statistical significance(P < 0.01). 92.3% of patients were satisfied or very satisfied with the clinical outcome. The cup survival rate at the last follow-up was 100%.

Conclusions

It can provide patients with satisfactory short-term clinical and imaging results in primary total hip arthroplasty to use porous coated trabecular titanium cup manufactured by electron beam melting technology based on structural optimization design. The acetabular cup has good initial stability, a high survival rate and good bone ingrowth, which can significantly improve the pain and function of the affected hip.

Arthroplasty

Replacement

Hip

Three-dimensional printing technology

Electron beam melting technology

Porous Titanium Alloy

With the increasing aging population worldwide, the incidence and number of patients with degenerative hip joint disease have been increasing annually, resulting in a corresponding increase in the number of patients undergoing primary total hip arthroplasty (THA) [1, 2]. Compared to the use of cemented acetabular cups in primary THA, non-cemented acetabular cups have achieved good clinical outcomes and long-term survival rates [3, 4]. Although surface treatment techniques for non-cemented acetabular cups, such as plasma spraying, high-temperature sintering, electrophoretic deposition, and micro-arc oxidation sol-gel method, provide suitable surfaces for bone ingrowth, there are also many reports of failures due to loosening of coated beads or coatings [5–7].

Three-dimensional (3D) printing technology as emerged in the past 20 years and is widely used in the field of orthopedic implant manufacturing. This technology uses three-dimensional model data as a basis and applies powdered metal or plastic adhesives to manufacture products with multi-level structures or complex geometric shapes [8]. Electron beam melting (EBM) technology, an important branch of 3D printing technology, can be used to prepare titanium alloy bone beam acetabular cups with high porosity, interconnectivity, appropriate pore size for bone ingrowth, low elastic modulus, and high surface friction coefficient. Studies have shown good bone-inducing and bone-conductive properties in vitro and in animal experiments [5, 9]. Some studies have also reported good short-term clinical and imaging results [10, 11].

However, currently there are relatively few reports in the literature on the use of such titanium alloy bone trabecular cups in initial total hip arthroplasty. Secondly, the sample sizes included in the reports are small, and the follow-up time is short. Therefore, further observation and research are needed on the clinical and imaging results of these relatively short-term titanium alloy bone beam acetabular cups. This study aims to use a relatively large sample size to study and evaluate the clinical and imaging results of the use of titanium alloy bone beam acetabular cups in primary THA, in order to provide evidence-based support for the clinical use of these acetabular cups.

1.1 General Information

This study prospectively collected patients' basic information, laboratory and imaging results, and clinical functional scoring data with patients' informed consent, in accordance with the Helsinki Declaration and approval from the hospital ethics committee (KY2020-015-01). Inclusion criteria: cases that underwent primary total hip arthroplasty (THA) with a 3D-printed porous titanium (Ti6Al4V) acetabular cup manufactured using EBM technology between January 2019 and June 2021 in our hospital. The inclusion criteria also required that the primary hip disease was hip osteoarthritis (HOA), femoral neck fracture (FFN), developmental dysplasia of the hip (DDH), avascular necrosis (AVN), rheumatoid arthritis (RA), ankylosing spondylitis (AS), or coxa valga (CV); and that patients were able to comply with follow-up requirements for outpatient or telephone reviews. Exclusion criteria were: primary hip disease due to infection, tumor, or neurogenic arthropathy; severe lower limb vascular disease, infectious disease, severe dysfunction of major visceral organs, and patients with significant limb movement or sensory impairment due to severe spinal diseases. A total of 251 patients were enrolled in the study. One patient died due to cardiovascular and cerebrovascular accidents during follow-up, and 14 patients were lost to follow-up within one year after surgery. Ultimately, 236 patients (96 males [40.6%] with 96 hips and 140 females [59.4%] with 140 hips) were included in the study. The mean follow-up time was 26.2 months (range: 17–46 months). The mean age of the patients was 57.7 years (range: 32–89 years), and the mean body mass index (BMI) was 23.38 kg/m2 (range: 18.1–27.2 kg/m2). The patients' primary diagnoses included 42 cases (17.8%) of HOA, 65 cases (27.5%) of DDH, 12 cases (5.1%) of RA, 78 cases (33.1%) of AVN, 26 cases (11.0%) of FFN, 7 cases (2.9%) of AS, and 6 cases (2.6%) of CV. The demographic data of the patients are shown in Table 1.

1.2 Surgical procedure and postoperative management:

In this study, 3D-printed ACT porous titanium (Ti6Al4V) bone structure acetabular cups (Aikang, Beijing, China; Fig. 1) were used on the acetabular side in all THA procedures. The cup has a 1.5mm thick porous coating, a porosity of 50–80%, a pore size of 600–800µm, and an interconnected pore structure inside. The average elastic modulus is 0.5–1.3 GPa, similar to that of human cancellous bone, and the coefficient of friction between the cup's rough surface and cancellous bone is 1.08, while that between the cortical bone is 0.93. The cup comes in 16 sizes, with diameters ranging from 40-70mm, with a 2mm difference between each size.

All surgeries were performed by two experienced chief orthopedic surgeons following the standard protocol for THA posterior-lateral approach described in literature [12]. Patients were positioned in a lateral decubitus position, and the incision was made 1-2cm posterior to the greater trochanter and 7-8cm above it, with a length of 10-15cm, bending from the starting point to the greater trochanter, and extending to the femoral shaft. The fascia lata was cut open to expose the tensor fasciae latae, and the gluteus maximus muscle fibers were separated. The piriformis and obturator internus muscles were cut, and the joint capsule was opened. The hip joint was dislocated by flexion and internal rotation. As mentioned earlier, the femoral neck was cut first, and the femoral head was removed. The routine steps of THA were then followed. All acetabular cups were implanted using a 1mm press-fit technique, and hip screws were implanted or not depending on the specific situation and the surgeon's preference. The joint capsule can be sutured or removed if necessary. The cut piriformis and obturator internus muscles were sutured, and the short external rotator muscles were reconstructed. The wound was closed layer by layer. Patients who did not undergo extrarticular osteotomy were not fitted with drainage tubes.

Postoperatively, patients were given diclofenac sodium tablets and intramuscular tramadol or dextromethorphan for pain relief. Other measures, such as sequential antifibrinolysis and anticoagulation, nutritional support, prevention of nausea and vomiting, pain management, and blood management, were carried out according to the recommended guidelines for accelerated rehabilitation after hip and knee arthroplasty [13–16]. On the second day after surgery, pelvic and anteroposterior views of the femoral neck on the affected side were obtained and patients were guided to weight-bearing exercises with the assistance of walking aids.

1.3 Observational Indicators

Prospectively record the clinical and imaging data of patients. Patients are required to have follow-up visits at the outpatient department at 1, 3, 6, and 12 months after surgery, followed by annual follow-up visits thereafter. For patients who cannot come to the outpatient department for follow-up visits, their clinical scores are recorded through telephone follow-up, and X-rays are taken at external hospitals and mailed to the researchers.

1.3.1 Clinical data: This includes patients' general demographic data. We use of the Harris Hip Score (HHS) [17], the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) [18] to evaluate the clinical effects, and a self-assessment questionnaire for satisfaction [19] (divided into five levels: very dissatisfied, dissatisfied, neutral, satisfied, or very satisfied) to assess patients' subjective satisfaction. The occurrence of perioperative and postoperative follow-up complications (nerve damage, deep venous thrombosis, dislocation, periprosthetic infection, periprosthetic fracture, revision, etc.) is recorded.

1.3.2 Imaging evaluation: At the postoperative and discharge follow-up time points, pelvic X-rays and anteroposterior X-rays of the affected femoral neck are taken. The imaging evaluation is independently conducted by a senior orthopedic surgeon who did not participate in the surgery or perioperative management. The imaging evaluation indicators include the following:

(1) Acetabular anteversion angle and inclination angle: On the pelvic X-ray, We measure the acetabular inclination and anteversion angles according to the method described by Lewinnek [20] (as shown in Fig. 2, B and C).

(2) The vertical and horizontal positions of the center of rotation (COR) (as shown in Fig. 2, D): The vertical distance of the COR (COR_ver) is defined as the perpendicular distance from the center of rotation to the tear drop line (b). The horizontal distance of the COR (COR_hor) is defined as the perpendicular distance from the center of rotation to the bottom of the tear drop (a). We compare the distance between the COR on the affected side and the healthy side in cases where the contralateral hip is a normal anatomical structure in order to reflect the recovery of the rotational center of the affected hip.

(3) Cup loosening and bone integration: Evaluate the radiolucent lines on the acetabular side according to the Deele and Charnley zone. Evaluate the stability and bone integration of the acetabular prosthesis during follow-up according to the criteria proposed by Moore et al. at the Anderson Orthopedic Research Center [21]. Acetabular loosening is defined as: the gradual appearance of continuous radiolucent lines around the prosthesis, with a width greater than 2mm; or acetabular prosthesis displacement greater than 5mm or acetabular angle change greater than 5° after surgery. The criteria for acetabular bone integration are: (1) no radiolucent line; (2) bony support zones are observed on the outer and upper side of the acetabulum on the X-ray film; (3) stress shielding is observed on the inner side of the acetabulum; and (4) bone trabeculae growing into the prosthesis on imaging.

1.4 Statistical Methods

All statistical analyses were performed using SPSS 26.0 software for Mac (SPSS Inc., Chicago, IL, USA) on personal computers. Continuous variables were expressed as means ± standard deviation, and t-tests were used for comparisons if they followed a normal distribution. If the data did not follow a normal distribution and/or exhibited heterogeneity of variance, Wilcoxon rank-sum tests were used instead. Chi-squared tests or Fisher's exact tests were used for categorical variables. A P-value less than 0.05 was considered statistically significant.

3.1. Clinical Data and Radiological Results

3.1.1. Clinical Data

This study included 236 patients (236 hips), among whom there were 96 males (40.6%) and 140 females (59.4%). 214 patients (90.7%) completed imaging and clinical evaluations through postoperative routine follow-up, and 22 patients (9.3%) partially followed up through phone and online communication. The postoperative follow-up period of this study was 17–46 months, with a mean of (26.2 ± 9.2) months. The patients had an average age of (57.7 ± 14.4) years and an average body mass index (BMI) of (23.38 ± 3.9) kg/m². The average operation time was (56.1 ± 9.2) minutes, and the average intraoperative blood loss was (163.47 ± 46.78) ml. 12 patients (5.1%) received blood transfusions during or after surgery. The average length of hospital stay for all patients was (7.5 ± 1.5) days. During the perioperative period, 19 patients (8.1%) were found to have deep vein thrombosis in the calf muscles before discharge, and after consultation with the vascular surgery department, anticoagulant therapy was adjusted, and regular follow-up was conducted in the outpatient department after discharge. Thrombus was found disappeared in four patients during the vascular surgery outpatient follow-up at 2 months after surgery, and the thrombus in the remaining 15 patients was also found to have disappeared during the follow-up at 3 months after surgery. Eleven patients (4.7%) had minor trochanteric fractures during surgery and were fixed with wires. They were able to walk with crutches on the second day after surgery after radiographic examination. Eight patients (3.4%) had dislocated hip joints during activity in the hospital after surgery and were treated by manual reduction. After repeated education to patients and their families on measures to prevent dislocation, no further dislocations occurred. No patients developed complications such as incision infection, poor wound healing, periprosthetic infection, or loosening of the prosthesis until the last follow-up.

The average HHS was 43.7 ± 6.8 before surgery, 70.6 ± 6.6 at 1 month after surgery, 86.4 ± 11.3 at 1 year after surgery, and 85.6 ± 9.3 at the last follow-up. The HHS at 1 month and 1 year after surgery were significantly different from the HSS scores before surgery(P < 0.01), while the HSS scores had no significant difference between 1 year after surgery and the last follow-up (P > 0.05). The WOMAC scores before surgery and at 1 month after surgery, 1 year after surgery, and the last follow-up were 59.2 ± 5.8, 25.2 ± 6.5, 12.5 ± 3.4, and 13.1 ± 3.5, respectively. The WOMAC scores at 1 month and 1 year after surgery were significantly different from that before surgery(P < 0.01), while the WOMAC scores had no significant difference between 1 year after surgery and the last follow-up (P > 0.05) (see Table 2). At the last follow-up, 157 patients (66.5%) reported that they were very satisfied with their treatment, 61 patients (25.8%) were satisfied, 14 patients (5.9%) were neutral, and 4 patients (1.7%) were dissatisfied. None of the patients (0%) reported being very dissatisfied. Among the dissatisfied patients, one had DDH IV and underwent shortening osteotomy during surgery, resulting in a limb length discrepancy of about 2 cm on the operated side, requiring the use of shoe inserts. Another patient had AS with hip joint stiffness, and also had involvement of the spine and sacroiliac joints, with pelvic tilt and persistent limping at the last follow-up. The other two patients had RA with concomitant involvement of the knee and ankle joints, and their walking was affected by pain in other joints.

3.1.2. Radiological Results

The average acetabular cup abduction angle was (36.2 ± 4.2)°, and the anteversion angle was (18.8 ± 4.5)° on the operated side. According to the Lewinnek safe zone description, 87.7% (207/236) of the acetabular cups were located within this zone. The mean distance between the operated and healthy sides of COR_ver was (2.8 ± 0.5) mm, and that of COR_hor was (3.8 ± 0.7) mm. At the last follow-up, all cups showed good bone integration (at least three or more bone integration criteria met), and no cases met the criteria of cup loosening. In 18 cases (7.6%), a translucent line of 2 mm or less was observed between the acetabular cup and the bone bed during the one-month postoperative review, which disappeared within six months postoperatively. Four cases (1.7%) showed bone resorption in the femoral shaft, mainly in Gruen zones[22] 1 and 14, but the patients had no clinical symptoms and were followed up for observation. Typical cases are shown in Figs. 3 and 4.

3.2. Figures, Tables and Schemes

Table.1 Demographic characteristics of included cases

Items	Cases (n = 236)
Gender (n, cases)	Male	96
Gender (n, cases)	Female	140
Age (x ± s, years)		57.7 ± 14.4
Body Mass Index (x ± s, kg/m²)		23.38 ± 3.9
Primary Diseases (n, cases)	OA	42
	DDH	65
	RA	12
	AVN	78
	FFN	26
	AS	7
	CV	6
Surgery time (x ± s, mins)		56.1 ± 9.2
Intraoperative bleeding (x ± s, ml)		163.47 ± 46.78
Mean hospitalization time (x ± s, days)		7.5 ± 1.5
Follow-up time (x ± s, months)		26.2 ± 9.2

Table.2 Comparison of HSS and WOMAC scores at different follow-up time

	pre	post-1m	post-1y	last follow-up	P1	P2	P3
HSS score	43.7 ± 6.8	70.6 ± 6.6	86.4 ± 11.3	85.6 ± 9.3	＜0.01	＜0.01	＞0.05
WOMAC score	59.2 ± 5.8	25.2 ± 6.5	12.5 ± 3.4	13.1 ± 3.5	＜0.01	＜0.01	＞0.05

P1: the comparison between 1 month after operation and preoperation; P2: the comparison between 1 year and 1 month after operation; P3: the comparison between the last follow-up and 1 year after operation. Pre, post-1m, post-1y respectively refer to preoperative, postoperative 1 month and postoperative 1 year.

Research on the design of hip joint prosthesis coatings has become a hot topic in recent years. Traditional techniques, such as ion spraying, high-temperature sintering, electrophoretic deposition, and micro-arc oxidation sol-gel method, can provide a certain degree of initial stability and long-term bone integration between the cup and the host bone. However, when dealing with cases with poor bone quality such as osteoporosis, bone radiation necrosis, and bone defects, the above techniques may only provide limited initial stability. At the same time, many studies have reported failures due to the sintering of titanium beads and coating shedding[5–7]. Traditional processing techniques usually have strong constraints on the design scheme, while metal additive manufacturing technology can manufacture acetabular cups with high porosity, appropriate and controllable pore size, elastic modulus similar to human bone, and better friction coefficient according to a three-dimensional model. Perticarini[23] et al.'s research reported the clinical results of using 3D printed titanium alloy trabecular acetabular cups in European patients. The study included 133 patients, mainly with HOA, AVN, and DDH. In at least 5 years of follow-up, all patients had significant pain relief and functional recovery. Castagnini[24] et al. conducted a retrospective study of continuous cases, including 24 cases with an average follow-up of 134 months. Their report confirmed the reliable mid-term clinical and radiographic results of 3D printed titanium alloy trabecular acetabular cups. Huang[10] et al. reported the results of using 3D printed titanium alloy bone beam acetabular cups in 32 cases in the first THA. The average follow-up was 93.5 months, the hip HSS score improved significantly, and there were no complications during the perioperative and follow-up periods. At the last follow-up, all acetabular cups showed good bone integration, and 89.0% of patients expressed satisfaction or very satisfaction with the surgery. Our study also showed that during the average follow-up period of 26.2 months, all 236 acetabular cups achieved good initial stability and long-term bone ingrowth. The hip HSS score of the patients improved significantly from 43.7 ± 6.8 points before surgery to 85.6 ± 9.3 points at the last follow-up. The WOMAC score improved significantly from 59.2 ± 5.8 points before surgery to 13.1 ± 3.5 points at the last follow-up. The high survival rate (100.0%) of the cup and patient satisfaction (92.3% satisfied or very satisfied) confirmed the safety and effectiveness of 3D printed titanium alloy trabecular acetabular cups in the first THA.

The good clinical and radiographic results of 3D printed titanium alloy trabecular acetabular cups depend on their good initial stability and long-term bone ingrowth, which may be related to the following factors. Firstly, the cup prepared by EBM electron beam melting technology with a structure optimized design has an average porosity of 80%, a pore size of 600–800µm, and a structure with interconnected pores in three-dimensional structure. The surface structure provides good friction between the cup and the host bone. Castagnini's research [24] reported that the friction coefficient between the cup and cancellous bone is 1.08, which is better than the friction coefficient of porous tantalum (0.98) and sintered titanium beads (0.5). A good friction coefficient provides good initial stability for the cup and also is beneficial to long-term bone ingrowth.

Secondly, the porous structure reduces the elastic modulus of the cup and can change the strength and mechanical properties of the material by adjusting the pore size [25, 26]. The elastic modulus of the cup is on average 0.5–1.3 GPa, which is similar to human cancellous bone. Stress shielding phenomenon is caused by a severe stiffness mismatch between the implanted prosthesis and the bone. Currently, the stiffness of most THA implant materials is much higher than that of bone. After the high elastic modulus prosthesis is implanted into the human body, it will bear most of the stress, which will prevent the stress transmission to the host bone. The redistribution of stress will cause bone reconstruction, and bone resorption will occur in areas with low stress, which will cause micro-movement of the implant-bone interface and eventually lead to implant loosening [27]. Therefore, the elastic modulus of the cup helps to reduce the risk of stress shielding and bone resorption and improve bone ingrowth rate [28].

Furthermore, the characteristics of the cup's porous, solid, and pore-connected three-dimensional structure simulate the structure of natural bone beams. Research by Ponader [29] and Otsuki [30] have confirmed that high porosity is conducive to improving local blood flow and vascular formation, reducing fibrosis of the surrounding tissue of the implant, and stimulating new bone growth into the pores. Similarly, research by Devine [31] has also confirmed that the aforementioned characteristics of the 3D printed titanium alloy trabecular acetabular cup can stimulate the proliferation and differentiation of bone cells, stimulate tissue vascularization, and have bone-inducing and bone-conducting properties. The above characteristics of the cup provide a good foundation and necessary conditions for long-term bone ingrowth. In a 2-year follow-up study of 91 titanium alloy trabecular acetabular cups produced using EBM technology, Massari [28] and other scholars did not observe any radiolucent lines between the cup and the host bone. Similarly, Perticarini [23] reported that in a follow-up study of 134 titanium alloy trabecular acetabular cups, with an average follow-up time of 72.7 months, no radiolucent lines were observed between the cup and the host bone. Our study found that all cups showed good bone integration (meeting at least three or more bone integration criteria) at the last follow-up, and no cases met the cup loosening criteria. At the one-month postoperative review, 18 cases showed radiolucent lines of less than 2mm between the cup and the bone bed, all of which disappeared after six months postoperatively.

Although this study reported good early clinical and imaging results, as well as patient satisfaction in 236 cases of 3D-printed titanium alloy acetabular cups with bone ingrowth, the study still have some limitations. Firstly, although the number of cases is relatively large, the follow-up time is relatively short and there is no control group. Long-term prospective randomized controlled studies are needed to confirm its long-term safety and efficacy. Secondly, there were some lost to follow-up cases, which may have some impact on the results. Thirdly, the surgeries in this study were performed by two senior orthopedic surgeons, but they may also have some confounding effects on the results. Finally, in the current study, evaluations such as CT three-dimensional reconstruction and bone density DXA were not performed, and the serum metal ion concentration of the cases was not detected to evaluate the corrosion safety of the acetabular cup. These issues need to be considered and improved in future studies.

The use of 3D printed titanium alloy porous acetabular cups with structurally optimized design through EBM technology showed good short-term clinical and radiological results in primary total hip arthroplasty. It demonstrated good initial stability, high survival rate of the cup, and good bone ingrowth in short-term stage, significantly improving the patient's hip pain and function. However, larger sample sizes and multi-center prospective randomized controlled studies are still needed to verify the mid-to-long-term safety and effectiveness of this cup.

Conflict of interest: All authors declare that there is no conflict of interest in the course of the study and the writing of the article. The project funding did not affect the authors' views or the objective reporting and statistical analysis of the research data.

Ethical issues: The research plan was approved by the Ethics Committee of the Sichuan Provincial Orthopedic Hospital(grant number KY2020-015-01).

Author Contributions: Conceptualization, CHEN Guo; methodology, CHEN Guo, ZHANG Peng and SI Yan; software, YI Linhong; validation, HAN Jie and LU Lisha; formal analysis, CHEN Guo, BI Mengna and LI Zhong; investigation, CHEN Guo and ZHANG Shangshang; resources, SI Yan, SHEN Hai, ZHANG Huiwu and ZENG Fanwei; data curation, MA Zou and WANG Yicheng; writing—original draft preparation, CHEN Guo; writing—review and editing, CHEN Guo, ZHANG Peng and SI Yan; supervision, ZHANG Peng and SI Yan; project administration, CHEN Guo. All authors have read and agreed to the published version of the manuscript.

Funding: This research was funded by Sichuan Provincial Health Commission Cadre Health Research Project(grant number CGY2020-606); Sichuan Medical Association Youth Innovation Scientific Research Project(grant number Q19011); Sichuan Provincial Orthopedic Hospital Scientific Research Project(grant number 20ZD01);

Institutional Review Board Statement: The study was conducted in accordance with the Declaration of Helsinki, and approved by the Ethics Committee of Sichuan Provincial Orthopedic Hospital(grant number KY2020-015-01).

Informed Consent Statement: Informed consent was obtained from all subjects involved in the study. Written informed consent has been obtained from the patients to publish this paper

Data Availability Statement: Original data supporting the results of this study are available from the corresponding author upon request if needed.

Conflicts of Interest: Authors declare that they have no conﬂicts of interest.

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No competing interests reported.

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Evaluation of short-term clinical and imaging outcomes of porous coated trabecular titanium cup manufactured with electron beam melting technique in primary total hip arthroplasty: prospective study of 236 cases

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Abstract

Background

Methods

Results

Conclusions

Figures

1. Introduction

2. Materials And Methods

1.1 General Information

1.2 Surgical procedure and postoperative management:

1.3 Observational Indicators

1.4 Statistical Methods

3. Results

3.1. Clinical Data and Radiological Results

3.1.1. Clinical Data

3.1.2. Radiological Results

3.2. Figures, Tables and Schemes

4. Discussion

5. Conclusions

Declarations

References

Additional Declarations

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