Revue de chirurgie orthopdique et rparatrice de lappareil moteur (2008) 94, e17e22

Disponible en ligne sur www.sciencedirect.com

ORIGINAL ARTICLE

Results of the Evora dual-mobility socket after a

minimum follow-up of ve years
Rsultat cinq ans de la cupule double
mobilit Evora
S. Leclercq a,, J.-Y. Benoit b, J.-P. de Rosa c, P. Euvrard d,
C. Leteurtre e, P. Girardin f
a

Centre hospitalier priv Saint-Martin, 18, rue des Roquemonts, 14000 Caen, France
Centre hospitalier,12, rue de Nesmond, 14400 Bayeux, France
c
Clinique chirurgicale, 23, rue Flix-Faure, 76190 Yvetot, France
d
Clinique Notre-Dame, 23, rue des acres, 14500 Vire, France
e
Centre hospitalier, boulevard Bercagnes, 14700 Falaise, France
f
Centre hospitalier, BP 219, 42605 Montbrison cedex, France
b

Accepted 15 October 2007

KEYWORDS
Dual mobility;
Total hip
arthroplasty;
Socket;
Tripolarunconstrained
cup

Summary
Purpose of the study. Dislocation is a well-known complication of total hip arthroplasty. The
risk can be reduced to one or two cases per thousand using a dual-mobility cup. The survival rate
achieved with the Bousquet implant is 95% at 10 years. The complications with this implant are
early mobilization and inguinal pain. An overly-large cup and insufcient primary and secondary
xation can be implicated. The design of the original implant was later modied to limit these
early complications. The purpose of this study was to check the validity of these design changes.
Patients and methods. The chromiumcobalt moulded cementless cup was used. The outer
surface of this cup presents large geometric striations and is coated with hydroxyapatite. The
cup has the shape of a 180 half sphere and a posterior wall prolongation measuring 6.5 mm.
Three mechanisms were used for the primary xation: an asymmetrical growth ring, four anchorage stems and a superior screw. Two hundred cementless cups were implanted in 194 patients.
The femoral piece was a Charnley stainless-steel implant (n = 139), a titanium SEM implant
(n = 59) or another implant (n = 12). Cement was used for femoral xation in 193 implantations.
The series included 97 women and 103 men with osteoarthritis (n = 180), necrosis (n = 16) and
surgery for fracture and primary arthroplasty (n = 9). The Harris and PostelMerle-dAubign
scores were noted. Eight radiographic criteria were analyzed to assess the position of the cup
and the radiological course of the interface.

DOI of original article:10.1016/j.rco.2007.10.009.

Corresponding author.
E-mail address: sylvainleclercq@wanadoo.fr (S. Leclercq).

0035-1040/$ see front matter 2008 Elsevier Masson SAS. All rights reserved.
doi:10.1016/j.rco.2007.10.015

e18

S. Leclercq et al.
Results. The mean follow-up was six years and the minimum was ve years. The mean age
at surgery was 70 years (range, 32 to 91). At last follow-up, 17 patients had died, eight were
lost to follow-up and ve were bedridden. Three patients underwent revision surgery. Thus,
this analysis included 170 prostheses followed for more than ve years (mean, six years; range,
ve to seven years). The Harris score improved from 48 to 92 and the PostelMerle-dAubign
score from 2/5/4 to 5.8/5.9/5.5 (range, 4 to 6/5 to 6/1 to 6). None of the patients complained
of anterior pain during active hip exion in supine position (related to ilio-psoas irritation).
Cup inclination was 46 on average (range, 62 to 22 ). Medialization, lateralization or ascension
greater than 10 mm from the center of rotation was not observed on the postoperative lms. At
the last follow-up, no measurable mobilization or migration could be identied on plain X-rays.
Radiolucent lines, condensations and bony defects around the cup, when visible postoperatively, were not found on the last follow-up X-rays. There were two cemented femoral pieces
that developed a radiolucent line in the nonspecic metaphyseal area. There were no cases of
granuloma and no cam effect. Three patients underwent revision for femoral loosening, fracture of the femur below the prosthesis and hematogenous infection. There were no cases of
dislocation.
Discussion. Changing the design of the implant to modify its volume, material and primary
xation has eliminated the early mobilizations and inguinal pain described for the original
Bousquet cup. These options have not had any deleterious effect on prosthesis stability. The
question of long-term wear remains an important problem and requires optimization: a neck
as thin as possible, optimized surfacing, elimination of laser marks, extraction leads and head
skirts.
2008 Elsevier Masson SAS. All rights reserved.

MOTS CLS
Prothse totale de
hanche ;
Double mobilit ;
Cupule

Rsum La double mobilit a t propose par G. Bousquet au dbut des annes 1980.
Lintrt de ce type dimplant dans le traitement prventif et curatif de linstabilit prothtique a dj t dmontr. Les mobilisations prcoces et des douleurs inguinales taient des
complications prcoces, qui en limitaient les rsultats. Les auteurs proposent une volution
avec une prothse dun volume infrieur, en chromecobalt, une xation primaire assure par
un accroissement annulaire asymtrique, des picots dancrage et une xation secondaire par
hydroxyapatite avec repousse osseuse dans une surface macrogomtrique. Deux cents prothses, chez 194 malades, ont t implantes dans le cadre dune valuation multicentrique
continue, prospective, non randomise. Elles ont t suivies avec un recul minimum de cinq
ans. la rvision, 17 patients taient dcds, huit taient perdus de vue et cinq taient
grabataires. Trois malades ont t roprs (un descellement fmoral, une fracture du fmur
traumatique et une infection hmatogne). Cent soixante-dix prothses taient analysables audel de cinq ans. Il ny a pas eu de reprise pour cause actabulaire, aucune douleur inguinale et
aucune luxation. Les volutions proposes apportent une solution aux complications prcoces
de la cupule originale de Bousquet, sans effet dltre sur la stabilit prothtique.
2008 Elsevier Masson SAS. All rights reserved.

Introduction
Total hip arthroplasty (THA) dislocation remains a risk today,
for which primary implants have been evaluated at 2.2%
at one year, 3.8% at 10 years and 6% at 20 years [1]. It
can occur following all surgical approaches [2]. After a dislocation episode, the risk of recurrence is evaluated at
33% [3]. Surgical treatment of recurring dislocation results
in 20 to 40% failures [4]. Of 436 THA revisions, 14% are
required for implant instability [5]. The dual-mobility principle is an invention dating from 1978 and attributed to
Bousquet et al. [6]; it reduces this risk of dislocation to
one or two out of 1000 [7]. The indication for a dualmobility socket in treating recurring dislocation has proved
its worth [8,9]. The original cup was in stainless steel, with
the convex surface coated in alumina. Primary xation came
from an original geometric mechanism that was called a tripod and was made of two inferior studs and one superior
screw.

The original implant survival was 95% at 10 years [1013]

and 90.8% at 10 years for a patient population under the
age of 50 years [14]. Revisions in the rst 10 years were
related to cup mobilization in 1.1% of cases [12,15], resulting from an insufcient primary and/or secondary xation.
The porous alumina surface was not sufciently porous to
allow bone ingrowth (the alumina surface is inert and there
is no physical and chemical liaison with the bone surface).
Long-term xation depends on the primary xation obtained
during surgery. This is ensured by the press-t effect and the
tripod effect. Insufcient bone quality or insufcient preparation may make these mechanisms decient. Inguinal pain
can be induced by impingement of the cups anterior rim on
the iliac psoas tendon [16,17] or perhaps by a micromobility in the cup. Changing the primary and secondary xation
principles and reducing the volume of the implant may allow
for better control of these early complications.
Polyethylene wear is observed in three areas: the
concave area, the convex area and the collar. The wear in

Results of the Evora dual-mobility socket: Five years follow-up

the concave and convex areas has been measured at 67 and
9 m/year, respectively [18]. The total volume of wear, a
mean 54.3 mm3 /year, is on the same order of magnitude as
that reported by Wroblewski [19] with xed polyethylene.
Collar retention wear is part and parcel of the very principle of dual mobility. Over the long term, it is responsible for
intraprosthetic dislocation [20]. Optimization of the morphometric parameters and the neck materials is the only
means available today that can minimize this wear. The prosthesis studied here does not modify the tribological behavior
of the original prosthesis, except perhaps for the convex
area of the polyethylene when chromiumcobalt is used,
which provides a better surface nish.
The review at ve years was designed to ascertain
whether the early complications of the Bousquet cup had
been controlled without inducing detrimental effects, particularly in terms of prosthetic stability. The objective of
this study was to evaluate the hypotheses on this new dualmobility cup model.

Patients and methods

The prosthesis
The implant was made of cast chromiumcobalt (Fig. 1).
The outside surface had macrogeometric irregularities. It
was coated with hydroxyapatite 100 m thick. The inside
surface was treated to obtain a 0.05-m roughness. The
sphericity tolerance was 0.03 mm. It accounted for a 180
sphere extended with a 6.5-mm cylindrical posterior wall.
The cup was available in sizes from 44 to 64 mm in 2-mm
increments.
Primary xation consisted of three mechanisms:
an asymmetrical-growth ring: the difference in elasticity
of the circumference of the acetabulum compared to the
geometry of the anterior and posterior horns was compensated by an increased maximal thickness of the cup in
its lower part;

Figure 1

Evora dual-mobility cup.

e19
anchoring studs: four 4-mm studs prevented any searing
stress as soon as the cup was impacted;
a superior screw: an optional 4.5-mm screw could be used
to reinforce the xation if necessary.
Secondary xation was provided by the hydroxyapatite interface. The macrogeometric irregularity of the
chromiumcobalt surface was designed to allow a bone xation after resorption of the hydroxyapatite.
The mobile insert in polyethylene was obtained by dry
machining of plates that were turned, compressed and
sterilized with ethylene oxide. The concavitys center of
rotation was off-center by 0.3 mm compared to the center
of convexity so as to recenter the mobile insert in an optimal position. Retention was provided by a beveled collar.
The mobile insert was available in 22.2, 26 and 28 mm.

Patients
Two hundred protheses were implanted in 194 patients
between January 1998 and December 2000 within a
prospective, nonrandomized and consecutive multicenter
evaluation (three public centers and two private centers).
None of the surgeons worked exclusively with dual-mobility
sockets. The indication was based on the assessment
of potential instability and varied from one operator to
another. The mean follow-up (review date minus intervention date) was six years. The mean patient age was 70 years
(range, 32 to 91 years). The femoral piece was a Charnley stainless-steel implant (n = 139) (Fig. 2), a titanium SEM
implant (n = 59) or another implant (n = 12). Cement was
used for 193 implantations. The femoral head was in ceramic
(n = 11) or metal (n = 189). Fifty-three stems were non modular implants. The head diameter was 22.2 mm (n = 175),
26 mm (n = 18) and 28 mm (n = 7). The mean-cup diameter
was 52 mm (range, 46 to 60). The series included 97 females
and 103 males. The diagnosis was osteoarthritis (n = 180),
necrosis (n = 16) and rheumatoid arthritis (n = 4). One hundred eighty-six patients had no history of surgery, ve had
been operated on for a hip fracture and nine had had a
primary THA. In the Charnley classication, 152 were A,

Figure 2 Postoperative X-ray with cemented Charnley Kerboull stem and cementless Evora cup.

e20
44 B and four C. Sixty-eight patients had a BMI under 25,
82 patients between 25 and 30 and 62 patients had a BMI
over 30.

Methods
All medical les were analyzed clinically for Harris [21]
and Merle-dAubign [22] scores. Seven radiological criteria were analyzed (Fig. 3). Cup abduction was evaluated
on the frontal image. The cup was not hemispherical and
we retained the straight line passing through the center of
the cup and its most lateral point. The distance from the
bottom of the cup to the quadrilateral plate was measured
in millimeters. The ideal center of rotation was dened
by the symmetry of the opposite hip if it was healthy; if
not, it was dened in relation to the desired center on
the preoperative plan. The position of the cups center of
rotation in relation to the ideal center was measured along
two axes: x and y (lateralization/medialization, lengthening/shortening). The x-axis was a straight line parallel to
the teardrop and the y-axis a straight line perpendicular
to x going through the base of the teardrop. The distance
from the center of the implant head in relation to the ideal
center was measured along two axes, x and y. The y-axis
was the femur axis and the x-axis was a perpendicular line
going through the summit of the greater trochanter. The
lucent lines, domes and condensations were localized in
three frontal and lateral sectors on the acetabulum [23] and
the seven frontal and lateral sectors on the femur [24,25].
The measurements were taken postoperatively and at each
revision.

S. Leclercq et al.

Results
All patients were operated on or before January 2001 and
called in for a follow-up visit after 1st January 2005. At
revision, 17 patients had died, eight were lost to follow-up
and ve were bedridden. Three patients underwent a
second surgery. We were able to analyze 170 prostheses
beyond ve years. The mean follow-up was six years (range,
ve to seven years).
The mean patient age at surgery was 70 years (range, 32
to 91 years) and varied depending on the surgeon from 67
to 73 years of age. The prosthesis was implanted without
screws in 103 cases. In seven cases, the operator deemed
a screw necessary and in 90 cases used one as a matter
of principle. For the Charnley classication, 143 patients
were classied A, 25 B and 12 C; 14 did not have the necessary information. The Harris score increased from 48 to
92 and the Merle-dAubign score increased from 2/5/4 to
5.8/5.9/5.5 (range, four to six for pain, ve to six for mobility, one to six for stability). None of the patients complained
of anterior inguinal pain with hip exion against resistance.
The cups were implanted with a mean 46 cup abduction,
but ranging from 22 to 62 with no consequences to date.
On the rst interpretable postoperative X-ray, there was no
medialization, lateralization or ascension of the cups center
of rotation greater than 10 mm compared to the ideal center measured on the preoperative X-ray. Comparing the rst
X-ray with the last X-ray at more than ve years showed no
migration of the center of rotation greater than 3 mm and
no changes in abduction greater than 3 . Around the cup,
21 lucent lines out of 22 after surgery had disappeared at
the last follow-up. The 11 condensations and the eight postoperative domes were no longer visible on the last X-ray. As
for the femur, two cemented implants presented a lucent
line in the metaphyseal zone, which did not evolve. There
were no granulomas. There was no sign of a cam effect,
particularly on the neck as viewed on the lateral X-ray. No
off-centering could be measured between the cup and the
femur head.
Three patients underwent revision surgery:
aseptic loosening of the femur at three years;
a fracture of the femur with the prosthesis three years
after implantation, operated and complicated with infection;
a hematogenic infection at three years.
There were no dislocations. In terms of cup survival, no
revision related to the acetabulum was done, giving a 100%
ve-year survival rate (number at risk at ve years: 175).

Figure 3 Radiographic measurements. : cup abduction

angle; : osseous uncovered angle of the cup; CH: distance
between the bottom of the cup and the quadrilateral plate;
CI: ideal center of rotation evaluated by the symmetry of the
opposite side if healthy or based on the preoperative plan; CCH:
distance between the center of the cup and the ideal center on
the horizontal line; CCV: distance between the center of the cup
and the ideal center on the vertical line; CFH: distance between
the center of the head and the ideal center on the horizontal
line; CFV: between the center of the head and the ideal center
on the vertical line.

Discussion
Mobilization and anterior pain hampered the early results
of the original Bousquet cup [12,15]. One could hypothesize
that some of the options chosen in 1980 were responsible
for these complications. The aluminabone interface and
the bulk with its risk of impingement with the psoas [17]
were modied with a new interface and a new design. It
remained to be shown that these changes did not have a
deleterious effect. The radiographic measurements on plain
X-rays presented certain limits [26] and at the very most, it

Results of the Evora dual-mobility socket: Five years follow-up

can be said that mobilization, migration and wear are not
quantiable by the method used.
The tripolar system of Bousquets original implant coated
with alumina provides excellent preoperative primary stability, but the bone does not heal such that permanent xation
is assured in all cases. Since 1986, the interfaces in hydroxyapatite have proved their reliability [27], provided that
a perfect primary xation can be obtained during surgery.
The survival rate was 99.4% at 10 years in the series of
hydroxyapatite-coated cups reported by Epinette et al. [28].
The technical options retained for the cup studies
improve the results obtained with Bousquets original cup.
None of the implants were revised because of problems with
the acetabulum. In terms of ve-year survival, the improved
primary xation provides the dual-mobility socket with the
same result as a cemented Charnley implant. The implants
stability provided by the dual-mobility socket depends on
three factors. The greater the external diameter of the
polyethylene and the smaller the neck diameter, the greater
implant stability there will be. Cup depth has two opposite
effects. A deep cup is more stable, but exposes the patient
to the risk of impingement with the psoas and the neck,
particularly if there is a position defect. Reducing the depth
reduces stability. Cup volume is therefore a compromise and
the options chosen here seem reasonable, since they did not
increase the risk of dislocation.
The changes proposed with this model do not change the
wear of the retentive collar. The general rules should be
respected: as thin a neck as possible, optimized surface nishing, removal of any laser markings, extraction key and
skirted heads. Using a Morse taper (head/neck modularity)
allows simple treatment of any future intra-articular dislocation. Concave and convex friction surface wear depends
on how the mobile insert functions [29]. Catastrophic wear
of the polyethylene mobile inserts in Bousquet implants has
been observed when there is mobilization of the metallic cup. This is worn with three components secondary to
the release of alumina particles or even metallic debris.
This type of wear should no longer be seen with the disappearance of implant mobilization. The kinematics of a
dual-mobility implants mobile insert probably varies from
one patient to another, with different solicitations on the
two friction surfaces. Two opposing hypotheses can be postulated:
the mobile insert may be practically immobile. It continues to rotate, as shown by the circumferential wear of the
collar, which can be observed on the Bousquet cups. The
convex surface wears only slightly and the concave surface is particularly solicited. However, it does not wear
as in a cemented Charnley implant, because the loaded
surface is in continual movement around the neck axis,
which can explain less wear because of a more homogenous distribution of the surfaces subjected to stresses;
the mobile insert may be hypermobile. In this case, the
convex surface undergoes more stress and a polished
CrCo surface provides only advantages compared to a
stainless-steel surface. The results at more than 15 years
should conrm this hypothesis.
The indications for this implant are the same as for any
dual-mobility cup. Instability caused by laxity in a context

e21
of weak-muscle tone in the older subject remains the indication most frequently encountered in daily practice. The
potential risk of instability cannot be measured and the
operator must make the assessment, which explains the differences observed between surgeons in terms of the age
of populations. The behavior of the interface between the
bone and the hydroxyapatite-coated implant is satisfying
whatever the patients age, osteoporosis status and sex [30].
It does not seem necessary to take the potential risks of
a cemented metal-back interface to provide older patients
with the advantages of the dual-mobility socket. The question arises when revisions requiring bone reconstruction and
a cemented cup is required whenever the reconstruction is
based on a metal ring. The indication should be extended to
other populations at risk:

in cases of tumor resection;

treatment of recurring dislocations;
in a neurological context;
in revisions of the implant with no bone reconstruction.

Implant instability can be regarded from an economic

angle [31]. The cost of orthopedic reduction and the cost
of surgical revision for implant instability account for 19
and 148%, respectively, of the cost of a primary implant,
an argument for the advantages of dual-mobility indications
beyond the medical benet to the patient. The modications
reported herein compared to Bousquets original implant
improve the early results by preventing mobilizations and
anterior impingements without challenging the stability of
dual-mobility implants.

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