Clinical Orthopaedics and Related Research®

, Volume 471, Issue 2, pp 486–497 | Cite as

Smoking May Be a Harbinger of Early Failure With Ultraporous Metal Acetabular Reconstruction

  • Adolph V. LombardiJr
  • Keith R. Berend
  • Joanne B. Adams
  • Ryan C. Jefferson
  • Michael A. Sneller
Symposium: Papers Presented at the Annual Meetings of The Hip Society



Smoking is considered a risk factor for surgical complications in total hip arthroplasty (THA) and has been linked to a higher rate of aseptic loosening in uncemented acetabular components. Acetabular reconstruction with newer ultraporous metals in both complex primary and revision THA has increased survivorship but it is unclear whether smoking affects survival of these implants.


We reviewed our early experience with THA using ultraporous acetabular components to assess the incidence and etiology of early failure and examine if any preoperative variables, including smoking, related to failure.


We used ultraporous acetabular components in 498 patients (534 hips), beginning with one case each in 1999 and 2004, 17 in 2005, and the majority from 2006 through March 2010. There were 159 complex primary and 375 revision cases. Of these patients, 17% were smokers (averaging 35 pack-years), 31% previous smokers (averaging 29 pack-years), 41% nonsmokers, and 1% unknown. Failure modes possibly related to smoking were infection, aseptic loosening, or periacetabular fracture and unrelated were dislocation and implant breakage. Minimum followup was 1 month (average, 32 months; range, 1–78 months).


There were 34 cup failures (6%): 17 infections, 14 aseptic loosening, and one each liner breakage, dislocation, and periacetabular fracture. The failure rate (uncontrolled for potentially confounding variables) was 10% in both current (9 of 89) and prior smokers (17 of 167) and 3% in nonsmokers 8 of 271).


With ultraporous metal technology in complex primary and revision THA, smoking, both past and current, may be a risk factor for early failure.

Level of Evidence

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.


  1. 1.
    AbdelSalam H, Restrepo C, Tarity TD, Sangster W, Parvizi J. Predictors of intensive care unit admission after total joint arthroplasty. J Arthroplasty. 2012;27:720–725.PubMedCrossRefGoogle Scholar
  2. 2.
    Argintar E, Triantafillou K, Delahay J, Wiesel B. The musculoskeletal effects of perioperative smoking. J Am Acad Orthop Surg. 2012;20:359–363.PubMedCrossRefGoogle Scholar
  3. 3.
    Baad-Hansen T, Kold S, Nielsen PT, Laursen MB, Christensen PH, Soballe K. Comparison of trabecular metal cups and titanium-fiber mesh cups in primary hip arthroplasty. Acta Orthop. 2011;82:155–160.PubMedCrossRefGoogle Scholar
  4. 4.
    Ballester Alfaro JJ, Sueiro Fernández J. Trabecular metal buttress augment and the trabecular metal cup-cage construct in revision hip arthroplasty for severe acetabular bone loss and pelvic discontinuity. Hip Int. 2010;20(Suppl 7):119–127.PubMedGoogle Scholar
  5. 5.
    Blumenfeld TJ, Bargar WL. Surgical technique: a cup-in-cup technique to restore offset in severe protrusio acetabular defects. Clin Orthop Relat Res. 2012;470:435–441.PubMedCrossRefGoogle Scholar
  6. 6.
    Bobyn JD, Poggie RA, Krygier JJ, Lewallen DG, Hanssen AD, Lewis RJ, Unger AS, O’Keefe TJ, Christie MJ, Nasser S, Wood JE, Stulberg SD, Tanzer M. Clinical validation of a structural porous tantalum biomaterial for adult reconstruction. J Bone Joint Surg Am. 2004;86(Suppl 2):123–129.PubMedGoogle Scholar
  7. 7.
    Bobyn JD, Stackpool GJ, Hacking SA, Tanzer M, Krygier JJ. Characteristics of bone ingrown and interface mechanics of a new porous tantalum biomaterial. J Bone Joint Surg Br. 1999;81:907–914.PubMedCrossRefGoogle Scholar
  8. 8.
    Bobyn JD, Toh K, Hacking SA, Tanzer M, Krygier JJ. Tissue response to porous tantalum acetabular cups: a canine model. J Arthroplasty. 1999;14:347–354.PubMedCrossRefGoogle Scholar
  9. 9.
    Centers for Disease Control and Prevention. Body measurements. Updated November 2, 2012. Available at: Accessed September 28, 2012.
  10. 10.
    Chassanidis CG, Malizos KN, Varitimidis S, Samara S, Koromila T, Kollia P, Dailiana Z. Smoking affects mRNA expression of bone morphogenetic proteins in human periosteum. J Bone Joint Surg Br. 2012;94:1427–1432.PubMedCrossRefGoogle Scholar
  11. 11.
    Davies JH, Laflamme GY, Delisle J, Fernandes J. Trabecular metal used for major bone loss in acetabular hip revision. J Arthroplasty. 2011;26:1245–1250.PubMedCrossRefGoogle Scholar
  12. 12.
    Del Gaizo DJ, Kancherla V, Sporer SM, Paprosky WG. Tantalum augments for Paprosky IIIA defects remain stable at midterm followup. Clin Orthop Relat Res. 2012;470:395–401.PubMedCrossRefGoogle Scholar
  13. 13.
    Fernández-Fairen M, Murcia A, Blanco A, Meroño A, Murcia A Jr, Ballester J. Revision of failed total hip arthroplasty acetabular cups to porous tantalum components: a five-year follow up study. J Arthroplasty. 2010;25:865–872.PubMedCrossRefGoogle Scholar
  14. 14.
    Fini M, Giavaresi G, Salamanna F, Veronesi F, Martini L, De Mattei M, Tschon M. Harmful lifestyles on orthopedic implantation surgery: a descriptive review on alcohol and tobacco use. J Bone Miner Metab. 2011;29:633–644.PubMedCrossRefGoogle Scholar
  15. 15.
    Flecher X, Paprosky W, Grillo JC, Aubaniac JM, Argenson JN. Do tantalum components provide adequate primary fixation in all acetabular revisions? Orthop Traumatol Surg Res. 2010;96:235–241.PubMedCrossRefGoogle Scholar
  16. 16.
    Flecher X, Sporer S, Paprosky W. Management of severe bone loss in acetabular revision using a trabecular metal shell. J Arthroplasty. 2008;23:949–955.PubMedCrossRefGoogle Scholar
  17. 17.
    Gross AE, Goodman SB. Rebuilding the skeleton: the intraoperative use of trabecular metal in revision total hip arthroplasty. J Arthroplasty. 2005;20(Suppl 2):91–93.PubMedCrossRefGoogle Scholar
  18. 18.
    Gruen TA, Poggie RA, Lewallen DG, Hanssen AD, Lewis RJ, O’Keefe TJ, Stulberg SD, Sutherland CJ. Radiographic evaluation of a monoblock acetabular component: a multicenter study with 2- to 5-year results. J Arthroplasty. 2005;20:369–378.PubMedCrossRefGoogle Scholar
  19. 19.
    Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J Bone Joint Surg Am. 1969;51:737–755.PubMedGoogle Scholar
  20. 20.
    Hasart O, Perka C, Lehnigk R, Tohtz S. [Reconstruction of large acetabular defects using trabecular metal augments] [in German]. Oper Orthop Traumatol. 2010;22:268–277.PubMedCrossRefGoogle Scholar
  21. 21.
    Hawn MT, Houston TK, Campagna EJ, Graham LA, Singh J, Bishop M, Henderson WG. The attributable risk of smoking on surgical complications. Ann Surg. 2011;254:914–920.PubMedCrossRefGoogle Scholar
  22. 22.
    Hoogendoorn JM, Simmermacher RK, Schellekens PP, van der Werken C. [Adverse effects if smoking on healing of bones and soft tissues] [in German]. Unfallchirurg. 2002;105:76–81.PubMedCrossRefGoogle Scholar
  23. 23.
    Jafari MS, Bender B, Coyle C, Parvizi J, Sharkey PF, Hozack WJ. Do tantalum and titanium cups show similar results in revision hip arthroplasty? Clin Orthop Relat Res. 2010;468:459–465.PubMedCrossRefGoogle Scholar
  24. 24.
    Joglekar SB, Rose PS, Lewallen DG, Sim FH. Tantalum acetabular cups provide secure fixation in THA after pelvic irradiation at minimum 5-year followup. Clin Orthop Relat Res. 2012;470:3041–3047.PubMedCrossRefGoogle Scholar
  25. 25.
    Kim WY, Greidanus NV, Duncan CP, Masri BA, Garbuz DS. Porous tantalum uncemented acetabular shells in revision total hip replacement: two to four year clinical and radiographic results. Hip Int. 2008;18:17–22.PubMedGoogle Scholar
  26. 26.
    Komarasamy B, Vadivelu R, Bruce A, Kershaw C, Davison J. Clinical and radiological outcome following total hip arthroplasty with an uncemented trabecular metal monoblock acetabular cup. Acta Orthop Belg. 2006;72:320–325.PubMedGoogle Scholar
  27. 27.
    Kosashvili Y, Backstein D, Safir O, Lakstein D, Gross AE. Acetabular revision using an anti-protrusion (ilio-ischial) cage and trabecular metal acetabular component for severe acetabular bone loss associated with pelvic discontinuity. J Bone Joint Surg Br. 2009;91:870–876.PubMedCrossRefGoogle Scholar
  28. 28.
    Kosashvili Y, Safir O, Backstein D, Lakstein D, Gross AE. Salvage of failed acetabular cages by nonbuttressed trabecular metal cups. Clin Orthop Relat Res. 2010;468:466–471.PubMedCrossRefGoogle Scholar
  29. 29.
    Kostakos AT, Macheras GA, Frangakis CE, Stafilas KS, Baltas D, Xenakis TA. Migration of the trabecular metal monoblock acetabular cup system. J Arthroplasty. 2010;25:35–40.PubMedCrossRefGoogle Scholar
  30. 30.
    Kwiatkowski TC, Hanley EN Jr, Ramp WK. Cigarette smoking and its orthopedic consequences. Am J Orthop (Belle Mead NJ). 1996;25:590–597.Google Scholar
  31. 31.
    Kwong FN, Harris MB. Recent developments in the biology of fracture repair. J Am Acad Orthop Surg. 2008;16:619–625.PubMedGoogle Scholar
  32. 32.
    Lachiewicz PF, Soileau ES. Tantalum components in difficult acetabular revisions. Clin Orthop Relat Res. 2010;468:454–458.PubMedCrossRefGoogle Scholar
  33. 33.
    Lakstein D, Backstein D, Safir O, Kosashvili Y, Gross AE. Trabecular metal cups for acetabular defects with 50% or less host bone contact. Clin Orthop Relat Res. 2009;467:2318–2324.PubMedCrossRefGoogle Scholar
  34. 34.
    Lavernia CJ, Sierra RJ, Gomez-Marin O. Smoking and joint replacement; resource consumption and short-term outcome. Clin Orthop Relat Res. 1999;367:172–180.PubMedCrossRefGoogle Scholar
  35. 35.
    Lindström D, Sadr Azodi O, Wladis A, Tønnesen H, Linder S, Nåsell H, Ponzer S, Adami J. Effects of a perioperative smoking cessation intervention on postoperative complications: a randomized trial. Ann Surg. 2008;248:739–745.PubMedCrossRefGoogle Scholar
  36. 36.
    Lingaraj K, Teo YH, Bergman N. The management of severe acetabular bone defects in revision hip arthroplasty using modular porous metal components. J Bone Joint Surg Br. 2009;91:1555–1560.PubMedCrossRefGoogle Scholar
  37. 37.
    Macheras G, Kateros K, Kostakos A, Koutsostathis S, Danomaras D, Papagelopoulos PJ. Eight- to ten-year clinical and radiographic outcome of a porous tantalum monoblock acetabular component. J Arthroplasty. 2009;24:705–709.PubMedCrossRefGoogle Scholar
  38. 38.
    Macheras GA, Kateros K, Koutsostathis SD, Tsakotos G, Galanakos S, Papadakis SA. The trabecular metal monoblock acetabular component in patients with high congenital hip dislocation: a prospective study. J Bone Joint Surg Br. 2010;92:624–628.PubMedCrossRefGoogle Scholar
  39. 39.
    Macheras GA, Papagelopoulos PJ, Kateros K, Kostakos AT, Baltas D, Karachalios TS. Radiological evaluation of the metal-bone interface of a porous tantalum monoblock acetabular component. J Bone Joint Surg Br. 2006;88:304–309.PubMedCrossRefGoogle Scholar
  40. 40.
    Malizos KN, Bargiotas K, Papatheodorou L, Hantes M, Karachalios T. Survivorship of monoblock trabecular metal cups in primary THA: midterm results. Clin Orthop Relat Res. 2008;466:159–166.PubMedCrossRefGoogle Scholar
  41. 41.
    Malkani AL, Price MR, Crawford CH 3rd, Baker DL. Acetabular component revision using a porous tantalum biomaterial: a case series. J Arthroplasty. 2009;24:1068–1073.PubMedCrossRefGoogle Scholar
  42. 42.
    Markuszewski J, Wierusz-Kozłowska M, Woźniak W, Łapaj Ł, Kokoszka P. [Porous tantalum modular cups in revision hip arthroplasty] [in Polish]. Chir Narzadow Ruchu Ortop Pol. 2011;76:197–200.PubMedGoogle Scholar
  43. 43.
    Meldrum RD, Wurtz LD, Feinberg JR, Capello WN. Does smoking affect implant survivorship in total hip arthroplasty? A preliminary retrospective case series. Iowa Orthop J. 2005;25:17–24.PubMedGoogle Scholar
  44. 44.
    Moghaddam A, Weiss S, Wölfl CG, Schmeckenbecher K, Wentzensen A, Grützner PA, Zimmermann G. Cigarette smoking decreases TGF-b1 serum concentrations after long bone fracture. Injury. 2010;41:1020–1025.PubMedCrossRefGoogle Scholar
  45. 45.
    Møller AM, Pederson T, Villebro N, Munksgaard A. Effect of smoking on early complications after elective orthopaedic surgery. J Bone Joint Surg Br. 2003;85:178–181.PubMedCrossRefGoogle Scholar
  46. 46.
    Møller AM, Villebro N, Pederson T, Tønnesen H. Effect of preoperative smoking intervention on postoperative complications: a randomized clinical trial. Lancet. 2002;359:114–117.PubMedCrossRefGoogle Scholar
  47. 47.
    Myles PS, Iacono GA, Hunt JO, Fletcher H, Morris J, McIlroy D, Fritchsi L. Risk of respiratory complications and wound infection in patients undergoing ambulatory surgery: smokers versus nonsmokers. Anesthesiology. 2002;97:842–847.PubMedCrossRefGoogle Scholar
  48. 48.
    Nakashima Y, Mashima N, Imai H, Mitsugi N, Taki N, Mochida Y, Owan I, Arakaki K, Yamamoto T, Mawatari T, Motomura G, Ohishi M, Doi T, Kanazawa M, Iwamoto Y. Clinical and radiographic evaluation of total hip arthroplasties using porous tantalum modular acetabular components: 5-year follow-up of clinical trial. Mod Rheumatol. 2012 Mar 7 [Epub ahead of print].Google Scholar
  49. 49.
    Nehme A, Lewallen DG, Hanssen AD. Modular porous metal augments for treatment of severe acetabular bone loss during revision hip arthroplasty. Clin Orthop Relat Res. 2004;429:201–208.PubMedCrossRefGoogle Scholar
  50. 50.
    Paprosky WG, O’Rourke M, Sporer SM. The treatment of acetabular bone defects with an associated pelvic discontinuity. Clin Orthop Relat Res. 2005;441:216–220.PubMedCrossRefGoogle Scholar
  51. 51.
    Paprosky WG, Perona PG, Lawrence JM. Acetabular defect classification and surgical reconstruction in revision arthroplasty. J Arthroplasty. 1994;9:33–44.PubMedCrossRefGoogle Scholar
  52. 52.
    Pierannunzii L, Mambretti A, D’Imporzano M. Trabecular metal cup without augments for acetabular revision in case of extensive bone loss and low bone-prosthesis contact. Int J Immunopathol Pharmacol. 2011;24(Suppl 2):133–137.PubMedGoogle Scholar
  53. 53.
    Porter SE, Hanley EN Jr. The musculoskeletal effects of smoking. J Am Acad Orthop Surg. 2001;9:9–17.PubMedGoogle Scholar
  54. 54.
    Ramappa M, Bajwa A, Kulkarni A, McMurtry I, Port A. Early results of a new highly porous modular acetabular cup in revision arthroplasty. Hip Int. 2009;19:239–244.PubMedGoogle Scholar
  55. 55.
    Rose PS, Halasy M, Trousdale RT, Hanssen AD, Sim FH, Berry DJ, Lewallen DG. Preliminary results of tantalum acetabular components for THA after pelvic radiation. Clin Orthop Relat Res. 2006;453:195–198.PubMedCrossRefGoogle Scholar
  56. 56.
    Sadr Azodi O, Bellocco R, Eriksson K, Adami J. The impact of tobacco use and body mass index on the length of stay in hospital and the risk of postoperative complications among patients undergoing total hip replacement. J Bone Joint Surg Br. 2006;88:1316–1320.PubMedCrossRefGoogle Scholar
  57. 57.
    Siegmeth A, Duncan CP, Masri BA, Kim WY, Garbuz DS. Modular tantalum augments for acetabular defects in revision hip arthroplasty. Clin Orthop Relat Res. 2009;467:199–205.PubMedCrossRefGoogle Scholar
  58. 58.
    Silverstein P. Smoking and wound healing. Am J Med. 1992;93:22S–24S.PubMedCrossRefGoogle Scholar
  59. 59.
    Simon JP, Bellemans J. Clinical and radiological evaluation of modular trabecular metal acetabular cups. Short term results in 64 hips. Acta Orthop Belg. 2009;75:623–630.PubMedGoogle Scholar
  60. 60.
    Singh JA. Smoking and outcomes after knee and hip arthroplasty: a systemic review. J Rheumatol. 2011;38:1824–1834.PubMedCrossRefGoogle Scholar
  61. 61.
    Singh JA, Houston TK, Ponce BA, Maddox G, Bishop M, Richman J, Campagna EJ, Henderson WG, Hawn MT. Smoking as a risk factor for short-term outcomes following primary total hip and total knee replacements in veterans. Arthritis Care Res (Hoboken). 2011;63:1365–1374.CrossRefGoogle Scholar
  62. 62.
    Skyttä ET, Eskelinen A, Paavolainen PO, Remes VM. Early results of 827 trabecular metal revision shells in acetabular revision. J Arthroplasty. 2011;26:342–345.PubMedCrossRefGoogle Scholar
  63. 63.
    Sloan A, Hussain I, Maqsood M, Eremin O, El-Sheemy M. The effects of smoking on fracture healing. Surgeon. 2010;8:111–116.PubMedCrossRefGoogle Scholar
  64. 64.
    Sørensen LT. Wound healing and infection in surgery. The clinical impact of smoking and smoking cessation: a systematic review and meta-analysis. Arch Surg. 2012;147:373–383.PubMedCrossRefGoogle Scholar
  65. 65.
    Sørensen LT. Wound healing and infection in surgery: the pathophysiological impact of smoking, smoking cessation, and nicotine replacement therapy: a systematic review. Ann Surg. 2012;255:1069–1079.PubMedCrossRefGoogle Scholar
  66. 66.
    Sorensen LT, Karlsmark T, Gottrup F. Abstinence from smoking reduces incisional wound infection: a randomized controlled trial. Ann Surg. 2003;238:1–5.PubMedGoogle Scholar
  67. 67.
    Sporer SM, Paprosky WG. Acetabular revision using a trabecular metal acetabular component for severe acetabular bone loss associated with a pelvic discontinuity. J Arthroplasty. 2006;21(Suppl 2):87–90.PubMedCrossRefGoogle Scholar
  68. 68.
    Sporer SM, Paprosky WG. The use of a trabecular metal acetabular component and trabecular metal augment for severe acetabular defects. J Arthroplasty. 2006;21(Suppl 2):83–86.PubMedCrossRefGoogle Scholar
  69. 69.
    Sternheim A, Backstein D, Kuzyk PR, Goshua G, Berkovich Y, Safir O, Gross AE. Porous metal revision shells for management of contained acetabular bone defects at a mean follow-up of six years: a comparison between up to 50% bleeding host bone contact and more than 50% contact. J Bone Joint Surg Br. 2012;94:158–162.PubMedCrossRefGoogle Scholar
  70. 70.
    Thomsen T, Tønnesen H, Møller AM. Effect of preoperative smoking cessation intervention on postoperative complications and smoking cessation. Br J Surg. 2009;96:451–461.PubMedCrossRefGoogle Scholar
  71. 71.
    Tønnesen H, Nielsen PR, Lauritzen JB, Møller AM. Smoking and alcohol intervention before surgery: evidence for best practice. Br J Anaesth. 2009;102:297–306.PubMedCrossRefGoogle Scholar
  72. 72.
    Unger AS, Lewis RJ, Gruen T. Evaluation of a porous tantalum uncemented acetabular cup in revision total hip arthroplasty: clinical and radiological results of 60 hips. J Arthroplasty. 2005;20:1002–1009.PubMedCrossRefGoogle Scholar
  73. 73.
    Van Kleunen JP, Lee GC, Lementowski PW, Nelson CL, Garino JP. Acetabular revisions using trabecular metal cups and augments. J Arthroplasty. 2009;24(Suppl):64–68.PubMedCrossRefGoogle Scholar
  74. 74.
    Weeden SH, Paprosky WG. Porous-ingrowth revision acetabular implants secured with peripheral screws. A minimum twelve-year follow-up. J Bone Joint Surg Am. 2006;88:1266–1271.PubMedCrossRefGoogle Scholar
  75. 75.
    Weeden SH, Schmidt RH. The use of tantalum porous metal implants for Paprosky 3A and 3B defects. J Arthroplasty. 2007;22(Suppl 2):151–155.PubMedCrossRefGoogle Scholar
  76. 76.
    Xenakis TA, Macheras GA, Stafilas KS, Kostakos AT, Bargiotas K, Malizos KN. Multicentre use of a porous tantalum monoblock acetabular component. Int Orthop. 2009;33:911–916.PubMedCrossRefGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2013

Authors and Affiliations

  • Adolph V. LombardiJr
    • 1
    • 2
    • 3
    • 4
  • Keith R. Berend
    • 1
    • 2
    • 4
  • Joanne B. Adams
    • 1
  • Ryan C. Jefferson
    • 1
  • Michael A. Sneller
    • 1
  1. 1.Joint Implant Surgeons, IncNew AlbanyUSA
  2. 2.Department of OrthopaedicsThe Ohio State UniversityColumbusUSA
  3. 3.Department of Biomedical EngineeringThe Ohio State UniversityColumbusUSA
  4. 4.Mount Carmel Health SystemNew AlbanyUSA

Personalised recommendations