Reduced Dislocation Rates and Excellent Functional Outcomes With Large-Diameter Femoral Heads

doi:10.1016/j.arth.2012.11.017

The Journal of Arthroplasty

Volume 28, Issue 8, September 2013, Pages 1415-1420

https://doi.org/10.1016/j.arth.2012.11.017 Get rights and content

Abstract

The purpose of this study was to compare the dislocation rates, functional outcomes, and radiographic results between large- and small-diameter femoral head components. A total of 225 patients (248-hips) who received total hip arthroplasties with large-diameter components (36 mm or greater) were compared to 501 patients (559-hips) who received smaller diameter components (less than 36 mm). Rates of dislocation and revision, Harris hip score, radiographic findings, and complications were compared between the groups. At a mean follow-up of approximately 5 years, a significantly higher rate of dislocation was noted in the small-diameter group (10 of 559) compared to the large-diameter group (0 of 248). The overall implant survivorship, mean Harris hip scores, complication rates, and radiographic outcomes were similar for the two groups. The authors believe that large-diameter components significantly reduced the risk of dislocation in susceptible patients, while preserving good to excellent functional outcomes.

Section snippets

Methods

We reviewed all primary total hip arthroplasties performed by two experienced joint surgeons (MAM and RED) at a single high-volume institution between the years of 2001 to 2010. All patients who received large-diameter components (36 or 40 mm) who had a minimum of two years of follow-up post-surgery were included, excluding any patients who received a constrained polyethylene liner, or who had a previous hip resurfacing or hemiarthroplasty. A total of 244 patients met these inclusion criteria.

Results

At final follow-up, a significantly higher rate of dislocation was noted in the small-diameter group (10 of 559, 1.8%) compared to the large-diameter group (0 of 248, 0%) (P = 0.036). The ten instances of dislocation occurred in ten separate patients (6 patients had osteoarthritis, 3 patients had osteonecrosis, and 1 patient had post-traumatic arthritis) with various demographic factors, hospital courses, and follow-up as detailed in Table 2. The mean age for this subgroup was 58 years (range, 44

Discussion

Avoiding dislocation in total hip arthroplasty is a multi-factorial concept requiring a thorough understanding of patient risk factors and appropriate pre-operative surgical planning. Among the available implant options, locking liners have been used to reduce instability in patients at high risk of dislocation [20], although often at the loss of range of motion. Large-diameter femoral heads are gaining acceptance as multiple reports have shown efficacy in reducing dislocation for both primary

References (32)

G.S. Shapiro et al.
The use of a constrained acetabular component for recurrent dislocation
J Arthroplasty
(2003)
C.V. Sikes et al.
Instability after total hip arthroplasty: treatment with large femoral heads vs constrained liners
J Arthroplasty
(2008)
C.L. Peters et al.
Reduction in early dislocation rate with large-diameter femoral heads in primary total hip arthroplasty
J Arthroplasty
(2007)
J.M. Cuckler et al.
Large versus small femoral heads in metal-on-metal total hip arthroplasty
J Arthroplasty
(2004)
C.B. Phillips et al.
Incidence rates of dislocation, pulmonary embolism, and deep infection during the first six months after elective total hip replacement
J Bone Joint Surg Am
(2003)
S. Bystrom et al.
Femoral head size is a risk factor for total hip luxation: a study of 42,987 primary hip arthroplasties from the Norwegian Arthroplasty Register
Acta Orthop Scand
(2003)
D.J. Berry et al.
Effect of femoral head diameter and operative approach on risk of dislocation after primary total hip arthroplasty
J Bone Joint Surg Am
(2005)
M. von Knoch et al.
Late dislocation after total hip arthroplasty
J Bone Joint Surg Am
(1949)
P.E. Beaule et al.
Jumbo femoral head for the treatment of recurrent dislocation following total hip replacement
J Bone Joint Surg Am
(2002)
K.L. Ong et al.
Economic burden of revision hip and knee arthroplasty in Medicare enrollees
Clin Orthop Relat Res
(2006)

P. Grigoris et al.

Tripolar hip replacement for recurrent prosthetic dislocation

Clin Orthop Relat Res

(1994)

R. Biedermann et al.

Reducing the risk of dislocation after total hip arthroplasty: the effect of orientation of the acetabular component

J Bone Joint Surg Br

(2005)

E.L. Peak et al.

The role of patient restrictions in reducing the prevalence of early dislocation following total hip arthroplasty. A randomized, prospective study

J Bone Joint Surg Am

(2005)

J.J. Callaghan et al.

Use of a constrained tripolar acetabular liner to treat intraoperative instability and postoperative dislocation after total hip arthroplasty: a review of our experience

Clin Orthop Relat Res

(2004)

C. Berton et al.

The Durom large diameter head acetabular component: early results with a large-diameter metal-on-metal bearing

J Bone Joint Surg Br

(2010)

M.A. Mont et al.

The use of dual-mobility bearings in difficult hip arthroplasty reconstructive cases

Surgical Technology International XXI

(2012)

Cited by (64)

Fibromyalgia Increases Post-operative Healthcare Utilization Following total Hip Arthroplasty
2023, Journal of Arthroplasty
Preoperative factors can complicate the postoperative course and increase health care utilization following total hip arthroplasty (THA). Fibromyalgia is not generally recognized as a modifiable risk factor prior to THA. The aim of this investigation was to assess the effect of fibromyalgia on postoperative health care utilization following THA.
Patients who underwent primary THA from 2018 to 2019 were identified from a large national database using Current Procedural Terminology and International Classification of Diseases, tenth revision (International Classification of Diseases-10) codes. Patient demographics, age, sex, and preoperative opioid use were collected. Analysis compared patients who did and did not have fibromyalgia for postoperative health care utilization metrics; lengths of stay (LOS), 90-day postoperative opioid usages, dislocations, and emergency room visits. Independent t-tests were used to compare LOS and rates of ongoing opioid use. Logistic regression analyses with adjusted odds ratios evaluated the risk of dislocation and emergency room visit after adjusting for demographic characteristics and comorbidities.
Compared to those who did not have fibromyalgia, patients who had fibromyalgia experienced longer LOS (P < .0001), increased odds of opioid use 90 days postoperatively (P < .0001) as well as increased odds of hip dislocation (P < .0001) and presentation to the emergency room (P < .0001). Patients who had fibromyalgia were also more likely to be “frequent flyers” with ≥5 emergency room visits after THA (P < .0001).
Fibromyalgia can complicate postoperative care following THA with increased LOS, higher rates of opioid use, and increased odds of dislocation and emergency room visits. As focus shifts to preoperative optimization and risk stratification, more attention should be placed on fibromyalgia prior to THA.
Direct Anterior Approach for Primary Total Hip Arthroplasty Lowers the Risk of Dislocation Compared to the Posterior Approach: A Single Institution Experience
2022, Journal of Arthroplasty
Citation Excerpt :
Multiple studies have shown that larger heads are associated with reduced dislocation rates [16,23–25]. Stroh et al [24] found reduced dislocation rates among 36 mm or greater femoral heads in a study of the anterolateral approach. Berry et al found that femoral head diameter had the greatest effect on cases performed through the PA, but it also affected cases using the anterolateral approach [15].
One purported benefit of the direct anterior approach (DAA) for total hip arthroplasty (THA) is a lower rate of postoperative dislocation.
An institutional database was used to identify 8840 primary THAs performed from 2003 to 2020 including 5065 (57%) performed using the DAA and 3775 (43%) performed via the posterior approach (PA). Direction and mechanism of dislocation were determined from chart review. Outcomes were compared using Kaplan-Meier survivorship with dislocation as the endpoint and a Cox multivariate regression was used to investigate factors associated with dislocation. The mean follow-up was 1.7 ± 2.0 years for the DAA and 3.1 ± 3.3 years for the PA.
The 0.5% (26/5065) incidence of dislocation among DAA hips was significantly less than the 3.3% (126/3775) among PA cases (P < .001). The majority of dislocations were posterior (DAA 57%, PA 79%) and occurred during activities of daily living (DAA 82%, PA 77%). Five-year survivorship was significantly higher for the DAA group compared to the PA group (99.1% vs 95.4%, P < .001). Dislocation risk was 4.9 times higher for the PA compared to the DAA (hazard ratio = 4.9, 95% confidence interval = 3.2-7.5, P < .001). Increasing head diameter reduced the risk (hazard ratio = 0.70, 95% confidence interval = 0.57-0.86, P < .001). The 0.2% incidence (10/5065) of revision for instability among the DAA group was significantly lower than the 1.1% (43/3775) rate for the PA group (P < .001).
Compared to primary THAs performed with the PA, DAA cases had a lower risk of dislocation, higher survivorship with dislocation as an endpoint, and a lower risk of revision for instability in this single institution cohort.
Monobloc Dual Mobility With a Minimum 5-Year Follow-Up: A Safe and Effective Solution in Primary Total Hip Arthroplasty
2022, Journal of Arthroplasty
Instability constitutes over 20% of revisions after total hip arthroplasty (THA). Dual mobility (DM) designs were introduced as a solution to this problem. However, the few publications that have reported promising results for monobloc DM constructs have been limited by sample size or length of follow-up. The purpose of this study is to evaluate mid-term outcomes (minimum 5-year follow-up) of a single-surgeon series utilizing a monobloc DM acetabular component in patients with high risk for dislocation.
This is a single-surgeon consecutive series of 207 primary THAs implanted with a monobloc DM component in patients who were considered at high risk for dislocation. Patient demographics and case-specific data were collected retrospectively. All patients had a minimum of 5-year follow-up. The Mann-Whitney U test was used to assess continuous variables, whereas categorical variables were analyzed using the chi-square test. Survival probability was calculated using the Kaplan-Meier method.
Radiographic analysis did not reveal acetabular radiolucency in any patients, and there were no revisions for aseptic loosening. In addition, there were no dislocations. Seven of 205 patients (3.4%) were revised, 5 on the femoral side due to periprosthetic fracture and the remaining two for infection. Survivorship of the acetabular component from revision was 99%. The mean Veteran RAND (VR-12) physical score improved from 7 (standard deviation [SD]: 13.7) preoperatively to 9.5 (SD: 17.6) at the final follow-up. Similarly, the hip disability osteoarthritis score improved from 8 (SD: 17.9) preoperatively to 21.2 (SD: 37).
Monobloc DM components reliably prevent dislocation after primary THA in high-risk patients. At mid-term follow-up, this DM monobloc component demonstrates excellent implant survivorship, radiographic fixation, and improved functional outcomes.
Outcome of Dual Mobility Constructs for Adverse Local Tissue Reaction Associated Abductor Deficiency in Revision Total Hip Arthroplasty
2020, Journal of Arthroplasty
Treatment of adverse local tissue reaction (ALTR) is challenging owing to high complications and poor outcomes after a revision surgery. As dislocation is the most common cause of reoperation, it is often necessary to use advanced articulations such as dual mobility. This study aims to evaluate the outcome and complication rates after revision surgery with dual mobility constructs, compared to constrained and conventional articulations in the setting of significant abductor deficiency due to ALTR.
Out of a total of 338 revision total hip arthroplasties for ALTR, 234 patients with a significant tissue necrosis and abductor muscle insufficiency (grade 3) were evaluated. The complication rates after revisions were compared between 42 hips with dual mobility implants, 24 hips with constrained liners, 104 hips with large diameter heads (36-40 mm), and 64 hips with small diameter heads (≤32 mm).
After an average of 4 years of follow-up (2.8-8.6), the dual mobility articulation had no dislocation, compared to 4.1% and 15.5% for constrained liner and conventional articulations, respectively (P < .001). Utilization of dual mobility and constrained liner cup also did not increase the risk of nondislocation complications, including periprosthetic joint infection and periprosthetic fracture (P = .18 and .52).
This study demonstrates significantly lower dislocation rates for dual mobility when compared to conventional articulations and comparable to constrained liners in cases of severe abductor deficiency due to ALTR, suggesting that dual mobility implants are viable surgical treatment alternatives to constrained liners to minimize dislocation during revision total hip arthroplasty in the setting of significant abductor deficiency due to ALTR.
Plain radiography findings to predict dislocation after total hip arthroplasty
2019, Journal of Orthopaedic Translation
Citation Excerpt :
With the improvement of the surgical techniques and prosthesis design, the rate of dislocation after total hip arthroplasty (THA) has decreased to 0.05–3.9%, according to the recent reports [1–3].
With the improvements of modern surgical techniques and hip prosthesis, the causes for dislocation after total hip arthroplasty (THA) have changed. The aim of this retrospective analysis was to identify new plain radiography findings to predict dislocation after THA.
Five thousand five hundred thirteen consecutive primary THAs performed between January 2000 and December 2014 were reviewed through a nested case–control study design. Among them, 38 patients with 39 hip dislocations (dislocation group) were selected and matched to 78 hips in 78 patients without dislocation (control group). The factors that might influence the prosthetic stability were identified by univariate analyses, and a multivariate logistic regression analysis was performed to determine the odds ratio of each factor.
The difference of the cup position was not statistically significant. The newly identified risk factors were the following: preoperative hip adduction deformity combined with limb lengthening of 2 cm postoperatively; a knee valgus combined with pelvic obliquity deformity and bilateral pathological hips.
Patients with soft tissue imbalance, across joint deformity around hips and bilateral pathological hips seem more predisposed to suffer from dislocation after THA. Appropriate surgical intervention strategies along with meticulously postoperative management may help preventing dislocation after THA.
A better understanding of the probable causes of dislocation after THA proposed a new clinical application of plain radiography. This radiography-related clinical research may reveal the novel mechanism of dislocation after THA and new preventive measures.
The Role of Crosslinked Polyethylene in Reducing Aggregated Costs of Total Hip Arthroplasty in the United States
2019, Journal of Arthroplasty
Widespread adoption of crosslinked polyethylene for the acetabular articular surface for total hip arthroplasty has substantially reduced revision rates and dislocation rates. We aim to provide estimates of the resulting magnitude of the annual reduction in aggregated costs of total hip arthroplasty surgery in the United States.
After we obtained, from the literature, the contrasting mid-term rates of revisions and dislocations of total hip arthroplasty using conventional polyethylene vs those using crosslinked polyethylene, specifically from only registry studies and prospective, randomized controlled studies, we multiplied these incidence figures by the cost estimates of these failures to generate approximations of the cost savings in the United States from the use of crosslinked polyethylene.
The estimates suggest that in the United States these savings might be one billion dollars per annual cohort over a 15-year duration.
The use of crosslinked polyethylene has reduced substantially the overall costs of total hip arthroplasty surgery in the United States.

View all citing articles on Scopus

: The Conflict of Interest statement associated with this article can be found at http://dx.doi.org/10.1016/j.arth.2012.11.017.

View full text

Reduced Dislocation Rates and Excellent Functional Outcomes With Large-Diameter Femoral Heads

Abstract

Section snippets

Methods

Results

Discussion

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

Incidence rates of dislocation, pulmonary embolism, and deep infection during the first six months after elective total hip replacement

J Bone Joint Surg Am

Femoral head size is a risk factor for total hip luxation: a study of 42,987 primary hip arthroplasties from the Norwegian Arthroplasty Register

Acta Orthop Scand

Effect of femoral head diameter and operative approach on risk of dislocation after primary total hip arthroplasty

J Bone Joint Surg Am

Late dislocation after total hip arthroplasty

J Bone Joint Surg Am

Jumbo femoral head for the treatment of recurrent dislocation following total hip replacement

J Bone Joint Surg Am

Economic burden of revision hip and knee arthroplasty in Medicare enrollees

Clin Orthop Relat Res

Tripolar hip replacement for recurrent prosthetic dislocation

Clin Orthop Relat Res

Reducing the risk of dislocation after total hip arthroplasty: the effect of orientation of the acetabular component

J Bone Joint Surg Br

The role of patient restrictions in reducing the prevalence of early dislocation following total hip arthroplasty. A randomized, prospective study

J Bone Joint Surg Am

Use of a constrained tripolar acetabular liner to treat intraoperative instability and postoperative dislocation after total hip arthroplasty: a review of our experience

Clin Orthop Relat Res

The Durom large diameter head acetabular component: early results with a large-diameter metal-on-metal bearing

J Bone Joint Surg Br

The use of dual-mobility bearings in difficult hip arthroplasty reconstructive cases

Surgical Technology International XXI