Original article
A multimodal approach prevents instability after total hip arthroplasty: A 1 year follow-up prospective study

https://doi.org/10.1016/j.jcot.2016.11.004Get rights and content

Abstract

Introduction

Joint dislocation is one of the most frequent complications after hip arthroplasty. Multiple strategies have demonstrated ability to prevent instability when used in isolation, but the effect when more than one intervention is implemented has not been measured. The purpose of this study is to assess the rate of dislocation after implementation of a protocol of combined strategies for prevention of instability.

Materials and methods

Consecutive patients undergoing primary total hip replacement for hip osteoarthritis between February 2012 and June 2014 were included. A multimodal protocol including patient education, use of large femoral heads, posterior soft-tissue repair, and intraoperative adjustment of limb length and hip offset was applied. Dislocation episodes were documented trough medical records review and a telephonic follow-up at 3 and 12 months after surgery.

Results

During the period of study 331 patients were included, mean age was 66 years and 68.8% were females. Only 0.91% of patients were lost to follow-up. Eighty-nine percent of patients received all interventions. Cumulative dislocation rate at 3 months was 0.60% and 0.90% at 12 months.

Conclusions

The implementation of a multimodal protocol for prevention of prosthesis instability produces a low rate of dislocation, which compares favorably with benchmarks. We recommend the use of a combination of multiple interventions to prevent this complication.

Introduction

Prosthesis dislocation is one of the most frequent complications after hip arthroplasty.1 The prevalence of this complication ranges between 0.2 and 7%1, 2, 3 and it is the third cause of revision surgery after aseptic loosening and periprosthetic infection.4, 5, 6, 7 Despite that two thirds of the cases of instability can be resolved with non-surgical treatment,8 the Australian National Registry of Joint Replacements reports that 13–42% of re-operations are due to this complication.9 Although dislocation might occur at any moment after implantation of the hip prosthesis, it has been described that there is a high risk for dislocation during first 3 months after surgery.1, 10, 11 Meek et al. reviewed the Scottish National arthroplasty non-voluntary registry and found that 23% of dislocations occurred during the first 3 months and 43% between 3 and 12 months.12

Instability after primary total hip replacement is associated with multiple risk factors that depend on the characteristics of the patient, surgical technique and implant selection.1, 8, 9, 13, 14 Factors related to patients are: gender, age, obesity, ASA (American Society of Anesthesiologists) classification, epilepsy, neuromuscular disorders, ligamentous laxity, rheumatoid arthritis, avascular necrosis of the femoral head, intracapsular fractures.9, 15, 16

On the other hand, factors associated with the procedure such as surgical technique, implant selection, restoration of limb length and offset, adequate implant positioning, use of large femoral heads,17, 18 and posterior soft-tissue repair (posterior capsule, piriformis tendon, and conjoined tendon),13, 19 have demonstrated to prevent instability when used in isolation,20, 21 but the effect, when more than one intervention is implemented, has not been measured. Therefore, a multimodal protocol for prevention of instability has been developed and implemented in our institution in order to diminish the risk of dislocation after total primary hip arthroplasty.

The contribution of this study to current orthopedic knowledge is to report the rate of dislocation when a multimodal protocol for prevention of instability is implemented. It further seeks to describe the rate of dislocation after total primary hip arthroplasty when multiple proven strategies are combined for prevention of instability, which is yet to be reported in current orthopedic studies.

Section snippets

Materials and methods

A prospective cohort study was conducted, including consecutive patients who were scheduled for primary total hip arthroplasty and in whom the multimodal protocol for prevention of instability was implemented, between February 2012 and June 2014. Identification of cases of dislocation was carried out by telephonic follow-up at 3 and 12 months after the date of surgery. Every patient included for analysis had a 12 month follow-up assessment. Patients requiring hip arthroplasty for hip fractures

Theory

As previously stated prosthesis instability remains one of the most common causes of revision surgery after total hip replacement. There exists several strategies for the prevention of this complication however, to the best of our knowledge, there are no descriptions in the literature regarding the effect of combining these strategies. Therefore this study seeks to describe the implementation of a protocol for prevention of hip prosthesis dislocation that includes 6 different approaches, and to

Results

During the period of study 331 patients were included, 228 females and 103 males. Mean age was 66.2 years. Three patients (0.91%) were lost to follow-up: 2 patients died within the first month after surgery and 1 patient was not available for contact (Table 1). With the exception of these losses to follow-up, patients were contacted at 3 months and 1 year after surgery.

Eighty-nine percent of patients (295/331) received all interventions. All patients received education according to parameters

Discussion

Hip replacement surgery is a safe and effective procedure for the treatment of osteoarthritis and hip fractures. Regardless the high level of standardization of this procedure, instability remains one of the most frequent and disturbing complications.1, 2, 3 Although several strategies have demonstrated to be effective in reducing dislocation rates, to the best of our knowledge this is the first time that a multimodal protocol comprising these interventions has been assessed in a prospective

Conclusion

With the implementation of multiple preventive strategies for dislocation, we obtained results comparable to the lowest dislocation rates previously reported in the literature.1, 2 Thus, we consider that the implementation of combined strategies during hip replacement surgery is more effective than their use in isolation and we recommend the implementation of a multimodal protocol for prevention of prosthetic instability.

Research involving human participants and/or animals

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.

Ethical approval

All applicable international, national, and/or institutional guidelines for the care and use of animals were followed.

Informed consent

Local IRB did not request the consent form patients as per the study design.

Conflicts of interest

  • Dr. Omar Amado has nothing to disclose.

  • Dr. Maria Bautista has received other financial support from DePuy Synthes (Orthopedics) and Grunenthal, outside this work.

  • Dr. Jose Moore has nothing to disclose.

  • Dr. Guillermo Bonilla has participated as paid speaker for Boehringer-Ingelheim, Pfizer, Bristol-Myers-Squibb, DePuy Synthes (Orthopedics) and Stryker; has received other financial support from DePuy Synthes (Orthopedics) and Grunenthal, outside this work.

  • Nicolas Jimenez has nothing to disclose.

Acknowledgements

The authors wish to thank and acknowledge Camilo Gutierrez for his invaluable assistance when writing this article. His medical editing and writing were pivotal for the production of this paper.

We thoughtfully thank Dr. José Navas for his substantial contribution in the elaboration of this concept. Dr. Navas proposed the model of implementation of multiple strategies, rather than a single one, for the prevention of instability after hip replacement, and has worked during several years on

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