Dislocation and Infection After Revision Total Hip Arthroplasty: Comparison Between the First and Multiply Revised Total Hip Arthroplasty

doi:10.1016/j.arth.2011.04.022

The Journal of Arthroplasty

Volume 26, Issue 8, December 2011, Pages 1170-1175

https://doi.org/10.1016/j.arth.2011.04.022 Get rights and content

Abstract

Dislocation and infection are common complications of total hip arthroplasty (THA). This study evaluated the correlation between the number of revision THAs and the incidence of these complications. Data were obtained from 749 revision THAs. Average follow-up was 13.2 ± 5.9 years. Patients were grouped as first, second, third, and fourth or greater revision THA. Dislocation rates (5.68%, 7.69%, 8.33%, and 27.45%) and infection rates (1.35%, 1.92%, 2.5%, and 7.84%) in the first, second, third, and fourth or greater groups, respectively, correlated directly with the revision number and were highest (P < .001) in the fourth or greater group. Dislocation and infection are exponentially correlated with the number of revision THA. From the fourth revision onward, those risks are multiplied.

Section snippets

Materials and Methods

Between January 1982 and December 2005, 887 revision THAs were performed in 761 patients by the senior author (A.E.G.). After each revision, data were recorded in a prospective database. One hundred six revisions (11.9%) that consisted of liner exchange only (54 revisions) or were specifically performed for infection (28 revisions) or instability (24 revisions) were excluded. In addition, 32 (3.6%) revisions were lost to follow-up, leaving 749 revision THAs in 632 patients available for

Results

Dislocations were encountered after 61 (8.14%) revisions. Rates of dislocations were similar in male and female subjects. Forty-one (8.2%) dislocations occurred in female and 20 (8.03%) in male subjects (P = .468).

Dislocation rate correlated directly with the number of the revision and was found significantly higher (P < .001) in the group that had 4 or more revisions (5.68%, 7.69%, 8.33%, and 27.45%, respectively; Fig. 1). Dislocation rates increased by 35%, 46%, and 383% after the second,

Discussion

Hip arthroplasty is widely recognized as an effective surgical procedure that provides reliable pain relief, improved level of function, and better quality of life to patients with coxarthrosis [17]. Approximately 200 000 primary and 36 000 revision THAs were performed in the United States in 2003 [6]. With prolonged life expectancy and more hip arthroplasties performed in young patients, revision hip arthroplasties are expected to be performed with increasing frequency.

Dislocations and

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Cited by (56)

Dual-Mobility versus Large Femoral Heads in Revision Total Hip Arthroplasty: Interim Analysis of a Randomized Controlled Trial
2023, Journal of Arthroplasty
This multicenter randomized controlled trial evaluated if dual-mobility bearings (DM) lower the risk of dislocation compared to large femoral heads (≥36 mm) for patients undergoing revision total hip arthroplasty (THA) via a posterior approach.
A total of 146 patients were randomized to a DM (n = 76; 46 mm median effective head size, range 36 to 59 mm) or a large femoral head (n = 70; twenty-five 36 mm heads [35.7%], forty-one 40 mm heads [58.6%], and four 44 mm heads [5.7%]). There were 71 single-component revisions (48.6%), 39 both-component revisions (26.7%), 24 reimplantations of THA after 2-stage revision (16.4%), seven isolated head and liner exchanges (4.8%), four conversions of hemiarthroplasty (2.7%), and 1 revision of a hip resurfacing (0.7%). Power analysis determined that 161 patients were required in each group to lower the dislocation rate from 8.4 to 2.2% (power = 0.8, alpha = 0.05).
At a mean of 18.2 months (range, 1.4 to 48.2), there were three dislocations in the large femoral head group compared to two in the DM cohort (4.3 versus 2.6%; P = .67). One patient in the large head group and none in the DM group were successfully treated with closed reduction without subsequent revision.
Interim analysis of this randomized controlled trial found no difference in the risk of dislocation between DM and large femoral heads in revision THA, although the rate of dislocation was lower than anticipated and continued follow-up is needed.
Irrigation Solutions and Antibiotic Powders: Should I Use Them in Primary and Revision Total Joint Arthroplasty?
2022, Journal of Arthroplasty
Citation Excerpt :
There is limited clinical data in arthroplasty on the use of hydrogen peroxide for the prevention or treatment of PJI. Recent studies use hydrogen peroxide in combination with dilute PI where it has been shown to have synergistic effect and lower the cytotoxic concentration of each compound needed to be effective [20,21]. Acetic acid is a weak organic acid that is produced by the oxidation of ethanol [22].
The prevention and treatment of periprosthetic joint infection is of utmost importance to orthopedic surgeons. Irrigation solutions have become a popular additive to the prevention and treatment armamentarium.
This symposium summarizes the mechanism of action, basic science, and clinical research to date on the use of irrigation solutions. The four most commonly used irrigation solutions, povidone iodine, chlorhexidine, hydrogen peroxide, and acetic acid, are discussed. In addition, the role of antibiotic powers is reviewed.
Each solution has its risks and benefits that must be weighed by the surgeon. There is no clear irrigation solution that is superior. The role of additive antibiotic powder (vancomycin) remains controversial.
More rigorous prospective clinical trials are needed to determine the optimal irrigation solution for the prevention and treatment of periprosthetic joint infection.
The use of a triflange salvage system for catastrophic pelvic osteolysis after failed total hip arthroplasty
2021, Journal of Orthopaedics
Citation Excerpt :
Aside from her severe pelvic osteolysis, she was at an increased risk for recurrent dislocations due to her history of avascular necrosis29 and multiple surgical revisions prior to the triflange implant.37 Kosashvili et al. reported that revisions posed a significantly higher risk of dislocation and infection in patients who underwent four or more revision surgeries,37 which is consistent with this patient's history. Another potential disadvantage of the triflange implant is its manufacturing process.
The custom triflange acetabular implant (CTAI) has been described to address catastrophic pelvic osteolysis, but long-term outcome data is scarce.
Revision-free survivorship after revision THA with a CTAI was retrospectively reviewed in seven patients.
Mean and median follow-up time were 7.39 (1.61–16.8) years and 7.50 years, respectively. Revision-free survivorship was 85.7% (6/7). One patient underwent revision for recurrent dislocations. All patients were able to ambulate at recent follow-up— 2/7 without assistance.
The CTAI is a viable option for patients with catastrophic pelvic osteolysis. There is a high complication rate, but the incidence of revision is low.
What to Do When Revision Procedures Fail to Prevent Recurrent Hip Dislocation in THA? A Novel Simple Technique for Selected Patients
2021, Arthroplasty Today
Failure to achieve postoperative stability is disappointing for both surgeons and patients after revision total hip arthroplasty. In particular, when available revision options have been exhausted. We describe our modification of previously reported surgical techniques without revising any component in a high-risk female patient with persistent hip dislocation despite multiple cup revisions using different implants. To stabilize the hip through the posterolateral approach, a synthetic polyethylene tube was used. This relatively simple, modified technique may be a solution in disappointing cases with failure to achieve hip stability in revision total hip arthroplasty.
Anterior Revision Hip Arthroplasty is Associated With Higher Wound Complications but Fewer Dislocations Compared to Posterior Revision Hip Surgery
2021, Journal of Arthroplasty
Citation Excerpt :
Although a statistically significant difference in BMI between groups on univariate analysis was found, it likely does not meet the minimal clinically important difference for obesity. The deep surgical-site infection rates seen in our study of 5.1% and 5.2% for the DAA and posterior groups, respectively, are in keeping with previously published infection rates after revision THA, which range from 1.35% to 7.84% [12,13]. Of the 7 wound complications noted in the DAA cohort, all were after aseptic revisions.
Wound complication after primary direct anterior (DAA) hip arthroplasty has been reported in the literature but there has been no comparison regarding revision anterior vs revision posterior (PA) hip arthroplasty. The authors hypothesize that anterior approach revision surgery may have increased wound complications compared with posterior hip revisions and also report on secondary outcome metrics.
Ninety-nine DAA and 191 PA revisions were included for analysis. Preoperative demographic characteristics, indication for revision, operative details, type of revision performed, components utilized, and postoperative complications were compared between DAA and PA groups including multivariate analysis.
The DAA cohort demonstrated an increased risk of superficial wound complications (7.1% vs 0.5%, P = .003) and a decreased dislocation rate (2.0% vs 13.1%, P = .002). There was a trend toward increased overall complications in the PA group (OR 1.71, P = .078).
Revision DAA THA is associated with an increased risk of superficial wound complications, but may impart a decreased dislocation rate.
Tripolar Articulations as a “High Stability Bearing” for Revision Total Hip Arthroplasty: Success Rates and Risk Factors for Failure
2020, Journal of Arthroplasty
Unconstrained tripolar articulations have been theorized to increase hip stability. The purpose of this study is to report the performance of tripolar articulations in revision THA and identify factors associated with success and failure.
Between 1994 and 2016, 67 revision THAs were performed with an unconstrained tripolar articulation. Mean follow-up was 5.4 years. Patient charts were retrospectively reviewed emphasizing factors associated with risk of instability. There were 21 patients with neither a history of instability (HI) nor abductor insufficiency (AI), 20 patients with HI alone, 13 with AI alone, and 13 had both HI and AI.
Twelve THAs sustained at least one postrevision dislocation at an average of 2.1 years. One bipolar dissociation occurred early (1.2 y). Nine hips had a re-revision to address these complications. Survival free from dislocation at 2, 5, and 10 years was 88%, 85%, and 74%, respectively. Survival free from re-revision at 2, 5, and 10 years was 91%, 84%, and 65%, respectively. Patients with combined AI and HI had the worst survivorship free from dislocation at 2, 5, and 10 years (77%, 68%, and 55%), respectively. In contrast, patients with neither HI nor AI experienced zero dislocations. There were no failures associated with bearing wear.
Off-the-shelf tripolar articulations were associated with reasonable survival at midterm follow-up. In patients with both AI and HI, the risks and benefits of alternative options such as dual mobility or constrained liners should be explored as the risk of dislocation at 10 years approached 50%.

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: The Conflict of Interest statement associated with this article can be found at doi:10.1016/j.arth.2011.04.022

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Dislocation and Infection After Revision Total Hip Arthroplasty: Comparison Between the First and Multiply Revised Total Hip Arthroplasty

Abstract

Section snippets

Materials and Methods

Results

Discussion

Orthop Clin North Am

Ortho clin North Am

J Tissue Viability

J Arthroplasty

Total hip arthroplasties: what are the reasons for revision?

Int Orthop

Dislocation after Revision THA; analysis of risk factors and treatment options

J Bone Joint Surg Am

Rates and outcomes of primary and revision total hip replacement in the United States medicare population

J Bone Joint Surg Am

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

J Bone Joint Surg Am

Incidence and short-term outcomes of primary and revision hip replacement in the United States

J Bone Joint Surg Am

Dislocation after total hip arthroplasty: implant design and orientation

J Am Acad Orthop Surg

Impingement with total hip replacement

J Bone Joint Surg Am

Dislocations after total hip-replacement arthroplasties

J Bone Joint Surg Am