Utilizing Dual Mobility Components for First-Time Revision Total Hip Arthroplasty for Instability

doi:10.1016/j.arth.2017.09.029

The Journal of Arthroplasty

Volume 33, Issue 2, February 2018, Pages 505-509

https://doi.org/10.1016/j.arth.2017.09.029 Get rights and content

Abstract

Background

Dislocation following total hip arthroplasty (THA) remains a significant clinical problem. Few studies have focused on the use of dual mobility (DM) components in the setting of first-time revision for instability following THA. Here, we investigate patient outcomes following first-time revision THA with DM components for a diagnosis of instability.

Methods

Institution-wide revision THAs using DM components performed between 2010 and 2013 were identified. Chart review identified 40 patients with average 3-year follow-up who had undergone first-time revision for instability, defined as instability after primary THA. Etiology of instability was classified by Wera type. Patient demographics, medical co-morbidities, re-dislocations, and re-revisions were recorded. Component position and leg-length discrepancy were measured on pre-operative and post-operative radiographs when available. Utilizing Student's t-test or Fisher's exact test, we analyzed differences between those who endured recurrent dislocation and those who did not.

Results

Recurrent dislocation occurred in 2 patients (5%). Both patients underwent re-revision for recurrent instability and carried diagnoses of instability of unresolved etiology. Two patients underwent re-revision for reasons unrelated to the DM construct. All-cause re-revision rate at final follow-up was therefore 10% (4 patients). No medical, demographic, or radiographic factors were significantly associated with risk of recurrent instability (P > .05).

Conclusion

The use of DM components for first-time revision THA for a diagnosis of instability carried a re-dislocation rate of 5% and an all-cause re-revision rate of 10% at average 3-year follow-up. Instability of unresolved etiology was associated with re-dislocation following revision surgery.

Section snippets

Methods

This is an Institutional Review Board–approved retrospective cohort study. Cases of revision THA using DM components between 2010 and 2013 were identified using a hospital-wide total joint registry. A retrospective chart review identified 40 patients who had undergone first-time revision for a diagnosis of instability. Patient demographics, medical co-morbidities, re-dislocations, and re-revisions were identified. Etiology of instability was classified using the scheme proposed by Wera et al [9]

Results

No radiolucent lines surrounding acetabular components or component position changes were noted at latest follow-up. Thirty-eight patients had experienced no recurrent dislocations at final follow-up. Recurrent instability occurred in 2 patients (5%) at final follow-up, both of whom had been classified as having type VI instability (unresolved etiology) pre-operatively. Both patients experienced 2 or more recurrent dislocations, and were subsequently re-revised for a diagnosis of recurrent

Discussion

The use of DM components in the setting of first-time revision THA for a diagnosis of instability carried a recurrent dislocation rate of 5% at average 3-year follow-up. No significant medical, demographic, or radiographic risk factors for recurrent instability following revision THA could be identified, but we must emphasize that the small cohort size may affect our ability to determine significant differences. Patients revised for acetabular component malposition, impingement, and late wear

Conclusions

In summary, we have reported a favorable recurrent dislocation rate (5%) at short-term follow-up after first-time revision THA with DM components for a diagnosis of instability. No risk factors for recurrent dislocation or re-operation following revision surgery could be identified. Although our cohort was small, no patients undergoing revision for component malposition, late wear, or impingement sustained subsequent dislocations after revision surgery. We also note that all patients in whom a

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Cited by (21)

Short Term Outcomes (Average Follow-Up of 2.4 Years) of a Constrained Acetabular Liner in Primary and Revision Total Hip Arthroplasty
2023, Journal of Arthroplasty
As instability continues to be a burden post-total hip arthroplasty (THA), there has been a controversial discussion on the ideal implant choice. We report the outcomes of a modern constrained acetabular liner (CAL) system in primary and revision THA at an average follow-up of 2.4 years.
We performed a retrospective study of all patients undergoing primary and revision hip arthroplasty and being implanted with the modern CAL system from 2013 to 2021. We identified 31 hips, of which 13 underwent primary THA and the remaining 18 underwent revision THA for instability.
Of those implanted with CAL primarily, 3 had concomitant abductor tear repair and gluteus maximus transfer, 5 had Parkinson’s disease, 2 had inclusion body myositis, 1 had amyotrophic lateral sclerosis, and the remaining two were over 94 years of age. All patients implanted with the CAL had active instability post-primary THA and underwent only liner and head exchange without revision of the acetabular or femoral components. At an average follow-up of 2.4 years (ranging from 9 months to 5 years and 4 months), we had 1 case (3.2%) of dislocation post-CAL implantation. None of the patients undergoing surgery with CAL for active instability had a redislocation.
In conclusion, a CAL provides excellent stability in both primary THA in high-risk individuals and revision THA in cases of active instability. There were no dislocations when using a CAL to treat active instability post-THA.
A Meta-Analysis of the Incidence and Temporal Trends of Postoperative Dislocation in Revision Total Hip Arthroplasty Utilizing Constrained Acetabular Components or Dual Mobility Implants
2023, Journal of Arthroplasty
The incidence of dislocation after revision total hip arthroplasty (rTHA) is reported to be up to 25% and remains a common source of failure. Constrained acetabular components and dual mobility implants are two implant classes being utilized to alleviate this burden in patients who have recurrent instability or major intraoperative instability. This meta-analysis evaluated the incidence and temporal trends of dislocation after implantation with constrained acetabular components and dual mobility implants in rTHA.
Longitudinal studies reporting dislocation after the use of constrained acetabular components or dual mobility implants in rTHA were sought from Medline and Embase to October 2022. Secondary outcomes included re-revision surgery for dislocation and all causes. A total of 75 relevant citations were identified comprising 36 datasets of 3,784 constrained acetabular components and 47 datasets of 10,216 dual mobility implants.
For constrained acetabular components, the pooled incidence of dislocation was 9% (95% confidence interval: 7.2, 11.7) (range 0.0%-35.3%) over a weighted mean follow-up of 6 years, in contrast to 3% (95% confidence interval: 2.2, 4.4) (range 0.0%-21.4%) over 5 years for dual mobility implants. Re-revision rates for dislocation after using constrained acetabular components were around 9%, in contrast to 2% for dual mobility implants. Re-revision rates for all causes after using constrained acetabular components were around 19%, in contrast to 8% for dual mobility implants.
Dual mobility implants in the context of rTHA demonstrate lower incidences of dislocation (3% versus 9%), re-revision for dislocation (2% versus 9%), and rer-evision for any cause (8% versus 19%) in contrast to constrained acetabular components. This must be considered by surgeons when implanting such devices, often selected to treat instability.
Femoral Neck Notching in Dual Mobility Implants: Is This a Reason for Concern?
2021, Journal of Arthroplasty
Dual mobility (DM) total hip arthroplasty (THA) implants have been advocated for patients at risk for impingement due to abnormal spinopelvic mobility. Impingement against cobalt-chromium acetabular bearings, however, can result in notching of titanium femoral stems. This study investigated the incidence of femoral stem notching associated with DM implants and sought to identify risk factors.
A multicenter retrospective study reviewed 256 modular and 32 monoblock DM components with minimum 1-year clinical and radiographic follow-up, including 112 revisions, 4 conversion THAs, and 172 primary THAs. Radiographs were inspected for evidence of femoral notching and to calculate acetabular inclination and anteversion. Revisions and dislocations were recorded.
Ten cases of femoral notching were discovered (3.5%), all associated with modular cylindrospheric cobalt-chromium DM implants (P = .049). Notches were first observed radiographically at mean 1.3 years after surgery (range 0.5-2.7 years). Notch location was anterior (20%), superior (60%), or posterior (20%) on the prosthetic femoral neck. Notch depth ranged from 1.7% to 20% of the prosthetic neck diameter. Eight cases with notching had lumbar pathology that can affect spinopelvic mobility. None of these notches resulted in stem fracture, at mean 2.7-year follow-up (range 1-7.6 years). There were no dislocations or revisions in patients with notching.
Femoral notching was identified in 3.5% of DM cases, slightly surpassing the dislocation rate in a cohort selected for risk of impingement and instability. Although these cases of notching have not resulted in catastrophic failures thus far, further study of clinical sequelae is warranted. Component position, spinopelvic mobility, and implant design may influence risk.
Cementation of a monoblock dual mobility bearing in a newly implanted porous revision acetabular component in patients undergoing revision total hip arthroplasty
2019, Arthroplasty Today
Citation Excerpt :
This design affords the patient a greater impingement-free ROM while enlarging the effective size of the femoral head, conferring the mechanical advantages offered by a larger femoral head-jump distance. The current generation of DM implants has shown remarkably low dislocation rates following primary THA and rTHA [18-26]. A recent meta-analysis by Levin et al. [27] reported a short- to mid-term dislocation rate of 2.2% following rTHA with the use of DM articulations.
The most common indications for revision total hip arthroplasty are instability/dislocation and mechanical loosening. Efforts to address this have included the use of dual mobility (DM) articulations. The aim of this study is to report on the use of cemented DM cups in complex acetabular revision total hip arthroplasty cases with a high risk of recurrent instability.
A multicenter, retrospective study was conducted. Patients who received a novel acetabular construct consisting of a monoblock DM cup cemented into a fully porous metal shell were included. Outcome data included 90-day complications and readmissions, revision for any reason, and Harris Hip Scores.
Thirty-eight hips in 38 patients were included for this study. At a median follow-up of 215.5 days (range 6-783), the Harris Hip Score improved from a mean of 50 ± 12.2 to 78 ± 11.2 (P < .001). One (2.6%) patient experienced a dislocation on postoperative day 1, and was closed reduced with no further complications. There was 1 (2.6%) reoperation for periprosthetic joint infection treated with a 2-stage exchange.
In this complex series of patients, cementation of a monoblock DM cup into a newly implanted fully porous revision shell reliably provided solid fixation with a low risk of dislocation at short-term follow-up. Although longer term follow-up is needed, utilization of this novel construct should be considered in patients at high risk for instability.
Fretting and Corrosion Damage of Retrieved Dual-Mobility Total Hip Arthroplasty Systems
2019, Journal of Arthroplasty
Dual-mobility (DM) total hip arthroplasty (THA) systems are designed to increase stability while potentially avoiding problems associated with large femoral heads. Complications of these systems are not yet fully understood. This study aims at characterizing in vivo performance of DM hip systems and assessing modes of clinical failure.
Under an institutional review board–approved implant retrieval protocol, 18 DM THA systems from 17 patients were included. Implants were graded at the head-neck junction for fretting and corrosion based on the system of Goldberg et al. Components were also macroscopically examined for different damage modes. Demographics and surgical data were collected from medical records, and radiographs were assessed for component positioning. Data were analyzed through Spearman rank-order correlation and Mann-Whitney U-tests, with α = 0.05.
The average length of implantation was 13.4 months with mild to moderate fretting corrosion damage. Polyethylene (PE) liners exhibited edge deformation, scratching, and pitting damage. Metallic components exhibited burnishing and scratching damage. Summed fretting and corrosion scores were strongly correlated (ρ = 0.967, P < .0001). Summed corrosion score was moderately correlated with presence of embedding on the PE liner (ρ = 0.690, P = .017). PE liner abrasion and edge deformation of the femoral stem taper were moderately positively correlated (ρ = 0.690, P = .017). Fretting and corrosion damage were not significantly correlated with patient demographics or radiographic positioning of implants. There were no differences in scores between modular and monoblock designs.
These findings demonstrate that dual-mobility THA systems may be susceptible to the same fretting and corrosion damage observed in traditional modular THA systems. Future studies are needed to confirm these results and clinical significance.
Modern Dual-Mobility Cups in Revision Total Hip Arthroplasty: A Systematic Review and Meta-Analysis
2018, Journal of Arthroplasty
Citation Excerpt :
The authors of 2 studies reported using only a posterolateral surgical approach [24,26,28]; 1 used only a direct lateral approach [19]; 3 used a combination of surgical approaches based on index surgical approach and surgeon preference [22,23,27]; and 3 did not specify the surgical approach used [21,25,29]. The types of studies included were 1 prospective case series [26], 3 retrospective cohort studies comparing DM to fixed-bearing cups [19,21,25], and 5 retrospective case series [22–24,27–29]. Authors of all 9 studies reported survivorship rates, and all reported causes of failure of revision THA, which allowed us to stratify survivorship by all-cause survivorship and aseptic survivorship.
The purpose of this systematic review is to analyze the outcomes of dual-mobility (DM) cups in revision total hip arthroplasty (THA). Specifically, we evaluated the following: (1) all-cause and aseptic survivorship rates; (2) dislocation rates; (3) complications; and (4) clinical outcomes reported using validated health status measures.
A comprehensive literature search included studies that reported the following: (1) re-revision rates, (2) complications, and (3) clinical outcomes following DM use in revision THA. The following exclusion criteria were used: (1) studies that did not stratify their analysis between primary and revision THA, (2) studies that utilized off-label techniques, (3) review articles, (4) case studies, (5) basic science articles, (6) non–English language reports, and (6) reports on patients who underwent surgery before 2010, in order to reflect modern DM implants use and technology. A total of 9 studies were included in our final analysis.
Aseptic and all-cause survivorship rates were 97.7% and 94.5%. Prevalence of dislocation was 2.2%, and 0.3% for intraprosthetic dislocation. Meta-analysis comparing DM to fixed-bearing prostheses demonstrated a significantly lower odds of dislocation in the DM cohort (odds ratio 0.24, P = .002). Complications occurred in 7.4% of revision THAs with DM cups, while infection rates totaled to 3.3% of cases. Studies comparing outcomes using Harris Hip Scores did not demonstrate a statistically significant difference in improved postoperative scores (P > .05).
DM cups have demonstrated excellent survivorship, low dislocation, and overall complication rates. Therefore, it can be considered a safe and effective option, particularly in the high-risk patients who undergo revision THA.

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: Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

: One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to https://doi.org/10.1016/j.arth.2017.09.029.

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Revision ArthroplastyUtilizing Dual Mobility Components for First-Time Revision Total Hip Arthroplasty for Instability

Abstract

Background

Methods

Results

Conclusion

Section snippets

Methods

Results

Discussion

Conclusions

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

Orthop Traumatol Surg Res

Orthop Traumatol Surg Res

J Arthroplasty

J Arthroplasty

Dislocation after revision total hip arthroplasty: an analysis of risk factors and treatment options

JBJS Am

Acetabular revision with the contour antiprotrusio cage

Clin Orthop Relat Res

Revision hip arthroplasty for late instability secondary to polyethylene wear

Clin Orthop Relat Res

The Frank Stinchfield Award: dislocation in revision THA: do large heads (36 and 40 mm) result in reduced dislocation rates in a randomized clinical trial?

Clin Orthop Relat Res

Risk factors for dislocation after revision total hip arthroplasty

Clin Orthop Relat Res

Dislocation after the first and multiple revision total hip arthroplasty: comparison between acetabulum-only, femur-only and both component revision hip arthroplasty

Can J Surg

Revision Arthroplasty
Utilizing Dual Mobility Components for First-Time Revision Total Hip Arthroplasty for Instability