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Dual-Mobility Articulations for Patients at High Risk for Dislocation
The Journal of Arthroplasty xxx (2016) 1e5
Contents lists available at ScienceDirect
The Journal of Arthroplasty journal homepage: www.arthroplastyjournal.org
AAHKS Supplement paper
Dual-Mobility Articulations for Patients at High Risk for Dislocation Darren R. Plummer, MD, MBA a, *, Jonathan M. Christy, MD b, Scott M. Sporer, MD c, d, Wayne G. Paprosky, MD c, d, Craig J. Della Valle, MD c a
Department of Orthopaedic Surgery, The Ohio State University, Columbus, Ohio Optim Orthopedics, Savannah, Georgia c Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois d Department of Orthopaedic Surgery, Central DuPage Hospital, Winfield, Illinois b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 24 November 2015 Received in revised form 23 February 2016 Accepted 1 March 2016 Available online xxx
Background: The purpose of this study was to evaluate the performance of dual-mobility articulations in patients at high risk for dislocation after revision total hip arthroplasty. Methods: We reviewed the results of 36 consecutive revision total hip arthroplasties performed on patients considered high risk for instability. Indications for inclusion included abductor insufficiency, recurrent instability, failure of constrained liner, or inadequate intraoperative stability when trialing. Results: At a minimum of 2 years, there were 4 (11.1%) repeat revisions including both dual-mobility liners that were cemented into an acetabular shell and 2 for deep infection treated with a 2-stage exchange. There was one dislocation that was successfully closed reduced but no revisions for recurrent instability. The mean Harris hip score improved from 45 to 90 points (P < .001). Conclusion: Dual-mobility articulations are associated with a low rate of failure with no revisions for instability in this challenging group of patients. © 2016 Elsevier Inc. All rights reserved.
Keywords: dislocation dual mobility revision total hip arthroplasty instability high risk
Instability after total hip arthroplasty (THA) remains a persistent problem. It is the most common cause for revision THA in the United States and similarly is the most common complication after revision THA [1-3]. Current reports estimate the rate of dislocation to be as high as 28% after revision THA [4-6]. Despite the numerous advances in implant design, surgical technique, and postoperative management, the rate of instability remains relatively high following revision procedures [7]. Numerous prosthetic options and surgical approaches have been attempted to both prevent and treat instability. Dual-mobility bearings are relatively new to the North American market, but variations on the concept have been used clinically in Europe for more than 35 years. The design affords greater range of motion (ROM), a greater head-to-neck ratio, and a larger effective head size that increases jump distance. Several studies suggest that these articulations can be used for preventing or treating instability
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 doi: http://dx.doi.org/10.1016/j.arth.2016.03.021. * Reprint requests: Darren R. Plummer, MD, MBA, Department of Orthopaedic Surgery, The Ohio State University Wexner Medical Center, 140 Liberty Street, Apt 3110, Columbus, OH 43215. http://dx.doi.org/10.1016/j.arth.2016.03.021 0883-5403/© 2016 Elsevier Inc. All rights reserved.
[8-11]. Although these bearings have their own concerns, including intraprosthetic dislocation and theoretically higher wear rates due to the dual articulating nature of the design, our group viewed them as a potential alternative for managing complex patients at high risk for instability after revision THA. The risk of recurrent dislocation is greater after revision surgery than primary THA [5,12-14], and hence, the use of dual mobility is attractive for revision procedures and for the treatment of the hip that is unstable as an alternative to conventional larger diameter (>36 mm) femoral heads and constrained liners. Patients who have been noted to be at particularly high risk for instability include those with abductor insufficiency and those specifically revised for instability [7,15-17]. We are unaware of prior reports that have evaluated the use of dual-mobility bearings in these most complex of situations, and in some reports, abductor insufficiency is described as a contraindication to their use. The purpose of our study was to evaluate the outcomes of dual-mobility bearings when used in these most challenging of situations where a constrained liner has traditionally been used.
Methods After obtaining institutional review board approval, we reviewed the medical records of 36 consecutive patients
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D.R. Plummer et al. / The Journal of Arthroplasty xxx (2016) 1e5
Table 1 Indication for Revision Arthroplasty. Indication
Dual-Mobility Group (N ¼ 36)
Instability Periprosthetic joint infection Implant loosening Wear/osteolysis Periprosthetic fracture
14 9 6 6 1
(38.9%) (25%) (16.7%) (16.7%) (2.7%)
considered high risk for instability who underwent revision arthroplasty utilizing dual-mobility bearing by one of the 3 surgeons between September 2010 and November 2012. The most common indications for revision included recurrent instability and treatment of a deep periprosthetic joint infection (Table 1). Indications for the dual-mobility bearing included revision for instability or a history of instability in 22 patients, abductor deficiency in 8 patients, and inadequate intraoperative stability when trialing in 6 patients; these are situations in which we traditionally would have used a constrained liner. Three of the patients included were undergoing repeat revision secondary to a failed constrained liner. The mean age and body mass index was 64 years (range, 4287 years) and 28.6 kg/m2 (range, 20.8-43.6 kg/m2). All revisions were performed via a posterior approach including an extended trochanteric osteotomy in one patient. Posterior hip precautions were maintained for a total of 90 days postoperatively and weight bearing varied based on the concomitant revision performed. Both components were revised in 21 patients (58.3%) and the acetabular component only was revised in 15 (41.6%) patients (Fig. 1A and B). Monoblock dual-mobility acetabular components were cemented into a metal shell in 9 of the 36 hips (Fig. 2A and B; 6 anatomic dual mobility, Stryker, Mahwah, NJ and 3 Polar Cup, Smith & Nephew, Memphis, TN). In 2 patients earlier in
this series, a dual-mobility “liner” (modular dual mobility, Stryker, Mahwah, NJ) was cemented into a metal shell after the backside had been roughened with a burr and based on their early failure as described in the following section (Fig. 3), this technique was abandoned in favor of cementation of a monoblock dual-mobility cup. Implants used for each group are included in Table 2. Patients were evaluated preoperatively and postoperatively at 3 weeks, 6 weeks, 3 months, 1 year, and annually thereafter for a physical examination and plain radiographs. Radiographs were reviewed for evidence of acetabular and femoral component loosening [18,19], and clinical outcomes were assessed using the Harris hip score (HHS) [20]. Clinical scores and radiographic evaluations were performed by 2 observers who were not directly involved with the index surgical procedures. Patients were followed for a minimum of 2 years (mean 2.4 years, range 2-4 years), and no patients were lost to follow-up.
Results Of the 36 patients studied, there was one dislocation in a patient initially revised for periprosthetic joint infection, which was successfully closed reduced, requiring no further interventions. There were 4 (11.1%) repeat revisions; 2 for periprosthetic joint infection treated with a 2-stage exchange and 2 for dissociation of a dualmobility “liner” that had been cemented into a metal shell (Fig. 3A-D). Both of these failures were early in our experience and both failed within the first 90 days postoperatively. There were no failures among the monoblock dual-mobility shells that were cemented inside a metal shell. No cases of intraprosthetic dislocation were identified, and there was no loosening of the femoral or acetabular components. At a minimum of 2 years, the mean HHS improved
Fig. 1. (A) Preoperative X-ray of a 62-year-old male with an infected proximal femoral arthroplasty used to treat a giant cell tumor of the proximal femur. This is the first case in this series. (B) Postoperative X-ray showing a monoblock dual-mobility shell used in this patient who is abductor deficient.
D.R. Plummer et al. / The Journal of Arthroplasty xxx (2016) 1e5
3
Fig. 2. (A) Preoperative X-rays of a 75-year-old female with a history of multiple prior revisions who presented with polyethylene wear and osteolysis. Note the deficiency of the greater trochanter; deficiency of the abductor musculature was confirmed intraoperatively. (B) Postoperative X-rays showing a 49-mm monoblock dual-mobility shell that was cemented into the 64-mm well fixed cup.
by 44 points, from 45 preoperatively to 90 points postoperatively (P < .001). Discussion Instability after THA is a devastating and costly complication and remains the most common reason for revision THA in the United States [21,22]. The management of patients who are considered high risk for instability remains a challenge for even the most experienced orthopedic surgeon [23]. Given the limitations of constrained liners [24], we have attempted to use dual-mobility articulations as an alternative for this challenging patient population. In our initial experience with 36 patients, we identified only one dislocation that was successfully closed reduced. Dual-mobility bearings provide greater ROM, a greater head-toneck ratio, and a more physiologic effective head size ultimately offering greater resistance to dislocation [16]. In comparison, constrained liners are usually associated with lower ROM. Furthermore, an important disadvantage of constrained liners is the increased forces seen at the implant bone interface, which can be particularly problematic in complex acetabular revisions where a constrained liner can lead to catastrophic failure of the construct. The risk of intraprosthetic dislocation is among the main disadvantages of dual-mobility articulations [25-29], and although not observed in this series, further follow-up of this cohort will be necessary to monitor for later complications. One of the most important findings of this study was that while cementation of a monoblock dual-mobility shell into a retained or
freshly implanted fully porous shell performed well, both cases where a dual-mobility “liner” was cemented into place failed within a very short time span. Similar to the common practice of cementing a polyethylene liner into a metal shell, the backside was roughened with a high-speed burr and then the liner was cemented into place (Fig. 3). Given the rapid and near uniform failure of this construct, we strongly recommend against it. If we desire to use a dual-mobility bearing in a patient where the acetabular component is not compatible with the metal shell that is in place, we presently either cement in a dual-mobility shell that was designed for cemented use (Polar Cup, Smith & Nephew) or a monoblock cementless dual-mobility shell (anatomic dualmobility, Stryker) with no failures seen to date. This construct has been tested and suggests that cementation of the monoblock shell into a metal shell is safe [30]. Several short to midterm studies (range, 2-11 years) have reported low dislocation rates in patients revised to a dual-mobility bearing, with dislocation rates ranging from 1.0% to 5.5% [16,31-34]. A recent study by Hailer et al [34] reviewed 228 patients from the Swedish Hip Arthroplasty Registry who were revised for chronic instability to dual-mobility bearings. At 2 years post revision, they found a 1.0% dislocation rate. A longer term study by LeiberWackenheim et al [35] reported a dislocation rate of 1.8% at a mean of 8 years (range, 6-11 years) in a group of patients revised to dual-mobility bearings. Our study similarly found that dualmobility articulations are a good option for patients' deemed higher risk for instability after revision arthroplasty; however, our series focused on what we feel is a more challenging subset of
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D.R. Plummer et al. / The Journal of Arthroplasty xxx (2016) 1e5
Fig. 3. (A) Preoperative X-rays of a 57-year-old female with a Type 3B acetabular defect. (B) The backside of a dual-mobility liner (Stryker, MDM) was roughened with a high-speed burr and then cemented into a highly porous metal shell. (C) Post-revision X-rays. (D) The patient presented with acute pain at 10 weeks postoperatively, and the liner was noted to have spun out from the cement mantle.
patients, namely those with abductor deficiency, those revised for instability or when trialing with a large head stability was still felt to be inadequate. In contrast, the rates of dislocation after revision to a constrained acetabular liner vary more widely, ranging from 6%
to 40% [6,9,36,37]. In one of the larger studies to date, Berend et al [6] reported a dislocation rate of 28.2% in patients with a history of recurrent instability revised to a constrained liner and a 14.2% dislocation rate in patients without a history of instability.
D.R. Plummer et al. / The Journal of Arthroplasty xxx (2016) 1e5 Table 2 Revision Acetabular Component Bearings Used. Dual-Mobility Group (N ¼ 36)
Cases
Modular dual-mobility (MDM), Stryker Anatomic dual-mobility (ADM), Stryker Polar Cup, Smith & Nephew
18 (50%) 16 (44.4%) 2 (5.6%)
This study has several limitations including its retrospective nature. As this was not a randomized controlled trial, it is unknown if a large head or a constrained liner would have provided equivalent results. However, given the data of Kung and Ries [38], it is unlikely that large heads alone would have been adequate. Similarly, the work by Wera et al [24] suggests that constrained liners have a higher failure rate when used in the most complex of cases [6]. Our length of follow-up was also relatively short, and further follow-up will be required to determine longer term implant survival and the risk of wear-related complications including intraprosthetic dislocation. In terms of instability, however, numerous reports have found most dislocations occur within the early postoperative period (within the first 3 months), which our series adequately covers [24,39,40]. In conclusion, our results suggest a low risk of dislocation, and no repeat revisions for instability when dual-mobility bearings were used for patients who are at high risk for instability after a revision THA. Patients who received dual-mobility implants also had excellent clinical outcomes with a mean HHS of 89 points at the time of most recent follow-up. On the basis of our experience, we believe dual-mobility bearings provide an excellent option for orthopedic surgeons faced with patients at high risk for postoperative dislocation after revision THA and in our practice are used in lieu of constrained liners.
References 1. Bozic KJ, Kurtz SM, Lau E, et al. The epidemiology of revision total hip arthroplasty in the United States. J Bone Joint Surg Am 2009;91(1):128. 2. Dy CJ, Bozic KJ, Pan TJ, et al. Risk factors for early revision after total hip arthroplasty. Arthritis Care Res 2014;66(6):907. 3. Schairer WW, Sing DC, Vail TP, et al. Causes and frequency of unplanned hospital readmission after total hip arthroplasty. Clin Orthop Relat Res 2014;472(2):464. 4. Parvizi J, Picinic E, Sharkey PF. Revision total hip arthroplasty for instability: surgical techniques and principles. J Bone Joint Surg Am 2008;90(5):1134. 5. Alberton GM, High WA, Morrey BF. Dislocation after revision total hip arthroplasty: an analysis of risk factors and treatment options. J Bone Joint Surg Am 2002;84-A(10):1788. 6. Berend KR, Lombardi Jr AV, Mallory TH, et al. The long-term outcome of 755 consecutive constrained acetabular components in total hip arthroplasty examining the successes and failures. J Arthroplasty 2005;20(7 Suppl 3):93. 7. Wetters NG, Murray TG, Moric M, et al. Risk factors for dislocation after revision total hip arthroplasty. Clin Orthop Relat Res 2013;471(2):410. 8. Saadat E, Diekmann G, Takemoto S, et al. Is an algorithmic approach to the treatment of recurrent dislocation after THA effective? Clin Orthop Relat Res 2012;470(2):482. 9. Bremner BR, Goetz DD, Callaghan JJ, et al. Use of constrained acetabular components for hip instability: an average 10-year follow-up study. J Arthroplasty 2003;18(7 Suppl 1):131. 10. Shapiro GS, Weiland DE, Markel DC, et al. The use of a constrained acetabular component for recurrent dislocation. J Arthroplasty 2003;18(3):250. 11. Callaghan JJ, O'Rourke MR, Goetz DD, 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;(429):117. 12. Kershaw CJ, Atkins RM, Dodd CA, et al. Revision total hip arthroplasty for aseptic failure. A review of 276 cases. J Bone Joint Surg Br 1991;73(4):564.
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13. Philippot R, Adam P, Reckhaus M, et al. Prevention of dislocation in total hip revision surgery using a dual mobility design. Orthop Traumatol Surg Res 2009;95(6):407. 14. Khatod M, Barber T, Paxton E, et al. An analysis of the risk of hip dislocation with a contemporary total joint registry. Clin Orthop Relat Res 2006;447:19. 15. Plummer DR, Botero HG, Berend KR, et al. Salvage of monoblock metal-on-metal acetabular components using a dual-mobility bearing. J Arthroplasty 2015. 16. Plummer DR, Haughom BD, Della Valle CJ. Dual mobility in total hip arthroplasty. Orthop Clin North Am 2014;45(1):1. 17. Healy WL, Iorio R, Clair AJ, et al. Complications of total hip arthroplasty: standardized list, definitions, and stratification developed by the hip society. Clin Orthop Relat Res 2016;474(2):357. 18. Kim YH, Kim VE. Uncemented porous-coated anatomic total hip replacement. Results at six years in a consecutive series. J Bone Joint Surg Br 1993;75(1):6. 19. Kim YH, Park JW, Patel C, et al. Polyethylene wear and osteolysis after cementless total hip arthroplasty with alumina-on-highly cross-linked polyethylene bearings in patients younger than thirty years of age. J Bone Joint Surg Am 2013;95(12):1088. 20. Nilsdotter A, Bremander A. Measures of hip function and symptoms: Harris Hip Score (HHS), Hip Disability and Osteoarthritis Outcome Score (HOOS), Oxford Hip Score (OHS), Lequesne Index of Severity for Osteoarthritis of the Hip (LISOH), and American Academy of Orthopedic surgeons (AAOS) Hip and Knee Questionnaire. Arthritis Care Res 2011;63(Suppl 11):S200. 21. Bozic KJ, Kamath AF, Ong K, et al. Comparative epidemiology of revision arthroplasty: failed THA poses greater clinical and economic burdens than failed TKA. Clin Orthop Relat Res 2015;473(6):2131. 22. Assmann G, Kasch R, Maher CG, et al. Comparison of health care costs between aseptic and two stage septic hip revision. J Arthroplasty 2014;29(10):1925. 23. Melvin JS, Karthikeyan T, Cope R, et al. Early failures in total hip arthroplasty e a changing paradigm. J Arthroplasty 2014;29(6):1285. 24. Wera GD, Ting NT, Moric M, et al. Classification and management of the unstable total hip arthroplasty. J Arthroplasty 2012;27(5):710. 25. Philippot R, Boyer B, Farizon F. Intraprosthetic dislocation: a specific complication of the dual-mobility system. Clin Orthop Relat Res 2013;471(3):965. 26. Combes A, Migaud H, Girard J, et al. Low rate of dislocation of dual-mobility cups in primary total hip arthroplasty. Clin Orthop Relat Res 2013;471(12): 3891. 27. Hamadouche M, Arnould H, Bouxin B. Is a cementless dual mobility socket in primary THA a reasonable option? Clin Orthop Relat Res 2012;470(11):3048. 28. Massin P, Orain V, Philippot R, et al. Fixation failures of dual mobility cups: a mid-term study of 2601 hip replacements. Clin Orthop Relat Res 2012;470(7): 1932. 29. Philippot R, Farizon F, Camilleri JP, et al. Survival of cementless dual mobility socket with a mean 17 years follow-up. Rev Chir Orthop Reparatrice Appar Mot 2008;94(8):e23. 30. Wegrzyn J, Thoreson AR, Guyen O, et al. Cementation of a dual-mobility acetabular component into a well-fixed metal shell during revision total hip arthroplasty: a biomechanical validation. J Orthop Res 2013;31(6):991. 31. Mohammed R, Hayward K, Mulay S, et al. Outcomes of dual-mobility acetabular cup for instability in primary and revision total hip arthroplasty. J Orthop Traumatol 2015;16(1):9. 32. Jakobsen T, Kappel A, Hansen F, et al. The dislocating hip replacement revision with a dual mobility cup in 56 consecutive patients. Open Orthop J 2014;8:268. 33. van Heumen M, Heesterbeek PJ, Swierstra BA, et al. Dual mobility acetabular component in revision total hip arthroplasty for persistent dislocation: no dislocations in 50 hips after 1-5 years. J Orthop Traumatol 2015;16:15. 34. Hailer NP, Weiss RJ, Stark A, et al. Dual-mobility cups for revision due to instability are associated with a low rate of re-revisions due to dislocation: 228 patients from the Swedish Hip Arthroplasty Register. Acta Orthop 2012;83(6): 566. 35. Leiber-Wackenheim F, Brunschweiler B, Ehlinger M, et al. Treatment of recurrent THR dislocation using of a cementless dual-mobility cup: a 59 cases series with a mean 8 years' follow-up. Orthop Traumatol Surg Res 2011;97(1):8. 36. Della Valle CJ, Chang D, Sporer S, et al. High failure rate of a constrained acetabular liner in revision total hip arthroplasty. J Arthroplasty 2005;20(7 Suppl 3):103. 37. Goetz DD, Bremner BR, Callaghan JJ, et al. Salvage of a recurrently dislocating total hip prosthesis with use of a constrained acetabular component. A concise follow-up of a previous report. J Bone Joint Surg Am 2004;86-A(11): 2419. 38. Kung PL, Ries MD. Effect of femoral head size and abductors on dislocation after revision THA. Clin Orthop Relat Res 2007;465:170. 39. Meek RM, Allan DB, McPhillips G, et al. Epidemiology of dislocation after total hip arthroplasty. Clin Orthop Relat Res 2006;447:9. 40. Phillips CB, Barrett JA, Losina E, 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;85-A(1):20.
Contents lists available at ScienceDirect
The Journal of Arthroplasty journal homepage: www.arthroplastyjournal.org
AAHKS Supplement paper
Dual-Mobility Articulations for Patients at High Risk for Dislocation Darren R. Plummer, MD, MBA a, *, Jonathan M. Christy, MD b, Scott M. Sporer, MD c, d, Wayne G. Paprosky, MD c, d, Craig J. Della Valle, MD c a
Department of Orthopaedic Surgery, The Ohio State University, Columbus, Ohio Optim Orthopedics, Savannah, Georgia c Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois d Department of Orthopaedic Surgery, Central DuPage Hospital, Winfield, Illinois b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 24 November 2015 Received in revised form 23 February 2016 Accepted 1 March 2016 Available online xxx
Background: The purpose of this study was to evaluate the performance of dual-mobility articulations in patients at high risk for dislocation after revision total hip arthroplasty. Methods: We reviewed the results of 36 consecutive revision total hip arthroplasties performed on patients considered high risk for instability. Indications for inclusion included abductor insufficiency, recurrent instability, failure of constrained liner, or inadequate intraoperative stability when trialing. Results: At a minimum of 2 years, there were 4 (11.1%) repeat revisions including both dual-mobility liners that were cemented into an acetabular shell and 2 for deep infection treated with a 2-stage exchange. There was one dislocation that was successfully closed reduced but no revisions for recurrent instability. The mean Harris hip score improved from 45 to 90 points (P < .001). Conclusion: Dual-mobility articulations are associated with a low rate of failure with no revisions for instability in this challenging group of patients. © 2016 Elsevier Inc. All rights reserved.
Keywords: dislocation dual mobility revision total hip arthroplasty instability high risk
Instability after total hip arthroplasty (THA) remains a persistent problem. It is the most common cause for revision THA in the United States and similarly is the most common complication after revision THA [1-3]. Current reports estimate the rate of dislocation to be as high as 28% after revision THA [4-6]. Despite the numerous advances in implant design, surgical technique, and postoperative management, the rate of instability remains relatively high following revision procedures [7]. Numerous prosthetic options and surgical approaches have been attempted to both prevent and treat instability. Dual-mobility bearings are relatively new to the North American market, but variations on the concept have been used clinically in Europe for more than 35 years. The design affords greater range of motion (ROM), a greater head-to-neck ratio, and a larger effective head size that increases jump distance. Several studies suggest that these articulations can be used for preventing or treating instability
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 doi: http://dx.doi.org/10.1016/j.arth.2016.03.021. * Reprint requests: Darren R. Plummer, MD, MBA, Department of Orthopaedic Surgery, The Ohio State University Wexner Medical Center, 140 Liberty Street, Apt 3110, Columbus, OH 43215. http://dx.doi.org/10.1016/j.arth.2016.03.021 0883-5403/© 2016 Elsevier Inc. All rights reserved.
[8-11]. Although these bearings have their own concerns, including intraprosthetic dislocation and theoretically higher wear rates due to the dual articulating nature of the design, our group viewed them as a potential alternative for managing complex patients at high risk for instability after revision THA. The risk of recurrent dislocation is greater after revision surgery than primary THA [5,12-14], and hence, the use of dual mobility is attractive for revision procedures and for the treatment of the hip that is unstable as an alternative to conventional larger diameter (>36 mm) femoral heads and constrained liners. Patients who have been noted to be at particularly high risk for instability include those with abductor insufficiency and those specifically revised for instability [7,15-17]. We are unaware of prior reports that have evaluated the use of dual-mobility bearings in these most complex of situations, and in some reports, abductor insufficiency is described as a contraindication to their use. The purpose of our study was to evaluate the outcomes of dual-mobility bearings when used in these most challenging of situations where a constrained liner has traditionally been used.
Methods After obtaining institutional review board approval, we reviewed the medical records of 36 consecutive patients
2
D.R. Plummer et al. / The Journal of Arthroplasty xxx (2016) 1e5
Table 1 Indication for Revision Arthroplasty. Indication
Dual-Mobility Group (N ¼ 36)
Instability Periprosthetic joint infection Implant loosening Wear/osteolysis Periprosthetic fracture
14 9 6 6 1
(38.9%) (25%) (16.7%) (16.7%) (2.7%)
considered high risk for instability who underwent revision arthroplasty utilizing dual-mobility bearing by one of the 3 surgeons between September 2010 and November 2012. The most common indications for revision included recurrent instability and treatment of a deep periprosthetic joint infection (Table 1). Indications for the dual-mobility bearing included revision for instability or a history of instability in 22 patients, abductor deficiency in 8 patients, and inadequate intraoperative stability when trialing in 6 patients; these are situations in which we traditionally would have used a constrained liner. Three of the patients included were undergoing repeat revision secondary to a failed constrained liner. The mean age and body mass index was 64 years (range, 4287 years) and 28.6 kg/m2 (range, 20.8-43.6 kg/m2). All revisions were performed via a posterior approach including an extended trochanteric osteotomy in one patient. Posterior hip precautions were maintained for a total of 90 days postoperatively and weight bearing varied based on the concomitant revision performed. Both components were revised in 21 patients (58.3%) and the acetabular component only was revised in 15 (41.6%) patients (Fig. 1A and B). Monoblock dual-mobility acetabular components were cemented into a metal shell in 9 of the 36 hips (Fig. 2A and B; 6 anatomic dual mobility, Stryker, Mahwah, NJ and 3 Polar Cup, Smith & Nephew, Memphis, TN). In 2 patients earlier in
this series, a dual-mobility “liner” (modular dual mobility, Stryker, Mahwah, NJ) was cemented into a metal shell after the backside had been roughened with a burr and based on their early failure as described in the following section (Fig. 3), this technique was abandoned in favor of cementation of a monoblock dual-mobility cup. Implants used for each group are included in Table 2. Patients were evaluated preoperatively and postoperatively at 3 weeks, 6 weeks, 3 months, 1 year, and annually thereafter for a physical examination and plain radiographs. Radiographs were reviewed for evidence of acetabular and femoral component loosening [18,19], and clinical outcomes were assessed using the Harris hip score (HHS) [20]. Clinical scores and radiographic evaluations were performed by 2 observers who were not directly involved with the index surgical procedures. Patients were followed for a minimum of 2 years (mean 2.4 years, range 2-4 years), and no patients were lost to follow-up.
Results Of the 36 patients studied, there was one dislocation in a patient initially revised for periprosthetic joint infection, which was successfully closed reduced, requiring no further interventions. There were 4 (11.1%) repeat revisions; 2 for periprosthetic joint infection treated with a 2-stage exchange and 2 for dissociation of a dualmobility “liner” that had been cemented into a metal shell (Fig. 3A-D). Both of these failures were early in our experience and both failed within the first 90 days postoperatively. There were no failures among the monoblock dual-mobility shells that were cemented inside a metal shell. No cases of intraprosthetic dislocation were identified, and there was no loosening of the femoral or acetabular components. At a minimum of 2 years, the mean HHS improved
Fig. 1. (A) Preoperative X-ray of a 62-year-old male with an infected proximal femoral arthroplasty used to treat a giant cell tumor of the proximal femur. This is the first case in this series. (B) Postoperative X-ray showing a monoblock dual-mobility shell used in this patient who is abductor deficient.
D.R. Plummer et al. / The Journal of Arthroplasty xxx (2016) 1e5
3
Fig. 2. (A) Preoperative X-rays of a 75-year-old female with a history of multiple prior revisions who presented with polyethylene wear and osteolysis. Note the deficiency of the greater trochanter; deficiency of the abductor musculature was confirmed intraoperatively. (B) Postoperative X-rays showing a 49-mm monoblock dual-mobility shell that was cemented into the 64-mm well fixed cup.
by 44 points, from 45 preoperatively to 90 points postoperatively (P < .001). Discussion Instability after THA is a devastating and costly complication and remains the most common reason for revision THA in the United States [21,22]. The management of patients who are considered high risk for instability remains a challenge for even the most experienced orthopedic surgeon [23]. Given the limitations of constrained liners [24], we have attempted to use dual-mobility articulations as an alternative for this challenging patient population. In our initial experience with 36 patients, we identified only one dislocation that was successfully closed reduced. Dual-mobility bearings provide greater ROM, a greater head-toneck ratio, and a more physiologic effective head size ultimately offering greater resistance to dislocation [16]. In comparison, constrained liners are usually associated with lower ROM. Furthermore, an important disadvantage of constrained liners is the increased forces seen at the implant bone interface, which can be particularly problematic in complex acetabular revisions where a constrained liner can lead to catastrophic failure of the construct. The risk of intraprosthetic dislocation is among the main disadvantages of dual-mobility articulations [25-29], and although not observed in this series, further follow-up of this cohort will be necessary to monitor for later complications. One of the most important findings of this study was that while cementation of a monoblock dual-mobility shell into a retained or
freshly implanted fully porous shell performed well, both cases where a dual-mobility “liner” was cemented into place failed within a very short time span. Similar to the common practice of cementing a polyethylene liner into a metal shell, the backside was roughened with a high-speed burr and then the liner was cemented into place (Fig. 3). Given the rapid and near uniform failure of this construct, we strongly recommend against it. If we desire to use a dual-mobility bearing in a patient where the acetabular component is not compatible with the metal shell that is in place, we presently either cement in a dual-mobility shell that was designed for cemented use (Polar Cup, Smith & Nephew) or a monoblock cementless dual-mobility shell (anatomic dualmobility, Stryker) with no failures seen to date. This construct has been tested and suggests that cementation of the monoblock shell into a metal shell is safe [30]. Several short to midterm studies (range, 2-11 years) have reported low dislocation rates in patients revised to a dual-mobility bearing, with dislocation rates ranging from 1.0% to 5.5% [16,31-34]. A recent study by Hailer et al [34] reviewed 228 patients from the Swedish Hip Arthroplasty Registry who were revised for chronic instability to dual-mobility bearings. At 2 years post revision, they found a 1.0% dislocation rate. A longer term study by LeiberWackenheim et al [35] reported a dislocation rate of 1.8% at a mean of 8 years (range, 6-11 years) in a group of patients revised to dual-mobility bearings. Our study similarly found that dualmobility articulations are a good option for patients' deemed higher risk for instability after revision arthroplasty; however, our series focused on what we feel is a more challenging subset of
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Fig. 3. (A) Preoperative X-rays of a 57-year-old female with a Type 3B acetabular defect. (B) The backside of a dual-mobility liner (Stryker, MDM) was roughened with a high-speed burr and then cemented into a highly porous metal shell. (C) Post-revision X-rays. (D) The patient presented with acute pain at 10 weeks postoperatively, and the liner was noted to have spun out from the cement mantle.
patients, namely those with abductor deficiency, those revised for instability or when trialing with a large head stability was still felt to be inadequate. In contrast, the rates of dislocation after revision to a constrained acetabular liner vary more widely, ranging from 6%
to 40% [6,9,36,37]. In one of the larger studies to date, Berend et al [6] reported a dislocation rate of 28.2% in patients with a history of recurrent instability revised to a constrained liner and a 14.2% dislocation rate in patients without a history of instability.
D.R. Plummer et al. / The Journal of Arthroplasty xxx (2016) 1e5 Table 2 Revision Acetabular Component Bearings Used. Dual-Mobility Group (N ¼ 36)
Cases
Modular dual-mobility (MDM), Stryker Anatomic dual-mobility (ADM), Stryker Polar Cup, Smith & Nephew
18 (50%) 16 (44.4%) 2 (5.6%)
This study has several limitations including its retrospective nature. As this was not a randomized controlled trial, it is unknown if a large head or a constrained liner would have provided equivalent results. However, given the data of Kung and Ries [38], it is unlikely that large heads alone would have been adequate. Similarly, the work by Wera et al [24] suggests that constrained liners have a higher failure rate when used in the most complex of cases [6]. Our length of follow-up was also relatively short, and further follow-up will be required to determine longer term implant survival and the risk of wear-related complications including intraprosthetic dislocation. In terms of instability, however, numerous reports have found most dislocations occur within the early postoperative period (within the first 3 months), which our series adequately covers [24,39,40]. In conclusion, our results suggest a low risk of dislocation, and no repeat revisions for instability when dual-mobility bearings were used for patients who are at high risk for instability after a revision THA. Patients who received dual-mobility implants also had excellent clinical outcomes with a mean HHS of 89 points at the time of most recent follow-up. On the basis of our experience, we believe dual-mobility bearings provide an excellent option for orthopedic surgeons faced with patients at high risk for postoperative dislocation after revision THA and in our practice are used in lieu of constrained liners.
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