- Email: [email protected]
Risk factors for dislocation after revision total hip arthroplasty: A systematic review and meta-analysis
Accepted Manuscript Risk factors for dislocation after revision total hip arthroplasty: A systematic review and meta-analysis Lele Guo, Yanjiang Yang, Biao An, Yantao Yang, Linyuan Shi, Xiangzhen Han, Shijun Gao PII:
S1743-9191(16)31298-5
DOI:
10.1016/j.ijsu.2016.12.122
Reference:
IJSU 3420
To appear in:
International Journal of Surgery
Received Date: 21 October 2016 Revised Date:
23 December 2016
Accepted Date: 29 December 2016
Please cite this article as: Guo L, Yang Y, An B, Yang Y, Shi L, Han X, Gao S, Risk factors for dislocation after revision total hip arthroplasty: A systematic review and meta-analysis, International Journal of Surgery (2017), doi: 10.1016/j.ijsu.2016.12.122. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Risk factors for dislocation after revision total hip arthroplasty: A systematic review and meta-analysis Lele Guo1; Yanjiang Yang 2; Biao An2;Yantao Yang2; Linyuan Shi2;Xiangzhen Han2; Shijun Gao 1, 2*
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1, Department of Joint Surgery, the Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050051, P.R. China
2, Department of Scientific bureau, the Third Hospital of Hebei Medical University, Hebei, 050051,
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P.R. China
3, Department of Hand Surgery, the Third Hospital of Hebei Medical University, Hebei, 050051, P.R.
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China
4, Department of respiratory, Hebei General Hospital, Shijiazhuang, Hebei, 050051, P.R. China *Contributed equally. Lele Guo
E-mail:[email protected]
E-mail:[email protected]
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Yanjiang Yang Biao An Yantao Yang
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Xiangzhen Han
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Linyuan Shi
Shijun Gao
E-mail: 1159052936 @qq.com E-mail: 419641897 @qq.com E-mail:[email protected] E-mail:[email protected] E-mail:[email protected]
Correspondence: Shijun Gao
Department of Joint Surgery , the 3rd Hospital, Hebei Medical University NO.139 Ziqiang Road, Shijiazhuang 050051, P.R. China Tel: +86-311-88602315 Fax: +86-311-87023626
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E-mail: [email protected]
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Risk factors for dislocation after revision total hip arthroplasty: A
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systematic review and meta-analysis
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Abstract
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Background
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performed up to now to summarize the risk factors of dislocation after
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revision total hip arthroplasty(THA).
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Aims The present study aimed to quantitatively and comprehensively
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conclude the risk factors of dislocation after revision total hip
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arthroplasty.
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No formal systematic review or meta-analysis was
Methods
A search was applied to CNKI, Embase, Medline, and
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Cochrane central database (all up to October 2016). All studies assessing
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the risk factors of dislocation after revision THA without language
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restriction were reviewed, and qualities of included studies were assessed
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using the Newcastle–Ottawa Scale. Data were pooled and a meta-analysis
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completed.
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Results A total of 8 studies were selected, which altogether included
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4656 revision THAs. 421 of them were cases of dislocation occurred after
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surgery, suggesting the accumulated incidence of 9.04%. Results of
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meta-analyses showed that age at surgery (standardized mean difference
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-0.222; 95% CI -0.413–-0.031), small-diameter femoral heads（≤28mm）
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(OR 1.451; 95%CI 1.056-1.994), history of instability (OR 2.739; 95%CI
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1.888-3.974), number of prior revisions ≥ 3 (OR, 2.226; 95% CI,
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1.569-3.16) and number of prior revisions ≥ 2 (OR 1.949; 95% CI
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1.349-2.817), acetabular components with elevated rim liner were less
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likely to develop dislocation after revision THA (OR 0.611; 95% CI
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0.415-0.898).
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Conclusions
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patients involved with above-mentioned risk factors to prevent
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dislocation after revision THA.
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Keywords: dislocation, revision total hip arthroplasty, risk factors.
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Related prophylaxis strategies should be implemented in
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Introduction
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Postoperative dislocation remains as one of the most common
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complications following revision total hip arthroplasty (THA), with
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reported incidences ranging between 4 to 30%[1, 2]. Several patient- and
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surgery-specific risk factors have been described previously, including
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femoral head size, deficient abductors, surgical approach, malposition of
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components, using of a liner with an elevated rim, cup position, and
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number of previous hip surgeries[3-7]. Identifying risk factors for this
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complication is important, as the identification of patients at risk can
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assist with preoperative patient education and management at the time of
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revision surgery. However, these studies had some limitations, such as a
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small sample and containing a single or very few potential risk factors in
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the individual study. In addition, some results obtained from individual
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studies were inconsistent and even contradictory. Thus, it is still uncertain
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whether these identified factors from individual studies are able to predict
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dislocation after revision total hip arthroplasty.
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Until now, no formal systematic review or meta-analysis was performed
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to summarize the risk factors of dislocation after revision THA to obtain a
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definitive conclusion. Therefore in this study, we summarized these risk
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factors from the previous original researches and conducted a
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meta-analysis. It would be most informative in guiding clinicians for
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identifying high risk patients and helping them preventing postoperative
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dislocation after revision THA to improve the patients’ prognosis.
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Materials and methods
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Literature search
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CNKI, Embase, Medline, and Cochrane central database were searched
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using a broad range of terms to identify original research, published all
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through October 2016 and selecting potential studies to consider. The
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main key words were as follows: “factor’’ or ‘‘predictor’’ or “risk’’ AND
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‘‘dislocation’’ or “luxation” AND ‘‘hip arthroplasty’’ or ‘‘THA’’ AND
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‘‘revision’’. Also, a manual search of references in the identified articles
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and systematic reviews was performed for possible inclusion.
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Eligibility criteria
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Two reviewers (Yan Jiang Yang and Biao An) independently evaluated
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the titles and abstracts of the identified studies. Only full-text articles
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without language restriction were included in this meta-analysis. The
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following inclusive selection criteria were applied: (1) a study was
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performed to explore risk factors for dislocation occurrence after revision
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THA; (2) cases and controls were defined based on the presence or
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absence of dislocation, respectively; (3) sufficient data were published for
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estimating an odds ratio (OR) or hazard ratio (HR) or standardized mean
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difference (SMD) with 95 % confidence interval (95 % CI)
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Quality of included studies
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The quality of the included studies was evaluated using the Newcastle–
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Ottawa Scale (NOS)[8]: based on the three main items: the selection of
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the study groups (0–4 points), the comparability of the groups (0–2 points)
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and the determination of either the exposure or the outcome of interest
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(0–3 points), with a perfect score of 9.
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Data extraction
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All the data were carefully extracted from all eligible studies
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independently by the two reviewers (Yan Jiang Yang and Biao An). The
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following variables were extracted from each study: first author’s name,
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publication year, country, significant risk factors, definitions and numbers
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of cases and controls and numbers of citations for each potential risk
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factor for dislocation after revision THA. Any disagreement was resolved
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by discussion and consensus.
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Statistical analyses
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ORs or SMDs and corresponding 95% CI were estimated and pooled
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across studies to assess the association between different variables and
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the risk of dislocation with a value of P<0.05 as significance.
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Heterogeneity among studies was tested by Q-test statistics with
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significance set at P<0.10[9] and further measured by I2 statistics with I2
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more than 50% indicating significant inconsistency. A random-effect
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model was used to calculate pooled ORs in the case of significant
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heterogeneity (P<0.10 or I2>50 %); otherwise, a fixed-effect model was
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used[10] . The outcome of meta-analysis for variables was summarized
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graphically using a forest plot. If necessary, a sensitive analysis by
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excluding outlier study one by one was conducted to investigate the
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sources for heterogeneity. Potential publication bias was detected by
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Begg’s funnel plots, and P<0.05 was judged as statistically significant.
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All analyses were performed by the software Stata 11.0 (Stata
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Corporation, College Station, TX).
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Results
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Characteristics of identified studies
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Fig. 1 indicates the flowchart of the article screening and the detailed
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selection process. Initial search yielded 221 titles and abstracts from the
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electronic databases. After duplicates were removed, 125 abstracts were
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reviewed for initial screening and 38 for the next stage of review. After
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inclusion and exclusion criteria were applied, 8 full text articles were
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chosen for this meta-analysis. All of them were published in English with
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publication time from 2002 to 2016. These 8 studies altogether included
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4656 patients with hip fracture; 421 cases of dislocation occurred after
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surgery, suggesting the accumulated incidence of 9.04%. Detailed
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information about these included studies is shown in Table 1.
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Methodological quality assessment
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The outcome of methodology quality assessment was as follows: one
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studies[11] scored 9，two studies[3, 4] scored 8, three studies[5, 7, 12]
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scored 7，and two studies[6, 13] scored 6.
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Age and gender
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Two studies reported the admission age of 64.25 years in postoperative
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dislocation patients, which was 1.05 years younger than that in
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nondislocation groups, and the pooled results for meta-analysis suggested
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a difference (SMD -0.222; 95% CI -0.413– -0.031;). There was no
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evidence of heterogeneity among studies (P=0.567, I2=0; Table 2). Sex
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difference of the occurrence of dislocation after revision total hip
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arthroplasty was reported in 7 studies. Results of meta-analysis suggested
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no significant difference.
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Femoral head size
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Postoperative dislocation incidence was consistently higher in those who
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had small-diameter femoral heads（≤28mm） compared with those who
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had large-diameter femoral heads（≥32mm）. A total of 3 studies reported
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the small-diameter femoral head as a risk factor and meta-analysis of
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these studies showed that patients with small-diameter femoral heads
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were more prone to develop dislocation after revision total hip
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arthroplasty (OR 1.451, 95% CI 1.056–1.994). There was no evidence of
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heterogeneity among studies (P=0.222, I2=33.6%; Table 2; Fig. 2a).
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History of instability
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Three studies have previously reported history of instability as a risk
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factor associated with dislocation after revision total hip arthroplasty,
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with a significant difference (OR 2.739; 95%CI 1.888-3.974), with no
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heterogeneity (P=0.945, I2=0; Table 2; Fig. 2b).
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Number of prior revisions
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Two studies have previously reported number of prior revisions≥3 as a
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risk factor associated with dislocation after revision total hip arthroplasty,
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with a significant difference (OR 2.226; 95%CI 1.569-3.16), with no
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heterogeneity (P=0.484, I2=0; Table 2). Also，two studies have previously
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reported number of prior revisions≥2 as a risk factor associated with
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dislocation after revision total hip arthroplasty, with a significant
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difference (OR 1.949; 95%CI 1.349-2.817), with no heterogeneity
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(P=0.977, I2=0; Table 2).
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Elevated rim liner
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Elevated rim liner of the occurrence of dislocation after revision total hip
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arthroplasty was reported in 3 studies. Results of meta-analysis showed
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that with an elevated rim liner was less likely to sustain dislocation, and
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the combinable OR was 0.611 (95% CI 0.415–0.898), with no
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heterogeneity (P=0.177, I2=42.2%; Table 2; Fig. 2c).
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Discussion
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Dislocation is one of the most frequent complications after revision total
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hip arthroplasty. Results in this meta-analysis suggested the overall
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prevalence of postoperative dislocation was 9.04%, which is comparable
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to the range of 4–30% in THA patients reported by others[1, 2]. This
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meta-analysis demonstrates that history of instability and prior revisions
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are the most consistently significant risk factors for dislocation after
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revision THA, followed by age at surgery, femoral head size and with no
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elevated rim liner.
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Larger femoral heads have the potential to decrease dislocation rate in
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primary THA, but it is unclear whether they do so in revision THA. Wang
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et al.[14] reported femoral head size was the only factor with significant
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difference between the dislocated and stable groups. Other investigators
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also reported a reduction in dislocation rates with larger diameter
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heads[15, 16]. About dislocation after revision THA, Garbuz et al.[17]
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reported that in a randomized controlled trial, patients with 32-mm heads
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had a dislocation rate of 8.7%, while using 36- and 40-mm diameter
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heads lowered that rate to 1.1% at a minimum follow up of 2 years. This
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meta-analysis found, postoperative dislocation incidence was consistently
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higher in those who had small-diameter femoral heads( ≤ 28mm)
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compared with those who had large-diameter femoral heads（≥32mm）.
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So, femoral head size should be an important factor in dislocation risk
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assessment.
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Itokawa et al.[18] had discussed several factors associated with recurrent
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dislocations in primary THA, while those after revision THA have not
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been well characterized. Daly et al.[19] reported that, high recurrence rate
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when the hip is revised specifically for instability, reporting 39%
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recurrence in 95 hips at average of 7.6 years. In our study, Patients with
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prior dislocation were 2.74 times more at risk of developing dislocation
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than patients who without the dislocation history.
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Previous reports demonstrated that number of previous revisions should
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be the predictor of dislocation after revision hip arthroplasty[20, 21]. Jo et
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al.[11] noted that history of more than 2 previous hip surgeries was
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identified as patient related risk factors associated with dislocation. This
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meta-analysis found the risk of implant dislocation was 2.23 times higher
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in the Number of prior revisions≥3 groups than the groups Number of
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prior revisions＜3. This meta-analysis also found the risk of implant
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dislocation was 1.95 times higher in the Number of prior revisions≥2
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groups than the groups Number of prior revisions＜2.
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An elevated rim liner can reduce the occurrence of dislocation after
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revision total hip arthroplasty, and the risk of implant dislocation was 1.8
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times higher in the no an elevated rim liner groups than the groups with
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an elevated rim liner. Cobb et al.[22] reported that elevated rim liners can
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reduce the rates of dislocation in revision arthroplasties. Alberton et al.[3]
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reported that elevated rim liner was least beneficial with an isolated
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acetabular revision. When both components were revised, hips that had
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insertion of a cup with an elevated rim liner were significantly more
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stable.
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Advanced age has been associated with a higher risk of dislocation in
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some series[23, 24].And it is likely related to decreased muscle
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control/strength and increased risk of falling in the elderly[25].
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Yoshimoto et al.[5] noted that advanced age should be an independent
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risk factors for any dislocation. Interestingly, This meta-analysis found
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that, the admission age of 64.25 years in postoperative dislocation
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patients was 1.05 years younger than that in nondislocation groups.
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Other factors, such as constrained liner, trochanteric osteotomy, Cup
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inclination, cup anteversion, BMI, single component revision were not
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found to be risk factors. However, Della et al.[26] noted that, the higher
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failure rate observed when constrained liner was placed into a retained
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cup indicates that it is essential to optimize other factors that may
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contribute to instability in order to decrease the mechanical failure as was
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emphasized. Alberton et al.[3] reported that trochanteric osteotomy was a
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significant risk factor which has been demonstrated in other studies as
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well[27, 28]. They noted that, Trochanteric nonunion occurred in only 2.3%
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(nine) of 399 hips that had a trochanteric osteotomy. And, seven of the
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nine hips with trochanteric nonunion had a subsequent episode of
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instability. The role of cup inclination and anteversion on the dislocation
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rate has been extensively studied, both independently and combined.
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Sadhu et al.[29] reported that patients sustaining a dislocation after THA
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have acetabular components less frequently positioned within the
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safe zone for both inclination and anteversion, with a mean position
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in increased inclination and decreased anteversion. But, our meta-analysis
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suggested no significant difference about cup inclination and anteversion
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difference of the occurrence of dislocation after revision total hip
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arthroplasty. Obese patients may also be at increased risk for dislocation
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owing tocomponent malpositioning and soft tissue impingement related
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to difficult exposure[30, 31]. Yet, this meta-analysis found that, obesity
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could not to be a risk factor. Some scholars believe that, single
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component revision should be a risk factor about dislocation after
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revision total hip arthroplasty[3, 20, 32], The increased soft tissue
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releases required to perform a single-component revision. However, this
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meta-analysis found that, single component revision was not a risk factor.
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In our meta-analysis, gender, left or right, original diagnosis and
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bone-grafting were not found to be risk factors. This may also relate to
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the similarity in those factors between dislocators and nondislocators.
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Some limitations in this meta-analysis have to be mentioned. Firstly, a
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weakness exists in the analyses, in which not all the ORs regarding the
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potential risk factors applied for the meta-analysis were adjusted because
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a lot of reports could only provide the univariate rather than multivariate
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statistics. Likewise, some studies might choose not to report insignificant
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results or results of no interest, potentially resulting in a considerable
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amount of missing data. Hence, our overall effect may be somewhat an
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overestimate. Secondly, most of the included studies were observational
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and therefore with inevitable recall and interviewer biases, which might
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affect the associations between the risk factor and dislocation. Thirdly,
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the measurements of various risk factors differed from each other, and
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follow-up periods ranged widely from several months to several years.
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Fourthly, there might be operator-dependent and append subjective
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factors in the quality of assessment process. Nevertheless, the two
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reviewers evaluated the identified studies independently and any
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disagreement was resolved by discussion and consensus. Although this
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meta-analysis investigates some risk factors for postoperative dislocation
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after revision THA, we should treat these results cautiously on the
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background of potential defects, and more research studies with larger
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sample size and better design should be conducted.
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Although some limitations were unavoidable, this study has some merits.
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Firstly, the search style based on the computer and manual search ensures
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a complete inclusion of relevant studies. Secondly, no significant
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heterogeneity was observed in most variables except for the item of
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active external rotation; even so, heterogeneity was diminished using
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sensitivity analysis and this did not alter the result. Last but most
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important, this is by far the first study to quantitatively summarize the
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risk factors for the development of dislocation after revision THA.
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Acknowledgments
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We are grateful to C W and Y Z of the Department of Orthopedics, and to
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D T and Z L of the Department of Statistics and Applications for their
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kind assistance.
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Conflict of interest
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The authors declare that they have no conflict of interest.
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30. Elson LC, Barr CJ, Chandran SE, Hansen VJ, Malchau H, Kwon YM Are morbidly obese patients undergoing total hip arthroplasty at an increased risk for component malpositioning? J Arthroplasty 28 (2013) 41-44.
31. Hayashi S, Nishiyama T, Fujishiro T, Hashimoto S, Kanzaki N, Nishida K, Kurosaka M Obese patients may have more soft tissue impingement following primary total hip arthroplasty. Int Orthop 36 (2012) 2419-2423.
32. Parvizi J, Kim KI, Goldberg G, Mallo G, Hozack WJ Recurrent instability after total hip arthroplasty: beware of subtle component malpositioning. Clin Orthop Relat Res 447 (2006) 60-65.
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Figure 1 Flowchart of literature search.
371
Figure 2a Forest plots of the meta-analysis of femoral head size.
372
Figure 2b Forest plots of the meta-analysis of history of instability.
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Figure 2c Forest plots of the meta-analysis of elevated rim liner.
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First author
Publication year
Country
Case
Control
Total
Age
Significant factors Gender,
left or right,
femoral head size,
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original diagnosis, bone-grafting,
Alberton3
2002
USA
115
1433
1548
63
trochanteric
osteotomy, cup
inclination, cup
Kosashivili
Cogan
13
2011
2011
Canada
17
France
2013
USA
225
242
65
61
4
688
57
749
61
Jo
11
2015
component revision , elevated rim liner Femoral head size
Gender, femoral head size, bone-grafting , number of prior
64±14.3
revisions ≥ 3, number of prior revisions ≥ 2, elevated rim liner Age, gender, cup
65.8
inclination, cup anteversion,BMI Age, gender, trochanteric osteotomy,BMI, history of instability,
113
1039
1152
64.7
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Wetters NG4
USA
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7
2009
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Hummel
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12
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anteversion , single
number of prior revisions ≥ 3, Constrained liners, elevated rim liner, single component revision Gender ,
USA
86
453
539
NA
number of
prior revisions ≥ 2, Constrained liners Gender, original diagnosis, trochanteric
Yoshimoto5
2016
Japan
16
162
178
65.2±10.6
osteotomy, history of instability, single component revision
Steman 6
2016
USA
9
178
187
58.9
Gender, left or right, history of instability,
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revision
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Pooled OR
LL95%
UL 95%
studies
or SMDs
CI
CI
7
1.061
0.856
1.316
0.589a
0.117
41.1
-0.031
0.023
a
0.567
<0.001
0.098
a
0.451
<0.001
0.021a
0.222
33.6
0.147a
0.87
<0.001
0.253a
0.183
43.6
2
Left(VS right) Femoral head size(≤ 28mmvs32mm) Aseptic loosening(VS other) Bone-grafting trochanteric osteotomy Cup inclination Cup anteversion
0.729
0.502
1.06
3
1.451
1.056
1.994
3
0.707
0.442
1.129
2
1.2
0.878
1.639
3
0.99
0.72
2
-0.356
-1.063
2
History of instability Number of prior revisions≥3 Number of prior
Constrained liners single component revision vs multiple component revision
0.026
0.502
-0.888
0.952a
0.797
<0.001
0.352
0.324 b
0.136
55.1
a
0.168
0.219
1.892
0.791 0.479
b
47.5
0.008
85.8
a
0.945
<0.001
1.888
3.974
<0.001
2
2.226
1.569
3.16
<0.001a
0.484
<0.001
2
1.949
1.349
2.817
<0.001a
0.977
<0.001
3
0.66
0.222
1.959
0.454 b
0.012
77.4
4
1.263
0.921
1.732
0.148a
0.12
48.7
3
0.611
0.415
0.898
0.012a
0.177
42.2
a
Fixed-effects model was performed.
b
Fandom-effects model was performed.
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I (%)
1.361
BMI, Body Mass Index; OR, odds ratio; LL, lower limit; UL, upper limit.
c 2
c 2
2.739
EP
elevated rim
-0.167
(P)
3
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revisions≥2
-0413
2
2
BMI
-0.222
Q-test
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Age
SC
Female (VS male)
P value
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Potential risks
I statistic was defined as the proportion of heterogeneity not due to chance or random error.
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Research highlights ► Many risk factors have been identified for the dislocation following revision THA. However, these factors are still undergoing controversial
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or have been not been well summarized. ► Constrained liner, trochanteric osteotomy, Cup inclination, cup anteversion, BMI, single
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component revision were not found to be risk factors. ► history of instability and prior revisions are the most consistently significant risk
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factors for dislocation after revision THA, followed by age at surgery,
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femoral head size, with no elevated rim liner.
S1743-9191(16)31298-5
DOI:
10.1016/j.ijsu.2016.12.122
Reference:
IJSU 3420
To appear in:
International Journal of Surgery
Received Date: 21 October 2016 Revised Date:
23 December 2016
Accepted Date: 29 December 2016
Please cite this article as: Guo L, Yang Y, An B, Yang Y, Shi L, Han X, Gao S, Risk factors for dislocation after revision total hip arthroplasty: A systematic review and meta-analysis, International Journal of Surgery (2017), doi: 10.1016/j.ijsu.2016.12.122. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Risk factors for dislocation after revision total hip arthroplasty: A systematic review and meta-analysis Lele Guo1; Yanjiang Yang 2; Biao An2;Yantao Yang2; Linyuan Shi2;Xiangzhen Han2; Shijun Gao 1, 2*
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1, Department of Joint Surgery, the Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050051, P.R. China
2, Department of Scientific bureau, the Third Hospital of Hebei Medical University, Hebei, 050051,
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P.R. China
3, Department of Hand Surgery, the Third Hospital of Hebei Medical University, Hebei, 050051, P.R.
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4, Department of respiratory, Hebei General Hospital, Shijiazhuang, Hebei, 050051, P.R. China *Contributed equally. Lele Guo
E-mail:[email protected]
E-mail:[email protected]
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Yanjiang Yang Biao An Yantao Yang
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Xiangzhen Han
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Linyuan Shi
Shijun Gao
E-mail: 1159052936 @qq.com E-mail: 419641897 @qq.com E-mail:[email protected] E-mail:[email protected] E-mail:[email protected]
Correspondence: Shijun Gao
Department of Joint Surgery , the 3rd Hospital, Hebei Medical University NO.139 Ziqiang Road, Shijiazhuang 050051, P.R. China Tel: +86-311-88602315 Fax: +86-311-87023626
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E-mail: [email protected]
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Risk factors for dislocation after revision total hip arthroplasty: A
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systematic review and meta-analysis
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Abstract
4
Background
5
performed up to now to summarize the risk factors of dislocation after
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revision total hip arthroplasty(THA).
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Aims The present study aimed to quantitatively and comprehensively
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conclude the risk factors of dislocation after revision total hip
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arthroplasty.
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No formal systematic review or meta-analysis was
Methods
A search was applied to CNKI, Embase, Medline, and
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Cochrane central database (all up to October 2016). All studies assessing
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the risk factors of dislocation after revision THA without language
13
restriction were reviewed, and qualities of included studies were assessed
14
using the Newcastle–Ottawa Scale. Data were pooled and a meta-analysis
15
completed.
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Results A total of 8 studies were selected, which altogether included
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4656 revision THAs. 421 of them were cases of dislocation occurred after
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surgery, suggesting the accumulated incidence of 9.04%. Results of
19
meta-analyses showed that age at surgery (standardized mean difference
20
-0.222; 95% CI -0.413–-0.031), small-diameter femoral heads（≤28mm）
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(OR 1.451; 95%CI 1.056-1.994), history of instability (OR 2.739; 95%CI
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1.888-3.974), number of prior revisions ≥ 3 (OR, 2.226; 95% CI,
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1.569-3.16) and number of prior revisions ≥ 2 (OR 1.949; 95% CI
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1.349-2.817), acetabular components with elevated rim liner were less
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likely to develop dislocation after revision THA (OR 0.611; 95% CI
26
0.415-0.898).
27
Conclusions
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patients involved with above-mentioned risk factors to prevent
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dislocation after revision THA.
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Keywords: dislocation, revision total hip arthroplasty, risk factors.
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Introduction
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Postoperative dislocation remains as one of the most common
47
complications following revision total hip arthroplasty (THA), with
48
reported incidences ranging between 4 to 30%[1, 2]. Several patient- and
49
surgery-specific risk factors have been described previously, including
50
femoral head size, deficient abductors, surgical approach, malposition of
51
components, using of a liner with an elevated rim, cup position, and
52
number of previous hip surgeries[3-7]. Identifying risk factors for this
53
complication is important, as the identification of patients at risk can
54
assist with preoperative patient education and management at the time of
55
revision surgery. However, these studies had some limitations, such as a
56
small sample and containing a single or very few potential risk factors in
57
the individual study. In addition, some results obtained from individual
58
studies were inconsistent and even contradictory. Thus, it is still uncertain
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whether these identified factors from individual studies are able to predict
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dislocation after revision total hip arthroplasty.
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Until now, no formal systematic review or meta-analysis was performed
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to summarize the risk factors of dislocation after revision THA to obtain a
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definitive conclusion. Therefore in this study, we summarized these risk
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factors from the previous original researches and conducted a
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meta-analysis. It would be most informative in guiding clinicians for
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identifying high risk patients and helping them preventing postoperative
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dislocation after revision THA to improve the patients’ prognosis.
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Materials and methods
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Literature search
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CNKI, Embase, Medline, and Cochrane central database were searched
71
using a broad range of terms to identify original research, published all
72
through October 2016 and selecting potential studies to consider. The
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main key words were as follows: “factor’’ or ‘‘predictor’’ or “risk’’ AND
74
‘‘dislocation’’ or “luxation” AND ‘‘hip arthroplasty’’ or ‘‘THA’’ AND
75
‘‘revision’’. Also, a manual search of references in the identified articles
76
and systematic reviews was performed for possible inclusion.
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Eligibility criteria
78
Two reviewers (Yan Jiang Yang and Biao An) independently evaluated
79
the titles and abstracts of the identified studies. Only full-text articles
80
without language restriction were included in this meta-analysis. The
81
following inclusive selection criteria were applied: (1) a study was
82
performed to explore risk factors for dislocation occurrence after revision
83
THA; (2) cases and controls were defined based on the presence or
84
absence of dislocation, respectively; (3) sufficient data were published for
85
estimating an odds ratio (OR) or hazard ratio (HR) or standardized mean
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difference (SMD) with 95 % confidence interval (95 % CI)
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Quality of included studies
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The quality of the included studies was evaluated using the Newcastle–
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Ottawa Scale (NOS)[8]: based on the three main items: the selection of
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the study groups (0–4 points), the comparability of the groups (0–2 points)
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and the determination of either the exposure or the outcome of interest
92
(0–3 points), with a perfect score of 9.
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Data extraction
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All the data were carefully extracted from all eligible studies
95
independently by the two reviewers (Yan Jiang Yang and Biao An). The
96
following variables were extracted from each study: first author’s name,
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publication year, country, significant risk factors, definitions and numbers
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of cases and controls and numbers of citations for each potential risk
99
factor for dislocation after revision THA. Any disagreement was resolved
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by discussion and consensus.
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Statistical analyses
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ORs or SMDs and corresponding 95% CI were estimated and pooled
103
across studies to assess the association between different variables and
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the risk of dislocation with a value of P<0.05 as significance.
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Heterogeneity among studies was tested by Q-test statistics with
106
significance set at P<0.10[9] and further measured by I2 statistics with I2
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more than 50% indicating significant inconsistency. A random-effect
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model was used to calculate pooled ORs in the case of significant
109
heterogeneity (P<0.10 or I2>50 %); otherwise, a fixed-effect model was
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used[10] . The outcome of meta-analysis for variables was summarized
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graphically using a forest plot. If necessary, a sensitive analysis by
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excluding outlier study one by one was conducted to investigate the
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sources for heterogeneity. Potential publication bias was detected by
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Begg’s funnel plots, and P<0.05 was judged as statistically significant.
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All analyses were performed by the software Stata 11.0 (Stata
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Corporation, College Station, TX).
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Results
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Characteristics of identified studies
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Fig. 1 indicates the flowchart of the article screening and the detailed
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selection process. Initial search yielded 221 titles and abstracts from the
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electronic databases. After duplicates were removed, 125 abstracts were
122
reviewed for initial screening and 38 for the next stage of review. After
123
inclusion and exclusion criteria were applied, 8 full text articles were
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chosen for this meta-analysis. All of them were published in English with
125
publication time from 2002 to 2016. These 8 studies altogether included
126
4656 patients with hip fracture; 421 cases of dislocation occurred after
127
surgery, suggesting the accumulated incidence of 9.04%. Detailed
128
information about these included studies is shown in Table 1.
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Methodological quality assessment
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The outcome of methodology quality assessment was as follows: one
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studies[11] scored 9，two studies[3, 4] scored 8, three studies[5, 7, 12]
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scored 7，and two studies[6, 13] scored 6.
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Age and gender
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Two studies reported the admission age of 64.25 years in postoperative
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dislocation patients, which was 1.05 years younger than that in
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nondislocation groups, and the pooled results for meta-analysis suggested
137
a difference (SMD -0.222; 95% CI -0.413– -0.031;). There was no
138
evidence of heterogeneity among studies (P=0.567, I2=0; Table 2). Sex
139
difference of the occurrence of dislocation after revision total hip
140
arthroplasty was reported in 7 studies. Results of meta-analysis suggested
141
no significant difference.
142
Femoral head size
143
Postoperative dislocation incidence was consistently higher in those who
144
had small-diameter femoral heads（≤28mm） compared with those who
145
had large-diameter femoral heads（≥32mm）. A total of 3 studies reported
146
the small-diameter femoral head as a risk factor and meta-analysis of
147
these studies showed that patients with small-diameter femoral heads
148
were more prone to develop dislocation after revision total hip
149
arthroplasty (OR 1.451, 95% CI 1.056–1.994). There was no evidence of
150
heterogeneity among studies (P=0.222, I2=33.6%; Table 2; Fig. 2a).
151
History of instability
152
Three studies have previously reported history of instability as a risk
153
factor associated with dislocation after revision total hip arthroplasty,
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with a significant difference (OR 2.739; 95%CI 1.888-3.974), with no
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heterogeneity (P=0.945, I2=0; Table 2; Fig. 2b).
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Number of prior revisions
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Two studies have previously reported number of prior revisions≥3 as a
158
risk factor associated with dislocation after revision total hip arthroplasty,
159
with a significant difference (OR 2.226; 95%CI 1.569-3.16), with no
160
heterogeneity (P=0.484, I2=0; Table 2). Also，two studies have previously
161
reported number of prior revisions≥2 as a risk factor associated with
162
dislocation after revision total hip arthroplasty, with a significant
163
difference (OR 1.949; 95%CI 1.349-2.817), with no heterogeneity
164
(P=0.977, I2=0; Table 2).
165
Elevated rim liner
166
Elevated rim liner of the occurrence of dislocation after revision total hip
167
arthroplasty was reported in 3 studies. Results of meta-analysis showed
168
that with an elevated rim liner was less likely to sustain dislocation, and
169
the combinable OR was 0.611 (95% CI 0.415–0.898), with no
170
heterogeneity (P=0.177, I2=42.2%; Table 2; Fig. 2c).
171
Discussion
172
Dislocation is one of the most frequent complications after revision total
173
hip arthroplasty. Results in this meta-analysis suggested the overall
174
prevalence of postoperative dislocation was 9.04%, which is comparable
175
to the range of 4–30% in THA patients reported by others[1, 2]. This
176
meta-analysis demonstrates that history of instability and prior revisions
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are the most consistently significant risk factors for dislocation after
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revision THA, followed by age at surgery, femoral head size and with no
179
elevated rim liner.
180
Larger femoral heads have the potential to decrease dislocation rate in
181
primary THA, but it is unclear whether they do so in revision THA. Wang
182
et al.[14] reported femoral head size was the only factor with significant
183
difference between the dislocated and stable groups. Other investigators
184
also reported a reduction in dislocation rates with larger diameter
185
heads[15, 16]. About dislocation after revision THA, Garbuz et al.[17]
186
reported that in a randomized controlled trial, patients with 32-mm heads
187
had a dislocation rate of 8.7%, while using 36- and 40-mm diameter
188
heads lowered that rate to 1.1% at a minimum follow up of 2 years. This
189
meta-analysis found, postoperative dislocation incidence was consistently
190
higher in those who had small-diameter femoral heads( ≤ 28mm)
191
compared with those who had large-diameter femoral heads（≥32mm）.
192
So, femoral head size should be an important factor in dislocation risk
193
assessment.
194
Itokawa et al.[18] had discussed several factors associated with recurrent
195
dislocations in primary THA, while those after revision THA have not
196
been well characterized. Daly et al.[19] reported that, high recurrence rate
197
when the hip is revised specifically for instability, reporting 39%
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recurrence in 95 hips at average of 7.6 years. In our study, Patients with
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prior dislocation were 2.74 times more at risk of developing dislocation
200
than patients who without the dislocation history.
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Previous reports demonstrated that number of previous revisions should
202
be the predictor of dislocation after revision hip arthroplasty[20, 21]. Jo et
203
al.[11] noted that history of more than 2 previous hip surgeries was
204
identified as patient related risk factors associated with dislocation. This
205
meta-analysis found the risk of implant dislocation was 2.23 times higher
206
in the Number of prior revisions≥3 groups than the groups Number of
207
prior revisions＜3. This meta-analysis also found the risk of implant
208
dislocation was 1.95 times higher in the Number of prior revisions≥2
209
groups than the groups Number of prior revisions＜2.
210
An elevated rim liner can reduce the occurrence of dislocation after
211
revision total hip arthroplasty, and the risk of implant dislocation was 1.8
212
times higher in the no an elevated rim liner groups than the groups with
213
an elevated rim liner. Cobb et al.[22] reported that elevated rim liners can
214
reduce the rates of dislocation in revision arthroplasties. Alberton et al.[3]
215
reported that elevated rim liner was least beneficial with an isolated
216
acetabular revision. When both components were revised, hips that had
217
insertion of a cup with an elevated rim liner were significantly more
218
stable.
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Advanced age has been associated with a higher risk of dislocation in
220
some series[23, 24].And it is likely related to decreased muscle
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control/strength and increased risk of falling in the elderly[25].
222
Yoshimoto et al.[5] noted that advanced age should be an independent
223
risk factors for any dislocation. Interestingly, This meta-analysis found
224
that, the admission age of 64.25 years in postoperative dislocation
225
patients was 1.05 years younger than that in nondislocation groups.
226
Other factors, such as constrained liner, trochanteric osteotomy, Cup
227
inclination, cup anteversion, BMI, single component revision were not
228
found to be risk factors. However, Della et al.[26] noted that, the higher
229
failure rate observed when constrained liner was placed into a retained
230
cup indicates that it is essential to optimize other factors that may
231
contribute to instability in order to decrease the mechanical failure as was
232
emphasized. Alberton et al.[3] reported that trochanteric osteotomy was a
233
significant risk factor which has been demonstrated in other studies as
234
well[27, 28]. They noted that, Trochanteric nonunion occurred in only 2.3%
235
(nine) of 399 hips that had a trochanteric osteotomy. And, seven of the
236
nine hips with trochanteric nonunion had a subsequent episode of
237
instability. The role of cup inclination and anteversion on the dislocation
238
rate has been extensively studied, both independently and combined.
239
Sadhu et al.[29] reported that patients sustaining a dislocation after THA
240
have acetabular components less frequently positioned within the
241
safe zone for both inclination and anteversion, with a mean position
242
in increased inclination and decreased anteversion. But, our meta-analysis
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suggested no significant difference about cup inclination and anteversion
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difference of the occurrence of dislocation after revision total hip
245
arthroplasty. Obese patients may also be at increased risk for dislocation
246
owing tocomponent malpositioning and soft tissue impingement related
247
to difficult exposure[30, 31]. Yet, this meta-analysis found that, obesity
248
could not to be a risk factor. Some scholars believe that, single
249
component revision should be a risk factor about dislocation after
250
revision total hip arthroplasty[3, 20, 32], The increased soft tissue
251
releases required to perform a single-component revision. However, this
252
meta-analysis found that, single component revision was not a risk factor.
253
In our meta-analysis, gender, left or right, original diagnosis and
254
bone-grafting were not found to be risk factors. This may also relate to
255
the similarity in those factors between dislocators and nondislocators.
256
Some limitations in this meta-analysis have to be mentioned. Firstly, a
257
weakness exists in the analyses, in which not all the ORs regarding the
258
potential risk factors applied for the meta-analysis were adjusted because
259
a lot of reports could only provide the univariate rather than multivariate
260
statistics. Likewise, some studies might choose not to report insignificant
261
results or results of no interest, potentially resulting in a considerable
262
amount of missing data. Hence, our overall effect may be somewhat an
263
overestimate. Secondly, most of the included studies were observational
264
and therefore with inevitable recall and interviewer biases, which might
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affect the associations between the risk factor and dislocation. Thirdly,
266
the measurements of various risk factors differed from each other, and
267
follow-up periods ranged widely from several months to several years.
268
Fourthly, there might be operator-dependent and append subjective
269
factors in the quality of assessment process. Nevertheless, the two
270
reviewers evaluated the identified studies independently and any
271
disagreement was resolved by discussion and consensus. Although this
272
meta-analysis investigates some risk factors for postoperative dislocation
273
after revision THA, we should treat these results cautiously on the
274
background of potential defects, and more research studies with larger
275
sample size and better design should be conducted.
276
Although some limitations were unavoidable, this study has some merits.
277
Firstly, the search style based on the computer and manual search ensures
278
a complete inclusion of relevant studies. Secondly, no significant
279
heterogeneity was observed in most variables except for the item of
280
active external rotation; even so, heterogeneity was diminished using
281
sensitivity analysis and this did not alter the result. Last but most
282
important, this is by far the first study to quantitatively summarize the
283
risk factors for the development of dislocation after revision THA.
284
Acknowledgments
285
We are grateful to C W and Y Z of the Department of Orthopedics, and to
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D T and Z L of the Department of Statistics and Applications for their
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kind assistance.
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Conflict of interest
289
The authors declare that they have no conflict of interest.
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References
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hip arthroplasty: comparison between the first and multiply revised total hip arthroplasty. J
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approach on risk of dislocation after primary total hip arthroplasty. J Bone Joint Surg Am 87 (2005)
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2456-2463. 17. Garbuz DS, Masri BA, Duncan CP, Greidanus NV, Bohm ER, Petrak MJ, Della Valle CJ, Gross AE 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 470 (2012) 351-356. 18. Itokawa T, Nakashima Y, Yamamoto T, Motomura G, Ohishi M, Hamai S, Akiyama M, Hirata M, Hara D, Iwamoto Y Late dislocation is associated with recurrence after total hip arthroplasty. Int Orthop 37
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23. Bystrom S, Espehaug B, Furnes O, Havelin LI 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 74 (2003) 514-524.
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27. Kaplan SJ, Thomas WH, Poss R Trochanteric advancement for recurrent dislocation after total hip arthroplasty. J Arthroplasty 2 (1987) 119-124.
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Figure 1 Flowchart of literature search.
371
Figure 2a Forest plots of the meta-analysis of femoral head size.
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Figure 2b Forest plots of the meta-analysis of history of instability.
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Figure 2c Forest plots of the meta-analysis of elevated rim liner.
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ACCEPTED MANUSCRIPT Table 1 The basic characteristics of these 8 included studies and participants
First author
Publication year
Country
Case
Control
Total
Age
Significant factors Gender,
left or right,
femoral head size,
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original diagnosis, bone-grafting,
Alberton3
2002
USA
115
1433
1548
63
trochanteric
osteotomy, cup
inclination, cup
Kosashivili
Cogan
13
2011
2011
Canada
17
France
2013
USA
225
242
65
61
4
688
57
749
61
Jo
11
2015
component revision , elevated rim liner Femoral head size
Gender, femoral head size, bone-grafting , number of prior
64±14.3
revisions ≥ 3, number of prior revisions ≥ 2, elevated rim liner Age, gender, cup
65.8
inclination, cup anteversion,BMI Age, gender, trochanteric osteotomy,BMI, history of instability,
113
1039
1152
64.7
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Wetters NG4
USA
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7
2009
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Hummel
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12
SC
anteversion , single
number of prior revisions ≥ 3, Constrained liners, elevated rim liner, single component revision Gender ,
USA
86
453
539
NA
number of
prior revisions ≥ 2, Constrained liners Gender, original diagnosis, trochanteric
Yoshimoto5
2016
Japan
16
162
178
65.2±10.6
osteotomy, history of instability, single component revision
Steman 6
2016
USA
9
178
187
58.9
Gender, left or right, history of instability,
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revision
ACCEPTED MANUSCRIPT Table 2 Detailed data on potential risk factors for dislocation after revision total hip arthroplasty and the outcomes of meta-analysis. No of
Pooled OR
LL95%
UL 95%
studies
or SMDs
CI
CI
7
1.061
0.856
1.316
0.589a
0.117
41.1
-0.031
0.023
a
0.567
<0.001
0.098
a
0.451
<0.001
0.021a
0.222
33.6
0.147a
0.87
<0.001
0.253a
0.183
43.6
2
Left(VS right) Femoral head size(≤ 28mmvs32mm) Aseptic loosening(VS other) Bone-grafting trochanteric osteotomy Cup inclination Cup anteversion
0.729
0.502
1.06
3
1.451
1.056
1.994
3
0.707
0.442
1.129
2
1.2
0.878
1.639
3
0.99
0.72
2
-0.356
-1.063
2
History of instability Number of prior revisions≥3 Number of prior
Constrained liners single component revision vs multiple component revision
0.026
0.502
-0.888
0.952a
0.797
<0.001
0.352
0.324 b
0.136
55.1
a
0.168
0.219
1.892
0.791 0.479
b
47.5
0.008
85.8
a
0.945
<0.001
1.888
3.974
<0.001
2
2.226
1.569
3.16
<0.001a
0.484
<0.001
2
1.949
1.349
2.817
<0.001a
0.977
<0.001
3
0.66
0.222
1.959
0.454 b
0.012
77.4
4
1.263
0.921
1.732
0.148a
0.12
48.7
3
0.611
0.415
0.898
0.012a
0.177
42.2
a
Fixed-effects model was performed.
b
Fandom-effects model was performed.
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I (%)
1.361
BMI, Body Mass Index; OR, odds ratio; LL, lower limit; UL, upper limit.
c 2
c 2
2.739
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elevated rim
-0.167
(P)
3
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revisions≥2
-0413
2
2
BMI
-0.222
Q-test
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Age
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Female (VS male)
P value
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Potential risks
I statistic was defined as the proportion of heterogeneity not due to chance or random error.
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Research highlights ► Many risk factors have been identified for the dislocation following revision THA. However, these factors are still undergoing controversial
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or have been not been well summarized. ► Constrained liner, trochanteric osteotomy, Cup inclination, cup anteversion, BMI, single
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component revision were not found to be risk factors. ► history of instability and prior revisions are the most consistently significant risk
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factors for dislocation after revision THA, followed by age at surgery,
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femoral head size, with no elevated rim liner.