Large Femoral Heads and Select Dual-Mobility Bearings Are Associated With Reduced Instability in Contemporary Posterior Approach Total Hip Arthroplasty

Early Failure of a Novel Modular Dual Mobility Liner After Metal Release: Clinical Presentation and Detailed Retrieval Analysis

Cobalt chrome alloy (CoCrMo) corrosion and subsequent metal release has been described as a potential complication of total hip arthroplasty. Here, we present the case of a patient with a well-seated dual mobility (DM) implant revised after 10 months. Prior to revision, the patient experienced pain and stiffness. Following a negative infection workup, we measured elevated metal concentrations, hypothesized to originate from the CoCrMo DM liner. While corrosion has been extensively reported in other constructs, the CoCrMo liner described here includes a post and tabs, features added to reduce the risk of corrosion. Retrieval analysis demonstrated a severe chemically based corrosion attack on the liner. Continued caution and ongoing close monitoring of outcomes associated with the use of modular DM constructs is likely warranted.

Impact of CT-based navigation, large femoral head, and dual-mobility liner on achieving the required range of motion in total hip arthroplasty

Aims

This study aimed to investigate whether the use of CT-based navigation enhances: 1) the accuracy of cup placement; and 2) the achievement rate of required range of motion (ROM). Additionally, we investigated the impact of using a large femoral head and dual-mobility liner on the achievement rates.

Methods

This retrospective study analyzed 60 manual and 51 CT-based navigated primary total hip arthroplasties performed at a single facility. Postoperative CT scans and CT-based simulation software were employed to measure the cup orientation and to simulate the ROM. We compared the absolute errors for radiological inclination (RI) and radiological anteversion (RA) between the two groups. We also examined whether the simulated ROM met the required ROM criteria, defined as flexion > 110°, internal rotation > 30°, extension > 30°, and external rotation > 30°. Furthermore, we performed simulations with 36 mm femoral head and dual-mobility liner.

Results

The absolute errors of RI and RA from the preoperative plan were significantly smaller in the CT-based navigation group (3.7° (SD 3.5°) vs 5.1° (SD 3.5°); p = 0.022, and 3.9° (SD 3.5°) vs 6.8° (SD 5.0°); p = 0.001, respectively). The proportion of cases achieving the required ROM in all directions was significantly higher in the CT-based navigation group (42% vs 63%; p = 0.036). The achievement rates of the required ROM were significantly higher with the use of a 36 mm ball or dual-mobility liner compared to the use of a 32 mm ball (65% vs 51%; p = 0.040 and 77% vs 51%; p ≤ 0.001, respectively).

Conclusion

CT-based navigation enhanced required ROM achievement rates by > 20%, regardless of the ball diameter. The improved accuracy of cup placement through CT-based navigation likely contributed to the enhancement. Furthermore, the use of large femoral heads and dual-mobility liners also improved the required ROM achievement rates. In cases with a high risk of dislocation, use of these devices is preferred.

Clinical outcomes and complications of a non-modular dual-mobility acetabular device, minimum 2 years follow-up

INTRODUCTION

Non-modular dual-mobility (DM) acetabular bearing constructs are becoming more popular due to their potential advantages for addressing range of motion (ROM) and stability. The objective of this post-market clinical study was to assess clinical outcomes, including patient satisfaction, pain and function, survivorship, and component positioning, in patients ⩾2 years after primary THA using non-modular DM acetabular components.

METHODS

This retrospective, multicentre study evaluated complications and functional outcomes in recipients of non-modular DM acetabular constructs at least 2 years post-THA. Our primary outcomes included the dislocation rate and mean Hip disability and Osteoarthritis Outcomes Score (HOOS). Secondary outcomes included radiographic measurements, patient satisfaction, Forgotten Joint Score (FJS), Harris Hip Score (HHS), and survivorship.

RESULTS

316 eligible patients enrolled in this study across 3 sites, including 168 men (53%) and 148 women (47%). The cohort averaged 5.37 years post-THA (range 2.2-10.1 years) at the study visit. The mean FJS, HHS, and HOOS were good to excellent, with values of 82.3, 90.7, and 92.0, respectively. Patient satisfaction averaged 4.68, between "Very Good" (4) and "Excellent" (5). Minimal radiolucent lines (RLL) surrounded the acetabulum. More RLL surrounded the femur, but most lines were less than 1 mm (4.7% of the study population). There were few adverse events (4 events, 1.3%). Three revisions were performed (0.9%), with one patient requiring removal of the acetabular cup.

DISCUSSION

The high mid- to long-term survivorship and low to no dislocation and reoperation rates indicate this acetabular DM device is a viable option for THA patients. The patient metrics reflect satisfaction, alleviated pain, and restored function with a low risk of adverse outcomes.

Contemporary insights into spinopelvic mechanics

Understanding spinopelvic mechanics is important for the success of total hip arthroplasty (THA). Despite significant advancements in appreciating spinopelvic balance, numerous challenges remain. It is crucial to recognize the individual variability and postoperative changes in spinopelvic parameters and their consequential impact on prosthetic component positioning to mitigate the risk of dislocation and enhance postoperative outcomes. This review describes the integration of advanced diagnostic approaches, enhanced technology, implant considerations, and surgical planning, all tailored to the unique anatomy and biomechanics of each patient. It underscores the importance of accurately predicting postoperative spinopelvic mechanics, selecting suitable imaging techniques, establishing a consistent nomenclature for spinopelvic stiffness, and considering implant-specific strategies. Furthermore, it highlights the potential of artificial intelligence to personalize care.

Decreased Instability in High-Risk (Hip-Spine 2B) Patients After Modifications of Surgical Planning and Technique

BACKGROUND

Patients undergoing primary total hip arthroplasty (THA) who have spinal deformity and a stiff spine are the highest-risk group for instability. Despite the increasing use of dual-mobility cups and large femoral heads, dislocation remains a major complication after THA. Preoperative planning becomes a critical aspect of ensuring precise component positioning within a safe zone. The purpose of this study was to investigate dislocation rates over a 9-year period.

METHODS

A retrospective review of 4,731 THAs performed by 3 orthopaedic surgeons between January 2014 and March 2023 was performed. Spinopelvic measurements were conducted to determine the hip-spine classification group for each patient. Only patients classified as 2B (pelvic incidence-lumbar lordosis > 10° and Δsacral slope < 10°) were eligible. Both absolute and relative dislocation frequencies were then analyzed using time-series analysis techniques and Fisher's exact tests.

RESULTS

A total of 281 hip-spine 2B patients undergoing primary THA were eligible for analysis (57% women; mean age, range: 66 years, 23 to 87; mean body mass index, range: 28, 16 to 45). The overall dislocation rate was 4.3%. Use of femoral head sizes ≥ 40 mm increased from 4% in 2014 to 2019 to 37% in 2020 to 2023 (P < .001), while the use of dual-mobility cups decreased from 100% in 2014 to 2019 to 37% in 2020 to 2023 (P < .001). Acetabular component planning was changed from the supine plane to the standing plane in February 2020. Those changes in surgical practice were notably correlated with a significant decrease in dislocation rates from 6.8% in 2014 to 2019 to 1.5% in 2020 to 2023 (P = .03).

CONCLUSIONS

Our study demonstrates that the introduction of advanced preoperative THA planning to the standing plane, coupled with precise intraoperative technology for implant placement, can significantly reduce the risk of instability in high-risk THA patients. Notably, we observed a significant decrease in dislocation rates, which aligned with the shift in surgical practice.

LEVEL OF EVIDENCE

IV.

Malseated Liner in Modular Dual Mobility Total Hip Replacement: A Report of Three Cases

Modular dual mobility total hip arthroplasty (THA) can be associated with complications if the liner is malseated, which can be unappreciated intraoperatively. A meticulous surgical technique is needed to ensure that the liner is perfectly seated. In addition, a malseated liner can be missed if the postoperative films are not carefully reviewed by the surgeon. We present three cases of THA associated with a malseated modular dual mobility liner. In one case, the malpositioned liner was appreciated intraoperatively, but it was wedged in place and could not be removed. The entire shell needed to be revised. In two other cases, malseating was not detected intra-operatively. Both were appreciated postoperatively, and early revision surgery was needed.

Instability in Patients With Lumbar Spine Disease Undergoing Posterior Approach and Lateral Approach Primary Total Hip Arthroplasty

INTRODUCTION

Dislocation rates in patients who have fixed spinopelvic motion have been reported up to 20%. Few studies have directly compared dislocation rates in patients who have spine pathology undergoing total hip arthroplasty (THA) through different surgical approaches. This study compared postoperative dislocation rates in patients who had lumbar spine disease and underwent primary THA using a posterior or direct lateral approach.

METHODS

Between 2011 and 2017, consecutive cohorts of primary THAs were retrospectively reviewed. One surgeon routinely used a posterior approach, while the other used a direct lateral approach. Chart and radiographic review were conducted to identify patients who had lumbar spine disease. Dislocations among cohorts with and without lumbar spine disease were compared by posterior and direct lateral approaches.

RESULTS

The overall dislocation rate was 1.3% (15/1,198). The top four predictors of dislocation were presence of lumbar spine disease (odds ratio [OR] 5.0; P = 0.014), posterior surgical approach (OR, 6.5; P = 0.074), cases performed for fracture (OR, 4.4; P = 0.035), and women (OR, 4.6; P = 0.050). Dislocation rates among direct lateral approach patients who had lumbar spine pathology were significantly lower than posterior approach patients who had lumbar spine pathology (0.0% versus 3.6%; P = 0.011).

DISCUSSION

Although dislocation rates were low in both groups, study results suggest that a direct lateral approach for primary THA may reduce postoperative dislocations for patients who have limited spinopelvic motion due to lumbar spine pathology. Furthermore, surgeons using the posterior approach might consider optimizing the femoral head to acetabular cup ratio in patients who have lumbar spine disease.

Dislocation Following Anterior and Posterior Total Hip Arthroplasty in the Setting of Spinal Deformity and Stiffness: Evolving Trends Using a High-Risk Protocol at a Single Tertiary Center

BACKGROUND

Patients who have spinal stiffness and deformity are at the highest risk for dislocation after total hip arthroplasty (THA). Previous reports of this cohort are limited to antero-lateral and postero-lateral (PL) approaches. We investigated the dislocation rate after direct anterior (DA) and PL approach THA with a contemporary high-risk protocol to optimize stability.

METHODS

We investigated patients undergoing THA who had preoperative biplanar imaging from January-December 2019. Patients were identified using radiographic criteria of spinal-stiffness (<10-degree change in sacral slope from standing to seated) and deformity (flatback deformity with >10-degree difference in pelvic incidence and lumbar lordosis). There were 367 patients identified (181 DA, 186 PL). The primary outcome was dislocation rate at 2-years postoperatively. Risk-factors for dislocation were evaluated using logistic regressions (significance level of 0.05).

RESULTS

There were 6 (1.6%) dislocations in the entire cohort, with low dislocation rates for both DA (0.6%) and PL-THA (2.7%). We observed increased utilization of dual mobility with larger outer head bearings (>38 mm) with PL-THA (34.4 versus 5.0%, P < .01) and conversely increased utilization of 32-mm femoral-heads with DA-THA (39.4 versus 7.0%, P < .001). Surgical approach (PL) was not a significant risk-factor for dislocation (odds ratio: 5.03, P = .15). Patients who had a history of lumbar-fusion had 8-times higher odds for dislocation (OR: 8.20, P = .020).

CONCLUSIONS

To the best of our knowledge, this is the largest series to date evaluating DA and PL-THA in the hip-spine 2B-group. Our results demonstrate lower dislocation rate than expected with either surgical approach using a high-risk protocol.