Constrained liners in revision: total hip arthroplasty an overuse syndrome: in opposition

Short term outcomes (average follow up of 2.4 years) of a constrained acetabular liner in primary and revision total hip arthroplasty

BACKGROUND

As instability continues to be a burden post total hip arthroplasty (THA), there has been a controversial discussion on the ideal implant choice. We report here the outcomes of a modern constrained acetabular liner (CAL) system in primary and revision THA at an average follow up of 2.4 years.

METHODS

We performed a retrospective study of all patients undergoing primary and revision hip arthroplasty and being implanted with the modern CAL system from 2013 to 2021. We identified 31 hips, of which 13 underwent primary THA and the remaining 18 underwent revision THA for instability.

RESULTS

Of those implanted with CAL primarily, 3 had concomitant abductor tear repair and gluteus maximus transfer, 5 had Parkinson's disease, 2 had inclusion body myositis, 1 had amyotrophic lateral sclerosis, and the remaining 2 were above 94 years of age. All patients implanted with the CAL were as a result of active instability post-primary THA and underwent only liner and head exchange without revision of the acetabular or femoral components. At an average follow up of 2.4 years (range, 9 months to 5 years and 4 months), we had 1 case (3.2 %) of dislocation post-CAL implantation. None of the patients undergoing surgery with CAL for active instability had a re-dislocation.

CONCLUSION

In conclusion, a constrained acetabular liner provides excellent stability in both primary THA in high risk individuals and revision THA in cases of active instability. There were no dislocations when using a constrained acetabular liner to treat active instability post THA.

Outcomes of total hip arthroplasty with a standard prosthesis for the affected hip in patients with poliomyelitis sequelae: a mid-term retrospective follow-up study

INTRODUCTION

Total hip arthroplasty for poliomyelitis sequelae could be a technical challenge due to the higher risk for prosthetic dislocation and degenerative changes in the affected limbs. This study aimed to analyse the mid-term outcomes of primary total hip arthroplasty on the affected hip with standard prosthesis.

MATERIALS AND METHODS

From January 2008 to January 2018, 32 patients with poliomyelitis sequelae underwent total hip arthroplasty on the affected hip with standard prosthesis. Clinical and radiographical outcomes, complications, and prosthesis survival rates were evaluated.

RESULTS

After a mean follow-up of 7.9 (4.4-13.1) years, the Harris Hip Score, University of California Los Angeles activity level rating, and 12-item Short Form Health Survey Questionnaire scale score significantly improved. The abduction and flexion motions of the hip joint improved dramatically, and the visual analogue scale pain score decreased significantly. The leg length discrepancy was effectively corrected. During the follow-up, one patient experienced prosthetic dislocation, one underwent revision surgery due to acetabular component loosening, two had osteolysis, four had heterotopic ossification, two experienced transient sciatic nerve palsy, and one had intermuscular vein thrombosis. The prosthesis survival rate was 96.9% at 5 years postoperatively. No periprosthetic infection occurred.

CONCLUSION

Total hip arthroplasty with standard prosthesis could be an effective treatment for hip arthropathy on the affected hip of patients with poliomyelitis sequelae, resulting in good clinical outcomes and few complications. Constrained liner and dual mobility articulation are not recommended unless the hip muscle strength of the abductor is < III.

Outcomes of dual mobility articulation total hip arthroplasty in ipsilateral residual poliomyelitis

BACKGROUND

Patients with poliomyelitis underwent total hip arthroplasty (THA) are known to be at higher risk of dislocation on account of muscular atrophy. This study aimed to investigate clinical outcomes, radiographic outcomes, complication rates, and survivorship of dual mobility THA in displaced femoral neck fractures of elderly with poliomyelitis.

MATERIALS AND METHODS

We retrospectively included 17 patients (17 hips) with residual poliomyelitis who underwent THA with dual mobility articulation. Clinical outcomes were assessed with the visual analog scale (VAS) pain score, Oxford hip score, and University of California Los Angeles activity (UCLA) score. Radiographic outcomes were examined by radiographs. Complications and re-operations following THA were recorded.

RESULTS

The mean follow-up period was 77.05 months. The mean VAS, Oxford hip score, and UCLA score were improved significantly. In all but one patient, no complications were occurred. Re-operation was carried out in one patient due to posterior dislocation. The Kaplan-Meier survivorship with an end point of re-operation for any reason was 94.1%.

CONCLUSIONS

THA with dual mobility system is proved to be effective in strengthening stability and reducing the risk of dislocation, which is suitable for patients with neuromuscular disease. Hence, in elderly with residual poliomyelitis, dual mobility THA is a valid choice as a treatment for displaced femoral neck fractures.

Survivorship and Clinical Outcomes of Constrained Acetabular Liners in Primary and Revision Total Hip Arthroplasty: A Systematic Review

BACKGROUND

Several studies have evaluated the survivorship and clinical outcomes of constrained acetabular liners (CALs) in complex primary and revision total hip arthroplasty with hip instability; however, there remains no consensus on the overall performance of this constrained implant. We therefore performed a systematic review of the literature to examine survivorship and complication rate of CAL usage.

METHODS

A systematic review of the literature in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed. A comprehensive search of PubMed, MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews was conducted for English articles using various combinations of keywords.

RESULTS

In all, 37 articles met the inclusion criteria. A total of 4152 CALs were implanted. The all-cause reoperation-free survivorship was 79.9%. The overall complication rate was 22.2%. Dislocation was the most common complications observed and the most frequent reason for reoperation with an incidence of 9.4% and 9.2%, respectively. Infection after CAL placement had an incidence of 4.6%. The reoperation rate for aseptic acetabular component loosening was 2.9%. Overall, patients had improved outcomes as documented by postoperative hip scores.

CONCLUSION

CALs usage have a relatively high complication rate, particularly when compared with current bearing alternatives (dual mobility cups and large diameter femoral heads), however, it remains a valuable salvage procedure in complex patients affected by recurrent dislocation and implant instability. Newer designs have shown reduced impingement and higher survivorship free from dislocation. However, CALs should only be used when the reasons of instability have been correctly recognized and optimized.

Mid-Term Survivorship of a Novel Constrained Acetabular Device

BACKGROUND

Recurrent instability after total hip arthroplasty is a difficult complication. In certain cases, a constrained acetabular device is needed to address these issues. The purpose of this study is to report the midterm outcomes and survivorship of a single novel constrained liner device.

METHODS

A retrospective review as performed on all procedures (except first stage exchange for infection) in which a Freedom Constrained (Zimmer Biomet, Warsaw, IN) liner was used between December 2003 and November 2016. Patients with 2-year minimum follow-up or failure were included, yielding a cohort of 177 patients. Procedures were 130 aseptic revisions, 40 reimplantations following infection eradication, and 7 complex primaries. The constrained mechanism was implanted in 46 hips (26%) to treat active instability and 131 hips (74%) for increased risk of instability and intraoperative instability. Patients had on average 3.4 previous surgeries.

RESULTS

With an average 7.1-year follow-up, 11 hips dislocated (6.2%), and 13 hips (7.3%) were revised for acetabular aseptic loosening, resulting in an overall constrained aseptic or mechanical failure rate of 13.6%. Nineteen hips (10.7%) failed from infection with 58% of these having had a previous infection. Patients with active instability had significantly higher failure for dislocation than patients who were at risk (15.2% vs 3%, P = .01). All-cause survival rate at 7 years was 74.8%, aseptic survival was 83.6%, and survival for instability was 91.8%.

CONCLUSION

Revision for instability remains challenging as many patients have had numerous previous surgeries and at-risk anatomy. Constrained inserts are one option to manage instability, but a high rate of recurrence can still occur.

Long-term Outcome of Unconstrained Primary Total Hip Arthroplasty in Ipsilateral Residual Poliomyelitis

Incapacitating articular sequelae in the hip joint have been described for patients with late effects of poliomyelitis. In these patients, total hip arthroplasty (THA) has been associated with a substantial rate of dislocation. This study was conducted to evaluate the long-term clinical and radiologic outcomes of unconstrained THA in this specific group of patients. The study included 6 patients with ipsilateral polio who underwent primary THA between 1985 and 2006. Patients with polio who underwent THA on the nonparalytic limb were excluded. Mean follow-up was 119.5 months (minimum, 84 months). Clinical outcomes were evaluated with the modified Harris Hip Score (mHHS) and the visual analog scale (VAS) pain score. Radiographs were examined to identify the cause of complications and determine the need for revision surgery. All patients showed significantly better functional results when preoperative and postoperative mHHS (67.58 vs 87.33, respectively; P=.002) and VAS pain score (7.66 vs 2, respectively; P=.0003) were compared. Although 2 cases of instability were diagnosed, only 1 patient needed acetabular revision as a result of component malpositioning. None of the patients had component loosening, osteolysis, or infection. Unconstrained THA in the affected limb of patients with poliomyelitis showed favorable long-term clinical results, with improved function and pain relief. Nevertheless, instability may be a more frequent complication in this group of patients compared with the general population. [Orthopedics. 2017; 40(2):e255-e261.].

High Failure Rate of Modular Exchange With a Specific Design of a Constrained Liner in High-Risk Patients Undergoing Revision Total Hip Arthroplasty

BACKGROUND

Addressing recurrent instability in patients with poor bone stock and inadequate abductor tensioning remains a challenge in revision total hip arthroplasty. One treatment method is implantation of a constrained liner. The purpose of this study was to determine clinical outcomes, redislocation rate, and revisions of a focally constrained liner in a high-risk patient cohort.

METHODS

Fifty-eight hips between 2008 and 2011 underwent implantation of a focally constrained liner. Nineteen were placed concurrent with acetabular component revision and 39 were placed into a well-fixed acetabular shell. Mean age was 69 years and mean number of previous ipsilateral hip surgeries was 4.2. At mean follow-up of 3.5 years, we analyzed clinical outcomes, redislocation, and revisions.

RESULTS

Mean Harris Hip Scores was 74. Fourteen hips (24%) were revised and 3 hips (5%) required reoperation at final follow-up. Eleven hips (19%) redislocated at a mean time to dislocation of 12.2 months; 31% (11 of 36 patients) that underwent modular exchange specifically for instability redislocated. Risk factors for redislocation included number of previous surgeries (P = .013), implantation of a 28 mm femoral head (hazards ratio 12.8), revision indication of instability (P = .04), and modular exchange with constrained liner implantation without acetabular shell revision (P = .01).

CONCLUSION

Implantation of a focally constrained liner in revision total hip arthroplasty for recurrent instability has a high failure rate, especially with a modular exchange. Although concurrent acetabular revision had a lower redislocation rate, the decision to revise a well-fixed cup should be weighed with potential complications associated with cup revision.

Treatment of the Failed Modular Neck Stems: Tips and Tricks

BACKGROUND

Modular femoral components emerged because of the advantages of recreating limb length, offset, and native femoral version in total hip arthroplasty. Despite its potential benefits, the increase in modularity at the head-neck junction can lead to corrosion and subsequently failure of the implant.

METHODS

We present 3 case examples of patients who underwent revision surgery secondary to corrosion of their modular femoral components.

RESULTS

Issues addressed include understanding corrosion at the head-neck junction, presentations of adverse local tissue reactions, efficacy of metal ion testing and metal artifact reduction sequence magnetic resonance imaging, and approaches to revision surgery for failed modular neck stems.

CONCLUSIONS

When revision surgery is indicated for failed modular neck stems, we recommend a thoughtful approach with contemporary extraction techniques and options to enhance stability. Furthermore, long-term follow-up is needed to define the growing effect of modularity in total hip arthroplasty.

Component selection in revision total hip arthroplasty

Component selection for revision total hip arthroplasty is important for creating a stable hip, providing offset to maximize joint mechanics, and restoring appropriate leg lengths. On the femoral side, fully porous coated stems, modular tapered stems, and proximal femoral replacements can be used depending on the level of bone loss. For the acetabulum, smaller defects can be contained using second-generation porous coating hemispherical cups, whereas larger acetabular defects can be contained with cup cages, cages, or custom triflange implants. In addition, acetabular liners can improve stability through altered cup version, dual mobility, or constraint of the femoral head.

Proximal femoral reconstruction with a constrained acetabulum in oncologic patients

Metallic endoprostheses are used for oncological reconstruction around the proximal femur and hip joint. Common modes of failure with hemiarthroplasty or standard hip arthroplasty after proximal femoral replacement include dislocation, late hip pain, and infection. The authors reviewed hospital records to identify patients undergoing constrained tripolar hip arthroplasty for oncological reasons between 2002 and 2012. Inclusion criterion was at least 12-cm proximal femoral resection, including patients with total femur reconstruction. A total of 33 patients were reviewed. Information regarding demographics, length of follow-up, treatment characteristics, and patient outcomes was extracted. Average follow-up for all patients was 912.33 days (30.4 months). Average follow-up was 1396.1 days for living patients and 428.6 days for deceased patients. Average estimated blood loss was 462.12 cc: an average of 1080 cc for patients undergoing total femoral resection and replacement and 315.8 cc for patients undergoing proximal femoral resection and replacement. Average operative time was 137.7 minutes: an average of 205 minutes for patients undergoing total femoral resection and replacement and 119.1 minutes for patients undergoing proximal femoral resection and replacement. Average Musculoskeletal Tumor Society score was 21.7. There were no dislocations in the cohort. A constrained tripolar device can be safely used for oncological proximal femoral reconstructions while minimizing the risk of dislocation. Positioning of the acetabular implant in neutral anatomic version in conjunction with a neutral-placed femoral component provides the greatest range of motion, reduction of liner impingement, and improved hip stability.

The double-mobility acetabular component in revision total hip replacement

We present our experience with a double-mobility acetabular component in 155 consecutive revision total hip replacements in 149 patients undertaken between 2005 and 2009, with particular emphasis on the incidence of further dislocation. The mean age of the patients was 77 years (42 to 89) with 59 males and 90 females. In all, five patients died and seven were lost to follow-up. Indications for revision were aseptic loosening in 113 hips, recurrent instability in 29, peri-prosthetic fracture in 11 and sepsis in two. The mean follow-up was 42 months (18 to 68). Three hips (2%) in three patients dislocated within six weeks of surgery; one of these dislocated again after one year. All three were managed successfully with closed reduction. Two of the three dislocations occurred in patients who had undergone revision for recurrent dislocation. All three were found at revision to have abductor deficiency. There were no dislocations in those revised for either aseptic loosening or sepsis.

These results demonstrate a good mid-term outcome for this component. In the 29 patients revised for instability, only two had a further dislocation, both of which were managed by closed reduction.

Classification and management of the unstable total hip arthroplasty

Seventy-five total hip arthroplasty revisions for instability were classified into 6 primary etiologies: I, acetabular component malposition; II, femoral component malposition; III, abductor deficiency; IV, impingement; V, late wear; or VI, unresolved etiology. The most common etiologies were cup malposition (type I; 33%) and abductor deficiency (type III; 36%). At a mean of 35.3 months, 11 redislocations occurred (14.6%). Acetabular revisions were protective against redislocation (P < .015). The number of previous operations (P = .0379) and previously failed constrained liners (P < .02) were risk factors for failure. Tripolar constrained liners demonstrated improved survivorship vs locking ring types (P < .02); cemented constrained liners failed more often than modular constrained liners (P < .0018). The highest risk of failure was in patients with abductor insufficiency with revisions for other etiologies having a success rate of 90%.

Dislocation and infection after revision total hip arthroplasty: comparison between the first and multiply revised total hip arthroplasty

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

Salvage of failed acetabular cages by nonbuttressed trabecular metal cups

Acetabular revision of failed cages or rings may be facilitated by previously placed bone graft, enabling the use of highly porous cementless hemispheric cups. We retrospectively reviewed all 15 patients who had conversion of failed antiprotrusion cages (10 patients) or roof rings (five patients) to cementless cups. All patients had restoration of bone stock (three major column, eight morselized, four combined bone grafts) performed in conjunction with their index cage or ring reconstruction arthroplasty. The minimum followup was 24 months (average, 48.3 months; range, 24-72 months). Failure was defined as radiographic cup migration. In 12 of the 15 patients, there was no radiographic change in cup position at the last followup or symptoms indicative of loosening. The average Harris hip scores improved from 31 (range, 15-48) to 69 (range, 56-87) at latest followup. Cup failure occurred in three patients. In two patients, the failed cups were revised; the third patient refused additional surgery. Our experience suggests treatment of failed cages by highly porous cementless cups is a reasonable option. However, we recommend patients be followed closely to detect cup migration, which can occur until satisfactory bony ingrowth occurs.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Closed reduction of constrained total hip arthroplasty in the ED

A dislocated hip prosthesis is a common occurrence in the Emergency Department. To combat this problem, orthopedists use constraint devices in an attempt to reduce the incidence of dislocation. However, when these devices fail, a more complicated case arises. We discuss a case report in which a patient presented with a dislocation of his hip after implantation of a constrained total hip arthroplasty. We describe a closed reduction procedure using deep sedation, fluoroscopy, and adequate assistance.