Introduction:. Since2007, we have used CT-based fluoroscopy-matching navigation system (Vector Vision Hip Ver.3.5.2, BrainLAB, Germany) in revision total hip arthroplasty. This system completes the registration procedure semi-automatically by matching the contours of fluoroscopic images and touching 3 adequate points to the contours of 3D bone model created in the computer. Registration procedure using fluoroscopic figures has finished before making surgical incision. It needs no elongation time during the operation. The objective of this study was to evaluate the accuracy of CT-based fluoroscopy-matching navigation system in revision THA. Material and method:. We analysed the acetabular cup in consecutive 33 hips with both intra-operative and post-operative alignment data (based on navigation system and CT evaluation) We further compared these measurements with results from primary THA. Data for primary THA were therefore obtained from 40 consecutive patients who underwent primary THA between August 2007 and May 2013 using the same navigation system by postero-lateral approach. We aimed the cup angle for Revision THA as following, the inclination: 40 degrees, the anteversion: 20 degrees Anteversion on the navigation system must be adjusted by the pelvic tilt. Results:. There was one dislocation in 33 Revision THAs. There was no other obvious complication (nerve palsy, VTE and Infection). The all cup alignments were within 7 degrees from the preoperative orientation. In the Revision THA group the differences between the intra- and post-operative measurement of cup inclination were 2.3 ± 1.9 degrees. The differences of cup anteversion were 2.7 ± 2.5 degrees. In the primary THA group, the differences between the intra- and post-operative measurement of cup inclination were 1.9 ± 2.1 degrees. The differences of cup anteversion were 2.1 ± 2.5 degrees. There was no significant difference with two groups. Discussion:. CT-based navigation THA is very useful for severe deformity of hip osteoarthritis. We had used CT-based navigation system (landmark matching) since 2003. It needs some technical skills to improve the accuracy of landmark matching. The registration with CT-based fluoroscopy-matching navigation system is much easier and more simple than with landmark matching navigation system. CT images of revision patients included metal artifacts caused by implants. However this system is not so affected by metal artifacts. And we found this system provided high accuracy even in revision THA

Introduction: Although Metal wires and cables are popular tools to fix greater trochanter in revision THA, non union, pain and breakage are well known. For these situations, we used polyethylene tape which is occasionally applied for the spine surgery. The purpose of this study is to evaluate clinical result of greater trochanter fixation using polyethylene tape in revision THA cases. Materials and Methods: We retrospectively reviewed patients who underwent revisions THA (six cases) and re-revision THA (two cases) (mean age at operation; seventy), with a minimum followup of two years. In revision cases, we attached greater trochanter to proximal femur fixing like figure eight with this tape. Migration of greater trochanter, union rate, pain and dislocation were evaluated in this study. Result: Bone union was achieved without migration and we did not experience any patients with pain. However migration of greater trochanter to cranially and anteriorly 3mm was observed in all re-revision cases. A patient dislocated twice after the re-revision. Discussion: We demonstrated that the polyethylene tape had several advantages used in greater trochanter fixation. Strength of the polyethylene tape has been reported as strong as the stainless cable. The polyethylene tape did not cause any adverse effects including pain and cheese cut phenomenon because of broad contact area with bone. The tape could be put directly on the stem, which is impossible with metal wires and cables. In addition, we do not expect any third body wear. We concluded that polyethylene tape applied for fixing greater trochanter in revision THA would be safe and effective

Introduction and Aims: The incidence and technical complexity of revision total hip arthroplasty (THA) has and will continue to increase dramatically. We report the results of revision THA using a non-cemented, dual threaded, cone shaped, (DTCS) modular femoral component. Method: Between June of 1999 and July of 2003, 41 revision THAs using a DTCS modular femoral component. Fifty-four percent of the patients were male and 46% were female with an average weight of 84kg (std dev: 30kg, range 57–60 kg), an average height of 170cm (sdt dev: 9cm, range: 155–182 cm) and an average body mass index (BMI) of 26 (std dev: 4, range: 18–31). The average patient age was 71 years (std dev: 12 years, range: 39–85 years). Results: The average patient follow-up was 16 months (range 6–49 months). The average Harris hip score (HHS) at the most recent time to follow-up was 76. Broken into the HHS component parts, the average pain score was 40 of a possible 44, average motion was nine of a possible nine, and average function was 28 of a possible 47. Radiographic evaluation revealed wellfixed and positioned components with evidence of bone densing in areas in intimate contact with the DTCS component. Radiographic evidence of minor stress shielding was observed in the greater trochanter (Gruen Zone 1) and the proximal calcar/neck cut region (Gruen Zone 7). Post-operative complications included recurrent infection in four (10%), subsequently resolved with IV antibiotics; dislocation in three (7%), successfully treated by closed reduction and protective bracing; aseptic loosening in one (2%), with femoral component revision to a larger size; intra-operative periprosthetic fracture in one (2%), treated with ORIF (bone, plate and screws); and a non-union of a pre-revision fracture with subsequent component loosening in one (2%). Regardless of the degree of femoral deficiency, there was no incidence of component disassociation or component fracture. Conclusion: Revision THA is a demanding undertaking and involves multivariate technical challenges that may include mechanical and material considerations such as prosthetic loosening, prosthetic and periprosthetic fracture. We show that the use of a DTCS modular femoral component affords the surgeon results equal to those reported for revision THA and allows intra-operative versatility independent of bone quality

Introduction and Aims: Currently, multiple femoral component types and sizes exist for primary total hip arthroplasty. However, component sizes for small femoral geometry are generally not available. The purpose of this study is to present the short-term use of a femoral component with sizes that extend into small femoral morphometry applications. Method: Between November 2001 and December 2003, 20 primary THA cases and three revision THA cases were performed utilising a non-cemented, dual threaded, cone shaped (DTCS) modular femoral component manufactured in off-the-shelf sizes, which include those sizes for small femora. The components are made of CoCr and include a size ‘Z’ (19mm proximal, 9mm distal) and a size ‘Y’ (17mm proximal, 8mm distal). Both components have hydroxyapatite coating for stimulating increased bone on-growth and a modular neck allowing intra-operative adjustments of leg length, version, offset and neck length. Results: The average patient follow-up was 10 months (range 64 days to 27 months). There were 19 (83%) hips in which the ‘Z’ component was used, and four (17%) hips with the ‘Y’ component. Radiographic evaluation revealed well-fixed and positioned components with evidence of bone densing in areas in intimate contact with the DTCS component. Radiographic evidence of minor stress shielding was observed in the greater trochanter (Gruen Zone 1) and the proximal calcar/neck cut region (Gruen Zone 7). Two revision cases (8%) required the additional use of a 6cm modular extension component (MEC) to bridge a proximal femoral deficiency. Two cases (8%) required adjunctive strut allografting at the time of surgery to protect a thin or deficient femoral cortex. There were no reported postoperative complications related to the femoral component. There was no disassociation of the modular neck from the femoral stem and there was no incidence of femoral component fracture. Conclusion: While expanding component profile offerings into larger sizes is common, developing similar component designs for abnormally small femora is uncommon, beyond the scope of the materials used and only done as a ‘custom’ order. The DTCS modular femoral component used affords a versatile option when presented with cases involving small femoral morphometry. We conclude that the DTCS component in smaller sizes is promising and warranted for continued use

Introduction:. Acetabular revision Jumbo cups are used in revision hip surgeries to allow for large bone to implant contact and stability. However, jumbo cups may also result in hip center elevation and instability. They may also protrude through anterior wall leading to ilopsoas tendinitis. Methods:. The study was conducted using two methods:. Computer simulation study. 265 pelvic CT scans consisting of 158 males and 107 females were converted to virtual 3-dimensional bones. The average native acetabular diameter was 52.0 mm, SD = 4.0 mm (males in 52.4 mm, SD = 2.8 mm and 46.4 mm, SD = 2.6 mm in females). Images were analyzed by custom CT analytical software (SOMA™ V.3.2). 1. and over-sized reaming was simulated. Four distinct points, located in and around the acetabular margins, were used to determine the reamer sphere. Points 1, 2, 3 were located at the inferior and inferior-medial acetabular margins, and Point 4 was located superiorly and posteriorly in the acetabulum to simulate a bony defect in this location, Point 4 was placed at 10%, 20%, 30%, 40%, 50% and 60% of the distance from the superior – posterior margin of the acetabular rim to the sciatic notch to simulate bony defects of increasing size. (Figure 1). Radiographical study. Retrospective chart review of patient records for all cementless acetabular revisions utilizing jumbo cups between January 1, 1998 and March 30, 2012 at UCFS (98 patients with 57 men, 41 women). Jumbo cups: ≥66 mm in males; <62 mm in females. Reaming was directed inferiorly to the level of the obturator foramen to place the inferior edge of the jumbo cup at the inferior acetabulum. To determine the vertical position of the hip center, a circle was first made around both the jumbo and the contralateral acetabular surfaces using Phillips iSite PACS software. The center of this circle was assumed to correspond to the “hip center”. The height of the hip center was estimated by measuring the height of a perpendicular line arising from the interteardrop line (TL) and ending at the hip center. Results:. The computer simulation and radiographic analysis deomonstrated similar results. The computer simulation predicted that the hip center shifted superiorly and anteriorly as the reamer size increased. The hip center shifted 0.27 mm superiorly and 0.02 mm anteriorly for every millimeter in diameter increased for the reaming. (Figure 2) Anterior column bone removal was increased 0.86 mm for every 1 mm of reamer size increase. (Figure 3). Results of radiographical study is shown in Table bellow:. Discussion:. Use of a jumbo cup in revision THA results in elevation of the hip center. Therefore a longer femoral head may be needed to compensate for hip center elevation when a jumbo cup is used. Reaming for a jumbo cup can also result in loss of anterior bone stock and protrusion of the cup anteriorly which may cause iliopsoas tendonitis

Constrained liners are a tantalizing solution to both prevent and treat instability, as they markedly increase the force needed for a dislocation to occur. They have, however, several important negatives that the surgeon must consider before entertaining their use including: Increased stresses at the implant bone interface which can increase the risk of loosening or cause catastrophic failure in the early post-operative period; Decreased range of motion with a greater risk of impingement; and Usually require an open reduction if they dislocate or otherwise fail. Given the limitations of constrained liners, we have looked to dual mobility articulations as an alternative to constrained liners in the past five years in our practice, including patients with abductor deficiency. We retrospectively compared a consecutive series of revision THA that were at high risk for instability and treated with either a constrained liner or a dual mobility articulation. Indications for both groups included abductor insufficiency, revision for instability, or inadequate intra-operative stability when trialing. Forty-three hips were reviewed in the constrained group (mean follow-up 3.4 years) and thirty-six in the dual-mobility group (mean follow-up 2.4 years). The rate of failure was compared using a Fisher's exact test with a p-value of < 0.05 considered significant. At a minimum of two years, there were 10 dislocations in the constrained group (10/43 or 23.3%) compared to 3 in the dual-mobility group (3/36 or 8.3%; p = 0.06). There were 15 repeat revisions in the constrained group (10 for instability, 4 for infection, and 1 broken locking mechanism) compared to 4 in the dual mobility group (2 mechanical failures of cemented dual mobility liners with dislocation and 2 for infection); 34.9% vs. 11.1% (p = 0.01). With repeat revision for instability as an endpoint, the failure rate was 23% for the constrained group and 5.5% for the dual mobility group (p = 0.03). Mean Harris Hip Score (HHS) improved from 45 to 76 points in the constrained liner group, and from 46 to 89 points in the dual-mobility group. Dual mobility articulations offer anatomic sized femoral heads that greatly increase jump distance, without many of the negatives of a constrained liner. While dual mobility is associated with its own concerns and problems (including intra-prosthetic dislocation and wear) our initial results suggest that they are a viable alternative to a constrained liner, even in the most challenging situations

Background: Infection diagnosis in THA remains difficult in some cases. Intraoperative analysis of frozen sections is related to the high sensitivity, specificity, positive predictive value, negative predictive value and accuracy. However, it is a technically demanding procedure and is not a universally accepted method. In the present study, we compared interleukin-6 (IL6) serum level with the erythrocyte sedimentation rate (ESR), the level of C-reactive protein (CRP) and the analysis of frozen sections of intraoperative specimens (FS). Materials: Sixty-nine patients with a THA needing a reoperation due to a suspected infection or another aseptic failure were studied. Patients with chronic inflam-matory diseases, antibiotic treatment prior to surgery, Paget’s diseases and immunodeficiency syndromes were excluded from the study. The mean age at the time of the operation was 68 years old (range: 39 to 91). ESR, CRP and the serum level of IL6 were measured in blood samples before surgery. The cut-off levels were: ESR: ≥ 32 mm/hr, CRP: ≥ 3.2 mg/dl and interleukin-6 ≥ 12 pg/ml. Intraoperatively, samples of tissues were taken to be analyzed immediately on FS, to be routinely processed at the moment and to be referred for bacteriological cultures and histological study. Results: Eleven (16%) of the 69 hips were infected. ESR showed a sensitivity of 0.72 (0.41 to 1.00), a specificity of 0.86 (0.76 to 0.95), a positive predictive value of 0.50 (0.22 to 0.77), and a negative predictive value of 0.94 (0.84 to 1.00).CRP showed a sensitivity of 0.72 (0.41 to 1.00), a specificity of 0.91 (0.83 to 0.99), a positive predictive value of 0.61 (0.31 to 0.91), and a negative predictive value of 0.94 (0.87 to 1.00). IL6 showed a sensitivity of 0.36 (0.30 to 0.69), a specificity of 0.94 (0.88 to 1.00), a positive predictive value of 0.57 (0.13 to 1.00), and a negative predictive value of 0.88 (0.80 to 0.97). The evaluation of the FS showed a sensitivity of 0.81 (0.54 to 1.00), a specificity of 0.98 (0.94 to 1.00), a positive predictive value of 0.90 (0.66 to 1.00), and a negative predictive value of 0.96 (0.91 to 1.00).The combination of CRP and IL6 identified all patients with deep infection of the implant and showed a sensitivity of 0.57 (0.13 to 1.00), a specificity of 1.00 (0.99 to 1.00), a positive predictive value of 1.00 (0.87 to 1.00), and a negative predictive value of 0.94 (0.87 to 1.00). Conclusion: In this study, we obtained similar results combining CRP and IL6 as with the analysis of the frozen sections, which has been in the past our first option to determine whether a THA is infected or not. IL6 and CRP may be used as a valuable routine diagnostic tool in revision THA

One hundred and thirty-one cemented femoral stems inserted during revision total hip arthroplasty were reviewed to determine component survival. Harris Hip scores and complete radiographs were analysed. Survival at 10.5 years was 86.9%. Radiographically, 76.9% of the remaining components were classified as stable or possibly loose. Chi-square analysis of demographic and surgical factors determined age < 60 years, male gender and stems > 200 mm in length contributed significantly to failure (p < 0.05). Contrary to published results, we found that longer stems were more susceptible to failure. Revision femoral THA to a cemented component is an effective procedure that exhibits good long-term survival. The purpose of this study was to determine the long-term survival of cemented femoral components in revision total hip arthroplasty (THA) and to identify factors significant to implant failure. Cemented femoral components demonstrate good long-term survival and remain a suitable option for revision THA for hips with an intact cortical tube. We report high long-term survival for this increasingly popular procedure, and contradict published results regarding the relationship between stem length and failure. A consecutive series of one hundred and thirty-one THA revisions using a cemented femoral component were reviewed. Ninety-four hips in eighty-five patients alive > six years post-operatively were studied with a mean follow-up of 10.5 years. Hips excluded from analysis were thirty deceased and seven lost to follow-up before six years post-operatively. Implant success was graded radiographically and by comparing pre-operative to recent Harris Hip scores. Of the ninety-four hips, fifteen (16%) femoral components were subsequently revised; nine (9.6%) for aseptic loosening, three (3.2%) for periprosthetic fracture, and one (1.1%) for each of stem fracture, instability, and sepsis. Survival at 10.5 years was 86.9% for all reasons and 91.0% for aseptic loosening as an endpoint. 76.9% of the retained components were radiologically classified as stable or possibly loose at follow-up. Factors significant for failure included age at revision < sixty years (p = 0.003), male patients (p = 0.036) and stems > 200 mm in length (p = 0.024)

The aim of this study is the presentation of the results in 48 cases of revision THA with excessive proximal bone loss with the use of the Wagner cementless femoral stem. The bone loss classified with the AAOS system for proximal femoral bone deficiency in type I (17 patients), II (27 patients), and III (4 patients). We used the titanium alloy Wagner stem trying to achieve primary distal stabilisation because of its conical shape and its longitudinal ridges while we expected secondary proximal stabilization due to the osseointegration properties of the material. We didn’t use grafts. The mean follow- up is 9, 6 years. The results are very satisfactory to excellent with marked pain relief, improvement of the walking ability and excessive bone restoration in the proximal part of the femur. 7 of the patients had a symptomless stem subsidence up to 16mm the first year with subsequent stabilization thereafter. One of the patients required a new revision the 7th postoperative year due to stem’s fracture in its distal part. We conclude that the Wagner stem in these difficult THA revisions offers firm primary distal fixation, impressive proximal bone regeneration and satisfactory clinical outcomes without using grafts

Introduction and Aims: The use of porous coated femoral stems in revision hip arthroplasty has been associated with a high rate of complications including femoral fracture, femoral perforation and eccentric reaming. The purpose is to determine if using a distally slotted-fluted femoral stem is associated with lower incidence of the above three intra-operative complications. Method: The intra-operative complications of 175 cementless revision total hip arthropasties (THA) using a distally slotted-fluted femoral stem were reviewed. Three categories of complications were recorded: femoral fracture, femoral perforation and eccentric reaming. Radiographic evaluation was based on standard antero-posterior and lateral views of the hip joint performed in the intra-operative or immediate post-operative period. Statistical analysis for factors associated with complications was performed using the chi-square test. Results: Intra-operative complications occurred in 16 patients (9.1%). There was no statistically significant association between complication rate and type of surgical approach, stem length, stem diameter, or host bone quality. The complication rate was significantly lower than the 44% total complication rate previously reported utilising a long, solid, extensively coated revision stem without a slot or flute (p< .01). These results are consistent with laboratory testing, which revealed significantly lower bone strains at the isthmus when inserting a long cementless revision stem with a slot and flute compared to a solid fully coated stem of identical geometry. Conclusion: The use of a distally slotted fluted porous coated femoral stem in revision hip arthroplasty results in a dramatically lower complication rate compared to rates previously reported for solid porous stems. These results strongly support the continued use of such a prosthesis for revision THA

Total hip arthroplasty continues to be one of the most effective procedures. Aseptic loosening compromises the long term outcome of this otherwise successful procedure. Large hemispherical cups may be used during revision surgery for patients with severe bone loss. Acetabular revision with cementless components has been remarkably successful with some series reporting no revisions for aseptic loosening at an average follow-up of 13.9 years. Another study on 186 patients (196 hips) receiving jumbo acetabular components, noted a survivorship of 98% at 4 years and 96% at 16 years. Cementless acetabular revision is now feasible for a wide range of revision situations, including some cases of pelvic discontinuity. The Paprosky classification is useful in predicting the reconstructive technique that will be required. Type I and many Type II defects may be reconstructed with standard cementless components. Many Type II and Type III defects, which involve the loss of additional structural bone, can be reconstructed with a jumbo cup. A jumbo cup is defined by Whaley et al. as a component that is >61 mm in women and >65 mm in men, a definition that is based on a shell that is >10 mm greater than the average diameter cup implanted in women and men. The jumbo cup has the advantage of an increased contact area between host bone and cup which maximises the surface area for ingrowth or ongrowth. The increased area of contact also prevents cup migration by allowing for force dissipation over a large area. Use of a jumbo cup may also decrease the need to use bone graft. In contrast to positioning the cup in the so-called high hip center, a jumbo cup can help to restore the hip center of rotation.

The disadvantages of this technique are that host bone may have to be removed to implant the cup, that bone stock is not restored by the reconstruction, and that hemispherical cups have limited applicability in situations of oblong bone stock deficiency.

Jumbo acetabular components can be used in combination with both structural and cancellous bone graft. In these cases, the cementless cup must achieve adequate contact with host bone in order to allow bone ingrowth to occur.

Porous-coated acetabular hemispherical components have proven successful in all but the most severe revision acetabular defects. A revision jumbo porous coated component has been defined as a cup with minimum diameter of 66 mm in men and 62 mm in women. In published studies this size cup is used in 14% – 39% of acetabular revisions. The advantages of this technique are ease of use, most deficiencies can be treated without structural graft, host bone contact with the porous surface is maximised, and the hip center is generally normal. Jumbo cups are typically used in Paprosky type 2, 3A, and many 3B defects. Requirements for success include circumferential acetabular exposure, an intact posterior column, and much of the posterior wall. The cup should be stable with a press-fit between the ischium and anterior superior acetabulum with the addition of some superior lateral support. Additional support is provided with multiple dome or rim screws. Survivorship of the metal shell with revision for any reason has been reported to be 80% – 96% at time frames from 15 – 20 years. The most common post-operative complication is dislocation.

Acetabular revision surgery can be complex and challenging. The technique selected depends upon the amount of bone deficiency. One of the most useful ways to assess remaining bone stock has been described by Paprosky, based on the location and severity of bone loss, and the likelihood of obtaining a stable construct with a hemispherical cup.

In almost all cases of acetabular revision, the remaining bone is in fact capable of supporting a hemispherical socket, as long as details of technique are followed. The implant is larger than the native acetabulum and the removed socket by several sizes, and may approach quite large proportions, hence the term “Jumbo Cup”. The principle is to gradually enlarge the acetabulum with hemispherical reamers, taking care to protect the posterior and superior bone, at the expense of the less crucial anterior and inferior bone.

As reaming proceeds, there comes a point where the reamer is stable within the acetabulum. High areas have been reamed down, and remaining cavitary defects are then back-filled with autogenous reamings or allograft cancellous chips. This is then re-reamed in reverse to distribute the graft into the defects. A large or “Jumbo” cup, 2–3 mm larger than the last reamer, is then impacted into place, and supplemented with screws.

In many cases, the anterior lip, and to a lesser extent the medial wall, may be sacrificed to obtain stability, without compromising long-term results.

Traditionally the most commonly used femoral implants in revision hip arthroplasty are distally fixed monoblock designs. Ability to adjust length version and offset is limited once the stem is inserted. Revision using this type of stem has been associated with high incidence of complications including dislocation. Modular distally fixed femoral implants have been developed in order to decrease the complication rate by restoring normal hip mechanics. The goal of this study is to evaluate the performance of these type stems as it relates to fixation and instability.

Seventy three revisions were done using three modular stem designs. All stems were common in design featuring a proximal cone shape body attached by a taper to a fluted distal stem. Revisions were performed for loosening, periprosthetic fractures and infections. Most revisions were in patients with severe bone loss. Follow-up range from 6 to 72 months with an average of 30 months. Parameters evaluated included fixation and instability.

In this series we obtained excellent bony fixation as well as an acceptable dislocation rate in revision of severely compromised femurs. There were no stem fractures at the modular junction at early follow-up. Dislocation was readily managed by revision of the proximal portion of the stem without compromising distal fixation. This study demonstrates that modular approaches can be used successfully.

Introduction: The objectives of this study were to evaluate acetabular bone deficiency in revision THA with a simple classification on the anteroposterior pelvis radiograph and correlate the results of cementless hemispherical porous coated cup and cancellous bone graft reconstruction. Methods: 70 acetabular revisions reconstructed employing large ‘jumbo’ porous coated cups with cancellous allo-grafting were evaluated at a mean follow-up of 5 years (range 2 – 10 years). During this time period 7 additional acetabular reconstructions required impaction grafting, cage reinforcement and cemented cups. Pre- and postoperative measurements of acetabular bone loss and the position of the revision component were performed with respect to a previously described triangle defining the placement and size of an idealcup. Impaction bone allo-grafting techniques were employed to fill defects. A minimum of 40% implant contact to host bone, especially in the weight-bearing dome region was attained in all cases and a minimum of 2 screws supplemented fixation to the ilium. Clinical evaluation comprised the HSS score and a patient assessment questionnaire (PAQ). Radiographically, cups were examined for filling of defects, ingrowth, graft consolidation, and stability. Results: The mean HSS score improved from 18 to 33 out of a maximum of 40. The mean superior bone defect was 18 mm (range 10 – 25mm) and the mean medial bone defect was 7 mm (range 0 – 22mm). All the cement-less acetabular components were bone ingrown with the exception of one stable fibrous union. Allograft incorporation occurred at a mean of 7 months after surgery. Neither the status of Kohler’s line nor the Paprosky class correlated with eventual radiographic or clinical results. Discussion: We present a simple method of evaluation of acetabular bone deficiency on the A-P pelvis radiograph employing a triangle that locates the ideal center of rotation of the hip. Superior bone loss upto 25 mm and medial migration as much as 22 mm has been successfully reconstructed employing impacted, cancellous allograft, large porous coated hemispherical Cementless acetabular components and screw fixation with excellent outcomes at intermediate-follow-up. Larger defects necessitate complex reinforced cage reconstruction

A trochanteric osteotomy offers extensile exposure of the hip on both the acetabular and femoral sides. The classical trochanteric osteotomy which is transverse and involved a release of the vastus lateralis muscles is complicated by a significant incidence of trochanteric nonunion and more importantly, trochanteric migration. The trochanteric slide was designed to avoid trochanteric migration by keeping the trochanteric fragment in continuity with the abductors and the vastus lateralis. Even if there was a trochanteric nonunion, a trochanteric migration was prevented by continuity of muscles enclosing the greater trochanter in a sling of muscle.

When we first started doing the trochanteric slide, we used the technique originally described which involved starting with the posterior approach to take down the external rotators and the posterior capsule, and then proceeding with the trochanteric osteotomy. We found that our incidence of posterior dislocation increased to 15%. We therefore decided that we would attempt to do this operation but try to preserve the external rotators and the posterior capsule so they remained in situ attached to the main body of the femur, so that the trochanteric osteotomy was carried out just anterior to these muscles and posterior capsule. As a result of this our dislocation rate went from 15% to 3%.

This exposure provides an extensile exposure of the pelvis and femur. If femoral component removal is anticipated to be difficult, then we use exactly the same approach but we extend the trochanteric fragment down as in an extended trochanteric osteotomy.

Background:

Dual mobility components in total hip arthroplasty have been successfully in use in Europe for greater than 25 years. However, these implants have only recently obtained FDA approval and acceptance among North American arthroplasty surgeons. Both decreased dislocation rate and decreased wear rates have been proposed benefits of dual mobility components. These components have been used for primary total hip arthroplasty in patients at high risk for dislocation, total hip arthroplasty in the setting of femoral neck fracture, revision for hip instability, and revision for large metal-on-metal (MoM) hip articulation. The literature for the North American experience is lacking.

Dual mobility components for total hip arthroplasty provide for an additional articular surface, with the goals of improving range of motion, jump distance, and overall stability of the prosthetic hip joint. A large polyethylene head articulates with a polished metal acetabular component, and an additional smaller metal or ceramic head is snap-fit into the large polyethylene. New components have been released for use in North America over the past eight years and additional modular designs will be forthcoming. In some European centers, these components are routinely used for primary total hip arthroplasty. However, their greatest utility may be to prevent and manage recurrent dislocation in the setting of revision total hip arthroplasty. Several retrospective series have shown satisfactory results for this indication at medium-term follow-up times. The author has used dual mobility components on two occasions to salvage a failed constrained liner. However, at least one center reported failure of dual mobility if the abductor mechanism is absent. There are important concerns with dual mobility, including late polyethylene wear causing intra-prosthetic dislocation, and the lack of long-term follow-up data with most designs. Modular dual mobility components, with screw fixation, are the author's first choice for the treatment of recurrent dislocation in younger patients, revision of failed metal-metal resurfacing, total hips, large head unipolar arthroplasties, and salvage of failed constrained liners. There are more recent concerns of iliopsoas tendonitis, elevated metal levels with one design, and acute early intra-prosthetic dissociation following attempted closed reduction. However, in 2016, a dual mobility component, rather than a constrained liner, may be the preferred solution in revision surgery to prevent and manage recurrent dislocation.

In primary total hip replacements there are numerous options available for providing hip stability in difficult situations (i.e. Down's syndrome, Parkinson's disease).

However, in the revision situation in general and in revision for recurrent dislocation specifically, it is important to have all options available including dual mobility constrained liners in order to optimise the potential for hip stability as well as function of the arthroplasty. Even with the newer options, available dislocation rates of higher than 5% have been reported in the first two years following revision surgery at institutions where high volumes of revision surgery are performed. Because of the deficient abductors, other soft tissue laxity and the requirement for large diameter cups, revision cases will always have more potential for dislocation. In these situations in the lower demand patient and where, a complex acetabular reconstruction that requires time for ingrowth before optimal implant bone stability to occur isn't present, dual mobility with constraint has provided excellent success in terms of preventing dislocation and maintaining implant construct fixation to bone at intermediate term follow-up. Hence in these situations dual mobility with constraint remains the option we utilise. We are also confident in using this device in cases with instability or laxity where there is a secure well-positioned acetabular shell. We cement a dual mobility constrained liner in these situations using the technique described below.

Present indication for dual mobility constrained liners: low demand patient, large outer diameter cups, instability with well-fixed shells that are adequately positioned, abductor muscle deficiency or soft tissue laxity, multiple operations for instability

Technique of cementing liner into shell: score acetabular shell if no holes, score liner in spider web configuration, all one or two millimeters of cement mantle

Results: Constrained Dual Mobility Liner – For Dislocation: 56 Hips, 10 year average follow-up, 7% failure of device, 5% femoral loosening, 4% acetabular loosening. For Difficult Revisions: 101 hips, 10 year average follow-up, 6% failure of device, 4% femoral loosening, 4% acetabular loosening. Cementing Liner into Shell: 31 hips, 3.6 year average follow-up (2–10 years), 2 of 31 failures.

In primary total hip replacements there are numerous options available for providing hip stability in difficult situations i.e. Down's syndrome, Parkinson's disease. However, in the revision situation, in general, and in revision for recurrent dislocation situations specifically, it is important to have all options available including dual mobility constrained liners in order to optimise the potential for hip stability as well as function of the arthroplasty. Even with the newer options available dislocation rates of higher than 5% have been reported in the first two years following revision surgery at institutions where high volumes of revision surgery are performed [Della Valle, Sporer, Paprosky unpublished data]. Because of the deficient abductors, other soft tissue laxity and the requirement for large diameter cups, revision cases will always have more potential for dislocation. In these situations in the lower demand patient and where, a complex acetabular reconstruction that requires time for ingrowth before optimal implant bone stability to occur isn't present, dual mobility with constraint has provided excellent success in terms of preventing dislocation and maintaining implant construct fixation to bone at intermediate term follow-up. Hence in these situations dual mobility with constraint remains the option we utilise. We are also confident in using this device in cases with instability or laxity where there is a secure well-positioned acetabular shell. We cement a dual mobility constrained liner in these situations using the technique described below.

Present indication for dual mobility constrained liners: low demand patient, abductor muscle deficiency or soft tissue laxity, large outer diameter cups, multiple operations for instability, and instability with well-fixed shells that are adequately positioned.

Technique of cementing liner into shell: score acetabular shell if no holes; score liner in spider web configuration; all one or two millimeters of cement mantle.