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    How Can Surgeons Reduce Dislocations after Revision THA?

    Dr. Jesus Villa and Dr. Carlos Higuera-Rueda answer ICJR’s question about their study that investigated which factors are most important in protecting against early dislocations in patients undergoing aseptic total hip arthroplasty revisions with stem retention.

    ICJR: What question did you and your co-authors want to answer with this study?

    Jesus M. Villa, MD: Dislocations can occur in patients who have undergone aseptic revision total hip arthroplasty for any reason – not just instability – making it one of the most common reasons for re-revision. [1-5] These patients are at higher risk for postoperative complications, readmissions, and a challenging rehabilitation, and they may also need to undergo a subsequent re-revision procedure. [1-5]

    Understanding how to prevent dislocation following revision THA, therefore, is a critical step in improving patient outcomes and eliminating unnecessary costs of care. With that in mind, we undertook a study to determine which perioperative factors are most important in protecting against dislocations in patients who undergo aseptic THA revisions with stem retention.

    RELATED: Re-Revision THA Due to Dislocation: Does the Implant Matter?

    ICJR: What did you conclude?

    Dr. Villa: In our study, patients who had undergone aseptic revision for dislocation continued to be at risk for instability – and subsequent re-revision – after revision THA. Patients were at a lower risk if they had a stable hip prior to revision or if their acetabular component was fully revised. We concluded, therefore, that acetabular revision and revision for a reason other than instability were the most important protectors against post-revision dislocation. In this study, neither the use of a dual mobility liner alone without revising the acetabular component in cases of malposition nor the use of an anterior approach were unique protectors against instability.

    ICJR: How did you reach this conclusion? What was your study cohort and what did you find with your analysis?

    Dr. Villa: For this study, we retrospectively reviewed data on a consecutive series of aseptic THA revisions with stem retention performed by 5 surgeons at our institution, Cleveland Clinic Florida, between August 2017 and January 2020. The surgeons revised the head, liner, and/or acetabular component; femoral component revisions were excluded. We also excluded patients with a preoperative diagnosis of infection. We recorded patient demographics, preoperative diagnosis, intraoperative variables (surgical approach, use of a dual-mobility component, acetabular revision), and complications for the 83 patients included in the study.

    Overall, the postoperative dislocation rate was 12% (10/83). We found an association between postoperative dislocations and preoperative diagnosis, as well as between dislocations and type of procedure. Logistic regression analyses indicated that preoperative diagnosis other than instability (OR=0.23, 95% CI 0.060-0.922; P=0.038) and revision of the acetabular component (OR=0.130, 95% CI 0.026-0.660; P=0.014) were statistically significant protectors against dislocations. The use of dual-mobility systems or anterior approach per se were not significant protectors.

    ICJR: Why are your findings significant for clinical practice?

    Carlos A. Higuera-Rueda, MD: A malpositioned acetabular component is a risk factor for postoperative dislocation, and as our research suggests, surgeons should take the time to revise a well-fixed but malpositioned acetabular component when performing a revision THA. Doing so was protective against dislocation in our study; in fact, it may be the most critical step in preventing post-revision dislocations. The use of a dual-mobility liner or an anterior approach will not make up for an incorrectly positioned acetabular component, we found.

    The surgeon should carefully perform an intraoperative assessment, ideally with either intraoperative range of motion trialing to test for impingement and instability or additional imaging to assist in the difficult task of determining if a cup is malpositioned.

    Source

    Villa JM, Pannu TS, Patel PD, Barsoum WK, Higuera Rueda CA, Riesgo AM. What Factors Reduce the Incidence of Early Dislocations in Liner and Acetabular Hip Revisions? (Paper 767). Presented at the 2021 Annual Meeting of the American Academy of Orthopaedic Surgeons, August 31-September 3, San Diego, California.

    About the Experts

    Jesus M. Villa, MD, is an orthopaedic clinical researcher at Cleveland Clinic Florida in Weston, Florida. Carlos A. Higuera-Rueda, MD, is the Director of the Orthopaedic & Rheumatologic Center and Chairman of the Levitetz Department of Orthopaedic Surgery at Cleveland Clinic Florida in Weston, Florida.

    Disclosures: Dr. Villa has no disclosures relevant to this article. Dr. Higuera-Rueda has disclosed that he has stock or stock options in PSI; that he is a paid consultant and paid presenter or speaker for and receives research support from KCI and Stryker; and that he receives research support from CD Diagnostics, Ferring Pharmaceuticals, Lyfstone, Orthofix, Stryker, and Zimmer Biomet.

    References

    1. Yu S, Saleh H, Bolz N, et al. Re-revision total hip arthroplasty: epidemiology and factors associated with outcomes. J Clin Orthop Trauma. 2020 Jan-Feb; 11(1): 43–46. doi: 10.1016/j.jcot.2018.08.021.
    2. Khatod M, Cafri G, Inacio MCS, Schepps AL, Paxton EW, Bini SA. Revision total hip arthroplasty: factors associated with re-revision surgery. J Bone Joint Surg Am. 2015;97:359–366.
    3. Ong KL, Lau E, Suggs J, Kurtz SM, Manley MT. Risk of subsequent revision after primary and revision total joint arthroplasty. Clin Orthop Relat Res. 2010;468:3070–3076.
    4. Springer BD, Fehring TK, Griffin WL et al. Why revision total hip arthroplasty fails. Clin Orthop Relat Res. 2009;467(1):166–173. https://doi.org/10.1007/s11999-008-0566-z.
    5. Lie SA, Havelin LI, Furnes ON, Engesaeter LB, Vollset SE. Failure rates for 4,762 revision total hip arthroplasties in the Norwegian Arthroplasty Register. J Bone Joint Surg Br. 2004 May;86(4):504–509.