Total Hip Arthroplasty Instability





Epidemiology


Dislocation subsequent to total hip arthroplasty (THA) represents the most common cause for revision surgery after total hip arthroplasty (rTHA) in the United States. Rates of instability cited in the literature range from 0.5% to 10% after primary THA and from 10% to 25% subsequent to rTHA. In fact, the cumulative risk of dislocation does not remain constant over time; rather, it increases as a result of trauma, polyethylene wear, increased capsular laxity, and deterioration of abductor muscle strength with aging. Furthermore, over 60% of patients having sustained a dislocation encounter repeat events, and over half require revision surgery.


Although the incidence of dislocation has decreased over the past several decades consequent to improvements in implant design, durability, and surgical technique, the overall number of primary THAs being performed has been steadily increasing over time. As such, a net increase in the volume of rTHAs being performed for instability has been noted and is likely to continue along a similar trend in the coming years.


Dislocation events can broadly be classified in a temporal fashion: early versus late. Early and late dislocations are defined as less than 2 years versus greater than 2 years from the index procedure, respectively. More useful, however, are classification systems attempting to identify the causative process that may then translate to treatment targeting the source of instability. A traditional method to determine the pathology responsible for THA instability is to consider patient factors, implant factors, and surgical factors. Along this thought process, Dorr et al. described instability as a result of hip position, soft-tissue imbalance, and component malposition. Similarly, Wera et al. devised a classification system based on six etiologies ranging from component malposition to unexplained etiology, and provided an algorithmic approach to management ( Table 19.1 ). In this chapter, risk factors for instability will be outlined. Additionally, a systematic approach to the diagnosis of instability and subsequent management will be presented.



TABLE 19.1

Classification System for the Unstable Total Hip Arthroplasty

Modified from Wera GD, Ting NT, Moric M, Paprosky WG, Sporer SM, Della Valle CJ. Classification and management of the unstable total hip arthroplasty. J Arthroplasty . 2012 May;27(5):710–715.
































































Type Acetabular Component Orientation Femoral Component Orientation Abductor-Trochanteric Complex Impingement Late Wear Intervention
I Incorrect Correct Intact Absent Absent Acetabular component revision
II Correct Incorrect Intact Absent Absent Femoral component revision
III Correct Correct Absent Absent Absent Constrained liner
IV Correct Correct Intact Present Absent 1. Remove source of impingement
2. Upsize modular head and liner
V Correct Correct Intact Absent Present 1. Modular component exchange
2. Upsize modular head and liner
VI Correct Correct Intact Absent Absent Constrained liner


Risk Factors and Prevention


Prior to both primary and revision THA, careful consideration of patient and surgical factors that could compromise final construct stability is imperative. Patient factors associated with increased risk of instability can represent an inherent baseline characteristic or result from acquired disease ( Table 19.2 ).



TABLE 19.2

Risk Factors for Total Hip Arthroplasty Instability








































Patient Factors Surgical Factors
Extremes of age Implant malpositioning
Obesity Component impingement
Alcohol abuse Small femoral head-neck ratio
Lumbosacral pathology Lack of capsular repair
Prior hip surgery Limited surgeon experience
Dementia Posterior surgical approach
Neuromuscular disorders
Abductor dysfunction
Osteonecrosis of the femoral head
Femoral neck fracture
Congenital hip dysplasia


Inherent patient risks for instability include the following: extremes of age, obesity, , alcohol abuse, lumbosacral pathology, , and prior hip surgery. Although advanced age has consistently demonstrated an association with increased risk for instability, a definite cutoff has not been clearly defined and ranges from 70 to 85 years of age. , , Moreover, a recent study by Esposito et al. retrospectively assessing 22,097 THAs suggested instead a bimodal distribution of age for risk of dislocation after THA, with individuals <50 and ≥70 years of age at increased risk. Similarly, although a definite body mass index cutoff defining increased risk remains a matter of debate, several large studies have cited an increased risk associated with a body mass index >30 to 35 kg/m 2 . , Within the last decade, there has been increasing evidence outlining the influence of sagittal balance and lumbosacral mobility on the functional version and inclination of the acetabulum. , It is imperative that the treating surgeon identify patients with poor spinopelvic mobility and adjust the preoperative plan to prevent potential impingement resulting in dislocation. Patients with lumbosacral fusion appear to be especially at risk for instability consequent to the resultant spinopelvic immobility ( Fig. 19.1 ). In a study by Buckland et al., the authors compared 14,747 patients with spinal fusion having undergone THA to a control group of 839,004 individuals. Dislocation in the spinal fusion group was noted to be proportionally greater in the spinal fusion cohort according to the number of spinal levels fused: 1.5% in controls, 2.96% for 1- to 2-level fusion, and 4.12% for ≥3-level fusion. Lastly, rTHA carries a significantly greater risk of postoperative instability compared with primary THA. In fact, rates of dislocation after rTHA are frequently reported to near 10% with a history of prior dislocation, abductor deficiency, and significant acetabular bone loss all contributing to such an elevated risk.




Fig. 19.1


Standing (A) and sitting (B) radiographic views demonstrating a patient with lumbar spine posterior instrumented fusion at L3–L4, and a stiff lumbosacral spine. The loss of lumbar lordosis results in “flatback” deformity.


Similarly, several acquired risk factors have been described as they relate to both the pathologic process affecting the hip and disease or dysfunction impairing the individual. Specific pathologic processes with increased risk for instability after THA include osteonecrosis of the femoral head , and femoral neck fracture. Early work by Woo and Morrey demonstrated that compared with THA performed for degenerative arthritis, the dislocation rate was double for avascular necrosis, triple for congenital dislocation, and fourfold higher for fractures. Several recent studies, however, negate such an association with high-grade congenital hip dysplasia and suggest that satisfactory results with low rates of instability can be achieved. Similarly, acquired disease processes such as neuromuscular disorders, , abductor dysfunction, and dementia have been associated with an increased risk of THA instability. A multidisciplinary approach to the care of patients with neuromuscular dysfunction is necessary due to the abnormal muscular tone surrounding the THA. Common conditions that may present with hip pain requiring THA include those with spinal cord injury or history of stroke, poliomyelitis, cerebral palsy (CP), multiple sclerosis (MS), and Parkinson disease (PD). , However, data from the Scottish National arthroplasty nonvoluntary registry assessing 1399 THAs performed between 1996 and 2004 in patients with a history of cerebrovascular accident has demonstrated annual rates of dislocation ranging from 0.0 to 0.3, suggesting that low rates of instability can be achieved. Similarly, a recent study by DeDeugd et al. comparing revision rates of the affected versus unaffected limb in 51 patients with a history of poliomyelitis having undergone THA demonstrated similar survivorship and complication rates to reported results for patients undergoing THA for osteoarthritis. On the other hand, multiple studies have demonstrated substantial rates of postoperative instability in patients undergoing THA using conventional implants. Similarly, a recent study assessing 207,285 THAs from the Nationwide Readmission Database between 2012 and 2014 demonstrated an odds ratio for dislocation of 1.6 for patients with PD and 1.9 for patients with dementia when compared with unaffected controls.


Also important is the consideration of surgical factors associated with instability after THA. These risk factors should be especially important to the treating physician, as they may potentially be more readily modifiable intraoperatively. Traditionally, surgical factors associated with increased risk of postoperative instability after THA have included the following: posterior surgical approach, lack of capsular repair, implant malpositioning, component impingement, small femoral head-neck ratio, and limited surgeon experience. Surgical approach and its relationship to instability has historically been a topic of heated debate. Evidence discussing approach-related dislocation risk emerged from the large series by Woo and Morrey, demonstrating a 5.8% versus 2.3% rate of dislocation after THA with the posterior and anterolateral approaches, respectively ( P < .01). However, subgroup analysis demonstrated similar dislocation rates with the posterior approach to other approaches when performed with larger heads (32 mm vs. 22 and 28 mm). Multiple subsequent studies comparing dislocation rates between approaches have reported markedly low dislocation rates (<1%) when attentive posterior soft-tissue repair is performed. , As such, differences in rates of instability may not be of significant importance when employing commonly used 32- to 36-mm head sizes and attention is paid to adequate soft-tissue repair. Lastly, THA instability can result from improper acetabular or femoral component placement. Popularized by Lewinnek et al., the authors described a “safe zone” for acetabular component placement, 15 ± 10 degrees of anteversion and 40 ± 10 degrees of abduction, with the goal of minimizing postoperative instability. Recently, however, such a fixed target has been questioned. , In fact, in a retrospective analysis of 206 THAs that subsequently dislocated, Abdel et al. observed that the majority (58%) had an acetabular socket within the Lewinnek safe zone. As a result, recent literature has instead focused on a more individualized approach to component placement, with an emphasis on functional component anteversion in the context of spinopelvic alignment. ,


Diagnosis


The diagnosis of THA dislocation is made through a combination of patient history, physical examination, and radiographic assessment. Adequate history collection is important to identify the mechanism of dislocation that can occur with minimal force or can be the result of more substantial trauma, such as a fall. The former scenario suggests a high degree of instability, whereas the latter can be concerning for concomitant fracture. Moreover, identification of leg position resulting in THA dislocation can be useful to identify “at-risk” positioning. Additionally, clarification of the operative date and any previous episodes of dislocation should be noted. Lastly, any history suggestive of potential infection should be elicited, and erythrocyte sedimentation rate and C-reactive protein should be drawn. If there is any suspicion for potential concomitant infection on history and/or laboratory assessment, aspiration of the hip joint should be performed prior to any consideration for revision surgery.


Classically, patients with THA dislocation present with a shortened and internally rotated limb in the context of posterior instability or external rotation of the extremity in the presence of anterior instability. Special attention to a detailed neurovascular examination of the leg with a focus on sciatic nerve function, both before and after any reduction attempt, is important and should be clearly documented. Moreover, assessment of abductor mechanism strength is essentially due to the influence of the abductor musculature on dynamic hip stability. Lastly, in the context of a fall, a thorough exam to exclude associated injuries to other areas of the body is required.


Plain radiographic examination consisting of anteroposterior and lateral views help confirm both the diagnosis and direction of dislocation, and help exclude associated fractures. Repeat images after closed reduction can help identify potential sources of instability and guide eventual treatment. Radiographic assessment of leg lengths and femoral offset provides insight into the appropriateness of soft-tissue tensioning surrounding the prosthetic joint. Identification of displaced fractures of the greater trochanter must be identified as a potential source of ongoing instability consequent to the dynamic stability conferred by the abductor mechanism of the hip. Additionally, component position, especially anteversion, is an important element to assess as a potential cause of instability that should be addressed. At our center, we have found that in the context of THA instability, evaluation through computed tomography is of great benefit to determine component version. Important to consider, however, is that inclusion of the entire pelvis is required to properly assess acetabular component version. Similarly, to correctly determine femoral component version, an ipsilateral cut of the distal femur is required to determine the knee’s transepicondylar axis.


Treatment


Essential to the development of an adequate treatment plan is a thorough workup to identify the potential cause(s) of instability. As proposed by Ullmark, sources of instability can be (1) locally caused with explanatory radiographic findings, (2) locally caused without explanatory radiographic findings, or (3) nonlocally caused as in neuromuscular or cognitive disorders or a combination of the three.


Reduction


Initial treatment, subsequent to the preliminary workup of dislocation after primary THA, should consist of an attempted closed reduction (CR). The chances of CR being a successful definitive treatment modality are dependent on the adequacy of component placement at the time of index surgery. Moreover, previous failed CR and the temporal nature of the episode relative to the proximity to surgery are important determinants of success. If dislocation occurs as an isolated event in the early postoperative period, within 3 months of surgery, with correctly positioned implants, reasonable chances of successful CR without further surgical intervention can be expected. In fact, studies have demonstrated success rates of 67% to 81% for CR treatment of early dislocation. , Important to the success of a CR attempt is an understanding of the prosthetic components implanted. Recently, evidence has suggested elevated rates of early intraprosthetic dislocation in patients with dual-mobility articulations after CR attempt ( Fig. 19.2 ). Such a potential complication warrants that CR of these implants be performed under fluoroscopic guidance. Similarly, CR of constrained acetabular liners is generally not feasible and, as such, requires surgical intervention.




Fig. 19.2


Anteroposterior radiographs demonstrating the dislocation of a dual-mobility total hip arthroplasty (left) in a patient with posterior spinal instrumented fusion and resultant intraprosthetic dislocation (right) after closed reduction attempt. Note the eccentric position of the femoral head within the acetabular shell and the characteristic “bubble sign” ( orange circle ) outlining the polyethylene bearing now dissociated from the femoral head.


When attempted CR is performed, the achievement of adequate sedation and muscle relaxation is important. This should be performed by a dedicated medical team located at the patient’s head, ensuring adequate oxygenation and hemodynamic stability. The orthopaedic team should consist of two members, one holding the patient’s pelvis steady and the other performing the CR. Fluoroscopic assistance can be beneficial at this stage to help guide and confirm reduction and in identifying the direction and position of instability. As previously outlined, documentation of the pre- and postreduction neurovascular examinations is necessary after attempted CR.


Unfortunately, between 3% and 6% of dislocations cannot be reduced by closed means and require open reduction in the operative suite. , , Lastly, in scenarios in which open reduction is planned, the treating surgeon must be prepared to perform rTHA.


Revision


Revision surgery for instability after THA represents a challenging problem, with rates of complication and failure known to be elevated. A study by Wera et al. noted the incidence of recurrent dislocation after rTHA to be 14.6% at a mean of 12 months after revision surgery. At 60 months after rTHA, the rate of recurrence was noted to be 21%. Furthermore, the authors reported even higher rates of failure in patients noted to have abductor deficiency and when constrained acetabular liners were used. Similarly, an elevated incidence of deep infection of approximately 10% was observed, with an overall complication rate of 24% noted after 2 years.


To maximize the chances of success, a targeted approach directed at the correction of the identifiable source(s) of instability is preferred. In scenarios in which the cause of instability cannot be readily identified, manipulation of the hip under fluoroscopic imaging can be of benefit. During such an assessment, the treating surgeon can identify the positions of instability and simultaneously assess for areas of impingement. If impingement is observed, culprit osteophytes and/or cement must be resected and, if required, components exchanged to improve impingement-free range of motion. Regardless of the potential source of instability, revision surgery should aim to upsize head and liner components with respect to offset and leg length to optimize soft-tissue tension and impingement-free range of motion. Such an approach is beneficial regardless of other surgical measures in place to address the cause of instability. Tension of the soft tissues can be achieved through the exchange of modular components, femoral revision (through optimization of offset and leg length), and capsulorrhaphy or trochanteric advancement. However, such procedures must be weighed against potential resultant alterations in limb length and kinematics. In scenarios of soft-tissue deficiency, creation of a posterior pseudocapsule can sometimes be shaped from periacetabular scar tissue and attached to the greater trochanter with good results. Alternatively, in cases in which such reconstruction is not possible, a fascia lata flap preserving its trochanteric attachment can be mobilized and attached to the lateral acetabular rim.


Abductor Deficiency


Abductor deficiency represents a difficult and incompletely solved problem after THA, and has been reported as the main source of instability in rTHA in up to 21% of cases. , Moderate abductor deficiency is most commonly encountered after THA performed through a direct lateral approach with failure of tendon repair. Although more minor deficiencies can result in pain and limp, in isolation, they rarely represent the primary source of instability and should be addressed after attempting to identify other potential drivers of dislocation. More severe deficiencies can result in THA instability with recurrent dislocation episodes. Such scenarios are frequently encountered in the context of destructive pathology, such as deep infection and adverse local tissue reactions, and in the multiply revised patient. In such scenarios, severe soft-tissue loss is often present, precluding primary repair of the gluteus minimus and medius tendons.


Several techniques have been described attempting to reconstruct the soft-tissue envelope provided by the abductor mechanism with reasonable success. Two factors are important to consider when selecting the most appropriate reconstruction technique for a given situation. First, the status of the abductor muscles and innervation should be ascertained, best assessed on the T1 magnetic resonance imaging sequence and by electromyography, respectively. Second, the presence and quality of the greater trochanter and/or proximal bone should be examined. In scenarios of severe abductor loss in which repair is not possible and/or significant fatty infiltration is present, reconstruction using local muscle transfer can be of benefit. First popularized by Whiteside and separately by Safir, a technique using a combination of flaps from the gluteus maximus and fascia lata has demonstrated significant improvements in pain and Trendelenburg gait ( Fig. 19.3 ). Similarly, Kohl et al. describe a technique using a flap from the vastus lateralis and noted improvements in pain, gait, and abduction strength. It must be noted that no results regarding improvements in rates of dislocation are provided, however. Lastly, techniques using allograft material have also been reported with modest results. Such techniques can be used to augment or bridge a gap, aid direct soft-tissue healing, or create a tenodesis effect in place of the absent abductors. Techniques using Achilles tendon and knee extensor mechanism allografts have been described by Fehm et al. and by Drexler et al., respectively. , Such techniques should be viewed as salvage procedures and require some viable trochanteric bone for anchorage of the allograft material.


Jun 18, 2022 | Posted by in ORTHOPEDIC | Comments Off on Total Hip Arthroplasty Instability

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