Effect of femoral head size and surgical approach on risk of revision for dislocation after total hip arthroplasty

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Abstract

Background and purpose

Recurrent dislocation is the commonest cause of early revision of a total hip arthropasty (THA). We examined the effect of femoral head size and surgical approach on revision rate for dislocation, and for other reasons, after total hip arthroplasty (THA).

Patients and methods

We analyzed data on 166,231 primary THAs and 3,754 subsequent revision THAs performed between 2007 and 2015, registered in the Dutch Arthroplasty Register (LROI). Revision rate for dislocation, and for all other causes, were calculated by competing-risk analysis at 6-year follow-up. Multivariable Cox proportional hazard regression ratios (HRs) were used for comparisons.

Results

Posterolateral approach was associated with higher dislocation revision risk (HR =1) than straight lateral, anterolateral, and anterior approaches (HR =0.5–0.6). However, the risk of revision for all other reasons (especially stem loosening) was higher with anterior and anterolateral approaches (HR =1.2) and lowest with posterolateral approach (HR =1). For all approaches, 32-mm heads reduced the risk of revision for dislocation compared to 22- to 28-mm heads (HR =1 and 1.6, respectively), while the risk of revision for other causes remained unchanged. 36-mm heads increasingly reduced the risk of revision for dislocation but only with the posterolateral approach (HR =0.6), while the risk of revision for other reasons was unchanged. With the anterior approach, 36-mm heads increased the risk of revision for other reasons (HR =1.5).

Interpretation

Compared to the posterolateral approach, direct anterior and anterolateral approaches reduce the risk of revision for dislocation, but at the cost of more stem revisions and other revisions. For all approaches, there is benefit in using 32-mm heads instead of 22- to 28-mm heads. For the posterolateral approach, 36-mm heads can safely further reduce the risk of revision for dislocation.

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Most cited references 29

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What is the learning curve for the anterior approach for total hip arthroplasty?

Richard de Steiger, Michelle Lorimer, Michael Solomon (2015)

There are many factors that may affect the learning curve for total hip arthroplasty (THA) and surgical approach is one of these. There has been renewed interest in the direct anterior approach for THA with variable outcomes reported, but few studies have documented a surgeon's individual learning curve when using this approach.

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Effect of femoral head diameter and operative approach on risk of dislocation after primary total hip arthroplasty.

D. Berry, Cathy Schleck, William S. Harmsen … (2005)

It has been postulated that use of a larger femoral head could reduce the risk of dislocation after total hip arthroplasty, but only limited clinical data have been presented as proof of this hypothesis. From 1969 to 1999, 21,047 primary total hip arthroplasties with varying femoral head sizes were performed at one institution. Patients routinely were followed at defined intervals and were specifically queried about dislocation. The operative approach was anterolateral in 9155 arthroplasties, posterolateral in 3646, and transtrochanteric in 8246. The femoral head diameter was 22 mm in 8691 of the procedures, 28 mm in 8797, and 32 mm in 3559. One or more dislocations occurred in 868 of the 21,047 hips. The cumulative risk of first-time dislocation was 2.2% at one year, 3.0% at five years, 3.8% at ten years, and 6.0% at twenty years. The cumulative ten-year rate of dislocation was 3.1% following anterolateral approaches, 3.4% following transtrochanteric approaches, and 6.9% following posterolateral approaches. The cumulative ten-year rate of dislocation was 3.8% for 22-mm-diameter femoral heads, 3.0% for 28-mm heads, and 2.4% for 32-mm heads in hips treated with an anterolateral approach; 3.5% for 22-mm heads, 3.5% for 28-mm heads, and 2.8% for 32-mm heads in hips treated with a transtrochanteric approach; and 12.1% for 22-mm heads, 6.9% for 28-mm heads, and 3.8% for 32-mm heads in hips treated with a posterolateral approach. Multivariate analysis showed the relative risk of dislocation to be 1.7 for 22-mm compared with 32-mm heads and 1.3 for 28-mm compared with 32-mm heads. In total hip arthroplasty, a larger femoral head diameter was associated with a lower long-term cumulative risk of dislocation. The femoral head diameter had an effect in association with all operative approaches, but the effect was greatest in association with the posterolateral approach.

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The risk of revision due to dislocation after total hip arthroplasty depends on surgical approach, femoral head size, sex, and primary diagnosis

Nils Hailer, Rüdiger J Weiss, Andre Stark … (2012)

Background and purpose The effects of patient-related and technical factors on the risk of revision due to dislocation after primary total hip arthroplasty (THA) are only partly understood. We hypothesized that increasing the femoral head size can reduce this risk, that the lateral surgical approach is associated with a lower risk than the posterior and minimally invasive approaches, and that gender and diagnosis influence the risk of revision due to dislocation. Patients and methods Data on 78,098 THAs in 61,743 patients performed between 2005 and 2010 were extracted from the Swedish Hip Arthroplasty Register. Inclusion criteria were a head size of 22, 28, 32, or 36 mm, or the use of a dual-mobility cup. The covariates age, sex, primary diagnosis, type of surgical approach, and head size were entered into Cox proportional hazards models in order to calculate the adjusted relative risk (RR) of revision due to dislocation, with 95% confidence intervals (CI). Results After a mean follow-up of 2.7 (0–6) years, 399 hips (0.5%) had been revised due to dislocation. The use of 22-mm femoral heads resulted in a higher risk of revision than the use of 28-mm heads (RR = 2.0, CI: 1.2–3.3). Only 1 of 287 dual-mobility cups had been revised due to dislocation. Compared with the direct lateral approach, minimally invasive approaches were associated with a higher risk of revision due to dislocation (RR = 4.2, CI: 2.3–7.7), as were posterior approaches (RR = 1.3, CI: 1.1–1.7). An increased risk of revision due to dislocation was found for the diagnoses femoral neck fracture (RR = 3.9, CI: 3.1–5.0) and osteonecrosis of the femoral head (RR = 3.7, CI: 2.5–5.5), whereas women were at lower risk than men (RR = 0.8, CI: 0.7–1.0). Restriction of the analysis to the first 6 months after the index procedure gave similar risk estimates. Interpretation Patients with femoral neck fracture or osteonecrosis of the femoral head are at higher risk of dislocation. Use of the minimally invasive and posterior approaches also increases this risk, and we raise the question of whether patients belonging to risk groups should be operated using lateral approaches. The use of femoral head diameters above 28 mm or of dual-mobility cups reduced this risk in a clinically relevant manner, but this observation was not statistically significant.

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Author and article information

Journal

Journal ID (nlm-ta): Acta Orthop

Journal ID (iso-abbrev): Acta Orthop

Journal ID (publisher-id): IORT

Title: Acta Orthopaedica

Publisher: Taylor & Francis

ISSN (Print): 1745-3674

ISSN (Electronic): 1745-3682

Publication date (Print): August 2017

Publication date (Electronic): 25 April 2017

Volume: 88

Issue: 4

Pages: 395-401

Affiliations

[1 ]Department of Orthopaedics, Medical Center Leeuwarden, Leeuwarden;

[2 ]Landelijke Registratie Orthopedische Implantaten (Dutch Arthroplasty Register), ’s Hertogenbosch;

[3 ]Department of Orthopaedics, Radboud University Medical Center, Nijmegen;

[4 ]Department of Orthopaedics, University Medical Center Leiden, Leiden, the Netherlands

Author notes

Correspondence: Wierd.Zijlstra@ 123456ZNB.NL

Article

Publisher ID: iort-88-395

DOI: 10.1080/17453674.2017.1317515

PMC ID: 5499330

PubMed ID: 28440704

SO-VID: 0ef91501-b988-408c-b155-8d33419d98ef

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution-Non-Commercial License ( https://creativecommons.org/licenses/by-nc/3.0)

Effect of femoral head size and surgical approach on risk of revision for dislocation after total hip arthroplasty : An analysis of 166,231 procedures in the Dutch Arthroplasty Register (LROI)

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Abstract

Background and purpose

Patients and methods

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Interpretation

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Most cited references 29

What is the learning curve for the anterior approach for total hip arthroplasty?

Effect of femoral head diameter and operative approach on risk of dislocation after primary total hip arthroplasty.

The risk of revision due to dislocation after total hip arthroplasty depends on surgical approach, femoral head size, sex, and primary diagnosis

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