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Abstract
Implant design and positioning are important factors in maintaining stability
and minimizing dislocation after total hip arthroplasty. Although the advent of
modular femoral stems and acetabular implants increased the number of head,
neck, and liner designs, the features of recent designs can cause intra-articular
prosthetic impingement within the arc of motion required for normal daily
activities and thus lead to limited motion, increased wear, osteolysis, and subluxation or dislocation. Minimizing impingement involves avoiding skirted
heads, matching a 22-mm head with an appropriate acetabular implant, maximizing the head-to-neck ratio, and, when possible, using a chamfered acetabular
liner and a trapezoidal, rather than circular, neck cross-section. Computer
modeling studies indicate the optimal cup position is 45 to 55 abduction.
Angles <55 require anteversion of 10 to 20 of both the stem and cup to minimize the risk of impingement and dislocation.
J Am Acad Orthop Surg 2003;11:89-99
89
Head Size
Clinical Studies
The effect of head size on the incidence of dislocation is undetermined. Woo and Morrey13 reviewed
more than 10,000 procedures and
reported dislocation rates of 2.9%
and 3.3% with 22- and 32-mm implants, respectively. More recently,
no clinical correlation was shown
between hip dislocation and the use
of the 22-mm head size compared
with 32-mm.4
Hedlundh et al 14 reported on
3,197 cases using Charnley stems
(DePuy, Warsaw, IN) with 22-mm
heads compared with 2,875 cases
using Lubinus stems (Waldemar
Link, Hamburg, Germany) with 32mm heads; dislocation rates at 1 year
were 2.4% and 2.5%, respectively
(not statistically significant). Late
dislocation occurred more frequently
with the Charnley stems (3.7% ver-
Table 1
Relationship of Surgical Approach, Implant Head Size, and Hip Dislocation
Head Size
22 mm
Surgical
Approach
Anterior
Lateral
Posterior
28 mm
32 mm
Total
No. of
Hips
Dislocation
(%)
No. of
Hips
Dislocation
(%)
No. of
Hips
Dislocation
(%)
No. of
Hips
Dislocation
(%)
571
2.6
151
1.3
48
2.1
770
2.3
1,251
2.7
295
4.1
352
3.4
1,898
3.1
88
6.8
511
6.0
86
3.5
685
5.8
2.9
957
4.7
486
3.3
3,353
3.5
(Adapted with permission from Morrey BF: Instability after total hip arthroplasty. Orthop Clin North Am 1992;23:237-248.)
90
Robert L. Barrack, MD
Laboratory Studies
Because of the controversy regarding the effect of head diameter
on stability, recent laboratory studies have used cadaveric models,
implant retrieval studies, finite element analysis, and virtual reality
computer animation to study the
effect of head size on range of motion and stability. Bartz et al19 used
a cable system in six fresh cadaveric
specimens to simulate muscle action
of the major muscle groups. The
three-dimensional position of the
seated position (hip flexed 90, adducted 0, and externally rotated 0).
The values measured included the
peak intrinsic moment resisting dislocation, the range of motion before
impingement of the neck on the
acetabular liner, and the range of
motion before dislocation. A number
of specific liner design features as
well as femoral head diameter were
studied. Increased head size did
indeed lead to improvement in the
peak intrinsic moment resisting dislocation, but when the head-to-neck
ratio remained constant, there was
no notable improvement in implant
range of motion.
Barrack et al12 used virtual reality
computer modeling to simulate the
range of motion of ideally positioned total hip implants. Implants
were digitized and animated through
a range of motion; the range of motion until impingement occurred
between the neck and liner was
quantified in every direction, and a
composite arc of motion was calculated. The authors determined that
changing from a 28- to 32-mm head
increased the arc of flexion by 6
(Fig. 1). This technique did not sim-
Abduction
Flexion
Extension
Adduction
Figure 1 Composite cone of motion produced by computer animation. Increasing
from a 28-mm (dark shading) to 32-mm
(light shading) head size increased the arc
of flexion to impingement by approximately 6. (Adapted with permission from
Barrack RL, Thornberry RL, Ries MD,
Lavernia C, Tozakoglou E: The effect of
component design on range of motion to
impingement in total hip arthroplasty.
Instr Course Lect 2001;50:275-280.)
91
92
Femoral Offset
Femoral offset can affect stability. Fackler and Poss24 as well as
Morrey15 both described a positive
correlation between decreased offset
and dislocation, which may be the
result of several factors. Decreasing
offset reduces soft-tissue tension,
leading to a propensity for dislocation. Decreasing offset also reduces
the clearance between the femur
and the pelvis, which may lead to
dislocation through bony impingement.2 In addition, decreasing offset has biomechanical consequences
such as increasing the joint reaction
force; this can increase the forces at
the bone-cement or head-liner interfaces, leading to higher wear rates.
Care should be taken if offset is
reproduced by use of long modular
heads; as noted, the longer modular heads with flanges can decrease
passive range of motion. In addition, longer modular heads increase length as well as offset and
can result in unintentional lengthening.
Dual-offset implants that use the
same neck/shaft angle but a more
medial takeoff point for the neck of
the implant allow the addition of
several millimeters of offset without changing length. Increased
femoral offset increases the rotational forces on femoral implants;
whether this affects implant loosening rates is not known. A lateralized liner also can be used to increase abductor muscle tension
without resorting to a skirted modular head, although this method
increases length and offset to ap-
Robert L. Barrack, MD
Figure 3 A, Anteroposterior radiograph showing anterior dislocation that occurred with extension and external rotation consistent with
impingement of the skirted head on the elevated rim liner. Intraoperative photographs confirm impingement (arrow) of the skirted head
on the elevated rim liner (B), which was not present with a neutral liner (C). (Reproduced with permission from Barrack RL, Thornberry
RL, Ries MD, Lavernia C, Tozakoglou E: The effect of component design on range of motion to impingement in total hip arthroplasty.
Instr Course Lect 2001;50:275-280.)
Neck Geometry
Amstutz and Kody25 emphasized
the importance of neck design on
the stability of the THA, using a
pelvis-mounted apparatus to evaluate the effect of head size and neck
geometry on arc of motion in various planes. The 22-mm Charnley
prosthesis has a head-to-neck ratio
of 1.74; it impinged at 80 of flexion.
A trapezoidal-28 (T-28) prosthesis
has a trapezoidal neck design,
which resulted in a variable headto-neck ratio of 1.97 to 2.97; it
achieved motion and flexion to
114 before impingement occurred.
Compared with the Charnley, the
T-28 allowed 36 more internal rotation at 90 of flexion and 32 more
external rotation in extension. Most
modular heads were combined with
a circular neck, which sacrificed the
advantages of a trapezoidal neck
demonstrated by the T-28.25
In a recent study of dislocations
after revision THA, the effect of
93
Laboratory Studies
Elevated rim liners have been the
subject of a number of laboratory
testing protocols. Krushell et al10
used a three-dimensional protractor
94
B
Figure 4 Elevated rim liners. A, Liner
type A reorients the axis of rotation,
increasing flexion but not providing additional support once subluxation is initiated.
B, Type B does not increase motion to
impingement but does provide support
from dislocation once subluxation begins.
(Adapted with permission from Krushell
RJ, Burke DW, Harris WH: Elevated-rim
acetabular components: Effect on range of
motion and stability in total hip arthroplasty. J Arthroplasty 1991;6[suppl]:S53-S58.)
Implant Position
Implant orientation is among the
most critical factors in assuring stability. 4 Acetabular orientation is
Robert L. Barrack, MD
Abduction
Narrow chamfer
Wide chamfer
Flexion
Extension
Adduction
Figure 5 Comparison of a liner with a high-angle, narrow chamfer zone (A) with a liner with a low-angle, wide chamfer zone (B).
C, Comparison of the cone of motion for the combination of a trapezoidal neck with a wide chamfer zone (light shading) and a circular neck
with a narrow chamfer zone (dark shading). (Adapted with permission from Barrack RL, Thornberry RL, Ries MD, Lavernia C, Tozakoglou E:
The effect of component design on range of motion to impingement in total hip arthroplasty. Instr Course Lect 2001;50:275-280.)
95
High Dislocation
Anteversion
30
Acceptable Range
20
Target
10
35
45
55
Abduction
Figure 7 Implants positioned in the safe
zone are less likely to dislocate than those
outside the safe zone. (Adapted with permission from Barrack RL, Lavernia C, Ries
M, Thornberry R, Tozakoglou E: Virtual
reality computer animation of the effect of
component position and design on stability
after total hip arthroplasty. Orthop Clin
North Am 2001;32:569-577.)
96
Table 2
Combinations of Prosthetic Orientations That Permit Tying a Shoelace
and Stooping
Acetabular Abduction
Femoral Anteversion
Acetabular Anteversion
35
35
35
35
45
55
0
10
20
30
All positions
All positions
No position
10
All positions
10
All positions
All positions
(Reprinted with permission from DLima DD, Urquhart AG, Buehler KO, Walker RH,
Colwell CW Jr: The effect of the orientation of the acetabular and femoral components
on the range of motion of the hip at different head-neck ratios. J Bone Joint Surg Am
2000;82:315-321.)
Robert L. Barrack, MD
Table 3
Implant Orientations and Summary of Results
Cup
Cup
Stem
Case Abduction Anteversion Anteversion
1
2
3
4
5
6
7
45
45
45
45
25
25
25
20
0
10
10
20
0
0
15
15
15
45
15
15
0
Sitting
Stooping
Satisfactory
Marginal
Unsatisfactory
Marginal
Satisfactory
Unsatisfactory
Unsatisfactory
Satisfactory
Unsatisfactory
Unsatisfactory
Marginal
Unsatisfactory
Unsatisfactory
Unsatisfactory
motion to achieve sitting and stooping. Robinson et al39 and Seki et al40
also used computer modeling and
demonstrated less flexion before
impingement with low cup angles.
Clinical examples of dislocation with
Summary
Implant design and orientation affect the arc of motion achieved
before implant impingement. Max-
Figure 8 Massive pelvic osteolysis noted radiographically (A) was associated with gross rim wear evident in retrieved liners (B and C).
97
References
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The influence of patient-related factors
and the position of the acetabular component on the rate of dislocation after
total hip replacement. J Bone Joint Surg
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2. Hedlundh U, Fredin H: Patient characteristics in dislocations after primary
total hip arthroplasty: 60 patients compared with a control group. Acta
Orthop Scand 1995;66:225-228.
3. Eftekhar NS: Dislocation and instability, in Eftekhar NS (ed): Total Hip
Arthroplasty. St. Louis, MO: MosbyYear Book, 1993, pp 1505-1553.
4. Morrey BF: Dislocation, in Morrey BF,
An KN (eds): Reconstructive Surgery of
the Joints, ed 2. New York, NY: Churchill-Livingstone, 1996, vol 2, pp 12471260.
5. Hedlundh U, Ahnfelt L, Hybbinette
CH, Weckstrom J, Fredin H: Surgical
experience related to dislocations after
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6. Fender D, Harper WM, Gregg PJ:
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England: The results at five years from
a regional hip register. J Bone Joint Surg
Br 1999;81:577-581.
7. Kelley SS, Lachiewicz PF, Hickman
JM, Paterno SM: Relationship of
femoral head and acetabular size to
the prevalence of dislocation. Clin
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