The number of dislocations following THA is increasing in tandem with the increased number of primary and revision THAs being performed [2, 4]. Dual mobility (DM) articulations can address this complication by allowing the use of larger diameter femoral heads [5], which may contribute to a reduced risk of dislocation associated with DM components. Perhaps for these reasons, the use of DM implants in both primary and revision THA is increasing as well [1, 3, 6-8]. Most DM implants used in the United States employ a modular cobalt chrome liner that engages the acetabular shell with a mated Morse taper. In order to perform acetabular revision on one of these modular components, the modular liner must first be dissociated from the acetabular component. Many manufacturers provide instruments or technique suggestions, but despite these, dissociating a modular DM liner from its shell can be very difficult to do. Design-specific challenges, mechanical and chemical degeneration resulting in cold welding, and corrosion causing abnormal mating of the taper interface can make these liners resistant to removal. We propose a liner removal technique that makes it easier. Techniques to loosen the taper engagement of modular cobalt chrome bearings typically involve introducing mechanical vibration to the rim or face of the acetabular component to disengage the taper using tamps or extractor “plates” [9]. This can be challenging because the force and frequency of vibration required to disengage the liner may be inconsistent and unpredictable. We found that a battery-powered, handheld impaction system (Fig. 1) provides vibration with consistent and sufficient force, frequency, and direction to loosen the modular taper junction of modular DM liners or modular metal liners without damaging the existing well-fixed acetabular shell behind the liner. The battery-powered, handheld impaction system is a standard device that is made by any of the companies that offer drill/reamer power kits.Fig. 1: The battery-powered, handheld impaction system is shown. The system shown here is provided free of charge with the DePuy primary hip system. This particular system offers several modular attachments that can be used for THA. We utilized the bullet tip attachment for this technique.To use this system, we perform a revision approach to the hip of the surgeon’s choosing, and following removal or retraction of the femoral component, we obtain adequate exposure of the acetabular component. We then position the handheld system with the tip of the adaptor on the exposed rim of the acetabular component (Fig. 2). This system typically uses an adapter to attach to the acetabular component and femoral broaches; however, a bullet tip adapter that does not require component attachment is also available. In the example depicted here, we demonstrate the bullet tip stem insertion adaptor provided by the manufacturer. After several (three to five) consistent strikes to the rim of the acetabular component, the liner usually is unseated from the acetabular shell behind it, and its displacement is both visible (Fig. 3) and palpable to the surgeon.Fig. 2: The bullet tip for the impaction system is positioned on the rim of the well-fixed acetabular component after full exposure.Fig. 3: In some cases, the cobalt chrome liner can be visualized to disengage from the acetabular component. In this view, the liner is no longer sitting flush with the rim of the component, indicating disengagement.In modular DM design in this demonstration, the liner frequently seats flush with the rim of the component, making it difficult to grasp the liner for removal from the shell even after it is unseated. Sometimes, though, visual disengagement is not clearly observed; however, in our experience, three to five taps is enough to disengage it. Therefore, in our technique, we would either use a suction device provided by the manufacturer (Fig. 4) or the suction provided by the pulse irrigation system to grasp the liner and remove it from the component (Fig. 5). Once the liner has been removed, the surfaces of the shell and liner can be assessed for corrosion and the revision operation can proceed as planned. We have successfully used this technique to remove the modular DM liner from a number of different manufacturers and modular metal liners from metal-on-metal THA with similar consistency and success.Fig. 4: A suction device is utilized to grasp the unseated liner for removal.Fig. 5: The liner is removed after it is unseated using the suction device.
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