Use Of Constrained Liners Research Articles

LOW RISK OF CUP FIXATION FAILURE AT TEN YEARS USING CONSTRAINED LINER AT THE SAME TIME OF ACETABULAR COMPONENT REVISION

There remains concern with the use of constrained liners (CL) implanted at the time of acetabular cup revision in revision total hip replacement (rTHA). The aim of this study was to determine the implant survival in rTHA when a CL was implanted at the same time as acetabular cup revision.We reviewed our institutional database to identify all consecutive rTHAs where a CL was implanted simultaneously at the time acetabular cup revision from 2001 to 2021. One-hundred and seventy-four revisions (173 patients) were included in the study. Mean follow-up of 8.7 years (range two – 21.7). The most common indications for rTHA were instability (35%), second-stage periprosthetic joint infection (26.4%), and aseptic loosening (17.2%).Kaplan Meier Analysis was used to determine survival with all-cause re-revision and revision for cup aseptic loosening (fixation failure) as the endpoints.A total of 32 (18.3%) patients underwent re-revision at a mean time of 2.9 years (range 0.1 – 14.1). The most common reasons for re-revision were instability (14), periprosthetic joint infection (seven), and loosening of the femoral component (four). Three (1.7%) required re-revision due to aseptic loosening of the acetabular component (fixation failure) at a mean of two years (0.1 – 5.1). Acetabular component survival free from re-revision due to aseptic loosening was 98.9% (95% CI 97.3 – 100) at five-years and 98.1% (95% CI 95.8 – 100) at 10-years. There were no acetabular component fixation failures in modern highly porous shells.CLs implanted at the time acetabular cup revision in rTHA have a 98.1% 10-year survival free from acetabular cup aseptic loosening (fixation failure). There were no cup fixation failures in modern highly porous shells. Thus, when necessary, implanting a CL during revision of an acetabular component with stable screw fixation is safe with an extremely low risk of cup fixation failure.

Short term analysis of total hip replacement done with constrained acetabular component - functional and radiological outcome

<p class="abstract"><strong>Background:</strong> Dislocation remains at the forefront of complications after primary total hip arthroplasty (THA). In our study, we talk about the use of constrained liners and its outcomes in an unstable hip.</p><p class="abstract"><strong>Methods:</strong> The total number of patients included in the study was 15. The total number of hips in the study were 15. The age group of the patients varied between 51 years and 89 years with mean age group of 73 years. The most common indication in our study was dislocation contributing 60% (n=9) of the hips.<strong></strong></p><p class="abstract"><strong>Results:</strong> The post-operative mean Harris hip score (HHS) at immediate post-operative was 67.6. There was a gradual improvement in the HHS through 6 months (77.6), one year (83.3), two years (86.7) and 3 years (90.33). There were no cases with post-operative septic or aseptic loosening in the radiological analysis. The mean cup inclination was 34.3. Out of the 13 hips, in eight hips the femoral stem was in varus. Five hips had a centrally placed femoral stem. Stability management in THA have seen the component design take centre stage, primarily with the use of larger diameter femoral heads and the rise in popularity of constrained acetabular liners (CAL). Several authors have done studies which talk about the stability of this implant design and the reliability of this implant in unstable hips and in hips where instability was expected.</p><p class="abstract"><strong>Conclusions:</strong> In our study, proximal femur tumours, dislocated total hips, abductor insufficiencies and aseptic loosening all showed good results.</p>

Emerging Concepts in the Surgical Management of Peri-Acetabular Metastatic Bone Disease.

The pelvis is a common site of metastatic bone disease. Peri-acetabular lesions are particularly challenging and can cause severe pain, disability and pathologic fractures. Surgical management of these lesions has historically consisted of cementoplasty for contained lesions and Harrington reconstructions for larger, more destructive lesions. Due to the limitations of these procedures, a number of novel procedures have been developed to manage this challenging problem. Percutaneous techniques—including acetabular screw fixation and cementoplasty augmented with screws—have been developed to minimize surgical morbidity. Recent literature has demonstrated a reliable reduction in pain and improvement in function in appropriately selected patients. Several adjuncts to the Harrington procedure have been utilized in recent years to reduce complication rates. The use of constrained liners and dual mobility bearings have reduced the historically high dislocation rates. Cage constructs and porous tantalum implants are becoming increasingly common in the management of large bony defects and destructive lesions. With novel and evolving surgical techniques, surgeons are presented with a variety of surgical options to manage this challenging condition. Physicians must take into account the patients’ overall health status, oncologic prognosis and anatomic location and extent of disease when developing an appropriate surgical plan.

Total Hip Arthroplasty in Patients with Spasticity: A Critical Analysis Review.

» Patients with neuromuscular spasticity about the hip with concomitant painful hip arthritis can be effectively treated with total hip arthroplasty, with excellent clinical outcomes and durable implant survivorship.» Certain subsets of patients in this population are at increased risk of dislocation, component loosening, and heterotopic ossification and are also prone to postoperative medical complications.» Strategies that may mitigate the risk of dislocation include using large femoral heads or dual-mobility articulations with cautious use of constrained liners, careful repairing of soft-tissue structures at the conclusion of the surgical procedure, and performing concomitant adductor and flexor tenotomies. In addition, the other common complications can be reduced by coordinating perioperative care with neurological and medical specialists and administering perioperative heterotopic ossification prophylaxis, most commonly in the form of nonsteroidal anti-inflammatory medications, if tolerated.

Proximal femoral replacement in non-oncologic patients undergoing revision total hip arthroplasty.

Proximal femoral replacements (PFRs) have been recently utilized in complex revision arthroplasties where proximal femoral bone is compromised. The purpose of this study is to evaluate the clinical outcomes, complications, and survivorship of PFRs as a salvage treatment for severe bone loss after non-oncologic revision total hip arthroplasty. This is a retrospective review of all patients who underwent femoral revision surgery using a single design PFR between 2004 and 2013 at our institution. Forty patients (41 hips) were included with a mean age of 64years (29-90). According to Paprosky classification, 15 femurs had type IIIB defect, and 26 had type IV defect. Patients were followed for a mean of five years (2-10). The average length of reconstruction was 150mm (81-261). A Kaplan-Meier analysis was used to determine the survival of the PFR. A total of nine patients (9 PFRs, 22%) were re-operated upon. Three re-operations were for infection, two for dislocation, two for aseptic loosening, and two for periprosthetic fracture. The survivorship at fiveyears was 95.1% for revision of the femoral stem for aseptic loosening. We did not find length of the segmental reconstruction or the indication for revision, to be a risk factor for implant failure or re-revision. Proximal femoral replacements have shown an acceptable survivorship in non-oncologic revision hip arthroplasties for severe proximal femoral bone loss. The frequent use of constrained liners may decrease the risk of dislocation due to the loss of the abductor mechanism encountered in these complex reconstructions.

CONSTRAINED LINERS AND DUAL MOBILITY SYSTEMS FOR PREVENTION OF INSTABILITY IN REVISION HIP ARTHROPLASTY

Purpose. Instability is a challenging complication of revision hip arthroplasty and a frequent cause of repeat revisions. Constrained liners and dual mobility systems have gained major attention among the options of dislocation prophylaxis. The aim of this study is to compare the outcomes of revision hip arthroplasy with use of constrained liners and dual mobility systems. Materials and Methods. We used DePuy Duraloc (inner diameter 28 mm) and Zimmer Trilogy (inner diameter 32 mm) systems in the constrained liners group (N 78, mean follow-up — 66.2 month, 54-82), Serf Novae and Biomet Avantage systems in the dual mobility group (N 58, mean follow-up — 17.8 month, 10-41). The two groups were comparable in age, sex and different potential dislocation risk factors, however, dual mobility cups were used more frequently in revisions due to unreduced and recurrent dislocations and in patients with the history of instability following total hip arthroplasty. There were also differences in the structure of primary diagnosis. Results. We observed 14 (17.9%) dislocations, 10 (12.8%) of which occurred within 2 years after surgery, and also 3 (3.8%) cases of aseptic loosening of the acetabular component, 4 (5.1%) cases of locking mechanism damage without dislocation and 8 (10.3%) cases of deep infection in the constrained liners group. In the dual mobility group we observed 3 (5.17%) large articulation dislocations, 1 (1.7%) case of aseptic loosening of the acetabular component and 4 (6.9%) cases of deep infection. The difference in dislocation rates in two groups was significant (p0.05). The analysis of the constrained liners group revealed an increased risk of dislocation in cases when a constrained system was implanted into a retained acetabular component compared to cases with acetabular shell revision (p0.01; RR = 7.2, 95% CI: 2.05-25.26), as well as a trend for increased risk of dislocation in cases when DePuy Duraloc liners (inner diameter 28 mm) were used compared to Zimmer Trilogy (inner diameter 32 mm) (p = 0.07; RR = 4.97, 95% CI: 1.03-24.04). Conclusion. Dual mobility systems proved to be more effective than constrained liners in revision hip arthroplasty although being used more frequently as a treatment rather than prophylaxis of instability. Constrained liners bear a higher risk of dislocations when implanted into retained acetabular components and when used with heads of lesser diameter.

Effectiveness of Constrained Liner Use During Harrington Hip Reconstruction in Oncology Patient

BackgroundPatients with destructive acetabular lesions are at high risk for morbidity. Harrington described reinforcing acetabular diseased bone with methylmethacrylate, supplemented by metal fixation, to allow total hip reconstruction. However, all published studies using this technique report dislocations. We believe that initial use of constrained liners would help alleviate dislocation risk, without increasing component loosening or polyethylene wear. MethodsSixty-eight patients who underwent Harrington hip arthroplasties for metastatic cancer from August 2005 to March 2015 were identified. All patients had a constrained acetabular liner implanted during their index procedure. Electronic medical records and radiographs were reviewed. A literature review of studies with similar technique was used as a historical control. ResultsForty-seven patients (69.2%) died 22.7 ± 22.7 months after surgery, at age 62.4 ± 17.2 years. At an average clinical follow-up of 9.9 ± 14.2 months (range 2-50 months), we found no incidents of dislocation. No patients had component failure requiring revision or evidence of loosening on x-ray. Thirteen papers, comprising 185 patients, demonstrated 39 patients (21.1%) with dislocations and 13 patients (7.0%) requiring revision surgery for aseptic loosening. ConclusionModified Harrington technique has demonstrated relative durability when reconstructing metastatic acetabular disease, although dislocation occurs in approximately 20% of patients. This study demonstrates that initial use of a constrained liner can alleviate postoperative dislocations without increasing risk of perioperative complications. Even modest reduction in complications during the limited lifespan of oncologic patients can have dramatic positive effects on quality of life.

Successful Closed Reduction of a Dislocated Constrained Total Hip Arthroplasty

This case report and literature review examines whether closed reduction is a viable option to manage hip dislocation when the patient has a constrained liner. Introduction Dislocation after total hip arthroplasty (THA) ranges from less than 1% to 6% of primary cases [1] and from 15% to 30% of revision cases [2]. Unfortunately, the success rate of non-operative treatment of dislocation after THA can be unreliable, and a third of such patients have recurrences [1].Surgical procedures used to treat instability and dislocation include:•Tightening the abductor musculature•Removing sources of impingement•Repositioning malaligned components•Using acetabular liners with elevated rimsSuch treatments fail in 30% to 50% of patients, however [3].The use of constrained liners, which relies on a locking mechanism to capture the femoral head, has been developed to help manage this problem [4]. Despite such efforts, patients continue to be at high risk for instability, and 3% to 18% experience recurrent dislocation even after constrained components have been implanted [5,6]. Generally, open surgical reduction is thought to be the only available treatment for such cases. However, this compromises the integrity of the joint and exposes the patient to the additional risk of surgery [7]. Several authors have reported closed reduction for dislocation of a constrained liner [7-13].Constrained acetabular liners are currently available in various designs, with differences in the locking mechanisms. To our knowledge, ours is the first reported case of a successful closed reduction of a dislocated constrained THA using a Trilogy Acetabular System Constrained liner (Zimmer, Inc, Warsaw, Indiana, USA).The study protocol adhered to the ethics guidelines of the 1975 Declaration of Helsinki, and the study was approved by the Institutional Review Board of Stanford University.

Surgical challenges and clinical outcomes of total hip replacement in patients with Down’s syndrome

Down's syndrome is associated with a number of musculoskeletal abnormalities, some of which predispose patients to early symptomatic arthritis of the hip. The purpose of the present study was to review the general and hip-specific factors potentially compromising total hip replacement (THR) in patients with Down's syndrome, as well as to summarise both the surgical techniques that may anticipate the potential adverse impact of these factors and the clinical results reported to date. A search of the literature was performed, and the findings further informed by the authors' clinical experience, as well as that of the hip replacement in Down Syndrome study group. The general factors identified include a high incidence of ligamentous laxity, as well as associated muscle hypotonia and gait abnormalities. Hip-specific factors include: a high incidence of hip dysplasia, as well as a number of other acetabular, femoral and combined femoroacetabular anatomical variations. Four studies encompassing 42 hips, which reported the clinical outcomes of THR in patients with Down's syndrome, were identified. All patients were successfully treated with standard acetabular and femoral components. The use of supplementary acetabular screw fixation to enhance component stability was frequently reported. The use of constrained liners to treat intra-operative instability occurred in eight hips. Survival rates of between 81% and 100% at a mean follow-up of 105 months (6 to 292) are encouraging. Overall, while THR in patients with Down's syndrome does present some unique challenges, the overall clinical results are good, providing these patients with reliable pain relief and good function.

Are abductor muscle quality and previous revision surgery predictors of constrained liner failure in hip arthroplasty?

Dislocation is one of the most common complications of total hip arthroplasty. The use of constrained liners is an option for the management of chronic hip instability, typically used after other methods have failed. The purposes of this study were to evaluate the overall clinical outcomes and failure rates of a tripolar constrained liner design, to assess the radiographic outcomes of its use, and to examine whether various factors such as abductor mechanism quality and history of previous revision surgeries were associated with an increased risk of failure. Forty-three hips in 39 patients who had a mean follow-up of 51 months (range, 24-110 months) were reviewed. Ninety-one percent of the hips (39 of 43 hips) did not need any revisions over the study period. A new liner was implanted in all four failed hips with concurrent revision of the acetabular cup in three cases. No further dislocations occurred in this group. The mean hip score for surviving hips was 82 points (range, 38-100 points) at final follow-up. Radiographic evaluation revealed stable, well-fixed acetabular components in all surviving hips without progressive radiolucencies. No association was found between abductor muscle quality and the incidence of failure, but patients who experienced a constrained liner failure were more likely to have undergone at least one previous hip revision operation. Tripolar constrained acetabular liners can provide successful outcomes in patients with hip instability, although it is important not to rely on the use of a constrained liner alone in an attempt to compensate for other correctable factors such as component positioning.

Constrained Liners in Revision: Total Hip Arthroplasty An Overuse Syndrome: In Opposition

Use of constrained liners in revision total hip arthroplasty is frequently a necessary evil. Concomitant with the increasing complexity of the operative intervention is the deterioration of periarticular soft-tissue envelope integrity, causing increased risk of dislocation. Risk factors can be categorized as impingement independent or impingement related. Impingement-independent risk factors include those related to compromised soft-tissue tension, patient-specific issues, and surgical approach. Impingement-related risk factors include head-to-neck size and geometry, acetabular liner geometry, and surgical technique. Indications for constraint include recurrent hip instability after arthroplasty, intraoperative multidirectional hip instability, neuromuscular diseases that impair hip dynamics, neurologic diseases that impair the patient's ability to restrict activities, and proximal muscle weakness with or without deficiency of the protective muscular. Newer designs featuring large heads, improved range of motion, and reduced impingement hold the promise of improved results.

Constrained Liners in Revision Total Hip Arthroplasty: An Overuse Syndrome: In the Affirmative

Instability after primary and revision total hip arthroplasty continues to be problematic for the surgeon. The use of constrained liners, which use a locking mechanism to capture the femoral head, has increased to help manage this problem. Constrained liners, however, present problems with acetabular component loosening, dissociation of the liner/shell interface, failure by breakage, and excessive polyethylene wear. Rather than resort to constrained liners, our approach has been to restore joint stability with large-diameter femoral heads. The advantages are increased range of motion due to more favorable head/neck ratio, increased resistance to dislocation due to increased jump distance, and the avoidance of skirted femoral heads. With the addition of cross-linked polyethylene, the volumetric wear associated with large heads is much decreased and makes this a viable option today.

Instability after Total Hip Replacement

Instability after total hip replacement is a major cause of patient morbidity, second only to aseptic loosening of the components. Many factors, including surgical approach, implant design, soft tissue integrity, patient compliance, and experience of the surgeon, play an important role in the etiology of hip dislocation. An understanding of the timing, mechanism, and direction of the instability helps in formulating a treatment plan whether surgical or nonoperative. Radiographic evaluation, especially component orientation, restoration of offset, and leg length, can give valuable information about any abnormal biomechanics of the dislocated hip. Initial treatment of postoperative hip dislocation may not require surgery, but recurrent dislocation with an identifiable cause is best managed surgically. Revision hip surgery for recurrent instability can be a challenging problem. A better understanding of the etiology and the use of constrained liners at many centers have shown improved results with surgical management. Patients should be counseled regarding realistic expectations before revision surgery for recurrent dislocations. As a result of the greater emphasis paid to meticulous capsule repair, orientation of the components, and soft tissue tension, the incidence of instability after a primary hip arthroplasty is extremely low.

The role of constrained liners in total hip arthroplasty.

Recurrent instability after total hip replacement is a complex problem with extensive literature detailing multiple etiologies and solutions. It has been shown that the success of surgical treatment depends on the identification of the cause. Unfortunately, in certain situations, there may not be an optimal solution for dealing with the cause, or the cause may remain unidentified. In these cases, the success rate of surgical treatment of the unstable total hip replacement is only 40% to 50%. Constrained acetabular liners were developed to address the problem of recurrent instability by holding the femoral head captive within the socket. Before the use of constrained liners, there were no reliable solutions to dislocation arising from inadequate soft tissues, a deficient abductor mechanism, or neuromuscular disorders. We have used a constrained liner for these situations, with poor patient compliance and instability without a clear cause as relative indications for its use. Our experience with attaining joint stability using one type of constrained liner has resulted in a 97.6% success rate (83 of 85 hips) at 4.8 years, surpassing the outcomes achieved by other means. The intermediate followup after implantation of a constrained liner has not shown significant rates of component wear or loosening.