The Journal of Arthroplasty Vol. 22 No. 4 Suppl.

1 2007

The Dislocating Hip Arthroplasty

Prevention and Treatment

Preetesh D. Patel, MD, Aaron Potts, MD, and Mark I. Froimson, MD, MBA

Abstract: The dislocating hip is functionally impairing and leads to patient

dissatisfaction. The etiology is multifactorial and may include component malposi-
tioning, soft tissue laxity, and component or anatomical impingement. Initial
treatment of dislocation usually consists of closed reduction followed by the use of
an abduction pillow or brace or a knee immobilizer, although evidence to support
these actions is limited. Operative intervention is generally reserved for patients with
more than 2 dislocations and should aim to correct the cause of dislocation using a
simple algorithm. Proper component positioning is key to prevention of further
dislocation, but other tools include modular implants, jumbo heads, and increased
offset. Finally, constrained acetabular components may be considered if a patient
fails one of the above surgical options. Key words: hip, replacement, dislocation,
prevention, treatment, review.
n 2007 Published by Elsevier Inc.

Dislocation after total hip arthroplasty (THA) con-
tinues to be one of the leading causes of early
revision. The dislocating hip is functionally impair-
ing and leads to patient apprehension and dissatis-
faction. The reported incidence varies from 0.2% to
7% after primary THA and 10% to 25% after
revision arthroplasty. Early dislocation is defined
as occurring within the first 3 months postopera-
tively and carries a better prognosis with a lower rate
of recurrence [1]. In comparison, late dislocations
have a multifactorial etiology including polyethyl-
ene wear and soft-tissue laxity which leads to a
higher recurrence rate [2]. The management of a
dislocation initially is nonoperative, including
closed reduction, bracing, and physical therapy for
From the Department of Orthopaedic Surgery, Cleveland Clinic,
Cleveland, Ohio.
Submitted September 28, 2006; accepted December 24, 2006.
No benefits or funds were received in support of the study.
Reprint requests: Mark I. Froimson, MD, MBA, Department
of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleve-
land, OH 44195.
n 2007 Published by Elsevier Inc.
0883-5403/07/1906-0004$32.00/0
doi:10.1016/j.arth.2006.12.111
patient reeducation. Recurrent instability, unre-
sponsive to nonoperative trials, usually warrants
operative intervention. The success of revision
surgery depends upon identifying the direction
and causative factors most responsible for the
recurrent events. Prevention is the best strategy
and can be accomplished with proper patient
selection and approaches, as well as optimum
component selection and orientation.
Risk Factors
Patient Factors
Some investigators have reported that cognitive
and neuromuscular disorders, including cerebral
palsy, muscular dystrophy, and dementia, have
higher associated dislocation rates. Fackler and Poss
[3] found a 22% incidence of confusion and
neuromuscular disease in patients with single
dislocations and 75% in patients with multiple
dislocations. Patients greater than 80 years of age
have a higher dislocation risk, likely secondary to
muscle control/weakness, propensity to fall, and

86

lack of adherence to postoperative protocol [4].
Historically, studies have suggested women are
twice as likely to have a dislocation when com-
pared to men [1,4], but this is not supported by
more recent data [5,6]. Paterno et al [5] reported a
higher incidence in patients with a history of
alcohol abuse, 23% vs 5%. Other identifiable risk
factors include prior hip surgery, history of frac-
tures, developmental dysplasia, osteonecrosis, or
inflammatory arthropathy [7].
Surgical Factors
Surgical factors contributing to dislocation include
operative approach, component design, component
position, and soft-tissue tensioning. Surgical ap-
proach continues to be a factor that influences hip
stability after THA. Historically, Woo and Morrey [1]
reported higher dislocation rates for the posterior
approach (5.8%) vs the anterolateral approach
(2.3%, P b .01). A large meta-analysis performed
recently reviewed 13 203 primary THAs. The
reported dislocation rates were 1.27% for trans-
trochanteric, 3.23% for posterior (2.03% with
posterior capsular repair), 2.18% for anterolateral,
and 0.55% for the direct lateral approach [8]. A
meticulous posterior capsular repair has also been
shown by other investigators to decrease the dislo-
cation rates to comparable levels to other
approaches. Pellici et al [9] reported a reduction
from 4.1% to 0.0% in 395 patients with posterior
capsular repair. Goldstein et al [10] reported a
statistically significant decrease with capsulorrha-
phy in 1515 patientsfrom 4.8% to 0.7%. White et
al [11] demonstrated a reduction from 2.8% to 0.6%
in 1000 patients. Another risk factor for dislocation is
the integrity of greater trochanter and the abductor
musculature. Trochanteric nonunion of greater than
1 cm increased dislocation by sixfold [1,4]. Finally,
poor abductor muscle function results in diminished
soft-tissue tension and increased risk of dislocation.
Component design and selection each play a
pivotal role in prevention and treatment of disloca-
tions. Femoral head diameter impacts hip stability
with larger femoral heads having both distinct
theoretical advantages and increasing clinical evi-
dence of lower susceptibility to dislocation [12-14].
A more favorable head-to-neck ratio increases the
primary arc of motion before impingement. A larger
head, in addition, sits deeper in the liner requiring a
greater excursion distance (bjump distanceQ) before
dislocation [14]. Finally, larger heads allow for
greater neck length without the use of the skirted
necks, a significant source of component impinge-
ment. Selecting implants that allow for variable
The Dislocating Hip Arthroplasty ! Patel et al 87
anteversion (eg, modular implants), high-offset
neck options, and acetabular liners with elevated
rim profiles also allow for reconstructive options
that can decrease the risk of postoperative disloca-
tion. In fact, the use of high-offset devices has
increased significantly in recent years.
Both acetabular and femoral component posi-
tioning errors must be avoided to prevent instabil-
ity. Inadequate version and excessive abduction on
the acetabular side are the 2 most critical position-
ing errors leading to instability. Nishii et al [15]
reported on 181 nondislocating hips with a cup
version greater than 208 vs 9 dislocating hips with a
cup version of less than 208. A posterior approach
with the same implant and head size was used in
all. They concluded that cup anteversion was the
single major determinant of dislocation risk in their
series [15]. Other authors have reported on a bsafe
zoneQ for cup orientationanterversion 158 F 108
and abduction 408 F 108 [16,17]. Higher disloca-
tion rates were seen when the cup position was
outside of this zone. Inadequate offset, length, and/
or version on the femoral side can lead to
instability; however, these factors have been less
well studied. Finally, the lack of recognition of
impinging soft tissues and/or osteophytes on either
side of the joint can also lead to instability.
Treatment
Nonoperative
Assuming the components are well positioned, a
closed reduction can be successful in two thirds of
patients [1]. Adequate sedation and muscle relaxa-
tion are necessary before an attempt at closed
reduction. If adequate sedation cannot be achieved
in the emergency room, a regional or general
anesthetic should be considered to prevent repeti-
tive attempts at closed reduction and subsequent
damage to the femoral head. In a retrieval study of 3
femoral heads that underwent open reduction after
failed difficult closed reduction, Schuh et al [17]
demonstrated macroscopically and microscopically
(scanning electron microscopy) significant surface
damage to the metal and ceramic heads [18].
After successful closed reduction, many surgeons
support the use of an abduction brace for 6 to
12 weeks. Despite its popularity, support for abduc-
tion bracing comes from small-scale studies [19,20].
In a larger study, Dewal et al [21] evaluated 91 first-
time and 58 recurrent dislocators. All patients were
deemed to have adequate component position
and therefore were treated with closed reduction.
They found no difference between bracing and
88 The Journal of Arthroplasty Vol. 22 No. 4 Suppl. 1 June 2007
nonbracing in the prevention of recurrent instability
in either group. They concluded that bracing was
ineffective in preventing recurrent instability [21].
For stable hips, some surgeons advocate more simple
modalities such as hip precautions and/or a knee
immobilizer. In the most noncompliant patients, a
hip spica cast can be considered, but is generally
poorly tolerated in this patient population.
Operative
Indications for operative intervention include
recurrent instability (N2 dislocations), chronic dis-
location, irreducible dislocation, malpositioned
components, and inadequate soft-tissue tension
leading to instability. The treatment of this difficult
problem can be addressed with a simple algorithm
(Fig. 1). If the components are malpositioned, they
should be revised. Parvizi et al [22] recently reported
on their series of patients with recurrent instability
that required a revision surgery. Cup malpositioning
was identified as the major cause in 33 (35%) of
93 patients. Revision surgery was successful in
preventing recurrence of instability in 84 (91%) of
92 patients in their series. Historically, however, the
recurrence rate after component revision has been
significantly higher (39%-47%) [23,24].
Well-positioned components may dislocate either
because of impingement or abductor deficiency,
and these issues should be addressed individually.
Impingement can be related to the implant charac-
teristics or the patients femoral and pelvic anatomy.
Fig. 1. Algorithm for management of the unstable
total hip.
Treatment should be focused on modular exchange
(eg, increase length/head size, liner exchange) [25]
and debulking of offending soft-tissues and osteo-
phytes. Abductor deficiency or instability despite
well-positioned components may be addressed with
several options: jumbo head [26], constrained liner,
bipolar arthroplasty [23,27], trochanteric advance-
ment [28,29], or soft-tissue enforcement [30].
Jumbo heads are commonly used for preventing
dislocation and offer several advantages. These
include a larger range of motion before impinge-
ment of the prosthetic neck on the acetabular
component, and an increased jump distance.
Beaule et al [26] reported on 12 patients treated
with jumbo femoral heads (average diameter, 44
mm) for recurrent instability. In their series, the 12
patients had an average of 4 previous operations
and 7 prior dislocations. At an average follow-up of
6.5 years, 10 patients had no further episodes of
instability [26].
It is not clear whether progressively increasing
femoral head size reliably decreases the risk for
dislocation for head sizes greater than 32 mm.
When using these larger heads, osseous structures
may start to impinge before the prosthetic neck,
although increasingly larger heads still have the
advantage of the increased jump height [31]. It is
also unknown whether the theoretical advantage
of increased jump height alone translates into a
decreased dislocation rate. However, data from hip
resurfacing literature have suggested that jumbo
femoral heads in metal-on-metal articulations may
decrease the incidence of dislocation to less than
1%, raising the possibility that jumbo articulations
may be very useful in preventing dislocation
[32,33]. Previously, metal-on-polyethylene con-
structs with large femoral heads demonstrated
increased wear, limiting their use [34]. More recent
literature on large femoral heads demonstrates that
wear characteristics may be improved with highly
cross-linked polyethylene liners, thus expanding
the options for jumbo femoral head constructs [35].
Constrained liners continue to gain popularity as a
treatment alternative in patients with recurrent
instability, but should be used with caution as a
salvage attempt, and not in every recurrent dislo-
cation. Surgeons should not implement a con-
strained liner when a correctable cause of
dislocation is identified owing to concerns of
decreased range of motion, acetabular loosening,
and separation of individual components. The
definite indications for a constrained liner are
recurrent dislocators who have inadequate soft
tissue, especially deficient abductor mechanism,
or neuromuscular disorders. Many surgeons will

also use them in dislocators without a known
cause, patients who have failed previous revisions,
or poorly compliant patients [36]. In a series
evaluating 755 consecutive constrained acetabular
components, Berend et al [37] reported a disloca-
tion rate of 17.5% overall. When a constrained
component was specifically used for patients with a
history of recurrent dislocations, there was a 29%
redislocation rate (37/128 patients). They conclud-
ed that constrained components prevented recur-
rence in 71% of patients with recurrent instability,
but had an overall failure rate of 41% in their large
series secondary to other causes (eg, loosening,
periprosthetic fractures, infection, and dissociation)
[37]. Another long-term study reported the use of a
tripolar constrained acetabular component to treat
recurrent instability. Goetz et al [38] evaluated
56 hips (55 patients), with an average follow-up of
10 years, treated with a tripolar constrained
component. Recurrent dislocation occurred in only
4 (7%) of 56 patients. Their overall failure rate was
21% (eg, loosening, fracture, infection, osteolysis)
[38]. A common problem with the use of a
constrained liner is whether to revise well-posi-
tioned, well-fixed acetabular components not com-
patible with the chosen constrained liner. In this
situation, the liner can be cemented into place with
reportedly high success rates. Callaghan et al [39]
cemented 31 constrained liners into patients with
well-fixed acetabular shells and demonstrated a
success rate of more than 90%.
Dislocation after THA is the second most common
complication of surgery. The associated risk includes
both patient and surgical factors. Closed reduction
techniques have been successful in most cases, but
patients with recurrent instability or component
malposition should be considered for surgery. The
success of revision arthroplasty largely depends
upon identifying the underlying etiology. With the
use of a treatment algorithm, the surgeon can fully
understand all of the treatment options available to
aid in revision arthroplasty. The increased availabil-
ity and use of larger diameter articulations promise
to dramatically reduce the incidence and favorably
impact the treatment of prosthetic hip instability.
Finally, bipolar athroplasty and constrained acetab-
ular components should be reserved as salvage
procedures for patients who have failed more
conservative surgical measures.
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