SCIENTIFIC PAPER Anterior Dislocation Following Primary Total Hip Replacement by the Posterior Approach Aetiology and Treatment
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1 Hong HKJOS Kong Journal of Orthopaedic Surgery 2003;7(1): SCIENTIFIC PAPER Anterior Dislocation Following Primary Total Hip Replacement by the Posterior Approach Aetiology and Treatment Ng TP, Yau WP, Tang WM, Chiu KY Division of Joint The University of Hong Kong, Queen Mary Hospital, Hong Kong ABSTRACT Objective: Review of 5 patients after anterior dislocation of prosthesis following primary total hip replacements done from the posterior approach. Patients and Methods: The implanted prostheses included 3 hybrid hips and 2 cementless hips. Results: The mean age of the patients was 60 years. Dislocation occurred between 2 and 25 days after operation. All dislocations were treated by closed reduction. The hips were unstable in extension, adduction, and external rotation. Special splints were designed to protect the hips in the safety zone of flexion, abduction, and internal rotation. After an average protection period of 2.7 weeks, all hips were stable after a mean follow-up of 31 months. Total anteversion angle was measured under fluoroscopy in 3 hips and this ranged from 50 to 75. Conclusion: Anterior dislocation was proposed to be associated with excessive anteversion of the components. The special rehabilitation method was effective for treating anterior dislocation, even with sub-optimally positioned components. Key Words: Anterior dislocation, Rehabilitation, Total hip replacement!!"#$%&' ()*= =!" = = =!R!"#$%&'() *+,-./ !"#$%3!"2!"#!"2 25!"#$%&'()" *+,-./ :!"#$%&'()*+,-./ :;!"#$%2.7!"#$% 31!"#$%&'(C!"#$3!"#$%&'()50 75!"#!"#$%&'()*#+,-./ :;<=>$?@A.!"#7BC& INTRODUCTION Dislocation is one of the most disabling and embarrassing complications after total hip replacement, both for patients and surgeons. 1 Dislocation has been reported as the second most common major complication of total hip replacement. 2 The direction of dislocation is reported to be associated with the surgical approach. Posterior approaches predispose to posterior dislocation and anterior approaches predispose to anterior dislocation. Anterior dislocation after primary total hip replacement done by the posterior approach is uncommon. 2,3 This report is of a series of 5 patients who experienced this uncommon anterior dislocation and proposes the underlying reasons. The specific rehabilitation for anterior dislocation, which is not well described in the literature, is also discussed. Correspondence: Dr TP Ng, Medical Officer, Department of Orthopaedic Surgery, The University of Hong Kong, 5/F, Professorial Block, Queen Mary Hospital, Pokfulam, Hong Tel: (852) ; Fax: (852) Hong Kong Orthopaedic Association & Hong Kong College of Orthopaedic Surgeons.
2 Anterior Dislocation Following Total Hip Replacement Table 1 Patients characteristics. Patient Sex/age (years) M/68 F/46 F/62 M/58 M/65 Primary diagnosis Non-union after Rheumatoid Rheumatoid Avascular Avascular femoral neck fracture arthritis arthritis necrosis necrosis Prosthesis Hybrid Replica A Hybrid Hybrid Omnifit HA Precipitating factor Nil Nil Nil Previous bone Nil grafting procedure Time of first dislocation (days after hip replacement) Number of dislocations Anteversion of cup/stem (total) 45º/30º (75º) 30º/40º (70º) 25º/25º (50º) PATIENTS AND METHODS From 1995 to 2000, five patients experiencing anterior dislocation after primary total hip replacement performed through the southern approach were noted. Hybrid fixation was used for 3 hips; Duraloc acetabular components (Depuy, Warsaw, USA) and Elite plus femoral components (Depuy, Warsaw, USA) were implanted. The other 2 were cementless hip systems; one was Replica A (Depuy, Warsaw, USA) and the other was Omnifit HA (Osteonics, Stryker, Allendale, USA). The outer diameter of acetabular components ranged from 48 mm to 64 mm. Twenty eight mm diameter femoral heads were used in all hips. There was no predisposing factor to dislocation for 4 patients. One patient had a previous vascular bone grafting operation through the anterior approach in the affected hip meaning that the anterior soft tissue integrity was probably compromised. All patients were rehabilited in the standard way after hip replacement. An abduction pillow was used to protect the hip on the day of surgery. On the second day, hip mobilisation exercise was performed in a Russell suspension sling in bed. From day 2 onwards, the patients performed walking exercise supervised by a physiotherapist. Dislocation occurred from 2 to 25 days after the hip replacement (Table 1). None of the dislocations were preceded by a fall or trauma. All hip dislocations were treated by closed reduction 4 under spinal/general anaesthesia and 1 using sedation. Post-reduction stability was routinely tested and the same pattern of instability was found in all hips. All hips were stable posteriorly when the hips were put in flexion, adduction, and internal rotation. The hips were unstable anteriorly in extension, adduction, and external rotation and the stability was worst with a combination of the 3 movements. The hips were more stable when they were flexed beyond 30. Stability was further improved with internal rotation and abduction. This special position of midflexion, internal rotation, and abduction was termed the safety zone of anterior hip dislocation. A special splint was designed to maintain the hip in the safety zone while the patient was in bed (Figures 1 and 2). The incorporation of the splint in hanging slings allowed the patient to perform mobilisation and abductor muscle strengthening exercises while the hip was maintained in the safety zone during daytime. A specially designed abduction and flexion pillow (Figure 3) was used to keep the hip in the safety zone when the patient was at rest or during the night. To determine the relationship between the version and the dislocation, the version was measured by fluoroscopy in 3 patients. RESULTS The demographic data of the patients are summarised in Table 1. The mean age of the patients was 60 years (range, 46 to 68 years). Three patients were male and Figure 1 Specially designed splint to keep the hip in the safety zone while allowing abductor muscle exercise. 15
3 HKJOS finally became stable after 3 weeks. No patients had dislocations after the rehabilitation period with a mean follow up of 31 months (range, 23 to 59 months). One patient (patient 5) died from unrelated causes 5 years after the hip replacement and did not experience a dislocation before his death. Figure 2 Specially designed splint to keep the hip in the safety zone while allowing abductor muscle exercise. Figure 3 Specially designed abduction and flexion pillow to immobilise the hip in the safety zone. 2 were female. The primary diagnosis was rheumatoid arthritis for 2 patients, avascular necrosis for 2, and non-union complicating multiple screws fixation of femoral neck fracture for 1. The patients were rehabilitated in bed according to the regimen mentioned above from 1.5 to 4 weeks (mean, 2.7 weeks) after reduction, depending on the degree of instability. Four patients had no further dislocation and 1 patient (patient 4, Table 1) had 2 further dislocations during the rehabilitation period. This patient had had a previous anterior-approach bone grafting procedure. He was also an alcoholic with poor compliance to the rehabilitation regimen. The second and third dislocations occurred 3 and 14 days after the first and all were treated by closed reduction. This patient was rehabilitated using the same regimen after further reductions and his hip The cup and stem anteversion in 3 of the 5 patients were measured by fluoroscopy and this is summarised in Table 1. The total anteversion angle (the sum of cup and stem anteversion angles) ranged from 50 to 75. The mean Harris hip score at the latest follow-up was 91 points (standard deviation, 8.7; range, 76 to 97). There was no fixed flexion contracture in 3 hips and, in the other 2 hips, 10 fixed flexion contracture was found. DISCUSSION A posterior approach is reported to be associated with posterior dislocation after total hip replacement. Anterior dislocation is relatively uncommon with a reported incidence of 3% to 7% of all dislocations. 2,3 Posterior instability is explained by the loss of posterior soft tissue restraints after a posterior approach and malposition of the cup with less anteversion with unnoticed forward rotation of the pelvis. 2 On the other hand, excessive acetabular anteversion has been reported to be associated with anterior dislocation after the posterior approach. 4 In the classic paper of Lewinnek et al, the acetabular anteversion angle of the 3 anterior dislocated hips was between 25.0 to 43.0, which was significantly larger than the mean anteversion angle of 15.6 for the study group. 4 As the positions of the acetabular and femoral components interacted to affect hip stability, the concept of total anteverion was proposed. 5 Ranawat et al recommended total anteversion of 20 and 25 to 45 degrees. 6 In this study, the acetabular component anteversion screened under fluoroscopy ranged from 25 to 45, which were similar to those of the patients in the anterior dislocated group of Lewinnek et al. 4 The total anteversion of 50 to 75 was also much larger than the recommended angle and was suspected to have caused the anterior dislocations. Some surgeons may try to position the femoral and acetabular components in a more anteverted position to prevent posterior instability. One should remember the wisdom of the saying the enemy of good is better the component anteversion should be optimised to balance the anterior and posterior stability. The incidence of anterior dislocation is much lower than posterior dislocation after total hip replacement. 16
4 Anterior Dislocation Following Total Hip Replacement The reduction method is also different from that for the posterior dislocation. In posterior dislocation, the most commonly used method is Allis method with traction along the axis of femur with the hip and knee flexed at 90. In anterior dislocation, traction is applied along the axis of the femur with the hip in extension or slight flexion, together with an internal rotation force. In difficult cases, an assistant can apply a posteromedial directing force on the thigh to help the reduction. As the position and duration of protection are determined by the individual safety zone, it is prudent to examine the post-reduction stability in every patient. Figure 4 Posterior dislocation less prominent lesser trochanter with internal rotation of the hip. Figure 5 Anterior dislocation more prominent lesser trochanter with external rotation of hip. The pathology of anterior dislocation is not well described in the literature. Surgeons, especially the junior trainees, often misdiagnose anterior dislocation as posterior dislocation. It is essential to differentiate the 2, not only because they have different patho-anatomy and different reduction methods but, most importantly, the rehabilitation methods are totally different. Differentiation between the 2 dislocations can be clinical and radiological. Clinically, the limb is usually slightly flexed, internally rotated, and adducted in posterior dislocation while, in anterior dislocation, the limb is usually extended, externally rotated, and in neutral abduction/adduction. Radiological hint can also be found to differentiate the 2 conditions. In posterior dislocation, the lesser trochanter is less prominent because of hip internal rotation (Figure 4) but, in anterior dislocation, the lesser trochanter is more prominent due to the external rotation (Figure 5). Rehabilitation after posterior dislocation usually consists of a period of bed rest with the involved hip kept in extension, avoiding flexion and internal rotation. With gravity, the limb usually rests in external rotation. This position is not desirable in anterior dislocation because the hip is prone to dislocate in extension and external rotation. At Queen Mary Hospital, the hip is rehabilitated in flexion and internal rotation instead. This can prevent further dislocation and allow the anterior soft tissue envelope to heal. Using the hanging splint, the patient can perform abductor muscle strengthening exercises while the hip is maintained in the safety zone. The angle of hip flexion can be easily adjusted by changing the length of the hanging strings. As the splint is connected to the hanging strings by magic tapes (Figures 1 and 2), the degree of hip rotation tailored for an individual patient can also be easily adjusted. In the series of Lewinnek et al, secondary operation was required for 5 of 9 hip dislocations and 2 patients had significant cardiopulmonary complications. 4 In the small series reported here, all patients had no further dislocation after a mean follow-up of 31 months. This also included the non-compliant patient with defective anterior soft tissue after a previous bone grafting procedure. The authors conclude that the described rehabilitation method is adequate for anterior dislocation after primary total hip replacement, even with sub-optimally positioned components. ACKNOWLEDGEMENTS The authors would like to thank the Prosthetic and Orthotic Department, Queen Mary Hospital, for their help in the design and production of the splints and pillows. REFERENCES 1. Heithoff BE, Callaghan JJ, Goetz DD, Sullivan PM, Pedersen DR, Johnston RC. Dislocation after total hip arthroplasty, a 17
5 HKJOS single surgeon s experience. Orthop Clin North Am 2001; 32: Woo RYG, Morrey BF. Dislocations after total hip arthroplasty. J Bone Joint Surg Am 1982;64: Jolles BM, Zangger P, Leyvraz PF. Factors predisposing to dislocation after primary total hip arthroplasty. J Arthroplasty 2002;17: Lewinnek GE, Lewis JL, Tarr R, Compere CL, Zimmerman JR. Dislocations after total hip-replacement arthroplasties. J Bone Joint Surg Am 1978;60: Sanchez-Sotelo J, Berry DJ. Epidemiology of instability after total hip replacement. Ortho Clin North America 2001; 32: Ranawat CS, Maynard MJ, Deshmukh RG. Cemented primary total hip arthroplasty. In: Sledge C, editor. Master techniques in orthopaedic surgery: the hip. Philadelphia: Lippincott-Raven; 1998: The Authors NG T-P, MBChB, FHKAM (Orth Surg), Division of Joint YAU W-P, MBBS, FHKAM (Orth Surg), Division of Joint TANG W-M, MBBS, FHKAM (Orth Surg), Division of Joint CHIU K-Y, MBBS, FHKAM (Orth Surg), Division of Joint 18
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