Orthopaedics & Traumatology: Surgery & Research 100 (2014) S25–S34

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Review article

Surgical management of recurrent dislocation

after total hip arthroplasty
J.-L. Charissoux ∗ , Y. Asloum , P.-S. Marcheix
Service d’orthopedie traumatologie, CHU Dupuytren, 2, avenue Martin-Luther-King, 87042 Limoges cedex, France

a r t i c l e i n f o a b s t r a c t

Article history: Dislocation is a major complication of total hip arthroplasty (THA), whose frequency has been unaffected
Accepted 6 November 2013 by improvements in surgical techniques and implants. The dislocation rate depends on multiple factors
related to the patient, hip disease, and surgical procedure and is therefore also dependent on the surgeon.
Keywords: The many published studies on THA dislocation, its causes, and its treatment have produced conflicting
Total hip arthroplasty results. The objective of this work is to review the management of THA dislocation, which is a severe event
Instability for both the patient and the surgeon. This lecture starts with a brief review of data on THA dislocation rates
Recurrent dislocation
and the many factors that influence them. Emphasis is then put on the evaluation for a cause and, more
Cup orientation
Tripolar arthroplasty
specifically, on the challenges raised by detecting suboptimal cup position. Next, reported techniques
Constrained liners for treating THA dislocation and the outcomes of each are discussed. Finally, a management strategy for
Large femoral head patients selected for revision surgery is suggested.
Cup lip augmentation © 2013 Elsevier Masson SAS. All rights reserved.

1. Introduction
Dislocation remains a major complication of total hip arthro-
plasty (THA). Dislocation is the third leading reason for revision
THA overall, after loosening and infection, and is probably the most
common reason for early revision THA [1–3].
THA is widely perceived by the public as producing excellent
outcomes that usually allow a return to previous activities. Dis-
location is viewed by both patients and surgeons as a serious
complication, with good reason since the risk of recurrence after
a first episode is approximately 33% [4].
• the surgical approach and femoral head size, as discussed below;
• follow-up duration (6% after 20 years and 7% after 25 years) [6,8];
• and many other factors such as [6] female gender, advanced age,
specific causes (avascular necrosis of the femoral head, proximal
femoral fracture or non-union) [6], obesity [9], co-morbidities
with an ASA score of 3 or more [10], neuromuscular impair-
ments (e.g., Parkinson’s disease or stroke-related impairments),
neuro-cognitive impairments (e.g., psychiatric disease or mental
disability), and exposure neurotoxins (e.g., alcohol abuse). Finally,
the dislocation rate is higher in patients with a history of surgery
on the same hip, most notably previous THA procedures [10].

2. Dislocation rates, cause, and time to occurrence
Studies of primary THA found dislocation rates of 1.7% [5], 4.8%
(of 6623 cemented THAs with 22.2-mm femoral heads) [6], and 0.3%
to 10% [2]. Revision THA was followed by higher dislocation rates of
5.1% to 14.4% in one study [7] and 28% in another [2]. Counting sub-
luxation episodes in addition to dislocations would produce even
higher rates. Subluxation is difficult to diagnose and therefore fre-
quently overlooked, a fact that hinders an exact evaluation of its
incidence rate, which has been estimated at 2–5.5% [4].
Dislocation rates vary with many factors including the follow-
ing:
∗ Corresponding author. Tel.: +33 555 056 678.
E-mail address: Jean-louis.charissoux@chu-limoges.fr (J.-L. Charissoux).
Although most dislocations occur early after THA, the disloca-
tion rate increases with follow-up duration. Three categories can
be defined based on time to occurrence [4]:
• early dislocations within the first 3 (or 6) months after THA are
the most common (50 to 70% [4]) and are promoted by inadequate
healing;
• secondary dislocations occur after the resumption of previous
activities, between 3–6 months and 5 years after THA, in relation
to increased hip mobilisation; this category contributes 15 to 20%
of all THA dislocations;
• and late dislocations, occurring more than 5 years after THA, are
often related to polyethylene wear; their rate may be underesti-
mated [4] and may reach 32%, with a mean time to occurrence of
11.3 years.

1877-0568/$ – see front matter © 2013 Elsevier Masson SAS. All rights reserved.
http://dx.doi.org/10.1016/j.otsr.2013.11.008
S26 J.-L. Charissoux et al. / Orthopaedics & Traumatology: Surgery & Research 100 (2014) S25–S34

Fig. 1. Dislocation, apparently in the anterior direction.

3. Evaluation of the unstable THA In addition to the above-listed risk factors, many factors that
contribute to THA dislocation are related to the surgical technique,
The prerequisite to developing an appropriate treatment strat- including the following:
egy is a thorough evaluation to identify the causes of the dislocation.
The direction of the dislocation should be assessed based on • surgical approach;
the causative movement, femoral head position on the lateral view • component orientation;
(which unfortunately is often not obtained) (Figs. 1 and 2) and, • femoral head diameter;
above all, direction of the instability as determined during reduc- • restoration of femoral offset and leg length;
tion. • cam impingements;
• condition of the soft tissues.

3.1. Surgical approach

The postero-lateral approach is associated with a higher dis-

location rate (mean, 6.9% [2,8,11]) compared to the antero-lateral
approach (3.1% [8]) and anterior approach (0.6 to 1.3% [2]).

3.2. Component orientation

Suboptimal component position often results in early or sec-

ondary dislocation but may be difficult to demonstrate.

3.2.1. Cup
Lewinnek et al. [12] defined a safe zone of 40◦ ± 10◦ of incli-
nation and 15◦ ± 10◦ of anteversion. However, many patients have
cups outside this safe zone yet do not experience dislocation [2,13].
A cup that is too vertical and/or anteverted increases the risk of
anterior dislocation, whereas a cup that is too horizontal and/or
insufficiently anteverted increases the risk of posterior disloca-
tion. Inclination can be reliably measured on a standard radiograph,
whereas anteversion cannot. Although numerous radiograph and
computed tomography (CT) protocols have been developed, the
values often differ between two measurements (Figs. 3 and 4).
Several groups [14,15] have therefore developed CT measurement
protocols that take into account the degree of pelvic tilt measured
on a standing lateral radiograph and involve measurements of
anteversion in the lying, sitting, and standing positions. This point
is important, as the orientation of the pelvis and, therefore, of the
Fig. 2. Posterior dislocation. cup, changes with body position. The influence of pelvis position
 J.-L. Charissoux et al. / Orthopaedics & Traumatology: Surgery & Research 100 (2014) S25–S34
◦
Fig. 3. A. Anteversion measured at 13 on the left. B. Anteversion measured at 4 .◦
in the sagittal plane has been assessed in many studies, including
those conducted by Lazennec [15].
Thus, before diagnosing suboptimal cup position in a patient
with one or more dislocation episodes, the measurement proto-
col must be considered. Failing this precaution, overdiagnosis of
cup malposition may occur, prompting an inappropriate surgical
Fig. 4. A. Anterior dislocation. B. Marked acetabular retroversion.
S27
procedure that is unlikely to produce a good outcome; or, on the
opposite, cup malposition may be overlooked.
Navigation may optimise component positioning, producing
substantially lower proportions of cups outside the safe zone com-
pared to conventional surgery, as demonstrated in a prospective
study reported by Parratte et al. in 2007 [16]. However, difficulties
in identifying the anatomic landmarks used to determine the ante-
rior pelvic plane, together with the considerable variability in this
plane [17], have prompted some groups to use navigation based on
joint kinematics [18].
One means of obviating the need for navigation may consist
in positioning the infero-medial cup rim parallel to the transverse
acetabular ligament. In the hands of a Japanese group, this method
produced 21.2◦ of mean anteversion, with no significant differ-
ence between patients with and without hip dysplasia [19]. The
combined anteversion of the cup an the femoral component is
important (35 ± 10◦ ) [20].
3.2.2. Femoral component
Anteversion of the femoral component is easier to determine,
by measuring the angle between the prosthetic neck axis and the
line tangent to the posterior femoral condyles on a CT scan. This
value often differs from the surgeon’s estimate, by a mean of 16.8◦
according to a study by Dorr et al. [20].
3.3. Femoral head diameter
Femoral head diameter influences the stability of the prosthetic
joint. In a study by Berry et al. [8], femoral heads measuring 22 mm
in diameter were associated with higher dislocation rates; how-
ever, the posterior approach was used in most patients. In a study
of 2020 THAs performed via the antero-lateral approach with heads
measuring 36 mm or more in diameter, Lombardi et al. [21] iden-
tified a single case of dislocation (0.05%) after a mean follow-up of
31 months. Howie et al. [22] conducted a prospective randomised
controlled trial to compare 28-mm to 36-mm heads implanted via
the postero-lateral approach. The dislocation rate was five times
S28 J.-L. Charissoux et al. / Orthopaedics & Traumatology: Surgery & Research 100 (2014) S25–S34
higher with the smaller heads. A larger head diameter increases
the head/neck ratio and delays contact between the neck and the
cup. In addition, the ‘jumping’ distance is increased, allowing for a
greater range of ‘subluxation’ before complete dislocation occurs
[23].
3.4. Restoration of femoral offset
This point is crucial to hip stability, mobility, and optimal abduc-
tor muscle efficiency. Femoral offset measured on radiographs
varies with femoral anteversion. Merle et al. [24] reported underes-
timation of femoral offset on antero-posterior pelvic radiographs,
with improved accuracy on antero-posterior hip radiographs. Nav-
igation and 3-D pre-operative planning may improve restoration
of the native offset [25].
3.5. Restoration of leg length
Leg length restoration also improves stability, by maintain-
ing muscle tension. A clinical and radiological evaluation of leg
length, although mandatory, is associated with numerous pitfalls
and errors, most notably in patients with a contra-lateral prosthetic
hip.
3.6. Cam impingements
Contact between the neck and cup is the most common form. A
smaller head and wider neck are associated with earlier neck-cup
contact during hip movements. A femoral head skirt or prominent
cup lip increases the risk of contact.
Unwanted contact may also occur between the neck and an
osteophyte, a cement fragment, or hypertrophied or ossified soft
tissues. When medialised, the femoral metaphysis can contact the
pelvis, either directly or through the soft tissues, producing cam
impingement [4].
3.7. Condition of the soft tissues
Soft tissue damage (failed healing of a posterior or antero-
lateral approach) explains many dislocations but is difficult to
demonstrate before revision surgery. Healing failure rates increase
with the number of surgical procedures. Non-union of the greater
trochanter results in slackness of the abductor muscles, thereby
increasing the risk of dislocation, most notably when the greater
trochanter is displaced upwards.
Thus, THA instability can be related to a single cause, and the
treatment is then relatively easy. In most cases, however, multiple
factors are involved, which complicates the therapeutic manage-
ment [4].
4. Stabilisation techniques
4.1. Changing a component or modular components
Suboptimal component position usually involves the cup, as
found in 33% of cases by Morrey [26]. When poor position is demon-
strated, changing the component is a logical procedure that has
produced highly variable success rates. A 2-year success rate of
69% after cup revision was reported in one study [26], whereas
Carter et al. [27] obtained a higher success rate of 86% but often
increased the head diameter (36 mm) in addition to changing the
cup. Changing a poorly positioned femoral component is desirable
but considerably more invasive than cup revision; in the study by
Carter et al., this procedure was performed in only 11.5% of 156 hips.
Changing only the liner may carry an even higher failure rate,
of 34% to 55% in the study by Carter et al. [27], as a result of
Fig. 5. Polyethylene lip augmentation device.
With permission from Iceram Inc.
unrecognized suboptimal cup position. In contrast, Tooney et al.
[28] reported successful stabilisation of 10/13 hips 5.8 years
after modular component exchange (shallower head allowing an
increase in neck length, increased head diameter, liner with an ele-
vated rim, or lateralised liner). However, the patients were carefully
selected, in particular based on absence of malposition. A modular
neck increases the range of adaptation options.
4.2. Systems that increase cup depth
Cups with elevated rims were first suggested by Charnley as
early as 1979 [4]. Liners with elevated rims are now available
for insertion into cementless cups. Although these liners decrease
the dislocation rate [29], they also place considerable mechanical
stresses on the cup and can result in cam impingement.
Polyethylene lip augmentation devices (Fig. 5) are either par-
tial or complete (Fig. 6) and may have a metal backing plate; they
allow THA stabilisation while keeping the same cup and requiring
only a short operative time. McConway et al. [30] reported a 1.6%
recurrence rate in 302 cases after a mean follow-up of nearly 7 years
and with less than 2% of radiolucent lines accentuation. However,
similar to elevated-rim cups, or perhaps even to a greater extent,
lip augmentation devices are associated with cam impingements,
increased mechanical stresses on the cup, and weakening of the
polyethylene by the screw trajectories. In addition, complete lip
augmentation devices decrease prosthesis clearance by 40% [4].
4.3. Constrained cups
Constrained cups were developed several years ago. Their mod-
ern cemented version was designed by Lefèvre (Fig. 7A-B) in France.
In a study by Hernigou et al. [31], constrained liners proved
highly reliable in preventing dislocation in patients with neurolog-
ical or cognitive impairments. After a mean follow-up of 7 years,
the dislocation rate in 164 hips was only 2% (compared to 25% with
standard prostheses and hemi-arthroplasties), and a single patient
had required revision surgery for loosening. In theory, constrained
cups allow 122◦ of mobility with a 28-mm head. Their efficacy in
the treatment of THA dislocation has not been assessed.
In a case-series study by Berend et al. [2] of 755 constrained cups
(usually implanted during revision surgery), the outcomes were
unsatisfactory, with 5- and 10-year prosthesis survival rates of only
68.5 and 51.7%, respectively, and a dislocation rate of 17.5% overall
 J.-L. Charissoux et al. / Orthopaedics & Traumatology: Surgery & Research 100 (2014) S25–S34
Fig. 6. Complete lip augmentation device in a left total hip arthroplasty.
Fig. 7. A. Constrained cup. B. The mechanism.
With permission from Lepine Inc.
S29
and 28.9% after revision for recurrent dislocation; in addition, cup
and femoral head loosening occurred in some patients. Outcomes
were substantially better with a cup allowing for 110◦ of mobility
before contact with the neck, which provided a success rate of 11/12
(92%) in patients with recurrent dislocation, but with a follow-up
of one year. Noble et al. [32] examined 57 constrained cups of four
different designs recovered during THA revision surgery performed
36 months on average after the primary procedure. Locking ring
failure explained 51% of revisions and cup loosening a further 28%.
Similar to Berend et al. [2], the authors concluded that constrained
cups cannot ensure long-term stability unless the range of motion
before neck impingement can be increased.
4.4. Tripolar constrained cups
Tripolar constrained cups, which are used in the US, comprise a
mobile cup that articulates with a polyethylene cup equipped with
a locking ring (Fig. 8). The constrained cup can be inserted into a
cementless metal cup or secured to the acetabulum itself or, more
rarely, placed into a securely fixed metal cup. The decreased thick-
ness required by this design may be associated with diminished
survival.
In a prospective study conducted by Khan et al. [33] in 34
patients, 97% of hips were stable after 3 years but 11.8% showed
evidence of cup loosening. The Trident (Stryker® ) constrained cup
used in this study, usually without cement, allows for only 88◦ of
prosthetic clearance.
Guyen et al. [34] studied 389 hips with tripolar constrained cups
(Osteonics® ) and a mean follow-up of 28.4 months. The overall
S30 J.-L. Charissoux et al. / Orthopaedics & Traumatology: Surgery & Research 100 (2014) S25–S34
Fig. 8. Tripolar constrained cup.
Permission requested from J Bone Joint Surg Am.
failure rate was 11% and the mechanical failure rate was 8%, with
involvement of the various cup interfaces or of the locking ring.
These authors felt that the failure rate was underestimated, as some
patients with failed prostheses had satisfactory hip function.
Tripolar constrained cups should be reserved for salvage surgery
in the most difficult cases.
4.5. Unconstrained tripolar cups
The principle of the unconstrained tripolar cup was developed
by Bousquet (Fig. 9) then used by many different manufacturers.
A 22- or 28-mm head is held captive in a polyethylene cup, which
is mobile within a cemented or press-fit metal cup made of steel
or cobalt-chromium (Fig. 10). Either standard or highly reticulated
Fig. 9. Dual-mobility cup.
With permission from Tornier Inc.
Fig. 10. Dual-mobility cup made of cobalt-chromium.
With permission from SEM Inc.
polyethylene is used, and the head can be made of ceramic. The
intermediate component is made of ceramic in some models.
Outcomes after the implantation of dual-mobility cups for THA
instability have been evaluated in numerous studies, of which the
earliest was conducted by Leclercq et al. [35]. After 2.5 years of
follow-up, 13 hips with recurrent dislocation were stabilised with-
out correction of the causes of the instability. Mertl et al. [36]
studied 59 cases and found a 1.7% recurrence rate and a 98% 8-
years survival rate. In 54 cases, Guyen et al. [37] reported a 5.5%
recurrence rate after a mean follow-up of 4 years and in 47 cases
Hamadouche et al. [38] recorded a 4% recurrence rate after 6 years.
Dual-mobility cups are now very widely used to prevent insta-
bility after revision THA. In a prospective study of 2107 revision
THAs including 62% with dual-mobility cups, Delaunay et al. [39]
found a 3-month dislocation rate of only 4%.
Enthusiasm about these very good results must be tempered
by knowledge of the fixation problems seen with press-fit dual-
mobility cups. Massin et al. [40] found a lower 8-year survival
rate of press-fit grit-blasted cups made of hydroxyapatite-coated
steel, compared to the original tripod cup and to cobalt-chromium
cups (91% versus 98% and 100%, respectively). Mertl et al. [36] have
recommended cups with hydroxyapatite surface treatment over a
porous metallic substrate.
Finally, the deeper concavity of dual-mobility cups is associated
with greater wear [23], which carries a risk of intra-prosthetic dislo-
cation due to locking system failure. Mean time to intra-prosthetic
dislocation is 10 years. The risk of this complication can be minimi-
sed by avoiding neck-cup impingement and is extremely low with
the newest generation implants [23,40]. Nevertheless, even with
the original tripod cup, 15-year survival rates were greater than
85% in the long-term studies by Philippot et al. [41] and Lautridou
et al. [42], each of which included more than 400 cases.
4.6. Large-diameter femoral heads
As indicated above, large-diameter heads are associated with
decreased dislocation rates [8,21–23] and are therefore useful for
the treatment of THA instability (Fig. 11). For a given neck diame-
ter, stability increases with the diameter of the femoral head up to
38 mm; with larger diameters, variable results have been reported
[43].
In a study by Amstutz et al. [44] of 29 THA revisions for dis-
location managed with head diameters of 36 mm or more, the
recurrence rate was 13.7%. Suboptimal cup orientation was noted
 J.-L. Charissoux et al. / Orthopaedics & Traumatology: Surgery & Research 100 (2014) S25–S34 S31

Fig. 11. Large-diameter heads. Top row: metal; bottom row: Ceramic (Biolox). Fig. 12. Removable cones.
With permission from Tornier Inc.
With permission from Amplitude Inc.

in the six hips with persistent instability; after correction of cup

position, none of the hips was unstable after a mean follow-up of • capsular plication, trans-osseous soft tissue repair, or even plas-
5.5 years. ties involving the implantation of allografts or a mesh to generate
Several studies found markedly lower dislocation rates after fibrosis, which may be useful in patients with severe soft tissue
revision THA for reasons other than instability: 1.8% [44], 4.9% [25], deficiency [2];
and 1.1% with 36- or 40-mm heads versus 8.7% with 32-mm heads • lowering of the greater trochanter (by 18 ± 6 mm), which can be
after a mean follow-up of 5 years [45]. very helpful in stabilising the THA by re-tensioning the abductor
Most of the available studies focussed on the impact of large muscles and increasing their lever arm, provided the components
head diameter on primary THA stability and wear debris volume. are properly positioned. Hook plates facilitate the procedure
They used various friction couples for which the medium- and (Fig. 13). Nevertheless, non-union can occur. In an analysis of four
long-term outcomes are unclear. With metal and either standard published case-series, Morrey [29] found a 73% success rate (54
or highly reticulated polyethylene, volumetric wear increased, par- of 74 hips);
ticularly with heads larger than 36 mm in diameter [36], whereas • treatment of greater trochanter non-union is crucial to ensure
linear wear was unchanged. However, Hammerberg et al. [46] stability and function. However, healing may be difficult to
reported that the annual volumetric wear rate, although increased obtain, despite the availability of improved internal fixation
2-fold with head diameters of 38 and 44 mm, remained far devices and the use of bone grafts. Factors that can compro-
below the values associated with osteolysis (29.1 ± 14.8 versus mise healing include gluteus medius and minimus contracture,
80 mm3 /year). which is a common abnormality; fragility of the trochanteric frag-
Using metal-on-metal implants, Mertl et al. [47] obtained good ment; loss of bone from the lateral metaphysis; and the high
30-month outcomes with dislocation (due to trauma) in only 1.8% loads placed on the fixation. After the procedure, weight-bearing
of 106 patients. Nevertheless, unexplained pain was noted in 4.7%
of patients. Bosker et al. [48] reported a high pseudo-tumour for-
mation rate of 39% in a series of 108 hips, with a 12% revision rate,
and identified adverse reaction to metal debris as the main cause.
Ceramic-on-ceramic implants release very few wear particles,
which are extremely well tolerated. Nevertheless, heads greater
than 36 mm in diameter require a decrease in liner thickness, which
increases the risk of rupture. In addition, even with composite
ceramics, a number of problems persist, such as squeaking; sub-
luxation during hip movements responsible for micro-separation
and edge-loading, which in turn may cause fractures; and increased
loading at the bone-cup interface due to eccentric positioning of the
head centre, which can result in cup tilting [23].

4.7. Restoration of soft tissue tension and elimination of

impingements

These procedures are consistently used in combination with the

above-described techniques:

• restoration of the femoral offset, which is easier to achieve using

modular implants, at the cost of an increase in the number of
interfaces (Fig. 12);
• restoration of lower limb length after a careful pre-operative eval-
uation;
• elimination of impingements, which should be looked for
routinely and are already minimised by the above-described pro- Fig. 13. Hooks for fixation of the greater trochanter.
cedures; With permission from Zimmer Inc.
S32 J.-L. Charissoux et al. / Orthopaedics & Traumatology: Surgery & Research 100 (2014) S25–S34
Fig. 14. Internal fixation of greater trochanter non-union.
ambulation is allowed with two forearm crutches for 4 months
[4] (Fig. 14).
4.8. Post-operative immobilisation
Post-operative immobilisation regimens vary widely. The goal
is to promote soft tissue healing. Post-operative immobilisation is
less often used after revision THA than after closed reduction.
Available methods include suspension traction, a pantaloon or
hemi-pantaloon cast made of resin (or with a removable version),
an abduction pad, and a knee brace.
Many groups recommend immediate ambulation and rehabil-
itation using appropriate methods after revision surgery for THA
dislocation [3,21,22,39]. Others advocate tailoring the immobilisa-
tion regimen based on a number of criteria such as the surgical
approach and patient-related factors [49].
5. Indications [2,4,26,28,47,49]
Surgical treatment for THA instability is usually considered after
the second or even the third dislocation episode, in patients with-
out obvious component malposition, failed closed reduction, or
significant greater trochanter displacement.
5.1. Cup malposition, wear, or loosening
In a patient who is younger than 70 years of age and has no
risk factors, the cup should be changed and properly positioned. If
allowed by the implants, the head diameter should be increased. In
cases of isolated wear, a change of liner, with a preference for an
elevated lip design, deserves consideration.
In patients who are older than 70 years and/or have risk factors
for instability (multiple surgical procedures or neurological impair-
ments for instance), a dual-mobility cup seems the best solution.
A constrained cup may be considered, particularly in the oldest
patients.
Brogan et al. [50] has described a technique involving milling of
a well-fixed polyethylene cup with preservation of the cement, in
which holes are made for fixation of the new cup. This technique
spares the bone stock and decreases the invasiveness of the revision
procedure. Similarly, in patients who have a well-fixed cementless
cup, a polyethylene cup can be cemented in the appropriate posi-
tion. The 5-year survival rate with this method was 78% in a study
by Beaulé et al. [51].
5.2. Appropriate cup position with no wear or loosening and no
femoral cause of dislocation
With a cementless cup, the liner can be exchanged for an
elevated-lip liner and the head diameter can be increased if allowed
by the implants. With a cemented cup, a lip augmentation device
can be considered. In young patients, however, a change of cup with
an increase in head diameter seems preferable.
A dual-mobility cup can be considered also, chiefly in patients
older than 60 years of age.
5.3. Femoral cause of THA dislocation
In the event of inadequate femoral offset or excessive antever-
sion or retroversion, replacement of the femoral component should
be considered.
A lateralised component or a component with a greater degree
of varus is usually required to restore offset. A less invasive means of
restoring offset consists in changing the length of the neck and/or
the diameter of the head (if the cup liner can be changed); care
should be taken, however, to avoid excessive lengthening of the
lower limb.
When the primary THA includes a removable neck, this com-
ponent alone can be changed, and it length and orientation can be
modified. When changing a femoral component, the use of a remov-
able neck design can be considered to optimise anteversion, offset,
and neck length.
The stem should be changed if it is loose or unstable.
5.4. Soft tissue repair
The soft tissues must always be repaired to the extent possible.
In addition to the above-described procedures, suturing the fascia
lata to the greater trochanter and vastus lateralis muscle with the
hip in abduction is useful.
A fracture or non-union of the greater trochanter should be
treated.
When no cause is identified, lowering of the greater trochanter
can be considered but carries a risk of non-union.
5.5. Immobilisation
Immobilisation can be helpful in patients with severe soft tissue
alterations or with factors such as agitation or poor motor coordi-
nation.
6. Conclusion
Recurrent dislocation after THA is difficult to treat and poses a
major challenge to surgeons. Although most cases are multifacto-
rial, every effort should be made to identify a predominant cause,
whose treatment will provide an optimal outcome.
When the need for surgical treatment has been established
based on a comprehensive evaluation of the instability, the sur-
geon must make sure that all the material needed is available and
 J.-L. Charissoux et al. / Orthopaedics & Traumatology: Surgery & Research 100 (2014) S25–S34
appropriate for the current prosthesis. Implant exchange is usually
needed and is more often partial than complete. The decision rests
on the pre-operative data and findings at revision surgery. Even
when an apparent cause is identified, there should be no hesita-
tion in combining several stabilising procedures, such as a change
in cup position, the use of a larger femoral head if allowed by the
implants, correction of inadequate femoral offset, and anteversion
optimisation. Soft tissue repair should be performed routinely.
The objective is to avoid further dislocation, a devastating event
whose frequency increases with the number of surgeries on the hip.
Prevention remains the best treatment.
Disclosure of interest
The authors declare that they have no conflicts of interest con-
cerning this article.
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