DISLOCATION

A COMPARATIVE AND

OF
STUDY AUGMENTED

TOTAL
OF STANDARD,

HIP

REPLACEMENTS
LONG POSTERIOR WALL

ACETABULAR

COMPONENTS

RICHARD

M.

NICHOLAS,

JOHN

F.

ORR,

RAYMOND

A.

B.

MOLLAN,

JAMES

W.

CALDERWOOD,

JAMES

R. NIXON,

PETER

WATSON

From

Queens

University

and

Musgrave

Park

Hospital,

Belfast

Augmentation

of the acetabular

component We report to dislocate

of total

hip replacements

is a method

of increasing

stability

and preventing recurrent dislocation. turning moments and angles required prostheses.

a series of mechanical experiments designed to evaluate the standard, long posterior wall and two different augmented

Dislocation

following

total

hip

replacement

is a serious

complication for both patient and surgeon. The incidence of dislocation has ranged from less than 1% to 8% (Bergstrom et al 1973; Charnley and Cupic 1973; Coventry et al 1974 ; Fraser and Wroblewski 1981 ; Khan, Brakenbury and Reynolds 1981 ; Dorr et al 1983). Many factors are involved ; they may act independently or may summate and have been discussed by many authors. Previous operations or injuries at the hip may have disrupted the soft tissues around the arthroplasty (Carlsson and Gentz 1977; Lewinnek Ct al 1978; Fackler and Poss l90; Woo and Morrey 1982; Dorr et al 1983). Woo and Morrey (1982) showed that a posterior surgical approach was associated with an increased dislocation rate. have Acetabular both been of and femoral shown to be component important malposition factors. Retromay be at operation. femoral due to Too

Internal rotation the femoral component acetabular component causing has Fluid been

of the femur causing to contact the anterior may result in a lever

the

neck of rim of the arm action,

posterior dislocation (Coventry et al 1974). collection within the pseudocapsule of the hip implicated (Ritter 1980), while mental and disturbances can contribute. a higher 1980) primary 1982). hip flexion complication (Khan et Revision rate al 1981) surgery such as is associAndersson

neurological Parkinsonism ated with and Herberts (20%) than and Mallory increasing

(Ahnfelt,

and a much higher dislocation rate replacement (Williams, G#{246}ttesman Coventry et al (1974) suggested that due to a gradual stretching of the by hip 1983; but was

pseudocapsule could account for late dislocations. Management of recurrent dislocation. Treatment brace has been described (Clayton and Thirupathi Dorr et al 1983) for recurrent instability

version inadequate much both

the acetabular component positioning of the patient little the anteversion likelihood of the of instability

or too increase

component on movement
;

satisfactory only in selected cases. Williams et al (1982) described a six week period of immobilisation in an above knee hip spica after open or closed reduction ; they had success in 1 5 of 16 selected cases. The design of a standard Charnley prosthesis prevents dislocation by any uniaxial load, unless the neck of the margin femoral (Fig. component 1). In theory, impinges on the acetabular the larger the head of the

of the hip (Lewinnek et al 1978; Khan and Morrey 1982; Dorr et al 1983).

et al 1981

Woo

R. M. Nicholas, J. F. Orr, PhD, R. A. B. Mollan,

BDS, CEng, MD,

MB BCh, BAO, Senior House Officer MIMechE, Senior Bioengineer FRCS, FRCSI, Professor of Orthopaedics

J. W. Calderwood, FRCS, Consultant Orthopaedic Surgeon J. R. Nixon, MCh(Orth), FRCS, Consultant Orthopaedic Surgeon
P. Watson, Musgrave Correspondence PhD, AMIMechE, Affiliate ASME, Research Fellow Park Hospital, Belfast BT9 7JB, Northern Ireland. should be sent to Dr R. M. Nicholas. Joint Surgery

femoral should moved

component the more stable the hip replacement be, since dislocation would require the head to be through a greater distance. Woo and Morrey that this of femoral can factor head was of less importance diameter to neck width. either by augmenting the the distance through before dislocating, or thus removing

(1982) showed than the ratio Dislocations

be prevented

1990

British Editorial Society of Bone and 0301-620X/90/3075 $2.00 JBonefointSurgfBr] 1990; 72-B: 418-22.

acetabular component, which the femoral head by increasing the range

to increase must move of free

movement,

418

THE

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SURGERY

DISLOCATION

OF TOTAL

HIP

REPLACEMENTS

419

the points example, gutter

of impingement. by narrowing

the

This could be achieved, femoral neck or cutting described augmenta-

for a

component, have used

and Watson a metal-backed

et al (personal augmentation

communication) device in three ignored

in the acetabular cup. Olerud and Karlstr#{246}m (1985)

patients. Previous studies the consequent restriction

of augmentation have in range of movement.

tion of the acetabular another identical with two or three further dislocations though opposite one oftheir direction.

component, using a sector cut from acetabular component, and secured cortical screws. They reported no in the augmented region of the cup patients sustained a dislocation is a relatively arthroplasty recurrent 1985). Gie, in the simple with dislocation Mogensen, its We Augmentation

MATERIALS

AND

METHODS

turning

designed a machine moments and long posterior

in which angles wall and

we could required augmented

measure the to dislocate total hip

technique in comparison to revision high incidence (33% to 44%) of (Woo and Morrey 1982; Coventry Arnason (1989) and J#{243}nsson (1986), and have described augmentation

standard,

Scott and Ling of the acetabular

replacements (inverted cup and metal backed). A compression testing machine simulated joint loading of 300 N to the articulated prostheses. This load was chosen for convenience and represented the weight of the compression testing machine anvil. A head, with the standard Charnley neck) placed testing femoral prosthesis (22 mm standard the neck compression was mounted in a fixed position vertically in the axis of loading of machine. A standard Charnley diameter) was a tight-fitting

acetabular mounted

component (47 mm outside in an aluminium block using

Secondary

Impjngement

Fig. Diagram cation. showing the mechanism

1 of impingement leading to dislo-

nylon retaining collar (Fig. 2). The block was then mounted using 0.5 inch diameter steel stub-axles between a pair of radial ball bearings whose axis of rotation coincided with the centre of the acetabular prosthesis. This assembly was therefore free to rotate around the centre of rotation ofthe static femoral head under turning moments wheel. minimise inaccuracy dislocation. A spring The applied entire lateral and by means apparatus loading to cope was of an aluminium was placed on caused with attached by any displacements loading rollers to machining during wheel

balance

to the loading

so that the turning moment applied to the cup could be calculated. Attached to the loading wheel was a 360#{176} protractor to measure angles and ranges of movement. Primary impingement occurred when the neck contacted Secondary the femoral of the nents the inner impingement component margin (P1) was of the femoral (SI) occurred first contacted deemed to component component. neck of margin when the the outer have first

of the acetabular

acetabular remained made

component (Fig. in full engagement the components turning were

1). The joint compountil secondary unstable moments recorded. dislocations could have : sudden at primary

impingement

dislocation followed. The and secondary impingement Experimental dislocations. 1) Repeated may damage dislocation. the inner

Repeated face. This

of a cup given an

erroneous turning moment on subsequent dislocations. A standard acetabular component was therefore dislocated in the apparatus 18 times in succession, noting the
Fig. The compression standard acetabular test machine components. 2 showing femoral and

turning moment at which dislocation occurred. The angles of primary and secondary impingement and the range of movement before and after the series of dislocations were also noted.

VOL.

72-B,

No.

3, MAY

1990

420

R. M. NICHOLAS,

J. F. ORR.

R. A. B. MOLLAN,

J. W. CALDERWOOD,

J. R. NIXON,

P. WATSON

2) Standard acetabular component. Five new standard cups were dislocated once each, noting the angles of primary and secondary impingement, the range of movement and the turning moment to dislocation.
3) Long posterior wall cups were primary movement femoral containing and stall component. dislocated once secondary turning always Five new long posterior each, noting the angles of the range of to dislocation. out of the The sector

regression, the line of best fit had the equation Y = 0.0003 X + 0.229. The gradient of 0.0003 is therefore virtually horizontal up to 1 8 dislocations. However the range ofdata points were large (0.22 to 0.26 Nm) and the correlation Before the this seem became coefficient experiment,
-

(R) the but

of the line was range of movement of only some wear after

.

only was was

0.179. 88#{176}; not noted

impingement, moment dislocated

89#{176} increase an component

1 1%. This faceting

did

and the head was the wall.

to be significant,

on the acetabular

multiple

dislocations.

o5:
E z
C a,

-,

Consecutive
I

dislocations

of one

component

//

0245 \1stlrtippingement 0.24 0.235 0.23 O.225 0.22 1 2 3 4 5 6 7 8 9 10 11 12 13 14 number 15 16 1718

\\
/1

//

E
0

\ /\
\\
#{149} .

/\
I

E a)
C C I-

/
\., /

\
\\\\

2nd Impingement
/

\
/

\__.

\\

,/

II

Fig.

Dislocation

The methods of augmentation used with the inverted cup method (left) and the metal-backed UHMW polyethylene device (right). These are both shown mounted on long posterior wall components.

Fig. Repeated dislocation of the same

4 standard acetabular component.

4) Augmented posterior wall

acetabular component. cups had cup augmentation

Five new long in the manner

Table

I. Mean angles impingement in degrees Long posterior wall 7 6 5 6 6

between primary in five specimens

and

secondary

of Olerud and Karlstr#{246}m (1985). Three AO cortical screws were used (Fig. 3). Each augmented cup was dislocated once, noting the angles of primary and secondary impingement, the range of movement and the turning were only moment used be used because with this to dislocation. the type Long of component. posterior procedure wall cups could augmentation

Standard acetabular component 12 11 10 11

11

Inverted cup augmentation 4 7 7 7 6

Metal-backed augmentation Secondary impingement not obtained

5) Metal-backed UHM W polyethylene augmented acetabular component. A standard cup was augmented using this device. Five AO screws were used to secure the device to the cup (Fig. 3). Even when the apparatus was loaded to the maximum turning moment dislocation did not occur. Therefore only the angles to primary impingement and the range of movement were noted. Secondary impingement could not be achieved. are RESULTS The effect ofrepeateddislocation on acetabular component to dislocate number of to linear

The ranges shown in

ofmovement Figure 5. noted

allowed by all the prostheses The largest mean range for the standard acetabular had a mean cup allowed

of

movement

(106.2#{176}) as w

prosthesis. The long range of movement only

posterior wall prosthesis of 95#{176}, augmented the

are shown in Figure the prosthesis did dislocations. When

4: the turning moment not decrease with the the data were subjected

68.8#{176} the metal-backed and The angles between primary ment are shown in Table I ; they
THE JOURNAL

device 67#{176}. and secondary impingewere virtually the same

AND JOINT SURGERY

OF BONE

DISLOCATION

OF TOTAL

HIP

REPLACEMENTS

421

for each prosthesis.

of

the five The mean

samples tested turningmoments

from each type of required to produce

40%. This restriction authors to provide Karlstr#{246}m 1985; The turning posterior those for wall the

of range increased

was believed by stability (Olerud

other and a long than be

primary and secondary 6. That for secondary wall prostheses (0.34 augmented cup devices UHMW polyethylene be dislocated.

impingement are shown in Figure impingement in the long posterior Nm) was greater than that in the (0.29 Nm). The metal-backed could not augmentation devices

Mogensen moments prosthesis

et al 1986). required to dislocate were, cup. surprisingly, No explanation higher

augmented but it indicated any additional and

could

found for this, not providing ing reports

that the augmentation was stability despite encourag;

(Olerud

Karlstr#{246}m 1985

Gie

at al 1988).

The inability to dislocate polyethylene augmentation

110 100
-

the metal-backed UHMW device in the mechanical jig

.--

90
80 70
C) .

showed that this system However, it also suggested loading in vivo (possibly movement) such a rigid the cement fixation and/or device. the /
,/

provided the greatest stability. that in a situation of extreme caused by the restriction in system could lead to failure of fracture ofthe screws locating

a, a, 0) a, 0 a, 0) C

60;
50 40

augmentation

30
20

o45T
0 .4 0.35
. --...

-----

-.--.

2nd Impingement 1st Impingement

.

io;
0
.

I Long posterior wall

...T:_

Standard acetabular component

Inverted cup augmentation device

Metal-backed UHMW polyethylene augmentation device

E z

0.3.

I I
. . . . . . ...,

r
.

0.25 0.2
.

E 0)0.15
C C

. .

. . .

Fig. Mean range of movement

5 of all prostheses.

0.1.
I.

.
.

0.05k 0..--...

:
.

:
..
I.--

I
Long posterior

.-

Standard acetabular component

wall

Inverted cup augmentation device

Metal-backed

UHMW
polyethylene augmentation device

Clinical

results.

We

have

used

acetabular total

augmentation All hip replacethree had position.

Mean turning impingement. moments required Fig. 6 to produce primary

for three patients ments with well posterior After further tated dislocation reduction dislocations by minor

who had Charnley aligned components. in falls under general (four, two trauma. from

a standing

and

secondary

anaesthesia they had and three times) precipiprocedures were

Augmentation

performed, which was with three sustained

sectioning a long posterior wall prosthesis then secured to the acetabular component cortical further screws. dislocations. None of these patients have

Augmentation has a role in the management of recurrent dislocation of total hip arthroplasties, since it involves a shorter operation time, a smaller incision, less soft-tissue damage These advantages and would no disruption clearly be of most hard tissues. beneficial in

DISCUSSION Multiple that the dislocation. dislocations number did This of the same not significantly but component affect clinically showed the ease of there is an initial rather

elderly tation with modular

and infirm device has both standard in design,

patients. The an advantage and which different long means sizes

metal-backed augmenin that it may be used wall cost cups. and It is also flexibility low

posterior

is reassuring,

increased risk of recurrent event. This is probably due than

dislocation to soft tissue

after the disruption

in accommodating

of cup.

wear of the prosthesis. The ranges of movement allowed by the augmentation devices were significantly lower than those of standard and long posterior wall prostheses, by almost
VOL. 72-B, No. 3, MAY 1990

We would like to thank Mr V. Rimmer of Chas. F. Thackray Ltd. for providing materials which were used in this study. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

422

R. M. NICHOLAS,

J. F. ORR,

R. A. B. MOLLAN,

J. W. CALDERWOOD,

J. R. NIXON,

P. WATSON

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