Otto Aufranc Award: Dual-mobility Constructs in Revision THA Reduced Dislocation, Rerevision, and Reoperation Compared With Large Femoral Heads

Abstract

Background: Dislocation is one of the most common complications after revision THA. Dual-mobility constructs and large femoral heads (ie, 40 mm) are two contemporary, nonconstrained bearing options used in revision THA to minimize the risk of dislocation; however, it is not currently established if there is a clear benefit to using dual-mobility constructs over large femoral heads in the revision setting.

Questions/purposes: We sought to determine if dual-mobility constructs would provide a reduction in dislocation, rerevision for dislocation, and reoperation or other complications as compared with large femoral heads in revision THA.

Methods: From 2011 to 2014, a series of 355 THAs underwent revision for any reason and received either a dual-mobility construct (146 THAs) or a 40-mm large femoral head (209 THAs). Indications for either construct were based on surgeon judgment; however, there is a preference to use dual-mobility constructs in patients believed to be at higher risk of dislocation. In the dual-mobility group, 20 of 146 (14%) were excluded because of loss of followup before 2 years or because they had a dual-mobility shell cemented into a preexisting acetabular component. In the large head group, 33 of 209 (16%) were lost to followup before 2 years. Followup in the dual-mobility group was 3.3 ± 0.8 years and followup in the large head group was 3.9 ± 0.9 years. Primary endpoints included dislocation, rerevisions for dislocation, and reoperations, which were determined through our institution's total joint registry and verified by individual patient chart review. Age and body mass index were not different with the numbers available between the groups, but there was a slight predominance of females in the dual-mobility group (52% [66 of 126] female) versus the 40-mm large head group (41% [72 of 176] female) (p = 0.05). Notably, 33% (41 of 126) of patients receiving the dual-mobility constructs had the index revision THA done for a diagnosis of recurrent dislocation versus 9% (17 of 176) in the 40-mm large head group. Mean effective head size in the dual-mobility group was 47 mm (range, 38-58 mm).

Results: The subsequent frequency of dislocation in the dual-mobility construct group was less (3% [four of 126] dual-mobility versus 10% [17 of 176] in the 40-mm large head group; hazard ratio, 3.2 [1.1-9.4]; p = 0.03). Rerevision for dislocation in the dual-mobility construct group was less frequent (1% [one of 126] dual-mobility versus 6% [10 of 176] in the 40-mm large head group; hazard ratio, 7.1 [0.9-55.6]; p = 0.03). Reoperation for any cause in the dual-mobility construct group was less frequent (6% [eight of 126] dual-mobility versus 15% [27 of 176] in the 40-mm large head group; hazard ratio, 2.5 [1.1-5.5]; p = 0.02); there were no differences between the groups in terms of the overall percentage of complications in each group.

Conclusions: When compared with patients treated with a 40-mm large femoral head, patients undergoing revision THA who received a dual-mobility construct had a lower risk of subsequent dislocation, rerevision for dislocation, and reoperation for any reason in the first several years postoperatively. Those findings were present despite selection bias in this study to use the dual-mobility construct in patients at the highest risk for subsequent dislocation. Given the lower risk of subsequent dislocation, rerevision, and reoperation with the dual-mobility construct, some surgeons may wish to consider whether the role of dual-mobility should be judiciously expanded in contemporary revision THA.

Level of evidence: Level III, therapeutic study.

Fig. 1

Survival free of dislocation is demonstrated. The majority of dislocations occurred within the first year of rerevision.

Fig. 2

Survivorship free of rerevision is demonstrated for both groups. In the dual-mobility group, rerevision occurred early and then plateaued, whereas the larger femoral head group showed decreased survivorship over time out to 4 years.

Fig. 3

Survivorship free of reoperation for any reason is shown. Both groups underwent the majority of reoperations within the first year after surgery. Likewise, after the first year, both continue to have gradually decreased survivorship out to 4 years.