JBJS | Jumbo Femoral Head for the Treatment of Recurrent Dislocation Following Total Hip Replacement

The Journal of Bone & Joint Surgery, Volume 84, Issue 2

Scientific Article | February 01, 2002

Jumbo Femoral Head for the Treatment of Recurrent Dislocation Following Total Hip Replacement

Paul E. Beaulé, MD, FRCSC; Thomas P. Schmalzried, MD; Pacharapol Udomkiat, MD; Harlan C. Amstutz, MD

Investigation performed at the Joint Replacement Institute at Orthopaedic Hospital, Los Angeles, California

Paul E. Beaulé, MD, FRCSC
Thomas P. Schmalzried, MD
Pacharapol Udomkiat, MD
Harlan C. Amstutz, MD
Joint Replacement Institute at Orthopaedic Hospital, 2400 South Flower Street, Los Angeles, CA 90007

In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from Los Angeles Orthopaedic Hospital Foundation. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

The Journal of Bone & Joint Surgery. 2002; 84:256-263

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Abstract

Background: The purpose of this study was to assess the results of the use of a jumbo femoral head to restore stability in hips that had sustained recurrent dislocations after total hip replacement.

Methods: Twelve hips in twelve patients who had had multiple hip operations and recurrent instability of the hip underwent a total hip replacement with use of a femoral head with an average diameter of 44 mm (range, 40 to 50 mm). The average age of the patients was fifty-nine years (range, twenty-nine to eighty-four years). The twelve patients had had an average of four previous operations (range, one to eight operations) and seven dislocations (range, two to twenty dislocations). A bipolar head was used in ten hips that had a femoral stem with a fixed (non-modular) head, and a modular head (unipolar) was used in two hips. (One hip was first treated with a bipolar head and then with a unipolar head.)

Results: One patient died of unrelated causes fourteen months postoperatively. The hip had remained stable until the time of death. After an average duration of follow-up of 6.5 years (range, 3.2 to 11.8 years), ten of the remaining eleven hips had had no additional episodes of instability. One hip dislocated within one week after the revision, necessitating revision surgery to reposition the acetabular component. This hip was found to be stable at the time of follow-up 7.6 years after the revision. There were four other reoperations: one was done because of a fracture of the polyethylene; one, because of entrapment of cement within the articulation; one, because of pain related to loosening of the femoral stem; and one, because of late hematogenous infection. The preoperative and postoperative University of California at Los Angeles hip scores for the series were, respectively, 7 and 9 points for pain, 5 and 7 points for walking, 4 and 6 points for function, and 3 and 5 points for activity.

Conclusions: A jumbo-diameter femoral head provided stability and improved function without compromising range of motion in patients with recurrent dislocations following total hip arthroplasty.

Figures in this Article

Introduction

Introduction | Materials and Methods | Results | Discussion | References

Except for aseptic loosening, dislocation is the most common cause for a reoperation after total hip replacement^1,2. The incidence of dislocation is increased following revision surgery (reported rates, 9% to 21%^2-4). Furthermore, 16% to 59% of patients with dislocation have recurrent dislocations^2,3,5-8. Although numerous surgical and nonsurgical methods have been described for treating dislocation after total hip replacement^5,8-17, no single method has been uniformly successful.

The use of a constrained acetabular liner in total hip replacement has become popular for patients who are at high risk for dislocation because of intraoperative instability or the absence of abductor function as well as for the salvage of hips with recurrent dislocations^9,12,18-20. However, use of these components restricts the range of motion because of impingement of the femoral neck on the polyethylene liner, and there is a possibility of dissociation of the components requiring subsequent reoperation^13,18.

Another approach to the treatment of recurrent instability is the use of a jumbo-size (>39-mm) femoral head to restore joint stability^21,22. Increasing the diameter of the head has two advantages: (1) the range of motion prior to impingement of the femoral neck on the acetabular component increases as the ratio of the head diameter to the neck diameter increases, and (2) since the depth of a hemispherical acetabular liner is equal to the radius of the femoral head, the latter must be displaced by a distance equal to its radius before the hip can dislocate. Additionally, the larger head in combination with a thin-walled socket enhances capsular stability.

The objective of this study was to review the midterm results of patients in whom recurrent dislocations after total hip replacement had been treated with a jumbo femoral head.

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Fig. 1-A:: Figs. 1-A and 1-B Case 2. Fig. 1-A Anteroposterior pelvic radiograph made one day before revision surgery in a twenty-nine-year-old woman with recurrent dislocation of a Charnley 22-mm femoral head from a Harris-Galante acetabular component. Note the area of osteolysis adjacent to the distal margin of the acetabular component.

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Fig. 1-B:: Anteroposterior radiograph of the pelvis, made ten years after revision with a bipolar component (outside diameter, 47 mm; inside diameter, 28 mm), showing no evidence of progressive osteolysis around either component. No more dislocations occurred after the surgery.

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Fig. 2-A:: Figs. 2-A through 2-D Case 9. Fig. 2-A Anteroposterior radiograph made prior to revision surgery performed because of a failure of the acetabular component of a right total hip replacement in a thirty-seven-year-old patient.

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Fig. 2-B:: Fig. 2-B Anteroposterior radiograph made after the revision. Two months later, recurrent instability developed.

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Fig. 2-C:: Fig. 2-C Radiograph made after revision of the acetabular component with a bipolar component (outside diameter, 44 mm; inside diameter, 28 mm). The patient had no more episodes of dislocation, but thigh pain developed.

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Fig. 2-D:: Fig. 2-D Radiograph made seven years after revision of the femoral component with a 44-mm unipolar head. The hip remained stable, and there was no more thigh pain.

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TABLE I: Patient Demographics

*ORIF = Open reduction and internal fixation.

Case	Primary Diagnosis	Previous Operations*	Onset of Instability After Last Operation (mo)	No. of Dislocations	Age at Operation (yr)	Time to Operation with Jumbo Head After First Dislocation (mo)	Recurrence of Dislocation	Reoperations and Complications	Remarks	Follow-up (mo)
?1	Osteoarthritis	Total hip replacement	??1.5	Never reduced	71	?12	None			?72
?2	Posttraumatic osteoarthritis	ORIF, acetabular fracture; ectopic bone excision; surface arthroplasty; exploratory surgery; cemented total hip replacement; shell revision	??1	?3	29	?12	None			141
?3	Osteoarthritis	Total hip replacement; constrained cup; revision total hip replacement; acetabular lip augmentation	??4	20	75	??2	None			?14 (Deceased)
?4	Developmental dysplasia of the hip	Osteotomy; cemented total hip replacement; greater trochanter advancement; cemented revision with eccentric shell	?60	?3	35	?24	None			123
?5	Posttraumatic osteoarthritis	Hip exploration; cup arthroplasty; cemented total hip replacement; cementless revision	?24	?6	42	?24	None	Hematogenous infection requiring resection arthroplasty at 4 yr		?44
?6	Posttraumatic osteoarthritis	Total hip replacement	?12	Never reduced	72	??2	Yes	Redislocation at 1 wk requiring reorientation of both components	Stable at 7.6 yr after revision	?91
?7	Osteonecrosis	Total hip replacement	192	12	62	?24	None			108
?8	Posttraumatic osteoarthritis	Total hip replacement; resection arthroplasty; total hip replacement; 2 revisions within 2 yr; revision with femoral allograft	??6	?7	77	132	None	Femoral loosening requiring revision at 24 mo	Patient doing well at 7 yr after revision	?85
?9	Benign proximal femoral tumor	Hemiarthroplasty; total hip replacement; 2 revisions	??2	?8	46	?72	None			108
10	Posttraumatic osteoarthritis	Bipolar hemiarthroplasty	??2	?2	67	??6	None	Fracture of polyethylene liner at 3.8 yr; exchange of polyethylene liner	Patient doing well at 14 mo after revision	?47
11	Osteoarthritis	Surface arthroplasty; total hip replacement; revision total hip replacement	??2	?3	84	??8?	None	Entrapment of cement within articulation; exploration and exchange of polyethylene liner	Patient doing well at 1 yr after revision	?38
12	Osteonecrosis; systemic lupus erythematosus	Coring; total hip replacement; Girdlestone procedure for infection; total hip replacement; 2 revision total hip replacements for dislocation; 2 incision & drainage procedures for infection; direct exchange	?72	16	51	?38	None			?59
Avg.			?31.5	?7	59	?29.7				?78

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TABLE I: Patient Demographics

*ORIF = Open reduction and internal fixation.

Case	Primary Diagnosis	Previous Operations*	Onset of Instability After Last Operation (mo)	No. of Dislocations	Age at Operation (yr)	Time to Operation with Jumbo Head After First Dislocation (mo)	Recurrence of Dislocation	Reoperations and Complications	Remarks	Follow-up (mo)
?1	Osteoarthritis	Total hip replacement	??1.5	Never reduced	71	?12	None			?72
?2	Posttraumatic osteoarthritis	ORIF, acetabular fracture; ectopic bone excision; surface arthroplasty; exploratory surgery; cemented total hip replacement; shell revision	??1	?3	29	?12	None			141
?3	Osteoarthritis	Total hip replacement; constrained cup; revision total hip replacement; acetabular lip augmentation	??4	20	75	??2	None			?14 (Deceased)
?4	Developmental dysplasia of the hip	Osteotomy; cemented total hip replacement; greater trochanter advancement; cemented revision with eccentric shell	?60	?3	35	?24	None			123
?5	Posttraumatic osteoarthritis	Hip exploration; cup arthroplasty; cemented total hip replacement; cementless revision	?24	?6	42	?24	None	Hematogenous infection requiring resection arthroplasty at 4 yr		?44
?6	Posttraumatic osteoarthritis	Total hip replacement	?12	Never reduced	72	??2	Yes	Redislocation at 1 wk requiring reorientation of both components	Stable at 7.6 yr after revision	?91
?7	Osteonecrosis	Total hip replacement	192	12	62	?24	None			108
?8	Posttraumatic osteoarthritis	Total hip replacement; resection arthroplasty; total hip replacement; 2 revisions within 2 yr; revision with femoral allograft	??6	?7	77	132	None	Femoral loosening requiring revision at 24 mo	Patient doing well at 7 yr after revision	?85
?9	Benign proximal femoral tumor	Hemiarthroplasty; total hip replacement; 2 revisions	??2	?8	46	?72	None			108
10	Posttraumatic osteoarthritis	Bipolar hemiarthroplasty	??2	?2	67	??6	None	Fracture of polyethylene liner at 3.8 yr; exchange of polyethylene liner	Patient doing well at 14 mo after revision	?47
11	Osteoarthritis	Surface arthroplasty; total hip replacement; revision total hip replacement	??2	?3	84	??8?	None	Entrapment of cement within articulation; exploration and exchange of polyethylene liner	Patient doing well at 1 yr after revision	?38
12	Osteonecrosis; systemic lupus erythematosus	Coring; total hip replacement; Girdlestone procedure for infection; total hip replacement; 2 revision total hip replacements for dislocation; 2 incision & drainage procedures for infection; direct exchange	?72	16	51	?38	None			?59
Avg.			?31.5	?7	59	?29.7				?78

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TABLE II: Component Reconstruction at the Time of Insertion of the Jumbo Femoral Head

*Outer diameter/inner diameter. †Patient died. ‡A resection arthroplasty was performed four years after surgery because of hematogenous periprosthetic infection.

Case	Femoral Side at Index Surgery	Acetabular Side at Index Surgery	Comorbidities	Shell Size (mm)	Head Size* (mm)
?1	Left in situ	Cemented metal-backed; cementless revision	No active abduction, contralateral hemipelvectomy	77	47/28
?2	Revised with cementing in preexisting mantle	Loose; cementless revision	Adductor contracture	70	47/28
?3†	Left in situ	Damaged cup; cemented revision (surface arthroplasty component)	Alzheimer disease; no active abduction	70	47/28
?4	Loose; cementless revision	Loose with major bone loss; cemented revision	No active abduction; preexisting ipsilateral dropfoot	66	44/28
?5‡	Left in situ	Loose; cementless revision		72	44/28
?6	Left in situ	Left in situ; liner exchange	No active abduction	68	44/28
?7	Loose; cemented revision	Well fixed with 3 mm of wear; cementless revision		68	44/28
?8	Left in situ	Excessive superolateral wear; cemented revision		66	44/28
?9	1st: left in situ; 2nd: cementless revision	Well fixed but maloriented; cementless revision	No active abduction	64	1st: 44/28; 2nd: 44
10	Left in situ	No previous acetabular component		53	40/22
11	Left in situ	Well-fixed cementless shell left in situ; new liner cemented in (double shell)		55	40/28
12	Cemented revision	Cementless revision	Previous infection	59	50
Avg.				66	44

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TABLE II: Component Reconstruction at the Time of Insertion of the Jumbo Femoral Head

*Outer diameter/inner diameter. †Patient died. ‡A resection arthroplasty was performed four years after surgery because of hematogenous periprosthetic infection.

Case	Femoral Side at Index Surgery	Acetabular Side at Index Surgery	Comorbidities	Shell Size (mm)	Head Size* (mm)
?1	Left in situ	Cemented metal-backed; cementless revision	No active abduction, contralateral hemipelvectomy	77	47/28
?2	Revised with cementing in preexisting mantle	Loose; cementless revision	Adductor contracture	70	47/28
?3†	Left in situ	Damaged cup; cemented revision (surface arthroplasty component)	Alzheimer disease; no active abduction	70	47/28
?4	Loose; cementless revision	Loose with major bone loss; cemented revision	No active abduction; preexisting ipsilateral dropfoot	66	44/28
?5‡	Left in situ	Loose; cementless revision		72	44/28
?6	Left in situ	Left in situ; liner exchange	No active abduction	68	44/28
?7	Loose; cemented revision	Well fixed with 3 mm of wear; cementless revision		68	44/28
?8	Left in situ	Excessive superolateral wear; cemented revision		66	44/28
?9	1st: left in situ; 2nd: cementless revision	Well fixed but maloriented; cementless revision	No active abduction	64	1st: 44/28; 2nd: 44
10	Left in situ	No previous acetabular component		53	40/22
11	Left in situ	Well-fixed cementless shell left in situ; new liner cemented in (double shell)		55	40/28
12	Cemented revision	Cementless revision	Previous infection	59	50
Avg.				66	44

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

From February 1987 to April 1996, twelve hips in twelve patients with recurrent dislocations were treated with revision total hip arthroplasty with a prosthetic femoral head that had a diameter of >39 mm (Table I). The average outside diameter of the femoral head was 44 mm (range, 40 to 50 mm). There were four male and eight female patients. The average age at the index operation was fifty-nine years (range, twenty-nine to eighty-four years). The average number of operations preceding revision with the jumbo head was four (range, one to eight). The average number of previous dislocations was seven (range, two to twenty); two hips (Cases 1 and 6) were never reduced after the initial dislocation. Seven of the twelve patients had additional musculoskeletal problems that contributed to hip instability, such as a lack of active abduction, generalized ligament laxity, and a contralateral hemipelvectomy.

The instability began an average of 31.5 months (median, five months; range, one to 192 months) following the most recent hip operation, and the jumbo femoral head was inserted an average of 29.7 months (range, two to 132 months) after the first dislocation. The direction of the instability, which was determined in five hips, was posterior in three and multidirectional in two. The causes for the dislocation were generally multifactorial. All cases were initially treated by us with closed reduction and physiotherapy or bracing for six weeks. When nonoperative treatment failed, we performed revision surgery.

The average outside diameter of the femoral head was 44 mm (range, 40 to 50 mm). A bipolar femoral head (average outside diameter, 44 mm; inner diameter, 22 or 28 mm) was used in eleven hips with a nonmodular femoral stem (Figs. 1-A and 1-B). Six bipolar heads had a surface bearing of cobalt-chromium alloy (Zimmer, Warsaw, Indiana), and five had a surface bearing of alumina ceramic (Biomet, Warsaw, Indiana). Two jumbo-diameter heads (average outside diameter, 44 and 47 mm) were used with a modular femoral stem. (In Case 9, a bipolar head was used first and then a unipolar head was used [Figs. 2-A, 2-B, 2-C, and 2-D].) Both unipolar bearings were alumina ceramic (Kinamed, Newbury Park, California).

The average outside diameter of the acetabular components was 65 mm (range, 53 to 77 mm). The average ratio of the femoral head to the acetabular shell was 0.67 (range, 0.61 to 0.85).

During the twelve index revisions, ten acetabular shells and four femoral components were revised because of aseptic loosening, infection, or malorientation (Table II). In two hips with a stable well-positioned acetabular shell, the polyethylene liner was changed to accept a jumbo-size head: one was changed to a custom-made liner that locked into the acetabular shell (Case 6), and the other was changed to an older surface arthroplasty liner that was cemented into the pre-existing shell (Case 11). A cementless acetabular component augmented with screw fixation was used in nine hips, and an all-polyethylene cemented cup was used in three. Six metal shells had a wall thickness of 3 to 3.5 mm and a polyethylene thickness of approximately 4 mm (Porous Surface Replacement; DePuy, Warsaw, Indiana). Three other porous-coated metal shells had a wall thickness of 5 mm and a polyethylene thickness of 4 to 7 mm (Anthropometric Total Hip [ATH]; Kinamed). The all-polyethylene cemented shells were from the THARIES surface arthroplasty system (Zimmer) and had a polyethylene thickness of about 5 mm.

The operative approach was transtrochanteric in four hips and posterior in eight. Six patients used an abduction brace for an average of three months (range, 1.5 to six months) postoperatively. The other patients were managed with physical therapy and education regarding positioning of the involved hip. Patients were evaluated postoperatively with the University of California at Los Angeles hip score²³ at four, eight, and sixteen weeks; at one year; and then annually. Patients were specifically asked about episodes of instability or dislocation, including any that were treated elsewhere. Anteroposterior radiographs of the pelvis and a modified table-down lateral radiograph were reviewed specifically for component position and evidence of loosening or osteolysis. Without carefully standardized radiographs, the abduction angle as well as anteversion of the acetabular component can be considered only approximations; these were measured as described by Woo and Morrey⁸.

Results

Introduction | Materials and Methods | Results | Discussion | References

One patient (Case 3) died fourteen months postoperatively of causes unrelated to the hip surgery. The hip, which was stable at the time of death, was excluded from further analysis. At an average of 6.5 years (range, 3.2 to 11.8 years) postoperatively, the other eleven hips were also stable. The average preoperative University of California at Los Angeles hip scores (maximum, 10 points for each category) were 7, 5, 4, and 3 points for pain, walking, function, and activity, respectively. At the last follow-up evaluation, the average scores were 9, 7, 6, and 5 points, respectively (p < 0.05). The postoperative range of motion of the involved hips averaged 115Â° (range, 95Â° to 125Â°) for the flexion arc, 95Â° (range, 65Â° to 130Â°) for the rotation arc, and 70Â° (range, 59Â° to 95Â°) for the abduction-adduction arc.

Five reoperations were performed (Table I); one was done because of dislocation (Case 6); one, because of fracture of the polyethylene (Case 10); one, because of entrapment of the cement within the articulation (Case 11); one, because of pain related to loosening of the femoral stem (Case 8); and one, because of late hematogenous infection (Case 5).

After the index procedure, the angle of the acetabular components averaged 42Â° (range, 30Â° to 52Â°) and anteversion of the acetabular components averaged 9Â° (range, 5Â° of retroversion to 20Â° of anteversion). Although all of the patients had some degree of osteolysis prior to the procedure, it did not affect fixation or any other outcome measure.

Discussion

Introduction | Materials and Methods | Results | Discussion | References

The stability of a larger-diameter femoral head has been recognized since the early 1970s^24,25. A larger femoral head must travel a greater distance before subluxating or dislocating, and a greater range of motion is allowed before the femoral neck impinges on the acetabular component and levers the head from the shell²⁶. A previous finding of a 0.3% prevalence of dislocation after 850 surface arthroplasties with head sizes ranging from 38 to 51 mm (average, 46 mm) supports the use of the jumbo head to treat hip instability²⁷.

Eleven of our twelve patients had late-onset instability²⁸ (at a median of five months and an average of 31.5 months). They had had an average of four previous hip operations and also had musculoskeletal comorbities such as previous infection and lack of active abduction; therefore, they were at high risk for instability²⁹. Following the revision procedure, however, ten of the eleven hips in the living patients had no recurrent dislocations at an average of 6.5 years postoperatively.

The use of a jumbo femoral head is only part of the solution to instability after total hip replacement. Nine of our twelve hips also had reorientation of the acetabular component as part of the revision procedure. However, we believe that the jumbo head played an important role in achieving stability because Daly and Morrey30 reported only a 69% success rate after component reorientation alone for treatment of recurrent instability after total hip replacement. In our series, the jumbo head was successful in all twelve hips (if one hip [Case 6] that dislocated within one week after the revision but subsequently remained stable for 7.6 years after acetabular component reorientation is considered as having had long-term stability).

An initial study of range of motion after total hip replacement by Amstutz et al.24 emphasized the importance of head and neck geometry as well as the head-neck ratio. Kelley et al.31 reported that the outer diameter of the acetabular shell has a significant impact on the prevalence of dislocation. A 28-mm head matched with a shell with an outer diameter of >62 mm had a dislocation rate of 14% compared with a dislocation rate of 4% when the shell size was <60 mm. The head-shell (outside diameter) ratio with a 28-mm head and a 62-mm shell is <0.5. In our series, if a 28-mm head had been used in all hips, the mean head-shell ratio would have been 0.42, as opposed to the 0.67 ratio that we obtained with use of the jumbo femoral head.

The goals of revision surgery for the treatment of recurrent instability include optimizing component position, removing intra-articular and extra-articular sources of femoral-acetabular impingement, and increasing soft-tissue tension (e.g., with trochanteric advancement). In more difficult revisions, a constrained acetabular component has been used. Anderson et al.⁹ reported the results at an average of thirty-one months after twenty-one arthroplasties with the S-ROM constrained shell (Johnson and Johnson, Raynham, Massachusetts); of eighteen patients who had been treated for dislocation, 50% had a poor outcome and 33% had a failure. Goetz et al.¹² reported a 96% success rate at an average of sixty-four months after arthroplasty with the Osteonics (Allendale, New Jersey) constrained shell; recurrent dislocation was an indication for use of the constrained liner in 56% of the hips. Although only 68% of the hips were available for radiographic analysis, there was a 24% prevalence of radiographic loosening. More recently, Parvizi and Morrey³² reported on the use of a bipolar component articulating against the native acetabulum in order to restore hip stability. Use of this component is based on the same principles as is use of the jumbo headæi.e., increasing the head-neck ratio and the distance that the femoral head must travel to dislocate. Stability was achieved in 81% of the twenty-seven hips in that study. However, because the bipolar component articulates directly against the acetabulum, the existing acetabular component must be removed. Also, pain relief is less predictable; 44% of the patients in the study by Parvizi and Morrey had hip pain.

In the present study, four hips required subsequent revision surgery for reasons other than recurrent dislocation. One patient (Case 5 ) required a resection arthroplasty because of late hematogenous infection, and another (Case 8) had a revision because of pain related to loosening of the femoral stem. In another patient (Case 11), large pieces of cement migrated into the articulation and caused the hip to subluxate. At the time of the reoperation, the liner was well fixed and there was some evidence of scratching on the bipolar head. The fourth patient (Case 10) had a fracture of the polyethylene cup, which was thought to be secondary to its increased brittleness³³. The time-dependent degradation of the material properties and wear resistance of polyethylene³⁴, subsequent to sterilization by gamma irradiation in air, was not known when these hips were operated on.

Increased volumetric wear of the polyethylene liner is a concern when a large-diameter head is used. However, radiographically apparent osteolysis did not progress in any hip in our series. This was due, at least in part, to the low activity levels of these patients. The average University of California at Los Angeles score of 5 points for the activity level represents approximately 570,000 cycles/yr³⁵; thus, wear is not likely to be a problem. Thermally stabilized, cross-linked polyethylene³⁶ and metal-on-metal bearings³⁷ may have sufficiently low particle production to allow the long-term survival of hips with a large-diameter femoral head in more active patients. With these materials, the benefit of increased stability from a jumbo femoral head may outweigh the risk of osteolysis.

Our midterm results after use of the jumbo femoral head have thus far confirmed our initial enthusiasm for this technique²¹. Every effort should be directed primarily toward thorough preoperative planning, meticulous surgical technique, and proper postoperative care. Because dislocation is a complex problem, it is impossible to create stability with any single method of treatment. Our present indication for the use of the jumbo femoral head is a history of recurrent instability in a patient who is at high risk for subsequent dislocations. Patients who have this high risk include those who are unable to take precautions to prevent dislocation, those with compromised abductor muscle function, and those who have intraoperative instability of the hip with a conventional-diameter femoral head.

References

Introduction | Materials and Methods | Results | Discussion | References

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Fig. 2-B:: Fig. 2-B Anteroposterior radiograph made after the revision. Two months later, recurrent instability developed.

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Fig. 2-D:: Fig. 2-D Radiograph made seven years after revision of the femoral component with a 44-mm unipolar head. The hip remained stable, and there was no more thigh pain.

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TABLE I: Patient Demographics

*ORIF = Open reduction and internal fixation.

Case	Primary Diagnosis	Previous Operations*	Onset of Instability After Last Operation (mo)	No. of Dislocations	Age at Operation (yr)	Time to Operation with Jumbo Head After First Dislocation (mo)	Recurrence of Dislocation	Reoperations and Complications	Remarks	Follow-up (mo)
?1	Osteoarthritis	Total hip replacement	??1.5	Never reduced	71	?12	None			?72
?2	Posttraumatic osteoarthritis	ORIF, acetabular fracture; ectopic bone excision; surface arthroplasty; exploratory surgery; cemented total hip replacement; shell revision	??1	?3	29	?12	None			141
?3	Osteoarthritis	Total hip replacement; constrained cup; revision total hip replacement; acetabular lip augmentation	??4	20	75	??2	None			?14 (Deceased)
?4	Developmental dysplasia of the hip	Osteotomy; cemented total hip replacement; greater trochanter advancement; cemented revision with eccentric shell	?60	?3	35	?24	None			123
?5	Posttraumatic osteoarthritis	Hip exploration; cup arthroplasty; cemented total hip replacement; cementless revision	?24	?6	42	?24	None	Hematogenous infection requiring resection arthroplasty at 4 yr		?44
?6	Posttraumatic osteoarthritis	Total hip replacement	?12	Never reduced	72	??2	Yes	Redislocation at 1 wk requiring reorientation of both components	Stable at 7.6 yr after revision	?91
?7	Osteonecrosis	Total hip replacement	192	12	62	?24	None			108
?8	Posttraumatic osteoarthritis	Total hip replacement; resection arthroplasty; total hip replacement; 2 revisions within 2 yr; revision with femoral allograft	??6	?7	77	132	None	Femoral loosening requiring revision at 24 mo	Patient doing well at 7 yr after revision	?85
?9	Benign proximal femoral tumor	Hemiarthroplasty; total hip replacement; 2 revisions	??2	?8	46	?72	None			108
10	Posttraumatic osteoarthritis	Bipolar hemiarthroplasty	??2	?2	67	??6	None	Fracture of polyethylene liner at 3.8 yr; exchange of polyethylene liner	Patient doing well at 14 mo after revision	?47
11	Osteoarthritis	Surface arthroplasty; total hip replacement; revision total hip replacement	??2	?3	84	??8?	None	Entrapment of cement within articulation; exploration and exchange of polyethylene liner	Patient doing well at 1 yr after revision	?38
12	Osteonecrosis; systemic lupus erythematosus	Coring; total hip replacement; Girdlestone procedure for infection; total hip replacement; 2 revision total hip replacements for dislocation; 2 incision & drainage procedures for infection; direct exchange	?72	16	51	?38	None			?59
Avg.			?31.5	?7	59	?29.7				?78

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TABLE I: Patient Demographics

*ORIF = Open reduction and internal fixation.

Case	Primary Diagnosis	Previous Operations*	Onset of Instability After Last Operation (mo)	No. of Dislocations	Age at Operation (yr)	Time to Operation with Jumbo Head After First Dislocation (mo)	Recurrence of Dislocation	Reoperations and Complications	Remarks	Follow-up (mo)
?1	Osteoarthritis	Total hip replacement	??1.5	Never reduced	71	?12	None			?72
?2	Posttraumatic osteoarthritis	ORIF, acetabular fracture; ectopic bone excision; surface arthroplasty; exploratory surgery; cemented total hip replacement; shell revision	??1	?3	29	?12	None			141
?3	Osteoarthritis	Total hip replacement; constrained cup; revision total hip replacement; acetabular lip augmentation	??4	20	75	??2	None			?14 (Deceased)
?4	Developmental dysplasia of the hip	Osteotomy; cemented total hip replacement; greater trochanter advancement; cemented revision with eccentric shell	?60	?3	35	?24	None			123
?5	Posttraumatic osteoarthritis	Hip exploration; cup arthroplasty; cemented total hip replacement; cementless revision	?24	?6	42	?24	None	Hematogenous infection requiring resection arthroplasty at 4 yr		?44
?6	Posttraumatic osteoarthritis	Total hip replacement	?12	Never reduced	72	??2	Yes	Redislocation at 1 wk requiring reorientation of both components	Stable at 7.6 yr after revision	?91
?7	Osteonecrosis	Total hip replacement	192	12	62	?24	None			108
?8	Posttraumatic osteoarthritis	Total hip replacement; resection arthroplasty; total hip replacement; 2 revisions within 2 yr; revision with femoral allograft	??6	?7	77	132	None	Femoral loosening requiring revision at 24 mo	Patient doing well at 7 yr after revision	?85
?9	Benign proximal femoral tumor	Hemiarthroplasty; total hip replacement; 2 revisions	??2	?8	46	?72	None			108
10	Posttraumatic osteoarthritis	Bipolar hemiarthroplasty	??2	?2	67	??6	None	Fracture of polyethylene liner at 3.8 yr; exchange of polyethylene liner	Patient doing well at 14 mo after revision	?47
11	Osteoarthritis	Surface arthroplasty; total hip replacement; revision total hip replacement	??2	?3	84	??8?	None	Entrapment of cement within articulation; exploration and exchange of polyethylene liner	Patient doing well at 1 yr after revision	?38
12	Osteonecrosis; systemic lupus erythematosus	Coring; total hip replacement; Girdlestone procedure for infection; total hip replacement; 2 revision total hip replacements for dislocation; 2 incision & drainage procedures for infection; direct exchange	?72	16	51	?38	None			?59
Avg.			?31.5	?7	59	?29.7				?78

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TABLE II: Component Reconstruction at the Time of Insertion of the Jumbo Femoral Head

*Outer diameter/inner diameter. †Patient died. ‡A resection arthroplasty was performed four years after surgery because of hematogenous periprosthetic infection.

Case	Femoral Side at Index Surgery	Acetabular Side at Index Surgery	Comorbidities	Shell Size (mm)	Head Size* (mm)
?1	Left in situ	Cemented metal-backed; cementless revision	No active abduction, contralateral hemipelvectomy	77	47/28
?2	Revised with cementing in preexisting mantle	Loose; cementless revision	Adductor contracture	70	47/28
?3†	Left in situ	Damaged cup; cemented revision (surface arthroplasty component)	Alzheimer disease; no active abduction	70	47/28
?4	Loose; cementless revision	Loose with major bone loss; cemented revision	No active abduction; preexisting ipsilateral dropfoot	66	44/28
?5‡	Left in situ	Loose; cementless revision		72	44/28
?6	Left in situ	Left in situ; liner exchange	No active abduction	68	44/28
?7	Loose; cemented revision	Well fixed with 3 mm of wear; cementless revision		68	44/28
?8	Left in situ	Excessive superolateral wear; cemented revision		66	44/28
?9	1st: left in situ; 2nd: cementless revision	Well fixed but maloriented; cementless revision	No active abduction	64	1st: 44/28; 2nd: 44
10	Left in situ	No previous acetabular component		53	40/22
11	Left in situ	Well-fixed cementless shell left in situ; new liner cemented in (double shell)		55	40/28
12	Cemented revision	Cementless revision	Previous infection	59	50
Avg.				66	44

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TABLE II: Component Reconstruction at the Time of Insertion of the Jumbo Femoral Head

*Outer diameter/inner diameter. †Patient died. ‡A resection arthroplasty was performed four years after surgery because of hematogenous periprosthetic infection.

Case	Femoral Side at Index Surgery	Acetabular Side at Index Surgery	Comorbidities	Shell Size (mm)	Head Size* (mm)
?1	Left in situ	Cemented metal-backed; cementless revision	No active abduction, contralateral hemipelvectomy	77	47/28
?2	Revised with cementing in preexisting mantle	Loose; cementless revision	Adductor contracture	70	47/28
?3†	Left in situ	Damaged cup; cemented revision (surface arthroplasty component)	Alzheimer disease; no active abduction	70	47/28
?4	Loose; cementless revision	Loose with major bone loss; cemented revision	No active abduction; preexisting ipsilateral dropfoot	66	44/28
?5‡	Left in situ	Loose; cementless revision		72	44/28
?6	Left in situ	Left in situ; liner exchange	No active abduction	68	44/28
?7	Loose; cemented revision	Well fixed with 3 mm of wear; cementless revision		68	44/28
?8	Left in situ	Excessive superolateral wear; cemented revision		66	44/28
?9	1st: left in situ; 2nd: cementless revision	Well fixed but maloriented; cementless revision	No active abduction	64	1st: 44/28; 2nd: 44
10	Left in situ	No previous acetabular component		53	40/22
11	Left in situ	Well-fixed cementless shell left in situ; new liner cemented in (double shell)		55	40/28
12	Cemented revision	Cementless revision	Previous infection	59	50
Avg.				66	44