Intra-prosthetic dislocation of dual-mobility cups after total hip arthroplasty: potential causes from a clinical and biomechanical perspective

Recurrent dislocation of total hip arthroplasty is a frequent indication for revision surgery. Hip joint stability depends on implant design, cup position and crucially on femoral head diameter. Due to an effective ultra-large diameter femoral head, dual-mobility cups are considered an attractive solution to prevent dislocation in unstable conditions. Although patients obviously benefit for many years in terms of mobility and pain, an increase of intra-prosthetic dislocation reports using dual-mobility cups has been recently observed. However, the failure mechanism of this implant-specific complication, which is characterized by the loss of the positive-locking between the femoral head and the mobile liner, is not yet completely understood.

A comprehensive search was performed with the PubMed database and a search engine to overview this topic and to identify potential causes for this implant-specific failure from a clinical and biomechanical perspective.

Peri-operative findings indicate extensive fibrosis at the large articulation as well as cup loosening as potential causes. In addition, current research has shown that the failure mechanism is affected by the surface topography of the femoral neck and in particular by the design of the mobile liner.

In clinical practice it is necessary to differentiate a classic dislocation between the mobile liner and the metallic shell from an intra-prosthetic dislocation between the femoral head and the liner.

Due to the increasing popularity of dual-mobility cups in total hip arthroplasty, the understanding of which implant-specific features or tissue response may increase the risk of intra-prosthetic dislocation is of major importance for reduced revision rates by using optimized surgical techniques and implant designs.