What is the failure rate of constrained liners in complex revision total hip arthroplasty?

Recurrent hip dislocation after multiple revision total hip arthroplasty is a severe complication. Therefore, constrained acetabular liners (CL) have been used during salvage procedures. We report our experience of constrained liners in a re-revision setting with focus on re-dislocation. We also evaluated acetabular and femoral bone loss as potential risk factor.

Between January 2013 and December 2016, 65 patients were treated in a single institution for revision and re-revision hip arthroplasty using CL. The indication for using a CL was a high risk of re-redislocation after multiple recurrent hip dislocation including failed Dual Mobility Cups (DMC). Compromising soft tissue defects as well as severe bone defect were therefore regarded as high risks. Thirty-eight patients (77.6%) underwent a minimum of three surgical procedures before the index revision procedure. Sixteen patients (24.6%) were excluded as they were lost to follow-up, expired before minimum follow-up or refused study participation, leaving 49 patients in the analysis (75.4%). The mean follow-up was 62 months (44-74; SD = 7.7). We assessed the following potential risk factors for revision or dislocation: type of surgical setting (septic/aseptic), BMI, cup inclination angle, size of liner used and acetabular and femoral bone loss according to Paprosky classification. The primary endpoints were dislocation or repeat revision for any reason.

Of the 49 patients, we found an overall re-revision rate of 40.8% (20/49) and a dislocation rate of 30.6% (15/49). There were no significant differences among the surgical re-revision rate or dislocation rate as a factor of patient characteristics. In terms of bone loss, there was a trend towards higher revision rates for increasing acetabular and femoral bone loss, but without statistical significance.

We found the use of a constrained liner in a re-revision setting still bears a high risk of re-revision and re-dislocation. Therefore we restrained from using constrained liners in favour of Dual mobility cups. In this study there was no significant higher dislocation rate in the subgroup of periprosthetic infection. Furthermore the rigid design of a constrained liner bears the known risk of structural failure of acetabular reconstruction implants. Severe acetabular or femoral bone defects seem to have an impact on the revision rate, but not on the dislocation rate with regards to the restored offset and center of the hip. Results have to be taken into context such that the study population inherently has a predisposition for poorer outcomes. Indications should be strongly filtered for patients at high risk for recurrent hip joint dislocation including failed DMCs with only limited bone loss and moderate soft tissue defects. Our modification to the existing classification with a high inter and intraobserver reliability will make future studies more comparable regarding revisions and bone stock loss. Still further research using objective and reproducible parameters is needed to better analyze data especially in the background of complex revision hip arthroplasty.