Dual mobility cup reduces dislocation rate after arthroplasty for femoral neck fracture
© Tarasevicius et al; licensee BioMed Central Ltd. 2010
Received: 9 November 2009
Accepted: 6 August 2010
Published: 6 August 2010
Hip dislocation after arthroplasty for femoral neck fractures remains a serious complication. The aim of our study was to investigate the dislocation rate in acute femoral neck fracture patients operated with a posterior approach with cemented conventional or dual articulation acetabular components.
We compared the dislocation rate in 56 consecutive patients operated with conventional (single mobility) cemented acetabular components to that in 42 consecutive patients operated with dual articulation acetabular components. All the patients were operated via posterior approach and were followed up to one year postoperatively.
There were 8 dislocations in the 56 patients having conventional components as compared to no dislocations in those 42 having dual articulation components (p = 0.01). The groups were similar with respect to age and gender distribution.
We conclude that the use of a cemented dual articulation acetabular component significantly reduces the dislocation rates in femoral neck fracture patients operated via posterior approach.
Dislocations of hip prosthesis in femoral neck fracture patients remain a serious problem. A metaanalysis  revealed a median dislocation rate of 10,7% in femoral neck fracture patients treated with THA (total hip arthroplasty), five time higher as compared to arthroplasty for osteoarthritis. Possible explanations may be a greater tendency to fall, less muscular control, and increased ligament laxity in hip fracture patients [1, 2]. However, the dislocation rate is also affected by other factors directly related to the surgical procedure; e.g. surgical approach, choice of implant, and orientation of the acetabular and femoral components. Morrey  reported that the dislocation rate was 2 to 3 times greater after primary THA with the posterior approach as compared to THA with an anterior approach. Enocson et al.  investigated factors influencing the stability of the prosthetic hip in femoral neck fracture patients and reported that the anterolateral approach was associated with a lower risk of dislocation than the posterolateral approach. Despite the reported greater dislocation rate with posterior approach it is still widely used. Therefore, surgeons using this approach in patients with a high risk of dislocation might consider selecting a more suitable implant. It has been reported that using a greater femoral head size or bipolar acetabular components reduces the risk of dislocation . Recently, dual articulation acetabular systems have been reported to provide better implant stability as well as good long term results .
We are not aware of any reports on the use of dual articulation acetabular components in femoral neck fractures. Thus, the aim of our study was to investigate the dislocation rate in femoral neck fracture patients treated with conventional or dual articulation acetabular components.
Our study concerns patients treated for femoral neck fracture in the Kaunas Medical University Hospital from July 2004 to July 2008. 128 patients were treated during this period of which 116 had a total arthroplasty (THA). Twelve patients treated with hemiarthroplasty were excluded.
Implant related data in the conventionally cemented cup group (n = 63)
Number of patients
C-stem with 28 mm femoral head
Aesculap bicontact with 28 mm femoral head
WLink with 32 mm femoral head
ScanHip Classic II with 28 mm femoral head
During the four year period, all THA were performed by one of 4 experienced orthopedic surgeons.
All patients were operated via posterior approach without posterior soft tissue repair with either spinal or epidural anesthesia, and all patients received the same rehabilitation program.
Both groups of patients were followed for a period of one year after surgery and the dislocation rate was registered. 23 patients died during the first year after surgery (12 in the conventional THA group and 11 in the dual articulation group) none of which dislocated and they were excluded from further analysis.
T-test was used to compare the differences in age between the groups. Chi square test was used to compare proportions of dislocations and gender between groups. A p-value of < 0.05 was considered significant. We used the SPSS software.
The study was approved by the ethical committee of the Kaunas Medical University Clinics (BE-2-8).
Choice of cup, age and sex distribution in patients alive one year after surgery.
Gender (M-male, F-female)
Conventional cup, n = 56
74 (SD 10)
DAC group, n = 42
75 (SD 10)
Dislocated THA in the conventional cup group.
Number of dislocations
Aesculap Bicontact, 28 mm
Aesculap Bicontact 28 mm
Aesculap Bicontact 28 mm
Aesculap Bicontact 28 mm
ScanHip 28 mm
ScanHip 28 mm
WLink 32 mm
WLink 32 mm
Within one year of surgery, 8 out of 56 hips with a conventional cemented cup had dislocated. Considering the known high dislocation rate after THA for femoral neck fracture  it might be considered either not to use a posterior approach or select an implant less prone to dislocate. With the DAC we had no dislocations. As with DAC in our material, it has been reported that bipolar hip prostheses significantly reduce dislocation rates as compared to conventional THA , and they are widely used for treatment of femoral neck fractures . However, bipolar implants have been associated with migration into the acetabulum and acetabular osteolysis .
In our study, all the THA were performed by one of 4 experienced orthopedic surgeons. Although 4 different THA systems were used in the conventional group and two different head sizes, these implants had been in use for a long period before the study was started, thus they were familiar to the surgeons, and our dislocation rate was similar to that reported in the literature . Furthermore, no dislocations occurred after the introduction of DAC in spite of a possible "learning curve" with the introduction of a new implant.
That both 28 mm and 32 mm heads were used in the conventional THA group may be regarded as a weakness of the paper. Larger head size in THA has been associated with decreasing dislocation rates  which is in concordance with our material in which the dislocation for 28 mm femoral heads was 3 times higher than for 32 mm heads. However, some surgeons may be reluctant to opt for larger head sizes considering that they have been associated with higher polyethylene wear and increased risk of aseptic loosening [10–12].
The economy when choosing an implant is of great importance. The Dual articulation Avantage cup is approximately three times more expensive than a conventional cemented cup. In 56 femoral neck fracture patients we had 14 episodes of prosthetic dislocation in 8 patients within one year after surgery with associated additional costs, and there were 3 revisions due to recurrent dislocations. Adding to the cost of surgery there were additional costs for prolonged hospital stay as well as postoperative rehabilitation. Consequently the initial savings using a conventional implant, at least one with 28 mm head, may be questionable not considering the pain and suffering of the patients involved.
We found that changing from conventional THA, using a mixture of 28 mm and 32 mm heads, to a dual articular acetabular component arthroplasty significantly reduced the dislocation rate, mainly due to a higher risk of dislocation in the 28 mm group.
This study was supported by: Pfizer EU ARTICULUM Fellowship, Lunds sjukvårdsdistrikt/Region Skåne, the Swedish Research Council (Project 73X-09509), the Swedish National Board of Health and Welfare and the Medical Faculty, University of Lund, Sweden.
- Iorio R, Healy WL, Lemos DW, Appleby D, Lucchesi CA, Saleh KJ: Displaced femoral neck fractures in the elderly: outcomes and cost effectiveness. Clin Orthop. 2001, 383: 229-42. 10.1097/00003086-200102000-00027.View ArticlePubMedGoogle Scholar
- Hudson JI, Kenzora JE, Hebel JR, Gardner JF, Scherlis L, Epstein RS, Magaziner JS: Eight-year outcome associated with clinical options in the management of femoral neck fractures. Clin Orthop. 1998, 348: 59-66.View ArticlePubMedGoogle Scholar
- Morrey BF: Instability after total hip arthroplasty. Orthop Clin North A. 1992, 23 (2): 237-48.Google Scholar
- Enocson A, Hedbeck CJ, Tidermark J, Pettersson H, Ponzer S, Lapidus LJ: Dislocation of total hip replacement in patients with fractures of the femoral neck. Acta Orthop. 2009, 80 (2): 184-9. 10.3109/17453670902930024.View ArticlePubMedPubMed CentralGoogle Scholar
- Leighton RK, Schmidt AH, Collier P, Trask K: Advances in the treatment of intracapsular hip fractures in the elderly. Injury. 2007, 38 (Suppl 3): S24-34. 10.1016/j.injury.2007.08.008.View ArticlePubMedGoogle Scholar
- Philippot R, Camilleri JP, Boyer B, Adam P, Farizon F: The use of a dual-articulation acetabular cup system to prevent dislocation after primary total hip arthroplasty: analysis of 384 cases at a mean follow-up of 15 years. Int Orthop. 2009, 33 (4): 927-32. 10.1007/s00264-008-0589-9.View ArticlePubMedGoogle Scholar
- Enocson A, Tidermark J, Tornkvist H, Lapidus LJ: Dislocation of hemiarthroplasty after femoral neck fracture: better outcome after the anterolateral approach in a prospective cohort study on 739 consecutive hips. Acta Orthop. 2008, 79 (2): 211-7. 10.1080/17453670710014996.View ArticlePubMedGoogle Scholar
- Nakata K, Ohzono K, Masuhara K, Matsui M, Hiroshima K, Ochi T: Acetabular osteolysis and migration in bipolar arthroplasty of the hip: five- to 13-year follow-up study. J Bone Joint Surg Br. 1997, 79 (2): 258-64. 10.1302/0301-620X.79B2.7181.View ArticlePubMedGoogle Scholar
- Conroy JL, Whitehouse SL, Graves SE, Pratt NL, Ryan P, Crawford RW: Risk factors for revision for early dislocation in total hip arthroplasty. J Arthroplasty. 2008, 23 (6): 867-72. 10.1016/j.arth.2007.07.009.View ArticlePubMedGoogle Scholar
- Tarasevicius S, Kesteris U, Robertsson O, Wingstrand H: Femoral head diameter affects the revision rate in total hip arthroplasty: an analysis of 1,720 hip replacements with 9-21 years of follow-up. Acta Orthop. 2006, 77 (5): 706-9. 10.1080/17453670610012872.View ArticlePubMedGoogle Scholar
- Tarasevicius S, Robertsson O, Kesteris U, Kalesinskas RJ, Wingstrand H: Effect of femoral head size on polyethylene wear and synovitis after total hip arthroplasty: a sonographic and radiographic study of 39 patients. Acta Orthop. 2008, 79 (4): 489-93. 10.1080/17453670710015472.View ArticlePubMedGoogle Scholar
- Lachiewicz PF, Heckman DS, Soileau ES, Mangla J, Martell JM: Femoral head size and wear of highly cross-linked polyethylene at 5 to 8 years. Clin Orthop Relat Res. 2009, 467 (12): 3290-6. 10.1007/s11999-009-1038-9.View ArticlePubMedPubMed CentralGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2474/11/175/prepub