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Constrained liners in revision total hip replacement

M. P. Abdel, D. E. Padgett
From Hospital for Special Surgery, Weill Cornell Medical College, Cornell University, United States

Instability after total hip replacement (THR) is the primary cause for revision surgery and historically surgical management has not been reliably successful. While the results of revision surgery for instability using constrained components have been promising, reoperation for various failure modes has increased. Currently available constrained liners have several limitations, including 1 - reduced range of movement to impingement, 2 excessive wear, 3 - risk of disassembly, 4 - increased stresses on the bone-prosthesis interface and 5 - increased radiolucency and early loosening of the acetabular component requiring revision. The observation of these failure modes, ranging from either fixation failures to overt biomaterial failure, has led us to be cautious in the routine use of constrained liners in revision THR. Implant instability due to poor position should be revised to correct the alignment. The use of either larger diameter heads or the emerging use of dual-mobility articulations seems more appropriate at the current time.

M. P . Abdel, MD, Adult Reconstruction Fellow, Senior Clinical Associate D. E. Padgett, MD, Associate Attending Orthopedic Surgeon, Associate Professor of Orthopaedic Surgery Hospital for Special Surgery , Weill Cornell Medical College, Cornell University, 535 East 70th Street, New York, 10021, USA. Correspondence should be sent to D. E. Padgett; e-mail: 2013 The British Editorial Society of Bone & Joint Surgery doi:10.1302/0301-620X.95B. 33361 $2.00 Bone Joint J 2013;95-B, Supple A. Received 17 October 2013; Accepted after revision 17 October 2013

By 2030, the demand for primary total hip replacement (THR) annual procedures in the United States is expected to grow by 174% to 572 000.1 Total hip revisions are also projected to grow by 137% from 2005 to 2030.1 After primary THR, dislocation rates are reported to be 0.5% to 10%, and after revision surgery, dislocation rates increase to between 10% and 25%.2 Hip instability remains one of the most common reasons for reoperation after THR, and accounts for approximately 25% of Medicare hip revisions in the United States.3 Historically, the rate of failure for reoperation of hip instability has been high, with some reports indicating only 60% success.4 Fortunately, a better understanding of hip instability, and new technologies to solve the problem, make the success rate of the operation greater. Hip instability can be caused by component malposition, impingement, and/or insufficient soft tissue tension or integrity.5 Additionally, some patients may have cognitive problems, neuromuscular disorders, or activity demands that put them at increased risk. In many cases, the etiology is multifactorial. For these reasons, surgeons must solve the specific identified problem, while at the same time employing additional measures as needed to improve the likelihood of success. Constrained liners, which rely on a locking mechanism to capture the femoral head, were developed to deal with the problem of recurrent dislocations, but are associated with unique weaknesses.

Constrained liners There are two main types of constrained implants, including sockets with constraint provided by a metal locking ring around the periphery of a polyethylene, and constrained tripolar devices.6 The Osteonics Omnifit (previously Osteonics Corporation, Allendale, New Jersey and currently Stryker Howmedica Osteonics, Mahwah, New Jersey) constrained acetabular insert includes a bipolar articulating with an outer, true liner. The tested range of movement (ROM) is from 72 to 84 with a pull-out strength of 514 pounds and lever-out strength of 450 inch-pounds.5 The DePuy Duraloc and superior-range of movement (S-ROM) constrained acetabular components (Warsaw, Indiana) use a locking ring mechanism. The advantage of the locking ring mechanism is that the thickness of the liner is not compromised. The pull-out and lever-out strength before dislocation for the Duraloc are greater than that of the S-ROM liners: 416 pounds versus 300 pounds and 170 inch-pounds versus 150 inchpounds, respectively.5 Other manufacturers have also produced constrained liners with the locking ring mechanism concept, including the Zimmer Trilogy Longevity Constrained Liner (Warsaw, Indiana) and the Biomet Freedom Constrained Liner (Warsaw, Indiana). Constrained implants provide immediate stability and may be the only viable solution when the entire abductor mechanism is deficient. These implants provide an excellent option for

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Fig. 1 Intra-operative photograph of a constrained tripolar implant with macroscopic impingement and wear.

patients with recurrent dislocations of unknown etiology, elderly patients in whom the components are well fixed, and patients with neurologic impairment such as Parkinsons disease, post-polio syndrome, cerebral palsy, and residual weakness after stroke.7-12

Clinical concerns While there remains a role for constrained implants in certain patients, there are some reservations, including 1 - reduced ROM to impingement; 2 - risk of excessive wear; 3 - risk of disassembly and 4 - increased stresses on the bone-prosthesis interface resulting in increased radiolucency and early loosening.6,11,13 Reduced ROM and increased impingement. The reduced ROM from constrained liners leads to a greater prevalence of impingement, particularly in flexion and internal rotation.7,14-18 When impingement occurs, the forces that would otherwise lead to dislocation are transferred to the rim and shell of the constrained component (Fig. 1).6 While this generates impingement damage to the liner, it may also cause failure at any of the junctions of the constrained mechanism. Noble et al analysed 57 retrieved constrained components of four different designs submitted to their lab.14 They found that overt failure of the locking ring was responsible for 51% of failures, whereas 28% of revisions were the result of acetabular cup loosening, 6% due to backside wear, and 22% from infection. Moreover, impingement damage of the rim of the polyethylene liner was seen in all retrievals, with 54% suffering moderate or severe damage. Excessive wear. Along with impingement, premature wear also occurs. This is secondary to the constraint leading to increased forces against the polyethylene. Furthermore, with constrained tripolars, there are additional bearing surfaces. Shah et al reviewed 70 Stryker Trident constrained liners (Mahwah, New Jersey) that were retrieved at revision surgery.19 The failure mechanisms necessitating removal of the constrained liners included bearing surface failure (26.6%), liner dissociation (26.6%), cup/cage failure (15.6%), infection

(18.8%), femoral stem failure (9.4%) and biomaterial failure (4.7%). Outer rim impingement was statistically greater than inner rim impingement (80% vs 15.7%, respectively; p < 0.05). All wear modes (scratching, burnishing, pitting, surface deformation, abrasion, delamination, and embedded debris) were statistically greater for the outer rim (p < 0.05). The outer rim impingement was higher than that reported for unconstrained liners in primary THRs (39% to 59%).20-22 Similarly, Noble et revealed that the mean volumetric wear rate of the articular surface was 95 mm3/year in their 57 retrieved constrained liners.14 Risk of disassembly. Given the modularity of constrained liners, failure can occur at any junction. Cooke et al described three failure types of a constrained tripolar implant, resulting in a 13.8% rate of constrained implant failure.23 Type-I failures occurred at the bone-prosthesis interface (three patients), Type-II failures included dysfunction in the liner locking mechanism (two patients), and Type-III failures occurred at the femoral head locking mechanism (one patient). Guyen, Lewallen and Cabanela modified the classification to include Type-I failures (boneprosthesis interface in 11 hips), Type-II failures (failure of the mechanisms holding the constrained liner to the metal shell in six hips), Type-III failures (failure of the retaining mechanism of the bipolar component in 10 hips), Type-IV failures (dislocation of the prosthetic head at the inner bearing of the bipolar component in three hips), and Type-V failures (infection in 12 hips).24 In all, they found an 11% failure rate of the constrained mechanism. Callaghan et al also noted six failures in their series, including three due to the outer bearing-bipolar interface and locking mechanism, two due to the shell-liner interface, and one due to the shell-bone interface.25 Such failures can be minimised with supplemental screw fixation, seating the liner fully with scoring of the polyethylene (when the liner is cemented), and avoiding impingement, respectively. Yun et al retrospectively reviewed 29 failed constrained liners, including both constrained tripolars (24 hips) and locking rings (five hips). The authors broadly classified four modes of failure for constrained liners, including failure of fixation to the pelvis (13 hips), liner dissociation (15 hips), biomaterial failure (seven hips), and femoral head dislocation (two hips).26 Anderson, Murray and Skinner were one of first to describe the use of constrained liners in patients with recurrent dislocation.7 They reported a success rate of 72% in a study of 18 patients followed for a mean of 31 months. Four of the six failures occurred with disassembly and disengagement of one specific design. Fisher and Kiley also reported two mechanical failures of the S-ROM liner that occurred by disassembly of the liner from the shell.27 Moreover, Della Valle et al reviewed 55 constrained liners placed for instability and found that 16% failed secondary to failure of the locking ring.28 Increased bone-prosthesis stresses/risk of loosening. Given that loads usually leading to dislocation are transferred to the bone-prosthesis interface, constrained implants may


Fig. 2 Anteroposterior (AP) radiograph of a patient with a Type-I catastrophic failure at the bone-prosthesis interface.

Table I. Summary of constrained liners in the literature.1 Study Anderson et al7 Lombardi et al9 Berend et al15,16 Goetz et al29 Shapiro et al30 Goetz et al32 Shrader et al13 Cooke et al23 Bremner et al31 Guyen et al24 Constrained device S-ROM S-ROM Osteonics Osteonics Osteonics Osteonics Osteonics Osteonics Osteonics Osteonics No. of hips 21 57 667 55 85 56 109 58 101 43 Duration of follow-up (months) 31 30 127 64 58 124 38 24 124 28.4 Radiographic loosening 5.3% NR NR 23% 3.5% 23% 14% NR 9.9% NR Acetabular revision rate 29% 9% 34.8% 13% 7% 21% 7% 13.8% 17% NR Overall revision rate NR 12% 42.1% 7.1% 8.2% 7.1% 8.2% NR 13.9% 11%

lead to increased stresses.6 In general, the more tenuous the implant fixation, the less desirable a constrained implant becomes. As previously depicted, multiple authors have shown these Type-I failures at this interface (Fig. 2).23-26 In the series by Cooke et al, 50% of their failures occurred at this junction.23 When analysing aseptic failures in the investigation by Guyen et al, more than one-third were at the bone-prosthesis junction.24 Similarly, Yun et al found that 27% of failures were a Type-I failure.26 In addition to catastrophic failures, the increased boneprosthesis stresses may result in increased radiolucency and early loosening. For instance, while Shrader, Parvizi and Lewallen found that 98% of hip instability was successfully treated with a constrained liner, radiographic analysis revealed radiolucent lines around the acetabular component in 15 hips (15 patients) (14%).13 Radiolucent lines were noted in all three zones in six hips, in zones I and II in four hips, in zones II and III in four hips, and in zones I and III in one hip. These lines were progressive in 10 hips (9%). As a consequence, five patients had gross loosening and migration of the acetabular cup requiring revision surgery.

In a study by Goetz et al, two (5%) of 38 hips with adequate radiographic follow-up were thought to be definitely loose and seven (18%) of 38 hips had progressive radiolucent lines around the acetabular component.29 Anderson et al also noted radiolucent lines around three of 19 cups after 31 months of follow-up.7 However, the authors felt as if these were non-progressive and did not require revision. Shapiro et al found that out of their 85 patients, 3.5% showed aseptic loosening and 2.4% had osteolysis.30 Out of 101 patients, Callaghan et al demonstrated significant rates of aseptic loosening (6.5% for the acetabular component and 8.7% for the femoral component).25 Acetabular component revisions. The increased interfacial stresses of constrained liners may result in accelerated acetabular loosening and thus revisions. The reported revision rates of acetabular constraining devices in the literature range from 7% to 34.8% (Table I).7-9,13,23,24,30 At 10.2 years, Bremner et al reported a 6% failure rate secondary to recurrent dislocation or liner failure, but a 17% cup revision rate.31 In 1991, Lombardi et al9 described their early results with the S-ROM and found a 9% cup revision rate. Later, in a long-term investigation by the same

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authors, the failure rate of the constrained implant was found to be 42.1%, with 34.8% of cups requiring revision.15 At a mean of 10.2 years after the use of 56 constrained tripolar devices, Goetz et al reported a 7% failure rate secondary to recurrent dislocation, osteolysis, or aseptic loosening.29,32 Moreover, the cup revision rate was 21%. Shapiro et al noted a cup revision rate of 7%.30 Finally, Noble et al found that 28% of their cups were loose in 57 revision THRs with a constrained liner.14

Conclusion While constrained liners reduce recurrent instability, there are limitations which include decreased ROM, increased impingement, risk of disassembly, increased radiolucency and wear, and increased load transfer at the bone-prosthesis interface leading to accelerated acetabular loosening and possible reoperation. Implant instability due to poor position should be revised as appropriate to correct the alignment. The use of either larger diameter heads or the emerging use of dual-mobility articulations seems more appropriate at this time. Constrained liners in revision THR should be limited to salvage scenarios in patients with recurrent dislocation, multidirectional intra-operative instability, abductor insufficiency, and neuromuscular disability in whom options such as increasing head size, change in component orientation or advancing the trochanter in order to increase abductor tension are not practical or have not been successful.
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

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