The Journal of Arthroplasty xxx (2018) 1e9

Contents lists available at ScienceDirect

The Journal of Arthroplasty

journal homepage: www.arthroplastyjournal.org

AAHKS Symposium

Prevention of Dislocation After Total Hip Arthroplasty

Fiachra E. Rowan, MD, FRCS(Orth), Biju Benjamin, MBBS,
Jurek R. Pietrak, MB BCh, FC Orth(SA), Fares S. Haddad, BSc, MD(Res), FRCS(Orth) *
Department of Trauma and Orthopaedic Surgery, University College London Hospital, London, United Kingdom

a r t i c l e i n f o a b s t r a c t

Article history: Background: Prevention of dislocation after primary total hip arthroplasty (THA) begins with patient
Received 14 November 2017 preoperative assessment and planning.
Received in revised form Methods: We performed a literature search to assess historical perspectives and current strategies to
20 January 2018
prevent dislocation after primary THA. The search yielded 3458 articles, and 154 articles are presented.
Accepted 24 January 2018
Results: Extremes of age, body mass index >30 kg/m2, lumbosacral pathology, surgeon experience, and
Available online xxx
femoral head size influence dislocation rates after THA. There is mixed evidence regarding the effect of
neuromuscular disease, sequelae of pediatric hip conditions, and surgical approach on THA instability.
Keywords:
total hip arthroplasty
Sex, simultaneous bilateral THA, and restrictive postoperative precautions do not influence the dislo-
dislocation cation rates of THA. Navigation, robotics, lipped liners, and dual-mobility acetabular components may
instability improve dislocation rates.
revision hip arthroplasty Conclusions: Risks for dislocation should be identified, and measures should be taken to mitigate the risk.
complication Reliance on safe zones of acetabular component positioning is historical. We are in an era of bespoke THA
surgery.
© 2018 Published by Elsevier Inc.

Dislocation after total hip arthroplasty (THA) is the most
common cause for revision hip surgery in the United States [1].
Although incidence of dislocation has decreased, the volume of
primary THAs is set to increase and may account for a net in-
crease in unstable THAs [2e4]. Over 60% of patients that sustain a
dislocation have multiple occurrences and over half require
revision surgery [5]. Unstable THAs increase hospital costs by up
to 300% of the cost of a primary hip arthroplasty [6,7]. The
economic and human implication of this complication is impor-
tant, and strategies to reduce the risk of dislocation should be
adopted by surgeons and health care providers. Prevention
against dislocation requires thorough preoperative planning and
assessment, attention to surgical detail, and good postoperative
care [8]. By identifying the patient at risk for instability, greater
attention can be paid to factors that the surgeon can control.
Dislocations that occur within 2 years of surgery are “early”
dislocations and “late” dislocations occur beyond the second
postoperative year [2]. A traditional method to determine etiol-
ogy of THA instability has been to consider patient factors,
surgeon factors, and implant factors [9]. Others have described a
classification of instability that seeks to identify the pathology
involved: Dorr et al [10] described instability because of hip
position, soft tissue imbalance, and component malposition.
Wera et al [11] devised another method for understanding
instability by classifying the unstable THA according to 6 etiol-
ogies ranging from acetabular component malpositioning to
unexplained instability and provide a management algorithm. In
this article, we present a stepwise strategy to reduce the inci-
dence of THA dislocation by identifying risks and offering inter-
vention from patient presentation to postoperative follow-up.

One or more of the authors of this paper have disclosed potential or pertinent
conflicts of interest, which may include receipt of payment, either direct or indirect,
institutional support, or association with an entity in the biomedical field which
may be perceived to have potential conflict of interest with this work. For full
disclosure statements refer to https://doi.org/10.1016/j.arth.2018.01.047.
* Reprint requests: Fares S. Haddad, BSc, MD(Res), FRCS(Orth), Department of
Trauma and Orthopaedic Surgery, University College London Hospital, 235 Euston
Road, London NW1 2BU, United Kingdom.
Methods
We performed a literature search to assess historical per-
spectives and current strategies to prevent dislocation after
primary THA using the PubMed platform. The search terms were
“Instability” OR “Dislocation” OR “Subluxation” OR “Sex”
OR “Age” OR “weight” OR “Neuromuscular” OR “Spine” OR
“Mobility” OR “Surgeon” OR “Approach” OR “Inclination” OR

https://doi.org/10.1016/j.arth.2018.01.047
0883-5403/© 2018 Published by Elsevier Inc.
2 F.E. Rowan et al. / The Journal of Arthroplasty xxx (2018) 1e9

“Anteversion” OR “Offset” OR “Impingement” OR “Flouroscopy” Body Mass Index

OR “Robot” OR “Navigation” OR “Precautions” OR “Retrictions”
AND “Total hip arthroplasty” OR “Total Hip Replacement.” The A meta-analysis has shown that dislocation after THA occurs
search yielded 3458 articles and English-language publications more often in patients with a body mass index (BMI) of >30 (odds
were considered for inclusion in the review. Article titles, ab- ratio ¼ 0.5, confidence interval: 0.38e0.75) [19]. In a single insti-
stracts, and full texts were read and included if deemed tution study of 21, 361 primary THAs performed over a 27-year
appropriate to discussion of prevention of dislocation after period, early dislocation rates were higher for patients with a BMI
primary THA. Relevant articles that did not appear in the orig- of 35 kg/m2, with a 5% increase for each BMI unit >35 kg/m2
inal search but were in bibliographies were included. Results of (hazard ratio [HR], 1.05; P ¼ .02) [20]. Another study showed that
the search are presented according to the patient and surgeon dislocation rates were increased for overweight patients (BMI >25.1
journey from preoperative assessment and intraoperative events kg/m2) [21]. Patients with increased BMI may have comparable
to postoperative care such that the reader can recognize points pain and functional outcomes to nonobese patients, and there is no
of intervention to reduce the risk of postoperative THA insta- benefit to weight loss before THA; therefore, overweight and obese
bility. A summary table is provided (Table 1). patients will continue to be offered THA [22,23]. It remains unclear
what predisposes patients with increased BMI to dislocation. Deep
Preoperative Assessment and Planning operative fields may compromise implant positioning, but this has
not been convincingly shown in the literature [24,25]. It is possible
Patient history, physical examination, and radiological studies that large limbs act as larger levers with more periarticular tissue
provide the surgeon with almost all the data required to stratify a for impingement, but this is difficult to scientifically prove. A
patient according to risk for postoperative THA instability. French study showed that obese patients had lower dislocation
rates if they received a dual-mobility or constrained liner (2%)
Sex compared with obese patients who underwent preoperative bar-
iatric surgery (13%) or obese control subjects with standard liners
Despite conventional belief, patient sex is not a risk factor for that did not have bariatric surgery (6-9%) [26].
dislocation in modern single institution and registry studies, and
the rate of revision for instability is not different between men and Mobility and Neuromuscular Pathology
women [13e16].
Loss of agonistic and antagonistic balance or general loss of
Age muscle tone around a THA may predispose to instability. Cerebral,
spinal, neuromuscular junction, and muscle-tendon-bone integrity
Older age has consistently shown to be an independent risk is required for normal hip function and stability. Common neuro-
factor for dislocation after THA although there is no consistent logical conditions that may present in patients with intractable
cutoff age for increased instability, which ranged from 70 to 85 pain requiring THA are post-stroke, Parkinson's disease (PD), ac-
years of age [2,17,18]. There is a bimodal distribution of age vs quired brain injury, cerebral palsy, and acquired spinal cord injury.
dislocation of THA according to a retrospective analysis of A review by Queally et al [27] recommended using constrained
22,079 THAs that showed patients aged <50 and
70 years had devices for patients who are at risk for instability such as those with
a higher risk of dislocation compared to patients aged 50-69 spinal injury, poliomyelitis, and cerebral palsy. The authors found
years [18]. that other neurological conditions such as PD did not increase the
risk for instability. Subsequent articles have shown both a higher
rate of dislocation for 297 patients with PD in the first year after
THA (HR, 2.33, 95% confidence interval 1.02 to 5.32) compared to
Table 1
Factors Influencing Instability and Interventions to Reduce Dislocation. control subjects and no dislocations in a case series of 11 patients
with PD undergoing THA [28,29]. A recent comparative study of
Factor Intervention
patients with cerebral palsy showed no increased risk for disloca-
Low-volume surgeon Refer high-risk patients tion after THA when judicious use of muscle releases, lipped and
Age <50 and >70 Elevated liner dual-mobility liners are used by experienced hip reconstruction
Dual-mobility linera
Obesity Dual-mobility liner
surgeons [30]. A registry study of patients with Alzheimer's disease
Constrained liner showed that they do not dislocate THAs more than matched control
Neurological conditions Dual-mobility liner subjects although the authors do not detail whether constrained
Constrained liner implants were used [31]. Failure of abductor dysfunction is a risk
Spinopelvic pathology Spinal surgery before THA
factor for postoperative THA instability, and muscle transfers have
Navigation or robotic-assisted
implant positioning been described [32,33]. Arthrodesis take-down was traditionally
Increase acetabular anteversion considered a risk factor for dislocation due to abductor atrophy, yet
Dual mobility a number of series have shown good stability after THA [34e36].
Posterior approach Capsular repair
Increased native offset Lateralized liners and stems
Resurfacing arthroplasty
Lumbosacral Pathology
Increased native Femur-first preparation and trial
Femoral anteversion Sagittal balance and lumbosacral mobility influences the func-
Intraoperative impingement Excise hypertrophied capsule tional position of the native acetabulum and femoral neck during
Remove osteophytes
deep hip flexion [37e42]. The surgeon should recognize the patient
Osteotomize AIIS
Intraoperative instability Change to elevated liner with poor spinopelvic mobility as these patients demonstrate more
Change to dual-mobility liner femoroacetabular flexion putting the patient at risk of impinge-
AIIS, anterior inferior iliac spine; THA, total hip arthroplasty.
ment and posterior dislocation [39]. Patients who may need
a
Concern exists regarding taper junctions between cobalt-chromium liners and lumbosacral fusion before or after THA are at risk for instability.
titanium acetabular shells with modular dual-mobility designs in young people [12]. Buckland et al [37] showed that the dislocation rate for 14,747
 F.E. Rowan et al. / The Journal of Arthroplasty xxx (2018) 1e9
patients who had undergone THA and spinal fusion was higher
compared with 839,004 control subjects. Dislocation rate for THA
without spinal fusion was 1.5% compared with 2.96% and 4.12% for
patients who underwent 1-2 level fusion and 3 þ level fusion with
subsequent THA, respectively. Patients with inflammatory condi-
tions such as ankylosing spondylitis have higher rates of post-
operative anterior and posterior THA instability [43]. Authors have
recommended performing spinal osteotomy and correction where
possible before THA for patients with ankylosing spondylitis to
reduce risk of dislocation [44]. In practice, the surgeon should
examine and perform radiographs of patients with suspicion for
lumbar pathology as the findings may influence cup positioning.
Bilateral Hip Degeneration
No difference in hip stability has been shown between patients
undergoing simultaneous and staged bilateral THA [45,46].
Diagnosis and Radiographic Planning
The surgical goals of primary THA are to recreate center of
rotation and restore leg length and combined offset. Anatomical
challenges in achieving these goals should be recognized preop-
eratively because each factor may contribute to postoperative THA
instability. The etiology of hip degeneration leading to THA will
determine implant choice and reconstructive strategy. Common
indications for THA in young people are sequelae of pediatric hip
pathology, trauma, and femoroacetabular impingement [47].
Morphological abnormalities have even been described for osteo-
necrosis, a condition that was considered an intraosseous pathol-
ogy. In a case-control matched study, abnormalities including
reduced neck-shaft angle and increased femoral version were
described in 73% of hips with osteonecrosis [48]. Patients under-
going THA for hip osteonecrosis have a higher rate of postoperative
instability and are twice as likely to undergo revision for instability
compared to control subjects [49,50]. Patients with developmental
dysplasia of the hip may present with acetabular dysplasia with an
enlocated femoral head, a teratogenic hip dislocation, or a range of
femoral head center positions in between [51]. Anatomical chal-
lenges include anterosuperior acetabular bone deficiency, femoral
anteversion with a valgus neck, narrow femoral diaphysis, a high
hip center, and need for subtrochanteric osteotomy. Despite these
morphological abnormalities, instability is not a significant
complication of THA for developmental dysplasia of the hip as
demonstrated by 3 series that had one dislocation in total [52e54].
Pelvis and proximal femur morphology in “normal” individuals can
contribute to THA instability. Virtual computed tomography (CT)
data from 112 patients with THAs showed that posterior bony
impingement is more likely in patients with a posterior pelvic tilt,
wider ischium, and narrower ischiofemoral space [55]. Patients
with coxa vara can present a challenge for hip center restoration as
conventional high offset stems and lateralized liners may not
restore the combined offset. Although large metal on metal resur-
facing has fallen out of favor, there is a biomechanical argument to
choose these devices [56,57].
Surgeon Experience
In a Canadian study of nearly 38,000 patients, surgeons who
performed <35 THAs a year had a dislocation rate of 1.9% vs 1.3% for
surgeons with greater volumes [58]. It has been shown that for
every 10 THAs performed, a surgeon's dislocation rate decreases by
50% [59]. Institution volume also influences dislocation as
demonstrated by a comparison of high- and low-volume centers
[60]. A crude measure of surgeon skill is operative time. Although
3
this does not account for case complexity, operative time of
180-210 minutes was associated with 4.97% early dislocation rate
compared with 3.65% for operative time <90 minutes in one study
[2]. It is the surgeon's responsibility to maintain technical compe-
tence and acknowledge limitations of volume or expertise.
Intraoperative Factors
Anesthesia
Regional anesthesia and multimodal pain control has facilitated
rapid recovery, early discharge, and same-day surgery for THA [61].
Perioperative loss of muscle tone with epidural anesthesia can
cause radiographic subluxation in the recovery room with no long-
standing risk for dislocation [62]. There is sparse data comparing
early and late dislocation and mode of anesthesia, but there is
evidence supporting lower complications and better pain control
with regional anesthesia [16,63e65].
Surgical Approach
Registries report increased dislocation rates for posterior
approach when compared to anterior, direct lateral, or anterolateral
approach, but pooled data studies do not support this finding
[14,66e73]. A registry analysis of 2061 THAs showed that acetab-
ular component positioning was 20% more accurate with posterior
approach than direct lateral or anterolateral approaches [25]. This
suggests other factors such as femoral implant position or soft
tissue integrity may influence stability. By improving posterior
closure technique, 2 high-volume surgeons significantly reduced
dislocation rates from 4% and 6.2% to 0% and 0.8%, respectively [74].
One of the surgeons subsequently reported intact quadratus fem-
oris and posterior capsule in a magnetic resonance imaging study
after THA in 96% of cases at a minimum of 4 years [75]. Although
piriformis and conjoined tendon of obturator internus and gemel-
lus superior and inferior were not attached in any case, there were
no dislocations in the group suggesting that repair of capsule and
quadratus femoris is more important. A transosseous technique
was used, but a comparative study of transmuscular repair showed
no difference in THA stability [76]. It is recommended that surgeons
pay attention to arthrotomy closure to reduce risk of dislocation
[77].
Acetabular Components
Acetabular cup diameter influences postoperative stability.
Kelley et al [78] showed that acetabular component outer diameter

56 mm increased the risk of dislocation in a prospective
controlled study. Similar results were reported from a retrospec-
tively studied series of 668 primary THAs that found a higher
dislocation rate with acetabular cups >58 mm diameter [79]. Both
studies assessed the femoral head size. Kelley et al reported higher
dislocation rates with 22-mm heads vs 28-mm heads, but Robinson
et al reported no difference between 32-mm and 36-mm heads. It is
postulated that a thicker, pincer effect of liner polyethylene causes
impingement and dislocation or that a capacious capsule in-
troduces laxity. Robinson et al recommend using 40-mm heads for
cups >58 mm outer diameter.
Traditional practice is to place the acetabular component in a
“safe zone” of 15 ± 10 degrees of anteversion and 40 ± 10 degrees of
inclination as described by Lewinnek et al [80] 40 years ago for 300
primary and revision THAs. Lewinnek found that the dislocation
rate was 1.5% for acetabular components within the safe zone and
6.1% for those outside the safe zone. Surgeons can use local
anatomical cues, simple mechanical guides, or technological aids to
4 F.E. Rowan et al. / The Journal of Arthroplasty xxx (2018) 1e9
achieve the “safe zone” implant position. Using the transverse
acetabular ligament as a version guide is associated with adequate
cup positioning and a low dislocation rate [81,82]. Some surgeons
are satisfied with mechanical alignment guides [83]. Navigation
and robotics are discussed later in the article.
Modern literature is questioning the validity of the “safe zone”
in isolation as a predictor of instability, and some authors have
proposed tighter limits on anteversion and inclination [25,84,85].
In a recent series of almost 10,000 THAs, there were 206 disloca-
tions of which 58% were within Lewinnek's safe zone [86]. A
systematic review similarly failed to show that postoperative cup
position influenced dislocation [87]. The authors concluded that
cup position target for stability is influenced by many factors and
may be patient specific. In a 3-dimensional simulation experiment,
deep flexion maneuvers performed by 10 individuals with simu-
lated idealized THAs resulted in 8 THAs impinging despite being
placed within the safe zone [88]. The authors in this study
recommend patient-specific targets for component positioning
with good intraoperative assessment. It is clear that safe zones
alone are insufficient to protect against instability [18].
Acetabular liner morphology influences hip stability. Lipped or
elevated liners of varying angles up to 20 are available. Using a 15-
degree liner in the posterior quadrant with a 28-mm head increases
the internal rotation range of movement by 8.9 degrees without
causing anterior dislocation [89]. Lateralized offset liners can be
used to restore hip center of rotation when the acetabular shell is
medial or the reconstructed femoral offset is reduced compared to
the contralateral hip or preoperative offset. In a series of 668 pri-
mary THAs with an overall dislocation rate of 1.3%, decreased
postoperative offset increased the risk for dislocation [79].
Liner tribology influences THA postoperative stability. Poly-
ethylene wear >2 mm is a risk factor for late dislocation [90]. Loss of
component congruity due to wear with associated soft tissue laxity
and/or bony loss due to osteolysis is implicated. Advances in
polyethylene characteristics by increasing cross-linking have
resulted in lower femoral head penetration rates [91]. Eliminating
polyethylene may reduce dislocation rates: ceramic on ceramic
(CoC) has a reduced the rate of late dislocation compared with
metal on polyethylene (MoP); however, this outcome was not
found in a 13-year analysis of 1219 of 192,275 primary THAs revised
for instability in the Australian Joint Registry [92,93]. In the registry
study, there was no significant difference in dislocation rates
among bearing surfaces for CoC, ceramic-on-polyethylene (CoP),
and MoP although a difference was shown for 36-mm heads
whereby MoP had a higher revision HR (1.6, P < .05) compared with
CoP and CoC.
Dual-Mobility and Constrained Liners
Although introduced in France 40 years ago, there is renewed
interest in the cost-effectiveness of dual-mobility devices and their
use in high-risk patients undergoing primary THA [94e98]. Dual-
mobility liners have good results in revision THA [99,100]. They
increase the head-neck ratio and increase the arc of motion before
impingement [12,101]. Monoblock cups and modular cup liners are
available. Concern has been raised about taper junction corrosion
between modular cobalt-chrome dual-mobility liners and titanium
acetabular cups [102,103]. Another concern for surgeons is an
intraprosthetic dissociation that requires open reduction
[104e107]. Dual-mobility liners have shown good results in
patients with obesity and cerebral palsy and young people
[26,108,109]. A comparative study showed that patients <55 years
of age with dual-mobility liners had no intraprosthetic dissocia-
tions or dislocations vs 5.1% of a matched cohort with fixed bearing
that dislocated [110]. Constrained liners have a hemisphere greater
than 180 that capture a bipolar or unipolar femoral head. Range of
movement is reduced by the stability conferred by the capture of
the femoral head. In a series of 10 high-risk primary THAs
(neurological conditions and deficient abductor muscle), Munro
et al [111] reported no dislocations using a constrained device. A
larger series of 55 patients at risk for THA instability demonstrated
a dislocation rate of 1.5% using constrained devices [112]. In a single
institution comparative study, dislocation rate for standard bear-
ings (132 THAs) was 25% and 2% for constrained bearings (164
THAs) in patients with increased and decreased muscle tone [113].
Some authors have reported high complication rates with con-
strained liners in both primary and revision THAs and recommend
reserving their use for salvage or extreme cases [114,115]. We
recommend reserving constrained implant use unless there is
intraoperative instability of dual-mobility trials.
Femoral Head Size
Increasing femoral head size
36 mm reduced dislocation rates
in a National Joint Registry report [116]. Other registry and cohort
studies show that 22-mm and 28-mm heads have higher disloca-
tion rates compared with 32-mm and 36-mm heads [14,71,117].
Computer modeling studies support the use of large femoral heads
to avoid impingement and dislocation [118]. Increasing head-neck
ratio increases hip range of movement before impingement but
may increase wear [119]. In a prospective trial of 644 patients
randomized to 28-mm or 36-mm femoral heads and followed up to
1 year, the incidence of dislocation was lower for hips with 36-mm
heads (0.8% vs 4.4%; P ¼ .024) [120]. Large metal head diameters are
more stable compared to 36-mm heads and resurfacing devices
with good track record and in the hands of experienced surgeons,
may be appropriate to use in patients who are at high risk for
dislocation [121e123].
Femoral Components and Combined Implant Factors
Restoring hip center is a key principle of THA. Choosing the
appropriate femoral component is the responsibility of the surgeon
and should be based on preoperative planning and intraoperative
assessment. Dual modular stems are an attractive option for
restoring hip center, but many have been withdrawn and recalled
due to taper corrosion [124e126]. Others have not shown a benefit
in postoperative THA stability [127,128]. We do not recommend
routine use of dual modular stems in primary THA.
Traditional surgical flow in THA is to prepare and implant the
acetabular component first followed by the femur to achieve the
desired hip reconstruction. Femoral broaching for cementless
implants and final stem position is influenced by proximal femoral
anatomy. Loppini et al [129] proposed femoral preparation first and
acetabular component implantation second according to a trialed
combined anteversion of 35 . The authors report no dislocations
after 1 year in 40 patients. The Ranawat combined anteversion
test was described in 1991 [130]. A CT study showed that high
(72.2 ) and low (27.4 ) combined anteversion is associated with
anterior and posterior dislocation compared to control subjects
(47.8 ) [131].
Intraoperative Stability Assessment
Upon reduction of trials or final implants, stability assessment
should be performed regardless of the approach used, and closure
should not begin until the surgeon is satisfied with hip stability.
Hip adduction and hip and knee flexion at 45 mimics a lateral
sleeping position and may cause subluxation. External rotation and
abduction mimics stepping out of a car seat and is a risk for anterior
 F.E. Rowan et al. / The Journal of Arthroplasty xxx (2018) 1e9
THA dislocation. Internal rotation and hip flexion can occur when
putting on footwear and is a risk for posterior dislocation. Deep
flexion occurs with rising from a low seat such as a toilet and is
similarly a risk for posterior dislocation. If there is impingement
between anterior inferior iliac spine or anterior capsule and greater
trochanter or ischial tuberosity and lesser trochanter, this should be
addressed by removing osteophyte or thickened capsule, osteoto-
mizing anterior inferior iliac spine or increasing offset [132].
Exchanging a neutral acetabular liner to a lipped liner can offer
stability against extremes of movement in the direction of insta-
bility [133]. Soft tissue tension can infer THA stability. The Shuck
test was not accurate compared to caliper measurement during a
prospective comparative assessment of tissue tension in THA [134].
Unplanned postoperative leg length discrepancy was 1.18 cm in the
Shuck test group and 0.37 mm in the caliper group. Although the
authors do not provide follow-up evidence of instability, the study
highlights the flaw of the test. Assessing tension of the abductor
muscles, capsule, short-external rotators, or even sciatic nerve may
confer information regarding tissue tension, but these tests require
significant surgeon experience and largely remain unreported or
validated.
Fluoroscopy, Navigation, and Robotics
Intraoperative tools can offer the surgeon more data that may
improve decision-making regarding implant positioning. Intra-
operative fluoroscopy has not shown benefit in acetabular
component positioning compared with freehand placement [135].
In a comparison of anterior approach with fluoroscopy and a
nonguided posterior approach, there was no difference in cup
inclination or dislocation at early follow-up [136]. Intraoperative
cup anteversion targets were different and therefore different at
postoperative analysis. Cup positions were similarly not improved
for another study of anterior fluoroscopic-assisted THA compared
to conventional posterior THA [137].
Using preoperative CT images to plan and a robotic arm
(MAKO; Stryker, NJ), to execute acetabular component positioning
showed better cup positioning using the robotic arm for 50
matched pairs in a retrospective analysis [138]. The targets for cup
inclination and anteversion were 40 and 20 , respectively. Final
inclination was more accurate and precise in the robotic group
(40.0 ± 3.2 vs 42.6 ± 5.4 ). Anteversion was only more precise in
the robotic group (16.7 ± 3.0 vs 13.3 ± 7.0 ) because both groups
failed to achieve the target of 20 . In a similar study comparing
conventional posterior THA with robotic-assisted anterior and
posterior THA, robotic-assisted cup placement was within
Lewinnek's safe zone in 100% of cases compared with 80% of
conventional cases [138]. Another institution demonstrated the
precision of acetabular component positioning using stereotactic
armeassisted acetabular component placement with cup place-
ment within ±4 of preoperative plan but no difference in
postoperative complications [139,140]. A subsequent article from
the same authors demonstrated no dislocations in 100 robotically
assisted THA compared to 5% and 3% dislocation rate for early (first
100 cases) and late (last 100 cases) manual THAs for the same
surgeon [141].
The first robotic-assisted system entered use in 1992 (ROBO-
DOC; Integrated Surgical Systems, CA) and showed better femoral
component fit and positioning compared with conventional tech-
nique [142]. A subsequent investigation showed a higher THA
dislocation (5.3% vs 1.4%) rate using the same robotic-assisted
system. Although this was not statistically significant and the
authors blamed falls in 3 cases, it is a clinically relevant outcome
because only 1 patient dislocated in the control group.
5
An imageless computer navigation system (Navitrack; ORTHO-
soft, Inc, Montreal, Canada) achieved combined anteversion within
Ranawat's safe zone (25 -50 ) in 96% of cases that had post-
operative CT assessment [143]. In the same article, the authors
show that surgeons' intraoperative assessment of femoral ante-
version was not as precise as the navigation system and that
surgeon visual estimate of combined anteversion was not accurate.
Although postoperative dislocation was not an end point in the
study, it remains unclear what clinical relevance the findings pose.
Current philosophy regarding component positioning is that
there is no safe zone that is safe for all patients [86,144]. Surgeons
should consider bespoke implant positioning in patients at risk for
THA instability. Current technologies that have shown superior
implant position accuracy and precision can be used to achieve
targets.
Postoperative Follow-Up
Postoperative Precautions
Traditional precautions against postoperative THA dislocation
include prohibited hip positions and maneuvers. Isolated or com-
bined hip flexion above 90 , internal rotation beyond 0 , and
adduction across the midline are typically forbidden. Low chairs are
off limits, and elevated toilet seats are provided. Sleeping position is
often restricted to supine, and pillows are placed between the legs
when lying in the lateral position.
A comparison of dislocation rates of 2275 THAs performed via
the posterior approach before and after abandoning restrictions
showed lower dislocation rates after removing precautions [145].
This did not achieve significance and so the authors concluded no
difference in stability. Therapists favor a move away from “blanket”
restrictions [146]. Patients are not adhering to restrictions upon
discharge. Lee et al [147] showed that at 8 weeks after THA, most
patients were not compliant and felt that restrictions interfered
with activity and sleep. This is in contrast to a comparison of pa-
tients that underwent preoperative education session regarding
muscle rehabilitation and hip movement restrictions to a group of
nonparticipants [148]. The authors showed an adjusted odds ratio
of 2.79 for dislocation within 6 months of THA in the noneducated
group. Some surgeons may be slow to abandon all precautions with
such results. Of 265 patients randomized to full postoperative
restrictions or avoidance of combined hip flexion, adduction, and
internal rotation alone, there was only one dislocation [149]. The
authors used an anterolateral approach and proposed that the
approach influenced the result. A subsequent study from the same
institution after the abandonment of restrictions demonstrated a
dislocation rate of 0.15% for 2612 THAs performed via an anterior or
anterolateral approach [150]. Posterior capsular and muscular
repair has encouraged surgeons to liberalize restrictions. A com-
parison of minimal precautions and full precautions showed no
difference in dislocation rates at 3 months for posterior approach
THA [151]. Another study of posterior approached THAs with soft
tissue repair proposed reducing minimal precautions from 6 weeks
to 4 weeks [152].
In summary, pooled evidence suggests that patient satisfaction
and return to activity is increased regardless of approach used in
THA with liberal lifestyle and precautions after surgery [153].
Summary
Prevention of dislocation after primary THA requires individu-
alized approach to reducing the risk for instability. Many factors
contribute towards dislocation, and the role of the surgeon is to
mitigate risk by recognizing these factors and adjusting
6 F.E. Rowan et al. / The Journal of Arthroplasty xxx (2018) 1e9
reconstruction strategy accordingly [154]. Low-volume surgeons in
particular should recognize limitations in their skill set and refer
at-risk patients appropriately. Recreating the native hip center of
rotation with restoration of combined offset and leg length are the
operative goals of THA. Technologies that aid acetabular and
femoral component implantation will reduce outlying positions
that may reduce dislocation risk. Dual-mobility and constrained
liners can improve stability. Judicious use of postoperative mobility
restrictions may benefit select patients.
References
[1] Gwam CU, Mistry JB, Mohamed NS, Thomas M, Bigart KC, Mont MA, et al.
Current epidemiology of revision total hip arthroplasty in the United States:
National Inpatient Sample 2009 to 2013. J Arthroplasty 2017;32:2088e92.
https://doi.org/10.1016/j.arth.2017.02.046.
[2] Malkani AL, Ong KL, Lau E, Kurtz SM, Justice BJ, Manley MT. Early- and
late-term dislocation risk after primary hip arthroplasty in the Medicare
Population. J Arthroplasty 2010;25:21e5. https://doi.org/10.1016/
j.arth.2010.04.014.
[3] Bozic KJ, Kamath AF, Ong K, Lau E, Kurtz S, Chan V, et al. Comparative
epidemiology of revision arthroplasty: failed THA poses greater clinical and
economic burdens than failed TKA. Clin Orthop Relat Res 2015;473:2131e8.
https://doi.org/10.1007/s11999-014-4078-8.
[4] Bozic KJ, Kurtz SM, Lau E, Ong K, Vail TP, Berry DJ. The Epidemiology of
revision total hip arthroplasty in the United States. J Bone Joint Surg
2009;91:128e33. https://doi.org/10.2106/JBJS.H.00155.
[5] Kotwal RS, Ganapathi M, John A, Maheson M, Jones SA. Outcome of treat-
ment for dislocation after primary total hip replacement. J Bone Joint Surg Br
2009;91:321e6. https://doi.org/10.1302/0301-620X.91B3.21274.
[6] Abdel MP, Cross MB, Yasen AT, Haddad FS. The functional and financial
impact of isolated and recurrent dislocation after total hip arthroplasty. Bone
Joint J 2015;97:1046e9. https://doi.org/10.1302/0301-620X.97B8.
[7] Sanchez-Sotelo J, Haidukewych GJ, Boberg CJ. Hospital cost of dislocation
after primary total hip arthroplasty. J Bone Joint Surg 2006;88:290. https://
doi.org/10.2106/JBJS.D.02799.
[8] Haddad FS. Even the winners are losers. Bone Joint J 2017;99eB:561e2.
https://doi.org/10.1302/0301-620X.99B5.38087.
[9] Brooks PJ. DIslocation following total hip replacement: causes and cures.
Bone Joint J 2013;95-B(11 Suppl A):67e9. https://doi.org/10.1302/0301-
620X.95B11.32645.
[10] Dorr LD, Wolf AW, Chandler R, Conaty JP. Classification and treatment of
dislocations of total hip arthroplasty. Clin Orthop Relat Res 1983:151e8.
[11] Wera GD, Ting NT, Moric M, Paprosky WG, Sporer SM, Della Valle CJ. Clas-
sification and management of the unstable total hip arthroplasty. J Arthro-
plasty 2012;27:710e5. https://doi.org/10.1016/j.arth.2011.09.010.
[12] Heffernan C, Banerjee S, Nevelos J, Macintyre J, Issa K, Markel DC, et al. Does
dual-mobility cup Geometry Affect posterior Horizontal dislocation dis-
tance? Clin Orthop Relat Res 2014;472:1535e44. https://doi.org/10.1007/
s11999-014-3469-1.
[13] Fessy MH, Putman S, Viste A, Isida R, Ramdane N, Ferreira A, et al. What are
the risk factors for dislocation in primary total hip arthroplasty? A multi-
center case-control study of 128 unstable and 438 stable hips. Orthop
Traumatol Surg Res OTSR 2017;103:663e8. https://doi.org/10.1016/
j.otsr.2017.05.014.
[14] Bystro€ m S, Espehaug B, Furnes O, Havelin LI. Femoral head size is a risk factor
for total hip luxation: a study of 42,987 primary hip arthroplasties from the
Norwegian Arthroplasty Register. Acta Orthop Scand 2003;74:514e24.
https://doi.org/10.1080/00016470310017893.
[15] Inacio MCS, Ake CF, Paxton EW, Khatod M, Wang C, Gross TP, et al. Sex and
risk of hip implant failure: assessing total hip arthroplasty outcomes in the
United States. JAMA Intern Med 2013;173:435e41. https://doi.org/10.1001/
jamainternmed.2013.3271.
[16] Jørgensen CC, Kjaersgaard-Andersen P, Solgaard S, Kehlet H. Lundbeck
Foundation Centre for Fast-track Hip and Knee Replacement Collaborative
Group. Hip dislocations after 2,734 elective unilateral fast-track total hip
arthroplasties: incidence, circumstances and predisposing factors. Arch
Orthop Trauma Surg 2014;134:1615e22. https://doi.org/10.1007/s00402-
014-2051-3.
[17] Malkani AL, Dilworth B, Ong K, Baykal D, Lau E, Mackin TN, et al. High risk of
Readmission in Octogenarians undergoing primary hip arthroplasty. Clin
Orthop Relat Res 2017;475:2878e88. https://doi.org/10.1007/s11999-017-
5241-9.
[18] Esposito CI, Gladnick BP, Lee Y, Lyman S, Wright TM, Mayman DJ, et al. Cup
position alone does not Predict risk of dislocation after hip arthroplasty.
J Arthroplasty 2015;30:109e13. https://doi.org/10.1016/j.arth.2014.07.009.
[19] Haverkamp D, Klinkenbijl MN, Somford MP, Albers GHR, van der Vis HM.
Obesity in total hip arthroplastyddoes it really matter? Acta Orthop
2011;82:417e22. https://doi.org/10.3109/17453674.2011.588859.
[20] Wagner ER, Kamath AF, Fruth KM, Harmsen WS, Berry DJ. Effect of body
mass index on complications and Reoperations after total hip arthroplasty.
J Bone Joint Surg 2016;98:169e79. https://doi.org/10.2106/JBJS.O.00430.
[21] Azodi OS, Adami J, Lindstro € m D, Eriksson KO, Wladis A, Bellocco R. High body
mass index is associated with increased risk of implant dislocation following
primary total hip replacement: 2,106 patients followed for up to 8 years.
Acta Orthop 2008;79:141e7. https://doi.org/10.1080/17453670710014897.
[22] Li W, Ayers DC, Lewis CG, Bowen TR, Allison JJ, Franklin PD. Functional Gain
and pain relief after total joint replacement according to obesity Status.
J Bone Joint Surg 2017;99:1183e9. https://doi.org/10.2106/JBJS.16.00960.
[23] Lui M, Jones CA, Westby MD. Effect of non-surgical, non-pharmacological
weight loss interventions in patients who are obese prior to hip and knee
arthroplasty surgery: a rapid review. Syst Rev 2015;4:121. https://doi.org/
10.1186/s13643-015-0107-2.
[24] Pirard E, De Lint JA. Anteversion of the acetabular component in obese
patients. Hip Int 2007;17:99e103.
[25] Callanan MC, Jarrett B, Bragdon CR, Zurakowski D, Rubash HE,
Freiberg AA, et al. The john charnley award: risk factors for cup malpo-
sitioning: Quality improvement through a joint registry at a tertiary
hospital. Clin Orthop Relat Res 2011;469:319e29. https://doi.org/10.1007/
s11999-010-1487-1.
[26] Hernigou P, Trousselier M, Roubineau F, Bouthors C, Flouzat Lachaniette CH.
Dual-mobility or constrained liners are more effective than preoperative
bariatric surgery in prevention of THA dislocation. Clin Orthop Relat Res
2016;474:2202e10. https://doi.org/10.1007/s11999-016-4859-3.
[27] Queally JM, Abdulkarim A, Mulhall KJ. Total hip replacement in patients with
neurological conditions. J Bone Joint Surg Br 2009;91eB:1267e73. https://
doi.org/10.1302/0301-620X.91B10.22934.
[28] J€
amsen E, Puolakka T, Peltola M, Eskelinen A, Lehto MUK. Surgical outcomes
of primary hip and knee replacements in patients with Parkinson's disease.
Bone Joint J 2014;96eB:486e91.

[29] Mathew PG, Sponer P, Ku
cera T, Grinac M, Kní zek J. Total hip arthroplasty in
patients with Parkinson's disease. Acta Med (Hradec Kral Czech Republic)
2013;56:110e6. https://doi.org/10.14712/18059694.2014.18.
[30] Houdek MT, Watts CD, Wyles CC, Trousdale RT, Milbrandt TA, Taunton MJ.
Total hip arthroplasty in patients with cerebral palsy. J Bone Joint Surg
2017;99:488e93. https://doi.org/10.2106/JBJS.16.00528.
[31] Jamsen E, Peltola M, Puolakka T, Eskelinen A, Lehto MUK. Surgical outcomes of hip
and knee arthroplasties for primary osteoarthritis in patients with Alzheimer's
disease: a nationwide registry-based case-controlled study. Bone Joint J
2015;97eB:654e61. https://doi.org/10.1302/0301-620X.97B5.34382.
[32] Jang SA, Cho YH, Byun YS, Gu TH. Abductor reconstruction with
Gluteus maximus transfer in primary abductor deficiency during total
hip arthroplasty. Hip Pelvis 2016;28:178e81. https://doi.org/10.5371/
hp.2016.28.3.178.
[33] Whiteside LA. Surgical technique: Gluteus maximus and tensor fascia lata
transfer for primary deficiency of the abductors of the hip. Clin Orthop Relat
Res 2014;472:645e53. https://doi.org/10.1007/s11999-013-3161-x.
[34] Tamaki T, Oinuma K, Miura Y, Shiratsuchi H. Total hip arthroplasty through a
direct anterior approach for fused hips. Hip Int 2015;25:549e52. https://
doi.org/10.5301/hipint.5000308.
[35] Zahar A, Cross MB, Lakatos T, Lakatos J, Major B, Kendoff D, et al. Conversion
arthroplasty of the hip: mid-term results are good. Hip Int 2015;25:520e4.
https://doi.org/10.5301/hipint.5000256.
[36] Celiktas M, Kose O, Turan A, Guler F, Ors C, Togrul E. Conversion of hip fusion
to total hip arthroplasty: clinical, radiological outcomes and complications in
40 hips. Arch Orthop Trauma Surg 2017;137:119e27. https://doi.org/
10.1007/s00402-016-2597-3.
[37] Buckland AJ, Puvanesarajah V, Vigdorchik J, Schwarzkopf R, Jain A,
Klineberg EO, et al. Dislocation of a primary total hip arthroplasty is more
common in patients with a lumbar spinal fusion. Bone Joint J 2017;99-B:
585e91.
[38] Lazennec JY, Brusson A, Rousseau MA. Lumbar-pelvic-femoral balance on
sitting and standing lateral radiographs. Orthop Traumatol Surg Res OTSR
2013;99:S87e103. https://doi.org/10.1016/j.otsr.2012.12.003.
[39] Esposito CI, Miller TT, Kim HJ, Barlow BT, Wright TM, Padgett DE, et al. Does
degenerative lumbar spine disease influence femoroacetabular flexion in
patients undergoing total hip arthroplasty? Clin Orthop Relat Res 2016;474:
1788e97. https://doi.org/10.1007/s11999-016-4787-2.
[40] Kanawade V, Dorr LD, Wan Z. Predictability of acetabular component
Angular Change with Postural Shift from standing to sitting position. J Bone
Joint Surg Am 2014;96:978e86. https://doi.org/10.2106/JBJS.M.00765.
[41] Pierrepont J, Hawdon G, Miles BP, Connor BO, Bare  J, Walter LR, et al.
Variation in functional pelvic tilt in patients undergoing total hip arthro-
plasty. Bone Joint J 2017;99eB:184e91. https://doi.org/10.1302/0301-
620X.99B2.BJJ-2016-0098.R1.
[42] Stefl M, Lundergan W, Heckmann N, McKnight B, Ike H, Murgai R, et al.
Spinopelvic mobility and acetabular component position for total hip
arthroplasty. Bone Joint J 2017;99eB:37e45. https://doi.org/10.1302/0301-
620X.99B1.BJJ-2016-0415.R1.
[43] Putnis SE, Wartemberg GK, Khan WS, Agarwal S. A literature review of total
hip arthroplasty in patients with ankylosing spondylitis: Perioperative
Considerations and outcome. Open Orthop J 2015;9:483e8.
[44] Zheng GQ, Zhang YG, Chen JY, Wang Y. Decision making regarding spinal
osteotomy and total hip replacement for ankylosing spondylitis experience
 F.E. Rowan et al. / The Journal of Arthroplasty xxx (2018) 1e9
with 28 patients. Bone Joint J 2014;96:360e5. https://doi.org/10.1302/0301-
620X.96B3.
[45] Shao H, Chen C-L, Maltenfort MG, Restrepo C, Rothman RH, Chen AF. Bilateral
total hip arthroplasty: 1-Stage or 2-Stage? A Meta-Analysis. J Arthroplasty
2017;32:689e95. https://doi.org/10.1016/j.arth.2016.09.022.
[46] Tsiridis E, Pavlou G, Charity J, Tsiridis E, Gie G, West R. The safety and efficacy
of bilateral simultaneous total hip replacement an analysis of 2063 cases.
Bone Joint Surg Br 2008;90:1005e12. https://doi.org/10.1302/0301-
620X.90B8.
[47] Wyles CC, Heidenreich MJ, Jeng J, Larson DR, Trousdale RT, Sierra RJ. The john
charnley award: Redefining the natural history of osteoarthritis in patients
with hip dysplasia and impingement. Clin Orthop Relat Res 2017;475:
336e50. https://doi.org/10.1007/s11999-016-4815-2.
[48] Ollivier M, Lunebourg A, Abdel MP, Parratte S, Argenson J-N. Anatomical
findings in patients undergoing total hip arthroplasty for Idiopathic femoral
head osteonecrosis. J Bone Joint Surg 2016;98:672e6. https://doi.org/
10.2106/JBJS.14.01099.
[49] Yang S, Halim AY, Werner BC, Gwathmey FW, Cui Q. Does osteonecrosis of
the femoral head increase surgical and medical complication rates after total
hip arthroplasty? A comprehensive analysis in the United States. Hip Int
2015;25:237e44. https://doi.org/10.5301/hipint.5000224.
[50] Bergh C, Fenstad AM, Furnes O, Garellick G, Havelin LI, Overgaard S, et al.
Increased risk of revision in patients with non-traumatic femoral head
necrosis. Acta Orthop 2014;85:11e7. https://doi.org/10.3109/
17453674.2013.874927.
[51] Crowe JF, Mani VJ, Ranawat CS. Total hip replacement in congenital dislo-
cation and dysplasia of the hip. J Bone Joint Surg Am 1979;61:15e23.
[52] Colo E, Rijnen WHC, Gardeniers JWM, Van Kampen A, Schreurs BW, Colo E,
et al. Satisfying results of primary hip arthroplasty in patients with hip
dysplasia at a mean Followup of 20 Years. Clin Orthop Relat Res 1999;474:
2462e8. https://doi.org/10.1007/s11999-016-4998-6.
[53] Nawabi DH, Meftah M, Nam D, Ranawat AS, Ranawat CS. Durable Fixation
achieved with Medialized, high hip center cementless THAs for Crowe II and
III dysplasia. Clin Orthop Relat Res 2014;472:630e6. https://doi.org/10.1007/
s11999-013-3187-0.
[54] Mu W, Yang D, Xu B, Mamtimin A, Guo W, Cao L. Midterm outcome of
cementless total hip arthroplasty in Crowe IVeHartofilakidis Type III
developmental dysplasia of the hip. J Arthroplasty 2016;31:668e75. https://
doi.org/10.1016/j.arth.2015.10.011.
[55] Shoji T, Yamasaki T, Izumi S, Murakami H, Mifuji K, Sawa M, et al. Factors
affecting the potential for posterior bony impingement after total hip
arthroplasty. Bone Joint J 2017;99:1140e6. https://doi.org/10.1302/0301-
620X.99B9.
[56] Langton DJ, Jameson SS, Joyce TJ, Gandhi JN, Sidaginamale R, Mereddy P, et al.
Accelerating failure rate of the ASR total hip replacement. Bone Joint J
2011;93eB:1011e6. https://doi.org/10.1302/0301-620X.93B8.26040.
[57] Nunley RM, Della Valle CJ, Barrack RL. Is patient selection important for hip
resurfacing? Clin Orthop Relat Res 2009;467:56e65. https://doi.org/10.1007/
s11999-008-0558-z.
[58] Ravi B, Jenkinson R, Austin PC, Croxford R, Wasserstein D, Escott B, et al.
Relation between surgeon volume and risk of complications after total hip
arthroplasty: propensity score matched cohort study. BMJ 2014;348:g3284.
https://doi.org/10.1136/bmj.g3284.
[59] Hedlundh U, Ahnfelt L, Hybbinette CH, Weckstrom J, Fredin H. Surgical
experience related to dislocations after total hip arthroplasty. J Bone Joint
Surg Br 1996;78:206e9.
[60] Kaneko T, Hirakawa K, Fushimi K. Relationship between peri-operative
outcomes and hospital surgical volume of total hip arthroplasty in Japan.
Health Policy (New York) 2014;117:48e53. https://doi.org/10.1016/
j.healthpol.2014.03.013.
[61] Russo MW, Parks NL, Hamilton WG. Perioperative pain management and
Anesthesia. Orthop Clin North Am 2017;48:401e5. https://doi.org/10.1016/
j.ocl.2017.06.006.
[62] Miric A, Kahn B, Waldman B, Sculco TP. Characteristics and natural history of
transient postoperative pseudosubluxation after total hip arthroplasty.
J Arthroplasty 2000;15:736e43. https://doi.org/10.1054/arth.2000.6627.
[63] Hunt LP, Ben-Shlomo Y, Clark EM, Dieppe P, Judge A, MacGregor AJ, et al.
90-day mortality after 409 096 total hip replacements for osteoarthritis,
from the National Joint Registry for England and Wales: a retrospective
analysis. Lancet 2013;382:1097e104. https://doi.org/10.1016/S0140-
6736(13)61749-3.
[64] Perlas A, Chan VWS, Beattie S. Anesthesia technique and mortality after total
hip or knee arthroplasty. Anesthesiology 2016;125:724e31. https://doi.org/
10.1097/ALN.0000000000001248.
[65] Jules-Elysee KM, Goon AK, Westrich GH, Padgett DE, Mayman DJ,
Ranawat AS, et al. Patient-controlled epidural Analgesia or multimodal pain
Regimen with periarticular Injection after total hip arthroplasty. J Bone Joint
Surg Am 2015;97:789e98. https://doi.org/10.2106/JBJS.N.00698.
[66] Masonis JL, Bourne RB. Surgical approach, abductor function, and total hip
arthroplasty dislocation. Clin Orthop Relat Res 2002:46e53.
[67] Cebatorius A, Robertsson O, Stucinskas J, Smailys A, Leonas L, Tarasevicius S.
Choice of approach, but not femoral head size, affects revision rate due to
dislocations in THA after femoral neck fracture: results from the Lithuanian
Arthroplasty Register. Int Orthop 2015;39:1073e6. https://doi.org/10.1007/
s00264-014-2618-1.
7
[68] Maratt JD, Gagnier JJ, Butler PD, Hallstrom BR, Urquhart AG, Roberts KC. No
difference in dislocation seen in anterior vs posterior approach total hip
arthroplasty. J Arthroplasty 2016;31:127e30. https://doi.org/10.1016/
j.arth.2016.02.071.
[69] Mjaaland KE, Svenningsen S, Fenstad AM, Havelin LI, Furnes O, Nordsletten L.
Implant Survival after minimally invasive anterior or anterolateral
vs. Conventional posterior or direct lateral approach. J Bone Joint Surg
2017;99:840e7. https://doi.org/10.2106/JBJS.16.00494.
[70] Jolles BM, Bogoch ER. Posterior versus lateral surgical approach for total hip
arthroplasty in adults with osteoarthritis. In: Jolles BM, editor. Cochrane
Database Syst Rev. Chichester, UK: John Wiley & Sons, Ltd; 2006. CD003828.
https://doi.org/10.1002/14651858.CD003828.pub3.
[71] Zijlstra WP, Hartog BDE, Van Steenbergen LN, Willem SCHEURS B, H H
Nelissen RG. Effect of femoral head size and surgical approach on risk of
revision for dislocation after total hip arthroplasty an analysis of 166,231
procedures in the Dutch Arthroplasty Register (LROI). Acta Orthop 2017;88:
395e401. https://doi.org/10.1080/17453674.2017.1317515.
[72] Sheth D, Cafri G, Inacio MCS, Paxton EW, Namba RS. Anterior and antero-
lateral approaches for THA are associated with lower dislocation risk without
higher revision risk. Clin Orthop Relat Res 2015;473:3401e8. https://doi.org/
10.1007/s11999-015-4230-0.
[73] Hailer NP, Weiss RJ, Stark A, Ka €rrholm J. The risk of revision due to dislo-
cation after total hip arthroplasty depends on surgical approach, femoral
head size, sex, and primary diagnosis. An analysis of 78,098 operations in the
Swedish Hip Arthroplasty Register. Acta Orthop 2012;83:442e8. https://
doi.org/10.3109/17453674.2012.733919.
[74] Pellicci PM, Bostrom M, Poss R. Posterior approach to total hip replacement
using enhanced posterior soft tissue repair. Clin Orthop Relat Res 1998:
224e8.
[75] McLawhorn AS, Potter HG, Cross MB, Boettner F, Lim W, Lee Y, et al. Posterior
soft tissue repair after primary THA is durable at mid-term Followup: a
prospective MRI study. Clin Orthop Relat Res 2015;473:3183e9. https://
doi.org/10.1007/s11999-015-4380-0.
[76] Spaans EA, Spaans AJ, van den Hout JAAM, Bolder SBT. The result of trans-
muscular versus transosseous repair of the posterior capsule on early dis-
locations in primary hip arthroplasty. Hip Int 2015;25:537e42. https://
doi.org/10.5301/hipint.5000279.
[77] White RE, Forness TJ, Allman JK, Junick DW. Effect of posterior capsular
repair on early dislocation in primary total hip replacement. Clin Orthop
Relat Res 2001:163e7.
[78] Kelley SS, Lachiewicz PF, Hickman JM, Paterno SM. Relationship of femoral
head and acetabular size to the prevalence of dislocation. Clin Orthop Relat
Res 1998:163e70.
[79] Robinson M, Bornstein L, Mennear B, Bostrom M, Nestor B, Padgett D, et al.
Effect of restoration of combined offset on stability of large head THA. Hip Int
2012;22:248e53. https://doi.org/10.5301/HIP.2012.9283.
[80] Lewinnek GE, Lewis JL, Tarr R, Compere CL, Zimmerman JR. Dislocations after
total hip-replacement arthroplasties. J Bone Joint Surg Am 1978;60:217e20.
[81] Beverland DE, ONeill CKJ, Rutherford M, Molloy D, Hill JC. Placement of the
acetabular component. Bone Joint J 2016;98eB:37e43. https://doi.org/
10.1302/0301-620X.98B1.36343.
[82] Archbold HAP, Mockford B, Molloy D, McConway J, Ogonda L, Beverland D.
The transverse acetabular ligament: an aid to orientation of the acetabular
component during primary total hip replacement: a preliminary study of
1000 cases investigating postoperative stability. J Bone Joint Surg Br
2006;88eB:883e6. https://doi.org/10.1302/0301-620X.88B7.17577.
[83] Wohlrab D, Radetzki F, Noser H, Mendel T. Cup positioning in total hip
arthoplasty: spatial alignment of the acetabular entry plane. Arch Orthop
Trauma Surg 2012;132:1e7. https://doi.org/10.1007/s00402-011-1379-1.
[84] Danoff JR, Bobman JT, Cunn G, Murtaugh T, Gorroochurn P, Geller JA, et al.
Redefining the acetabular component safe zone for posterior approach total
hip arthroplasty. J Arthroplasty 2016;31:506e11. https://doi.org/10.1016/
j.arth.2015.09.010.
[85] Mclawhorn AS, Sculco PK, Durham Weeks K, Nam D, Mayman DJ. An original
study targeting a New safe zone: a Step in the development of patient-
specific Compo- nent positioning for total hip arthroplasty. Am J Orthop
(Belle Mead NJ) 2015;44:270e6.
[86] Abdel MP, von Roth P, Jennings MT, Hanssen AD, Pagnano MW. What safe
Zone? The Vast Majority of dislocated THAs are within the Lewinnek safe
zone for acetabular component position. Clin Orthop Relat Res 2016;474:
386e91. https://doi.org/10.1007/s11999-015-4432-5.
[87] Seagrave KG, Troelsen A, Malchau H, Husted H, Gromov K. Acetabular cup
position and risk of dislocation in primary total hip arthroplasty A systematic
review of the literature. Acta Orthop 2017;88:10e7. https://doi.org/10.1080/
17453674.2016.1251255.
[88] McCarthy TF, Alipit V, Nevelos J, Elmallah RK, Mont MA. Acetabular cup
anteversion and inclination in hip range of motion to impingement.
J Arthroplasty 2016;31:264e8. https://doi.org/10.1016/j.arth.2016.01.067.
[89] Sultan PG, Tan V, Lai M, Garino JP. Independent contribution of elevated-rim
acetabular liner and femoral head size to the stability of total hip implants.
J Arthroplasty 2002;17:289e92.
[90] Parvizi J, Wade FA, Rapuri V, Springer BD, Berry DJ, Hozack WJ. Revision
hip arthroplasty for late instability secondary to polyethylene wear.
Clin Orthop Relat Res 2006;447:66e9. https://doi.org/10.1097/
01.blo.0000218751.14989.a6.
8 F.E. Rowan et al. / The Journal of Arthroplasty xxx (2018) 1e9
[91] Kurtz SM, Gawel H a, Patel JD. History and systematic review of wear
and osteolysis outcomes for first-generation highly crosslinked poly-
ethylene. Clin Orthop Relat Res 2011;469:2262e77. https://doi.org/10.1007/
s11999-011-1872-4.
[92] Shah SM, Walter WL, Tai SM, Tr F, Lorimer MF, de Steiger RN. Complications
-other late dislocations after total hip arthroplasty: is the bearing a factor?
J Arthroplasty 2017;32:2852e6. https://doi.org/10.1016/j.arth.2017.04.037.
[93] Hernigou P, Homma Y, Pidet O, Guissou I, Hernigou J. Ceramic-on-ceramic
bearing decreases the cumulative long-term risk of dislocation. Clin Orthop
Relat Res 2013;471:3875e82. https://doi.org/10.1007/s11999-013-2857-2.
[94] Lautridou C, Lebel B, Burdin G, Vielpeau C. Survival of the cementless
Bousquet dual mobility cup: minimum 15-year follow-up of 437 total hip
arthroplasties. Rev Chir Orthopedique Reparatrice L'appareil Mot 2008;94:
731e9. https://doi.org/10.1016/j.rco.2008.06.001.
[95] Plummer DR, Christy JM, Sporer SM, Paprosky WG, Della Valle CJ. Dual-
mobility Articulations for patients at high risk for dislocation. J Arthroplasty
2016;31:131e5. https://doi.org/10.1016/j.arth.2016.03.021.
[96] Barlow BT, Mclawhorn AS, Westrich GH. The cost-effectiveness of dual
mobility implants for Primary Total Hip Arthroplasty: A Computer-Based
Cost-Utility Model. J Bone Joint Surg Am 2017;99:768e77.
[97] Boyer B, Philippot R, Geringer J, Farizon F. Primary total hip arthroplasty with
dual mobility socket to prevent dislocation: a 22-year follow-up of 240 hips.
Int Orthop 2012;36:511e8. https://doi.org/10.1007/s00264-011-1289-4.
[98] Epinette JA, Lafuma A, Robert J, Doz M. Cost-effectiveness model comparing
dual-mobility to fixed-bearing designs for total hip replacement in France.
Orthop Traumatol Surg Res 2016;102:143e8. https://doi.org/10.1016/
j.otsr.2015.12.008.
[99] Hailer NP, Weiss RJ, Stark A, Ka€rrholm J. Dual-mobility cups for revision due
to instability are associated with a low rate of re-revisions due to dislocation:
228 patients from the Swedish Hip Arthroplasty Register. Acta Orthop
2012;83:566e71. https://doi.org/10.3109/17453674.2012.742395.
[100] De Martino I, D'Apolito R, Soranoglou VG, Poultsides LA, Sculco PK, Sculco TP,
et al. Dislocation following total hip arthroplasty using dual mobility
acetabular components. Bone Joint J 2017;99eB:18e24. https://doi.org/
10.1302/0301-620X.99B1.BJJ-2016-0398.R1.
[101] D'Apuzzo MR, Nevelos J, Yeager A, Westrich GH. Relative head size increase
using an anatomic dual mobility hip Prosthesis compared to traditional hip
arthroplasty: impact on hip stability. J Arthroplasty 2014;29:1854e6.
́
https://doi.org/10.1016/j.arth.2014.04.035. ́
[102] Nam D, Salih R, Brown KM, Nunley RM, Barrack RL. Metal Ion levels in
young, active patients receiving a modular, dual mobility total hip
arthroplasty. J Arthroplasty 2017;32:1581e5. https://doi.org/10.1016/
j.arth.2016.12.012.
[103] D'Apuzzo MR, Koch CN, Esposito CI, Elpers ME, Wright TM, Westrich GH.
Assessment of Damage on a dual mobility acetabular system. J Arthroplasty
2016;31:1828e35. https://doi.org/10.1016/j.arth.2016.01.039.
[104] Waddell BS, De Martino I, Sculco T, Sculco P. Total hip arthroplasty dislo-
cations are more Complex than they appear: a case report of Intraprosthetic
dislocation of an anatomic dual-mobility implant after closed reduction.
Ochsner J 2016;16:185e90.
[105] Banka TR, Ast MP, Parks ML. Early Intraprosthetic dislocation in a revision
dual-mobility hip Prosthesis. Orthopedics 2014;37:e395e7. https://doi.org/
10.3928/01477447-20140401-63.
[106] Odland AN, Sierra RJ. Intraprosthetic dislocation of a Contemporary dual-
mobility design used during Conversion THA. Orthopedics 2014;37:
e1124e8. https://doi.org/10.3928/01477447-20141124-90.
[107] Philippot R, Boyer B, Farizon F. Intraprosthetic dislocation: a specific
complication of the dual-mobility system. Clin Orthop Relat Res 2013;471:
965e70. https://doi.org/10.1007/s11999-012-2639-2.
[108] Sanders RJM, Swierstra BA, Goosen JHM. The use of a dual-mobility concept
in total hip arthroplasty patients with spastic disorders. Arch Orthop Trauma
Surg 2013;133:1011e6. https://doi.org/10.1007/s00402-013-1759-9.
[109] Epinette JA, Harwin SF, Rowan FE, Tracol P, Mont MA, Chughtai M, et al.
Early experience with dual mobility acetabular systems featuring highly
cross-linked polyethylene liners for primary hip arthroplasty in patients
under fifty five years of age: an international multi-centre preliminary
study. Int Orthop 2017;41:543e50. https://doi.org/10.1007/s00264-016-
3367-0.
[110] Rowan FE, Salvatore AJ, Lange JK, Westrich GH. Dual-mobility vs fixed-
bearing total hip arthroplasty in patients under 55 Years of age: a single-
institution, matched-cohort analysis. J Arthroplasty 2017;32:3076e81.
https://doi.org/10.1016/j.arth.2017.05.004.
[111] Munro JT, Vioreanu MH, Masri BA, Duncan CP. Acetabular liner with focal
constraint to prevent dislocation after THA. Clin Orthop Relat Res 2013;471:
3883e90. https://doi.org/10.1007/s11999-013-2858-1.
[112] Gill K, Whitehouse SL, Hubble MJW, Wilson MJ. Short-term results with a
constrained acetabular liner in patients at high risk of dislocation after pri-
mary total hip arthroplasty. Hip Int 2016;26:580e4. https://doi.org/10.5301/
hipint.5000396.
[113] Hernigou P, Filippini P, Flouzat-Lachaniette CH, Batista SU, Poignard A.
Constrained liner in neurologic or cognitively impaired patients undergoing
primary THA. Clin Orthop Relat Res 2010;468:3255e62. https://doi.org/
10.1007/s11999-010-1340-6.
[114] Yang C, Goodman SB. Outcome and complications of constrained acetabular
components. Orthopedics 2009;32:115.
[115] Guyen O, Lewallen DG, Cabanela ME. Modes of failure of Osteonics con-
strained Tripolar implants: a retrospective analysis of Forty-three failed
implants. J Bone Joint Surg Am 2008;90:1553e60. https://doi.org/10.2106/
JBJS.G.00317.
[116] Jameson SS, Lees D, James P, Serrano-Pedraza I, Partington PF, Muller SD,
et al. Lower rates of dislocation with increased femoral head size after pri-
mary total hip replacement: a five-year analysis of NHS patients in England.
Bone Joint J 2011;93eB:876e80. https://doi.org/10.1302/0301-
620X.93B7.26657.
[117] Amlie E, Høvik Ø, Reikerås O. Dislocation after total hip arthroplasty with 28
and 32-mm femoral head. J Orthop Traumatol 2010;11:111e5. https://
doi.org/10.1007/s10195-010-0097-8.
[118] Bunn A, Colwell CW, D'Lima DD. Effect of head diameter on passive and
active dynamic hip dislocation. J Orthop Res 2014;32:1525e31. https://
doi.org/10.1002/jor.22659.
[119] Lachiewicz PF, Soileau ES, Martell JM. Wear and osteolysis of highly crosslinked
polyethylene at 10 to 14 Years: the effect of femoral head size. Clin Orthop
Relat Res 2016;474:365e71. https://doi.org/10.1007/s11999-015-4319-5.
[120] Howie DW, Holubowycz OT, Middleton R. Large Articulation study group.
Large femoral heads decrease the incidence of dislocation after total hip
arthroplasty. J Bone Joint Surg Am 2012;94:1095e102. https://doi.org/
10.2106/JBJS.K.00570.
[121] Haughom BD, Plummer DR, Moric M, Della Valle CJ. Is there a benefit to head
size greater than 36 mm in total hip arthroplasty? J Arthroplasty 2016;31:
152e5. https://doi.org/10.1016/j.arth.2015.08.011.
[122] Brooks PJ. Hip resurfacing: a large, US single-surgeon series. Bone Joint J
2016;98eB:10e3. https://doi.org/10.1302/0301-620X.98B1.36360.
[123] Mehra A, Berryman F, Matharu GS, Pynsent PB, Isbister ES. Birmingham hip
resurfacing: a single surgeon series reported at a minimum of 10 Years
follow-up. J Arthroplasty 2015;30:1160e6. https://doi.org/10.1016/
j.arth.2015.01.042.
[124] Nawabi DH, Do HT, Ruel A, Lurie B, Elpers ME, Wright T, et al. Comprehensive
analysis of a recalled modular total hip system and Recommendations for
management. J Bone Joint Surg Am 2016;98:40e7. https://doi.org/10.2106/
JBJS.N.01121.
[125] Graves SE, de Steiger R, Davidson D, Donnelly W, Rainbird S, Lorimer MF,
et al. The use of femoral stems with exchangeable necks in primary total hip
arthroplasty increases the rate of revision. Bone Joint J 2017;99:766e73.
https://doi.org/10.1302/0301-620X.99B6.
[126] Molloy DO, Munir S, Jack CM, Cross MB, Walter WL, Walter WK. Fretting and
corrosion in modular-neck total hip arthroplasty femoral stems. J Bone Joint
Surg 2014;96:488e93. https://doi.org/10.2106/JBJS.L.01625.
[127] Gofton WT, Illical EM, Feibel RJ, Kim PR, Beaule  PE. A single-center experi-
ence with a titanium modular neck total hip arthroplasty. J Arthroplasty
2017;32:2450e6. https://doi.org/10.1016/j.arth.2017.03.025.
[128] Colas S, Allalou A, Poichotte A, Piriou P, Dray-Spira R, Zureik M. Exchangeable
femoral neck (Dual-Modular) THA Prostheses have poorer Survivorship than
other designs: a nationwide cohort of 324,108 patients. Clin Orthop Relat Res
2017;475:2046e59. https://doi.org/10.1007/s11999-017-5260-6.
[129] Loppini M, Longo UG, Caldarella E, Rocca ADella, Denaro V, Grappiolo G.
Femur first surgical technique: a smart non- computer-based procedure to
achieve the combined anteversion in primary total hip arthroplasty. BMC
Musculoskelet Disord 2017;18:331. https://doi.org/10.1186/s12891-017-
1688-9.
[130] Ranawat C, Maynard M. Modern technique of cemented total hip arthro-
plasty. Tech Orthop 1991;6:17e25.
[131] Komeno M, Hasegawa M, Sudo A, Uchida A. Computed tomographic evalu-
ation of component position on dislocation after total hip arthroplasty. Or-
thopedics 2006;29:1104e8.
[132] Malik A, Maheshwari A, Dorr LD. Impingement with total hip replacement.
J Bone Joint Surg Am 2007;89:1832e42. https://doi.org/10.2106/
JBJS.F.01313.
[133] Sculco PK, Cottino U, Abdel MP, Sierra RJ. Avoiding hip instability and limb
length discrepancy after total hip arthroplasty. Orthop Clin North Am
2016;47:327e34. https://doi.org/10.1016/j.ocl.2015.09.006.
[134] Naito M, Ogata K, Asayama I. Intraoperative limb length measurement in
total hip arthroplasty. Int Orthop 1999;23:31e3. https://doi.org/10.1007/
s002640050298.
[135] Beamer BS, Morgan JH, Barr CB, Weaver MJ, Vrahas MS, Beamer BS, et al.
Does fluoroscopy improve acetabular component placement in total hip
arthroplasty? Clin Orthop Relat Res 2014;472:3953e62. https://doi.org/
10.1007/s11999-014-3944-8.
[136] Rathod PA, Bhalla S, Deshmukh AJ, Rodriguez JA, Rathod PA, Bhalla S, et al.
Does fluoroscopy with anterior hip arthoplasty decrease acetabular cup
Variability compared with a Nonguided posterior approach? Clin Orthop
Relat Res 2014;472:1877e85. https://doi.org/10.1007/s11999-014-3512-2.
[137] Nam D, Sculco PK, Su EP, Alexiades MM, Figgie MP, Mayman DJ. Acetabular
component positioning in primary THA via an anterior, posterolateral, or
posterolateral-navigated surgical technique. Orthopedics 2013;36:e1482e7.
[138] Domb BG, El Bitar YF, Sadik AY, Stake CE, Botser IB. Comparison of robotic-
assisted and conventional acetabular cup placement in THA: a matched-
pair controlled study. Clin Orthop Relat Res 2014;472:329e36. https://
doi.org/10.1007/s11999-013-3253-7.
[139] Elson L, Dounchis J, Illgen R, Marchand RC, Padgett DE, Bragdon CR, et al.
Precision of acetabular cup placement in robotic integrated total hip
 F.E. Rowan et al. / The Journal of Arthroplasty xxx (2018) 1e9
arthroplasty. Hip Int 2015;25:531e6. https://doi.org/10.5301/
hipint.5000289.
[140] Bukowski BR, Anderson P, Khlopas A, Chughtai M, Mont MA, Illgen RL.
Improved functional outcomes with robotic compared with manual total hip
arthroplasty. Surg Technol Int 2016;XXIX:303e8.
[141] Illgen RL, Bukowski BR, Abiola R, Anderson P, Chughtai M, Khlopas A, et al.
Robotic-assisted total hip arthroplasty: outcomes at minimum two-year
follow-up. Surg Technol Int 2017;30:365e72.
[142] Bargar WL, Bauer A, Bo €rner M. Primary and revision total hip replacement
using the Robodoc system. Clin Orthop Relat Res 1998:82e91.
[143] Dorr LD, Malik A, Dastane M, Wan Z. Combined anteversion technique for
total hip arthroplasty. Clin Orthop Relat Res 2009;467:119e27. https://
doi.org/10.1007/s11999-008-0598-4.
[144] Timperley AJ, Biau D, Chew D, Whitehouse SL. Dislocation after total hip
replacement e there is no such thing as a safe zone for socket placement
with the posterior approach. Hip Int 2016;26:121e7. https://doi.org/
10.5301/hipint.5000318.
[145] Gromov K, Troelsen A, Stahl Otte K, Ørsnes T, Ladelund S, Husted H. Removal
of restrictions following primary THA with postero- lateral approach does
not increase the risk of early dislocation. Acta Orthop 2015;86:463e8.
https://doi.org/10.3109/17453674.2015.1028009.
[146] Smith TO, Sackley CM. UK survey of occupational therapist's and physio-
therapist's experiences and attitudes towards hip replacement precautions
and equipment. BMC Musculoskelet Disord 2016;17:228. https://doi.org/
10.1186/s12891-016-1092-x.
[147] Lee GRH, Berstock JR, Whitehouse MR, Blom AW. Recall and patient per-
ceptions of hip precautions 6 weeks after total hip arthroplasty. Acta Orthop
2017;88:496e9. https://doi.org/10.1080/17453674.2017.1350008.
9
[148] Lübbeke A, Suva  D, Perneger T, Hoffmeyer P. Influence of preoperative
patient education on the risk of dislocation after primary total hip
arthroplasty. Arthritis Rheum 2009;61:552e8. https://doi.org/10.1002/
art.24340.
[149] Peak EL, Parvizi J, Ciminiello M, Purtill JJ, Sharkey PF, Hozack WJ, et al. The
role of patient restrictions in reducing the prevalence of early dislocation
following total hip arthroplasty. J Bone Joint Surg 2005;87:247e53. https://
doi.org/10.2106/JBJS.C.01513.
[150] Restrepo C, Mortazavi SMJ, Brothers J, Parvizi J, Rothman RH. Hip dislocation:
are hip precautions necessary in anterior approaches? Clin Orthop Relat Res
2011;469:417e22. https://doi.org/10.1007/s11999-010-1668-y.
[151] Kornuijt A, Das D, Sijbesma T, van der Weegen W. The rate of dislocation is
not increased when minimal precautions are used after total hip arthro-
plasty using the posterolateral approach: a prospective, comparative safety
study. Bone Joint J 2016;98eB:589e94. https://doi.org/10.1302/0301-
620X.98B5.36701.
[152] Schmidt-Braekling T, Waldstein W, Akalin E, Benavente P, Frykberg B,
Boettner F. Minimal invasive posterior total hip arthroplasty: are 6 weeks of
hip precautions really necessary? Arch Orthop Trauma Surg 2015;135:
271e4. https://doi.org/10.1007/s00402-014-2146-x.
[153] van der Weegen W, Kornuijt A, Das D. Do lifestyle restrictions and pre-
cautions prevent dislocation after total hip arthroplasty? A systematic re-
view and meta-analysis of the literature. Clin Rehabil 2016;30:329e39.
https://doi.org/10.1177/0269215515579421.
[154] Kim Y-H, Choi Y, Kim J-S. Influence of patient-, design-, and surgery-
related factors on rate of dislocation after primary cementless total hip
arthroplasty. J Arthroplasty 2009;24:1258e63. https://doi.org/10.1016/
j.arth.2009.03.017.