HSSJ (2020) 16 (Suppl 2):S245–S255
DOI 10.1007/s11420-019-09704-z
ORIGINAL ARTICLE
Treatment of Recurrent Dislocation after Total Hip Arthroplasty
Using Advanced Imaging and Three-Dimensional Modeling
Techniques: A Case Series
Sean A. Sutphen, DO & Joseph D. Lipman, MS & Seth A. Jerabek, MD & David J. Mayman, MD &
Christina I. Esposito, PhD
Received: 31 January 2019/Accepted: 1 July 2019 /Published online: 25 July 2019
* The Author(s) 2019
Abstract Background: Surgical treatment options for ad-
dressing recurrent dislocation after total hip arthroplasty
(THA) vary. Identifying impingement mechanisms in an
unstable THA may be beneficial in determining appropriate
treatment. Questions/Purposes: We sought to assess the
effectiveness of developing pre-operative plans for treating
hip instability after THA. We used advanced imaging and
three-dimensional modeling techniques to perform impinge-
ment analyses in patients with unstable THA. Methods: We
evaluated a series of eight patients who would require revi-
sion THA to treat recurrent dislocation. Using a pre-
operative algorithmic approach, we built patient-specific
models and evaluated hip range of motion with computed
tomographic scanning and biplanar radiography. This infor-
mation was used to determine a surgical treatment plan that
was then executed intra-operatively. Patients were followed
for 2 years to determine whether they experienced another
hip dislocation following treatment. Results: Pre-operative
kinematic modeling showed four of the eight patients had
limited hip range of motion during flexion and internal
Level of Evidence: Therapeutic Study Level IV
Electronic supplementary material The online version of this article
(https://doi.org/10.1007/s11420-019-09704-z) contains supplementary
material, which is available to authorized users.
S. A. Sutphen, DO : J. D. Lipman, MS : S. A. Jerabek, MD :
D. J. Mayman, MD : C. I. Esposito, PhD (*)
Hospital for Special Surgery,
535 East 70th Street,
New York, NY 10021, USA
e-mail: ciesposito@gmail.com
rotation; a prominent anterior inferior iliac spine (AIIS)
was found to limit hip range of motion in some of these
cases. In the other four patients, range of motion was ac-
ceptable, suggesting soft-tissue causes of dislocation. No
patients in this series experienced dislocation after undergo-
ing revision THA. Conclusion: Advanced modeling tech-
niques may be useful for identifying the impingement
mechanisms responsible for instability after THA. Once
variables contributing to limited hip range of motion are
identified, surgeons can develop treatment plans to improve
patient outcomes. Resecting a hypertrophic AIIS may im-
prove hip range of motion and may be an important consid-
eration for hip surgeons when revising unstable THAs.
Keywords dislocation . impingement . instability .
surgical planning . total hip arthroplasty
Introduction
Dislocation is one of the most common complications seen
after total hip arthroplasty (THA). It can occur during the
early or late post-operative period [6]. Reported rates of
dislocation range from 0.1 to 9% after primary THA and 5
to 30% after revision THA [1, 16, 17, 24, 37, 39]. Single
episodes of instability may be successfully treated with
reinforcement of “hip precautions” (exercises and activities
to avoid) if the components are properly aligned and proper
hip mechanics have been restored. However, in approxi-
mately a third of patients with dislocation, conservative
treatments fail and surgery is required [14]. Recurrent dislo-
cation after THA can be devastating and is the most com-
mon reason for revision THA in the USA, accounting for
S246 HSSJ (2020) 16 (Suppl 2):S245–S255

Table 1 Patient demographics liners might be greater wear of the liner and greater taper
corrosion [15, 35]. Constrained or tripolar cup designs
Patient no. Age Sex Time to post-THA dislocation event (months)
have reduced post-operative dislocation rates, but mechan-
ical failure of the locking ring or dissociation of the
1 43 F 72
2 62 F 12
cemented liner continues to be a problem [44]. The use
3 51 F 8 of dual-mobility constructs has led to a clear improvement
4 61 M 9 in terms of preventing dislocation, reducing the disloca-
5 69 F 7 tion rate to 4% in revision THA after 6 months, but
6 75 F 5 whether their ability to provide long-term stability or
7 74 M 12
8 63 F 120 fixation longevity remains unknown [39].
Developing a plan for surgical treatment of dislocation
THA total hip arthroplasty may be difficult if the causes of instability are unclear.
Dislocation after THA is thought to be related to impinge-
ment, a mechanical abutment between bone, implants, or
approximately 23% of revision THAs performed [9]. Unfor- soft tissues. Impingement is a dynamic process that is diffi-
tunately, surgical intervention does not always improve hip cult to identify or characterize on the basis of clinical eval-
stability, and there remains a 21 to 30% risk of recurrent hip uation or plain radiographs [32] and may be driven by
dislocation after revision THA [8, 12]. multiple factors, including hip offset, implant design, com-
Surgical procedures commonly used to treat hip insta- ponent position, and bony geometry. An understanding of
bility include increasing femoral head size; correcting the underlying dislocation mechanism is crucial to determin-
malpositioned components; using an elevated liner, a ing the appropriate surgical treatment for the instability [2,
dual-mobility construct, or a constrained liner; and 13, 14, 23, 43].
repairing the soft tissues [28, 34]. The literature shows An algorithmic approach to identifying types of impingement
varying effectiveness of strategies for treating dislocation. in THA may direct whether component revision or bony resec-
A larger-diameter femoral head reduces the risk of dislo- tion would be more effective in improving hip range of motion
cation caused by greater jumping distance and a greater during revision surgery for instability. We used advanced imag-
range of motion before impingement [7, 27, 41]. But ing and three-dimensional modeling techniques to identify the
possible drawbacks of a larger head size in polyethylene type of impingement (bone on bone or implant on implant)

Fig. 1. Algorithm for pre-operatively planning the surgical management of hip.

HSSJ (2020) 16 (Suppl 2):S245–S255 S247

Fig. 2. Acetabular inclination, acetabular anteversion, and femoral anteversion were measured in a 51-year-old woman. a An anteroposterior
view of a pelvis 3-dimensional computed tomographic reconstruction shows an acetabular component with 44° of radiographic inclination. b A
sagittal view of the same pelvis shows the acetabular component having 24° of radiographic anteversion. c The coupled femoral component from
the same total hip arthroplasty had 25° of femoral anteversion.

occurring during simulated dislocation activities in patients un- instability. This series of patients was followed for 2 years after
dergoing revision surgery for instability to guide the development revision surgery to determine whether the treatment plan im-
of a pre-operative plan to improve hip range of motion and treat proved hip stability in the short term.

Fig. 3. a A 3-dimensional computed tomographic (CT) reconstruction is shown of a 75-year-old woman lying supine in the CT scanner. b The
CT model was superimposed over a standing radiograph to show the functional position of the pelvis, femur, and implants in standing position.
There was an increase in posterior pelvic tilt from supine to standing; as a result, the functional anteversion of the acetabular component increased
from supine to standing. c A head-to-toe standing radiograph shows a large thoracic scoliosis curve.
S248 HSSJ (2020) 16 (Suppl 2):S245–S255

Fig. 4. a A sitting pelvis radiograph shows the alignment of the pelvis in the coronal plane. b The 3-dimensional computed tomographic (3D CT)
model of the pelvis was aligned in the coronal plane matching the radiograph shown in (a). c The sitting lateral pelvis radiograph shows the
alignment of the pelvis in the sagittal plane. d The 3D CT reconstruction of the pelvis was aligned in the sagittal plane matching the radiograph
shown in (c). The coronal and lateral radiographs were taken simultaneously using the EOS imaging system, so we could align the pelvis model 3-
dimensionally in a sitting position.

Materials and Methods
We obtained institutional review board approval to conduct
a case series. We identified eight patients (two men, six
women; mean age, 62 years) who experienced recurrent
dislocation after THA from 2013 to 2015 (Table 1). The
selection criteria were patients who required revision sur-
gery for dislocation by two surgeons (D.J.M. or S.A.J.)
during the 2-year period. All original THAs were performed
using the posterior approach, and all hip dislocations oc-
curred posteriorly as patients rose from a low chair, tied
shoes, or bent over to reach objects. We had developed an
algorithmic approach to pre-operatively identify the type of
impingement occurring in each patient and to develop a
treatment plan for each patient (Fig. 1). We built three-
dimensional bone and implant models from advanced imag-
ing and measurements of acetabular and femoral implant
position (Fig. 2). Each patient underwent a computed tomo-
graphic (CT) scan, as well as standing biplanar frontal and
lateral plane two-dimensional radiographs from the spine to
the ankles using a low-dose radiation system (EOS Imaging
System, EOS Imaging, SA., Paris, France). As the planning
algorithm matured, we added sitting biplanar radiographs to
account for pelvic alignment in different functional posi-
tions. CT scans were taken supine and included the pelvis
from the anterior superior iliac spines to the proximal third
of the femur, as well as the distal femur, in order to measure
femoral torsion. The CT scans were segmented using
MIMICs software (Materialise, Leuven, Belgium), and seg-
mentation data from the pelvis, proximal femur, distal femur,
femoral component, and acetabular component were
exported as .stl files. We then aligned the models to func-
tional imaging (standing, sitting, and supine radiographs) to
simulate range of motion and measure component position
in functional positions (Figs. 3 and 4).
We simulated the patient activities during which the hips
dislocated to determine range of motion to impingement. To
do so, the CT files were imported into a multibody dynamic
modeling software (SimWise 4D, Design Simulation Tech-
nologies, Canton, MI, USA) for range of motion analysis
(Fig. 5). Because the posterior dislocations occurred with
flexion, adduction, and internal rotation, we calculated the
range of motion to maximum flexion (with neutral abduction
and neutral rotation) and maximum internal rotation at 90°
of flexion (with neutral abduction). In the model, the pelvis
was fixed in position, and the femur was rotated about the
center of the femoral head in the motions described above.
Contact conditions were established, so the analysis ended
when contact was detected. To determine the threshold
values for the acceptable or limited range of motion using
our modeling methodology, we had previously measured
maximum hip flexion, internal rotation at 90° of flexion,
and external rotation at 20° of extension in seven fresh-
frozen cadaveric pelvis-to-knee specimens from donors
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Fig. 5. The top row demonstrates how different surgical plans change maximum hip flexion in a 51-year-old woman with instability. Without
treatment, the patient had maximum flexion to 105°. When the anterior femoral osteophyte was removed in the model (as shown in Fig. 6), hip
flexion increased to 106°. When the anterior inferior iliac spine bone was also removed (as shown in Fig. 7), hip flexion further increased to 113°.
In addition, if the neck length increased 4 mm with a high-offset head (as shown in Fig. 8), hip flexion increased to 114°. The bottom row shows
how the same surgical plans also improved hip internal rotation at 90° of flexion.

Fig. 6. a A 3-dimensional computed tomographic (CT) reconstruction of the proximal femur shows an anterior femoral osteophyte (blue arrow).
b A transverse CT slice also shows the presence of the anterior femoral osteophyte (blue arrow). c A sagittal view of the proximal femur shows the
surgical plan for removal of the osteophyte intra-operatively (blue arrow indicates the location of bone removal).
S250 HSSJ (2020) 16 (Suppl 2):S245–S255

Fig. 7. a A 3-dimensional computed tomographic reconstruction of a pelvis shows the location of the anterior inferior iliac spine (AIIS) (blue
arrow). b The same pelvis is rotated axially to show the location of the AIIS and the surgical plan to remove bone intra-operatively.

who had undergone THA. We found mean hip flexion to be
118° ± 6°, mean internal rotation to be 38° ± 3°, and mean
external rotation to be 28° ± 5°. Two standard deviations
below the means were 106° for flexion, 32° for internal
rotation, and 20° for external rotation, which were the values
we used to identify limited hip range of motion.
The location and type of impingement (bone on bone or
implant on implant) were determined and used to develop a
pre-operative plan for improving range of motion. Surgical
options for improving hip range of motion included reorien-
tation of the acetabular component, reorientation of the
femoral component, revision of the femoral head to increase
hip offset, and removal of impinging bone (Fig. 1).
The images shown in Figs. 4, 5, 6, 7, and 8 are repre-
sentative of the pre-operative planning algorithm, al-
though the patient, a 51-year-old woman undergoing
revision surgery for hip dislocation, was not included in
our study. Figure 5 shows how different surgical plans
improve hip range of motion. Before treatment, the patient
had limited range of motion in flexion and internal rota-
tion as a result of bone-on-bone impingement between the
anterior inferior iliac spine (AIIS) and the anterior aspect
of the proximal femur; there was evidence of a prominent
AIIS and a proximal femoral osteophyte, so the pre-
operative plan was to remove bone at these locations
(Figs. 6 and 7). The model showed that this plan would
improve the patient’s range of motion from 105 to 113° of
flexion and from 18 to 32° of internal rotation (Fig. 5). If
the surgeon also elected to increase the neck length an
additional 4 mm with the use of a high-offset head or
lateralized liner, the hip range of motion would improve
further, to 114° of flexion and 38° of internal rotation
(Figs. 5 and 8).
In our study, revisions were performed through the pos-
terior approach, and patients were followed for 2 years to
determine outcomes.

Fig. 8. A 3-dimensional computed tomographic reconstruction shows the surgical plan to increased neck length along the neck of the femoral
stem. Increasing the neck length by 4 mm showed improved hip range of motion in maximum flexion and internal rotation at 90° (see Fig. 5).
HSSJ (2020) 16 (Suppl 2):S245–S255 S251

Internal rotation impingement type

Results

The eight patients in this case series who experienced recur-

rent dislocations had variability in component orientation,
hip range of motion, and hip impingement mechanisms
Implant on implant
Implant on implant

Implant on implant
(Table 2). Four out of the eight patients had acetabular
Implant on bone
Did not flex 90°

components within the “Lewinnek safe zone” (40° ± 10° of

Bone on bone
Bone on bone

Bone on bone
inclination and 15° ± 10° of anteversion) when they
dislocated, which indicates that this traditional safe zone
does not provide a low risk of dislocation for every patient.
In four patients (patients 1, 4, 5, and 7), hip range of
motion was limited in flexion (less than 106°) or inter-
nal rotation (less than 32°); in three of these patients
Did not flex 90°
Internal rotation

(patients 1, 4, and 5), there was bone-on-bone impinge-

ment involving either the AIIS or an acetabular osteo-
phyte, and in two patients (patients 4 and 5), the
femoral component was in retroversion (Table 2). Patient
68°
36°

63°
22°
40°

18°
0°

4 had a large AIIS that required resection of 1 cm of

bone in order to prevent future anterior impingement on
Flexion impingement type

the femur. Patient 1 not only had a prominent AIIS but

also had a proximal femoral osteophyte, which limited
range of motion at the hip to only 83° of maximum
Implant on implant
Implant on implant

Implant on implant

flexion (Table 2). The osteophyte was removed intra-

Bone on bone

Bone on bone

Bone on bone
Bone on bone

Bone on bone

operatively. Figures 9 and 10 show a 69-year-old wom-

an (patient 5) with a prominent AIIS and a cemented
femoral component in retroversion. The AIIS and the
position of the femoral component were not apparent on
the conventional radiographs (Fig. 9). The surgical plan
for this patient (Fig. 10) was to remove AIIS bone and
Max flexion

to reorient the cemented femoral component with greater

anteversion.
130°

148°
120°

104°
144°
110°

The other four patients in this study (patients 2, 3, 6,

83°

90°

and 8) had acceptable ranges of motion (Table 2). This

suggested possible soft-tissue causes of dislocation. In
these patients, the surgical plan was to revise the ace-
Femoral anteversion

tabular component and implant either a dual-mobility

2° retroversion
6° retroversion

bearing or an elevated liner (Table 3).

In summary, all but one patient underwent an acetabular
component revision, and two patients underwent a femoral
component revision for the treatment of recurrent dislocation
16°
17°
13°

24°
7°
0°

in this study. No patients in this case series experienced a

dislocation within 2 years after revision surgery.
Cup anteversion
Table 2 Implant position and hip range of motion

Discussion
29°

20°
19°

27°
43°

10°
8°

0°

Impingement involving bone, implant, or soft tissues is an

important consideration in the surgical treatment of instabil-
ity after THA [3, 4, 10, 33, 36]. Modeling hip kinematics
Cup inclination

may elucidate the underlying impingement mechanism re-

sponsible for hip dislocation. We considered implant posi-
tion, hip range of motion, and location of impingement when
developing a strategy for treating hip instability. In four
38°
41°
42°
51°
41°
32°
49°
40°

patients, we found limited hip range of motion attributed to

bone or implant impingement. However, in the other four
Patient no.

patients, there was no evidence of limited hip range of

motion when we considered bone and implants alone, sug-
gesting soft-tissue causes of dislocation. To our knowledge,
1
2
3
4
5
6
7
8
S252
Fig. 9. a A pelvis radiograph of a 69-year-old woman after left total hip arthroplasty (THA). b A radiograph of the same patient with a THA
dislocation on the left side. c A head-to-toe standing radiograph of the same patient shows bilateral THA, a right total knee arthroplasty, and a
large thoracic scoliosis curve.
this is the first study to use a dynamic modeling tool for pre-
operative planning of revision THA.
There are limitations to our study design. First, this study
applied the treatment algorithm only to eight patients with
hip instability; however, it is difficult to collect a large group
of patients with hip dislocations because the dislocation rate
after primary THA is low (1 to 3%). Second, although we
used advanced imaging pre-operatively to develop treatment
plans, we did not do so post-operatively to confirm surgical
execution. We cannot be certain of how implants were
reoriented or how much bone was removed during revision
surgery. Third, we did not include pelvic tilt or leg length as
a part of our algorithm because that would have necessitated
a more complex and time-intensive analysis. Because these
are important variables, we hope future models will auto-
matically incorporate different pelvic tilt positions and leg
lengths into the algorithm. Fourth, as a case series, our study
may have involved selection bias; also, because it did not
have a control group, the generalizability of our findings
may be limited. Finally, we did not take soft tissues into
account in our modeling efforts, but it is clear that soft-tissue
repair is an important part of THA stability [38].
Bony impingement was common in our modeling anal-
ysis and may not be detected by THA surgeons because
HSSJ (2020) 16 (Suppl 2):S245–S255
prominent bony features such as the AIIS cannot be seen
on conventional anteroposterior radiographs. It is important
to remember the principles regarding impingement in the
native hip put forth by Ganz and colleagues [5, 22, 42]. An
underlying bone-on-bone impingement in a patient’s native
osteoarthritic hip may continue after THA [32]. AIIS defor-
mity has been shown to be an extra-articular source of
impingement in the native hip [25], and hypertrophy of the
AIIS has been shown to limit hip range of motion [26]. Our
models suggest mechanical abutment can occur between the
AIIS and the femoral bone in patients with unstable THAs.
In our study, bone-on-bone impingement occurred most
commonly in hips with decreased anteversion of the femoral
stem (less than 5°) and short neck length with the distal end
of the AIIS and anterior superior aspect of the capsule often
having to be excised.
Precision is important when placing THA implants because
implant malalignment has been associated with instability, high
wear, and poor hip range of motion [18, 32, 40]. We identified
implant malalignment in hips with limited motion as a result of
implant impingement. However, it was difficult to determine
what the new alignment target needed to be for a malpositioned
component, and the intra-operative execution of the pre-operative
plan was not always easy. Component revision can be difficult,
HSSJ (2020) 16 (Suppl 2):S245–S255 S253

Fig. 10. The computed tomographic scan from the 69-year-old patient shown in Fig. 9 was reconstructed. The images on the left show the left
cemented femoral component was in 6° of retroversion. The model suggested limited hip range of motion, with maximum flexion of 104° and
internal rotation of 18°. A potential treatment plan is shown in the images on the right. If the femoral component was revised to 14° of anteversion,
hip range of motion improved to 119° maximum flexion and 32° internal rotation.

and it is not always in the best interest of the patient to remove a
well-fixed implant [11]. For example, in patient 4, the femoral
stem was found to be in 2° of retroversion, which was an
indication for revising the femoral component (Table 2). How-
ever, the surgeon did not do so because he performed an intra-
operative hip range of motion check and found no evidence of
impingement after the cup was revised and the AIIS was resected.
Rather than revising components, surgeons may elect to be
conservative and increase neck length to improve hip range of
motion. In all but one patient in this series (patient 7), a dual-
mobility bearing or elevated liner was implanted for improved
hip stability. Although these constructs may contribute to the
favorable outcomes we report in this series, our models showed
that merely exchanging a bearing for a dual-mobility construct
may not solve a bone-on-bone impingement problem.
Accurate pre-operative assessment of implant position and
impingement is dependent on the functional orientation of the
pelvis and the femur during the performance of activities of daily
living and the assumption of provocative positions that cause
instability [30]. We used functional imaging in both the standing
and sitting positions to align the pelvis and the femur in our
models. In most patients, the pelvic tilt and femoral rotation in the
CT scan differed depending on whether the patient was standing
or seated (Fig. 3). Pelvic tilt will affect range of motion to
impingement and is directed by the spine mechanics [20, 29].
Interestingly, all patients in this study had cervical, thoracic, or
lumbar spine disease (or a combination of these). Two patients in
our study had large thoracic scoliosis curves (Figs. 3 and 9).
Spine disease can limit a patient’s ability to accommodate pos-
tural changes through the lumbar spine, which alters hip kine-
matics and increases the risk of hip dislocation [21].
The pre-operative planning performed in these cases required
extensive communication between the modeling analyst and the
orthopedic surgeon. Impingement modeling may show improved
range of motion with component revision, but the orientation of
the implants or the bony resections performed intra-operatively
should still remain within an acceptable clinical range. Tradition-
ally, the Lewinnek safe zone has been used as an indicator of a
low risk of hip dislocation [31]. Interestingly, half of the patients
in our study had acetabular components within the safe zone, and
they still experienced hip dislocation. This supports evidence in
more recent research showing that a truly safe zone for acetabular
component position alone does not exist [19]. One incentive for
surgeons to consider using this time-intensive pre-operative
modeling algorithm is to avoid constrained liners, which may
be beneficial in patients who have either instability of unclear
etiology or cognitive problems but may not be ideal for high-
demand (more active) patients requiring revision THA [44]. All
patients in this study experienced posterior hip dislocations.
However, by evaluating hip external rotation range of motion
in extension, a similar algorithm could be used to determine
treatment in patients with anterior hip dislocations. In future
S254 HSSJ (2020) 16 (Suppl 2):S245–S255

anterior femoral osteophyte

Location of bone removed

Anterior pelvic osteophyte

studies, this kinematic modeling platform can be used to plan
optimal implant position or bony resections around native hips or
THAs.
AIIS and proximal

Compliance with Ethical Standards

AIIS Conflict of Interest: Sean A. Sutphen, DO, and Christina I. Esposito,

No
No

No
No
No
PhD, declare that they have no conflicts of interest. Joseph D. Lipman,
MS, reports royalties from Exactech, Inc., Lima Corporate, Mathys
Acetabular component revision Dual-mobility construct 20° elevated liner Femoral component revision

Ltd., and Ortho Development Corporation, outside the submitted work.

Seth A. Jerabek, MD, reports personal fees, royalties, and grants from
Stryker and stock or stock options from Imagen Technologies, outside
the submitted work. David J. Mayman, MD, reports personal fees and
grants from Smith & Nephew, stock or stock options from Imagen
Technologies and OrthAlign, and board membership in the Knee
Society, outside the submitted work.

Human/Animal Rights: All procedures followed were in accordance

Yes

Yes
No

No
No
No

No

No

with the ethical standards of the responsible committee on human

experimentation (institutional and national) and with the Helsinki
Declaration of 1975, as revised in 2013.

Informed Consent: Informed consent was obtained from all patients

for being included in this study.
Yes

Yes
No

No

No
No

No
No

Required Author Forms Disclosure forms provided by the authors

are available with the online version of this article.

Open Access This article is distributed under the terms of the Creative
C o m m on s At t r ib u t i o n 4 .0 I n t e r n a t i on a l Li c e n s e (h t t p : //
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use, distribution, and reproduction in any medium, provided you give
appropriate credit to the original author(s) and the source, provide a
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link to the Creative Commons license, and indicate if changes were

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