DUAL MOBILITY CUPS – KHOULA Hospital EXPERIENCE Dr. Jatinder S. Luthra MS, DNB, MRCS Dr. Mohamad Kasim Allami FRCS, FRCS ( Trauma & Ortho)

THR – 1.5 million worldwide One of most succesful procedure

Rate of THR grow by 174% by 2030 The Burden of Hip Osteoarthritis in The United States : epidemiologi and economic consideration NHO et al JAAOS 2013

THR – Dislocation Cumulative risk of dislocation increases with time Posterolateral approach > 70 years Head Diameter Female Sex The cumulative long –term risk of dislocation after primary Charnley total hip arthroplasty Berry et al JBJS 2004

Surgical Factors Implant Factors Patient Factors Impingement Jump Distance Reduction

Dual Mobility - Concept Gilles Bosquet and Raoul Lambart Based on Low friction arthroplasty ( Charnley) Low dislocation rate – Large Femoral Head (Mackee Farrar)

Larger femoral head reduced dislocation -Better head neck ratio – better movement -Greater translocation is required before dislocation

3 components & 3 joints - Acetabular socket (cemented / cementless) Poly Liner Metal / Ceramic head Liner is free in acetabular component

Small Joint – Poly liner & head Large joint – Poly liner metal cup Recruitment Phenomenon

Indications > 65 yrs Prior Hip Surgery Neuromuscular disease Cognitive Dysfunction ASA > 3 Revision THR

Khoula Experience Early results Mar 2011 – Till Date

Total 47 cases Male – 18 Female – 29 Age range from – 23 yrs to 91 yrs – Mean age 61 yrs Patients < 40 yrs – 5 Patients > 40 Yrs - 42 Multisurgeon study

Total Case - 47 Primary THR Revision THR 22 27

Primary THR Osteoarthritis - 12 # Neck Femur – 7 # Acetabulum – 2 Sickler - 1

Revision THR Failed DHS - 5 Failed Hemi - 9 Infection - 3 Periprosthetic fracture - 2 Revision THR - 4 Failed Osteosynthesis - 2

Posterior approach Avantage Privelege Cup system ( Biomet) Patients with high risk of post op dislocation

Acetabular Size Size Size 46 – 10 Size 48 – 5 Size Size

Femoral Sizes Size Size Size Size Size

Cemented – 36 (76%) Uncemented - 2 (4%) Hybrid – 9 ( 19%)

Fluoroscopic evaluation 7 pt agreed in follow up to undergo fluoroscopic evaluation No impingement at extremes of movement

Fluoroscopic evaluation

Complications Deep infection – 1 Dislocation – 1 Mortality – 1 Intraop Fracture - 2

Results Follow up range from 4mths to 42mths Good early Results in high risk cases in Omani population Dislocation - 2% ( Revision THR)

Radiological Evaluation No reported cases of osteolysis No signs of aseptic loosening Fluoroscopy demonstrates – no impingement

Dual mobility cup - Sickler

Dual mobility cup – Failed Osteosynthesis

Dual mobility cup - # Neck Femur

Dual mobility cup – Failed DHS

Dual mobility cup – Failed Hemi

Dual mobility cup - Arthritis

Dual mobility cup – Post Infection

Dual mobility cup – Old Acetab. #

Dual mobility cup – Revision THR

Intraprosthetic dislocation Concern about early Intraprosthetic Dislocation in Dual Mobility Implants Marc et Al JBJS Case Connector 2013 Femoral head dislodgement complicating use of a Dual Mobility Prosthesis for recurrent Instability Banzhof et al Journal of Arthroplasty 2010 Severe Metallosis owing to intraprosthetic dislocation in a failed Dual – mobility cup Primary Total Hip Arthroplasty Mohammad et al Journal of Arthroplasty 2011

Dual mobility cups in primary THR 10 years follow up survivorship – 94% – 97% Dislocation rate 0%-1% Causes of failure – Aseptic loosening Excessive PE wear

StudyHipsSurvivorshipYears Aubriot, %5 Farizon %10 Leclerc, %10 Philippot, %10 Philippot, %10

Dislocation in Primary THR – Dual Mobility Cup StudyNo of CasesNo of Dislocation Philippot, Aubriot, Vanel, Bejui- Hughes, Philippot,

Dual Mobility cup in Revision THR Dislocation after conventional THR – dislocation 5% to 30 %  Muscular insufficiency  Bone loss Aggressive capsulectomy  Difficulty in implant positioning

Dislocation in Revision THR – Dual Mobility Cup StudyNo Of Revision THRNo of Dislocation Aubriot, Beguin, SFHG, Guyen,

Dual mobility in fracture neck femur Mean Dislocation rate - 10 % ( conventional THR) Tarasevicius et al compared dislocation rates for DM cup and conventional cups At 1 year 14 % dislocation in conventional gp and no dislocation in DM gp

Dual mobility in tumor resection Bone loss & soft tissue compromise – high dislocation rate Philippeau et al – 9 % dislocation in 71 pt with Tumor resection Can be further reduced by reattaching abductors and avoid gluteus max resection

Dual mobility cup in spastic disorder Dislocation rate – 14 % Sanders et al – 10 hips – no dislocation – 3 yrs

Summary Excellent implant for Thr in high risk patients in middle east population Constrained liners are not needed Elderly pt with fracture neck femur – Dual mobility cup is treatment of choice

THANK YOU