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

2. THR – 1.5 million worldwide One of most succesful procedure

3. 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

4. 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

5. Surgical Factors Implant Factors Patient Factors Impingement Jump Distance Reduction

6. Dual Mobility - Concept Gilles Bosquet and Raoul Lambart - 1975 Based on Low friction arthroplasty ( Charnley) Low dislocation rate – Large Femoral Head (Mackee Farrar)

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

8. 3 components & 3 joints - Acetabular socket (cemented / cementless) Poly Liner Metal / Ceramic head Liner is free in acetabular component

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

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

11. Khoula Experience Early results Mar 2011 – Till Date

12. 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

13. Total Case - 47 Primary THR Revision THR 22 27

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

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

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

17. Acetabular Size Size 44 - 25 Size 46 – 10 Size 48 – 5 Size 50 - 4 Size 52 - 3

18. Femoral Sizes Size 7 - 8 Size 9 - 26 Size 11 - 10 Size 13 - 2 Size 15 - 1

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

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

21. Fluoroscopic evaluation

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

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

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

25. Dual mobility cup - Sickler

26. Dual mobility cup – Failed Osteosynthesis

27. Dual mobility cup - # Neck Femur

28. Dual mobility cup – Failed DHS

29. Dual mobility cup – Failed Hemi

30. Dual mobility cup - Arthritis

31. Dual mobility cup – Post Infection

32. Dual mobility cup – Old Acetab. #

33. Dual mobility cup – Revision THR

34. 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

35. 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

36. StudyHipsSurvivorshipYears Aubriot, 1993 10097%5 Farizon 199813595.4%10 Leclerc, 199915396%10 Philippot, 2004 10694.6%10 Philippot, 2006 10095%10

37. Dislocation in Primary THR – Dual Mobility Cup StudyNo of CasesNo of Dislocation Philippot, 20041060 Aubriot, 19931101 Vanel, 20031271 Bejui- Hughes, 20061670 Philippot, 2006700

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

39. Dislocation in Revision THR – Dual Mobility Cup StudyNo Of Revision THRNo of Dislocation Aubriot, 1995130 Beguin, 2002420 SFHG, 20064038 Guyen, 2009543

40. 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

41. 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

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

43. 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

44. THANK YOU