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The Journal of Bone & Joint Surgery, Volume 83, Issue 2 suppl 1

Scientific Article | October 01, 2001

Prevalence of Dislocation After Total Hip Arthroplasty Through a Posterolateral Approach with Partial Capsulotomy and Capsulorrhaphy

Wayne M. Goldstein, MD; Thomas F. Gleason, MD; Matthew Kopplin, MD; Jill J. Branson, BSN, RN

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Wayne M. Goldstein, MD
Thomas F. Gleason, MD
Jill J. Branson, BSN, RN
The Center for Orthopaedic Surgery, Illinois Bone and Joint Institute, 150 North River Road, Suite 100, Des Plaines, IL 60016

Matthew Kopplin, MD
Department of Orthopaedics, University of Illinois at Chicago, 209 Medical Sciences South, 901 South Wolcott Avenue, Chicago, IL 60612-7342

In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from Smith and Nephew. In addition, one or more of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity (Smith and Nephew). No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

The Journal of Bone & Joint Surgery. 2001; 83:S2-7

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Abstract

Abstract

The senior author altered his surgical technique during total hip arthroplasty from capsulectomy and capsulotomy with closure of the external rotator muscles to capsulotomy and capsulorrhaphy. One thousand patients (500 treated with each procedure) were studied retrospectively in order to determine the prevalences of dislocation after surgery with the two different techniques. The prevalence of dislocation was 2.8% after the capsulectomy and capsulotomy, whereas it was 0.6% after the new technique; this was a significant decrease in the rate of dislocation (p < 0.005, Image not available = 0.10).

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Introduction

Introduction | Methods | Results | Conclusions | References

Hip dislocation and its complications after arthroplasty can be painful and can lengthen the patient’s rehabilitative time-period. Recurrent dislocation can affect the patient’s well-being and can be an expensive chronic problem because of repeat emergency-room visits or hospitalizations. Morrey estimated that $60 to $75 million will be spent in the United States annually to treat this complication¹. Dislocation after surgery has been attributed to several different causes, including implant position, soft-tissue tension or instability, disruption of the trochanteric abductor mechanism, impingement, lack of patient cooperation, and unknown factors^2,3. Clough and Hodgkinson found initially unexplained instability to be caused by the development of a large, sterile, fluid-filled cavity bounded by a pseudocapsule around the implant neck³. The prosthesis dislocates into this cavity, and it can be successfully treated with a two-stage surgical technique. The rate of posterior dislocation after total hip replacement through a posterior approach has been reported to be 1% to 9%^4,5. In 2000, Chiu et al. reported, after a thirty-eight-month follow-up period, no dislocations in ninety-six hips in which the wound had been closed with capsulorrhaphy compared with two dislocations in eighty-four hips in which the wound had been closed without capsulorrhaphy². Pellicci et al. found a significant decrease in the dislocation rate after total hip arthroplasties performed with an enhanced posterior repair that reconstructed, as completely as possible, the posterior soft-tissue sleeve⁶.

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Fig. 1:: Fig. 1 Lateral capsular cut along the femoral neck.

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Fig. 2:: Fig. 2 "T" cut along the femoral neck.

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Fig. 3:: Fig. 3 Forming the double door.

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Fig. 4:: Fig. 4 Completion.

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Fig. 5:: Finished posterior capsulotomy.

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Fig. 6:: Anterior capsulotomy with curved 8-in (20.3-cm) clamp anteriorly.

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Figs. 7 and 8:: Fig. 7 Repair of posterior flaps. Fig. 8 Completed capsular flap repair.

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Fig. 9:: Completion of repair with suture of external rotators.

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Fig. 10:: Fig. 10 Hip before posterior dislocation.

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Fig. 11:: Fig. 11 Hip after posterior dislocation.

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Fig. 12:: Fig. 12 Hip before anterior dislocation.

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Fig. 13:: Fig. 13 Hip after anterior dislocation.

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TABLE I: Data on Fourteen Patients with Dislocation After Total Hip Arthroplasty with Capsulotomy Only

Patient	Implant (Primary)	Area of Dislocation	Treatment for Dislocation	Follow-up Status
45-yr-old man, 5 ft, 10 in [177.8 cm], 195 lb [88.5 kg]	Optifix 20° liner, information on other components not available	Posterior	Multiple closed reductions	Continues to dislocate
79-yr-old woman, 5 ft, 1 in [154.9 cm], 136 lb [61.7 kg]	52-mm Biomet high-wall liner, 28-mm + 8-mm head, 10-mm cemented Geri stem	Posterior	Revised to 10° high-wall liner, failed; then revised to 35° liner, succeeded	Success
78-yr-old man, deceased, 6 ft, 2 in [188 cm], 227 lb [103 kg]	62-mm Optifix 20° liner (lip posterior), 28-mm + 12-mm head, 14-mm cemented Geri stem	Posterior	Multiple closed reductions, treated with hip spica cast	Success
85-yr-old woman, 5 ft [152.4 cm], 130 lb [59 kg]	52-mm Optifix 20° liner (lip posterior), 28-mm + 8-mm head, 10-mm cemented Geri stem	Posterior	Revised to 35 liner	Success
66-yr-old woman, 5 ft, 7 in [170.2 cm], 136 lb [61.7 kg]	55-mm Reflection 20 liner, 28-mm head, other neck and stem sizes not known	Posterior	Multiple reductions	Continues to dislocate
61-yr-old man, 5 ft, 10 in [177.8 cm], 180 lb [81.6 kg]	62-mm Biomet high-wall liner, 28-mm + 3-mm head, 15-mm cemented Answer stem	Posterior	Revised to 35 liner, 20-mm + 6-mm head	Continues to dislocate
60-yr-old woman, 5 ft, 5 in [165.1 cm], 160 lb [72.6 kg]	50-mm Biomet high-wall liner, 28-mm standard head, 11-mm uncemented Integral stem	Posterior	Revised to 10 high-wall liner, failed; then revised to 35° liner, succeeded	Success
86-yr-old man, 5 ft, 11 in [180.3 cm], 205 lb [93 kg]	62-mm Biomet high-wall liner, 28-mm + 3-mm head, 15-mm cemented Answer stem	Posterior	Multiple closed reductions	Continues to dislocate, not surgical candidate
51-yr-old woman, 5 ft, 4 in [162.6 cm], 160 lb [72.6 kg]	50-mm Biomet high-wall liner, 28-mm + 3-mm head, stem information not available	Posterior	One closed reduction	Success
83-yr-old man, 5 ft, 6 in [167.6 cm], 185 lb [83.9 kg]	60-mm Biomet high-wall liner, 28-mm + 3-mm head, stem information not available	Posterior	Revised to press-fit bipolar prosthesis	Success
72-yr-old man, 6 ft, 2 in [188 cm], 290 lb [131.5 kg]	58-mm Biomet high-wall liner, 28-mm + 3-mm head, 15-mm cemented Answer stem	Posterior	Stopped dislocating after 6 mo	Success
43-yr-old woman, 5 ft, 2 in [157.5 cm], 200 lb [90.7 kg]	50-mm Biomet high-wall liner, 28-mm + 3-mm head, stem information not available	Anterior	Revised to anterior 10 liner	Success
73-yr-old man, 6 ft, 1 in [185.4 cm], 230 lb [104.3 kg]	58-mm Biomet high-wall liner, Ranawat-Burstein cup, 28-mm + 3-mm head, 13-mm cemented Answer stem	Posterior	Revised to 20-mm + 3-mm head, 58-mm bipolar acetabular component	Success
76-yr-old man, 6 ft, 1 in [185.4 cm] , 247 lb [112.0 kg]	60-mm Biomet high-wall liner, Ranawat-Burstein cup, 28-mm + 6-mm head, 15-mm cemented Answer stem	Posterior	Stopped dislocating after 1 yr	Success

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TABLE I: Data on Fourteen Patients with Dislocation After Total Hip Arthroplasty with Capsulotomy Only

Patient	Implant (Primary)	Area of Dislocation	Treatment for Dislocation	Follow-up Status
45-yr-old man, 5 ft, 10 in [177.8 cm], 195 lb [88.5 kg]	Optifix 20° liner, information on other components not available	Posterior	Multiple closed reductions	Continues to dislocate
79-yr-old woman, 5 ft, 1 in [154.9 cm], 136 lb [61.7 kg]	52-mm Biomet high-wall liner, 28-mm + 8-mm head, 10-mm cemented Geri stem	Posterior	Revised to 10° high-wall liner, failed; then revised to 35° liner, succeeded	Success
78-yr-old man, deceased, 6 ft, 2 in [188 cm], 227 lb [103 kg]	62-mm Optifix 20° liner (lip posterior), 28-mm + 12-mm head, 14-mm cemented Geri stem	Posterior	Multiple closed reductions, treated with hip spica cast	Success
85-yr-old woman, 5 ft [152.4 cm], 130 lb [59 kg]	52-mm Optifix 20° liner (lip posterior), 28-mm + 8-mm head, 10-mm cemented Geri stem	Posterior	Revised to 35 liner	Success
66-yr-old woman, 5 ft, 7 in [170.2 cm], 136 lb [61.7 kg]	55-mm Reflection 20 liner, 28-mm head, other neck and stem sizes not known	Posterior	Multiple reductions	Continues to dislocate
61-yr-old man, 5 ft, 10 in [177.8 cm], 180 lb [81.6 kg]	62-mm Biomet high-wall liner, 28-mm + 3-mm head, 15-mm cemented Answer stem	Posterior	Revised to 35 liner, 20-mm + 6-mm head	Continues to dislocate
60-yr-old woman, 5 ft, 5 in [165.1 cm], 160 lb [72.6 kg]	50-mm Biomet high-wall liner, 28-mm standard head, 11-mm uncemented Integral stem	Posterior	Revised to 10 high-wall liner, failed; then revised to 35° liner, succeeded	Success
86-yr-old man, 5 ft, 11 in [180.3 cm], 205 lb [93 kg]	62-mm Biomet high-wall liner, 28-mm + 3-mm head, 15-mm cemented Answer stem	Posterior	Multiple closed reductions	Continues to dislocate, not surgical candidate
51-yr-old woman, 5 ft, 4 in [162.6 cm], 160 lb [72.6 kg]	50-mm Biomet high-wall liner, 28-mm + 3-mm head, stem information not available	Posterior	One closed reduction	Success
83-yr-old man, 5 ft, 6 in [167.6 cm], 185 lb [83.9 kg]	60-mm Biomet high-wall liner, 28-mm + 3-mm head, stem information not available	Posterior	Revised to press-fit bipolar prosthesis	Success
72-yr-old man, 6 ft, 2 in [188 cm], 290 lb [131.5 kg]	58-mm Biomet high-wall liner, 28-mm + 3-mm head, 15-mm cemented Answer stem	Posterior	Stopped dislocating after 6 mo	Success
43-yr-old woman, 5 ft, 2 in [157.5 cm], 200 lb [90.7 kg]	50-mm Biomet high-wall liner, 28-mm + 3-mm head, stem information not available	Anterior	Revised to anterior 10 liner	Success
73-yr-old man, 6 ft, 1 in [185.4 cm], 230 lb [104.3 kg]	58-mm Biomet high-wall liner, Ranawat-Burstein cup, 28-mm + 3-mm head, 13-mm cemented Answer stem	Posterior	Revised to 20-mm + 3-mm head, 58-mm bipolar acetabular component	Success
76-yr-old man, 6 ft, 1 in [185.4 cm] , 247 lb [112.0 kg]	60-mm Biomet high-wall liner, Ranawat-Burstein cup, 28-mm + 6-mm head, 15-mm cemented Answer stem	Posterior	Stopped dislocating after 1 yr	Success

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TABLE II: Data on Three Patients with Dislocation After Total Hip Arthroplasty with Capsulotomy and Capsulorrhaphy

Patient	Implant (Primary)	Area of Dislocation	Treatment for Dislocation	Follow-up Status
45 yr-old-man, 6 ft, 2 in [188 cm], 195 lb [88.5 kg]	62-mm Interfit 20 liner, 28-mm + 4-mm head, 14-mm uncemented Synergy press-fit stem	Anterior	Revised to 20 anterior liner and 28-mm + 8-mm head	Success
63 yr-old-woman, 5 ft, 4 in [162.6 cm], 180 lb [81.6 kg]	54-mm Biomet Ranawat- Burstein cup, 28-mm standard head, 9-mm cemented Answer stem	Anterior	Closed reduction	Success
75 yr-old-woman, 5 ft, 1 in [154.9 cm], 95 lb [43.1 kg]	50-mm Interfit 20º liner, 26-mm standard head, 12-mm cemented Synergy stem	Anterior	Revised and repositioned cup	Success

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TABLE II: Data on Three Patients with Dislocation After Total Hip Arthroplasty with Capsulotomy and Capsulorrhaphy

Patient	Implant (Primary)	Area of Dislocation	Treatment for Dislocation	Follow-up Status
45 yr-old-man, 6 ft, 2 in [188 cm], 195 lb [88.5 kg]	62-mm Interfit 20 liner, 28-mm + 4-mm head, 14-mm uncemented Synergy press-fit stem	Anterior	Revised to 20 anterior liner and 28-mm + 8-mm head	Success
63 yr-old-woman, 5 ft, 4 in [162.6 cm], 180 lb [81.6 kg]	54-mm Biomet Ranawat- Burstein cup, 28-mm standard head, 9-mm cemented Answer stem	Anterior	Closed reduction	Success
75 yr-old-woman, 5 ft, 1 in [154.9 cm], 95 lb [43.1 kg]	50-mm Interfit 20º liner, 26-mm standard head, 12-mm cemented Synergy stem	Anterior	Revised and repositioned cup	Success

Methods

Introduction | Methods | Results | Conclusions | References

The results of 1000 consecutive cementless or hybrid primary total hip arthroplasties performed through a posterolateral (Gibson) approach between June 1993 and April 1999 were studied retrospectively⁷. The first 500 patients (Group 1) underwent excision of the posterior and inferior aspects of the capsule with a partial anterior capsulotomy. The only posterior repair that was performed was done to suture the external rotators to the gluteus medius tendon. The second 500 patients (Group 2) had posterior capsulotomy with partial anterior capsulotomy and capsulorrhaphy (closure of both the capsule and the anterior capsular flap). The external rotators were then sutured back to the gluteus medius tendon as in Group 1.

The implants that were used included the Biomet Integral and Answer stems with a Ranawat-Burstein cup and high-wall liner, a Richards Optifix stem and cup, Richards Geri-Hip and Smith and Nephew Synergy stems, and Reflection acetabular components with a 20° lipped liner in the posterior-inferior position.

The postoperative plans of care and physical therapy were identical for all patients and included precautions to avoid hip flexion of >90° for one year and to limit crossing of the legs for three months. When a total hip replacement dislocated, the patient was treated with a closed reduction and the precautions were reinforced. After a second dislocation, a brace was applied and worn for three months. After another dislocation, the patient was advised to have a revision. Patients were followed for one year before the operation was classified as a success.

Group-2 Procedure (Figs. 1, 2, 3, 4, 5, 6, 7, 8, and 9)

The external rotators were tagged and then cut. The posterior aspect of the capsule was incised like a double door and retracted. The anterior aspect of the capsule was cut through the anterosuperior sector. Special posterior capsular retractors were used for exposure. At closure, the double door was closed, the anterior capsular flap was advanced and sutured to the posterior flap, and the external rotators were sutured to the gluteus medius tendon in a separate layer.

Statistical Analysis

Statistical analysis was performed with use of the Pearson chi-square statistic for testing equality of two proportions, and the effect size was calculated with use of the observed and expected number of hip dislocations⁸. The guidelines for interpreting the effect size ( Image Not Available

are 0.1 (small effect), 0.3 (medium effect), and 0.5 (large effect).

Results

Introduction | Methods | Results | Conclusions | References

Group 1

Fourteen (2.8%) of the 500 hips dislocated (Table I); thirteen of the hips dislocated posteriorly and one, anteriorly (Figs. 10, 11, 12, and 13). All but one dislocated more than once. Seven hips were revised.

Group 2

Three (0.6%) of the 500 hips dislocated, all anteriorly (Table II). Two of these hips dislocated recurrently and were successfully revised.

Conclusions

Introduction | Methods | Results | Conclusions | References

With use of this new technique, our prevalence of dislocation decreased from 2.8% to 0.6% (p < 0.005, Image Not Available

= 0.10). The technique tightens the capsule circumferentially and is analogous to a capsular shift in the shoulder. It differs from other techniques in that it preserves the entire original hip capsule in the exposure.

In patients with severe contracture, the surgeon may be unable to suture the shortened external rotators. In one patient, excluded from this study, the senior author was unable to preserve the capsule because of the patient’s obesity, which limited exposure. The capsule was excised to enable exposure, and the hip subsequently dislocated.

The repair heals and strengthens with time. Revisions done for other reasons more than one year postoperatively in Group 2 demonstrated a thick, fully healed capsule.

We recommend this successful technique, which differs from those in which the capsule or external rotators and posterior aspect of the capsule are sutured to the greater trochanter (sometimes through drill-holes). Those techniques may lead to recurrence of an external rotation contracture, which is often a clinical problem in the arthritic hip. Currently, we remove all restrictions on the patient’s activity after twelve weeks if the capsule was repaired and the patient has not had a dislocation. Prevention of hip dislocation remains the surgeon’s priority and can be addressed by surgical technique and implant selection¹.

References

Introduction | Methods | Results | Conclusions | References

MorreyBF. Hip dislocation: it’s later than you think. Orthopedics,2000;23: 935-6. 23935 2000 [PubMed]

ChiuFY, Chen CM, Chung TY, Lo WH,Chen TH. The effect of posterior capsulorrhaphy in primary total hip arthroplasty: a prospective randomized study. J Arthroplasty,2000;15: 194-9. 15194 2000 [PubMed]

CloughTM,Hodgkinson JP. Two-stage revision with pseudocapsular resection for recurrent dislocation of total hip prostheses. J Arthroplasty,2000;15: 1017-9. 151017 2000 [PubMed]

McCollumDE,Gray WJ. Dislocation after total hip arthroplasty. Causes and prevention. Clin Orthop,1990;261: 159-70. 261159 1990 [PubMed]

VicarAJ,Coleman CR. A comparison of the anterolateral, transtrochanteric, and posterior surgical approaches in primary total hip arthroplasty. Clin Orthop,1984;188: 152-9. 188152 1984 [PubMed]

PellicciPM, Bostrom M,Poss R. Posterior approach to total hip replacement using enhanced posterior soft tissue repair. Clin Orthop,1998;355: 224-8. 355224 1998 [PubMed]

Canale ST, editor. Campbell’s operative orthopaedics. 9th ed. St. Louis: Mosby; 1998. Surgical Techniques and Approaches; p 91.

Kirk RE. Statistics: an introduction. 4th ed. Fort Worth: Harcourt Brace College Publishers; 1999.

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Fig. 1:: Fig. 1 Lateral capsular cut along the femoral neck.

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Fig. 2:: Fig. 2 "T" cut along the femoral neck.

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Fig. 3:: Fig. 3 Forming the double door.

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Fig. 4:: Fig. 4 Completion.

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Fig. 5:: Finished posterior capsulotomy.

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Fig. 6:: Anterior capsulotomy with curved 8-in (20.3-cm) clamp anteriorly.

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Figs. 7 and 8:: Fig. 7 Repair of posterior flaps. Fig. 8 Completed capsular flap repair.

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Fig. 9:: Completion of repair with suture of external rotators.

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Fig. 10:: Fig. 10 Hip before posterior dislocation.

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Fig. 11:: Fig. 11 Hip after posterior dislocation.

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Fig. 12:: Fig. 12 Hip before anterior dislocation.

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Fig. 13:: Fig. 13 Hip after anterior dislocation.

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TABLE I: Data on Fourteen Patients with Dislocation After Total Hip Arthroplasty with Capsulotomy Only

Patient	Implant (Primary)	Area of Dislocation	Treatment for Dislocation	Follow-up Status
45-yr-old man, 5 ft, 10 in [177.8 cm], 195 lb [88.5 kg]	Optifix 20° liner, information on other components not available	Posterior	Multiple closed reductions	Continues to dislocate
79-yr-old woman, 5 ft, 1 in [154.9 cm], 136 lb [61.7 kg]	52-mm Biomet high-wall liner, 28-mm + 8-mm head, 10-mm cemented Geri stem	Posterior	Revised to 10° high-wall liner, failed; then revised to 35° liner, succeeded	Success
78-yr-old man, deceased, 6 ft, 2 in [188 cm], 227 lb [103 kg]	62-mm Optifix 20° liner (lip posterior), 28-mm + 12-mm head, 14-mm cemented Geri stem	Posterior	Multiple closed reductions, treated with hip spica cast	Success
85-yr-old woman, 5 ft [152.4 cm], 130 lb [59 kg]	52-mm Optifix 20° liner (lip posterior), 28-mm + 8-mm head, 10-mm cemented Geri stem	Posterior	Revised to 35 liner	Success
66-yr-old woman, 5 ft, 7 in [170.2 cm], 136 lb [61.7 kg]	55-mm Reflection 20 liner, 28-mm head, other neck and stem sizes not known	Posterior	Multiple reductions	Continues to dislocate
61-yr-old man, 5 ft, 10 in [177.8 cm], 180 lb [81.6 kg]	62-mm Biomet high-wall liner, 28-mm + 3-mm head, 15-mm cemented Answer stem	Posterior	Revised to 35 liner, 20-mm + 6-mm head	Continues to dislocate
60-yr-old woman, 5 ft, 5 in [165.1 cm], 160 lb [72.6 kg]	50-mm Biomet high-wall liner, 28-mm standard head, 11-mm uncemented Integral stem	Posterior	Revised to 10 high-wall liner, failed; then revised to 35° liner, succeeded	Success
86-yr-old man, 5 ft, 11 in [180.3 cm], 205 lb [93 kg]	62-mm Biomet high-wall liner, 28-mm + 3-mm head, 15-mm cemented Answer stem	Posterior	Multiple closed reductions	Continues to dislocate, not surgical candidate
51-yr-old woman, 5 ft, 4 in [162.6 cm], 160 lb [72.6 kg]	50-mm Biomet high-wall liner, 28-mm + 3-mm head, stem information not available	Posterior	One closed reduction	Success
83-yr-old man, 5 ft, 6 in [167.6 cm], 185 lb [83.9 kg]	60-mm Biomet high-wall liner, 28-mm + 3-mm head, stem information not available	Posterior	Revised to press-fit bipolar prosthesis	Success
72-yr-old man, 6 ft, 2 in [188 cm], 290 lb [131.5 kg]	58-mm Biomet high-wall liner, 28-mm + 3-mm head, 15-mm cemented Answer stem	Posterior	Stopped dislocating after 6 mo	Success
43-yr-old woman, 5 ft, 2 in [157.5 cm], 200 lb [90.7 kg]	50-mm Biomet high-wall liner, 28-mm + 3-mm head, stem information not available	Anterior	Revised to anterior 10 liner	Success
73-yr-old man, 6 ft, 1 in [185.4 cm], 230 lb [104.3 kg]	58-mm Biomet high-wall liner, Ranawat-Burstein cup, 28-mm + 3-mm head, 13-mm cemented Answer stem	Posterior	Revised to 20-mm + 3-mm head, 58-mm bipolar acetabular component	Success
76-yr-old man, 6 ft, 1 in [185.4 cm] , 247 lb [112.0 kg]	60-mm Biomet high-wall liner, Ranawat-Burstein cup, 28-mm + 6-mm head, 15-mm cemented Answer stem	Posterior	Stopped dislocating after 1 yr	Success

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TABLE I: Data on Fourteen Patients with Dislocation After Total Hip Arthroplasty with Capsulotomy Only

Patient	Implant (Primary)	Area of Dislocation	Treatment for Dislocation	Follow-up Status
45-yr-old man, 5 ft, 10 in [177.8 cm], 195 lb [88.5 kg]	Optifix 20° liner, information on other components not available	Posterior	Multiple closed reductions	Continues to dislocate
79-yr-old woman, 5 ft, 1 in [154.9 cm], 136 lb [61.7 kg]	52-mm Biomet high-wall liner, 28-mm + 8-mm head, 10-mm cemented Geri stem	Posterior	Revised to 10° high-wall liner, failed; then revised to 35° liner, succeeded	Success
78-yr-old man, deceased, 6 ft, 2 in [188 cm], 227 lb [103 kg]	62-mm Optifix 20° liner (lip posterior), 28-mm + 12-mm head, 14-mm cemented Geri stem	Posterior	Multiple closed reductions, treated with hip spica cast	Success
85-yr-old woman, 5 ft [152.4 cm], 130 lb [59 kg]	52-mm Optifix 20° liner (lip posterior), 28-mm + 8-mm head, 10-mm cemented Geri stem	Posterior	Revised to 35 liner	Success
66-yr-old woman, 5 ft, 7 in [170.2 cm], 136 lb [61.7 kg]	55-mm Reflection 20 liner, 28-mm head, other neck and stem sizes not known	Posterior	Multiple reductions	Continues to dislocate
61-yr-old man, 5 ft, 10 in [177.8 cm], 180 lb [81.6 kg]	62-mm Biomet high-wall liner, 28-mm + 3-mm head, 15-mm cemented Answer stem	Posterior	Revised to 35 liner, 20-mm + 6-mm head	Continues to dislocate
60-yr-old woman, 5 ft, 5 in [165.1 cm], 160 lb [72.6 kg]	50-mm Biomet high-wall liner, 28-mm standard head, 11-mm uncemented Integral stem	Posterior	Revised to 10 high-wall liner, failed; then revised to 35° liner, succeeded	Success
86-yr-old man, 5 ft, 11 in [180.3 cm], 205 lb [93 kg]	62-mm Biomet high-wall liner, 28-mm + 3-mm head, 15-mm cemented Answer stem	Posterior	Multiple closed reductions	Continues to dislocate, not surgical candidate
51-yr-old woman, 5 ft, 4 in [162.6 cm], 160 lb [72.6 kg]	50-mm Biomet high-wall liner, 28-mm + 3-mm head, stem information not available	Posterior	One closed reduction	Success
83-yr-old man, 5 ft, 6 in [167.6 cm], 185 lb [83.9 kg]	60-mm Biomet high-wall liner, 28-mm + 3-mm head, stem information not available	Posterior	Revised to press-fit bipolar prosthesis	Success
72-yr-old man, 6 ft, 2 in [188 cm], 290 lb [131.5 kg]	58-mm Biomet high-wall liner, 28-mm + 3-mm head, 15-mm cemented Answer stem	Posterior	Stopped dislocating after 6 mo	Success
43-yr-old woman, 5 ft, 2 in [157.5 cm], 200 lb [90.7 kg]	50-mm Biomet high-wall liner, 28-mm + 3-mm head, stem information not available	Anterior	Revised to anterior 10 liner	Success
73-yr-old man, 6 ft, 1 in [185.4 cm], 230 lb [104.3 kg]	58-mm Biomet high-wall liner, Ranawat-Burstein cup, 28-mm + 3-mm head, 13-mm cemented Answer stem	Posterior	Revised to 20-mm + 3-mm head, 58-mm bipolar acetabular component	Success
76-yr-old man, 6 ft, 1 in [185.4 cm] , 247 lb [112.0 kg]	60-mm Biomet high-wall liner, Ranawat-Burstein cup, 28-mm + 6-mm head, 15-mm cemented Answer stem	Posterior	Stopped dislocating after 1 yr	Success

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TABLE II: Data on Three Patients with Dislocation After Total Hip Arthroplasty with Capsulotomy and Capsulorrhaphy

Patient	Implant (Primary)	Area of Dislocation	Treatment for Dislocation	Follow-up Status
45 yr-old-man, 6 ft, 2 in [188 cm], 195 lb [88.5 kg]	62-mm Interfit 20 liner, 28-mm + 4-mm head, 14-mm uncemented Synergy press-fit stem	Anterior	Revised to 20 anterior liner and 28-mm + 8-mm head	Success
63 yr-old-woman, 5 ft, 4 in [162.6 cm], 180 lb [81.6 kg]	54-mm Biomet Ranawat- Burstein cup, 28-mm standard head, 9-mm cemented Answer stem	Anterior	Closed reduction	Success
75 yr-old-woman, 5 ft, 1 in [154.9 cm], 95 lb [43.1 kg]	50-mm Interfit 20º liner, 26-mm standard head, 12-mm cemented Synergy stem	Anterior	Revised and repositioned cup	Success

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TABLE II: Data on Three Patients with Dislocation After Total Hip Arthroplasty with Capsulotomy and Capsulorrhaphy

Patient	Implant (Primary)	Area of Dislocation	Treatment for Dislocation	Follow-up Status
45 yr-old-man, 6 ft, 2 in [188 cm], 195 lb [88.5 kg]	62-mm Interfit 20 liner, 28-mm + 4-mm head, 14-mm uncemented Synergy press-fit stem	Anterior	Revised to 20 anterior liner and 28-mm + 8-mm head	Success
63 yr-old-woman, 5 ft, 4 in [162.6 cm], 180 lb [81.6 kg]	54-mm Biomet Ranawat- Burstein cup, 28-mm standard head, 9-mm cemented Answer stem	Anterior	Closed reduction	Success
75 yr-old-woman, 5 ft, 1 in [154.9 cm], 95 lb [43.1 kg]	50-mm Interfit 20º liner, 26-mm standard head, 12-mm cemented Synergy stem	Anterior	Revised and repositioned cup	Success