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Scientific Articles   |    
Large Femoral Heads Decrease the Incidence of Dislocation After Total Hip ArthroplastyA Randomized Controlled Trial
Donald W. Howie, MBBS, FRACS, PhD1; Oksana T. Holubowycz, PhD, MPH1; Robert Middleton, MBBChir, MA, FRCS(Orth)2; the Large Articulation Study Group
1 Department of Orthopaedics and Trauma, Level 4, Bice Building, North Terrace, Royal Adelaide Hospital, Adelaide, SA 5000, Australia. Email address for O.T. Holubowycz: oksana.holubowycz@health.sa.gov.au
2 34 Alington Road, Poole BH148LZ, England
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Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of an aspect of this work. In addition, one or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

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Department of Orthopaedics and Trauma, Level 4, Bice Building, North Terrace, Royal Adelaide Hospital, Adelaide, SA 5000, Australia. Email address for O.T. Holubowycz: oksana.holubowycz@health.sa.gov.au
34 Alington Road, Poole BH148LZ, England
Investigation initiated and undertaken by the Discipline of Orthopaedics and Trauma, University of Adelaide, Adelaide, South Australia, Australia and performed at Royal Adelaide, St Andrew's, Glenelg, and Modbury Hospitals, Adelaide, South Australia, Australia; Whyalla Hospital, Whyalla, South Australia, Australia; Royal North Shore Hospital, Sydney, New South Wales, Australia; St. John of God and Ballarat Base Hospitals, Ballarat, Victoria, Australia; Geelong Hospital, Geelong, Victoria, Australia; Maroondah and St. Vincent's Hospitals, Melbourne, Victoria, Australia; Royal Bournemouth Hospital, Bournemouth, England; Southampton General Hospital, Southampton, England; and Ninewells Hospital, Dundee, Scotland

Copyright © 2012 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2012 Jun 20;94(12):1095-1102. doi: 10.2106/JBJS.K.00570
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Abstract

Background: 

The use of larger femoral heads has been proposed to reduce the risk of dislocation after total hip arthroplasty, but there is a lack of evidence to support this proposal. The aim of this multicenter randomized controlled trial was to determine whether the incidence of dislocation one year after total hip arthroplasty is significantly lower in association with the use of a 36-mm femoral head articulation as compared with a 28-mm articulation.

Methods: 

Six hundred and forty-four middle-aged and elderly patients undergoing primary or revision arthroplasty were randomized intraoperatively to receive either a 36 or 28-mm metal femoral head on highly cross-linked polyethylene. Patients who were at high risk of dislocation (including those with dementia and neuromuscular disease) and those undergoing revision for the treatment of recurrent hip dislocation or infection were excluded. Patients were stratified according to other potential risk factors for dislocation, including diagnosis and age. Diagnosis of hip dislocation required confirmation by a physician and radiographic evidence of a dislocation.

Results: 

Overall, at one year of follow-up, hips with a 36-mm femoral head articulation had a significantly lower incidence of dislocation than did those with a 28-mm articulation (1.3% [four of 299] compared with 5.4% [seventeen of 316]; difference, 4.1% [95% confidence interval, 1.2% to 7.2%]) when controlling for the type of procedure (primary or revision) (p = 0.012). The incidence of dislocation following primary arthroplasty was also significantly lower for hips with a 36-mm femoral head articulation than for those with a 28-mm articulation (0.8% [two of 258] compared with 4.4% [twelve of 275]; difference, 3.6% [95% confidence interval, 0.9% to 6.8%]) (p = 0.024). The incidence of dislocation following revision arthroplasty was 4.9% (two of forty-one) for hips with a 36-mm articulation and 12.2% (five of forty-one) for hips with a 28-mm articulation; this difference was not significant with the relatively small sample size of the revision group (difference, 7.3% [95% confidence interval, −5.9% to 21.1%]) (p = 0.273).

Conclusions: 

Compared with a 28-mm femoral head articulation, a larger 36-mm articulation resulted in a significantly decreased incidence of dislocation in the first year following primary total hip arthroplasty. However, before a 36-mm metal-on-highly cross-linked polyethylene articulation is widely recommended, the incidence of late dislocation, wear, periprosthetic osteolysis, and liner fracture should be established.

Level of Evidence: 

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

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    References

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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