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J Vet Clin 2022; 39(6): 390-394

https://doi.org/10.17555/jvc.2022.39.6.390

Published online December 31, 2022

Dual Mobility Cup for Revision of Dislocation of a Hip Prosthesis in a Dog with Chronic Hip Dislocation

Jaemin Jeong , Haebeom Lee

Department of Veterinary Surgery, College of Veterinary Medicine, Chungnam National University, Daejeon 34134, Korea

Correspondence to:*seatiger76@cnu.ac.kr

Received: October 27, 2022; Revised: December 2, 2022; Accepted: December 12, 2022

Copyright © The Korean Society of Veterinary Clinics.

A 6-year-old, 36.5 kg castrated male Golden Retriever presented for revision surgery for left total hip replacement. The patient underwent removal of the cup and head implants due to unmanageable prosthetic hip dislocation, despite revision surgery. On physical examination, the dog showed persistent weight-bearing lameness after exercise of the left hindlimb with mild muscle atrophy. Radiographic examination revealed dorsolateral displacement of the femur with a remnant stem and bony proliferation around the cranial and caudal acetabulum rims. The surgical plan was to apply the dual mobility cup to increase the range of motion and jump distance to correct soft tissue elongation and laxity caused by a prolonged period of craniodorsal dislocation of the femur. The preparation of the acetabulum for cup fixation was performed with a 29-mm reamer, and the 29.5-mm outer shell was fixed with five 2.4-mm cortical screws. The head and medium neck of the dual-mobility system were placed on the cup, and the hip joint was reduced between the neck and stem. The dog exhibited slight weight bearing on a controlled leash walk the day after surgery. The patient was discharged 2 weeks postoperatively without any complications. Six months postoperatively, osseointegration and a well-positioned cup implant were observed, and the dog showed excellent limb function without hip dislocation until 18 months of phone call follow-up.

Keywords: total hip replacement, chronic hip dislocation, revision, dual mobility cup.

Revision total hip replacement (THR) is usually indicated in cases of aseptic loosening, prosthetic dislocation, or infection (1,3). Dorsal hip dislocation is one of the most common complications after THR and has been reported to occur in 4%-15% of early complications after primary THR in large-breed dogs (4,7,10,19). Revision THR is more challenging than primary THR because of anatomical changes in both the femur and acetabulum and alteration of surrounding soft tissues (17). It has been reported that the incidence of dislocation following revision THR is more than three times higher than that of primary THR in humans (14).

Causes of dislocation include severe preoperative hip laxity (luxoid hip) due to poor quality of the joint capsule, low soft tissue tension, periarticular osteophytes with fibrous tissue formation causing impingement, and implant malorientation (10,16). Several surgical methods have been reported to address dorsal hip dislocation, including adjusting the orientation of the cup implant or reimplantation, neck lengthening, and iliofemoral sutures to reinforce hip joint stability (6,13,16). Despite several revision strategies, a standard of care that can lead to successful outcomes has not yet been reported.

The dual mobility (DM) cup system was recently developed to reduce the dislocation of the hip prosthesis, and both successful cases of cemented and cementless DM cups have been reported in veterinary medicine (8,12). The cementless DM cup consists of three components: a smaller head, larger polyether ether ketone (PEEK) hemisphere, and outer acetabular shell (12). In this system, the increase in the range of motion through two articulations between the three components and the increased jump distance according to the large head diameter effectively prevented postoperative hip dislocation.

To date, retrospective studies of clinical outcomes following the DM cup system as a primary THR have been reported in veterinary medicine (8,9,12,18). However, a clinical description of DM cup application in cases of chronic dislocation after primary THR has not been reported. Therefore, we report the surgical description and long-term clinical outcomes of successful management using the DM cup system in cases of unmanageable hip dislocation even after multiple revision surgeries (5).

A 6-year-old, 36.5 kg, castrated male Golden Retriever presented for revision surgery of the left cementless THR, which had been operated 2 years ago. The angles of lateral opening and retroversion were 45° and 20°, respectively, and the neck length was short at the time of the primary THR. The hip dislocation occurred 4 weeks postoperatively and was revised by repositioning the cup orientation and replacing the medium neck with a long neck. However, the patient underwent removal of the cup and head implants due to unmanageable prosthetic hip dislocation occurred 3 weeks after revision surgery. Despite rehabilitation and anti-inflammatory drugs administration, the dog continued to have waxing and waning clinical signs including lameness and reluctant to walk for 22 months.

On physical examination, the dog showed persistent weight-bearing lameness after active exercise of the left hindlimb with mild muscle atrophy. Radiographic examination revealed dorsolateral displacement of the femur with a well-fixed remnant stem and bony proliferation around the cranial and caudal acetabulum rims (Fig. 1). The distance between the center of the neck of the femoral stem and acetabulum was 24.5 mm, indicating severe lateralization of the femoral stem.

Figure 1.Pre- and post-operative radiographs of the left hip joint. (A) Severe laxity of the hip joint before primary THR. Immediate postoperative radiograph of (B) primary THR, (C) revision THR, and (D) at 2 years postoperative radiographs following explantation of the cup implant. (D, E) Dorsolateral displacement of the femur with a well-fixed remnant stem and bony proliferation around the acetabular rims were identified.

The patient was incompatible with the conventional THR revision method, including standard cup reimplantation and a longer neck, due to failure of previous attempts. The surgical plan was to apply the DM cup to increase the free range of motion and jump distance to correct soft tissue elongation and laxity caused by a prolonged period of craniodorsal dislocation of the hip joint.

The dog was premedicated with hydromorphone (0.1 mg/kg intravenously [IV]) and midazolam (0.2 mg/kg, IV). General anesthesia was induced with propofol (6 mg/kg, IV) and maintained with isoflurane in oxygen. Remifentanil was administered by constant rate infusion (0.1-0.3 μg/kg/min) for analgesia. Cefazolin (22 mg/kg, IV) was administered 30 min before the incision and repeated every 90 min. A standard craniolateral approach to the left hip joint was performed.

Revision surgery using DM cup system was performed according to previous surgical description (12). Briefly, preparation of the acetabulum was performed with a series of 26-, 28-, and 29-mm spherical cup reamers. The outer shell of a 29.5 mm DM cup (Kyon Inc., Zürich, Switzerland) was impacted into the prepared acetabulum and fixed with five 2.4-mm cortical screws (Fig. 2). Subsequently, the inner shell was impacted into the outer shell with a coaxial alignment by the spike of the inner shell. The 19-mm ceramic head and carbon fiber-reinforced PEEK head were assembled and impacted on the medium neck. The preassembled DM head and neck were placed on the cup first, and the hip joint was reduced between the neck and peg of the femoral stem. During reduction, a narrow Hohmann retractor was inserted caudally to the acetabulum to lever the femur distolaterally, and the neck was manipulated using straight hemostats to combine with the peg of the femoral stem. The iliofemoral suture was applied using an anchor screw and two PDS sutures to reinforce hip joint stability. The surgical site was copiously lavaged, and a surgical site swab was taken for submission of the culture test. Closure of the surgical site was performed in a routine manner.

Figure 2.(A) Intraoperative photograph of cup implantation. The outer shell of a 29.5-mm DM cup was impacted into the prepared acetabulum. (B) The outer shell was fixed with five 2.4-mm cortical screws. (C) Preassembled head and neck components. (D) Routine closure was performed after reduction of the hip prosthesis.

Radiographs were obtained immediately after surgery, which revealed the intended implantation of the DM cup (Fig. 3). The angles of the lateral opening and retroversion of the DM cup were 38° and 18°, respectively. Amoxicillin-clavulanic acid (12.5 mg/kg, IV) and clindamycin (8.5 mg/kg, IV) were administered postoperatively for two weeks without a positive culture test. Remifentanil (0.1 μg/kg/min CRI) was administered during the first 6 h and then converted to meloxicam (0.2 mg/kg subcutaneously once daily on day 1, 0.1 mg/kg orally once daily on Days 2-7) for seven days postoperatively. The patient was able to bear weight at a controlled leash walk the day after the surgery, and the limb function improved progressively. The patient showed almost normal limb function and was discharged two weeks postoperatively. A stable DM cup and osseointegration were noted on radiographic images at 6 months follow-up (Fig. 3). The owner reported excellent clinical outcomes without hip dislocation until 18 months of follow-up via phone call.

Figure 3.Postoperative ventro-dorsal and lateral radiographs of the left hip joint with DM cup (A-C) immediately postoperatively and (D-F) at 6 months postoperatively. No evidence of loosening or change in implant position and osseointegration between the cup and acetabulum can be observed on the radiographs.

This study described acetabular revision surgery using a dual-mobility cup system in a dog with habitual prosthetic hip dislocation following THR surgery. To the best of our knowledge, this is the first report on the application of a DM cup system to address chronic prosthetic hip dislocation for over 2 years. The clinical outcomes showed excellent limb function without any complications until 18 months of follow-up.

Poor quality of the joint capsule, severe laxity, and contracture of the soft tissues around the hip joint have been reported as risk factors for THR dislocation (10,16). Improper implant selection and orientation have been reported as surgeon-related risk factors for prosthetic dislocation (6). In our case, prosthetic dislocation occurred one month after surgery, even though the cup and stem were implanted according to the anatomic reference of the patient. Prosthetic dislocation could not be addressed despite the repositioning of the cup implant and neck lengthening. Lanz et al. (12) reported that very unstable hip joints called ‘luxoid hips’ in large and giant breed dogs are the risk factors for dislocation with a high incidence of 8.5% within 2 months following primary THR. The patient had chronic hip luxation at a young age and had undergone primary THR at 4 years of age. Thus, poor quality of the soft tissue and severe laxity were considered causes of repeated hip dislocation.

A DM cup system has been developed to prevent hip dislocation and improve prosthetic stability through various mechanisms (9,12). First, the large head diameter of the DM cup increases the femoral head-to-neck ratio, which increases prosthetic stability by increasing the ‘jump distance’ required for the dislocation of the femoral head from the acetabular component (2,11,15). Additionally, the Zurich cementless DM cup has a range of motion of 145°, which is increased by 10° compared to the standard cup through double bearing, and can reduce impingement, one of the major causes of prosthetic dislocation (12). The DM cup system has been successfully applied in both human and veterinary medicine, and our case of chronic hip dislocation could be successfully revised using the DM cup (11,12,17).

According to previous retrospective studies where the DM cup system was applied to the primary THR, dislocation was reported in only one case out of 103 cases in which cementless was applied, and no dislocation occurred in 50 cases in which the cement DM cup was applied (8,12). These clinical outcomes were consistent with the 1%-2% incidence of dislocation following DM cup application reported in human medicine (11,17). In our case, there was no dislocation at the follow-up of 18 months, and an excellent clinical outcome was observed.

The limitations of this case report include the fact that it was based on a single case and there is a lack of extended long-term follow-up of more than several years to observe complications such as wearing and aseptic loosening, even though it showed excellent clinical outcomes in our follow-up periods.

This case report describes a revision strategy for THR using a dual-mobility cup system in a dog with unmanageable hip dislocation following primary THR. Based on the clinical outcomes, dual-mobility cup systems can be an alternative to standard THR systems in dogs with challenges in addressing hip dislocations following primary THR surgery.

This work was supported by Korea Institute of Planning and Evaluation for Technology in Food, Agriculture and Forestry (IPET) through Companion Animal Whole Cycle Industialization Technology Development Program, funded by Ministry of Agriculture, Food and Rural Affairs (MAFRA) (322090).

Author 1: conception of the study, data collection, interpretation of the results, manuscript preparation, critical review of the article, and approval of the final manuscript; Author 2: conception of the study, data collection, performed surgical procedures, interpretation of the results, manuscript preparation, critical review of the article, and approval of the final manuscript.

  1. Allen MJ. Advances in total joint replacement in small animals. J Small Anim Pract 2012; 53: 495-506.
    Pubmed CrossRef
  2. Berry DJ, von Knoch M, Schleck CD, Harmsen WS. Effect of femoral head diameter and operative approach on risk of dislocation after primary total hip arthroplasty. J Bone Joint Surg Am 2005; 87: 2456-2463.
    CrossRef
  3. Bozic KJ, Kurtz SM, Lau E, Ong K, Vail TP, Berry DJ. The epidemiology of revision total hip arthroplasty in the United States. J Bone Joint Surg Am 2009; 91: 128-133.
    Pubmed CrossRef
  4. Conzemius MG, Vandervoort J. Total joint replacement in the dog. Vet Clin North Am Small Anim Pract 2005; 35: 1213-1231, vii.
    Pubmed CrossRef
  5. Cook JL, Evans R, Conzemius MG, Lascelles BD, McIlwraith CW, Pozzi A, et al. Proposed definitions and criteria for reporting time frame, outcome, and complications for clinical orthopedic studies in veterinary medicine. Vet Surg 2010; 39: 905-908.
    Pubmed CrossRef
  6. Dyce J, Wisner ER, Wang Q, Olmstead ML. Evaluation of risk factors for luxation after total hip replacement in dogs. Vet Surg 2000; 29: 524-532.
    Pubmed CrossRef
  7. Guerrero TG, Montavon PM. Zurich cementless total hip replacement: retrospective evaluation of 2nd generation implants in 60 dogs. Vet Surg 2009; 38: 70-80.
    Pubmed CrossRef
  8. Guillaumot P, Autefage A, Dembour T, Chancrin JL. Outcome and complications after dual mobility total hip replacement: fifty cases with a minimum of six months clinical and radiographic follow-up. Vet Comp Orthop Traumatol 2012; 25: 511-517.
    Pubmed CrossRef
  9. Guillaumot P, Autefage A, Palierne S, Dembour T, Chancrin JL. Dual mobility canine total hip prosthesis: implant characteristics and surgical procedure. Vet Comp Orthop Traumatol 2012; 25: 506-510.
    Pubmed CrossRef
  10. Hayes GM, Ramirez J, Langley Hobbs SJ. Does the degree of preoperative subluxation or soft tissue tension affect the incidence of postoperative luxation in dogs after total hip replacement? Vet Surg 2011; 40: 6-13.
    Pubmed CrossRef
  11. Lachiewicz PF, Watters TS. The use of dual-mobility components in total hip arthroplasty. J Am Acad Orthop Surg 2012; 20: 481-486.
    Pubmed CrossRef
  12. Lanz OI, Forzisi I, Vezzoni A. Zurich cementless dual mobility cup for canine total hip prosthesis: implant characteristics and surgical outcome in 105 cases. Vet Comp Orthop Traumatol 2021; 34: 294-302.
    Pubmed CrossRef
  13. Peck JN, Marcellin-Little DJ. Advances in small animal total joint replacement. West Sussex: John Wiley & Sons. 2013.
    CrossRef
  14. Phillips CB, Barrett JA, Losina E, Mahomed NN, Lingard EA, Guadagnoli E, et al. Incidence rates of dislocation, pulmonary embolism, and deep infection during the first six months after elective total hip replacement. J Bone Joint Surg Am 2003; 85: 20-26.
    Pubmed CrossRef
  15. Plummer DR, Haughom BD, Della Valle CJ. Dual mobility in total hip arthroplasty. Orthop Clin North Am 2014; 45: 1-8.
    Pubmed CrossRef
  16. Roe SC, Sidebotham C, Marcellin-Little DJ. Acetabular cup liner and prosthetic head exchange to increase the head diameter for management of recurrent luxation of a prosthetic hip in two dogs. Vet Comp Orthop Traumatol 2015; 28: 60-66.
    Pubmed CrossRef
  17. Vasukutty NL, Middleton RG, Matthews EC, Young PS, Uzoigwe CE, Minhas TH. The double-mobility acetabular component in revision total hip replacement: the United Kingdom experience. J Bone Joint Surg Br 2012; 94: 603-608.
    Pubmed CrossRef
  18. Vedrine B, Guillaumot P, Chancrin JL. Dislocation of a dual mobility total hip replacement following fracture of the polyethylene liner. Vet Comp Orthop Traumatol 2016; 29: 259-264.
    Pubmed CrossRef
  19. Vezzoni L, Vezzoni A, Boudrieau RJ. Long-term outcome of Zürich cementless total hip arthroplasty in 439 cases. Vet Surg 2015; 44: 921-929.
    Pubmed CrossRef

Article

Case Report

J Vet Clin 2022; 39(6): 390-394

Published online December 31, 2022 https://doi.org/10.17555/jvc.2022.39.6.390

Copyright © The Korean Society of Veterinary Clinics.

Dual Mobility Cup for Revision of Dislocation of a Hip Prosthesis in a Dog with Chronic Hip Dislocation

Jaemin Jeong , Haebeom Lee

Department of Veterinary Surgery, College of Veterinary Medicine, Chungnam National University, Daejeon 34134, Korea

Correspondence to:*seatiger76@cnu.ac.kr

Received: October 27, 2022; Revised: December 2, 2022; Accepted: December 12, 2022

This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

A 6-year-old, 36.5 kg castrated male Golden Retriever presented for revision surgery for left total hip replacement. The patient underwent removal of the cup and head implants due to unmanageable prosthetic hip dislocation, despite revision surgery. On physical examination, the dog showed persistent weight-bearing lameness after exercise of the left hindlimb with mild muscle atrophy. Radiographic examination revealed dorsolateral displacement of the femur with a remnant stem and bony proliferation around the cranial and caudal acetabulum rims. The surgical plan was to apply the dual mobility cup to increase the range of motion and jump distance to correct soft tissue elongation and laxity caused by a prolonged period of craniodorsal dislocation of the femur. The preparation of the acetabulum for cup fixation was performed with a 29-mm reamer, and the 29.5-mm outer shell was fixed with five 2.4-mm cortical screws. The head and medium neck of the dual-mobility system were placed on the cup, and the hip joint was reduced between the neck and stem. The dog exhibited slight weight bearing on a controlled leash walk the day after surgery. The patient was discharged 2 weeks postoperatively without any complications. Six months postoperatively, osseointegration and a well-positioned cup implant were observed, and the dog showed excellent limb function without hip dislocation until 18 months of phone call follow-up.

Keywords: total hip replacement, chronic hip dislocation, revision, dual mobility cup.

Introduction

Revision total hip replacement (THR) is usually indicated in cases of aseptic loosening, prosthetic dislocation, or infection (1,3). Dorsal hip dislocation is one of the most common complications after THR and has been reported to occur in 4%-15% of early complications after primary THR in large-breed dogs (4,7,10,19). Revision THR is more challenging than primary THR because of anatomical changes in both the femur and acetabulum and alteration of surrounding soft tissues (17). It has been reported that the incidence of dislocation following revision THR is more than three times higher than that of primary THR in humans (14).

Causes of dislocation include severe preoperative hip laxity (luxoid hip) due to poor quality of the joint capsule, low soft tissue tension, periarticular osteophytes with fibrous tissue formation causing impingement, and implant malorientation (10,16). Several surgical methods have been reported to address dorsal hip dislocation, including adjusting the orientation of the cup implant or reimplantation, neck lengthening, and iliofemoral sutures to reinforce hip joint stability (6,13,16). Despite several revision strategies, a standard of care that can lead to successful outcomes has not yet been reported.

The dual mobility (DM) cup system was recently developed to reduce the dislocation of the hip prosthesis, and both successful cases of cemented and cementless DM cups have been reported in veterinary medicine (8,12). The cementless DM cup consists of three components: a smaller head, larger polyether ether ketone (PEEK) hemisphere, and outer acetabular shell (12). In this system, the increase in the range of motion through two articulations between the three components and the increased jump distance according to the large head diameter effectively prevented postoperative hip dislocation.

To date, retrospective studies of clinical outcomes following the DM cup system as a primary THR have been reported in veterinary medicine (8,9,12,18). However, a clinical description of DM cup application in cases of chronic dislocation after primary THR has not been reported. Therefore, we report the surgical description and long-term clinical outcomes of successful management using the DM cup system in cases of unmanageable hip dislocation even after multiple revision surgeries (5).

Case Report

A 6-year-old, 36.5 kg, castrated male Golden Retriever presented for revision surgery of the left cementless THR, which had been operated 2 years ago. The angles of lateral opening and retroversion were 45° and 20°, respectively, and the neck length was short at the time of the primary THR. The hip dislocation occurred 4 weeks postoperatively and was revised by repositioning the cup orientation and replacing the medium neck with a long neck. However, the patient underwent removal of the cup and head implants due to unmanageable prosthetic hip dislocation occurred 3 weeks after revision surgery. Despite rehabilitation and anti-inflammatory drugs administration, the dog continued to have waxing and waning clinical signs including lameness and reluctant to walk for 22 months.

On physical examination, the dog showed persistent weight-bearing lameness after active exercise of the left hindlimb with mild muscle atrophy. Radiographic examination revealed dorsolateral displacement of the femur with a well-fixed remnant stem and bony proliferation around the cranial and caudal acetabulum rims (Fig. 1). The distance between the center of the neck of the femoral stem and acetabulum was 24.5 mm, indicating severe lateralization of the femoral stem.

Figure 1. Pre- and post-operative radiographs of the left hip joint. (A) Severe laxity of the hip joint before primary THR. Immediate postoperative radiograph of (B) primary THR, (C) revision THR, and (D) at 2 years postoperative radiographs following explantation of the cup implant. (D, E) Dorsolateral displacement of the femur with a well-fixed remnant stem and bony proliferation around the acetabular rims were identified.

The patient was incompatible with the conventional THR revision method, including standard cup reimplantation and a longer neck, due to failure of previous attempts. The surgical plan was to apply the DM cup to increase the free range of motion and jump distance to correct soft tissue elongation and laxity caused by a prolonged period of craniodorsal dislocation of the hip joint.

The dog was premedicated with hydromorphone (0.1 mg/kg intravenously [IV]) and midazolam (0.2 mg/kg, IV). General anesthesia was induced with propofol (6 mg/kg, IV) and maintained with isoflurane in oxygen. Remifentanil was administered by constant rate infusion (0.1-0.3 μg/kg/min) for analgesia. Cefazolin (22 mg/kg, IV) was administered 30 min before the incision and repeated every 90 min. A standard craniolateral approach to the left hip joint was performed.

Revision surgery using DM cup system was performed according to previous surgical description (12). Briefly, preparation of the acetabulum was performed with a series of 26-, 28-, and 29-mm spherical cup reamers. The outer shell of a 29.5 mm DM cup (Kyon Inc., Zürich, Switzerland) was impacted into the prepared acetabulum and fixed with five 2.4-mm cortical screws (Fig. 2). Subsequently, the inner shell was impacted into the outer shell with a coaxial alignment by the spike of the inner shell. The 19-mm ceramic head and carbon fiber-reinforced PEEK head were assembled and impacted on the medium neck. The preassembled DM head and neck were placed on the cup first, and the hip joint was reduced between the neck and peg of the femoral stem. During reduction, a narrow Hohmann retractor was inserted caudally to the acetabulum to lever the femur distolaterally, and the neck was manipulated using straight hemostats to combine with the peg of the femoral stem. The iliofemoral suture was applied using an anchor screw and two PDS sutures to reinforce hip joint stability. The surgical site was copiously lavaged, and a surgical site swab was taken for submission of the culture test. Closure of the surgical site was performed in a routine manner.

Figure 2. (A) Intraoperative photograph of cup implantation. The outer shell of a 29.5-mm DM cup was impacted into the prepared acetabulum. (B) The outer shell was fixed with five 2.4-mm cortical screws. (C) Preassembled head and neck components. (D) Routine closure was performed after reduction of the hip prosthesis.

Radiographs were obtained immediately after surgery, which revealed the intended implantation of the DM cup (Fig. 3). The angles of the lateral opening and retroversion of the DM cup were 38° and 18°, respectively. Amoxicillin-clavulanic acid (12.5 mg/kg, IV) and clindamycin (8.5 mg/kg, IV) were administered postoperatively for two weeks without a positive culture test. Remifentanil (0.1 μg/kg/min CRI) was administered during the first 6 h and then converted to meloxicam (0.2 mg/kg subcutaneously once daily on day 1, 0.1 mg/kg orally once daily on Days 2-7) for seven days postoperatively. The patient was able to bear weight at a controlled leash walk the day after the surgery, and the limb function improved progressively. The patient showed almost normal limb function and was discharged two weeks postoperatively. A stable DM cup and osseointegration were noted on radiographic images at 6 months follow-up (Fig. 3). The owner reported excellent clinical outcomes without hip dislocation until 18 months of follow-up via phone call.

Figure 3. Postoperative ventro-dorsal and lateral radiographs of the left hip joint with DM cup (A-C) immediately postoperatively and (D-F) at 6 months postoperatively. No evidence of loosening or change in implant position and osseointegration between the cup and acetabulum can be observed on the radiographs.

Discussion

This study described acetabular revision surgery using a dual-mobility cup system in a dog with habitual prosthetic hip dislocation following THR surgery. To the best of our knowledge, this is the first report on the application of a DM cup system to address chronic prosthetic hip dislocation for over 2 years. The clinical outcomes showed excellent limb function without any complications until 18 months of follow-up.

Poor quality of the joint capsule, severe laxity, and contracture of the soft tissues around the hip joint have been reported as risk factors for THR dislocation (10,16). Improper implant selection and orientation have been reported as surgeon-related risk factors for prosthetic dislocation (6). In our case, prosthetic dislocation occurred one month after surgery, even though the cup and stem were implanted according to the anatomic reference of the patient. Prosthetic dislocation could not be addressed despite the repositioning of the cup implant and neck lengthening. Lanz et al. (12) reported that very unstable hip joints called ‘luxoid hips’ in large and giant breed dogs are the risk factors for dislocation with a high incidence of 8.5% within 2 months following primary THR. The patient had chronic hip luxation at a young age and had undergone primary THR at 4 years of age. Thus, poor quality of the soft tissue and severe laxity were considered causes of repeated hip dislocation.

A DM cup system has been developed to prevent hip dislocation and improve prosthetic stability through various mechanisms (9,12). First, the large head diameter of the DM cup increases the femoral head-to-neck ratio, which increases prosthetic stability by increasing the ‘jump distance’ required for the dislocation of the femoral head from the acetabular component (2,11,15). Additionally, the Zurich cementless DM cup has a range of motion of 145°, which is increased by 10° compared to the standard cup through double bearing, and can reduce impingement, one of the major causes of prosthetic dislocation (12). The DM cup system has been successfully applied in both human and veterinary medicine, and our case of chronic hip dislocation could be successfully revised using the DM cup (11,12,17).

According to previous retrospective studies where the DM cup system was applied to the primary THR, dislocation was reported in only one case out of 103 cases in which cementless was applied, and no dislocation occurred in 50 cases in which the cement DM cup was applied (8,12). These clinical outcomes were consistent with the 1%-2% incidence of dislocation following DM cup application reported in human medicine (11,17). In our case, there was no dislocation at the follow-up of 18 months, and an excellent clinical outcome was observed.

The limitations of this case report include the fact that it was based on a single case and there is a lack of extended long-term follow-up of more than several years to observe complications such as wearing and aseptic loosening, even though it showed excellent clinical outcomes in our follow-up periods.

Conclusions

This case report describes a revision strategy for THR using a dual-mobility cup system in a dog with unmanageable hip dislocation following primary THR. Based on the clinical outcomes, dual-mobility cup systems can be an alternative to standard THR systems in dogs with challenges in addressing hip dislocations following primary THR surgery.

Source of Funding

This work was supported by Korea Institute of Planning and Evaluation for Technology in Food, Agriculture and Forestry (IPET) through Companion Animal Whole Cycle Industialization Technology Development Program, funded by Ministry of Agriculture, Food and Rural Affairs (MAFRA) (322090).

Conflicts of Interest

The authors have no conflicting interests.

Author Contributions

Author 1: conception of the study, data collection, interpretation of the results, manuscript preparation, critical review of the article, and approval of the final manuscript; Author 2: conception of the study, data collection, performed surgical procedures, interpretation of the results, manuscript preparation, critical review of the article, and approval of the final manuscript.

Fig 1.

Figure 1.Pre- and post-operative radiographs of the left hip joint. (A) Severe laxity of the hip joint before primary THR. Immediate postoperative radiograph of (B) primary THR, (C) revision THR, and (D) at 2 years postoperative radiographs following explantation of the cup implant. (D, E) Dorsolateral displacement of the femur with a well-fixed remnant stem and bony proliferation around the acetabular rims were identified.
Journal of Veterinary Clinics 2022; 39: 390-394https://doi.org/10.17555/jvc.2022.39.6.390

Fig 2.

Figure 2.(A) Intraoperative photograph of cup implantation. The outer shell of a 29.5-mm DM cup was impacted into the prepared acetabulum. (B) The outer shell was fixed with five 2.4-mm cortical screws. (C) Preassembled head and neck components. (D) Routine closure was performed after reduction of the hip prosthesis.
Journal of Veterinary Clinics 2022; 39: 390-394https://doi.org/10.17555/jvc.2022.39.6.390

Fig 3.

Figure 3.Postoperative ventro-dorsal and lateral radiographs of the left hip joint with DM cup (A-C) immediately postoperatively and (D-F) at 6 months postoperatively. No evidence of loosening or change in implant position and osseointegration between the cup and acetabulum can be observed on the radiographs.
Journal of Veterinary Clinics 2022; 39: 390-394https://doi.org/10.17555/jvc.2022.39.6.390

References

  1. Allen MJ. Advances in total joint replacement in small animals. J Small Anim Pract 2012; 53: 495-506.
    Pubmed CrossRef
  2. Berry DJ, von Knoch M, Schleck CD, Harmsen WS. Effect of femoral head diameter and operative approach on risk of dislocation after primary total hip arthroplasty. J Bone Joint Surg Am 2005; 87: 2456-2463.
    CrossRef
  3. Bozic KJ, Kurtz SM, Lau E, Ong K, Vail TP, Berry DJ. The epidemiology of revision total hip arthroplasty in the United States. J Bone Joint Surg Am 2009; 91: 128-133.
    Pubmed CrossRef
  4. Conzemius MG, Vandervoort J. Total joint replacement in the dog. Vet Clin North Am Small Anim Pract 2005; 35: 1213-1231, vii.
    Pubmed CrossRef
  5. Cook JL, Evans R, Conzemius MG, Lascelles BD, McIlwraith CW, Pozzi A, et al. Proposed definitions and criteria for reporting time frame, outcome, and complications for clinical orthopedic studies in veterinary medicine. Vet Surg 2010; 39: 905-908.
    Pubmed CrossRef
  6. Dyce J, Wisner ER, Wang Q, Olmstead ML. Evaluation of risk factors for luxation after total hip replacement in dogs. Vet Surg 2000; 29: 524-532.
    Pubmed CrossRef
  7. Guerrero TG, Montavon PM. Zurich cementless total hip replacement: retrospective evaluation of 2nd generation implants in 60 dogs. Vet Surg 2009; 38: 70-80.
    Pubmed CrossRef
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Vol.39 No.6 2022-12-31

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The Korean Society of Veterinary Clinics

pISSN 1598-298X
eISSN 2384-0749

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