Late dislocation after total hip arthroplasty.

BACKGROUND:
Some patients have a dislocation for the first time many years after a total hip arthroplasty, but little is known about the risk factors and outcomes associated with late dislocation. The purposes of this study were (1) to determine the prevalence of late dislocation after total hip arthroplasty, (2) to characterize demographic and other factors associated with such late dislocations, and (3) to report the outcomes of such late dislocations.

METHODS:
Between 1969 and 1995, 19,680 primary total hip arthroplasties were performed in 15,964 patients at our institution. According to a prospective surveillance protocol, the patients were followed routinely at regular intervals and were specifically queried at each time-point about whether (and, if so, when) the hip had dislocated. First dislocations that occurred five years or more after the operation were defined as late dislocations.

RESULTS:
Five hundred and thirteen (2.6%) of the 19,680 hips dislocated. Of the 513 hips, 165 (0.8% of the entire cohort; 32% of the dislocated hips) first dislocated five or more years after the primary arthroplasty. The median time until the occurrence of these late dislocations was 11.3 years (range, five to 24.9 years) after the operation. Late dislocation was more frequent than early dislocation in women (p = 0.03), and late dislocation was associated with a younger age at the time of the primary total hip arthroplasty (median, sixty-three years) than was early dislocation (median, sixty-seven years) (p = 0.02). Clinical factors associated with late dislocation included previous subluxations without dislocation in twenty patients, a substantial episode of trauma in eleven patients, and onset of marked cognitive or motor neurologic impairment in eleven patients. Radiographically, the late dislocation occurred in association with polyethylene wear of >2 mm in eighteen hips, with implant loosening with migration or a change in position in eight, and with initial malposition of the acetabular implant (anteversion of < 0 degrees or >30 degrees or abduction of >55 degrees) in thirty. Late dislocation recurred in ninety (55%) of the 165 hips and was treated with a reoperation in fifty-five hips (33% of the hips with late dislocation; 61% of the hips with recurrent dislocation).

CONCLUSIONS:
Late dislocation is more common than was previously thought. Several separate processes, some distinct from those associated with early dislocation, can lead to late dislocation. Late dislocation can occur in association with a long-standing problem with the prosthesis that manifests late (such as malposition of the implant or recurrent subluxation), it can occur in association with a new problem (such as neurologic decline, an episode of trauma, or polyethylene wear), or it can occur in association with any combination of these factors. The likelihood of the first late dislocation recurring is high.