Abstract
This systematic review assessed the efficacy, survivorship, and complications of Total Hip Replacement (THR) in Parkinson's Disease (PD). Databases were searched according to the Preferred Reporting Items for Systematic Reviews. PD patients had higher wound infections, dislocations, peri-prosthetic fractures, and revision surgery compared to their non-PD counterparts. They also had inferior functional outcomes, and longer and expensive hospital admissions. Dual-mobility (DM) implants had the lowest survival rate. THR in PD patients is associated with significant surgical complications and peri-operative challenges. Despite the use of DM implants to minimize instability, there is insufficient evidence on its effectiveness and long-term survivorship.
Keywords: Total hip arthroplasty, Dual mobility implant, Parkinson's disease, Complications, Functional outcome
1. Introduction
Total hip replacements (THR) are highly effective for relieving painful hip arthritis. Although rare, post-surgical complications can occur which are minimized by various interventions and strategies. The benefits of large registry data sets mean small differences can be identified within populations, which is vital in investigating rarer events.
Parkinson's disease (PD) has long been associated with challenges in patients undergoing THR.1 Increased muscle tone and poor muscular control can lead to difficulties in the intra-operative and post-operative management of THR patients. PD is proven to give an increased complication rate in patients undergoing THR, particularly instability and concerns regarding post-operative rehabilitation.2
It is recognised that patients with PD can have a general functional decline following operative intervention secondary to disease progression.3 There are also concerns that patients with PD have an increased risk of post-operative cognitive decline,4 with poor cognition further increasing dislocation risk secondary to failure to follow post-operative restrictions. Mean length of stay is longer in patients with PD.2
Aside from surgical challenges, anaesthetists must account for several difficulties with this cohort including autonomic dysfunction, respiratory dysfunction, neuropsychiatric considerations as well as potential drug interactions.5
Surgeons have attempted to offset the increased risk of dislocation by altering the choice of implants used. Strategies include using large bearings, which relatively increase the head/neck ratio, improving the primary arc of the bearing before impingement occurs.6 Captive sockets increase constraint within the system by creating a mechanical block to dislocation. Unfortunately, these can have the unwanted results of increasing strain at the implant/bone interface - potentially leading to unwanted early aseptic loosening of the implant.7 More recently, there has been renewed interest in dual mobility implants.8 These implants have two intended articulations, the first between the acetabular component and the acetabular insert, and a second between the insert and the head of the femoral prosthesis.6 First introduced in France in the 1970s, the intended benefit of this double articulation is to reduce both the dislocation rates and the strain at the bone implant interface.9
We have identified a paucity of recent evidence related to THR in patients with PD, and particularly limited published outcome studies of newer dual modality implants on the market. We have undertaken a systematic review of the literature, with the primary aim to assess the current efficacy, survivorship and complication rate associated with THR in patients with PD. Our secondary aims were to evaluate whether the evidence supports the use of dual mobility bearings in PD, as well as investigating patient reported outcome measures, particularly regarding post-operative mobility.
2. Methods
A systematic review was carried out with reporting according to the standards in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA).10
The review was conducted over three meetings that took place four to twelve weeks apart. At the first meeting, the protocol was reviewed and agreed, including the choice of outcomes, the search terms and inclusion/exclusion criteria. At the second meeting, the titles and abstracts of the studies were screened and studies were selected for full text review. At the third meeting, agreement was reached about which studies should be included, and extracted data were presented and conclusions drawn.
2.1. Literature search
A search of Medline, OVID Embase and Cochrane Central Register of Controlled Trials was conducted from the inception of the databases to February 2020. The terms included ‘dual mobility hip’ or ‘total hip arthroplasty’ or ‘total hip replacement’ AND ‘Parkinson's’ or ‘Parkinson's Disease’. No restrictions were made on language and effort was made to obtain English translated versions of all included studies. Bibliographies of all included studies were examined for missed and potentially relevant studies.
2.2. Outcome measures
Studies of total hip replacements or dual mobility implants in Parkinson's Disease patients were included which reported on the following outcomes: a) post-surgical complications – wound infections, dislocations, peri-prosthetic fracture, implant survival, revision surgery and medical complications, b) pain and functional outcomes and c) length of hospital stay and hospital charges. Exclusion criteria were non-human studies, case reports or expert opinions, foreign papers not translatable to English, retrospective studies with fewer than ten arthroplasties and publications pertaining to surgical techniques.
2.3. Assessment of studies
Two reviewers (DM, KB) independently assessed the quality of the studies. This was undertaken using a Modified Coleman Methodological Score (MCMS), modified to account for the subject matter. (Table 1).11 This tool has two parts, the first assesses the methodology of the study and the second assesses the outcome measures used. An absolute score was used to scrutinise the quality of the study. Any discrepancy of more than 4 points between both reviewers were highlighted and resolved by the senior author (NAS). On this basis, publications scoring less than 50 were excluded from our analysis.
Table 1.
Modified Coleman's criteria used for the assessment of the quality of studies.
| Criteria | ||
|---|---|---|
| Part A | ||
| Study Size (PD Patients) | >40 | 15 |
| 25–40 | 10 | |
| 11f- h25 | 5 | |
| <10 | 0 | |
| Mean follow up (months) | >24 | 10 |
| 12h-h24 | 5 | |
| <12, not clear/not stated | 0 | |
| Type of study (methodology) | Randomized controlled trial | 12 |
| Prospective cohort study | 7 | |
| Retrospective cohort study | 0 | |
| Diagnostic certainty (underlying aetiology e.g. Parkinsons/motor neurone disease/neuropathy) | In all | 5 |
| >80% | 3 | |
| <80% | 0 | |
| Part B | ||
| Outcome criteria | Clearly defined outcome | 3 |
| Timing of outcome assessment clearly stated | 3 | |
| Established reliability | 3 | |
| Good sensitivity | 3 | |
| Procedures for assessing outcomes | Clearly defined | 3 |
| Objective | 3 | |
| Computer algorithm, blinding | 3 | |
| Multiple observers | 3 | |
| Description of subject population | Inclusion criteria reported and unbiased | 4 |
| Recruitment rate reported >80% | 3 | |
| Recruitment rate reported <80% | 2 | |
| Recruitment rate not reported | 0 | |
| All eligible subjects accounted for in methodology | 3 | |
| Post-operative rehabilitation | Well described | 6 |
| Not adequately described | 3 | |
| Protocol not reported | 0 | |
| Surgical technique | Implant specified | 2 |
| Surgical approach stated | 2 | |
| Constraint or size of femoral head stated | 2 | |
| Complications recorded | All with explanations | 6 |
| Selected complications recorded | 3 | |
| Incomplete record | 2 | |
| None | 0 | |
| Revisions reported | Method of failure | 3 |
| Time of failure | 3 | |
3. Results
A total of 50 studies were identified from the initial search before 4 duplicates were removed. Following review of the title and abstracts, 23 papers were excluded. The full text of 23 papers were reviewed, of which 12 were then excluded after the Coleman criteria was applied. After extraction of full data, we recognised that there was insufficient data to undertake a meta-analysis. We therefore proceeded to do a qualitative synthesis of the data. 2 of the included studies gave overall data for outcomes but not specifically for PD and therefore were excluded for analysis but the conclusions were considered as part of the overall message from these studies.12,13 The full data were extracted from the remaining 9 studies, which were included in the review.1,3,14, 15, 16, 17, 18, 19, 20 This is summarised in Fig. 1. The characteristics of the final papers are provided in Table 2.
Fig. 1.
Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart.
Table 2.
Baseline characteristics of included studies.
| Authors | Year | Study Design | Study Size | Patients with Parkinson Disease | Gender (of PD patients) |
Age (PD patients) (mean) | Prosthesis |
|||
|---|---|---|---|---|---|---|---|---|---|---|
| Male | Female | Head Diameter | Constrained Liner | Dual Mobility | ||||||
| Shah et al.14 | 2019 | Prospective | 470 | 235 | 122 | 113 | 74.3 | No report | No report | No report |
| Kleiner et al.15 | 2019 | Retrospective Cohort | 16,012 | 4,003 | 1,941 | 2,062 | 74.5 | No report | No report | No report |
| Rondon et al.16 | 2018 | Retrospective Cohort | 145 | 52 | 29 | 23 | 68.7 | No report | No report | No report |
| Sponer et al.17 | 2017 | Retrospective Case Series | 24 | 24 | 8 | 15 | 75.2 | 28 mm in 20 |
0/24 | 0/24 |
| 32 mm in 4 | ||||||||||
| Mathew et al.18 | 2013 | Retrospective Case Series | 15 | 15 | 6 | 8 | 76 | No report | 0/15 | 0/15 |
| Weber et al.1 | 2002 | Retrospective Case Series | 107 | 107 (58 primary, 33 revision) | 49 | 49 | 72 | No report | No report | No report |
| Newman et al.19 | 2018 | Retrospective Cohort | 42,198 | 10,519 | 5,373 | 5,146 | 73 | No report | No report | No report |
| Lazennac et al.3 | 2018 | Retrospective case series | 63 | 59 (42 primary, 21 revision) | 34 | 25 | 72.5 | No report | 0/63 | 63/63 (Concept DM) |
| Wojtowich et al.20 | 2019 | Retrospective cohort | 980 | 490 | 245 | 245 | 73 | No report | No report | No report |
| Authors | Mean follow up (months) | Outcomes | Modified Coleman |
Modified Coleman |
Modified Coleman |
|---|---|---|---|---|---|
| A Score | B score | Total Score | |||
| Shah et al.14 | 24 | LOS, hospital charges, wound infection, dislocation, revision, medical complications | 32 | 31 | 63 |
| Kleiner et al.15 | N/A | LOS, hospital charges, in-hospital mortality, medical complications | 20 | 31 | 51 |
| Rondon et al.16 | 64 | Dislocation, Peri-prosthetic fracture, Revision, Implant Survival, Function (SF-12) | 30 | 31 | 61 |
| Sponer et al.17 | 36 | Dislocation, Peri-prosthetic fracture, Revision, Medical complications, Function (Merle and Postel score), mobility | 20 | 42 | 62 |
| Mathew et al.18 | 36 | LOS, Dislocation, Peri-prosthetic fracture Revision, Medical complications, Wound infection, Pain and mobility | 20 | 37 | 57 |
| Weber et al.1 | 12 | Wound infection, Dislocation, peri-prosthetic fracture, Implant survival, Revision, medical complications, mobility | 25 | 29 | 54 |
| Newman et al.19 | N/A | LOS, hospital charges, Wound infection, dislocation, medical complications | 20 | 31 | 51 |
| Lazennac et al.3 | 87.5 | Wound infection, dislocation, peri-prosthetic fracture, revision, implant survival, medical complications, pain | 30 | 31 | 61 |
| Wojtowich et al.20 | 56.4 | Dislocation, Peri-prosthetic fracture, Revision, Pain, Function (EQ-5D) | 30 | 32 | 62 |
LOS – length of stay, SF-12 – Short form 12 item survey.
In total, fifteen thousand, four hundred and ninety-three (15,493) patients with Parkinson's Disease had a total hip replacement. Upon accounting for the fifteen patients receiving bilateral hip replacements, this brought the total to fifteen thousand, five hundred and eight (15,508). However, one study did not declare the full number of surgical complications in Parkinson's patients and this was excluded from analysis.19 The average age and mean follow-up were 73.4 years and 45.4 months respectively for all studies. After exclusion of the above study,19 the average age and mean follow-up were 74.2 years and 45.4 months, respectively. The baseline characteristics are summarised in Table 2.
3.1. Methodological quality of studies
Three studies commented on the type of prosthesis used including a constraint liner or dual-mobility implants.3,17,18 Of these studies, only one reported femoral head diameter size (Table 2).17
Outcome: Post- surgical complications (See Table 3)
Table 3.
Post-operative complications in patients with Parkinson's disease following Total Hip Replacement.
| Authors | Comparative arm | Post-surgical complications following THR in PD patients |
||||||
|---|---|---|---|---|---|---|---|---|
| Wound infection | Dislocations/Instability | Peri-prosthetic fracture | Implant survival | Revision |
Medical complications | |||
| Numbers revised | Reason for revision | |||||||
| Shah et al.14 | Non-PD patients | 19/235 (PD > non-PD, | 7/235 (PD ~ non-PD, | – | – | 15/235 (PD ~ non-PD, | Not reported | 64/235 (PD ~ non-PD, 64 vs. 62, p = 0.835) |
| 19 vs 6, p = 0.008) | 7 vs 6, p = 0.779) | 15 vs. 11, p = 0.420) | ||||||
| Kleiner et al.15 | Non-PD patients | – | – | – | – | – | – | 584/4003 (PD > non-PD, 14.6% vs. 11.7%, p < 0.001) |
| Rondon et al.16 | Non-PD patients | – | 4g/52 (PD > non-PD, 4 vs. 0, p = 0.0013) | 4g/52 (PD > non-PD, 4 vs.0, p = 0.0013) | 94.3% at 2 years | 14/52 | Peri-prosthetic fracture (4), Dislocation (4), Aseptic loosening (1), Peri-prosthetic infection (1), Wear (1) | – |
| 85.3% at 5 years | PD > non-PD (OR 11.05, | |||||||
| 78.7% at 10 years | 3.00–40.7, p = 0.003) | |||||||
| Sponer et al.17 | Nil | – | 2/24 | 2/24 | – | 2/24 | Peri-prosthetic fracture (2) | 21/24 |
| Mathew et al.18 | Nil | 0/15 | 0/15 | 2/15 | – | 4/15 | Aseptic loosening (3), Peri-prosthetic fracture (1) | 10f/h15 |
| Weber et al.1 | Nil | 1/107 | 6/107 | 1/107 | 93% at 5 years | 42/107 | 33 revision THA: Failed Prosthesis (21), Aseptic loosening (10), Failed cup arthroplasty (2). | 25/107 |
| 9 post-surgery from study: Dislocation (1), Wound infection (1), Peri-prosthetic fracture (1), Trochanteric nonunion (1), Wire removal (1), Instability (1), Aseptic loosening (3). | ||||||||
| Newman et al.19 | Non-PD patients | – | – | – | – | – | – | PD > non-PD (OR 1.54, 1.38–1.71, p < 0.0001) |
| Lazennac et al.3 | Nil | 2f/463 | 1f/463 | 44/h63 | 91.5% at 2 years | 26/63 | 21 revision THA: Dislocation (11), Polyethylene wear (6), femoral loosening (4). | 24/63 |
| 79.7% at 5 years | 5 post-surgery from study: Peri-prosthetic fracture (4), Dislocation (1), | |||||||
| Wojtowich et al.20 | Non-PD patients | – | 8/490 | 4/490 | – | 23/490 PD > non-PD (2.1% vs. 0.41%, p = 0.021) | Aseptic loosening (10), Peri-prosthetic infection (22), Peri-prosthetic fracture (4), Dislocation (8), | – |
Wound infections. This was reported in four studies giving data for four hundred and twenty Parkinson's patients.1,3,14,18 Of this, twenty-two patients (5.24%) developed a post-operative wound infection. One study found wound infections to be higher in Parkinson's patients compared to non-Parkinson's following total hip replacement.14
Instability. This was reported in all but one study.15 Of the nine hundred and eight-six patients, twenty-eight patients (2.84%) sustained a dislocation post-operatively. However, in Lazennac's study,3 eleven Parkinson's patients were having a revision THA at the start of the study due to a dislocation. Thus, thirty-nine patients (4.0%) in total had a dislocation in the Parkinson's group. Two studies compared the dislocation rate with non-Parkinson's patient.14,16 One suggested significantly higher dislocation rate in Parkinson patients (p = 0.0013),16 whilst the other reported no differences (p = 0.779).14
Peri-prosthetic fracture. This was reported in six studies accounting for seven hundred and fifty-one patients.1,3,16, 17, 18,20 Seventeen patients (2.3%) sustained a fracture with one study suggesting higher peri-prosthetic fracture rates compared to non-Parkinson patients (p = 0.0013).16
Implant survival. Of the three reported studies,1,3,16 implant survival ranged from 79.7% to 93% at 5 years. On further analysis of the implants used, only one study reported on this with the Dual Mobility implant having the lowest survivorship (79.7%).3
Revision. This was reported in seven studies.1,3,14,16, 17, 18,20 One hundred and twenty-six of the nine-hundred and eighty-six Parkinson's patients (12.8%) required revision surgery at the start of the study or during follow up. Commonest causes for revision were aseptic loosening (n = 31), instability (n = 25), peri-prosthetic joint infection (n = 23) and peri-prosthetic fractures (n = 16). Of the three studies comparing to non-Parkinson's patients,14,16,20 two found significant higher revision rates in Parkinson patients (p = 0.003 and p = 0.021).16,20
Total surgical complications. Although Newman et al. did not declare the full numbers of surgical complications, they did find Parkinson patients to be 30% higher risk for any surgical complications in the Parkinson's cohort (n = 10,519) compared to the non-Parkinson disease cohort (31,679) (OR = 1.30, 1.38 to 1.71, p < 0.0001). Of the four studies that compared Parkinson's to non-Parkinson's patients regarding surgical complications,14,16,19,20 Newman's study contributed to 96.4% of the weighted mean. This suggests surgical complications are more likely in Parkinson patients following a total hip replacement.
Medical complications. Although seven studies reported on this,1,3,14,15,17, 18, 19 data on types of medical complications were only available for six.1,3,14,15,17,18 Seven hundred and twenty-eight of four thousand, four hundred and forty-seven Parkinson's patients (16.4%) had some form of post-operative medical complication. This included post-operative delirium, acute myocardial infarction, pulmonary embolus, pneumonia, stroke, gastrointestinal, acute renal failure, urinary tract infection, deep vein thrombosis, blood transfusion and sepsis. Of the three studies comparing overall medical complications to non-Parkinson's patients,14,15,19 two found significantly higher medical complications (p < 0.001 and p < 0.0001).15,19 Both papers contributed to 27.3% and 71.9% of the weighted mean, suggesting medical complications are also more likely in Parkinson patients following a total hip replacement.
Outcome: Pain and Patient Reported Outcome Measures (see Table 4)
Table 4.
Pain and functional outcomes in Parkinson Patients post Total Hip Replacement.
| Authors | Comparative arm | Functional outcomes |
||||||
|---|---|---|---|---|---|---|---|---|
| Follow up |
Scoring system |
|||||||
| Mean follow up for PROMs | Number of PD patients on final follow up | SF-12 | Merle d’Aubigne and Postel | EQ-5D | Pain | Independent walk/decreased support | ||
| Shah et al.14 | Non-PD patients | 24 | – | – | – | – | – | – |
| Kleiner et al.15 | Non-PD patients | N/A | – | – | – | – | – | – |
| Rondon et al.16 | Non-PD patients | 64 | 26/52 | Delta Score: 6.2 Non-PD > PD (11.8 vs. 6.2, p = 0.029) | – | – | – | – |
| Sponer et al.17 | Nil | 36 | 17/23 | – | Improved at 6 months (p < 0.001). Nil thereafter | – | Improved at 6 months (p < 0.001). Nil thereafter | Pre-operatively: 23/23 |
| At 36 months: 10/17 | ||||||||
| Mathew et al.18 | Nil | 36 | 12h/h15 | – | – | – | Improved at 36 months (p = 0.00065) | At discharge: 9/15 |
| At 36 months: 5/12 (p = 0.042) | ||||||||
| Weber et al.1 | Nil | 84 | 75/107 | – | – | – | Improved at 12 months (p < 0.001). Nil thereafter (p > 0.1) | ↑ at 1 year (p < 0.01) |
| ↓ at 84 months (p < 0.01) | ||||||||
| Newman et al.19 | Non-PD patients | – | – | – | – | – | – | – |
| Lazennac et al.3 | Nil | 87.5 | 47/63 | – | – | – | Good to excellent pain relief in 40/47 at 87.5 months | – |
| Wojtowich et al.20 | Non-PD patients | 12 | 155/490 | – | – | Mean change: 0.30 Non-PD > PD (0.42 vs 0.30, p = 0.003 | Mean change: −47.18 PD ~ non-PD (−47.18 vs. −48.85), p = 0.51) | – |
Pain. Five of the nine studies reported on pain following total hip replacement in Parkinson's’ patients.1,3,17,18,20 This included a total of three hundred and six patients followed up at a mean of 52.1 months. Although three studies showed significant improvement in pain from the pre-operative state, these were all at different lengths of follow-up with no significant improvements thereafter (6, 12 and 36 months).1,17,18 One study compared post-operative pain with non-PD patients and found no difference between the groups at one year.20
Patient reported outcome measures. Three studies assessed functional outcome with the use of a scoring system.16,17,20 These included the SF-12, Merle d’Aubigne and Postal and EQ-5D. Two studies found non-PD patients reported better functional outcomes at 6 months (p = 0.029) and 1 year (p = 0.003).16,20
Mobility. Three studies assessed mobility post-operatively of one hundred and forty-five patients.1,17,18 One hundred and four patients were available on final follow up. These studies found that although patients were increasingly independent up to one year following surgery, they started regressing in their mobility from 36 months onwards with increase in limp, walking supports and decreased walking distances.
Outcome: Length of inpatient stay and hospital charges (see Table 5)
Table 5.
Hospital stay and costs in Parkinson patients post Total Hip Replacement.
| Authors | Comparative arm | Length of hospital stay (days) | Hospital charges (pounds) |
|---|---|---|---|
| Shah et al.14 | Non-PD patients | 4.97 (PD > non-PD, 4.97 vs 4.07, p = 0.001) | 39,531.71 (PD ~ non-PD, 39,531.71 vs. 36,802.34, p = 0.198) |
| Kleiner et al.15 | Non-PD patients | 3.1 (PD > non-PD, 3.1 vs. 2.7, p < 0.001) | 38,081.15 (PD > non-PD, 38,081.15 vs.35,372.21, p < 0.001) |
| Rondon et al.16 | Non-PD patients | – | – |
| Sponer et al.17 | Nil | – | – |
| Mathew et al.18 | Ni | 19 | – |
| Weber et al.1 | Nil | – | |
| Newman et al.19 | Non-PD patients | 3.89 (PD > non-PD, 3.89 vs 3.59, p < 0.0001) | 13,536.15 (PD > non-PD, 13,536.15 vs. 12,995.92, p < 0.0001) |
| Lazennac et al.3 | Nil | – | – |
| Wojtowich et al.20 | Nil | – | – |
Inpatient stay. Three studies,14,15,19 of which two were nationwide studies,15,19 found patients with Parkinson's disease are more likely to have a longer admission than those without following total hip replacement (4.97 vs 4.07 days, p = 0.001, 3.1 vs 2.7 days, p < 0.001 and 3.89 vs 3.59 days, p < 0.0001).
Hospital charges. The same studies as above assessed hospital charges.14,15,19 Although one showed no significant difference,14 the remaining two studies, both nationwide,15,19 showed a more expensive running cost for Parkinson's patients compared to those without the disease in total hip replacement (£38,081.15 vs. £35,372.21, p < 0.001 and £13,536.15 vs. £12,995.92, p < 0.0001).
3.2. Outcomes: dual mobility implants
This was assessed only in Lazennec et al.’s study,3 in which dual mobility cups were used in 63 hips of Parkinson's patients. Although no dislocations were observed at a mean of 8.3 years, one patient developed a dislocation at 9 years due to posterior impingement. 5 patients required revision following dual mobility due to dislocation (n = 1) and peri-prosthetic fracture following a fall (n = 4) due to PD progression. All patients experienced improvement in pain in early follow up and maintained improvement on latest follow-up. Implant survival at 2 and 5 years was 91.5% and 79.7% respectively.
4. Discussion
Our systematic review confirms that PD represents a unique challenge in THR. Evidence is positive for the efficacy of THR in relieving a patients’ pre-operative pain and should thus continue to be offered to such patients with both patient and surgeon reassured that pain and function should improve post-operatively.1,16, 17, 18,20
We also support the view that such patients have an increased risk of surgical complications and medical complications when compared to non-PD patients.14, 15, 16,19,20 Although studies are heterogeneous in their methodology, results suggest PD to be an independent risk factor for major complications such as infection, dislocation, peri-prosthetic fracture and overall revision rate.14,16,20 The differences in study designs mean we are unable to accurately quantify this increase in risk. With this in mind, it is important to counsel patients and their families regarding their individual patient-specific risks when considering THR. The multi-disciplinary team should pre-empt such difficulties and appropriate resources should be utilised when such cases arise, with the hospital expecting a prolonged inpatient stay and increased costs.14,15,19 It is important to emphasise the post-operative medical complications to the patient, and although the procedure provides good pain relief, the outcomes as regards mobility are still not predictable with the current evidence base.1,17,18
With the increased revision rate in PD patients undergoing THR acknowledged, surgeons and implant companies have understandably looked to address this by modifying implant design.6,8,9 Dual mobility implants address instability. However, evidence for their long-term success in well designed studies is greatly lacking.8 Questions regarding their use remain, as increasing constraint to prevent instability has the potential to influence implant survivorship, with potentially negative impacts on aseptic loosening.7 Both instability and loosening are potential causes for revision surgery. A well designed randomised controlled trial comparing conventional implants to dual mobility implants in PD patients would offer important insights into this, though the numbers of recruited patients required for a fully powered study may be large and challenging to set up in one locality. This would also take some time to yield useful data on dislocation rates and revision rates. Surgeons may have concerns recruiting such patients, willing to accept a potential longer-term risk of loosening over a short term and more immediate risk of dislocation. Over time, registry data may give some indication as to their efficacy, however the patient group undergoing dual mobility implants would be at risk of selection bias, as they are predominantly used in high risk situations.
Our criteria demonstrated a low number of papers of sufficient quality, contributing to the overall paucity of high-quality evidence relating to either outcomes of PD patients undergoing THR or any added benefit of dual mobility implants. This further demonstrates the need for ongoing research into a group of patients with unique set of challenges.
5. Conclusion
THR in PD patients have a predictable and sustained pain relief with adequate post-operative function. However, the current literature suggests the condition to be an independent risk factor for major peri-operative medical and post-operative surgical complications. Although modifying implant design to address some of these concerns are being recently explored, the current evidence base is lacking on longer term function and survivorship. Their efficacy may only be observed after future analysis of longer-term registry data.
Contributorship
D. McCormack: Collection of Data, Writing of manuscript for publication, final approval of manuscript.
K. Boksh: Collection of Data, Data analysis and interpretation, Writing of manuscript, final approval of manuscript.
N. Sheikh: Conception, Design, writing of manuscript, final approval of manuscript.
Funding
Nil.
Ethical approval
N/A.
Data sharing statement
All relevant data are included in the article.
Declaration of competing interest
None of the authors have any conflicts of interest to disclose.
Acknowledgements
Nil.
Contributor Information
Daniel McCormack, Email: daniel.mccormack@gmail.com.
Khalis Boksh, Email: khalis_boksh@hotmail.co.uk.
Nomaan Sheikh, Email: nomaan.sheikh2@nhs.net.
References
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