JOA - 2026-04-20 - Journal Article
Instability Following Head and Liner Exchange: 8-Fold Reduction in Dislocation with the Direct Anterior Approach.
Gausden EB, Afzal S, Bhatti P, Gallagher PJ, Anatone A, Jolissaint J, Zhu J, Debbi E, Rodriguez JA
Topics
Key Takeaway
Direct anterior approach for isolated head and liner exchange reduces dislocation risk 7.68-fold compared to posterolateral approach at one year (2.4% vs. 12.4%, p=0.04).
Summary Depth
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Summary
This study asked whether DAA reduces dislocation after isolated head and liner exchange (HLE) for polyethylene wear compared to PLA. Cox proportional hazards regression on 176 cases showed DAA yielded 2.4% vs. 12.4% dislocation at one year (HR 7.68, p=0.04), despite DAA patients receiving dislocation-mitigating implants less frequently (no DMC or constrained liners, elevated liners in only 6.4% vs. 45.7%). Reoperation-free survivorship did not differ significantly between groups (2.7% DAA vs. 6.2% PLA, p=0.20).
Key Limitation
Retrospective design with non-randomized approach assignment introduces unmeasured confounding; surgeons likely selected DAA for patients with more favorable soft-tissue envelopes or component positions, making the true magnitude of the approach effect uncertain.
Original Abstract
INTRODUCTION
Isolated head and liner exchange (HLE) can be utilized as a less invasive option for specific indications in revision total hip arthroplasty (THA). Historically, the most common complication following HLE is dislocation. The objective of this study was to determine if the direct anterior approach (DAA) results in a lower incidence of dislocation when compared to the postero-lateral approach (PLA) for HLE.
METHODS
A retrospective review identified 176 cases undergoing isolated HLE (129 PLA and 47 DAA) for polyethylene wear between 2016 and 2025. Cases that had a previous periprosthetic joint infection (PJI) or previous instability were excluded. Cox proportional hazards regressions were used to compare the DAA versus PLA approach in terms of reoperation and dislocation survival outcomes. Femoral head diameter was increased in 74.1% of PLA and 32.4% of DAA. Elevated liners were placed in 45.7% of PLA HLE versus 6.4% of DAA and dual mobility construct (DMC) or a constrained liner in 6.9 and 4.7% of PLA, respectively, but in none of the DAA cohort.
RESULTS
At one year, dislocation incidence was lower after DAA than PLA (2.4 versus 12.4%), with higher dislocation-free survivorship for DAA (log-rank Chi-square = 5.55, P = 0.02; hazard ratio (HR) for PLA versus
DAA
7.68, P = 0.04). The one-year reoperation incidence was 2.7% after DAA versus 6.2% after PLA, with no significant difference in reoperation-free survivorship (log-rank Chi-square = 1.64, P = 0.20; HR 2.54, P = 0.22).
CONCLUSION
Use of the DAA for isolated HLE was associated with a nearly eight-fold lower risk of dislocation compared to PLA, despite less frequent use of dislocation-mitigating implants in the DAA cohort. Surgeons may consider DAA for HLE to reduce postoperative instability.