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Luthringer TA, Vigdorchik JM. A Preoperative Workup of a "Hip-Spine" Total Hip Arthroplasty Patient: A Simplified Approach to a Complex Problem. J Arthroplasty 2019; 34:S57-S70. [PMID: 30755374 DOI: 10.1016/j.arth.2019.01.012] [Citation(s) in RCA: 97] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 01/07/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND A large body of evidence has confirmed that patients with spinal deformity, lumbar fusion, and abnormal spinopelvic mobility are at significantly increased risk for instability, dislocation, and revision after total hip arthroplasty (THA). METHODS Achieving a stable construct in patients with pre-existing spine disease requires an understanding of basic spinopelvic parameters and the compensatory mechanisms associated with abnormal spinopelvic motion. Indicated patients with concomitant hip-spine pathology should be assessed for (1) the presence of spinal deformity and (2) the presence of spinal stiffness before undergoing THA. Preoperative imaging should include a standing anteroposterior pelvis x-ray, as well as two lateral spinopelvic radiographs in the standing and seated position. RESULTS Based on the presence of spinal deformity and/or spinal stiffness, patients may be categorized as one of the four groups of the "Hip-Spine Classification in THA." A series of illustrative case examples is provided. CONCLUSION A simple three-step assessment with minimal measurements will effectively identify the complex "hip-spine" THA patient at high risk for postoperative instability. Adhering to group-specific recommendations for acetabular cup position can help to further reduce the burden of instability and related revisions in this challenging population.
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Affiliation(s)
- Tyler A Luthringer
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY
| | - Jonathan M Vigdorchik
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, NY
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Lum ZC, Klineberg EO, Danielsen B, Giordani M, Meehan JP. Female Sex and Longer Fusion Constructs Significantly Increase the Risk of Total Hip Arthroplasty Following Spinal Fusion. J Bone Joint Surg Am 2019; 101:675-681. [PMID: 30994584 DOI: 10.2106/jbjs.18.00667] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Previous studies have noted the progression of arthritis due to increased forces in articular structures adjacent to a fused joint. It is unknown whether spinal fusion generates increased forces at the hip joint causing progression to arthritis leading to total hip arthroplasty (THA). We sought to determine (1) is there a relationship between spinal fusion and THA, (2) what are risk factors for subsequent THA, and (3) is there a time interval from spinal fusion to THA? METHODS A large patient discharge dataset was utilized to evaluate all patients who underwent spinal fusion and subsequent THA in California from 2004 through 2013. Patients were categorized by age, sex, hospital type, hospital volume, and number of spinal levels fused. Multivariate analysis was performed to investigate the relationship between spinal fusion and THA. Hazard ratios were calculated for risk factors for THA after spinal fusion. Patients were excluded for previous spinal fusion or hip arthroplasty, inflammatory arthropathy, cancer, and an age of ≤40 years, a surrogate for adolescent and neuromuscular scoliosis. RESULTS A total of 101,206 patients underwent spinal fusion; 2,803 (2.77%) subsequently underwent THA. In a bivariate analysis comparing 1 to 2 levels versus >2 levels fused, males had a 17% increased relative risk of undergoing subsequent THA (relative risk [RR] = 1.17; 95% confidence interval [CI] = 1.16 to 1.17) and female patients had a 35% increased relative risk (RR = 1.35; 95% CI = 1.34 to 1.35) when the fusion involved >2 levels. For females, the relative risk increased by 119% when >7 levels were fused compared with 1 to 7 levels (RR = 2.19; 95% CI = 2.16 to 2.21). Using multivariate random-effects analysis, significant risk factors for THA after spinal fusion included female sex (hazard ratio [HR] = 1.21; 95% CI = 1.13 to 1.31; p < 0.0001) and spinal fusion of >7 levels (HR = 1.52; 95% CI = 1.03 to 2.24; p = 0.035). CONCLUSIONS Patients with longer spinal fusion constructs, especially female patients, had a significantly increased risk of undergoing subsequent THA. Patients should be educated regarding the potential for the progression to hip arthritis after spinal fusion and the possibility of future THA. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Zachary C Lum
- Department of Orthopaedic Surgery, UC Davis Medical Center, Sacramento, California
| | - Eric O Klineberg
- Department of Orthopaedic Surgery, UC Davis Medical Center, Sacramento, California
| | | | - Mauro Giordani
- Department of Orthopaedic Surgery, UC Davis Medical Center, Sacramento, California
| | - John P Meehan
- Department of Orthopaedic Surgery, UC Davis Medical Center, Sacramento, California
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Variability of Pelvic Orientation in the Lateral Decubitus Position: Are External Alignment Guides Trustworthy? J Arthroplasty 2018; 33:3496-3501. [PMID: 30150153 DOI: 10.1016/j.arth.2018.07.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Revised: 06/26/2018] [Accepted: 07/24/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The position of the acetabular component in total hip arthroplasty (THA) is critical for success. However, this remains the most variable aspect of the surgery. We hypothesized that there is wide variation in pelvic orientation in the lateral decubitus position. We sought to determine the variability in pelvic positioning and the frequency of pelvic malposition during THA in lateral decubitus with regard to pelvic tilt and pelvic rotation. METHODS We analyzed preoperative standing and intraoperative anteroposterior pelvis X-rays in 248 consecutive THAs performed in lateral decubitus by one surgeon. Pelvic tilt and rotation were determined for preoperative and intraoperative X-rays. Proper intraoperative positioning was defined as less than 10° change in tilt or rotation between preoperative and intraoperative X-rays. RESULTS With regard to pelvic tilt, the intraoperative position was proper in 188 (76%) cases. There was a pelvic tilt discrepancy of 10°-20° in 43 (17.5%) cases and greater than 20° in 16 (6.5%) patients. With regard to pelvic rotation, the intraoperative position was proper in 202 (81%) cases. There was a pelvic rotation discrepancy of 10°-20° in 38 (15.4%) cases and greater than 20° in 7 (2.8%) cases. In 248 cases, only 154 (62.1%) had intraoperative positioning within 10° of preoperative tilt and axial rotation. Pelvic malposition occurred in 38% of cases overall. CONCLUSION There is wide variation in pelvic orientation in lateral decubitus and frequent discrepancy in pelvic tilt and rotation between preoperative and intraoperative anteroposterior X-rays. Anatomic landmarks should be used to guide acetabular component positioning. LEVEL OF EVIDENCE III Diagnostic.
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Gonzalez Della Valle A, Shanaghan K, Benson JR, Carroll K, Cross M, McLawhorn A, Sculco PK. Pelvic pitch and roll during total hip arthroplasty performed through a posterolateral approach. A potential source of error in free-hand cup positioning. INTERNATIONAL ORTHOPAEDICS 2018; 43:1823-1829. [DOI: 10.1007/s00264-018-4141-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 09/03/2018] [Indexed: 10/28/2022]
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Yeganeh A, Moghtadaei M, Motalebi M. A challenge on Orthopedic Sciences: The Influence of Spinal Disease and Deformities on Total Hip Arthroplasty: A Review on Literature. THE ARCHIVES OF BONE AND JOINT SURGERY 2018; 6:346-352. [PMID: 30320172 PMCID: PMC6168225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 01/09/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND Adult degenerative disorders of hip and spine are common. The recent studies inconsistently have discussed about the influence of spinal disorders on total hip arthroplasty (THA). In this review, we discussed clearly about these relationships and their effects on the most appropriate position of the acetabular component. METHODS We searched on databases and evaluated the articles about spinopelvic parameters in patients with spinal disorders who needed THA. RESULTS The literature search showed a prevalence of 21.2 % to 60.4% of low back pain (LBP) in patients, who are candidates for primary THA. The coexistence of degenerative disease of hip and spine or other diseases can significantly alter spinopelvic alignment. Accordingly, pain management or any other treatment in these patients requires proper understanding about the biomechanics of the hip and the spinal and their corresponding interactions. In this review article, we discussed about these interactions and their effects on the most appropriate position of the acetabular component. CONCLUSION We concluded that counseling sessions among patients, orthopedic surgeons and spine surgeons can result in obtaining the best outcome for these individuals.
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Affiliation(s)
- Ali Yeganeh
- Research performed at Rasool-e-akram Hospital, Tehran, Iran
- Department of Orthopedics, Rasool-e-akram Hospital, Iran University of Medical Science, Tehran, Iran
- Department of Orthopedics, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
| | - Mehdi Moghtadaei
- Research performed at Rasool-e-akram Hospital, Tehran, Iran
- Department of Orthopedics, Rasool-e-akram Hospital, Iran University of Medical Science, Tehran, Iran
- Department of Orthopedics, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
| | - Mohsen Motalebi
- Research performed at Rasool-e-akram Hospital, Tehran, Iran
- Department of Orthopedics, Rasool-e-akram Hospital, Iran University of Medical Science, Tehran, Iran
- Department of Orthopedics, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
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Marques CJ, Martin T, Kochman A, Goral A, Lampe F, Breul V, Kozak J. Pelvic Tilt Angle Differences Between Symptom-Free Young Subjects and Elderly Patients Scheduled for THA: The Rationale for Tilt-Adjusted Acetabular Cup Implantation. Open Orthop J 2018; 12:364-372. [PMID: 30288191 PMCID: PMC6142662 DOI: 10.2174/1874325001812010364] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 08/08/2018] [Accepted: 08/14/2018] [Indexed: 12/03/2022] Open
Abstract
Background: The question whether Pelvic Tilt (PT) angles measured in the supine position are adequate for the alignment of the acetabular cup without an adjustment for anatomical differences between patients is of clinical importance. The aim of this work was to test for factors that can significantly affect PT angles. Methods: In the present retrospective cohort comparison, the PT angles of 12 Symptom-Free Young Subjects (SFYS) and 45 patients scheduled for Total Hip Arthroplasty (THA) were compared. The data was collected during two studies with the use of a novel smartphone-based navigated ultrasound measurement system. Multi-factorial analysis of variance was run to determine which factors significantly affect PT. Results: Body position (F= 126.65; P< 0.001) and group (SFYS vs. THA patients) (F= 17.52; P< 0.001) had significant main effects on PT. There was also a significant interaction between body position and group (F= 25.59; P< 0.001). The mean PT increased by 8.1° from an interiorly to a neutral tilted position (P< 0.001) and 21.4° from a neutral to a posteriorly tilted position (P< 0.001) with the transition from the supine into the upright position for the SFYS and THA patients, respectively. Conclusion: In both groups, PT changed significantly with a transition from the supine to the upright position. A position-dependent mean PT increase in the patient group showed that acetabular cup alignment based on PT in the supine position is not reliable without taking into consideration the inclination of the pelvis in standing position. This may lead to instability and dislocations.
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Affiliation(s)
- Carlos J Marques
- Research Center of the Orthopaedic and Joint Replacement Department at the Schoen Klinik Hamburg Eilbek, Dehnhaide 120, D-22081 Hamburg, Germany
| | - Tobias Martin
- Navigation Lab, Aesculap AG, Am Aesculap-Platz, D-78532 Tuttlingen, Germany.,AGH University of Science and Technology, Krakow, Poland
| | - Andrzej Kochman
- Trauma and Orthopedic Department, Hospital of the Ministry of Internal Affairs, Wroclaw, Poland
| | - Adrian Goral
- AGH University of Science and Technology, Krakow, Poland
| | - Frank Lampe
- Orhtopaedic and Joint Replacement Department at the Schoen Klinik Hamburg Eilbek, Dehnhaide 120, D-22081 Hamburg, Germany.,Faculty of Life Sciences at the Hamburg University of Applied Sciences, Lohbrügger Kirchstraße 65, D-21033 Hamburg, Germany
| | - Viktor Breul
- Medical Scientific Affairs, Aesculap AG, Am Aesculap-Platz, D-78532 Tuttlingen, Germany
| | - Josef Kozak
- Navigation Lab, Aesculap AG, Am Aesculap-Platz, D-78532 Tuttlingen, Germany.,AGH University of Science and Technology, Krakow, Poland
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Tezuka T, Inaba Y, Kobayashi N, Choe H, Higashihira S, Saito T. The influence of patient factors on femoral rotation after total hip arthroplasty. BMC Musculoskelet Disord 2018; 19:189. [PMID: 29885651 PMCID: PMC5994239 DOI: 10.1186/s12891-018-2110-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 05/24/2018] [Indexed: 11/25/2022] Open
Abstract
Background A postoperative change in femoral rotation following total hip arthroplasty (THA) might be the cause of dislocation due to the change in combined anteversion. However, very few studies have evaluated the femoral rotation angle following THA, or the factors that influence femoral rotation. We aimed to evaluate changes in femoral rotation after THA, and to investigate preoperative patient factors that influence femoral rotation after THA. Methods This study involved 211 hips treated with primary THA. We used computed tomography to measure the femoral rotation angle before and one week after THA. In addition, multiple regression analysis was performed to evaluate preoperative patient factors that could influence femoral rotation after THA. Results The femoral rotation angle was 0.2 ± 14° externally before surgery and 4.4 ± 12° internally after surgery (p < 0.001). Multiple regression analysis revealed that sex (β = 0.19; p = 0.003), age (β = 0.15; p = 0.017), preoperative anatomical femoral anteversion (β = − 0.25; p = 0.002), and preoperative femoral rotation angle (β = 0.36; p < 0.001) were significantly associated with the postoperative femoral rotation angle. The final model of the regression formula was described by the following equation: [postoperative femoral rotation angle = 5.41 × sex (female: 0, male: 1) + 0.15 × age - 0.22 × preoperative anatomical femoral anteversion + 0.33 × preoperative femoral rotation angle - 10.1]. Conclusion The current study showed the mean internal change of 4.6° in the femoral rotation angle one week after THA. Sex, age, preoperative anatomical femoral anteversion and preoperative femoral rotation were associated with postoperative femoral rotation. The patients who were male, older, and who exhibited lesser preoperative anatomical femoral anteversion or greater preoperative femoral rotation angles, tended to demonstrate an externally rotated femur after THA. Conversely, patients who were female, younger, and who exhibited greater preoperative anatomical femoral anteversion or lesser preoperative femoral rotation angles, tended to demonstrate an internal rotation of the femur after THA.
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Affiliation(s)
- Taro Tezuka
- Department of Orthopedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan.
| | - Yutaka Inaba
- Department of Orthopedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan
| | - Naomi Kobayashi
- Department of Orthopedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan
| | - Hyonmin Choe
- Department of Orthopedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan
| | - Syota Higashihira
- Department of Orthopedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan
| | - Tomoyuki Saito
- Department of Orthopedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan
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The Use of Fluoroscopy During Direct Anterior Hip Arthroplasty: Powerful or Misleading? J Arthroplasty 2018; 33:1775-1779. [PMID: 29500087 DOI: 10.1016/j.arth.2018.01.040] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 01/09/2018] [Accepted: 01/11/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Direct anterior approach total hip arthroplasty (THA) with fluoroscopic assistance is growing in popularity. Variables such as pelvic tilt, c-arm technique, and patient positioning can affect the perceived fluoroscopic view. This study evaluates the effect of these variables on the position of the acetabular component. METHODS Forty-one hips in 40 patients undergoing direct anterior arthroplasty THA with fluoroscopic assistance underwent routine postoperative radiographs and postoperative pelvic computed tomography scan. The acetabular component position as defined by a 3-dimensional reconstruction was compared to the surgeon's intraoperative perception of the component's position and compared to routine postoperative plain radiograph measurements. RESULTS Although fluoroscopy was used to create an anteroposterior pelvic radiograph utilizing the coccyx to pubis symphysis distance, a 3D reconstruction created in the same pelvic orientation as the fluoroscopic images confirmed that 39/41 hips were placed with unrecognized excess of anteversion and inclination secondary to imaging the pelvis in extension. CONCLUSION Intraoperative imaging during supine direct anterior arthroplasty THA confirms appropriate component placement. Pelvic tilt can greatly affect the perceived position of the acetabular component and cannot be accurately compensated for by assessing the relationship between the coccyx and pubic symphysis due to morphologic variation and orientation. We recommend positioning the c-arm so that the size and shape of the obturator foramen matches the standing preoperative anteroposterior pelvis image. This technique allows for the native standing pelvic tilt to be accounted for intraoperatively and will result in the least variation in intraoperative and postoperative standing acetabular component orientation.
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Sultan AA, Khlopas A, Piuzzi NS, Chughtai M, Sodhi N, Mont MA. The Impact of Spino-Pelvic Alignment on Total Hip Arthroplasty Outcomes: A Critical Analysis of Current Evidence. J Arthroplasty 2018; 33:1606-1616. [PMID: 29233568 DOI: 10.1016/j.arth.2017.11.021] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 10/29/2017] [Accepted: 11/08/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND In this review, we (1) evaluated the effect of adult spine deformity (ASD) and its surgical correction on patients who had a total hip arthroplasty (THA); (2) evaluated the outcomes of THA in patients who have had previous spinal fusion; and (3) we presented an algorithm on how to surgically address patients who simultaneously require THA and ASD correction. METHODS A comprehensive literature search was conducted. Our final analysis included 14 studies. Overall, there were 3 studies that reported on the impact of ASD on THA outcomes, 6 studies reported on the effect of ASD correction on THA outcomes, and 5 studies reported on the effect of spinal fusion on THA outcomes. RESULTS Patients with concurrent ASD and THA are at increased risk of THA dislocations and revisions with studies reporting a compiled 2.9% dislocation rate in 1167 patients. Patients who underwent ASD correction demonstrated a post-operative reduction of acetabular anteversion (mean reduction range 4.96°-11.2°, P < .001) and tilt (mean -7° ± 10°, P < .001). In THA patients with concurrent lumbosacral fusion, dislocation rates ranged between 3% at 1 year and 7.5% at 2 years compared to 0.4%-2.1% dislocation rates in matching cohorts (P < .001). CONCLUSION Spine balance can alter THA outcomes, but the exact mechanism is yet to be elucidated. We aimed at bridging the gap between hip and spine surgeons with an up-to-date analysis of the best available evidence and presented an algorithm for approaching patients who may simultaneously need ASD correction and THA.
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Affiliation(s)
- Assem A Sultan
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Anton Khlopas
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Nicolas S Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Morad Chughtai
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Nipun Sodhi
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Michael A Mont
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
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Effect of Pelvic Tilt and Rotation on Cup Orientation in Both Supine and Standing Positions. J Arthroplasty 2018; 33:1442-1448. [PMID: 29276116 DOI: 10.1016/j.arth.2017.11.069] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 11/15/2017] [Accepted: 11/30/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The purpose of this study is to analyze the effect of pelvic tilt and rotation on radiographic measurement of cup orientation. METHODS A total of 68 patients (79 hips) were included in this study. The patients had a computed tomography study and approximately 3 months of postoperative standing anteroposterior pelvic radiographs in both supine and standing positions. We used 2-dimensional (2D)/3-dimensional (3D) matching to measure pelvic tilt and rotation, and cup orientation. RESULTS There was a wide range of pelvic tilt between individuals in both supine and standing positions. Supine pelvic tilt was different from standing pelvic tilt (P < .05). There were differences in cup anteversion before and after 2D/3D matching in both supine and standing positions (P < .05). Supine and standing pelvic tilt correlated with differences in cup anteversion before and after 2D/3D matching. When all 79 hips were separated into right and left side, pelvic rotation inversely correlated with the pelvic tilt-adjusted difference in anteversion before and after 2D/3D matching of the right side but directly correlated with that of the left side in both supine and standing positions. CONCLUSION This study demonstrated that the measurement of cup anteversion on anteroposterior radiographs is significantly affected by both pelvic tilt and pelvic rotation (depending on the side). Improved understanding of pelvic orientation and improved ability to measure pelvic orientation may eventually allow for desired cup positioning to potentially protect against complications associated with malposition of the cup.
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Gallart X, Riba J, Fernández-Valencia J, Bori G, Muñoz-Mahamud E, Combalia A. Hip prostheses in young adults. Surface prostheses and short-stem prostheses. Rev Esp Cir Ortop Traumatol (Engl Ed) 2018. [DOI: 10.1016/j.recote.2018.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
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Abstract
BACKGROUND Cup malposition is a common cause of impingement, limitation of ROM, acceleration of bearing wear, liner fracture, and instability in THA. Previous studies of the safe zone based on plain radiographs have limitations inherent to measuring angles from two-dimensional projections. The current study uses CT to measure component position in stable and unstable hips to assess the presence of a safe zone for cup position in THA. QUESTIONS/PURPOSES (1) Does acetabular component orientation, when measured on CT, differ in stable components and those revised for recurrent instability? (2) Do CT data support historic safe zone definitions for component orientation in THA? METHODS We identified 34 hips that had undergone revision of the acetabulum for recurrent instability that also had a CT scan of the pelvis between August 2003 and February 2017. We also identified 175 patients with stable hip replacements who also had a CT study for preoperative planning and intraoperative navigation of the contralateral side. For each CT study, one observer analyzed major factors including acetabular orientation, femoral anteversion, combined anteversion (the sum of femoral and anatomic anteversion), pelvic tilt, total offset difference, head diameter, age, sex, and body mass index. These measures were then compared among stable hips, hips with cup revision for anterior instability, and hips with cup revision for posterior instability. We used a clinically relevant measurement of operative anteversion and inclination as opposed to the historic use of radiographic anteversion and inclination. The percentage of unstable hips in the historic Lewinnek safe zone was calculated, and a new safe zone was proposed based on an area with no unstable hips. RESULTS Anteriorly unstable hips compared with stable hips had higher operative anteversion of the cup (44° ± 12° versus 31° ± 11°, respectively; mean difference, 13°; 95% confidence interval [CI], 5°-21°; p = 0.003), tilt-adjusted operative anteversion of the cup (40° ± 6° versus 26° ± 10°, respectively; mean difference, 14°; 95% CI, 10°-18°; p < 0.001), and combined tilt-adjusted anteversion of the cup (64° ± 10° versus 54° ± 19°, respectively; mean difference, 10°; 95% CI, 1°-19°; p = 0.028). Posteriorly unstable hips compared with stable hips had lower operative anteversion of the cup (19° ± 15° versus 31° ± 11°, respectively; mean difference, -12°; 95% CI, -5° to -18°; p = 0.001), tilt-adjusted operative anteversion of the cup (19° ± 13° versus 26° ± 10°, respectively; mean difference, -8°; 95% CI, -14° to -2°; p = 0.014), pelvic tilt (0° ± 6° versus 4° ± 6°, respectively; mean difference, -4°; 95% CI, -7° to -1°; p = 0.007), and anatomic cup anteversion (25° ± 18° versus 34° ± 12°, respectively; mean difference, -9°; 95% CI, -1° to -17°; p = 0.033). Thirty-two percent of the unstable hips were located in the Lewinnek safe zone (11 of 34; 10 posterior dislocations, one anterior dislocation). In addition, a safe zone with no unstable hips was identified within 43° ± 12° of operative inclination and 31° ± 8° of tilt-adjusted operative anteversion. CONCLUSIONS The current study supports the notion of a safe zone for acetabular component orientation based on CT. However, the results demonstrate that the historic Lewinnek safe zone is not a reliable predictor of future stability. Analysis of tilt-adjusted operative anteversion and operative inclination demonstrates a new safe zone where no hips were revised for recurrent instability that is narrower for tilt-adjusted operative anteversion than for operative inclination. Tilt-adjusted operative anteversion is significantly different between stable and unstable hips, and surgeons should therefore prioritize assessment of preoperative pelvic tilt and accurate placement in operative anteversion. With improvements in patient-specific cup orientation goals and acetabular component placement, further refinement of a safe zone with CT data may reduce the incidence of cup malposition and its associated complications. LEVEL OF EVIDENCE Level III, diagnostic study.
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Abstract
INTRODUCTION Patients with lumbar spine and hip disorders may, during the course of their treatment, undergo spinal fusion and THA. There is disagreement among prior studies regarding whether patients who undergo THA and spinal fusion are at increased risk of THA dislocation and other hip-related complications. QUESTIONS / PURPOSES Is short or long spinal fusion associated with an increased rate of postoperative complications in patients who underwent a prior THA? PATIENTS AND METHODS A retrospective study of New York State's Department of Health database (SPARCS) was performed. SPARCS has a unique identification code for each patient, allowing investigators to track the patient across multiple admissions. The SPARCS dataset spans visit data of patients of all ages and races across urban and rural locations. The SPARCs dataset encompasses all facilities covered under New York State Article 28 and uses measures to further representative reporting of data concerning all races. Owing to the nature of the SPARCS dataset, we are unable to comment on data leakage, as there is no way to discern between a patient who does not subsequently seek care and a patient who seeks care outside New York State. ICD-9-Clinical Modification codes identified adult patients who underwent elective THA from 2009 to 2011. Patients who had subsequent spinal fusion (short: 2-3 levels, or long: ≥ 4 levels) with a diagnosis of adult idiopathic scoliosis or degenerative disc disease were identified. Forty-nine thousand nine hundred twenty patients met the inclusion criteria of the study. In our inclusion and exclusion criteria, there was no variation with respect to the distribution of sex and race across the three groups of interest. Patients who underwent a spinal procedure (short versus long fusion) had comparable age. However, patients who did not undergo a spinal procedure were older than patients who had short fusion (65 ± 12.4 years versus 63 ± 10.7 years; p < 0.001). Multivariate binary logistic regression models that controlled for age, sex, and Deyo/Charlson scores were used to investigate the association between spinal fusion and THA revisions, postoperative dislocation, contralateral THAs, and total surgical complications to the end of 2013. A total of 49,920 patients who had THAs were included in one of three groups (no subsequent spinal fusion: n = 49,209; short fusion: n = 478; long fusion: n = 233). RESULTS Regression models revealed that short and long spinal fusions were associated with increased odds for hip dislocation, with associated odds ratios (ORs) of 2.2 (95% CI, 1.4-3.6; p = 0.002), and 4.4 (95% CI, 2.7-7.3; p < 0.001), respectively. Patients who underwent THA and spinal surgery also had an increased odds for THA revision, with ORs of 2.0 (95% CI, 1.4-2.8; p < 0.001) and 3.2 (95% CI, 2.1-4.8; p < 0.001) for short and long fusion, respectively. However, spinal fusions were not associated with contralateral THAs. Further, short and long spinal fusions were associated with increased surgical complication rates (OR = 2.8, 95% CI, 2.1-3.8, p < 0.001; OR = 5.3, 95% CI, 3.8-7.4, p < 0.001, respectively). CONCLUSION We showed that spinal fusion in adults is associated with an increased frequency of complications and revisions in patients who have had a prior THA. Specifically, patients who had a long spinal fusion after THA had 340% higher odds of experiencing a hip dislocation and 220% higher odds of having to undergo a revision THA. Further research is necessary to determine whether this relationship is associated with the surgical order, or whether more patient-specific surgical goals of revision THA should be developed for patients with a spinal deformity. LEVEL OF EVIDENCE Level III, therapeutic study.
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Fotouhi J, Alexander CP, Unberath M, Taylor G, Lee SC, Fuerst B, Johnson A, Osgood G, Taylor RH, Khanuja H, Armand M, Navab N. Plan in 2-D, execute in 3-D: an augmented reality solution for cup placement in total hip arthroplasty. J Med Imaging (Bellingham) 2018; 5:021205. [PMID: 29322072 DOI: 10.1117/1.jmi.5.2.021205] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 12/12/2017] [Indexed: 01/15/2023] Open
Abstract
Reproducibly achieving proper implant alignment is a critical step in total hip arthroplasty procedures that has been shown to substantially affect patient outcome. In current practice, correct alignment of the acetabular cup is verified in C-arm x-ray images that are acquired in an anterior-posterior (AP) view. Favorable surgical outcome is, therefore, heavily dependent on the surgeon's experience in understanding the 3-D orientation of a hemispheric implant from 2-D AP projection images. This work proposes an easy to use intraoperative component planning system based on two C-arm x-ray images that are combined with 3-D augmented reality (AR) visualization that simplifies impactor and cup placement according to the planning by providing a real-time RGBD data overlay. We evaluate the feasibility of our system in a user study comprising four orthopedic surgeons at the Johns Hopkins Hospital and report errors in translation, anteversion, and abduction as low as 1.98 mm, 1.10 deg, and 0.53 deg, respectively. The promising performance of this AR solution shows that deploying this system could eliminate the need for excessive radiation, simplify the intervention, and enable reproducibly accurate placement of acetabular implants.
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Affiliation(s)
- Javad Fotouhi
- Johns Hopkins University, Computer Aided Medical Procedures, Baltimore, United States
| | - Clayton P Alexander
- Johns Hopkins Hospital, Department of Orthopaedic Surgery, Baltimore, United States
| | - Mathias Unberath
- Johns Hopkins University, Computer Aided Medical Procedures, Baltimore, United States
| | - Giacomo Taylor
- Johns Hopkins University, Computer Aided Medical Procedures, Baltimore, United States
| | - Sing Chun Lee
- Johns Hopkins University, Computer Aided Medical Procedures, Baltimore, United States
| | - Bernhard Fuerst
- Johns Hopkins University, Computer Aided Medical Procedures, Baltimore, United States
| | - Alex Johnson
- Johns Hopkins Hospital, Department of Orthopaedic Surgery, Baltimore, United States
| | - Greg Osgood
- Johns Hopkins Hospital, Department of Orthopaedic Surgery, Baltimore, United States
| | - Russell H Taylor
- Johns Hopkins University, Laboratory for Computational Sensing and Robotics, Baltimore, United States
| | - Harpal Khanuja
- Johns Hopkins Hospital, Department of Orthopaedic Surgery, Baltimore, United States
| | - Mehran Armand
- Johns Hopkins University, Laboratory for Computational Sensing and Robotics, Baltimore, United States.,Johns Hopkins University, Applied Physics Laboratory, Laurel, Maryland, United States
| | - Nassir Navab
- Johns Hopkins University, Computer Aided Medical Procedures, Baltimore, United States.,Technische Universität München, Computer Aided Medical Procedures, Munich, Germany
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The Current Knowledge on Spinopelvic Mobility. J Arthroplasty 2018; 33:291-296. [PMID: 28939031 DOI: 10.1016/j.arth.2017.08.013] [Citation(s) in RCA: 95] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 08/06/2017] [Accepted: 08/11/2017] [Indexed: 02/01/2023] Open
Abstract
Recent studies may suggest that our conventional knowledge of risk factors for dislocation may need rethinking. Previous studies have demonstrated a large majority of total hip arthroplasty instability with acetabular cups implanted in safe zones. Recently discovered spinopelvic motion is a coordinated biomechanical relationship among acetabular anteversion, pelvic tilt, and lumbar lordosis. Classification includes normal, hypermobile, stiff, stuck standing, stuck sitting, and fused. Normal spinopelvic motion from standing to sitting occurs with hip flexion, posterior sacral tilt, and decreased lumbar lordosis to accommodate a flexed femur and prevent impingement and dislocation. Acetabular cup implantation ideally is adapted based on spinopelvic interactions. This may lower the rate of impingement and subsequent dislocation. These new biomechanical interactions may provide a better understanding of the safe zones of anteversion and inclination.
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Iwakiri K, Kobayashi A, Ohta Y, Minoda Y, Takaoka K, Nakamura H. Efficacy of a Pelvic Lateral Positioner With a Mechanical Cup Navigator Based on the Anatomical Pelvic Plane in Total Hip Arthroplasty. J Arthroplasty 2017; 32:3659-3664. [PMID: 28712802 DOI: 10.1016/j.arth.2017.06.033] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 05/30/2017] [Accepted: 06/19/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The acetabular component orientation in total hip arthroplasty (THA) is of critical importance to the good clinical results. However, traditional widely used cup alignment guides for cup placement are reported to be relatively unreliable. The present study aims at comparing a novel cup alignment guide, which can be attached to our anatomical pelvic plane (APP) pelvic lateral positioner for reducing discrepancies in sagittal pelvic tilt and indicate a targeted cup angle based on the APP, with a conventional cup alignment guide. METHODS The subjects were 136 hips of 136 patients who underwent unilateral THA using the APP positioner. The procedure was performed with the conventional cup alignment guide (conventional group; 60 hips) and with the novel cup navigator (mechanical navigator group; 76 hips). Postoperative cup angles and discrepancies of postoperative cup angles (inclination and anteversion angles) from the targeted angles were compared between the 2 groups to evaluate the usefulness of these navigators. RESULTS The mean cup angles in the conventional group were 39.0° ± 5.3° for the inclination angle and 21.7° ± 6.4° for the anteversion angle, whereas those in the mechanical navigator group were 40.6° ± 3.2° and 18.3° ± 4.6°, respectively (P = .018, P < .0001). The discrepancies from the targeted angles were 3.5° ± 3.1° for the inclination angle and 4.6° ± 3.4° for the anteversion angle in the conventional group and 2.3° ± 2.3° and 3.2° ± 2.7°, respectively, in the mechanical navigator group (P = .020, P = .012). CONCLUSION The mechanical cup navigator easily attachable to the APP positioner is a tool that can improve the accuracy of cup placement in a simple, economical, and noninvasive manner in THA via the lateral position.
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Affiliation(s)
- Kentaro Iwakiri
- Department of Orthopaedic Surgery, Shiraniwa Hospital, Nara, Japan
| | - Akio Kobayashi
- Department of Orthopaedic Surgery, Shiraniwa Hospital, Nara, Japan
| | - Yoichi Ohta
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yukihide Minoda
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Kunio Takaoka
- Department of Orthopaedic Surgery, Shiraniwa Hospital, Nara, Japan
| | - Hiroaki Nakamura
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
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Gallart X, Riba J, Fernández-Valencia JA, Bori G, Muñoz-Mahamud E, Combalia A. Hip prostheses in young adults. Surface prostheses and short-stem prostheses. Rev Esp Cir Ortop Traumatol (Engl Ed) 2017; 62:142-152. [PMID: 29196225 DOI: 10.1016/j.recot.2017.10.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 08/31/2017] [Accepted: 10/28/2017] [Indexed: 12/22/2022] Open
Abstract
The poor results obtained in young patients when using a conventional prosthesis led to the resurgence of hip resurfacing to find less invasive implants for the bone. Young patients present a demand for additional activity, which makes them a serious challenge for the survival of implants. In addition, new information technologies contribute decisively to the preference for non-cemented prostheses. Maintaining quality of life, preserving the bone and soft tissues, as well as achieving a very stable implant, are the goals of every hip orthopaedic surgeon for these patients. The results in research point to the use of smaller prostheses, which use the metaphyseal zone more and less the diaphyseal zone, and hence the large number of the abovementioned short stem prostheses. Both models are principally indicated in the young adult. Their revision should be a more simple operation, but this is only true for hip resurfacing, not for short stems.
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Affiliation(s)
- X Gallart
- Instituto Clínico de Especialidades Médico-Quirúrgicas (ICEMEQ), Servicio de Cirugía Ortopédica y Traumatología, Unidad de Cadera, Hospital Clínic, Universidad de Barcelona, Barcelona, España.
| | - J Riba
- Instituto Clínico de Especialidades Médico-Quirúrgicas (ICEMEQ), Servicio de Cirugía Ortopédica y Traumatología, Unidad de Cadera, Hospital Clínic, Universidad de Barcelona, Barcelona, España
| | - J A Fernández-Valencia
- Instituto Clínico de Especialidades Médico-Quirúrgicas (ICEMEQ), Servicio de Cirugía Ortopédica y Traumatología, Unidad de Cadera, Hospital Clínic, Universidad de Barcelona, Barcelona, España
| | - G Bori
- Instituto Clínico de Especialidades Médico-Quirúrgicas (ICEMEQ), Servicio de Cirugía Ortopédica y Traumatología, Unidad de Cadera, Hospital Clínic, Universidad de Barcelona, Barcelona, España
| | - E Muñoz-Mahamud
- Instituto Clínico de Especialidades Médico-Quirúrgicas (ICEMEQ), Servicio de Cirugía Ortopédica y Traumatología, Unidad de Cadera, Hospital Clínic, Universidad de Barcelona, Barcelona, España
| | - A Combalia
- Instituto Clínico de Especialidades Médico-Quirúrgicas (ICEMEQ), Servicio de Cirugía Ortopédica y Traumatología, Unidad de Cadera, Hospital Clínic, Universidad de Barcelona, Barcelona, España
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Can Surgeons Reduce the Risk for Dislocation After Primary Total Hip Arthroplasty Performed Using the Posterolateral Approach? J Arthroplasty 2017. [PMID: 28625687 DOI: 10.1016/j.arth.2017.04.047] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Hip dislocation is one of the most common postoperative complications after total hip arthroplasty (THA). Potential contributors include patient- and surgical-related factors. We performed a retrospective cohort study to identify risk factors for postoperative dislocation in patients receiving THA via the posterolateral approach. METHODS We assessed 1326 consecutive primary THAs performed between 2010 and 2015. Patient information was documented, and plain radiographic films were used to evaluate cup positioning, hip offset, and hip length change. A multiple logistic regression was used to identify risk factors for dislocation. Follow-up was coordinated by the Danish National Patient Registry. RESULTS Age and American Society of Anesthesiologists scores were higher in dislocating THA compared with those in the nondislocating THA. Cup anteversion was less in dislocating THA compared with that in nondislocating THA. Independent risk factors for cup dislocation were increased age, body mass index <25 and >30 kg/m2, and leg shortening of >5 mm. CONCLUSION Surgeons should aim for a shortening of leg length <5 mm to reduce the risk of postoperative dislocation in primary THA. Although anteversion was reduced for dislocating THA, there is likely no universal safe zone for cup positioning. Hip stability is multifactorial, and optimal cup positioning may vary from patient to patient.
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Wang L, Thoreson AR, Trousdale RT, Morrey BF, Dai K, An KN. Radiographic cup anteversion measurement corrected from pelvic tilt. Med Eng Phys 2017; 49:103-108. [PMID: 28888787 DOI: 10.1016/j.medengphy.2017.08.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 07/29/2017] [Accepted: 08/12/2017] [Indexed: 11/30/2022]
Abstract
The purpose of this study was to develop a novel technique to improve the accuracy of radiographic cup anteversion measurement by correcting the influence of pelvic tilt. Ninety virtual total hip arthroplasties were simulated from computed tomography data of 6 patients with 15 predetermined cup orientations. For each simulated implantation, anteroposterior (AP) virtual pelvic radiographs were generated for 11 predetermined pelvic tilts. A linear regression model was created to capture the relationship between radiographic cup anteversion angle error measured on AP pelvic radiographs and pelvic tilt. Overall, nine hundred and ninety virtual AP pelvic radiographs were measured, and 90 linear regression models were created. Pearson's correlation analyses confirmed a strong correlation between the errors of conventional radiographic cup anteversion angle measured on AP pelvic radiographs and the magnitude of pelvic tilt (P < 0.001). The mean of 90 slopes and y-intercepts of the regression lines were -0.8 and -2.5°, which were applied as the general correction parameters for the proposed tool to correct conventional cup anteversion angle from the influence of pelvic tilt. The current method proposes to measure the pelvic tilt on a lateral radiograph, and to use it as a correction for the radiographic cup anteversion measurement on an AP pelvic radiograph. Thus, both AP and lateral pelvic radiographs are required for the measurement of pelvic posture-integrated cup anteversion. Compared with conventional radiographic cup anteversion, the errors of pelvic posture-integrated radiographic cup anteversion were reduced from 10.03 (SD = 5.13) degrees to 2.53 (SD = 1.33) degrees. Pelvic posture-integrated cup anteversion measurement improves the accuracy of radiographic cup anteversion measurement, which shows the potential of further clarifying the etiology of postoperative instability based on planar radiographs.
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Affiliation(s)
- Liao Wang
- Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, PR China; Biomechanics Laboratory, Division of Orthopedic Research, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905, USA
| | - Andrew R Thoreson
- Biomechanics Laboratory, Division of Orthopedic Research, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905, USA
| | | | - Bernard F Morrey
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | - Kerong Dai
- Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, PR China
| | - Kai-Nan An
- Biomechanics Laboratory, Division of Orthopedic Research, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905, USA .
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Iwakiri K, Kobayashi A, Ohta Y, Takaoka K. Efficacy of the Anatomical-Pelvic-Plane Positioner in Total Hip Arthroplasty in the Lateral Decubitus Position. J Arthroplasty 2017; 32:1520-1524. [PMID: 28041773 DOI: 10.1016/j.arth.2016.11.048] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Revised: 11/09/2016] [Accepted: 11/30/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Total hip arthroplasty in the lateral position involves particularly large variance in the sagittal tilt of pelvis fixation, which affects the imprecision of the cup anteversion leading to poor outcomes. We have added an additional compression pad to an existing device, also to be used in the lateral position, but theoretically enabling fixation on the anatomical pelvic plane (APP) serving as the reference plane. The present study aims to evaluate the usefulness of this device in comparison with the conventional device. METHODS We have studied 141 patients who underwent total hip arthroplasty at our hospital. Two frontal plain x-rays of the pelvis were obtained preoperatively for each patient after pelvis fixation; one with the conventional lateral fixation device and the other with an APP lateral fixation device. The sagittal tilt of the pelvis in each position was measured with 3D templating software, and variance in the sagittal tilt was compared between the 2 devices. RESULTS The mean bias in sagittal tilt relative to the functional pelvic plane (FPP) in the conventional device was -5.0° ± 4.8° (minus mean backward tilt) and was within 5° relative to the functional pelvic plane in 43%. The mean bias in the sagittal tilt relative to the APP in the APP lateral position device was 1.7° ± 3.1° (forward tilt) and was within 5° relative to the APP in 89%. The APP lateral device significantly reduced the variance in the sagittal tilt. CONCLUSION This device holds promise as a means of reducing the sagittal tilt in a simple, minimally invasive, and highly cost-effective manner.
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Affiliation(s)
- Kentaro Iwakiri
- Department of Orthopaedic Surgery, Shiraniwa Hospital, Ikoma City, Nara, Japan
| | - Akio Kobayashi
- Department of Orthopaedic Surgery, Shiraniwa Hospital, Ikoma City, Nara, Japan
| | - Yoichi Ohta
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka City, Osaka, Japan
| | - Kunio Takaoka
- Department of Orthopaedic Surgery, Shiraniwa Hospital, Ikoma City, Nara, Japan
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Dorr LD. Letter to the Editor: Editor's Spotlight/Take 5: No Benefit after THA Performed with Computer-assisted Cup Placement: 10-year Results of a Randomized Controlled Study. Clin Orthop Relat Res 2017; 475:565-566. [PMID: 27858244 PMCID: PMC5213954 DOI: 10.1007/s11999-016-5163-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Accepted: 11/07/2016] [Indexed: 01/31/2023]
Affiliation(s)
- Lawrence D Dorr
- Orthopedic Department, Keck Medical Center of USC, 1520 San Pablo Street, #2000, Los Angeles, CA, 90033, USA.
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Abstract
Being one of the most successful surgeries in the history of medicine, the indications for total hip arthroplasty have widened and are increasingly being offered to younger and fitter patients. This has also led to high expectations for longevity and outcomes. Acetabular cup position has a significant impact on the results of hip arthroplasty as it affects dislocation, abductor muscle strength, gait, limb lengths, impingement, noise generation, range of motion (ROM), wear, loosening, and cup failure. The variables in cup position are depth, height, and angular position (anteversion and inclination). The implications of change in depth of center of rotation (COR) are medialized versus anatomical positioning. As opposed to traditional medialization with beneficial effects on joint reaction force, the advantages of an anatomical position are increasingly recognized. The maintained acetabular offset offers advantages in terms of ROM, impingement, cortical rim press fit, and maintaining medial bone stock. The height of COR influences muscle activity and limb lengths and available bone stock for cup support. On the other hand, ideal angular position remains a matter of much debate and reliably achieving a target angular position remains elusive. This is not helped by variations in the way we describe angular position, with operative, radiologic, or anatomic definitions being used variably to describe anteversion and inclination. Furthermore, pelvic tilt plays a major role in functional positions of the acetabulum. In addition, commonly used techniques of positioning often do not inform us of the real orientation of the pelvis on operating table, with possibility of significant adduction, flexion, and external rotation of the pelvis being possibilities. This review article brings together the evidence on cup positioning and aims to provide a systematic and pragmatic approach in achieving the best position in individual cases.
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Affiliation(s)
- Deepu Bhaskar
- Department of Trauma and Orthopaedics, Centre for Hip Surgery, Wrightington Hospital, Hall Lane, Appley Bridge, Lancashire WN6 9EP, UK
| | - Asim Rajpura
- Department of Trauma and Orthopaedics, Centre for Hip Surgery, Wrightington Hospital, Hall Lane, Appley Bridge, Lancashire WN6 9EP, UK
| | - Tim Board
- Department of Trauma and Orthopaedics, Centre for Hip Surgery, Wrightington Hospital, Hall Lane, Appley Bridge, Lancashire WN6 9EP, UK,Address for correspondence: Prof. Tim Board, Centre for Hip Surgery, Wrightington Hospital, Hall Lane, Appley Bridge, Lancashire WN6 9EP, UK. E-mail:
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Zahn RK, Grotjohann S, Pumberger M, Ramm H, Zachow S, Putzier M, Perka C, Tohtz S. Influence of pelvic tilt on functional acetabular orientation. Technol Health Care 2016; 25:557-565. [PMID: 27911346 DOI: 10.3233/thc-161281] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Pelvic tilt influences acetabular orientation (AO). Anatomical AO can be measured in relation to the anterior pelvic plane (APP), functional AO can be calculated relative to table's plane. OBJECTIVE To assess to what extent functional AO is determined by pelvic tilt and if APP and table plane give equal information for correct AO. METHODS AO was evaluated by computed tomography (CT) scans of 138 patients. Pelvic tilt, anatomical and functional AO were measured, differences between the two reference planes were calculated. RESULTS Anatomical and functional acetabular anteversion (AA) were found to be different in 21% of individuals with an enhanced extent of pelvic tilt. Functional AA was increased compared to anatomical AA at high posterior pelvic tilt (p < 0.001). Enlarged anterior tilting of the pelvis reduced APP-related AA (p < 0.002). Anatomical AA positively correlated with pelvic tilt, particularly in females (p < 0.01, correlation coefficient = 0.698, R2 = 0.523). CONCLUSIONS APP and table plane do not provide equal information about AO at enhanced pelvic tilt. Functional orientation of the acetabulum is dependent on pelvic tilt, which itself is influenced by anatomical AA and should therefore be analyzed for precise AO.
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Affiliation(s)
- Robert K Zahn
- Department for Orthopaedics, Department for Traumatology, Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, 10117 Berlin, Germany
| | - Sarah Grotjohann
- Department for Orthopaedics, Department for Traumatology, Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, 10117 Berlin, Germany
| | - Matthias Pumberger
- Department for Orthopaedics, Department for Traumatology, Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, 10117 Berlin, Germany
| | - Heiko Ramm
- Visualization & Data Analysis Medical Planning & Computational Medicine Groups, Zuse Institute Berlin, 14195 Berlin, Germany
| | - Stefan Zachow
- Visualization & Data Analysis Medical Planning & Computational Medicine Groups, Zuse Institute Berlin, 14195 Berlin, Germany
| | - Michael Putzier
- Department for Orthopaedics, Department for Traumatology, Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, 10117 Berlin, Germany
| | - Carsten Perka
- Department for Orthopaedics, Department for Traumatology, Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, 10117 Berlin, Germany
| | - Stephan Tohtz
- HELIOS Klinikum Emil von Behring, Oskar-Helene-Heim, Department for Orthopaedics and Traumatology, 14165 Berlin, Germany
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Repeated posterior dislocation of total hip arthroplasty after spinal corrective long fusion with pelvic fixation. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2016; 26:100-106. [DOI: 10.1007/s00586-016-4880-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Revised: 09/24/2016] [Accepted: 11/11/2016] [Indexed: 10/20/2022]
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A novel fluoroscopic approach to assessing patient positioning in total hip arthroplasty: accuracy and the influence of body mass index. Hip Int 2016; 26:550-553. [PMID: 27739565 DOI: 10.5301/hipint.5000397] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/22/2016] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Accurate prosthetic cup placement is important in total hip arthroplasty (THA) and can be influenced by patient positioning. This study aims to assess the accuracy of patient positioning prior to THA, describe a new technique of assessment, and evaluate the influence of body mass index (BMI) on positioning error. METHODS A consecutive series of 37 patients undergoing unilateral THA were investigated. After patient positioning in lateral decubitus, a lateral fluoroscopic image through the table was taken. The C-arm of the image intensifier was manipulated in 2 planes (coronal, transverse) until a perfect lateral view of the pelvis was obtained, defined as when the native acetabulae were superimposed. Degrees of positioning error in the 2 planes were recorded, along with patient BMI. RESULTS There were 6 patients (16%) positioned within 2° of true lateral in both planes. A further 21 patients (57%) had an error of 5° or more in at least 1 plane. Mean absolute positioning error was 3.0° (SD 2.2°; range 0°-9°) and 3.0° (SD 3.2°; range 0°-13°) in the transverse and coronal planes respectively. Pelvic adduction in the coronal plane was 4.5 fold more likely than abduction (49% vs. 11%). Correlation was shown between patient BMI and the combined error in the 2 planes (R = 0.48, p = 0.001). DISCUSSION Fluoroscopic positioning assessment prior to THA demonstrates that significant malpositioning is common and more likely with increasing BMI. This technique may be particularly useful for patients with a BMI of >30 kg m-2.
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Quantification of pelvic tilt and rotation by width/height ratio of obturator foramina on anteroposterior radiographs. Hip Int 2016; 26:462-467. [PMID: 27174062 DOI: 10.5301/hipint.5000374] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/05/2016] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Compared to sagittal pelvic tilt, only a few studies have examined axial rotation on anteroposterior radiographs. We therefore quantified 3-D pelvic rotation using the width and height ratio of the obturator foramina under the various pelvic tilts. METHODS Using CT reconstructions of 10 healthy pelvises, anterior pelvic planes (APPs) were rotated by 20° in 5° increments on the axial plane with various degrees of sagittal pelvic tilt. The correlation between the pelvic rotation angle and the width ratio (WR) in the axial plane and the height/width ratio (H/W) in the sagittal plane were examined. RESULTS Axial pelvic rotation and WR showed a high linear correlation regardless of the sagittal tilt, with the correlation coefficient ranging from 0.93 to 0.98 in males and 0.87 to 0.95 in females. The angle that resulted in a WR of 1:2 was approximately 13° in males and 18° in females. H/W also showed a linear regression with sagittal tilt. Axial rotation was determined by the following equation incorporating pelvic tilts; axial rotation (male:female) = (19.9:24.2) + (2.1:3.6) × Hright/Wright + (0.9:1.5) × Hleft/Wleft - (23.2:25.1) × WR. CONCLUSIONS Pelvic tilt and rotation could be quantified by the equation using width and height ratios of the obturator foramina on a plain anteroposterior radiograph. Width and height ratios of the obturator foramina proved to be useful parameters in clinical practice for understanding pelvic rotation.
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Huang GY, Zhao GL, Xia J, Wei YB, Wang SQ, Wu JG. An Alternative Intraoperative Radiographic Method for Optimizing Cup Inclination during Total Hip Arthroplasty. Orthop Surg 2016; 8:345-51. [PMID: 27627718 DOI: 10.1111/os.12272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 06/16/2016] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE During total hip arthroplasty (THA), the location of the acetabular prosthesis is very important for guaranteeing successful surgery. However, this remains a challenge for many surgeons. This study aimed to investigate the feasibility of using the intraoperative fluoroscopic iliopubic tangential angle (IPTA) to determine the valgus angles of acetabular prostheses. METHODS In the first stage, the IPTA and valgus angles of native acetabula were defined and measured in 102 THAs obtained from the picture archiving and communication systems of our hospital. Obturator foramen morphology was also measured and divided into groups according to the axial length ratio. Correlations between obturator foramen morphology and IPTA and valgus angles of native acetabula were then determined. In the second stage, angular differences (angle θ) between the IPTA and valgus angles of native acetabula were measured during unilateral THA in 136 patients to determine whether this is a stable value that could be used as a reference for placement of acetabular prostheses. Postoperative data such as Harris Hip Score (HHS) scores and complications were collected and evaluated. RESULTS The average IPTA at the apex of the true acetabulum was 58.8° ± 4.1°. The average valgus angle of native acetabula was 43.1° ± 3.9° and angle θ was 15.7° ± 1.3°. Obturator foramen morphology was divided into five groups according to the axial length ratio. IPTA was closely related to obturator foramen morphology (Pearson r = 0.489, P ≈ 0.000). Angle θ was stable and independent of obturator foramen morphology. When the IPTA and angle θ were used as references for placing acetabular prostheses in 136 THAs, the average postoperative valgus angles of acetabular prostheses was 45.13° ± 4.07° and the good-to-excellent rate was 97.05%. There were no short-term complications such as fracture, dislocation or infection. The average HHS score 6 months after surgery was 37.2 higher than the preoperative score, this difference being significant (P < 0.01). Neither infection nor dislocation was found 6 months after surgery. CONCLUSIONS The IPTA (at the apex of the true acetabulum) and angle θ (obtained by intraoperative fluoroscopy) are consistent in determining the postoperative valgus angle of acetabular prosthesis during THA. Thus, IPTA and angle θ are of value in guiding placement of acetabular prostheses; in particular, this method can facilitate the learning of young surgeons.
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Affiliation(s)
- Gang-Yong Huang
- Division of Orthopaedic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Guang-Lei Zhao
- Division of Orthopaedic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Jun Xia
- Division of Orthopaedic Surgery, Huashan Hospital, Fudan University, Shanghai, China.
| | - Yi-Bing Wei
- Division of Orthopaedic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Si-Qun Wang
- Division of Orthopaedic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Jian-Guo Wu
- Division of Orthopaedic Surgery, Huashan Hospital, Fudan University, Shanghai, China
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78
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Sing DC, Barry JJ, Aguilar TU, Theologis AA, Patterson JT, Tay BK, Vail TP, Hansen EN. Prior Lumbar Spinal Arthrodesis Increases Risk of Prosthetic-Related Complication in Total Hip Arthroplasty. J Arthroplasty 2016; 31:227-232.e1. [PMID: 27444852 DOI: 10.1016/j.arth.2016.02.069] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Revised: 01/28/2016] [Accepted: 02/09/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Degenerative hip disorders often coexist with degenerative changes of the lumbar spine. Limited data on this patient population suggest inferior functional improvement and pain relief after surgical management. The purpose of this study is to compare the rates of prosthetic-related complication after primary total hip arthroplasty (THA) in patients with and without prior lumbar spine arthrodesis (SA). METHODS Medicare patients (n = 811,601) undergoing primary THA were identified and grouped by length of prior SA (no fusion, 1-2 levels fused [S-SAHA], and ≥3 levels fused [L-SAHA]). RESULTS Compared with controls, patients with prior SA had significantly higher rates of complications including dislocation (control: 2.36%; S-SAHA: 4.26%; and L-SAHA: 7.51%), revision (control: 3.43%, S-SAHA: 5.55%, and L-SAHA: 7.77%), loosening (control: 1.33%, S-SAHA: 2.10%, and L-SAHA: 3.04%), and any prosthetic-related complication (control: 7.33%, S-SAHA: 11.15% [relative risk: 1.52], and L-SAHA: 14.16% [relative risk: 1.93]) within 24 months (P < .001). CONCLUSION The interplay of coexisting degenerative hip and spine disease deserves further attention of both arthroplasty and spine surgeons.
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Affiliation(s)
- David C Sing
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California
| | - Jeffrey J Barry
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California
| | - Thomas U Aguilar
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California
| | - Alexander A Theologis
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California
| | - Joseph T Patterson
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California
| | - Bobby K Tay
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California
| | - Thomas P Vail
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California
| | - Erik N Hansen
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California
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Khan M, Beckingsale T, Marsh M, Holland J. Difference in the acetabular cup orientation in standing and supine radiographs. J Orthop 2016; 13:168-70. [PMID: 27408490 DOI: 10.1016/j.jor.2016.03.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 03/27/2016] [Indexed: 01/19/2023] Open
Abstract
Acetabular orientation changes with that of the pelvis during lying and standing. This study was designed to measure these changes. We assessed 17 BHR replacements using EBRA software. The mean acetabular anteversion was more (p = 0.02) on erect than supine radiographs. Linear regression analysis showed that anteversion and inclination increased in some while decreased in others, and Bland and Altman analysis showed wide limits of agreement. The changes in acetabular orientation are thus subject to significant variations between the patients. We suggest studying the factors affecting acetabular orientation in standing to help reduce joint reaction forces and improve outcomes.
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Affiliation(s)
- Munir Khan
- Newcastle Upon Tyne Hospitals NHS Trust, Freeman Hospital, Newcastle Upon Tyne, England NE7 7DN, United Kingdom
| | - Tom Beckingsale
- Newcastle Upon Tyne Hospitals NHS Trust, Freeman Hospital, Newcastle Upon Tyne, England NE7 7DN, United Kingdom
| | - Martin Marsh
- Newcastle Upon Tyne Hospitals NHS Trust, Freeman Hospital, Newcastle Upon Tyne, England NE7 7DN, United Kingdom
| | - Jim Holland
- Newcastle Upon Tyne Hospitals NHS Trust, Freeman Hospital, Newcastle Upon Tyne, England NE7 7DN, United Kingdom
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Inaba Y, Kobayashi N, Suzuki H, Ike H, Kubota S, Saito T. Preoperative planning for implant placement with consideration of pelvic tilt in total hip arthroplasty: postoperative efficacy evaluation. BMC Musculoskelet Disord 2016; 17:280. [PMID: 27412447 PMCID: PMC4944317 DOI: 10.1186/s12891-016-1120-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 06/09/2016] [Indexed: 11/13/2022] Open
Abstract
Background In total hip arthroplasty (THA), tilting of the pelvis alters the cup placement angles. Thus, the cup angles need to be planned with consideration of the effects of pelvic tilt. In the present study, we evaluated the efficacy of preoperative planning for implant placement with consideration of pelvic tilt in THA, and the accuracy of a CT-based computer navigation for implant positioning. Methods We examined 75 hips of 75 patients who underwent THA and were followed-up for one year postoperatively. The patients were divided into three groups (anterior, intermediate, posterior tilt) according to their preoperative pelvic tilt. Preoperative planning for implant placement was made with consideration of pelvic tilt and a CT-based navigation was used to execute the preoperative planning. Cup inclination, cup anteversion, and combined anteversion (CA) in supine and standing positions were examined 1 year after THA. The accuracy of the computer navigation was also examined. Results Mean CA was 35.0 ± 5.8° in supine position and 39.3 ± 5.7° in standing position. CA did not differ among the three subgroups (anterior, intermediate, posterior tilt) in either supine or standing position, indicating implant placements to be equally effective. The desired CA (37.3°) was midway between those in supine and standing positions for each subgroup. Respective mean absolute errors between preoperative planning and postoperative CT measurement was 5.3 ± 5.2° for CA. Conclusion We obtained favorable THA results with preoperative planning with consideration of pelvic tilt by demonstrating supine and standing CA to be unaffected by preoperative pelvic tilt one year postoperatively. Mean absolute error of CA between preoperative planning and postoperative measurement was 5° with use of the CT-based navigation.
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Affiliation(s)
- Yutaka Inaba
- Department of Orthopaedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan.
| | - Naomi Kobayashi
- Department of Orthopaedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Haruka Suzuki
- Department of Orthopaedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Hiroyuki Ike
- Department of Orthopaedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - So Kubota
- Department of Orthopaedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Tomoyuki Saito
- Department of Orthopaedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
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Ranawat CS, Ranawat AS, Lipman JD, White PB, Meftah M. Effect of Spinal Deformity on Pelvic Orientation from Standing to Sitting Position. J Arthroplasty 2016; 31:1222-1227. [PMID: 26725131 DOI: 10.1016/j.arth.2015.11.035] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Revised: 11/19/2015] [Accepted: 11/23/2015] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The effect of fixed spinal deformities on a functional pelvis from standing to sitting is not fully understood. We aimed to assess the change in preoperative sagittal pelvic tilt angle (SPTA) from standing to sitting in patients undergoing total hip arthroplasty, comparing flexible and fixed spinal deformities. METHODS Between July 2011 and October 2011, 68 consecutive unilateral total hip arthroplasties were implanted in 68 patients with a mean age of 71 ± 6 years. Fixed spinal deformity was defined as <10° of the change in SPTA from standing to sitting. Preoperative radiographic evaluation included standing (weight-bearing) anteroposterior and lateral pelvic and lumbosacral radiographs and a sitting lateral pelvic radiograph. RESULTS The mean standing and sitting SPTA was 3.7° of anterior tilt and 17.7° of posterior tilt, respectively (change of 21.4 ± 12.5°). Seventy-five percent had flexible pelvises, all of which had a posterior tilt from standing to sitting. One patient in the fixed pelvis (1.4%) had a loss of posterior tilt from standing to sitting. The mean change of SPTA from standing to sitting in the fixed and flexible pelvis groups was 5.9 ± 3.5° to 26.7 ± 9.6° of posterior tilt, which was statistically significant (P < .05). CONCLUSION There was a significant change in sagittal pelvic tilt from standing to sitting, especially in patients with a flexible spine, in which the functional anteversion increases with sitting. The patients with a fixed pelvis had significantly less SPTA in standing (less anteversion) with less posterior sagittal tilt in sitting, which should be incorporated in cup positioning.
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Affiliation(s)
| | - Amar S Ranawat
- Department of Orthopaedics, Hospital for Special Surgery, New York, New York
| | - Joseph D Lipman
- Department of Biomechanics, Hospital for Special Surgery, New York, New York
| | - Peter B White
- Department of Orthopaedics, Hospital for Special Surgery, New York, New York
| | - Morteza Meftah
- Department of Orthopaedics, NYU Langone Medical Center, Hospital for Joint Disease, New York, New York
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Pelvic orientation for total hip arthroplasty in lateral decubitus: can it be accurately measured? Hip Int 2016; 26:254-9. [PMID: 27079286 DOI: 10.5301/hipint.5000345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/01/2015] [Indexed: 02/04/2023]
Abstract
INTRODUCTION During total hip arthroplasty (THA), accurately predicting acetabular cup orientation remains a key challenge, in great part because of uncertainty about pelvic orientation. This pilot study aimed to develop and validate a technique to measure pelvic orientation; establish its accuracy in the location of anatomical landmarks and subsequently; investigate if limb movement during a simulated surgical procedure alters pelvic orientation. METHODS The developed technique measured 3-D orientation of an isolated Sawbone pelvis, it was then implemented to measure pelvic orientation in lateral decubitus with post-THA patients (n = 20) using a motion capture system. RESULTS Orientation of the isolated Sawbone pelvis was accurately measured, demonstrated by high correlations with angular data from a coordinate measurement machine; R-squared values close to 1 for all pelvic axes. When applied to volunteer subjects, largest movements occurred about the longitudinal pelvic axis; internal and external pelvic rotation. Rotations about the anteroposterior axis, which directly affect inclination angles, showed >75% of participants had movement within ±5° of neutral, 0°. CONCLUSIONS The technique accurately measured orientation of the isolated bony pelvis. This was not the case in a simulated theatre environment. Soft tissue landmarks were difficult to palpate repeatedly. These findings have direct clinical relevance, landmark registration in lateral decubitus is a potential source of error, contributing here to large ranges in measured movement. Surgeons must be aware that present techniques using bony landmarks to reference pelvic orientation for cup implantation, both computer-based and mechanical, may not be sufficiently accurate.
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84
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Ishidou Y, Hirotsu M, Setoguchi T, Nagano S, Kakoi H, Yokouchi M, Yamamoto T, Komiya S. A Kirschner wire as a transverse-axis guide to improve acetabular cup positioning. J Orthop Surg (Hong Kong) 2016; 24:22-6. [PMID: 27122507 DOI: 10.1177/230949901602400107] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE To compare cup-positioning accuracy in total hip arthroplasty (THA) with or without use of a Kirschner wire as a transverse-axis guide for pelvic alignment. METHODS Records of 18 men and 73 women (mean age, 60 years) who underwent primary THA with (n=49) or without (n=42) use of a Kirschner wire as a transverse-axis guide for pelvic alignment were reviewed. A 2.4-mm Kirschner wire as a transversea-xis guide was inserted to the anterior superior iliac spine and was parallel to a line linking the left and right anterior superior iliac spine. The safe zone for cup positioning was defined as 30º to 50° abduction and 10º to 30º anteversion. Of the 5 operative surgeons, 2 were classified as experienced (total surgical volume >300) and 3 as inexperienced (total surgical volume of <50). The proportion of patients with the cup in the safe zone was compared in patients with or without use of the transverse-axis guide and in experienced and inexperienced surgeons. RESULTS For inexperienced surgeons, the use of the transverse-axis guide significantly improved the proportion of patients with the cup in the safe zone from 90% to 100% for abduction, from 50% to 82.4% for anteversion, and from 40% to 82.4% for both. Patients with the cup inside or outside the safe zone were comparable in terms of body height, weight, BMI, subcutaneous fat thickness, incision length, and acetabular cup size. CONCLUSION The use of the transverse-axis guide improved the accuracy of cup positioning by inexperienced surgeons.
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Affiliation(s)
- Y Ishidou
- Department of Medical Joint Materials, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - M Hirotsu
- Department of Orthopaedic Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - T Setoguchi
- The Near-Future Locomotor Organ Medicine Creation Course, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - S Nagano
- Department of Orthopaedic Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - H Kakoi
- Department of Orthopaedic Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - M Yokouchi
- Department of Orthopaedic Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - T Yamamoto
- Department of Orthopaedic Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - S Komiya
- Department of Medical Joint Materials & Department of Orthopaedic Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan & The Near-Future Locomotor Organ Medicine Creation Course, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
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85
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Yoon BH, Ha YC, Lee YK, Jo WL, Lee KM, Koo KH. Is transverse acetabular ligament a reliable guide for aligning cup anteversion in total hip arthroplasty?: A measurement by CT arthrography in 90 hips. J Orthop Sci 2016; 21:199-204. [PMID: 26714668 DOI: 10.1016/j.jos.2015.11.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Revised: 10/05/2015] [Accepted: 11/19/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Transverse acetabular ligament (TAL) has been used as a landmark for aligning cup anteversion. The use of TAL as a guide is based on the assumption that TAL version is distributed within the safe zone of acetabular cup. However, there was rarely reported to compare anteversion between TAL and acetabulum using direct measurement methods. The purpose of this study was to measure the anteversion of TAL in computed tomography arthrography (CTA) and compare it with Lewinnek's safe zone and anteversion of bony acetabulum. METHODS 81 patients (90 hips) were selected among 204 patients (228 hips) who received CTA for hip pathology evaluation between March 2010 and June 2013. The anteversion of TAL measured at the lowest level of the acetabular notch and the anteversion of the acetabulum was measured at the level of femoral head center. RESULTS The mean TAL anteversion was 11.8° (SD 4.5, range 0-22.2). In eight hips (8.8%), TAL anteversion was outside the safe zone (15° ± 10°) as defined by Lewinnek. The mean acetabular anteversion was 13.3° ± 4.4° (range -1.0° to 22.6°). There was a strong correlation between TAL anteversion and acetabular anteversion (Pearson's correlation coefficient; 0.908, p < 0.001). CONCLUSIONS TAL anteversion has a large individual variation, and considerable portion of hips have TAL anteversion outside the safety zone of cup anteversion. TAL anteversion is influenced by acetabular anteversion. In hips with retroverted or pauci-anteverted acetabulum, TAL should be used cautiously because there is a risk of cup malposition.
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Affiliation(s)
- Byung-Ho Yoon
- Department of Orthopaedic Surgery, Inje University College of Medicine, Seoul Paik Hospital, Seoul, South Korea.
| | - Yong-Chan Ha
- Department of Orthopaedic Surgery, Chung-Ang University College of Medicine, Seoul, South Korea.
| | - Young-Kyun Lee
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea.
| | - Woo-Lam Jo
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea.
| | - Kyoung-Min Lee
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea.
| | - Kyung-Hoi Koo
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea.
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Sculco PK, McLawhorn AS, Carroll KM, McArthur BA, Mayman DJ. Anteroposterior Radiographs Are More Accurate than Cross-Table Lateral Radiographs for Acetabular Anteversion Assessment: a Retrospective Cohort Study. HSS J 2016; 12:32-8. [PMID: 26855625 PMCID: PMC4733699 DOI: 10.1007/s11420-015-9472-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 09/14/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Measuring acetabular anteversion is relevant to routine follow-up of total hip arthroplasties (THAs) and for malfunctioning THAs. Imageless navigation facilitates acetabular component orientation relative to the anterior pelvic plane (APP) or to the APP adjusted for sagittal pelvic tilt (PT). The optimal plain radiographic method for the postoperative assessment of anteversion is not agreed upon. QUESTIONS/PURPOSES (1) Do anteversion measurements on plain radiographs correlate more with APP anteversion or PT-adjusted anteversion? (2) Do measurements of anteversion performed on supine anteroposterior (AP) radiographs more accurately reflect intraoperative anteversion values for navigated THA compared to anteversion measured on cross-table lateral (CL) radiographs? METHODS Seventy patients receiving primary navigated THA were included. APP and PT-adjusted anteversion were recorded; the latter defined the intraoperative target for anteversion. Postoperative anteversion was measured on supine AP pelvis radiographs with computer software and CL radiographs with conventional methods. Intraoperative measurements were used as the reference standards for comparisons. RESULTS Mean intraoperative APP anteversion was 20.6° ± 5.6°. Mean intraoperative PT-adjusted anteversion was 22.9° ± 4.5°. Mean anteversion was 22.7° ± 4.7° on AP radiographs and 27.2° ± 4.2° on CL radiographs (p < 0.001). Only correlations between PT-adjusted anteversion and radiographic assessments of anteversion were significant. The mean difference between PT-adjusted anteversion and anteversion on AP radiographs was -0.2° ± 4.3°, while the mean difference between the PT-adjusted anteversion and anteversion measured on CL radiographs was 4.3 ± 5.1° (p < 0.001). CONCLUSION Plain film assessment of anteversion was more accurate on supine AP radiographs than on CL radiographs, which overestimated acetabular anteversion.
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Affiliation(s)
- Peter K. Sculco
- />Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Alexander S. McLawhorn
- />Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Kaitlin M. Carroll
- />Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Benjamin A. McArthur
- />Washington Orthopedics and Sports Medicine, 5215 Loughboro Road NW, Suite 200, Washington, DC 20016 USA
| | - David J. Mayman
- />Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
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Suzuki H, Inaba Y, Kobayashi N, Ishida T, Ike H, Saito T. Postural and Chronological Change in Pelvic Tilt Five Years After Total Hip Arthroplasty in Patients With Developmental Dysplasia of the Hip: A Three-Dimensional Analysis. J Arthroplasty 2016; 31:317-22. [PMID: 26276573 DOI: 10.1016/j.arth.2015.07.026] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Revised: 07/01/2015] [Accepted: 07/15/2015] [Indexed: 02/01/2023] Open
Abstract
The pelvis generally tilts to the posterior with movement from the supine to standing position, and with time after total hip arthroplasty (THA). This study aimed to investigate changes in pelvic tilt from the preoperative supine position to the standing position at 5 years after THA (pelvic change, PC). We measured pelvic tilt using a 2D-3D matching technique in 77 unilaterally affected patients who underwent primary THA. PC in 8% of all patients was ≤-20°, and the greatest PC was -25°. In these patients, posterior pelvic tilt continued up to 5 years after THA. These patients were older, and their lumbo-lordotic angle was small. For such cases, cup orientation should be planned to account for continuous posterior change in pelvic tilt after THA.
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Affiliation(s)
- Haruka Suzuki
- Department of Orthopaedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan
| | - Yutaka Inaba
- Department of Orthopaedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan
| | - Naomi Kobayashi
- Department of Orthopaedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan
| | - Takashi Ishida
- Department of Orthopaedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan
| | - Hiroyuki Ike
- Department of Orthopaedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan
| | - Tomoyuki Saito
- Department of Orthopaedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan
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Blizzard DJ, Nickel BT, Seyler TM, Bolognesi MP. The Impact of Lumbar Spine Disease and Deformity on Total Hip Arthroplasty Outcomes. Orthop Clin North Am 2016; 47:19-28. [PMID: 26614917 DOI: 10.1016/j.ocl.2015.08.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Concurrent spine and hip disease is common. Spinal deformities can restrict lumbar range of motion and lumbar lordosis, leading to pelvic obliquity and increased pelvic tilt. A comprehensive preoperative workup and component templating ensure appropriate compensation for altered pelvic parameters for implantation of components according to functional positioning. Pelvic obliquity from scoliosis must be measured to calculate appropriate leg length. Cup positioning should be templated on standing radiograph to limit impingement from cup malposition. In spinal deformity, the optimal position of the cup that accommodates pelvic parameters and limits impingement may lie outside the classic parameters of the safe zone.
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Affiliation(s)
- Daniel J Blizzard
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Brian T Nickel
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Thorsten M Seyler
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Michael P Bolognesi
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
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89
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Kanazawa M, Nakashima Y, Ohishi M, Hamai S, Motomura G, Yamamoto T, Fukushi JI, Ushijima T, Hara D, Iwamoto Y. Pelvic tilt and movement during total hip arthroplasty in the lateral decubitus position. Mod Rheumatol 2015; 26:435-40. [PMID: 26375057 DOI: 10.3109/14397595.2015.1092914] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES Total hip arthroplasty (THA) is often performed in the lateral decubitus (lateral) position. In this position, the pelvis may have various degrees of tilt leading to implant malposition. We sought to quantify the pelvic tilt in lateral position and further pelvic movement during surgery. METHODS In 95 cases with primary THA, three-dimensional pelvic tilts were quantified by superimposing images reconstructed from CT data onto antero-posterior radiographs taken in lateral position at set-up and after cup placement. Pelvises were fixed with a device compressing anterior superior iliac spines and sacrum. RESULTS Various degrees of pelvic tilt occurred compared to the supine position; sagittal: -3.1° (-25.5° to 10.2°), axial: 3.9° (-8.4° to 17°), coronal: 0.9° (-11.9° to 13.2°). Absolute changes more than 5° were observed 43%, 47%, and 12% in the sagittal, axial, and coronal planes, respectively. The more preoperative posterior pelvic tilt resulted in the more change in the sagittal plane. Further pelvic movement of about 3° in three planes were observed ranging from -11° to 20° after cup placement. CONCLUSION This study showed various pelvic tilt and movement during THA. As pelvic tilt directly alters the cup orientation, its changes should be well understood. Improved tools for positioning and holding the pelvis are required.
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Affiliation(s)
- Masayuki Kanazawa
- a Department of Orthopaedic Surgery , Kyushu University , Higashi-Ku , Fukuoka , Japan
| | - Yasuharu Nakashima
- a Department of Orthopaedic Surgery , Kyushu University , Higashi-Ku , Fukuoka , Japan
| | - Masanobu Ohishi
- a Department of Orthopaedic Surgery , Kyushu University , Higashi-Ku , Fukuoka , Japan
| | - Satoshi Hamai
- a Department of Orthopaedic Surgery , Kyushu University , Higashi-Ku , Fukuoka , Japan
| | - Goro Motomura
- a Department of Orthopaedic Surgery , Kyushu University , Higashi-Ku , Fukuoka , Japan
| | - Takuaki Yamamoto
- a Department of Orthopaedic Surgery , Kyushu University , Higashi-Ku , Fukuoka , Japan
| | - Jun-Ichi Fukushi
- a Department of Orthopaedic Surgery , Kyushu University , Higashi-Ku , Fukuoka , Japan
| | - Takahiro Ushijima
- a Department of Orthopaedic Surgery , Kyushu University , Higashi-Ku , Fukuoka , Japan
| | - Daisuke Hara
- a Department of Orthopaedic Surgery , Kyushu University , Higashi-Ku , Fukuoka , Japan
| | - Yukihide Iwamoto
- a Department of Orthopaedic Surgery , Kyushu University , Higashi-Ku , Fukuoka , Japan
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90
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Tiberi JV, Antoci V, Malchau H, Rubash HE, Freiberg AA, Kwon YM. What is the Fate of Total Hip Arthroplasty (THA) Acetabular Component Orientation When Evaluated in the Standing Position? J Arthroplasty 2015; 30:1555-60. [PMID: 25863890 DOI: 10.1016/j.arth.2015.03.025] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2014] [Revised: 03/13/2015] [Accepted: 03/15/2015] [Indexed: 02/01/2023] Open
Abstract
This retrospective study measured the change of the acetabular component orientation between supine and standing radiographs in 113 THA patients and identified the associated anatomical parameters that may help direct pre-operative planning. The mean change of the acetabular component inclination and version from supine to standing was 4.6° and 5.9° respectively (P<0.0001), with 49 (43%) hips showing inclination change >5° and 69 (53%) hips showing version change >5°. Twelve (43%) of 28 'malpositioned' cups became 'well-positioned' and 26 (31%) of 85 'well-positioned' cups became 'malpositioned' upon standing. Changes in inclination were associated with leg length discrepancy and pelvic obliquity; and changes in version were associated with pelvic tilt and pelvic incidence. Standing position and patient factors should be considered when defining "optimal" acetabular orientation.
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Affiliation(s)
- John V Tiberi
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Valentin Antoci
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Henrik Malchau
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Harry E Rubash
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Andrew A Freiberg
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Young-Min Kwon
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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91
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Mudrick CA, Melvin JS, Springer BD. Late posterior hip instability after lumbar spinopelvic fusion. Arthroplast Today 2015; 1:25-29. [PMID: 28326365 PMCID: PMC4926821 DOI: 10.1016/j.artd.2015.05.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 05/04/2015] [Accepted: 05/07/2015] [Indexed: 12/03/2022] Open
Abstract
The kinematic relationship between the hip and the axial skeleton is dynamic and can be variable based on individual anatomy. It has been shown [1] that pelvic incidence (sacral slope + pelvic tilt) can be used as a proxy to determine the ability of the pelvis to accommodate changes in sagittal balance. Individuals have varied pelvic incidence and thus may adapt differently degenerative and/or iatrrogenic to changes that occur in the axial spine. This is a case report in which surgical changes to the lumbopelvic spine resulted in chronic posterior periprosthetic hip instability. The focus of this discussion reflects the intimate relationship between the hip and spine and highlights the role between sagittal balance and acetabular version, specifically as it pertains to total hip arthroplasty.
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Affiliation(s)
| | | | - Bryan D. Springer
- Corresponding author. 2001 Vail Avenue, Suite 200A, Charlotte, NC 28207, USA. Tel.: +1 704 323 3836.
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92
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Fluoroscopy assessment during anterior minimally invasive hip replacement is more accurate than with the posterior approach. INTERNATIONAL ORTHOPAEDICS 2015; 40:21-7. [DOI: 10.1007/s00264-015-2803-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Accepted: 04/27/2015] [Indexed: 12/14/2022]
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93
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Maratt JD, Esposito CI, McLawhorn AS, Jerabek SA, Padgett DE, Mayman DJ. Pelvic tilt in patients undergoing total hip arthroplasty: when does it matter? J Arthroplasty 2015; 30:387-91. [PMID: 25453626 PMCID: PMC4359644 DOI: 10.1016/j.arth.2014.10.014] [Citation(s) in RCA: 160] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Revised: 09/17/2014] [Accepted: 10/13/2014] [Indexed: 02/01/2023] Open
Abstract
Pelvic tilt (PT) affects the functional anteversion and inclination of acetabular components in total hip arthroplasty (THA). One-hundred and thirty-eight consecutive patients who underwent unilateral primary THA were reviewed. Most cases had some degree of pre-operative PT, with 17% having greater than 10° of PT on standing pre-operative radiographs. There was no significant change in PT following THA. A computer model of a hemispheric acetabular component implanted in a range of anatomic positions in a pelvis with varying PT was created to determine the effects of PT on functional anteversion and inclination. Based on the study results, tilt-adjustment of the acetabular component position based on standing pre-operative imaging will likely improve functional component position in most patients undergoing THA.
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94
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Beamer BS, Morgan JH, Barr C, Weaver MJ, Vrahas MS. Does fluoroscopy improve acetabular component placement in total hip arthroplasty? Clin Orthop Relat Res 2014; 472:3953-62. [PMID: 25238804 PMCID: PMC4397754 DOI: 10.1007/s11999-014-3944-8] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Accepted: 09/08/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND The success of THA largely depends on correct placement of the individual components. Traditionally, these have been placed freehand using anatomic landmarks, but studies have shown poor accuracy with this method. QUESTIONS/PURPOSES Specifically, we asked (1) does using fluoroscopy lead to more accurate and greater likelihood of cup placement with the Lewinnek safe zone than does freehand cup placement; (2) is there a learning curve associated with the use of fluoroscopy for cup placement; (3) does the use of fluoroscopy increase operative time; and (4) is there a difference in leg length discrepancy between freehand and fluoroscopic techniques? METHODS This series consisted of 109 consecutive patients undergoing primary THA, conversion of a previous hip surgery to THA, and revision THA during a 24-month period. No patients were excluded from analysis during this time. The first 52 patients had cups placed freehand, and then the next 57 patients had acetabular components placed using fluoroscopy; the analysis began with the first patient treated using fluoroscopy, to include our initial experience with the technique. The abduction, version, and limb length discrepancy were measured on 6-week postoperative pelvic radiographs obtained with the patient in the supine position. Operative time, sex, age, BMI, diagnosis, operative side, and femoral head size were recorded as possible confounders. RESULTS Cups inserted freehand were placed in the ideal range of abduction (30°-45°) and anteversion (5°-25°) 44% of the time. With fluoroscopy, placement in the Lewinnek safe zone for both measures significantly increased to 65%. The odds of placing the cup in the Lewinnek safe zone for abduction and version were 2.3 times greater with the use of fluoroscopy (95% CI, 1.2-5.0; p = 0.03). Patients undergoing primary THAs (32 freehand, 35 C-arm) had cup placement in the safe zone for abduction and version 44% of the time freehand and 57% of the time with fluoroscopy, which failed to reach statistical significance. There was no difference in operative time, patient age, sex, operative side, diagnosis, limb length discrepancy, or femoral head size between the two groups. CONCLUSIONS The use of fluoroscopy to directly observe pelvic position and acetabular component placement increased the success of placement in the Lewinnek safe zone in this cohort of patients having complex and primary THAs. This is a simple, low-cost, and quick method for increasing successful acetabular component alignment. The study population included a large proportion of patients having complex THAs, and further validation of this technique in patients undergoing straightforward, primary THAs needs to be done to understand if similar gains in accuracy for component placement can be expected in that group. LEVEL OF EVIDENCE Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Brandon S Beamer
- Department of Orthopaedic Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA,
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95
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Grammatopoulos G, Pandit HG, da Assunção R, Taylor A, McLardy-Smith P, De Smet KA, Murray DW, Gill HS. Pelvic position and movement during hip replacement. Bone Joint J 2014; 96-B:876-83. [PMID: 24986939 DOI: 10.1302/0301-620x.96b7.32107] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The orientation of the acetabular component is influenced not only by the orientation at which the surgeon implants the component, but also the orientation of the pelvis at the time of implantation. Hence, the orientation of the pelvis at set-up and its movement during the operation, are important. During 67 hip replacements, using a validated photogrammetric technique, we measured how three surgeons orientated the patient's pelvis, how much the pelvis moved during surgery, and what effect these had on the final orientation of the acetabular component. Pelvic orientation at set-up, varied widely (mean (± 2, standard deviation (sd))): tilt 8° (2sd ± 32), obliquity -4° (2sd ± 12), rotation -8° (2sd ± 14). Significant differences in pelvic positioning were detected between surgeons (p < 0.001). The mean angular movement of the pelvis between set-up and component implantation was 9° (sd 6). Factors influencing pelvic movement included surgeon, approach (posterior > lateral), procedure (hip resurfacing > total hip replacement) and type of support (p < 0.001). Although, on average, surgeons achieved their desired acetabular component orientation, there was considerable variability (2sd ± 16) in component orientation. We conclude that inconsistency in positioning the patient at set-up and movement of the pelvis during the operation account for much of the variation in acetabular component orientation. Improved methods of positioning and holding the pelvis are required.
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Affiliation(s)
- G Grammatopoulos
- University of Oxford, NDORMS, Windmill Road, Headington, Oxford, OX3 7LD, UK
| | - H G Pandit
- University of Oxford, NDORMS, Windmill Road, Headington, Oxford, OX3 7LD, UK
| | - R da Assunção
- Western Sussex Hospitals NHS Foundation Trust, Lyndhurst Rd, Worthing BN11 2DH, UK
| | - A Taylor
- Oxford University Hospitals, Nuffield Orthopaedic Centre, Windmill Road, Headington, OX3 7LD, UK
| | - P McLardy-Smith
- Oxford University Hospitals, Nuffield Orthopaedic Centre, Windmill Road, Headington, OX3 7LD, UK
| | - K A De Smet
- ANCA Clinic, Xavier de Cocklaan 68/1, 9831 Sint-Martens-Latem, Deurle, Belgium
| | - D W Murray
- University of Oxford, NDORMS, Windmill Road, Headington, Oxford, OX3 7LD, UK
| | - H S Gill
- University of Bath, Dept of Mechanical Engineering, Claverton Down, Bath BA2 7AY, UK
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96
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Kanawade V, Dorr LD, Wan Z. Predictability of Acetabular Component Angular Change with Postural Shift from Standing to Sitting Position. J Bone Joint Surg Am 2014; 96:978-986. [PMID: 24951732 DOI: 10.2106/jbjs.m.00765] [Citation(s) in RCA: 181] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The angles of the acetabular component of a total hip replacement change with body postural changes, and this change can affect stability and wear. We sought to correlate the intraoperative angles of inclination and anteversion of the cup with the changes in these angles when patients moved from standing to sitting and determine if these changes were predictable. METHODS Eighty-five patients (eighty-five hips) had sagittal (lateral) spinopelvic radiographs made while they were standing and while they were sitting before and after undergoing total hip replacement. The spinosacral tilt and the pelvic tilt were measured on these radiographs. The angles of acetabular inclination and anteversion achieved at surgery changed during sitting. Each patient was classified according to the stiffness of the spine/pelvis as measured by the change in posterior sacral or pelvic tilt between the standing and sitting positions. The magnitude of change of the sagittal cup position (termed ante-inclination) was correlated to the stiffness classification of the pelvis. An experimental phantom model reproduced possible combinations of intraoperative inclination and anteversion and correlated them to sagittal ante-inclination according to pelvic tilt. RESULTS The pelves with normal stiffness tilted posteriorly 20° to 35° with the postural change from standing to sitting. Ante-inclination of the acetabular cup averaged 29.6° ± 8.4° (95% confidence interval [CI] = 13.1° to 46°) with standing and 54.6° ± 10.2° (95% CI = 44.4° to 64.8°) with sitting. The stiff pelves had a mean of 4° less tilt than those with normal stiffness and 13° less than the hypermobile pelves with the postoperative sitting position. The phantom model showed ante-inclination could be predicted by measuring the preoperative degrees of change in sacral/pelvic tilt from standing to sitting. CONCLUSIONS Ante-inclination during sitting results in a more vertical acetabular cup, which can result in hip instability, especially drop-out dislocation, and edge-loading wear. Patients with supine coronal cup inclination of ≥50° and anteversion of ≥25° and those with a hypermobile pelvis are at risk. It is the pelvic spatial position during postural change that creates the postoperative consequences of the surgical cup placement.
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Affiliation(s)
- Vaibhav Kanawade
- Orthopedic Department, Keck Medical Center of USC, 1520 San Pablo Street, Suite 2000, Los Angeles, CA 90033. E-mail address for L.D. Dorr:
| | - Lawrence D Dorr
- Orthopedic Department, Keck Medical Center of USC, 1520 San Pablo Street, Suite 2000, Los Angeles, CA 90033. E-mail address for L.D. Dorr:
| | - Zhinian Wan
- Orthopedic Department, Keck Medical Center of USC, 1520 San Pablo Street, Suite 2000, Los Angeles, CA 90033. E-mail address for L.D. Dorr:
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97
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Rathod PA, Bhalla S, Deshmukh AJ, Rodriguez JA. Does fluoroscopy with anterior hip arthroplasty decrease acetabular cup variability compared with a nonguided posterior approach? Clin Orthop Relat Res 2014; 472:1877-85. [PMID: 24549773 PMCID: PMC4016457 DOI: 10.1007/s11999-014-3512-2] [Citation(s) in RCA: 109] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Accepted: 02/04/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND The direct anterior approach for THA offers some advantages, but is associated with a significant learning curve. Some of the technical difficulties can be addressed by the use of intraoperative fluoroscopy which may improve the accuracy of acetabular component placement. QUESTIONS/PURPOSES The purposes of this study were to determine if (1) there is decreased variability of acetabular cup inclination and anteversion with the direct anterior approach using fluoroscopic guidance as compared with the posterior approach THA without radiographic guidance; (2) if there is a learning curve associated with achieving accuracy with the direct anterior approach THA. We also wanted (3) to assess the frequency of complications including dislocation with the anterior approach, which initially had a learning curve, and the posterior approach. METHODS This retrospective, comparative study of 825 THAs (372 posterior THAs without fluoroscopic guidance and 453 direct anterior THAs, performed by one surgeon, focused on a radiographic analysis to determine cup inclination and anteversion on standardized pelvic radiographs using specialized software. The first 100 direct anterior THAs performed while transitioning from the posterior approach to the direct anterior approach were included in the learning curve group. During this learning curve period, the direct anterior approach was used for all patients except those with conversion of previously fixed intertrochanteric or femoral neck fractures to THAs, gluteus medius tears, and obese patients with an immobile abdominal pannus (100 of 127 THAs). Variability of the acetabular component was compared among the posterior group, learning curve group, and direct anterior group. RESULTS Variances for cup inclination and anteversion were significantly lower in the direct anterior group (19 and 16 respectively, p < 0.01) as compared with the posterior group (50 and 79 respectively).Target inclination and anteversion were achieved better in the direct anterior group (98% and 97% respectively) as compared with the posterior group (86% and 77% respectively) (p < 0.01, OR for inclination = 9.1, 95% CI, 3.5 to 23.4; OR for anteversion = 8, 95% CI, 4 to 16). In the learning curve group, target anteversion achieved (91% of cases) was marginally lower than that of the direct anterior group (p = 0.03; OR = 2.9, 95% CI, 1.1 to 7.3) and target inclination (95%) was similar (p = 0.13). There was one posterior dislocation in the posterior group, two anterior dislocations in the learning curve group, and none in the direct anterior group. CONCLUSIONS Use of fluoroscopy with the patient in the supine position during direct anterior THA enables intraoperative assessment of cup orientation resulting in decreased variability of acetabular cup anteversion. However, there is a learning curve associated with achieving this accuracy. We could not discern whether this difference was the result of the approach or the use of fluoroscopy in the direct anterior group. LEVEL OF EVIDENCE Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Parthiv A Rathod
- Center for Joint Preservation & Reconstruction, NorthshoreLIJ/Lenoxhill Hospital, 130 E 77th Street, 11th Floor, New York, NY, 10075, USA,
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98
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Lee YK, Biau DJ, Yoon BH, Kim TY, Ha YC, Koo KH. Learning curve of acetabular cup positioning in total hip arthroplasty using a cumulative summation test for learning curve (LC-CUSUM). J Arthroplasty 2014; 29:586-9. [PMID: 23998991 DOI: 10.1016/j.arth.2013.07.023] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Revised: 07/12/2013] [Accepted: 07/21/2013] [Indexed: 02/01/2023] Open
Abstract
Despite advances in surgical techniques and instrumentation, optimal cup positioning in total hip arthroplasty (THA) is challenging with a limited accuracy. We evaluated whether a learning curve exists for the optimal cup positioning, using the LC-CUSUM test (Learning curve cumulative summation test). We evaluated the first 100 consecutive THA performed by two surgeons, who had a year of fellowship training in the same teaching hospital. A learning curve of cup positioning was plotted in each series using the LC-CUSUM score. There was no significant difference of numbers of outlier between two surgeons (P = 0.079). Both surgeons completed the learning curve of optimal cup positioning before 50 procedures, and maintained competence. A substantial learning period is necessary in the optimal positioning of an acetabular cup.
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Affiliation(s)
- Young-Kyun Lee
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Bundang-gu, Seongnam, South Korea
| | - David J Biau
- Department of Orthopaedic Surgery, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Université Paris Descartes, Paris, France
| | - Byung-Ho Yoon
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Bundang-gu, Seongnam, South Korea
| | - Tae-Young Kim
- Department of Orthopaedic Surgery, Hallym University Sacred Heart Hospital, Dongan-gu, Anyang, South Korea
| | - Yong-Chan Ha
- Department of Orthopaedic Surgery, Chung-Ang University College of Medicine, Dongjak-gu, Seoul, South Korea
| | - Kyung-Hoi Koo
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Bundang-gu, Seongnam, South Korea
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99
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Derbyshire B, Diggle PJ, Ingham CJ, Macnair R, Wimhurst J, Jones HW. A new technique for radiographic measurement of acetabular cup orientation. J Arthroplasty 2014; 29:369-72. [PMID: 23896357 DOI: 10.1016/j.arth.2013.06.024] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Revised: 05/29/2013] [Accepted: 06/17/2013] [Indexed: 02/01/2023] Open
Abstract
Accurate radiographic measurement of acetabular cup orientation is required in order to assess susceptibility to impingement, dislocation, and edge loading wear. In this study, the accuracy and precision of a new radiographic cup orientation measurement system were assessed and compared to those of two commercially available systems. Two types of resurfacing hip prostheses and an uncemented prosthesis were assessed. Radiographic images of each prosthesis were created with the cup set at different, known angles of version and inclination in a measurement jig. The new system was the most accurate and precise and could repeatedly measure version and inclination to within a fraction of a degree. In addition it has a facility to distinguish cup retroversion from anteversion on anteroposterior radiographs.
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100
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Nawabi DH, Conditt MA, Ranawat AS, Dunbar NJ, Jones J, Banks S, Padgett DE. Haptically guided robotic technology in total hip arthroplasty: a cadaveric investigation. Proc Inst Mech Eng H 2013; 227:302-9. [PMID: 23662346 DOI: 10.1177/0954411912468540] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The longevity of total hip arthroplasty (THA) continues to improve with advancements in design and bearing materials. However, the incidence of dislocation and impingement-related failures continue to rise, with the inability of the surgeon to achieve optimal component orientation cited as a cause. Computer-assistance has been shown to increase the accuracy of component orientation and robotic-assistance has been developed to translate this advantage into precise surgical execution. We sought to validate a haptically-guided robotic arm system in performing THA with the aim of comparing the accuracy of robotic-assisted acetabular cup placement to manual placement. We implanted 12 acetabular components in 6 cadaveric pelvises comparing robotic-assistance on one side with manual implantation on the other. We measured planned and actual center of rotation (COR), cup position, leg-length equalization and offset for each THA using computed tomography and the robotic platform. The root-mean-square (RMS) error for the robotic-assisted system was within 3 degrees for cup placement and within 1 mm for leg-length equalization and offset when compared to computed tomography. The robotic-assisted system was significantly more accurate than manual implantation in reproducing the COR and cup orientation, as determined by a preoperative plan. The RMS error for manual implantation compared to robotic-assistance was 5 times higher for cup inclination and 3.4 times higher for cup anteversion (p < 0.01). Robotic-assistance is more accurate than manual implantation in achieving optimal cup orientation. It has the ability to eliminate human error from THA and should be considered in light of THA failures due to component malposition.
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Affiliation(s)
- Danyal H Nawabi
- Adult Reconstruction and Joint Replacement Division, Hospital for Special Surgery, New York 10021, USA
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