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Klemt C, Limmahakhun S, Bounajem G, Xiong L, Yeo I, Kwon YM. Effect of postural changes on in vivo pelvic tilt and functional component anteversion in total hip arthroplasty patients with lumbar disc degenerations. Bone Joint J 2020:1-7. [PMID: 32955350 DOI: 10.1302/0301-620x.102b9.bjj-2020-0777.r1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The complex relationship between acetabular component position and spinopelvic mobility in patients following total hip arthroplasty (THA) renders it difficult to optimize acetabular component positioning. Mobility of the normal lumbar spine during postural changes results in alterations in pelvic tilt (PT) to maintain the sagittal balance in each posture and, as a consequence, markedly changes the functional component anteversion (FCA). This study aimed to investigate the in vivo association of lumbar degenerative disc disease (DDD) with the PT angle and with FCA during postural changes in THA patients. METHODS A total of 50 patients with unilateral THA underwent CT imaging for radiological evaluation of presence and severity of lumbar DDD. In all, 18 patients with lumbar DDD were compared to 32 patients without lumbar DDD. In vivo PT and FCA, and the magnitudes of changes (ΔPT; ΔFCA) during supine, standing, swing-phase, and stance-phase positions were measured using a validated dual fluoroscopic imaging system. RESULTS PT, FCA, ΔPT, and ΔFCA were significantly correlated with the severity of lumbar DDD. Patients with severe lumbar DDD showed marked differences in PT with changes in posture; there was an anterior tilt (-16.6° vs -12.3°, p = 0.047) in the supine position, but a posterior tilt in an upright posture (1.0° vs -3.6°, p = 0.005). A significant decrease in ΔFCA during stand-to-swing (8.6° vs 12.8°, p = 0.038) and stand-to-stance (7.3° vs 10.6°,p = 0.042) was observed in the severe lumbar DDD group. CONCLUSION There were marked differences in the relationship between PT and posture in patients with severe lumbar DDD compared with healthy controls. Clinical decision-making should consider the relationship between PT and FCA in order to reduce the risk of impingement at large ranges of motion in THA patients with lumbar DDD.
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Affiliation(s)
- Christian Klemt
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sakkadech Limmahakhun
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Georges Bounajem
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Liang Xiong
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ingwon Yeo
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Young-Min Kwon
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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102
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Li L, Zhang Y, Lin YY, Li ZX, Chen L, Chen DS, Fan P. A Specific Anteversion of Cup and Combined Anteversion for Total Hip Arthroplasty Using Lateral Approach. Orthop Surg 2020; 12:1663-1673. [PMID: 32924261 PMCID: PMC7767786 DOI: 10.1111/os.12790] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 07/27/2020] [Accepted: 06/30/2020] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To determine the implant orientation, especially the combined anteversion measurements in total hip arthroplasty (THA) using lateral approach, and to compare with implant orientation using posterior-lateral (P-L) approach. The secondary goal was to identify the factors associated with implant orientation. METHODS Five hundred and one patients (545 hips) who underwent primary THA with the modified Hardinge approach between January 2016 and November 2019 by one senior surgeon in our department in a retrospective study were followed up. A survey to inquire about the history of dislocation of the hip after THA was designed and responses were gathered by telephone, WeChat software, and outpatient follow-up. The mean age of the patients was 61.97 ± 11.72 years, and there were 254 males and 247 females. The average follow-up time was 25.2 ± 13.7 months (range, 3.2-49.7 months). Among the patients who were followed up, 97 patients (104 hips) underwent computed tomography (CT) scans from L4 to the tuberosity of the tibia. The implant orientation, including the anteversion and inclination of the cup, anteversion of the stem, combined anteversion, and pelvic tilt were measured based on CT scans of these patients. The results were compared with the implant orientation reported in previous reports measured by CT. Factors that may be associated with implant orientation were investigated, including the patient's age, sex, body mass index (BMI), and diagnosis; size of the cup; diameter of the femoral head component; and pelvic tilt. Data and statistical analyses were performed using SPSS 20.0. RESULTS No cases of dislocation were found in the 501 patients (545 hips) who underwent primary THA during this period. The mean inclination and anteversion of the cups were 38.83° ± 5.04° (24.5°-53.1°) and 9.26° ± 11.19° (-15°-48°), respectively. The mean anteversion of the stem was 13.83° ± 10.7° (-10.2°-42.3°). The combined anteversion was 23.1° ± 13.4° (-7.4°-54.6°). Compared with the reported combined anteversion and anteversion of the cup, the mean anteversion of the cup and combined anteversion using the lateral approach were much lower than the reported values in the literature using the P-L approach. Pelvic tilt was found to be the only independent factor for cup anteversion. Factors including age, sex, BMI, diagnosis, cup size, and diameter of the femoral head component were not associated with implant orientation. CONCLUSION THA using the lateral approach yields smaller cup anteversion and combined anteversion values than using the P-L approach. Pelvic tilt is the only predictor for cup anteversion.
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Affiliation(s)
- Li Li
- Zhejiang Provincial Key Laboratory of Anesthesiology, The Second Affiliated Hospital of Wenzhou Medical University, Yuying Children's Hospital, Wenzhou, China
| | - Yu Zhang
- Zhejiang Provincial Key Laboratory of Orthopedics, The Second Affiliated Hospital of Wenzhou Medical University, Yuying Children's Hospital, Wenzhou, China
| | - Yuan-Yuan Lin
- Zhejiang Provincial Key Laboratory of Orthopedics, The Second Affiliated Hospital of Wenzhou Medical University, Yuying Children's Hospital, Wenzhou, China
| | - Zhen-Xing Li
- Zhejiang Provincial Key Laboratory of Orthopedics, The Second Affiliated Hospital of Wenzhou Medical University, Yuying Children's Hospital, Wenzhou, China
| | - Liang Chen
- Zhejiang Provincial Key Laboratory of Orthopedics, The Second Affiliated Hospital of Wenzhou Medical University, Yuying Children's Hospital, Wenzhou, China
| | - Dao-Sen Chen
- Zhejiang Provincial Key Laboratory of Orthopedics, The Second Affiliated Hospital of Wenzhou Medical University, Yuying Children's Hospital, Wenzhou, China
| | - Pei Fan
- Zhejiang Provincial Key Laboratory of Orthopedics, The Second Affiliated Hospital of Wenzhou Medical University, Yuying Children's Hospital, Wenzhou, China.,Department of Orthopaedics, The Second Affiliated Hospital of Wenzhou Medical University, Yuying Children's Hospital, Wenzhou, China
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103
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[Intraoperative assessment of pelvic tilt and cup position in total hip arthroplasty: the relevance of navigation and robotics]. DER ORTHOPADE 2020; 49:893-898. [PMID: 32909050 DOI: 10.1007/s00132-020-03978-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The optimal 3D positioning of the prosthesis components is of great importance for the stability and function of a total hip endoprosthesis. Pelvic tilt has a particular influence on the position of the implant. In order to use intraoperatively the knowledge on pelvic kinematics gained through preoperative imaging procedures and movement analyses, "image-based" and "image-free" robotic and navigation procedures are available. With the "image-based" procedures, a 3D CT scan serves as the surgeon's basis for operative planning. The "image-free" procedures are based on the principles of stereotaxy. In the future, information about static and dynamic pelvic tilt will be conntected with navigation and robotic systems for total hip arthroplasty. Along with intraoperative data a patientindividual optimized implant position can be achieved.
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104
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Cotter BD, Innmann MM, Dobransky JS, Merle C, Beaulé PE, Grammatopoulos G. Does Functional Cup Orientation Change at Minimum of 10 Years After Primary Total Hip Arthroplasty? J Arthroplasty 2020; 35:2507-2512. [PMID: 32444235 DOI: 10.1016/j.arth.2020.04.075] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 04/14/2020] [Accepted: 04/21/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Cup orientation has been shown to influence the postoperative risk of impingement and dislocation following total hip arthroplasty (THA) and may change over time due to changes in pelvic tilt that occur with aging. The purpose of this study is to determine if there is a significant change in acetabular cup inclination and anteversion over a 10-year period following THA. METHODS A retrospective, multisurgeon, single-center cohort study was conducted of 46 patients that underwent THA between 1995 and 2002. A total of 46 patients were included, with a median age at surgery of 56 years, and a median time between initial postoperative radiograph and the most recent one being 13.5 years (minimum 10 years). Cup orientation was measured from postoperative and follow-up supine anterior-posterior pelvic radiographs. Using a validated software, inclination and anteversion were calculated at each interval and the change in cup anteversion and inclination angle was determined. Furthermore, the difference in the sacro-femoral-pubic angle was measured, reflecting the difference in pelvic tilt between intervals. RESULTS No significant difference was detected between measurements taken from initial postoperative radiograph and measurements a minimum of 10 years later (P > .45), with the median (interquartile range) change in anteversion, inclination, and sacro-femoral-pubic being 0° (-1° to 3°), 1° (-3° to 2°), and 0° (-2° to 3°), respectively. CONCLUSION Our study found no significant change in functional cup orientation a minimum of 10 years after THA. No shifts in functional cup orientation as a result of altering spinopelvic alignment seemed to be present over a 10-year period.
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Affiliation(s)
- Brendan D Cotter
- Division of Orthopaedic Surgery, The Ottawa Hospital General Campus, Ottawa, Ontario, Canada
| | - Moritz M Innmann
- Department of Orthopaedic and Trauma Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Johanna S Dobransky
- Division of Orthopaedic Surgery, The Ottawa Hospital General Campus, Ottawa, Ontario, Canada
| | - Christian Merle
- Department of Orthopaedic and Trauma Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Paul E Beaulé
- Division of Orthopaedic Surgery, The Ottawa Hospital General Campus, Ottawa, Ontario, Canada
| | - George Grammatopoulos
- Division of Orthopaedic Surgery, The Ottawa Hospital General Campus, Ottawa, Ontario, Canada
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105
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Harold RE, Delagrammaticas D, Keller T, Butler B, Stover MD, Manning DW. Are single plane intraoperative and biplanar postoperative radiographic measurements of acetabular cup position the same? Hip Int 2020; 30:530-535. [PMID: 31242760 DOI: 10.1177/1120700019859902] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE Supine positioning and the use of fluoroscopy during direct anterior approach total hip arthroplasty (DAA THA) have been reported to improve acetabular component positioning. This study aims to compare 2-dimensional intraoperative radiographic RadLink measurements of acetabular component position with 3-dimensional postoperative 3D SterEOS measurements. METHODS Intraoperative fluoroscopy and RadLink (El Segundo, CA, USA) were used to measure acetabular cup position intraoperatively in 48 consecutive patients undergoing DAA THA. Cup position was measured on 6-week postoperative standing EOS images using 3D SterEOS software (EOS Imaging, SA, Paris, France) and compared to RadLink findings using Student's t-test. Safe-zone outliers were identified. We evaluated for measurement difference of > +/- 5°. RESULTS RadLink acetabular cup abduction measurement (mean 43.0°) was not significantly different than 3D SterEOS in the anatomic plane (mean 42.6°, p = 0.50) or in the functional plane (mean 42.7°, p = 0.61). RadLink acetabular cup anteversion measurement (mean 17.9°) was significantly different than 3D SterEOS in both the anatomic plane (mean 20.6°, p = 0.022) and the functional plane (mean 21.2°, p = 0.002). RadLink identified 2 cups outside of the safe-zone. However, SterEOS identified 12 (anatomic plane) and 10 (functional plane) outside of the safe-zone. In the functional plane, 58% of anteversion and 92% of abduction RadLink measurements were within +/- 5° of 3D SterEOS. CONCLUSIONS Intraoperative fluoroscopic RadLink acetabular anteversion measurements are significantly different than 3D SterEOS measurements, while abduction measurements are similar. Significantly more acetabular cups were noted to be outside of the safe-zone when evaluated with 3D SterEOS versus RadLink.
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Affiliation(s)
- Ryan E Harold
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Dimitri Delagrammaticas
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Tyler Keller
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Bennet Butler
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Michael D Stover
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - David W Manning
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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106
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Ransone M, Fehring K, Fehring T. Standardization of lateral pelvic radiograph is necessary to predict spinopelvic mobility accurately. Bone Joint J 2020; 102-B:41-46. [DOI: 10.1302/0301-620x.102b7.bjj-2019-1548.r1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims Patients with abnormal spinopelvic mobility are at increased risk for instability. Measuring the change in sacral slope (ΔSS) can help determine spinopelvic mobility preoperatively. Sacral slope (SS) should decrease at least 10° to demonstrate adequate posterior pelvic tilt. There is potential for different ΔSS measurements in the same patient based on sitting posture. The purpose of this study was to determine the effect of sitting posture on the ΔSS in patients undergoing total hip arthroplasty (THA). Methods In total, 51 patients undergoing THA were reviewed to quantify the variability in preoperative spinopelvic mobility when measuring two different sitting positions using SS for planning. Results A total of 32 patients had standardized relaxed sitting radiographs, while 35 patients had standardized flexed sitting images. Of the 32 patients with relaxed sitting views, the mean ΔSS was 20.7° (SD 8.9°). No patients exhibited an increase in SS during relaxed sitting (i.e. anterior pelvic tilt or so-called reverse accommodation). Of the 35 patients with flexed sitting radiographs, the mean ΔSS was only 2.1° (SD 9.7°) with 16/35 (45.71%) showing anterior pelvic tilt, or so-called reverse accommodation, unexpectedly increasing the sitting SS compared to the standing SS. Overall, 18 patients had both relaxed sitting and flexed sitting radiographs. In patients with both types of sitting radiographs, the mean relaxed sit to stand ΔSS was 18.06° (SD 6.07°), while only a 3.00° (SD 10.53°) ΔSS was noted when flexed sitting. There was a mean ΔSS difference of 15.06° (SD 7.67°) noted in the same patient cohort depending on sitting posture (p < 0.001). Conclusion A 15° mean difference was noted depending on the sitting posture of the patient. Since decisions on component position can be made on preoperative lateral sit-stand radiographs, postural standardization is crucial. If using ΔSS for preoperative planning, the relaxed sitting radiograph is preferred. Cite this article: Bone Joint J 2020;102-B(7 Supple B):41–46.
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Affiliation(s)
- Michael Ransone
- Carolinas Medical Center, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, USA
| | - Keith Fehring
- OrthCarolina Hip & Knee Center, Charlotte, North Carolina, USA
| | - Thomas Fehring
- OrthCarolina Hip & Knee Center, Charlotte, North Carolina, USA
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107
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Uemura K, Atkins PR, Okamoto M, Tokunaga K, Anderson AE. Can measurements from an anteroposterior radiograph predict pelvic sagittal inclination? J Orthop Res 2020; 38:1477-1485. [PMID: 32320097 PMCID: PMC7335595 DOI: 10.1002/jor.24701] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 03/12/2020] [Accepted: 04/15/2020] [Indexed: 02/04/2023]
Abstract
Pelvic sagittal inclination (PSI) is often evaluated in patients with hip pathology using lateral radiographs. However, it would be useful if PSI could be predicted from an anteroposterior radiograph since this film is ubiquitous in the evaluation of hip pathology. Herein, computer-modeling was applied to predict PSI from radiographic measurements assessed in the anteroposterior plane. Three-dimensional surface models of the pelvis, femur, and sacrum were reconstructed from computed tomography images of 50 women with hip dysplasia. This study cohort was selected as changes in PSI alter femoral head coverage, which is relevant to the diagnosis and treatment of hip dysplasia, a known cause of hip osteoarthritis. Five radiographic parameters commonly used to independently estimate PSI were evaluated after bone surfaces were projected to an anteroposterior plane, including the symphysis to sacrococcygeal joint distance (S-S distance), the pelvic foramen aspect ratio (PF ratio), the distance between the symphysis and a line connecting the femoral head centers (S-H distance), the sacro-femoral-pubic angle (SFP angle), and the pelvic vertical ratio (PVR). Regression models determined the ability of these parameters to predict PSI from -20° to 20° at 1° increment. All five parameters showed a strong correlation with the PSI (all r > 0.9). From the regression models, PSI was estimated with a median (maximum) absolute error of 3.6° (18.4°), 3.8° (17.7°), 5.2° (17.9°), 5.8° (28.8°), and 3.2° (23.5°) for the S-S distance, PF ratio, S-H distance, SFP angle, and PVR, respectively. The regression model for S-S distance had a mean slope of 2.18 that ranged from 1.98 to 2.41 when the sacrococcygeal joint was located superior to the symphysis. Results indicated that substantial errors occur when estimating the actual value of PSI from an anteroposterior radiograph. However, the change in PSI could be estimated from the S-S distance, which may aid surgeons to successfully increase head coverage through periacetabular osteotomy and to locate the acetabular cup in a functional position for total hip arthroplasty.
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Affiliation(s)
- Keisuke Uemura
- Department of Orthopaedics, University of Utah, Salt Lake City, UT, 84108, USA
| | - Penny R. Atkins
- Department of Orthopaedics, University of Utah, Salt Lake City, UT, 84108, USA,Department of Bioengineering, University of Utah, Salt Lake City, UT, 84112, USA
| | - Masashi Okamoto
- Department of Radiology, Kameda Daiichi Hospital, Niigata City, Niigata, 9500165, Japan
| | - Kunihiko Tokunaga
- Niigata Hip Joint Center, Kameda Daiichi Hospital, Niigata City, Niigata, 9500165, Japan
| | - Andrew E. Anderson
- Department of Orthopaedics, University of Utah, Salt Lake City, UT, 84108, USA,Department of Bioengineering, University of Utah, Salt Lake City, UT, 84112, USA,Scientific Computing and Imaging Institute, University of Utah, Salt Lake City, UT, 84112, USA,Department of Physical Therapy, University of Utah, Salt Lake City, UT, 84108, USA
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108
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Abstract
PURPOSE OF REVIEW Advances in technology, implant design, and surgical technique have lowered the dislocation rate in primary total hip arthroplasty (THA). Despite these advances, there remain a large number of instability episodes without a known etiology. Recent research suggests that the pelvic and lumbar spine interrelationship may be the explanation in prosthetic dislocations without a known cause. In this review, we describe the biomechanics, measurements, diagnoses, classification, management, and outcomes of total hip and revision total hip instability as it relates to spinopelvic alignment. RECENT FINDINGS As a person goes from standing to sitting, lumbar lordosis decreases, and the sacrum and entire pelvis tilts posteriorly with sacrum and coccyx rotating posterior-inferiorly, resulting in increased acetabular cup anteversion to accommodate femoral flexion. A fused spine and associated fixed acetabulum can result in abnormal pelvic femoral motion, impingement, and dislocation. Classifying the spinopelvic mechanics by sacral motion based on sitting and standing lateral radiographs provides an understanding of how the acetabulum behaves in space. This information helps appropriate cup positioning, reducing the risk of femoral side impingement and subsequent dislocation. Surgical techniques to consider in the spinopelvic at-risk patient are positioning considerations in acetabular cup inclination and anteversion, high offset femoral stems, high offset acetabular liners, dual mobility articulations, and removal of impinging structures. Future research is needed to define the safest order of operation in concomitant hip and spine pathology, the effects on pelvic femoral biomechanics in spine surgery, and whether preoperative and intraoperative management strategies have a long-term beneficial effect on the dislocation rate.
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Affiliation(s)
- Zachary C Lum
- Adult Reconstruction Division, Department of Orthopaedic Surgery, University of California: Davis Medical Center, 4860 Y Street, Suite 3800, Sacramento, CA, 95817, USA.
| | - Mauro Giordani
- Adult Reconstruction Division, Department of Orthopaedic Surgery, University of California: Davis Medical Center, 4860 Y Street, Suite 3800, Sacramento, CA, 95817, USA
| | - John P Meehan
- Adult Reconstruction Division, Department of Orthopaedic Surgery, University of California: Davis Medical Center, 4860 Y Street, Suite 3800, Sacramento, CA, 95817, USA
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Ike H, Bodner RJ, Lundergan W, Saigusa Y, Dorr LD. The Effects of Pelvic Incidence in the Functional Anatomy of the Hip Joint. J Bone Joint Surg Am 2020; 102:991-999. [PMID: 32496744 DOI: 10.2106/jbjs.19.00300] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The spine-pelvis-hip interaction during postural change should be considered in the functional anatomy of the hip. The component parts of this anatomy and how they influence hip function are important to know. Pelvic incidence (PI) is one of these components. We studied if PI was preoperatively predictive of impingement risk and if it postoperatively influences hip position, which could cause outliers from the functional safe zone of hip replacement. METHODS This was a prospective radiographic study of 187 consecutive patients (200 hips) who had lateral spinopelvis-hip radiographs before and after primary total hip arthroplasty with measurements of the component factors that influence mobility and position of the functional anatomy. The predictive value of PI for risk of impingement of the hip and its postoperative relationship to functional safe-zone outliers were assessed. Forty-one dislocations from our clinical practice were also reviewed. RESULTS Of 200 hips, the PI was normal in 145 hips (73%), low in 18 hips (9%), and high in 37 hips (19%). Eighty-two hips had spinopelvic imbalance: 12 (67%) of the 18 hips with low PI, 56 (39%) of the 145 hips with normal PI, and 14 (38%) of the 37 hips with high PI. Low-PI hips was the most predictive of the risk of impingement and postoperatively these hips had the most outliers from the functional safe zone. CONCLUSIONS PI is an anatomical component that is predictive of both impingement risk and functional safe-zone outliers. Preoperative risk, based on factors such as the Lewinnek zones and combined anteversion, is an established guide in determining cup position in hip replacement. Low-PI hips that have the "terrible triad" of a posteriorly tilted pelvis, stiff pelvic mobility, and increased femoral flexion therefore have no functional safe zone. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Hiroyuki Ike
- Departments of Orthopaedic Surgery (H.I.) and Biostatistics (Y.S.), Yokohama City University School of Medicine, Yokohama, Japan
| | | | | | - Yusuke Saigusa
- Departments of Orthopaedic Surgery (H.I.) and Biostatistics (Y.S.), Yokohama City University School of Medicine, Yokohama, Japan
| | - Lawrence D Dorr
- Dorr Institute for Arthritis Research and Education, Pasadena, California
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110
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Ueno T, Kabata T, Kajino Y, Takagi T, Ohmori T, Yoshitani J, Tsuchiya H. Influence of pelvic sagittal tilt on 3-dimensional bone coverage in total hip arthroplasty: a simulation analysis. Hip Int 2020; 30:288-295. [PMID: 31409140 DOI: 10.1177/1120700019868780] [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] [Indexed: 02/04/2023]
Abstract
BACKGROUND In total hip arthroplasty with computer navigation assistance, cup orientation is generally determined according to the coordinate system relative to the functional pelvic plane (FPP). However, there is a large difference in the cup anteversion between a posterior pelvic tilt relative to the computed tomography (CT) table in the sagittal plane and anterior pelvic tilt, even when the cup is set at the same orientation angle according to each FPP. The present study analysed this difference from the viewpoint of 3-dimensional (3D) coverage of the acetabular component (3D coverage) to determine how the 3D acetabular coverage is altered with changes in pelvic sagittal tilt. METHODS We analysed 3D-simulated acetabular coverage measured in 3D pelvic models reconstructed from the preoperative CT data of 50 patients. In each patient, we created 5 pelvic models with a sagittal tilt of 10° increments between 20° anterior tilt and 20° posterior tilt relative to the CT table. RESULTS We found that 3D coverage decreased as the pelvis tilted posteriorly. Particularly, there were significant differences between the pelvis with 20° anterior tilt and that with neutral tilt (p < 0.001). There was also a difference between the pelvis with neutral tilt and that with a 20° posterior tilt (p < 0.01). The mean decrease in 3D coverage between the pelvis with neutral tilt and that with 20° posterior tilt was 7.2 ± 1.6%. CONCLUSIONS We found that 3D coverage differed among pelvis with different sagittal tilts when the cup orientation angle was determined according to FPP.
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Affiliation(s)
- Takuro Ueno
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, Japan
| | - Tamon Kabata
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, Japan
| | - Yoshitomo Kajino
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, Japan
| | - Tomoharu Takagi
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, Japan
| | - Takaaki Ohmori
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, Japan
| | - Junya Yoshitani
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, Japan
| | - Hiroyuki Tsuchiya
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, Japan
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111
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Sagittal Pelvic Kinematics in Hip Arthroplasty. Curr Rev Musculoskelet Med 2020; 13:240-246. [PMID: 32318965 DOI: 10.1007/s12178-020-09628-w] [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] [Indexed: 10/24/2022]
Abstract
PURPOSE OF REVIEW The orientation of the spine relative to the pelvis-particularly that in the sagittal plane-has been shown in both kinematic and radiographic studies to be paramount in governance of acetabular alignment during normal bodily motion. The purpose of this review is to better understand the challenges faced by arthroplasty surgeons in treating patients that have concurrent lumbar disease and are therefore more likely to have poorer clinical outcomes after THA than in patients without disease. RECENT FINDINGS The concept of an "acetabular safe zone" has been well described in the past regarding the appropriate orientation of acetabular component in THA. However, this concept is now under scrutiny, and rising forth is a concept of functional acetabular orientation that is based on clinically evaluable factors that are patient and motion specific. The interplay between the functional position of the acetabulum and the lumbar spine is complex. The challenges that are thereby faced by arthroplasty surgeons in terms of proper acetabular cup positioning when treating patients with concomitant lumbar disease need to be better understood and studied, so as to prevent catastrophic and costly complications such as periprosthetic joint dislocations and revision surgeries.
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112
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Tetsunaga T, Yamada K, Tetsunaga T, Sanki T, Kawamura Y, Ozaki T. An accelerometer-based navigation system provides acetabular cup orientation accuracy comparable to that of computed tomography-based navigation during total hip arthroplasty in the supine position. J Orthop Surg Res 2020; 15:147. [PMID: 32295628 PMCID: PMC7161129 DOI: 10.1186/s13018-020-01673-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Accepted: 04/03/2020] [Indexed: 11/21/2022] Open
Abstract
Background Inadequate acetabular component orientation is associated with postoperative impingement, dislocation, and accelerated polyethylene wear. Computed tomography (CT)-based navigation systems provide accuracy for total hip arthroplasty (THA) but are not available in all facilities. Accelerometer-based navigation systems are inexpensive, but their accuracy remains undetermined. This study compares the accuracy of cup orientation in THA using CT-based and accelerometer-based navigation systems. Methods This retrospective study included 35 consecutive patients (11 males, 24 females; mean age, 65 years) who underwent primary cementless THA via an anterolateral approach in the supine position. Both CT-based and accelerometer-based navigation systems were used simultaneously. The accuracy of cup orientation was compared between the two systems using postoperative CT. Results The accuracy of cup inclination was 2.7° ± 2.0° in the CT-based group and 3.3° ± 2.4° in the accelerometer-based group. The accuracy of cup anteversion was 2.8° ± 2.6° in the CT-based group and 3.4° ± 2.2° in the accelerometer-based group. No significant difference was observed in cup inclination (p = 0.29) or cup anteversion (p = 0.34) between CT-based and accelerometer-based navigation. Conclusions The accuracy of cup positioning did not differ significantly between CT-based and accelerometer-based navigation systems.
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Affiliation(s)
- Tomonori Tetsunaga
- Department of Orthopaedic Surgery, Okayama University Hospital, 2-5-1 Shikata-cho, Kitaku, Okayama, 700-8558, Japan.
| | - Kazuki Yamada
- Department of Medical Materials for Musculoskeletal Reconstruction, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kitaku, Okayama, 700-8558, Japan
| | - Tomoko Tetsunaga
- Department of Orthopaedic Surgery, Okayama University Hospital, 2-5-1 Shikata-cho, Kitaku, Okayama, 700-8558, Japan
| | - Tomoaki Sanki
- Department of Orthopaedic Surgery, Okayama University Hospital, 2-5-1 Shikata-cho, Kitaku, Okayama, 700-8558, Japan
| | - Yoshi Kawamura
- Department of Orthopaedic Surgery, Okayama University Hospital, 2-5-1 Shikata-cho, Kitaku, Okayama, 700-8558, Japan
| | - Toshifumi Ozaki
- Department of Orthopaedic Surgery, Okayama University Hospital, 2-5-1 Shikata-cho, Kitaku, Okayama, 700-8558, Japan
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113
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Buckland AJ, Abotsi EJ, Vasquez-Montes D, Ayres EW, Varlotta CG, Vigdorchik JM. Lumbar Spine Degeneration and Flatback Deformity Alter Sitting-Standing Spinopelvic Mechanics-Implications for Total Hip Arthroplasty. J Arthroplasty 2020; 35:1036-1041. [PMID: 31839349 DOI: 10.1016/j.arth.2019.11.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 10/24/2019] [Accepted: 11/13/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Spinal degeneration and lumbar flatback deformity can decrease recruitment of protective posterior pelvic tilt when sitting, leading to anterior impingement and increased instability. We aim at analyzing regional and global spinal alignment between sitting and standing to better understand the implications of spinal degeneration and flatback deformity for hip arthroplasty. METHODS Spinopelvic parameters of patients with full-body sitting-standing stereoradiographs were assessed: lumbar lordosis (LL), spinopelvic tilt (SPT), pelvic incidence minus LL (PI-LL), sagittal vertical axis (SVA), and T1 pelvic angle (TPA). Lumbar spines were classified as normal, degenerative (disc height loss >50%, facet arthropathy, or spondylolisthesis), or flatback (degenerative criteria and PI-LL >10°). Independent t-tests and analysis of variance were used to analyze alignment differences between groups. RESULTS After propensity matching for age, sex, and hip osteoarthritis grade, 57 patients per group were included (62 ± 11 years, 58% female). Mean standing and sitting SPT, PI-LL, SVA, and TPA increased along the spectrum of disease severity. Increasing severity of disease was associated with decreasing standing and sitting LL. The flatback group demonstrated the greatest sitting SPT, PI-LL, SVA, and TPA. The amount of sitting-to-standing change in SPT, LL, PI-LL, SVA, and TPA decreased along the spectrum of disease severity. CONCLUSION Spinal degeneration and lumbar flatback deformity both significantly decrease lower lumbar spine mobility and posterior SPT from standing to sitting in a stepwise fashion. The demonstrated hypomobility in flatback patients likely serves as a pathomechanism for the previously observed increased risk of dislocation in total hip arthroplasty.
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Affiliation(s)
- Aaron J Buckland
- Division of Spine Surgery, Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY
| | - Edem J Abotsi
- Division of Spine Surgery, Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY
| | - Dennis Vasquez-Montes
- Division of Spine Surgery, Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY
| | - Ethan W Ayres
- Division of Spine Surgery, Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY
| | - Christopher G Varlotta
- Division of Spine Surgery, Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY
| | - Jonathan M Vigdorchik
- Division of Adult Reconstruction, Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY
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114
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Uemura K, Takao M, Otake Y, Koyama K, Yokota F, Hamada H, Sakai T, Sato Y, Sugano N. Reproducibility of pelvic sagittal inclination while acquiring radiographs in supine and standing postures. J Orthop Surg (Hong Kong) 2020; 27:2309499019828515. [PMID: 30798713 DOI: 10.1177/2309499019828515] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE Pelvic position on the sagittal plane is usually evaluated with the pelvic sagittal inclination (PSI) angle from a single radiograph. However, the reproducibility of pelvic positioning has not been investigated, and thus, the validity of measuring the PSI from a single film/time point is not understood. Herein, the reproducibility of a patient's pelvic positions in supine and standing postures was analyzed. METHODS A total of 34 patients who underwent either a pelvic osteotomy or total hip arthroplasty were enrolled in this study. Preoperative radiographs in both supine and standing postures were acquired twice (first X-ray and second X-ray) within 6 months; preoperative computed tomography (CT) images of the full pelvis were also acquired in a supine posture (preop-CT). To eliminate measurement variability, each PSI was automatically measured from radiographs and CT images through the use of CT segmentation and landmark localization followed by intensity-based 2D-3D registration. The absolute difference of PSI among each image was calculated and the intra-class correlation coefficient (ICC) in each posture was also analyzed. RESULTS The median absolute differences of PSI in the supine posture were 1.3° between the first and second X-rays, 1.2° between the first X-ray and preop-CT, and 1.3° between the second X-ray and preop-CT. The median absolute difference of PSI in the standing posture was 1.5°. The ICC was 0.965 (95% CI: 0.939-0.981) in supine and 0.977 (95% CI: 0.954-0.988) during standing. CONCLUSIONS Pelvic positions in supine and standing postures are reproducible. Thus, measuring the PSI from a single radiograph is reliable.
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Affiliation(s)
- Keisuke Uemura
- 1 Department of Orthopaedic Medical Engineering, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Masaki Takao
- 1 Department of Orthopaedic Medical Engineering, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Yoshito Otake
- 2 Graduate School of Information Science, Nara Institute of Science and Technology, Ikoma, Nara, Japan
| | - Koki Koyama
- 2 Graduate School of Information Science, Nara Institute of Science and Technology, Ikoma, Nara, Japan
| | - Futoshi Yokota
- 2 Graduate School of Information Science, Nara Institute of Science and Technology, Ikoma, Nara, Japan
| | - Hidetoshi Hamada
- 3 Department of Orthopaedic Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Takashi Sakai
- 3 Department of Orthopaedic Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Yoshinobu Sato
- 2 Graduate School of Information Science, Nara Institute of Science and Technology, Ikoma, Nara, Japan
| | - Nobuhiko Sugano
- 1 Department of Orthopaedic Medical Engineering, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
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115
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Feng JE, Anoushiravani AA, Eftekhary N, Wiznia D, Schwarzkopf R, Vigdorchik JM. Techniques for Optimizing Acetabular Component Positioning in Total Hip Arthroplasty: Defining a Patient-Specific Functional Safe Zone. JBJS Rev 2020; 7:e5. [PMID: 30817692 DOI: 10.2106/jbjs.rvw.18.00049] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- James E Feng
- Department of Orthopaedic Surgery, NYU Langone Orthopaedic Hospital, NYU Langone Health, New York, NY
| | - Afshin A Anoushiravani
- Department of Orthopaedic Surgery, NYU Langone Orthopaedic Hospital, NYU Langone Health, New York, NY.,Department of Orthopaedics, Albany Medical Center, Albany, New York
| | - Nima Eftekhary
- Department of Orthopaedic Surgery, NYU Langone Orthopaedic Hospital, NYU Langone Health, New York, NY
| | - Daniel Wiznia
- Department of Orthopaedic Surgery, NYU Langone Orthopaedic Hospital, NYU Langone Health, New York, NY.,Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut
| | - Ran Schwarzkopf
- Department of Orthopaedic Surgery, NYU Langone Orthopaedic Hospital, NYU Langone Health, New York, NY
| | - Jonathan M Vigdorchik
- Department of Orthopaedic Surgery, NYU Langone Orthopaedic Hospital, NYU Langone Health, New York, NY
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116
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Yang G, Li Y, Zhang H. The Influence of Pelvic Tilt on the Anteversion Angle of the Acetabular Prosthesis. Orthop Surg 2020; 11:762-769. [PMID: 31663281 PMCID: PMC6819173 DOI: 10.1111/os.12543] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 08/24/2019] [Accepted: 08/28/2019] [Indexed: 12/23/2022] Open
Abstract
The concept of the "safe area" of the acetabular prosthesis has a long history and has been recognized by many scholars. It is generally believed that postoperative hip dislocation rate is low, when the acetabular anteversion angle is placed in the range of 15° ± 10°. Despite this, hip dislocation is a common complication after total hip arthroplasty. In recent years, more and more scholars have paid attention to the influence of pelvic tilt on the acetabular anteversion angle. The concept of acetabular anteversion changes as the pelvic tilt changes, and is challenging the traditional acetabular prosthesis "safe area." This study summarized the potential influencing factors of pelvic tilt and discussed the influence of the phenomenon on the anteversion angle of total hip arthroplasty (THA) acetabular prosthesis based on the literature review. We conclude that from the supine position to standing, followed by sitting, the pelvis tends to move backward. Pelvic sagittal activity, lumbar disease (ankylosing spondylitis), lumbar fusion (lumbar fusion, spine-pelvic fusion), and other factors related to the tilt are THA risk factors for postoperative dislocation and revision. With the change of body position, the degree of acetabular anteversion is directly related to the degree of pelvic tilt. The acetabular anteversion varies greatly, which leads to increased hip prosthesis wear and even hip dislocation. The lateral X-ray of the spine and pelvis is recommended in supine, standing, and sitting positions before THA. In addition, the pelvic tilt should be regarded as a reference of the acetabular prosthesis in the preoperative planning of THA.
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Affiliation(s)
- Guoyue Yang
- Orthopaedic Department, Third Central Hospital of Tianjin, Tianjin, China.,Tianjin Institute of Hepatobiliary Disease, Tianjin, China.,Tianjin Key Laboratory of Artificial Cell, Tianjin, China.,Artificial Cell Engineering Technology Research Center of Public Health Ministry, Tianjin, China
| | - Yayue Li
- Orthopaedic Department, Third Central Hospital of Tianjin, Tianjin, China.,Tianjin Institute of Hepatobiliary Disease, Tianjin, China.,Tianjin Key Laboratory of Artificial Cell, Tianjin, China.,Artificial Cell Engineering Technology Research Center of Public Health Ministry, Tianjin, China
| | - Hong Zhang
- Orthopaedic Department, The Fourth Medical Center of the Chinese People's Liberation Army General Hospital, Beijing, China
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Labral tears with axial plane disorders. Jt Dis Relat Surg 2020; 31:109-14. [PMID: 32160503 PMCID: PMC7489133 DOI: 10.5606/ehc.2020.70193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES This study aims to determine if there is an axial plane coverage insufficiency in patients with symptomatic labral tears compared to the contralateral asymptomatic side and healthy control subjects. PATIENTS AND METHODS This retrospective study was conducted between December 2017 and January 2019. Thirty patients (21 males, 9 females; mean age 28 years; range, 20 to 36 years) operated due to unilateral symptomatic acetabular labral tears secondary to femoroacetabular impingement were evaluated. Twenty asymptomatic patients (13 males, 7 females; mean age 27±9 years; range, 19 to 36 years) were included in the control group. The relationship between acetabular morphology and labral tear was investigated with the comparison of unilateral symptomatic hips with contralateral asymptomatic hips and the control group by using radiological parameters on plain radiographs and computed tomography. RESULTS When the patient group symptomatic side was compared to the control group, acetabular anteversion angle (A A A) and alpha (α) angle were higher, while posterior acetabular sector angle and horizontal acetabular sector angle were lower. When the asymptomatic side was compared to the control group, AAA was higher in the patient group. There was no difference between the symptomatic and asymptomatic sides in the patient group; the symptomatic side yielded a higher α; angle. CONCLUSION Posterior axial plane coverage deficiency in combination with cam deformity (increased α angle) seems to play a role in the pathogenesis of symptomatic acetabular labral tears, even creating a side-to-side difference in some individuals.
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118
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Zhao JX, Su XY, Zhao Z, Xiao RX, Zhang LC, Tang PF. Radiographic assessment of the cup orientation after total hip arthroplasty: a literature review. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:130. [PMID: 32175423 DOI: 10.21037/atm.2019.12.150] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Optimal acetabular cup orientation is of substantial importance to good long-term function and low complication rates after total hip arthroplasty (THA). The radiographic anteversion (RA) and inclination (RI) angles of the cup are typically studied due to the practicability, simplicity, and ease of interpretation of their measurements. A great number of methods have been developed to date, most of which have been performed on pelvic or hip anteroposterior radiographs. However, there are primarily two influencing factors for these methods: X-ray offset and pelvic rotation. In addition, there are three types of pelvic rotations about the transverse, longitudinal, and anteroposterior axes of the body. Their effects on the RA and RI angles of the cup are interactively correlated with the position and true orientation of the cup. To date, various fitted or analytical models have been established to disclose the correlations between the X-ray offset and pelvic rotation and the RA and RI angles of the cup. Most of these models do not incorporate all the potential influencing parameters. Advanced methods for performing X-ray offset and pelvic rotation corrections are mainly performed on a single pelvic AP radiograph, two synchronized radiographs, or a two-dimensional/three-dimensional (2D-3D) registration system. Some measurement systems, originally developed for evaluating implant migration or wear, could also be used for correcting the X-ray offset and pelvic rotation simultaneously, but some drawbacks still exist with these systems. Above all, the 2D-3D registration technique might be an alternative and powerful tool for accurately measuring cup orientation. In addition to the current methods used for postoperative assessment, navigation systems and augmented reality are also used for the preoperative planning and intraoperative guidance of cup placement. With the continuing development of artificial intelligence and machine learning, these techniques could be incorporated into robot-assisted orthopaedic surgery in the future.
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Affiliation(s)
- Jing-Xin Zhao
- Department of Orthopaedics, the First Medical Centre, Chinese PLA General Hospital, Beijing 100853, China.,National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing 100853, China
| | - Xiu-Yun Su
- Department of Orthopaedics, the First Medical Centre, Chinese PLA General Hospital, Beijing 100853, China.,Intelligent and Digital Surgery Innovation Center, Southern University of Science and Technology Hospital, Shenzhen, Guangdong 518055, China
| | - Zhe Zhao
- Department of Orthopaedics, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing 102218, China
| | - Ruo-Xiu Xiao
- School of Computer and Communication Engineering, University of Science and Technology Beijing, Beijing 100083, China
| | - Li-Cheng Zhang
- Department of Orthopaedics, the First Medical Centre, Chinese PLA General Hospital, Beijing 100853, China.,National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing 100853, China
| | - Pei-Fu Tang
- Department of Orthopaedics, the First Medical Centre, Chinese PLA General Hospital, Beijing 100853, China.,National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing 100853, China
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119
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Gu J, Feng H, Feng X, Zhou Y. Degeneration of three or more lumbar discs significantly decreases lumbar spine/hip ROM ratio during position change from standing to sitting in AVN patients before THA. BMC Musculoskelet Disord 2020; 21:39. [PMID: 31954404 PMCID: PMC6969977 DOI: 10.1186/s12891-020-3043-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 01/06/2020] [Indexed: 11/30/2022] Open
Abstract
Background Limitations in the lumbar spine movement reduce lumbar vertebral motion and affect spinopelvic kinematics. We studied the influence of lumbar intervertebral disc degeneration on spinofemoral movement, from standing to sitting, in patients undergoing total hip arthroplasty (THA). Methods Of 138 consecutive patients scheduled for THA due to unilateral avascular necrosis (AVN) of the femoral head, those with ≥3 discs with University of California at Los Angeles (UCLA) disc degeneration score > 1 were defined as the lumbar degenerative disc disease (LDD) group, and the remaining patients constituted d the control group. Full body anteroposterior and lateral EOS images in the standing and sitting positions were obtained. Pelvic incidence (PI), L1 slope (L1 s), lumbar lordosis angle (LL), pelvic tilt (PT), sacral slope (SS), femoral slope (Fs), sagittal vertical axis (SVA), hip flexion, lumbar spine flexion, and total spinofemoral flexion were measured on the images and compared between groups. Results No significant between-group differences were observed in the height, weight, body mass index, AVN staging, or PI, SS, and Fs on standing. The LDD group included more females and older patients, had 5° lesser LL, 5° greater PT, and larger SVA. From standing to sitting, the PI remained constant in both groups. Total spinofemoral flexion was 7° less, lumbar spine flexion 16° less, L1 slope change 6° less, and SS change 8° less, and hip flexion was 7° more in the LDD than in the control group. The spine/hip flexion ratio was significantly lower in the LDD group (0.3 versus 0.7; p < 0.001). On regression analysis, the LDD group (p < 0.001) and older age (p = 0.048) but not sex, weight, or height were significant univariate predictors of decreased spine/hip ratio. Conclusions Patients with LDD leant more forward and had a larger pelvis posterior tilt angle on standing and a decreased lumbar spine/hip flexion ratio, with more hip joint flexion, on sitting, to compensate for reduced lumbar spine flexion. Surgeons should be aware that elderly patients with multiple LDD have significantly different spinofemoral movements and increased risk of posterior dislocation post-THA. Preoperative patient identification, intraoperative surgical technique modification, and individualized rehabilitation protocols are necessary.
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120
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Yun HH, Murphy WS, Ward DM, Zheng G, Hayden B, Murphy SB. Effect of pelvic tilt and rotation on cup orientation in standing anteroposterior radiographs. Hip Int 2020; 30:48-55. [PMID: 30834795 DOI: 10.1177/1120700019831665] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Individual pelvic tilt and rotation have wide variability that can affect the measurement of cup orientation in anteroposterior (AP) radiographs. The purpose of this study was to analyse the effect of pelvic tilt and rotation on radiographic measurements of cup orientation. METHODS A total of 53 patients (63 hips) were included in this study. The patients underwent a computed tomography study with standing AP pelvis radiographs taken both preoperatively and approximately 3 months postoperatively. We used 2-dimensional/3-dimensional matching to measure the pelvic tilt and rotation, and the non-standardised and standardised cup orientation. RESULTS There was no difference in the pelvic tilt and rotation between the preoperative and postoperative radiographs. The distribution of the differences between the non-standardised and standardised cup anteversion exhibited a change within 5° in only 34/63 (54%) hips. The pelvic tilt correlated with the difference between the non-standardised and standardised cup anteversion, but the pelvic rotation did not. When all 63 hips were separated into the right and left sides, the pelvic rotation inversely correlated with the pelvic tilt-adjusted difference between the non-standardised and standardised cup anteversion of the right side but directly correlated with that of the left side. CONCLUSIONS The current study demonstrated that the measurement of cup anteversion in standing AP radiographs is significantly affected by both the pelvic tilt and pelvic rotation. An improved understanding of the pelvic orientation may eventually allow for desired cup positioning on a patient-specific basis to potentially reduce complications associated with the malposition of the cup.
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Affiliation(s)
- Ho Hyun Yun
- Department of Orthopaedic Surgery, Seoul Veterans Hospital, Seoul, Republic of Korea
| | - William S Murphy
- Center for Computer Assisted and Reconstructive Surgery, New England Baptist Hospital, Tufts University School of Medicine, Boston, USA
| | - Daniel M Ward
- Center for Computer Assisted and Reconstructive Surgery, New England Baptist Hospital, Tufts University School of Medicine, Boston, USA
| | - Guoyan Zheng
- ARTORG Center for Biomedical Engineering Research, ISTB-Institute for Surgical Technology and Biomechanics, University of Bern, Switzerland
| | - Brett Hayden
- Center for Computer Assisted and Reconstructive Surgery, New England Baptist Hospital, Tufts University School of Medicine, Boston, USA
| | - Stephen B Murphy
- Center for Computer Assisted and Reconstructive Surgery, New England Baptist Hospital, Tufts University School of Medicine, Boston, USA
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Uemura K, Atkins PR, Peters CL, Anderson AE. The effect of pelvic tilt on three-dimensional coverage of the femoral head: A computational simulation study using patient-specific anatomy. Anat Rec (Hoboken) 2019; 304:258-265. [PMID: 31755243 DOI: 10.1002/ar.24320] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 10/14/2019] [Accepted: 10/21/2019] [Indexed: 01/23/2023]
Abstract
Improved understanding of how three-dimensional (3D) femoral head coverage changes as the pelvic sagittal inclination (PSI) is altered would advance clinical diagnosis of hip pathoanatomy. Herein, we applied computer modeling of 3D computed tomography reconstructions of the pelvis and proximal femur to quantify relationships between the PSI and regional 3D femoral head coverage. Eleven healthy, young adult participants with typically developed hip anatomy were analyzed. The orientation of the pelvis was altered to define a PSI of -30° to 30° at 1° increments. Hip adduction and rotation were fixed in a standing position, which was measured by direct in vivo imaging of the pelvis and femur bones using dual fluoroscopy. Femoral head coverage was quantified in the anterior, superior, posterior, and inferior regions for each PSI position. Change in coverage was largest in the anterior region (29.8%) and smallest in the superior region (6.5%). Coverage increased linearly in the anterior region as the PSI increased, while a linear decrease was found in the posterior region and the inferior region (all p < .001). The slopes of the regression line for these regions were 0.513, -0.316, and -0.255, respectively. For the superior region, coverage increased when the PSI was altered from -30° to 5° and decreased when the PSI was larger than 5°. Overall, a 1° increase in PSI resulted in an increase of 0.5% in anterior coverage and a decrease of 0.3% in posterior coverage. Our findings provide baseline data that improve understanding of the effect of PSI on femoral coverage.
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Affiliation(s)
- Keisuke Uemura
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah
| | - Penny R Atkins
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah.,Department of Bioengineering, University of Utah, Salt Lake City, Utah
| | | | - Andrew E Anderson
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah.,Department of Bioengineering, University of Utah, Salt Lake City, Utah.,Scientific Computing and Imaging Institute, University of Utah, Salt Lake City, Utah.,Department of Physical Therapy, University of Utah, Salt Lake City, Utah
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122
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Muir JM, Vincent J, Schipper J, Gobin VD, Govindarajan M, Fiaes K, Vigdorchik J. A Novel Method for Correcting Pelvic Tilt on Anteroposterior Pelvic Radiographs. Cureus 2019; 11:e6274. [PMID: 31911867 PMCID: PMC6939981 DOI: 10.7759/cureus.6274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background Anteroposterior (AP) pelvic radiographs remain the standard for pre- and postoperative imaging during total hip arthroplasty (THA), despite the known limitation of plain films, including the inability to adequately account for distortion caused by variations in pelvic orientation such as pelvic tilt. The purpose of this study was to develop a reliable method for correcting pelvic tilt on AP pelvic radiographs in patients undergoing THA. Methods CT scans from 20 patients/cadaver specimens (10 male, 10 female) were used to create 3D renderings, from which synthetic radiographs of each pelvis were generated. For each pelvis, 13 synthetic radiographs were generated, showing the pelvis at between -30° and 30° of pelvic tilt, in 5° increments. On each image, eight unique parameters/distances were measured to determine the most appropriate parameters for the calculation of pelvic tilt. The most reliable and accurate of these parameters was determined via regression analysis and used to create gender-specific nomograms from which pelvic tilt measurements could be calculated. The accuracy and reliability of the nomograms and correction method were subsequently validated using both synthetic radiographs (n=50) and stereoradiographic images (n=58). Results Of the eight parameters measured, the vertical distance between the superior margin of the pubic symphysis and the transischial line (PSTI) was determined to be the most reliable (r=-0.96, ICC=0.94). Using that parameter and applying the associated nomograms to 50 synthetic radiographs of random pelvic tilt, the mean difference between the actual pelvic tilt and that calculated using the correction method was 0.1°±5.1° (p=0.98, r=0.96). In 58 stereoradiographic images, the mean difference between actual and measured pelvic tilt was -0.2°±6.4° (p=0.74, r=0.77). The pooled results indicate no significant difference between actual (2.2°±13.9°) and measured pelvic tilt (2.1°±14.3°, p=0.93, r=0.91). No significant differences were noted based on gender. Conclusions Our method of correcting for pelvic tilt using the vertical distance from the pubic symphysis to the transischial line provides a reliable method for correcting for pelvic tilt on AP pelvic radiographs.
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Affiliation(s)
| | - John Vincent
- Medicine, Faculty of Applied Health Sciences, School of Public Health and Health Systems, University of Waterloo, Waterloo, CAN
| | - Joseph Schipper
- Orthopaedics, Research & Development, Intellijoint Surgical, Kitchener, CAN
| | | | - Meinusha Govindarajan
- Epidemiology and Public Health, School of Public Health and Health Systems, University of Waterloo, Waterloo, CAN
| | - Karlina Fiaes
- Epidemiology and Public Health, School of Public Health and Health Systems, University of Waterloo, Waterloo, CAN
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Huang G, Zhao G, Chen K, Wei Y, Wang S, Xia J. How much does lumbar fusion change sagittal pelvic tilt in individuals receiving total hip arthroplasty? ARTHROPLASTY 2019; 1:14. [PMID: 35240766 PMCID: PMC8796607 DOI: 10.1186/s42836-019-0014-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 10/25/2019] [Indexed: 11/29/2022] Open
Abstract
Background This study primarily aims to examine the effect of lumbar fusion on changes in sagittal pelvic tilt (SPT) in total hip arthroplasty (THA) patients. Methods We reviewed 19 hip osteoarthritic patients undergoing THA with or without lumbar fusion. The gender, age, primary disease, Deyo comorbidity score, and year of surgery were sorted and matched. All patients were followed up for at least 12 months. They were compared in terms of the SPT angle, Harris hip score (HHS) and complications. Results On average, the patients receiving lumbar fusion had a − 3.9 (95% CI − 7.7 to − 1.5) degrees of SPT before THA and − 2.7 (95% CI − 6.5 to 1.1) degrees postoperatively, and the THA patients without lumbar fusion averaged 2.5 (95% CI − 0.1 to 5.0) degrees and 4.2 (95% CI 2.0 to 6.4) degrees, respectively. In the lumbar fusion patients, the mean SPT was − 3.9 (95% CI − 9.9 to 2.0) degrees with L5S1 fusion and − 4.0(95% CI − 10.0 to 2.1) degrees without L5S1 fusion on the standing radiograph before THA (t = 0.01, P = 0.99). The mean SPT was − 1.2 (95% CI − 4.9 to 2.6) degrees with one- and two-segment fusion and − 10.0 (95% CI − 18.5 to 1.5) degrees with three- and four-segment fusion before THA (t = 2.60, P = 0.02). There was no statistically significant difference in cup inclination and cup anteversion after THA between the lumbar fusion and control groups. These patients in the two groups achieved a similar HHS 12 months after THA despite the fact that they had different SPT and HHS before THA. Conclusion Lumbar fusion appears to increase the posterior SPT by approximately 6 degrees in the patients undergoing THA. Lumbar fusion of more than two segments is a predictor of more posterior SPT changes, but fusion of L5S1 is not.
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Does It Matter: Total Hip Arthroplasty or Lumbar Spinal Fusion First? Preoperative Sagittal Spinopelvic Measurements Guide Patient-Specific Surgical Strategies in Patients Requiring Both. J Arthroplasty 2019; 34:2652-2662. [PMID: 31320187 DOI: 10.1016/j.arth.2019.05.053] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 05/24/2019] [Accepted: 05/29/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND In patients requiring both total hip arthroplasty (THA) and lumbar spinal fusion (LSF), consideration of preoperative sagittal spinopelvic measurements can aid in the prediction of postfusion compensatory changes in pelvic tilt (PT) and inform adjustments to traditional THA cup anteversion. This study aims to identify relationships between spinopelvic measurements and post-THA hip instability and to determine if procedure order reveals a difference in hip dislocation rate. METHODS Patients at a single practice site who received both THA and LSF between 2005 and 2015 (292: 158 = LSF prior to THA, 134 = THA prior to LSF) were retrospectively reviewed for incidents of THA instability. Those with complete radiograph series (89) had their sagittal (standing) spinopelvic profiles measured preoperatively, immediately postoperatively, and 3 months, 6 months, 1 year, 1.5 years, and 2 years postoperatively. Measured parameters included lumbar lordosis (LL), pelvic incidence (PI), PT, and sacral slope (SS). RESULTS No significant differences in dislocation rates between operative order groups were elicited (7/73 LSF first, 4/62 THA first; Z = 0.664, P = .509). Compared to nondislocators, dislocators had lower LL (-10.9) and SS (-7.8), and higher PT (+4.3) and PI-LL (+7.3). Additional risk factors for dislocation included sacral fusion (relative risk [RR] = 3.0) and revision fusion (RR = 2.7) . Predictive power of the model generated through multiple regression to characterize individual profiles of post-LSF PT compensation based on perioperative measurements was most significant at 1 year (R2 = 0.565, F = 0.000456, P = .028) and 2 years (R2 = 0.741, F = 0.031, P = .001) postoperatively. CONCLUSION In performing THA after LSF, it is theoretically ideal to proceed with THA at a postfusion interval of at least 1 year, beyond which further compensatory PT change is minimal. However, the order of surgical procedure revealed no statistical difference in hip instability rates. In cases characterized by large PI-LL mismatch (larger or less predictable compensation profiles) or large SS or LL loss (considerably atypical muscle recruitment), consideration of full functional anteversion range between sitting and standing positions to account for abnormalities not appreciated with standing radiographic assessment alone may be warranted.
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Does Acetabular Coverage Vary Between the Supine and Standing Positions in Patients with Hip Dysplasia? Clin Orthop Relat Res 2019; 477:2455-2466. [PMID: 31389893 PMCID: PMC6903855 DOI: 10.1097/corr.0000000000000898] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although variation in physiologic pelvic tilt may affect acetabular version and coverage, postural change in pelvic tilt in patients with hip dysplasia who are candidates for hip preservation surgery has not been well characterized, and its clinical importance is unknown. QUESTIONS/PURPOSES The aim of this study was to determine (1) postural changes in sagittal pelvic tilt between the supine and standing positions; (2) postural changes in the acetabular orientation and coverage of the femoral head between the supine and standing positions; and (3) patient demographic and morphologic factors associated with sagittal pelvic tilt. METHODS Between 2009 and 2016, 102 patients underwent pelvic osteotomy to treat hip dysplasia. All patients had supine and standing AP pelvic radiographs and pelvic CT images taken during their preoperative examination. Ninety-five patients with hip dysplasia (lateral center-edge angle < 20°) younger than 60 years old were included. Patients with advanced osteoarthritis, other hip disease, prior hip or spine surgery, femoral head deformity, or inadequate imaging were excluded. Sixty-five patients (64%) were eligible for participation in this retrospective study. Two board-certified orthopaedic surgeons (TT and MF) investigated sagittal pelvic tilt, spinopelvic parameters, and acetabular version and coverage using pelvic radiographs and CT images. Intra- and interobserver reliabilities, evaluated using the intraclass correlation coefficient (0.90 to 0.98, 0.93 to 0.99, and 0.87 to 0.96, respectively), were excellent. Demographic data (age, gender, and BMI) were collected by medical record review. Sagittal pelvic tilt was quantified as the angle formed by the anterior pelvic plane and a z-axis (anterior pelvic plane angle). Using a 2D-3D matching technique, we measured the change in sagittal pelvic tilt, acetabular version, and three-dimensional coverage between the supine and standing positions. We correlated sagittal pelvic tilt with demographic and CT measurement parameters using Pearson's or Spearman's correlation coefficients. RESULTS Although functional pelvic tilt varied widely among individuals, the pelvis of patients with hip dysplasia tilted posteriorly from the supine to the standing position (mean APP angle 8° ± 6° versus 2° ± 7°; mean difference -6°; 95% CI, -7° to -5°; range -17° to 4.1°; p < 0.001; paired t-test).The pelvis tilted more than 5° posteriorly from the supine to the standing position in 39 patients (60%), and the change was greater than 10° in 12 (18%). In the latter subgroup of patients, the mean acetabular anteversion angle increased (22° ± 5° versus 27° ±5°; mean difference 5°; 95% CI, 4°-6°; p < 0.001) and the mean anterosuperior acetabular sector angle notably deceased from the supine to the standing position (91° ± 11° versus 77° ± 14°; mean difference -14°; 95% CI, -17° to -11°; p < 0.001; paired t-test). Postural change in pelvic tilt was not associated with any of the studied demographic or morphologic parameters, including patient age, gender, BMI, and acetabular version and coverage. CONCLUSIONS On average, the pelvis tilted posteriorly from the supine to the standing position in patients with hip dysplasia, resulting in increased acetabular version and decreased anterosuperior acetabular coverage in the standing position. Thus, assessment with a supine AP pelvic radiograph may overlook changes in acetabular version and coverage in weightbearing positions. We recommend assessing postural change in sagittal pelvic tilt when diagnosing hip dysplasia and planning hip preservation surgery. Further studies are needed to determine how postural changes in sagittal pelvic tilt affect the biomechanical environment of the hip and the clinical results of acetabular reorientation osteotomy. LEVEL OF EVIDENCE Level IV, diagnostic study.
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Rueckl K, Alcaide DJ, Springer B, Rueckl S, Kasparek MF, Boettner F. Intraoperative measurement of cup inclination using fluoroscopy requires a correction factor. Arch Orthop Trauma Surg 2019; 139:1511-1517. [PMID: 30937525 DOI: 10.1007/s00402-019-03168-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Malpositioning of the cup in total hip arthroplasty (THA) is associated with dislocation, early polyethylene wear, and impingement. The direct anterior approach (DAA) THA allows for intraoperative fluoroscopy imaging (IF). The current study investigates the following research hypotheses: (1) intraoperative measurements of radiographic cup inclination (RI) are reliable and reproducible. (2) A correction factor can compensate for the complex parallax effects when using IF. METHODS In 2016, 100 consecutive hips underwent primary THA utilizing DAA and IF for cup placement. RI was measured on intraoperative fluoroscopy images and postoperative AP pelvis radiographs. RESULTS Determination of RI on IF images is reliable and reproducible (ICC 0.851-0.950). RI measurement on IF images had a good correlation with the corresponding postoperative RI on AP pelvis radiographs (r = 0.538, p < 0.001). However, intraoperative RI measurements are on average 4.9° lower compared to postoperative measurements (SD 2.5°). CONCLUSION Intraoperative fluoroscopy is a reliable tool to measure RI during DAA THA. The surgeon needs to apply a 5°. correction factor to the intraoperative measurements to adjust for parallax.
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Affiliation(s)
- Kilian Rueckl
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Diego J Alcaide
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Bernhard Springer
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Stefan Rueckl
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Maximilian F Kasparek
- Department of Orthopaedics and Trauma Surgery, Vienna General Hospital, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Friedrich Boettner
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA.
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Onggo JR, Nambiar M, Onggo JD, Phan K, Ambikaipalan A, Babazadeh S, Hau R. Clinical outcomes and complication profile of total hip arthroplasty after lumbar spine fusion: a meta-analysis and systematic review. 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 2019; 29:282-294. [PMID: 31676947 DOI: 10.1007/s00586-019-06201-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 09/20/2019] [Accepted: 10/24/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Hip and spine pathology can alter the biomechanics of spino-pelvic mobility. Lumbar spine fusions can reduce the mobility of the lumbar spine and therefore result in compensatory femoral motion, contributing towards dislocations of THA. PURPOSE This meta-analysis aims to determine the effect of pre-existing spine fusions on THA outcomes, and complication profile including hip dislocations, all-cause revisions and all complications. METHODS A multi-database search was performed according to PRISMA guidelines. All studies that compared patients who underwent THA with and without prior SF were included in the analysis. RESULTS Ten studies were included in this review, consisting of 28,396 SF THA patients and 1,550,291 non-SF THA patients. There were statistically significant higher rates of hip dislocation (OR 2.20, 95% CI 1.71-2.85, p < 0.001), all-cause revision (OR 3.43, 95% CI 1.96-6.00, p < 0.001) and all complications (OR 2.83, 95% CI 1.28-6.24, p = 0.01) in SF than in non-SF THA patients. When registry data were excluded, these rates were approximately doubled. Subgroup analysis of revisions for dislocations was not statistically significant (OR 5.28, 95% CI 0.76-36.87, p = 0.09). While no meta-analysis was performed on clinical outcomes due to heterogeneous parameter reporting, individual studies reported significantly poorer outcomes in SF patients than in non-SF patients. CONCLUSION THA patients with SF are at higher risks of hip dislocations, all-cause revisions and all complications, which may adversely affect patient-reported outcomes. Surgeons should be aware of these risks and appropriately plan to account for altered spino-pelvic biomechanics, in order to reduce the risks of hip dislocations and other complications. LEVEL OF EVIDENCE II (Meta-analysis of non-homogeneous studies). These slides can be retrieved under Electronic Supplementary Material.
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Affiliation(s)
| | - Mithun Nambiar
- Department of Orthopaedic Surgery, Box Hill Hospital, Box Hill, VIC, Australia.,Department of Surgery, The University of Melbourne, Parkville, VIC, Australia
| | - Jason Derry Onggo
- Department of Orthopaedic Surgery, Box Hill Hospital, Box Hill, VIC, Australia.,School of Medicine, Flinders University, Adelaide, SA, Australia
| | - Kevin Phan
- NeuroSpine Research Group, Sydney, NSW, Australia
| | | | - Sina Babazadeh
- Department of Orthopaedic Surgery, Box Hill Hospital, Box Hill, VIC, Australia.,Department of Orthopaedic Surgery, St Vincent's Hospital, East Melbourne, VIC, Australia
| | - Raphael Hau
- Department of Orthopaedic Surgery, Box Hill Hospital, Box Hill, VIC, Australia.,Epworth Eastern Hospital, Box Hill, VIC, Australia
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Murphy MP, Killen CJ, Ralles SJ, Brown NM, Hopkinson WJ, Wu K. A precise method for determining acetabular component anteversion after total hip arthroplasty. Bone Joint J 2019; 101-B:1042-1049. [PMID: 31474147 DOI: 10.1302/0301-620x.101b9.bjj-2019-0085.r1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Several radiological methods of measuring anteversion of the acetabular component after total hip arthroplasty (THA) have been described. These are limited by low reproducibility, are less accurate than CT 3D reconstruction, and are cumbersome to use. These methods also partly rely on the identification of obscured radiological borders of the component. We propose two novel methods, the Area and Orthogonal methods, which have been designed to maximize use of readily identifiable points while maintaining the same trigonometric principles. PATIENTS AND METHODS A retrospective study of plain radiographs was conducted on 160 hips of 141 patients who had undergone primary THA. We compared the reliability and accuracy of the Area and Orthogonal methods with two of the current leading methods: those of Widmer and Lewinnek, respectively. RESULTS The 160 anteroposterior pelvis films revealed that the proposed Area method was statistically different from those described by Widmer and Lewinnek (p < 0.001 and p = 0.004, respectively). They gave the highest inter- and intraobserver reliability (0.992 and 0.998, respectively), and took less time (27.50 seconds (sd 3.19); p < 0.001) to complete. In addition, 21 available CT 3D reconstructions revealed the Area method achieved the highest Pearson's correlation coefficient (r = 0.956; p < 0.001) and least statistical difference (p = 0.704) from CT with a mean within 1° of CT-3D reconstruction between ranges of 1° to 30° of measured radiological anteversion. CONCLUSION Our results support the proposed Area method to be the most reliable, accurate, and speedy. They did not support any statistical superiority of the proposed Orthogonal method to that of the Widmer or Lewinnek method. Cite this article: Bone Joint J 2019;101-B:1042-1049.
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Affiliation(s)
- Michael P Murphy
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, Illinois, USA
| | - Cameron J Killen
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, Illinois, USA
| | - Steven J Ralles
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, Illinois, USA
| | - Nicholas M Brown
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, Illinois, USA
| | - William J Hopkinson
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, Illinois, USA
| | - Karen Wu
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, Illinois, USA
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Zhao JX, Su XY, Zhao Z, Xiao RX, Sun GF, Zhang LC, Tang PF. The synergetic effect of pelvic rotation and X-ray offset on radiographic angles of the acetabular cup. Med Biol Eng Comput 2019; 57:2359-2371. [PMID: 31502181 DOI: 10.1007/s11517-019-02041-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 08/24/2019] [Indexed: 01/08/2023]
Abstract
The objective of this study is to investigate the synergetic effect of the pelvic rotation and X-ray offset on the radiographic anteversion/inclination (RA/RI) angles of the acetabular cup using a mathematical model. A cone model for establishing the spatial relationship between a three-dimensional (3D) circle and its two-dimensional (2D) elliptical projection is utilized to quantify the relationship between the 3D RA/RI angles of the cup and their 2D counterparts with different types of pelvic rotations in pelvic/hip anteroposterior radiographs. The results reveal that the effect of inlet/outlet views on the 2D RA angle is similar to that of iliac/obturator views. The permissible ranges of pelvic rotation for the 2D RA angle with an acceptable bias are the 3D space formed by the limits of triple axial rotations. For a specified acceptable bias of the 2D RA angle, these ranges are almost equal between pelvic and hip radiographs. The combined inlet/obturator or outlet/iliac views can maintain the 2D RA angle of a pelvic radiograph within the same range of acceptable bias as that of a hip radiograph. For a 2D RA angle with an acceptable bias, the permissible range of pelvic rotation needs to be evaluated with equal attention in both radiographs. Graphical abstract The traditional methods for calculating the radiographic angles of the acetabular cup are based on the ellipse projection of the opening circle of the cup on radiographs. However, with varying locations of the X-ray source and pelvis rotations about different axes, the outline of this ellipse projection will change, and accordingly, the traditional method and calculating results will be inaccurate. In this study, a cone model for three-dimensional circle-to-two-dimensional ellipse projection is utilized to incorporate the effect of X-ray offset and quantify the relationships of the radiographic angles of the cup with the true orientation of the cup and pelvic rotations in either pelvic or hip anteroposterior radiographic situation.
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Affiliation(s)
- Jing-Xin Zhao
- Department of Orthopaedics, Chinese PLA General Hospital, Beijing, 100853, China
| | - Xiu-Yun Su
- Department of Orthopaedics, Chinese PLA General Hospital, Beijing, 100853, China
| | - Zhe Zhao
- Department of Orthopaedics, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, 102218, China
| | - Ruo-Xiu Xiao
- School of Computer and Communication Engineering, University of Science and Technology Beijing, Beijing, 100083, China
| | - Guo-Fei Sun
- Department of Orthopaedics, Chinese PLA General Hospital, Beijing, 100853, China
| | - Li-Cheng Zhang
- Department of Orthopaedics, Chinese PLA General Hospital, Beijing, 100853, China.
| | - Pei-Fu Tang
- Department of Orthopaedics, Chinese PLA General Hospital, Beijing, 100853, China.
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Vigdorchik J, Eftekhary N, Elbuluk A, Abdel MP, Buckland AJ, Schwarzkopf RS, Jerabek SA, Mayman DJ. Evaluation of the spine is critical in the workup of recurrent instability after total hip arthroplasty. Bone Joint J 2019; 101-B:817-823. [PMID: 31256675 DOI: 10.1302/0301-620x.101b7.bjj-2018-1502.r1] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS While previously underappreciated, factors related to the spine contribute substantially to the risk of dislocation following total hip arthroplasty (THA). These factors must be taken into consideration during preoperative planning for revision THA due to recurrent instability. We developed a protocol to assess the functional position of the spine, the significance of these findings, and how to address different pathologies at the time of revision THA. PATIENTS AND METHODS Prospectively collected data on 111 patients undergoing revision THA for recurrent instability from January 2014 to January 2017 at two institutions were included (protocol group) and matched 1:1 to 111 revisions specifically performed for instability not using this protocol (control group). Mean follow-up was 2.8 years. Protocol patients underwent standardized preoperative imaging including supine and standing anteroposterior (AP) pelvis and lateral radiographs. Each case was scored according to the Hip-Spine Classification in Revision THA. RESULTS Survival free of dislocation at two years was 97% in the protocol group (three dislocations, all within three months of surgery) versus 84% in the control group (18 patients). Furthermore, 77% of the inappropriately positioned acetabular components would have been unrecognized by supine AP pelvis imaging alone. CONCLUSION Using the Hip-Spine Classification System in revision THA, we demonstrated a significant decrease in the risk of recurrent instability compared with a control group. Without the use of this algorithm, 77% of inappropriately positioned acetabular components would have been unrecognized and incorrect treatment may have been instituted. Cite this article: Bone Joint J 2019;101-B:817-823.
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Affiliation(s)
- J Vigdorchik
- Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York, USA
| | - N Eftekhary
- NYU Langone Orthopaedic Hospital, New York, New York, USA
| | - A Elbuluk
- Hospital for Special Surgery, New York, New York, USA
| | - M P Abdel
- Mayo Clinic, Rochester, Minnesota, USA
| | - A J Buckland
- NYU Langone Orthopaedic Hospital, New York, New York, USA
| | | | - S A Jerabek
- Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York, USA
| | - D J Mayman
- Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York, USA
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131
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Eftekhary N, Shimmin A, Lazennec JY, Buckland A, Schwarzkopf R, Dorr LD, Mayman D, Padgett D, Vigdorchik J. A systematic approach to the hip-spine relationship and its applications to total hip arthroplasty. Bone Joint J 2019; 101-B:808-816. [DOI: 10.1302/0301-620x.101b7.bjj-2018-1188.r1] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
There remains confusion in the literature with regard to the spinopelvic relationship, and its contribution to ideal acetabular component position. Critical assessment of the literature has been limited by use of conflicting terminology and definitions of new concepts that further confuse the topic. In 2017, the concept of a Hip-Spine Workgroup was created with the first meeting held at the American Academy of Orthopedic Surgeons Annual Meeting in 2018. The goal of this workgroup was to first help standardize terminology across the literature so that as a topic, multiple groups could produce literature that is immediately understandable and applicable. This consensus review from the Hip-Spine Workgroup aims to simplify the spinopelvic relationship, offer hip surgeons a concise summary of available literature, and select common terminology approved by both hip surgeons and spine surgeons for future research. Cite this article: Bone Joint J 2019;101-B:808–816.
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Affiliation(s)
- N. Eftekhary
- Division of Adult Reconstructive Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, New York, USA
| | - A. Shimmin
- Melbourne Orthopaedic Group, Windsor, Australia
| | - J. Y. Lazennec
- Pitié-Salpêtrière Hospital, Pierre-and-Marie-Curie University, Paris, France
| | - A. Buckland
- Division of Adult Reconstructive Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, New York, USA
| | - R. Schwarzkopf
- Division of Adult Reconstructive Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, New York, USA
| | - L. D. Dorr
- Keck Medical Center of USC, Los Angeles, California, USA
| | - D. Mayman
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York, USA
| | - D. Padgett
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York, USA
| | - J. Vigdorchik
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York, USA
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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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Kanto M, Maruo K, Tachibana T, Fukunishi S, Nishio S, Takeda Y, Arizumi F, Kusuyama K, Kishima K, Yoshiya S. Influence of Spinopelvic Alignment on Pelvic Tilt after Total Hip Arthroplasty. Orthop Surg 2019; 11:438-442. [PMID: 31148364 PMCID: PMC6595105 DOI: 10.1111/os.12469] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 04/14/2018] [Accepted: 05/07/2018] [Indexed: 11/29/2022] Open
Abstract
Objective To evaluate the impact of spinopelvic parameters and hip contracture on change in the pelvic tilt (PT) after Total hip arthroplasty (THA). Methods One hundred patients (15 male and 85 female) who underwent THA were included in this prospective study. Radiographic data were obtained preoperatively and 1 year after THA. Radiographic parameters included sagittal anterior pelvic plane (APP), sagittal vertical axis (SVA), sacral slope (SS), pelvic inclination (PI), and lumbar lordosis angle (LL). The APP was defined as the angle between the anterior pelvic plane and the vertical plane. A positive value indicates pelvic retroversion. Postoperative changes in PT were divided into three groups: the PA group (pelvic anteversion, ΔAPP < −5°), the PR group (pelvic retroversion, ΔAPP > 5°), and the PT group (minimal change, ΔAPP ≤ ± 5°). The Kruskal–Wallis test and the Steel–Dwass test were used to compare the preoperative and postoperative spinopelvic parameters among the three groups. The Spearman's rank correlation coefficient was used to evaluate the correlation between ΔAPP and spinopelvic parameters. Results Minimal change in pelvic tilt was observed in 59% of patients, while pelvic anteversion was observed in 16% of patients and pelvic retroversion was observed in 25% of patients. There were no significant changes in the spinopelvic parameters, including TK, LL, SVA, LL, SS, and APP after THA. The Femoral angle (FA) was significantly decreased after THA (P < 0.001). Preoperative APP was significantly more retroverted in the PA group than the PR group, and the PT group (6.8 ± 12.2, 0.2 ± 9.9, −8.3 ± 8.3, P < 0.001). Preoperative SS, PI‐LL, and PI were significantly smaller in the PA group than the PT group and the PR group. A significant negative correlation was identified between preoperative APP and ΔAPP (r = −0.418, P < 0.001). Conclusion Approximately 60% of the patients did not have any marked change in PT after THA. Preoperative APP was the only predictive factor associated with marked anterior or posterior change in PT.
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Affiliation(s)
- Makoto Kanto
- Department of Orthopaedic Surgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Keishi Maruo
- Department of Orthopaedic Surgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Toshiya Tachibana
- Department of Orthopaedic Surgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Shigeo Fukunishi
- Department of Orthopaedic Surgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Shoji Nishio
- Department of Orthopaedic Surgery, Takarazuka City Hospital, Japan
| | - Yu Takeda
- Department of Orthopaedic Surgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Fumihiro Arizumi
- Department of Orthopaedic Surgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Kazuki Kusuyama
- Department of Orthopaedic Surgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Kazuya Kishima
- Department of Orthopaedic Surgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Shinichi Yoshiya
- Department of Orthopaedic Surgery, Hyogo College of Medicine, Nishinomiya, Japan
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Higuera Rueda CA, Ferguson DF, Scholl L, Klika AK. Influence of Acetabular Shell Position and Component Design on Hip Dynamic Dislocation. J Arthroplasty 2019; 34:766-771. [PMID: 30639282 DOI: 10.1016/j.arth.2018.12.012] [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: 11/27/2017] [Revised: 12/06/2018] [Accepted: 12/10/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Dislocation is a major complication following total hip arthroplasty, with risk factors such as surgical technique, implant positioning, and implant design. Literature has suggested the distance the femoral head must travel before dislocation to be a predictive factor of dislocation where smaller travel distance has increased dislocation risk. The purpose of this study was to compare 3 designs (hemispherical, metal-on-metal, and dual mobility [DM]) in terms of the dynamic dislocation distance and force required to dislocate. METHODS This dynamic dislocation distance model used a material testing system that defined acetabular component inclination (30°, 45°, and 60°), anteversion angles (0°, 15°, and 30°), and pelvic tilt (5° [standing] and 26° [chair rise]). Testing groups included a hemispherical shell with a modular polyethylene liner and 32-mm head, a metal-on-metal hip resurfacing cup design with a 40-mm CoCr head, and a DM design with a 42-mm outside diameter articulating liner and an inner 28-mm articulating head. RESULTS The dynamic dislocation distance of the DM hip was greater than that of the other designs for all inclination, anteversion, and pelvic tilt angles tested with the exception of 60° inclination/0° anteversion. At 26° pelvic tilt, it was observed that dislocation distance increased with greater anteversion and decreased with larger inclination. CONCLUSION Clinical results have shown the DM design may reduce dislocation. These data support those findings and suggest that if instability is a concern preoperatively or intraoperatively, using a DM implant increases the dynamic dislocation distance.
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Affiliation(s)
| | - David F Ferguson
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | | | - Alison K Klika
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
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2018 Frank Stinchfield Award: Spinopelvic Hypermobility Is Associated With an Inferior Outcome After THA: Examining the Effect of Spinal Arthrodesis. Clin Orthop Relat Res 2019; 477:310-321. [PMID: 30300162 PMCID: PMC6370094 DOI: 10.1097/corr.0000000000000367] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Many patients undergo both THA and spinal arthrodesis, and those patients may not fare as well as those who undergo one procedure but not the other. The mechanisms of how spinal arthrodesis affects patient function after THA remain unclear. QUESTIONS/PURPOSES The aims of our study were to (1) determine how patient-reported outcome measures (PROMs), including the Oxford hip score as well as dislocations and complications compare after THA between patients with and without spinal arthrodesis; (2) characterize sagittal pelvic changes in these patients that occur when moving between different functional positions and test for differences between patients with and without spinal arthrodesis; and (3) assess whether differences in sagittal pelvic dynamics are associated with PROMs, complications, and dislocations after THA. METHODS In this case-control study, we identified 42 patients (60 hips) who had undergone both THA and spinal arthrodesis between 2002 and 2016 and who were available for followup at a minimum of 12 months (mean, 6 ± 5 years) after the later of the two procedures. These cases were case-control-matched for age, gender, and body mass index with 42 patients (60 hips) who underwent only THA and had no known spinal pathology. All patients completed PROMs, including the Oxford hip score, and underwent four radiographs of the pelvis and spinopelvic complex in three positions (supine, standing, and deep-seated). Cup orientation and various spinopelvic parameters, including pelvic tilt and pelvic-femoral angle, were measured. The difference in pelvic tilt between standing and seated allowed for patient classification based on spinopelvic mobility into normal (± 10°-30°), stiff (< ± 10°) or hypermobile (> ± 30°) groups. RESULTS Compared with the THA-only group, the THA-spinal arthrodesis group had inferior PROMs (Oxford hip score, 33 ± 10 versus 43 ± 6; p < 0.001) and more surgery-related complications (such as dislocation, loosening, periprosthetic fracture or infection, psoas irritation) (12 versus 3; p = 0.013), especially dislocation (5 versus 0; p = 0.023). We detected no difference in change of pelvic tilt between supine and standing positions between the groups. When standing, patients undergoing THA-spinal arthrodesis had greater pelvic tilt (25° ± 11° versus 17° ± 8°; p < 0.001) and the hip was more extended (193° ± 22° versus 185° ± 30°; p = 0.012). We found that patients undergoing THA-spinal arthrodesis were more likely to have spinopelvic hypermobility (12 of 42 versus three of 42; odds ratio, 5.2; p = 0.02) with anterior tilting of the pelvis. Of all biomechanical parameters, only spinopelvic hypermobility was associated with inferior PROMs (Oxford hip score, 35 ± 9 versus 40 ± 7 in normal mobility; p = 0.049) and was also present in dislocating hips that underwent revision despite acceptable cup orientation. CONCLUSIONS In patients with spinal arthrodesis who have undergone THA, spinopelvic hypermobility is associated with inferior outcomes, including hip instability. Spinopelvic hypermobility should be routinely assessed because these patients may have a narrow zone of optimum cup orientation that would require new technology to define and assist the surgeon in obtaining it.Level of Evidence Level III, therapeutic study.
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136
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Lee C, Jang J, Kim HW, Kim YS, Kim Y. Three-dimensional analysis of acetabular orientation using a semi-automated algorithm. Comput Assist Surg (Abingdon) 2019; 24:18-25. [DOI: 10.1080/24699322.2018.1545872] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Affiliation(s)
- Changhwan Lee
- Department of Biomedical Engineering, Hanyang University, Seoul, Korea
| | - Jongseong Jang
- Center for Integration of Advanced Medicine Life Science Innovative Technologies (CAMIT), Department of Advanced Medical Initiatives, Kyushu University, Fukuoka, Japan
| | - Hyung Wook Kim
- Institute of Innovative Surgical Technology, Hanyang University, Seoul, Korea
| | - Young Soo Kim
- Institute of Innovative Surgical Technology, Hanyang University, Seoul, Korea
| | - Yeesuk Kim
- Department of Orthopedic Surgery, Hanyang University, Seoul, Korea
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137
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Calculation of impingement-free combined cup and stem alignments based on the patient-specific pelvic tilt. J Biomech 2019; 82:193-203. [DOI: 10.1016/j.jbiomech.2018.10.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 10/18/2018] [Accepted: 10/20/2018] [Indexed: 11/30/2022]
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Snijders TE, Willemsen K, van Gaalen SM, Castelein RM, Weinans H, de Gast A. Lack of consensus on optimal acetabular cup orientation because of variation in assessment methods in total hip arthroplasty: a systematic review. Hip Int 2019; 29:41-50. [PMID: 29772949 DOI: 10.1177/1120700018759306] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION: Dislocation is 1 of the main reasons for revision of total hip arthroplasty but dislocation rates have not changed in the past decades, compromising patients' well-being. Acetabular cup orientation plays a key role in implant stability and has been widely studied. This article investigates whether there is a consensus on optimal cup orientation, which is necessary when using a navigation system. METHODS: A systematic search of the literature in the PubMed, Embase and Cochrane databases was performed (March 2017) to identify articles that investigated the direct relationship between cup orientation and dislocation, including a thorough evaluation of postoperative cup orientation assessment methods. RESULTS: 28 relevant articles evaluating a direct relation between dislocation and cup orientation could not come to a consensus. The key reason is a lack of uniformity in the assessment of cup orientation. Cup orientation is assessed with different imaging modalities, different methodologies, different definitions for inclination and anteversion, several reference planes and distinct patient positions. CONCLUSIONS: All available studies lack uniformity in cup orientation assessment; therefore it is impossible to reach consensus on optimal cup orientation. Using navigation systems for placement of the cup is inevitably flawed when using different definitions in the preoperative planning, peroperative placement and postoperative evaluation. Further methodological development is required to assess cup orientation. Consequently, the postoperative assessment should be uniform, thus differentiating between anterior and posterior dislocation, use the same definitions for inclination and anteversion with the same reference plane and with the patient in the same position.
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Affiliation(s)
- Thom E Snijders
- 1 Clinical Orthopedic Research Centre - mN, Zeist, Utrecht, The Netherlands
| | - Koen Willemsen
- 1 Clinical Orthopedic Research Centre - mN, Zeist, Utrecht, The Netherlands
| | | | - Rene M Castelein
- 2 Department of Orthopaedics, University Medical Centre Utrecht, Utrecht, The Netherlands.,3 Department of Rheumatology, University Medical Center Utrecht, Utrecht, The Netherlands.,4 Department of Biomechanical Engineering, Delft University of Technology, Delft, The Netherlands
| | - Harrie Weinans
- 2 Department of Orthopaedics, University Medical Centre Utrecht, Utrecht, The Netherlands.,3 Department of Rheumatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Arthur de Gast
- 1 Clinical Orthopedic Research Centre - mN, Zeist, Utrecht, The Netherlands
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139
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Tezuka T, Heckmann ND, Bodner RJ, Dorr LD. Functional Safe Zone Is Superior to the Lewinnek Safe Zone for Total Hip Arthroplasty: Why the Lewinnek Safe Zone Is Not Always Predictive of Stability. J Arthroplasty 2019; 34:3-8. [PMID: 30454867 DOI: 10.1016/j.arth.2018.10.034] [Citation(s) in RCA: 160] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 10/29/2018] [Accepted: 10/30/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The Lewinnek "safe zone" is not always predictive of stability after total hip arthroplasty (THA). Recent studies have focused on functional hip motion as observed on lateral spine-pelvis-hip x-rays. The purpose of this study was to assess the correlation between the Lewinnek safe zone and the functional safe zone based on hip and pelvic motion in the sagittal plane. METHODS Three hundred twenty hips (291 patients) underwent primary THA using computer navigation. Two hundred ninety-six of these hips (92.5%) were within the Lewinnek safe zone as determined by inclination of 40° ± 10° and anteversion of 15° ± 10°. All patients had preoperative and postoperative standing and sitting lateral spinopelvic x-rays. The combined sagittal index (CSI), a combination of sagittal acetabular and femoral position, was measured for each patient and used to assess the functional safe zone. Data analysis was performed to identify hips in the Lewinnek safe zone inside and outside the sagittal functional safe zone. Predictive factors for hips outside the functional safe zone were identified. RESULTS Of the 296 hips within the Lewinnek safe zone, 254 (85.8%) were also in the functional safe zone. Forty-two patients were outside the functional safe zone based on CSI; 19 had an increased standing CSI and 23 had a decreased sitting CSI, all were considered at risk for dislocation. Predictive factors for falling outside the functional safe zone were increased femoral mobility (P < .001, r = 0.632), decreased spinopelvic mobility (P < .001, r = 0.455), and pelvic incidence (P < .001, r = 0.400). CONCLUSION In this study, 14.2% of hips within the Lewinnek safe zone were outside the functional safe zone, identifying a potential reason hips dislocate despite having "normal" cup angles. The best predictor for falling outside the functional safe zone, both preoperatively and postoperatively, was femoral mobility, not the sagittal cup position (ie, cup anteinclination). LEVEL OF EVIDENCE Level III, retrospective review.
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Affiliation(s)
- Taro Tezuka
- Department of Orthopaedic Surgery, Yokohama City University, Yokohama, Japan
| | | | | | - Lawrence D Dorr
- Department of Orthopaedic Surgery, Keck Medical Center of USC, Los Angeles, CA
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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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Affiliation(s)
- M. J. Halawi
- University of Connecticut Health Center, Farmington, USA
| | - F. S. Haddad
- The Bone & Joint Journal, Professor of Orthopaedic Surgery, University College London Hospitals, The Princess Grace Hospital, and The NIHR Biomedical Research Centre at UCLH, London, UK
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Combining acetabular and femoral morphology improves our understanding of the down syndrome hip. Clin Biomech (Bristol, Avon) 2018; 58:96-102. [PMID: 30064043 DOI: 10.1016/j.clinbiomech.2018.07.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 07/18/2018] [Accepted: 07/23/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Hip instability is frequent in patients with Down syndrome. Recent studies have suggested that skeletal hip alterations are responsible for this instability; however, there are currently no studies simultaneously assessing femoral and acetabular anatomy in subjects with Down syndrome in the standing position. The aim was to analyze the three-dimensional anatomy of the Down syndrome hip in standing position. METHODS Down syndrome subjects were age and sex-matched to asymptomatic controls. All subjects underwent full body biplanar X-rays with three-dimensional reconstructions of their pelvises and lower limbs. Parameter means and distributions were compared between the two groups. FINDINGS Forty-one Down syndrome and 41 control subjects were recruited. Acetabular abduction (mean = 52° [SD = 9°] vs. mean = 56° [SD = 8°]) and anteversion (mean = 14° [SD = 8°] vs. mean = 17.5° [SD = 5°]) as well as posterior acetabular sector angle (mean = 91° [SD = 7°] vs. mean = 94° [SD = 7°]) were significantly lower in Down syndrome subjects compared to controls (P < 0.01). Anterior acetabular sector angle (mean = 62° [SD = 10°] vs. mean = 59° [SD = 7°]; P < 0.01) was significantly higher in Down syndrome compared to controls. The distributions of acetabular anteversion (P = 0.002;V = 0.325), femoral anteversion (P = 0.004;V = 0.309) and the instability index (P < 0.001;V = 0.383) were significantly different between the two groups, with subjects with Down syndrome having both increased anteversion and retroversion for each of these parameters. INTERPRETATION Subjects with Down syndrome were found to have a significantly altered and more heterogeneous anatomy of their proximal hips compared to controls. This heterogeneity suggests that treatment strategies of hip instability in Down syndrome should be subject-specific and should rely on the understanding of the underlying three-dimensional anatomy of each patient.
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143
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Snijders T, Schlösser T, van Gaalen S, Castelein R, Weinans H, de Gast A. Trigonometric Algorithm Defining the True Three-Dimensional Acetabular Cup Orientation: Correlation Between Measured and Calculated Cup Orientation Angles. JB JS Open Access 2018; 3:e0063. [PMID: 30533596 PMCID: PMC6242317 DOI: 10.2106/jbjs.oa.17.00063] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Acetabular cup orientation plays a key role in implant stability and the success of total hip arthroplasty. To date, the orientation has been measured with different imaging modalities and definitions, leading to lack of consensus on optimal cup placement. A 3-dimensional (3D) concept involving a trigonometric description enables unambiguous definitions. Our objective was to test the validity and reliability of a 3D trigonometric description of cup orientation. METHODS Computed tomographic scans of the pelvis, performed for vascular assessment of 20 patients with 22 primary total hip replacements in situ, were systematically collected. On multiplanar reconstructions, 3 observers independently measured cup orientation retrospectively in terms of coronal inclination, sagittal tilt, and transverse version. The angles measured in 2 planes were used to calculate the angle in the third plane via a trigonometric algorithm. For correlation and reliability analyses, intraobserver and interobserver differences between measured and calculated angles were evaluated with use of the intraclass correlation coefficient (ICC). RESULTS Measured and calculated angles had ICCs of 0.953 for coronal inclination, 0.985 for sagittal tilt, and 0.982 for transverse version. Intraobserver and interobserver reliability had ICCs of 0.987 and 0.987, respectively, for coronal inclination; 0.979 and 0.981, respectively, for sagittal tilt; and 0.992 and 0.978, respectively, for transverse version. CONCLUSIONS The 3D concept with its trigonometric algorithm is a valid and reliable tool for the measurement of cup orientation. CLINICAL RELEVANCE By calculating the transverse version of cups from coronal inclination and sagittal tilt measurements, the trigonometric algorithm enables a 3D definition of cup orientation, regardless of the imaging modality used. In addition, it introduces sagittal tilt that, like pelvic tilt, rotates around the transverse axis.
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Affiliation(s)
- T.E. Snijders
- Department of Orthopaedics, Clinical Orthopedic Research Center – mN, Diakonessenhuis Zeist, Zeist, the Netherlands
| | - T.P.C. Schlösser
- Department of Orthopaedics, Clinical Orthopedic Research Center – mN, Diakonessenhuis Zeist, Zeist, the Netherlands
- Department of Orthopaedics, UMC Utrecht, Utrecht, the Netherlands
| | - S.M. van Gaalen
- Department of Orthopaedics, Clinical Orthopedic Research Center – mN, Diakonessenhuis Zeist, Zeist, the Netherlands
| | - R.M. Castelein
- Department of Orthopaedics, UMC Utrecht, Utrecht, the Netherlands
| | - H. Weinans
- Department of Orthopaedics, UMC Utrecht, Utrecht, the Netherlands
- Department of Biomechanical Engineering, TU Delft, Delft, the Netherlands
| | - A. de Gast
- Department of Orthopaedics, Clinical Orthopedic Research Center – mN, Diakonessenhuis Zeist, Zeist, the Netherlands
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Alzyoud K, Hogg P, Snaith B, Flintham K, England A. Optimum Positioning for Anteroposterior Pelvis Radiography: A Literature Review. J Med Imaging Radiat Sci 2018; 49:316-324.e3. [DOI: 10.1016/j.jmir.2018.04.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 04/06/2018] [Accepted: 04/09/2018] [Indexed: 12/23/2022]
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Schwarz T, Benditz A, Springorum HR, Matussek J, Heers G, Weber M, Renkawitz T, Grifka J, Craiovan B. Assessment of pelvic tilt in anteroposterior radiographs by means of tilt ratios. Arch Orthop Trauma Surg 2018; 138:1045-1052. [PMID: 29651575 DOI: 10.1007/s00402-018-2931-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Indexed: 11/24/2022]
Abstract
INTRODUCTION In anteposterior (AP) radiographs, cup position in total hip arthroplasty and acetabular anatomy in hip-preserving surgery are highly influenced by pelvic tilt. The sagittal rotation of the anterior pelvic plane is an important measurement of pelvic tilt during hip surgery. Thus, correct evaluation of cup position and acetabular parameters requires the assessment of pelvic tilt in AP radiographs. METHODS Changes in pelvic tilt inversely change the height of the lesser pelvis and the obturator foramen in AP radiographs. Tilt ratios were calculated by means of these two parameters in simulated radiographs for ten male and ten female pelvises in defined tilt positions. A tilt formula obtained by exponential regression analysis was evaluated by two blinded investigators by means of 14 simulated AP radiographs of the pelvis with pelvic tilts ranging from + 15° to - 15°. RESULTS No differences were found between male and female tilt ratios for each 5° step of simulated pelvic tilt. Pelvic tilt and tilt ratios correlated exponentially. Using the tilt formula, the two blinded investigators were able to assess pelvic tilt with high conformity, a mean relative error of + 0.4° (SD ± 4.6°), and a mean absolute error of 3.9° (SD ± 2.3°). Neutral pelvic tilt is indicated by a tilt ratio of 0.5 when the height of the lesser pelvis is twice the height of the obturator foramen. CONCLUSION The analysis and interpretation of cup position and acetabular parameters may be improved by our method for assessing pelvic tilt in AP radiographs.
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Affiliation(s)
- T Schwarz
- Department of Orthopedic Surgery, University Medical Center Regensburg, Kaiser-Karl-V.-Allee 3, 93077, Bad Abbach, Germany.
| | - A Benditz
- Department of Orthopedic Surgery, University Medical Center Regensburg, Kaiser-Karl-V.-Allee 3, 93077, Bad Abbach, Germany
| | - H-R Springorum
- Department of Orthopedic Surgery, University Medical Center Regensburg, Kaiser-Karl-V.-Allee 3, 93077, Bad Abbach, Germany
| | - J Matussek
- Department of Orthopedic Surgery, University Medical Center Regensburg, Kaiser-Karl-V.-Allee 3, 93077, Bad Abbach, Germany
| | - G Heers
- Department of Orthopedic Surgery, University Medical Center Regensburg, Kaiser-Karl-V.-Allee 3, 93077, Bad Abbach, Germany
| | - M Weber
- Department of Orthopedic Surgery, University Medical Center Regensburg, Kaiser-Karl-V.-Allee 3, 93077, Bad Abbach, Germany
| | - T Renkawitz
- Department of Orthopedic Surgery, University Medical Center Regensburg, Kaiser-Karl-V.-Allee 3, 93077, Bad Abbach, Germany
| | - J Grifka
- Department of Orthopedic Surgery, University Medical Center Regensburg, Kaiser-Karl-V.-Allee 3, 93077, Bad Abbach, Germany
| | - B Craiovan
- Department of Orthopedic Surgery, University Medical Center Regensburg, Kaiser-Karl-V.-Allee 3, 93077, Bad Abbach, Germany
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Predictability of Pelvic Tilt During Total Hip Arthroplasty Using a Traction Table. J Arthroplasty 2018; 33:2556-2559. [PMID: 29656970 DOI: 10.1016/j.arth.2018.03.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 02/23/2018] [Accepted: 03/05/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Pelvic positioning during total hip arthroplasty (THA) affects functional position of the acetabular component. We sought to evaluate whether preoperative pelvic tilt correlated with intraoperative pelvic tilt while positioned on a traction table for direct anterior THA and furthermore to evaluate whether there was a consistent and predictable effect on pelvic tilt while positioned for surgery. METHODS We evaluated the sagittal spinopelvic preoperative standing and supine pelvic tilt radiographic measurements as compared with intraoperative measurements of 25 patients. Changes in pelvic tilt were analyzed for statistical significance and interobserver reliability. RESULTS The mean standing pelvic tilt was 13.5° ± 5.7°. The mean supine pelvic tilt was 13.3° ± 6.1°. There was no statistically significant difference between standing and supine pelvic tilt (P = .866). The mean intraoperative pelvic tilt was 3.0° ± 6.2°. There was a statistically significant decrease in pelvic tilt between both standing to intraoperative comparison and supine to intraoperative comparison (P < .0001 for both). Difference in mean between these comparisons was 10.5° ± 4.6° (95% confidence interval, 8.7°-12.3°) and 10.3° ± 6.3° (95% confidence interval, 7.8°-12.8°), respectively. CONCLUSION Patient positioning on a traction table for direct anterior THA has a reliable effect on pelvic tilt in the magnitude of approximately 10° decreased pelvic tilt. This effect on pelvic tilt correlates to approximately 7.4° and 3° altered anteversion and inclination, respectively. Taking into account this change in pelvic tilt at the time of surgery will allow the hip arthroplasty surgeon to more accurately place acetabular components in the desired functional position.
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Langston J, Pierrepont J, Gu Y, Shimmin A. Risk factors for increased sagittal pelvic motion causing unfavourable orientation of the acetabular component in patients undergoing total hip arthroplasty. Bone Joint J 2018; 100-B:845-852. [DOI: 10.1302/0301-620x.100b7.bjj-2017-1599.r1] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims It is important to consider sagittal pelvic rotation when introducing the acetabular component at total hip arthroplasty (THA). The purpose of this study was to identify patients who are at risk of unfavourable pelvic mobility, which could result in poor outcomes after THA. Patients and Methods A consecutive series of 4042 patients undergoing THA had lateral functional radiographs and a low-dose CT scan to measure supine pelvic tilt, pelvic incidence, standing pelvic tilt, flexed-seated pelvic tilt, standing lumbar lordotic angle, flexed-seated lumbar lordotic angle, and lumbar flexion. Changes in pelvic tilt from supine-to-standing positions and supine-to-flexed-seated positions were determined. A change in pelvic tilt of 13° between positions was deemed unfavourable as it alters functional anteversion by 10° and effectively places the acetabular component outside the safe zone of orientation. Results For both men and women, the degree of lumbar flexion was a significant predictor of risk in hip flexion (p < 0.0001) with increased odds of unfavourable pelvic mobility in those with lumbar flexion of < 20° (men, odds ratio (OR) 6.74, 95% confidence interval (CI) 3.83 to 11.89; women, OR 2.97, 95% CI 1.87 to 4.71). In women, age and standing pelvic tilt were significant predictors of risk in hip extension (p = 0.0082 and p < 0.0001, respectively). The risk of unfavourable pelvic mobility was higher in those aged > 75 years (OR 2.28, 95% CI 1.56 to 3.32) and those with standing pelvic tilt of < -10° for extension risk (OR 7.10, 95% CI 4.10 to 10.29). In men, only standing pelvic tilt was significant (p < 0.0001) for hip extension with an increased risk of unfavourable pelvic mobility (OR 8.68, 95% CI 5.19 to 14.51). Conclusion Patients found to have unfavourable pelvic mobility had limited lumbar flexion and more posterior standing pelvic tilt in both men and women, as well as increasing age in women. We recommend that patients undergo preoperative functional radiographic screening to determine specific parameters that can affect the functional orientation of the acetabular component. Cite this article: Bone Joint J 2018;100-B:845–52.
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Affiliation(s)
- J. Langston
- Melbourne Orthopedic Group, Windsor, Australia
| | | | - Y. Gu
- Corin Group, Pymble, Australia
| | - A. Shimmin
- Monash University, Windsor, Australia
and Consultant Orthopedic Surgeon, Melbourne
Orthopedic Group, Windsor, Australia
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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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Jang ES, Lin JD, Shah RP, Geller JA, Cooper HJ. The effect of c-arm tilt on accuracy of intraoperative fluoroscopy in assessing acetabular component position during direct anterior approach for hip arthroplasty. J Orthop 2018; 15:447-449. [PMID: 29881174 DOI: 10.1016/j.jor.2018.03.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 03/25/2018] [Indexed: 10/17/2022] Open
Abstract
Intraoperative fluoroscopy can improve the precision of acetabular component positioning during direct anterior hip arthroplasty. However, changes in pelvic tilt with c-arm positioning may compromise accuracy. A geometric model of an acetabular component's projection onto fluoroscopy images was created and manipulated to simulate c-arm tilt. An apparently ideally-placed cup will have its effective anteversion changed by 7.5° with just 10° of caudal/cephalad tilt of the c-arm. This effect is greater in cups that are more horizontally placed or less anteverted. Accurate c-arm positioning is crucial, as small errors in tilt can have considerable effects on final cup position.
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Affiliation(s)
- Eugene S Jang
- Department of Orthopaedic Surgery, Columbia University Medical Center, 622 West 168th Street, New York, NY 10032, United States
| | - James D Lin
- Department of Orthopaedic Surgery, Columbia University Medical Center, 622 West 168th Street, New York, NY 10032, United States
| | - Roshan P Shah
- Department of Orthopaedic Surgery, Columbia University Medical Center, 622 West 168th Street, New York, NY 10032, United States
| | - Jeffrey A Geller
- Department of Orthopaedic Surgery, Columbia University Medical Center, 622 West 168th Street, New York, NY 10032, United States
| | - H John Cooper
- Department of Orthopaedic Surgery, Columbia University Medical Center, 622 West 168th Street, New York, NY 10032, United States
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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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