151
|
Effect of Pelvic Tilt and Rotation on Cup Orientation in Both Supine and Standing Positions. J Arthroplasty 2018; 33:1442-1448. [PMID: 29276116 DOI: 10.1016/j.arth.2017.11.069] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 11/15/2017] [Accepted: 11/30/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The purpose of this study is to analyze the effect of pelvic tilt and rotation on radiographic measurement of cup orientation. METHODS A total of 68 patients (79 hips) were included in this study. The patients had a computed tomography study and approximately 3 months of postoperative standing anteroposterior pelvic radiographs in both supine and standing positions. We used 2-dimensional (2D)/3-dimensional (3D) matching to measure pelvic tilt and rotation, and cup orientation. RESULTS There was a wide range of pelvic tilt between individuals in both supine and standing positions. Supine pelvic tilt was different from standing pelvic tilt (P < .05). There were differences in cup anteversion before and after 2D/3D matching in both supine and standing positions (P < .05). Supine and standing pelvic tilt correlated with differences in cup anteversion before and after 2D/3D matching. When all 79 hips were separated into right and left side, pelvic rotation inversely correlated with the pelvic tilt-adjusted difference in anteversion before and after 2D/3D matching of the right side but directly correlated with that of the left side in both supine and standing positions. CONCLUSION This study demonstrated that the measurement of cup anteversion on anteroposterior radiographs is significantly affected by both pelvic tilt and pelvic rotation (depending on the side). Improved understanding of pelvic orientation and improved ability to measure pelvic orientation may eventually allow for desired cup positioning to potentially protect against complications associated with malposition of the cup.
Collapse
|
152
|
Parvizi J, Benson JR, Muir JM. A new mini-navigation tool allows accurate component placement during anterior total hip arthroplasty. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2018; 11:95-104. [PMID: 29606894 PMCID: PMC5868583 DOI: 10.2147/mder.s151835] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Introduction Computer-assisted navigation systems have been explored in total hip arthroplasty (THA) to improve component positioning. While these systems traditionally rely on anterior pelvic plane registration, variances in soft tissue thickness overlying anatomical landmarks can lead to registration error, and the supine coronal plane has instead been proposed. The purpose of this study was to evaluate the accuracy of a novel navigation tool, using registration of the anterior pelvic plane or supine coronal plane during simulated anterior THA. Methods Measurements regarding the acetabular component position, and changes in leg length and offset were recorded. Benchtop phantoms and target measurement values commonly seen in surgery were used for analysis. Measurements for anteversion and inclination, and changes in leg length and offset were recorded by the navigation tool and compared with the known target value of the simulation. Pearson's r assessed the relationship between the measurements of the device and the known target values. Results The device accurately measured cup position and leg length measurements to within 1° and 1 mm of the known target values, respectively. Across all simulations, there was a strong, positive relationship between values obtained by the device and the known target values (r=0.99). Conclusion The preliminary findings of this study suggest that the novel navigation tool tested is a potentially viable tool to improve the accuracy of component placement during THA using the anterior approach.
Collapse
Affiliation(s)
- Javad Parvizi
- Department of Orthopaedic Surgery, Thomas Jefferson University Hospital, College of Biomedical Science, Philadelphia, PA, USA.,Orthopaedics, Rothman Institute, Philadelphia, PA, USA
| | - Jessica R Benson
- Department of Clinical Research, Intellijoint Surgical, Waterloo, ON, Canada
| | - Jeffrey M Muir
- Department of Clinical Research, Intellijoint Surgical, Waterloo, ON, Canada
| |
Collapse
|
153
|
Kochman A, Goral A, Kozak J, Marek W, Morawska-Kochman M, Synder M. Preoperative Ultrasonographic Assessment of the Anterior Pelvic Plane for Personalized Total Hip Replacement. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2018; 37:949-958. [PMID: 29027688 DOI: 10.1002/jum.14431] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Revised: 06/07/2017] [Accepted: 07/15/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES Correct positioning of the acetabular component is a key factor in minimizing the risk of dislocation after total hip replacement (THR) surgery. A "safe" orientation of the cup is usually defined by 2 angles measured between its geometric axis and the anterior pelvic plane. However, in the current state-of-the-art approach to THR surgery, the intraoperative orientation of the anterior pelvic plane cannot be measured. Even less is known about the functional orientation of the pelvis, which determines the postoperative orientation of the cup during the patient's everyday activities. The aim of this article is to present an original approach to personalized THR surgery, in which the necessary measurements are done preoperatively without interfering with the surgical work flow, and the individual orientation of the cup is obtained without navigation using standard tools that are available in the operating room. METHODS To quantify the effect of the anatomic conditions on the final orientation of the cup, we measured the orientation of the anterior pelvic plane in 43 patients scheduled for THR using a newly developed noninvasive method based on ultrasonography and mobile devices. RESULTS Our results confirm a large variability of the pelvic orientation in both supine and standing positions. We further show how this variability affects the final position of the cup and discuss its consequences for the patient. Finally, we explore a few practical solutions for individualized cup placement, including our own approach, which is based on tilting of the operating table. CONCLUSIONS In this work, we show that the common guidelines used today for cup implantation can only be effectively applied to a small portion of the population. In most cases, it is crucial that the orientation of the cup is readjusted for the particular anatomy of the individual patient.
Collapse
Affiliation(s)
| | - Adrian Goral
- Department of Measurements and Electronics, Akademia Górniczo-Hutnicza University of Science and Technology, Krakow, Poland
| | | | - Wojciech Marek
- Department of Trauma and Orthopedics, Hospital of the Ministry of Internal Affairs, Wroclaw, Poland
| | - Monika Morawska-Kochman
- Department and Clinic of Otolaryngology Head and Neck Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Marek Synder
- Medical University of Lodz Clinic of Orthopedics and Pediatric Orthopedics, Lodz, Poland
| |
Collapse
|
154
|
Nishiwaki T, Hata R, Oya A, Nakamura M, Matsumoto M, Kanaji A. Pelvic Tilt Displacement Before and After Artificial Hip Joint Replacement Surgery. J Arthroplasty 2018; 33:925-930. [PMID: 29122388 DOI: 10.1016/j.arth.2017.10.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 09/20/2017] [Accepted: 10/05/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Prediction of pelvic displacement before total hip arthroplasty (THA) is important for accurate acetabular implant placement. This study aimed to evaluate the effect of contralateral joint conditions on pelvic displacement after THA. METHODS A total of 355 cases that underwent computed tomography before and after THA for osteoarthritis due to developmental dysplasia were assessed. The pelvic plane was based on preoperative and postoperative day 1 computed tomography images. The displacement in the anteversion direction was expressed as +. Subjects with a minimal joint space <2 mm in the contralateral hip joint were in group N; subjects with ≥2 mm were in group W; subjects with THA were in group P; and subjects who underwent THA simultaneously on both sides were in group B. The Bartlett test was used when conducting the equal variance test among the groups. The F test was used for pairwise comparison. A P value <.01 was considered statistically significant. RESULTS Groups N, W, P, and B had 49, 227, 55, and 24 cases, respectively, and their displacements were -0.2° ± 2.7°, 0.8° ± 3.9°, 0.5° ± 2.6°, and 1.1° ± 4.0°, respectively; the variance between the groups was significantly different (P = .0001). The differences between groups W and N (P = .0020), between groups W and P (P = .0003), and between groups P and B (P = .0086) were statistically significant. CONCLUSION When the contralateral joint space is wide, the variance of the displacement is high. The contralateral joint affects pelvic displacement.
Collapse
Affiliation(s)
- Toru Nishiwaki
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Ryosuke Hata
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Akihito Oya
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Masaya Nakamura
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Morio Matsumoto
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Arihiko Kanaji
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| |
Collapse
|
155
|
Derbyshire B. Correction of radiographic measurements of acetabular cup wear for variations in pelvis orientation. Proc Inst Mech Eng H 2018; 232:299-309. [PMID: 29473454 PMCID: PMC5846875 DOI: 10.1177/0954411918754924] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Radiographic measurement of two-dimensional acetabular cup wear is usually carried out on a series of follow-up radiographs of the patient's pelvis. Since the orientation of the pelvis might not be consistent at every X-ray examination, the resulting change in view of the wear plane introduces error into the linear wear measurement. This effect is amplified on some designs of cup in which the centre of the socket is several millimetres below the centre of the cup or circular wire marker. This study describes the formulation of a mathematical method to correct radiographic wear measurements for changes in pelvis orientation. A mathematical simulation of changes in cup orientation and wear vectors caused by pelvic tilt was used to confirm that the formulae corrected the wear exactly if the radiographic plane of the reference radiograph was parallel to the true plane of wear. An error analysis showed that even when the true wear plane was not parallel to the reference radiographic plane, the formulae could still provide a useful correction. A published correction formula was found to be ineffective.
Collapse
Affiliation(s)
- Brian Derbyshire
- Brian Derbyshire, Centre for Hip Surgery, Wrightington Hospital, Hall Lane, Appley Bridge, Wigan, WN6 9EP UK.
| |
Collapse
|
156
|
The Current Knowledge on Spinopelvic Mobility. J Arthroplasty 2018; 33:291-296. [PMID: 28939031 DOI: 10.1016/j.arth.2017.08.013] [Citation(s) in RCA: 88] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 08/06/2017] [Accepted: 08/11/2017] [Indexed: 02/01/2023] Open
Abstract
Recent studies may suggest that our conventional knowledge of risk factors for dislocation may need rethinking. Previous studies have demonstrated a large majority of total hip arthroplasty instability with acetabular cups implanted in safe zones. Recently discovered spinopelvic motion is a coordinated biomechanical relationship among acetabular anteversion, pelvic tilt, and lumbar lordosis. Classification includes normal, hypermobile, stiff, stuck standing, stuck sitting, and fused. Normal spinopelvic motion from standing to sitting occurs with hip flexion, posterior sacral tilt, and decreased lumbar lordosis to accommodate a flexed femur and prevent impingement and dislocation. Acetabular cup implantation ideally is adapted based on spinopelvic interactions. This may lower the rate of impingement and subsequent dislocation. These new biomechanical interactions may provide a better understanding of the safe zones of anteversion and inclination.
Collapse
|
157
|
Schwarzkopf R, Muir JM, Paprosky WG, Seymour S, Cross MB, Vigdorchik JM. Quantifying Pelvic Motion During Total Hip Arthroplasty Using a New Surgical Navigation Device. J Arthroplasty 2017; 32:3056-3060. [PMID: 28559196 DOI: 10.1016/j.arth.2017.04.046] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 03/21/2017] [Accepted: 04/24/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Accurate cup positioning is one of the most challenging aspects of total hip arthroplasty (THA). Undetected movement of the patient during THA surgery can lead to inaccuracies in cup anteversion and inclination, increasing the potential for dislocation and revision surgery. Investigations into the magnitude of patient motion during THA are not well represented in the literature. METHODS We analyzed intraoperative pelvic motion using a novel navigation device used to assist surgeons with cup position, leg length, and offset during THA. This device uses an integrated accelerometer to measure motion in 2 orthogonal degrees of freedom. We reviewed the data from 99 cases completed between February and September 2016. RESULTS The mean amount of pitch recorded per patient was 2.7° (standard deviation, 2.2; range, 0.1°-9.9°), whereas mean roll per patient was 7.3° (standard deviation, 5.5; range, 0.3°-31.3°). Twenty-one percent (21 of 99) of patients demonstrated pitch of >4°. Sixty-nine percent (68 of 99) of patients demonstrated >4° of roll, and 25% (25 of 99) of patients demonstrated roll of ≥10°. CONCLUSION Our findings indicate that while the majority of intraoperative motion is <4°, many patients experience significant roll, with a large proportion rolling >10°. This degree of movement has implications for acetabular cup position, as failure to compensate for this motion can result in placement of the cup outside the planned safe zone, thus, increasing the potential for dislocation. Further study is warranted to determine the effect of this motion on cup position, leg length, and offset.
Collapse
Affiliation(s)
- Ran Schwarzkopf
- Department of Orthopaedic Surgery, NYU Langone Medical Center-Hospital for Joint Diseases, New York, New York
| | - Jeffrey M Muir
- Department of Clinical Research, Intellijoint Surgical, Inc, Waterloo, Ontario, Canada
| | - Wayne G Paprosky
- Department of Orthopedics, Central DuPage Hospital, Winfield, Illinois
| | - Scott Seymour
- Department of Orthopedics, MacNeal Hospital, Berwyn, Illinois
| | - Michael B Cross
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Jonathan M Vigdorchik
- Department of Orthopaedic Surgery, NYU Langone Medical Center-Hospital for Joint Diseases, New York, New York
| |
Collapse
|
158
|
Wang L, Thoreson AR, Trousdale RT, Morrey BF, Dai K, An KN. Radiographic cup anteversion measurement corrected from pelvic tilt. Med Eng Phys 2017; 49:103-108. [PMID: 28888787 DOI: 10.1016/j.medengphy.2017.08.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 07/29/2017] [Accepted: 08/12/2017] [Indexed: 11/30/2022]
Abstract
The purpose of this study was to develop a novel technique to improve the accuracy of radiographic cup anteversion measurement by correcting the influence of pelvic tilt. Ninety virtual total hip arthroplasties were simulated from computed tomography data of 6 patients with 15 predetermined cup orientations. For each simulated implantation, anteroposterior (AP) virtual pelvic radiographs were generated for 11 predetermined pelvic tilts. A linear regression model was created to capture the relationship between radiographic cup anteversion angle error measured on AP pelvic radiographs and pelvic tilt. Overall, nine hundred and ninety virtual AP pelvic radiographs were measured, and 90 linear regression models were created. Pearson's correlation analyses confirmed a strong correlation between the errors of conventional radiographic cup anteversion angle measured on AP pelvic radiographs and the magnitude of pelvic tilt (P < 0.001). The mean of 90 slopes and y-intercepts of the regression lines were -0.8 and -2.5°, which were applied as the general correction parameters for the proposed tool to correct conventional cup anteversion angle from the influence of pelvic tilt. The current method proposes to measure the pelvic tilt on a lateral radiograph, and to use it as a correction for the radiographic cup anteversion measurement on an AP pelvic radiograph. Thus, both AP and lateral pelvic radiographs are required for the measurement of pelvic posture-integrated cup anteversion. Compared with conventional radiographic cup anteversion, the errors of pelvic posture-integrated radiographic cup anteversion were reduced from 10.03 (SD = 5.13) degrees to 2.53 (SD = 1.33) degrees. Pelvic posture-integrated cup anteversion measurement improves the accuracy of radiographic cup anteversion measurement, which shows the potential of further clarifying the etiology of postoperative instability based on planar radiographs.
Collapse
Affiliation(s)
- Liao Wang
- Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, PR China; Biomechanics Laboratory, Division of Orthopedic Research, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905, USA
| | - Andrew R Thoreson
- Biomechanics Laboratory, Division of Orthopedic Research, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905, USA
| | | | - Bernard F Morrey
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | - Kerong Dai
- Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, PR China
| | - Kai-Nan An
- Biomechanics Laboratory, Division of Orthopedic Research, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905, USA .
| |
Collapse
|
159
|
Soderquist MC, Scully R, Unger AS. Acetabular Placement Accuracy With the Direct Anterior Approach Freehand Technique. J Arthroplasty 2017; 32:2748-2754. [PMID: 28499624 DOI: 10.1016/j.arth.2017.04.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 04/05/2017] [Accepted: 04/07/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Acetabular cup placement in total hip arthroplasty (THA) has been recognized as an important factor in operative success, and accurate cup placement has been the impetus for novel medical technologies. METHODS This article examines the cup placement in 955 THAs using a freehand Direct Anterior Approach on a standard operating table. Acetabular anteversion and inclination were determined using the circle theorem. Measurements were divided into safe zone placement determined by Callanan et al as 5°-25° for anteversion and 30°-45° for inclination, as well as by Lewinnek et al as 5°-25° for anteversion and 30°-50° for inclination. Dislocation rate was determined and correlated to safe zone placement. RESULTS Although technology has advanced for cup placement, this investigation shows that a freehand technique demonstrates 0.31% dislocation after THA with an accuracy of 85% for the Lewinnek safe zone and 61% for Callanan, potentially because of the sparing of the posterior hip capsule. CONCLUSION The direct anterior approach to the hip on a regular operating table is safe and reliable. Our results demonstrate improvement in cup positioning compared with other freehand techniques. Surgeon awareness and control of the position of the pelvis within space optimizes acetabular component accuracy and precision without the need for special equipment, such as intraoperative fluoroscopy.
Collapse
Affiliation(s)
| | - Ryan Scully
- Department of Orthopedic Surgery, George Washington University, Washington, DC
| | - Anthony S Unger
- Department of Orthopedic Surgery, George Washington University, Washington, DC
| |
Collapse
|
160
|
Reina N, Putman S, Desmarchelier R, Sari Ali E, Chiron P, Ollivier M, Jenny JY, Waast D, Mabit C, de Thomasson E, Schwartz C, Oger P, Gayet LE, Migaud H, Ramdane N, Fessy MH. Can a target zone safer than Lewinnek's safe zone be defined to prevent instability of total hip arthroplasties? Case-control study of 56 dislocated THA and 93 matched controls. Orthop Traumatol Surg Res 2017. [PMID: 28629942 DOI: 10.1016/j.otsr.2017.05.015] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Various factors contribute to instability of total hip arthroplasty (THA), with implant orientation being a major contributor. We performed a case-control study with computed tomography (CT) data to determine whether: 1) orientation contributes to THA instability and 2) a safer target zone for stability than Lewinnek's classic safe zone can be defined. MATERIAL AND METHODS We included prospectively 363 cases of THA dislocation that occurred during the calendar 2013 year in 24 participating hospitals. Of the 128 dislocations that occurred in patients who underwent THA at these centers, 56 (24 anterior, 32 posterior) had CT scans, thus were included in the analysis. The control group was matched 4:1 based on implant type, year of implantation, age, sex, bearing types and THA indication. Of the 428 matched control THA cases, 93 had CT scans. In all, the CT scans from 149 cases (56 unstable, 93 stable) were analyzed to determine the acetabular cup's inclination and anteversion, and the femoral stem's anteversion. RESULTS In the unstable THA group, cup inclination was 46.9°±7.4°, cup anteversion was 20.4°±10.8° and stem anteversion was 14.2°±9.9°. In the stable THA group, cup inclination was 44.9°±5.3° (P=0.057), cup anteversion was 22.1°±5.1° (P=0.009) and stem anteversion was 13.4°±4.4° (P=0.362). The optimal total anteversion (cup+stem) of 40-60° was achieved in 16.5% of unstable THA cases and 13.9% of stable THA cases, thus this parameter does not predict stability (odds ratio [OR] of 0.40, P=0.144). The cup was positioned in Lewinnek's safe zone in 44.6% of patients in the unstable group and 68.2% of those in the stable group (OR 3.74, P=0.003). A target zone defined as 40-50° inclination and 15-30° anteversion was better able to distinguish between unstable cases (23.2%) and stable cases (71.6%) resulting in an OR of 13.91 (P<0.001). DISCUSSION Implant positioning was the only risk factor for instability found in this study. Moreover, our findings reinforce the theory put forward by other authors that Lewinnek's safe zone is not specific enough to differentiate between stable and unstable THA implantations. The target zone for acetabular cups proposed here (40-50° inclination and 15°-30° anteversion) is related to a lower risk of instability. This orientation can be used as a guide, but must be combined with other technical elements to optimize stability. By balancing stability and biomechanics, the 40-50° inclination and 15°-30° anteversion target zone redefines the optimal positioning window. LEVEL OF EVIDENCE III case-control study.
Collapse
Affiliation(s)
- N Reina
- Institut locomoteur (ILM), hôpital Pierre-Paul-Riquet, CHU de Toulouse, 31059 Toulouse, France.
| | - S Putman
- Hôpital Salengro, CHU de Lille, place de Verdun, 59000 Lille, France
| | - R Desmarchelier
- Service de chirurgie orthopédique et traumatologique, hospices civils de Lyon, centre hospitalier Lyon-Sud, université de Lyon, 69002 Pierre-Bénite, France
| | - E Sari Ali
- Service de chirurgie orthopédique et traumatologique, hôpital la Pitié-Salpétrière, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - P Chiron
- Institut locomoteur (ILM), hôpital Pierre-Paul-Riquet, CHU de Toulouse, 31059 Toulouse, France
| | - M Ollivier
- Service de chirurgie orthopédique et traumatologique, hôpital St. Marguerite, 13009 Marseille, France
| | - J Y Jenny
- Service de chirurgie orthopédique et traumatologique, hôpital de Hautepierre, CHU de Strasbourg, 67091 Strasbourg, France
| | - D Waast
- Service de chirurgie orthopédique et traumatologique, Hôtel-Dieu, 1, place Alexis-Ricordeau, 44093 Nantes, France
| | - C Mabit
- Service de chirurgie orthopédique et traumatologique, CHU Dupuytren, avenue M.-Luther-King, CHU de Limoges, 87000 Limoges, France
| | - E de Thomasson
- Institut mutualiste Montsouris, 42, boulevard Jourdan, 75014 Paris, France
| | - C Schwartz
- Centre d'orthopédie clinique des 3-frontières, 68300 Saint-Louis, France
| | - P Oger
- Hopital A.-Mignot, 177, route De-Versailles, 78150 Le Chesnay, France
| | - L E Gayet
- Service de chirurgie orthopédique et traumatologique, CHU de Poitiers, 86021 Poitiers, France
| | - H Migaud
- Hôpital Salengro, CHU de Lille, place de Verdun, 59000 Lille, France
| | - N Ramdane
- Unité de biostatistique, pôle de santé publique, CHRU de Lille, 59000 Lille, France
| | - M H Fessy
- Service de chirurgie orthopédique et traumatologique, hospices civils de Lyon, centre hospitalier Lyon-Sud, université de Lyon, 69002 Pierre-Bénite, France
| |
Collapse
|
161
|
Blizzard DJ, Penrose CT, Sheets CZ, Seyler TM, Bolognesi MP, Brown CR. Ankylosing Spondylitis Increases Perioperative and Postoperative Complications After Total Hip Arthroplasty. J Arthroplasty 2017; 32:2474-2479. [PMID: 28438449 DOI: 10.1016/j.arth.2017.03.041] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 03/14/2017] [Accepted: 03/18/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Ankylosing spondylitis (AS) is a chronic autoimmune spondyloarthropathy that primarily affects the axial spine and hips. Progressive disease leads to pronounced spinal kyphosis, positive sagittal balance, and altered biomechanics. The purpose of this study is to determine the complication profile of patients with AS undergoing total hip arthroplasty (THA). METHODS The Medicare sample was searched from 2005 to 2012 yielding 1006 patients with AS who subsequently underwent THA. Risk ratios (RRs) with 95% confidence intervals (CIs) were calculated for 90-day, 2-year, and the final postoperative follow-up for complications including hip dislocation, periprosthetic fracture, wound complication, revision THA, and postoperative infection. RESULTS Compared to controls, AS patients had an RR of 2.50 (CI, 1.04-5.99) of THA component breakage at 90-days post-operatively and 1.99 (CI, 1.10-3.59) at 2-years. The RR of periprosthetic hip dislocation was elevated at 90 days (1.44; CI, 0.93-2.22) and significantly increased at 2-years (1.67; CI, 1.25-2.23) and overall follow-up (1.49; CI, 1.14-1.93). Similarly, the RR for THA revision was elevated at 90-days (1.46; CI, 0.97-2.18) and significantly increased at 2-years (1.69; CI, 1.33-2.14) and overall follow-up (1.51; CI, 1.23-1.85). CONCLUSION Patients with AS are at increased risk for complications after THA. Altered biomechanics from a rigid, kyphotic spine place increased demand on the hip joints. The elevated perioperative and postoperative risks should be discussed preoperatively, and these patients may require increased preoperative medical optimization as well as possible changes in component selection and position to compensate for altered spinopelvic biomechanics.
Collapse
Affiliation(s)
- Daniel J Blizzard
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Colin T Penrose
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Charles Z Sheets
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Thorsten M Seyler
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Michael P Bolognesi
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Christopher R Brown
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| |
Collapse
|
162
|
Uemura K, Takao M, Otake Y, Koyama K, Yokota F, Hamada H, Sakai T, Sato Y, Sugano N. Change in Pelvic Sagittal Inclination From Supine to Standing Position Before Hip Arthroplasty. J Arthroplasty 2017; 32:2568-2573. [PMID: 28392134 DOI: 10.1016/j.arth.2017.03.015] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 03/01/2017] [Accepted: 03/07/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Cup anteversion and inclination are important for avoiding implant impingement and dislocation in total hip arthroplasty. However, functional cup anteversion and cup inclination also change as the pelvic sagittal inclination (PSI) changes. Therefore, PSI in both supine and standing positions was measured in a large cohort in this study. METHODS A total of 422 patients (median age, 61; range, 15-87) who underwent total hip arthroplasty were the subjects of this study. There were 83 patients with primary osteoarthritis (OA), 274 patients with developmental dysplasia-derived secondary OA, 48 patients with osteonecrosis, and 17 patients with rapidly destructive coxopathy (RDC). Preoperative PSI in supine and standing positions was measured by automated computed topography segmentation and landmark localization of the pelvis followed by intensity-based 2D-3D registration, and the number of cases in which PSI changed more than 10° posteriorly was calculated. Hip disease, sex, and age were analyzed if they were related to a PSI change of more than 10°. RESULTS The median PSI was 5.1° (interquartile range, 0.4°-9.4°) in supine and -1.3° (interquartile range, -6.5° to 4.2°) in standing position. There were 79 cases (19%) in which the PSI changed more than 10° posteriorly from supine to standing. Elder age and patients with primary OA and RDC were revealed to be the related factors. CONCLUSION PSI changed more than 10° posteriorly from supine to standing in 19% of cases. Age and diagnosis of primary OA and RDC were the significant factors for the posterior rotation.
Collapse
Affiliation(s)
- Keisuke Uemura
- Department of Orthopaedic Medical Engineering, Osaka University Graduate School of Medicine, Suita City, Osaka, Japan
| | - Masaki Takao
- Department of Orthopaedic Medical Engineering, Osaka University Graduate School of Medicine, Suita City, Osaka, Japan
| | - Yoshito Otake
- Imaging-based Computational Biomedicine Lab, Nara Institute of Science and Technology, Ikoma City, Nara, Japan
| | - Koki Koyama
- Imaging-based Computational Biomedicine Lab, Nara Institute of Science and Technology, Ikoma City, Nara, Japan
| | - Futoshi Yokota
- Imaging-based Computational Biomedicine Lab, Nara Institute of Science and Technology, Ikoma City, Nara, Japan
| | - Hidetoshi Hamada
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Suita City, Osaka, Japan
| | - Takashi Sakai
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Suita City, Osaka, Japan
| | - Yoshinobu Sato
- Imaging-based Computational Biomedicine Lab, Nara Institute of Science and Technology, Ikoma City, Nara, Japan
| | - Nobuhiko Sugano
- Department of Orthopaedic Medical Engineering, Osaka University Graduate School of Medicine, Suita City, Osaka, Japan
| |
Collapse
|
163
|
Loppini M, Longo UG, Caldarella E, Rocca AD, Denaro V, Grappiolo G. Femur first surgical technique: a smart non-computer-based procedure to achieve the combined anteversion in primary total hip arthroplasty. BMC Musculoskelet Disord 2017; 18:331. [PMID: 28764697 PMCID: PMC5539744 DOI: 10.1186/s12891-017-1688-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 07/24/2017] [Indexed: 11/17/2022] Open
Abstract
Background The relevance of prosthetic component orientation to prevent dislocation and impingement following total hip arthroplasty (THA) has been widely accepted. We investigated the use of a non-computer-based surgery to address the reciprocal orientation of the acetabular and femoral components. Methods In the femur first technique, the cup is positioned relative to the stem. When the definitive antetorsion of femoral component is fixed, the cup is positioned in a compliant anteversion to the stem. Clinical and radiographic assessments were performed before and 3 months after THA. Radiographic assessment was performed in standing position with the EOS 2D/3D radiography system. 3D images were used to preoperative anterior pelvic plane (APP) angle, postoperative acetabular inclination (AI) and anteversion (AA), and postoperative stem antetorsion. Clinical assessment was performed with Harris Hip Score (HHS). Results Forty patients (40 hips) underwent primary THA with an average age of 61 years (range, 36–84). Average HHS increased from 43 ± 5 (range, 37–52) preoperatively to 97 ± 6 (range, 86–100) at the last follow-up (P < 0.0001). Average combined anteversion value of cup with liner and stem was 38° ± 9° (range, 12°-55°). Average AI value of cup with liner was 39° ± 6° (range, 30°-55°) in the group with standard stem and 45° ± 7° (range, 39°-58°) in the group with varized stem (P = 0.007). Relationship analysis showed no correlation between the combined anteversion values of the cup with liner and stem with APP angle values (r = 0.26, P = 0.87). Conclusions Femur first technique allows the surgeon to achieve a combined anteversion ranging from 25° to 50° with a cup inclination ranging from 30° to 50°. The cup is positioned according to the functional plane of the patient regardless the preoperative pelvic tilt.
Collapse
Affiliation(s)
- Mattia Loppini
- Hip Diseases and Joint Replacement Surgery Unit, Humanitas Clinical and Research Centre, Via Alessandro Manzoni 56, 20089, Rozzano, Milan, Italy. .,Humanitas University, Via Alessandro Manzoni 113, 20089, Rozzano, Milan, Italy.
| | - Umile Giuseppe Longo
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo 200, 00128, Trigoria, Rome, Italy
| | - Emanuele Caldarella
- Hip Diseases and Joint Replacement Surgery Unit, Humanitas Clinical and Research Centre, Via Alessandro Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Antonello Della Rocca
- Hip Diseases and Joint Replacement Surgery Unit, Humanitas Clinical and Research Centre, Via Alessandro Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Vincenzo Denaro
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo 200, 00128, Trigoria, Rome, Italy
| | - Guido Grappiolo
- Hip Diseases and Joint Replacement Surgery Unit, Humanitas Clinical and Research Centre, Via Alessandro Manzoni 56, 20089, Rozzano, Milan, Italy
| |
Collapse
|
164
|
Letter to the Editor on "Abnormally High Dislocation Rates of Total Hip Arthroplasty After Spinal Deformity Surgery". J Arthroplasty 2017; 32:2619-2620. [PMID: 28434693 DOI: 10.1016/j.arth.2017.02.083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 02/21/2017] [Indexed: 02/01/2023] Open
|
165
|
Changes in spinopelvic indices after hip arthroplasty and its influence on acetabular component orientation. J Orthop 2017; 14:434-437. [PMID: 28794584 DOI: 10.1016/j.jor.2017.07.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Accepted: 07/30/2017] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To evaluate spinopelvic changes after hip arthroplasty in standing and ready-to-rise positions. METHODS We compared pelvic tilt, sacral slope, cobb's angle, and hip flexion on pre and postoperative spinopelvic radiographs. RESULTS Standing: All postoperative indices were similar to preoperative ones except sacral slope (mean difference:1.6°, p = 0.046). Ready-to-rise: All postoperative indices were similar to preoperative ones except pelvic tilt which was significantly greater postoperatively (mean difference: 5.1°, p = 0.017). Fifteen patients showed >10° increase in pelvic tilt postoperatively. CONCLUSION Changes in pelvic tilt in ready-to-rise position can predispose to posterior edge loading, edge wear, and dislocation; especially with inadequate cup anteversion.
Collapse
|
166
|
Qin Y, Li X, Chen S, Liu L, Gao Z, Wang J, Xiao J. Correcting pelvic obliquity in the lateral position to improve acetabular component orientation during total hip arthroplasty. Technol Health Care 2017:THC160717. [PMID: 28759976 DOI: 10.3233/thc-160717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The acetabular component orientation during total hip arthroplasty (THA) impacts future hip function and early revision. Correcting pelvic obliquity may improve outcomes. OBJECTIVE To correct pelvic obliquity in the lateral position by applying a gradienter and plumb during THA using fluoroscopy. METHODS Fifty patients undergoing THA were randomized and divided into 2 groups. In controls, acetabular components were placed using traditional methods. In experimental patients, acetabular components were placed after correcting pelvic obliquity. We measured pelvic obliquity and recorded intra-operative and post-operative abduction angles, comparing abduction angle bias between post-operative measurements and intra-operation estimations. RESULTS Before correction, the average pelvic obliquity was -1.647∘± 4.512∘ in experimental patients. The average abduction angle in experimental patients was 42.685∘± 3.355∘ postoperatively, differing by 1.962∘± 1.515∘ from intra-operative estimates, while in control patients, it was 44.534∘± 4.844∘ postoperatively, differing by 4.244∘± 3.042∘ from intra-operative estimates. The bias of the abduction angle was much greater in control than in experimental patients (P< 0.05). CONCLUSION The pelvic obliquity in the lateral position affects surgeon judgment during THA. By correcting pelvic obliquity with a gradienter and plumb, the abduction angle bias can be reduced.
Collapse
Affiliation(s)
- Yanguo Qin
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, Jilin 130000, China
| | - Xuezhou Li
- Department of Orthopedics, Qilu Hospital of Shangdong University, Jinan, Shangdong 250012, China
| | - Shangjun Chen
- Norman Bethune Medical School, Jilin University, Changchun, Jilin 130000, China
| | - Liang Liu
- Image Department of China-Japan Union Hospital, Jilin University, Changchun, Jilin 130000, China
| | - Zhongli Gao
- Department of Orthopedics, China-Japan Union Hospital of Jilin University, Changchun, Jilin 130000, China
| | - Jincheng Wang
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, Jilin 130000, China
| | - Jianlin Xiao
- Department of Orthopedics, China-Japan Union Hospital of Jilin University, Changchun, Jilin 130000, China
| |
Collapse
|
167
|
Davenport D, Kavarthapu V. Computer navigation of the acetabular component in total hip arthroplasty: a narrative review. EFORT Open Rev 2017; 1:279-285. [PMID: 28670481 PMCID: PMC5467635 DOI: 10.1302/2058-5241.1.000050] [Citation(s) in RCA: 11] [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] [Indexed: 11/11/2022] Open
Abstract
Total hip arthroplasty (THA) is a common procedure for primary osteoarthritis, but increasing numbers are also being performed for other pathologies such as secondary arthritis, inflammatory arthropathies and trauma. Estimates suggest that around 8.5 million people in the UK are affected by joint pain secondary to arthritis and a rising ageing population has resulted in an increase in THA operations of around 4% per year over the last six years. Multiple studies have shown that THA provides improved quality of life scores, but there remains the burden of complications which account for 15% of £1bn NHS liability payouts. DaPalma et al analysed the financial impact of complications following THA and found the additional cost of a dislocation within six weeks of surgery is 342% of the primary cost. Following primary THA, complications may occur as a result of incorrect component positioning of the femoral stem, the acetabular cup or both. It is known that acetabular malposition may lead to increased rates of dislocation, impingement, edge-loading, polyethylene wear, pelvic osteolysis and prosthesis failure. Acetabular component positioning has been described as the single most important factor in dictating risk of dislocation following THA. Furthermore, instability and dislocation after primary THA is the most common single reason for revision surgery accounting for 22.5% of all revisions and 33% of acetabular revisions. We outline the currently available methods of acetabular navigation comparing freehand techniques with computer and robotic-assisted navigation of the acetabular component.
Cite this article: Davenport D, Kavarthapu V. Computer navigation of the acetabular component in total hip arthroplasty: a narrative review. EFORT Open Rev 2016;1:279-285. DOI: 10.1302/2058-5241.1.000050.
Collapse
Affiliation(s)
- Dominic Davenport
- Department of Trauma & Orthopaedics, Princess Royal University Hospital & King's College Hospital, UK
| | - Venu Kavarthapu
- Department of Trauma & Orthopaedics, Princess Royal University Hospital & King's College Hospital, UK
| |
Collapse
|
168
|
Kochman A, Goral A, Martin T, Marek W, Kozak J, Morawska-Kochman M, Synder M. Application of Navigated Ultrasound for Assessment of the Anterior Pelvic Plane in Patients With Degenerative Hip Diseases. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2017; 36:1373-1380. [PMID: 28390166 DOI: 10.7863/ultra.16.07016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Accepted: 09/23/2016] [Indexed: 06/07/2023]
Abstract
OBJECTIVES Correct positioning of the acetabular cup is the key for successful total-hip replacement. In common clinical practice, the target alignment of the cup is defined with respect to the anterior pelvic plane. In patients with substantial anterior pelvic plane inclination, this condition may lead to inappropriate distribution of the load on the cup, as most of the forces exerted within the hip joint act along the vertical axis. With the known pelvic inclination, it is possible to readjust the position of the cup with respect to the individual posture of the patient. In this work, we present the first clinical evaluation of a new approach to measurement of the pelvic tilt angle using navigated ultrasound. METHODS In our method, the ultrasound probe is tracked with an optical localizer implemented on a handheld mobile device. The method was tested by taking preoperative measurements from 20 patients with osteoarthritis in standing, sitting, and supine positions. RESULTS The mean values of the measured angles were consistent with the corresponding results reported by other authors. CONCLUSIONS Considering the noninvasiveness of the method and affordability of the hardware used in our system, it can be used in preoperative and postoperative measurements of pelvic orientation for supporting surgery planning and evaluation of treatment outcomes.
Collapse
Affiliation(s)
- Andrzej Kochman
- Trauma and Orthopedic Department, Hospital of the Ministry of Internal Affairs, Wroclaw, Poland
| | - Adrian Goral
- Department of Measurements and Electronics, AGH University of Science and Technology, Krakow, Poland
| | | | - Wojciech Marek
- Trauma and Orthopedic Department, Hospital of the Ministry of Internal Affairs, Wroclaw, Poland
| | | | - Monika Morawska-Kochman
- Department of Otolaryngology and Head and Neck Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Marek Synder
- Clinic of Orthopedics and Pediatric Orthopedics, Medical University of Lodz, Lodz, Poland
| |
Collapse
|
169
|
Milone MT, Schwarzkopf R, Meere PA, Carroll KM, Jerabek SA, Vigdorchik J. Rigid Patient Positioning is Unreliable in Total Hip Arthroplasty. J Arthroplasty 2017; 32:1890-1893. [PMID: 28111126 DOI: 10.1016/j.arth.2016.12.038] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Revised: 12/10/2016] [Accepted: 12/19/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND To our knowledge, no study has assessed the ability of rigid patient positioning devices to afford arthroplasty surgeons with ideal acetabular orientation throughout surgery. The purpose of this study is to use robotic arm-assisted computer navigation to assess the reliability of pelvic position in total hip arthroplasty performed on patients positioned with rigid positioning devices. METHODS A prospective cohort of 100 hips (94 patients) underwent robotic-guided total hip arthroplasty in the lateral decubitus position from the posterior approach, 77 stabilized by universal lateral positioner, and 23 by peg board. Before reaming, computed tomography-templated computer software generated true values of pelvic anteversion and inclination based on the position of the robot arm registered to the patient's preoperative pelvic computed tomography. RESULTS Mean alteration in anteversion and inclination values was 1.7° (absolute value, 5.3°; range, -20° to 20°) and 1.6° (absolute value, 2.6°; range, -8° to 10°), respectively. And 22% of anteversion values were altered by >10° and 41% by >5°. There was no difference between hip positioners used (P = .36). Anteversion variability was correlated with body mass index (P = .02). CONCLUSION Despite the use of rigid patient positioning devices-a lateral hip positioner or peg board-this study reveals clinically important malposition of the pelvis in many cases, especially with regard to anteversion. These results show a clear need to pay particular attention to anatomic landmarks or computer-assisted techniques to assure accurate acetabular cup positioning. Patient positioning should not be solely trusted.
Collapse
Affiliation(s)
- Michael T Milone
- Department of Orthopedic Surgery, NYU Langone Orthopaedics, Hospital for Joint Diseases, New York, New York
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Orthopaedics, Hospital for Joint Diseases, New York, New York
| | - Patrick A Meere
- Department of Orthopedic Surgery, NYU Langone Orthopaedics, Hospital for Joint Diseases, New York, New York
| | | | | | - Jonathan Vigdorchik
- Department of Orthopedic Surgery, NYU Langone Orthopaedics, Hospital for Joint Diseases, New York, New York
| |
Collapse
|
170
|
Total Hip Arthroplasty in the Spinal Deformity Population: Does Degree of Sagittal Deformity Affect Rates of Safe Zone Placement, Instability, or Revision? J Arthroplasty 2017; 32:1910-1917. [PMID: 28153459 DOI: 10.1016/j.arth.2016.12.039] [Citation(s) in RCA: 144] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 12/02/2016] [Accepted: 12/19/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Changes in spinal alignment and pelvic tilt alter acetabular orientation in predictable ways, which may have implications on stability of total hip arthroplasty (THA). Patients with sagittal spinal deformity represent a subset of patients who may be at particularly high risk of THA instability because of postural compensation for abnormal spinal alignment. METHODS Using standing stereoradiography, we evaluated the spinopelvic parameters, acetabular cup anteversion, and inclination of 139 THAs in 107 patients with sagittal spinal deformity. Standing images were compared with supine pelvic radiographs to evaluate dynamic changes in acetabular cup position. Dislocation and revision rates were procured through retrospective chart review. The spinal parameters and acetabular cup positions among dislocators were compared with those who did not dislocate. RESULTS The rate of THA dislocation in this cohort was 8.0%, with a revision rate of 5.8% for instability. Patients who sustained dislocations had significantly higher spinopelvic tilt, T1-pelvic angle, and mismatch of lumbar lordosis and pelvic incidence. Among all patients, 78% had safe anteversion while supine, which decreased significantly to 58% when standing due to increases in spinopelvic tilt. Among dislocating THA, 80% had safe anteversion, 80% had safe inclination, and 60% had both parameters within the safe zone. CONCLUSION In this cohort, patients with THA and concomitant spinal deformity have a particularly high rate of THA instability despite having an acetabular cup position traditionally thought of as within acceptable alignment. This dislocation risk may be driven by the degree of spinal deformity and by spinopelvic compensation. Surgeons should anticipate potential instability after hip arthroplasty and adjust their surgical plan accordingly.
Collapse
|
171
|
Snijders T, van Gaalen S, de Gast A. Precision and accuracy of imageless navigation versus freehand implantation of total hip arthroplasty: A systematic review and meta-analysis. Int J Med Robot 2017; 13. [DOI: 10.1002/rcs.1843] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 03/27/2017] [Accepted: 04/24/2017] [Indexed: 12/31/2022]
Affiliation(s)
- Thom Snijders
- Clinical Orthopedic Research Center - mN, Orthopedics; Zeist 3707 HL Netherlands
- Diakonessenhuis Utrecht Zeist Doorn - Locatie Zeist; Zeist 3700 BA Netherlands
| | - S.M. van Gaalen
- Clinical Orthopedic Research Center - mN, Orthopedics; Zeist 3707 HL Netherlands
| | - A. de Gast
- Clinical Orthopedic Research Center - mN, Orthopedics; Zeist 3707 HL Netherlands
| |
Collapse
|
172
|
Buckland AJ, Puvanesarajah V, Vigdorchik J, Schwarzkopf R, Jain A, Klineberg EO, Hart RA, Callaghan JJ, Hassanzadeh H. Dislocation of a primary total hip arthroplasty is more common in patients with a lumbar spinal fusion. Bone Joint J 2017; 99-B:585-591. [DOI: 10.1302/0301-620x.99b5.bjj-2016-0657.r1] [Citation(s) in RCA: 176] [Impact Index Per Article: 25.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 01/09/2017] [Indexed: 11/05/2022]
Abstract
Aims Lumbar fusion is known to reduce the variation in pelvic tilt between standing and sitting. A flexible lumbo-pelvic unit increases the stability of total hip arthroplasty (THA) when seated by increasing anterior clearance and acetabular anteversion, thereby preventing impingement of the prosthesis. Lumbar fusion may eliminate this protective pelvic movement. The effect of lumbar fusion on the stability of total hip arthroplasty has not previously been investigated. Patients and Methods The Medicare database was searched for patients who had undergone THA and spinal fusion between 2005 and 2012. PearlDiver software was used to query the database by the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) procedural code for primary THA and lumbar spinal fusion. Patients who had undergone both lumbar fusion and THA were then divided into three groups: 1 to 2 levels, 3 to 7 levels and 8+ levels of fusion. The rate of dislocation in each group was established using ICD-9-CM codes. Patients who underwent THA without spinal fusion were used as a control group. Statistical significant difference between groups was tested using the chi-squared test, and significance set at p < 0.05. Results At one-year follow-up, 14 747 patients were found to have had a THA after lumbar spinal fusion (12 079 1 to 2 levels, 2594 3 to 7 levels, 74 8+ levels). The control group consisted of 839 004 patients. The dislocation rate in the control group was 1.55%. A higher rate of dislocation was found in patients with a spinal fusion of 1 to 2 levels (2.96%, p < 0.0001) and 3 to 7 levels (4.12%, p < 0.0001). Patients with 3 to 7 levels of fusion had a higher rate of dislocation than patients with 1 to 2 levels of fusion (odds ratio (OR) = 1.60, p < 0.0001). When groups were matched for age and gender to the unfused cohort, patients with 1 to 2 levels of fusion had an OR of 1.93 (95% confidence interval (CI) 1.42 to 2.32, p < 0.001), and those with 3 to 7 levels of fusion an OR of 2.77 (CI 2.04 to 4.80, p < 0.001) for dislocation. Conclusion Patients with a previous history of lumbar spinal fusion have a significantly higher rate of dislocation of their THA than age- and gender-matched patients without a lumbar spinal fusion. Cite this article: Bone Joint J 2017;99-B:585–91.
Collapse
Affiliation(s)
- A. J. Buckland
- Hospital for Joint Diseases at NYU Langone
Medical Center, 306 E. 15th St, New
York, NY, 10003, USA
| | - V. Puvanesarajah
- Johns Hopkins Hospital, 102
Crane Meadow Place, Chapel Hill, NC
27514, USA
| | - J. Vigdorchik
- Hospital for Joint Diseases at NYU Langone
Medical Center, 306 E. 15th St, New
York, NY, 10003, USA
| | - R. Schwarzkopf
- Hospital for Joint Diseases at NYU Langone
Medical Center, 301 E.17th St, New
York, NY 10003, USA
| | - A. Jain
- Johns Hopkins Hospital, 1800
Orleans Street, Baltimore, MD, 21205, USA
| | - E. O. Klineberg
- University of California - Davis, 4860
Y St, Suite 3800, Sacramento, CA
95817, USA
| | - R. A. Hart
- Swedish Medical Center, 550
17th Ave, James Tower, 5th
Floor, Seattle, WA 98122, USA
| | - J. J. Callaghan
- University of Iowa, 200
Hawkins Dr, Iowa City, IA
52242, USA
| | - H. Hassanzadeh
- University of Virginia, PO
Box 800159, Charlottesville, VA
22908, USA
| |
Collapse
|
173
|
Ragsdale MI, Wong FS, Boutin RD, Meehan JP. Pelvic Tilt Evaluation From Frontal Radiographs: The Validity, Interobserver Reliability and Intraobserver Reproducibility of the Sacro-Femoral-Pubic Parameter. J Arthroplasty 2017; 32:1665-1669. [PMID: 28012720 DOI: 10.1016/j.arth.2016.11.026] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 10/24/2016] [Accepted: 11/15/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The sacro-femoral-pubic (SFP) parameter, calculated using the SFP angle measured on a frontal pelvis radiograph, has previously been shown to have a strong correlation with sagittal pelvic tilt (PT) measured on a lateral x-ray. The purpose of this study is to assess the validity, interobserver reliability and intraobserver reproducibility of the SFP parameter in predicting the sagittal PT. METHODS This is a retrospective study of 100 patients with frontal and lateral radiographs of the pelvis. Two observers independently measured the SFP angle on frontal x-ray (midpoint of S1 end plate to centroid of acetabula to upper midpoint of the pubic symphysis) and PT on lateral x-ray (midpoint of sacral plate to the centroid of acetabula to vertical plane). The SFP parameter was defined using the equation: SFP parameter = 75 - SFP angle. The interobserver reliability and intraobserver reproducibility were calculated using interclass correlation coefficient (ICC). Validity of the SFP parameter was calculated using Pearson correlation coefficient. RESULTS The intraobserver reproducibility of the SFP parameter was excellent (ICC >0.90) for both observers. The interobserver reliability of all measurements was substantial for the SFP parameter (ICC >0.80) and PT (ICC >0.70). The concurrent validity of the SFP parameter was substantial (r = 0.70). CONCLUSION Calculating PT from a frontal radiograph using the equation for the SFP parameter is a valid, reliable, and reproducible formula that may be used to predict sagittal PT.
Collapse
Affiliation(s)
- Mary I Ragsdale
- Department of Orthopedic Surgery, University of California, Davis, Sacramento, California
| | - Felix S Wong
- Department of Radiology, University of California, Davis, Sacramento, California
| | - Robert D Boutin
- Department of Radiology, University of California, Davis, Sacramento, California
| | - John P Meehan
- Department of Orthopedic Surgery, University of California, Davis, Sacramento, California
| |
Collapse
|
174
|
Nam D, Riegler V, Clohisy JC, Nunley RM, Barrack RL. The Impact of Total Hip Arthroplasty on Pelvic Motion and Functional Component Position is Highly Variable. J Arthroplasty 2017; 32:1200-1205. [PMID: 27919581 DOI: 10.1016/j.arth.2016.11.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 11/07/2016] [Accepted: 11/08/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND This study's purpose was to determine the impact of THA implantation on pelvic motion, and to assess motion in patients with a history of lumbar fusion or prosthetic dislocation. METHODS This was an IRB-approved, prospective investigation of 3 cohorts: (1) patients without a history of lumbar surgery undergoing THA (group A), (2) patients with a lumbar fusion (group B), and (3) patients with a THA prosthetic dislocation (group C). All patients received both standing and sitting lateral pelvis images to measure sacral slope and pelvic tilt in the sagittal plane. RESULTS Fifty-eight patients were enrolled (24 group A, 27 group B, and 7 group C), with no differences in age, gender, or body mass index (P = .1-.7). In group A, the mean change in sacral slope from standing to sitting was 22.1° ± 15.2° preoperatively and 19.5° ± 14.8° postoperatively. However, in 13 patients, the difference in pelvic motion from the standing to seated position, from preoperatively to postoperatively, was >5° and in 10 patients, this difference was >10°. The change in standing to sitting sacral slope was significantly less in patients with a lumbar fusion (9.8° ± 8.2°) and history of prosthetic dislocation (12.5° ± 4.7°) vs group A (P < .001 and P = .008). CONCLUSION Implantation of a THA can increase or decrease sagittal plane pelvic motion from the standing to seated position with a high degree of variability. Thus, the ability to predict ideal component positioning from preoperative images may be challenging.
Collapse
Affiliation(s)
- Denis Nam
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Venessa Riegler
- Department of Orthopedic Surgery, Washington University School of Medicine/Barnes-Jewish Hospital, St. Louis, Missouri
| | - John C Clohisy
- Department of Orthopedic Surgery, Washington University School of Medicine/Barnes-Jewish Hospital, St. Louis, Missouri
| | - Ryan M Nunley
- Department of Orthopedic Surgery, Washington University School of Medicine/Barnes-Jewish Hospital, St. Louis, Missouri
| | - Robert L Barrack
- Department of Orthopedic Surgery, Washington University School of Medicine/Barnes-Jewish Hospital, St. Louis, Missouri
| |
Collapse
|
175
|
Inoue D, Kabata T, Kajino Y, Taga T, Hasegawa K, Yamamoto T, Takagi T, Ohmori T, Tsuchiya H. The influence of surgical approach on postoperative pelvic tilt after total hip arthroplasty. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2017; 27:1131-1138. [DOI: 10.1007/s00590-017-1946-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 03/11/2017] [Indexed: 12/29/2022]
|
176
|
Chang JD, Kim IS, Bhardwaj AM, Badami RN. The Evolution of Computer-Assisted Total Hip Arthroplasty and Relevant Applications. Hip Pelvis 2017; 29:1-14. [PMID: 28316957 PMCID: PMC5352720 DOI: 10.5371/hp.2017.29.1.1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 01/31/2017] [Accepted: 02/09/2017] [Indexed: 12/27/2022] Open
Abstract
In total hip arthroplasty (THA), the accurate positioning of implants is the key to achieve a good clinical outcome. Computer-assisted orthopaedic surgery (CAOS) has been developed for more accurate positioning of implants during the THA. There are passive, semi-active, and active systems in CAOS for THA. Navigation is a passive system that only provides information and guidance to the surgeon. There are 3 types of navigation: imageless navigation, computed tomography (CT)-based navigation, and fluoroscopy-based navigation. In imageless navigation system, a new method of registration without the need to register the anterior pelvic plane was introduced. CT-based navigation can be efficiently used for pelvic plane reference, the functional pelvic plane in supine which adjusts anterior pelvic plane sagittal tilt for targeting the cup orientation. Robot-assisted system can be either active or semi-active. The active robotic system performs the preparation for implant positioning as programmed preoperatively. It has been used for only femoral implant cavity preparation. Recently, program for cup positioning was additionally developed. Alternatively, for ease of surgeon acceptance, semi-active robot systems are developed. It was initially applied only for cup positioning. However, with the development of enhanced femoral workflows, this system can now be used to position both cup and stem. Though there have been substantial advancements in computer-assisted THA, its use can still be controversial at present due to the steep learning curve, intraoperative technical issues, high cost and etc. However, in the future, CAOS will certainly enable the surgeon to operate more accurately and lead to improved outcomes in THA as the technology continues to evolve rapidly.
Collapse
Affiliation(s)
- Jun-Dong Chang
- Arthroplasty Center, Department of Orthopedic Surgery, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Korea
| | - In-Sung Kim
- Arthroplasty Center, Department of Orthopedic Surgery, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Korea
| | - Atul M Bhardwaj
- Arthroplasty Center, Department of Orthopedic Surgery, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Korea
| | - Ramachandra N Badami
- Arthroplasty Center, Department of Orthopedic Surgery, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Korea
| |
Collapse
|
177
|
Lee C, Kim Y, Kim HW, Kim YS, Jang J. A robust method to extract the anterior pelvic plane from CT volume independent of pelvic pose. Comput Assist Surg (Abingdon) 2017; 22:20-26. [PMID: 28245365 DOI: 10.1080/24699322.2017.1293737] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
PURPOSE The anterior pelvic plane (APP) is commonly used as a reference plane to assess acetabular orientation. However, conventional methods for determining the APP may not be accurate and are prone to user variability. To overcome these issues, we developed a robust method to accurately extract the APP independent of pelvic pose using three-dimensional pelvic computed tomography (CT). MATERIALS AND METHODS Twenty-eight studies for suspected nonmusculoskeletal conditions were obtained. The APP was determined by four landmarks that were automatically extracted from user-defined regions of interest (ROIs) with compensation of pelvic pose. The APP defined from these landmarks was quantitatively compared to the APPs determined by an expert and an unskilled. Intraobserver reliability was measured to evaluate the time-interval variability. Finally, we evaluate the robustness of this method to patient posture using an arbitrarily rotated volume. The intraclass correlation coefficients (ICCs) were calculated to determine the interobserver and intraobserver reliabilities. RESULTS The ICC values for the four landmarks and the APP were similar between the semiautomated method and expert determination (ICC >0.937). The ICC values for intraobserver reliability over time for our method were all 1, demonstrating high reliability. Furthermore, agreement between the parameters determined from the original volume and the rotated volume was nearly perfect. CONCLUSIONS Our method is a useful measurement tool for the APP as it is robust, and the results were similar to an experienced surgeon's determination. Furthermore, it was independent to the direction of the CT slice and more robust than a measurement by an unskilled.
Collapse
Affiliation(s)
- Changhwan Lee
- a Department of Biomedical Engineering , Hanyang University , Seoul , Korea
| | - Yeesuk Kim
- b Department of Orthopedic Surgery , College of Medicine, Hanyang University , Seoul , Korea
| | - Hyung Wook Kim
- c Institute of Innovative Surgical Technology , Hanyang University , Seoul , Korea
| | - Young Soo Kim
- c Institute of Innovative Surgical Technology , Hanyang University , Seoul , Korea
| | - Jongseong Jang
- c Institute of Innovative Surgical Technology , Hanyang University , Seoul , Korea
| |
Collapse
|
178
|
Does Pelvic Sagittal Inclination in the Supine and Standing Positions Change Over 10 Years of Follow-Up After Total Hip Arthroplasty? J Arthroplasty 2017; 32:877-882. [PMID: 27693053 DOI: 10.1016/j.arth.2016.08.035] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 07/27/2016] [Accepted: 08/22/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Functional anteversion and inclination of the cup change as the pelvic sagittal inclination (PSI) changes. The purposes of this study were to investigate the chronological changes of PSI during a 10-year follow-up period after total hip arthroplasty (THA) and to report the characteristics of patients who showed a greater than 10° change in the PSI from the supine to the standing position. METHODS The subjects were 70 patients who were followed up for 10 years after THA. PSI values in the supine and standing positions were measured by 2D-3D matching using computed tomography images and pelvic radiographs. PSI values before THA and 1, 5, and 10 years after THA were compared in both the supine and standing positions. RESULTS Supine PSI showed less than 5° of change, whereas standing PSI showed a significant decrease with time over the 10-year period. Although 43% of patients with less than 10° of difference in the PSI between the supine and standing positions before THA increased PSI posteriorly (reclining) more than 10° in standing from the supine position at 10 years, no late dislocation was observed. CONCLUSION Supine PSI showed no significant change, but standing PSI showed a significant increase posteriorly with time over a 10-year period. However, this PSI change did not reach the level that it caused negative consequences such as late dislocation. The pelvic position in the supine position might still be a good functional reference position of the pelvis for aiming to achieve proper cup alignment at 10 years.
Collapse
|
179
|
Analysis of the Pelvic Functional Orientation in the Sagittal Plane: A Radiographic Study With EOS 2D/3D Technology. J Arthroplasty 2017; 32:1027-1032. [PMID: 27789098 DOI: 10.1016/j.arth.2016.09.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 09/15/2016] [Accepted: 09/19/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND We investigated the relationship between pelvic incidence (PI) with anterior pelvic plane angle (APPA), pelvic tilt (PT) angle, and sacral slope (SS) in standing and sitting positions to identify the best parameter expressing the pelvic functional orientation in the sagittal plane. METHODS We enrolled 109 consecutive patients (M:F = 43:66) eligible for a primary total hip arthroplasty (THA) with an average age of 63.4 years (15-85). EOS 2D/3D radiography was performed in standing and sitting positions before THA to evaluate the functional pelvic orientation. 3D images took into account the patient-specific sagittal balance measuring APPA, PT, SS, and PI. RESULTS In standing position, functional parameters measured 5° ± 7.1 for APPA, 11° ± 8.3 for PT, 43° ± 8.5 for SS, and 53° ± 10.9 for PI. In sitting position, they were -18° ± 10.4 for APPA, 34° ± 11.8 for PT, 20° ± 12.6 for SS, and 54° ± 10.9 for PI. There was no significant difference between men and women in terms of the functional parameters in both positions. No relationship was found between APPA and PI in both positions. SS correlated with PI in standing (r = 0.66; P < .0001; R2 = 0.44) and sitting (r = 0.51; P < .0001; R2 = 0.26). PT correlated with PI in standing (r = 0.65; P < .0001; R2 = 0.42) and sitting (r = 0.38; P < .0001; R2 = 0.14). CONCLUSION SS shows the highest correlation with functional pelvic tilt. The study suggests that adjustments in acetabular anteversion during primary THA should be based on SS.
Collapse
|
180
|
Zhang H, Wang Y, Ai S, Chen X, Wang L, Dai K. Three-dimensional acetabular orientation measurement in a reliable coordinate system among one hundred Chinese. PLoS One 2017; 12:e0172297. [PMID: 28207829 PMCID: PMC5313188 DOI: 10.1371/journal.pone.0172297] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 02/02/2017] [Indexed: 11/18/2022] Open
Abstract
Determining three-dimensional (3D) acetabular orientation is important for several orthopaedic scenarios, but the complex geometries of both pelvis and acetabulum make measurements of orientation unreliable. Acetabular orientation may also differ between the sexes or racial groups. We aimed to (1) establish and evaluate a novel method for measuring 3D acetabular orientation, (2) apply this new method to a large population of Chinese subjects, and (3) report relevant characteristics of native acetabular orientation in this population. We obtained computed tomography scans taken for non-orthopaedic indications in 100 Chinese subjects (50 male, 50 female). A novel algorithm tailored to segmentation of the hip joint was used to construct 3D pelvic models from these scans. We developed a surface-based method to establish a reliable 3D pelvic coordinate system and software to semi-automatically measure 3D acetabular orientation. Differences in various acetabular orientations were compared within and between subjects, between male and female subjects, and between our subjects and subjects previously reported by another group. The reported method was reliable (intraclass correlation coefficient >0.999). Acetabular orientations were symmetrical within subjects, but ranged widely between subjects. The sexes differed significantly in acetabular anteversion (average difference, 3.0°; p < 0.001) and inclination (1.5°; p < 0.03). Acetabular anteversion and inclination were substantially smaller among our Chinese subjects than previously reported for American subjects. Thus, our method was reliable and sensitive, and we detected sex differences in 3D acetabular orientation. Awareness of differences between the sexes and races is the first step towards better reconstruction of the hip joint for all individuals and could also be applied to other orthopaedic scenarios.
Collapse
Affiliation(s)
- Henghui Zhang
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedics, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yiping Wang
- Institute of Biomedical Manufacturing and Life Quality Engineering, State Key Laboratory of Mechanical System and Vibration, School of Mechanical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Songtao Ai
- Department of Radiology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaojun Chen
- Institute of Biomedical Manufacturing and Life Quality Engineering, State Key Laboratory of Mechanical System and Vibration, School of Mechanical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Liao Wang
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedics, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- * E-mail: (LW); (KD)
| | - Kerong Dai
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedics, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- * E-mail: (LW); (KD)
| |
Collapse
|
181
|
Differentiating Hip Pathology From Lumbar Spine Pathology: Key Points of Evaluation and Management. J Am Acad Orthop Surg 2017; 25:e23-e34. [PMID: 28045713 DOI: 10.5435/jaaos-d-15-00740] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
The diagnosis and treatment of patients who have both hip and lumbar spine pathologies may be a challenge because overlapping symptoms may delay a correct diagnosis and appropriate treatment. Common complaints of patients who have both hip and lumbar spine pathologies include low back pain with associated buttock, groin, thigh, and, possibly, knee pain. A thorough patient history should be obtained and a complete physical examination should be performed in these patients to identify the primary source of pain. Plain and advanced imaging studies and diagnostic injections can be used to further delineate the primary pathology and guide the appropriate sequence of treatment. Both the surgeon and the patient should understand that, although one pathology is managed, the management of the other pathology may be necessary because of persistent pain. The recognition of both entities may help reduce the likelihood of misdiagnosis, and the management of both entities in the appropriate sequence may help reduce the likelihood of persistent symptoms.
Collapse
|
182
|
Pierrepont J, Hawdon G, Miles BP, Connor BO, Baré J, Walter LR, Marel E, Solomon M, McMahon S, Shimmin AJ. Variation in functional pelvic tilt in patients undergoing total hip arthroplasty. Bone Joint J 2017; 99-B:184-191. [DOI: 10.1302/0301-620x.99b2.bjj-2016-0098.r1] [Citation(s) in RCA: 125] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Accepted: 10/25/2016] [Indexed: 11/05/2022]
Abstract
Aims The pelvis rotates in the sagittal plane during daily activities. These rotations have a direct effect on the functional orientation of the acetabulum. The aim of this study was to quantify changes in pelvic tilt between different functional positions. Patients and Methods Pre-operatively, pelvic tilt was measured in 1517 patients undergoing total hip arthroplasty (THA) in three functional positions – supine, standing and flexed seated (the moment when patients initiate rising from a seated position). Supine pelvic tilt was measured from CT scans, standing and flexed seated pelvic tilts were measured from standardised lateral radiographs. Anterior pelvic tilt was assigned a positive value. Results The mean pelvic tilt was 4.2° (-20.5° to 24.5°), -1.3° (-30.2° to 27.9°) and 0.6° (-42.0° to 41.3°) in the three positions, respectively. The mean sagittal pelvic rotation from supine to standing was -5.5° (-21.8° to 8.4°), from supine to flexed seated was -3.7° (-48.3° to 38.6°) and from standing to flexed seated was 1.8° (-51.8° to 39.5°). In 259 patients (17%), the extent of sagittal pelvic rotation could lead to functional malorientation of the acetabular component. Factoring in an intra-operative delivery error of ± 5° extends this risk to 51% of patients. Conclusion Planning and measurement of the intended position of the acetabular component in the supine position may fail to predict clinically significant changes in its orientation during functional activities, as a consequence of individual pelvic kinematics. Optimal orientation is patient-specific and requires an evaluation of functional pelvic tilt pre-operatively. Cite this article: Bone Joint J 2017;99-B:184–91.
Collapse
Affiliation(s)
- J. Pierrepont
- The University of Sydney, School of Aerospace,
Mechanical and Mechatronic Engineering, Building J07, Sydney NSW
2006, Australia and Optimized Ortho, 17 Bridge
Street, Pymble NSW 2073, Australia
| | - G. Hawdon
- Malabar Orthopaedic Clinic, 43
The Avenue, Windsor, VIC
3181, Australia
| | - B. P. Miles
- Optimized Ortho, 17
Bridge Street, Pymble NSW 2073, Australia
| | - B. O’ Connor
- Optimized Ortho, 17
Bridge Street, Pymble NSW 2073, Australia
| | - J. Baré
- Melbourne Orthopaedic Group, 33
The Avenue, Windsor, VIC
3191, Australia
| | - L. R. Walter
- Peninsula Orthopaedics, 812
Pittwater Rd, Dee Why, NSW
2099, Australia
| | - E. Marel
- Peninsula Orthopaedics, 812
Pittwater Rd, Dee Why, NSW
2099, Australia
| | - M. Solomon
- Sydney Orthopaedic Specialists, Suite
29, Prince of Wales Private Hospital, Randwick
NSW 2031, Australia
| | - S. McMahon
- Monash University, 43
The Avenue, Windsor VIC 3181, Australia
| | - A. J. Shimmin
- Monash
University, 43 The Avenue, Windsor VIC 3181, Australia and Melbourne
Orthopaedic Group, 33 The Avenue, Windsor, VIC
3191, Australia
| |
Collapse
|
183
|
Seagrave KG, Troelsen A, Malchau H, Husted H, Gromov K. Acetabular cup position and risk of dislocation in primary total hip arthroplasty. Acta Orthop 2017; 88:10-17. [PMID: 27879150 PMCID: PMC5251254 DOI: 10.1080/17453674.2016.1251255] [Citation(s) in RCA: 146] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - Hip dislocation is one of the most common complications following total hip arthroplasty (THA). Several factors that affect dislocation have been identified, including acetabular cup positioning. Optimal values for cup inclination and anteversion are debatable. We performed a systematic review to describe the different methods for measuring cup placement, target zones for cup positioning, and the association between cup positioning and dislocation following primary THA. Methods - A systematic search of literature in the PubMed database was performed (January and February 2016) to identify articles that compared acetabular cup positioning and the risk of dislocation. Surgical approach and methods for measurement of cup angles were also considered. Results - 28 articles were determined to be relevant to our research question. Some articles demonstrated that cup positioning influenced postoperative dislocation whereas others did not. The majority of articles could not identify a statistically significant difference between dislocating and non-dislocating THA with regard to mean angles of cup anteversion and inclination. Most of the articles that assessed cup placement within the Lewinnek safe zone did not show a statistically significant reduction in dislocation rate. Alternative target ranges have been proposed by several authors. Interpretation - The Lewinnek safe zone could not be justified. It is difficult to draw broad conclusions regarding a definitive target zone for cup positioning in THA, due to variability between studies and the likely multifactorial nature of THA dislocation. Future studies comparing cup positioning and dislocation rate should investigate surgical approach separately. Standardized tools for measurement of cup positioning should be implemented to allow comparison between studies.
Collapse
Affiliation(s)
- Kurt G Seagrave
- Faculty of Medicine, University of New South Wales, Sydney, Australia,Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre. Copenhagen, Denmark
| | - Anders Troelsen
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre. Copenhagen, Denmark
| | - Henrik Malchau
- Harris Orthopaedic Laboratory, Massachusetts General Hospital,Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA, USA
| | - Henrik Husted
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre. Copenhagen, Denmark
| | - Kirill Gromov
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre. Copenhagen, Denmark,Correspondence:
| |
Collapse
|
184
|
Abstract
Being one of the most successful surgeries in the history of medicine, the indications for total hip arthroplasty have widened and are increasingly being offered to younger and fitter patients. This has also led to high expectations for longevity and outcomes. Acetabular cup position has a significant impact on the results of hip arthroplasty as it affects dislocation, abductor muscle strength, gait, limb lengths, impingement, noise generation, range of motion (ROM), wear, loosening, and cup failure. The variables in cup position are depth, height, and angular position (anteversion and inclination). The implications of change in depth of center of rotation (COR) are medialized versus anatomical positioning. As opposed to traditional medialization with beneficial effects on joint reaction force, the advantages of an anatomical position are increasingly recognized. The maintained acetabular offset offers advantages in terms of ROM, impingement, cortical rim press fit, and maintaining medial bone stock. The height of COR influences muscle activity and limb lengths and available bone stock for cup support. On the other hand, ideal angular position remains a matter of much debate and reliably achieving a target angular position remains elusive. This is not helped by variations in the way we describe angular position, with operative, radiologic, or anatomic definitions being used variably to describe anteversion and inclination. Furthermore, pelvic tilt plays a major role in functional positions of the acetabulum. In addition, commonly used techniques of positioning often do not inform us of the real orientation of the pelvis on operating table, with possibility of significant adduction, flexion, and external rotation of the pelvis being possibilities. This review article brings together the evidence on cup positioning and aims to provide a systematic and pragmatic approach in achieving the best position in individual cases.
Collapse
Affiliation(s)
- Deepu Bhaskar
- Department of Trauma and Orthopaedics, Centre for Hip Surgery, Wrightington Hospital, Hall Lane, Appley Bridge, Lancashire WN6 9EP, UK
| | - Asim Rajpura
- Department of Trauma and Orthopaedics, Centre for Hip Surgery, Wrightington Hospital, Hall Lane, Appley Bridge, Lancashire WN6 9EP, UK
| | - Tim Board
- Department of Trauma and Orthopaedics, Centre for Hip Surgery, Wrightington Hospital, Hall Lane, Appley Bridge, Lancashire WN6 9EP, UK,Address for correspondence: Prof. Tim Board, Centre for Hip Surgery, Wrightington Hospital, Hall Lane, Appley Bridge, Lancashire WN6 9EP, UK. E-mail:
| |
Collapse
|
185
|
Repeated posterior dislocation of total hip arthroplasty after spinal corrective long fusion with pelvic fixation. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2016; 26:100-106. [DOI: 10.1007/s00586-016-4880-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Revised: 09/24/2016] [Accepted: 11/11/2016] [Indexed: 10/20/2022]
|
186
|
Spencer-Gardner L, Pierrepont J, Topham M, Baré J, McMahon S, Shimmin AJ. Patient-specific instrumentation improves the accuracy of acetabular component placement in total hip arthroplasty. Bone Joint J 2016; 98-B:1342-1346. [DOI: 10.1302/0301-620x.98b10.37808] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Accepted: 06/02/2016] [Indexed: 01/02/2023]
Abstract
Aims Accurate placement of the acetabular component during total hip arthroplasty (THA) is an important factor in the success of the procedure. However, the reported accuracy varies greatly and is dependent upon whether free hand or navigated techniques are used. The aim of this study was to assess the accuracy of an instrument system that incorporates 3D printed, patient-specific guides designed to optimise the placement of the acetabular component. Patients and Methods A total of 100 consecutive patients were prospectively enrolled and the accuracy of placement of the acetabular component was measured using post-operative CT scans. Results The mean absolute deviation from the planned inclination and anteversion was 3.9° (0.0° to 13.6°) and 3.6° (0.0° to 12.9°), respectively. In 91% of cases the planned target of +/-10° was achieved for both inclination and anteversion. Conclusion Accurate placement of the acetabular component can be achieved using patient-specific guides and is superior to free hand techniques and comparable to navigated and robotic techniques. Cite this article: Bone Joint J 2016;98-B:1342–6.
Collapse
Affiliation(s)
- L. Spencer-Gardner
- Melbourne Orthopaedic Group, 33
The Avenue, Windsor, VIC
3181, Australia
| | - J. Pierrepont
- University of Sydney, Building
J07, Level 4. Sydney, NSW
2006, Australia
| | - M. Topham
- Optimized Ortho, 17
Bridge Street Pymble, NSW 2073, Australia
| | - J. Baré
- Melbourne Orthopaedic Group, 33
The Avenue, Windsor, VIC
3181, Australia
| | - S. McMahon
- Monash University, Malabar Orthopaedic
Clinic, 43 The Avenue, Windsor, VIC
3181, Australia
| | - A. J. Shimmin
- Monash University, 33
The Avenue, Windsor 3181, Victoria, Australia
| |
Collapse
|
187
|
Bendaya S, Anglin C, Lazennec JY, Allena R, Thoumie P, Skalli W. Good vs Poor Results After Total Hip Arthroplasty: An Analysis Method Using Implant and Anatomic Parameters With the EOS Imaging System. J Arthroplasty 2016; 31:2043-52. [PMID: 27297114 DOI: 10.1016/j.arth.2015.12.036] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 12/03/2015] [Accepted: 12/21/2015] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Existing imaging techniques and single-parameter analyses, in nonfunctional positions, fail to detect the differences between patients with good vs poor results after total hip arthroplasty. METHODS The present study developed an analysis method using the EOS full-body, low-dose, biplanar, weightbearing imaging system to compare good vs poor patients after total hip arthroplasty and to report on our preliminary experiences (17 good, 18 poor). RESULTS All revision cases were found to have at least 4 high or low implant or anatomic parameters relative to the good group. These included acetabular cup orientation, sagittal pelvic tilt, sacral slope, femoral offset, and neck-shaft angle. Acetabular cup orientation differed significantly between groups. CONCLUSION With the EOS system, a large cohort can be studied relatively quickly and at low dose, which could lead to patient-specific guidelines.
Collapse
Affiliation(s)
- Samy Bendaya
- Institut de Biomécanique Humaine Georges Charpak, Arts et Métiers ParisTech, Paris, France; Hôpital Rothschild AP-HP, Paris, France
| | - Carolyn Anglin
- Institut de Biomécanique Humaine Georges Charpak, Arts et Métiers ParisTech, Paris, France; Biomedical Engineering Civil Engineering, and McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Canada
| | - Jean-Yves Lazennec
- Institut de Biomécanique Humaine Georges Charpak, Arts et Métiers ParisTech, Paris, France; Departments of Orthopaedics and Anatomy, Hôpital Universitaire Pitié-Salpêtrière, UPMC, Paris, France
| | - Rachele Allena
- Institut de Biomécanique Humaine Georges Charpak, Arts et Métiers ParisTech, Paris, France
| | | | - Wafa Skalli
- Institut de Biomécanique Humaine Georges Charpak, Arts et Métiers ParisTech, Paris, France
| |
Collapse
|
188
|
Acetabular Cup Anteversion and Inclination in Hip Range of Motion to Impingement. J Arthroplasty 2016; 31:264-8. [PMID: 27067753 DOI: 10.1016/j.arth.2016.01.067] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 01/20/2016] [Accepted: 01/26/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND It is advocated that to avoid complications associated with femoral stem impingement, acetabular positioning should be within a "safe zone." However, instability remains prevalent despite accurate cup positioning, with studies showing dislocations of cups despite positioning within safe zones. We assessed cup position angles associated with impingement in a group of subjects during (1) squatting; (2) object pick-up; and (3) low chair rise. METHODS Ten subjects (mean age, 69 years; body mass index, 28.4 kg/m(2)) performed object pick up, squatting, and low-chair rising. Femur-to-pelvis relative motions were recorded for flexion/extension, abduction/adduction, and internal/external rotation. A previously reported custom-validated hip range-of-motion 3-dimensional simulator was used, set for neutral pelvic tilt and 15(°) of stem version. Acetabular cup abduction and anteversion combinations were chosen. The software computed minimum clearances between components for any hip position. An idealized tapered wedge stem with a 132° neck angle and a 36-mm femoral head was used. RESULTS Eight subjects had impingement on squatting between 21(°) and 51(°) of inclination. During object pick-up, 9 subjects had impingement with inclination and anteversion angles within the "safe zone." In low-chair rise, 8 subjects had impingement at cup inclination angles between 14.5(°) and 49.5(°). CONCLUSION The true acetabular target for impingement-avoidance motion is much smaller than previously believed and varies considerably between patients. Certain activities, such as picking up an object, low-chair rise, and squatting reduce the size of the safe zone. This study supports the need for better individualized preoperative patient-specific planning and intraoperative execution for placement of the components.
Collapse
|
189
|
Esposito CI, Miller TT, Kim HJ, Barlow BT, Wright TM, Padgett DE, Jerabek SA, Mayman DJ. Does Degenerative Lumbar Spine Disease Influence Femoroacetabular Flexion in Patients Undergoing Total Hip Arthroplasty? Clin Orthop Relat Res 2016; 474:1788-97. [PMID: 27020429 PMCID: PMC4925410 DOI: 10.1007/s11999-016-4787-2] [Citation(s) in RCA: 157] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 03/08/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Sitting pelvic tilt dictates the proximity of the rim of the acetabulum to the proximal femur and, therefore, the risk of impingement in patients undergoing total hip arthroplasty (THA). Sitting position is achieved through a combination of lumbar spine segmental motions and/or femoroacetabular articular motion in the lumbar-pelvic-femoral complex. Multilevel degenerative disc disease (DDD) may limit spine flexion and therefore increase femoroacetabular flexion in patients having THAs, but this has not been well characterized. Therefore, we measured standing and sitting lumbar-pelvic-femoral alignment in patients with radiographic signs of DDD and in patients with no radiographic signs of spine arthrosis. QUESTIONS/PURPOSES We asked: (1) Is there a difference in standing and sitting lumbar-pelvic-femoral alignment before surgery among patients undergoing THA who have no radiographic signs of spine arthrosis compared with those with preexisting lumbar DDD? (2) Do patients with lumbar DDD experience less spine flexion moving from a standing to a sitting position and therefore compensate with more femoroacetabular flexion compared with patients who have no radiographic signs of arthrosis? METHODS Three hundred twenty-five patients undergoing primary THA had preoperative low-dose EOS spine-to-ankle lateral radiographs in standing and sitting positions. Eighty-three patients were excluded from this study for scoliosis (39 patients), spondylolysis (15 patients), not having five lumbar vertebrae (7 patients), surgical or disease fusion (11 patients), or poor image quality attributable to high BMI (11 patients). In the remaining 242 of 325 patients (75%), two observers categorized the lumbar spine as either without radiographic arthrosis or having DDD based on defined radiographic criteria. Sacral slope, lumbar lordosis, and proximal femur angles were measured, and these angles were used to calculate lumbar spine flexion and femoroacetabular flexion in standing and sitting positions. Patients were aligned in a standardized sitting position so that their femurs were parallel to the floor to achieve approximately 90° of apparent hip flexion. RESULTS After controlling for age, sex, and BMI, we found patients with DDD spines had a mean of 5° more posterior pelvic tilt (95% CI, -2° to -8° lower sacral slope angles; p < 0.01) and 7° less lumbar lordosis (95% CI, -10° to -3°; p < 0.01) in the standing position compared with patients without radiographic arthrosis. However, in the sitting position, patients with DDD spines had 4° less posterior pelvic tilt (95% CI, 1°-7° higher sacral slope angles; p = 0.02). From standing to sitting position, patients with DDD spines experienced 10° less spine flexion (95% CI, -14° to -7°; p < 0.01) and 10° more femoroacetabular flexion (95% CI, 6° to 14°; p < 0.01). CONCLUSIONS Most patients undergoing THA sit in a similar range of pelvic tilt, with a small mean difference in pelvic tilt between patients with DDD spines and those without radiographic arthrosis. However, in general, the mechanism by which patients with DDD of the lumbar spine achieve sitting differs from those without spine arthrosis with less spine flexion and more femoroacetabular flexion. CLINICAL RELEVANCE When planning THA, it may be important to consider which patients sit with less posterior pelvic tilt and those who rotate their pelvises forward to achieve a sitting position, as both mechanisms will limit or reduce the functional anteversion of the acetabular component in a patient with a THA. Our study provides some additional perspective on normal relationships between pelvic tilt and femoroacetabular flexion, but further research might better characterize this relationship in outliers and the possible implications for posterior instability after THA.
Collapse
Affiliation(s)
| | - Theodore T. Miller
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Han Jo Kim
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Brian T. Barlow
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Timothy M. Wright
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Douglas E. Padgett
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Seth A. Jerabek
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - David J. Mayman
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| |
Collapse
|
190
|
Khan M, Beckingsale T, Marsh M, Holland J. Difference in the acetabular cup orientation in standing and supine radiographs. J Orthop 2016; 13:168-70. [PMID: 27408490 DOI: 10.1016/j.jor.2016.03.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 03/27/2016] [Indexed: 01/19/2023] Open
Abstract
Acetabular orientation changes with that of the pelvis during lying and standing. This study was designed to measure these changes. We assessed 17 BHR replacements using EBRA software. The mean acetabular anteversion was more (p = 0.02) on erect than supine radiographs. Linear regression analysis showed that anteversion and inclination increased in some while decreased in others, and Bland and Altman analysis showed wide limits of agreement. The changes in acetabular orientation are thus subject to significant variations between the patients. We suggest studying the factors affecting acetabular orientation in standing to help reduce joint reaction forces and improve outcomes.
Collapse
Affiliation(s)
- Munir Khan
- Newcastle Upon Tyne Hospitals NHS Trust, Freeman Hospital, Newcastle Upon Tyne, England NE7 7DN, United Kingdom
| | - Tom Beckingsale
- Newcastle Upon Tyne Hospitals NHS Trust, Freeman Hospital, Newcastle Upon Tyne, England NE7 7DN, United Kingdom
| | - Martin Marsh
- Newcastle Upon Tyne Hospitals NHS Trust, Freeman Hospital, Newcastle Upon Tyne, England NE7 7DN, United Kingdom
| | - Jim Holland
- Newcastle Upon Tyne Hospitals NHS Trust, Freeman Hospital, Newcastle Upon Tyne, England NE7 7DN, United Kingdom
| |
Collapse
|
191
|
Inaba Y, Kobayashi N, Suzuki H, Ike H, Kubota S, Saito T. Preoperative planning for implant placement with consideration of pelvic tilt in total hip arthroplasty: postoperative efficacy evaluation. BMC Musculoskelet Disord 2016; 17:280. [PMID: 27412447 PMCID: PMC4944317 DOI: 10.1186/s12891-016-1120-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 06/09/2016] [Indexed: 11/13/2022] Open
Abstract
Background In total hip arthroplasty (THA), tilting of the pelvis alters the cup placement angles. Thus, the cup angles need to be planned with consideration of the effects of pelvic tilt. In the present study, we evaluated the efficacy of preoperative planning for implant placement with consideration of pelvic tilt in THA, and the accuracy of a CT-based computer navigation for implant positioning. Methods We examined 75 hips of 75 patients who underwent THA and were followed-up for one year postoperatively. The patients were divided into three groups (anterior, intermediate, posterior tilt) according to their preoperative pelvic tilt. Preoperative planning for implant placement was made with consideration of pelvic tilt and a CT-based navigation was used to execute the preoperative planning. Cup inclination, cup anteversion, and combined anteversion (CA) in supine and standing positions were examined 1 year after THA. The accuracy of the computer navigation was also examined. Results Mean CA was 35.0 ± 5.8° in supine position and 39.3 ± 5.7° in standing position. CA did not differ among the three subgroups (anterior, intermediate, posterior tilt) in either supine or standing position, indicating implant placements to be equally effective. The desired CA (37.3°) was midway between those in supine and standing positions for each subgroup. Respective mean absolute errors between preoperative planning and postoperative CT measurement was 5.3 ± 5.2° for CA. Conclusion We obtained favorable THA results with preoperative planning with consideration of pelvic tilt by demonstrating supine and standing CA to be unaffected by preoperative pelvic tilt one year postoperatively. Mean absolute error of CA between preoperative planning and postoperative measurement was 5° with use of the CT-based navigation.
Collapse
Affiliation(s)
- Yutaka Inaba
- Department of Orthopaedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan.
| | - Naomi Kobayashi
- Department of Orthopaedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Haruka Suzuki
- Department of Orthopaedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Hiroyuki Ike
- Department of Orthopaedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - So Kubota
- Department of Orthopaedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Tomoyuki Saito
- Department of Orthopaedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
| |
Collapse
|
192
|
Pierrepont JW, Feyen H, Miles BP, Young DA, Baré JV, Shimmin AJ. Functional orientation of the acetabular component in ceramic-on-ceramic total hip arthroplasty and its relevance to squeaking. Bone Joint J 2016; 98-B:910-6. [DOI: 10.1302/0301-620x.98b7.37062] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2015] [Accepted: 03/07/2016] [Indexed: 11/05/2022]
Abstract
Aims Long-term clinical outcomes for ceramic-on-ceramic (CoC) bearings are encouraging. However, there is a risk of squeaking. Guidelines for the orientation of the acetabular component are defined from static imaging, but the position of the pelvis and thus the acetabular component during activities associated with edge-loading are likely to be very different from those measured when the patient is supine. We assessed the functional orientation of the acetabular component. Patients and Methods A total of 18 patients with reproducible squeaking in their CoC hips during deep flexion were investigated with a control group of 36 non-squeaking CoC hips. The two groups were matched for the type of implant, the orientation of the acetabular component when supine, the size of the femoral head, ligament laxity, maximum hip flexion and body mass index. Results The mean functional anteversion of the acetabular component at the point when patients initiated rising from a seated position was significantly less in the squeaking group than in the control group, 8.1° (-10.5° to 36.0°) and 21.1° (-1.9° to 38.4°) respectively (p = 0.002). Conclusion The functional orientation of the acetabular component during activities associated with posterior edge-loading are different from those measured when supine due to patient-specific pelvic kinematics. Individuals with a large anterior pelvic tilt during deep flexion might be more susceptible to posterior edge-loading and squeaking as a consequence of a significant decrease in the functional anteversion of the acetabular component. Cite this article: Bone Joint J 2016;98-B:910–16.
Collapse
Affiliation(s)
- J. W. Pierrepont
- The University of Sydney, NSW
2006, Australia; Optimized Ortho, NSW, Australia
| | - H. Feyen
- Melbourne Orthopaedic Group, 33
The Avenue, Windsor, VIC
3181, Australia
| | | | - D. A. Young
- Melbourne Orthopaedic Group, 33
The Avenue, Windsor, VIC
3181, Australia
| | - J. V. Baré
- Melbourne Orthopaedic Group, 33
The Avenue, Windsor, VIC
3181, Australia
| | - A. J. Shimmin
- Melbourne Orthopaedic Group, 33
The Avenue, Windsor, VIC
3181, Australia
| |
Collapse
|
193
|
Accuracy of measuring acetabular cup position after total hip arthroplasty: comparison between a radiographic planning software and three-dimensional computed tomography. INTERNATIONAL ORTHOPAEDICS 2016; 41:731-738. [PMID: 27277948 DOI: 10.1007/s00264-016-3240-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 05/31/2016] [Indexed: 12/26/2022]
Abstract
PURPOSE Various methods are available for measuring acetabular cup position after total hip arthroplasty (THA) on standard anterior-posterior (AP) radiographs. We compared the accuracy of a commercial radiographic planning software program with that of three-dimensional computed tomography (3D-CT) scans. METHODS We obtained plain AP radiographs and 3D-CTs from 65 patients after THA. In addition to calculating cup anteversion and inclination with 3D-CT, we determined the cup position using the radiographic planning software program mediCAD® 2.5 (Hectec, Niederviehbach, Germany). Furthermore, we compared the measurements using the inter-teardrop and bi-ischial lines as pelvic landmarks. RESULTS The mean difference in anteversion between 3D-CT and mediCAD® software was 0.1° using the inter-teardrop line (standard deviation [SD], 8.8°; range, -21° to 23°; p = 0.97) and 0.4° using the bi-ischial line (SD, 8.8°; range, -23° to 21°; p = 0.72). Inclination showed a mean difference of 0.6° using the inter-teardrop line (SD, 4.4°; range, -9° to 21°; p = 0.24) and 0.5° using bi-ischial line (SD, 4.6°; range, -9° to 22°; p = 0.35). The means for absolute differences were 7.2° for anteversion and 3.1° for inclination. With regard to using the bi-ischial or inter-teardrop line, no significant difference was found between the two pelvic landmarks. The intra-class correlation coefficient (ICC) was analysed for anteversion and inclination using either the inter-teardrop line or the bi-ischial line as radiographic baseline. CONCLUSIONS A radiographic planning software program (mediCAD®) is a helpful tool for measuring cup inclination on AP radiographs. With respect to anteversion, measurements are rather susceptible to mistakes with mean inaccuracies of over 7°. Thus, 3D-CT remains the "gold standard" if a lower tolerance limit (±3°) is required for more complex biomechanical evaluations. As a pelvic landmark, the interteardrop line is preferential to the bi-ischial line because of its lower impact on the position of the pelvis.
Collapse
|
194
|
Ranawat CS, Ranawat AS, Lipman JD, White PB, Meftah M. Effect of Spinal Deformity on Pelvic Orientation from Standing to Sitting Position. J Arthroplasty 2016; 31:1222-1227. [PMID: 26725131 DOI: 10.1016/j.arth.2015.11.035] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Revised: 11/19/2015] [Accepted: 11/23/2015] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The effect of fixed spinal deformities on a functional pelvis from standing to sitting is not fully understood. We aimed to assess the change in preoperative sagittal pelvic tilt angle (SPTA) from standing to sitting in patients undergoing total hip arthroplasty, comparing flexible and fixed spinal deformities. METHODS Between July 2011 and October 2011, 68 consecutive unilateral total hip arthroplasties were implanted in 68 patients with a mean age of 71 ± 6 years. Fixed spinal deformity was defined as <10° of the change in SPTA from standing to sitting. Preoperative radiographic evaluation included standing (weight-bearing) anteroposterior and lateral pelvic and lumbosacral radiographs and a sitting lateral pelvic radiograph. RESULTS The mean standing and sitting SPTA was 3.7° of anterior tilt and 17.7° of posterior tilt, respectively (change of 21.4 ± 12.5°). Seventy-five percent had flexible pelvises, all of which had a posterior tilt from standing to sitting. One patient in the fixed pelvis (1.4%) had a loss of posterior tilt from standing to sitting. The mean change of SPTA from standing to sitting in the fixed and flexible pelvis groups was 5.9 ± 3.5° to 26.7 ± 9.6° of posterior tilt, which was statistically significant (P < .05). CONCLUSION There was a significant change in sagittal pelvic tilt from standing to sitting, especially in patients with a flexible spine, in which the functional anteversion increases with sitting. The patients with a fixed pelvis had significantly less SPTA in standing (less anteversion) with less posterior sagittal tilt in sitting, which should be incorporated in cup positioning.
Collapse
Affiliation(s)
| | - Amar S Ranawat
- Department of Orthopaedics, Hospital for Special Surgery, New York, New York
| | - Joseph D Lipman
- Department of Biomechanics, Hospital for Special Surgery, New York, New York
| | - Peter B White
- Department of Orthopaedics, Hospital for Special Surgery, New York, New York
| | - Morteza Meftah
- Department of Orthopaedics, NYU Langone Medical Center, Hospital for Joint Disease, New York, New York
| |
Collapse
|
195
|
|
196
|
Woerner M, Sendtner E, Springorum R, Craiovan B, Worlicek M, Renkawitz T, Grifka J, Weber M. Visual intraoperative estimation of cup and stem position is not reliable in minimally invasive hip arthroplasty. Acta Orthop 2016; 87:225-30. [PMID: 26848628 PMCID: PMC4900086 DOI: 10.3109/17453674.2015.1137182] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Background and purpose - In hip arthroplasty, acetabular inclination and anteversion-and also femoral stem torsion-are generally assessed by eye intraoperatively. We assessed whether visual estimation of cup and stem position is reliable. Patients and methods - In the course of a subgroup analysis of a prospective clinical trial, 65 patients underwent cementless hip arthroplasty using a minimally invasive anterolateral approach in lateral decubitus position. Altogether, 4 experienced surgeons assessed cup position intraoperatively according to the operative definition by Murray in the anterior pelvic plane and stem torsion in relation to the femoral condylar plane. Inclination, anteversion, and stem torsion were measured blind postoperatively on 3D-CT and compared to intraoperative results. Results - The mean difference between the 3D-CT results and intraoperative estimations by eye was -4.9° (-18 to 8.7) for inclination, 9.7° (-16 to 41) for anteversion, and -7.3° (-34 to 15) for stem torsion. We found an overestimation of > 5° for cup inclination in 32 hips, an overestimation of > 5° for stem torsion in 40 hips, and an underestimation < 5° for cup anteversion in 42 hips. The level of professional experience and patient characteristics had no clinically relevant effect on the accuracy of estimation by eye. Altogether, 46 stems were located outside the native norm of 10-20° as defined by Tönnis, measured on 3D-CT. Interpretation - Even an experienced surgeon's intraoperative estimation of cup and stem position by eye is not reliable compared to 3D-CT in minimally invasive THA. The use of mechanical insertion jigs, intraoperative fluoroscopy, or imageless navigation is recommended for correct implant insertion.
Collapse
|
197
|
Demzik AL, Alvi HM, Delagrammaticas DE, Martell JM, Beal MD, Manning DW. Inter-Rater and Intra-Rater Repeatability and Reliability of EOS 3-Dimensional Imaging Analysis Software. J Arthroplasty 2016; 31:1091-5. [PMID: 26732038 DOI: 10.1016/j.arth.2015.11.026] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 11/05/2015] [Accepted: 11/10/2015] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Quantifying ideal component position for the acetabulum and stem during total hip arthroplasty (THA) has been described by many methods. A new imaging method using low-dose digital stereoradiography, the EOS imaging system, is a biplanar low-dose X-ray system that allows for 3-dimensional modeling of lower limbs and semiautomated measurement of pelvic parameters and implant alignment. METHODS Twenty-five patients who underwent primary THA by a single surgeon between October 2014 and December 2014 were retrospectively selected. Only patients with unilateral THA without associated spine pathologies were included, totaling 16 right hips and 9 left hips. There were 8 men and 17 women in the cohort, with a mean age of 67 years (range, 53-82). Three individuals performed measurements of pelvic parameters and implant alignment on 3 separate occasions. An interclass correlation of >0.75 was accepted as evidence of excellent agreement and a confirmation of measurement reliability. RESULTS Before reviewing patient radiographs, 4 pelvic phantom models were analyzed using the EOS 3-dimensional software to verify accuracy. All anatomic and implant measurements performed by the 3 independent reviewers showed interobserver and intraobserver agreement with interclass correlation >0.75. CONCLUSION Three-dimensional modeling of hip implants with the EOS imaging system is a reasonable option for the evaluation of component position after THA.
Collapse
Affiliation(s)
- Alysen L Demzik
- Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Hasham M Alvi
- Department of Orthopaedic Surgery, Northwestern University, Chicago, Illinois
| | | | - John M Martell
- Department of Orthopaedic Surgery, The University of Chicago, Chicago, Illinois
| | - Matthew D Beal
- Department of Orthopaedic Surgery, Northwestern University, Chicago, Illinois
| | - David W Manning
- Department of Orthopaedic Surgery, Northwestern University, Chicago, Illinois
| |
Collapse
|
198
|
Musielak B, Jóźwiak M, Rychlik M, Chen BPJ, Idzior M, Grzegorzewski A. Does hemipelvis structure and position influence acetabulum orientation? BMC Musculoskelet Disord 2016; 17:131. [PMID: 26984181 PMCID: PMC4794903 DOI: 10.1186/s12891-016-0982-2] [Citation(s) in RCA: 2] [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: 10/27/2015] [Accepted: 03/10/2016] [Indexed: 11/19/2022] Open
Abstract
Background Although acetabulum orientation is well established anatomically and radiographically, its relation to the innominate bone has rarely been addressed. If explored, it could open the discussion on patomechanisms of such complex disorders as femoroacetabular impingement (FAI). We therefore evaluated the influence of pelvic bone position and structure on acetabular spatial orientation. We describe this relation and its clinical implications. Methods This retrospective study was based on computed tomography scanning of three-dimensional models of 31 consecutive male pelvises (62 acetabulums). All measurements were based on CT spatial reconstruction with the use of highly specialized software (Rhinoceros). Relations between acetabular orientation (inclination, tilt, anteversion angles) and pelvic structure were evaluated. The following parameters were evaluated to assess the pelvic structure: iliac opening angle, iliac tilt angle, interspinous distance (ISD), intertuberous distance (ITD), height of the pelvis (HP), and the ISD/ITD/HP ratio. The linear and nonlinear dependence of the acetabular angles and hemipelvic measurements were examined with Pearson’s product − moment correlation and Spearman’s rank correlation coefficient. Correlations different from 0 with p < 0.05 were considered statistically significant. Results Comparison of the axis position with pelvis structure with orientation in the horizontal plane revealed a significant positive correlation between the acetabular anteversion angle and the iliac opening angle (p = 0.041 and 0.008, respectively). In the frontal plane, there was a positive correlation between the acetabular inclination angle and the iliac tilt angle (p = 0.025 and 0.014, respectively) and the acetabular inclination angle and the ISD/ITD/HP ratio (both p = 0.048). Conclusions There is a significant correlation of the hemipelvic structure and acetabular orientation under anatomic conditions, especially in the frontal and horizontal planes. In the anteroposterior view, the more tilted-down innominate bone causes a more caudally oriented acetabulum axis, whereas in the horizontal view this relation is reversed. This study may serve as a basis for the discussion on the role of the pelvis in common disorders of the hip.
Collapse
Affiliation(s)
- Bartosz Musielak
- Department of Paediatric Orthopaedics and Traumatology, Poznan University of Medical Sciences, Fredry 10, Poznan, 61-701, Poland.
| | - Marek Jóźwiak
- Department of Paediatric Orthopaedics and Traumatology, Poznan University of Medical Sciences, Fredry 10, Poznan, 61-701, Poland
| | - Michał Rychlik
- Division of Virtual Engineering, Poznan University of Technology, Piotrowo 3, Poznan, 60-965, Poland
| | - Brian Po-Jung Chen
- Department of Paediatric Orthopaedics and Traumatology, Poznan University of Medical Sciences, Fredry 10, Poznan, 61-701, Poland
| | - Maciej Idzior
- Department of Paediatric Orthopaedics and Traumatology, Poznan University of Medical Sciences, Fredry 10, Poznan, 61-701, Poland
| | - Andrzej Grzegorzewski
- Department of Orthopaedics and Paediatric Orthopaedics, Medical University of Lodz, Kościuszki 4, Łódź, Poland
| |
Collapse
|
199
|
Yoon BH, Ha YC, Lee YK, Jo WL, Lee KM, Koo KH. Is transverse acetabular ligament a reliable guide for aligning cup anteversion in total hip arthroplasty?: A measurement by CT arthrography in 90 hips. J Orthop Sci 2016; 21:199-204. [PMID: 26714668 DOI: 10.1016/j.jos.2015.11.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Revised: 10/05/2015] [Accepted: 11/19/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Transverse acetabular ligament (TAL) has been used as a landmark for aligning cup anteversion. The use of TAL as a guide is based on the assumption that TAL version is distributed within the safe zone of acetabular cup. However, there was rarely reported to compare anteversion between TAL and acetabulum using direct measurement methods. The purpose of this study was to measure the anteversion of TAL in computed tomography arthrography (CTA) and compare it with Lewinnek's safe zone and anteversion of bony acetabulum. METHODS 81 patients (90 hips) were selected among 204 patients (228 hips) who received CTA for hip pathology evaluation between March 2010 and June 2013. The anteversion of TAL measured at the lowest level of the acetabular notch and the anteversion of the acetabulum was measured at the level of femoral head center. RESULTS The mean TAL anteversion was 11.8° (SD 4.5, range 0-22.2). In eight hips (8.8%), TAL anteversion was outside the safe zone (15° ± 10°) as defined by Lewinnek. The mean acetabular anteversion was 13.3° ± 4.4° (range -1.0° to 22.6°). There was a strong correlation between TAL anteversion and acetabular anteversion (Pearson's correlation coefficient; 0.908, p < 0.001). CONCLUSIONS TAL anteversion has a large individual variation, and considerable portion of hips have TAL anteversion outside the safety zone of cup anteversion. TAL anteversion is influenced by acetabular anteversion. In hips with retroverted or pauci-anteverted acetabulum, TAL should be used cautiously because there is a risk of cup malposition.
Collapse
Affiliation(s)
- Byung-Ho Yoon
- Department of Orthopaedic Surgery, Inje University College of Medicine, Seoul Paik Hospital, Seoul, South Korea.
| | - Yong-Chan Ha
- Department of Orthopaedic Surgery, Chung-Ang University College of Medicine, Seoul, South Korea.
| | - Young-Kyun Lee
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea.
| | - Woo-Lam Jo
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea.
| | - Kyoung-Min Lee
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea.
| | - Kyung-Hoi Koo
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea.
| |
Collapse
|
200
|
Suzuki H, Inaba Y, Kobayashi N, Ishida T, Ike H, Saito T. Postural and Chronological Change in Pelvic Tilt Five Years After Total Hip Arthroplasty in Patients With Developmental Dysplasia of the Hip: A Three-Dimensional Analysis. J Arthroplasty 2016; 31:317-22. [PMID: 26276573 DOI: 10.1016/j.arth.2015.07.026] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Revised: 07/01/2015] [Accepted: 07/15/2015] [Indexed: 02/01/2023] Open
Abstract
The pelvis generally tilts to the posterior with movement from the supine to standing position, and with time after total hip arthroplasty (THA). This study aimed to investigate changes in pelvic tilt from the preoperative supine position to the standing position at 5 years after THA (pelvic change, PC). We measured pelvic tilt using a 2D-3D matching technique in 77 unilaterally affected patients who underwent primary THA. PC in 8% of all patients was ≤-20°, and the greatest PC was -25°. In these patients, posterior pelvic tilt continued up to 5 years after THA. These patients were older, and their lumbo-lordotic angle was small. For such cases, cup orientation should be planned to account for continuous posterior change in pelvic tilt after THA.
Collapse
Affiliation(s)
- Haruka Suzuki
- Department of Orthopaedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan
| | - Yutaka Inaba
- Department of Orthopaedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan
| | - Naomi Kobayashi
- Department of Orthopaedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan
| | - Takashi Ishida
- Department of Orthopaedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan
| | - Hiroyuki Ike
- Department of Orthopaedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan
| | - Tomoyuki Saito
- Department of Orthopaedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan
| |
Collapse
|