Cup alignment in total hip arthroplasty using the muscle-sparing modified Watson-Jones approach—comparison between lateral and supine positions

A Comparison of Postoperative Outcomes Between Supine and Lateral Patient Positioning in Total Hip Arthroplasty Using the Anterior-Based Muscle Sparing Surgical Approach

Background

To determine any differences in clinical outcomes between patients in the supine vs the lateral position during anterior-based muscle sparing (ABMS) total hip arthroplasty (THA).

Methods

A retrospective review was performed of 368 patients undergoing THA via the ABMS approach (201 lateral vs 167 supine position) at our institution (2015-2019) with a minimum follow-up of 12 months. Inclusion criteria were all patients undergoing primary THA. Exclusion criteria were any revision surgeries and patients who did not undergo the ABMS THA. Outcomes assessed were postoperative complication rates, ambulation distance, length of stay, and Western Ontario and McMaster Universities Osteoarthritis Index pain, stiffness, and physical function scores at 3 time periods (preoperative, 3 months postoperative, and 1 year postoperative).

Results

The supine group had significantly greater postoperative day 0 ambulation distance (150 vs 60 meters; P < .001), while no difference was observed on postoperative day 1 (210 meters in supine vs 200 in lateral; P = .921). Median length of stay was significantly shorter in the supine group (1; interquartile range 0-1) with respect to the lateral group (1; interquartile range 0-2; P < .001). The in-hospital complication rates (2.4% in supine vs 1.5% in lateral; P = .780), return to operating room rates (2.4% in supine vs 1.5% in lateral; P = .780), and readmission rates (5.4% in supine vs 5.0% in lateral; P = .631) were not significantly different between the groups. No significant differences were observed across any Western Ontario and McMaster Universities Osteoarthritis Index scores.

Conclusions

Both supine and lateral patient positioning provide acceptable early surgical outcomes, suggesting that satisfactory results can be obtained via both positions in THAs.

Robotic arm-assisted total hip arthroplasty via a minimally invasive anterolateral approach in the supine position improves the precision of cup placement in patients with developmental dysplasia of the hip

BACKGROUND

This study evaluated the accuracy of the cup alignment angles and spatial cup positioning on computed tomography (CT) images in patients with osteoarthritis secondary to developmental dysplasia of the hip (DDH) who underwent total hip arthroplasty (THA) using a minimally invasive technique via an anterolateral approach in the supine position according to whether a robotic arm-assisted system or a CT-based navigation system was used.

METHODS

We reviewed 60 robotic arm-assisted (RA)-THA cases and 174 navigation-assisted (NA)-THA cases. After propensity score matching, there were 52 hips in each group. Postoperative cup alignment angles and position were assessed by superimposition of a three-dimensional cup template onto the actual implanted cup using postoperative CT images with pelvic coordinates matching the preoperative planning.

RESULTS

The mean absolute error of the inclination angle and the anteversion angle between the preoperative planning and the postoperative measurement was significantly smaller in the RA-THA group (inclination, 1.1° ± 0.9; anteversion, 1.3° ± 1.0) than in the NA-THA group (inclination, 2.2° ± 1.5; anteversion, 3.3° ± 2.5). For acetabular cup positioning, the mean discrepancy between the preoperative planning and the postoperative measurement was 1.3 ± 1.3 mm on the transverse axis, 2.0 ± 2.0 mm on the longitudinal axis, and 1.3 ± 1.7 mm on the sagittal axis in the RA-THA group and 1.6 ± 1.4 mm, 2.6 ± 2.3 mm, and 1.8 ± 1.3 mm, respectively, in the NA-THA group. High precision of cup positioning was observed in both groups with no statistically significant difference.

CONCLUSION

Robotic arm-assisted THA using a minimally invasive technique via an anterolateral approach in the supine position allows accurate cup placement in patients with DDH.

Does total hip arthroplasty result in intercostal nerve injury? A case report and literature review

Neuropathy in surgical-related locations has received concerns after total hip arthroplasty (THA), while the contralateral intercostal nerve (ICN) injury has not been reported. A 25-year-old female patient with a body mass index (BMI) of 17.9 kg/m² visited the orthopedic outpatient clinic with complaints of progressive left hip pain for 20 days. She was diagnosed with left end-stage hip osteoarthritis and developmental dysplasia of the bilateral hips after radiographs and a detailed history-taking. After painstaking consideration, a cementless THA with the standard posterolateral approach was performed under general anesthesia. The procedure was difficult but successful. Unexpectedly, the numbness and slight tingling in the skin of the right breast, lateral chest wall, and axilla cropped up on the first postoperative day. Following the clinical features and the conclusion of the multidisciplinary discussion, we assume that ICN neuropathy is the diagnosis in this case due to compression of the lateral decubitus position during the operation. Her symptoms completely disappeared after using mecobalamin injection (0.5 mg, intramuscular injection, every other day) for 11 days. The Harris left hip score improved from 39 to 94, and the visual analogue scale from 7 was reduced to 2 on the day of discharge. There were no other complications within the first year after the operation. For THA, we should pay attention to some unexpected complications by virtue of the special position, especially in thin and low-BMI people, which suggested that further comprehensive perioperative nursing measures and the beneficial surgical position and anesthesia type were called for.

The role of patient surgical positioning on hip arthroplasty component placement and clinical outcomes: a systematic re-view and meta-analysis

Total Hip Arthroplasty (THA) may be performed through various approaches; however, depending on the surgical position of the patient, the superiority of lateral or supine position is still debated. The aim of this systematic review and meta-analysis was to compare the supine versus lateral position in THA in terms of intraoperative and postoperative outcomes and component placement. The systematic literature search was performed by the use of Cochrane Central, Pub-Med-Medline, and Google Scholar in order to select studies that evaluated clinical outcomes and the outliers of cup alignment for inclination and anteversion between supine and lateral position for hip arthroplasty. Finally, 9 articles were included in this review. The meta-analysis showed no significant differences between the two groups for clinical outcomes, unless for blood loss and VAS (respectively p = 0.05 and p = 0.004 in favour of lateral decubitus). Regarding the number of outliers, the supine decubitus showed significant differences only for the cup anteversion (p = 0.01). However, more prospective studies with a longer follow-up that analyze both clinical and radiological parameters are needed to assess the superiority of supine or lateral patient position for total hip arthroplasty.

Differences in the setting of acetabular component alignment guides between the supine and lateral positions for total hip arthroplasty

The acetabular component orientation in total hip arthroplasty is of critical importance to clinical results. Although navigation systems and surgical robots have been introduced, most surgeons still use acetabular component alignment guides. This study aimed to compare the accuracy between modern acetabular component alignment guides for the lateral position and those for the supine position. Thirteen alignment guides for the lateral position and 10 for the supine position were investigated. All the lateral position alignment guides indicated cup alignment in operative definition, and the supine position alignment guides indicated cup alignment in radiographic definition. For lateral position alignment guides, the anteversion actually indicated by the alignment guide itself was smaller than that indicated by the manufacturer by a mean of 6° (maximum, 9°), and the inclination actually indicated by alignment guides themselves was larger than that by the manufacturer (p < 0.01) by a mean of 2° (maximum, 4°). For supine position alignment guides, the inclination and anteversion indicated by the alignment guide itself were identical with those indicated by the manufacturer. The current study showed that the angles actually indicated and those stated by manufacturers were not identical for lateral position alignment guides.

Difference in tapered wedge stem alignment between supine and lateral position in cementless total hip arthroplasty via modified Watson-Jones anterolateral approach

BACKGROUND

Whether different body positions during surgery affect postoperative stem alignment in total hip arthroplasty (THA) remains unclear. The purpose of this study was to clarify differences in tapered wedge stem alignment between supine and lateral positions in THA under the modified Watson-Jones anterolateral approach.

METHODS

We reviewed 242 consecutive, primary cementless THAs performed with ceramic-on-cross-linked polyethylene via the modified Watson-Jones approach in either supine or lateral positions between 2009 and 2015 (supine group: 113 cases; lateral group: 129 cases). No specific reasons to select supine or lateral positions for the surgery were given during the study period. Computed tomography was performed pre- and postoperatively to measure preoperative femoral anteversion and postoperative stem anteversion, respectively. Stem alignment in coronal and sagittal planes was also evaluated.

RESULTS

Mean difference in stem anteversion and femoral anteversion was 8.6 ± 9.4 in the supine position and 13.0 ± 11.4 in the lateral position (p = 0.0013). Although no significant difference was seen between groups for stem alignment in the coronal plane, flexed implantation was more likely in the supine group (46/113, 40.7%) than in the lateral group (20/129, 15.5%). A significant correlation was found between femoral anteversion and stem anteversion in both the supine and lateral groups (r = 0.68, p < 0.0001 and r = 0.52, p < 0.0001, respectively).

CONCLUSION

Although stem anteversion was more strongly correlated with femoral anteversion in the supine position than in the lateral position, neutral position in the sagittal plane was more likely to be found with the lateral position than with the supine position. Surgeons can achieve ideal stem positioning by considering these results in the modified Watson-Jones approach in both the supine and lateral positions.

Nerve palsy, dislocation and revision rate among the approaches for total hip arthroplasty: a Bayesian network meta-analysis

BACKGROUND

Total hip arthroplasty (THA) is one of the most performed intervention in orthopaedics surgery. Currently, there is no unanimous approval concerning the best approach for THA in terms of nerve palsies, dislocations and further revisions. Hence, a Bayesian network meta-analysis was conducted.

METHODS

The present study was conducted according to the PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of healthcare interventions. The literature search was performed in September 2019. The NMA was performed through the STATA Software/MP routine for Bayesian hierarchical random-effects model analysis.

RESULTS

Data from 10,675 THA were collected. The mean follow-up was 10 months. The anterior approach reported the lowest risk to incur a post-operative dislocation (overall inconsistency P = 0.99). The posterolateral approach reported the lowest risk to incur a nerve palsy (overall inconsistency P = 0.77). The funnel plot revealed a low risk of publication bias. The lateral approach was found to have the lowest risk of resulting in a revision surgery (overall inconsistency P = 0.90).

CONCLUSION

According to our network comparisons, the posterolateral approach for THA represent the favourable exposure with regards to nerve palsy, further dislocations and revision surgeries.

Accuracy of acetabular cup insertion in an anterolateral supine approach using an accelerometer-based portable navigation system

The purpose of this study was to determine the accuracy of acetabular cup insertion during total hip arthroplasty (THA) in a supine position using an accelerometer-based portable navigation system. A single-surgeon study was conducted in which 62 prospective patients with navigation and 42 retrospective patients without navigation as historical controls were compared. The patients underwent THA via an anterolateral supine approach. The absolute values of errors of radiographic inclination and anteversion were calculated. The navigation error was also calculated. The factors that affected the absolute values of errors of cup alignment were determined. The mean absolute error of the postoperative CT measurement from the target angle for radiographic inclination was 3.8° in the navigation group and 6.6° in the control group (P < 0.001). The mean absolute error for anteversion was 3.3° in the navigation group and 5.9° in the control group (P < 0.001). The mean absolute values of navigation error were 3.7° ± 2.8° in inclination and 3.0° ± 2.6° in anteversion. Changes in the pelvic tilt angle among preoperative, intraoperative, and postoperative were the significant risk factors for the absolute values of navigation error of anteversion relative to the anterior pelvic plane. Other factors affecting the absolute values of errors in the navigation group were not found for radiographic inclination and anteversion. The portable navigation system significantly improved the accuracy of cup inclination and anteversion. Changes in the pelvic tilt were the risk factors for the error of anteversion relative to the anterior pelvic plane.

Supine versus lateral position for accurate positioning of acetabular cup in total hip arthroplasty using the modified Watson-Jones approach: A randomized single-blind controlled trial

BACKGROUND

The orientation of the acetabular cup is a critical factor for prevention of various postoperative complications in total hip arthroplasty (THA). Although most patients are treated in either supine or lateral position during surgery, it is still unclear which position is superior to achieve more accurate cup positioning. Our study was conducted in order to answer the following questions: (1) does the supine position provide a higher accuracy of cup positioning than the lateral position in THA using modified Watson-Jones approach? (2) is there any difference in the distribution of cup position between the two positions? Hypothesis Our hypothesis was that the supine position would provide a higher accuracy of cup positioning than the lateral position in THA using modified Watson-Jones approach.

PATIENTS AND METHODS

A single-center prospective randomized study (registration number: UMIN000021627) was conducted between May 2016 and December 2017. We recruited a total of 60 participants undergoing unilateral primary cementless THA using modified Watson-Jones anterolateral approach based on the result of the sample size calculation. They were randomly assigned to either supine position (n=29) or lateral position (n=31). The cup alignment was targeted using a goniometer during surgery. The radiographic cup inclination was targeted to 40° and the radiographic cup anteversion was targeted considering the femoral stem anteversion during surgery. Postoperative cup alignment was measured by plain radiography and computed tomography. We defined the difference between postoperative and target cup angle as target error and our primary outcome was the absolute value of the target angle. As secondary outcome, the distribution of the target error was evaluated. The target errors of each inclination and anteversion were divided into 3 groups; neutral (-3°≤the target error≤3°), positive error (3°<the target error), and negative error (the target error<-3°).

RESULTS

The assessment of primary outcome for all recruited patients showed that supine group was significantly more accurate than lateral group in terms of radiographic inclination (2.4° vs. 4.5°, respectively, mean difference 2.1°; 95% confidence interval, 0.7 to 3.5; p<0.01). There was no significant difference in terms of radiographic cup anteversion (5.6° vs. 5.2°, mean difference 0.4°; 95% confidence interval, -1.8 to 2.6; p=0.69). The rate of positive error of anteversion in supine and lateral group was larger than that of negative value of anteversion (51.7% vs. 10.3% and 48.4% vs. 12.9%, respectively). Any acute complication (dislocation, fracture, and infection) was not found in both groups during postoperative 3 months.

DISCUSSION

In this randomized-controlled trial, higher accuracy of acetabular cup inclination was provided by supine position than by lateral position in THA. On the other hand, there was no significant difference between both groups in terms of cup anteversion. In both groups, most cups were placed with larger anteversion than we targeted. Modified Watson-Jones approach in both positions should be performed considering these results.

STUDY REGISTRATION NUMBER

UMIN000021627. Level of evidence II, randomised controlled study (population-limited).