No difference in clinical outcome, bone density and polyethylene wear 5-7 years after standard navigated vs. conventional cementfree total hip arthroplasty

Spinopelvic alignment and low back pain after total hip arthroplasty: a scoping review

Objective

Spinopelvic alignment is increasingly considered as an essential factor for maintaining an energy-efficient posture in individuals with normal or pathological status. Although several previous studies have shown that changes in the sagittal spinopelvic alignment may occur in patients undergoing total hip arthroplasty (THA), no review of this area has been completed so far. Thus, the objective of this scoping review was to summarize the evidence investigating changes in spinopelvic alignment and low back pain (LBP) following THA.

Data sources

We adhered to the established methodology for scoping reviews. Four electronic databases were systematically searched from inception-December 31, 2021.

Study selection

We selected prospective or retrospective observational or intervention studies that included patients with THA.

Data extraction

Data extraction and levels of evidence were independently performed using standardized checklists.

Data synthesis

A total of 45 papers were included in this scoping review, involving 5185 participants with THA. Pelvic tilt was the most common parameter measured in the eligible studies (n = 26). The results were not consistent across all studies; however, it was demonstrated that the distribution of pelvic tilt following THA had a range of 25° posterior to 20° anterior. Moreover, decreased sacral slope and lower pelvic incidence were associated with increased risk of dislocation in patients with THA. Lumbar spine scoliosis did not change significantly after THA in patients with bilateral hip osteoarthritis (5.50°(1.16°) vs. 3.73°(1.16°); P-value = 0.29). Finally, one study indicated that LBP improvement was not correlated with postoperative changes in spinopelvic alignment parameters. Several methodological issues were addressed in this study, including no sample size calculation and no type-I error adjustment for outcome multiplicity.

Conclusions

Changes in spinopelvic alignment may occur after THA and may improve with time. Patients with a THA dislocation usually show abnormal spinopelvic alignment compared to patients without a THA dislocation. LBP usually improves markedly over time following THA.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05154-7.

Anterior pelvic plane registration accuracy and cup position measurement using ultrasound- and pointer-based navigation in primary total hip arthroplasty

BACKGROUND

Incorrect cup positioning in primary total hip arthroplasty is known as a risk factor for early implant failure. The use of navigation systems leads to more accurate cup positioning.

OBJECTIVE

The aim of this study was to compare the registration accuracy of the anterior pelvic plane and the measurement accuracy of the definite cup position for a pointer computer-assisted orthopaedic navigation system (P-CAOS) and an ultrasound-based navigation tool (US-CAOS) in an intra-individual study design.

METHODS

Anterior pelvic plane registration was performed in 44 patients receiving a primary total hip arthroplasty with P-CAOS and US-CAOS. The cup implantation was performed using US-CAOS. Intraoperatively, the cup position was assessed using P-CAOS and US-CAOS. The postoperative cup position was determined via CT scan. Inclination and anteversion errors were calculated using intraoperative values and CT data. All operations were performed by a single, high-volume surgeon using a minimally invasive anterolateral approach.

RESULTS

The mean inclination error was 0.9∘ in the US-CAOS group and -1.1∘ in the P-CAOS group. This was not statistically significant. The mean anteversion error was significantly reduced (p< 0.001) in the US-CAOS group (1.4∘) compared to the P-CAOS group (-8.0∘). Significantly more cups (23 of 44; 52%) in the P-CAOS group were outliers regarding to the defined anteversion error range of 15∘± 10∘. Outliers in the US-CAOS group amounted to two (of 44; 5%) (p< 0.001). The number of outliers regarding the inclination error range of 40∘± 10∘, did not differ significantly between the P-CAOS (2; 5%) and US-CAOS (1; 2%) group.

CONCLUSION

We were able to show a systematic anterior pelvic plane registration error in this intraindividual study design. US-CAOS based APP landmark registration showed to be significantly more precise compared to P-CAOS registration. The anteversion error of the cup using US-CAOS showed to be significantly reduced compared to the P-CAOS method.

[The superiority of navigation and robotics in hip arthroplasty: fact or myth?]

Computer-assisted surgery represents a relatively novel treatment option in total hip arthroplasty, which has been supported by the technological progress over the latest decades. Navigation and robotics enable increasing the precision of cup positioning, as well as successful biomechanical restoration of leg length and offset. However, the intended target area is still one of debate in literature. Besides the learning curve, the use of navigation and robotics requires additional time and financial expense, which has not yet been addressed in the German healthcare system. This is one reason why computer-assisted surgery has not fully attained everyday routine. The number of comparative studies is limited, but the results are promising. However, if these surrogate measures will end in reduced revision rates or better outcome is unclear. Further prospective studies and register analysis might illuminate the potential benefit of navigation and robotics.

Augmented Reality for Acetabular Component Placement in Direct Anterior Total Hip Arthroplasty

BACKGROUND

Malposition of the acetabular component of a hip prosthesis can lead to poor outcomes. Traditional placement with fluoroscopic guidance results in a 35% malpositioning rate. We compared the (1) accuracy and precision of component placement, (2) procedure time, (3) radiation dose, and (4) usability of a novel 3-dimensional augmented reality (AR) guidance system vs standard fluoroscopic guidance for acetabular component placement.

METHODS

We simulated component placement using a radiopaque foam pelvis. Cone-beam computed tomographic data and optical data from a red-green-blue-depth camera were coregistered to create the AR environment. Eight orthopedic surgery trainees completed component placement using both methods. We measured component position (inclination, anteversion), procedure time, radiation dose, and usability (System Usability Scale score, Surgical Task Load Index value). Alpha = .05.

RESULTS

Compared with fluoroscopic technique, AR technique was significantly more accurate for achieving target inclination (P = .01) and anteversion (P = .02) and more precise for achieving target anteversion (P < .01). AR technique was faster (mean ± standard deviation, 1.8 ± 0.25 vs 3.9 ± 1.6 minute; P < .01), and participants rated it as significantly easier to use according to both scales (P < .05). Radiation dose was not significantly different between techniques (P = .48).

CONCLUSION

A novel 3-dimensional AR guidance system produced more accurate inclination and anteversion and more precise anteversion in the placement of the acetabular component of a hip prosthesis. AR guidance was faster and easier to use than standard fluoroscopic guidance and did not involve greater radiation dose.

Trends and patient factors associated with technology-assisted total hip arthroplasty in the United States from 2005 to 2014

Background

Technology-assisted total hip arthroplasty (TA-THA) using either computer-assisted navigation or robotic assistance has become increasingly more popular. The purpose of this study was to examine the trends and patient factors associated with TA-THA.

Methods

This is a retrospective review utilizing the National Inpatient Sample, a large national database incorporating inpatient hospitalization information. International Classification of Diseases, 9th Revision codes were used to identify patients with hip osteoarthritis who underwent primary total hip arthroplasty (THA). Patients were then separated into those who underwent TA-THA or conventional THA. Outcomes of interest included annual TA-THA utilization; patient and hospital characteristics associated with TA-THA; and trends for length of stay (LOS), cost, and discharge to home.

Results

From 2005 to 2014, a total of 2,588,304 patients with hip osteoarthritis who underwent THA were identified in the National Inpatient Sample database. Of those, 39,700 (1.5%) underwent TA-THA. The number of TA-THA procedures increased from 178 (0.1% of all THA) in 2005 to 10,045 (3.0% of all THA) in 2014, which represented a 30-fold increase in incidence (P-trend <.0001). TA-THA was associated with Hispanic race, higher patient income, and the Western region of the United States. During the study period, there was a trend toward decreased LOS and increased discharge to home for both TA-THA and conventional THA. TA-THA was associated with higher inpatient cost.

Conclusion

TA-THA is being increasingly used in the United States and is associated with specific patient factors. However, the value of TA-THA compared to conventional THA remains unclear and should be assessed with future research.

Level of Evidence

III (retrospective cohort study).

The Accuracy of the Computed Tomography-Based Navigation System in Total Hip Arthroplasty Is Comparable With Crowe Type IV and Crowe Type I Dysplasia: A Case-Control Study

BACKGROUND

Clinical outcomes of total hip arthroplasty (THA) for Crowe type IV are poorer than for Crowe type I, because it is more difficult to accurately position the acetabular components. This study aimed to examine the accuracy of the computed tomography (CT)-based navigation system for acetabular component positioning in primary THA for Crowe type IV.

METHODS

From 2006 to 2018, 29 patients who underwent 34 primary THAs for Crowe type IV were enrolled in the "Type IV" group and 32 patients who underwent 34 THAs for Crowe type I were enrolled in the "Type I" group, formed by matching patients in the Type IV group on age, gender, body mass index, and surgical approach. We investigated (1) the accuracy of the cup size between that at preoperative planning and that actually implanted and (2) the mean deviation of the cup angle and 3-dimensional position of acetabular components between preoperative plan and postoperative records.

RESULTS

The accuracy of the cup size was 79.4% and 94.1% in the Type IV and Type I groups, respectively, without a statistically significant change detected (P = .075). The mean deviations of the cup angle and 3-dimensional position were comparable in both groups.

CONCLUSION

Using the CT-based navigation system, it was possible to accurately implant the acetabular component for Crowe type IV, and the accuracy was comparable to that for Crowe type I. The CT-based navigation system is a useful intraoperative tool to accurately implant the acetabular component, especially with severe pelvic deformities such as Crowe type IV.

Can some early revision total hip arthroplasties be avoided?

Aims

Studying the indications for revision total hip arthroplasty (THA) may enable surgeons to change their practice during the initial procedure, thereby reducing the need for revision surgery. The aim of this study was to identify and describe the potentially avoidable indications for revision THA within five years of the initial procedure.

Patients and Methods

A retrospective review of 117 patients (73 women, 44 men; mean age 61.5 years (27 to 88)) who met the inclusion criteria was conducted. Three adult reconstruction surgeons independently reviewed the radiographs and medical records, and they classified the revision THAs into two categories: potentially avoidable and unavoidable. Baseline demographics, perioperative details, and quality outcomes up to the last follow-up were recorded.

Results

A total of 60 revision THAs (51.3%) were deemed potentially avoidable and 57 (48.7%) were deemed unavoidable. The following were identified as avoidable factors: suboptimal positioning of the acetabular component (29; 48%), intraoperative fracture or a fracture missed on an intraoperative radiograph (20; 33%), early (less than two weeks) aseptic loosening (seven; 11.7%), and symptomatic leg length discrepancy of > 1 cm (four; 6.7%).

Conclusion

A surprisingly large proportion of acute revision THAs are potentially avoidable. Surgeons must carefully evaluate the indications for revision THAs in their practice and identify new methods to address these issues. Cite this article: Bone Joint J 2019;101-B(6 Supple B):97–103.

Technology in Arthroplasty: Are We Improving Value?

PURPOSE OF REVIEW

Total joint arthroplasty is regarded as a highly successful procedure. Patient outcomes and implant longevity, however, are related to proper alignment and position of the prostehses. In an attempt to reduce outliers and improve accuracy and precision of component position, navigation and robotics have been introduced. These technologies, however, come at a price. The goals of this review are to evaluate these technologies in total joint arthroplasty and determine if they add value.

RECENT FINDINGS

Recent studies have demonstrated that navigation and robotics in total joint arthroplasty can decrease outliers while improving accuracy in component positioning. While some studies have demonstrated improved patient reported outcomes, not all studies have shown this to be true. Most studies cite increased cost of equipment and longer operating room times as the major downsides of the technologies at present. Long-term studies are just becoming available and are promising, as some studies have shown decreased revision rates when navigation is used. Finally, there are relatively few studies evaluating the direct cost and value of these technologies. Navigation and robotics have been shown to improve component position in total joint arthroplasty, which can improve patient outcomes and implant longevity. These technologies offer a promising future for total joint arthroplasty.

Advances in hip arthroplasty surgery: what is justified?

Total hip arthroplasty (THA) surgery has shown dramatic changes in terms of increased number of procedures and of technical development in recent years. It has been described as “the operation of the 20^th century” for the excellent results, the high satisfaction of the patients and the improvement of the quality of life.

A lot of variations have been introduced over the last few decades in THA especially in terms of indications (both in younger and older patients), techniques and devices (approaches, tissue preservation, biomaterials and industrial finishing), per-operative management (blood loss and pain control) and post-operative protocols (the so called “fast track” surgery). Looking at all these advances the emerging question is: have all of them been justified both in terms of improvement of the results for the patients and of the cost/benefit ratio from an economical point of view?

The purpose of this paper is to critically analyse the advantages and the disadvantages of the theoretically proposed “advances in hip arthroplasty” and attempt to understand which are justified of such “advances” nowadays, based on the international and the European perspective with a focus on the author’s personal clinical experience.

Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.170008. Originally published online at www.efortopenreviews.org

What do we get from navigation in primary THA?

Navigation in primary total hip arthroplasty has a history of over 20 years. During this process, imageless computer navigation can be particularly helpful in optimally restoring the hip’s biomechanics. This involves the accurate placement of the acetabular component with the determination of the anteversion and abduction, whereby the navigated femur-first technique also allows for a calculation of the combined anteversion. Additional critical parameters such as the reconstruction of the rotation centre, as well as the femoral and acetabular offset, can also be optimally adjusted. Last but not least, an intra-operative evaluation and equalisation of the leg length is possible.

Nonetheless, the disadvantages of this surgical technique in terms of the high costs in the acquisition and preservation of the necessary devices, as well as the longer operation time, must be taken into account. However, economic aspects are not the only thing preventing widespread use of the navigation technique. Determining the plane of reference (APP) for the optimal orientation of the implants is based on palpation of the bony landmarks – and this is influenced by the thickness of the soft tissue layer. Furthermore, the experience of the surgeon constitutes a variable that influences the accuracy of navigation.

In summary, hip navigation certainly offers an interesting technique for the optimisation of total hip arthroplasty with reconstruction of proper biomechanics. At the same time, there is currently a lack of high-quality randomised controlled long-term trials that evaluate the clinical advantage for the patients, together with cost utility and survival rates.

Cite this article: Renner L, Janz V, Perka C, Wassilew GI. What do we get from navigation in primary THA? EFORT Open Rev 2016;1:205-210. 10.1302/2058-5241.1.000034.

No Benefit After THA Performed With Computer-assisted Cup Placement: 10-year Results of a Randomized Controlled Study

BACKGROUND

Computer-assisted surgery (CAS) for cup placement has been developed to improve the functional results and to reduce the dislocation rate and wear after total hip arthroplasty (THA). Previously published studies demonstrated radiographic benefits of CAS in terms of implant position, but whether these improvements result in clinically important differences that patients might perceive remains largely unknown.

QUESTIONS/PURPOSES

We hypothesized that THA performed with CAS would improve 10-year patient-reported outcomes measured by validated scoring tools, reduce acetabular polyethylene wear as measured using a validated radiological method, and increase survivorship.

METHODS

Sixty patients operated on for a THA between April 2004 and April 2005 were randomized into two groups using either the CAS technique or a conventional technique for cup placement. All patient candidates for a THA with the diagnosis of primary arthritis or avascular necrosis were eligible for the CAS procedure and randomly assigned to the CAS group by the Hospital Informatics Department with use of a systematic sampling method. The patients assigned to the freehand cup placement group were matched for sex, age within 5 years, pathological condition, operatively treated side, and body mass index within 3 points. All patients were operated on through an anterolateral approach (patient in the supine position) using cementless implants. In the CAS group, a specific surgical procedure using an imageless cup positioning computer-based navigation system was performed. There were 16 men and 14 women in each group; mean age was 62 years (range, 24-80 years), and mean body mass index was 25 ± 3 kg/m(2). No patient was lost to followup at 10 years, but five patients have died (two in the CAS group and three in the control group). At the 10-year followup, an independent observer blinded to the type of technique performed patients' evaluation. Cup positioning was evaluated postoperatively using a CT scan in the two groups with results previously published. At 10 years, we assessed subjective functional outcome and quality of life using validated questionnaires (SF-12, Harris hip score [HHS], Hip injury and Osteoarthritis Outcome Score). Wear rate was then evaluated on standardized radiographs using a previously validated semiautomated computer analogic measurement method (dual circle method). Complications and survivorship were compared between groups. With our available sample size, this study had 80% power to detect a difference of 4 points out of 100 on the HHS at the p < 0.05 level.

RESULTS

With the numbers available, we found we found no differences between groups regarding HSS at last followup 95.3 ± 5.9 points (CAS group) versus 96.2 ± 4.5 points, a mean difference of 0.9 points (95% confidence interval [CI], -4.3 to 4.6; p = 0.6). There was no difference between the groups in terms of the mean (± SD) acetabular linear wear at 10 years. The mean wear was 0.71 ± 0.6 mm in the CAS group versus 0.77 ± 0.52 mm in the control group, a mean difference of 0.06 mm (95% CI, -0.1 to 0.2; p = 0.54). With the numbers available, there was no difference between the CAS group and the conventional THA groups in terms of survivorship free from aseptic loosening (100%; 95% CI, 100%-95%, versus 100%; 95% CI, 100%-94%; p = 0.3).

CONCLUSIONS

Our observations suggest that CAS used for cup placement does not confer any substantial advantage in function, wear rate, or survivorship at 10 years after THA. Because CAS is associated with added costs and surgical time, future studies need to identify what clinically relevant advantages it offers, if any, to justify its continued use in THA.

LEVEL OF EVIDENCE

Level II, therapeutic study.

Retentive Cup Arthroplasty in Selected Hip Fracture Patients-A Prospective Series With a Minimum 3-Year Follow-Up

Objective:

To evaluate the efficacy of the use of retentive cup primary total hip replacement (THR) in high-dislocation risk subcapital fracture patients.

Methods:

During the years 2008 to 2012, 354 patients with displaced subcapital fracture were operated at our institute. The patients were selected to undergo primary constrained THR according to the following criteria: (1) a preinjury grade 4 or more on the Functional Independence Measure mobility item “5. Locomotion: walking/wheelchair” and grade 4 is defined as “4. Minimal assistance Requiring incidental hands-on help only” (patient performs >75% of the task) and (2) a disease leading to poor motor control. Exclusion criteria were normal muscular control and known infection of the involved joint.

Results:

Of the 354 patients, 87 fulfilled the inclusion criteria and underwent constrained total hip. Average age was 78 years with a female predominance (73%). Fifteen patients had prior hemiparesis, 19 had Parkinson disease, and 35 had generalized sarcopenia. Eighty-five patients had an uneventful recovery, with an average Hip Disability and Osteoarthritis Outcome Score (HOOS) of 76 ± 7 at 2 years. In 2 patients, the prostheses dislocated. In both cases, the dislocation was due to ring displacement and the inner head dislocated. One case was infected and the patient was treated by a Girdlestone procedure. In the other case, the prosthetic head was revised. The patient remained asymptomatic and at 4-year follow-up had an HOOS of 85.

Discussion:

It appears that constrained prosthesis is a suitable treatment for patients with poor muscular control having subcapital fractures. The functional results appear to be superior to those of bipolar arthroplasty and similar to the results of primary total hip arthroplasty while the dislocation risk is <3%.

Conclusion:

Semielective total hip arthroplasty using a retentive cup liner appears to offer good functional results with a low dislocation rate in patients with poor muscular control.

Decreased femoral periprosthetic bone mineral density: a comparative study using DXA in patients after cementless total hip arthroplasty with osteonecrosis of the femoral head versus primary osteoarthritis

INTRODUCTION

Trabecular properties in osteonecrosis of the femoral head (ONFH) are altered for bone volume and structure in the femoral head and proximal femoral canal. We analysed the periprosthetic bone mineral density (BMD) as a correlate to bony ingrowth in patients with ONFH who received a cementless THA.

MATERIALS AND METHODS

We performed a matched-pair analysis of 100 patients with ONFH (n = 50) and primary osteoarthritis (n = 50) who received the same, unilateral cementless THA. We compared the periprosthetic BMD 5 years after surgery by means of dual energy X-ray absorptiometry (DXA) analysing the seven femoral regions of interest (ROIs) according to Gruen.

RESULTS

Within the ONFH group, significantly lower BMD values were found in the ROI 1 and 7 (p < 0.05). No statistically significant difference was found for ROIs 2-6.

CONCLUSIONS

An altered periprosthetic bone stock in the proximal femur in patients with prior ONFH might be a possible risk factor for premature loosening of the femoral stem in THA. Surgeons need to consider coating and fixation philosophy of cementless implants when choosing the right stem for patients with ONFH.

Difference in periprosthetic acetabular bone mineral density: Prior total hip arthroplasty: Osteonecrosis of the femoral head versus primary osteoarthritis

BACKGROUND

Total hip arthroplasty (THA) could be associated with a higher failure rate in patients after osteonecrosis of the femoral head (ONFH) compared to a patient population with primary osteoarthritis prior THA, especially regarding the acetabular component. One major reason could be the compromised acetabular bone quality. Therefore, we performed a retrospective case matched study to assess: 1) Is there a difference in periprosthetic bone mineral density between patients with an ONFH prior THA and controls? 2) Do patients with an ONFH prior THA have a lower bone mineral density compared to controls? 3) Which region in the periprosthetic bone stock is more likely to present differences in periprosthetic bone mineral density between both groups?

HYPOTHESIS

We hypothesized that there is a poorer bone mineral density (BMD) in the periacetabular bone stock in patients with an ONFH prior THA compared to controls receiving a THA due to primary osteoarthritis.

PATIENTS AND METHODS

We compared the BMD of 50 patients with ONFH to 50 controls with primary osteoarthritis prior THA using the same implant in mean 5 years after surgery by means of dual energy X-ray absorptiometry (DXA). We analysed 3 acetabular ROIs according to DeLee and Charnley in a modified measurement technique.

RESULTS

In ROI 3, representing acetabulum's upper aspect, statistically significant lower BMD values for the ONFH group could be found (P < 0.05). No difference was found for the modified ROIs 1 and 2 (respectively medial and lower acetabulum).

DISCUSSION

The results indicate a poorer periacetabular BMD in patients with ONFH prior THA, which might be responsible for premature loosening of the acetabular cup in THA. Due to a lack of literature, further clinical investigations are required to confirm our results.

LEVEL OF EVIDENCE

III: retrospective case-control study.