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Rivera RJ, Karasavvidis T, Pagan C, Haffner R, Ast MP, Vigdorchik JM, Debbi EM. Functional assessment in patients undergoing total hip arthroplasty. Bone Joint J 2024; 106-B:764-774. [PMID: 39084648 DOI: 10.1302/0301-620x.106b8.bjj-2024-0142.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/02/2024]
Abstract
Aims Conventional patient-reported surveys, used for patients undergoing total hip arthroplasty (THA), are limited by subjectivity and recall bias. Objective functional evaluation, such as gait analysis, to delineate a patient's functional capacity and customize surgical interventions, may address these shortcomings. This systematic review endeavours to investigate the application of objective functional assessments in appraising individuals undergoing THA. Methods The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were applied. Eligible studies of THA patients that conducted at least one type of objective functional assessment both pre- and postoperatively were identified through Embase, Medline/PubMed, and Cochrane Central database-searching from inception to 15 September 2023. The assessments included were subgrouped for analysis: gait analysis, motion analysis, wearables, and strength tests. Results A total of 130 studies using 15 distinct objective functional assessment methods (FAMs) were identified. The most frequently used method was instrumented gait/motion analysis, followed by the Timed-Up-and-Go test (TUG), 6 minute walk test, timed stair climbing test, and various strength tests. These assessments were characterized by their diagnostic precision and applicability to daily activities. Wearables were frequently used, offering cost-effectiveness and remote monitoring benefits. However, their accuracy and potential discomfort for patients must be considered. Conclusion The integration of objective functional assessments in THA presents promise as a progress-tracking modality for improving patient outcomes. Gait analysis and the TUG, along with advancing wearable sensor technology, have the potential to enhance patient care, surgical planning, and rehabilitation.
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Affiliation(s)
- Richard J Rivera
- Adult Reconstruction and Joint Replacement, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
- University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Theofilos Karasavvidis
- Adult Reconstruction and Joint Replacement, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Cale Pagan
- Adult Reconstruction and Joint Replacement, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Rowan Haffner
- Adult Reconstruction and Joint Replacement, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Michael P Ast
- Adult Reconstruction and Joint Replacement, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Jonathan M Vigdorchik
- Adult Reconstruction and Joint Replacement, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Eytan M Debbi
- Adult Reconstruction and Joint Replacement, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
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Fey B, Brenneis M, Stief F, van Drongelen S. Effect of Stem Design and Positioning on the Leg Axis after Total Hip Arthroplasty: A Secondary Analysis. J Clin Med 2024; 13:4453. [PMID: 39124720 PMCID: PMC11313081 DOI: 10.3390/jcm13154453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Revised: 07/10/2024] [Accepted: 07/25/2024] [Indexed: 08/12/2024] Open
Abstract
Background/Objectives: Various parameters, like femoral offset and leg length, are associated with good patient outcomes after total hip arthroplasty. In this prospective study, the effects of stem design, its placement in the proximal femur and the resulting femoral offset on the total leg axis were investigated. Methods: The 27 patients included in this study received biplanar radiography (EOS®, EOS Imaging) with 3D reconstruction using sterEOS® both preoperatively and postoperatively. For all leg alignment parameters obtained from the 3D reconstruction and from measurements using mediCAD, the deltas between the postoperative and preoperative values were determined. Patients were divided into those who received a short-stem prosthesis and those who received a straight-stem prosthesis. Results: The change in femoral offset with the implantation of a short-stem prosthesis was significantly greater than that with the implantation of a straight-stem prosthesis (11.4 ± 5.9 vs. 4.6 ± 7.4 mm, p = 0.014). Compared with the straight-stem implantation, short-stem implantation caused a significantly greater increase in the varus orientation of the leg (-1.4 ± 0.9 vs. -0.4 ± 1.4°, p = 0.048). There was no significant difference in the positioning of the short-stem prosthesis compared to the straight-stem prosthesis in the proximal femur (3.6 ± 3.1 vs. 2.6 ± 1.9°, p = 0.317). Conclusions: These findings substantiate the impact of prosthesis design on offset and leg alignment. The implantation of short-stems is more variable and requires precise planning. Intraoperative non-physiological offset changes and varus deviation of the leg axis should be avoided. Trial registration: This study was retrospectively registered with the German Clinical Trials Register (DRKS) under the number DRKS00015053 on the 1 August 2018.
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Affiliation(s)
- Benjamin Fey
- Department of Trauma Surgery and Orthopedics, University Hospital Frankfurt, Goethe University Frankfurt, Marienburgstr. 2, 60528 Frankfurt, Germany; (B.F.); (M.B.); (F.S.)
| | - Marco Brenneis
- Department of Trauma Surgery and Orthopedics, University Hospital Frankfurt, Goethe University Frankfurt, Marienburgstr. 2, 60528 Frankfurt, Germany; (B.F.); (M.B.); (F.S.)
| | - Felix Stief
- Department of Trauma Surgery and Orthopedics, University Hospital Frankfurt, Goethe University Frankfurt, Marienburgstr. 2, 60528 Frankfurt, Germany; (B.F.); (M.B.); (F.S.)
| | - Stefan van Drongelen
- Dr. Rolf M. Schwiete Research Unit for Osteoarthritis, Department of Trauma Surgery and Orthopedics, University Hospital Frankfurt, Goethe University Frankfurt, Marienburgstr. 2, 60528 Frankfurt, Germany
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3
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Brand A, Alexander N, Bauer L, Böhm H, Stief F, van Drongelen S, Wolf SI, Trinler U. [An update on clinical gait analysis : Current developments and applications]. ORTHOPADIE (HEIDELBERG, GERMANY) 2024; 53:494-502. [PMID: 38847874 DOI: 10.1007/s00132-024-04516-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/02/2024] [Indexed: 06/29/2024]
Abstract
The objective acquisition and assessment of joint movements and loads using instrumented gait analysis has become an established tool in clinical diagnostics. In particular, marker-based 3D gait analyses make use of an increasingly comprehensive database for the assessment of orthopaedic or neurological questions. Based on this data and medical-scientific experience, increasingly reliable approaches and evaluation strategies are emerging, which also draw on methods from artificial intelligence and musculoskeletal modelling. This article focusses on marker-based gait analyses of the lower extremity (hip, knee, foot) and how these can be used in a clinically relevant way using current methods, e.g. for determining indications or optimization of surgical planning. Finally, current developments and applications by using alternative methods from sensor technology and optical motion capture will be briefly discussed.
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Affiliation(s)
- Andreas Brand
- Institut für Biomechanik, BG Unfallklinik Murnau, Murnau, Deutschland
- Paracelsus Medizinische Privatuniversität Salzburg, Salzburg, Österreich
| | - Nathalie Alexander
- Labor für Bewegungsanalyse, Ostschweizer Kinderspital, St. Gallen, Schweiz
| | - Leandra Bauer
- Experimentelle Orthopädie, Universitätsklinikum Jena, Campus Eisenberg, Waldkliniken Eisenberg, Eisenberg, Deutschland
| | - Harald Böhm
- Orthopädische Kinderklinik, Behandlungszentrum Aschau gGmbH, Aschau im Chiemgau, Deutschland
- Fakultät Ingenieurwissenschaften und Gesundheit, Hochschule für angewandte Wissenschaft und Kunst Hildesheim/Holzminden/Göttingen, Hildesheim, Deutschland
| | - Felix Stief
- Klinik für Unfallchirurgie und Orthopädie, Universitätsklinikum, Goethe-Universität, Frankfurt am Main, Deutschland
- BG Service- und Rehabilitationszentrum, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt am Main, Deutschland
| | - Stefan van Drongelen
- Dr. Rolf M. Schwiete Forschungsbereich für Arthrose, Klinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Frankfurt, Goethe-Universität Frankfurt, Frankfurt am Main, Deutschland
| | - Sebastian I Wolf
- Klinik für Orthopädie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Ursula Trinler
- Andreas Wentzensen Forschungsinstitut, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland.
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Femoral Anteversion in Total Hip Arthroplasty: Retrospective Comparison of Short- and Straight-Stem Models Using CT Scans. J Clin Med 2023; 12:jcm12062391. [PMID: 36983391 PMCID: PMC10058265 DOI: 10.3390/jcm12062391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/08/2023] [Accepted: 03/16/2023] [Indexed: 03/22/2023] Open
Abstract
Data on reconstruction of the femoral anteversion (FA) and the center of rotation after total hip arthroplasty (THA) are rare. We aimed to answer whether a short-stem fixation enables improved anatomical reconstruction of the FA compared to a straight-stem. Methods: One hundred and thirty patients who underwent short- (n = 89, group A, prospective) or straight-stem THA (n = 41, group B, retrospective) were included. CT scans of the hip, knee, and ankle were performed pre- and postoperatively in group A and in group B during the last follow-up. Femoral torsion was determined using three-dimensional models. Results: The mean preoperative FA was 22.4° ± 11.0°, and the mean postoperative FA was 23.4° ± 10.1°. The relative difference was −0.8° ± 8°, and the absolute difference was 6.4° ± 4.9°. Gender analysis revealed significant differences in preoperative FA between female (f) and male (m) patients (28.1° ± 11.2° (f) vs. 18.4° ± 8.3° (m); p > 0.001) as well as in postoperative FA (26.7° ± 23.5° (f) vs. 21.0° ± 9.7° (m); p < 0.007) in group A. Postoperative FA was higher in group A (mean 6.8°; 23.9° ± 10.1° (f) vs. 16.6° ± 8.6° (m); p < 0.001). Conclusions: The study’s findings suggest that short-stem THA leads to improved anatomical FA reconstruction; however, a substantial postoperative gender-related FA difference was detectable, which may warrant consideration by surgeons when determining the final stem anteversion. It should be noted that the impact of the postoperative gender-related FA difference on clinical outcomes is not entirely clear, and further research is warranted to elucidate this relationship.
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Kato M, Warashina H, Kataoka A, Ando T, Mitamura S. Localization of the ilioischial line on axial computed tomography images for preoperative planning of total hip arthroplasty. BMC Musculoskelet Disord 2022; 23:1032. [PMID: 36451146 PMCID: PMC9710038 DOI: 10.1186/s12891-022-06021-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 11/23/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND If the bony region indicating the ilioischial line is established on the preoperative axial computed tomography (CT) image, the distance between the simulated cup and the ilioischial line can be measured on this image so that the surgeon can use these data to define a more accurate preoperative two-dimensional (2D) template of total hip arthroplasty (THA). This study aimed to verify the hypothesis that on the CT axial image, the cortical bone area, indicated by the superimposition of a line (line α) with a perspective projection angle to the ilioischial line on radiography and tangent to the medial acetabular wall, is the cortical bone that represents the ilioischial line on radiography. METHODS Study 1: If the two measured distances (distance A' and distance B) are sufficiently equal, then the hypothesis can be supported. Distance A' was calculated by multiplying the distance A, between the ilioischial line and the medial margin of the metal cup after THA measured at the level of the hip joint center on the pelvic radiograph, by 0.91 to correct for radiographic magnification. Distance B was defined as the distance between the medial margin of the metal cup and line α on the axial CT image at the level of the hip joint center. These two distances were measured for all 51 hip joints included in the study. Study 2: The difference between distance A and distance A# (distance A on the 2D template) was compared between the group containing 59 primary THAs in which distance B' was measured (distance B in the simulation) and the control group containing 59 primary THAs. RESULTS Study 1: The average distance for A' was 4.5 ± 2 mm, and the average distance for B was 4.7 ± 2.1 mm. The difference between distances A and B was 0.2 ± 0.2 mm. Study 2: The mean difference between distance A and distance A# for the measurement and control groups was 1.8 ± 1.3 mm and 3.7 ± 2.4 mm, respectively (P < 0.001). CONCLUSIONS The ilioischial line is located in the bony region where line α intersects the medial acetabular wall with a maximum overlap on axial CT images.
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Affiliation(s)
- Michitaka Kato
- Nagoya Joint Replacement Orthopaedic Clinic, Iponbashi, Takadaji, Kita-Nagoya, Aichi 481-0011 Japan
| | - Hideki Warashina
- Nagoya Joint Replacement Orthopaedic Clinic, Iponbashi, Takadaji, Kita-Nagoya, Aichi 481-0011 Japan
| | - Akito Kataoka
- Nagoya Joint Replacement Orthopaedic Clinic, Iponbashi, Takadaji, Kita-Nagoya, Aichi 481-0011 Japan
| | - Takanori Ando
- Nagoya Joint Replacement Orthopaedic Clinic, Iponbashi, Takadaji, Kita-Nagoya, Aichi 481-0011 Japan
| | - Shingo Mitamura
- Nagoya Joint Replacement Orthopaedic Clinic, Iponbashi, Takadaji, Kita-Nagoya, Aichi 481-0011 Japan
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DeJesus J, Nishioka S, Andrews SN, Mathews K, Nakasone CK. Improved hip symmetry with an adjustable fluoroscopic grid during total hip arthroplasty. Hip Int 2022:11207000221089274. [PMID: 36127848 DOI: 10.1177/11207000221089274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The use of intraoperative fluoroscopy (IF) is common with direct anterior total hip arthroplasty (THA), however image distortion in IF may limit its usefulness. The supplementation of IF with an adjustable grid (AG) may provide consistently better accuracy in component placement. Therefore, the purpose of this study was to compare the accuracy, consistency, and surgical efficiency between IF only and AG supplementation. METHODS 2 cohorts were retrospectively evaluated, including 573 IF only patients and 211 AG patients having undergone unilateral THA between 2011 and 2018. Post-THA radiographic assessment was performed to evaluate the accuracy of component placement, with target placements for global hip offset (GHO) and leg-length differences (LLD) <10 mm and acetabular cup abduction of 45° (±10°). Accuracy and surgical efficiency were evaluated between groups and over time. RESULTS The AG group had a significant greater percentage of components placed within the target zone compared to IF only for GHO (99.5%, 92.7%, p < 0.001), LLD (99.1%, 96.5%, p = 0.039) and abduction (99.5%, 96.3%, p = 0.009), with no difference in fluoroscopic time (p = 0.973). Over time, accuracy was significantly different in IF group for GHO (p = 0.008) and abduction (p = 0.002) and trended toward significance for LLD (p = 0.055). There were no significant differences over time for the AG group. CONCLUSIONS The addition of an AG to IF significantly increased the accuracy of component placement during direct anterior THA. These results were consistent over 2 years of use and did not decrease surgical efficiency.
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Affiliation(s)
| | - Scott Nishioka
- Straub Medical Center, Bone and Joint Center, Honolulu, HI, USA
| | - Samantha N Andrews
- Straub Medical Center, Bone and Joint Center, Honolulu, HI, USA.,Department of Surgery, University of Hawai'i, Honolulu, HI, USA
| | - Kristin Mathews
- Straub Medical Center, Bone and Joint Center, Honolulu, HI, USA
| | - Cass K Nakasone
- Straub Medical Center, Bone and Joint Center, Honolulu, HI, USA.,Department of Surgery, University of Hawai'i, Honolulu, HI, USA
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7
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Meermans G, Grammatopoulos G, Innmann M, Beverland D. Cup placement in primary total hip arthroplasty: how to get it right without navigation or robotics. EFORT Open Rev 2022; 7:365-374. [PMID: 35638598 PMCID: PMC9257731 DOI: 10.1530/eor-22-0025] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Acetabular component orientation and position are important factors in the short- and long-term outcomes of total hip arthroplasty. Different definitions of inclination and anteversion are used in the orthopaedic literature and surgeons should be aware of these differences and understand their relationships. There is no universal safe zone. Preoperative planning should be used to determine the optimum position and orientation of the cup and assess spinopelvic characteristics to adjust cup orientation accordingly. A peripheral reaming technique leads to a more accurate restoration of the centre of rotation with less variability compared with a standard reaming technique. Several intraoperative landmarks can be used to control the version of the cup, the most commonly used and studied is the transverse acetabular ligament. The use of an inclinometer reduces the variability associated with the use of freehand or mechanical alignment guides.
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Kaszuba SV, Behrens KM, Anderson CB, Gordon AC. A Workflow Change in Anterior Approach Total Hip Arthroplasty Leads to Improved Accuracy of Biomechanical Reconstruction Without Increased Risk of Complications. Arthroplast Today 2021; 10:99-104. [PMID: 34337115 PMCID: PMC8318915 DOI: 10.1016/j.artd.2021.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 05/26/2021] [Accepted: 06/14/2021] [Indexed: 11/21/2022] Open
Abstract
Background During anterior approach total hip arthroplasty (THA), the femur may be an impediment for acetabular access, pushing reamers proximally and consequently altering the hip center. In an effort to address this, the senior author changed the surgical workflow from acetabulum first (AF) to femur first (FF). The objective of this study was to compare the precision of biomechanical hip reconstruction and clinical outcomes between the FF and AF techniques. Methods This is a retrospective, case-control study of 267 anterior THAs (132 AF and 135 FF). A normal, contralateral hip was used to determine the native biomechanical parameters. Using a calibrated software program, radiographic measurements were performed to calculate the hip center position, femoral offset, global offset, and leg length of the operative and native hips using 2-week postoperative anteroposterior pelvis radiographs. Demographics, operative information, hemoglobin change, and complication data were obtained. Functional outcomes were assessed with the Hip Dysfunction and Osteoarthritis Outcome Score for Joint Replacement survey at 1 year postoperatively. Results The groups exhibited similar demographic characteristics. The FF group demonstrated significantly more accurate and more precise reconstruction of horizontal and vertical hip centers, femoral offset, and leg length. There was no significant difference in operative time, hemoglobin change, complication rate, or Hip Disability and Osteoarthritis Outcome Score, Joint Replacement scores between groups. Conclusions The FF technique allowed for more accurate and precise reconstruction of the hip center, leg length, and offset in THA than the AF workflow. Furthermore, the FF approach demonstrated no significant differences in complication rate or blood loss, nor in clinical outcomes. Level of Evidence Therapeutic Study Level III.
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Affiliation(s)
- Stephanie V. Kaszuba
- Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
- Department of Orthopedic Surgery, Illinois Bone & Joint Institute, Morton Grove, IL, USA
| | - Kyle M. Behrens
- Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
- Department of Orthopedic Surgery, Illinois Bone & Joint Institute, Morton Grove, IL, USA
| | - Chad B. Anderson
- Department of Orthopedic Surgery, Illinois Bone & Joint Institute, Morton Grove, IL, USA
- Department of Orthopedic Surgery, Advocate Lutheran General Hospital, Park Ridge, IL, USA
- Department of Orthopedic Surgery, NorthShore Skokie Hospital, Skokie, IL, USA
| | - Alexander C. Gordon
- Department of Orthopedic Surgery, Illinois Bone & Joint Institute, Morton Grove, IL, USA
- Department of Orthopedic Surgery, Advocate Lutheran General Hospital, Park Ridge, IL, USA
- Department of Orthopedic Surgery, NorthShore Skokie Hospital, Skokie, IL, USA
- Corresponding author. Department of Orthopedic Surgery, Illinois Bone & Joint Institute, 9000 Waukegan Road, Suite 200, Morton Grove, IL 60053, USA. Tel.: +1 847-375-3000.
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Biggi S, Banci L, Tedino R, Capuzzo A, Cattaneo G, Tornago S, Camera A. Restoring global offset and lower limb length with a 3 offset option double-tapered stem. BMC Musculoskelet Disord 2020; 21:646. [PMID: 33008343 PMCID: PMC7532558 DOI: 10.1186/s12891-020-03674-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 09/24/2020] [Indexed: 11/10/2022] Open
Abstract
Background A proper restoration of hip biomechanics is fundamental to achieve satisfactory outcomes after total hip arthroplasty (THA). A global hip offset (GO) postoperatively reduction of more than 5 mm was known to impair hip functionality after THA. This study aimed to verify the restoration of the GO radiographic parameter after primary THA by the use of a cementless femoral stem available in three different offset options without length changing. Methods From a consecutive series of 201 patients (201 hips) underwent primary cementless THA in our center with a minimum 3-year follow up, 80 patients (80 hips) were available for complete radiographic evaluation for GO and limb length (LL) and clinical evaluation with Harris hip score (HHS). All patients received the same femoral stem with three different offset options (option A with – 5 mm offset, option B and option C with + 5 mm offset, constant for each sizes) without changing stem length. Results Mean GO significantly increased by + 3 mm (P < 0.05) and mean LL significantly decreased by + 5 mm (P < 0.05) after surgery, meaning that postoperatively the limb length of the operated side increased by + 5 mm. HHS significantly improved from 56.3 points preoperatively to 95.8 postoperatively (P < 0.001). Offset option A was used in 1 hip (1%), B in 59 hips (74%) and C in 20 hips (25%). Conclusions The femur is lateralized with a mean of + 5 mm after surgery than, the native anatomy, whatever type of stem was used. Thus, the use of this 3-offset options femoral stem is effective in restoring the native biomechanical hip parameters as GO, even if 2 offset options were considered sufficient to restore GO.
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Affiliation(s)
- Stefano Biggi
- Clinica Città di Alessandria - Policlinico di Monza, via Moccagatta 30, 15122, Alessandria, AL, Italy. .,Fondazione Lorenzo Spotorno - Onlus, Albenga, SV, Italy.
| | | | - Riccardo Tedino
- Clinica Città di Alessandria - Policlinico di Monza, via Moccagatta 30, 15122, Alessandria, AL, Italy.,Fondazione Lorenzo Spotorno - Onlus, Albenga, SV, Italy
| | - Andrea Capuzzo
- Clinica Città di Alessandria - Policlinico di Monza, via Moccagatta 30, 15122, Alessandria, AL, Italy.,Fondazione Lorenzo Spotorno - Onlus, Albenga, SV, Italy
| | - Gabriele Cattaneo
- Clinica Città di Alessandria - Policlinico di Monza, via Moccagatta 30, 15122, Alessandria, AL, Italy.,Fondazione Lorenzo Spotorno - Onlus, Albenga, SV, Italy
| | | | - Andrea Camera
- Clinica Città di Alessandria - Policlinico di Monza, via Moccagatta 30, 15122, Alessandria, AL, Italy.,Fondazione Lorenzo Spotorno - Onlus, Albenga, SV, Italy
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