Positionnement acétabulaire assisté par ordinateur dans les prothèses totales de hanche

Spinopelvic Motion: A Simplified Approach to a Complex Subject

Knowledge of the relationship between the hip and spine is essential in the effort to minimize instability and improve outcomes following total hip arthroplasty (THA). A detailed yet straightforward preoperative imaging workup can provide valuable information on pelvic positioning, which may be helpful for optimum placement of the acetabular cup. For a streamlined preoperative assessment of THA candidates, classification systems with a capacity for providing a more personalized approach to performance of THA have been introduced. Familiarity with these systems and their clinical application is important in the effort to optimize component placement and reduce the risk of instability. Looking ahead, the principles of the hip-spine relationship are being integrated using emerging innovative technologies, promising further streamlining of the evaluation process.

Total Hip Arthroplasty Imageless Navigation Does Not Reduce 90-Day Adverse Events or Five-Year Revisions in a Large National Cohort

BACKGROUND

Computer navigation is an increasingly utilized technology that is considered with total hip arthroplasty (THA). However, the evidence to support this practice is mixed. The current study leveraged a large national administrative database to compare 90-day adverse events as well as 5-year all-cause revision and dislocation rates following THA performed with and without imageless navigation.

METHODS

From 2010 to 2020, a large national database was queried for THA cases performed for osteoarthritis. Cases with or without imageless navigation were matched at 1:4 based on age, sex, and Elixhauser Comorbidity Index (ECI) score. Ninety-day adverse events were assessed and compared with multivariate analyses. Five-year incidence of revision and dislocation were also assessed between cohorts.

RESULTS

Use of THA imageless navigation increased from 2010 (2.5% of cases) to 2020 (5.5% of cases; P < .001). After matching, 11,990 THA patients with navigation and 47,948 without navigation were identified. Overall, 90-day adverse events were observed in 7.0% of the population. Multivariate analysis controlling for age, sex, and ECI demonstrated a difference in only one 90-day adverse event; wound dehiscence, which had higher odds in the navigation group (odds ratio, 1.60, P < .001). At 5 years, revisions for the navigated group were higher (4.4 versus 3.6%: P = .006), while dislocations were not significantly different.

CONCLUSION

THA imageless navigation was not found to be associated with improved 90-day postoperative adverse events or differences in the 5-year rates of revision or dislocation. The current data were unable to identify clear advantages of this evolving technology for primary THA.

Image-Less THA Cup Navigation in Clinical Routine Setup: Individual Adjustments, Accuracy, Precision, and Robustness

Background and Objectives: Even after the ‘death’ of Lewinnek’s safe zone, the orientation of the prosthetic cup in total hip arthroplasty is crucial for success. Accurate cup placement can be achieved with surgical navigation systems. The literature lacks study cohorts with large numbers of hips because postoperative computer tomography is required for the reproducible evaluation of the acetabular component position. To overcome this limitation, we used a validated software program, HipMatch, to accurately assess the cup orientation based on an anterior-posterior pelvic X-ray. The aim of this study were to (1) determine the intraoperative ‘individual adjustment’ of the cup positioning compared to the widely suggested target values of 40° of inclination and 15° of anteversion, and evaluate the (2) ‘accuracy’, (3) ‘precision’, and (4) robustness, regarding systematic errors, of an image-free navigation system in routine clinical use. Material and Methods: We performed a retrospective, accuracy study in a single surgeon case series of 367 navigated primary total hip arthroplasties (PiGalileoTM, Smith+Nephew) through an anterolateral approach performed between January 2011 and August 2018. The individual adjustments were defined as the differences between the target cup orientation (40° of inclination, 15° of anteversion) and the intraoperative registration with the navigation software. The accuracy was the difference between the intraoperative captured cup orientation and the actual postoperative cup orientation determined by HipMatch. The precision was analyzed by the standard deviation of the difference between the intraoperative registered and the actual cup orientation. The outliers were detected using the Tukey method. Results: Compared to the target value (40° inclination, 15° anteversion), the individual adjustments showed that the cups are impacted in higher inclination (mean 3.2° ± 1.6°, range, (−2)−18°) and higher anteversion (mean 5.0° ± 7.0°, range, (−15)−23°) (p < 0.001). The accuracy of the navigated cup placement was −1.7° ± 3.0°, ((−15)−11°) for inclination, and −4.9° ± 6.2° ((−28)−18°) for anteversion (p < 0.001). Precision of the system was higher for inclination (standard deviation SD 3.0°) compared to anteversion (SD 6.2°) (p < 0.001). We found no difference in the prevalence of outliers for inclination (1.9% (7 out of 367)) compared to anteversion (1.63% (6 out of 367), p = 0.78). The Bland-Altman analysis showed that the differences between the intraoperatively captured final position and the postoperatively determined actual position were spread evenly and randomly for inclination and anteversion. Conclusion: The evaluation of an image-less navigation system in this large study cohort provides accurate and reliable intraoperative feedback. The accuracy and the precision were inferior compared to CT-based navigation systems particularly regarding the anteversion. However the assessed values are certainly within a clinically acceptable range. This use of image-less navigation offers an additional tool to address challenging hip prothesis in the context of the hip−spine relationship to achieve adequate placement of the acetabular components with a minimum of outliers.

Imageless navigation for primary total hip arthroplasty: a meta-analysis study

BACKGROUND

There has been a growing interest in imageless navigation for primary total hip arthroplasty (THA). Its superiority over standard THA is debated. This meta-analysis compared surgical duration, implant positioning, Harris Hip Score and rate of dislocation of imageless navigation versus conventional THA.

METHODS

The present study was conducted according to the PRISMA 2020 guidelines. All the clinical trials comparing imageless navigation versus conventional for primary THA were accessed. In January 2022, the following databases were accessed: PubMed, Web of Science, Google Scholar and Embase. No time constraints were used for the search. The outcomes of interest were to compare cup inclination and anteversion, leg length discrepancy, surgical duration, Harris Hip Score and rate of dislocation of imageless navigation versus conventional THA.

RESULTS

Twenty-one studies (2706 procedures) were retrieved. Fifty-two percent of patients were women. There was between-group comparability at baseline in terms of age, body mass index (BMI), visual analogue scale, Harris Hip Score and leg length discrepancy (P > 0.1). Compared with conventional THA, the navigated group demonstrated slightly lower leg length discrepancy (P = 0.02) but longer duration of the surgical procedure (P < 0.0001). Cup anteversion (P = 0.6) and inclination (P = 0.5), Harris Hip Score (P = 0.1) and rate of dislocation (P = 0.98) were similar between the two interventions.

CONCLUSION

Imageless navigation may represent a viable option for THA.

The journey to preventing dislocation after total hip arthroplasty : how did we get here?

Dislocation following total hip arthroplasty (THA) is a well-known and potentially devastating complication. Clinicians have used many strategies in attempts to prevent dislocation since the introduction of THA. While the importance of postoperative care cannot be ignored, particular emphasis has been placed on preoperative planning in the prevention of dislocation. The strategies have progressed from more traditional approaches, including modular implants, the size of the femoral head, and augmentation of the offset, to newer concepts, including patient-specific component positioning combined with computer navigation, robotics, and the use of dual-mobility implants. As clinicians continue to pursue improved outcomes and reduced complications, these concepts will lay the foundation for future innovation in THA and ultimately improved outcomes. Cite this article: Bone Joint J 2022;104-B(1):8-11.

Early postoperative clinical recovery of robotic arm-assisted vs. image-based navigated Total hip Arthroplasty

BACKGROUND

This study compared the early clinical recovery of total hip arthroplasty (THA) using computer navigation systems (nTHA) and robotic arm-assisted THA (rTHA).

METHODS

Thirty prospective subjects who underwent rTHA were clinically compared to 30 subjects who underwent nTHA. Clinical data (surgical time, intraoperative blood loss, pain severity, number of days to independent walking, and Harris Hip Score (HHS) at discharge), and radiographic parameters (inclination and anteversion angles) were statistically compared between the two groups.

RESULTS

Follow-up times were 24.3 ± 6.0 and 27.0 ± 7.0 days in the rTHA and nTHA groups, respectively. The surgical time (135.1 ± 13.9 min vs. 146.2 ± 12.8 min, p = 0.002), number of days to independent walking (7.2 ± 2.0 vs. 11.5 ± 3.0 days, p < 0.001), and postoperative pain using a numeric rating scale on postoperative days 7, 10,, and 14 (1.4 ± 0.9 vs. 2.2 ± 1.2, p = 0.005; 1.0 ± 0.8 vs. 1.8 ± 1.1, p = 0.002; 0.3 ± 0.5 vs. 1.1 ± 0.9, p < 0.001; respectively) were significantly reduced in the rTHA group compared to the nTHA group. The rTHA group showed a significantly higher postoperative HHS compared to the nTHA group (85.3 ± .3.2 vs. 81.0 ± 8.5, p = 0.014). No statistically significant difference was observed in radiographic parameters between the groups; however, the incidence of intraoperative target angle changes was significantly lower in the rTHA group than in the nTHA group (0/30 subjects [0%] vs. 11/30 subjects [36.7%], p < 0.001).

CONCLUSION

The surgical time, postoperative pain, and number of days to independent walking were significantly shorter, and the HHS at discharge was significantly higher in the rTHA group than in the nTHA group. Thus, compared to the nTHA group, the rTHA group showed improved early clinical recovery.

Electromagnetic navigation system for acetabular component placement in total hip arthroplasty is more precise and accurate than the freehand technique: a randomized, controlled trial with 84 patients

Background and purpose - The accuracy of conventional navigation systems depends on precise registration of bony landmarks. We investigated the clinical use of electromagnetic navigation (EMN), with a unique device for precise determination of the anterior pelvic plane. Patients and methods - We randomly allocated patients scheduled for total hip arthroplasty into 2 groups of 42 patients each. In the study group, cups were placed at the predetermined target angles (inclination: 42.5°; anteversion: 15°) with the support of EMN. In the control group, cups were placed freehand aiming at the same target angles. Postoperatively the true position of the cup was determined using computed tomography scan of the pelvis. Precision (root mean squared error, RMSE) bias (mean bias error, ME), accuracy, and duration of surgery were compared between the methods. Results - Cup anteversion was more accurate and precise in the navigated group. The ME in the navigated and freehand group was -1.7° (95% CI -2.4 to 1.1) and -4.5° (CI -6.5 to 2.5), respectively. The RMSE in the navigated and freehand group was 2.8° (CI 2.3-3.2) and 8.0° (CI 6.3-9.5), respectively. The inclination was also more precise in the navigated group, with the RMSE in the navigated and freehand group at 4.6° (CI 3.4-5.9) and 6.5° (CI 5.4-7.5), respectively. The accuracy of the inclination and the duration of surgeries were similar between the groups. Interpretation - Cup placement with the help of EMN is more precise than the freehand technique and it does not affect the duration of surgery.

The current role of robotics in total hip arthroplasty

Robotic total hip arthroplasty (THA) improves accuracy in achieving the planned acetabular cup positioning compared to conventional manual THA.

Robotic THA improves precision and reduces outliers in restoring the planned centre of hip rotation compared to conventional manual THA.

Improved accuracy in restoring hip biomechanics and acetabular cup positioning in robotic THA have not translated to any differences in early functional outcomes, correction of leg-length discrepancy, or postoperative complications compared to conventional manual THA.

Limitations of robotic THA include substantive installation costs, additional radiation exposure, steep learning curves for gaining surgical proficiency, and compatibility of the robotic technology with a limited number of implant designs.

Further higher quality studies are required to compare differences in conventional versus robotic THA in relation to long-term functional outcomes, implant survivorship, time to revision surgery, and cost-effectiveness.

Cite this article: EFORT Open Rev 2019;4:618-625. DOI: 10.1302/2058-5241.4.180088

Clinical efficacy of orthopilot navigation system versus conventional manual of total hip arthroplasty: A systematic review and meta-analysis

BACKGROUND

To compare the clinical efficacy between Orthopilot navigation system and conventional manual surgery in total hip arthroplasty (THA).

METHODS

Electronic databases were searched to identify randomized controlled trials (RCTs) investigating Orthopilot navigation system versus conventional manual in patients undergoing THA. Outcome measurements include anteversion angle, inclination angle, preoperative leg length discrepancy, postoperative leg length discrepancy and femoral offset. Statistical software Stata 12.0 was used for data-analysis.

RESULTS

A total of 5 studies were finally included in this meta-analysis. The results showed that the conventional manual group have a less anteversion angle than that in Orthopilot navigation system group (weighted mean difference (WMD) = 4.67, 95% confidence interval (CI) = 3.53, 5.82, P = .000). And pooled analysis showed that the inclination angle in Orthopilot navigation group was less than that in conventional manual group (WMD = -4.19, 95% CI = -8.00, -0.37, P = .031). There was no significant difference between the preoperative leg length discrepancy and postoperative leg length discrepancy (P > .05). Orthopilot navigation system compared with conventional manual procedure was associated with decreased of femoral offset by 2.76 (WMD = -2.76, 95%CI = -3.90, -1.62, P = .000).

CONCLUSION

Both Orthopilot navigation system and conventional THA result in significant improvements in patient function with similar overall complication rates and have their own edges in cup position.

Higher Acetabular Anteversion in Direct Anterior Total Hip Arthroplasty: A Retrospective Case-Control Study

BACKGROUND

Surgical approach is known as a risk factor that influences cup malposition while performing total hip arthroplasty (THA). However, no study has been conducted comparing cup positioning between the supine direct anterior (DA) and supine direct lateral (DL) THA approaches.

QUESTIONS/PURPOSES

(1) Is there a difference in acetabular cup positioning between supine DA and supine DL THA approaches? (2) Are there differences in complications based on acetabular cup positioning between the two approaches?

METHODS

From 2012 to 2014, 186 patients who underwent primary THAs using DA approach were matched with 186 patients using DL approach by body mass index, age, and gender. Cup anteversion and abduction angles were measured from standing anteroposterior pelvis radiographs by two blinded observers. The Lewinnek safe zone was used as the standard for cup positioning. Cup anteversion, abduction angles, and complications were recorded and compared.

RESULTS

Cup anteversion was on average 3° higher in the DA approach compared to the DL approach. The abduction angle for the DA approach was equivalent to the DL approach both averaging 46° to 47°. There were more DA hips outside of the safe zone (10%) for anteversion than DL (3%) hips. There were no differences in complications between DA and DL approaches.

CONCLUSION

There is a tendency to antevert the acetabular cup when performing THAs using the DA approach, and one must be mindful of this when implanting the acetabular component.

A Smart Tool for Intraoperative Leg Length Targeting in Total Hip Arthroplasty: A Retrospective Cohort Study

BACKGROUND

Leg length discrepancies following total hip arthroplasty (THA) may necessitate subsequent interventions, from heel lifts to revision surgery. Current intraoperative methods of determining leg length are either inaccurate or expensive and invasive.

OBJECTIVE

The objective of the current study was to investigate the ability of a novel, intraoperative smart tool (Intellijoint HIP^®, Intellijoint Surgical^®, Inc., Waterloo, ON) to provide accurate, real-time leg length measurements during THA.

METHODS

We retrospectively reviewed the medical records of 25 patients who underwent THA utilizing the Intellijoint HIP smart tool between February and August 2014. Intraoperative leg length data was compared with radiographic leg length calculations. Two observers blinded to the Intellijoint HIP findings independently assessed all post-procedure radiographs.

RESULTS

The mean difference between smart tool and radiographic measurements was 1.3 mm [CI: -0.1, 2.7]. 88% (22/25) of intraoperative measurements were within 5 mm of radiographic measurements; 100% (25/25) were within 10 mm. A Bland-Altman analysis showed excellent agreement, with 96% (24/25) of measurements within the statistical limit for acceptable agreement, and 84% (21/25) within the clinically acceptable range (± 5 mm). Removal of the first 13 procedures (surgeon training) decreased the mean difference between methods to 0.6 mm [-0.6, 1.9]. All post-training procedures were associated with a difference of <5 mm. There were no reported adverse events related to the use of the smart tool.

CONCLUSION

The Intellijoint HIP smart tool is a safe and accurate tool for providing intraoperative measurements of leg length in real-time.

Total hip arthroplasty with minimal invasive surgery in elderly patients with neck of femur fractures: our institutional experience

The purpose of this study was to investigate whether minimal invasive surgery (MIS) in elderly patients with neck of femur fractures would reduce the peri-operative complications and improve the post-operative ambulation and length of hospital stay in his cohort of patients. Forty elderly patients were treated with either total hip arthroplasty (THA) or bipolar prosthesis using MIS transgluteal approach. A matched reference group treated with a conventional surgical approach formed the control group. All procedures were performed by the same surgeon. Selection of acetabular component included Novae® uncemented press fit dual mobility concept socket or Bipolar Hemi-Arthroplasty (BHA). The femoral implant was Corail® uncemented stem or Fjord® cemented stem when primary instability was encountered. The follow-up was done for all patients and its minimum length was more than thirty-six months. The average length of the skin incision was 7 (6-8) SD 0.7 cm. Eighteen THA, twenty-two BHA, thirty-seven uncemented femoral stems and three cemented stems were implemented. The length of the procedure was the same as those of the reference group. The operative and post-operative blood loss and analgesic use were significantly decreased in the MIS group. Radiographic implants positioning was similar amongst the two groups. No skin complication, no primary infection, no death within ninety days and no dislocations were observed. MIS approach for implanting THA after a femoral neck fracture in the elderly appears to be a reliable procedure.

Use of intraoperative X-rays to optimize component position and leg length during total hip arthroplasty

Proper femoral and acetabular component position and leg length equality are important intraoperative considerations during total hip arthroplasty. Unfortunately, traditional surgical techniques often lead to suboptimal component position, and such deviations have been associated with increased rates of prosthetic wear, dislocation, component loosening, and patient dissatisfaction. Although surgical navigation has been shown to improve reproducibility of component alignment, such technology is not universally available and is associated with significant costs and additional surgical/anesthetic time. In the current study, we found that a routine intraoperative pelvic radiograph could successfully identify malpositioned components and leg length inequalities and could allow for successful correction of identified problems. Unexpected component malposition and leg length inequality occurred in only 1.5% of cases where an intraoperative pelvic radiograph was utilized.

Modification of pelvic orientation after total hip replacement in primary osteoarthritis

The acetabular anteversion angle varies according to the position of the pelvis. The objective goal of our study was to investigate changes in pelvic orientation after total hip replacement for primary osteoarthritis. We studied 89 patients who underwent total hip replacement for primary unilateral osteoarthritis. Lateral pelvic X-rays that included the hips were performed pre-operatively and one year post-operatively. Reference values were calculated by carrying out the same analysis in 100 asymptomatic healthy volunteers. Pelvic orientation was analyzed using the sacral slope. Patients having surgery for osteoarthritis had a decreased pelvic range of motion pre-operatively and post-operatively when compared to healthy volunteers. Post-operatively, this range of motion increased by 3 degrees but remained lower than the norm. Compared to asymptomatic healthy volunteers, patients affected by osteoarthritis had a posterior pelvic extension that decreased post-operatively but did not return to norm. This post-operative pelvic inclination generates a significant decrease in the final cup anteversion and thus may predispose to posterior dislocation. As this post-operative alteration to pelvic orientation cannot be anticipated, computer-aided surgery for cup positioning may not improve the accuracy of the acetabular anteversion in some patients.

Accuracy of reconstruction of the hip using computerised three-dimensional pre-operative planning and a cementless modular neck

Pre-operative computerised three-dimensional planning was carried out in 223 patients undergoing total hip replacement with a cementless acetabular component and a cementless modular-neck femoral stem. Components were chosen which best restored leg length and femoral offset. The post-operative restoration of the anatomy was assessed by CT and compared with the pre-operative plan.

The component implanted was the same as that planned in 86% of the hips for the acetabular implant, 94% for the stem, and 93% for the neck-shaft angle. The rotational centre of the hip was restored with a mean accuracy of 0.73 mm (sd 3.5) craniocaudally and 1.2 mm (sd 2) laterally. Limb length was restored with a mean accuracy of 0.3 mm (sd 3.3) and femoral offset with a mean accuracy of 0.8 mm (sd 3.1).

This method appears to offer high accuracy in hip reconstruction as the difficulties likely to be encountered when restoring the anatomy can be anticipated and solved pre-operatively by optimising the selection of implants. Modularity of the femoral neck helped to restore the femoral offset and limb length.

Reduced variability in cup positioning: the direct anterior surgical approach using navigation

BACKGROUND AND PURPOSE

Correct positioning of the acetabular component is important in total hip arthroplasty (THA). We evaluated the effect of an imageless navigation system on the accuracy of cup positioning using a minimally invasive direct anterior approach.

METHODS

Hip replacements were performed in 44 cadaveric hips (22 cadavers) that were divided randomly into 2 groups. In the study group, THA was performed using an imageless navigation system. In the control group, no navigation system was used. CT scans were taken postoperatively. Using 3D reconstructions, the cup position was determined in relation to the frontal pelvic plane. The goal was to place each cup at 45 degrees of inclination and 20 degrees of anteversion, as recommended by the manufacturer.

RESULTS

In the navigated group, there was a statistically significantly smaller range of deviation from the target angles of inclination and anteversion relative to the control group.

INTERPRETATION

We conclude that imageless navigation improves the accuracy of cup placement in minimally invasive THA using the direct anterior approach.