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Kaptein BL, Pijls B, Koster L, Kärrholm J, Hull M, Niesen A, Heesterbeek P, Callary S, Teeter M, Gascoyne T, Röhrl SM, Flivik G, Bragonzoni L, Laende E, Sandberg O, Solomon LB, Nelissen R, Stilling M. Guideline for RSA and CT-RSA implant migration measurements: an update of standardizations and recommendations. Acta Orthop 2024; 95:256-267. [PMID: 38819193 PMCID: PMC11141406 DOI: 10.2340/17453674.2024.40709] [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] [Received: 01/10/2024] [Accepted: 04/08/2024] [Indexed: 06/01/2024] Open
Abstract
Opening remarks: These guidelines are the result of discussions within a diverse group of RSA researchers. They were approved in December 2023 by the board and selected members of the International Radiostereometry Society to update the guidelines by Valstar et al. [1]. By adhering to these guidelines, RSA studies will become more transparent and consistent in execution, presentation, reporting, and interpretation. Both authors and reviewers of scientific papers using RSA may use these guidelines, summarized in the Checklist, as a reference. Deviations from these guidelines should have the underlying rationale stated.
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Affiliation(s)
- Bart L Kaptein
- Department of Orthopedics, Leiden University Medical Center, Leiden, The Netherlands.
| | - Bart Pijls
- Department of Orthopedics, Leiden University Medical Center, Leiden, The Netherlands
| | - Lennard Koster
- Department of Orthopedics, Leiden University Medical Center, Leiden, The Netherlands
| | - Johan Kärrholm
- Department of Orthopedics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Maury Hull
- Orthopedic Surgery Department, University of California, Davis, United States
| | - Abby Niesen
- Orthopedic Surgery Department, University of California, Davis, United States
| | - Petra Heesterbeek
- Orthopedic Research Department, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - Stuart Callary
- Department of Orthopedics and Trauma, Royal Adelaide Hospital, Adelaide, Australia
| | - Matthew Teeter
- Department of Medical Biophysics, Western University, London, Canada
| | | | - Stephan M Röhrl
- Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Gunnar Flivik
- Department of Orthopedics, Skane University Hospital, Lund, Sweden
| | | | - Elise Laende
- Department of Surgery, Dalhousie University, Halifax, Canada
| | | | - L Bogdan Solomon
- Department of Orthopedics and Trauma, Royal Adelaide Hospital, Adelaide, Australia
| | - Rob Nelissen
- Department of Orthopedics, Leiden University Medical Center, Leiden, The Netherlands
| | - Maiken Stilling
- Department of Orthopedics, Aarhus University Hospital, Aarhus, Denmark
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Kok RY, Koster LA, Kaptein BL, Fiocco M, Keizer SB. A model-based radiostereometric analysis (RSA) randomized control trial evaluating the stability of the cementless Taperloc hip stem: the TapHip study. Acta Orthop 2022; 93:212-221. [PMID: 34984483 PMCID: PMC8815382 DOI: 10.2340/17453674.2021.1127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 12/02/2021] [Indexed: 01/31/2023] Open
Abstract
Background and purpose - The Taperloc Complete hip is the successor of the Taperloc hip, aiming to increase range of motion and optimizing femoral fit with intermediate stem sizes. We evaluated whether these design changes affect fixation, and this RSA study compares 2-year migration. Patients and methods - In this prospective, multi-arm study, 100 patients were randomized to cementless total hip arthroplasty (THA) with Taperloc Complete full profile (TCFP), Taperloc Complete reduced distal (TCRD), Taperloc full profile (TFP), or Taperloc reduced distal (TRD). Migration was measured with model-based RSA postoperatively, and after 3, 12, and 24 months. Results - Results based on mixed-model analysis on 2-year postoperative RSA data from 74 patients showed similar subsidence (mm) in the first 3 months (mean [95% CI] TCFP 0.44 [0.20-0.69], TCRD 0.91 [0.40-1.42], TFP 0.71 [0.22-1.19], TRD 1.25 [0.58-1.91]) and stabilization afterwards. The TCFP showed statistically significantly less retroversion (°) at 2-year postoperatively compared with TFP and TCRD (mean [95% CI] TCFP: -0.13 [-0.64 to 0.38], TCRD: 0.84 [0.35-1.33], TFP: 0.56 [0.12-1.00], TRD: 0.37 [-0.35 to 1.09]). Interpretation - As expected in successful cementless THA, RSA shows stabilization after initial subsidence. Based on these results the Taperloc Complete stem is expected to have similar long-term fixation to the Taperloc stems. The reduced distal groups have larger, but statistically non-significant, initial migration compared with the TCFP group, which could be due to implantation in Dorr B, C femur types. It may be important to consider the femur shape for choosing a full profile or reduced distal stem to minimize migration.
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Affiliation(s)
- Ruben Y Kok
- Focuskliniek Orthopedie, Haaglanden Medical Center, the Hague; Department of Orthopaedics, Leiden University Medical Center, Leiden.
| | - Lennard A Koster
- Department of Orthopaedics, Leiden University Medical Center, Leiden.
| | - Bart L Kaptein
- Department of Orthopaedics, Leiden University Medical Center, Leiden.
| | - Marta Fiocco
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden; Mathematical Institute, Leiden University, Leiden, The Netherlands.
| | - Stefan B Keizer
- Focuskliniek Orthopedie, Haaglanden Medical Center, the Hague.
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Finnilä S, Löyttyniemi E, Aro HT. Denosumab in Cementless Total Hip Arthroplasty: Multivariate Reanalysis of
3D
Femoral Stem Migration and the Influence on Outliers. JBMR Plus 2021; 6:e10588. [PMID: 35229065 PMCID: PMC8861983 DOI: 10.1002/jbm4.10588] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 11/10/2021] [Accepted: 11/22/2021] [Indexed: 11/13/2022] Open
Abstract
In cementless total hip arthroplasty, adequate implant stability is necessary for the success of osseointegration and rapid clinical recovery. Postoperative femoral stem migration, measured by radiostereometric analysis (RSA), defines the initial stability achieved during surgical implantation. In a recent trial of 65 postmenopausal women randomized 1:1 denosumab:placebo, denosumab failed to reduce the initial migration of a cementless femoral stem despite the successful prevention of periprosthetic bone loss. The trial applied the current RSA standard, which examined stem migration on an axis‐by‐axis basis and did not consider more complex three‐dimensional (3D) migration. Therefore, we performed a reanalysis of the trial data using a multivariate hierarchical linear mixed model (LMM). As an additional limitation, the data included influential outliers. Women with normal bone mineral density exhibited significantly (p = 0.036) less stem subsidence compared with osteopenic and osteoporotic women. Denosumab significantly decreased the variance of stem migration in osteopenic and osteoporotic women. The mean magnitude of 3D stem migration did not differ between denosumab‐treated and placebo‐treated women (p = 0.820). After application of a common statistical definition for RSA outlier identification, there were eight (12%) outliers, six in the placebo group and two in the denosumab group (p = 0.149). After exclusion of the outliers, the repeated LMM analysis demonstrated a trending difference in 3D stem migration (p = 0.086), with a significant difference of z‐axis rotation (valgus‐varus tilt) of the femoral stem (p = 0.029). The observed effect size was small and without clinically important differences in postoperative recovery. Based on a Monte Carlo simulation with random‐generated 3D migration data, multivariate LMM showed greater statistical power than univariate analyses. The application of hierarchical LMM facilitated the analysis of implant migration as a factual 3D event. The observed trend in the lower number of RSA outliers in denosumab‐treated subjects warrants powered large‐scale trials. © 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Sami Finnilä
- Department of Orthopaedic Surgery and Traumatology Turku University Hospital and University of Turku Turku Finland
| | - Eliisa Löyttyniemi
- Unit of Biostatistics, Department of Clinical Medicine University of Turku Turku Finland
| | - Hannu T Aro
- Department of Orthopaedic Surgery and Traumatology Turku University Hospital and University of Turku Turku Finland
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Grupp RB, Murphy RJ, Hegeman RA, Alexander CP, Unberath M, Otake Y, McArthur BA, Armand M, Taylor RH. Fast and automatic periacetabular osteotomy fragment pose estimation using intraoperatively implanted fiducials and single-view fluoroscopy. Phys Med Biol 2020; 65:245019. [PMID: 32590372 DOI: 10.1088/1361-6560/aba089] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Accurate and consistent mental interpretation of fluoroscopy to determine the position and orientation of acetabular bone fragments in 3D space is difficult. We propose a computer assisted approach that uses a single fluoroscopic view and quickly reports the pose of an acetabular fragment without any user input or initialization. Intraoperatively, but prior to any osteotomies, two constellations of metallic ball-bearings (BBs) are injected into the wing of a patient's ilium and lateral superior pubic ramus. One constellation is located on the expected acetabular fragment, and the other is located on the remaining, larger, pelvis fragment. The 3D locations of each BB are reconstructed using three fluoroscopic views and 2D/3D registrations to a preoperative CT scan of the pelvis. The relative pose of the fragment is established by estimating the movement of the two BB constellations using a single fluoroscopic view taken after osteotomy and fragment relocation. BB detection and inter-view correspondences are automatically computed throughout the processing pipeline. The proposed method was evaluated on a multitude of fluoroscopic images collected from six cadaveric surgeries performed bilaterally on three specimens. Mean fragment rotation error was 2.4 ± 1.0 degrees, mean translation error was 2.1 ± 0.6 mm, and mean 3D lateral center edge angle error was 1.0 ± 0.5 degrees. The average runtime of the single-view pose estimation was 0.7 ± 0.2 s. The proposed method demonstrates accuracy similar to other state of the art systems which require optical tracking systems or multiple-view 2D/3D registrations with manual input. The errors reported on fragment poses and lateral center edge angles are within the margins required for accurate intraoperative evaluation of femoral head coverage.
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Affiliation(s)
- R B Grupp
- Department of Computer Science, Johns Hopkins University, Baltimore, MD, United States of America
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Parashin S, Gascoyne T, Zarrabian M. A phantom and cadaveric study of radiostereometric analysis in posterior cervical and lumbar spinal fusion. Spine J 2020; 20:1333-1343. [PMID: 32272254 DOI: 10.1016/j.spinee.2020.03.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 03/26/2020] [Accepted: 03/27/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Detecting pseudarthrosis following spinal fusion is important for accurate diagnosis and treatment. Current diagnostic measures hold certain drawbacks. Radiostereometric analysis (RSA) is a radiographic technique with the capability to measure intervertebral segment changes and may be a novel way of assessing fusion. PURPOSE The purpose of this work was to measure the accuracy and precision of RSA in instrumented posterior cervical and lumbar spinal fusion for measuring intervertebral movement. Further, to gain surgical practice with RSA in spine and determine optimal bead placements. STUDY DESIGN Artificial bone and cadaveric spine models were used to simulate a 3-level cervical (C3-C6) and a 2-level (L4-S1) lumbosacral posterior spinal fusion to analyze bead placements and to measure RSA accuracy and precision. METHODS Preliminary RSA bead placements were planned and measured in the artificial model. Secondary bead placements were adjusted slightly in the cadaveric model to consider additional fusion scenarios. Bead spread, detectability, and stability were measured to determine optimal placements. Translational and rotational precision of both models were measured. Accuracy was measured in the artificial spine model. Model-based RSA software was used for analysis. RESULTS Optimal bead placements were found to be throughout the lateral mass of C3-C6 and in the spinous process, transverse process, and within the screw canal of L4-S1. Detectability was high among all segments. Spread was greater in L4-S1 than C3-C6 due to bead collinearity along the transverse axis of the cervical vertebrae. Translational and rotational RSA accuracy in cervical and lumbosacral regions ranged between 0.005 to 0.014 mm and 0.058 to 0.208°. Translational and rotational precision measured in the phantom models ranged 0.017 to 0.131 mm and 0.058 to 0.394° in C3-C6, and 0.086 to 0.191 mm and 0.200 to 0.369° in L4-S1. Translational and rotational precision measured in the cadaveric models ranged 0.054 to 0.548 mm and 0.148 to 1.386° in C3-C6, and 0.068 to 0.164 mm and 0.100 to 0.270° in L4-S1. CONCLUSIONS RSA was found to be a feasible radiographic technique in C3-C6 and L4-S1 spinal fusion when measured in artificial and cadaveric models. Optimal bead placements were determined. Bead spread was shown to be better throughout the lumbar region than the cervical region due to anatomical size variations. RSA accuracy and precision were within acceptable RSA criteria. CLINICAL SIGNIFICANCE The results from this work contribute to the accuracy, precision, and bead placements for studying RSA in cervical and lumbar spinal fusions. This work may further support the development of clinical studies to assess spinal fusion by evaluating postoperative intervertebral movement using RSA.
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Affiliation(s)
- Sara Parashin
- The Orthopaedic Innovation Centre, Suite 320-1155 Concordia Avenue, Winnipeg, Manitoba, Canada, R2K 2M9.
| | - Trevor Gascoyne
- The Orthopaedic Innovation Centre, Suite 320-1155 Concordia Avenue, Winnipeg, Manitoba, Canada, R2K 2M9
| | - Mohammad Zarrabian
- Department of Surgery, Faculty of Medicine, AE 101-820 Sherbrook Street, University of Manitoba, Winnipeg, Manitoba, Canada, R3A 1R9
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Aro HT, Nazari-Farsani S, Vuopio M, Löyttyniemi E, Mattila K. Effect of Denosumab on Femoral Periprosthetic BMD and Early Femoral Stem Subsidence in Postmenopausal Women Undergoing Cementless Total Hip Arthroplasty. JBMR Plus 2019; 3:e10217. [PMID: 31687650 PMCID: PMC6820573 DOI: 10.1002/jbm4.10217] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 06/21/2019] [Accepted: 06/25/2019] [Indexed: 12/11/2022] Open
Abstract
Antiresorptive denosumab is known to improve the quality and strength of cortical bone in the proximal femurs of osteoporotic women, but its efficacy in preventing periprosthetic bone loss and reducing femoral stem migration has not been studied in women undergoing cementless total hip arthroplasty. We conducted a single-center, randomized, double-blinded, placebo-controlled trial of 65 postmenopausal women with primary hip osteoarthritis and Dorr type A or B proximal femur anatomy. The patients randomly received subcutaneous injections of denosumab 60 mg or placebo once every 6 months for 12 months, starting 1 month before surgery. The primary endpoint was the change in bone mineral density (BMD) of the proximal femur (Gruen zone 7) at week 48, and the secondary endpoint was stem subsidence measured by radiostereometric analysis (RSA) at week 48. Exploratory endpoints included changes in BMDs of the contralateral hip, lumbar spine and distal radius, serum levels of bone turnover markers, walking speed, walking activity, patient-reported outcome measures, and radiographic assessment of stem osseointegration. The participants underwent vertebral-fracture assessment in an extension safety study at 3 years. Denosumab significantly decreased bone loss in the medial femoral neck (zone 7) and increased periprosthetic BMD in the greater trochanteric region (zone 1) and lesser trochanteric region (zone 6). Denosumab did not reduce temporary femoral stem migration. The migration occurred mainly during the settling period (0 to 12 weeks) after implantation of the prosthesis. All of the stems osseointegrated, as evaluated by RSA and radiographs. There were no intergroup differences in functional recovery. Discontinuation of denosumab did not lead to any adverse events. In conclusion, denosumab increased periprosthetic BMD in the clinically relevant regions of the proximal femur, but the treatment response was not associated with any reduction of initial stem migration. © 2019 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of the American Society for Bone and Mineral Research.
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Affiliation(s)
- Hannu T Aro
- Departments of Orthopaedic Surgery and Traumatology Turku University Hospital and University of Turku Turku Finland
| | - Sanaz Nazari-Farsani
- Departments of Orthopaedic Surgery and Traumatology Turku University Hospital and University of Turku Turku Finland
| | - Mia Vuopio
- Departments of Orthopaedic Surgery and Traumatology Turku University Hospital and University of Turku Turku Finland
| | - Eliisa Löyttyniemi
- Unit of Biostatistics, Department of Clinical Medicine University of Turku Turku Finland
| | - Kimmo Mattila
- Department of Diagnostic Imaging Turku University Hospital Turku Finland
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Vestergaard RF, Søballe K, Hasenkam JM, Stilling M. Sternal instability measured with radiostereometric analysis. A study of method feasibility, accuracy and precision. J Cardiothorac Surg 2018; 13:41. [PMID: 29776382 PMCID: PMC5960092 DOI: 10.1186/s13019-018-0735-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 05/10/2018] [Indexed: 11/21/2022] Open
Abstract
Background A small, but unstable, saw-gap may hinder bone-bridging and induce development of painful sternal dehiscence. We propose the use of Radiostereometric Analysis (RSA) for evaluation of sternal instability and present a method validation. Methods Four bone analogs (phantoms) were sternotomized and tantalum beads were inserted in each half. The models were reunited with wire cerclage and placed in a radiolucent separation device. Stereoradiographs (n = 48) of the phantoms in 3 positions were recorded at 4 imposed separation points. The accuracy and precision was compared statistically and presented as translations along the 3 orthogonal axes. 7 sternotomized patients were evaluated for clinical RSA precision by double-examination stereoradiographs (n = 28). Results In the phantom study, we found no systematic error (p > 0.3) between the three phantom positions, and precision for evaluation of sternal separation was 0.02 mm. Phantom accuracy was mean 0.13 mm (SD 0.25). In the clinical study, we found a detection limit of 0.42 mm for sternal separation and of 2 mm for anterior-posterior dislocation of the sternal halves for the individual patient. Conclusion RSA is a precise and low-dose image modality feasible for clinical evaluation of sternal stability in research. Trial registration ClinicalTrials.gov Identifier: NCT02738437, retrospectively registered.
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Affiliation(s)
- Rikke Falsig Vestergaard
- Dept. of Cardio-Thoracic Surgery, Aarhus University Hospital, Skejby, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark. .,Dept. of Clinical Medicine, Aarhus University, Incuba/Skejby, Bygning 2, Palle Juul-Jensens Boulevard 82, 8200, Aarhus N, Denmark.
| | - Kjeld Søballe
- Dept. of Orthopedic Surgery, Aarhus University Hospital, Tage Hansens Gade 2, 8000, Aarhus C, Denmark.,Dept. of Clinical Medicine, Aarhus University, Incuba/Skejby, Bygning 2, Palle Juul-Jensens Boulevard 82, 8200, Aarhus N, Denmark
| | - John Michael Hasenkam
- Dept. of Clinical Medicine, Aarhus University, Incuba/Skejby, Bygning 2, Palle Juul-Jensens Boulevard 82, 8200, Aarhus N, Denmark
| | - Maiken Stilling
- Dept. of Orthopedic Surgery, Aarhus University Hospital, Tage Hansens Gade 2, 8000, Aarhus C, Denmark.,Dept. of Clinical Medicine, Aarhus University, Incuba/Skejby, Bygning 2, Palle Juul-Jensens Boulevard 82, 8200, Aarhus N, Denmark
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