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Pour AE, Green J, Christensen TH, Muthusamy N, Schwarzkopf R. The Current Proposed Total Hip Arthroplasty Surgical Planning Guidelines Based on Classification of Spine Stiffness May be Flawed Due to Incorrect Assumptions. J Arthroplasty 2023; 38:1075-1081. [PMID: 36863577 PMCID: PMC10200739 DOI: 10.1016/j.arth.2023.02.063] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 02/09/2023] [Accepted: 02/21/2023] [Indexed: 03/04/2023] Open
Abstract
BACKGROUND The available classifications and preoperative planning tools for total hip arthroplasty assume that: 1) there is no variation in the sagittal pelvic tilt (SPT) if the radiographs are repeated, and 2) there is no significant change in the postoperative SPT postoperatively. We hypothesized that there would be significant differences in postoperative SPT tilt as measured by the sacral slope, thus rendering the current classifications and tools flawed. METHODS This study was a multicenter, retrospective analysis of preoperative and postoperative (1.5-6 months) full-body imaging of 237 primary total hip arthroplasty (standing and sitting positions). Patients were categorized as 1) stiff spine (standing sacral slope sitting sacral slope < 10°) and 2) normal spine (standing sacral slope-sitting sacral slope ≥ 10°). Results were compared using the paired t-test. The posthoc power analysis showed a power of 0.99. RESULTS The difference in mean standing and sitting sacral slope between the preoperative and postoperative measurements was 1°. However, in standing position, this difference was more than 10° in 14.4% of patients. In the sitting position, this difference was more than 10° in 34.2% of patients and more than 20° in 9.8% of patients. Postoperatively, 32.5% of patients switched groups based on the classification, which rendered the preoperative planning suggested by the current classifications flawed. CONCLUSION Current preoperative planning and classifications are based on a single acquisition of preoperative radiographs without the incorporation of possible postoperative changes in SPT. Validated classifications and planning tools should incorporate repeated measurements to determine the mean and variance in SPT and consider the significant postoperative changes in SPT.
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Affiliation(s)
- Aidin Eslam Pour
- Department of Orthopaedic Surgery, Yale University, New Haven, CT, USA
| | - Jordan Green
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA
| | | | - Nishanth Muthusamy
- Department of Orthopaedic Surgery, New York University, New York, NY, USA
| | - Ran Schwarzkopf
- Department of Orthopaedic Surgery, New York University, New York, NY, USA
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Labott JR, Smith JRH, Mara KC, Wyles CC, Taunton MJ, Abdel MP. Pubic Symphysis to Sacrococcygeal Joint: A Poor Correlate to Other Spinopelvic Measurements. J Arthroplasty 2023:S0883-5403(23)00072-4. [PMID: 36754336 DOI: 10.1016/j.arth.2023.01.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 01/27/2023] [Accepted: 01/31/2023] [Indexed: 02/10/2023] Open
Abstract
BACKGROUND The hip-spine relationship is increasingly recognized as critical for optimizing stability following total hip arthroplasty (THA). However, these measurements are not routinely obtained during THA workup. It has been suggested that insight can be gained from supine antero-posterior pelvis radiograph, measuring the distance from the superior border of the pubic symphysis to the sacro-coccygeal joint (PSCD). This study assessed the correlation between PSCD and lateral lumbar radiographic metrics in a cohort of preoperative THA patients. METHODS We retrospectively evaluated 250 consecutive patients who underwent THA with preoperative supine antero-posterior pelvis and lateral lumbar radiographs. The mean age was 68 years (range, 42 to 89), 61% were women, and the mean body mass index was 30 kg/m2 (range, 19 to 52). Two reviewers measured PSCD, pelvic tilt (PT), sacral slope (SS), pelvic incidence (PI), and lumbar lordosis (LL). Inter-observer reliability was calculated for all measurements, and correlation coefficients were calculated for PSCD with respect to PT, SS, PI, and LL. RESULTS Correlations between PSCD and lumbar radiographic metrics were all statistically significant, except for PI in men but graded as "weak" or "very weak" for men and women, respectively, as follows: PT = -0.30 (P < .01) and -0.46 (P < .01); SS = 0.27 (P < .01) and 0.22 (P < .01); PI = -0.04 (P = .70) and -0.19 (P = .02); and LL = 0.45 (P < .01) and 0.30 (P < .01). Inter-observer reliability was graded as "strong" for every metric. CONCLUSION The PSCD was weakly correlated with all evaluated lateral lumbar radiographic metrics in both sexes, despite strong inter-observer reliability. Therefore, PSCD cannot reliably serve as a proxy for evaluating the hip-spine relationship.
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Affiliation(s)
- Joshua R Labott
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Kristin C Mara
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Cody C Wyles
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Matthew P Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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Vigdorchik JM, Shafi KA, Kolin DA, Buckland AJ, Carroll KM, Jerabek SA. Does Low Back Pain Improve Following Total Hip Arthroplasty? J Arthroplasty 2022; 37:S937-S940. [PMID: 35304301 DOI: 10.1016/j.arth.2022.03.038] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 03/09/2022] [Accepted: 03/09/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Frequently, patients indicated for total hip arthroplasty (THA) present with low back pain (LBP) and hip pain. The purpose of this study was to compare patients whose back pain resolved after THA with those where back pain did not resolve and identify how to predict this using spinopelvic parameters. METHODS We reviewed a series of 500 patients who underwent THA for unilateral hip osteoarthritis by 2 surgeons. Patients underwent biplanar standing and sitting EOS radiographs pre-operatively. Patients with previous spine surgery or femoral neck fracture were excluded. Demographic data was analyzed at baseline. The Oswestry Disability Index (ODI) scores were calculated pre-operatively and at 1 year postoperatively. Spinopelvic parameters included, pelvic incidence and sacral slope (SS) change from standing to sitting. RESULTS Two hundred and four patients (41%) had documented LBP before THA. The Oswestry Disability Index (ODI) for patients improved from 38.9 ± 17.8 pre-operatively to 17.0 ± 10.6 at 1 year post-operatively (P < .001). At 1- and 2-year follow-up, resolution of back pain occurred in 168 (82.4%) and 187 (91.2%) patients, respectively. Pelvic incidence was not predictive of back pain resolution. All patients whose back pain resolved had a sacral slope change from standing to sitting of >10°, while those patients whose back pain did not resolve had a change of <10°. CONCLUSION This study demonstrates that symptomatic low back pain (LBP) resolves in 82% of patients after THA. The results of this study may be used to counsel patients on back pain and its resolution following total hip replacement.
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Affiliation(s)
- Jonathan M Vigdorchik
- Division of Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York
| | - Karim A Shafi
- Division of Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York
| | - David A Kolin
- Division of Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York
| | | | - Kaitlin M Carroll
- Division of Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York
| | - Seth A Jerabek
- Division of Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York
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Sicat CS, Buchalter DB, Luthringer TA, Schwarzkopf R, Vigdorchik JM. Intraoperative Technology Use Improves Accuracy of Functional Safe Zone Targeting in Total Hip Arthroplasty. J Arthroplasty 2022; 37:S540-S545. [PMID: 35428540 DOI: 10.1016/j.arth.2022.02.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 02/09/2022] [Accepted: 02/10/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Targets of acetabular inclination and anteversion have been suggested based on a patient's spinopelvic mobility. Current methods in total hip arthroplasty (THA) include manual instrumentation, computer-assisted navigation, and robotic-assisted surgery. This study aims to compare the accuracy of these 3 methods in targeting the functional safe zone. METHODS This is a prospective multicenter study including a series of 251 consecutive primary posterior THA patients from April 2019 to January 2021. Preoperative lateral standing and sitting spinopelvic radiographs were obtained. Each patient was classified using the Hip-Spine Classification. A functional safe zone plan was determined. Surgeons used their preferred method (manual instrumentation, computer-assisted, or robotic-assisted). Postoperative anteversion and inclination was measured and compared to the preoperative plan. Mean differences between preoperative and postoperative values were calculated. Welch's t-test was used to assess significant between-group differences with P < .05 considered significant. RESULTS Of the 249 patients, there were 63 manual instrumentation, 68 computer-assisted navigation, and 118 robotic-assisted surgery. Robotic-assisted surgery (rTHA) was significantly more accurate in targeting anteversion (1 ± 2) compared to manual instrumentation (mTHA; 7 ± 6, P < .001) and computer-assisted navigation (cTHA; 6 ± 6, P < .001). rTHA was also significantly more accurate in targeting inclination (1 ± 1) compared to mTHA (8 ± 7, P < .001) and cTHA (6 ± 7, P < .001). Although cTHA had greater accuracy in targeting both inclination and anteversion compared to mTHA, these differences were not statistically significant. CONCLUSION Robotic-assisted surgery was more accurate than both computer-assisted navigation and manual instrumentation in targeting the functional safe zone in primary THA. Further research is needed to evaluate the effect of improved accuracy on dislocation rates.
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Affiliation(s)
- Chelsea S Sicat
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | | | | | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
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Pheasant MS, Coulter JL, Wallace C, Kropp Lopez AK, DelSole EM, Mercuri JJ. Lumbar Spine Fusion and Symptoms of Leg Length Discrepancy After Hip Arthroplasty. J Arthroplasty 2021; 36:3241-3247.e1. [PMID: 34112541 DOI: 10.1016/j.arth.2021.05.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 05/03/2021] [Accepted: 05/05/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Hip length discrepancy (HLD) is common after total hip arthroplasty (THA); however, the effect of spinal fusion on perceived leg length discrepancy (LLD) symptoms after THA has not been examined. This study tested the hypothesis that LLD symptoms are increased in patients who underwent lumbar spinal fusion and THA, compared with patients with THA only. METHODS This retrospective cohort study included 67 patients who underwent lumbar spinal fusion and THA, along with 78 matched control patients who underwent THA only. Hip and spine measurements were taken on postoperative, standing anterior-posterior pelvic, lateral lumbar, and anterior-posterior lumbar spinal radiographs. Perceived LLD symptoms were assessed via telephone survey. RESULTS Between the spinal fusion and control groups, there was no significant difference in HLD (M = 7.10 mm, SE = 0.70 and M = 5.60 mm, SE = 0.49) (P = .403). The spinal fusion patients reported more frequently noticing a difference in the length of their legs than the control group (P = .046) and reported limping "all the time" compared with the control group (P = .001). Among all patients with an HLD ≤10 mm, those in the spinal fusion group reported limping at a higher frequency than patients in the control group (P = .008). Patients in the spinal fusion group were also more likely to report worsened back pain after THA (P = .011) than the control group. CONCLUSION Frequencies of a perceived LLD, limping, and worsened back pain after THA were increased in patients with THA and a spinal fusion compared with patients who had THA only, even in a population with HLD traditionally considered to be subclinical. The results indicate that in patients with prior spinal fusion, precautions should be taken to avoid even minor LLD in the setting of THA.
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Abstract
BACKGROUND Patients with spinopelvic pathology, including lumbar spine stiffness and sagittal spinal deformity, are at increased risk for postoperative complications, including instability, dislocation, and revision after total hip arthroplasty (THA). Recent evidence has suggested that the Lewinnek safe zone should no longer be considered an appropriate target for all patients, especially those with spinopelvic pathology, as the safe zone is a dynamic rather than static target. There are 2 distinct issues for arthroplasty surgeons to consider: lumbar spinal stiffness and sagittal spinal deformity, each of which has its own management. METHODS In order to manage patients with spinopelvic pathology undergoing THA, a basic understanding of spinopelvic parameters, including sagittal balance, sacral slope, and anterior pelvic plane, is essential. Techniques outlined in this manuscript describe a systematic preoperative work-up and intraoperative management of acetabular component positioning according to patient-specific spinopelvic parameters, ensuring optimal component placement and a reduced risk for impingement, instability, and poor postoperative outcomes. RESULTS Evaluation of each patient's spinopelvic parameters informs patient classification according to the Hip-Spine Classification for THA. Patient classification is determined by the presence of spinal stiffness and spinal deformity, with corresponding scoring and classification into one of the 4 categories used to determine risk for postoperative dislocation, define patient-specific cup positioning, and create their functional safe zone. CONCLUSION A simple 2-step preoperative assessment with measurements of the anterior pelvic plane and the sacral slope on standing and seated lateral X-rays will identify patients at high risk for postoperative dislocation due to spinal deformity and/or stiffness. Accounting for spinopelvic pathology and adhering to the Hip-Spine Classification guidelines for acetabular component positioning can help reduce the burden of instability and revisions in this complex patient population.
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Affiliation(s)
- Abhinav K Sharma
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY
| | - Jonathan M Vigdorchik
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY
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Elbuluk AM, Wright-Chisem JI, Vigdorchik JM, Nunley RM. Applying the Hip-Spine Relationship: What X-Rays and Measurements Are Important? J Arthroplasty 2021; 36:S94-S98. [PMID: 33752926 DOI: 10.1016/j.arth.2021.02.058] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 02/23/2021] [Indexed: 02/02/2023] Open
Abstract
Understanding spinopelvic motion and the dynamic relationship of the hip, spine, and pelvis is essential in decreasing the risk of instability after total hip arthroplasty. The hip-spine relationship is complex, and a detailed analysis of each patient's spinopelvic mobility is warranted to help guide safe acetabular component positioning. Through the use of a standing anteroposterior pelvis X-ray, lateral spinopelvic radiographs in the standing and seated position, and advanced functional imaging, key spinopelvic parameters can be obtained. A systematic preoperative workup can help to identify hip-spine pathology that predisposes patients to instability, and can help in planning and establishing a patient-specific "safe zone." Based on the presence of concomitant hip-spine pathology, patients must be evaluated thoroughly with preoperative imaging to plan for the optimal target acetabular cup position. This paper guides readers through important parameters and imaging associated to spinopelvic motion as it relates to total hip arthroplasty stability.
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Affiliation(s)
- Ameer M Elbuluk
- Division of Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY
| | - Joshua I Wright-Chisem
- Division of Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY
| | - Jonathan M Vigdorchik
- Division of Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY
| | - Ryan M Nunley
- Department of Orthopedic Surgery, Washington University at St. Louis, St. Louis, MO
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Luthringer TA, Vigdorchik JM. A Preoperative Workup of a "Hip-Spine" Total Hip Arthroplasty Patient: A Simplified Approach to a Complex Problem. J Arthroplasty 2019; 34:S57-S70. [PMID: 30755374 DOI: 10.1016/j.arth.2019.01.012] [Citation(s) in RCA: 97] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 01/07/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND A large body of evidence has confirmed that patients with spinal deformity, lumbar fusion, and abnormal spinopelvic mobility are at significantly increased risk for instability, dislocation, and revision after total hip arthroplasty (THA). METHODS Achieving a stable construct in patients with pre-existing spine disease requires an understanding of basic spinopelvic parameters and the compensatory mechanisms associated with abnormal spinopelvic motion. Indicated patients with concomitant hip-spine pathology should be assessed for (1) the presence of spinal deformity and (2) the presence of spinal stiffness before undergoing THA. Preoperative imaging should include a standing anteroposterior pelvis x-ray, as well as two lateral spinopelvic radiographs in the standing and seated position. RESULTS Based on the presence of spinal deformity and/or spinal stiffness, patients may be categorized as one of the four groups of the "Hip-Spine Classification in THA." A series of illustrative case examples is provided. CONCLUSION A simple three-step assessment with minimal measurements will effectively identify the complex "hip-spine" THA patient at high risk for postoperative instability. Adhering to group-specific recommendations for acetabular cup position can help to further reduce the burden of instability and related revisions in this challenging population.
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Affiliation(s)
- Tyler A Luthringer
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY
| | - Jonathan M Vigdorchik
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, NY
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