The role of the femoral component orientation on dislocations in THA: a systematic review.

INTRODUCTION: Dislocation remains a major complication in total hip arthroplasty (THA), in which femoral component orientation is considered a key parameter. New imaging modalities and definitions on femoral component orientation have been introduced, describing orientation in different planes. This study aims to systematically review the relevance of the different orientation parameters on implant stability. METHODS: A systematic review was performed according to the PRISMA guidelines to identify articles in the PubMed and EMBASE databases that study the relation between any femoral component orientation parameters and implant stability in primary THA. RESULTS: After screening for inclusion and exclusion criteria and quality assessment, nine articles were included. Definitions to describe the femoral component orientation and methodologies to assess its relevance for implant stability differed greatly, with lack of consensus. Seven retrospective case-control studies reported on the relevance of the transversal plane orientation: Low femoral- or low combined femoral and acetabular anteversion was statistical significantly related with more posterior dislocations, and high femoral- or combined femoral and acetabular anteversion with anterior dislocations in two studies. There were insufficient data on sagittal and coronal component orientation in relation to implant stability. CONCLUSION: Because of incomparable definitions, limited quality and heterogeneity in methodology of the included studies, there is only weak evidence that the degree of transverse component version is related with implant stability in primary THA. Recommendations about the optimal orientation of the femoral component in all three anatomical planes cannot be provided. Future studies should uniformly define the three-dimensional orientation of the femoral component and systematically describe implant stability.

The Effect of Postural Pelvic Dynamics on the Three-dimensional Orientation of the Acetabular Cup in THA Is Patient Specific.

BACKGROUND: Sagittal pelvic dynamics mainly consist of the pelvis rotating anteriorly or posteriorly while the hips flexes, and this affects the femoroacetabular or THA configuration. Thus far, it is unknown how the acetabular cup of the THA in the individual patient reorients with changing sagittal pelvic dynamics. QUESTIONS/PURPOSES: The aim of this study was to validate a method that establishes the three-dimensional (3-D) acetabular cup orientation with changing sagittal pelvic dynamics and describe these changes during functional pelvic dynamics. METHODS: A novel trigonometric mathematical model, which was incorporated into an easy-to-use tool, was tested. The model connected sagittal tilt, transverse version, and coronal inclination of the acetabular cup during sagittal pelvic tilt. Furthermore, the effect of sagittal pelvic tilt on the 3-D reorientation of acetabular cups was simulated for cups with different initial positions. Twelve pelvic CT images of patients who underwent THA were taken and rotated around the hip axis to different degrees of anterior and posterior sagittal pelvic tilt (± 30°) to simulate functional pelvic tilt in various body positions. For each simulated pelvic tilt, the transverse version and coronal inclination of the cup were manually measured and compared with those measured in a mathematical model in which the 3-D cup positions were calculated. Next, this model was applied to different acetabular cup positions to simulate the effect of sagittal pelvic dynamics on the 3-D orientation of the acetabular cup in the coronal and transverse plane. After pelvic tilt was applied, the intraclass correlation coefficients of 108 measured and calculated coronal and transverse cup orientation angles were 0.963 and 0.990, respectively, validating the clinical use of the mathematical model. RESULTS: The changes in 3-D acetabular cup orientation by functional pelvic tilt differed substantially between cups with different initial positions; the change in transverse version was much more pronounced in cups with low coronal inclination (from 50° to -29°) during functional pelvic tilt than in cups with a normal coronal inclination (from 39° to -11°) or high coronal inclination (from 31° to 2°). However, changes in coronal inclination were more pronounced in acetabular cups with high transverse version. CONCLUSION: Using a simple algorithm to determine the dynamic 3-D reorientation of the acetabular cup during functional sagittal pelvic tilt, we demonstrated that the 3-D effect of functional pelvic tilt is specific to the initial acetabular cup orientation and thus per THA patient. CLINICAL RELEVANCE: Future studies concerning THA (in)stability should not only include the initial acetabular cup orientation, but also they need to incorporate the effect of sagittal pelvic dynamics on the individual 3-D acetabular cup orientation. Clinicians can also use the developed tool, www.3d-hip.com, to calculate the acetabular cup's orientation in other instances, such as for patients with spinopelvic imbalance.

The Effect of Functional Pelvic Tilt on the Three-Dimensional Acetabular Cup Orientation in Total Hip Arthroplasty Dislocations.

BACKGROUND: Anterior and posterior pelvic tilt appears to play a role in total hip arthroplasty (THA) stability. When changing from the standing to the sitting position, the pelvis typically rotates posteriorly while the hips flex and this affects the femoro-acetabular positions. This case-control study compares changes in 3-D acetabular cup orientation during functional pelvic tilt between posterior THA dislocations vs stable THAs. METHODS: Standing and sitting 3-D cup orientation was compared between fifteen posterior dislocations vs 233 prospectively followed stable THAs. 3-D cup orientation was calculated using previously validated trigonometric algorithms on biplanar radiographs. Those algorithms combine the angles in the three anatomical planes (coronal inclination, transverse version, and sagittal ante-inclination) in the standing position with the change in sagittal pelvic tilt from standing to sitting to calculate the 3-D orientation in the sitting position. RESULTS: The standing cup orientation of the dislocated THAs was only characterized by a lower coronal inclination (P = .039). Compared with the controls, from standing to sitting, they showed less posterior pelvic tilt (P < .001). This led to a significant lower coronal inclination (P < .001) and sagittal ante-inclination (P < .001) in the sitting position but similar transverse version (P = .366). CONCLUSIONS: Comparing posterior THA dislocations to stable THAs, there is a lower increase of all three orientation angles from standing to sitting. This leads to a decreased sitting coronal inclination and sagittal ante-inclination which may lead to an increased risk of impingement ensued by THA instability. By contrast, the transverse version was not significantly different in both positions. This confirms the importance of biplanar data on functional cup orientation. LEVEL OF EVIDENCE: Diagnostic, Level III.

A vitamin E blended highly cross-linked polyethylene acetabular cup results in less wear: 6-year results of a randomized controlled trial in 199 patients.

Background and purpose - Survivorship of total hip arthroplasty (THA) with the ultra-high molecular weight polyethylene (UHMWPE) monoblock cup has been limited due to periprosthetic osteolysis and aseptic loosening, secondary to wear of the UHMWPE. In response, a vitamin E blended highly cross-linked polyethylene (HXLPE) cup was developed. This study set out to compare the wear and clinical 6-year outcomes of vitamin E blended HXLPE with UHMWPE in an isoelastic monoblock cup in patients with hip osteoarthritis who underwent uncemented THA. The 2-year results have been reported previously. Patients and methods - For this randomized controlled trial 199 patients were included. 102 patients received the vitamin E blended HXLPE uncemented acetabular cup and 97 patients the uncemented UHMWPE monoblock cup. Clinical and radiographic parameters were obtained preoperatively, directly postoperatively, and at 3, 12, 24, and 72 months. Wear rates were compared using the femoral head penetration (FHP) rate. Results - 173 patients (87%) completed the 6-year follow-up. The mean NRS scores for rest pain, load pain, and patient satisfaction were 0.3 (SD 1), 0.6 (SD 1), and 8.6 (SD 1) respectively. The mean Harris Hip Score was 93 (SD 12). The FHP rate was lower in the vitamin E blended HXLPE cup (0.028 mm/year) compared with the UHMWPE cup (0.035 mm/year) (p = 0.002). No adverse reactions associated with the clinical application of vitamin E blended HXLPE were observed. 15 complications occurred, equally distributed between the two cups. The 6-year survival to revision rate was 98% for both cups. There was no aseptic loosening. Interpretation - This study shows the superior performance of the HXLPE blended with vitamin E acetabular cup with clinical and radiographic results similar to the UHMWPE acetabular cup.

2-year results of an RCT of 2 uncemented isoelastic monoblock acetabular components: lower wear rate with vitamin E blended highly cross-linked polyethylene compared to ultra-high molecular weight polyethylene.

Background and purpose - The long-term survival of arthroplasty components may be limited by polyethylene wear-related problems such as periprosthetic osteolysis and aseptic loosening. Highly cross-linked polyethylene (HXLPE) blended with vitamin E was introduced to improve oxidative stability and to avoid long-term embrittlement. This study clinically compares the tribological behavior and clinical outcome of vitamin E blended HXLPE with ultra-high molecular weight polyethylene (UHMWPE) in an isoelastic monoblock cup for uncemented total hip arthroplasty.Patients and methods - In this randomized controlled trial (RCT), 199 patients were included: 102 patients received the vitamin E blended HXLPE cup, 97 patients the UHMWPE cup. Clinical and radiographic parameters were obtained preoperatively, directly postoperative and at 3, 12, and 24 months. Wear rates were compared using the mean linear femoral head penetration (FHP) rate.Results - 188 patients (94%) completed the 2-year follow-up. Mean patient satisfaction was higher in the vitamin E blended HXLPE group (8.9 [1]) than in in the control group (8.5 [2], p = 0.03). The Harris Hip Score (HHS) was higher in the vitamin E blended HXLPE group (95 [8]) than in the control group (92 [11], p = 0.3). The FHP rate was lower in the vitamin E blended HXLPE group: 0.046 mm/year compared with 0.056 mm/year in the control group (p = 0.05). No adverse reactions associated with the clinical application of vitamin E blended HXLPE were observed during follow-up, with an excellent 2-year survival to revision rate of 98% for both cups.Interpretation - This study shows the superior performance of the HXLPE blended with vitamin E acetabular cup with lower linear femoral head penetration rates and better clinical results compared with the UHMWPE acetabular cup after 2 years.

Calculation of the 3-D femoral component's orientation in total hip arthroplasty using a trigonometric algorithm.

Femoral component orientation plays a key role in implant stability and therefore the success rate of total hip arthroplasty. To date, this topic has been studied using various definitions and a variety of imaging modalities and protocols. The aim of this study is a proof of concept that a new algorithm can be used to describe the femoral component's 3D orientation on the three orthogonal anatomical planes and relative to its mechanical axis using input from two orthogonal planes. CT scans of 18 patients with a total of 22 hip arthroplasties were collected. From these, orthogonal coronal and sagittal projections of the complete femur were acquired in the scanning position (MIPs) and relative to the femoral mechanical axis (corrected MIPs). On these images, the orientation of the neck of the femoral component in space and relative to the femoral axis, respectively, was measured by coronal inclination (CIF), sagittal inclination (SIF) and transverse version (TVF). With the algorithm, TVF was also calculated based on CIF and SIF. Differences between measured and calculated TVF and intra- and inter-observer reliability were evaluated using intra-class correlation coefficients (ICC). The error of non-orthogonal imaging (85° angle between the sagittal and coronal reconstructions) was tested on a third series of MIPs. The ICC between the calculated TVF and manually measured TVF, in space and relative to the femoral axis, was 0.98 for both with median absolute differences of 1.3 and 1.5°. For non-orthogonal images this was 0.70 with a median absolute difference of 5°. ICCs for intra-observer and inter-observer reliability for the calculated TVF values were 0.98 and 0.88, respectively. With this algorithm the transverse orientation of the neck of the femoral component can be assessed in space and relative to the mechanical femoral axis by combining its sagittal and coronal orientation. As long as the imaging visualizes two orthogonal planes, the orientation of an implant can be assessed in 3-D, regardless of the imaging modality.

Functional Outcomes of Arthroscopic Partial Meniscectomy Versus Physical Therapy for Degenerative Meniscal Tears Using a Patient-Specific Score: A Randomized Controlled Trial.

BACKGROUND: It is unknown whether the treatment effects of partial meniscectomy and physical therapy differ when focusing on activities most valued by patients with degenerative meniscal tears. PURPOSE: To compare partial meniscectomy with physical therapy in patients with a degenerative meniscal tear, focusing on patients' most important functional limitations as the outcome. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: This study is part of the Cost-effectiveness of Early Surgery versus Conservative Treatment with Optional Delayed Meniscectomy for Patients over 45 years with non-obstructive meniscal tears (ESCAPE) trial, a multicenter noninferiority randomized controlled trial conducted in 9 orthopaedic hospital departments in the Netherlands. The ESCAPE trial included 321 patients aged between 45 and 70 years with a symptomatic, magnetic resonance imaging-confirmed meniscal tear. Exclusion criteria were severe osteoarthritis, body mass index >35 kg/m2, locking of the knee, and prior knee surgery or knee instability due to an anterior or posterior cruciate ligament rupture. This study compared partial meniscectomy with physical therapy consisting of a supervised incremental exercise protocol of 16 sessions over 8 weeks. The main outcome measure was the Dutch-language equivalent of the Patient-Specific Functional Scale (PSFS), a secondary outcome measure of the ESCAPE trial. We used crude and adjusted linear mixed-model analyses to reveal the between-group differences over 24 months. We calculated the minimal important change for the PSFS using an anchor-based method. RESULTS: After 24 months, 286 patients completed the follow-up. The partial meniscectomy group (n = 139) improved on the PSFS by a mean of 4.8 ± 2.6 points (from 6.8 ± 1.9 to 2.0 ± 2.2), and the physical therapy group (n = 147) improved by a mean of 4.0 ± 3.1 points (from 6.7 ± 2.0 to 2.7 ± 2.5). The crude overall between-group difference showed a -0.6-point difference (95% CI, -1.0 to -0.2; P = .004) in favor of the partial meniscectomy group. This improvement was statistically significant but not clinically meaningful, as the calculated minimal important change was 2.5 points on an 11-point scale. CONCLUSION: Both interventions were associated with a clinically meaningful improvement regarding patients' most important functional limitations. Although partial meniscectomy was associated with a statistically larger improvement at some follow-up time points, the difference compared with physical therapy was small and clinically not meaningful at any follow-up time point. REGISTRATION: NCT01850719 (ClinicalTrials.gov identifier) and NTR3908 (the Netherlands Trial Register).

Restoring femoral offset and leg length; the potential of a short curved stem in total hip arthroplasty.

BACKGROUND: Total hip arthroplasty (THA) is a very successful procedure in orthopedics. Still polyethylene wear and gait deficits are limiting the clinical success.It is important to reconstruct leg length (LL) and femoral offset (FO) anatomically in order to have the best possible result of a THA. Gait deficits can arise due to leg length discrepancy as well as changes in the abductor moment arm. In THA, LL and FO are strongly determined by the orientation, size and geometry of the femoral stem. METHODS: This radio-anatomical study used the data of a prospective cases series of 112 patients who underwent 126 primary THAs and had completed a 1-year follow-up examination. FO and LL were compared between the conventional straight stem in vivo and a computed simulated implantation of a short curved stem, using the pre- and postoperative pelvic radiographs of the same patients. RESULTS: In this simulation of the short curved stem statistically significantly restored native FO (p = 0.010) and LL (p = 0.000) better, compared to the conventional straight stem. CONCLUSIONS: Thus, the short curved stem restores FO and LL better, and could potentially prevent gait deficits.

Non-equivalent Results from Different Anteversion Measurements Methods for the Evaluation of the Acetabular Cup Orientation in Total Hip Arthroplasty.

OBJECTIVE: To determine the comparability among 10 radiographic anteversion methods for acetabular cup orientation in total hip arthroplasty (THA) found in the literature and the "gold" standard of assessing the anteversion with CT. METHODS: This is a retrospective study that blindly compares 10 different conventional radiographic anteversion measurements with the "gold" standard, the measurement of anteversion on the transverse plane of the 3-D images made with CT. The patient archiving and communications system (PACS) was systematically searched for subjects that had undergone a CT angiogram of the abdomen and lower extremities, including the pelvis, had at least one THA in situ and had undergone anterior-posterior (AP) and cross-lateral pelvic radiography between January 2013 and August 2016 in the Diakonessenhuis Hospital Utrecht/Zeist, a non-academic institution. CT scans of patients (n = 16) were systematically collected. Three observers independently measured cup anteversion from radiographs, using a total of 10 different methods, and measured the "gold" standard on CT images. The outcomes of the 10 radiographic anteversion were compared in terms of linear correlation with the "gold" standard on CT images. RESULTS: The correlations of the radiographic measured anteversions with the "gold" standard measured on CT images were 0.528 for the method of Liaw, 0.556 for Wan, 0.562 for the cross-lateral method, 0.586 for Hassan, 0.594 for Dorr, 0.602 for Lewinnek, 0.624 for Widmer, 0.671 for the lateral CT, 0.747 for Ackland, and 0.771 for the method of Riten Pradham. CONCLUSION: Anteversion measurement methods represent different projectional angles of the acetabular cup in different planes around different axes. Therefore, they differ from the "gold" standard and are not interchangeable, as is shown by this study. We consider the anatomical anteversion in the transverse plane rotating around the longitudinal axis as the "gold" standard and recommend avoiding using the term anteversion for other projectional angles in different planes.

Lack of consensus on optimal acetabular cup orientation because of variation in assessment methods in total hip arthroplasty: a systematic review.

INTRODUCTION:: Dislocation is 1 of the main reasons for revision of total hip arthroplasty but dislocation rates have not changed in the past decades, compromising patients' well-being. Acetabular cup orientation plays a key role in implant stability and has been widely studied. This article investigates whether there is a consensus on optimal cup orientation, which is necessary when using a navigation system. METHODS:: A systematic search of the literature in the PubMed, Embase and Cochrane databases was performed (March 2017) to identify articles that investigated the direct relationship between cup orientation and dislocation, including a thorough evaluation of postoperative cup orientation assessment methods. RESULTS:: 28 relevant articles evaluating a direct relation between dislocation and cup orientation could not come to a consensus. The key reason is a lack of uniformity in the assessment of cup orientation. Cup orientation is assessed with different imaging modalities, different methodologies, different definitions for inclination and anteversion, several reference planes and distinct patient positions. CONCLUSIONS:: All available studies lack uniformity in cup orientation assessment; therefore it is impossible to reach consensus on optimal cup orientation. Using navigation systems for placement of the cup is inevitably flawed when using different definitions in the preoperative planning, peroperative placement and postoperative evaluation. Further methodological development is required to assess cup orientation. Consequently, the postoperative assessment should be uniform, thus differentiating between anterior and posterior dislocation, use the same definitions for inclination and anteversion with the same reference plane and with the patient in the same position.

Precision and accuracy of imageless navigation versus freehand implantation of total hip arthroplasty: A systematic review and meta-analysis.

BACKGROUND: Total hip arthroplasty (THA) is named the most successful surgical procedure of the twentieth century. To remain a success in the twenty-first century THA should meet the higher demands of patients and society with regard to technical and functional outcome, costs and implant survival. To meet these demands optimal acetabular cup positioning is necessary. An imageless navigation system (NAV) might prevent malpositioning of the acetabular cup in THA. The aim of this study has been to compare the precision and accuracy of the anteversion and inclination of the acetabular cup position after NAV implantation and after freehand implantation of THA. METHODS: A systematic review and meta-analysis was conducted to assess the precision (variance) and accuracy (deviation from the target) from all available high-quality randomised control trials to date. RESULTS: Six out of seven studies concluded a statistically significant difference in precision in anteversion between the NAV group and the freehand group. Five out of seven studies concluded a statistically significant difference in precision in inclination. There is a significantly better accuracy for the NAV group than for the freehand group for anteversion (p = 0.002) and for inclination (p = 0.01). CONCLUSION: This study showed that NAV placement is more precise and has an improved accuracy for anteversion and inclination than freehand placement of the acetabular cup. However, there is a lack of evidence to support an improved functional outcome and a reduction of complications and revisions.