Dual-Energy Computed Tomography in Loosening of Revision Hip Prosthesis: A Comparison Between MARS and non-MARS Images.

PURPOSE: The aim of the study was to assess potential endoprosthesis loosening in patients after revision total hip arthroplasty, based on monochromatic dual-energy computed tomography (DECT) images obtained with and without metal artifact reduction software (MARS) and comparison with the clinical examination and hip function. MATERIALS AND METHODS: Twenty-five consecutive patients underwent DECT examinations. Two monochromatic data sets were generated: with MARS (75-keV MARS) and without MARS (140-keV non-MARS) and evaluated for signs of loosening, using a dedicated radiological score. The Harris Hip Score (HHS) was used to evaluate patients' hip function. RESULTS: The mean radiological score for loosening in the non-MARS group was 16.2, in the MARS group 17.0 and was significantly higher (P < 0.001). Radiological loosening evaluation in non-MARS images correlated with the HHS score (ρ = 0.43, P = 0.03), whereas there was no correlation between MARS images and HHS (ρ = 0.15, P = 0.47). New MARS-related artifacts, which hinder implant-bone interface evaluation, were found in 75-keV MARS images ("pseudo-loosening" in 33 of 34 prostheses, "ground-glass blurring" in 20 of 32). CONCLUSIONS: High-energy monochromatic DECT images are superior to low-energy DECT MARS images in assessment of the potential loosening and correlate better with the clinical examination outcomes. For revision total hip arthroplasty evaluation, 2 data sets should be assessed inseparably because of extra artifacts in MARS images.

Preoperative Ultrasonographic Assessment of the Anterior Pelvic Plane for Personalized Total Hip Replacement.

OBJECTIVES: Correct positioning of the acetabular component is a key factor in minimizing the risk of dislocation after total hip replacement (THR) surgery. A "safe" orientation of the cup is usually defined by 2 angles measured between its geometric axis and the anterior pelvic plane. However, in the current state-of-the-art approach to THR surgery, the intraoperative orientation of the anterior pelvic plane cannot be measured. Even less is known about the functional orientation of the pelvis, which determines the postoperative orientation of the cup during the patient's everyday activities. The aim of this article is to present an original approach to personalized THR surgery, in which the necessary measurements are done preoperatively without interfering with the surgical work flow, and the individual orientation of the cup is obtained without navigation using standard tools that are available in the operating room. METHODS: To quantify the effect of the anatomic conditions on the final orientation of the cup, we measured the orientation of the anterior pelvic plane in 43 patients scheduled for THR using a newly developed noninvasive method based on ultrasonography and mobile devices. RESULTS: Our results confirm a large variability of the pelvic orientation in both supine and standing positions. We further show how this variability affects the final position of the cup and discuss its consequences for the patient. Finally, we explore a few practical solutions for individualized cup placement, including our own approach, which is based on tilting of the operating table. CONCLUSIONS: In this work, we show that the common guidelines used today for cup implantation can only be effectively applied to a small portion of the population. In most cases, it is crucial that the orientation of the cup is readjusted for the particular anatomy of the individual patient.

Application of Navigated Ultrasound for Assessment of the Anterior Pelvic Plane in Patients With Degenerative Hip Diseases.

OBJECTIVES: Correct positioning of the acetabular cup is the key for successful total-hip replacement. In common clinical practice, the target alignment of the cup is defined with respect to the anterior pelvic plane. In patients with substantial anterior pelvic plane inclination, this condition may lead to inappropriate distribution of the load on the cup, as most of the forces exerted within the hip joint act along the vertical axis. With the known pelvic inclination, it is possible to readjust the position of the cup with respect to the individual posture of the patient. In this work, we present the first clinical evaluation of a new approach to measurement of the pelvic tilt angle using navigated ultrasound. METHODS: In our method, the ultrasound probe is tracked with an optical localizer implemented on a handheld mobile device. The method was tested by taking preoperative measurements from 20 patients with osteoarthritis in standing, sitting, and supine positions. RESULTS: The mean values of the measured angles were consistent with the corresponding results reported by other authors. CONCLUSIONS: Considering the noninvasiveness of the method and affordability of the hardware used in our system, it can be used in preoperative and postoperative measurements of pelvic orientation for supporting surgery planning and evaluation of treatment outcomes.

Pelvic Tilt Angle Differences Between Symptom-Free Young Subjects and Elderly Patients Scheduled for THA: The Rationale for Tilt-Adjusted Acetabular Cup Implantation.

BACKGROUND: The question whether Pelvic Tilt (PT) angles measured in the supine position are adequate for the alignment of the acetabular cup without an adjustment for anatomical differences between patients is of clinical importance. The aim of this work was to test for factors that can significantly affect PT angles. METHODS: In the present retrospective cohort comparison, the PT angles of 12 Symptom-Free Young Subjects (SFYS) and 45 patients scheduled for Total Hip Arthroplasty (THA) were compared. The data was collected during two studies with the use of a novel smartphone-based navigated ultrasound measurement system. Multi-factorial analysis of variance was run to determine which factors significantly affect PT. RESULTS: Body position (F= 126.65; P< 0.001) and group (SFYS vs. THA patients) (F= 17.52; P< 0.001) had significant main effects on PT. There was also a significant interaction between body position and group (F= 25.59; P< 0.001). The mean PT increased by 8.1° from an interiorly to a neutral tilted position (P< 0.001) and 21.4° from a neutral to a posteriorly tilted position (P< 0.001) with the transition from the supine into the upright position for the SFYS and THA patients, respectively. CONCLUSION: In both groups, PT changed significantly with a transition from the supine to the upright position. A position-dependent mean PT increase in the patient group showed that acetabular cup alignment based on PT in the supine position is not reliable without taking into consideration the inclination of the pelvis in standing position. This may lead to instability and dislocations.

Computed tomography in evaluation of revision hip arthroplasty outcomes.

Background. This study aimed to assess contact between Recon Shell reinforcement cages used in revision hip arthroplasty and the bony base. Radiographic examinations were performed with the use of multi-energy computed tomography. Material and methods. We tentatively assess the fixation of Burch-Schneider reinforcement cages (Recon Shell made by Aesculap company) implanted in 10 patients, using two methods of evaluation. An analysis of dual energy CT scans enabled us to assess contact between the reinforcement cages and the bony base. Results. The two methods of evaluation produced different results. The evaluation method based on the division of the acetabular component into a weight-bearing zone and a non-weight-bearing zone (accounting for screw fixation) showed lack of support in the weight-bearing zone in 6 out of 10 cases and direct contact with the implant bed in only one case. The assessment of contact at anchorage holes of reinforcement cages fixed at primary procedures revealed no such support in only one case and the presence of direct contact in 5 cases. There was no correlation between the radiological outcomes and clinical results based on the Harris Hip Score. Conclusions. 1. Multi-energy computed tomography (MARS) is useful in evaluating results of revision hip allo-plasty. 2. The introduction of new imaging techniques for the evaluation of revision procedures demonstrates a need for new, unified methods of outcome assessment adjusted to the characteristics of a particular procedure.