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Z Orthop Unfall 2019; 157(03): 292-299
DOI: 10.1055/a-0725-8527
Review/Übersicht
Georg Thieme Verlag KG Stuttgart · New York

Patient-Specific Restoration of Biomechanics in Total Hip Arthroplasty

Article in several languages: English | deutsch
Markus Weber
Asklepios Klinikum Bad Abbach, Klinik und Poliklinik für Orthopädie der Universität Regensburg, Bad Abbach
,
Joachim Grifka
Asklepios Klinikum Bad Abbach, Klinik und Poliklinik für Orthopädie der Universität Regensburg, Bad Abbach
,
Tobias Renkawitz
Asklepios Klinikum Bad Abbach, Klinik und Poliklinik für Orthopädie der Universität Regensburg, Bad Abbach
› Author Affiliations
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Publication History

Publication Date:
15 October 2018 (online)

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Abstract

Restoration of biomechanics is crucial in total hip arthroplasty, in order to ensure a free postoperative range of motion for activities of daily life. Failure may result in impingement and thus instability, limping and finally patient dissatisfaction. In daily practice, preoperative templating is usually performed on magnification-corrected, plain radiographs of the hip. Due to the divergence of the X-ray beams and the position of the pelvis in relation to the film, measurements on plain radiographs are susceptible to error. Whereas leg length measurements are highly accurate, femoral offset is frequently underestimated on plain radiographs. The benchmark for acceptable postoperative leg length and offset differences is still under debate in the literature. However, discrepancies of 1 cm in relation to the non-affected, contralateral side should not be exceeded. Gait analysis is able to detect even differences in leg length and offset above 5 mm due to altered gait kinematics. For intraoperative control of leg length and offset, a variety of different methods have been described in the literature. Beside alignment guides, rulers and other tools, intraoperative fluoroscopy and computer-guided navigation allow the surgeon to intraoperatively analyse leg length and offset changes. Both techniques show high accuracy, although the precision is higher for navigation with a reduced number of outliers. For measurement of stem torsion, computed tomography is the gold standard. However, stem torsion can also be evaluated on plain hip radiographs by measuring the projected prosthetic neck-stem angle. Native femoral anteversion can be assessed by the size of the lesser trochanter. Since the version of the femoral stem can highly vary from the native femoral anteversion, the Isthmus Ratio (iRatio) – the relationship between canal isthmus and calcar isthmus in the anteroposterior and Lauenstein view – helps to predict the torsion of the final intraoperative stem.

Key words

biomechanical restoration - leg length - offset - templating - total hip arthroplasty
 

  • References/Literatur

  • 1 Learmonth ID, Young C, Rorabeck C. The operation of the century: total hip replacement. Lancet 2007; 370: 1508-1519
    CrossrefPubMedSearch in Google Scholar
  • 2 Abdel MP, Cross MB, Yasen AT. et al. The functional and financial impact of isolated and recurrent dislocation after total hip arthroplasty. Bone Joint J 2015; 97-B: 1046-1049
    CrossrefPubMedSearch in Google Scholar
  • 3 Abdel MP, von Roth P, Jennings MT. et al. What Safe Zone? The Vast Majority of Dislocated THAs Are Within the Lewinnek Safe Zone for Acetabular Component Position. Clin Orthop Relat Res 2015;
    CrossrefPubMedSearch in Google Scholar
  • 4 Herberts P, Malchau H. Long-term registration has improved the quality of hip replacement: a review of the Swedish THR Register comparing 160,000 cases. Acta Orthop Scand 2000; 71: 111-121
    CrossrefPubMedSearch in Google Scholar
  • 5 Abe H, Sakai T, Takao M. et al. Difference in Stem Alignment Between the Direct Anterior Approach and the Posterolateral Approach in Total Hip Arthroplasty. J Arthroplasty 2015; 30: 1761-1766
    CrossrefPubMedSearch in Google Scholar
  • 6 Phillips CB, Barrett JA, Losina E. et al. Incidence rates of dislocation, pulmonary embolism, and deep infection during the first six months after elective total hip replacement. J Bone Joint Surg Am 2003; 85-A: 20-26
    CrossrefPubMedSearch in Google Scholar
  • 7 Kennedy JG, Rogers WB, Soffe KE. et al. Effect of acetabular component orientation on recurrent dislocation, pelvic osteolysis, polyethylene wear, and component migration. J Arthroplasty 1998; 13: 530-534
    CrossrefPubMedSearch in Google Scholar
  • 8 Malik A, Maheshwari A, Dorr LD. Impingement with total hip replacement. J Bone Joint Surg Am 2007; 89: 1832-1842
    PubMedSearch in Google Scholar
  • 9 Clark CR, Huddleston HD, Schoch 3rd EP. et al. Leg-length discrepancy after total hip arthroplasty. J Am Acad Orthop Surg 2006; 14: 38-45
    CrossrefPubMedSearch in Google Scholar
  • 10 Dastane M, Dorr LD, Tarwala R. et al. Hip offset in total hip arthroplasty: quantitative measurement with navigation. Clin Orthop Relat Res 2011; 469: 429-436
    CrossrefPubMedSearch in Google Scholar
  • 11 Konyves A, Bannister GC. The importance of leg length discrepancy after total hip arthroplasty. J Bone Joint Surg Br 2005; 87: 155-157
    PubMedSearch in Google Scholar
  • 12 Varghese B, Muthukumar N, Balasubramaniam M. et al. Reliability of measurements with digital radiographs – a myth. Acta Orthop Belg 2011; 77: 622-625
    PubMedSearch in Google Scholar
  • 13 Levine B, Fabi D, Deirmengian C. Digital templating in primary total hip and knee arthroplasty. Orthopedics 2010; 33: 797
    PubMedSearch in Google Scholar
  • 14 Crowe JF, Mani VJ, Ranawat CS. Total hip replacement in congenital dislocation and dysplasia of the hip. J Bone Joint Surg Am 1979; 61: 15-23
    CrossrefPubMedSearch in Google Scholar
  • 15 Kjellberg M, Al-Amiry B, Englund E. et al. Measurement of leg length discrepancy after total hip arthroplasty. The reliability of a plain radiographic method compared to CT-scanogram. Skeletal Radiol 2012; 41: 187-191
    CrossrefPubMedSearch in Google Scholar
  • 16 Weber M, Woerner ML, Springorum HR. et al. Plain radiographs fail to reflect femoral offset in total hip arthroplasty. J Arthroplasty 2014; 29: 1661-1665
    CrossrefPubMedSearch in Google Scholar
  • 17 Pasquier G, Ducharne G, Ali ES. et al. Total hip arthroplasty offset measurement: is CT scan the most accurate option?. Orthop Traumatol Surg Res 2010; 96: 367-375
    CrossrefPubMedSearch in Google Scholar
  • 18 Lecerf G, Fessy MH, Philippot R. et al. Femoral offset: anatomical concept, definition, assessment, implications for preoperative templating and hip arthroplasty. Orthop Traumatol Surg Res 2009; 95: 210-219
    CrossrefPubMedSearch in Google Scholar
  • 19 Woolson ST, Hartford JM, Sawyer A. Results of a method of leg-length equalization for patients undergoing primary total hip replacement. J Arthroplasty 1999; 14: 159-164
    CrossrefPubMedSearch in Google Scholar
  • 20 Ranawat CS, Rao RR, Rodriguez JA. et al. Correction of limb-length inequality during total hip arthroplasty. J Arthroplasty 2001; 16: 715-720
    CrossrefPubMedSearch in Google Scholar
  • 21 Friberg O. Clinical symptoms and biomechanics of lumbar spine and hip joint in leg length inequality. Spine (Phila Pa 1976) 1983; 8: 643-651
    CrossrefPubMedSearch in Google Scholar
  • 22 Nishio S, Fukunishi S, Fukui T. et al. Adjustment of leg length using imageless navigation THA software without a femoral tracker. J Orthop Sci 2011; 16: 171-176
    CrossrefPubMedSearch in Google Scholar
  • 23 Little NJ, Busch CA, Gallagher JA. et al. Acetabular polyethylene wear and acetabular inclination and femoral offset. Clin Orthop Relat Res 2009; 467: 2895-2900
    CrossrefPubMedSearch in Google Scholar
  • 24 Mahmood SS, Mukka SS, Crnalic S. et al. Association between changes in global femoral offset after total hip arthroplasty and function, quality of life, and abductor muscle strength. Acta Orthop 2016; 87: 36-41
    CrossrefPubMedSearch in Google Scholar
  • 25 Sariali E, Klouche S, Mouttet A. et al. The effect of femoral offset modification on gait after total hip arthroplasty. Acta Orthop 2014; 85: 123-127
    CrossrefPubMedSearch in Google Scholar
  • 26 Benedetti MG, Catani F, Benedetti E. et al. To what extent does leg length discrepancy impair motor activity in patients after total hip arthroplasty?. Int Orthop 2010; 34: 1115-1121
    CrossrefPubMedSearch in Google Scholar
  • 27 Winter DA, Patla AE, Frank JS. et al. Biomechanical walking pattern changes in the fit and healthy elderly. Phys Ther 1990; 70: 340-347
    CrossrefPubMedSearch in Google Scholar
  • 28 Renkawitz T, Weber T, Dullien S. et al. Leg length and offset differences above 5 mm after total hip arthroplasty are associated with altered gait kinematics. Gait Posture 2016; 49: 196-201
    PubMedSearch in Google Scholar
  • 29 Parratte S, Argenson JN. Validation and usefulness of a computer-assisted cup-positioning system in total hip arthroplasty. A prospective, randomized, controlled study. J Bone Joint Surg Am 2007; 89: 494-499
    CrossrefPubMedSearch in Google Scholar
  • 30 Renkawitz T, Worner M, Sendtner E. et al. [Principles and new concepts in computer-navigated total hip arthroplasty]. Orthopade 2011; 40: 1095-1102
    CrossrefPubMedSearch in Google Scholar
  • 31 Ezzet KA, McCauley JC. Use of intraoperative X-rays to optimize component position and leg length during total hip arthroplasty. J Arthroplasty 2014; 29: 580-585
    CrossrefPubMedSearch in Google Scholar
  • 32 Sendtner E, Tibor S, Winkler R. et al. Stem torsion in total hip replacement. Acta Orthop 2010; 81: 579-582
    CrossrefPubMedSearch in Google Scholar
  • 33 Bargar WL, Jamali AA, Nejad AH. Femoral anteversion in THA and its lack of correlation with native acetabular anteversion. Clin Orthop Relat Res 2010; 468: 527-532
    CrossrefPubMedSearch in Google Scholar
  • 34 Widmer KH, Zurfluh B. Compliant positioning of total hip components for optimal range of motion. J Orthop Res 2004; 22: 815-821
    CrossrefPubMedSearch in Google Scholar
  • 35 Weber M, Lechler P, von Kunow F. et al. The validity of a novel radiological method for measuring femoral stem version on anteroposterior radiographs of the hip after total hip arthroplasty. Bone Joint J 2015; 97-B: 306-311
    CrossrefPubMedSearch in Google Scholar
  • 36 Budin E, Chandler E. Measurement of femoral neck anteversion by a direct method. Radiology 1957; 69: 209-213
    CrossrefPubMedSearch in Google Scholar
  • 37 Lewinnek GE, Lewis JL, Tarr R. et al. Dislocations after total hip-replacement arthroplasties. J Bone Joint Surg Am 1978; 60: 217-220
    CrossrefPubMedSearch in Google Scholar
  • 38 Dorr LD, Malik A, Dastane M. et al. Combined anteversion technique for total hip arthroplasty. Clin Orthop Relat Res 2009; 467: 119-127
    CrossrefPubMedSearch in Google Scholar
  • 39 Hisatome T, Doi H. Theoretically optimum position of the prosthesis in total hip arthroplasty to fulfill the severe range of motion criteria due to neck impingement. J Orthop Sci 2011; 16: 229-237
    CrossrefPubMedSearch in Google Scholar
  • 40 Yoshimine F. The safe-zones for combined cup and neck anteversions that fulfill the essential range of motion and their optimum combination in total hip replacements. J Biomech 2006; 39: 1315-1323
    CrossrefPubMedSearch in Google Scholar
  • 41 Jolles BM, Zangger P, Leyvraz PF. Factors predisposing to dislocation after primary total hip arthroplasty: a multivariate analysis. J Arthroplasty 2002; 17: 282-288
    CrossrefPubMedSearch in Google Scholar
  • 42 Weber M, Woerner M, Craiovan B. et al. Current standard rules of combined anteversion prevent prosthetic impingement but ignore osseous contact in total hip arthroplasty. Int Orthop 2016; 40: 2495-2504
    CrossrefPubMedSearch in Google Scholar