A novel imageless accelerometer-based navigation system improves acetabular cup placement accuracy during total hip arthroplasty in the lateral decubitus position

INTRODUCTION

The accuracy of acetabular cup placement using conventional portable imageless navigation systems in total hip arthroplasty (THA) in the lateral decubitus position remains challenging. Several novel portable imageless navigation systems have been developed recently to improve cup placement accuracy in THA. This study compared the accuracy of acetabular cup placement using a conventional accelerometer-based portable navigation (c-APN) system and a novel accelerometer-based portable navigation (n-APN) system during THA in the lateral decubitus position.

MATERIALS AND METHODS

This retrospective cohort study compared 45 THAs using the c-APN and 45 THAs using the n-APN system. The primary outcomes were the absolute errors between the intraoperative and postoperative values of acetabular cup radiographic inclination and anteversion angles and the percentage of cases with absolute errors within 5°. Intraoperative values were shown on navigation systems, and postoperative measurements were conducted using computed tomography images.

RESULTS

The median absolute errors of the cup inclination angles were significantly smaller in the n-APN group than in the c-APN group (3.9° [interquartile range 2.2°-6.0°] versus 2.2° [interquartile range 1.0°-3.3°]; P = 0.002). Additionally, the median absolute errors of the cup anteversion angles were significantly smaller in the n-APN group than in the c-APN group (4.4° [interquartile range 2.4°-6.5°] versus 1.9° [interquartile range 0.8°-2.7°]; P < 0.001). Significant differences were observed in the percentage of cases with absolute errors within 5° of inclination (c-APN group 67% versus n-APN group 84%; P = 0.049) and anteversion angles (c-APN group 62% versus n-APN group 91%; P = 0.001).

CONCLUSIONS

The n-APN system improved the accuracy of the cup placement compared to the c-APN system for THA in the lateral decubitus position.

Evaluation of the reproducibility of preoperative three-dimensional computed tomography planning for posterolateral approach total hip arthroplasty

The anteversion of the stem is occasionally intentionally changed by the surgeon for patients with smaller femoral neck anteversion during total hip arthroplasty (THA). However, the reproducibility of preoperative planning with increasing anteversion has been rarely assessed. The present study investigated it using two types of stems. This retrospective study included patients who underwent primary posterolateral THA using taper-wedge (TS group; 73 hips) and anatomical (AS group; 70 hips) stems. Characteristics of sex and age were matched in the two groups by propensity score matching. In both groups, the relationship between the preoperative three-dimensional planning and postoperative stem position, and the relationship between postoperative stem position and femoral neck anteversion (FNA) were evaluated. In the TS group, there were no significant differences in average stem anteversion (SA) between preoperative planning and postoperative placement (36.1° ± 7.0° and 36.6° ± 11.1°, respectively: p = 0.651). The absolute error of SA was 8.1° ± 6.4°. In the AS group, the postoperative SA was significantly smaller than the preoperative planning SA (22.7° ± 11.6° and 30.0° ± 9.3°, respectively: p < 0.001). The absolute error of SA was 9.0° ± 5.8°. The postoperative SA was significantly larger than the FNA in the TS group (36.6° ± 11.1° and 26.3° ± 10.9°, respectively: p < 0.001). However, no significant differences between the two were observed in the AS group (23.7° ± 10.1° and 22.7° ± 11.6°, respectively: p = 0.253). The preoperative planning of intentional increasing anteversion did not show high reproducibility with taper-wedge and anatomical stems. The anatomical stem was placed according to the femoral medullary canal regardless of preoperative planning with increased SA.

Cup safe zone and optimal stem anteversion in total hip arthroplasty for patients with highly required range of motion

To avoid dislocation after total hip arthroplasty, it is desirable to avoid implant impingement during activities of daily living. Numerous simulation studies have been performed at 30° of internal rotation (IR) with 90° of flexion. However, these studies may not reflect the impingement that occurs during activities such as floor sitting, which require a larger IR during flexion. The purpose of this study was to assess the impact of varying IR angles during flexion on the impingement-free safe zone and optimal stem anteversion. In this study, implant impingement simulation was evaluated in computer simulation. The prosthesis used a flat liner, and a 32- or 40-mm femoral head and stem. Three patterns of required IR angle (30° IR/40° IR/50° IR with 90° flexion) combined with 13 directions of the required range of motion were simulated. The optimal stem anteversion to maximize the safe zone was analyzed. Increasing the required IR at 90° flexion decreased the safe zone, particularly with small stem anteversion angles. With a 32-mm head, the desirable stem anteversion at 40° of cup inclination was 15°/25°/35° in required 30° IR/40° IR/50° IR with 90° flexion, respectively. The safe zone area of the 32-mm head was smaller than that of the 40-mm head. For patients who require a larger IR with 90° flexion, the stem and cup target anteversion should be adjusted according to the implant design, head diameter, and patient's required IR at flexion in their lifestyle.

Mechanobiochemical bone remodelling around an uncemented acetabular component: influence of bone orthotropy

Mechanical loosening of an implant is often caused by bone resorption, owing to stress/strain shielding. Adaptive bone remodelling elucidates the response of bone tissue to alterations in mechanical and biochemical environments. This study aims to propose a novel framework of bone remodelling based on the combined effects of bone orthotropy and mechanobiochemical stimulus. The proposed remodelling framework was employed in the finite element model of an implanted hemipelvis to predict evolutionary changes in bone density and associated orthotropic bone material properties. In order to account for variations in load transfer during common daily activities, several musculoskeletal loading conditions of hip joint corresponding to sitting down/up, stairs ascend/descend and normal walking were considered. The bone remodelling predictions were compared with those of isotropic strain energy density (SED)-based, isotropic mechanobiochemical and orthotropic strain-based bone remodelling formulations. Although similar trends of bone resorption were predicted by orthotropic mechanobiochemical (MBC) and orthotropic strain-based models across implanted acetabulum, more volume (10-20%) of bone elements was subjected to bone resorption for the orthotropic MBC model. Higher bone resorption (75-85%) was predicted by the orthotropic strain-based and orthotropic MBC models compared to the isotropic MBC and SED-based models. Higher bone apposition (35-160%) across the implanted acetabulum was predicted by the isotropic MBC model, compared to the SED-based model. The remodelling predictions indicated that a reduction in estrogen level might lead to an increase in bone resorption. The study highlighted the importance of including mechanobiochemical stimulus and bone anisotropy to predict bone remodelling adequately.

Reliability and accuracy of intraoperative fluoroscopy assessment of acetabular cup anteversion in supine direct anterior approach total hip arthroplasty

Poor implantation positioning of hip prostheses is considered the primary factor affecting postoperative joint wear. Cup anteversion in direct anterior approach (DAA) total hip arthroplasty (THA) is often excessive. Intraoperative fluoroscopy (IF) are effective for improving implant placement accuracy. This study aimed to analyze IF's reliability and accuracy in assessing intraoperative anteversion. Sixty-two consecutive hips underwent primary THA utilizing DAA alongside IF for cup placement. Intraoperative anteversion was measured using IF images, while postoperative CT and standard anteroposterior (AP) radiographs were used to calculate true anteversion component angles. Differences and correlations between intraoperative and true anteversions were analyzed, and intraclass correlation coefficients (ICC) determined the inter- and intra-observer reliabilities. Excellent intra- and inter-observer reliabilities were observed for all radiographic and CT methods (ICC > 0.9). Strong correlations (PCC > 0.6) existed between anteversion measured on IF image and postoperative CT and AP pelvic measurements. Intraoperative anteversion measured on IF images (16.8 ± 3.2°) was smaller than anteversion measured postoperatively on AP X-rays (21.3 ± 4.7°, P < 0.001) and CT (22.0 ± 4.9°, P < 0.001), with average differences of 4.5°and 5.3°, respectively. Under several influencing factors, the accuracy of IF in assessing cup anteversion in DAA-THA may be limited. However, this still requires large-sample experiments for verification.

Roles of combined femoral and acetabular anteversion in pathological changes of hip dysplasia and hip reconstructive surgery

Combined femoral and acetabular anteversion is the sum of femoral and acetabular anteversion, representing their morphological relationship in the axial plane. Along with the increasing understanding of hip dysplasia in recent years, numerous scholars have confirmed the role of combined femoral and acetabular anteversion in the pathological changes of hip dysplasia. At present, the reconstructive surgery for hip dysplasia includes total hip replacement and redirectional hip preservation surgery. As an important surgery index, combined femoral and acetabular anteversion have a crucial role in these surgeries. Herein, we discuss the role of combined femoral and acetabular anteversion in pathological changes of hip dysplasia, total hip replacement, and redirectional hip preservation surgery.

Accuracy of cup placement compared with preoperative surgeon targets in primary total hip arthroplasty using standard instrumentation and techniques: a global, multicenter study

BACKGROUND

Acetabular cup positioning in total hip arthroplasty (THA) is closely related to outcomes. The literature has suggested cup parameters defined by the Lewinnek safe zone; however, the validity of such measures is in question. Several studies have raised concerns about the benefits of using the Lewinnek safe zone as a predictor of success. In this study we elected to use prospective surgeon targets as the basis for comparison to see how successful surgeons are positioning their cup using standard instruments and techniques.

METHODS

A prospective, global, multicenter study was conducted. Cup positioning success was defined as a composite endpoint. Both cup inclination and version needed to be within 10° of the surgeon target to be considered a success. Radiographic analysis was conducted by a third-party reviewer.

RESULTS

In 170 subjects, inclination, target versus actual, was 44.8° [standard deviation (SD 0.9°)] and 43.1° (SD 7.6°), respectively (p = 0.0029). Inclination was considered successful in 84.1% of cases. Mean version, target versus actual, was 19.4° (SD 3.9°) and 27.2° (SD 5.6°), respectively (p < 0.0001). Version was considered successful in 63.4% of cases, and combined position (inclination and version) was considered successful in 53.1%.

CONCLUSION

This study shows that with traditional methods of placing the cup intraoperatively, surgeons are only accurate 53.1% of the time compared with a predicted preoperative plan. This study suggests that the inconsistency in cup positioning based on the surgeon's planned target is potentially another important variable to consider while using a mechanical guide or in freehand techniques for cup placement in THA.

TRIAL REGISTRATION

This study is registered on ClinicalTrials.gov, NCT03189303.

Clinical effects of combined anteversion and offset on postoperative dislocation in total hip arthroplasty

BACKGROUND

Implant impingement and soft tissue tension are factors involved in dislocation after total hip arthroplasty (THA). Combined anteversion (CA) has been used as an indicator for implant placement. However, optimal implant placement remains a challenge. Moreover, the effect of changes in offset on dislocation is still unclear. In this study, we aimed to clarify the effects of postoperative CA and pre- and postoperative changes in offset on dislocation.

METHODS

Included were patients who underwent primary cementless THA between 2013 and 2020. The mean values of CA and offset in the dislocation and non-dislocation groups were compared. The CA values within ± 10% of the recommended values were defined as good CA, and those outside the range were rated as poor CA. The dislocation rates were compared between the good and poor CA groups and between the groups with and without increased offset.

RESULTS

A total of 283 hips were included. The mean values of CA in the dislocation and non-dislocation groups were significantly different (P < 0.05). The dislocation rate was significantly lower in the good CA group (P < 0.05). The dislocation rates in the groups with and without increased total offset were 0.5% and 4.3%, respectively (P = 0.004). There were no dislocations in patients with good CA and increased offset.

CONCLUSIONS

The dislocation rate was significantly lower when implants were placed within ± 10% of the recommended CA value. Our results suggest that dislocation can be avoided by placing the implant in the good CA range and considering the increase in total offset on the operative side.

Is there still an indication for the Birmingham Hip Resurfacing in femoral head osteonecrosis?

PURPOSE

Osteonecrosis of the femoral head (ONFH) is a progressive hip disease. Hip resurfacing arthroplasty (HRA) is a preferred surgical procedure among hip arthroplasty performed in young patients. The aim of this study is to show the long-term clinical and radiological results of HRA procedures performed for patients suffering from ONFH.

METHODS

Forty-five patients who underwent hip resurfacing with the diagnosis of femoral head osteonecrosis were included in the study. The Harris Hip Score (HHS) was used for clinical scoring of the patients. The blood chromium, cobalt, white blood cell (WBC) count, and CRP levels of patients were checked. Ultrasonography (USG) was performed for all patients at mid-term control checked for pseudo-tumours. For the radiological evaluation, acetabular inclination, stem shaft angle, prothesis-to-neck ratio, osteolysis zones, and heterotopic ossification were used.

RESULTS

The mean age of the patients was 46.6 ± 9.3 years, and the mean follow-up period was 11.83 ± 2.9 years. The mean HHS was 90.3 ± 12.8 for final follow-up. The mean WBC value was 8.2 109/L, mean CRP value was 6.3 mg/L, mean chromium value was 4.9 µg/L, and mean cobalt value was 1.8 µg/L. Inclination changing 0.2°(p = 0.788), stem shaft angle changing 0.7°(p = 0.424), and neck-to-prosthesis ratio changing 0.01°(p = 0.075). No pseudo-tumours were detected in any patients in USG examination.

CONCLUSION

HRA provides long-term implant survival and excellent clinical outcomes for end-stage ONFH patients with low complication rates.

Robotic-assisted total hip arthroplasty in patients with developmental dysplasia of the hip

PURPOSES

Due to the morphological diversity of deformities, technical difficulties, improperly designed components, and so on, THA remains a challenging task in dysplastic hips, especially in highly dislocated hips. The purpose of this study was to comprehensively evaluate the clinical outcomes of robot-assisted THA in patients with DDH through a large cohort study, including the precision of acetabular cup positioning, indicators of inflammatory response, indicators of muscle damage, and complications.

METHODS

We retrospectively analyzed patients with DDH who underwent THA in our prospectively constructed joint registry between August 2018 and August 2022. Finally, 147 manual THAs and 147 robotic-assisted THAs were included in the final analysis. Patient demographics, indicators of inflammation, indicators of muscle damage, operative time, Harris hip scores (HHS), and forgotten joint score (FJS) were recorded for analysis. The precision of the positioning of the acetabular component was assessed with plain radiographs.

RESULTS

In the Crowe II/III groups, the reconstructed center of rotation (COR) in the robotic-assisted group was closer to the anatomical COR with less variation than the manual group (absolute horizontal distances of COR 3.5 ± 2.8 vs. 5.4 ± 4.9 mm, p < 0.05; absolute vertical distances of COR 6.4 ± 4.1 vs. 11.7 ± 8.2 mm, p = 0.001). For all Crowe subtypes, the robotic-assisted THA significantly increased the proportion of acetabular cups located in the safety zone within 5° (all p < 0.05). Interleukin-6 and creatine kinase levels were slightly lower and significantly different in the robotic-assisted group at three days postoperatively (all p < 0.05).

CONCLUSIONS

Compared to the manual technique, the robot-assisted technique improved the precision and reproducibility of acetabular component positioning, particularly in DDH patients with Crowe types II/III. The robotic-assisted technique did not increase operative time, bleeding, complications, or revision rates, and had a slighter early inflammatory response and muscle damage.

Accuracy of portable navigation during THA in patients with severe developmental dysplasia of hip

INTRODUCTION

Correct cup placement in total hip arthroplasty (THA) for patients with developmental dysplasia of the hip (DDH) is considerably difficult. This study aimed to analyze the orientation accuracy of cup insertion during THA using a portable navigation system in patients with DDH.

MATERIALS AND METHODS

In this retrospective cohort study, we analyzed data from 64 patients who underwent THA using infrared stereo camera-matching portable navigation. Patients underwent THA via the anterolateral approach in the lateral decubitus position. Navigation records for intraoperative cup angles, postoperative cup angles measured on computed tomography (CT) images, and cup angle measurement differences were measured and compared between patients with non-DDH/mild DDH and severe DDH. Furthermore, the predictive factors for outliers of accurate acetabular cup placement were analyzed.

RESULTS

The average measurement absolute abduction differences (postoperative CT-navigation record) were 3.9 ± 3.5° (severe DDH) and 3.3 ± 2.6° (non-DDH/ mild DDH), and the anteversion differences were 4.7 ± 3.4° (severe DDH) and 2.3 ± 2.1° (non-DDH/ mild DDH). The anteversion difference was different between the two groups. Multivariate analysis showed that the navigation difference (absolute difference in anteversion between postoperative CT and navigation records of > 5°) was significantly associated with severe DDH (odds ratio [OR]: 3.3; p = 0.049, 95% confidence interval [CI]: 1.0-11.1) and posterior pelvic tilt (OR: 1.1; p = 0.042, 95% CI: 1.0-1.27).

CONCLUSIONS

In patients with severe DDH, it is important to pay close attention during THA using portable navigation. However, the average difference was < 5º even in patients with severe DDH, and the accuracy may be acceptable in a clinical setting when the cost is considered.

Evaluating Pelvic Tilt Using the Pelvic Antero-Posterior Projection Images: A Systematic Review

BACKGROUND

Pelvic tilt (PT) is a routinely evaluated parameter in hip and spine surgeries, and is usually measured on a sagittal pelvic radiograph. This may not always be feasible due to limitations such as landmark visibility, pelvic anomaly, and hardware presence. Tremendous efforts have been dedicated to using pelvic antero-posterior (AP) radiographs for assessing sagittal PT. Thus, this systematic review aimed to collect these methods and evaluate their performances.

METHODS

Two independent reviewers searched the PubMed, Ovid, Cochrane, and Web of Science databases in June 2023 with backward reference trailing (Google Scholar archive). There were 30 studies recruited. Risk of bias was assessed using the prediction model risk of bias assessment tool. The relevant data were tabulated in a standardized form for evaluating either the absolute PT or relative PT. Disagreement was resolved by discussing with the senior author.

RESULTS

There were 19 parameters from pelvic AP projection images involved, with 4 studies which used artificial intelligence, eyeball, or statistical shape method not involving a specific parameter. In comparing the PT values from pelvic sagittal images with those extrapolated from antero-posterior projection images, the highest correlation coefficient was found to be 0.91. The mean absolute difference (error) was 2.6°, with a maximum error reaching 10.9°. Most studies supported the feasibility of using AP parameters to calculate changes in PT.

CONCLUSIONS

No individual AP parameter was found to precisely estimate absolute PT. However, relative PT can be derived by evaluating serial AP radiographs of a patient in varying postures, employing any AP parameters.

How to Estimate Femoral Stem Anteversion During Direct Anterior Approach Total Hip Arthroplasty

Background

There are various traditional landmarks used to estimate the femoral component version, yet none are widely accepted by direct anterior surgeons. The purpose of this study was to compare bony landmarks easily accessible to direct anterior surgeons and to estimate which one provides the best estimate of femoral component anteversion.

Methods

A computed tomography database was used to identify 736 left entire-femur computed tomography scans. Seven visible anatomic landmarks were identified using a computer model in which a 45° virtual neck resection was made at 10 mm above the lesser trochanter. Thirteen axes, to reference the femoral stem position, were created between the 7 landmarks. Means and standard deviations (SDs) of angles between each axis and the transepicondylar axis (TEA) were compared for their precision.

Results

The traditional lesser trochanter predicted anteversion from the TEA was 34.1° (SD 9.7°). Predicted anteversion from the TEA was 3.3° (SD 8.1°) when aligned from the center of the canal to the middle of the medial calcar; 14.0° (SD 8.1°) from the center of the canal to the anterior 1/3 of the medial calcar; and 24.8° (SD 8.5°) from the center of the canal to the most anterior point on the medial calcar.

Conclusions

Compared to the lesser trochanter, 7 axes were more precise (lower SD) when predicting the version. Estimating the femoral component position, via simulated data, using 3 points along the medial calcar is a relatively precise and easily accessible tool for surgeons.

Femoral Neck Anteversion: Which Distal Femur Landmark Matters?

Background

Femoral neck anteversion has traditionally been measured by the angle between the distal femur posterior condylar axis (PCA) and a line drawn through the center of the femoral head and neck. While less common, the transepicondylar axis (TEA) has also been used to reference femoral neck anteversion. The purpose of this study was to compare femoral neck version of the PCA vs the TEA using computerized tomography (CT).

Methods

A total of 1507 femoral CTs were included. Precise bony landmarks were established: lateral epicondyle, medial epicondyle, posteromedial condyle, posterolateral condyle, center of the femoral neck, and center of the femoral head. Femoral version was calculated between the head and neck axis and either the PCA or TEA. Differences between sex and ethnicity were evaluated.

Results

The mean femoral anteversion was 12.7° ± 9.1° based on the PCA and 11.5° ± 7.9° based on the TEA (mean difference 1.2° ± 1.9°, P < .001). Males were less anteverted than females (9.8° ± 7.6° vs 13.5° ± 7.8°, P < .001). African Americans had less anteversion than other groups (8.1° ± 9.2° vs 11.5° ± 7.8°, P = .04), while Asians were more anteverted than other groups (12.1° ± 9.0° vs 11.2° ± 7.3°, P = .04). These values were referenced on the TEA.

Conclusions

In this series of over 1500 femoral CT scans, the mean difference between anteversion measurements referencing the PCA and TEA was 1.2°. Native femoral version varied widely between gender and ethnic groups. Extreme femoral version, defined as <0° or >30°, was present in 11.8% of patients referencing the PCA.

Accuracy of femoral component anteversion in robotic total hip arthroplasty

Aims

Femoral component anteversion is an important factor in the success of total hip arthroplasty (THA). This retrospective study aimed to investigate the accuracy of femoral component anteversion with the Mako THA system and software using the Exeter cemented femoral component, compared to the Accolade II cementless femoral component.

Methods

We reviewed the data of 30 hips from 24 patients who underwent THA using the posterior approach with Exeter femoral components, and 30 hips from 24 patients with Accolade II components. Both groups did not differ significantly in age, sex, BMI, bone quality, or disease. Two weeks postoperatively, CT images were obtained to measure acetabular and femoral component anteversion.

Results

The mean difference in femoral component anteversion between intraoperative and postoperative CT measurements (system accuracy of component anteversion) was 0.8° (SD 1.8°) in the Exeter group and 2.1° (SD 2.3°) in the Accolade II group, respectively (p = 0.020). The mean difference in anteversion between the plan and the postoperative CT measurements (clinical accuracy of femoral component anteversion) was 1.2° (SD 3.6°) in the Exeter group, and 4.2° (SD 3.9°) in the Accolade II group (p = 0.003). No significant differences were found in acetabular component inclination and anteversion; however, the clinical accuracy of combined anteversion was significantly better in the Exeter group (0.6° (SD 3.9°)) than the Accolade II group (3.6° (SD 4.1°)).

Conclusion

The Mako THA system and software helps surgeons control the femoral component anteversion to achieve the target angle of insertion. The Exeter femoral component, inserted using Mako THA system, showed greater precision for femoral component and combined component anteversion than the Accolade II component.

The Long-Term Efficacy of Computed Tomography-Navigated Total Hip Arthroplasty: An 18-Year Follow-Up Study

Backgroumd: There have been few reports on the long-term survival of computed tomography (CT)-navigated total hip arthroplasty (THA), which should lead to a lower incidence of dislocation and loosening. In this study, we examined survivorship, dislocation, and loosening incidence using plain radiographs over a minimum 15-year follow-up after CT-navigated THA.

METHODS

We retrospectively reviewed 145 consecutive CT-navigated THAs for >15 years. We surveyed the angles placed in both the acetabular and femoral components, survivorship, the occurrence of dislocation, the revision rate, and the fixation grade of the acetabular component.

RESULTS

The mean follow-up duration was 18.4 years. Overall, 73.8% of THAs were within the safe zone of Lewinnek. There were four dislocations (2.8%), with three occurring within 1 month after surgery and the other within 7 years after surgery. Revision THA was performed in one case (0.69%); consequently, the survival rate was 99.3%. The fixation grade was evaluated in 144 hips, and those were evaluated as having "no loosening".

CONCLUSIONS

CT-navigated THA was speculated to contribute to long-term survivorship, with a low rate of loosening, even after 18 years of follow-up. It was speculated that the acetabular component was placed at an acceptable insertion angle and a suitable position for stable initial fixation.

Concurrent Learning Approach for Estimation of Pelvic Tilt from Anterior-Posterior Radiograph

Accurate and reliable estimation of the pelvic tilt is one of the essential pre-planning factors for total hip arthroplasty to prevent common post-operative complications such as implant impingement and dislocation. Inspired by the latest advances in deep learning-based systems, our focus in this paper has been to present an innovative and accurate method for estimating the functional pelvic tilt (PT) from a standing anterior-posterior (AP) radiography image. We introduce an encoder-decoder-style network based on a concurrent learning approach called VGG-UNET (VGG embedded in U-NET), where a deep fully convolutional network known as VGG is embedded at the encoder part of an image segmentation network, i.e., U-NET. In the bottleneck of the VGG-UNET, in addition to the decoder path, we use another path utilizing light-weight convolutional and fully connected layers to combine all extracted feature maps from the final convolution layer of VGG and thus regress PT. In the test phase, we exclude the decoder path and consider only a single target task i.e., PT estimation. The absolute errors obtained using VGG-UNET, VGG, and Mask R-CNN are 3.04 ± 2.49, 3.92 ± 2.92, and 4.97 ± 3.87, respectively. It is observed that the VGG-UNET leads to a more accurate prediction with a lower standard deviation (STD). Our experimental results demonstrate that the proposed multi-task network leads to a significantly improved performance compared to the best-reported results based on cascaded networks.

Short- to Mid-Term Clinical and Radiological Results of Selective Laser Melting Highly Porous Titanium Cup in Primary Total Hip Arthroplasty

(1) Background: The aim of this study was to evaluate short- to mid-term clinical and radiological results in patients undergoing primary total hip arthroplasty (THA) with the use of a Selective Laser Melting 3D-printed highly porous titanium acetabular cup (Jump System Traser®, Permedica Orthopaedics). (2) Methods: We conducted a retrospective study and collected prospective data on 125 consecutive patients who underwent primary THA with the use of highly porous titanium cup. Each patient was evaluated preoperatively and postoperatively with a clinical and radiological assessment. (3) Results: The final cohort consisted of 104 patients evaluated after a correct value of 52 (38-74) months. The median Harris Hip Score (HHS) significantly improved from 63.7 (16-95.8) preoperatively to 94.8 (38.2-95.8) postoperatively (p < 0.001), with higher improvement associated with higher age at surgery (β = 0.22, p = 0.025). On postoperative radiographs, the average acetabular cup inclination and anteversion were 46° (30°-57°) and 15° (1°-32°), respectively. All cups radiographically showed signs of osseointegration with no radiolucency observed, or component loosening. (4) Conclusions: The use of this highly porous acetabular cup in primary THA achieved excellent clinical, functional, and radiological results at mid-term follow-up. A better clinical recovery can be expected in older patients. The radiological evaluation showed excellent osseointegration of the cup with complete absence of periprosthetic radiolucent lines.

Safe Sex After Total Hip Arthroplasty: Using Computed Tomography-Based Robotics to Evaluate "At-Risk" Sexual Positions

BACKGROUND

Total hip arthroplasty (THA) can improve sexual satisfaction, but fear of dislocation can lead to sexual difficulties following this procedure. Previous kinematic research identified 4 sexual positions in women and 2 in men that were considered at risk for impingement. This study aimed to validate these findings using current robotic THA simulations.

METHODS

The 3-dimensional renderings from 12 patients who received computed tomography (CT)-based robotic THA were used to assess for prosthetic and/or bony impingement among 12 popular sexual positions. There were 9 cup orientations tested for each position (a combination of anteversion [0 °, 15 °, and 30 °] and inclination [40 °, 45 °, and 60 °]). The at-risk positions were tested again using the unique hip positions and cup orientations where previous geometric modeling data found impingement to occur.

RESULTS

Using mean hip positions, impingement occurred in at least 1 patient in 1 of the 12 positions for women (position 5) and 5 of the 12 positions for men (positions 1, 5, 8, 10, and 11). Among the at-risk positions, impingement occurred in none of the 2 at-risk women positions (0 of 17 cup orientations) and in both at-risk men positions (9 of 9 cup orientations for position 8 and 1 of 1 for position 11).

CONCLUSION

Recreating popular and at-risk sexual positions following THA with a CT-based robotics system yielded results that were inconsistent with previous geometric modeling data. Resolving these discrepancies is crucial for surgeons to provide accurate postoperative patient education. The CT-based robotic systems may provide necessary input to feasibly individualize such recommendations, but current limitations in CT-based robotics require continued attention and innovation.

Evaluating computed bony range of motion (BROM) by registering in-vitro cadaver-based functional range of motion (FROM) to a hip motion simulation

BACKGROUND

While modern hip replacement planning relies on hip motion simulation (HMS), it lacks the capability to include soft-tissues and ligaments restraints on computed bony range of motion (BROM), often leading to an overestimation of the in-vivo functional range of motion (FROM). Furthermore, there is a lack of literature on BROM assessment in relation to FROM. Therefore, the study aimed to assess computed BROM using in-vitro cadaver-derived FROM measurements, registered to a CT-based in-house HMS, and to further investigate the effect of functional and anatomical hip joint centres (FHJC and AHJC) on BROM.

METHOD

Seven limiting and three non-limiting circumducted passive FROM of four cadaver hips were measured using optical coordinate measuring machine with reference spheres (RSs) affixed to the pelvis and the femur, following CT-scan of the specimen. The RSs' centres were used to register the measured FROM in HMS, enabling its virtual recreation to compute corresponding BROM by detecting nearest bony impingement. FHJC, estimated from non-limiting FROM, was compared with AHJC to examine their positional differences and effect on BROM.

RESULTS

Differences in BROM and FROM were minimal in deep flexion (3.0° ± 4.1°) and maximum internal rotation (IR) at deep flexion (3.0° ± 2.9°), but substantially greater in extension (53.2° ± 9.5°). Bony impingement was observed during flexion, and IR at deep flexion for two hips. The average positional difference between FHJC and AHJC was 3.1 ± 1.2 mm, resulting in BROM differences of 1°-13° across four motions.

CONCLUSIONS

The study provided greater insight into the applicability and reliability of computed BROM in pre-surgical planning.

The Empty Ischial Fossa Sign: A Visual Representation of Relative Inadequate Anteversion in the Posteriorly Tilted Pelvis

Background

Instability is a known complication following total hip arthroplasty (THA) and is influenced by spinopelvic alignment. Radiographic markers have been investigated to optimize the acetabular cup position. This study evaluated if the empty ischial fossa (EIF) sign and the position of the trans-teardrop line were predictive of postoperative instability.

Methods

All patients who underwent THA from 2011 to 2018 at a single institution were retrospectively reviewed. Pelvic tilt was measured using a trans-teardrop line compared to the superior aspect of the pubic symphysis on standing anteroposterior pelvis radiographs. Postoperative dislocations were identified through chart review and radiographic review. The EIF sign was determined by the presence of uncovered bone below the posterior inferior edge of the acetabular component at the level of the native ischium and posterior wall on standing postoperative anteroposterior radiographs.

Results

One thousand seven hundred fifty patients (952 anterior approach and 798 posterior approach) were included. The EIF sign was present in 458 patients (26.2%) and associated with an increased dislocation rate (3.9% vs 0.9%, P < .0001). Patients with spondylosis/instrumented fusion, and positive EIF sign had a dislocation risk of 5.1% vs 1.3% (P = .001). A postoperative outlet pelvis was not significant for increased dislocation risk (odds ratio 2.16, P = .058). Patients with combined spondylosis/fusion, posterior approach, outlet pelvis, and EIF sign had a dislocation rate of 14.5%.

Conclusions

The EIF sign was an independent risk factor for postoperative instability and may represent failure to account for pelvic tilt. Avoidance of the EIF sign during cup positioning may help reduce dislocations following THA.

Intraoperative Assessment of Stability in Total Hip Arthroplasty: A Novel Method Utilizing Implant Collinearity

Background

Hip dislocation remains a leading cause of revision following total hip arthroplasty, and intraoperative assessment of acetabular positioning can be difficult to perform. There are multiple clinical tests, as well as computer and robotic techniques, that aim to reduce dislocation rates after hip arthroplasty. These approaches aim to optimize the relationship between acetabular and femoral component positioning. It is hypothesized in this study that implant collinearity assessment intraoperatively can help determine appropriate acetabular component position. More specifically, implant collinearity, when achieved with a specific leg position, can reliably predict appropriate acetabular positioning.

Methods

A single-surgeon, single-centered study with 55 patients was undertaken between August 2017 and March 2020. Using preoperative imaging and computer simulation, data points were taken for 3 different acetabular configurations and comparing using 2 femoral positions. The angle differences from the collinear position (0 degrees) were compared between groups.

Results

A total of 55 patients' imaging was analyzed using 3 acetabular configurations and 2 femoral positions. The test leg position (30-degree flexion/30-degree internal rotation/10-degree adduction) was closer to collinearity than the control position (30-degree flexion/30-degree internal rotation/0-degree adduction) in all 3 acetabular configurations by a mean of 8 degrees (P < .001), 7 degrees (P < .001), and 4 degrees (P < .001), respectively.

Conclusions

The use of a 10-degree adducted position more reliably recreates implant collinearity when determining acetabular positioning during total hip arthroplasty. This intraoperative test adds another data point to assist the surgeon in achieving safe component positioning.

Femoral Neck Design Does Not Impact Revision Risk After Primary Total Hip Arthroplasty Using a Dual Mobility Cup

Background

The use of dual mobility (DM) cups has increased quickly. It is hypothesized that femoral neck taper geometry may be involved in the risk of prosthetic impingement and DM cup revision. We aim to (1) explore the reasons for revision of DM cups or head/liners and (2) explore whether certain femoral neck characteristics are associated with a higher risk of revision of DM cups.

Methods

Primary total hip arthroplasties with a DM cup registered in the Dutch Arthroplasty Register between 2007 and 2021 were identified (n = 7603). Competing risk survival analyses were performed, with acetabular component and head/liner revision as the primary endpoint. Reasons for revision were categorized in cup-/liner-related revisions (dislocation, liner wear, acetabular loosening). Femoral neck characteristics were studied to assess whether there is an association between femoral neck design and the risk of DM cup/liner revision. Multivariable Cox proportional hazard analyses were performed.

Results

The 5- and 10-year crude cumulative incidence of DM cup or head/liner revision for dislocation, wear, and acetabular loosening was 0.5% (CI 0.4-0.8) and 1.9% (CI 1.3-2.8), respectively. After adjusting for confounders, we found no association between the examined femoral neck characteristics (alloy used, neck geometry, CCD angle, and surface roughness) and the risk for revision for dislocation, wear, and acetabular loosening.

Conclusions

The risk of DM cup or head/liner revision for dislocation, wear, and acetabular loosening was low. We found no evidence that there is an association between femoral neck design and the risk of cup or head/liner revision.

Insufficient stem antetorsion and lower cup abduction is a combined risk factor for posterior hip dislocation in patients undergoing THA for femoral neck fractures: a retrospective analysis

BACKGROUND

The role of acetabular and femoral component positions with respect to the risk of post-operative instability and dislocation remains debated. In this study, we aimed to identify potential risk factors for early dislocation following primary total hip arthroplasty (THA) for displaced intracapsular femoral neck fractures (FNF) using radiological measurements.

METHODS

We retrospectively analyzed data for patients who underwent cementless primary THA for FNF using a posterolateral approach between January 2018 and December 2021. Follow-up duration, age, sex, affected side, and mean time from THA to dislocation were recorded. Leg-length inequality, abductor lever arm, vertical and horizontal femoral offsets, vertical and horizontal hip centers of rotation, abduction, anteversion of the acetabulum and femoral prosthesis, and combined anteversion were measured.

RESULTS

The study sample included 17 men and 34 women, with 21 and 30 patients undergoing left- and right-hip operations, respectively. The mean patient age was 70.18 ± 7.64 years, and the mean follow-up duration was 27.73 ± 13.52 months. The mean time between THA and dislocation was 1.58 ± 0.79 months. Seven patients (13.73%) sustained posterior dislocation of the hip. The abduction angle (36.05 ± 6.82° vs. 45.68 ± 8.78°) (p = 0.008) and anteversion of the femoral prosthesis (8.26 ± 4.47° vs. 19.47 ± 9.01°) (p = 0.002) were significantly lower in the dislocation group than in the control group. There were no significant differences in other parameters.

CONCLUSIONS

Insufficient stem antetorsion combined with lower abduction angle of the acetabular component were associated with a high risk of dislocation, especially in patients with deep flexion or internal rotation of the flexed hip joint and knees, or in patients with a stiff spine or anterior pelvic tilt, impingement may then occur in the neck of the prosthesis and cup component, ultimately resulting in posterior dislocation. These findings could remind surgeons to avoid simultaneous occurrence of both in THA surgery. These results provide new insight into risk factors for hip dislocation in patients undergoing primary THA for FNF and may aid in reducing the risk of instability and dislocation.

LEVEL OF EVIDENCE

Prospective comparative study Level II.

Effect of longer femoral head on leg length, offset, and range of motion in total hip arthroplasty: a simulation study

In this study, we investigated the relationship between head length, leg length, offset, and dislocation resistance using range of motion (ROM) simulations based on computed tomography data to examine if a longer femoral head reduces the risk of dislocation. The femoral components were set to eliminate leg length differences with a + 0 mm head, and variations for + 4-, + 7-, and + 8-mm heads were analyzed. Offset and ROM were assessed when longer heads were used, with the leg length adjusted to be similar to that of the contralateral side. While internal rotation at flexion and external rotation at extension increased with + 4-mm longer heads, the + 7- and + 8-mm heads did not increase dislocation resistance. When adjusting for leg length, the longer heads showed no significant differences in offset and ROM. Enhancing dislocation resistance by solely increasing the offset with a longer head, while simultaneously adjusting the depth of stem insertion, may be a beneficial intraoperative technique. Although a + 4-mm longer head possibly increases ROM without impingement, heads extended by + 7 or + 8 mm may not exhibit the same advantage. Therefore, surgeons should consider this technique based on the implant design.

Acetabular cup size trends in total hip arthroplasty

BACKGROUND

Total hip arthroplasty (THA) is a common procedure for end stage osteoarthritis. The learning curve for THA is complex and challenging. One of the most difficult skills to master is acetabular reaming. We wish to identify if experience in arthroplasty leads to preservation of more bone stock.

AIM

To investigate if increasing surgeon experience will predict an ever decreasing acetabular cup size.

METHODS

A retrospective case series of four attending orthopaedic surgeons was completed. All uncemented elective total hip arthroplasties since appointment were selected for inclusion. The size of acetabular cup used was noted and logistic regression was used to identify if a trend to smaller cups existed.

RESULTS

A total of 1614 subjects were included with a mean age of 64 years. Overall cups were on average 0.18mm smaller per year (95% confidence interval -0.25 to -0.11, P < 0.001). Individual surgeon trends showed cup sizes to decrease 0.27 mm/year for surgeon A, 0.02 mm/year for surgeon B, 0.15 mm/year for surgeon C and 0.29 mm/year for surgeon D. Three of the four surgeons had a more pronounced trend to smaller cups for male subjects than their female counterparts.

CONCLUSION

We found increasing surgeon experience to be associated with an ever-decreasing acetabular cup size. Smaller acetabular cup size may act as a surrogate marker of surgical proficiency by virtue of decreased acetabular reaming.

Variety of femoral anteversion and its measurement in cementless total hip arthroplasty: Does robotic technology improve accuracy?

BACKGROUND

High-performance total hip arthroplasty (THA) depends on the accurate position of components. However, femoral anteversion is variable, and current studies only used traditional instruments to evaluate it, such as protractor and spirit level with limited cases. This study aimed to identify the variability in the measured femoral native anteversion and intraoperative stem anteversion under different measurement methods, including intraoperative robotic method. We hypothesized that robotic technology was more accurate than traditional instruments for femoral anteversion evaluation.

METHODS

This study included 117 hips of patients who underwent robotic-assisted THA between November 2019 and March 2021. Preoperative native femoral anteversion was measured using a robotic system. Intraoperative femoral stem anteversion was evaluated visually, and then measured with a goniometer and a robotic system, respectively. Variability in the measured femoral native anteversion and intraoperative femoral stem anteversion was calculated and compared. Intraclass correlation coefficient (ICC) and Pearson correlation analysis were used to assess the consistency and correlation of anteversion of different measurements and postoperative CT-measured stem anteversion, respectively.

RESULTS

The result of measurement for preoperative native femoral anteversion was more variable than the intraoperative robotic-measured stem anteversion. Intraoperative robotic-measured stem version showed the highest correlation with postoperative CT measurement of stem version (r = 0.806, P < 0.001), while intraoperative surgeon estimation had the lowest correlation coefficient (r = 0.281, P = 0.025). As for the consistency with postoperative CT measurement of femoral stem anteversion, the intraoperative robotic-measured femoral stem version also had the highest value (ICC = 0.892, P < 0.001).

CONCLUSION

Native femoral anteversion was variable preoperatively. Using cementless stems, anteversion was also highly variable. Robotic assessment for stem anteversion during surgery was more consistent with the final position than the preoperative assessment and conventional intraoperative estimation.

Fluoroscopy-based robotic assistance for total hip arthroplasty improves acetabular cup placement accuracy for obese patients compared to the manual, fluoroscopic- assisted technique

BACKGROUND

Patient obesity is a risk factor for poor acetabular cup positioning in total hip arthroplasty (THA).

OBJECTIVE

To assess the impact of using a novel, fluoroscopy-based robotic THA system on acetabular cup placement in obese versus non-obese patients.

METHODS

A review of 105 consecutive manual unassisted (mTHA) (47 Obese/58 Non-obese) and 102 robotic-assisted (RA-THA) (50 Obese/52 Non-obese) primary, direct anterior approach THA procedures was conducted. All cases were performed by a single surgeon, for a pre-operative diagnosis of osteoarthritis, avascular necrosis, or rheumatoid arthritis. Obesity was defined as a Body Mass Index (BMI) ⩾ 30 kg/m2. Outcomes included acetabular cup inclination and anteversion, and the proportion of cups within the Lewinnek safe-zone.

RESULTS

Obese patients in the mTHA cohort had larger cup inclination angles on average compared to non-obese patients (44.82∘± 6.51 vs. 41.39∘± 6.75; p= 0.009). Obese mTHA patients were less likely to have cup placement within the Lewinnek zone compared to non-obese mTHA patients (0.48 vs. 0.67; p= 0.027). Obesity had no effect on the accuracy of RA-THA.

CONCLUSION

Obesity affects the placement of the acetabular component in manual THA. The novel, fluoroscopy-based robotic THA system in this study demonstrated accurate cup placement regardless of obesity status.

CT-based, robotic-arm assisted total hip arthroplasty (Mako) through anterior approach provides improved cup placement accuracy but no difference in clinical outcomes when compared to conventional technique

BACKGROUND

With the restoration of the natural hip biomechanics, a successful total hip arthroplasty (THA) and long-term survival is pursued. Although robotic THA (rTHA) has been developed to increase accuracy of implant positioning, leg lengths and offsets, discussions about its radiological and clinical advantages over conventional THA (cTHA) continues.

OBJECTIVE

The aim of this study was to compare clinical and radiological outcomes of robotic and conventional THA.

METHODS

This retrospective study compares functional and radiological outcomes of 82 rTHA with a matched group of 82 cTHA in terms of age, sex, body mass index and preoperative functional scores. The minimum follow up was 12 months for all patients. Functional outcomes were Harris Hip Score (HHS) and the Western Ontario and McMaster University Osteoarthritis index (WOMAC) evaluated pre- and postoperatively. Radiological evaluations included position of cup placement according to Lewinnek and Callanan safe zones, Canal Fill Ratio (CFR), Leg Length Discrepancy (LLD), Lateral offset (LO) and Femoral Component Alignment (FCA). Complications were also evaluated.

RESULTS

In the rTHA group, 91.5% (75 out of 82) of the acetabular cups were positioned within the safe zone whereas it was 63.4% (52 out of 82) for the cTHA group (p< 0.001). According to Callanan, they were 84.1% and 50%, respectively (p< 0.001). Between the groups, no statistically significant difference was found in CFR, LLD, HO, FCA, AI, AA, WOMAC, HHS and major complication rates.

CONCLUSION

rTHA is superior to cTHA in terms of accuracy and reproducibility of the cup placement, however no apparent clinical benefit was found in short term follow.

Anatomical cup implantation assisted with dynamic 3D planning improves functional outcomes in primary total hip arthroplasty: A retrospective study

BACKGROUND

Anatomical cup implantation is a promising approach in primary total hip arthroplasty (THA) and improves functional outcomes.

OBJECTIVE

We aimed to evaluate the cup position and functional outcomes in primary THA with preoperative dynamic 3D planning.

METHODS

We retrospectively reviewed 54 hips in 48 patients who underwent primary THA with anatomical cup implantation (mean follow-up time: 52 months). Cup positions were evaluated based on patient-specific morphology, the acetabular fossa and the combined anteversion test. Functional outcomes were assessed after THA. The paired-sample t-test was performed for surgical and contralateral native hips among 42 patients who underwent unilateral THA.

RESULTS

Two hips suffered intraoperative trochanteric fracture, but no hip dislocations occurred. No patients reported groin or thigh pain, and all patients were capable of deep squatting and one-leg standing. The mean Harris hip score, WOMAC score, and physical SF-36 score were 94.46 ± 6.16, 10.41 ± 3.62, and 95.19 ± 8.74, respectively. Except for acetabular offset, THA restored biomechanics to those of contralateral native hip, including cup anteversion, abduction, femoral offset and acetabular height (P> 0.05).

CONCLUSION

This study provided evidence for the application of anatomical cup implantation assisted with dynamic 3D planning in primary THA, which restored morphology and improved functional outcomes.

Quantification of soft tissue artifacts using CT registration and subject-specific multibody modeling

The potential use of gait analysis for quantitative preoperative planning in total hip arthroplasty (THA) has previously been demonstrated. However, the joint kinematic data measured through this process tend to be unreliable for surgical planning due to distortions caused by soft tissue artifacts (STAs). In this study, we developed a novel motion capture framework by combining computed tomography (CT)-based postural calibration and subject-specific multibody dynamics modeling to prevent the effect of STAs in measuring hip kinematics. Three subjects with femoroacetabular impingement syndrome were recruited, and CT data for each patient were collected by attaching marker clusters near the hip. A subject-specific multibody hip joint model was developed based on reconstructed CT data. Spring-dashpot network calculations were performed to minimize the distance between the anatomical landmark and its corresponding infrared reflective marker. The STAs of the thigh was described as six degrees of freedom viscoelastic bushing elements, and their parameter values were identified via smooth orthogonal decomposition. Least squares optimization was used to modify the pelvic rotations to compensate for the rigid components of STAs. The results showed that CT-assisted motion tracking enabled the successful identification of STA influences in gait and squat positions. Furthermore, STA effects were found to alter maximal pelvis tilt and hip rotations during a squat. Compared to other techniques, such as dual fluoroscopic imaging, the adopted framework does not require additional medical imaging for patients undergoing robot-assisted THA surgery and is thus a practical way of evaluating hip joint kinematics for preoperative surgical planning.

Combined Anteversion Threshold to Avoid Anterior Dislocation in Primary Total Hip Arthroplasty Performed Through the Direct Anterior Approach

BACKGROUND

Component malposition in total hip arthroplasty (THA) can lead to dislocation, early implant failure, and revision surgery. As the surgical approach might affect the targeted combined anteversion (CA) of THA components, the present study aimed to evaluate the optimal CA threshold to avoid anterior dislocation in primary THA performed through a direct anterior approach (DAA).

METHODS

A total of 1,176 THAs in 1,147 consecutive patients (men: 593, women: 554) who had an average age of 63 years (range, 24 to 91) and a mean body mass index of 29 (range, 15 to 48) were identified. Medical records were reviewed for dislocation, whereas postoperative radiographs were assessed to measure the acetabular inclination and CA using a previously validated radiographic method.

RESULTS

An anterior dislocation occurred in 19 patients at an average of 40 days postoperatively. The average CA in patients who did and did not have a dislocation was 66 ± 8° and 45 ± 11°, respectively (P < .001). In 5 of 19 of the patients, a THA was performed for secondary osteoarthritis and 17 of 19 had a 28-mm femoral head. A CA ≥ 60° yielded a sensitivity of 93% and specificity of 90% for predicting an anterior dislocation in the present cohort. A CA ≥ 60° was associated with a significantly higher risk of anterior dislocation (odds ratio = 75.6; P < .001) compared to patients who had a CA<60 points.

CONCLUSION

The optimal CA to avoid anterior dislocations in THA performed through the DAA should be less than 60°.

LEVEL OF EVIDENCE

Cross-sectional study, Level III.

A patient-specific algorithm for predicting the standing sagittal pelvic tilt one year after total hip arthroplasty

Aims

The aim of this study was to evaluate the reliability and validity of a patient-specific algorithm which we developed for predicting changes in sagittal pelvic tilt after total hip arthroplasty (THA).

Methods

This retrospective study included 143 patients who underwent 171 THAs between April 2019 and October 2020 and had full-body lateral radiographs preoperatively and at one year postoperatively. We measured the pelvic incidence (PI), the sagittal vertical axis (SVA), pelvic tilt, sacral slope (SS), lumbar lordosis (LL), and thoracic kyphosis to classify patients into types A, B1, B2, B3, and C. The change of pelvic tilt was predicted according to the normal range of SVA (0 mm to 50 mm) for types A, B1, B2, and B3, and based on the absolute value of one-third of the PI-LL mismatch for type C patients. The reliability of the classification of the patients and the prediction of the change of pelvic tilt were assessed using kappa values and intraclass correlation coefficients (ICCs), respectively. Validity was assessed using the overall mean error and mean absolute error (MAE) for the prediction of the change of pelvic tilt.

Results

The kappa values were 0.927 (95% confidence interval (CI) 0.861 to 0.992) and 0.945 (95% CI 0.903 to 0.988) for the inter- and intraobserver reliabilities, respectively, and the ICCs ranged from 0.919 to 0.997. The overall mean error and MAE for the prediction of the change of pelvic tilt were -0.3° (SD 3.6°) and 2.8° (SD 2.4°), respectively. The overall absolute change of pelvic tilt was 5.0° (SD 4.1°). Pre- and postoperative values and changes in pelvic tilt, SVA, SS, and LL varied significantly among the five types of patient.

Conclusion

We found that the proposed algorithm was reliable and valid for predicting the standing pelvic tilt after THA.

Liaw's Ellipse Anteversion Method for Distinguishing Acetabular Component Retroversion from Anteversion on Plain Radiographs

Improper acetabulum component position is a significant risk factor for postoperative dislocation after total hip arthroplasty. Several radiographic two-dimensional methods exist for measuring acetabulum component anteversion, but they cannot distinguish between anteversion and retroversion. "Liaw's version," initially proposed as a simple mathematical standardized two-dimensional method, was modified to the computerized ellipse method, proving superior accuracy to traditional two-dimensional methods. In this article, we demonstrated its application in detecting and measuring retroverted acetabulum component. We obtained anteroposterior pelvis radiographs from a patient undergoing total hip arthroplasty on the day of surgery and 2 weeks postoperatively. The computerized ellipse method was used to measure the acetabulum component orientation. Upon comparison, the difference between θ assigned to be retroverted (9.52-8.56 = 0.96) is much smaller than the difference between θ assigned to be anteverted (23.81-18.86 = 4.95), leading us to determine retroversion. This was further confirmed by computed tomography at the 6-week follow-up. We propose that using the computerized ellipse method to measure Liaw's version can be a valuable tool in identifying acetabulum component retroversion on anteroposterior radiographs during routine postoperative follow-up and retrospective assessments of total hip arthroplasty patients.

Augmented reality-assisted versus conventional total hip arthroplasty: a systematic review and meta-analysis

BACKGROUND

Extended reality (XR), including virtual reality, augmented reality (AR), and mixed reality, has been used to help achieve accurate acetabular cup placement in total hip arthroplasty (THA). This study aimed to compare the differences between XR-assisted and conventional THA.

METHODS

In this systematic review and meta-analysis, electronic databases including PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), and clinicaltrials.gov were searched for studies from inception to September 10, 2023. The outcomes were accuracy of inclination and anteversion, duration of surgery, and intraoperative blood loss. Meta-analysis was performed using Review Manager 5.4 software.

RESULTS

A total of five studies with 396 patients were included in our study. The pooled results indicated AR-assisted THA had better accuracy of inclination and anteversion than conventional THA (SMD = - 0.51, 95% CI [- 0.96 to - 0.07], P = 0.02; SMD = - 0.96, 95% CI [- 1.19 to - 0.72], P < 0.00001), but duration of surgery and intraoperative blood loss were similar in the two groups.

CONCLUSION

This systematic review and meta-analysis found that AR-assisted THA had better accuracy of inclination and anteversion than conventional THA, but the duration of surgery and intraoperative blood loss were similar in the two groups. Based on the pooled results, we suggested that AR can provide more precise acetabular cup placement than conventional methods in THA.

Accuracy comparison of cup positioning during total hip arthroplasty using Hip Align and AR-Hip in the supine position

INTRODUCTION

The aim of this study is to compare the accuracy of acetabular cup positioning between the accelerometer-based navigation system and the augmented reality-based navigation system during THA in the supine position.

MATERIALS AND METHODS

This retrospective study included 66 patients (70 hips) who underwent THA using two types of portable navigation system, Hip Align or AR-Hip, in the spine position. The absolute difference between the intraoperative navigation record and postoperative measurement using computed tomography data was evaluated. Preoperative clinical factors that decreased the accuracy of cup positioning by ≥ 3° were analyzed via multiple logistic regression analyses.

RESULTS

The average absolute error of inclination was 2.8 ± 2.6° in Hip Align and 2.7 ± 1.8° in AR-Hip, and absolute anteversion error was 2.5 ± 2.0° in Hip Align and 2.6 ± 2.2° in AR-Hip, and there was no significantly different between the two navigation systems. There was a significant association between the absolute measurement error (≥ 3°) of cup inclination and patients' BMI in the Hip Align group [odds ratio (OR) 1.350; 95% confidence interval (CI) 1.035-1.760; p = 0.027], but not in the AR-Hip group.

CONCLUSIONS

The accuracy of the acetabular cup positioning between the Hip Align and AR-Hip showed no difference during THA in the spine position. The high BMI could have negative influence on the accuracy of cup positioning in THA using Hip Align, thus AR-Hip could be designable for obesity patients.

Advancement in total hip implant: a comprehensive review of mechanics and performance parameters across diverse novelties

The UK's National Joint Registry (NJR) and the American Joint Replacement Registry (AJRR) of 2022 revealed that total hip replacement (THR) is the most common orthopaedic joint procedure. The NJR also noted that 10-20% of hip implants require revision within 1 to 10 years. Most of these revisions are a result of aseptic loosening, dislocation, implant wear, implant fracture, and joint incompatibility, which are all caused by implant geometry disparity. The primary purpose of this review article is to analyze and evaluate the mechanics and performance factors of advancement in hip implants with novel geometries. The existing hip implants can be categorized based on two parts: the hip stem and the joint of the implant. Insufficient stress distribution from implants to the femur can cause stress shielding, bone loss, excessive micromotion, and ultimately, implant aseptic loosening due to inflammation. Researchers are designing hip implants with a porous lattice and functionally graded material (FGM) stems, femur resurfacing, short-stem, and collared stems, all aimed at achieving uniform stress distribution and promoting adequate bone remodeling. Designing hip implants with a porous lattice FGM structure requires maintaining stiffness, strength, isotropy, and bone development potential. Mechanical stability is still an issue with hip implants, femur resurfacing, collared stems, and short stems. Hip implants are being developed with a variety of joint geometries to decrease wear, improve an angular range of motion, and strengthen mechanical stability at the joint interface. Dual mobility and reverse femoral head-liner hip implants reduce the hip joint's dislocation limits. In addition, researchers reveal that femoral headliner joints with unidirectional motion have a lower wear rate than traditional ball-and-socket joints. Based on research findings and gaps, a hypothesis is formulated by the authors proposing a hip implant with a collared stem and porous lattice FGM structure to address stress shielding and micromotion issues. A hypothesis is also formulated by the authors suggesting that the utilization of a spiral or gear-shaped thread with a matched contact point at the tapered joint of a hip implant could be a viable option for reducing wear and enhancing stability. The literature analysis underscores substantial research opportunities in developing a hip implant joint that addresses both dislocation and increased wear rates. Finally, this review explores potential solutions to existing obstacles in developing a better hip implant system.

Accuracy and safety of a new robotic arm for both femoral and acetabular side in total hip arthroplasty: a cadaveric study

BACKGROUND

To investigate the accuracy and safety of a newly constructed robotic arm which can cover the whole process of THA, we performed a series of robot-assisted total hip replacement on the cadaver.

METHODS

Fifteen frozen cadaveric specimens (30 hips) were used for this study. In this investigation, united hip system and Longwell robotic-assisted system were used. The entire lower limb was CT scanned prior to surgery. The 3D model was produced based on CT data; the site of the prosthesis, including acetabular anteversion, inclination angle, and the position of femoral prosthesis, was planned. With the assistance of a robotic arm, the surgeon changed the parameters based on the preoperative plan and the actual condition during surgery, and completed the whole procedure. Following surgery, we measured the acetabular anteversion angle, acetabular inclination angle, femur anteversion angle, combined anteversion angle, stem angulation, and canal fill ratio.

RESULTS

The parameters proved that the acetabular anteversion angle was 16.85 ± 3.00°, the acetabular inclination angle was 40.38 ± 5.37°, femur anteversion angle was 15.90 ± 9.01°, combined anteversion angle was 32.75 ± 9.03°, stem angulation was 1.84 ± 0.99°, and leg length discrepancy was 2.47 ± 1.43 mm. The canal fill ratio (CFR) of femoral prosthesis of osteotomy line in sagittal section is 99.72 ± 1.54% and in coronal section is 62.94 ± 8.91%; below osteotomy line 2.5 cm in sagittal section is 100.00% and in coronal section is 81.48 ± 12.94%; below osteotomy line 7.5 cm in sagittal section is 59.51 ± 12.94% and in coronal section is 89.79 ± 11.13%; femoral shaft isthmus in sagittal section is 56.41 ± 13.80% and in coronal section is 84.95 ± 15.17%.

CONCLUSION

The accuracy and safety of this novel robotic arm are suitable for preparing both the acetabular and femoral sides, providing evidence for clinical trial.

A novel algorithm to efficiently calculate the impingement-free range of motion of irregularly-shaped total hip arthroplasty components

There is great difficulty in quickly calculating the impingement-free range of motion (IFROM) of hip components with complex shapes after total hip arthroplasty. We have established a new algorithm to investigate the effect of different shapes of hip components on the IFROM and impingement-free safe zone (IFSZ). Then find the best combination of hip prosthesis and the optimal mounting position of the elevated-rim liner under different radiographic anteversion (RA) and radiographic inclination (RI) of the cup. We found the larger the opening angle of the beveled-rim liner and the smaller the cross-sectional area of the stem neck with an inverted teardrop cross-sectional shape, the greater the IFROM of the hip component. The beveled-rim liner in combination with the stem neck with an inverted teardrop-shaped cross-section could provide the greatest IFSZ (excluding the flat-rim liner). The optimal orientation of the elevated-rim liner was the posterior-inferior side (RI ≤ 37°), posterior-superior side (RI ≥ 45°), and posterior side (37° ≤ RI ≤ 45°). Our novel algorithm provides a solution to analyze the IFROM of any hip prosthesis with any complex shape. The shape and size of the cross-section of the stem neck, the orientation of the elevated rim, and the shape and opening angle of the liner are all critical factors for the quantitative calculation of the IFROM and mounting safe zone of the prosthesis. Stem necks with inverted teardrop cross-section and beveled-rim liner improved the IFSZ. The optimal direction of the elevated rim is not constant but varies with RI and RA.

Do hip resurfacing and short hip stem arthroplasties differ from conventional hip stem replacement regarding impingement-free range of motion?

Total hip joint replacement (THR) is clinically well-established. In this context, the resulting range of motion (ROM) is crucial for patient satisfaction when performing joint movements. However, the ROM for THR with different bone preserving strategies (short hip stem and hip resurfacing) raises the question of whether the ROM is comparable with conventional hip stems. Therefore, this computer-based study aimed to investigate the ROM and type of impingement for different implant systems. An established framework with computer-aided design 3D models based on magnetic resonance imaging data of 19 patients with hip osteoarthritis was used to analyse the ROM for three different implant systems (conventional hip stem vs. short hip stem vs. hip resurfacing) during typical joint movements. Our results revealed that all three designs led to mean maximum flexion higher than 110°. However, hip resurfacing showed less ROM (-5% against conventional and -6% against short hip stem). No significant differences were observed between the conventional and short hip stem during maximum flexion and internal rotation. Contrarily, a significant difference was detected between the conventional hip stem and hip resurfacing during internal rotation (p = 0.003). The ROM of the hip resurfacing was lower than the conventional and short hip stem during all three movements. Furthermore, hip resurfacing shifted the impingement type to implant-to-bone impingement compared with the other implant designs. The calculated ROMs of the implant systems achieved physiological levels during maximum flexion and internal rotation. However, bone impingement was more likely during internal rotation with increasing bone preservation. Despite the larger head diameter of hip resurfacing, the ROM examined was substantially lower than that of conventional and short hip stem.

A review of robotic-assisted total hip arthroplasty

Total hip arthroplasty (THA) is a successful surgical method for hip replacement but still poses challenges and risks. Robotic-assisted THA (rTHA) using new generation robotic systems has emerged to improve surgical precision and outcomes. The purpose of this paper is to review the literature on rTHA, with a focus on its advantages, such as individualized preoperative planning, intraoperative assistance, and improved accuracy in implantation, especially in complex cases. Additionally, it aims to explore the disadvantages associated with the use of rTHA, including high costs, the learning curve, and prolonged operation time compared to manual THA (mTHA), which are critical drawbacks that require careful consideration and efforts for minimization. Some financial analyses suggest that rTHA may offer cost-effectiveness and reduced postoperative costs compared to mTHA. While technological advancements are expected to reduce technical complications, there are still debates surrounding long-term outcomes. Practical limitations, such as limited availability and accessibility, also warrant attention. Although the development of rTHA shows promise, it is still in its early stages, necessitating critical evaluation and further research to ensure optimal patient benefits.

Could We Expect Postoperative Cup Anteversion after Total Hip Arthroplasty Using Postoperative Plain Anteroposterior and Lateral Radiograph? A Three-Dimensional Experimental Operation Study

BACKGROUND

A postoperative radiograph in total hip arthroplasty (THA) is usually obtained to evaluate the inclination and anteversion of the acetabular components. However, there is no gold-standard method for calculating the exact inclination and anteversion of the acetabular components on post-THA radiographs. We aimed to measure the actual anteversion of the acetabular component on postoperative radiographs by obtaining correlation data between the virtual and actual acetabular component positioning using virtual three-dimensional (3D) surgery.

METHODS

A total of 64 hip scans of 32 patients who underwent lower-extremity computed tomography (CT) were retrospectively reviewed. We reconstructed 3D models of the 64 hips using customized computer software (Mimics). Furthermore, to identify the safe zone of acetabular component position in THA, we performed virtual 3D surgery simulations for five anteversion (-10°, 0°, 10°, 20°, and 30°) and five inclination (20°, 30°, 40°, 50°, and 60°) types. We analyzed the acetabular anatomy using 3D models to measure the radiographic, anatomical, and operative anteversion (RA, AA, OA) and inclination (RI, AI, OI) angles. Additionally, we used the Woo-Morrey (WM) method to calculate the anteversion angle in the reconstructed cross-table lateral (CL) radiographs and determined the correlation between these measurements.

RESULTS

The safe zone of the acetabular component was visualized on post-THA CL radiographs using the WM method of anteversion measurement based on the different anteversions and inclinations of the acetabular component. The AA, RA, OA, OI, and WM differed significantly between males and females (p value < 0.05). As the anatomical inclination or anteversion increased, the WM anteversion measurements also increased. The radiographic anteversion measurement best matched the WM method of measurement, followed by anatomical and operative methods.

CONCLUSIONS

The actual anteversion of the acetabular component after THA can be measured on CL radiographs with the WM method using a 3D virtual program, with good reproducibility.

Combined Anteversion Technique for Total Hip Arthroplasty With Handheld Accelerometer-Based Navigation System

Aiming for a combined cup and stem anteversion within a target range is one way to assess appropriate prosthetic component orientation and restoration of functional range of motion. We describe a surgical technique that allows the surgeon to assess the combined anteversion using a handheld accelerometer-based navigation system for total hip arthroplasty through a posterior approach. The femur is prepared first, at which time the femoral version is estimated by the surgeon. The acetabular component is then positioned using the navigation system to estimate anteversion, with the goal of providing a combined version of 37° ± 7°. The described technique allows surgeons to achieve the desired intraoperative combined anteversion.

Level of evidence

IV (technical note).

Prediction of Change in Pelvic Tilt After Total Hip Arthroplasty Using Machine Learning

BACKGROUND

A postoperative change in pelvic flexion following total hip arthroplasty (THA) is considered to be one of the causes of dislocation. This study aimed to predict the change of pelvic flexion after THA integrating preoperative and postoperative information with artificial intelligence.

METHODS

This study involved 415 hips which underwent primary THA. Pelvic flexion angle (PFA) is defined as the angle created by the anterior pelvic plane and the horizontal/vertical planes in the supine/standing positions, respectively. Changes in PFA from preoperative supine position to standing position at 5 years after THA were recorded and which were defined as a 5-year change in PFA. Machine learning analysis was performed to predict 5-year change in PFA less than -20° using demographic, blood biochemical, and radiographic data as explanatory variables. Decision trees were constructed based on the important predictors for 5-year change in PFA that can be handled by humans in clinical practice.

RESULTS

Among several machine learning models, random forest showed the highest accuracy (area under the curve = 0.852). Lumbo-lordotic angle, femoral anteversion angle, body mass index, pelvic tilt, and sacral slope were most important random forest predictors. By integrating these preoperative predictors with those obtained 1 year after the surgery, we developed a clinically applicable decision tree model that can predict 5-year change in PFA with area under the curve = 0.914.

CONCLUSION

A machine learning model to predict 5-year change in PFA after THA has been developed by integrating preoperative and postoperative patient information, which may have capabilities for preoperative planning of THA.

Defining the optimal position of the lipped liner in combination with cup orientation and stem version

Aims

The aim of this study was to identify the optimal lip position for total hip arthroplasties (THAs) using a lipped liner. There is a lack of consensus on the optimal position, with substantial variability in surgeon practice.

Methods

A model of a THA was developed using a 20° lipped liner. Kinematic analyses included a physiological range of motion (ROM) analysis and a provocative dislocation manoeuvre analysis. ROM prior to impingement was calculated and, in impingement scenarios, the travel distance prior to dislocation was assessed. The combinations analyzed included nine cup positions (inclination 30-40-50°, anteversion 5-15-25°), three stem positions (anteversion 0-15-30°), and five lip orientations (right hip 7 to 11 o'clock).

Results

The position of the lip changes the ROM prior to impingement, with certain combinations leading to impingement within the physiological ROM. Inferior lip positions (7 to 8 o'clock) performed best with cup inclinations of 30° and 40°. Superior lip positions performed best with cup inclination of 50°. When impingement occurs in the plane of the lip, the lip increases the travel distance prior to dislocation. Inferior lip positions led to the largest increase in jump distance in a posterior dislocation provocation manoeuvre.

Conclusion

The lip orientation that provides optimal physiological ROM depends on the orientation of the cup and stem. For a THA with stem anteversion 15°, cup inclination 40°, and cup anteversion 15°, the optimal lip position was posterior-inferior (8 o'clock). Maximizing jump distance prior to dislocation while preventing impingement in the opposite direction is possible with appropriate lip positioning.

A novel method for evaluating combined component anteversion in total hip arthroplasty on cross-table lateral hip radiographs

INTRODUCTION

Accurate measurement of combined component anteversion (CA) is important in evaluating the radiographic outcomes following total hip arthroplasty (THA). The aim of the present study was to evaluate the accuracy and reliability of a novel radiographic method in estimating CA in THA.

MATERIALS AND METHODS

The radiographs and computer tomography of patients who underwent a primary THA were retrospectively reviewed, to measure the radiographic CA (CAr), defined as the angle between a line connecting the center of the femoral head to the most anterior rim of the acetabular cup and a line connecting the center of the femoral head to the base of the femoral head to allow a comparison with the CA measured on the CT (CACT). Subsequently, a computational simulation was performed to evaluate the effect of cup anteversion, inclination, stem anteversion, and leg rotation on the CAr and develop a formula that would correct the CAr according to the acetabular cup inclination based on the best-fit equation.

RESULTS

In the retrospective analysis of 154 THA, the average CAr_cor, and CACT were 53 ± 11° and 54 ± 11° (p > 0.05), respectively. A strong correlation was found between CAr and CACT (r = 0.96, p < 0.001), with an average bias of - 0.5° between CAr_cor and CACT. In the computational simulation, the CAr was strongly affected by the cup anteversion, inclination, stem anteversion, and leg rotation. The formula to convert the CAr to CA_cor was: CA-cor = 1.3*Car - (17* In (Cup Inclination) - 31.

CONCLUSION

The combined anteversion measurement of THA components on the lateral hip radiograph is accurate and reliable, implying that it could be routinely used postoperatively but also in patients with persistent complaints following a THA.

LEVEL OF EVIDENCE

Cross-sectional study, Level III.

Patient-Specific Safe Zones for Acetabular Component Positioning in Total Hip Arthroplasty: Mathematically Accounting for Spinopelvic Biomechanics

BACKGROUND

Despite a growing understanding of spinopelvic biomechanics in total hip arthroplasty (THA), there is no validated approach for executing patient-specific acetabular component positioning. The purpose of this study was to (1) validate quantitative, patient-specific acetabular "safe zone" component positioning from spinopelvic parameters and (2) characterize differences between quantitative patient-specific acetabular targets and qualitative hip-spine classification targets.

METHODS

From 2,457 consecutive primary THA patients, 22 (0.88%) underwent revision for instability. Spinopelvic parameters were measured prior to index THA. Acetabular position was measured following index and revision arthroplasty. Using a mathematical proof, we developed an open-source tool translating a surgeon-selected, preoperative standing acetabular target to a patient-specific safe zone intraoperative acetabular target. Difference between the patient-specific safe zone and the actual component position was compared before and after revision. Hip-spine classification targets were compared to patient-specific safe zone targets.

RESULTS

Of the 22 who underwent revision, none dislocated at follow-up (4.6 [range, 1 to 6.9]). Patient-specific safe zone targets differed from prerevision acetabular component position by 9.1 ± 4.2° inclination/13.3 ± 6.7° version; after revision, the mean difference was 3.2 ± 3.0° inclination/5.3 ± 2.7° version. Differences between patient-specific safe zones and the median and extremes of recommended hip-spine classification targets were 2.2 ± 1.9° inclination/5.6 ± 3.7° version and 3.0 ± 2.3° inclination/7.9 ± 3.5° version, respectively.

CONCLUSION

A mathematically derived, patient-specific approach accommodating spinopelvic biomechanics for acetabular component positioning was validated by approximating revised, now-stable hips within 5° version and 3° inclination. These patient-specific safe zones augment the hip-spine classification with prescriptive quantitative targets for nuanced preoperative planning.

Effect of hip flexion contracture on the pelvic sagittal tilt in the supine position: A retrospective case-series study

OBJECTIVES

The functional pelvic plane, which adopts the natural pelvic sagittal tilt in the supine position, is a good reference for determining the cup angle in total hip arthroplasty. However, hip flexion contracture may change pelvic tilt postoperatively by the release of contracture. This study investigated the influence of hip flexion contracture on pelvic sagittal tilt in the supine position.

METHODS

This study included 300 patients who underwent primary unilateral total hip arthroplasty. We divided the participants into two groups: with a preoperative hip extension angle of <0° (hip flexion contracture group) and without (non-contracture group). The pelvic sagittal tilt and femoral flexion angle were investigated using computed tomography or pelvic radiographs performed preoperatively and postoperatively.

RESULTS

The femoral flexion angle had significantly reduced postoperatively in the hip flexion contracture group but remained unchanged in the non-contracture group. The preoperative and postoperative pelvic sagittal tilt showed no significant differences between the two groups up to 1 year postoperatively.

CONCLUSIONS

The influence of hip flexion contracture on the pelvic sagittal tilt in the supine position was minimal. The functional pelvic plane in the supine position could be a good reference to ascertain the cup orientation, even in hip flexion contracture cases.

Does Augmented Reality-based Portable Navigation Improve the Accuracy of Cup Placement in THA Compared With Accelerometer-based Portable Navigation? A Randomized Controlled Trial

BACKGROUND

Previous studies reported good outcomes of acetabular cup placement using portable navigation systems during THA. However, we are aware of no prospective studies comparing inexpensive portable navigation systems using augmented reality (AR) technology with accelerometer-based portable navigation systems in THA.

QUESTIONS/PURPOSES

(1) Is the placement accuracy of the acetabular cup using the AR-based portable navigation system superior to that of an accelerometer-based portable navigation system? (2) Do the frequencies of surgical complications differ between the two groups?

METHODS

We conducted a prospective, two-arm, parallel-group, randomized controlled trial involving patients scheduled for unilateral THA. Between August and December 2021, we treated 148 patients who had a diagnosis of osteoarthritis, idiopathic osteonecrosis, rheumatoid arthritis, or femoral neck fracture and were scheduled to undergo unilateral primary THA. Of these patients, 100% (148) were eligible, 90% (133) were approached for inclusion in the study, and 85% (126) were finally randomized into either the AR group (62 patients) or the accelerometer group (64 patients). An intention-to-treat analysis was performed, and there was no crossover between groups and no dropouts; all patients in both groups were included in the analysis. There were no differences in any key covariates, including age, sex, and BMI, between the two groups. All THAs were performed via the modified Watson-Jones approach with the patient in the lateral decubitus position. The primary outcome was the absolute difference between the cup placement angle displayed on the screen of the navigation system and that measured on postoperative radiographs. The secondary outcome was intraoperative or postoperative complications recorded during the study period for the two portable navigation systems.

RESULTS

There were no differences between the AR and accelerometer groups in terms of the mean absolute difference in radiographic inclination angle (3° ± 2° versus 3° ± 2° [95% CI -1.2° to 0.3°]; p = 0.22). The mean absolute difference in radiographic anteversion angle displayed on the navigation screen during surgery compared with that measured on postoperative radiographs was smaller in the AR group than that in the accelerometer group (2° ± 2° versus 5° ± 4° [95% CI -4.2° to -2.0°]; p < 0.001). There were few complications in either group. In the AR group, there was one patient each with a surgical site infection, intraoperative fracture, distal deep vein thrombosis, and intraoperative pin loosening; in the accelerometer group, there was one patient each with an intraoperative fracture and intraoperative loosening of pins.

CONCLUSION

Although the AR-based portable navigation system demonstrated slight improvements in radiographic anteversion of cup placement compared with the accelerometer-based portable navigation system in THA, whether those small differences will prove clinically important is unknown. Until or unless future studies demonstrate clinical advantages that patients can perceive that are associated with such small radiographic differences, because of the costs and the unquantified risks associated with novel devices, we recommend against the widespread use of these systems in clinical practice.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Acetabular, Femoral, and Combined Anteversion in a Province in South Korea: Computed Tomography-Based Study

Background

The purpose of this study was to investigate the femoral, acetabular, and combined anteversion of the hip joint in South Koreans using computed tomography (CT).

Methods

We measured anteversion using CT venograms taken from 2016 to 2020. Of the total 1,073 patients, 952 patients were included in the study except for those with pelvic fractures, previous femoral fractures, childhood hip joint disease, osteoarthritis, or hip dysplasia (lateral center-edge angle, < 20), foreigners, and hip and knee replacement patients. Measurements were taken twice by two orthopedic surgeons.

Results

The femoral anteversion in women was 10.64° ± 10.26° (≤ 49 years), 15.75° ± 9.40° (50-59 years), 10.81° ± 9.14° (60-69 years), 12.38° ± 8.55° (70-79 years), and 11.23° ± 8.44° (≥ 80 years). The femoral anteversion in men was 12.02° ± 11.38° (≤ 49 years), 10.62° ± 9.11° (50-59 years), 6.09° ± 9.95° (60-69 years), 6.57° ± 9.51° (70-79 years), and 5.53° ± 9.29° (≥ 80 years). The acetabular anteversion in women was 17.65° ± 6.58° (≤ 49 years), 19.24° ± 6.42° (50-59 years), 20.30° ± 6.25° (60-69 years), 22.38° ± 7.36° (70-79 years), and 23.34° ± 6.98° (≥ 80 years). The acetabular anteversion in men was 15.21° ± 8.14° (≤ 49 years), 17.68° ± 6.00° (50-59 years), 17.54° ± 5.93° (60-69 years), 18.68° ± 6.62° (70-79 years), and 18.19° ± 6.94° (≥ 80 years). The combined anteversion in women was 28.29° ± 14.30° (≤ 49 years), 34.99° ± 10.62° (50-59 years), 31.11° ± 11.52° (60-69 years), 34.76° ± 10.86° (70-79 years), and 34.57° ± 11.45° (≥ 80 years). The combined anteversion in men was 27.23° ± 15.11° (≤ 49 years), 28.30° ± 11.23° (50-59 years), 23.63° ± 11.77° (60-69 years), 25.25° ± 12.02° (70-79 years), and 23.72° ± 11.88° (≥ 80 years).

Conclusions

Femoral anteversion tended to decrease with age in men and acetabular anteversion tended to increase in both men and women. Combined anteversion showed a tendency to increase slightly in women.