Perioperative management of leg-length discrepancy in total hip arthroplasty: a review

Usefulness of an Extensible Trial Neck in Total Hip Arthroplasty

BACKGROUND

Maintaining appropriate soft tissue tension is essential in total hip arthroplasty (THA). Surgeons generally achieve this by altering the neck length. However, experimenting with different neck lengths is time-consuming, as it requires repeated hip dislocations. To address this, we have used a new extensible trial neck device that allows for easy adjustment of neck length during surgery. This device can help surgeons avoid the need for repeated hip dislocations to determine the correct neck size. The objective of this research was to investigate whether this device could help shorten operative times and decrease surgical invasion for patients.

MATERIALS AND METHODS

Patients undergoing THA were randomly separated into two groups. The first group used the extensible trial neck during trial reduction after the stem and cup were placed (group M), while the second group used a conventional trial neck (group C). Operative time, blood loss, number of additional dislocations needed during the operation, and C-reactive protein (CRP) and creatine phosphokinase (CPK) levels after the operation were compared.

RESULTS

Operative time was significantly shorter and the number of additional dislocations required to choose the final neck size was significantly lower in group M compared with group C. No significant difference in blood loss was observed. CRP and CPK levels days 3 and 7 after surgery decreased in group M compared with group C.

CONCLUSION

The extensible trial neck was useful for THA by greatly reducing operative time and stress on the patient. [Orthopedics. 2025;48(2):e88-e93.].

Adverse spinopelvic mobility in patients undergoing total hip arthroplasty is associated with high mobility of the hip in a flexed seated position

PURPOSE

Adverse spinopelvic mobility from a standing to a flexed seated position of more than 20° of the spinopelvic tilt (∆SPT) has been shown to have a high risk of dislocation. If hypermobility of the hip analysed with the pelvic femoral angle (∆PFA) has a high risk of impingement, the correlation between the range of motion of the hip from a standing to a flexed seated position and its implication in adverse spinopelvic mobility has not been described.

METHODS

A series of 337 patients treated with primary THA underwent lateral x-ray in standing and flexed seated positions to analyse ∆SPT, ∆PFA and spinopelvic parameters. The objectives were to establish a ∆PFA threshold associated with a ∆SPT ⩾20° and to subsequently investigate its influence in conjunction with spinopelvic risk factors on the occurrence of adverse spinopelvic mobility.

RESULTS

The area under the curve was 0.904 (95%CI, 0.864-0.945) for ∆PFA to predict ∆SPT ⩾ 20°; it was predicted by ∆PFA ⩾ 95° with a sensitivity of 91.7% and a specificity of 74.4% at the Youden optimal threshold. Patients with a ∆SPT < 20° (277 patients) had a mean ∆PFA of 83° compared to 110° if ∆SPT ⩾ 20° (60 patients) (p < 0.001). Patients with a ∆PFA < 95° (203 patients) had a mean ∆SPT of -6° compared to 18° if ∆PFA ⩾ 95° (134 patients) (p < 0.001). ∆PFA ⩾ 95° rates were 95% (57/60) and 27.8% (77/200) in patients with ∆SPT ⩾ 20° and ∆SPT < 20°, respectively (OR 49.35; CI, 15.01-162.28; p < 0.001).

CONCLUSIONS

High mobility of the hip (∆PFA ⩾ 95°) seems to be a necessary condition for adverse spinopelvic mobility. A preoperative analysis of patients with lower hip mobility, associated with spinopelvic risk factors, might identify patients with abnormal spinopelvic mobility after the restoration of femoral flexion.

TRIAL REGISTRATION

IDRCB 2023-A01390, CNIL MR004 2225508 (07/06/2023), retrospectively registered.

An Intraoperative Method to Minimize Leg Length Discrepancy in Anterior Minimally Invasive Total Hip Arthroplasty-A Prospective Study

While several intraoperative devices have been described in the literature for assessing leg length discrepancy (LLD), none have been utilized during total hip arthroplasty (THA) performed via the Anterior Minimally Invasive Surgery (AMIS) approach. The aim of this prospective study was to evaluate the efficacy and accuracy of a compass device in assessing leg length during THA performed using the AMIS technique. A prospective study was conducted involving 35 patients who consecutively underwent unilateral primary THA using the AMIS technique at our department from September 2017 to December 2018. LLD was measured by comparing preoperative and postoperative anteroposterior radiographs of the pelvis, independently assessed by two observers. The mean preoperative LLD was 3.6 (SD 3.9, range, 0.2-19.3) mm. The mean postoperative LLD was 2.5 (SD 3.0, range, 0-12.2) mm. A postoperative LLD of less than 5 mm was observed in 88.2% of cases, with 94.1% having values less than 10 mm. In conclusion, the compass device emerged as a valuable tool for ensuring precise limb length control in THA with the AMIS approach, offering both efficiency and cost-effectiveness in clinical practice.

The Impact of Early Rehabilitation and the Acceptance of the Disease on the Quality of Life of Patients after Hip Arthroplasty: An Observational Study

Background: The early introduction of physiotherapy significantly shortens the time required for a patient to regain full mobility after hip arthroplasty. Obtaining the expected result is determined by cooperation with a physiotherapist and the patient's involvement in the rehabilitation process. The aim of this study was to assess the quality of life, life satisfaction, and motor ability of patients after hip arthroplasty. Methods: This study included 147 patients who underwent hip arthroplasty at the Orthopedic and Trauma Department. The research material was collected using questionnaires, and the study used the Barthel Index (BI), Harris Hip Score (HHS), Visual Analogue Scale (VAS), Acceptance of Illness Scale (AIS), and Quality of Life Assessment Questionnaire (WHOQOL-BREF). In the studied group of patients, the Excia cementless endoprosthesis was primarily used (69.39%), as well as the Metha Short Hip prosthesis (15.65%), AM hip prosthesis (10.20%), and bipolar hip prosthesis (4.76%). Results: The analyzed group of patients included 95 women (64.63%) and 52 men (35.37%); the average age was 67 years. Six weeks after hip arthroplasty, mild disability occurred in 53.74% of the patients, while the remaining 46.26% had no disability, and 95.24% of the patients achieved a high level of acceptance of the disease and quality of life. Conclusions: Early improvement after hip replacement surgery contributes to eliminating the disability of the hip joint in the following areas: pain sensation, functionality, lack of deformation, and range of motion. Each subsequent stage of treatment increased the level of acceptance of the disease in the study group. The applied surgical treatment increased satisfaction with overall health and quality of life.

The effect of intraoperative fluoroscopy on acetabular component positioning and patient anatomy restoration during posterior or posterolateral approach total hip arthroplasty: a meta-analysis

BACKGROUND

Positioning implant components and restoring patient anatomy during total hip arthroplasty (THA) are essential for joint stability, polyethylene liner wear, and range of motion. Previous studies comparing intraoperative fluoroscopy with no fluoroscopy during the posterior or posterolateral approach have reported conflicting results. This meta-analysis evaluated if intraoperative fluoroscopy improves component positioning and femoral component position compared to no fluoroscopy during posterior or posterolateral approach total hip arthroplasty.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards were followed when conducting the systematic review. We searched Web of Science, Embase, PubMed, Cochrane Controlled Trials Register, Cochrane Library, Highwire, CBM, CNKI, VIP, and Wanfang database in May 2023 to identify studies involving Intraoperative fluoroscopy versus no fluoroscopy during posterior or posterolateral approach total hip arthroplasty. Finally, we identified 1133 patients (1145 hips) assessed in seven studies.

RESULTS

There were no significant differences in terms of acetabular cup inclination angle (ACIA, P = 0.43), ACIA within safe zone rate (P = 0.58), acetabular cup anteversion angle (ACAA, P = 0.46); ACAA within safe zone rate (P = 0.72), Combined safe zone rate (P = 0.28), dislocation rate (P = 0.64) and infection rate (P = 0.94) between two groups. Compared with the no fluoroscopy group, the intraoperative fluoroscopy group had more operation time (P < 0.00001), less femoral component offset difference (FCOD, P = 0.03), and less LLD (P < 0.00001).

CONCLUSION

Even though intraoperative fluoroscopy was not related to an improvement in cup location or dislocation incidence. Our findings demonstrate that the restoration of leg lengths and femoral offset can be significantly improved by using intraoperative fluoroscopy to supplement good surgical skills in THA. The advantages of intraoperative fluoroscopy might become more apparent for surgeons with less experience. To ascertain whether intraoperative fluoroscopy for posterior or posterolateral approach total hip arthroplasty will have clinical benefits and improve the survival of prostheses, more well-powered and well-designed long-term follow-up studies were necessary.

A new designed full process coverage robot-assisted total hip arthroplasty: a multicentre randomized clinical trial

OBJECTIVE

To compare the effect of a new complete robot-assisted total hip arthroplasty (RA-THA) with that of the manual total hip arthroplasty (MTHA) and to verify the accuracy and safety of the former.

METHODS

Overall, 148 patients were enroled from 3 March 2021 to 28 December 2021 in this study and classified into RA-THA ( n =74 patients) and MTHA ( n =74 patients) groups. The sex, age, operative side, BMI, diagnosis, other basic information, operative time, acetabular prosthesis anteversion and inclination, femoral prosthesis anteversion and angulation, femoral prosthesis filling rate, leg length discrepancy (LLD), Harris hip score, and visual analogue scale (VAS) score of the two groups were compared.

RESULTS

No significant differences were observed in the two groups regarding sex, age, operative side, BMI, diagnosis, Harris hip score, VAS score, acetabular inclination, acetabular prosthesis anteversion, femoral prosthesis anteversion, combined anteversion, and femoral prosthesis filling rate ( P >0.05). The operative time was significantly longer in the RA-THA group than in the MTHA group (106.71±25.22 min vs. 79.42±16.16 min; t=7.30, P <0.05). The femoral angulation (1.78°±0.64°) and LLD (2.87±1.55 mm) in the RA-THA group were significantly lesser than those in the MTHA group (2.22°±1.11° and 5.81±6.27 mm, respectively; t=-2.95 and t=-3.88, P <0.05).

CONCLUSION

The complete RA-THA has some advantages over the traditional procedure in restoring the lower limb length and controlling the femoral prosthesis angulation. Thus, this study verifies the accuracy and safety of the robot-assisted system.

Low pelvic incidence with low lordosis and distal apex of lumbar lordosis associated with higher rates of abnormal spinopelvic mobility in patients undergoing THA

Aims

The risk factors for abnormal spinopelvic mobility (SPM), defined as an anterior rotation of the spinopelvic tilt (∆SPT) ≥ 20° in a flexed-seated position, have been described. The implication of pelvic incidence (PI) is unclear, and the concept of lumbar lordosis (LL) based on anatomical limits may be erroneous. The distribution of LL, including a unusual shape in patients with a high lordosis, a low pelvic incidence, and an anteverted pelvis seems more relevant.

Methods

The clinical data of 311 consecutive patients who underwent total hip arthroplasty was retrospectively analyzed. We analyzed the different types of lumbar shapes that can present in patients to identify their potential associations with abnormal pelvic mobility, and we analyzed the potential risk factors associated with a ∆SPT ≥ 20° in the overall population.

Results

ΔSPT ≥ 20° rates were 28.3%, 11.8%, and 14.3% for patients whose spine shape was low PI/low lordosis (group 1), low PI anteverted (group 2), and high PI/high lordosis (group 3), respectively (p = 0.034). There was no association between ΔSPT ≥ 20° and PI ≤ 41° (odds ratio (OR) 2.01 (95% confidence interval (CI)0.88 to 4.62), p = 0.136). In the multivariate analysis, the following independent predictors of ΔSPT ≥ 20° were identified: SPT ≤ -10° (OR 3.49 (95% CI 1.59 to 7.66), p = 0.002), IP-LL ≥ 20 (OR 4.38 (95% CI 1.16 to 16.48), p = 0.029), and group 1 (OR 2.47 (95% CI 1.19; to 5.09), p = 0.0148).

Conclusion

If the PI value alone is not indicative of SPM, patients with a low PI, low lordosis and a lumbar apex at L4-L5 or below will have higher rates of abnormal SPM than patients with a low PI anteverted and high lordosis.

Accuracy of Leg Length and Offset Measurements During Total Hip Arthroplasty Using an Imageless Navigation System

Introduction Leg length and offset are important considerations in total hip arthroplasty (THA). Navigation systems are capable of providing intra-operative measurements of leg length and offset, and high accuracy has been shown in experimental studies. This study assesses the accuracy of an imageless navigation system with a pinless femoral array (Hip 5.1, BrainLAB, Feldkirchen, Germany) in measuring leg length and offset changes in vivo. Methods A prospective, consecutive series of 37 patients undergoing navigated THA were included in the study. Intra-operative measurements of leg length and offset were recorded using the navigation system. For each patient, pre- and post-operative digital radiographs were scaled and analyzed to provide radiographic measurements for comparison. Results Measurements of leg length change made by the navigation system showed a strong correlation with the size of change measured radiographically (R = 0.71; p<0.0001). The mean difference between the radiographic and navigational measurement was 2.6mm ± 3.0mm (0.0-16.0mm) (mean, SD, range). The navigation system was accurate to within 1mm of the radiographic measurement in 49% of cases, within 2mm in 66% of cases, and within 5mm in 89% of cases. Measurements of offset change by the navigation system also showed a correlation with radiographic measurements, albeit less pronounced (R = 0.35; p=0.035). The mean difference between navigational and radiographic measurements was 5.5mm ± 4.7mm (0.0-16.0mm) (mean, SD, range). The navigation system was accurate within 1mm of the radiographic measurement in 22% of cases, within 2mm in 35% of cases, and within 5mm in 57% of cases. Conclusions This research demonstrates in vivo that an imageless, non-invasive navigation system is a reliable tool for intra-operative leg length (accurate within 2mm) and to a lesser extent offset measurement (accurate within 5mm) when compared to standard practice of plain film radiographs.