Effect of Acetabular Component Positioning on Functional Outcomes in Primary Total Hip Arthroplasty

doi:10.1016/j.arth.2016.08.024

The Journal of Arthroplasty

Volume 32, Issue 3, March 2017, Pages 843-848

https://doi.org/10.1016/j.arth.2016.08.024 Get rights and content

Abstract

Background

Acetabular component positioning is crucial to a successful total hip arthroplasty (THA). This study evaluated the effect of absolute acetabular component position as well as acetabular position relative to bony anatomy on patient-reported functional outcomes after primary THA.

Methods

Primary, press fit, hemispherical metal-on-polyethylene THA performed between 2003 and 2011 were analyzed. Western Ontario and McMaster Osteoarthritis Index (WOMAC), Harris Hip Score (HHS), Short Form-12 scores, and radiographs between 2 and 3 years after the index procedure were assessed.

Results

Of the 1241 primary THA included, the mean abduction and anteversion angles were 44.4 ± 6.94 and 21.7 ± 11.9 degrees, respectively. The mean anterior and lateral overhang were 1.9 ± 3.6 and 2.5 ± 3.4 mm, respectively. There was no correlation between functional outcomes and acetabular inclination. A weak positive correlation between anteversion and HHS (P < .001) and WOMAC (P = .02) scores was found. For relative position, anterior overhang of the acetabular component beyond the bone resulted in inferior Short Form-12 physical function (P = .001), HHS (P = .004), and WOMAC (P < .001) scores compared to those with bony coverage. Mean HHS pain score was 41.20 ± 5.69 in patients with lateral overhang and 41.97 ± 5.04 in those who had bony coverage of the lateral edge of the acetabular component (P = .02).

Conclusion

The tribology and biomechanics of acetabular component position have been extensively studied without examination of how it affects patient function. Although statistical significance was seen, clinical outcome scores were not sensitive enough to show a clinically significant effect of the absolute or relative position of the acetabular component.

Section snippets

Materials and Methods

Ethics approval from our institutional research ethics board was obtained. Fellowship-trained arthroplasty surgeons, with high-volume practices performed the THAs between 2003 and 2011. Patients were identified with the use of our institutional arthroplasty database. Further patient demographics, including their age, sex, date of procedure, side operated on, and implant details were extracted from the database. Postoperative Western Ontario and McMaster Osteoarthritis Index (WOMAC), Harris hip

Results

The study population included 1241 hips with 502 males (40.5%) and 739 females (59.5%). The average length of clinical follow-up was 2.32 years. Mean BMI was 29.53 ± 6.18 kg/m². A total of 580 hips (46.7%) were left sided and 661 (53.3%) were right sided. The mean absolute position of the population included 21.7 ± 11.9 degrees of anteversion and 44.4 ± 6.9 degrees of inclination angle. The range of anteversion in our cohort was between −19.1 and 58.5 degrees. The range of inclination angle was

Discussion

Outcome measurements are important to clinical research as they allow us to evaluate the effectiveness of our interventions [33]. Their use in improving quality of care cannot be understated as functional outcome measures allow us to judge outcomes from a patient perspective [34]. Generic outcome measures, such as SF-12, provide insight into patients' general health status including physical symptoms, function, and emotional dimensions of health. They may not, however, be sensitive in their

References (40)

I.D. Learmonth et al.
The operation of the century: total hip replacement
Lancet
(2007)
L. Shan et al.
Total hip replacement: a systematic review and meta-analysis on mid-term quality of life
Osteoarthritis Cartilage
(2014)
C.J. Lavernia et al.
Quality of life and cost-effectiveness 1 year after total hip arthroplasty
J Arthroplasty
(2011)
W.Y. Shon et al.
Impingement in total hip arthroplasty: a study of retrieved acetabular components
J Arthroplasty
(2005)
K.H. Widmer et al.
Compliant positioning of total hip components for optimal range of motion
J Orthop Res
(2004)
M. Yamaguchi et al.
The spatial location of impingement in total hip arthroplasty
J Arthroplasty
(2000)
D. Williams et al.
Metal-on-metal hip resurfacing: the effect of cup position and component size on range of motion to impingement
J Arthroplasty
(2009)
B.M. Jolles et al.
Factors predisposing to dislocation after primary total hip arthroplasty: a multivariate analysis
J Arthroplasty
(2002)
R.T. Trousdale et al.
Anterior iliopsoas impingement after total hip arthroplasty
J Arthroplasty
(1995)
K. Heaton et al.
Surgical release of iliopsoas tendon for groin pain after total hip arthroplasty
J Arthroplasty
(2002)

M. O'Sullivan et al.

Iliopsoas tendonitis a complication after total hip arthroplasty

J Arthroplasty

(2007)

R. Iorio et al.

Lateral trochanteric pain following primary total hip arthroplasty

J Arthroplasty

(2006)

J.M. Quintana et al.

Responsiveness and clinically important differences for the WOMAC and SF-36 after hip joint replacement

Osteoarthritis Cartilage

(2005)

J.G. Kennedy et al.

Effect of acetabular component orientation on recurrent dislocation, pelvic osteolysis, polyethylene wear, and component migration

J Arthroplasty

(1998)

Z. Wan et al.

The influence of acetabular component position on wear in total hip arthroplasty

J Arthroplasty

(2008)

M.S. Prime et al.

The national joint registry of England and Wales

Orthopedics

(2011)

S. Kurtz et al.

Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030

J Bone Joint Surg Am

(2007)

N. Mahomed et al.

The importance of patient expectations in predicting functional outcomes after total joint arthroplasty

J Rheumatol

(2002)

V.C. Gould et al.

Long-term patient-reported outcomes after total hip replacement: comparison to the general population

Hip Int

(2012)

V. Santic et al.

Measuring improvement following total hip and knee arthroplasty using the SF-36 Health Survey

Coll Antropol

(2012)

Cited by (9)

Techniques and Technologies for the Intraoperative Assessment of Component Positioning, Leg Lengths, and Offset in Total Hip Arthroplasty: A Systematic Review
2024, Arthroplasty Today
Many techniques and technologies exist for the intraoperative assessment of component positioning, leg lengths, and offset in total hip arthroplasty, but with limited comparative data. We conducted a systematic review of the available literature to evaluate the range of techniques and technologies for the intraoperative assessment of component position as well as leg lengths and offset in terms of accuracy, precision, surgical time, cost, and relationship to clinical outcomes.
A comprehensive search of the Embase and Medline databases from 1974 to 2023 was performed. We included controlled or comparative prospective clinical studies. Cochrane’s risk-of-bias tool for randomized trials and Risk of Bias in Non-Randomized Studies – of Interventions tools were used by 2 independent reviewers to evaluate each study for risk of bias. We conducted both qualitative and quantitative analyses of the studies included. However, a meta-analysis was deemed not to be feasible due to heterogeneity.
Our review included 25 studies with 52 intraoperative techniques and technologies. Mechanical guides and computerized navigation were most frequently evaluated in the included studies. Computerized navigation systems consistently showed the greatest accuracy and precision across all measures, at the cost of longer mean operative time. In contrast, freehand techniques demonstrated the poorest accuracy and precision. Insufficient data were found to reach any meaningful conclusions in terms of differences in overall surgical cost or clinical outcomes.
Evidence shows that computerized navigation systems are most accurate and precise in positioning components during total hip arthroplasty. Further research is needed to determine their health and economic impact and whether the accuracy and precision of navigated techniques are justified in terms of clinical outcomes.
Variability in Acetabular Component Position in Patients Undergoing Direct Anterior Approach Total Hip Arthroplasty Who Have Concomitant Spine Pathology
2022, Journal of Arthroplasty
Citation Excerpt :
Accurate placement and positioning of the acetabular cup plays a key role in determining the outcome of THA. Acetabular orientation is an important factor long known to influence a variety of outcomes such as dislocations [2,3], range of motion [18,19], noise [20], impingement [4], and patient-reported outcome measures [21]. Placement of acetabular components was initially guided by the literature suggesting that an acetabular inclination of 40° ± 10° and anteversion of 15° ± 10° predicted lower risk of future complications [3].
Hip instability following total hip arthroplasty (THA) can be a major cause of revision surgery. Physiological patient position impacts acetabular anteversion and abduction, and influences the functional component positioning. Osteoarthritis of the spine leads to abnormal spinopelvic biomechanics and motion, but there is no consensus on the degree of component variability for THAs performed by anterior approach. Therefore, we sought to present guidelines for changes in acetabular component positioning between supine and standing positions for patients undergoing primary THA by a uniform anterior approach.
Perioperative patient radiographs of the pelvis and lumbar spine were collected. Images were used to determine acetabular component positioning and degree of coexisting spinal pathology, categorized as a Lane Grade (LG). Final analysis of variance was performed on a sample size of 643 anterior primary THAs.
From supine to standing position, as the severity of lumbar pathology increased the change in anteversion also increased (LG:0 = −0.11° ± 4.65°, LG:1 = 2.02° ± 4.09°, LG:2-3 = 5.78° ± 5.72°, P < .001). The mean supine anteversion in patients with absent lumbar pathology was 19.72° ± 5.05° and was lower in patients with worsening lumbar pathology (LG:1 = 18.25° ± 4.81°, LG:2-3 = 16.73° ± 5.28°, P < .001).
Patients undergoing primary THA by anterior approach with worsening spinal pathology have larger increases in component anteversion when transitioning from supine to standing positions. Consideration should be given to this expected variability when placing the patient’s acetabular component.
Change in Acetabular Cup Orientation From Supine to Standing Position and Its Effect on Wear of Highly Crosslinked Polyethylene
2018, Journal of Arthroplasty
The purpose of this study is to measure acetabular cup position and wear of the highly crosslinked polyethylene liner in the supine and standing position for patients at a minimum of 10 years after the operation.
A total of 38 patients were recruited at a mean of 12.5 years after the operation. All patients received a single acetabular cup design with a highly crosslinked liner and a 28-mm cobalt-chromium femoral head. Patients underwent supine and standing radiostereometric examinations in which the X-ray sources and detectors were positioned to obtain an anterior-posterior and cross-table lateral radiograph. Acetabular cup position and the three-dimensional wear rate were measured from the radiographs, and outcome scores were recorded for each patient.
Anteversion significantly increased (P < .0001) a mean of 12° from supine (15.1° ± 10.4°) to standing (27.2° ± 10.5°) position. Inclination also significantly increased (P = .001) a mean of 2° from supine (44.4° ± 6.8°) to standing (46.3° ± 7.7°) position. There was no difference (P = .093) in wear rate between supine (0.067 ± 0.070 mm/y) and standing (0.073 ± 0.074 mm/y) positions. There were no correlations between cup orientation and wear rate in either position.
Highly crosslinked polyethylene is a forgiving bearing material. Although adherence to the traditional acetabular position target zone is recommended, ensuring hip stability and consideration of the patient's functional position are also important objectives to consider for the acetabular position.
A Prospective Randomized Trial of Mini-Incision Posterior and 2-Incision Total Hip Arthroplasty: Minimum 5-Year Follow-Up
2017, Journal of Arthroplasty
Citation Excerpt :
None of these patients experienced a complication or underwent a revision procedure. Recent studies have called the Lewinnek “safe zones” into question, reporting no direct correlation of the safe zones on patient outcome scores or complications [37,38]. Abdel et al [37] reported the majority of contemporary THA dislocations to occur within the Lewinnek safe zone, concluding stability is likely multifactorial and the ideal cup position for some patients might lie outside the Lewinnek safe zone.
We previously described the results of a randomized controlled trial of mini-posterior vs 2-incision total hip arthroplasty and were unable to demonstrate significant differences in early outcomes. As less-invasive anterior approaches remain popular, the purpose of this report was to re-examine the outcomes at a minimum 5-year follow-up.
Seventy-two patients undergoing primary total hip arthroplasty were randomized to a mini-posterior or 2-incision approach. Complications, revisions, and clinical outcome measures were compared. Radiographs were reviewed for implant loosening. A power analysis using a minimal clinically important difference value of 6 points for the Harris hip score revealed 28 patients required per group.
At a mean of 8.2 years (range, 5-10 years), 6 patients died without revision surgery and 63 of 66 living patients were reviewed. There were 6 total failures, 3 in each group. For unrevised patients, there were no significant differences between groups (posterior vs 2-incision) in the Harris hip score (95.5 ± 3.5 vs 95.7 ± 6.3; P = .88), 12-item Short Form Survey physical composite score (50.5 ± 8.5 vs 49.0 ± 9.1; P = .53), 12-item Short Form Survey mental composite score (57.3 ± 4.1 vs 55.4 ± 8.0; P = .25), or single assessment numeric evaluation score (97.1 ± 3.7 vs 97.8 ± 5.2; P = .55).
We found no differences in midterm outcomes between the 2 approaches. Given the increased complexity, operative time, and need for fluoroscopy with the 2-incision approach combined with equivalent early and midterm outcomes, the 2-incision approach has been abandoned in the senior author's practice.
Determination of Relationships between Symmetry-Based, Performance-Based, and Functional Outcome Measures in Patients Undergoing Total Hip Arthroplasty
2023, Journal of Personalized Medicine
Computer-Assisted Navigation Accurately Delivers Preoperative Targets for Acetabular Component Orientation During Direct Anterior Approach Total Hip Arthroplasty
2023, Orthopedics

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: One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to http://dx.doi.org/10.1016/j.arth.2016.08.024.

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Primary ArthroplastyEffect of Acetabular Component Positioning on Functional Outcomes in Primary Total Hip Arthroplasty

Abstract

Background

Methods

Results

Conclusion

Section snippets

Materials and Methods

Results

Discussion

Lancet

Osteoarthritis Cartilage

J Arthroplasty

J Arthroplasty

J Orthop Res

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

Osteoarthritis Cartilage

J Arthroplasty

J Arthroplasty

The national joint registry of England and Wales

Orthopedics

Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030

J Bone Joint Surg Am

The importance of patient expectations in predicting functional outcomes after total joint arthroplasty

J Rheumatol

Long-term patient-reported outcomes after total hip replacement: comparison to the general population

Hip Int

Measuring improvement following total hip and knee arthroplasty using the SF-36 Health Survey

Coll Antropol

Primary Arthroplasty
Effect of Acetabular Component Positioning on Functional Outcomes in Primary Total Hip Arthroplasty