Abstract
Background
Improper acetabular component orientation in THA has been associated with increased dislocation rates, component impingement, bearing surface wear, and a greater likelihood of revision. Therefore, any reasonable steps to improve acetabular component orientation should be considered and explored.
Questions/purposes
We therefore sought to compare THA with a robotic-assisted posterior approach with manual alignment techniques through a posterior approach, using a matched-pair controlled study design, to assess whether the use of the robot made it more likely for the acetabular cup to be positioned in the safe zones described by Lewinnek et al. and Callanan et al.
Methods
Between September 2008 and September 2012, 160 THAs were performed by the senior surgeon. Sixty-two patients (38.8%) underwent THA using a conventional posterior approach, 69 (43.1%) underwent robotic-assisted THA using the posterior approach, and 29 (18.1%) underwent radiographic-guided anterior-approach THAs. From September 2008 to June 2011, all patients were offered anterior or posterior approaches regardless of BMI and anatomy. Since introduction of the robot in June 2011, all THAs were performed using the robotic technique through the posterior approach, unless a patient specifically requested otherwise. The radiographic cup positioning of the robotic-assisted THAs was compared with a matched-pair control group of conventional THAs performed by the same surgeon through the same posterior approach. The safe zone (inclination, 30°–50°; anteversion, 5°–25°) described by Lewinnek et al. and the modified safe zone (inclination, 30°–45°; anteversion, 5°–25°) of Callanan et al. were used for cup placement assessment. Matching criteria were gender, age ± 5 years, and (BMI) ± 7 units. After exclusions, a total of 50 THAs were included in each group. Strong interobserver and intraobserver correlations were found for all radiographic measurements (r > 0.82; p < 0.001).
Results
One hundred percent (50/50) of the robotic-assisted THAs were within the safe zone described by Lewinnek et al. compared with 80% (40/50) of the conventional THAs (p = 0.001). Ninety-two percent (46/50) of robotic-assisted THAs were within the modified safe zone described by Callanan et al. compared with 62% (31/50) of conventional THAs p (p = 0.001). The odds ratios for an implanted cup out of the safe zones of Lewinnek et al. and Callanan et al. were zero and 0.142, respectively (95% CI, 0.044, 0.457).
Conclusions
Use of the robot allowed for improvement in placement of the cup in both safe zones, an important parameter that plays a significant role in long-term success of THA. However, whether the radiographic improvements we observed will translate into clinical benefits for patients—such as reductions in component impingement, acetabular wear, and prosthetic dislocations, or in terms of improved longevity—remains unproven.
Level of Evidence
Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.
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References
Ali Khan MA, Brakenbury PH, Reynolds IS. Dislocation following total hip replacement. J Bone Joint Surg Br. 1981;63:214–218.
Archbold HA, Mockford B, Molloy D, McConway J, Ogonda L, Beverland D. The transverse acetabular ligament: an aid to orientation of the acetabular component during primary total hip replacement: a preliminary study of 1000 cases investigating postoperative stability. J Bone Joint Surg Br. 2006;88:883–886.
Beverland D. The transverse acetabular ligament: optimizing version. Orthopedics. 2010;33:631.
Biedermann R, Tonin A, Krismer M, Rachbauer F, Eibl G, Stockl B. Reducing the risk of dislocation after total hip arthroplasty: the effect of orientation of the acetabular component. J Bone Joint Surg Br. 2005;87:762–769.
Callanan MC, Jarrett B, Bragdon CR, Zurakowski D, Rubash HE, Freiberg AA, Malchau H. The John Charnley Award: risk factors for cup malpositioning: quality improvement through a joint registry at a tertiary hospital. Clin Orthop Relat Res. 2011;469:319–329.
De Haan R, Pattyn C, Gill HS, Murray DW, Campbell PA, De Smet K. Correlation between inclination of the acetabular component and metal ion levels in metal-on-metal hip resurfacing replacement. J Bone Joint Surg Br. 2008;90:1291–1297.
Digioia AM 3rd, Jaramaz B, Plakseychuk AY, Moody JE Jr, Nikou C, Labarca RS, Levison TJ, Picard F. Comparison of a mechanical acetabular alignment guide with computer placement of the socket. J Arthroplasty. 2002;17:359–364.
Dorr LD. Acetabular cup position: the imperative of getting it right. Orthopedics. 2008;31:898–899.
Dorr LD, Malik A, Dastane M, Wan Z. Combined anteversion technique for total hip arthroplasty. Clin Orthop Relat Res. 2009;467:119–127.
Epstein NJ, Woolson ST, Giori NJ. Acetabular component positioning using the transverse acetabular ligament: can you find it and does it help? Clin Orthop Relat Res. 2011;469:412–416.
Gallo J, Havranek V, Zapletalova J. Risk factors for accelerated polyethylene wear and osteolysis in ABG I total hip arthroplasty. Int Orthop. 2010;34:19–26.
Ha YC, Yoo JJ, Lee YK, Kim JY, Koo KH. Acetabular component positioning using anatomic landmarks of the acetabulum. Clin Orthop Relat Res. 2012;470:3515–3523.
Haaker RG, Tiedjen K, Ottersbach A, Rubenthaler F, Stockheim M, Stiehl JB. Comparison of conventional versus computer-navigated acetabular component insertion. J Arthroplasty. 2007;22:151–159.
Hassan DM, Johnston GH, Dust WN, Watson G, Dolovich AT. Accuracy of intraoperative assessment of acetabular prosthesis placement. J Arthroplasty. 1998;13:80–84.
Hohmann E, Bryant A, Tetsworth K. A comparison between imageless navigated and manual freehand technique acetabular cup placement in total hip arthroplasty. J Arthroplasty. 2011;26:1078–1082.
Jaramaz B, DiGioia AM 3rd, Blackwell M, Nikou C. Computer assisted measurement of cup placement in total hip replacement. Clin Orthop Relat Res. 1998;354:70–81.
Jolles BM, Genoud P, Hoffmeyer P. Computer-assisted cup placement techniques in total hip arthroplasty improve accuracy of placement. Clin Orthop Relat Res. 2004;426:174–179.
Kalteis T, Handel M, Bathis H, Perlick L, Tingart M, Grifka J. Imageless navigation for insertion of the acetabular component in total hip arthroplasty: is it as accurate as CT-based navigation? J Bone Joint Surg Br. 2006;88:163–167.
Kalteis T, Handel M, Herold T, Perlick L, Baethis H, Grifka J. Greater accuracy in positioning of the acetabular cup by using an image-free navigation system. Int Orthop. 2005;29:272–276.
Kalteis T, Sendtner E, Beverland D, Archbold PA, Hube R, Schuster T, Renkawitz T, Grifka J. The role of the transverse acetabular ligament for acetabular component orientation in total hip replacement: an analysis of acetabular component position and range of movement using navigation software. J Bone Joint Surg Br. 2011;93:1021–1026.
Kennedy JG, Rogers WB, Soffe KE, Sullivan RJ, Griffen DG, Sheehan LJ. Effect of acetabular component orientation on recurrent dislocation, pelvic osteolysis, polyethylene wear, and component migration. J Arthroplasty. 1998;13:530–534.
Kumar PG, Kirmani SJ, Humberg H, Kavarthapu V, Li P. Reproducibility and accuracy of templating uncemented THA with digital radiographic and digital TraumaCad templating software. Orthopedics. 2009;32:815.
Kummer FJ, Shah S, Iyer S, DiCesare PE. The effect of acetabular cup orientations on limiting hip rotation. J Arthroplasty. 1999;14:509–513.
Leenders T, Vandevelde D, Mahieu G, Nuyts R. Reduction in variability of acetabular cup abduction using computer assisted surgery: a prospective and randomized study. Comput Aided Surg. 2002;7:99–106.
Leslie IJ, Williams S, Isaac G, Ingham E, Fisher J. High cup angle and microseparation increase the wear of hip surface replacements. Clin Orthop Relat Res. 2009;467:2259–2265.
Lewinnek GE, Lewis JL, Tarr R, Compere CL, Zimmerman JR. Dislocations after total hip-replacement arthroplasties. J Bone Joint Surg Am. 1978;60:217–220.
McCollum DE, Gray WJ. Dislocation after total hip arthroplasty: causes and prevention. Clin Orthop Relat Res. 1990;261:159–170.
Morrey BF. Difficult complications after hip joint replacement: dislocation. Clin Orthop Relat Res. 1997;344:179–187.
Murphy SB, Ecker TM. Evaluation of a new leg length measurement algorithm in hip arthroplasty. Clin Orthop Relat Res. 2007;463:85–89.
Murray DW. The definition and measurement of acetabular orientation. J Bone Joint Surg Br. 1993;75:228–232.
Parratte S, Argenson JN. Validation and usefulness of a computer-assisted cup-positioning system in total hip arthroplasty: a prospective, randomized, controlled study. J Bone Joint Surg Am. 2007;89:494–499.
Saxler G, Marx A, Vandevelde D, Langlotz U, Tannast M, Wiese M, Michaelis U, Kemper G, Grutzner PA, Steffen R, von Knoch M, Holland-Letz T, Bernsmann K. The accuracy of free-hand cup positioning: a CT based measurement of cup placement in 105 total hip arthroplasties. Int Orthop. 2004;28:198–201.
Shon WY, Baldini T, Peterson MG, Wright TM, Salvati EA. Impingement in total hip arthroplasty a study of retrieved acetabular components. J Arthroplasty. 2005;20:427–435.
Siebenrock KA, Kalbermatten DF, Ganz R. Effect of pelvic tilt on acetabular retroversion: a study of pelves from cadavers. Clin Orthop Relat Res. 2003;407:241–248.
Steinberg EL, Shasha N, Menahem A, Dekel S. Preoperative planning of total hip replacement using the TraumaCad system. Arch Orthop Trauma Surg. 2010;130:1429–1432.
Wan Z, Malik A, Jaramaz B, Chao L, Dorr LD. Imaging and navigation measurement of acetabular component position in THA. Clin Orthop Relat Res. 2009;467:32–42.
Westacott DJ, McArthur J, King RJ, Foguet P. Assessment of cup orientation in hip resurfacing: a comparison of TraumaCad and computed tomography. J Orthop Surg Res. 2013;8:8.
Widmer KH, Zurfluh B. Compliant positioning of total hip components for optimal range of motion. J Orthop Res. 2004;22:815–821.
Woo RY, Morrey BF. Dislocations after total hip arthroplasty. J Bone Joint Surg Am. 1982;64:1295–1306.
Yamaguchi M, Akisue T, Bauer TW, Hashimoto Y. The spatial location of impingement in total hip arthroplasty. J Arthroplasty. 2000;15:305–313.
Ybinger T, Kumpan W, Hoffart HE, Muschalik B, Bullmann W, Zweymuller K. Accuracy of navigation-assisted acetabular component positioning studied by computed tomography measurements: methods and results. J Arthroplasty. 2007;22:812–817.
Acknowledgments
We thank Zachary Finley BA, Ryan Baise BS, Jennifer C. Stone MA, and Anthony P. Trenga BA for assistance with data collection and analysis and literature review.
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The institution of one or more of the authors (BGD) has received, during the study period, funding from Mako Corporation (Fort Lauderdale, FL, USA) in an amount less than USD 10,000. The institution of one author (BGD) has received, during the study period, funding from Arthrex Inc (Naples, FL, USA).
All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.
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Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.
This work was performed at the American Hip Institute, Westmont, IL, USA.
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Domb, B.G., El Bitar, Y.F., Sadik, A.Y. et al. Comparison of Robotic-assisted and Conventional Acetabular Cup Placement in THA: A Matched-pair Controlled Study. Clin Orthop Relat Res 472, 329–336 (2014). https://doi.org/10.1007/s11999-013-3253-7
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DOI: https://doi.org/10.1007/s11999-013-3253-7