Biplanar Low-Dose Radiography Is Accurate for Measuring Combined Anteversion After Total Hip Arthroplasty
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Acetabular component position alone has not been predictive of stability after total hip arthroplasty (THA). Combined anteversion of the acetabulum and femur has the potential of being more predictive of stability. Unfortunately, femoral component position is difficult to measure on plain radiographs. Computed tomography (CT) is the gold standard for measuring implant position post-operatively, but CT exposes patients to a substantial amount of radiation.
We sought to determine whether biplanar low-dose radiography can be used to accurately measure both acetabular and femoral implant position after THA.
Twenty patients underwent standing low-dose biplanar spine-to-ankle radiographs and supine CT scans 6 weeks after THA. Measurements of acetabular inclination, acetabular anteversion, and femoral anteversion were performed by two blinded observers and compared.
The average absolute differences between biplanar radiographs and CT scans were 2° ± 2° for acetabular inclination, 3° ± 2° for acetabular anteversion, and 4° ± 4° for femoral anteversion between EOS measurements and CT measurements. Interobserver agreement was good for acetabular inclination, acetabular anteversion, and femoral anteversion (Cronbach’s α = 0.90) using biplanar low-dose imaging.
Biplanar radiography is a reliable low-radiation alternative for measuring acetabular inclination, acetabular anteversion, femoral version, and thus combined anteversion compared to CT. Femoral anteversion had the most variability but is still clinically relevant.
Keywordstotal hip arthroplasty imaging implant position computed tomography anteversion
Compliance with Ethical Standards
Conflict of Interest
Christina I. Esposito, PhD, and Kaitlin M. Carroll, BS, declare that they have no conflicts of interest. David J. Mayman, MD, reports stock or stock options from Imagen Technologies and OrthAlign; personal fees for consultancy, lectures, and grants from Smith & Nephew; and board membership with the Knee Society. Douglas E. Padgett, MD, reports board membership with American Joint Replacement Registry, Journal of Arthroplasty, and Hip Society; personal fees and royalties from DJ Orthopaedics and PixarBio; and stock or stock options from PixarBio. Joseph D. Lipman, MS, reports royalties from Exactech, Inc., LimaCorporate, Mathys Ltd., and Ortho Development Corporation. Seth A. Jerabek, MD, reports personal fees, speakers’ fees, royalties, and grants from Stryker and stock and stock options from Imagen Technologies. Theodore T. Miller, MD, reports educational fees from Amirsys Publishing Co.
All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2013.
Informed consent was obtained from all patients for being included in this study.
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- 1.Abdel MP, von Roth P, Jennings MT, Hanssen AD, Pagnano MW. What safe zone? The vast majority of dislocated THAs are within the Lewinnek safe zone for acetabular component position. Clin Orthop. 2016;474:386–391.Google Scholar
- 2.Buck FM, Guggenberger R, Koch PP, Pfirrmann CWA. Femoral and tibial torsion measurements with 3D models based on low-dose biplanar radiographs in comparison with standard CT measurements. Am J Roentgenol. 2012;199:W607–612.Google Scholar
- 3.Chaibi Y, Cresson T, Aubert B, et al. Fast 3D reconstruction of the lower limb using a parametric model and statistical inferences and clinical measurements calculation from biplanar X-rays. Comput Methods Biomech Biomed Engin. 2012;15:457–466.Google Scholar
- 4.Craiovan B, Renkawitz T, Weber M, Grifka J, Nolte L, Zheng G. Is the acetabular cup orientation after total hip arthroplasty on a two dimension or three dimension model accurate? Int Orthop. 2014;38:2009–2015.Google Scholar
- 5.Demzik AL, Alvi HM, Delagrammaticas DE, Martell JM, Beal MD, Manning DW. Inter-rater and intra-rater repeatability and reliability of EOS 3-dimensional imaging analysis software. J Arthroplasty. 2016;31:1091–1095.Google Scholar
- 6.Dorr LD, Malik A, Dastane M, Wan Z. Combined anteversion technique for total hip arthroplasty. Clin Orthop. 2009;467:119–127.Google Scholar
- 7.Escott BG, Ravi B, Weathermon AC, et al. EOS low-dose radiography: a reliable and accurate upright assessment of lower-limb lengths. J Bone Joint Surg Am. 2013;95:e1831–1837.Google Scholar
- 8.Esposito CI, Gladnick BP, Lee Y-Y, et al. Cup position alone does not predict risk of dislocation after hip arthroplasty. J Arthroplasty. 2014;30(1):109–113.Google Scholar
- 9.Esposito CI, Carroll KM, Sculco PK, Padgett DE, Jerabek SA, Mayman DJ. Total hip arthroplasty patients with fixed spinopelvic alignment are at higher risk of hip dislocation. J Arthroplasty. 2018;33(5):1449–1454.Google Scholar
- 10.Folinais D, Thelen P, Delin C, Radier C, Catonne Y, Lazennec JY. Measuring femoral and rotational alignment: EOS system versus computed tomography. Orthop Traumatol Surg Res. 2013;99:509–516.Google Scholar
- 11.Guenoun B, Zadegan F, Aim F, Hannouche D, Nizard R. Reliability of a new method for lower-extremity measurements based on stereoradiographic three-dimensional reconstruction. Orthop Traumatol Surg Res. 2012;98:506–513.Google Scholar
- 12.Guenoun B, El Hajj F, Biau D, Anract P, Courpied J-P. Reliability of a new method for evaluating femoral stem positioning after total hip arthroplasty based on stereoradiographic 3D reconstruction. J Arthroplasty. 2015;30:141–144.Google Scholar
- 13.Hisatome T, Doi H. Theoretically optimum position of the prosthesis in total hip arthroplasty to fulfill the severe range of motion criteria due to neck impingement. J Orthop Sci. 2011;16:229–237.Google Scholar
- 14.Journé A, Sadaka J, Bélicourt C, Sautet A. New method for measuring acetabular component positioning with EOS imaging: feasibility study on dry bone. Int Orthop 2012;36:2205–2209.Google Scholar
- 15.Kim Y-H, Cho K-H, Park Y-G. Is the acetabular cup orientation after total hip arthroplasty on a two-dimensional or three-dimensional model accurate? Int Orthop. 2015;39:819–820.Google Scholar
- 16.Kutzner KP, Freitag T, Donner S, Kovacevic MP, Bieger R. Outcome of extensive varus and valgus stem alignment in short-stem THA: clinical and radiological analysis using EBRA-FCA. Arch Orthop Trauma Surg. 2017;137:431–439.Google Scholar
- 17.Lazennec JY, Brusson A, Rousseau M-A. THA patients in standing and sitting positions: a prospective evaluation using the low-dose “full-body” EOS® imaging system. Semin Arthroplasty. 2012;23:220–225.Google Scholar
- 18.Lazennec JY, Rousseau MA, Rangel A, et al. Pelvis and total hip arthroplasty acetabular component orientations in sitting and standing positions: measurements reproductibility with EOS imaging system versus conventional radiographies. Orthop Traumatol Surg Res. 2011;97:373–380.Google Scholar
- 19.Lazennec JY, Brusson A, Dominique F, Rousseau M-A, Pour AE. Offset and anteversion reconstruction after cemented and uncemented total hip arthroplasty: an evaluation with the low-dose EOS system comparing two- and three-dimensional imaging. In Orthop. 2015;39:1259–1267.Google Scholar
- 20.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.Google Scholar
- 21.Lin F, Lim D, Wixson RL, Milos S, Hendrix RW, Makhsous M. Validation of a computer navigation system and a CT method for determination of the orientation of implanted acetabular cup in total hip arthroplasty: a cadaver study. Clin Biomech Bristol Avon. 2008;23:1004–1011.Google Scholar
- 22.Mahboub-Ahari A, Hajebrahimi S, Yusefi M, Velayati A. EOS imaging versus current radiography: a health technology assessment study. Med J Islam Repub Iran. 2016;30:331.Google Scholar
- 23.Maratt JD, Esposito CI, McLawhorn AS, Jerabek SA, Padgett DE, Mayman DJ. Pelvic tilt in patients undergoing total hip arthroplasty: when does it matter? J Arthroplasty. 2015;30(3):387–391.Google Scholar
- 24.McArthur B, Cross M, Geatrakas C, Mayman D, Ghelman B. Measuring acetabular component version after THA: CT or plain radiograph? Clin Orthop. 2012;470:2810–2818.Google Scholar
- 25.Morvan G, Guerini H, Carré G, Vuillemin V. Femoral torsion: impact of femur position on CT and stereoradiography measurements. Am J Roentgenol. 2017;209:W93–W99.Google Scholar
- 26.Nakashima Y, Hirata M, Akiyama M, et al. Combined anteversion technique reduced the dislocation in cementless total hip arthroplasty. Int Orthop. 2014;38:27–32.Google Scholar
- 27.Nunley RM, Keeney JA, Zhu J, Clohisy JC, Barrack RL. The reliability and variation of acetabular component anteversion measurements from cross-table lateral radiographs. J Arthroplasty. 2011;26:84–87.Google Scholar
- 28.Ranawat CS, Maynard MJ. Modern techniques of cemented total hip arthroplasty. Tech Orthop. 1991;6:17–25.Google Scholar
- 29.Rosskopf AB, Pfirrmann CWA, Buck FM. Assessment of two-dimensional (2D) and three-dimensional (3D) lower limb measurements in adults: comparison of micro-dose and low-dose biplanar radiographs. Eur Radiol. 2016;26:3054–3062.Google Scholar
- 30.Rosskopf AB, Buck FM, Pfirrmann CWA, Ramseier LE. Femoral and tibial torsion measurements in children and adolescents: comparison of MRI and 3D models based on low-dose biplanar radiographs. Skeletal Radiol. 2017;46:469–476.Google Scholar
- 31.Tsai T-Y, Dimitriou D, Li G, Kwon Y-M. Does total hip arthroplasty restore native hip anatomy? three-dimensional reconstruction analysis. Int Orthop. 2014;38:1577–1583.Google Scholar
- 32.Wan Z, Boutary M, Dorr LD. The influence of acetabular component position on wear in total hip arthroplasty. J Arthroplasty. 2008;23:51–56.Google Scholar
- 33.Widmer K-H, Zurfluh B. Compliant positioning of total hip components for optimal range of motion. J Orthop Res. 2004;22:815–821.Google Scholar
- 34.Wines AP, McNicol D. Computed tomography measurement of the accuracy of component version in total hip arthroplasty. J Arthroplasty. 2006;21:696–701.Google Scholar
- 35.Yoshimine F. The safe-zones for combined cup and neck anteversions that fulfill the essential range of motion and their optimum combination in total hip replacements. J Biomech. 2006;39:1315–1323.Google Scholar