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Pathologic spinopelvic balance in patients with hip osteoarthritis

Preoperative screening and therapeutic implications

Pathologische spinopelvine Balance bei Patienten mit Coxarthrose

Präoperatives Screening und therapeutische Konsequenzen

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Abstract

Recently spinopelvic balance and mobility, i.e. the dynamic interaction of the spine, pelvis and the femur in the sagittal plane between different postures, has been identified as a relevant factor influencing the outcome of primary total hip arthroplasty (THA). Individual spinopelvic balance and mobility seem to affect patient reported outcome and the risk of impingement and dislocation following THA. The aim of this article is to provide a concise overview of normal and pathologic spinopelvic alignment, to characterize relevant spinopelvic parameters and the diagnostic assessment in patients with hip OA and to discuss potential implications for THA with respect to implant selection and component orientation.

Spinopelvic characteristics are highly variable. Patients with stiff lumbar spines and mobile hips seem to be at an increased risk of impingement and dislocation and can be screened with single lateral standing radiographs of the spinopelvic complex before THA. In patients with hip and spine pathology, particular attention should be paid to evaluate the individual pathoanatomy of the hip and established clinical measurements should be diligently taken with respect to the reconstruction of the center of rotation, hip offset, leg length and soft tissue tension in order to minimize the risk of impingement and dislocation. No evidence-based recommendations for novel target zones concerning implant position can currently be made. In patients at risk 36 mm heads should be used whenever possible. In high risk patients, such as the combination of a stiff unbalanced lumbar spine (“flatback”) and a mobile hip or in the presence of long spinal fusions or fusions involving the sacrum, dual mobility cups offer additional stability.

Zusammenfassung

In den letzten Jahren wurden das spinopelvine Alignement und die spinopelvine Mobilität – die dynamische Interaktion der Wirbelsäule, des Beckens und des Femurs in verschiedenen Körperhaltungen in der sagittalen Ebene – als klinisch relevanter Einflussfaktor auf das postoperative Outcome und das Luxationsrisiko nach Implantation einer Hüfttotalendoprothese (HTEP) identifiziert. Das Ziel dieses Beitrags ist es, einen Überblick über normale und pathologische Formen der spinopelvinen Mobilität zu geben, sowie klinisch relevante spinopelvine Parameter und deren Erhebung bei Patienten mit fortgeschrittener Coxarthrose zu beschreiben und die potentiellen Konsequenzen für die Versorgung mit einer HTEP bezüglich Implantatauswahl und -positionierung zu diskutieren. Die spinopelvinen Charakteristika sind individuell hochvariabel. Patienten mit einer steifen Lendenwirbelsäule (LWS) und relativ mobilen Hüftgelenken scheinen ein deutlich erhöhtes Risiko für ein Impingement und eine Luxation nach Implantation einer HTEP zu haben. Diese Patienten können durch ein präoperatives Screening mittels stehenden seitlichen Röntgenaufnahmen des spinopelvinen Komplexes identifiziert werden. Bei Patienten mit einer gleichzeitig vorliegenden Pathologie von LWS und Hüfte sollte ein besonderes Augenmerk auf die individuelle Pathoanatomie der Hüfte gelegt werden um entsprechend der Prothesenplanung das Drehzentrum, das Hüft-Offset, die Weichteilspannung sowie die Beinlänge bestmöglich zu rekonstruieren und damit das Risiko eines Impingements und einer Luxation zu minimieren. Gegenwärtig liegen noch keine evidenzbasierten Empfehlungen hinsichtlich individuell angepasster Zielzonen für die Implantatpositionierung vor, die das spinopelvine Alignement und dessen Mobilität berücksichtigen. Hinsichtlich der Implantatwahl sollte bei Risikopatienten mit pathologischer spinopelviner Mobilität versucht werden, Prothesenköpfe mit einem Durchmesser von 36 mm einzusetzen. Bei Patienten mit stark erhöhtem Risiko für eine Luxation, z. B. bei einer Kombination aus steifer LWS, unbalanciertem spinopelvinem Übergang („flatback“) und relativ mobilen Hüften bzw. bei Patienten mit langstreckigen Spondylodesen oder Spondylodesen, die das Os sacrum einbeziehen, sollten tripolare Pfannensysteme in Betracht gezogen werden, um eine zusätzliche Luxationssicherheit zu erzielen.

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Abbreviations

AI:

Ante-inclination

CSI:

Combined sagittal index

CT:

Computed tomography

HSS:

Hip-spine syndrome

LL:

Lumbar lordosis

MRI:

Magnetic resonance imaging

OA:

Osteoarthritis

PFA:

Pelvic-femoral angle

PI:

Pelvic incidence

PT:

Pelvic tilt

SS:

Sacral slope

THA:

Total hip arthroplasty

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Authors and Affiliations

  1. Klinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Heidelberg, Heidelberg, Germany

    Moritz M. Innmann,  Johannes Weishorn &  Christian Merle M.Sc.

  2. Division of Orthopaedic Surgery, The Ottawa Hospital—General Campus, University of Ottawa, Ottawa, Ontario, Canada

    Paul E. Beaule Chief, Professor, MD, FRCSC & George Grammatopoulos MBBS DPhil Oxon MRCS FRCS

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  1. Moritz M. Innmann
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  2. Johannes Weishorn
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  3. Paul E. Beaule Chief, Professor, MD, FRCSC
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  4. George Grammatopoulos MBBS DPhil Oxon MRCS FRCS
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  5. Christian Merle M.Sc.
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Correspondence to Christian Merle M.Sc..

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M.M. Innmann, J. Weishorn, P.E. Beaule, G. Grammatopoulos and C. Merle declare that they have no competing interests.

All studies performed were in accordance with the ethical standards indicated in each case. Additional written informed consent was obtained from all individual participants or their legal representatives for whom identifying information is included in this article.

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Innmann, M.M., Weishorn, J., Beaule, P.E. et al. Pathologic spinopelvic balance in patients with hip osteoarthritis. Orthopäde 49, 860–869 (2020). https://doi.org/10.1007/s00132-020-03981-x

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