Skeletal Radiology

, Volume 43, Issue 8, pp 1041–1051 | Cite as

Computed tomography for preoperative planning in total hip arthroplasty: what radiologists need to know

  • Alexander HuppertzEmail author
  • Sebastian Radmer
  • Moritz Wagner
  • Torsten Roessler
  • Bernd Hamm
  • Martin Sparmann
Review Article


The number of total hip arthroplasties is continuously rising. Although less invasive surgical techniques, sophisticated component design, and intraoperative navigation techniques have been introduced, the rate of peri- and postoperative complications, including dislocations, fractures, nerve palsies, and infections, is still a major clinical problem. Better patient outcome, faster recovery and rehabilitation, and shorter operation times therefore remain to be accomplished. A promising strategy is to use minimally invasive techniques in conjunction with modular implants, aimed at independently reconstructing femoral offset and leg length on the basis of highly accurate preoperative planning. Plain radiographs have clear limitations for the correct estimation of hip joint geometry and bone quality. Three-dimensional assessment based on computed tomography (CT) allows optimizing the choice and positions of implants and anticipating difficulties to be encountered during surgery. Postoperative CT is used to monitor operative translation and plays a role in arthroplastic quality management. Radiologists should be familiar with the needs of orthopedic surgeons in terms of CT acquisition, post-processing, and data transfer. The CT protocol should be optimized to enhance image quality and reduce radiation exposure. When dedicated orthopedic CT protocols and state-of-the-art scanner hardware are used, radiation exposure can be decreased to a level just marginally higher than that of conventional preoperative radiography. Surgeons and radiologists should use similar terminology to avoid misunderstanding and inaccuracies in the transfer of preoperative planning.


Computed tomography Total hip arthroplasty 3D post-processing Radiation exposure Hip measurements Modular endoprosthesis Minimally invasive surgery 


Conflict of interest

Alexander Huppertz has been a full time paid employee of Siemens AG since 1 June 2004. He is Associate Director of the Imaging Science Institute Charité. The Institute is a scientific cooperation between the Charité, University Hospitals of Berlin, Germany and Siemens Healthcare in the form of a private–public partnership (PPP). Sebastian Radmer and Martin Sparmann received speakers’ honoraria for specific speeches from Symbios Orthopédie SA, Switzerland.


  1. 1.
    Kiefer H. Differences and opportunities of THA in the USA, Asia and Europe. In: Chang J-D, Billau K, editors. Bioceramics and alternative bearings in joint arthroplasty. 12th BIOLOX Symposium Proceedings. Darmstadt, Germany: Steinkopff-Verlag; 2007. p. 3–8.CrossRefGoogle Scholar
  2. 2.
    Malik A, Dorr LD. The science of minimally invasive total hip arthroplasty. Clin Orthop Relat Res. 2007;463:74–84.PubMedGoogle Scholar
  3. 3.
    Woolson ST. In the absence of evidence–why bother? A literature review of minimally invasive total hip replacement surgery. Instr Course Lect. 2006;55:189–93.PubMedGoogle Scholar
  4. 4.
    Soohoo NF, Farng E, Lieberman JR, Chambers L, Zingmond DS. Factors that predict short-term complication rates after total hip arthroplasty. Clin Orthop Relat Res. 2010;468:2363–71.PubMedCentralPubMedCrossRefGoogle Scholar
  5. 5.
    Goosen JH, Kollen BJ, Castelein RM, Kuipers BM, Verheyen CC. Minimally invasive versus classic procedures in total hip arthroplasty: a double-blind randomized controlled trial. Clin Orthop Relat Res. 2011;469:200–8.PubMedCentralPubMedCrossRefGoogle Scholar
  6. 6.
    Flecher X, Parratte S, Aubaniac JM, Argenson JN. Three-dimensional custom-designed cementless femoral stem for osteoarthritis secondary to congenital dislocation of the hip. J Bone Joint Surg (Br). 2007;89:1586–91.CrossRefGoogle Scholar
  7. 7.
    Sariali E, Mouttet A, Pasquier G, Durante E, Catone Y. Accuracy of reconstruction of the hip using computerised three-dimensional pre-operative planning and a cementless modular neck. J Bone Joint Surg (Br). 2009;91(3):333–40.CrossRefGoogle Scholar
  8. 8.
    Ilchmann T, Gersbach S, Zwicky L, Clauss M. Standard transgluteal versus minimal invasive anterior approach in hip arthroplasty: a prospective, consecutive cohort study. Orthop Rev (Pavia). 2013;5:e31.CrossRefGoogle Scholar
  9. 9.
    Dorr LD, Thomas D, Long WT, Polatin PB, Sirianni LE. Psychologic reasons for patients preferring minimally invasive total hip arthroplasty. Clin Orthop Relat Res. 2007;458:94–100.PubMedGoogle Scholar
  10. 10.
    Ciminiello M, Parvizi J, Sharkey PF, Eslampour A, Rothman RH. Total hip arthroplasty: is small incision better? J Arthroplasty. 2006;21:484–8.PubMedCrossRefGoogle Scholar
  11. 11.
    Chimento GF, Pavone V, Sharrock N, Kahn B, Cahill J, Sculco TP. Minimally invasive total hip arthroplasty: a prospective randomized study. J Arthroplasty. 2005;20:139–44.PubMedCrossRefGoogle Scholar
  12. 12.
    Wright JM, Crockett HC, Delgado S, Lyman S, Madsen M, Sculco TP. Mini-incision for total hip arthroplasty: a prospective, controlled investigation with 5-year follow-up evaluation. J Arthroplasty. 2004;19:538–45.PubMedCrossRefGoogle Scholar
  13. 13.
    Kennon RE, Keggi JM, Wetmore RS, Zatorski LE, Huo MH, Keggi KJ. Total hip arthroplasty through a minimally invasive anterior surgical approach. J Bone Joint Surg Am. 2003;85 Suppl 4:39–48.PubMedGoogle Scholar
  14. 14.
    Matta JM, Shahrdar C, Ferguson T. Single-incision anterior approach for total hip arthroplasty on an orthopaedic table. Clin Orthop Relat Res. 2005;441:115–24.PubMedCrossRefGoogle Scholar
  15. 15.
    Woolson ST, Mow CS, Syquia JF, Lannin JV, Schurman DJ. Comparison of primary total hip replacements performed with a standard incision or a mini-incision. J Bone Joint Surg Am. 2004;86-A(7):1353–8.PubMedGoogle Scholar
  16. 16.
    Husmann O, Rubin PJ, Leyvraz PF, de Roguin B, Argenson JN. Three-dimensional morphology of the proximal femur. J Arthroplasty. 1997;12:444–50.PubMedCrossRefGoogle Scholar
  17. 17.
    Krishnan SP, Carrington RW, Mohiyaddin S, Garlick N. Common misconceptions of normal hip joint relations on pelvic radiographs. J Arthroplasty. 2006;2:409–12.CrossRefGoogle Scholar
  18. 18.
    Asayama I, Chamnongkich S, Simpson KJ, Kinsey TL, Mahoney OM. Reconstructed hip joint position and abductor muscle strength after total hip arthroplasty. J Arthroplasty. 2005;20:414–20.PubMedCrossRefGoogle Scholar
  19. 19.
    Jolles BM, Zangger P, Leyvraz PF. Factors predisposing to dislocation after primary total hip arthroplasty: a multivariate analysis. J Arthroplasty. 2002;17:282–8.PubMedCrossRefGoogle Scholar
  20. 20.
    Ng VY, Kean JR, Glassman AH. Limb-length discrepancy after hip arthroplasty. J Bone Joint Surg Am. 2013;95:1426–36.PubMedCrossRefGoogle Scholar
  21. 21.
    Benedetti MG, Catani F, Benedetti E, Berti L, Di Gioia A, Giannini S. To what extent does leg length discrepancy impair motor activity in patients after total hip arthroplasty? Int Orthop. 2010;34:1115–21.PubMedCentralPubMedCrossRefGoogle Scholar
  22. 22.
    Marcucci M, Indelli PF, Latella L, Poli P, King D. A multimodal approach in total hip arthroplasty preoperative templating. Skelet Radiol. 2013;42:1287–94.CrossRefGoogle Scholar
  23. 23.
    Bertz A, Indrekvam K, Ahmed M, Englund E, Sayed-Noor AS. Validity and reliability of preoperative templating in total hip arthroplasty using a digital templating system. Skeletal Radiol. 2012;41:1245–9.PubMedCrossRefGoogle Scholar
  24. 24.
    Kosashvili Y, Shasha N, Olschewski E, Safir O, White L, Gross A, et al. Digital versus conventional templating techniques in preoperative planning for total hip arthroplasty. Can J Surg. 2009;52:6–11.PubMedCentralPubMedGoogle Scholar
  25. 25.
    Linclau L, Dokter G, Peene P. Radiological aspects in preoperative planning and postoperative assessment of cementless total hip arthroplasty. Acta Orthop Belg. 1993;59:163–7.PubMedGoogle Scholar
  26. 26.
    Sugano N, Ohzono K, Nishii T, Haraguchi K, Sakai T, Ochi T. Computed-tomography-based computer preoperative planning for total hip arthroplasty. Comput Aided Surg. 1998;3:320–4.PubMedCrossRefGoogle Scholar
  27. 27.
    Sariali E, Mouttet A, Pasquier G, Durante E. Three-dimensional hip anatomy in osteoarthritis. Analysis of the femoral offset. J Arthroplasty. 2009;24:990–7.PubMedCrossRefGoogle Scholar
  28. 28.
    Lee CH, Goo JM, Ye HJ, Ye SJ, Park CM, Chun EJ, et al. Radiation dose modulation techniques in the multidetector CT era: from basics to practice. Radiographics. 2008;28:1451–9.PubMedCrossRefGoogle Scholar
  29. 29.
    Kalteis T, Handel M, Herold T, Perlick L, Paetzel C, Grifka J. Position of the acetabular cup—accuracy of radiographic calculation compared to CT-based measurement. Eur J Radiol. 2006;58:294–300.PubMedCrossRefGoogle Scholar
  30. 30.
    Huppertz A, Radmer S, Asbach P, Juran R, Schwenke C, Diederichs G, et al. Computed tomography for preoperative planning in minimal-invasive total hip arthroplasty: Radiation exposure and cost analysis. Eur J Radiol. 2011;78:406–13.PubMedCrossRefGoogle Scholar
  31. 31.
    Wall BF, Hart D. Revised radiation doses for typical X-ray examinations. Report on a recent review of doses to patients from medical X-ray examinations in the UK by NRPB. National Radiological Protection Board. Br J Radiol. 1997;70:437–9.PubMedCrossRefGoogle Scholar
  32. 32.
    Jurik AG, Jensen LC, Hansen J. Total effective radiation dose from spiral CT and conventional radiography of the pelvis with regard to fracture classification. Acta Radiol. 1996;37:651–4.PubMedCrossRefGoogle Scholar
  33. 33.
    Al-Malki MA, Abulfaraj WH, Bhuiyan SI, Kinsara AA. A study on radiographic repeat rate data of several hospitals in Jeddah. Radiat Prot Dosim. 2003;103:323–30.CrossRefGoogle Scholar
  34. 34.
    Sayed-Noor AS, Hugo A, Sjödén GO, Wretenberg P. Leg length discrepancy in total hip arthroplasty: comparison of two methods of measurement. Int Orthop. 2009;33:1189–93.PubMedCentralPubMedCrossRefGoogle Scholar
  35. 35.
    Terry MA, Winell JJ, Green DW, Schneider R, Peterson M, Marx RG, et al. Measurement variance in limb length discrepancy: clinical and radiographic assessment of interobserver and intraobserver variability. J Pediatr Orthop. 2005;25:197–201.PubMedCrossRefGoogle Scholar
  36. 36.
    Aitken AG, Flodmark O, Newman DE, Kilcoyne RF, Shuman WP, Mack LA. Leg length determination by CT digital radiography. AJR Am J Roentgenol. 1985;144:613–5.PubMedCrossRefGoogle Scholar
  37. 37.
    Sabharwal S, Kumar A. Methods for assessing leg length discrepancy. Clin Orthop Relat Res. 2008;466:2910–22.PubMedCentralPubMedCrossRefGoogle Scholar
  38. 38.
    Escott BG, Ravi B, Weathermon AC, Acharya J, Gordon CL, Babyn PS, et al. EOS low-dose radiography: a reliable and accurate upright assessment of lower-limb lengths. J Bone Joint Surg Am. 2013;95:e1831–7.PubMedCrossRefGoogle Scholar
  39. 39.
    Tannast M, Langlotz U, Siebenrock KA, Wiese M, Bernsmann K, Langlotz F. Anatomic referencing of cup orientation in total hip arthroplasty. Clin Orthop Relat Res. 2005;436:144–50.PubMedCrossRefGoogle Scholar
  40. 40.
    Tannast M, Murphy SB, Langlotz F, Anderson SE, Siebenrock KA. Estimation of pelvic tilt on anteroposterior X-rays–a comparison of six parameters. Skelet Radiol. 2006;35:149–55.CrossRefGoogle Scholar
  41. 41.
    Murray DW. The definition and measurement of acetabular orientation. J Bone Joint Surg (Br). 1993;75:228–32.Google Scholar
  42. 42.
    Lewinnek GE, Lewis JL, Tarr R, Compere CL, Zimmerman JR. Dislocations after total hip-replacement arthroplasties. J Bone Joint Surg Am. 1978;60:217–20.PubMedGoogle Scholar
  43. 43.
    Murtha PE, Hafez MA, Jaramaz B, DiGioia 3rd AM. Variations in acetabular anatomy with reference to total hip replacement. J Bone Joint Surg (Br). 2008;90:308–13.CrossRefGoogle Scholar
  44. 44.
    Widmer KH. Containment versus impingement: finding a compromise for cup placement in total hip arthroplasty. Int Orthop. 2007;31 Suppl 1:S29–33.PubMedCrossRefGoogle Scholar
  45. 45.
    Iwai S, Kabata T, Maeda T, Kajino Y, Kuroda K, Fujita K, et al. Using simulation before and after rotational acetabular osteotomy to assess the femoroacetabular impingement. Bone Joint J. 2013;95-B(Suppl 15):203.Google Scholar
  46. 46.
    Grupp TM, Weik T, Bloemer W, Knaebel HP. Modular titanium alloy neck adapter failures in hip replacement–failure mode analysis and influence of implant material. BMC Musculoskelet Disord. 2010;11:3.PubMedCentralPubMedCrossRefGoogle Scholar
  47. 47.
    Bosker BH, Verheyen CC, Horstmann WG, Tulp NJ. Poor accuracy of freehand cup positioning during total hip arthroplasty. Arch Orthop Trauma Surg. 2007;127:375–9.PubMedCentralPubMedCrossRefGoogle Scholar
  48. 48.
    Beckmann J, Stengel D, Tingart M, Götz J, Grifka J, Lüring C. Navigated cup implantation in hip arthroplasty. Acta Orthop. 2009;80:538–44.PubMedCentralPubMedCrossRefGoogle Scholar
  49. 49.
    Murphy SB, Ecker TM, Tannast M. THA performed using conventional and navigated tissue-preserving techniques. Clin Orthop Relat Res. 2006;453:160–7.PubMedCrossRefGoogle Scholar
  50. 50.
    Jaramaz B, DiGioia 3rd AM, Blackwell M, Nikou C. Computer assisted measurement of cup placement in total hip replacement. Clin Orthop Relat Res. 1998;354:70–81.PubMedCrossRefGoogle Scholar
  51. 51.
    Sendtner E, Boluki D, Grifka J. Current state of doing minimal invasive total hip replacement in Germany, the use of new implants and navigation–results of a nation-wide survey. Z Orthop Unfall. 2007;145:297–302.PubMedGoogle Scholar
  52. 52.
    Sotereanos NG, Miller MC, Smith B, Hube R, Sewecke JJ, Wohlrab D. Using intraoperative pelvic landmarks for acetabular component placement in total hip arthroplasty. J Arthroplasty. 2006;21:832–40.PubMedCrossRefGoogle Scholar
  53. 53.
    Steppacher SD, Kowal JH, Murphy SB. Improving cup positioning using a mechanical navigation instrument. Clin Orthop Relat Res. 2011;469:423–8.PubMedCentralPubMedCrossRefGoogle Scholar

Copyright information

© ISS 2014

Authors and Affiliations

  • Alexander Huppertz
    • 1
    • 2
    Email author
  • Sebastian Radmer
    • 3
  • Moritz Wagner
    • 1
  • Torsten Roessler
    • 4
  • Bernd Hamm
    • 1
  • Martin Sparmann
    • 3
    • 5
  1. 1.Department of RadiologyCharité—University Hospitals BerlinBerlinGermany
  2. 2.Imaging Science Institute CharitéBerlinGermany
  3. 3.Proendo, Orthopedic SurgeryBerlinGermany
  4. 4.Department of Trauma and Orthopedic SurgeryKlinikum Ernst von BergmannPotsdamGermany
  5. 5.Charité—University HospitalBerlinGermany

Personalised recommendations