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Does Balancing a Total Hip Arthroplasty Require a New Paradigm? Functional 3-Dimensional Balancing in Total Hip Arthroplasty

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Abstract

Background

Traditional principles for successful outcomes in Total Hip Arthroplasty (THA) have relied largely on placing the socket in the native position and trying to restore static anatomical femoral parameters gauged on X-rays or intra-operative measurement. Stability is conventionally achieved by making appropriate changes during the time of trial reduction. Post-operative complications of dislocation and significant Limb Length Discrepancy (LLD) requiring foot wear modification represents opposite ends of the spectrum from a biomechanical perspective and these continue to be relatively high. A move towards giving more importance to functional dynamic parameters rather than static anatomical parameters and less reliance on stability testing at trial reduction is warranted.

Methods

Intraoperative 3D functional balancing of THA without stability testing at trial reduction was practiced in all subjects undergoing THA in our unit from April 2014. To date 1019 patients have had their hips replaced with the same technique. They were followed up till April 2020 for post-operative complications of dislocation and significant LLD needing footwear modification. A secondary cohort of 114 patients from 1st January to December 31st 2017 within this primary group were analyzed clinically and radiologically to ascertain the implications of functional 3D balancing on X-ray parameters, clinical outcome scores (Harris Hip Score and Oxford Hip Score), ability to squat, and subtle subjective post-operative perception of limb lengthening (POPLL).

Results

In the primary group of 1019 patients, there were only two dislocations and no patient needed footwear modification for LLD. In the detailed analysis of the secondary cohort of 114 patients, the correlation with restoration of static radiological parameters was inconsistent. 40 patients could not squat and 4 patients had subtle subjective post-operative perceived limb lengthening (POPLL). Measured outcomes such as HHS and OHS were improved in all patients with significant statistical significance (P < 0.001).

Conclusion

This study underlines the fact that more importance must be given to functional dynamic parameters by 3D balancing of the THA and not on static anatomical X-rays parameters and stability testing during trial reduction. This represents a paradigm shift in the evolution of total hip arthroplasty.

Level of Evidence

A Level II study. (Data collected from the ongoing prospective study) (http://www.spine.org/Documents/LevelsofEvidenceFinal.pdf).

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Acknowledgements

(1) Clinical fellows who assisted in data recovery: Dr. Karthik J, Dr. Ketan J Khatri, Dr. Sai Suchitra G, Dr. Kiran Manohar. (2) Mr. Ramalingam Rajendran: image formatting and database archive management. (3) Mr. Mohan Kumar: database entry and Patient Coordination

Funding

No specific financial support was received for this study.

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Authors and Affiliations

  1. Asian Joint Reconstruction Institute @ SIMS Hospitals, Chennai, Tamil Nadu, India

    Vijay C. Bose, Suryanarayan Pichai, P. S. Ashok Kumar, Kalaivanan Kanniyan & Subramanyam Yadlapalli

  2. SRM Medical College, SRM IST, Kattankulathur, Tamil Nadu, India

    Shantanu Patil

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  1. Vijay C. Bose
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Contributions

VCB: manuscript writing and chief operating surgeon. SP: manuscript edit and chief operating surgeon. AK: data collection and operating surgeon. KK: manuscript writing and operating surgeon. SY: data collection, analysis, and manuscript writing. SP: statistics workup, manuscript writing, and edit.

Corresponding authors

Correspondence to Vijay C. Bose or Shantanu Patil.

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This article does not contain any studies with human or animal subjects performed by the any of the authors.

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The study was approved by SIMS Institutional Review Board and informed consent from patients was obtained.

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Bose, V.C., Pichai, S., Ashok Kumar, P.S. et al. Does Balancing a Total Hip Arthroplasty Require a New Paradigm? Functional 3-Dimensional Balancing in Total Hip Arthroplasty. JOIO 55, 1240–1249 (2021). https://doi.org/10.1007/s43465-021-00505-3

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