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The direct anterior approach provokes varus stem alignment when using a collarless straight tapered stem

  • Orthopaedic Surgery
  • Published:
Archives of Orthopaedic and Trauma Surgery Aims and scope Submit manuscript

Abstract

Introduction

Inaccurate stem implantation can cause unsatisfactory offset reconstruction and may result in insufficient gluteal muscle function or aseptic loosening. In this study, stem alignment of a collarless straight tapered HA-coated stem was retrospectively analyzed during the learning phase of the direct anterior approach (DAA) for primary total hip arthroplasty (THA).

Material and methods

From Jan 2013 to Jun 2015, a total of 93 cementless THA were implanted in patients with unilateral coxarthrosis via the DAA in a two surgeon setting using the Corail® or Trendhip® stem (DePuy Synthes or Aesculap). Varus(+)/Valgus(−) stem alignment was analyzed in postoperative anteroposterior pelvic radiographs. Effects on femoral offset reconstruction and correlation to patient’s individual clinical and radiological parameters were evaluated.

Results

55 stems were implanted in varus (59%), 32 in neutral (34%) and 6 in valgus alignment (7%). Mean stem alignment in varus position was + 2.2° (SD ± 1.4°). Varus alignment was associated with male gender and preoperative coxa vara deformity: low CCD, high femoral offset and long thigh neck (p ≤ 0.001). Alignment was not correlated to femoral offset restoration, BMI or leg length difference. Mean cup inclination was 44° (SD ± 4.7°) and 90% matched the coronal Lewinnek safe zone.

Conclusion

In the learning curve, the DAA can be associated with a high incidence of varus stem alignment when using a straight tapered stem, especially in men with coxa vara deformity: low CCD, high femoral offset and long thigh neck. An insufficient capsule release makes femur exposure more difficult and might be an additional factor for this finding. We recommend intraoperative X-ray in the learning phase of the DAA to verify correct implant positioning and to adjust offset options.

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References

  1. Hallert O, Li Y, Brismar H, Lindgren U (2012) The direct anterior approach: initial experience of a minimally invasive technique for total hip arthroplasty. J Orthop Surg Res 7:17. https://doi.org/10.1186/1749-799X-7-17

    Article  PubMed  PubMed Central  Google Scholar 

  2. Homma Y, Baba T, Ochi H, Ozaki Y, Kobayashi H, Matsumoto M, Yuasa T, Kaneko K (2016) Greater trochanter chip fractures in the direct anterior approach for total hip arthroplasty. Eur J Orthop Surg Traumatol. https://doi.org/10.1007/s00590-016-1798-3

    Article  PubMed  Google Scholar 

  3. Soderquist MC, Scully R, Unger AS (2017) Acetabular placement accuracy with the direct anterior approach freehand technique. J Arthroplasty 32(9):2748–2754. https://doi.org/10.1016/j.arth.2017.04.011

    Article  PubMed  Google Scholar 

  4. Lum ZC, Dorr LD (2018) Restoration of center of rotation and balance of THR. J Orthop 15(4):992–996. https://doi.org/10.1016/j.jor.2018.08.040

    Article  PubMed  PubMed Central  Google Scholar 

  5. Shishido T, Tateiwa T, Takahashi Y, Masaoka T, Ishida T, Yamamoto K (2018) Effect of stem alignment on long-term outcomes of total hip arthroplasty with cementless Bi-Metric femoral components. J Orthop 15(1):134–137. https://doi.org/10.1016/j.jor.2018.01.008

    Article  PubMed  PubMed Central  Google Scholar 

  6. Bender B, Nogler M, Hozack WJ (2009) Direct anterior approach for total hip arthroplasty. Orthop Clin North Am 40(3):321–328. https://doi.org/10.1016/j.ocl.2009.01.003

    Article  PubMed  Google Scholar 

  7. Doria C, De Santis V, Falcone G, Proietti L, De Santis E (2003) Osseointegration in hip prostheses: experimental study in sheep. Int Orthop 27(5):272–277. https://doi.org/10.1007/s00264-003-0474-5

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  8. Zang J, Uchiyama K, Moriya M, Li Z, Fukushima K, Yamamoto T, Takahira N, Takaso M, Liu J, Feng W (2018) Long-term clinical and radiographic results of the cementless Spotorno stem in Japanese patients: a more than 15-year follow-up. J Orthop Surg (Hong Kong) 26(1):2309499017750310. https://doi.org/10.1177/2309499017750310

    Article  Google Scholar 

  9. Fottner A, Woiczinski M, Kistler M, Schroder C, Schmidutz TF, Jansson V, Schmidutz F (2018) Varus malalignment of cementless hip stems provides sufficient primary stability but highly increases distal strain distribution. Clin Biomech (Bristol, Avon) 58:14–20. https://doi.org/10.1016/j.clinbiomech.2018.07.006

    Article  Google Scholar 

  10. Chambers B, St Clair SF, Froimson MI (2007) Hydroxyapatite-coated tapered cementless femoral components in total hip arthroplasty. J Arthroplasty 22(4 Suppl 1):71–74. https://doi.org/10.1016/j.arth.2007.01.019

    Article  PubMed  Google Scholar 

  11. Al-Dirini RMA, O'Rourke D, Huff D, Martelli S, Taylor M (2018) Biomechanical robustness of a contemporary cementless stem to surgical variation in stem size and position. J Biomech Eng. https://doi.org/10.1115/1.4039824

    Article  PubMed  Google Scholar 

  12. Jahnke A, Wiesmair AK, Fonseca Ulloa CA, Ahmed GA, Rickert M, Ishaque BA (2020) Outcome of short- to medium-term migration analysis of a cementless short stem total hip arthroplasty using EBRA-FCA: a radiological and clinical study. Arch Orthop Trauma Surg 140(2):247–253. https://doi.org/10.1007/s00402-019-03315-3

    Article  PubMed  Google Scholar 

  13. Louboutin L, Viste A, Desmarchelier R, Fessy MH (2017) Long-term survivorship of the Corail standard stem. Orthop Traumatol Surg Res 103(7):987–992. https://doi.org/10.1016/j.otsr.2017.06.010

    Article  CAS  PubMed  Google Scholar 

  14. Boldt JG, Cartillier JC, Machenaud A, Vidalain JP (2015) Long-term bone remodeling in HA-coated stems: a radiographic review of 208 total hip arthroplasties (THAs) with 15–20 years follow-up. Surg Technol Int 27:279–286

    PubMed  Google Scholar 

  15. Hailer NP, Lazarinis S, Makela KT, Eskelinen A, Fenstad AM, Hallan G, Havelin L, Overgaard S, Pedersen AB, Mehnert F, Karrholm J (2015) Hydroxyapatite coating does not improve uncemented stem survival after total hip arthroplasty! Acta Orthop 86(1):18–25. https://doi.org/10.3109/17453674.2014.957088

    Article  PubMed  PubMed Central  Google Scholar 

  16. Lazarinis S, Makela KT, Eskelinen A, Havelin L, Hallan G, Overgaard S, Pedersen AB, Karrholm J, Hailer NP (2017) Does hydroxyapatite coating of uncemented cups improve long-term survival? An analysis of 28,605 primary total hip arthroplasty procedures from the Nordic Arthroplasty Register Association (NARA). Osteoarthritis Cartilage 25(12):1980–1987. https://doi.org/10.1016/j.joca.2017.08.001

    Article  CAS  PubMed  Google Scholar 

  17. Batailler C, Fary C, Servien E, Lustig S (2018) Influence of femoral broach shape on stem alignment using anterior approach for total hip arthroplasty: a radiologic comparative study of 3 different stems. PLoS ONE 13(10):e0204591. https://doi.org/10.1371/journal.pone.0204591

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  18. Murphy CG, Bonnin MP, Desbiolles AH, Carrillon Y, Aїt Si Selmi T (2016) Varus will have varus; a radiological study to assess and predict varus stem placement in uncemented femoral stems. Hip Int 26(6):554–560. https://doi.org/10.5301/hipint.5000412

    Article  PubMed  Google Scholar 

  19. Thaler M, Lechner R, Putzer D, Mayr E, Huber DC, Liebensteiner MC, Nogler M (2018) Two-year gait analysis controls of the minimally invasive total hip arthroplasty by the direct anterior approach. Clin Biomech (Bristol, Avon) 58:34–38. https://doi.org/10.1016/j.clinbiomech.2018.06.018

    Article  Google Scholar 

  20. Nogler M, Krismer M, Hozack WJ, Merritt P, Rachbauer F, Mayr E (2006) A double offset broach handle for preparation of the femoral cavity in minimally invasive direct anterior total hip arthroplasty. J Arthroplasty 21(8):1206–1208. https://doi.org/10.1016/j.arth.2006.08.003

    Article  PubMed  Google Scholar 

  21. Bjordal F, Bjorgul K (2015) The role of femoral offset and abductor lever arm in total hip arthroplasty. J Orthop Traumatol 16(4):325–330. https://doi.org/10.1007/s10195-015-0358-7

    Article  PubMed  PubMed Central  Google Scholar 

  22. Holzer LA, Scholler G, Wagner S, Friesenbichler J, Maurer-Ertl W, Leithner A (2019) The accuracy of digital templating in uncemented total hip arthroplasty. Arch Orthop Trauma Surg 139(2):263–268. https://doi.org/10.1007/s00402-018-3080-0

    Article  PubMed  Google Scholar 

  23. Cech A, Kase M, Kobayashi H, Pagenstert G, Carrillon Y, O'Loughlin PF, Ait-Si-Selmi T, Bothorel H, Bonnin MP (2020) Pre-operative planning in THA. Part III: do implant size prediction and offset restoration influence functional outcomes after THA? Arch Orthop Trauma Surg. https://doi.org/10.1007/s00402-020-03342-5

    Article  PubMed  Google Scholar 

  24. Haversath M, Wendelborn C, Jager M, Schmidt B, Kowalczyk W, Landgraeber S (2017) Geometric analysis and clinical outcome of two cemented stems for primary total hip replacement with and without modular necks. Arch Orthop Trauma Surg 137(11):1571–1578. https://doi.org/10.1007/s00402-017-2785-9

    Article  PubMed  Google Scholar 

  25. Worlicek M, Weber M, Worner M, Schwarz T, Zeman F, Grifka J, Renkawitz T, Craiovan B (2018) The final implant position of a commonly used collarless straight tapered stem design (Corail((R))) does not correlate with femoral neck resection height in cement-free total hip arthroplasty: a retrospective computed tomography analysis. J Orthop Traumatol 19(1):20. https://doi.org/10.1186/s10195-018-0513-z

    Article  PubMed  PubMed Central  Google Scholar 

  26. Kase M, O'Loughlin PF, Ait-Si-Selmi T, Pagenstert G, Langlois J, Bothorel H, Bonnin MP (2020) Pre-operative templating in THA. Part I: a classification of architectural hip deformities. Arch Orthop Trauma Surg. 140(1):129–137. https://doi.org/10.1007/s00402-019-03298-1

    Article  PubMed  Google Scholar 

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Acknowledgements

One of the authors is a consultant at Microport Orthopedics and Wright Medical. The authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript.

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Authors and Affiliations

  1. Department of Orthopaedics, St. Vinzenz-Krankenhaus, Schloßstraße 85, 40477, Düsseldorf, Germany

    Marcel Haversath, Sebastian Serong & Stefan Landgraeber

  2. Medical Faculty, University of Duisburg-Essen, Hufelandstraße 55, 45122, Essen, Germany

    Martin Lichetzki

  3. Department of Orthopaedics and Orthopaedic Surgery, Saarland University, Homburg, Germany

    Sebastian Serong & Stefan Landgraeber

  4. Department of Orthopaedics, Trauma and Reconstructive Surgery, St. Marien-Hospital Mülheim a.d. Ruhr, 45468, Mülheim an der Ruhr, Germany

    André Busch & Marcus Jäger

  5. Gelenkzentrum Bergisch Land, Freiheitstraße 203, 42853, Remscheid, Germany

    Tjark Tassemeier

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  1. Marcel Haversath
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Correspondence to Marcel Haversath.

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Ethical approval was obtained from the local ethics committee for this retrospective study (Reference: 16–6828-BO).

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Haversath, M., Lichetzki, M., Serong, S. et al. The direct anterior approach provokes varus stem alignment when using a collarless straight tapered stem. Arch Orthop Trauma Surg 141, 891–897 (2021). https://doi.org/10.1007/s00402-020-03457-9

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  • DOI: https://doi.org/10.1007/s00402-020-03457-9

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