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Does Fluoroscopy With Anterior Hip Arthoplasty Decrease Acetabular Cup Variability Compared With a Nonguided Posterior Approach?

  • Clinical Research
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

The direct anterior approach for THA offers some advantages, but is associated with a significant learning curve. Some of the technical difficulties can be addressed by the use of intraoperative fluoroscopy which may improve the accuracy of acetabular component placement.

Questions/purposes

The purposes of this study were to determine if (1) there is decreased variability of acetabular cup inclination and anteversion with the direct anterior approach using fluoroscopic guidance as compared with the posterior approach THA without radiographic guidance; (2) if there is a learning curve associated with achieving accuracy with the direct anterior approach THA. We also wanted (3) to assess the frequency of complications including dislocation with the anterior approach, which initially had a learning curve, and the posterior approach.

Methods

This retrospective, comparative study of 825 THAs (372 posterior THAs without fluoroscopic guidance and 453 direct anterior THAs, performed by one surgeon, focused on a radiographic analysis to determine cup inclination and anteversion on standardized pelvic radiographs using specialized software. The first 100 direct anterior THAs performed while transitioning from the posterior approach to the direct anterior approach were included in the learning curve group. During this learning curve period, the direct anterior approach was used for all patients except those with conversion of previously fixed intertrochanteric or femoral neck fractures to THAs, gluteus medius tears, and obese patients with an immobile abdominal pannus (100 of 127 THAs). Variability of the acetabular component was compared among the posterior group, learning curve group, and direct anterior group.

Results

Variances for cup inclination and anteversion were significantly lower in the direct anterior group (19 and 16 respectively, p < 0.01) as compared with the posterior group (50 and 79 respectively).Target inclination and anteversion were achieved better in the direct anterior group (98% and 97% respectively) as compared with the posterior group (86% and 77% respectively) (p < 0.01, OR for inclination = 9.1, 95% CI, 3.5 to 23.4; OR for anteversion = 8, 95% CI, 4 to 16). In the learning curve group, target anteversion achieved (91% of cases) was marginally lower than that of the direct anterior group (p = 0.03; OR = 2.9, 95% CI, 1.1 to 7.3) and target inclination (95%) was similar (p = 0.13). There was one posterior dislocation in the posterior group, two anterior dislocations in the learning curve group, and none in the direct anterior group.

Conclusions

Use of fluoroscopy with the patient in the supine position during direct anterior THA enables intraoperative assessment of cup orientation resulting in decreased variability of acetabular cup anteversion. However, there is a learning curve associated with achieving this accuracy. We could not discern whether this difference was the result of the approach or the use of fluoroscopy in the direct anterior group.

Level of Evidence

Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

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References

  1. Barrett WP, Turner SE, Leopold JP. Prospective randomized study of direct anterior vs postero-lateral approach for total hip arthroplasty. J Arthroplasty. 2013;28:1634–1638.

    Article  PubMed  Google Scholar 

  2. Biedermann R, Tonin A, Krismer M, Rachbauer F, Eibl G, Stöckl B. Reducing the risk of dislocation after total hip arthroplasty: the effect of orientation of the acetabular component. J Bone Joint Surg Br. 2005;87:762–769.

    Article  CAS  PubMed  Google Scholar 

  3. De Geest T, Vansintjan P, De Loore G. Direct anterior total hip arthroplasty: complications and early outcome in a series of 300 cases. Acta Orthop Belg. 2013;79:166–173.

    PubMed  Google Scholar 

  4. D’Lima DD, Urquhart AG, Buehler KO, Walker RH, Colwell CW Jr. The effect of the orientation of the acetabular and femoral components on the range of motion of the hip at different head-neck ratios. J Bone Joint Surg Am. 2000;82:315–321.

    PubMed  Google Scholar 

  5. Eddine TA, Migaud H, Chantelot C, Cotten A, Fontaine C, Duquennoy A. Variations of pelvic anteversion in the lying and standing positions: analysis of 24 control subjects and implications for CT measurement of position of a prosthetic cup. Surg Radiol Anat. 2001;23:105–110.

    Article  CAS  PubMed  Google Scholar 

  6. Jolles BM, Zangger P, Leyvraz PF. Factors predisposing to dislocation after primary total hip arthroplasty: a multivariate analysis. J Arthroplasty. 2002;17:282–288.

    Article  CAS  PubMed  Google Scholar 

  7. Kennedy JG, Rogers WB, Soffe KE, Sullivan RJ, Griffen DG, Sheehan LJ. Effect of acetabular component orientation on recurrent dislocation, pelvic osteolysis, polyethylene wear, and component migration. J Arthroplasty. 1998;13:530–534.

    Article  CAS  PubMed  Google Scholar 

  8. Klausmeier V, Lugade V, Jewett BA, Collis DK, Chou LS. Is there faster recovery with an anterior or anterolateral THA? A pilot study. Clin Orthop Relat Res. 2010;468:533–541.

    Article  PubMed Central  PubMed  Google Scholar 

  9. Leenders T, Vandevelde D, Mahieu G, Nuyts R. Reduction in variability of acetabular cup abduction using computer assisted surgery: a prospective and randomized study. Comput Aided Surg. 2002;7:99–106.

    Article  CAS  PubMed  Google Scholar 

  10. 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.

    CAS  PubMed  Google Scholar 

  11. Liaw CK, Yang RS, Hou SM, Wu TY, Fuh CS. Measurement of the acetabular cup anteversion on simulated radiographs. J Arthroplasty. 2009;24:468–474.

    Article  PubMed  Google Scholar 

  12. Little NJ, Busch CA, Gallagher JA, Rorabeck CH, Bourne RB. Acetabular polyethylene wear and acetabular inclination and femoral offset. Clin Orthop Relat Res. 2009;467:2895–2900.

    Article  PubMed Central  PubMed  Google Scholar 

  13. Lovell TP. Single-incision direct anterior approach for total hip arthroplasty using a standard operating table. J Arthroplasty. 2008;23(7 suppl):64–68.

    Article  PubMed  Google Scholar 

  14. Matta JM, Shahrdar C, Ferguson T. Single-incision anterior approach for total hip arthroplasty on an orthopaedic table. Clin Orthop Relat Res. 2005;441:115–124.

    Article  PubMed  Google Scholar 

  15. McCollum DE, Gray WJ. Dislocation after total hip arthroplasty: causes and prevention. Clin Orthop Relat Res. 1990;261:159–170.

    PubMed  Google Scholar 

  16. Nho JH, Lee YK, Kim HJ, Ha YC, Suh YS, Koo KH. Reliability and validity of measuring version of the acetabular component. J Bone Joint Surg Br. 2012;94:32–36.

    Article  PubMed  Google Scholar 

  17. Nishikubo Y, Fujioka M, Ueshima K, Saito M, Kubo T. Preoperative fluoroscopic imaging reduces variability of acetabular component positioning. J Arthroplasty. 2011;26:1088–1094.

    Article  PubMed  Google Scholar 

  18. Ranawat CS, Maynard MJ. Modern techniques of cemented total hip arthroplasty. Techniques Orthop. 1991;6:17–25.

    Article  Google Scholar 

  19. Ranawat CS, Ranawat AS, Rasquinha VJ. Mastering the art of cemented femoral stem fixation. J Arthroplasty. 2004;19(4 suppl 1):85–91.

    Article  PubMed  Google Scholar 

  20. Ranawat CS, Rao RR, Rodriguez JA, Bhende HS. Correction of limb-length inequality during total hip arthroplasty. J Arthroplasty. 2001;16:715–720.

    Article  CAS  PubMed  Google Scholar 

  21. Restrepo C, Parvizi J, Pour AE, Hozack WJ. Prospective randomized study of two surgical approaches for total hip arthroplasty. J Arthroplasty. 2010;25:671–679.

    Article  PubMed  Google Scholar 

  22. Rodriguez JA, Deshmukh AJ, Rathod PA, Greiz ML, Deshmane PP, Hepinstall MS, Ranawat AS. Does the direct anterior approach in THA offer faster rehabilitation and comparable safety to the posterior approach? Clin Orthop Relat Res. 2013;472:455–463.

    Article  Google Scholar 

  23. Rüdiger HA, Betz M, Zingg PO, McManus J, Dora CF. Outcome after proximal femoral fractures during primary total hip replacement by the direct anterior approach. Arch Orthop Trauma Surg. 2013;133:569–573.

    Article  PubMed  Google Scholar 

  24. Saxler G, Marx A, Vandevelde D, Langlotz U, Tannast M, Wiese M, Michaelis U, Kemper G, Grützner PA, Steffen R, von Knoch M, Holland-Letz T, Bernsmann K. The accuracy of free-hand cup positioning: a CT based measurement of cup placement in 105 total hip arthroplasties. Int Orthop. 2004;28:198–201.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  25. Siguier T, Siguier M, Brumpt B. Mini-incision anterior approach does not increase dislocation rate: a study of 1037 total hip replacements. Clin Orthop Relat Res. 2004;426:164–173.

    Article  PubMed  Google Scholar 

  26. Woolson ST, Pouliot MA, Huddleston JI. Primary total hip arthroplasty using an anterior approach and a fracture table: short-term results from a community hospital. J Arthroplasty. 2009;24:999–1005.

    Article  PubMed  Google Scholar 

  27. Zhu J, Wan Z, Dorr LD. Quantification of pelvic tilt in total hip arthroplasty. Clin Orthop Relat Res. 2010;468:571–575.

    Article  PubMed Central  PubMed  Google Scholar 

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Authors and Affiliations

  1. Center for Joint Preservation & Reconstruction, NorthshoreLIJ/Lenoxhill Hospital, 130 E 77th Street, 11th Floor, New York, NY, 10075, USA

    Parthiv A. Rathod MD, Sean Bhalla BS, Ajit J. Deshmukh MD & Jose A. Rodriguez MD

Authors
  1. Parthiv A. Rathod MD
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  2. Sean Bhalla BS
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  3. Ajit J. Deshmukh MD
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  4. Jose A. Rodriguez MD
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Correspondence to Parthiv A. Rathod MD.

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Each author certifies that he or she, or a member of his or her immediate family, has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.

Each author certifies that his or her institution approved the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research.

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Rathod, P.A., Bhalla, S., Deshmukh, A.J. et al. Does Fluoroscopy With Anterior Hip Arthoplasty Decrease Acetabular Cup Variability Compared With a Nonguided Posterior Approach?. Clin Orthop Relat Res 472, 1877–1885 (2014). https://doi.org/10.1007/s11999-014-3512-2

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  • DOI: https://doi.org/10.1007/s11999-014-3512-2

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