Dislocation Rates following Anterior Approach THA: The Role of Functional Pelvic Tilt

Abstract

Various target zones for acetabular cup placement have been suggested to minimize dislocation following total hip arthroplasty (THA), though dislocations occur despite proper positioning. The authors have reported accuracy of fluoroscopic guidance in cup positioning during direct anterior approach (DAA) THA when using a standardized fluoroscopic technique functional pelvic tilt. They believe that cup placement with regard to functional pelvic tilt, rather than static reference frames, will offer improved stability. A cohort of 1,597 fluoroscopy-assisted DAA primary unilateral THA patients was prospectively followed for a minimum of 1 year and component position measured radiographically. Target cup position was based off the standing anteroposterior pelvis while using conventional safe zone parameters. Dislocation rate was assessed. Average follow-up was 13.1 months (range 1–6 years). The mean abduction angle was 37.7° and the mean anteversion angle was 16.2°. Overall, 1,517 (95.0%) fell within the targeted abduction range, 1,528 (95.7%) fell within the targeted anteversion range, and 1,456 (91.2%) simultaneously met both criteria. There were nine dislocations, eight within the combined safe zone, for a dislocation rate of 0.56%. Fluoroscopy can improve accuracy and precision of cup placement in DAA THA. Conventional safe zone parameters applied using functional pelvic tilt resulted in a low dislocation rate, with most dislocations occurring within the safe zone. Using a dynamic functional safe zone may further reduce dislocation rates after DAA THA, though other factors that contribute to instability must be accounted for in future studies. This study had a III level of evidence.

Keywords

accuracy - complication - component position - fluoroscopy - hip arthroplasty

• References

• 1 Barrack RL, Krempec JA, Clohisy JC. , et al. Accuracy of acetabular component position in hip arthroplasty. J Bone Joint Surg Am 2013; 95 (19) 1760-1768
• 2 Scheerlinck T. Cup positioning in total hip arthroplasty. Acta Orthop Belg 2014; 80 (03) 336-347
• 3 Paterno SA, Lachiewicz PF, Kelley SS. The influence of patient-related factors and the position of the acetabular component on the rate of dislocation after total hip replacement. J Bone Joint Surg Am 1997; 79 (08) 1202-1210
• 4 Higa M, Tanino H, Abo M, Kakunai S, Banks SA. Effect of acetabular component anteversion on dislocation mechanisms in total hip arthroplasty. J Biomech 2011; 44 (09) 1810-1813
• 5 Kwon MS, Kuskowski M, Mulhall KJ, Macaulay W, Brown TE, Saleh KJ. Does surgical approach affect total hip arthroplasty dislocation rates?. Clin Orthop Relat Res 2006; 447 (447) 34-38
• 6 Rathod PA, Bhalla S, Deshmukh AJ, Rodriguez JA. Does fluoroscopy with anterior hip arthroplasty decrease acetabular cup variability compared with a nonguided posterior approach?. Clin Orthop Relat Res 2014; 472 (06) 1877-1885
• 7 Callanan MC, Jarrett B, Bragdon CR. , et al. The John Charnley Award: risk factors for cup malpositioning: quality improvement through a joint registry at a tertiary hospital. Clin Orthop Relat Res 2011; 469 (02) 319-329
• 8 Yoon Y-S, Hodgson AJ, Tonetti J, Masri BA, Duncan CP. Resolving inconsistencies in defining the target orientation for the acetabular cup angles in total hip arthroplasty. Clin Biomech (Bristol, Avon) 2008; 23 (03) 253-259
• 9 Lewinnek GE, Lewis JL, Tarr R, Compere CL, Zimmerman JR. Dislocations after total hip-replacement arthroplasties. J Bone Joint Surg Am 1978; 60 (02) 217-220
• 10 Timperley AJ, Biau D, Chew D, Whitehouse SL. Dislocation after total hip replacement - there is no such thing as a safe zone for socket placement with the posterior approach. Hip Int 2016; 26 (02) 121-127
• 11 Abdel MP, von Roth P, Jennings MT, Hanssen AD, Pagnano MW. What safe zone? The vast majority of dislocated THAs are within the Lewinnek safe zone for acetabular component position. Clin Orthop Relat Res 2016; 474 (02) 386-391
• 12 Seagrave KG, Troelsen A, Malchau H, Husted H, Gromov K. Acetabular cup position and risk of dislocation in primary total hip arthroplasty. Acta Orthop 2017; 88 (01) 10-17
• 13 Ng VY, McShane MA. Understanding acetabular cup orientation: the importance of convention and defining the safe zone. Hip Int 2011; 21 (06) 646-652
• 14 Murray DW. The definition and measurement of acetabular orientation. J Bone Joint Surg Br 1993; 75 (02) 228-232
• 15 Philippot R, Wegrzyn J, Farizon F, Fessy MH. Pelvic balance in sagittal and Lewinnek reference planes in the standing, supine and sitting positions. Orthop Traumatol Surg Res 2009; 95 (01) 70-76
• 16 Babisch JW, Layher F, Amiot L-P. The rationale for tilt-adjusted acetabular cup navigation. J Bone Joint Surg Am 2008; 90 (02) 357-365
• 17 Lembeck B, Mueller O, Reize P, Wuelker N. Pelvic tilt makes acetabular cup navigation inaccurate. Acta Orthop 2005; 76 (04) 517-523
• 18 Ross JR, Tannenbaum EP, Nepple JJ, Kelly BT, Larson CM, Bedi A. Functional acetabular orientation varies between supine and standing radiographs: implications for treatment of femoroacetabular impingement. Clin Orthop Relat Res 2015; 473 (04) 1267-1273
• 19 Eilander W, Harris SJ, Henkus HE, Cobb JP, Hogervorst T. Functional acetabular component position with supine total hip replacement. Bone Joint J 2013; 95-B (10) 1326-1331
• 20 Pullen WM, Henebry A, Gaskill T. Variability of acetabular coverage between supine and weightbearing pelvic radiographs. Am J Sports Med 2014; 42 (11) 2643-2648
• 21 Phan D, Bederman SS, Schwarzkopf R. The influence of sagittal spinal deformity on anteversion of the acetabular component in total hip arthroplasty. Bone Joint J 2015; 97-B [phone]
• 22 Slotkin EM, Patel PD, Suarez JC. Accuracy of fluoroscopic guided acetabular component positioning during direct anterior total hip arthroplasty. J Arthroplasty 2015; 30 (9, Suppl): 102-106
• 23 Ji W, Stewart N. Fluoroscopy assessment during anterior minimally invasive hip replacement is more accurate than with the posterior approach. Int Orthop 2016; 40 (01) 21-27
• 24 Maratt JD, Gagnier JJ, Butler PD, Hallstrom BR, Urquhart AG, Roberts KC. No difference in dislocation seen in anterior vs posterior approach total hip arthroplasty. J Arthroplasty 2016; 31 (9, Suppl): 127-130
• 25 Matta JM, Shahrdar C, Ferguson T. Single-incision anterior approach for total hip arthroplasty on an orthopaedic table. Clin Orthop Relat Res 2005; 441 (441) 115-124
• 26 Tripuraneni KR, Munson NR, Archibeck MJ, Carothers JT. Acetabular abduction and dislocations in direct anterior vs posterior total hip arthroplasty: a retrospective, matched cohort study. J Arthroplasty 2016; 31 (10) 2299-2302
• 27 Sierra RJ, Raposo JM, Trousdale RT, Cabanela ME. Dislocation of primary THA done through a posterolateral approach in the elderly. Clin Orthop Relat Res 2005; 441 (441) 262-267
• 28 Masonis JL, Bourne RB. Surgical approach, abductor function, and total hip arthroplasty dislocation. Clin Orthop Relat Res 2002; (405) 46-53
• 29 Tannast M, Langlotz F, Kubiak-Langer M, Langlotz U, Siebenrock K-A. Accuracy and potential pitfalls of fluoroscopy-guided acetabular cup placement. Comput Aided Surg 2005; 10 (5-6): 329-336
• 30 Bedard NA, Martin CT, Slaven SE, Pugely AJ, Mendoza-Lattes SA, Callaghan JJ. Abnormally high dislocation rates of total hip arthroplasty after spinal deformity surgery. J Arthroplasty 2016; 31 (12) 2884-2885
• 31 Masonis J, Thompson C, Odum S. Safe and accurate: learning the direct anterior total hip arthroplasty. Orthopedics 2008; 31(12, Suppl 2). orthosupersite.com/view.asp?rID=37187
• 32 Jennings JD, Iorio J, Kleiner MT, Gaughan JP, Star AM. Intraoperative fluoroscopy improves component position during anterior hip arthroplasty. Orthopedics 2015; 38 (11) e970-e975
• 33 Beamer BS, Morgan JH, Barr C, Weaver MJ, Vrahas MS. Does fluoroscopy improve acetabular component placement in total hip arthroplasty?. Clin Orthop Relat Res 2014; 472 (12) 3953-3962
• 34 Danoff JR, Bobman JT, Cunn G. , et al. Redefining the acetabular component safe zone for posterior approach total hip arthroplasty. J Arthroplasty 2016; 31 (02) 506-511
• 35 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 (05) 530-534
• 36 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 (11) 2895-2900
• 37 Tezuka T, Inaba Y, Kobayashi N. , et al. Influence of pelvic tilt on polyethylene wear after total hip arthroplasty. BioMed Res Int 2015; 2015: 327217
• 38 Daniel M, Rijavec B, Dolinar D, Pokorný D, Iglič A, Kralj-Iglič V. Patient-specific hip geometry has greater effect on THA wear than femoral head size. J Biomech 2016; 49 (16) 3996-4001