An In Vivo Model for Intraoperative Assessment of Impingement and Dislocation in Total Hip Arthroplasty

doi:10.1016/j.arth.2007.07.004

The Journal of Arthroplasty

Volume 23, Issue 5, August 2008, Pages 714-720

https://doi.org/10.1016/j.arth.2007.07.004 Get rights and content

Abstract

We have developed an intraoperative model to quantify total hip arthroplasty impingement and dislocation mechanics using fluoroscopy and shape-matching techniques. Two patient groups were investigated: group 1 consisted of 12 hips using 28- or 32-mm femoral heads and an anterolateral surgical approach, and group 2 consisted of 17 hips using 22- or 26-mm femoral heads and a posterolateral surgical approach. During intraoperative hip stability testing consisting of extension and external rotation motions, group 1 was more unstable, and prosthetic impingement was the major reason for dislocation. With flexion and internal rotation motions, group 2 was more unstable, and superior-lateral impingement or soft tissue traction was the major reason for dislocation. Intraoperative quantitative assessment of hip mechanics provides a safe and clinically relevant method to characterize potential complications and evolve techniques to prevent them.

Section snippets

Methods

Twenty-nine patients with 29 THAs were studied. All patients provided written informed consent and the study protocol was approved by the institutional review board. The average patient age was 62 years (range, 51-84 years); 20 of the patients were women and 9 were men, with a total of 12 right hips and 17 left hips. Arthroplasties were performed by 2 surgeons, one in North America (group 1) and one in Asia (group 2). Group 1 included 12 hips, used 3 designs of cementless femoral components;

Results

From 29 cases, it was possible for 20 hips to subluxate or dislocate during the intraoperative hip stability testing motions. With hip extension and external rotation, 58% of group 1 (7 hips) showed subluxations or dislocations, and 0% in group 2 (Fig. 1). Analyses of the fluoroscopic data showed COR between the stem and cup moved from the center of the cup to a point near the edge of the cup in all cases of subluxation/dislocations with hip extension and external rotation (7/7 cases) (Fig. 2,

Discussion

An intraoperative in vivo model for studying hip arthroplasty impingement and dislocation has been developed, and the influence of surgical approach was evaluated. This study used fluoroscopy to measure 3-dimensional hip kinematics, to detect prosthetic impingement, and to identify the impingement site between the stem neck and liner rim. The calculated 15, 16 instantaneous COR of the femoral component relative to the acetabular component was used to describe the fulcrum point for subluxation

Acknowledgment

The authors thank the following individuals for participating in the planning, conduct, data analysis, and patient recruitment: Toshiki Nakamura, Koichi Kuramoto, and Haruhiko Ishizaka.

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Cited by (29)

Computer simulation based on in vivo kinematics of a replaced hip during chair-rising for elucidating target cup and stem positioning with a safety range of hip rotation
2022, Clinical Biomechanics
Background
After total hip arthroplasty, dislocation can occur when a patient unexpectedly assumes internal/external limb positions, even during chair-rising, which is a frequently activity of daily life. Therefore, determining the target cup position to avoid impingement in unexpected limb positions using in vivo data of daily life activities is critical.
Methods
A computer simulation was performed on 21 total hip arthroplasty patients using patient-specific component placements and hip kinematics obtained during chair-rising analysis using image-matching techniques. The liner-to-neck distance and impingement were evaluated by simulating the change in internal/external rotation angle at maximum hip flexion/extension from 0 to 90°. The cutoff values of cup anteversion and combined anteversion at 60° of internal/external rotation were determined.
Findings
The anterior/posterior liner-to-neck distances were negatively correlated with internal/external rotation angles (r = −0.82 and −0.78, respectively) and decreased by 1.7 and 1.8 mm for every 15° increase, respectively. Three cases (14%) of anterior/posterior impingement were observed at 60° of internal/external rotation angle, respectively. The cutoff values for cup anteversion and combined anteversion to avoid impingement at 60° of internal/external rotation angle were 12°–25°/38°–62°, respectively. The stem anteversion, adjustable by cup anteversion to meet both the target cup anteversion and combined anteversion, was 13°–50°.
Interpretation
Simulated unintentional internal or external hip rotation, even during chair-rising, caused impingement and posed a dislocation risk. If the stem anteversion is excessively small or large in meeting the target combined anteversion, adjustments to stem anteversion could be recommended in addition to adjustments in cup anteversion.
Determining 3D Kinematics of the Hip Using Video Fluoroscopy: Guidelines for Balancing Radiation Dose and Registration Accuracy
2017, Journal of Arthroplasty
Video fluoroscopy is a technique currently used to retrieve the in vivo three-dimensional kinematics of human joints during activities of daily living. Minimization of the radiation dose absorbed by the subject during the measurement is a priority and has not been thoroughly addressed so far. This issue is critical for the motion analysis of the hip joint, because of the proximity of the gonads. The aims of this study were to determine the x-ray voltage and the irradiation angle that minimize the effective dose and to achieve the best compromise between delivered dose and accuracy in motion retrieval.
Effective dose for a fluoroscopic study of the hip was estimated by means of Monte Carlo simulations and dosimetry measurements. Accuracy in pose retrieval for the different viewing angles was evaluated by registration of simulated radiographs of a hip prosthesis during a prescribed virtual motion.
Absorbed dose can be minimized to about one-sixth of the maximum estimated values by irradiating at the optimal angle of 45° from the posterior side and by operating at 80 kV. At this angle, accuracy in retrieval of internal-external rotation is poorer compared with the other viewing angles.
The irradiation angle that minimizes the delivered dose does not necessarily correspond to the optimal angle for the accuracy in pose retrieval, for all rotations. For some applications, single-plane fluoroscopy may be a valid lower dose alternative to the dual-plane methods, despite their better accuracy.
Dynamic hip kinematics in patients with hip osteoarthritis during weight-bearing activities
2016, Clinical Biomechanics
Citation Excerpt :
Our previous study demonstrated activity-dependent kinematics of healthy hip joints with coordinated pelvic and femoral dynamic movements (Hara et al., 2014) (e.g. maximum hip flexion angles during chair-rising and squatting: 81° and 102° on average, respectively). On the other hand, hip kinematics in patients after THA showed smaller hip flexion angles than those in healthy subjects (Koyanagi et al., 2011; Tanino et al., 2008; Tsai et al., 2013) (e.g. maximum hip flexion angles during squatting: 86° on average). Previous gait analyses using optical motion capture revealed significantly reduced hip flexion angles in patients with OA of the hip (Eitzen et al., 2012; Kubota et al., 2007).
There is an interest in quantifying the hip kinematics of patients with end-stage hip disorders before total hip arthroplasty. The purpose of the present study was to obtain dynamic hip kinematics under four different conditions, including deep flexion and rotation, in patients with osteoarthritis of the hip.
Continuous X-ray images were obtained in 14 patients during gait, chair-rising, squatting, and twisting, using a flat panel X-ray detector. These patients received computed tomography scan to generate virtual digitally reconstructed radiographs. The density-based digitally reconstructed radiographs were then compared with the serial X-ray images acquired using image correlations. These 3D-to-2D model-to-image registration techniques determined the 3D positions and orientations of the pelvis and femur during the movement cycle of each activity.
For gait, chair-rising, and squatting, the maximum hip flexion angles averaged 22°, 64°, and 68°, respectively. The pelvis was tilted anteriorly by an average of around 7° during the full gait cycle. For chair-rising and squatting, the maximum absolute values of anterior/posterior pelvic tilt averaged 8°/17° and 6°/18°, respectively. Hip flexion showed maximum flexion angle on the way of movement due to further anterior pelvic tilt during both chair-rising and squatting. For twisting, the maximum absolute values of internal/external hip rotation averaged 3°/13°.
Patients with hip osteoarthritis prior to total hip arthroplasty demonstrated the limited ranges of coordinated motion of the pelvis, femur, and hip joint during each activity, especially in deeply flexed and rotated postures.
A novel dual fluoroscopic imaging method for determination of THA kinematics: In-vitro and in-vivo study
2013, Journal of Biomechanics
Citation Excerpt :
Medical imaging techniques provide a non-invasive way to determine the poses of the implants directly without the interference of soft tissue artifacts. Two-dimensional to three-dimensional (2D-to-3D) registration techniques with single fluoroscopic system and models of implants were proposed to measure in-vivo kinematics of the THA during functional activities to examine the implant impingement, subluxation and dislocation (Dennis et al., 2001; Komistek et al., 2002; Koyanagi et al., 2011; Lombardi et al., 2000; Tanino et al., 2008). The radiostereometric analysis (RSA) (Selvik, 1990) is an alternative medical imaging technique for in-vivo joint kinematics measurement by tracking roentgen opaque markers embedded in the bones.
Accurate measurement of six-degrees-of-freedom in-vivo kinematics of the total hip arthroplasty (THA) is essential in gaining insights into in-vivo THA performance. The objective of this study was to validate a novel dual fluoroscopy imaging system (DFIS) for determination of the THA kinematics using both in-vitro and in-vivo approaches. The in-vitro validation utilized cadaveric hip specimens to compare the THA motion using the DFIS technique with those measured by a radiostereometric analysis (RSA). The differences between the DFIS technique and the RSA were within 0.33±0.81 mm (mean±SD) in translation and 0.45±0.65° in rotation during dynamic motion of the hips. In the in-vivo validation, the THA kinematics of two patients during a treadmill gait was assessed for the feasibility/repeatability of the DFIS technique in measurement of THA kinematics. The poses of the THAs during the treadmill gait was measured using the DFIS technique with the maximum standard deviation of 0.35 mm in translation and of 0.55° in rotation. This study demonstrated that the DFIS technique has comparable accuracy of the RSA and is highly repeatable for measurement of dynamic THA motion, suggesting that the DFIS is a promising tool in evaluating the in-vivo THA biomechanics during functional activities.
Effect of acetabular component anteversion on dislocation mechanisms in total hip arthroplasty
2011, Journal of Biomechanics
Citation Excerpt :
Bartz et al. (2000) investigated dislocation mechanisms using in vitro cadaver simulations with load cables to simulate muscle tractions and they reported spontaneous dislocation occurring without impingement. Similarly, an in vivo intraoperative study suggested that soft-tissue traction could be a major cause of subluxation or dislocation with hip flexion and internal rotation (Tanino et al., 2008). Such findings suggest that soft tissues might play an important role in dislocation after THA.
Quantifying soft-tissue tension around the hip joint during total hip arthroplasty remains difficult. In this study, a three-dimensional computer-aided design model was developed to clarify how component position in total hip arthroplasty contributes to the primary cause of posterior dislocation in cases of flexion, adduction and internal rotation. To better understand the influences of anteversion angle of the acetabular component, its effects on the primary causes of dislocations and the range of motion were investigated. Three different primary dislocation mechanisms were noted: impingement of the prosthetic femoral neck on the cup liner; impingement of the osseous femur on the osseous pelvis; and spontaneous dislocation caused by soft-tissue traction without impingement. Spontaneous dislocation could be detected by calculating hip forces at any thigh position using the computer-aided design model developed. In computer analysis, a transition from prosthetic impingement rate to osseous impingement rate occurred with increasing anteversion angle of the acetabular component. Spontaneous dislocation was detected at angles >10° of anteversion of the acetabular component when flexion occurred with extreme adduction and internal rotation. This study demonstrated the possibility of spontaneous dislocation that results not from prosthetic or bony impingement but from muscle traction with increased range of motion.
In vivo kinematic analysis of squatting after total hip arthroplasty
2011, Clinical Biomechanics
Citation Excerpt :
The basic principle of a 2D/3D registration technique is to match the 3D model of components of a total joint arthroplasty with known shapes and sizes to projected two-dimensional (2D) images in order to determine the six degrees of freedom (6-DOF), position and orientation (3D pose) of the components. The in vivo kinematics of the hip after THA have been evaluated using 2D/3D registration techniques by examining separation during gait on a treadmill and an abduction/adduction leg-lift maneuver (Lombardi et al., 2000; Komistek et al., 2006), sound during gait on a treadmill (Glaser et al., 2008), and intra-operative stability tests (Tanino et al., 2008). However, the in vivo 3D kinematics of squatting after THA remains unclear.
The in vivo kinematics of squatting after total hip arthroplasty is unclear. The purpose of the present study was to determine the range of motion of the hip joint during squatting after total hip arthroplasty.
Using fluoroscopy, we investigated 15 primary cementless total hip arthroplasties performed using a computed tomography-based navigation system. An acetabular component with concavities around the rim and a femoral component with reduced neck geometry were used. The motion of the acetabular and femoral components based on the neutral standing position was analyzed using a two-dimensional to three-dimensional registration technique.
No prosthetic impingement occurred in any hips. The mean maximum hip flexion range of motion was 86.2° (range, 55.1°–117.4°) and was not always consistent with maximum squatting. The mean maximum pelvic posterior tilting angle was 25.7° (range, 5.5°–43.5°). The pelvis began to tilt posteriorly at 50°–70° of the hip flexion range of motion. At maximum squatting, the mean ratio of the pelvic posterior tilting angle to the femoral flexion angle was 23.2% (range, 3.8%–45.7%). The mean minimum angle up to the theoretical prosthetic impingement was 26.2° (range, 11.8°–39.8°).
Although this is a preliminary study, three-dimensional assessment of dynamic squatting motion after total hip arthroplasty using the two-dimensional to three-dimensional registration technique appears to enable elucidation of the range of motion of the hip joint, the contribution of pelvic posterior tilting, and the minimum angle up to theoretical prosthetic impingement during squatting.

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: No benefits or funds were received in support of the study.

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Original articleAn In Vivo Model for Intraoperative Assessment of Impingement and Dislocation in Total Hip Arthroplasty

Abstract

Section snippets

Methods

Results

Discussion

Acknowledgment

J Arthroplasty

J Arthroplasty

J Orthop Res

J Arthroplasty

J Biomech

J Arthroplasty

Orthop Clin North Am

J Arthroplasty

J Biomech

Intermediate-term results after hybrid total hip arthroplasty for the treatment of dysplastic hips

J Bone Joint Surg Am

Total hip arthroplasty using an omniflex modular system: 5 to 12 years follow-up

Clin Orthop

Dislocations after total hip arthroplasty

J Bone Joint Surg Am

Operative correction of an unstable total hip arthroplasty

J Bone Joint Surg Am

A finite element analysis of factors influencing total hip dislocation

Clin Orthop

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

Original article
An In Vivo Model for Intraoperative Assessment of Impingement and Dislocation in Total Hip Arthroplasty