Effects of changes in whole-body alignment on ipsilateral knee pain after total hip arthroplasty

BackgroundTotal hip arthroplasty decreases hip pain and often reduces knee pain in patients with hip osteoarthritis. Whole-body alignment may be associated with knee pain, but to our knowledge this relationship has not been previously investigated. The purpose of this study was to investigate the effect of changes in whole-body alignment on ipsilateral knee pain in patients after total hip arthroplasty.MethodsIn total, 94 patients with unilateral hip osteoarthritis who underwent total hip arthroplasty were enrolled in this study. A visual analog scale (VAS) was used to investigate perioperative knee pain. An EOS 2D/3D X-ray system was used to quantify the whole-body alignment of the spine, pelvis, and lower extremities in the standing position. The relationship between perioperative changes in knee pain and whole-body alignment was investigated.ResultsAmong 61 patients who had preoperative ipsilateral knee pain, pain resolved in 30 (50%) and persisted in 31 (50%) after surgery. In these patients, average ipsilateral knee pain decreased significantly after surgery, from 41 mm to 14 mm on the VAS (P < 0.01). Preoperative knee pain was correlated with femorotibial rotation, and postoperative knee pain was correlated with K-L grade, preoperative knee pain visualized analog scale, and preoperative sagittal vertical axis. Multiple linear regression identified preoperative sagittal vertical axis as significantly associated with residual postoperative ipsilateral knee pain.ConclusionsIpsilateral knee pain decreased in half of patients after total hip arthroplasty. Patients with a considerable forward-bent posture may have residual ipsilateral knee pain after total hip arthroplasty.     

The sagittal stem alignment and the stem version clearly influence the impingement-free range of motion in total hip arthroplasty: a computer model-based analysis

Purpose

The component alignment in total hip arthroplasty influences the impingement-free range of motion (ROM). While substantiated data is available for the cup positioning, little is known about the stem alignment. Especially stem rotation and the sagittal alignment influence the position of the cone in relation to the edge of the socket and thus the impingement-free functioning. Hence, the question arises as to what influence do these parameters have on the impingement-free ROM?

Methods

With the help of a computer model the influence of the sagittal stem alignment and rotation on the impingement-free ROM were investigated. The computer model was based on the CT dataset of a patient with a non-cemented THA. In the model the stem version was set at 10°/0°/?10° and the sagittal alignment at 5°/0°/?5°, which resulted in nine alternative stem positions. For each position, the maximum impingement-free ROM was investigated.

Results

Both stem version and sagittal stem alignment have a relevant influence on the impingement-free ROM. In particular, flexion and extension as well as internal and external rotation capability present evident differences.In the position intervals of 10° sagittal stem alignment and 20° stem version a difference was found of about 80° in the flexion and 50° in the extension capability. Likewise, differences were evidenced of up to 72° in the internal and up to 36° in the external rotation.

Conclusions

The sagittal stem alignment and the stem torsion have a relevant influence on the impingement-free ROM. To clarify the causes of an impingement or accompanying problems, both parameters should be examined and, if possible, a combined assessment of these factors should be made.

     

The association between the sagittal femoral stem alignment and the resulting femoral head centre in total hip arthroplasty

Adequate stem alignment is essential for the success of Total Hip Arthroplasty (THA) to avoid dislocation and impingement. One factor that has not been sufficiently investigated so far is the stem tilting in the sagittal plane, which has an influence on the position of the centre of the femoral head and thus also on prosthesis torsion. We aimed to evaluate sagittal stem position using 3D-CTs in patients with THA and to develop a mathematical-geometrical model to simulate the functional correlation between sagittal stem tilting and the influence on functional anteversion. Thirty patients with THA underwent a CT-scan. By 3D-reconstruction of the CT-data, femoral-/prosthesis-axis, torsion and sagittal tilt were determined. In accordance with the position of the femoral and prosthesis axes, the rotatory (rAV) (surgically adjusted) and functional (depending on sagittal tilt) anteversion (fAV) was measured. A three dimentional-coordinate transformation was also performed using the Euler-angles to derive a mathematical-geometrical correlation between sagittal stem tilting and corresponding influence on anteversion. The mean rAV was 8° (-11.6 - 26°), the fAV 18° (6.2 - 37°), and the difference 10° (8.8 - 18°). The mean degree of stem tilting was 5.2° (0.7 - 9°) anterior towards the femoral axis. The individually measured parameters are reflected in the mathematical-geometrical model. Depending on the extent of the sagittal deviation, a clear influence on the torsion emerges. For example, a stem implanted at a 15° anteverted angle with a sagittal tilt by two degrees towards anterior results in a fAV of 20°. A clear association between the sagittal stem alignment and the impact on the fAV was demonstrated. Hence, the rotatory anteversion intended by the surgeon may be functionally significantly different. This might pose an increased risk of dislocation or impingement. The sagittal tilt of the prosthesis should therefore be considered in the context of impingement and dislocation diagnosis. In this respect, we recommend a 3D-analysis of stem alignment.     

Revision arthroplasty of the hip joint. A retrospective analysis

During the period 1974-1983, 768 total hip arthroplasties were performed at the Surgical Hospital, University Central Hospital in Helsinki. Brunswik prostheses were used until 1980, and after this the operations were routinely performed with Lubinus prostheses. Additionally, from 1977 to 1981 Wagner and Freeman resurfacing prostheses were used in 107 cases. Of all these patients, 44 (5.7%) needed revision arthroplasty. The average interval between the primary operation and revision arthroplasty was 3.7 years and the follow-up period after the second operation averaged 2.9 years. The patients who underwent revision arthroplasty were compared with a matched control group. In the revision group, radiographs revealed that the medial cement packing was complete in 28% of the hips, this being the case in 78% of the controls (P less than 0.001). Also, the cement tip packing was more often incomplete in the revision hips than in the controls (P less than 0.01). Regarding the lateral cement packing there was no statistical difference between the two groups. The revision rate of the resurfacing prostheses was 14.9%, compared with 7.8% of the Brunswik prostheses which were inserted at the same time. At the follow-up, the patients with revised hips had less pain than before the primary operation (P less than 0.001) and their mobility was similarly improved. We conclude that adequate medial and tip cement packing must be emphasized in the primary arthroplasty. Resurfacing prostheses have a relatively high loosening tendency. Revision arthroplasty is the treatment of aseptic loosening after total hip replacement and it gives good clinical results. Aseptic loosening is the most common long-term complication after total hip replacement surgery.(ABSTRACT TRUNCATED AT 250 WORDS)     

Revision arthroplasty of the hip joint

Summary During the period 1974–1983, 768 total hip arthroplasties were performed at the Surgical Hospital, University Central Hospital in Helsinki. Brunswik prostheses were used until 1980, and after this the operations were routinely performed with Lubinus prostheses. Additionally, from 1977 to 1981 Wagner and Freeman resurfacing prostheses were used in 107 cases. Of all these patients, 44 (5.7%) needed revision arthroplasty. The average interval between the primary operation and revision arthroplasty was 3.7 years and the follow-up period after the second operation averaged 2.9 years. The patients who underwent revision arthroplasty were compared with a matched control group. In the revision group, radiographs revealed that the medial cement packing was complete in 28% of the hips, this being the case in 78% of the controls (P < 0.001). Also, the cement tip packing was more often incomplete in the revision hips than in the controls (P < 0.01). Regarding the lateral cement packing there was no statistical difference between the two groups. The revision rate of the resurfacing prostheses was 14.9%, compared with 7.8% of the Brunswik prostheses which were inserted at the same time. At the follow-up, the patients with revised hips had less pain than before the primary operation (P < 0.001) and their mobility was similarly improved. We conclude that adequate medial and tip cement packing must be emphasized in the primary arthroplasty. Resurfacing prostheses have a relatively high loosening tendency. Revision arthroplasty is the treatment of aseptic loosening after total hip replacement and it gives good clinical results.Aseptic loosening is the most common long-term complication after total hip replacement surgery. Clinical loosening rates are mostly judged by the number of patients who have been reoperated on, this probably leading to somewhat low figures. Reports on prosthesis loosening usually concern cemented prostheses, and both analyses based on radiographical evidence and revision rates have been published [1, 3, 4, 10, 12, 14]. It appears that most of the prostheses, at least as concerns femoral components, loosen during the first 5 years, and the numbers increase only slowly between 5 and 10 years postoperatively [16, 17].A certain proportion of prostheses will loosen even when the most progressive operative methods are used, and revision arthroplasties of the hip joint are part of the routine of orthopedic departments. We have analyzed our total hip revision arthroplasties, focusing on the factors leading to prosthesis loosening and on the outcome of hip revision operations.     

Total hip arthroplasty after arthrodesis of the hip joint

The results of 15 conversions of a hip arthrodesis into a total hip arthroplasty performed in the years 1980-1995 are reported. Fifteen patients (8 men, 7 women) underwent total hip arthroplasty 30.9 (range 2-61) years after spontaneous or operative fusion of a hip joint. The primary indications of the conversion were low-back pain (n = 10), knee pain (n = 2) and hip problems (n = 3). At follow-up examination 5.4 (range 2-13.3) years postoperatively, the Harris Hip Score averaged 86.0 (range 70.1-99.0). Six patients were pain-free, 7 had less pain, 2 felt no improvement of pain. All patients confirmed that they would undergo the operation again. The Trendelenburg sign was negative or mild in 8 patients and moderate to severe in 7. Aseptic loosening of 2 stems (1 cemented, 1 cementless) and 2 deep infections required revision surgery. We conclude that this operation can lead to satisfactory results even after a long duration of the arthrodesis. However, full function with no pain and a negative Trendelenburg sign could be obtained in only 20% (3/15) of the cases.     

髋关节骨性关节炎患者腰椎骨盆矢状面参数的初步研究

[目的]探讨无下腰痛的髋关节骨关节炎(hip osteoarthritis,HOA)患者与正常成年人脊柱骨盆矢状面平衡的差异并分析其临床意义。[方法]回顾性分析正常对照组56例,HOA组22例,收集其腰椎正侧位X线片,分别测量腰椎前凸角(lumbar lordosis,LL)、骨盆入射角(pelvic incidence,PI)、骨盆倾斜角(pelvic tilt,PT)、骶骨倾斜角(sacral slope,SS)。分析两组脊柱骨盆矢状面参数之间的差异。[结果]所测数据均呈正态分布。观察者间和观察者自身ICC值均0.8,提示测量值可靠性优。HOA组与正常对照组的PI值分别为(47.14±10.14)°和(43.38±10.63)°;PT值分别为(8.89±10.89)°和(11.94±8.03)°;LL值分别为(32.86±8.90)°和(30.77±7.94)°,PI、PT及LL在两组间差异无统计学意义(P0.05)。HOA组SS(37.77±5.13)°大于正常对照组(31.21±8.78)°,差异有统计学意义(P0.05)。[结论]无下腰痛的HOA患者PI、LL、PT与正常对照组无明显差异,SS较正常对照组更大,表明HOA患者骨盆较正常成年人前倾更大,为今后的HOA患者的手术治疗及维持良好的矢状面平衡提供了必要的参考。     

Radiographic cost reduction strategy in total joint arthroplasty: A prospective analysis

A consecutive series of 222 patients who underwent cemented total knee arthroplasty (124) and uncemented total hip arthroplasty (98) were evaluated prospectively. The purpose of this study was to determine if routine radiologic interpretation of postoperative total hip and total knee radiographs is cost effective. Also, the study was designed to determine if routine predischarge radiographs, in conjunction with recovery room radiographs, are worthwhile. There were no changes in postoperative patient management based on orthopaedic or radiologic review of either radiograph. No additional information was gained from review of the radiologic evaluations. Therefore, obtaining one series of routine inpatient postoperative total joint radiographs and eliminating postoperative radiologic consultation will significantly reduce costs without compromising patient care.     

Simultaneous bilateral dual mobility total hip arthroplasty dislocation in a patient with hepatic encephalopathy: A case report

Introduction and importanceDislocation is a severe complication after total hip arthroplasty (THA). It is one of the most common reasons for failure and revision surgery. This is the first case of a documented simultaneous bilateral dual mobility (DM) THA dislocation.Case presentationA forty-nine-year-old man presented with bilateral hip pain, immobility and deformity. X-ray images demonstrated simultaneous bilateral posterior THA dislocation. Previously, the patient had presented atraumatic dislocations recurrently. When he was thoroughly re-interrogated, he complained of uncontrolled and generalized muscle contractions, which were compatible with myoclonus due to hepatic encephalopathy (HE). Multidisciplinary treatment was performed satisfactorily to control myoclonus symptomatology and to prevent dislocation.Clinical discussionPatient’s most important risk factor was a neuromuscular disorder, which we initially gave little notice and undervalued. HE is a serious but reversible syndrome, observed in patients with liver dysfunction. It leads to a wide spectrum of neuropsychiatric abnormalities. Management is based on prevention of episodes, avoiding the underlying triggers.Due to the high risk for dislocation of our patient, we decided to use DM cups bilaterally. This system has demonstrated lower rates of dislocation.ConclusionThis case report reminds us that a careful evaluation through meticulous history and physical examination are mandatory when faced with recurrent instability. Furthermore, prevention of dislocation is vastly preferable to treating this challenging complication. High-risk patients should be identified, and appropriate surgical approach, technique and implants have to be collectively used to reach a strategy that mitigates and ideally prevents dislocation.     

Fracture of the femoral alignment stem of a hip resurfacing arthroplasty. A case report

Metal-on-metal hip resurfacing arthroplasty has become increasingly popular for the treatment of osteoarthritis in a younger patient population. While the initial complication of femoral neck fracture is being addressed, we describe a fracture of the femoral alignment stem in a component two years from the primary procedure.     

Prevention of dislocation of total hip arthroplasty: the dual mobility cup

The concept of dual mobility cup has been developed to associate the advantages of the low friction total hip arthroplasty with those of large femoral head diameter, with the goal of preventing the dislocations. In this study, 100 primary THA and 34 revision THA with the use of dual mobility cup were analyzed clinically and radiological over a period of fellow up of ten years. It appears that the dual mobility cup is effective against dislocation. Any concerns regarding the survival of this type of prosthesis can be relativized. Literature datas indicate that mean total volumetric wear is of the same order as that reported for Charnley prosthesis with a head of 22,2 mm. However, uncertainty regarding the problem of intraprosthetic dislocation did persist.     

The age-specific normative values of standing whole-body sagittal alignment parameters in healthy adults: based on international multicenter data

European Spine Journal - To investigate the age-specific normative values of whole-body sagittal alignment (WBSA) including global balance parameters in healthy adults and to clarify the...