Total Hip Arthroplasty Through a Minimal Posterior Approach Using Imageless Computer-Assisted Hip Navigation

doi:10.1016/j.arth.2005.04.024

The Journal of Arthroplasty

Volume 20, Supplement 3, October 2005, Pages 51-56

https://doi.org/10.1016/j.arth.2005.04.024 Get rights and content

Abstract

With decreased exposure in a minimal posterior hip incision, navigation with computer assistance provides an alternative method to accurately place the components. This study compares the results of a series of 82 navigated total hips to a retrospective cohort of 50 hips done with conventional instruments. The surgical incision split the gluteus maximus but did not extend distally into the fascia. The goal of cup placement was 40° to 45° of abduction (ABD) and 17° to 23° of flexion (FLX). Postoperative radiographs were digitized and analyzed. In the study group, 82 hips were done with computer assistance and compared with 50 done with conventional methods (manual) through the same incision. Radiographic analysis showed that there were significantly fewer cases inside the desired range of ABD and FLX in the manual group (6%) compared with the navigation group (30%), P = .001, with significant differences in the variances of ABD and FLX (P = .011 and .028). Improved accuracy of cup placement was found with increased experience in the use of navigation by the surgeon over the time of the series. The use of a computer-assisted surgery navigation system with a minimal posterior incision for a total hip arthroplasty results in significantly more reproducible acetabular component placement.

Section snippets

Methods

The limited posterior surgical approach and computer-assisted navigation were used on all patients presenting for a primary total hip arthroplasty. The series of navigation patients includes the first cases done and includes the senior author's learning experience. Patients were positioned in a lateral decubitus position with pelvic and trunk supports to maintain a stable position of the body during surgery. After preparation of the skin and draping, percutaneous pins were placed in the iliac

Results

In the manual group, there was a single, 1-time, early anterior dislocation that was not recurrent in a patient with a 28-mm head, where the cup was measured in 55° ABD and 22° ANT, which was outside the target range. One patient in the navigated group had a nondisplaced calcar fracture that was identified at surgery and treated with extension of the incision and cerclage with uneventful healing and recovery. An additional patient in the navigated group had a fracture of the medial wall of the

Discussion

The results of this study indicate that using a limited posterior incision combined with imageless computer-assisted navigation on patients for a primary total hip arthroplasty can improve the accuracy of component placement and reduce the number of outliers. Although the navigated technique correlates well with the ABD placement of the cup, the degree of ANT achieved at surgery did not correlate with values measured off of the radiographs. The method of measuring the ANT is dependent on the

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Cited by (91)

Computer Navigation vs Conventional Total Hip Arthroplasty: A Medicare Database Analysis
2019, Journal of Arthroplasty
Citation Excerpt :
We hypothesize the increase in early revision rate may be partially due to the learning curve induced by implementing CAS-THA. Perioperative complications including deep vein thrombosis and pulmonary embolism have not been widely assessed in CAS-THA [14,38–41]. Surprisingly, we found a significant decrease in deep vein thrombosis and pulmonary embolism in the CAS-THA group.
Computer-assisted surgery (CAS) is applied to total hip arthroplasty (THA) in an attempt to optimize implant positioning. The effect of CAS on postoperative complications after THA remains unknown. Our study aims to assess the change in complication rates when CAS is used in THA.
The Medicare database was studied from 2005 to 2012. All THAs performed with CAS were identified. A total of 64,944 THAs were identified, including 5412 CAS-THAs and 59,532 conventional THAs. Medical and surgical adverse events were collected at various time points.
CAS-THA was not associated with a decreased rate of dislocation at 30 days (1.0% vs 1.2%; odds ratio [OR], 1.14; P = .310), 90 days (1.1% vs 1.4%; OR, 1.23; P = .090), or 2 years (2.3% vs 2.3%; OR, 1.01; P = .931). CAS-THA was associated with a significantly higher rate of periprosthetic fracture at 30 days (0.4% vs 0.6%; OR, 1.46; P = .040) as well as revision THA at 30 days (1.0% vs 1.4%; OR, 1.43; P = .003) and 90 days (1.2% vs 1.7%; OR, 1.42; P < .002) when compared to conventional THA. CAS-THA was associated with a significantly lower rate of deep vein thrombosis and pulmonary embolism when compared to conventional THA at all time points (P < .05).
Administrative coding data fail to demonstrate any clinically significant reduction in short-term adverse events with CAS-THA. Further study is warranted to evaluate whether the purported benefits of CAS result in a reduction of the adverse events after THA.
Accuracy and Precision of Acetabular Component Placement With Imageless Navigation in Obese Patients
2019, Journal of Arthroplasty
Obesity is a risk factor for acetabular component malposition when total hip arthroplasty is performed with manual techniques. The utility of imageless navigation in obese patients remains unknown. This study compared the accuracy and precision of imageless navigation for component orientation between obese and nonobese patients.
A total of 459 total hip arthroplasties performed for osteoarthritis using imageless navigation were reviewed from a single surgeon’s institutional review board–approved database. Einzel-Bild-Roentgen Analyse determined component orientation on 6-week postoperative anteroposterior radiographs. Mean orientation error (accuracy) and precision were compared between obese (body mass index ≥ 30 kg/m²) and nonobese patients. Regression analysis evaluated the influence of obesity on component position.
The difference in mean inclination and anteversion between obese and nonobese groups was 1.1° (43.0° ± 3.5°; range, 35.8°-57.8° vs 41.9° ± 4.4°; range, 33.0°-57.1° and 24.9° ± 6.3°; range, 14.2°-44.3° vs 23.8° ± 6.6°; range, 7.0°-38.6°, respectively). Inclination precision was better for nonobese patients. No difference in inclination accuracy or anteversion accuracy or precision was detected between groups. And 83% of components were placed within the target range. There was no relationship between obesity (dichotomized) and component placement outside the target ranges for inclination, anteversion, or both. As a continuous variable, increased body mass index correlated with higher odds of inclination outside the target zone (odds ratio, 1.06; P = .001).
Using imageless navigation, inclination orientation was less precise for obese patients, but the observed difference is likely not clinically relevant. Accurate superficial registration of landmarks in obese patients is achievable, and the use of imageless navigation similarly improves acetabular component positioning in obese and nonobese patients.
Therapeutic Level IV.
Intraoperative O-arm-navigated resection in musculoskeletal tumors
2018, Journal of Orthopaedic Science
Although emerging evidence has suggested that computer-assisted navigation allows surgeons to plan the optimal level of resection without compromising the surgical margins, the precise accuracy of the procedures has been unclear. The aim of this study was to investigate the accuracy and safety of the musculoskeletal tumor resection using O-arm/Stealth intraoperative navigation assistance.
A retrospective study of six patients with bone and soft tissue tumors who underwent surgical resection using O-arm/Stealth navigation system was performed. The histological diagnosis was osteosarcoma, metastatic bone tumor, leiomyosarcoma, undifferentiated sarcoma, and synovial sarcoma, respectively. Tumor resection was performed according to planned osteotomy planes determined on O-arm/Stealth three-dimensional intraoperative images. The resection accuracy, length of time for the procedures, surgical margins, and perioperative complications were evaluated.
The distances between the entry and exit points for the planned and actual cuts were 1.5 ± 0.3 mm and 2.3 ± 0.3 mm, respectively, and the mean discrepancy of the osteotomy angle was 2.8 ± 1.2°. The mean length of time required for navigation was 14 min. A histological examination revealed clear margins in all patients. There were no complications related to navigation, and no patients developed local recurrence during a mean follow-up of 30.6 months.
The O-arm/Stealth intraoperative CT navigation system provides safe and accurate osteotomy in musculoskeletal tumor resections. However, surgeons should keep in mind and be careful of minimal errors during osteotomy, which are around 2 mm from the planned line.
Revision Total Hip Arthroplasty Using Imageless Navigation With the Concept of Combined Anteversion
2017, Journal of Arthroplasty
The purpose of the study was to evaluate the implant positions and clinical results of revision total hip arthroplasty (THA) using an imageless navigation with the concept of combined anteversion.
A total of 40 cementless revision THAs (24 men and 16 women) using an imageless navigation with the concept of combined anteversion were retrospectively evaluated. The concept of combined anteversion was applied in cup positioning based on Widmer's equation (cup anteversion + 0.7 × stem anteversion). The mean follow-up period was 80.7 months. Postoperatively, the inclination of the cup was evaluated on standard anteroposterior view of the radiograph, and the anteversion of the cup and femoral stem was evaluated using computed tomography scan. A cup inclination of 40° ± 10° and combined anteversion of the cup and femoral stem of 37° ± 10° based on Widmer's equation were regarded as the “safe zone.”
The average anteversion of the revised femoral stems was 15.3° ± 2.9° (range, 9.5°-21.5°), whereas that of the remained femoral stems was 17.4° ± 9.7° (range, 4.2°-29.8°). The inclination, anteversion of the cup, and combined anteversion after revision THA were 42.3° ± 3.1° (range, 32.1°-48.2°), 25.0° ± 2.9° (range, 16.9°-29.5°), and 36.1° ± 3.4° (range, 27.2°-42.9°), respectively. Therefore, the position of the implants, relative to the safe zone, showed no outliers after the revision surgery. Neither dislocation nor osteolysis was observed after the surgery.
Favorable results of this study indicate that imageless navigation helps the surgeon in placing the components of revision THA in the safe zone. This study also shows that when this safe zone is consistently obtained, then no postoperative dislocations were observed in these patients over the 6-year follow-up period.
Comparison of acetabular shell position using patient specific instruments vs. standard surgical instruments: A randomized clinical trial
2014, Journal of Arthroplasty
Citation Excerpt :
Additionally using prospective, randomization of PSI or STD treatment, improved our design compared to other studies using retrospective data for conventional methods and prospective for the computer assisted adding bias to the computer assisted operations due to increased surgeon experience at positioning acetabular components over time. While some navigation techniques depend on superficial landmarks [29–31,48,49,52,55], this PSI technology relies solely on the bony anatomy of the acetabulum eliminating other potential areas of error such as: soft tissue, patient positioning, or degree of pathology. It has been shown that higher BMI correlates with malpositioned cups [56].
Total hip arthroplasty (THA) survivorship relies largely upon appropriate acetabular cup placement. The purpose of this prospective randomized controlled trial was to determine whether the use of a preoperative 3D planning software in combination with patient specific instrumentation (PSI) results in improved cup placement compared with traditional techniques. Thirty-six THA patients were randomized into standard (STD) or PSI technique. Standard approach was completed using traditional techniques, while PSI cases were planned and customized surgical instruments were manufactured. Postoperative CT scans were used to compare planned to actual results. Differences found between planned and actual anteversion were − 0.2° ± 6.9° (PSI) and − 6.9° ± 8.9° (STD) (P = 0.018). Use of 3D preoperative planning along with PSIs resulted in significantly greater anteversion accuracy than traditional planning and instrumentation.
Imageless computer-assisted versus conventional total hip arthroplasty: One surgeon's initial experience
2014, Journal of Arthroplasty
Computer-assisted surgery (CAS) systems are advocated to improve component positioning in THA, though potential operative risks and costs of CAS have fueled debate. The present study examines the radiographic outcomes, operative efficiency, cost, and midterm functional outcomes for patients who underwent THA, either with CAS or conventional instrumentation. Patient baseline characteristics were recorded for 126 lower-extremities in the CAS series, and 215 in the conventional series. There was no difference in Harris Hip Score or leg length discrepancy between series. Inclination angle, blood loss, and operating room times were increased for CAS. These results suggest that CAS confers no advantage over conventional methods regarding accuracy of THA component placement, drives unreimbursed increases in procedure costs, may expose patients to additional operative risk, and produces no functional benefit at midterm follow-up.

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: Benefits or funds were received in partial or total support of the research material described in this article from Stryker.

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Total Hip Arthroplasty Through a Minimal Posterior Approach Using Imageless Computer-Assisted Hip Navigation

Abstract

Section snippets

Methods

Results

Discussion

J Arthroplasty

J Arthroplasty

J Arthroplasty

Injury

Oper Tech Orthop

J Arthroplasty

Modification of the posterolateral approach to the hip for insertion of femoral head prostheses

J Bone Joint Surg

A new low posterior approach. American Academy of Orthopaedic Surgeons

Instr Course Lect

Ueber die Schussverletzungen der Huftgelenks

Arch Clin Chir

Surgical approach, abductor function, and total hip arthroplasty dislocation

Clin Orthop Relat Res

A clinical comparison of the anterolateral and posterolateral approaches to the hip

Clin Orthop Relat Res

Comparison of two different posterior approaches for hemiarthroplasty of the hip

Arch Orthop Trauma Surg

Posterior approach to total hip replacement using enhanced posterior soft tissue repair

Clin Orthop Relat Res