Anatomical cup implantation assisted with dynamic 3D planning improves functional outcomes in primary total hip arthroplasty: A retrospective study

Abstract

BACKGROUND:

Anatomical cup implantation is a promising approach in primary total hip arthroplasty (THA) and improves functional outcomes.

OBJECTIVE:

We aimed to evaluate the cup position and functional outcomes in primary THA with preoperative dynamic 3D planning.

METHODS:

We retrospectively reviewed 54 hips in 48 patients who underwent primary THA with anatomical cup implantation (mean follow-up time: 52 months). Cup positions were evaluated based on patient-specific morphology, the acetabular fossa and the combined anteversion test. Functional outcomes were assessed after THA. The paired-sample $t$ -test was performed for surgical and contralateral native hips among 42 patients who underwent unilateral THA.

RESULTS:

Two hips suffered intraoperative trochanteric fracture, but no hip dislocations occurred. No patients reported groin or thigh pain, and all patients were capable of deep squatting and one-leg standing. The mean Harris hip score, WOMAC score, and physical SF-36 score were 94.46 $\pm$ 6.16, 10.41 $\pm$ 3.62, and 95.19 $\pm$ 8.74, respectively. Except for acetabular offset, THA restored biomechanics to those of contralateral native hip, including cup anteversion, abduction, femoral offset and acetabular height ( $P>$ 0.05).

CONCLUSION:

This study provided evidence for the application of anatomical cup implantation assisted with dynamic 3D planning in primary THA, which restored morphology and improved functional outcomes.

Keywords

Total hip arthroplasty acetabular cup implantation 3D planning retrospective study

1. Introduction

Total hip arthroplasty (THA) is a highly successful surgical procedure for treating various end-stage hip diseases [1]. The restoration of native hip anatomy and biomechanics is crucial to achieve a pain-free THA. The Charnley cement THA was reported to increase the socket and stem survival rates when radiographic loosening was defined as the endpoint [2]. Malposition of the hip components can lead to failed THA, resulting in issues such as instability, leg-length discrepancy, impingement and prosthesis aseptic loosening [3, 4, 5, 6, 7].

It is controversial to use Lewinnek Safe Zone (LSZ) or anatomical position in the cup implanted. LSZ has been regarded as a standardized range for the acetabular cup, typically involving cup anteversion between 5^∘ and 25^∘ and inclination between 30^∘ and 50^∘ [8]. However, LSZ has been criticized for ignoring combined hip anteversion, postural acetabular orientation changes, and patient-specific morphology [9, 10, 11]. Three-dimensional (3D) anatomical studies of acetabular orientation showed that natural acetabular anteversion ranged from 20.1^∘ to 23.2^∘ and abduction from 53.6^∘ to 56.5^∘ [12, 13], which differed from the LSZ. Some studies suggested favorable outcomes with anatomical anteversion and abduction for cup placement [14, 15, 16].

Archbold et al. [17] used the transverse acetabular ligament (TAL) as a guide for acetabular cup orientation in 1000 consecutive THA cases, resulting in a dislocation rate of only 0.6% over a minimum of 8 months follow-up. On the contrary, Epstein et al. [18] reported that the TAL was identified in only 47% of hips and the cup position assisted with TAL was no more accurate than the freehand implantation. Consequently, Ha et al. [16] explored the use of the transverse and anterior acetabular notch (ANN) as bone landmarks for cup placement. Unfortunately, not all patients had the ANN in the acetabular ridge, as there are four distinct configurations, curved, angular, irregular and straight [19].

Li et al. [20] identified the anatomical characteristics of the acetabular fossa as stable, with its central axis serving as a reliable landmark for acetabular abduction alignment. Anatomical cup placement was shown to maintain the hip rotation center and component containment, and restore natural hip biomechanics. Long-term follow-up studies of THA have demonstrated excellent radiological results and prosthesis survival with acetabular anatomic reconstruction [2, 21, 22, 23, 24, 25].

Optimal cup placement is crucial for long-term stability and function in THA. To address the lack of consensus on the ideal position, dynamic 3D-assisted THA has emerged as a promising technique. By utilizing preoperative dynamic 3D planning and advanced imaging, this approach enables precise visualization of the patient’s hip anatomy and facilitates optimal placement of the acetabular cup. Therefore, since 2015, we have been using the acetabular fossa as the landmark for cup implantation in primary THA, assisted by preoperative dynamic 3D planning. To date, no study has applied this technology to restoring hip component position and functional outcomes in THA with anatomical acetabular reconstruction. We hypothesized that acetabular implantation could accurately match patient-specific anatomy with preoperative dynamic 3D planning. The combined anteversion was optimized to ensure hip stability first, followed by assessing anterior cup overhang with direct 3D visualization [26]. Cup and femoral stem anteversion were adjusted until satisfactory cup containment and hip stability were obtained. Finally, the landmarks certified in a 3D model were utilized for precise accurate cup implantation in surgery. In summary, this study aimed to evaluate the cup position in THA targeting patient-specific zones. assisted by preoperative dynamic 3D planning, and to assess the surgical safety and patient functional outcomes after THA.

2. Materials and methods

2.1 Participants

A total of 48 patients (54 hips) were recruited for this retrospective study following ethical approval. All patients underwent primary THA between January 2015 and February 2016. Among them, 42 cases underwent unilateral THA (right 23 hips, left 19 hips), and 6 cases underwent bilateral THA. The surgical indication included femoral neck fracture 21 hips (Garden III 7 hips, IV 14 hips), femoral head osteonecrosis 28 hips (Ficat stage III 10 hips, IV 18 hips), osteoarthritis 4 hips (Kellgreen-Lawrence stage IV). Patients with rheumatoid arthritis, infective arthritis, and developmental hip dysplasia were excluded.

2.2 Preoperative dynamic 3D planning

Figure 1.

3D pelvic model. A. 3D model of the proximal femur and pelvic. B. Three landmarks determined by the acetabular fossa: UP (upper point), AP (anterior point), and PP (posterior point). C. The cup and femoral trial model implanted with points registration. D. Combined anteversion test with the merged proximal femur and prosthesis internally rotated 45^∘.

The preoperative dynamic 3D planning was designed by Medical Engineer Yang Zhi. CT scans were obtained with the patient in a supine position with both legs internally rotated to keep the patellar parallel to the table. Transaxial CT images (DICOM) were transferred to Mimics software (version 10.01, Materialise, Belgium), and the 3D pelvic model was reconstructed. The pelvic and femur were separated (Fig. 1A), and the 3D model was adjusted until the bilateral sciatic notches overlapped. The acetabulum was cut vertically to the central plane of the fossa’s upper role. Three points across the cut plane and the acetabular rim were identified as the upper point (UP), anterior point (AP) and posterior point (PP) (Fig. 1B). The appropriate trial model of acetabular cups (STL) was selected and implanted with Mimics points registration module (Fig. 1C). The femoral prosthesis trial model (STL) was inserted with anteversion determined by the long axis of the femoral neck cut surface. The merged proximal femur and femoral prosthesis were internally rotated 40–45^∘ to simulate the combined anteversion test [27, 28] (Fig. 1D). If the anterior cup overhang exceeded 3 mm, the cup anteversion increased and the femoral prosthesis anteversion declined accordingly. The final acetabular position and the corresponding bone landmarks on the rim were recorded.

Figure 2.

Operation processes. A. Acetabular exposure assisted with three pins and two Homman retractors. B. Three blush signs after cartilage removal. C. Socket implanted anatomically with secure press fit and ceramic liner inserted. D. Intraoperative combined anteversion test, ensuring the femoral head base is paralleled to the liner surface.

2.3 Operative technique

All operations were performed by the same surgeon (ZS) using a posterolateral approach. To obtain complete acetabular exposure, the labrum and TAL were removed. After debridement of central soft tissue and osteophyte, the cotyloid fossa was exposed, and the three landmarks were marked as preoperative dynamic 3D planning (Fig. 2A). Acetabular reaming started with the smallest size (40#) and was directed vertically to the cotyloid fossa. As the anterior and posterior column peripheral cartilage gradually contacted the reamer with increasing size, the final reaming direction changed to the acetabulum opening face. With the identification of three blush signs (Fig. 2B), the cementless cup was implanted, and orientation was adjusted by preoperative certified bone landmarks. Finally, the cup achieved a secure press fit and adequate orientation (Fig. 2C). The ceramic or polyethylene liner was inserted, and the 10^∘ lipped polyethylene liner was placed in the posterolateral position. After preparing the femoral canal according to the preoperative design, the stem and femoral head were placed, and the combined anteversion was checked. With the surgical leg internally rotated 40–45^∘, the base of the femoral head should be parallel to the liner surface (Fig. 2D). In closure, the posterior capsule and short rotators were repaired through drilled holes in the greater trochanter, and no drainage was applied in all patients. Postoperatively, patients were instructed to walk one day later with the aid of two crutches, and full weight-bearing began 3 days post-surgery. Three months later, all patients were allowed to take deep squatting and one-leg standing exercises.

2.4 Follow up evaluation

The Harris hip score (HHS), Western Ontario McMaster Universities osteoarthritis index (WOMAC) and SF-36 were calculated to assess functional outcomes. HHS evaluated functional outcomes and pain levels, while the WOMAC assessed symptoms and functional limitations in hip osteoarthritis patients. The SF-36 measured overall health-related quality of life, covering physical and mental health aspects. These well-established scores provided comprehensive insights into patients’ postoperative functional outcomes, pain, and overall well-being, allowing for an effective evaluation of the surgical approach’s success. The presence of thigh or groin pain, the ability of deep squatting and one-leg standing were evaluated (Fig. 3A). At the last follow-up, the weight-bearing pelvic anterioposterior (Fig. 3B) was obtained and measured with RadiAnt DICOM Viewer (Medixant, Poland).

Figure 3.

Follow-up evaluation. A. Deep squatting 4 months after right THA surgery. B. Radiological measurements on weight-bearing pelvic X-ray. AO (acetabular offset), FO (femoral offset), AH (acetabular height), and LL (limp length, distance from the lesser trochanteric tip to the ischium tubercle line), $\alpha$ (abduction angle: 55.2^∘). C. Application of Lewinnek methods for socket anteversion measurement, calculated as arcsin (short diameter/large diameter) $=$ 17.52^∘.

The parameters included the acetabular and femoral offset, acetabular height and leg length. The acetabular anteversion and abduction angle in native hips, as well as the cup anteversion and abduction angle post-surgery, were evaluated. The preoperative data were collected during the patients’ preoperative assessments, the postoperative data were obtained immediately after surgery, and the follow-up data were recorded at regular intervals (every year) during the mean follow-up period of 52 months. Preoperative acetabular anteversion was measured in the axial CT through the acetabular fossa center. Post-surgery, the cup anteversion was determined by Lewinnek methods [8] (Fig. 3C). Two authors who did not participate in the surgeries (NL and JH) reviewed the clinical and radiographic assessments independently.

2.5 Statistical analysis

The cup position was determined by the comparison between surgical and contralateral native hips in patients who underwent unilateral THA. Continuous variables were shown as mean $\pm$ standard deviation. To compare the cup position between surgical and contralateral native hips among patients who underwent unilateral THA, the paired-sample $t$ -test was performed in this study. A $P$ -value $<$ 0.05 was considered significant. All analyses were conducted using SPSS statistical software version 19.0 (SPSS Inc., Chicago, IL, USA).

3. Results

3.1 Description of the study participants

All 48 patients (54 hips) were aged ranging from 34 to 81 years, with a mean age of 61.1 $\pm$ 11.64 years. They were followed up for 4 to 5 years (mean follow-up time: 52 months), with a treatment compliance rate of 100% and 0% dropouts. The mean body mass index was 25.0 $\pm$ 3.1 kg/m2. There were 30 men (62.5%) and 18 women (37.5%).

Two patients (2 hips, adverse effects rate: 3.7%) suffered greater trochanter fractures intraoperatively (Zimmer, CLS Spotorno stem) and were treated with Kirschner wire plus tension band. No other complications were identified during follow-up, including dislocation, superficial or deep infection, nerve palsies and periprosthetic fractures. At the last follow-up, no hip showed radiographic signs of components loosening (recurrence rate: 0%). All implants were porous-coated cementless components from two manufacturers (LINK-Germany: 32 hips, Zimmer-USA: 22 hips). For the femoral head and liners, there were ceramic to ceramic (17 hips), ceramic to polyethylene (21 hips), and metal to polyethylene (16 hips). The cup size ranged from 46–60 mm (median: 52 mm) in women and 50–60 mm (median: 54 mm) in men.

3.2 Results of functional outcomes

Regarding functional outcomes, no patients reported groin or thigh pain, and patients were able to do deep squatting and one-leg standing 6 months post-surgery. The mean HHS was 94.46 $\pm$ 6.16 (range: 80–100) at the last follow-up. The outcome was rated as excellent in 46 hips (85.2%) and good in 8 (14.8%). The total WOMAC score was 10.41 $\pm$ 3.62 (range: 3–30). The SF-36 physical score was 95.19 $\pm$ 8.74 (range: 75–100), the SF-36 mental 94.74 $\pm$ 5.65 (range: 84–100), the SF-36 social 88.50 $\pm$ 9.41 (range: 77.78–100).

3.3 Results of the parameters before and after THA

Table 1
Radiological comparison between surgical and native hips (Mean $\pm$ Standard Deviation)

	Acetabular offset (mm)	Femoral offset (mm)	Acetabular height (mm)	Leg length (mm)	Anteversion (^∘)	Abduction (^∘)
Native hip	31.28 $\pm$ 3.70	34.26 $\pm$ 5.65	16.64 $\pm$ 3.58	8.19 $\pm$ 5.39	16.71 $\pm$ 4.47	53.22 $\pm$ 4.48
Surgical hip	29.67 $\pm$ 3.39	35.19 $\pm$ 4.81	16.87 $\pm$ 3.80	7.79 $\pm$ 5.38	17.42 $\pm$ 4.12	52.29 $\pm$ 5.53
$P$ value	0.001*	0.185	0.645	0.190	0.446	0.408

^*Significant differences between the native and surgical hips.

Among the 42 cases who underwent unilateral THA and were evaluated for the hip components position, the comparison results between surgical and native hips were listed in Table 1. The acetabular anteversion and abduction angle in native hips were 16.71 $\pm$ 4.47^∘ and 53.22 $\pm$ 4.48 ^∘, respectively. The cup anteversion and abduction angle were 17.42 $\pm$ 4.12^∘ and 52.29 $\pm$ 5.53^∘ post-surgery^∘, respectively. There were no significant differences compared to the native hips ( $P$ > 0.05). The acetabular offset decreased by 1.94 $\pm$ 3.22 mm from 31.28 $\pm$ 3.70 mm preoperatively to 29.67 $\pm$ 3.39 mm postoperatively ( $P=$ 0.001). Except for the acetabular offset, the replaced hip restored the biomechanical parameters to the native hips, including femoral offset, acetabular height and leg length ( $P>$ 0.05). Considering both the anteversion and abduction, 32 hips (59.26%) had the cup outside the LSZ.

4. Discussion

Appropriate cup placement is essential for THA, as it affects implant stability, longevity and hip biomechanics. However, there has been historical controversy regarding ideal cup positioning, and methods for aligning the cup can be categorized into mechanical, anatomical, combined anteversion and lumbopelvic kinematics adjusted alignment [29, 3]. The mechanical alignment philosophy is still considered to be the gold standard, and the LSZ was recommended to keep hip stability in primary THA. However, the primary data from the Lewinnek study had significant limitations when analyzed critically [11]. First, the 300 THA hips were performed by 5 different surgeons, and adequate data were available in only 122 cases (dislocation 9 cases). Second, the most experienced surgeon who performed 190 hips (with 1 dislocation, 0.5%) did not place a significantly greater number of cups within the safe zone. Additionally, a recent follow-up of 9784 primary THAs with 206 dislocations identified that 58% of dislocated hips had a cup within the LSZ [10].

Our study utilized the cotyloid fossa as a reliable landmark for anatomical cup implantation, with three constant points (UP, AP, and PP) that are easily identified. Preoperative dynamic 3D simulation in Mimics software ensured surgical safety by determining these landmarks and the combined anteversion, providing a relatively easy and accurate approach compared to other planning methods [31, 32]. A native acetabular anteversion angle of 16.71^∘ was measured in axial CT, which was less than Higgins (23.2^∘) and Zhang (20.1^∘) using 3D measurements. This difference may be attributed to the variations between 2D and 3D views. For the acetabular abduction, our results (53.22^∘) were similar to the reports of Hoggins and Zhang (56.5^∘ and 53.6^∘). Using anatomical cup implantation assisted with dynamic 3D planning, the acetabular height and femoral offset were restored to match those of the native hip. However, the cup offset (29.67 $\pm$ 3.39 mm) was slightly less than that of the native hip (31.28 $\pm$ 3.70 mm), and the cup medialization was the result of acetabular deepening. The medialization (1.94 mm) was larger than that reported by the Meermans [33] using the peripheral acetabular reaming technique (0.8 $\pm$ 1.4 mm), but it remained within the safe zone (0–5 mm) as described by Dastane et al. [34].

Table 2
Literature review on the acetabular cup positioned with anatomical landmarks assistance

Authors	Published year	Cases (hips)	Landmarks	Safe zone	Abduction (^∘)	Anteversion (^∘)	Follow-up	Dislocation	Function
McCollum and Gray [32]	1990	441 hips	Sciatic notch, ASIS, standing X-ray	FSZ	42.0 $\pm$ 4.4 (30.0–55.0) 100 hips measured	30.0 $\pm$ 5.5 (20–50), Lewinnek method 8	–	5 (1.14%)	–
Archbold et al. [17]	2006	1000 (1000)	TAL	PSTZ	–	–	8–41 months	6 (0.6%)	–
Sotereanos et al. [36]	2006	617 (617)	ilium, superior pubic ramus, superior acetabulum	LSZ	44.4 (24–58) 150 hips measured	13.2 (1–25), Widmer method [42]	average 4.5 years (10 lost, 6 died)	5 (0.81%)	HHS 84 (34–97)
Epstein et al. [18]	2010	30 (30)	TAL	LSZ	41.0 $\pm$ 6.6 (28–54)	23.6 $\pm$ 9.9 (10–39), cross-table lateral view	minimum 3 months	No (0%)	–
Ha et al. [16]	2012	46 (50)	TAN, AAN	LSZ	41.6 $\pm$ 3.8 (32.7–49.1)	16.0 $\pm$ 4.4 (7.5–26.5) cross-table lateral view	60–65 months	No (0%)	HHS 94 (86–100)
Miyoshi et al. [43]	2012	46 (47) (from 114 hips)	TAL, MAG	LSZ	38 $\pm$ 7 (22.1–54.1) CT measure	21.2 $\pm$ 4.1 (10.5–28.8), 3D CT measure	–	–	–
Meftah et al. [37]	2013	76 (78)	TAL, AAN, pelvic tilt	FSZ	41.2 $\pm$ 5 (29–53.4 )	18.4 $\pm$ 6 (1.5–36.4 ), EBRA software	1.4 $\pm$ 0.3 year (5–22 months)	No (0%)	–
Spencer-Gardner et al. [31]	2016	100 (100)	3D acetabular PSI	PSTZ	41.8 (29.6–58.1)	25.1 (9.6–36.3), 3D CT measure	–	No (0%)	–
Meermans et al. [33]	2016	50 (50)	Acetabular peripheral rim	PSTZ	38.8 $\pm$ 4.4	–	–	–	–

– Not reported, ASIS anterior superior iliac spine, FSZ functional safe zone, TAL transverse acetabular ligament, PSTZ patient-specific target zone, LSZ Lewinnek safe zone, TAN transverse acetabular notch, AAN anterior acetabular notch, MAG mechanical alignment guide, PSI patient-specific instrumentation.

Table 2 provides a literature review of studies on the acetabular cup positioned with anatomical landmarks assistance. McCollum and Gray [35] initially introduced cup positioning based on anatomical landmarks. However, their cups’ abduction was 42.0 $\pm$ 4.4^∘, and anteversion was 30.0 $\pm$ 5.5^∘, which was quite different from our studies. As for the anteversion, Sotereanos et al. [36], Meftah et al. [37] and Ha et al. [16] reported similar results to our study (17.42 $\pm$ 4.12), with values of 13.2^∘, 18.4^∘ and 16.0^∘, respectively. The largest cup abduction was reported by Sotereanos et al. [36] at 44.4^∘, as they intentionally placed the cup with low abduction to maintain a superior cup overhang. Archbold et al. [17] advocated for correct cup placement assisted with TAL, but their subsequent research by hip MRI showed acetabular anteversion (23.0 $\pm$ 7.4^∘) and abduction (45.6 $\pm$ 3.2^∘) [38]. The variation in cup abduction and anteversion angles observed in our study compared to others can be attributed to multiple factors, such as patient demographics, surgical techniques, implant designs, and methodologies. Utilizing preoperative dynamic 3D planning and relying on the acetabular fossa as a dependable landmark for cup implantation have been pivotal aspects of our research. Our patient-specific approach, which incorporated the combined anteversion test, was designed to restore hip stability and biomechanics, ultimately leading to favorable functional recovery in our cohort. Although our results lend support to the efficacy of our approach, further research is warranted to validate our findings and explore the long-term implications of different cup positioning methods on prosthesis survival.

Regarding the concern raised about the relatively large cup abduction angle (52.29 $\pm$ 5.53^∘) in our study, the dissenter worried about the liner edge wear. Malik et al. [39] indicated the anatomical acetabular orientation (55^∘ inclination and 12^∘ anteversion) might be unfavorable due to potential liner wear and hip stability issues. However, Goyal et al. [40] evaluated the effect of acetabular position on polyethylene liner wear with a minimum 10 years follow-up and found no significant correlation between polyethylene wear rate and the abduction ( $P=$ 0.82) or anteversion angle ( $P=$ 0.11). Similarly, Teeter et al. [41] reviewed 100 hips with at least ten years of follow-up and proved that placing the acetabular component within or outside the LSZ did not alter the wear rate of polyethylene liner to a risked osteolysis level. In our study, we observed that none of the hips showed radiographic signs of components loosening with at least four years of follow-up.

Only two studies in the literature performed functional analysis of the anatomical acetabular reconstruction. Sotereanos et al. [36] reported an HHS score of 84 (range: 34–97), while Ha et al. [16] reported a score of 94 (range: 86–100). The HSS score in our study was similar to that reported by Ha et al., at 94.46 $\pm$ 6.16 (range: 80–100). During a 2.5-year follow-up, Schmitz et al. [25] reported the total WOMAC score of 34.0 (range: 23–89), the SF-36 physical score of 75.0 (range: 5–100), and the SF-36 mental score of 88.0 (range: 32–100). Our study demonstrated better functional outcomes, with a total WOMAC score of 10.41 $\pm$ 3.62, an SF-36 physical score of 95.19 $\pm$ 8.74, and an SF-36 mental score of 94.74 $\pm$ 5.65.

This study had some limitations. Firstly, its retrospective design and the inclusion of all eligible patients who underwent anatomical cup implantation with dynamic 3D planning at our hospital may have introduced selection bias. Additionally, the limited sample size may have affected the generalizability of the findings to a broader population. The absence of a calculated sample size might have impacted the statistical power of the study. Furthermore, the lack of long-term follow-up limited our ability to assess factors such as liner wear and prosthesis survival. Moreover, the method’s reliance on preoperative CT scans, without full leg scans, may have introduced some limitations in accurately determining femoral neck anteversion. Lastly, the study’s focus on patients without serious acetabular degeneration or deformity may restrict the applicability of the findings to more complex cases. Future studies with larger sample sizes, formal sample size calculations, and a prospective design are needed to validate and strengthen these results.

5. Conclusion

This is the first study to evaluate the application of anatomical cup implantation assisted with preoperative dynamic 3D planning in primary THA. We introduced dynamic 3D assisted cup placement in total hip arthroplasty, offering clinicians a personalized and precise technique to enhance surgical outcomes, minimize complications, and improve patient care, while also contributing to the advancement of research in the field.

Ethical approval

The study was approved by the Ethics Committee of the People’s Hospital of Gansu Province (ethics number: 2021-223).

Informed consent

All participants were informed of the study’s purpose and signed an informed consent form.

Funding

None to report.

Data availability statement

The data used to support the findings of this study are available from the corresponding author upon reasonable request.

Footnotes

Acknowledgments

None to report.

Conflict of interest

The authors declare that they have no conflicts of interest.

References

Charnley

. The long-term results of low-friction arthroplasty of the hip performed as a primary intervention. Journal of Bone & Joint Surgery-british Volume. 1972; 54(1): 61-76.

Goto

Teranishi

Tsuji

Ando

. Long-term clinical results of Charnley total hip arthroplasty using a matte satin-finished stem: a 30-year average follow-up study. J Orthop Sci. 2014 Nov; 19(6): 959-64. Epub 2014/08/12.

Egan

Kummer

Frankel

. Biomechanics of total hip arthroplasty. Seminars in Arthroplasty. 1993; 4(4): 288.

Fukushi

Kawano

Motomura

Hamai

Kawaguchi

Nakashima

. Does hip center location affect the recovery of abductor moment after total hip arthroplasty? Orthop Traumatol Surg Res. 2018 Dec; 104(8): 1149-53. Epub 2018/10/08.

Pagnano

Hanssen

Lewallen

Shaughnessy

. The effect of superior placement of the acetabular component on the rate of loosening after total hip arthroplasty. Journal of Bone & Joint Surgery. 1996; 78(7): 1004-14.

Yoder

Brand

Pedersen

O’Gorman

. Total hip acetabular component position affects component loosening rates. Clin Orthop Relat Res. 1988; 228(228): 79.

Houcke

Khanduja

Pattyn

Audenaert

. The History of Biomechanics in Total Hip Arthroplasty. Indian journal of orthopaedics. 2017 Jul-Aug; 51(4): 359-67. Epub 2017/08/10.

Lewinnek

Lewis

Tarr

Compere

Zimmerman

. Dislocations after total hip-replacement arthroplasties. J Bone Joint Surg Am. 1978 Mar; 60(2): 217-20. Epub 1978/03/01.

Reina

Putman

Desmarchelier

Sari Ali

Chiron

Ollivier

, et al. Can a target zone safer than Lewinnek’s safe zone be defined to prevent instability of total hip arthroplasties? Case-control study of 56 dislocated THA and 93 matched controls. Orthop Traumatol Surg Res. 2017 Sep; 103(5): 657-61. Epub 2017/06/21.

10.

Abdel

von Roth

Jennings

Hanssen

Pagnano

. What Safe Zone? The Vast Majority of Dislocated THAs Are Within the Lewinnek Safe Zone for Acetabular Component Position. Clin Orthop Relat Res. 2016 Feb; 474(2): 386-91.

11.

Dorr

Callaghan

. Death of the Lewinnek “Safe Zone”. J Arthroplasty. 2019 Jan; 34(1): 1-2.

12.

Higgins

Spratley

Boe

Hayes

Jiranek

Wayne

. A novel approach for determining three-dimensional acetabular orientation: results from two hundred subjects. J Bone Joint Surg Am. 2014 Nov 5; 96(21): 1776-84. Epub 2014/11/08.

13.

Zhang

Wang

Chen

Wang

Dai

. Three-dimensional acetabular orientation measurement in a reliable coordinate system among one hundred Chinese. PLoS One. 2017 Feb; 12(2): e0172297. Epub 2017/02/17.

14.

Patel

Wagle

Usrey

Thompson

Incavo

Noble

. Guidelines for implant placement to minimize impingement during activities of daily living after total hip arthroplasty. J Arthroplasty. 2010 Dec; 25(8): 1275-81e1. Epub 2009/12/22.

15.

D’Lima

Urquhart

Buehler

Walker

Colwell

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 Mar; 82(3): 315-21. Epub 2000/03/21.

16.

Yoo

Lee

Kim

Koo

. Acetabular component positioning using anatomic landmarks of the acetabulum. Clin Orthop Relat Res. 2012 Dec; 470(12): 3515-23. Epub 2012/07/11.

17.

Archbold

Mockford

Molloy

McConway

Ogonda

Beverland

. The transverse acetabular ligament: an aid to orientation of the acetabular component during primary total hip replacement: a preliminary study of 1000 cases investigating postoperative stability. J Bone Joint Surg Br. 2006 Jul; 88(7): 883-6.

18.

Epstein

Woolson

Giori

. Acetabular component positioning using the transverse acetabular ligament: can you find it and does it help? Clin Orthop Relat Res. 2011 Feb; 469(2): 412-6.

19.

Maruyama

Feinberg

Capello

D’Antonio

. The Frank Stinchfield Award: Morphologic features of the acetabulum and femur: anteversion angle and implant positioning. Clin Orthop Relat Res. 2001 Dec; 393(393): 52-65.

20.

Gao

Yang

Zhang

. Using acetabular fossa as a guide for anticipated inclination of uncemented cup in total hip replacement. International journal of clinical and experimental medicine. 2015; 8(1): 181-7. Epub 2015/03/19.

21.

Shon

Park

Yun

. Total Hip Arthroplasty: Past, Present, and Future. What Has Been Achieved? Hip & pelvis. 2019 Dec; 31(4): 179-89. Epub 2019/12/12.

22.

Wroblewski

Siney

Fleming

. Charnley low-friction arthroplasty: survival patterns to 38 years. J Bone Joint Surg Br. 2007 Aug; 89(8): 1015-8. Epub 2007/09/06.

23.

Hernández-Vaquero

Suárez-Vazquez

Fernandez-Lombardia

. Charnley low-friction arthroplasty of the hip. Five to 25; years survivorship in a general hospital. BMC Musculoskelet Disord. 2008 May 15; 9: 69. Epub 2008/05/17.

24.

Callaghan

Bracha

Liu

Piyaworakhun

Goetz

Johnston

. Survivorship of a Charnley total hip arthroplasty. A concise follow-up, at a minimum of thirty-five years, of previous reports. J Bone Joint Surg Am. 2009 Nov; 91(11): 2617-21. Epub 2009/11/04.

25.

Schmitz

, van Susante

JLC

Hol

Brokelman

, van Loon

CJM

. No decline in high patient satisfaction after total hip arthroplasty at long-term follow-up. Eur J Orthop Surg Traumatol. 2019 Jan; 29(1): 91-5. Epub 2018/06/03.

26.

Buller

Menken

Hawkins

Bas

Roc

Jr. Cooper

, et al. Iliopsoas Impingement After Direct Anterior Approach Total Hip Arthroplasty: Epidemiology, Risk Factors, and Treatment Options. J Arthroplasty. 2020 Dec 13. Epub 2021/01/09.

27.

Dorr

Malik

Dastane

Wan

. Combined anteversion technique for total hip arthroplasty. Clin Orthop Relat Res. 2009 Jan; 467(1): 119-27.

28.

Ohmori

Kabata

Kajino

Inoue

Taga

Yamamoto

, et al. The optimal combined anteversion pattern to achieve a favorable impingement-free angle in total hip arthroplasty. J Orthop Sci. 2019 May; 24(3): 474-81.

29.

Maillot

Harman

Villet

Cobb

Rivière

. Modern cup alignment techniques in total hip arthroplasty: A systematic review. Orthop Traumatol Surg Res. 2019 Sep; 105(5): 907-13. Epub 2019/05/06.

30.

Seki

Yuasa

Ohkuni

. Analysis of optimal range of socket orientations in total hip arthroplasty with use of computer-aided design simulation. Journal of Orthopaedic Research. 2010; 16(4): 513.

31.

Spencer-Gardner

Pierrepont

Topham

Bare

McMahon

Shimmin

. Patient-specific instrumentation improves the accuracy of acetabular component placement in total hip arthroplasty. Bone & Joint Journal. 2016; 98-B(10): 1342.

32.

Amiri

Masri

Garbuz

Anglin

Wilson

. A multiplanar radiography method for assessing cup orientation in total hip arthroplasty. J Biomech Eng. 2012 Oct; 134(10): 101008. Epub 2012/10/23.

33.

Meermans

Doorn

Kats

. Restoration of the centre of rotation in primary total hip arthroplasty: the influence of acetabular floor depth and reaming technique. Bone Joint J. 2016 Dec; 98-b(12): 1597-603. Epub 2016/12/03.

34.

Dastane

Dorr

Tarwala

Wan

. Hip offset in total hip arthroplasty: quantitative measurement with navigation. Clin Orthop Relat Res. 2011 Feb; 469(2): 429-36. Epub 2010/09/17.

35.

McCollum

Gray

. Dislocation after total hip arthroplasty. Causes and prevention. Clin Orthop Relat Res. 1990 Dec; (261): 159-70. Epub 1990/12/01.

36.

Meftah

Yadav

Wong

Ranawat

. A novel method for accurate and reproducible functional cup positioning in total hip arthroplasty. J Arthroplasty. 2013 Aug; 28(7): 1200-5. Epub 2013/03/07.

37.

Sotereanos

Miller

Smith

Hube

Sewecke

Wohlrab

. Using intraoperative pelvic landmarks for acetabular component placement in total hip arthroplasty. J Arthroplasty. 2006 Sep; 21(6): 832-40. Epub 2006/09/05.

38.

Archbold

Slomczykowski

Crone

Eckman

Jaramaz

Beverland

. The relationship of the orientation of the transverse acetabular ligament and acetabular labrum to the suggested safe zones of cup positioning in total hip arthroplasty. Hip international: the journal of clinical and experimental research on hip pathology and therapy. 2008 Jan-Mar; 18(1): 1-6.

39.

Malik

Maheshwari

Dorr

. Impingement with total hip replacement. J Bone Joint Surg Am. 2007 Aug; 89(8): 1832-42.

40.

Goyal

Howard

Yuan

Teeter

Lanting

. Effect of Acetabular Position on Polyethylene Liner Wear Measured Using Simultaneous Biplanar Acquisition. J Arthroplasty. 2017 May; 32(5): 1670-4. Epub 2017/01/15.

41.

Teeter

Lanting

Naudie

McCalden

Howard

MacDonald

. Highly crosslinked polyethylene wear rates and acetabular component orientation: a minimum ten-year follow-up. Bone Joint J. 2018 Jul; 100-B(7): 891-7. Epub 2018/ 06/30.

42.

Widmer

. A simplified method to determine acetabular cup anteversion from plain radiographs. J Arthroplasty. 2004 Apr; 19(3): 387-90. Epub 2004/04/07.

43.

Miyoshi

Mikami

Oba

Amari

. Anteversion of the acetabular component aligned with the transverse acetabular ligament in total hip arthroplasty. J Arthroplasty. 2012 Jun; 27(6): 916-22.

Anatomical cup implantation assisted with dynamic 3D planning improves functional outcomes in primary total hip arthroplasty: A retrospective study

Abstract

BACKGROUND:

OBJECTIVE:

METHODS:

RESULTS:

CONCLUSION:

Keywords

1. Introduction

2. Materials and methods

2.1 Participants

2.2 Preoperative dynamic 3D planning

2.4 Follow up evaluation

3. Results

3.1 Description of the study participants

3.2 Results of functional outcomes

3.3 Results of the parameters before and after THA

Table 1 Radiological comparison between surgical and native hips (Mean ± Standard Deviation)

Table 2 Literature review on the acetabular cup positioned with anatomical landmarks assistance

Ethical approval

Informed consent

Funding

Data availability statement

Footnotes

Acknowledgments

Conflict of interest

References

Table 1
Radiological comparison between surgical and native hips (Mean $\pm$ Standard Deviation)

Table 2
Literature review on the acetabular cup positioned with anatomical landmarks assistance