A radiographic comparison of femoral offset after cemented and cementless total hip arthroplasty

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1 Hip Int 2014; 00 ( 00 ): DOI: /hipint ORIGINAL ARTICLE A radiographic comparison of femoral offset after cemented and cementless total hip arthroplasty James R. Berstock, Adrian M. Hughes, Amy M. Lindh, Evert J. Smith Avon Orthopaedic Centre, Southmead Hospital, Bristol - UK Restoring femoral offset during total hip arthroplasty is important. Femoral offset and leg lengths are inextricably linked by the caput-collum-diaphysis (CCD) angle of the implant being used. We investigate the restoration of offset and leg lengths using the radiographs of a consecutive series of patients following implantation with either a high CCD angled cementless, or an anatomical CCD angled cemented femoral component. Although our data suggests that we are able to restore femoral offset and leg lengths using either device, we recommend additional caution when using non-anatomical high CCD angled implants. Keywords: Arthroplasty, Replacement, Hip, Cementation, Leg length inequality, Digital radiography Accepted: May 6, 2014 INTRODUCTION Restoration of an appropriate femoral offset is fundamental to the long-term survival of a total hip replacement and is important for providing patients with the satisfaction expected of their hip joint replacement. An appreciation of the biomechanics of the hip joint, in particular the abductor muscle function, is critical. The surgeon s choice of femoral stem is a key factor in influencing outcomes. The femoral offset is the perpendicular distance measured from the centre of rotation (COR, i.e. centre of the femoral head) to the longitudinal axis of the centre of the femoral canal. The femoral offset determines the abductor lever arm. Optimising femoral offset restores the soft tissue tension, minimises impingement, dislocation and implant loosening, but also improves the postoperative range of movement and normalises the gait pattern (1, 2). A reduced femoral offset disadvantages the abductors by reducing the lever arm, increasing the joint reaction forces of the hip thus leading to increased wear of the bearing surfaces (3, 4). Different brands of contemporary cemented and cementless femoral implants offer a variety of offsets. The ability to alter femoral offset and stem size varies widely between systems. The caput-collum-diaphysis (CCD), or neck shaft angle of the stem, is the key variable, coupling femoral offset with leg length. Few clinical studies offer insight into the choice of implant design and the relationship to femoral offset. We hypothesise that the cemented, anatomical CCD angled device may restore both leg length and femoral offset more reliably than a high CCD angled device. This radiographic study compares the restoration of femoral offset and leg length with both devices. METHOD AND MATERIALS Two femoral components used routinely in our unit were selected for comparison. The cemented Exeter V40 (Stryker, Newbury, UK) with a neck-shaft angle of 125 was compared with the cementless Taperloc (Biomet, Bridgend, UK) stem with a CCD angle of 138. An Exceed ABT (Biomet, Bridgend, UK) cementless acetabular cup was used in all of the patients. The radiographs of consecutive patients with unilateral osteoarthritis requiring a total hip replacement between 1

2 Femoral offset after cemented and cementless total hip arthroplasty Fig. 1 - Measurement of offset and leg length from the immediate postoperative radiograph showing a Taperloc stem and Exceed ABT cup and 2012 were retrospectively recruited into each group. Younger patients (<65 years) tended to receive a cementless femoral implant. Patients with inadequate radiographs, contralateral hip degenerative disease or a contralateral THR were excluded until 40 patients were recruited to each group. All operations were performed using a posterior approach and either performed or supervised by the senior author. Immediate postoperative anteroposterior (AP) radiographs were taken according to a standardised local protocol with low centring of the image on the pelvis and 20 of internal rotation of both lower limbs. The ratio of the actual and radiographically measured diameter of the prosthetic femoral head was used as a magnification factor for each individual patient to scale measurements taken from the postoperative AP radiographs. The femoral offset (the perpendicular distance from the anatomical axis of the femur to the COR) was measured on the postoperative radiographs. Leg lengths were also measured postoperatively from a line drawn through the most inferior points of the ischial tuberosities to the most medial point of the lesser trochanter. The contralateral non-diseased side was used to determine the patient s normal anatomy, against which postoperative values were compared (Fig. 1). Two authors measured offset and leg length independently from each other. Data analysis and statistics An a priori power calculation was performed to detect a 5 mm difference in restoration in femoral offset between the groups as this was deemed clinically relevant. Preliminary data indicated that leg length varies with a standard deviation of 8 mm. Using an alpha value of 0.05 and a power of 80%, 40 patients were required in each group. The data were analysed using SPSS software (version 17.0; SPSS, Chicago, Illinois). A statistician performed inter-observer analyses of the measurements. Assumptions of normality were confirmed with Shapiro Wilk testing, and homogeneity of variances confirmed with Levine s testing. Accordingly data from the two groups was analysed with a two-tailed t-test of the null hypothesis that there would be no difference in femoral offset or leg lengths between the groups. RESULTS Postoperative radiographs for forty consecutive patients undergoing cemented hip replacement and forty consecutive patients undergoing cementless total hip replacement were analysed by two independent observers. There was a statistically significant strong Pearson s correlation between the two observers for lateral offset (p<0.001), and for leg length (p<0.001). As such, individual 2

3 Berstock et al TABLE I - COMPARISON OF CEMENTED AND CEMENT- LESS GROUPS Cemented (Exeter) Cementless (Taperloc) p value Offset (mm) +2.4 (5.6) +2.1 (6.3) 0.83 Leg length (mm) -1.0 (5.1) +0.5 (7.0) 0.27 Values are presented as means with standard deviations in parenthesis. measurements were averaged for both observers for further statistical analysis. Results are summarised in Table I. Restoration of lateral offset The mean change in lateral offset was an increase of 2.42 mm (95% CI 0.69, 4.15) with cemented implants, and 2.13 mm (95% CI 0.16, 4.10) in the cementless group. This difference was not statistically significant, (p = 0.83). Restoration of leg length The mean change in leg length was a shortening of mm (95% CI -2.62, 0.55) in the cemented group, and lengthening of 0.49 mm (95% CI -1.67, 2.64) in the cementless group. This difference was not statistically significant (p = 0.27). DISCUSSION Our results demonstrate a subtle trend towards greater increases in offset with the low CCD angled cemented stems, and greater increases in leg length with the high CCD angled cementless stems. Although these results did not reach statistical significance, the trend supports the hypothesis that CCD angle impacts offset and leg length. Obtaining excellent operative outcomes including long term implant survival requires a detailed knowledge of the implant. The CCD or neck shaft angle of the stem is the key variable in determining the femoral offset. Market leading brands, such as the Spotorno (Zimmer, Warsaw, Indiana), Taperloc, and Corail (DePuy, Leeds, UK) cementless stems have CCD angles of 145, 138 and 135 respectively. The cemented C-stem AMT (DePuy, Leeds, UK), CPT (Zimmer, Warsaw, Indiana), and Exeter V40 Fig. 2 - Mathematical relationship between caput-collum-diaphysis (CCD), femoral offset (FO), and leg length (LL). have CCD angles of 130, 125 and 125 respectively. The stem neck-shaft angle has a significant effect on the offset. As neck alignment progresses to an increasingly valgus position, femoral offset reduces. This positions the femur closer to the pelvis, such that an extreme reduced offset may initiate subluxation or dislocation of the hip joint. The difference in the stem CCD angle also impacts on the ability to correct and adjust leg length, as described by the mathematical equation in Figure 2. In vivo, mechanisms for varying femoral offset are numerous but sometimes complex. They include medialisation of the acetabulum (deepening the socket), trochanteric advancement, lateralisation of the acetabular liner, increasing the length of the femoral neck, reducing the CCD angle within a femoral implant system, or choosing a different femoral component altogether (5). An increase in the stem neck length inevitably increases the leg length of the operated leg. The Exeter prosthesis offset does not alter with increasing stem size. The stem position can be held up or driven into the cemented medullary canal to alter leg length, but the femoral offset remains static. The femoral neck length can be adjusted with the +4 or -4 mm femoral heads, resulting in +/ mm of offset, and +/ mm in leg lengths for all the standard sizes of Exeter 37.5 and 44 offset stems. This design rationale is common in cemented stems. In contrast, the offset increases with increasing size of femoral prosthesis in the majority of cementless stems. The anatomical variation of a wide femoral medullary canal with a varus CCD angle does not permit the use of the 138 Taperloc stem. An extremely low neck cut is required which may render the stem unstable due to lack of medial support and also increased risk of a femoral fracture. A narrow femur canal with a long neck requires an extended femoral offset and this combination is not available in this cementless stem system. An anatomical analysis of the proximal femur identified that a stem system with a single neck-shaft angle, will not allow accurate restoration of the biomechanical centre of the hip or femoral offset in 67% of patients (6). 3

4 Femoral offset after cemented and cementless total hip arthroplasty A greater selection of femoral shaft sizes is necessary to restore normal offset, but only if the femoral stem system has a near normal CCD angle (7). We can only speculate on the variation in CCD angles available on the market. Cementless implants may employ more valgus neck angles to safeguard against cantilever failure that may be less of a problem among cemented stems. Softer metals such as titanium may also require more valgus neck angles when compared with stainless steel implants to prevent implant fracture. Despite the excellent long-term results, use of cemented femoral components is decreasing in favour of cementless stems (8). Biomechanical studies support the use of an increased-offset femoral component with cementless fixation (9). There is variability in survivorship within cementless acetabular and femoral components, and this appears to be related to specific design features (8). The outcome of cemented implants appears to be more generic (10). However, in 2011, the Swedish Hip Arthroplasty Registry presented medium term data to show that the cementless stems used nationally have an improved survival rate as compared with cemented stems (8). The cross-over in terms of survival occurs at around eight years. Radiographic templating is important for distinguishing the correct choice, size and position of the components and identifies the true COR and the normalised femoral offset. The resection of the femoral neck and leg length can be evaluated. Osteophyte removal can be targeted in relation to the acetabular cup position and the patient bone stock and position of metal work in situ can be assessed. The versatility of modular neck-stem junction designs may offer distinct advantages in patients with complex anatomy as leg lengths and offset can be adjusted independent of each other. Such modularity has however been associated with adverse outcomes, and increased rates of failure in the joint registries. Problems associated with neck fracture (11), dissociation (12), corrosion at the modular interface (13), metal ion release and soft tissue reactions have been identified (14). For this reason we do not currently recommend highly modular implants for the vast majority of cases. Our study is limited by the small number of participants and possible selection bias that arises when random allocation is not undertaken. These issues do not detract from publicising the relationship between CCD, femoral offset and leg length. We recommend caution when using a high neck shaft angle femoral stem when attempting to restore femoral anatomy under normal circumstances. Near anatomical neck shaft angled stems may provide a more reliable method of restoring both offset and leg length simultaneously. The surgeon should consider all the variables including patient demographics when making decisions about implant selection, surgical technique or when deciding on a cementless stem system as compared with a cemented stem. This series from a high volume unit demonstrates that with good knowledge of the characteristics of individual implants, restoration of the femoral offset and equal leg length can be obtained, regardless of design. A detailed knowledge of ones implants is key to success. ACKNOWLEDGEMENTS We are grateful to Dr Iain Wier and the applied statistics group at the University of the West of England, for all statistical analysis. Financial Support: None. Conflict of Interest: Senior author (ES) is designer of the cementless cup used in this series. Address for correspondence: James Berstock Avon Orthopaedic Centre Southmead Hospital Southmead Road Bristol, BS10 5NB, UK jberstock@gmail.com REFERENCES 1. Bourne RB, Rorabeck CH. Soft tissue balancing: the hip. J Arthroplasty. 2002;17(4 Suppl 1): Mahoney CR, Pellicci PM. Complications in primary total hip arthroplasty: avoidance and management of dislocations. Instr Course Lect. 2003;52: Davey JR, O Connor DO, Burke DW, Harris WH. Femoral component offset. Its effect on strain in bone-cement. J Arthroplasty. 1993;8(1): Sakalkale DP, Sharkey PF, Eng K, Hozack WJ, Rothman RH. Effect of femoral component offset on polyethylene wear in total hip arthroplasty. Clin Orthop Relat Res. 2001;(388):

5 Berstock et al 5. Charnley J. Low friction arthroplasty of the hip: theory and practice. Berlin: Springer-Verlag, Massin P, Geais L, Astoin E, Simondi M, Lavaste F. The anatomic basis for the concept of lateralized femoral stems: a frontal plane radiographic study of the proximal femur. J Arthroplasty 2000;15(1): Noble PC, Alexander JW, Lindahl LJ, Yew DT, Granberry WM, Tullos HS. The anatomic basis of femoral component design. Clin Orthop Relat Res. 1988;(235): Swedish Hip Arthroplasty Register annual report Available at: 117_SKAR_2012_Engl_1.0.pdf. Accessed August 1, Wong PKC, Otsuka NY, Davey JR, Fornasier VL, Binnington AG. The effect of femoral component offset in uncemented total hip arthroplasty. Canadian Orthopaedic Society 48 th Annual Meeting. Montreal, Quebec, Morshed S, Bozic KJ, Ries MD, Malchau H, Colford JM, Jr. Comparison of cemented and uncemented fixation in total hip replacement: a meta-analysis. Acta Orthopaedica. 2007;78(3): Sotereanos NG, Sauber TJ, Tupis TT. Modular femoral neck fracture after primary total hip arthroplasty. J Arthroplasty. 2013;28(1):196 e Kouzelis A, Georgiou CS, Megas P. Dissociation of modular total hip arthroplasty at the neck-stem interface without dislocation. J Orthop Traumatol. 2012;13(4): Dangles CJ, Altstetter CJ. Failure of the modular neck in a total hip arthroplasty. J Arthroplasty. 2010;25(7):1169 e Gill IP, Webb J, Sloan K, Beaver RJ. Corrosion at the neck-stem junction as a cause of metal ion release and pseudotumour formation. J Bone Joint Surg Br. 2012;94(7):

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