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Acetabular Center Axis: Is It the Future of Hip Navigation?

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Acetabular Center Axis: Is It the Future of Hip Navigation? ■ Feature Article Acetabular Center Axis: Is It the Future of Hip Navigation? SAM HAKKI, MD; VICTOR BILOTTA, MD; J. DANIEL OLIVEIRA, MD; LUIS DORDELLY, BS abstract There are 2 distinct methods of cup navigation in total hip arthroplasty. One resorted to piercing the skin to improve predicts orientation of the acetabulum through bony landmarks outside the ac- their registration efforts; others resorted etabulum (eg, the anterior pelvic plane); its unreliability is well published. The to using “adjusted” APP registration other identifi es acetabular center axis (ACA) and is patient-specifi c method that in which the APP registration is calcu- is independent of pelvic tilt, making it more reliable. Data from readily pal- lated according to the change of APP pable acetabular registration points were compared with postoperative pelvic with changes of pelvic tilt. Some results computed tomography images in 137 cases. Findings show that ACA software showed fairly accurate registration and is accurate in determining acetabular/cup version and inclination. Cup center good prediction of the inclination angle axis should coincide within 4 mm of ACA to minimize impingement and maxi- and version of the acetabulum.16-18 How- mize stability without altering preoperative femoral version. ever, the new hip center could be cranial, caudal, anterior, or posterior in relation to the acetabular center, or it could be he femoral neck axis normally device (eg, a Tilt-Meter) or by imaging, medialized by implant design or to gain coincides with the acetabu- such as computed tomography (CT).1-6 A more stability. These changes made for T lar center axis (ACA), rotating classic example of the indirect method the new hip center and axis of rotation around the center of the acetabulum dur- of registering bony landmarks is palpa- must be addressed so that the preopera- ing range of motion of the hip, produc- tion of the anterosuperior iliac spines tive acetabulum/femur relationship is ing maximum stability and minimum and symphysis pubis, called the anterior maintained to avoid impingement and impingement. The ideal navigation sys- pelvic plane (APP).7-9 Other examples of instability. tem should be based on that simple fact indirect registration are (1) palpation of The direct method of registration has of reproducing the initial kinematics be- the transverse pelvic plane (TPP), which evolved in response to this need.19,20 The tween femur and acetabulum even in the relies on the posterosuperior iliac spines direct method of registration relies on severly arthritic hips because they usu- and the sacral slope adjustment (SSA), the ACA, which is patient-specifi c and ally maintain that relationship. which correlates with functional spinal Currently, total hip arthroplasty parameters in identifying the APP, and (THA) navigation relies on 2 different (2) palpation of the transverse acetabu- Drs Hakki, Bilotta, and Oliveira, and Mr 10-12 Dordelly are from the Bay Pines Medical Center, principles of registration to achieve the lar ligament (TAL). However, varia- Bay Pines, Florida. desired cup/stem relationship. The fi rst tion in thickness of subcutaneous tissue, Dr Hakki is a consultant for B. Braun Aesculap. method is the indirect method, which re- ossifi cation, movement during the regis- Drs Bilotta and Oliveira, and Mr Dordelly have no lies on digitalization of bony landmarks tration process, and anatomic variations relevant fi nancial relationships to disclose. Correspondence should be addressed to: outside of the acetabulum that defi ne the of acetabular version among healthy in- Sam Hakki, MD, PO Box 22429, St Petersburg, frontal pelvic plane by simple palpation dividuals have resulted in major errors FL 33742. or by ultrasound, or aided by a mechanical in cup orientation.13-15 Some clinicians doi: 10.3928/01477447-20100510-52 OCTOBER 2010 | Volume 33 • Number 10/SUPPLEMENT 43 ■ Feature Article The ACA registration was done by 3 3 Points Acetabular Rim REGISTRATION points of palpation of the superior rim, 3 points of the most anterior rim, and 3 points of the most posterior rim of the acetabulum (Figure 1). The superior Superior POINT point must be chosen consistently. We Anterior determined the superior point of the ac- POINT etabulum as the point of transection of a Posterior line from the prominent iliac tubercle to POINT the center of transverse acetabular liga- One Point Registration ment (acetabular notch) (Figure 2). The Base of the fovea definition 1 2 software averages the points (Figure 1) and maps out the orientation of the ace- Figure 1: Three points are needed for ACA software Figure 2: The superior point is the most important to calculate the acetabular center and center axis. point to obtain to ensure consistency. This point is not tabulum and its center, which determines One more point is needed at the base of the fovea at the 12-o’clock position, but rather is more poste- the ACA. This axis guides the surgeon to alert the surgeon during reaming that the reamer rior. The line from iliac tuberosity to mid-TAL touches where to position the reamer for place- is at the medial wall when the ACA is zero. the superior point of the acetabular rim. ment at the center of the acetabulum. The surgeon has the option of choosing the independent of variations in anatomy or comparable with CT in its accuracy in desired acetabular version or inclination pelvic position, and relies on readily ac- determining the inclination and ver- angle to accommodate individual patient cessible anatomic landmarks of the ace- sion angles of the acetabulum and cup anatomy while maintaining the center of tabulum. This method takes into account implant. The new hip center was Ͼ4 the acetabulum if possible when ream- the center of rotation of the acetabulum mm outside the desired ACA in only 4 ing. The center of the acetabulum is cal- and the new hip (cup) center. (The soft- of 135 patients; all 4 patients reported culated by the computer program as zero. ware for this method of acetabular/cup impingement symptoms. None of the Any deviation is calculated in millime- navigation is called ACA software.) remaining patients had dislocation or ters, whether directed medially, anteri- This system relies on reproducing the impingement. orly, posteriorly, caudally, or cranially preoperative hip center axis and adjust- (Figures 3, 4). We planned to be within ing the hip center, especially in dys- MATERIALS AND METHODS 2 mm from the center of acetabular axis plastic or protrusio hips. Therefore, the This prospective study compares the (Figure 5). In this way the preoperative version of the stem need not be changed ACA registration data with postoperative version of the neck of the femur could be because the axis of the femoral neck pelvis CT scan in anterolateral intermus- maintained without fear of impingement (version) will automatically coincide cular minimally-invasive computer-as- or excessive combined version of cup and with the ACA because the acetabular/fe- sisted THA. Since March 2007, 137 con- stem (Figures 4, 6). Stem navigation fol- mur axis relationship was not altered by secutive patients underwent OrthoPilot lowed ACA, and a femoral/patella/foot ACA software. Furthermore, changing navigated press-fi t Excia (B. Braun Aes- plane was established to ensure proper the version of the stem would throw the culap, Tuttlingen, Germany) or Metha leg navigation (Figure 7). Here, 3 points foot into internal or external deformity THA system (B. Braun Aesculap). Two are required for leg length and offset: 1 compared with its preoperative position. were excluded for lack of complete data. at any marked point (by Bovie or methy- Therefore, the navigation of the stem Patient age ranged from 34 to 86 years lene blue) of the greater trochanter, 1 at is limited to achieving the desired leg (mean, 65 years). One hundred sixteen a marked point at the lateral epicondyle length and offset. (The software of navi- patients had primary osteoarthritis; 14 (marker pen or methylene blue), and 1 at gation of the cup and the stem is called had avascular necrosis; 5 had rheuma- a marked point at the ankle. The surgeon ACA-PLUS.) toid arthritis. Mean body mass index was may use a small temporary K-wire or just Since March 2007, we collected data 32.2 kg/m2. Dysplastic acetabulum was drill a hole in the lateral epicondyle as from ACA software registration of mini- present in 12% of patients, and protru- a point of navigation for leg length with invasive computer-navigated THAs and sio was present in 4%. Patients were fol- the hip in neutral position. compared those data with postoperative lowed up for a minimum of 1 year with Preoperative plain pelvis radiographs CT images of the pelvis in 137 cases. postoperative radiographs, CT scan, and with anteroposterior and cross-table lat- Findings showed ACA software to be Harris score assessment. eral views were obtained as routine. They 44 ORTHOPEDICS | www.ORTHOSuperSite.com ACETABULAR CENTER AXIS FOR HIP NAVIGATION | HAKKI ET AL 3 4 Figure 3: The circled −4∘ refers to reaming at 4∘ less than the shaded 46∘ ac- Figure 4: The reamer should be within 2 mm of the ACA. Here, it is 1 mm etabular inclination. The circled +8∘ refers to reaming at 8∘ more anteversion caudal and 1 mm posterior. We medialized the reamer by 4 mm, but we did not than the shaded 14∘ acetabular version. The ACA diameter at the lower corner breach the base of the fovea. Note the red column reading of zero. accurately measures the size of the acetabulum. Reaming need not be more than 4 mm larger than 51 mm. The large head choice will give a zero lengthening and 4-2= +2 offset 5 6 7 Figure 5: ACA software has identifi ed the Figure 6: The actual cup version will be Figure 7: Three points are required for leg length and offset: new hip center and will compare it with the 46∘+1∘=47∘, whereas actual cup version will 1 at any marked point (by Bovie or methylene blue) of the original center of acetabulum (see Figures be 14∘−2∘=12∘ anteverted in an anterolateral greater trochanter, 1 at a marked point at the lateral epicon- 3 and 4).
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