Aims

In computer simulations, the shape of the range of motion (ROM) of a stem with a cylindrical neck design will be a perfect cone. However, many modern stems have rectangular/oval-shaped necks. We hypothesized that the rectangular/oval stem neck will affect the shape of the ROM and the prosthetic impingement.

There remains confusion in the literature with regard to the spinopelvic relationship, and its contribution to ideal acetabular component position. Critical assessment of the literature has been limited by use of conflicting terminology and definitions of new concepts that further confuse the topic. In 2017, the concept of a Hip-Spine Workgroup was created with the first meeting held at the American Academy of Orthopedic Surgeons Annual Meeting in 2018. The goal of this workgroup was to first help standardize terminology across the literature so that as a topic, multiple groups could produce literature that is immediately understandable and applicable. This consensus review from the Hip-Spine Workgroup aims to simplify the spinopelvic relationship, offer hip surgeons a concise summary of available literature, and select common terminology approved by both hip surgeons and spine surgeons for future research.

Cite this article: Bone Joint J 2019;101-B:808–816.

Background

Postural change after total hip arthroplasty (THA) is still a matter of discussion. Previous studies have mainly concentrated on the pelvic motions. We report the postoperative changes of the global sagittal posture using pelvic, spinal and lower extremities parameters.

Introduction

Spatial orientation of the pelvis in the sagittal plane is a key parameter for hip function. Pelvic extension (or retroversion) and pelvic flexion(or anteversion) are currently assessed using Sacral Slope (SS) evaluation (respectively SS decrease and SS increase). Pelvic retroversion may be a risk situation for THA patients. But the magnitude of SS is dependant on the magnitude of pelvic incidence (PI) and may fail to discriminate pelvic position due to patient's anatomy and the potential adaptation mechanisms: a high PI patient has a higher SS but this situation can hide an associated pelvic extension due to compensatory mechanisms of the pelvic area. A low PI patient has a lower SS with less adaptation possibilities in case of THA especially in aging patients. The individual relative pelvic version (RPV) is defined as the difference between « measured SS » (SSm) minus the « normal SS »(SSn) described for the standard population. The aim of the study was to evaluate RPV in standing and sitting position with a special interest for high and low PI patients.

Introduction

Literature describes pelvic rotation on lateral X rays from standing to sitting position. EOS full body lateral images provide additional information about the global posture. The projection of the vertical line from C7 (C7 VL) is used to evaluate the spine balance. C7 VL can also measure pelvic sagittal translation (PST) by its horizontal distance to the hip center (HC). This study evaluates the impact of a THA implantation on pelvic rotation and sagittal translation.

INTRODUCTION

Lumbar total disc replacement (TDR) is an alternative treatment to avoid fusion related adverse events, specifically adjacent segment disease. New generation of elastomeric non-articulating devices have been developed to more effectively replicate the shock absorption and flexural stiffness of native disc. This study reports 5 years clinical and radiographic outcomes, range of motion and position of the center of rotation after a viscoelastic TDR.

Introduction

Stand to sit pelvis kinematics is commonly considered as a rotation around the bicoxofemoral axis. However, abnormal kinematics could occur for patients with musculoskeletal disorders affecting the hip-spine complex. The aim of this study is to perform a quantitative analysis of the stand to sit pelvis kinematics using 3D reconstruction from bi-planar x-rays.

Introduction

The viscoelastic cervical disk prosthesis CP-ESP is an innovative one-piece deformable but cohesive interbody spacer. It is an evolution of the LP-ESP lumbar disk implanted since 2006. The implant provides 6 full degrees of freedom including shock absorption. The design allows a limitation for rotation and translation with resistance to motion (elastic return property) aimed at avoiding overload of the posterior facets. The rotation center can vary freely during motion. It thus differs substantially from current prostheses.

This study reports the clinical results of a prospective observational study series of 89 patients who are representative of the current use of the ESP implant since 2012.

The radiological results are focused on the evolution of the mean center of rotation (MCR) as an additional information to the range of motion (ROM) for the evaluation of the quality of spine movement.

Introduction

The viscoelastic cervical disk prosthesis ESP is an innovative one-piece deformable but cohesive interbody spacer. It is an evolution of the LP ESP lumbar disk implanted since 2006. CP ESP provides 6 full degrees of freedom about the 3 axes including shock absorption. The prosthesis geometry allows limited rotation and translation with resistance to motion (elastic return property) aimed at avoiding overload of the posterior facets. The rotation center can vary freely during motion (figure 1)

It thus differs substantially from current prostheses. This study reports the results of a prospective series of 49 patients who are representative of the current use of the ESP implant since 2012.

Introduction

The assessment of leg length is essential for planning the correction of deformities and for the compensation of length discrepancy, especially after hip or knee arthroplasty. CT scan measures the “anatomical” lengths but does not evaluate the “functional” length experienced by the patients in standing position. Functional length integrates frontal orientation, flexion or hyperextension. EOS system provides simultaneously AP and lateral measures in standing position and thus provides anatomical and functional evaluations of the lower limb lengths.

The objective of this study was to measure 2D and 3D anatomical and functional lengths, to verify whether these measures are different and to evaluate the parameters significantly influencing these potential differences

Introduction

The gold standard for knee surgery is the restoration of the so-called «neutral mechanical alignment ». Recent literature as pointed out the patients with «constitutional varus »; in these cases, restoring neutral alignment could be abnormal and even undesirable. The same situation can be observed in patients with «constitutional valgus alignment ». To date, these outliers cases have only been explored focusing on the lower limb; the influence of the pelvic morphotype has not been studied. Intuitively, the pelvic width could be a significant factor. The EOS low dose imaging technique provides full body standing X-rays to evaluate the global anatomy of the patient. This work explores the influence of the pelvic parameters on the frontal knee alignment.

Introduction

Coronal misalignment of the lower limbs is closely related to the onset and progression of osteoarthritis. In cases of severe genu varus or valgus, evaluating this alignment can assist in choosing specific surgical strategies. Furthermore, restoring satisfactory alignment after total knee replacement promotes longevity of the implant and better functional results. Knee coronal alignment is typically evaluated with the Hip-Knee-Ankle (HKA) angle. It is generally measured on standing AP long-leg radiographs (LLR). However, patient positioning influences the accuracy of this 2D measurement. A new 3D method to measure coronal lower limb alignment using low-dose EOS images has recently been developed and validated. The goal of this study was to evaluate the relevance of this technique when determining knee coronal alignment in a referral population, and more specifically to evaluate how the HKA angle measured with this 3D method differs from conventional 2D methods.

This study of retrieved 28 mm Metasul™ (cemented) revealed for the first time adverse wear effects created by impingement-subluxation in MOM. The 10 cases selected (with femoral stems) had annual follow-up 3–11 years. (1) Unequivocal evidence here shows that all heads routinely subluxed from the Metasul liners.

Femoral stems revealed well-demarcated notches (DN) on necks and trunnions (Fig. 1a: n = 6), shallow cosmetic blemishes (Fig. 1b CB: n = 4), and abrasion by cement (Fig. 1b: PMMA). As demonstrated by EOS radiographs, impingement locations varied with implant positioning, pelvic mobility and patient functionality – both anterior and posterior notching (Fig. 1). The first impingement notch occurred with head located (Fig. 2a), whereas the head had subluxed from the cup at 2^nd notch (Fig. 2b). The model demonstrated that patients gained 20° motion by such head-subluxation manoeuvres. It was surprising that there was no collateral damage evident on the liners. Even with severe notching of Ti6Al4V and CoCr stems, the cup rims generally appeared well-polished.

Femoral heads revealed macro-stripe damage on articular surfaces (Fig. 3), as did cups. Basal and polar macro-stripes on heads were always located at hip impingement positions. The equatorial stripes were formed at main-wear zone boundaries. Thus equatorial stripes were likely created by some form of rim-impact damage (micro-separation) or by local ingress of 3^rd-body wear particles under the cup rim.

Micro-grooving was evident within these macro-size stripes and frequently featured large raised lips (Fig. 3), interpreted as signs of adverse 3^rd-body wear mechanisms, and rarely described.(2) It would appear that large metal particulates were released during MOM impingement-subluxation manoeuvres and circulated the hip joint to producing severe 3^rd-body abrasion. Gradual decomposition of such large debris to nano-sized particulates under joint loading would then produce the often-referenced ‘self polishing’ effect of CoCr. EDS studies revealed metal smears on the CoCr surfaces containing the elements of titanium alloy (Ti, Al, V). This was further evidence of impingement-subluxation manoeuvres.(1, 3)

In-vivo cup wear patterns also appeared much larger than those produced in MOM simulators. Such differences likely reflected head-subluxation in vivo, whereby heads unconstrained by the subluxation maneuver were free to orbit up and even cross cup rims, i.e. “edge wear”. This appears to be the first study detailing the adverse wear mechanisms in MOM bearings. There are two limitations to our retrieval study, a) these wear results may not be representative for all MOM designs, and b) it is unknown whether such results have relevance to MOM cases continuing successfully.

Introduction

Accurate evaluation of femoral offset is difficult with conventional anteroposterior (AP) X-rays. Routine CT imaging is costly and exposes patients to a significant dose of radiation. The EOS® imaging system is an innovative slot-scanning radiography system that makes possible the acquisition of simultaneous and orthogonal AP and lateral images of the patient in standing position. These 2-dimensional (2D) images are equivalent to standard plane X-rays. Three-dimension (3D) reconstructions are obtained from these paired images according to a validated protocol. This prospective study explores for the first time the value of the EOS® imaging system for comparing measurements of femoral offset obtained from 2D images and 3D reconstructions.

Introduction

The viscoelastic lumbar disk prosthesis ESP is an innovative one-piece deformable but cohesive interbody spacer; it provides 6 full degrees of freedom about the 3 axes including shock absorption. The prosthesis geometry allows limited rotation and translation with resistance to motion (elastic return property) aimed at avoiding overload of the posterior facets. The rotation center can vary freely during motion. It thus differs substantially from current prostheses. This study reports the results of a prospective series of 120 patients who are representative of the current use of the ESP implant since 2006.

Controversy exists over the role of fretting-corrosion in modular junctions of large-diameter metal-on-metal (MOM) heads given the many design plus alloy mix-and-match variations. Overall data was also scant regarding a) fitting stem trunnions to head tapers, b) role of taper angles, c) role of smooth vs threaded trunnion junctions, d) role of head neck-lengths and e) role of head diameters. While the “12: 14” taper has been used with small CoCr heads for 40 years, we could not find retrieval analyses on this European ‘gold-standard’. We therefore selected 10 femoral stems with 28 mm modular heads for analysis (3–8 years follow-up). Unique to this study were the threaded taper profiles on both stems and heads (Fig. 1).

Six stems were cemented Ti6Al4V (Alize, FH-Orthopedics, France) with 12/14 taper angle defined as 5° 42′. These represented Ti64: CoCr combinations from 2 vendors. The other four were CoCr stems including the CoCrMo (Protasul-2) and CoNiCrMo (Protasul-10) alloys (cemented and HA-coated; Sulzer, Switzerland). These CoCr: CoCr combinations from one vendor had “12/14” stem-taper defined as 5° 38′. Anatomical positioning of Metasul heads (Sulzer, Switzerland) was identified by main-wear zone maps. Femoral heads were then bi-valved in horizontal plane for direct imaging by interferometry (WLI) and SEM. Visual corrosion mapping (3) was recorded digitally in 4 anatomical views. Quantitative analysis used 1 to 5 taper zones with 6-replicate measurements per zone (Fig. 1).

The WLI and SEM studies showed that non-contacting taper zones inside CoCr heads (Fig. 2) were threaded with pitch of 70 μm (PV: peak-valley depth = 5–7 μm). The non-contact zones on Sulzer stems had 130 μm pitch (PV = 4–8 μm) whereas Alize stems had 210 μm pitch (PV = 10–12 μm). Threads on both stem types were much coarser than CoCr heads; Ti64 stem threads were much coarser than CoCr stems. In contact zones, the Metasul threads had flattened (avg. roughness = 0.45 μm Ra). With CoCr stems there was little difference. Difference in pitch of stem-threads vs head-threads indicated there was no imprinting onto head tapers. Nor were there statistically significant differences evident in the contact zones along CoCr or Ti64 tapers. Small damaged areas (Fig. 3: arrows) may have been due to alternatively; initial machining, surgical impaction, in-vivo cold-welds, fretting, corrosion, or from surgical-removal. The as labeled “corrosion damage” was well within the “mild” grade for all implants.(3) Thus even with this considerable variety of design and material parameters, we were satisfied that these gold-standard taper junctions with threaded interfaces had performed very well with 28 mm MOM at 3–8 years follow-up.

Introduction

The position and orientation of the lower extremities are fundamental for planning and follow-up imaging after arthroplasty and lower extremity osteotomy. But no studies have reported the reproducibility of measurements over time in the same patient, and experience shows variability of the results depending on the protocols for patient positioning. This study explores the reproducibility of measurements in the lower extremity with the patients in “comfortable standing position” by the EOS® imaging system.

Unlike conventional radiographic methods, the newly introduced EOS system provides simultaneously-synchronized anteroposterior (AP) and true-lateral (LAT) x-ray images. EOS offers considerable potential for calculating parameters such as true femoral and acetabular angular positioning, impingement sites, and also for measuring wear in polyethylene cups. In this study we used THA wear-simulation fixtures to assess 3D-wear in polyethylene cups using EOS algorithms.

Introduction

Femoral stem anteversion after total hip arthroplasty (THA) has always been assessed using CT scan in supine position. In this study, we evaluated the anteversion of the femoral prosthesis neck in functional standing position using EOS® technology with repeatability and reproducibility of the measurements. The data obtained were compared with conventional anatomic measurements.

Introduction

Current artificial discs include 1 or 2 bearing surfaces, providing 3 or 5 degrees of freedom. The ESP® is a one-piece e implant made of silicon and polycarbonate -urethane securely fixed to titanium endplates. It allows limited rotation and translation with elastic return. This cushion without fixed rotation center achieves 6 degrees of freedom including shock absorption. This objective of this study was to evaluate the safety and efficacy of the concept in a prospective nonrandomized trial.