Accuracy of intraoperative estimation of femoral stem anteversion in cementless total hip arthroplasty by using a digital protractor and a spirit level.

BACKGROUND: The femoral component anteversion during surgery is traditionally assessed by a visual assessment of the surgeon and has proven to be imprecise. We sought to determine the accuracy of a digital protractor and a spirit level to measure the stem anteversion during cementless THA. METHODS: A prospective study was conducted among 107 patients (114 hips) who underwent primary cementless THA via posterolateral approach. A pipe with a spirit level was attached to the tibial tubercle and intermalleolar midpoint. While the leg was held perpendicularly to the floor, stem anteversion was estimated by 3 methods: method A by visual assessment; method B by a digital protractor alone; and method C by a digital protractor combined with a spirit level. The angles were compared with the true anteversion measured by postoperative CT scan. RESULTS: The average anteversion by method C (22.8° ± 6.9°, range -2° to 40°) was significantly lower than method A (24.6° ± 5.2°, range 0° to 30°) (p=0.033), but not different from the true anteversion (22.1° ± 8.2°, range -5.4° to 43.1°) (p=0.445). There were no significant differences between method B (23.2° ± 8.2°, range -4° to 45°) and method A, C or the true anteversion. The mean deviation of the intraoperative estimation from the true anteversion was 0.8° ± 3.7° (range -7.1° to 8.0°) by method C; 1.2° ± 5.1° (range -8.8° to 14.3°) by method B; and 2.5° ± 7.4° (range -19.0° to 16.0°) by method A. Estimation error within 5° was found in 107 hips (93.9%) with method C; 86 hips (75.4%) with method B; and 59 hips (51.8%) with method A. CONCLUSION: Accurate estimation of stem anteversion during cementless THA can be determined intraoperatively by the use of a digital protractor and a spirit level. TRIAL REGISTRATION: Thai Clinical Trials Registry ( TCTR 20180326003 ). Registered on 20 March 2018. Retrospectively registered.

Midterm follow-up of closing wedge high tibial osteotomy with upper tibiofibular joint capsulotomy.

Closing wedge high tibial osteotomy is a popular surgery for correcting varus knee in symptomatic patients. One of the major drawbacks of this method is complications related to fibular osteotomy. This study describes pearl and pitfalls of closing wedge high tibial osteotomy with upper tibiofibular joint capsulotomy, avoiding fibular osteotomy and proposes that it has less complications and better results. Closing wedge high tibial osteotomy with upper tibiofibular joint capsulotomy was carried on 34 knees (19 patients) between September 2011 and June 2015 (thirteen males and six females). Operated men were between 19 and 38 years with mean 21 years. Operated women were between 23 years and 51 years. Considering that only one woman was 23 years old and the other four were between 45 and 51, better results and fewer complications were obtained in younger individuals with less body mass index and milder deformities. As a conclusion, when selecting patients, it is vital to stick to inclusion criteria. When in two or more factors, the patient is close to upper limits of inclusion criteria, unsatisfactory outcomes might be expected.

Concordancia entre el análisis computarizado de la marcha y el examen físico en pacientes con anteversión femoral aumentada sin alteraciones neurológicas / Concordance between computerised gait analysis and physical examination in patients with augmented femoral anteversion

Introducción: La marcha es el punto máximo de independencia funcional de una persona y allí radica su importancia como patrón de movimiento, cuya medición ha sido desarrollada a través de los años. Objetivo: Evaluar la concordancia entre las variables de 2 herramientas de medición: el análisis computarizado de la marcha (ACM) y el examen físico (EF), en pacientes con anteversión femoral aumentada sin alteraciones neurológicas. Metodología: Es un estudio observacional analítico de concordancia; los datos se obtuvieron de forma retrospectiva de los años 2010 al 2014 en el laboratorio de análisis de la marcha del Instituto de Ortopedia Infantil Roosevelt por medio de una sola aplicación del ACM y del EF. Resultados: Se observó que existen alteraciones evidentes en el EF, pues a nivel de la cadera existe una disminución de la rotación externa y un aumento de la rotación interna. En el ACM se encontró que en la cadera existe una disminución del rango de rotación interna-externa en la fase de apoyo y balanceo; que en la rodilla hay una disminución del rango flexión-extensión durante la fase de balanceo, y en el tobillo se halló una disminución del rango dorsiflexión-plantiflexión en la fase de apoyo y balanceo. Conclusión: Este estudio determinó que el EF y el ACM son pruebas que no se correlacionan, por lo tanto, se puede deducir que son complementarias y aportan información con un abordaje diferencial para la toma de decisiones a nivel clínico

Introduction: Human gait is the highest point in a person's functional independence; therefore, its importance as a movement pattern has led to the development of measuring tools. Objective: To assess the concordance between 2 measuring tools: computerised gait analysis (CGA) and physical examination (PE) in patients with increased femoral anteversion without neurological alterations. Methods: We conducted an observational analytic study of concordance. Data were obtained retrospectively from 2010 to 2014 in the gait analysis laboratory of the Roosevelt Children's Orthopaedics Institute through a single application of CGA and PE. Results: There were evident alterations in the PE because, at the hip, the internal-external rotation range decreases in the stance and swing phases. In the knee, there was a decrease in the flexion-extension range during the swing phase and in the ankle there was also a decrease in the dorsiflexion-plantarflexion range in the stance and swing phases. Conclusion: This study found that there was no concordance between PE and CGA. Therefore, these tests are complementary and provide information for a differential approach in clinical decision-making

Femoral anteversion assessment: Comparison of physical examination, gait analysis, and EOS biplanar radiography.

BACKGROUND: Multiple measurement methods are available to assess transverse plane alignment of the lower extremity. RESEARCH QUESTION: This study was performed to determine the extent of correlation between femoral anteversion assessment using simultaneous biplanar radiographs and three-dimensional modeling (EOS imaging), clinical hip rotation by physical examination, and dynamic hip rotation assessed by gait analysis. METHODS: Seventy-seven patients with cerebral palsy (GMFCS Level I and II) and 33 neurologically typical children with torsional abnormalities completed a comprehensive gait analysis with same day biplanar anterior-posterior and lateral radiographs and three-dimensional transverse plane assessment of femoral anteversion. Correlations were determined between physical exam of hip rotation, EOS imaging of femoral anteversion, and transverse plane hip kinematics for this retrospective review study. RESULTS: Linear regression analysis revealed a weak relationship between physical examination measures of hip rotation and biplanar radiographic assessment of femoral anteversion. Similarly, poor correlation was found between clinical evaluation of femoral anteversion and motion assessment of dynamic hip rotation. Correlations were better in neurologically typical children with torsional abnormalities compared to children with gait dysfunction secondary to cerebral palsy. SIGNIFICANCE: Dynamic hip rotation cannot be predicted by physical examination measures of hip range of motion or from three-dimensional assessment of femoral anteversion derived from biplanar radiographs.

Comparison of Intraoperative Fluoroscopic Dunn View With Magnetic Resonance Imaging to Determine Femoral Version.

PURPOSE: To compare femoral version measured with a fluoroscopic Dunn view taken at the time of hip arthroscopy with values derived from axial magnetic resonance imaging (MRI) scans. METHODS: Of 159 hip arthroscopies performed from January 2014 through March 2015, 50 patients had magnetic resonance imaging (MRI) scans with a protocol that incorporates femoral version analysis. Dunn views are performed as a routine part of the preoperative fluoroscopic examination at the time of arthroscopy. Femoral version was measured from the fluoroscopic views and compared with values calculated from axial MRI images. The measurements were compared with a paired t test for difference in means, the intraclass correlation coefficient (ICC) for reliability, and the limits of agreement method of Bland and Altman. RESULTS: There was a very small but statistically significant difference between the measurement on fluoroscopic Dunn view and the value on axial MRI (mean difference, 1.4°, P = .03). The ICC was 0.809 (P < .0001), indicating substantial agreement. By the Bland and Altman method, the 95% limits of agreement for fluoroscopic versus MRI measurement were -7.6 to 10.4, with no significant difference in variance by Pitman test (P = .526). CONCLUSIONS: With careful attention to technique, the fluoroscopically simulated Dunn view can be used to measure femoral version with acceptable accuracy and obviates the need for repeat 3-dimensional imaging for patients who already have an MRI scan without version analysis. LEVEL OF EVIDENCE: Level II, testing of previously developed diagnostic criteria with a gold standard.

The Relationship Between Early-Stage Knee Osteoarthritis and Lower-Extremity Alignment, Joint Laxity, and Subjective Scores of Pain, Stiffness, and Function.

CONTEXT: Knee osteoarthritis (OA) is a debilitating disease that affects an estimated 27 million Americans. Changes in lower-extremity alignment and joint laxity have been found to redistribute the medial and/or lateral loads at the joint. However, the effect that changes in anteroposterior knee-joint laxity have on lower-extremity alignment and function in individuals with knee OA remains unclear. OBJECTIVE: To examine anteroposterior knee-joint laxity, lower-extremity alignment, and subjective pain, stiffness, and function scores in individuals with early-stage knee OA and matched controls and to determine if a relationship exists among these measures. DESIGN: Case control. SETTING: Sports-medicine research laboratory. PARTICIPANTS: 18 participants with knee OA and 18 healthy matched controls. INTERVENTION: Participants completed the Western Ontario McMaster (WOMAC) osteoarthritis questionnaire and were tested for total anteroposterior knee-joint laxity (A-P) and knee-joint alignment (ALIGN). MAIN OUTCOME MEASURES: WOMAC scores, A-P (mm), and ALIGN (°). RESULTS: A significant multivariate main effect for group (Wilks' Λ = 0.30, F7,26 = 8.58, P < .0001) was found. Knee-OA participants differed in WOMAC scores (P < .0001) but did not differ from healthy controls on ALIGN (P = .49) or total A-P (P = .66). No significant relationships were identified among main outcome measures. CONCLUSION: These data demonstrate that participants with early-stage knee OA had worse pain, stiffness, and functional outcome scores than the matched controls; however, ALIGN and A-P were no different. There was no association identified among participants' subjective scores, ALIGN, or A-P measures in this study.

Magnetic Resonance Three-dimensional Cube Technique in the Measurement of Piglet Femoral Anteversion.

BACKGROUND: The accurate measurement of the femoral anteversion (FA) angle is always a topic of much debate in the orthopedic surgery and radiology research. We aimed to explore a new FA measurement method to acquire accurate results without radiation damage using piglet model. METHODS: A total of thirty piglets were assigned to two groups based on the age. Bilateral femora were imaged with 3.0-T magnetic resonance (MR) and 64-slice computed tomography (CT) examinations on all piglets. FA was measured on MR-three-dimensional (3D) postprocessing software with a four-step method: initial validation of the femoral condylar axis, validation of the condylar plane, validation of the femoral neck axis, and line-plane angle measurement of FA. After MR and CT examinations, all piglets were sacrificed and their degree of FA was measured using their excised, dried femora. MR, CT, and dried-femur measurement results were analyzed statistically; MR and CT measurements were compared for accuracy against each other and against the gold standard dried femur measurement. RESULTS: In both groups, the mean FA value measured by MR was lower than that measured by CT. A statistically significant difference was observed between CT- and dried-femur measurements but not between MR- and dried-femur measurements. A higher correlation (0.783 vs. 0.408) and a higher consistency (0.863 vs. 0.578) with dried-femur measurement results were seen for MR measurements than CT measurements in the 1-week age group. However, in the 8-week age group, similar correlations (0.707 vs. 0.669) and consistencies (0.864 vs. 0.821) were observed. CONCLUSIONS: Noninvasive MR-3D-Cube reconstruction was able to accurately measure FA in piglets. Particularly in the 1-week age group with a larger proportion of cartilaginous structures, the correlation and consistency between MR- and dried-femur measurement results were higher than those between CT- and dried-femur measurements, suggesting that MR may be a new useful examination tool for FA-related diseases in children.

Ipsilateral varus knee alignment correlates with increased femoral stem anteversion in primary total hip arthroplasty.

PURPOSE: The purpose of this study was to evaluate whether the ipsilateral knee alignment secondary to knee osteoarthritis affect positioning of the femoral component anteversion during total hip arthroplasty. METHODS: Preoperative and postoperative computed tomography-based 3-D femoral models were reconstructed for 20 total hip arthroplasty patients. Prosthetic femoral stem and native femoral anteversion was measured and compared. RESULTS: An average increase by 4.5° ± 8.1° in femoral anteversion was found following total hip arthroplasty (p = 0.02). Strong positive correlation was found between the knee varus angle and the changes in femoral anteversion (R = 0.87, p<0.0001). The knee alignment was an independent factor for predicting the intraoperative positioning of femoral stem anteversion. CONCLUSIONS: The ipsilateral knee varus deformity should be considered to optimise the femoral component position during contemporary total hip arthroplasty.

Effect of femoral anteversion on clinical outcomes after hip arthroscopy.

PURPOSE: To compare the clinical outcomes after hip arthroscopy of patients with femoral retroversion, normal femoral version, and excessive femoral anteversion. METHODS: Patients who underwent primary hip arthroscopy from August 2008 to April 2011 and underwent femoral anteversion measurement by magnetic resonance imaging/magnetic resonance arthrogram were included. The patients were divided into 3 groups: retroversion, normal version, and excessive anteversion. The normal-version group was considered to have a value within 1 SD of the mean femoral version value. Four patient-reported outcome scores and the visual analog pain score were prospectively collected with analysis performed retrospectively. RESULTS: Two hundred seventy-eight patients met the inclusion criteria. Among these patients, mean anteversion was 8.2° ± 9.3°, creating a retroversion group defined as -2° or less and an anteversion group defined as 18° or greater. There were 25 patients in the retroversion group, 219 in the normal-version group, and 34 in the excessive-anteversion group. Most labral tears were noted in the 12- to 2-o'clock range, with the main difference at the anterior 3-o'clock position, where the excessive-anteversion group showed a lower incidence of tearing (30%) than the retroversion group (73%) and normal-anteversion group (78%). Postoperatively, there was a statistically significant improvement from preoperative scores in all 3 groups and for all scores (P < .001). When the postoperative scores were compared for the 3 groups, although all scores were higher in the retroversion group than in the other 2 groups, this was not statistically significant and there were no significant differences in scores among the 3 groups (modified Harris Hip Score, P = .104; Non-Arthritic Hip Score, P = .177; Hip Outcome Score-Activities of Daily Living, P = .152; Hip Outcome Score-Sport-Specific Subscale, P = .276; visual analog scale score, P = .508). CONCLUSIONS: On the basis of patient-reported outcome scores without accounting for diagnoses and treatments, the amount of femoral anteversion does not appear to affect the clinical outcomes after hip arthroscopy. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Femoral derotational osteotomy: surgical indications and outcomes in children with cerebral palsy.

Excessive femoral anteversion is common among children with cerebral palsy, and is, frequently treated by a femoral derotational osteotomy (FDO). It is important to understand surgical, indications for FDO, and the impact of these indications on the treatment outcomes. The Random Forest algorithm was used to objectively identify historical surgical indications in a large retrospective, cohort of 1088 limbs that had previously undergone single-event multi-level surgery. Treatment, outcome was based on transverse plane kinematics obtained from three-dimensional gait analysis. The, classifier effectively identified the historic indications (accuracy = .85, sensitivity = .93, specificity = .69, positive predictive value = .86, negative predictive value = .82), and naturally divided limbs into four, clusters: two homogeneous +FDO clusters (with/without significant internal hip rotation during gait), one homogeneous -FDO cluster, and a mixed cluster. Concomitant surgeries were similar among the, clusters. Limbs with excessive anteversion and internal hip rotation during gait had excellent outcomes, in the transverse plane. Limbs with excessive anteversion but only mild internal hip rotation had good, outcomes at the hip level; but a significant number of these limbs ended up with an excessive external, foot progression angle. The Random Forest algorithm was highly effective for identifying and, organizing historic surgical indications. The derived criteria can be used to give surgical decision making, guidance in a majority of limbs. The results suggest that limbs with anteversion and significant, internal hip rotation during gait benefit from an FDO, but limbs with excessive anteversion and only, mild internal hip rotation are at risk of developing an excessive external foot progression angle.

Relationship between femoral anteversion and findings in hips with femoroacetabular impingement.

The purpose of this study was to investigate the relationship between femoral neck version and pre- and intraoperative findings in hips with femoroacetabular impingement (FAI). The authors retrospectively reviewed prospectively collected data on 188 patients (204 hips) who underwent hip arthroscopy for FAI and labral pathology. Femoral version was measured on magnetic resonance imaging by a fellowship-trained musculoskeletal radiologist. The study group comprised 100 men and 88 women with a mean age of 35 years (range, 18 to 62 years). Mean femoral version was 9° (range, -10° to 27°). No relationship was found between femoral version and patient demographics (ie, age, sex, weight, height, and body mass index). A significant correlation was found between version and degrees of external rotation (r=-0.208; P=.027) and internal rotation (r=0.231; P=.002) on physical examination. Patients with femoral version less than 5° had significantly increased external rotation (P=.027). Intraoperative findings demonstrated that femoral version greater than 15° was related to larger labral tears that averaged approximately 38 mm in size, whereas patients with anteversion less than 5° had tear sizes measuring 30 mm and patients with angles between 5° and 15° had tear sizes averaging 34 mm (P=.008). Hips with femoral version greater than 15° were 2.2 times more likely (95% confidence interval, 1.2 to 4.1) to have labral tears that extended beyond the 3 o'clock position, denoting more anterior tears. Hips in which a psoas release was performed had higher version angles (8° vs 11°; P=.023).

A new method of measuring acetabular cup anteversion on simulated radiographs.

PURPOSE: Optimal positioning of acetabular components is crucial for maintaining stability of THA. Postoperative assessment of acetabular anteversion is a vital but difficult task. Various methods have been devised with good results for measuring anteversion on plain radiographs but these methods are either too complicated or require special objects like scientific calculators, special protectors, tables, etc. A new simplified method of measuring anteversion on plain radiographs was created based on basic geometry. METHODS: Anteversion of acetabular components was estimated on computer generated images of the acetabular cup by our method and compared with two previously established methods of Liaw and Pradhan. Measurement was done at 400 different positions of acetabular cup and compared with actual values. Another analysis was done after adding the femoral head to the acetabular component, thus obscuring some of the acetabular rim. RESULTS: Mean and standard deviation of error for our method was 0.77° ± 0.75° as compared to 0.93° ± 0.86° and 0.72° ± 0.68° for the methods of Liaw and Pardhan, respectively, with no significant differences from actual values. Maximal errors for our method, Liaw's and Pradhan's method were 3°, 4°, and 2.91°, respectively. On analysis, after the adding femoral head, there was a significant error of measurement with Liaw's method, while our method as well as Pardhan's remained accurate. All methods showed high inter- and intraobserver reliability. CONCLUSION: Our new simplified method of measuring acetabular anteversion on plain radiographs is acceptable in comparision to other established methods and requires only routinely used goniometer and calliper.

Femoral anteversion in the hip: comparison of measurement by computed tomography, magnetic resonance imaging, and physical examination.

PURPOSE: The purpose of this study was to evaluate the correlation between computed tomography (CT) and magnetic resonance imaging (MRI) measurements of femoral anteversion, as well as the relation of anteversion with physical examination and radiographic findings. METHODS: Preoperative CT and MRI measurements of anteversion along with clinical examination were performed on 129 consecutive hips before hip arthroscopy for nonarthritic hip injuries. All anteversion measurements were performed by 2 musculoskeletal radiologists. The radiographic findings and physical examination findings were analyzed for statistically significant correlations. For statistical analysis purposes, the patients were divided into 3 groups according to the mean CT anteversion measurement: group I (low), less than 10°; group II (medium), 10° to 22°; and group III (high), greater than 22°. RESULTS: High interobserver correlation was found for femoral anteversion measurement by CT and MRI (r = 0.95 and r = 0.86, respectively; P < .0001 for both). CT and MRI measurements showed high correlation with each other (r = 0.80, P < .0001). However, in 96% of the cases, the CT measurement was larger, with a mean difference of 8.9° (range, -37° to 1.5°). A significant correlation coefficient was found between internal rotation and anteversion angles as measured by CT (r = 0.36, P < .0001). However, no correlation was found with other hip movement measurements. Abnormal femoral acetabular bony architecture of the hip was found in 64% of the patients; isolated cam impingement was more prevalent in group I, whereas isolated pincer impingement was more prevalent in group III (P = .01). CONCLUSIONS: Although high correlation was found between anteversion angle measurements by CT and MRI, significant discrepancies in the absolute anteversion number between the 2 techniques suggest that they may not be interchangeable. Furthermore, CT was found to have higher interobserver reliability than MRI. There was a significant correlation between CT and examination of internal rotation of the hip. Clinically, the findings of the study show that the diagnosis of excessive femoral anteversion or retroversion should have different thresholds according to MRI and CT measurements; moreover, the diagnosis should not rely exclusively on either examination or radiologic criteria. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Three dimensional-CT evaluation of femoral neck anteversion, acetabular anteversion and combined anteversion in unilateral DDH in an early walking age group.

PURPOSE: At present, the indications for femoral derotational osteotomy remain controversial due to the inconsistent findings in femoral neck anteversion in developmental dysplasia of the hip (DDH). Moreover, combined anteversion is not assessed in unilateral DDH using three dimensional-CT. Therefore, the purposes of our study were to observe whether the femoral neck anteversion (FA), acetabular anteversion (AA) and combined anteversion (CA) on the dislocated hips were universally presented in unilateral DDH according to the classification system of Tönnis. METHODS: Sixty-two patients with unilateral dislocation of hip were involved in the study, including 54 females and eight males with a mean age of 21.63 months (range, 18-48 months). The FA, AA and CA were measured and compared between the dislocated hips and the unaffected hips. RESULTS: Although no significant difference was observed in FA between the dislocated hips and the unaffected hips (P = 0.067, 0.132, respectively) in Tönnis II and III type, FA was obviously increased on the dislocated hips compared with the unaffected hips in Tönnis IV type. Increased AA on the dislocated hips was a universal finding in Tönnis II, III and IV types. Meanwhile, a wide safe range of CA from 24° to 62° was demonstrated on the unaffected hips. CONCLUSION: Femoral derotational osteotomy seems not to be necessary in Tönnis II and III types in unilateral DDH. Femoral derotational osteotomy should be considered in DDH, especially in Tönnis IV type, if the CA is still above 62° and the hip joints present instability in operation after abnormal acetabular anteversion, acetabular index and acetabular coverage of the femoral head are recovered to normal range through pelvic osteotomy.

Intraoperative estimation of femoral anteversion in cementless total hip arthroplasty using the lesser trochanter.

INTRODUCTION: The intraoperative estimation of the anteversion of the femoral component of a total hip arthroplasty is generally made by the surgeon's visual assessment of the stem position relative to the condylar plane of the femur. AIM: The aim of this study was to evaluate the femoral component anteversion relative to lesser trochanter during cementless total hip arthroplasty. The intraoperative estimation of the anteversion of the femoral component of a total hip arthroplasty is generally made by the surgeon's visual assessment of the stem position relative to the condylar plane of the femur. The aim of this study was to evaluate the femoral component anteversion relative to lesser trochanter during cementless total hip arthroplasty. METHOD: The authors investigated the version of the lesser trochanter (LTV) relative to the posterior femoral condyles. Fifty-seven patients (59 hips) scheduled for primary cementless total hip arthroplasty underwent preoperative computed tomography and it was measured the LTV and collo-femoral version at the level of the proximal-most portion of the inferior neck, with respect to the lesser trochanter (native collo-trochanteric angle, NCTA). During surgery, the operative collo-trochanteric angle (OCTA) was measured. RESULTS: The mean LTV was 34.1 ± 3.0°, the mean NCTA was 49.1 ± 5.6°, and the mean OCTA was 48.8 ± 6.0°, which did not differ significantly from the NCTA (p = 0.495); the correlation coefficient was 0.872 (p < 0.0001). Based on the data, there was a constant relationship between the lesser trochanter and posterior femoral condyles and a good correlation between NCTA and OCTA. CONCLUSION: The authors recommend first estimating the anteversion of the femoral component relative to lesser trochanter and then adjusting the position of the acetabular component to that anteversion of the femoral component to improve stability and reduce impingement.