Top

Archives of Orthopaedic and Trauma Surgery

Published in:

Open Access 23-09-2021 | Hip-TEP | Hip Arthroplasty

High varus stem alignment in short-stem total hip arthroplasty: a risk for reconstruction of femoro-acetabular offset, leg length discrepancy and stem undersizing?

Authors: Matthias Luger, Julian Stiftinger, Jakob Allerstorfer, Rainer Hochgatterer, Tobias Gotterbarm, Lorenz Pisecky

Published in: Archives of Orthopaedic and Trauma Surgery | Issue 10/2022

Abstract

Purpose

Short stems are increasingly used in in total hip arthroplasty (THA) because of advantages in bone and soft tissue preservation and reconstruction of hip geometry. Short stems can be inserted in a more varus position compared to conventional straight stems. This poses the risk of final varus misplacement of the femoral component, which is not intended in all femoral short stems.

Methods

We wanted to evaluate the effect of a high varus stem positioning in MIS THA on hip offset, leg length and femoral canal fill index. A series of 1052 consecutive THAs with a singular cementless femoral short stem and press-fit cup was retrospectively screened for inclusion. One hundred six patients with unilateral THA and a contralateral healthy hip met the inclusion criteria. Measurements were carried out on preoperative and 3 months anterior–posterior postoperative radiographs. Patients were divided into Group A (varus stem alignment ≤ 3°) and Group B (varus stem alignment > 3°).

Results

Hip offset (HO) increased significantly in Group B by 4 mm (p = 0.013). No influence on leg length difference was detected in both groups. Preoperative CCD angle was significantly lower in Group B (p < 0.001). Canal Fill Indices (CFI) were significantly lower in Group B (CFI I: p < 0.001; CFI II p = 0.003; CF III p = 0.002).

Conclusion

High varus stem alignment > 3° leads to a statistically significant but minor increase in HO and poses the risk of stem undersizing. A preoperatively low genuine CCD angle pose a risk for varus stem positioning.

Kutzner KP, Kovacevic MP, Roeder C, Rehbein P, Pfeil J (2015) Reconstruction of femoro-acetabular offsets using a short-stem. Int Orthop 39(7):1269–1275. https://doi.org/10.1007/s00264-014-2632-3CrossRefPubMed

Gustke K (2012) Short stems for total hip arthroplasty: initial experience with the Fitmore stem. J Bone Joint Surg Br 94(11 Suppl A):47–51. https://doi.org/10.1302/0301-620X.94B11.30677CrossRefPubMed

Lombardi AV Jr, Berend KR, Ng VY (2011) Stubby stems: good things come in small packages. Orthopedics 34(9):e464-466. https://doi.org/10.3928/01477447-20110714-26CrossRefPubMed

Pipino F, Molfetta L (1993) Femoral neck preservation in total hip replacement. Ital J Orthop Traumatol 19(1):5–12PubMed

Khanuja HS, Banerjee S, Jain D, Pivec R, Mont MA (2014) Short bone-conserving stems in cementless hip arthroplasty. J Bone Joint Surg Am 96(20):1742–1752. https://doi.org/10.2106/JBJS.M.00780CrossRefPubMed

Merschin D, Hane R, Tohidnezhad M, Pufe T, Drescher W (2018) Bone-preserving total hip arthroplasty in avascular necrosis of the hip-a matched-pairs analysis. Int Orthop 42(7):1509–1516. https://doi.org/10.1007/s00264-018-3896-9CrossRefPubMed

Schnurr C, Schellen B, Dargel J, Beckmann J, Eysel P, Steffen R (2017) Low short-stem revision rates: 1–11 year results from 1888 total hip arthroplasties. J Arthroplasty 32(2):487–493. https://doi.org/10.1016/j.arth.2016.08.009CrossRefPubMed

Schmalzried TP, Jasty M, Harris WH (1992) Periprosthetic bone loss in total hip arthroplasty. Polyethylene wear debris and the concept of the effective joint space. J Bone Joint Surg Am 74(6):849–863CrossRef

Reichert JC, von Rottkay E, Roth F, Renz T, Hausmann J, Kranz J, Rackwitz L, Noth U, Rudert M (2018) A prospective randomized comparison of the minimally invasive direct anterior and the transgluteal approach for primary total hip arthroplasty. BMC Musculoskelet Disord 19(1):241. https://doi.org/10.1186/s12891-018-2133-4CrossRefPubMedPubMedCentral

10.

Pisecky L, Hipmair G, Schauer B, Bohler N (2018) 30-years of experience with the cementless implanted Alloclassic total hip arthroplasty system—an ultra-long-term follow-up. J Orthop 15(1):18–23. https://doi.org/10.1016/j.jor.2017.11.003CrossRefPubMed

11.

Snijders TE, van Erp JHJ, de Gast A (2019) Restoring femoral offset and leg length; the potential of a short curved stem in total hip arthroplasty. J Orthop 16(5):396–399. https://doi.org/10.1016/j.jor.2019.04.013CrossRefPubMedPubMedCentral

12.

McGrory BJ, Morrey BF, Cahalan TD, An KN, Cabanela ME (1995) Effect of femoral offset on range of motion and abductor muscle strength after total hip arthroplasty. J Bone Joint Surg Br 77(6):865–869CrossRef

13.

Sakalkale DP, Sharkey PF, Eng K, Hozack WJ, Rothman RH (2001) Effect of femoral component offset on polyethylene wear in total hip arthroplasty. Clin Orthop Relat Res 388:125–134. https://doi.org/10.1097/00003086-200107000-00019CrossRef

14.

Asayama I, Chamnongkich S, Simpson KJ, Kinsey TL, Mahoney OM (2005) Reconstructed hip joint position and abductor muscle strength after total hip arthroplasty. J Arthroplasty 20(4):414–420. https://doi.org/10.1016/j.arth.2004.01.016CrossRefPubMed

15.

Cassidy KA, Noticewala MS, Macaulay W, Lee JH, Geller JA (2012) Effect of femoral offset on pain and function after total hip arthroplasty. J Arthroplasty 27(10):1863–1869. https://doi.org/10.1016/j.arth.2012.05.001CrossRefPubMed

16.

Gkagkalis G, Goetti P, Mai S, Meinecke I, Helmy N, Bosson D, Kutzner KP (2019) Cementless short-stem total hip arthroplasty in the elderly patient—is it a safe option?: a prospective multicentre observational study. BMC Geriatr 19(1):112. https://doi.org/10.1186/s12877-019-1123-1CrossRefPubMedPubMedCentral

17.

Chammai Y, Brax M (2015) Medium-term comparison of results in obese patients and non-obese hip prostheses with Metha(R) short stem. Eur J Orthop Surg Traumatol 25(3):503–508. https://doi.org/10.1007/s00590-014-1574-1CrossRefPubMed

18.

Jerosch J (2012) Kurzschaftendoprothesen wo liegen die unterschiede? Deutscher Ärzte-Verlag, Köln

19.

Innmann MM, Maier MW, Streit MR, Grammatopoulos G, Bruckner T, Gotterbarm T, Merle C (2018) Additive influence of hip offset and leg length reconstruction on postoperative improvement in clinical outcome after total hip arthroplasty. J Arthroplasty 33(1):156–161. https://doi.org/10.1016/j.arth.2017.08.007CrossRefPubMed

20.

Innmann MM, Streit MR, Kolb J, Heiland J, Parsch D, Aldinger PR, Konigshausen M, Gotterbarm T, Merle C (2015) Influence of surgical approach on component positioning in primary total hip arthroplasty. BMC Musculoskelet Disord 16:180. https://doi.org/10.1186/s12891-015-0623-1CrossRefPubMedPubMedCentral

21.

Kellgren JH, Lawrence JS (1957) Radiological assessment of osteo-arthrosis. Ann Rheum Dis 16(4):494–502. https://doi.org/10.1136/ard.16.4.494CrossRefPubMedPubMedCentral

22.

Crowe JF, Mani VJ, Ranawat CS (1979) Total hip replacement in congenital dislocation and dysplasia of the hip. J Bone Joint Surg Am 61(1):15–23CrossRef

23.

Aldinger PR, Jung AW, Breusch SJ, Ewerbeck V, Parsch D (2009) Survival of the cementless Spotorno stem in the second decade. Clin Orthop Relat Res 467(9):2297–2304. https://doi.org/10.1007/s11999-009-0906-7CrossRefPubMedPubMedCentral

24.

Haversath M, Lichetzki M, Serong S, Busch A, Landgraeber S, Jager M, Tassemeier T (2020) The direct anterior approach provokes varus stem alignment when using a collarless straight tapered stem. Arch Orthop Trauma Surg. https://doi.org/10.1007/s00402-020-03457-9CrossRefPubMed

25.

Haversath M, Busch A, Jager M, Tassemeier T, Brandenburger D, Serong S (2019) The ‘critical trochanter angle’: a predictor for stem alignment in total hip arthroplasty. J Orthop Surg Res 14(1):165. https://doi.org/10.1186/s13018-019-1206-xCrossRefPubMedPubMedCentral

26.

Takada R, Whitehouse S, Hubble M, Wilson MJ, Howell JR, Timperley AJ, Kassam A (2019) Does varus or valgus alignment of the exeter stem influence survival or patient outcome in total hip arthroplasty? A review of 4126 cases with a minimum follow-up of five years. Orthop Proc 101-B(SUPP_6):22–22. https://doi.org/10.1302/1358-992X.2019.6.022CrossRef

27.

de Beer J, McKenzie S, Hubmann M, Petruccelli D, Winemaker M (2006) Influence of cementless femoral stems inserted in varus on functional outcome in primary total hip arthroplasty. Can J Surg 49(6):407–411PubMedPubMedCentral

28.

Kutzner KP, Kovacevic MP, Freitag T, Fuchs A, Reichel H, Bieger R (2016) Influence of patient-related characteristics on early migration in calcar-guided short-stem total hip arthroplasty: a 2 year migration analysis using EBRA-FCA. J Orthop Surg Res 11:29. https://doi.org/10.1186/s13018-016-0363-4CrossRefPubMedPubMedCentral

29.

Dastane M, Dorr LD, Tarwala R, Wan Z (2011) Hip offset in total hip arthroplasty: quantitative measurement with navigation. Clin Orthop Relat Res 469(2):429–436. https://doi.org/10.1007/s11999-010-1554-7CrossRefPubMed

30.

Wedemeyer C, Quitmann H, Xu J, Heep H, von Knoch M, Saxler G (2008) Digital templating in total hip arthroplasty with the Mayo stem. Arch Orthop Trauma Surg 128(10):1023–1029. https://doi.org/10.1007/s00402-007-0494-5CrossRefPubMed

31.

Merle C, Waldstein W, Pegg E, Streit MR, Gotterbarm T, Aldinger PR, Murray DW, Gill HS (2012) Femoral offset is underestimated on anteroposterior radiographs of the pelvis but accurately assessed on anteroposterior radiographs of the hip. J Bone Joint Surg Br 94(4):477–482. https://doi.org/10.1302/0301-620X.94B4.28067CrossRefPubMed

32.

Innmann MM, Spier K, Streit MR, Aldinger PR, Bruckner T, Gotterbarm T, Merle C (2018) Comparative analysis of the reconstruction of individual hip anatomy using 3 different cementless stem designs in patients with primary hip osteoarthritis. J Arthroplasty 33(4):1126–1132. https://doi.org/10.1016/j.arth.2017.11.026CrossRefPubMed

33.

Waldt S, Eiber M, Wörtler K (2011) Messverfahren und klassifikationen in der muskuloskelettalen radiologie. Thieme, StuttgartCrossRef

34.

Dorr LD, Faugere MC, Mackel AM, Gruen TA, Bognar B, Malluche HH (1993) Structural and cellular assessment of bone quality of proximal femur. Bone 14(3):231–242. https://doi.org/10.1016/8756-3282(93)90146-2CrossRefPubMed

35.

Noble PC, Alexander JW, Lindahl LJ, Yew DT, Granberry WM, Tullos HS (1988) The anatomic basis of femoral component design. Clin Orthop Relat Res 235:148–165CrossRef

36.

Lewinnek GE, Lewis JL, Tarr R, Compere CL, Zimmerman JR (1978) Dislocations after total hip-replacement arthroplasties. J Bone Joint Surg Am 60(2):217–220CrossRef

37.

Lu M, Zhou YX, Du H, Zhang J, Liu J (2013) Reliability and validity of measuring acetabular component orientation by plain anteroposterior radiographs. Clin Orthop Relat Res 471(9):2987–2994. https://doi.org/10.1007/s11999-013-3021-8CrossRefPubMedPubMedCentral

38.

Innmann MM, Weishorn J, Bruckner T, Streit MR, Walker T, Gotterbarm T, Merle C, Maier MW (2019) Fifty-six percent of proximal femoral cortical hypertrophies 6 to 10 years after total hip arthroplasty with a short Cementless curved hip stem—a cause for concern? BMC Musculoskelet Disord 20(1):261. https://doi.org/10.1186/s12891-019-2645-6CrossRefPubMedPubMedCentral

39.

Mahmood SS, Mukka SS, Crnalic S, Wretenberg P, Sayed-Noor AS (2016) Association between changes in global femoral offset after total hip arthroplasty and function, quality of life, and abductor muscle strength. A prospective cohort study of 222 patients. Acta Orthop 87(1):36–41. https://doi.org/10.3109/17453674.2015.1091955CrossRefPubMed

40.

Little NJ, Busch CA, Gallagher JA, Rorabeck CH, Bourne RB (2009) Acetabular polyethylene wear and acetabular inclination and femoral offset. Clin Orthop Relat Res 467(11):2895–2900. https://doi.org/10.1007/s11999-009-0845-3CrossRefPubMedPubMedCentral

41.

Sariali E, Klouche S, Mouttet A, Pascal-Moussellard H (2014) The effect of femoral offset modification on gait after total hip arthroplasty. Acta Orthop 85(2):123–127. https://doi.org/10.3109/17453674.2014.889980CrossRefPubMedPubMedCentral

42.

Whitehouse MR, Stefanovich-Lawbuary NS, Brunton LR, Blom AW (2013) The impact of leg length discrepancy on patient satisfaction and functional outcome following total hip arthroplasty. J Arthroplasty 28(8):1408–1414. https://doi.org/10.1016/j.arth.2012.12.009CrossRefPubMed

43.

Streit MR, Innmann MM, Merle C, Bruckner T, Aldinger PR, Gotterbarm T (2013) Long-term (20- to 25-year) results of an uncemented tapered titanium femoral component and factors affecting survivorship. Clin Orthop Relat Res 471(10):3262–3269. https://doi.org/10.1007/s11999-013-3033-4CrossRefPubMedPubMedCentral

44.

Bieger R, Ignatius A, Decking R, Claes L, Reichel H, Durselen L (2012) Primary stability and strain distribution of cementless hip stems as a function of implant design. Clin Biomech (Bristol, Avon) 27(2):158–164. https://doi.org/10.1016/j.clinbiomech.2011.08.004CrossRef

45.

Murphy CG, Bonnin MP, Desbiolles AH, Carrillon Y, Asmallyi USST (2016) Varus will have varus; a radiological study to assess and predict varus stem placement in uncemented femoral stems. Hip Int 26(6):554–560. https://doi.org/10.5301/hipint.5000412CrossRefPubMed

46.

Soderquist MC, Scully R, Unger AS (2017) Acetabular placement accuracy with the direct anterior approach freehand technique. J Arthroplasty 32(9):2748–2754. https://doi.org/10.1016/j.arth.2017.04.011CrossRefPubMed

47.

Bingham JS, Spangehl MJ, Hines JT, Taunton MJ, Schwartz AJ (2018) Does intraoperative fluoroscopy improve limb-length discrepancy and acetabular component positioning during direct anterior total hip arthroplasty? J Arthroplasty 33(9):2927–2931. https://doi.org/10.1016/j.arth.2018.05.004CrossRefPubMed

48.

Beamer BS, Morgan JH, Barr C, Weaver MJ, Vrahas MS (2014) Does fluoroscopy improve acetabular component placement in total hip arthroplasty? Clin Orthop Relat Res 472(12):3953–3962. https://doi.org/10.1007/s11999-014-3944-8CrossRefPubMedPubMedCentral

49.

Leucht P, Huddleston HG, Bellino MJ, Huddleston JI (2015) Does intraoperative fluoroscopy optimize limb length and the precision of acetabular positioning in primary THA? Orthopedics 38(5):e380-386. https://doi.org/10.3928/01477447-20150504-54CrossRefPubMed

50.

Grammatopoulos G, Thomas GE, Pandit H, Beard DJ, Gill HS, Murray DW (2015) The effect of orientation of the acetabular component on outcome following total hip arthroplasty with small diameter hard-on-soft bearings. Bone Joint J 97-B(2):164–172. https://doi.org/10.1302/0301-620X.97B2.34294CrossRefPubMed

51.

Tipton SC, Sutherland JK, Schwarzkopf R (2016) The assessment of limb length discrepancy before total hip arthroplasty. J Arthroplasty 31(4):888–892. https://doi.org/10.1016/j.arth.2015.10.026CrossRefPubMed

Title: High varus stem alignment in short-stem total hip arthroplasty: a risk for reconstruction of femoro-acetabular offset, leg length discrepancy and stem undersizing?
Authors: Matthias Luger
Julian Stiftinger
Jakob Allerstorfer
Rainer Hochgatterer
Tobias Gotterbarm
Lorenz Pisecky
Publication date: 23-09-2021
Publisher: Springer Berlin Heidelberg
Keywords: Hip-TEP
Hip-TEP
Published in: Archives of Orthopaedic and Trauma Surgery / Issue 10/2022
Print ISSN: 0936-8051
Electronic ISSN: 1434-3916
DOI: https://doi.org/10.1007/s00402-021-04176-5

At a glance: The STEP trials

Springer Medicine

High varus stem alignment in short-stem total hip arthroplasty: a risk for reconstruction of femoro-acetabular offset, leg length discrepancy and stem undersizing?

Abstract

Purpose

Methods

Results

Conclusion

At a glance: The STEP trials

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusion

Please log in to get access to this content

Other articles of this Issue 10/2022

Cycling-related orthopaedic fractures admitted to the Major Trauma Centre in the cycling capital of the UK

Medium-term outcomes in single anaesthetic bilateral total knee replacement surgery: a single surgeon series

Single-stage total hip arthroplasty after failed fixation of proximal femoral fractures: an increased risk for periprosthetic joint infections?

Tip–neck distance ratio as a novel predictor for failure in cephalomedullary nailing of unstable trochanteric fractures (UTF)

Periprosthetic joint infection rates across primary total hip arthroplasty surgical approaches: a systematic review and meta-analysis of 653,633 procedures

Comorbidities, substance abuse, weight and age are independent risk factors for postoperative complications following operation for proximal humerus fractures: a retrospective analysis of 1109 patients