Positioning of the acetabular component: Preoperative planning


By design, total hip arthroplasty (THA) requires the careful consideration of each patient’s unique anatomy. Surgeons must carefully plan their approach, customizing the procedure based on preoperative images, physical examinations, a patient’s history, and their own experience. Accurately templating the placement of the acetabular cup is critical to a successful THA. Anticipating potential complications and having the right instrumentation and device options on hand is also integral to good planning. We look at preoperative planning considerations that prioritize a patient’s anatomy and share expert opinion on the relationship between stiff/fused spines and cup placement.


For any surgical discipline, preoperative planning is critical to the success of a procedure. The AO Principles of Fracture Management remind us that planning is a focused endeavor that allows surgeons to contemplate their approach and “mentally rehearse the operation: Problems can be anticipated and avoided and alternative plans can be developed in case of arising difficulties” [1].

Aside from facilitating the delivery of a considered, patient-specific total hip arthroplasty (THA), the records generated by comprehensive planning can communicate the professionalism, thought, and motivation behind a surgeon’s approach, which could help in the defense against litigation [1].

Inaccurate cup placement is a persistent problem that has been linked to dislocations and bearing surface wear. [2] Jolles et al. reported dislocation risk to be 6.9 times higher if total anteversion did not fall between 40°–60° and stated that “ [s]urgeons should pay attention to total anteversion (cup and stem) of THA [3]. Part I of this article series looked at the elements that influence accurate acetabular cup placement.

Callanan et al. found that out of 1823 hips, only 50 percent of the acetabular cups were placed within the safe zone (abduction (30°–45°) and version (5°–25°)) for both anteversion and inclination. In their study, low volume surgeons (two times higher risk), a minimally invasive approach (six times higher risk), and obesity (1.3 times higher risk) were contributing factors to malpositioned cups [4]. 

THA is a surgically demanding procedure and preoperative planning for acetabular cup placement involves consideration of several related factors. Bassam Masri, MD, and Head of Orthopaedics at the University of British Columbia, Canada, points out that,

“The most important technical aspect in planning hip replacement is restoring the biomechanics of the hip by restoring an anatomic center of rotation, restoring femoral offset, and equalizing leg lengths.”

That being said, let’s see how a surgeon’s preoperative plan can improve the likelihood that cup placement will be as precise as possible for each patient.

 

Patient assessment

Preoperative, comprehensive patient assessment is vitally important, but this is tempered with the knowledge that too many tests risk fatiguing and burdening the patient, stressing clinical resources, and demand time to document and interpret. When assessing function, surgeons usually combine elements from a patient-reported questionnaire and functional tests [5].

New technologies, such as accelerometers, are making it possible to gather real-time information about a patient’s movement as they go about their lives [5]. However, these types of technology are in early stages of adoption by the orthopedic field and despite being identified as feasible, they currently have little proof of efficacy, particularly in the post-THA rehabilitation phase [6].

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  • Thorough medical history
  • Physical assessment
  • Special consideration of the spine
  • The role of imaging
  • Templating: defining the puzzle pieces
  • Digital templating
  • Digital templating with acetate overlay
  • Landmarking and making measurements when templating
  • Conclusion
  • References
Additional Resources

Additional AO resources

Access videos, tools, and other assets to learn more about this topic.

Contributing experts

This series of articles was created with the support of the following specialists (in alphabetical order):

Mohamad Allami

MD, Alarabi Hospital for Surgical Specialty, Baghdad, Iraq

Chad Johnson

MD, University of British Columbia UBC, Vancouver, Canada

Bas Masri

Bas Masri

MD, University of British Columbia UBC, Vancouver, Canada

This issue was created by Word+Vision Media Productions, Switzerland

 

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