Aims. The aim of this study was to evaluate the suitability of the tapered cone stem in total hip arthroplasty (THA) in patients with excessive femoral anteversion and after femoral osteotomy. Methods. We included patients who underwent THA using Wagner Cone due to proximal femur anatomical abnormalities between August 2014 and January 2019 at a single institution. We investigated implant survival time using the endpoint of dislocation and revision, and compared the prevalence of prosthetic impingements between the Wagner Cone, a tapered cone stem, and the Taperloc, a tapered wedge stem, through simulation. We also collected Oxford Hip Score (OHS), visual analogue scale (VAS) satisfaction, and VAS pain by postal survey in August 2023 and explored variables associated with those scores. Results. Of the 58 patients (62 hips), two (two hips) presented with dislocation or reoperation, and Kaplan-Meier analysis indicated a five-year survival rate of 96.7% (95% CI 92.4 to 100). Mean stem anteversion was 35.2° (SD 18.2°) for the Taperloc stem and 29.8° (SD 7.9°) for the Wagner Cone stem; mean reduction from Taperloc to Wagner Cone was 5.4° (SD 18.8°). Overall, 55 hips (52 patients) were simulated, and the prevalence of prosthetic impingement was lower for the Wagner Cone (5.5%, 3/55) compared with the Taperloc (20.0%, 11/55) stem, with an odds ratio of 0.20 (p = 0.038). Among the 33 respondents to the postal survey (36 hips), the mean scores were VAS pain 10.9, VAS satisfaction 86.9, and OHS 44.7. A multivariable analysis revealed that reduction of stem anteversion from Taperloc to Wagner Cone was more favourable for VAS pain (p = 0.029) and VAS satisfaction (p = 0.002). Conclusion. The mid-term survival rate for THA using the Wagner Cone stem was high, which may be supported by a reduction in prosthetic impingement. The reduction in excessive stem anteversion by using a tapered cone stem was associated with reduced pain and increased patient satisfaction. Cite this article: Bone Jt Open 2024;5(10):858–867

The purposes of this study were to report the accuracy of stem anteversion for Exeter cemented stems with the Mako hip enhanced mode and to compare it to Accolade cementless stems. We reviewed the data of 25 hips in 20 patients who underwent THA through the posterior approach with Exeter stems and 25 hips in 19 patients with Accolade stems were matched for age, gender, height, weight, disease, and approaches. There was no difference in the target stem anteversion (20°–30°) between the groups. Two weeks after surgery, CT images were taken to measure stem anteversion. The difference in stem anteversion between the plan and the postoperative CT measurements was 1.2° ± 3.8° (SD) on average with cemented stems and 4.2° ± 4.2° with cementless stems, respectively (P <0.05). The difference in stem anteversion between the intraoperative measurements and the postoperative CT measurements was 0.75° ± 1.8° with Exeter stems and 2.2° ± 2.3° with Accolade stems, respectively (P <0.05). This study demonstrated a high precision of anteversion for Exeter cemented stems with the Mako enhanced mode and its clinical accuracy was better with the cemented stems than that with the cementless stems. Although intraoperative stem anteversion measurements with the Mako system were more accurate with the cemented stems than that with the cementless stem, the difference was about 1° and the accuracy of intra-operative anteversion measurements was quite high even with the cementless stems. The smaller difference in stem anteversion between the plan and postoperative measurements with the cemented stems suggested that stem anteversion control was easier with cemented stems under the Mako enhanced mode than that with cementless stems. Intraoperative stem anteversion measurement with Mako total hip enhanced mode was accurate and it was useful in controlling cemented stem anteversion to the target angle

Introduction. The posterior condylar axis of the distal femur is the common reference used to describe femoral anteversion. In the context of Total Hip Arthroplasty (THA), this reference can be used to define the native femoral anteversion, as well as the anteversion of the stem. However, these measurements are fixed to a femoral reference. The authors propose that the functional position of the proximal femur must be considered, as well as the functional relationship between stem and cup (combined anteversion) when considering the clinical implications of stem anteversion. This study investigates the post-operative differences between anatomically-referenced and functionally-referenced stem and combined anteversion in the supine and standing positions. Method. 18 patients undergoing pre-operative analysis with the Trinity OPS® planning (Optimized Ortho, Sydney Australia, a division of Corin, UK) were recruited for post-operative assessment. Anatomic and functional stem anteversion in both the supine and standing positions were determined. The anatomic anteversion was measured from CT and referenced to the posterior condyles. The supine functional anteversion was measured from CT and referenced to the coronal plane. The standing functional anteversion was measured to the coronal plane when standing by performing a 3D/2D registration of the implants to a weight-bearing AP X-ray. Further, functional acetabular anteversion was captured to determine combined functional anteversion in the supine and standing positions. Results. The average anatomical stem anteversion was 9.9° (6.7° to 13.0°). In all cases, the anatomical stem anteversion was different than the measured functional stem anteversion in both the supine and standing positions. The functional femoral anteversion decreased from supine to stand by an average of 7.1° (4.9°−9.2°), suggesting more internal rotation of the femurs when weight-bearing. In all patients, the pelvis rotated posteriorly in the sagittal plane from supine to standing, increasing the functional acetabular anteversion by a mean of 5.1°. Conclusions. Anatomic stem anteversion differs significantly from functional stem anteversion in both the supine and standing positions, as a consequence of the patient specific differences in internal/external rotation of the femur in the functional postures. In the same way that the Anterior Pelvic Plane is now widely recognized as an inappropriate reference for cup orientation due to variation in sagittal pelvic tilt, referencing the femoral stem anteversion to the native anatomy (distal femur) maybe also be misleading and not provide a suitable description of the functional anteversion of the stem. This has implications for determining optimal combined alignment in THA

We have previously reported on the improved all-cause revision and improved revision for instability risk in lipped liner THAs using the NJR dataset. These findings corroborate studies from the Australian (AOANJRR) and New Zealand (NZOA) joint registries. The optimal orientation of the lip in THAs utilising a lipped liner remains unclear to many surgeons. The aim of this study was to identify impingement-free optimal liner orientations whilst considering femoral stem version, cup inclination and cup version. A cementless THA kinematic model was developed using a 20 degree XLPE liner. Physiological ROM and provocative dislocation manoeuvre analyses were performed. A total of 9 cup positions were analysed (inclination 30–40–50 degrees, anteversion 5-15-25 degrees) and combined with 3 stem positions (anteversion 0-15-30 degrees) and 5 lip orientations (right hip 11 to 7 o'clock). Some lip orientation/component position combinations lead to impingement within the physiological ROM range. Using a lipped liner increases the femoral head travel distance prior to dislocation when impingement occurs in the plane of the lip. In THAs with a cup inclination of 30 and 40 degrees, inferior lip orientations (7–8 o'clock for a right hip) performed best. Superior lip orientation performed best with a cup inclination of 50 degrees. Femoral stem version has a significant effect on the range of movement prior to impingement and hence the preferred lip orientation. The optimal orientation of the lip in lipped liner THA is dependent on the position of both the acetabular and femoral components. In the common component orientation combination of stem anteversion 15, cup inclination 40 and cup anteversion 15, the optimal lip orientation was postero-inferiorly (8 o'clock for a right hip). Preventing impingement during physiological ROM is possible with appropriate lip liner orientation

Introduction. Accurate implantation is important for total hip arthroplasty to achieve a maximized, stable range of motion and to reduce the risk of dislocation. We had estimated total cup and stem anteversion(AV) visually during operations without navigation system. The purpose of this study is to assess the correlation between total AV estimated visually during operation and total AV evaluated with CT and X-ray postoperatively. Materials & Methods. We investigated 145 primary total hip arthroplasties performed with direct anterior approach in supine position. 17 hips were in men and 128 in women. The mean age at operation was 65.6 years. During operations “intraoperative total AV” was defined as an angle from neutral hip position to internal rotated position at a concentric circle of acetabular rim and the equator of femoral head. We also measured cup inclination with X-ray and cup anteversion and stem anteversion with computed tomography after THA. “Radiographic total AV” was defined as the sum of cup and stem anteversion measured with CT. Correlation between “intraoperative total AV” and “Radiographic total AV” was evaluated statistically. Results. The mean “intraoperative total AV” was 24.2±5.6 degree. The mean cup inclination was 44.8 ±5.4 degree. The mean cup and stem anteversion was 25.0 ±7.4 and 17.8 ±11.0 degree respectively. The mean “radiographic total AV” was 42.8 ±12.8 degree. “Intraoperative total AV” was correlated to stem anteversion and “radiographic total AV” statistically. Discussions and Conclusions. “Intraoperative total AV” was correlated to “radiographic total AV”. Therefore, this method was useful to achieve an accurate implantation in THA

Introduction. Proper femoral stem and acetabular implant orientation is critical to the initial and long-term success of THA. Post-operative determination of cup and stem anteversion is important in cases of hip instability and planning isolated component revisions. At ISTA 2010 Dubai, we introduced a novel, simple stem modification that can be added to any stem design to help assess stem, and possibly cup anteversion with plain post-operative radiographs throughout the lifespan of the implant. [Figure 1] As the stem is rotated, the visible hole pattern changes. [Figure 2] This study was performed to further validate the accuracy and potential usefulness of this design. Methods. We prospectively reviewed 100 consecutive THA cases using the stem reference hole modification on rectangular tapered Zweymuller-type stems implanted from September 2010 to May 2012. Post-operative hip/femur CT scans were obtained to determine the true cup and stem orientation to validate and quanitify the precision of the reference holes. Intra-operative estimates of stem anteversion and combined anteversion (Ranawat Sign) were recorded. Post-operative radiograph measurement of stem anteversion (AP hip x-ray with leg in neutral rotation) was obtained and compared to the CT scan measurement referencing stem rotation relative to the knee epicondylar axis. [Figure 3] In addition, we compared the modified reference hole anteversion assessment to a control group of original unmodified stems assessed using the same methods. Results. All 100 patients had post-operative CT scans and ‘neutral’ rotation AP hip radiographs. The modified reference hole design was accurate to within 4.1 degrees compared to CT measurements. Estimates of stem anteversion in the control group (original Alloclassic or SL-Plus stems) was accurate to only 19.6 degrees with wide variablity as expected. The difference was statistically significant. Residual hip flexion contracture (2 patients) made the reference holes undetectable on radiographs. Morbid obesity did not decrease accuracy but required x-ray beam intensity modification. There was no statistical difference between standing and supine x-ray ‘neutral’ rotation radiograph measurements. The Ranawat combined stem and cup anteversion value could not predict cup anteversion reliably when subtracting the stem rotation. Two patients sustained post-operative THA dislocations that required closed reduction (occuring 2 months and 15 months after index THA). Conclusion. We conclude that hip stems with this pattern of modified anteversion reference holes provides an accurate and reliable method of determining stem component orientation post-operatively by using only simple plain radiographs. Initial finite element analysis of the modified stem hole pattern predicted that the fatigue strength was actually higher than that of the original unmodified implants indicating it is safe in the square taper design. The clinical usefulness became apparent when two hips in this series suffered dislocations. Review of the ‘neutral’ rotation xrays indicated the stem was placed in the ‘safe zone’ from 15–25 degrees and the hips would not likely need stem implant revision. We will continue to test this technology and improve the measuring techniques to accurately predict implant position post-operatively

Introduction: Progressive retroversion of the stem within the femur has been suggested to be an important initial mode of hip prosthesis failure. We have assessed the relationship between postoperative stem anteversion angle, measured with CT, and the rotational stability as measured with repeated radiostereometric analysis (RSA) with 5 years follow up. Patients and methods: 57 patients were operated on with THA using a cemented, matt and collared stem. The achieved stem anteversion angles were measured postoperatively with 3-D CT-examinations. The patients were divided into three groups depending on their ante-version angle: ≤10°, 11°–25° and ≥25°. They were followed with repeated RSA examinations for 5 years to determine the stem migration pattern. Results: The mean postoperative anteversion angle was 20.5° (range 1°–43°). At 5 years, all except one stem had rotated into retroversion. There was a strong correlation between the postoperative anteversion angle and later rotation into retroversion (p=0.007). The group with ≤10° of stem anteversion rotated significantly more into retroversion, seen as early as 3 months (p=0.02), but more obvious at 5 years (p=0.002) with a mean of 9.9° of retroversion compared to 3.8° in the 11°–25° group and 2.4 ° in the ≥25° group. The distal stem migration results were accordant with more migration at 5 years (p=0.008) for the ≤10° anteversion group (1.6 mm subsidence compared to 0.5 and 0.3 mm respectively). Two stems have been revised because of aseptic loosening, both with a low initial anteversion angle (7° and 1°) and large retroversion at 5 years (7 ° and 31° respectively). Conclusion: Measured by RSA, rotation into retroversion of the femoral stem was a regular finding in this study using a conventional prosthesis design. We propose that such rotation is a common finding in hip arthroplasty, but the degree may be design sensitive. Our results strongly suggest that the initial rotational position of the femoral component during surgery is decisive for the degree of later retroversion and probably prosthetic longevity; the less anteverted position the more the stem will migrate into a more retroverted position after the operation. This rotational migratory pattern is correlated to subsidence and eventual loosening. Hence, meticulous attention should be paid to the rotational position of the femoral stem during surgery, with less than 10° of anteversion appearing deleterious. However, too much anteversion will risk impingement and possibly other unwanted biomechanical effects, and an upper limit still remains to be established

Introduction

The midcortical line, the midline between the anterior and the posterior cortical walls has been reported as an intraoperative reference guide for reproducing the true femoral anteversion in cross-sectional computed tomography (CT) image study but we suspected that the version of the midcortical line on the cutting surface is different from that on the axial image. The three-dimensional (3D) CT-based preoperative planning software for THA enabled us to evaluate the cut surface of the femoral neck osteotomy. When we planned the straight non-anatomic stem placement in 20° of anteversion, we noticed that the line connecting the trochanteric fossa and the middle of the medial cortex of the femoral neck (T line) was coincident with the component torsion in almost all cases except those involving secondary osteoarthritis of the hip. Therefore we hypothesised that the T-line would provide an accurate reference guide for anteversion of the femoral component in THA. We performed this study to answer the question: which is the better intraoperative reference guide for reproducing the true femoral anteversion, the midcortical line or the T line?

Aims. The aim of this study was to identify the optimal lip position for total hip arthroplasties (THAs) using a lipped liner. There is a lack of consensus on the optimal position, with substantial variability in surgeon practice. Methods. A model of a THA was developed using a 20° lipped liner. Kinematic analyses included a physiological range of motion (ROM) analysis and a provocative dislocation manoeuvre analysis. ROM prior to impingement was calculated and, in impingement scenarios, the travel distance prior to dislocation was assessed. The combinations analyzed included nine cup positions (inclination 30-40-50°, anteversion 5-15-25°), three stem positions (anteversion 0-15-30°), and five lip orientations (right hip 7 to 11 o’clock). Results. The position of the lip changes the ROM prior to impingement, with certain combinations leading to impingement within the physiological ROM. Inferior lip positions (7 to 8 o’clock) performed best with cup inclinations of 30° and 40°. Superior lip positions performed best with cup inclination of 50°. When impingement occurs in the plane of the lip, the lip increases the travel distance prior to dislocation. Inferior lip positions led to the largest increase in jump distance in a posterior dislocation provocation manoeuvre. Conclusion. The lip orientation that provides optimal physiological ROM depends on the orientation of the cup and stem. For a THA with stem anteversion 15°, cup inclination 40°, and cup anteversion 15°, the optimal lip position was posterior-inferior (8 o’clock). Maximizing jump distance prior to dislocation while preventing impingement in the opposite direction is possible with appropriate lip positioning. Cite this article: Bone Joint Res 2023;12(9):571–579

Dislocation is a serious complication to be avoided in total hip arthroplasty (THA) and its incidence risk increases in revision surgery. Combined anteversion (CA) of the cup and stem is a concept for appropriate implant positioning; however, the effect of functional changes in femoral rotation has not been well investigated. The aim of this study was to investigate whether functional CA, considering femoral rotation, is associated with dislocation in patients undergoing revision THA. Seventy-three patients who underwent revision THA and had at least one year of follow-up with pre- and postoperative supine CT imaging were included. Cup and stem were placed with a target combined angle of 37.3° using Widmer's formula. Anatomical and functional CA was calculated postoperatively using the following formula: Anatomical CA: cup anteversion + 0.7 × anatomical stem anteversion; Functional CA: cup anteversion + 0.7 × (anatomical stem anteversion + femoral rotation). Patient demographics, cup and stem angles, CA and their relationship to dislocation were statistically evaluated. Dislocation was observed in 12 patients. In these dislocated cases, there were no significant differences in cup angle, stem angle and anatomical CA compared to non-dislocated cases. However, dislocated cases showed significantly higher values of functional CA [52.7 ± 17.5° (range, 5.9–69.3) vs. 36.0 ± 12.5° (range, 8.6–68.8), p=0.009] and significant deviation from identical CA [17.3 ± 9.6° (range, 2.8–32) vs. 7.5 ± 7.1° (range, 0.1–28.7), p=0.010]. Functional CA considering femoral rotation was associated with dislocation in revision THA patients. This finding suggests that consideration of femoral rotation may be necessary for implant positioning in revision THA

Introduction. Appropriate prosthetic alignment is an important factor in maintaining stability and maximising the performance of the bearing after total hip replacement (THR). With a cementless component, the anteversion of the native femur has been shown to influence the anteversion of the prosthetic stem. However, the extent to which anteversion of a cementless stem can be adjusted from the native anteversion has seldom been reported. The aim of this study was to investigate the difference between native and stem anteversion with two different cementless stem designs. Method. 116 patients had 3-dimensional templating as part of their routine planning for THR (Optimized Ortho, Sydney). 96 patients from 3 surgeons (AS, JB, SM) received a blade stem (TriFit TS, Corin, UK) through a posterior approach. 18 patients received a fully HA-coated stem (MetaFix, Corin, UK) through a posterior approach by a single surgeon (WB). The anteversion of the native femoral neck was measured from a 3D reconstruction of the proximal femur. All patients received a post-operative CT scan which was superimposed onto the pre-op CT scan. The difference between native and achieved stem anteversion was then measured. As surgeons had differing philosophies around target stem anteversion, the differences amongst surgeons were also investigated. Results. On average, stems were implanted in less anteversion than native. The mean deviation between native and stem anteversion of the blade stems was −3.5° (−34.8° to 13.8°). The mean deviations of the three surgeons using the blade stem were −7.9° (−34.8° to 10.4°), −3.1° (−18.1° to 12.0°) and 2.7° (−8.9° to 13.8°). These were statistically significant, and represented a difference in philosophy around target anteversion amongst surgeons. The mean deviation between native and stem anteversion of the fully HA-coated stems was −6.5° (−24.6° to 9.2°). Conclusions. Cementless stem anteversion is not dictated by the native femoral anteversion. There were differences in target anteversion philosophies amongst surgeons and this was seen in the results. Surgical approach, proximal entry point, osteotomy angle, stem design and patient anatomy will all influence the ability to dictate cementless stem anteversion. The effect of these variables are the subject of on-going work

Introduction & aims. Correct prosthetic alignment is important to the longevity and function of a total hip replacement (THR). With the growth of 3-dimensional imaging for planning and assessment of THR, the importance of restoring, not just leg length and medial offset, but anterior offset has been raised. The change in anterior offset will be influenced by femoral anteversion, but there are also other factors that will affect the overall change after THR. Consequently, the aim of this study was to investigate the relationship between anterior offset and stem anteversion to determine the extent to which changing anteversion influences anterior offset. Method. Sixty patients received a preoperative CT scan as part of their routine planning for THR (Optimized Ortho, Sydney). All patients received a Trinity cementless shell and a cemented TaperFit stem (Corin, UK) by the senior author through an anterolateral approach. Stem anteversion was positioned intraoperatively to align with cup anteversion via a modified Ranawat test. Postoperatively, patients received a CT scan which was superimposed onto the pre-op CT scan. The difference between native and achieved stem anteversion was measured, along with the 3-dimensional change in head centre from pre-to post-op. Finally, the relationship between change in stem anteversion and change in anterior offset was investigated. Results. Mean change in anterior offset was −2.3mm (−14.0 to 7.0mm). Mean change in anteversion from native was −3.0° (−18.8° to 10.5°). There was a strong correlation between change in anterior offset and change in anteversion, with a Pearson correlation coefficient of 0.89. A 1° increase in anteversion equated to a 0.7mm increase in anterior offset. Conclusions. A change in the anteroposterior position of the femoral head is primarily affected by a change in stem anteversion, with a 1° increase in anteversion equating to a 0.7mm increase in anterior offset. The AP position of the stem in the canal, along with the flexion of the stem will also contribute. Given the well-recognised influence of leg length, medial offset and combined anteversion on restoring hip function, it seems reasonable to assume that anterior offset will also have a significant effect on the biomechanics of the replaced hip

Aims. Hip arthroplasty aims to accurately recreate joint biomechanics. Considerable attention has been paid to vertical and horizontal offset, but femoral head centre in the anteroposterior (AP) plane has received little attention. This study investigates the accuracy of restoration of joint centre of rotation in the AP plane. Methods. Postoperative CT scans of 40 patients who underwent unilateral uncemented total hip arthroplasty were analyzed. Anteroposterior offset (APO) and femoral anteversion were measured on both the operated and non-operated sides. Sagittal tilt of the femoral stem was also measured. APO measured on axial slices was defined as the perpendicular distance between a line drawn from the anterior most point of the proximal femur (anterior reference line) to the centre of the femoral head. The anterior reference line was made parallel to the posterior condylar axis of the knee to correct for rotation. Results. Overall, 26/40 hips had a centre of rotation displaced posteriorly compared to the contralateral hip, increasing to 33/40 once corrected for sagittal tilt, with a mean posterior displacement of 7 mm. Linear regression analysis indicated that stem anteversion needed to be increased by 10.8° to recreate the head centre in the AP plane. Merely matching the native version would result in a 12 mm posterior displacement. Conclusion. This study demonstrates the significant incidence of posterior displacement of the head centre in uncemented hip arthroplasty. Effects of such displacement include a reduction in impingement free range of motion, potential alterations in muscle force vectors and lever arms, and impaired proprioception due to muscle fibre reorientation. Cite this article: Bone Joint Res 2022;11(3):180–188

INTRODUCTION. Dislocation is one of the most important complications in THA. Dual mobility cup (DMC) inserts reduce the risk for dislocation after total hip arthroplasty by increasing the oscillation angle. A lower rate of dislocation with use of a DMC insert has been reported in different studies. But there is no available research that clearly delineates the stability advantages of DMC inserts in primary THA. The aim of our study was to evaluate the area of the safe zone for a DMC insert, compared to a fixed insert for different anteversion angles of the femoral component. Material and Methods. A model of the pelvis and femur were developed from computed tomography images. We defined the coordinate system of the pelvis relative to the anterior pelvic plane and the coordinate system of the femur relative to the posterior condylar plane. In our model, we simulated a positive anteversion position of the acetabular cup. The lower border for cup inclination is 50°. The safe zone was evaluated for the following range of motion of the implant: 120° of flexion, 90° of flexion 30° of internal rotation, 30° of extension, 40° of abduction, 40° of adduction, and 30° of external rotation. (Fig.1) The safe zone was calculated for both a fixed insert and a DMC insert over a pre-determined range of three-dimensional motion, and the effect of increasing the anteversion position of the femoral component from 5° to 35° quantified. The ratio of the safe zone for a DMC insert to a fixed insert was calculated. Results. A wider safe zone was obtained for a DMC insert over all range of motion conditions. A DMC insert increased the stability of the implant between 10° and 15° along both anterior-posterior and vertical axes of the acetabular cup. (Fig.2) When stem anteversion were varied 5°, 10°, 15°, 20°, 25°, 30°, 35°, ratio of safe zone (a DMC insert / a fixed insert) were changed 8, 10.1, 6.3, 4.9, 5.2, 6.6, 10.6. (Fig.3). Discussion. The safe zone of a DMC insert is always larger than a fixed type insert. In every stem anteversion patterns, safe zones were expanded to all direction with 10° to 15°. Under 15° of stem anteversion, area of both inserts are almost stable. Area ratio is lowest with 20° of stem anteversion. Over 25° of stem anteversion, both area decreased and area ratio increased gradually. Over 30° of stem anteverison, safe zone of a fixed type are very small area. It is difficult for us to set acetabular shell in that small area. But we will get a larger area by using DMC. We performed a simulation analysis to evaluate the increase in area of the safe zone when using DMC inserts, compared to fixed inserts. To use of a DMC insert would bring in a 5–11-fold expanded area of the safe zone. In especially, DMC is a useful when stem anteversion is over 30°. For figures/tables, please contact authors directly.

Introduction. Pelvic posterior tilt change (PPTC) after THA is caused by release of joint contracture and degenerative lumbar kyphosis. PPTC increases cup anteversion and inclination and results in a risk of prosthesis impingement (PI) and edge loading (EL). There was reportedly no component orientation of fixed bearing which can avoid PI and EL against 20°PPTC. However, dual mobility bearing (DM) has been reported to have a large oscillation angle and potential to withstand EL without increasing polyethylene (PE) wear against high cup inclination such as 60∼65°. Objective. The purpose of this study was to investigate the optimal orientation of DM-THA for avoiding PI and EL against postoperative 20°PPTC. Methods. Our study was performed with computer tomography -based three-dimensional simulation software (ZedHip. LEXI co. Japan). The CT data of hip was derived from asian typical woman with normal hips. Used prosthesises were 50mm cup and 42mm outer head of modular dual mobility system and Accolade II 127°(stryker). Femoral coordinate system was retrocondylar plane with z-axis from trochanteric fossa to intercondylar notch. Cup orientation was described as anatomical definition. The safe zone was calculated by the required hip range of motion which was defined as 130°flexion, 40°extension, 30°external rotation, and 50°internal rotation with 90°flexion and the maximum inclination of DM cup which was 60°in consideration of withstanding EL. Cup orientations withstanding 20°PPTC were defined as the primary cup orientation which changes consistently within the safe zone with the match of 20°PPTC. And among them cup orientation with lowest inclination was defined as the optimal cup orientation. result. The optimal orientations could be identified only within stem anteversion from 15°to 40°. The relationship between the optimal cup orientation and stem anteversion could be automatically identified. The correlation between stem anteversion and cup anteversion was linearly distributed and could be expressed as an approximated line of the formula that (stem anteversion)+(cup anteversion)=36.8. And likewise the relationship between stem anteversion and cup inclination was curved-linerly distributed and could be expressed as an approximated curved line of the formula that (cup inclination)=0.04(stem anteversion). 2. 2.18(stem anteversion)+74.8. Cup orientation calculated by the Widmer's combined anteversion theory is easily deviated from the safe zone by PPTC. The optimal cup orientation calculated in this study could be set more inclination and retroversion than it calculated by the Widmer's theory in contribution of large oscillation angle and admissibility of high inclination cup setting of DM. Therefore it could be possible to withstand 20°PPTC. Conclusion. Performing THA with considering postoperative PPTC is necessary for good long term outcome without dislocation and PE wear. The solution for 20°PPTC after THA is to apply dual mobility bearing and the formula of combined orientation theory calculated in this study

Purpose:. In order to acquire good stability of an arthroplasty hip, the proper placement of the implants, which prevents impingement between the stem neck and the socket, is important. In general, the anteversion of the uncemented femoral stem depends on the relationship between the three-dimensional structure of the proximal femoral canal and the proximal stem geometry. The exact degree of the anteversion will be known just after broaching during the operation. If the stem anteversion could be forecasted, preoperative planning of the socket placement would be relatively easy. Furthermore, when a high degree of anteversion is forecasted, a special femoral stem to reduce it, such as a modular stem, could be prepared. However, we experienced that the preoperatively measured anteversion of the femoral neck using computer tomography (CT) was sometimes different from that of the stem measured during the operation. The purpose of this study was to investigate whether the preoperative measurement would be helpful to predict the stem anteversion by examining the relationship between the anteversion of the femoral neck and the stem. Patients and methods:. A total of 57 primary THAs by one senior surgeon from April 2011 until March 2012 were carried out. Two THAs using a modular stem and one for the hip after previous proximal femoral osteotomy were excluded. The remaining 54 THAs were examined. The used uncemented stems were designed for proximal metaphyseal fixation. CT scans, including the distal femoral condyles as well as the hips, were carried out in all cases preoperatively. The anteversion of the femoral neck was measured as the angle of the maximum longitudinal line of the cross section of the femoral neck to the line connecting the posterior surfaces of both of the distal femoral condyles (Fig. 1). The femoral neck anteversion was measured at three levels (Fig. 1). The stem anteversion was measured just after the femoral broaching during the THA. The relationship between the anteversion angles of the femoral neck and of the stem was examined by using a regression analysis. The institutional review board approved this study. Results:. The anteversion angles of the femoral neck varied widely when they were measured at all of the levels (Table 1). The anteversion angle of the femoral neck was not always identical to that of the stem. There were 32–46% of cases in which the difference between the stem anteversion and the femoral neck anteversion was within 5 degrees. There was a significant relationship between the anteversion of the stem and that of the femoral neck measured at all three levels (Fig. 2). When it was measured just below the femoral head, it was the closest to one, and the p-value was the lowest. Discusssion and Conclusions:. The anteversion of the uncemented stem could be calculated by using the formula to show the relationship between the stem anteversion and the femoral neck antevesion measured preoperatively. The values appeared to be sufficiently correct for making clinical decisions, although a prospective study may be necessary to confirm this

Purpose. While changes in lower limb alignment and pelvic inclination after total hip arthroplasty (THA) using certain surgical approaches have been studied, the effect of preserving the joint capsule is still unclear. We retrospectively investigated changes in lower limb alignment, length and pelvic inclination before and after surgery, and the risk of postoperative dislocation in patients who underwent capsule preserving THA using the anterolateral-supine (ALS) approach. Methods. Between July 2016 and March 2018, 112 hips (non-capsule preservation group: 42 hips, and capsule preservation group: 70 hips) from patients with hip osteoarthritis who underwent THA were included in this study. Patients who underwent spinal fusion and total knee arthroplasty on the same side as that of the THA were excluded. Using computed tomography, we measured lower limb elongation, external rotation of the knee, and femoral neck/stem anteversion before operation and three to five days after operation. We examined the pelvic inclination using vertical/transverse ratio of the pelvic cavity measured by X-ray of the anteroposterior pelvic region in the standing position before and six to 12 months after operation. All operations were performed using the ALS approach and taper wedge stem. Results. No dislocation was found in both groups. Lower limb elongation was 14.5±6.3 (mean±SD) mm in the non-capsule preservation group and 9.4±8.8 mm in the capsule preservation group. A significant reduction was found in the capsule preservation group (p<0.05). Changes in knee external rotation was 7.2±10.5 degrees in the non-capsule preservation group and 3.5±10.3 degrees in the capsule preservation group. A trend toward decreased knee external rotation in the capsule preservation group (p=0.07) was observed. There was no difference in femoral neck/stem anteversion and vertical/transverse ratio of the pelvic cavity between both groups. Discussion. Patients in the capsule preservation group tended to have reduced external rotation of lower limb, which might prevent postoperative anterior dislocation due to preservation of anterior structures. The capsule preservation group had significantly reduced lower limb elongation, suggesting that preservation of the hip joint capsule ligament contributes to joint stability. There was no significant difference in the pelvic inclination between both groups. Long-term changes will be assessed by regular follow up after operation

Introduction. Appropriate femoral stem anteversion is an important factor in maintaining stability and maximizing the performance of the bearing after total hip replacement (THR). The anteversion of the native femoral neck has been shown to have a significant effect on the final anteversion of the stem, particularly with a uncemented femoral component. The aim of this study was to quantify the variation in native femoral neck anteversion in a population of patients requiring total hip replacement. Methods. Pre-operatively, 1215 patients received CT scans as part of their routine planning for THR. Within the 3D planning, each patient's native femoral neck anteversion, measured in relation to the posterior condyles of the knee, was determined. Patients were separated into eight groups based upon gender and age. Males and females were divided by those under 55 years of age, those aged 55 to 64, 65 to 74 and those 75 or older. Results. The median anteversion in males was 12.7° (−27.1°–45.5°, IQR 6.0°–19.1°), compared to female anteversion of 16.0° (− 14.0°–54.5°, IQR 9.7°– 22.4°). These gender differences were statistically significant, p < 0.0001. Femoral anteversion in young males (<55) was significantly higher than in older males (>75), p=0.002. This age-related difference approached significance in females, p = 0.06. 14% of patients had extreme anteversion (<0° or >30°). Conclusions. The Native femoral neck anteversion in patients requiring THR is widely variable, with a range of over 80°. Females have more anteverted femurs than males. Femoral anteversion in young males was significantly higher than in older males. This age-related difference approached significance in females. Having an understanding of 3D patient morphology can greatly assist in pre-operative planning of THR, as post-op stem anteversion is likely influenced by the anteversion of the native femoral neck

Short stems are an option for primary THR, but these are the technical challenges. Stem anteversion is increased with short stems usually above 20 degrees so cup anteversion must be adjusted lower. Offset is better if increased up to 5 mm more because more bony neck is retained and with increased stem anteversion the greater trochanter is more posterior, and both of these increase the risk of bony impingement. Short stems are best in A bone, okay in B bone, not recommended yet in C bone. With standard stems performing so well use caution for conversion to short stems

Introduction. Dislocation is one of severe complications after total hip arthroplasty (THA). Direct anterior approach (DAA) is useful for muscle preservation. Therefore, it might be also effective to reduce dislocation. The purpose of this study is to investigate the ratio and factors of dislocations after THA with DAA. Materials & methods. Nine hundred fifity two primary THAs with DAA are examined. Mean age at operation was 64.9 yrs. 838 joints are in women and 114 (joints) in men. All THAs were performed under general anesthesia in supine position. We reviewed the ratio, onset and frequency of dislocations, build of the patients, preoperative Japanese Orthopaedic Association (JOA) Hip scores, implant setting angles, pelvic tilt angles and diameter of inner heads. Results. The ratio of dislocation was 14 joints (1.47%). All patients were women and mean age was 67.1 yrs. Anterior dislocation was in 9 joints and posterior was in 5 joints. Primary diagnosis for THA was the following: osteoarthritis in 9 hips and rheumatoid arthritis in 5 (hips). About primary onset, 7 joints were within 3 weeks, 5 joints from 3 weeks to 3 months and 2 joints after 3 months. About frequency, 9 joins were simple and 5 joints were multiple. Revision surgery was done in 2 joints due to ceramic fracture and cup migration. About build of the patients, mean body height was 153.1cm, mean body weight (was) 55.6 kg and mean BMI (was) 23.6. Mean preoperative JOA score was 40.0 points. Implant setting angles were the following: mean cup inclination was 42.4 degree, mean cup anteversion (was) 24.8 degree and mean stem anteversion (was) 18.7 degree. Cup inclination and anteversion in the anterior dislocation group were bigger than that in no dislocation group. Stem anteversion in the posterior dislocation group was smaller than that in no dislocation group. The difference of pelvic tilt angle between supine and standing position was 6.4 degree. It was significant bigger in the posterior dislocation group. The most of used Inner head was 28mm in 375 joints. There was no significant difference of the dislocation rate among inner head size. Discussion and conclusion. DAA-THA can expect the reduction of dislocation rate due to intermusclar approach; however there are some reports of high dislocation rate because of difficult technique. In our study, dislocation ratio was 1.47%. Risk factors of dislocation after THA was rheumatoid arthritis, large cup inclination and anteversion for anterior dislocation, small stem anteversion and large difference of pelvic tilt angle between supine and standing position for posterior dislocation