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

Reverse total shoulder arthroplasty (RTSA) has had rapidly increasingly utilization since its approval for U.S. use in 2004. RTSA accounted for 11% of extremity market procedure growth in 201. Although RTSA is widely used, there remain significant challenges in determining the location and configuration of implants to achieve optimal clinical and functional results. The goal of this study was to measure the 3D position of the shoulder joint center, relative to the center of the native glenoid face, in 16 subjects with RTSA of three different implant designs, and in 12 healthy young shoulders. CT scans of 12 healthy and 16 pre-operative shoulders were segmented to create 3D models of the scapula and humerus. A standardized bone coordinate system was defined for each bone (Figure 1). For healthy shoulders, the location of the humeral head center was measured relative to the glenoid face center. For the RTSA shoulders, a two-step measurement was required. First, 3D models of the pre-operative bones were reconstructed and oriented in the same manner as for healthy shoulders. Second, 3D model-image registration was used to determine the post-operative implant positioning relative to the bones. The 3D position and orientation of the implants and bones were determined in a sequence of six fluoroscopic images of the arm during abduction, and the mean implant-to-bone relationships were used to determine the surgical positioning of the implants (Figure 2). The RTSA center of rotation was defined as the offset from the center of the implant glenosphere to the center of the native glenoid face. The center of rotation in RTSA shoulders varied over a much greater range than the native shoulders (Table 1 (Figure 3)). Lateral offset of the joint center in RTSA shoulders was at least 6 mm smaller than the smallest joint center offset in the healthy shoulders. The center of rotation in RTSA shoulders was significantly more inferior than in healthy shoulders. The range of anterior/posterior placement of the rotation center for RTSA shoulders was bounded by the range for normal shoulders. How to best position RTSA implants for optimal patient outcomes remains a topic of great debate and research interest. We found that the 3D joint center position can vary over a supraphysiologic range in shoulders with RTSA, and that this variation is primarily in the coronal plane. By relating these geometric variations to muscle, shoulder and clinical function, we hope to establish methods and strategies for predictably obtaining the best clinical and functional outcomes for RTSA patients on a per-subject basis

“How does the knee move?” is a question of fundamental importance for treatment of knee injuries and knee replacement design. Unfortunately, we lack unambiguous and comprehensive knee function data sets and/or consensus on how healthy knees move. One can just as easily find reports stating the natural knee has a center of axial rotation in the medial compartment of the knee as in the lateral. This is due to technical and practical issues: It is extremely difficult to accurately measure knee motions during ambulatory activities and, when that can be done, very few studies have examined a range of weightbearing activities in the same study cohort. The purpose of this study is to report knee kinematics in a cohort of healthy older subjects whose motions were examined during four different movements, three of them weightbearing ambulation, using a high-speed stereoradiographic system. Six healthy consenting subjects (age = 61 ± 5 years, body mass = 75 ± 8 kg, BMI = 27 ± 4) were observed using a high-speed stereoradiographic system while completing four tasks. Subjects were instructed to perform an unloaded, seated knee extension from high flexion to full extension; to walk at a self selected pace; to step down from a 7 inch platform; and to walk and perform a 90° direction change (pivoting). Stereoradiographic images (1080 × 1080 pixels) were acquired at 100 images/second using 40cm image intensifiers and pulsed x-ray exposures. The three-dimensional knee kinematics were measured using the XROMM software suite (. xromm.org. , Brown University). Post-processing of the kinematics was performed in custom Matlab programs, and included fitting spheres to the posterior condylar surfaces of each knee, and then tracking the motions of the sphere centers relative to a fixed tibial reference frame (Figure 1). The motions of these flexion-facet centers, were used to determine an average center of axial rotation (CoR) over each activity as previously reported by Banks and Hodge. Average CoRs for all four activities were in the posterior-medial quadrant of the knee, with the CoR for open-chain knee extension being the most medial and gait the most lateral (Table 1, Figure 2). One-way ANOVA showed average CoRs are different (p « 0.001). There was considerable variation in individual CoRs, for example, with two knees showing lateral CoRs for gait and the remaining knees having medial CoRs. It should not be surprising that natural knee motions vary with dynamic activity, yet knee kinematics often are presented as being one stereotypic, monolithic pattern of motion. Our data show that the same healthy subjects performing different dynamic activities manifest different knee motions, with open-chain knee extension having the most medial CoR and gait the most lateral. This finding is consistent with previous reports comparing stair climbing and gait in knees with various implant designs. Additional experimental data and, ultimately, validated numerical simulations should facilitate an increasingly accurate process for designing improved treatments for diseased and damaged knees

Purpose. To determine if clinical outcomes are correlated with center of rotation (COR) in patients implanted with a viscoelastic total disc replacement (VTDR). Methods. Fifty patients with single-level, symptomatic lumbar DDD between L4 and S1 were enrolled in a clinical trial of a VTDR across three surgical centres. A comprehensive, independent review and statistical analysis of both clinical and radiographic outcomes was performed and analyzed for correlations. Data from preoperative through 2 years were available. The COR was calculated for the index levels and compared to data for an asymptomatic population. Each COR coordinate was classified as abnormal if outside of the 95% confidence interval for an asymptomatic population. Results. At most recent follow-up, 69% of the patients had achieved at least a 15 point Oswestry Disability Index (ODI) improvement. 76% of the patients achieved at least a 10 point improvement. At most recent follow-up, 78% of cases had a normal COR-X and 92% had a normal COR-Y. Results from three statistical tests show the association between COR-X and outcomes. 1) Based on latest available time point for each patient, the improvement in ODI score was significantly better for patients with a normal anterior-posterior (AP) coordinate of the COR (P=0.03). 2) Anterior COR corresponded with anterior placement of the device in the disc space, and patients were almost 7 times less likely to achieve at least a 15 point improvement in the ODI score if the COR was positioned too anteriorly. 3) This effect was also seen in the average AP coordinate of the COR for patients who achieved a 15 point ODI improvement. Conclusions. A viscoelastic TDR can restore a normal COR. This is the first study to show that restoration of a normal COR correlates with a significant and clinically relevant improvement in patient disability

Purpose. To determine if clinical outcomes are correlated with center of rotation (COR) in patients implanted with a viscoelastic total disc replacement (VTDR). Methods. Fifty patients with single-level, symptomatic lumbar DDD between L4 and S1 were enrolled in a clinical trial of a VTDR across three surgical centres. A comprehensive, independent review and statistical analysis of both clinical and radiographic outcomes was performed and analyzed for correlations. Data from preoperative through 2 years were available. The COR was calculated for the index levels and compared to data for an asymptomatic population. Each COR coordinate was classified as abnormal if outside of the 95% confidence interval for an asymptomatic population. Results. At most recent follow-up, 69% of the patients had achieved at least a 15 point Oswestry Disability Index (ODI) improvement. 76% of the patients achieved at least a 10 point improvement. At most recent follow-up, 78% of cases had a normal COR-X and 92% had a normal COR-Y. Results from three statistical tests show the association between COR-X and outcomes. 1) Based on latest available time point for each patient, the improvement in ODI score was significantly better for patients with a normal anterior-posterior (AP) coordinate of the COR (P=0.03). 2) Anterior COR corresponded with anterior placement of the device in the disc space, and patients were almost 7 times less likely to achieve at least a 15 point improvement in the ODI score if the COR was positioned too anteriorly. 3) This effect was also seen in the average AP coordinate of the COR for patients who achieved a 15 point ODI improvement. Conclusions. A viscoelastic TDR can restore a normal COR. This is the first study to show that restoration of a normal COR correlates with a significant and clinically relevant improvement in patient disability

Introduction. Restoration of the femoral head centre during THR should theoretically improve muscle function and soft tissue tension. The aim of this study was to assess whether 3D planning and an accurately controlled neck osteotomy could help recreate hip anatomy. Methods. 100 consecutive THR patients received OPS. TM. 3D femoral planning. For each patient a 3D stem+head position was pre-operatively planned which restored the native head height, restored global offset after cup medialisation and reproduced anterior offset, in the superior-inferior, medial-lateral and anterior-posterior directions respectively. The femoral osteotomy was planned preoperatively and controlled intra-operatively with a patient specific guide. All procedures were performed through a posterior approach with a TriFit/Trinity uncemented implant combination. Post-op implant position was determined from CT. Results. The mean difference between planned and achieved head height was 0.9mm (−1.2mm to 4.6mm). The mean difference between planned and achieved medial offset was −0.9mm (−6.2mm to 3.1mm). The mean difference between planned and achieved anterior offset was 3.2mm (−0.4mm to 6.6mm). Resultant 3D change between the planned and achieved head centre was 4.4mm (0.6mm to 9.1mm). The change in anterior offset was strongly correlated (r=0.78) to the change in achieved stem anteversion in comparison to the plan; mean values of 16.3° and 10.5° respectively. Conclusions. In this single centre pilot study, femoral centre of rotation was accurately reproduced by using 3D templating and controlling the femoral neck osteotomy with a patient-specific guide

Purpose: A functional centre of rotation (CoR) is often required in biomechanical analysis of the hip or as a landmark in computer guided surgery. It was previously shown that circumduction motions predict a CoR that is inferior and lateral to the geometric centre of the hip bearing surfaces. It is therefore necessary to establish the best method for determining the CoR to improve surgical planning. The objective of this study was to compare the predicted CoR from circumduction and star motions, and to compare these to the geometric centre of the joint. Method: Eight cadaveric hips from four cadavers were tested. Prior to testing, CT scans of the cadavers were made from the iliac crest to the tibial plateau; the alpha angle for all hips was less than 50° so all hips were considered ‘normal’. Reflective marker arrays were rigidly mounted on the femoral diaphysis and iliac spine using 4mm Steinman pins. A five-camera Vicon system (Oxford, UK) was used to track the motions of the arrays during manipulation of the lower limb. To determine the functional hip centre, trials consisting of five cycles each of circumduction, flexion-extension and abduction-adduction were performed on each lower limb; three trials of each motion were performed. The range of motion was approximately 45° in the coronal and sagittal planes. For the ‘star’ motion, the flexion-extension and abduction-adduction trial data were combined. Following the trials the hip was dissected to expose the articular surfaces of the femoral head and acetabulum. These surfaces were traced using a pointer equipped with reflective markers to determine the geometric centre. To calculate the functional centre, the 3D coordinates of the markers were used to construct a local-to-global 3D transform for each frame throughout the trial. The geometric centre was calculated using a least-squares sphere fit (Gauss-Newton) of the trace data, calculated in the respective local coordinate systems. The coordinates of the functional centres were then transformed to an anatomic coordinate system, using the geometric centre as the origin. All calculations were performed using Matlab (Mathworks, Inc, MA, USA). A t-test was performed in each anatomic direction to detect differences in CoR predicted by the two motions. Results: Both the circumduction and star motions resulted in a similar CoR. Differences were 0.41±2.25mm in the anterior-posterior direction; 0.09±0.72mm in the superior-inferior direction; and 0.21±0.82mm in the medial-lateral direction, none of which were significant (p> 0.5). The overall mean distance between the CoR predicted by the two motions was 2.0±1.3mm. The functional centre was also found to be lateral and inferior to the geometric centre, and was consistent for each motion. Results for the acetabulum showed similar trends. Conclusion: This study has shown that circumduction and star motions are equivalent in predicting the hip functional CoR; differences were small compared to the dimensions involved in studies such as gait analyses. However, both motions predicted a CoR that was inferior and lateral to the spherical centre of the femoral head, suggesting that the hip does not act as a true ball-and-socket joint with congruent spherical bearing surfaces. This may have important consequences in studies at the scale of the hip joint, especially for pathological conditions such as femoroacetabular impingement

Purpopse. Few Cervical Total Disc Replacement (TDR) devices are engineered to address both the Center of Balance (COB) and the Center of Rotation (COR) of the cervical motion segments. The COB is the axis in the intervertebral disc through which the axial compressive load is transmitted. TDRs placed posterior of this point tend to fall into kyphosis while devices placed anterior of this point tend to fall into lordosis. Thus from a “balancing” point of view the ideal placement would be at the COB. However, the COR position has been shown to be posterior and inferior to the disc space. It has also been shown that constrained devices tend to lose motion when there is a mismatch between device and anatomic centers. Mobile core devices may be placed at the COB since their unconstrained rotations and translations allow for the device COR to follow the anatomic COR, but they rely heavily on the facet joints and other anatomic features to resist the paradoxiacal motion. The TriLobe cervical TDR (Figure 2) was engineered for both the COB and COR. The purpose of this study was to compare the 3D kinematic and biomechanical performance of the TriLobe to a ball and trough(BT) cervical TDR in an augmented pure moment cadaveric study to find the ideal AP implant placement. Materials and methods. Specimen were CT imaged for three-dimensional reconstruction. Visual, CT, and DEXA screening was utilized to verify that specimens are free from any defects. Specimens were prepared by resecting all nonligamentous soft tissue leaving the facet joint capsules and spinal ligaments intact. C2 and T1 were potted to facilitate mounting in the testing apparatus (7-axis Spine Tester, Univ. of Utah, Salt Lake City, UT). OptoTRAK motion tracking flags were attached to each vertebra including C2/C3 and T1 to track the 3D motion of each vertebra. •. Specimens C2–T1. •. Treatment Level C5–C6. •. Insertion of fixture pins under fluoro. •. Load Control Testing to 2.5Nm in FE, LB, AR at 0.5Hz. •. 15 Pre-cycles in load control in FE / LB / AR (2.5Nm). •. Test implants in load control in FE / LB / AR to 2.5Nm for 4 cycles with data recorded for all cycles. Results. [Results Table - Figure 1]. Discussion. This study showed that the TriLobe had better control of motion compared to the ball and trough both in ROM and varibility for FE, LB, and AR. The TriLobe had better control of limiting kyphosis over the ball and trough by 41% of the flexion motion. The neutral zone slope, an measure for device stability, showed that the TriLobe was 51% more stable than the BT. AP placement of devices showed there was a general trend of decreasing stability from anterior to posterior placement; however, statistical significance was not established

Background. The position of the hip-joint centre of rotation (HJC) within the pelvis is known to influence functional outcome of total hip replacement (THR). Superior, lateral and posterior relocations of the HJC from anatomical position have been shown to be associated with greater joint reaction forces and a higher incidence of aseptic loosening. In biomechanical models, the maximum force, moment-generating capacity and the range of motion of the major hip muscle groups have been shown to be sensitive to HJC displacement. This clinical study investigated the effect of HJC displacement and acetabular cup inclination angle on functional performance in patients undergoing primary THR. Methods. Retrospective study of primary THR patients at the RNOH. HJC displacement from anatomical position in horizontal and vertical planes was measured relative to radiological landmarks using post-operative, calibrated, anterior-posterior pelvic radiographs. Acetabular cup inclination angle was measured relative to the inter-teardrop line. Maximum range of passive hip flexion, abduction, adduction, external and internal rotation were measured in clinic. Patient reported functional outcome was assessed by Oxford Hip Score (OHS) and WOMAC questionnaires. Data analysed using a linear regression model. Results. 109 THRs were studied in 104 patients (69 Female). Mean age at THR=63 years (22-88). Mean follow-up=17 months (11-39 months). Median OHS=16, WOMAC=8. Increasing vertical HJC displacement (in either superior or inferior direction) from anatomical position was associated with worsening OHS (p<0.05) and WOMAC scores (p<0.05) and a reduced range of passive hip flexion (p<0.05). No relationship was found between either horizontal HJC displacement or acetabular cup inclination angle and patient functional outcome. Conclusion. A significant relationship was identified between increasing vertical displacement of the HJC and worsening patient functional outcome. This supports current opinion regarding the disadvantageous consequences of a superiorly displaced HJC in terms of survivorship and function. We therefore advocate an anatomical restoration of HJC position wherever possible

INTRODUCTION. Accurate knowledge of knee joint kinematics following total knee arthroplasty (TKA) is critical for evaluating the functional performance of specific implant designs. Biplane fluoroscopy is currently the most accurate method for measuring 3D knee joint kinematics in vivo during daily activities such as walking. However, the relatively small imaging field of these systems has limited measurement of knee kinematics to only a portion of the gait cycle. We developed a mobile biplane X-ray (MoBiX) fluoroscopy system that enables concurrent tracking and imaging of the knee joint for multiple cycles of overground gait. The primary aim of the present study was to measure 6-degree-of-freedom (6-DOF) knee joint kinematics for one complete cycle of overground walking. A secondary aim was to quantify the position of the knee joint centre of rotation (COR) in the transverse plane during TKA gait. METHODS. Ten unilateral posterior-stabilised TKA patients (5 females, 5 males) were recruited to the study. Each subject walked over ground at their self-selected speed (0.93±0.12 m/s). The MoBiX imaging system tracked and recorded biplane X-ray images of the knee, from which tibiofemoral kinematics were calculated using an image processing and pose-estimation pipeline created in MATLAB. Mean 6-DOF tibiofemoral joint kinematics were plotted against the mean knee flexion angle for one complete cycle of overground walking. The joint COR in the transverse plane was calculated as the least squares intersection of the femoral flexion axis projected onto the tibial tray during the stance and swing phases. The femoral and tibial axes and 6-DOF kinematics were defined in accordance with the convention defined by Grood and Suntay in 1983. RESULTS AND DISCUSSION. The offset in secondary joint motions at a given flexion angle was greater at larger knee flexion angles than at smaller flexion angles for abduction, anterior drawer, and lateral shift, whereas the opposite was true for external rotation. Significant variability was observed between subjects for the COR. The mean COR was on the lateral side during stance, consistent with results reported in the literature for the intact knee. Interestingly, the mean COR was on the medial side during swing. CONCLUSIONS. Our results suggest that secondary joint motions in the TKA knee, specifically, external rotation, abduction, anterior drawer and lateral shift, are determined not only by implant geometry and ligament anatomy but also by external loading, and are therefore task-dependent. The mean COR in the transverse plane shifted from the lateral to the medial side of the knee as the leg transitioned from stance to swing. Mobile dynamic X-ray imaging is a valuable tool for evaluating the functional performance of knee implants during locomotion over ground

The reverse ball and socket shoulder replacement, employing a humeral socket and glenosphere, has revolutionized the treatment of patients with arthritis and rotator cuff insufficiency. The RSP (DjO Surgical, Inc., Austin, Texas) is one such device, characterized by a lateral center of rotation and approved for use in the United States since 2004. Multiple studies by the implant design team have documented excellent outcomes and low revision rates for the RSP, but other published outcomes data are relatively sparse. The objective of this study is to report on the complications and early outcomes in the first consecutive 60 RSPs implanted in 57 patients by a single shoulder replacement surgeon between 2004 and 2010. Forty-four patients were female and mean age at the time of reverse shoulder arthroplasty was 75 years (range 54 to 92 years). The RSP was used as a primary arthroplasty in 42 shoulders and to revise a failed prosthetic shoulder arthroplasty in 18 shoulders. During the study period, 365 shoulder replacements were implanted so that the RSP was used selectively, accounting for only 17% of all shoulder arthroplasties (8.4% for 2004-2007, 24.2% for 2008-2010). Most patients had pseudoparalysis and profound shoulder dysfunction so that mean pre-operative active forward elevation was to 45°, active abduction to 43°, active internal rotation to the buttock, and the mean pre-operative Simple Shoulder Test (SST) score was 1 out of 12. At final follow-up, mean active forward elevation had improved to 101° (p<0.0001), active abduction to 91° (p<0.0001), active internal rotation to the lumbosacral junction (p<0.001), and the mean final SST score was 7 out of 12. There were 16 complications in 14 patients, including 7 reoperations in 6 patients (11%): 3 closed reductions for dislocation, 2 open revisions for instability and for a dissociated liner in the same patient, one evacuation of a hematoma, and one open reduction and internal fixation of a post-operative scapular spine fracture. Two additional scapular spine or acromion fractures and one acromioclavicular joint separation developed postoperatively that impacted outcome adversely but did not require re-operation. None of the glenoid baseplates or humeral stems has been revised and no deep infections have occurred. Experience with reverse shoulder arthroplasty appears to influence the reoperation rate, as 3 of the reoperations occurred following the first 15 reverse shoulder arthroplasties. Overall improvements in active motion and self-assessed shoulder function were comparable to those reported previously. Final active motion results were somewhat lower than those reported previously, which may relate to the selection of predominately pseudoparalytic patients for reverse shoulder arthroplasty in this series. Use of the RSP device for reverse shoulder arthroplasty leads to improved motion and function in carefully selected older patients with pseudoparalysis or a failed shoulder replacement. Re-operations and complications occur but the learning curve may not be as steep as previously reported. This may relate to specific features of the implant system used in this series, as well as to surgeon experience

Introduction: The foot is a very complex structure acting as the platform for all gait patterns. At present, little is known about the exact biomechanics of the foot due to the difficulties in modeling all of the components of the foot accurately. This has made it virtually impossible to develop a complete understanding of the aetiology of many diseases of the foot including hallux rigidus. We hypothesize that sagittal plane incongruency of the rotation of the 1. st. Metatarsophalangeal Joint (MTPJ), or an increase in the tension of the intrinsic plantar flexors is responsible for the development of hallux rigidus. Materials & Methods: Ground reaction forces and kinematic data from gait analysis together with anthropometric data from MRI scans of a 24 y.o. female were used to create a Mimics model of the articulation of a normal 1st MTPJ during a gait cycle. The centre of rotation was calculated by triangulating the articular surfaces. Finite element analysis was performed on the model and on similar models with the hypothesized;. joint incongruency,. an increased tension in the Flexor Hallicus Brevis and. an increased tension in the plantar fascia. Results: The results demonstrated a significant increase in the peak stresses, contact areas and stress distributions between the incongruent models compared to the congruent models. Discussion: To the best of our knowledge this is the most accurate FE model of the 1st MTPJ calculated. Hallux Rigidus is a very common forefoot disorder, with multiple etiologies and treatments advocated. This model demonstrates that an increased tension in the plantar flexors results in a reduced ROM with increased contact stresses on the joint surface. Conclusion: While it is known Hallux Rigidus has a multi-factorial etiology, the authors feel the above study demonstrates an important inherent etiology

Introduction. Lateralizing the center of rotation (COR) of reverse total shoulder arthroplasty (rTSA) has the potential to increase functional outcomes of the procedure, namely adduction range of motion (ROM). However, increased torque at the bone-implant interface as a result of lateralization may provoke early implant loosening, especially in situations where two, rather than four, fixation screws are used. The aim of this study was to utilize finite element (FE) models to investigate the effects of lateralization and the number of fixation screws on micromotion and adduction ROM. Methods. Four patient-specific scapular geometries were developed from CT data in 3D Slicer using a semi-automatic threshold technique. A generic glenoid component including the baseplate, a lateralization spacer, and four fixation screws was modelled as a monoblock. Screws were simplified as 4.5 mm diameter cylinders. The glenoid of each scapula was virtually reamed after which the glenoid component was placed. Models were meshed with quadratic tetrahedral elements with an edge length of 1.3 mm. The baseplate and lateralization spacer were assigned titanium material properties (E = 113.8 GPa and ν = 0.34). Screws were also assigned titanium material properties with a corrected elastic modulus (56.7 GPa) to account for omitted thread geometry. Cortical bone was assigned an elastic modulus of 17.5 GPa and Poisson's ratio of 0.3. Cancellous bone material properties in the region of the glenoid were assigned on an element-by-element basis using previously established equations to convert Hounsfield Units from the CT data to density and subsequently to elastic modulus [1]. Fixed displacement boundary conditions were applied to the medial border of each scapula. Contact was simulated as frictional (μ = 0.8) between bone and screws and frictionless between bone and baseplate/spacer. Compressive and superiorly-oriented shear loads of 686 N were applied to the baseplate/spacer. Lateralization of the COR up to 16 mm was simulated by applying the shear load further from the glenoid surface in 4 mm increments (Fig. 1A). All lateralization levels were simulated with four and two (superior and inferior) fixation screws. Absolute micromotion of the baseplate/spacer with respect to the glenoid surface was averaged across the back surface of the spacer and normalized to the baseline configuration considered to be 0 mm lateralization and four fixation screws. Adduction ROM was measured as the angle between the glenoid surface and the humeral stem when impingement of the humeral cup occurred (Fig. 1B). Results. Lateralization (p = 0.015) and reducing the number of fixation screws (p = 0.008) significantly increased micromotion (Fig. 2). Lateralization significantly increased adduction ROM (p = 0.001). Relationships between lateralization, the number of fixation screws, micromotion, and adduction ROM were shoulder-specific (Fig. 3). Conclusions. Lateralizing the COR of rTSA can improve functional outcomes of the procedure, however may compromise long-term survival of the implant by increasing micromotion. Our results indicate that the trade-offs of lateralizing should be considered on a patient-specific basis, taking into account factors such as quality and availability of bone stock

CT-based, customised femoral stem enables optimal reconstruction of hip mechanics and leg length. However, traditional planning and execution of cup insertion may jeopardise these biomechanical parameters. The aim of this study was to examine the agreement of the preoperative planning of cup position and the final position of the cup.

Thirty total hip replacements with an uncemented acetabular cup (Duraloc, DePuy) or a cemented cup (Elite-Plus, DePuy) were included. A customised femoral stem was used in all hips. On the preoperative X-rays the planned position and orientation of the cup had been marked prior to the surgery. The pre- and postoperative X-ray images were then digitised and scaled. The planned and final positions of the cup centre in the frontal plane was then measured relative to a horizontal line defined by the tear-drops and to a vertical line through the centre of the tear-drop on the operated side. In addition the concurrence between the planned and final cup size was examined.

In the horizontal direction the cups were positioned 1.4 (7.6) mm (median, ±2SD) more medial than planned on the preoperative X-rays. In the vertical direction the corresponding figures were 1.2 (6.6) mm (median, ±2SD) and the cups were usually placed more cranially than was planned. The maximum discrepancy between the planned and final position was 10,6 mm in the horizontal direction (medial) and 7.1 mm in the vertical direction (cranial). In 63% of the hips there was agreement between the size of the cup planned preoperatively and the cup that was finally inserted. In 25% of the hips the final cup was larger and in 12% the final cup was smaller.

In most cases the acetabular cups were inserted within a few millimetres of the planned position. The combination of a standard uncemented or cemented cup with a custom femoral stem enables the surgeon to restore hip mechanics and leg length.

Introduction: Several techniques have been described for revision of acetabulum associated with severe superior bony defects. An Oblong cup inserted without bone cement has the advantage of restoration of the centre of hip rotation and maintenance of bone stock. The aim of this study was to analyse the medium-term results of acetabular revision using Oblong cup for severe superior bony defects. Methods: Thirty-five acetabular revisions using porous coated Oblong cups (S-Rom, Depuy) in 34 patients were performed by the senior author between 1998–2001. All patients were followed-up clinically and thirty-one hips were analysed radiologically for a mean duration of 39.6 months (range 18 to 60). The clinical assessment was performed using Harris hip score and subjective patient’s satisfaction. The acetabular defects were classified according to the method described by Paprosky et al. The position of the acetabular implant, restoration of the centre of hip rotation and the extent of osseo-integration of the acetabular shell were assessed in the post-operative radiographs. Results: The mean Harris hip score has improved from a preoperative value of 40.6 to 69.4 post-operatively. According to the Leprosy’s method, two acetabula were classified as type 2B, 12 as type 3A and 17 as 3B. The post-operative radiographs showed a mean abduction angle of the Oblong cups of 54.2 degrees (range 40–80). Osseointegration was achieved in 29(94%) of cups. Three cups showed early migration, of which two eventually stabilised and osseointegrated by 12 months. The centre of rotation of hip improved from a mean lateral migration of 8.3 mm and superior migration of 23.5 mm in the pre-operative radiographs to 2.8 mm and 4.3 mm respectively post-operatively. Discussion: Acetabular revision using porous coated oblong cup for severe superior acetabular defects provides satisfactory medium-term results with predictable restoration of hip centre of rotation

Aims. Custom triflange acetabular components (CTACs) play an important role in reconstructive orthopaedic surgery, particularly in revision total hip arthroplasty (rTHA) and pelvic tumour resection procedures. Accurate CTAC positioning is essential to successful surgical outcomes. While prior studies have explored CTAC positioning in rTHA, research focusing on tumour cases and implant flange positioning precision remains limited. Additionally, the impact of intraoperative navigation on positioning accuracy warrants further investigation. This study assesses CTAC positioning accuracy in tumour resection and rTHA cases, focusing on the differences between preoperative planning and postoperative implant positions. Methods. A multicentre observational cohort study in Australia between February 2017 and March 2021 included consecutive patients undergoing acetabular reconstruction with CTACs in rTHA (Paprosky 3A/3B defects) or tumour resection (including Enneking P2 peri-acetabular area). Of 103 eligible patients (104 hips), 34 patients (35 hips) were analyzed. Results. CTAC positioning was generally accurate, with minor deviations in cup inclination (mean 2.7°; SD 2.84°), anteversion (mean 3.6°; SD 5.04°), and rotation (mean 2.1°; SD 2.47°). Deviation of the hip centre of rotation (COR) showed a mean vector length of 5.9 mm (SD 7.24). Flange positions showed small deviations, with the ischial flange exhibiting the largest deviation (mean vector length of 7.0 mm; SD 8.65). Overall, 83% of the implants were accurately positioned, with 17% exceeding malpositioning thresholds. CTACs used in tumour resections exhibited higher positioning accuracy than rTHA cases, with significant differences in inclination (1.5° for tumour vs 3.4° for rTHA) and rotation (1.3° for tumour vs 2.4° for rTHA). The use of intraoperative navigation appeared to enhance positioning accuracy, but this did not reach statistical significance. Conclusion. This study demonstrates favourable CTAC positioning accuracy, with potential for improved accuracy through intraoperative navigation. Further research is needed to understand the implications of positioning accuracy on implant performance and long-term survival. Cite this article: Bone Jt Open 2024;5(4):260–268

Aims. Achieving accurate implant positioning and restoring native hip biomechanics are key surgeon-controlled technical objectives in total hip arthroplasty (THA). The primary objective of this study was to compare the reproducibility of the planned preoperative centre of hip rotation (COR) in patients undergoing robotic arm-assisted THA versus conventional THA. Methods. This prospective randomized controlled trial (RCT) included 60 patients with symptomatic hip osteoarthritis undergoing conventional THA (CO THA) versus robotic arm-assisted THA (RO THA). Patients in both arms underwent pre- and postoperative CT scans, and a patient-specific plan was created using the robotic software. The COR, combined offset, acetabular orientation, and leg length discrepancy were measured on the pre- and postoperative CT scanogram at six weeks following surgery. Results. There were no significant differences for any of the baseline characteristics including spinopelvic mobility. The absolute error for achieving the planned horizontal COR was median 1.4 mm (interquartile range (IQR) 0.87 to 3.42) in RO THA versus 4.3 mm (IQR 3 to 6.8; p < 0.001); vertical COR mean 0.91 mm (SD 0.73) in RO THA versus 2.3 mm (SD 1.3; p < 0.001); and combined offset median 2 mm (IQR 0.97 to 5.45) in RO THA versus 3.9 mm (IQR 2 to 7.9; p = 0.019). Improved accuracy was observed with RO THA in achieving the desired acetabular component positioning (root mean square error for anteversion and inclination was 2.6 and 1.3 vs 8.9 and 5.3, repectively) and leg length (mean 0.6 mm vs 1.4 mm; p < 0.001). Patient-reported outcome measures were comparable between the two groups at baseline and one year. Participants in the RO THA group needed fewer physiotherapy sessions postoperatively (median six (IQR 4.5 to 8) vs eight (IQR 6 to 11; p = 0.005). Conclusion. This RCT suggested that robotic-arm assistance in THA was associated with improved accuracy in restoring the native COR, better preservation of the combined offset, leg length correction, and superior accuracy in achieving the desired acetabular component positioning. Further evaluation through long-term and registry data is necessary to assess whether these findings translate into improved implant survival and functional outcomes. Cite this article: Bone Joint J 2024;106-B(4):324–335

Aims

One goal of total hip arthroplasty is to restore normal hip anatomy. The aim of this study was to compare displacement of the centre of rotation (COR) using a standard reaming technique with a technique in which the acetabulum was reamed immediately peripherally and referenced off the rim.

Aims. Complex total hip arthroplasty (THA) with subtrochanteric shortening osteotomy is necessary in conditions other than developmental dysplasia of the hip (DDH) and septic arthritis sequelae with significant proximal femur migration. Our aim was to evaluate the hip centre restoration with THAs in these hips. Methods. In all, 27 THAs in 25 patients requiring THA with femoral shortening between 2012 and 2019 were assessed. Bilateral shortening was required in two patients. Subtrochanteric shortening was required in 14 out of 27 hips (51.9%) with aetiology other than DDH or septic arthritis. Vertical centre of rotation (VCOR), horizontal centre of rotation, offset, and functional outcome was calculated. The mean followup was 24.4 months (5 to 92 months). Results. The mean VCOR was 17.43 mm (9.5 to 27 mm) and horizontal centre of rotation (HCOR) was 24.79 mm (17.2 to 37.6 mm). Dislocation at three months following acetabulum reconstruction required femoral shortening for offset correction and hip centre restoration in one hip. Mean horizontal offset was 39.72 (32.7 to 48.2 mm) compared to 42.89 (26.7 to 50.6 mm) on the normal side. Mean Harris Hip Score (HHS) of 22.64 (14 to 35) improved to 79.43 (68 to 92). Mean pre-operative shortening was 3.95 cm (2 to 8 cm). Residual limb length discrepancy was 1.5 cm (0 to 2 cm). Sciatic neuropraxia in two patients recovered by six months, and femoral neuropraxia in one hip recovered by 12 months. Mean Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) was 13.92 (9 to 19). Mean 12-item short form survey (SF-12) physical scores of 50.6 and mental of 60.12 were obtained. Conclusion. THA with subtrochanteric shortening is valuable in complex hips with high dislocation. The restoration of the hip centre of rotation and offset is important in these hips. Level of evidence IV. Femoral shortening useful in conditions other than DDH and septic sequelae. Restoration of hip centre combined with offset to be planned and ensured

Aims. The aim of this study was to compare the biomechanical models of two frequently used techniques for reconstructing severe acetabular defects with pelvic discontinuity in revision total hip arthroplasty (THA) – the Trabecular Metal Acetabular Revision System (TMARS) and custom triflange acetabular components (CTACs) – using virtual modelling. Methods. Pre- and postoperative CT scans from ten patients who underwent revision with the TMARS for a Paprosky IIIB acetabular defect with pelvic discontinuity were retrospectively collated. Computer models of a CTAC implant were designed from the preoperative CT scans of these patients. Computer models of the TMARS reconstruction were segmented from postoperative CT scans using a semi-automated method. The amount of bone removed, the implant-bone apposition that was achieved, and the restoration of the centre of rotation of the hip were compared between all the actual TMARS and the virtual CTAC implants. Results. The median amount of bone removed for TMARS reconstructions was significantly greater than for CTAC implants (9.07 cm. 3. (interquartile range (IQR) 5.86 to 21.42) vs 1.16 cm. 3. (IQR 0.42 to 3.53) (p = 0.004). There was no significant difference between the median overall implant-bone apposition between TMARS reconstructions and CTAC implants (54.8 cm. 2. (IQR 28.2 to 82.3) vs 56.6 cm. 2. (IQR 40.6 to 69.7) (p = 0.683). However, there was significantly more implant-bone apposition within the residual acetabulum (45.2 cm. 2. (IQR 28.2 to 72.4) vs 25.5 cm. 2. (IQR 12.8 to 44.1) (p = 0.001) and conversely significantly less apposition with the outer cortex of the pelvis for TMARS implants compared with CTAC reconstructions (0 cm. 2. (IQR 0 to 13.1) vs 23.2 cm. 2. (IQR 16.4 to 30.6) (p = 0.009). The mean centre of rotation of the hip of TMARS reconstructions differed by a mean of 11.1 mm (3 to 28) compared with CTAC implants. Conclusion. In using TMARS, more bone is removed, thus achieving more implant-bone apposition within the residual acetabular bone. In CTAC implants, the amount of bone removed is minimal, while the implant-bone apposition is more evenly distributed between the residual acetabulum and the outer cortex of the pelvis. The differences suggest that these implants used to treat pelvic discontinuity might achieve short- and long-term stability through different biomechanical mechanisms. Cite this article: Bone Joint J 2024;106-B(5 Supple B):74–81