Accuracy of cup placement in total hip arthroplasty by means of a mechanical positioning device: a comprehensive cadaveric 3d analysis of 16 specimens

Arthur J Kievit, Johannes G G Dobbe, Wouter H Mallee, Leendert Blankevoort, Geert J Streekstra, Matthias U Schafroth, Arthur J Kievit, Johannes G G Dobbe, Wouter H Mallee, Leendert Blankevoort, Geert J Streekstra, Matthias U Schafroth

Abstract

Introduction: We tested whether a mechanical device (such as Hipsecure) to pinpoint the anterior pelvic plane (APP) as a guide can improve acetabular cup placement. To assess accuracy we asked: (1) is the APP an effective guide to position acetabular cup placement within acceptable ° of divergence from the optimal 40° inclination and 15° anteversion; (2) could a mechanical device increase the number of acetabular cup placements within Lewinnek's safe zone (i.e. inclination 30° to 50°; anteversion 5° to 25°)?

Methods: 16 cadaveric specimens were used to assess the 3D surgical success of using a mechanical device APP to guide acetabular cup placement along the APP. We used the Hipsecure mechanical device to implant acetabular cups at 40° inclination and 15° anteversion. Subequently, all cadaveric specimens with implants were scanned with a CT and 3D models were created of the pelvis and acetabular cups to assess the outcome in terms of Lewinnek's safe zones.

Results: The mean inclination of the 16 implants was 40.6° (95% CI, 37.7-43.4) and the mean anteversion angle was 13.4° (95% CI, 10.7-16.1). All 16 cup placements were within Lewinnek's safe zone for inclination (between 30° and 50°) and all but 2 were within Lewinnek's safe zone for anteversion (between 5° and 25°).

Conclusion: In cadaveric specimens, the use of a mechanical device and the APP as a guide for acetabular cup placement resulted in good positioning with respect to both of Lewinnek's safe zones.

Keywords: 3D analysis; Lewinnek’s safe zone; accuracy study; anterior pelvic plane; anteversion; inclination; total hip arthroplasty.

Conflict of interest statement

Declaration of conflicting interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: The manufacturer of the Hipsecure system supplied us with the hardware to perform the study. Smith & Nephew Netherlands (Smith & Nephew, Andover, MA, USA) supplied us with a cadaveric training set to implant the acetabular components. Zimmer Biomet (Zimmer Biomet Inc, Warsaw, IN, USA) supplied the department of Orthopaedics of the Amsterdam University Medical Centre with an unrestricted research grant for the employment of a PhD student.

Figures

Figure 1.
Figure 1.
(a) The HipSecure system showing the frame that guides the pin placement to which is attached the guiding rod. (b) 3D model of a pelvis with a plane fitted to the anterior pelvic plane. Example of difference between the pelvic pin normal vector (nrs) and the normal vector of the anterior pelvic plane (napp) on a lateral view in the ZY plane, in this case the pin is tipped backwards which in theory would result in more anteversion.
Figure 2.
Figure 2.
A cadaveric specimen in supine position following pin placement on the right side.
Figure 3.
Figure 3.
The coordinate system (XYZ) in which the normal vectors of both the cup (ncup) and the pin are projected is shown in red. The z-axis is parallel to the craniodistal mechanical axis, the x-axis perpendicular to this and in medio-lateral direction and the y-axis points from posterior to anterior. The white arrow driving through the cup represents the normal vector (ncup).
Figure 4.
Figure 4.
The white arrow driving through the cup represents the normal vector (ncup). On the left, AP view of the acetabular cup plane and normal vector projected in the XZ plane provides the inclination angle. On the right, a lateral view of the acetabular cup plane and normal vector projected in the ZY plane provides the anteversion angle.
Figure 5.
Figure 5.
Angulation errors for all 16 specimens in anteversion (– too much, + too little) and inclination (– too much, + too little). Target angles (with an error of zero °s) are 40° of inclination and 15° of anteversion. The box represents Lewinnek’s safe zone. Each dot represents the error in placing each individual acetabular cup.

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