Accuracy of acetabular cup placement in computer-assisted, minimally-invasive THR in a lateral decubitus position

Abstract

In a prospective and randomised clinical study, we implanted acetabular cups either by means of an image-free computer-navigation system (navigated group, n = 32) or by free-hand technique (freehand group n = 32, two drop-outs). Total hip replacement was conducted in the lateral position and through a minimally invasive anterior approach (MicroHip). The position of the component was determined postoperatively on CT scans of the pelvis using CT-planning software. We found an average inclination of 42.3° (range 32.7-50.6°; SD ± 3.8°) and an average anteversion of 24.5° (range 12.0-33.3°; SD ± 6.0°) in the computer-assisted study group and an average inclination of 37.9° (range 25.6-50.2°; SD ± 6.3°) and an average anteversion of 23.8° (range 5.6-46.9°; SD ± 10.1°) in the freehand group. The higher precision of computer navigation was indicated by the lower standard deviations. For both measurements we found a significant heterogeneity of variances (p < 0.05, Levene's test). The mean difference between the cup inclination/anteversion values displayed by computer navigation and the true cup position (CT control) was 0.37° (SD 3.26) and -5.61° (SD 6.48), respectively. We found a bias (underestimation) with regard to anteversion determined by the imageless computer navigation system. A bias for inclination was not found. Registration of the landmarks of the anterior pelvic plane in lateral position with undraped percutaneous methods leads to an error in cup anteversion, but not to an error in cup inclination. The bias we found is consistent with a correct registration of the anterosuperior iliac spine (ASIS) and with a registration of the symphysis 1 cm above the bone, corresponding to the less compressible overlying soft tissue in this region. There was no significant correlation between the bias and the thickness of soft tissue above the pubic tubercles. We suggest use of a percutaneous registration of ASIS and an invasive registration above the pubic tubercles when computer-assisted navigation is performed in minimally invasive THR in a lateral position.

Fig. 1

Inclination of the acetabular component following freehand and navigation. Levene's test for homogeneity of variances, p = 0.007

Fig. 2

Anteversion of the acetabular component following freehand and navigation. Levene's test for homogeneity of variances, p = 0.024

Fig. 3

Inclination: deviation of the navigation values to CT values compared to their mean. Dotted lines represent the 95% limits of agreement (Bland-Altman graph)

Fig. 4

Anteversion: deviation of the navigation values to CT values compared to their mean. Dotted lines represent the 95% limits of agreement (Bland-Altman graph)

Fig. 5

Soft tissue thickness overlying a the pubic tubercles (PT) and b the anterior superior iliac spine (ASIS) measured in axial CT images. Soft tissue overlying ASIS potentially contains abdominal wall and bowel structures