Acetabular cup position and risk of dislocation in primary total hip arthroplasty

Abstract

Background and purpose - Hip dislocation is one of the most common complications following total hip arthroplasty (THA). Several factors that affect dislocation have been identified, including acetabular cup positioning. Optimal values for cup inclination and anteversion are debatable. We performed a systematic review to describe the different methods for measuring cup placement, target zones for cup positioning, and the association between cup positioning and dislocation following primary THA. Methods - A systematic search of literature in the PubMed database was performed (January and February 2016) to identify articles that compared acetabular cup positioning and the risk of dislocation. Surgical approach and methods for measurement of cup angles were also considered. Results - 28 articles were determined to be relevant to our research question. Some articles demonstrated that cup positioning influenced postoperative dislocation whereas others did not. The majority of articles could not identify a statistically significant difference between dislocating and non-dislocating THA with regard to mean angles of cup anteversion and inclination. Most of the articles that assessed cup placement within the Lewinnek safe zone did not show a statistically significant reduction in dislocation rate. Alternative target ranges have been proposed by several authors. Interpretation - The Lewinnek safe zone could not be justified. It is difficult to draw broad conclusions regarding a definitive target zone for cup positioning in THA, due to variability between studies and the likely multifactorial nature of THA dislocation. Future studies comparing cup positioning and dislocation rate should investigate surgical approach separately. Standardized tools for measurement of cup positioning should be implemented to allow comparison between studies.

Figure 1.

PRISMA flow diagram of search strategy and review of literature (Moher et al. 2009).

Figure 2.

Radiographic cup inclination (I) measured on AP pelvic radiographs (Jolles et al. 2002).

Figure 3.

Radiographic cup anteversion as calculated using an AP radiograph (Abdel et al. 2016). d: short axis of the ellipse of the acetabular component; D: long axis of the ellipse of the acetabular component. Anteversion (A) is calculated as: A = sin⁻¹ (d/D).

Figure 4.

Radiographic cup anteversion (A) from a lateral shoot-through radiograph (Jolles et al. 2002).

Figure 5.

Anatomical cup anteversion using CT imaging (Kim et al. 2009). A: anatomical anteversion with respect to the sagittal plane measured on CT transverse images.