Introduction
A modern artificial hip joint is designed to last for
at least 15 years. Most people have a significant reduction in pain and
improvement in their range of movement. According to the National Joint
Registry (NJR), only 7 in 100 hip replacements may need further surgery after
13 years. However, this depends on the type of implant and how it was fixed in
place (National joint register). Common complications following total hip
replacement are nerve damage, and component malposition resulting in
dislocation, and leg length inequality [1]. Any variation in the hip joint
centre of rotation (COR) after total hip arthroplasty influences the lever arm
and tension of the abductor muscles as well as the lever arm of the body
weight, and thus the force required by the muscles to balance the pelvis [2-5].
Increased femoral offset, increases the range of motion of the hip and reduces
the risk of dislocation and polyethylene wear [6]. Correspondingly, patients
with reduced femoral offset perform lower on functional tests [7].
Medialization of the cup with a respective increase in femoral offset has been
advocated; however, medialization of the COR in THA may have negative effects
on joint reaction forces and may cause bone loss and changes in proprioception
[3,4,8,9]. The aim of the current paper was to assess the hip X-ray, first day
after surgery and weeks later when positioning of the patient and the limb will
be easier with the reduction of pain and better mobility. The current paper
aims to highlight whether there is discrepancy between early and late
radiographic assessment of the hip measurements of the total hip component
positioning.
Material and Methods
Twenty-one patients (25 hips) were included in this
retrospective radiographic study underwent primary total hip replacement. Male
to female ratio was 10/11. Two patients had subsequent total hip replacement at
different stages. In 15 patients, the right hip was replaced, and the left hip
in ten. No ethical approval was required to conduct this study. The mean age of
the patients included was 69 years (50-81) with male to female ratio of. There
were 17cemented total hip replacements, 6 uncemented and two hybrid total hip
replacements. The procedure was performed in Bridlington district hospital. The
osteoarthritis was primary with no unusual deformities. Revision arthroplasty
and rheumatoid patients were excluded from this series. All these patients’
radiographs were preoperatively templated for the right implant and the total
hip procedure were considered satisfactory on hip arthorplasty governance
review conducted to check postoperative radiographs by the arthroplasty team.
These patients underwent total hip replacement using Harding modified
anterolateral approach of hip, and there were no recorded postoperative complications.
The early (within 24 hours) postoperative radiographs of the hip and late
follow-up radiographs were reviewed and assessed using trauma computerised
aided diagnosis (CAD). Radiographs were performed with the patient lying down.
For anteroposterior radiographs, the leg is put 15 degrees internally rotated
and 10 degrees abduction of both hips. The current study assesses the
anteroposterior radiographs using the CAD. Lateral views were also reviewed by
the investigator. The magnification error of the radiographs was calculated at
120% of postoperative radiographs.
Results
The postoperative hip outcome measurements were
analysed and readings of the two X-rays using CAD, were compared (Table 1). The
mean duration between the first and the 2nd X-rays of the hip of the
patients was 20 weeks (1-54 weeks).
The hip outcome functions radiologically were studied:
The centre of rotation of the hip. This measures the
horizontal and vertical centre of rotation.
The eighteen patients, the range difference of the
centre of rotation between the first and second X-ray was (-eleven, +6), with
mean difference of 2.4mm. He centre of rotation was similar on early and late
postoperative radiographs of seven hips.
Femoral
offset: The range femoral offset was -8, +21,
with a mean of 6.8mm difference.
Medial
offset: The range difference between the two
radiographs was -12, +5 (mean of 2.5mm).
Ilioischial
offset: the range variance for ilioischial offset
was -6, +6 (mean of 2.2m).
The hip height range of difference between the two
readings was -16 to +4 mm (mean change of 5.4mm). In 17 patients the hip height
was 5.4 mm shorter, in 8 patients, the hip height was 5.2 higher in the 2nd
reading. Varus stem alignment of 1.3 degrees were noticed between the two hip
outcome reading in 11 patients and in 13 patient the stem was 1.84 degrees
valgus, the stem was neutral in one hips on both reading (Figure 1) (Table 1).
The above findings when abnormal were statistically significant p value 0.05 using Mann-Whitney test.
Figure
1: Trauma
Cad measurement of postoperative x-ray of the hip function.
Discussion
The analysis of the two radiographs taken in the first
postoperative day and few weeks later, were not concordant in the current
study; this highlights the issue of the lack of consistency of the radiographic
assessment of the total hip replacement using CAD assessment of the two x rays
taken for each patient in the first postoperative day and later. We believe
that the difference in the readings is because of the limb positioning errors
affected by pain and range of movement. There often is muscle spasm and
swelling of the thigh in the first postoperative day restricting a good
positioning of the hip. We assume the 2nd radiograph performed once the pain
and positioning of the limb during X ray have improved is a better reflection
of the component positioning of the total hip. Limb position and quality of
X-ray, is not the only factor making the proper assessment of the hip
radiographic assessment inadequate; inter-observer error is another factor.
Routine recovery room radiographs are ineffective for screening and unsuitable
as baseline for longitudinal follow-up evaluation immediate recovery room hip
radiographs following total hip arthroplasty rarely reveal unknown
complications. The X-rays are often of suboptimal quality, have minimal
clinical utility, and are less cost-effective [10,11]. In a comparative study
on radiographs of patients who underwent primary unilateral THA taken in the
theatres and later on, it was concluded that postoperative radiographs in the
department of X-ray are characterized by better penetration (69.1% vs 27.3%, p
< 0.001) [12]. There is a lack of national consensus on the use of
postoperative radiographs. In a study on 46 patients who underwent total hip
replacement, it was demonstrated that the late post-operative radiographs following
THR are of better quality than the early ones. These early radiographs were of
poor quality and we question their role as a baseline for further examinations
[13]. In a study on 50 consecutive patients that underwent a primary total hip
replacement and had post-operative period A-P and lateral check radiographs of
the hip, it was concluded that initial post-operative radiographs are of
inferior quality and do not alter the management of the patient. Consideration
should be given to performing check radiographs at the first out-patient clinic
follow-up as an alternative [14].
Conclusion
The current paper compares plain radiographic
assessment on the hip on two occasions. It is hard to justify a successful
litigation using plain radiograph as the best examination of the quality of
total hip arthroplasty because of the
lack of consistency.
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