Abstract
Introduction
Femoral component loosening is one of the most common failure modes in cementless total hip arthroplasty (THA). Patient age, weight, gender, osteopenia, stem design and Dorr-C bone have all been proposed as risk factors for poor fixation and subsequent stem subsidence and poor outcome. With the increased popularity of CT-based assistive technologies in THA, (Stryker MAKO and Corin OPSTM), we sought to develop a technique to predicted femoral stem fixation using pre-operative CT.
Methods
Fourteen patients requiring THA were randomly selected from a previous study investigating component alignment. Mean age was 64 (53 to 76), and 57% were female. All patients received pre-operative CT for 3D dynamic templating (OPSTM), and a TriFit stem and Trinity cup (Corin, UK) implanted through a posterior approach. Post-operatively, patients received an immediate CT and AP x-ray prior to leaving the hospital, and a 1-year follow-up x-ray. On both the immediate post-op x-ray and 1-year follow-up x-ray, the known cup diameter was used to scale the image. On both images, the distance between the most superior point of the greater trochanter and the shoulder of the stem was measured. The difference was recorded as stem subsidence. Subsidence greater than 4mm was deemed clinically relevant. The post-operative CT was used to determine the precise three-dimensional placement of the stem immediately after surgery by registering the known 3D implant geometry to the CT. For each patient, the achieved stem position from post-op CT was then virtually implanted back into the pre-operative OPSTM planning software. The software provides a colour map of the bone density at the stem/bone interface using the Hounsfield Units (HU) of each pixel of the CT [Fig. 1]. Blue represents low density bone transitioning through to green and then red (most dense).
Results
Mean stem subsidence was 2.1mm (0.2mm to 11.1mm). Two patients had clinically relevant subsidence. The first stem in a 68M subsided 11.1mm. The second in a 58M subsided 5.0mm. Both density colour plots had significant areas of blue (low density bone) around the proximal portion of the stem, with minimal medium/high density fixation when compared to the stems with minimal subsidence.
Discussion
Using the Hounsfield units of the CT scan as an indicator for bone density, we were able to predict poor implant fixation and subsequent subsidence in a taper wedge stem. This new technology might have pre-operative value in providing a more quantitative measure of fixation and resultant stem choice.
For any figures or tables, please contact the authors directly.
