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      Does body mass index affect restoration of femoral offset, leg length and cup positioning after total hip arthroplasty? A prospective cohort study

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          Abstract

          Background

          In obese patients, total hip arthroplasty (THA) can be technically demanding with increased perioperative risks. The aim of this prospective cohort study is to evaluate the effect of body mass index (BMI) on radiological restoration of femoral offset (FO) and leg length as well as acetabular cup positioning.

          Methods

          In this prospective study, patients with unilateral primary osteoarthritis (OA) treated with THA between September 2010 and December 2013 were considered for inclusion. The perioperative plain radiographs were standardised and used to measure the preoperative degree of hip osteoarthritis, postoperative FO, leg length discrepancy (LLD), acetabular component inclination and anteversion.

          Results

          We included 213 patients (74.5% of those considered for inclusion) with a mean BMI of 27.7 (SD 4.5) in the final analysis. The postoperative FO was improper in 55% and the LLD in 15%, while the cup inclination and anteversion were improper in 13 and 23% of patients respectively. A multivariable logistic regression model identified BMI as the only factor that affected LLD. Increased BMI increased the risk of LLD (OR 1.14, 95% CI 1.04 to 1.25). No other factors included in the model affected any of the primary or secondary outcomes.

          Conclusion

          Increased BMI showed a negative effect on restoration of post-THA leg length but not on restoration of FO or positioning of the acetabular cup. Age, gender, OA duration or radiological severity and surgeon’s experience showed no relation to post-THA restoration of FO, leg length or cup positioning.

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          Most cited references33

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          Femoral offset: anatomical concept, definition, assessment, implications for preoperative templating and hip arthroplasty.

          G Lecerf, M.H. Fessy, R. Philippot … (2009)
          BACKGROUND OBJECTIVE: Femoral offset is supposed to influence the results of hip replacement but little is known about the accurate method of measure and the true effect of offset modifications. This article is a collection of independent anatomic, radiological and clinical works, which purpose is to assess knowledge of the implications of femoral offset for preoperative templating and total hip arthroplasty. There is a strong correlation between femoral offset, abductors lever arm and hip abductor strength. Hip lateralization is independent of the femoral endomedullary characteristics. The abductors lever arm is highly correlated to the gluteus medius activation angle. There were correlations between femoral offset and endomedullary shape. The hip center was high and medial for stovepipe metaphysis while it was lower and lateralized for champagne - flute upper femur. A study was performed to compare the femoral offset measured by X-ray and CT-scan in 50 patients, demonstrated that plain radiography underestimates offset measurement. The 2D templating cannot appreciate the rotation of the lower limb. Taking into account the horizontal plane is essential to obtain proper 3D planning of the femoral offset. A randomized study was designed to compare femoral offset measurements after hip resurfacing and total hip arthroplasty. This study underlined hip resurfacing reduced the femoral offset, while hip replacement increased offset. However, the reduction of femoral offset after hip resurfacing does not affect the function. A pilot study was designed to assess the results of 120 hip arthroplasties with a modular femoral neck. This study showed that the use of a modular collar ensures an easier restoration of the femoral offset. A cohort of high offset stems (Lubinus 117 degrees) was retrospectively assessed. The survival rate was slightly lower that the standard design reported in the Swedish register. Finally, the measurement of offset and leg length was assessed with the help of computer assistance. The software changed the initial schedule (obtained by templating) in 29%. Therefore, femoral offset restoration is essential to improve function and longevity of hip arthroplasty. CT-scan is more accurate than plain radiography to assess femoral offset. Hip resurfacing decreases offset without effect on function. Modular neck and computer assistance may improve intraoperative calculation and reproduction of femoral offset. Increasing offset with a standard cemented design may decrease long-term fixation. Level IV: Retrospective or historical series.
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            The importance of leg length discrepancy after total hip arthroplasty.

            Roger Bannister, A Konyves (2005)
            We assessed leg length discrepancy and hip function in 90 patients undergoing primary total hip arthroplasty before surgery and at three and 12 months after. Function was measured using the Oxford hip score (OHS). After surgery the mean OHS improved by 26 points after three months and by 30 points after 12. After operation 56 (62%) limbs were long by a mean of 9 mm and this was perceived by 24 (43%) patients after three months and by 18 (33%) after 12. The mean OHS in patients who perceived true lengthening was 27% worse than the rest of the population after three months and 18% worse after 12. In 55 (98%) patients, lengthening occurred in the femoral component. Appropriate placement of the femoral component could significantly reduce a patient's perception of discrepancy of length.
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              Association between changes in global femoral offset after total hip arthroplasty and function, quality of life, and abductor muscle strength

              Sarwar S Mahmood, Sebastian S. Mukka, Sead Crnalic … (2015)
              Background and purpose There is no consensus on the association between global femoral offset (FO) and outcome after total hip arthroplasty (THA). We assessed the association between FO and patients’ reported hip function, quality of life, and abductor muscle strength. Patients and methods We included 250 patients with unilateral hip osteoarthritis who underwent a THA. Before the operation, the patient’s reported hip function was evaluated with the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index and quality of life was evaluated with EQ-5D. At 1-year follow-up, the same scores and also hip abductor muscle strength were measured. 222 patients were available for follow-up. These patients were divided into 3 groups according to the postoperative global FO of the operated hip compared to the contralateral hip, as measured on plain radiographs: the decreased FO group (more than 5 mm reduction), the restored FO group (within 5 mm restoration), and the increased FO group (more than 5 mm increment). Results All 3 groups improved (p < 0.001). The crude results showed that the decreased FO group had a worse WOMAC index, less abductor muscle strength, and more use of walking aids. When we adjusted these results with possible confounding factors, only global FO reduction was statistically significantly associated with reduced abductor muscle strength. The incidence of residual hip pain and analgesics use was similar in the 3 groups. Interpretation A reduction in global FO of more than 5 mm after THA appears to have a negative association with abductor muscle strength of the operated hip, and should therefore be avoided.
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                Author and article information

                Contributors
                Bariq Al-Amiry: Bariq.amiry@gmail.com
                Georgios Pantelakis: Georgios.pantelakis@rvn.se
                Sarwar Mahmood: Sarwar_sardar2003@yahoo.com
                Bakir Kadum: Baqir_kareem@yahoo.com
                Torkel B. Brismar: Torkel.brismar@gmail.com
                Arkan S. Sayed-Noor: 0046 739 688 466 , arkansam@hotmail.com
                Journal
                Journal ID (nlm-ta): BMC Musculoskelet Disord
                Journal ID (iso-abbrev): BMC Musculoskelet Disord
                Title: BMC Musculoskeletal Disorders
                Publisher: BioMed Central (London )
                ISSN (Electronic): 1471-2474
                Publication date (Electronic): 12 September 2019
                Publication date PMC-release: 12 September 2019
                Publication date Collection: 2019
                Volume: 20
                Electronic Location Identifier: 422
                Affiliations
                [1 ]ISNI 0000 0001 1034 3451, GRID grid.12650.30, Department of Surgical and Perioperative Sciences, , Umeå University, ; 901 85 Umeå, Sweden
                [2 ]ISNI 0000 0001 2162 9922, GRID grid.5640.7, Institutionen för klinisk och experimentell medicin, , Linköping University, ; 58183 Linköping, Sweden
                [3 ]ISNI 0000 0004 1937 0626, GRID grid.4714.6, Department of Clinical Science, Intervention and Technology, , Karolinska Institute, ; 171 77 Stockholm, Sweden
                Article
                Publisher ID: 2790
                DOI: 10.1186/s12891-019-2790-y
                PMC ID: 6739956
                PubMed ID: 31510993
                SO-VID: 43969ea4-9585-439d-a375-3afb9370755e
                Copyright © © The Author(s). 2019
                License:

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                Date received : 15 January 2019
                Date accepted : 27 August 2019
                Categories
                Subject: Research Article
                Custom metadata
                issue-copyright-statement © The Author(s) 2019

                ScienceOpen disciplines: Orthopedics
                Keywords: bmi,hip arthroplasty,femoral offset,leg length discrepancy,cup positioning
                Data availability:
                ScienceOpen disciplines: Orthopedics
                Keywords: bmi, hip arthroplasty, femoral offset, leg length discrepancy, cup positioning

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