JCLB-03790; No of Pages 7 Clinical Biomechanics xxx (2014) xxx–xxx

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Risk of edge-loading and prosthesis impingement due to posterior pelvic tilting after total hip arthroplasty Hidenobu Miki a,⁎, Takayuki Kyo a, Yasuo Kuroda a, Ichiro Nakahara a, Nobuhiko Sugano b a b

Department of Orthopedic Surgery, Osaka National Hospital, Osaka, Japan Department of Orthopedic Surgery, Medical School of Osaka University, Osaka, Japan

a r t i c l e

i n f o

Article history: Received 22 March 2013 Accepted 12 May 2014 Keywords: Cup orientation Pelvic tilt Prosthesis impingement Edge-loading Total hip arthroplasty

a b s t r a c t Background: Proper implant orientation is essential for avoiding edge-loading and prosthesis impingement in total hip arthroplasty. Although cup orientation is affected by a change in pelvic tilt after surgery, it has been unclear whether surgeons can prevent impingement and edge-loading by proper positioning by taking into account any change in pelvic alignment associated with alteration of hip range of motion. Methods: We simulated implant orientation without edge-loading and prosthesis impingement, even with a change in pelvic tilt and associated change in hip range of motion after surgery, by collision detection using implant models created with computer-aided design. Findings: If posterior pelvic tilting with a corresponding hyperextension change in hip range of motion after surgery remains within 10°, as occurs in 90% of cases, surgeons can avoid edge-loading and impingement by correctly orienting the implant, even when using a conventional prosthesis. However, if a 20° change occurs after surgery, it may be difficult to avoid those risks. Interpretation: Although edge-loading and impingement can be prevented by performing appropriate surgery in most cases, even when taking into account postoperative changes in pelvic tilt, it may also be important to pay attention to spinal conditions to ensure that pelvic tilting is not extreme because of increasing kyphosis. © 2014 Elsevier Ltd. All rights reserved.

1. Introduction In total hip arthroplasty (THA), acetabular cup orientation is essential for avoiding edge-loading and prosthesis impingement, which may lead to serious complications such as dislocation, mechanical loosening, wear or breakage of the polyethylene liner, metallosis or metal ion release in metal-on-metal bearings, and squeaking or breakage in ceramic-on-ceramic bearings (Bader et al., 2004; Barrack, 2003; Chen et al., 2005; De Haan et al., 2008; Gambera et al., 2002; Grammatopoulos et al., 2010; Iida et al., 1999; Shon et al., 2005). Many clinical and basic-science studies (Callanan et al., 2011; De Haan et al., 2008; Little et al., 2009) have shown that to avoid edge-loading, which means that the femoral head makes contact with the acetabular component near the rim in loading conditions, it is recommended to position the acetabular cup radiographically at an inclination of b50°. Moreover, since the 1990s several authors (D'Lima et al., 2000; Jerosch

⁎ Corresponding author at: Department of Orthopedic Surgery, Osaka National Hospital, 2-1-14, Hoenzaka, Chu-o-ku, Osaka 540-0006, Japan. E-mail addresses: [email protected] (H. Miki), [email protected] (T. Kyo), [email protected] (Y. Kuroda), [email protected] (I. Nakahara), [email protected] (N. Sugano).

J et al., 2002; Seki et al., 1998; Widmer and Zurfluh, 2004; Yoshimine, 2005) have investigated what prosthesis orientation and design features are best for maximizing range of motion (RoM) and thus preventing prosthesis impingement. Prosthesis RoM is affected by stem anteversion, cup inclination, cup anteversion, neck-shaft angle, and oscillation angle (Fig. 1). Oscillation angle, which is the maximum movable arc of the neck on a cross-sectional plane through the top of the dome of the cup, is dependent on head size, head–neck ratio, and cup opening plane level (Yoshimine, 2005) (Fig. 1). It was reported that cup inclination less than 35° significantly reduced prosthesis RoM (Kummer et al., 1999), and it has been recommended that cup anteversion be decided by positioning the stem in anteversion to prevent prosthesis impingement within a required hip RoM, which is the so-called combined anteversion theory (Widmer and Zurfluh, 2004). A neck-shaft angle between 125° and 131° has been reported to produce maximum prosthesis RoM (Widmer and Majewski, 2005), and an oscillation angle of N135° has been recommended to provide sufficient prosthesis RoM to avoid prosthesis impingement in conventional THA (Yoshimine, 2005). Although many available prostheses have an appropriate neck-shaft angle, there are few hip implant systems with such a large oscillation angle. A larger prosthesis RoM can be obtained by selecting a larger head size from system options (Chandler et al., 1982), although there are limits to how large a head can be used,

http://dx.doi.org/10.1016/j.clinbiomech.2014.05.002 0268-0033/© 2014 Elsevier Ltd. All rights reserved.

Please cite this article as: Miki, H., et al., Risk of edge-loading and prosthesis impingement due to posterior pelvic tilting after total hip arthroplasty, Clin. Biomech. (2014), http://dx.doi.org/10.1016/j.clinbiomech.2014.05.002

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H. Miki et al. / Clinical Biomechanics xxx (2014) xxx–xxx

Fig. 1. The coordinate system of the femoral stem and the acetabular cup, radiographic cup inclination and anteversion, stem anteversion, neck-shaft angle, cup opening plane level, head– neck ratio, and oscillation angle. The z-axis of the stem passes through the center of the distal cylindrical portion. The y-axis is perpendicular to the z-axis and the line perpendicular to the circular plane of the top of the neck. The x-axis is perpendicular to the y-axis and z-axis. The xa-axis and ya-axis of the cup are included in the opening plane of the cup, and the za-axis passes through the top of the cup's dome. Radiographic cup inclination and anteversion were defined as the angles around the ya-axis and xa-axis of the cup, respectively, from the position in which the cup and the pelvic coordinate systems were parallel. Stem anteversion was defined as the rotation angle around the z-axis of the stem from the position in which the stem and the femoral coordinate systems were parallel. Neck-shaft angle is the angle between the z-axis of the stem and the line perpendicular to the circular plane of the top of the neck. Cup opening plane level is the distance between the head center and the cup opening plane. Head–neck ratio is a value calculated from the following formula; the diameter of the head (Dh) / the diameter of the neck at the level of impingement point to the liner (Dn). Oscillation angle is the maximum movable arc of the neck on a cross-sectional plane through the top of the dome of the cup.

because head size is dependent on cup size and liner thickness, and too large a head size can introduce the risk of corrosion at the head–neck junction (Dyrkacz et al., 2013). Therefore, in modern THA surgeons commonly aim for a cup inclination of 40° to 45°, choose cup anteversion on the basis of combined anteversion theory, and select a larger head size if possible. In addition, cup orientation can be affected by pelvic position, because the acetabular cup is fixed on the pelvis. Preoperative cup planning has been generally performed using supine anteroposterior (AP) radiographs of the pelvis. However, it is known that the preoperative change in pelvic tilt from the supine to the standing position (positional change) tends to be in the posterior direction and that it is maintained in the early stages just after THA (Nishihara et al., 2003; Parratte et al., 2009; Taki et al., 2012) (Fig. 2). Moreover, when the pelvis is in the standing position, it tends to tilt posteriorly (temporal change) after surgery (Babisch et al., 2008; Nishihara et al., 2003; Parratte et al., 2009; Taki et al., 2012) (Fig. 2). A large posterior pelvic tilt of N 10° has been seen in almost 10% of cases in both preoperative positional change and temporal change in the standing position (Nishihara et al., 2003; Taki et al., 2012). These changes are seen especially in older patients and are considered to be associated with degenerative changes in the lumbar spine (Kyo et al., 2013; Miki et al., 2012). Therefore, as the size of the elderly population increases, it is important take into consideration that a discrepancy in pelvic tilt in comparison with the supine pelvic position at preoperative planning might generate edge-loading and prosthesis impingement a long time after the THA. Until recently, surgeons have focused appropriate cup orientation for patients with a large preoperative posterior positional change in pelvic tilt. In these patients, the standing hip position was further extended than in the supine neutral position. Therefore, some authors theorized

that in these patients, the hip neutral position and hip RoM might shift in the direction of extension (a change to hyperextension) because of the extent of posterior pelvic tilt, and thus they recommended decreasing cup inclination and anteversion in initial operations to help avoid new edge-loading or prosthesis impingement (Nishihara et al., 2003; Sato et al., 2013; Taki et al., 2012). However, it was reported that such a change to hyperextension did not occur in the early stages just after THA and that it was not necessary to change cup target orientation even in patients with a large preoperative positional posterior pelvic tilt (Miki et al., 2012). Indeed, no cases of anterior dislocation have been reported one year after THA with appropriate orientation using a navigation system, even for patients with a large preoperative positional posterior change in pelvic tilt (Kyo et al., 2013). However, studies have not focused on the temporal posterior change in pelvic tilt, although it has been reported that a posterior change in pelvic tilt in the standing position long after surgery might cause new prosthesis impingement between the femoral neck and the posterior edge of the acetabular cup (Di Schino et al., 2009; Onda et al., 2008). Di Schino et al. and Onda et al. also showed that it is possible that a change in hip RoM to hyperextension is associated with a posterior temporal change in pelvic tilt (Fig. 2). Regarding edge-loading, it was reported that a maximum change in pelvic tilt from the preoperative supine position to the standing position 1 year after THA was 23° in the same patient and that cup inclination was within 50° when the original cup inclination was set at 40°, even if the maximum posterior pelvic tilt occurred soon after THA (Kyo et al., 2013). However, the effect of further posterior tilting because of a temporal change had not been elucidated. Therefore the objective of this study was to investigate what was the appropriate cup orientation when some temporal posterior change in pelvic tilt is present in the

Please cite this article as: Miki, H., et al., Risk of edge-loading and prosthesis impingement due to posterior pelvic tilting after total hip arthroplasty, Clin. Biomech. (2014), http://dx.doi.org/10.1016/j.clinbiomech.2014.05.002

H. Miki et al. / Clinical Biomechanics xxx (2014) xxx–xxx

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Fig. 2. The clinical course of the change in pelvic tilt and hip range of motion (RoM) after total hip arthroplasty (THA). Preoperative cup planning is commonly performed with the pelvis in the supine position according to the combined anteversion theory, which prevents prosthesis impingement within the required hip RoM. The pelvis tends to tilt posteriorly from the supine to the standing position (positional change) before surgery, and the change is usually maintained during the early period after THA. Also, hip RoM does not change in regard to the pelvis in the early period after THA. However, an additional posterior pelvic tilt (temporal change) in the standing position can occur long after surgery and is associated with change in hip RoM to hyperextension.

standing position in patients with some preoperative positional posterior change in tilt long after THA. 2. Methods We used implant models constructed with computer-aided design. We used only size 5 CentPillar stems, Triad cups with an outer diameter of 50 mm and X3 polyethylene liner (Stryker Orthopaedics, Mahwah, NJ, USA) throughout our study because that size is used most frequently in Japan. When a 50-mm cup is used, the options for head size are 28, 32, 36, and 40 mm. The neck-shaft angle of the stem was 127°. The head offset was set at 0 mm for all heads. This system provided oscillation angles of 126°, 130°, 132°, and 136° with the use of 28-, 32-, 36-, and 40-mm heads, respectively. The coordinate system for the stem was defined as follows: The z-axis of the stem passes through the center of the distal cylindrical portion. The y-axis is perpendicular to the z-axis and the line perpendicular to the circular plane of the top of the neck. The x-axis is perpendicular to the y-axis and z-axis (Fig. 1). The xa-axis and ya-axis of the cup are included in the opening plane of the cup, and the za-axis passes through the top of the cup's dome (Fig. 1). The original pelvic and femoral coordinate systems were set to be parallel to the world coordinate system. Stem flexion, adduction, and version angle were defined as the angles around the x-axis, y-axis, and z-axis of the stem, respectively, from the position in which the stem and the femoral coordinate systems were parallel. The original stem position was set to 5° of flexion, 5° of adduction, and 0° to 60° (in increments of 5°) of anteversion to simulate implantation in the proximal femur (Fig. 3). Cup inclination and anteversion were defined as the angles around the ya-axis and xa-axis of the cup, respectively, from the position in which the cup and the pelvic coordinate systems were parallel (using the radiographic definition) (Fig. 1). Hip flexion, adduction, and internal rotation were defined as the angles around the x-axis, y-axis,

and z-axis of the femoral coordinate system from the neutral position, respectively. The hip neutral position in the supine position was defined as the original position in which the pelvic and femoral coordinate systems were parallel (Fig. 4). First, in the supine neutral position, we determined the original safe zone of the cup without prosthesis impingement in a required hip RoM when cup inclination was 40° and cup anteversion was between 0° and 25°. We investigated prosthesis RoM with a well-known collision detection technique for three-dimensional objects using models created with computer-aided design (Gottschalk et al., 1996; Miki and Sugano,

Fig. 3. An outline of the calculation of the original safe zone. CAD, computer-aided design; Ext., extension; Int., internal.

Please cite this article as: Miki, H., et al., Risk of edge-loading and prosthesis impingement due to posterior pelvic tilting after total hip arthroplasty, Clin. Biomech. (2014), http://dx.doi.org/10.1016/j.clinbiomech.2014.05.002

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Fig. 4. Definition of hip RoM. The neutral position of the hip RoM was defined as the position in which the x-, y-, and z-axes of the femoral coordinate system were parallel to the x-, y-, and z-axes, respectively, of the pelvic coordinate system. The hip RoM is expressed as rotation angles into the local femoral coordinate system from the neutral position. The first rotation is performed around the x-axis, which means flexion or extension. The second and third rotations are around the y-axis and z-axis, which means abduction or adduction and external or internal rotation, respectively.

2011). This technique includes an algorithm for efficient and exact collision detection among complex polygonal models by representing those as hierarchically separated tight-fitting bounding boxes. The collision angle was calculated from the supine neutral position to the collision point between prostheses in the directions of flexion, extension, external rotation, and internal rotation at 90°. We used the reference range (120° of flexion, 40° of extension, 40° of external rotation, and 40° of internal rotation at 90° flexion) as the required hip RoM (Miki et al., 2012) (Fig. 3). This original safe zone is applied to supine AP radiographs when planning an actual surgical procedure. The angle of preoperative posterior positional change in pelvic tilt (PC angle) was selected from 0°, 10° and 20°, because the mean + 2 SD was reported to be 14° to 19° (Babisch et al., 2008; Miki et al., 2012;

Nishihara et al., 2003; Taki et al., 2012) (Fig. 5). The angle of postoperative posterior temporal change in pelvic tilt (TC angle) in the standing position was set from 10° and 20°, because the mean + 2 SD has been reported to be 13.6° to 19° (Nishihara et al., 2003; Parratte et al., 2009; Taki et al., 2012) (Fig. 5). We assumed that the neutral position and the required hip RoM shifted in the extension direction to the same degree as the TC angle to simulate adaptation by the soft tissue long after THA, as seen in previous reports (Di Schino et al., 2009; Onda et al., 2008) (Fig. 5). The PC angle and TC angle were defined on the basis of the angle around the x-axis of the pelvis. We investigated an area in the original safe zone, in which cup inclination was b50°, and prosthesis impingement did not occur even after changes in pelvic tilt and hip RoM.

Fig. 5. An outline of the design of our simulations. The angle of preoperative posterior positional change in pelvic tilt is the PC angle. The temporal change in posterior pelvic tilt in standing is the TC angle, and the associated shift of the hip range of motion (RoM) to the pelvis occurs via the TC angle in the direction of extension.

Please cite this article as: Miki, H., et al., Risk of edge-loading and prosthesis impingement due to posterior pelvic tilting after total hip arthroplasty, Clin. Biomech. (2014), http://dx.doi.org/10.1016/j.clinbiomech.2014.05.002

H. Miki et al. / Clinical Biomechanics xxx (2014) xxx–xxx

We calculated new values for cup inclination and anteversion after posterior tilting. The formula we used is as follows: 2

1 60 Mx ¼ 6 40 0

0 cosCA sinCA 0

2

cosCI 6 0 My ¼ 6 4 − sinCI 0 2

1 60 Mp ¼ 6 40 0

3 0 07 7 05 1

0 − sinCA cosCA 0

0 1 0 0

sinCI 0 cosCI 0

0 0 cosδ − sinδ sinδ cosδ 0 0

3 0 07 7 05 1 3 0 07 7 05 1

N ¼ My  Mx  ð0; 0; −1Þ 0 0 0 0 N x ; y ; z ¼ Mp  N

 0 0 0 CI ¼ arctan −x =z

0

CA ¼ arccos

qffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi ðx0 Þ2 þ ðz0 Þ2

where CA = original radiographic cup anteversion, CI = original radiographic cup inclination, δ = posterior pelvic tilt angle, N = normal unit vector to the opening plane of the cup in the original position, N′ = normal unit vector to the opening plane of the cup after posterior tilt (δ) from the original cup position, CA′ = radiographic cup anteversion after posterior tilt (δ) from the original cup position, and CI′ = radiographic cup inclination after posterior tilt (δ) from the original cup position. The cup orientation after total change in pelvic tilt—that is, the sum of the PC angle and the TC angle—was directly calculated by the above formula, and we verified whether the cup inclination was beyond 50°. Whether new prosthesis impingement could occur with the original cup after the assumed shift of the required hip RoM via the TC angle is the same mathematic problem as whether impingement could occur within the required hip RoM on the newly oriented cup rotated posteriorly around the x-axis of the pelvis via the TC angle. Therefore, we calculated the rotated cup orientation by using the formula already described, and we confirmed prosthesis impingement within the required hip RoM using the collision detection technique as described earlier. As an example, one patient underwent THA using a 36-mm acetabular head. The original prosthesis orientation was 35° of stem anteversion, 40° of radiographic inclination, and 10° of radiographic cup anteversion in comparison with the preoperative supine pelvic position. We assume here that the patient had a 10° positional posterior pelvic tilt before surgery, and that at his final follow-up evaluation long after surgery, he had a 10° temporal posterior pelvic tilt in the standing position with 10° of hyperextension change in his hip RoM. The inclination and anteversion of the cup would seem to be 44° and 25°, respectively, on the standing hip AP radiograph at the final follow-up, because the final sum of the posterior tilt angle was 20°. Because cup inclination was not beyond 50°, we judged that the risk of edge-loading was low. The shift in neutral position and hip RoM occurred 10° posterior to the pelvis and was associated with a temporal change in pelvic

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tilt. When it was seen from the neutral position, the cup rotated 10° posteriorly. Therefore, we measured hip RoM without prosthesis impingement when cup inclination and anteversion were 42° and 18°, respectively, with 35° of stem anteversion. Because flexion, extension, external rotation, and internal rotation at 90° of flexion were 134°, 41°, 45°, and 55°, respectively, it was our judgment that there was no prosthesis impingement within the required RoM (120° of flexion, 40° of extension, 40° of external rotation, and 40° of internal rotation at 90° flexion). 3. Results We simulated some situations in which a patient with 0°, 10°, or 20° of preoperative posterior positional change in pelvic tilt had 10° or 20° of posterior temporal change in pelvic tilt in the standing position with hyperextension of the hip long after THA. We found that the original cup safe zone and the cup orientation were not at risk for edge-loading or prosthesis impingement after changes in the original safe zone when using 28-mm, 32-mm, 36-mm, and 40-mm heads (Fig. 6). There was no orientation that adapted to those changes when a 28-mm head was used. When a head with a diameter of N32 mm was used, there were suitable orientations at about 30° to 35° of stem anteversion and 10° to 15° cup anteversion with 10° of posterior temporal change whether the preoperative positional posterior pelvic tilt was small or large. However, when there was a posterior temporal change of 20°, it was possible to resolve those risks only by using a head with a diameter N40 mm and by implanting with an appropriate orientation. If the posterior temporal change was N20°, no strategy worked. 4. Discussion To the best of our knowledge, there have been no reports on investigations of the influence of temporal posterior pelvic tilt on edgeloading and prosthesis impingement in patients with a variety of preexisting positional changes in pelvic tilt. We showed, independently of positional posterior change in pelvic tilt before surgery, that even if there was 10° of posterior temporal change in pelvic tilt with hyperextension of the hip, our findings point to a strategy: The surgeon should select a head with a diameter of ≥ 32 mm and aim for 30° to 35° of stem anteversion and 10° to 15° of cup anteversion, to achieve stem anteversion at 40° of cup inclination. When there is a posterior temporal change in pelvic tilt of 20°, it is necessary to use a head size of ≥40 mm as well as to adjust prosthesis orientation. However, if a posterior temporal change of N20° occurs with hyperextension of the hip, it is difficult to avoid new edge-loading or impingement. Some authors have reported that the temporal posterior change in pelvic tilt by 1 to 4 years after THA is within 10° in 84% to 89% of all patients. The 95% upper limit was estimated to be 13.6° to 19° because the mean (SD) values were reported to be mean 2° (SD 7.5°), mean 3° (SD 5.3°), and mean 5.2° (SD 6.2°) (Nishihara et al., 2003; Parratte et al., 2009; Taki et al., 2012). The change seems to reach a plateau beyond 1 year after THA (Taki et al., 2012). Therefore, because a 10° posterior temporal change may include almost 90% of cases and a 20° posterior temporal change may be near the upper limit, then even if the temporal posterior change in pelvic tilt naturally occurred with hip hyperextension, the risk of new edge-loading and prosthesis impingement could be decreased by precise implantation in most conventional THAs. However, the risk might increase greatly when the temporal posterior change in pelvic tilt is N 20° with hip hyperextension. The pelvis tends to tilt posteriorly to compensate for increasing kyphosis (Roussouly and Pinheiro-Franco, 2011). Kyphosis is thought to be associated with increased age, disk degeneration, weakness of back muscles, osteoporosis, and compression fractures (Barrey et al., 2007; De Smet et al., 1988; Mika et al., 2005; Thevenon et al., 1987). Moreover, preoperative compression fractures, spondylolisthesis, and disk-space

Please cite this article as: Miki, H., et al., Risk of edge-loading and prosthesis impingement due to posterior pelvic tilting after total hip arthroplasty, Clin. Biomech. (2014), http://dx.doi.org/10.1016/j.clinbiomech.2014.05.002

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Fig. 6. Results of our simulations when using 28-mm, 32-mm, 36-mm, and 40-mm heads. The original cup safe zones are indicated by white areas bounded by bold lines. Gray areas and cross-hatched zones indicate the cup orientation that is safe from the risk of edge-loading and prosthesis impingement after temporal changes of 10° (gray) and 20° (cross-hatched) in the posterior pelvic tilt (TC angle) in the standing position with corresponding hyperextension of the hip RoM, when the patient had 0°, 10°, or 20° of preoperative positional change in pelvic tilt (PC angle).

narrowing have been reported to be predictive of increased pelvic posterior tilt after THA (Kyo et al., 2013; Tamura et al., in press). Therefore, surgeons must pay special attention to spinal conditions, including osteoporosis, in addition to performing appropriate surgical procedures, to ensure good long-term THA outcomes. There were some limitations to our study. We used only certain implant designs. It is possible to produce dissimilar results when using different combinations of implant design and sizes. Prosthesis RoM is affected by neck-shaft angle and oscillation angle as well as by implant orientation, as already noted. Oscillation angles in modern available systems might be included in those that we used in this study. However, the neck-shaft angle is the factor that distinguishes each type of stem. The CentPillar stem that we used has a neck-shaft angle of 127°. When a stem with very different neck-shaft angle is used, the safe zone may be narrower than that in our study; it has been reported that a neck-shaft angle between 125° and 131° produces maximum prosthesis RoM (Widmer and Majewski, 2005). A shift angle of hip RoM in the direction of extension associated with a posterior temporal pelvic change was set to the same angle as the angle of the posterior temporal pelvic change. If the shift angle was larger than our setting, the target of prosthesis orientation became narrower than in our results. Therefore, further research is necessary to clarify how change may occur in the hip RoM long after THA. 5. Conclusion In conclusion, if there is N20° of posterior pelvic tilting with hyperextension change in the hip RoM in the standing position after THA, it may be difficult to avoid edge-loading and prosthesis impingement in THA. However, if the change can be constrained to 10°, it may be possible

to prevent edge-loading and impingement by choosing an appropriate implant design and ensuring correct implant orientation. Therefore, surgeons should pay special attention to spinal conditions, including osteoporosis, as well as perform appropriate surgical procedures, to ensure the best long-term outcome for THA. Acknowledgments We received CAD data from Stryker Orthopaedics without compensation under an agreement to use it only for research. We have not received any financial support for this study. Medical editor Katharine O'Moore-Klopf, ELS (East Setauket, NY, USA) provided professional English-language editing of this article. References Babisch, J.W., Layher, F., Amiot, L.P., 2008. The rationale for tilt-adjusted acetabular cup navigation. J. Bone Joint Surg. Am. 90, 357–365. Bader, R., Steinhauser, E., Zimmermann, S., Mittelmeier, W., Scholz, R., Busch, R., 2004. Differences between the wear couples metal-on-polyethylene and ceramic-on-ceramic in the stability against dislocation of total hip replacement. J. Mater. Sci. Mater. Med. 15, 711–718. Barrack, R.L., 2003. Dislocation after total hip arthroplasty: implant design and orientation. J. Am. Acad. Orthop. Surg. 11, 89–99. Barrey, C., Jund, J., Noseda, O., Roussouly, P., 2007. Sagittal balance of the pelvis-spine complex and lumbar degenerative diseases: a comparative study about 85 cases. Eur. Spine J. 16, 1459–1467. Callanan, M.C., Jarrett, B., Bragdon, C.R., Zurakowski, D., Rubash, H.E., Freiberg, A.A., Malchau, H., 2011. The John Charnley Award: risk factors for cup malpositioning: quality improvement through a joint registry at a tertiary hospital. Clin. Orthop. Relat. Res. 469, 319–329. Chandler, D.R., Glousman, R., Hull, D., McGuire, P.J., Kim, I.S., Clarke, I.C., et al., 1982. Prosthetic hip range of motion and impingement. The effects of head and neck geometry. Clin. Orthop. Relat. Res. 166, 284–291.

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Please cite this article as: Miki, H., et al., Risk of edge-loading and prosthesis impingement due to posterior pelvic tilting after total hip arthroplasty, Clin. Biomech. (2014), http://dx.doi.org/10.1016/j.clinbiomech.2014.05.002

Risk of edge-loading and prosthesis impingement due to posterior pelvic tilting after total hip arthroplasty.

Proper implant orientation is essential for avoiding edge-loading and prosthesis impingement in total hip arthroplasty. Although cup orientation is af...
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