University of Groningen The biomechanical outcome after total hip replacement Weber, Tim

140 Pages·2015·27.21 MB·English

University of Groningen

The biomechanical outcome after total hip replacement
Weber, Tim
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Weber, T. (2015). The biomechanical outcome after total hip replacement: Quantitative biomechanical
evaluation of Computer-Assisted Femur First THR. [Thesis fully internal (DIV), University of Groningen].
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The Biomechanical Outcome
after Total Hip Replacement

Quantitative biomechanical evaluation
of Computer-Assisted Femur First THR

PhD thesis

to obtain the degree of PhD at the
University of Groningen
on the authority of the
Rector Magnificus Prof. E. Sterken
and in accordance with
the decision by the College of Deans.

This thesis will be defended in public on

Wednesday 17 June 2015 at 11.00 hours

by

Tim Arne Weber
born on 29 June 1985
in Hannover, Germany
Supervisors
Prof. G.J. Verkerke
Prof. S.K. Bulstra
Prof. S. Dendorfer

Co-supervisor
Prof. T. Renkawitz

Assessment committee
Prof. R.L. Diercks
Prof. E.R. Valstar
Prof. N.N.J. Verdonschot

Paranymphs
Lars Krenkel
Franz Süß
This work was conducted in cooperation:
“It is not enough to know, we must apply; it is not enough to want, we must do.”
Johann Wolfgang von Goethe
Dedicated to my family...
ISBN(printed): 978-90-367-7976-0
ISBN(electronic): 978-90-367-7975-3
(cid:13)c 2015TimArneWeber,Regensburg,Germany
All rights reserved. No part of this publication may be reproduced or transmitted in any form by any means,
electronicalormechanical,includingphotocopy,recordingoranyinformationstoreageorretrievalsystem,without
thepriorwrittenpermissionofthecopyrightowner.
Layoutandcover: TimArneWeber,Regensburg,Germany
CONTENTS
1 Introduction 1
1.1 State of the Art . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2 Research question. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
1.3 Outline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2 Quantifying the subjective and objective outcome after Total Hip Replacement 15
2.1 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
2.2 Material and Methods / Search Strategy . . . . . . . . . . . . . . . . . . . . . . . . 16
2.3 Results. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
2.4 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
3 The influence of surgical approach on the Hip Reaction Forces and Their Ori-
entations 37
3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
3.2 Material and Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
3.3 Results. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
3.4 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
4 Gait six month and one-year after computer assisted Femur First THR vs.
conventional THR. Results of a patient- and observer- blinded randomized con-
trolled trial 51
4.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
4.2 Patients and Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
4.3 Results. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
4.4 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Contents
5 QuantifyingtheBiomechanicsduringgaitusingsubject-specificMusucloskeletal
Models 65
5.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
5.2 Material and Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
5.3 Results. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
5.4 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
6 Quantitative Musculoskeletal Modeling after Computer-Assisted Femur First
THR using a patient-specific model 81
6.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
6.2 Material and Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
6.3 Results. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
6.4 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
7 General Discussion 105
7.1 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
7.2 Strengths and Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
7.3 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
8 Summary 115
8.1 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
8.2 Sammenvatting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
9 Acknowledgments 125
10 Curriculum Vitae 127
A List of Publications during the making of this thesis 129
B SHARE - previous dissertations 131
1
CHAPTER
Introduction
State of the Art
Total Hip Replacement
H
ip arthritis, also called Coxarthritis or Osteoarthritis (OA) in general, has been a disease
pattern for centuries1. Archaeology has provided us with evidence for joint pathologies in many
differentpopulationsrangingfromearlyNeanderthalpopulations2 torelativelymodernhomosapi-
enspopulations(Saxons,medieval3orRoman4). Duethelackofpropersurgicaltechniques,proper
implantsorthehygieneintheoperationroomthetreatmentofsuchadiseasewasbasicallyampu-
tationforthousandsofyears. Onlyaftertheunderstandingofthehumanbodyasamusculoskeletal
andbiomechanicalsystemincreased,thefirstsurgeonsinthe18th and19th centurywerereadyand
prepared to perform such interventions5. Whilst there were spectacular successes, the outcome of
such an operation was practically unpredictable; the chances for improvement of the patients were
low. In 1821 the first excision of a hip joint was performed by a surgeon called Anthony White
(1782-1849). Hedidnotreporttheoperationhimself, butthisoperationgainedhimrecognitionin
the medical/scientific community. He was able to reduce pain and to preserve mobility, but only
for the sake of stability. The first synthetic mold prostheses have been implanted in 1923 by a
Norwegian born, American surgeon called Marius Smith-Petersen. He also developed the anterior
surgical approach that still bears his name6. In the 1940s Robert Girdlestone popularized the re-
sectionofthefemoralhead. Hisradicalexcisionarthroplastybearshisnameandisstillusedaslast
resortinfailedTHR,euphemisticallycalled’conversiontoGirdlestone’7. Thefirsthiparthroplasty
products that were widely distributed have first been developed by the Judet brothers8 and have
been refined of the following decades by many others to a point where the implant even allowed
bone ingrowth9–11. PeterRingusedcementlesscomponentswithametal-on-metalarticulationin
1964. With his technique he was able to achieve a survival rate of 97% after 17years12. His model
was abandoned in the 1970s in favor for the Charnley model, but was ’rediscovered’ in the 1980s.
Nevertheless,thestagewassetfortheevolutionofatrulysuccessfulprocedurethatisnamedafter
its inventor, Sir John Charnley13. Today Hip Replacement (THR) is one of the most performed
orthopedic interventions and because of the demographic change that our society is subject to,
the number of operations is likely to further increase14,15. The main goal of THR is to restore
1
Chapter I Introduction State of the Art
the patients well-being and function so that he or she is able to participate in normal life without
persistent pain or restrictions in activities of daily living (ADL).
In order to improve the intervention and shorten hospitals stays minimally-invasive surgery (MIS)
has been developed. Over the past decade MIS-THR has been controversially discussed and it
still is. Supporter of MIS-THR claim that the benefits of MIS-THR are less blood-loss, less tissue
traumaandearlierrecoveryofthepatients16–18. CriticsofMIS-THRarguethatthepoorvisibility
during MIS leads to poor implant positioning19–21. Also the improvement of the early outcome
has been doubted by some authors22,23. Whilst some of the above mentioned studies discuss
some correct arguments, meta-analysis of the scientific literature disproves most of the points
mentioned24–26. ProperImplantpositioningcanbeachievedduetotheuseofacomputer-assisted
System (CAS)27. Systems like this are often expensive and their application has to be justified by
an improved postoperative outcome of the patient.
One of the major clinical challenges during Total Hip Replacement (THR) is to find an optimized
compromise between the trias of hip biomechanics, tribology and postoperative functionality. In
the end, all three elements are dependent on each other: The position of total hip components
correlatestotheriskfordislocation, implantfailure, articularwearandprostheticrangeofmotion
(ROM). It is a fact that sub-optimal implant component position and orientation with respect to
each other leads to either bony or prosthetic impingement28,29. Sub-optimal implant orientation
also leads to so called edge- or rim-loading which causes higher wear rates in the implant system,
subsequently leading to a shorter lifespan of the implant system30. Early impingement occurs
when contact between the prosthetic femoral neck, the acetabular cup and/or bony parts (e.g.
greatertrochanter,acetabularrim,resectionplane)occurswithinapatient’snormalROM.Several
authorshaveproposedstartingwiththepreparationofthefemurandthentransferringthepatient-
individual orientation of the stem relative to the cup intraoperatively (’Femur First’/’combined
anteversion’) in order to minimize the risk of impingement and dislocation (see Figure 1)31–33.
a) conventional THR
b) Femur First THR
Figure 1: THR workflow; a) conventional THR workflow b) ’Femur First’ workflow
2
State of the Art Chapter I Introduction
To address this issue a novel, computer-assisted surgical method (CAS) for THR following the
concept of ’Femur First/combined anteversion’ (CAS FF) has been developed. This incorporates
various aspects of performing a functional optimization of the prosthetic stem and cup position in
order to improve implant component positioning and orientation34–36.
Motion Capture Gait Analysis
Asstatedbefore,oneofthemaingoalsofmodernTHRistorestorethepatients’abilitytopartici-
pateinnormallife. OneofthemostperformedADLforTHRpatientsiswalking37. Overthetime
courseofoneday,peoplewalkupto15.000steps/day. Thissumsuptoabout2−5milllionsteps/year
and to a mean distance of 27.000km/year. Restriction in walking, or an ’unusual’ way to walk may
lead to an unfavorable load-case throughout the musculoskeletal system. Amongst others, OA is
partially caused by ’wear and tear’ which means that abnormal forces in particular areas of a joint
may lead to OA38. Therefore an ’unusual’ way to walk that causes abnormal load-cases in the
musculoskeletal system is additionally to gender and age another risk factor that may promote
Coxarthritis even further. This raises the question, what is an ’unusual’ way to walk? To analyze
’unusual’ and ’usual’ gait patterns, scientists use gait analysis. The term ’gait analysis’ actually
refers to different ways of analyzing walking in a controlled, laboratory environment. In general
gait analysis consists of three pillars, where all three reflect different aspects of human walking
(Figure 2).
human walking
s r
c s ay
ati tic culvit
m e si
n ut
e c
n ki ma
i
k
Figure 2: The three pillars of human gait
Kinematics refers to the gait pattern which is a combination of different joint angles over time
in all three spatial dimensions. The range from minimum to maximum joint angle is the active
range of motion (aROM) and a measure if one is restricted in walking. Because the motion itself
can be carried out in more than one anatomical plane it requires active muscle activation. The
aROMcanbeassessedduetovisualestimation,two-armgoniometerandmotioncapture(MoCap)
systems (see Figure 3). In order to determine the error of measurement many studies have been
conducted39–41. Theclinicaluseofgaitanalysishasbeenproven42 aswellasithasbeenpreviously
used for investigating operation-dependent differences43–45.
3