The 2014 Frank Stinchfield Award: The 'landing zone' for wear and stability in total hip arthroplasty is smaller than we thought: a computational analysis

Jacob M Elkins, John J Callaghan, Thomas D Brown
Clinical Orthopaedics and related Research 2015, 473 (2): 441-52

BACKGROUND: Positioning of total hip bearings involves tradeoffs, because cup orientations most favorable in terms of stability are not necessarily ideal in terms of reduction of contact stress and wear potential. Previous studies and models have not addressed these potentially competing considerations for optimal total hip arthroplasty (THA) function.

QUESTIONS/PURPOSES: We therefore asked if component positioning in total hips could be addressed in terms of balancing bearing surface wear and stability. Specifically, we sought to identify acetabular component inclination and anteversion orientation, which simultaneously resulted in minimal wear while maximizing construct stability, for several permutations of femoral head diameter and femoral stem anteversion.

METHODS: A validated metal-on-metal THA finite element (FE) model was used in this investigation. Five dislocation-prone motions as well as gait were considered as were permutations of femoral anteversion (0°-30°), femoral head diameter (32-48 mm), cup inclination (25°-75°), and cup anteversion (0°-50°), resulting in 4320 distinct FE simulations. A novel metric was developed to identify a range of favorable cup orientations (so-called "landing zone") by considering both surface wear and component stability.

RESULTS: When considering both wear and stability with equal weight, ideal cup position was more restrictive than the historically defined safe zone and was substantially more sensitive to cup anteversion than to inclination. Ideal acetabular positioning varied with both femoral head diameter and femoral version. In general, ideal cup inclination decreased with increased head diameter (approximately 0.5° per millimeter increase in head diameter). Additionally, ideal inclination increased with increased values of femoral anteversion (approximately 0.3° per degree increase in stem anteversion). Conversely, ideal cup anteversion increased with increased femoral head diameter (0.3° per millimeter increase) and decreased with increased femoral stem anteversion (approximately 0.3° per degree increase). Regressions demonstrated strong correlations between optimal cup inclination versus head diameter (Pearson's r=-0.88), between optimal cup inclination versus femoral anteversion (r=0.96), between optimal cup anteversion versus head diameter (r=0.99), and between optimal cup anteversion and femoral anteversion (r=-0.98). For a 36-mm cup with a 20° anteverted stem, the ideal cup orientation was 46°±12° inclination and 15°±4° anteversion.

CONCLUSIONS: The range of cup orientations that maximized stability and minimized wear (so-called "landing zone") was substantially smaller than historical guidelines and specifically did not increase with increased head size, challenging the presumption that larger heads are more forgiving. In particular, when the cup is oriented to improve not only stability, but also wear in the model, there was little or no added stability achieved by the use of larger femoral heads. Additionally, ideal cup positioning was more sensitive to cup anteversion than to inclination.

CLINICAL RELEVANCE: Positioning THA bearings involves tradeoffs regarding stability and long-term bearing wear. Cup positions most favorable to minimization of wear such as low inclination and elevated anteversion were detrimental in terms of construct stability. Orientations were identified that best balanced the competing considerations of wear and stability.

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