Infrared stereo camera matching portable navigation reproduces accurate acetabular cup placement during total hip arthroplasty: A matched cohort study

doi:10.21203/rs.3.rs-3329995/v1

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Infrared stereo camera matching portable navigation reproduces accurate acetabular cup placement during total hip arthroplasty: A matched cohort study

https://doi.org/10.21203/rs.3.rs-3329995/v1

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Background

Positioning of the acetabular cup during total hip arthroplasty (THA) is important for early and long-term outcomes; however, accurate cup positioning is difficult even for experienced surgeons. This study compared the accuracy of an infrared stereo camera-matching portable navigation system for cup positioning during THA in the lateral decubitus position.

Methods

This retrospective cohort study analyzed data from 104 THA patients who underwent surgery using either infrared stereo camera-matching portable navigation (n = 40) or non-navigation control (n = 64). Patients underwent THA via the anterolateral approach in the lateral decubitus position using a portable navigation system. Patient characteristics including age, body mass index, sex, treated side, target inclination, and target anteversion were adjusted by propensity score matching. Subsequently, we assessed navigation records for intraoperative cup angles, postoperative cup angles measured on CT images, cup angle measurement errors, and other clinical parameters.

Results

The mean absolute difference in radiographic anteversion between patients with use of navigation and non-navigation was smaller after propensity score matching (3.4 ± 3.1° vs. 5.6 ± 3.0°, p = 0.047). Navigation error (absolute difference in anteversion between postoperative CT and navigation records of > 5°) was significantly associated with posterior pelvic tilt in the navigation group (OR, 1.27; p = 0.030, 95% CI, 1.02–1.57).

Conclusions

Infrared stereo camera matching portable navigation provides clinically comparable precision and accuracy to determine the orientation of cup placement compared to non-navigation during THA in the lateral decubitus position. Clinicians should consider the use of this navigation system in patients with posterior pelvic tilt during THA.

total hip arthroplasty

computer-assisted surgery

portable navigation

lateral decubitus position

Positioning of the acetabular cup is important for early and long-term outcomes of total hip arthroplasty (THA), and malpositioning is recognized as a risk factor for impingement, dislocation, and polyethylene wear after surgery (1–3). However, accurate cup positioning remains difficult even for experienced surgeons (4). To resolve this difficulty, various techniques, such as manual guides, intraoperative landmarks, intraoperative radiography or fluoroscopy, computer navigation, and robotics have been introduced to improve the accuracy and precision of acetabular cup positioning in THA (5). Previous reports have demonstrated the accuracy of cup positioning in navigation and robot-assisted THA (6, 7). Hasegawa et al. reported the accuracy of cup placement with navigation; the absolute mean deviations between preoperative planning and postoperative measurement were 1.9°±1.5°(inclination) and 3.0°±2.3°(anteversion) in patients with THA using CT-based navigation (7). The average measurement of absolute differences for the postoperative CT-preoperative plan were 1.8 ± 2.0° (inclination) and 1.9 ± 2.3° (anteversion) in patients with robotic-assisted THA (6). Furthermore, computer-assisted navigation and robotics have decreased the rate of postoperative complications (8).

Despite such benefits, navigation system use for THA has not increased, owing to the high cost and longer operative times (9).

Recently, several portable navigation systems have been developed, which have been reported to facilitate accurate cup positioning (10–13). We previously reported that accelerometer-based portable navigation can accurately reproduce the cup placement plan at a much lower cost than conventional navigation systems (10). Most previous reports regarding portable navigation systems have demonstrated the accuracy of cup placement in THA in the supine position (10, 12–15). Grammatopoulos et al. reported that the pelvic position was more reliable when the patient was in the supine position than when in the lateral decubitus position, leading to a more consistent orientation of the acetabular component. Significant differences in pelvic tilt and rotation were observed in patients in the lateral decubitus position (16). Therefore, surgeons require a more reliable portable navigation system during THA in the lateral decubitus position. However, few reports were found regarding portable navigation systems in the lateral decubitus position (11, 17).

Naviswiss (Naviswiss AG, Brugg, Switzerland) is an infrared stereo camera matching portable navigation system that can be integrated into the standard surgical THA workflow with minimal disruption. The navigation unit includes an infrared stereo camera that measures the position and orientation of small tags. An infrared flash illuminates the field of view to avoid available light disturbance, and the inertial measurement unit which measures the orientation in space is built-in. Recently, Hasegawa et al. demonstrated the high accuracy of an infrared stereo camera matching portable navigation for cup positioning during THA in the supine position. However, the accuracy of cup orientation using this infrared stereo camera to match portable navigation in the lateral decubitus position is unclear (18). Therefore, this study aimed to analyze the orientation accuracy of cup insertion during THA using an infrared stereo camera-matching portable navigation system in the lateral decubitus position.

Patients

This retrospective cohort study included a consecutive series of THA for osteoarthritis or avascular necrosis of the femoral head in the lateral decubitus position using the anterolateral approach with the Sqrum TT cup and Initia stem or SC stem (Kyocera, Kyoto, Japan), with an infrared stereo camera matching the portable navigation system (Naviswiss AG, Brugg, Switzerland), or with an alignment guide between Sep 2017 and Mar 2022. Sixty-four hips underwent THA without navigation use between Sep 2017 and July 2020, and 43 hips with infrared stereo camera matching portable navigation use between Aug 2020 and Mar 2022. Three hips with portable navigation were excluded from this study because of loosening of the femoral tracker during THA. The analysis included 40 hips with an infrared stereo camera matching the portable navigation. The procedures were performed by a single senior surgeon (S.H.), and no mechanical complications were observed.

Propensity score‑matched analysis

To adjust for baseline patient characteristics in the patients with navigation use or not, propensity score matching was performed (19). Propensity scores were calculated using logistic regression models. In the present study, patient characteristic data (sex, age, BMI, target inclination angle, and target anteversion angle) at surgery were used to compute a propensity score Here, one patient with navigation use was matched to another patient with non-navigation use with the same propensity score. The pairing was achieved with a caliper tolerance of 20% of the standard deviation of the propensity score, and a random selection was made among patients with the same propensity score. Finally, 20 pairs of patients were matched between the two groups. Patient characteristics before and after propensity matching are shown in Table 1.

Table 1

Patient’s background
	before matching			after matching
	portable navigation	Non-navigation	p-value	portable navigation	Non-navigation	p-value
Patients number	40	64		20	20
Sex (male/ female)	8/32	12/51	0.905	8/12	8/12	1.000
Treated side (Rt/ Lt)	17/23	37/27	0.252	11/9	9/11	0.527
Age	60.4 ± 12.5	63.6 ± 8.2	0.088	59.8 ± 10.6	62.0 ± 8.0	0.247
BMI (kg/m²)	26.3 ± 6.6	24.9 ± 3.5	0.498	25.7 ± 7.2	25.3 ± 3.5	0.800
Target inclination	40	40		40	40
Target anteversion	18.3 ± 2.6	18.8 ± 2.1	0.171	18.2 ± 2.4	18.0 ± 2.5	0.627

Registration and navigation during THA

The registration procedure was performed in the supine position prior to the surgery. Two fixation pins were placed parallel to the iliac crest, and the pelvic base unit was secured parallel to both pins. A pelvic tag was placed on the base unit. A pelvic caliper with the tag was placed on the bilateral anterior superior iliac spines (ASIS) (Fig. 1a). The functional pelvic plane was registered by visualizing the two tags using an infrared stereo camera (Fig. 1b). The patient’s position was changed to the lateral decubitus position, covering two pelvic pins after registration. During surgery, the system relays its positional coordinates based on the functional pelvic plane and provides real-time cup alignment data displayed on the monitor of the infrared stereo camera to surgeons (Fig. 1c). The target cup inclination angle was fixed at 40°, and the anteversion angle was determined preoperatively according to Widmer’s combined anteversion theory (20) using a 3D template. In all cases, target cup angles were not modified during surgery, neutral liners were implemented, and stable cup placement was achieved.

Postoperative measurement of cup alignment

Computer-aided design models of the implants were manually adjusted for postoperative multiplanar reconstruction of CT images using a 3-D template software (ZedHip). Cup inclination and anteversion angles were measured with respect to the functional pelvic plane. The reliability of this method has been previously reported by measuring inter-observer (N = 5) and intra-observer (N = 5) variabilities (10). To analyze the accuracy of the intraoperative navigation records for cup inclination and anteversion, we compared the intraoperative cup angles using the navigation records with the preoperative target angles or postoperative angles using the postoperative CT data.

Statistical analysis

The differences between intraoperative cup angles using navigation records or preoperative target angles and postoperative angles using postoperative CT data were measured. The differences in patient backgrounds between the patients with navigation use and non-navigation group were analyzed using the Mann–Whitney U test and paired t-test before and after propensity matching, respectively (Table 1). The differences in cup angles between those evaluated in postoperative CT measurements were analyzed using a paired t-test. The outliers of the accurate acetabular cup placement were defined as an absolute difference in inclination or anteversion of > 5°, according to previous reports (21–23). Outliers and non-outliers were compared using the Fisher’s exact test for nominal variables. The correlation between absolute differences in inclination or anteversion and BMI, age, or pelvic tilt was analyzed using the Spearman's rank correlation test. Additionally, we performed multivariate analysis to test the association between BMI and pelvic tilt with cup placement outliers. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated using the Fisher’s exact test and multivariate analysis. The data were analyzed using SPSS (version 16.0; IBM Corp., Armonk, NY, USA). Statistical significance was set at p < 0.05.

Ethics

Informed consent for participation in the study was obtained from all participants. This research was approved by the institutional review board of the participating institution, and the study was performed in accordance with the ethical standards of the 1964 Declaration of Helsinki.

Reproducibility of portable navigation system for preoperative planning of cup angles

The mean values of postoperative CT evaluation of inclination and anteversion were similar between the patients with portable navigation use and non-navigation after propensity score matching, and no significant difference in target inclination angle and postoperative CT evaluation was found between the patients with portable navigation use and non-navigation (Table 2). However, the average absolute errors of anteversion (postoperative CT- target angle) were significantly lower for portable navigation use than for non-navigation (Table 3).

Table 2

Results of cup orientation after propensity score matching
	Radiographic inclination			Radiographic anteversion
	portable navigation	Non-navigation	p-value	portable navigation	Non-navigation	p-value
Target angle	40	40		18.2 ± 2.4	18.0 ± 2.5	0.627
Postoperative	36.7 ± 2.7	36.1 ± 3.8	0.600	18.3 ± 4.2	17.6 ± 6.5	0.621
Difference (postoperative- target angle)	-3.3 ± 2.7	-3.9 ± 3.7	0.600	0.1 ± 4.7	-0.5 ± 6.5	0.751
Absolute difference (postoperative-target angle)	3.4 ± 2.6	4.8 ± 2.4	0.123	3.4 ± 3.1	5.6 ± 3.0	0.047

Table 3

Results of cup orientation
	radiographic inclination	radiographic anteversion
Navigation record	37.1 ± 2.2	21.3 ± 3.6
Postoperative	37.1 ± 2.9	19.1 ± 4.1
Difference (postoperative- navigation)	-0.0 ± 2.5	-2.2 ± 3.5
Absolute difference (postoperative-navigation)	3.3 ± 2.9	3.1 ± 2.7

Navigation accuracy

Table 2 provided the navigation accuracy. The average measurement error between postoperative CT measurement and intraoperative navigation record was 0.0 ± 2.5° (inclination) and − 2.2 ± 3.5° (anteversion) (Table 3). The average measurement absolute error (postoperative CT- navigation record) was 3.3 ± 2.9° (inclination) and 3.1 ± 2.7° (anteversion) (Table 3).

Posterior pelvic tilt was associated with cup malalignment for portable navigation use

The absolute measurement error of cup inclination and anteversion (postoperative CT navigation record) was not associated with treated side, sex, acetabular shape, or patient age during portable navigation use (Tables 4 and 5). The absolute measurement error of cup anteversion was significantly correlated with patients’ BMI (correlation coefficient = -0.35, p = 0.029) and anterior pelvic tilt (correlation coefficient = 0.43, p = 0.006) (Table 5). We further noted that two predictive factors (patients’ BMI and pelvic tilt) were related to postoperative cup malposition with portable navigation using THA based on Spearman's rank correlation coefficient test. However, the predictive factors for outliers may be dependent on multiple confounders. Therefore, these two significant predictive factors were used as covariates in multivariate analysis. Outliers of postoperative cup anteversion with portable navigation using THA were significantly associated with posterior pelvic tilt (OR, 1.27; p = 0.030, 95% CI, 1.02–1.57).

Table 4

Comparison between the accuracy of cup orientation and patient’s background
		Frequency of absolute difference of cup inclination or anteversion ≧ 5 degree (postoperative-navigation record)
treated side	right	39.1% (9/23)
	left	29.4% (5/17)
	p-value	0.739
	Odds (95% CI)	1.53 (0.34–7.52)
gender	male	25.0% (2/8)
	female	37.5% (12/32)
	p-value	0.689
	Odds (95% CI)	0.56 (0.05–3.86)
acetabular shape	DDH	50.0% (8/16)
	non-DDH	25.0% (6/24)
	p-value	0.176
	Odds (95% CI)	2.91 (0.64–14.26)

Table 5

Correlation between the accuracy of cup orientation and patient’s background
	absolute difference of cup inclination	absolute difference of cup anteversion
BMI	0.14 (p = 0.387)	-0.35 (p = 0.029)
age	-0.08 (p = 0.643)	-0.29 (p = 0.075)
pelvic tilt	-0.02 (p = 0.892)	0.43 (p = 0.006)

Complications

Neither short-term complications, such as infection, dislocation, periprosthetic fracture, nor complications related to pin array insertion, such as pin site infection, neurologic injury, vascular injury, or fracture, were noted in this series.

Our findings showed that the average measurement absolute infrared stereo camera matching portable navigation record error (postoperative CT-navigation record) was 3.3 ± 2.9° (inclination) and 3.1 ± 2.7° (anteversion), and the average absolute errors of anteversion (postoperative CT-target angle) were significantly lower in portable navigation use than in non-navigation use during THA in the lateral decubitus position. Moreover, multivariate analysis demonstrated that posterior pelvic tilt affected the accuracy of postoperative cup anteversion with portable navigation using THA.

Several reports demonstrated the accuracy of cup placement during THA using portable navigation in the lateral decubitus position (11) (17) (24). Tanino et al. demonstrated that the absolute differences of the postoperative CT measured angles from the target position were 3.7 ± 3.0° (inclination) and 6.0 ± 4.5° (anteversion) using accelerometer-based portable navigation in the lateral position (17). Cross et al. reported that the absolute values of inclination errors of the postoperative CT measured angles from the navigation records were 4.2 ± 3.2°, while the anteversion errors were 4.0 °± 4.0° using 3-D mini-optical navigation in the lateral position (24). Tsukada et al. reported that the absolute differences in the postoperative X-ray measured angles from the target position was 2.5 ± 1.7° (inclination) and 2.1 ± 1.8° (anteversion) using augmented reality (AR) -based portable navigation in the lateral position (11). These reports, except for the study by Tsukada et al., indicate lower accuracy in the determination of cup positioning compared to this study, which may be due to different registration positions during surgery. Accelerometer-based portable navigation and 3-D mini-optical navigation creates a 3-dimensional coordinate system to define the positional information of the acetabular cup based on the surgical table during THA with the patient in the lateral decubitus position. The navigation systems calculated the inclination and anteversion angles of the acetabular cup based on the pelvis being positioned strictly vertically during registration. However, several studies have shown that the initial position of the pelvis showed large variation and moved easily during the THA (25, 26).

In contrast, this infrared stereo camera matching portable navigation and AR-based portable navigation can create a 3-dimensional coordinate system based on the functional pelvic plane (FPP) in the supine position, and surgeons can change the patient’s position to the lateral decubitus position after determining the FPP in the supine position. Therefore, the difference in registration positions should affect the accuracy of portable navigation for cup positioning during THA, with the patient in the lateral decubitus position.

Previous reports have demonstrated the accuracy of cup placement with navigation in DDH patients (27, 28). Tsutsui et al. reported that the absolute mean differences were 1.5 ± 1.3° (inclination) and 2.1 ± 1.8° (anteversion) with CT-based navigation in DDH cases (27). We have demonstrated that the absolute mean differences were 1.7 ± 1.5° (inclination) and 2.4 ± 2.0°(anteversion) with robot-assisted THA in DDH cases. Hasegawa et al. reported that the absolute mean differences were not significantly different between DDH and non-DDH patients who underwent portable navigation THA in the supine position (18). Our current study demonstrated that the absolute difference in cup inclination or anteversion did not change between DDH and non-DDH patients who underwent portable navigation THA, even in the lateral decubitus position.

We also demonstrated that the posterior pelvic tilt affected the accuracy of postoperative cup anteversion with portable navigation using THA. Buckland et al. reported that pelvic tilt changes may lead to changes in acetabular anteversion (29). Hasegawa et al. reported that posterior pelvic tilt affected the accuracy of the postoperative cup anteversion angle in a mini-anterolateral approach using an accelerometer-based portable navigation system (30). We also previously reported that preoperative posterior pelvic tilt significantly affected greater pelvic motion on the axial axis during surgery (31), and that greater motion could cause anteversion errors with infrared stereo camera matching portable navigation THA.

This study had some limitations. First, it did not include a prospective control group for concurrent patient comparisons. Second, the pelvic tilt on the operating table could be different from that on CT imaging; such a difference in pelvic tilt may affect the verification of the relationship between pelvic tilt and the postoperative cup anteversion angle. Third, loosening of the fixation pin on the iliac crest can occur in some cases during surgery. Despite these limitations, the present study is valuable as it is the first to demonstrate the accuracy of an infrared stereo camera matching portable navigation during THA in the lateral decubitus position.

Infrared stereo camera matching portable navigation provides clinically comparable precision and accuracy for determining the orientation of cup placement in comparison with non-navigation during THA in the lateral decubitus position.

Ethics approval and consent to participate

The study protocol was approved by the Institutional Review Board on September 8, 2011 (No. 1220), and patients provided informed consent for participation.

Consent for publication

Not applicable

Availability of data and materials

All data generated or analyzed during this study are included in this published article.

Competing interests

The authors declare that they have no competing interests.

Funding

No funding was received for this study.

Author contributions

SH participated in the study design, drafting of the manuscript, and data collection. YK carried out data collection and drafting of the manuscript. NN participated in the data collection and drafting of the manuscript. TM participated in the study design and helped to revised the manuscript. TK participated in the data collection and drafting of the manuscript. RK participated in the study design and helped to revised the manuscript. All authors read and approved the final manuscript.

Acknowledgements

Not applicable

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No competing interests reported.

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You are reading this latest preprint version

Infrared stereo camera matching portable navigation reproduces accurate acetabular cup placement during total hip arthroplasty: A matched cohort study

Status:

Version 1

Abstract

Background

Methods

Results

Conclusions

Figures

Introduction

Methods

Patients

Propensity score‑matched analysis

Registration and navigation during THA

Postoperative measurement of cup alignment

Statistical analysis

Ethics

Results

Reproducibility of portable navigation system for preoperative planning of cup angles

Navigation accuracy

Posterior pelvic tilt was associated with cup malalignment for portable navigation use

Complications

Discussion

Conclusions

Declarations

References

Additional Declarations

Status:

Version 1