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76 (); 330-334
doi:
10.1016/j.jor.2026.03.042

The influence of reconstruction of the center of rotation on total hip arthroplasty instability

, , , , ,
a Clinical Orthopedic Research Center mN, Zeist, the Netherlands
b Diakonessenhuis, Utrecht, the Netherlands
c University Medical Center Utrecht, the Netherlands
d Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, the Netherlands

⁎Corresponding author: J.H.J. van Erp. jverp@diakhuis.nl

Received: , Accepted: ,
Professor P K Surendran Memorial Education Foundation
Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Abstract

The aim of this study is to determine the influence of the center of rotation (CoR) and offset reconstruction in stable and unstable THAs.

A prospective matched case-control study included patients who underwent primary THA and had a dislocation treated with closed reduction within two years. Cases were matched 1:2 by age, gender, and ASA classification to stable THA patients with >2 years follow-up. THAs performed for indications other than hip osteoarthritis or with unknown surgical approach/implants were excluded. Coronal CoR reconstruction (vertical and horizontal shifts) and offset were measured on calibrated pre- and postoperative pelvic radiographs. Logistic regression was used to calculate Odds Ratios (OR), 95% Confidence Intervals (CI), and p-values. Confounders altering regression coefficients were adjusted for, yielding adjusted ORs (aOR).

25 unstable THAs were matched to 50 controls. The maximum distance from the preoperative femoral CoR is 6.71 mm in unstable THA and 7.38 mm in stable THA. The maximum distance from the preoperative acetabular CoR is 6.85 mm in unstable THA and 7.22 mm in stable THA. No statistically significant differences between the unstable and stable THA were found for either the shifting of horizontal/vertical CoR and the femoral/total offset. Logistic regression for CoR shifting were not statistically significant, aORs were non-significant as well.

No differences in CoR or femoral and total offset reconstruction were found between unstable and stable primary THAs.

Keywords

Total hip arthroplasty
THA
Dislocation
Center of rotation
Femoral and total offset
1

1 Introduction

Total hip arthroplasty (THA) is a reliable treatment for patients with end-stage hip osteoarthritis. THA is widely recognized for its effectiveness in alleviating pain and restoring mobility. A well-known complication following THA is instability. 1–4 Studies show there is a dislocation rate of 1.7% following primary THA.5,6 In case of recurrent dislocations, revision surgery is indicated.1,4,7,8 Given the clinical impact of THA dislocation, it is important to study factors that are related to this outcome, with the aim of reducing its incidence. Reconstruction of the center of rotation (CoR) is a potential influencing factor. The CoR is the pivoting point of the hip joint. Acetabular CoR is reconstructed by cup placement, after which the femoral CoR of the prosthesis head will line up with the acetabular CoR of the cup.1,7 An optimal reconstruction of CoR results in normal muscle tension, good range of motion, balance stress distribution across the joint, reduce wear and prolong the survival of the prosthetic implants. 8–11

An inadequate biomechanical reconstruction of the joint might contribute to an increased risk of dislocation.12 Ensuring acetabular offset and restoration of the COR enhances outcomes related impingement, ROM, global offset restoration and maintaining medial bone stock, and other factors known to increase the risk of dislocation, such as impingement. 8,10,12–21

Reconstructing the CoR can be challenging, especially in the coronal plane, due to osteoarthritic changes in the acetabulum and limitations in available prosthetic components and designs. As a result, surgeons often focus on reconstructing the total offset as surgical objective. Total offset encompasses both horizontal CoR and femoral offset. Acetabular offset is the distance from the femoral axis to the pelvis and femoral offset is the distance from the femoral axis to the ipsilateral CoR—as surgical objectives. 9,22–25 Therefore, it is important to consider their roles in hip offset reconstruction and their potential combined effect on dislocation risk. 9,22–25

The aim of this study was to determine the influence of the coronal CoR reconstruction and femoral and total offset reconstruction in stable and unstable THAs. Our hypothesis is that the CoR and/or offset reconstruction influence the stability of THAs.

2

2 Methods

2.1

2.1 Study characteristics

A prospective case-control study was performed with patients who underwent THA at the Diakonessenhuis, Utrecht in the Netherlands. Informed consent for the use of their clinical and radiographic data was obtained.

Inclusion criteria for case subjects (unstable THA) were primary THA with dislocation treated with closed reduction within two years after surgery and available preoperative and postoperative radiographs. Inclusion criteria for the control subjects (stable THA) were patients with a minimum of one-year follow-up after THA without a dislocation. Exclusion criteria for both case and control subjects were revision THA, THA with another indication than hip osteoarthritis, neuromuscular or psychiatric disorders and unknown surgical approach and/or implants.

Control subjects were matched to case subjects based on sex, age, and American Society of Anesthesiology (ASA) score.

2.2

2.2 Measurements

The CoR reconstruction was evaluated by comparing the pre-operative CoR to the CoR of the arthroplasty using the upright preoperative and the upright postoperative anteroposterior (AP) radiographs of the pelvis.

Radiographic measurements were performed by using TraumaCad software (Version 2.5, Brainlab Ltd.). All radiographs were calibrated prior to the measurements with a calibration sphere, to correct for radiograph magnification factor. In the postoperative radiographs, calibration was performed based on the prosthesis head size. All preoperative and postoperative radiographs were compared for pelvic tilt and rotation to ensure acceptable similarity.26,27 All CoR measurements and calculations were described in the coronal plane using radiographic landmarks. The following outcomes were measured:•CoR: the anatomical CoR was measured on the preoperative a-p radiograph in standing position. The native (preoperative) femoral CoR was located by tracing a circle over the femoral head and determine the midpoint. The native (preoperative) acetabular CoR was located by tracing a circle over the border of the acetabulum and determine the midpoint. The reconstructed (postoperative) femoral CoR was located on the postoperative radiograph in the coronal plane by tracing a circle over the prosthetic head and determine the midpoint (Fig. 1

Measurement of CoR, Femoral Offset, and Total Offset on preoperative (left) and postoperative (right) radiographic images. S: line S. hCoR: horizontal CoR. TO: Total Offset. FO: Femoral Offset. vCoR: vertical CoR. TD: Teardrop line.
Fig. 1 Measurement of CoR, Femoral Offset, and Total Offset on preoperative (left) and postoperative (right) radiographic images. S: line S. hCoR: horizontal CoR. TO: Total Offset. FO: Femoral Offset. vCoR: vertical CoR. TD: Teardrop line.
). 28–30•Shifting of CoR: vertical orientation of the CoR was defined as the distance between the CoR and the imagined line through the teardrop line (line teardrop) (Fig. 1). Horizontal orientation was defined as the distance between the CoR and the imagined line perpendicular to line teardrop and through the midpoint of the pubic symphysis (line S) (Fig. 1). The vertical and horizontal shifting is determined as the difference between the preoperative and the postoperative orientation point. 28–30 A positive horizontal shifting was medial translation, and a negative shifting was lateral translation. A positive vertical shifting was cranial and a negative shifting was caudal. We calculated the maximum shifting using the Pythagorean Theorem.•Femoral offset and total offset: femoral offset was measured by tracing a line through the middle of the femoral shaft and measuring the shortest distance from the femoral CoR to this femoral shaft axis. Total offset was calculated by adding femoral offset to the distance from the CoR to line S (Fig. 1).

Differences in vertical and horizontal orientations of femoral and acetabular CoRs, as well as changes in femoral and total offsets between preoperative and postoperative radiographs, were calculated for all subjects.

2.3

2.3 Statistical analysis

Statistical analyses were preformed using SPSS Statistics software (version 26, IBM Corp.), results were checked for normality. T-tests were used to determine statistically significant differences between case and control groups. A logistic regression analysis was used to obtain Odds Ratios (OR), 95% Confidence Intervals (CI), and p-values. A p-value less than 0.05 was considered statistically significant.

Odds ratios (OR) were calculated to assess the risk of dislocation as a function of the distance between the reconstructed CoR and the femoral anatomical CoR, as well as the distance between the reconstructed CoR and the acetabular anatomical CoR. ORs were also calculated for dislocation risk based on the difference between the reconstructed total offset and the anatomical total offset. Subgroup analyses were conducted for patients with and without a reconstructed total offset within 5 mm to assess the impact of CoR reconstruction on dislocation risk. Similarly, subgroup analyses were performed based on whether the reconstructed CoR was within 5 mm to evaluate the risk of dislocation as a function of total offset reconstruction.

Potential confounding factors, such as sex, age, and ASA score, were controlled for by matching case and control subjects. Confounding factors related to surgical technique and prosthetic head size were explored using logistic regression, adding them to the model to assess their influence on the original regression coefficient. Any factor that significantly altered the regression coefficient was considered a confounder and included in the logistic regression model, resulting in an adjusted OR (aOR).

3

3 Results

3.1

3.1 Study population

25 unstable THAs were included. All cases were matched to two control subjects, which resulted in a total study population of 75 patients. Patient characteristics are shown in Table 1. The mean age was comparable in the case group (73 ± (standard deviation) 8) and the control group (73 ± 8). Both groups consisted of 48% males and 52% females and they were matched for ASA classification.

Table 1 Characteristics of case subjects (unstable THA) and control subjects (stable THA).
Unstable THA (n = 25) Stable THA (n = 50)
Age (mean) 73 ± 8 73 ± 8
Male (%) 12 (48%) 24 (48%)
ASA score 1 1 (4%) 2 (4%)
ASA score 2 18 (72%) 38 (76%)
ASA score 3 6 (24%) 10 (20%)
Anterolateral 3 (12%) 8 (16%)
Direct anterior 4 (16%) 5 (10%)
Direct lateral 1 (4%) 22 (44%)
Posterolateral 17 (68%) 15 (30%)
Head size 28 4 (16%) 4 (8%)
Head size 32 18 (72%) 23 (46%)
Head size 36 3 (12%) 23 (46%)
3.2

3.2 Radiographic outcomes

3.2.1

3.2.1 Shifting of CoR

The maximum distance from the preoperative femoral CoR is 6.71 mm in unstable THA and 7.38 mm in stable THA. The maximum distance from the preoperative acetabular CoR is 6.85 mm in unstable THA and 7.22 mm in stable THA.

Analysis of preoperative and postoperative femoral CoR showed a mean of 6.1 ± 0.8 mm horizontal shifting of the femoral CoR in the unstable THAs and a mean of 6.7 ± 0.7 mm in the stable THA. In vertical direction, femoral CoR shifted 2.8 ± 0.4 in the unstable THA and 3.1 ± 0.5 in the unstable THAs (Table 2). Logistic regression for horizontal shifting and vertical shifting were not statistically significant. aORs were further calculated for shifting horizontal and vertical, which were statistically non-significant as well (Table 3).

Table 2 Means of shifting and change of the CoR, femoral offset and total offset in unstable and stable THA.
Unstable THA Stable THA Total
n = Mean n = Mean p-value
Femoral CoR Horizontal shift 25 6.1 ± 0.8 50 6.7 ± 0.7 0.615
Vertical shift 25 2.8 ± 0.4 50 3.1 ± 0.5 0.625
Acetabular CoR Horizontal shift 25 6.0 ± 0.7 50 6.2 ± 0.7 0.796
Vertical shift 25 3.3 ± 0.5 50 3.7 ± 0.5 0.618
Femoral offset Absolute change 25 5.2 ± 0.9 50 5.8 ± 0.6 0.602
Increase 14 6.2 ± 1.3 30 7.0 ± 0.8 0.586
Decrease 11 3.9 ± 1.0 20 3.9 ± 0.9 0.995
Total Offset Absolute change 25 7.4 ± 1.0 50 6.5 ± 0.8 0.522
Increase 9 4.8 ± 1.2 16 5.3 ± 1.2 0.765
Decrease 16 8.8 ± 5.2 34 7.1 ± 1.0 0.326
Table 3 OR, 95%-Confidence Interval, and p-value of shifting and change of CoR, Femoral Offset, and Total Offset in Stable and Instable THA.
OR [95%-CI] Adjusted OR [95%-CI] p-value
Femoral CoR Horizontal shift 0.9 [0.8-1.1] 1.0 [0.9-1.3] 0.308
Vertical shift 1.0 [0.8-1.1] 1.0 [0.8-1.3] 0.985
Acetabular CoR Horizontal shift 1.0 [0.9-1.1] 1.0 [0.9-1.2] 0.468
Vertical shift 1.0 [0.8-1.1] 1.0 [0.9-1.4] 0.507
Femoral Offset Absolute change 1.0 [0.9-1.1] 1.0 [0.8-1.1] 0.497
Increase 1.0 [0.8-1.1] 1.0 [0.8-1.1] 0.577
Decrease 1.0 [0.8-1.2] 1.0 [1.0-1.2] 0.995
Total Offset Absolute change 1.0 [0.9-1.2] 1.0 [1.0-1.2] 0.196
Increase 1.0 [0.8-1.2] 1.0 [0.8-1.2] 0.754
Decrease 1.1 [1.0-1.2] 1.1 [1.0-1.3] 0.096

Comparison of preoperative and postoperative acetabular CoR showed a mean of 6.0 ± 0.7 mm horizontal shift and 3.3 ± 0.5 mm vertical shift in the unstable THA and a mean of 6.2 ± 0.7 mm horizontal shift and 3.7 ± 0.5 mm vertical shift in the stable THA (Table 2). aORs obtained through logistic regression showed no statistically significant results for horizontal and vertical acetabular CoR shifting (Table 3).

3.2.2

3.2.2 Femoral and total offset

Femoral offset was reconstructed with an accuracy of 5.2 ± 0.9 mm in the unstable THA and with an accuracy of 5.8 ± 0.6 mm in the stable THAs. Total offset differed 7.4 ± 1.0 mm before and after THA in unstable THA and 6.5 ± 0.8 mm before and after THA in stable THA (Table 2). There were no statistically significant differences in aORs for both femoral and total offset (Table 3).

4

4 Discussion

This prospective study with 75 subjects found no differences in CoR reconstruction between stable and unstable THAs. No differences between the femoral/total offset reconstruction between stable and unstable THA were found either. In our study, we reviewed the influence of the CoR independently from other factors. However, it should be taken into consideration that dislocation after THA could have a multifactorial etiology.

The results from this study are supported by Jolles et al., who investigated the influence of various factors on THA dislocation. In this study, they found two factors highly predictive of dislocation: total anteversion of <40° or >60° and an ASA score of 3 or 4. They did not found an association between the CoR and THA dislocation.31

Our study found no significant differences between the femoral/total offset reconstruction between stable and unstable THA. Kaij et al. preformed a single center retrospective study with 12582 included subjects. They found no association between offset and an increased risk of dislocation as well.32

Our findings are in contrast with the results of Sariali et al. They investigated the tree-dimensional hip anatomy (using CT-scan) in 12 patient with unstable THA versus 12 paired patients with stable THA and also 36 non-operated control patients with osteoarthritis. In their study the CoR was significantly shifted medially and posteriorly in the unstable THA group compared to the stable THA group (p = .0008). The main difference is that Sariali et al. conducted their measurements using software for a CT scan, whereas we used radiography.33 In our study all preoperative and postoperative radiographs were compared for pelvic tilt and rotation to ensure acceptable similarity.26,27 However, there is a lack of research on whether a CT scan is more accurate than X-ray for determining the CoR. Sariali et al. had a small sample size with only 12 patients in the unstable THA group. They investigated the correlation of anterior dislocation and were only using the direct anterior approach.33

Our findings are also in contrast with the results of Garcia- Rey et al. They found that a greater distance of the CoR is a risk factor for dislocation (p = .018). However, horizontal distance and vertical distance were no significant risk factors. Garcia- Rey et al. included only cemented primary THAs.14 Research shows that cemented THAs have a higher dislocation rate. 34,35

A strength of this study is that matched case and control group were prospectively matched for age, gender and ASA score. Older age is associated with an increased risk of dislocation.36 Woman have an increased risk of dislocation.32 The dislocation risk is higher in patients with high ASA scores. 31,37 Another strength is that we excluded neuromuscular diseases, femoral neck fractures and osteonecrosis of the femoral head are at higher risk of dislocation.38

Several limitations to this study can be identified. Firstly, the relatively sample size of our study. Because of this, we cannot exclude whether no significant association in CoR or femoral and total offset between unstable and stable THA was found due to our small sample size, this was due to the fact that the dislocation rate following primary THA is low, approximately 1.7%.5,6 Secondly, our study did not match for surgical approach and prosthetic head size. In our control group (stable THA) the surgical approach was divided, while in the case group (unstable THA) 68% received THA by the posterolateral approach, which might be a confounder, which is heavily debated in the literature. Koster et al. preformed a systematic review with meta-analysis of 2025 patients. No significant difference between surgical approaches and risk of dislocations was found.39 However Christensen et al. found a significant difference in dislocation rate between posterior approach, direct anterior approach, and laterally-based approach cohorts (1.1% versus 0.7% versus 0.5%, p = .026).40 Dion et al. found a significantly lower mean number of dislocations per patient in the anterior approach group with 1.5 ± 0.7 dislocations compared to the lateral (2.4 ± 1.2; p = .03) and the posterior (2.1 ± 1.0; p = .02) approach groups.16

Another limitation might be the difference in head-size (Table 1). Singh et al. investigated a significantly decreased dislocation rate as the femoral head size increased in primary THA, they compared the dislocation rate between femoral head size 28 mm and 36 mm.41 Hosam et al. found a significantly reduced risk of revision for dislocation in both 32 mm and 36 mm head sizes. The revision rate for dislocation was the lowest in the 36 mm group.42 Fourthly, even though all radiographs were verified for comparability between preoperative and postoperative images, small differences in pelvic tilt and pelvic rotation could still influence horizontal and vertical CoR measurements. We minimalized this by choosing the teardrop line as anatomical reference point instead of the biisichial line, which lies further from the CoR and is therefore more sensitive to tilt influence.

Despite the above mentioned limitations, we believe that this study provides valuable insights.

5

5 Conclusion

In this study, no differences in CoR or femoral and total offset reconstruction between unstable and stable THAs were found. However further research is required to explore the impact of the CoR on other clinical aspects such as wear and clinical functioning.

Credit author statement

E.A. Cats: Conceptualization; Data curation; Formal analysis; Methodology; Writing – original draft, J.H.J. van Erp: Supervision; Conceptualization; Writing – original draft; Writing – review & editing, R.E Bohnsack: Conceptualization; Data curation; Writing – original draft, T.P.C. Schlösser: Supervision; Writing – review & editing, B. Hentenaar: Supervision, T.E.Snijders: Supervision; Writing – review & editing.

Funding

No funding was received for this project.

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