INTRODUCTION: Malposition of the pelvis at the time of acetabular component insertion can contribute to malpositioning of the acetabular component. This study measures the variation in intraoperative positioning of the pelvis on the operating table during surgery by matching intraoperative radiographs with pre-operative computed tomograms (CT) using 2D-3D matching. METHODS: This prospective study was comprised of a random sample of 45 patients (n = 45, 26 female, 19 male) who had received a total hip arthroplasty (THA) from a single surgeon from 10/21/2003 to 9/6/2007. No THA candidate was excluded for any reason, including body habitus (mean BMI = 27.7, range 17.5 – 42.3), underlying disease process, age (mean age at surgery = 57, range 27 – 80), sex or side of surgery (21 left THAs, 24 right THAs). According to our standard clinical treatment protocol, each patient had a pre-operative CT scan for CT-based surgical navigation of the hip arthroplasty and each patient had an intraoperative radiograph taken to assess component positioning. All THAs were performed in the lateral decubitus position on a radiolucent peg-board positioning device. Each patient’s intraoperative pelvic radiograph was taken after acetabular component and trial femoral component insertion with the leg placed in a neutral position on the operating table and with the xray plate aligned squarely with the operating table. The orientation of the pelvis on the operating table was calculated by comparing the intraoperative 2D projection to the 3D CT data-set using software that can perform 2D-3D matching (XAlign). This software has been validated previously. By matching the 3D CT dataset to the magnification and orientation of the plain radiograph, the position of the anterior pelvic plane relative to the operating table could be calculated. RESULTS: The mean pelvic tilt (rotation around the medial-lateral axis) was 6.84 degrees of anterior pelvic tilt (lordosis) with a standard deviation of 7.95 degrees and a range from 27.24 degrees of lordosis to 4.96 degrees of kyphosis. The mean pelvic obliquity (rotation around the longitudinal axis) was 2.89 degrees anterior from neutral with a standard deviation of 9.44 degrees and a range from 29.36 anterior to 16.59 posterior from neutral. The mean pelvic rotation (rotation around the anterior-posterior axis) was 2.56 degrees cephelad, with a standard deviation of 4.10 degrees and a range from 10.88 degrees cephalad to 5.97 degrees caudad. Pearson correlation statistics showed no relation among pelvic position and body mass index or age. A correlation was seen between pelvic obliquity and pelvic rotation. CONCLUSION: This study shows a high variability of intraoperative pelvic positioning in the clinical setting using accurate measurement tools. The greatest variation was seen in pelvic obliquity which has the greatest influence on anteversion/retroversion of the acetabular component. Additionally, pelvic obliquity and rotation appear related in our series. Since all of our intraoperative radiographs were taken with the leg in a neutral position, it is likely that the pelvis is even more greatly malpositioned at other times during the surgery when forces applied by retractors or upon the leg may be greater.

Background Ensuring optimal position of the acetabular component during total hip arthroplasty is a complex problem. Although computer assisted techniques have been developed to achieve this, these systems may result in improper cup alignment caused by errors in registration of the anterior pelvic plane. Furthermore, set goals for cup placement do not reflect the variation in acetabular morphology. A need exists to develop a method for cup positioning that is patient specific and eliminates the need to register the anterior pelvic plane. It is our hypothesis that the transverse acetabular ligament can be used to do this. The objective of this study was to define the version of acetabular components placed using this technique. Methods In this series of 40 consecutive primary hip replacements, the transverse acetabular ligament was used as the sole method to define cup version. Postoperative CT scans of the pelvis were analyzed to measure the anteversion of the acetabular component. Results At a minimum follow-up of 12 months (range 12–18 months), none of the hips dislocated. Using the transverse acetabular ligament as the sole method to control the version of the acetabular component resulted in an average radiographic anteversion of 19.7° ± 8.1° (mean ± standard deviation) which equates to an operative anteversion of 28.1° ± 11.3° (mean ± standard deviation). Conclusions This paper highlights the variation in cup version when the transverse acetabular ligament is used to establish and control cup placement. This questions the one-size- fits-all philosophy of a set goal for cup positioning.

Xalign is a tool designed to measure implant orientation after joint arthroplasty by co-registering a projection of an implant model and a digitally reconstructed radiograph of the patient's anatomy with a post operative x-ray. A mutual information based registration method is used to automate alignment. When using basic mutual information, the presence of local maxima can result in misregistration. To increase robustness of registration, our research is aimed at improving the similarity function by modifying the information measure and incorporating local spatial information. A test dataset with known groundtruth parameters was created to evaluate the performance of this measure. A synthetic radiograph was generated first from a preoperative pelvic CT scan to act as the gold standard. The voxel weights used to generate the image were then modified and new images were generated with the CT rigidly transformed. The roll, pitch and yaw angles span a range of -10/+10 degrees, while x, y and z translations range from -10mm to +10mm. These images were compared with the reference image. The proposed cost function correctly identified the correct pose in all tests and did not exhibit any local maxima which would slow or prevent locating the global maximum.

Variations in pelvic orientation affect preoperative planning decisions, intraoperative navigation, and postoperative measurements. By providing the means to measure pelvic flexion at low cost and reporting pelvic flexion using the standard reference system, a lateral radiograph technique based on the pubic tubercles and anterior superior iliac spines may be useful for studying functional pelvic orientation and functional alignment and for improving accuracy of postoperative measurement. We evaluated the accuracy of this method by synthesizing 50 lateral pelvic radiographs. Six observers performed manual landmark-based pelvic flexion measurements on the resultant radiographs. Pelvic flexion measurement errors were small (0.004º ± 1.38º). Apart from one outlier with an error of 12.4º, the errors ranged from −4.0º to 3.0º. The data suggest that accurate measurements of pelvic flexion can be made from lateral radiographs with respect to the standard anatomic reference system. However, failure to correctly observe a landmark can introduce large errors. Therefore, the clarity of the relevant landmarks should be considered carefully before applying this technique. Lateral radiographs can be easily acquired and analyzed, making this technique convenient and inexpensive.

Measurements of cup alignment after total hip replacement (THR) surgery are typically performed on postoperative pelvic radiographs. Radiographic measurement of cup orientation depends on the position and orientation of the pelvis on the X-ray table, and its variability could introduce significant measurement errors. We have developed a tool to accurately measure 3D implant orientation from postoperative antero-posterior radiographs by registering to preoperative CT scans. The purpose of this study is to experimentally and clinically validate the automatic CT/X-ray matching algorithm by comparing the X-ray based measurements of cup orientation with direct 3D measurements from postoperative CT scans. The mean measurement errors (± stdev) found in this study were 0.4°±0.8° for abduction and 0.6°±0.8° for version. In addition, radiographic pelvic orientation measurements demonstrated a wide range of inter-subject variability, with pelvic flexion ranging from –5.9° to 11.2°.

Surgical navigation systems assist surgeons by tracking targets attached to the patient's bones and to the surgical tools. Fluoroscopic navigation is a technology that adds "live" imaging to surgical navigation. In order to identify the limitations and potential sources of errors in fluoroscopic navigation, a virtual environment is created in which all the key steps of fluoroscopic navigation can be rehearsed. This provides a low-cost, highly portable, and radiation-free training environment with the ability of instant accuracy validation and reliable measurement of trainee progress. This virtual environment also is suitable for comparing different fluoroscopic registration techniques and protocols. Although the imaging component of the navigation is simulated, physical interaction with the environment can be modeled at different levels; from a fully virtual environment, to miniature models, to life-size dummies and cadavers. Each of these options satisfies different specific training needs, such as the need for portability and easy setup to the need for a completely realistic simulation of the entire clinical environment and operating procedure. In this study, we present the example of a system based on a scaled-down model with a specific focus on analyzing and training bony landmark localization using fluoroscopic navigation.

This study presents a clinical validation of postoperative measurements of acetabular cup alignment following total hip arthroplasty (THA). The methodology was based on concurrent anatomic three-dimensional (3D) measurements of both the acetabular cup alignment and pelvic orientation, using an original CT/X-ray matching algorithm named Xalign. The subjects were 19 patients who had undergone bilateral THA using CT-based surgical navigation. All patients had postoperative pelvic CT scans and multiple antero-posterior (AP) pelvic X-rays. Using a proprietary software algorithm, the X-rays included in the study were matched with the corresponding postoperative CT scans. The goal of this method was to allow 3D anatomic pelvic and acetabular measurements on two-dimensional AP X-rays. The postoperative cup abduction, version and pelvic flexion angles were determined in three different ways: using CT images directly, applying the Xalign method, and finally by performing conventional (abduction only) measurements on AP pelvic X-rays. The cup orientation measured on CT images was taken as the ground truth. The Xalign measurement errors were defined as the difference between the CT cup values and those obtained by applying the matching method. The mean cup abduction error was 0.85 degrees +/- 1.3 degrees (+/- standard deviation) and the mean version error was 0.01 degrees +/- 1.99 degrees . Conventionally measured cup abduction ranged from 44 degrees to 62 degrees and correlated significantly (p = 0.001, r = -0.5) with pelvic flexion angle, proving the linear negative correlation between pelvic flexion and the error in conventional radiographic cup measurements. The Xalign method offered reasonable accuracy for cup orientation, and allowed cup and pelvic 3D anatomic measurements at different times.