title: Does fluoroscopy improve acetabular component placement in total hip arthroplasty?
abstract: BACKGROUND
  The success of THA largely depends on correct placement of the individual components. Traditionally, these have been placed freehand using anatomic landmarks, but studies have shown poor accuracy with this method.
  
  
  OBJECTIVE
  Specifically, we asked (1) does using fluoroscopy lead to more accurate and greater likelihood of cup placement with the Lewinnek safe zone than does freehand cup placement; (2) is there a learning curve associated with the use of fluoroscopy for cup placement; (3) does the use of fluoroscopy increase operative time; and (4) is there a difference in leg length discrepancy between freehand and fluoroscopic techniques?
  
  
  METHODS
  This series consisted of 109 consecutive patients undergoing primary THA, conversion of a previous hip surgery to THA, and revision THA during a 24-month period. No patients were excluded from analysis during this time. The first 52 patients had cups placed freehand, and then the next 57 patients had acetabular components placed using fluoroscopy; the analysis began with the first patient treated using fluoroscopy, to include our initial experience with the technique. The abduction, version, and limb length discrepancy were measured on 6-week postoperative pelvic radiographs obtained with the patient in the supine position. Operative time, sex, age, BMI, diagnosis, operative side, and femoral head size were recorded as possible confounders.
  
  
  RESULTS
  Cups inserted freehand were placed in the ideal range of abduction (30°-45°) and anteversion (5°-25°) 44% of the time. With fluoroscopy, placement in the Lewinnek safe zone for both measures significantly increased to 65%. The odds of placing the cup in the Lewinnek safe zone for abduction and version were 2.3 times greater with the use of fluoroscopy (95% CI, 1.2-5.0; p = 0.03). Patients undergoing primary THAs (32 freehand, 35 C-arm) had cup placement in the safe zone for abduction and version 44% of the time freehand and 57% of the time with fluoroscopy, which failed to reach statistical significance. There was no difference in operative time, patient age, sex, operative side, diagnosis, limb length discrepancy, or femoral head size between the two groups.
  
  
  CONCLUSIONS
  The use of fluoroscopy to directly observe pelvic position and acetabular component placement increased the success of placement in the Lewinnek safe zone in this cohort of patients having complex and primary THAs. This is a simple, low-cost, and quick method for increasing successful acetabular component alignment. The study population included a large proportion of patients having complex THAs, and further validation of this technique in patients undergoing straightforward, primary THAs needs to be done to understand if similar gains in accuracy for component placement can be expected in that group.
  
  
  METHODS
  Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.
authors.affiliation: Department of Orthopaedic Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA, bbeamer@partners.org.
authors.forename: Brandon S
authors.initials: BS
authors.lastname: Beamer
authors.forename: Jordan H
authors.initials: JH
authors.lastname: Morgan
authors.forename: Christopher
authors.initials: C
authors.lastname: Barr
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Weaver
authors.forename: Mark S
authors.initials: MS
authors.lastname: Vrahas
mesh_terms: D000077:Acetabulum / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D000368:Aged; D059925:Anatomic Landmarks; D019644:Arthroplasty, Replacement, Hip / Q000009:adverse effects / Q000295:instrumentation*; D001696:Biomechanical Phenomena; D005260:Female; D005471:Fluoroscopy; D006621:Hip Joint / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D006622:Hip Prosthesis; D006801:Humans; D007870:Leg Length Inequality / Q000209:etiology; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D061646:Operative Time; D011474:Prosthesis Design; D015641:Radiography, Interventional / Q000379:methods; D016059:Range of Motion, Articular; D012189:Retrospective Studies; D013997:Time Factors; D016896:Treatment Outcome