HIP

Using a calliper to restore the centre of the femoral head during total hip replacement

J. C. Hill, H. A. P. Archbold, O. J. Diamond, J. F. Orr, B. Jaramaz, D. E. Beverland

From Musgrave Park Hospital, Belfast, United Kingdom

Restoration of leg length and offset is an important goal in total hip replacement. This paper reports a calliper-based technique to help achieve these goals by restoring the location of the centre of the femoral head. This was validated first by using a co-ordinate measuring machine to see how closely the calliper technique could record and restore the centre of the femoral head when simulating hip replacement on Sawbone femur, and secondly by using CT in patients undergoing hip replacement. Results from the co-ordinate measuring machine showed that the centre of the femoral head was predicted by the calliper to within 4.3 mm for offset (mean 1.6 (95% confidence interval (CI) 0.4 to 2.8)) and 2.4 mm for vertical height (mean -0.6 (95% CI -1.4 to 0.2)). The CT scans showed that offset and vertical height were restored to within 8 mm (mean -1 (95% CI -2.1 to 0.6)) and -14 mm (mean 4 (95% CI 1.8 to 4.3)), respectively. Accurate assessment and restoration of the centre of the femoral head is feasible with a calliper. It is quick, inexpensive, simple to use and can be applied to any design of femoral component.

J. C. Hill, MEng, MSc, PhD, Biomechanical Engineer H. A. P Archbold, MD, FRCS, . Consultant Orthopaedic Surgeon O. J. Diamond, FRCS, Orthopaedic Surgeon D. E. Beverland, MD, FRCS, Consultant Orthopaedic Surgeon Musgrave Park Hospital, Outcomes Assessment Unit, Stockmans Lane, Belfast BT9 7JB, UK. J. F Orr, BSc, PhD, FIMechE, . Professor Queens University Belfast, School of Mechanical & Aerospace Engineering, Belfast BT9 5AH, UK. B. Jaramaz, PhD, Professor Blue Belt Technologies, 2828 Liberty Avenue, Suite 100, Pittsburgh, Pennsylvania 15222, USA. Correspondence should be sent to Dr J. C. Hill; e-mail: janet.hill@ belfasttrust.hscni.net 2012 British Editorial Society of Bone and Joint Surgery doi:10.1302/0301-620X.94B11. 29144 $2.00 J Bone Joint Surg Br 2012;94-B:146874. Received 27 January 2012; Accepted after revision 12 June 2012

Restoration of leg length1-3 and stability4-6 are two important goals during total hip replacement (THR). These goals are best achieved by ensuring correct orientation of the acetabular component and restoration of the centre of rotation of the hip.7-11 Recently computeraided surgery (CAS) systems have become widely available for use in THR.12-14 However, these systems can add considerably to both the cost and time of surgery and have not been widely adopted.15-17 Instead a number of intra-operative methods using a variety of rulers, pins and callipers have been described to restore leg length.18-22 Most of these techniques consider the acetabulum and femur as a single unit measuring a distance between two fixed points marked on the pelvis and femur. This method is prone to considerable error.2 Few papers have highlighted the importance of restoring femoral offset.23-26 We believe that in order to optimise the biomechanics of the hip, the patientspecific morphology (PSM) should be restored and the acetabulum and femur should be considered separately, although if the centre of rotation cannot be restored on the acetabular side this must be compensated for on the femoral side. The centre of the acetabulum and the version of the acetabular component may be restored by referencing

from the transverse acetabular ligament (TAL)27 and the centre of the femoral head by using a calliper.26 The use of PSM refers to the practice of allowing the form and structure of the patients bony and soft-tissue anatomy to guide the reconstruction.28 This philosophy has been promoted by Archbold et al.23,26 Two previous reports have described methods that use fixed points on the femur to restore leg length.23,26 This removes the effect of positioning errors between the pelvis and femur and allows the independent measurement of femoral height and/or offset. The senior author (DEB) has used the calliper to control leg length in > 9000 THRs since 1991 and has reported this experience.26 In 2005 the calliper technique was modified such that it could also be used to restore offset and be used with any off-theshelf femoral component either cemented or cementless. This paper begins by describing this new calliper technique and then describes two methods of validation: first in the laboratory using a co-ordinate measuring machine (CMM) to see how closely the calliper could predict the centre of the femoral head when simulating THR on a Sawbone femur (Sawbones Europe AB, Malm, Sweden) femora and secondly using CT to record

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Fig. 2a

Fig. 1 Photograph showing the calliper design used for neck resection measurement.

restoration of the centre of the femoral head in 40 patients undergoing THR using the calliper technique.

Patients and Methods Although applicable to any off-the-shelf femoral component, this technique is described using the Corail cementless THR (DePuy International, Leeds, United Kingdom). This design is available with three neck configurations and three neck lengths allowing a range of different offsets and heights with respect to the centre of the femoral head. The calliper used in this study was a neck-resection calliper (DePuy International) manufactured from surgical grade stainless steel (Fig. 1). During surgery the patient is held in the lateral decubitus position with appropriate pelvic supports. The hip is exposed through a posterior approach and at dislocation the offset reference measurement, Of, is recorded using the calliper (Fig. 2) with the paddle arm held against the most medial aspect of the femoral head and the osteotome arm used to make an arbitrary mark on the posterior aspect of the greater trochanter. The purpose of this measurement is not to measure true offset but to enable the change in offset following insertion of the femoral component to be calculated as described below. This measurement is made approximately at right angles to the anatomical axis. The osteotome indentation in the greater trochanter is marked with a diathermy burn to enable identification later. In order to restore the original height of the centre of the femoral head, the length of the femoral neck (NLf) is then measured. The paddle arm of the calliper is held against the femoral head (Fig. 3) and the osteotome arm marks the base of the femoral neck. The neck is resected just proximal to this mark. The diameter of the femoral head (Df) is then measured. The acetabulum is then prepared and acetabular component inserted. The calliper technique assumes that the femoral head is spherical. Using the three measurements described above and the planned diameter of the head of the femoral
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Fig. 2b

Fig. 2c Photographs showing the reference offset measurement (Of) (a) before neck resection in a right hip intra-operatively (b), in the Sawbone posterior operative perspective (c) and the Sawbone superior view.

prosthesis (Dp); the predicted values for the values of its offset (Op) and neck length (NLp), which would be required to restore the centre of the femoral head, are calculated using equations 1 and 2. The difference between Of and Op and NLf and NLp is half the difference in diameter between the native and the prosthetic femoral heads. Equation 1. Op = Of ([Df Dp] / 2) Equation 2. NLp = NLf ([Df Dp] / 2) With the trial broach in the femur, a neck piece and head are attached. The calliper must first be used to

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Fig. 3a

Fig. 3b

Fig. 3c

Photographs showing neck-length measurement (NLf) (a) before division of the femoral neck in a right hip intra-operatively), (b) in the Sawbone posterior operative perspective and (c) the Sawbone superior view (right).

Validation techniques. CMM measurement of simulated THR stem insertion. The

Fig. 4 Intra-operative photograph showing the final offset measurement, superior view (right hip).

restore the offset of the prosthesis before its neck length. If the measured offset is not equal to the predicted offset of the prosthesis (Op) adjustments are made using the head/ neck modularity available. For example the patient illustrated in Figures 2 and 3 required a +8.5 mm head with a standard neck piece head to restore offset and neck length, as shown in Figure 4. If the offset is correct but the neck length is too long, despite the modular options available, the broach can be exchanged for a smaller one that will be stable at a more distal level in the femoral canal thus reducing the vertical height while still allowing the modularity to restore offset. Once the surgeon is satisfied that the centre of the prosthetic head has been restored satisfactorily, the trial head of appropriate diameter is used for the trial reduction. If stability and softtissue tension are satisfactory the definitive component is then inserted with the appropriate modular head followed by reduction, posterior repair and wound closure.

aim of this experiment was to accurately determine the change in head centre (in terms of offset and vertical height on the coronal plane of the femur) using a calliper when inserting a femoral component into a Sawbone femur. This was verified by comparing the position of the centre of the head before and after division of the femoral neck using a CMM (MXCEL PFX 454; Brown and Sharpe Manufacturing Company, North Kingstown, Rhode Island) that has an accuracy of 10-7 m according to the manufacturers specifications. Insertion of the femoral component during THR was replicated on Sawbone femora with cortical shells. Three small (head diameter: 39 mm), three medium (diameter: 45 mm) and three large (diameter: 52 mm) proximal femoral Sawbones were used. The senior author (DEB) aimed to restore the centre of the femoral head as close as possible to the original centre given the limitations of modularity. These restrictions imposed a difference between predicted offset and height based on the equations and that achieved with the calliper. Prior to division of the femoral neck the calibrated CMM was used to determine the centre of the femoral head, by interpolation from 20 point measurements on the surface of the femoral head, in terms of vertical height and offset in the coronal plane of the femur. This was repeated when the prosthesis was inserted enabling calculation of the difference between the centre of the head of the prosthesis and that of the femoral head in terms of offset (offset discrepancy) and vertical height (vertical height discrepancy). The CMM results are not directly comparable to those obtained from using equations 1 and 2 with the calliper measurements. Although measurement of the offset made with the calliper is similar to that made by the CMM, since it is approximately perpendicular to the femoral axis, the measurement of the neck length using the calliper is not vertical with reference to the anatomical axis of the femur.
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Table I. Difference between predicted and achieved calliper measurements for Sawbone femur not confirmed by the co-ordinate measurement machine Small 1 Calliper difference (achieved predicted) (mm) Offset Neck length -1 3 2 0 0 3 0 2 Medium 1 -2 1 2 0 0 3 0 0 Large 1 2 3

0.5 0.5 -0.5 2.5 2.5 -0.5

The CMM measured the co-ordinates of the axis of the femur. A femur was located accurately on the CMM and the x, y and z co-ordinates of the centre of the head and its diameter were determined. The femoral head was removed and the surgeon inserted the femoral component using the calliper technique (Figs 2 and 3). The femur was then returned to the CMM, in its previous orientation and the coordinates of the centre of the head of the prosthesis were measured so that the true differences between the intact femur and the centre of the head of the prosthesis could be determined in terms of offset and vertical height. The difference between the predicted and achieved calliper measurements were reported with a positive difference in offset and neck length indicating that the achieved value was greater than the predicted value. Results obtained from the CMM show differences between the intact Sawbone femur and the centre of the head of the femoral prosthesis in terms of offset and vertical height. A positive difference in offset indicated an increase in femoral offset and a positive difference in vertical height indicated an increase in leg length. CT evaluation of femoral head centre restoration. Following ethical approval, 40 consecutive patients who underwent primary THR using this technique were enrolled in this prospective study. There were 21 men and 19 women with a mean age of 68 years (42 to 88). Informed consent was obtained from all patients. The principal inclusion criterion was that the contralateral hip had no deformity and osteoarthritis was Grade 0, 1 or 2 on the Kellgren and Lawrence scale.29 The goal of reconstruction was to restore the centre of the femoral head to its original position based on the contralateral side. For each patient a post-operative pelvic CT scan was obtained using a 16-slice multi-slice CT scanner (SOMATOM Sensation 16; Siemens, Forchheim, Germany), with a 0.75 mm slice collimation and a 0.6 mm pitch, dose modulation (Caredose). Two reconstructions were made with a slice thickness of 1 mm (0.5 mm reconstruction increments) using bone and soft-tissue kernels. This enabled comparisons between the reconstructed femur and the healthy contralateral femur. A standard pelvic co-ordinate system based on the plane contacting the anterior superior iliac spines and the pubic tubercles was established on the postoperative CT scans. The healthy hemi-pelvis with the femur was reflected in the mid-sagittal plane so that it could be registered and compared with the operative side. For both sides
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the centre of the hip was identified as the centre of the respective femoral head. This was done by interactively fitting a sphere to the surface of the head and localising the centre of the sphere. The healthy hemi-pelvis was then registered to the operative pelvis using the standard procedure.30 Measurements of changes in centre of the femoral head in terms of offset, vertical height and version were obtained, although as the direct focus was to evaluate the use of the calliper, only the offset and height are reported. Results are expressed as mean values with standard deviation (SD) with the minimum and maximum values. A positive offset indicated an increase in offset (medial displacement of centre of the femoral head), and a positive vertical height indicated an increase in leg length (superior displacement of centre of the femoral head). Statistical analysis. This was performed for all results using the Students t-tests looking at the change in offset and vertical height against the null hypothesis that there was no change in offset and vertical height (mean = 0). The analyses were undertaken using Stata v12 software (StataCorp LP, College Station, Texas).

Results Table I shows the differences between predicted and achieved calliper measurements on each of the nine Sawbones for offset and neck length. With respect to offset, the calliper measurements were within 1 mm of the predicted value in eight cases (88.9%) and within 2 mm in all cases. With respect to neck length, calliper measurements were within 1 mm in five cases (55.6%), within 2 mm in six cases (66.7%) and within 3 mm in all cases. Table II shows the differences between the intact Sawbone femur and the centre of the prosthetic heads in terms of offset and vertical height for each of the Sawbone femora as measured by the CMM. Results indicate that the offsets of all femoral head centres were restored to within 4.3 mm (mean 1.6 (95% confidence interval (CI) 0.4 to 2.8)), with five (55.6%) restored to within 1 mm. All vertical heights were restored to within 2.4 mm (mean 0.6 (95% CI 1.4 to 0.2)) with six (66.7%) restored to within 1 mm. Table III shows the results obtained from all nine Sawbones femora for both the calliper technique and from the CMM. The mean absolute differences, that is, taking account of numerical difference only and not the positive or negative value, between the predicted calliper values and the achieved values were 0.5 mm for offset and 1.3 mm for

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Table II. Co-ordinate measurement machine (CMM) results for Sawbone femur Small 1 CMM difference (prosthesis femur) (mm) Offset Vertical height 2 3 Medium 1 2 3 Large 1 2 3

3.5 4.3 2.9 -2.4 0.9 -0.6

0.3 1.2 0.4 0.0 -1.3 -0.3

0.8 0.2 0.6 0.5 -0.4 -2.0

Table III. Summary of absolute results of calliper and co-ordinate measuring machine (CMM) measurements where p < 0.05 indicates the result is significantly different from 0 (CI, confidence interval) Mean (range) Calliper difference (achieved predicted) (mm) Offset Neck length CMM difference (prosthesis femur) (mm) Offset Vertical height 0.5 (0 to 2) 1.3 (0 to 3) 1.6 (0.2 to 4.3) 0.9 (0 to 2.4) Median (SD; 95% CI) 0.5 (0.7; 0.008 to 1.008) 1.0 (1.2; 0.334 to 2.221) 0.8 (1.6; 0.378 to 2.777) 0.6 (0.8; 0.308 to 1.557) p-value 0.053 0.014 0.016 0.009

neck length while the mean difference in offset between the prosthesis and original femur was 1.6 mm for offset and 0.9 mm for vertical height as determined by the CMM. The mean gain in offset (0.52 (SE 1.56), p = 0.017) was statistically significantly different from 0 but there was no evidence that the mean height gain (0.36 (SE -0.60), p = 0.137) was statistically significantly different from 0. Figure 5 shows the distributions of the changes in offset and vertical height to the nearest millimetre of the centre of the femoral heads for each patient. One was excluded due to an error in the digitisation of the CT scan and a further patient was removed due to stem subsidence. The mean change in offset for all 38 patients was -1 mm (SD 4; -8 to 8) and the mean change in vertical height was 4 mm (SD 3; -3 to 14). There was no evidence that the mean gain in offset (-0.72 (SE 0.67), p = 0.286) was statistically different from zero. However there was a statistically significant mean gain in height (3.05 (SE 0.59), p < 0.001).

Discussion Restoration of leg length1-3 and offset25 following THR is an important goal for patients and surgeons. Many techniques have been described to correct leg length intraoperatively by combining the effects of both acetabular and femoral height into one single measurement.19-22,24 Jasty et al24 used a calliper in combination with pre-operative templating and found that only 16% of patients had postoperative leg length inequality; 13% were lengthened between 5 mm and10 mm. In an attempt to minimise the effect of the position of the leg, Shiramizu et al19 designed and used an L-shaped calliper with a significant reduction in leg length inequality when compared to a standard calliper. Takigami et al20 using a calliper with a dual pin retractor, reported a mean post-operative leg length inequality of 4.2 mm (SD 3.2) in a series of 56 patients. Woolson and Harris21 reported an inequality of < 6 mm in 86% of patients in a series of 408 hips when using pre-operative

templating and a calliper. Ranawat et al22 inserted a Steinmann pin in the infracotyloid groove of the acetabulum to mark the greater trochanter pre- and post-reconstruction in 100 consecutive THRs and found that the post-operative leg length inequality ranged from -7 mm to +8 mm. Although these methods help to minimise inequality they are anatomically incorrect in that the contribution made by the acetabulum and femur are not considered separately. In addition these techniques are prone to considerable error as they rely on accurate repositioning of the limb. When using a method to restore leg length that combines acetabular and femoral height as a single measurement, Sarin et al2 found that a 5 error of abduction/adduction caused an 8 mm error in the measurement of leg length with a 10 error leading to a 14 mm to 17 mm error. In an attempt to increase the accuracy of the restoration of leg length Archbold et al26 and more recently Lakshmanan et al23 have reported methods that use fixed points on the femur removing the effect of positioning. These methods are based on the principle that for the anatomical restoration of length and offset the acetabulum and femur should be addressed separately. Archbold et al26 used a calliper to control vertical placement of the femoral component and the TAL to control the vertical height of the acetabular component in 200 patients and found that 94% had a leg length inequality of 6 mm or less (mean 0.38 (-8 to 8)). That technique differs from the one described in this paper in that the calliper was only used to control the depth of insertion of the femoral component as custom made components with patient-specific offsets were used. This paper describes and validates a new calliper technique to control both femoral offset and the height of the centre of the femoral head using a CMM, where the technique was replicated on Sawbone femora, and post-operative CT scans of patients who had undergone THR. Theoretically, even if the calliper was precise in terms of locating the centre of the femoral head it could not be restored exactly due
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14 13 12 11 10 9 8 7 6 5 4 3 2 1 0 -1 -2 -3 -4 -5 -6 -7 -8 -9

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Offset

Vertical height

Difference in head centre (mm)

3 4 Number of patients
Fig. 5

Histogram showing change in offset and vertical height of the centre of the femoral head for all patients.

Fig. 6a

to limitations imposed by head and neck modularity, especially when using a cementless system. As a result when using the calliper in some cases there were differences between the actual and predicted offset and neck lengths. These differences indicate that modularity would have to be infinite to predict the centre of the femoral head. Using the CMM and calliper technique results in mean changes in the centre of the femoral head of 1.6 mm for offset and 0.9 mm for vertical height. One limitation is that, although both the CMM and the calliper each record offset, the CMM records vertical height while the calliper records neck length, which is a surrogate measure of height, making direct comparisons impossible. Another limitation of this study is that because of its size (n = 9), the significance of the statistical analysis is limited. Figure 5 shows that in the THRs 26% of femoral heads were replaced to within 1 mm of head centre for offset, 79% within 5 mm and all were within 8 mm of the original offset (mean -1 (95% CI 2.1 to 0.6)). The vertical height was within 1 mm of the original head centre for 26% of cases, within 5 mm for 71% of cases and within 14 mm in all cases (mean 4 (95% CI 1.8 to 4.3)). The CT results reveal a general tendency to leave the femoral head centre high (mean 3.70 mm). On occasion the surgeon is required to do this to restore soft-tissue tension and stability. Although it is the senior authors (DEB) philosophy to restore the centre of the acetabulum independently,27 at times, particularly when there is significant loss of acetabular bone stock, this is not possible. In this situation global offset31 and leg length need to be compensated for on the femoral side. In general the surgeon achieved better results in the simulated THR when compared with the results of the CT study. In the laboratory soft-tissue tension and particularly acetabular destruction are not factors. Also the femoral heads have not lost their sphericity.
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Fig. 6b Photographs showing the correct use of the (a) calliper with axis parallel to central axis of the neck of the femur and (b) incorrect use.

Using the calliper technique to restore the centre of the femoral head during THR is inexpensive, fast and in principle can be used with any design of femoral component. It also reduces the need for pre-operative templating of the centre of the head, but templating is still recommended to identify the most appropriate size of femoral component and in cases where femoral and acetabular anatomy are particularly abnormal. The technique has a number of advantages over pre-operative templating of joint geometry such as the avoidance of magnification errors, preventing errors due to foreshortening of offset because of external rotation, and avoiding inaccuracies that can occur from

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taking measurements from structures such as the lesser trochanter that has an indeterminate start point due to its curved profile. Marked discrepancies of leg length can be avoided, which as well as being important clinically, have significant medico-legal implications. In the United States the most frequent reason for litigation against orthopaedic surgeons after hip replacement is leg-length discrepancy.32 There are some potential disadvantages to the technique. The simplicity of the technique can be deceptive and an untrained surgeon could make errors during measurement. The measuring bar of the calliper must be parallel to the coronal plane of the femur, which is not always clearly evident in theatre (Fig. 6). As with any surgical technique training is required to use the calliper properly but this is minimal compared with that required for CAS and it is suggested that surgeons train on Sawbone femora until they are familiar with the technique. Difficulty can arise with loss of sphericity of the femoral head. Patients who require THR can have substantial loss of superior femoral head bone through wear, which reduces the neck length measurement. If this is not appreciated, measurement of neck length will lead to a loss in the vertical height of the centre of the femoral head. Similarly, and although uncommon, medial osteophytes on the fovea of the femoral head could give a false increase in the measurement of offset if not removed. In cases of excessive coxa vara the surgeon may use the calliper to reduce the offset and increase the height of the centre of the femoral head and vice versa for coxa valgum. In conclusion, accurate assessment and restoration of the centre of the femoral head including height and offset is achievable through the use of the calliper. The advantages of this device are that it is quick, inexpensive and relatively simple to use, and can be used with any femoral component.
The authors wish to thank Mr R. Finney (School of Mechanical and Aerospace Engineering, Queens University Belfast) for his assistance in using the co-ordinate measuring machine, Dr K. Eckman (Carnegie Mellon University, Pittsburgh, Pennsylvania) who assisted in the analysis of the CT scans, Mr D. Taylor (Consultant Radiologist, Musgrave Park Hospital) for his advice on CT scanning, Ms C. McDowell and Ms R. Verghis (The Northern Ireland Clinical Research Support Centre) for their statistical advice, and Professor J. Nixon (School of Medicine and Dentistry, Queens University Belfast) for advice during preparation of the manuscript. The author or one or more of the authors have received or will receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this article. In addition, benefits have been or will be directed to a research fund, foundation, educational institution, or other nonprofit organisation with which one or more of the authors are associated.

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