Squatting After Total Hip Arthroplasty: Patient-Reported Outcomes and In Vivo Three-Dimensional Kinematic Study

Published:December 27, 2021DOI:https://doi.org/10.1016/j.arth.2021.12.028

      Abstract

      Background

      Squatting is an important function for many daily activities, but has not been well documented after total hip arthroplasty (THA). This study investigated the participation rate of squatting and in vivo kinematics during squatting.

      Methods

      A survey questionnaire about squatting was mailed to patients who underwent primary THA and 328 patients returned acceptable responses. Additionally, 32 hips were evaluated for dynamic 3-dimensional kinematics of squatting using density-based image-matching techniques. Multivariate analyses were applied to determine which factors were associated with anterior liner-to-neck distance at maximum hip flexion.

      Results

      Patients who could easily squat significantly increased this ability postoperatively (23.5% vs 46%, P < .01). In 29.5% of the patients there was still no ability to squat after THA; the main reason was anxiety of dislocation (34.2%). Kinematic analysis revealed that maximum hip flexion averaged 80.7° ± 12.3° with 12.8° ± 10.7° of posterior pelvic tilt and 9.7 ± 3.0 mm of anterior liner-to-neck distance. Neither liner-to-neck, bone-to-bone, nor bone-to-implant contact was observed in any of the hips. Larger hip flexion and smaller cup anteversion were negatively associated with the anterior liner-to-neck distance at maximum hip flexion (P < .05).

      Conclusion

      Postoperatively, approximately 70% of patients squatted easily or with support. Anxiety of dislocation made patients avoid squatting after THA. In vivo squatting kinematics suggest no danger of impingement or subsequent dislocation, but excessively large hip flexion and small cup anteversion remain as risks.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic and Personal
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to The Journal of Arthroplasty
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Learmonth I.D.
        • Young C.
        • Rorabeck C.
        The operation of the century: total hip replacement.
        Lancet. 2007; 370: 1508-1519
        • Hamai S.
        • Nakashima Y.
        • Mashima N.
        • Yamamoto T.
        • Kamada T.
        • Motomura G.
        • et al.
        Comparison of 10-year clinical wear of annealed and remelted highly cross-linked polyethylene: a propensity-matched cohort study.
        J Mech Behav Biomed Mater. 2016; 59: 99-107
        • Nakashima Y.
        • Sato T.
        • Yamamoto T.
        • Motomura G.
        • Ohishi M.
        • Hamai S.
        • et al.
        Results at a minimum of 10 years of follow-up for AMS and PerFix HA-coated cementless total hip arthroplasty: impact of cross-linked polyethylene on implant longevity.
        J Orthop Sci. 2013; 18: 962-968
        • Sato T.
        • Nakashima Y.
        • Akiyama M.
        • Yamamoto T.
        • Mawatari T.
        • Itokawa T.
        • et al.
        Wear resistant performance of highly cross-linked and annealed ultra-high molecular weight polyethylene against ceramic heads in total hip arthroplasty.
        J Orthop Res. 2012; 30: 2031-2037
        • Skyttä E.T.
        • Jarkko L.
        • Antti E.
        • Huhtala H.
        • Ville R.
        Increasing incidence of hip arthroplasty for primary osteoarthritis in 30-to 59-year-old patients: a population based study from the Finnish Arthroplasty Register.
        Acta Orthop. 2011; 82: 1-5
        • Garber C.E.
        • Blissmer B.
        • Deschenes M.R.
        • Franklin B.A.
        • Lamonte M.J.
        • Lee I.M.
        • et al.
        Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: Guidance for prescribing exercise.
        Med Sci Sports Exerc. 2011; 43: 1334-1359
        • Hara D.
        • Hamai S.
        • Komiyama K.
        • Motomura G.
        • Shiomoto K.
        • Nakashima Y.
        Sports participation in patients after total hip arthroplasty vs periacetabular osteotomy: a propensity score-matched Asian cohort study.
        J Arthroplasty. 2018; 33: 423-430
        • Vu-Han T.
        • Hardt S.
        • Ascherl R.
        • Gwinner C.
        • Perka C.
        Recommendations for return to sports after total hip arthroplasty are becoming less restrictive as implants improve.
        Arch Orthop Trauma Surg. 2021; 141: 497-507
        • Marchetti E.
        • Krantz N.
        • Berton C.
        • Bocquet D.
        • Fouilleron N.
        • Migaud H.
        • et al.
        Component impingement in total hip arthroplasty: Frequency and risk factors. A continuous retrieval analysis series of 416 cup.
        Orthop Traumatol Surg Res. 2011; 97: 127-133
        • Hara D.
        • Nakashima Y.
        • Yamamoto T.
        • Higashihara S.
        • Todo M.
        • Hirata M.
        • et al.
        Late failure of annealed highly cross-linked polyethylene acetabular liner.
        J Mech Behav Biomed Mater. 2013; 28: 206-212
        • Nakashima Y.
        • Hirata M.
        • Akiyama M.
        • Itokawa T.
        • Yamamoto T.
        • Motomura G.
        • et al.
        Combined anteversion technique reduced the dislocation in cementless total hip arthroplasty.
        Int Orthop. 2014; 38: 27-32
        • Gwam C.U.
        • Mistry J.B.
        • Mohamed N.S.
        • Thomas M.
        • Bigart K.C.
        • Mont M.A.
        • et al.
        Current epidemiology of revision total hip arthroplasty in the United States: National inpatient sample 2009 to 2013.
        J Arthroplasty. 2017; 32: 2088-2092
        • Shoji T.
        • Ota Y.
        • Saka H.
        • Murakami H.
        • Takahashi W.
        • Yamasaki T.
        • et al.
        Factors affecting impingement and dislocation after total hip arthroplasty – computer simulation analysis.
        Clin Biomech. 2020; 80: 105151
        • Harada S.
        • Hamai S.
        • Shiomoto K.
        • Hara D.
        • Fujii M.
        • Ikemura S.
        • et al.
        Patient-reported outcomes after primary or revision total hip arthroplasty: a propensity score-matched Asian cohort study.
        PLoS One. 2021; 16: e0252112
        • Saiz A.M.
        • Lum Z.C.
        • Pereira G.C.
        Etiology, evaluation, and management of dislocation after primary total hip arthroplasty.
        JBJS Rev. 2019; 7: 1-11
        • Jolles B.M.
        • Zangger P.
        • Leyvraz P.F.
        Factors predisposing to dislocation after primary total hip arthroplasty: a multivariate analysis.
        J Arthroplasty. 2002; 17: 282-288
        • Cheatham S.W.
        • Stull K.R.
        • Fantigrassi M.
        • Montel I.
        Hip musculoskeletal conditions and associated factors that influence squat performance: a systematic review.
        J Sport Rehabil. 2018; 27: 263-273
        • Hemmerich A.
        • Brown H.
        • Smith S.
        • Marthandam S.S.K.
        • Wyss U.P.
        Hip, knee, and ankle kinematics of high range of motion activities of daily living.
        J Orthop Res. 2006; 24: 770-781
        • Tang H.
        • Du H.
        • Tang Q.
        • Yang D.
        • Shao H.
        • Zhou Y.
        Chinese patients’ satisfaction with total hip arthroplasty: what is important and dissatisfactory?.
        J Arthroplasty. 2014; 29: 2245-2250
        • Dorr L.D.
        • Malik A.
        • Dastane M.
        • Wan Z.
        Combined anteversion technique for total hip arthroplasty.
        Clin Orthop Relat Res. 2009; 467: 119-127
        • Akiyama M.
        • Nakashima Y.
        • Fujii M.
        • Sato T.
        • Yamamoto T.
        • Mawatari T.
        • et al.
        Femoral anteversion is correlated with acetabular version and coverage in Asian woman with anterior and global deficient subgroups of hip dysplasia: a CT study.
        Skeletal Radiol. 2012; 41: 1411-1418
        • Khanuja H.S.
        • Vakil J.J.
        • Goddard M.S.
        • Mont M.A.
        Cementless femoral fixation in total hip arthroplasty.
        J Bone Joint Surg Am. 2011; 93: 500-509
        • Hara D.
        • Nakashima Y.
        • Hamai S.
        • Higaki H.
        • Ikebe S.
        • Shimoto T.
        • et al.
        Dynamic Hip kinematics during the golf swing after total hip arthroplasty.
        Am J Sports Med. 2016; 44: 1801-1809
        • Hara D.
        • Nakashima Y.
        • Hamai S.
        • Higaki H.
        • Ikebe S.
        • Shimoto T.
        • et al.
        Dynamic hip kinematics in patients with hip osteoarthritis during weight-bearing activities.
        Clin Biomech. 2016; 32: 150-156
        • Komiyama K.
        • Hamai S.
        • Hara D.
        • Ikebe S.
        • Higaki H.
        • Yoshimoto K.
        • et al.
        Dynamic hip kinematics during squatting before and after total hip arthroplasty.
        J Orthop Surg Res. 2018; 13: 1-7
        • Shiomoto K.
        • Hamai S.
        • Hara D.
        • Higaki H.
        • Gondo H.
        • Wang Y.
        • et al.
        In vivo kinematics, component alignment and hardware variables influence on the liner-to-neck clearance during chair-rising after total hip arthroplasty.
        J Orthop Sci. 2019; 25: 452-459
        • Koyanagi J.
        • Sakai T.
        • Yamazaki T.
        • Watanabe T.
        • Akiyama K.
        • Sugano N.
        • et al.
        In vivo kinematic analysis of squatting after total hip arthroplasty.
        Clin Biomech. 2011; 26: 477-483
        • Heckmann N.
        • McKnight B.
        • Stefl M.
        • Trasolini N.A.
        • Ike H.
        • Dorr L.D.
        Late dislocation following total hip arthroplasty: spinopelvic imbalance as a causative factor.
        J Bone Joint Surg Am. 2018; 100: 1845-1853
        • Murray D.W.
        The definition and measurement of acetabular orientation.
        J Bone Joint Surg Br. 1993; 75: 228-232
        • Lewinnek G.E.
        • Lewis J.L.
        • Tarr R.
        • Compere C.L.
        • Zimmerman J.R.
        Dislocations after total arthroplasties.
        J Bone Joint Surg Am. 1978; 60: 217-220
        • Ochi H.
        • Baba T.
        • Homma Y.
        • Matsumoto M.
        • Nojiri H.
        • Kaneko K.
        Importance of the spinopelvic factors on the pelvic inclination from standing to sitting before total hip arthroplasty.
        Eur Spine J. 2016; 25: 3699-3706
        • Dorr L.D.
        • Callaghan J.J.
        Death of the Lewinnek “safe zone”.
        J Arthroplasty. 2019; 34: 1-2
        • McGinley J.L.
        • Baker R.
        • Wolfe R.
        • Morris M.E.
        The reliability of three-dimensional kinematic gait measurements: a systematic review.
        Gait Posture. 2009; 29: 360-369
        • Hara D.
        • Nakashima Y.
        • Hamai S.
        • Higaki H.
        • Ikebe S.
        • Shimoto T.
        • et al.
        Kinematic analysis of healthy hips during weight-bearing activities by 3D-to-2D model-to-image registration technique.
        Biomed Res Int. 2014; 457573: 1-9
        • Furuhashi H.
        • Yamato Y.
        • Hoshino H.
        • Shimizu Y.
        • Hasegawa T.
        • Yoshida G.
        • et al.
        Dislocation rate and its risk factors in total hip arthroplasty with concurrent extensive spinal corrective fusion with pelvic fixation for adult spinal deformity.
        Eur J Orthop Surg Traumatol. 2021; 31: 283-290
        • Snijders T.E.
        • Schlösser T.P.C.
        • van Stralen M.
        • Castelein R.M.
        • Stevenson R.P.
        • Weinans H.
        • et al.
        The effect of postural pelvic dynamics on the three-dimensional orientation of the acetabular cup in THA is patient specific.
        Clin Orthop Relat Res. 2021; 479: 561-571
        • Lembeck B.
        • Mueller O.
        • Reize P.
        • Wuelker N.
        Pelvic tilt makes acetabular cup navigation inaccurate.
        Acta Orthop. 2005; 76: 517-523
        • Babisch J.W.
        • Layher F.
        • Amiot L.-P.
        The rationale for tilt-adjusted acetabular cup navigation.
        J Bone Joint Surg Am. 2008; 90: 357-365
        • Miki H.
        • Sugano N.
        • Yonenobu K.
        • Tsuda K.
        • Hattori M.
        • Suzuki N.
        Detecting cause of dislocation after total hip arthroplasty by patient-specific four-dimensional motion analysis.
        Clin Biomech. 2013; 28: 182-186
        • Callanan M.C.
        • Jarrett B.
        • Bragdon C.R.
        • Zurakowski D.
        • Rubash H.E.
        • Freiberg A.A.
        • et al.
        The John Charnley Award: risk factors for cup malpositioning: quality improvement through a joint registry at a tertiary hospital.
        Clin Orthop Relat Res. 2011; 469: 319-329
        • Grammatopoulos G.
        • Pandit H.G.
        • Da Assunção R.
        • Taylor A.
        • McLardy-Smith P.
        • De Smet K.A.
        • et al.
        Pelvic position and movement during hip replacement.
        Bone Joint J. 2014; 96 B: 876-883
        • Shoji T.
        • Yasunaga Y.
        • Yamasaki T.
        • Izumi S.
        • Hachisuka S.
        • Ochi M.
        Low femoral antetorsion and total hip arthroplasty: a risk factor.
        Int Orthop. 2015; 39: 7-12
        • Vigdorchik J.M.
        • Sharma A.K.
        • Madurawe C.S.
        • Elbuluk A.M.
        • Baré J.V.
        • Pierrepont J.W.
        Does prosthetic or bony impingement occur more often in total hip arthroplasty: a dynamic preoperative analysis.
        J Arthroplasty. 2020; 35: 2501-2506
        • Sato T.
        • Nakashima Y.
        • Matsushita A.
        • Fujii M.
        • Iwamoto Y.
        Effects of posterior pelvic tilt on anterior instability in total hip arthroplasty: a parametric experimental modeling evaluation.
        Clin Biomech. 2013; 28: 178-181
        • Park K.K.
        • Tsai T.Y.
        • Dimitriou D.
        • Kwon Y.M.
        Utility of preoperative femoral neck geometry in predicting femoral stem anteversion.
        J Arthroplasty. 2015; 30: 1079-1084
        • Malik A.
        • Dorr L.D.
        • Long W.T.
        Impingement as a mechanism of dissociation of a metasul metal-on-metal liner.
        J Arthroplasty. 2009; 24: 323.e13-323.e16