
==== Front
Medicine (Baltimore)
Medicine (Baltimore)
MD
Medicine
0025-7974
1536-5964
Lippincott Williams & Wilkins Hagerstown, MD

MD-D-23-07775
00064
10.1097/MD.0000000000039528
3
7100
Research Article
Systematic Review and Meta-Analysis
The effect of intraoperative fluoroscopy on acetabular component positioning and patient anatomy restoration during total hip arthroplasty: A systematic review and meta-analysis
Sun Changjiao a
Gao Hong b
Ma Qi MD maqi2019@sina.com
a
Li Huimin c
Zhang Xiaofei d
Cai Xu a*
a Orthopedic Sports Medicine Center, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
b Beijing MEDERA Medical Group, Beijing, China
c Department of Nurse, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
d Department of Clinical Epidemiology and Biostatistics, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China.
* Correspondence: Xu Cai, Orthopedic Sports Medicine Center, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Dongxiaokou Town, Changping District, Beijing 102218, China (e-mail: sunchangjiao@163.com).
13 9 2024
13 9 2024
103 37 e3952816 9 2023
18 3 2024
08 5 2024
Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.
2024
https://creativecommons.org/licenses/by-nc/4.0/ This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is permissible to download, share, remix, transform, and buildup the work provided it is properly cited. The work cannot be used commercially without permission from the journal.

Background:

In total hip arthroplasty (THA), the positioning of components holds critical importance for factors such as joint stability, polyethylene liner wear, and range of motion. This meta-analysis aimed to compare the effects of intraoperative fluoroscopy (IF) versus no use of IF on component positioning and the restoration of patient anatomy during THA.

Methods:

We conducted our systematic review following the recommendations outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. The literature search was performed from the inception of medical databases up to August 2023. PubMed, Embase, Web of Science, Cochrane Controlled Trials Register, Cochrane Library, Highwire, Wanfang, China National Knowledge Infrastructure (CNKI), China Biology Medicine Disc (CBM), and China Science and Technology Journal (CSTD) databases were systematically searched to identify relevant studies comparing IF versus no IF during primary THA.

Results:

Thirteen studies involving 2195 patients (2207 hips) were incorporated in the Analysis. No statistically significant differences were observed between the groups in terms of acetabular cup inclination angle (ACIA, P = .9), ACIA within the safe zone rate (P = .87), acetabular cup anteversion angle (ACAA, P = .42), ACAA within the safe zone rate (P = .35), combined safe zone rate (P = .30), limb length difference (LLD, P = .13), dislocation rate (P = .76), and infection rate (P = .97). In comparison to the no fluoroscopy group, the IF group exhibited prolonged operation time (P < .00001) and reduced femoral component offset difference (FCOD, P = .03).

Conclusion:

IF did not demonstrate improvements in acetabular cup placement, limb length difference, or dislocation occurrence. Nonetheless, IF showed a significant enhancement in restoring femoral offset. It is noteworthy that surgeons operating in facilities with lower patient volumes may observe more pronounced benefits from IF.

dislocation
intraoperative fluoroscopy
limb length difference
safe zone
total hip arthroplasty
OPEN-ACCESSTRUE
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pmc1. Introduction

There remains a need for further clarification and discussion regarding whether the advantages of intraoperative fluoroscopy (IF) in enhancing component positioning and restoring patient anatomy outweigh the potential drawbacks associated with its utilization, including increased costs, prolonged operation times, and radiation exposure. According to some studies,[1–3] no statistically or clinically significant disparities were observed in component positioning or patient anatomy restoration, such as limb length and femoral component offset, between groups subjected to fluoroscopy and those without. Conversely, other research studies suggest that IF during total hip arthroplasty (THA) could improve acetabular component positioning or patient anatomy restoration compared to THA without fluoroscopy.[4–6] Our comprehensive systematic review conducted a meta-analysis to assess the evidence comparing IF to no fluoroscopy during THA. Specifically, our objectives were to compare the following outcomes: acetabular cup inclination angle (ACIA); ACIA within safe zone rate; acetabular cup anteversion angle (ACAA); ACAA within safe zone rate; combined safe zone rate; limb length difference (LLD); femoral component offset difference (FCOD); operation time; dislocation rate; and periprosthetic joint infection (PJI) rate.

2. Methods

2.1. Protocol and registration

Our systematic review followed the guidelines provided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020,[7] and we adhered to the methodology outlined in the Cochrane Handbook.[8] A predefined protocol was established in accordance with the PRISMA guidelines. Furthermore, prior to data extraction, our study protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) under the registration number CRD42022316521.

2.2. Search strategy

We conducted a literature search for original articles published prior to August 31, 2023. The databases searched included PubMed, Embase, Web of Science, Cochrane Controlled Trials Register, Cochrane Library, Highwire, Wanfang, China National Knowledge Infrastructure (CNKI), China Biology Medicine disc (CBM), and China Science and Technology Journal (CSTD) to identify studies comparing IF versus no IF during THA. During the systematic search, the following search terms were utilized: “total hip arthroplasty,” “total hip replacement,” “fluoroscopy,” and “X-ray,” combined using Boolean operators “AND” or “OR.” Meta-analysis was performed using Review Manager Software. Two independent reviewers initially screened the title and abstract of each article to determine eligibility for inclusion. Subsequently, the full text of each study meeting the preliminary criteria underwent further evaluation by 2 reviewers using identical inclusion and exclusion criteria.

2.3. Eligibility criteria

The inclusion criteria for selecting studies in this meta-analysis were as follows: all articles comparing the use of IF versus no IF during primary THA. Both randomized controlled trials (RCTs) and observational studies were considered for inclusion. Additional inclusion criteria included the availability of full-text articles and reporting on relevant outcomes (as specified below). Exclusion criteria comprised cadaveric studies, case reports, studies involving THA revision procedures, and studies with unclear or incomplete sample data. Efforts were made to contact authors to obtain missing data.

2.4. Outcomes

The study assessed several outcomes, including ACIA, ACIA within the safe zone rate, ACAA, ACAA within the safe zone rate, combined safe zone rate, LLD, FCOD, operation time, dislocation rate, and PJI rate. Detailed definitions of select outcomes are provided in Table 1.

Table 1 Definition of some outcomes.

Outcome	Definition	
ACIA	Viewed on a standard, weight-bearing AP radiograph, acetabular cup inclination is measured in degrees between a line drawn along the angle of the rim of the cup and the horizontal, trans-obturator foramen nadir reference line (a line drawn between the most inferior point of the obturator foramen)	
ACAA	Acetabular anteversion was measured on the cross-table lateral image according to the method described by Woo and Morrey	
LLD	Viewed on a standard, weight-bearing AP radiograph, LLD is measured in millimeters as the difference in perpendicular distance between the horizontal, trans-ischial reference line, and the medial tip of the lesser trochanter, as compared to the contralateral side. The trans-ischial line was chosen as reference as it has been validated in the literature as a reliable point of reference	
FCOD	Viewed on a standard, weight-bearing AP radiograph, femoral offset difference is measured in millimeters as the difference in perpendicular distance between the longitudinal anatomic axis of the femur and the center of rotation of the femoral head, as compared to the contralateral side	
Abbreviations: ACAA = acetabular cup anteversion angle, ACIA = acetabular cup inclination angle, FCOD = femoral component offset difference, LLD = limb length discrepancy.

2.5. Data extraction process

The selection process was conducted by 2 independent review authors (CJS and HG) following the removal of duplicates. Studies underwent screening based on their title, abstract, and full text after duplicate removal. Full-text screening was carried out to address cases where abstracts lacked sufficient information. Any disagreements were resolved through consensus involving a senior reviewer (XC). Baseline characteristics of the included studies were extracted, encompassing research features (such as authors, year of publication, country, and study type), population information (including age, gender, body mass index [BMI], and follow-up time), and clinical details (pertaining to outcomes). Data extraction was performed independently by 2 authors.

2.6. Data transformation

For reports with incomplete or missing data, efforts were made to contact the authors of the original reports to obtain additional details and any missing data. In several studies, outcome data were reported using the median, first quartile, and third quartile or the median, minimum, and maximum values. To incorporate such data into our meta-analysis, we estimated the sample mean using the method described by Luo et al[9] and the sample standard deviation (SD) based on the method proposed by Wan et al.[10] This approach for calculating mean and SD values has been demonstrated to be reliable.[11–14]

2.7. Assessment of studies

Two independent researchers evaluated the methodological quality of the included studies using the nine-star Newcastle-Ottawa Scale (NOS). This scale is a validated tool widely used for assessing the quality of nonrandomized research studies.[15] It primarily focuses on assessing the selection and comparability of cohorts, as well as evaluating outcomes and follow-up. The methodological foundation and quality of RCTs were assessed by 2 researchers using the Cochrane Handbook for Systematic Reviews of Interventions.[16] Any disagreements were resolved by a third investigator.

2.8. Ethical consideration

Ethical approval was deemed unnecessary as this study is based solely on existing literature. The results of this systematic review will be disseminated through publication in a peer-reviewed journal.

2.9. Statistical analysis

Mean and SD were utilized to represent continuous variables. Mean difference (MD) with a 95% confidence interval (CI) was employed to evaluate continuous outcomes such as ACIA, ACAA, LLD, FCOD, and operation time. Dichotomous variables were expressed using counts and percentages. Odds ratio (OR) with a corresponding 95% CI was calculated for dichotomous outcomes, including ACIA within the safe zone rate, ACAA within the safe zone rate, combined safe zone rate, dislocation rate, and PJI rate. According to Cornfield assumption regarding rare diseases, the reported OR was expected to approximate the relative risk (RR). Heterogeneity between studies was quantified using the I2 and Q tests. A random-effects model was adopted in instances where P values ≤ .1 or I2 values > 50% indicated substantial heterogeneity, while a fixed-effects model was applied otherwise. Both combined and individual effect sizes were assessed using 95% Cis. Statistical significance was considered if P values were <.05. Sensitivity analysis was conducted to assess the stability of results when necessary. All statistical analyses were conducted using Review Manager (version 5.4 for MAC, the Cochrane Collaboration, Copenhagen).

3. Results

3.1. Search results

The process of literature search and selection is illustrated in the PRISMA 2020 flow diagram (Fig. 1). Ultimately, thirteen publications were included in the meta-analysis. The detailed screening process is depicted in the PRISMA flow diagram (Fig. 1). Initially, 413 relevant citations were identified from the databases. Following the removal of 360 duplicates, 53 articles remained. Upon review of the titles and abstracts of these articles, 36 irrelevant clinical studies were excluded. Subsequently, after a full-text review of the remaining 17 articles, 4 were excluded due to inappropriate comparison groups and lack of relevant outcome data. Consequently, thirteen articles were considered suitable for inclusion. 2195 patients (2207 hips) were assessed across these thirteen articles.[1–6,17–23]

Figure 1. The literature search and selection process.

3.2. Study characteristics and quality

Tables 2 and 3 provide comprehensive details on baseline and clinical characteristics. Table 4 presents information on study outcomes. No significant differences were observed between the 2 groups. All included studies were published in English and Chinese between 2006 and 2022.

Table 2 The detailed baseline characteristics information.

The detailed baseline characteristics information	
Author/year	Country	Study type	Intraoperative fluoroscopy/no intraoperative fluoroscopy	
Patients	THAs	Mean age (yr)	Female gender (%)	BMI	Follow-up time (mo)	
Belyea 2022[5]	USA	RCS	18/44	18/44	62/64	78/80	NA	24/24	
Bingham 2018[17]	USA	RCS	125/140	125/140	63.6/67.9	58/83	29.9/26.7	NA	
Brown 2021[1]	USA	RCS	100/100	100/100	65/64	54/48	28.5/29.1	1/1	
Chen 2006[18]	China	RCT	69/72	75/78	62.3/60.5	53.6/54.2	32/34	43.2/44.4	
Goodman 2017[19]	USA	RCS	100/100	100/100	63.5/65.5	54/65	28.31/28.13	4/4	
Hambright 2018[4]	USA	RCS	50/50	50/50	59.68/63	40/64	30.97/30.21	NA	
Holst 2020[20]	USA	PCS	42/42	42/42	65.2/62.7	50/59.5	25.3/26	1.5/1.5	
Hu 2020[23]	China	RCS	50/50	50/50	57.5/63	50/50	22.5/22.9	6/6	
Jennings 2015[21]	USA	RCS	98/101	98/101	69/66	54.1/50.5	28.1/25.8	6/6	
Leucht 2014[2]	USA	RCS	100/100	100/100	59.3/60.3	52/57	28.3/28.9	1.5/1.5	
Summers 2021[22]	USA	RCS	154/60	154/60	59.4/52.7	NA	28.29/27.4	36/36	
Tischler 2015[3]	USA	RCS	170/160	170/160	63.9/64.6	51.2/56.9	28.9/29.6	3/3	
Ying 2012[6]	China	RCT	50/50	50/50	60.8/63.8	52/58	NA	2 to 10	
Summary of studies characteristics, including year of publication, country, study type, the number of patients, THAs, age, gender, BMI, and follow-up time of 2 groups.

Abbreviations: BMI = body mass index, PCS = prospective cohort study, RCS = retrospective cohort study, RCT = randomized control trial, THA = total hip arthroplasty.

Table 3 The detailed information of clinical characteristics including diagnosis and approach.

Author/year	Diagnosis (intraoperative fluoroscopy/no intraoperative fluoroscopy)	Approach	
Femoral neck fracture	Acetabular dysplasia	Osteoarthritis	Femoral head necrosis	Rheumatoid arthritis	
Belyea 2022[5]	NA	NA	NA	NA	NA	Posterior	
Bingham 2018[17]			125/140			DAA	
Brown 2021[1]	NA	NA	NA	NA	NA	Posterior	
Chen 2006[18]	23/25	10/13	17/15	16/17	9/8	Posterior	
Goodman 2017[19]	NA	NA	NA	NA	NA	DAA	
Hambright 2018[4]	0/1		46/40	3/6	1/3	Posterolateral	
Holst 2020[20]	NA	NA	NA	NA	NA	DAA	
Hu 2020[23]	NA	NA	NA	NA	NA	DAA	
Jennings 2015[21]	NA	NA	NA	NA	NA	DAA	
Leucht 2014[2]	NA	NA	NA	NA	NA	DAA	
Summers 2021[22]	2/1	17/6	92/16	42/37	1/0	DAA	
Tischler 2015[3]			170/160			Posterior	
Ying 2012[6]	15/13		8/10	25/23	2/4	Posterolateral	
Abbreviations: DAA = direct anterior approach.

Table 4 The detailed information of outcomes.

Author/year	Outcome	
Belyea 2022 [5]	ACIA, FCOD	
Bingham 2018[17]	ACIA, ACAA, LLD	
Brown 2021[1]	ACIA, ACAA, LLD,FCOD, ACIA within safe zone rate, ACAA within safe zone rate, combined safe zone rate	
Chen 2006[18]	ACIA, ACAA, FCOD, LLD; operating time, blood loss, Harris score, dislocation rate, infection rate	
Goodman 2017[19]	ACIA, ACAA, ACIA within safe zone rate, ACAA within safe zone rate, dislocation rate	
Hambright 2018[4]	ACIA, ACAA, FCOD, LLD, ACIA within safe zone rate, ACAA within safe zone rate, combined safe zone rate	
Holst 2020[20]	ACIA, ACAA, FCOD, ACIA within safe zone rate, ACAA within safe zone rate, combined safe zone rate, dislocation rate	
Hu 2020[23]	ACIA, ACAA, LLD, operating time, blood loss, Harris score	
Jennings 2015[21]	ACIA, ACAA, ACIA within safe zone rate, ACAA within safe zone rate, combined safe zone rate, infection rate	
Leucht 2014[2]	ACIA, ACAA, LLD, ACIA within safe zone rate, ACAA within safe zone rate, combined safe zone rate, dislocation rate, infection rate	
Summers 2021[22]	ACIA, ACAA, ACIA within safe zone rate, ACAA within safe zone rate, combined safe zone rate	
Tischler 2015[3]	ACIA, FCOD, LLD, ACIA within safe zone rate, operating time, dislocation rate, infection rate	
Ying 2012[6]	Dislocation rate, infection rate	
Abbreviations: ACAA = acetabular cup anteversion angle, ACIA = acetabular cup inclination angle, FCOD = femoral component offset difference, LLD = limb length discrepancy.

3.3. Risk of bias assessment

The methodological quality scores of the included studies ranged from 7 to 8, as presented in Table 5. Table 6 illustrates the risk of bias summary and risk of bias graph for RCTs. Consequently, it was concluded that the overall quality of the included studies was satisfactory.

Table 5 Risk of bias assessment for the studies included in the meta-analysis (NOS).

(nRCT) study = 10	Selection	Comparability	Outcome/exposure	Score	
Item 1	Item 2	Item 3	Item 4	Item 5	Item 6	Item 7	Item 8	
Belyea 2022[5]	*		*	*	**	*	*	*	8	
Bingham 2018[17]	*		*	*	**	*		*	7	
Brown 2021[1]	*		*	*	**	*		*	7	
Goodman 2017[19]	*		*	*	**	*		*	7	
Hambright 2018[4]	*		*	*	**	*		*	7	
Holst 2020[20]	*		*	*	**	*		*	7	
Hu 2020[23]	*		*	*	**	*		*	7	
Jennings 2015[21]	*		*	*	**	*		*	7	
Leucht 2014[2]	*		*	*	**	*		*	7	
Summers 2021[22]	*		*	*	**	*	*	*	8	
Tischler 2015[3]	*		*	*	**	*		*	7	
The methodological quality of the involved studies ranged from 7 to 8. Item 1: is the case definition adequate/representativeness of the exposed cohort; item 2: representativeness of the case/selection of the non-exposed cohort; item 3: selection of controls/ascertainment of exposure to implants; item 4: definition of controls/demonstration that outcome of interest was not present at start of study; item 5: comparability of cases and controls on the basis of design or analysis/comparability of cohorts on the basis of the design or analysis; item 6: ascertainment of exposure/assessment of outcome; item 7: the same method of ascertainment for cases and controls/was follow-up long enough for outcomes to occur; item 8: non-response rate/adequacy of follow-up of cohorts.

Table 6 Methodological assessment according to 6 domains of potential biases (Cochrane risk of bias tool).

RCT study = 2	Random sequence generation	Allocation concealment	Blinding of participants and personnel	Blinding of outcome assessment	Incomplete outcome data	Selective reporting	Other bias	
Chen 2006[18]	Low	Low	High	Low	Low	Low	Unclear	
Ying 2012[6]	Low	Low	High	Low	Low	Low	Unclear	
The RCTs’ methodological quality and basis were assessed as follows: randomization, allocation concealment, blind method, selective reporting, group similarity at baseline, incomplete outcome data, compliance, the timing of outcome assessments, and intention-to-treat analysis.

Abbreviation: RCT = randomized controlled trials.

3.4. Results of outcomes

3.4.1. Acetabular cup inclination angle

Twelve studies provided data on ACIA. No significant difference in ACIA was observed between THA procedures utilizing IF and those without IF (MD = 0.08, 95% CI [−1.24, 1.41], P = .9; Fig. 2).

Figure 2. The combined data revealed no discernible difference in the ACIA between the 2 groups (MD = 0.08, 95% CI [−1.24, 1.41], P = .9).

3.4.2. ACIA within safe zone rate

Eight studies reported the ACIA rate. No significant difference was found in the ACIA rate between THA procedures utilizing IF and those without IF (OR = 1.07, 95% CI [0.46, 2.51], P = .87; Fig 3).

Figure 3. The forest plot showed that the ACIA rates for both groups were similar (OR = 1.07, 95% CI [0.46, 2.51], P =.87).

3.4.3. Acetabular cup anteversion angle

Ten studies provided data on the ACAA. There was no significant difference in ACAA between THA using IF and those without utilizing IF (MD = −0.63, 95% CI [−2.17, 0.90], P = .42; Fig. 4).

Figure 4. The forest plot showed that the ACAA for both groups was similar (MD = −0.63, 95% CI [−2.17, 0.90], P = .42).

3.4.4. ACAA within safe zone rate

Seven studies provided data on the ACAA rate. There was no significant difference in ACAA rate between THA using IF and those without utilizing IF (OR = 1.69, 95% CI [0.56, 5.04], P = .35; Fig. 5).

Figure 5. The forest plot showed that the ACIA rates for both groups were similar (OR = 1.69, 95% CI [0.56, 5.04], P = .35).

3.4.5. Combined safe zone rate

Six studies provided data on the combined safe zone rate. There was no significant difference in the combined safe zone rate between THA using IF and those without utilizing IF (OR = 1.65, 95% CI [0.64, 4.25], P = .30; Fig. 6).

Figure 6. The forest plot showed that both groups’ combined safe zone rates were similar (OR = 1.65, 95% CI [0.64, 4.25], P = .30).

3.4.6. Femoral component offset difference

Six studies provided data on the FCOD. The forest plot revealed that the FCOD was significantly less in the IF group than in no IF group (MD = −1.3, 95% CI [−2.44, −0.16], P = .03; Fig. 7).

Figure 7. The forest plot revealed that the FCOD was significantly less in the IF group than in no IF group (MD = −1.3, 95% CI [−2.44, −0.16], P = .03).

3.4.7. Limb length discrepancy

Seven studies provided data on LDD. There was no significant difference in LLD between THA using IF and those without utilizing IF (MD = −0.08, 95% CI [−0.02, −0.17], P = .13; Fig. 8).

Figure 8. There was no significant difference in LLD between THA using IF and those without utilizing IF (MD = −0.08, 95% CI [−0.02, −0.17], P = .13).

3.4.8. Operation time

Three studies provided data on operation time. The forest plot revealed that compared with no IF group, the IF group had more operation time (MD = 11.91, 95% CI [10.54, 13.29], P < .00001; Fig. 9).

Figure 9. The forest plot revealed that compared with no IF group, the IF group had more operation time (MD = 11.91, 95% CI [10.54, 13.29], P < .00001).

3.4.9. Dislocation rate

Six studies provided data on the rate of dislocation. There was no significant difference in dislocation rate between THA using IF and those without utilizing IF (RD = −0.00, 95% CI [−0.02, 0.01], P = .76; Fig. 10).

Figure 10. There was no significant difference in dislocation rate between THA using IF and those without utilizing IF (RD = −0.00, 95% CI [−0.02, 0.01], P = .76).

3.4.10. Infection rate

Five studies reported the rate of infection. There was no significant difference in infection rate between THA using IF and those without utilizing IF (RD = −0.00, 95% CI [−0.01, 0.01], P = .97; Fig. 11).

Figure 11. There was no significant difference in infection rate between THA using IF and those without utilizing IF (RD = −0.00, 95% CI [−0.01, 0.01], P = .97).

4. Discussion

To date, there is a paucity of high-quality data assessing the benefit of IF on component positioning and patient anatomy restoration in THA. An article comparing the utilization of IF versus no IF in posterior approach THA is available.[24] However, this article exclusively encompasses studies conducted via posterior approaches and does not encompass data from anterior approach THA studies. Currently, only 1 meta-analysis has been conducted comparing IF with no IF during primary THA with all surgical approaches, as per our knowledge.[25] However, this meta-analysis included several nonrandomized studies, potentially introducing selection bias. Furthermore, previous meta-analyses were restricted to English-language publications, which may limit the inclusivity of patient data from non-English-language studies and the overall statistical power. Hence, we conducted this study to evaluate existing evidence from both RCTs and non-RCTs comparing IF with no IF during THA, aiming to provide a more compelling and convincing conclusion. Our study incorporates not only English-language studies but also Chinese studies. Additionally, we present detailed complications such as dislocation and PJI rates, offering a more precise conclusion and serving as a supplement to previous meta-analyses.

The success of THA is influenced by the orientation of the acetabular component, restoration of leg lengths, and femoral offset.[26,27] Revision rates following primary THA due to mispositioning of prosthesis components range from 0.6% to 1.4%, as reported by most national joint replacement registries.[25] To enhance the accuracy of component position, various modern technologies such as robotics, computer navigation, and patient-specific instruments have been developed.[28–32] Despite their high precision, these techniques are associated with longer operating times, higher costs, and limited accessibility for all surgeons. Therefore, achieving correct anteversion and inclination of the acetabular component is often facilitated by the use of IF.[33,34]

The absence of a statistically significant difference in cup anteversion and inclination between the 2 groups was a key finding of the study, consistent with previous meta-analyses.[25] However, it is important to highlight several aspects when interpreting the results. Firstly, acetabular component location characteristics represent radiological outcomes, and there is no consensus on how these findings may impact implant survivorship. Even if differences in acetabular cup implant location measurements were observed, they would not necessarily correlate with differences in implant survivorship. secondly, while there is a widely recognized “safe zone” of 30° to 50° of abduction and 5° to 25° of anteversion for acetabular component implantation.[35] The position of the acetabular cup within this safe zone is crucial for reducing short-term dislocation frequency. Long-term research has also indicated that cup positions beyond the safe zone range may lead to poorer bone support, increased polyethylene wear, edge stress, impingement, ceramic squeaking, and higher rates of adverse tissue reaction in metal-on-metal hips.[36,37] However, recent studies have questioned the concept of this safe zone,[38] suggesting that dislocation is influenced by factors beyond acetabular component angulation characteristics.

The position of the femoral component can be determined by assessing offset and LLD in comparison to the contralateral side, which can be easily identified on the standard anteroposterior (AP) radiograph. LLD following THA has been associated with complications such as nerve damage, low back pain, abnormal gait, patient dissatisfaction, and legal action.[39,40] Our investigation revealed no significant differences in LLD detection between the 2 groups, consistent with findings from a previous meta-analysis.[25] However, our study demonstrated that the use of intraoperative radiographs was associated with improved restoration of femoral offset, contrary to the previous meta-analysis.[25] This discrepancy may be attributed to the inclusion of RCTs and Chinese articles in our meta-analysis, which should have been included in the previous Analysis.

The dislocation and PJI outcomes were not assessed in previous meta-analyses, making our results potentially valuable as a supplement to the existing literature. Our findings revealed no significant differences in the detection of dislocation rates between the 2 groups. It is important to note that dislocation is influenced by numerous factors beyond just acetabular and femoral component locations.[41] Consideration should also be given to the direction of the acetabular cup relative to unique patient conditions such as hip–spine pathology, spinal stiffness, or deficient anterior wall.[42] Concerns regarding contamination of the sterile fluoroscopy arm covering during the procedure, potentially leading to an increased PJI rate, were addressed in our meta-analysis, which found no significant difference in PJI rate between the 2 groups.

Our meta-analysis revealed that the utilization of IF did not significantly affect acetabular cup location, LLD, dislocation, or PJI rate. It is essential to consider that the majority of the studies included in our Analysis were conducted in hospitals where surgeons were experienced in performing THA. The precision of acetabular cup placement is heavily reliant on the surgeon’s experience with THA procedures. Although our meta-analysis did not specifically address the potential benefits of IF for improving the accuracy of acetabular cup placement, it is reasonable to anticipate that less experienced surgeons or those practicing in facilities with lower patient volumes may derive greater benefit from the use of IF.

It is important to acknowledge the potential drawbacks associated with the use of IF during THA, including the additional time required to obtain images, increased costs, and radiation exposure for both the patient and surgical team.[43–46] However, these negative aspects may be acceptable if the patient derives significant benefits from the use of IF.

When assessing our findings, it is essential to acknowledge the limitations of the dataset. Firstly, the evidence supporting this meta-analysis may be relatively weak due to the limited number of prospective, comparative research studies and RCTs available. Despite our comprehensive inclusion of pertinent studies and efforts to gather additional data, further confirmation through prospective randomized trials exploring various clinical data is warranted. Secondly, variations in the collected radiographs may introduce heterogeneity among the investigations. While there is a standardized procedure for obtaining pelvic radiographs, minor variations in rotation between radiographs could result in discrepancies in radiographic measurements. Thirdly, we did not conduct a separate analysis for anterior and posterior approaches. Although the surgical approach significantly impacts THA dislocation, it represents only 1 of several influencing factors. Fourthly, the follow-up duration in the included studies remains relatively short. More extensive follow-up studies, with well-defined groups randomly assigned to THA with or without intraoperative radiography, may provide valuable insights. Nonetheless, our meta-analysis offers an up-to-date and comprehensive overview of numerous measurement outcomes derived from the available evidence on this subject.

5. Conclusion

IF did not demonstrate improvements in acetabular cup placement, LLD, or dislocation occurrence. Nonetheless, IF showed a significant enhancement in restoring femoral offset. It is noteworthy that surgeons operating in facilities with lower patient volumes may observe more pronounced benefits from IF. Further, adequately powered and meticulously designed long-term follow-up trials are necessary to ascertain whether IF for THA confers clinical advantages and enhances prosthesis survival.

Author contributions

Conceptualization: Changjiao Sun, Hong Gao, Xu Cai.

Data curation: Hong Gao, Qi Ma, Huimin Li, Xiaofei Zhang.

Formal analysis: Changjiao Sun, Hong Gao.

Funding acquisition: Hong Gao, Qi Ma.

Investigation: Changjiao Sun, Hong Gao, Qi Ma, Xiaofei Zhang.

Methodology: Changjiao Sun, Qi Ma, Huimin Li, Xiaofei Zhang.

Project administration: Changjiao Sun, Huimin Li.

Resources: Qi Ma, Huimin Li.

Software: Changjiao Sun, Qi Ma, Huimin Li, Xiaofei Zhang.

Supervision: Huimin Li, Xiaofei Zhang, Xu Cai.

Validation: Qi Ma, Huimin Li.

Visualization: Changjiao Sun, Qi Ma.

Writing – original draft: Changjiao Sun.

Writing – review & editing: Xu Cai.

Abbreviations:

ACAA acetabular cup anteversion angle

ACIA acetabular cup inclination angle

BMI body mass index

CBM China Biology Medicine disc

CENTRAL Cochrane Central Register of Controlled Trials

CIs confidence intervals

CNKI China National Knowledge Infrastructure

CSTD China Science and Technology Journal

EMBASE Excerpta Medica Database

LLD limb length discrepancy

OR odds ratio

PCS prospective cohort study

PROSPERO International Prospective Register of Systematic Reviews

RCS retrospective cohort study

RCTs randomized controlled trials

RR risk ratio

THA total hip arthroplasty

VMD weighted mean difference

The authors have no funding and conflicts of interest to disclose.

Consent for publication is not applicable.

This study is not subject to ethical approval because it is based on published research.

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

How to cite this article: Sun C, Gao H, Ma Q, Li H, Zhang X, Cai X. The effect of intraoperative fluoroscopy on acetabular component positioning and patient anatomy restoration during total hip arthroplasty: A systematic review and meta-analysis. Medicine 2024;103:37(e39528).

CS and HG contributed equally to this work.
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