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ORIGINAL ARTICLE
Year : 2019  |  Volume : 22  |  Issue : 12  |  Page : 1728-1736

Geometrical Analysis of the Proximal Femur and the Clinical Application in Total Hip Replacement: A Study of the Igbo Population of South East Nigeria


1 Department of Anatomy, University of Nigeria, Nsukka, Nigeria
2 Department of Radiation Medicine, University of Nigeria, Nsukka, Nigeria
3 Department of Radiology, University of Nigeria, Teaching Hospital, Enugu, Nigeria

Date of Submission11-Dec-2018
Date of Acceptance19-Jul-2019
Date of Web Publication3-Dec-2019

Correspondence Address:
Dr. N R Njeze
Department of Radiation Medicine, College of Medicine, University of Nigeria, Nsukka
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_634_18

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   Abstract 


Background: Adult hip reconstruction following trauma and hip pathologies depends on a sound knowledge of the proximal femoral geometry (PFG), which varies from one ethnic population to another. Aim: The aim of the study, therefore, was to evaluate parameters of the proximal femoral geometry in Igbos of South Eastern Nigeria. Methodology: A 5-year review of normal X-rays of the pelvis showing both hips of patients' age 18–64 between 1 January 2012 to 31 December 2016 at Radiology Department of University of Nigeria Teaching Hospital Enugu was done. Results: There were 554 patients, 273 (49.3%) males and 281 (50.7%) females. The values of the head width established in this study showed there was a mean difference between the right and left proximal femurs, which was statistically significant (P < 0.05). There was statistical significant difference (P < 0.05) between the means of the parameters of the proximal femoral geometry when compared between gender, the only exception being the left medial cortical thicknes, which did not show any difference (P > 0.05). A comparison of means of PFG parameters of the Igbos and that of the Turkish population showed that there was statistically significant difference on both sides. Conclusion: Our study demonstrated that there was no difference in the means of both sides of femoral neck width and the intertrochanteric width of the left side. The correlations between PFG parameters showed that there was strong positive correlation that was significant apart from the right acetabular angle that did not correlate with other parameters.

Keywords: Igbos South East Nigeria, proximal femoral geometry, total hip replacement


How to cite this article:
Katchy A U, Njeze N R, Ezeofor S, Nnamani K. Geometrical Analysis of the Proximal Femur and the Clinical Application in Total Hip Replacement: A Study of the Igbo Population of South East Nigeria. Niger J Clin Pract 2019;22:1728-36

How to cite this URL:
Katchy A U, Njeze N R, Ezeofor S, Nnamani K. Geometrical Analysis of the Proximal Femur and the Clinical Application in Total Hip Replacement: A Study of the Igbo Population of South East Nigeria. Niger J Clin Pract [serial online] 2019 [cited 2019 Dec 10];22:1728-36. Available from: http://www.njcponline.com/text.asp?2019/22/12/1728/272214




   Introduction Top


The hip joint is a synovial joint of ball and socket variety. However, the work of Menschik[1] described it as a rotational conchoids. The biomechanics of the hip joint depends on the geometry of the proximal femur. Proximal femoral geometry (PFG) plays a major role as an independent risk factor in osteoporotic hip fractures in the elderly irrespective of the bone mineral density (BMD).[2] In addition to this, PFG has been implicated in the etiogenesis of hip osteoarthritis,[3],[4] development dysplasia of the hip (DDH),[5],[6] and gluteal tendinopathy.[7]

In the practice of orthopedic surgery, operations around the proximal femur are common but not limited to osteosynthesis for fracture treatment, osteotomies, as well as partial and total hip replacement. The aim of these procedures was to restore the hip biomechanics for optimal function. Consequent to this, implants namely dynamic hip screws (DHS), Asnis screws, cancellous screws, and blade plates are designed to achieve this goal. In case of total hip replacement (THR), it is mandatory that the design and the dimensions of the femoral component should match the anatomy of the native femur.[8],[9] These implants are designed based on the western parameters whose constitutional and biochemical factors are not the same with the Igbos of South Eastern Nigeria. It has also been shown that the use of orthopedic implants designed accordingly, yield poor results when used in other populations.[10] Some of the major parameters of the PFG that play a role in hip biomechanics are as follows: acetabular angle (Aa), hip axis length (HAL), femoral neck axis length (FAL), acetabular width (AW), femoral head width (HW), femoral neck width (FW), femoral shaft width (FSW), intertrochanteric width (Tw), lateral and medial cortical thickness of the femoral shaft (LCT, SMCT) femoral neck cortical thickness (NMCT), and femoral neck shaft angle (Q-angle).

These parameters are likely to be affected by racial variations, hereditary, climate, and other geographical factors related to life style.[11] Variations also exist within regional ethnic groups.[12]

PFG also plays a role in forensics and it seems obvious that PFG measurements could show differences between various populations from different ages and they need to be updated.[13]

PFG parameters produced by this study will be of immense benefits to engineers in implant design and to surgeons in implant positioning during THR in patients of Igbo extraction, thus enhancing better performance and outcomes. There is no published comprehensive literature, to our knowledge, on these parameters in the ethnic Igbos population.

Therefore, there is an urgent need to establish the normal values among the ethnic Igbos of South East Nigeria.

The aim of the study, therefore, was to evaluate parameters of the proximal femoral geometry in Igbos of South Eastern Nigeria and compare those with a known population, determine any correlation between these parameters, and other variables like age, gender, and body laterality as well as discuss the clinical implications in total hip replacement.


   Methodology Top


A 5-year review of all X-rays of the pelvis showing both hips done between 1 January 2012 to 31 December at radiology department of University of Nigeria Teaching Hospital Enugu was done.

All normal well positioned pelvic radiographs of patients aged between 18 and 64 reported by the consultant radiologist were included in study. Patients with a radiological proven hip pathology such as tumors, fractures, infections, osteoarthritis, etc., previously operated bone surgery on the hip, knee spine with or without implants, and patients of non-Igbo origin were excluded from the study. Measurements' protocol was developed using the Havva Talay Calis et al.[14] definitions. Standard AP views of the pelvis of these X-rays were placed on the viewing box and the following the geometric measurements were taken [Figure 1]:
Figure 1: Measurements protocol: Femoral neck axis length (HAL): Femoral neck axis Length (FAL): Line measured from the caput femoris to the inner pelvic brim depth (AW). Head width (HW): Head width (FW): Femoral shaft width (FSW). Trochanteric width (TW) Lateral cortex thickness of the shaft (LCT): Medial cortical thickness of the shaft (SMCT): Femoral neck cortical thickness (NMCT)

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  1. Acetabular angle (Aa): Measuring the angle between a line drawn from lateral edge of the acetabular roof and the horizontal line joining the two “pelvic tear drop.”
  2. Hip axis length (HAL): taking our measurements from the base of the lateral part of the greater trochanter to the inner pelvic rim.
  3. Femoral neck axis length (FAL): taking our measurements from the base of the lateral part of the greater trochanter to the caput femoris.
  4. Line measured from the caput femoris to the inner pelvic brim (AW).
  5. Head width (HW): taken from the broadest cross section of the femoral head.
  6. Femoral neck width (FW): measured from the narrowest cross section of the femoral neck.
  7. Femoral shaft width (FSW): width measured from 3 cm below the center of the lesser trochanter.
  8. Trochanteric width (Tw):cross section measured from immediately above the lesser trochanter to the most lateral part of the greater trochanter.
  9. Lateral cortex thickness of the shaft (LCT): taken at the level of the width measurement in the femoral shaft.
  10. Medial cortical thickness of the shaft (SMCT): taken at the level of width measurement at the femoral shaft.
  11. Femoral neck cortical thickness (NMCT): at the level of the width measurement at the femoral neck.


Measurements were taken twice by the same observer and the average recorded.

Statistical analysis

We used the IBM SPSS package (IBM Corp., IBM SPSS Statistics for Windows, Version 25.0, Armonk, NY, USA). developed by International Business Machines Corporation (IBM) to analyze our data. Descriptive statistics were calculated for all variables of interest. Continuous measures were summarized as means and standard deviations. The P values for comparing means of continuous variables were determined after selecting a level of significance (α = 0.05). We used a paired-sample t-test for comparison between sides, one sample t-test for comparison with a Turkish population, and independent t-test for gender to compare the means for the determined PFG parameters. The Pearson correlation coefficient was used to determine Correlation between the PFG parameters for both sides as well with age. The significance level (α) was set at 0.5.


   Results Top


Descriptive statistics

There were 554 patients: 273 (49.3%) males and 281 (50.7%) females. The mean of the values were as follows: Right_Aa: 36.00 ± 5.08, Left_Aa: 38.61 ± 25.85, Right_HAL: 12.01 ± 1.13, Left_HAL: 11.97 ± 1.12, Right_FAL: 10.48 ± 0.90, Left_FAL: 10.49 ± 1.09, Right_AW: 1.54 ± 0.43, Left AW: 1.45 ± 0.44, Right_HW: 5.27 ± 0.47, Left_HW: 5.21 ± 0.46, Right_FW: 3.60 ± 0.39, Left_FW: 3.58 ± 0.40, Right_Tw: 6.22 ± 0.61, Left_Tw: 6.25 ± 0.59, Right_FSW: 3.44 ± 0.35, Left_FSW: 3.47 ± 0.34, Right_SMCT: 0.86 ± 0.17, Left_SMCT: 0.86 ± 0.17, Right_LCT: 0.74 ± 0.16, Left_LCT: 0.78 ± 0.16 [Table 1].
Table 1: Means of the parameters of the proximal femoral geometry

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Comparison of means of PFG parameters on both sides

The mean differences between right and left hips and their P values were as follows: Right_Aa - Left_Aa: −2.61372, P = 019, Right_HAL - Left_HAL: 0.04043, P = 0.024, Right_FAL - Left_FAL: −0.00686, P = 0.824, Right_AW - Left_LAW: 0.08877, P = 000, Right_HW-Left_HW: 0.05325, P = 0.000, Right_FW - Left_FW: 0.01661, P = 0.134, Right_Tw - Left_Tw: −0.02780, P = 0.028, Right_FSW - Left_FSW: −0.02419, P = 0.001, Right_SMCT - Left_SMCT: 0.00415, P = 0.397, Right_LCT - Left_LCT: −0.04440, P = 0.000 [Table 2].
Table 2: Comparison of means of PFG parameters on both sides

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Comparison of means of PFG parameters between genders

The mean differences between right and left hips for both gender and their P values with equal variances assumed showed there were mean differences which were all significant with the exception of Left_SMCT which had a mean difference of 0.02422 and a P value of 0.093 [Table 3].
Table 3: Independent samples test for gender for proximal femoral geometry parameters

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Comparison of means of PFG parameters of the Igbos and the Turkish population

The P values for the compared means with that of the Turkish population were as follows [Table 4]:
Table 4: Comparison of Means of nine of the study parameters with that of Turkish population

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HA: Right; P = 0.000, Left; P = 0.0000. FAL: Right; P = 0.000, Left; P = 0.000.

AW: Right; P = 0.000, Left; P = 0.000. HW: Right; P = 0.002 Left; P = 0.000.

FW: Right; P = 0.242, Left; P = 0.667.

TW: Right; P = 0.252, Left: 0.039, FSW: Right; P = 0.000, Left; 0.000.

SMCT: Right; P = 0.000, Left; 0.000, LCT: Right; P = 0.000, Left; P = 0.000.

Correlations between PFG parameters on the right side

There were no correlation between the Right_Aa and other parameters.

There were strong significant correlations between: Right_HAL and Right_FAL, Right_AW, Right_HW, Right_FW, Right_Tw, Right_FSW, Right_SMCT and Right_LCT.

The Right_FAL had a strong significant correlation with Right_HAL, Right_HW, Right_FW, Right_Tw and Right_FSW. The Right_FSW had a strong significant correlation with the Right_HAL only [Table 5]a.


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The Right_HW had a strong significant correlation with Right_HAL, Right_FALRight_FW, Right_TW, and Right_FSW. The was a strong correlation between Right_FW, Right_HAL, Right_FAL, Right_HW, Right_FW, and Right_Tw.

Correlations between PFG parameters on the left side

There were strong correlations between Left_HAL and Left_FAL. Left_AW, Left_HW, Left_FW, Left_Tw, and Left_FSW. Left_FAL showed strong correlations with Left_HW, Left_Tw, and Left_FSW [Table 5]b.

Left_ HW has a strong correlation with Left_HAL, Left_FAL, Left_ FW, Left_ Tw, and Left_FSW.

Left_FW had a strong correlation with Left_HAL, Left_HW Left_ Tw and Left_FSW.

Left_Tw had a strong correlation with Left_HAL, Left_FAL, Left_HW, Left_FW and Left_FSW. Left_FSW had strong correlation with Left_HAL, Left_FAL, Left_HW, Left_FW, and Left_Tw. Left_SMCT had a strong correlation with Left_LCT.

Correlations between age and parameters of PFG

There were no correlation between age and the parameters on both sides [Table 6].
Table 6: Correlation between Proximal Femoral Geometry Parameters and Age on Both Sides

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   Discussion Top


Adult hip reconstruction following trauma and hip pathologies have increased over the last 10 years worldwide and it is expected to double in the next 30 years.[15] THR, internal fixation of proximal femoral fractures using DHS and proximal femoral nails depends on a sound knowledge of the proximal femoral geometry which varies from one ethnic population to another.[16],[17] The goal of this is to restore the normal hip biomechanics and ensure longtime survivorship of the implant. Furthermore, there is a consensus that to achieve this, there should be a close geometric fit between the femoral component and the support bone.[18],[19],[20]

The HW which is known as the femoral head diameter is an important parameter of the PFG that is taken into consideration during total hip replacement. The values of the HW established in this study were 5.27 ± 0.47 and 5.21 ± 0.46 for right and left proximal femurs, respectively. This mean difference was statistically significant (P < 0.05). This is in consonance with the findings of Laumonerie et al.[21] who demonstrated asymmetry of proximal femurs, which was mostly independent of demographic parameters. This asymmetry in this study appears to be more pronounced in the following PFG parameters: acetebular angle (Aa), femoral neck axis length (FAL), trochanter width (Tw), and lateral cortex thickness of the shaft (LCT). Dorr et al.[22] had used the canal flare index (CFI) calculated from these parameters to classify the femur into three shapes namely, normal, stovepipe, and champagne flute. These parameters are important in consideration of Dorr's classification during templating for THR or insertion of DHS and proximal femoral when treating fractures of the proximal femur.

There was statistical significant difference (P < 0.05) between the means of the parameters of the proximal femoral geometry when compared between gender, the only exception being the left medial cortical thickness (SMCT) which did not show any difference (P > 0.05). This is in keeping with findings of Nissen et al.[23] who demonstrated significant difference within gender in the proximal femoral geometry in the Danish population. This is at variance with the findings of Sanchita et al.[24] who did not find any significant differences in the value of the measured parameters among left or right side in both sexes in Eastern Indians. Nelson and Megyesi[25] had recommended gender-specific implants following similar findings in their study on sex and ethnic differences.

A comparison of means of PFG parameters of the Igbos and that of the Turkish population showed that there was statistically significant difference on both sides for HAL, FAL, AW, HW, FSW, SMCT, and LCT, whereas Tw showed statistical significant difference (P < 0.05) on the left only. Our study demonstrated that there was no difference in the means of both sides of FW and the TW of the left side. This further confirms the variability among ethnic population by previous authors.[26],[27],[28],[29] The correlations between PFG parameters showed there were strong positive correlation that were significant apart from the right acetabular angle that did not correlate with other parameters. This is important as the consequences of an increase is altered acetabular orientation, which increases the risk of osteoarthritis.[30]

HAL had strong correlation with many of the other parameters on both sides in this study. Many authors[31],[32],[33] have demonstrated in various studies that HAL has been implicated as a direct risk of hip fracture independent of bone mineral density.

There was no correlation between age and the parameters on both sides. This is at variance with the findings of Van der Meulen[34] who in their study demonstrated a statistically significant correlation between age and proximal femur geometry. The limitation with this study is that the measured distances are good enough for the evaluation of the needed values but the acetabular deep length or according to the position, the length of the head of femur inside the acetabulum may be the additional needed measurement values in the aspect of designing biomechanical devices.

Implant mismatch and stiffness can cause thigh pain and can as well affect survivorship,[35],[36],[37],[38] hence the need to have a good fit implant devoid of this anomaly. In considerations during templating and surgery, our surgeons should take into account the variation of the proximal femoral geometry established by our study.


   Conclusion Top


The established PFG parameters will be of immense benefit and it is recommended as guidance for hip replacement surgeons as well as implant manufacturers and distributors in our society.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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