Selected Instructional Course Lecture   |    
Soft-Tissue Balancing of the HipThe Role of Femoral Offset Restoration
Mark N. Charles, MD1; Robert B. Bourne, MD1; J. Roderick Davey, MD2; A. Seth Greenwald, MD3; Bernard F. Morrey, MD4; Cecil H. Rorabeck, MD1
1 London Health Sciences Centre, 339 Windermere Road, London, ON N6A 5A5, Canada. E-mail address for R.B. Bourne: robert.bourne@lhsc.on.ca
2 Toronto Western Hospital, 399 Bathurst Street, 1-011 Edith Cavell Wing, Toronto, ON M5T 2S8, Canada
3 Orthopaedic Research Laboratories, Lutheran Hospital, Cleveland Clinic Health System, 1730 West 25th Street, Cleveland, OH 44113
4 Mayo Clinic, 200 First Street S.W., Rochester, MN 55905
View Disclosures and Other Information
The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. One or more of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity (Smith and Nephew). In addition, commercial entities (Biomet, Zimmer, Stryker, and Smith and Nephew) paid or directed, or agreed to pay or direct, benefits to a research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Printed with permission of the American Academy of Orthopaedic Surgeons. This article, as well as other lectures presented at the Academy's Annual Meeting, will be available in February 2005 in Instructional Course Lectures, Volume 54. The complete volume can be ordered online at www.aaos.org, or by calling 800-626-6726 (8 a.m.-5 p.m., Central time).
An Instructional Course Lecture, American Academy of Orthopaedic Surgeons

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2004 May 01;86(5):1078-1088
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Inadequate soft-tissue balancing is a major yet often underemphasized cause of failure of primary and revision total hip arthroplasty1-3. Accordingly, contemporary cemented and cementless hip prostheses have been designed with consideration of this issue, and this has substantially increased the long-term survival of total hip replacements4. The primary objective of this article is to provide the reader with an overview of the rationale, biomechanical principles, and clinical implications associated with soft-tissue balancing of the hip. The final section will address several strategies to avoid inadequate soft-tissue balancing. In particular, a systematic technique to restore adequate soft-tissue tensioning during total hip arthroplasty will be presented.
Figures in this Article


    femur ; hip joint ; limb ; neck

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Robert B. Bourne
    Posted on June 02, 2004
    Dr. Bourne responds:
    University of Western Ontario, London, Ontario, Canada

    To the Editor:

    I thank Dr. Anderson for his interest in our article, "Soft Tissue Balancing of the Hip. The Role of Femoral Offset Restoration". The purpose of our article was to re-emphasize the importance of considering femoral head offset restoration as well as leg length equalization during total hip replacement. Hopefully, we have properly addressed the advantages of getting both leg length and offset restoration just right during total hip replacement.

    We both seem to agree that use of a femoral component with a single neck shaft angle and with the option to use a standard or medialized neck can improve femoral head offset without adversely affecting leg length. The use of lateralized acetabular liners is indeed a little more controversial.

    I would agree that use of a lateralized liner increases not only leg length but also has the potential to lateralize the center of the hip joint. We actually only use lateralized liners in situations where the center of the hip joint is medialized (i.e. protrusio acetabular deformities) in an effort to place the center of rotation in the proper location.

    Thank you once again for your interest in our article and for your insightful comments.

    Sincerely, R. B. Bourne, MD, FRCSC

    D. Ron Anderson, MD
    Posted on May 21, 2004
    The biomechanical effects of "lateralized" or "offset" acetabular liners versus high offset stems.
    Southern California Permanente Medical Group

    To the Editor:

    A casual review of this Instructional Course Lecture may lead the reader to believe that using an offset liner is mechanically equivalent to using a high offset stem. Figure 8 incorrectly states "that a modular ‘offset’ or ‘lateralized’ liner increases the offset while preserving limb length".

    But from a biomechanical standpoint, these liners only translate the hip center laterally. They do not increase the offset (defined as the distance from the hip center to the long axis of the femur) as shown in Figure 1. While both techniques( increasing femoral offset or lateralizing the hip center) increase the tension in the soft-tissues, they have opposite effects on the forces across the articulation and on abductor tension. As pointed out in the text of the article, lateralizing the hip center with these liners actually produces the detrimental mechanical effects of increased joint reaction force and higher abductor tension.

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