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C OPYRIGHT Ó 2018 T HE AUTHORS . P UBLISHED BY T HE J OURNAL OF B ONE AND J OINT S URGERY, I NCORPORATED.

Current Concepts Review

Spine-Pelvis-Hip Relationship in the
Functioning of a Total Hip Replacement
Downloaded from https://journals.lww.com/jbjsjournal by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3fgGGXf0fUkCsUCQydWvpVC9A66FB0GVnw3Qly5IUez/wHgmoiOMCDQ== on 12/07/2018

Hiroyuki Ike, MD, Lawrence D. Dorr, MD, Nicholas Trasolini, MD, Michael Stefl, MD, Braden McKnight, MD, and
Nathanael Heckmann, MD

Investigation performed at the Department of Orthopaedic Surgery, Keck Medical Center of the University of Southern California,
Los Angeles, California

ä Spine-pelvis-hip motion is normally coordinated to allow balance of the mass of the trunk and hip motion with
standing and sitting.

ä Normal motion from standing to sitting involves hip flexion of 55° to 70° and pelvic posterior tilt of 20°. Because
the acetabulum is part of the pelvis, as the pelvis tilts posteriorly during sitting, the inclination and anteversion
increase (the acetabulum opens) to allow clearance of the femoral head and neck during hip flexion. This can be
considered the biological opening of the acetabulum.

ä Decreased tilt of the pelvis during movement occurs with stiffness of the spine. Loss of pelvic mobility forces hip
motion to increase to accommodate postural change. Increased hip motion combined with change in the opening
of the acetabulum increases the risk of impingement.

ä Hip stiffness can also reduce pelvic mobility because pelvic mobility is affected by both the spine and the hip.
Relief of hip stiffness with total hip replacement can improve pelvic mobility postoperatively.

ä For hip surgeons, the clinical consequences of changes in the mobility of the spine and pelvis (spinopelvic mobility)
can be impingement after total hip replacement, with the most obvious complication being dislocation. The
reported increased dislocations in patients with surgical spine fusions is a clinical example of this consequence.

Recent research on the functional anatomy of the hip has
increased our understanding of the interrelationship of the
spine, pelvis, and hip. The work of Lazennec et al. with EOS
Imaging (EOS, formerly biospace med) must be credited with
stimulating research in multiple centers over the last 15 years1-9.
This research has furthered our knowledge of the coordinated
motion of the spine-pelvis-hip joint during postural change
such as from lying to standing and from standing to sitting. It
has taught us that the pelvis tilts during postural changes, and
because the acetabulum is part of the pelvis, pelvic motion
changes the anteversion and inclination of the acetabulum as
patients move around (i.e., it does not remain in the position
achieved at the time of surgery) (Fig. 1). This change of the
acetabular angles is the reason Lazennec et al.1-3 discussed the
sagittal “functional” cup position in total hip replacement as
opposed to the coronal inclination and anteversion achieved at
surgery. The purposes of this Current Concepts Review were to
summarize the knowledge about the interaction among the
spine, pelvis, and hip as we know it and to discuss how this
knowledge might affect total hip replacement. As some terms

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with the online version of the article, one or more of the authors checked “yes” to indicate that the author had a relevant financial relationship in the
biomedical arena outside the submitted work (http://links.lww.com/JBJS/E882).

Copyright Ó 2018 The Authors. Published by The Journal of Bone and Joint Surgery, Incorporated. All rights reserved. This is an open-access article
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and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

J Bone Joint Surg Am. 2018;100:1606-15 d http://dx.doi.org/10.2106/JBJS.17.00403

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Fig. 1
Illustrations showing normal sagittal spine-pelvis-hip motion from standing to sitting. The illustration on the left shows the normal standing position. The
angles measured are sacral tilt (45°), which is an angle tangent to the end plate of S1 and a transverse line; pelvic incidence (55°), which is a measure of the
anterior-to-posterior dimension of the pelvis and is an angle formed by a line from femoral head to the center of the S1 end plate and a line tangent to the S1
end plate; pelvic femoral angle (180°) describes the position of the femur relative to the pelvis and is an angle formed by a line from the center of the S1 end
plate to the center of the femoral head and a second line that parallels the femoral diaphysis; and acetabular ante-inclination (35°), which is the sagittal
angle of the acetabulum to a transverse line representing the transverse axis of the body. The illustration on the right shows the normal sagittal spine-pelvis-
hip angles in the sitting position: the sacral tilt is 20° so there is 25° of posterior pelvic tilt; pelvic incidence (55°) is a static measurement so it remains the
same as standing; the pelvic femoral angle is 125° so there is 55° of hip flexion relative to the pelvis compared with the standing position; and ante-
inclination is 60° as the acetabulum opens more with both inclination and anteversion to allow clearance for the flexing femoral head. Table III has the
normal values for these measurements.

used with this new research may not be familiar to the ortho-
paedic surgeon, a glossary is provided in Table I.
What Is Normal Spine-Pelvis-Hip Motion?
The position of the spine, pelvis, and hip balances the mass of
the trunk above it, and the mobility of these articulations allows
for coordinated motion during activities such as moving from
standing to sitting or bending forward at the waist1,10,11. This
spine-pelvis-hip relationship can be captured on a lateral
radiograph that includes the L3 vertebra to the proximal part of
the femur1,4. The hip is influenced most by the lower 3 lumbar
vertebrae, so this is all of the lumbar spine that is included in
the radiograph5.
When standing, the pelvis is tilted anteriorly, the lumbar
spine is in lordosis, and the legs are extended (Fig. 1). This
balances the trunk above the pelvis, and positions the acetabu-
lum over the femoral head1,2,7 (Video 1). When sitting, the hip
does not simply flex 90°. Rather, the pelvis tilts posteriorly as the
spine becomes less lordotic, and the hip flexes (Fig. 1, Video 1).
The acetabulum is part of the pelvis so when the pelvis tilts the
acetabulum tilts as well. When the pelvis tilts posteriorly, there is
an increase in the anteversion and inclination of the acetabulum.
This change is termed the biological opening of the acetabulum
because it occurs during normal posterior tilt of the pelvis when
sitting. The sagittal acetabular angle viewed on the lateral spine-
pelvis-hip radiograph is termed ante-inclination because its angle
is affected by the changes in both anteversion and inclination4.
Lazennec et al.1 considered this sagittal cup position to be the
operative inclination described by Murray11; however, in a lab-
oratory study, Kanawade et al.4 showed that it was a combination
of inclination and anteversion and thus was named ante-
inclination to reflect both angles. The normal range for standing
ante-inclination has been reported to be 41° to 63° (mean and
standard deviation, 52° ± 11°)5.
The acetabular change as the pelvis tilts posteriorly
during sitting accommodates the necessary hip flexion and
internal rotation1,2,12,13. The posterior pelvic tilt from standing
to sitting is normally 20°, and the femur flexes only 55° to 70°
to accomplish sitting (Fig. 1, Video 1)1,12. Bending forward
from the waist to pick up an object on the floor requires
increased flexion of the hip to 85° combined with internal
rotation of 12°13. When a patient is supine, the pelvis tilts
anteriorly and the lumbar lordosis is increased from standing
by only 3° to 5°; thus, the average pelvic arc of motion from
lying down to standing is <5°, which is the reason why research
has focused on the movement from standing to sitting.
In normal patients, there is variance in the amount of
pelvic tilt, the degree of lordosis in the lumbar spine, and the
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TABLE I Glossary of Terms Used

Term Definition

Acetabular The biological opening is the increase of inclination and anteversion when the pelvis normally tilts posteriorly during
opening sitting. The mechanical opening is the inclination and anteversion created by the surgeon in a total hip arthroplasty.
Ante-inclination The sagittal angle of the acetabulum (or cup, with total hip replacement) that changes with the motion of the pelvis and
is so named because the angle is affected by a combination of the anteversion and inclination of the cup, as shown in
Figure 1.
Pelvic femoral The sagittal hip-femur position that is a measure of the flexion of the hip with sitting or in extension with standing in
angle relation to the pelvic position, as shown in Figure 1.
Pelvic incidence The static measurement of the relationship of the femoral heads to the sacral end plate as shown in Figures 1, 2-A, and
2-B and Table II.
Sacral tilt (slope) The dynamic motion of the spinopelvic structure is the mobility of the first sacral end plate and measures the sagittal tilt
of the pelvis during postural change as shown in Figure 1.
Spinal Abnormal spinal mobility due to hypermobility or stiffness.
imbalance
Spinopelvic Lumbar spine and pelvis that move together by the connection of the sacrum to the pelvis.
Spine-pelvis-hip The coordinated mobility of the spine, pelvis, and hip (including the proximal part of the femur), as seen in Video 1.
Stiffness Pathologic stiffness occurs when the dynamic mobility of the pelvis is effectively fused as indicated by a sacral tilt
mobility of <5°, which means that sagittal acetabular mobility is <5°. Surgical spinal fusions are a common cause of
pathologic stiffness. Dangerous stiffness occurs when sacral tilt mobility is £10° and is combined with a pelvis fixed either
posteriorly or anteriorly. With total hip replacement, dangerous stiffness is overcome by correct coronal cup position,
whereas pathologic stiffness is not improved by cup position.

location of the femoral heads underneath the spine. These
variations may be explained by differences in pelvic incidence,
an angle described by Legaye et al.14. It is a fixed measurement
of the anterior to posterior dimension of the pelvis (Philippot
et al. called it the anatomic parameter7) that determines the
position of the femoral heads in relation to the spine. It is for
this reason that spine surgeons use this measurement to
determine an optimal spinal fusion position. It is not known
why people have differences in standing pelvic tilt, and different
degrees of pelvic incidence, but this variance affects hip
motion. The 3 variants of pelvic incidence, and how they
change pelvic position and the hip or femoral position, are
shown in Figure 1 (normal pelvic incidence), Figure 2-A (high
pelvic incidence), and Figure 2-B (low pelvic incidence). The
difference in dynamic spine-pelvis-hip motion with each pelvic
incidence is shown in Table II.
While the pelvic incidence is a static measurement
unaffected by a pelvic change in position, the most reproduc-
ible measurement used to assess dynamic motion of the pelvis
(the positional parameter described by Philippot et al.7) is
sacral tilt (also called sacral slope)1,3-5,7. The sacral tilt is nor-
mally 40° while standing and decreases to 20° when sitting,
representing 20° of pelvic motion between standing and sitting.
The femur is extended relative to the pelvis when standing and
flexes in relation to the pelvis when sitting. The pelvic femoral
angle can be used to measure the position of the femur relative
to the pelvis when standing (180°) and sitting (125°), and
differences between the standing and sitting values can be used
to assess the dynamic motion of the femur. The normal values
for these commonly assessed measurements of spinopelvic
mobility are listed in Table III.
What Happens with Abnormal Spine-Pelvis-Hip Motion?
Because motion of the spine, pelvis, and hip is coordinated
during postural changes, any disease that affects the mobility of
one will often affect the others. If one part of a mobile segment
stiffens (i.e., reduced motion), then the other sections of the
segment must accommodate for this by becoming more
mobile. Orthopaedic surgeons have long understood that, after
a spine fusion, the vertebral segment cephalad to the fusion has
more stress because it must move more. This same stiff spine
can force the femoral side of the hip to flex more with sitting, or
extend more with standing, and this excessive hip motion can
cause impingement of the greater trochanter on the pelvis1,2,5.
The pelvis is connected to the spine by the lumbosacral
joint (the pelvis has been termed an accessory vertebra). The
motion of the spine and pelvis is called spinopelvic mobility, and
abnormal motion results in an unbalanced spine and pelvis1,2,4-8.
The patterns of spinopelvic mobility abnormalities have been
categorized by 2 studies5,6 into 2 types: too much motion
(hypermobility) and reduced motion (stiffness). Hypermobility is
defined as pelvic motion of ‡30° between standing and sitting.
Hypermobility may be a normal variant, and it is found mostly
in younger patients and women (Fig. 3-A). No adverse conse-
quences of hypermobility have been identified. Hypermobility
provides an advantage for patients because it requires less hip
motion during postural change, and therefore is associated with
the lowest risk of impingement. Hypermobility is considered to
be unbalanced when it is a result of the lumbar spine tilting into
kyphosis with sitting (the Stefl kyphosis5 or the Phan flexible and
unbalanced category6) (Fig. 3-B). The kyphosis pattern is repre-
sented by a seated sacral tilt of <10° and is considered severe when
<5°. This pattern is most commonly associated with 3 conditions:
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Fig. 2-A

Fig. 2-B

Figs. 2-A and 2-B These figures show the different morphologies for high and low pelvic incidence (PI; see Figure 1 for normal PI). Fig. 2-A Preoperative
standing and sitting lateral spine-pelvis-hip radiographs of a hip with high PI (73°) so the femoral heads are anterior to S1. This figure is also an example of a
patient who has fixed anterior tilt of the pelvis, so the sacral tilt (ST) is 44° with standing and 39° with sitting (sitting tilt must be <30° to qualify as posterior
tilt). Therefore, the acetabular ante-inclination (AI) with standing (57°) is high and with sitting (52°) is normal (but this is pathologic stiffness because the
difference is 5°). The standing pelvic femoral angle (PFA) is high at 201°, but posterior impingement does not occur because of fixed anterior tilt and the
anterior position of the femoral heads. Sitting PFA of 122° is normal. Fig. 2-B Postoperative standing and sitting lateral spine-pelvis-hip radiographs of a
patient with low pelvic incidence (PI = 35°) so the femoral heads are directly below S1. This is a typical radiograph for low PI, in which the hip is geometrically
fixed in posterior tilt (see Table II). This figure is also an example of pathologic stiffness because the change in sacral tilt (ST) motion is 3°. Likewise, the
change in ante-inclination (AI) mobility is 3° (38° to 41°) because this mirrors the ST. The pelvic femoral angle (PFA) is normal with standing but shows
increased flexion with sitting (109°), which is typical in patients with low PI because the femoral heads are posterior, and more flexion is needed to sit
because the pelvis has limited posterior tilt even when not stiff like this one. The intraoperative cup angles were an inclination of 45°, anteversion of 21°,
and combined anteversion of 33°, which keeps the head centered in both the standing and sitting positions, providing mechanical stability; however, if the
leg length and/or offset were shortened, this hip would have osseous impingement.

stiff hips that have flexion of £50°, which forces increased pos-
terior tilt of the pelvis during sitting; patients with a body mass
index (BMI) of >40 kg/m2, who have a large trunk mass that
forces increased posterior tilt of the pelvis with sitting to balance
their body8; and patients with neuromuscular imbalance2.
Spinopelvic stiffness is defined as £10° of motion at the
spine-pelvis junction between the standing and seated positions
(i.e., change in sacral tilt between standing and sitting positions)
(Figs. 2-A and 2-B). This immobility is almost always caused by
lumbar degenerative disc disease, facet spondylosis of the lumbar
spine, lumbar fusion, or ankylosing spondylitis1,7,8. Hip and spine
surgeons recognize that degenerative changes of the spine and
hip osteoarthritis commonly coexist. Two studies found that
approximately 40% of patients with hip osteoarthritis undergoing
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impingement. After total hip replacement, dislocation can

TABLE II Characteristics of Pelvic Incidence (PI)*
occur because of the loss of functional anteversion, resulting
Spinopelvic in anterior impingement.
Mobility Low PI Normal PI High PI If the stiffness is so severe that the spinopelvic motion
Sacral slope between sitting and standing is <5°, the spinopelivic junction
Standing 30.1° ± 8.0° 38.4° ± 7.2° 44.1° ± 11.1° is essentially fused, either biologically from degenerative
Sitting 14.4° ± 11.5° 18.5° ± 8.4° 23.2° ± 12.1° changes or surgically. Stefl et al.5 termed this condition
Change 14.3° ± 9.8° 20.3° ± 10.4° 22.4° ± 11.8° pathologic stiffness. As noted by Phan et al.6, this is an extreme
Pelvic femoral version of the rigid and unbalanced pattern, whereby the
angle immobile pelvis and acetabulum transfers all motion for
Standing 180.2° ± 9.1° 186.8° ± 9.0° 195.7° ± 10.0°
postural changes to the hip, creating the highest possible risk
Sitting 111.2° ± 14.0° 124.5° ± 12.9° 133.8° ± 12.7°
for impingement (Figs. 2-A and 2-B). The dangerous stiffness
Change 69.0° ± 17.1° 62.3° ± 13.5° 62.1° ± 13.2°
described by Stefl et al. is less severe because there is up to 10°
Ante-inclination
of spinopelvic motion (i.e., the difference between standing
Standing 33.7° ± 8.9° 34.1° ± 8.3° 35.6° ± 8.3°
and sitting sacral tilt is 5° to 10°), but this stiffness is often
Sitting 49.2° ± 12.4° 53.7° ± 8.8° 56.1° ± 8.6°
Change 15.5° ± 10.5° 19.6° ± 9.2° 20.5° ± 11.6°
present with a pelvis fixed in either posterior or anterior tilt.
In the next section, the consequences of these different pat-
*The values are given as the mean and the standard deviation. Hips with low PI terns of stiffness in relation to total hip replacement are
have a low standing mean sacral slope, which means that many hips with low PI addressed.
are fixed in posterior tilt as their normal pattern. Therefore, hips with low PI require
more flexion to sit, which is reflected in the low sitting pelvic femoral angle mean
of 111°. As PI progresses from low to high, the pelvis tilts more anteriorly with Clinical Consequences of Spinopelvic Imbalance
standing and the femoral heads move further anteriorly in the pelvis because the
spine has more lordosis. With high PI, the femur flexes less so the risk of The clinical consequences of spinopelvic imbalance can
impingement is less with high PI. It is important to note the PI of the patient because affect both the lumbar spine and the hip. The management of
the cup inclination and anteversion need to be adjusted for the flexibility of the
pelvis and femur. degenerative diseases of the intervertebral disc and of spinal
stenosis have been well described and are not the focus of our
review. This review focuses on newer research related to the
primary total hip replacement had degenerative disc disease of the relationship between spinopelvic alignment (and motion)
lumbar spine that was related to age5,8. In our patients, 30% of and negative outcomes following total hip replacement.
those who were <60 years old had radiographic stiffness of the Deleterious consequences are often the result of decreased
spine compared with 55% of those who were ‡60 years old. spinopelvic motion, and the only hypermobility imbalance
Stiffness can occur in 3 patterns as described by Stefl et al.5. In the to cause complications is the kyphosis pattern (i.e., the
first pattern, the pelvis tilts posteriorly from standing to sitting flexible and unbalanced pattern described by Phan et al.6)
£10°, such that the sacral tilt crosses a value of 30° (i.e., a sacral tilt (Figs. 3-B and 4). Lazennec et al. were the first, to our
of 34° while standing and sacral tilt of 26° while sitting). This knowledge, to describe the effects of spine and pelvic
pattern is characterized by decreased pelvic motion, but is not mobility on the hip, and we refer readers interested in this
fixed anteriorly or posteriorly. The second pattern, termed stuck subject to their studies1-3.
standing, is loss of posterior tilt when sitting so that the pelvis is Surgeons are accustomed to viewing the hip on standard
fixed in anterior tilt (sitting sacral tilt is >30°). In the study by anteroposterior radiographs, which assess the acetabulum in the
Phan et al.6, this pattern is called rigid and balanced (Fig. 2-A). In coronal plane. However, the use of lateral radiographs and the
the third pattern, termed stuck sitting, the pelvis is fixed in pos- assessment of sagittal motion of the hip during postural change
terior tilt and never tilts anteriorly with standing (standing sacral
tilt is <30°). Phan et al.6 called this pattern rigid and unbalanced
(Fig. 2-B). The patterns of fixed posterior tilt and fixed anterior TABLE III Normal Radiographic Spinopelvic Values*
tilt can be combined with marked stiffness of the pelvis, defined
Standing† Sitting† Change‡
as a <10° change in sacral tilt during postural changes, which
compounds these fixed patterns and increases the risk of Pelvic incidence 53° ± 11° 53° ± 11° –
impingement and dislocation. Sacral slope 40° ± 10° 20° ± 9° 11°-29°
There is a 0.8° change in acetabular anteversion for each Pelvic femoral angle 180° ± 15° 125° ± 15° 50°-75°
degree of pelvic tilt15 so the amount of functional anteversion
Ante-inclination 35° ± 10° 52° ± 11° –
can be calculated when sitting based on pelvic motion. Laz-
ennec et al.16 used computed tomography (CT) scans to 5
*Data are from Stefl et al. . †The values are given as the mean
measure 15.6° of increased acetabular anteversion with the and the standard deviation. ‡Change is the difference between
normal 20° of posterior pelvic tilt with sitting, which con- standing and sitting; pelvic incidence is a static anatomic mea-
firmed this calculation. Since the acetabulum anteverts more surement, so it does not differ between standing and sitting. The
other 3 measurements are dynamic (positional parameters) so
with sitting to contain the flexed and internally rotated fem- they differ between standing and sitting.
oral head, the loss of this anteversion increases the risk of
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Fig. 3-A

Fig. 3-B

Figs. 3-A and 3-B Illustrations of high and low pelvic incidence (normal pelvic incidence is shown in Figure 1). Fig. 3-A Illustration of high pelvic incidence
(70°) that often has hypermobility of sacral tilt (50° of sacral tilt with standing to 20° with sitting, which is 30° of motion). Pelvic femoral angle motion is from
184° to 155°, which is 29°, and is low because pelvic posterior motion is above normal. Fig. 3-B Illustration of kyphosis, or a flexible unbalanced hip, which
means the sacral tilt is posteriorly tilted to <5° and is 0° in this illustration. The spine tilts backward. This can occur with any pelvic incidence, so it is
inconsequential. With this amount of posterior tilt, the acetabular inclination and anteversion increase so much with sitting that the ante-inclination is very
vertical—in this illustration, it is 70° with sitting. Because no hip surgeon wants a cup at 70°, the dotted lines outline the ante-inclination of 50° if the
intraoperative cup angles are between 35° and 40° and anteversion is 15° to 20° (Table IV). With standing, the cup outline is 30°, with osseous ante-
inclination of 45°. The pelvic femoral angle moves from 210° to 135°.

are relatively new1-3. The consequences of spinal imbalance on
hip function in a nonarthritic hip have not been fully studied. It
has been suggested that patients with low pelvic incidence are at
greater risk for osseous impingement of the greater trochanter
on the ilium because more hip motion is routinely observed in
such individuals (Table II)3. In the past 5 years, research has
focused on the consequences of spinal imbalance after a total
hip replacement, so we focused on this area.
The interest in studying the sagittal cup position is, first,
to understand its relationship to the cup position seen on the
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Fig. 4
Postoperative lateral spine-pelvis-hip radiograph made with the patient
sitting shows a kyphotic pattern (sitting sacral tilt [ST] = 4°). The pelvic
incidence (PI) is 56°, which is normal. The sitting ante-inclination (AI) is
high (77°) because the pelvis has tilted posteriorly so much with a cup
that has coronal radiographic inclination of 54° and anteversion of 18°.
Dropout dislocation occurred in the first week postoperatively as the
patient sat in a deep soft couch and shifted position. The vertical cup
position provided no inferior mechanical block, so the head dropped out
(in biomechanical language, it exceeds its jump distance). The cup
inclination for a patient with lumbar kyphosis should be no more than
40° (Table IV).
anteroposterior radiograph and to determine if understanding
the sagittal cup position would be helpful in identifying the best
intraoperative cup position2,5,17,18. Second, the coronal cup
position has not been reliable in predicting postoperative dis-
location following total hip replacement, and thus there is
interest in whether the sagittal radiographs will be better. If the
sagittal view is better, then we need to understand the impact of
spinopelvic abnormalities that it may demonstrate. Phan et al.6
emphasized the influence of spinal imbalance on anteversion.
This is important because anteversion has been labeled as the
most important implant parameter6,19-21, and anteversion
changes substantially for each degree of pelvic change (as dis-
cussed above). In almost all such studies, investigators have
researched the potential for spinal imbalance to influence
impingement with total hip replacement1-9. Surgeons cannot
easily diagnose hip impingement following total hip replace-
ment because it is a clinical diagnosis, and no currently avail-
able imaging or computerized technique can reliably identify
impingement22. Dislocation is the most recognized conse-
quence of impingement. It occurs when the impingement,
either component or osseous, is severe enough that the
mechanical constraint of the implants, and the biological
constraint of the capsule and muscle tension, cannot prevent
escape at the egress site19. A second cause is when the cup
position is too vertical, and impingement occurs with excessive
hip flexion so that the femoral head has no cup constraint
inferiorly and may dislocate posteriorly (Fig. 3-B)19,23. In
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biomechanical terms, the head has exceeded its jump dis-
tance23. In primary total hip replacement done by experienced
surgeons, the cup inclination and anteversion are maintained
within a 10° range, and stability and wear are optimal20,24. The
dislocation is more commonly caused by decreased leg length
or offset25. The association between dislocation and coronal
cup position has been unpredictable26.
In primary hip replacement, the highest risk for
impingement from spinal imbalance is pathologic stiffness
(rigid and unbalanced hips, according to Phan et al.6). The
effect on total hip replacement stability in the presence of a
spinal fusion, which creates this imbalance, has been stud-
ied27-29. These investigations all noted a higher rate of dislo-
cation in patients with fused spines. The patients with a fused
spine provided the clearest data to date on the impact of
spinal imbalance on impingement. However, other compli-
cations also occur because of impingement. Pain is a known
consequence of impingement but may be difficult to iden-
tify30; wear debris and fluid collections around the joint may
be caused by impingement and may be destructive31,32; and
loosening of components may occur from severe impinge-
ment, which may explain the recent findings of loosening of
the femoral components at 3 to 5 years after the direct
anterior approach33,34.
The coronal cup position implanted at surgery directly
influences the sagittal cup position (ante-inclination) mea-
sured on the lateral spinopelvic radiographs. It is possible that
sagittal cup measurements can provide a more predictable
“safe zone” for optimal cup position (the combination of
anteversion and inclination) than coronal safe zones such as
those described by Lewinnek et al.35. As long ago as 1990,
McCollum and Gray, in their study on dislocation, recom-
mended lateral radiographs of the cup36. Further research and
validation is necessary before that can be accepted in routine
clinical practice; however, research has been done to deter-
mine coronal cup positions that keep the cup angle in the
normal sagittal range10,17,18. Multiple studies have shown that
normal spine-pelvis-hip mobility (flexible and balanced ac-
cording to Phan et al.6) can have a wider range of coronal cup
positions without failure from instability10,24,26,37; however, a
component range of 10° seems optimal (Table IV). A 10°
range duplicates the findings in the laboratory that were
ideal for stability and wear20. In addition, McCarthy et al.38
showed that, for functional activities such as bending,
low sitting, and squatting, a smaller safe zone than that
described by Lewinnek et al.35 is required. One problem with
accepting cups outside even the broad zones described by
Lewinnek et al. is that, although the cups have been tested for
instability26, there have been no studies, to our knowledge,
on the longevity of cups outside this zone. Goyal et al.24 re-
ported dislocation and adverse wear in 1% of their patients at
12 years after total hip arthroplasty performed by experi-
enced surgeons. However, data from high-volume centers
with skilled surgeons are not always consistent with data
from the larger orthopaedic community, which have shown
that 15.8% to 32.4% of patients were readmitted because of
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TABLE IV Ideal Cup Position by Spinopelvic Mobility*
Combined
Inclination Anteversion Anteversion
Normal 35°-45° 15°-25° 25°-45°
Stiff 45°-50°† 20°-25° 35°-45°
Kyphotic 35°-40° 15°-20° 25°-35°
Hypermobile 35°-40° 12°-20° 25°-35°
*Cup anteversion is dependent on combined anteversion, which
must be higher for stiff imbalance and lower for hypermobile
hips to keep sitting ante-inclination within its normal range. In
hips that are retroverted, it is difficult to achieve cup antever-
sion exceeding 12° to 15° so combined anteversion becomes
critical in achieving stability for those hips. The range for each of
these patterns is within 10°, and it is difficult to achieve this
precision at surgery without some form of navigation. However,
these would be the ideal coronal cup angles for these patterns to
keep the sagittal ante-inclination in its normal range. Total hip
replacement has done so well for so many years because these
cup angle numbers are within the cup positions that most sur-
geons strive to achieve at surgery. †Inclination of 50° is reserved
for elderly patients.
dislocation after primary total hip replacement39-41. Disloca-
tion also ranks as the second most common mechanical cause
of revision after primary total hip replacement, with a rate of
12.2% of revisions39. In addition, the increased prevalence of
dislocations after total hip replacement in patients with a
spinal fusion provide the basis for the development of a
sagittal “safe zone.”27-29 Therefore, orthopaedic surgeons need
to gain further insight into the spine-pelvis-hip relationship
to minimize such cases of postoperative instability.
For new meaningful safe zones to be recommended, we
need studies that assess the stability and survival of acetabular
cups placed outside the currently recommended ranges of
inclination and anteversion. Until those data are available, the
cup positions currently suggested for the different spinal
imbalances can be used (Table IV). For patients with stiff
spinopelvic motion, the acetabular cup requires more coronal
inclination and anteversion; and, for hips with hypermobility,
the cup needs less coronal inclination and anteversion. Primary
total hip replacement has been successful because surgeons
have targeted cups at 40° to 45° of inclination and 15° to 20° of
anteversion, and these positions keep the cup in the sagittal safe
zone even with most spinopelvic abnormalities. Stefl et al.5
observed dislocations when cup inclination was <35° and/or
anteversion was <15°, and Tang et al.17 observed cup coverage
deficiencies at these low angles.
An important confounding factor to consider when
including spinopelvic mobility into preoperative planning
for primary total hip replacement is that the postoperative
spinopelvic mobility may change from the preoperative
mobility9,42-44. One reason for this postoperative change is
that the preoperative contractures of the hip, which reduce
its motion, affect the pelvic mobility, and after these con-
tractures are released at surgery, the postoperative mobility
S P I N E - P E LV I S -H I P R E L AT I O N S H I P IN THE FUNCTIONING OF A T O TA L
HI P REP LACE MEN T
of both the hip and the pelvis may change. The preoperative
measurements of sacral tilt may change as much as 20°
postoperatively9,42,44. In patients with normal spine-pelvis-
hip mobility, Sariali et al.44 found an average change of 5°
with standing and 3° with sitting after total hip replacement;
however, 46% of patients while standing and 33% of those
sitting had a change of >5°. What has not been determined
is how often these changes cause the sagittal position of
the cup to fall outside its normal ante-inclination range. In
other words, the change in pelvic mobility may be clinically
insignificant if it does not force the sagittal cup position out
of its normal range. Future research to establish the clinical
relevance of the relationship between the change in post-
operative pelvic mobility and the sagittal cup position is
required. If this research validates the sagittal cup position as
a predictable measure of hip stability, it will be of benefit to
hip surgeons and their patients.
The impact of spinal imbalance is greatest with revisions,
with late dislocations, and in elderly patients. The rate of dis-
location resulting in readmission was reported to be 4.4% after
revision total hip replacement compared with 0.7% after pri-
mary total hip replacement in 1 study39. In our study of patients
10 years after primary total hip replacement, 60% of the
patients had spinal stiffness compared with 20% of those
undergoing primary total hip replacement5,45. This is consistent
with the findings of Tamura et al.46 and Okanoue et al.47 , who
both found increased tilt of the pelvis 10 years after primary
total hip replacement. Dislocation following revision surgery
and late dislocations following primary total hip replacement
are more often affected by spine disease as these complications
are more likely to occur in older patients8,45-48. In our unpub-
lished data from 20 late dislocations, we found that 18
patients had spinopelvic stiffness as well as soft-tissue changes
that combined to cause unstable impingement. In our
patients who had late dislocation, the most common imbal-
ance was fixed anterior tilt and stiffness (i.e., stuck standing or
rigid and unbalanced) that resulted in posterior dislocation.
These older patients had spinopelvic changes that were fixed
with no postoperative change in sacral tilt after revision
surgery. These patients commonly have soft-tissue weak-
ness—capsular laxity and muscle weakness, especially of the
abductors—that, when combined with an unbalanced spine,
creates a high risk for dislocation48. In most of these patients,
we use constrained liners or dual mobility articulations at
revision total hip replacement to enhance the mechanical
stability of the articulation.
We suggest that standing and sitting lateral spine-pelvis-
hip radiographs be made before surgical treatment involving
revision total hip replacement, especially for acute or late
dislocation, and primary total hip replacement in patients with
spinal fusion or known spine disease (Table IV). In patients
with severe spinopelvic stiffness, the surgeon must pay
attention to the cup position and consider increased constraint
of the articulation. When surgical fusions of the lower lumbar
spine are present, awareness of the increased risk of dislocation
should prompt the surgeon to pay close attention to cup
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position as well as biomechanical reconstruction of offset and
hip length and to consider the use of constraint or a dual
mobility articulation. n
NOTE: The authors thank Patricia Paul for manuscript preparation, Michael Smith for audiovisual
assistance, and Dr. Russell Bodner for contributions to the concepts discussed in this manuscript.
Hiroyuki Ike, MD1
Lawrence D. Dorr, MD1
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Nicholas Trasolini, MD1
Michael Stefl, MD1
Braden McKnight, MD1
Nathanael Heckmann, MD1
1Department of Orthopaedic Surgery, Keck School of Medicine of the
University of Southern California, Los Angeles, California
E-mail address for L.D. Dorr: patriciajpaul@yahoo.com
ORCID iD for L.D. Dorr: 0000-0002-9664-2416
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