HIP

 
A systematic approach to the hip-spine
­relationship and its applications to total hip
arthroplasty

N. Eftekhary,
A. Shimmin,
J. Y. Lazennec,
A. Buckland,
R. Schwarzkopf,
L. D. Dorr,
D. Mayman,
D. Padgett,
J. Vigdorchik
From Division of
Adult Reconstructive
Surgery, NYU Langone
Orthopedic Hospital,
NYU Langone Health,
New York, New York,
United States
Correspondence should be
sent to J. Vigdorchik; email:
jvigdorchik@gmail.com
©2019 The British Editorial
Society of Bone & Joint Surgery
doi:10.1302/0301-620X.101B7.
BJJ-2018-1188.R1 $2.00
Bone Joint J
2019;101-B:808–816.
There remains confusion in the literature with regard to the spinopelvic relationship,
and its contribution to ideal acetabular component position. Critical assessment of the
literature has been limited by use of conflicting terminology and definitions of new
concepts that further confuse the topic. In 2017, the concept of a Hip-Spine Workgroup
was created with the first meeting held at the American Academy of Orthopedic Surgeons
Annual Meeting in 2018. The goal of this workgroup was to first help standardize
terminology across the literature so that as a topic, multiple groups could produce
literature that is immediately understandable and applicable. This consensus review from
the Hip-Spine Workgroup aims to simplify the spinopelvic relationship, offer hip surgeons a
concise summary of available literature, and select common terminology approved by both
hip surgeons and spine surgeons for future research.
Cite this article: Bone Joint J 2019;101-B:808–816.
In their landmark paper from 40 years ago, Lew- the American Academy of Orthopedic Surgeons
innek et al1 defined a ‘safe zone’ for acetabular Annual Meeting in 2018. The goal of this work-
component position, a range of abduction and ante- group was to first help standardize terminology
version angles, within which the authors showed a across the literature so that as a topic, multiple
lower dislocation rate than values outside of this groups could produce literature that is immedi-
zone. Component position was assessed on a sin- ately understandable and applicable. This consen-
gle supine anteroposterior (AP) pelvis radiograph sus review from the Hip-Spine Workgroup aims
with the x-ray beam perpendicular to the anterior to simplify the spinopelvic relationship, offer hip
pelvic plane (APP). This radiograph is a static surgeons a concise summary of available litera-
representation of acetabular orientation. Data col- ture, and select common terminology approved by
lected from these momentary snapshots of pelvic both hip surgeons and spine surgeons for future
position proceeded to guide hip surgeons for the research.
next 40 years.
A now-recognized shortcoming of a protective Background
safe zone that is defined from a single radiograph Despite widespread implementation of a universal
is that it assumes that the acetabular component is safe zone as proposed by Lewinnek et al,1 sev-
constant and static. However, defining an updated eral authors have recently demonstrated that the
acetabular orientation target 40 years later requires Lewinnek safe zone may not be appropriate for all
an understanding of the dynamic relationship patients. Abdel et al2 demonstrated that in a cohort
between the hip joint, the spine, and the pelvis, as of 9784 patients with an overall dislocation rate
well as the alterations in posture and the effect of of 2.1%, 58% of dislocations occurred despite the
that relationship upon total hip arthroplasty (THA) acetabular components being placed within Lewin-
stability. nek’s safe zone,1,2 with a mean acetabular abduc-
Due to the difficult nature of this topic, and a tion angle of 44° and mean anteversion of 15°.
disconnect in recent years between hip and spine Esposito et al3 similarly demonstrated that in
surgeons, there remains confusion in the literature a population of 7040 primary THA with a 2.1%
with regard to the spinopelvic relationship and its dislocation rate, there was no difference in abduc-
contribution to ideal acetabular component posi- tion and anteversion angles between dislocators
tion. Critical assessment of the literature has been and non-dislocators. Furthermore, patients with
limited by use of conflicting terminology and defi- acetabular components deemed unsafe by con-
nitions of new concepts that further confuse the ventional analysis may have fully stable hips,
topic. In 2017, the concept of a Hip-Spine Work- while patients with ‘normal’ standing acetabular
group was created with the first meeting held at orientation can have significant instability issues.4

808 THE BONE & JOINT JOURNAL

 A systematic approach to the hip-spine ­relationship and its applications to total hip arthroplasty 809
Fig. 1a
This figure demonstrates measurement of the anterior pelvic plane tilt (APPt) and spinopelvic tilt (SPT) in a) standing and b) sitting postures. APPt
is defined as the angle between the vertical and a plane connecting the midpoint of the two anterior superior iliac spines with the pubic symphysis.
SPT is defined as the angle between the vertical and a line connecting the centre of the femoral heads with the centre of the S1 endplate.
In addition, the literature has been confusing, as Lewinnek et al1
used the radiological definition of acetabular component ante-
version, while most other papers use CT scan measurements
of anteversion. While classical literature was focused on the
anatomical definition of acetabular component anteversion,
a conceptual breakthrough was represented by the concept of
‘functional anteversion’. In this new paradigm, the pelvis is
considered a mobile unit (like a vertebra) allowing more or less
anterior opening of the acetabulum.
The spine and pelvis have a complex and dynamic relation-
ship that can greatly affect hip stability following THA. Obtain-
ing a stable THA, particularly in patients with pre-existing spine
pathology, is dependent upon an understanding of spinopelvic
parameters and compensatory mechanisms in patients with
abnormal spinopelvic movement.
Defining the problem
A number of aetiologies exist for dislocation following THA.
These include patient-specific factors such as female sex,
developmental dysplasia of the hip or post-traumatic diag-
noses, alcoholism, and neurological impairment, as well as
surgery-­related factors like component malposition, femoral
head size, surgical approach, impingement, abductor muscle
dysfunction, and revision surgery. Even with these identified
risk factors for dislocation, in one study, the cause of disloca-
tion could not be determined in 17% of patients.5 Other authors
have suggested that due to advances in modern implants, most
atraumatic dislocations actually occur from altered spinopel-
vic kinematics that lead to a functionally unsafe acetabular
position.6,7
Degenerative spine and hip pathology often coexist,8-10
with 3.5% of THA patients undergoing prior spinal surgery.11
Patients with a stiff spine or spinal fusion have been shown to
be at increased risk for instability after THA.12,13 It is important
VOL. 101-B, No. 7, JULY 2019
Fig.1b
to recognize that spinal stiffness is not only in patients with a
fused spine; a degenerative spine can be stiff as well. Both a
stiff degenerative spine and a fused spine can behave in a sim-
ilar manner. Clearly, the interplay between the spine and pel-
vis is a dynamic one, and spinopelvic movement can have a
significant effect on functional acetabular orientation and THA
stability. THA dislocation rates are increased in patients with
a stiff spine. One study noted a 1.55% dislocation rate in THA
without previous spinal fusion, a 2.73% dislocation rate in short
spinal fusions (one to two levels), and a 4.62% dislocation rate
in fusion of three or more intervertebral disc levels.14
Multiple studies have confirmed the increased dislocation and
revision rates in patients with adult spinal deformity,15,16 non-­
instrumented spinal disease,13 fixed spinopelvic alignment,17
and previous lumbar fusion.12,14,15,18-22 There are published dis-
location rates between 2.73% and as high as 20%, with reported
relative risk for dislocation somewhere between 1.62-fold and
seven-fold.12-14,16,19,21,23 Multiple studies have also demonstrated
that the relative risk of revision THA in patients with spinal
disease is at least 62% higher and up to 700% higher than in a
primary THA population without spinal disease.12-14,21,22
Spinopelvic parameters simplified
In an effort to better define the spinopelvic relationship, the hip
arthroplasty surgeon must first understand relevant spinopelvic
alignment parameters. Currently, many parameters have been
described and their use is not standardized. Specifically, there are
terms that hip surgeons use that spine surgeons do not, and vice
versa. We will attempt to summarize key terms here, and then
further in the manuscript, demonstrate how to use these terms.
Spine surgeons measure pelvic tilt (PT) in a different way
than hip surgeons. Therefore, PT is a catch-all term used to
describe pelvic rotation in the sagittal plane, which we will dis-
cuss further below.
810 N. Eftekhary, A. Shimmin, J. Y. Lazennec, A. Buckland, R. Schwarzkopf, L. D. Dorr, D. Mayman, D. Padgett, J. Vigdorchik 

Fig. 2

The functional pelvic plane (FPP) is the same as the coronal plane of the body and can be defined in both supine
and standing positions. APP, anterior pelvic plane; ASIS, anterior superior iliac spine.

Hip surgeons have defined PT from the APP in an effort to
enable reference to the pre-existing acetabular component safe
zone as defined by Lewinnek et al.1 The APP is defined by three
anatomical landmarks on a lateral radiograph: the two ante-
rior superior iliac spines (ASIS) and the pubic symphysis. The
angle created between the APP and the vertical or horizontal is
defined as APP tilt (APPt), which is also frequently found in the
literature as APP pelvic tilt (APP-PT) (Fig. 1). In a study of 138
consecutive patients undergoing THA, Maratt et al24 noted a
mean preoperative supine APPt of 0.6° (sd 7.3°; 19.0° to 17.9°).
Spine surgeons define PT differently and use the term
spinopelvic tilt (SPT), which is the angle on a lateral radiograph
between a line from the centre of the S1 endplate and the centre
of the segment between the two femoral heads (the bicoxofem-
oral axis) and the vertical (Fig. 1).
The functional pelvic plane (FPP) is the same as the coronal
plane of the body and can be defined in both supine and stand-
ing positions (Fig. 2).
Both the SPT and the APPt allow for measurement of pelvic
movement between sagittal postures and are frequently used to
quantify pelvic mobility. SPT and APPt can both be measured
in standing or sitting postures.
Regardless of the method of PT measured, the pelvis can
rotate anteriorly or posteriorly in the sagittal plane. The work-
group would like to avoid using the following terms: pelvic ante-
version/retroversion, pelvic flexion/extension, and positive or
negative tilt or rotation. Pelvic retroversion/extension/negative
tilt is a posterior rotation of the pelvis around the femoral heads,
Follow us @BoneJointJ
while pelvic anteversion/flexion/positive tilt is an anterior rota-
tion of the pelvis. Importantly, pelvic retroversion/extension/
negative tilt can lead to anterior acetabular opening and thus an
increase of functional acetabular anteversion, while pelvic ante-
version/flexion/anterior tilt can decrease acetabular opening and
thus decrease functional acetabular anteversion.25 Therefore, we
would like to propose using the terms anterior PT (ASIS rotate
anteriorly) and posterior PT (ASIS rotate posteriorly).
Another parameter used for assessing pelvic rotation is the
sacral slope (SS). This is the angle between a horizontal ref-
erence line and a line parallel to the superior endplate of S1
(Fig. 3). In fact, PT and SS have an inverse relationship in
spinopelvic kinematics, with a 1° increase in SPT or APPt cor-
relating directly with a 1° decrease in SS.
These three parameters, the APPt, SPT, and the SS, are three
different ways to assess spinopelvic kinematics and pelvic rota-
tion between postures. It is yet to be determined which provides
the most value, but all are inter-related and give similar infor-
mation. We feel that SS is the easiest to calculate and easiest
to use when judging mobility from the standing position to the
sitting position.
SPT and SS are connected by a third parameter known as
pelvic incidence (PI). This is not commonly used by hip arthro-
plasty surgeons. PI is a morphological parameter that does not
change with spinopelvic movement or with spinal degeneration
and remains constant throughout adulthood. PI is defined as
the angle between a line drawn from the centre of the femoral
heads to the centre of the S1 endplate, and another line drawn
THE BONE & JOINT JOURNAL
 A systematic approach to the hip-spine ­relationship and its applications to total hip arthroplasty 811

Fig. 3a Fig.3b

a) The standing lateral and b) sitting lateral images are analyzed for functional changes in pelvic
tilt as measured via changes in sacral slope (SS). SS is defined as the angle between the horizon-
tal and a line parallel to the S1 endplate.

Fig. 4a Fig.4b

This figure demonstrates measurement of pelvic incidence (PI) while a) standing and b) sitting. Because this morphological parameter remains con-
stant, there is no change between standing and sitting. PI is defined as the angle between one line connecting the centre of the femoral heads and
the centre of the S1 endplate, and a second line perpendicular to the S1 endplate.

perpendicular to the S1 endplate (Fig. 4). Average PI is 52° (25°
to 100°).26,27
PI is related to SS and SPT by the following formula:
PI = SPT + SS. In spinopelvic movement, PI remains constant
and a change in SPT must be accompanied by an inverse change
in SS, which is directly correlated to changes in lumbar lordo-
sis.28,29 Lumbar lordotic angle (LLA) is the angle between a line
drawn at the superior endplate of L1 and another line drawn at
the superior endplate of S1 (Fig. 5).
Anteinclination is a dynamic measurement of the opening of
the acetabulum as the pelvis tilts posteriorly30 and is the same
as ‘operative anteversion’ as described by Murray.31 This is per-
haps best understood as the sagittal inclination of the acetabular
component. Anteinclination is measured on a lateral radiograph

VOL. 101-B, No. 7, JULY 2019

812 N. Eftekhary, A. Shimmin, J. Y. Lazennec, A. Buckland, R. Schwarzkopf, L. D. Dorr, D. Mayman, D. Padgett, J. Vigdorchik
Fig. 5a
Lumbar lordosis is calculated as the angle between a line drawn at the superior endplate of L1 and another line drawn at the superior endplate of S1:
a) the standing and b) supine lateral radiographs demonstrate an expected decrease in lumbar lordosis when going from standing to seated.
as the angle between the horizontal and a line connecting the
anterior and posterior walls of the acetabulum.30 Multiple stud-
ies have attempted to define normal anteinclination in standing
(mean 35° (sd 10°)) and sitting (mean 52° (sd 11°)).30,32
Spinopelvic movement and compensatory
­mechanisms explained
Acetabular orientation is a fluid and dynamic parameter and
can be affected in multiple planes. Any force that acts upon the
pelvis can affect acetabular orientation, including SPT, obliq-
uity, and rotation. These forces can originate from the spine
(alignment), hip (muscle weakness or joint degeneration), or
below the hip (leg-length discrepancy).30,33-37 Of these parame-
ters, sagittal pelvic rotation (i.e. anterior or posterior PT) has the
most predictable effect on acetabular orientation but has been
currently poorly understood by many hip arthroplasty surgeons.
When a patient with a normal spine moves from standing
to a relaxed seated posture, the pelvis tilts posteriorly (and SS
decreases) (Fig. 6). This postural change increases acetabu-
lar anteversion and, therefore, anterior clearance to allow the
proximal femur to flex more. This protective mechanism can
therefore decrease the risk of impingement and posterior THA
dislocation when in a relaxed seated position. The change in PT
(or SS) between standing and sitting is unique to each patient,
with a normal expected difference of between 20° and 35° of
posterior PT when sitting.30,35,37,38 For each degree change in PT,
the surgeon can anticipate a concomitant increase in antever-
sion of approximately 0.7° or 0.8°.24,37,39
In a ‘stiff’ spine as a result of degeneration, flatback (i.e. sag-
ittal imbalance with a loss of lumbar lordosis), or prior fusion,
there is less change in PT between standing and sitting (Fig. 7).
Follow us @BoneJointJ

Fig.5b
Of particular concern is the patient with a stiff spine who has
either no change in PT or a paradoxical anterior change in PT
when going from standing to sitting. In a stiff spine, the protec-
tive movement of posterior PT (and thus increasing functional
acetabular anteversion) when sitting is reduced or altogether
eliminated, increasing the risk of anterior impingement and
posterior dislocation.40 As shown by Esposito et al,41 patients
with degenerative spinal disease demonstrate decreased poste-
rior PT when sitting. These patients must, therefore, compen-
sate with increased femoroacetabular (hip joint) flexion. Due
to their pathology, these patients are limited in their ability
to posteriorly tilt the pelvis when sitting and must, therefore,
increase hip flexion while seated to compensate, further con-
tributing to these patients’ increased risk of dislocation after
THA.
Patient evaluation
As a consequence of the individual variability in spinopelvic
parameters described above, different patients will have a dif-
ferent ideal acetabular component position; there cannot be one
safe zone that will suit all patients. It is possible with a thorough
systematic preoperative evaluation to identify patients who may
be at risk of extreme sagittal pelvic movement and hence be at
higher risk of edge-loading and dislocation.
Further preoperative radiological evaluation can reveal the
presence of spinal deformity and postural changes in pelvic
rotation that change the functional acetabular version and incli-
nation.42 As a consequence of this evaluation, the surgeon may
recognize that implanting acetabular components based upon
conventional techniques or anatomical landmarks, such as the
transverse acetabular ligament or the anterior/posterior wall,
THE BONE & JOINT JOURNAL
 A systematic approach to the hip-spine ­relationship and its applications to total hip arthroplasty 813

Fig. 6a Fig.6b

A normal change between standing and sitting is demonstrated in a patient indicated for upcoming THA: a) the patient has a n­ ormal
spinopelvic tilt (SPT) when standing; and b) demonstrates an appropriate increase in SPT when going to the seated position.

Fig. 7a Fig.7b

A patient who has undergone previous spinal fusion and total hip arthroplasty. The black line over the S1 endplate represents sacral slope
(SS). There is only a small change in SS when going from a) standing to b) sitting in this patient with pre-existing spinopelvic pathology.

may yield an acetabular anteversion or inclination that is within
a previously defined safe zone but unsafe and inappropriate for
that particular patient’s spinopelvic mechanics/mobility.43
Several studies have recommended standing and sitting lat-
eral radiographs to evaluate for spinopelvic imbalance, espe-
cially in the setting of spinal disease, previous spine surgery, or
THA instability.29,30,32,44 Particularly in these settings, members
of the Hip-Spine Workgroup obtain a supine AP pelvis radio-
graph, a standing AP pelvis, and standing and sitting spinopel-
vic views (pelvis including the lumbar spine L1 to L5). The AP
and lateral radiographs can be normal flat-plate radiographs or
stereoradiographs (EOS Imaging, Paris, France). A high-­quality
standing AP radiograph is obtained with the patellas facing
forward, while high-quality lateral imaging is obtained with
overlap of the left and right ASIS. Because stereroradiographic
imaging may not currently be available to most surgeons, stand-
ard 36-inch cassettes are sufficient.30
The lateral images taken in the seated position mentioned
above can either be in a ‘relaxed’ seated position or a ‘flexed’
seated position, mimicking the movement of getting up from a
chair, which is the position most frequently implicated in pos-
terior THA dislocations. Pierrepont et al45 and Shah et al46 rec-
ommend using the flexed seated position to evaluate functional
flexion, as the flexed torso forces the pelvis to tilt anteriorly.
This represents the position during which posterior edge-­
loading47 or anterior impingement and posterior dislocation are
more likely to occur.45
The authors of this article recommend that at a minimum,
the lumbar spine and spinopelvic movement are systematically
evaluated preoperatively in patients with an apparent differ-
ence between the supine and standing AP pelvis radiograph
(discussed below), in patients with known or suspected spinal
disease or prior spinal surgery, and prior to revision THA for
instability, with the following goals in mind. However, admit-
tedly, we acknowledge a limitation of these recommendations.
A number of authors in the workgroup are prospectively eval-
uating these interventions, obtaining the appropriate number of
patients and follow-up to demonstrate a significant decrease in
the instability rate with these measures. To date, their experi-
ence with these interventions is still unpublished. We humbly

VOL. 101-B, No. 7, JULY 2019

814 N. Eftekhary, A. Shimmin, J. Y. Lazennec, A. Buckland, R. Schwarzkopf, L. D. Dorr, D. Mayman, D. Padgett, J. Vigdorchik
agree with the authors of a recent current concepts review on
the topic48 that if and when upcoming research validates the
sagittal acetabular component position as a reliable predictor
of hip stability, the benefit will be great to both patients and
surgeons alike.
Goal 1. Identify the patient with a spinal deformity: 1) The
supine AP pelvis is compared with the standing AP pelvis for
any apparent differences in PT, obliquity, or rotation. A change
in PT is noted if the standing AP pelvis appears to be more of an
inlet or outlet pelvis when compared with the supine AP pelvis.
A change in pelvic obliquity (the cephalad-caudad position of
the iliac crests) or pelvic rotation (as evidenced by asymme-
try of the obturator foramen and iliac wings) may be sugges-
tive of scoliosis, leg-length discrepancy, or abductor muscle
contracture.
2) The standing lateral spinopelvic radiograph is evalu-
ated for anterior or posterior PT as determined by the APPt.
Although much variability exists in this parameter, assessing
for PT can unmask spinal deformity, the clinical significance of
which is explained in goal 3.
Goal 2. Identify the patient with spinal stiffness: 1) Standing
lateral spinopelvic radiographs are evaluated for the presence
of spinal fusion, degenerative disc disease, spondylolisthesis,
or flatback deformity.
2) The standing and sitting lateral images are compared for
functional changes of APPt, SPT, and SS (changes < 20° are
considered stiff).30 Again, we feel that SS is the easiest to calcu-
late and easiest to use when judging changes from the standing
position to the sitting position.
Goal 3. Adjust acetabular position based on the above goals 1
and 2: 1) In patients with spinal deformity whose pelvis tilts
posteriorly from the supine to the standing AP pelvis radio-
graph, less anteversion is suggested to prevent anterior dislo-
cation when standing. This is because posterior PT creates an
increase in functional anteversion; every 1° change in poste-
rior PT leads to a 0.8° increase in anteversion.35 The angle that
should cause concern is not a specific number for APPt, but
rather, the change from one position to another. Other authors
have defined excessive change in PT as 13°, as this correlates
to a 10° change in version.49 For example, consider a patient
with 25° of anteversion on the supine AP pelvis radiograph. If
there is 20° of posterior PT change on the standing lateral radio-
graph, the acetabular component will functionally be 41° (25 +
20 × 0.8). These patients need to be identified preoperatively
to minimize the risk of posterior impingement and anterior
edge-loading/dislocation.
2) In patients with anterior PT when standing, it needs
to be determined whether this is the result of a hip flexion
contracture or true spinal deformity. If a flexion contracture,
this may resolve to some degree after THA and, therefore,
anatomical positioning is acceptable. The authors assess for
hip flexion contracture in the supine position by flexing the
contralateral hip and knee to 90°, then maximally extending
the affected hip. Any persistent hip flexion in this position is
indicative of a hip flexion contracture. If spinal deformity,
increased anteversion is suggested. Patients with stiff spines
will have less posterior PT when moving from standing to the
relaxed seated position. These patients need to be identified
Follow us @BoneJointJ

preoperatively as they will require increased anteversion to
accommodate femoral flexion when sitting. A particular chal-
lenge is the patient who tilts posteriorly when standing but
has little posterior PT when going from standing to seated, as
this patient has a very narrow range of anteversion that will
prevent seated impingement while not causing anterior insta-
bility while standing. Currently, we believe the goal degrees
of anteversion in the relaxed seated position is 30° planned
to the FPP.
Risk classification
There are multiple ways to classify the hip-spine relation-
ship and what defines an at-risk scenario for hip arthroplasty
patients, but the literature and terminology can be confusing.
Langston et al49 classify patients based upon their risk of
compromise to THA function in flexed (seated) or extended
(standing) postures. They define independent risk factors for
extreme changes in functional acetabular component position
(> 10°).
The independent risk factor creating risk in flexion (i.e. pos-
terior edge-loading or instability) is a stiff spine as defined by a
change in LLA of < 20° when moving from standing to a flexed
seated position. This holds true for both men and women.49 The
independent risk factors creating risk in extension are: stand-
ing posterior PT of greater than 10° (APPt < -10°); and women
over 75 years old, likely a consequence of thoracic kyphosis
and subsequent posterior femoral rotation to maintain sagittal
balance.49
Phan et al50 classify patients by the flexibility of the spinopel-
vic segment and by whether the spinal deformity is balanced,
in an attempt to guide both acetabular component position and
the sequence of treatment in a patient with both spinal and hip
pathology.50
Rivière et al51 classify based on the patient’s PI and spinopel-
vic mobility. Patients with stiff spines or flatback syndrome
are more likely to have a stiff spinopelvic segment and must
thus rely on range of movement of the hip to perform activities
of daily living. These ‘hip users’ have a PI under 40°. ‘Spine
users’ have flexible spines and a PI above 40°, so they can use
changes in SPT to perform daily activities. Many patients fall
under a mixed category, demonstrating some combination of
the above.25,51,52
Treatment
The increased risk of dislocation in patients with spinopelvic
pathology undergoing THA is well established. In these high-
risk patients, a dedicated surgical workflow can be of great ben-
efit to the surgeon.
First, the surgeon may choose to make patient-specific
changes in acetabular version based upon the findings of the
preoperative imaging evaluation. Babisch et al38 factored PT into
acetabular component implantation and reported no dislocations
in the computer-adjusted group that factored in the PT, although
it bears noting that this was in 98 patients not deemed to be high-
risk for instability. The acetabular component position should
be planned to the FPP in standing, as anatomical landmarks
may be unreliable due to PT. Next, careful attention should be
paid to restoring hip length and offset and using large femoral
THE BONE & JOINT JOURNAL
 A systematic approach to the hip-spine ­relationship and its applications to total hip arthroplasty 815
heads. Although outside the scope of this review, the surgeon
should be familiar with previously mentioned risk factors for
instability, and may choose to use a dual-mobility construct in
certain high-risk patients. Many authors have demonstrated suc-
cess with dual-mobility constructs in patients at high risk for
dislocation.53-56 The goal of these interventions is to maximize
impingement-free range of movement and jump distance.
The literature regarding the hip-spine relationship and THA
is convoluted, without a standardized terminology or clas-
sification system. This consensus review by the Hip-Spine
Workgroup seeks to advance understanding of this complex
relationship through simplification of the available literature.
The ultimate goal is to allow hip surgeons to effectively under-
stand and apply the principles discussed in this review. The
Hip-Spine Workgroup calls for hip surgeons to evolve past the
concept of a static safe zone and rather seek out the ‘functional
safe zone’, a patient-specific acetabular position target based
upon a thorough preoperative evaluation and analysis of each
patient’s spinopelvic movement. This evolution cannot occur
without an understanding of the role of the dynamic spinopelvic
relationship in stability following THA.
Clearly, further prospective investigation into the efficacy of
these principles will be greatly beneficial. The concepts dis-
cussed in this review are exciting and present an opportunity to
clearly define not only the reliability of functional acetabular
component positioning in reducing the rate of hip instability,
but also to better understand how to reliably implement intraop-
erative acetabular component placement in line with patient-­
specific preoperative planning. The authors of this paper
acknowledge that more data are needed but the education of
surgeons on the issues created by variability in functional ace-
tabular positioning should not be delayed.
Take home message
- The hip and the spine are intimately connected, and spine
pathology can have a pronounced effect on functional ace-
tabular position following total hip arthroplasty (THA).
- With awareness of how to interpret radiographs for spine pathology, the
hip surgeon can be prepared to account for this effect.
- This is a quickly growing field in THA, and we are seeking to introduce
and simplify this concept for surgeons looking to learn more about the
hip-spine relationship.
References
1. Lewinnek GE, Lewis JL, Tarr R, Compere CL, Zimmerman JR. Dislocations after
total hip-replacement arthroplasties. J Bone Joint Surg [Am] 1978;60-A:217–220.
2. Abdel MP, von Roth P, Jennings MT, Hanssen AD, Pagnano MW. What Safe
Zone? The vast majority of dislocated THAs are within the Lewinnek safe zone for
acetabular component position. Clin Orthop Relat Res 2016;474:386–391.
3. Esposito CI, Gladnick BP, Lee YY, et al. Cup position alone does not predict risk
of dislocation after hip arthroplasty. J Arthroplasty 2015;30:109–113.
4. McCarthy TF, Alipit V, Nevelos J, Elmallah RK, Mont MA. Acetabular cup
anteversion and inclination in hip range of motion to impingement. J Arthroplasty
2016;31(Suppl):264–268.
5. Dorr LD, Wolf AW, Chandler R, Conaty JP. Classification and treatment of dislo-
cations of total hip arthroplasty. Clin Orthop Relat Res 1983;173:151–158.
6. Sariali E, Lazennec JY, Khiami F, Catonné Y. Mathematical evaluation of jump-
ing distance in total hip arthroplasty: influence of abduction angle, femoral head
offset, and head diameter. Acta Orthop 2009;80:277–282.
7. Miki H, Kyo T, Kuroda Y, Nakahara I, Sugano N. Risk of edge-loading and pros-
thesis impingement due to posterior pelvic tilting after total hip arthroplasty. Clin
Biomech 2014;29:607–613.
VOL. 101-B, No. 7, JULY 2019
8. McNamara MJ, Barrett KG, Christie MJ, Spengler DM. Lumbar spinal stenosis
and lower extremity arthroplasty. J Arthroplasty 1993;8:273–277.
9. Saito J, Ohtori S, Kishida S, et al. Difficulty of diagnosing the origin of lower leg
pain in patients with both lumbar spinal stenosis and hip joint osteoarthritis. Spine
2012;37:2089–2093.
10. Fogel GR, Esses SI. Hip spine syndrome: management of coexisting radiculopathy
and arthritis of the lower extremity. Spine J 2003;3:238–241.
11. Eneqvist T, Nemes S, Brisby H, et al. Lumbar surgery prior to total hip arthro-
plasty is associated with worse patient-reported outcomes. Bone Joint J
2017;99-B:759–765.
12. Buckland AJ, Puvanesarajah V, Vigdorchik J, et al. Dislocation of a primary
total hip arthroplasty is more common in patients with a lumbar spinal fusion. Bone
Joint J 2017;99-B:585–591.
13. DelSole EM, Vigdorchik JM, Schwarzkopf R, Errico TJ, Buckland AJ. Total
hip arthroplasty in the spinal deformity population: does degree of sagittal deform-
ity affect rates of safe zone placement, instability, or revision? J Arthroplasty
2017;32:1910–1917.
14. Perfetti DC, Schwarzkopf R, Buckland AJ, Paulino CB, Vigdorchik JM. Pros-
thetic dislocation and revision after primary total hip arthroplasty in lumbar fusion
patients: a propensity score matched-pair analysis. J Arthroplasty 2017;32:1635–
1640.e1.
15. Sultan AA, Khlopas A, Piuzzi NS, et al. The impact of spino-pelvic alignment on
total hip arthroplasty outcomes: a critical analysis of current evidence. J Arthroplasty
2018;33:1606–1616.
16. Zheng GQ, Zhang YG, Chen JY, Wang Y. Decision making regarding spinal
osteotomy and total hip replacement for ankylosing spondylitis: experience with 28
patients. Bone Joint J 2014;96-B:360–365.
17. Esposito CI, Carroll KM, Sculco PK, et al. Total hip arthroplasty patients with
fixed spinopelvic alignment are at higher risk of hip dislocation. J Arthroplasty
2018;33:1449–1454.
18. Barry JJ, Sing DC, Vail TP, Hansen EN. Early outcomes of primary total hip
arthroplasty after prior lumbar spinal fusion. J Arthroplasty 2017;32:470–474.
19. Bedard NA, Martin CT, Slaven SE, et al. Abnormally high dislocation rates of total
hip arthroplasty after spinal deformity surgery. J Arthroplasty 2016;31:2884–2885.
20. Furuhashi H, Togawa D, Koyama H, et al. Repeated posterior dislocation of total
hip arthroplasty after spinal corrective long fusion with pelvic fixation. Eur Spine J
2017;26(Suppl 1):S100-S106.
21. Sing DC, Barry JJ, Aguilar TU, et al. Prior lumbar spinal arthrodesis increases
risk of prosthetic-related complication in total hip arthroplasty. J Arthroplasty
2016;31(Suppl):227–232.e1.
22. An VVG, Phan K, Sivakumar BS, Mobbs RJ, Bruce WJ. Prior lumbar spinal
fusion is associated with an increased risk of dislocation and revision in total hip
arthroplasty: a meta-analysis. J Arthroplasty 2018;33:297–300.
23. Buckland AJ, Vigdorchik J, Schwab FJ, et al. Acetabular anteversion changes
due to spinal deformity correction: bridging the gap between hip and spine surgeons.
J Bone Joint Surg [Am] 2015;97:1913–1920.
24. Maratt JD, Esposito CI, McLawhorn AS, et al. Pelvic tilt in patients undergoing
total hip arthroplasty: when does it matter? J Arthroplasty 2015;30:387–391.
25. Lazennec JY, Brusson A, Rousseau MA. Lumbar-pelvic-femoral balance on sitting
and standing lateral radiographs. Orthop Traumatol Surg Res 2013;99(Suppl):S87-S103.
26. Boulay C, Tardieu C, Hecquet J, et al. Sagittal alignment of spine and pelvis
regulated by pelvic incidence: standard values and prediction of lordosis. Eur Spine J
2006;15:415–422.
27. Legaye J, Duval-Beaupère G, Hecquet J, Marty C. Pelvic incidence: a funda-
mental pelvic parameter for three-dimensional regulation of spinal sagittal curves.
Eur Spine J 1998;7:99–103.
28. Schwab F, Lafage V, Patel A, Farcy JP. Sagittal plane considerations and the
pelvis in the adult patient. Spine 2009;34:1828–1833.
29. Schwab FJ, Blondel B, Bess S, et al. Radiographical spinopelvic parameters and
disability in the setting of adult spinal deformity: a prospective multicenter analysis.
Spine 2013;38:E803-E812.
30. Kanawade V, Dorr LD, Wan Z. Predictability of acetabular component angular
change with postural shift from standing to sitting position. J Bone Joint Surg [Am]
2014;96:978–986.
31. Murray DW. The definition and measurement of acetabular orientation. J Bone
Joint Surg [Br] 1993;75-B:228–232.
32. Stefl M, Lundergan W, Heckmann N, et al. Spinopelvic mobility and acetabu-
lar component position for total hip arthroplasty. Bone Joint J 2017;99-B(1 Supple
A):37–45.
816 N. Eftekhary, A. Shimmin, J. Y. Lazennec, A. Buckland, R. Schwarzkopf, L. D. Dorr, D. Mayman, D. Padgett, J. Vigdorchik
33. Lafage V, Schwab F, Vira S, et al. Spino-pelvic parameters after surgery can
be predicted: a preliminary formula and validation of standing alignment. Spine
2011;36:1037–1045.
34. Lazennec JY, Boyer P, Gorin M, Catonné Y, Rousseau MA. Acetabular ante-
version with CT in supine, simulated standing, and sitting positions in a THA patient
population. Clin Orthop Relat Res 2011;469:1103–1109.
35. Lembeck B, Mueller O, Reize P, Wuelker N. Pelvic tilt makes acetabular cup
navigation inaccurate. Acta Orthop 2005;76:517–523.
36. Tiberi JV, III, Antoci V, Malchau H, et al. What is the fate of total hip arthroplasty
(THA) acetabular component orientation when evaluated in the standing position? J
Arthroplasty 2015;30:1555–1560.
37. Zhu J, Wan Z, Dorr LD. Quantification of pelvic tilt in total hip arthroplasty. Clin
Orthop Relat Res 2010;468:571–575.
38. Babisch JW, Layher F, Amiot LP. The rationale for tilt-adjusted acetabular cup
navigation. J Bone Joint Surg [Am] 2008;90-A:357–365.
39. Wan Z, Malik A, Jaramaz B, Chao L, Dorr LD. Imaging and navigation measure-
ment of acetabular component position in THA. Clin Orthop Relat Res 2009;467:32–42.
40. Lum ZC, Coury JG, Cohen JL, Dorr LD. The current knowledge on spinopelvic
mobility. J Arthroplasty 2018;33:291–296.
41. Esposito CI, Miller TT, Kim HJ, et al. Does degenerative lumbar spine disease
influence femoroacetabular flexion in patients undergoing total hip arthroplasty? Clin
Orthop Relat Res 2016;474:1788–1797.
42. Spencer-Gardner L, Pierrepont J, Topham M, et al. Patient-specific instrumen-
tation improves the accuracy of acetabular component placement in total hip arthro-
plasty. Bone Joint J 2016;98-B:1342–1346.
43. Yoon BH, Ha YC, Lee YK, et al. Is transverse acetabular ligament a reliable guide
for aligning cup anteversion in total hip arthroplasty?: A measurement by CT arthrog-
raphy in 90 hips. J Orthop Sci 2016;21:199–204.
44. Rillardon L, Levassor N, Guigui P, et al. Validation of a tool to measure pelvic
and spinal parameters of sagittal balance. Rev Chir Orthop Reparatrice Appar Mot
2003;89:218–227. (Article in French)
45. Pierrepont J, Hawdon G, Miles BP, et al. Variation in functional pelvic tilt in
patients undergoing total hip arthroplasty. Bone Joint J 2017;99-B:184–191.
46. Shah SM, Munir S, Walter WL. Changes in spinopelvic indices after hip
arthroplasty and its influence on acetabular component orientation. J Orthop
2017;14:434–437.
47. Pierrepont J, Yang L, Arulampalam J, et al. The effect of seated pelvic tilt on
posterior edge-loading in total hip arthroplasty: a finite element investigation. Proc
Inst Mech Eng H 2018;232:241–248.
48. Ike H, Dorr LD, Trasolini N, et al. Spine-pelvis-hip relationship in the functioning
of a total hip replacement. J Bone Joint Surg [Am] 2018;100:1606–1615.
49. Langston J, Pierrepont J, Gu Y, Shimmin A. Risk factors for increased sagit-
tal pelvic motion causing unfavourable orientation of the acetabular component in
patients undergoing total hip arthroplasty. Bone Joint J 2018;100-B:845–852.
50. Phan D, Bederman SS, Schwarzkopf R. The influence of sagittal spinal deformity
on anteversion of the acetabular component in total hip arthroplasty. Bone Joint J
2015;97-B:1017–1023.
51. Rivière C, Lazennec JY, Van Der Straeten C, et al. The influence of spine-hip
relations on total hip replacement: a systematic review. Orthop Traumatol Surg Res
2017;103:559–568.
52. Lazennec JY, Brusson A, Rousseau MA. Hip-spine relations and sagittal balance
clinical consequences. Eur Spine J 2011;20(Suppl 5):686–698.
53. Darrith B, Courtney PM, Della Valle CJ. Outcomes of dual mobility compo-
nents in total hip arthroplasty: a systematic review of the literature. Bone Joint J
2018;100-B:11–19.
Follow us @BoneJointJ

54. Reina N, Pareek A, Krych AJ, et al. Dual-mobility constructs in primary and revi-
sion total hip arthroplasty: a systematic review of comparative studies. J Arthro-
plasty 2019;34:594–603.
55. Epinette JA, Béracassat R, Tracol P, Pagazani G, Vandenbussche E. Are
modern dual mobility cups a valuable option in reducing instability after primary hip
arthroplasty, even in younger patients? J Arthroplasty 2014;29:1323–1328.
56. Jones CW, De Martino I, D’Apolito R, et al. The use of dual-mobility bearings in
patients at high risk of dislocation. Bone Joint J 2019;101-B(1 Suppl A):41–45.
Author information:
N. Eftekhary, MD, Senior Resident
A. Buckland, MBBS, FRACS, Orthopaedic Surgeon
R. Schwarzkopf, MD, MSc, Orthopaedic Surgeon
Division of Adult Reconstructive Surgery, NYU Langone Orthopedic Hospital,
NYU Langone Health, New York, New York, USA.
A. Shimmin, MBBS, FRACS, Orthopaedic Surgeon, Melbourne Orthopaedic
Group, Windsor, Australia.
J. Y. Lazennec, MD, PhD, Orthopaedic Surgeon, Pitié-Salpêtrière Hospital,
Pierre-and-Marie-Curie University, Paris, France.
L. D. Dorr, MD, Orthopaedic Surgeon, Keck Medical Center of USC,
Los Angeles, California, USA.
D. Mayman, MD, Orthopaedic Surgeon
D. Padgett, MD, Orthopaedic Surgeon
J. Vigdorchik, MD, Orthopaedic Surgeon
Adult Reconstruction and Joint Replacement Service, Hospital for Special
Surgery, New York, New York, USA.
Author contributions:
N. Eftekhary: Designed the study, Reviewed the literature, Wrote the
manuscript.
A. Shimmin: Designed the study, Edited the manuscript, Provided support
and guidance.
J. Y. Lazennec: Designed the study, Edited the manuscript, Provided support
and guidance.
A. Buckland: Designed the study, Edited the manuscript, Provided support
and guidance.
R. Schwarzkopf: Designed the study, Edited the manuscript, Provided
support and guidance.
L. D. Dorr: Designed the study, Edited the manuscript, Provided support and
guidance.
D. Mayman: Designed the study, Edited the manuscript, Provided support
and guidance.
D. Padgett: Designed the study, Edited the manuscript, Provided support
and guidance.
J. Vigdorchik: Designed the study, Wrote and edited the manuscript,
Reviewed the literature, Provided support and guidance.
Funding statement:
The author or one or more of the authors have received or will receive
benefits for personal or professional use from a commercial party related
directly or indirectly to the subject of this article.
ICMJE COI statement:
J. Vigdorchik reports consultancy fees from Corin, Intellijoint, and Stryker
related to this study.
This article was primary edited by M. Barry.
THE BONE & JOINT JOURNAL