The Journal of Arthroplasty 34 (2019) S53eS56

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The Journal of Arthroplasty

journal homepage: www.arthroplastyjournal.org

2018 AAHKS Annual Meeting Symposium

Spinopelvic Motion and Impingement in Total Hip Arthroplasty

Braden M. McKnight, MD *, Nicholas A. Trasolini, MD, Lawrence D. Dorr, MD
Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA

a r t i c l e i n f o a b s t r a c t

Article history: The stability of a total hip arthroplasty relies on proper positioning of the acetabular cup. Recent research
Received 15 January 2019 has shown that this cup position is more dynamic than previously thought. The 3-dimensional orien-
Accepted 15 January 2019 tation of the acetabular cup changes when the pelvis tilts anteriorly or posteriorly. These changes in
Available online 24 January 2019
pelvic tilt are directly related to the biomechanics of the lumbosacral junction. In normal physiology, the
lumbar spine straightens with sitting and becomes more lordotic with standing. This directly translates
Keywords:
to posterior or anterior pelvic tilt due to the rigid sacroiliac attachments. During sitting, increased
impingement
posterior pelvic tilt opens the acetabulum to accommodate flexion and internal rotation of the hip. This
dislocation
spine
helps prevent anterior impingement and posterior hip dislocation. During standing, anterior pelvic tilt
pelvis increases superior coverage of the acetabulum. This helps prevent posterior impingement and anterior
total hip arthroplasty hip dislocations. When lumbosacral motion becomes pathologic, spinopelvic motion changes and
spinopelvic motion acetabular cup orientation is affected. In cases of decreased lumbosacral motion, patients rely on greater
hip motion to reach standing or sitting positions. This can cause pathologic impingement. In addition,
traditional safe zones for cup position may not apply in the presence of pathologic spinopelvic motion.
This article discusses the normal physiology of spinopelvic motion, the patterns of pathologic change,
and the clinical implications therein.
© 2019 Elsevier Inc. All rights reserved.

What Is Normal Spinopelvic Motion?
In order to maintain sagittal alignment and balance of the
weight of the body over the feet, there is coordinated motion of the
spine, pelvis, and hips which enables such activities as bending
forward at the waist and going from sitting to standing [1,2]. The
interplay of the spine, pelvis, and hips during these motions is best
observed on a lateral radiograph extending from the L3 vertebra to
the proximal femur [3,4]. In order to interpret these radiographs, a
complete understanding of the sagittal radiographic measurements
and their clinical implications is necessary.
During standing, the lumbar spine is in lordosis, the pelvis is
tilted anteriorly, and the hips are extended. This position balances
the trunk over the acetabulum and places the acetabulum over the
femoral heads and the shaft of the femur. The change in position
One or more of the authors of this paper have disclosed potential or pertinent
conflicts of interest, which may include receipt of payment, either direct or indirect,
institutional support, or association with an entity in the biomedical field which
may be perceived to have potential conflict of interest with this work. For full
disclosure statements refer to https://doi.org/10.1016/j.arth.2019.01.033.
* Reprint requests: Braden M. McKnight, MD, Department of Orthopaedic Sur-
gery, Keck School of Medicine of USC, 1520 San Pablo Street #2000, Los Angeles, CA
90033.
from standing to sitting is accomplished through a flattening of the
lumbar spine, posterior tilt of the pelvis, and flexion of the hip
(Fig. 1). Because the acetabulum is part of the pelvis, any change in
pelvic orientation directly correlates to changes in sagittal acetab-
ular orientation. In transitioning from standing to sitting, the pelvis
tilts posteriorly (normal change is 20
) which opens the acetabu-
lum by increasing the anteversion and inclination providing
clearance for the flexed and internally rotated femur. This change in
acetabular positioning allows the patient to sit without anterior
impingement of the femur on the acetabulum [1,5e8].
Pelvic incidence (PI) is a measurement of the anterior to pos-
terior relationship of the femoral head and the lower spine [9,10]. PI
is a fixed anatomic parameter that does not change in sitting to
standing with a normative value of 53
(Fig. 1). Sacral slope (SS)
refers to the sagittal slope of the lumbosacral junction as measured
from the top of the S1 endplate. A normal SS is 40
when standing
and 20
when sitting. The change in SS from sitting to standing
(DSS) represents the motion of the pelvis that occurs during
changes in position. A normal DSS is 11
-30
. Ante-inclination (AI)
refers to the sagittal angle of the acetabulum as viewed on a lateral
radiograph [3]. Following total hip arthroplasty, cup inclination and
anteversion contribute to AI with normal means of 35
when
standing and 52
when sitting [3]. Because the acetabulum is
embedded in the pelvis, AI changes occur in almost a 1:1 ratio to

https://doi.org/10.1016/j.arth.2019.01.033
0883-5403/© 2019 Elsevier Inc. All rights reserved.
S54 B.M. McKnight et al. / The Journal of Arthroplasty 34 (2019) S53eS56

the SS [11]. Pelvic femoral angle (PFA) is a measurement of the
relative sagittal position of the femur in reference to the pelvis and
represents the motion of the femur relative to the pelvis. Normal
standing PFA is 180
and sitting is 125
. Combined sagittal index
(CSI) is the summation of the cup AI and the PFA. Normal CSI is 218

standing and 180
sitting. CSI has particular relevance to total hip
arthroplasty as abnormal CSI has been shown to predict impinge-
ment patterns related to late dislocations [12].
What Is Abnormal Spinopelvic Motion?
Because changes in postural position require a coordinated
motion of the hip, pelvis, and spine, a decrease in motion of one
component of this kinetic chain forces the remaining components
to compensate. It is easiest to think of the pelvis as a “gear” and the
lumbosacral junction as the posterior hinge with the hip joint as the
anterior hinge. If there is a relative decrease in motion of the
lumbosacral junction, there must be a relative increase in the
motion of the hip in order to accommodate changes in postural
position. This is of particular interest for hip arthroplasty surgeons
because increased femoral flexion while sitting, and increased
femoral extension while standing, can result in bony or component
impingement [1,5,8,12].
Spinopelvic motion outside of the normal range (DSS 11
-30
)
can be considered abnormal and has been categorized as too much
motion (hypermobility, DSS >30
) or too little motion (stiffness,
DSS <11
) [4,13]. Hypermobility may be a normal variant seen
primarily in younger female patients. It provides protection against
femoral-pelvic bony impingement in patients following total hip
arthroplasty because the increased pelvic motion requires less
femoral motion with changes in posture. If hypermobility is com-
bined with extreme posterior tilt of the pelvis with sitting (SS <10
,
lumbar spine kyphosis), this imbalance does increase the risk of
instability [4]. Instability is a consequence of intraoperative cup
inclination >50
and/or anteversion >20
(combined anteversion
>40
) which results in a steep vertical cup (AI >75
) during sitting
that can permit drop out dislocation [14]. This risk is greatest with
sitting SS <5
, which commonly does not change postoperatively.
Kyphosis is present in stiff arthritic spines of elderly patients with
body mass index >40 and those with an extension contraction of
the femur [14,15]. Patients with an extension contracture of the hip
preoperatively will correct postoperatively.
Spinopelvic stiffness is characterized by DSS 10
. This is a
result of stiffness in the lower 3 vertebrae of the lumbar spine
which causes stiffness of the posterior hinge, so the pelvis does
not tilt with postural change. Lumbar degenerative diseases
including degenerative disk disease, advanced spondylosis, and
ankylosing spondylitis as well as spinal fusion are causes of this
stiffness [1,10,15]. There are 3 variations of spinopelvic imbalance
that combine with stiffness to have clinical significance for hip
replacement [4]: stuck sitting, stuck standing, and neutral stiff.
Patients who are stuck sitting have DSS 10
and SS <30
when
both sitting and standing. Conceptually, these patients have a
pelvis that is always “stuck” in the posteriorly tilted position of
sitting so that while standing the femur must hyperextend for
balance which creates risk of the greater trochanter on the pelvis
and resultant anterior dislocation (Fig. 2) [12]. The more stem
anteversion that is present the greater the risk because the greater
trochanter is more posterior. Patients who are stuck standing have
DSS 10
and SS >30
when both sitting and standing. These
patients have a pelvis that is always in the anteriorly tilted posi-
tion of standing so the femur must flex more to sit creating risk of
bony impingement of the anterior trochanter on the pelvis and
resultant posterior dislocation (Fig. 3) [12]. Patients who are
neutral stiff have DSS 10
, but the pelvis is not stuck anteriorly or
posteriorly (ie, standing SS 35
and sitting SS 27
). These patients
are at most risk for anterior impingement and posterior disloca-
tion because the acetabulum does not open for clearance of the
femur. The risk for anterior or posterior impingement is best
determined by the functional safe zone which is determined from
the CSI. This measure is the sum of AI þ PFA (Fig. 1). Patients with
standing CSI >243
are at risk of anterior bony impingement,
while patients with sitting CSI <151
are at risk of posterior
impingement [12].

Fig. 1. Illustrations representing normal spinopelvic parameters with standing (left) and sitting (right). PI (55
) is a measurement of the anterior to posterior relationship of the
femoral head and the lower spine and does not change with changes in position. SS (45
left standing, 20
right sitting) is the sagittal slope of the pelvis. The change in sacral slope
from standing to sitting is the primary measurement used to determine spinopelvic motion (DSS). AI (35
left standing, 60
right sitting) is the sagittal inclination angle of the
acetabulum. PFA (180
left, 125
right) is a measurement of the femur in relation to the pelvis. The CSI is 215
standing (180
þ 35
) and 185
sitting (125
þ 60
) which is the sum of
AI þ PFA.
 B.M. McKnight et al. / The Journal of Arthroplasty 34 (2019) S53eS56 S55

Fig. 2. Standing (A) and sitting (B) lateral spinopelvic X-rays of a patient demonstrating decreased spinopelvic mobility with excessive posterior pelvic tilt during standing (stuck
sitting). During standing, these patients require increased hip extension in order to maintain a stable upright center of mass. This patient has a standing CSI that is outside the safe
upper limit of 243
which is predictive of anterior dislocation, which the patient sustained more than 2 years postoperatively. The coronal angles of anteversion and inclination were
13
and 54
, respectively. This hip required cup revision (inclination 50
, anteversion 22
, combined anteversion 37
) with increased offset and excision of a portion of the greater
trochanter (without impacting the medius tendon) to avoid posterior bony impingement.

How Does Spinopelvic Motion Factor Into Component
Positioning?
Intraoperative component positioning has been regulated by
the Lewinnek safe zone for 40 years, but recent evidence brings its
validity into question [8,12]. This data suggests that the functional
safe zone (CSI) is a more predictive criterion than coronal acetab-
ular angles for safety. This is emphasized by the fact that femur
motion has been shown to correlate more closely with risk of
impingement than acetabular position (although both matter as
with combined anteversion and AI) [8,12,15]. Tezuka et al [8] have
identified 3 factors more important than the acetabulum for pre-
dicting functional safe zone than the acetabulum: femur position
(PFA), spinopelvic stiffness (DSS), and low PI (<40
). For example, a
patient with a highly flexed femur when sitting (sitting PFA <110
)
and a low sitting sagittal cup angle (sitting AI <40
) has a CSI of 151

which falls out of the functional safe zone, putting the patient at
risk for anterior impingement and posterior dislocation. The lower
the sitting CSI, the higher the risk. A patient with an extended fe-
mur when standing (standing PFA >205
) and a high standing
sagittal cup angle (standing AI >45
) has a standing CSI of 250
and
is at high risk for posterior impingement and anterior dislocation
[8,12]. When patients have decreased spinopelvic motion, their
sagittal cup position (AI) does not change significantly with posi-
tional change. As such, the cup position achieved at surgery has a
great deal of influence on their CSI at the extremes of motion
because it changes less than patients with normal spinopelvic
motion. For patients who are stuck standing, the stiffer the

Fig. 3. Standing (A) and sitting (B) lateral spinopelvic X-rays of a patient after posterior spinal fusion with instrumentation with fused spinopelvic motion in a stuck standing pattern
(DSS ¼ 1
). Because sacral slope and ante-inclination are directly proportional, the cup angle cannot change either. The consequence is that the cup does not rotate posteriorly to
clear the femoral head during hip flexion and internal rotation during sitting. In addition, the stiff spine necessitates increased hip motion to reach a sitting position (PFA ¼ 102
).
Although this patient had an inclination and anteversion within the Lewinnek safe zone (48
and 17
), they had a sitting CSI of 134
which is outside the functional safe zone,
increasing anterior impingement. Anterior impingement combined with decreased posteroinferior coverage caused a late posterior dislocation. This is a patient in whom we would
use a dual mobility articulation.
S56 B.M. McKnight et al. / The Journal of Arthroplasty 34 (2019) S53eS56
Table 1
Suggested Cup Positions to Avoid Impingement in Spinopelvic Stiffness.
Cup Position for Patterns of Spinopelvic Imbalance Inclination
Hypermobile 35
-45

Stuck standing 45
-50

Neutral stiff 40
-45

Stuck sitting 35
-40

Stem anteversion must be known so that the combined anteversion can be near 40
.
spinopelvic motion the greater the inclination and anteversion
should be in order to avoid impingement with the greatest
contribution coming from anteversion. Patients who are stuck
standing and those with hypermobility (particularly in kyphosis
with sitting SS <5
) require lower cup angles at surgery to avoid
impingement (Table 1).
The rationale for intraoperative avoidance of impingement be-
gins with correct reconstruction of hip length and offset. If these are
short, the component positions cannot protect against impinge-
ment. In patients who are stuck standing or stuck sitting, we
recommend the offset be increased by 5 mm for protection against
bony impingement. The preoperative clinical assessment of flexion
range of motion of the femur can help identify these patients as
those with hypermobility have femoral flexion 75
-80
while stiff
patients have flexion of at least 90
. There is mounting evidence
that Lewinnek safe zones do not ensure safety. Elkins et al [16]
found that inclination is best at 35
-50
and anteversion at 15
-
25
to protect against dislocation. Additionally, combined ante-
version is more important than cup anteversion alone. Tezuka et al
found that 14.2% of patients in their cohort who had a cup within
the Lewinnek safe zone had a CSI that put them out of the func-
tional safe zone. Risk factors for falling out of the functional safe
zone included increased femoral mobility, stiff spinopelvic
mobility, and low PI [8]. Adopting less margin of error for cup
positioning at the time of surgery in patients with stiff spinopelvic
motion would help keep patients within the functional safe zone,
and help decrease impingement which can help decrease the rates
of dislocation. To our knowledge, no study to date has tested the
survivability of cups placed outside of the currently recommended
safe zones. Until data that studies acute dislocations and spino-
pelvic imbalance are available, the cup positions suggested here
may be used (Table 1). Patients who are stuck standing require more
inclination and anteversion to provide them with a higher AI to
help prevent anterior impingement. We use inclination 45
-50

and anteversion 20
-25
with combined anteversion near 40
. We
also use this cup goal in patients who are neutral stiff. Patients who
are stuck sitting have a relatively more open acetabulum so we use
inclination 35
-40
and anteversion 15
-20
to help prevent pos-
terior impingement. For hypermobility, especially with kyphosis,
we use inclination 35
-45
and anteversion 15
-25
. If the patient
has stiff spinopelvic motion, especially those stuck sitting or stuck
standing, plus increased femoral mobility and low PI, they are at a
particularly high risk of impingement and dislocation. In these
patients we use dual mobility cups. We also use dual mobility cups
in patients over the age of 75 with spinopelvic stiffness as their
Anteversion stiffness is likely to worsen with advancing age, increasing their
15
-25

need for femoral flexion and giving them a high risk of
20
-25
impingement.
20
-25

15
-20

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