The Journal of Arthroplasty 38 (2023) 713e718

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The Journal of Arthroplasty

journal homepage: www.arthroplastyjournal.org

Primary Hip

Sacral Slope Change From Standing to Relaxed-Seated Grossly

Overpredicts the Presence of a Stiff Spine
Abhinav K. Sharma, MD a, George Grammatopoulos, MBBS, BSc, DPhil b,
Jim W. Pierrepont, PhD c, Chameka S. Madurawe, BEng c, Moritz M. Innmann, MD b, d,
Jonathan M. Vigdorchik, MD e, *, Andrew J. Shimmin, MBBS f
a
Department of Orthopaedic Surgery, University of California, Irvine, School of Medicine, Orange, California
b
Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
c
Corin Group, The Corinium Centre, Cirencester, Gloucestershire
d
Division of Orthopaedics and Trauma Surgery, Heidelberg University Hospital, Heidelberg, Germany
e
Department of Orthopedic Surgery, Hospital for Special Surgery, Adult Reconstruction and Joint Replacement, New York, New York
f
Melbourne Orthopaedic Group, Melbourne, Australia

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

Article history: Background: Several authors propose that a change in sacral slope of
10 between the standing and
Received 3 January 2022 relaxed-seated positions (DSSstanding/relaxed-seated) identifies a patient with a stiff lumbar spine and has
Received in revised form suggested the use of dual-mobility bearings for such patients undergoing a total hip arthroplasty (THA).
12 April 2022
The aim of this study was to assess how accurately DSSstanding/relaxed-seated can identify patients with a
Accepted 10 May 2022
stiff spine.
Available online 16 May 2022
Methods: A prospective, multicentre, consecutive cohort series of 312 patients had standing, relaxed-
seated, and flexed-seated lateral radiographs prior to THA. DSSstanding/relaxed-seated was determined by
Keywords:
total hip arthroplasty
the change in sacral slope between the standing and relaxed-seated positions. Lumbar flexion (LF) was
stiff spine defined as the difference in lumbar lordotic angle between standing and flexed-seated. LF
20 was
spinopelvic considered a stiff spine. The predictive value of DSSstanding/relaxed-seated for characterizing a stiff spine was
sacral slope assessed.
lumbar flexion Results: A weak correlation between DSSstanding/relaxed-seated and LF was identified (r2 ¼ 0.13). Eighty six
patients (28%) had DSSstanding/relaxed-seated
10 and 19 patients (6%) had a stiff spine. Of the 86 patients
with DSSstanding/relaxed-seated
10 , 13 had a stiff spine. The positive predictive value of DSSstanding/relaxed-

seated
10 for identifying a stiff spine was 15%.
Conclusion: In this cohort, DSSstanding/relaxed-seated
10 was not correlated with a stiff spine. Using this
simplified approach could lead to a 7-fold overprediction of patients with a stiff lumbar spine and
abnormal spinopelvic mobility, unnecessary use of dual-mobility bearings, and incorrect component
alignment targets. Referring to patients with DSSstanding/relaxed-seated
10 as being stiff is misleading.
The flexed-seated position should be used to effectively assess a patient’s spine mobility prior to THA.
© 2022 Elsevier Inc. All rights reserved.

Total hip arthroplasty (THA) is a highly successful and cost-
effective procedure for hip osteoarthritis, with estimates of
survival of up to 25 years in up to 58% of patients, including 96%
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.2022.05.020.
* Address correspondence to: Jonathan M. Vigdorchik, MD, Hospital for Special
Surgery, 535 E 70th St, New York, NY 10021.
of patients aged 60 years or older at 10 years [1,2]. Although
THA is a well-established option for improving patient’s quality
of life through pain alleviation, patients with concomitant hip
and spinopelvic pathology have been shown to have higher
postoperative complication rates [3e8]. Pathologic alterations to
the biomechanics and coordinated motion of the spine, hip, and
pelvis in patients with spinal stiffness may lead to unpredictable
changes in pelvic motion during the transition from standing to
seated and therefore alter functional cup orientation and lead to
inferior patient-reported outcomes, impingement, instability,
and dislocation [5,8e21]. Identifying these patients

https://doi.org/10.1016/j.arth.2022.05.020
0883-5403/© 2022 Elsevier Inc. All rights reserved.
714 A.K. Sharma et al. / The Journal of Arthroplasty 38 (2023) 713e718

Table 1
Analysis of Spinopelvic Parameters in the Selected Patient Cohort.

Statistical Measure Age at Spinopelvic Parameters

Surgery
PI Stand SS Stand LL Flexed Flexed Relaxed Relaxed PI-LL DSS Lumbar
Seated SS Seated LL Seated SS Seated LL (Stand-Relaxed) Flexion (DLL)

Mean 66 56.2 41.7 56.1 40.7 12.7 23.6 35.6 0.1 18.1 43.5
SD 12 11.2 9 13.4 14.9 14.1 12 15.9 12 11.8 14.4
Min 23 30.7 17.2 3.6 3.9 25 13.3 10 33.3 3.3 3.6
Max 90 89.2 71.8 93.2 79.2 49.9 56.2 81.3 46.6 52.3 77.2

preoperatively is important for appropriate surgical planning to Patient Cohort

mitigate the increased risk of postoperative dislocation in this
population.
Spinal stiffness affects pelvic rollback during the transition
between the standing and seated positions and can result in an
increased risk of impingement [22e24]. As such, it is an
essential parameter to measure preoperatively and account for
intraoperatively. The assessment for identifying patients with
stiff lumbar spines is not standardized in the literature, and
there are two methods commonly used: (1) pelvic mobility and
sacral slope (SS) as surrogate markers of spinal stiffness between
the standing and relaxed-seated positions and (2) lumbar spine
flexion between the standing and deep-flexed seated positions
[14,25e27]. While pelvic mobility is assessed by changes in SS
from standing to relaxed-seated positions (DSSstanding/relaxed-
seated), with DSSstanding/relaxed-seated of
10 being used to infer

spinopelvic stiffness, lumbar flexion (LF) is defined by the
change in lumbar lordosis (LL) from the standing to flexed-
seated position and is used to define the stiffness of the lum-
bar spine [18,19].
Relaxed-seated x-rays, often used for pelvic mobility and SS
measurements, are obtained by asking patients to sit upright with
the femurs parallel to the floor. In the relaxed-seated position,
however, one does not test the maximum potential movement of
the spine as it is not a position of testing functional-seated capacity
as is the case in the flexed-seated (rise above to stand up from
sitting) position [17,28]. The utility of the flexed-seated position is
in assessing maximum spine movement, which is measured to
calculate LF [9,17,28,29]. Recent literature has shown no correlation
between true LF and pelvic mobility from the standing to relaxed-
seated positions and a significantly greater identification of pa-
tients with stiff lumbar spines using the flexed-seated position,
challenging the use of SS as more than an assessment of the posi-
tion of the pelvis in space and as a valid measure of spinal stiffness
[15,17].
Therefore, the aims of this study were to (1) characterize the
correlation of radiographic spinopelvic measurements performed
with two different assessments during transitions from the
standing to seated functional positions and (2) test how accurately
DSSstanding/relaxed-seated can identify patients with a stiff spine and
whether it can be used to infer a stiff spine.
Methods
After an institutional review board approval (Bellberry Ltd.,
Australia: 2020-08-764-A-1; Heidelberg University, Germany: S-
065/2017), a combination of a consecutive cohort series study
(Germany) and identical data obtained as part of standard of care
(AUS) were reviewed. All patients who underwent THA received
preoperative functional x-ray imaging series and exclusion criteria
included those with obvious pathologic spinopelvic characteristics
including large sagittal spinal deformities and lumbar spine
fusions.
Three hundred and twelve consecutive patients evaluated met
the radiographic inclusion criteria and had adequate supine ante-
roposterior (AP) pelvis x-rays followed by standing, relaxed-seated,
and flexed-seated lateral spinopelvic imaging to undergo complete
spinopelvic evaluation.
This cohort consisted of 172 (55%) females and 140 (45%) males
with a mean age of 66 years (range: 23-90) and body mass index
(BMI) of 27.1 (range: 19.8-43.3) (Table 1). One hundred and sixty
eight (54%) patients received right THAs and 144 (46%) received left
THAs.
Radiographic Analysis
The preoperative images included supine AP pelvis x-rays
followed by standing, relaxed-seated, and flexed-seated lateral
spinopelvic imaging. Each institution in this multicenter study
performed the requisite imaging using this standardized
protocol.
Lumbar Spine and Pelvis Evaluation and Spinopelvic Measurements
From these images the lumbar spine and pelvis were evaluated
as follows:
(1) SS (Fig. 1):
a. SS is the angle between a horizontal reference line and a
line parallel to the superior endplate of S1.
b. The change of SS between the standing and relaxed-
seated positions DSSstanding/relaxed-seated was used to
quantify pelvic mobility.
a. Other authors have suggested that limited pelvic
mobility (DSSstanding/relaxed-seated
10 ) can be used to
characterize a stiff spine [18,19].
b. Pelvic hypermobility has been defined as DSSstan-

ding/relaxed-seated > 30 [23,27,30].
(2) LF (Fig. 2):
a. LL was calculated from the standing lateral x-ray as the
Cobb angle between a line drawn at the superior endplate
of L1 and another line drawn at the superior endplate of
S1.
b. LF was measured on lateral x-rays by the difference be-
tween standing LL and flexed-seated LL:
i. Lumbar flexion
20 was used to define a stiff lumbar
spine [7,15,16].
Outcomes of Interest
These spinal and pelvic mobility assessments were measured for
all patients. DSSstanding/relaxed-seated was calculated, the correlation
between DSSstanding/relaxed-seated and LF computed, and the pre-
dictive value of DSSstanding/relaxed-seated for characterizing a stiff
spine (LF
20 ) was assessed.
 A.K. Sharma et al. / The Journal of Arthroplasty 38 (2023) 713e718 715

Fig. 1. DSSstanding/relaxed-seated was determined by the change in sacral slope between the standing and relaxed-seated positions.

Statistical Analysis
Spinopelvic measurements were performed by multiple
qualified engineers for each patient studied, as part of the pre-
operative functional planning process. A statistical analysis was
performed using SPSS software (version 26.0, Armonk, NY: IBM
Corp.). Internal consistency and reliability between observer
spinopelvic measurements were assessed by the intraclass cor-
relation coefficient (ICC). Data analysis included descriptive sta-
tistics with reported means and standard deviations for
continuous variables of the study population. Frequencies and
percentages were used to report all discrete variables. A linear
regression was used to model the relationship between LF and SS,
with the coefficient of determination (r2) calculated to explain
the proportion of variance between the two variables. A receiver
operating characteristic (ROC) curve with DSSstanding/relaxed-seated
as a continuous variable was used to measure the classification
accuracy of DSSstanding/relaxed-seated as a predictor of true spinal
stiffness, defined by a LF
20 . DSSstanding/relaxed-seated
10 and
>30 were tested as thresholds on the ROC from which corre-
sponding sensitivity, specificity, positive and negative predictive
values, and positive and negative likelihood ratios were

Fig. 2. Lumbar flexion (LF) was defined as the difference in lumbar lordotic angle between standing and flexed-seated. LF
20 was considered a stiff spine.
716 A.K. Sharma et al. / The Journal of Arthroplasty 38 (2023) 713e718

80° DSSstanding/relaxed-seated
10 (Table 2) and DSSstanding/relaxed-

seated >30 (Table 3) were tested as thresholds in the ROC analysis.
Lumbar Flexion

70° In the DSSstanding/relaxed-seated
10 cohort, 86 patients (28%) had

DSSstanding/relaxed-seated
10 and 19 patients (6%) had a stiff spine.
60° Of the 86 patients with DSSstanding/relaxed-seated
10 , 13 (15%) had a
R² = 0.1348 stiff spine. The positive predictive value of DSSstanding/relaxed-seated
50°
10 for identifying a stiff spine was 15% and positive likelihood
ratio was 2.72. The negative predictive value was 97% and negative
40° likelihood ratio was 0.42. In the DSSstanding/relaxed-seated >30
cohort, 42 patients (13%) had DSSstanding/relaxed-seated >30 and 19
30° patients (6%) had a stiff spine. Of the 42 patients with DSSstan-

ding/relaxed-seated >30 , 41 (98%) did not have a stiff spine. The
20° positive predictive value of DSSstanding/relaxed-seated >30 for iden-
tifying a flexible spine was 98% and positive likelihood ratio was
10° 2.66. The negative predictive value was 7% and negative likelihood
ratio was 0.91.
0°
Internal consistency and reliability between observer spino-
-10° 0° 10° 20° 30° 40° 50° 60° pelvic measurements were assessed by the ICC and the confidence
ΔSS from standing to relaxed-sing interval (CI) of the ICC, with values of 0.83 (95% CI, 0.89-0.91)
demonstrating an excellent repeatability index.
Fig. 3. A linear regression analysis demonstrates weak correlation between DSSstan-
Several weak associations were found between demographics
and LF (r2 ¼ 0.13). DSSstanding/relaxed-seated
10 defined limited
ding/relaxed-seated
pelvic mobility and LF
20 defined a stiff lumbar spine. DSSstanding/relaxed-seated
10 and LF and DSSstanding/relaxed-seated. Age and LF was the strongest
was not correlated with a stiff spine in this cohort. association (r2 ¼ 0.293, P < .001), such that those classified with a
stiff spine were 9 years older than those with normal spines (74.4
versus 65.4, P < .0001). Age and DSSstanding/relaxed-seated reported a
calculated to determine predictability of the test. Student’s weaker association (r2 ¼ 0.078, P < .001) but maintained a signif-
t-tests were used to investigate gender, side, and spinopelvic icant difference in age between the stiff and not-stiff groups (70.5
stiffness classification (LF
20 and DSSstanding/relaxed-seated versus 64.3, P < .0001). Associations with BMI and gender were still

10 ), a Chi-squared test was used to investigate associations weaker (supplement).
between gender and stiffness classification, and Spearman’s Rho
correlations were used to investigate age and BMI differences in
Discussion
LF and SS measurements. In all statistical tests, a critical P value
of .05 was used.
This multicentre study of 312 patients describes the relationship
between DSSstanding/relaxed-seated and LF and evaluates whether
Results DSSstanding/relaxed-seated is an accurate measure to use during pre-
operative evaluation for spinal stiffness. Many reports in the liter-
A weak correlation between DSSstanding/relaxed-seated and LF was ature have evaluated the relationship between spinal stiffness,
identified (r2 ¼ 0.13) (Fig. 3). The ROC curve with DSS as a contin- pathology, and patient outcomes following THA and have demon-
uous variable demonstrated a corresponding area under the curve strated a link between spinal stiffness and poorer postoperative
(AUC) of 0.75 (Fig. 4). outcomes [16,26,27,31,32]. DSSstanding/relaxed-seated has been used
to infer THA patients’ pelvic mobility and as a surrogate for spinal
stiffness; however, no study to date has directly compared it to LF, a
metric considered the gold standard for defining lumbar spinal
stiffness [17e19,28]. DSSstanding/relaxed-seated measurements rely on
standing and relaxed-seated lateral x-rays. With a relaxed-seated
x-ray, the maximum potential movement of the spine is not
examined, and thus LF and lumbar spine stiffness cannot be directly
evaluated. Conversely, LF and spinopelvic measurements obtained
in the flexed-seated posture assess maximum spine movement and
offer a more representative view of lumbar spine mobility [9,29].

Table 2
DSS
10and Corresponding Sensitivity, Specificity, Positive and Negative Predictive
Values, and Positive and Negative Likelihood Ratios.

Statistical Measure Stiff Not-Stiff Total

Positive (DSS
10) 13 73 86

Negative (DSS >10) 6 220 226
19 293 312
Sensitivity 68%
Specificity 75%
1-specificity 25%
Positive Predictive Value 15%
Fig. 4. Receiver operating characteristic (ROC) curve with DSS as a continuous variable
Negative Predictive Value 97%
and the DSS
10 point identified. The corresponding area under the curve (AUC) is
Likelihood Ratio þ 2.72
0.75, indicating moderate classification accuracy of DSS as a predictor of true spinal
Likelihood Ratio  0.42
stiffness.
 A.K. Sharma et al. / The Journal of Arthroplasty 38 (2023) 713e718
Table 3
DSS >30and Corresponding Sensitivity, Specificity, Positive and Negative Predictive
Values, and Positive and Negative Likelihood Ratios.
Statistical Measure Stiff Not-Stiff Total
Positive (DSS >30) 1 41 42
Negative (DSS <30) 18 252 270
19 293 312
Sensitivity 14%
Specificity 95%
1-specificity 5%
Positive Predictive Value 98%
Negative Predictive Value 7%
Likelihood Ratio þ 2.66
Likelihood Ratio  0.91
This work evaluates DSSstanding/relaxed-seated and LF to determine
the correlation between the two measures in evaluating lumbar
spine stiffness. A recent study by Innmann et al has shown a higher
accuracy of detecting stiff lumbar spines in standing to deep-flexed
seated as opposed to standing to relaxed-seated radiographs, call-
ing into question the use of the relaxed-seated radiographs and
associated parameters, including DSSstanding/relaxed-seated, as more
than an assessment of pelvic position [17]. Therefore, the goals of
this study included comparing LF and DSSstanding/relaxed-seated in
preoperative assessments of lumbar spinal stiffness and assessing
the accuracy of DSSstanding/relaxed-seated in identifying THA patients
with stiff spines.
The data from this study reveal that DSSstanding/relaxed-seated is
not a measure that can be accurately used as a surrogate to ascer-
tain spinal stiffness, as there was a weak correlation between
DSSstanding/relaxed-seated and LF (r2 ¼ 0.13). The AUC of the ROC curve
was 0.75, indicating a moderate classification accuracy of DSS as a
predictor of true spinal stiffness. In addition, the positive predictive
value of the test variable (DSSstanding/relaxed-seated
10 ) was 15%,
indicating the overall poor predictive value of DSSstanding/relaxed-
seated for characterizing a stiff spine. Likewise, DSSstanding/relaxed-

seated >30 has a weak predictive value for characterizing a flexible
spine. Although the positive predictive value for the test variable
was 98%, the negative predictive value was 7%, indicating that a
high proportion of spines with normal flexibility were classified as
stiff. LF is the gold standard for directly evaluating lumbar spine
stiffness from the standing to flex-seated positions and should be
used to guide surgical decision-making and implant choices in THA.
Demographics were weakly associated with both stiffness
measurements. Patient age was most associated and showed that
older patients were more prevalent in the stiff group using both
techniques, although a stronger association was found with LF than
DSSstanding/relaxed-seated [33]. In contrast, BMI and gender demon-
strated differences in stiffness classification using the DSSstan-
ding/relaxed-seated but not the LF technique. The LF technique
therefore may be less impacted by demographics and more tar-
geted for identifying a stiff spine across a wider population.
This study is not without some limitations. It is not known
whether there was an appreciable difference in functional out-
comes between patients with a DSSstanding/relaxed-seated
10 and
those with LF
20 following THA as there are no outcomes data for
this cohort, including percentages of dislocations or other compli-
cations. Although this study explored the relationship between LF
and DSSstanding/relaxed-seated, it does not give guidance as to how
these results translate to postoperative clinical outcomes in a
general THA population. It should be noted that instability and
dislocation following THA is multifactorial and can be caused by
other factors in addition to spinal and pelvic mobility parameters,
such as surgical approach, failure to correct leg length, offset, and
femoral version, and failure to minimize bony, soft tissue, and
717
implant-related impingement risk. Innmann et al. have previously
reported on the poor utility of using the change in sacral slope as a
marker of lumbar spine stiffness, as there is little association be-
tween DSSstanding/relaxed-seated and LF [17]. However, future studies
can address the long-term clinical implications of these measures
when applied in practice, including functional outcomes and rates
of postoperative adverse events.
Conclusion
DSSstanding/relaxed-seated
10 was not correlated with a stiff
spine in this cohort. Using this simplified approach could lead to a
7-fold overprediction of patients with a stiff lumbar spine. This, in
turn, could lead to an overprediction of patients with abnormal
lumbar spine mobility, unnecessary use of dual mobility bearings,
and incorrect targets for component alignment. Overutilization of
dual-mobility implants can result in a corresponding increase in
dual-mobilityeassociated complications, including polyethylene
wear, backside metallosis, fretting corrosion at the taper-trunnion
interface, and intraprosthetic dislocation [34]. Referring to pa-
tients with DSSstanding/relaxed-seated
10 as being stiff is
misleading. The authors recommend the flexed-seated position to
effectively assess a patient’s spinal mobility prior to THA.
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Appendix

Supplementary Material

Associations between BMI, gender, and LF and DSSstanding/relaxed-seated

BMI and LF reported the weakest negative associate (r2 ¼ 0.035, P ¼ .001) and showed no difference in BMI between stiff and not-stiff
groups. A weak positive association was also identified between BMI and DSSstanding/relaxed-seated (r2 ¼ 0.030, P ¼ .003) in which stiff spines
reported a 1.3 kg/m2 lower BMI (26.8 versus 28.1, P ¼ .049). A difference was identified between gender and mean DSSstanding/relaxed-seated
(Male: 19.8 , Female: 16.5 , P ¼ .013) in which females were more likely to be classified as a stiff spine than males (34% versus 21%, P ¼ .006);
however, this association was not found for the LF measure.