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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- of patients aged 60 years or older at 10 years [1,2]. Although
effective procedure for hip osteoarthritis, with estimates of THA is a well-established option for improving patient’s quality
survival of up to 25 years in up to 58% of patients, including 96% 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
One or more of the authors of this paper have disclosed potential or pertinent the biomechanics and coordinated motion of the spine, hip, and
conflicts of interest, which may include receipt of payment, either direct or indirect, pelvis in patients with spinal stiffness may lead to unpredictable
institutional support, or association with an entity in the biomedical field which changes in pelvic motion during the transition from standing to
may be perceived to have potential conflict of interest with this work. For full
seated and therefore alter functional cup orientation and lead to
disclosure statements refer to https://doi.org/10.1016/j.arth.2022.05.020.
* Address correspondence to: Jonathan M. Vigdorchik, MD, Hospital for Special inferior patient-reported outcomes, impingement, instability,
Surgery, 535 E 70th St, New York, NY 10021. 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. Three hundred and twelve consecutive patients evaluated met
Spinal stiffness affects pelvic rollback during the transition the radiographic inclusion criteria and had adequate supine ante-
between the standing and seated positions and can result in an roposterior (AP) pelvis x-rays followed by standing, relaxed-seated,
increased risk of impingement [22e24]. As such, it is an and flexed-seated lateral spinopelvic imaging to undergo complete
essential parameter to measure preoperatively and account for spinopelvic evaluation.
intraoperatively. The assessment for identifying patients with This cohort consisted of 172 (55%) females and 140 (45%) males
stiff lumbar spines is not standardized in the literature, and with a mean age of 66 years (range: 23-90) and body mass index
there are two methods commonly used: (1) pelvic mobility and (BMI) of 27.1 (range: 19.8-43.3) (Table 1). One hundred and sixty
sacral slope (SS) as surrogate markers of spinal stiffness between eight (54%) patients received right THAs and 144 (46%) received left
the standing and relaxed-seated positions and (2) lumbar spine THAs.
flexion between the standing and deep-flexed seated positions
[14,25e27]. While pelvic mobility is assessed by changes in SS
Radiographic Analysis
from standing to relaxed-seated positions (DSSstanding/relaxed-
seated), with DSSstanding/relaxed-seated of 10 being used to infer

The preoperative images included supine AP pelvis x-rays
spinopelvic stiffness, lumbar flexion (LF) is defined by the
followed by standing, relaxed-seated, and flexed-seated lateral
change in lumbar lordosis (LL) from the standing to flexed-
spinopelvic imaging. Each institution in this multicenter study
seated position and is used to define the stiffness of the lum-
performed the requisite imaging using this standardized
bar spine [18,19].
protocol.
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, Lumbar Spine and Pelvis Evaluation and Spinopelvic Measurements
however, one does not test the maximum potential movement of From these images the lumbar spine and pelvis were evaluated
the spine as it is not a position of testing functional-seated capacity as follows:
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 (1) SS (Fig. 1):
in assessing maximum spine movement, which is measured to a. SS is the angle between a horizontal reference line and a
calculate LF [9,17,28,29]. Recent literature has shown no correlation line parallel to the superior endplate of S1.
between true LF and pelvic mobility from the standing to relaxed- b. The change of SS between the standing and relaxed-
seated positions and a significantly greater identification of pa- seated positions DSSstanding/relaxed-seated was used to
tients with stiff lumbar spines using the flexed-seated position, quantify pelvic mobility.
challenging the use of SS as more than an assessment of the posi- a. Other authors have suggested that limited pelvic
tion of the pelvis in space and as a valid measure of spinal stiffness mobility (DSSstanding/relaxed-seated 10 ) can be used to
[15,17]. characterize a stiff spine [18,19].
Therefore, the aims of this study were to (1) characterize the b. Pelvic hypermobility has been defined as DSSstan-

correlation of radiographic spinopelvic measurements performed ding/relaxed-seated > 30 [23,27,30].
with two different assessments during transitions from the (2) LF (Fig. 2):
standing to seated functional positions and (2) test how accurately a. LL was calculated from the standing lateral x-ray as the
DSSstanding/relaxed-seated can identify patients with a stiff spine and Cobb angle between a line drawn at the superior endplate
whether it can be used to infer a stiff spine. 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:
Methods
i. Lumbar flexion  20 was used to define a stiff lumbar
spine [7,15,16].
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 Outcomes of Interest
(Germany) and identical data obtained as part of standard of care
(AUS) were reviewed. All patients who underwent THA received These spinal and pelvic mobility assessments were measured for
preoperative functional x-ray imaging series and exclusion criteria all patients. DSSstanding/relaxed-seated was calculated, the correlation
included those with obvious pathologic spinopelvic characteristics between DSSstanding/relaxed-seated and LF computed, and the pre-
including large sagittal spinal deformities and lumbar spine dictive value of DSSstanding/relaxed-seated for characterizing a stiff
fusions. 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 percentages were used to report all discrete variables. A linear
regression was used to model the relationship between LF and SS,
Spinopelvic measurements were performed by multiple with the coefficient of determination (r2) calculated to explain
qualified engineers for each patient studied, as part of the pre- the proportion of variance between the two variables. A receiver
operative functional planning process. A statistical analysis was operating characteristic (ROC) curve with DSSstanding/relaxed-seated
performed using SPSS software (version 26.0, Armonk, NY: IBM as a continuous variable was used to measure the classification
Corp.). Internal consistency and reliability between observer accuracy of DSSstanding/relaxed-seated as a predictor of true spinal
spinopelvic measurements were assessed by the intraclass cor- stiffness, defined by a LF 20 . DSSstanding/relaxed-seated 10 and
relation coefficient (ICC). Data analysis included descriptive sta- >30 were tested as thresholds on the ROC from which corre-
tistics with reported means and standard deviations for sponding sensitivity, specificity, positive and negative predictive
continuous variables of the study population. Frequencies and 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.

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
DSS10and 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 717

Table 3 implant-related impingement risk. Innmann et al. have previously


DSS >30and Corresponding Sensitivity, Specificity, Positive and Negative Predictive reported on the poor utility of using the change in sacral slope as a
Values, and Positive and Negative Likelihood Ratios.
marker of lumbar spine stiffness, as there is little association be-
Statistical Measure Stiff Not-Stiff Total tween DSSstanding/relaxed-seated and LF [17]. However, future studies
Positive (DSS >30) 1 41 42 can address the long-term clinical implications of these measures
Negative (DSS <30) 18 252 270 when applied in practice, including functional outcomes and rates
19 293 312 of postoperative adverse events.
Sensitivity 14%
Specificity 95%
1-specificity 5% Conclusion
Positive Predictive Value 98%
Negative Predictive Value 7%
Likelihood Ratio þ 2.66 DSSstanding/relaxed-seated 10 was not correlated with a stiff
Likelihood Ratio  0.91 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,
This work evaluates DSSstanding/relaxed-seated and LF to determine
and incorrect targets for component alignment. Overutilization of
the correlation between the two measures in evaluating lumbar
dual-mobility implants can result in a corresponding increase in
spine stiffness. A recent study by Innmann et al has shown a higher
dual-mobilityeassociated complications, including polyethylene
accuracy of detecting stiff lumbar spines in standing to deep-flexed
wear, backside metallosis, fretting corrosion at the taper-trunnion
seated as opposed to standing to relaxed-seated radiographs, call-
interface, and intraprosthetic dislocation [34]. Referring to pa-
ing into question the use of the relaxed-seated radiographs and
tients with DSSstanding/relaxed-seated 10 as being stiff is
associated parameters, including DSSstanding/relaxed-seated, as more
misleading. The authors recommend the flexed-seated position to
than an assessment of pelvic position [17]. Therefore, the goals of
effectively assess a patient’s spinal mobility prior to THA.
this study included comparing LF and DSSstanding/relaxed-seated in
preoperative assessments of lumbar spinal stiffness and assessing
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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.

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