Accepted Manuscript

The Current Knowledge on Spinopelvic Mobility

Zachary C. Lum, DO, John G. Coury, DO, Jonathan L. Cohen, MD, Lawrence D. Dorr,
MD

PII: S0883-5403(17)30702-7
DOI: 10.1016/j.arth.2017.08.013
Reference: YARTH 56043

To appear in: The Journal of Arthroplasty

Received Date: 23 May 2017

Revised Date: 6 August 2017
Accepted Date: 11 August 2017

Please cite this article as: Lum ZC, Coury JG, Cohen JL, Dorr LD, The Current Knowledge on
Spinopelvic Mobility, The Journal of Arthroplasty (2017), doi: 10.1016/j.arth.2017.08.013.

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 ACCEPTED MANUSCRIPT

The Current Knowledge on Spinopelvic Mobility

Zachary C. Lum, DOᶧ; John G. Coury, DOᶧ; Jonathan L. Cohen, MDᶧ, Lawrence D. Dorr, MDⱡ

Review performed at:

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ᶧValley Orthopedic Surgery Residency, Modesto, CA

Phone: (209) 578-1211

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Address: 1400 Florida Avenue Suite 200, Modesto, CA 95350
ⱡ

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Keck School of Medicine of University of Southern California, Los Angeles, CA

Address: 1520 Pablo Street Suite 2000, Los Angeles, CA 90033

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Zachary C. Lum, DO will handle correspondence at all stages of refereeing and publication and

also postpublication.
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Email: zacharylum@gmail.com
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Phone: 1 (209) 576-3506

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Address: 1400 Florida Avenue Suite 200, Modesto, CA 95350

Keywords: Spinopelvic alignment; spinopelvic mobility; total hip arthroplasty; dislocation; hip
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instability.
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1 Abstract

2 Recent studies may suggest our conventional knowledge of risk factors for dislocation may

3 need rethinking. Previous studies have demonstrated a large majority of total hip

4 arthroplasty (THA) instability with acetabular cups implanted in safe zones. Recently

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5 discovered spinopelvic motion is a coordinated biomechanical relationship between

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6 acetabular anteversion, pelvic tilt, and lumbar lordosis.

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8 Classification includes normal, hypermobile, stiff, stuck standing, stuck sitting and fused.

9 Normal spinopelvic motion from standing to sitting occurs with hip flexion, posterior sacral

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10 tilt and decreased lumbar lordosis to accommodate a flexed femur and prevent

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impingement and dislocation. Acetabular cup implantation ideally is adapted based upon
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12 spinopelvic interactions. This may lower the rate of impingement and subsequent

13 dislocation. These new biomechanical interactions may provide a better understanding of

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14 the safe zones of anteversion and inclination.

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15

16 Spinopelvic Motion
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17 The hip and the spine are coordinated together in a biomechanical concert. As one goes
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18 from standing to sitting, the sacrum tilts posteriorly, lumbar lordosis decreases, and the
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19 acetabulum anteverts more to accommodate a flexed femur thus avoiding impingement

20 and dislocation (Figure 1) [1-3,4-6]. Recent evidence suggests that if the sacrum is unable

21 to tilt posteriorly, such as in a lumbosacral fusion, the acetabulum cannot antevert and thus

22 impingement and dislocation may occur. Dislocation may occur based upon sacral tilt (a

23 surrogate for the position of the acetabulum) in sitting and standing. Additionally, if

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24 dislocation does not occur, the femur must undergo additional flexion in order to

25 accommodate the lack of sacral motion to reach a 90 degree sitting position. Multiple

26 studies have quantified the amount of motion each spinopelvic segment undergoes during

27 sitting and standing [7-9]. Normalized pelvic motion is considered 20-40 degrees

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28 difference between sacral tilt in sitting and standing on the lateral radiograph.

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29 Additionally, studies categorize groups of patients based upon spinopelvic balance, degree

30 of motion and position of the acetabulum.[10-14]

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31

32 Why should I care?

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33 Recent studies may suggest our conventional knowledge of risk factors for dislocation may

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need rethinking. Abdel et al [15] looked at 9784 primary THA procedures for which 206
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35 hips experienced a dislocation. They noted that 58% of the dislocations were in the

36 Lewinnek “safe zone” with an average cup abduction angle of 44 degrees and anteversion
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37 of 15 degrees.[15,16] Esposito et al [17] reported a 2.1% dislocation frequency from their

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38 cohort of 147 dislocators out of 7040 patients undergoing primary THA. They compared

39 randomized patient matched data between dislocators and nondislocators and found no
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40 difference between cup abduction angle and anteversion. They suggested that additional
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41 factors may play a role in hip instability.[17]

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43 Factors that contribute to increased incidence of THA dislocation include patient factors

44 (female gender, previous ipsilateral hip surgery, neuromuscular weakness), surgical factors

45 (component malpositioning, utilization of a posterior approach, osteotomy and avulsion of

46 the greater trochanter), and design factors (smaller prosthetic femoral head

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47 diameter).[16,18-23] While some of these factors have been identified and stratified to

48 reduce risk such as posterior capsule repair for posterior approach, larger diameter

49 femoral heads of 32-36mm and constrained or dual mobility bearings for neuromuscular

50 disorders or abductor insufficiency, there is a significant group of patients whose etiology

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51 for instability still unknown. Dorr et al [20] classified patients with hip dislocations by

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52 underlying etiology. While they attributed a majority to an identifiable cause, 17 percent of

53 patients had no known etiology. This may suggest other risk factors for instability not

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54 known at that time. While many hip surgeons were relying solely on AP radiographs to

55 determine acetabular cup position, some had begun to acknowledge there is a clear

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56 relationship between the pelvis and the spine that may influence instability.

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58 Who is at risk for it? Who isn’t?

59 Bedard et al. [24] evaluated the prevalence of dislocations in patients with concurrent
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60 spinopelvic fusion. They used their own institutional database as well as the PearlDiver
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61 database and found patients with concurrent spinopelvic fusion and THA to have a

62 dislocation rate of 20% and 8.3%, respectively. They concluded that this was an alarmingly
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63 high rate compared to control rates of 2.9%.

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65 Dorr et al [14] further investigated which type of patient was at risk for dislocation due to

66 spinopelvic imbalance. They categorized 40 THA dislocations into 3 groups: acute

67 dislocations after primary THA, acute dislocations after revision THA, and late dislocations

68 greater than 1 year. Radiographic measurements of pelvic incidence, sacral tilt, pelvic

69 femoral angle and ante-inclination were performed. They found few acute primary THA

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70 dislocations were the result of spinopelvic imbalance, however 70% of revision THA

71 dislocation and 87.5% of late dislocation were due to spinopelvic imbalance. The authors

72 concluded that in revision THA or late THA dislocation, perioperative management for

73 spinopelvic mobility should be initiated.

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74

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75 Several studies have recommended standing and sitting lateral radiographs for patients

76 undergoing THA to evaluate for spinopelvic imbalance, especially if there has been

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77 previous back surgery, spinal disease, or history of hip instability.[29,30,12-14] The lateral

78 radiograph is used to calculate ante-inclination, sacro-acetabular angle (SAA), and

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79 combined sagittal angle to determine risks for dislocation (Figure 1, Table 3). Additionally,

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hip abductor strength is evaluated to rule out weakness. With this information, patients can
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81 be categorized according to their ante-inclination angles and spinopelvic motion and

82 recommended, inclination and ante-inclination values (Table 1). If patients are in the stiff
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83 pelvii category, identification of cup position is critical to prevent impingement, subsequent

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84 dislocation, and obtain appropriate implant position.

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86 What are the categories?

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87 Spinal deformities of the lumbar spine can be based on flexibility and sagittal
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88 balance.[10,12-14,25-28] These factors are considered when performing hip arthroplasty.

89 Phan et al [10] described 4 categories of spinopelvic motion based on lumbar spine

90 pathology (Table 2). They included: (1) Flexible and balanced, (2) flexible and unbalanced,

91 (3) rigid and balanced, and (4) rigid and unbalanced.

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93 Flexible and balanced patients are those with no prior spinal conditions who have a fully

94 mobile spino-pelvic junction, a neutral sagittal balance and full compensation of the spine

95 to accommodate positional changes of the pelvis. Patients in the rigid and balanced group

96 demonstrated degenerative changes or prior long lumbosacral fusion resulting in a spine

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97 that is balanced while standing but lacks the ability to compensate with positional change.

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98 In these patients, acetabular anteversion will not increase with sitting causing loss of

99 functional flexion of the hip which can lead to anterior impingement and posterior

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100 dislocation. Flexible and unbalanced patients include those with post-laminectomy

101 kyphosis or neuromuscular kyphosis (eg. Parkinson’s or dystonic disorders). These

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102 patients will demonstrate increased pelvic retroversion and increased acetabular

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anteversion during standing to compensate for the sagittal imbalance. This can lead to
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104 posterior impingement and anterior dislocation when extending the hip. Finally, rigid and

105 unbalanced patients are those with significant ankyloses or long lumbosacral fusion with a
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106 resultant unbalanced spine in the standing and sitting positions. Their initial article
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107 categorized and treated patients based upon spinopelvic mobility and balance. While their

108 paper was helpful, it did not have suggestions upon specific perioperative management
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109 strategies, including preoperative radiographs.

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111 While the flexibility and sagittal balance classification by Phan et al was helpful, other

112 authors suggested additional classifications to help identify preoperative risks, suggest

113 intraoperative corrections and predict postoperative angles to lower risks of impingement

114 and dislocation. Kanawade et al [13] sought to predict acetabular inclination and

115 anteversion using radiographic parameters in sitting and standing. They categorized 85

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116 patients into 3 groups of spinopelvic motion depending on magnitude of posterior sacral

117 tilt when standing and sitting. Normal pelvic motion ranged from 20-35 degrees between

118 sitting and standing, with a stiff pelvis defined as pelvic motion less than 20 degrees and a

119 hypermobile pelvis defined as motion greater than 35 degrees (Figures 1-3). Additionally,

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120 they furthered the understanding of the sagittal cup measurement which they named ante-

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121 inclination (AI) by categorizing it according to dynamic spinopelvic motion and with

122 treatment recommendations according to their group (Table 1). They defined anti-

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123 inclination as the angle between the horizon and line between anterior and posterior

124 acetabulum on the lateral radiograph. Lastly, they suggested that while many total hip

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125 arthroplasties will never experience a dislocation, the understanding of spinopelvic

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mobility may help explain hip instability with no previous known etiology.
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128 Stefl et al [12] reported on a similar group of 160 THAs in 151 patients evaluating
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129 acetabular cup positions on sagittal radiographs utilizing ante-inclination and

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130 sacroacetabular angles for guidance to reduce impingement risks. They reported their

131 preoperative evaluation of 160 hips into 5 groups based upon the original Dorr
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132 classification of spinopelvic mobility (Table 4). They noted that while normal and
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133 hypermobile spinopelvic motion had almost no risk for impingement, fixed or fused
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134 spinopelvic motion had a higher risk for dislocation due to imbalance. Specifically, they

135 grouped these stiff pelvii into anterior tilt, posterior tilt, kyphotic, or fused (Figures 2-5).

136 Their analysis reported that while many of these hips are still safe from impingement, a

137 stiff fixed posterior tilted pelvis had a high risk for impingement even with correct

138 acetabular position. They further categorized these abnormal spinopelvic parameters into

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139 3 groups; pathologic imbalance: correct cup position did not overcome the spinal

140 imbalance and thus the patient remained a high risk for impingement; dangerous

141 imbalance: correct cup position allows for normalized ante-inclination and sacroacetabular

142 angles, but precise cup position is required; and inconsequential imbalance: an abnormal

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143 measurement of usually one angle that is clinically irrevelant. Lastly, they reported that

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144 83% of their hips were placed within normal AI and SAA values, 17% had abnormal values

145 with 7.5% inconsequential, 5% dangerous and 4.5% pathologic imbalance. They concluded

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146 that while careful preoperative and intraoperative component positioning will lower the

147 impingement risk factors, a small group of patients with stiff pelvii may still be at risk for

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148 dislocation.

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150 How do I measure it?

151 There are 3 measureable types of anteversion, described by Murray [11]. Anatomic
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152 anteversion is the angle between the transverse axis and the acetabular axis in the
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153 transverse plane. Radiographic anteversion is the angle between the coronal plane and the

154 acetabular axis, also called the planar anteversion and can be determined from lateral
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155 radiographs. Operative anteversion is the angle between the longitudinal axis of the
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156 patient and the sagittal plane.

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158 Sacral slope, pelvic tilt and pelvic incidence have been described in a geometric

159 relationship: Pelvic incidence (PI) = sacral slope (SS) + pelvic tilt (PT). These relations

160 were confirmed by multiple studies [11-13]. Bouley et al evaluated 149 healthy patients

161 with standing lateral radiographs and computerized tomography (CT) scans and compared

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162 the relationship between pelvic incidence, sacral slope and pelvic tilt within different

163 morphologic positions. They confirmed a strong relationship between the three

164 measurements, suggesting the spinopelvic equation is reliable for different positions and

165 morphologies[25].

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166

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167 This spinopelvic relationship was furthered by Lazennec et al again [2-4]. He compared

168 anatomic acetabular anteversion in 328 patients with THA in sitting and standing. They

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169 reported anteversion changed between supine (24.2 degrees), standing (31.7 degrees), and

170 sitting (38.8 degrees) and suggested a biomechanical theory for this. As the pelvis goes

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171 from standing to sitting, posterior tilt occurs, allowing increased anteversion for a flexed

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femur. If there is not sufficient anteversion, impingement may occur resulting in
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173 dislocation.

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175 Lembeck et al reported the relationship of pelvic tilt to acetabular anteversion [7]. They
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176 performed radiographic and ultrasonographic measurements on 30 healthy volunteers and

177 correlated the anteversion based on a mathematical formula. They reported for every 1
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178 degree of posterior pelvic tilt, 0.7 degrees of anteversion was created. Additionally, they
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179 defined the anterior pelvic plane (APP), a surrogate for pelvic tilt used in computer
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180 navigation. This was further studied by Babisch et al by measuring APP, CT scans and

181 standing radiographs in patients undergoing THA with and without computer navigation

182 [8]. They reported pelvic tilt varied between individuals, and suggested factoring pelvic tilt

183 into cup implantation may improve cup positioning. They reported no dislocations in the

184 pelvic tilt adjusted computer navigated group. Zhu et al reported their results of pelvic tilt

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185 and anteversion in 477 THAs with computer navigation [9]. They reported pelvic tilt was

186 present in 73% of their patients with 16% having more than a 10 degree magnitude of tilt.

187 Additionally, they confirmed that pelvic tilt affects acetabular anteversion by a conversion

188 factor of 1 degree of pelvic tilt for 0.7 degrees of anteversion. They suggested that

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189 measuring pelvic tilt may improve the accuracy of cup anteversion.

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190

191 Lazennec et al described an angle between the sacral slope and the acetabular sagittal tilt

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192 or ante-inclination angle on the lateral radiograph called the sacro-acetabular angle (SAA)

193 [5]. Similar to the pelvic incidence, the angle described is a fixed number that does not

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194 change with position. Radcliff et al [6] evaluated the relationship between spine and pelvic

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alignment using CT scans of 164 patients. They noted that SAA was influenced by
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196 increasing PI and acetabular wall coverage. Additionally, they commented that although

197 SAA was a static pelvic parameter similar to PI, SAA was different than PI in that it was
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198 affected by acetabular anteversion. Thus, SAA appeared to be a reproducible angle that
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199 may be more help to the arthroplasty surgeon to predict anteversion effects from the spine.

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201 How should we treat or manage abnormal spinopelvic motion?

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202 Total hip arthroplasty has been a successful surgery with an overall low complication rate.
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203 Recent studies have suggested that hip instability due to spinopelvic imbalance is more

204 often associated with late dislocations and revision THAs, not primary THA [12,14]. This

205 may suggest, although spinopelvic motion exists in all patients, pathologic, or only hips at

206 may benefit the most with evaluation of lateral radiographs in sitting and standing

207 positions. Additional studies are needed to determine confirm or refute this. It is the

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208 position of the senior author that all THA patients should be evaluated with lateral

209 radiographs in sitting and standing position.

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211 One author suggested acetabular cup positions be implanted according to their 4 categories

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212 of flexibility and balance.[10] Flexible and balanced spinopelvic motion should have

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213 acetabular anteversion be dictated by surgeon preference but be within the safe zone of 5

214 to 25 degrees. Rigid and balanced may benefit from acetabular component placement more

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215 anteverted to help correct relative acetabular retroversion while sitting. Flexible and

216 balanced have two suggested treatment pathways; the first being spinal fusion in a

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217 balanced position, placing them in the rigid and balanced category (this provides a more

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predictable outcome in terms of dislocation rates). The second option is to proceed with
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219 THA with acetabular component placement more replicating that of the balanced patient (if

220 these patients later undergo spinal fusion they may require acetabular component revision.
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221 Lastly, rigid and unbalanced patients also have two treatment pathways based on their
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222 probability of future spinal surgery. The first being, spinal re-alignment surgery to place

223 them in the rigid and balanced category and the second is to proceed with THA attempting
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224 to place the acetabular component in a position to balance the patients. In the second
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225 treatment modality the acetabular component may, again, require revision following a
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226 spinal realignment.

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228 Other authors [12,13] suggested that normal and hypermobile pelvii tend to be tolerant of

229 cup position, impingement and instability due to normal spinopelvic biomechanics. During

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230 cup implantation, maintaining normal surgical technique and regular cup safe zone

231 implantation of 15° +/- 10° anteversion and 40° +/- 10° inclination is recommended.

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233 Stefl & Dorr et al [12,13] recommended that stiff pelvii, which demonstrate less than 10

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234 degrees of sacral tilt change between sitting and standing, are categorized by the

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235 acetabular position they are in. The “stuck standing” or posterior tilt position indicates a

236 more horizontal acetabulum and anterior impingement thus posterior dislocation risk

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237 (Figure 4). “Stuck sitting” or anterior tilt position indicates possible posterior

238 impingement and anterior instability (Figure 3). These positions of the cup help guide the

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239 surgeon to the ideal location for cup implantation. Goals of cup position in a stiff

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spinopelvic class is 45-50 inclination (50 degrees in elderly patients and 45 degrees in
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241 younger patients) and 20-25 anteversion with a combined anteversion of 35-40.

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243 Dual mobility articulation is considered if a patient’s ante-inclination values change less
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244 than 5° between sitting and standing, meaning the acetabulum does not accommodate in

245 spinopelvic motion and is at pathologic risk for dislocation. Additionally, if ante-inclination
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246 values are greater than 75 degrees in sitting, the femoral head can dislocate posteriorly due
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247 to falling out of cup, a term coined “drop out dislocation.” Drop out dislocation occurs
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248 during flexion and results from the femoral head exceeding the jump distance of the

249 inferior edge of the cup due to the loss of protection of the cup at the egress site. These

250 patients may benefit from dual mobility articulation as well.

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252 Conclusion

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253 The hip and spine coexist in a biomechanical coordination that highlight an additional

254 etiology of THA instability. Understanding the spinopelvic classifications, location and risk

255 factors for impingement are paramount to treatment. Surgeons must determine if the

256 pelvis is in a standing, sitting or fusion position, and address cup placement based upon

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257 spinopelvic motion. More studies are necessary to further study the relationship between

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258 spinopelvic motion and instability.

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369 Figure 1: Standing and sitting lateral spinopelvic-hip x-ray of patient with normal motion.

370 Standing is on the left and pelvic incidence (PI) = 60° which is high normal; the sacral tilt
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371 (ST) = 41°; the pelvic femoral angle (PFA) = 189°; the anteinclination (AI) of the bony
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372 acetabulum = 34°; sacral acetabular angle (SAA) = 75°. On the right is the sitting x-ray and

373 the PI and SAA are static numbers which remain the same. As the patient sits, the lumbar
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374 spine straightens and the pelvis tilts posteriorly the sacral tilt becomes 16° (∆ST = 25°); AI
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375 = 59°; and PFA = 142°. This is within the normal pelvic motion.
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376

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378

379
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Figure 2: Postoperative standing and sitting lateral spinopelvic hip x-rays of a stuck sitting
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380 pattern. Pelvic incidence (PI) is low at 35°, a typical x-ray finding which is seen with a stiff

381 pelvis category. The ∆ST is 3° (27°-24°) which is pathologic stiffness. Likewise, the ante-
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382 inclination (AI) change is 3° as this mirrors the sacral tilt. The PFA is normal standing, but
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383 shows increased flexion sitting (186°-109°) due to the inability of the pelvis to tilt

384 posteriorly, thus the femur must flex more, increasing a risk for impingement and
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385 subsequent dislocation. The intraoperative cup angles were inclination 45°, anteversion

386 21° and combined anteversion 33°. Because of the low AI combined with low PFA in sitting
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387 this patient is at risk for posterior dislocation. Increased cup inclination/anteversion and
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388 combined anteversion would have resulted in a higher AI and reduced the risk for

389 posterior dislocation (this hip did not dislocate). This patient is a candidate for dual

390 mobility articulation due to the spinopelvic impingement risk factors.

391

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392

393

394

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395

396 Figure 3: Radiograph of stuck sitting/kyphotic pattern with ST 14° standing to 3° sitting.
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397 The standing PFA of 215° caused posterior bony impingement and anterior dislocation in
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398 this patient. Anterior dislocation with this pattern requires bony excision of the posterior
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399 greater trochanter because that is the cause of the anterior dislocation.

400
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401
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407

408

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409

410 Figure 4: Preoperative standing and sitting lateral spinopelvic-hip x-rays of stuck standing
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411 pattern. The ST is 44° standing and 39° sitting which is pathologic stiffness. This is
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412 commonly associated with a high pelvic incidence (PI = 73°). The standing anteinclination

413 (AI) = 52° which is high normal PI but not abnormally high PI. The sitting AI of 57° is at low
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414 normal for a high PI. This pattern is unlikely to change postoperatively because the

415 standing ST is 44° so the cup needs to be placed anteverted or anterior impingement and
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416 subsequent posterior dislocation may result. Consideration for dual mobility or removal of
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417 anterior impinging structures is reasonable to prevent posterior dislocation.

418

419

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421 Table 1: Ante-Inclination & sacral tilt values according to the Dorr classification of
422 spinopelvic mobility
Mean and Standard Deviation (Range) (deg)
Parameter Stiff (S) Normal (N) Hypermobile (H) P Value
Ante-inclination
Standing 30.3 ± 7 (12 to 29.1 ± 8.7 (5 to 31.5 ± 9.4 (20 to No significant
39) 47) 48) difference

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Sitting 49.1 ± 8 (36 to 54.4 ± 9 (32 to 64.4 ± 12.8 (40 to S vs. H < 0.0005
60) 75) 79) N vs. H = 0.006
Difference 18.8 ± 6 (2 to 25.3 ± 9.4 (5 to 32.9 ± 8.6 (20 to 46) S vs. N = 0.02

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between standing 24) 44) S vs. H < 0.0005
and sitting† N vs. H = 0.01
Inclination† 38.6 ± 3.5 (31 39.4 ± 3.5 (31 39.2 ± 3 (34 to 44) No significant

SC
to 45) to 48) difference
Anteversion† 22.1 ± 4.7 (14 21.9 ± 4.4 (12 24.8 ± 4.3 (17 to No significant
to 31) to 31) 30) difference

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Mean and Standard Deviation (Range) (deg)
Sacral Tilt Stiff (S) Normal (N) Hypermobile (H) P Value
Standing
Preoperative 35.3 ± 8.6 (22 to
52)
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39 ± 8.8 (17 to
60)
47.8 ± 5.5 (38 to 57) S vs. H = 0.001
N vs. H = 0.005
Postoperative 33 ± 6.6 (24 to 38.1 ± 8.5 (20 to 45.5 ± 9 (31 to 62) N vs. H <0.0005
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47) 59) N vs. H = 0.01
Sitting
Preoperative 20.7 ± 9.4 (4 12.4 ± 8.1 (-11 10.8 ± 4 (3 to 15) S vs. N = 0.001
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to 41) to 34) S vs. H = 0.005

Postoperative 15.6 ± 11.7 (- 13.1 ± 9.1 (-10 10.8 ± 4 (3 to 15) No significant
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13 to 31) to 43) difference

423 †Inclination and anteversion are the angles of the cup achieved intraoperatively as

424 measured by computer navigation. † The p value indicates a significant difference between
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425 preoperative and postoperative values.

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428 Table 2: Spinopelvic mobility classification based on spinal flexibility and balance.
Balanced Unbalanced
Flexible Acetabular component Spinal Realignment followed by THA – component
anteversion from 5 to 25 anteversion from 15 to 25 deg
deg OR
Primary THA – kyphotic – decrease component
anteversion

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Rigid Acetabular component Spinal realignment followed by THA – component
anteversion from 15 to anteversion from 15 to 25 deg
25 deg OR

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Primary THA – kyphotic – decrease component
anteversion
429 THA: total hip arthroplasty. Reproduced with modification. Phan D, Bederman SS,

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430 Schwarzkopf R. The influence of sagittal spinal deformity on anteversion of the

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431 acetabular component in total hip arthroplasty. Bone Joint J. 2015 Aug;97-B(8):1017-

432

433
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435 Table 3: Spinopelvic measurements on the lateral hip radiograph

Angle Name How to Measure/What it means

Sacral Tilt Angle between the sacral slope & a horizontal reference
line.

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A surrogate marker for pelvic tilt

Pelvic Incidence Angle centered at mid sacral base, perpendicular to the

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sacral base and center of the femoral heads.

Constant value that does not change with sitting and

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standing.

Ante-inclination Angle between a line from anterior & posterior wall and a
horizontal reference line.

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Sacro Acetabular Angle
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Angle between a line from anterior & posterior wall and
sacral slope
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Proximal Femoral Angle Angle centered at femoral head, between mid sacral base
and down femoral shaft
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During spinopelvic motion, the femur flexes along with

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sacral tilt to accommodate a 90 degree sitting pattern. The

flex must flex more or less in accordance to the amount of
sacral motion.
EP

436

437
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438

439 Table 4: Understanding spinopelvic mobility with cup implantation recommendations

Spinopelvic Sacral Tilt angle b/t Treatment Goals
Motion sitting & standing
Normal 20-40° b/t sitting and 35-45° Inclination
standing 15-25° Anteversion

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Hypermobile >30°b/t sitting and 35-40° Inclination
standing 15-20° Anteversion
Stiff <10° b/t sitting and Anterior Tilt 45-50° Inclinationᶧ

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standing (stuck standing) 20-25° Anteversion
Standing ST <30° 35-40° Combined
Posterior Tilt (stuck anteversion

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sitting) Consider dual
Sitting ST >30° mobility articulation
Fused

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<5° ST change
Kyphotic Risk for dropout

440
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Sitting ST <5° dislocation due to AI
<75°
ᶧ50 degrees inclination is only advised for elderly, wear increases with >45 degrees in
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441 young patients. b/t: between, ST: sacral tilt, AI: ante-inclination.

442
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443
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