A stiff spine leads to increased demand on the hip, creating an increased risk of total hip arthroplasty (THA) dislocation. Several authors propose that a change in sacral slope of ≤10° between the standing and relaxed-seated positions (ΔSSstanding→relaxed-seated) identifies a patient with a stiff lumbar spine and have suggested use of dual-mobility bearings for such patients. However, such assessment may not adequately test the lumbar spine to draw such conclusions. The aim of this study was to assess how accurately ΔSSstanding→relaxed-seated can identify patients with a stiff spine. This is a prospective, multi-centre, consecutive cohort series. Two-hundred and twenty-four patients, pre-THA, had standing, relaxed-seated and flexed-seated lateral radiographs. Sacral slope and lumbar lordosis were measured on each functional X-ray. ΔSSstanding→relaxed-seated seated was determined by the change in sacral slope between the standing and relaxed-seated positions. Lumbar flexion (LF) was defined as the difference in lumbar lordotic angle between standing and flexed-seated. LF≤20° was considered a stiff spine. The predictive value of ΔSSstanding→relaxed-seated for characterising a stiff spine was assessed. A weak correlation between ΔSSstanding→relaxed-seated and LF was identified (r2= 0.15). Fifty-four patients (24%) had ΔSSstanding→relaxed-seated ≤10° and 16 patients (7%) had a stiff spine. Of the 54 patients with ΔSSstanding→relaxed-seated ≤10°, 9 had a stiff spine. The positive predictive value of ΔSSstanding→relaxed-seated ≤10° for identifying a stiff spine was 17%. ΔSSstanding→relaxed-seated ≤10° was not correlated with a stiff spine in this cohort. Utilising this simplified approach could lead to a six-fold overprediction of patients with a stiff lumbar spine. This, in turn, could lead to an overprediction of patients with abnormal spinopelvic mobility, unnecessary use of dual mobility bearings and incorrect targets for component alignment. Referring to patients ΔSSstanding→relaxed-seated ≤10° as being stiff can be misleading; we thus recommend use of the flexed-seated position to effectively assess pre-operative spinopelvic mobility

Introduction. Spatial orientation of the pelvis in the sagittal plane is a key parameter for hip function. Pelvic extension (or retroversion) and pelvic flexion(or anteversion) are currently assessed using Sacral Slope (SS) evaluation (respectively SS decrease and SS increase). Pelvic retroversion may be a risk situation for THA patients. But the magnitude of SS is dependant on the magnitude of pelvic incidence (PI) and may fail to discriminate pelvic position due to patient's anatomy and the potential adaptation mechanisms: a high PI patient has a higher SS but this situation can hide an associated pelvic extension due to compensatory mechanisms of the pelvic area. A low PI patient has a lower SS with less adaptation possibilities in case of THA especially in aging patients. The individual relative pelvic version (RPV) is defined as the difference between « measured SS » (SSm) minus the « normal SS »(SSn) described for the standard population. The aim of the study was to evaluate RPV in standing and sitting position with a special interest for high and low PI patients. Materials and Methods. 96 patients without THA (reference group) and 96 THA patients were included. Pelvic parameters (SS and PI) were measured on standing and sitting EOS images. RPV standing (SSm-SSn) was calculated using the formula SSm – (9 + 0.59 × PI) according to previous publications. SSn in sitting position was calculated according to PI using linear regression: RPV sitting was calculated using the formula RPV = SS – (3,54+ 0,38 × PI). Three subgroups were defined according to pelvic incidence (PI): low PI <45°, 45°<normal PI<65° or high PI>65°. Results. For THA patients, pelvic parameters were:. SSm standing 41° (SD 11°; 8°.73°). SSm sitting 25° (SD 12°;−3°.54°). SSm variation 16°(SD 11°; 9°.46°). RPV standing −2°(SD 9°; −27°.21°). RPV sitting 7° (SD 10; −15°.29°). For non THA patients, pelvic parameters were:. SSm standing39° (SD 10°; 13°.63°). SSm sitting 17° (SD 11°;−5°.48°). SSm variation 27°(SD 13°; −27°.46°). RPV standing −1°(SD 7°; −29°.12°). RPV sitting 0° (SD 10,5; −29.35). Standing-sitting SS variations and RPV were not correlated with PI. Low PI incidence patients had very low RPV standing and sitting. In non THA patients RPV standing and sitting were very low. In THA patients standing-sitting SS variations and RPV were higher than for non THA patients. Sitting RPV was higher than in standing position. Discussion, Conclusion. The overall analysis of SS has limitations: higher or lower SS may be linked to 2 factors: pelvic morphology (PI) and sagittal orientation of the pelvis. RPV and PI were not correlated: a higher or lower value of RPV directly represents the sagittal orientation of the pelvis. Low PI patients have a specific postural pattern with low pelvic adaptability. THA patients specificity for RPV needs further studies for understanding the impact on postoperative rebalancing and instability problems

Aims. Spinopelvic characteristics influence the hip’s biomechanical behaviour. However, to date there is little knowledge defining what ‘normal’ spinopelvic characteristics are. This study aims to determine how static spinopelvic characteristics change with age and ethnicity among asymptomatic, healthy individuals. Methods. This systematic review followed the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines to identify English studies, including ≥ 18-year-old participants, without evidence of hip or spine pathology or a history of previous surgery or interventional treatment, documenting lumbar lordosis (LL), sacral slope (SS), pelvic tilt (PT), and pelvic incidence (PI). From a total of 2,543 articles retrieved after the initial database search, 61 articles were eventually selected for data extraction. Results. When all ethnicities were combined the mean values for LL, SS, PT, and PI were: 47.4° (SD 11.0°), 35.8° (SD 7.8°), 14.0° (SD 7.2°), and 48.8° (SD 10°), respectively. LL, SS, and PT had statistically significant (p < 0.001) changes per decade at: −1.5° (SD 0.3°), −1.3° (SD 0.3°), and 1.4° (SD 0.1°). Asian populations had the largest age-dependent change in LL, SS, and PT compared to any other ethnicity per decade at: −1.3° (SD 0.3°) to −0.5° (SD 1.3°), –1.2° (SD 0.2°) to −0.3° (SD 0.3°), and 1.7° (SD 0.2°) versus 1.1° (SD 0.1°), respectively. Conclusion. Ageing alters the orientation between the spine and pelvis, causing LL, SS, and PT to modify their orientations in a compensatory mechanism to maintain sagittal alignment for balance when standing. Asian populations have the largest degree of age-dependent change to their spinopelvic parameters compared to any other ethnicity, likely due to their lower PI. Cite this article: Bone Joint Res 2023;12(4):231–244

Aims. Computer-assisted 3D preoperative planning software has the potential to improve postoperative stability in total hip arthroplasty (THA). Commonly, preoperative protocols simulate two functional positions (standing and relaxed sitting) but do not consider other common positions that may increase postoperative impingement and possible dislocation. This study investigates the feasibility of simulating commonly encountered positions, and positions with an increased risk of impingement, to lower postoperative impingement risk in a CT-based 3D model. Methods. A robotic arm-assisted arthroplasty planning platform was used to investigate 11 patient positions. Data from 43 primary THAs were used for simulation. Sacral slope was retrieved from patient preoperative imaging, while angles of hip flexion/extension, hip external/internal rotation, and hip abduction/adduction for tested positions were derived from literature or estimated with a biomechanical model. The hip was placed in the described positions, and if impingement was detected by the software, inspection of the impingement type was performed. Results. In flexion, an overall impingement rate of 2.3% was detected for flexed-seated, squatting, forward-bending, and criss-cross-sitting positions, and 4.7% for the ankle-over-knee position. In extension, most hips (60.5%) were found to impinge at or prior to 50° of external rotation (pivoting). Many of these impingement events were due to a prominent ischium. The mean maximum external rotation prior to impingement was 45.9° (15° to 80°) and 57.9° (20° to 90°) prior to prosthetic impingement. No impingement was found in standing, sitting, crossing ankles, seiza, and downward dog. Conclusion. This study demonstrated that positions of daily living tested in a CT-based 3D model show high rates of impingement. Simulating additional positions through 3D modelling is a low-cost method of potentially improving outcomes without compromising patient safety. By incorporating CT-based 3D modelling of positions of daily living into routine preoperative protocols for THA, there is the potential to lower the risk of postoperative impingement events. Cite this article: Bone Jt Open 2023;4(6):416–423

Aims. This study aimed to evaluate sagittal spinopelvic alignment (SSPA) in the early stage of rapidly destructive coxopathy (RDC) compared with hip osteoarthritis (HOA), and to identify risk factors of SSPA for destruction of the femoral head within 12 months after the disease onset. Methods. This study enrolled 34 RDC patients with joint space narrowing > 2 mm within 12 months after the onset of hip pain and 25 HOA patients showing femoral head destruction. Sharp angle was measured for acetabular coverage evaluation. Femoral head collapse ratio was calculated for assessment of the extent of femoral head collapse by RDC. The following parameters of SSPA were evaluated using the whole spinopelvic radiograph: pelvic tilt (PT), sacral slope (SS), pelvic incidence (PI), sagittal vertical axis (SVA), thoracic kyphosis angle (TK), lumbar lordosis angle (LL), and PI-LL. Results. The HOA group showed higher Sharp angles compared with the RDC group. PT and PI-LL were higher in the RDC group than the HOA group. SS and LL were lower in the RDC group than the HOA group. No difference was found in PI, SVA, or TK between the groups. Femoral head collapse ratio was associated with PT, SS, SVA, LL, and PI-LL. A PI-LL > 20° and a PT > 30° correlated with greater extent of femoral head destruction by RDC. From regression analysis, SS and SVA were significantly associated with the femoral head collapse ratio within 12 months after disease onset. Conclusion. Compared with HOA, RDC in the early stage correlated with sagittal spinopelvic malalignment. SS and SVA may partially contribute to the extent of femoral head destruction by RDC within 12 months after the onset of hip pain. The present study indicates a potential role of SSPA assessment in identification of RDC patients at risk for subsequent bone destruction. Cite this article: Bone Jt Open 2022;3(1):77–84

Aims

Precise implant positioning, tailored to individual spinopelvic biomechanics and phenotype, is paramount for stability in total hip arthroplasty (THA). Despite a few studies on instability prediction, there is a notable gap in research utilizing artificial intelligence (AI). The objective of our pilot study was to evaluate the feasibility of developing an AI algorithm tailored to individual spinopelvic mechanics and patient phenotype for predicting impingement.

Introduction. Patients with abnormal spinopelvic mobility are at increased risk for hip instability. Measuring the change in sacral slope (ΔSS) with standing and seated lateral radiographs is commonly used to determine spinopelvic mobility pre-operatively. Sacral slope should decrease at least 10 degrees to demonstrate adequate accommodation. Accommodation of <10 deg necessitates acetabular component position change or use of a dual mobility implant. There is potential for different ΔSS measurements in the same patient based on sitting posture. Methods. 78 patients who underwent THA were reviewed to quantify the variability in pre-operative spinopelvic mobility when two different seated positions (relaxed sitting v. pre-rise sitting) were used in the same patient. Results. 34 patients had standardized pre-rise sitting x-rays, while 44 patients had standardized relaxed sitting x-rays. Of the 44 patients with relaxed sitting x-rays, the mean ΔSS (ΔrSS) was 20.4 degrees. No patients exhibited an increase in sacral slope when sitting (ie; reverse accommodation). Of the 34 patients with pre-rise sitting x-rays, the mean pre-rise sit-stand change (ΔprSS) was only 1.85 degrees with 47% (16/34) showing reverse accommodation, actually increasing the seated sacral slope compared to standing sacral slope. 18 patients had both pre-rise and relaxed sitting x-rays. In patients with both seated x-rays, the mean relaxed sit-stand change in sacral slope (ΔrSS) was 18.1 ± 6.1 degrees and only 3.0 ± 10.5 degrees for pre-rise sit-stand (ΔprSS), with a mean ΔSS difference of the 15.1 degrees (p <0.0001). Conclusion. A 15 degrees error could be made in pre-operative planning depending on the seated posture of the patient. Since decisions on component position or use of dual-mobility are made on pre-operative lateral sit-stand radiographs, postural standardization is critical. The relaxed seated radiograph is the preferred posture at the time of the seated lateral radiograph. For any tables or figures, please contact the authors directly

Aims. The aim of this study was to evaluate the reliability and validity of a patient-specific algorithm which we developed for predicting changes in sagittal pelvic tilt after total hip arthroplasty (THA). Methods. This retrospective study included 143 patients who underwent 171 THAs between April 2019 and October 2020 and had full-body lateral radiographs preoperatively and at one year postoperatively. We measured the pelvic incidence (PI), the sagittal vertical axis (SVA), pelvic tilt, sacral slope (SS), lumbar lordosis (LL), and thoracic kyphosis to classify patients into types A, B1, B2, B3, and C. The change of pelvic tilt was predicted according to the normal range of SVA (0 mm to 50 mm) for types A, B1, B2, and B3, and based on the absolute value of one-third of the PI-LL mismatch for type C patients. The reliability of the classification of the patients and the prediction of the change of pelvic tilt were assessed using kappa values and intraclass correlation coefficients (ICCs), respectively. Validity was assessed using the overall mean error and mean absolute error (MAE) for the prediction of the change of pelvic tilt. Results. The kappa values were 0.927 (95% confidence interval (CI) 0.861 to 0.992) and 0.945 (95% CI 0.903 to 0.988) for the inter- and intraobserver reliabilities, respectively, and the ICCs ranged from 0.919 to 0.997. The overall mean error and MAE for the prediction of the change of pelvic tilt were -0.3° (SD 3.6°) and 2.8° (SD 2.4°), respectively. The overall absolute change of pelvic tilt was 5.0° (SD 4.1°). Pre- and postoperative values and changes in pelvic tilt, SVA, SS, and LL varied significantly among the five types of patient. Conclusion. We found that the proposed algorithm was reliable and valid for predicting the standing pelvic tilt after THA. Cite this article: Bone Joint J 2024;106-B(1):19–27

Introduction. Optimal implant position is critical to hip stability after total hip arthroplasty (THA). Recent literature points out the importance of the evaluation of pelvic position to optimize cup implantation. The concept of Functional Combined Anteversion (FCA), the sum of acetabular/cup anteversion and femoral/stem neck anteversion in the horizontal plane, can be used to plan and control the setting of a THA in standing position. The main purpose of this preliminary study is to evaluate the difference between the combined anteversion before and after THA in weight-bearing standing position using EOS 3D reconstructions. A simultaneous analysis of the preoperative lumbo pelvic parameters has been performed to investigate their potential influence on the post-operative reciprocal femoro-acetabular adaptation. Material and Methods. 66 patients were enrolled (unilateral primary THAs). The same mini-invasive anterolateral approach was performed in a lateral decubitus for all cases. None of the patients had any postoperative complications. For each case, EOS full-body radiographs were performed in a standing position before and after unilateral THA. A software prototype was used to assess pelvic parameters (sacral slope, pelvic version, pelvic incidence), acetabular / cup anteversion, femoral /stem neck anteversion and combined anteversion in the patient horizontal functional plane (the frontal reference was defined as the vertical plane passing through centers of the acetabula or cups). Sub-analysis was made, grouping the sample by pelvic incidence (<55°, 55°–65°, >65°) and by pre-operative sacral slope in standing position (<35°, 35°–45°, >45°). Paired t-test was used to compare differences between preoperative and postoperative parameters within each subgroup. Statistical significance was set at p < 0.05. Results. In the full sample, mean FCA increased postoperatively by 9,3° (39,5° vs 30,2°; p<0.05). In groups with sacral slope < 35° and sacral slope > 45°, postoperative combined anteversion increased significantly by 11,7° and 12,9°, respectively. In the group with pelvic incidence > 65°, postoperative combined anteversion increased significantly by 14,4°. There was no significant change of combined anteversion in the remaining subgroups. Discussion. In this series the FCA increased after THA, particularly in patients with a low or high sacral slope on the pre-operative evaluation in standing position. This may be related to a greater difficulty for the surgeon in anticipating the postoperative standing orientation of the pelvis in these patients, as they were standardly oriented during surgery (lateral decubitus). Interestingly the combined anteversion was also increased in patients with a high pelvic incidence that is commonly associated with a high sacral slope. Conclusion. Post-operative increase of anatomical cumulative anteversion has been previously reported using anterior approach. The FCA concept based on EOS 3D reconstructions brings new informations about the reciprocal femoro-acetabular adaptation in standing position. Differences found in combined anteversion before and after the surgery show that a special interest should be given to patients with high pelvic incidence and low or high sacral slope, to optimize THA orientation in standing position

Introduction. The effect of spine-pelvis position and motion on hip arthroplasty function has been increasingly appreciated in the past several years. Some authors have stressed the importance of using precision technologies for component placement while others have advocated the use of dual mobility articulations or large bearings and lateralized liners in patients with fused lumbar spines. The current study assesses the prevalence of stiff and fused spines in an elective total hip arthroplasty population. Methods. One hundred and forty-nine patients undergoing elective total hip arthroplasty were assessed preoperatively with CT (computed tomography) and functional radiographs for the purpose of CT based planning and intraoperative navigation of total hip arthroplasty (HipXpert System, Surgical Planning Associates, Inc., Boston, MA). The functional radiographs included standing and sitting lateral images (EOS Imaging, SA, Paris, France). Patients were assessed for supine, standing and sitting pelvic tilt (PT) and change in sacral slope (SS). Spine stiffness was defined by a change in sacral slope (SS) of less than or equal to 10 degrees on the standing to sitting lateral radiographs according to Luthringer et al JOA 2019. Results. Of these 149 patients, 2 (1.5%) had been previously treated by instrumented lumbar fusion. Thirty-nine additional patients (26.1%) had stiff spines as defined by a change in sacral slope of less than 10 degrees from standing to sitting. The mean supine PT measured by CT scan was 3.46 degrees of anterior PT which is similar to previously described in the literature. The mean supine PT in stiff spine patients measured 1.5 degrees of anterior tilt which was not statistically significant. The mean standing pelvic tilt measured 0.0 degrees in the all patients and −4.3 degrees in stiff spine patients. The mean sitting pelvic tilt was −18.9 degrees in the entire cohort and −11.3 degrees in the stiff spine patients. The difference in pelvic tilt between these two groups was statistically significant with p-values of 0.002 and 0.006, respectively. Discussion and Conclusion. Although the incidence of formal instrumented spine fusion was low in this cohort (1.5%), the incidence of spine stiffness was very high at 27.6%. Given that hip instability has been decreasing owing to a variety of techniques including larger bearings, intraoperative radiography, and intraoperative precision technologies, advocacy for the use of dual mobility implants simply for a history of spine fusion does not appear to be logical given that most stiff spines have not had a surgical fusion

Introduction The main objective of this study is to describe the morphology and the mechanism of organization of the lumbar lordosis regarding the both position and shape of the pelvis. According to the orientation of the sacral plate, a classification of the lumbar lordosis is proposed. A symptomatic cohort of patient suffering of low back pain is analysed according to this new classification. Methods 160 asymptomatic, young adult volunteers and 51 symptomatic low back patients were x-rayed in a standardized standing position. Analysis of the spine and pelvis was performed with the SagittalSpine® software. The pelvic parameters were: pelvic incidence, sacral slope, pelvic tilt. Thoracic kyphosis and lumbar lordosis were divided by the inflexion point. The lumbar lordosis was bounded by the sacral plate and the inflexion point. At the apex, the lumbar curve was divided in two tangent arcs of circle, quantified by an angle and a number of vertebrae. The upper one was geometrically equal to the sacral slope. Regarding the vertical line, a lordosis tilt angle was designed between the inflexion point and the anterior limit of the sacral end. The second group was operated with a disc prosthesis at the degenerated level. Results The value of the lumbar lordosis was very variable. The best correlation was between lumbar lordosis and sacral slope, then between sacral slope and pelvic incidence in both groups. The upper arc of a circle remained constant, when the lower one changed with the sacral slope. There were good correlations of the sacral slope with the position of the apex, and with the lordosis tilt angle. When restoring the disc height at level L4L5 or L5S1 by a prosthesis insertion the local balance is modified but the global balance is unchanged. The prosthesis insertion at level L5S1 modifies significantly the balance at L4L5 which seems to be the most important level to restore a good lumbar lordosis. Discussion Regarding the sacral slope, the lumbar lordosis can be classified in four types. When the sacral slope is low, the lumbar lordosis can be short and curved with a low apex and a backward tilt (type 1), either both long and flat with a higher position of apex (type 2). When the sacral slope increases, lumbar lordosis increases in angle and number of vertebrae with an upper apex, and it tilts progressively forward (type 3and 4). Depending of the both shape and position of the pelvis, the morphology of the lumbar lordosis could be the main mechanical cause of lumbar degenerative diseases. Total disc arthroplasty at one level L4L5 or L5S1 can significantly restore a good balance in the lumbar without modification on the global balance of the spine. When two levels are involved in the DDD process, the fusion at L5S1 and a prosthesis at L4L5 do not modify the global balance and the clinical results are similar to one level disc arthroplasty. This has to be underlined because all studies with two levels arthroplasties showed worst clinical outcomes than one level

Purpose: Analysis of the sagittal balance of the spine is a fundamental step in understanding spinal disease and proposing appropriate treatment. The objectives of this prospective study were to establish the physiological values of pelvic and spinal parameters of sagittal spinal balance and to study their interrelations. Material and methods: Two hundred fifty lateral views of the spine taken in the standing position and including the head, the spine and the pelvis were studied. The following variables were noted: lumbar lordosis, thoracic kyphosis, sagittal tilt at 9, sacral slope, pelvic incidence, pelvic version, intervertebral angle, and the vertebral wedge angle from T9 to S1. These measures were taken after digitalising the x-rays. Two types of analysis were performed. A descriptive univariate analysis was used to characterise angular parameters and a multivariate analysis (correlation, principal component analysis) was used to compare interrelations between the variables and determine how economic balance is achieved. Results and discussion: Mean angular values were: maximal lumbar lordosis 61±12.7°, maximal thoracic kyphosis 41.4±9.2°, sacral slope 42±8.5°, pelvic version 13±6°, pelvic incidence 55±11.2°, sagittal tilt at T9 10.5±3.1°. There was a strong correlation between sacral slope and pelvic incidence (r=0.8), lumbar lordosis and sacral slope (r=0.86), pelvic version and pelvic incidence (r=0.66), lumbar lordosis pelvic incidence pelvic version and thoracic kyphosis (r=0.9), and finally between pelvic incidence and sagittal tilt at T9, sacral slope, pelvic version, lumbar lordosis, and thoracic kyphosis (r=0.98). Multivariate analysis demonstrated three independent parameters influencing sagittal tilt at T9, reflecting the lateral balance of the spine. The first was a linear combination of the pelvic incidence, lumbar lordosis and sacral slope. The second was pelvic version and the third thoracic kyphosis. Conclusion: This work provides an aid for analysis and comprehension of anteroposterior imbalance observed in spinal disease and also to calculate with the linear regression equations describing the corrections to be obtained with treatment

Introduction: Computer assisted total hip replacement (THA) usually uses the anterior pelvic plane (plane of Lewinneck, APP) for reference because the anatomical landmarks are easy to access during the surgical procedure. However, a recent study shows the lack of correlation in between the Lewinnek angle in standing position (L) and the spinal radiological parameters for sagittal balance, specifically the incidence angle and the sacral slope. The anatomical variations of the anterior superior iliac spines account for the discrepancy. The authors propose here the assessment of the Lewin-nek – sacrum angle (LS) (anterior pelvic plane to the sacral endplate) Methods: 120 asymptomatic patients with THA had low dose lateral X-rays of the lumbo-pelvic area (Definium 8000, GE Healthcare ;dose 0,6 mSivert). The measurements of the sacral slope, incidence angle, and APP were done by two independent observers. Results: The sacral slope and incidence angles were similar to other series. The APP was no clearly identified in 78 cases. The average L angle was −3° (SD 8°) in standing position, −23° (SD 11°) in sitting postion, and −2° (SD 8°) in lying position. The average LS angle was 47° (SD 13°). The geometrical relationship between the LS a ngle, the L angle and the sacral slope is reported. Conclusion: THA stability supposes that the orientation of the acetabular component shall remain within extreme values in standing, sitting, and lying postures. The adjustment of the acetabulum takes into account the functionnal anatomy of the lumbopelvic area. The sacral slope is a reliable radiological reference and is related to the sagittal balance of the spine. The APP presents some interindividual variability and is poorly visible on the radiographs, but it is easily accessible during surgery. The author suggest using the Lewinnek sacrum (LS) angle for radiological planification and for surgical navigation procedures

Aims. High-grade dysplastic spondylolisthesis is a disabling disorder for which many different operative techniques have been described. The aim of this study is to evaluate Scoliosis Research Society 22-item (SRS-22r) scores, global balance, and regional spino-pelvic alignment from two to 25 years after surgery for high-grade dysplastic spondylolisthesis using an all-posterior partial reduction, transfixation technique. Methods. SRS-22r and full-spine lateral radiographs were collected for the 28 young patients (age 13.4 years (SD 2.6) who underwent surgery for high-grade dysplastic spondylolisthesis in our centre (Scottish National Spinal Deformity Service) between 1995 and 2018. The mean follow-up was nine years (2 to 25), and one patient was lost to follow-up. The standard surgical technique was an all-posterior, partial reduction, and S1 to L5 transfixation screw technique without direct decompression. Parameters for segmental (slip percentage, Dubousset’s lumbosacral angle) and regional alignment (pelvic tilt, sacral slope, L5 incidence, lumbar lordosis, and thoracic kyphosis) and global balance (T1 spino-pelvic inclination) were measured. SRS-22r scores were compared between patients with a balanced and unbalanced pelvis at final follow-up. Results. SRS-22r domain and total scores improved significantly from preoperative to final follow-up, except for the mental health domain that remained the same. Slip percentage improved from 75% (SD 15) to 48% (SD 19) and lumbosacral angle from 70° (SD 11) to 101° (SD 11). Preoperatively, 35% had global imbalance, and at follow-up all were balanced. Preoperatively, 63% had an unbalanced pelvis, and at final follow-up this was 32%. SRS-22r scores were not different in patients with a balanced or unbalanced pelvis. However, postoperative pelvic imbalance as measured by L5 incidence was associated with lower SRS-22r self-image and total scores (p = 0.029). Conclusion. In young patients with HGDS, partial reduction and transfixation improves local lumbosacral alignment, restores pelvic, and global balance and provides satisfactory long-term clinical outcomes. Higher SRS-22r self-image and total scores were observed in the patients that had a balanced pelvis (L5I < 60°) at two to 25 years follow-up. Cite this article: Bone Jt Open 2021;2(3):163–173

Variation in pelvic tilt during postural changes may affect functional alignment. The primary objective of this study was to quantify the changes in lumbo-pelvic-femoral alignment from sitting to standing in patients undergoing THA. 144 patients were enrolled. Standing and sitting radiographs using the EOS imaging system were analyzed preoperatively and 1-year postoperatively. Pelvic incidence (PI), lumbar lordosis (LL), sacral slope (SS), proximal femoral angle (PFA) and spine/femoroacetabular flexion were determined. 38 patients had multilevel DDD (26%). Following THA, patients sat with increased anterior pelvic tilt demonstrated by a significant increase in sitting lumbar lordosis (28° preop vs 35° postop; p<0.01) and sacral slope (18° vs 23°; p<0.01). Following THA, patients flexed less through their spines (preop 26° vs postop 19°; p<0.01) and more through their hips (femoroacetabular flexion) (preop 60° vs postop 67°; p<0.01) to achieve sitting position. Patients with multilevel DDD sat with less spine flexion (normal 22° vs spine 13°; p<0.01), less change in sacral slope (more relative anterior tilt) (17° vs 9°; p<0.01), and more femoroacetabular flexion (64° vs 71°; p<0.01). For the majority of patients after THA, a larger proportion of lumbo-pelvic-femoral flexion necessary to achieve a sitting position is derived from femoroacetabular flexion with an associated increase in anterior pelvic tilt and a decrease in lumbar spine flexion. These changes are more pronounced among patients with multilevel DDD. Surgeons may consider orienting the acetabular component with greater anteversion and inclination in patients identified preoperatively to have anterior pelvic tilt or significant DDD

Hip-spine relationships should be better investigated in THP as lumbo-sacral orientation in the sagittal plane plays a critical role in the function of the hip joints. Lateral X-rays showing spine and hips together in standing, sitting or squatting positions characterize the adaptations of the sagittal balance and the functionnal interactions between hips and spine. Acetabular cup implantation has to be planned for frontal inclination, axial anteversion, and sagittal orientation. The later refers to the sacro-acetabular angle, key-point in the spine – hip relationships, and that is redefined by the surgeon at the time of implantation. Usual standard CT-sections are biased for evaluating acetabular anteversion. The conventional CT procedure does not refer to the pelvic bony frame and. the measured anteversion is a projected angle on a transverse plane, depending on the pelvic adaptation in lying position. This measured angle is often considered as anatomical anteversion, leading to some confusion. Therefore this angle is only a “functional” supine anteversion, reflecting the anterior opening angle of the acetabulum in a specific position. According to the sagittal orientation of the pelvis, the true functional acetabular orientation can virtually be assessed in various postures from adjusted CT-scan sections. The EOS. ™. low irradiation 2D-3D X-ray scanner is an innovative technology already used for global evaluation of the spine. This technology allows simultaneously “full body” frontal and lateral X-rays with the patient in standing, sitting or squatting positions; a tridimensionnal patient specific bone recontruction can be performed and the cup anteversion can be directly assessed according to the position. We investigated the lumbo-pelvic parameters influencing the tridimensionnal orientation of the acetabulum. We compared the data obtained for real postural situations using the EOS. ™. system and the measures from plane X Rays and classical CT scan cuts replicating standing, and sitting positions.368 patients with cementless THP were involved in a prospective follow-up protocol. Sacral slope and pelvic tilt, incidence angle, acetabular frontal and sagittal inclination were evaluated on AP and lateral standard XRays. Functionnal anteversion of the cup has been measured using a previously described protocol with CTscan cuts oriented according to standing and sitting sacral slope. The mean difference between CTscan and EOS. ™. system was 4,4° with comparable accuracy and reproductibility. Sacral slope decrease in sitting position was linked to anteversion increase (38,8° SD 5,4°). Sacral slope increase in standing position was linked to lower ante-version (31,7° SD 5,6°). The anatomical acetabular anteversion, the frontal inclination, and the sagittal inclination were functional parameter which significantly varied between the standing, sitting, and lying positions. We noticed that the acetabular parameters in lying position highly correlated to the one in standing position, while poorly correlated with the one in sitting position. The difference between the lying and the sitting positions was about 10°, 25°, and 15° for the cup anteversion (CA) and the frontal and sagittal inclinations (FI,SI) respectively. The poor correlation between the lying and sitting positions suggests that the usual CT scan protocol is biased and not fully appropriate for investigating the cases of posterior THP dislocation and subluxation, which happen in sitting position. On the contrary, a strong correlation was observed between lying and standing measurements with all the acetabular parameters (CA,FI, SI), suggesting that the classical CT assessment of the cup anteversion remains an interesting source of information in case of anterior THP. Each patient is characterized by a morphological parameter, the incidence angle. High incidence angle is linked to low acetabular anteversion, increasing the instability risk and anterior impingement in sitting and squatting position; higher anteversion angles are observed in low incidence angle patients, leading to more internal rotation of the hip in any position. Lumbo-sacral orientation in the sagittal plane influences the tridimensionnal orientation of the acetabulum, especially for anteversion. Aging of the hip-spine complex is linked to progressive pelvic posterior extension. Impingement phenomenons, orientation of stripe wear zones and some instability situations can be interpreted according to those data. This study points out the opportunity to adjust the CT scan sections to the sacral slope in functional position for properly investigating the orientation of the acetabular cup, mainly in case of posterior dislocation. In addition, the mobility of the lumbo-sacral junction could be a crucial parameter in the mechanical functioning and the stability of a THP due to its impact on sacral slope and pelvic tilt. Therefore we also recommend doing dynamic lateral radiographs of the lumbo sacral junction in standing and sitting position for planning a THP implantation in order to detect stiff lumbosacral junction or sagittal pelvic malposition

Introduction: Hip dislocation remains a relevant complication of total hip arthroplasty.The implants position plays a major role, especially cup anteversion.It has been demonstrated that anteversion measured on CTscan depends on the pelvic position in a lying patient. This prospective study evaluates the influence of pelvic tilt according to standing and sitting positions. Material and Methods: The radiological records of 328 consecutive asymptomatic patients with THP were analyzed. These were routine radiological controls of non cemented THP with metal back acetabular implants. All patients had AP and lateral radiographs in standing and sitting position and a “low-dose” CT scan of the pelvis in lying position.Patients were checked for the absence lower limb length discrepancy and lumbosacral junction abnormality. All the measurements were done by two independent observers and averaged. From the standard radiographs, the sacral slope (SS), the acetabular frontal inclination (AFI), and the acetabular sagittal inclination (ASI) were measured in standing, sitting, and lying positions. From the CT scan sections, the anatomical ante-version (AA) was measured in lying position on axial images according to Murray. The results were compared to a previously described protocol replicating standing and sitting positions: CTscan sections were oriented according to sacral slope. Results: We confirmed that the anatomical anteversion (AA), the frontal inclination (FI), and the sagittal inclination (SI) were functional parameter which significantly varied between standing, sitting, and lying positions according to sacral slope variations.The acetabular parameters in lying position highly correlated to the one in standing position, while poorly correlated with sitting position. The difference between the lying and the sitting positions was about 10°, 25°, and 15° for the AA, the AFI, and the ASI respectively.Mean lying anteversion angle was 24.2° (SD6,9°).Posterior pelvic tilt in sitting position, (sacral slope decrease) was linked to anteversion increase (mean value 38,8° - SD 5,4°). Anterior pelvic tilt in standing position (sacral slope increase) was linked to lower anteversion (mean value 31,7° - SD5,6°). Discussion and Conclusions: Our study confirms the interest CTscan sections oriented according to sacral slope.The strong correlation between lying and standing measurements suggests that classical CTscan protocol is relevant for standing anteversion. According to the poor correlation between lying and sitting positions, it is less contributive for the investigation of dislocations in sitting position

Introduction. Optimal implant position is the important factor in the hip stability after THA. Both the acetabular and femoral implants are placed in anteversion. While most hip dislocations occur either in standing position or when the hip is flexed, preoperative hip anatomy and postoperative implants position are commonly measured in supine position with CT scan. The isolated and combined anteversions of femoral and acetabular components have been reported in the literature. The conclusions are questionable as the reference planes are not consistent: femoral anteversion is measured according to the distal femoral condyles plane (DFCP) and acetabulum orientation in the anterior pelvic plane (APP)). The EOS imaging system allows combined measurements for standing position in the “anatomical” reference plane or anterior pelvic plane (APP) or in the patient “functional” plane (PFP) defined as the horizontal plane passing through both femoral heads. The femoral anteversion can also be measured conventionally according to the DFCP. The objective of the study was to determine the preoperative and postoperative acetabular, femoral and combined hip anteversions, sacral slope, pelvic incidence and pelvic tilt in patients who undergo primary THA. Material and Methods. The preoperative and postoperative 3D EOS images were assessed in 62 patients (66 hips). None of these patients had spine or lower extremity surgery other than THA surgery in between the 2 EOS assessments. None had dislocation within the follow up time period. Results. Pelvic values. The preoperative sacral slope was 42.4°(11° to 76°) as compared to the postoperative sacral slope (40.3°, −4° to 64°)(p=0.014). The preoperative pelvic tilt was 15.3° (−10° to 44°) as compared to the postoperative tilt (17.2°, −6° to 47°)(p=0.008). The preoperative pelvic incidence was 57.7°(34° to 93°) and globally unchanged as compared to the postoperative incidence (57.5°, 33° to 79°)(p=0.8). Acetabular values. Surgeons increased the anteversion according to the APP by an average of 12.6°(−13° to 53°)(p<0.001). Acetabular anteversion was increased by 14.3° in the PFP (−11° to 51°)(p<0.001). Femoral values. In the DFCP, preoperative neck anteversion was decreased postoperatively by an average of −3,2°(−48° to 33°)(p=0,0942). In the PFP, preoperative neck anteversion was decreased postoperatively by an average of −6,3°(−47° to 17°)(p<0,001). Combined values. According to the classical methods (acetabular orientation in the APP and femoral anteversion in the DFCP), mean preoperative combined anteversion was 36.1° (4° to 86°) and was increased postoperatively to 45.5°(−12° to 98°)(p=0.0003). According to the PFP, mean preoperative combined anteversion was 30,7°(5° to 68°) and was increased postoperatively to 38,8°(−10° to 72°)(p=0,0001). Conclusion. This study reports two methods for the measurement of acetabular and femoral anteversion, “anatomical” according to the APP and DFCP and “functional” according to the PFP. Surgeons tend to increase the anteversion of the acetabular implant and to decrease femoral anteversion during the surgery. The trend is the same for postoperative evolution of values using the “anatomical” or the “functional” methods but numerical discrepancies are explained by significant APP orientation changes. The assessment of the true combined anteversion provides new perspectives to optimize our understanding of THA stability and function

Adult Spine Deformity (ASD) is a degenerative condition of the adult spine leading to altered spine curvatures and mechanical balance. Computational approaches, like Finite Element (FE) Models have been proposed to explore the etiology or the treatment of ASD, through biomechanical simulations. However, while the personalization of the models is a cornerstone, personalized FE models are cumbersome to generate. To cover this need, we share a virtual cohort of 16807 thoracolumbar spine FE models with different spine morphologies, presented in an online user-interface platform (SpineView). To generate these models, EOS images are used, and 3D surface spine models are reconstructed. Then, a Statistical Shape Model (SSM), is built, to further adapt a FE structured mesh template for both the bone and the soft tissues of the spine, through mesh morphing. Eventually, the SSM deformation fields allow the personalization of the mean structured FE model, leading to generate FE meshes of thoracolumbar spines with different morphologies. Models can be selectively viewed and downloaded through SpineView, according to personalized user requests of specific morphologies characterized by the geometrical parameters: Pelvic Incidence; Pelvic Tilt; Sacral Slope; Lumbar Lordosis; Global Tilt; Cobb Angle; and GAP score. Data quality is assessed using visual aids, correlation analyses, heatmaps, network graphs, Anova and t-tests, and kernel density plots to compare spinopelvic parameter distributions and identify similarities and differences. Mesh quality and ranges of motion have been assessed to evaluate the quality of the FE models. This functional repository is unique to generate virtual patient cohorts in ASD. Acknowledgements: European Commission (MSCA-TN-ETN-2020-Disc4All-955735, ERC-2021-CoG-O-Health-101044828)

In 2021, Vigdorchik et al. published a large multicentre study validating their simple Hip-Spine Classification for determining patient-specific acetabular component positioning in total hip arthroplasty (THA). The purpose of our study was to apply this Hip-Spine Classification to a sample of Australian patients undergoing THA surgery to determine the local acetabular component positioning requirements. Additionally, we propose a modified algorithm for adjusting cup anteversion requirements. 790 patients who underwent THA surgery between January 2021 and June 2022 were assessed for anterior pelvic plane tilt (APPt) and sacral slope (SS) in standing and relaxed seated positions and categorized according to their spinal stiffness and flatback deformity. Spinal stiffness was measured using pelvic mobility (PM); the ΔSS between standing and relaxed seated. Flatback deformity was defined by APPt <-13° in standing. As in Vigdorchik et al., PM of <10° was considered a stiff spine. For our algorithm, PM of <20° indicated the need for increased cup anteversion. Using this approach, patient-specific cup anteversion is increased by 1° for every degree the patient's PM is <20°. According to the Vigdorchik simple Hip-Spine classification groups, we found: 73% Group 1A, 19% Group 1B, 5% Group 2A, and 3% Group 2B. Therefore, under this classification, 27% of Australian THA patients would have an elevated risk of dislocation due to spinal deformity and/or stiffness. Under our modified definition, 52% patients would require increased cup anteversion to address spinal stiffness. The Hip-Spine Classification is a simple algorithm that has been shown to indicate to surgeons when adjustments to acetabular cup anteversion are required to account for spinal stiffness or flatback deformity. We investigated this algorithm in an Australian population of patients undergoing THA and propose a modified approach: increasing cup anteversion by 1° for every degree the patient's PM is <20°