The anterior pelvic plane has been introduced as a concept of the reference plane to image free navigation-assisted cup placement of total hip arthroplasty. With the neutral pelvis, the anteversion relative to the conventional coordinate system is equal to the that of relation to the anatomical coordinate system. This is the rationale of image free navigation system. But, currently, two major concerns about image-free navigation assisted total hip arthroplasty are tilting of anatomic coordinate system and the cutaneous palpation procedure. Therefore, it was the goal of this study to provide both the bone anterior pelvic plane (Bone_APP) and the overlying soft tissue plane (Soft_APP) simultaneously, and to find possible correlations of biometrical parameters and effect of ante-version were an additional motivation of this study. 23 Korean adult patients underwent image-free navigation-assisted total hip arthroplasty. The tilting of Bone_APP, soft tissue thickness on ASIS, pubis, and then tilting of Soft_APP, and anteversion of cup were measured with reconstructed CT and 3D workstation system. The average age was 66.1 years, the average height was 162.5cm at a weight of 59.2 kg. The average body mass index was 22.3. And the average lumbar lordosis was measured as 30.4 degrees. The soft tissue on the level of the pubis was 17.6 mm thicker than that on the level of ASIS in average. In all cases, Soft_APP was positive, that is from 3.5 to 16.5 degrees of backward rotation. We also found a high-intersubject variability in the Bone_APP from 13.4 of forward rotatation to 23 degrees of backward rotation. Overall, there are no correlation between biometrical parameters and difference of navigated data to others measured on CT. Averaged navigated data was 22.4 degrees. The average anatomic, operative, and planar anteversion were 29.2, 27.2 and 21.3 degrees respectively. The value of anteversion measured on the transverse plane and sagittal plane shows higher than navigated anteversion in paired comparison. This could be comprehended that the navigation system had under-estimated the anteversion than that of transverse and sagittal plane, This means navigation assessed pelvic plane as back ward tilting rather than forward tilting intraoperatively. None of cases showed the Bone_APP was parallel to conventional coordinate system. Comparing the variable bone APP tilt, all of cases showed an backward tilted soft tissue plane. There were no correlation between bone APP and biometrical parameters. Overall, navigated data were less than anatomic and operative anteversion. Rather than anatomic coordinate system (Bone-APP), backward tilting due to overlying soft tissue (Soft-APP) might to make the navigated data have the tendency to under-estimated the anteversion of cup measured with CT. In conclusion, anterior pelvic plane does not satisfactory reliability with should be easily identified during operation. Image-free navigation system would take into account variations of individuals including both bone tilt and soft tissue plane

The palpation of the controlateral iliac spinae remains a major hurdle to the success of navigation in lateral position. Several studies are seeking for alternative landmarks to compute the anterior pelvic plane (APP). Up to now, none of those methods have been used in clinical routine. Ultrasound navigation offers a great potential to identify new bony landmarks. The tubercles of the lower lumbar spine and the symphysis can easily be imaged. Those points define a sagittal plane, that can be used as a symmetry plane to compute a virtual controlateral spinae from the acquired colateral spinae. A virtual pelvic plane can then be computed. The objective of this study was to check the accuracy and reproducibility of this virtual anterior pelvic plane. 6 hips (3 left, 3 right) from 4 cadavers (mean BMI 22,6; range 19,5–26,7) embalmed with glycerol and alcohol were used for this study. All anatomic landmarks were acquired with the OrthoPilot® Ultrasound navigation system. One experienced surgeon acquired the reference APP with the cadavers lying supine. The cadavers were then placed in lateral position. Two experienced surgeons acquired 6 times following landmarks: 3 lower lumbar tubercles, 3 sacral tubercles (see Figure 1), the posterior spines, the symphysis and the colateral iliac spine. Several sagittal planes were computed using all points (least square plane) and all possible combinations between one symphysis point, one lower lumbar tubercle point (L5, L4 or L3), and one sacral tubercle point (S2 or S1). The angular error of the resulting virtual APP to the reference APP was computed. For each cadaver, an error map was computed to visualize the error of the virtual APP with respect to the height of the used sacral and lumbar tubercles along the spine. The reference APP was acquired with a good reproducibility: the deviation between each acquisition to the mean of all acquisitions was smaller than 1° (except for cadaver 2 right side, the deviation reached 2 ° in the frontal plane). As some sacral and lumbar points were mixed during the acquisition, the line joining the posterior spines was used to separate the sacral from the lumbar points. The mean errors and standard deviations were comparable between operators. The least square plane computed with all points strongly depended on the cadaver positioning : for the same cadaver, the mean error reached 0°on the left side and 8° on the right side. More constant results were obtained by using a combination of 3 points. 5 outliers were identified and removed as they clearly corresponded to erroneous acquisitions on bad quality images. After having removed those outliers, the mean error ranged between 2° and 5° and the standard deviation between 1° and 3°. The best combination of points was a point on the symphysis, the lowest sacral tubercle (S2) and the lowest lumbar tubercle (L5). This study shows that the symphysis, the lower lumbar and sacral tubercles can be used to define a sagittal plane and thereby define a virtual anterior pelvic plane. Outliers should be suppressed by taking special care to the image quality and by adding a guided ultrasound functionality: visualizing the resulting sagittal plane on the ultrasound picture would enable the surgeon to easily control the accuracy of his acquired plane. The next steps consist in checking the feasibility in a clinical set-up

The anterior pelvic plane (APP) is used as a reference in various pelvic surgeries in orthopaedics. Current methods for identifying the APP are limited in accuracy and efficiency. A quick and accurate method for registering the pelvis orientation can be very useful. Previously, we have introduced a Tracked C-arm (TC-arm) system for use with any C-arm fluoroscopy for producing spatially calibrated imaging views. This system has been tried for estimating the APP. Early results, however, has shown limited repeatability in identifying the anterior superior iliac spine (ASIS) landmarks. This study improves the previous algorithms for a robust registration of the APP. A Sawbone pelvis was used, and its APP was marked by radio-dense ball-bearings. In the new addition, the TC-arm allowed segmenting the ASIS in an interactive user-interface by taking guidance from a reference line tangential to the ipsilateral pubic tubercle for marking the most anterior point on the iliac-crest. The imaging and analysis was repeated 10 times. The results were compared to reconstruction of the fiducial markers placed on the true APP. Accuracy of 1.4° and 4.4° were found for registering the pelvic tilt and rotation, correspondingly. The overall accuracy and precision of registration of the APP were 4.7° and 0.82°, correspondingly. The new method showed 7.5 times improvement in repeatability of measuring the pelvic tilt (SD<0.4°) compared to the previous fluoroscopic methods. This technique addresses an important challenge in estimation of the pelvic bone which is crucial for reliable device placement and producing standard radiographic views in surgery

Most of computer-assisted computer assisted system rely on the peri-operative acquisition of the anterior pelvic plane defined as the plane crossing the two anterior iliac spine and the symphysis. The goal of this study was to evaluate in vivo and in vitro the accuracy of the anterior pelvic plane acquisition, considered as the reference for computer-assisted total hip arthroplasty (THA). Cup placement was performed using an imageless computer-assisted system in thirty patients during THA. Post-operatively the position of the cup was evaluated on computed tomography using a validated tridimensional software. The differences between the perioperative and postoperative angles for abduction and anteversion were compared using a two-group pair test. On two cadavers four clinicians performed ten times the anterior pelvic plane acquisition using three Methods: percutaneously, with ultrasound and by direct bony acquisition defined as the reference. The mean error for each anterior pelvic plane acquisition method was compared using a univariate variance model for repeated measurements. In vivo, the mean difference between the perioperative and postoperative abduction angles was 4° and not statistically significant. For anteversion, the difference was 4° and not significant in patients with BMI < 27. The difference was 11° and significant in patients with BMI > 27 (p< 0.001). In vitro, the mean errors for rotation and tilt were respectively 3.8 ° and 19.25 ° for cutaneous acquisition, 2.8° and 6.2° for ultrasound acquisition method. The errors were statistically higher with the percutaneous method (p< 0.001). According to our results, the accuracy of the standard percutaneous acquisition method of the anterior pelvic plane in computer-assisted THA is limited. The ultrasound acquisition method may represent a reliable alternative

Introduction: A good cup positioning requires reliable anatomical landmarks expecially for navigation. The anterior pelvic plane (APP) seems to be a good reference for navigation because it is in relation with pelvic tilt which do affect the position of the cotyle and consequently the position of the cup. The value of this plane is not well known according to gender, age, weight… The aim of the study is to assess radiologically the APP in standing and supine position before and after total hip arthroplasty. MATERIALS AND Methods: 92 Patients (32 males, 60 females, mean age 65 years) underwent strict lateral X-rays in standing and supine standardized position. Uninterpretable or unsatisfying X rays were withdrawn. 45 patients underwent a standing X-ray, 24 a supine X-ray, 21 a supine and standing X ray. Statistical analysis used a Student t-test. Results: Non matched values showed a retroversion of the pelvis of 6.4° (+/− 6.9) in supine position, 0.3° (+/− 7.4) in standing position. Matches values showed an retroversion of the pelvic of 6.9° (+/− 5.3) in supine position, 0.3° (+/− 5.03) in standing position (significant difference). Extreme values varied from −15° to + 18° (3 patients showed no variation, 2 patients a retroversion from supine to standing position). There was no statistical difference between male and female but a statistical differences in females. Discussion: The APP is easily assessable by X rays in standing as in supine position. Bony landmarks of the plane are also assessable by navigation tools and to can be a good plane as reference. Several authors showed the repercussion of the pelvic tilt on the cotyle position. The difference between standing and supine position is about 6°. But for some patients the difference is may be of 20°and that could explain some impigment and instability. A cup well positioned in supine position may be not so good in standing position because of the pelvic tilt. Conclusion: The value of the APP is important to know before THA and seems to be a good plane as reference for navigation

The anterior pelvic plane (APP) through the bilateral anterior superior iliac spines (ASIS) and pubic tuberosities is often used as a pelvic reference in measuring orientation of the acetabular cup in total hip arthroplasty. Apophyses such as ASIS are, however, anatomically variable among patients and APP does not always represent the functional pelvic tilt in the sagittal plane in each patient. Therefore, malposition of the cup and recurrent dislocation may occur even though the cup is placed in a safe zone when measured against APP. We analyzed dynamic pelvic tilt angle in the sagittal plane using a motion analysis system after THA and we found a case of recurrent dislocation due to an unusual APP tilt. A 77-year-old woman underwent primary THA 3 years ago and cup re-implantation was done with the use of a 10-degree elevated liner and the head diameter was increased from 26mm to 28 mm after two anterior dislocations. However, posterior dislocation occurred 11 times after this. A second revision was performed with a 36 mm head and cup anteversion was optimized against APP. Further posterior dislocations occurred twice again. To probe the cause of recurrent dislocation, we performed motion analysis using a 6-camera VICON system and the markers were registered to the bone and implant models based on the postoperative CT images. This system visually represents four-dimensional dynamic motions that include the time sequential transitions of components and their posture. The cup had been placed in 6 degrees of radiographic anteversion against APP, and in −13 degrees of radiographic retroversion in supine (FPP), because the pelvic flexion angle in supine was 17.6 degrees. Furthermore, when standing, the pelvic flexion angle increased 10 degrees. Malposition of the acetabular cup in THA is the most common cause of dislocation. To avoid errors in cup placement, computer navigation systems have been introduced and most of the navigation systems refer APP to establish cup orientation. There are two drawbacks in using APP as the reference. One is that apophyses such as ASIS develop variably in each patient with a resulting variability in APP tilt in the sagittal plane in supine. The other is significant changes in pelvis tilt during various activities of daily living such as standing, walking, and sitting. Therefore, even if cup orientation is acceptable when referencing APP, it can be mal-oriented in a functional position of the pelvis as in this case, which showed proper anteversion against APP but retroversion in supine, standing and sitting. In conclusion, we found that there exists a case in which APP is not a suitable pelvic reference in determining orientation of the cup

There is a significant variation in registering anterior pelvic plane (APP) among experienced navigated hip surgeons reflecting negatively on the accuracy of determining the inclination and anteversion angles. Registering the APP in a lateral decubitus position is more challenging in obese patients as palpation of pubic tubercle or anterior superior iliac spines (ASIS) is inconsistent. We propose an alternative and easier novel method in which palpation of the posts (pegs) that stabilizes the pelvis will accurately determine the APP plane. The computer data obtained from peg’s palpation was compared to data obtained from post-operative CT scan of the pelvis in determining acetabular and cup version and inclination angles. The APP was defined and registered in 40 navigated total hip arthroplasty (THA) patients using our novel method. The patient is securely stabilized in a lateral decubitus position as routine with multiple pegs. One peg is positioned against both ASIS with 2 EKG pads placed on the pegs (each represent an ASIS). The other peg supports the pubic symphysis with one EKG pad representing the pubic tubercle. All efforts are made to make sure that the distance between the EKG nipples and the corresponding ASIS or pubic tubercle is equal before scrubbing and draping of the hip. Registration is achieved afterwards, by touching the nipples of the EKG pads placed on the pegs through the drape while the patient is secured in lateral decubitus position. This way sterility is uncompromised. To test the validity of our method of identifying the APP plane, a post-operative CT scan measurements of cup inclination and version angles were independently observed and the data were compared to our navigation registration method using t-student test analysis.(p=0.05 is significant). The mean CT-scan cup version was 19.4(S.D. ±6.3), and the mean of APP navigated cup version was 14.2(S. D.±3.1). There was no statistical significant difference (p=0.045). Similarly, there was no significant difference between mean CT scan cup inclination angle of 42.3(S. D.±3.7) and the mean navigated cup inclination of 40.9(S.D.± 4.6), (p= 0.69). Therefore, we conclude that the APP plane can be registered reliably and accurately by simply touching the EKG pads on the pegs and through the drapes. Not to mention, both the cup version and inclination angles were within safety zone of Lewinick. It seems that the accuracy of measuring the inclination angle through our method, although not significant, is better than the accuracy of measuring the cup version. This emphasizes the point that identifying the pubic tubercle is difficult whichever method of registration is used. However, inaccessibility of ASIS or pubic tubercle during manual APP registration leads to great cup orientation inaccuracies. The readily palpable EKG nipples on the pegs, irrespective of patient’s weight or the thickness of surgical draping, makes this novel technique a reliable and an easier alternative registration method than the manual palpation of APP in navigated THA

The anterior pelvic plane (APP) angle is often used as a reference to decide pelvic alignment for hip surgeons. However, Rousseau criticised the validness of the APP angles because the APP angles in standing position measured on conventional standing X-ray films never showed correlation with the other pelvic alignment parameters, such as sacral slope (SS). We measured the APP angles, SS and pelvic tilt (PT) on the non-distorted anteroposterior (AP) and lateral digitally reconstructed radiography (DRR) images in supine position (with CT scans) and AP and lateral X-ray images in standing position (with EOS X-ray machine [EOS imaging, Paris, France]) by using of the same EOS software. Our data showed that the pre- and post-operative APP angles correlated with SS and PT in both supine and standing positions. Our non-distorted high quality images and the EOS software revealed these correlations. Therefore, we can still use the APP angles to decide pelvic alignment for patients who undergo total hip arthroplasty (THA). Recent papers demonstrated positional or chronological dramatic changes of the APP angles between pre- and post-operative states in patients who underwent THA. The EOS system will be a powerful tool to investigate these changes of the pelvic alignments

Introduction: The anterior pelvic plane (APP), described by Lewinnek, is defined by the following points : anterior iliac spines, pubic symphysis. This plan is mostly considered as vertical in weight bearing and is currently used as the reference to guide cup insertion by means of imageless computer assistance (CAS). However, to our knowledge, there is no data that strongly confirm APP is vertical in weight bearing and how much his orientation is modified with regards operative position, or THA insertion. This study assessed these data by means of a radiological analysis. Material and Methods: The orientation of the APP was measured with regards to the vertical plane on weight-bearing profile X-rays of the pelvis in 106 subjects including:. 1) 82 patients with THA (40 who had at least one dislocation, and 42 matched patients without instability randomly selected, 19 of these 42 underwent a profile X-ray of the pelvis before and after THA insertion). 2) and 24 standard subjects who underwent lying and weight-bearing profile X-rays of the pelvis to assess the modifications of orientation of the pelvis between these two positions. Results: Thirty-eight percent of the subjects in weight-bearing had an orientation of the APP different of more than ± 5° from vertical plane and 13% were out of the interval ±10°. The orientation of the APP was not significantly different between the groups (standard and THA) nor between the groups who had stable or unstable THA. The orientation of the APP was significantly modified between lying and weight-bearing posture, from a mean of 1,2° lying to −2,25° upright. Under these conditions, 12 subjects presented a variation of more than 7°. Insertion of a THA did not significantly modify the orientation of the APP in weight-bearing among the 19 subjects (variations were small (−1° ± 7° [from – 21° to 8°]), but were more than 5° for 7 of the 19 subjects). Discussion and Conclusion: Most of the surgeons use the APP as a reference to guide navigation for cup insertion, considering it is vertical in weight-bearing. However, it is not true for 38% with a margin of 10°, which is equivalent to approximately half of the anatomical anteversion of the acetabulum. Standing up produced a significant variation of the orientation of the APP with regards to lying position. These errors that are not integrated by most of the CAS without preoperative CT scans, may produce cam effect or dislocation when the patient is moving to sited position. The variations of APP orientation with regards to vertical plane suggest it is not adequate to guide the CAS insertion of the cup. There is no reliable reference, easily identifiable during surgery that integrates the variations of position of the pelvis. This leads us to promote a new CAS for THA insertion free of reference plane, based on kinematics

There is increasing interest in the use of image free computer assisted surgery (CAS) in total hip arthroplasty (THA). Many of these systems require the registration of the Anterior Pelvic Plane (APP) via the bony landmarks of the anterior superior iliac spines (ASIS) and pubic tubercles (PT) in order to accurately orient the acetabular cup in terms of anteversion and inclination. Given system accuracies are within 1mm and 1° and clinical validation studies have given accuracy by cup position. However, clinical outcomes contain not only system inaccuracies but also variations due to clinical practice. To understand the effects of variation in landmark acquisition on the identification of the acetabular cup orientation, independent bench testing is required. This requires a phantom model that can represent the range of pelvises, male and female, encountered during THA and introduce deliberate known errors to the acquisition to see the effect on anteversion and inclination angles. However, there is a paucity of information in the literature with regards to these specific pelvic dimensions (pelvic width and height). Therefore the aims of this work were to generate the normal expected range of sizes of the APP for both males and females and to use these to manufacture a phantom model that could be used to assess CT free navigation systems. In the first part of the study 35 human cadavers and 100 pelvic computed tomography (CT) scans were examined. All cadavers had no gross pelvic abnormalities or previous surgeries. Measurements were carried out with cadavers placed in a supine position. The first author made three sets of measurements using a millimeter ruler. Solid steel pins were used to identify the palpated ASISs and PTs. String was tied between the two ASIS pins and the pelvic width measured. The midpoint of the pubic tubercles was taken to be the midpoint of the pubic symphysis. Pelvic height was measured from the midpoint of the ASIS distance (marked on the string) to the midpoint of the PTs. One hundred pelvic CT scans with no bony abnormalities, previous surgery or metal prosthesis (due to artefacts) were obtained retrospectively from the hospital radiological online system (PACS, Kodak). Mimics software (Mimics12 Materialise, Leuven, Belgium) was used to automatically reconstruct three-dimensional (3D) models using the ‘Bone’ thresholding function. This eliminated any soft tissue from the 3D models. The most anterior ASIS and PT points were then identified on the 3D model surface and measurements of distances made. As the software did not allow identification of points not on the model surface it was not possible to directly obtain the midpoint of the ASIS distance. Therefore to obtain the pelvic height measurements the distance between each ASIS and the ipsilateral and contralateral PTs was also measured. The pelvic height was then calculated using trigonometric functions. The ratio of width to height was calculated (ratio > 1 indicating pelvis width greater than pelvis height). Student's t test was used analyse any differences between male and female pelvic measurements with a p<0.05 being statistically significant. Using the results from above an aluminium pelvic phantom model was designed and manufactured. It was machined from a billet of marine grade aluminium alloy using a vertical computer numerical controlled (CNC) milling machine. The top surface represented the APP and sides (which represented the acetabuli) were angled to give anteversion and inclination angles of 20° and 45° respectively. Co-ordinates for ASIS and PT points were given based on the 99% prediction intervals from the pelvic data and additional points were milled to give up to a 20 mm error mediolaterally and also in height. Each co-ordinate point was drilled with a 2.0mm diameter ball-nose cutter to a depth of 1.0mm, these holes designed to accommodate the ball-nosed pointer tip to ensure it remained at the same position in space at all orientations of the pointer. Further to this, known errors in height were introduced using accurately manufactured blocks with similar points milled on the surface to fit a ball-nosed pointer. These blocks could be secured to the top surface of the model using screws. A Perspex base unit with tracker attachments was made to hold the phantom and provide the reference frame. A further support that enables the phantom to also be used in the “lateral” position was manufactured. For the assessment of pelvic size there were 66 females and 69 males, mean age 62.3 years (range from 20 to 99 years). The mean width was 238 mm (SD 20 mm) and mean height was 93 mm (SD 11 mm) with a mean ratio of 2.6 (SD 0.3). There were no statistically significant differences in mean between males and females (p>0.4 in all cases). From this data set the range of APP sizes required to cover 99% of population (width 186 to 290 mm and height 66 to 120 mm) and therefore the measurements for the model were generated. The manufactured model can be used to give the range of pelvis sizes from 170mm to 290mm in width and 60mm to 120mm in height and also to add up to 20 mm of error in palpation of each of the ASISs and PT. This study generated APP sizes to cover 99% of the general population over a wide age range. It illustrated that a single pelvic model would fit both sexes. The model allows the determination of the effects of changes of the pelvic dimensions may have on the acetabular orientation measured on an image free CAS system including the assessment of point acquisition and deliberate errors. The model has been successfully used in preliminary testing and can be used to assess any CT free system

Background. Recent literature points out the potential interest of standing and sitting X-rays for the evaluation of THA patients. The accuracy of the anterior pelvic plane measures is questionable due to the variations in the quality of lateral standing and sitting X-rays. The EOS® (EOS imaging, Paris, France) is an innovative slot-scanning radiograph system allowing the acquisition of radiograph images while the patient is in weightbearing position with less irradiation than standard imagers. This study reports the “functionnal” positions of a 150 THA cohort, including the lateral orientation of the cups. Methods. The following parameters were measured: sacral slope (SS), pelvic tilt (PT), pelvic incidence (PI) and anterior pelvic plane (APP) sagittal inclination (ASI), frontal inclination (AFI) and planar anteversion (ANT). Irradiation doses were calculated in standing and sitting acquisitions. Variations of sagittal orientation of the cup were measured on lateral standing and sitting images. Descriptive and multivariate analysis were performed for the different parameters studied. Results. The mean doses for full body were 0,80 mGy ± 0,13 for standing position and 0,94 mGy ± 0,25 for sitting position. The mean value for PI was 55,8° ± 11,4. The mean values standing position were 39,01° ± 9,9 for SS, 17,23° ± 10,2 for PT, and 0,74° ± 8,4 for APP. The mean values were 46,36° ± 9,8 for AFI, 39,49° ± 15,1 for ASI and 22,09° ± 11,1 for ANT. In sitting position, the mean values were 20,87° ± 10,2 for SS, 35,37° ± 13,1 for PT and 21,13° ± 11,2 for APP. The mean values were 56,41° ± 12,3 for AFI, 51,71° ± 14,7 for ASI and 33,45° ± 12,9 for ANT. Conclusions and Clinical Relevance. Unexpected variations of the anterior pelvic plane can be observed as well as the influence of pelvic incidence on pelvic orientation. The EOS® imaging system provides new informations regarding the pelvis functionnal anatomy in THA patients with potential applications for the study of unstable cases and wear phenomenons

Optimum component orientation in hip arthroplasty is vital in an effort to avoid dislocation and excessive wear. Computer navigation in hip arthroplasty surgery has the potential to improve accuracy in component placement. However, it has been slow to gain widespread acceptance. One of the major concerns surgeons have is the difficulty in registering pelvic landmarks. We used a retrospective series of 200 pelvic CT scans to validate a new methodology to construct the anterior pelvic plane, using anatomical landmarks that are easily palpated with the patient positioned and draped in the lateral decubitus position. Analysis of the scans was also made in an effort to stimulate the inaccuracies of obtaining the anterior pelvic plane through soft tissue. When comparing the new registration methodology to the anterior pelvic plane, the error in acetabular component inclination was 0.69° (SD 2.96) and anteversion was 1.17° (SD 3.53). This compares favourably to the error in acetabular component inclination of −0.92° (SD 0.26) and anteversion of −5.24° (SD 2.09) when the anterior pelvic plane is registered through soft tissue. The data also shows that using the new registration method in more than 99.6% of cases the acetabular placement is within the safe zone as described by Lewinnek. This study appears to show that through the identification of anatomical constants we are able to construct the anterior pelvic plane from anatomical landmarks that are easily palpable in the lateral decubitus position during hip arthroplasty. These landmarks also appear to be more accurate in obese patients than registering the anterior pelvic plane

Background. Acetabular component malpositioning during hip arthroplasty increases the risk of dislocation, reduces range of motion and can be responsible for early wear and loosening. There have been numerous reports on the optimal orientation of the acetabular component in total hip arthroplasty (THA). Lewinnek et al recommended an abduction angle of 40°±10° and an anteversion of 15°±10° for cup alignment in THA. The purpose of the in vivo study was to compare computer assisted acetabular component insertion versus free-hand placement. The goal of the cadaveric study was to compare in vitro a new tool using ultrasound with the standard percutaneous manual methods for the anterior pelvic plane registration during computer-assisted total hip arthroplasty. Methods. A controlled randomized matched prospective study was performed in two groups of 30 patients. In the first group, cup positioning was assisted by an imageless computer assisted orthopaedics system, based on Bone Morphingâ (CAOS+ group). In the control group, a free-hand cup placement was performed (CAOS- group). A same cementless cup has been used in the two groups. All the patients were operated by the same surgeon through an anterolateral approach. Cup anteversion and abduction angles were measured on three-dimensional CT-scan reconstruction postoperatively for each patient by an independent observer with special cup evaluation software. In vitro, four clinicians were asked to register ten times in a randomly change order the anterior pelvic plane landmarks in four different acquisition conditions: a cutaneous acquisition, a draped cutaneous acquisition, ultrasound acquisition and a direct bone acquisition on two cadavers. The mean and standard deviation of error for each anterior pelvic plane acquisition method were expressed as rotation and tilt about the relevant reference plane and compared. Results. There were 16 males and 14 females in each group, the mean age was 62 years (24–80) and mean Body Mass Index was 25. Mean additional time of the CAOS procedure was 12 minutes (8–20). Intraoperative subjective agreement of the surgeon with the computer guidance system demonstrated a high correlation in 23 cases, weak correlation in 6 cases and a poor correlation in 1 case. There were no statistical differences between the CAOS+ group and the CAOS- group regarding means of the abduction and anteversion angles but a significant heterogeneity of variances, with the lowest variations in the CAOS+ group. In vitro, for the draped cutaneous acquisition method the mean of the rotation and tilt around the reference plane for the two cadavers and the four operators were respectively 3.8 °±0.21° and 19.25 °±4.1°, for the for the ultrasound acquisition method respectively 2.8 °±0.21° and 6.2 °± 4.1°, for the cutaneous acquisition method respectively 2 °±0.21° and 16.2 °±4.1°. Discussion. The in vivo study has shown the accuracy of cup positioning using a CT-free navigation system in a prospective randomized controled protocol. Based on the number of the cadaveric study, ultrasound acquisition of the anterior pelvic plane is more accurate, reliable and reproducible in vitro than actual cutaneous digitization

Acetabular component positioning is commonly referenced with the pelvis in the supine position in direct anterior approach THA. Changes in pelvic tilt (PT) from the pre-operative supine to the post-operative standing positions have not been well investigated and may have relevance to optimal acetabular component targeting for reduced risk of impingement and instability. The aims of this study were therefore to determine the change in PT that occurs from pre-operative supine to post-operative standing, and whether any factors are associated with significant changes in tilt ≥13° in posterior direction. 13° in a posterior direction was chosen as that amount of posterior rotation creates an increase in functional anteversion of the acetabular component of 10°. 1097 THA patients with pre-operative supine CT and standing lateral radiographic imaging and 1 year post-operative standing lateral radiographs (interquartile range 12–13 months) were reviewed. Pre-operative supine PT was measured from CT as the angle between the anterior pelvic plane (APP) and the horizontal plane of the CT device. Standing PT was measured on standing lateral x-rays as the angle between the APP and the vertical line. Patients with ≥13° change from supine pre-op to standing post-op (corresponding to a 10° change in cup anteversion) were grouped and compared to those with a <13° change using unpaired student's t-tests. Mean pre-operative supine PT (3.8±6.0°) was significantly different from mean post-operative standing PT (−3.5±7.1°, p<0.001), ie mean change of −7.3±4.6°. 10.4% (114/1097) of patients had posterior PT changes ≥13° supine pre-op to standing post-op. A significant number of patients, ie 1 in 10, undergo a clinically significant change in PT and functional anteversion from supine pre-op to standing post-op. Surgeons should be aware of these changes when planning component placement in THA

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°

Pelvic tilt (PT) is always described as the pelvic orientation along the transverse axis, yet four PT definitions were established based on different radiographic landmarks: anterior pelvic plane (PT. a. ), the centres of femoral heads and sacral plate (PT. m. ), pelvic outlet (PT. h. ), and sacral slope (SS). These landmarks quantify a similar concept, yet understanding of their relationships is lacking. Some studies referred to the words “pelvic tilt” for horizontal comparisons, but their PT definitions might differ. There is a demand for understanding their correlations and differences for education and research purposes. This study recruited 105 sagittal pelvic radiographs (68 males and 37 females) from a single clinic awaiting their hip surgeries. Hip hardware and spine pathologies were examined for sub-group analysis. Two observers annotated four PTs in a gender-dependent manner and repeated it after six months. The linear regression model and intraclass correlation coefficient (ICC) were applied with a 95% significance interval. The SS showed significant gender differences and the lowest correlations to the other parameters in the male group (-0.3< r <0.2). The correlations of SS in scoliosis (n = 7) and hip implant (female, n = 18) groups were statistically different, yet the sample sizes were too small. PT. m. demonstrated very strong correlation to PT. h. (r > 0.9) under the linear model PT. m. = 0.951 × PT. h. - 68.284. The PT. m. and PT. h. are interchangeable under a simple linear regression model, which enables study comparisons between them. In the male group, SS is more of a personalised spinal landmark independent of the pelvic anatomy. Female patients with hip implant may have more static spinopelvic relationships following a certain pattern, yet a deeper study using a larger dataset is required. The understanding of different PTs improves anatomical education

Imageless computer navigation systems have the potential to improve acetabular cup position in total hip arthroplasty (THA), thereby reducing the risk of revision surgery. This study aimed to evaluate the accuracy of three alternate registration planes in the supine surgical position generated using imageless navigation for patients undergoing THA via the direct anterior approach (DAA). Fifty-one participants who underwent a primary THA for osteoarthritis were assessed in the supine position using both optical and inertial sensor imageless navigation systems. Three registration planes were recorded: the anterior pelvic plane (APP) method, the anterior superior iliac spines (ASIS) functional method, and the Table Tilt (TT) functional method. Post-operative acetabular cup position was assessed using CT scans and converted to radiographic inclination and anteversion. Two repeated measures analysis of variance (ANOVA) and Bland-Altman plots were used to assess errors and agreement of the final cup position. For inclination, the mean absolute error was lower using the TT functional method (2.4°±1.7°) than the ASIS functional method (2.8°±1.7°, ρ = .17), and the ASIS anatomic method (3.7°±2.1, ρ < .001). For anteversion, the mean absolute error was significantly lower for the TT functional method (2.4°±1.8°) than the ASIS functional method (3.9°±3.2°, ρ = .005), and the ASIS anatomic method (9.1°±6.2°, ρ < .001). All measurements were within ± 10° for the TT method, but not the ASIS functional or APP methods. A functional registration plane is preferable to an anatomic reference plane to measure intra-operative acetabular cup inclination and anteversion accurately. Accuracy may be further improved by registering patient location using their position on the operating table rather than anatomic landmarks, particularly if a tighter target window of ± 5° is desired

Introduction. Studies show that cup malpositioning using conventional techniques occurs in 50 to 74% of cases defined. Assessment of the utility of improved methods of placing acetabular components depends upon the accuracy of the method of measuring component positioning postoperatively. The current study reports on our preliminary experience assessing the accuracy of EOS images and application specific software to assess cup orientation as compared to CT. Methods. Eighteen patients with eighteen unilateral THA had pre-operative EOS images were obtained for preoperative assessment of leg-length difference and standing pelvic tilt. All of these patients also had preoperative CT imaging for surgical navigation of cup placement. This allows us to compare cup orientation as measured by CT to cup orientation as measured using the EOS images. Application specific software modules were developed to measure cup orientation using both CT and EOS images (HipSextant Research Application 1.0.13 Surgical Planning Associates Inc., Boston, Massachusetts). Using CT, cup orientation was determined by identifying Anterior Pelvic Plane coordinate system landmarks on a 3D surface model. A multiplanar reconstruction module allows for creation of a plane parallel with the opening plane of the acetabulum and subsequent calculation of plane orientation in the AP Plane coordinate space according to Murray's definitions of operative anteversion and operative inclination. Using EOS DICOM images, spatial information from the images were used to reconstruct the fan beam projection model. Each image pair is positioned inside this projection model. Anterior Pelvic Plane coordinate points are digitized on each image and back-projected to the fan beam source. Corresponding beams are then used to compute the 3D intersection points defining the 3D position and orientation of the Anterior Pelvic Plane. Ellipses with adjustable radii were then used to define the cup border in each EOS image. By respecting the fan beam projection model, 3D planes defining the projected normal of the ellipse in each image are computed. 3D implant normal was estimated by determining 3D plane intersection lines for each image pair. Implant center points are defined by using the back-projected and intersected ellipse center beams in the image pairs (Figure 1). Results. The results are shown in Figure 2. The mean anteversion error was −0.9 degrees (SD 4.1, range −6.9 to 10.3). The mean inclination error was 1.8 (SD 2.1, range −2.9 to 8.6). All three cups with errors greater than 7 degrees were in cups with 40 or more degrees of anteversion. Discussion and Conclusion. The current study, while very preliminary, demonstrates the potential that EOS images can be used to measure cup orientation with a reasonable degree of accuracy. Accurate determination of cup orientation appears to be more challenging in cups with higher anteversion

Introduction: With the increasing use of CAOS techniques in Orthopaedic Surgery it is important to be aware of verification studies and sources of error that can occur. Computer assisted navigation systems should be tested with a known true standard such as a phantom model and then verified with cadaver studies before clinical trials are instituted. Errors can occur. Materials and Methods: A major focus for hip arthroplasty navigation has been on acetabular cup anteversion and inclination. Non CT navigation systems rely on an anterior pelvic plane, which is selected by the surgeon. This study looked at repeated measurements of a surgeon’s ability to manually pick the pubic symphysis and the ASIS and compared this to the same points selected fluoroscopically. A navigated acetabular cup was performed aiming for abduction of 45° and anteversion of 20°. The software model was then manipulated to transpose the different registrations to see what compound effect the anterior pelvic plane error would have. Results: Significant intra and inter observation error was recorded for registration by palpation compared to points registered by the fluoroscopic method. An error of up to 9.6° cup inclination and 11.2 ° cup anteversion could be introduced with a palpation method. Conclusion: This cadaver study indicates that with hip arthroplasty, registration from a fluoroscopic image was more accurate with a respect to determining the anterior pelvic plane when compared to direct palpation. Like all surgery done with computer navigation, registration requires an accurate determination of the points that the software needs for calculation. This must always be borne in mind when evaluating methods for CAOS

Introduction. The pelvis is not a static structure. It rotates in the sagittal plane depending upon the activity being performed. These dynamic changes in pelvic tilt have a substantial effect on the functional orientation of the acetabulum. The aim of this study was to quantify the changes in sagittal pelvic position between three functional postures. Methodology. Pre-operatively, 1,517 total hip replacement patients had their pelvic tilt measured in 3 functional positions – standing, supine and flexed seated (point when patients initiate rising from a seated position). Lateral radiographs were used to define the pelvic tilt in the standing and flexed seated positions. Pelvic tilt was defined as the angle between a vertical reference line and the anterior pelvic plane (defined by the line joining both anterior superior iliac spines and the pubic symphysis). In the supine position pelvic tilt was defined as the angle between a horizontal reference line and the anterior pelvic plane. Supine pelvic tilt was measured from computed tomography. Results. The mean supine pelvic tilt was 4.2°, with a range of −20.5° to 24.5°. The mean standing pelvic tilt was −1.3°, with a range of −30.2° to 27.9°. Mean pelvic tilt in the flexed seated position was 0.6°, with a range of −42.0° to 41.3°. The mean absolute change from supine to stand, and supine to flexed seated was 6.0° (SD = 3.8°) and 10.7° (SD = 8.1°) respectively. 6% of patients rotated posteriorly by more than 13° from supine to stand, consequently putting them at risk of excessive functional anteversion in extension. 11% of patients rotated anteriorly by more than 13° from supine to seated, consequently retroverting their cup and putting them at risk in flexion. Therefore, 17% of patients had sagittal pelvic rotations that could lead to functional cup malorientation even with a supposedly ideal orientation of 40°/20°. Factoring in an intraoperative delivery error of ± 5° extends this risk to 51% of patients. Conclusions. The position of the pelvis in the sagittal plane changes significantly between functional activities. The extent of change is specific to each patient. 17% of patients had sagittal pelvic rotations that could lead to functional cup malorientation in functional flexion or extension, even with an apparently perfectly-orientated component. This number extended to 51% when an intra-operative delivery error of ± 5° was considered. Planning and measurement of cup placement in the supine position can lead to large discrepancies in orientation during more functionally relevant postures. Optimal cup orientation is likely patient-specific and requires an evaluation of functional pelvic dynamics to pre-operatively determine the target angles