Purpose. Minimally invasive anterolateral approach (ALA) for total hip arthroplasty (THA) has gained popularity in recent years as better postoperative functional recovery and lower risk of postoperative dislocation are claimed. However, difficulties for femur exposure and intraoperative complications during femoral canal preparation and component placement have been reported. This study analyzes the anatomical factors likely to be related with intraoperative complications and the difficulties of access noted by the surgeons through a modified minimally invasive ALA. The aim is to define the profile for patient at risk of intraoperative complications during minimally invasive ALA. Methods. We retrospectively included 310 consecutive patients (100 males, 210 females) who had primary unilateral THA using the same technique in all cases. The approach was performed between the tensor fascia lata and the gluteus medius and minimus, without incising or detaching muscles and tendons. Posterior translation was combined to external rotation for proximal femur exposure (Fig. 1). All patients were reviewed clinically and radiologically. For the radiological evaluation, all patients underwent pre- and postoperative standing and sitting full-body EOS acquisitions. Pelvic [Sacral slope, Pelvic incidence (PI), Anterior pelvic plane angle] and femoral parameters were measured preoperatively. We assessed all intraoperative and postoperative complications for femoral preparation and implantation. Intraoperative complications included the femoral fractures and difficulties for femoral exposure (limitations for exposure and lateralization of the proximal femur). The patients were divided into two groups: patients with or without intraoperative complications. Results. Ten patients (3.2%) had intraoperative femoral fractures (greater trochanter: 2 cases, calcar: 8 cases). Five fractures required additional wiring. Difficult access to proximal femur was reported in the operative records for 10 other patients (3.2%). There was no difference in diagnosis, age, sex, BMI between the patients with or without intraoperative complications. No significant group differences were found for surgical time, and blood loss. Patients with intraoperative complication, presented a significantly lower pelvic incidence than patients without intraoperative complications (mean PI: 39.4° vs 56.9°, p<0.001). The relative risk of intraoperative complications in patients with low PI (PI<45°) was more than thirteen times (relative risk; 13.3, 95% CI= 8.2 to 21.5. p<0.001) the risk for patients with normal and high PI (PI>45°). Conclusions. Anterolateral approach for THA implantation in lateral decubitus is reported to have anatomical and functional advantages. Nevertheless, the exposure of the femur remains a limitation. This study highlights a significant increased risk in case of low PI less than 45°. This specific anatomical pattern reduces the local working space as the possibility for posterior translation and elevation of the proximal femur is less on a narrow pelvis. This limitation is due to the length and the orientation of the hip abductor and short external rotator muscles related to the relative positions of iliac wing and greater trochanter (Fig. 2). This study points out the importance of pelvic incidence for the detection of anatomically less favourable patients for THA implantation using ALA. For any figures or tables, please contact the authors directly

Pelvic incidence is as a key factor for sagittal balance regulation that describes the anatomical configuration of the pelvis. The sagittal alignment of the pelvis is usually evaluated in two-dimensional (2D) sagittal radiographs in standing position by pelvic parameters of sacral slope, pelvic tilt and pelvic incidence (PI). However, the angle of PI remains constant for an arbitrary subject position and orientation, and can be therefore compared among subjects in standing, sitting or supine position. Such properties also enable the measurement of PI in three-dimensional (3D) images, commonly acquired in supine position. The purpose of this study is to analyse the sagittal alignment of the pelvis in terms of PI in 3D computed tomography (CT) images. A computerised method based on image processing techniques was developed to determine the anatomical references, required to measure PI, i.e. the centre of the left femoral head, the centre of the right femoral, the centre of the sacral endplate, and the inclination of the sacral endplate. First, three initialisation points were manually selected in 3D at the approximate location of the left femoral head, right femoral head and L5 vertebral body. The computerised method then determined the exact centres of the femoral heads in 3D from the spheres that best fit to the 3D edges of the femoral heads. The exact centre of the sacral endplate in 3D was determined by locating the sacral endplate below the L5 vertebral body and finding the midpoint of the lines between the anterior and posterior edge, and between the left and right edge of the endplate. The exact inclination of the sacral endplate in 3D was determined from the plane that best fit to the endplate. Multiplanar 3D image reformation was applied to obtain the superposition of the femoral heads in the sagittal view, so that the hip axis was observed as a straight not inclined line and all anatomical structures were completely in line with the hip axis. Finally, PI was automatically measured as the angle between the line orthogonal to the inclination of the sacral endplate and the line connecting the centre of the sacral endplate with the hip axis. The method was applied to axially reconstructed CT scans of 426 subjects (age 0–89 years, pixel size 0.4–1.0 mm, slice thickness 3.0–4.0 mm). Thirteen subjects were excluded due to lumbar spine trauma and presence of the sixth lumbar segment. For the remaining subjects, the computerised measurements were visually assessed for errors, which occurred due to low CT image quality, low image intensity of bone structures, or other factors affecting the determination of the anatomical references. The erroneous or ambiguous results were detected for 43 subjects, which were excluded from further analysis. For the final cohort of 370 subjects, statistical analysis was performed for the obtained PI. The resulting mean PI ± standard deviation was equal to 46.6 ± 9.2 degrees for males (N = 189, age 39.7 ± 20.3 years), 47.6 ± 10.7 degrees for females (N = 181, age 43.4 ± 19.9 years), and 47.1 ± 10.0 degrees for both genders (N = 370, age 41.5 ± 20.1 years). Correlation analysis yielded relatively low but statistically significant correlation between PI and age, with the correlation coefficient r = 0.20 (p < 0.005) for males, r = 0.32 (p < 0.0001) for females, and r = 0.27 (p < 0.0001) for both genders. No statistically significant differences (p = 0.357) were found between PI for male and female subjects. This is the first study that evaluates the sagittal alignment of the pelvis in terms of PI completely in 3D. Studies that measured PI manually from 2D sagittal radiographs reported normative PI in adult population of 52 ± 10 degrees, 53 ± 8 degrees and 51 ± 9 degrees for 25 normal subjects aged 21–40, 41–60, and over 60 years, respectively [3], and 52 ± 5 degrees for a cohort of 160 normal subjects [4]. The PI of 47 ± 10 degrees obtained in our study is lower than the reported normative values, which indicates that radiographic measurements may overestimate the actual PI. Radiographic measurements are biased by the projective nature of X-ray image acquisition, as it is usually impossible to obtain the superposition of the two femoral heads. The midpoint of the line connecting the centres of femoral heads in 2D is therefore considered to be the reference point on the hip axis, moreover, the inclination of the sacral endplate in the sagittal plane is biased by its architecture and inclination in the coronal plane. On the other hand, the measurements in the present study were obtained by applying a computerized method to CT images that determined the exact anatomical references in 3D. Perfect sagittal views were generated by multiplanar reformation, which aligned the centres of the femoral heads in 3D. The measurement of PI was therefore not biased by acquisition projection or structure orientation, as all anatomical structures were completely in line with the hip axis. Moreover, the range of the PI obtained in every study (standard deviation of around 10 degrees) indicates that the span of PI is relatively large. It can be therefore concluded that an increased or decreased PI may not necessary relate to a spino-pelvic pathology

Introduction. Post op cup anatomical and functional orientation is a key point in THP patients regarding instability and wear. Recently literature has been focused on the consequences of the transition from standing to sitting regarding anteversion, frontal and sagittal inclination. Pelvic incidence (PI) is now considered as a key parameter for the analysis of sagittal balance and sacral slope (SS) orientation. It's influence on THP biomechanics has been suggested. Interestingly, the potential impact of this morphological angle on cup implantation during surgery and the side effects on post op functional orientation have not been studied. Our study explores this topic from a series of standing and sitting post-op EOS images. Material and methods. 310 patients (mean age 63,8, mean BMI 30,2) have been included prospectively in our current post-operative EOS protocol. All patients were operated with the same implants and technique using anterior approach in lateral decubitus. According to previous literature, 3 groups were defined: low PI less than 45° (57 cases), high PI if more than 60° (63 cases), and standard PI in 190 other cases. Results. Mean PI was 55,8° (SD 11,5). -In High PI, postop SS in standing was significantly higher than in Low and Medium PI. In Medium PI, postop SS in standing was significantly higher than in Low PI. -In High PI, postop SS in sitting was significantly higher than in Low and Medium PI. -In Low PI, postop Functional anteversion in sitting was significantly higher than in Medium PI, but not different from High PI. -In Low PI, Anatomical anteversion was significantly higher than in Medium and High PI. Discussion, Conclusion. This preliminary study points out the potential influence of pelvis morphology expressed by PI on per-operative cup orientation. As surgeons are accustomed to follow bony landmarks during cup implantation, unexpected variations for cup adjustment may be observed if PI is not standard. For any figures or tables, please contact authors directly

Aims. The aetiologies of common degenerative spine, hip, and knee pathologies are still not completely understood. Mechanical theories have suggested that those diseases are related to sagittal pelvic morphology and spinopelvic-femoral dynamics. The link between the most widely used parameter for sagittal pelvic morphology, pelvic incidence (PI), and the onset of degenerative lumbar, hip, and knee pathologies has not been studied in a large-scale setting. Methods. A total of 421 patients from the Cohort Hip and Cohort Knee (CHECK) database, a population-based observational cohort, with hip and knee complaints < 6 months, aged between 45 and 65 years old, and with lateral lumbar, hip, and knee radiographs available, were included. Sagittal spinopelvic parameters and pathologies (spondylolisthesis and degenerative disc disease (DDD)) were measured at eight-year follow-up and characteristics of hip and knee osteoarthritis (OA) at baseline and eight-year follow-up. Epidemiology of the degenerative disorders and clinical outcome scores (hip and knee pain and Western Ontario and McMaster Universities Osteoarthritis Index) were compared between low PI (< 50°), normal PI (50° to 60°), and high PI (> 60°) using generalized estimating equations. Results. Demographic details were not different between the different PI groups. L4 to L5 and L5 to S1 spondylolisthesis were more frequently present in subjects with high PI compared to low PI (L4 to L5, OR 3.717; p = 0.024 vs L5 to S1 OR 7.751; p = 0.001). L5 to S1 DDD occurred more in patients with low PI compared to high PI (OR 1.889; p = 0.010), whereas there were no differences in L4 to L5 DDD among individuals with a different PI. The incidence of hip OA was higher in participants with low PI compared to normal (OR 1.262; p = 0.414) or high PI (OR 1.337; p = 0.274), but not statistically different. The incidence of knee OA was higher in individuals with a high PI compared to low PI (OR 1.620; p = 0.034). Conclusion. High PI is a risk factor for development of spondylolisthesis and knee OA. Low pelvic incidence is related to DDD, and may be linked to OA of the hip. Level of Evidence: 1b. Cite this article: Bone Joint J 2020;102-B(9):1261–1267

Introduction. Excessive standing posterior pelvic tilt (PT), lumbar spine stiffness, low pelvic Incidence (PI), and severe sagittal spinal deformity (SSD) have been linked to increased dislocation rates. We aimed to compare the prevalence of these 4 parameters in unstable and stable primary Total Hip Arthroplasty (THA) patients. Methods. In this retrospective cohort study, 40 patients with instability following primary THA for osteoarthritis were referred for functional analysis. All patients received lateral X-rays in standing and flexed seated positions to assess functional pelvic tilt and lumbar lordosis (LL). Computed tomography scans were used to measure pelvic incidence and acetabular cup orientation. Literature thresholds for “at risk” spinopelvic parameters were standing pelvic tilt ≤ −10°, lumbar flexion (LL. stand. – LL. seated. ) ≤ 20°, PI ≤ 41°, and sagittal spinal deformity (PI – LL. stand. mismatch) ≥ 10°. The prevalence of each risk factor in the dislocation cohort was calculated and compared to a previously published cohort of 4042 stable THA patients. Results. Median supine cup inclination for the dislocating cohort was 43° (range, 26°- 58°). Median cup anteversion was 23° (range, 7° − 40°) for the dislocating cohort. 65% of the dislocating patients had socket positions within the Lewinnek safe zone (Figure 1). Standing PT (-10° v −1°), lumbar flexion (20° v 45°), and PI-LL mismatch (12° v −1°) were all significantly different (p < 0.001) in the dislocating group compared to the stable THA population (Figure 2). There was no difference in PI between the dislocating group and the stable THA population (58° v 56° respectively, p = 0.33), with the numbers available. 80% of the dislocating patients had one or more of the 3 statistically significant risk factors, compared to only 24% of the stable THA population. Conclusion. Excessive standing posterior pelvic tilt, low lumbar flexion and a severe SSD are highly prevalent in unstable THAs. Pre-op screening for these parameters may reduce the prevalence of dislocation. For any figures or tables, please contact the authors directly

The study of spinopelvic anatomy and movement has received great interest as these characteristics influence the biomechanical behavior (and outcome) following hip arthroplasty. However, to-date there is little knowledge of what “normal” is and how this varies with age. This study aims to determine how dynamic spino-pelvic characteristics change with age, with well-functioning hips and assess how these changes are influenced by the presence of hip arthritis. This is an IRB-approved, cross-sectional, cohort study; 100 volunteers (asymptomatic hips, Oxford-Hip-sore>45) [age:53 ± 17 (24-87) years-old; 51% female; BMI: 28 ± 5] and 200 patients with end-stage hip arthritis [age:56 ± 19 (16-89) years-old; 55% female; BMI:28 ± 5] were studied. All participants underwent lateral spino-pelvic radiographs in the standing and deep-seated positions to determine maximum hip and spine flexion. Parameters measured included lumbar-lordosis (LL), pelvic incidence, pelvic-tilt (PT), pelvic-femoral angles (PFA). Lumbar flexion (ΔLL), hip flexion (ΔPFA) and pelvic movement (ΔPT) were calculated. The prevalence of spinopelvic imbalance (PI–LL>10?) was determined. There were no differences in any of the spino-pelvic characteristics or movements between sexes. With advancing age, standing LL reduced and standing PT increased (no differences between groups). With advancing age, both hip (4%/decade) and lumbar (8%/decade) flexion reduced (p<0.001) (no difference between groups). ΔLL did not correlate with ΔPFA (rho=0.1). Hip arthritis was associated with a significantly reduced hip flexion (82 ±;22? vs. 90 ± 17?; p=0.003) and pelvic movements (1 ± 16? vs. 8 ± 16?; p=0.002) at all ages and increased prevalence of spinopelvic imbalance (OR:2.6; 95%CI: 1.2-5.7). With aging, the lumbar spine loses its lumbar lordosis and flexion to a greater extent that then the hip and resultantly, the hip's relative contribution to the overall sagittal movement increases. With hip arthritis, the reduced hip flexion and the necessary compensatory increased pelvic movement is a likely contributor to the development of hip-spine syndrome and of spino-pelvic imbalance

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

Adverse spinopelvic characteristics (ASC) have been associated with increased dislocation risk following primary total hip arthroplasty (THA). A stiff lumbar spine, a large posterior standing tilt when standing and severe sagittal spinal deformity have been identified as key risk factors for instability. It has been reported that the rate of dislocation in patients with such ASC may be increased and some authors have recommended the use of dual mobility bearings or robotics to reduce instability to within acceptable rates (<2%). The aims of the prospective study were to 1: Describe the true incidence of ASC in patients presenting for a THA 2. Assess whether such characteristics are associated with greater symptoms pre-THA due to the concomitant dual pathology of hip and spine and 3. Describe the early term dislocation rate with the use of ≤36mm bearings. This is an IRB-approved, two-center, multi-surgeon, prospective, consecutive, cohort study of 220 patients undergoing THA through anterolateral- (n=103; 46.8%), direct anterior- (n=104; 27.3%) or posterior- approaches (n=13; 5.9%). The mean age was 63.8±12.0 years (range: 27.7-89.0 years) and the mean BMI 28.0±5.0 kg/m. 2. (range: 19.4-44.4 kg/m. 2. ). There were 44 males (47.8%) and 48 females (52.2%). The mean follow-up was 1.6±0.5 years. Overall, 54% of femoral heads was 32 mm, and 46% was 36mm. All participants underwent lateral spinopelvic radiographs in the standing and deep-flexed seated positions were taken to determine lumbar lordosis (LL), sacral slope (SS), pelvic tilt (PT), pelvic-femoral angle (PFA) and pelvic incidence (PI) in both positions. Spinal stiffness was defined as lumbar flexion <20° when transitioning between the standing and deep-seated position; adverse standing PT was defined as >19° and adverse sagittal lumbar balance was defined as mismatch between standing PI and LL >10°. Pre-operative patient reported outcomes was measured using the Oxford Hip Score (OHS) and EuroQol Five-Dimension questionnaire (EQ-5D). Dislocation rates were prospectively recorded. Non-parametric tests were used, significance was set at p<0.05. The prevalence of PI-LL mismatch was 22.1% (43/195) and 30.4% had increased standing PT (59/194). The prevalence of lumbar stiffness was 3.5% (5/142) and these patients had all three adverse spinopelvic characteristics (5/142; 3.5%). There was no significant difference in the pre-operative OHS between patients with (20.7±7.6) and patients without adverse spinopelvic characteristics (21.6±8.7; p=0.721), nor was there for pre-operative EQ5D (0.651±0.081 vs. 0.563±0.190; p=0.295). Two patients sustained a dislocation (0.9%): One in the lateral (no ASC) and one in the posterior approaches, who also exhibited ASC pre-operatively. Sagittal lumbar imbalance, increased standing spinal tilt and spinal stiffness are not uncommon among patients undergoing THA. The presence of such characteristics is not associated with inferior pre-operative PROMs. However, when all characteristics are present, the risk of instability is increased. Patients with ASC treated with posterior approach THA may benefit from the use of advanced technology due to a high risk of dislocation. The use of such technology with the anterior or lateral approach to improve instability is to date unjustified as the rate of instability is low even amongst patients with ASCs

Introduction. The purpose of this study was to compare pre-operative acetabular cup parameters using this novel dynamic imaging sequence to the Lewinnek safe zone. Methods. We retrospectively reviewed 350 consecutive primary THAs that underwent dynamic pre-operative acetabular cup planning utilizing a pre-operative CT scan to capture the individual's hip anatomy, followed by standing (posterior pelvic tilt), sitting (anterior pelvic tilt), and supine X-rays. Using these inputs, we modeled an optimal cup position for each patient. Radiographic parameters including inclination, anteversion, pelvic tilt, pelvic incidence, and lumbar flexion were analyzed. Results. Mean age of patients was 63 years (range, 18 to 95). Mean supine pelvic tilt was 4.7o (range, −31o to 21o), standing pelvic tilt was −0.3o (range, −33o to 23o), and flex-seated pelvic tilt was −0.7o (range, −42o to 32o). Mean pelvic incidence was 54o (range, 24o to 88o) and mean lumbar flexion was 43o (range, 0o to 78o). Mean inclination was 40° (range, 34 to 49) and mean anteversion was 24° (range, 3.5 to 39). Only 56% of the dynamically planned cups were within the Lewinnek safe zone (p<0.05, Figure 1). Mean inclination and anteversion difference between dynamic and Lewinnek safe zone was 1.3o (range, 0o to 12o) and 8.9o (range, 0o to 25o), respectively. Conclusion. Our study demonstrates that historical target parameters for cup inclination and anteversion significantly differ to target values obtained with the use of functional imaging. Understanding the individual spinopelvic motion for each patient allows for more accurate placement of the acetabular component, which may help to reduce the risk of dislocation, premature wear and squeaking of bearing surfaces, and improve functional outcomes

Introduction. The functional ante-inclination (AI) of the cup after total hip arthroplasty (THA) is a key component in the combined sagittal index (CSI) to predict joint stability after THA. To accurately predict AI, we deducted a mathematic algorithm between the radiographic anteversion (RA), radiographic inclincation (RI), pelvic tilting (PT), and AI. The current study aims (1) to validate the mathematic algorithm; (2) to convert the AI limits in the CSI index (standing AI ≤ 45°, sitting AI ≥ 41°) into coronal functional safe zone (CFSZ) and explore the influences of the stand-to-sit pelvic motion (PM) and pelvic incidence (PI) on CFSZ; (3) to locate a universal cup orientation that always fulfill the AI criteria of CSI safe zone for all patients or subgroups of PM(PM ≤ 10°, 10° < PM ≤ 30°, and PM > 30°) and PI (PI≤ 41°, 41°< PI ≤ 62°, and PI >62°), respectively. Methods. A 3D printed phantom pelvic model was designed to simulate changing PT values. An acetabular cup was implanted with different RA, RI, and PT settings using robot assisted technique. We enrolled 100 consecutive patients who underwent robot assisted THA from April, 2019 to June, 2019 in our hospital. EOS images before THA and at 6-month follow-up were collected. AI angles were measured on the lateral view radiographs as the reference method. Mean absolute error (MAE), Bland-Altman analysis and linear regression were conducted to assess the accuracy of the AI algorithm for both the phantom and patient radiographic studies. The 100 patients were classified into three subgroups by PM and PI, respectively. Linear regression and ANOVA analysis were conducted to explore the relationship between the size of CFSZ, and PM and PI, respectively. Intersection of the CFSZ was conducted to identify if any universal cup orientation (RA, RI) existed for the CSI index. Results. The mathematic algorithm for calculating AI based on RI, RA, and PT is highly accurate according to the phantom and patient radiographic study. CFSZ size corresponds linearly with PM (R² = 0.638) and PI (R² = 0.129), respectively. There are significant differences in the size of CFSZ, as well as in the intersection of CFSZ and LSZ, between the subgroups of PM and PI, respectively (P<0.017). There is no universal cup orientations could be identified to fulfill the AI limits of the CSI index for all the 100 patients or any of the three subgroups, according to either PM or PI. Conclusions. The cup target orientation should be individualized. The validated algorithm between AI and RA, RI, and PT parameters can serve as the quantitative tool for patient-specific optimization of functional cup AI in different postures

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

The sagittal orientation of the pelvis commonly called pelvic tilt has an effect on the orientation of the cup in total hip arthroplasty (THA). Pelvic tilt is different between individuals and changes during activities of daily living. In particular the pelvic tilt in standing position should be considered during the planning of THA to adapt the target angles of the cup patient-specifically to minimise wear and the risk of dislocation. Methods to measure pelvic tilt require an additional step in the planning process, may be time consuming and require additional devices or x-ray imaging. In this study the relationship between three functional parameters describing the sagittal pelvic orientation in standing position and seven morphological parameters of the pelvis was investigated. Correlations might be used to estimate the pelvic tilt in standing position by the morphology of the pelvis in order to avoid additional measuring techniques of pelvic tilt in the planning process of THA. For 18 subjects a semi-automatic process was established to match a 3D-reconstruction of the pelvis from CT scans to orthogonal EOS imaging in standing position and to calculate the morphological and functional parameters of the pelvis subsequently. The two strongest correlations of the linear correlation analysis were observed between morphological pelvic incidence and functional sacral slope (r = 0.78; p = 0.0001) and between morphological pubic symphysis-posterior superior iliac spines-ratio and functional tilt of anterior pelvic plane (r = −0.59; p = 0.0098). The results of this study suggest that patient-specific adjustments to the orientation of the cup in planning of THA without additional measurement of the sagittal pelvic orientation in standing position should be based on the correlation between morphological pelvic incidence and functional sacral slope

Spinopelvic mobility describes the change in lumbar lordosis and pelvic tilt from standing to sitting position. For 1° of posterior pelvic tilt, functional cup anteversion increases by 0.75° after total hip arthroplasty (THA). Thus, spinopelvic mobility is of high clinical relevance regarding the risk of implant impingement and dislocation. Our study aimed to 1) determine the proportion of OA-patients with stiff, normal or hypermobile spino-pelvic mobility and 2) to identify clinical or static standing radiographic parameters predicting spinopelvic mobility. This prospective diagnostic cohort study followed 122 consecutive patients with end-stage osteoarthritis awaiting THA. Preoperatively, the Oxford Hip Score, Oswestry Disability Index and Schober's test were assessed in a standardized clinical examination. Lateral view radiographs were taken of the lumbar spine, pelvis and proximal femur using EOS© in standing position and with femurs parallel to the floor in order to achieve a 90°-seated position. Radiographic measurements were performed for the lumbar lordosis angle (LL), sacral slope (SS), pelvic tilt (PT), pelvic incidence (PI) and pelvic-femoral-angle (PFA). The difference in PT between standing and seated allowed for patient classification based on spino-pelvic mobility into stiff (±30°). From the standing to the sitting position, the pelvis tilted backwards by a mean of 19.6° (SD 11.6) and the hip was flexed by a mean of 57° (SD 17). Change in pelvic tilt correlated inversely with change in hip flexion. Spinopelvic mobility is highly variable in patients awaiting THA and we could not identify any clinical or static standing radiographic parameter predicting the change in pelvic tilt from standing to sitting position. In order to identify patients with stiff or hypermobile spinopelvic mobility, we recommend performing lateral view radiographs of the lumbar spine, pelvis and proximal femur in all patients awaiting THA. Thereafter, implants and combined cup inclination/anteversion can be individually chosen to minimize the risk of dislocation. No predictors could be identified. We recommend performing sitting and standing lateral view radiographs of the lumbar spine and pelvis to determine spinopelvic mobility in patients awaiting THA

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

Background. Postural change after total hip arthroplasty (THA) is still a matter of discussion. Previous studies have mainly concentrated on the pelvic motions. We report the postoperative changes of the global sagittal posture using pelvic, spinal and lower extremities parameters. Methods. 139 patients (primary THA, without previous spinal or lower extremity surgery) were included. We measured pelvic parameters [SS: Sacral Slope, PI: Pelvic Incidence, PT: Pelvic Tilt, APP angle: Anterior Pelvic Plane angle] and the global posture parameters (SVA: Sagittal Vertical Angle, GSA: Global Sagittal Angle, TPA: T1 pelvic angle). Patients were categorized into low PI group <45°, 45°< medium PI <65° and high PI >65°. Results. Mean GSA and SVA decreased postoperatively (p=0.005 and p=0.004 respectively). The TPA change was not significant (p=0.078). In low PI group, GSA (5.4 ± 5.0 to 4.3 ± 4.0, p=0.005) and SVA (5.4 ± 4.9 to 4.2 ± 4.1, p=0.038) decreased with more posterior pelvic tilt. Postoperative TPA was significantly higher (8.4 ± 10.6 to 9.8 ± 10.7; p=0.048). In medium PI group, SVA decreased (4.2 ± 4.6 to 3.6 ± 4.5, p=0.020) with more posterior pelvic tilt. In high PI group, pelvic and global posture parameters did not evolve significantly. Conclusion. PI is the key determining factor in pelvic tilt modification after THA. Patients with low PI demonstrate significant modification in spine, pelvic and lower extremities. Pelvic tilt is the main adaptation mechanism for medium incidence patients whereas pelvic tilt does not change in high PI patients after surgery

Introduction. Stand to sit pelvis kinematics is commonly considered as a rotation around the bicoxofemoral axis. However, abnormal kinematics could occur for patients with musculoskeletal disorders affecting the hip-spine complex. The aim of this study is to perform a quantitative analysis of the stand to sit pelvis kinematics using 3D reconstruction from bi-planar x-rays. Materials and Methods. Thirty healthy volunteers as a control group (C), 30 patients with hip pathology (Hip) and 30 patients with spine pathology (Spine) were evaluated. All subjects underwent standing and sitting full-body bi-planar x-rays. 3D reconstruction was performed in each configuration and then translated such as the middle of the line joining the center of each acetabulum corresponds to the origin. Rigid registration quantified the finite helical axis (FHA) describing the transition between standing and sitting with two specific parameters. The orientation angle (OA) is the signed 3D angle between FHA and bicoxofemoral axis and the rotation angle (RA) represents the signed angle around FHA. Pelvic incidence, sacral slope and pelvic tilt were also measured. After checking normality of distribution, parameters were compared statistically between the 3 groups (p<0.05). Results. The mean value of the orientation angle in control group was −1.8° (SD 10.8°, range −26° to 25°). The mean value of the OA was 0.3° (SD 12.3°, range to −31° to 37°) in Hip group and −4.7° (SD 21.5°, range −86° to 38°) in Spine group. There was no significant difference in mean OA among groups. However, the more subnormal and abnormal patients were in Spine group compared to C and Hip groups. The mean value of the rotation angle in C group was 18.1° (SD 9.1°, range 5° to 43°). There was significant difference in RA between Hip and Spine groups (21.1° (SD 8.0°) and 16.0° (SD 10.7°), respectively) (p=0.04). Conclusion. This study highlights new informations obtained by the quantitative analysis of pelvis rotation between standing and sitting in healthy, hip pathology patients and spine pathology patients using 3D reconstruction from bi-planar radiographs. Hip and spine pathologies affect stand to sit pelvic kinematics. Surgeons should be aware of potential abnormal stand to sit transition in such clinical situations. This improved assessment of the pelvic rotational adaptation could lead to a more personalized approach for the planning of hip prostheses

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

Objectives. For patients with Developmental Dysplasia of the Hip (DDH) who progress to needing total joint arthroplasty it is important to understand the morphology of the femur when planning for and undertaking the surgery, as the surgery is often technically more challenging in patients with DDH on both the femoral and acetabular parts of the procedure. 1. The largest number of male DDH patients with degenerative joint disease previously assessed in a morphological study was 12. 2. In this computed tomography (CT) based morphological study we aimed to assess whether there were any differences in femoral morphology between male and female patients with developmental dysplasia undergoing total hip arthroplasty (THA) in a cohort of 49 male patients, matched to 49 female patients. Methods. This was a retrospective study of the pre-operative CT scans of all male patients with DDH who underwent THA at two hospitals in Japan between 2006–2017. Propensity score matching was used to match these patients with female patients in our database who had undergone THA during the same period, resulting in 49 male and 49 female patients being matched on age and Crowe classification. The femoral length, anteversion, neck-shaft angle, offset, canal-calcar ratio, canal flare index, lateral centre-edge angle, alpha angle and pelvic incidence were measured for each patient on their pre-operative CT scans. Results. Significant differences were found in femoral anteversion with a mean male anteversion of 22 ˚ (±14.2), compared to 30˚ (±15.5), in females (p=0.02, Confidence Interval (C.I.) 1.6 to 14.9, Figure 1), offset, with a mean male offset of 31 mm (±6.2), compared to 29 mm (±6.1) in females, (p=0.04, C.I: 0.2 to 4.8), and femoral length with a mean femoral length of 434 mm in males (±22.2), compared to 407 mm in females (±23.9), (p<0.001, C.I: 19.2 to 34.3, Figure 2). No significant differences between male and female patients were found for the other measurements. Discussion. This was the first study of this size assessing femoral morphology in male patients with DDH undergoing THA. Significant differences were found between male and female patients in femoral anteversion, length and offset. This should be taken into account when planning and performing THA in these patients. Based on the findings from this study, a more anteverted femoral neck can be expected at the time of surgery in a female patient with DDH undergoing total hip arthroplasty, compared to a male patient

INTRODUCTION. Standing spinal alignment has been the center of focus recently, particularly in the setting of adult spinal deformity. Humans spend approximately half of their waking life in a seated position. While lumbopelvic sagittal alignment has been shown to adapt from standing to sitting posture, segmental vertebral alignment of the entire spine is not yet fully understood, nor are the effects of DEGEN or DEFORMITY. Segmental spinal alignment between sitting and standing, and the effects of degeneration and deformity were analyzed. METHODS. Segmental spinal alignment and lumbopelvic alignment (pelvic tilt (PT), pelvic incidence (PI), lumbar lordosis (LL), PI-LL, sacral slope) were analyzed. Lumbar spines were classified as NORMAL, DEGEN (at least one level of disc height loss >50%, facet arthropathy, or spondylolisthesis), or DEFORMITY (PI-LL mismatch>10°). Exclusion criteria included lumbar fusion/ankylosis, hip arthroplasty, and transitional lumbosacral anatomy. Independent samples t-tests analyzed lumbopelvic and segmental alignment between sitting and standing within groups. ANOVA assessed these differences between spine pathology groups. RESULTS. There were 183 NORMAL, 216 DEGEN and 92 DEFORMITY patients with significant differences in age, gender, and hip OA grades. After propensity matching for these factors, there were 56 patients in each group (age 63±14, 58% female) [Fig. 1]. Significant differences were noted between spinal pathology groups with regard to changes from standing to sitting alignment with regard to NORMAL vs DEGEN vs DEFORMITY groups in PT (13.93° vs −11.98° vs − 7.95°; p=0.024), LL (21.91° vs 17.45° vs 13.23°; p=0.002), PI-LL (−22.32° vs −17.28° vs −13.18°; p<0.001), SVA (−48.99° vs −29.98° vs −32.12°; p=0.002), and TPA(−16.35° vs −12.69° vs −9.64; p=0.001). TK (−2.08° vs −2.78° vs −2.00°, p=0.943) and CL (−3.84° vs −4.14° vs −3.57°, p=0.621) were not significantly different across spinal pathology groups [Fig. 2]. NORMAL patients had overall greater mobility in the lower lumbar spine from standing to sitting compared to DEGEN and DEFORMITY patients. L4-L5 (7.50° vs 5.23° vs 4.74°, p=0.012) and L5-S1 (6.96° vs 5.28° and 3.69°, p=0.027). There were no significant differences in change in alignment from standing to sitting at the upper lumbar levels or lower thoracic levels between the three groups [Fig. 3]. CONCLUSION. The lower lumbar spine provides the greatest sitting to standing change in lumbopelvic alignment in normal patients. Degeneration and deformity of the spine significantly reduces the mobility of the lower lumbar spine and PT. With lumbar spine degeneration and flatback deformity, relatively more alignment change occurs at the upper lumbar spine and thoracolumbar junction

Introduction. Literature describes pelvic rotation on lateral X rays from standing to sitting position. EOS full body lateral images provide additional information about the global posture. The projection of the vertical line from C7 (C7 VL) is used to evaluate the spine balance. C7 VL can also measure pelvic sagittal translation (PST) by its horizontal distance to the hip center (HC). This study evaluates the impact of a THA implantation on pelvic rotation and sagittal translation. Materials and Method. Lumbo-pelvic parameters of 120 patients have been retrospectively assessed pre and post- operatively on both standing and sitting acquisitions (primary unilateral THA without complication). PST is zero when C7VL goes through the center of the femoral heads and positive when C7VL is posterior to the hips' center (negative if anterior). Three subgroups were defined according to pelvic incidence (PI): low PI <45°, 45°<normal PI<65° or high PI>65°. Results. Pre-operatively PST standing was −0.9 cm (SD 4.5; [−15.1 to 7.2]) and PST sitting was 1.3cm (SD 3.3; [−7.7 to 11.8]). The overall mean change from standing to sitting was 2.2 cm ([−7.2 to 17.4]) (p<0.05). Post-operatively PST standing was 0.2 cm (SD 4.7; [−17 to 8.1]) and PST sitting was 1.4cm (SD 3.5; [−7.3 to 10.4]). The overall mean change from standing to sitting was 1.2 cm ([−14.2 to 22.4]) (p<0.05). In low PI group pre and post-operatively, PST increased significantly from standing to sitting (p<0.05; with HC going anterior to C7VL). When comparing pre and post operative changes, standing PST significantly increased (p=0.001). Pre to postoperative PST variation (sitting-standing) decreased significantly (p=0,01). In normal PI group pre-operatively, PST increased from standing to sitting (p=0.004). When comparing pre and postoperative changes, PST increased (p=0.006). Pre to postoperative PST variation (sitting-standing) decreased significantly (p=0,04). In high PI group pre and post operatively, PST increased from standing to sitting (p=0.034) while there are no significant changes from pre to post-operative status in standing and in sitting. Discussion. Anteroposterior pelvic tilt is not the only adaptation strategy for postural changes from standing to sitting positions. Anteroposterior pelvic translation (quantified by PST) is an important adaptation mechanism for postural changes. Comparison of pre and post-operative values of PST points out the importance of pelvic translation for low and standard PI patients after THA. The anteroposterior translation appears to change significantly in different functional positions pre and post operatively. This is an important variable to consider when assessing the patients' posture change or investigating the causes of the hip dislocation after total hip arthroplasty or spinal fusion. Conclusion. Pelvic translation must be considered as a significant mechanism of adaptation after THA. Further studies are needed to study the impact on subluxation or dislocation