Purpose of Review
Advances in technology, implant design, and surgical technique have lowered the dislocation rate in primary total hip arthroplasty (THA). Despite these advances, there remain a large number of instability episodes without a known etiology. Recent research suggests that the pelvic and lumbar spine interrelationship may be the explanation in prosthetic dislocations without a known cause. In this review, we describe the biomechanics, measurements, diagnoses, classification, management, and outcomes of total hip and revision total hip instability as it relates to spinopelvic alignment.
As a person goes from standing to sitting, lumbar lordosis decreases, and the sacrum and entire pelvis tilts posteriorly with sacrum and coccyx rotating posterior-inferiorly, resulting in increased acetabular cup anteversion to accommodate femoral flexion. A fused spine and associated fixed acetabulum can result in abnormal pelvic femoral motion, impingement, and dislocation. Classifying the spinopelvic mechanics by sacral motion based on sitting and standing lateral radiographs provides an understanding of how the acetabulum behaves in space. This information helps appropriate cup positioning, reducing the risk of femoral side impingement and subsequent dislocation.
Surgical techniques to consider in the spinopelvic at-risk patient are positioning considerations in acetabular cup inclination and anteversion, high offset femoral stems, high offset acetabular liners, dual mobility articulations, and removal of impinging structures. Future research is needed to define the safest order of operation in concomitant hip and spine pathology, the effects on pelvic femoral biomechanics in spine surgery, and whether preoperative and intraoperative management strategies have a long-term beneficial effect on the dislocation rate.
This is a preview of subscription content, log in to check access.
Buy single article
Instant access to the full article PDF.
Price includes VAT for USA
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
This is the net price. Taxes to be calculated in checkout.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
Ulrich SD, Seyler TM, Bennett D, Delanois RE, Saleh KJ, Thongtrangan I, et al. Total hip arthroplasties: what are the reasons for revision? Int Orthop. 2008;32(5):597–604.
Wera GD, Ting NT, Moric M, Paprosky WG, Sporer SM, Della Valle CJ. Classification and management of the unstable total hip arthroplasty. J Arthroplast. 2012;27(5):710–5.
Woo RY, Morrey BF. Dislocations after total hip arthroplasty. J Bone Joint Surg Am. 1982;64(9):1295–306.
Dorr LD, Wolf AW, Chandler R, Conaty JP. Classification and treatment of dislocations of total hip arthroplasty. Clin Orthop Relat Res. 1983;173:151–8.
Dorr LD, Wan Z. Causes of and treatment protocol for instability of total hip replacement. Clin Orthop Relat Res. 1998;355:144–51.
Lewinnek GE, Lewis JL, Tarr R, Compere CL, Zimmerman JR. Dislocations after total hip-replacement arthroplasties. J Bone Joint Surg Am. 1978 Mar;60(2):217–20.
•• Esposito CI, Gladnick BP, Lee YY, Lyman S, Wright TM, Mayman DJ, et al. Cup position alone does not predict risk of dislocation after hip arthroplasty. J Arthroplast. 2015;30(1):109–13 Their retrospective review of 147 patients who sustained an early dislocation were compared to a matched control group. They found no difference in cup position between dislocators and non-dislocators, suggesting a re-evaluation of ideal cup positioning.
• Abdel MP, von Roth P, Jennings MT, Hanssen AD, Pagnano MW. What safe zone? The vast majority of dislocated THAs are within the Lewinnek safe zone for acetabular component position. Clin Orthop Relat Res. 2016;474(2):386–91 Review of 9784 primary total hips at their institution revealed a 2% dislocation rate totaling 206 dislocated THAs. Patients who suffered a dislocation had cup anteversion and inclination in the Lewinneck safe zone 58% of the time, calling into the question the dogma of cup positioning.
Dorr LD, Callaghan JJ. Death of the Lewinnek “safe zone”. J Arthroplast. 2019;34(1):1–2.
Tezuka T, Heckmann ND, Bodner RJ, Dorr LD. Functional safe zone is superior to the Lewinnek safe zone for total hip arthroplasty: why the Lewinnek safe zone is not always predictive of stability. J Arthroplast. 2019;34(1):3–8.
Salib CG, Reina N, Perry KI, Taunton MJ, Berry DJ, Abdel MP. Lumbar fusion involving the sacrum increases dislocation risk in primary total hip arthroplasty. Bone Joint J. 2019;101-B(2):198–206.
DelSole EM, Vigdorchik JM, Schwarzkopf R, Errico TJ, Buckland AJ. Total hip arthroplasty in the spinal deformity population: does degree of sagittal deformity affect rates of safe zone placement, instability, or revision? J Arthroplast. 2017;32(6):1910–7.
Luthringer TA, Vigdorchik JM. A preoperative workup of a “hip-spine” total hip arthroplasty patient: a simplified approach to a complex problem. J Arthroplast. 2019;34(7S):S57–70.
Malkani AL, Himschoot KJ, Ong KL, Lau EC, Baykal D, Dimar JR, et al. Does timing of primary total hip arthroplasty prior to or after lumbar spine fusion have an effect on dislocation and revision rates? J Arthroplast. 2019;34(5):907–11 S0883–5403(19)30036–1.
Malkani AL, Garber AT, Ong KL, Dimar JR, Baykal D, Glassman SD, et al. Total hip Arthroplasty in patients with previous lumbar fusion surgery: are there more dislocations and revisions? J Arthroplast. 2018;33(4):1189–93.
•• Buckland AJ, Puvanesarajah V, Vigdorchik J, Schwarzkopf R, Jain A, Klineberg EO, et al. Dislocation of a primary total hip arthroplasty is more common in patients with a lumbar spinal fusion. Bone Joint J. 2017;99-B(5):585–91 Comparison of total hip arthroplasty patients and those with and without spinal fusion found spinal fusion and increased fusion levels were at higher risk for dislocation.
Lazennec JY, Charlot N, Gorin M, Roger B, Arafati N, Bissery A, et al. Hip-spine relationship: a radio-anatomical study for optimization in acetabular cup positioning. Surg Radiol Anat. 2004;26(2):136–44.
Lazennec JY, Boyer P, Gorin M, Catonné Y, Rousseau MA. Acetabular anteversion with CT in supine, simulated standing, and sitting positions in a THA patient population. Clin Orthop Relat Res. 2011;469(4):1103–9.
Lazennec JY, Rousseau MA, Rangel A, Gorin M, Belicourt C, Brusson A, et al. Pelvis and total hip arthroplasty acetabular component orientations in sitting and standing positions: measurements reproductibility with EOS imaging system versus conventional radiographies. Orthop Traumatol Surg Res. 2011;97(4):373–80.
Lazennec JY, Brusson A, Rosseau MA. Hip-spine relations: an innovative paradigm in THR surgery, recent advances in arthroplasty, Dr. Samo Fokter (Ed.) 2012, ISBN: 978–953–307-990-5, InTech, Available from: http://www.intechopen.com/books/recent-advances-in-arthroplasty/hip-spine-relations-an-innovative-paradigm-in-thr-surgery
Lazennec JY, Riwan A, Gravez F, Rousseau MA, Mora N, Gorin M, et al. Hip spine relationships: application to total hip arthroplasty. Hip Int. 2007;17(Suppl 5):S91–104.
Lum ZC, Coury JG, Cohen JL, Dorr LD. The current knowledge on spinopelvic mobility. J Arthroplast. 2018;33(1):291–6.
Kanawade V, Dorr LD, Wan Z. Predictability of acetabular component angular change with postural shift from standing to sitting position. J Bone Joint Surg Am. 2014;96(12):978–86.
•• Heckmann N, Stefl M, Trasolini N, McKnight B, Ike H, Dorr LD. The influence of spinopelvic motion on acute and late dislocation following total hip arthroplasty. J Bone Joint Surg Am. 2018. This study found late dislocations and revision THAs were at higher risk to have spinopelvic abnormalities and impingement and dislocation risk factors.
Legaye J, Duval-Beaupère G, Hecquet J, Marty C. Pelvic incidence: a fundamental pelvic parameter for three-dimensional regulation of spinal sagittal curves. Eur Spine J. 1998;7(2):99–103.
Ike H, Dorr LD, Trasolini N, Stefl M, McKnight B, Heckmann N. Spine-pelvis-hip relationship in the functioning of a total hip replacement. J Bone Joint Surg Am. 2018;100(18):1606–15.
• Stefl M, Lundergan W, Heckmann N, Mcknight B, Ike H, Murgai R, et al. Spinopelvic mobility and acetabular component position for total hip arthroplasty. Bone Joint J. 2017;99-B(1 supple a):37–45 This study highlights the concepts of spinopelvic motion and suggests acetabular cup positioning based upon spinopelvic motion categories.
Lembeck B, Mueller O, Reize P, Wuelker N. Pelvic tilt makes acetabular cup navigation inaccurate. Acta Orthop. 2005;76(4):517–23.
Zhu J, Wan Z, Dorr LD. Quantification of pelvic tilt in total hip arthroplasty. Clin Orthop Relat Res. 2010;468(2):571–5.
Wan Z, Malik A, Jaramaz B, Chao L, Dorr LD. Imaging and navigation measurement of acetabular component position in THA. Clin Orthop Relat Res. 2009;467(1):32–42.
Jaramaz B, DiGioia AM 3rd, Blackwell M, Nikou C. Computer assisted measurement of cup placement in total hip replacement. Clin Orthop Relat Res. 1998;354:70–81.
Schwab FJ, Blondel B, Bess S, Hostin R, Shaffrey CI, Smith JS, et al. Radiographical spinopelvic parameters and disability in the setting of adult spinal deformity: a prospective multicenter analysis. Spine (Phila Pa 1976). 2013;38(13):E803–12.
Luo TD, Stans AA, Schueler BA, Larson AN. Cumulative radiation exposure with EOS imaging compared with standard spine radiographs. Spine Deform. 2015;3(2):144–50.
Lazennec JY, Rousseau MA, Brusson A, Folinais D, Amel M, Clarke I, et al. Total hip prostheses in standing, sitting and squatting positions: an overview of our 8 years practice using the EOS imaging technology. Open Orthop J. 2015;9:26–44.
Farfan HF. The pathological anatomy of degenerative spondylolisthesis. A cadaver study. Spine (Phila Pa 1976). 1980;5(5):412–8.
Kalichman L, Kim DH, Li L, Guermazi A, Berkin V, Hunter DJ. Spondylolysis and spondylolisthesis: prevalence and association with low back pain in the adult community-based population. Spine (Phila Pa 1976). 2009;34(2):199–205.
Bedard NA, Martin CT, Slaven SE, Pugely AJ, Mendoza-Lattes SA, Callaghan JJ. Abnormally high dislocation rates of total hip arthroplasty after spinal deformity surgery. J Arthroplast. 2016;31(12):2884–5.
Gerhardt DMJM, Bisseling P, de Visser E, van Susante JLC. Modular necks in primary hip arthroplasty without anatomical deformity: no clear benefit on restoration of hip geometry and dislocation rate. An exploratory study. J Arthroplast. 2014;29:1553–8.
Cogan A, Klouche S, Mamoudy P, Sariali E. Total hip arthroplasty dislocation rate following isolated cup revision using Hueter’s direct anterior approach on a fracture table. Orthop Traumatol Surg Res. 2011;97:501–5.
Robinson M, Bornstein L, Mennear B, Bostrom M, Nestor B, Padgett D, et al. Effect of restoration of combined offset on stability of large head THA. Hip Int. 2012;22:248–53.
Hayashi S, Nishiyama T, Fujishiro T, Hashimoto S, Kanzaki N, Nishida K, et al. Excessive femoral offset does not affect the range of motion after total hip arthroplasty. Int Orthop. 2013;37(7):1233–7.
Shoji T, Yamasaki T, Izumi S, Hachisuka S, Ochi M. The influence of stem offset and neck shaft angles on the range of motion in total hip arthroplasty. Int Orthop. 2016;40(2):245–53.
Brown TD, Elkins JM, Pedersen DR, Callaghan JJ. Impingement and dislocation in total hip arthroplasty: mechanisms and consequences. Iowa Orthop J. 2014;34:1–15.
Bouchard SM, Stewart KJ, Pedersen DR, Callaghan JJ, Brown TD. Design factors influencing performance of constrained acetabular liners: finite element characterization. J Biomech. 2006;39(5):885–93.
Hernigou P, Filippini P, Flouzat-Lachaniette CH, Batista SU, Poignard A. Constrained liner in neurologic or cognitively impaired patients undergoing primary THA. Clin Orthop Relat Res. 2010;468:3255–62.
Berend KR, Lombardi AV Jr, Mallory TH, Adams JB, Russell JH, Groseth KL. The long-term outcome of 755 consecutive constrained acetabular components in total hip arthroplasty examining the successes and failures. J Arthroplast. 2005;20(7 suppl 3):93–102.
Farizon F, de Lavison R, Azoulai JJ, Bousquet G. Results with a cementless alumina-coated cup with dual mobility. A twelve-year follow-up study. Int Orthop. 1998;22(4):219–24.
Philippot R, Farizon F, Camilleri JP, Boyer B, Derhi G, Bonnan J, et al. Survival of cementless dual mobility socket with a mean 17 years follow-up. Rev Chir Orthop Reparatrice Appar Mot. 2008;94:e23–7.
Boyer B, Philippot R, Geringer J, Farizon F. Primary total hip arthroplasty with dual mobility socket to prevent dislocation: a 22-year follow-up of 240 hips. Int Orthop. 2012;36:511–8.
Jones CW, De Martino I, D'Apolito R, Nocon AA, Sculco PK, Sculco TP. The use of dual-mobility bearings in patients at high risk of dislocation. Bone Joint J. 2019;101-B(1_Supple_A):41–5.
Kreipke R, Rogmark C, Pedersen AB, Kärrholm J, Hallan G, Havelin LI, et al. Dual mobility cups: effect on risk of revision of primary total hip arthroplasty due to osteoarthritis: a matched population-based study using the Nordic arthroplasty register association database. J Bone Joint Surg Am. 2019;101(2):169–76.
Kaiser D, Kamath AF, Zingg P, Dora C. Double mobility cup total hip arthroplasty in patients at high risk for dislocation: a single-center analysis. Arch Orthop Trauma Surg. 2015;135(12):1755–62.
Plummer DR, Christy JM, Sporer SM, Paprosky WG, Della Valle CJ. Dual-mobility articulations for patients at high risk for dislocation. J Arthroplast. 2016;31(Suppl):131–5.
Tarity TD, Koch CN, Burket JC, Wright TM, Westrich GH. Fretting and corrosion at the backside of modular cobalt chromium acetabular inserts: a retrieval analysis. J Arthroplast. 2017;32(3):1033–9.
De Martino I, D'Apolito R, Waddell BS, McLawhorn AS, Sculco PK, Sculco TP. Early intraprosthetic dislocation in dual-mobility implants: a systematic review. Arthroplast Today. 2017;3(3):197–202.
Malik A, Maheshwari A, Dorr LD. Impingement with total hip replacement. J Bone Joint Surg Am. 2007;89(8):1832–42.
Matsushita A, Nakashima Y, Jingushi S, Yamamoto T, Kuraoka A, Iwamoto Y. Effects of the femoral offset and the head size on the safe range of motion in total hip arthroplasty. J Arthroplast. 2009;24(4):646–51.
McGrory BJ, Morrey BF, Cahalan TD, An KN, Cabanela ME. Effect of femoral offset on range of motion and abductor muscle strength after total hip arthroplasty. J Bone Joint Surg (Br). 1995;77(6):865–9.
Innmann MM, Maier MW, Streit MR, Grammatopoulos G, Bruckner T, Gotterbarm T, et al. Additive influence of hip offset and leg length reconstruction on postoperative improvement in clinical outcome after total hip arthroplasty. J Arthroplast. 2018;33(1):156–61.
Liebs TR, Nasser L, Herzberg W, Rüther W, Hassenpflug J. The influence of femoral offset on health-related quality of life after total hip replacement. Bone Joint J. 2014;96-B(1):36–42.
Conflict of Interest
Zachary Lum, John Meehan, Mauro Giordani declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Lum, Z.C., Giordani, M. & Meehan, J.P. Total Hip Instability and the Spinopelvic Link. Curr Rev Musculoskelet Med 13, 425–434 (2020). https://doi.org/10.1007/s12178-020-09648-6
- Spinopelvic motion
- total hip arthroplasty instability
- Sacro-acetabular angle
- Spinopelvic mobility