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Background Patients with increased pelvic tilt (PT) are at risk for instability following total hip arthroplasty (THA). Identification of increased PT using anteroposterior (AP) pelvic radiographs could avoid additional spinopelvic radiographs. This study aimed to (1) describe which AP pelvic parameters most accurately estimate sagittal PT, and (2) determine thresholds for these parameters that can identify patients with increased PT. Methods This was a retrospective, consecutive, cohort study in a tertiary referral hospital on 225 patients (age: 66 ± 12 years-old; 52% female) listed for THA. Patients underwent pre-operative standing AP pelvic radiographs to measure distance- and angular- based parameters from several anatomical landmarks. Sagittal PT was measured on a standing lateral spinopelvic radiograph and considered high when ≥ 20°. Results No AP pelvic parameters correlated strongly with sagittal PT. Ratio between horizontal and vertical diameter of the pelvic foramen (C/D ratio) ( rho − 0.341; p  < 0.001); and vertical distance between trans-SIJ and trans-ASIS line (SITA) ( rho 0.307; p  < 0.001) correlated moderately with sagittal PT. Sacro-femoral-pubic (SFP) angle < 60° had highest sensitivity (85%), but lowest specificity (52%) to differentiate between patients with and without increased PT. If SITA > 62 mm, C/D ratio < 0.5 and SFP < 60°, specificity increased (88%), but sensitivity was low (49%). Conclusion In the absence of computerized models, AP pelvic parameters cannot accurately predict sagittal PT. However, an SFP < 60° should alert a hip surgeon that a patient may have an increased PT, and would benefit from additional lateral spinopelvic imaging prior to THA. Level of evidence Level II, diagnostic study.

Purpose Pelvic tilt (PT) is important to consider when planning total hip arthroplasty (THA) due to its dynamic impact on acetabular orientation. The degree of sagittal pelvic rotation varies during functional activities and can be difficult to measure without proper imaging. The purpose of this study was to evaluate PT variation in the supine, standing, and seated positions. Methods A multi-centre cross-sectional study was performed that included 358 THA patients who had preo-perative PT measured from supine CT scan and standing and upright seated lateral radiographs. Supine, standing, and seated PT and associated changes between functional positions were evaluated. Anterior PT was assigned a positive value. Results In the supine position, mean PT was 4° (range, -35° to 20°), where 23% had posterior PT and 69% anterior PT. In the standing position, mean PT was 1° (range, -23° to 29°), where 40% had posterior PT and 54% anterior PT. In the seated position, mean PT was -18° (range, -43° to 47°), where 95% had posterior PT and 4% anterior PT. From standing to seated, the pelvis rotated posteriorly in 97% of cases (maximum 60°) with 16% of cases considered stiff (change ≤ 10°) and 18% of cases considered hypermobile (change ≥ 30°). Conclusion Patients undergoing THA have marked PT variation in the supine, standing, and seated positions. There was wide variability in PT change from standing to seated, with 16% of patients considered stiff and 18% considered hypermobile. Functional imaging should be performed on patients prior to THA to allow for more accurate planning.

Purpose : The relationship between spinopelvic mobility and dislocation in total hip arthroplasty (THA) has recently attracted attention. This study aimed to investigate the differences in sacral slope (SS) between two types of upright seated positions and to determine which seated position was appropriate for assessing spinopelvic mobility (change in SS from standing to sitting) before THA. Materials and methods : This prospective cohort study included 75 hips from 75 patients who had undergone primary THA. Each patient underwent preoperative lateral spinopelvic radiography in standing (st) and two seated positions: relaxed (rs) and straight (ss). The change in SS between each position (Δ) was measured. Results : Differences in all spinopelvic sagittal alignment parameters between the two seated positions were statistically significant ( p  < 0.001). The range, median, and mean values of ΔSS ss-rs were −2.0° to 26.5°, 6.8°, and 8.3°, respectively. ΔSS ss-rs was significantly correlated with SS, LLA, and PFA in the relaxed seated position ( r  = −0.52, −0.39, and 0.37; p  < 0.001, p  < 0.001, and p  = 0.001, respectively), but was not correlated to these parameters in the straight seated position. Of the 52 patients with normal spinopelvic mobility in the relaxed seated position (ΔSS st-rs  > 10°), 24 (46%) patients were misrepresented as having a stiff spine in the straight seated position (ΔSS st-ss  < 10°). Conclusion : The change in SS from the straight to the relaxed seated position widely varied in patients before THA. The spinopelvic radiograph in the relaxed seated position is appropriate when evaluating spinopelvic mobility for preoperative planning.

PurposeThe complex and dynamic spinopelvic interplay is not well understood. The aims of the present study were to investigate the following: (1) whether native acetabular anteinclination (AI) in standing position changes following lumbar spinal fusion (LSF); (2) potential correlations between AI change (ΔAI) and several spinopelvic parameters such as the change in lumbar lordosis (ΔLL), pelvic tilt (ΔPT), and anterior pelvic plane angle (ΔaPP).MethodsA total of 485 patients (Males: 262, Females: 223) with an average age of 64 ± 13 years who underwent a primary LSF were identified from our institutional database. The difference (Δ) between pre-and postoperative acetabular anteinclination (AI), lumbar lordosis (LL), anterior pelvic plane angle (aPP), sacral slope (SS), and pelvic tilt (PT) were measured on a standing lateral radiograph (EOS®) and compared to find the effect of LSF on the lumbopelvic geometry.ResultsFollowing LSF, the average absolute ΔAI was 5.4 ± 4 (0 to 26)°, ΔLL: 5.5 ± 4 (0 to 27)°, ΔaPP: 5.4 ± 4 (0 to 38)°, ΔPT: 7 ± 5 (0 to 33)° and ΔSS: 5.3 ± 4 (0 to 33)°. No significant differences were observed between LSF levels. A ΔAI ≥ 10° was observed in 66 (13.6%) and ΔAI ≥ 20° in 5 (1%) patients. The Pearson correlation demonstrated a strong negative correlation of ΔAI with ΔLL (r = 0.72, p < .001).ConclusionClinical decision-making should consider the relationship between native anteinclination and lumbar lordosis to reduce the risk of functional acetabular component malalignment in patients with concomitant hip and spine pathology.Level of evidenceRetrospective case–control study, Level III.

Introduction The optimal positioning of the hip prosthesis components is influenced by the mobility and balance of the spine. The present study classifies patients with pathology of the spino-pelvic-hip complex, showing possible methods of preventing hip dislocations after arthroplasty. Hypothesis Hip-Spine Classification helps arthroplasty surgeons to implant components in more patient-specific position. Materials and methods The group of 100 patients treated with total hip arthroplasty. Antero-posterior (AP) X-rays of the pelvis in a standing position, lateral spine (standing and sitting) and AP of the pelvis (supine after the procedure) were analyzed. We analyzed a change in sacral tilt value when changing from standing to sitting (∆SS), Pelvic Incidence (PI), Lumbar Lordosis (LL) Mismatch, sagittal lumbar pelvic balance (standing position). Patients were classified according to the Hip-Spine Classification. Postoperatively, the inclination and anteversion of the implanted acetabular component were measured. Results In our study 1 A was diagnosed in 61% of all cases, 1B in 18%, 2 A in 16%, 2B in 5%. 50 out of 61 (82%) in group 1 A were placed within the Levinnek “safe zone”. In 1B, 2 A, 2B, the position of the acetabular component was influenced by both the spinopelvic mobility and sagittal spinal balance. The mean inclination was 43.35° and the anteversion was 17.4°. Conclusions Categorizing patients according to Hip-Spine Classification one can identify possible consequences the patients at risk. Pathology of the spino-pelvic-hipcomplex can lead to destabilization or dislocation of hip after surgery even though implanted according to Lewinnek’s indications. Our findings suggest that Lewinnek safe zone should be abandoned in favor of the concept of functional safe zones.

PurposeDislocation is one of the remaining challenges after total hip arthroplasty. The spinopelvic mobility is considered to be the key to solve this problem and is of interest both to arthroplasty and spine surgeons. The purpose of this letter is to discuss the spinopelvic mobility and spinal stiffness described in the paper titled “Impact of spinal alignment and stiffness on impingement after total hip arthroplasty: a radiographic study of pre‑ and post‑operative spinopelvic alignment.” by Hagiwara S, et al.MethodsExamining the consistency between this paper and previously published papers on spinopelvic mobility.ResultsIn this article, radiographic clearance of anterior impingement was defined as adding of femoral shaft angle and sacral slope (SS), and that of posterior impingement as adding SS and femoral shaft angle subtracting 90º in the sitting position. The impingement itself and other factors for dislocation including implant design, implant orientation, extra-prosthetic impingement and their mobilities are not considered in this parameter, and it is better if the validity of this parameter is shown. The term “rigid spine” and “spinal stiffness” are used in the manuscript. When THA candidates are evaluated, they are categorized according to the flexibility and/or sagittal balance. It would be better if the definition was described in the text and the clearance for impingement was shown to be affected by spinal stiffness.ConclusionThe conclusions and titles are overstated from the results, but this paper is highly valuable in reminding spinal surgeons of the importance of spinopelvic alignment and mobility in THA.

Objective We sought to correlate various spinopelvic and lower limb alignments, and to examine the current spinopelvic theories on a Chinese cohort. Methods We retrospectively reviewed 166 patients undergoing THA. Among them, 138 patients with unilateral THA met the inclusion criteria. Sagittal alignments and cup orientations were measured on standing and sitting lateral EOS images. Patients were categorized into two groups with a scoring system for lumbar spine degeneration. Patients’ demographics including age, sex, lumbar spine degeneration and radiographic measurements were studied. Results PT, SS, LL and TK differed significantly between standing and sitting within each group except for TK in degenerative group (32.8 ± 13.9 vs. 32.9 ± 14.2, p  = 0.905). Compared with degenerative spine group, non-degenerative spine patients have great pelvic mobility (ΔPT, -24.4 ± 12.5° vs. -17.6 ± 10.7, p  = 0.0008), greater lumbar mobility (ΔLL, -34.8 ± 15.2 vs. -21.7 ± 12.2, p  = < 0.0001) and compensatory cup orientation changes (ΔRA, -15.5 ± 11.1 vs. -12.0 ± 8.4, p  = 0.00920; ΔRI, -10.8 ± 11.5 vs. -5.6 ± 7.5, p  = 0.0055). Standing PT and ankle dorsiflexion angle correlated positively (R 2  = 0.236, p  = 0.005). Conclusion THA patients in this cohort showed a spinopelvic motion paradigm similar to that from previous studies on Caucasians. Ankle dorsiflexion indicate greater posterior pelvic tilt on standing. Surgeons should beware of risks of instability in patients with lower limb compensations. Advances in knowledge This study provides new insights into the clinical relevance of lower limb alignments to spinopelvic motion after THA in a relatively young Chinese population.

Dental professionals are exposed to significant unavoidable physical stress, and theoretical ergonomic recommendations for a sitting workplace are inapplicable in many dental activities. Work-related musculoskeletal disorders (WMSDs) represent a serious health problem among dental professionals (prevalence: 64–93%), showing involvement of 34–60% for the low back and 15–25% for the hips. Muscle stress; prolonged sitting; forward bending and twisting of the torso and head; unbalanced working postures with asymmetrical weight on the hips and uneven shoulders; and others are inevitable for dental professionals. Therefore, the approach for the prevention and treatment of WMSDs must be therapeutic and compensatory. This project was conceived to provide a Yoga protocol for dental professionals to prevent or treat WMSDs from a preventive medicine perspective, and it would represent a Yoga-based guideline for the self-cure and prevention of musculoskeletal problems. Methods: Specific Yoga positions (āsana, such as Virāsana, Virabhadrāsana, Garudāsana, Utkatāsana, Trikonāsana, Anuvittāsana, Chakrāsana, Uttanāsana, Pashimottanāsana) have been selected, elaborated on and adapted to be practiced in a dental office using a dental stool or the dental office walls or a dental unit chair. The protocol is specifically devised for dental professionals (dentists, dental hygienists and dental assistants) and targeted for the low back, hips and legs (including knees and ankles). The protocol includes Visranta Karaka Sthiti (supported positions) in sitting (Upavistha Sthiti) and standing (Utthistha Sthiti) positions, twisting/torsions (Parivrtta), flexions/forward bend positions (Pashima) and extensions/arching (Purva) for musculo-articular system decompression and mobilization. Results: Over 60 Yogāsana—specifically ideated for back detensioning and mobilization, lumbar lordosis restoration, trunk side elongation, hip release and leg stretches and decontraction—are shown and described. The paper provides a meticulous description for each position, including the detailed movement, recommendations and mistakes to avoid, and the breathing pattern (breath control) in all the breath-driven movements (āsana in vinyāsa). An exhaustive analysis of posture-related disorders affecting the lower body among dental professionals is reported, including low-back pain, hip pain and disorders, piriformis syndrome and quadratus femoris dysfunction (gluteal pain), iliopsoas syndrome, multifidus disorders, femoroacetabular and ischiofemoral impingement, spinopelvic mobility, lumbopelvic rhythm, impairment syndromes, lower crossed syndrome, leg pain, knee pain and ankle disorders. Conclusions: A detailed guideline of āsana for low-back decompression, hip joint destress, piriformis and gluteal muscle release, lumbar lordosis recovery and a spinopelvic mobility increase has been elaborated on. The designed Yogāsana protocol represents a powerful tool for dental professionals to provide relief to retracted stiff muscles and unbalanced musculoskeletal structures in the lower body.

Measuring pelvic tilt and pelvic obliquity during functional positions is important for surgical planning of total hip arthroplasty as these orientations affect optimal acetabular cup position and post-operative hip stability. The objective of this study was to compare pelvic tilt, pelvic obliquity, and pelvic mobility across 3 cohorts of age-matched patients: 1) healthy controls 2) THA patients without spinal fusion and 3) patients with instrumented spinal fusions. We hypothesized that (1) the healthy and THA cohorts would demonstrate similar pelvic mobility across the range of position demand and (2) individuals with spinal fusions would have significantly less pelvic mobility than both the healthy and THA cohorts. We compared 10 patients in each of these cohorts using stereo radiography to quantify pelvic tilt and pelvic obliquity across a range of clinically relevant poses of varying demand on pelvic mobility. Results demonstrated that the overall pelvic mobility of the spinal fusion cohort was consistently similar in magnitude to health controls but biased anteriorly by 6.5% and 33.5% compared to the healthy and total hip cohorts, primarily due to less posterior tilting across the functional positions (Healthy: 39.6° ± 10.2°; Spinal fusion: 39.5° ± 7.3°; Total hip: 37.8° ± 7.6°). Obliquity angles varied substantially between some clinically relevant pose combinations. Low and high coronal plane mobility patients were identified in each of the three cohorts, with mobility ranging between 4.4° and 28.3°, respectively, across positions. Substantial intragroup variability was exhibited within each cohort across the six functional poses, highlighting the patient-specific nature of the spinopelvic relationship regardless of previous surgery at the hip or spine. The larger pelvic tilt angles demonstrated during more demanding poses in seated and standing highlights the importance of imaging patients in poses that capture the full extent of pelvic mobility.

Background Total hip arthroplasty (THA) instability is influenced by acetabular component positioning, spinopelvic function and sagittal spinal alignment. Obesity is considered as a risk factor of THA instability, but the causal relationship remains unknown. This study aimed to investigate the influence of BMI on (1) spinopelvic function (lumbar flexibility, pelvic mobility and hip motion), (2) sagittal spinal alignment pre- and postoperatively and (3) acetabular cup position postoperatively in primary THA patients in a prospective setting. Methods One hundred ninety patients receiving primary total hip arthroplasty were enrolled in a prospective cohort study and retrospectively analysed. All patients received stereoradiography (EOS) in standing and relaxed sitting position pre-and postoperatively. C7-sagittal vertical axis (C7-SVA), lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), anterior plane pelvic tilt (APPT), and pelvic femoral angle (PFA) were assessed. Key parameters of the spinopelvic function were defined as lumbar flexibility (∆ LL = LL standing  − LL sitting ), pelvic mobility (∆ PT = PT standing  − PT sitting ) and hip motion (∆ PFA = PFA standing  − PFA sitting ). Pelvic mobility was further defined based on ∆ PT as stiff, normal and hypermobile (∆ PT < 10°; 10°–30°; > 30°). The patients were stratified to BMI according to WHO definition: normal BMI ≥ 18.5–24.9 kg/m 2 (n = 68), overweight ≥ 25.0–29.9 kg/m 2 (n = 81) and obese ≥ 30–39.9 kg/m 2 (n = 41). Post-hoc analysis according to Hochberg's GT2 was applied to determine differences between BMI groups. Results Standing cup inclination was significant higher in the obese group compared to the normal BMI group (45.3° vs. 40.1°; p  = 0.015) whereas standing cup anteversion was significantly decreased (22.0° vs. 25.3°; p  = 0.011). There were no significant differences for spinopelvic function key parameter lumbar flexibility (∆ LL), pelvic mobility (∆ PT) and hip motion (∆ PFA) in relation to BMI stratified groups. The obese group demonstrated significant enhanced pelvic retroversion compared to the normal BMI group (APPT − 1.8° vs. 2.4°; p  = 0.028). The preoperative proportion of stiff pelvic mobility was decreased in the obese group (12.2%) compared to normal (25.0%) and overweight (27.2%) groups. Spinal sagittal alignment in C7-SVA and PI-LL mismatch demonstrated significantly greater imbalance in the obese group compared to the normal BMI group (68.6 mm vs. 42.6 mm, p  = 0.002 and 7.7° vs. 1.2°, p  = 0.032, respectively) The proportion of patients with imbalanced C7-SVA was higher in the obese (58.5%) than in the normal BMI group (44.1%). Conclusions The significantly increased spinal sagittal imbalance with altered pelvic mechanics is a potential cause for the reported increased risk of THA dislocations in obese patients. Consequently, the increased spinal sagittal imbalance in combination with normal pelvic mobility need to be taken into account when performing THA in obese patients.