Does Degenerative Lumbar Spine Disease Influence Femoroacetabular Flexion in Patients Undergoing Total Hip Arthroplasty?

BACKGROUND: Sitting pelvic tilt dictates the proximity of the rim of the acetabulum to the proximal femur and, therefore, the risk of impingement in patients undergoing total hip arthroplasty (THA). Sitting position is achieved through a combination of lumbar spine segmental motions and/or femoroacetabular articular motion in the lumbar-pelvic-femoral complex. Multilevel degenerative disc disease (DDD) may limit spine flexion and therefore increase femoroacetabular flexion in patients having THAs, but this has not been well characterized. Therefore, we measured standing and sitting lumbar-pelvic-femoral alignment in patients with radiographic signs of DDD and in patients with no radiographic signs of spine arthrosis. QUESTIONS/PURPOSES: We asked: (1) Is there a difference in standing and sitting lumbar-pelvic-femoral alignment before surgery among patients undergoing THA who have no radiographic signs of spine arthrosis compared with those with preexisting lumbar DDD? (2) Do patients with lumbar DDD experience less spine flexion moving from a standing to a sitting position and therefore compensate with more femoroacetabular flexion compared with patients who have no radiographic signs of arthrosis?
METHODS: Three hundred twenty-five patients undergoing primary THA had preoperative low-dose EOS spine-to-ankle lateral radiographs in standing and sitting positions. Eighty-three patients were excluded from this study for scoliosis (39 patients), spondylolysis (15 patients), not having five lumbar vertebrae (7 patients), surgical or disease fusion (11 patients), or poor image quality attributable to high BMI (11 patients). In the remaining 242 of 325 patients (75%), two observers categorized the lumbar spine as either without radiographic arthrosis or having DDD based on defined radiographic criteria. Sacral slope, lumbar lordosis, and proximal femur angles were measured, and these angles were used to calculate lumbar spine flexion and femoroacetabular flexion in standing and sitting positions. Patients were aligned in a standardized sitting position so that their femurs were parallel to the floor to achieve approximately 90° of apparent hip flexion.
RESULTS: After controlling for age, sex, and BMI, we found patients with DDD spines had a mean of 5° more posterior pelvic tilt (95% CI, -2° to -8° lower sacral slope angles; p < 0.01) and 7° less lumbar lordosis (95% CI, -10° to -3°; p < 0.01) in the standing position compared with patients without radiographic arthrosis. However, in the sitting position, patients with DDD spines had 4° less posterior pelvic tilt (95% CI, 1°-7° higher sacral slope angles; p = 0.02). From standing to sitting position, patients with DDD spines experienced 10° less spine flexion (95% CI, -14° to -7°; p < 0.01) and 10° more femoroacetabular flexion (95% CI, 6° to 14°; p < 0.01).
CONCLUSIONS: Most patients undergoing THA sit in a similar range of pelvic tilt, with a small mean difference in pelvic tilt between patients with DDD spines and those without radiographic arthrosis. However, in general, the mechanism by which patients with DDD of the lumbar spine achieve sitting differs from those without spine arthrosis with less spine flexion and more femoroacetabular flexion. CLINICAL RELEVANCE: When planning THA, it may be important to consider which patients sit with less posterior pelvic tilt and those who rotate their pelvises forward to achieve a sitting position, as both mechanisms will limit or reduce the functional anteversion of the acetabular component in a patient with a THA. Our study provides some additional perspective on normal relationships between pelvic tilt and femoroacetabular flexion, but further research might better characterize this relationship in outliers and the possible implications for posterior instability after THA.