A Narrative Review of Spinopelvic Alignment Changes After Total Hip Arthroplasty

Total hip arthroplasty (THA) reliably restores function, yet instability remains a clinically relevant complication. Increasing evidence indicates that postoperative stability is strongly influenced by the dynamic spine-pelvis-hip interaction, which modulates functional acetabular orientation across postures. This narrative review summarizes current evidence on postoperative spinopelvic alignment changes after THA with emphasis on temporal patterns, underlying mechanisms, and predictive factors. Early after THA, restoration of hip motion can partially normalize hip-driven compensatory patterns, however substantial interindividual variability persists. Mid- to long-term follow-up shows that pelvic orientation continues to evolve, particularly progressive posterior pelvic tilt in standing, largely driven by aging and spinal degeneration, with acceleration in older patients and those with spinal pathology. Prediction of postoperative pelvic behavior requires integrated assessment of pelvic orientation, spinal alignment and mobility, contralateral hip status, and whether imbalance is hip-driven versus spine-driven. Although classification- and model-based approaches can estimate postoperative pelvic tilt, clinically meaningful prediction uncertainty remains, supporting a strategy focused on risk stratification and adaptive preoperative planning.