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Pelvic Tilt Reproducibility Using Fluoroscopy in Direct Anterior Approach Total Hip Arthroplasty.

Karlos Zepeda1, Tsion Yared1, Carmelo Burgio1

  • 1Department of Orthopaedic Surgery, Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York.

The Journal of Arthroplasty
|April 24, 2026
PubMed
Summary

Intraoperative fluoroscopy during direct anterior approach total hip arthroplasty achieved moderate accuracy in recreating standing pelvic tilt. While 76% of patients were within 7°, variability suggests adjunctive methods may improve acetabular positioning consistency.

Keywords:
direct anterior approachfluoroscopypelvic tiltspinopelvic mobilitytotal hip arthroplasty

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Area of Science:

  • Orthopedic Surgery
  • Surgical Navigation
  • Radiographic Imaging

Background:

  • Accurate acetabular component positioning in total hip arthroplasty (THA) relies on precise recreation of pelvic tilt (PT).
  • The direct anterior approach (DAA) allows for intraoperative fluoroscopy to assess PT in real-time.
  • The accuracy of recreating preoperative standing PT using intraoperative methods during DAA THA has not been previously evaluated.

Purpose of the Study:

  • To evaluate the precision of intraoperative pelvic tilt (PT) recreation compared to preoperative standing PT during direct anterior approach total hip arthroplasty (DAA THA).
  • To assess the accuracy of visual fluoroscopic assessment in reproducing functional pelvic tilt during DAA THA.

Main Methods:

  • A retrospective cohort of 325 patients undergoing primary unilateral DAA THA was analyzed.
  • Sagittal pelvic tilt (PT) was measured on preoperative EOS radiographs (standing and sitting) and intraoperative fluoroscopic images.
  • Antero-posterior PT and sacro-femoral-pubic (SFP) angles were calculated, with measurements performed by two blinded observers (ICC > 0.80).

Main Results:

  • Intraoperative fluoroscopy reproduced standing PT within ±7.0° in 76% of patients and within ±13.0° in 95%.
  • However, preoperative standing and intraoperative AP PT showed low correlation (r = 0.294), indicating significant variability.
  • The change in SFP angle correlated moderately with the change in AP PT (r = 0.422), further highlighting limited PT recreation precision.

Conclusions:

  • Visual fluoroscopic assessment of standing PT during DAA THA offers moderate accuracy, with approximately three-quarters of patients achieving clinically relevant precision.
  • The observed variability in reproducing functional pelvic tilt suggests that relying solely on visual assessment may be insufficient.
  • Adjunctive verification methods could enhance the consistency of acetabular positioning during DAA THA.