Symposium - Total Hip Arthroplasty

Current Concepts in Acetabular Positioning in Total Hip Arthroplasty

Abstract Deepu Bhaskar,

Being one of the most successful surgeries in the history of medicine, the indications for total hip Asim Rajpura,
arthroplasty have widened and are increasingly being offered to younger and fitter patients. This has also Tim Board
led to high expectations for longevity and outcomes. Acetabular cup position has a significant impact
Department of Trauma and
on the results of hip arthroplasty as it affects dislocation, abductor muscle strength, gait, limb lengths,
Orthopaedics, Centre for Hip
impingement, noise generation, range of motion (ROM), wear, loosening, and cup failure. The variables Surgery, Wrightington Hospital,
in cup position are depth, height, and angular position (anteversion and inclination). The implications Hall Lane, Appley Bridge,
of change in depth of center of rotation (COR) are medialized versus anatomical positioning. As Lancashire WN6 9EP, UK
opposed to traditional medialization with beneficial effects on joint reaction force, the advantages of an
anatomical position are increasingly recognized. The maintained acetabular offset offers advantages in
terms of ROM, impingement, cortical rim press fit, and maintaining medial bone stock. The height of
COR influences muscle activity and limb lengths and available bone stock for cup support. On the other
hand, ideal angular position remains a matter of much debate and reliably achieving a target angular
position remains elusive. This is not helped by variations in the way we describe angular position, with
operative, radiologic, or anatomic definitions being used variably to describe anteversion and inclination.
Furthermore, pelvic tilt plays a major role in functional positions of the acetabulum. In addition,
commonly used techniques of positioning often do not inform us of the real orientation of the pelvis on
operating table, with possibility of significant adduction, flexion, and external rotation of the pelvis being
possibilities. This review article brings together the evidence on cup positioning and aims to provide a
systematic and pragmatic approach in achieving the best position in individual cases.

Keywords: Acetabular cup position, angular position, anteversion, depth, height, inclination,
mediolateral, pelvic tilt, superoinferior
MeSH terms: Acetabulum, replacement, arthroplasty, hip, biomechanics

Introduction accuracy of cup placement remains

variable. This review aims to bring together
Total hip arthroplasty (THA) has
the evidence on cup positioning and discuss
become one of the most successful and
a pragmatic approach to applying these
cost‑effective interventions in the history of
principles.
medicine.1 Over time patient demands have
increased significantly, with a greater focus Section I – Defining Cup Position
on range of motion and function as well as
pain relief. Due to its success, surgery is Variables defining acetabular positioning
now offered to younger and fitter patients are:
and thus achieving longevity for the implant 1. Depth or mediolateral position
has become a bigger challenge. 2. Height or superoinferior position
Address for correspondence:
3. Angular placement including inclination
Accurate biomechanical reconstruction of Prof. Tim Board,
and version. Centre for Hip Surgery,
the joint is essential to achieve function Wrightington Hospital,
and longevity, with acetabular positioning Depth of cup Hall Lane, Appley Bridge,
being a key factor. The consequences of Mediolateral position determines the lever Lancashire WN6 9EP, UK.
malposition include instability,2 increased E‑mail: [email protected]
arms of body weight and abductor force and
wear,3‑5 impaired muscle function,6 reduced thus joint reaction force (JRF) [Figure 1]. It
range of motion (ROM),7 impingement,7‑9 contributes to offset, a reduction, in which Access this article online
bearing‑related noise generation,10,11 can result in a reduced ROM,7 increased
poor functional outcomes, limb length
12
dislocation risk,18 impaired gait,6,19 and
Website: www.ijoonline.com
DOI:
discrepancy,13,14 and loosening and cup accelerated bearing wear [Figure 1].3‑5 10.4103/ortho.IJOrtho_144_17
failure.15‑17 Despite advances in technique, Quick Response Code:
The traditional Charnley approach20
This is an open access article distributed under the terms of the advocates medialization of acetabular
Creative Commons Attribution-NonCommercial-ShareAlike 3.0
License, which allows others to remix, tweak, and build upon the
work non-commercially, as long as the author is credited and the How to cite this article: Bhaskar D, Rajpura A,
new creations are licensed under the identical terms. Board T. Current concepts in acetabular positioning in
For reprints contact: [email protected] total hip arthroplasty. Indian J Orthop 2017;51:386-96.

386 © 2017 Indian Journal of Orthopaedics | Published by Wolters Kluwer - Medknow

 Bhaskar, et al.: Acetabular positioning in total hip arthroplasty

Impingement can be component‑to‑component (CCI),

bone‑to‑bone (BBI), or component‑to‑bone impingement.23
Excessive medialization may lead to impingement,
especially when peripheral osteophytes are not removed,
due to premature contact between proximal femur and
pelvic bone/soft tissue (BBI).7‑9 Conversely, excessively
lateral placement of cup, especially in a horizontal position
with lateral uncoverage, can also lead to impingement
between metal femoral neck and cup liner (CCI) leading to
early loosening.24 Simulation studies of ROM before bony
impingement found that decreased global offset and length
reduce ROM7 with acetabular offset and height having
a greater effect than femoral offset and height. Restoring
offset by increasing femoral offset or osteophyte removal
did not fully restore ROM before impingement. Thus,
anatomic positioning of cup, preserving acetabular offset
has been proposed.8,24
Component containment is another important consideration
when choosing depth of cup. Press‑fit uncemented
components rely on a rim of peripheral cortical bone for
Figure 1: X-ray pelvis with both hip joints anteroposterior view showing their initial stability.23,25 Medialization past this supportive
importance of mediolateral position in determining joint reaction rim into cancellous bone can increase the risk of loosening.
force. Medialization reduces body weight lever arm and increases
An over‑lateralized cup is also at the risk of loosening due
abductor lever arm reducing joint reaction force which is calculated as
JRF = BWxB – AbxA. Right side shows femoral offset, acetabular offset, to inadequate superolateral bony support.23,24 In contrast, a
and their contribution to global offset. BW – Body weight, Ab – Abductor cemented component will require greater medialization to
force, A – Abductor moment arm, B – Body weight moment arm, JRF – Joint
containment.
reaction force, AO – Acetabular offset, FO – Femoral offset
Despite traditionally espoused benefits, medialization has
component to reduce JRF. However, medialization can deleterious effects too. Attention to acetabular offset and
reduce global offset which is the sum of femoral offset restoration of an anatomic COR has advantages in terms
(perpendicular distance from the center of rotation [COR] of impingement, ROM, global offset restoration, cortical
of femoral head to the central axis of femur) and acetabular rim press‑fit, and maintaining medial bone stock. We would
offset (distance between COR of femoral head and recommend an individualized approach to each patient,
inner wall of quadrilateral plate/true floor) [Figure 1]. considering each of these factors, rather than routine
Medialization reduces acetabular contribution to global medialization for all.
offset and to restore it, a stem with offset greater than the
Height of cup
natural offset of femur is required.
The superoinferior position of cup affects limb length and
Bonnin et al.9 examined three scenarios of acetabular and
JRF.
femoral offset, namely, medialization of cup with native
femoral offset, medialization with increased femoral A change in cup height can cause limb length discrepancy.
offset to restore global offset, and anatomic position of Clinical consequences include gait disturbance, low back
cup with femoral offset increased. Medialization resulted pain, neurological symptoms, and instability of hip.13
in the least stress at cup‑head interface and abductor Although the usual problem is a high COR with shortening,
muscles, with optimum outcome when femoral offset was lower placement of COR has been described as a cause of
increased to restore the global offset. The increased JRF lengthening. Parvizi et al.14 have described revision THA
seen with decreased medialization has been implicated in for lengthening caused by the cup extending below the
increased wear in hard‑on‑hard bearings and squeaking in level of teardrop.
ceramic‑on‑ceramic (CoC) bearings.10,11 Araised COR causes higher JRF, increasing risk of
Downsides of medialization includes reduced ROM, premature wear, aseptic loosening, and implant failure.15‑17
increased risk of bony impingement, risk of microseparation Raising the COR reduces perpendicular distance to
if global offset is not restored resulting in accelerated abductors and Asayama et al.6 showed that it negatively
wear, particularly in hard‑on‑hard bearings,21,22 loss of correlates with abductor strength. They recommended
bone medially that may have implications for revision a slight inferomedial position of COR with a slight
surgery, change in working length of muscles, and changed increase in femoral offset to optimize abductor function.
proprioception due to nonanatomic positioning.6 In dysplastic hips with a superiorly displaced COR, the

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 Bhaskar, et al.: Acetabular positioning in total hip arthroplasty

best outcomes are associated with reconstruction of the anteversion. To achieve a target radiographic anteversion,
anatomic COR. This results in a reduction in JRF and the operative angle should be higher.
abductor muscle force.15,16,19
During surgery in lateral position, operative inclination is
During THA, the acetabular reaming vector can cause assessed by looking from a point perpendicular to the plane
minor displacements of COR superiorly and posteriorly. of anteversion of the cup inserter. Radiographic inclination
It is believed that superior displacements of up to 13 mm can be assessed by standing directly behind the patient and
(and medial of 7.5 mm)24 have no clinical consequence. looking (from a point perpendicular to the coronal plane) at
However, more recent work suggests that when COR is the insertion angle with floor [Figure 2]. The radiographic
raised >3 mm (and medialized >5 mm) restoration of offset projection will be greater than this due to anteversion.
within 5 mm becomes difficult.26,27 The operative anteversion is assessed by looking down,
Angular position of cup to project the insertion angle onto sagittal plane, and
measuring against the longitudinal axis. This angle will be
Angular position includes anteversion and inclination
greater than the projected radiographic angle [Figure 2].
(abduction angle) of cup.
An illustration of these differences is the interpretation
A variety of values has been recommended to help reduce
wear, bearing‑related noise, impingement, and risk of of Lewinnek’s safe zone by Murray.31 Lewinnek et al.2
dislocation. Inclination past 45° has been shown to increase
wear rate,28,29 metal‑on‑metal bearings with inclinations past
55° have shown raised blood levels of metal ions,30 CoC
bearings outside a zone of 35°–45° inclination, and 15°–35°
anteversion are 29 times more likely to squeak.11 However,
the vast majority of studies relate to dislocation, with a
wide range of recommended values. The most commonly
quoted study is by Lewinnek et al.2 He found an increased
dislocation rate in cups placed outside anteversion angles
of 5°–25° and 30°–50° of inclination. To a certain extent,
the variation in recommended angles can be attributed to
different ways of measuring these angles. An understanding
of this is vital in achieving optimum cup placement.
Quantifying angular position
Angular position is the angle subtended by acetabular
axis, which passes through the center of socket
and is perpendicular to plane of the socket face
(Calandruccio, 1987). In practical terms, this is represented
by the inserter handle of an uncemented socket. The
angle of this axis can be measured in three different
ways, depending on the plane or the axis from which
it is measured. Inclination and anteversion can thus be
operative, radiologic, or anatomic [Table 1].31
Operative and radiographic angles are the most relevant Figure 2: Schematic diagram showing surgeon position to assess
surgically in lateral position of the patient. Due to radiographic and operative inclination. Position 1 assesses the projection
of the operative inclination on the coronal plane, and therefore, the
anteversion, the radiographic inclination is higher than radiographic angle. Position 2 perpendicular to the vertical plane passing
operative inclination and increases with increasing through inserter handle assesses operative inclination

Table 1: Definitions of operative, radiographic and anatomic inclination

Operative Radiographic Anatomic
Definition Angle between acetabular axis Angle between assumed longitudinal axis and Angle between acetabular axis and
inclination (inserter handle) and floor acetabular axis when projected on to coronal plane assumed longitudinal axis
Angle seen in anteroposterior radiograph Angle measured by CT scan
Definition Angle in the sagittal plane between Angle between acetabular axis and coronal plane Angle in the transverse plane between
anteversion the acetabular axis and the assumed Angle seen in lateral ‘shoot through’ radiograph the acetabular axis and the coronal plane
longitudinal axis of the patient Angle measured by CT scan
Any combination of these can be used to describe angular placement. CT=Computed tomography

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 Bhaskar, et al.: Acetabular positioning in total hip arthroplasty

reported 25° as the upper limit of anteversion beyond defined safe zones.41‑45 As previously discussed, there is
which 15% hips dislocated. This is a radiographic angle large variation in recommended values46‑53 partly due to the
and, on conversion, equivalent to 38° operative anteversion, use of different reference frames and angular definitions.
above which 21% hips dislocated. Therefore, Murray
Yoon et al.32 have attempted to resolve these
recommends that Lewinnek’s statement should have been
interpreted as ‑ hips should be inserted at <35° of operative inconsistencies by amalgamating data from nine different
anteversion to avoid dislocations. papers recommending safe zones and computed angles to
a unified system by transferring to a pelvic reference plane
Pelvic tilt and functional acetabular positions (based on a pelvic tilt of −8° standing and −4° lying34).
The angle between the coronal plane of the patient and the Using their common reference, the averaged target
anterior pelvic plane (APP) (plane passing through both orientation is 41° inclination and 16° anteversion for
anterior superior iliac spines [ASIS] and pubic tubercles) is radiographic angles. This equates to operative angles of
called pelvic tilt [Figure 3].32 It can be judged on radiographs 39° inclination and 21° anteversion. Based on the evidence
by looking at symphysis pubis to sacrococcygeal distance so far, this seems to be a good generalization that can be
with normal values of 32 mm (range 8–50 mm) in offered to minimize the incidence of dislocation.
women and 47 mm (range 15‑72 mm) in men.33 The
distance increases with forward tilt and decreases when Section II ‑ Planning and Execution in Cup
tilted backward. The average pelvis has a posterior tilt, Positioning
−12° and −8° in standing and supine, respectively,34 that Callanan et al.54 studied the accuracy of cup positioning and
tilts further back when sitting [Figure 3]. concluded that only 50% of hips were within the targeted
Dynamic changes to pelvic tilt affects radiographic safe zone for both anteversion and inclination (63%
anteversion,35 with 0.7°–0.8° increase for each degree of for inclination and 79% for version). Surgeon volume
posterior tilt.36,37 There is a mean increase in anteversion and high body mass index (BMI) were independent risk
of 7° (range −2° to 18°) in standing compared to supine, factors, with obesity, low volume surgeons, and minimally
with 52% of patients having more than 5° increase.36 There invasive surgery conferring a 1.3‑fold, 2‑fold, and 6‑fold
is a larger change moving from standing to sitting with an higher risk of malposition, respectively. Techniques that
average increase of 15.6°.38 can be used to improve the accuracy of positioning are
Forward or anteriorpelvic tilt causes a decrease in discussed below.
inclination and vice versa.37 Although the mean change Templating
is not significant (mean 2°),39 as the change in inclination
happens in a nonlinear manner, patients with larger posterior Templating is an essential step in the THA surgical process.
tilts have a larger change in inclination (mean change 0.29° Two‑dimensional templating is the most common method,
per degree of posterior pelvic tilt as opposed to 0.47° per and while, this does have limitations, it provides enough
degree when patient has 15° posterior tilt).40 information to carry out uncomplicated primary THAs
[Figure 4].
Safe zone considering differing angular measurements
and reference frames
There is controversy whether a generic safe zone exists
for cup position as some researchers have found that a
significant proportion of cups that dislocate lie within

Figure 4: X-ray pelvis with hip joints and proximal 1/3 rd of femur
Figure 3: Schematic representation on saw bones demonstrating pelvic anteroposterior view showing templating for an uncemented total hip
tilt - the difference between the anterior pelvic plane and the coronal plane arthroplasty

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 Bhaskar, et al.: Acetabular positioning in total hip arthroplasty

Predicting implant size from templating is imprecise, number were placed within safe zone (80.75% vs. 62.34%)
with correct size prediction ranging from 16%–62%,55,56 and had lower dislocation rate (1.03% vs. 2.49%) using
improving to 52%–98% if a range of sizes one above navigation. A meta‑analysis of cup position in navigated
and below is accepted. Some of this inaccuracy has been versus nonnavigated groups61 showed that a significantly
attributed to differences in magnification, poor placement lower number of cups were outliers with regard to the safe
of calibrating ball, and distortion due to projection.57 position in the navigated group (10.7% vs. 41.8%).
Work from our institution58 suggest that a major factor is
There is active, semi‑active, and passive navigation. Active
incorrect placement of cup template on radiographs and
navigation uses robots to implant cups. Semi‑active systems
that an understanding of relationship between teardrop and
allow the surgeons to move the robotic arms but do not
the most inferior extent of posterior acetabular rim (IPAR)
allow the arm to move beyond a milling boundary that has
may help to improve sizing.
been determined by preoperative three‑dimensional imaging.
The “teardrop” is a radiographic landmark created by The data from robotic THA is only starting to come through
superimposition of the most distal part of the medial wall and is not presented here. Passive navigation only guides
of the acetabulum and the tips of the anterior and posterior the surgeon to implant in the right position and consists of
horns. A line drawn between both teardrops can be used three types of navigation ‑  imageless navigation, computed
as a reference from which to measure inclination and leg tomography‑based navigation, and fluoroscopic navigation.
length. However, rather than teardrop, it is the posterior
Most passive navigation systems use APP as the reference
and inferior part of the semilunar weight bearing bone of
plane. Although this aids accurate placement of cup in
the acetabulum that is the most inferior and we call this
relation to the pelvis, it does not consider pelvic tilt.
IPAR [Figure 5]. The IPAR and teardrop were at different
Babisch et al.62 produced a nomogram for pelvic tilt and
levels in 86% cases, and the inferior extent of most cups
used it to adjust for pelvic tilt during navigation resulting
tends to sit between the radiographic projection of IPAR
in 98% accuracy of cup placement. Although current
and teardrop on postoperative X‑rays. Placing template at
navigation systems consider mean pelvic tilt, the future
the level of teardrop would tend to undersize and placing at
lies in adjusting cup position according to functional pelvic
IPAR would oversize the component [Figure 5].
position of each individual.
However, the aim of templating is not to predict implant
Despite these advantages, navigation is not commonly used
sizes (other than in extreme situations), as this can be
due to cost and operative time implications.
done easily during surgery, but to predict cup position in
terms of restoring COR and height, depth, and angular Patient positioning and its significance
position [Figure 4].
Supine positioning, with the use of anterior, anterolateral,
Computerized navigation – passing fad or lasting or direct lateral approaches, has the advantage that it is
benefits? easier to assess whether the pelvis is square and to assess
limb lengths. In addition, surgery takes place in the coronal
Navigation can lead to more reliable cup placement within
plane which is the functional plane.
safe zones.59 An evidence‑based analysis60 showed that
though there was no significant difference in mean angles However, the vast majority of THA uses lateral decubitus
between navigated and nonnavigated cups (though with position using posterior, anterolateral, anterior, or the
less variation in the navigated group), a significantly higher newer direct superior approach. Here, pelvic position tends

Figure 5: X-ray pelvis with both hip joints and proximal 1/3rd of femur anteroposterior view showing the difference in position between teardrop and inferior
extent of posterior acetabular rim. To size the acetabulum accurately in templating as well as to understand cup positioning, it’s important to recognize
the distance between the two

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 Bhaskar, et al.: Acetabular positioning in total hip arthroplasty

to have wide variation at setup. Pelvic tilt can range from lead to lateral uncoverage, and therefore, a medialized
25° posterior to 20° anterior (55% hips having posterior position should be chosen [Figures 6 and 7].
tilt, 38% anterior) with 16.1% patients having a tilt of
Ifan anatomic position is chosen, the transverse acetabular
10° or greater.39 Therefore, while we tend to think that the
ligament (TAL) and labrum can be used to define the cup
pelvis is aligned with the coronal plane of the patient when
not only in version but also its depth of placement.64,66
positioned on operating table, the truth is that we do not
Beverland et al.65 has described his technique of reaming
know its real orientation.
the acetabulum conservatively to no more than 4 mm
While maximum variation is for pelvic tilt, 8° bigger than femoral head size until the final reamer is
(2 standard deviation [SD] ± 32°), it is also adducted, cradled by labrum and TAL. The depth, version, and height
−4° (2SD ± 12°), and externally rotated, −8° (2SD ± 14°).63 (not inclination) of a hemispherical cup is guided by this.
It is recommended that while positioning, both ASIS and
If medialization is chosen, reamer/osteotomes are used
pubic tubercles are considered, and position of posterior
to expose the true floor. Care must be taken to restore
support in craniocaudal direction is used to control
global offset, as conventional reaming displaces COR
pelvic tilt.64 To control pelvic obliquity, a helpful method
medially by a mean of 5 mm and elevates it by 3.7 mm,
described by Beverland et al.65 is to draw parallel lines
compared to the anatomic position which displaces it by
at lumbosacral region using a spirit level with the patient
a mean of <1 mm in each direction.27 In planning, stem
seated preoperatively. In the lateral position, these lines
offset should be measured from intended final position of
then demonstrate the degree of pelvic adduction before
hip COR (based on final cup position) rather than COR
application of posterior support. This may not be as
of femoral head. The profile of the lesser trochanter (LT)
helpful in high BMI patients.
should also be noted, as an externally rotated hip, as
How to Achieve Target Depth evidenced by a prominent LT can cause a 20% reduction in
measurement of femoral offset19 on templating.
Individualized depth of cup placement is based on
achieving optimum cup fixation as the priority, with the To check global offset intraoperatively, there are several
main variable being adequate cup coverage. Where there techniques described. Jigs are available to measure from
is an adequate acetabulum an anatomic position, with its a fixed point above acetabulum before hip dislocation,
associated advantages, can be chosen [Figure 6]. Care measuring length, and offset. The senior author has
should be exercised in choosing a medialized position described his technique of using a suture from a Judd
in a person with large native offset, as medialization can pin inserted into the illium just superior to acetabulum to
result in medial movement of COR up to 14 mm27 making measure intraoperative leg length [Figure 8].67,68 The angle
it difficult to find a stem that would restore global offset. of this suture, with respect to the floor, can also be used to
Similarly, in a person with a deep acetabulum further determine the restoration of global offset. For this technique,
medialization can lead to impingement and loss of ROM. it is necessary to accurately place the limb in same position
On the other hand, in an acetabulum that is shallow or each time, as any change in angular position of the limb can
tending toward dysplasia, the anatomical position would affect measurement significantly. Another technique is direct
measurement of the distance from COR of the femoral head
to greater trochanter before neck resection and restoring it
along with the length of any medialization. The use of a
caliper to measure diameter of the resected head and using
this measurement to estimate the distance to the prosthetic
head from fixed points on greater trochanter and resected

Figure 6: X-ray pelvis with both hip joints and proximal half of femur,
anteroposterior view in this patient, an anatomical position has been chosen Figure 7: Preoperative and postoperative radiographs of pelvis with both hips
for the cup. Reducing the acetabular offset would mean that a femoral stem and proximal femur anteroposterior view in a patient with shallow acetabulum
with greater offset would have been required. Risk of impingement and where the medialized position has been chosen. Choosing the anatomic
reduced range of movement could result from medialization position in this patient would have resulted in lateral uncoverage of the cup

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 Bhaskar, et al.: Acetabular positioning in total hip arthroplasty

neck to accurately reproduce femoral offset and height when patients, care must be taken to ensure that inclination is
an anatomic COR is chosen has been described [Figure 8].69 not changed by abutment of the cup inserter against soft
tissues (angled/offset inserter is useful in such situations).
How to Achieve Target Height However, orthopedic surgeons are not very good at visually
The TAL can also be used to determine height.64 Ideally, estimating angles subtended by Jigs.66 A digital protractor
the reamer should be cradled by TAL and labrum66 which placed on the inserter handle can help improve the accuracy
ensures that the cup will not migrate proximally. The effect of insertion angles.70
of medialization must be considered as it can elevate COR Achieving the correct angle between inserter handle
by up to 18.9 mm.24 The inferior extent of the cotyloid and the floor or the operating table does not ensure
fossa is projected as teardrop on radiographs, and at the satisfactory cup inclination. Hill et al.71 reported a 12.7°
correct inclination, the inferior extent of the cup should variation between implanted inclination angle and final
not be above this. However, in dysplasia, sometimes position on radiographs despite careful implantation.
medialization and elevation of COR ID required to achieve They indicated that although this is in large part related
good lateral coverage. to the difference between operative and radiographic
inclination, it is also partly due to adduction of the
How to Achieve Target Angular Position
pelvis on operating table. They, therefore, recommend
Due to the disparity between operative and radiographic an operative inclination target of 35° to prevent outliers
angles, Grammatopoulos et al.63 recommended implanting at above what is seen as a critical inclination of 50° of
the cup in 5° less inclination and 8° more anteversion to radiographic inclination.
achieve the target radiographic position. The most common
technique used to guide angular position remains the use a We have discussed variability of pelvic position at setup.
jig during cup insertion. In smaller incisions and high BMI There is also significant intraoperative movement of the
pelvis during surgery. Factors influencing movement
include surgeon, pelvic supports (two ASIS supports better),
approach (posterior more movement than anterolateral),
and procedure type (resurfacing more than THA).62 Such
pelvic movement during surgery can affect cup position.
A solution is to use internal landmarks that are independent
of patient position. The relationship between the
superolateral most point of the bony acetabulum and the
lateral extent of the templated acetabular cup can be used
for this purpose. The distance between these points can
be measured during templating and can then be recreated
intraoperatively to guide inclination [Figure 9].
The use of TAL to guide anteversion has been reported to
reduce dislocation rates to 0.6%.64 Another intrapelvic guide
to cup version is the acetabular notch or psoas groove.
Especially in anatomical position of cup, care should be
Figure 8: Peroperative photograph showing a Judd pin is inserted at the exercised that there should be adequate anteversion so that
supraacetabular level, and the suture with a knot is used to mark the
distance to a fixed point on the greater trochanter before dislocation. This the anterior margin of cup is deep to the notch to prevent
suture can be used to assess leg length and offset intraoperatively psoas irritation.

Figure 9: X-ray (L) hip joint anteroposterior view and peroperative photograph showing measuring the lateral overhang of template and reproducing it
intraoperatively to achieve correct cup inclination

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 Bhaskar, et al.: Acetabular positioning in total hip arthroplasty

Table 2: A pragmatic approach to cup positioning

Indian Journal of Orthopaedics | Volume 51 | Issue 4 | July-August 2017 393

 Bhaskar, et al.: Acetabular positioning in total hip arthroplasty

Where it is suspected that the femoral version is abnormal, Financial support and sponsorship
the version of the implanted stem should be considered,
Nil.
before the definitive cup is implanted. In these cases, the
use of combined anteversion angle is recommended.24,25 It Conflicts of interest
is beyond the scope of this article to discuss this technique There are no conflicts of interest.
in detail, however, it is recommended that the surgeon is
familiar with this concept where abnormal femoral anatomy References
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