AccScience Publishing / STI / Volume 46 / Issue 1 / DOI: 10.36922/sti.0332
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RESEARCH ARTICLE

Determining Cup Position, Leg Length, and Offset using Intraoperative 2D/3D Registration in Direct Anterior Approach Total Hip Arthroplasty: A Cadaveric Laboratory Study

Nicholas M. Brown1 ,  Whisper Grayson1* ,  Jevan Arulampalam2 ,  Moritz F. Ehlke2 ,  Christopher Plaskos2 ,  Jim Pierrepont2 ,  Camdon Fary3,4 ,  Eric M. Slotkin5 ,  James A. Sullivan6,7 ,  Arjun Saxena8
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1 Department of Orthopedic Surgery and Rehabilitation, Loyola University Health System, Maywood, Illinois, United States of America
2 Corin Ltd, Cirencester, Gloucestershire, United Kingdom
3 Department of Surgery, Epworth Healthcare, The University of Melbourne, Parkville, Victoria, Australia
4 Department of Orthopaedics, Western Hospital, Melbourne, Victoria, Australia
5 Orthopaedic Associates of Reading, LTD., Reading, Pennsylvania, United States of America
6 Department of Orthopaedic Surgery, Sydney Adventist Hospital, Wahroonga, New South Wales, Australia
7 Department of Orthopaedic Surgery, Norwest Private Hospital, Bella Vista, New South Wales, Australia
8 Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
STI 2026, 46(1), 56–64; https://doi.org/10.36922/sti.0332
Received: 14 October 2025 | Revised: 1 December 2025 | Accepted: 9 December 2025 | Published online: 15 January 2026
© 2026 by the Author(s). This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution 4.0 International License ( https://creativecommons.org/licenses/by/4.0/ )
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Abstract

Introduction: Intraoperative 2D fluoroscopy has well-documented variability in accuracy when measuring acetabular position, leg length, and offset in total hip arthroplasty (THA).

Objective: To evaluate the accuracy of a new 2D/3D registration software for intraoperative measurement of THA parameters.

Methods: Eight direct anterior approach (DAA) THAs were performed on four bilateral pelvis-to-toe cadavers by eight surgeons. 3D planning of the acetabular and femoral components was performed on preoperative computed tomography (CT) scans. Intraoperative 2D fluoroscopic images captured the trial and final positioned implants. Preoperative 3D models of the pelvis, cup, femur, and femoral head were registered to the 2D fluoroscopic images intraoperatively using a novel 2D/3D registration software.that reported cup position, leg length, and offset. The mean absolute error (MAE) of the final registered measurements was compared to the ground-truth values measured on postoperative CT.

Results: Cup anteversion and inclination MAE were 1.7° and 1.5°, with maximum errors of 3.4° and 3.1°, respectively. Cup mediolateral and superoinferior MAE were <1 mm, with maximum errors ≤1.6 mm. Leg length and offset MAE were 2.5 and 1.9 mm, with maximum errors of 4.8 and 3.4 mm, respectively.

Conclusion: This cadaver study demonstrated high accuracy and efficiency of 2D/3D registration for determining cup position, leg length, and offset in DAA THA, potentially overcoming some of the limitations associated with using 2D intraoperative imaging.

Level of Evidence: V (Laboratory Cadaveric Study)

Keywords
2D/3D registration
Accuracy
Direct anterior approach
Intraoperative fluoroscopy
Total hip arthroplasty
References
  1. Singh JA, Yu S, Chen L, Cleveland JD. Rates of total joint replacement in the United States: future projections to 2020–2040 using the national inpatient sample. J Rheumatol. 2019;46(9):1134-1140. doi:10.3899/jrheum.170990
  2. Ethgen O, Bruyère O, Richy F, Dardennes C, Reginster JY. Health-related quality of life in total hip and total knee arthroplasty. J Bone Joint Surg Am. 2004;86(5):963-974. doi:10.2106/00004623-200405000-00012
  3. Evans JT, Evans JP, Walker RW, Blom AW, Whitehouse MR, Sayers A. How long does a hip replacement last? A systematic review and meta-analysis of case series and national registry reports with more than 15 years of follow-up. Lancet. 2019;393(10172):647-654. doi:10.1016/s0140-6736(18)31665-9
  4. Negm AM, Beaupre LA, Goplen CM, Weeks C, Jones CA. A scoping review of total hip arthroplasty survival and reoperation rates in patients of 55 years or younger: health services implications for revision surgeries. Arthroplast Today. 2022;16:247-258.e6. doi:10.1016/j.artd.2022.05.012
  5. Patel I, Nham F, Zalikha AK, El-Othmani MM. Epidemiology of total hip arthroplasty: demographics, comorbidities and outcomes. Arthroplasty. 2023;5(1):2. doi:10.1186/s42836-022-00156-1
  6. Bordoni V, Marelli N, Previtali D, Gaffurini P, Filardo G, Candrian C. Outpatient total hip arthroplasty does not increase complications and readmissions: a meta-analysis. Hip Int. 2020;32(3):326-333. doi:10.1177/1120700020948797
  7. Shen TS, Gu A, Bovonratwet P, Ondeck NT, Sculco PK, Su EP. Etiology and complications of early aseptic revision total hip arthroplasty within 90 days. J Arthroplasty. 2020;36(5):1734-1739. doi:10.1016/j.arth.2020.11.011
  8. Aggarwal VK, Elbuluk A, Dundon J, et al. Surgical approach significantly affects the complication rates associated with total hip arthroplasty. Bone Joint J. 2019;101-B(6):646-651. doi:10.1302/0301-620x.101b6.bjj-2018-1474.r1
  9. Novikov D, Mercuri JJ, Schwarzkopf R, Long WJ, Bosco JA III, Vigdorchik JM. Can some early revision total hip arthroplasties be avoided? Bone Joint J. 2019;101-B(6_Supple_B):97-103. doi:10.1302/0301-620x.101b6.bjj-2018-1448.r1
  10. Louette S, Wignall A, Pandit H. Spinopelvic relationship and its impact on total hip arthroplasty. Arthroplast Today. 2022;17:87-93. doi:10.1016/j.artd.2022.07.001
  11. Attenello JD, Harpstrite JK. Implications of spinopelvic mobility on total hip arthroplasty: review of current literature. Hawaii J Health Soc Welf. 2019;78(11 Suppl 2):31-40.
  12. Stefl M, Lundergan W, Heckmann N, et al. Spinopelvic mobility and acetabular component position for total hip arthroplasty. Bone Joint J. 2017;99-B(1_Supple_A):37-45. doi:10.1302/0301-620X.99B1.BJJ-2016-0415.R1
  13. Dennis DA, Smith GH, Phillips JLH, et al. Does individualization of cup position affect prosthetic or bone impingement following total hip arthroplasty? J Arthroplasty. 2023;38(7):S257-S264. doi:10.1016/j.arth.2023.04.031
  14. Driesman AS, Jennings JM, Yang CC, Dennis DA. Offset considerations in total hip arthroplasty. J Am Acad Orthop Surg. 2024;32(20):921-928. doi:10.5435/jaaos-d-23-00931
  15. Li W, Huang Y, Zou Z, Liu X, Li X. Reliability and accuracy of intraoperative fluoroscopy assessment of acetabular cup anteversion in supine direct anterior approach total hip arthroplasty. Sci Rep. 2024;14(1):12469. doi:10.1038/s41598-024-62964-6
  16. Brush PL, Santana A, Toci GR, et al. Surgeon estimations of acetabular cup orientation using intraoperative fluoroscopic imagining are unreliable. Arthroplast Today. 2023;20:101109. Published March 7, 2023. doi:10.1016/j.artd.2023.101109
  17. Brown NM, McDonald JF, Sershon RA, Hopper RH. The effect of intraoperative radiographs on component position and leg length during routine posterior approach total hip arthroplasty. Hip Pelvis. 2021;33(3):128-139. doi:10.5371/hp.2021.33.3.128
  18. Killen CJ, Murphy MP, Ralles SJ, et al. Characterising acetabular component orientation with pelvic motion during total hip arthroplasty. Hip Int. 2020;31(6):743-750. doi:10.1177/1120700020925013
  19. Wines AP, McNicol D. Computed tomography measurement of the accuracy of component version in total hip arthroplasty. J Arthroplasty. 2006;21(5):696-701. doi:10.1016/j.arth.2005.11.008
  20. Delagrammaticas DE, Ochenjele G, Rosenthal BD, Assenmacher B, Manning DW, Stover MD. Intraoperative evaluation of acetabular cup position during anterior approach total hip arthroplasty: are we accurately interpreting? Hip Int. 2019;30(1):40-47. doi:10.1177/1120700019868665
  21. Jennings JD, Iorio J, Kleiner MT, Gaughan JP, Star AM. Intraoperative fluoroscopy improves component position during anterior hip arthroplasty. Orthopedics. 2015;38(11):e970-e975. doi:10.3928/01477447-20151020-04
  22. Aubert T, Galanzino G, Gerard P, Strat VL, Rigoulot G, Lhotellier L. Accuracy of preoperative 3D vs 2D digital templating for cementless total hip arthroplasty using a direct anterior approach. Arthroplast Today. 2023;24:101260. doi:10.1016/j.artd.2023.101260
  23. Sharma AK, Cizmic Z, Dennis DA, Kreuzer SW, Miranda MA, Vigdorchik JM. Low dislocation rates with the use of patient specific "Safe zones" in total hip arthroplasty. J Orthop. 2021;27:41-48. doi:10.1016/j.jor.2021.08.009
  24. Corin Ltd Internal Report - OPSReview™ Repeatability And Reliability Report.
  25. Lembeck B, Mueller O, Reize P, Wuelker N. Pelvic tilt makes acetabular cup navigation inaccurate. Acta Orthop. 2005;76(4):517-523. doi:10.1080/17453670510041501
  26. Fontalis A, Yasen AT, Kayani B, et al. Two-dimensional versus three-dimensional preoperative planning in total hip arthroplasty. J Arthroplasty. 2024;39(9):S80-S87. doi:10.1016/j.arth.2024.05.054
  27. Foissey C, Batailler C, Coulomb R, et al. Image-based robotic-assisted total hip arthroplasty through direct anterior approach allows a better orientation of the acetabular cup and a better restitution of the centre of rotation than a conventional procedure. Int Orthop. 2022;47(3):691-699. doi:10.1007/s00264-022-05624-6
  28. Llombart-Blanco R, Mariscal G, Barrios C, Vera P, Llombart-Ais R. MAKO robot-assisted total hip arthroplasty: a comprehensive meta-analysis of efficacy and safety outcomes. J Orthop Surg Res. 2024;19(1):698. doi:10.1186/s13018-024-05199-5
  29. Ramadanov N, Voss M, Hable R, Prill R, Ezechieli M, Becker R. Meta-regression analysis of the association between acetabular cup positioning and functional outcome for patients with iliopsoas impingement syndrome after total hip arthroplasty. Arthroplast Today. 2025;34:101760. doi:10.1016/j.artd.2025.101760
  30. Chou LB, Johnson B, Shapiro LM, et al. Increased prevalence of breast and all-cause cancer in female orthopaedic surgeons. J Am Acad Orthop Surg Glob Res Rev. 2022;6(5):e22.00031. Published May 1, 2022. doi:10.5435/JAAOSGlobal-D-22-00031
  31. Chou LB, Chandran S, Harris AHS, Tung J, Butler LM. Increased breast cancer prevalence among female orthopedic surgeons. J Womens Health. 2012;21(6):683-689. doi:10.1089/jwh.2011.3342
  32. Hayda RA, Hsu RY, DePasse JM, Gil JA. Radiation exposure and health risks for orthopaedic surgeons. J Am Acad Orthop Surg. 2018;26(8):268-277. doi:10.5435/jaaos-d-16-00342
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Surgical Technology International, Electronic ISSN: 1090-3941 Published by AccScience Publishing
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