Overview
Preoperative planning for total hip arthroplasty combines confirmation of the pain generator, optimization of modifiable risks and a reconstruction plan for the acetabulum and femur. Templating helps anticipate component size, fixation, hip center, neck resection, leg length and offset; it does not replace intraoperative assessment (Campbell, Chapter 4).
Confirm the Diagnosis and Functional Goals
Correlate symptoms with examination and imaging. Lumbar disease, vascular claudication, trochanteric pain and other disorders may coexist with radiographic hip arthritis.
Document pain, walking capacity, assistive devices, motion and the activities the patient wants to regain.
Assess abductor strength, contractures and the spine. Adduction contracture can create apparent shortening, while abduction contracture can produce apparent lengthening.
Distinguish true structural leg-length inequality from pelvic obliquity or fixed spinal deformity.
Review prior surgery, scars, implants and possible infection. When indicated, investigate with inflammatory markers and joint aspiration before elective reconstruction.
(Campbell, Chapter 4.)
Optimize the Patient
Domain | Planning priorities in Campbell |
|---|---|
Cardiopulmonary and renal disease | Assess operative risk and obtain appropriate specialist input, especially with symptoms or established disease. |
Diabetes | Identify poor glycemic control and arrange treatment before surgery; risk thresholds vary in the cited literature. |
Nutrition and anemia | Recognize malnutrition, low body mass and anemia, and develop a blood-management plan. |
Obesity and tobacco use | Discuss increased wound and infection risks and support risk reduction without assuming a single threshold applies to every patient. |
Medication exposure | Coordinate antithrombotic and immunomodulating medication plans with the relevant clinicians. Review preoperative opioid use and supplements. |
Infection prevention | Address active skin or other infection and apply the institutional screening, decolonization and prophylaxis pathway. |
Optimization is an active process rather than a binary clearance label. Medication interruption and resumption depend on the drug, indication and patient; the general planning discussion should not be used as a stand-alone prescription (Campbell, Chapter 4).
Required Imaging
Obtain an AP pelvis including the proximal femora and a lateral view of the affected hip and proximal femur.
Assess acetabular bone stock, medial wall, coverage and prior fractures; use additional views or CT when anatomy is complex.
Evaluate femoral canal width, bowing, previous osteotomy and retained hardware. Confirm that the intended stem can be inserted along the canal.
Obtain spine and knee imaging when the clinical findings indicate another deformity or source of symptoms.
Use an appropriate calibration method for digital or film templating, accounting for image magnification and limb rotation.
(Campbell, Chapter 4.)
Templating Technique
Establish Reliable References
Check that the pelvis is positioned adequately and both proximal femora are included.
When possible, obtain the AP image with about 15 degrees of internal rotation to define femoral geometry and offset. Fixed external rotation can make templating inaccurate.
Calibrate the image using the selected method and match the template scale to the image.
Choose a reproducible pelvic reference, such as the interteardrop line, and compare perpendicular distances to the lesser trochanters.
Use an undistorted opposite hip as a secondary reference where appropriate, rather than assuming it is normal.
(Campbell, Chapter 4, Technique 4.1.)
Template the Acetabulum
Select a cup size that matches the acetabular contour without requiring excessive subchondral removal.
Identify the intended medial and inferior positions using the teardrop and adjacent pelvic landmarks.
Mark the reconstructed center of rotation and assess available coverage.
Identify defects that may require graft, supplemental fixation or a different reconstructive strategy.
(Campbell, Chapter 4, Technique 4.1.)
Template the Femur
Select the stem design and size to suit canal shape and bone quality. If cemented fixation is planned, allow for the intended cement mantle.
Match the reconstructed head center to the acetabular center while incorporating the planned correction of true shortening.
Choose neck length and offset together; lengthening alone may not be the best way to restore soft-tissue tension.
Mark the intended neck cut and measure its relationship to the lesser trochanter for intraoperative use.
Check the lateral view for fit, bowing and possible cortical conflict. Plan the necessary extraction or osteotomy equipment for previous hardware or deformity.
(Campbell, Chapter 4, Technique 4.1.)
Hip-Spine Assessment
A cup that appears acceptable on a static pelvic image may be functionally unsafe when the patient stands or sits. Lumbar stiffness, fusion and sagittal deformity alter pelvic motion and therefore functional acetabular orientation. Campbell notes that many dislocations occur despite cup placement within a conventional static safe zone (Chapter 4).
For a patient with spinal fusion, deformity or significant stiffness, assess standing and seated lateral spinopelvic views and incorporate the findings into component planning. The source describes normal postural accommodation through posterior pelvic tilt when sitting; a stiff spine may prevent this and increase impingement risk. Do not apply one anteversion target to every hip-spine pattern.
Final Operative Plan
Define approach, fixation method, expected component sizes and backup options.
Record intended hip center, neck resection, leg-length correction and offset.
Plan how length and offset will be measured intraoperatively using reproducible limb positioning.
Anticipate bone defects, retained hardware, abnormal femoral version and instability risk.
Confirm the perioperative medical, analgesia, infection-prevention, blood-management and rehabilitation pathways.
(Campbell, Chapter 4.)
Pearls and Pitfalls
Do not attribute all regional pain to the hip because arthritis is visible.
Do not confuse apparent inequality from contracture with true shortening.
Check calibration and rotation before accepting a templated size or offset.
Do not assume static cup orientation captures spinopelvic function.
Make backup equipment available before surgery rather than discovering a canal or hardware problem during reconstruction.
(Campbell, Chapter 4.)
References
Harkess JW, Crockarell JR Jr. Arthroplasty of the hip. In: Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Elsevier; 2026. Chapter 4, evaluation and optimization, pp. 213–216; radiographs and templating, pp. 216–218, Technique 4.1; hip-spine relationship, pp. 218–219.