Apical Vertebral Translation as a Coronal Risk Factor for Side-Specific Hip Osteoarthritis in Adult Degenerative Scoliosis

Abstract

Study design

A retrospective cross-sectional study.

Objectives

To evaluate the impact of coronal plane imbalance in adult degenerative scoliosis (ADS) on the severity and side-specific pattern of hip osteoarthritis (OA).

Methods

Patients older than 50 years with Cobb angle >10° who underwent preoperative EOS images were retrospectively recruited. Hip OA severity was assessed using Kellgren–Lawrence (KL) grades and categorized into mild (KL <3 bilaterally) or severe (≥ one hip with KL ≥3). Coronal parameters—including Cobb angle, apical vertebral translation (AVT), pelvic obliquity (PO), and coronal balance distance—along with sagittal spinopelvic parameters were measured. Associations between radiographic variables and OA severity (worse, concave, and convex sides) were evaluated using Spearman correlation and multivariate logistic regression.

Results

Among 189 patients, those with severe hip OA demonstrated significantly greater AVT and PO despite similar Cobb angles. AVT correlated with worse-side OA (r = 0.259, P < 0.001), convex-side OA (r = 0.154, P = 0.034), and concave-side OA (r = 0.246, P < 0.001); PO correlated with worse-side and concave-side OA. Logistic regression identified AVT as an independent risk factor for worse-side (OR 1.062) and concave-side OA (OR 1.077), whereas Cobb angle appeared protective for convex-side OA (OR 0.942). Sagittal parameters (PT, PI–LL, SVA) were also elevated in severe OA patients, consistent with hip–spine compensatory mechanisms.

Conclusion

Coronal imbalance in ADS, particularly increased AVT and pelvic obliquity, is associated with the severity and asymmetry of hip OA independent of Cobb angle magnitude. AVT may serve as a radiographic marker for identifying ADS patients at higher risk of asymmetric hip degeneration.

Keywords

adult degenerative scoliosis hip osteoarthritis coronal imbalance apical vertebral translation

Introduction

Adult degenerative scoliosis (ADS) is a complex deformity characterized by a Cobb angle greater than 10°, often accompanied by low back pain and radiculopathy.^1,2 As the most common type of adult spinal deformity(ASD), malalignment originating in the spine could lead to compensatory mechanisms in the pelvis and lower limbs.³ This mechanical interaction is clinically defined as the Spine-Hip Syndrome (SHS).⁴

To date, extensive literature has investigated HSS, primarily focusing on the relationship between sagittal spinal alignment and the severity of hip and knee osteoarthritis (OA).^5–7 Despite the recognized importance of sagittal parameters, few study reported the impact of coronal deformity to the severity and asymmetry of hip OA. Theoretically, deviation of the trunk center mandates asymmetric stress distribution on the lower kinetic chain, potentially underlying side-specific discrepancies. However, the roles of coronal parameters in the progression of LOA remained unclear.

This study aimed to evaluate the impact of coronal imbalance in ADS on the overall severity and asymmetric patterns of hip OA. We hypothesized that global coronal malalignment would emerge as an independent risk factor for severe HOA, and disproportionately affecting the hip joint located on the different side of the scoliotic curve.

Methods and Materials

Study Design

Patients were retrospectively recruited from consecutive admissions to the spine surgery department at our institution between 2022 and 2024. Inclusion criteria were as follows: (1) age >50 years; and (2) diagnosed as degenerative scoliosis and available preoperative EOS imaging with a Cobb angle >10°. Exclusion criteria included: (1) presence of other spinal pathologies (eg, tumor, infection); (2) history of instrumented spinal surgery or arthroplasty (hip, knee); (3) congenital and neuromuscular pathology in the hip joint; and (4) secondary hip osteoarthritis, defined as osteoarthritis attributable to identifiable structural or pathological causes, including developmental dysplasia of the hip, avascular necrosis, post-traumatic deformity, inflammatory arthritis, etc. (Figure 1) Demographic data were obtained from electronic medical records. Institutional Review Board approval was secured (JL-K202101-17-04), and informed consent was obtained from all participants.

Figure 1.

Flowchart of patient selection

Radiographic Analysis

Hip OA severity was evaluated using the Kellgren-Lawrence (KL) grading system, ranging from Grade 0 (normal) to Grade 4 (gross deformity).⁸ Spinopelvic and lower extremity parameters were measured on EOS images by two independent orthopedists. Coronal parameters included: Cobb angle, coronal balance distance (CBD), apical vertebral translation (AVT), shoulder balance, T1 tilt, L5 tilt, pelvic obliquity (PO), head-shaft angle (HSA), and hip-knee-ankle angle (HKA). Sagittal parameters included: pelvic incidence (PI), sacral slope (SS), pelvic tilt (PT), lumbar lordosis (LL), PI-LL mismatch, thoracolumbar junction angle (TLJ), thoracic kyphosis (TK), and sagittal vertical axis (SVA). All parameters were measured according to established protocols^8,9 (Figure 2). Intra-observer interclass coefficient (ICCs) were 0.896 and 0.922 for observers 1 and 2, respectively, and inter-observer ICC was 0.905, indicating excellent measurement reliability. Additionally, the location of the apical vertebra and the orientation of the main curve were documented.

Figure 2.

Schematic illustration of radiographic measurements on EOS images

Statistical Analysis

The cohort was stratified into two groups: the severe hip OA group (SOA), defined as having at least one hip with a KL grade ≥3; and the mild hip OA group (MOA), defined as having bilateral KL grades <3. This stratification was consistent with previous studies,^8,10 as KL ≥3 is commonly considered a clinically meaningful cutoff indicating at least moderate radiographic osteoarthritis and is more likely to be associated with functional limitation and clinical decision-making. Demographic and radiographic parameters were compared using Student’s t-tests or Mann-Whitney U tests for continuous variables, and Chi-square tests for categorical variables. Spearman rank correlation analysis was utilized to investigate relationships between spinopelvic parameters and KL grades (worse-side, ΔOA Grade, concave-side, and convex-side). Variables demonstrating significant associations in univariate or correlation analysis were included in multivariable binary logistic regression models²¹. Statistical analysis was performed using SPSS version 27.0 (IBM, Armonk, NY, USA), with significance set at P <0.05.

Results

A total of 189 patients were included: 63 in the SOA group and 126 in the MOA group. Demographic characteristics are summarized in Table 1; patients in the SOA group were significantly older than those in the MOA group (P = 0.039).

Table 1.

Demographic Data and Spinopelvic Parameters Between Two Groups

Variable	Mild OA group(n = 126)	Severe OA group (n = 63)	P value
Age (years)	68.5 ± 8.2	71.0 ± 6.9	0.039*
Gender (n)			0.287
Male	50	20
Female	76	43
BMI(Kg/m²)	25.2(3.3)	25.3(3.9)	0.886
Smoking status (n)
No	98	52	0.446
Yes	28	11
Alcohol (n)
No	92	47	0.816
Yes	34	16
Coxalgia (n)
No	97	40	0.050
Yes	29	23

Regarding spinopelvic parameters (Table 2), the SOA group exhibited significantly greater sagittal imbalance, including higher PT (24.6° ± 10.7° vs 21.0° ± 8.9°), PI-LL mismatch (22.6° ± 21.7° vs 15.7° ± 15.4°), TLJ angle (15.6° ± 15.0° vs 10.2° ± 16.2°), and SVA (55.7 vs 36.8 mm) compared to the MOA group. In the coronal plane, while Cobb angles did not differ between groups, the SOA group demonstrated significantly greater AVT (7.1 mm vs 3.9 mm) and pelvic obliquity (1.8 vs 1.4°). No significant differences were observed in ΔHSA or ΔHKA between the groups. As shown in Figure 3, the location of the apical vertebra differed significantly (P = 0.015), concentrating in the thoracolumbar segment in the SOA group, whereas the apex was typically lower in the MOA group.

Table 2.

Spinopelvic Parameters Between Two Groups

Variable	Mild OA group(n = 126)	Severe OA group (n = 63)	P value
Cobb	19.5 (7.9)	20.2 (8.5)	0.585
CBD(mm)	23.3 (17.7)	22.6 (16.8)	0.792
AVT(mm)	3.9 (1.9,7.2)	7.1 (3.1,15.4)	<0.001*
Shoulder balance	2.1 (0.8,3.8)	1.7 (0.8,3.3)	0.727
T1tilt	4.0 (2.7)	4.3 (3.3)	0.513
Pelvic oblique	1.4 (0.8,2.4)	1.8 (1.0,3.2)	0.031*
L5tilt	5.1 (3.9)	5.7 (4.5)	0.304
PI	46.0 (10.6)	49.3 (12.1)	0.056
SS	25.0 (11.2)	24.7 (12.1)	0.851
PT	21.0 (8.9)	24.6 (10.7)	0.005*
LL	30.3 (16.9)	26.7 (23.0)	0.273
PI-LL	15.7 (15.4)	22.6 (21.7)	0.026*
TLJ	10.2 (16.2)	15.6 (15.0)	0.028*
TK	26.1 (14.2)	25.9 (17.8)	0.930
SVA	36.8 (5.2,81.1)	55.7 (20.2,108.0)	0.018*
ΔHSA	4.9 (3.6)	5.2 (4.7)	0.586
ΔHKA	2.0 (1.2,3.6)	2.4 (1.0,4.4)	0.304

CBD, coronal balance distance; AVT, apical vertebral translation, PI, pelvic incidence; SS, sacral slope; PT, pelvic tilt; LL, lumbar lordosis; TLJ, thoracolumbar junction; TK, thoracic kyphosis; SVA, sagittal vertical axis; HSA, head-shaft angle; HKA, hip-knee-ankle angle.

*P < 0.05.

Figure 3.

The distribution of apical vertebra between two groups

Correlation Analysis

According to the Wilcoxon signed-rank test for the total of participants, there was no significant difference in the hip OA grade between the convex and concave sides of scoliosis. As shown in Table 3, the worse-side OA grade was positively correlated with AVT (r = 0.259, P < 0.001) and PO (r = 0.197, P = 0.007), while no parameters demonstrated association with the mismatch of bilateral OA grade (ΔHip OA Grade). When stratified by scoliosis orientation, convex-side OA grade correlated with Cobb angle (r = 0.149, P = 0.04) and AVT (r = 0.154, P = 0.034), while concave-side OA correlated with PO (r = 0.200, P = 0.006) and AVT (r = 0.246, P <0 .001).

Table 3.

Spearman Correlation Analysis Between Spinopelvic Parameters and OA Grade

	Cobb	CBD	AVT	Shoulder balance	T1 tilt	Pelvic oblique	L5tilt	ΔHSA	ΔHKA
Worse-side hip OA grade	R = 0.071	R = 0.017	R = 0.259	R = −0.006	R = 0.096	R = 0.197	R = 0.117	R = 0.035	R = 0.123
Worse-side hip OA grade	P = 0.332	P = 0.813	P < 0.001*	P = 0.932	P = 0.190	P = 0.007*	P = 0.109	P = 0.631	P = 0.090
ΔHip OA grade	R = −0.040	R = −0.007	R = 0.141	R = −0.020	R = 0.102	R = 0.118	R = 0.116	R = 0.044	R = 0.039
ΔHip OA grade	P = 0.582	P = 0.925	P = 0.053	P = 0.782	P = 0.162	P = 0.107	P = 0.113	P =0.549	P = 0.595
Hip OA grade (convex side)	R =0.149	R = 0.053	R = 0.154	R = 0.034	R = 0.060	R = 0.117	R = 0.062	R = 0.076	R = 0.100
Hip OA grade (convex side)	P = 0.040^*	P = 0.469	P = 0.034*	P = 0.638	P = 0.411	P = 0.109	P = 0.399	P = 0.301	P = 0.172
Hip OA grade (concave side)	R = 0.043	R = −0.015	R = 0.246	R = −0.042	R = 0.063	R = 0.200	R = 0.102	R = −0.039	R = 0.138
Hip OA grade (concave side)	P = 0.557	P = 0.840	P < 0.001*	P = 0.569	P = 0.388	P = 0.006*	P = 0.161	P = 0.596	P = 0.058

CBD, coronal balance distance; AVT, apical vertebral translation, HSA, head-shaft angle; HKA, hip-knee-ankle angle. ^*P < 0.05.

Logistic Regression Analysis

In multivariate logistic regression analysis, AVT was identified as an independent risk factor for worse-side (Table 4, OR 1.062, CI: 1.024-1.102) and concave-side OA (Table 5, OR 1.077, CI: 1.021-1.135). Conversely, the Cobb angle was identified as a protective factor for convex-side OA (Table 6, OR 0.942, CI: 0.915-0.969). ROC analysis was conducted to determine AVT thresholds associated with unilateral hip osteoarthritis. The AUC was 0.664 with an optimal cutoff of 6.05 mm for worse-side OA and 0.701 with a cutoff of 6.95 mm for concave-side OA.

Table 4.

Multivariate Logistic Regression for Worse Side OA Grade Adjusted for Age and Gender

Variable	β value	Wald value	OR	OR (95%CI)	P value
Position of apical vertebrae	0.279	0.412	1.322	0.564-3.100	0.521
AVT	0.061	10.362	1.062	1.024-1.102	0.001*
Pelvic oblique	0.122	1.958	1.130	0.952-1.340	0.162

AVT, apical vertebral translation. ^*P < 0.05.

Table 5.

Multivariate Logistic Regression for Concave OA Grade Adjusted for Age and Gender

Variable	β value	Wald value	OR	OR (95%CI)	P value
AVT	0.079	7.552	1.077	1.021-1.135	0.006*
Pelvic oblique	0.011	0.008	1.011	0.796-1.283	0.930

AVT, apical vertebral translation. ^*P < 0.05.

Table 6.

Multivariate Logistic Regression for Convex OA Grade Adjusted for Age and Gender

Variable	β value	Wald value	OR	OR (95%CI)	P value
Cobb	−0.060	16.862	0.942	0.915-0.969	<0.001*
AVT	0.019	1.106	1.020	0.983-1.057	0.293
Pelvic oblique	0.063	0.539	1.065	0.901-1.258	0.463

AVT, apical vertebral translation. ^*P < 0.05.

Discussion

Our study analyzed the impact of spinal alignment on hip OA severity. The finding that patients with severe hip OA exhibited greater sagittal imbalance (higher PT, PI-LL mismatch, and SVA) confirms established concepts of Hip-Spine Syndrome and aligns with previous studies.^8,11 This interaction is often attributed to reduced hip extension mobility secondary to advanced OA, which limits the pelvis’s compensatory retroversion capacity.^8,10

While the association between sagittal alignment and lower extremity OA is well-documented, the influence of coronal deformity remains largely unexplored. Our study reveals that coronal imbalance parameters—specifically AVT and pelvic obliquity—are significantly associated with the severity and asymmetry of hip OA, independent of Cobb angle magnitude. Notably, patients with severe OA demonstrated greater AVT and pelvic obliquity despite similar Cobb angles to the mild OA group. Furthermore, side-specific analysis suggested distinct biomechanical environments: concave-side severity correlated with AVT and PO, while convex-side severity correlated with Cobb angle and AVT.

Interestingly, logistic regression identified the Cobb angle as a protective factor for convex-side OA. This apparent paradox, contrasting with the correlation analysis, may be attributed to the statistical handling of OA grade (binary in regression vs ordinal in correlation). However, AVT consistently emerged as a risk factor for both worse-side and concave-side OA, whereas upper cervical or thoracic parameters (CBD, T1 tilt) showed no association. This suggests that the pathological mechanical interaction is predominantly driven by the lumbosacral-pelvic complex rather than the upper thoracic segment.

Biomechanically, the lumbar spine, pelvis, and hip joints form a tightly coupled kinematic chain.¹² Deformities in the lower lumbar segments may transmit asymmetric loads and muscle forces to the acetabulum via the pelvis (Figure 4). This hypothesis is supported by electromyographic evidence showing that unilateral hip OA necessitates asymmetric erector spinae activation for trunk stabilization.¹³ Such paraspinal asymmetry is a known driver of scoliotic progression,¹⁴ suggesting a shared biomechanical pathway for both scoliotic progression and hip osteoarthritis involving asymmetric loading and compensatory muscle activation. Although lower limb mechanical axis alignment could theoretically influence hip loading in ADS, additional analysis demonstrated no significant association between side-specific HKA deviation and AVT or hip OA severity, nor significant convex–concave asymmetry (see Supplemental Material), suggesting that the observed AVT–OA relationship was unlikely to be mediated by lower limb alignment.

Figure 4.

Radiograph of two scoliosis patients with unilateral hip OA. Note that patients with concave side OA (a) had a greater AVT than patients with convex-side OA (b)

To the best of our knowledge, this is one of the few studies to isolate the impact of coronal plane deformity on hip OA, distinguishing it from the well-documented sagittal interactions.^8,10,15 Miyagi et al performed a correlation analysis between hip OA grade and spinal alignment in patients with coxalgia,¹⁶ though no significant correlation was found between the coronal spinal parameters and hip joint parameters. By focusing on ADS and incorporating AVT, pelvic obliquity, and side-specific analysis, our study provides a more global assessment of coronal imbalance, which revealed asymmetric loading patterns linked to hip OA.

These findings support an integrated hip–spine assessment in ADS by incorporating coronal translational parameters, particularly AVT, as radiographic markers of asymmetric hip osteoarthritis severity. Clinically, elevated AVT or persistent coronal malalignment may warrant more frequent hip surveillance in conservatively managed patients and more comprehensive assessment before surgical planning. In patients considered for THA or spinal fusion, recognition of concomitant coronal deformity may influence shared decision-making,¹⁷ as spinal deformities have been associated with inferior THA-reported outcomes and functional imbalance in prior studies.^18,19 While causality cannot be established in this cross-sectional analysis, our findings highlight the importance of coordinated hip–spine evaluation in treatment planning.

However, this study had several limitations. First, the retrospective, single-center design with a narrow inclusion window inherently limits causal inference, and may introduce selection bias and limit generalizability to broader ADS populations. Second, the radiographic analysis was based on static EOS images, which cannot capture dynamic compensatory patterns of the hip-spine syndrome. Third, since this was a cross-sectional study, the causal relationship between hip and spinal degeneration cannot be established or analyzed. Future prospective studies incorporating dynamic assessments (eg, gait analysis or 3D motion capture) are warranted to validate whether coronal imbalance predicts subsequent hip OA progression and to clarify temporal relationships within the hip–spine interaction.

Conclusion

Coronal imbalance in ADS, particularly increased AVT and pelvic obliquity, is an independent factor contributing to the severity and asymmetry of hip OA, regardless of Cobb angle magnitude. These findings support an integrated hip–spine assessment model to optimize alignment goals and rehabilitation strategies. Elevated AVT may warrant closer hip evaluation and monitoring for asymmetric osteoarthritis, even in patients managed conservatively.

Supplemental Material

Suppplemental Material - Apical Vertebral Translation as a Coronal Risk Factor for Side-Specific Hip Osteoarthritis in Adult Degenerative Scoliosis

Suppplemental Material for Apical Vertebral Translation as a Coronal Risk Factor for Side-Specific Hip Osteoarthritis in Adult Degenerative Scoliosis by Zhongning Xu, Xiaofeng Ma, Xin Chen, Shuquan Zhang, Bin Xiao, Yanbin Zhang in Global Spine Journal

Footnotes

ORCID iDs

Zhongning Xu

Yanbin Zhang

Ethical Considerations

The study received approval from our institution’s Ethics Committee (JL-K202101-17-04).

Consent to Participate

All participants included in this study have obtained informed consent and agreed to publication.

Author Contributions

Z.X. contributed to the conception and design of the study, analysis and interpretation of data, drafting of the manuscript, statistical analysis, and supervision. X.M. contributed to the data acquisition, drafting of the manuscript, and statistical analysis. X.C. participated in data acquisition and provided administrative, technical and material support, critical revision of the manuscript for important intellectual content. S.Z. contributed to analysis and interpretation of data, technical, or material support and revision of the manuscript. B.X. was involved in data acquisition, critical revision of the manuscript for important intellectual content, statistical analysis, and administrative, technical, or material support. Y.Z. contributed to the conception and design of the study, critical revision of the manuscript for important intellectual content, statistical analysis, and supervision. All authors have read and approved the final manuscript.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by the Beijing Hospitals Authority Clinical Medicine Development Special Funding (YGLX202511) and the Beijing Natural Science Foundation (L242164).

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The data presented in this article can be obtained by contacting the corresponding author via email.*

Supplemental Material

Supplemental material for this article is available online.

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