Editorial| Volume 34, ISSUE 1, P1-2, January 2019

Death of the Lewinnek “Safe Zone”

      Forty years ago, Lewinnek et al [
      • Lewinnek G.E.
      • Lewis J.L.
      • Tarr R.
      • Compere C.L.
      • Zimmerman J.R.
      Dislocations after total hip-replacement arthroplasties.
      ] published their work entitled “Dislocation after Total Hip-Replacement Arthroplasties”. The authors suggested “that there is a relatively safe range of orientations for the cup. A number of such ranges were investigated,” and the range of 40° ± 10° of lateral opening and 15° ± 10° of anteversion “proved most satisfactory.” In that article, the authors published a figure (Fig. 4) [
      • Lewinnek G.E.
      • Lewis J.L.
      • Tarr R.
      • Compere C.L.
      • Zimmerman J.R.
      Dislocations after total hip-replacement arthroplasties.
      ] of a scatter diagram of the orientation of the acetabular components studied with a superimposed square depicting the area, in which the “most satisfactory” cup position was depicted. Over the last 4 decades, this has been referred to as the “Lewinnek safe zone” for cup placement in total hip arthroplasty (THA). The article has been cited in close to 2000 publications in the English language [
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The Journal of Arthroplasty
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Lewinnek G.E.
        • Lewis J.L.
        • Tarr R.
        • Compere C.L.
        • Zimmerman J.R.
        Dislocations after total hip-replacement arthroplasties.
        J Bone Joint Surg Am. 1978; 60: 217-220
      1. (Website:)
        Date accessed: October 29, 2018
        • Callanan M.C.
        • Jarrett B.
        • Bragdon C.R.
        • Zurakowski D.
        • Rubash H.E.
        • Freiberg A.A.
        • et al.
        The John Charnley Award: risk factors for cup malpositioning: quality improvement through a joint registry at a tertiary hospital.
        Clin Orthop Relat Res. 2011; 469: 319-329
        • DelSole E.M.
        • Vigdorchik J.M.
        • Schwarzkopf R.
        • Errico T.J.
        • Buckland A.J.
        Total hip arthroplasty in the spinal deformity population: does degree of sagittal deformity affect rates of safe zone placement, instability, or revision?.
        J Arthroplasty. 2017; 32: 1910-1917
        • Sadhu A.
        • Nam D.
        • Coobs B.R.
        • Barrack T.N.
        • Nunley R.M.
        • Barrack R.L.
        Acetabular component position and the risk of dislocation following primary and revision total hip arthroplasty: a matched cohort analysis.
        J Arthroplasty. 2017; 32: 987-991
        • Kanawade V.
        • Dorr L.D.
        • Wan Z.
        Predictability of acetabular component angular change with postural shift from standing to sitting position.
        J Bone Joint Surg Am. 2014; 96: 978-986
        • Ike H.
        • Dorr L.D.
        • Trasolini N.
        • Stefl M.
        • McKnight B.
        • Heckmann N.
        Spine-pelvis-hip relationship in the functioning of a total hip replacement.
        J Bone Joint Surg Am. 2018; 100: 1606-1615
        • Widmer K.H.
        • Zurfluh B.
        Compliant positioning of total hip components for optimal range of motion.
        J Orthop Res. 2004; 22: 815-821
        • Elkins J.M.
        • Callaghan J.J.
        • Brown T.D.
        The 2014 Frank Stinchfield Award: the 'landing zone' for wear and stability in total hip arthroplasty is smaller than we thought: a computational analysis.
        Clin Orthop Relat Res. 2015; 473: 441-452
        • Jolles B.M.
        • Zangger P.
        • Leyvraz P.F.
        Factors predisposing to dislocation after primary total hip arthroplasty: a multivariate analysis.
        J Arthroplasty. 2002; 17: 282-288
        • Komeno M.
        • Hasegawa M.
        • Sudo A.
        • Uchida A.
        Computed tomographic evaluation of component position on dislocation after total hip arthroplasty.
        Orthopedics. 2006; 29: 1104-1108
        • Esposito C.I.
        • Gladnick B.P.
        • Lee Y.Y.
        • Lyman S.
        • Wright T.M.
        • Mayman D.J.
        • et al.
        Cup position alone does not predict risk of dislocation after hip arthroplasty.
        J Arthroplasty. 2015; 30: 109-113
        • Tezuka T.
        • Heckmann N.
        • Bodner R.
        • Dorr L.D.
        Functional safe zone is superioer to the Lewinnek safe zone for total hip arthroplasty: why the Lewinnek safe zone is not always predictive of stability.
        J Arthroplasty. 2019; 34: 3-8
        • Lazennec J.Y.
        • Brusson A.
        • Rousseau M.A.
        Lumbar-pelvic-femoral balance on sitting and standing lateral radiographs.
        Orthop Traumatol Surg Res. 2013; 99: S87-S103
        • Lazennec J.Y.
        • Charlot N.
        • Gorin M.
        • Roger B.
        • Arafati N.
        • Bissery A.
        • et al.
        Hip-spine relationship: a radio-anatomical study for optimization in acetabular cup positioning.
        Surg Radiol Anat. 2004; 26: 136-144
        • Stefl M.
        • Lundergan W.
        • Heckmann N.
        • McKnight B.
        • Ike H.
        • Murgai R.
        • et al.
        Spinopelvic mobility and acetabular component position for total hip arthroplasty.
        J Bone Joint Surg Br. 2017; 99-B: 37-45
        • DiGioia 3rd, A.M.
        • Jaramaz B.
        • Colgan B.D.
        Computer assisted orthopaedic surgery. Image guided and robotic assistive technologies.
        Clin Orthop Relat Res. 1998; : 8-16
        • Espisito C.I.
        • Miller T.T.
        • Kim H.J.
        • Barlow B.T.
        • Wright T.M.
        • Padgett D.E.
        • et al.
        Does degenerative lumbar spine disease influence femoral acetabular flexion in patients undergoing total hip arthroplasty.
        Clin Orthop Relat Res. 2016; 474: 1788-1797
        • Buckland A.J.
        • Puvanesarajah V.
        • Vigdorchik J.
        • Schwarzkopf R.
        • Jain A.
        • Klineberg E.O.
        • et al.
        Dislocation of a primary total hip arthroplasty is more common in patients with a lumbar spinal fusion.
        Bone Joint J. 2017; 99-B: 585-591
        • Bedard N.A.
        • Martin C.T.
        • Slaven S.E.
        • Pugely A.J.
        • Mendoza-Lattes S.A.
        • Callaghan J.J.
        Abnormally high dislocation rates of total hip arthroplasty after spinal deformity surgery.
        J Arthroplasty. 2016; 31: 2884-2885
        • Miki H.
        • Kyo T.
        • Kuroda Y.
        • Nakahara I.
        Sugano 367 N: Risk of edge-loading and prosthesis impingement due to posterior pelvic tilting after total hip arthroplasty.
        Clin Biomech. 2014; 29: 607-613
        • Heckmann N.
        • McKnight B.
        • Stefl M.
        • Trasolini N.
        • Ike H.
        • Dorr L.D.
        Late dislocation following total hip arthroplasty: spinopelvic imbalance as a causative factor.
        J Bone Joint Surg Am. 2018; 100: 1845-1853