After experimental and preclinical evaluation of a CT-free image guided surgical navigation system for acetabular cup placement, the system was introduced into clinical routine. The computation of the angular orientation of the cup is based on reference coordinates from the anterior pelvic plane concept. A hybrid strategy for pelvic landmark acquisition has been introduced, involving percutaneous pointer-based digitization with the noninvasive bi-planar landmark reconstruction using multiple registered fluoroscopy images. From January 2001 to October 2003, a total of 236 consecutive patients (mean age 66 years, 144 male, 92 female, 124 left and 112 right hip joints) were operated on with the hybrid CT-free navigation system. During each operation, the angular orientation of the inserted implant was recorded. To determine the placement accuracy of the acetabular components, the first 50 consecutive patients underwent a CT scan 7-10 days postoperatively to analyze the cup position relative to the anterior pelvic plane. This procedure was done blinded and with commercial planning software. There was no significant learning curve observed for the use of the system. Mean values for postoperative inclination read 42 degrees (SD 3.6, range (37-49)) and anteversion 21 degrees (SD 3.9, range (10-28)). The resulting system accuracy, ie, the difference between intraoperatively calculated cup orientation and postoperatively measured implant position shows a maximum error of 5 degrees for the inclination (mean 1.5 degrees, SD 1.1) and 6 degrees for the anteversion (mean 2.4 degrees, SD 1.3). An accuracy of better than 5 degrees inclination and 6 degrees anteversion was achieved under clinical conditions, which implies that there is no significant difference in performance from the established CT-based navigation methods. Image-guided CT-free cup navigation provides a reliable solution for future total hip arthroplasty (THA).