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After experimental and preclinical evaluation (HAP Paul Award 2001) 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 (APP) concept. A hybrid strategy for pelvic landmark acquisition has been introduced involving percutaneous pointer-based digitization with the noninvasive biplanar landmark reconstruction using multiple registered fluoroscopy images. From January 2001 to May 2002, 118 consecutive patients (mean age 68 years, 82 male, 36 female, and 62 left and 56 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 APP. This was done blinded with commercial planning software. There was no significant learning curve observed for the use of the system. Mean values for postoperative inclination read 43 degrees (SD 3.0, range 37-49) and anteversion 19 degrees (SD 3.9, range 10-28). The resulting system accuracy, i.e., 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).