CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Number 393, pp. 5265 2001 Lippincott Williams & Wilkins, Inc.

The Frank Stinchfield Award

Morphologic Features of the Acetabulum and Femur

Anteversion Angle and Implant Positioning
Masaaki Maruyama, MD; Judy R. Feinberg, PhD; William N. Capello, MD; and James A. DAntonio, MD

Morphologic features of the hips, in particular those features germane to determination of acetabular and femoral anteversion angles and femoral head offset, were studied in 50 male and 50 female human skeletons with bilateral normal joints. Four distinct congurations were identied relative to the anterior acetabular ridge. The majority (121, 60.5%) were curved; 51 (25.5%) were angular; 19 (9.5%) were irregular; and nine (4.5%) were straight. The acetabular anteversion angle measured 19.9 6.6 (range, 7 42 ) and was signicantly larger in females (21.3 7.1 ) versus males (18.5 5.8 ). The notch acetabular angle, which can be identied easily intraoperatively, was dened as the angle created at the intersection of a line from the sciatic notch along the posterior acetabular ridge and a line from the posterior to the anterior acetabular wall. This angle is almost perpendicular (89.0 3.5 ) and, therefore, may provide an acFrom the Department of Orthopaedic Surgery, Chushin Matsumoto National Hospital, Matsumoto, Nagano, Japan. This research was supported by Stryker Howmedica Osteonics, Rutherford, NJ. Reprint requests to Masaaki Maruyama, MD, Department of Orthopaedic Surgery, Chushin Matsumoto National Hospital, 811 Kotobuki Toyooka, Matsumoto, Nagano 399-0021, Japan.

curate estimate of acetabular anteversion during cup placement. Awareness of the anatomic differences between genders for acetabular anteversion angle, anterolateral bowing of the femur, and neck shaft angle may help reduce the relatively higher incidence of dislocation in females and may lead to different implant designs for male and female patients.

It is important to know the normal acetabular and femoral anteversion for proper implant positioning and to prevent dislocation in total hip arthroplasty.2,10 Adequate anteversion provides for a satisfactory functional range of motion. The acetabulum is not a simple hemispheric shape. As a result, the acetabular anteversion angle would seem to be inuenced by the point of measurement along a possibly curved or angular conguration. Neither standard radiographs nor two-dimensional computed tomography (CT) scans allow for accurate determination of anatomic conguration3 and, therefore, assuming acetabular wall conguration has some inuence, accurate measurement of the anatomic anteversion angle cannot be determined. Three-dimensional CT scanning has potential for detection of varia-

52

Number 393 December, 2001

Acetabular and Femoral Structure

53

tions in conguration,1 although this technology currently is not used routinely nor is it cost-effective for routine use as a preoperative assessment tool to aid in intraoperative determination of anteversion. Despite the potential importance of acetabular ridge features, there have been no reports on how differences in anatomic structure inuence measurement of acetabular anteversion. A similar problem exists for accurate measurement of the medial offset of the femoral head. Offset measurement is affected by femoral anteversion and bowing, neither of which can be appreciated adequately on twodimensional radiographs. Accurate assessment is complicated by the fact that most patients with advanced osteoarthritis of the hip cannot internally rotate their hip on radiographs obtained preoperatively and therefore, the offset is inuenced by the inability to attain the necessary derotation of the femur. Several studies of proximal femoral anatomy have regarded the femoral shaft as straight in the standard anteroposterior (AP) view.8,21,23 It is well known that the femoral shaft has some anterior bowing and clinically other congurations have been seen. The overall incidence of dislocation after primary total hip arthroplasty averages between 2% and 3%.18 Several risk factors have been identied. There is a denite predilection in female patients with some studies reporting rates double that of male patients.10,12,19,27 Component positioning has been linked directly to incidence of dislocation. Fackler and Poss6 reported a signicant increase in postoperative dislocations when femoral offset was decreased by inserting the femoral component with a valgus neck shaft angle. Cup orientation is particularly critical. Lewinnek et al13 described a safe zone of acetabular component orientation as a lateral opening of 40 10 with anteversion of 15 10 to decrease the likelihood of dislocation after total hip arthroplasty. Surgical approach also can affect proper positioning of the acetabular component. For example, it has been shown that the surgeon tends to place the cup in 5 to 7 less anteversion with a posterior ap-

proach.17 Positioning the patient in the lateral decubitus position during total hip arthroplasty can allow the pelvis to rotate forward and result in placement of the cup in a retroverted position.18 Yet, despite all of these reports as to the importance of controlling the amount of anteversion, there have been no reports of how to measure anteversion in an accurate and consistent manner. External alignment guides have been shown to be helpful in reproducing abduction but inaccurate regarding anteversion of the acetabular component.7 Recently a computer-assisted and image-guided system (HipNav, Center for Orthopaedic Research, Pittsburgh, PA) was developed and is being tested clinically for precise planning and placement of the acetabular component in total hip replacement surgery.9 The aims of the current study were to: (1) evaluate in detail the morphologic features of the pelvis and femur particularly for conguration of the acetabular anterior and posterior columns and the medial offset of the femoral head relative to the conguration of the femoral shaft; (2) evaluate any differences attributable to gender; and (3) determine whether there is any practical way to accurately assess acetabular anteversion intraoperatively either directly or indirectly. MATERIALS AND METHODS Specimens
This study was done in collaboration with the Department of Physical Anthropology at the Cleveland Museum of Natural History. The department houses the Hamann-Todd Osteological Collection, which was amassed between 1912 and 1938 by Drs. C.A. Hamann and T.W. Todd of the Western Reserve University, Department of Anatomy, and it contains 3100 skeletons of the unclaimed dead of the Cleveland area.16 Only normal pelves and femurs were included for this study. Specimens with osteoarthritis of the hip, evidence of previous trauma to the pelvis or femur, or skeletal disorders such as multiple epiphyseal dysplasia or osteogenesis imperfecta were excluded. Because gender differences were considered a primary aim of the study, the sample group consisted of 50 female and

54

Maruyama et al

Clinical Orthopaedics and Related Research

50 male skeletons with age and race distribution selected to be similar to the population having total hip arthroplasty in the United States. Specimens were selected randomly based on the following conditions: ve were younger than 40 years, ve were between 40 and 49 years, 15 were between 50 and 59 years, 15 were between 60 and 69 years, and 10 were 70 years or older. Twenty percent of the skeletons in each age group were from African-Americans. The average age was 57.9 12.2 years (range, 2882 years) for males and 57.5 13.5 years (range, 1882 years) for females. Two hundred normal femur and pelvis combinations (100 male, 100 female) were studied. All measurements were done by one author (MM). The individual bones (iliums, sacrums, and femurs) were stored in separate areas in the museum, and therefore required reconstruction for this study. The pelves were reconstructed using a thin clay (0.5 to 1.5 cm, proportional to the size of the pelvis)25 and rubber bands. An anatomic frontal plane of the pelvis was dened by the anterosuperior iliac spines and by the pubic symphysis. This plane is nearly vertical during upright sitting, standing, and walking.1,15 In this study, the pelvis was laid on a at glass table (craniograph) in a prone position so that the anterosuperior iliac spines and the pubic symphysis were in contact with the glass. The glass table was regarded as the anatomic frontal plane. The femur was placed on an osteometric board in the supine position so that the posterior aspects of the medial and lateral femoral condyles and the base of the femoral neck were in direct contact with the board.

and a line from the posterior to the anterior acetabular ridge. Because the line from the sciatic notch along the posterior acetabular ridge had an inclination, the notch acetabular plane is not horizontal. Pelvic dimensions were measured as the following: height (HP), AP width (APW), mediolateral width (MLW), and distance between the right and left acetabular oors (DAF). The ratio (percent) of distances between the acetabular oors and AP width (DAF/MLW) was calculated for each pelvis.

Femoral Measurements
Femoral anteversion was dened based on the previous works of Billing5 and Murphy et al.20 The long axis of the femur (FLA) is the line dened by two points: the center of the knee (the centroid of the distal femoral metaphysis on a cross section through the femoral condyles) (K), and the center of the base of the femoral neck (the centroid of the femoral diaphysis on a cross section through the base of the femoral neck) (O) (Fig 1). The axis of the femoral neck (FNA) is the line dened by two points: the center of the femoral head (C), and the center of the base of the femoral neck (O). This axis bisects and passes through the midline between the anterior and posterior borders of the femoral neck (Fig 1). In this study, neutral rotation of the femur was dened by the posterior condylar line. Direct bone measurement was done using a craniometer on the osteometric board for determination of the anteversion angle from the proximal ( ) and distal ( o) views. In addition to the anteversion angle, the following dimensions were measured directly from the femurs: femoral neck-shaft angle ( ) (Fig 1), AP diameter of the femoral head (HAP), craniocaudal diameter of the femoral head (HCC), AP diameter of the femoral neck (NAP), and the craniocaudal diameter of the femoral neck (NCC). The reconstructed pelvis was combined with the femurs to recreate the hips so static radiographs could be obtained of all specimens. First, the right and left femurs were placed in neutral rotation and an AP radiograph was taken. Then both femurs were put in a position such that each femur was derotated (commonly internally rotated) around its long axis by the angle of anteversion from the distal view. Anteroposterior and lateral radiographs were taken in this derotated position. The tube was set on the pubic symphysis with a tube-to-lm distance of 47.5 inches. Radiographic magnication

Acetabular Measurements
The acetabular anteversion angle was measured at the center of the acetabulum in a vertical plane to the glass table (horizontal plane) along the anterior to posterior ridges.14 For acetabula that were not straight, the long axis of the anterior wall was converted to a straight line, and the midpoint then was established along that line. The inward wing of the ilium was evaluated by measuring the angle created at the intersection of a line from the posterior to the anterior iliac spines and the glass table on a horizontal plane. The superior to inferior inclination of the acetabulum was measured in a parallel plane to the glass table. The notch acetabular angle was dened as the angle created at the intersection of a at line from the sciatic notch along the posterior acetabular ridge

Number 393 December, 2001

Acetabular and Femoral Structure

55

Fig 1. Placement of the femur on an osteometric board (OB) with the condylar plane (CP) parallel is shown. Points of orientation include the center of the femoral head (C), the center of the base of the femoral neck (O), the center of the knee (K), and the posterior aspects of the medial (M) and lateral (L) femoral condyles. The anteversion plane (AVP) is shown as are the long (FLA) and femoral neck (FNA) axes of the femur. (FPA: axis of the proximal femur; FCA: axis of the femoral condyles.) Pertinent measurements in this position include the femoral neck shaft angle ( ) and the femoral anteversion angle from distal view ( 0).

femur and then divided into tenths. The axis of the proximal femur (FPA) was set as a line connecting the midpoints of the mediolateral width of the femur at a distance of 210 and 310 from the top of the greater trochanter. Anterior bowing angle ( ), based on the lateral radiograph of the hip in the derotated position, was measured as the angle between the following two axes: a femoral axis at the proximal 210 and 310 lengths and a femoral axis at the 610 and 810 lengths (Fig 2A). Lateral bowing angle of the femur ( ) was determined by direct bone measurement from the distal-to-proximal view (Fig 2B). The lateral bowing angle from the anterior-to-posterior view in neutral rotation ( 0) was dened as an angle between the axis of the proximal femur (FPA) at the 2 10 and 310 positions and a line connecting the intersection of the neck and proximal femur axes and the center of the femoral condyles (Fig 2C). In the same manner, the lateral bowing angle from anterior to posterior in derotation ( 1) was dened as the lateral bowing of the femur in the derotated position. Based on the AP radiograph of the bilateral hips with a neutrally rotated femur, the angle ( 0) was dened as the angle between the femoral axis at 210 and 310 points with the axis at 410 and 510 points. Therefore, a positive number indicated varus and a negative number indicated valgus. The same angle with the femur derotated is denoted by 1. This varus or valgus angle essentially is the degree of discrepancy between the previously described denition of the long axis of the femur and the long axis as determined considering the effect of bowing in the AP plane.

Statistical Analysis
Statistical analyses for comparison of morphologic features between males and females were done using unpaired t tests or chi square analysis. Comparisons from right to left femur were done using paired t tests. Correlations between variables were calculated using the Pearson product moment coefcient of correlation (r). The signicance level was set at 0.05. The statistical package used was Microsoft Excel and its statistical software (Microsoft Corporation, Redmond, WA).

was corrected by comparing the actual with the radiographic diameter of the femoral head. The following dimensions were measured from the radiographs: the distance between the right and left femoral head centers (HC), the femoral neck-shaft angle based on the AP radiograph in neutral ( 0) and derotated ( 1) positions, and the medial offset of the femoral head based on the AP radiograph in the neutral ( j0) and derotated ( j1) positions. For consistency of measurement, the total length of the femur from the top of the greater trochanter to the base of the condyles (GT) was measured for each

RESULTS Morphologic Features of the Pelvis Four distinct congurations of the anterior acetabular ridge were identied and denoted as curved, straight, angular, or irregular (Fig 3).

56

Maruyama et al

Clinical Orthopaedics and Related Research

Fig 2AC. The anterior bowing angle of the femur ( ) as would be seen on a lateral radiograph is shown. Lateral bowing angle of the femur ( ) from the distal-to-proximal view along the plane of the femoral long axis (LB) and relative to the plane of the femur on the osteometric board (OB) is shown. Lateral bowing angle of the femur ( ) from the anterior-to-posterior view is shown. The axes of the proximal femur (FPA) and the femoral neck (FNA) are shown for orientation.

Most of the pelves (121; 60.5%) had a curved conguration, 51 (25.5%) were angular, 19 (9.5%) were irregular, and nine (4.5%) were straight. Of the 100 pelves examined, 51 had the same conguration of both anterior acetabular ridges and 49 had differing congurations from one side to the other. There were no differences between genders regarding either breakdown of congurations seen (57 males and 64 females had curved congurations; p .087) or side-toside similarities or differences (29 male and 22 female pelves had the same conguration bilaterally; p .161). All posterior columns were a simple hemicircle or straight classication. The anteversion angle of the acetabulum was measured as 19.9 6.6 (range, 7 42 ). The corrected acetabular angle for the acetabula that were not straight was approximately 6.2 smaller than the uncorrected acetabular angle on

average. The acetabular anteversion angle was signicantly greater in females than males (21.3 versus 18.5 ; p .002). The inward wing and inclination angles also were signicantly greater in females than in males (60.5 versus 58.7 ; p .005; 38.9 versus 37.8 ; p .038, respectively). The notch acetabular angle was almost perpendicular, measuring 89.0 3.5 (range, 77 100 ). As with the other angles measured, the average notch acetabular angle from females was greater than the average notch acetabular angle from males (89.6 versus 88.4 ; p .014). There were no signicant differences between right and left sides for males or females for any of the measured pelvic angles. There were no signicant differences found in the anteversion angle and the notch acetabular angle between younger ( 60 years) and older ( 60 years) group within each gender.

Number 393 December, 2001

Acetabular and Femoral Structure

57

Fig 3AD. The four anterior acetabular ridge congurations are shown. (A) The straight type was seen in 4.5%, (B) the curved type was seen in 60.5%, (C) the angular type was seen in 25.5%, (D) and the irregular type was seen in 9.5% of the acetabula.

Measurements for the pelvis are shown in Table 1. The distance between the acetabular oors (DAF) was signicantly larger in females than males, although the height (HP), AP width (APW), and mediolateral width (MLW) were
TABLE 1. Pelvic Size Measurements
Total Group
21.0 13.4 26.9 11.5 1.4 (18.224.8) 1.0 (11.016.0) 1.8 (23.031.2) 0.9 (9.614.7) 22.0 13.6 27.3 11.1

signicantly smaller in females than in males. The resultant DAF/MLW ratio was greater in females than in males (44.6% versus 40.8%; p .001). The DAF/MLW ratio correlated signicantly with the acetabular anteversion angle

Measurement (cm)
Height of pelvis Anteroposterior width of pelvis Mediolateral width of pelvis Distance between right and left acetabular oors DAF/MLW (%)

Males
1.1 (18.324.8) 1.0 (11.016.0) 1.8 (23.431.2) 0.7 (9.612.7) 20.0 13.1 26.6 11.8

Females
1.0 (18.222.5) 0.9 (11.315.2) 1.7 (23.031.0) 0.9 (10.214.7)

p Value
1 10 29 0.0002 0.0058 2 10
9

42.7

3.4 (33.355.5)

40.8

2.3 (33.345.3)

44.6

3.3 (36.455.5)

10

17

Average standard deviation (range); DAF/MLW mediolateral width of the pelvis.

Ratio between the distance between the right and left acetabular oors and

58

Maruyama et al

Clinical Orthopaedics and Related Research

(r .448, p 3 10 6 in males; r .317, p .0013 in females) and with the inward wing angle of the ilium (r .311, p .0016 in males; r .399, p .00004 in females). This ratio correlated with the inclination angle in females (r .356; p .0003) but not in males (r .0962; p .3461). The ratio and the notch acetabular angle were inversely correlated in females (r .268; p .0071) but not in males (r .116; p .2489). Morphologic Features of the Femur Each of the femoral angles and dimensions measured are summarized in Tables 2 and 3 for the total group and for comparative differences between males and females. Three distinct congurations of the femoral shaft were identied in the AP view (Fig 4). Of the 200 femurs, in a neutral rotation, 162 (81%) had lateral bowing. The average angle of lateral bowing ( ) on direct bone measurement was 12.9 9.6 , with the angle averaging 5.6 larger in males than in females (p .001). Thirty-two (16%) had a double or S curve, and six (3%) had medial bowing. All double or S curves had lateral bowTABLE 2.

ing proximally and medial bowing distally. With the femur in the derotated position, 124 (62%) were classied as having lateral bowing, 32 (16%) with a double curve, and 44 (22%) with medial bowing. By rotating the femur from neutral to the derotated position, the direction of bowing in 38 (19%) femurs appeared to change from lateral to medial. In the neutral and derotated positions, femoral shaft conguration differed between males and females with the females having a greater occurrence of medial bowing (six versus 0 in neutral rotation and 29 versus 15 in derotation; p .05). All but six of the 100 specimens had the same conguration bilaterally in the neutral position, and all but 15 had the same femoral conguration in derotation. If the lateral bowing angle from anterior to posterior ( ) measured 2 or less and the femur had minimal lateral bowing, more females than males had straight femurs (38 versus 16, respectively; p .001). The anterior bowing angle of the femur ) averaged 9.7 2.3 , with males averaging approximately 1.3 more anterior bowing than females as measured on the lateral radiograph (p .001).

Angular Measurement of the Femur

Total Group
9.8 11.6 8.5 ( 15 to 9.1 ( 30 to 34) 9.8

Angle (degrees)
Anteversion (proximal view) ( ) Anteversion (distal view) ( 0) Neck-shaft ( ) Neck-shaftNR* ( 0) Neck-shaftIR* ( 1) Anterior bowing* ( ) Lateral bowing ( ) distal to proximal Lateral bowing ( 0)NR anterior to posterior Lateral bowing ( 1)IR anterior to posterior Varus-valgusNR* ( 0) (varus ) Varus-valgusIR* ( 1) (varus )
NR neutral rotation; IR

Males
9.0 ( 15 to 30) 9.8

Females
8.0 ( 12 to 7.8 ( 5 to

p Value
34) 0.954 34) 0.399 0.395 0.014 0.0158 5.7 10 3.3 10 1.5 10

34) 11.1

10.3 ( 30 to

34) 12.2

125.0 4.8 (106137) 124.2 6.0 (107141) 122.8 5.7 (106140) 9.7 2.3 (417) 12.9 9.6 ( 20 to 37) 3.5 2.3 ( 1 to 13)

124.7 5.3 (106135) 123.2 6.3 (107134) 121.8 6.1 (106134) 10.3 2.0 (616) 15.7 8.7 (037) 4.2 2.3 (012)

125.3 4.2 (115137) 125.3 5.4 (112141) 123.8 5.2 (111140) 9.0 2.4 (417) 10.1 9.7 ( 20 to 35) 2.8 2.1 ( 1 to 13)

5 5

1.5

2.6 ( 5 to

11)

2.2

2.6 ( 2 to

11)

0.8

2.4 ( 5 to

8)

0.0001

1.7 0.8

1.8 ( 4 to 1.7 ( 4 to

9) 5)

1.6 0.7

2.0 ( 4 to 1.8 ( 4 to

6) 5)

1.7 0.9

1.6 ( 2 to 1.7 ( 4 to

9) 5)

0.736 0.570

internal rotation (derotated position); *

measured from radiographs; Average

standard deviation (range).

Number 393 December, 2001

Acetabular and Femoral Structure

59

TABLE 3.

Femoral Size Measurements

Total Group Males Females p Value
0.646

Measurements

Distance between 18.7 1.3 (15.223.0) 18.7 1.1 (16.221.3) 18.8 1.4 (15.223.0) right and left centers of femoral heads (cm) (Hc) Fem head 44.9 3.9 (36.955.0) 47.9 2.7 (42.555.0) 42.0 2.4 (36.947.9) diameterAP plane (mm) (HAP) Fem head 45.3 3.9 (37.455.5) 48.3 2.8 (42.555.5) 42.4 2.4 (37.449.0) diameterCC plane (mm) (HCC) Fem neck 24.6 2.4 (19.631.3) 26.0 1.9 (20.931.3) 23.1 2.0 (19.628.6) diameterAP plane (mm) (NAP) Fem neck 32.1 3.3 (25.040.5) 34.4 2.4 (29.540.5) 29.8 2.5 (25.037.8) diameterCC plane (mm) (NCC) Femur length to 41.3 2.9 (33.149.7) 43.0 2.5 (36.749.7) 39.5 2.3 (33.144.9) top of gr troch (cm) (GT) Femur length to 43.2 3.0 (34.251.5) 44.9 2.6 (38.551.5) 41.4 2.4 (34.246.4) top of fem head (cm) (H) Deviation from 2.4 1.5 ( 0.7 to 7.7) 2.0 1.5 ( 0.6 to 7.7) 2.9 1.3 ( 0.7 to 6.4) mechanical axis to H (cm) (D) Medial offset of 44.6 6.7 (28.564.5) 47.2 6.4 (30.064.5) 41.9 5.9 (28.561.5) fem headNR (mm) (j0) Medial offset of 47.2 6.1 (32.065.0) 50.1 5.3 (36.065.0) 44.3 5.4 (32.063.0) fem headIR (mm) (j1)

1.1

10

38

2.5

10

37

2.4

10

21

6.9

10

29

4.7

10

20

1.2

10

19

8.3

10

6.2

10

8.0

10

13

Fem femoral; AP anteroposterior; CC craniocaudal; Gr Troch greater trochanter; Mechanical axis distance from the midpoint between the femoral condyles to center of femoral head; NR neutral rotation; IR internal rotation (derotated); Average standard deviation (range).

The anteversion angle ( ) of the femoral neck was 9.8 8.5 (range, 15 34 ) from the proximal view and 11.6 9.1 from the distal view with no difference between males and females. There was no signicant correlation between either the anterior or the lateral bowing angles and the anteversion angle. The femoral neck shaft angle ( ) averaged 125 4.8 on direct bone measurement. Compared with direct bone measurement, the femoral neck shaft angle averaged 122.8 5.7 in internal rotation (p .001) and 124.2 6.0 in neutral rotation (p .01) on radiographic assessment. Females had a more val-

gus femoral neck-shaft angle on radiographic assessment than males in neutral and internal rotation. (p .05). The medial offset of the femoral head ( j) was signicantly larger when measured in internal rotation versus neutral rotation (47.2 6.1 mm versus 44.6 6.7 mm, respectively; p .0001). The medial offset on the radiograph was inuenced greatly by the anterolateral bowing of the femoral shaft and anteversion of the femoral neck. On radiographic measurement, there was no difference in the distance between the right and left femoral head centers in males and females;

60

Maruyama et al

Clinical Orthopaedics and Related Research

Fig 4AC. The three femoral shaft congurations as seen in neutral rotation in the AP plane are shown. (A) Lateral bowing was most common, occurring in 81% of the femurs. (B) Sixteen percent of the femurs had a double curve with a lateral bowing proximal and medial bowing distal, and (C) medial bowing was seen in 3% of femurs.

however, the diameters of the femoral head and femoral neck in females were signicantly smaller than those of the males in the AP and craniocaudal planes (p .0001). The neck-tohead ratios (NAP/HAP, NCC/HCC) were calculated as 54.7% 3.0% in the AP plane and 70.8% 3.4% in the craniocaudal plane, and these ratios did not differ between males and females. The overall length of the femurs on direct bone measurement revealed an average 3.5 cm difference in males greater than females (p .0001). The distance (D) from the midpoint between the femoral condyles distally and the midpoint of the femoral head proximally was greater in females than males (2.9 cm versus 2 cm; p .001) because the long axis of the femur is more valgus in females. Because gender differences commonly were observed, it was decided to examine whether age was a signicant factor within each gender

group. Each gender group was subdivided into two age groups ( 60 or 60 years) of 50 femurs (25 bilateral specimens). The average age of the young male group was 48.2 8.3 years (range, 2858 years). The average age of the older male group was 67.6 6.2 years (range, 6082 years). The average age of the young female group was 47.4 10.9 years (range, 1859 years) and 67.6 6.3 (range, 6082 years) in the older female group. There were no differences found in any parameters between younger and older males. In females, the deviation angle as a component of lateral bowing increased signicantly from 6.9 10.9 in young females to 13.4 7.1 in older females (p .001) (Table 4). The varus angle ( ) also increased with age, whereas the neck shaft angle, on direct bone measurement and radiographic measurement, decreased with age in females (p .05).

Number 393 December, 2001

Acetabular and Femoral Structure

61

TABLE 4. Younger ( Gender Groups

Dimensional Parameter
Anteversion angle ( 0) Neck shaft angle ( ) Neck shaft angle ( 0) Neck shaft angle ( 1) Medial offset (j0) (mm) Medial offset (j1) (mm) Anterior bowing angle ( ) Lateral bowing angle ( ) Lateral bowing angle ( 0) Lateral bowing angle ( 1)
*p 0.05; **p 0.01; ***p

60 years) Versus Older (60

Younger Males
11.6 125.6 123.8 122.4 46.2 49.3 10.3 14.5 4.0 1.8 9.9 4.4 5.7 5.1 5.7 4.6 2.1 9.4 2.2 2.5

years) Age Comparisons in

Younger Females
13.5 126.1 126.7 124.8 40.7 43.9 8.9 6.9 2.3 0.1 8.6 4.2 5.6 5.6 6.1 5.5 2.4 10.9 2.5 2.7

Older Males
10.5 123.8 122.7 121.3 48.2 50.8 10.3 16.9 4.5 2.6 10.7 6.0 6.9 6.9 6.9 5.9 1.9 7.9 2.2 2.7

Older Females
10.8 124.4 123.9 122.7 43.2 44.7 9.2 13.4 3.3 1.5 8.6 4.2* 4.9** 4.5* 5.4* 5.3 2.3 7.1*** 1.6* 1.7**

0.001; (all others not statistically signicant).

DISCUSSION The current authors identied anatomic features of the acetabulum and femur not previously described, which may be relevant in the design and implantation of hip implants. The variations in conguration of the anterior acetabular wall and in bowing of the femur provide new information that affects the accuracy of the current methods of measurement of acetabular and femoral anteversion. The posterior acetabular ridge almost always forms a simple semicircle. However, the anterior ridge either is curved, angular, straight, or irregularly congured. Because of these variations, the amount of anteversion is affected by the point of measurement along the anterior ridge. In the anatomic model, the anteversion angle varied by an average of 6.2 when nonstraight anterior ridges were converted to a straight conguration, therefore, the anteversion angle is dependent on the point of measurement along the ridge. This nding is important because the conguration of the anterior acetabular ridge is not discernible on a standard twodimensional radiograph nor is it possible to discern intraoperatively through palpation because of soft tissue, the presence of osteophytes, or both. Because greater than 95% of the 200 acetabula in this study had nonstraight anterior ridges, had they undergone total hip arthroplasty, the amount of acetabular ante-

version easily could have been underestimated in these cases depending on the point of determination along the acetabular walls intraoperatively. The presence of osteophytes, in particular those along the anterior acetabular ridge, could result in an overestimation of the notch acetabular angle. Medial offset of the femoral head is measured based on the assumption that the long axis of the femur is straight. Because standard radiographs of the hip usually only include the proximal femur, measurements that are taken have only the proximal femur available to determine the long axis. Noble et al22 dened the medullary axis using the proximal femur as a line passing through the midpoints of the medullary canal at 20 mm proximal and distal to the canal isthmus. However, because other authors4,24 described changes in the medullary canal with aging and osteoporosis, the extracortical borders were used to dene the femoral axes in this study. The amount of offset was inuenced by rotation of the femur seen on the radiograph because of femoral anteversion with the value of the offset in derotation signicantly larger than in neutral rotation. Derotation of the femur was useful in negating the effect of the femoral anteversion; however, it often is not possible to position the patient with end-stage hip arthritis who has yet to have surgery in a derotated position. Therefore, the amount of offset may be underesti-

62

Maruyama et al

Clinical Orthopaedics and Related Research

mated on the standard radiograph, obtained preoperatively. Medial offset also was found to be inuenced by not only the anteversion of the femoral neck but also by the anterolateral bowing of the femoral shaft. The long axis of the proximal femur was altered depending on rotation attributable to the bowing. It is known that the femur has an anterior bowing of the shaft. The current authors, however, described an average lateral bowing of approximately 13 with 81% of femurs having lateral bowing. The effect of lateral bowing on the apparent long axis of the femur was a change toward varus of 3.5 in neutral rotation and 1.5 in the derotated position. In the current study, the lateral bowing angle was measured based on neutral rotation as determined from the posterior condylar line. However, if neutral rotation were to be determined from the transepicondylar line, then the lateral bowing angle possibly could appear decreased. Clinically, the effect of lateral bowing would mean that an implant placed in apparent neutral alignment, as determined by viewing the radiograph of the proximal femur, actually would be in slight varus regarding the true long axis of the femur in the majority of cases (Fig 5). It is not known whether this slight varus positioning could affect the longevity of the implant adversely although varus orientation of the stem led to increased failure with the Charnley low friction arthroplasty.11 Numerous differences were found between morphologic features of male and female pelves and femurs. The overall height and width of the pelvis and the overall femoral length were larger in males, yet the distances between the right and left acetabular oors and those between the femoral head centers were larger in females. The acetabular anteversion angle was greater in females, which is similar to the reported ndings of others.14,15 No gender differences were found relative to amount of femoral anteversion, and no correlation was found between acetabular and femoral anteversion angles, which is in agreement with previous reports.3,26 Males had a signicantly greater

Fig 5AB. (A) A standard AP radiograph as used in preoperative planning for total hip arthroplasty is shown. (B) The postoperative radiograph of the same femur shows the femoral component placed in a slightly varus postion.

medial offset of the femoral head and greater anterior and lateral bowing of the femoral shaft. In neutral rotation, medial bowing of the femur was seen in six females and no males. There were no signicant differences between younger and older males for femoral dimen-

Number 393 December, 2001

Acetabular and Femoral Structure

63

sions. However, older females had signicantly increased lateral bowing in the proximodistal and AP views and a decreased neck shaft angle than the younger female group. Noble et al22 found similar differences between younger and older females relative to changes in the femur. Proper component positioning in total hip arthroplasty relative to the amount of acetabular and femoral anteversion is important in preventing postoperative dislocation. Although this orientation is critically important, it is extremely difcult to assess intraoperatively. Even with proper acetabular component positioning, excessive anteversion or retroversion of the femoral component can lead to component dislocation.6 Furthermore, the most common error in femoral malpositioning is excessive anteversion.6 The most important factor in minimizing the rate of dislocation under the surgeons control is positioning of the components in total hip arthroplasty.17 The results of this anatomic study may explain why component positioning relative to anteversion is so difcult. On the acetabular side, the anteversion angle is inuenced greatly by the point of measurement and conguration of the anterior acetabular ridge. The anteversion angle, when measured with the above considerations, differed signicantly between males and females. On the femoral side, the complexity of the bowing of the femoral shaft could inuence femoral component positioning relative to anteversion and medial offset. The anterior and lateral bowing angles differed signicantly between males and females, and these angles differed depending on the rotation of the hip. Although there was no difference between males and females regarding the varus-valgus angle of the femur, there was a signicant increase in the lateral bowing angle in older females compared with younger females. The notch acetabular angle (the angle created at the intersection of the line from the sciatic notch to the posterior acetabular ridge and the line from the posterior to anterior acetabular ridge) was measured in this study using a special tool that was placed between the sci-

atic notch and the posterior acetabular ridge. This notch acetabular angle has been used by two authors (JAD, WNC) to estimate the amount of acetabular anteversion necessary for accurate cup placement. With the patient in the lateral decubitus position and the surgeon

Fig 6. The pelvis is viewed from cranial to caudal. Lines 1 and 2 are parallel to the long axis of the tool that was used to measure the notch acetabular angle on the anatomic specimen. In the anatomic model, the tool was hooked onto the sciatic notch along the posterior acetabular ridge. Line 1 passes along the posterior acetabular ridge and the top of the sciatic notch and is shown for orientation purposes. Line 2 is a translation of that line to the center of the acetabulum. Line 3 lies across the anterior and posterior walls of the acetabulum. The broken Line 4 depicts an increased anteversion angle from the anatomic anteversion. Line 4 angles toward the top of the sciatic notch. Therefore, placing a cup parallel to Line 2 would result in placement in anatomic anteversion and placing a cup parallel to Line 4 would result in approximately 10 to 15 more anteversion than anatomic anteversion.

64

Maruyama et al

Clinical Orthopaedics and Related Research

on the anterior or abdominal side of the patient, the surgeon palpates using the index nger along a line from the posterior wall of the acetabulum to the greater sciatic notch. A rod is placed parallel to the index and a mark is made on the posterosuperior aspect of the acetabulum using electrocauterization. This angle, as determined in this study by direct bone measurement, averages 89 with a small standard deviation. Therefore, because that line essentially is perpendicular to the plane of the face of the acetabulum, reaming for a hemispherical cup parallel to that line would result in placement of the cup in anatomic anteversion for that patient. However, if the surgeon wishes to place the acetabular component in increased anteversion, particularly when using a posterior approach, the direction of the reaming and insertion of the cup will be divergent from that line and will angle toward the top of the sciatic notch instead of the center of the ilial wing. A schematic drawing of how the desired anteversion angle is determined intraoperatively is shown in Figure 6. The fact that the notch acetabular angle was measured as nearly perpendicular in the 200 pelves in this study suggests that this angle is an accurate estimation of acetabular anteversion and that the use of this technique intraoperatively may aid the surgeon in determining more accurate placement of the acetabular component. Because an improperly angled cup is a recognized cause of dislocation, the incidence of dislocation after primary total hip arthroplasty may be reduced with use of this technique. This study of 200 pelves and femurs identies morphologic details not previously described. In particular, four distinct congurations of the anterior acetabular ridge were identied and the inuence of these congurations on the accuracy of anteversion angle measurement was shown. Similarly, bowing of the femur was found to be more complex than previously thought. In addition to an anterior bow, femurs were found to have a lateral bow, and in some cases and depending on rotation, this additional bow appeared to be medial. Detailed measurements of dimensions re-

vealed differences between males and females and between younger and older females, which may help to explain the increased incidence of dislocation after total hip arthroplasty in females. These results have implications relative to implant design in that normal anatomy has a wide variation of congurations, and therefore one implant design may not be adequate for all cases. In particular, differences in male and female anatomy regarding anteversion angles may indicate that either different implants or different guidelines for implant positioning are needed. Furthermore, it was shown that hip rotation inuences critical measurements used in implant positioning. The use of the notch acetabular angle as an indirect estimate of acetabular anteversion may be a useful tool to decrease the incidence of dislocation after primary total hip arthroplasty. Acknowledgments
The authors thank Bruce Latimer, PhD, Curator, and Lyman M. Jellema, Collections Manager, Department of Physical Anthropology, Cleveland Museum of Natural History, for their excellent assistance.

References
1. Abel MF, Sutherland DH, Wenger DR, et al: Evaluation of CT scans and 3-D reformatted images for quantitative assessment of the hip. J Pediatr Orthop 14:4853, 1994. 2. Ackland MK, Bourne WB, Uhthoff HK: Anteversion of the acetabular cup: Measurement of angle after total hip replacement. J Bone Joint Surg 68B:409413, 1986. 3. Anda S, Terjesen T, Kvistad KA, et al: Acetabular angles and femoral anteversion in dysplastic hips: CT investigation. J Comput Assist Tomogr 15:115120, 1991. 4. Atkinson PJ, Woodhead C: The development of osteoporosis: A hypothesis based on a study of human bone structure. Clin Orthop 90:217228, 1973. 5. Billing L: Roentgen examination of the proximal femur end in children and adolescents: A standardized technique also suitable for determination of the collum-, anteversion-, and epiphyseal angles: A study of slipped epiphysis and coxa plana. Acta Radiol 110 (Suppl):180, 1954. 6. Fackler CD, Poss R: Dislocation in total hip arthroplasty. Clin Orthop 151:169178, 1980. 7. Hassan DM, Johnston GH, Dust WN, et al: Accuracy of intraoperative assessment of acetabular prosthesis placement. J Arthroplasty 13:8084, 1998.

Number 393 December, 2001

Acetabular and Femoral Structure

65

8. Husmann O, Rubin PJ, Leyvaz PF, et al: Threedimensional morphology of the proximal femur. J Arthroplasty 12:444450, 1997. 9. Jaramaz B, DiGioia III AM, Blackwell M, et al: Computer assisted measurement of cup placement in total hip replacement. Clin Orthop 354: 7081, 1998. 10. Khan MA, Brackenbury PH, Reynolds ISR: Dislocation following total hip arthroplasty. J Bone Joint Surg 63B:214218, 1981. 11. Kobayashi S, Eftekar NS, Terayama K: Predisposing factors in xation failure of femoral prostheses following primary Charnley low friction arthroplasty: A 10- to 20-year followup study. Clin Orthop 306:7383, 1994. 12. Kristiansen B, Jorgensen L, Holmich P: Dislocation following total hip replacement. Arch Orthop Trauma Surg 103:375377, 1985. 13. Lewinnek GE, Lewis JC, Taur R, et al: Dislocation after total hip replacement. J Bone Joint Surg 60A:217220, 1978. 14. McKibbin B: Anatomical factors in the stability of the hip joint in the newborn. J Bone Joint Surg 52B:148159, 1970. 15. Menke W, Schmitz B, Schild H, et al: Transversale skelettachsen der unteren extremitt bei coxartrose. Z Orthop Ihre Grenzgeb 129:255259, 1991. 16. Mensforth RP, Latimer B: Hamann-Todd collection aging studies: Osteoporosis fracture syndrome. Am J Phys Anthropol 80:461479, 1989. 17. Mohler CG, Collis DK: Early Complications and

18. 19. 20. 21. 22. 23.

24. 25. 26. 27.

Their Management. In Callaghan JJ, Rosenberg AG, Rubash HE (eds). The Adult Hip. Philadelphia, Lippincott-Raven Publishers 11251147, 1998. Morrey BF: Instability after total hip arthroplasty. Orthop Clin North Am 23:237248, 1992. Morrey BF: Difcult complications after hip joint replacement. Clin Orthop 344: 179187, 1997. Murphy SB, Simon SR, Kijewski PK, et al: Femoral anteversion. J Bone Joint Surg 69A:1691176, 1987. Noble PC, Alexander JW, Lindahl LJ, et al: The anatomic basis of femoral component design. Clin Orthop 235:148165, 1988. Noble PC, Box GG, Kamaric E, et al: The effect of aging on the shape of the proximal femur. Clin Orthop 316:3144, 1995. Rubin PJ, Leyvraz PF, Aubaniac JM, et al: The morphology of the proximal femur: A three-dimensional radiographic analysis. J Bone Joint Surg 74B:2832, 1992. Ruff CB, Hayes WC: Subperiosteal expansion and cortical remodeling of the human femur and tibia with aging. Science 217:945948, 1982. Tague RG: Variation in pelvic size between males and females. Am J Phys Anthropol 80:5971, 1989. Visser JD, Jonkers A, Hillen B: Hip joint measurements with computerized tomography. J Pediatr Orthop 2:143146, 1982. Woo RYG, Morrey BF: Dislocation after total hip arthroplasty. J Bone Joint Surg 64A:12951306, 1982.