M u s c u l o s k e l e t a l I m a g i n g • R ev i ew

Beltran et al.
Imaging of Developmental Hip Dysplasia

Musculoskeletal Imaging
Review
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Imaging Evaluation of
Developmental Hip Dysplasia
in the Young Adult
Luis S. Beltran1 OBJECTIVE. The purpose of this article is to review the clinical and imaging features
Zehava S. Rosenberg1 as well as the potential complications of hip dysplasia in the young adult. Hip dysplasia is an
Jason D. Mayo 2 important cause of secondary osteoarthrosis, which accounts for a significant proportion of
Maria Diaz De Tuesta3 patients requiring total hip arthroplasty. The radiographic diagnosis of mild hip dysplasia in
Olga Martin 3 the young adult may be subtle and is primarily based on the detection of deficient coverage of
the femoral head by the acetabulum.
Luis P. Neto 4
CONCLUSION. Cross-sectional imaging, including CT and MRI, afford improved de-
Jenny T. Bencardino1 tection and characterization by providing morphologic information about acetabular deficien-
Beltran LS, Rosenberg ZS, Mayo JD, et al. cy. MRI also allows evaluation of potential associated injuries to the articular cartilage, the la-
brum, and the ligamentum teres. Familiarity with the radiographic and cross-sectional imaging
findings of mild hip dysplasia in the young adult may allow a timely diagnosis and implementa-
tion of treatment strategies, which may prevent or delay the development of early osteoarthritis.

Keywords: complications, CT, developmental dysplasia
of the hip, MRI, radiography
DOI:10.2214/AJR.12.9360
Received June 6, 2012; accepted after revision
August 2, 2012.
Winner of the Society of Skeletal Radiology Excellence
Award for an Exhibit: Diagnostic Evaluation of Hip
Dysplasia in the Young Adult: Emphasis on Cross-Sec-
tional Imaging at the 2011 Society of Skeletal Radiology
annual meeting.
1
Department of Radiology, New York University Langone
Medical Center and Hospital for Joint Diseases, Room
600, 301 East 17th St, New York, NY 10016. Address
correspondence to L. S. Beltran (luis.beltran@nyumc.org).
2
New Britain Radiologic Associates, New Britain, CT.
3
Hospital Universitario Ramón y Cajal, Madrid, Spain.
4
Universidade Federal de São Paulo - UNIFESP/HSP,
São Paulo, Brazil.
AJR 2013; 200:1077–1088
0361–803X/13/2005–1077
© American Roentgen Ray Society
D
evelopmental dysplasia of the hip
encompasses a wide spectrum of
hip abnormality, ranging from a
shallow acetabulum to a complete-
ly dislocated “high-riding” hip. The diagno-
sis of developmental hip dysplasia can be ob-
vious but may sometimes be subtle, with a
normally shaped femoral head and neck that
simply lack sufficient coverage by the ace-
tabulum. Despite attempts at early diagnosis
by screening at birth and during infancy for
hip dysplasia, a relatively significant number
of cases go undetected until adulthood, with
an estimated prevalence of 0.1% [1]. The de-
layed diagnosis and lack of early intervention
can lead to early osteoarthritis in the young
adult [2–5].
The natural history of developmental dys-
plasia of the hip has been well evaluated in
the literature [2, 6] and has been noted to
lead to the development of osteoarthrosis in
25–50% of patients by the age of 50.3 years.
More specifically, Wiberg [5] in his stud-
ies of congenital subluxation of the hip not-
ed that all of his patients with definite sub-
luxation showed osteoarthrosis by the age of
50–60 years. Wedge and Wasylenko [4] indi-
cated that, in general, patients with develop-
mental dysplasia develop coxarthrosis about
10 years later than those with subluxation.
Additionally, increased femoral anteversion
and acetabular dysplasia have been implicat-
ed as causative factors in “primary” or “idio-
pathic” osteoarthrosis of the hips [7].
Wedge and Wasylenko [4] on the basis of
a consensus of the literature showed that if
concentric reduction and normal function are
achieved before 1 year of age, femoral antever-
sion and acetabular dysplasia improve sponta-
neously. Before 4 years of age, concentric re-
duction plus correction of either the anteversion
or the acetabular dysplasia result in improve-
ment of the other. After the age of 4 years,
spontaneous improvement is unlikely, and con-
centric reduction must be accompanied by sur-
gical correction for secondary deformity on
both sides of the joint [4]. It is generally accept-
ed that if developmental dysplasia of the hip is
recognized early, correction of the deranged
anatomy must be undergone to prevent coxar-
throsis [4]. Even in mild hip dysplasia, the rela-
tive lateralization of the hip center of rotation,
the poor coverage of the femoral head, and the
smaller contact area between the femoral head
and dysplastic acetabulum can produce highly
asymmetric concentration of force across the
hip joint (Fig. 1) and secondary articular car-
tilage and labral damage [8–10].
Treatment of adult hip dysplasia is aimed at
prolonging longevity of the joint by perform-
ing periacetabular osteotomy, femoral varus
osteotomy, or both early in the course of the

AJR:200, May 2013 1077


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A B
disease. Hip joint replacement is required in
patients who develop severe arthrosis.
Hip replacement options include standard
total hip replacement and hip resurfacing arth-
roplasty. The long-term problem with total hip
replacement is failure resulting in revision sur-
gery. Failure of total hip replacement is often
caused by aseptic loosening secondary to poly-
ethylene wear [11] or dislocation of the prosthe-
sis [12]. Hip resurfacing arthroplasty has been
advocated because it uses alternative bearing
surfaces that have lower wear and allow larger
femoral head sizes. In theory, hip resurfacing
arthroplasty when compared with convention-
al total hip replacement has better preservation
of bone stock (less bone removal), fewer dis-
locations attributed to a larger femoral head
size, and easier revision surgery to a total hip
replacement given greater availability of bone
stock [13]. Hence, hip resurfacing arthroplasty
may present a better alternative for younger pa-
tients in whom life expectancy after implanta-
tion is long.
Nevertheless, a recent study [14] showed
that 6.2% of metal-on-metal hip implants had
failed within 5 years, compared with 1.7%
of metal-on-plastic and 2.3% of ceramic-on-
ceramic hip implants. Furthermore, larger,
rather than lower, femoral head sizes in met-
al-on-metal hip resurfacing articulations in-
crease implant failure rates, with each 1-mm
increase in head size of metal-on-metal hip
implants being associated with a 2% increase
in failure. This study has led to a reevaluation
of metal-on-metal hip resurfacing arthroplas-
ty. In particular, the United States Food and
Drug Administration (FDA) issued a patient
advisory on metal-on-metal hip implants and
established an advisory panel 2-day meeting
in June 2012 [15], recommending that evalu-
1078 AJR:200, May 2013
Beltran et al.
ation of patients for adverse effects associated
with a metal-on-metal hip implant should in-
clude an expedited physical examination with
an orthopedic surgeon, routine radiography,
and both standard and metal (cobalt and chro-
mium) titers in blood tests.
A significant number of hip arthroplasties
are performed for the treatment of develop-
mental dysplasia of the hip with superimposed
arthrosis. A recent study by Engesaeter et al.
[16] performed in patients younger than 44
years found that 26% of 634 hip replacements
were performed for the treatment of osteoar-
thritis secondary to hip dysplasia. Several au-
thors have shown that the number of patients
requiring hip replacement may be modified by
early diagnosis and treatment of this condition.
In particular, a study performed by Takatori et
al. [17] evaluated the results of rotational ac-
etabular osteotomies in 13 severely dysplastic
hips with subluxation in 11 young women be-
tween 20 and 35 years old at the time of sur-
gery. At a minimum follow-up period of 10
years, the patients had minimal or no pain and
of the 13 hips, 12 showed no significant find-
ings of osteoarthritis. Comparing the outcome
of these patients with the natural evolution of
severely dysplastic hips, the authors concluded
that rotational acetabular osteotomy may pre-
vent the onset of articular cartilage damage.
A study by Badra et al. [18] assessed the
functional outcome of a group of adult patients
after Bernese periacetabular osteotomy in 24
patients with mean follow-up of 3.5 years. They
found that 75% of their patients had good to ex-
cellent results. Even patients with radiographic
evidence of mild coxarthrosis benefited from
Bernese periacetabular osteotomy, with good
to excellent results seen in 75% of patients hav-
ing Tonnis osteoarthritis grade 1 and 81.8% of
Fig. 1—Normal and dysplastic hips.
A and B, Anteroposterior radiographs of right hip
with graphic representations in 29-year-old woman
(A) with normal acetabular roof with weightbearing
forces applied over entire surface and 24-year-old
woman (B) with dysplastic shallow acetabular roof
with weightbearing forces distributed over smaller
area. Arrows indicate acetabular roof and arcs
indicate weightbearing forces.
patients having Tonnis osteoarthritis grade 2,
delaying or eliminating the need for total hip
arthroplasty. However, a trend toward a poorer
outcome was observed in patients with preop-
erative noncongruent joints and Tonnis osteo-
arthritis grade 3.
The radiographic diagnosis of hip dyspla-
sia in the young adult may be subtle. Cross-
sectional imaging of hip dysplasia, includ-
ing CT and MRI, can provide additional
morphologic information that may improve
detection and characterization of acetabu-
lar deficiency. MRI can also assess the hip
joint for potential associated injuries to the
articular cartilage, labrum, and the ligamen-
tum teres. In this article, we discuss the mor-
phologic features of hip dysplasia, the radio-
graphic and cross-sectional imaging features
of acetabular coverage, and the complica-
tions of hip dysplasia. In addition, less-well-
recognized features in hip dysplasia, includ-
ing abnormalities of the ligamentum teres
and labral abnormality, are also discussed.
Imaging of Hip Dysplasia in
the Young Adult
Radiographic Evaluation
The diagnosis of hip dysplasia has tradition-
ally been based on radiographic evaluation.
The most commonly used measurements of
hip dysplasia are the center-edge angle, verti-
cal-center-anterior margin angle, and acetabu-
lar index angle, which provide information on
acetabular deficiency, and the caput collum di-
aphysis angle, which focuses on the femoral
head-neck-shaft relationship. Radiography has
been used as the mainstay for diagnosis in hip
dysplasia and has certain advantages, such as
lower cost and better accessibility, compared
with CT and MRI; however, radiography lacks
 Imaging of Developmental Hip Dysplasia

TABLE 1:  Radiographic Measurements of Developmental Dysplasia of the Hip

Measurement Technique Description Normal vs Abnormal Values Example Figure
Center-edge angle Anteroposterior pelvis Angle between vertical line through femoral head center Normal > 25° 2
radiography and line tangential to lateral margin of acetabulum Borderline dysplasia = 20–25°
Dysplasia < 20°
Vertical-center-anterior Lateral “false profile” Angle between vertical line through femoral head center Normal > 25° 3
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margin angle and anterior margin of acetabulum Borderline dysplasia = 20–25°

Dysplasia < 20°
Femoral head-neck-shaft Anteroposterior pelvis Angle between line through femoral head center along Normal 120–135° 4
angle radiography axis of femoral neck and intersecting line drawn along Coxa valga > 135°
femoral shaft axis Coxa vara < 120°
Tonnis angle Anteroposterior pelvis Angle between horizontal line at level of medial edge of Normal ≤ 13° 5
radiography sourcil and line tangential to medial and lateral edges of Dysplastic > 13°
sourcil
Delta angle Anteroposterior pelvis Angle between lines drawn through medial edge of Normal > 10° 6
radiography sourcil and superior edge of fovea capitis through Fovea alta ≤ 10°
femoral head center

sensitivity for assessing early coxarthrosis.
Furthermore, significant measurement errors
may occur on radiographs due to suboptimal
patient positioning and difficulties in identi-
fying the exact osseous landmarks in patients
with hip dysplasia. Additionally, the imaging
evaluation provided by radiographic methods
lacks the 3D information obtained with cross-
sectional imaging and thus limits accurate
quantification of the degree and location of ab-
normalities in the hip joint articular surfaces.
Center-Edge Angle and Vertical-Center-
Anterior Margin Angle
The diagnosis of hip dysplasia can be made
with a center-edge angle of Wiberg of less
than 20° measured on a well-centered antero-
posterior radiograph of the pelvis (Table 1 and
Fig. 2). A center-edge angle value greater than
25° is normal [5]. Values of 20–25° are con-
sidered borderline dysplasia and describe pa-
tients who are at the lower limits of normal in
terms of coverage of the femoral head but not
quite considered to have uncovering [5].
The anteroposterior radiograph of the pel-
vis should be obtained with the patient supine
on the table with both lower extremities ori-
ented in 15° of internal rotation to maximize
the length of the femoral neck [19]. The x-ray
tube-to-film distance should be 120 cm, with
the tube oriented perpendicular to the table
[19]. The crosshairs of the beam should be cen-
tered on the point midway between the supe-
rior border of the pubic symphysis and a line
drawn connecting the anterior superior iliac
spines [19]. Stulberg and Harris [20] reported
that the average center-edge angle of 60 nor-
mal patients was 37° in men and 35° in women.
Reliable measurements of the center-edge
angle have been reported on the basis of both
3D CT [21] and MRI [22] assessment of the
hip. A refined version of the classic Wiberg
center-edge angle on the pelvis radiograph was
proposed by Ogata et al. [23] when they ob-
served that, in some hips that had a normal Wi-
berg center-edge angle, the lateral point of os-
seous condensation of the acetabular roof did
not reach the lateral rim of the acetabular roof

A B
Fig. 2—Measurement of center-edge angle.
A, Drawing shows center-edge angle (CEA), which is measured by drawing line through center of both femoral heads on well-centered anteroposterior pelvis radiograph
perpendicular line in femoral head of interest and line through lateral margin of acetabulum and femoral head. Angle formed between perpendicular and lateral margin of
acetabulum is CEA.
B, Anteroposterior pelvis radiograph in 38-year-old woman shows dysplastic left hip (CEA < 20°).

AJR:200, May 2013 1079


and poor acetabular coverage developed later.
They stated that the classic center-edge angle
was not reliable in these hips, and they modi-
fied the center-edge angle measurement meth-
od to account for this factor by measuring the
center-edge angle at the lateral point of osseous
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condensation of the acetabular roof when that
point did not reach the lateral rim of the ace-
tabular roof. Omeroglu et al. [24] subsequent-
ly evaluated the intraobserver variability and
interobserver variability of the classic Wiberg
center-edge angle method and the refined Oga-
ta method. They reported an average intraob-
server variation of 3.1 ± 3.0° (range, 0 –17°)
for the classic center-edge angle and 3.8 ± 2.8°
(range, 0–17°) for the refined center-edge angle
(Student t test, p = 0.02). Average interobserver
variation was 4.0 ± 3.6° (range, 0–26°) for the
classic center-edge angle and 5.1 ± 4.8° (range,
0–26°) for the refined center-edge angle (Stu-
dent t test, p < 0.001). They attributed the near-
ly 1° less intraobserver and interobserver vari-
ability in the classic center-edge angle method
compared with the refined center-edge angle
method to easier determination of the most lat-
eral point of the acetabular roof used by the
classic method than that of the osseous con-
densation used by the refined method. How-
ever, they pointed out that although the clas-
sic center-edge angle measurement may have
less intraobserver and interobserver variabili-
ty, it carries the risk of radiographic overesti-
mation of the lateral femoral head coverage in
some cases. Nevertheless, the center-edge an-
gle measurement of Wiberg remains the most
used measurement and is included in most ra-
diographic classifications of hip dysplasia [25].
A vertical-center-anterior margin angle,
also known as anterior-center-edge angle,
evaluates for anterior coverage of the femo-
ral head by the acetabulum (Table 1 and Fig.
3). The vertical-center-anterior margin is mea-
sured on a lateral or “false-profile” view (Fig.
3) of the hip as the angle formed between a
vertical line through the center of the femo-
ral head and a line tangential to the anterior
margin of the acetabular roof. Normal ante-
rior acetabular coverage is present when the
vertical-center-anterior margin is greater than
25°. A vertical-center-anterior margin measur-
ing less than 20° is considered diagnostic of
hip dysplasia. Vertical-center-anterior margin
measurements between 20° and 25° are repre-
sentative of borderline dysplasia [26–28]. The
interobserver reproducibility of the vertical-
center-anterior margin radiographic measure-
ment has been reported to be satisfactory on
the basis of the intraclass coefficient (ICC) of
1080 AJR:200, May 2013
Beltran et al.
Fig. 3—Measurement of vertical-center-anterior
margin (VCA).
A, Drawing shows patient positioning for “false-
profile” view of hip used to measure vertical-center-
anterior margin (VCA) angle for evaluation of anterior
acetabular coverage. Insert shows VCA angle used
to evaluate anterior acetabular coverage. Vertical
line is drawn through center of femoral head in lateral
false-profile view. Second line is drawn connecting
anterior margin of acetabulum and center of femoral
head. Angle between these two lines is VCA.
B, False-profile radiograph in 36-year-old woman
shows VCA measuring less than 20°, considered
diagnostic of hip dysplasia.
A B
0.83 (95% CI, 0.72–0.90) [29]. However, the
kappa coefficient of 0.41 (95% CI, 0.07–0.74)
indicates only moderate reproducibility [29].
The false-profile radiograph is obtained
with the patient in a standing position with
the affected hip against the cassette and the
pelvis rotated 65° in relation to the Bucky
wall stand (Fig. 3) [19]. The foot on the same
side as the affected hip should be positioned
so that it is parallel to the cassette [19]. The
central beam is then centered on the femoral
head, with a tube-to-film distance of approx-
imately 102 cm [19].
Femoral Head-Neck-Shaft Angle
The femoral head-neck-shaft angle, or ca-
put collum diaphysis angle, is measured at the
intersection of the femoral neck axis with the
long axis of the femoral shaft (Table 1 and
Fig. 4). Normal values for the caput collum
diaphysis angle in adults range from 120° to
135°. An increased caput collum diaphysis an-
gle greater than 135° is diagnostic of coxa val-
ga, whereas a decreased caput collum diaphy-
sis angle of less than 120° is consistent with
coxa vara [30]. Although hip dysplasia may
be associated with coxa valga, patients with
hip dysplasia may have a normal caput col-
lum diaphysis angle or, less commonly, coxa
vara; therefore, the caput collum diaphysis an-
gle is of limited value as a diagnostic marker.
However, the caput collum diaphysis angle is
of clinical importance because it may affect
the treatment decision and surgical planning.
A study by Clohisy et al. [31] indicated that
in their research of 108 dysplastic hips, which
were corrected with periacetabular osteotomy,
44% had coxa valga and 4% had coxa vara.
They concluded that identifying and treating
these proximal femoral abnormalities in pa-
tients with acetabular dysplasia may optimize
joint congruency and minimize secondary im-
pingement after acetabular reorientation. Mea-
surements of the caput collum diaphysis angle
should be performed on a true anteroposterior
view of the hip; external rotation of the femur
may simulate a coxa valga deformity. Simi-
larly, femoral anteversion may produce a false
appearance of coxa valga deformity. There-
fore, when an increased caput collum diaphy-
sis angle is encountered on radiographs, it is
probably better to use the term “apparent coxa
valga,” particularly if the hip is suboptimally
positioned. The interobserver reproducibility of
 Imaging of Developmental Hip Dysplasia
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A B
Fig. 4—Measurement of femoral head-neck-shaft or caput collum diaphysis (CCD).
A, Drawing shows femoral head-neck-shaft or caput collum diaphysis (CCD) angle
formed by line extending through center of femoral head along axis of femoral
neck with intersecting line drawn along axis of femoral shaft.
B and C, Anteroposterior pelvis radiographs in 32-year-old man (B) with mild
left and moderate right hip dysplasia and coxa valga (CCD > 135°) with CCD
measurement shown for left hip and 39-year-old man (C) with severe bilateral hip
dysplasia with dislocated hips and coxa vara (CCD < 120°) with CCD measurement
shown for left hip.

Fig. 5—Measurement of weightbearing acetabular

index (Tonnis angle).
A, Drawing shows measurement of weightbearing
acetabular index (Tonnis angle) or horizontal toit
externe angle, formed by angle between horizontal
line at level of medial edge of sourcil and line
tangential to medial and lateral edges of sourcil.
B, Anteroposterior pelvis radiograph cropped and
magnified to right hip in 32-year-old man shows
dysplastic hip with horizontal toit externe angle > 13°.
A B

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 Beltran et al.
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A B C

D E F
Fig. 6—Assessment of fovea capitis position.
A, Drawing shows assessment of fovea capitis position. The δ angle is created by drawing lines extending from medial edge of sourcil (point A) and superior edge of
fovea capitis (point B) to center of femoral head.
B and C, Anteroposterior radiograph of right hip (B) and corresponding coronal T1-weighted MR image (C) in 33-year-old man show normal δ angle > 10°.
D, Drawing shows proposed theory of early superior acetabular chondral wear due to decreased femoral head contact area in setting of fovea alta.
E and F, Anteroposterior radiograph of right hip (E) and corresponding coronal T1-weighted MR image (F) in 31-year-old man show dysplastic hip with “fovea alta” and δ
angle ≤ 10°. In this case, angle is negative because of overlap of superior edge of fovea and medial edge of sourcil.

the caput collum diaphysis radiographic mea-
surement has been reported to be satisfacto-
ry on the basis of the ICC of 0.83 (95% CI,
0.72–0.90) and a kappa coefficient of 1.00
(95% CI, 1–1), indicating almost perfect re-
producibility [29].
Acetabular Index
The weightbearing acetabular index (Ton-
nis angle), or horizontal toit externe angle,
measures the weightbearing surface of the
acetabulum or sourcil. More precisely, the
sourcil represents an area of subchondral os-
seous condensation in the acetabular roof,
which is a response by the articular portion
of the ilium to the stress provoked by the
compressive forces acting on it [32]. This
angle is formed between a horizontal and a
tangential line extending from the medial to
lateral edges of the sourcil (Table 1 and Fig.
5). A weightbearing acetabular index equal
to or less than 13° is considered normal [33],
whereas a measurement greater than 13° is
a radiographic sign of hip dysplasia. The in-
terobserver reproducibility of the acetabular
index radiographic measurement has been
reported to be satisfactory on the basis of the
ICC of 0.84 (95% CI, 0.73–0.90) and a kappa
coefficient of 0.71 (95% CI, 0.47–0.93), indi-
cating substantial reproducibility [29].
Fovea Alta Measurements
Nötzli et al. [34] reported the abnormal
superior position of the fovea capitis, also
referred to as “fovea alta,” in the adult dys-
plastic hip as a potential radiographic diag-
nostic marker. These authors quantified the
position of the fovea capitis along the femo-
ral head with the use of the delta angle mea-
sured on radiographs in the anteroposterior
view. On MRI, a mid-coronal MR image in
which the fovea capitis is seen best is selected
using triangulation with the sagittal and coro-
nal planes. The delta angle is formed between
the lines drawn from the center of the femo-
ral head to the medial edge of the sourcil and
to the superior edge of the fovea capitis [34]
(Table 1 and Fig. 6). A normal delta angle is
greater than 10° and a dysplastic hip with fo-
vea alta has a delta angle ≤ 10°. Nötzli et al.
suggested that fovea alta might serve as a con-
tributing factor in the development of coxar-
throsis by decreasing the contact area of the
femoral head with the superior weightbearing
articular surface of the acetabulum, thus, pre-
disposing to acetabular articular cartilage in-
jury. Further research is needed to determine
the role of the fovea alta as a diagnostic mark-
er of hip dysplasia and its potential association
with pathology in the hip joint.
Cross-Sectional Imaging
CT
Several studies have assessed the utility of
CT in the precise evaluation of acetabular
morphologic deficiencies. CT is useful for

1082 AJR:200, May 2013

 Imaging of Developmental Hip Dysplasia

TABLE 2:  CT Measurements of Developmental Dysplasia of the Hip

Measurement Technique Description Normal vs Abnormal Values Example Figure
Anterior acetabular Axial CT one cut above Angle between lines through centers of both femoral Normal > 50° 7
sector angle greater trochanter heads and line tangential to anterior lip of acetabulum Dysplastic ≤ 50°
Posterior acetabular Axial CT one cut above Angle between lines through centers of both femoral Normal > 90° 7
sector angle greater trochanter heads and line tangential to posterior lip of acetabulum Dysplastic ≤ 90°
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Horizontal acetabular Axial CT one cut above Angle between lines from anterior lip of acetabulum Normal > 140° 7
sector angle greater trochanter through center of femoral head and posterior lip of Dysplastic ≤ 140°
acetabulum

characterizing adult hip dysplasia to anterior,
posterior, or global deficiency [35–41]. In ad-
dition, the modality can be used to measure
and confirm the 2D CT correlates of radio-
graphic center-edge angle, vertical-center-an-
terior margin, and acetabular index.
Axial CT images can also provide morpho-
logic analysis of acetabular deficiencies by
measuring the anterior acetabular sector an-
gle, the posterior acetabular sector angle, and
the horizontal acetabular sector angle [37]
(Table 2 and Fig. 7). The measurements are
obtained using the axial CT slice located one
cut above the greater trochanters. The anterior
acetabular sector angle assesses for adequate
anterior coverage of the femoral head by the
acetabulum and is measured by drawing lines
through the center of the femoral head and the
contralateral femoral head and tangential to
the anterior lip of the acetabulum. Adequate
anterior acetabular coverage is present when
the anterior acetabular sector angle is greater
than 50°. The posterior acetabular sector an-
gle evaluates for adequate posterior coverage
of the femoral head by the acetabulum and is
measured by drawing lines through the center
of the femoral head and the contralateral fem-
oral head and tangential to the posterior lip of
the acetabulum. Adequate posterior acetabu-
lar coverage is present when the posterior ace-
tabular sector angle is greater than 90°. The
horizontal acetabular sector angle evaluates
for global deficiency of femoral head coverage
by the acetabulum and is measured by draw-
ing lines from the anterior lip of the acetab-
ulum through the center of the femoral head
and the posterior lip of the acetabulum. Ad-
equate global acetabular coverage is present
when the horizontal acetabular sector angle is
greater than 140° [35]. These measurements
have been described only with CT. To the best
of our knowledge, there are no published data
available to support the use of MRI for calcu-
lating these measurements.
The 3D reconstruction capabilities of CT
have enabled a more precise evaluation of the
severity of acetabular dysplasia [21, 37, 39,
42, 43]. CT can contribute to the radiographic
assessment of hip dysplasia in the preopera-
tive evaluation of the type and degree of ac-
etabular deficiency [21]. Three-dimensional
CT is useful because it provides the surgeon
with a preoperative road map for correction of
the acetabular deficiency, which may not be

Fig. 7—Measurement of anterior acetabular sector

angle (AASA), posterior acetabular sector angle
(PASA), and horizontal acetabular sector angle
(HASA).
A, Drawing shows measurement of anterior
acetabular sector angle (AASA), posterior acetabular
sector angle (PASA), and horizontal acetabular
sector angle (HASA). Values are measured on axial
CT one cut above greater trochanters. Anterior
acetabular sector angle is created by drawing lines A
through centers of femoral heads and line tangential
to anterior lip of acetabulum. Adequate anterior
acetabular coverage is present when anterior
acetabular sector angle is greater than 50°. PASA
is measured by drawing lines through centers of
femoral heads and line tangential to posterior lip
of acetabulum. Adequate posterior acetabular
coverage is present when PASA is greater than 90°.
HASA is measured by drawing lines from anterior
lip of acetabulum through center of femoral head
and posterior lip of acetabulum. Adequate global
acetabular coverage is present when HASA is
greater than 140°.
B, CT image in 29-year-old woman shows dysplastic
hip with deficient anterior coverage (anterior
acetabular sector angle < 50°), deficient global
coverage (HASA < 140°), and borderline deficient
posterior coverage (normal PASA > 90°).
B

AJR:200, May 2013 1083

 Beltran et al.

Fig. 8—Normal and dysplastic hips.

A and B, Three-dimensional volumetric reformatted
images show 48-year-old man (A) without hip
dysplasia (diagnostic-quality images not shown) with
normal position of fovea capitis (circle) and 37-year-
old woman (B) with hip dysplasia (diagnostic-quality
images not shown) with high position of fovea capitis
(circle) or “fovea alta.”
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A B
as apparent to the surgeon on cross-sectional
2D images. Furthermore, assessing the utili-
ty of the fovea alta as a diagnostic marker of
hip dysplasia may potentially benefit from use
of reconstructed 3D CT images to accurately
characterize the position of the fovea capitis
along the femoral head (Fig. 8).
CT-based assessment of hip dysplasia has
the disadvantages of radiation exposure of
the patient and relative insensitivity to early
changes of cartilage damage. Conversely, CT
arthrography, with direct intraarticular injec-
tion of contrast material, has been shown to be
a sensitive and reproducible method for assess-
ing substantial articular cartilage loss in pa-
tients with hip dysplasia [44]. Limitations of
the latter technique, however, include invasive-
ness, higher cost, and relative inaccessibility.
MRI
Several studies have evaluated the util-
ity of MRI in the evaluation of hip dyspla-
sia [22, 44–49]. The lack of ionizing radi-
ation exposure is an obvious advantage of
MRI over radiography and CT. Similar to
the latter techniques, MRI provides morpho-
logic information about acetabular deficien-
cy in hip dysplasia. Chen et al. [22] showed
that MRI measurements of center-edge an-
gle using anterior to middle coronal MR im-
ages determined by triangulation with sag-
ittal and axial images in which the femoral
head forms a circle correlate well with radio-
graphic measurements and can be used to as-
sess acetabular deficiency (Table 3 and Fig.
9). Conversely, center-edge angle measure-
ments performed on posterior coronal slic-
es, determined by triangulation with sagittal
and axial images, correlated poorly with ra-
diographic measurements [22].
Early detection of osteoarthritis [44, 45],
manifested as chondral and labral damage,
can also be assessed using MRI. Nishii et
al. [49] reported chondral defects along the
acetabular articular cartilage in dysplastic
hips. Reported MRI findings of labral dis-
ease in hip dysplasia include morphologic al-
terations, such as labral hypertrophy and tear
(Fig. 10); labral intrasubstance signal change;
and labral chondral junction disruption [45].
Ligamentum teres elongation, degeneration,
and tear can also be visualized. Detection
of all these abnormalities can be improved
with direct MR arthrography. With indirect
MR arthrography, however, there have been
conflicting reports regarding effectiveness in
detecting articular cartilage lesions in the hip.
A study by Pozzi et al. [50] showed that in a
series of 21 hip joints, indirect MR arthrogra-
phy showed higher sensitivity (92%) and ac-
curacy (95%) than standard MRI in detect-
ing chondral damage. In contrast, Zlatkin et
al. [51] showed that in a series of 14 hip joints,
identification of chondral abnormalities was
not improved using indirect MR arthrography
over conventional MRI.
A few studies have evaluated the effec-
tiveness of applying leg traction during MRI
of the hip to differentiate between acetab-
ular and femoral cartilage by interposition
of a joint fluid layer, and these studies have
shown improved detection of cartilage le-
sions on traction images compared with non-
traction images [52–54]. This technique may
be a further step toward better imaging of
cartilage defects of the hip that warrants fur-
ther investigation; however, it has not yet be-
come a part of routine clinical practice. Ad-
vanced biochemical MRI techniques, such as
delayed gadolinium-enhanced MRI of carti-
lage (dGEMRIC), T2 mapping, and T1-rho

TABLE 3:  MRI Measurements of Developmental Dysplasia of the Hip

Measurement Technique Description Normal vs Abnormal Values Example Figure
Center-edge angle Anterior to mid-coronal Angle between vertical line through femoral head center and Normal > 25° 9
line tangential to lateral margin of acetabulum Borderline dysplasia = 20–25°
Dysplasia < 20°
Delta angle Mid-coronal Angle between lines drawn through medial edge of sourcil and Normal > 10° 6
superior edge of fovea capitis through femoral head center Fovea alta ≤ 10°

1084 AJR:200, May 2013

 Imaging of Developmental Hip Dysplasia

can detect biochemical changes of the artic- Fig. 9—MRI

measurement of center-
ular cartilage in the hip joint and therefore edge angle.
have the potential to detect chondral injury A and B, Coronal T1-
in dysplastic hips early in the disease pro- weighted images of pelvis
cess before radiographically noticeable cox- show measurement of
center-edge angle as
arthrosis. The position of the fovea capitis it is applied to MRI in
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can easily be determined with the delta angle 27-year-old woman (A)
measurement on MRI (Table 3)[55]. with normal center-
edge angle > 25° and
32-year-old woman
Differentiating Hip Dysplasia From (B) with dysplastic hip
Femoro­acetabular Impingement with center-edge angle
< 20°. Measurements
Repetitive microtrauma from impingement
are based on anterior or
of the femoral head against the acetabulum is mid-coronal images of
believed to be the likely cause in femoroace- acetabulum determined A
tabular impingement. There are two potential by triangulation with
sagittal and axial images
morphologic abnormalities that may occur in where femoral head
isolation or concurrently: pincer deformity re- forms circle and teardrop
ferring to overcoverage of the femoral head by (asterisk), which is well
delineated.
the acetabulum and cam deformity represent-
ing loss of femoral head and neck offset. As-
sociated injuries, best seen on MRI related to
the impingement include contrecoup postero-
inferior chondrolabral injury (pincer type) and
anterior femoral head and neck edema or cys-
tic changes (cam type). In contrast to hip dys-
plasia, the primary abnormality in pincer-type
femoroacetabular impingement is overcover-
age of the femoral head, such as seen in cas- B
es of coxa profunda. Similarly, with cam-type

A B C
Fig. 10—32-year-old woman with hip dysplasia and
labral disease.
A–C, Coronal proton density–weighted (A) and
sagittal fat-saturated proton density–weighted (B
and C) MR images show redundant patulous labrum
with extensive intrasubstance signal abnormality
(curved arrows, A and B) associated with anterior
acetabular subchondral cysts (dashed arrow, C).
D, Anteroposterior pelvis radiograph performed 7
days before MRI shows center-edge angle of 12° in
right hip, which is consistent with developmental
dysplasia of hip. Although femoral head
undercoverage appears subtle, particularly on MRI
study, this patient has significant undercoverage
of right femoral head based on center-edge angle,
which can easily go undetected.
D

AJR:200, May 2013 1085

 Beltran et al.

femoroacetabular impingement, the prima-

ry abnormality is the decreased femoral head
and neck offset rather than undercoverage of
the femoral head seen in hip dysplasia. Never-
theless, there is often difficulty in differentiating
collar-type osteophytes secondary to secondary
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osteoarthritis in mild hip dysplasia versus a fem-

oral head and neck osseous bump. A normal cen-
ter-edge angle noted in isolated cam morphology
is in contradistinction to the typically decreased
center-edge angle in hip dysplasia.

Complications of Hip Dysplasia

Subchondral Fractures
Most cases of subchondral insufficiency frac- A
tures occur in the absence of significant trauma,
suggesting an underlying subchondral bone in-
sufficiency, such as osteoporosis or excessive
mechanical stress on the subchondral bone,
such as occurs in hip dysplasia [56, 57]. A study
by Obermayer-Pietsch et al. [58] evaluated 240
premenopausal women (age 33 ± 7 years) us-
ing dual-energy x-ray absorptiometry and bio-
chemical parameters of bone metabolism and
showed a 6.3-fold increased risk for low bone
mineral density at the hip but not in the lumbar
spine in patients with developmental hip dyspla-
sia. The authors concluded that a history of con-
servatively treated developmental hip dysplasia
may be a major risk factor for low bone miner-
al density at the hip in about one in 10 women. B C
Deficient lateral acetabular coverage of the fem- Fig. 11—28-year-old woman with left hip dysplasia and subchondral impaction fracture.
oral head, characteristic of hip dysplasia, may A, Coronal fat-saturated T2-weighted MR image of pelvis shows deficient acetabular roof in left hip (center-
edge angle < 20°), consistent with hip dysplasia.
result in diffuse chondral injury along the ace- B and C, Coronal proton density–weighted (B) and coronal fat-saturated T2-weighted (C) MR images show
tabular and femoral head articular surfaces. Sec- subchondral fracture line (arrow) located in superior weightbearing aspect of femoral head. Note subtle
ondary subchondral bone impaction fracture of subchondral plate indentation, minimal cortical flattening, and surrounding bone marrow edema.

A B C
Fig. 12—Hip dysplasia.
A–C, Anteroposterior pelvis radiographs cropped to involved hip in 43-year-old woman (A) with right hip dysplasia shown by deficient lateral femoral head coverage (white
arrow) and changes of mild secondary osteoarthritis, including mild superior joint space narrowing and osteophyte formation (black arrows); 37-year-old woman (B) with left
hip dysplasia shown by deficient lateral femoral head coverage (white arrow) and changes of moderate secondary osteoarthritis, including moderate superior joint space
narrowing and marginal osteophyte formation (black arrows); and 40-year-old man (C) with right hip dysplasia shown by deficient lateral femoral head coverage (white
arrow) and changes of severe secondary osteoarthritis, including bone-on-bone superior joint space narrowing and large marginal osteophyte formation (black arrows).

1086 AJR:200, May 2013


the superior femoral head, where there is max-
imum force during weightbearing, can ensue.
Motomura et al. [57] reported subchondral in-
sufficiency fracture of both the acetabulum and
femoral head in a patient with developmental
hip dysplasia. Ishihara et al. [59] noted a greater
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incidence of hip dysplasia in patients with sub-
chondral insufficiency fractures of the femoral
head compared with asymptomatic hips, spec-
ulating that the fractures are due to excessive
stress on the acetabular edge in the dysplastic
hips. Subchondral insufficiency fracture is eas-
ily detected on MRI as a subchondral fracture
line or flattening of the subchondral plate, sub-
chondral collapse, and extensive subchondral
bone marrow edema (Fig. 11).
Osteoarthritis
Early coxarthrosis is a major complica-
tion of delayed diagnosis and treatment of hip
dysplasia in the young adult. Osteoarthritis is
expected to ensue in all hips with untreated
moderate hip dysplasia (a lateral center-edge
angle of ≤ 15°) by the seventh decade of life
[2]. In addition to providing assessment of lat-
eral femoral head undercoverage, character-
istic of hip dysplasia, radiography and cross-
sectional imaging also show superior joint
space narrowing with bone-on-bone contact,
osteophyte formation, subchondral sclerosis,
and cystic change, all imaging markers of os-
teoarthritis (Fig. 12).
Currently, the diagnosis of osteoarthritis is
based on radiographic findings, which are a late
manifestation of the disease process. MRI has
the potential to detect chondral injury in dys-
plastic hips, early in the disease process be-
fore radiographically noticeable coxarthrosis.
Kim et al. [46], using dGEMRIC, showed a di-
rect correlation for the delayed gadolinium-en-
hanced MRI of the cartilage index—a measure
of the biochemical integrity of cartilage—and
the pain and grade of dysplasia. The dGEMRIC
index was significantly different among groups
of hips with mild, moderate, and severe dyspla-
sia, suggesting that it may be a sensitive mea-
sure of early osteoarthritis. Jessel et al. [60] sub-
sequently also identified patient age, severity of
the dysplasia, and the presence of a labral tear
as factors associated with clinically relevant
osteoarthritis based on the dGEMRIC index.
Treatment response in patients with hip dyspla-
sia after periacetabular osteotomy can also be
measured using MRI by assessment of the ar-
ticular cartilage thickness. Mechlenburg et al.
[61] showed no significant changes in cartilage
thickness manifested by stable chondral thin-
ning in MRI follow-up 2.5 years after surgery
AJR:200, May 2013 1087
Imaging of Developmental Hip Dysplasia
compared with baseline preoperative MRI as a
short-term outcome indicator after periacetabu-
lar osteotomy. These emerging advanced MRI
techniques have great potential in predicting
disease progression in hip dysplasia and show-
ing response to therapeutic interventions. How-
ever their precise role in routine clinical prac-
tice has yet to be determined.
Conclusion
Delayed diagnosis of mild hip dysplasia is
an important cause of secondary osteoarthritis
despite routine screening of infants, account-
ing for approximately 25% of all patients re-
quiring total hip arthroplasty. The radiograph-
ic diagnosis of hip dysplasia in the young adult
may be subtle. CT and MRI provide addition-
al morphologic information about acetabular
deficiency in hip dysplasia. MRI can also de-
tect associated intraarticular injuries to the ar-
ticular cartilage, labrum, and the ligamentum
teres. Familiarity with the radiographic and
cross-sectional imaging findings of mild dys-
plasia may allow timely implementation of
appropriate treatment strategies to prevent the
development of early osteoarthritis of the hip
in the young adult population.
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