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C OPYRIGHT Ó 2013 BY T HE J OURNAL OF B ONE AND J OINT S URGERY, I NCORPORATED

the
Orthopaedic
forum
EOS Imaging of the Human Pelvis: Reliability, Validity, and
Controlled Comparison with Radiography
Bernd Bittersohl, MD, Joana Freitas, MD, Daniela Zaps, MD, Matthew R. Schmitz, MD, James D. Bomar, MPH,
Abd R. Muhamad, MD, and Harish S. Hosalkar, MD

Background: The EOS technique represents a unique imaging modality combining low radiation exposure with high
image quality. As its applications for pelvic imaging may increase with time, we performed a pilot study to evaluate the
validity and reliability of this technique for the assessment of gross pelvic and acetabular morphology.
Methods: Consecutive conventional and EOS radiographs of a human cadaveric pelvis were made in 5° intervals of
sagittal tilt and axial rotation (range, 215° to 15° for each). Six measurements were made on each image: (1) the
vertical distance between the sacrococcygeal joint and the upper border of the pubic symphysis, (2) the horizontal
distance between the midpoints of these structures, (3) the distance between the anterior superior iliac spines, (4) the
distance between the facets of S1, (5) the Sharp angle, and (6) the Tönnis angle. Coxa profunda and crossover signs
were also evaluated. The findings of the two imaging techniques were correlated with each other and with true linear
measurements made on the cadaveric pelvis. All measurements were performed by two independent observers, and
one observer repeated all measurements to assess reproducibility. Both observers were blinded to the true linear
measurements made on the pelvis.
Results: There was a strong correlation between the results of the conventional and EOS radiography (Pearson cor-
relation coefficient, 0.644 to 0.998), and both modalities had high intraobserver and interobserver reproducibility (in-
traclass correlation coefficient, 0.795 to 1.000). Intraobserver and interobserver agreement on the presence of coxa
profunda were both 100%. Intraobserver agreement (96.2%) and interobserver agreement (92.3%) on the presence of
the crossover sign were marginally lower. Linear measurements differed significantly between the two modalities be-
cause of distortion caused by magnification effects in the conventional radiographic imaging (p < 0.05).
Conclusions: The EOS imaging technique proved reliable for the assessment of gross pelvic and acetabular mor-
phology, and it may be an alternative to current radiography for primary imaging in the pediatric population and
potentially in adults as well. This study did not evaluate the ability of EOS imaging to detect subtle radiographic
anatomic abnormalities.

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any
aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this
work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, one or
more of the authors has had another relationship, or has engaged in another activity, that could be perceived to influence or have the potential to influence
what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of
the article.

J Bone Joint Surg Am. 2013;95:e58(1-9) d http://dx.doi.org/10.2106/JBJS.K.01591

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TABLE I Radiographic Parameters Measured with Use of Conventional Radiography and EOS Imaging

Pearson Correlation
Parameter Conventional Radiography* EOS* P Value† Coefficient

Vertical distance 28.5 ± 27.0 mm‡ 18.3 ± 19.9 mm‡ 0.014 0.990
from pubic symphysis
to sacrococcygeal joint
Horizontal distance 1.6 ± 18.9 mm‡ 20.2 ± 14.5 mm‡ 0.345 0.998
from pubic symphysis
to sacrococcygeal joint
Distance between 331.5 ± 14.2 mm 241.8 ± 3.7 mm <0.001 0.644
anterior superior iliac
spines
Distance between 57.2 ± 3.3 mm 42.4 ± 1.0 mm 0.001 0.715
facets
Sharp angle 32.6° ± 2.2° 32.3° ± 1.0° 0.125 0.833
Tönnis angle 210.3° ± 2.8° 210.6° ± 2.4° 0.239 0.824

*Values are given as the mean and the standard deviation. †Although the correlation between these two modalities was high (Pearson correlation
coefficients ranging from 0.644 to 0.998), the difference between the modalities reached significance (p < 0.05) for three of the four distances
because of magnification effects in the conventional radiographic technique. ‡The mean values of the vertical and horizontal distances were
systematically affected by rotation and tilting, as indicated by the high standard deviations.

The follow-up of pediatric hip disorders, such as Legg-Calvé-
Perthes disease, slipped capital femoral epiphysis (SCFE), and
developmental dysplasia of the hip, typically involves numerous
diagnostic imaging studies throughout childhood and adoles-
cence. The authors of several studies have pointed out the po-
tential adverse effects of ionizing radiation, particularly in the
case of computed tomography (CT) scans1-3. Efforts are being
made to reduce the radiation dose, especially in the pediatric
population. However, reduction of the radiation dose should not
be achieved at the expense of valuable diagnostic information.
The new EOS imaging technique (EOS Imaging, Paris,
France) was devised through multidisciplinary cooperation by
the ENSAM Biomechanics Laboratory in Paris, the Imagery
and Orthopedics Research Laboratory (LIO) in Montreal, the
Departments of Radiology and Orthopedics at Saint Vincent de
Paul Hospital in Paris, and Biospace Instruments (now EOS
Imaging), and it has been approved by the U.S. Food and Drug
Administration (FDA). It is a novel slot-scanning radiographic
imager that allows high-resolution imaging combined with
lower radiation exposure than that for standard radiographic
imagers; the resolution is approximately 0.5 mm and the radi-
ation dose has been estimated to be up to ten times less than that
for conventional radiography4-6.
The EOS design is based on two perpendicular fan-shaped
x-ray beams and two variable gaseous particle detectors, which
allow detection of very small radiation exposures. In 1992,
Georges Charpak (Paris) was awarded the Nobel Prize in Physics
for his invention and development of extremely sensitive gaseous

TABLE II Intraclass and Interclass Correlation Coefficients (ICCs) for Conventional Radiography and EOS Imaging*

Intraobserver ICC Interobserver ICC

Parameter Conventional Radiography EOS Conventional Radiography EOS

Vertical distance from pubic symphysis to 1.000 0.999 0.999 0.999

sacrococcygeal joint
Horizontal distance from pubic symphysis to 0.999 0.999 0.999 0.999
sacrococcygeal joint
Distance between anterior superior iliac spines 0.993 0.932 0.995 0.914
Distance between facets 0.972 0.900 0.884 0.848
Sharp angle 0.899 0.868 0.809 0.795
Tönnis angle 0.809 0.842 0.830 0.823

*Two-way mixed single measures, absolute agreement. ICC values for both modalities were high (range, 0.795 to 1.000). All p values were <0.001.
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Fig. 1
Diagram illustrating setup of the apparatus for controlling pelvic rotation and tilt. An enclosure was constructed for the cadaveric pelvis to facilitate precise
rotation and tilting. This comprised a box with a position-pointing device and three wooden wedges to allow accurate rotation and tilting of the flat baseboard
by ±5°, ±10°, and ±15°. Relevant anatomical landmarks such as the vertebral body of S1 and the anterior superior iliac spines were left prominently
displayed outside the foam fixation. These landmarks were subsequently used to center the x-ray beam on the pelvis.

particle detectors. In the EOS system, the particle detectors are imaging was performed on this specimen with use of both conventional ra-
mounted on a C-arm that moves vertically. This allows for diography and EOS imaging. Subsequently, measurements of gross radio-
graphic parameters were made on the two sets of images with use of an
the simultaneous generation of frontal and lateral weight-bearing
digital radiographs. These high-contrast radiographs are made
line-by-line by a collimated beam and detector, which reduces the
amount of scattered radiation and increases the effective de-
tection quantum efficiency and signal-to-noise ratio7,8.
Because of these potential benefits, the EOS imaging sys-
tem represents an alternative to conventional radiography for the
assessment of the musculoskeletal system. However, the available
data on the potential of this system for the assessment of pelvic
and acetabular parameters remain limited at this time. The abil-
ity of this new technique to detect subtle osseous changes (e.g.,
minor destructive lesions resulting from metastatic disease, im-
plant loosening, or early degenerative changes) remains unclear
at present, and the present study did not address this uncertainty.
The purpose of this pilot study was to evaluate the validity
and reproducibility of this new technique, in comparison with
conventional radiography, for the assessment of gross pelvic and
acetabular morphology. We hypothesized that radiographs ob-
Fig. 2
tained with use of the EOS system would be as reliable and repro-
Diagram illustrating conventional radiographic imaging of the pelvis at 15°
ducible as conventional radiographs for gross pelvic assessment.
tilt and 0° rotation. The beam was centered to obtain a standardized pelvic
radiograph with the box placed next to the film to minimize distortion due to
Materials and Methods
Model magnification effects. Anatomic structures such as the vertebral body of S1
The current study was conducted on a dry human cadaveric pelvis in sequen- and the anterior superior iliac spines were used as landmarks to center the
tial positions of sagittal tilt and axial rotation. Anteroposterior frontal-plane x-ray beam on the pelvis.
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Fig. 3
Comparable conventional and EOS radiographs made at various angles of pelvic rotation. The single asterisk indicates measurement of the vertical distance
between the sacrococcygeal joint and the upper border of the pubic symphysis. The double asterisk indicates measurement of the horizontal distance
between the midpoints of these structures.

external high-resolution medical diagnostic viewing station with direct access
to a digital picture archiving and communication system (PACS). Measure-
ments obtained from both the standard radiographs and the EOS images were
compared with each other and also with the true linear measurements made
on the cadaveric pelvis.
An enclosure was constructed for the cadaveric pelvis to facilitate precise
tilting and rotation. This enclosure comprised a box, a flat wooden baseboard, gap-
filling foam, and a position-pointing device. Three wooden wedges were created to
allow accurate tilting of the flat baseboard to ±5°, ±10°, and ±15° (Fig. 1).
The cadaveric pelvis was placed and stabilized in the center of the
cardboard box with use of gap-filling insulating foam. The pelvis was carefully
positioned in an anatomical orientation in the foam, and the center of rota-
tion was aligned between the acetabula. A trial positioning was performed
with a Sawbones pelvic model (Pacific Research Laboratories, Vashon, Wash-
ington) to facilitate this step and help with precise positioning. Relevant anatom-
ical landmarks such as the vertebral body of S1 and the anterior superior iliac
spines were prominently displayed outside the foam fixation. These landmarks
were used to center the x-ray beam on the pelvis. Pilot anteroposterior pelvic

Fig. 4 Fig. 5
Fig. 4 Measurement of the distance between the anterior superior iliac spines. Fig. 5 Measurement of the distance between the facets of S1.
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Fig. 6
Identification of the crossover sign in a right acetabulum (Fig. 6-A), identification of coxa profunda (Fig. 6-B), measurement of the Sharp angle (Fig. 6-C), and
measurement of the Tönnis angle (Fig. 6-D) at various pelvic rotation angles.

radiographs were made to reconfirm proper positioning of the pelvis within cranial part of the acetabulum and crosses the latter in the distal part of the
the box prior to further analyses. acetabulum. True linear measurements made on the cadaver included the
distance between the anterior superior iliac spines and the distance between
Imaging Analyses the facets of S1.
After the proper positioning of the pelvis was confirmed, sequential antero- All primary radiographic measurements on both the standard radio-
posterior images were made at 5° intervals of sagittal tilt and then at 5° graphs and the EOS images were made by the principal investigator, with the
intervals of axial rotation (range, 215° to 15° for each) with use of conven- standard radiographs and the EOS images analyzed separately. The standard
tional radiography and EOS imaging (a total of thirteen images with each radiographs were not available to the investigator during performance of the
modality). The beam was centered to obtain a standardized pelvic radio- equivalent analyses of the EOS images, and vice versa.
graph with the box placed next to the film to minimize magnification dis-
tortion (Fig. 2). The standard 100-cm focus-to-film distance was used for
conventional radiography, and a distance of 130 cm was used for the EOS
system.
After confirming that both modalities had depicted identical planes of
the pelvis, six measurements were obtained: (1) the vertical distance between
the sacrococcygeal joint and the upper border of the pubic symphysis, (2) the
horizontal distance between the midpoints of these two structures (Fig. 3), (3)
the distance between the anterior superior iliac spines (Fig. 4), (4) the distance
between the facets of S1 (Fig. 5), (5) the Sharp angle (angle between a horizontal
line and the line joining the outermost ossified portion of the acetabulum to the
9
pelvic teardrop) , and (6) the Tönnis angle (angle between a horizontal line and
a line extending from the medial to the lateral edge of the sourcil [the sub-
chondral osseous condensation in the acetabular roof], which indicates the
10
acetabular index of the weight-bearing zone) (Fig. 6). Of note, the vertical
distance between the sacrococcygeal joint and the pubic symphysis was mea-
sured at various tilt angles, and the horizontal distance between the sacrococ-
cygeal joint and the pubic symphysis was measured at various rotation angles.
In addition, the presence of coxa profunda and the presence of the crossover
sign were evaluated. Coxa profunda is defined as being present when the floor
of the acetabular fossa touches or overlaps the ilioischial line medially. The Fig. 7
crossover sign is defined as the ‘‘figure-8’’ configuration formed when the line Measurement of the true linear distance between the anterior superior iliac
representing the anterior acetabular rim is lateral to the posterior rim in the spines on the cadaveric pelvis.
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Fig. 8
Distance measurements on the EOS and conventional radiographic images at various tilt and rotation angles differed significantly because of image
magnification effects with the conventional imaging technique. No magnification effects were noted with the EOS technique. The broken lines represent the
true linear distance measurements made on the pelvis. Note that the vertical distance measured between the sacrococcygeal joint and the upper border of
the pubic symphysis increased systematically with increasing tilt, whereas the horizontal distance measured between the midpoints of these structures
increased systematically with increasing rotation.
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Fig. 9
The mean Sharp and Tönnis angle measurements at various tilt and rotation angles revealed high correlation between the two imaging modalities (maximum
difference, 3°).

For reproducibility assessment, all radiographs were remeasured by a
second independent investigator and the principal investigator repeated all
measurements after a time period of two weeks. Both investigators were blinded
to the true linear measurements (the distances between the iliac spines and
between the facets), which were made on the cadaveric pelvis by a third inde-
pendent observer (Fig. 7).
Statistical Analyses
SPSS software (version 19.0; IBM, Armonk, New York) was used for all statis-
tical analyses. Mean values and standard deviations were calculated at each
combination of tilt angle and rotation angle. Prior to further statistical analyses,
all variables were shown to follow a normal distribution by visual evaluation of
histograms and by the Kolmogorov-Smirnov test, which revealed p values
ranging from 0.315 to 1.000. Pearson correlation analysis was performed to
evaluate the level of agreement between the two imaging modalities, and any
significant differences were assessed with use of the paired-sample Student t
test. Intraobserver and interobserver reproducibility were assessed with use of
the intraclass correlation coefficient (ICC) (mixed model, pairwise correla-
tion, absolute agreement). A p value of <0.05 was considered significant for
all statistical analyses.
Source of Funding
No external funding was received for this study.
Results
A strong correlation was revealed between the conventional
radiography and EOS imaging, with Pearson correlation coef-
ficients ranging from 0.644 to 0.998 (Table I). This was consistent
with the ICC value range of 0.795 to 1.000, which indicated high
intraobserver and interobserver reproducibility for both modal-
ities (Table II). Both intraobserver and interobserver agreement
were 100% for assessment of the presence of coxa profunda.
Agreement on the presence of the crossover sign was mar-
ginally lower, 96.2% for the intraobserver agreement and 92.3%
for the interobserver agreement.
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Discussion
TABLE III Crossover and Coxa Profunda Signs at Various Pelvic
Technological advancements in diagnostic radiography have
Tilt and Rotation Angles with Use of Conventional
Radiography*
been focused on decreasing radiation exposure while maintain-
ing the quality of the imaging and information obtained. The
Crossover Sign Coxa Profunda reduction of radiation exposure is important, particularly in
the pediatric population, in which evaluation and follow-up of
Right Left Right Left
some orthopaedic conditions may require several radiographic
Tilt evaluations over a period of time during the years of growth. Any
215° N N Y Y technology that can potentially achieve these goals represents an
210° N† N Y Y
advance in pediatric diagnostic imaging.
The EOS imaging technique has several advantages: (1) it
25° Y† N Y Y
substantially reduces the radiation dose compared with con-
0° Y N† Y Y
ventional radiography, (2) it is capable of capturing anteropos-
5° Y Y† Y Y terior and lateral images at the same time, and (3) it allows for the
10° Y Y Y Y acquisition of radiographic images while the patient is in a
15° Y Y Y Y weight-bearing or a sitting position.
Rotation Previous investigations of the reliability of the EOS tech-
215° N† Y Y Y nique have yielded promising results. A clinical trial involving
210° Y† Y† Y Y
fifty patients with spinal deformities demonstrated a sixfold to
ninefold decrease in the radiation dose in the thoracoabdom-
25° Y N† Y Y
inal region when the EOS technique was used instead of conven-
0° Y N Y Y tional radiography. In the same study, the image quality achieved
5° Y N Y Y with the EOS (assessed with use of a four-level scale evaluating
10° Y N Y Y the visibility of anatomic landmarks) was rated significantly higher
15° Y N Y Y for nearly all structures in the frontal view (p < 0.006) and the
lateral view (p < 0.04); the exception was the lumbar spinous
*Findings with EOS imaging were identical to these conventional processes, which were seen better on the images obtained with
radiography findings except for the 210° rotation view, where a conventional radiography (p < 0.003)6.
positive crossover sign was noted on the left side only. †Evidence Lazennec et al. measured pelvic tilt and acetabular cup
for the presence of the sign changes between this angle and the
orientation in fifty patients with a unilateral total hip implant
adjacent one. Note that the crossover sign classification was
systemically influenced by the pelvic orientation. This emphasizes
on both conventional radiographs and EOS images11. The
the importance of examining the pelvis in the standard fashion to Spearman rank correlation coefficient ranged from 0.84 to
prevent a false-positive or false-negative diagnosis of acetabular 0.97, demonstrating strong correlations between the two mo-
retroversion. dalities. Intraobserver and interobserver agreement were also
high (ICC, 0.66 to 0.98). However, the variance was higher for
conventional radiographic imaging (p < 0.05); this was attributed
Distortion caused by magnification effects during to conical image distortion in the conventional radiographs.
conventional radiographic imaging resulted in significant In contrast, the slot-scanning EOS system emits beams that
differences in linear measurements between the two modalities are constantly aligned with the opposite detectors, decreasing
(p < 0.05). The distances between the iliac spines and between vertical distortion and leaving primarily horizontal distortion.
the facets were both overestimated on conventional radiogra- The EOS scanner is equipped with a digital graduation system
phy (mean, 331.5 and 57.2 mm, respectively, compared with that provides additional horizontal distortion correction, yield-
the true values of 242 and 42 mm; ;37% magnification). ing radiographs with less image distortion in both planes.
However, no such magnification effects were noted with the The findings in the present study are similar to those in
EOS imaging technique (mean distances, 241.8 and 42.4 mm, the previous studies in some aspects, although a valid compar-
respectively). Magnification effects for conventional radiogra- ison cannot be made because of differences in study design and
phy were further exaggerated when the measured points were measurement parameters. The purpose of the present study was
moved farther away from the film by tilting the pelvic model; to assess the validity and reproducibility of the EOS imaging
the estimated distance between the iliac spines was 302.6 mm at technique for the assessment of gross pelvic and acetabular mor-
215° of tilt compared with 357.1 mm at 15°. Similar findings phology. Although it represents a preliminary study, we were able
were observed for the distance between facets (estimated dis- to confirm the potential of this new imaging modality.
tance with use of conventional radiography, 50.8 mm at 215° The correlation between angular measurements made with
of tilt compared with 62.9 mm at 15°; Fig. 8). The estimated the two modalities was strong (Pearson correlation coefficient,
Tönnis angle (Fig. 9) as well as the evaluation of the crossover 0.833 and 0.824), and no significant differences between the an-
sign (Table III) were affected by rotation and tilting in both gular measurements were noted (p = 0.125 and 0.239). We noted
imaging techniques. a substantial magnification effect (;37%) for the conventional
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radiography technique despite optimal conditions and additional
efforts to minimize image distortion. In contrast, measurements
made with use of the EOS technique had high intraobserver and
interobserver reproducibility (ICC, 0.795 to 0.999) and there was
excellent correlation between these radiographic measurements
and the actual anatomic measurements, without any apparent
image magnification. The latter observation indicates that linear
measurements on images obtained with use of the EOS system
could potentially be used directly in pathologic assessments with-
out the distortion resulting from magnification effects in conven-
tional radiography, although the purpose of our study was not to
validate EOS images against true anatomic measurements.
Any grading system that is based on objective linear mea-
surements must be applied with caution to EOS images until
the existing grading system is shown to remain applicable.
Furthermore, the present study reemphasizes the need for an
accurate and standardized radiographic technique when any
imaging study is performed, because tilt or rotation may cause
false-positive or false-negative observations that could alter
treatment decisions12.
The purpose of this pilot study was to evaluate the valid-
ity and reliability of the low-radiation EOS technique for the
assessment of gross pelvic and acetabular morphology during
follow-up of pediatric hip disorders, which typically involves
numerous diagnostic radiographs of the growing patient. Al-
though this study revealed that EOS imaging can perform well
for gross morphological assessment, the ability of this new
technique to detect subtle osseous changes (such as minor de-
structive lesions due to metastatic disease, implant loosening,
or early degenerative changes) remains uncertain at this point.
Therefore, the conclusion that this new imaging modality will
eventually replace conventional radiography for the detection
of other osseous details is premature.
References
1. 1990 Recommendations of the International Commission on Radiological
Protection. Ann ICRP. 1991;21(1-3):1-201.
2. Brenner DJ, Hall EJ. Computed tomography—an increasing source of radiation
exposure. N Engl J Med. 2007;357(22):2277-84.
3. Brenner DJ. Estimating cancer risks from pediatric CT: going from the qualitative
to the quantitative. Pediatr Radiol. 2002 Apr;32(4):228-3; discussion 242-4. Epub
2002 Mar 7.
4. Dubousset J, Charpak G, Dorion I, Skalli W, Lavaste F, Deguise J, Kalifa G,
Ferey S. [A new 2D and 3D imaging approach to musculoskeletal physiology
and pathology with low-dose radiation and the standing position: the EOS system].
[Article in French]. Bull Acad Natl Med. 2005;189(2):287-97, discussion
297-300.
5. Kalifa G, Charpak Y, Maccia C, Fery-Lemonnier E, Bloch J, Boussard JM, Attal M,
Dubousset J, Adamsbaum C. Evaluation of a new low-dose digital x-ray device: first
dosimetric and clinical results in children. Pediatr Radiol. 1998;28(7):557-61.
6. Deschênes S, Charron G, Beaudoin G, Labelle H, Dubois J, Miron MC, Parent S.
Diagnostic imaging of spinal deformities: reducing patients radiation dose with a
new slot-scanning X-ray imager. Spine (Phila Pa 1976). 2010;35(9):989-94.
EOS I M AG I N G O F T H E H U M A N P E LV I S : R E L I A B I L I T Y, VA L I D I T Y,
AND C O N T R O L L E D C O M PA R I S O N W I T H R A D I O G R A P H Y
In summary, the EOS imaging technique was demon-
strated to possess a combination of low radiation and excellent
image quality, and it therefore proved to represent a serious
alternative to conventional radiography for primary imaging in
the pediatric population as well as in adults in certain cases.
One of the obvious shortcomings of the technique at the present
time is the lack of wide availability of the system. Its application
for pelvic imaging, like its application for spine imaging, is likely
to increase with time. Further prospective in vivo studies to sub-
stantiate the current radiographic indices, parameters, and
grading systems are essential to identify any substantial differ-
ences between conventional radiographic imaging and EOS
imaging. n
Bernd Bittersohl, MD
Joana Freitas, MD
Daniela Zaps, MD
James D. Bomar, MPH
Abd R. Muhamad, MD
Department of Orthopedic Surgery,
Rady Children’s Hospital San Diego,
3030 Children’s Way, San Diego, CA 92123
Matthew R. Schmitz, MD
San Antonio Military Medical Center,
3851 Roger Brooke Drive,
Fort Sam Houston, TX 78234
Harish S. Hosalkar, MD
Rady Children’s Hospital San Diego,
15151 Almond Orchard Lane,
San Diego, CA 92131
7. Samei E, Saunders RS, Lo JY, Dobbins JT 3rd, Jesneck JL, Floyd CE, Ravin CE.
Fundamental imaging characteristics of a slot-scan digital chest radiographic
system. Med Phys. 2004;31(9):2687-98.
8. Samei E, Lo JY, Yoshizumi TT, Jesneck JL, Dobbins JT 3rd, Floyd CE Jr, McAdams
HP, Ravin CE. Comparative scatter and dose performance of slot-scan and full-field
digital chest radiography systems. Radiology. 2005;235(3):940-9.
9. Sharp IK. Acetabular dysplasia: the acetabular angle. J Bone Joint Surg Br.
1961;43(2):268-72.
10. Tönnis D, Brunken D. [Differentiation of normal and pathological acetabular
roof angle in the diagnosis of hip dysplasia. Evaluation of 2294 acetabular roof
angles of hip joints in children]. Arch Orthop Unfallchir. 1968;64(3):197-228.
11. Lazennec JY, Rousseau MA, Rangel A, Gorin M, Belicourt C, Brusson A, Catonné
Y. Pelvis and total hip arthroplasty acetabular component orientations in sitting
and standing positions: measurements reproductibility with EOS imaging system
versus conventional radiographies. Orthop Traumatol Surg Res. 2011;97(4):373-80.
12. Tannast M, Siebenrock KA, Anderson SE. Femoroacetabular impingement:
radiographic diagnosis—what the radiologist should know. AJR Am J Roentgenol.
2007;188(6):1540-52.