This is an enhanced PDF from The Journal of Bone and Joint Surgery

The PDF of the article you requested follows this cover page.

Clinical determination of femoral anteversion. A comparison with

established techniques
PA Ruwe, JR Gage, MB Ozonoff and PA DeLuca
J Bone Joint Surg Am. 1992;74:820-830.

This information is current as of September 26, 2007

Reprints and Permissions
Publisher Information
Click here to order reprints or request permission to use material from this
article, or locate the article citation on jbjs.org and click on the [Reprints and
Permissions] link.
The Journal of Bone and Joint Surgery
20 Pickering Street, Needham, MA 02492-3157
www.jbjs.org
 CoprighI I 992 by The Journal of Bone iiid Joint Surgery, Incorporated

Clinical Determination of Femoral Anteversion

A COMPARISON WITH ESTABLISHED TECHNIQUES*

BY PATRICK A. RUWE. M.D.t. JAMES R. GAGE. M.D.. M. B. OZONOFF. MDI. AND PETER A. DELUCA. MDI.

NEWINGTON. CONNECTICUT

In vestigation performed at the Departments of Orthopaedic Surgery and Radiology, Newington C’hildre,z ‘s Hospital. Newington

ABSTRACT: We evaluated femoral anteversion pre- and the oblique plane passing through the femoral neck.
operatively in fifty-nine patients (ninety-one hips), us- In 1878, Mikulicz, using dried femora from specimens
ing a clinical method that we developed, Magilligan of bones of adults, measured normal anteversion of 11.6
radiographs, and computed tomographic scans. These degrees (range, -25 to +37 degrees). Additional stud-
measurements were then compared with values for an- ies on dried femora followed, with the largest and most
teversion that were obtained intraoperatively. To de- exact performed by Kingsley and Olmsted. Many studies
termine femoral anteversion clinically, the patient was claiming a new and reliable method for the determina-
placed in the prone position and the maximum lat- tion of femoral anteversion have appeared in the litera-
eral trochanteric prominence was related to the degree ture during the current century’ ‘‘‘ ‘‘

of internal rotation of the hip. Compared with compu- Early efforts to determine the degree of femoral
ted tomographic scanning and Magilligan radiographic anteversion used radiographic techniques. including flu-
determination, the clinically determined anteversion oroscopy, axial radiography, and biplane radiography. A
correlated most closely (to within 4 degrees) with the clinical method to determine femoral anteversion by
amount measured at the time of the operation. physical examination alone was discussed as early as
The clinical method was found to be superior to 1936. by Krida et al.. but the technique was incompletely
radiographic techniques for determination of the de- described and was universally condemned as maccu-
gree of femoral anteversion in children who have not rate’5’2. In 1930, Fairbank wrote that “The accurate esti-
had a previous operation about the hip. mation of the angle of antetorsion in the living subject
is a matter of considerable difficulty.” In 1931, Rogers
Excessive anteversion of the femur is a common stated that the head and neck of the normal femur are so
developmental deformity affecting rotational alignment deeply situated in soft tissue that it is impossible to
of the lower extremity in children on an idiopathic basis measure the angle of torsion by physical examination.
or due to muscle imbalance in certain neuromuscular Magilligan, with reference to his own radiographic tech-
disorders2425. The accurate measurement of femoral an- nique, wrote that “There is no conceivable way in which
teversion is important in the evaluation and selection of this method could be checked clinically.”
patients for derotation osteotomy. Wolff2725 is credited. Anteversion can be assessed clinically by determina-
through studies of the structural architecture of the fem- tion of the relative positions of the surface of the greater
oral neck, with first recognizing, in 1868, the normal trochanter and the transverse axis of the femoral con-
anterior torsion of the femur. Soutter and Bradford pro- dyles”. This method can be traced back to a doctoral
vided a precise definition of femoral anteversion: when thesis by Netter, which described the estimation of fem-
two planes are revolved through the axis ofthe shaft until oral anteversion by palpation of the maximum lateral
one plane includes a line bisecting both condyles and the prominence of the greater trochanter. With the patient
other, a line bisecting the femoral neck, the torsion is the lying supine on the examination table and the knees
difference between the inclinations of these two planes. flexed 90 degrees over the edge, the hip is internally
Thus, anteversion is represented by the intersection of rotated until the maximum prominence of the greater
the coronal plane passing through the femoral condyles trochanter is felt. Femoral anteversion is represented by
the measured arc through which the tibia moves from the
*No benefits in any form have been received or will be received original position to the position where the maximum
from a commercial party related directly or indirectly to the subject of prominence of the greater trochanter is felt laterally’.
this article. No funds were received in support of this study.
Netter found an interobserver and intraobserver van-
tDepartment of Orthopaedics and Rehabilitation, Yale Univer-
sity School of Medicine. 333 Cedar Street. New Haven. Connecticut ance of 5 to 10 degrees. However, he did not compare his
06510. determinations with those obtained by other methods or
IGillette Children’s Hospital. 200 East University Avenue. St. with actual measurements of femoral anteversion.
Paul. Minnesota 55101.
§Newington Children’s Hospital. 181 East Cedar Street. New- At present, there is no consensus concerning the
ington. Connecticut 061 1 1. optimum method for the measurement of anteversion in

820 THE JOURNAL OF BONE AND JOINT SURGERY

 CLINICAL DETERMINATION OF FEMORAL ANTEVERSION 821

FIG. 1-A
Figs. 1 -A and I -B: Technique for the clinical assessment of femoral anteversion with the patient lying in the prone position.
Fig. 1 -A: To measure the right hip. the examiner stands on the contralateral side: the left hand is used to palpate the greater trochanter while
the right hand internally rotates the hip. with the patients knee flexed to 90 degrees. At the point of maximum trochanteric prominence,
representing the most lateral position of the trochanter. the angle subtended between the tibia and the true vertical (angle of trochanteric
prominence). representing the femoral anteversion. is measured with a goniometer.

children who have cerebral palsy, congenital dislocation

of the hip. or idiopathic excessive anteversion. commonly
associated with ligamentous laxity and an in-toeing gait.
Radiographic studies evaluating the accuracy of biplane
radiography (the Magilligan technique) and computed
tomographic scanning have relied entirely on specimens
from cadavera, multiple radiographic techniques, and
interobserver variance to substantiate their conclusions.
To our knowledge, no researchers have attempted to
compare radiographic or clinical measurements with ad-
tual intraoperative values.
We have developed a clinical method at Newington
Children’s Hospital that accurately determines the de-
gree of femoral anteversion in children who have exces-
sive anteversion. The purpose of the current study was
twofold: first. to compare established radiographic meas-
unements with intraoperative measurements of femoral
anteversion, and second, to compare the clinical method
(the trochanteric prominence angle test) with actual in-
traoperative measurements.

Materials and Methods

Subjects
Between December 1. 1988, and June 1. 1990, sev-
enty-nine patients had clinical and radiographic meas-
urement of femoral anteversion and subsequently had a
proximal femoral denotation or varus denotation osteot-
omy performed by one of us (J. R. G. or P. A. D.) at FIG. 1-B
Newington Children’s Hospital. Approval was obtained Drawing demonstrating the lateral position of the greater trochan-
from the hospital’s Institutional Review Board. Charts, ter with internal rotation of the hip.

VOL. 74.A, NO. 6. JULY 1992

822 P. A. RUWE. J. R. GAGE. M. B. OZONOFF. AND P. A. Di I.tJCA

varus derotation osteotomy: three had proximal femoral

denotation bilaterally and two. unilaterally.The mean age
at the time of the operation was 8.5 years (range. four to
twenty-six years). A minority of the patients were clini-
cally obese.
Preoperative measurement of femoral anteversion
was made on Magilligan radiognaphs for forty-one pa-
tients (eighty hips), on computed tomographic scans for
twelve patients (twenty-four hips), and by physical cx-
amination for all fifty-nine patients (ninety-one hips). All
patients were operated on in the prone position, which
allowed ease and reproducibility of the intraoperative
technique of measurement.

Techniques of Measureinetit iiid Desigiz of the Study

Clinical assessment of anteversion: Clinical anteven-

sion is routinely measured with use of the trochantenic
prominence angle test in the outpatient clinics and the
Kinesiology Laboratory at Newington Children’s Hospi-
tal. All examinations were done by one of us (J. R. G. or
P. A. D.). To measure the night hip, the examiner stands
on the contralateral side of the patient. and, with the
patient’s knee flexed to 90 degrees, the examiner’s left
hand is used to palpate the greater tnochanten while
the right hand internally rotates the hip. At the point
of maximum trochantenic prominence. representing the
most lateral position of the trochanter. the neck of the
femur is parallel to the floor. The angle subtended he-
tween the tibia and true vertical, representing the femo-
Fi. 2-A ral antevension, is measured with a goniometer (Figs. 1-A
Figs. 2-A through 2-D: Technique for the intraoperative assessment and 1-B). In our experience. the method is easily mas-
of femoral anteversion.
Fig. 2-A: After a standard lateral approach to the proximal part of
tered by orthopaedic surgeons and residents as well as
the femur has been performed. biplane fluoroscopy is used to place a by physical therapists. For the purposes of this study. the
smooth Steinmann pin down the absolute center of the femoral neck measurement was made in the operating room by an
for both the anteroposterior and the lateral radiographs. With the leg
held in the vertical position. the condylar plane is horizontal. The angle
between the pin or a chisel and the horizontal axis is the true angle of
anteversion.

radiographs. operative summaries, and gait-analysis re-

ports were reviewed for all patients. Data concerning
actual (intraoperative) and clinically measured antever-
sion were gathered in a prospective manner. Patients
were included only if they had had preoperative deter-
mination of femoral anteversion by means of computed
tomography. Magilligan nadiographs, clinical examina-
tion, or a combination of the three methods, followed by
intraoperative determination. Patients who had had a
previous operation on the bone about the hip were cx-
cluded. This left fifty-nine patients (ninety-one hips) in
the study group.
There were thirty-five male and twenty-four female
patients. Of these fifty-nine patients. fifty-two had cene-
bral palsy: three, idiopathic increased femoral antever-
sion: two. congenital dysplasia of the hip: and two.
another diagnosis (poliomyelitis in one and congenital FI(. 2-B
rubella in one). Twenty-nine patients had bilateral varus DrawIng showing the skeletal orientation and position of the chisel
denotation osteotomy and twenty-five had unilateral for the intraoperative measurement depicted in Figure 2-A.

THE JOURNAL OF BONE AND JOINT SURGERY

 (‘LINI(’AL DETERMINATION OF FEMORAL ANTEVERSION 823

readily obtained in all patients. The patient’s knee was

then flexed to 90 degrees with the hip extended, the tibia
vertical, and, thus, the condylar plane horizontal. The
angle between the chisel and the horizontal axis is, by
definition, the true angle of anteversion (Figs. 2-A and
2-B). For ease and reproducibility of measurement, the
hip was then internally rotated until the chisel was par-
allel to the floor (Figs.2-C and 2-D).The angle subtended
between the tibia and the true vertical was measured
with a sterile goniometer and reported as the true femo-
ral anteversion (Figs. 2-C and 2-D).
Magilligan radiographs: The technique of Magilligan
was used to make an anteropostenior and a lateral radio-
graph for forty-one patients. For the determination of
femoral anteversion, eight points were standardized for
measurement of the anteroposterior and lateral projec-
tions (Figs. 3-A and 3-B). A line was drawn on the femur
through the central axis of the femoral neck, bisecting
the cortical borders and center of the femoral head. The
central axis was intersected by a line bisecting the prox-
imal three centimeters of the femoral cortex, distal to
the axis of the lesser trochanter. The true angle of an-
teversion was determined from the measured or appar-
ent angle through trigonometric formulae, as referenced
by Magilligan. All angles were measured by one of us
(P. A. R.), with strict adherence to the criteria just de-
scribed. Interobserver variance was determined for the

Fi. 2-C

For ease and reproducibility of measurement. the hip is internally

rotated until the chisel is parallel to the floor. The angle between the
tibia and the vertical is the measure of femoral anteversion.

independent observer (the resident, fellow, or operating-

room nurse) after the operating surgeon had positioned
the leg, and it was recorded preoperatively in the medical
record as the clinically measured anteversion. Further-
more. to eliminate bias. this clinical measurement had
been recorded earlier by a registered physical therapist
or a kinesiologist for seventeen ofthe children when they
had had preoperative gait analysis in the Kinesiology
Laboratory. These values also were compared with those
obtained by the independent observer in the operating
room.
Intraoperative determination ofanteversion: Intraop-
erative measurements were obtained for all fifty-nine
patients. After a standard lateral approach to the prox-
imal part of the femur was made with the patient in
a prone position’. biplane fluoroscopy was used and
a smooth Steinmann pin and then an AO chisel were
placed down the absolute center of the femoral neck in
both the anteroposterior and lateral projections. The
position of the chisel was altered until it was central in
the neck. and then the femur was rotated, under fluoro-
scopic control. until the chisel was in line with the femoral FIi. 2-D
shaft. With the patient prone. and elevated on support Drawing showing the skeletal orientation and position of the chisel
rolls. the external rotation required to achieve this was for the intraoperative measurement depicted in Figure 2-C.

VOL. 74-A, NO. 6. JULY 1992

824 P. A. RUWE. J. R. GAGE. M. B. OZONOFF. AND P. A. Dt[.t(A

FI(. 3-A
Figs. 3-A and 3-B: Anteroposterior and lateral radiographs showing the standardized technique for determination of the axes of the femoral
neck and shaft. A line is drawn through the central axis of the femoral neck. This line bisects the cortical horders of the neck and the center of
the femoral head and is intersected h a line bisecting the proximal three centimeters of the femoral cortex distal to the lesser trochanter. These
angles are used to calculate fenioral anteversion with use of the Magilligan nomograni.

values obtained by the chiefradiologist (M. B. 0.) and by

one senior surgeon (P. A. D.).
Computed tonographic scans: The computed tomo-
graphic scans were used to measure the femoral ante-
version in twelve patients. according to the method of
Weiner et al. and Hernandez et al. When possible. three
cuts. two proximal and one distal. were made in accor-
dance with the method of Murphy et al. The computed
tomographic scanner (model 8800: General Electric. Mil-
waukee, Wisconsin) was used with the patient in the
supine position. All measurements were made by the
chief radiologist (M. B. 0.).

Results
The clinical and radiographic determinations of fem-
oral anteversion were compared with the actual angle of
femoral anteversion that had been obtained intraopera-
tively. Linear regression was performed on the data with
use of tests of concordance, and a correlation coefficient
was established in accordance with the line of regression.
Anteversion (leterini/zed cluuicallv compared is’it/i ac-
tual anteversion deterituned intraoperativelv ( Figs. 4-A
and 4-B): The clinical determination of femonal anteven-
sion most closely approximated the actual, intraopera-
tively determined value. On the right side, the mean
difference was 3.5 ± 3.9 degrees (range. -10 to +12 de-
grees). On the left side. the mean difference was 4. 1 ± 3.2
degrees (range, -10 to +10 degrees). The Pearson come-
lation coefficient R value was 0.930 for the right hip and
0.877 for the left hip. FI;. 3-B

TIlE JOURNAL OF l1()NI ANI) JOINT SURGERY

 CLINICAL DETERMINATION OF FEMORAL ANTEVERSION 825

90

80

70
I-

60
-a

I-
C.)
50

40

30

20
20 30 40 50 60 70 80 90

CLINICAL RIGHT
(degrees)
FIG. 4-A

I.-
ILl
-.

I-
C.)

30 40 50 60 70 80 90
CLINICAL LEFT

(degrees)
FIG. 4-B
Figs. 4-A and 4-B: Graphs showing the relationship between the values for actual and clinical femoral anteversion, determined by
intraoperative measurement and clinical assessment of the right (Fig. 4-A) and left (Fig. 4-B) hips.

Anteversion determined on Magilligan radiographs graphs was the least accurate method for the estimation
compared with actual anteversion determined intraoper- of femoral anteversion. On the right side, the mean dif-
atively (Figs. 5-A and 5-B): The use of Magilligan radio- ference was 9.6 ± 8.4 degrees (range, -30 to #{247}15
degrees).

VOL. 74-A, NO. 6. JULY 1992

826 P. A. RUWE. J. R. GAGE. M. B. OZONOFF. AND P. A. DiLtiCA

I-
=
C-,

I-
C-)

20 30 40 50 60 70 80

MAGILLIGAN RIGHT
(degrees)
FIr;. 5-A

80

70

I-
U- 60
UI

I-
0 50
4

40

30
20 30 40 50 60 70 80
MAGILLIGAN LEFT
(degrees)
FI. 5-B
Figs. 5-A and 5-B: Graphs showing the relationship between the values for actual and clinical femoral anteversion, determined by
intraoperative measurement and Magilligan radiographs of the right (Fig. 5-A) and left (Fig. 5-B) hips.

On the left side, the mean difference was 9.5 ± 9.1 degrees ments obtained by two of us (P. A. R. and P. A. D.) were
(range, -44 to +27 degrees). The Pearson R value was compared, and the mean intraobserver difference was
0.438 for the right hip and 0.399 for the left hip. Measure- 4.6 ± 4.5 degrees (range of reproducibility, -15 to +3

THE JOURNAL OF BONE AND JOINT SURGERY

 CLINICAL DETERMINATION OF FEMORAL ANTEVERSION 827

70

60

I-
I 50

I-
40
0
4

30

20
-20 -10 0 10 20 30 40 50

CT SCAN RIGHT
(degrees)
FIG. 6-A

70

60
I-
U-
UI

0
4
50

40
20 30 40 50 60
CT SCAN LEFT
(degrees)
FIG. 6-B
Figs. 6-A and 6-B: Graphs showing the relationship between the values for actual and clinical femoral anteversion, determined by
intraoperative measurement and computed tomographic scanning of the right (Fig. 6-A) and left (Fig. 6-B) hips.

degrees). The Pearson R value was 0.941. operatively (Figs. 6-A and 6-B): The determination of
Anteversion determined on computed tomographic femoral anteversion on computed tomographic scans
scans compared with actual anteversion determined intra- consistently resulted in underestimation of the actual

VOL. 74-A, NO. 6. JULY 1992

828 P. A. RUWE. J. R. GAGE. M. B. OZONOFF. AND P. A. DELUCA

angle of femoral anteversion. On the right side, the mean Recognition of this principle led to studies by other
difference was -29.6 ± 31.8 degrees (range, -12 to -50 investigators. In 1953, Dunlap et al. reported on their use
degrees). On the left side, the mean difference was -19.5 of mathematical formulae to compensate for underesti-
± 22.5 degrees (range, -9 to -34 degrees). The Pearson R mation secondary to abduction. They included a special
value was 0.557 for the right hip and 0.363 for the left hip. apparatus for precise positioning of the extremity for a
Preoperative clinical measurements: Measurements lateral radiograph at 10 degrees of abduction and 90
obtained by us and by the physical therapist or kinesiol- degrees of flexion at the hip and knee. A lateral radio-
ogist were compared, and the mean difference was 5.2 ± graph is used to measure the apparent angle of torsion.
11 degrees (range of reproducibility. 0 to +15 degrees). A posteroantenior radiograph, made with the patient in
The Pearson R value was 0.774. the prone position, was used to show the apparent angle
of inclination. The true angle of torsion was calculated
Discussion from these apparent angles by means of a trigonometric
Precise measurement of femoral anteversion is im- formula.
portant in the selection of patients and the preoperative Another study based on this principle was simulta-
planning for denotation osteotomy of the femur. An- neously reported by Ryder and Crane. Again, a special
teversion should be documented by a method that is positioning apparatus was used to make an abduction
accurate, easily available, and reproducible. radiograph, with the hip and knee in 90 degrees of flexion
The results of this study indicate that, in the young and the thigh abducted 30 degrees. The anteropostenior
population of patients at our institution, femoral an- radiograph was then made without changing the position
teversion can be accurately measured by the clinical test of the tube or the x-ray beam. The projected angle of
that we have described. This measurement correlates anteversion on the abduction radiograph and the pro-
well with intraoperative measurements and is more ad- jected angle of inclination on the anteropostenior radio-
curate than commonly used radiographic techniques. graph were measured. The true torsion was measured by
Early efforts to determine femoral anteversion in- reference to a standardized table, in which the angles
volved fluoroscopy, axial radiography, or biplane radiog- were derived from trigonometric calculations’.
raphy. On the basis of previous work by Stewart and Three years later, Magilligan presented his variation
Karshner, Rogers described a procedure in which the of these techniques; that method is employed at Newing-
patient lies prone on a fluoroscopic table, with the hip ton Children’s Hospital. The position of the patient and
extended and the knee flexed to 90 degrees. and with a of the extremities remains constant, whereas the direc-
tube placed directly below the hip. The hip is externally tion of the x-ray beam is changed, which eliminates the
rotated under fluoroscopic control until the shadow of need for a special positioning device. A standard an-
the femoral head is directly in line with the femoral shaft; teropostenior radiograph is made with the knee directly
thus, the axial plane of the femoral neck is directly in the forward. For the lateral radiograph, the cassette is held
path of the x-ray beam. The proximal end of the femur is against the lateral portion of the patient’s trunk and the
thus in a known position, and the rotation of the distal x-ray tube is placed between the thighs. The cassette is
end can be measured with the flexed leg as an indicator. held at a right angle to the diacondylar plane and parallel
A goniometer is used to determine the angle of torsion, to the previously determined long axis of the femoral
formed by the angle between the limb and the plane of neck as determined on the anteropostenior radiograph.
the table. The true angle of anteversion is then calculated with use
In 1952, Dunn described an axial radiographic tech- of trigonometric functions, from the projected angles of
nique. With the patient lying in the supine position, the cervical-femoral anteversion.
hip and knee are flexed to 90 degrees and held by a To assess the accuracy of these methods, those au-
special support. The x-ray beam is directed vertically thors34’22’ took a normal femur and replaced the neck
along the femoral shaft so that the femoral condyles and trochantenic regions with a metal rod that could be
appear superimposed on the femoral neck. The angle rotated to simulate different degrees of anteversion. Ry-
between the transcondylar plane and the neck is mea- den and Crane found errors of ±10 degrees. In a clinical
sured directly on the radiograph. The problem with this setting, however, measurements of anteversion that are
method, inherent to all radiographic methods, is that the made with these techniques are subject to error from at
shadows of the condyles and of the soft tissue about the least two additional sources: inaccurate positioning of
hip overlie the femoral neck and obscure it. Therefore, the patient for the radiographs and inaccurate location
Dunn abducted the limb 15 degrees. By altering the of the axes on measurement of the radiographs.
position of the shaft, he produced a projected angle of At our institution, large discrepancies between intra-
the femoral neck and a projected angle of antevension, operative and radiographic determinations of femoral
neither of which represented the true values of these anteversion that are found with biplane radiography are
angles. In response, Dunn added a crude conversion table probably the result of inaccurate positioning of the pa-
to account for relative underestimation of anteversion tient when Magilligan radiognaphs are made. In the cur-
secondary to abduction. rent study, great effort was made to locate the axes on

THE JOURNAL OF BONE AND JOINT SURGERY

 CLINICAL DETERMINATION OF FEMORAL ANTEVERSION 829

the radiographs accurately and in a uniform fashion; to the clinical examination. Most authors have been quick
this end, our results show an acceptable intraobserven to condemn this method as inaccurate and have relied
variance between two of us (P. A. R. and P. A. D.). instead on internal notation of the hip of more than 70
In 1979. Ruby et al. compared the three established degrees as presumptive evidence of increased anteven-
methods: fluonoscopy. axial radiography. and biplane ma- sion and on radiographic methods for determination57’.
diography, in both a cadaver model and in thirty-two No previous study that we are aware of has compared
children,eighteen ofwhom had rotational abnormalities. clinical determinations with actual intraoperative find-
He found only small differences with regard to accuracy ings. In fact, no study, to our knowledge. has compared
in determinations of anteversion in the cadaver model the results of biplane radiography or computed tomog-
(average error. ±5 degrees). The fluoroscopic method was raphy with actual intraoperative measurements in chil-
the most accurate and the biplane model, the most repro- dren: these studies have instead relied on results derived
ducible and the safest in terms of exposure to radiation2’. from the dried femona of adult cadavera or from models
Recently, technical difficulties as well as the lack of that were constructed with polymenized methylmethac-
precision of earlier methods have led to the use of rylate on metal pins and rods to replace the femoral neck
cross-sectional computed-tomographic images to mea- and trochantenic regions of the femora of cadavera.
sure anteversion directly. In early descriptions, a cut was Modern techniques for computed tomographic de-
made through the distal femoral condyles, and the axes termination of femoral anteversion have been shown
ofthe femoral neck were approximated on a single image to be accurate to within ±1 degree in cadaver models’5.
somewhere along the neck. Despite these crude methods, Even if such accuracy could be achieved in actual clinical
intnaobserver and interobserver differences of as little as application, one might question the need for this degree
2 to 3 degrees were reported57. Again. however, deter- of precision to make screening decisions for denota-
minations of actual femoral anteversion were not made. tion osteotomy. At our institution, techniques for palpa-
Murphy et al. recently investigated these findings, tion of the trochantenic prominence have been clearly
using previously described techniques on specimens defined, quickly mastered, and widely applied in outpa-
from cadavera. They found anteversion to be underesti- tient clinics and the operating room. We believe that the
mated by an average of 10 degrees and reproducible only mean errors of 3.5 and 4.0 degrees for clinically deter-
to within 3.6 degrees. By making two transverse cuts, the mined anteversion that were found in the current study
first through the femoral head and the second through provide sufficient accuracy for clinical decision-making.
the base of the femoral neck, and by using the posterior While we did not specifically study intnaobserver error,
aspects of the femonal condyles, these authors achieved we consider a mean intenobserver error of S degrees to
accuracy to within ±1 degree. In addition, they showed be acceptable in our population of patients. Magilligan
that most techniques consistently underestimate the radiognaphs and computed tomographic scans are no
femoral antevension in models by approximately 10 de- longer routinely made pneopenatively at our institution
grees. At our institution. techniques of computed to- for all patients who are to have a derotation osteotomy.
mographic scanning have been refined, and recent scans but these studies are still used for patients who have had
have proved more accurate; however, as described by a previous operation about the hip. Scarring, intracapsu-
Murphy et al., these methods still consistently under- lam adhesions. and, perhaps. obesity might limit the reli-
estimate actual femoral anteversion. Since most of our ability of the clinical evaluation. We believe that final
patients had cerebral palsy, the associated coxa valga decisions regarding the exact degree of denotation are
may have contributed to the difficulty with computed best left to intraoperative determination and not to pre-
tomographic measurement. More cuts through the fern- operative radiographic evaluation.
oral neck may increase the accuracy of definition of the Finally, our clinical technique offers clinicians the
neck areas. ability to determine, accurately and quickly. values for
It has been known, at least since Netter’s work in femoral anteversion for diagnostic and therapeutic pun-
1940, that the actual angle of femoral anteversion can be poses, while minimizing expenses and limiting the expo-
approximated by a method of measurement used during sure of these young patients to radiation.

References
I . Berman, Laurence; Mitchell, Rhiannon; and Katz, David: Ultrasound assessment of femoral anteversion. A comparison with computerised
tomography. ]. Bone and Joint Surg.. 69-B(2): 268-270. 1987.
2. Burr, D. B.; Cook, L. T.; Cilento, E. V.; Martin, N. L.; Lark, Dick; and Asher, Marc: A method for radiographically measuring true femoral
rotation. C/in. Ort/zop., 167: 139-144. 1982.
3.

4.
Dunlap,
femur. J. Bone
Dunn,
Knox;

D. M.: Anteversion
Shands,
and Joint
A. R., Jr.; Hollister,
Surg.,
ofthe
35-A:
neck
289-3
ofthe
,
L. C., Jr.; Gaul,
1 1 April
femur.
1953.
A method
J. S., Jr.; and

of measurement.].
Streit, H. A.: A new

Bone
method

atli/Joint Surg.,
for determination

34-B(2): 181-186.
of torsion

1952.
of the

S. Fabry, Guy; MacEwen, G. D.; and Shands, A. R., Jr.: Torsion of the femur. A follow-up study in normal and abnormal conditions. ]. Bone
andJoint Surg., 55-A: 1726-1738, Dec. 1973.
6. Fairbank, H. A. T.: Congenital dislocation ofthe hip: with special reference to the anatomy. British J. Siirg.. 17: 380-416. 1930.

VOL. 74-A, NO. 6. JULY 1992

830 P. A. RUWE. i. R. GAGE. M. B. OZONOFF. AND 1’. A. I)iLUCA

7. Gelberman, R. H.; Cohen, M. S.; Desai, S. S.; (,rifTin, P. P.; Salamon, P. B.; and O’Brien, T. M.: Femoral anteversion. A clinical assessment
of idiopathic intoeing gait in children. .1 Bone (111(1 Joint Siirg., 69-B( I ): 75-79. 1987.
8. Hernandez, R.J.;Tachdjian, M. 0.; Poznanski, A. K.; and Dias, L. S.: CT determination of femoral torsion. A]R:Am. ]. Roentgeno/.. 137:
97-101. 1981.
9. Kingsley, P. C., and Olmsted, K. L.: A study to determine the angle of anteversion of the neck of the femur. .1. Bone and ]oint Surg.. 30-A:
745-751. July 1948.
10. Kling,T. F.,Jr., and Hensinger, R. N.: Angular and torsional deformities of the lower limbs in children. C/in. Ortliop., 176: 136-147. 1983.
1 1. Krida, Arthur; Colonna, P. C.; and Carr, F. J., Jr.: Analysis of results of early treatment of congenital dislocation of the hip by manipulation
and osteoclasis for anterior distortion.]. Bone anil]oint Surg.. 18: 1018-1026. Oct. 1936.
I 2. Magilligan, D. J.: Calculation of the angle of anteversion by means of horizontal lateral roentgenography. ]. bite and Joint Surg.. 38-A:
l23l-l246.Dec. 1956.
13. Mikulicz, Johann: Ueher individuelle Formdifferenzen am Femur und an der Tibia des Menschen. Mit BerOcksichtigung der Statik des
Kniegelenks. Arc/i. Anat. itizi/ P/ivsiol., 1: 351-404, 1878.
14. Moulton, A., and Upadhyay. S. S.: A direct method of measuring femoral anteversion using ultrasound. .1. Bone tz,i/ ]oint Surg., 64-B(4):
469-472. 1982.
15. Murphy, S. B.; Simon, S. R.; Kijewski, P. K.; Wilkinson, R. H.; and Griscom, N. T.: Femoral anteversion. J. Bone and Joint Sari,’., 69-A:
I 169-1 176. Oct. 1987.
16. Netter, Robert: Role de l’anteversion du col’fmoral dans la statique de Ia hanche normale et pathologique. These pour Ic doctorat en
m#{233}decine. Paris. Legrand. Amede. 1940.
I 7. Peterson, H. A.; Klassen, R. A.; McLeod, R. A.; and Hoffman, A. D.: The use of computerised tomography in dislocation of the hip and

I 8.
19.
femoral
Rogers,
Root, Leon,
neck

and
anteversion
S. P.: A method
Siegal,
for
Tzony:
in children.].
determining
Osteotomy
Bone
the
of the
and]oint
angle of torsion
hip
Surg.,

in children:
63-B(2):
of the neck
posterior
198-208.
of the
approach.
1981.
femur.
].
J. Boize
Bone
and
and Joint
]oint Surg.
Sort,’..
, 13: 821 -824.
62-A: 571-575.
Oct.
June
1 931.
1980.
20. Ruby, Leonard; Mital, M. A.; O’Connor, John; and Patel, Upendra: Anteversion of the femoral neck. Comparison of methods of
measurement in patients. J. Bone and Joint Sing. . 6 1-A: 46-5 1. Jan. 1979.
21. Ryder, C. T., and Crane, Lawrence: Measuring femoral anteversion: the problem and a method. ]. Bone tln(/ Joint Sort,’.. 35-A: 32 1-328.
April 1953.
22. Shands, A. R., Jr., and Steele, M. K.: Torsion of the femur. A follow-up report on the use of the Dunlap method for its determination.].
Bone and Joint Surg.. 40-A: 803-8 16. July 1958.
23. Soutter, Robert, and Bradford, E. H.: Twists in normal and in congenitally dislocated femora. New York Med. ]., 78: 1071 - 1077, 1903.
24. Staheli, L. T.: lorsional deformity. Pediat. C/i,,. North America, 24: 799-81 1 . 1977.
25. Staheli, L. T.; Duncan, W. R.; and Schaefer, Ethel: Growth alterations in the hemiplegic child. A study of femoral anteversion. neck-shaft
angle. hip rotation. CE. angle. limb length and circumference in 50 hemiplegic children. Cliii. Orthop.. 60: 205-212. 1968.
26. Stewart, S. F., and Karshner, R. G.: Congenital dislocation of the hip. A method of determining the degree of antetorsion of the femoral
neck. Am. ]. Roentgeno/., 15: 258-260. 1926.
27. Weiner, D. S.; Cook, A. J.; Hoyt, W. A., Jr.; and Oravec, C. E.: Computed tomography in the measurement of femoral anteversion.
Orthopedics, I : 299-306. 1978.
28. Wolff, Julius: Dos Gcsetz (icr Transfrl?latioll (icr Knoc/u’n. Berlin, Hirschwald. 1892.

FIlE JOURNAl. OF BONE AND JOINT SURGERY