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Correspondence
Patrick A. Ruwe, James R. Gage, M. B. Ozonoff and Peter A. DeLuca
J Bone Joint Surg Am. 1993;75:1111-1112.

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 CORRESPONDENCE 1111

method described by Ruwe et al. must therefore be associated with tional studies, as well as experience from other institutions, will settle
a certain degree of uncertainty. We doubt that intraoperative meas- the question as to whether the presented clinical method is suffi-
urement of femoral anteversion, as was done by Ruwe et al., is ciently reliable.
sufficiently accurate to serve as the method of reference. Svein Anda, M.D., Ph.D.
Magilligan6 adhered to the suggestion of Laage et al.5 to employ Terje Terjesen. M.D., Ph.D.
the long axis of the femur for the measurement of anteversion. This University Hospital of Trondheim
line is drawn through the center of the femoral condyles and the Regionsykehuset i Trondheim
proximal part of the femoral shaft. Ruwe et al. disregarded Mag- N-7006 Trondheim, Norway
illigan’s direction and used the short proximal axis of the femoral
shaft. In this way. the anterior curvature of the femoral shaft is Dr. Ruwe, Dr. Gage, Dr. Ozonoff and Dr. DeLuca reply:
disregarded. which tends to cause an overestimation of the femoral
anteversion. In response to the detailed letter of Anda and Terjesen, we
Many of the authors’ patients had coxa valga. It is therefore acknowledge that all radiographic techniques for the measurement
a shortcoming that numerical values were not presented for the of femoral anteversion are fraught with potential errors. The main
neck-shaft angle. as this may have had practical implications for the focus of our study was to correlate the measurement of femoral
measurements. Femoral anteversion is commonly defined as the an- anteversion, as assessed by the clinical examination, with the find-
gulation of the projections of the posterior condylar line and the ing at the time of the operation. Whether or not our modifications
central femoral-neck line onto a plane perpendicular to the long axis of Magilligan’s6 radiographic techniques of measurement (which
of the femoral shaft. Magilligan6 pointed out, on the basis of his include an anteroposterior measurement to assess the neck-shaft
graph and mathematical table, that this definition causes peculiari- angle) or our method of measurement on the computerized tomog-
ties with regard to measurements in patients who have extreme raphy scans contribute to errors in measurement, as indicated by
valgus. Konig and Schult4 discussed this phenomenon further and Anda and Terjesen, we were able to demonstrate satisfactorily that
showed that the projected femoral-neck angle always approaches the clinical measurement of anteversion closely correlates with that
90 degrees when the neck-shaft angle approaches 180 degrees. The found at the time of the operation.
commonly accepted definition of femoral neck anteversion should As detailed in our article, the positioning of the Steinmann pin
consequently be questioned in femora with a large valgus deformity. and of the AO chisel was undertaken carefully. Only when a central
Substantial errors of measurement are therefore to be expected in position was obtained, as seen in both the anteroposterior and the
these cases, irrespective of which method is employed. lateral planes, were the measurements made. The fluoroscopic beam
The accuracy of the computerized tomographic measurements was centered over the femoral neck to minimize any distortion. Cer-
of Ruwe et al. may also be questioned. It has been demonstrated tainly any measurement technique that relies on the human eye for
adequately that computerized tomographic measurements, made a final determination, whether it be a clinical measurement or a
according to the methods suggested by Weiner et al.8 and by Her- radiographic measurement, will be less than perfect.
nandez et al.3, tend to lead to an underestimation of femoral ante- While valgus angulation of the femoral neck distorts the true
version7. It seems that Ruwe et al. used a variation of these methods, definition of femoral anteversion, we should point out that, in pa-
at least initially. The problem with these measurements is that the tients who have extreme valgus deformity, excessive internal rota-
proper slices must be chosen for measurement. The center of the tion of the hip is a common finding and is what one would expect
femoral head is easily defined, and the posterior condylar line is eas- from excessive anteversion.
ily determined. The difficult point to determine is the mid-portion We agree with Anda and Terjesen that any instability of the
of the lateral aspect of the femoral neck, as the anatomy of the neck knee would cause an error in measurement, especially toward an
is not usually perfectly symmetrical. Murphy et al.7 solved this prob- overestimation of the anteversion. This effect can be minimized if
lem by choosing the centroid of the femoral shaft at the base of the the reference point is shifted from the axis of the tibia to that of the
femoral neck as the mid-point. This point is different from those examining table, or conversely to the vertical position.
employed previously and has several advantages: it is easily deter- We continue to use clinical examination to assess femoral an-
mined with computerized tomography, the method is reproducible, teversion in patients who are undergoing an evaluation or who are
and it does not lead to an underestimation of femoral anteversion. to be managed with a derotational femoral osteotomy. In patients
Ruwe et al. maintained that they used this method in the final part who have had a previous operation that involves potential scarring
of their investigation, but we have doubts about whether they really about the hips, or in especially obese patients, we continue to sup-
made the measurements on the computerized tomography scans, plement our clinical measurements with computerized tomography
according to the suggestions of Murphy et al. Furthermore, fewer and to use the technique of Murphy et al.7.
measurements were made with computerized tomography than with Patrick A. Ruwe, M.D.
the other methods. This may indicate that the dedication to the Department of Orthopaedics and Rehabilitation
computerized tomographic measurements was not optimum. Yale University School of Medicine
It may be concluded that Ruwe et al. did not employ the imag- 333 Cedar Street
ing methods for determination of femoral anteversion in the best New Haven. Connecticut 06510
possible manner and that their methods contained sources of error
that must be considered. Moreover, sources of error in the intraop- James R. Gage, M.D.
erative measurements of femoral anteversion were not discussed. Gillette Children’s Hospital
We consequently maintain that this report does not permit evalua- 200 East University Avenue
tion of the reliability of imaging methods for the measurement of St. Paul, Minnesota 55101
femoral anteversion.
We have no experience with the clinical method, suggested by M. B. Ozonoff, M.D.
Ruwe et a!., that uses the maximum prominence of the trochanter Peter A. DeLuca, M.D.
major on internal rotation for measurement of femoral anteversion. Newington Children’s Hospital
However, possible laxity of the knee joint is a source of error in all 181 East Cedar Street
methods that employ 90 degrees of flexion of the knee for evalua- Newington, Connecticut 06111
tion of femoral This laxity tends to lead to an overestima-
tion of femoral anteversion. Still, if the method offered what the 1 . Brattstr#{246}m, H.: Two sources of error in measurement of the antever-
authors promise, it would be almost too good to be true. Only addi- sion angle of the femur.Acta Orthop. Scandinavica, 32: 252-256, 1962.

VOL. 75-A, NO. 7, JULY 1993

1112 CORRESPONDENCE

2. Cooper, L. A.: Understanding complex images. Perspectives from genography of the hip in children. A preliminary report. J. Bone
visual cognition. Invest. Radiol., 26: 765-768, 1991. and Joint Surg., 35-A: 387-398, April 1953.
3. Hernandez, R. J.; Tachdjian, M. 0.; Poznanski, A. K.; and Dma, 6. Magilligan, D. J.: Calculation of the angle of anteversion by means
L. S.: CT determination of femoral torsion. AJR: Am. J. Roent- of horizontal lateral radiography. J. Bone and Joint Surg., 38-A:
genol., 137: 97-101, 1981. 1231-1246, Dec. 1956.
4. K#{246}nig, G., and Schult, W.: Der Antetorsions - und Schenkel- 7. Murphy, S. B.; Simon, S. R.; Kijewski, P. K.; Wilkinson, R. H.; and
halsschaftwinkel des Femur. Probleme de rontgenologischen Bes- Griscom, N. T.: Femoral anteversion. J. Bone and Joint Surg., 69-A:
timmung und der operativen Korrektur. Stuttgart, Ferdinand 1169-1176, Oct. 1987.
Enke, 1973. 8. Weiner, D. S.; Cook, A. J.; Hoyt, W. A., Jr.; and Oravec, C. E.:
5. Laage, H.; Barnett,J. C.; Brady,J. M.; Dulligan, P.J.,Jr.; Fett, H. C., Computed tomography in the measurement of femoral antever-
Jr.; Gallagher, T. F.; and Schneider, B. A.: Horizontal lateral roent- sion. Orthopedics, 1: 299-306, 1978.

ERRATUM

In “Prosthetic Replacement of the Shoulder for the Treatment of Defects in the Rotator Cuff and the Surface of the Glenohumeral Joint”
(75-A: 485-491, April 1993), by Arntz et al., on page 486, the text should have stated that the resection was performed “with the humerus in 35
degrees of external rotation.”

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