Clin Orthop Relat Res (2018) 476:1680-1684
DOI 10.1097/01.blo.0000534679.75870.5f
In Brief
Classifications in Brief: Tönnis Classification of Hip Osteoarthritis
Boris Kovalenko MD, Prashoban Bremjit MD, Navin Fernando MD
Received: 1 September 2017 / Accepted: 8 March 2018 / Published online: 17 July 2018
Copyright © 2018 by the Association of Bone and Joint Surgeons
History
Hip osteoarthritis represents one of the most prevalent
diseases affecting older adults, consistently ranking as one
of the most common causes of functional disability in ad-
dition to carrying an immense socioeconomic burden [20].
Published reports from the World Health Organization
indicate that approximately 10% of men and 18% of
women older than 60 years of age have symptomatic os-
teoarthritis [29]. The level of functional disability can be
highly variable, but it is estimated that approximately 80%
of those with osteoarthritis have some limitation in
movement and up to one-third of them can be considered
“severely disabled.” It is an issue that will only increase in
incidence over time, because it is estimated that the pro-
portion of people older than 60 years of age will triple by
2050 [29] Ackerman et al. [1] reviewed the lifetime risk of
THA in males and females using registry data from five
countries, finding the lifetime risk to be as high as one in
seven women in Norway and one in 10 men in Finland by
2013; women consistently had higher lifetime risks of THA
in their review. Epidemiologic studies evaluating hip os-
teoarthritis have demonstrated marked regional differences
in the prevalence of the disease with Asians and Africans
having a prevalence of 1.2% and 2.8% and North
Each author certifies that he or she has no commercial associations
(eg, consultancies, stock ownership, equity interest, patent/
licensing arrangements, etc) that might pose a conflict of interest
in connection with the submitted article.
University of Washington, Seattle, WA, USA
N. D. Fernando (✉), University of Washington, 10330 Meridian
Avenue N, Suite 270, Seattle, WA 98133, USA, email: navinf@uw.edu
All ICMJE Conflict of Interest Forms for authors and Clinical Or-
thopaedics and Related Research® editors and board members are
on file with the publication and can be viewed on request.
Copyright Ó 2018 by the Association of Bone and Joint Surgeons. Unauthorized reproduction of this article is prohibited.
Americans and Europeans having a prevalence of 7.2% and
20.1%, respectively [12, 14].
Numerous classification systems for hip osteoarthritis
have been proposed, including the Tönnis classification,
Croft classification [13] as well as the Kellgren-Lawrence
classification previously reviewed in this section [17].
The Tönnis classification originally rose from a series of
research articles published in 1972 by Professor Dietrich
Tönnis and his colleagues in Dortmund, Germany [5, 6].
The aim of these studies was to develop a quantitative
method to differentiate between normal and dysplastic ju-
venile hips. In their article entitled “A New Method for
Roentgenologic Evaluation of the Hip Joint—the Hip Fac-
tor,” the authors assessed 817 adult hip radiographs (patient
age 21-50 years, excluding patients who had undergone hip
surgery) to develop a quantitative measurement for assess-
ing hip dysplasia, ie, “the hip factor.” As part of the analysis,
the authors grouped the patients into three separate grades of
osteoarthritis based on the evaluation of a standard AP pelvis
radiograph, which became the foundation of the classifica-
tion scheme now bearing Tönnis’ name [6].
Purpose
Creating a new classification system for a particular pa-
thology may be done for a number of reasons such as to
improve effectiveness of communication among providers
and/or researchers or even to dictate management of the
pathology. Tönnis’ classification was initially created by
him and his colleagues for the purposes of research to serve
as a qualitative grade for severity of degenerative radio-
graphic changes in adults [6] and was later used by Tönnis to
correlate femoral/acetabular anteversion to severity of ar-
throsis [25]. In these articles, nothing is said regarding the
choice to create a new system in light of other systems
having already been published at that time [16].
As a qualitative analysis based off of a plain AP radiograph
of the pelvis, the Tönnis classification offers the advantage of
 Volume 476, Number 8
easy application to a clinic setting when compared with
schemes requiring advanced imaging or quantitative meas-
urements. Such characteristics make the scheme appealing for
use in daily clinical practice as a potential tool to help sub-
divide surgical management. This warrants exploration into
the reliability, and moreover the possibility in guiding man-
agement, of the Tönnis classification.
Description of the Tönnis Classification
The Tönnis classification, as originally described in 1972
by Busse et al. [6], consists of three progressive degrees of
degenerative changes to the hip; it was later republished
by Tönnis and Heinecke in 1999 [25] with the addition of
a Grade 0, or hip absent of arthrosis. Grade 1 indicates
slight narrowing of the joint space, slight lipping at the
joint margin, and slight sclerosis of the femoral head or
acetabulum; Grade 2 indicates the presence of small bony
cysts, further narrowing of the joint space, and moderate
loss of femoral head sphericity; Grade 3 is the most severe
and indicates large cysts, severe narrowing of the joint
space, severe femoral head deformity, and avascular ne-
crosis (Table 1).
In addition to Tönnis’ classification, there have been
a number of other well-described classification schemes for
osteoarthritis; these include schemes published by Croft [13],
Kellgren-Lawrence [16], the International Knee Docu-
mentation Committee [30], Fairbank [15], Altman et al. [3],
and Ahlbäck [2]. Of the aforementioned classifications,
only the Kellgren-Lawrence and Croft classifications are
applicable to the hip with the remainder describing the knee
specifically. The Kellgren-Lawrence scale is a 5-point
grading scale from 0 to 4;0 indicates no joint space nar-
rowing nor reactive changes (no osteoarthritis [OA]); 1
indicates doubtful joint space narrowing with possible
lipping osteophytes (doubtful OA); 2 indicates definite
osteophytes with possible joint space narrowing (mild
Table 1. Tönnis grading scale of hip osteoarthritis
Grade Radiographic features
0 - No signs of osteoarthritis
1 - Slight narrowing of joint space
- Slight lipping at joint margin
- Slight sclerosis of the femoral head or acetabulum
2 - Small cysts in the femoral head or acetabulum
- Increasing narrowing of joint space
- Moderate loss of sphericity of the femoral head
3 - Large cysts
- Severe narrowing or obliteration of joint space
- Severe deformity of the femoral head
- Avascular necrosis
Copyright Ó 2018 by the Association of Bone and Joint Surgeons. Unauthorized reproduction of this article is prohibited.
Tönnis Classification of Hip Osteoarthritis 1681
OA); 3 indicates moderate osteophytes with definite joint
space narrowing, some sclerosis, and possible bony de-
formity (moderate OA); and 4 indicates progression to
large osteophytes, severe sclerosis, and definite bone end
deformity (severe OA). Croft et al. [13] devised a 6-point
grading scale from 0 to 5; 0 indicates no radiographic ab-
normalities; 1 indicates only osteophytosis; 2 indicates joint
space narrowing only; 3 indicates the presence of two out of
the following: osteophytosis, joint space narrowing, pres-
ence of cysts, and subchondral sclerosis; 4 indicates three of
the aforementioned criteria; and 5 indicates progression to
femoral head deformity.
Validation and Reliability
The Tönnis classification is widely utilized by arthroplasty
surgeons, arthroscopic surgeons, rheumatologists, radiol-
ogists, and physical therapists [4, 9, 10, 24]. Despite its
widespread use, the utility of the Tönnis classification has
been a point of contention because of conflicting data re-
garding its reliability [7, 11, 18, 19, 23, 27, 28].
In a 2008 study that included 63 patients who un-
derwent a Bernese periacetabular osteotomy approxi-
mately 20 years prior, Steppacher et al. [23] evaluated the
validity of the Tönnis classification using two orthopaedic
surgeons to grade 50 pelvic radiographs on two separate
occasions. They found substantial interobserver (k =
0.74) and intraobserver reliability (k = 0.73-0.76) using
the standardized Landis and Koch benchmarks for
agreement [18, 23].
Clohisy et al. [11] evaluated reliability using 77
patients with femoroacetabular impingement, develop-
mental dysplasia of the hip, or no hip pain and found
slightly lower reliability than that of Steppacher et al.
with moderate interobserver reliability (k = 0.59) and
intraobserver reliability (k = 0.60). Their study used five
hip specialists as well as a fellow to interpret the images.
The authors attributed the lower agreement in their re-
port compared with that of Steppacher to the inclusion of
a control group.
By contrast, a critical review of the Tönnis classification
used three orthopaedic surgeons to classify the hip radio-
graphs of 61 patients by Tönnis grade, divided into two
cohorts (one included candidates for hip preservation sur-
gery, whereas the control group consisted of patients
without hip pain). This study found only slight to fair in-
terobserver reliability (k = 0.173-0.397) and fair intra-
observer reliability (k = 0.364-0.397). The most frequent
cause of disagreement in this study involved differentiating
Grade 0 from Grade 1 hips [28].
Nepple et al. [19] also focused on younger patients with
hip pain in a study evaluating 25 radiologic parameters
 1682 Kovalenko et al.
of dysplasia and OA in 70 patients undergoing hip preser-
vation surgery. Four hip specialists interpreted the radio-
graphs. The average patient age was 31 years, and 55 of the
70 patients had femoroacetabular impingement with the
remainder diagnosed with acetabular dysplasia. They
found grading patients by the Tönnis classification had
only fair interobserver reliability (k = 0.22) and moderate
intraobserver reliability (k = 0.53). Like Valera et al. [28],
the radiographs in this study were weighted heavily toward
early arthritis with only 4.5% of patients graded as either
Grade 2 or 3. In contrast, joint space width was found to
have substantial inter- and intraobserver reliability (k =
0.62 and 0.71, respectively) [19].
Another reliability analysis by Carlisle et al. used five
physicians of various disciplines and levels of training to
evaluate 45 patients with developmental dysplasia of the
hip, femoroacetabular impingement, or normal anatomy.
One orthopaedic attending, two physiatry attendings,
one orthopaedic fellow, and two orthopaedic residents
interpreted the images. They found only slight interob-
server agreement for Tönnis grade (k = 0.17) but moderate
intraobserver reproducibility (k = 0.57) [7].
In a study by Troelsen et al. [26], four observers
(medical student, orthopaedic resident, orthopaedic at-
tending, and radiology attending) reviewed 25 pelvic
radiographs and subsequently their associated CT scans
and graded them according to Tönnis’ classification. They
found poor interobserver reliability with k values ranging
from -0.02 to 0.33; they found that interobserver agreement
increased when Tönnis grade was dichotomized to Grades
0 to 1 and 2 to 3 (k values 0.20-0.39) and that joint space
width < 2 mm on plain radiographs was a more reliable
marker of OA (k values 0.40-0.46) [27].
Limitations
The development of the Tönnis classification system was
based on studies that specifically focused on the hip. By
extension, it most directly applies to a spheroidal (ie, ball-
and-socket) synovial joint that is reinforced by
the presence of a fibrocartilaginous lip (the acetabular
labrum). Because other diarthrodial joints have different
anatomy, and different roles in weightbearing and mo-
tion, the Tönnis grading system cannot be applied
broadly to all joints.
Studies on the classification seem to suggest less val-
idity in its lower grades because studies with higher num-
bers of low-grade OA demonstrate lower validity for the
Tönnis classification [11]. This is especially important in
one common application of the Tönnis classification,
which is to help guide the decision of whether a patient may
be a good candidate for hip preservation surgery, which is
Copyright Ó 2018 by the Association of Bone and Joint Surgeons. Unauthorized reproduction of this article is prohibited.
Clinical Orthopaedics and Related Research®
known to be less effective in patients who have even mild
arthritis [31]. In addition, because the Tönnis classification
relies exclusively on radiographic findings, other variables
that may play a role in the success of hip preservation
surgery (such as articular cartilage health, three-
dimensional femoroacetabular anatomy, labral integrity,
among others) obviously are not considered under the
Tönnis rubric, and adequate evaluation of those factors
generally calls for advanced imaging.
Ultimately, a major criticism of the Tönnis classification
system is that it is subjective. The Tönnis classification has
been criticized as being unclear in its terminology as well as
for its failure of overlapping parameters [28]. Five major
radiographic findings are used in the classification: pres-
ence of sclerosis, joint space width, head sphericity, cyst
size, and osteophyte formation, the latter of which is de-
scribed as “lipping at the joint margins.” None of these
parameters includes quantitative definitions. For example,
Tönnis Grade 2 arthritis includes “small” subchondral
cysts, and Grade 3 is defined by “large” cysts, but there are
no sizes designated in the original article.
In addition, Tönnis’ original article does not help the
user decide which grade to use if findings from two dif-
ferent grades are present on one radiograph. For example,
if a patient has moderate loss of sphericity of the femoral
head (a Tönnis Grade 2 finding) alongside only slight
narrowing of the joint (a Grade 1 finding)—such as might
occur in a patient with early Legg-Calvé-Perthes
disease—the Tönnis classification is unclear about
whether this would be a patient with Grade 1 or Grade 2
arthritis. Instead, the classification assumes a stepwise
progression in which all parameters radiographically
worsen over time equally in accordance with the de-
scribed classification, which is not always the case. As
noted by Valera et al. [28], although sphericity of the
femoral head is one of the more reliably reproducible
parameters used by Tönnis, it could easily lead to con-
fusion in grading in patients with nondegenerative cam
deformity and no radiographic findings of OA.
Conclusions
Although the Tönnis classification has limitations, it
remains a simple system that provides a qualitative de-
scription of commonly obtained radiographic imaging of
the hip and continues to be frequently used in clinical
practice as well as research. It relies on the visual assess-
ment of an AP pelvis radiograph and does not require ad-
ditional time or resources to make digital or manual
measurements of the radiographs.
The subjective nature of the classification and the lack of
consensus on its reliability (particularly at early stages of hip
 Volume 476, Number 8
arthritis, where the user wishes to distinguish Grade 0 from
Grade 1 [11, 19, 28]) make it difficult to recommend its
widespread use, particularly given that alternative classifi-
cation schemes including the Kellgren-Lawrence and Croft
systems have been demonstrated in studies to be more reli-
able measures.
In a reliability study by Reijman et al. [22], the
Kellgren-Lawrence system had higher interobserver re-
liability (k = 0.68) than Croft’s (k = 0.52) and demon-
strated both a stronger association with clinical
symptoms of hip OA as well as being predictive of the
eventual need for hip replacement. Similarly, additional
studies have demonstrated support for the validity of the
Kellgren-Lawrence scheme in particular [21].
Several studies have found that patients with higher grade
Tönnis grades who undergo hip preservation surgery have
poorer patient-reported outcome scores and are more likely
to undergo premature conversion to THA [8]. This suggests
that despite the problems of reliability, the Tönnis classifi-
cation may be used to good effect as a tool of communica-
tion, prognosis, and research in the right circumstances.
In our opinion, the Tönnis classification is a straight-
forward qualitative description of a stepwise pattern of hip
OA but has limited utility in the research setting. Its re-
liability has not consistently demonstrated superiority
over other classification systems. Ultimately, without
stronger evidence supporting its reliability or validity, it
cannot be recommended as a tool with which to routinely
guide management and treatment options.
Acknowledgments We thank Michael Neininger for his work in
providing English translations of the original German Tönnis papers in
which the classification scheme was founded.
References
1. Ackerman IN, Bohensky MA, de Steiger R, Brand CA, Eskelinen A,
Fenstad AM, Furnes O, Graves SE, Haapakoski J, Mäkelä K.
Lifetime risk of primary total hip replacement surgery for osteoar-
thritis from 2003-013: a multi-national analysis using national reg-
istry data. Arthritis Care Res. 2017;69:1659–1667.
2. Ahlbäck S. Osteoarthrosis of the knee. A radiographic in-
vestigation. Acta Radiol Diagn (Stockh). 1968;Suppl 277:7–72.
3. Altman R, Asch E, Bloch D, Bole G, Borenstein D, Brandt K,
Christy W, Cooke T, Greenwald R, Hochberg M. Development of
criteria for the classification and reporting of osteoarthritis: clas-
sification of osteoarthritis of the knee. Arthritis Rheumatol. 1986;
29:1039–1049.
4. Bittersohl B, Steppacher S, Haamberg T, Kim Y-J, Werlen S, Beck
M, Siebenrock K-A, Mamisch TC. Cartilage damage in femo-
roacetabular impingement (FAI): preliminary results on comparison
of standard diagnostic vs delayed gadolinium-enhanced magnetic
resonance imaging of cartilage (dGEMRIC). Osteoarthritis
Cartilage. 2009;17:1297–1306.
5. Brückl R, Hepp W, Tönnis D. [Differentiation of normal and
dysplastic juvenile hip joints by means of the summarized hip
factor] [in German]. Arch Orthop Unfallchir. 1971;74:13–32.
Copyright Ó 2018 by the Association of Bone and Joint Surgeons. Unauthorized reproduction of this article is prohibited.
Tönnis Classification of Hip Osteoarthritis 1683
6. Busse J, Gasteiger W, Tönnis D. [A new method for roentgen-
ologic evaluation of the hip joint—the hip factor] [in German].
Arch Orthop Unfallchir. 1971;72:1–9.
7. Carlisle JC, Zebala LP, Shia DS, Hunt D, Morgan PM, Prather H,
Wright RW, Steger-May K, Clohisy JC. Reliability of various
observers in determining common radiographic parameters of
adult hip structural anatomy. Iowa Orthop J. 2011;31:52–58.
8. Chandrasekaran S, Darwish N, Gui C, Lodhia P, Suarez-Ahedo
C, Domb BG. Outcomes of hip arthroscopy in patients with
Tönnis grade-2 osteoarthritis at a mean 2-year follow-up: eval-
uation using a matched-pair analysis with Tönnis grade-0 and
grade-1 cohorts. J Bone Joint Surg Am. 2016;98:973–982.
9. Cibulka MT, Threlkeld J. The early clinical diagnosis of oste-
oarthritis of the hip. J Orthop Sports Phys Ther. 2004;34:
461–467.
10. Clohisy JC, Carlisle JC, Beaulé PE, Kim Y-J, Trousdale RT,
Sierra RJ, Leunig M, Schoenecker PL, Millis MB. A systematic
approach to the plain radiographic evaluation of the young adult
hip. J Bone Joint Surg Am. 2008;90(Suppl 4):47–66.
11. Clohisy JC, Carlisle JC, Trousdale R, Kim Y-J, Beaule PE,
Morgan P, Steger-May K, Schoenecker PL, Millis M.
Radiographic evaluation of the hip has limited reliability. Clin
Orthop Relat Res. 2009;467:666–675.
12. Cooper C, Javaid MK, Arden N. Epidemiology of osteoarthritis.
In: N Arden, ed. Atlas of Osteoarthritis. Tarporley, UK: Springer
Healthcare Communications; 2014:21–36.
13. Croft P, Cooper C, Wickham C, Coggon D. Defining osteoarthritis
of the hip for epidemiologic studies. Am J Epidemiol. 1990;132:
514–522.
14. Dagenais S, Garbedian S, Wai EK. Systematic review of the
prevalence of radiographic primary hip osteoarthritis. Clin Orthop
Relat Res. 2009;467:623;637.
15. Fairbank T. Knee joint changes after meniscectomy. Bone Joint
J. 1948;30:664–670.
16. Kellgren J, Lawrence J. Radiological assessment of osteo-ar-
throsis. Ann Rheum Dis. 1957;16:494–502.
17. Kohn MD, Sassoon AA, Fernando ND. Classifications in Brief:
Kellgren-Lawrence classification of osteoarthritis. Clin Orthop
Relat Res. 2016;474:1886–1893.
18. Landis JR, Koch GG. The measurement of observer agreement
for categorical data. Biometrics. 1977;33:159–174.
19. Nepple JJ, Martell JM, Kim Y-J, Zaltz I, Millis MB, Podeszwa DA,
Sucato DJ, Sink EL, Clohisy JC; ANCHOR Study Group. In-
terobserver and intraobserver reliability of the radiographic analysis
of femoroacetabular impingement and dysplasia using computer-
assisted measurements. Am J Sports Med. 2014;42:2393–2401.
20. Nho SJ, Kymes SM, Callaghan JJ, Felson DT. The burden of hip
osteoarthritis in the United States: epidemiologic and economic
considerations. J Am Acad Orthop Surg. 2013;21(Suppl 1):
S1–S6.
21. Reijman M, Hazes J, Koes B, Verhagen A, Bierma-Zeinstra S.
Validity, reliability, and applicability of seven definitions of hip
osteoarthritis used in epidemiological studies: a systematic ap-
praisal. Ann Rheum Dis. 2004;63:226–232.
22. Reijman M, Hazes J, Pols H, Bernsen R, Koes B, Bierma-Zein-
stra S. Validity and reliability of three definitions of hip osteo-
arthritis: cross sectional and longitudinal approach. Ann Rheum
Dis. 2004;63:1427–1433.
23. Steppacher SD, Tannast M, Ganz R, Siebenrock KA. Mean 20-
year followup of Bernese periacetabular osteotomy. Clin Orthop
Relat Res. 2008;466:1633–1644.
24. Terjesen T, Gunderson RB. Radiographic evaluation of osteo-
arthritis of the hip: an inter-observer study of 61 hips treated for
late-detected developmental hip dislocation. Acta Orthop. 2012;
83:185–189.
 1684 Kovalenko et al.
25. Tönnis D, Heinecke A. Acetabular and femoral anteversion: re-
lationship with osteoarthritis of the hip. J Bone Joint Surg Am.
1999;81:1747–1770.
26. Troelsen A, Elmengaard B, Søballe K. Medium-term outcome
of periacetabular osteotomy and predictors of conversion to
total hip replacement. J Bone Joint Surg Am. 2009;91:
2169–2179.
27. Troelsen A, Rømer L, Kring S, Elmengaard B, Søballe K. Assess-
ment of hip dysplasia and osteoarthritis: variability of different
methods. Acta Radiol. 2010;51:187–193.
28. Valera M, Ibañez N, Sancho R, Tey M. Reliability of Tönnis clas-
sification in early hip arthritis: a useless reference for hip-preserving
surgery. Arch Orthop Trauma Surg. 2016;136:27–33.
Copyright Ó 2018 by the Association of Bone and Joint Surgeons. Unauthorized reproduction of this article is prohibited.
Clinical Orthopaedics and Related Research®
29. Wittenauer R, Smith L, Aden K. Background Paper 6.12 Osteoar-
thritis. Geneva, Switzerland: World Health Organization; 2013.
30. Wright RW, Ross JR, Haas AK, Huston LJ, Garofoli EA, Harris
D, Patel K, Pearson D, Schutzman J, Tarabichi M. Osteoarthritis
classification scales: interobserver reliability and arthroscopic
correlation. J Bone Joint Surg Am. 2014;96:1145–1151.
31. Zhang W, Doherty M, Arden N, Bannwarth B, Bijlsma J,
Gunther K-P, Hauselmann HJ, Herrero-Beaumont G, Jordan K,
Kaklamanis P. EULAR evidence based recommendations for
the management of hip osteoarthritis: report of a task force of
the EULAR Standing Committee for International Clinical
Studies Including Therapeutics (ESCISIT). Ann Rheum Dis.
2005;64:669–681.