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HIP Table of Contents   
Year : 2005  |  Volume : 39  |  Issue : 3  |  Page : 137-144
Femoral neck anteversion: A comprehensive Indian study


1 Department of Orthopaedics, University College of Medical Sciences and Guru Teg Bahadur Hospital, Shahdara, Delhi, India
2 Department of Anthropology, University of Delhi, Delhi, India
3 Department of Radiodiagnosis, University College of Medical Sciences and Guru Teg Bahadur Hospital, Shahdara, Delhi, India

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   Abstract 

Background: The femoral neck anteversion has important implications. Since these values are not documented for our population, we undertook this study to define this for Indian population.
Methods: FNA was calculated on 300 dry femora by the Kingsley Olmsted method, and prospectively on otherwise normal living adults by CT method (n=72 hips), by biplanar radiography (n=138 hips) and clinically (n=138 hips).
Results: The mean FNA by CT was 7.4° (SD 4.6°) and more than 75% of cases were between 3.4° and 11.4°. The mean FNA by X-ray method was 11.5° (SD 5.4°) and more than 71% of cases were between 6.5° and 16.5°. The mean, clinically, was 13.1° (SD 4.6°) and almost 75% of cases were between 9.1° to 17.1°. The mean FNA on dry femora has been calculated as 8.1° (SD 6.6°) and almost 62% of cases were between 3.1° to 13.1°. The mean FNA on right side was statistically significantly 1.7° less than on the left side. Statistically significant difference between the sexes was found only by the dry bone method (F>M = 3°).
Conclusions: Considering CT to be most accurate on living subjects, FNA in our study has been found to be 7.4° (SD 4.6°). It is 4 -12° lower than most of the western studies by all these methods. Readings are 4.1° higher by the X-ray method and 5.7° by the clinical method. Correlation and regression equations have also been formed between the various methods and the clinical method correlates better than the X-ray method to the CT method.

Keywords: Femoral neck anteversion, dry bone, CT, X-rays, clinical.

How to cite this article:
Jain A K, Maheshwari AV, Singh M P, Nath S, Bhargava S K. Femoral neck anteversion: A comprehensive Indian study. Indian J Orthop 2005;39:137-44

How to cite this URL:
Jain A K, Maheshwari AV, Singh M P, Nath S, Bhargava S K. Femoral neck anteversion: A comprehensive Indian study. Indian J Orthop [serial online] 2005 [cited 2019 Sep 19];39:137-44. Available from: http://www.ijoonline.com/text.asp?2005/39/3/137/36685

   Introduction Top


The femoral neck anteversion (FNA) has important implications in arthroplasties, evaluation of pathologic conditions of the hip and consequent various corrective osteotomies [1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19]. However, review of literature reveals a wide range of normal FNA globally without any mention about the impact of the origin of the population on this value [1],[6],[7],[9]. Racial variation is expected to exist because of different social needs of the different races. Since, Indians are more apt to floor level activities, we tend to externally rotate our hips and use them in extreme of range of motion. This would certainly make our hips to be evolutionally and morphologically different from western counterparts. No comprehensive study has been reported on the normal value of FNA on Indian population, which constitutes about 1/6 th of the world's population.

Apart on dry bones, FNA can be measured by CT, X­rays and clinically. Because of the wide variation in health infrastructure in our country, it may not be possible to get estimation by the accurate CT method every time and everywhere. Thus, it is important to know the true value of FNA in our population and its relationship to values obtained by various methods of FNA estimation. Therefore, this prospective study has been undertaken to ascertain and correlate the average FNA in Indian adults by various methods so that this figure may be applied for various orthopaedic diagnosis and procedures, well suited to Indian population.

Materials and methods

The study was conducted on:

  • Group A: Dry Bone Group
  • Group B: Clinical Group


Group A

Three hundred dry femora were studied, after differentiating their side and sex.

FNA was measured by two different methods [6],[7] :

  • The Kingsley Olmsted (KO) Method
  • The Broca Method


However, as it had been previously shown there is no statistically significant difference between these methods, we have used our results of the KO method for analysis and discussion [6] .

Group B

Patients of Group B were otherwise medically fit Indian adults. Hip pathology and osteopenic status were ruled out by appropriate clinico-radiological and biochemical examinations. Informed consent was taken in each case. This group comprised of:

  • Forty patients who underwent CT scan and X-rays around the hip region (e.g. pelvis or thigh) for primarily hip unrelated pathologies, were evaluated bilaterally by the CT, biplane X-rays and clinical methods.
  • Thirty one consecutive patients, who underwent close reduction / open reduction and internal fixation for post-traumatic fresh intracapsular fractures of neck of the femur or undisplaced intertrochanteric fractures of the femur were evaluated intraoperatively by our own devised method [9] , and bilaterally by biplane X-rays and clinical methods 3­6 months after surgery, when there was evidence of radiological union with adequate range of motion. The intraoperative results have been previously published [9].


However due to various reasons, all the patients could not be evaluated by all the methods. The FNA was finally estimated bilaterally on 36 patients (72hips) by CT method and 69 patients (138 hips) by X-ray and clinical methods. The various methods used for estimation of FNA are described below.

Kingsley Olmsted (KO) method

The femur was placed on a smooth horizontal surface (a glass sheet on a table). Two smooth blocks, 1cm in thickness, were then placed - one beneath the femoral condyles and other beneath the posterior aspect of the greater trochanter. The anteroposterior width of the neck was determined at the proximal and distal ends of the neck of femur by vernier calipers. The center points of these two ends were then marked. A 1mm Kirschner wire was then place along these two points using clay adhesive representing the central axis of the neck. This line was then continued to the surface supporting the bone. A devised protractor with a long metal arm was mounted on a base whose thickness was exactly the same as the block on which the femur was placed. By manipulating this metal arm of the protractor to the same level as the anteversion Kirschner wire under vision, when both of these appeared overlapping, the angle was read on the protractor to estimate the true angle of anteversion [Figure - 1] [6],[7].

CT scan method

A Quad Slice Siemens Somatome Plus 4 Volume Zoom body scanner was used. The patient was examined in the supine position and was strapped to a specially designed plastic footboard to immobilize his lower limbs while the proximal and distal sections were being taken. Placing sand bags further stabilized the board. Two sections were then taken [11],[20]

a) at the level of symphysis pubis through the femoral neck, including the superior border of greater trochanter.

b) at the condyles, just below the upper pole of patella.

The center of the neck was then marked at its proximal and distal ends. By joining these two points, we obtained the central axis of the neck [20] .The condylar axis was drawn by joining the two most posterior aspects of the femoral condyles 11. The angle between the axis of neck and condylar axis was measured and it ( ) represented the degree of version [Figure - 2].

Biplanar radiog1raphic method

The biplanar X-ray method described by Ogata et al 12 was used to calculate the FNA. The patient was placed supine with the knees flexed to 90° over the edge of the table and the legs suspended down. This makes the condylar axis parallel to the table. An anteroposterior (AP) film is then taken with the X-ray tube centered over the femoral neck and the beam perpendicular to the table. For the lateral roentgenogram of the femoral neck, the hip was flexed to 90° and externally rotated till the entire lateral aspect of the leg touches the table. This position rotates the femur to 90° on its long axis and the condylar axis becomes perpendicular to the table. Thus one AP and two lateral views of either side were obtained on each patient. The central axis of the neck is located on each film by a line connecting the center of the neck at its proximal and distal ends. Two points were then marked; just inferior to the lesser trochanter and 10 cms distal to the lesser trochanter. The line joining the center of the shaft at these two points represents the axis of the femoral shaft [21]. Angle was measured between the shaft axis and the neck axis on AP and lateral films [Figure - 3] . FNA of both sides was then determined by trigonometric calculations (FNA = tan of angle in lat. view / tan of angle in AP view) or by available normograms [12] .

Clinical method

The anteversion is measured clinically with the use of the trochanteric prominence angle test [15] .The patient is made to lie prone on a hard surface with knee flexed to 90° and legs vertically up. To measure the right hip the examiner stands on the contralateral (left) side of the patient. The left hand is used to palpate the greater trochanter while the right hand externally rotates the leg. At the point of maximum trochanteric prominence, representing the most lateral position of the trochanter, the neck of the femur is parallel to the ground. The angle subtended between the tibia and true vertical is measured with a goniometer, and this represents the angle of anteversion of femoral neck [Figure - 4] .

Three different readings were taken for each case by all these methods and the average of three readings was taken as final for that case. All these data was then statistically analyzed.


   Observations and results Top


A total of 300 dry femora and 71 patients (142 hips) were studied. After compilation of data, final analysis was possible on :

Dry bone method [6] - 300 bones, 147 R (right) and 153L (left), 240 M (male) and 60 F (female)

CT method-72 hips, 36 R and 36 L, 34 M and 38 F

X-ray method -138 hips, 69 R and 69 L, 78 M and 60 F

Clinical method -138 hips, 69 R and 69 L, 78 M and 60 F

The mean FNA on dry bones was 8.1° with a standard deviation (SD) of 6.6° [Table - 1]. The mean value of the male type was 7.5° (SD 6.6°) and of female type was 10.5° (SD 6.1°). The mean value of right side was 7.3° (SD 6.7°) and of left side was 8.9° (SD 6.5°). Retroversion was observed in 28 bones (9.33%). Neutral or almost neutral version (-1 to +1°) was found in 22 bones (7.33%). 15.33% of the bones were in the range of 0-5°, 57.66% range of 0-10°, 79% of the bones were in the range of 0-15°. Almost 42% of bones were in the range of 5-10°. 67% bones had anteversion less than 10° [Table - 2]. Statistical analysis using unpaired 't' test was done between the sexes and the sides. The mean of the female type bone was significantly higher than the male type bone by 3° (p= 0.002). Also the mean of left sided bone was significantly higher than the right sided bone by 1.6° (p= 0.04).

The mean FNA by the CT method was obtained as 7.4 0 (SD 4.6 0 ) [Table I,II,III]. Femoral neck retroversion was observed in 4 cases (1 bilateral and 2 unilateral) [Figure - 5]. Tests of significance were done for the two sides and the two sexes using the paired and the unpaired t- tests respectively. The mean of males was 6.3 0 (SD 5.1 0 ) and mean of females was 8.4 0 (SD 3.9 0 ). The mean of right side was 6.5 0 (SD 4.7 0 ) and of left side was 8.2 0 (SD 4.4 0 ). Statistically significant difference has been found between the right side and the left side (p= 0.002), the right side being less by 1.7 0 . No such significant difference was found between the two sexes (p= 0.05).

With the X-ray method, the mean was obtained as 11.5 0 (SD 5.4 0 ) [Table I,II,III]. Three hips also had retroversion (1 bilateral, 1 unilateral). These also showed the same with CT [Figure - 5]. The unilateral hip that showed -1 0 FNA by CT method, showed +1.6 0 by the X-ray method. The mean of males was 11.5 0 (SD 5.9 0 ) and mean of females was 11.4 0 (SD 4.7 0 ). The mean of right side was 10.6 0 (SD 5.3 0 ) and of left side was 12.3 0 (SD 5.4 0 ). Statistically significant difference has been found between the right side and the left side (p= 0.001), the right side being less by 1.7 0 . No such significant difference was found between the two sexes (p= 0.86).

Clinically, the mean was obtained as 13.1 0 (SD 4.6 0 ) [Table I]. Three hips also had retroversion (1 bilateral, 1 unilateral). The unilateral hip that showed -1 0 FNA by CT and +1.6 0 by X­ray method was -2 0 clinically. However, other unilateral hip that showed -3 0 FNA by CT and -2.8 0 by X-ray method was neutral clinically. Bilateral hips of one patient showed retroversion by all three methods. The mean of males was 12.8 0 (SD 5.2 0 ) and mean of females was 13.4 0 (SD 3.5 0 ). The mean of right side was 12.2 0 (SD 4.6 0 ) and of left side was 13.9 0 (SD 4.4 0 ). Statistically significant difference has been found between the right side and the left side (p= 0.001), the right side being less by 1.7 0 . No such significant difference was found between the two sexes (p= 0.47).

Comparison of methods: The readings obtained by all these three methods were then compared with each other [Table - 4].

CT versus clinical methods: On the right side the mean difference was 4.9° (SD 2.5°) with an agreement limit (mean difference + 2 SD) from 10.1° to -0.1°. On the left side the mean difference was 5.9° (SD 3.2°) with an agreement limit from 12.4° to -0.6°. The correlation coefficient was 0.88 for the right and 0.86 for the left side with statistically significant difference between the two methods (p= 0.001).

CT versus X-ray methods: On the right side the mean difference was 3.2° (SD 3.8°) with an agreement limit from 10.9° to -4.3°. On the left side the mean difference was 3.5° (SD 4.9°) with an agreement limit from 13.3° to -6.3°. The correlation coefficient was 0.72 for the right and 0.66 for the left side with statistically significant difference between the two methods (p= 0.001).

X-ray versus clinical methods: On the right side the mean difference was 1.6° (SD 3.4°) with an agreement limit from 8.5° to -5.3°. On the left side the mean difference was 1.6° (SD 3.9°) with an agreement limit from 9.5° to -6.3°. The correlation coefficient was 0.76 for the right and 0.69 for the left side with statistically significant difference between the two methods (p= 0.001).

Thus, clinical method shows better correlation with narrower agreement limit to the CT method, as compared to the X-rays method. Regression equations have also been derived between variables wherever there was a significant difference between different methods (right side with right side and left side with left side) using the SPSS/PC+ computerized statistical package.

Right side

FNA (X-ray) = (FNA - CT x 0.81) +4.45

FNA (X-ray) = (FNA - Clinical x 0.88) - 0.24

FNA (Clinical) = (FNA - CT x 1.02) + 4.78

Left side

FNA (X-ray) = (FNA - CT x 0.63) + 6.51

FNA (X-ray) = (FNA - Clinical x 0.84) + 0.62

FNA (Clinical) = (FNA - CT x 0.97) + 6.07


   Discussion Top


A precise measurement of femoral neck anteversion is important in various orthopaedic diagnosis and procedures[1]­ 25. It is important to know the angle of anteversion in a particular population and this should be documented by a method that is accurate, easily available and reproducible.

The accurate estimation of femoral neck anteversion in living subjects has always been difficult with lots of shortcomings and lack of reproducibility [1] . Estimation of anteversion on dry bone is considered to be the most accurate method [1]. But their greatest drawback is that involvement of femora from some of the skeletons with pathologic conditions having extreme range of values cannot be ruled out and then they may influence the statistical analysis. It is also assumed that though it may give a profile of the sample population, it may not be relevant for clinical practice since clinical measurement of the angle of anteversion may be different from those obtained on dry femora. However, it is still worthwhile to conduct this study and compare the data with various races and document the range of normal FNA and the existent racial variation. To know the different relationship between the various clinical measurements this study was also done to estimate the FNA using CT, biplane X-rays and clinical methods.

Different investigators have used various methods to determine FNA on dry bones. Since wide variation has been documented for the mean average angle, it is thought that sources of error are present in those methods regarding the precise location of the axes. We did not use the center of the head to estimate the neck axis [11] as it has been shown that majority of the femoral heads are not in the center of the femoral neck [1],[6],[7],[9],[21]. The Kingsley Olmsted method has been used in large number of bones by various authors and is considered the most accurate one till date. The Broca's methods, though indirect, uses scientific rationale and precise instruments - - thus making the study scientifically sound. We used both this method for accurate estimation and to see any difference between them. Since no statistically significant difference was found between them with a correlation coefficient of 0.99, we have used the KO method for our results [6] .

On CT, the sections through the femoral neck, where the superior border of the greater trochanter lies, shows the greatest length of the neck and thus has been used to estimate the neck axis [20] . Identification of the condylar plane is necessary for the measurement of anteversion. However, different condylar axes have been defined, eg. classic table top, widest diameter, centroid and bisector methods [11]. Although centroid method is more consistent in determining the condylar axis, the table top method is considered to be second most accurate and the most reproducible[11] . It has the best combination of simplicity and reproducibility, not only on the same image, but also on separate images. This method also has the advantage of theoretically correlating with the dry bone method and clinicoradiological methods of measurement, whereby the knee is flexed to 90°, the tibia is vertical, and the condylar plane is assumed to be horizontal. Hence it was chosen.

The biplanar X-ray technique of Ogata et al [12] requires no special equipment or positioning apparatus and can be done quickly and easily and has been found to be accurate and reproducible in clinical practice [9] . The femoral neck-shaft angle as well as FNA can be determined simultaneously. Ogata drew the axes on the roentgenograms simply by eye. However to add objectivity and reproducibility, we used the technique described by Hubbard and Staheli[21] as most of the X-rays of this region contained these points.

Netter [26] was the first one to estimate the angle of femoral anteversion on living subjects by a clinical method. Though most authors consider it to be inaccurate, Ruwe et al correlated it well to the readings obtained intraoperatively in pathological hips [15] . Since this method is influenced by various extrinsic and intrinsic variables like tension of the hip capsule, inclination of the acetabulum, muscle and fat mass over the trochanter and patient's cooperation, this is often not used for investigative purpose. There is no study in literature that has estimated the normal FNA in a population by this method. But if the correlation can be obtained between the clinical and other methods, we may have a more precise data regarding the anteversion angle of that subject by a simple clinical test.

Formation of groups and subgroups increased our sample size and gave us the advantage to compare the various methods used on the same subjects and also to compare the difference between the various groups. However, there were no significant differences between the groups, but significant differences were there between various methods. Thus we could merge our patients together and form correlation and regression coefficient equations between various methods, so that the measurement of angle of anteversion can be grossly predicted for other accurate methods (e.g. CT), when we have readings from one method. As clinical method has shown better correlation to the CT method, as compared to the X-ray method, we can also conclude that clinical method is better than X-ray method for estimation of anteversion angle [15] . This makes things easier in busy OPDs. This also has the advantage that no radiation exposure is required, is less time consuming and is simpler. Though better modalities like CT method are desirable if any surgical procedure is being contemplated (e.g. restoration osteotomies), its use can be precluded by its cost factor and non-availability at all centres, radiation fear and its less reliability in cases of excessive coxa valga or excessive FNA [10].

Studies to estimate the mean FNA and to compare this by different methods on the same normal living subjects are not available. Hence no extensive statistical analysis is available on these normal morphological values. Since this group comprised of healthy Indian adult population without any hip pathology, we feel that this group represented the true sample to estimate the normal angles of anteversion and believe that our results are statistically significant to draw the conclusion that it is comparable to the average Indian adult population. Our mean FNA by CT was 7.4° (SD 4.6°), which was 4.1° lower than the X-ray [11.5° (SD 5.4°)] and 5.7° lower than the clinical method [13.1° (SD 4.6°)]. Our CT values are comparable to the dry bone method (difference of 1°), though the subjects are not comparable. In our series, all the methods showed different readings in the same patient. Thus, there is a method specific variation in the angle of anteversion with a wide range of mean difference between various methods.The comparison of various series of one method and estimation by different methods may be improper to define the profile of normal angle of anteversion That is why we measured this angle by CT, clinical and X-ray methods in the same patient. CT is known to give lower results than other methods [10],[15],[17], though it has not been compared to the X­ray method or clinical before in the same normal living subjects. The right side was 1.7° less than the left side by all the methods. Though statistically significant, this small difference may have less clinical relevance. Few other studies have also shown inconsistent side and sex based differences [7],[13],[19] but they had never been statistically proven before. However, no correlation was found between the age of the patients and these values indicating that the anteversion values do not change after completion of growth. Though no report describes the accuracy of estimated anteversion necessary to achieve optimum surgical correction, clinical experience shows that accuracy within 10° is always adequate 10. That is why we have included the mean ± 5° data in our analysis [Table - 3].

Studies to find the average anteversion in normal population are available mainly by direct observations on dry bones. Most authors have quoted a wide range (-25° to +50°) with the mean angle varying from 8 to 28° [1],[6],[7],[9]. The combined statistics of four of the major reports, where number of the bones were specified (n=806, Soutter et al, Parsons, Durham and Pick et al;) show the variation to be from -20 to + 50°, with a combined average of +14.09° [1] . However, the study by Kingsley and Olmsted gave a reading comparable to ours (8.021° on 720 bones) [7] . But still, a larger percentage of our bones showed FNA on the lower side in comparison [6] . The studies by other methods on FNA have mainly been done to check the accuracy or reliability of the method rather than to estimate the average value, thus limiting the sample type and its size [1],[2],[3],[4],[5],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17] , [20],[21],[22],[23],[24],[25] . The average FNA has been reported to be 11.4 to 19.8° by CT [5],[10],[11],13],[16],[18],[19],[23] and 15 to 28° by various biplanar X-ray techniques [1],[4],[8],[14],[22],[24],[25] as on specimens and living subjects. However, no extensive statistical analysis has been ever done for interpretation of these data by any of these investigators. Thus FNA in our study has been found to be less than the western data, except the Dunlop's series (biplane X-ray, where the mean was 8.7°) [1] and the Kingsley and Olmsted series [7] . Since CT values should be truly nearer to the existing angle of anteversion in a particular population, we feel that the 75% of the population lies between 3.4° to 11.4°. This is less than the western data by 4-12°. By CT scan almost 59% cases lie between 5-10°, 74% between 0-10° and 18% between 10-15°. By X-ray method 67% cases lie between 5-15° and 19% more than 15°. By clinical method 40% cases lie between 10-15°, 21% less than 10° and 40% more than 15. By the dry bone method, 43% cases lie between 5-10°, 58 % between 0-10° and 21 % between 10-15° [Table - 2]. It has been shown that increased FNA and consequent unfavourable relationship between FNA and AA has been a contributory factor in the pathogenesis of osteoarthritis11, [23]. Since we have found decreased FNA in our population, it may explain the lower incidence of primary osteoarthritis of the hip in our Indian population. Though large controlled studies are required to prove this hypothesis, it is interesting to note that the majority of our hips (69.6 to 98.7% as by different methods) have decreased FNA even when compared to the mean of the western values (15 0 ) [Table - 2].

Clinical implications

Considering CT to be the most accurate on living subjects, the mean FNA in Indians has been found to be 7.4° (SD 4.6°), which is less than most of the western studies by 4 -12°. More than 75% of the population have anteversion between 3.4 -11.4°. FNA reading has been lowest by CT scan method. It is 4.1° higher by the X-rays method and 5.7° by the clinical method. FNA is less on the right side by 1.7° as compared to the left side. Correlation and regression equations have been drawn between various methods and the clinical method correlates better than the x rays to the CT method. Thus if we can estimate the anteversion angle by any one method, readings can be predicted for other accurate methods (e.g. CT) as well without actually performing the other methods.



 
   References Top

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26. Netter R. Role de l'anteversion du col' femoral dans la statiqua de la hanche normale et pathologique. These pour la doctoraten medecine. Paris : Legrand. Amedde 1940.  Back to cited text no. 26    

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Correspondence Address:
A K Jain
A-10, Part-B, Ashok Nagar, Ghaziabad - 201001,UP
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5413.36685

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    Abstract
    Introduction
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