1. by D. TÖNNIS, and A. HEINECKE
Current Concepts Review - Acetabular and Femoral Anteversion: Relationship with Osteoarthritis of the Hip*
by D. TÖNNIS, and A. HEINECKE
J Bone Joint Surg Am
Volume 81(12):
December 1, 1999
©1999 by The Journal of Bone and Joint Surgery, Inc.

2. Fig. 1-A Photographs demonstrating internal torsion of the tibiae with greatly reduced femoral anteversion in a six-year-old girl.
Fig. 1-A Photographs demonstrating internal torsion of the tibiae with greatly reduced femoral anteversion in a six-year-old girl. When the feet are parallel, the patellae point outward (Fig. 1-A). When the knees are placed in neutral rotation, the legs and feet show pronounced internal rotation (Fig. 1-B). An intertrochanteric rotational osteotomy was performed bilaterally to increase femoral anteversion, and a proximal tibial osteotomy was performed bilaterally to externally rotate the tibiae.
D. TÖNNIS, and A. HEINECKE J Bone Joint Surg Am 1999;81:
©1999 by The Journal of Bone and Joint Surgery, Inc.

3. Fig. 1-B Photographs demonstrating internal torsion of the tibiae with greatly reduced femoral anteversion in a six-year-old girl.
Fig. 1-B Photographs demonstrating internal torsion of the tibiae with greatly reduced femoral anteversion in a six-year-old girl. When the feet are parallel, the patellae point outward (Fig. 1-A). When the knees are placed in neutral rotation, the legs and feet show pronounced internal rotation (Fig. 1-B). An intertrochanteric rotational osteotomy was performed bilaterally to increase femoral anteversion, and a proximal tibial osteotomy was performed bilaterally to externally rotate the tibiae.
D. TÖNNIS, and A. HEINECKE J Bone Joint Surg Am 1999;81:
©1999 by The Journal of Bone and Joint Surgery, Inc.

4. Fig. 1-C Photographs showing increased femoral anteversion in a nine-year-old girl.
Fig. 1-C Photographs showing increased femoral anteversion in a nine-year-old girl. When the feet are placed parallel to each other, the knees are rotated inward (Fig. 1-C). When the knees are rotated so that the patellae are facing directly forward, there is evidence of external tibial torsion (Fig. 1-D).
D. TÖNNIS, and A. HEINECKE J Bone Joint Surg Am 1999;81:
©1999 by The Journal of Bone and Joint Surgery, Inc.

5. Fig. 1-D Photographs showing increased femoral anteversion in a nine-year-old girl.
Fig. 1-D Photographs showing increased femoral anteversion in a nine-year-old girl. When the feet are placed parallel to each other, the knees are rotated inward (Fig. 1-C). When the knees are rotated so that the patellae are facing directly forward, there is evidence of external tibial torsion (Fig. 1-D).
D. TÖNNIS, and A. HEINECKE J Bone Joint Surg Am 1999;81:
©1999 by The Journal of Bone and Joint Surgery, Inc.

6. Fig. 2-A through 2-D: Anteroposterior radiographs demonstrating various degrees of acetabular anteversion.
Fig. 2-A through 2-D: Anteroposterior radiographs demonstrating various degrees of acetabular anteversion. The appearance of the acetabulum is altered by an anterior, posterior, or lateral pelvic tilt; thus, images made with tilting of the pelvis cannot be used to make a definitive diagnosis. Fig. 2-A: The anterior and posterior acetabular margins are normally approximately 1.5 centimeters apart as measured from the center of the head in a plane vertical to the anterior aspect of the acetabular rim. The distance shown here is at the lower limit of the normal range.
D. TÖNNIS, and A. HEINECKE J Bone Joint Surg Am 1999;81:
©1999 by The Journal of Bone and Joint Surgery, Inc.

7. Fig. 2-B: The anterior and posterior acetabular margins appear close together, indicating approximately 0 degrees of anteversion.
Fig. 2-B: The anterior and posterior acetabular margins appear close together, indicating approximately 0 degrees of anteversion.
D. TÖNNIS, and A. HEINECKE J Bone Joint Surg Am 1999;81:
©1999 by The Journal of Bone and Joint Surgery, Inc.

8. Fig. 2-C: The acetabular margins appear farther apart than normal, suggesting increased anteversion.
D. TÖNNIS, and A. HEINECKE J Bone Joint Surg Am 1999;81:
©1999 by The Journal of Bone and Joint Surgery, Inc.

9. Fig. 2-D: The posterior acetabular margin is more medial than the anterior margin in relation to the superior aspect of the acetabular rim, suggesting the presence of acetabular retroversion.
Fig. 2-D: The posterior acetabular margin is more medial than the anterior margin in relation to the superior aspect of the acetabular rim, suggesting the presence of acetabular retroversion.
D. TÖNNIS, and A. HEINECKE J Bone Joint Surg Am 1999;81:
©1999 by The Journal of Bone and Joint Surgery, Inc.

10. Fig. 3 Graph showing the age distribution of the patients in the study.
Fig. 3 Graph showing the age distribution of the patients in the study. (One patient [one hip] is not included.)‏
D. TÖNNIS, and A. HEINECKE J Bone Joint Surg Am 1999;81:
©1999 by The Journal of Bone and Joint Surgery, Inc.

11. Fig. 4 Computerized tomographic scan demonstrating the lines used to measure acetabular anteversion.
Fig. 4 Computerized tomographic scan demonstrating the lines used to measure acetabular anteversion. A line is drawn midway between the two halves of the pelvis; this is the best method for defining the sagittal plane when the scan cuts the hemipelves at different levels or when the pelvis is not perfectly horizontal. On each side, a parallel line is drawn in the sagittal plane, beginning at the posterior margin of the acetabulum. The angle of acetabular anteversion is measured between the line corresponding to the sagittal plane and a line drawn tangential to the anterior and posterior acetabular margins. At this level, the femoral head is in full and congruent contact with the anterior surface of the acetabulum (see Figs. 5-A, 5-B, and 5-C).
D. TÖNNIS, and A. HEINECKE J Bone Joint Surg Am 1999;81:
©1999 by The Journal of Bone and Joint Surgery, Inc.

12. Figs. 5-A, 5-B, and 5-C: Computerized tomographic scans illustrating different levels of scanning through the femoral head.
Figs. 5-A, 5-B, and 5-C: Computerized tomographic scans illustrating different levels of scanning through the femoral head. (The terms left and right refer to the sides of the images as visualized by the reader.) Figs. 5-A: Computerized tomographic scan demonstrating the optimum level of scanning through the femoral head. In both hips, the anterior part of the acetabulum covers the femoral head congruently.
D. TÖNNIS, and A. HEINECKE J Bone Joint Surg Am 1999;81:
©1999 by The Journal of Bone and Joint Surgery, Inc.

13. Fig. 5-B On the left side, the diameter of the femoral head is greater than that shown in Fig. 5-A but the congruence is still perfect.
Fig. 5-B On the left side, the diameter of the femoral head is greater than that shown in Fig. 5-A but the congruence is still perfect. Therefore, the measurement was made at this level. On the right side, however, there is no congruence at the anterior part of the acetabulum. Therefore, the anteversion was measured at the level shown in Fig. 5-A.
D. TÖNNIS, and A. HEINECKE J Bone Joint Surg Am 1999;81:
©1999 by The Journal of Bone and Joint Surgery, Inc.

14. Fig. 5-C On the right side, the anterior surface of the acetabulum appears to be even smaller than that shown in Fig. 5-B and there is no congruence.
Fig. 5-C On the right side, the anterior surface of the acetabulum appears to be even smaller than that shown in Fig. 5-B and there is no congruence. The degree of anteversion would be high if measured on this image.
D. TÖNNIS, and A. HEINECKE J Bone Joint Surg Am 1999;81:
©1999 by The Journal of Bone and Joint Surgery, Inc.

15. Figs. 6-A, 6-B, and 6-C: Computerized tomographic scans illustrating the method used to measure femoral anteversion.
Figs. 6-A, 6-B, and 6-C: Computerized tomographic scans illustrating the method used to measure femoral anteversion. Fig. 6-A: The transverse axis of the knee joint is indicated by a line drawn tangential to the posterior surfaces of the femoral condyles. The scan used for the measurement should define the complete posterior convexity of the condyles. The vertical line against which the transverse axis is drawn is the line that corresponds to the midline between the iliac wings (not shown).
D. TÖNNIS, and A. HEINECKE J Bone Joint Surg Am 1999;81:
©1999 by The Journal of Bone and Joint Surgery, Inc.

16. Fig. 6-B This image of the femoral neck is composed of a few computerized tomographic scans made at various levels.
Fig. 6-B This image of the femoral neck is composed of a few computerized tomographic scans made at various levels. It is necessary to cover the full width of the femoral neck and to draw a correctly positioned central axis that passes through the center of the femoral head.
D. TÖNNIS, and A. HEINECKE J Bone Joint Surg Am 1999;81:
©1999 by The Journal of Bone and Joint Surgery, Inc.

17. Fig. 6-C This image, which represents the final summation image of all of the sections of the femoral neck, is used to measure the degree of femoral anteversion.
Fig. 6-C This image, which represents the final summation image of all of the sections of the femoral neck, is used to measure the degree of femoral anteversion. The transverse axis of the limb should form a 90-degree angle with the sagittal plane of the pelvis, which is defined by a line drawn midway between the iliac wings. The starting point of the axis of the femoral neck is drawn a bit too laterally in this example and should be in the medial part of the femoral neck and pass to the center of the femoral head.
D. TÖNNIS, and A. HEINECKE J Bone Joint Surg Am 1999;81:
©1999 by The Journal of Bone and Joint Surgery, Inc.

18. Figs. 7-A through 7-D: Radiographs of a twenty-year-old woman who had decreased femoral and acetabular anteversion.
Figs. 7-A through 7-D: Radiographs of a twenty-year-old woman who had decreased femoral and acetabular anteversion. The patient complained of pain in the left hip. At the time that the patient was examined, in 1983, operative treatment was limited to an intertrochanteric rotational osteotomy to increase femoral anteversion. Today, we also would rotate the acetabulum to 15 to 20 degrees of anteversion. Nevertheless, the patient had only moderate pain at the time of the most recent examination. Fig. 7-A: On the anteroposterior radiograph, the femoral necks appear to show no anteversion. The pelvis shows an unusual degree of ischial torsion with marked projection of the ischial spine toward the midline. The posterior acetabular margin terminates quite medial to the anterior margin. A computerized tomographic scan (not known) demonstrated that acetabular and femoral anteversion were reduced to 0 degrees.
D. TÖNNIS, and A. HEINECKE J Bone Joint Surg Am 1999;81:
©1999 by The Journal of Bone and Joint Surgery, Inc.

19. Fig. 7-B Dunn-Rippstein radiograph showing markedly decreased femoral anteversion.
D. TÖNNIS, and A. HEINECKE J Bone Joint Surg Am 1999;81:
©1999 by The Journal of Bone and Joint Surgery, Inc.

20. Fig. 7-C Anteroposterior radiograph of the pelvis and hips, made after rotational osteotomy of the left femur and fixation with a 90-degree AO plate.
Fig. 7-C Anteroposterior radiograph of the pelvis and hips, made after rotational osteotomy of the left femur and fixation with a 90-degree AO plate.
D. TÖNNIS, and A. HEINECKE J Bone Joint Surg Am 1999;81:
©1999 by The Journal of Bone and Joint Surgery, Inc.

21. Fig. 7-D True lateral radiograph showing the femoral anteversion after intertrochanteric rotational osteotomy.
Fig. 7-D True lateral radiograph showing the femoral anteversion after intertrochanteric rotational osteotomy. The anteversion is substantially greater than that seen in Fig. 7-B. Intraoperatively, the degree of anteversion and the range of motion of the hip can be monitored with image intensification.
D. TÖNNIS, and A. HEINECKE J Bone Joint Surg Am 1999;81:
©1999 by The Journal of Bone and Joint Surgery, Inc.

22. Figs. 8-A, 8-B, and 8-C: A thirty-four-year-old man who complained of severe pain in the right hip.
Figs. 8-A, 8-B, and 8-C: A thirty-four-year-old man who complained of severe pain in the right hip. Fig. 8-A: Anteroposterior radiograph showing evidence of early osteoarthritis of the right hip.
D. TÖNNIS, and A. HEINECKE J Bone Joint Surg Am 1999;81:
©1999 by The Journal of Bone and Joint Surgery, Inc.

23. Fig. 8-B Computerized tomographic scan showing 2 degrees of acetabular anteversion and 4 degrees of femoral retroversion.
Fig. 8-B Computerized tomographic scan showing 2 degrees of acetabular anteversion and 4 degrees of femoral retroversion.
D. TÖNNIS, and A. HEINECKE J Bone Joint Surg Am 1999;81:
©1999 by The Journal of Bone and Joint Surgery, Inc.

24. Fig. 8-C Anteroposterior radiograph made three years after the acetabulum was rotated to 15 degrees of anteversion by means of a triple pelvic osteotomy.
Fig. 8-C Anteroposterior radiograph made three years after the acetabulum was rotated to 15 degrees of anteversion by means of a triple pelvic osteotomy. The femoral neck was also corrected to 15 to 20 degrees of anteversion by means of a valgus osteotomy with slight lateral rotation of the acetabulum. The radiograph demonstrates the round femoral head and maintenance of the joint space. At the time of the most recent examination, the patient was working full-time and was playing tennis, and he complained of pain only after walking for more than three hours.
D. TÖNNIS, and A. HEINECKE J Bone Joint Surg Am 1999;81:
©1999 by The Journal of Bone and Joint Surgery, Inc.

25. Figs. 9-A, 9-B, and 9-C: A fifteen-year-old girl who complained of repeated episodes of giving-way of the right knee into flexion and internal rotation when walking.
Figs. 9-A, 9-B, and 9-C: A fifteen-year-old girl who complained of repeated episodes of giving-way of the right knee into flexion and internal rotation when walking. Fig. 9-A: Radiograph of the right hip, showing no obvious abnormalities other than increased separation of the anterior and posterior acetabular margins. A Dunn-Rippstein radiograph (not shown) revealed only a moderate increase in femoral anteversion.
D. TÖNNIS, and A. HEINECKE J Bone Joint Surg Am 1999;81:
©1999 by The Journal of Bone and Joint Surgery, Inc.

26. Fig. 9-B Computerized tomographic scan demonstrating a marked increase in acetabular anteversion (27 degrees) and a moderate increase in femoral anteversion (23 degrees).
Fig. 9-B Computerized tomographic scan demonstrating a marked increase in acetabular anteversion (27 degrees) and a moderate increase in femoral anteversion (23 degrees). The two angles yield a McKibbin instability index43 of 50, indicating severe instability.
D. TÖNNIS, and A. HEINECKE J Bone Joint Surg Am 1999;81:
©1999 by The Journal of Bone and Joint Surgery, Inc.

27. Fig. 9-C Radiograph made after a triple pelvic osteotomy in which the acetabulum was externally rotated by 15 degrees.
Fig. 9-C Radiograph made after a triple pelvic osteotomy in which the acetabulum was externally rotated by 15 degrees. The distance between the anterior and posterior acetabular margins of the right hip is within the normal range of approximately 1.5 centimeters. The range of internal rotation was no longer increased, and the episodes of instability ceased.
D. TÖNNIS, and A. HEINECKE J Bone Joint Surg Am 1999;81:
©1999 by The Journal of Bone and Joint Surgery, Inc.

28. Figs. 10-A and 10-B: A fifty-three-year-old man who had severe osteoarthritis of the right hip.
Figs. 10-A and 10-B: A fifty-three-year-old man who had severe osteoarthritis of the right hip. The only treatment option was total hip replacement. Fig. 10-A: Anteroposterior radiograph of the pelvis and hips, showing evidence of severe osteoarthritis of the right hip.
D. TÖNNIS, and A. HEINECKE J Bone Joint Surg Am 1999;81:
©1999 by The Journal of Bone and Joint Surgery, Inc.

29. Fig. 10-B Computerized tomographic scan showing both acetabular and femoral anteversion to be decreased to 0 degrees.
Fig. 10-B Computerized tomographic scan showing both acetabular and femoral anteversion to be decreased to 0 degrees.
D. TÖNNIS, and A. HEINECKE J Bone Joint Surg Am 1999;81:
©1999 by The Journal of Bone and Joint Surgery, Inc.