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. 2008 Nov;90 Suppl 4(Suppl 4):47-66.
doi: 10.2106/JBJS.H.00756.

A systematic approach to the plain radiographic evaluation of the young adult hip

John C Clohisy  1 , John C Carlisle, Paul E Beaulé, Young-Jo Kim, Robert T Trousdale, Rafael J Sierra, Michael Leunig, Perry L Schoenecker, Michael B Millis
Affiliations

A systematic approach to the plain radiographic evaluation of the young adult hip

John C Clohisy et al. J Bone Joint Surg Am. 2008 Nov.
No abstract available

PubMed Disclaimer

Figures

Fig. 1-A Fig. 1-B Fig. 1-C Fig. 1-D Fig. 1-E Fig. 1-F
Fig. 1-A Fig. 1-B Fig. 1-C Fig. 1-D Fig. 1-E Fig. 1-F
Figs. 1-A through 1-F Radiographic views: anteroposterior pelvic (Fig. 1-A), cross-table lateral (Fig. 1-B), 45° Dunn (Fig. 1-C), 90° Dunn (Fig. 1-D), frog-leg lateral (Fig. 1-E), and false profile (Fig. 1-F).
Fig. 1-A Fig. 1-B Fig. 1-C Fig. 1-D Fig. 1-E Fig. 1-F
Fig. 1-A Fig. 1-B Fig. 1-C Fig. 1-D Fig. 1-E Fig. 1-F
Figs. 1-A through 1-F Radiographic views: anteroposterior pelvic (Fig. 1-A), cross-table lateral (Fig. 1-B), 45° Dunn (Fig. 1-C), 90° Dunn (Fig. 1-D), frog-leg lateral (Fig. 1-E), and false profile (Fig. 1-F).
Fig. 1-A Fig. 1-B Fig. 1-C Fig. 1-D Fig. 1-E Fig. 1-F
Fig. 1-A Fig. 1-B Fig. 1-C Fig. 1-D Fig. 1-E Fig. 1-F
Figs. 1-A through 1-F Radiographic views: anteroposterior pelvic (Fig. 1-A), cross-table lateral (Fig. 1-B), 45° Dunn (Fig. 1-C), 90° Dunn (Fig. 1-D), frog-leg lateral (Fig. 1-E), and false profile (Fig. 1-F).
Fig. 1-A Fig. 1-B Fig. 1-C Fig. 1-D Fig. 1-E Fig. 1-F
Fig. 1-A Fig. 1-B Fig. 1-C Fig. 1-D Fig. 1-E Fig. 1-F
Figs. 1-A through 1-F Radiographic views: anteroposterior pelvic (Fig. 1-A), cross-table lateral (Fig. 1-B), 45° Dunn (Fig. 1-C), 90° Dunn (Fig. 1-D), frog-leg lateral (Fig. 1-E), and false profile (Fig. 1-F).
Fig. 1-A Fig. 1-B Fig. 1-C Fig. 1-D Fig. 1-E Fig. 1-F
Fig. 1-A Fig. 1-B Fig. 1-C Fig. 1-D Fig. 1-E Fig. 1-F
Figs. 1-A through 1-F Radiographic views: anteroposterior pelvic (Fig. 1-A), cross-table lateral (Fig. 1-B), 45° Dunn (Fig. 1-C), 90° Dunn (Fig. 1-D), frog-leg lateral (Fig. 1-E), and false profile (Fig. 1-F).
Fig. 1-A Fig. 1-B Fig. 1-C Fig. 1-D Fig. 1-E Fig. 1-F
Fig. 1-A Fig. 1-B Fig. 1-C Fig. 1-D Fig. 1-E Fig. 1-F
Figs. 1-A through 1-F Radiographic views: anteroposterior pelvic (Fig. 1-A), cross-table lateral (Fig. 1-B), 45° Dunn (Fig. 1-C), 90° Dunn (Fig. 1-D), frog-leg lateral (Fig. 1-E), and false profile (Fig. 1-F).
Fig. 2-A Fig. 2-B
Fig. 2-A Fig. 2-B
Figs. 2-A and 2-B The positioning for an anteroposterior pelvic radiograph (ASIS = anterior superior iliac spine).
Fig. 2-A Fig. 2-B
Fig. 2-A Fig. 2-B
Figs. 2-A and 2-B The positioning for an anteroposterior pelvic radiograph (ASIS = anterior superior iliac spine).
Fig. 3
Fig. 3
The positioning for a cross-table lateral radiograph with the limb in 15° of internal rotation. The black arrow points to the center of the femoral head (black dot), the target for the crosshairs of the x-ray beam.
Fig. 4-A Fig. 4-B
Fig. 4-A Fig. 4-B
Figs. 4-A and 4-B The positioning for a 90° Dunn view with the hips flexed 90° and abducted 20°. Fig. 4-B The black arrow points to the crosshairs, centered at a point midway between the pubic symphysis and the anterior superior iliac spine.
Fig. 4-A Fig. 4-B
Fig. 4-A Fig. 4-B
Figs. 4-A and 4-B The positioning for a 90° Dunn view with the hips flexed 90° and abducted 20°. Fig. 4-B The black arrow points to the crosshairs, centered at a point midway between the pubic symphysis and the anterior superior iliac spine.
Fig. 5-A Fig. 5-B Fig. 6 Fig. 7
Fig. 5-A Fig. 5-B Fig. 6 Fig. 7
Figs. 5-A and 5-B The positioning for a 45° Dunn view with the hips flexed 45° and abducted 20°. The x-ray beam is centered at a point midway between the pubic symphysis and the anterior superior iliac spine. Fig. 6 The positioning for a frog-leg lateral view with the hip abducted 45° and the crosshairs centered at a point midway between the anterior superior iliac spine (black dot) and the pubic symphysis (black line). Fig. 7 The false-profile view of the right hip is obtained with the pelvis rotated 65° in relationship to the bucky wall stand, with the foot on the affected side parallel to the radiographic cassette (shown with two black lines).
Fig. 5-A Fig. 5-B Fig. 6 Fig. 7
Fig. 5-A Fig. 5-B Fig. 6 Fig. 7
Figs. 5-A and 5-B The positioning for a 45° Dunn view with the hips flexed 45° and abducted 20°. The x-ray beam is centered at a point midway between the pubic symphysis and the anterior superior iliac spine. Fig. 6 The positioning for a frog-leg lateral view with the hip abducted 45° and the crosshairs centered at a point midway between the anterior superior iliac spine (black dot) and the pubic symphysis (black line). Fig. 7 The false-profile view of the right hip is obtained with the pelvis rotated 65° in relationship to the bucky wall stand, with the foot on the affected side parallel to the radiographic cassette (shown with two black lines).
Fig. 5-A Fig. 5-B Fig. 6 Fig. 7
Fig. 5-A Fig. 5-B Fig. 6 Fig. 7
Figs. 5-A and 5-B The positioning for a 45° Dunn view with the hips flexed 45° and abducted 20°. The x-ray beam is centered at a point midway between the pubic symphysis and the anterior superior iliac spine. Fig. 6 The positioning for a frog-leg lateral view with the hip abducted 45° and the crosshairs centered at a point midway between the anterior superior iliac spine (black dot) and the pubic symphysis (black line). Fig. 7 The false-profile view of the right hip is obtained with the pelvis rotated 65° in relationship to the bucky wall stand, with the foot on the affected side parallel to the radiographic cassette (shown with two black lines).
Fig. 5-A Fig. 5-B Fig. 6 Fig. 7
Fig. 5-A Fig. 5-B Fig. 6 Fig. 7
Figs. 5-A and 5-B The positioning for a 45° Dunn view with the hips flexed 45° and abducted 20°. The x-ray beam is centered at a point midway between the pubic symphysis and the anterior superior iliac spine. Fig. 6 The positioning for a frog-leg lateral view with the hip abducted 45° and the crosshairs centered at a point midway between the anterior superior iliac spine (black dot) and the pubic symphysis (black line). Fig. 7 The false-profile view of the right hip is obtained with the pelvis rotated 65° in relationship to the bucky wall stand, with the foot on the affected side parallel to the radiographic cassette (shown with two black lines).
Fig. 8
Fig. 8
The technique for assessing the tilt and rotation of an anteroposterior pelvic radiograph is described.
Fig. 9
Fig. 9
The radiographic appearance of coxa profunda on an anteroposterior pelvic view. Line A represents the ilioischial line, and line B represents the floor of the acetabular fossa, which is medial to line A. A similar pathologic condition can also be seen on the radiograph of the patient's left hip.
Fig. 10
Fig. 10
The radiographic appearance of protrusio acetabuli, with the medial aspect of the femoral head medial to the ilioischial line.
Fig. 11-A Fig. 11-B
Fig. 11-A Fig. 11-B
Figs. 11-A and 11-B Technique for calculation of acetabular inclination and the lateral center-edge angle. A line is drawn connecting the inferior aspect of the left and right-sided acetabular teardrops (line 1). A second line, parallel to the first (line 2), is drawn through the inferior aspect of the acetabular sourcil. Lastly, a line connecting the inferior and lateral aspects of the acetabular sourcil is drawn (line 3). The angle created by the intersection of lines 2 and 3 (the Tönnis angle) should be between 0° and 10° (Fig. 11-A). To determine the lateral center-edge angle, a line is drawn through the center of the femoral head, perpendicular to the transverse axis of the pelvis. A second line is drawn through the center of the femoral head, passing through the most superolateral point of the sclerotic weight-bearing zone of the acetab-ulum. The angle created by the intersection of these two lines is the lateral center-edge angle (Fig. 11-B). Values of <25° may indicate inadequate coverage of the femoral head.
Fig. 11-A Fig. 11-B
Fig. 11-A Fig. 11-B
Figs. 11-A and 11-B Technique for calculation of acetabular inclination and the lateral center-edge angle. A line is drawn connecting the inferior aspect of the left and right-sided acetabular teardrops (line 1). A second line, parallel to the first (line 2), is drawn through the inferior aspect of the acetabular sourcil. Lastly, a line connecting the inferior and lateral aspects of the acetabular sourcil is drawn (line 3). The angle created by the intersection of lines 2 and 3 (the Tönnis angle) should be between 0° and 10° (Fig. 11-A). To determine the lateral center-edge angle, a line is drawn through the center of the femoral head, perpendicular to the transverse axis of the pelvis. A second line is drawn through the center of the femoral head, passing through the most superolateral point of the sclerotic weight-bearing zone of the acetab-ulum. The angle created by the intersection of these two lines is the lateral center-edge angle (Fig. 11-B). Values of <25° may indicate inadequate coverage of the femoral head.
Fig. 12
Fig. 12
Technique for calculating the anterior center-edge angle on a false-profile radiograph. A vertical line is drawn through the center of the femoral head. A second line is drawn through the center of the femoral head, passing through the most anterior point of the acetabular sourcil. The angle created by the intersection of these two lines is the anterior center-edge angle. Values of <20° can be indicative of structural instability.
Fig. 13-A Fig. 13-B
Fig. 13-A Fig. 13-B
Figs. 13-A and 13-B The radiographic appearance of an anteverted (Fig. 13-A) and retroverted (Fig. 13-B) acetabulum with the presence of a crossover sign in the latter. The contralateral, unmarked hips demonstrate similar anatomy in both images.
Fig. 13-A Fig. 13-B
Fig. 13-A Fig. 13-B
Figs. 13-A and 13-B The radiographic appearance of an anteverted (Fig. 13-A) and retroverted (Fig. 13-B) acetabulum with the presence of a crossover sign in the latter. The contralateral, unmarked hips demonstrate similar anatomy in both images.
Fig. 14-A Fig. 14-B
Fig. 14-A Fig. 14-B
Figs. 14-A and 14-B Radiographs demonstrating a spherical femoral (Fig. 14-A) head and a femoral head with a perthes-like deformity (Fig. 14-B). A Mose template is useful in making this determination in hip with a subtle deformity.
Fig. 14-A Fig. 14-B
Fig. 14-A Fig. 14-B
Figs. 14-A and 14-B Radiographs demonstrating a spherical femoral (Fig. 14-A) head and a femoral head with a perthes-like deformity (Fig. 14-B). A Mose template is useful in making this determination in hip with a subtle deformity.
Fig. 15-A Fig. 15-B
Fig. 15-A Fig. 15-B
Figs. 15-A and 15-B An example of a patient with a spherical femoral head noted on an anteroposterior pelvic radiograph (Fig. 15-A) despite a clear head-neck offset deformity on the frog-leg lateral radiograph (Fig. 15-B).
Fig. 15-A Fig. 15-B
Fig. 15-A Fig. 15-B
Figs. 15-A and 15-B An example of a patient with a spherical femoral head noted on an anteroposterior pelvic radiograph (Fig. 15-A) despite a clear head-neck offset deformity on the frog-leg lateral radiograph (Fig. 15-B).
Fig. 16-A Fig. 16-B
Fig. 16-A Fig. 16-B
Figs. 16-A and 16-B These radiographs demonstrate the normal position of the femoral head (Fig. 16-A) as compared with a lateralized femoral head in a patient with a dysplastic hip (Fig. 16-B).
Fig. 16-A Fig. 16-B
Fig. 16-A Fig. 16-B
Figs. 16-A and 16-B These radiographs demonstrate the normal position of the femoral head (Fig. 16-A) as compared with a lateralized femoral head in a patient with a dysplastic hip (Fig. 16-B).
Fig. 17-A Fig. 17-B Fig. 17-C
Fig. 17-A Fig. 17-B Fig. 17-C
Figs. 17-A, 17-B, and 17-C These radiographs demonstrate a spectrum of abnormalities with regard to femoral head-neck offset including: normal and/or symmetric concavities (Fig. 17-A), moderate reduction in head-neck offset and/or mild cam impingement (Fig. 17-B), and antero-lateral head-neck prominence (Fig. 17-C). The arrows highlight regions of reduced head-neck offset.
Fig. 17-A Fig. 17-B Fig. 17-C
Fig. 17-A Fig. 17-B Fig. 17-C
Figs. 17-A, 17-B, and 17-C These radiographs demonstrate a spectrum of abnormalities with regard to femoral head-neck offset including: normal and/or symmetric concavities (Fig. 17-A), moderate reduction in head-neck offset and/or mild cam impingement (Fig. 17-B), and antero-lateral head-neck prominence (Fig. 17-C). The arrows highlight regions of reduced head-neck offset.
Fig. 17-A Fig. 17-B Fig. 17-C
Fig. 17-A Fig. 17-B Fig. 17-C
Figs. 17-A, 17-B, and 17-C These radiographs demonstrate a spectrum of abnormalities with regard to femoral head-neck offset including: normal and/or symmetric concavities (Fig. 17-A), moderate reduction in head-neck offset and/or mild cam impingement (Fig. 17-B), and antero-lateral head-neck prominence (Fig. 17-C). The arrows highlight regions of reduced head-neck offset.
Fig. 18
Fig. 18
The technique for calculating the alpha angle on a frog-leg lateral radiograph. A line is drawn connecting the center of the femoral head and the center of the femoral neck. A second line is drawn from the center of the femoral head to the point on the anterolateral head-neck junction where the radius of the femoral head begins to increase beyond the radius found more centrally in the acetabulum where the head is more spherical (i.e., where a prominence starts). The intersection of these two lines forms the alpha angle, and values of >42° are suggestive of a head-neck offset deformity.
Fig. 19
Fig. 19
The technique for calculating the head-neck offset ratio. Three parallel lines are drawn, with line 1 drawn through the center of the long axis of the femoral neck, line 2 drawn through the anteriormost aspect of the femoral neck, and line 3 drawn through the anteriormost aspect of the femoral head. The head-neck offset ratio is calculated by measuring the distance between lines 2 and 3 and dividing by the diameter of the femoral head. If the ratio is <0.17, a cam deformity is likely present.
Fig. 20-A Fig. 20-B Fig. 20-C
Fig. 20-A Fig. 20-B Fig. 20-C
Figs. 20-A and 20-B Radiographs demonstrating a congruent (Fig. 20-A), a mildly incongruent (Fig. 20-B), an incongruent (Fig. 20-C) joint.
Fig. 20-A Fig. 20-B Fig. 20-C
Fig. 20-A Fig. 20-B Fig. 20-C
Figs. 20-A and 20-B Radiographs demonstrating a congruent (Fig. 20-A), a mildly incongruent (Fig. 20-B), an incongruent (Fig. 20-C) joint.
Fig. 20-A Fig. 20-B Fig. 20-C
Fig. 20-A Fig. 20-B Fig. 20-C
Figs. 20-A and 20-B Radiographs demonstrating a congruent (Fig. 20-A), a mildly incongruent (Fig. 20-B), an incongruent (Fig. 20-C) joint.
Fig. 21-A Fig. 21-B Fig. 21-C Fig. 21-D
Fig. 21-A Fig. 21-B Fig. 21-C Fig. 21-D
Figs. 21-A through 21-D These radiographs demonstrate the four grades of osteoarthritis, as described in the Tönnis classification system. Fig. 21-A Grade 0: no signs of osteoarthritis. Fig. 21-B Grade 1: slight joint-space narrowing and mild sclerosis of the acetabulum. Fig. 21-C Grade 2: moderate joint-space narrowing, small cysts in the acetabulum, and mild loss of head sphericity. Fig. 21-D Grade 3: severe joint-space narrowing with large acetabular or femoral head cysts or more advanced asphericity of the femoral head.
Fig. 21-A Fig. 21-B Fig. 21-C Fig. 21-D
Fig. 21-A Fig. 21-B Fig. 21-C Fig. 21-D
Figs. 21-A through 21-D These radiographs demonstrate the four grades of osteoarthritis, as described in the Tönnis classification system. Fig. 21-A Grade 0: no signs of osteoarthritis. Fig. 21-B Grade 1: slight joint-space narrowing and mild sclerosis of the acetabulum. Fig. 21-C Grade 2: moderate joint-space narrowing, small cysts in the acetabulum, and mild loss of head sphericity. Fig. 21-D Grade 3: severe joint-space narrowing with large acetabular or femoral head cysts or more advanced asphericity of the femoral head.
Fig. 21-A Fig. 21-B Fig. 21-C Fig. 21-D
Fig. 21-A Fig. 21-B Fig. 21-C Fig. 21-D
Figs. 21-A through 21-D These radiographs demonstrate the four grades of osteoarthritis, as described in the Tönnis classification system. Fig. 21-A Grade 0: no signs of osteoarthritis. Fig. 21-B Grade 1: slight joint-space narrowing and mild sclerosis of the acetabulum. Fig. 21-C Grade 2: moderate joint-space narrowing, small cysts in the acetabulum, and mild loss of head sphericity. Fig. 21-D Grade 3: severe joint-space narrowing with large acetabular or femoral head cysts or more advanced asphericity of the femoral head.
Fig. 21-A Fig. 21-B Fig. 21-C Fig. 21-D
Fig. 21-A Fig. 21-B Fig. 21-C Fig. 21-D
Figs. 21-A through 21-D These radiographs demonstrate the four grades of osteoarthritis, as described in the Tönnis classification system. Fig. 21-A Grade 0: no signs of osteoarthritis. Fig. 21-B Grade 1: slight joint-space narrowing and mild sclerosis of the acetabulum. Fig. 21-C Grade 2: moderate joint-space narrowing, small cysts in the acetabulum, and mild loss of head sphericity. Fig. 21-D Grade 3: severe joint-space narrowing with large acetabular or femoral head cysts or more advanced asphericity of the femoral head.
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References

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