The Journal of Arthroplasty xxx (2020) 1e4

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The Journal of Arthroplasty

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The Relationship Between Canal Diameter and the Dorr

Classification
P.N. Karayiannis, MB BCh, BAO, MsC, MRCSEd a, *,
R.S. Cassidy, BSc (Hons), MMedSci, PhD a, J.C. Hill, MEng, PhD a, L.D. Dorr, MD b,
D.E. Beverland, MD, FRCS a
a
Primary Joint Unit, Musgrave Park Hospital, Belfast Health and Social Care Trust, Belfast, Northern Ireland
b
Dorr Institute for Research and Education, Pasadena, CA

a r t i c l e i n f o a b s t r a c t

Article history: Background: Particularly in broach-only uncemented total hip arthroplasty, a narrow femoral canal
Received 26 April 2020 presents a technical challenge. Traditionally such femurs have been considered to be Dorr A. To our
Received in revised form knowledge, however, no study has reported on the relationship between isthmus width and the Dorr
21 May 2020
classification.
Accepted 26 May 2020
Methods: We reviewed 500 high-quality, hard copy radiographs. Dorr classification and isthmus canal
Available online xxx
width were measured using an electronic caliper by 5 independent observers with intraobserver and
interobserver error calculated. For this study, we defined a narrow canal as being
10 mm at its nar-
Keywords:
Dorr classification
rowest point (isthmus).
canal width Results: Eight percent (40) were Dorr A, 85% (424) Dorr B, and 7% (36) Dorr C. With respect to isthmus
cementless total hip arthroplasty width for Dorr A, 63% (25) were
10 mm compared to just 13% (55) of Dorr B. However, overall because
narrow canal there were more Dorr B femurs, 69% of those with an isthmus of
10 mm were Dorr B.
Dorr A Conclusion: In this population, almost 70% of patients with an isthmus
10 mm were Dorr B, with only
Dorr B 30% being Dorr A. When using a broach-only technique, isthmus width should be routinely measured on
Dorr C the preoperative anteroposterior radiographs so as to alert the surgeon to potential problems.
Crown Copyright © 2020 Published by Elsevier Inc. All rights reserved.

When using cementless implants in total hip arthroplasty (THA),
primary stability is of paramount importance to achieve biological
fixation [1,2] and favorable transmission of forces to the proximal
femur [3e5]. The key to achieving this is metaphyseal fit within the
proximal femur [6]. Unfortunately, there is wide variation in the
geometry and anatomy of the proximal femur [7e9]. In particular, a
metaphyseal (large)/diaphyseal (small) mismatch can result in
technical difficulties and undersizing of the femoral component.
One or more of the authors of this paper have disclosed potential or pertinent
conflicts of interest, which may include receipt of payment, either direct or indirect,
institutional support, or association with an entity in the biomedical field which
may be perceived to have potential conflict of interest with this work. For full
disclosure statements refer to https://doi.org/10.1016/j.arth.2020.05.066.
Author Contribution: P.N.K. contributed to data collection, analysis, manuscript
drafting, editing, and dissemination. R.S.C. helped in data collection, analysis, and
manuscript editing. J.C.H. contributed to data analysis and manuscript editing. L.D.
D. assisted in manuscript editing and concept. D.E.B. helped in conception and
supervision of study, performing surgeries, preparing manuscript, and editing.
* Reprint requests: PN Karayiannis, MB BCh, BAO, MsC, MRCSEd, Dorr Institute for
Research and Education, Belfast, United Kingdom.
This has been shown to increase the risk of early revision [6,10,11].
For this reason, study and classification of the proximal femur are
important. The Dorr classification was initially published in 1993
and is the most commonly used today [12]. Femurs were classified
into A, B, or C based on their shape and bone structure. Classically
type A femurs would have the narrowest isthmus (narrowest part
of the femoral canal) with type C the widest, with the isthmus
being defined as the narrowest part of the canal. Particularly in a
femoral broach-only preparation technique, a narrow isthmus can
result in undersizing of the femoral component in the metaphysis
leading to reduced primary stability. In contrast, for many
cementless stems, the surgical technique includes a canal reamer
which ensures that the stem size as templated in the metaphysis
will be accommodated distally.
Patients with a Dorr A femur are often thought to have a narrow
isthmus but no study to date has examined the relationship be-
tween the isthmus and the Dorr classification. The aim of this study
is to examine this relationship in the preoperative anteroposterior
(AP) radiograph of 500 THA patients. Based on clinical experience,
we defined a narrow isthmus as being 10 mm or less.

https://doi.org/10.1016/j.arth.2020.05.066
0883-5403/Crown Copyright © 2020 Published by Elsevier Inc. All rights reserved.
2 P.N. Karayiannis et al. / The Journal of Arthroplasty xxx (2020) 1e4

Methods

Between March 1992 and April 2005, over 4000 cemented

Custom X-Press femoral stems (DePuy International Ltd, Leeds, UK)
were implanted under the care of one of the senior authors. These
stems were all manufactured on site from screened preoperative AP
and lateral radiographs of the proximal femur. The quality and
reproducibility of these radiographs were vital to the
manufacturing process. To take the AP radiograph, patients were
placed on a screening table with a film focus distance of 115 cm. To
achieve a true AP view of the proximal femur, the lower limb was
internally rotated until the appearance of the lesser trochanter (LT)
was that of a setting sun on the screened view. Frequently, as a
result of fixed external rotation, the ipsilateral hemi-pelvis also had
to be internally rotated by placing sand bags under the ipsilateral
buttock. Critically and immediately before taking the definitive
radiograph, the magnification marker was placed directly over the
greater trochanter. The further away the greater trochanter was
from the radiograph plate, the greater the magnification and on
occasion this would be up to 135%. As a testament to the accuracy of
the screened radiographs, on no occasion did the component size
prevent implantation. An audit of these radiographs was registered
as part of Standards, Quality and Audit within the Belfast Health
and Social Care Trust; audit number 6001. Fig. 2. Dorr A.
For this audit, we used the screened AP views of 500 patients
who had a THA between June 2, 1992, and June 21, 1995. Between
these dates, a total of 1126 THAs were performed under the care of
one of the senior authors. All radiographs that were still within our Measurements on the hard copy radiographs were taken by 5
filing system were used. No radiographs had to be rejected because independent observers with intraobserver and interobserver
of poor quality as all had been of the high standard required for measurements included. The measurements for the Dorr calcula-
component manufacture. The demographics of the 500 patients tions were taken from the studies by Dorr et al (1993) and Syed et al
were readily available from a prospectively maintained database. (2018) [12,13]. All measurements were taken using a digital caliper
as described in the steps below and in Figure 1. The canal-to-calcar
isthmus ratio (CC ratio) was used to classify the individual femurs,
and a narrow isthmus was defined as canal width of 10 mm or less
at its narrowest point.

Fig. 1. Dorr Calculations. Fig. 3. Dorr B.

 P.N. Karayiannis et al. / The Journal of Arthroplasty xxx (2020) 1e4 3

Table 2
Dorr Classification.

Dorr A Dorr B Dorr C Total

Female 20 (50.0%) 223 (52.6%) 25 (69.4%) 268 (53.6%)

Male 20 (50.0%) 201 (47.4%) 11 (30.6%) 232 (46.4%)
Total 40 (8.0%) 424 (84.8%) 36 (7.2%) 500 (100%)

previously measured by the other observers, again randomly

allocated. Intraclass correlation coefficients were then calcu-
lated for each variable: 0.60-0.74 classified as good and >0.75 as
excellent.
Statistical analysis was carried out using SPSS (version 22, IBM,
Armonk, NY); all data were assessed for normality using Shapiro-
Wilk test. Chi-squared test was used to compare categorical vari-
ables. Intraclass correlation coefficients were determined to pro-
vide both intraobserver and interobserver errors. Statistical
significance level was set at P < .05.
Figures 2 and 3 show Dorr A and B femurs with isthmus <10 mm
and Figure 4 is of a Dorr C femur.

Fig. 4. Dorr C.
Results

Table 1 shows the age demographics of the cohort: 268 pa-

tients were female (53.6%) and 232 males (46.4%). The majority
(1) Radiograph magnification was calculated by measuring the
of patients were over the age of 55 (93.6%). Of the 500 radio-
distance in millimeters between the 2 ball bearings and
graphs measured; 40 (8%) were classified as Dorr A, 424 (84.8%)
dividing by 100 (true marker distance ¼ 100 mm). For
as Dorr B, and 36 (7.2%) as Dorr C as shown in Table 2. As ex-
example, if the measured distance between the balls on
pected, a higher proportion of Dorr C were female (69.4%; 25 of
radiograph was 117 mm, magnification factor ¼ 117/100 ¼
36), whereas Dorr A and B were evenly distributed between male
1.17.
and female.
(2) A line was drawn through the midpoint of the LT perpen-
Dorr C patients were statistically significantly older than those
dicular to a line drawn along the long axis of the femur.
classified as A or B (P < .001). Similarly, in patients aged <54, there
(3) Two lines were marked 30 and 100 mm below the reference
was a significant difference in those classified as Dorr A compared
mark at the LT.
to Dorr B or C (P < .001). This is shown in Table 3.
(4) Longitudinal lines were drawn connecting canal widths at 30
Eighty (16%) patients had a canal diameter less than 10 mm; 25
mm and 100 mm.
(31%) were Dorr A, 55 (69%) were Dorr B, and none were Dorr C. A
(5) Canal width at the 100-mm line was measured
full breakdown of canal width by Dorr classification and gender is
(Xdintramedullary canal diameter).
presented in Table 4.
(6) Width of the subtended lines at LT measured (Y)
Although more patients with Dorr B femurs had a canal 10 mm
(7) CC ratio ¼ X/Y
or less (55/80, 68.8%), the proportion of patients with a narrow
(8) Width of femur at 100-mm reference mark was measured (Z)
canal was greater in type A patients (25/40, 62.5%) compared to
(9) Cortical index calculated (Z  X/Z)
type B (55/424, 13%).
(10) Narrowest point of the canal measured if not at 100 mm
Table 5 shows the range of upper (at 30 mm) and lower (at 100
mm) canal widths for all patients as per Dorr type.
Dorr A was classified as a CC ratio of <0.5, Dorr B as 0.5-0.75, and
The intraobserver and interobserver errors showed good or
Dorr C > 0.75.
excellent comparison in all variables (interclass correlation co-
Intraobserver and interobserver errors were calculated after
efficient of 0.891-0.991 and intraclass coefficient of 0.783-
each observer remeasured 20 randomly selected radiographs
0.999).
which they had previously measured and 20 radiographs

Table 1 Table 3
Patient Age and Gender Demographics of the Dorr Measurement Cohort. Patient Age and Dorr Classification of the Dorr Measurement Cohort.

Age (y) Female (%) Male (%) All (%) Age (y) Dorr A (%) Dorr B (%) Dorr C (%) All (%)

<45 3 (1.1%) 4 (1.7%) 7 (1.4%) <45 3 (7.5%) 4 (0.9%) d 7 (1.4%)

45-54 12 (4.5%) 13 (5.6%) 25 (5.0%) 45-54 10 (25%) 15 (3.5%) d 25 (5.0%)
55-64 48 (17.9%) 55 (23.7%) 103 (20.6%) 55-64 7 (17.5%) 94 (22.2%) 2 (5.6%) 103 (20.6%)
65-74 111 (43.4%) 95 (40.9%) 206 (41.2%) 65-74 14 (35.0%) 169 (39.9%) 23 (63.9%) 206 (41.2%)
75-84 81 (30.2%) 57 (24.6%) 138 (27.6%) 75-84 6 (15.0%) 126 (29.7%) 6 (16.7%) 138 (27.6%)
85 13 (4.9%) 8 (3.4%) 21 (4.2%) 85 d 16 (3.8%) 5 (13.9%) 21 (4.2%)
All 268 (53.6%) 232 (46.4%) 500 (100%) All 40 (8.0%) 424 (84.8%) 36 (7.2%) 500 (100%)

Percentages are presented of column totals. Chi-square analysis; P ¼ .454. Percentages are presented of column totals. Chi-square analysis; P < .001.
4 P.N. Karayiannis et al. / The Journal of Arthroplasty xxx (2020) 1e4

Table 4 create more accurate measurements, it would not be widely

Canal Width and Dorr Classification. applicable to current clinical practice. Secondly, although we have
Canal Gender Dorr A Dorr B Dorr C Total (% of P Value reported on and calculated intraobserver and interobserver errors
Width Full Cohort) and demonstrated good to excellent agreement between variables,

8 mm Female 3 5 d 8 (1.6%) N/A some variation in measurements is likely to be present.
Male d d d In conclusion, clinically if we define a narrow canal isthmus as

9 mm Female 9 14 d 31 (6.2%) .638 being
10 mm, then approximately 70% of these will occur in Dorr
Male 3 5 d
B femurs as this is by far the largest cohort (85%). Even if we

10 mm Female 16 35 d 80 (16.0%) .590
Male 9 20 d redefine a narrow canal width as
9 mm, the majority will still be

11 mm Female 19 61 1 136 (27.2%) .686 Dorr B (61.3%). However, Dorr A has a higher proportion of patients
Male 12 43 d with a narrow canal isthmus (63%) compared to Dorr B (13%). We

12 mm Female 20 111 2 234 (46.8%) .499
therefore propose that for all patients (especially Dorr A and B)
Male 15 82 4
>12 mm Female d 112 23a 266 (53.2%) .002
particularly when using a broach-only cementless femoral stem,
Male 5 119 7 isthmus diameter should be routinely measured preoperatively.
Furthermore, in cases where the isthmus is
10 mm, we recom-
N/A, not available.
a
Chi-square analysis; significantly more female patients had a Dorr C canal width mend that the canal be reamed before broaching.
of >12 mm compared to male patients, P ¼ .002 (odds ratio ¼ 3.8 [95% confidence
interval, 1.5-9.1]). Numbers in each column are cumulative. Acknowledgments
Discussion
Thanks to the following for making and recording X-ray
measurements.
To the best of our knowledge, this study is the first to report on
Dr Ryan Doherty and Dr John Vincent (Belfast Health and Social
the Dorr classification and its relationship to the narrowest part of
Care Trust). Mr David Elliott (medical student, Queen’s University
the femoral canal (isthmus). We have shown that a canal diameter of
Belfast) and Miss Rachel Thompson (medical student, University of
10 mm or less was found in 63% of type A femurs and 13% of type B.
Glasgow).
However, due to the large number of type B femurs, there were more
Also, thanks to the Belfast Arthroplasty Research Trust (BART)
type B femurs (55) with a canal diameter less than 10 mm compared
for supporting this study.
to Dorr A (25). There is a wide age range in the cohort (29-91), and
patients classified as Dorr C were significantly older and those
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