Copyrighl 979 by The Journal of Bone and Joint Surgery.

Incorporated

A Simple Biplanar Method of Measuring

Femoral Anteversion and Neck-Shaft Angle*
BY KOSUKE OGATA, M.D.t, AND EUGENE M. GOLDSAND, B.A.t, ST. LOUIS, MISSOURI

From the St. Louis Unit. Shriners Hospitalfor Crippled Children, and the Division of Orthopaedic Surgery,
Department of Surgery, Washington University School of Medicine, St. Louis

ABSTRACT: A simple biplanar roentgenographic must be centered over the femoral neck and the beam must
technique for measurement of femoral anteversion and be perpendicular to the table. An anteroposterior roent-
neck-shaft angle is described in which no special genogram of the femoral neck is made on an ordinary flat
equipment is required. An anteroposterior roentgeno- roentgenogram ofthe pelvis, with the patient’s knee flexed
gram of the pelvis and the femoral neck is made with to 90 degrees over the edge of the table and with the leg
the hip in neutral rotation. The true lateral roentgeno- parallel to the legs of the table. This positioning brings the
gram is made with the patient’s limb in a lateral posi- transcondylar axis of the distal end of the femur into the
tion with the hip and knee flexed and with the entire horizontal plane; that is, parallel to the table top. The true
lateral aspect of the leg in contact with the top of the lateral roentgenogram of the femoral neck is made with the
table. Projected cervicofemoral angulations are mea- patient lying on the table with the hip and knee flexed 90
sured on the roentgenograms. The method is described degrees and the entire lateral aspect of the leg contacting
to determine the true angles by dynamically illustrating the table top (Fig. 1). This positioning rotates the femur 90
the projected angles. Graphs have been prepared with
which one can readily determine the anteversion and
neck-shaft angles once the projected cervicofemoral
angulations have been measured.

The degree of femoral anteversion and the angle that

the femoral neck makes with the diaphysis in a living sub-
ject are difficult to determine. Many methods have been
described in the literature for making these measurements.
Monoplanar and axial roentgenography’-3, biplanar
roentgenography 2.11.8.9. 1 2. 1 3 fluoroscopy
, ‘ #{176}
‘ ‘‘ , and even
axial tomography and computed tomography have
been advocated. Although tomography may be the most
precise of these methods for measurement of femoral an-
teversion5”6, it requires special x-ray equipment and ex-
poses the patient to a relatively large amount of radiation.
Biplanar roentgenography may be accurate57-’5, but it
often requires special equipment for positioning the patient
or requires complicated geometric analysis to yield the re-
suits 6.9

In this study we describe a simple biplanar roentgen-

ographic technique for the two measurements in which no
special equipment is required. The principle on which the
method is based was originally described by Kai and later Position for lateral roentgenogram of the femoral neck. Note that the
knee is flexed 90 degrees and the entire lateral aspect of the leg contacts
by Reynolds and Herzer. We simplified their procedures the table top.
and calculations and present our technique for general use.
degrees on its long axis compared with the anteroposterior
Methods roentgenogram, so that the transcondylar plane is perpen-
For proper positioning of the patient, the x-ray tube dicular to the table. The projected cervicofemoral angula-
tions are measured on the two roentgenograms (Fig. 2).
* Read at the Residents ‘ Conference of The American Orthopaedic The geometric relationship between the anteroposterior
Association, Gainesville, Florida, April 6, 1979.
and the lateral roentgenograms is demonstrated in the
t Division of Orthopaedic Surgery, Washington University School
of Medicine, 4960 Audubon Avenue, St. Louis, Missouri 63110. three-dimensional diagram shown in Figure 3-A. In this

846 THE JOURNAL OF BONE AND JOINT SURGERY

 MEASURING FEMORAL ANTEVERSION AND NECK-SHAFT ANGLE 847

FIG. 2
The anteroposterior roentgenogram shows the projected cervicofemoral angulation a and the lateral roentgenogram shows the angle /3.

diagram, OP represents the axis of the femoral neck. R1 gles a, f3, and 0 is given by the formula:
and R1, show the directions of the x-ray beams for the an-
teroposterior and lateral roentgenograms respectively.
,
tan() = fi
tana
The Y-Z plane represents the transcondylar plane which
contains the anteroposterior projection of the neck axis If the proximal end of the femur is derotated to zero
(OE) and the projected cervicofemoral angulation a. The degrees of anteversion, an anteroposterior roentgenogram
x-z plane represents the sagittal plane which contains the will reveal the true neck-shaft angulation. In Figure 3-B,
lateral projection of the neck axis (OF) and projected cer- the axis of the femoral neck is derotated to zero degrees of
vicofemoral angulation /3. The true angle of anteversion 0 anteversion and is shown on the transcondylar plane as
is shown on the X-Y plane, which is perpendicular to both OH.
the Y-Z and the X-Z planes. The relationship between an- Angle ‘y represents the true femoral neck-shaft an-

- R

FI;. 3-A

The geometric relationship between the anteroposterior (OE) and the FIG 3 B
lateral projections (OF) of the axis of the femoral neck (OP). a: angle of .

anteroposterior view (R1) and /3: angle of lateral view (R,,). The degree of The geometric relationship between the true cervicofemoral angula-
anteversion (0) is shown on the X-Y plane, which is perpendicular to the tion (y) and the anteversion (0). The axis of the femoral neck (OP) is
Y-z (transcondylar) plane and X-Z (sagittal) plane. The following rela- derotated 0 degrees and shown on the transcondylar plane (OH). OD
tionship is derived: OG and DP = GH. The following relationship is derived:
BD CF OC tan/3 tan/3 CH OD OB cosec9 cosectl lana
IantI=.-=--=-----.----=---
OB CE DC tano tano OC CE cota CE cola cot cosO

VOL. 61-A, NO. 6, SEPTEMBER 1979

848 KOSUKE OGATA AND E. M. GOLDSAND

ZI
V
‘C

FIG. 4-A
First step of the procedure to determine the true angles. a: projected
angle of the anteroposterior view and /3: projected angle of the lateral
view. The right upper quadrant (Y-Z plane) corresponds to the transcon- FIG. 4-C
dylar plane and the left lower quadrant (X-Z’ plane), to the sagittal Determination of the true cervicofemoral angulation (y). OD = OG,
plane. OH = BE, and GH//BE/IXZ. The same relationship between the angles
in Fig. 3-B is derived:
gulation and is determined by the formula: tan)’ = ____
tana
cosO

tany -

cosO method was developed to determine 0 and y by dynami-

Therefore, once angles a and /3 have been measured on the cally illustrating the projected angles on the three essential
roentgenograms, 0 and y can be determined using a table planes opened out into a single plane. The procedure is as
of trigonometric functions. Since the calculation using a follows.
table of trigonometric functions is complicated, a simple 1 . Draw a horizontal axis YZ’ and a vertical axis XZ
so that YZ’
and XZ intersect at point 0 at right angles. The
z projected angle (a) of the anteroposterior view is repre-
sented by a line rotated clockwise from the axis OZ and the
C angle (f3) of the lateral view is represented by a line rotated
counterclockwise from the
(Fig. 4-A). axis OZ’
2. Take an C on the axis OZ and
appropriate point
draw a horizontal line CE parallel to the axis OY. Next,
take a point C’ on the axis OZ’ so that OC = OC’ and draw
a vertical line C’F parallel to the axis OX. Then draw a
vertical line from E and a horizontal line from F to deter-
mine an intersection D on the X-Y plane. The angle DOY
ZI V represents the degree of femoral anteversion 0 (Fig 4-B). , .

The angle 0 satisfies the formula:

tanO =

tana

3 - In order to determine the true cervicofemor#{225}l an-

gulation (Fig. 4-C), derotate OD to the axis OY and deter-
mine G so that OD = 0G. Since the distance BE is not
affected by the derotation, a vertical line GH is drawn so
that GH = BE. The angle HOZ represents the true cer-
x vicofemoral angulation, -y. The angle y satisfies the for-
FIG. 4-B mula:

tany =
cosO
Determination of the angle of anteversion (fI). OC OC’, CE/I
OY//FD, and CF//OX//ED (II: parallel). The same relationship be-
tween the angles in Fig. 3-A is derived:
The method of determining the true angles according

tantl = _____
tanf3
lana
to the figures
surgeons,
may not be practical
although
for busy orthopaedic
it takes only a few minutes to do the

THE JOURNAL OF BONE AND JOINT SURGERY

 MEASURING FEMORAL ANTEVERSION AND NECK-SHAFT ANGLE 849

90
--;; --;; -;;;77 z;
‘-‘- -.--. . “
80 - - - -
,0
-
. - - - -
--
.

Qp___ .--7
-7L . - 7’ 4- ;:
//
70
,, ,0 ., a .- ,- 0’
.d
“ J’ /
I!
/ / /.,

I
I / J -,0 - 0- -1-
I 4-

U L/7L /7d/77/(f
- /777/77t
fi
-T’I
I J////////J I
/((IJ//////1r
//,(jj////jC/
// I
I /r1//f//,
I- -‘a #- - -7’ -
I I
‘I
4- 4- 1- -7 .. -0 -‘a ,-

/
!_J
0”
/ -_
t: ,p4

U:; -- --

10 e;; __ --

.ie::::_______
--:;::--- --
-. - -

0 4+l +1- 4+ 1414 .-.. .. .. - *. . :: 1414 * 4+ H+l

C (0 20 30 40 50 60 70 80 90

FIG. 5-A
Graph used to determine the true anteversion (0) from the projected angles. a: anteroposterior view, /3: lateral view.

40 50
a
FIG. 5-B
Graph used to determine the true neck-shaft angles ( 180#{176}
- -y).

VOL. 61-A, NO. 6, SEPTEMBER 1979

850 KOSUKE OGATA AND E. M. GOLDSAND

TABLE I

COMPARISON OF FEMORAI. ANrEVERSION AND NECK-SHAFT ANGLES OF HUMAN CADAVER SPECIMENS MEASURED
BY OUR METHOD AND DIRECTLY WITH A GONIOMETER

Our Method (Degrees) Goniometer Me thod (Degrees)

- - Specimen Anteversion Neck-Shaft Anteversion Neck-Shaft

I 15 130 18 134
2 26 137 25 135
3 21 126 14 121
4 33 133 31 132
Range of error - 3 + 7 -4- + S
Mean error 3.3 3.0

calculation. To simplify matters further, graphs have been may be needed for accurate measurements. In the method
prepared with which one can readily determine the an- of Kai, a complicated procedure was described to draw the
teversion (Fig. 5-A) and neck-shaft angles (Fig. 5-B) from axes in the femoral neck and shaft. We have found that
any combination of the angles a and /3. The true neck- simply drawing the axis by eye usually is accurate enough.
shaft angles on the graph are expressed as ‘ ‘180 degrees - The presence of significant bowing of the femoral shaft
true cervicofemoral angulation -y’ ‘ which is more corn- can present a problem in locating the axis of the shaft. If
monly used. A Hewlett-Packard 9825A computer and a so, the average axis of the entire shaft should be used for
9872A plotter were used to make these graphs. 9.

Retroversion of the femoral neck is a rare pathologi- To evaluate the accuracy of our method, we used four
cal condition. In such a case, the lateral roentgenogram re- human lower extremities that were disarticulated at the
veals the posterior angulation of the neck in relation to the hips. The degree of femoral anteversion and the neck-shaft
femoral shaft. The same procedures and the graphs can be angles were measured by our method and compared with
used to determine the true angle of retroversion. those that were measured directly with a goniometer (Ta-
ble I). The range of error of our method as compared with
Discussion the direct measurement was between -3 and +7 degrees
Our method has several advantages over other tech- for the anteversion and between -4 and +5 degrees for
niques now in use. The procedure requires no special x-ray the neck-shaft angles The mean . errors were 3 .3 and 3.0
equipment or positioning apparatus and can be done degrees, respectively. Although no conclusion can be
quickly and easily. The true femoral neck-shaft angle as drawn regarding accuracy of our method from data ob-
well as the degree of femoral anteversion can be deter- tamed on a small number of specimens, our method has
mined simultaneously. been found to provide acceptable accuracy in clinical
Measurements made by this technique may be subject practice with high reproducibility.
to error if the location of the axes of the femoral neck and This method may be valuable in the planning of sur-
shaft on the roentgenograms is inaccurate. The magnitude gical procedures on the hip such as femoral varus-
of the error depends on the state of development of the derotational osteotomy, and it may be useful for statistical
hip1’. analysis of the results of such operations.
Before the center of ossification of the femoral head
has appeared, the location of the axis of the neck is No1E: The authors thank Dr. Perry L Schoenecker and Mr. Herberl J. Stritzel for their
advice in the preparation of this paper and Mr. Alan Greenwalt for assistance in the use of the
difficult to ascertain with accuracy. An arthrogram then HewIettPackard computerplotter system

References
I. BUDIN, E., and CHANDLER, E.: Measurement of Femoral Neck Anteversion by a Direct Method. Radiology, 69: 209-213, 1957.
2. DUNI AP, KNOX; A. R.; HOLI.ISTER,
SHANDS, L. C., JR.; GAUL, J. S., JR.; and STREIT, H. A.: A New Method of Determination ofTorsion of the
Femur. J. Bone and Joint Surg., 35-A: 289-311, April 1953.
3: DuNN, D. M.: Anteversion of the Neck of the Femur. A Method of Measurement. J. Bone and Joint Surg., 34-B: 181-186, May 1952.
4. FISHER, R. L.; DUNCAN, A. S.; and BRONZINO, J. D.: The Application of Axial Transverse Tomography to the Measurement of Femoral An-
teversion. Clin. Orthop. , 86: 6- 12, 1972.
5. HUBBARD, D. D., and STAHEII, L. T.: The Direct Radiographic Measurement ofFemoral Torsion Using Axial Tomography. Technic and Com-
parison with an Indirect Radiographic Method. Clin. Orthop. , 86: 16-20, 1972.
6. KAI, M .: [Roentgenographic Measurement of Proximal End of the Femur and Its Clinical Applicationl. Japanese J. Orthop. Surg. , 12: 389-448,
I 937.
7. LAGASSE, D. J., and STAHEII, L. T.: The Measurement of Femoral Anteversion. A Comparison of the Fluoroscopic and Biplane Roentgeno-
graphic Methods of Measurement. Clin. Orthop., 86: 13-15, 1972.
8. MAGII.I IGAN, D. J .: Calculation of the Angle of Anteversion by Means of Horizontal Lateral Roentgenography. J. Bone and Joint Surg. , 38-A:
1231-1246, Dec. 1956.
9. REYNoIoS, T. G., and HERZER, F. E.: Anteversion of the Femoral Neck. Clin. Orthop., 14: 80-89, 1959.
10. ROGERS, S. P.: A Method for Determining the Angle ofTorsion ofthe Neck ofthe Femur. J. Bone and Joint Surg.. 13: 821-824, Oct. 1931.
1 1. ROGERS, S. P.: Observations on Torsion of the Femur. J. Bone and Joint Surg., 16: 284-289, April 1934.
12. RUBY, LEONARD; MITAL, M. A.: O’CoNNoR, JOHN; and PATEL, UPENDRA: Anteversion ofthe Femoral Neck. Comparison of Methods of Mea-
surement in Patients. J. Bone and Joint Surg., 61-A: 46-51, Jan. 1979.

THE JOURNAL OF BONE AND JOINT SURGERY

 MEASURING FEMORAL ANTEVERSION AND NECK-SHAFT ANGLE 851

13. RYDER, C. T., and CRANE, LAWRENCE: Measuring Femoral Anteversion: The Problem and a Method. J. Bone and Joint Surg., 35-A: 32 1-328,
April 1953.
14. TACHDJIAN, M. 0.: Femoral Torsion. In Pediatric Orthopedics, p. 1448. Philadelphia, W. B. Saunders, 1972.
IS. VANHOUTTE, J. J., and RAESIDE. D. E.: A Generalization ofChevrot’s Method for Determining Anteversion and Cervico-Diaphyseal Angles.
Radiology, 128: 251-252, 1978.
16. WEINER, D. S.; CooK, A. J.; HOYT. W. A., JR.; and ORAVEC, C. E.: Computed Tomography in the Measurement of Femoral Anteversion.
Orthopedics, 1: 299-306, 1978.

Copyright I 979 by The Journal of ooi:d Joipit Surgery, 1n orporated

Osteonecrosis after Renal Transplantation in Children

BY PETER J. STERN, M.D.*, AND HUGH G. WATTS, M.D.t, BOSTON, MASSACHUSETTS

From the Children’s Hospital Medical Center, Boston

ABSTRACT: Osteonecrosis occurred in nine of months of the operation. Eight additional patients were
thirty-six children following renal transplantation. The excluded: four because they had to be returned to a dialysis
distal femoral condyle was the most common location program within one year of the transplant, two because
but the femoral head was the most symptomatic and they were not in the appropriate age group (they were more
required total hip replacement in three of five patients. than eighteen years old), and two because there were in-
Total steroid dosage did not correlate with the de- sufficient data on follow-up. This left thirty-six patients
velopment of osteonecrosis. There were no cases of Os- who were followed for between two and 6.5 years (aver-
teonecrosis in patients under the skeletal age of ten age, 4.2 years).
years or in patients who did not have rejection reac- There were fourteen boys and twenty-two girls. The
tions. In three children non-progressive focal lesions renal diseases of the patients included chronic gb-
developed, similar to those of osteochondritis dissec- merulonephritis hypoplastic , kidneys medullary cystic ,

ans. disease, and obstructive uropathy. Thirty-two of the renal

allografts came from living related donors, while the re-
The prognosis for patients with chronic renal failure maining four came from cadavera. No correlation could be
has greatly improved since the introduction of renal made between the source of the albograft and the develop-
allograft replacement. Despite increasing success with ment of osteonecrosis.
improved tissue-typing, surgical techniques, and im- Patients were dialyzed on the day prior to surgery and
munosuppressive drugs, osteonecrosis has continued to be were given azathioprine and prednisone. On the day of
a major problem, particularly in the weight-bearing joints. transplantation, patients received intravenous methyl-
Post-transplantation osteonecrosis was first reported prednisolone, two milligrams per kilogram of body
by Starzl and associates in 1964. It has often been reported weight. Postoperatively the dose of steroid was gradually
in adults since then 2.5.7.10.1 I.13.17.18.21.23.21i.29 Children who decreased, so that at the time of discharge they were re-
require renal allografts comprise a separate population ceiving two milligrams per kilogram of body weight per
from the adults because they tend to have severe pre- day of prednisone, and that was reduced over the next
transplantation renal osteodystrophy, growth retardation, thirty-six weeks to a daily dose of ten to fifteen milligrams
and epiphysiolysis9. In this paper we attempt to establish per day. Azathioprine was given at an initial dose of four
the incidence and clinical pattern of osteonecrosis in chil- milligrams per kilogram of body weight per day and was
dren and to show how it differs from that in adults. gradually reduced to one to two milligrams per kilogram
per day. Antilymphocytic serum was used in only a few
Materials and Methods
patients. The total hospitalization in uncomplicated cases
Between May 1971 and January 1, 1975, fifty-seven was fourteen to twenty-one days. Patients with the rejec-
renal transplants were done at the Children’s Hospital tion reaction were treated with steroid pulses of intrave-
Medical Center in fifty-four patients. Ten patients were nous methyiprednisolone, twelve milligrams per kilogram
excluded from the study because they died within six of weight per day, reduced over eight days to two milli-
grams per kilogram, and some patients received low-dose
radiation to the allograft. We calculated cumulative steroid
* Department of Orthopaedic Surgery, University of Cincinnati doses (milligrams per kilogram) for all patients for the first
College of Medicine, 231 Bethesda Avenue, Cincinnati, Ohio 45267.
Si x postoperative months converting
, methylprednisobone
t Department of Orthopaedic Surgery, Children ‘s Hospital Medical
Center, 300 Longwood Avenue, Boston, Massachusetts 021 15. to prednisone equivalent at a ratio of four milligrams of

VOL. 61-A, NO. 6, SEPTEMBER 1979