Asian Journal of Surgery xxx (xxxx) xxx

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Asian Journal of Surgery

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ORIGINAL ARTICLE

Trans-lateral decubitus radiograph of the hip: A new view to measure

the anteversion of the femoral stem
Yong-Chan Ha a, Jun-Il Yoo b, *, Joongl-Mo Ahn c, Young-Kyun Lee d, Yusuhn Kang c,
Kyung-Hoi Koo d
a
Department of Orthopaedic Surgery, Chung-Ang University College of Medicine, Seoul, South Korea
b
Department of Orthopaedic Surgery, Gyeongsang National University Hospital, Jinju, South Korea
c
Department of Radiology, Seoul National University Bundang Hospital, Bundang, South Korea
d
Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Bundang, South Korea

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

Article history: Background: Malposition of the femoral stem is a risk factor for dislocation after total hip arthroplasty
Received 5 February 2020 (THA). Currently, two radiological methods are available for the measurement of stem anteversion.
Received in revised form However, one method is not applicable in patients with a stiff hip, and the other one cannot differentiate
13 March 2020
the anteversion and retroversion of the stem. Therefore, we developed a method to measure the stem
Accepted 25 March 2020
Available online xxx
anteversion and assessed its reliability as well as validity.
Methods: Trans-lateral decubitus view of the proximal femur was taken with the patient in lateral de-
cubitus position, the hip in extension and the knee in 90
flexion. Hip anteroposterior (AP) view, trans-
Keywords:
Femoral stem anteversion
lateral decubitus view and CT scan of the hip were taken in 36 patients, who underwent THA. Their mean
Decubitus trans-lateral method age was 59.8 (27e84) years and the mean body mass index was 25.2 (18.8e30.9) kg/m2. The stem neck-
Total hip replacement femoral shaft angle was measured on hip AP view and the trans-lateral decubitus view. Then, the stem
anteversion was calculated using the Ogata-Goldsand formula. We assessed the intra- and inter-observer
reliabilities and evaluated the validity by comparing with the measurements on CT scan.
Results: The intra- and inter-observer reliabilities were 0.934 and 0.935, respectively. The calculated
stem anteversion (23.72
±8.17
) correlated well with the stem anteversion on CT scan (23.91
±10.25
),
especially when the radiological anteversion was <30
(correlation coefficient ¼ 0.729, p ¼ 0.001).
Conclusion: We developed a reliable and valid method to measure stem anteversion using hip AP view
and trans-lateral decubitus view of the femur. This method can replace conventional radiological
methods.
© 2020 Asian Surgical Association and Taiwan Robotic Surgery Association. Publishing services by
Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).

1. Introduction tomography (CT) scan is accurate in the measurement of the

Implant malposition is an important risk factor for dislocation
after total hip arthroplasty (THA) and accurate assessment of
implant position is critical to determine whether to change the
implant in dislocating hips.1e12 Although computerized
Abbreviations: THA, total hip arthroplasty; CT, computerized tomography; BMI,
body mass index; AP, anteroposterior; AIIS, antero-inferior iliac spine; ICCs, intra-
class correlation coefficients; CI, confidence interval; CCD, caput-collum-diaphy-
seal-angle; SV, stem anteversion.
* Corresponding author. Department of Orthopaedic Surgery, Gyeongsang Na-
tional University Hospital, 90 Chilamdong, Jinju, 660-702, South Korea.
E-mail address: furim@daum.net (J.-I. Yoo).
implant position, it is costly and has a radiation hazard.13e16 Several
studies reported reliable methods to measure the abduction and
anteversion of the acetabular component using plain radiographs.
However, the measurement of the stem anteversion on radiographs
is still under debate.17e22
To date, several methods were introduced to measure stem
anteversion using radiographs. In 1957, Budin and Chandler
developed a radiological measurement of femoral neck anteversion
in children.23 In 2012, Lee et al proposed a modified Budin method
to measure the stem anteversion on radiographs. However, it is not
applicable in patients who have a stiff hip joint.24 In 2015, Weber
et al reported a method to measure the stem anteversion on
anteroposterior (AP) hip radiograph using a computer program and

https://doi.org/10.1016/j.asjsur.2020.03.016
1015-9584/© 2020 Asian Surgical Association and Taiwan Robotic Surgery Association. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-
ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Please cite this article as: Ha Y-C et al., Trans-lateral decubitus radiograph of the hip: A new view to measure the anteversion of the femoral
stem, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2020.03.016
2 Y.-C. Ha et al. / Asian Journal of Surgery xxx (xxxx) xxx
mathematical formulas.25 However, this method cannot differen-
tiate the anteversion and retroversion of the femoral stem. There-
fore, a simple and reliable method to measure the stem anteversion
has been warranted. We presented a new method using two ra-
diographs, and assessed its reliability and validity.
2. Methods
This prospective study was approved by our institutional review
board, and informed consent was obtained from patients, who
participated in the study. The study was registered in the
ClinicalTrials.gov Protocol Registration System (NCT02554149).
A total of 49 patients, who underwent primary THA from
October 2015 to January 2016, were recruited. None of them had
any history of previous femoral fracture or underlying metabolic
disease. Among them, 4 patients declined to participate in the
study, and 9 patients refused postoperative CT scan. The remaining
36 patients were subjects of the study. There were 19 men and 17
women, their mean age was 59.8 years (SD 11.8; 27 to 84), and a
mean body mass index (BMI) was 25.2 kg/m2 (SD 3.0; 18.8 to 30.9)
at the time of operation. The primary diagnosis was femoral head
osteonecrosis in 18 hips (50%), and osteoarthritis in 18 hips (50%)
(Table 1).
Two high volume (<200 hip surgeries/year) surgeons performed
all THAs using Kocher-Langenbeck posterolateral approach.26 A
cementless acetabular component (Mirabo; Corentec, Seoul, South
Korea), a cementless stem (Bencox M; Corentec), a ceramic liner
(BIOLOX Delta; CeramTec AG, Plochingen, Germany), and 32 or 36-
mm ceramic head (BIOLOX Delta; CeramTec AG) were used in all
hips. Postoperative radiographs and CT scans were taken 5 days
after the THA.
2.1. Trans-lateral decubitus view
Trans-lateral decubitus view of the femur was a lateral image of
the proximal femur. To take this view, the patient was placed in a
lateral decubitus position on the affected side. The affected hip was
extended and the ipsilateral knee was flexed by 90
. A foam-block
was placed below the opposite leg to maintain the opposite hip at
100
flexion and 30
abduction (Fig. 1A). In this position, the
intercondylar axis was placed in the vertical plane and a true lateral
image of the femur could be obtained (Fig. 1B and C). The source-to-
film distance was 100 cm. All images were digitally acquired using
the Picture Archiving and Communication System (PACS) (Infinitt:
Infinitt Healthcare, Seoul, South Korea), and all radiological mea-
surements were made on a 19-inch LCD monitor using the PACS
software.
2.2. Preliminary study to identify the anterior angulation of the
proximal femur
In order to measure the stem anteversion on the trans-lateral
decubitus view, we should know the relationship between the
axis of the entire femur (entire femoral axis) and that of the
Table 1
Demographics of 36 patients.
Number of patients (hips) 36
Age (years) (mean ± SD) 59.8 ± 11.8
Body mass index (kg/m2) (mean ± SD) 25.2 ± 3.0
Primary diagnosis (number of hips)
Femoral head osteonecrosis 18
Osteoarthritis 18
SD; standard deviation.
Please cite this article as: Ha Y-C et al., Trans-lateral decubitus radiograph of the hip: A new view to measure the anteversion of the femoral
stem, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2020.03.016
proximal femur (proximal femoral axis) in the sagittal plane. Thus,
a preliminary study was conducted to reveal the relationship be-
tween the two axes. The entire femoral axis and the proximal
femoral axis were drawn on lateral image of the femur of 40 pa-
tients, who underwent primary THA from June 2015 to August
2015, and the angle between the two axes were measured. The
angle ranged from 13.8
to 16.5
with an average of 15.0
(Fig. 2).
2.3. Radiographic measurement of the stem neck-femoral shaft
angle
We measured stem neck-femoral shaft angle on hip ante-
roposterior (AP) view. On the decubitus lateral view, the stemeneck
axis was defined as the line between the center of the modular
head and the center at the base of the trunnion of the stem. The
angle between the stemeneck axis and the axis of the proximal
femur was measured (Fig. 3). Then, this angle was subtracted by
15
; the mean angle between the entire femoral axis and the
proximal femoral axis.
2.4. Calculation of stem anteversion from stem neck-femoral shaft
angle
From the stem neck-femoral shaft angle on hip AP vies and that
on the trans-lateral decubitus view, we calculated the real stem
anteversion (q) using the formula by Ogata and Goldsand.27 In brief,
“a” is stem neck-femoral shaft angle on the AP view, and “b” is stem
neck-femoral shaft angle on the trans-lateral decubitus view. Then,
tan q ¼ tan b/tan a, and q ¼ arctan [tan b/tan a], where arctan is the
inversion of the tangent. They described a (Equation (1)) and b
(Equation (2)) as supplementary angles to what we calculated as
neck-shaft angles, which we then corrected for in our equations.
We used Microsoft Excel (Microsoft Inc, Redmond, WA, USA) to
perform the calculations as follows:
1) Equation (1): stem neck-femoral shaft angle on hip AP view ¼ a
2) Equation (2): stem neck-femoral shaft angle on trans-lateral
decubitus view ¼ b
3) Equation (3): “q ¼ TAN (RADIANS [b])/TAN (RADIANS [a])” “tan
q ¼ tan b/tan a”
4) Equation (4): “Anteversion ¼ DEGREES(ATAN [q])”
2.5. Measurement of true stem anteversion on CT scan
Stem anteversion was measured with use of three cross-
sectional CT images. The angle between the axis of the stem neck
and the posterior intercondylar line was defined as the CT ante-
version of the stem. In previous study of Lee et al,24 we have
described a method for measuring stem anteversion using three
cross-sectional CT images.
The standard acquisition protocol for CT scans was as follows:
for cross-sectional CT a collimation of 0.63 mm was used; the field
of view at acquisition was 30 cm, and slice thickness was 0.67 mm
with 0.33 mm increments (50% section overlap). We could reduce
CT radiation dose to one third by scanning only two sections from
antero-inferior iliac spine (AIIS) to 10 cm below of the lesser
trochanter and range from the top to bottom of condyle on femur.
2.6. Comparison between the radiological stem anteversion and CT
stem anteversion
The stem anteversion was measured on radiographs and CT scans
by three independent evaluators in a random order. The observers
were unaware of any information regarding the patient's clinical data
 Y.-C. Ha et al. / Asian Journal of Surgery xxx (xxxx) xxx 3

Fig. 1. (A) Patient is placed in a lateral decubitus position on the affected side. The affected hip is extended and the ipsilateral knee is flexed by 90
(B) X-ray beam is centered at the
hip joint (C) This trans-lateral decubitus radiograph includes the lateral image of the proximal femur.

or the measurement results derived from other evaluators. The mean
value of three measurements by each evaluator was regarded as the
stem anteversion. The CT anteversion was used as the standard
reference to assess the validity of the radiological anteversion.
2.7. Statistical analysis
In this study, precision analysis was performed using intraclass
correlation coefficients (ICCs) at a target value of 0.8 and a 95%
confidence interval (CI) set at 0.2, and the minimum sample size
was estimated to be 36 hips.28 To assess intra-observer reliability,
all CT images and plane radiographs were re-evaluated by one
observer 3 weeks after the first assessment. Values greater than or
equal to 0.70 were considered adequate for reliability.29
In addition, Spearman's rho correlation coefficients were ob-
tained and characterized as poor (0.00e0.20), fair (0.21e0.40),
moderate (0.41e0.60), good (0.61e0.80) or excellent (0.81e1.00).
Statistical analyses were conducted using SPSS v15.0 (SPSS Inc.,
Chicago, Illinois) and P value < 0.05 was considered statistically
significant.

Fig. 2. (B) The axis of the proximal femur (black dot line) is bowed anteriorly by 15
from the axis of the entire femur (black line).

Please cite this article as: Ha Y-C et al., Trans-lateral decubitus radiograph of the hip: A new view to measure the anteversion of the femoral
stem, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2020.03.016
4 Y.-C. Ha et al. / Asian Journal of Surgery xxx (xxxx) xxx

When the radiological stem anteversion was <30
(Fig. 4A and

B), the correlation coefficient between the radiological measure-
ment and the CT measurement was 0.729 (p ¼ 0.001). For practical
use, we made a conversion table to obtain the real stem anteversion
from the radiological stem anteversion measured on the trans-
lateral decubitus view (Table 3).
The radiological stem anteversion is calculated by subtracting
15
from the angle between the axis of the stem neck and the axis
of the proximal femur on the trans-lateral decubitus view.

4. Discussion

Accurate measurement of the implant position is important

when evaluating a dislocating THA to determine whether to change
the implant. This study demonstrated that the stem anteversion
measurement using two radiographs; hip AP view and trans-lateral
decubitus view, is reliable and valid.
In a previous study by Lee et al,24 the stem anteversion was
Fig. 3. The angle between the line A (the axis of the stem neck) and line B (the axis of
measured on modified Budin's view.23 That view was taken in hip
the proximal femur) is measured on the trans-lateral decubitus view. Then, the angle is
subtracted by 15
to obtain stem neck-femoral shaft angle. abduction, and cannot be taken in patients who have a stiff hip.24
Weber et al developed a method to measure the stem anteversion
on AP radiographs of the hip.30 Because the stem anteversion was
3. Results calculated from the projected neck-shaft angle on the radiograph, a
highly standardized radiological technique was required. Another
There was no significant difference in the measurements on the deficit was that method could not differentiate the stem anteversion
radiographs and CT measurements (23.72
±8.17 versus and retroversion. Some studies used cross-table radiographs of the
23.91
± 10.25) (paired t-test, p ¼ 0.929). hip for the measurement of stem anteversion.31,32 However, a later
The intra- and inter-observer reliabilities were adequate in the study showed that these methods are not reliable.33
measurement of stem anteversion from the radiographs (r ¼ 0.934 There are several limitations in this study. First, our method is
and 0.935, respectively; p < 0.001) and that from the CT scan not applicable in deformed femurs. Second, our study used a stem
(r ¼ 0.941 and 0.975, respectively; p < 0.001) (Table 2). with a neck-shaft angle of 132
. Our method should be modified in
stems with other neck-shaft angles. Third, we used a foamblock to
hold the contralateral leg in the required position. The foamblock is
soft and might not consistently hold the patient's leg. This incon-
Table 2
Intra- and inter-observer reliabilities of stem anteversion measurements on radio-
sistency might result in an inaccurate measurement.
graphs and CT scan. In conclusion, our method to measure using the trans-lateral
view of the femur is reliable and valid for the measurement of
Intra-observer 95% CI P- Inter-observer 95% CI P-
reliability (r) value reliability (r) value
stem anteversion. Further studies including a large number of THA
patients are warranted to verify the accuracy of this new method.
Radiograph 0.934 0.892 <0.001 0.935 0.877 <0.001
e0.963 e0.966
CT scan 0.941 0.894 <0.001 0.975 0.952 <0.001 Ethics approval and consent to participate
e0.962 e0.987

ICC, Intraclass correlation coefficient; CI, confidence interval. This prospective study was approved by our institutional review
board, and informed written consent was obtained from patients,

Fig. 4. The stem anteversion measured on the trans-lateral decubitus view is almost similar with the real stem anteversion measured on CT scan, when it is < 30
(A) Stem with a
neck-shaft angle of 132
(B) Stem with a neck-shaft angle of 135
.

Please cite this article as: Ha Y-C et al., Trans-lateral decubitus radiograph of the hip: A new view to measure the anteversion of the femoral
stem, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2020.03.016
 Y.-C. Ha et al. / Asian Journal of Surgery xxx (xxxx) xxx 5

Table 3 Funding
Calculation table for stem anteversion using trans-lateral decubitus view.

A (
) B1 (
) B2 (
) A (
) B1 (
) B2 (
) There is no funding source.

48 90.0 0 0.0 0.0
45 64.2 90.0 2 1.8 2.0 Declaration of competing interest
‘-44 60.4 74.9 4 3.6 4.0
‘-42 54.2 64.2 6 5.4 6.0
All authors declare that they have no conflict of interest. No
40 49.1 57.0 8 7.3 8.1
38 44.7 51.4 10 9.1 10.2 benefits in any form have been received or will be received from a
36 40.9 46.6 12 11.0 12.3 commercial party related directly or indirectly to the subject of this
34 37.4 42.4 14 13.0 14.4 article.
32 34.2 38.7 16 15.0 16.7
30 31.3 35.3 18 17.0 19.0
28 28.6 32.1 20 19.1 21.3 Acknowledgments
26 26.1 29.2 22 21.3 23.8
24 23.6 26.4 24 23.6 26.4 No benefits in any form have been or will be received from a
22 21.3 23.8 26 26.1 29.2 commercial party related directly or indirectly to the subject of this
20 19.1 21.3 28 28.6 32.1
study by any of the authors.
18 17.0 19.0 30 31.3 35.3
16 15.0 16.7 32 34.2 38.7
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