0
Scientific Articles   |    
The Prevalence of Acetabular Retroversion Among Various Disorders of the Hip
Masamitsu Ezoe, MD1; Masatoshi Naito, MD1; Toshio Inoue, MD1
1 Department of Orthopaedic Surgery, Fukuoka University School of Medicine, 7-45-1, Nanakuma, Jyonan-ku, Fukuoka 814-0180, Japan. E-mail address for M. Ezoe: md010001@mms.bbiq.jp
View Disclosures and Other Information
The authors did not receive grants or outside funding in support of their research for or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at the Department of Orthopaedic Surgery, Fukuoka University School of Medicine, Fukuoka, Japan

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2006 Feb 01;88(2):372-379. doi: 10.2106/JBJS.D.02385
5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case

Abstract

Background: Acetabular retroversion can result from posterior wall deficiency in an otherwise normally oriented acetabulum or from excessive anterior coverage secondary to a malpositioned acetabulum, or both. Theoretically, a retroverted acetabulum, which adversely affects load transmission across the hip, may occur more frequently in hips with degenerative arthritis. The aim of this study was to assess the prevalence of acetabular retroversion in normal hips and in hips with osteoarthritis, developmental dysplasia, osteonecrosis, and Legg-Calvé-Perthes disease.

Methods: We retrospectively examined anteroposterior radiographs of the pelvis of 250 patients (342 hips). Fifty-six patients (112 hips) had normal findings; sixty-six patients (seventy hips) had osteoarthritis; sixty-four (seventy-four hips), developmental dysplasia; thirty (thirty-six hips), osteonecrosis of the femoral head; and thirty-four (fifty hips), Legg-Calvé-Perthes disease. The sole criterion for a diagnosis of acetabular retroversion was the presence of a so-called cross-over sign on the anteroposterior radiograph of the pelvis.

Results: The prevalence of acetabular retroversion was 6% (seven of 112 hips) in the normal group, 20% (fourteen of seventy hips) in the osteoarthritis group, 18% (thirteen of seventy-four hips) in the developmental dysplasia group, 6% (two of thirty-six hips) in the group with osteonecrosis of the femoral head, and 42% (twenty-one of fifty hips) in the group with Legg-Calvé-Perthes disease. In patients with Legg-Calvé-Perthes disease, the prevalence of acetabular retroversion was 68% in twenty-five hips with Stulberg class-III, IV, or V involvement. In contrast, only four (16%) of twenty-five hips with Stulberg class-I or II involvement had acetabular retroversion. The difference was significant (p = 0.0002). Patients with osteoarthritis, developmental dysplasia, or Legg-Calvé-Perthes disease are significantly more likely to have acetabular retroversion than are normal subjects (p < 0.05).

Conclusions: Acetabular retroversion occurs more commonly in association with a variety of hip diseases, in which the prevalence of subsequent degenerative arthritis is increased, than has been previously noted.

Level of Evidence: Diagnostic Level III. See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article
    Sign In to Your Personal ProfileSign In To Access Full Content
    Not a Subscriber?
    Get online access for 30 days for $35
    New to JBJS?
    Sign up for a full subscription to both the print and online editions
    Register for a FREE limited account to get full access to all CME activities, to comment on public articles, or to sign up for alerts.
    Register for a FREE limited account to get full access to all CME activities
    Have a subscription to the print edition?
    Current subscribers to The Journal of Bone & Joint Surgery in either the print or quarterly DVD formats receive free online access to JBJS.org.
    Forgot your password?
    Enter your username and email address. We'll send you a reminder to the email address on record.

     
    Forgot your username or need assistance? Please contact customer service at subs@jbjs.org. If your access is provided
    by your institution, please contact you librarian or administrator for username and password information. Institutional
    administrators, to reset your institution's master username or password, please contact subs@jbjs.org

    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
    CME Activities Associated with This Article
    Submit a Comment
    Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
    Comments are moderated and will appear on the site at the discretion of JBJS editorial staff.

    * = Required Field
    (if multiple authors, separate names by comma)
    Example: John Doe





    John A. Vlamis, M.D.
    Posted on June 18, 2006
    Retroversion of the acetabulum in DDH
    NULL

    To The Editor:

    I read with interest the article “ The prevalence of Acetabular retroversion among various disorders of the hip”(1) in which the authors conclude, “retroversion in DDH is more common than previously thought”.

    First, I would like to emphasize that frontal plane analysis of the hip as it is used by all traditional methods of analysis and classification for hip dysphasia is often inadequate even when supplemented with special oblique views. In addition to plain films, a CT scan provides the transverse plane anatomy of the acetabulum. I routinely evaluate hips with developmental dysplasia or dislocation in patients who are candidates for THA with plain AP x-rays and three dimensional CT of the pelvis to evaluate retro or excessive anteversion of the acetabulum.

    In my experience and in most of the cases found in the literature, retroversion of the acetabulum was present after pelvic osteotomy in younger patients or after conservative treatment with plaster or traction. Mechanical studies and clinical experience have demonstrated that with the performance of a pelvic osteotomy (Salter, Chiari, triple or Bernese) anteroloteral coverage is gained at the expense of posterior coverage. Interestingly, hips, which had undergone additional femoral derotational osteotomies, were associated with significantly more pronounced acetabular retroversion. I suppose that in most cases true retroversion of the acetabulum in DDH is iatrogenic. That is probably the reason why in type III hips (high dislocation) in which patients were usually left untreated retroversion of the acetabulum is absent(2).

    Second, the retroversion of the acetabulum in Hips with positive “cross – over” sigh is limited to the upper ¼ of the acetabulum the rest remaining within normal range of anteversion. There are also cases with an osteophyte covering the upper anterior part of the femoral head as an extension of the anterior wall that can give the false impression of retroversion. If the osteophyte is ignored the remaining anteversion is usually within normal range.

    I consider true retroversion the one that covers at least ¾ of the acetabulum and is due to posterior wall insufficiency or retroversion of the hemipelvis and not because of the extended anterior osteophyte. Meeting this criteria, retroversion was found mostly in cases with previous pelvic osteotomy.

    Furthermore, the anterior overcoverage of the femoral head with an osteophyte and the subsequent “retroversion” is possibly the result of osteoarthritis and not the cause of the disease.

    The author(s) of this letter to the editor did not receive payment or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author(s) are affiliated or associated.

    References:

    1. Ezoe M, Naito M, Inoue T. The prevalence of acetabular Retroversion among various diseases of the hip. J Bone Joint Surg. Am. 2006; 88:372-9.

    2. Vlamis J.A. Three dimensional classification of D.D.H in Adults. SICOT, SIROT third annual international conference, 2004:285

    Rainer G. Biedermann, M.D.
    Posted on March 23, 2006
    The effect of pelvic rotation and inclination on the cross-over sign
    Dept. Orthopedics, Innsbruck Medical University, Innsbruck, AUSTRIA

    EDITOR'S NOTE, 20 April 2006: The corresponding author was invited to respond to this letter, but to date, has not done so.

    To The Editor:

    With great interest we read Dr. Ezoe, et al, article on the prevalence of acetabular retroversion among various disorders of the hip.

    The key point in measuring acetabular anteversion is its differentiation from inclination. In their study on the effect of pelvic tilt on acetabular retroversion, Siebenrock, et al, (1) have shown a great variability of the presence or absence of retroversion signs on 86 radiographs within normal distribution of a healthy population. Within the range of measured distances between the symphysis and the sacrococcygeal joint in these x-rays, positive and negative retroversion signs in all tested acetabulums of four cadaver pelves were simulated. There was a linear correlation between this distance and the pelvic inclination angle.

    You included patients in your study whose distance was within the interquartile range of the measurements by Siebenrock, et al, (1) presuming the wide variation of presence of retroversion signs is not present within this 15mm range (corresponding to a range of the pelvic tilt of ~8° for men and ~3° for women; see Siebenrock, et al, - Fig 4). (1) This assumption is based on measurements of just two pelves for each gender, far below a statistical significant number. In addition to the pelvic tilt position, Siebenrock, et al, (1) have shown a 6°rotation around a vertical axis, corresponding to a 16mm deviation of the middle of the sacrococcygeal joint from the midline through the symphysis, leading to appearance of a cross-over and posterior wall sign in the ipsilateral acetabulum of all four pelves from cadavers. Therefore, the question whether you reported on pelvic tilt rather than acetabular version of your subgroups still remains open. Likewise, the projection of the obturator foramen in your Figures 1 and 2, presenting an anteverted (Figure 1) and a retroverted acetabulum (Figure 2), differs significantly.

    We therefore strongly recommend comparing mean values of measured distances between 1) the symphysis and the sacrococcygeal joint and 2) the middle of the sacrococcygeal joint and the midline through the symphysis statistically with a Student t-Test or Mann-Whitney Test respectively in order to present that comparison of your subgroups was valid.

    Reference:

    1. Effect of pelvic tilt on acetabular retroversion: a study of pelves from cadavers. Siebenrock KA, Kalbermatten DF, Ganz R. Clin Orthop 2003; 407: 241-248.

    Related Content
    The Journal of Bone & Joint Surgery
    JBJS Case Connector
    Topic Collections
    Related Audio and Videos
    PubMed Articles
    Clinical Trials
    Readers of This Also Read...
    JBJS Jobs
    02/28/2014
    District of Columbia (DC) - Children's National Medical Center
    04/02/2014
    W. Virginia - Charleston Area Medical Center
    12/04/2013
    New York - Icahn School of Medicine at Mount Sinai
    12/31/2013
    S. Carolina - Department of Orthopaedic Surgery Medical Univerity of South Carlonina