European Radiology

, Volume 27, Issue 3, pp 1295–1302 | Cite as

Influence of patient axial malpositioning on the trueness and precision of pelvic parameters obtained from 3D reconstructions based on biplanar radiographs

  • Bachir Ghostine
  • Christophe SauretEmail author
  • Ayman Assi
  • Ziad Bakouny
  • Nour Khalil
  • Wafa Skalli
  • Ismat Ghanem



Radiographs are often performed to assess pelvic and hip parameters, but results depend upon correct pelvis positioning. Three-dimensional (3D) reconstruction from biplanar-radiographs should provide parameters that are less sensitive to pelvic orientation, but this remained to be evaluated.


Computerized-tomographic scans of six patients were used both as a reference and for generating simulated frontal and lateral radiographs. These simulated radiographs were generated while introducing axial rotations of the pelvis ranging from 0° to 20°. Simulated biplanar-radiographs were utilized by four operators, three times each, to perform pelvic 3D-reconstructions. These reconstructions were used to assess the trueness, precision and global uncertainty of radiological pelvic and hip parameters for each position.


In the neutral position, global uncertainty ranged between ± 2° for pelvic tilt and ± 9° for acetabular posterior sector angle and was mainly related to precision errors (ranging from 1.5° to 7°). With increasing axial rotation, global uncertainty increased and ranged between ± 5° for pelvic tilt and ± 11° for pelvic incidence, sacral slope and acetabular anterior sector angle, mainly due to precision errors.


Radiological parameters obtained from 3D-reconstructions, based on biplanar-radiographs, are less sensitive to axial rotation compared to plain radiographs. However, the axial rotation should nonetheless not exceed 10°.

Key points

Pelvic radiological parameters could be affected by patient malpositioning.

Biplanar radiograph-based 3D reconstructions were performed at increments of axial rotation.

Trueness, precision and global uncertainty were evaluated for pelvic and hip radiological parameters.

Hip parameters were less affected by rotation compared to pelvic parameters.

Maintaining the pelvis close to the neutral position is recommended to ensure the highest possible accuracy.


Pelvis Rotation Biplanar X-rays Trueness Precision 



The scientific guarantor of this publication is Ismat Ghanem.

The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article. Wafa Skalli is coinventor of the EOS low dose bi-planar X-Ray system, without personal financial benefit.

This study has received funding by the research council of the University of Saint-Joseph (grant number FM276) and the French-Lebanese cooperation for research CEDRE (grant number 11 SCI F 44/L36). The sponsors had no involvement in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the article for publication. No complex statistical methods were necessary for this paper. Institutional Review Board approval was obtained.

Written informed consent was not required for this study because data were previously obtained for clinical purpose and subject gave their informed consent for their further use in research purposes. Methodology: retrospective, observational, performed at one institution.


  1. 1.
    Jacobsen S, Sonne-Holm S, Lund B, Söballe K, Kiaer T, Rovsing H et al (2004) Pelvic orientation and assessment of hip dysplasia in adults. Acta Orthop Scand 75:721–729CrossRefPubMedGoogle Scholar
  2. 2.
    Tannast M, Zheng G, Anderegg C, Burckhardt K, Langlotz F, Ganz R et al (2005) Tilt and rotation correction of acetabular version on pelvic radiographs. Clin Orthop Relat Res 438:182–190CrossRefPubMedGoogle Scholar
  3. 3.
    Weinert DJ (2005) Influence of axial rotation on chiropractic pelvic radiographic analysis. J Manip Physiol Ther 28:117–121CrossRefGoogle Scholar
  4. 4.
    Clohisy JC, Carlisle JC, Trousdale R, Kim YJ, Beaule PE, Morgan P et al (2009) Radiographic evaluation of the hip has limited reliability. Clin Orthop Relat Res 467:666–675CrossRefPubMedGoogle Scholar
  5. 5.
    van der Bom MJ, Groote ME, Vincken KL, Beek FJ, Bartels LW (2011) Pelvic rotation and tilt can cause misinterpretation of the acetabular index measured on radiographs. Clin Orthop Relat Res 469:1743–1749CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Dandachli W, Ul Islam S, Richards R, Hall-Craggs M, Witt J (2013) The influence of pelvic tilt on acetabular orientation and cover: a three-dimensional computerised tomography analysis. Hip Int 23:87–92CrossRefPubMedGoogle Scholar
  7. 7.
    Mitton D, Deschènes S, Laporte S, Godbout B, Bertrand S, de Guise JA et al (2006) 3D reconstruction of the pelvis from bi-planar radiography. Comput Methods Biomech Biomed Engin 9:1–5CrossRefPubMedGoogle Scholar
  8. 8.
    Humbert L, Carlioz H, Baudoin A, Skalli W, Mitton D (2008) 3D Evaluation of the acetabular coverage assessed by biplanar X-rays or single anteroposterior X-ray compared with CT-scan. Comput Methods Biomech Biomed Engin 11:257–262CrossRefPubMedGoogle Scholar
  9. 9.
    Bittersohl B, Freitas J, Zaps D, Schmitz MR, Bomar JD, Muhamad AR et al (2013) EOS imaging of the human pelvis: reliability, validity, and controlled comparison with radiography. J Bone Joint Surg Am 95:e581–e589CrossRefGoogle Scholar
  10. 10.
    Humbert L, De Guise JA, Aubert B, Godbout B, Skalli W (2009) 3D reconstruction of the spine from biplanar X-rays using parametric models based on transversal and longitudinal inferences. Med Eng Phys 31:681–687CrossRefPubMedGoogle Scholar
  11. 11.
    Chaibi Y, Cresson T, Aubert B, Hausselle J, Neyret P, Hauger O et al (2012) Fast 3D reconstruction of the lower limb using a parametric model and statistical inferences and clinical measurements calculation from biplanar X-rays. Comput Methods Biomech Biomed Engin 15:457–466CrossRefPubMedGoogle Scholar
  12. 12.
    Quijano S, Serrurier A, Aubert B, Laporte S, Thoreux P, Skalli W (2013) Three-dimensional reconstruction of the lower limb from biplanar calibrated radiographs. Med Eng Phys 35:1703–1712CrossRefPubMedGoogle Scholar
  13. 13.
    Assi A, Chaibi Y, Presedo A, Dubousset J, Ghanem I, Skalli W (2013) Three-dimensional reconstructions for asymptomatic and cerebral palsy children's lower limbs using a biplanar X-ray system: a feasibility study. Eur J Radiol 82:2359–2364CrossRefPubMedGoogle Scholar
  14. 14.
    Baudoin A, Skalli W, de Guise JA, Mitton D (2008) Parametric subject-specific model for in vivo 3D reconstruction using bi-planar X-rays: application to the upper femoral extremity. Med Biol Eng Comput 46:799–805CrossRefPubMedGoogle Scholar
  15. 15.
    Laurent CP, Jolivet E, Hodel J, Decq P, Skalli W (2011) New method for 3D reconstruction of the human cranial vault from CT-scan data. Med Eng Phys 33:1270–1275CrossRefPubMedGoogle Scholar
  16. 16.
    Aubert B, Vergari C, Ilharreborde B, Courvoisier A, Skalli W (2016) 3D reconstruction of rib cage geometry from biplanar radiographs using a statistical parametric model approach. Comput Methods Biomech Biomed Engin: Imaging & Visualization. doi: 10.1080/21681163.2014.913990
  17. 17.
    Sabourin M, Jolivet E, Miladi L, Wicart P, Rampal V, Skalli W (2010) Three-dimensional stereoradiographic modeling of rib cage before and after spinal growing rod procedures in early-onset scoliosis. Clin Biomech 25:284–291CrossRefGoogle Scholar
  18. 18.
    Barbier O, Skalli W, Mainard L, Mainard D (2014) The reliability of the anterior pelvic plane for computer navigated acetabular component placement during total hip arthroplasty: prospective study with the EOS imaging system. Orthop Traumatol Surg Res 100:S287–S291CrossRefPubMedGoogle Scholar
  19. 19.
    Bendaya S, Lazennec JY, Anglin C, Allena R, Sellam N, Thoumie P et al (2015) Healthy vs. osteoarthritic hips: a comparison of hip, pelvis and femoral parameters and relationships using the EOS system. Clin Biomech 30:195–204CrossRefGoogle Scholar
  20. 20.
    Dubousset J, Charpak G, Skalli W, Kalifa G, Lazennec JY (2007) EOS stereo-radiography system: whole-body simultaneous anteroposterior and lateral radiographs with very low radiation dose. Rev Chir Orthop Reparatrice Appar Mot 93:141–143CrossRefPubMedGoogle Scholar
  21. 21.
    Dubousset J, Charpak G, Skalli W, de Guise J, Kalifa G, Wicart P (2008) Skeletal and spinal imaging with EOS system. Arch Pediatr 15:665–666CrossRefPubMedGoogle Scholar
  22. 22.
    Duval-Beaupère G, Marty C, Barthel F, Boiseaubert B, Boulay C, Commard MC et al (2002) Sagittal profile of the spine prominent part of the pelvis. Stud Health Technol Inform 88:47–64PubMedGoogle Scholar
  23. 23.
    Legaye J, Duval-Beaupère G (2005) Sagittal plane alignment of the spine and gravity: a radiological and clinical evaluation. Acta Orthop Belg 71:213–220PubMedGoogle Scholar
  24. 24.
    Vialle R, Levassor N, Rillardon L, Templier A, Skalli W, Guigui P (2005) Radiographic analysis of the sagittal alignment and balance of the spine in asymptomatic subjects. J Bone Joint Surg Am 87:260–267PubMedGoogle Scholar
  25. 25.
    Legaye J, Duval-Beaupere G, Hecquet J, Marty C (1998) Pelvic incidence: a fundamental pelvic parameter for three-dimensional regulation of spinal sagittal curves. Eur Spine 7:99–103CrossRefGoogle Scholar
  26. 26.
    Wiberg G (1939) Studies on dysplastic acetabula and congenital subluxation of the hip joint. Acta Chir Scand 11(3):257–262Google Scholar
  27. 27.
    Anda S, Svenningsen S, Dale LG, Benum P (1986) The acetabular sector angle of the adult hip determined by computed tomography. Acta Radiol 27(4):443–447CrossRefGoogle Scholar
  28. 28.
    Stem ES, O'Connor MI, Kransdorf MJ, Crook J (2006) Computed tomography analysis of acetabular anteversion and abduction. Skeletal Radiol 35:385–389CrossRefPubMedGoogle Scholar
  29. 29.
    Zilber S, Lazennec JY, Gorin M, Saillant G (2004) Variations of caudal, central, and cranial acetabular anteversion according to the tilt of the pelvis. Surg Radiol Anat 26:462–465CrossRefPubMedGoogle Scholar
  30. 30.
    Tönnis D (1976) Normal values of the hip joint for the evaluation of X-rays in children and adults. Clin Orthop Relat Res 119:39–47Google Scholar
  31. 31.
    Idelberg K, Frank A (1951) Uber eine neue method zur bestimmung des pfannendachwinkels bei jugendlichen und erwachsesen. Z Orthop 82:257–262Google Scholar
  32. 32.
    Bland MJ, Altman DG (1986) Statistical methods for assessing agreement between two methods of clinical measurement. Lancet 327:307–310CrossRefGoogle Scholar
  33. 33.
    International Organization for Standardization (1994) ISO 5725-4: Accuracy (trueness and precision) of measurement methods and results - Part 4: Basic methods for the determination of the trueness of a standard measurement methodGoogle Scholar
  34. 34.
    International Organization for Standardization (1994) ISO 5725-2: Precision of test methods — Determination of repeatability and reproducibility for a standard test method by inter-laboratory testsGoogle Scholar
  35. 35.
    Tyrakowski M, Wojtera-Tyrakowska D, Siemionow K (2014) Influence of pelvic rotation on pelvic incidence, pelvic tilt, and sacral slope. Spine 39:1276–1283CrossRefGoogle Scholar
  36. 36.
    Assi A, Bakouny Z, Saghbini E, Khalil N, Chelala L, Naoum E, et al (2015) Malpositioning of the patient during x-ray acquisition can affect the assessment of sagittal pelvic parameters: evaluation in adults and children. Proceedings of the 25th congress of International Society of Biomechanics. July 12-16, Glasgow (UK)Google Scholar
  37. 37.
    Assi A, Bakouny Z, Saghbini E, Yared F, Bizdikian A, Esber S, et al (2015). Validity and reliability of hip parameters with pelvic axial rotation during X-ray acquisition. Proceedings of the 25th congress of International Society of Biomechanics. July 12-16, Glasgow (UK)Google Scholar
  38. 38.
    Rampal V, Hausselle J, Thoreux P, Wicart P, Skalli W (2013) Three-dimensional morphologic study of the child's hip: which parameters are reproducible? Clin Orthop Relat Res 471:1343–1348CrossRefPubMedGoogle Scholar
  39. 39.
    van Bosse HJ, Lee D, Henderson ER, Sala DA, Feldman DS (2011) Pelvic positioning creates error in CT acetabular measurements. Clin Orthop Relat Res 469:1683–1691CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Nelitz M, Guenther KP, Gunkel S, Puhl W (1999) Reliability of radiological measurements in the assessment of hip dysplasia in adults. Br J Radiol 72:331–334CrossRefPubMedGoogle Scholar
  41. 41.
    Tan L, Aktas S, Copuroglu C, Ozcan M, Ture M (2001) Reliability of radiological parameters measured on anteroposterior pelvis radiographs of patients with developmental dysplasia of the hip. Acta Orthop Belg 67:374–379PubMedGoogle Scholar
  42. 42.
    Adamczyk E, Sibiński M, Sobala W, Synder M (2011) The assessment of changes in radiological parameters of acetabulum of the hip joint according to position of the pelvis. Chir Narzadow Ruchu Ortop Pol 76:9–13PubMedGoogle Scholar
  43. 43.
    Weir JP (2005) Quantifying test-retest reliability using the intraclass correlation coefficient and the SEM. J Strength Cond Res 19:231–240PubMedGoogle Scholar
  44. 44.
    Rosskopf AB, Pfirrmann CWA, Buck FM (2016) Assessment of two-dimensional (2D) and three-dimensional (3D) lower limb measurements in adults: comparison of micro-dose and low-dose biplanar radiographs. Eur Radiol. doi: 10.1007/s00330-015-4166-5 Google Scholar

Copyright information

© European Society of Radiology 2016

Authors and Affiliations

  • Bachir Ghostine
    • 1
    • 2
  • Christophe Sauret
    • 1
    Email author
  • Ayman Assi
    • 1
    • 2
  • Ziad Bakouny
    • 2
  • Nour Khalil
    • 2
  • Wafa Skalli
    • 1
  • Ismat Ghanem
    • 2
    • 3
  1. 1.Institut de Biomécanique Humaine Georges Charpak, Arts et Métiers ParisTechParisFrance
  2. 2.Laboratory of Biomechanics and Medical Imaging, Faculty of MedicineUniversity of Saint-JosephBeirutLebanon
  3. 3.Hotel-Dieu de France HospitalUniversity of Saint-JosephBeirutLebanon

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