Pre-operative templating in THA. Part I: a classification of architectural hip deformities

  • Masanori Kase
  • Padhraig F. O’Loughlin
  • Tarik Aït-Si-Selmi
  • Geert Pagenstert
  • Jean Langlois
  • Hugo BothorelEmail author
  • Michel P. Bonnin
Hip Arthroplasty



While numerous classifications of hip arthritis have been proposed, none considered the magnitude and direction of femoral head translation relative to the native acetabulum. A more precise classification of architectural hip deformities is necessary to improve preoperative templating and anticipate surgical challenges of total hip arthroplasty (THA). The purpose of the present study was to introduce a classification system to distinguish different types of architectural hip deformities, based on femoral head translation patterns, and to evaluate its repeatability using plain radiographs (qualitative) and Computed Tomography (CT) measurements (quantitative).

Materials and methods

We studied pre-operative frontal and lateral hip radiographs and CT scans of 191 hips (184 patients) that received primary THA. The distance between the femoral head center (FC) and the acetabular center (AC) was measured, as well as femoral offset, acetabular offset, head center height, acetabular floor distance and femoral neck angle. The hips were classified qualitatively using frontal plain radiographs, and then quantitatively using CT scans (with an arbitrary threshold of 3 mm as Centered, Medialized, Lateralized, Proximalized or Proximo-lateralized. The agreement between qualitative and quantitative classification methods was compared for applying the same classification.


Qualitative classification identified 120 centered (63%), 8 medialized (4%), 49 lateralized (26%), 3 proximalized (2%), and 11 proximo-lateralized (6%) hips, while quantitative classification identified 116 centered (61%), 8 medialized (4%), 51 lateralized (27%), 5 proximalized (3%), and 11 proximo-lateralized (6%) hips. The agreement between the two methods was excellent (0.94; CI 0.90–0.98). Medialization reached 9.7 mm, while lateralization reached 10.9 mm, and proximalization reached 8.5 mm. Proximalized and proximo-lateralized hips had more valgus necks, while medialized hips had more varus necks (p = 0.003).


The classification system enabled repeatable distinction of 5 types of architectural hip deformities. The excellent agreement between quantitative and qualitative methods suggests that plain radiographs are sufficient to classify architectural hip deformities.


Arthritis Arthroplasty Hip Hip architecture Pelvis and acetabulum Preoperative planning Templating 



The authors are grateful to the Research and Education Department of Ramsay Santé for their financial support with statistical analysis and manuscript preparation and to  Mr. Mo Saffarini for his assistance with manuscript writing and illustrations.

Compliance with ethical standards

Conflict of interest

Authors MK, PFOL, JL and HB declare that they have no conflict of interest. TASS receives royalties and or consulting fees from DePuy-Synthes, Symbios, and Corin-Tornier. MPB receives royalties and or consulting fees from DePuy-Synthes, Symbios, Corin-Tornier, Wright-Tornier, and Integra.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional review board (IRB) who approved this study in advance (COS-RGDS-2019-05-003-BONNIN-M) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.


  1. 1.
    Berry DJ, Harmsen WS, Cabanela ME, Morrey BF (2002) Twenty-five-year survivorship of two thousand consecutive primary Charnley total hip replacements: factors affecting survivorship of acetabular and femoral components. J Bone Joint Surg Am 84-A(2):171–177CrossRefGoogle Scholar
  2. 2.
    Jacquot L, Bonnin MP, Machenaud A, Chouteau J, Saffarini M, Vidalain JP (2017) Clinical and radiographic outcomes at 25–30 years of a hip stem fully coated with hydroxylapatite. J Arthroplasty. CrossRefPubMedGoogle Scholar
  3. 3.
    Geesink RG, Hoefnagels NH (1995) Six-year results of hydroxyapatite-coated total hip replacement. J Bone Joint Surg Br 77(4):534–547CrossRefGoogle Scholar
  4. 4.
    McKellop H, Shen FW, Lu B, Campbell P, Salovey R (1999) Development of an extremely wear-resistant ultra high molecular weight polyethylene for total hip replacements. J Orthop Res 17(2):157–167. CrossRefPubMedGoogle Scholar
  5. 5.
    Bourne RB, Chesworth B, Davis A, Mahomed N, Charron K (2010) Comparing patient outcomes after THA and TKA: is there a difference? Clin Orthop Relat Res 468(2):542–546. CrossRefPubMedGoogle Scholar
  6. 6.
    Tang H, Du H, Tang Q, Yang D, Shao H, Zhou Y (2014) Chinese patients’ satisfaction with total hip arthroplasty: what is important and dissatisfactory? J Arthroplasty 29(12):2245–2250. CrossRefPubMedGoogle Scholar
  7. 7.
    Parvizi J, Sharkey PF, Bissett GA, Rothman RH, Hozack WJ (2003) Surgical treatment of limb-length discrepancy following total hip arthroplasty. J Bone Joint Surg Am 85(12):2310–2317CrossRefGoogle Scholar
  8. 8.
    Wylde V, Whitehouse SL, Taylor AH, Pattison GT, Bannister GC, Blom AW (2009) Prevalence and functional impact of patient-perceived leg length discrepancy after hip replacement. Int Orthop 33(4):905–909. CrossRefPubMedGoogle Scholar
  9. 9.
    Bjarnason JA, Reikeras O (2015) Changes of center of rotation and femoral offset in total hip arthroplasty. Ann Transl Med 3(22):355. CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Bourne RB, Rorabeck CH (2002) Soft tissue balancing: the hip. J Arthroplasty 17(4 Suppl 1):17–22CrossRefGoogle Scholar
  11. 11.
    Della Valle AG, Padgett DE, Salvati EA (2005) Preoperative planning for primary total hip arthroplasty. J Am Acad Orthop Surg 13(7):455–462CrossRefGoogle Scholar
  12. 12.
    Gonzalez Della Valle A, Slullitel G, Piccaluga F, Salvati EA (2005) The precision and usefulness of preoperative planning for cemented and hybrid primary total hip arthroplasty. J Arthroplasty 20(1):51–58. CrossRefPubMedGoogle Scholar
  13. 13.
    Sariali E, Mouttet A, Pasquier G, Durante E, Catone Y (2009) Accuracy of reconstruction of the hip using computerised three-dimensional pre-operative planning and a cementless modular neck. J Bone Joint Surg Br 91(3):333–340. CrossRefPubMedGoogle Scholar
  14. 14.
    Brumat P, Pompe B, Antolic V, Mavcic B (2018) The impact of canal flare index on leg length discrepancy after total hip arthroplasty. Arch Orthop Trauma Surg 138(1):123–129. CrossRefPubMedGoogle Scholar
  15. 15.
    Holzer LA, Scholler G, Wagner S, Friesenbichler J, Maurer-Ertl W, Leithner A (2019) The accuracy of digital templating in uncemented total hip arthroplasty. Arch Orthop Trauma Surg 139(2):263–268. CrossRefPubMedGoogle Scholar
  16. 16.
    Ganz R, Leunig M, Leunig-Ganz K, Harris WH (2008) The etiology of osteoarthritis of the hip: an integrated mechanical concept. Clin Orthop Relat Res 466(2):264–272. CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Hamilton HW, Jamieson J (2012) The classification of degenerative hip disease. J Bone Joint Surg Br 94(9):1193–1201. CrossRefPubMedGoogle Scholar
  18. 18.
    Wroblewski BM, Charnley J (1982) Radiographic morphology of the osteoarthritic hip. J Bone Joint Surg Br 64(5):568–569CrossRefGoogle Scholar
  19. 19.
    Liu R, Li Y, Bai C, Song Q, Wang K (2014) Effect of preoperative limb-length discrepancy on abductor strength after total hip arthroplasty in patients with developmental dysplasia of the hip. Arch Orthop Trauma Surg 134(1):113–119. CrossRefPubMedGoogle Scholar
  20. 20.
    Charles MN, Bourne RB, Davey JR, Greenwald AS, Morrey BF, Rorabeck CH (2005) Soft-tissue balancing of the hip: the role of femoral offset restoration. Instr Course Lect 54:131–141PubMedGoogle Scholar
  21. 21.
    Fottner A, Woiczinski M, Kistler M, Schroder C, Schmidutz TF, Jansson V, Schmidutz F (2017) Influence of undersized cementless hip stems on primary stability and strain distribution. Arch Orthop Trauma Surg 137(10):1435–1441. CrossRefPubMedGoogle Scholar
  22. 22.
    Bonnin MP, Neto CC, Aitsiselmi T, Murphy CG, Bossard N, Roche S (2015) Increased incidence of femoral fractures in small femurs and women undergoing uncemented total hip arthroplasty—why? Bone Joint J 97-B(6):741–748. CrossRefPubMedGoogle Scholar
  23. 23.
    Bonnin MP, Archbold PH, Basiglini L, Fessy MH, Beverland DE (2012) Do we medialise the hip centre of rotation in total hip arthroplasty? Influence of acetabular offset and surgical technique. Hip Int 22(4):371–378. CrossRefPubMedGoogle Scholar
  24. 24.
    Durand-Hill M, Henckel J, Satchithananda K, Sabah S, Hua J, Hothi H, Langstaff RJ, Skinner J, Hart A (2016) Calculating the hip center of rotation using contralateral pelvic anatomy. J Orthop Res 34(6):1077–1083. CrossRefPubMedGoogle Scholar
  25. 25.
    Ehrig RM, Taylor WR, Duda GN, Heller MO (2006) A survey of formal methods for determining the centre of rotation of ball joints. J Biomech 39(15):2798–2809. CrossRefPubMedGoogle Scholar
  26. 26.
    Lecerf G, Fessy MH, Philippot R, Massin P, Giraud F, Flecher X, Girard J, Mertl P, Marchetti E, Stindel E (2009) Femoral offset: anatomical concept, definition, assessment, implications for preoperative templating and hip arthroplasty. Orthop Traumatol Surg Res 95(3):210–219. CrossRefPubMedGoogle Scholar
  27. 27.
    Landis JR, Koch GG (1977) The measurement of observer agreement for categorical data. Biometrics 33(1):159–174CrossRefGoogle Scholar
  28. 28.
    Cicchetti D (1994) Guidelines, criteria, and rules of thumb for evaluating normed and standardized assessment instruments in psychology. Psychol Assess 6(4):284–290CrossRefGoogle Scholar
  29. 29.
    Takao M, Nishii T, Sakai T, Sugano N (2016) Postoperative limb-offset discrepancy notably affects soft-tissue tension in total hip arthroplasty. J Bone Joint Surg Am 98(18):1548–1554. CrossRefPubMedGoogle Scholar
  30. 30.
    Little NJ, Busch CA, Gallagher JA, Rorabeck CH, Bourne RB (2009) Acetabular polyethylene wear and acetabular inclination and femoral offset. Clin Orthop Relat Res 467(11):2895–2900. CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Sakalkale DP, Sharkey PF, Eng K, Hozack WJ, Rothman RH (2001) Effect of femoral component offset on polyethylene wear in total hip arthroplasty. Clin Orthop Relat Res 388:125–134CrossRefGoogle Scholar
  32. 32.
    Asayama I, Chamnongkich S, Simpson KJ, Kinsey TL, Mahoney OM (2005) Reconstructed hip joint position and abductor muscle strength after total hip arthroplasty. J Arthroplasty 20(4):414–420. CrossRefPubMedGoogle Scholar
  33. 33.
    Rudiger HA, Guillemin M, Latypova A, Terrier A (2017) Effect of changes of femoral offset on abductor and joint reaction forces in total hip arthroplasty. Arch Orthop Trauma Surg 137(11):1579–1585. CrossRefPubMedGoogle Scholar
  34. 34.
    Flecher X, Ollivier M, Argenson JN (2016) Lower limb length and offset in total hip arthroplasty. Orthop Traumatol Surg Res 102(1 Suppl):S9–S20. CrossRefPubMedGoogle Scholar
  35. 35.
    Bonnin MP, Archbold PH, Basiglini L, Selmi TA, Beverland DE (2011) Should the acetabular cup be medialised in total hip arthroplasty. Hip Int 21(4):428–435. CrossRefPubMedGoogle Scholar
  36. 36.
    Magill P, Blaney J, Hill JC, Bonnin MP, Beverland DE (2016) Impact of a learning curve on the survivorship of 4802 cementless total hip arthroplasties. Bone Joint J 98-B(12):1589–1596. CrossRefPubMedGoogle Scholar
  37. 37.
    Liebs TR, Nasser L, Herzberg W, Ruther W, Hassenpflug J (2014) The influence of femoral offset on health-related quality of life after total hip replacement. Bone Joint J 96-B(1):36–42. CrossRefPubMedGoogle Scholar
  38. 38.
    Weber M, Woerner M, Springorum R, Sendtner E, Hapfelmeier A, Grifka J, Renkawitz T (2014) Fluoroscopy and imageless navigation enable an equivalent reconstruction of leg length and global and femoral offset in THA. Clin Orthop Relat Res 472(10):3150–3158. CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Kubo Y, Motomura G, Ikemura S, Sonoda K, Yamamoto T, Nakashima Y (2017) Effect of collapse on the deformity of the femoral head-neck junction in osteonecrosis of the femoral head. Arch Orthop Trauma Surg 137(7):933–938. CrossRefPubMedGoogle Scholar
  40. 40.
    Cassidy KA, Noticewala MS, Macaulay W, Lee JH, Geller JA (2012) Effect of femoral offset on pain and function after total hip arthroplasty. J Arthroplasty 27(10):1863–1869. CrossRefPubMedGoogle Scholar
  41. 41.
    Dastane M, Dorr LD, Tarwala R, Wan Z (2011) Hip offset in total hip arthroplasty: quantitative measurement with navigation. Clin Orthop Relat Res 469(2):429–436. CrossRefPubMedGoogle Scholar
  42. 42.
    Mahmood SS, Mukka SS, Crnalic S, Wretenberg P, Sayed-Noor AS (2016) Association between changes in global femoral offset after total hip arthroplasty and function, quality of life, and abductor muscle strength. A prospective cohort study of 222 patients. Acta Orthop 87(1):36–41. CrossRefPubMedGoogle Scholar
  43. 43.
    Meermans G, Doorn JV, Kats JJ (2016) Restoration of the centre of rotation in primary total hip arthroplasty: the influence of acetabular floor depth and reaming technique. Bone Joint J 98-B(12):1597–1603. CrossRefPubMedGoogle Scholar
  44. 44.
    Kurtz WB, Ecker TM, Reichmann WM, Murphy SB (2010) Factors affecting bony impingement in hip arthroplasty. J Arthroplasty 25(4):624–634.–622) CrossRefPubMedGoogle Scholar
  45. 45.
    Baghdadi YM, Larson AN, Sierra RJ (2013) Restoration of the hip center during THA performed for protrusio acetabuli is associated with better implant survival. Clin Orthop Relat Res 471(10):3251–3259. CrossRefPubMedPubMedCentralGoogle Scholar
  46. 46.
    Sariali E, Klouche S, Mouttet A, Pascal-Moussellard H (2014) The effect of femoral offset modification on gait after total hip arthroplasty. Acta Orthop 85(2):123–127. CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Lazennec JY, Folinais D, Florequin C, Pour AE (2017) Does patients’ perception of leg length after total hip arthroplasty correlate with anatomical leg length? J Arthroplasty. CrossRefPubMedGoogle Scholar
  48. 48.
    Karimi D, Kallemose T, Troelsen A, Klit J (2018) Hip malformation is a very common finding in young patients scheduled for total hip arthroplasty. Arch Orthop Trauma Surg 138(4):581–589. CrossRefPubMedGoogle Scholar
  49. 49.
    Verbeek DO, van der List JP, Helfet DL (2019) Computed tomography versus plain radiography assessment of acetabular fracture reduction is more predictive for native hip survivorship. Arch Orthop Trauma Surg. CrossRefPubMedPubMedCentralGoogle Scholar
  50. 50.
    Huppertz A, Radmer S, Asbach P, Juran R, Schwenke C, Diederichs G, Hamm B, Sparmann M (2011) Computed tomography for preoperative planning in minimal-invasive total hip arthroplasty: radiation exposure and cost analysis. Eur J Radiol 78(3):406–413. CrossRefPubMedGoogle Scholar
  51. 51.
    Silva M, Lee KH, Heisel C, Dela Rosa MA, Schmalzried TP (2004) The biomechanical results of total hip resurfacing arthroplasty. J Bone Joint Surg Am 86-A(1):40–46CrossRefGoogle Scholar
  52. 52.
    Wegner A, Kauther MD, Landgraeber S, von Knoch M (2012) Fixation method does not affect restoration of rotation center in hip replacements: a single-site retrospective study. J Orthop Surg Res 7:25. CrossRefPubMedPubMedCentralGoogle Scholar
  53. 53.
    Patel S, Thakrar RR, Bhamra J, Hossain F, Tengrootenhuysen M, Haddad FS (2011) Are leg length and hip offset comparable after hip resurfacing and cementless total hip arthroplasty? Ann R Coll Surg Engl 93(6):465–469. CrossRefPubMedPubMedCentralGoogle Scholar
  54. 54.
    Parry MC, Povey J, Blom AW, Whitehouse MR (2015) Comparison of acetabular bone resection, offset, leg length and post operative function between hip resurfacing arthroplasty and total hip arthroplasty. J Arthroplasty 30(10):1799–1803. CrossRefPubMedGoogle Scholar
  55. 55.
    Loughead JM, Chesney D, Holland JP, McCaskie AW (2005) Comparison of offset in Birmingham hip resurfacing and hybrid total hip arthroplasty. J Bone Joint Surg Br 87(2):163–166CrossRefGoogle Scholar
  56. 56.
    Kanawade V, Dorr LD, Banks SA, Zhang Z, Wan Z (2015) Precision of robotic guided instrumentation for acetabular component positioning. J Arthroplasty 30(3):392–397. CrossRefPubMedGoogle Scholar
  57. 57.
    Girard J, Lavigne M, Vendittoli PA, Roy AG (2006) Biomechanical reconstruction of the hip: a randomised study comparing total hip resurfacing and total hip arthroplasty. J Bone Joint Surg Br 88(6):721–726. CrossRefPubMedGoogle Scholar
  58. 58.
    De Thomasson E, Mazel C, Guingand O, Terracher R (2002) Value of preoperative planning in total hip arthroplasty. Rev Chir Orthop Reparatrice Appar Mot 88(3):229–235PubMedGoogle Scholar
  59. 59.
    Ahmad R, Gillespie G, Annamalai S, Barakat MJ, Ahmed SM, Smith LK, Spencer RF (2009) Leg length and offset following hip resurfacing and hip replacement. Hip Int 19(2):136–140CrossRefGoogle Scholar
  60. 60.
    Waldstein W, Merle C, Schmidt-Braekling T, Boettner F (2014) Does stem design influence component positioning in total hip arthroplasty using a minimal invasive posterolateral approach? Int Orthop 38(7):1347–1352. CrossRefPubMedPubMedCentralGoogle Scholar
  61. 61.
    Dolhain P, Tsigaras H, Bourne RB, Rorabeck CH, Mac Donald S, Mc Calden R (2002) The effectiveness of dual offset stems in restoring offset during total hip replacement. Acta Orthop Belg 68(5):490–499PubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Orthopaedic SurgeryNissan Tamagawa HospitalTokyoJapan
  2. 2.Department of Orthopaedic SurgeryMater Hospital CorkCorkIreland
  3. 3.Ramsay Santé, Hôpital Privé Jean Mermoz, Centre Orthopédique SantyLyonFrance
  4. 4.Artro InstituteLyonFrance
  5. 5.Department of Clinical ResearchUniversity of BaselBaselSwitzerland
  6. 6.Clarahof Clinic of Orthopaedic SurgeryMerian-Iselin-Hospital Swiss Olympic Medical CenterBaselSwitzerland
  7. 7.Knee Institute BaselBaselSwitzerland
  8. 8.ReSurg SANyonSwitzerland

Personalised recommendations