Archives of Orthopaedic and Trauma Surgery

, Volume 136, Issue 1, pp 27–33 | Cite as

Reliability of Tönnis classification in early hip arthritis: a useless reference for hip-preserving surgery

  • Marius ValeraEmail author
  • Natalia Ibañez
  • Rogelio Sancho
  • Marc Tey
Orthopaedic Surgery



The Tönnis classification is widely accepted for grading hip arthritis, but its usefulness as a reference in hip-preserving surgery is yet to be demonstrated. We aimed to evaluate reproducibility of the Tönnis classification in early stages of hip osteoarthritis, and thus determine whether it is a reliable reference for hip-preserving surgery.

Materials and methods

Three orthopaedic surgeons with different levels of experience examined 117 hip X-rays that were randomly mixed of two groups: a group of 31 candidates for hip-preserving surgery and a control group of 30 patients that were asymptomatic with respect to the hip joint. The surgeons were asked to rate an eventual osteoarthritis according to the Tönnis classification. After 2 months, the surgeons were asked to re-evaluate the X-rays in a random order. Intra- and interobserver reliabilities were calculated by comparing the observers’ two estimations using Kappa statistics.


Kappa values for interobserver reliability were slight or fair (range 0.173–0.397). Kappa values for intraobserver reproducibility were fair (range 0.364–0.397). Variance in grading no and slight osteoarthritis was the most frequent cause for intra- and interobserver disagreements (76.3 and 73.01 % of the non-concordant observations, respectively). The confidence interval analysis showed that the observers’ experience did not affect reproducibility.


The Tönnis classification is a poor method to assess early stages of hip osteoarthritis. These findings suggest that its routine use in therapeutic decision-making for conservative hip surgery should be reconsidered.


Hip osteoarthritis Tönnis classification Hip-preserving surgery Interobserver reliability 


Compliance with ethical standards

Conflict of interest



  1. 1.
    Bogunovic L, Gottlieb M, Pashos G, Baca G, Clohisy JC (2013) Why do hip arthroscopy procedures fail? Clin Orthop Relat Res 471:2523–2529PubMedPubMedCentralCrossRefGoogle Scholar
  2. 2.
    Byrd JW, Jones KS (2010) Prospective analysis of hip arthroscopy with 10-year follow-up. Clin Orthop Relat Res 468:741–746PubMedPubMedCentralCrossRefGoogle Scholar
  3. 3.
    Domb BG, Gui C, Lodhia P (2015) How much arthritis is too much for hip arthroscopy: a systematic review. Arthroscopy 31:520–529PubMedCrossRefGoogle Scholar
  4. 4.
    Domb BG, Linder D, Finley Z, Botser IB, Chen A, Williamson J, Gupta A (2015) Outcomes of hip arthroscopy in patients aged 50 years or older compared with a matched-pair control of patients aged 30 years or younger. Arthroscopy 31:231–238PubMedCrossRefGoogle Scholar
  5. 5.
    Horisberger M, Brunner A, Herzog RF (2010) Arthroscopic treatment of femoroacetabular impingement of the hip: a new technique to access the joint. Clin Orthop Relat Res 468:182–190PubMedPubMedCentralCrossRefGoogle Scholar
  6. 6.
    Kamath AF, Componovo R, Baldwin K, Israelite CL, Nelson CL (2009) Hip arthroscopy for labral tears. Review of clinical outcomes with 4.8-year mean follow-up. Am J Sports Med 37:1721–1727PubMedCrossRefGoogle Scholar
  7. 7.
    Larson CM, Giveans MR, Taylor M (2011) Does arthroscopic FAI correction improve function with radiographic arthritis? Clin Orthop Relat Res 469:1667–1676PubMedPubMedCentralCrossRefGoogle Scholar
  8. 8.
    Skendzel JG, Philippon MJ, Briggs KK, Goljan P (2014) The effect of joint space on midterm outcomes after arthroscopic hip surgery for femoroacetabular impingement. Am J Sports Med 42:1127–1133PubMedCrossRefGoogle Scholar
  9. 9.
    Steppacher SD, Tannast M, Ganz R, Siebenrock KA (2008) Mean 20-year followup of Bernese periacetabular osteotomy. Clin Orthop Relat Res 466:1633–1644PubMedPubMedCentralCrossRefGoogle Scholar
  10. 10.
    Brückl R, Hepp WR, Tönnis D (1972) Eine Abgrenzung normaler und dysplastischer Hüftgelenke durch den Hüftwert. Arch Orthop and Trauma Surg 74:13–32Google Scholar
  11. 11.
    Busse J, Gasteiger W, Tönnis D (1972) Eine neue Methode zur röntgenologischen Beurteilung eines Hüftgelenkes—Der Hüftwert. Arch Orthop and Trauma Surg 72:1–9Google Scholar
  12. 12.
    Clohisy JC, Carlisle JC, Trousdale R, Kim YJ, Beaule PE, Morgan P, Steger-May K, Schoenecker PL, Millis M (2009) Radiographic evaluation of the hip has limited reliability. Clin Orthop Relat Res 467:666–675PubMedPubMedCentralCrossRefGoogle Scholar
  13. 13.
    Gedouin JE, May O, Bonin N et al (2010) Assessment of arthroscopic management of femoroacetabular impingement. A prospective multicenter study. Orthop Traumatol Surg Res 96 (Supl):59–67CrossRefGoogle Scholar
  14. 14.
    Haviv B, O’Donnell J (2010) The incidence of total hip arthroplasty after hip arthroscopy in osteoarthritic patients. Sports Med Arthrosc Rehabil Ther Technol 2:18PubMedPubMedCentralCrossRefGoogle Scholar
  15. 15.
    Kim KC, Hwang DS, Lee CH, Kwon ST (2007) Influence of femoroacetabular impingement on results of hip arthroscopy in patients with early osteoarthritis. Clin Orthop Relat Res 456:128–132PubMedCrossRefGoogle Scholar
  16. 16.
    Clohisy JC, Carlisle JC, Beaulé PE, Kim Y, Trousdale RT, Sierra RJ, Leunig M, Schoenecker PL, Millis MB (2008) A systematic approach to the plain radiographic evaluation of the young adult hip. J Bone Joint Surg Am 90(Suppl 4):47–66PubMedPubMedCentralCrossRefGoogle Scholar
  17. 17.
    Tönnis D, Heinecke A (1999) Acetabular and femoral anteversion: relationship with osteoarthritis of the hip. J Bone Joint Surg Am 81:1747–1770PubMedGoogle Scholar
  18. 18.
    Landis JR, Koch GG (1977) The measurement of observer agreement for categorical data. Biometrics 33:159–174PubMedCrossRefGoogle Scholar
  19. 19.
    Nepple JJ, Martell JM, Kim YJ, Zaltz I, Millis MB, Podeszwa DA, Sucato DJ, Sink EL, Clohisy JC, ANCHOR Study Group (2014) Interobserver and intraobserver reliability of the radiographic analysis of femoroacetabular impingement and dysplasia using computer-assisted measurements. Am J Sports Med 42:2393–2401PubMedCrossRefGoogle Scholar
  20. 20.
    Croft P, Cooper C, Wickham C, Coggon D (1990) Defining osteoarthritis of the hip for epidemiologic studies. Am J Epidemiol 132:514–522PubMedGoogle Scholar
  21. 21.
    Lane NEE, Nevitt MC, Hochberg MC, Hung YY, Palermo L (2004) Progression of radiographic hip osteoarthritis over eight years in a community sample of elderly white women. Arthritis Rheum 50:1477–1486PubMedCrossRefGoogle Scholar
  22. 22.
    Wright AA, Cook C, Abbott JH (2009) Variables associated with the progression of hip osteoarthritis: a systematic review. Arthritis Rheum 61:925–936PubMedCrossRefGoogle Scholar
  23. 23.
    Vignon E, Conrozier T, Piperno M, Richard S, Carrillon Y, Fantino O (1999) Radiographic assessment of hip and knee osteoarthritis. Recommendations: recommended guidelines. Osteoarthritis Cartilage 7:434–436PubMedCrossRefGoogle Scholar
  24. 24.
    Resnick D, Niwayama G, Coutt D (1977) Subchondral cysts (Geodes) in arthritic disorders: pathologic and radiographic appearance of the hip joint. Am J Roentgenol 128:799–806CrossRefGoogle Scholar
  25. 25.
    Günther KP, Sun Y (1999) Reliability of radiographic assessment in hip and knee osteoarthritis. Osteoarthritis Cartilage 7:239–246PubMedCrossRefGoogle Scholar
  26. 26.
    Pitt MJ, Graham AR, Shipman JH, Birkby W (1982) Herniation Pit of the Femoral Neck. AJR 138:1115–1121PubMedCrossRefGoogle Scholar
  27. 27.
    Goker B, Sancak A, Arac M, Shott S, Block JA (2003) The radiographic joint space width in clinically normal hips: effects of age, gender and physical parameters. Osteoarthritis Cartilage 11:328–334PubMedCrossRefGoogle Scholar
  28. 28.
    Goker B, Sancak A, Haznedaroglu S, Arac M, Block JA (2005) The effects of minor hip flexion, abduction or adduction and X-ray beam angle on the radiographic joint space width of the hip. Osteoarthritis Cartilage 13:379–386PubMedCrossRefGoogle Scholar
  29. 29.
    Altman RD, Bloch DA, Dougados M, Hochberg M, Lohmder S, Pavelka K, Spector T, Vignon E (2004) Measurement of structural progresssion in osteoarthritis of the hip: the Barcelona consensus group. Osteoarthr Cartil 12:515–524PubMedCrossRefGoogle Scholar
  30. 30.
    Pogrund H, Bloom R, Mogle P (1983) The normal width of the adult hip joint: the relationship to age, sex, and obesity. Skeletal Radiol 10:10–12PubMedCrossRefGoogle Scholar
  31. 31.
    Kellgren JH, Lawrence JS (1957) Radiological assessment of osteo-arthrosis. Ann Rheum Dis 16:494–502PubMedPubMedCentralCrossRefGoogle Scholar
  32. 32.
    Reijman M, Hazes JMW, Koes BW, Verhagen AP, Bierma-Zeinstra SMA (2004) Validity, reliability, and applicability of seven definitions of hip osteoarthritis used in epidemiological studies: a systematic appraisal. Ann Rheum Dis 63:226–232PubMedPubMedCentralCrossRefGoogle Scholar
  33. 33.
    Ochoa LM, Dawson L, Patzkowski JC, Hsu JR (2010) Radiographic prevalence of femoroacetabular impingement in a young population with hip complaints is high. Clin Orthop Relat Res 468:2710–2714PubMedPubMedCentralCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2015

Authors and Affiliations

  • Marius Valera
    • 1
    Email author
  • Natalia Ibañez
    • 1
  • Rogelio Sancho
    • 1
  • Marc Tey
    • 2
  1. 1.Orthopaedic Department, Hip Unit, Hospital de la Santa Creu i Sant PauUniversitat Autònoma de BarcelonaBarcelonaSpain
  2. 2.Parc de Salut Mar, Hip UnitUniversitat Autònoma de BarcelonaBarcelonaSpain

Personalised recommendations