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Scaling Marker Position Determines the Accuracy of Digital Templating for Total Hip Arthroplasty

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HSS Journal ®



Digital templating systems foster patient-specific measurements for preoperative planning.


We aim (1) to verify the accuracy of a templating system, (2) to describe the effects of scaling marker position on the accuracy of digital templating of the hip, and (3) to provide a practical guide for scaling marker position using patient body mass index (BMI).


A scaling sphere was placed in five positions along the anterior-posterior axis of an acetabular implant and pelvis phantom, and x-rays were obtained. Each radiograph was templated for the acetabular component and recorded. A retrospective review identified CT scans of preoperative hip arthroplasty cases. The center of the greater trochanter was calculated from these CT scans as the percent distance from the anterior thigh and recorded with the patient’s BMI.


By centering the scaling sphere on the acetabular component, an accurate cup size was achieved. A difference of 3.5 cm in sphere placement resulted in a full cup size magnification error. Positioning the scaling sphere at the level of the pubic symphysis resulted in a difference of four cup sizes. This patient population had an average BMI of 28.72 kg/m2 (standard deviation 6.26 kg/m2) and an average position of the center of the greater trochanter of 51% (standard deviation of 6%) from the anterior surface of thigh.


Digital templating relies on scaling marker position to accurately estimate implant size. Based on the findings in this study, scaling markers for hip imaging should be placed laterally, mid-thigh in the anterior-posterior direction for patients with a BMI between 25 and 40 kg/m2. If abnormal hip anatomy or extremes of BMI are discovered, then scaling sphere positioning should be optimized on a case-by-case basis. Digital templating systems for total hip arthroplasty must use precisely placed scaling markers at the level of the hip joint to allow for accurate implant size estimation.

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The authors would like to thank George Rodriguez, CRT, for his assistance in image acquisition.

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Correspondence to Jonathan M. Vigdorchik MD.

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Conflict of Interest

Austin J. Ramme MD, PhD; Nina D. Fisher, BS; Jonathan Egol; Gregory Chang, MD; Jonathan M. Vigdorchik, MD have declared that they have no conflict of interest.

Human/Animal Rights

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008 (5).

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Informed consent was waived from all patients for being included in the study.

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Disclosure forms provided by the authors are available with the online version of this article.

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Work performed at the NYU Hospital for Joint Diseases.

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Ramme, A.J., Fisher, N.D., Egol, J. et al. Scaling Marker Position Determines the Accuracy of Digital Templating for Total Hip Arthroplasty. HSS Jrnl 14, 55–59 (2018).

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