Reprintedfrom Cr-rNtcer-ORTHopAEDIcs,

September1976
Vol. 119
@ I. B. Lippincott Co. Printed in U.S.A.

Normal Values of the Hip Joint for the

Evaluationof X-rays in Childrenand Adults
D. TtiNNts*

the acetabular index gets lower. With diminished inclination, it is higher. For those cases
considerednormal, therefore, a defined position of the pelvis is necessary to avoid
increased mean error.
An index or gauge of "rotating of the
pelvis" has been devised by dividing the
diameter of the foramen obturatorium of the
right side by thti diameter of the left side
(Fig. l). In a neutral position this index
would be l. By turning to the right side, the
diameter of the right foramen gets smaller,
the left one larger. Therefore, the index
shows values below I when the pelvisl is
turned to the right and above I rvhen turt'red
to the left. In those considerednormal, only
casesbetweenindex 1.8 and 0.56 have been
selected.In this group the angles did not
differ more than 2".
To evaluate the degree of inclination of
the pelvis a "symphysis-os ischium angle"
has been introduced. Lines are drawn on
each side of the pelvis from the most prominent point to the symphysis to the inside of
the pelvis, then to the highest inside point of
the os ischium (Fig. l). In the total availabl e 1582 X -rays (3164 hi p j oi nts) the
angle was measuredand the material brought
into a normal distribution curve. A mean
distributionof each agegroup, in which most
of the cases are included. has been determi ned (Tabl e l ).
Within this group the acetabular index
differed only up to 3o with different inclinations.

The diagnosis of congenital hip dysplasia,

the prognosis of the further development of
deformities of the hip joint, and judgment
of the results of different methods of treatment are mainly based on X-rays of the hip
joint. Horvever, relatively little has been
written on what could be considered normal
in an X-ray of the hip and what is considered pathological. Mean valuesare of no help
in individual cases.It should be known how
far normal standards deviate and where
pathological values can be expected. In this
paper a short review of pertinent and of our
own investigationsshall be given.
ACETABULAR

INDEX (Hilgenreiner)

Our own material consists of 583 patients

with single X-rays and 238 patients with
326 X-rays (including controls) up to the
age of 7 years2eand 141 patients between
the age of 5 and 14 years.l The evaluation
shall be described here.
Tur' PosrrroN oF rHE Per-vrs er X-na,v
Measurementsof the acetabular index will
be considered reliable and reproducible provided some facts are taken into account.
When the pelvis is rotated to the side, the
angle of the side to which it is turned gets
lower, and the opposite side, higher. If the
pelvis is brought into increased inclination,
Received August l, 1975.
'FAssistant Professor of Orthopaedics, University of Muenster. Surgeon in Chief, Orthopaedische Klinik der Staedtischen,Kliniken Dortmund, D-46-Dortmund, F. R. Germany.

39

40

C l i ni c ol Or l hooqedi c s
qnd Relqted Reseorch

I o nn ts

FIc. l. When the

acetabular index (Hilgenreiner)is measured,
twisting of the pelvis
can be controlled by
dividing the diameter
of the right foramen
obturitorium by that
on the left side (see
text). Inclination of the
pelvis is determinedby
an angle between the
highest medial points
of the os ischium and
the symphysi s (see
text).
All cases not within these groups (Table
I ) and not within an index of rotating between 1.8 and 0.56 have been excluded
from the normal material.
EveLuerroN oF THE MltE,Rrlt
Two thousand two hundred ninety-four
acetabular angles have been compiled. Mean
values, single (s) and double (2s) standard
deviation, were evaluated (Fig. 2). In this
material, patients with no other diseasesand
apparently normal hip joints have been in-

TABLE I.

Age

Symphysis
Os-ischium angle
(degrees)

1-2 mon

9 8 -1 3 0

3-4 mon

1 0 0 -1 3 5

5-6 mon

9 8 -12 8

7-12 mon

96-126

l yr , Lm onI yr, 6 mon

90-127

l yr,T m on2yr

92-128

2 yr , lm on3yr

90-r24

3 yr , lm on5yr

8 5 -l 1 5

cluded and also patients where there were

doubts as to the normalcy of the hip joints.
Usually there are few difficulties in dividing
normal and pathologic hip joints in childen
of 3 to 5 years. In younger ones it is more
problematic. Therefore, children with angles
higher than the mean value have been controlled at different ages. Between 3 and 5
years of age,"normal" was determined mainly
by function and radiological findings. The
femoral head must be covered well, the inclination of the acetabulum, therefore, cannot be too high, and the epiphyseal plate
must be in a direction rectangular to the expected resulting force. By these conditions
the femur with its femoral shaft-neck angle
is already controlled. Coxa valga was considered pathological only if the relation of
the femoral head-acetabulum was not
normal.
By this method of evaluation, a certain
subjective control has to be taken into account. Therefore. we divided casesas: doubtless normal, doubtless pathological and uncertain or questionable.
By checking this material over a period
of several years, we found that acetabular
angleslower than the upper single standard
deviation were definitely normal and angles
above the double standard deviation were
definitely pathological. By controlling acetabular angles between s and 2s we found

Numbcr I 19
Septembcr, l?76

NormalValuesof the Hip Joint

4l

-9
CD
Ftc. 2. Mean value
of normal Acetabular
Index (girls).

c
o
g
J
lt
(!

6IJ
G

that 40.4 per cent remainedin this area of

extremevalues,40.4 per cent demonstrated
valuesbelow s (the area of normal angles)
and 19.2 per cent werelater found above2s
(the pathologicalarea). By judging these
casesradiologicallywe found, in the final
examination, 38.3 per cent definite dysplasias,38.3 per cent questionable
dysplasias
and23.4per centdefinitelynormalhip joints.
The transition from normal to pathologic
anglesin joints, of course,is not a sharpone
and there is a certain area of extremevalues
where it is difficult to say whether we are
dealing with already existing pathological
conditions. There is a certain number of
pathologicalhip joints within this "extreme
value."
In caseswhere Freijka pillows and other
splints are indicated,it seemsbetter to include caseswith acetabularanglesbetweens
and 2s in the treatment becausea number
Treatmentmay
of them becomepathological.
be stopped when anglesreach valuesbelow
upper standarddeviations.This usually becomesevidentwithin 3 to 6 monthsof life.30
Later, thereis lessevidenceof improvement.
The indicationsfor varusosteotomyand
additionalacetabuloplasty
are basedon these
definitions but discussedin the following
clinical paper.
Table 2 has been compiled for clinical
use.The valuesof s and 2s in boysand girls,
aswell as for the left and right side,aregiven

for each age. Values above "slightly dysplastic" (s) are possibly pathological, values
above "severe dysplastic" (2s) are definitely
pathological.
Comparing these values with those of
other authors6,ll, 18,28,34,3s we found no
extreme differences. Division by most authors is either by sex or by left and right
side. We investigated all factors and found
higher angles of dysplasia in girls and they
occurred mostly on the left side. The standard deviation given by Wilkinson and
Carter3awas quite similar to ours.
THE FEMORAL

SHAFT-NECK

ANGLE

The femoral shaft-neck angle has been

examined by Mikulicz,le Stieda,27v. Lanz
and Wachsmuth.rs Mirzoewa and Tikhonenkow,zoShandsand Steele,2aSchmidt,2sHeinrich,l0 Zippel3s and Hamacher.eAll authors
agree that there is considerable individual
variation and a wide standard deviation in
this angle. Zippel'5rs and Hamacher'sestandard deviation was an average of 5-6o, the
mean value beginning in Zippel's3scases at
137.1" in boys, and 135o in girls in the second year of life and then slowly decreasing
to values of 126/127 at adulthood. In Xrays taken without suspendingthe lower legs,
the shaft is frequently rotated externally.
Hamacherefound that in X-rays demonstrating internal rotation with full correction of
the antetorsion, the femoral shaft-neck angle

42

C l i ni c ol O r l hopoedi c s
ond R el ol ed R es eor c h

I on nts

TABLE 2. Acetabular Index of Slight and Severe

Dysplasias
in DifferentYearsof Life
(mos)

Girls

Lisht

*:ple!y-!!9!_,_J')
Age

r+ 2
3+ 4
5+ 6
7- 9
l0- 12
l3- r 5
16- r 8
t9-24
2-3 yrs
3-5 yrs
5-7 yrs

Severe
dysplasia above (2s)
right
left

Boys
Light
dysplasia above (s)
right
Ieft

right

left

35.8
31.4
27.3
25.3
24.7
24.6
25.0
24.1
21.8
17.9
19.3

3 6 .I

41.6

41.6

27.7

33.2

3 6 .3

38.7

29.3

3 t.8

34.r

26.6

29.4

2 7 .1

28.6

2 6 .9

29.0

2 6 .1
26.4

Severe

twle!!!!9!!J2')
right

lelt

3t.2

3l .8

35.2

27.9

29.1

32.4

33.7

24.2

26.8

29.0

31.6

3 1.1

24.6

25.4

28.9

29.5

3 1.4

23.2

25.2

27.0

29.1

3r.7
30.4

27.5

27.7

25.8

28.r

30.0

28.4

3 0.8

23.2

27 . r
2s.8
23.8

24.4
25.3
23.5
20.9

27.3

25.6

23.r
23.8
20.6
2t.0
t9.2
16.8

24.0

29.3

2 t.2

L t.)

1 9 .8

23.4

was at least 8-l2o less, and sometimesup

to l5o.
The fact that external rotation increases
the projected shaft-neck angle should be
taken into account. X-rays with suspended
legs are preferred. However, there should be
slight support under the knees; otherwise,the
pelvic inclination is increased and the acetabular index differs and is difficult to
measure.
THE DEGREE OF ANTETORSION
There have been frequent investigations
on the degree of antetorsion of the femoral
n ec k . 4,s , 7,e, r 0, 1 4 -1262, ,2 1 ,236s, T h e re i s
much individual variation in the degree of
antetorsion which is quite similar to the
variation of the shaft-neck angle. Most
authors found angles of 45-50" during the
first two years of life, and even at the age
of five Hamachere and Zippel3s report 40o
with a standard deviation of 5-6' and more.
Even angles of 50o at the age of five are not
necessarilypathologic, but rather an expression of the diversities in the development of
the human hip. Fabry, et al., MacBwen and

22.7
19.8
19.3

26.9
23.8
23.2

Shands.Thowever. considered children with

toeing-in gait outside the normal range.
Since relatively high valuesof antetorsionare
present in these cases,their normal material
demonstratesmean values of a much lesser
degree.To us it is questionablewhich criteria
could be used to appraise children with toeing-in gait and it seemsthat there is a smooth
transition to children with "extreme values."
Also as Fabry, et a1.,7point out that to date,
no definite proof is given that increased
antetorsion by itself is a pathogenetic factor.
These investigations show that so-called
coxa valga and increasedantetorsion should
not be considered pathologic too quickly or
considered an indication for femoral osteotomy if they are not accompaniedby a dysplasia of the acetabular roof.
WIBERG ANGLE
Investigationson the CE-angle of Wiberg32
have been made by many authors.l'8' 13'2l'
31.32

In our own investigation we found that

during the first three years of life children exhibit large diflerences in measurementsbe-

N u m b e r l1 9
September, 1976

NormalValuesof the Hip Joint

43

cause of difficulties in finding the center of

the femoral head. Also. in small children the
center of calcification moves laterally with
external rotation. We have, therefore, measured the angle only in children older than 5
years.l
The lowest normal limit for pathologic
angles has been determined by Glauner and
Marquarts to be l5o in small children. We
found by statisticalevaluation that the lowest
normal limit at the age of 5 to 8 years was
1 9 "; a t 9 t o 12 y ear s,2 5 o ; a t 1 3 to 1 6 y e a rs ,
between 26" and 30o; and at l7 to 20 years,
between 26 and 30o.
Wiberg3zreports a physiologic range of the
angle to be between 20o and 40o, Jentschural3 23" to 44".
HIP VALUE
After the age of 10 to 12 years, the acetabular index cannot be measuredany longer
and other methods have to be used to determine if we are dealing with a normal joint.
Three measurements have been tested the Wiberg32 angle (AZ), the angle of Idelberger and Frankrz (the ACM angle, Fig.
3), and the distanceof M-Z between the center of the femoral head (Z) and the center of
the acetabulum as constructed bv the ACM
angle (M).
The acetabular ACM angle of Idelberger
and Frankl2 shows no change in difterent
pelvic positions. In children younger than
10 years of age, it may be difficult to find
point B (Fig. 3). Point A is the lateral rim
of the acetabulum, point B is identical with
the last point of the acetabular rim at the
end of the facies lunata where there is
interruption by the incisura acetabuli.
On X-ray, there is a small incision or a
white point. At the middle (M) of line A-B,
a vertical line is erected. The point where it
reachesthe bony acetabularroof is called C.
The angle is determined between the A-C
and C-M line.
A new theory exhibitsl' 2' 3 the decentralization distance between the point M (middle

FIc. 3. For determination of the "HipValue" the center-edge-angle

of Wiberg (ZA)
and the ACM-angle of Idelberger and Frank
are drawn and measuredas well as the distance
between M & Z. With these three measurements, the Hip-Value can be found easily on
a Nomogram.
of the acetabulum as constructed by the
ACM angle) and the center of the femoral
head, as determined by the Wiberg angle,
in Figure 2 the ZA angle.
The ACM angle of Idelberger and Frankl2
is an index of the formation of the acetabulum. At an angle of 45" the acetabulum
would be a full hemisphere- an acetabulum
of 100 per cent. With an ACM angleof 50o,
the acetabulumwould only be 83 per cent of
a hemisphere.
The Wiberg angle is an index of the utilization of the acetabulum.In the transmission
of the vertical pressure the only part of the
acetabulum that is of importance is that
which covers the cranial-directed part of
the femoral head. If the acetabulum is considered a hemisphere,how much of the hemisphere covering the verticaldirected part of

Clinicol Orthopoedics
ond Rclolcd Reseorch

Tiinnis

Fto. 4. Distribution
curves of normal and
pathol ogi cal A C Mangles (see text).

the femoral head can be determined? With a

CE angle of 36' it would be 79 per cent,
with a CE angle of 3lo it would be 76 per
cent.
The distance MZ is an index of the degree
of decentralization which signifies the distance between the centers of the ball and the
socket. In a hip joint with an ACM-angle of
45", the two centerswould be identical.The
further they move apart, as an expression
of subluxation, the greater the distance of
MZ,
These three different gradientsof the form
of the hip joint have been combined to the
so-called "Hip Value."
The Hip Value is explained by the
formula:

H V: A +B +C +1 0
The different factors are:
A : 3 ACM-mean valueof ACM
standard deviation of ACM
B : 3 mean value of CE-CE
standard deviation of CE
C:

3 MZ-mean

value of MZ

standarddeviation of MZ
STATISTICAL EVALUATION OF
PHYSIOLOGIC AND PATHOLOGIC
HIP JOINTS
We attempted to define the margin between "normal" and "dysplastic"by statistical methodsinsteadof by the radiological
view. The groupingof the joints by X-ray
has only beendoneonly by comparison.We
examinedthree factors in our study: (l)

Pain in the hip joint; (2) Decreasedmovementof the hip joint; ( 3 ) Signsof coxarthrosis.
Patientsthat exhibited one or more of
thesefactors were consideredpathological,
the others physiologic. Coxarthrosis had
started when the follorving changeswere
visible:
Grade 1 Coxarthrosis: increasedsclerosis of femoral head and acetabulum.
slight decrease
in the heightof the cartilage, slight osteophytes.
Grade 2 Coxarthrosis: small cysts in
femoral head or acetabulum,marked
decreasein the height of cartilage,
slight deviationfrom the round form of
thefemoralhead.
Grade 3 Coxarthrosis: large cysts in
femoral head and acetabulum,severe
decreasein cartilageup to complete
absenceof the joint cleft, severedeviation of the round form of the femoral
head,avascularnecrosis.
Of 817 hip joints therewere358 considered physiological,459 pathological.
For statisticalevaluation,the following
factsshouldbe considered:Figure4,A.shows
the distribution curve of the ACM angles
of physiologichip joints. The curve illustratesthe normal form of a statisticaldistribution. However, at each ACM angle of
normal joints we can also find pathological
joints with pain or arthrosis that are not
causedby a primary deformation,but rather
by metabolicchanges,rheumatismand other
causes.Figure 48 shows the distribution
curve of these types of pathologic joints.

N u m b cr l l l
Seplembor, l?76

NormalValuesof ihe Hip Joint

45

HW
ACM

I
5
5

FIc. 5. Nomogram
to determine the Hipvalue (21-50 years)

35r
136
37t
[ 34
39[
l40
4t l
+ 42
43+
+41
45+
+15
a7+
t4!

ot
fto
5 r+
+52
53+
+s4
ss+
+55
57+
+st
s9+
+60
6l+
+52
63+
-164

CE

5-

4
5
6
7

t2

r3
l4

40

l5

l6

25
30

r0
tl

t5

17

35

1
6

45

IE
t9

r0
t2

20
2l

l4

22
23
21
25
26
27
2g
29
30

r3
14
t5

65r

Degrees

7
c

Degrees

16

17

r8

t6
l8
20

3lightly dctormcc

haavy dcformad

l9
20
Finally, when we include all pathologic joints
in the distribution curve, it shows the form
of Figure 4C.
The crack (marked with an arrow) in
Figure 4C indicates the critical point when
the normal values diminish and the pathological values increase. This is similarly the
case for the CE-angle, the MZ-distance and
the Hip-Value. The relationship of the number of normal joints to the number of pathologic joints has been evaluated by the ChiQuadrattest (error 5Vo) .
The critical points between physiologic
and pathologic hip joints were found to be as
follows: ACM-angle:49"; CE-angle:3O' ;
Mz-distance:6 mmi Hip value: l6.
These angles differ to some extent from
those found by other authors. Idelberger and

Frankl2 state that angles above 52o are

pathologic - we find 49'. Wiberg says that
angles below 25" are pathologic - we find
the critical value at 30o.
The four measurementswere examined to
determine the highest percentage of values
in the "normal rauge" and the highest percentageof values in the "pathological range."
We have to remember that each of these
measurementsis another expression of the
deformity of the hip joint. tt was found that
the Hip Value (the combination of the
three measurements)was most significant.
For clinical use, a Nomogram was developed where the Hip Value might be found
(Fig. 5). From the value of the ACM-angle,
a line has to be drawn to the value of the CEangle. The point where this line cuts the

46

Clinicol Orthopoedics
ond Reloted Reseorch

T6nnis

middle scale is then connected with the

value of the MZ-distance. This line then cuts
the scale of the Hip Value and allows the
reading of this value in the scale.
The Hip Value of normal joints in adults
ranges from 6-15. Hip values of less than
6 are found in casesof coxa profunda and
protrusio acetabuli. Between a value of 16
and 2l a slight deformitory of the hip joint
is present, at 22 and above there is a severe
deformity. In children the normal range goes
up to 14. A Hip Value here of 15 is already
pathological.
CORRELATION
DEFORMITY

look for the relationship between femoral

head and acetabulum.A new measurementthe Hip Value is based on measurementsof
the Idelberg--Frankr2 angle, the Wibergs2
angle and MZ-distance of decentralization.
By statistical methods, normal and pathological joints can be separated as follows:
in adult Hip Values, between6 and l5 indicate a normal joint form; valuesbetween16
and 2l indicate a slight deformation and
values of 22 and above are indications of a
severedeformation. in children in the normal
rangethe Hip Value reachesl4; valuesof l5
and up are pathological.

BETWEEN
AND

ONSET

OF PAIN
Both slightly and severelydeformed joints
have been examined for the onset of pain.
One would expect the onset of pain to be
earlier in the deformed joint. However, no
significant correlation was noticed.
Even slight deformities caused an early
onset of pain and some severe deformities
revealed a relatively late onset of pain.
Therefore, preventive surgical treatment
should be performed only in very severe cases
where a progressivedevelopmentis definitely
expected. In cases with slight deformities,
operative treatment can be postponed until
the onset of pain.
SUMMARY
X-ray measurementsof the hip joints of
children, with special reference to the
acetabular index, suggest that the upper
standard deviation of normal comprises the
borderline to a critical zone where extreme
values of normal and pathologic hips were
found together. Above the double standard
deviation only severedysplasiaswere present.
Investigations of the shaft-neck angle and
the degree of anteversion including the wide
standard deviation demonstrate that it is
very difficult to determine where these angles
become pathologic. It is more important to

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N u mb e r I 1 9
Se p l e mb cr,1 9 7 6

NormalValuesof the Hip Joini

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