A Study on the Usefulness of Dunn View in Measuring

Alpha Angle Used in the Diagnosis of Cam Type Femoro

Acetabular Impingement Syndrome

Poster No.: C-0348

Congress: ECR 2013
Type: Scientific Exhibit
Authors: 1 2 1 2
H. Y. Kim , S. H. Kim ; Seongnam-si/KR, Seongnam-Si,
Gyeonggi-Do/KR
Keywords: Diagnostic procedure, PACS, MR, Digital radiography, Pelvis,
Musculoskeletal joint, Bones, Efficacy studies, Technical aspects,
Pelvic floor dysfuntion, Image verification, Calcifications / Calculi
DOI: 10.1594/ecr2013/C-0348

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Purpose

st
With the development of modern civilization, the 21 century is showing the trend of
increase of hip joint disease patients of men and women of all ages and they suffer from
the disease.

Among them, what we will discuss is Femoroacetabular Impingement syndrome (FAI).

This disease occurs because the abnormal growth (spur) of acetabulum or the rubbing/
hitting between acetabulum and femoral head due to either the disfigurement/growth of
femoral head or the thickening of femoral neck bone.

FAI has 3 types.

Cam type occurs due to the hitting between acetabulum surface and femoral head or
femoral neck due to the growth/disfigurement.

Pincer type occurs due to the over#extension of acetabulum surface over the femoral
head.

Mixed type means that both Pincer and Cam types are present (1).

Among the 3 types, # angle measurement is an important factor to identify Cam type (4).

Magnetic Resonance Arthrography (MRA) measures #angle, which comprised of one

circle and two lines, and if #angle is more than 55#, diagnoses it as cam type FAI (2).

Our institution conducts Dunn view test (which is a type of simple x#ray test) to measure
#angle before MRA test.

This report was designed to find out the usefulness of Dunn view (45#, 90#) on the
measurement of #angle by comparative analysis with Hip MRA, AP view, Frog leg view,
and Trans lateral view.

Methods and Materials

1. Test subjects

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They were 66 adults who visited our facility due to hip joint disease pain and completed all
the tests of Hip MRA, Dunn view, AP view, Frog leg view, and Trans lateral view between
Aug. 2011 and Jan. 2012.

26 subjects were male and their average age was 47.6.

40 subjects were female and their average age was 52.4.

And the average age for both of male and female combined was 50.6.

2. Test equipments

#DR (digital diagnost TH, Philips, Netherlands)

#MRI (Achieva 3.0T scanner, Philips , Netherlands)

#PACS (Infinitt version 3.0.9.1, Infinitt Korea)

#SPSS (Statistical Package for the Social Sciences version 18, USA)

3. Test method

1) Hip MRA: We performed T1WI oblique axial fat suppression scan using 3.0T
equipment and we used the parameters of TR 400~600ms, TE 8~20ms, FA 90#, FOV
180*180, matrix 232*138, slice thickness & gap 2mm&0, NEX 2, and scan time 2min
57sec (Fig. 1).

2) AP view: From supine position, internally rotate both feet 15#and then use x#ray beam
onto 2.5cm above pubic symphysis in vertical incident angle (Fig. 2).

3) Frog leg view: From supine position, attach both feet to each other and then abduct
the femoral region 60#and then use x#ray beam onto the middle of hip joints in vertical
incident angle (Fig. 3).

4) Trans lateral view: From supine position, internally rotate and maintain a foot of the
side of x#ray procedure 15#and flex the other foot 80#and place it on the tube to get
support and then use x#ray beam onto the anterolateral surface of femoral head#neck
junction in vertical incident angle (Fig. 4).

5) Dunn 45#view: From supine position, flex hip joints 45#and then abduct 20#and
maintain foot in neutral position and use x#ray beam onto the middle of hip joints in
vertical incident angle (Fig. 5).

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6) Dunn 90#view: From supine position, flex hip joints 90#and then abduct 20#and
maintain foot in neutral position and use x#ray beam onto the middle of hip joints in
vertical incident angle (Fig. 6).

4. Assessment Method

Measurement was conducted by 1 radiologist and 3 seasoned radiation technicians

respectively. The #angle is formed by a line drawn from the center of the femoral head
(circle shape) through the center of the femoral neck and a line from the center of the
femoral head to the femoral head#neck junction (3).

Assessment methods (per each test)are listed in Fig. 7#Fig. 12.

5. Statistical Method

We used #angle from Hip MRA as a baseline value.

And we performed comparative analysis by correspondence test T analysis and

Pearson's correlation coefficient for the measurement values of Hip MRA, Dunn 45# view,
Dunn 90# view, AP view, Frog leg view, and Trans lateral view (each value was tested
for normality before comparative analysis).

Images for this section:

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Fig. 1: Position of MRA

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Fig. 2: Position of AP view

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Fig. 3: Position of Frog leg view

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Fig. 4: Position of Trans lateral view

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Fig. 5: position of Dunn 45# view

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Fig. 6: position of Dunn 90# view

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Fig. 7: Alpha angle of MRA

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Fig. 8: Alpha angle of AP view

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Fig. 9: Alpha angle of Frog leg view

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Fig. 10: Alpha angle of Trans lateral view

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Fig. 11: Alpha angle of Dunn 45# view

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Fig. 12: 12. Alpha angle of Dunn 90# view

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Results

Average of the measured values and standard deviation of the values from this study
were:

MRA 47.3120#±6.5480, AP view 63.4644#±15.4772, Frog leg view 56.5708#±9.9862,

Trans lateral view 49.0558#±5.4949, Dunn 45# view 54.9586#±8.4270, and Dunn 90#
view 47.8489#±6.5138 (table 1, 2).
Mean difference values were: between MRA and Dunn 90#view= 0.3505, between MRA
and Dunn 45#view= 0.9367, between MRA and Trans lateral view= 0.7303 , between
MRA and Frog leg view= 1.3372, between MRA and AP view= 2.1088 (table 3).

P values for each comparison were: MRA and Dunn 90# view= p>0.05, MRA and Dunn
45# view= p<0.05, MRA and Trans lateral view= p<0.05, MRA and Frog leg view=
p<0.05, and MRA and AP view= p<0.05(table 3).

So it indicates that there was no statistically significant difference between MRA and
Dunn 90# view.

But there were statistically significant differences between MRA and Dunn 45# view,
Trans lateral view, Frog leg view, and AP view.

Analysis of Pearson's correlation coefficient revealed that MRA and Dunn 90# view=
0.905, MRA and Dunn 45# view= 0.461, MRA and Trans lateral view= 0.526, MRA and
Frog leg view= 0.164, MRA and AP view= #0.95 (table 3).

In other words, Pearson's correlation coefficient between MRA and Dunn 90# view was
0.905 which is almost near 1.

Table 1. Result of survey (unit #)

n#Test MRI Dunn45 Dunn90 AP Frog leg Trans Lat

1 46.41 57.90 62.82 52.17 54.81 49.70
2 39.93 42.85 38.04 50.30 58.60 44.90
3 48.98 60.81 45.89 53.83 58.95 49.36
4 36.84 54.48 40.60 43.01 52.07 43.71
5 45.95 53.44 45.62 74.36 43.88 55.02
6 33.99 55.44 38.51 77.30 69.41 48.64
7 41.79 46.06 54.47 33.07 54.97 43.57

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8 41.47 37.88 39.57 46.54 47.30 36.35
9 52.86 60.31 52.09 88.26 74.91 55.06
10 36.09 51.95 35.57 84.26 44.41 59.20
11 64.51 65.12 59.36 68.26 84.54 50.64
12 53.38 51.89 53.85 66.78 67.41 39.92
13 42.88 54.24 44.94 60.59 54.35 49.76
14 51.35 66.69 52.63 69.86 58.68 52.62
15 48.63 57.82 48.96 68.20 66.83 41.87
16 42.03 57.09 43.90 70.95 46.87 51.19
17 46.49 62.78 46.18 81.95 59.04 52.06
18 38.67 51.88 39.23 78.65 58.13 49.36
19 50.18 82.51 50.40 88.76 55.90 50.10
20 38.40 43.93 38.34 83.01 65.44 53.12
21 41.68 50.70 41.72 80.50 55.17 49.36
22 42.26 61.35 41.68 69.23 84.19 48.84
23 47.49 64.57 47.84 72.95 73.88 47.78
24 46.85 53.24 46.58 79.88 55.05 48.58
25 40.76 56.51 40.21 75.90 39.46 47.63
26 35.30 47.55 32.68 94.46 66.39 41.67
27 33.01 56.96 33.73 87.57 62.94 56.34
28 56.81 68.07 56.03 78.31 46.08 47.28
29 45.06 46.88 44.34 85.07 48.10 46.39
30 41.09 50.91 42.17 47.52 44.99 49.22
31 50.01 48.09 49.02 41.75 57.39 53.64
32 40.84 57.46 40.64 95.45 66.06 46.70
33 43.15 40.12 43.84 46.56 44.19 48.25
34 54.11 50.14 55.29 83.18 81.61 57.89
35 65.37 73.55 65.13 54.62 73.19 48.38
36 46.17 49.10 47.78 38.91 57.35 63.35
37 60.36 66.92 60.33 92.20 50.28 47.91
38 57.53 56.80 57.24 54.70 44.54 45.30

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39 47.13 60.93 47.04 51.32 58.46 48.26
40 57.40 54.19 56.15 54.38 56.33 56.50
41 50.68 57.05 50.21 52.79 53.94 48.21
42 48.09 48.95 48.33 59.41 47.61 39.48
43 52.73 57.32 50.41 65.39 61.02 50.42
44 47.87 64.22 48.91 77.07 65.16 61.03
45 51.46 53.77 50.29 63.31 48.61 45.04
46 49.51 53.79 48.74 60.98 59.14 48.80
47 52.38 56.25 54.55 67.08 59.75 50.62
48 54.07 67.35 53.63 62.94 52.55 51.14
49 50.14 64.87 50.91 52.23 60.36 41.08
50 41.01 48.96 42.53 46.33 49.37 48.25
51 47.71 51.48 46.81 45.23 45.54 44.05
52 45.75 49.38 45.20 52.95 46.33 43.38
53 45.31 57.07 45.84 52.97 59.79 45.40
54 47.46 51.44 49.72 48.59 46.13 48.69
55 56.11 60.46 56.99 76.85 50.26 45.11
56 49.49 48.03 49.92 42.77 53.33 46.19
57 42.76 51.89 44.11 60.49 47.36 55.93
58 42.91 49.79 43.80 67.49 51.03 51.47
59 51.39 56.72 50.88 46.33 53.48 39.34
60 45.58 53.14 44.69 65.79 43.46 43.64
61 49.36 48.82 51.91 62.01 52.67 49.07
62 46.90 50.64 47.57 57.69 49.16 50.39
63 46.25 41.29 45.72 45.61 55.78 43.79
64 44.57 49.02 43.85 48.10 51.66 52.61
65 47.38 44.61 47.50 65.08 49.60 61.18
66 51.58 75.14 50.79 50.18 59.61 57.95

Table 2.Mean and standard deviation

Examination Mean Standard deviation

MRA 47.3120 6.5480

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AP 63.4644 15.4772
Frog leg 56.5708 9.9862
Trans lat 49.0558 5.4949
Dunn 45 54.9586 8.4270
Dunn 90 47.8489 6.5138

Table 3.Comparison of alpha angle

Comparison Mean difference P value Pearson's

correlation
coefficient
MRA vs Dunn 90 0.3505 p > 0.05 0.905
MRA vs Dunn 45 0.9367 p < 0.05 0.461
MRA vs Trans lat 0.7303 p < 0.05 0.526
MRA vs Frog leg 1.3372 p < 0.05 0.164
MRA vs AP 2.1088 p < 0.05 -0.950

Conclusion

If pain related to FAI is severe, arthroscopic surgery is required.

To perform surgery, correct identification between cam type and pincer type is crucial to
make the decision of surgery method (5).

So it's very important to measure #angle, among other criteria, to diagnose cam type FAI.

The most accurate test method to measure #angle is MRA (3).

But as we learnt from this study result, it is possible to measure relatively accurate #angle
with simple x#ray picture. And this x#ray test has been useful as a pre#MRA test to
diagnose cam type FAI.

Among x#ray tests, Dunn 90# view offers relatively accurate #angle measurement
compared to other simple x#ray tests.

And its reason is it can depict femoral head and femoral neck accurately and offers a
clear view of femoral head#neck junction.

Page 20 of 22
Also other advantages of the test are, compared to MRA test, it can decrease cost and
processing time for patients and it is a non#invasive test which does not use contrast
media.

But compared to Dunn 90#, Dunn 45# view and AP view do not provide clear borderline
of femoral head#neck junction so it was difficult to measure #angle.

In case of Frog leg view, compared to Dunn 90#, femoral neck was not seen spread out
widely enough.

In case of Trans lateral view, compared to Dunn 90#, Grid Line and Cut off phenomena
occur and they blur the socket of femoral head and in turn, creates the distortion of #angle
measurement.

The limitation of this study is when the pain is severe, the proper positioning of Dunn 45#,
90# is not possible and there was no tested device and accessory for Dunn 45#, 90# and
it can create the angle differences of flexion and abduction among examiners.

But as we have learnt from the previous comparison result with MRA test, Dunn 90# view
is a very useful test method to measure #angle and we think it will be useful to diagnose
cam type FAI without MRA test.

References

1. Ganz R, Parvizi J, Leunig M, Siebenrock KA: Femoroacetabular Impingement: a cause

for osteoarthritis of the hip, Clin Orthop Relat Res, 417:112-120 , 2003

2. Tanast M, Siebenrock K, Anderson S. Femoroacetabular Impingement:

Radiographic Diagnosis-What the Radiologist should know. American Journal Radiology
188:1540-1552, 2007

3. Notzli HP, Wyss TF, Stoecklin CH, Schmid MR, Treiber K, Hodler J. The contour for
the femoral head-neck junction as a predictor for the risk of anterior impingement. J Bone
Joint Surg Br. 84:556-560. 2002

4. Lohan DG, Seeger LL, Motamedi K, Hame S, Sayre J. Cam-type femoral-acetabular

impingement: is the alpha angle the best MR arthrography has to offer?, Skeletal
Radiology, 38(9):856-862, 2009

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5. Bardakos N.V., Vasconcelos J.C., Villar R.N. Early outcome of hip arthroscopy
for femoroacetabular impingement: the role of femoral osteoplasty in symptomatic
improvement. J Bone Joint Surg. Br, 90(12):1570-1575, 2008

Personal Information

Hyun Young Kim, Department of Radiology, Seoul National University Hospital Bundang ,
Korea

khyrad@naver.com

Sang Hyun Kim, Department of Radiology, Seoul National University Hospital Bundang ,
Korea

Shsnu@snubh.org

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