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ORIGINAL ARTICLE
Year : 2018  |  Volume : 45  |  Issue : 1  |  Page : 3-7

Evaluation of femoral neck-shaft angle in subHimalayan population of North West India using digital radiography and dry bone measurements


1 Department of Orthopedics, Dr. Rajendra Prasad Government Medical College, Kangra, Himachal Pradesh, India
2 Department of Anatomy, Dr. Rajendra Prasad Government Medical College, Kangra, Himachal Pradesh, India
3 Department of Radiodiagnosis, Dr. Rajendra Prasad Government Medical College, Kangra, Himachal Pradesh, India

Date of Web Publication27-Jul-2018

Correspondence Address:
Vipin Sharma
H. No 23, Type 5, Block B, Dr. Rajendra Prasad Government Medical College, Kangra, Himachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jss.JSS_34_17

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  Abstract 


Background: Femoral neck-shaft angle is an important parameter of proximal femoral geometry. Not only it has an anthropological value but also it gives an insight into possible underlying hip pathology. The present study was conducted with an aim to find femoral neck-shaft angle values in subHimalayan population of Northwest India, and to measure the neck-shaft angle of proximal femur in both gender types using two different methods. Materials and Methods: This study was carried out to determine the average femoral neck-shaft angle in subHimalayan population of Northwest India. Neck-shaft angle in 89 femora was measured by digital radiography using PACS software while 93 dry bones were analyzed by direct measurements. The results obtained were statistically analyzed. Results: The results were analyzed using SPSS software. The mean femoral neck-shaft angle using digital radiography method was 127.45 ± 2.50 when compared to dry bone group 126.90 ± 2.50. Gender-wise males had higher neck-shaft angle values when compared to females in both groups and were statistically nonsignificant. Conclusion: Any increase or decrease in the angle of femoral neck-shaft angle is associated with various clinical conditions. Data from this study would help to establish values for subHimalayan population of Northwest India, provide insight into various associated disease conditions, and also serve as guidelines for manufacturing of orthopedic implants.

Keywords: Digital radiography, dry bone measurements, femoral neck-shaft angle


How to cite this article:
Sharma V, Kumar K, Kalia V, Soni PK. Evaluation of femoral neck-shaft angle in subHimalayan population of North West India using digital radiography and dry bone measurements. J Sci Soc 2018;45:3-7

How to cite this URL:
Sharma V, Kumar K, Kalia V, Soni PK. Evaluation of femoral neck-shaft angle in subHimalayan population of North West India using digital radiography and dry bone measurements. J Sci Soc [serial online] 2018 [cited 2018 Aug 16];45:3-7. Available from: http://www.jscisociety.com/text.asp?2018/45/1/3/237760




  Introduction Top


The femoral neck-shaft angle is the angle formed by femoral shaft axis and femoral neck. A valgus in infancy, the femoral neck-shaft angle decreases progressively to reach a value of about 125° at puberty. Once growth is complete no further changes are noted in neck-shaft angle. Gender, side, and age-specific variations have been noted in femoral neck-shaft angle values and even in persons belonging to the same age group. The angle decreases during the period of growth, but after full growth has been attained, it does not usually undergo any change. Femoral neck-shaft angle values are important from a clinical perspective as well.

Coxa valga (>140°) may be associated with the increased risk of proximal femoral fractures, Genu varum and associated medial compartment knee arthritis while conditions such as greater trochanteric pain syndrome, Paget's disease of bone, osteogenesis imperfecta, osteomyelitis, and osteoporosis may be associated with coxa vara (<120°).[1],[2]

Moreover, neck-shaft angle values have a bearing on designing orthopedic implants, planning osteotomies about hip, designing, and placement of femoral stem in total hip replacement. Many methods are available for measuring the femoral neck-shaft angle which include fluoroscopy, radiography, computed tomography (CT), and magnetic reasoning imaging (MRI). Due to the wide variation in health infrastructure in our country, it may not always be possible to measure the femoral neck-shaft angle by CT and MRI.

The present study aimed to compare femoral neck-shaft angle of proximal femur as measured by digital radiography with that of dry bones using direct measurements in subHimalayan population of Northwest India, and to evaluate any variations of these measurements attributable to age and gender.


  Materials and Methods Top


This prospective hospital-based study was conducted at a tertiary care institute after due ethical approval, over a period of 1 year (2015–2016). All consecutive patients between 20–60 years of age were included in the study, while patients with age <20 years, fracture proximal shaft of femur, fracture of neck/head of femur, old operated patients with above-mentioned fractures, and patients with deformity in the hip and osteoarthritis of hip were excluded from the study.

Group A digital radiography method

A total of 89 patients (89 femora) were analyzed for femoral neck-shaft angle using this method. Patients were enrolled and subjected to detailed history and clinical examination. Patients were positioned on X-ray table with both lower limbs parallel to each other in 20° internal rotation. The X-ray beam was centered over symphysis pubis at a distance of 100 cm.

Neck-shaft angle was measured using Image Works, Dicom workstation (Allengers) by noting angle between two intersection lines representing proximal femoral shaft axis and the femoral neck axis. Femoral neck axis line was drawn joining two points as follows: (i) the center of the femoral head and (ii) the center of the femoral neck (neck axis) (midpoint of superior and inferior border on anteroposterior and midpoint of medial and lateral border on lateral projection). Proximal femoral shaft axis line was drawn joining the midpoints of two points on the proximal shaft of the femur below the lesser trochanter [Figure 1].
Figure 1: Measurement of femoral neck-shaft angle using digital radiography

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Group B dry bone method

Ninety-three dry bone femora were analyzed in this method. The axis of the neck was determined by a colored thread dividing the anterior surface of the neck into two equal halves. Axis of the shaft was marked using the same thread in the midsagittal plane over the anterior surface of femur. The angle was measured using a goniometer [Figure 2].[3]
Figure 2: Measurement of femoral neck-shaft angle in dry bone using goniometer

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Statistical analysis

Data were presented as frequency, percentage, and mean ± standard deviation. Difference between continuous and categorical variables was analyzed using student t-test and Chi-square test, respectively. A value of P < 0.05 was considered statistically significant. Statistical analysis was performed using SPSS Statistics for Windows, Version 23.0. (IBM Armonk, NY, USA).


  Results Top


In the present study, anthropometric measurements of the neck-shaft angle proximal femur using two different methods – digital radiography and dry bone measurements were taken. A total of 89 patients (89 femora) were studied using digital radiography (Group A), whereas dry bone measurements (Group B) were used in 93 femora (93 patients) [Figure 3]. Mean age of the patients in Group A and Group B was 37.31 ± 10.11 years (range: 30–60 years) and 46.64 ± 7.71 years (range: 20–56 years), respectively, with a male/female ratio of 3/1 (Group A) and 5/1 (Group B). It was observed that the femoral neck-shaft angle was higher (P = 0.0077) in digital radiography group (127.45 ± 2.50) when compared to dry bone group (126.90 ± 2.50). Statistically insignificant higher values of neck-shaft angle were noted for males in comparison to females [Table 1].
Figure 3: Bar-diagram showing sex and age group based comparative measurements of femoral neck anteversion on digital radiography and morphometric (dry bone) analysis

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Table 1: Mean femoral neck anteversion in males and females in digital radiography and dry bone (degree)

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  Discussion Top


Measurement of femoral neck-shaft angle is important as it is known to be associated with various disease conditions. Genu varum is known to be associated with Coxa valga (Neck-shaft angle >140) leading to early degeneration of medial compartment of knee; whereas coxa vara (Neck shaft angle <120) can have congenital, metabolic (Paget's disease), neglected trauma, and developmental (osteogenesis imperfecta) or postperthes as its etiology.

Analysis of femoral neck-shaft angle in a population assumes importance as this gives an insight into associated disease conditions and also serves as a guide to the manufacture precision orthopedic implants. A multitude of methods such as radiology, CT, MRI, and dry bone measurements have been used in the past to measure femoral neck-shaft angle.[4],[5] Radiography, especially digital radiography is easily available at most of the institutes as compared to CT and MRI, and hence, it can be an effective tool for measurement of neck-shaft angle. CT and MRI although more accurate are not easily available at many institutes, and their use is restrained by the cost factor. Limb positioning is important while using digital radiography for measurement of neck-shaft angle. Positioning lower limb in internal rotation can help to assess real varus-valgus of femoral neck-shaft angle.[6] Femoral axis is another important parameter for femoral neck-shaft axis measurements. There was a change toward varus angulations of the neck-shaft angle (an inward deviation of the distal femoral segment) if the measurement was performed using the long axis of the femoral shaft instead of using the axis of the proximal femur.[7]

Variations in neck-shaft angle have been noted from across the globes based upon race, side, and gender as well as a method of measurement. Lifestyle factors have also been known to influence various indices in the proximal femur.[5],[8] People involved in greater physical activity such as long-distance walking have higher values of neck-shaft angle as compared to the rest.[9]

In the present study, two different methods were used to assess femoral neck-shaft angle –digital radiography and dry bone measurements. The mean femoral neck-shaft angle using digital radiography method was 127.45 ± 2.50 while 126.90 ± 2.50 by dry bone measurements. Similarly, the dimensions of femoral neck-shaft angle were higher in males when compared to females, but statistically nonsignificant. Wider pelvis, obliquity of shaft femur, and a short femur could be the reasons for lesser neck-shaft angle values in females.[10] However, conversely, some studies have reported higher values of femoral neck-shaft angle.[11],[12] Population and gender-specific implants could be a viable option in such patients.[5]

The higher values of femoral neck-shaft angle from digital radiography as compared to dry bone measurements could be due to magnification error and variable limb positioning while doing digital radiography.

Femoral neck-shaft angle with almost identical values as our study have been reported by some studies from the Indian subcontinent.[13],[14] While other contemporary Indian studies have reported mean neck-shaft angle values as low as123° ±4.3° (using dry bone, X-ray measurements)[15] to values as high as 139.5° ± 7.5° (Using CT Measurements).[16] Similarly, variable values for femoral neck-shaft angle ranging from 121.0° ± 6.0° to 133.97 ± 4.28° have been reported from world literature also [Table 2].
Table 2: Comparison with contemporary literature

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World literature from rest of the continent has also reported femoral neck-shaft angle values ranging from 121.0° ± 6.0° to 140.48° ± 6.95°.[17]

Some studies have reported side-specific variations in femoral neck-shaft angle. Higher values of femoral neck-shaft angle on the left side as compared to right side have been reported in some studies,[18],[19] which could be due to a particular limb dominance. However, in this study, no significant difference was noted between the right and left side values of femoral neck-shaft angle. [25]

It was observed that the femoral neck-shaft angle was significantly higher (P = 0.0077) in digital radiography group when compared to dry bone group. The present study also observed that the neck-shaft angle was higher in males when compared to females (nonsignificant).


  Conclusion Top


The results of this study indicate that variations do exist in the dimensions between the neck-shaft angle of femur of the subHimalayan Northwest Indian population and that of the populations from other parts of the globe. Furthermore, race, sex, and side-specific variations do exist and need due consideration. Some numerical differences have been noted in neck-shaft angle values from two modes of measurement adopted in this study which could be due to patient positioning during radiography, limb position, and magnification errors. This study will be useful in establishing base line values of femoral neck angle in subHimalayan population of Northwest India.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2]



 

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