Accuracy and Reliability of Computed Tomography and Magnetic Resonance Imaging Compared With True Anatomic Femoral Version

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Abnormal torsion of the femur is correlated to lower extremity pathologies. Although computed tomography (CT) scan is the gold standard torsional measurement, magnetic resonance imaging (MRI) is proposed as a viable alternative. Our aim was to determine the accuracy and consistency of MRI and CT femur rotational studies based on 4 described protocols.


Twelve cadaveric femora were stripped of soft tissue before imaging and physical assessment of torsion. Four advanced imaging series were obtained for each specimen: CT with axial cuts of the femoral neck (CT-axial); CT with oblique cuts of the femoral neck (CT-oblique); MRI with axial cuts of the femoral neck (MR-axial); MRI with oblique cuts of the femoral neck (MR-oblique). Anatomic specimens were placed with the posterior femoral condyles flat on a dissection table for assessment of true torsion with digital images. Three independent reviewers performed all measurements, including true torsion, using imaging software. Bland-Altman analysis was repeated with the data from each reviewer.


Interobserver repeatability for all groups was high at 0.95, 0.87, 0.90, 0.97, and 0.92 for CT-axial, CT-oblique, MR-axial, MR-oblique, and true torsion, respectively. CT-axial had the lowest mean difference from clinical imaging for all three observers (all <1 degree) and held the tightest 95% limits of agreement for 2/3 observers. As torsion increases from neutral, MR-oblique linearly overestimates the rotation compared with true torsion. CT-oblique and MR-axial showed slightly greater differences from true torsion compared with CT-axial, but did not reach clinical significance.


CT-axial was both most accurate and reproducible when compared with true torsion of the femur and should be the gold standard imaging modality; however, both MR-axial and CT-oblique were accurate to a level that is likely less than clinical significance. MR-axial images should be used in clinical situations where radiation exposure needs to be limited. MR-oblique images can overestimate true antetorsion and should not be used.

Clinic Significance:

CT-axial followed by MRI-axial is the most accurate and consistent in measuring true torsion of the femur.

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