Effects of anteversion on femoral bone mineral density and geometry measured by dual energy X-ray absorptiometry: A cadaver study

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The effect of femoral neck anteversion on bone mineral density (BMD) and geometry as measured by dual energy X-ray absorptiometry (DXA) was assessed using 64 right proximal femora from 36 male and 28 female cadavers. The anteversion angle was measured on computed tomography (CT) images, and DXA measurements were made both in the neutral position (i.e., at 0° anteversion, femoral neck axis parallel to the table) and in the simulated anteverted position (i.e., femoral shaft axis parallel to the table, greater and lesser trochanters in contact with the table, and femoral neck free). The mean anteversion angle measured by CT was 19.3° (range 6°–38°). Anteversion was associated with a significant elevation in femoral neck BMD of +2.8% (range −5.3%–+9.8%) ( p < 0.05), and the femoral neck BMD increased with increasing anteversion ( p < 0.01). Trochanteric BMD was less affected by anteversion, with an average increase of only 0.2% (range −5%–5.9%) ( p = n.s.) in the anteverted position, but there was a significant positive association between the change in trochanteric BMD and the anteversion angle ( p < 0.01). Anteversion produced a mean reduction of −2.4% (range −7.6%–+4.3%) ( p < 0.001) in apparent femoral neck axis length, while femoral neck width remained generally unaffected. These data confirm that femoral BMD as measured by DXA is affected by femoral anteversion with a lesser magnitude than previously reported. The use of trochanteric BMD may minimize the influence of anteversion. While the mean changes in BMD and neck axis length attributable to anteversion are modest, the considerable interindividual variability in the magnitude of the effects demonstrates that other factors, such as, the complex geometry of femoral neck modifies the effect of anteversion on BMD measurements. The error in BMD introduced femoral anteversion may represent a significant confounding influence in cross-sectional and longitudinal studies. Careful repositioning of the foot and leg is essential in monitoring changes in BMD longitudinally. Knowledge of the effects of femoral anteversion may assist in understanding the relation of femoral BMD and neck axis length to hip fracture.