Can measurements from an anteroposterior radiograph predict pelvic sagittal inclination?

Pelvic sagittal inclination (PSI) is often evaluated in patients with hip pathology using lateral radiographs. However, it would be useful if PSI could be predicted from an anteroposterior radiograph since this film is ubiquitous in the evaluation of hip pathology. Herein, computer‐modeling was applied to predict PSI from radiographic measurements assessed in the anteroposterior plane. Three‐dimensional surface models of the pelvis, femur, and sacrum were reconstructed from computed tomography images of 50 women with hip dysplasia. This study cohort was selected as changes in PSI alter femoral head coverage, which is relevant to the diagnosis and treatment of hip dysplasia, a known cause of hip osteoarthritis. Five radiographic parameters commonly used to independently estimate PSI were evaluated after bone surfaces were projected to an anteroposterior plane, including the symphysis to sacrococcygeal joint distance (S‐S distance), the pelvic foramen aspect ratio (PF ratio), the distance between the symphysis and a line connecting the femoral head centers (S‐H distance), the sacro‐femoral‐pubic angle (SFP angle), and the pelvic vertical ratio (PVR). Regression models determined the ability of these parameters to predict PSI from −20° to 20° at 1° increment. All five parameters showed a strong correlation with the PSI (all r > 0.9). From the regression models, PSI was estimated with a median (maximum) absolute error of 3.6° (18.4°), 3.8° (17.7°), 5.2° (17.9°), 5.8° (28.8°), and 3.2° (23.5°) for the S‐S distance, PF ratio, S‐H distance, SFP angle, and PVR, respectively. The regression model for S‐S distance had a mean slope of 2.18 that ranged from 1.98 to 2.41 when the sacrococcygeal joint was located superior to the symphysis. Results indicated that substantial errors occur when estimating the actual value of PSI from an anteroposterior radiograph. However, the change in PSI could be estimated from the S‐S distance, which may aid surgeons to successfully increase head coverage through periacetabular osteotomy and to locate the acetabular cup in a functional position for total hip arthroplasty.