|Year : 2020 | Volume
| Issue : 2 | Page : 71-80
A comparative analysis of morphological parameters in south indian hip joints with review of literature
Supreeth Nekkanti, Alok Moogali, Arun Mahtani, Mruthyunjaya
Department of Orthopaedics, JSS Medical College and Hospital, JSS University, Mysore, Karnataka, India
|Date of Submission||20-Mar-2019|
|Date of Acceptance||13-Jan-2020|
|Date of Web Publication||30-Jun-2020|
Dr. Supreeth Nekkanti
Department of Orthopaedics, JSS Medical College and Hospital, JSS University, Mysore, Karnataka
Source of Support: None, Conflict of Interest: None
Introduction: The morphology of the proximal femur is an essential parameter in the design and development of implants for total hip replacement. Inappropriate implant design and size could affect the outcome of the surgery with reported complications such as stress shielding, micromotion, and loosening. Most of these implants are designed and manufactured in the European and North American regions, which are presumably based on the morphology of their respective populations. In this study, we try to demonstrate the significant variation in the morphology of South Indian hip joints compared to other ethnicities. Material and Methods: This prospective study includes the study of the morphology of 400 adult hip joints. The patients presented to our hospital with complaints other than that related to the hip joint. Various parameters were studied, comprehensively discussed, and compared with other studies done in different ethnic groups. Results: The hip joints of the South Indian population have a significantly smaller femoral head diameter and offsets, narrower neck width, and medullary canal diameter when compared to other ethnic groups. The neck-shaft angle was comparable to results from other studies. Gender- and laterality-based variations were observed as well. Discussion and Conclusion: Our study demonstrated that the South Indian hip joints are significantly smaller when compared to other Asian hip joints. There were significant gender- and laterality-based variations. This study also provides evidence that implants could be modified to replicate the morphology of the native hip joints.
Keywords: Hip joint, India, morphometric analysis, population, radiology, total hip replacement
|How to cite this article:|
Nekkanti S, Moogali A, Mahtani A, Mruthyunjaya. A comparative analysis of morphological parameters in south indian hip joints with review of literature. J Anat Soc India 2020;69:71-80
|How to cite this URL:|
Nekkanti S, Moogali A, Mahtani A, Mruthyunjaya. A comparative analysis of morphological parameters in south indian hip joints with review of literature. J Anat Soc India [serial online] 2020 [cited 2020 Jul 3];69:71-80. Available from: http://www.jasi.org.in/text.asp?2020/69/2/71/288670
| Introduction|| |
The proximal femoral anatomy differs from person to person based on their ethnicity, gender, age, bodyside, measurement methods, climate, clothing, and lifestyle. Ethnicity, however, is a crucial factor, and many studies have been conducted to prove the same.,,,,,,,,,,
The variation of the anatomy of the proximal femur is due to a difference in the femoral head diameter (FHD), neck-shaft angle (NSA), neck width (NW), acetabular version (AV), and acetabular angle (AA).,,, The AV is a significant parameter during total hip replacement (THR) as potential complications such as early postoperative dislocation of the prosthesis may be avoided if measured accurately.,, An abnormal AV predisposes the patient to osteoarthritis of the hip joint, developmental dysplasia of the hip joint,,, and gluteal tendinopathy.,
NSA is another essential morphological characteristic of the proximal femur. Studies have shown that an increase in NSA renders the patient vulnerable to proximal femoral fractures., On the contrary, lower NSA in females has been reported to cause greater trochanter pain syndrome.,
The commonly used implants for hip surgeries include a dynamic hip screw, cancellous screws, cephalomedullary proximal femoral nails, and prosthesis for hemiarthroplasty and THR., These implants are designed based on the morphometry of proximal femur and hip joints of the Western population. Siwach and Dahiya  studied the Indian cadavers and found that the implants in the proximal femur were oversized with a mismatch of angles and orientation of the implant. This causes the implant to fail, along with splintering or fractures. Pathrot et al. recommended customizing the cephalomedullary nails for Indian patients by reducing the NW. Leung et al. studied the need to modify the gamma nail to suit the Asian population due to narrow NW and smaller femoral head.,
During THR surgery, it is essential that the prosthesis matches the geometry of the native bone to avoid complications such as aseptic loosening, pain, and improper load distribution., The secondary biological integration of the uncemented stem depends on the quality of primary stability. Any mismatch between the implant and the native bone will affect the bone ingrowth into the implant due to micromotion during the postoperative period. This micromotion causes aseptic loosening, osteolysis, and thigh pain. It is also important that the prosthesis allows uniform load transfer through it to prevent stress shielding.
| Material and Methods|| |
This prospective study was conducted at JSS Medical College and Hospital, Mysore, from August 2017 to January 2018. The institutional review board clearance was taken for this study (JSSMC/IEC/04/2007/2017–2018). This study included the morphometric study of 400 hip joints from 200 patients both male and female who underwent a computed tomography (CT) scan of the abdomen and pelvis/CT kidney, ureter, and bladder (KUB) for nonorthopedic complaints. All patients between 20 and 75 years of age were included in this study. Patients who underwent abdomen/KUB/pelvis CT scan for other reasons in JSS Medical College and Hospital with clinically normal hip joints on examination were included in the study. Patients with preexisting hip joint pathologies such as osteoarthritis, rheumatoid arthritis, old fractures, dislocation of the hip joint, fracture of the proximal femur or acetabulum, and deformities of the lower limb and spine were excluded from the study. Radiographic assessment of both the hip joints was done for each patient. PHILIPS 124 sliced CT scan with a 1-mm slice thickness was used for the study. The patients were placed in the supine position during imaging with both hip joints in neutral rotation. The superimposition of motion artifact was avoided.
Radiological analysis of the hip joints included measurement of FHD, NW, neck-shaft angle (NSA), horizontal offset (HO), vertical offset (VO), medullary canal diameter at LT, AA of sharp, and AV using picture archiving and communication system. The measuring process was optimized using a full-screen view, and the images would be magnified to maximize resolution and accuracy. Radiographic parameters were defined as follows.
It is the angle intersected between the long axis of the femur and the long axis of the neck of the femur. The femoral shaft axis is a line drawn by extending through two equidistant points from the mediolateral surface of the femoral shaft in the center of the medullary canal. Neck axis is drawn by joining two points equidistant from the superior and inferior surface of the femoral neck.,
Femoral head diameter
A perfect circle is drawn over the ideally spherical femoral head, and circle diameter is measured.,
A perpendicular line to the neck axis at the narrowest part of the femoral neck is measured.,
The acetabular angle of sharp
The acetabular angle of sharp is the angle formed by the lateral margin of the acetabular roof, the inferior aspect of the pelvic teardrop and a horizontal line running between the inferior aspect of both pelvic teardrops. In the coronal sections of CT scan images, a horizontal line is drawn through the teardrop and another line drawn from the tip of the teardrop to the anterior edge of the acetabulum. The angle formed between these two lines is defined as the AA of sharp.,,
Horizontal offset or femoral offset is the horizontal distance from the center of rotation of the femoral head to a line bisecting the long axis of the shaft of the femur.
Two lines were drawn: one along the center of the femoral head and another along the middle of the femoral medullary canal. The measured distance between the two lines gives the HO.
Vertical offset or femoral head position is the vertical distance from the center of the femoral head to the tip of the lesser trochanter.,
Medullary canal diameter at the level of lesser trochanter
Mediolateral width of the medullary canal was measured at the level of the middle of the lesser trochanter.,
It is the angle measured between a line connecting both the posterior ischia and a line connecting the posterior lips of the acetabulum.,,,
The values were measured by two independent observers and were repeated after 2 weeks by the same observers to reduce the error of calculation. Statistical analysis was carried out using IBM Corp. Released 2015. IBM SPSS Statistics for Windows, Version 23.0. (Armonk, NY: IBM Corp).
| Results|| |
Femoral head diameter
The mean value for our population is found to be 40.09 mm, with a confidence interval (CI) of 39.34–40.83. The mean value for males was 42.48 mm and for females 33.70, with the CI narrowed down to 42.27–42.69 in males and 36.85–37.93 in females, respectively. The gender difference between FHDs was statistically significant (P < 0.001). There was no statistical significance among right and left hip joints.
The mean value for NW in our population was 28.29, with CI of 39.34–40.83. In males, it was 30.46, and in females, it was 25.85, with CI of 30.28–30.64 in males and 27.32–26.39 in females, respectively. Higher NW (P < 0.01) in males was statistically significant compared to female hip joints. However, there was no significant difference in NW between left and right hip joints.
Neck shaft angle
The mean value for NSA in our study population was 130.68, with CI of 129.61–131.75. The mean NSA in males was 131.22 and in females 130.06, with CI of 130.77–131.67 in males and 128.37–131.76 in females. There was no statistically significant difference between male and female NSA measurements. However, the left hip joint had a statistically significant higher (P < 0.001) mean NSA compared to the right hip joint.
The mean HO of our population was 36.50, with CI of 35.70–37.29. The mean value in males was 37.93 and in females 34.88, with CI of 37.63–38.22 and 33.89–35.87, respectively. There was a statistically significant higher (P < 0.01) HO among male hip joints compared to female hip joints. The mean HO of the right hip joint was significantly higher (P < 0.01) than that of the left hip joint.
The mean VO in our study population was found to be 49.20 mm, with CI of 47.86–50.53. The mean values for males were 52.42, and in females were 45.56, with CI of 51.65–53.19 and 44.13–46.99, respectively. The male hip joint demonstrated a statistically significant higher (P < 0.001) mean VO compared to the female hip joint. However, no significant difference in VO was observed between the left and right hip joints (P = 0.27).
Medullary canal diameter
The mean value of medullary canal diameter in our population was 26.14 and CI was 25.27-27.00. The mean among males was 27.01, with CI of 26.76–27.27, and the mean among females was 25.15, with CI of 23.75–26.54. The canal diameter was significantly higher in male hip joints compared to female hip joints (P < 0.01). The left femur had a wider diameter of medullary canals compared to the right side (P = 0.02).
Acetabular angle of sharp
The mean value of AA in our population was found to be 37.50, with CI of 36.78–38.21. The mean value for males was 37.44, and for females, it was 37.56. The CI was 37.20–37.68 among males and 36.51–38.61 among females. There was no statistically significant difference between male and female hip joints (P = 0.87). There was no significant variation in AA between left and right hip joints.
The mean value for AV in our population was 20.91, with CI of 20.05–21.78. In males, it was found to be 19.46 and in females 22.56, with CI of 19.08–19.84 and 21.53–23.58, respectively. The female hip joint demonstrated a statistically significant higher AV (P < 0.001) compared to male hip joints. Furthermore, left-sided hip joints showed a statistically significant higher AV (P < 0.001) compared to the right hip joint.
| Discussion|| |
Knowledge of the proximal femur and acetabular geometry is essential to understand the biomechanics of injuries, design of implants for various surgeries, and understanding joint-related pathologies such as arthritis. Due to regional and international migration, it is important to understand the subtle morphological variation existing in a given ethnic population set. Implant designs and measurements are generalized by extrapolating data of the Western population set. Our study aims to determine variation in anthropological data of a specific South Indian population set with the help of CT imaging technique such that the knowledge inferred from this can be used to design better-fitting implants that match the native bone geometry. The data from this study could help surgeons restore the normal biomechanics of the native hip joint during hip surgery.
Femoral head diameter
A correlation has been reported between FHD and height of the person [Figure 1]. In our study, we measured the FHD and compared it to various other studies conducted in India as well as different ethnic population subsets of the Western countries. It was found that the mean FHD in our research is 40.09 ± 3.72 mm [Table 1]. Rubin et al., Mahaisavariya et al., Lin et al., and Noble et al. studied the Swiss, Thai, Taiwanese, and the Caucasian population and found the mean FHDs to be 43.4 ± 2.6, 43.98 ± 3.47, 45.41 ± 3.20, and 45.9 mm, respectively. This allows the authors to conclude that Indian hip joints are significantly smaller in size when compared to European or Caucasian population subsets [Table 2].
|Table 1: Standard values obtained from our study in South Indian population|
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Studies conducted by Rawal et al., Siwach and Dahiya, and Roy et al. revealed that the mean FHDs in the North Indian population are 45.41 ± 3.36, 43.53 ± 3.4, and 45.41 ± 3.36 mm, respectively [Table 2]. This allows us to conclude that the FHDs are larger in the North Indian population compared to the South Indian population. Another study done on 400 South Indian hip joints by Sengodan et al. revealed that the mean FHD in their study was 42.6, which was comparable to our results. This study provides additional evidence of variation in the size of the North Indian and South Indian population subsets.
Asala et al. studied 504 Nigerian hip joints and reported significantly higher FHD in males compared to the females. Sengodan et al. reported a statistically significant (P < 0.01) higher FHD in males compared to females in their study of the South Indian hip joints, but there was no significant variation in the FHD of the right hip joint compared to the left. The FHD of the male hip joint (42.48) was significantly (P < 0.01) larger than that of the female hip joint (37.39) in our study as well [Table 3] and [Table 4]. Our investigation revealed that the mean FHD of the left hip joint (40.26) was higher than the right hip joint (39.92) [Table 5].
|Table 3: Anthropometric analysis of hip joint parameters in study population using paired t test|
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|Table 4: Gender and Side wise comparison of study parameters with overall population values|
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|Table 5: Comparison of present study parameters with results of other published studies|
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The FHD is of clinical significance when it involves designing an implant for total hip arthroplasty as a larger FHD of the implant prevents dislocation and reduces long-term morbidity postsurgery. The functional significance is that it helps displace the femoral shaft from the joint to a greater extent such that the range of mobility is not restricted.
Femoral neck width
In our study, the NW measured 28.29 mm [Figure 2], with a standard deviation (SD) of 3.44 mm [Table 1]. Ravichandran et al. studied the cadaveric femur and reported the mean NW to be 30.99 mm. Sengodan et al. reported the mean NW to be 27.5 mm, which is comparable to our study [Table 2]. The male hip joints in our study showed a significantly higher NW compared to females by 4.61 mm [Table 3] and [Table 4]. A similar variation was observed by Sengodan et al. with a gender variation in NW by 2.8 mm. There was no significant variation in NW between the right and left hip joints [Table 5]. The femoral NW has a clinical significance in predicting future risk of hip fractures in men and women. In our study, there was a statistical difference between NWs in men and women. This is of clinical significance because it was found that a cross-sectional moment of inertia, which is an index of bone rigidity, was declining in women at a much faster pace when compared to men. The net effect of this is that the mechanical stresses encountered by the femoral neck appear to increase three times per decade when compared with that of men. Hence, one of the factors of a higher fracture rate in women could be due to the aforementioned reason as well as lack of compensation through geometrical remodeling.
Gómez Alonso et al. and Gnudi et al. studied that the NSA is an essential predictor of hip fracture risk. Tuck et al[Figure 3]. studied the UK population and found that the female hip joint NSA was significantly lesser than that of males. They also correlated the NSA with vertebral fractures and distal forearm fractures and found that the mean NSA was considerably smaller in patients with vertebral fractures and larger in distal forearm fractures. Their analysis confirmed that the NSA was an essential predictor of hip joint injury.
Hoaglund and Low  reported that the average neck-shaft angle in adults is 135° among the Hong Kong population subset. Lin et al. studied 100 CT scans of the hip joints of Taiwanese people and reported the mean NSA to be 129.88 ± 5.76. Jiang et al. studied 466 CT scans of the Chinese population and published the mean NSA to be 133.02 ± 4.49. Mahaisavariya et al. studied 108 hip joints of the Thai community and found the mean NSA to be 128.04 ± 6.14. In our study, the mean neck-shaft angle was 130.68 ± 5.35, which is comparable to the East Asian population [Table 2].
Studies were done in the North Indian population by Rawal et al. (124.42 ± 5.49) and Roy et al. which demonstrated a lower mean NSA when compared to the South Indian population. One study of the North Indian community done by Saikia et al. revealed a higher mean NSA of 139.5 ± 7.5 when compared to our review of the South Indian population. Studies done in the South Indian community by Sengodan et al. reported the mean NSA of 135.4° [Table 2]. Our investigation revealed a lower mean NSA of 130.68 ± 5.35.
Rubin et al. (122.9 ± 7.6), Husmann et al. (129.2 ± 7.8), Noble et al. (125.4), and Tuck et al. (128 ± 1.7 in females and 130 ± 3.3 in males) studied the Swiss, French, Caucasian, and British populations, respectively, and the mean NSA was lower than the mean NSA of our study [Table 2]. Nelitz et al. reported that the mean NSA in the German population was 137.3 ± 9.0. Lequesne et al. published that the mean NSA in the French population was 132.83 ± 4.37. Boese et al. studied 800 German hip joints and reported the mean NSA to be 19.6 in males and 131.9 in females. Jalali Kondori et al. studied 260 hip joints of the Iranian population and reported the mean NSA to be 139.5. These studies revealed a higher mean NSA compared to the NSA in the South Indian population. The above results make it almost impossible to predict whether a particular ethnic group is susceptible to hip fractures. East Asians, in general, have lower NSA like the South Indian population, and it can be inferred that these population subsets are at high risk for hip fractures.
In a study conducted by Gnudi et al., it was found that females with a lower femoral neck bone mineral density and higher neck-shaft angle were more prone to hip fractures. Thus, a radiographic analysis of the neck-shaft angle can be used as a predictor of hip fractures. However, in our study, there was no statistically significant difference in the mean NSA between males and females. However, there was a significantly (P < 0.01) higher mean NSA of the left hip joint (131.80) compared to the right hip joint (129.56). Sengodan et al. similarly reported a significantly higher NSA in the left hip joint compared to the right by 1.6°. They also published a higher NSA in males compared to females by 2.6°.
A study correlating neck-shaft angle and hip fractures in males could be useful in helping us understand the predictability of hip fractures. It was also found in a study that an increase in 1 SD of NSA increased the odds ratio of developing a hip fracture in the future by 2.45 in men and 3.48 in women. Jiang et al. described that the NSA decreases with age due to a decrease in areal bone mineral density (aBMD). As the aBMD declines with age, the support strength of the proximal femur decreases. Wang et al. studied that the deterioration of aBMD without an inadequate compensatory change in the proximal femur geometry led to an increased risk of hip fractures in the elderly population and possibly in females as well.
Horizontal and vertical offsets
In our study, we compared the HO and VO [Figure 4] and [Figure 5] to various other studies conducted. The mean value of the HO in our study population was 36.50, with a CI of 35.70–37.29 [Table 1]. The mean value of HO in males was 37.93 and was significantly higher (P < 0.01) than HO in females (34.88) [Table 3] and [Table 4]. The HO was significantly (P < 0.01) higher in the right hip joint compared to the left [Table 5]. Other studies have not reported a significant side-based difference in HO. Gender-based differences in HO was observed by Sengodan et al. They studied a difference of 4 mm in the HO in between males and females compared to 3-mm gender-based difference in our study [Table 2].
We found that HO was lower in our study (36.50 ± 3.98) when compared to studies conducted by Rawal et al. (40.23 ± 4.85), Rubin et al. (47 ± 7.2), and Husmann et al. (40.5 ± 7.5). However, our results were comparable to Sengodan et al. who also studied the South Indian population and found the mean HO to be 37.6 mm. The normal range of HO is 41–44 mm and increases as the size of the femur increases. This further highlights the significant difference in the HO of the South Indian population from the other ethnic subsets around the world.
HO is of clinical significance as it helps improve abductor muscle strength,, reduces the need for crutches, reduces the chances of limping, enhances the range of motion, and reduces the chances of dislocation of the implant post-THA., Hence, femoral offset restoration is an essential part of THA. It can also be used to accurately measure the medullary canal width, which may be of use while designing implants.
The mean VO measured in our study was 49.20 ± 6.67 mm [Table 1]. The VO in our study was lower than that reported by Rawal et al. (52.33 ± 7.9), Rubin et al. (56.1 ± 8.2), and Husmann et al. (57.3 ± 8.1). However, Sengodan et al. (46.89) and Mahaisavariya et al. (48.94 ± 4.95) reported lower values of VO compared to our study [Table 2]. The knowledge of VO is important during THR to restore limb length. The normal hip biomechanics can be restored only when a normal vertical and HO are maintained during surgery. Sengodan et al. reported a significantly higher (P < 0.01) VO in males compared to females, which was concurrent with our results. In our study, male hip joints demonstrated a mean VO of 52.42 and females a mean VO of 45.56 [Table 3] and [Table 4]. There was no significant variation in the VO of the right hip joint compared to the left [Table 5].
Medullary canal diameter
The medullary canal diameter [Figure 6] computed in our study was 26.14 ± 4.32 mm, which was lower when compared to a survey conducted by Rubin et al. (27.9 ± 3.6) [Table 2]. However, Sengodan et al. reported a mean medullary canal diameter of 20.2. This probably provides evidence that South Indian femurs are narrower compared to the other ethnic subsets. There was no statistical difference in the medullary canal diameter between the right and left proximal femurs. There was no statistically significant variation of the medullary canal diameter between the male and female hip joints as well. This was concurrent with the findings of Sengodan et al.
Acetabular angle and version
The AA [Figure 7] of sharp is the most crucial indicator in the diagnosis of dysplasia of the acetabulum. An angle of more than 43° is considered dysplastic. The AA measured in our study was 37.50 ± 3.57. However, this was lower when compared to a survey conducted by Saikia et al., which was 39.2 ± 4.9. Jalali Kondori et al. described the mean AA in the Iranian population to be 37.1° which was comparable to our study. We observed the significantly higher AA (P < 0.01) in male hip joints compared to females. On the contrary, studies in German, British, Serbian, Malawian, and South Asian  populations reported higher AA than our study [Table 2]. These studies also reported higher AA in female hip joints compared to males. Studies in the Nigerian  and Korean  populations reported a mean AA comparable to our study. Oladipo et al. studied the Nigerian hip joints and reported a higher AA in the left compared to the right in both males and females. On the contrary, we found the AA of the right hip joint to be higher than the left by 0.48° (P = 0.20).
The center-edge angle is closely related to the AA. It has been found that a center edge angle fewer than 20° is associated with acetabular hip dysplasia; in turn, acetabular hip dysplasia is a factor in the causation of osteoarthritis of the hip. However, there are also some studies that disprove the hypothesis and say that the relationship is irrelevant.
Jiang et al. studied that AV [Figure 8] and NSA were two crucial indicators of proximal femoral geometry. AV is essential to describe the orientation of the acetabulum during the insertion of the cup in the right position during THR. Variations from the standard values predispose the patient to various hip disorders such as femoral-acetabular impingement (FAI), osteoarthritis of the hip, and fractures around the hip joint. This supports the evidence that identification of normal values of NSA and AV in a defined population and the various influencing factor is instrumental in issuing treatment protocols of the conditions above.
Stem et al. reported that an increase in acetabular version >70 years of age rendered the patient vulnerable to osteoarthritis of the hip joint. Pincer-type FAI was studied to be associated with acetabular retroversion, which is usually seen in females. This could also explain why females were susceptible to pincer-type FAI. This, however, is not the only explanation for the higher incidence of pincer FAI in females. Our also study showed that the AV was significantly higher (P < 0.01) in females compared to males by 3.1° which supports the above hypothesis [Table 3] and [Table 4].
The normal AV measured is 17°, with a SD of 6°. The AV measured in our study was 20.91 ± 4.33. This value was significantly higher when compared to the survey conducted by Saikia et al., which was 18.2 ± 5.6. Various studies have shown that there is a wide variation in the AV in the Indian population, and one hypothesis suggested that such a large difference could be due to evolutionary reasons as Indians are more accustomed to floor-level activities with the increased external rotation of the hip.
Our study also showed a higher AV in females (22.56) compared to males (19.46). Jiang et al. found a similar gender-based variation of the AV, being higher in females (20.25 ± 5.28) compared to males (17.88 ± 5.07) in the Chinese population. Sengodan et al. reported a higher AV in women compared to men by 1.6°, which was not significant. Murphy et al. also published a significantly higher AV in females compared to males by 5° in the American population. Zeng et al. reported a higher AV of the left hip joint in males compared to females by 0.5°. However, in their study of the right hip joint, they observed higher AV in females compared to males by 2.1°. Tallroth et al. studied Finnish hip joints and found a significantly higher AV in males compared to females by 6°.
We observed a statistically significant higher AV (P < 0.01) of the left hip joint compared to the right by 1.41°. Sengodan et al. reported a similar significant higher AV (P < 0.01) in the left hip joint compared to the right by 1.2°.
| Conclusion|| |
Morphology of the hip varies with different ethnic population groups. Our study demonstrated that the South Indian population has a significantly smaller FHD and offsets, narrower NW, and medullary canal diameter when compared to other ethnic population groups. The neck-shaft angle was comparable to results from other studies. Male hip joints demonstrated a larger head diameter, NW, and horizontal and VOs compared to females in our study. Females, however, demonstrated a larger AV angle compared to males. The neck-shaft angle and AV were significantly higher in the left hip joints compared to the right, and HOs showed similar results. This study confirms significant variations in morphometry of the hip joint of the South Indian population.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]