Radiographic markers of acetabular retroversion : Correlation of the cross-over sign, ischial spine sign and posterior wall sign

Published online: Apr 27 2010

Clément M.L. Werner, Carol E. Copeland, Thomas Ruckstuhl, Jeff Stromberg, Clifford H. Turen, Fabian Kalberer, Patrick O. Zingg

From the R Adams Cowley Shock Trauma Center, University of Maryland Medical Systems, Baltimore, U.S.A.


Radiological diagnosis of acetabular retroversion is based on the presence of the cross-over sign (COS), the posterior wall sign (PWS), and prominence of the ischial spine (PRISS). The primary purpose of the study was to correlate the quantitative cross-over sign with the presence or absence of the PRISS and PWS signs. The hypothesis was that both, PRISS and PWS are associated with a higher cross-over sign ratio or higher amount of acetabular retroversion. A previous study identified 1417 patients with a positive acetabular cross-over sign. Among these, three radiological parameters were assessed : (1) the amount of acetabular retroversion, quantified as a cross-over sign ratio ; (2) the presence of the PRISS sign ; (3) the presence of the PWS sign. The relation of these three parameters was analysed using Fisher's exact test, ANOVA, and linear regression analysis. In hips with cross-over sign, the PRISS was present in 61.7%. A direct association between PRISS and the cross-over sign ratio (p < 0.001) was seen. The PWS was positive in 31% of the hips and was also significantly related with the cross-over sign ratio (p < 0.001). In hips with a PRISS, 39.7% had a PWS sign, which was a significant relation (p < 0.001). In patients with positive PWS, 78.8% of the cases also had a PRISS (p < 0.001). Both the PRISS and PWS signs were significantly associated with higher grade cross-over values. Both the PRISS and PWS signs as well as the coexistence of COS, PRISS, and PWS are significantly associated with higher grade of acetabular retroversion. In conjunction with the COS, the PRISS and PWS signs indicate severe acetabular retroversion. Presence and recognition of distinct radiological signs around the hip joint might raise the awareness of possible femoroacetabular impingement (FAI).