Background: Three-dimensional (3D) acetabular orientation is a +/- fundamental topic in orthopedic surgery. Computed tomography (CT) allows 3D measurement of native acetabular orientation, but with a substantial radiation dose. The EOS imaging system was developed to perform this kind of evaluation, but has not been validated in this indication with specific attention to the acetabulum. We therefore performed a prospective study using EOS to assess: (1) the reproducibility of the 3D acetabulum orientation measures; (2) normative asymptomatic acetabular morphology in standing position, according to side and gender; and (3) the relationship between acetabular anteversion and pelvic incidence. Hypothesis: The low-doseEOS imaging system is a reproducible method for measuring 3D acetabular orientation in standing position. Patients and methods: In a previous prospective study of spine sagittal balance, 165 asymptomatic volunteers were examined on whole-body EOS biplanar X-ray; 102 had appropriate images for pelvic and acetabular analysis, with an equal sex-ratio (53 female, 49 male). These EOS images were reviewed using sterEOS 3D software, allowing automatic measurement of acetabular parameters (anteversion and inclination) and pelvic parameters (pelvic incidence, pelvic tilt and sacral slope) in an anatomical (anterior pelvic plane: APP) and a functional reference plane (patient vertical plane: PVP). Results: Both intra-and inter-observer analysis showed good agreement (ICC >0.90); Bland-Altman plot distributions were good. Acetabular anatomical anteversion and inclination relative to APP (AAAPP and AIAPP, respectively) were significantly greater in women than in men, with no effect of side (right AAA: women 21.3 degrees +/- 3.4 degrees vs. men 16.1 degrees +/- 3.3 degrees (P < 0001); right AIAPP: women 55.3 +/- 3.7 degrees vs. men 52.5 degrees +/- 3.0 degrees (P < 0001); left AAAPP: women 20.9 degrees +/- 3.5 degrees vs. men 15.6 degrees +/- 4.0 degrees (P < 0001); left AIAPP: women 54.6 degrees +/- 3.5 degrees vs. men 52.7 degrees +/- 2.8 degrees (P= 0003)). The same differences between men and women were observed when measurements were related to PVP. Pelvic incidence subgroup (62 degrees) correlated significantly with functional acetabular orientation in standing position: PVP functional anteversion decreased by 5 relative to APP anteversion with incidence62 degrees. Discussion: The use of a 3D sterEOS software prototype version for 3D reconstruction of the native acetabulum from standard EOS X-ray was shown to be a reliable and reproducible method. This innovative method enabled the reference values of 3D acetabular orientation in standing position to be measured for the first time. The results reinforced the concept of hip-spine relationships, and involved very low radiation dose. (C) 2016 Elsevier Masson SAS. All rights reserved.