BackgroundPlacement of femoral stem in excessive anteversion or retroversion can cause reduced range of motion, prosthetic impingement, and dislocation. The aim of this study was to assess the operative femoral anteversion in patients treated with total hip arthroplasty (THA) and analyze the need of adjusting stem anteversion.MethodsWe retrospectively included 101 patients (126 hips) who underwent cementless THA with a manual goniometer to determine the femoral anteversion between October 2017 and December 2018. The operative femoral anteversion we measured was recorded during THA. We further divided those hips into three subgroups based on the range of operative femoral anteversion: group 1 (<10°), group 2 (10–30°), and group 3 (>30°) and compared the differences of their demographic data. Univariate and multivariate logistic regression were used to identify the influencing factors for the need of neck-adjustable femoral stem. The clinical and radiographic outcomes were also assessed. Perioperative complications were recorded.ResultsAfter THA, the Harris hip scores improved from 52.87 ± 15.30 preoperatively to 90.04 ± 3.31 at the last follow-up (p < 0.001). No implant loosening, stem subsidence, and radiolucent lines were observed on radiographs. No severe complications occurred and no components needed revision at the latest follow-up. The mean operative femoral anteversion was 14.21° ± 11.80° (range, −9 to 60°). Patients with femoral anteversion more than 30° were about 10 years younger than others. Femoral anteversion >30° was more common in patients with developmental dysplasia of the hip (DDH). There were totally 14 hips treated with the neck-adjustable femoral stem. From the univariate analysis, we can observe that female sex, diagnosis of DDH (compared with osteonecrosis), and higher operative femoral anteversion and its value >30° (compared with <10°) are associated with higher rates of using the neck-adjustable femoral stem. However, all these factors were no longer considered as independent influencing factors when mixed with other factors.ConclusionsThis study highlighted the significance of operative femoral anteversion. Identification of abnormal femoral anteversion could assist in adjusting stem anteversion and reduce the risk of dislocation after THA.