Femoral Anteversion In Patients Research Articles

Changes in femoral anteversion after intramedullary nailing for pediatric femoral shaft fracture: a multicenter study

BackgroundThe rotational change after using a flexible intramedullary (IM) nail for femoral shaft fractures has been a concern for many surgeons. Recently, a statistical shape model (SSM) was developed for the three-dimensional reconstruction of the femur from two-dimensional plain radiographs. In this study, we measured postoperative femoral anteversion (FAV) in patients diagnosed with femoral shaft fractures who were treated with flexible IM nails and investigated age-related changes in FAV using the SSM.MethodsThis study used radiographic data collected from six regional tertiary centers specializing in pediatric trauma in South Korea. Patients diagnosed with femoral shaft fractures between September 2002 and June 2020 and patients aged < 18 years with at least two anteroposterior (AP) and lateral (LAT) femur plain radiographs obtained at least three months apart were included. A linear mixed model (LMM) was used for statistical analysis.ResultsOverall, 72 patients were included in the study. The average patient age was 7.6 years and the average follow-up duration was 6.8 years. The average FAV of immediate postoperative images was 27.5 ± 11.5°. Out of 72 patients, 52 patients (72.2%) showed immediate postoperative FAV greater than 20°. The average FAV in patients with initial FAV > 20° was 32.74°, and the LMM showed that FAV decreased by 2.5° (p = 0.0001) with each 1-year increase from the time of initial trauma.ConclusionsThis study explored changes in FAV after femoral shaft fracture using a newly developed technology that allows 3D reconstruction from uncalibrated 2D images. There was a pattern of change on the rotation of the femur after initial fixation, with a 2.5° decrease of FAV per year.

Correlation of Tibial Torsion With Lower Limb Alignment and Femoral Anteversion in Patients With Patellar Instability.

Alignment and rotation of the lower extremities have been suggested to be predisposing pathologic factors for patellar instability. To elucidate the relationship between the lower limb alignment and lower extremity rotation in patients with patellar instability. Cross-sectional study; Level of evidence, 3. Included were 83 patients with patellar instability. Computed tomography scans and standing full-leg radiographs were used to measure the tibial tuberosity-trochlear groove (TT-TG) distance, mechanical femorotibial angle (mFTA), mechanical lateral distal femoral angle (mLDFA), mechanical medial proximal tibial angle (mMPTA), femoral torsion, and tibial torsion of the different segments. The relationships between femoral torsion, tibial torsion of the different segments, and the mFTA, mLDFA, and mMPTA were evaluated. The levels of tibial torsion and femoral torsion in patients with varus, normal, or valgus alignment were compared with 1-way analysis of variance and chi-square test. The total tibial torsion was significantly associated with total femoral anteversion (r = 0.329; P = .002) and mFTA (r = -0.304; P = .005). There were no significant correlations between mFTA and TT-TG distance or femoral anteversion. Compared with patients with valgus malalignment, patients with varus malalignment tended to have higher tibial torsion. Tibial torsion was associated with leg axis alignment and femoral anteversion in patients with patellar instability. Patients with patellar instability, especially those with concurrent leg axis deformities, should undergo further radiological imaging so that tibial torsion can be assessed and a diagnosis of torsion deformity made early in the treatment pathway and the proper surgical plan formulated.

Abnormal Spinopelvic Motion and Spine Deformity are Associated With Native Femoral Retroversion in the Setting of Total Hip Arthroplasty

BackgroundThe effect of spinopelvic pathology on femoral version is unclear. This study investigated variability in native femoral anteversion in patients undergoing total hip arthroplasty (THA) and its relationship to the patient’s underlying spinopelvic pattern. MethodsA retrospective chart review was performed to include in the study all patients undergoing robot-assisted THA over a 3-year period. Native femoral version was measured for each patient using a preoperative computed tomography scan and categorized as excessive, normal, or retroverted. Additionally, a subset analysis was performed for all patients with sit-to-stand dynamic pelvic radiographs available, and cases were classified by spinopelvic pattern. ResultsA total of 119 patients were included in the study with a mean age of 68.6 years; 61 (51%) were female. The median femoral anteversion for the entire study group was 6.0° (−32° to 40°, interquartile range 13.5°). Eleven patients (9.2%) had excessive femoral anteversion, 54 of the 119 (45.4%) had normal femoral version, and 54 of the 119 (45.4%) had native retroversion. Forty-two patients (35.3%) had sit-to-stand radiographs available and were subclassified by femoral version type and spinopelvic parameters. Welch’s analysis of variance demonstrated a significant difference in femoral version among spinopelvic patterns (F = 7.826, P = .003), with Games-Howell post hoc analysis showing increased retroversion in deformity-stiff patients compared to deformity-normal mobility patients (P = .003). ConclusionsThis study demonstrates that native femoral retroversion is present in a significant number of patients undergoing THA and is more common in patients with stiff spine deformities. Based on this observation, currently available spinopelvic classification systems should be modified to account for native femoral version.

A new factor predicting excessive femoral anteversion in patients with recurrent patellar dislocation

PurposeDetermining a new imaging method on full-leg standing lower limb radiographs to predict excessive femoral anteversion in patients with patellar dislocation.MethodsThis study included 119 patients with patellar dislocation from January 2014 to January 2021. The femoral anteversion and tibial torsion were measured by CT scanning. The medial condylar angle was measured by the full-leg standing lower limb radiographs. Pearson correlation coefficient was used to evaluate the correlation between rotation parameters and medial condylar angle.ResultsIncluded patients were divided into DFO group and control group according to whether they received derotational femoral osteotomy (DFO) operation or not. DFO group had significantly higher femoral anteversion (29.8° ± 7.2° vs 23.1° ± 6.5°, P < 0.05), higher tibial torsion (28.6° ± 6.9° vs 24.7° ± 7.9°, P < 0.05), lower medial condylar angle (154.8° ± 4.7° vs 157.5° ± 6.7°, P < 0.05) than control group. Correlation analysis showed that the values of femoral anteversion were significantly correlated with medial condylar angle (r = -0.719, P < 0.001).ConclusionThis study showed that medial condylar angle had a negative correlation with excessive femoral anteversion on the full-leg standing lower limb radiographs. The medial condylar angle can be a good predictor of femoral anteversion and can be used to guide the performance of DFO to treat patellar dislocation in clinical practice.

FACTORS AFFECTING MORBIDITY IN CHILDREN WITH CEREBRAL PALSY SEQUELAE WHO UNDERWENT CORRECTIVE OSTEOTOMY

Objective: Cerebral palsy (CP) is a neurodevelopmental disease characterized by movement and posture disorders due to non-progressive damage. Femur varization-derotation osteotomy is a surgical procedure performed to correct femoral anteversion in patients with CP. The aim of this study is to determine the factors affecting morbidity in children with CP sequelae who underwent corrective osteotomy. Materials and Methods: Children with CP sequelae who underwent correction osteotomy were included in the study between 2007 and 2020. Information about the patients was obtained from the archived files and evaluated retrospectively. 105 patients were divided into two groups according to the perioperative morbidity: Group 1 (no morbidity) including 62 patients and group 2 (presence of morbidity) including 43 patients. Results: We did not report any significant differences between group 1 and 2 in terms of age and body mass index. In Group 2, ASA scores were higher significantly (p=0.006). Prognostic nutritional index was significantly lower in Group 2 (p=0.001). There was no significant difference in length of hospital and intensive care unit stay. Conclusion: Malnutrition is an important factor that causes an increase in postoperative morbidity in pediatric patients with CP sequelae. In patients with CP sequelae planned for varization-derotation osteotomy, a treatment plan can be prepared on a patient basis to reduce postoperative morbidity.

Retraction: Differences between the Craig's test and computed tomography in measuring femoral anteversion in patients with anterior cruciate ligament injuries.

[This retracts the article on p. 365 in vol. 32 PMCPMC7276780.].

Measurement of operative femoral anteversion during cementless total hip arthroplasty and influencing factors for using neck-adjustable femoral stem

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.

Malalignment sign on knee magnetic resonance imaging: a new predictor for excessive femoral anteversion in patients with patellar dislocation.

To evaluate the clinical relevance of the newly identified malalignment sign in predicting excessive femoral anteversion in patients with patellar dislocations. A total of 55 patients with patellar dislocation who underwent surgical treatment between 2016 and 2019 were included in this study. Femoral anteversion, tibial torsion, and the femorotibial index were measured via a CT scan. The malalignment sign on the knee MRI was defined as a malalignment between the lateral side of the intercondylar fossa of the femur and the lateral intercondylar eminence of the tibial plateau. A positive malalignment sign was observed in 36 of the 55 patients. Increased femoral anteversion was significantly correlated with the number of frames with a positive malalignment sign (r = 0.511, P < 0.001). The value of femoral anteversion was significantly greater in the group with a positive malalignment sign (P = 0.02). For a femoral anteversion value of 32°, the sensitivity and specificity of the malalignment sign reached the maximal level of 89.5% and 47.2%, respectively. Increased femoral anteversion correlated significantly with a positive malalignment sign on knee MRI. However, tibial torsion did not affect the malalignment sign. A positive malalignment sign is evidence for femoral derotation osteotomy. Level IV.

Retraction: Differences between the Craig’s test and computed tomography in measuring femoral anteversion in patients with anterior cruciate ligament injuries

[Purpose] This study aimed to compare the Craig’s test and computed tomography (CT) in measuring the femoral anteversion angle (FAA) in patients with anterior cruciate ligament (ACL) injuries. The relationship between the FAA measured on CT, and the range of axial rotation of the hip joint and muscle tightness around the hip joint was also investigated. [Participants and Methods] Twenty-six patients who received CT examination within 3 months after ACL reconstruction were enrolled in this study. The Craig’s test, internal and external rotation of the hip, the Ely test, Ober’s test, and FAA on the CT were assessed. [Results] The FAA on the Craig’s test and CT in female patients was 24.3 ± 3.9° and 23.0 ± 10.3°, respectively on the uninjured side and 25.0 ± 5.2° and 20.3 ± 11.2°, respectively on the injured side, indicating no significant correlation between the 2 measurement techniques. In contrast, the FAA on the CT was significantly correlated with the range of internal rotation of the hip, which was 40.5 ± 6.1° on the uninjured side and 37.8 ± 5.6° on the injured side. [Conclusion] The results suggest that measuring the internal hip rotation range rather than the Craig’s test, provides more reliable estimates of the magnitude of FAA, and may help to evaluate the risk of ACL injuries in female athletes.

Development and Validation of a Mobile Application for Measuring Femoral Anteversion in Patients With Cerebral Palsy.

Computed tomography (CT) provides benefits for 3-dimensional (3D) visualization of femur deformities. However, the potential adverse effects of radiation exposure have become a concern. Consequently, a biplanar imaging system EOS has been proposed to enable reconstruction of the 3D model of the femur. However, this system requires a calibrated apparatus, the cost of which is high, and the area occupied by it is substantial. The purpose of this study was to develop a mobile application that included a new method of 3D reconstruction of the femur from conventional radiographic images and to evaluate the validity and reliability of mobile the application when measuring femoral anteversion. The statistical shape model, graph-cut algorithm, and iterative Perspective-n-Point algorithm were utilized to develop the application. The anteroposterior and lateral images of a femur can be input using the embedded camera or by file transfer, and the touch interface aids accurate contouring of the femur. Regarding validation, the CT scans and conventional radiographic images of 36 patients with cerebral palsy were used. To evaluate concurrent validity, the femoral anteversion measurements on the images reconstructed from the mobile application were compared with those from the 3D CT images. Three clinicians assessed interobserver reliability. The mobile application, which reconstructs the 3D image from conventional radiographs, was successfully developed. Regarding concurrent validity, the correlation coefficient between femoral anteversion measured using 3D CT and the mobile application was 0.968 (P<0.001). In terms of interobserver reliability, the intraclass correlation coefficient among the 3 clinicians was 0.953. The measurement of femoral anteversion with the mobile application showed excellent concurrent validity and reliability in patients with cerebral palsy. The proposed mobile application can be used with conventional radiographs and does not require additional apparatus. It can be used as a convenient technique in hospitals that cannot afford a CT machine or an EOS system. Level III-diagnostic.

Association of Femoral Trochlear Dysplasia and Tibiofemoral Joint Morphology in Adolescent.

BackgroundTrochlear dysplasia (TD) often leads to anatomic variations of the knee. Little is known about the association of TD and tibiofemoral joint morphology in adolescent.Material/MethodsComputed tomography scans of 35 knees with TD and 55 knees with well-developed patella-femoral joint were analyzed randomly and retrospectively. Two researchers evaluated the posterior tibial slope (PTS), distal femoral rotation, proximal tibia varus angle, and femoral anteversion between the 2 groups. The independent Student’s t-test was used to evaluate the statistical significance of variables.ResultsThe study group had a smaller lateral PTS (4.7±2.97) than the control group (6.96±3.05) (P<0.01), while the medial PTS showed consistent values between the control and the study group (non-significant). Patients with TD had smaller external rotation of the distal femur (2.69±0.93) compared to the control group (3.77±1.46) (P<0.01). In addition, the study group showed a bigger proximal tibia varus angle (4.46±1.09) compared to the control group (3.35±0.76) (P<0.01). The femoral anteversion in the study group (17.46±9.95) was increased compared to the control group (12.22±5.39) (P<0.01). The femoral anteversion and distal femoral rotation in patients with TD showed a positive correlation (r2=0.326; P<0.001).ConclusionsPatients with TD had flatter lateral PTS compared to those without TD, but there were no differences in the medial PTS between the two groups. Patients with TD had smaller distal femoral rotation and bigger proximal tibia varus angle. The femoral anteversion in patients with TD was bigger than those without TD,and there was a positive correlation between the femoral anteversion and the external rotation of the distal femoral in the study group.

Calculation and evaluation of angle of acetabular anteversion in normal healthy Indian population

Studies have been carried out regarding the acetabular and femoral anteversion in patients with developmental dysplasia of hip. However, definitive criteria/measurements regarding the normal angle of acetabular anteversion in asymptomatic patients is lacking. In our study, angle of anteversion of the acetabulum was determined by use of computed tomography in 200 asymptomatic Indian adults. The overall normal anteversion of the acetabulum was found to be 16.43+6 0 (mean + standard deviation) with no significant sex related difference. Slight age related increase in the angle of acetabular anteversion was observed.

Distal femoral derotational osteotomy with external fixation for correction of excessive femoral anteversion in patients with cerebral palsy.

Patients with cerebral palsy (CP) disorder often develop rotational hip deformity. Increasing deformities impair already diminished walking abilities; femoral osteotomies are often performed to maintain and improve walking abilities. Fixation of osteotomies with condylar plates has been used successfully, but does not often enable immediate postoperative full weight-bearing. To avoid considerable postoperative rehabilitation deficit and additional bone loss because of inactivity, a postoperative treatment with full weight-bearing, is therefore, desirable. Self-tapping Schanz screws with a unilateral external fixator crossing the knee joint providing stronger anchoring in osteopenic bone might fulfill these demands. A retrospective study was carried out on 27 ambulatory CP patients, mean age 17.5 years (range 9-22 years); 11 patients with bilateral severe intoeing deformities underwent a supracondylar femoral osteotomy between September 2008 and April 2012. All patients were allowed to bear their full weight postoperatively. The aim of this study was to describe the technique, the results of this technique, to evaluate the time required for bone healing, and the type of complications associated with a distal derotational femoral osteotomy fixed with a uniaxial external fixator crossing the knee joint. A total of 27 patients were studied [mean weight 48.8 kg (range 29.8-75 kg)]. The mean preoperative rotation included internal rotation of 69° and external rotation of 17°. All patients were evaluated clinically and radiographically for a minimum of 1 year after surgery. There was a significant decrease in the mean medial rotation from 69° to 32° (P=0.00034). The lateral rotation increased significantly from preoperative 17° to postoperative 45° (P=0.0011). The femoral anteversion decreased significantly from a mean of 55° preoperatively to a mean 17° postoperatively (P=0.030). All patients, except one, achieved solid fusion uneventfully. One patient was a 16-year-old female who had sustained a knee flexion contracture of 30° because of a delay in the physiotherapy program. One 13-year-old female patient with a bilateral osteotomy had a nondisplaced fracture in her right femur after a direct trauma 2 weeks after removal of an external fixator, and was treated by a cast. Another 17-year-old male patient developed a nonunion because of loosening of two pins and achieved solid union after revision by dynamic compression plate plating. Besides four cases with superficial pin-tract infection, no other complications were documented. Minimally invasive supracondylar femoral derotational osteotomy fixed with a unilateral external fixators crossing the knee joint is a reliable procedure in CP patients. Most patients can be treated with early postoperative full weight-bearing. However, removal of the knee joint crossing fixator should be performed as early as possible to achieve a full range of motion.

Three-dimensional computed tomography for determination of femoral anteversion in a cerebral palsy model.

Previous investigation has proven 3-dimensional (3D) computed tomography (CT) to be a poor method of assessing femoral anteversion in patients with cerebral palsy. However, new advancements in CT software yield the potential to improve upon those dated results. CT was performed on 9 femoral models with varying amounts of anteversion (20 to 60 degrees) and varying neck-shaft angles (120 to 160 degrees). Each model was scanned in 2 holding devices. One holder placed the femur in an ideal position relative to the gantry. The other placed the femur in flexion, adduction, and internal rotation simulating a common lower extremity posture in cerebral palsy. Femoral anteversion was measured on 3D reconstructions by 4 observers on 2 separate occasions. Interobserver and intraobserver reliability, accuracy, and the effect of increasing neck-shaft angle of the measurements were examined and compared with previously published data using the same models. Pearson correlation coefficients between first and second measurements by the same examiner were all above 0.96 regardless of positioning of the femur in the gantry. The correlation coefficients among all examiners were 0.97 regardless of positioning of the femur in the gantry. Accuracy in measurements was comparable using 3D CT techniques with mean differences between the normal and cerebral palsy-positioned models of <3.6 degrees (SD, 3.1 to 3.3 degrees). Accuracy of the study's 3D CT technique in measuring femoral anteversion in cerebral palsy-positioned femurs was significantly more accurate than that of 2D CT (P<0.0001). Recent improvements in processing software and 3D reconstruction have made assessment of femoral anteversion with 3D CT accurate through the studied range of anteversion and neck-shaft angles. Using this technique, high intraobserver and interobserver reliability in the determination of femoral anteversion can be expected regardless of neck-shaft angle or postural deformity. Level II.