Frontal Plane Deformity Research Articles

Total Knee Arthroplasty Using a Pie-crusting Technique for Valgus Deformity

Valgus deformity correction with total knee arthroplasty is challenging. We hypothesized selective release of the tight lateral structures (pie-crusting technique), and of the lateral retinaculum in case of patellar maltracking, would obtain and maintain correction of the frontal plane deformity, restore patellar tracking and function, and avoid the complications of the extensive releases, including lateral condyle avascularity and residual lateral instability. We followed 48 patients with 53 valgus knees who underwent TKA and were followed a minimum of 5 years (mean, 8 years; range, 5-12 years). Soft tissue balancing of the lateral structures was performed with the pie-crusting technique. We employed either a fixed posterior stabilized or a mobile implant. A lateral release was performed in 67% of the cases. We observed one postoperative complication, a transient postoperative peroneal nerve palsy that spontaneously completely recovered. In 51 of the 53 knees (96%) we achieved alignment within 5 degrees from neutral. One patient had varus instability in extension. No component was revised. The pie-crusting technique reliably corrects moderate to severe fixed valgus deformities with a low complication rate and reasonable mid-term results. The multiple punctures allow gradual stretching of the lateral soft tissues and preservation of the popliteus tendon reducing the risk of posterolateral instability. Level IV, case series. See the Guidelines for Authors for a complete description of levels of evidence.

Correlation of Body Mass Index and Radiographic Deformities in Children with Blount Disease

Background: Children with Blount disease tend to be heavier than their peers; however, the relationship between the magnitude of obesity and the severity of limb deformities in Blount disease has not been well studied. Methods: A retrospective review of the preoperative medical records and radiographs of patients with previously untreated Blount disease was conducted. Demographic information including gender, ethnicity, the age when deformity was first noted, the age at the examination, and the body mass index was recorded. Frontal and sagittal plane deformities were analyzed by one examiner using full-length standing radiographs. The association of body mass index with various demographic and deformity parameters was then analyzed. Results: Over an eight-year period, forty-five patients with sixty-five limbs affected by Blount disease were identified. Seventeen children (twenty-seven limbs) had early-onset Blount disease, and twenty-eight children (thirty-eight limbs) had late-onset disease. Fifteen of the children with early-onset disease and twenty-six of those with late-onset disease were overweight. There was no significant relationship between body mass index and gender, ethnicity, or laterality. The children with early-onset disease tended to have a lower body mass index but a greater magnitude of radiographic deformities compared with the children with late-onset disease. Greater varus malalignment (r = 0.74, p < 0.0001) and tibial procurvatum (r = -0.79, p = 0.002) were noted with an increasing body mass index in the early-onset, but not the late-onset, group of patients. Irrespective of the age at onset, the correlation of body mass index with frontal and sagittal plane deformities was stronger in extremely obese children (body mass index of ≥40). Conclusions: There is a significant relationship between the magnitude of obesity and biplanar radiographic deformities in children with the early-onset form of Blount disease and in those with a body mass index of ≥40. These clinical findings are consistent with the literature concerning the effect of compressive forces on growth at the proximal tibial physis. Level of Evidence: Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.

Correlation of Body Mass Index and Radiographic Deformities in Children with Blount Disease

Children with Blount disease tend to be heavier than their peers; however, the relationship between the magnitude of obesity and the severity of limb deformities in Blount disease has not been well studied. A retrospective review of the preoperative medical records and radiographs of patients with previously untreated Blount disease was conducted. Demographic information including gender, ethnicity, the age when deformity was first noted, the age at the examination, and the body mass index was recorded. Frontal and sagittal plane deformities were analyzed by one examiner using full-length standing radiographs. The association of body mass index with various demographic and deformity parameters was then analyzed. Over an eight-year period, forty-five patients with sixty-five limbs affected by Blount disease were identified. Seventeen children (twenty-seven limbs) had early-onset Blount disease, and twenty-eight children (thirty-eight limbs) had late-onset disease. Fifteen of the children with early-onset disease and twenty-six of those with late-onset disease were overweight. There was no significant relationship between body mass index and gender, ethnicity, or laterality. The children with early-onset disease tended to have a lower body mass index but a greater magnitude of radiographic deformities compared with the children with late-onset disease. Greater varus malalignment (r = 0.74, p < 0.0001) and tibial procurvatum (r = -0.79, p = 0.002) were noted with an increasing body mass index in the early-onset, but not the late-onset, group of patients. Irrespective of the age at onset, the correlation of body mass index with frontal and sagittal plane deformities was stronger in extremely obese children (body mass index of > or =40). There is a significant relationship between the magnitude of obesity and biplanar radiographic deformities in children with the early-onset form of Blount disease and in those with a body mass index of > or =40. These clinical findings are consistent with the literature concerning the effect of compressive forces on growth at the proximal tibial physis. Prognostic Level II.

Comparison of Segmental Pedicle Screw Instrumentation Versus Anterior Instrumentation in Adolescent Idiopathic Thoracolumbar and Lumbar Scoliosis

A retrospective study. To compare the results of anterior instrumentation versus segmental pedicle screw instrumentation in adolescent idiopathic thoracolumbar and lumbar scoliosis. Anterior instrumentation is an established method of correcting adolescent idiopathic thoracolumbar and lumbar scoliosis. Posterior segmental pedicle screw instrumentation, with its more powerful corrective force over hooks, could offer significant advantages. A retrospective analysis was conducted on 36 consecutive female patients with adolescent idiopathic thoracolumbar and lumbar scoliosis who had surgery from December 1997. All had a minimum of 2-year follow-up. Eleven patients had posterior surgery. Mean age at surgery was similar between both groups. Length of surgery was significantly shorter in the posterior group (189 minutes vs. 272 minutes). Length of hospital stay was shorter in the posterior group (6.2 days vs. 8 days). Estimated blood loss, duration of analgesia, and ICU stay did not differ significantly between the 2 groups. No complications were encountered in both groups at the latest follow-up. The magnitudes and flexibility of the thoracolumbar/lumbar curves did not differ significantly between the 2 groups. The number of levels in the major curve was also similar between the groups. Fusion levels were shorter in the anterior group (mean, 4.1 vs. 5.0). The percentage correction of scoliosis was similar between the 2 groups at all stages of follow-up, being 74% at 1 week postsurgery, 70% at 6 months postsurgery, 68% at 1 year postsurgery and latest follow-up for the anterior group, and 71% at 1 week postsurgery, 67% at 6 months postsurgery, 68% at 1 year postsurgery, and 67% at the latest follow-up for the posterior group. Thoracolumbar sagittal alignment at T11-L2 was maintained for both groups throughout the follow-up period. The incidence of proximal junctional kyphosis was higher in the posterior group (P < 0.01). Surgical correction of both the frontal and sagittal plane deformity are comparable to anterior instrumentation. Shorter lengths of surgery and hospital stay are the potential benefits of posterior surgery. Posterior segmental pedicle screw instrumentation offer significant advantages and is a viable alternative to standard anterior instrumentation in idiopathic thoracolumbar and lumbar scoliosis.

Minimum 5-Year Follow-up Surgical Results of Post-traumatic Thoracic and Lumbar Kyphosis Treated With Anterior Instrumentation

A retrospective follow-up study of post-traumatic thoracic and lumbar kyphosis after anterior instrumentation with anterior plate and dual rod systems. To investigate the outcome of anterior vertebrectomy, anterior strut grafting, and anterior instrumentation in patients with > 30 degrees sagittal contour deformity. Post-traumatic kyphosis may lead to mechanical pain due to the impairment of physiologic sagittal contours as well as cosmetic complaints. Forty patients with post-traumatic kyphosis were followed for a minimum of 5 years. Mean age was 44.7 +/- 12.4 years (range, 18-65 years); 18 were female and 22 were male. All patients underwent anterior vertebrectomy and decompression; anterior fusion was carried out with costal or iliac ala grafts. Patients were randomly assigned into 2 treatment groups: correction and internal fixation was performed by using either plate-screw (n = 20) or double rod-screw (n = 20). Patients were also evaluated clinically by using Pain and Functional Assessment Scale (PFA) and SRS-22 questionnaire. Before surgery, the mean value for local sagittal contours was 51.4 degrees +/- 13.8 degrees; after surgery, it was reduced to 7.0 degrees +/- 7.6 degrees, resulting in an 88.7% +/- 11.3% correction (P = 0.00). At the last follow-up visit, a mean correction loss of 1.4 degrees +/- 1.8 degrees was found. A statistically significant improvement in local kyphosis angles and PFA scores was found after surgery and at the last visit. In 92.5% of the patients (n = 36), pain completely resolved; and in the remaining 3 patients, it is markedly reduced. Neurologic improvement was achieved in all of the 24 patients with neural claudication and other neurologic findings. Solid fusion mass was obtained in all patients. The type of instrumentation system did not differ significantly in terms of kyphotic deformity correction rates, correction losses, PFA scores, and SRS-22 scores. Final PFA scores showed a statistically significant correlation with SRS-22 scores (r = -0.918, P < 0.01). Final pain, function, mental status, self image and satisfaction domain scores and total SRS-22 score were > or = 4. The time from trauma to operation and the severity of kyphotic deformity were inversely correlated with postoperative correction rates. On the other hand, these 2 parameters were positively correlated with both final PFA and final SRS-22 scores (P < 0.01). In light of the present study's findings, we suggest that the technique of anterior decompression, strut grafting, and anterior instrumentation is an effective method for the treatment of post-traumatic kyphotic deformity and that the success of the technique depends on the time from trauma to operation and the severity of baseline deformity, regardless of the type of instrumentation.

Multiplanar Deformity Analysis of Untreated Blount Disease

Although varus malalignment of the proximal tibia is the primary pathology in Blount disease, other deformities may exist. To assess multiplanar lower limb deformities, children with previously untreated early- and late-onset Blount disease who subsequently needed surgical correction were identified. Preoperative frontal and sagittal plane deformity analysis using Paley's methodology and rotational profile assessment using prone clinical examination were performed by a single examiner. Results were compared between the 2 groups and with uninvolved limbs within each group. Additionally, rotational profile of the lower limb was compared with age-matched values. Over an 8-year period, 60 limbs (40 patients) including 26 with early-onset and 34 with late-onset Blount met the inclusion criteria. Although both groups exhibited proximal tibial varus, procurvatum, and internal torsion, patients with early-onset Blount disease had greater severity. Unlike the younger patients, approximately one third of the varus malalignment of the affected extremity was attributed to the distal femur in the late-onset patients. Neither group showed any significant deformity of the proximal femur and distal tibia or sagittal plane deformity of the distal femur. There was a correlation between the severity of varus malalignment of the limb with magnitude of proximal tibial deformities in both groups and with distal femoral varus in the late-onset group of patients. Multiplanar deformity analysis is a valuable tool in the comprehensive evaluation of children with Blount disease.

Minimum 10 years follow-up surgical results of adolescent idiopathic scoliosis patients treated with TSRH instrumentation

Last two decades witnessed great advances in the surgical treatment of idiopathic scoliosis. However, the number of studies evaluating the long-term results of these treatment methods is relatively low. During recent years, besides radiological and clinical studies, questionnaires like SRS-22 assessing subjective functional and mental status and life-quality of patients have gained importance for the evaluation of these results. In this study, surgical outcome and Turkish SRS-22 questionnaire results of 109 late-onset adolescent idiopathic scoliosis patients surgically treated with third-generation instrumentation [Texas Scottish Rite Hospital (TSRH) System] and followed for a minimum of 10 years were evaluated. The balance was analyzed clinically and radiologically by the measurement of the lateral trunk shift (LT), shift of head (SH), and shift of stable vertebra (SS). Mean age of the patients was 14.4+/-1.9 and mean follow-up period was 136.9+/-12.7 months. When all the patients were included, the preoperative mean Cobb angle of major curves in the frontal plane was 60.8 degrees +/-17.5 degrees . Major curves that were corrected by 38.7+/-22.1% in the bending radiograms, postoperatively achieved a correction of 64.0+/-15.8%. At the last follow-up visit, 10.3 degrees +/-10.8 degrees of correction loss was recorded in major curves in the frontal plane with 50.5+/-23.1% final correction rate. Also, the mean postoperative and final kyphosis angles and lumbar lordosis angles were 37.7 degrees +/-7.4 degrees , 37.0 degrees +/-8.4 degrees , 37.5 degrees +/-8.7 degrees , and 36.3 degrees +/-8.5 degrees , respectively. A statistically significant correction was obtained at the sagittal plane; mean postoperative changes compared to preoperative values were 7.9 degrees and 12.9 degrees for thoracic and lumbar regions, respectively. On the other hand, normal physiological thoracic and lumbar sagittal contours were achieved in 83.5% and 67.9% of the patients, respectively. Postoperatively, a statistically significant correction was obtained in LT, SH, and SS values (P<0.05). Although, none of the patients had completely balanced curves preoperatively, in 95.4% of the patients the curves were found to be completely balanced or clinically well balanced postoperatively. This rate was maintained at the last follow-up visit. Overall, four patients (3.7%) had implant failure. Early superficial infection was observed in three (2.8%) patients. Radiologically presence of significant consolidation, absence of implant failure, and correction loss, and clinical relief of pain were considered as the proof of a posterior solid fusion mass. About ten (9.2%) patients were considered to have pseudoarthrosis: four patients with implant failure and six patients with correction loss over 15 degrees at the frontal plane. About four (3.7%) patients among the first 20 patients had neurological deficit only wake-up test was used for neurological monitoring of these patients. No neurological deficit was observed in the 89 patients for whom intraoperative neurological monitoring with SSEP and TkMMEP was performed. Overall, average scores of SRS-22 questionnaire for general self-image, function, mental status, pain, and satisfaction from treatment were 3.8+/-0.7, 3.6+/-0.7, 4.0+/-0.8, 3.6+/-0.8, and 4.6+/-0.3, respectively at the last follow-up visit. Results of about 10 years of follow-up these patients treated with TSRH instrumentation suggest that the method is efficient for the correction of frontal and sagittal plane deformities and trunk balance. In addition, it results in a better life-quality.

Magnetic Resonance Imaging Abnormalities of Neural Axis in Lenke Type 1 Idiopathic Scoliosis

Patients with Lenke type 1 single thoracic idiopathic scoliosis were included in this prospective study. All patients had preoperative magnetic resonance imaging (MRI). To examine the frequency of neural axis abnormalities and the need for preoperative MRI in this group of patients. Because of the increasing use of MRI, neural axis abnormalities have been reported in association with certain clinical and radiologic findings in idiopathic scoliosis cases. A total of 104 patients (49 juvenile onset and 55 adolescent onset), older than 10 years, were included in the study. The association of neural axis abnormalities with pes cavus, abnormal deep tendon reflexes, age of onset, presence of pain, severity of the frontal plane deformity, and sagittal contours were investigated. All 7 patients with a neural axis abnormality on MRI had an early onset disease, and 6 of them had back pain. Thus, age of onset and back pain seem to be predictive of these abnormalities. Frequency of MRI abnormalities was as high as 45% for patients with back pain in addition to a type IC curve. In patients with juvenile idiopathic scoliosis and back pain, preoperative MRI should be performed to eliminate the risk of postoperative neurologic deficits, even if the scoliosis is Lenke type 1. However, in patients with Lenke type 1 idiopathic scoliosis, preoperative MRI studies seem unnecessary if intraoperative neural monitoring is to be performed.

Reliability of Visual Measurement of Forefoot Alignment

The purpose of this study was to determine the interrater reliability of visual rating of forefoot frontal plane deformities among clinicians with different training. Thirty individuals (16 men and 14 women) between the ages of 22 and 52 years of age participated in the study. None of the patients had a history of congenital deformity, pain, or trauma in the lower extremities during the 6 months before the study. Three clinicians of different educational backgrounds and experience visually evaluated each of the patients and rated forefoot alignment. None of the clinicians knew the rating assigned by either of the other two clinicians. The results of this study showed that two of the clinical raters agreed 61.7% of the time, but neither of them agreed with the third clinician more than 15% of the time. This study indicates that the commonplace method of visually rating forefoot frontal plane deformities is unreliable and of questionable clinical value.

Biomechanical simulations of the spine deformation process in adolescent idiopathic scoliosis from different pathogenesis hypotheses.

It is generally recognized that progressive adolescent idiopathic scoliosis (AIS) evolves within a self-sustaining biomechanical process involving asymmetrical growth modulation of vertebrae due to altered spinal load distribution. A biomechanical finite element model of normal thoracic and lumbar spine integrating vertebral growth was used to simulate the progression of spinal deformities over 24 months. Five pathogenesis hypotheses of AIS were represented, using an initial geometrical eccentricity (gravity line imbalance of 3 mm or 2 degrees rotation) at the thoracic apex to trigger the self-sustaining deformation process. For each simulation, regional (thoracic Cobb angle, kyphosis) and local scoliotic descriptors (axial rotation and wedging of the thoracic apical vertebra) were evaluated at each growth cycle. The simulated AIS pathogeneses resulted in the development of different scoliotic deformities. Imbalance of 3 mm in the frontal plane, combined or not with the sagittal plane, resulted in the closest representation of typical scoliotic deformities, with the thoracic Cobb angle progressing up to 39 degrees (26 degrees when a sagittal offset was added). The apical vertebral rotation increased by 7 degrees towards the convexity of the curve, while the apical wedging increased to 8.5 degrees (7.3 degrees with the sagittal eccentricity) and this deformity evolved towards the vertebral frontal plane. A sole eccentricity in the sagittal plane generated a non-significant frontal plane deformity. Simulations involving an initial rotational shift (2 degrees ) in the transverse plane globally produced relatively small and non-typical scoliotic deformations. Overall, the thoracic segment predominantly was sensitive to imbalances in the frontal plane, although unidirectional geometrical eccentricities in different planes produced three-dimensional deformities at the regional and vertebral levels, and their deformities did not cumulate when combined. These results support the hypothesis of a prime lesion involving the precarious balance in the frontal plane, which could concomitantly be associated with a hypokyphotic component. They also suggest that coupling mechanisms are involved in the deformation process.

Physical Therapy (93)

Intertester reliability of the McKenzie evaluation in assessing patients with mechanical low back pain. (Sunny Brook &amp; Women's College Health Sciences Centre, Toronto, Ontario, Canada) J Orthop Sports Phys Ther 2000;30:368–389.In this study, patients were assessed simultaneously by 2 physical therapists trained in the McKenzie evaluation system. The therapists were randomly assigned as examiner and observer. Agreement was estimated by Kappa statistics. Forty‐five subjects (47 ± 14 years), composed of 25 women and 20 men with acute, subacute, or chronic low back pain were examined. The agreement between raters for selection of the McKenzie syndromes was K = 0.70, and for the derangement subsyndromes was K = 0.96. Interrater agreement for the presence of lateral shift, relevance of lateral shift, relevance of lateral component, and deformity in the sagittal plane was K = 0.52, 0.85, 0.95, and 1.00, respectively. Intertester agreement on syndrome categories in 17 patients under 55 years of age was excellent with K = 1.00. Conclude that a form of low back evaluation, using patterns of pain response to repeated end range spinal test movements, was highly reliable when performed by 2 properly trained physical therapists. Comment by Karen Crawford, RPT.This article intends to address the ability for therapists to agree on a low back pain diagnosis using the McKenzie technique of classification. It is important for this study to select a clear clinical diagnosis in order to establish rationale for patient management and determine a prognosis. Another purpose for this study was to agree on the relevance of sagittal and frontal plane deformities using McKenzie methods in assessing patients with back pain. The subjects included adult patients with a history of acute, subacute, or chronic low back pain. Patients were referred by general practitioners or specialists for treatment at an outpatient department where the study was conducted. The examination consisted of taking a history, observational evaluation of the range of motion, and completion of a specified tests movements in the sagittal, frontal, and combined planes. Subjects were allowed to communicate only with the assessor. A total of 46 patients with a history of low back pain agreed to complete the assessment. Patients were divided into 2 groups, those 55 years of age and older and those younger than 55. McKenzie identifies only 3 mechanical syndromes: 1. Postural, 2. Dysfunction, 3. Derangement. Each of these syndromes were divided into separate subsyndromes according to location of the pain and presence or absence of spinal deformities. The study concluded that therapists trained in use of the McKenzie evaluation system can be highly reliable in reaching the same conclusion in respect to classifying patients into diagnostic syndromes and subsyndromes, especially in patients under the age of 55. In contrast to other published studies, the importance of advanced training for interpretation of symptom behavior definitely leads to selection of the correct diagnosis.

Segmental pedicle screw instrumentation in idiopathic thoracolumbar and lumbar scoliosis

The role of posterior correction and fusion in thoracolumbar and lumbar scoliosis as well as pedicle screw instrumentation in scoliosis surgery are matters of debate. Our hypothesis was that in lumbar and thoracolumbar scoliosis, segmental pedicle screw instrumentation is safe and enables a good frontal and sagittal plane correction with a fusion length comparable to anterior instrumentation. In a prospective clinical trial, 12 consecutive patients with idiopathic thoracolumbar or lumbar scolioses of between 40 degrees and 60 degrees Cobb angle underwent segmental pedicle screw instrumentation. Minimum follow-up was 4 years (range 48-60 months). Fusion length was defined according to the rules for Zielke instrumentation, normally ranging between the end vertebrae of the major curve. Radiometric analysis included coronal and sagittal plane correction. Additionally, the accuracy of pedicle screw placement was measured by use of postoperative computed tomographic scans. Major curve correction averaged 64.6%, with a loss of correction of 3 degrees. The tilt angle was corrected by 67.0%, the compensatory thoracic curve corrected spontaneously according to the flexibility on the preoperative bending films, and led to a satisfactory frontal balance in all cases. Average fusion length was the same as that of the major curve. Pathological thoracolumbar kyphosis was completely corrected in all but one case. One patient required surgical revision with extension of the fusion to the midthoracic spine due to a painful junctional kyphosis. Eighty-five of 104 screws were graded "within the pedicle", 10 screws had penetrated laterally, 5 screws bilaterally and 4 screws medially. No neurological complications were noted. In conclusion, despite the limited number of patients, this study shows that segmental pedicle screw instrumentation is a safe and effective procedure in the surgical correction of both frontal and sagittal plane deformity in thoracolumbar and lumbar scoliosis of less than 60 degrees, with a short fusion length, comparable to anterior fusion techniques, and minimal loss of correction.

Dysplasia epiphysealis hemimelica affecting the subtalar joint

The case presented here is unique because of the location of the lesions and the extent to which the foot was affected. A two-stage procedure was performed because of the degree of bone deformity. The first stage of the procedure was directed at reducing osseous proliferation; the second stage addressed the frontal and transverse plane deformities. One-stage procedures can be used in treating less severe deformities.

Deformity Planning for Frontal and Sagittal Plane Corrective Osteotomies

The authors have developed a universal system of geometric deformity planning based on the mechanical or anatomic axes. The place where the axes intersect is the center of rotation angulation (CORA) of a deformity. Osteotomy level and type should be considered relative to the CORA to avoid creating secondary deformities. This type of planning is applicable to both frontal and sagittal plane deformities.

Simultaneous Correction of Pelvic Obliquity, Frontal Plane, and Sagittal Plane Deformities in Neuromuscular Scoliosis Using a Unit Rod with Segmental Sublaminar Wires

Ten patients with neuromuscular scoliosis and pelvic obliquity had segmental spinal instrumentation using a unit Luque rod with sublaminar wires and fixation into the pelvis. Nine of the 10 patients also had anterior spinal fusion without instrumentation before the posterior procedure. Average preoperative pelvic obliquity was 42 degrees which was corrected to 6 degrees (82% correction). Average preoperative scoliosis was 92 degrees, which was corrected to 16 degrees (81% correction). Complications included a wound hematoma in one patient and a superficial wound dehiscence in another. There have been no pseudarthroses or hardware failures to date. Excellent correction of the pelvic obliquity and the spinal curve in neuromuscular scoliosis can be obtained with use of a unit rod and without use of anterior instrumentation.

Segmental analysis of the sagittal plane alignment of the normal thoracic and lumbar spines and thoracolumbar junction.

Recent advances in spinal instrumentation have brought about a new emphasis on the three-dimensional spinal deformity of scoliosis and especially on the restoration of normal sagittal plane contours. Normal alignment in the coronal and transverse planes is easily defined; however, normal sagittal plane alignment is not so simple. This retrospective study was undertaken to increase the understanding of the normal alignment of the spine in the sagittal plane, with a special emphasis on the thoracolumbar junction. Measurements were made from the lateral radiographs of 102 subjects with clinically and radiographically normal spines. Cobb measurements of the thoracic kyphosis (T3-T12), the thoracolumbar junction (T10-T12 and T12-L2), and the lumbar lordosis (L1-L5) were determined. The spices of the thoracic kyphosis and lumbar lordosis also were determined. Using a computerized digitalizing table, the segmental angulation was determined at each level from T1-2 to L5-S1. In conclusion, there is a wide range of normal sagittal alignment of the thoracic and lumbar spines. When using composite measurements of the combined frontal and sagittal plane deformity of scoliosis, this wide range of sagittal variance should be taken into consideration. Using norms established here for segmental alignment, areas of hypokyphosis and hypolordosis commonly seen in scoliosis can be more objectively evaluated. The thoracolumbar junction is for all practical purposes straight; lumbar lordosis usually starts at L1-2 and gradually increases at each level caudally to the sacrum.

Frontal plane deformity of the subtalar joint in flexible flat foot: a preliminary study.

Frontal plane deformity of the subtalar joint in flexible flat foot: a preliminary study.