Normal and Abnormal Torsional Development in Children

8/8/2019 Normal and Abnormal Torsional Development in Children

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CLINICAL ORTHOPAEDICS AND RELATED RESEARCHNumber 302, p. 22-268 1994 J. 8. Lippincott Company

Normal and Abnormal TorsionalDevelopment in Children

Guy Fabry, M.D., Ph.D., Liu Xue Cheng, M.D.,and Guy Molenaers, M.D.

This study presents findings in a series of 123children with intoeing gait. The intoeing wascaused by increased femoral anteversion(IFA) in 70% of the cases, and internal tibialtorsion (I")n 30%. Rotation of the hips,thigh-foot angle, Q-angle, and computed to-mography measured anteversion and tibialtorsion divided the two groups very clearly.In the IFA group, 40.3% of the patients pre-sented with an externally rotated tibia and59.7% had an internally rotated tibia. In theIT" group, the anteversion was normal forage and the tibial torsion was significantlydecreased. Eighty children who correctedtheir intoeing gait, and of whom 83.4% hadIFA, were also reviewed: a decrease in ante-version was observed in 20.5% of the pa-tients; 62.9% showed no decrease in antever-sion.

In an article published 20 years ago," 864anteversion studies were performed in 432normal children from one to 16 years oldusing the Dunlap-Shands m e t h ~ d . ~hesestudies showed a decrease in anteversionfrom an average of 32' at age one to 16'From Orthopaedic Department, University HospitalPellenberg, Katholieke Universiteit Leuven, Belgium.Reprint requests to Guy Fabry, M.D., University Hos-pital, O rthopaedic Department, W eligerveld 1,B-3212Pellenberg, Belgium.Received: September 16, 1993.Revised: November 18, 1993.Accepted: November 22, 1993.

at age 16 (Fig. 1). Children with intoeingshowed an average anteversion of 42.68'compared with an average of 24.14' in thenormal group. The children with intoeingwere reevaluated after an average follow-uptime of five years six months (154 hips).They showed no significant decrease inanteversion, which averaged 39.48". It wasnoted that after the age of eight no signifi-cant change in anteversion occurred. Thestudy also showed that conservative treat-ment did not effectively alter the antever-sion. An additional important finding was acompensatory external rotation of the tibia(ERT) that created a malalignment of thepatella in 30% of children in the first groupand 50% in the second group.

A review of the literature sho ws thatthe findings of this early article have notbeen challenged significantly, an d, to theauthors ' know ledge, no other large serieshas been published. A review of 1 25 chil-dren with rotational abnormalities waspublished by Cahuzac et al.,' classifyingthem clinically according to their gaitpattern. They observed that 30% walkedwith internal rotation of the knees andouttoeing fe et, resulting in com pensatoryERT.Svenningsen et al. 3 studied hip rotationand intoeing gait in 761 normal subjects,from age four years to adult. Sixteen percentof the subjects had an intoeing gait, decreas-

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Number 302May, 1994 Torsional Development in Children 23

AG E IN YEARS

Fig. 1. Normal anteversion (N) and comparison of femoral torsion in 154 hips in 77 patients withintoeing (2) after five years six months' follow-up time (1 = first study, 2 = after follow-up, N =normal). (Reprinted with permission from Fabry, G., MacEwen, G. D., and Shands, Jr., A. R.: Torsionof the femur. J. Bone Joint. Surg. 55A:1726, 1993.)

ing in frequency from 30% in the four-year-old group to 4% in adults. They report asignificant correlation between intoeing andincreased internal hip rotation or decreasedexternal hip rotation. The decrease in inter-nal hip rotation with age was very similar tothat found for fem oral anteversion in normalsubjects in the authors' original study.4studied 30 childrenwith intoeing who showed a decrease ofanteversion from an average of 42" at ageseven to 28" at age 16, suggesting that sig-nificant regression of the anteversion canoccur after eight years of age. The internalrotation of the hips also decreased, but notto normal values, and correlated with theincreased anteversion. They conclude thatall but five of the 30 children had a normalgait at the last examination, suggesting thatwith increased anteve rsion, most of the cor-rection has occurred at the tibial level.These finding s differ from those of the cu r-rent authors' earlier study. However, theypoint out that this series was much smallerand that anteversion at age 16 is stillabnormal.The problem of compensatory externaltibial rotation has led many authors to study

Svenningsen et al.

anterior knee pain in adolescents in view ofrotational deformities of the leg^.^,'^^,'^ Theproblem of possible secondary changes inknees and hips is far from elucidated. In-creased anteversion does not correct fullywith age and malrotation at the knee seemsto be frequent. In this paper, a recent studyon a series of children with intoeing gait,with a more de tailed analysis of the differentcomponents of the deformity, is presented.MATERIALS AND METHODSA consecutive group of 123 children was ana-lyzed during a period of approximately sixmonths for torsion problems of the lower ex-TABLE 1. Characteristicsof AllSubjects

NO.of Average age GenderGroup Limbs (Yeam) M FIFA 124 6.9 ? 2.9 43 43ITT 43 6.9 2 2.7 18 19COR 54 8.2 -c 2.8 36 44

IFA, increased femoral anteversion; ITT,nternal tibial torsion;COR, spontaneously corrected intoeing gait.


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Clinical Orthopaedics24 Fabry et al. and Related ResearchTABLE 2. Clinical and Computed TomographicMeasurementsSign IFA In COR

MR 73.2 2 12.4 53.5 2 8.7 61.8 ? 14.4LR 19.9 5 11.6 32.4 f 10.5 29.1 t 9.8TFA -4.3 t 10.3 -13.2 2 10.2 2.3 t 8.2Q-angle 16.2 % 5.8 13.2 2 6.2 16.9 2 5.8AV 39.1 t 7.9 24.0 2 5.6TT 12.6 t 11.8 -5.3 2 9.6MR.medial rotation of the hip; LR. lateral rotationof the hip; TFA, thigh-foot angle; AV, anteversion;V, tibial torsion; IFA, increased femoral anteversion;In.nternal tibial torsion; COR, spontaneouslycorrected intoeing gait.

tremities. One hundred twenty-four limbsshowed an increased femoral anteversion (IFA)an d 43 an increased internal tibial torsion ( I n ) .We a lso reviewed 80 children with intoeing wh ocorrected their gait during a mean period of 5.2years (Table 1).Clinical evaluation included the determina-tion of medial (MR) and lateral rotation (LR) ofthe hip in prone position with the knee flexed,the thigh-foot angle (TFA), and the Q-angle.Radiographic measurements included deter-mination by computed tomography (CT) scan ofthe anteversion according to Weiner et al.," andthe tibial torsion ('IT) according to Jacob e l a[.'Th e current authors established normal antever-sion of 24"based on values from their originala r t i ~ l e . ~ormal tibial torsion is 30".'

LR in the IFA group; in the IT T group, MRand LR are within normal limits. The TFAis low normal in the IFA group, but lessthan normal in the ITT group.The Q-angle is increased in the IFA andI'IT group, although less so in the latter.The anteversion is significantly increased inthe IFA group and normal for age in theITT group. The TI' is less than normal inthe IFA group and significantly decreasedin the I'IT group.In the correction group, there is also alarge discrepancy between MR and LR; theTFA is low normal, but the Q-angle isclearly increased. No CT measurementswere done in this group because of radiationhazards to the children. Clinical rotation

RESULTS TABLE 3. Comparison by Student'sTable 1documents the characteristics of allsubjects. Only the pathologic limbs wereconsidered fo r further analysis, as normal Probabilityvalues have been well established in previ- IRT ERT of Similarityous publications. The average age of thean older age for the correction group. Male-female distribution was almost even.The distribution of intoeing patients ac-cording to the pathology is as follows: IFA, TT 5.3 t 7.9 21.6 t 9.9 0.00

of Tw o

groups did not vary significantly, excep t for MR 73.0 5 10.8 74.6 i7 12.1 0.79LR 22.2 +- 11.4 16.5 t 10.2 0.14Q-angle 14.9 t 5.6 16.2 5 5.3 0.006TFA -9.0 t 8.5 0.1 2 6.6 0.00

38.2 2 7.8 40.6 % 8.2 0.8170%; I n , 30%. The clinical and CT mea-surements are listed in Table 2. mere s asignificant increase in MR and decrease in IRT, internal rotation tibia;ERT,external rotation tibia:MR,medialrotationof the hip; LR, ateral rotation of the hip; TFA, thigh-footangle; AV, anteversion;n,ibial torsion.


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Number 302May, 1994 Torsional Development in Children 25

L

P 50Uc0

Q>Q

-.- 40c5 30.c00 2omc-

10

IFA

1- NormalI I0 4 8 12 16 20

Fig. 2. Comparison of anteversion of the IFAversus normal group.

measurements correlated very well with ra-diographic determination^.^^'^In the correction group, 83.4% of patientswith intoeing had IFA. A decrease in antever-sion was observed in 11 patients (20.5%),and 34 (62.9%) patients developed compen-satory ERT. Seven pa tients with IT T and twowith metatarsus adductus showed a correc-tion of their deformity.The IFA group w as divided into two sub-groups, IRT and ERT. The IRT group (74limbs) walked with internally rotated kneesand feet, the ERT group (50 limbs) withinternally rotated knees and straight forwardor outward pointing feet.Table 3 lists the different measurementsin the two subgroups. Medial rotation, LR,and anteversion remain abnormal as ex-pected, with no difference between the twogroups. There is a significantly higher Q-angle, TFA , and TT in the ERT group. Thedata were evaluated by Student's t-test.DISCUSSIONThe primary cause of intoeing in midchild-hood is IFA and less frequently ITT. heauthors' study shows a frequency of 70%and 30% respectively at an average age ofseven years. The I l T usually corrects spon-taneously before age seven." Figure 2shows the degrees of anteversion of the IFA

IFA

0 3 6 9 12 15Fig. 3. Comparison of tibial torsion in IFA andI l T groups.

group, plotted against the normal curve.Again, no significant decrease in antever-sion appears to occur after age eight. Thecomparison of tibial torsion in the IFA andthe ITT group is interesting. In the lattergroup, the TT has a slight tendency to de-crease, and in the former a definite increaseof TT ccurs with age (Fig. 3). This is alsoreflected in the ERT subgroup (Table 3),with a very significant increase in externaltibial torsion, causing the Q-angle to in-crease and the intoeing gait to correct. Fiftylimbs (40.3%) in the IFA group presentedwith this deformity. This is a somewhathigher percentage than the 30% of C ahuzace t aL2According to Staheli et aZ.," the meanntMR is 50" in male and 40" in female pa-tients. The mean L R is 45" (range, 25'45")in both genders. The mean TFA is 10"(range , -5"-30"). Tibia1 torsion ave rages20" (range, 0'4 5"). All data refer to mid-childhood (approximately seven years ofage). The tibial torsion measured by CT av-erages 30". The Q-angle, as determined byBrattstrom,' averages 8"to 10" in male, and10" to 20" in female patients. According toHughston and Walsh? however, a Q-angleof more than 10" is considered pathologic.

The mean age of the ERT group is oneyear older than the IR T group. Ex ternal rota-tion of the tibia is present at all ages, and


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Clinical Orthopaedics26 Fabry et al. and Related Researchdoes not show a tendency to decrease. Ofthe children reviewed after their intoeinggait had been corrected, in 34 (75.5% ofthe 45 children with IFA) it occurred bycompensatory ERT. A substantial numberof children with IFA develop torsionalmalalignment syn drom e with an increasedQ-angle and possible consequences for theknee function. Correction of either the ante-version or the ERT does not seem to occur.Since it is not yet clear what the conse-quences of an uncorrected anteversion ormalalignment for the knee or hip are, thera-peutic restraint is indicated. However, oncemalalignment has occurred it is irreversible.When anteversion in excess of 50" with ex-tremes of MR and LR of the hip is diag-nosed, it should be corrected before ERToccurs (usually after eight years of age).Once rotational malalignment of the limboccurs, correction at two levels should onlybe considered in severe cases, or in thosepatients with painful knees.References

Brattstrom, H.: Patella alta in non-dislocating k neejoints. Acta Orthop. Scand. 4 1578, 1970.Cdhuzac, J . P., Hobatho, M. C., Baunin, C., Bou-lot, J., Darmana, R., and Autefage, A.:Classifica-tion of 125 children with rotational abnormalities.Part B. J. Pediatr. Orthop. 159 , 1992.Dunlap, K., Shands Jr., A . R., Hollister Jr., L. C.,Gaul, J. S., and Streit, H. A,: A new method fordetermination of torsion of the femur. J. BoneJoint Surg. 35A:289, 1953.

4. Fabry, G., MacEwen, G . D., and Shands Jr.,A. R.: Torsion of the femur. J . Bone Joint Surg.55A:1726, 1973.5. Fairbank, J. C., Pynsent, P. B., Van Poortvliet,J. A., and Philips, H.: Mechanical factors in theincidence of knee pain in adolescents and youngadults. J. Bone Joint Surg. 66B:685, 1984.6. Hughston, J. C., and Walsh, W. M.: P roximal anddistal reconstruction of the extensor mechanismfor patellar subluxation. Clin. Orthop. 144:36,1979.7. Insall, J., Falvo, K. A., and Wise, D. W.: Chondro-malacia patellae. A prospective study. J. BoneJoint Surg. 5 8 A 1 , 1976.8. Jacob, R. P., Haertel, M., and Stussi, E.: Tibia1torsion calculated by computerized tomographyand compared to other methods of measurements.J. Bone Joint Surg. 62B:238, 1980.9. Lefort, G., Cottalorda, J., Lefebvre, F., Buch-Pil-Ion, M. A., and Daoud, S.:Les instabilites fkmoro-patellaires chez I'enfant et I'adolescent. Rev. Chir.Orthop. 77:491, 1991.10. Staheli, L. T.: Torsion-treatment indications. Clin.Orthop. 247:61, 1989.

1 1 . Staheli, L. T., Corbett, M., and Wyss, C.: Lower-extremity rotational problems in children: No rmalvalues to guide management. J. Bone Joint Surg.67A:39, 1985.12. Svenningsen, S ., Apalset, K., Terjesen, T., andAnda, S. : Regression of femoral anteversion. Aprospective study of in-toeing children. Acta Or-thop. Scand. 60:170, 1989.13. Svenningsen, S., Terjesen, T., Auflem, M ., andBerg, V.: Hip rotation and in-toeing gait. A studyof normal subjects from four years until adult age.Clin. Orthop. 251:177, 1990.14. Turner, M. S., and Smilie, I. S.: The effect oftibia1 torsion on the pathology of the knee. J. BoneJoint Surg. 63B:396, 1981.15. Weiner, D. S., Cook, A. J. , Hoyt Jr., W. A., Ora-vec, C. E.: Computed tomography in the measure-ment of femoral anteversion. Orthopaedics 1 :299,1978.

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Normal and Abnormal Torsional Development in Children