FEMORAL

A CLINICAL ASSESSMENT

ANTEVERSION
INTOEING GAIT IN CHILDREN

OF IDIOPATHIC

RICHARD

H.

GELBERMAN,

MARK

S. COHEN, SHEKHAR S. DESA!, SALAMON, TIMOTHY M. OBRIEN

PAUL

P.

GRIFFIN,

PETER

B.

From

the

Childrens

Hospital

Medical

Center,

Boston

Hip rotation in extension and flexion was studied in 23 patients with idiopathic mtoeing gait. In extension all the hips had markedly increased medial rotation and limited lateral rotation, fulfilling the criteria of excessive femoral anteversion. In flexion, however, rotation varied widely; in one group of patients medial rotation remained greater than lateral, but in the second group lateral rotation was equal to or greater than
medial. second.

CT scans showed that the hips in the first group were significantly more anteverted than those in the Clearly measurement of hip rotation in extension alone does not provide a dependable indication of femoral anteversion in children with intoeing gait; rotation in flexion also needs to be measured. is at present
diagnosis of

There
clinical

no consensus
excessive

on the

criteria

for
in

The

purpose and

of

this

study

was

femoral

anteversion

correlation
in extension

of femoral gait.
MATERIALS

neck anteversion
in children

to investigate the with hip rotation

presenting with

otherwise
authors

normal patients with intoeing gait. Several believe that markedly increased medial rotation of the hip in extension, with corresponding limitation of lateral rotation, is presumptive evidence of excessive anteversion (Fabry, MacEwen and Shands 1973; MacEwen 1976; Kumar and MacEwen 1982; Kling and
Hensinger guidelines 1983). of hip

in flexion

intoeing

AND
who

METHODS
primarily with

Twenty-three

children

presented

Other
rotation

authors in

ascribe for

numerical diagnosis

intoeing

at

the

Childrens
and October

Hospital
1985 were

Medical
studied.

Center
There

extension

(Reynolds and Herzer 1959; Alvik 1962; Swanson, Greene and Allis 1963; Pitkow 1975; Staheli 1977).
However, arbitrary, most and authors agree that these criteria are

between January were 15 girls and

years.
profiles (1977,

All
1980)

eight boys ranging patients were examined

the clinical

in age from 3 to 10 and their torsional

criteria of Staheli

fulfilled

extension
anteversion Gasse and

it has been shown that hip alone is not a reliable determinant

(Staheli, Staheli

rotation in of femoral

Duncan and Schaefer 1968 ; La1972; Cyvin 1977; Reiker#{226}s and

Bjerkreim

1982).

for excessive idiopathic anteversion of the femoral neck. All measurements of hip rotation were recorded by one of us (RHO) to eliminate inter-observer variation (Luchini and Stevens 1983). Rotation. Hip rotation in extension was measured with the child lying prone and with the knees flexed to 90#{176} so
that the lower leg indicated the angle of rotation onto the ; the table

R. H. Gelberman, MD, Professor in Orthopaedic Surgery, University of California, San Diego Division of Orthopaedics and Rehabilitation, UCSD Medical Center,
225 Dickinson Street, H-894, San Diego, California 92103-9981, USA.

angle between the tibia Care was taken to hold

while

and the vertical the pelvis firmly

was measured.

M. S. Cohen, Medical Student Harvard University Medical School,

S. S. Desai, MS Orth, Fellow

Boston, and

Massachusetts,
Surgery

USA. of Boston,

in Orthopaedic

P.

P.

Griffin,

MD,

Professor
Center,

Chairman,
Longwood

Department Avenue,

Orthopaedic Childrens Massachusetts

Surgery Hospital Medical 021 15, USA.

300
Clinical

the lower leg was passively moved through an arc both medially and laterally. Hip rotation in flexion was measured with the child lying supine and with both the hip and knee held in 90#{176} flexion. of Each leg was examined separately and the measurements recorded

with
Professor
California, Finglas, RH. and Dublin Gelberman. Joint Surgery

a goniometer.

P. B. Salamon, Surgery
University

MD,

Assistant
Davis, Orthopaedic Hospital, should

in Orthopaedic
USA. 11, Eire.

All hips had

and limited
flexion divided flexion varied

of California,

Sacramento, Surgeon Cappagh, to Dr

lateral

markedly rotation

T. M. OBrien, FRCS, St Marys Orthopaedic Requests for reprints

greatly.

be sent Society

into two groups : Group I comprised

increased medial rotation in extension, but rotation in The patients were therefore based on the range of rotation in
15 patients (30 hips) in

1987 British 030l-620X/87/1005

Editorial $2.00

of Bone

whom medial rotation in flexion was consistently greater than lateral rotation ; Group II comprised eight patients
75

VOL.

69-B,

No.

I, JANUARY

1987

76

R. H. GELBERMAN,

M. S. COHEN,

S. 5. DESAI,

ET AL.

(16

hips)

in whom

lateral

rotation

of

the

flexed

hip

equalled or exceeded Twenty normal normal These

medial

rotation.

children aged 3 to 10 years, with gait, served as controls and formed Group III. children presented to the orthopaedic clinics for conditions not related to the lower

In cases of excessive coxa valga, an attempt was to obtain an extra CT image through the lower aspect of the femoral neck. These images were then superimposed to lengthen the image of the femoral neck and to determine more accurately the true cervical axis. 1978).

made

musculoskeletal limbs. Rotation measured. Anteversion. in Group determine carried about table occurring III,

Similarly,

serial

cross-sections

were

taken

through

of the hip in flexion

and extension

was

All patients underwent

in Groups I and computerised These

II, but not those tomography to CT studies were

the distal expansion of the lower end of the femur. A line connecting two points along the most posterior aspects of the femoral condyles, as seen on the tomographic projections on the television monitor, was selected for axis sections measurement. of the neck Photographs of the tomographic axis were measured from axis and the distal femoral and the angle directly of radiation CT and imaging was estimated

femoral

anteversion.

out with
30 minutes. with Velcro

a GE

9800

CT

scanner,

each

taking

The childs straps to

legs were secured to the prevent any movement

then
(Figs

superimposed
1 and Gonadal 2). dosage data on 1980)

lower
time

between performing the scans ofthe upper and femur. Images were made with a two-second scan
mAs varying with patient from head size. the A series femoral cross-sectional images

at 120 kVp,

published McCullough

(Carter
data Protection

et al.
and

from

contained

1977; in the

of tomographic

neck

were

viewed

on the monitor.
of the femoral

The tomogram

best

National Council on Radiation ments Report (1977). Dosage than

Measure-

was determined

to be less

representing The axis

the centre

was selected.

connecting
and inferior

of the femoral three points

surfaces

neck was equidistant

of the femoral

determined by a line between the superior

neck (Weiner et al.

50 millirads for both boys and girls, 150 millirads sustained by the female anteroposterior radiography

as compared to gonads during pelvis. Car-

routine

of the

cinogenic risk from this procedure can be estimated by evaluating the integral dose, which is the product of the dose and the volume of tissue irradiated. Total integral dose of three slices through the hip was found to be approximately radiography equal to that sustained in anteroposterior of the pelvis (3000 gram-rads).
t-

test.
p

Statistical analysis was carried out using Students Differences were regarded as significant when 0.05. The two-tailed test was used in all cases.

RESULTS
Group
ranging

I comprised
in age from

nine

girls

and
with

3 to 9 years,

six boys a mean lateral results rotation

(30 hips) age of 5.3

years, who all had greater medial than both extension and in flexion. Detailed in Table I. In extension, mean medial

rotation
are given measured

in

80#{176} mean lateral rotation and 10#{176}; while in flexion, mean medial rotation was 78#{176} lateral rotation and 45#{176}. The mean CT measurement of femoral anteversion was 49#{176}. Group II comprised six girls and two boys (16 hips)
ranging in ages from 3 to 10 years, with a mean age of 5.5 years (Table II). These patients also had excessive medial

rotation with limited lateral rotation with the hip in extension, measuring 71#{176} and 18#{176} respectively (Table III). However, in contrast to Group I all hips showed are in Table II. These hips showed a mean medial rotation in flexion of 46#{176} a mean lateral rotation with of 60#{176}. difference The in both medial and lateral rotation in flexion between Group I and Group II hips was highly significant (p<O.OO1). Mean femoral anteversion was 32#{176} Group in II hips, which was significantly less than the 49#{176} found in Group I hips (p<0.OOl).
THE JOURNAL OF BONE AND JOINT SURGERY

lateral rotation equal to or greater than with the hip in flexion. Detailed results

medial

rotation

Computerised

axial

tomograms

through constructed

the

femoral by drawin

necks

(Fig. a line

1) and

through
The

the distal
femoral neck

expansion
axis was

of the lower

end of the femora

(Fig. 2).
which

connected surfaces
connecting was related tomographic anteversion anteversion

three points of the femoral

equidistant between the superior and inferior neck ; and the distal femoral axis by a line

the posterior margins of the femoral condyles. Each line to the plane of the table-top, and photographs of the sections were then superimposed, allowina the angle of to be measured directly. In this patient, femoral measures 6l0 on the right and 64 on the left.

FEMORAL Table medial (Group I. Rotation rotation I) and greater anteversion (in degrees) in those hips with than lateral in both extension and flexion

ANTEVERSION Table medial (Group II. Rotation and rotation greater II) Rotation anteversion than lateral (in degrees) in extension in those but not

77
hips with in flexion

Rotation

in extension

Rotation

in flexion Femoral anteversion R/L 61/66 48/54 49/57 40/42 53/60 49/42 59/51 45/54 46/55 30/28 Table III. Mean

in extension

Rotation

in flexion Femoral anteversion R/L 23/23 38/38 30/29 35/40 26/26 35/26 33/34 37/34

Case 1

Sex F

Age (years) 3 4 4 9 6 7 6 5 3 7 4 3 4 8 6

Medial R/L 90/90 85/85 75/75 75/75 75/75 85/80 90/75 85/85 85/85 75/75 75/75 75/75 80/80 80/80 85/85

Lateral R/L 05/05 10/10 15/15 05/10 10/10 05/10 10/10 10/10 20/20 15/15 00/00 10/15 05/00 05/10 10/10

Medial R/L 85/85 85/85 75/80 70/70 75/80 75/75 80/85 85/85 80/80 70/70 75/75 75/75 75/75 80/80 75/75

Lateral R/L 45/30 50/50 50/45 45/30 45/40 45/55 50/60 65/70 60/45 45/45 30/35 55/50 55/50 45/30 15/15

Case 1

Sex F

Age (years) 6 3 10 7 3 5 5 5

Medial R/L 70/70 75/70 75/75 75/75 75/65 70/70 65/70 70/65

Lateral R/L 25/25 20/15 15/15 05/15 15/20 20/25 15/10 25/30

Medial R/L 45/45 55/55 45/55 45/45 45/45 40/40 35/45 50/50

Lateral R/L 75/70 70/75 45/55 55/60 60/50 70/70 55/45 55/50

2
3 4 5 6 7 8 9
10

F
F M F F M F M M F F M M F

2
3 4 5 6 7 8

F
F M F M F F

rotation

and one

standard

deviation

(in degrees)

in the

11 12 13 14 15

42/38 47/47 36/43 52/59 61/64

three

groups

of hips
Rotation in extension Rotation in flexion Femoral anteversion 49 10

Medial Groupl (n = 30) Groupll (n = 16) 805

Lateral 105

Medial 785

Lateral 4513

714

187

467

6010

32

Group
and years, 12 girls with

III,
(40

the control
hips) whose

group,
ages They

comprised
ranged all had

eight boys from 3 to 10

approxima-

GroupIlI (n = 40)

518

549

507

55

a mean

of 5. 1 years.

of medial and lateral rotation, in both extension and flexion. As shown in Table III, mean medial rotation in extension was significantly less than that for both Group I and Group II hips (p < 0.00 1), while mean lateral rotation was significantly greater (p<O.OO1). In flexion, mean medial rotation was still

tely equal

ranges

The natural course of femoral anteversion has been demonstrated by Fabry et al. (1973) in a 20-year followup of 1 148 hips. Using biplanar radiography, they found that the anteversion for normal children between the

significantlyless significantly
(p > 0.05)

than in Group I hips (p<O.OO1) but not different from that seen in Group II
mean lateral from rotation in flexion was

while

significantly
not significantly

greater

than

in Group

different

I (p<O.OOl) but was Group II hips (p > 0.05).

ages of three and six years was 27#{176} 8#{176}, between and seven and ten years was 22#{176}7#{176}. These values coincide with the findings of plain radiography (Dunlap et al. 1953 ; Ryder and Crane 1953 ; Budin and Chandler 1957; Shands and Steel 1958; Crane 1959; Beals 1969; Cyvin 1977) and those on cadaveric femora (Le Damany 1903;
Soutter Olmsted and Bradford 1948). 1903; Durham 1915; Kingsley and

DISCUSSION
Femoral anteversion is reported to be the most common

Computerised tomography mination of femoral anteversion Hernandez Eastgate

has improved
(Weiner

the deteret al. 1978;

cause of intoeing gait in children between the ages of 3 and 12 years (Hensinger 1976; Staheli 1977; Kumar and MacEwen 1982; Kling and Hensinger 1983). Various clinical criteria have been based on hip rotation in extension, or increased medial rotation in extension with relatively limited lateral rotation. However, it has been shown

1983;

et al. 1981 ; Peterson et al. 198 1 ; Bjersand and 1982; Reiker#{225}s, Bjerkreim and Kolbenstvedt Widjaja et al. 1985; Gelberman et al. 1986). It

correlates well with the measurement of anteversion obtained by conventional biplanar radiography (Reiker#{226}s et al. 1982). Slight variations in the location of the

that hip rotation in extension does not provide an sections within the femoral neck do not alter the measurement of femoral anteversion significantly and accurate measure of femoral anteversion (Staheli et al. 1968; LaGasse and Staheli 1972; Cyvin 1977; Reiker#{225}s, the mean intra-observer and inter-observer variations Bjerkreim and Kolbenstvedt 1982). are 2#{176} 3#{176} and respectively (Hernandez Ct al. 1981).
VOL. 69-B, No.
1, JANUARY 1987

78

R. H. GELBERMAN,

M. S. COHEN,

S. S. DE5AI,

ET AL.

In
anteversion, ing rotation

the

clinical

determination

of

femoral

when

the hip is tested in flexion

supports

this contention.
difference in hip III hips (p > 0.05).

all authors stress the importance of measurwith the hip held in extension. In flexion, the capsular and soft-tissue structures a greater range of lateral rotation. as measured in anteversion extension to as measured are relaxed, We found

In flexion, there rotation between By contrast, medial than significantly

was no significant Group II and Group

anterior
permitting hip

all Group I hips had consistently more lateral rotation in flexion and each was more anteverted than the Group II hips.

rotation

be a poor
by compu-

predictor of femoral tensed tomography.

extension greater

Patients
than 70#{176} had

with

medial
from

rotation
tomograph-

in

Therefore, the restriction of lateral rotation in flexion in Group I hips may reasonably be attributed to the
excessive femoral

computerised

ic measurements of anteversion (Tables I and II).

ranging

23#{176} 66#{176} to

We conclude

anteversion. that hip rotation

in extension

does

not

The
mean

hips

in our
rotation

medial

marked restriction hip held in 90#{176} flexion of

Group I and II patients all had a in extension greater than 70#{176} with of lateral rotation. However, with the
we could distinguish still between markedly

provide a dependable clinical guide to femoral anteversion, since there is a subgroup of children with intoeing and increased medial rotation who have normal

or only slightly increased femoral anteversion. The range of rotation with the hip in 90#{176}flexion provides of useful
additional information lateral rotation indicates while lateral rotation indicates normal ; persistence of more medial than increased femoral anteversion, equal to or greater than medial

Group

I hips

in which

medial

rotation

exceeded lateral rotation and Group II hips in which lateral rotation equalled or exceeded medial rotation, giving a highly significant difference (p<O.OO1). Group III hips had approximately equal mean medial and lateral rotation in both flexion and extension, a finding in normal children Computerised moral anteversion agreed by many tomographic authors. measurements of fe-

anteversion.

significantly
those reported

gave results in Group I which were greater than in Group II (p<O.OO1) and in
for normal children of the same age. In was
Alvik Beals

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VOL. 69-B,

No. 1, JANUARY

1987