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Femoral Anteversion

- Discussion:
    - femoral version is defined as the angular difference between axis of femoral neck and the transcondylar axis of the knee;
    - excessive femoral anteversion (medial femoral torsion) is most common cause of in-toeing that first presents in early childhood;
    - it is twice as common in girls as in boys, it is nearly always symmetrical, and it is often familial;
    - tripping as a result of crossing the feet may occur, and child may be teased by peers because of pigeon-toed gait and the awkward 
           running pattern;
    - normal values:
           - on average, femoral anteversion ranges from 30-40 deg at birth and decreases progressively throughout growth to about 15 deg at 
                   skeletal maturation;
           - in adults, anteversion averages between 8 and 14 deg, w/ an average of 8 degrees in men and 14 degrees in women;
    - diff dx of intoeing:
           - metatarsus adductus
           - tibial torsion
           - femoral anteversion
    - natural history:
           - parents usually become concerned after the child reaches age 3 years;
           - in-toeing secondary to medial femoral torsion is most pronounced between ages 4 to 6 years, but subsquently improves during 
                   later childhood, averaging about 1.5 degrees of correction per year;
                   - this is partially due to the fact that medial hip rotation is greatest during early childhood, but then declines with increasing age, 
                          decreasing about 2 or 3 degrees per year;
           - if assoc w/ internal tibial torsion, femoral anteversion may lead to patellofemoral subluxation due to an increase in the Q angle;
           - both the decrease in femoral anteversion and decrease in medial rotation, result in near complete resolution of the intoeing in 
                   more than 80 % of affected children, usually by age 10 years;
                   - additional concious compsensation may occur during adolescence;

- Exam:
    - increased medial rotation and decreased lateral rotation noted on exam of child with an intoeing gait with patellae medially rotated;
    - medial rotation of thigh in extension exceeding 70 deg is abnormal;
    - if hip rotation is asymmetric, then consider DDH;
    - gait:
          - child ambulates w/ patella medially rotated, and runs in an awkward pattern;
          - running is characterized by medial rotation of thighs during swing phase, which causes outward rotation of legs;
    - Reider Test:
          - prominence of the greater trochanter indicates axis of the femoral neck;
          - noting the position of the patella, an accurate determination of the femoral anteversion can be determined;

- Operative Indications:
    - procedure should be performed only after age of eight to ten years, for persistent, severe deformity;
    - child should have more than 50 degrees of measured anteversion & more than 80 degrees of medial hip rotation

Clinical determination of femoral anteversion. A comparison with established techniques.

Intertrochanteric versus supracondylar osteotomy for severe femoral anteversion.

Medial femoral torsion and osteoarthritis.

Lower-extremity rotational problems in children. Normal values to guide management.

The anatomy and functional axes of the femur.

Femoral anteversion

Femoral anteversion and physical properties in adolescent and adult life.