Femoral neck anteversion (FNA) is the angle between the femoral neck and femoral shaft, indicating the degree of torsion of the femur. Differences in FNA affect the biomechanics of the hip, through ...alterations in factors such as moment arm lengths and joint loading. Altered gait associated with differences in FNA may also contribute to the development of a wide range of skeletal disorders including osteoarthritis. FNA varies by up to 30° within apparently healthy adults. FNA increases substantially during gestation and thereafter decreases steadily until maturity. There is some evidence of a further decrease at a much lower rate during adulthood into old age, but the mechanisms behind it have never been studied. Development of FNA appears to be strongly influenced by mechanical forces experienced during everyday movements. This is evidenced by large differences in FNA in groups where movement is impaired, such as children born breech or individuals with neuromuscular conditions such as cerebral palsy. Several methods can be used to assess FNA, which may yield different values by up to 20° in the same participant. While MRI and CT are used clinically, limitations such as their cost, scanning time and exposure to ionising radiation limit their applicability in longitudinal and population studies, particularly in children. More broadly, applicable measures such as ultrasound and functional tests exist, but they are limited by poor reliability and validity. These issues highlight the need for a valid and reliable universally accepted method. Treatment for clinically problematic FNA is usually de‐rotational osteotomy; passive, non‐operative methods do not have any effect. Despite observational evidence for the effects of physical activity on FNA development, the efficacy of targeted physical activity remains unexplored. The aim of this review is to describe the biomechanical and clinical consequences of FNA, factors influencing FNA and the strengths and weaknesses of different methods used to assess FNA.
Femoral neck anteversion (FNA) is the angle between the femoral neck and femoral shaft, which affects the biomechanics of the hip. FNA changes substantially throughout growth, which may relate to motor development, and varies by up to 30° within adults. Several methods can be used to assess FNA, which may yield different values by up to 20° in the same participant. Treatment for clinically problematic FNA is usually de‐rotational osteotomy; passive, non‐operative methods do not have any effect.
The large economic losses caused by leg disorders have raised concerns in the broiler industry. Several types of leg disorders in broilers have been identified, such as tibial dyschondroplasia (TD), ...femoral head necrosis (FHN), and valgus-varus deformity (VVD). In this study, phenotypic changes associated with VVD were examined using clinical diagnosis, anatomical examination, measured growth performance, bone traits, and serum indicators. The incidence of VVD among the chicken population at a commercial facility in Tangshan China was 1.75% (n = 52,000), distributed about 1:1 (n = 122), between females and males. A majority of chickens were characterized by a unilaterally abnormality, while appropriately 17.6% by bilateral abnormality. Approximately 97.9% of affected broilers were classified as the “valgus” type. Growth traits, including body weight, shank length, and shank girth, were significantly lower in chickens with VVD, while tibia and metatarsal bone indexes were about 1.3-fold higher in the affected birds than in the normal birds. Bone mineral density, bone breaking strength, and several serum indicators were significantly different between affected and normal broilers. Sparse and disarranged bony trabecular was observed in abnormal broilers by histological analysis. Generally, leg disorders are associated with compromised growth, bone quality, bone structure, and lipid metabolism. This study provides a reference for clinical diagnosis of VVD and lays a foundation for exploring its underlying mechanisms.
Purpose
Restoration of correct alignment is one of the main objectives of total knee arthroplasty (TKA). However, the influence of residual malalignment on clinical and functional outcomes is ...currently uncertain. This study was therefore undertaken to ascertain its influence in patients undergoing TKA for varus osteoarthritis of the knee.
Methods
A cohort of 132 consecutive patients (143 knees) with pre-operative varus alignment was evaluated with a mean follow-up period of 7.2 years. Based upon the post-operative alignment, patients were stratified into three groups: neutral, mild varus, and severe varus. These groups were compared with respect to clinical and functional outcomes.
Results
All patients had post-operative improvements in Knee Society Score (KSS). Knees that were left in mild varus scored significantly better for the KSS and the Western Ontario and McMaster Universities Arthritis Index, compared with knees that were corrected to neutral and knees that were left in severe varus exceeding 6°. No revisions occurred in any of the groups at midterm follow-up.
Conclusion
The results of this study contradict the conventional assumption that correction to neutral mechanical alignment leads to the best outcome following TKA. Patients with pre-operative varus had better clinical and functional outcome scores if the alignment was left in mild varus, as compared with patients with an alignment correction to neutral.
Level of evidence
Therapeutic study, Level III.
Hip osteoarthritis often coexists with adult spinal deformity, an abnormality in which sagittal spinopelvic malalignment is present. Debate exists whether to perform spinal realignment correction or ...total hip arthroplasty first. Hip extension and pelvic tilt are important compensatory mechanisms in the setting of sagittal spinopelvic malalignment and change after spinal realignment. We performed this study to evaluate the effect that the spinal realignment surgical procedure has on acetabular anteversion.
This study is a retrospective review of a multicenter, prospective, consecutive database of patients with adult spinal deformity who underwent surgical spinal realignment. Only patients who already had undergone a total hip arthroplasty prior to the spinal realignment procedure were retained for analysis. Patients were excluded if they had insufficient imaging or large-head, metal-on-metal bearings or they had undergone revision total hip arthroplasty in the study period. Acetabular anteversion was calculated via the ellipse method on a standing, posterior-anterior, 90-cm radiograph with a well-centered pelvis. Anteversion was measured preoperatively and at six weeks or three months after the spinal realignment procedure. Spinopelvic parameters measured included pelvic incidence, pelvic tilt, sacral slope, lumbar lordosis, T1 pelvic angle, sagittal vertical axis, T1-spinopelvic inclination, and thoracic kyphosis.
Forty-one hips (thirty-three patients) were identified. Acetabular anteversion significantly reduced (p < 0.001) after spinal correction by mean change of -4.96° (range, -22.32° to +2.36°). The change in anteversion correlated with the changes in sagittal pelvic orientation (0.828 for the pelvic tilt, -0.757 for the sacral slope, and -0.691 for the lumbar lordosis) and global spinopelvic alignment (0.579 for the sagittal vertical axis and 0.585 for the T1 pelvic angle). Regression analysis revealed that anteversion decreased by 1° for each of the following spinopelvic parameter changes (p < 0.001): 1.105° for spinopelvic tilt, 1.032° for sacral slope, and 3.163° for lumbar lordosis.
Patients with spinopelvic malalignment had a high prevalence of excessively anteverted acetabular components. Sagittal spinal correction following total hip arthroplasty resulted in reduced acetabular anteversion, which may have implications for stability. Changes in anteversion are most closely related to changes in pelvic tilt in an almost one-to-one ratio.
An experiment was conducted to test the hypothesis that the growth rate of broilers influences their susceptibilities to bone abnormalities, causing major leg problems. Leg angulations, described in ...the twisted legs syndrome as valgus and bilateral or unilateral varus, were investigated in 2 subpopulations of mixed-sex Arkansas randombred broilers. Valgus angulation was classified as mild (tibia-metatarsus angle between 10 and 25°), intermediate (25–45°), or severe (>45°). Body weight was measured at hatch and weekly until 6 wk of age. There were 8 different settings of approximately 450 eggs each. Two subpopulations, slow growing (bottom quarter, n = 581) and fast growing (top quarter, n = 585), were created from a randombred population based on their growth rate from hatch until 6 wk of age. At 6 wk of age, tibial dyschondroplasia incidences were determined by making a longitudinal cut across the right tibia. The tibial dyschondroplasia bone lesion is characterized by an abnormal white, opaque, unmineralized, and unvascularized mass of cartilage occurring in the proximal end of the tibia. It was scored from 1 (mild) to 3 (severe) depending on the cartilage plug abnormality size. Mean lesion scores of left and right valgus and tibial dyschondroplasia (0.40, 0.38, and 0.06) of fast-growing broilers were higher than those (0.26, 0.28, and 0.02) of slow-growing broilers (P = 0.0002, 0.0037, and 0.0269), respectively. Growth rate was negatively associated with the twisted legs syndrome and a bone abnormality (tibial dyschondroplasia) in this randombred population.
The etiology of hip instability in Down syndrome is not completely understood. We investigated the morphology of the acetabulum and femur in patients with Down syndrome and compared measurements of ...the hips with those of matched controls.
Computed tomography (CT) images of the pelvis of 42 patients with Down syndrome and hip symptoms were compared with those of 42 age and sex-matched subjects without Down syndrome or history of hip disease who had undergone CT for abdominal pain. Each of the cohorts had 23 male and 19 female subjects. The mean age (and standard deviation) in each cohort was 11.3 ± 5.3 years. The lateral center-edge angle (LCEA), acetabular inclination angle (IA), acetabular depth-width ratio (ADR), acetabular version, and anterior and posterior acetabular sector angles (AASA and PASA) were compared. The neck-shaft angle and femoral version were measured in the patients with Down syndrome only. The hips of the patients with Down syndrome were further categorized as stable (n = 21) or unstable (n = 63) for secondary analysis.
The hips in the Down syndrome group had a smaller LCEA (mean, 10.8° ± 12.6° compared with 25.6° ± 4.6°; p < 0.0001), a larger IA (mean, 17.4° ± 10.3° compared with 10.9° ± 4.8°; p < 0.0001), a lower ADR (mean, 231.9 ± 56.2 compared with 306.8 ± 31.0; p < 0.0001), a more retroverted acetabulum (mean acetabular version as measured at the level of the centers of the femoral heads AVC, 7.8° ± 5.1° compared with 14.0° ± 4.5°; p < 0.0001), a smaller AASA (mean, 55.0° ± 9.9° compared with 59.7° ± 7.8°; p = 0.005), and a smaller PASA (mean, 67.1° ± 10.4° compared with 85.2° ± 6.8°; p < 0.0001). Within the Down syndrome cohort, the unstable hips showed greater femoral anteversion (mean, 32.7° ± 14.6° compared with 23.6° ± 10.6°; p = 0.002) and worse global acetabular insufficiency compared with the stable hips. No differences between the unstable and stable hips were found with respect to acetabular version (mean AVC, 7.8° ± 5.5° compared with 7.6° ± 3.8°; p = 0.93) and the neck-shaft angle (mean, 133.7° ± 6.7° compared with 133.2° ± 6.4°; p = 0.81).
Patients with Down syndrome and hip-related symptoms had more retroverted and shallower acetabula with globally reduced coverage of the femoral head compared with age and sex-matched subjects. Hip instability among those with Down syndrome was associated with worse global acetabular insufficiency and increased femoral anteversion, but not with more severe acetabular retroversion. No difference in the mean femoral neck-shaft angle was observed between the stable and unstable hips in the Down syndrome cohort.
Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Highlights • This study accurately predicted who will receive a femoral derotational osteotomy (FDO) based on gait and physical examination data. • The method was able to identify distinct subgroups ...based on preoperative characteristics. • The gait outcomes differed by subgroup. • The method suggests optimal indications for FDO.
The aims of this study were to examine the rate at which the positioning of the acetabular component, leg length discrepancy and femoral offset are outside an acceptable range in total hip ...arthroplasties (THAs) which either do or do not involve the use of intra-operative digital imaging.
A retrospective case-control study was undertaken with 50 patients before and 50 patients after the integration of an intra-operative digital imaging system in THA. The demographics of the two groups were comparable for body mass index, age, laterality and the indication for surgery. The digital imaging group had more men than the group without. Surgical data and radiographic parameters, including the inclination and anteversion of the acetabular component, leg length discrepancy, and the difference in femoral offset compared with the contralateral hip were collected and compared, as well as the incidence of altering the position of a component based on the intra-operative image.
Digital imaging took a mean of five minutes (2.3 to 14.6) to perform. Intra-operative changes with the use of digital imaging were made for 43 patients (86%), most commonly to adjust leg length and femoral offset. There was a decrease in the incidence of outliers when using intra-operative imaging compared with not using it in regard to leg length discrepancy (20%
52%, p = 0.001) and femoral offset inequality (18%
44%, p = 0.004). There was also a difference in the incidence of outliers in acetabular inclination (0%
7%, p = 0.023) and version (0%
4%, p = 0.114) compared with historical results of a high-volume surgeon at the same centre.
The use of intra-operative digital imaging in THA improves the accuracy of the positioning of the components at THA without adding a substantial amount of time to the operation. Cite this article:
2018;100B(1 Supple A):36-43.
Purpose
There is a lot of inter-individual variation in the rotational anatomy of the distal femur. This study was set up to define the rotational anatomy of the distal femur in the osteo-arthritic ...knee and to investigate its relationship with the overall coronal alignment and gender.
Methods
CT-scans of 231 patients with end-stage knee osteo-arthritis prior to TKA surgery were obtained. This represents the biggest series published on rational geometry of the distal femur in literature so far.
Results
The posterior condylar line (PCL) was on average 1.6° (SD 1.9) internally rotated relative to the surgical transepicondylar axis (sTEA). The perpendicular to trochlear anteroposterior axis (⊥TRAx) was on average 4.8° (SD 3.3°) externally rotated relative to the sTEA. The relationship between the PCL and the sTEA was statistically different in the different coronal alignment groups (
p
< 0.001): 1.0° (SD 1.8°) in varus knees, 2.1° (SD 1.8°) in neutral knees and 2.6° (SD 1.8°) in valgus knees. The same was true for the ⊥TRAx in these 3 groups (
p
< 0.02).There was a clear linear relationship between the overall coronal alignment and the rotational geometry of the distal femur. For every 1° in coronal alignment increment from varus to valgus, there is a 0.1° increment in posterior condylar angle (PCL vs sTEA).
Conclusion
The PCL was on average 1.6° internally rotated relative to the sTEA in the osteo-arthritic knee. The relationship between the PCL and the sTEA was statistically different in the different coronal alignment groups.
Level of evidence
III.
Purpose
To report the medium-term clinical and radiographic outcomes of a group of patients who underwent anterior cruciate ligament (ACL) surgery combined with high tibial osteotomy (HTO) for ...varus-related early medial osteoarthritis (OA) and ACL deficiency knee.
Methods
Thirty-two patients underwent single-bundle over-the-top ACL reconstruction or revision surgery and a concomitant closing-wedge lateral HTO. The mean age at surgery was 40.1 ± 8.1 years. Evaluation at a mean of 6.5 ± 2.7 years of follow-up consisted of subjective and objective IKDC, Tegner Activity Level, EQ-5D, VAS for pain and AP laxity assessment with KT-1000 arthrometer. Limb alignment and OA changes were evaluated on radiographs.
Results
All scores significantly improved from pre-operative status to final follow-up. KT-1000 evaluation showed a mean side-to-side difference of 2.2 ± 1.0 mm. Two patients were considered as failures. The mean correction of the limb alignment was 5.6° ± 2.8°. Posterior tibial slope decreased at a mean of 1.2° ± 0.9°. At final follow-up, the mechanical axes crossed the medial–lateral length of tibial plateau at a mean of 56 ± 23 %, with only 1 patient (3 %) presenting severe varus alignment. OA progression was recorded only on the medial compartment (
p
= 0.0230), with severe medial OA in 22 % of the patients. No patients underwent osteotomy revision, ACL revision, UKA or TKA.
Conclusions
The described technique allowed patients with medial OA, varus alignment and chronic ACL deficiency to restore knee laxity, correct alignment and resume a recreational level of activity at 6.5 years of follow-up.
Level of evidence
Case series with no comparison group, Level IV.
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