The contribution of lower limb rotational malalignment to patellofemoral pain and instability has been well recognized. The purpose of the present study is to review the role of computed tomography (CT) and magnetic resonance imaging (MRI) in assessment of abnormal rotational alignment of lower limb.
Evidence Acquisition:
An analysis of all available literature in the English language through 2010 was performed to provide data on a comparison between MRI and CT—specifically, the techniques and normative values used to determine abnormal lower limb alignment.
Results:
CT and MRI are highly accurate in defining abnormal alignment of the lower limb. Determination of axis of femoral anteversion in proximal femur has been the subject of debate in the literature. The determination of distal femoral condylar axis, proximal tibial axis and distal tibial axis are less controversial.
Conclusions:
CT and MRI are both used for assessing the rotational abnormalities of the femur and tibia during evaluation for patellofemoral disorders. MRI has an advantage over CT because femoral anteversion measurements are more accurate and ionizing radiation is avoided. A standardized protocol defining the level and axes for measurement of femoral and tibial alignment indices should be used to maintain consistency in measurements.
BaumanPASingsonRHamiltonWG. Femoral neck anteversion in ballerinas. Clin Orthop. 1994;302:57-63.
2.
BeaconsfieldTPintoreEMaffulliNPetriGJ. Radiological measurements in patellofemoral disorders: a review. Clin Orthop. 1994;308:18-28.
3.
BillingL. Roentgen examination of the proximal femur end in children and adolescents: a standardized technique also suitable for determination of the collum, anteversion and epiphyseal angles. A study of slipped epiphysis and coxa plana. Acta Radiol. 1954;110(suppl):1.
ChungCYLeeKMParkS. Validity and reliability of measuring femoral anteversion and neck-shaft angle in patients with cerebral palsy. J Bone Joint Surg Am. 2010;92:1195-1205.
6.
CitakMGardnerMJCitakM. Navigated femoral anteversion measurements: a new intraoperative technique. Injury. 2008;39:467-471.
7.
DejourHWalchGNove-JosserandLGuierC. Factors of patellar instability: an anatomic radiographic study. Knee Surg Sports Traumatol Arthrosc. 1994;2(1):19-26.
8.
DelgadoEDSchoeneckerPLRichMMCapelliAM. Treatment of severe torsional malalignment syndrome. J Pediatr Orthop. 1996;16:484-488.
9.
DunlapKShandsARJrHollisterLCJrGaulJSJrStreitHA. A new method for determination of torsion of the femur. J Bone Joint Surg Am. 1953;35:289-311.
10.
DunnDMNotleyB. Anteversion of the neck of the femur: a method of measurement. J Bone Joint Surg Br. 1952;34:181-186.
EckhoffDGMontgomeryWKKilcoyneRFStammER. Femoral morphometry and anterior knee pain. Clin Orthop. 1994;302:69-74.
13.
EliasDAWhiteLM. Imaging of patellofemoral disorders. Clin Radiol. 2004;59:543-557.
14.
FabryGMacEwenGDShandsARJr. Torsion of the femur: a follow-up study in normal and abnormal conditions. J Bone Joint Surg Am. 1973;55(8):1726-1738.
15.
FlandryFHughstonJC. Complications of extensor mechanism surgery for patellar malalignment. Am J Orthop. 1995;24:534-543.
16.
GalbraithRTGelbermanRHHajekPC. Obesity and decreased femoral anteversion in adolescence. J Orthop Res. 1987;5:523-528.
17.
GallandOWalchGDejourHCarretJP. An anatomical and radiological study of the femoropatellar articulation. Surg Radiol Anat. 1990;12:119-125.
18.
GuentherKPTomczakRKesslerS. Measurement of femoral anteversion by magnetic resonance imaging: evaluation of a new technique in children and adolescents. Eur J Radiol. 1995;21:47-52.
19.
HarbaughCMWilsonNASheehanFT. Correlating femoral shape with patellar kinematics in patients with patellofemoral pain. J Orthop Res. 2010;28:865-872.
20.
HernanadezRJTachdjianMOPoznanskiAKDiasLS. CT determination of femoral torsion. AJR Am J Roentgenol. 1981;137:97-101.
21.
HughstonJC. Subluxation of the patella. J Bone Joint Surg Am. 1968;50:1003-1026.
22.
JakobRPHaertelMStussiF. Tibial torsion calculated by computerized tomography and compared to other methods of measurement. J Bone Joint Surg Br. 1980;62B:238-242.
23.
JamesSL. Chondromalacia of the patella in the adolescent. In: KennedyJC, ed. The Injured Adolescent Knee. Baltimore, MD: Williams & Wilkins Co; 1979:205-251.
24.
JarrettDYOliveriaAMZouKHSnyderBDKleinmanPK. Axial oblique CT to assess femoral anteversion. AJR Am J Roentgenol. 2010;194:1230-1233.
25.
JonesRBBarlettECVainrightJRCarrollRG. CT determination of tibial tubercle lateralization in patients presenting with anterior knee pain. Skeletal Radiol. 1995;24:505-509.
26.
KimJSParkTSParkSB. Measurement of femoral neck anteversion in 3D: part 1. 3D imaging method. Med Biol Eng Comput. 2000;38:603-609.
27.
KingsleyPCOlmstedKL. A study to determine the angle of anteversion of the neck of the femur. J Bone Joint Surg Am. 1948;30:745-751.
28.
LeeTQAnzelSHBennettKAPangDKimWC. The influence of fixed rotational deformities of the femur on the patellofemoral contact pressures in human cadaver knees. Clin Orthop. 1994;302:69-74.
29.
LeratJLMoyenBBochuMGallandO. Femoropatellar pathology and rotational or torsional abnormalities of the inferior limb: the use of CT scan. In: MullerWHackenbruchW, eds. Surgery and Arthroscopy of the Knee: Second Congress of the European Society. Berlin, Germany: Springer-Verlag; 1988.
30.
MagilliganDJ. Calculation of the angle of anteversion by means of horizontal lateral roentgenography. J Bone Joint Surg Am. 1956;38:1231-1246.
31.
McNallyEGOstlereSJPalCPhillipsAReidHDoddC. Assessment of patellar maltracking using combined static and dynamic MRI. Eur Radiol. 2000;10:1051-1055.
32.
McWalterEJMacIntyreNJCibereJWilsonDR. A single measure of patellar kinematics is an inadequate surrogate marker for patterns of three-dimensional kinematics in healthy knees. Knee. 2010;17:135-140.
33.
MoultonAUpadhyaySS. A direct method of measuring femoral anteversion using ultrasound. J Bone Joint Surg Br. 1982;64:469-472.
34.
MunetaTYamamotoHIshibashiTAsahinaSFuruyaK. Computerized tomographic analysis of tibial tubercle position in the painful female patellofemoral joint. Am J Sports Med. 1994;22:67-71.
35.
MurphySBSimonSRKijewskiPKWilkinsonRHGriscomNT. Femoral anteversion. J Bone Joint Surg. 1987;69:1169-1176.
36.
NoyesFRBarber-WestinSD. Operative options for extensor mechanism malalignment and patellar dislocation. In: NoyesFRBarber-WestinSD, eds. Noyes Knee Disorders: Surgery, Rehabilitation and Clinical Outcomes. Philadelphia, PA: Elsevier; 2009:995-1025.
37.
PaulosLSwansonSCStoddardGJBarber-WestinSD. Surgical correction of limb malalignment for instability of the patella: a comparison of 2 techniques. Am J Sports Med. 2009;37(7):1288-1300.
38.
RadlerCKranzlAMannerHM. Torsional profile versus gait analysis: consistency between the anatomic torsion and the resulting gait pattern in patients with rotational malalignment of the lower extremity. Gait Posture. 2010;32:405-410.
39.
ReikerasOBjerkreimIKolbenstvedtA. Anteversion of the acetabulum and femoral neck in normals and in patients with osteoarthritis of the hip. Acta Orthop Scand. 1983;54:18-23.
40.
RogersSP. A method for determining the angle of torsion of the neck of the femur. J Bone Joint Surg. 1931;13:821-824.
41.
RosenHSandickH. The measurement of tibiofibular torsion. J Bone Joint Surg. 1955;37:847-855.
42.
RuwePAGageJROzonoffMBDeLucaPA. Clinical determination of femoral anteversion: a comparison with established techniques. J Bone Joint Surg Am. 1992;74:820-830.
43.
RyderCTCraneL. Measuring femoral anteversion: the problem and a method. J Bone Joint Surg Am. 1953;35:321-328.
44.
SchneiderBLaubenbergerJJemlichS. Measurement of femoral antetorsion and tibial torsion by magnetic resonance imaging. Br J Radiol. 1997;70:575-579.
45.
SeberSHazerBKoseNGokturkEGunalITurgutA. Rotational profile of the lower extremity and foot progression angle: computerized tomographic examination of 50 male adults. Arch Orthop Trauma Surg. 2000;120:255-258.
46.
ShinCSCarpenterRDMajumdarSMaCB. Three-dimensional in vivo patellofemoral kinematics and contact area of anterior cruciate ligament-deficient and reconstructed subjects using magnetic resonance imaging. Arthroscopy. 2009;25(11):1214-1223.
47.
SouzaRBPowersCM. Concurrent criterion-related validity and reliability of a clinical test to measure femoral anteversion. J Orthop Sports Phys Ther. 2009;39(8):586-592.
StaheliLTCorbettMWyssC. Lower extremity rotational problems in children: normal values to guide management. J Bone Joint Surg Am. 1985;67:39.
50.
StubergWTemmeJKaplanPClarkeAFuchsR. Measurement of tibial torsion and thigh-foot angle using goniometry and computed tomography. Clin Orthop. 1991;272:208-212.
51.
SuganoNNoblePCKamaricE. A comparison of alternative methods of measuring femoral anteversion. J Comput Assist Tomogr. 1998;22:610-614.
52.
TamariKTinleyPBriffaKBreidahlW. Validity and reliability of existing and modified clinical methods of measuring femoral and tibiofibular torsion in healthy subjects: use of different reference axes may improve reliability. Clin Anat. 2005;18:46-55.
53.
TeitgeRA. Patellofemoral disorders: correction of rotational malalignment of the lower extremity. In: Noyes Knee Disorders: Surgery, Rehabilitation and Clinical Outcomes. Philadelphia, PA: Elsevier; 2009:1026-1049.
54.
TomczakRJGuentherKPRieberA. MR Imaging measurement of the femoral antetorsional angle as a new technique: comparison with CT in children and adults. AJR Am J Roentgenol. 1997;168:791-794.
55.
WeinerDSCookAJHoytWAJrOravecCE. Computed tomography in the measurement of femoral anteversion. Orthopedics. 1978;1(4):299-306.
56.
Wynne-DaviesR. Talipes equinovarus: a review of eighty-four cases after completion of treatment. J Bone Joint Surg Br. 1964;46:464-476.
57.
YoshiokaYCookeDV. Femoral anteversion: assessment based on function axes. J Orthop Res. 1987;5:86-91.
