Full length articleThe impact of symptomatic femoral neck anteversion and tibial torsion on gait, function and participation in children and adolescents
Introduction
Idiopathic Torsional Deformities (ITD) of the lower limbs in children and adolescents are a common cause of in-toed gait, tripping and joint pain and have been described as ‘miserable malalignment’ [[1], [2], [3]]. Though torsional deformities may be both internal or external in nature at the femur and the tibia, the key feature of deformity discussed in this paper is children with symptomatic femoral neck anteversion (FNA) and external tibial torsion [4]. Symptoms may vary in severity but in some children they limit or prevent participation in the child’s preferred activities. These effects are a concern to children and their families. Children and adolescents with symptomatic ITD are presenting to The Royal Children’s Hospital, Melbourne, Australia, in increasing numbers, for orthopaedic assessment and management. Gait analysis is frequently used to evaluate the impact of lower limb torsion on gait and function.
Torsion is the amount of twist along the length of the bone. This is considered a torsional deformity when it is increased outside of the normal range [[5], [6], [7]]. Torsional deformities are considered as idiopathic when there is no known history of developmental hip dysplasia, neuromuscular, genetic, traumatic or other causative factor for the deformity.
Radiologically, FNA can be defined by the angle between the line passing through the centre of the femoral head-neck axis and the line passing parallel to the posterior aspect of the medial and lateral condyles of the distal femur in the transverse plane of the femur [8]. FNA at birth has been reported to be approximately 40° [6,9] and reduces under weight-bearing forces during the acquisition of standing and walking to approximately 15° by skeletal maturity [4]. Tibial torsion is defined as the angle between a line through the posterior aspect of the tibial plateau and a line through the bi-malleolar axis in the transverse plane of the tibia [5]. Tibial torsion is typically internal during infancy and becomes increasingly external with growth and weight-bearing [5].
Historically in-toed gait and ITD has often been described as a cosmetic issue, with minimal symptoms [5,6]. It has been suggested that it usually improves spontaneously with growth and time, with no need for surgical correction [5,6]. There is a growing body of evidence to question this view [1,2,10,11]. Three dimensional gait kinematics of ITD has been associated with increased anterior pelvic tilt, increased hip flexion, increased hip internal rotation and external knee rotation [1,2,11]. Several studies confirm the presence of joint pain and increased joint loading at the hip and patellofemoral joints [2,3,11,12]. However, there is limited reported evidence that ITD contributes to functional problems such as falls and tripping in children [13].
The World Health Organization’s International Classification of Functioning, Disability and Health (ICF) has focussed strongly on participation as the ultimate health outcome when characterising health and functioning in children and adolescents [14]. Participation is defined as attendance and involvement in a life situation [14,15]. There are no studies to date that have investigated the relationship between ITD, gait function, activity and participation.
The aim of this study was to examine relationships between symptomatic lower limb torsion and pain, gait function, activity and participation in children and adolescents.
Section snippets
Participants
This was a retrospective cohort study from standardized prospective data of children and adolescents with symptomatic ITD referred to the Hugh Williamson Gait Analysis Laboratory (HWGAL) at The Royal Children’s Hospital between January 2014 and January 2019. Children were referred from the orthopaedic clinic when clinical findings suggested ITD to be severe enough to evaluate for surgical intervention. Clinical findings included observation of gait indicating internal hip rotation, physical
Results
On medical imaging this cohort had mean (SD) FNA of 38° (13°) and ETT of 39° (12°) (Table 1). During gait this cohort had increased mean (SD) GPS of 7° (2°) with the mean normative score of our typical data being 4.9°, increased internal hip rotation GVS 10° (6°) compared to mean normative value of 5.4° and maximum hip rotation in stance (MHR) 13° (9°) (Table 1). This cohort of children walked with low mean (SD) internal foot progression 1° (9°) as measured by MFP (Table 1).
On physical
Discussion
This cohort of children were referred for gait assessment of symptomatic ITD. This study found that not all the children of this cohort had increased FNA or tibial torsion at a level that would be defined as having idiopathic torsional deformities. This reflects the range of severity of torsional deformities, symptoms and gait dysfunction seen routinely in the HWGAL. This cohort of children had on average increased prevalence of pain, altered joint range of motion, increased femoral and tibial
Summary
This study has highlighted that ITD is not purely a cosmetic issue. These children and adolescents have altered gait and experience pain leading to impaired function and diminished participation. We found a weak relationship between the severity of the ITD, gait and participation. To understand the impact of ITD on the individual child we suggest assessment across all domains of the ICF framework including medical imaging, 3DGA and an assessment of activity and participation.
Author’s contributions
Jessie Mackay (Conceptualization, Data curation; Formal analysis; Investigation; Methodology; Project administration; Roles/writing – original draft, review & editing)
Pam Thomason (Conceptualization, Formal analysis; Investigation; Methodology; Roles/writing – original draft, review & editing)
Morgan Sangeux (Conceptualization, Data curation; Roles/writing – original draft, review & editing)
Elyse Passmore (Conceptualization, Data curation; Formal analysis; Methodology; Roles/writing – original
Funding
This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.
Declaration of Competing Interest
Mackay J, Thomason P, Sangeux M, Passmore E, Francis K declare that they have no conflict of interest.
Dr H.K Graham is on Surgeon's Advisory Board of OrthoPediatrics Corp.
References (35)
- et al.
The impact of increased femoral antetorsion on gait deviations in healthy adolescents
J. Biomech.
(2019) - et al.
Biomechanical changes associated with femoral derotational osteotomy
Gait Posture
(2016) - et al.
Hip and patellofemoral joint loading during gait are increased in children with idiopathic torsional deformities
Gait Posture
(2018) - et al.
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) - et al.
Increased femoral anteversion-related biomechanical abnormalities: lower extremity function, falling frequencies, and fatigue
Gait Posture
(2019) - et al.
Femoral anteversion in the hip: comparison of measurement by computed tomography, magnetic resonance imaging, and physical examination
Arthroscopy
(2012) - et al.
A gait analysis data collection and reduction technique
Hum. Mov. Sci.
(1991) - et al.
Defining the medial-lateral axis of an anatomical femur coordinate system using freehand 3D ultrasound imaging
Gait Posture
(2016) Pelvic angles: a mathematically rigorous definition which is consistent with a conventional clinical understanding of the terms
Gait Posture
(2001)- et al.
Determination of the optimal locations of surface-mounted markers on the tibial segment
Gait Posture
(2009)