Changhoon Jeong; Jong Ho Noh

doi:10.12671/jkfs.2017.30.3.156

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Clinical and Radiological Analysis of Angular Deformity of Lower Extremities: Changhoon Jeong, M.D., Jong Ho Noh, M.D.; Journal of the Korean Fracture Society 2017;30(3):156-166.
DOI: https://doi.org/10.12671/jkfs.2017.30.3.156
Published online: January 10, 2017

Department of Orthopedic Surgery, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Korea

Correspondence to: Changhoon Jeong, M.D. Department of Orthopedic Surgery, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 327 Sosa-ro, Bucheon 14647, Korea Tel: +82-32-340-7089 Fax: +82-32-340-2671 E-mail: changhoonj@gmail.com

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Abstract
REFERENCES

Abstract

The alignment of lower extremities is an important consideration in many clinical situations, including fracture reduction, high tibia osteotomy, total knee arthroplasty, and deformity correction. Malalignment of lower extremities is not only a simple cosmetic problem, but it can also produce pain, limp, and early degenerative arthritis. An assessment of lower extremity alignment, including its location and magnitude of deformity, can be achieved via Malalignment test and mal-orientation test, using a lower extremity standing full-length radiography. Proper evaluation allows the surgeon to determine an effective treatment plan for deformity correction.
Key words: Deformity, Lower extremity

Fig. 1.

Nomenclature of the frontal plane joint orientation angle relative to the mechanical axis (A) and anatomic axis (B). (C) Nomenclature of the sagittal plane joint orientation angle relative to the anatomic axis. LPFA: lateral proximal femoral angle, mLDFA: mechanical lateral distal femoral angle, MPTA: medial proximal tibial angle, LDTA: lateral distal tibial angle, MPFA: medial proximal femoral angle, MNSA: medical neck shaft angle, LDFA: lateral distal femoral angle, JLCA: joint line convergence angle, PPFA: posterior proximal femoral angle, ANSA: anatomic neck shaft angle, PDFA: posterior distal femoral angle, PPTA: posterior proximal tibial angle, ADTA: anterior distal tibial angle.

Fig. 2.

Anatomic axis to joint center distance (aJCD) of the hip joint of the hip (A) and tibia (B). Bold line: anatomic axis, Dot line: joint center point. d: distance.

Fig. 3.

Anatomic axis to joint edge ratio (aJER) of the distal femur and proximal tibia.

Fig. 4.

Mechanical axis deviation (MAD).

Fig. 5.

(A) If center of rotation of angulation (CORA) lies at the point of obvious deformity apex in the bone and the joint orientations are normal, the deformity is uniapical. (B) If CORA lies outside the point of obvious deformity apex or either joint orientation is abnormal, a second CORA exists in that plane and the deformity is multiapical or a translational deformity exists in that plane. (C) When the CORA lies outside the boundaries of the involved bone, a multiapical deformity is likely to be present.

Fig. 6.

The Malalignment test is to identify the sources of mechanical axis deviation. Step 0 is to draw the mechanical axis; Step 1 is to measure the mLDFA; Step 2 is to measure the MPTA; Step 3 is to measure the JLCA; Step 4 is to measure the joint center distance; and Step 5 is to identify the joint surface Malalignment. mLDFA: mechanical lateral distal femoral angle, MPTA: medial proximal tibial angle, JLCA: joint line convergence angle, JCP: joint center point.

Fig. 7.

The standing lateral full length radiography of lower extremity shows 15° of hyperextension (HE) of the knee joint and 120° of PDFA, which is 36° recurvatum of the distal femur. Therefore, there is also 21° of knee joint flexion contracture and genu recurvatum. PDFA: posterior distal femoral angle, PPTA: posterior proximal tibial angle.

Fig. 8.

Analysis of uniapical deformity of the tibia using the mechanical axis: Draw the mechanical axis and measure MAD (A). Draw the mechanical axis of the femur and tibia. Measure mLDFA and MPTA (B). If MPTA is outside the normal range, the mechanical axis of the femur is extended distally as a mechanical axis line when mLDFA is within normal range. Draw the mechanical axis of distal tibia from the center of the ankle parallel to the diaphysis of the tibia and measure LDTA. If LDTA is within normal range, mark the CORA and measure the magnitude of angulation (C). MAD: mechanical axis deviation, mLDFA: mechanical lateral distal femoral angle, MPTA: medial proximal tibial angle, LDTA: lateral distal tibial angle, CORA: center of rotation of angulation, Mag: magnitude of deformity.

Table 1.

Normal Values for Joint Orientation Angles in Lower Extremity

Bone-Plane		Component	Mean value (°)	Normal range (°)
Femur-Frontal
Anatomic medial proximal femoral angle (aMPFA)	Anatomic axis	Trochanter-head line	84	80–89
Mechanical lateral proximal femoral angle (mLPFA)	Mechanical axis	Trochanter-head line	90	85–95
Neck shaft angle (NSA)	Anatomic axis	Femoral neck line	130	124–136
Anatomic lateral distal femoral angle (aLDFA)	Anatomic axis	Distal femoral joint orientation line	81	79–83
Mechanical lateral distal femoral angle (mLDFA)	Mechanical axis	Distal femoral joint orientation line	88	85–90
Femur-Sagittal
Posterior distal femoral angle (PDFA)	Mid-diaphyseal line	Sagittal distal femoral joint orientation line	83	79–87
Tibial-Frontal
Medial proximal tibial angle (MPTA)	Mechanical axis	Proximal tibial joint orientation line	87	85–90
Lateral distal tibial angle (LDTA)	Mechanical axis	Distal tibial joint orientation line	89	88–92
Tibial-Sagittal
Posterior proximal tibial angle (PPTA)	Mid-diaphyseal line	Sagittal proximal tibial joint orientation line	81	77–84
Anterior distal tibial angle (ADTA)	Mid-diaphyseal line	Sagittal distal tibial joint orientation line	80	78–82

Table 2.

Clinical Signs and Symptoms Associated with Sagittal Plane Deformity of Lower Extremity²¹⁾

Sagittal plane deformity	Clinical symptom & sign
Proximal femur flexion deformity	Hyperlordosis of spine
Proximal femur extension deformity	Loss of hip flexion
Distal femur procurvatum	Flexion deformity and stretching of posterior knee joint capsule
Distal femur recurvatum	Loss of flexion
Proximal tibia recurvatum	Chondromalacia patella
Proximal tibia procurvatum	Knee flexion deformiry, chondromalacia & pain
Distal tibia recurvatum	Late degenerative joint disease
Distal tibia procurvatum	Anterior impingement syndrome

REFERENCES

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3. Song HR, Soma Raju VV, Kumar S, et al. Deformity correction by external fixation and/or intramedullary nailing in hypophosphatemic rickets. Acta Orthop, 77:307-314. 2006.
4. Tetsworth K, Paley D. Malalignment and degenerative arthropathy. Orthop Clin North Am, 25:367-377. 1994.
5. Felson DT, Niu J, Gross KD, et al. Valgus malalignment is a risk factor for lateral knee osteoarthritis incidence and progression: findings from the multicenter osteoarthritis study and the osteoarthritis initiative. Arthritis Rheum, 65:355-362. 2013.
6. Moreland JR, Bassett LW, Hanker GJ. Radiographic analysis of the axial alignment of the lower extremity. J Bone Joint Surg Am, 69:745-749. 1987.
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8. Chao EY, Neluheni EV, Hsu RW, Paley D. Biomechanics of malalignment. Orthop Clin North Am, 25:379-386. 1994.
9. Cooke TD, Li J, Scudamore RA. Radiographic assessment of bony contributions to knee deformity. Orthop Clin North Am, 25:387-393. 1994.
10. Yoshioka Y, Siu D, Cooke TD. The anatomy and functional axes of the femur. J Bone Joint Surg Am, 69:873-880. 1987.
11. Brinker MR, O'Connor DP. Principles of malunions. In: Court-Brown CM, Heckman JD, McQueen MM, Ricci WM, III PT, editors. Rockwood and Green's fractures in adults. 8th ed.Philadelphia, Wolters Kluwer Health: 869–894; 2015.
12. Lesiak AC, Vosseller JT, Rozbruch SR. Osteotomy, arthrodesis, and arthroplasty for complex multiapical deformity of the leg. HSS J, 8:304-308. 2012.
13. Krettek C, Miclau T, Grün O, Schandelmaier P, Tscherne H. Intraoperative control of axes, rotation and length in femoral and tibial fractures. Technical note. Injury, 29 Suppl, 3:C29-C39. 1998.
14. Sheehy L, Cooke TD, McLean L, Culham E. Standardized standing pelvis-to-floor photographs for the assessment of lower-extremity alignment. Osteoarthr Cartil, 23:379-382. 2015.
15. Wu CC. Is clinical measurement of anatomic axis of the femur adequate? Acta Orthop, 1–4:2017.
16. Hollister AM, Jatana S, Singh AK, Sullivan WW, Lupichuk AG. The axes of rotation of the knee. Clin Orthop Relat Res, 290:259-268. 1993.
17. Wright JG, Treble N, Feinstein AR. Measurement of lower limb alignment using long radiographs. J Bone Joint Surg Br, 73:721-723. 1991.
18. Paley D. Principles of deformity correction. 3rd ed.Berlin; Springer: 2005.
19. Holme TJ, Henckel J, Hartshorn K, Cobb JP, Hart AJ. Computed tomography scanogram compared to long leg radiograph for determining axial knee alignment. Acta Orthop, 86:440-443. 2015.
20. Sabharwal S, Zhao C. Assessment of lower limb alignment: supine fluoroscopy compared with a standing full-length radiograph. J Bone Joint Surg Am, 90:43-51. 2008.
21. Paley D, Tetsworth K. Mechanical axis deviation of the lower limbs. Preoperative planning of uniapical angular deformities of the tibia or femur. Clin Orthop Relat Res, 280:48-64. 1992.
22. Paley D. Principles of deformity correction. Berlin: Springer; p. 1632005.
23. Paley D, Chaudray M, Pirone AM, Lentz P, Kautz D. Treatment of malunions and mal-nonunions of the femur and tibia by detailed preoperative planning and the Ilizarov techniques. Orthop Clin North Am, 21:667-691. 1990.

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REFERENCES

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Clinical and Radiological Analysis of Angular Deformity of Lower Extremities

J Korean Fract Soc. 2017;30(3):156-166. Published online July 31, 2017

DOI: https://doi.org/10.12671/jkfs.2017.30.3.156

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Clinical and Radiological Analysis of Angular Deformity of Lower Extremities

Fig. 1. Nomenclature of the frontal plane joint orientation angle relative to the mechanical axis (A) and anatomic axis (B). (C) Nomenclature of the sagittal plane joint orientation angle relative to the anatomic axis. LPFA: lateral proximal femoral angle, mLDFA: mechanical lateral distal femoral angle, MPTA: medial proximal tibial angle, LDTA: lateral distal tibial angle, MPFA: medial proximal femoral angle, MNSA: medical neck shaft angle, LDFA: lateral distal femoral angle, JLCA: joint line convergence angle, PPFA: posterior proximal femoral angle, ANSA: anatomic neck shaft angle, PDFA: posterior distal femoral angle, PPTA: posterior proximal tibial angle, ADTA: anterior distal tibial angle.

Fig. 2. Anatomic axis to joint center distance (aJCD) of the hip joint of the hip (A) and tibia (B). Bold line: anatomic axis, Dot line: joint center point. d: distance.

Fig. 3. Anatomic axis to joint edge ratio (aJER) of the distal femur and proximal tibia.

Fig. 4. Mechanical axis deviation (MAD).

Fig. 5. (A) If center of rotation of angulation (CORA) lies at the point of obvious deformity apex in the bone and the joint orientations are normal, the deformity is uniapical. (B) If CORA lies outside the point of obvious deformity apex or either joint orientation is abnormal, a second CORA exists in that plane and the deformity is multiapical or a translational deformity exists in that plane. (C) When the CORA lies outside the boundaries of the involved bone, a multiapical deformity is likely to be present.

Fig. 6. The Malalignment test is to identify the sources of mechanical axis deviation. Step 0 is to draw the mechanical axis; Step 1 is to measure the mLDFA; Step 2 is to measure the MPTA; Step 3 is to measure the JLCA; Step 4 is to measure the joint center distance; and Step 5 is to identify the joint surface Malalignment. mLDFA: mechanical lateral distal femoral angle, MPTA: medial proximal tibial angle, JLCA: joint line convergence angle, JCP: joint center point.

Fig. 7. The standing lateral full length radiography of lower extremity shows 15° of hyperextension (HE) of the knee joint and 120° of PDFA, which is 36° recurvatum of the distal femur. Therefore, there is also 21° of knee joint flexion contracture and genu recurvatum. PDFA: posterior distal femoral angle, PPTA: posterior proximal tibial angle.

Fig. 8. Analysis of uniapical deformity of the tibia using the mechanical axis: Draw the mechanical axis and measure MAD (A). Draw the mechanical axis of the femur and tibia. Measure mLDFA and MPTA (B). If MPTA is outside the normal range, the mechanical axis of the femur is extended distally as a mechanical axis line when mLDFA is within normal range. Draw the mechanical axis of distal tibia from the center of the ankle parallel to the diaphysis of the tibia and measure LDTA. If LDTA is within normal range, mark the CORA and measure the magnitude of angulation (C). MAD: mechanical axis deviation, mLDFA: mechanical lateral distal femoral angle, MPTA: medial proximal tibial angle, LDTA: lateral distal tibial angle, CORA: center of rotation of angulation, Mag: magnitude of deformity.

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Fig. 8.

Clinical and Radiological Analysis of Angular Deformity of Lower Extremities

Table 1.

Normal Values for Joint Orientation Angles in Lower Extremity

Bone-Plane		Component	Mean value (°)	Normal range (°)
Femur-Frontal
Anatomic medial proximal femoral angle (aMPFA)	Anatomic axis	Trochanter-head line	84	80–89
Mechanical lateral proximal femoral angle (mLPFA)	Mechanical axis	Trochanter-head line	90	85–95
Neck shaft angle (NSA)	Anatomic axis	Femoral neck line	130	124–136
Anatomic lateral distal femoral angle (aLDFA)	Anatomic axis	Distal femoral joint orientation line	81	79–83
Mechanical lateral distal femoral angle (mLDFA)	Mechanical axis	Distal femoral joint orientation line	88	85–90
Femur-Sagittal
Posterior distal femoral angle (PDFA)	Mid-diaphyseal line	Sagittal distal femoral joint orientation line	83	79–87
Tibial-Frontal
Medial proximal tibial angle (MPTA)	Mechanical axis	Proximal tibial joint orientation line	87	85–90
Lateral distal tibial angle (LDTA)	Mechanical axis	Distal tibial joint orientation line	89	88–92
Tibial-Sagittal
Posterior proximal tibial angle (PPTA)	Mid-diaphyseal line	Sagittal proximal tibial joint orientation line	81	77–84
Anterior distal tibial angle (ADTA)	Mid-diaphyseal line	Sagittal distal tibial joint orientation line	80	78–82

Table 2.

Clinical Signs and Symptoms Associated with Sagittal Plane Deformity of Lower Extremity²¹⁾

Sagittal plane deformity	Clinical symptom & sign
Proximal femur flexion deformity	Hyperlordosis of spine
Proximal femur extension deformity	Loss of hip flexion
Distal femur procurvatum	Flexion deformity and stretching of posterior knee joint capsule
Distal femur recurvatum	Loss of flexion
Proximal tibia recurvatum	Chondromalacia patella
Proximal tibia procurvatum	Knee flexion deformiry, chondromalacia & pain
Distal tibia recurvatum	Late degenerative joint disease
Distal tibia procurvatum	Anterior impingement syndrome

Table 1. Normal Values for Joint Orientation Angles in Lower Extremity

Table 2. Clinical Signs and Symptoms Associated with Sagittal Plane Deformity of Lower Extremity21)