Search Results (13)

Background: Pes planovalgus affects 44–54% of preschool children and represents one of the most common concerns in pediatric orthopedic practice. Aim: This narrative review synthesizes the evidence linking increased femoral antetorsion to pediatric flatfoot deformity. Methods: A comprehensive literature search was conducted in PubMed, Scopus, and Web of Science through January 2026. The initial search yielded 847 records; after screening, 52 studies were included, 29 of which are directly cited. Search terms included combinations of: “femoral antetorsion” OR “femoral anteversion” AND “flatfoot” OR “pes planovalgus” AND “children” OR “pediatric”. Results: Strong correlations exist between flatfoot and increased internal hip rotation (as a proxy for femoral antetorsion) in preschool children (r = 0.53–0.77), suggesting an association, though direct causation remains unproven. Both deformities share similar developmental trajectories with spontaneous resolution by school age. The biomechanical model proposes that elevated antetorsion reduces gluteus medius moment arms by 40–50%, necessitating compensatory hip internal rotation; however, this derives from computational models and cerebral palsy populations, with limited direct validation in typically developing children. Femoral derotation osteotomy improves the foot progression angle, though transfer efficiency is incomplete (~54% of surgical correction manifests distally). Conclusions: Femoral antetorsion and pes planovalgus are strongly associated in preschool children, though whether this represents a direct mechanistic cascade or parallel manifestations of common developmental factors remains uncertain. This understanding supports watchful waiting in preschool children and, in persistent cases, prioritizes the assessment of the entire rotational profile before intervention. Full article

The relationship between femoral deformity and gait deviation is complex. Femoral anteversion can be assessed using the trochanter prominence angle test or by imaging techniques. Hip rotation during gait can be determined using conventional 3D gait analysis methods including palpation of femoral epicondyles or by using functional calibration. This study re-evaluates the indications for femoral osteotomies in this context. Hip rotation was analysed using predictive and functional methods in 80 patients who were referred for gait analysis due to rotational gait issues. Femoral anteversion was determined both manually and via MRI. In severe cases of femoral malalignment, the trochanter prominence angle test systematically underestimates the deformity by up to 15° compared to MRI results. Hip rotation, as measured by functional methods, also underestimates the outcome obtained by conventional methods, by up to 5°. Regardless of the method used, significant variability in hip rotation is observed during gait when the femoral deformation is moderate (anteversion between 0° and 30°). More severe deformities are not fully compensated for during gait. In cases of severe femoral malalignment, the functional change after osteotomy does not match the amount of derotation. Furthermore, both the trochanter prominence angle test and hip rotation during gait, as monitored via functional methods, underestimate the problem in the transverse plane. Full article

Objectives: This retrospective study examines acetabular morphology and defects in children with cerebral palsy (CP). The study discovers the usefulness and reliability of a reconstructed 3D CT measurement technique and compares it to conventional radiographic measurements. Methods: 33 subjects with CP who underwent hip reconstruction, including Dega osteotomy and varus derotation femoral osteotomy, were included and compared to an age-matched group of 42 typically developing children. We reproduced a three directional acetabular index (3DAI), including anterosuperior, superolateral and posterosuperior indices in CT analysis, and compared them with established radiographic measurements for the migration percentage (MP) and the acetabular index (AI). Results: The results showed significantly higher 3DAI in every direction of wall deficiency, accentuating the methods sensitivity for acetabular dysplasia. The interrater and test–retest reliability were robust with ICC = 0.939–0.988 for the CP group. Conventional radiographic measurements demonstrated better discriminative power for identifying hip dislocation and correlated strongly with the 3DAI (p < 0.001). Conclusions: The 3DAI method showcases an important addition to the conventional radiographic measurements by enabling a quantification of the defect amount and direction for operative planning. The study supports the potential of a 3D analysis in the improvement of diagnostic precision and suggests a continuous refinement of the CT measurement technique. Full article

Background: The Derotational femoral osteotomy (DFO) is an effective surgical treatment for patients with disabling anterior knee pain associated with pathological Femoral anteversion (FAV). However, the complexity in determining the precise origin of the deformity has put limits on its use. This study aims to review the literature to learn how the authors study the origin of the deformity and then provide a new methodology using 3D technology to assess the origin of FAV. Methods: A search of the literature was conducted on PubMed utilizing the following search string: “anteversion” and “femur” or “origin” or “CT” or “MRI” or “3D”. In addition, an observational study was conducted on CT scans of six femurs from three female patients with unilateral pathological FAV. This work represents a pilot study and should be considered preliminary. Using the 3DSlicer (version 4.11.20210226), MeshMixer (version3.5), and 3DBuilder software (Microsoft.com), 3D biomodels were generated. A mirrored healthy femur served as a reference. The CloudCompare software (software version 2.13.0) was used to compare volumetric structures and analyze torsional deformities. Torsion at each level was quantified using MATLAB (software version 23.2). Results: The 3D technology identified three torsional patterns: 1. FAV predominantly originating at the femoral head (distance between the centroids = maximum deformity in the last discs, which coincides with the proximal region of the femur; heat maps = red in the proximal femur); 2. FAV primarily affects the mid-distal diaphysis (distance between the centroids = maximum deformity in the first discs, which coincides with mid-distal third of the femur; heat maps = red in the diaphyseal level); 3. a pan-diaphyseal deformity involving the entire femur (distance between the centroids = both the first and last discs, means deformity along the entire femur; heat maps = red along the entire femoral diaphysis). Conclusions: All femoral segments contributed to the total FAV, but the location and severity varied among the cases. Pathological FAV is a multifactorial deformity that can arise in different femoral regions. Individualized correction strategies are essential to improving DFO outcomes and preventing secondary deformities. It is important to note that the pilot data is intended to be purely illustrative and, as such, should not be utilized for the purposes of guiding clinical decision-making. Full article

Background: Femoral torsional malalignment is a common cause of in-toeing and out-toeing in children, often leading to gait disturbances, functional limitations, and increased risk of falls. Traditionally, osteotomy was the only surgical option for correction. A minimally invasive technique known as rotational guided growth (RGG) has recently been introduced to address these malalignments. This study aims to assess the effectiveness of rotational femoral malalignment correction by rotational epiphysiodesis with tension band 8-plates (Orthofix, Verona, Italy). Methods: Eleven patients with in-toeing and out-toeing (19 femurs) were treated using RGG with 8-plates. The 8-plates were applied laterally and medially, with screws placed above and below the growth plate of the distal femur, angled obliquely to the long axis of the bone in opposite directions. Changes in foot progression angle (FPA), femoral version, the alteration in the angle between the 8-plates, and the rate of correction were recorded. Results: All patients reported functional gait improvement. The FPA was corrected from a mean of 32 degrees to 7 degrees, the femoral version improved from a mean of 60 degrees to 22 degrees. The angle between the 8-plates changed from a mean of 75 degrees to 28 degrees, with a correction rate of 4.1 degrees per month. The average time for correction was 11 months. No complications were observed during the treatment. Conclusions: RGG using 8-plates is a novel, minimally invasive surgical technique that effectively corrects rotational femoral deformities and may serve as a preferred alternative to derotational osteotomy in growing patients. Full article

Background: Fibrous dysplasia (FD) is a rare condition in which normal spongy and cortical bone is replaced by non-neoplastic fibrous tissue, leading to weakened bone matrix and increased risk of pathological fractures and deformities. Treating these deformities poses a significant challenge for surgeons. While various cases of surgical stabilization and limb lengthening using intramedullary nails have been reported, there is limited evidence on the use of Motorized Intramedullary Limb-Lengthening Nails (MILLNs) in FD patients. This case report presents the clinical history of a patient with FD who underwent multiple surgical interventions to address severe lower limb length discrepancy (LLD) and angular deformity caused by multiple fractures. Case presentation: A sixteen-year-old Caucasian girl with polyostotic FD developed a severe post-traumatic LLD of 10 cm on the right side, associated with coxa vara, valgus knee, and patellar instability. The deformity of the proximal femur was addressed with a valgus and derotational femoral osteotomy. However, this procedure exacerbated the knee’s valgus deformity and only partially corrected the LLD, leading to the decision to proceed with femoral lengthening. A retrograde magnetic intramedullary nail (PRECICE, NuVasive) was utilized for this purpose. Approximately three months postoperatively, radiographs revealed the loosening of the proximal anchoring screw, while the nail had reached maximum distraction. We then proposed reactivating the previously implanted nail. Nine months after the final surgery, standing long-leg radiographs showed a residual shortening of 1 cm, with excellent healing at the fracture sites and the nail and screws remaining securely in place. The patient was monitored regularly, with the latest follow-up occurring four years and five months after the conclusion of the last lengthening procedure. Conclusions: This case report describes the reactivation of a MILLN in a patient with polyostotic fibrous dysplasia. While nail reactivation has been previously described in the literature, to our knowledge, it has not been reported for treating complications arising from FD. In cases of mechanical complications, this approach can equalize leg length discrepancies and correct deformities, avoiding additional invasive surgeries and reducing healthcare costs. As this is an off-label treatment, preoperative consent from both the patient and the parents is required. Full article

(1) Aim: The aim of this study was to determine the relationship between lower limb bone deformities and body functions, activity, and participation in ambulant children with CP and whether changing bone morphology affects outcomes in these domains. (2) Methods: A systematic literature search (PROSPERO CRD42020208416) of studies reporting correlations between measures of lower limb bone deformities and measures of body function, activity or participation, or post-surgical outcomes in these domains was conducted from 1990 to 2023 in Medline, Scopus, and Cochrane Library. We assessed study quality with the Checklist for Case Series (CCS) and a quality assessment developed by Quebec University Hospital. Meta-analysis was not possible; therefore, descriptive synthesis was performed. (3) Results: A total of 12 of 3373 screened articles were included. No studies evaluated the relationships between bone deformities and activity or participation, or the effect of isolated bone surgery on these domains. Correlations between bone deformities and body functions were poor-to-moderate. Internal hip rotation during gait improved after femoral derotation osteotomy. (4) Conclusions: A shift in paradigm is urgently required for the research and management of bone deformities in children with CP to include the activity and participation domains of the ICF, as well as consider more psychological aspects such as self-image. Full article

Asymmetry of pelvic rotation affects function. However, predicting the post-operative changes in pelvic rotation is difficult as the root causes are complex and likely multifactorial. This retrospective study explored potential predictors of the changes in pelvic rotation after surgery with or without femoral derotational osteotomy (FDRO) in ambulatory children with cerebral palsy (CP). The change in the mean pelvic rotation angle during the gait cycle, pre- to post-operatively, was examined based on the type of surgery (with or without FDRO) and CP distribution (unilateral or bilateral involvement). In unilaterally involved patients, pelvic rotation changed towards normal with FDRO (p = 0.04), whereas patients who did not undergo FDRO showed a significant worsening of pelvic asymmetry (p = 0.02). In bilaterally involved patients, the changes in pelvic rotation did not differ based on FDRO (p = 0.84). Pelvic rotation corrected more with a greater pre-operative asymmetry (β = −0.21, SE = 0.10, p = 0.03). Sex, age at surgery, GMFCS level, and follow-up time did not impact the change in pelvic rotation. For children with hemiplegia, internal hip rotation might cause compensatory deviation in pelvic rotation, which could be improved with surgical correction of the hip. The predicted changes in pelvic rotation should be considered when planning surgery for children with CP. Full article

Torsional deformities of the lower limb are common in children with cerebral palsy (CP)-determining gait problems. The mechanisms underlying transverse plane gait deviations arise from a combination of dynamic and static factors. The dynamic elements may be due to spasticity, contractures and muscle imbalances, while the static ones may result from excessive femoral anteversion, which decreases the efficiency of the hip abductors by reducing the muscular lever arms. A therapeutic approach has been identified in multi-level functional surgery for the lower limb. Treating the malalignments of the lower limb with femoral or tibial derotation provides optimal results, especially when supported by adequate biomechanical planning. This planning requires an integrated static-dynamic approach of morphological and functional evaluation, based on radiological measurements, physical examination and gait analysis. Instrumented gait analysis has been confirmed as essential in the evaluation and surgical decision making process for children affected by CP with transverse plane deformities. Computational simulations based on musculoskeletal models that integrate patient-specific CT morphological data into gait analysis can be used for the implementation of a surgical simulation system in pre-operative planning to test the possible effects of the different surgical treatment options on the torsional defects of the lower limbs. Recently, a computer-aided simulation process has been implemented in the preoperative planning of complex osteotomies for limb deformities in children. Three-dimensional (3D) digital models were generated from Computed Tomography (CT) scans, using free open-source software. The aim of this study is to integrate the patient-specific CT musculoskeletal model with morphological data and gait analysis data, with the personalized calculation of kinematic and kinetic parameters, which allow us to generate an “avatar” of the patient for a more in-depth evaluation of the gait abnormalities. The computational simulation platform proposed provides a realistic movable musculoskeletal model in a virtual environment, with the possibility of planning and monitoring the effects of virtual three-dimensional surgical corrections. Full article

Background: Hip displacement in children with cerebral palsy (CP) has a higher prevalence in non-ambulatory children. Progression can lead to pain, pelvic obliquity and difficulty with sitting. This can be addressed with hip reconstruction. Our study aims to report the long-term radiological outcomes after hip reconstruction, in particular the evolution of femoral head deformity. Methods: A total of 58 hips of non-ambulatory children with CP were evaluated retrospectively using pre-operative, early (median 120 days) and late post-operative (median 8.6 years) anteroposterior standardised radiographs. All the hips were treated with femoral shortening varus derotation osteotomy (VDRO), pelvic osteotomy and an open reduction, if indicated. The radiographical indices measured included the migration percentage (MP), sharp angle, acetabular index, centre-edge angle, neck shaft angle, head shaft angle, pelvic obliquity, femoral head sphericity, femoral head deformity (FHD) and growth plate orientation. Results: Improvements in hip congruency and morphology were evident after reconstructive hip surgery. These were maintained at the late post-operative time point. Median MP improved from 56% (IQR 46–85%) to 0% (IQR 0–15%) at early follow-up. This increased to 12% (IQR 0–20%) at late follow-up. Pre-operatively, FHDs of 14 hips (24%) were classified as grade A (spherical femoral head). This increased to 22 hips (38%) at early follow-up and increased further to 44 hips (76%) at late follow-up. Conclusions: Our study shows that hip reconstruction reduces hip displacement in the long term, indicated by decreased post-operative MP maintained at long-term follow-up. Although non-ambulatory children lack weight-bearing forces promoting bone remodelling, improved femoral head morphology after surgery alters the forces between the acetabulum and the femoral head. Mild femoral head deformity (grades A and B) remained stable and even improved after surgery, postulated to be due to severe osteoporosis allowing remodelling. Full article

Multibody optimisation approaches have not seen much use in routine clinical applications despite evidence of improvements in modelling through a reduction in soft tissue artifacts compared to the standard gait analysis technique of direct kinematics. To inform clinical use, this study investigated the consistency with which both approaches predicted post-surgical outcomes, using changes in Gait Profile Score (GPS) when compared to a clinical assessment of outcome that did not include the 3D gait data. Retrospective three-dimensional motion capture data were utilised from 34 typically developing children and 26 children with cerebral palsy who underwent femoral derotation osteotomies as part of Single Event Multi-Level Surgeries. Results indicated that while, as expected, the GPS estimated from the two methods were numerically different, they were strongly correlated (Spearman’s ρ = 0.93), and no significant differences were observed between their estimations of change in GPS after surgery. The two scores equivalently classified a worsening or improvement in the gait quality in 93% of the cases. When compared with the clinical classification of responders versus non-responders to the intervention, an equivalent performance was found for the two approaches, with 27/41 and 28/41 cases in agreement with the clinical judgement for multibody optimisation and direct kinematics, respectively. With this equivalent performance to the direct kinematics approach and the benefit of being less sensitive to skin artefact and allowing additional analysis such as estimation of musculotendon lengths and joint contact forces, multibody optimisation has the potential to improve the clinical decision-making process in children with cerebral palsy. Full article

Background: The origin of femoral maltorsion is often unknown. However, defining the origin of the rotation of the femoral maltorsion can be useful for establishing the most suitable point to do an external derotational osteotomy. Previous studies have not considered the femoral diaphysis in their investigations of the origin of the deformity. The study of the whole morphology of the femur with 3D volumetric tools, including the femoral diaphysis can contribute to a better understanding of the behavior of femoral maltorsion. Methods: An atypical case of unilateral femoral anteversion was selected. Both femurs were used to obtain 3D bio-models. The mirror image of the asymptomatic side was obtained and overlapped with the symptomatic femur. The Hausdorff–Besicovitch method was used to evaluate the morphologic discrepancies (in mm) between the two femurs in three zones: (1) the femoral neck, (2) the proximal diaphysis, and (3) the distal diaphysis. The differences between the two femurs were analyzed and its correlation was statistically defined using a lineal regression model. Results: The deformity in the distal diaphysis increased from the supracondylar area until the apex of the antecurvatum angle (R² = 0.91) and then decreased until the base of the femoral neck (R² = (−0.83)), to finally increase significantly in the femoral neck area (R² = 0.87). All of the correlations were statistically significant (p-value ˂ 0.001). Conclusion: The femoral maltorsion originates in the supracondylar area and its rotational axis is the longitudinal axis of the femoral diaphysis. Even though the deformity affects the femoral diaphysis, its clinical relevance is much higher in the femoral neck since the rotational axis passes through its base. Thus, the osteotomy can be conducted along all of the femoral diaphysis as long as it is done perpendicular to it. Full article

No previous studies have suggested a reliable criterion for determining the addition of a concomitant pelvic osteotomy by using a large patient cohort with quadriplegic cerebral palsy and a homogenous treatment entity of femoral varus derotational osteotomies (VDRO). In this retrospective study, we examined our results of hip reconstructions conducted without a concomitant pericapsular acetabuloplasty in patients with varying degrees of hip displacement. We wished to investigate potential predictors for re-subluxation or re-dislocation after the index operation, and to suggest the indications for a simultaneous pelvic osteotomy. We reviewed the results of 144 VDROs, with or without open reduction, in 72 patients, at a mean follow-up of 7.0 (2.0 to 16.0) years. Various radiographic parameters were measured, and surgical outcomes were assessed based on the final migration percentage (MP) and the Melbourne Cerebral Palsy Hip Classification Scale (MCPHCS) grades. The effects of potential predictive factors on the surgical outcome was assessed by multivariate regression analysis. A receiver operating characteristic (ROC) curve analysis was also performed to determine whether a threshold of each risk factor existed above which the rate of unsatisfactory outcomes was significantly increased. In total, 113 hips (78.5%) showed satisfactory results, classified as MCPHCS grades I, II, and III. Thirty-one hips (21.5%) showed unsatisfactory results, including six hip dislocations. Age at surgery and preoperative acetabular index had no effects on the results. Lower pre- and postoperative MP were found to be the influential predictors of successful outcomes. The inflection point of the ROC curve for unsatisfactory outcomes corresponded to the preoperative MP of 61.8% and the postoperative MP of 5.1%, respectively; these thresholds of the pre- and postoperative MP may serve as a guideline in the indication for a concomitant pelvic osteotomy. Our results also indicate that the severely subluxated or dislocated hip, as well as the hip in which the femoral head is successfully reduced by VDRO but is still contained within the dysplastic acetabulum, may benefit from concomitant pelvic osteotomy. Full article