Torsional profile versus gait analysis: Consistency between the anatomic torsion and the resulting gait pattern in patients with rotational malalignment of the lower extremity

doi:10.1016/j.gaitpost.2010.06.019

Gait & Posture

Volume 32, Issue 3, July 2010, Pages 405-410

https://doi.org/10.1016/j.gaitpost.2010.06.019 Get rights and content

Abstract

Measurements of femoral and tibial torsion obtained from radiographs or computed tomographic scans have been used to describe rotational malalignment of the lower extremities and to clarify indications for surgery. A weak relationship between anatomic torsion deformity and the resulting transverse plane gait pattern in patients with cerebral palsy has been described, but the observations have not yet been tested in an able-bodied patient population. We conducted a prospective study to investigate the correlation of femoral torsion and tibial torsion as measured by using computed tomography with transverse plane gait data for patients with rotational malalignment. Twenty-six lower limbs from 26 patients selected for surgery based on gait analysis were evaluated. Calculation of Pearson correlations showed that increase of femoral anteversion resulted in increase of pelvic range of motion. A very weak correlation between femoral torsion and hip rotation (determination coefficient, R² = 0.22) was found in a linear regression model, whereas tibial torsion and knee rotation showed a strong correlation (determination coefficient, R² = 0.71). The correlation between the foot progression angle and tibial torsion was higher than between the foot progression angle and femoral torsion. We conclude that there is a considerable dynamic influence of mechanisms of compensation, especially in the hip, that should be considered when evaluating the torsional profile. We therefore recommend conducting three-dimensional instrumented gait analysis for patients undergoing surgical correction of rotational malalignment.

Introduction

Rotational malalignment of the lower extremities is a common reason patients seek orthopaedic consultations. Although most rotational deformities seen in daily practice are minor and have little clinical significance, more severe rotational malalignment with functional and cosmetic disability may warrant surgical correction [1], [2], [3], [4]. Planning surgical correction requires assessment of amount of malrotation and determination of degree of derotation required.

Computed tomography (CT) currently is thought to be the most accurate diagnostic tool for analyzing femoral and tibial torsion [5], [6], [7], [8]. Torsional angle values and clinical evaluation of the torsional profile are the bases of current treatment recommendations [1]. However, in many cases, it seems that femoral and tibial torsion values shown by CT are not consistent with the rotational profile during gait as observed during clinical evaluation or gait analysis. This suggests mechanisms of dynamic compensation.

Bruce and Stevens [9] observed that many patients with miserable malalignment syndrome had significant inward rotation of the knee, even when more than 10° of outward femoral rotation was observed during range of motion examination, indicating that clinical range of motion, anatomic anteversion and resulting gait pattern are not consistent. A similar observation was made by Bennett et al. [10] who studied rotational osteotomies of the tibia and fibula. The authors recommended observation of gait as the most important part of physical examination to determine foot position during stance phase. They noted that although CT was extremely accurate in assessing structural torsional alignment, it did not recognize the dynamic component of a malrotated foot.

Influences of dynamic compensation in the transverse plane during gait have received little attention to date. Most reported studies on gait analysis for evaluation of rotational malalignment were performed in neuro-orthopaedic patient populations [11], [12]. In those patients, a significant dynamic component during gait and low correlation between gait analysis data and anatomic deformity were found [11]. Mechanisms of compensation have also been described for able-bodied patients with rotational malalignment, based on clinical observations in the gait laboratory [13], but no studies evaluating or confirming the mechanisms have been published.

We hypothesized that femoral torsion values measured with CT have weak correlation with transverse plane pelvis angle, hip joint angle, and foot progression angle from three-dimensional gait analysis, whereas tibial torsion is better reflected by gait pattern with good correlation with the transverse plane knee joint angle and foot progression angle. To test this hypothesis, we correlated transverse plane data from instrumented three-dimensional gait analysis with the anatomic rotational profile as revealed by CT.

Section snippets

Participants

Seventy-nine patients with rotational malalignment presented at our tertiary referral center for pediatric orthopaedics during a 3-year study period and underwent instrumented three-dimensional gait analysis. Thirty-four of the 79 patients were considered for surgical correction based on clinical examination and gait analysis findings and were referred for CT.

Exclusion criteria were time period longer than 4 months between gait analysis and CT, neurological disorder, surgery of the lower

Results

After a first examination of gait analysis data sets of 28 patients, eight lower limbs from six patients with bilateral rotational malalignment were excluded because they had more than 15° of frontal plane varus–valgus movement in the knee joint. Of the remaining 48 lower limbs, 22 right lower limbs were excluded to analyze only independent data points, leaving 26 lower limbs from 26 patients for statistical evaluation.

Mean femoral torsion assessed based on CT was 28° (range, 2° of femoral

Discussion

Our results confirm our hypothesis that even in an otherwise healthy patient population, femoral torsion is only conditionally reflected in rotational alignment during gait. This is direct evidence that mechanisms of compensation significantly influence rotational gait pattern at the hip joint level.

Correlations between femoral torsion values shown by CT and gait analysis data for the pelvis confirm compensation mechanisms of the pelvis in the presence of increased femoral anteversion.

Conflict of interest

The authors do not have any conflict of interest.

Funding

The present study was not supported by any funding source and no funding for writing assistance has been received.

Acknowledgments

We thank Senior Editor and Writer Dori Kelly, MA, for her expertise in the preparation of this manuscript.

All authors were fully involved in the study and preparation of the manuscript and the material within has not been and will not be submitted for publication elsewhere.

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Torsional profile versus gait analysis: Consistency between the anatomic torsion and the resulting gait pattern in patients with rotational malalignment of the lower extremity

Abstract

Introduction

Section snippets

Participants

Results

Discussion

Conflict of interest

Funding

Acknowledgments

Gait Posture

Gait Posture

Gait Posture

Gait Posture

Gait Posture

Rotational problems in children

J Bone Joint Surg Am

Angular and torsional deformities of the lower limbs in children

Clin Orthop Relat Res

Torsion—treatment indications

Clin Orthop Relat Res

Lower-extremity rotational problems in children. Normal values to guide management

J Bone Joint Surg Am

Three-dimensional computed tomography reconstruction of tibial torsion

Clin Orthop Relat Res

Tibial torsion calculated by computerised tomography and compared to other methods of measurement

J Bone Joint Surg Br

CT determination of femoral torsion

AJR Am J Roentgenol

Computed tomography in the measurement of femoral anteversion

Orthopedics

Surgical correction of miserable malalignment syndrome

J Pediatr Orthop