To determine the association between femoral torsion and anterior cruciate ligament (ACL) rupture and determine the level of torsion using magnetic resonance imaging (MRI).
The medical records of patients who were diagnosed with ACL injury were reviewed retrospectively. This descriptive epidemiological study included 2344 patients. MRI scans were examined and patients with femur and knee MRI scans obtained at the same time were identified (ACL-deficient group). Twenty-eight of them had femur and knee MRI scans because of an incidental benign lesion in the distal femur. Patients who were diagnosed with enchondroma were followed up by MRI evaluation of the femur and were randomly selected as controls. Supratrochanteric torsion (STT), infratrochanteric torsion (ITT), and femoral anteversion (FA) were measured by orthopedic surgeons with at least 5 years of experience.
Age, sex, and side properties were similar in both groups. The mean FA values were 19.4 ± 3.0 degrees and 11.9 ± 2.0 degrees in the ACL-deficient and control groups, respectively (p < 0.001). STT was similar in the ACL-deficient and control groups [mean: 38.2 ± 4.3 and 37.7 ± 3.3, respectively, (n.s.)]. ITT was increased in the ACL-deficient group compared with the control group (mean − 18.8 ± 4.3 and − 25.8 ± 3.8, respectively; p < 0.001).
According to our results, increased FA was associated with ACL rupture. Further, the torsional abnormality was developed from the ITT. We concluded that each ACL-deficient patient should be assessed by a clinician for torsional abnormality using physical examination.
Level of evidence
This is a preview of subscription content, log in to check access.
Buy single article
Instant access to the full article PDF.
Price includes VAT for USA
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
This is the net price. Taxes to be calculated in checkout.
Amraee D, Alizadeh MH, Minoonejhad H, Razi M, Amraee GH (2017) Predictor factors for lower extremity malalignment and non-contact anterior cruciate ligament injuries in male athletes. Knee Surg Sports Traumatol Arthrosc 25(5):1625–1631
Beaulieu ML, Oh YK, Bedi A, Ashton-Miller JA, Wojtys EM (2014) Does limited internal femoral rotation increase peak anterior cruciate ligament strain during pivoted landing? Am J Sports Med 42(12):2955–2963
Beebe MJ, Wylie JD, Bodine BG, Kapron AL, Maak TG, Mei-Dan O, Aoki SK (2017) Accuracy and reliability of computed tomography and magnetic resonance imaging compared with true anatomic femoral version. J Pediatr Orthop 37(4):e265–e270
Boszczyk A, Fudalej M, Kwapisz S, Klimek U, Maksymowicz M, Kordasiewicz B, Rammelt S (2018) Ankle fracture—correlation of Lauge-Hansen classification and patient reported fracture mechanism. Forensic Sci Int 282:94–100
Botser IB, Ozoude GC, Martin DE, Siddiqi AJ, Kuppuswami S, Domb BG (2012) Femoral anteversion in the hip: Comparison of measurement by computed tomography, magnetic resonance imaging, and physical examination. Arthroscopy 28(5):619–627
Brandon ML, Haynes PT, Bonamo JR, Flynn MI, Barrett GR, Sherman MF (2006) The association between posterior-inferior tibial slope and anterior cruciate ligament insufficiency. Arthroscopy 22(8):894–899
Chaudhari AM, Andriacchi TP (2006) The mechanical consequences of dynamic frontal plane limb alignment for non-contact ACL injury. J Biomech 39(2):330–338
Diederichs G, Köhlitz T, Kornaropoulos E, Heller MO, Vollnberg B, Scheffler S (2013) Magnetic resonance imaging analysis of rotational alignment in patients with patellar dislocations. Am J Sports Med 41(1):51–57
Faulks S, Brown K, Birch JG (2017) Spectrum of diagnosis and disposition of patients referred to a pediatric orthopaedic center for a diagnosis of intoeing. J Pediatr Orthop 37:e432–e435
Fritz B, Bensler S, Leunig M, Zingg PO, Pfirrmann CWA, Sutter R (2018) MRI assessment of supra- and infratrochanteric femoral torsion: association with femoroacetabular impingement and hip dysplasia. AJR Am J Roentgenol 211(1):155–161
Kaneko M, Sakuraba K (2013) Association between femoral anteversion and lower extremity posture upon single-leg landing: implications for anterior cruciate ligament injury. J Phys Ther Sci 25(10):1213–1217
LaPrade RF, Burnett QM (1994) Femoral intercondylar notch stenosis and correlation to anterior cruciate ligament injuries. A prospective study. Am J Sports Med 22(2):198–202
Lauge-Hansen N (1950) Fractures of the ankle. II. Combined experimental-surgical and experimental-roentgenologic investigations. Arch Surg 60(5):957–985
Maier C, Zingg P, Seifert B, Sutter R, Dora C (2012) Femoral torsion: reliability and validity of the trochanteric prominence angle test. Hip Int 22(5):534–538
Matovinović D, Nemec B, Gulan G, Sestan B, Ravlić-Gulan J (1998) Comparison in regression of femoral neck anteversion in children with normal, intoeing and outtoeing gait–prospective study. Coll Antropol 22(2):525–532
Muhamad AR, Freitas JM, Bomar JD, Dwek J, Hosalkar HS (2012) CT and MRI lower extremity torsional profile studies: measurement reproducibility. J Child Orthop 6(5):391–396
Remer EM, Fitzgerald SW, Friedman H, Rogers LF, Hendrix RW, Schafer MF (1992) Anterior cruciate ligament injury: MR imaging diagnosis and patterns of injury. Radiographics 12(5):901–915
Renstrom P, Ljungqvist A, Arendt E, Beynnon B, Fukubayashi T, Garrett W, Georgoulis T, Hewett TE, Johnson R, Krosshaug T, Mandelbaum B, Micheli L, Myklebust G, Roos E, Roos H, Schamasch P, Shultz S, Werner S, Wojtys E, Engebretsen L (2008) Non-contact ACL injuries in female athletes: an International Olympic Committee current concepts statement. Br J Sports Med 42(6):394–412
Sanders TG, Medynski MA, Feller JF, Lawhorn KW (2000) Bone contusion patterns of the knee at MR imaging: footprint of the mechanism of injury. Radiographics 20:135–151
Sankar WN, Neubuerger CO, Moseley CF (2009) Femoral anteversion in developmental dysplasia of the hip. J Pediatr Orthop 29(8):885–888
Shin C, Chaudhari AM, Andriacchi TP (2011) Valgus plus internal rotation moments increase anterior cruciate ligament strain more than either alone. Med Sci Sports Exerc 43(8):1484–1491
Shen X, Xiao J, Yang Y, Liu T, Chen S, Gao Z, Zuo J (2019) Multivariable analysis of anatomic risk factors for anterior cruciate ligament injury in active individuals. Arch Orthop Trauma Surg 139(9):1277–1285
Stride D, Wang J, Horner NS, Alolabi B, Khanna V, Khan M (2019) Indications and outcomes of simultaneous high tibial osteotomy and ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 27(4):1320–1331
Sutter R, Dietrich TJ, Zingg PO, Pfirrmann CW (2012) Femoral antetorsion: comparing asymptomatic volunteers and patients with femoroacetabular impingement. Radiology 263(2):475–483
Takagi S, Sato T, Watanabe S, Tanifuji O, Mochizuki T, Omori G, Endo N (2018) Alignment in the transverse plane, but not sagittal or coronal plane, affects the risk of recurrent patella dislocation. Knee Surg Sports Traumatol Arthrosc 26(10):2891–2898
Vasta S, Andrade R, Pereira R, Bastos R, Battaglia AG, Papalia R, Espregueira-Mendes J (2018) Bone morphology and morphometry of the lateral femoral condyle is a risk factor for ACL injury. Knee Surg Sports Traumatol Arthrosc 26(9):2817–2825
Yu B, Lin CF, Garrett WE (2006) Lower extremity biomechanics during the landing of a stop-jump task. Clin Biomech (Bristol, Avon) 21(3):297–305
Zhang L, Hacke JD, Garrett WE, Liu H, Yu B (2019) Bone bruises associated with anterior cruciate ligament injury as indicators of injury mechanism: a systematic review. Sports Med 49(3):453–462
Conflict of interest
Yakup Alpay, Atakan Ezici, Bilal Kurk, Osman Nuri Ozyalvac, Evren Akpinar, Avni Ilhan Bayhan declare no conflict of interest.
The study was approved by the Health Sciences University Baltalimani Bone and Joint Diseases Training and Research Hospital institutional review board (Approval ID number: 43-304).
The need for informed consent was waived because of the study’s retrospective descriptive epidemiological design.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Alpay, Y., Ezici, A., Kurk, M. et al. Increased femoral anteversion related to infratrochanteric femoral torsion is associated with ACL rupture. Knee Surg Sports Traumatol Arthrosc (2020). https://doi.org/10.1007/s00167-020-05874-0
- Anterior cruciate ligament injury
- Anterior cruciate ligament
- Femoral anteversion
- Supratrochanteric torsion
- Infratrochanteric torsion
- Risk factor