Skip to main content
SpringerLink
Log in

Proximal external femoral torsion increases lateral femoral shaft bowing: a study based on 3D CT reconstruction models

  • KNEE
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

Femoral bowing influences the genesis and management of knee osteoarthritis (OA). The aim of this study was to investigate the relationship between the femoral torsion angle (FTA) and femoral bowing angle (FBA) in a southern Chinese population. It was hypothesized that a greater FTA would lead to a greater lateral FBA.

Methods

A total of 381 lower extremities from 381 osteoarthritic patients (298 women, 83 men; 201 left, 180 right; mean age 66.5 ± 8.9 years) were retrospectively reviewed. Age, sex, body mass index (BMI), side, height, femoral length (FL), hip–knee–ankle angle (HKA) and FTA were set as FBA-related factors. The three-dimensional (3D) FBA, the angle between the anatomical axis of the proximal femur and the anatomical axis of the distal femur in the plane they form, and its projection on the coronal (lateral FBA) and sagittal (anterior FBA) planes were measured on 3D computed tomography (CT) models. The correlation of the 3D, lateral and anterior FBAs with each of the FBA-related factors was explored using multiple linear regression analysis. The correlation between the FBA and FTA was explored and verified after using propensity score matching to control for the other FBA-related factors.

Results

The mean lateral and anterior FBAs were 5.5°, with 53.5% greater than 5°, and 12.7°, with 70.3% greater than 11°, respectively. 3D FBA was positively correlated with age (Std.Co = 0.113, P < 0.05) and HKA (Std.Co = 0.129, P < 0.05). Lateral FBA was positively correlated with age (Std.Co = 0.118, P < 0.05), female sex (Std.Co = 0.206, P < 0.05), HKA (Std.Co = 0.184, P < 0.05) and FL (Std.Co = 0.220, P < 0.05). Anterior FBA was positively correlated with age (Std.Co = 0.108, P < 0.05) and male sex (Std.Co = 0.108, P < 0.05). When the related factors were balanced between the two groups (NS), FTA did not significantly affect 3D FBA or anterior FBA (NS), while FTA was positively correlated with lateral FBA (Std.Co = 0.165, P < 0.05).

Conclusion

External torsion of the proximal femur increases the lateral FBA by twisting a partial anterior FBA into a lateral FBA, especially in the female population. If a patient is found to have a large lateral FBA preoperatively, one should be alert to the possibility of a concomitant large FTA, as there are implications for femoral orthopedics, TKA and patellofemoral pressure distribution.

Level of evidence

III.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others

References

  1. Akamatsu Y, Kobayashi H, Kusayama Y, Kumagai K, Saito T (2016) Femoral shaft bowing in the coronal and sagittal planes on reconstructed computed tomography in women with medial compartment knee osteoarthritis: a comparison with radiograph and its predictive factors. Arch Orthop Trauma Surg 136:1227–1232

    Article  PubMed  Google Scholar 

  2. Akiyama K, Shibuya T (2018) Influence of femoral bowing on range of motion after total hip arthroplasty. Int Orthop 42:1795–1802

    Article  PubMed  Google Scholar 

  3. Bao Z, Qiao L, Qin J, Xu J, Zhou S, Chen D et al (2017) The assessment of femoral shaft morphology in the sagittal plane in Chinese patients with osteoarthritis-a radiographic analysis. J Orthop Surg Res 12:127

    Article  PubMed  PubMed Central  Google Scholar 

  4. Besier TF, Gold GE, Delp SL, Fredericson M, Beaupre GS (2008) The influence of femoral internal and external rotation on cartilage stresses within the patellofemoral joint. J Orthop Res 26:1627–1635

    Article  PubMed  Google Scholar 

  5. Boisgard S, Moreau PE, Descamps S, Courtalhiac C, Silbert H, Moreel P et al (2003) Computed tomographic study of the posterior condylar angle in arthritic knees: its use in the rotational positioning of the femoral implant of total knee prostheses. Surg Radiol Anat 25:330–334

    Article  CAS  PubMed  Google Scholar 

  6. Chang CB, Choi JY, Koh IJ, Seo ES, Seong SC, Kim TK (2010) What should be considered in using standard knee radiographs to estimate mechanical alignment of the knee? Osteoarthritis Cartilage 18:530–538

    Article  CAS  PubMed  Google Scholar 

  7. Cho MR, Lee YS, Choi WK (2018) Relationship between lateral femoral bowing and varus knee deformity based on two-dimensional assessment of side-to-side differences. Knee Surg Relat Res 30:58–63

    Article  PubMed  PubMed Central  Google Scholar 

  8. Demes B (2007) In vivo bone strain and bone functional adaptation. Am J Phys Anthropol 133:717–722

    Article  PubMed  Google Scholar 

  9. Dennis DA, Komistek RD, Kim RH, Sharma A (2010) Gap balancing versus measured resection technique for total knee arthroplasty. Clin Orthop Relat Res 468:102–107

    Article  PubMed  Google Scholar 

  10. Hauschild O, Muenzberg M, Knothe D, Konstantinidis L, Helwig P, Sudkamp NP et al (2013) Rotational limb alignment changes following total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 21:2346–2354

    Article  PubMed  Google Scholar 

  11. Imhoff FB, Funke V, Muench LN, Sauter A, Englmaier M, Woertler K et al (2020) The complexity of bony malalignment in patellofemoral disorders: femoral and tibial torsion, trochlear dysplasia, TT-TG distance, and frontal mechanical axis correlate with each other. Knee Surg Sports Traumatol Arthrosc 28:897–904

    Article  PubMed  Google Scholar 

  12. Kazemi SM, Shafaghi T, Minaei R, Osanloo R, Abrishamkarzadeh H, Safdari F (2017) The effect of sagittal femoral bowing on the femoral component position in total knee arthroplasty. Arch Bone Jt Surg 5:250–254

    PubMed  PubMed Central  Google Scholar 

  13. Kim HY, Lee SK, Lee NK, Choy WS (2012) An anatomical measurement of medial femoral torsion. J Pediatr Orthop B 21:552–557

    Article  PubMed  Google Scholar 

  14. Kim JM, Hong SH, Kim JM, Lee BS, Kim DE, Kim KA et al (2015) Femoral shaft bowing in the coronal plane has more significant effect on the coronal alignment of TKA than proximal or distal variations of femoral shape. Knee Surg Sports Traumatol Arthrosc 23:1936–1942

    Article  PubMed  Google Scholar 

  15. Krackow KA, Mandeville DS, Rachala SR, Bayers-Thering M, Osternig LR (2011) Torsion deformity and joint loading for medial knee osteoarthritis. Gait Posture 33:625–629

    Article  PubMed  Google Scholar 

  16. Lasam MP, Lee KJ, Chang CB, Kang YG, Kim TK (2013) Femoral lateral bowing and varus condylar orientation are prevalent and affect axial alignment of TKA in Koreans. Clin Orthop Relat Res 471:1472–1483

    Article  PubMed  Google Scholar 

  17. Lazennec JY, Chometon Q, Folinais D, Robbins CB, Pour AE (2017) Are advanced three-dimensional imaging studies always needed to measure the coronal knee alignment of the lower extremity? Int Orthop 41:917–924

    Article  PubMed  Google Scholar 

  18. Liaw CK, Chen YP, Wu TY, Fuh CS, Chang RF (2019) New computerized method in measuring the sagittal bowing of femur from plain radiograph-a validation study. J Clin Med 8:1598

    Article  PubMed  PubMed Central  Google Scholar 

  19. Lu Y, Zheng Z, Chen W, Lv H, Lv J, Zhang Y (2019) Dynamic deformation of femur during medial compartment knee osteoarthritis. PLoS One 20:12

    Google Scholar 

  20. Lu ZH, Yu JK, Chen LX, Gong X, Wang YJ, Leung KK (2012) Computed tomographic measurement of gender differences in bowing of the sagittal femoral shaft in persons older than 50 years. J Arthroplasty 27:1216–1220

    Article  PubMed  Google Scholar 

  21. Maratt J, Schilling PL, Holcombe S, Dougherty R, Murphy R, Wang SC et al (2014) Variation in the femoral bow: a novel high-throughput analysis of 3922 femurs on cross-sectional imaging. J Orthop Trauma 28:6–9

    Article  PubMed  Google Scholar 

  22. Matsumoto T, Hashimura M, Takayama K, Ishida K, Kawakami Y, Matsuzaki T et al (2015) A radiographic analysis of alignment of the lower extremities–initiation and progression of varus-type knee osteoarthritis. Osteoarthritis Cartilage 23:217–223

    Article  CAS  PubMed  Google Scholar 

  23. Matsumoto T, Tsumura N, Kurosaka M, Muratsu H, Kuroda R, Ishimoto K et al (2004) Prosthetic alignment and sizing in computer-assisted total knee arthroplasty. Int Orthop 28:282–285

    Article  PubMed  PubMed Central  Google Scholar 

  24. Moon YW, Kim HJ, Ahn HS, Park CD, Lee DH (2016) Comparison of soft tissue balancing, femoral component rotation, and joint line change between the gap balancing and measured resection techniques in primary total knee arthroplasty: a meta-analysis. Medicine (Baltimore) 95:e5006

    Article  PubMed  Google Scholar 

  25. Mullaji AB, Shetty GM, Lingaraju AP, Bhayde S (2013) Which factors increase risk of malalignment of the hip–knee–ankle axis in TKA? Clin Orthop Relat Res 471:134–141

    Article  PubMed  Google Scholar 

  26. Nakano N, Matsumoto T, Hashimura M, Takayama K, Ishida K, Araki D et al (2016) Coronal lower limb alignment in normal knees—A radiographic analysis of 797 normal knee subjects. Knee 23:209–213

    Article  PubMed  Google Scholar 

  27. Nejima S, Kumagai K, Kobayashi H, Yamada S, Akamatsu T, Ogino T et al (2020) Coronal shaft bowing of the femur affects varus inclination of the surgical transepicondylar axis in varus knee osteoarthritis. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-020-06025-1

    Article  PubMed  Google Scholar 

  28. Nguyen AD, Boling MC, Levine B, Shultz SJ (2009) Relationships between lower extremity alignment and the quadriceps angle. Clin J Sport Med 19:201–206

    Article  PubMed  PubMed Central  Google Scholar 

  29. Palanisami D, Iyyampillai G, Shanmugam S, Natesan R, S R, (2016) Individualised distal femoral cut improves femoral component placement and limb alignment during total knee replacement in knees with moderate and severe varus deformity. Int Orthop 40:2049–2054

    Article  PubMed  Google Scholar 

  30. Powers CM (2003) The influence of altered lower-extremity kinematics on patellofemoral joint dysfunction: a theoretical perspective. J Orthop Sports Phys Ther 33:639–646

    Article  PubMed  Google Scholar 

  31. Sebastian AS, Wilke BK, Taunton MJ, Trousdale RT (2014) Femoral bow predicts postoperative malalignment in revision total knee arthroplasty. J Arthroplasty 29:1605–1609

    Article  PubMed  Google Scholar 

  32. Seitlinger G, Moroder P, Scheurecker G, Hofmann S, Grelsamer RP (2016) The contribution of different femur segments to overall femoral torsion. Am J Sports Med 44:1796–1800

    Article  PubMed  Google Scholar 

  33. Shi X, Li H, Zhou Z, Shen B, Yang J, Pei F (2016) Comparison of postoperative alignment using fixed vs individual valgus correction angle in primary total knee arthroplasty with lateral bowing femur. J Arthroplasty 31:976–983

    Article  PubMed  Google Scholar 

  34. Shimosawa H, Nagura T, Harato K, Kobayashi S, Nakamura M, Matsumoto M et al (2019) Variation of three-dimensional femoral bowing and its relation to physical status and bone mineral density: a study with CT. Surg Radiol Anat 41:1489–1495

    Article  PubMed  Google Scholar 

  35. Soh HH, Chua ITH, Kwek EBK (2015) Atypical fractures of the femur: effect of anterolateral bowing of the femur on fracture location. Arch Orthop Trauma Surg 135:1485–1490

    Article  PubMed  Google Scholar 

  36. Takagi S, Sato T, Watanabe S, Tanifuji O, Mochizuki T, Omori G et al (2018) Alignment in the transverse plane, but not sagittal or coronal plane, affects the risk of recurrent patella dislocation. Knee Surg Sports Traumatol Arthrosc 26:2891–2898

    Article  PubMed  Google Scholar 

  37. Xuan R, Song Y, Baker JS, Gu Y (2020) The evaluation of bone mineral density based on age and anthropometric parameters in southeast Chinese adults: a cross-sectional study. Med Sci Monit 26:e923603

    Article  PubMed  PubMed Central  Google Scholar 

  38. Yau WP, Chiu KY, Tang WM, Ng TP (2007) Coronal bowing of the femur and tibia in Chinese: its incidence and effects on total knee arthroplasty planning. J Orthop Surg (Hong Kong) 15:32–36

    Article  CAS  PubMed  Google Scholar 

Download references

Funding

This study was not funded.

Author information

Author notes

  1. LiMing Liu and Kai Lei contributed to the work equally and should be regarded as co-first authors.

Authors and Affiliations

  1. Center for Joint Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), No. 30 Gaotanyan Street, Shapingba District, Chongqing, 400038, China

    LiMing Liu, Kai Lei, Xin Chen, DeJie Fu, Pengfei Yang, Liu Yang & Lin Guo

Authors
  1. LiMing Liu
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Kai Lei
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Xin Chen
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. DeJie Fu
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Pengfei Yang
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Liu Yang
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Lin Guo
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Lin Guo.

Ethics declarations

Conflict of interest

The authors declare that they have no competing interests.

Ethics approval

Ethical approval was obtained from the local ethical committee (KY201861). All procedures performed were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Liu, L., Lei, K., Chen, X. et al. Proximal external femoral torsion increases lateral femoral shaft bowing: a study based on 3D CT reconstruction models. Knee Surg Sports Traumatol Arthrosc 31, 1524–1532 (2023). https://doi.org/10.1007/s00167-021-06753-y

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00167-021-06753-y

Keywords

Search

Navigation