Increased Femoral Anteversion Does Not Lead to Increased Joint Forces During Gait in a Cohort of Adolescent Patients

Abstract

Orthopedic complications were previously reported for patients with increased femoral anteversion. A more comprehensive analysis of the influence of increased femoral anteversion on joint loading in these patients is required to better understand the pathology and its clinical management. Therefore, the aim was to investigate lower-limb kinematics, joint moments and forces during gait in adolescent patients with increased, isolated femoral anteversion compared to typically developing controls. Secondly, relationships between the joint loads experienced by the patients and different morphological and kinematic features were investigated. Patients with increased femoral anteversion (n = 42, 12.8 ± 1.9 years, femoral anteversion: 39.6 ± 6.9°) were compared to typically developing controls (n = 9, 12.0 ± 3.0 years, femoral anteversion: 18.7 ± 4.1°). Hip and knee joint kinematics and kinetics were calculated using subject-specific musculoskeletal models. Differences between patients and controls in the investigated outcome variables (joint kinematics, moments, and forces) were evaluated through statistical parametric mapping with Hotelling T2 and t-tests (α = 0.05). Canonical correlation analyses (CCAs) and regression analyses were used to evaluate within the patients’ cohort the effect of different morphological and kinematic predictors on the outcome variables. Predicted compressive proximo-distal loads in both hip and knee joints were significantly reduced in patients compared to controls. A gait pattern characterized by increased knee flexion during terminal stance (KneeFlextSt) was significantly correlated with hip and knee forces, as well as with the resultant force exerted by the quadriceps on the patella. On the other hand, hip internal rotation and in-toeing, did not affect the loads in the joints. Based on the finding of the CCAs and linear regression analyses, patients were further divided into two subgroups based KneeFlextSt. Patients with excessive KneeFlextSt presented a significantly higher femoral anteversion than those with normal KneeFlextSt. Patients with excessive KneeFlextSt presented significantly larger quadriceps forces on the patella and a larger posteriorly-oriented shear force at the knee, compared to patients with normal KneeFlextSt, but both patients’ subgroups presented only limited differences in terms of joint loading compared to controls. This study showed that an altered femoral morphology does not necessarily lead to an increased risk of joint overloading, but instead patient-specific kinematics should be considered.

Influence of femoral anteversion angle and neck-shaft angle on muscle forces and joint loading during walking

“…Heller et al [25] showed that increasing the AVA increases hip joint contact forces when tracking the same, subject-speci c motion capture data of four patients with a total hip arthroplasty, which was con rmed by recent simulation studies [26][27][28]. Increased hip and patellofemoral loading was found in children with increased AVA and normal foot progression angle [29], whereas decreased hip and knee loads were observed in children with increased AVA and internal foot progression angle compared to healthy control participants [30]. In summary, previous studies showed that increased AVA alters the moment arms of certain muscles and leads to increased hip and knee joint loads, which can be compensated with an altered gait pattern.…”

“…Neglecting the NSA or AVA, as previously done in some studies [27,30], might lead to errors up to a magnitude of ve times body weight and therefore could lead to mis-leading interpretations.…”

Prediction of ground reaction forces and moments during walking in children with cerebral palsy

“…Deviations in sagittal knee moments in patients compared to controls can be used in CGA to infer quadriceps weaknesses, patellar pain, or quadriceps overload ( Armand et al, 2016 ; De Pieri et al, 2022c ). Furthermore, the knee adduction moment is often used as a surrogate measure for the load distribution between the medial and lateral compartments of the knee ( Holder et al, 2020 ; De Pieri et al, 2022b ), while reduced hip abduction moment in patients can be associated with a functional deficit of the hip abductors in the presence of altered femeral morphologies ( Thielen et al, 2019 ; Alexander et al, 2022 ; De Pieri et al, 2022a ). However, significant differences between the two methods in the computed sagittal and frontal moments for both knee and hip between the two methods suggest that this these metrics should be interpreted carefully while predicting GRF&Ms.…”

“…Personalized models for each subject were created from a detailed generic model of the lower limb ( De Pieri et al, 2018 ) based on a reference cadaveric dataset ( Carbone et al, 2015 ) and scaled to match the overall anthropometrics and marker data collected during the static standing reference trial ( Lund et al, 2015 ; Figure 1 ). The geometry of the femur was linearly morphed to include a transversal rotation between the proximal and distal sections, matching the subject’s femoral anteversion obtained from the clinical assessment ( De Pieri et al, 2021 ; Alexander et al, 2022 ). The hip joints were modeled as 3 degrees-of-freedom (DoFs) ball-and-socket joints, while the knee, talocrural, and subtalar joints were modeled as 1-DoF hinges.…”

The effect of functional calibration methods on gait kinematics in adolescents with idiopathic rotational deformity of the femur

“…Interestingly, these evaluations pertain to static, unloaded situations -which poorly correlate with gait parameters (3)while pain complaints often occur during dynamic activities. 3D gait analysis can likely provide relevant insights into aberrant lower extremity biomechanics and identify relevant compensations during walking, but these analyses have been limited to research settings (2)(3)(4)(5)(6)(7)(8)(9).…”