Professional Documents
Culture Documents
24 (2000) 2: 521–527
UDC 572.781:611.711.718.4
Original scientific paper
ABSTRACT
The femoral neck anteversion angle is an important factor for hip stability and nor-
mal walking. It is multifactoral result of evolution, heredity, fetal development, intra-
uterine position, and mechanical forces. Abnormal FNA sometimes can be associated
with many clinical problems ranging from harmless intoeing gait in the early child-
hood, to disabling osteoarthritis of the hip and the knee in the adults.
In most cases is associated with minor functional problems in children during growth,
but cause a concern in parents for children future. The child must be examined carefully
and an accurate diagnosis must be established. The most important part of care is ob-
servation of the children. If abnormal femoral neck anteversion produces severe func-
tional disability, derotational osteotomy should be done, but delayed until late child-
hood.
521
G. Gulan et al.: Femoral Neck Anteversion, Coll. Antropol. 24 (2000) 2: 521–527
522
G. Gulan et al.: Femoral Neck Anteversion, Coll. Antropol. 24 (2000) 2: 521–527
ranging from 36° at birth to 33°, 28°, 26°, lopment of femoral neck anteversion.
25°, 22°, 21°, 16°,15° in group of age 2–4, Browne18 discussed the relationship of
4–6, 6–8, 8–10, 10–12, 12–14, 14–16 and intrauterine compressive forces and con-
adults, respectively. According to him, va- genital deformities. He observed that me-
lue of FNA regression is about 1.5 (0.2– chanical moulding of the uterus on the
3.1) degrees per year14. limbs resulted in rotational deformities.
Cyvin demonstrated a correlation be- However, the development of femoral
tween the FNA and the build of the anteversion is a multifactoral result of fe-
child15. Slender children on average have tal development, evolution, heredity, me-
higher values of the FNA compared with chanical forces, and intrauterine posi-
those of the more »athletic« type. On the tion19.
other hand, decreased femoral antever-
sion is commonly seen in the obese chil-
FNA and hip rotational movement
dren and in association with slipped capi-
tal femoral epiphysis. When is unilateral, Hip rotational movement is highly de-
it is more common on the right side. Cyvin pendable of the femoral neck anteversion,
was not able to find any correlation be- and some methods for clinical measuring
tween the age of walking start and the FNA are based on the value of hip rota-
values of the FNA, concluding that well tion. While femoral anteversion is great-
balanced muscle tone did not influence on est in children younger than two years of
the FNA15. age, external hip rotation exceeds inter-
nal rotation at three years of age11.
In children older than three years,
Prenatal development
there is a positive correlation between in-
Torsion is extension of a normal devel- ternal rotation of the hip and femoral
opmental process of lower limb. Negative anteversion7,20,21.
torsion in human embryonic femurs has Gelberman et al. (1989) suggested that
much variations. There is an initial nega- greater lateral rotation indicates normal
tive torsion of up to 26 degrees, followed anteversion22, while in our investigations
by the development of positive femoral (in press) we found negative correlation
anteversion averaging 25–31 degrees, at between lateral rotation and femoral an-
birth. No histological changes have ac- teversion. We also found a correlation be-
counted for the torsion4,16, but there may tween differences in passive medial/lat-
be a tendency for sidedness, especially in eral rotation and femoral anteversion
females16. which was the most evident.
Most torsional abnormalities are the
result of intrauterine moulding, and are
Measurement
extreme manifestations of normal devel-
opment. Staheli felt that intrauterine Precise measurement of femoral ante-
flexion, lateral rotation of the hips, and version is important in the selection of
medial rotation of the feet and tibia are patients and the preoperative planning
further exacerbated by compressive for- for derotational osteotomy of the femur.
ces, but that these moulding forces de- There are several methods for the mea-
creased after birth, resulting in gradual surement of femoral anteversion. Rent-
improvement of the deformities16. Accor- genographic techniques include fluorosco-
ding to Le Damany17 muscle tensions and py23, biplane imaging24–27, axial roentgeno-
local forces gave a rotary stress to the graphy28, axial tomography29, ultrasound30,
epiphysis that resulted in the deve- and computerised tomographic scann-
523
G. Gulan et al.: Femoral Neck Anteversion, Coll. Antropol. 24 (2000) 2: 521–527
524
G. Gulan et al.: Femoral Neck Anteversion, Coll. Antropol. 24 (2000) 2: 521–527
525
G. Gulan et al.: Femoral Neck Anteversion, Coll. Antropol. 24 (2000) 2: 521–527
have intoeing gait and radiographic evi- the hip more than 80 degrees44. Consider-
dence of increased femoral anteversi- able care should be taken with the tech-
on6,35,37,41,42. However, others suggested nique. We prefer straight lateral longitu-
that the relationship between increased dinal incision extending distally from the
FNA and idiopathic osteoarthritis has not great trochanter with intertrochanteric
been established sufficiently. level of osteotomy, because the available
In study of cadavers during eleven- bone will ensure good contact between
-year period, Wedge et al. could not con- fragment with good stability and rapid
firm that increased femoral anteversion healing. The rotation should be deter-
alter the risk for development of osteo- mined preoperatively as well as angle of
arthrosis of the hip43. the blade plate, entrance point and the
level of osteotomy. Intraoperatively rota-
tion is monitored by guide K-wires placed
Treatment along the anterior femoral neck and in
Many nonoperative methods have been distal femoral metaphysis perpendicular
proposed (shoe wedges, twister cables, to the long axis of the femur to ensure ac-
night splints)6. According to Staheli44 curacy. Postoperatively the child may be-
nonoperative treatment of abnormal fem- gin weight bearing with crutches within
oral angle anteversion is ineffective. On several days of surgery. Full weight bear-
the basis of medial hip rotation for more ing usually is allowed 8 weeks after sur-
than 70 degrees he suggested that ap- gery.
pearance of increased femoral antever-
sion under 8 years of age has to be ob-
Conclusion
served and in 99% has spontaneous re-
gression. This is confirmed by findings of Increased femoral neck anteversion is
Sveningsen who found that frequence of common problem in childhood. In most
intoieng gait decreased from 30% in 4 cases is associated with minor functional
years old children to 4% in adults. If it is problems in children during growth, but
mild to moderate increased femoral ante- cause a concern in parents for children
version which appear after 8 age the future. The child must be examined care-
treatment is the same. The operative pro- fully and an accurate diagnosis must be
cedure should be performed only in chil- established. The most important part of
dren after the age of 8 (Staheli) or 12 care is observation of the children. If ab-
(Sveningsen) if they still have consider- normal femoral neck anteversion produ-
able problems connected with walking. ces sever functional disability, derotati-
The angle of anteversion should be more onal osteotomy should be done, but
than 50 degrees and medial rotation of delayed until late childhood.
REFERENCES
1. LE DAMANY, P. Z., Ortop., 21 (1908) 129. — 2. JESEN, M. AUFLEM, V. BERG, Clin. Ortop. Rel.
MCKIBBIN, B. J., Bone Joint Surg., 48 (1970) 148. — Res., 60 (1989)177. — 8. MITTELEMIER, H., M. JA-
3. GETZ, B., Acta Orthop. Scand. Suppl., 18 (1955) — GER, Arch. Orthop. Unfall-Chir., 65 (1969) 1. — 9.
4. REIKARS, O., I. BJERKREIM, A. KOLBENS- SCHOLDER, P., Orthopade, 8 (1979) 12. — 10. FABRY,
TVEDT, Acta. Orthop Scand., 53 (1982) 781. — 5. G., D. MACEWEN, A. R. SHANDS, J. Bone Joint
SCHWARZENBACH, U., Arch. Orthop. Unfall-Chir., Surg., 55 (1973) 1726. — 11. STAHELI, L. T., Orthop.
70 (1971) 230. — 6. JANI, L., U. SCHWARZEN- Ttransl., 4 (1980) 64. — 12. EVANS, F. G., V. E.
BACH, K. AFIFI, P. SCHOLDER, P. GISLER, Ortho- KRAHL, Am. J. Anat., 76 (1945) 76. — 13. KATE, B.
pade, 8 (1979) 5. — 7. SVENNINGSEN, S., T. TER- R., Acta Anat., 94 (1976) 457. — 14. SVENNINGSEN,
526
G. Gulan et al.: Femoral Neck Anteversion, Coll. Antropol. 24 (2000) 2: 521–527
S., University of Trondheim, Faculty of Medicine, Radiol., 22 (1993) 33. — 31. WEINER, D. S., A. J.
Trondheim, Norvey 1991. — 15. CYVIN, K. B., Acta COOK, W. A. HOYT, C. E. ORFNAEC, Orthopaedics,
Orthop. Scand. Suppl., 166 (1971) 1. — 16. STAHELI, 1 (1989) 299. — 32. RUWE, P. A., J. R. AGAE, M. B.
L. T., M. CORBETT, C. WYSS, J. Bone Joint Surg., 39 OZHONOFF, P. A. DELUCA, J. Bone Joint Surg.,
(1985) 39. — 17. LE DAMANY, P., J., Anat et Phy- 74A (1992) 820. — 33. KO@I], S., G. GULAN, D. MA-
siol., 45 (1909) 589 — 18. BROWNE, D., Arch. Dis. TOVINOVI], B. NEMEC, B. [ESTAN, J. RAVLI]-
Child., 30 (1955) 37. — 19. GUIDERA K. J., T. M. GULAN, Acta Orthop. Scand., 66 (1997) 533. — 34.
GANEY, C. R. KENEALLY, J. OGDEN, Clin. Orthop. INSALL, J., K. A. FALVO, D. W. WISE, J. Bone Joint
Rel. Res., 302 (1994) 17. — 20. CRANE, L., J., Bone Surg., 58A (1976) 1 — 35. HALPERN, A. A., J. TANER,
Joint Surg., 41A (1959) 421. — 21. STAHELI, L. T., W. L. RINSKY, Clin. Orthop., 145 (1979) 213. — 36. TUR-
R. DUNCAN, E. SCHAEFER, Clin. Orthop., 60 (1968) NER, M. S., I. S. SMILIE, J. Bone Joint Surg., 63B
205. — 22. GELBERMAN, R. H, M. S. COHEN, S. S. (1981) 396. — 37. TERJESEN, T., P. BENUM, S. ANDA,
DESAI, P. P. GRIFFIN, P. B. SALAMON, T. M. S. SVENNINGSEN, Acta Orthop. Scand., 53 (1982)
O’BRIEN, J. Bone Joint Surg., 69B (1994) 75. — 23. 571. — 38. McEWEN, M. D., Postgrad. Med. 60 (1976)
ROGERS, S. P., J. Bone Joint Surg., 60B (1978) 530. 154. — 39. FAIRBANK, J. C., P. B. PYNSENT, J. A.
— 24. DUNLAP, K., A. R. Jr. SHANDS, J., Bone Joint VAN POORTVLIET, H. FHILIPS, J. Bone Joint Surg.,
Surg., 35A (1953) 289. — 25. LEE, D. Y., C. K. LEE, T. 66B (1984) 685. — 40. LEFORT, G., J. COTTALARD, F.
J. CHO, Internat. Orthop., 16 (1992) 277. — 26. LEFEVRE, M. A. BUCH-PILLON, S. DAOUD, Rev.
MAGILLIGAN, D. J., J., Bone Joint Surg., 38A (1956) Chir. Orthop., 77 (1991) 491. — 41. ALVIK, I., Clin. Ort-
846. — 27. OGATA, K., E. M. GOLDSAND, J. Bone hop., 22 (1962) 16. — 42. REIKARS, O., A. HOISETH,
joint Surg., 61A (1978) 846. — 28. DUNN, D. M., J., Acta Orthop. Scand., 53 (1982) 781. — 43. WEDGE, J.
Bone joint Surg., 34B (1952) 181. — 29. HUBBARD, H., I. MUNKACSI, D. LOBACK, J. Bone Joint Surg.,
D. D., L. T. STAHELI, Clin. Orthop., 86 (1972) 16. — 71A (1989) 1040. — 44. STAHELI, L. T., J. Bone Joint
30. TERJESEN, T., S. ANDA, H. RONNINGEN, Skel. Surg., 75A (1993) 939.
D. Matovinovi}
SA@ETAK
Anteverzija vrata femura predstavlja va`an ~imbenik stabilnosti kuka pri stajanju i
hodu. Brojni etiolo{ki ~imbenici utje~u na njen razvoj kao {to su evolucija, naslje|e,
fetalni razvoj, intrauterini polo`aj i djelovanje mehani~kih sila. Pove}an kut antever-
zije vrata femura mo`e biti uzrokom mnogih klini~kih problema, od bezazlenog hoda s
uvrnutim prstima, pa do te{kih osteoartrotskih promjena zgloba kuka i koljena. U
ve}ini slu~ajeva povezan je s prolaznim problemima tijekom razvoja djeteta, ali ~esto
uzrokuje zabrinutost roditelja. Djeca moraju pa`ljivo biti pregledana uz postavljanje
odgovaraju}e dijagnoze, pri ~emu promatranje djeteta mora biti jedan od najva`nijih
dijelova lije~enja. Ako pove}an kut anteverzije vrata femura uzrokuje zna~ajne funk-
cionalne smetnje preporu~a se u~initi derotacijsku osteotomiju u predpubertetskom
razdoblju.
527