DROR PALEY PRINCIPLES OF DEFORMITY CORRECTION

Springer-Verlag Berlin Heidelberg GmbH

 DROR PALEY

PRINCIPLES OF 0 EFOR M I TV
CORRECTION
With Editorial Assistance from J. E. Herzenberg

With More Than 1,800 Separate Illustrations,

Clinical Photographs, and Radiographs

i Springer
DROR PALEY,MD,FRCSC ISBN 978-3-642-63953-1 ISBN 978-3-642-59373-4 (eBook)
DOI 10.1007/978-3-642-59373-4
Director, Rubin Institute for Advanced Orthopedics
Sinai Hospital
1st ed. 2002. Corr. 3rd printing 2005
Co-Director, The International Center
for Limb Lengthening, Sinai Hospital CIP-data applied for
Baltimore, MD
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~---------------------------------------------------- ...

This book is dedicated to the memory of my father,

Zvi Paley, who gave so much and asked for so little.
 Foreword
What is genius? Analyzing complex problems and find-
ing simple ways to explain them in an understandable
manner. By this definition, this book is genius.
The most dramatic progress in orthopaedic surgery
during the last 2 decades has been in the field of defor-
mity correction. The treatment of deformities has occu-
pied and challenged orthopaedic surgeons since Nicho-
las Andry. So many brilliant people have worked in this
field. Among them, Friedrich Pauwel and Gavril Ilizarov
should be individually named. Dr. Ilizarov developed
new methods oflimb lengthening and deformity correc-
tion and sparked the newfound interest and develop-
ments in this field today. In Dror Paley, this spark be-
came a raging fire.
Dr. Paley inaugurated many innovations in the field
of deformity correction. Among them, his nomenclature
deserves special mention. Before his classification based
on joint orientation, we had a plethora of confusing
terminology and definitions leading to a confusion of
language reminiscent of the Tower of Babel. Dr. Paley's
nomenclature standardizes the terminology in a man-
ner that requires little memorization. This logically
based system has gained international recognition and
acceptance as the single language of deformity analysis
and correction. This book presents us with these con-
cepts.
The principles and concepts outlined in this book
were not discovered or understood overnight. They rep-
resent an evolution of Dr. Paley's ideas from the past
14 years of clinical work in the field of deformity correc-
tion. Unlike other texts, which come and go because they
-
are technique-centric, this tome is principle-based and
will therefore stand the test of time.
The limb lengthening and deformity reconstruction
center created by Drs. Paley and Herzenberg in Balti-
more is not only the clinical laboratory where this defor-
mity correction work was developed and understood
but has also become the Mecca for students in this med-
ical specialty, with visitors from allover the world trav-
eling to learn firsthand from these masters of deformity
correction. It is in this manner that I first became ex-
posed to the CORA method of mechanical and anatom-
ic axis planning. This has resulted in a long-standing col-
laboration between our two facilities, centered on our
common interest in this subspecialty. We routinely apply
these principles to deformity correction at our center in
Germany. Many of the new deformity correction devic-
es that I and others are designing are now based on the
CORA principles.
Dr. Paley'S deformity correction courses around the
world have popularized the planning methods and prin-
ciples espoused in this book. The annual Baltimore Limb
Deformity Course is the foundation for this book, work-
book, and CD. Each of its chapters has been presented as
lectures at this course, and the workbook and multime-
dia CD have been tested by live audiences at these cours-
es for many years.
I am sure this book will become the bible for the under-
standing, diagnosis, and treatment of lower limb defor-
mities.
Wiesbaden, Germany JOACHIM PFEIL
 Preface
My prediction: this book will become a classic. Brave
words, but I can safely make this statement because this
book is not about the latest surgical operation or about
our knowledge of certain pathologies, which is constant-
1y changing. Rather, this book presents a system of de-
formity analysis that is universal and applicable to any
past, current, or future surgical osteotomy techniques
and hardware. One needs only to think back to medical
school and realize that most of the textbooks that we so
carefully studied are now "of historic interest only:'
Grant's Atlas of Anatomy is perhaps the only book from
my medical school days that I still use. I predict that Pa-
ley's Principles of Deformity Correction will also have a
long shelflife. The treatment of skeletal deformity is the
heart of our specialty. Indeed, the very name of our spe-
cialty, orthopaedics, was coined by Nicholas Andry in
1741 as a word derived from two Greek words, orthos
(meaning straight) and paedis (meaning child) to indi-
cate his goal "to teach the different methods of prevent-
ing and correcting deformities of children" (from Mer-
cer Rang's Anthology of Orthopaedics, 1966).
Since Andry's writings 260 years ago, little progress
has been made in understanding, analyzing, and quan-
tifying the types of limb deformities. Rarely do we come
across an orthopaedic surgeon who is truly an artist (or
sculptor). Such an individual does not require accurate
preoperative planning to execute a flawless corrective
osteotomy. However, for the rest of us journeymen or-
thopaedic surgeons, achieving such beautiful artistic
and aesthetic outcomes is elusive. We tend to take a
wedge here or there, by eyeball estimation, and then
rationalize the less than perfect appearance of the final
X-ray. "It's not bad" or "it should remodel:' True, there
have been attempts by notable surgeons, such as Fried-
rich Pauwels and Maurice Mueller, to be more precise in
our planning. Although we may have received training
in the precise repositioning of fracture fragments with
plates and screws and accurate preoperative planning
and templating for hip osteotomies, what has eluded us
until now is a universally applicable lower extremity de-
formity planning system that takes into account the en-
tire limb, including associated joint compensation and
lever arm considerations: a unified or universal system
that is equally applicable to the diverse range of ages and
-
pathological abnormalities that come under the pur-
view of the adult and pediatric orthopaedist.
It has been my privilege and honor to be associated
professionally with Dr. Dror Paley for the past 10 years,
and I probably know him better than anyone else does. I
have therefore been in a unique position to observe how
he developed the CORA method and to contribute as a
co-developer, editor, and author. Dr. Paley has an uncan-
ny knack of clearly seeing and understanding ortho-
paedic deformities. More importantly, he has a unique
ability to then process and integrate this information to
make it accessible to the less clairvoyant. We have
striven to make this method practical and teachable. It
is not hard to learn, but it does take some effort and
practice. The method is mercifully low-tech: the only
tools required are a pencil, ruler, and goniometer. We
have honed our ability to teach this method during the
past 10 years at our annual Baltimore Limb Deformity
Course, and many of the figures and cases illustrated in
this book have been used in the course. The case studies
and the artists' diagrams are all derived from our own
practices and are representative of deformities that we
have treated. In this regard, we are greatly indebted to
our patients for providing us with both typical and atyp-
ical problems to study and illustrate.
Interestingly, the CORA method of deformity analy-
sis began simply as an attempt to make some sense of the
Ilizarov apparatus. As the orthopaedic surgeon who in-
troduced this method in Canada and the USA, Dr. Paley
struggled to understand the concept of the Ilizarov
hinge, which is what made the Ilizarov fixator so unique
in its ability to correct deformities in a controlled fash-
ion. In his early experience, he observed some of the sec-
ondary deformities that arose from mismatching the lo-
cation of the hinge and the CORA. In his effort to more
accurately identify the level for the Ilizarov hinge, he de-
rived the CORA method of mechanical and anatomic
axis planning described in this text.
He quickly realized that the concept of the CORA and
the osteotomy rules were not unique to the Ilizarov de-
vice but much more universally applicable to deformity
correction by any method. Indeed, with the CORA meth-
od, one can understand and plan surgery for any lower
extremity deformity from the hip to the foot. The gener-
al principle of this book is to first analyze, understand,
and quantify the deformity. Only then should you begin
to plan your surgical method and approach. Regardless
of which type and brand of fixation is selected (plates,
rods, or external fixator), the basic principles of defor-
mity analysis and planning are the same. Failure to ob-
serve these principles frequently results in less than per-
fect alignment and often in secondary deformities that
may be more difficult to correct than the original defor-
mities. Ultimately, the surgeon must decide which de-
vice works best in his or her hands. The first step of pre-
operative planning, however, is universally required and
beneficial. Chap. 11 includes a discussion of some of the
vagaries of selected hardware devices, and it is this chap-
ter that will most likely require updating and revision in
a future edition as new device innovations become avail-
able. The bulk of the book, however, encompasses prin-
ciples and concepts that will not change because they are
based on simple geometry.
Will the CORA method be supplanted by future tech-
nology? We think not. Even computer-dependent math-
ematical modeling of six-axis deformity correction (see
Chap. 12) is first dependent on the surgeon to accurate-
ly understand, analyze, and quantify the radiographic
deformity. We therefore think that the CORA method
complements rather than competes with such sophisti-
cated deformity correction methods.
Is this book the final word on the topic? Clearly not. The
CORA method is still a work in progress, and there is
room to extend its application to the upper extremity,
spine, pelvis, and perhaps even maxillofacial deformity
correction. It has recently been incorporated into com-
puter planning software. This book has already been
lO years in the making, and these other expansions will
have to wait for the second edition. We welcome readers'
comments, criticisms, and feedback to help us improve
future editions.
Baltimore, Maryland JOHN E. HERZENBERG
 The Story Behind This Book and the CORA Method
My first exposure to orthopaedics was as a medical stu-
dent learning physical examination. My patient had a se-
vere limp, which I attributed to weakness of his gluteus
medius. What today I would recognize as an obvious
Trendelenburg's gait, in 1977 was the pivotal event that
sparked my interest in orthopaedic surgery. I began to
read the works of Rene Caillet (The Biomechanics of
Joints) and of LA. Kapandji (Physiology ofJoints). Their
books made human mechanics easy to comprehend,
even for a medical student. With Principles of Deformity
Correction, I attempt to do the same regarding deformi-
ty analysis and treatment.
I am grateful to the many great teachers from my ortho-
paedic residency at the University of Toronto. They laid
the foundation for my interest in orthopaedics. Profes-
sor Robert Salter set the tone, teaching in a Socratic
manner. Dr. Alan Gross of Mt. Sinai Hospital first taught
me the concept of the mechanical axis of the lower limb
as well as the importance of preoperative planning for
osteotomies of the hip and knee. He frequently quoted
Renato Bombelli's Osteoarthritis of the Hip: Classifica-
tion and Pathogenesis - The Role of Osteotomy as a
Consequent Therapy (Springer-Verlag, 1983) and Paul
Maquet's Biomechanics of the Knee: With Application to
the Pathogenesis and the Surgical Treatment of Osteoar-
thritis (Springer-Verlag, 1984), which stimulated me to
read these books on the biomechanics of the hip and
knee, respectively. Drs. David MacIntosh and Ian Har-
rington taught me controversial concepts of high tibial
osteotomies and alignment. Dr. Harrington's book on
biomechanics (Biomechanics of Musculoskeletal Injury;
Williams & Wilkins, 1982) and his often misunderstood
article on high tibial osteotomy UBJS 65(2):247-259,
1983] greatly influenced my understanding of concepts
in this field. Drs. Marvin Tile, Joseph Schatzker, Robert
McMurtry, and James Kellam are responsible for teach-
ing me to think in terms of universal principles rather
than specific surgical techniques. Principles to ortho-
paedics are like laws to physics: they remain constant,
whereas specific operations and techniques come and
go.
The widest spectrum and complexity of deformity
occur in pediatric orthopaedics in that many conditions
-
affect the growth and development of the skeleton. My
teachers at the Hospital for Sick Children, Drs. Norris
Carroll, Colin Moseley, Mercer Rang, Walter Bobechko,
Robert Gillespie, and Robert Salter, provided my initial
exposure and understanding of the growth plate and the
pediatric skeleton. The training I received from them
during my residency and fellowship prepared me to
challenge many well-established practices and beliefs in
pediatric orthopaedics. Of all these, I received the great-
est support from Dr. Norris Caroll, who always had faith
in me and invested his time and patience to teach me
meticulous surgical technique and who encouraged me
at times of despair.
I acknowledge the support of two of pediatric ortho-
paedics' elder statesmen, Drs. Lynn Staheli and Mihran
Tachdjian. Dr. Staheli, as editor of the Journal of Pediat-
ric Orthopedics, invited me to write about current tech-
niques of limb lengthening in 1988 UPO 8:73-92, 1988)
and more recently to write an editorial on deformity
correction in the twenty-first century UPO 20:279-281,
2000). Both of these publications helped introduce and
heighten awareness to deformity correction principles.
The late Dr. Tachdjian involved me in his international-
ly renowned pediatric orthopaedic review course since
1988 and included my deformity planning method in his
textbooks (Pediatric Orthopedics, 1990; and Atlas of Pe-
diatric Orthopedic Surgery, 1994). Dr. Charles Price, who
took over this pediatric course, has included deformity
planning by the CORA method as an important theme
of the new course.
In November 1983, when I was a third-year ortho-
paedic resident in Toronto, I met Renato Bombelli who
was a visiting professor. Dr. Bombelli was a disciple of
Friedrich Pauwels and a contemporary of Maquet, an-
other of Dr. Pauwels' disciples. Through their writings, I
began to understand that complicated joint mechanics
could be reduced to simple principles. While in Toronto,
Dr. Bombelli briefly mentioned the Ilizarov method.
This offhand comment sparked my interest in a field to-
tally unknown in North America. Upon completing my
residency in 1985, I visited Dr. Maurizio Catagni in Italy
to learn more about the Ilizarov method. The next year,
I took my family to Europe and spent 6 months in Italy
and the USSR studying limb reconstruction with exter-
 nal fixation. I learned that deformities could occur in
multiple planes and that hinges could act as the axis of
correction. I learned to consider not only angulation but
also translation, rotation, and length when analyzing a
deformity. I also learned that deformities could be cor-
rected gradually or acutely and that there were virtually
no limits to how much angulation could be corrected.
I visited Kurgan three times during the Soviet era, and
I am greatly indebted to Professor Gavril Abramovich
Ilizarov for the opportunity to study at his institute. Al-
though I learned a great deal from Dr. Ilizarov's lectures,
articles, and books, he was personally at his best when
examining patients. Physical examination was a skill
emphasized in my training in Toronto during the annu-
al physical examination courses by Mr. Alan Graham
Aply. Learning Russian facilitated the learning process
and allowed me to speak to the Soviet doctors directly
without going through interpreters. Many people in
Kurgan contributed to my education, and some deserve
special mention. Igor Kataev taught me the principle of
hinges and of oblique plane deformity. Mr. Kataev was
not a physician but was in charge of the patent office at
Ilizarov's institute. Vladimir Shevtsov, Ilizarov's succes-
sor, answered the questions that I would not dare ask Ili-
zarov. He was direct and not evasive. Victor Makushin's
ability to clinically evaluate nonunions was uncanny but
could be divined only by reversing the Socratic method
I learned from Dr. Tile and the others in Toronto. Arnold
Popkov is a master at limb lengthening. He took the mid-
dle-of-the-road approach, allowing me to learn by an-
swering my own questions and acknowledging when I
hit upon the correct answers. Others helped in a clandes-
tine fashion to overcome the cold war Soviet secrecy of
the institute. The best example is Dr. Yaakov Odesky, who
is now in Israel. He allowed me to see treatments and
concepts that no Westerners had seen before. Finally,
Galena Dyachkova's openness helped me to understand
the basic science of the field of distraction, especially
regarding soft tissues.
In contrast to the struggle to learn in the USSR, Italy
presented a refreshing sense of openness. The team,
comprised of Roberto Cattaneo, Maurizio Catagni, and
Angelo Villa in Lecco, Fabio Argnani in Bergamo, and
Antonio Bianchi-Maiocchi in Milan, welcomed me with
sincerity, kindness, and warmth and did everything to
help me learn. I will forever be indebted to them. Of
these outstanding teachers, Dr. Catagni is most respon-
sible for my current understanding of deformities. He
possesses an intuitive understanding of deformities and
essentially computes a CORA analysis in his head as well
as I can on paper. My goal with this book was to codify
Dr. Catagni's intuitive approach into the objective CORA
method that can be performed in a step-by-step fashion
by all. One more important event occurred before all the
pieces were in place. When I returned home from Italy
and the USSR and began my pediatric orthopaedic fel-
lowship in Toronto in 1987, I came across an article by
Dr. Ken Krackow (Adv Orthop Surg 7:69,1983). This ar-
ticle introduced me to the concept of joint orientation
angles and was pivotal in my developing the malalign-
ment test.
With this foundation upon which to build, the CORA
method was developed. Placing hinges on the Ilizarov
device involved putting the hinge just below the ring for
metaphyseal deformities and at the apex of diaphyseal
deformities. It did not make sense that the hinge should
always be the same distance from the ring for all meta-
physeal deformities. For diaphyseal deformities, we al-
ways drew two mid-diaphyseal lines and placed the
hinge at the intersection of the two lines. In the meta-
physis, it was not possible to draw a mid-diaphyseal line
for the metaphyseal bone segment. I struggled with this
problem until March 1988, when I had to place hinges for
a supramalleolar osteotomy for ankle varus where the
joint line was clearly tilted around the lateral cortex of
the joint yet the osteotomy was much more proximal. In-
stead of placing the hinges just proximal to the distal tib-
ial ring, I placed the hinge distal to the ring in what is
now recognized as a juxta-articular hinge construct (see
Chap. 11). To my fascination, the osteotomy site correct-
ed with angulation and translation. The osteotomy rules
were born together with the CORA method. The basic
concepts in this book were developed over the next
2 years, based to the greatest extent on the clinical cases
I had the privilege and the challenge to treat but also on
a potpourri of ideas stimulated by colleagues with sim-
ilar interests. Most notably, Stuart Green from California
was my sounding board, especially when it came to post-
traumatic deformities. Together, we solved the mystery
of the relationship between the planes of angulation and
translation. I was privileged to have Dr. Kevin Tetsworth,
who has a brilliant mathematical mind, work with me as
a fellow between 1989 and 1990. In 1990, we published
the malalignment test and the first version of the CORA
method, although it was not yet called that (Clin Orthop
280:48-64; 65-71). Dr. Natsuo Yasui from Osaka, Japan,
coined the term CORA method, and it stuck.
The initial concept of writing a book about deformity
correction originated in 1991 through discussions with
Darlene Cooke, who was then a book editor at Williams
& Wilkins. The syllabus for the first annual Baltimore
Limb Deformity Course served as an outline for the
book. This course began in 1989, with Ilizarov as a fea-
tured guest speaker, and has continued ever since. The
success of this annual course led me to add more mate-
rial and to incorporate the concepts of some very inno-
vative contributors who participated in our course. Ms.
Cooke thought that I would never finish the book be-
cause I was a perfectionist and continued to add new
material every year. In many respects, she was right. On
the other hand, the book was not ready to be finished.
There were several concepts that were on the verge of
being clarified and that needed to be included in the
book to make it complete. For example, the six-axis de-
formity correction concepts introduced by Dr. J. Charles
Taylor and the lever arm deformity concepts presented
by Dr. James Gage. In 1998, Williams & Wilkins and I
agreed to drop the book project. Without Ms. Cooke as
my editor, the external push to complete the book was
gone. I saw 10 years of work to produce this book going
to waste. I decided upon a new strategy: finish the book
on our own, and then look for a publisher. With the help
of our in-house publishing team, Senior Editor Dori
Kelly, Medical Illustrator Joy Marlowe, and Multimedia
Specialist Mark Chrisman, this became a reality. It was
now time to seek a new publisher. This was easier said
than done. I could not get an American publishing com-
pany to share my vision of the importance of this book.
The project was finally salvaged by Dr. Joachim Pfeil, my
friend and colleague from Wiesbaden, Germany. Dr.
Pfeil has promoted the CORA method in Europe for
years and has co-authored an article on this subject in
the German language. He introduced me to Gabriele
Schroeder, Senior Medical Editor for Springer-Verlag in
Heidelberg in April 2000. This book has finally come to
fruition with the enthusiastic support of Springer-Ver-
lag.
This history and my acknowledgments would not be
complete without mentioning a few more people. First is
Dr. John E. Herzenberg, without whose editorial assis-
tance this book would not have been possible. Dr. Her-
zenberg has been my colleague and friend since we were
fellows together in Toronto in 1985 and 1986. We contin-
ued to correspond and collaborate at a distance until
1991, when Dr. Herzenberg moved to Maryland to help
achieve our common dream of developing a limb
lengthening and deformity correction center. The Mary-
land Center for Limb Lengthening & Reconstruction
(MCLLR) was born. John has been a valuable sounding
board for my ideas for more than 10 years. He encour-
aged me to continually strive to simplify my concepts to
make them teachable and practical. He has been my Co-
Chairman in the Deformity Course and my loyal partner
in practice. It is often impossible to separate who origi-
nated which ideas. Therefore, this book is as much a tes-
tament to his work as it is to mine. Second is Anil Bhave,
PT. Mr. Bhave has directed our gait laboratory and
served as clinical research coordinator since 1992. He
has contributed immeasurably to my understanding of
gait and dynamic deformities. The rest of the loyal staff
of the MCLLR have also contributed to this book in one
way or another. Kernan Hospital and the Department of
Orthopaedics have given me tremendous support and a
wonderful environment for my work during the past
14 years. lowe them all a great debt of gratitude.
Finally, I would like to acknowledge my family. My
wife, Wendy Schelew, and our children, Benjamin,
Jonathan, and Aviva, have stood beside me all these years
and tolerated my single-minded devotion to completing
this project. This book is a testimony to their patience,
love, and support. It is also a testimony to my parents.
From my mother, a school teacher, I inherited ambition,
love for the life sciences, and my skill of teaching. My
greatest sadness is that my father, who was my role
model, will never see this book. He was a holocaust sur-
vivor who at age 38 (when I was 10) completed his PhD.
He was a mechanical engineer who specialized in metal-
lurgy, working as a research scientist in Ottawa, Canada,
until his untimely death from cancer at age 54. My father
was a Renaissance man who spoke nine languages and
who stimulated my interest in many fields. Most of all, he
taught me to think critically. He grew up approximately
100 miles from Kurgan in the Soviet Union. He never got
to see me complete my residency, raise a family, learn
Russian, or achieve the publication of this book. It is to
his memory that I dedicate this book.
Baltimore, Maryland DROR PALEY
 Contributing Authors

I am indebted to the chapter contributors, without MICHAEL MONT,MD

whose input this book would be deficient. These select Co-Director, Joint Preservation and Replacement
authors were invited because of their original ideas and Center, Sinai Hospital
contributions to the field of deformity correction. The Baltimore, MD
numbers and titles of the chapters to which they con- CHAPTER 23: Total Knee Replacement and Total
tributed are listed below their names. For the consis- Hip Replacement Associated with
tency of this book, I have edited and added to each of Malalignment
these chapters to better incorporate these authors' ideas.
I especially thank my partner, John E. Herzenberg, who MICHAEL SCHWARTZ, PHD
in addition to contributing as an author to two chapters Director of Bioengineering Research
in the book helped me to develop and also originated Gillette Children's Hospital, St. Paul, MN
many of the deformity concepts presented herein. John Assistant Professor of Orthopaedics
acted as this book's content editor for both the text and University of Minnesota
the figures. This laborious task has refined and clarified Minneapolis, MN
the theoretical and practical principles that this book CHAPTER 22: Dynamic Deformities and Lever Arm
presents. Considerations
DROR PALEY, MD, FRCSC
SHAWN C. STANDARD, MD
Pediatric Orthopedic Surgeon
ANIL BHAVE,PT The International Center for Limb Lengthening,
Director of Rehabilitation and Gait Laboratory Sinai Hospital
The International Center for Limb Lengthening, Baltimore, MD
Sinai Hospital CHAPTER 12: Six-Axis Deformity Analysis
Baltimore, MD and Correction
CHAPTER 21: Gait Considerations
J. CHARLES TAYLOR,MD
JIM GAGE,MD Orthopedic Surgeon, Specialty Orthopedics
Medical Director, Gillette Children's Hospital Memphis, TN
St. Paul,MN CHAPTER 12: Six-Axis Deformity Analysis
Professor of Orthopaedics, University of Minnesota and Correction
Minneapolis, MN
CHAPTER 22: Dynamic Deformities and Lever Arm KEVIN TETSWORTH,MD
Considerations Director of Orthopaedics, Royal Brisbane Hospital
Brisbane, Queensland, Australia
JOHN E. HERZENBERG, MD, FRCSC CHAPTER 13: Consequences of Malalignment
Co-Director, The International Center
for Limb Lengthening, Sinai Hospital
Chief of Pediatric Orthopedics, Sinai Hospital
Baltimore, MD
CHAPTER 9: Rotation and Angulation-Rotation
Deformities
CHAPTER 12: Six-Axis Deformity Analysis
and Correction
CHAPTER 20: Growth Plate Considerations
Senior Editor
DORI KELLY,MA

Medical Illustrators
JOY MARLOWE, MA
MARY GOLDSBOROUGH,MA
STACY LUND, MA

Multimedia Specialist
MARK CHRISMAN,Bs

Drs. Dror Paley, MD, FReSe, and John E. Herzenberg, MD, FRese
DR 0 R PAL E Y was born in Tel Aviv, Israel, in 1956 and
moved to North America in 1960. He grew up in Ottawa,
Canada, for most of his youth. He graduated from the
University of Toronto Medical School in 1979, complet-
ed his internship in surgery at the Johns Hopkins Hos-
pital in Baltimore in 1980, and completed his ortho-
paedic surgery residency at the University of Toronto
Hospitals in 1985. After completing a hand and trauma
surgery fellowship at Sunnybrook Hospital in Toronto
and the AOA-COA North American Traveling Fellow-
ship, he spent 6 months studying limb lengthening and
reconstruction techniques in Italy and the USSR and
then completed a pediatric orthopaedics fellowship at
the Hospital for Sick Children in Toronto. This is where
he began his limb lengthening and deformity correction
experience. In November 1987, he organized the first in-
ternational meeting on the Ilizarov techniques with Dr.
Victor Frankel, at which Professor Gavril Abramovich
Ilizarov shared his knowledge in the United States for
the first time. The same month, Dr. Paley joined the or-
thopaedic faculty of the University of Maryland. Many
of the original concepts for this book were developed
during the next 3 years. In 1991, Drs. John E. Herzenberg
and Kevin Tetsworth joined Dr. Paley to form the Mary-
Contributing Authors _
land Center for Limb Lengthening & Reconstruction in
Baltimore.
In 1989, Dr. Paley organized and inaugurated ASAMI-
North America, the limb lengthening and reconstruc-
tion society, and served as the first president of this new
subspecialty society. The first AS AMI meeting also coin-
cided with the first Baltimore Limb Deformity Course.
The publication of this book will debut at the 11th An-
nual Baltimore Limb Deformity Course and will be the
manual of this internationally recognized course. Dr.
Paley has been active in teaching limb reconstruction
worldwide (more than 50 countries to date). He lectures
and reads in six languages (English, Hebrew, French,
Italian, Spanish, and Russian).
In 1990, Dr. Paley was awarded a Gubernatorial Cita-
tion for Outstanding Contributions in Orthopaedic Sur-
gery by the Governor of Maryland. He was also awarded
the Pauwels Medal in Clinical Biomechanics by the Ger-
man-Speaking Countries Orthopaedic Association in
1997. His most cherished award, however, is the Ortho-
paedic Residents Teaching Award, which he has received
on more than one occasion. Dr. Paley was the Chief of
Pediatric Orthopaedics at the University of Maryland
until June 2001 and was Professor of Orthopaedic Sur-
gery at the University of Maryland Medical System until
October 2003. He is well published in the peer-reviewed
literature and has also authored and edited several
books and numerous book chapters. He considers Prin-
ciples of Deformity Correction to be his thesis and his
most important academic achievement. On July 1,2001,
Dr. Paley, together with Drs. John Herzenberg, Michael
Mont, and Janet Conway, opened the Rubin Institute for
Advanced Orthopedics at Sinai Hospital, in Baltimore.
Dr. Paley is the Director of this new orthopaedic center
and Co-Director of The International Center for Limb
Lengthening.
Dr. Paley is married to Wendy Schelew, and they have
three children (Benjamin, Jonathan, and Aviva). For fun,
he enjoys personal fitness, skiing, scuba diving, biking,
and studying history.
JOHN E. HERZENBERG was born in 1955 in Spring-
field, Massachusetts. At the age of 15, he left to attend
high school at Kibbutz Kfar Blum in Israel. He studied
medicine at Boston University and completed his in-
ternship in surgery at Albert Einstein-Montefiore Hos-
pitals in New York. In 1985, he completed his residency
in orthopaedic surgery at Duke University in Durham,
NC, where he was drawn toward pediatric orthopaedics
by his mentor and chief, Dr. J. Leonard Goldner.
Dr. Herzenberg completed a pediatric orthopaedic
fellowship at the Hospital for Sick Children in Toronto,
where he first met Dr. Dror Paley. He was on the faculty
at the University of Michigan in Ann Arbor for 5 years,
with Dr. Robert Hensinger. Dr. Herzenberg traveled to It-
aly' USSR, and Baltimore to study limb reconstruction
techniques. This began his active collaboration with Dr.
Paley, which resulted in a joint vision to set up a nation-
al center devoted to limb reconstructive surgery. In 1991,
Dr. Herzenberg joined Drs. Paley and Tetsworth on the
full-time faculty of the University of Maryland in Balti-
more to establish the Maryland Center for Limb Length-
ening & Reconstruction.
Dr. Herzenberg has traveled extensively, teaching the
Ilizarov techniques and the CORA method of deformity
planning. He has served as president of ASAMI-North
America and is active as a volunteer surgeon with Oper-
ation Rainbow and Operation Smile, participating in
yearly missions to Central and South Americas. He was
awarded both the AOA-COA North American and ABC
Traveling Fellowships. He is extensively published in
many areas of pediatric orthopaedics and limb recon-
struction. Dr. Herzenberg was Professor of Orthopaedic
Surgery at the University of Maryland Medical System
until October 2003 and is currently Co-Director of the
International Center for Limb Lengthening and Chief of
Pediatric Orthopedics at Sinai Hospital.
Dr. Herzenberg is married to Merrill Chaus, and they
have three daughters (Alexandra, Danielle, and Britta-
ny). For fun, he enjoys personal fitness and Bible study.
 Contents

1 Normal lower limb Alignment 4 Frontal Plane Mechanical

and Joint Orientation ... 1 and Anatomic Axis Planning ... 61

Mechanical and Anatomic Bone Axes . . . Mechanical Axis Planning . . . . . . . . . . . . . .. 61

Joint Center Points ... 5 Anatomic Axis Planning . . . . . . . . . . . . . .. 63
Joint Orientation lines 5 Determining the CORA by Frontal Plane Mechanical
Ankle. . ..... . 5 and Anatomic Axis Planning: Step by Step. 64
Knee. . . . . . . . . . . 5 Part I: CORA Method, Tibial Deformities. . . . . 64
Hip. . . . . . . . . . .. . ........... 8 Mechanical Axis Planning
Joint Orientation Angles and Nomenclature . . . . .. 8 ofTibial Deformities . . 64
Mechanical Axis and Mechanical Axis Deviation (MAD). 10 Anatomic Axis Planning
Hip Joint Orientation . 12 of Tibial Deformities. . 74
Knee Joint Orientation . . . . . . . . . . . . . . . . . 13 Part II: CORA Method, Femoral Deformities . 76
Ankle Joint Orientation . . . . . . . . . . . . . . . . . 16 Mechanical Axis Planning
References. . . . . . . . . . . . . . . . . . . . . . . . 17 of Femoral Deformities 76
Anatomic Axis Planning
of Femoral Deformities 81
2 Malalignment and Malorientation Multiapical Deformities . . . . 97
in the Frontal Plane ... 19

Malalignment . . . . . . . . . . . . · . 19 5 Osteotomy Concepts

MAT . . . . . . . . . . . . . . . . . . · . 23 and Frontal Plane Realignment ... 99
Malorientation of the Ankle and Hip . . 28
Orientation of the Ankle and Hip in the Frontal Plane . 28 Angulation Correction Axis (ACA) . . . . . . . . . .. 99
MOT of the Ankle . . . . . . . . . . . . . . . . . . . . 28 Bisector Lines . . . . . . . . . . . . . . . . . . . . . . 101
MOT of the Hip. . 30 Relationship of Osteotomy Type to Bisector Lines. 101
References. . . . . . . . . . . . . . . . . . . . . . . . 30 Osteotomy Rules . . . . . . . . . . . . 102
Translation and length Displacement
atthe Osteotomy Line . . . . . . 105
3 Radiographic Assessment Opening Wedge Osteotomy. . 106
ofLower Limb Deformities ... 31 Closing Wedge Osteotomy. . . . . . . . 106
Focal Dome Osteotomy. . . . . . . . . . . . 112
Knee . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Clinical Choice of Osteotomy Level and Type 114
Ankle and Hip . . . . . . . . . . . . . . . . . . . . . . 40 Multiapical Osteotomy Solutions . . . 140
Radiographic Examination in the Sagittal Plane .... 46 Single Osteotomy Solutions. . . . . . . 140
Knee . . . . . . . . . . . . . . . . . . . . . . . . . 46 Multiple Osteotomy Solutions. 142
Ankle. . . . . . . . . . . . . . . . . . . 51 References . . . . . . . . . . . . . . . . . . . . . . . 154
Hip . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Radiographic Examination in One Plane
When There Is a Deformity Component 6 Sagittal Plane Deformities ... 155
in the Other Plane . . 57
References. . . . . . . . . . . . . . . . . . · . 60 Sagittal Plane Alignment in the lower Limb . 155
Sagittal Plane MAT . . . . . . . 157
Knee Joint Malorientation . . . . . . . . . . . 157
. . Contents

Overall Sagittal Plane MOT . . . . . . . 159 9 Rotation and Angulation-Rotation Deformities

Knee Level Sagittal Plane MOT .... . 163 ... 235
Overall Sagittal Plane MOT of the Ankle. 163
Ankle Level Sagittal Plane MOT of the Ankle 165
Sagittal Plane Anatomic Axis Planning Clinical Assessment of Rotation Deformities . . 235
ofTibial Deformity Correction . . . 165 Level of Osteotomy for Rotation Deformities . . 243
Sagittal Plane Anatomic Axis Planning Frontal Plane Preoperative Planning
of Femoral Deformity Correction. . 169 for Rotation Deformities . . . . . . . . . . 249
Osteotomies in the Sagittal Plane. 169 Factoring in Rotation for Mechanical Axis
References . . . . . . . . . . . . . . . . 174 Planning of the Femur . . . . . . . . . . 250
Frontal Plane Anatomic Axis Planning
for Rotation Deformities . . . . . . . . . 252
7 Oblique Plane Deformities ... 175 Combined Angulation and Rotation Deformities . . . 252
Locating the Inclined Axis . . . . . . . . . . . . . 259
Plane of Angulation . . 175 Locating the Inclined Osteotomy .... 261
Graphic Method. . . . . 179 Inclined Focal Dome Osteotomy . . . . . . . 266
Graphic Method Error.. 183 Clinical Examples. . . . . . . 266
Base ofTriangle Method . . . . . . . . 183 References . . . . . . . . . . . . . . . . . . 268
Axis of Correction of Angulatory Deformities . 186
Definition of Angulation. . 193
References . . . . . . . . . . . . . . . . . . . 193 10 Length Considerations: Gradual Versus
Acute Correction of Deformities ... 269

8 Translation and Angulation-Translation Length Considerations for Angular Corrections. . 276

Deformities ... 195 Neurovascular Structures . . . . . . . . 278
Nerves . . . . . . . . . . . . . . 282
Translation Deformity . . . . . . . . . . . · .. 195 Vessels . . . . . . . . . . . . . . . · 287
Two Angulations Equal One Translation . . · .. 200 Muscles, Tendons, and Fascia · 287
Translation Effects on MAD ... · .. 200 Ligaments .. . · 287
Osteotomies for Correction Skin .... . · 288
ofTranslation Deformity . . . 202 References . . . ........ 289
Combining Angulation and Translation . . · 203
a-t Deformities and MAD . . . . . · 205
Graphic Analysis of a-t Deformities . . · 205 11 Ha rdware and Osteotomy Considerations
Type 1: Angulation and Translation ... 291
in the Same Plane. . . . . . . . . 205
Anatomic Plane Deformity . . . . · 205 Choice of Hardware. . . . · 291
Oblique Plane Deformity . . . . . . . . .208 Patient Age . . . . . . · 291
Type 2: Angulation and Translation Osteotomy Types. . . · 291
in Different Planes . . . . . . . . . . . . . . . . · 209 Closing Wedge Osteotomy. · 291
Anatomic Plane Deformity with Angulation Opening Wedge Osteotomy . . . . . · 297
and Translation 90° Apart . . . . . . . . . . . 209 Angulation-Translation Osteotomy. · 300
Oblique Plane Deformity with Angulation Dome Osteotomy. · 300
and Translation 90° Apart . . . . . . . . . . . 211 Hardware . . . . . . . . . . · 300
One Anatomic and One Oblique Plane Plate Fixation . . . . . . · 300
Deformity with Angulation and Translation Intramedullary Nails .. . . 307
in Different Planes Less Than 90° Apart ... 214 External Fixation . . .. 346
Oblique Plane Deformity with Angulation Order of Correction. . . · 383
and Translation Less Than 90° Apart. . 216 Lever Arm Principle .. · 387
Osteotomy Correction of a-t Deformities . . 218 Method of Osteotomy · 389
Osteotomy Correction of Angulation References . . . . . . . · 410
and Translation in the Same Plane .. 219
Correction of Angulation and Translation
in Different Planes . . . . . . . . 222
Multilevel Fracture Deformities. . . . .. 231
References . . . . . . . . . . . . . . . . . . . 234
 Contents

12 Six-Axis Deformity Analysis and Correction , 6 Realign ment for Mono-com partment
... 411 Osteoarthritis of the Knee ... 479

The Taylor Spatial Frame Fixator. . · 412 Deformities in Association with MCOA . . 479
Introduction . . . . . . . · 412 Bone Deformities . . . 479
Modes of Correction. . · 416 Joint Deformities. . . . . . . . . . . . 479
Planning Methods . . . · 418 Customized HTO . . . . . . . . . . . . . . . . . 485
Fracture Method . . · 418 Malalignment Test form Mono-Compartment
CORAgin Method .. .420 Osteoarthritis. . . . . . . . . . . . . . . . 485
CORAsponding Point Method . . . . . . . . . 422 Femoral versus Tibial Osteotomy. . . . . . . 485
Virtual Hinge Method . . . . . . . . .424 Level of Center of Rotation of Angulation. . 492
Line of Closest Approach (LOCA) . · .426 Magnitude of Correction . . . . . . . . . . 492
Taylor Computer-assisted Design Type of Osteotomy and Fixation . . . . . . 494
(CAD) Software. . . . . . . . . . . · . 429 Considerations. . . . . . . . . . . . . .. ... 495
Reference Concepts . . . . . . . . . . . . 429 Medial Compartment Osteoarthritis
Rate of Correction and Structure at Risk (SAR). 430 Varus plus Medial Collateral
Parallactic Homologues of Deformity: Ligament Pseudo laxity . . . . . . . . . . . 495
Proximal versus Distal Reference Perspective . . . 433 Medial Compartment Osteoarthritis
References . . . . . . . . . . . . . . . . . . . . . . . 436 Varus plus Lateral Collateral
Ligament Pseudo laxity . . . . . . .. .. 497
Medial Compartment Osteoarthritis
13 Consequences of Malalignment . .. 437 Varus plus Rotation Deformity. . .. .. 497
Medial Compartment Osteoarthritis
Static Considerations. . . . · 438 Varus plus Hyperextension. . . . . . . . . 499
Dynamic Considerations . . .440 Medial Compartment Osteoarthritis
Rotational Considerations . · 443 Varus plus Fixed Flexion Deformity. .. 502
Animal Laboratory Models .444 Medial Compartment Osteoarthritis
Cadaver Laboratory Models .444 Varus plus Lateral Subluxation. . . . . . . 503
Clinical Longitudinal Studies . . .446 Medial Compartment Osteoarthritis
Summary. · 448 Varus plus Medial Plateau Depression. . . 503
References . . . . . . . . . . . . . . . . 448 Lateral Compartment Osteoarthritis (LCOA) . 504
References . . . . . . . . . . . . . . . . . . . . . . . 507

14 Malalignment Due to Ligamentous Laxity

ofthe Knee ... 4S 1 17 Sagittal Plane Knee Considerations ... 509

LCL Laxity. · . 451 Frontal Plane Knee Considerations . . · . 509

MCL Laxity · . 462 FFD ofthe Knee . . . . . . . . . . . . · . 509
References · .464 HE and Recurvatum Knee Deformity. . · . 538
Knee Extension Contracture . . . . · . 563
Patella Baja and Alta . · . 568
1S Knee Joint Li ne Deformity References . . . . . . . . . . . . . · . 569
Sources of Malalignment ... 465

References . . . . . . . . . . . . . . . . . . . . . . . 478 18 Ankle and Foot Considerations ... 571

Frontal Plane Ankle Deformities ... . ... 574

Supramalleolar Osteotomy for Varus
and Valgus Deformities. . . . . . . . . . 579
Sagittal Plane Ankle Deformities . . . . .. 581
Supramalleolar Osteotomy for Recurvatum
and Procurvatum Deformities . . . . . . . . . . . 585
Compensatory Mechanisms and Deformities:
Mobile, Fixed, and Absent. . . . . . . . . . . . . . 596
DIll Contents

Specific Ankle Malalignment Deformities. . . . . . 611 Growth Plate Considerations Relative

Ankle Fusion Malunion . . . . . . . . 611 to Deformity. . . . . . . . . . . . . . . . . . . . . 705
Flattop Talus Deformity. . . . . . . . . . 611 Cause of Deformities . . . . . . . . . . . . . . . 705
Ball and Socket Ankle Joint . . . . . . . . .. . 619 Developmental Angular Deformities. . . . . . . 705
Overcorrected Clubfoot and Other Lateral Angular Deformities: Gradual Correction
Translation Deformities of the Heel. . . · 623 by Hemi-epiphysiodesis . . . . . . . . . . . . . . . 708
Posterior Tibial Tendon Dysfunction . . . . . . . 627 Planning for Hemi-epiphyseal Stapling for
Completely Stiff Foot Treatment Angular Correction at the Knee in Children . 708
by Supramalleolar Osteotomy. . . · 627 Multiplier Method for Timing
Partial Growth Arrest . . . · 630 Hemi-epiphyseal Stapling for Correction
Malunion of Fibula . . . . · 630 of Angular Deformity . . . . . . . . . .. . 710
Ankle Contractu res . . . 630 Multiplier Method for Calculating
References . . . . . . . . . . . . .. 645 When to Remove Hemi-epiphyseal Staples
in Young Children. . 710
References . . . . . . . . . . . . . . . . . . . . . . . 715
19 Hip Joint Considerations ... 647

Limb in Neutral Alignment to Pelvis, No Intra- 21 Gait Considerations ... 717

or Periarticular Limitation of Range of Motion . 647
Varus Deformity. . . . . . . . . . 647 Gait Considerations in Association
Valgus Deformity . . . . . . . . . . . . . . . . . 653 with Lower Limb Deformities . · ... 717
Limb in Neutral Alignment to Pelvis, Sacrifice ofJoint Motion . . . . · . 717
Intra-articular Limitation of Range of Motion . . . 653 Fixed Joint Position . . . . . . . · 718
Varus Deformity. . . . . . . . . . . . . .. . 653 Abnormal Loading ofJoints ... · 721
Valgus Deformity . . . . . . . . . . . . . . . 653 Compensatory Mechanisms . . . . · 721
Lesser Trochanter Considerations . . . . . .. ... 656 Frontal Plane Malalignment. . . . · 722
Greater Trochanter Considerations . . . . . .. . 660 Distal Tibia Varus or Valgus. . . . . . . . · 722
Sagittal Plane Considerations . . . . . . . . .. . 672 Varus Deformity at the Knee . · . 725
Deformities of the Head and Neck of the Femur. . . . 673 Valgus Deformity of the Knee. . . . . . · 732
Pseudo-subluxation of the Hip . . . . . . . . . . . . 684 Varus or Valgus Deformity of the
Deformities Due to Hip Ankylosis and Arthrodesis Proximal Femur. . . . . · 735
between the Femur and the Pelvis. . . . 686 Sagittal Plane Deformity. . . . . . · 738
Pelvic Support Osteotomy . . 689 Ankle Equinus Deformity. . . · 739
References . . . . . . . . . . . . . . . . . · 694 Excessive Ankle Dorsiflexion
or Calcaneus Deformity . . . · 743
Ankle Arthrodesis Deformities. · 744
20 Growth Plate Considerations ... 695 Anterior Translation of the Foot . · . 746
Fixed Flexion Deformity of the Knee. . · ... 749
LLD . . . . . . . . . . . . .. 695 Recurvatum of the Knee. . . . . . . . · .. 751
Predicting LLD . . . . . . . . 695 Hip Flexion Deformity. . . . . . . . . . . · .. 751
Multiplier Method . . . 697 Hip Fusion. . . . . . . .. . .... . · . 752
Additional Growth Databases. . . . . . 701 Rotational Malalignment . . . . . . . . . · .. 753
Relationship of Multipliers for Boys Leg Length Considerations. . . . . . . . . · 755
to Multipliers for Girls. . . . . . . . 701 References . . . . . . . . . . . . . . . . . · . . . 758
Development of the Multiplier . . . . . . 702
Limb Length Discrepancy Prediction
Formulae . . . . . . . . . . . . . . . . .. 702 22 Dynamic Deformities and Lever Arm
Prediction of Limb Length Discrepancy Considerations ... 761
at Skeletal Maturity Using the Multiplier
Growth-Remaining Method for Cases Levers . . . . . . . . . · 761
of Postnatal Developmental Discrepancy. . 702 Mechanical Advantage. · 763
Percentage of Total Bone Growth from the Moments and Motions . · 763
Distal Femur and Proximal Tibia . . . .. . 703 Redundancy . . . . · 765
Using the Multiplier Method to Calculate Normal Function . . . . · 766
Timing for Epiphysiodesis. . . . 703 Introduction . . . . . . .. . . . . . 766
Growth Prediction Controversies. . . . . . 704 Mechanics of the Ankle: First Rocker. . . . . . . 766
 Contents _

Mechanics of the Ankle: Second Rocker . . . . . 766

Mechanics of the Ankle: Third Rocker . . . . . . 767
Force Production and Compensation . . . · 768
Pathological Function . · 768
Short Lever Arm . . . . . . . . · 768
Flexible Lever Arm. . . · 771
Malrotated Lever Arm. . . · 772
Unstable Fulcrum . . . . . · 773
Positional Abnormalities · 773
References . . . . . . . . . . . · 775

23 TKR and Total Hip Replacement

Associated with Malalignment ... 777

Normal Alignment Versus Malalignment

in Association with Total Knee Arthroplasty. · 777
Management of Fixed Soft Tissue Deformities . · 780
Clinical Assessment . . . . . . . . . . . . . · 780
Radiographic Assessment . . . . . . . . . . . · 780
Intraoperative Placement of Components
and Consequences of Malalignment . . . . · 782
Varus Deformities . . . . . . . . . · 783
Valgus Deformities. . . . . . . . . · 783
Flexion Deformity and Contracture · . 783
Recurvatum Deformity. . . . . . . · . 786
Peroneal Nerve Palsy and Operative Release . · . 786
Trial Reduction after Ligamentous Balancing. · . 786
Summary of Soft Tissue Balancing Principles . . . . . 787
Extra-articular Bone Deformities . . . . . . .. 788
Total Knee Arthroplasty after Failed HTO . . . . 792
Preoperative Assessment . . . . . . . . . . . 792
Proximal Tibial Osteotomy-Related Problems
forTKR . . . . . . . . . . . . . . 793
Proximal Femoral Deformities
and Total Hip Arthroplasty . . . · 794
Preoperative Planning . . . . . . . · 796
Soft Tissue Balancing. . . . . · 797
Bone Deformity Correction. · 797
References . . . . . . . . . . · 797

Subject Index .. . 799

 Glossary

a anatomic LOCA line of closest approach

A anterior LON lengthening over nail
ACA angulation correction axis LPFA lateral proximal femoral angle
ACL anterior cruciate ligament m mechanical
AOTA anterior distal tibial angle M medial
aJCO anatomic axis to joint center distance MAD mechanical axis deviation
aJCR anatomic axis: joint center ratio MAT malalignment test
aJEO anatomic axis to joint edge distance MCL medial collateral ligament
aJER anatomic axis:joint edge ratio MCOA medial compartment osteoarthritis
aLOFA anatomic lateral distal femoral angle MOA mid-diaphyseal angle
AMA anatomic-mechanical angle mLOFA mechanical lateral distal femoral angle
AP anteroposterior (for radiograph) MM medial malleolus
aPPTA anatomic posterior proximal tibial angle mMOFA mechanical medial distal femoral angle
ASIS anterior superior iliac spine MNSA medial neck shaft angle
a-t angulation-translation MOT malorientation test
CORA center of rotation of angulation MPFA medial proximal femoral angle
0 distal MPTA medial proximal tibial angle
OAA distal anatomic axis NSA neck shaft angle
OMA distal mechanical axis P posterior (when used in conjunction with
F femur A for anterior, M for medial, and L for lateral)
FAN fixator-assisted nailing P proximal
FFO fixed flexion deformity PAA proximal anatomic axis
GRV ground reaction vector POFA posterior distal femoral angle
HE hyperextension PPFA posterior proximal femoral angle
HTO high tibial osteotomy PMA proximal mechanical axis
IMN intramedullary nail PPTA posterior proximal tibial angle
JLCA joint line convergence angle SA surface area
L lateral SAR structure at risk
LAT lateral (for radiographic view only) SCFE slipped capital femoral epiphysis
IBL longitudinal bisector line SO standard deviation
LCL lateral collateral ligament T tibia
LCOA lateral compartment osteoarthritis tBL transverse bisector line
LOTA lateral distal tibial angle TKR total knee replacement
LLO limb length discrepancy WBF weight-bearing force
 CHAPTER 1 _____________________________________________ 111
Normal Lower Limb Alignment and Joint Orientation
To understand deformities of the lower extremity, it is
important to first understand and establish the parame-
ters and limits of normal alignment. The exact anatomy
of the femur, tibia, hip, knee, and ankle is of great impor-
tance to the clinician when examining the lower limb
and to the surgeon when operating on the bones and
joints. To better understand alignment and joint orien-
tation, the complex three-dimensional shapes of bones
and joints can be simplified to basic line drawings, sim-
ilar to the stick figures a child uses to represent a person
(~ Fig. I-I).
Fig.1-1
Axis lines. A stick figure can be used as a schematic of a com-
plex three-dimensional image of a person. In the same fashion,
axis and joint lines can be used to describe alignment and joint
orientation of the bones and joints of the lower limb.
Furthermore, for purposes of reference, these line
drawings should refer to either the frontal, sagittal, or
transverse anatomic planes. The two ways to generate a
line in space are to connect two points and to draw a line
through one point at a specific angle to another line. All
the lines that we use for planning and for drawing sche-
matics of the bones and joints are generated using one
of these two methods (~Fig.I-2).
a. ~----------------------------------4t
b.
•....................~ .
Fig. 1-2a,b
Two methods of drawing a line in space.
a Connect two points.
b Draw a line through one point at a specific angle to another
line.
Mechanical and Anatomic Bone Axes
Each long bone has a mechanical and an anatomic axis
(~Fig. 1-3). The mechanical axis of a bone is defined as
the straight line connecting the joint center points of the
proximal and distal joints. The anatomic axis of a bone
is the mid-diaphyseal line. The mechanical axis is always
a straight line connecting two joint center points, wheth-
er in the frontal or sagittal plane. The anatomic axis line
may be straight in the frontal plane but curved in the
sagittal plane, as in the femur. Intramedullary nails
(IMN) designed for the femur have a sagittal plane arc
to reflect this. In the tibia, the anatomic axis is straight in
_ CHAPTER 1· NormallowerLimbAlignmentandJointOrientation
a.
Mechanical axis Anatomic axis
c.
Mechanical axis Anatomic axis
Fig. 1-3 a-d
Mechanical and anatomic axes of bones. The mechanical axis
is the line from the center of the proximal joint to the center of
the distal joint. The mechanical axis is always a straight line
because it is always defined from joint center to joint center.
Therefore, the mechanical axis line is straight in both the fron-
tal and sagittal planes of the femur and tibia. The anatomic
axis of a long bone is the mid-diaphyseal line of that bone. In
straight bones (a,c), the anatomic axis follows the straight mid-
diaphyseal path. In curved bones (b,d),it follows a curved mid-
diaphyseal path. The anatomic axis can be extended into the
metaphyseal and juxta-articular portions of a bone by extend-
ing its mid-diaphyseal line in either direction.
both frontal and sagittal planes (~Fig. 1-3). Axis lines
are applicable to any longitudinal projection of a bone.
For practical purposes, we refer only to the two anatom-
ic planes, frontal and sagittal. The corresponding radio-
graphic projections are the anteroposterior (AP) and
lateral (LAT) views, respectively.
b.
Mechanical axis Anatomic axis
d.
Mechanical axis Anatomic axis
Fig. 1-4 a, b ~
a The tibial mechanical and anatomic axes are parallel but not
the same. The anatomic axis is slightly medial to the me-
chanical axis. Therefore, the mechanical axis of the tibia is
actually slightly lateral to the midline of the tibial shaft. Con-
verse
y, the anatomic axis does not pass through the center
of the knee joint. It intersects the knee joint line at the medi-
al tibial spine.
b The femoral mechanical and anatomic axes are not parallel.
The femoral anatomic axis intersects the knee joint line gen-
erally 1 cm medial to the knee joint center, in the vicinity of
the medial tibial spine. When extended proximally, it usual-
ly passes through the piriformis fossa just medial to the
greater trochanter medial cortex. The angle between the
femoral mechanical and anatomic axes (AMA) is 7±2°.
In the tibia, the frontal plane mechanical and ana-
tomic axes are parallel and only a few millimeters apart.
Therefore, the tibial anatomic-mechanical angle (AMA)
is 0° (~Fig. 1-4a). In the femur, the mechanical and an-
atomic axes are different and converge distally (~ Fig.
1-4b). The normal femoral AMA is 7±2°.
 (HA PT ER 1 . Normal Lower Limb Alignment and Joint Orientation _

a.

Mechanical axis Anatomic axis

;V
Mechanical
~natomi
axis
c
axis

b.

Mechanical Anatomic
Mechanical axis Anatomic axis axis axis
_ CHAPTER 1· NormalLowerLimbAlignmentandJointOrientation

iii

ii

b.

\ .........j" .........I.I ... 1\pe><

\. . _-- ,-. .; ., ./~T······r··
-
of f,mo,., "oleh
. .
Modpo'"' of ',mo,., oo""~,,
/ -r."'. ..... . . . . . . . . . . . . Center of tibial spines
s:( '\
\\
' ~' "
......:::::...................../ ................ Midpoint of soft tissue outline

( ...........J.... Midpoiot of tlb~r ~''''"'

c.
 CHAPTER 1· Normal Lower Limb Alignment and Joint Orientation _
Joint Center Points
As noted above, the mechanical axis passes through the
joint center points. Because the mechanical axis is con-
sidered mostly in the frontal plane, we need to define
only the frontal plane joint center points of the hip, knee,
and ankle (~ Fig. 1-5). Moreland et al. (1987) studied the
joint center points of the hip, knee, and ankle.
For the hip, the joint center point is the center of the
circular femoral head. The center of the femoral head
can best be identified using Mose circles. Practically, we
can use the circular part of a goniometer to define this
point (~Fig. I-Sa).
Moreland et al. (1987) evaluated different geometric
methods to define the center of the knee joint. They
demonstrated that the center of the knee joint is approx-
imately the same using a point at the top of the femoral
notch, the midpoint of the femoral condyles, the center
of the tibial spines, the midpoint of the soft tissue
around the knee, or the midpoint of the tibial plateaus
(~Fig.l-Sb). Using the top of the femoral notch or tibi-
al spines is the quickest way to mark the knee joint cen-
ter point without measuring the width of the bones or
soft tissues.
Similarly, the ankle joint center point is the same
whether measured at the mid-width of the talus, the
mid-width of the tibia and fibula at the level of the pla-
fond, or the mid-width of the soft tissue outline (~ Fig.
l-Sc). The mid-width of the talus or the plafond is the
easiest to use.
""II Fig. 1-5 a-c
a The midpoint of the femoral head is best identified using
Mose circles (i). If these are unavailable, measure the longi-
tudinal diameter of the femoral head and divide it in two.
Use this distance to measure from the medial edge of the
femoral head. The center of the femoral head is located
where the distance to the medial border of the femoral head
is the same as half of the longitudinal diameter (ii). Practi-
cally, we can use the circular part of a goniometer to define
this point (iii). r, radius.
b The midpoint of the knee joint line corresponds to the mid-
point between the tibial spines on the tibial plateau line and
the apex of the intercondylar notch on the femoral articular
surface. These points are not significantly different from the
mid condylar point of the distal femur and the mid plateau
point of the proximal tibia (modified from Moreland et al.
1987).
C The midpoint of the ankle joint line corresponds to the mid-
point of the tibial plafond measured between the medial ar-
ticular aspect of the lateral malleolus and the lateral articu-
lar aspect of the medial malleolus. The mid-width of the
talus and the mid-width of the ankle measured clinically
yield the same point (modified from Moreland et al.1987).
Joint Orientation Lines
A line can also represent the orientation of a joint in a
particular plane or projection. This is called the joint ori-
entation line (~Fig. 1-6).
Ankle
At the ankle, the joint orientation line in the frontal
plane is drawn across the flat subchondral line of the tib-
ial plafond in either the distal tibial subchondral line or
for the subchondral line of the dome of the talus (~ Fig.
l-6a). In the sagittal plane, the ankle joint orientation
line is drawn from the distal tip of the posterior lip to the
distal tip of the anterior lip of the tibia (~Fig.1-6b).
Knee
The frontal plane knee joint line of the proximal tibia is
drawn across the flat or concave aspect of the subchon-
dral line of the two tibial plateaus (~Fig. 1-6c). The
frontal plane knee joint orientation line of the distal
femur is drawn as a line tangential to the most distal
points on the convexity of the two femoral condyles
(~ Fig. 1-6d). In the sagittal plane, the proximal joint
line of the tibia is drawn along the flat subchondral line
of the plateaus (~Fig.1-6e).In the sagittal plane, the dis-
tal femoral articular shape is circular. The distal femoral
Fig.1-6a-h ~
a Ankle joint orientation line, frontal plane. Connect two
points at either end of the ankle plafond line.
b Ankle joint orientation line, sagittal plane. Connect two
points from anterior to posterior lip of joint.
c Proximal tibial knee joint orientation line, frontal plane.
Connect two points on the concave aspect of the tibial pla-
teau subchondral line.
d Distal femoral knee joint orientation line, frontal plane.
Draw a line tangent to the two most convex points on the
femoral condyles.
e Proximal tibial knee joint orientation line, sagittal plane.
Draw a line along the fiat portion of the subchondral bone.
Distal femoral joint orientation line, sagittal plane. Connect
the two anterior and posterior points where the condyle
meets the metaphysis. For children, this is drawn where the
growth plate exits anteriorly and posteriorly.
9 Neck of femur line, frontal plane. Draw a line from the cen-
ter of the femoral head through the mid-diaphyseal point of
the narrowest part of the femoral neck.
h Hip joint orientation line, frontal plane. Draw a line from the
proximal tip of the greater trochanter to the center of the
femoral head.
. . CHAPTER 1 · NormalLowerLimbAlignmentandJointOrientation

b.
a.

d.
c.
 CHAPTER 1 . NormalLower Limb Alignment and Joint Orientation _

e. I.

Growth plate Growth plate

open closed

g. h.

Fig. 1-6 a-h

_ CHAPTER 1· NormalLowerLimbAlignmentandJointOrientation

joint orientation can be drawn as a straight line connect- a. Mechanical

ing the two points where the femoral condyles meet the
metaphysis of the femur. For children, this can be drawn
where the growth plate exits anteriorly and posteriorly
(~ Fig. 1-6 f). Alternatively, Blumensaat's line, which can LPFA = 90·
be seen as a flat line representing the intercondylar (S5-95· )
notch, can be used as the joint orientation line of the dis-
tal femur in the sagittal plane. This is particularly useful
for evaluating sagittal plane deformities secondary to
growth arrest problems.

Hip
Because the femoral head is round, it is necessary to use
the femoral neck or the greater trochanter to draw a
joint line for hip orientation in the frontal plane (~ Fig.
1-6 g). The level of the tip of the greater trochanter has a
functional and developmental relationship to the center
of the femoral head. Similarly, the femoral neck main-
tains a developmental relationship to the femoral dia-
physis and femoral head. A line from the proximal tip of
the greater trochanter to the center of the femoral head
represents the hip joint orientation line of the hip joint
in the frontal plane. Alternatively, the mid-diaphyseal
line of the femoral neck can represent the orientation of
the hip joint (~Fig. 1-6h). This is drawn using the cen-
ter of the femoral head as one point and the mid-diaphy-
seal width of the neck as the second point.
Joint Orientation Angles and Nomenclature
The joint lines in the frontal and sagittal planes have a
characteristic orientation to the mechanical and ana-
tomic axes. For purposes of communication, it is impor-
tant to name these angles. These joint orientation angles
have been given various names by different authors in
different publications (Chao et al. 1994; Cooke et al.
1987,1994; Krackow 1983; Moreland et al.1987). There is
no standardization of the nomenclature used in the lit-
erature. This makes communication and comparison
difficult. We think that the names used by different au-
thors are confusing, difficult to remember, and not user
friendly. The nomenclature used in this text was devel-
oped so that the names could be easily remembered or
even derived without memorization (Paley et al. 1994).
In the frontal and sagittal planes, a joint line can be
drawn for the hip, knee, and ankle. The angle formed be-
tween the joint line and either the mechanical or ana-
tomic axis is called the joint orientation angle. The name
of each angle specifies whether it is measured relative to
a mechanical (m) or an anatomic (a) axis. The angle may
be measured medial (M),lateral (L), anterior (A), or pos-
terior (P) to the axis line. The angle may refer to the
proximal (P) or distal (D) joint orientation angle of a
JLCA
(0-2°)
LDTA = S9°
(S6-92/1T
Fig. 1-7 a-e
a Frontal plane joint orientation angle nomenclature and nor-
mal values relative to the mechanical axis.
b Frontal plane joint orientation angle nomenclature and nor-
mal values relative to the anatomic axis. MNSA, medial NSA.
c Sagittal plane joint orientation angle nomenclature and nor-
mal values relative to the anatomic axis. aPPFA, anatomic
posterior proximal femoral angle; aADTA, anatomic anteri-
or distal tibial angle.
d Anatomic axis-joint line intersection points. JCDs for the
frontal plane.
e Anatomic axis-joint line intersection points. JERs for the
sagittal plane.
bone (femur [F] or tibia [TD. Therefore, the mechanical
lateral distal femoral angle (mLDFA) is the lateral angle
formed between the mechanical axis line of the femur
and the knee joint line of the femur in the frontal plane.
Similarly, the anatomic LDFA (aLDFA) is the lateral
angle formed between the anatomic axis of the femur
and the knee joint line of the femur in the frontal plane.
Sagittal plane angles can just as easily be named. For
example, the anatomic posterior proximal tibial angle
(aPPTA) is the posterior angle between the anatomic
axis of the tibia and the joint line of the tibia in the sag-
ittal plane.
Schematic drawings of the nomenclature of the me-
chanical and anatomic frontal (~Fig. 1-7a and b) and
 CHA PIER 1 . Normll Lo," . Limb Alignment and JointO.ientation . .

b. Anatomic , Sagittal

Z.I MNSA = 130'

(124--136' )
MPFA = 84'
PPFA= 90;"·f \ ANSA= 170'
U (165-175' )
(80-89' )

aLDFA=8" PDFA = 83'

(79-83' )
(79-87') /
-¥-<-\t,.
~
JLCA
(D-2T -'==9=>/>4""
MPTA = 87" PPTA=81\
(85-90' ) (77-84' )

\i
LOTA", 89'
t'\'~TA = 80'
(86-92'Y i j 7
8-82' )

d. ,.
)

aJCD", piriformis fossa 1

a-JEA = 13

a-JER = 1'5

aJCD '" medial tibial spine

10±5mm

1
a-JER = /2

aJCD=4:t4mm
. . (H APTER 1 . Normal Lower Limb Alignment and Joint Orientation

sagittal (~Fig. 1-7 c) plane joint orientation angles are

shown. Each axis line and joint orientation line intersec-
tion forms two angles. Either angle could be named with
this nomenclature. For example, the mechanical medial
distal femoral angle (mMDFA) and the mLDFA are com-
plementary to each other (they add up to 180°). Al-
though either angle could be used to name the joint ori-
entation angle of the knee to the mechanical axis of the
femur, the mLDFA is the one used in this text (~Fig.
1-7a). The angles chosen in this text are those that are
normally less than 90° (normal value of the mLDFA= 87°
and normal value of the mMDFA=93°). If the normal
joint orientation was 90°, such as for the mechanicallat-
eral proximal femoral angle (mLPFA) and mechanical
medial proximal femoral angle (mMPFA), the lateral an-
gle was chosen as the standard angle in this text. When
it is obvious that the joint orientation angle refers to the
mechanical or anatomic axis, the m or a prefix can be
omitted. For example, sagittal plane orientation angles
usually refer to the anatomic axis because mechanical
axis lines are rarely used in the sagittal plane. The prefix
m or a is omitted because anatomic axis is implied. Be-
cause the mechanical and anatomic axes of the tibia are
parallel, the medial proximal tibial angle (MPTA) and
lateral distal tibial angle (LDTA) have the same value
whether they refer to the mechanical or anatomic axis. It
therefore does not matter whether the prefix m or a is
used. Finally, because LPFA is used by convention to de-
scribe joint orientation of the hip relative to the mechan-
ical axis and MPFA is used relative to the anatomic axis,
Shave et al.. unpublished results 4.1 ± 4 mm
the m and a prefixes can be omitted. Therefore, the only Paley et aI., 1994 9.7 ± 6.8 mm
time the m or a prefix must be used is with reference to
the LDFA. The mLDFA and the aLDFA are both normal-
ly less than 90° and are different from each other. There-
fore, the prefix should always be used to define which
LDFA is being referenced. of the joint. Similarly, the anatomic axis: joint center
The angle formed between joint orientation lines on ratio (aJCR) is the ratio of the aJCD and the total width
opposite sides of the same joint is called the joint line of the joint. The normal values and range are illustrated
convergence angle OLCA) (~Fig. 1-7a and b). In the (~ Fig.1-7e).
knee and ankle joints, these lines are normally parallel.
Two mid-diaphyseal points define anatomic axis
lines. The intersection of the anatomic axis with the joint Mechanical Axis and Mechanical Axis Deviation
line is fairly constant and is important in understanding (MAD)
normal alignment and in planning for deformity correc-
tion. The distance from the intersection point of ana- The normal relationship of the joints of the lower ex-
tomic axis lines with the joint line can be described rel- tremity has been the focus of several recent studies
ative to the center of the joint line or to one of its edges. (Chao et al.1994; Cooke et al.1987, 1994; Hsu et al.1990;
In the frontal plane, the distance on the joint line be- Moreland et al. 1987; Paley et al. 1994). There are two
tween the intersection with the anatomic axis line and considerations when evaluating the frontal plane of the
the joint center point is called the anatomic axis to joint lower extremity: joint alignment and joint orientation
center distance (aJCD) (~Fig. 1-7d). In the sagittal (Paley and Tetsworth 1992; Paley et al. 1990). Alignment
plane, the distance between the point of intersection of refers to the collinearity of the hip, knee, and ankle
the anatomic axis line with the joint line and the anteri- (~ Fig. 1-8a). Orientation refers to the position of each
or edge of the joint is called the anatomic axis to joint articular surface relative to the axes of the individual
edge distance (aJED). The anatomic axis:joint edge ratio limb segments (tibia and femur) (~Fig. 1-8b). Align-
(aJER) is the ratio between the aJED and the total width ment and orientation are best judged using long stand-
 CHAPTER 1· NormalLower Limb AlignmentandJoint Orientation . .

b. c.

Mechanical
tibiofemoral
angle

d.

Shave et aI., unpublished results 1.3 ± 1.3'

Chao et aI., 1994 1.2 ± 2.2'
Cook et aI., 1994 1 ± 2.8'
Hsu et aI., 1990 1.2 ± 2.2'
Moreland et aI., 1987 1.3 ± 2'

Fig. 1-8 a-d

a MAD is the perpendicular distance from the mechanical ax-
is line to the center of the knee joint line. The frontal plane
mechanical axis of the lower limb is the line from the center
of the femoral head to the center of the ankle plafond. The
normal mechanical axis line passes 8 ± 7 mm medial to the
center of the knee joint line.
b Knee joint malorientation is present when the angle between
the femoral and tibial mechanical axis lines and their respec-
tive knee joint lines (LDFA and/or MPTA) falls outside of
normal limits (normal=87.5±2°).
c Tibiofemoral mechanical alignment refers to the relation be-
tween the mechanical axes of the femur and tibia (normal =
1.3° varus).
d Tibiofemoral anatomic alignment refers to the relation be-
tween the anatomic axes of the femur and tibia.

Shave et aI. , unpublished results 6.85 ± 1.4'

_ CHAPTER 1· NormalLowerLimbAlignmentandJointOrientation

ing AP radiographs of the entire lower extremity on a

single cassette (described in greater detail in Chap. 3), so
that one can also assess the MAD.
In the frontal plane, the line passing from the center
of the femoral head to the center of the ankle plafond
is called the mechanical axis of the lower limb (. Fig.
1-8 a). By definition, malalignment occurs when the cen-
ter of the knee does not lie close to this line. Although
normal alignment is often depicted with the mechanical
axis passing through the center of the knee, a line drawn
from the center of the femoral head to the center of the
ankle typically passes immediately medial to the center
of the knee. Moreland et al. (1987) reviewed long stand-
ing AP radiographs of both lower extremities in 25
normal male volunteers and documented that the center Shave et aI. , unpublished results 122 ± 2.6'
Paley et aI., 1994 129.7 ± 6.2'
points of the hip, knee, and ankle are nearly collinear.
Yoshioka et aI., 1987 129'
The angle between the mechanical axis of the tibia and
femur (tibiofemoral angle) was 1.3 ± 2° varus (. Fig.
1-8c). A commonly measured value is the anatomic ti- Fig. 1-9
biofemoral angle. This is usually approximately 6° val- Hip joint orientation in the frontal plane. MNSA according to
gus (. Fig. 1-8d). Hsu et al. (1990) reviewed long stand- different authors (mean ± 1 standard deviation [SD]).
ing AP radiographs of the lower extremity of 120 normal
volunteers of various ages and reported that the me-
chanical axis generally passes immediately medial to the
center of the knee. In their population, the mechanical
tibiofemoral angle measured 1.2 ± 2.2° varus. In a study
of 50 asymptomatic French women older than 65 years
(Glimet et al. 1979), the mechanical tibiofemoral angle
measured 0°. Most recently, Bhave et al. (unpublished re-
suIts) studied a group of 30 adults older than 60 years, all
of whom had no history or evidence of injury, surgery,
arthrosis, or pain in their lower extremities. The me-
chanical tibiofemoral angle measured 1.3 ± 1.3°.
The distance between the mechanical axis line and
the center of the knee in the frontal plane is the MAD.
The MAD is described as either medial or lateraL Medi-
al and lateral MADs are also referred to as varus or val-
gus malalignments, respectively. In a retrospective study
of 25 knees in adult patients of different ages, the normal
MAD was 9.7±6.8 mm medial (Paley et aL 1994) (. Fig.
1-8a). In a recent prospective study of normal lower
limbs in people older than 60 years without any evidence
of pathological abnormality of the knee, the MAD was
4.1 ±4 mm (Bhave et aL, unpublished results).

Hip Joint Orientation

Previously, hip joint orientation was evaluated using the

neck shaft angle (NSA). The normal NSA is 125°-131°. Shave et aI., unpublished results 89.4 ± 4.8'
Chao et aI. , 1994 94.6 ± 5.5'
In an anatomic study of isolated cadaver femora, Yoshi- Paley et aI., 1994 89.9 ± 5.2'
oka et al. (1987) determined that the NSA in adult men
normally measures 129° (. Fig. 1-9). A line from the tip
of the greater trochanter to the center of the femoral Fig.l·10
head was described by Paley and Tetsworth (1992) to de- Hip joint orientation in the frontal plane. LPFA according to
fine the orientation of the hip in the frontal plane. Chao different authors (mean ± 1 SD).
 CHAPTER 1 · NormalLower Limb Alignmenta ndJoint Orientation _
Bhave et aI., unpublished resu lts 88 .1 :1: 1S
Chao et aI. , 1994 88.1 :I: 3.2'
Cooke et aI. , 1994 86 :1: 2.1'
Paley et aI., 1994 87.8 :1: 1.6'
Fig. 1-11
Distal femoral knee joint orientation in the frontal plane.
mLDFA according to different authors (mean ± 1 SD).
et al. (1994) also measured the LPFA, which they called
the horizontal orientation angle for the proximal femur,
from long standing radiographs in 127 normal volun-
teers and stratified the study group according to age and
gender. There was no significant change noted with age
in women, and the relationship of this line to the
mechanical axis of the femur measured 91.S±4.6° in
younger women and 92.7 ± 4.9° in older women. In men,
the relationship of this line relative to the mechanical
axis of the femur demonstrated an age-related tendency
toward increasing varus, measuring 89.2 ± 5.0° in young-
er men and 94.6 ± SS in older men. Data from our insti-
tution (Paley et al. 1994), based on a smaller group of 25
asymptomatic adults, revealed that this proximal femo-
ral joint orientation line measures 89.9 ± 5.2°. Another
study from our institution (Bhave et al., unpublished
results) of asymptomatic older adults (>60 years) with-
out gonarthrosis revealed an LPFA of 89.4±4.8°. Based
on these observations, we consider 89.9 ± 5.2° to be the
normal LPFA (Paley and Tetsworth 1992; Paley et al.
1990, 1994) (~Fig . 1-10).
Bhave et aI. , unpublished resu lts 88.3 :1: 2'
Chao et aI., 1994 87.5 :1: 2.6'
Cooke et aI. , 1994 86.7 :1: 2.3'
Paley et aI. , 1994 87.2 :1: 1.50
Fig. 1-12
Proximal tibial knee joint orientation in the frontal plane.
MPTA according to different authors (mean ± 1 SD).
Knee Joint Orientation
Regarding knee joint orientation, Chao et al. (1994) de-
termined that the distal femoral articular surface is nor-
mally in slight valgus relative to the femoral mechanical
axis, measuring 88.1 ± 3.2°. These results were confirmed
by our data (Paley et al. 1994), with the distal femur in
slight valgus relative to the mechanical axis of the femur
(mLDFA=87.8± 1.6°). Cooke et al. (1987,1994) obtained
radiographs of the knee and hip after positioning the
patient in a QUE STAR frame to improve reproducibility
of the radiographic technique. In 79 asymptomatic
young adults, the distal femoral orientation line mea-
sured valgus of 86±2.1°. In one study of older asymp-
tomatic adults (Bhave et al., unpublished results), the
LDFA was 88.1 ± IS. Based on all these studies, we con-
sider the normal mLDFA to be 87.5±2S (Paley et al.
1994) (~Fig.l-ll).
To consider the proximal tibial joint orientation,
Chao et al. (1994) again stratified their data by age and
_ (H APTER 1 • Normal Lower Limb Alignment and Joint Orientation

gender and found a significant difference when compar- a.

ing older with younger men. In all groups, the proximal
tibial joint orientation line measured slight varus rela-
tive to the mechanical axis of the tibia (87.2 ± 2.1°). In
women, there was no age differential. In asymptomatic
young men, there was slightly more varus (MPTA = 85.5
±2.9°) compared with asymptomatic older men (87.5
±2.6°). These data suggest that some young men with
more varus later develop symptomatic degenerative ar-
throsis and "drop out" of the asymptomatic group of
older men. This hypothesis is supported by data regard-
ing alignment of elderly normal lower limbs with no
previous history of injury or surgery and with no evi-
dence of knee arthrosis or pain. One study (Glimet et al.
1979) of 50 elderly asymptomatic French women docu-
mented that the mechanical tibiofemoral angle in this
select group measures 0° instead of slight varus as is
seen in the normal population. The second study, from
our institution (Bhave et al., unpublished results), dem-
onstrated an MPTA of 88.3 ± 2° in patients older than
60 years. Cooke et al. (1994) reviewed standardized ra-
diographs obtained using a positioning frame and
found that the MPTA is 86.7±2.3°. These results were
confirmed by our data (Paley et a1.1994), with an MPTA
of 87.2° varus ± IS, and by the data presented by More-
land et al. (1987), with an MPTA of 87.2° varus± IS.
Based on these observations, we consider the normal
MPTA to be 87±2S (Paleyet al. 1994) (~Fig. 1-12).
The knee joint orientation measures approximately
3° off the perpendicular, such that the distal femoral
joint line is in slight valgus and the tibia is in slight varus
to the proximal tibial joint line (by convention, we al-
ways refer to the distal segment relative to the proximal
segment when describing deformity of the lower ex-
tremity) (Krackow 1983; Moreland et a1.1987; Paleyet al.
1990, 1994). When walking, the feet progress one in front
of the other along the same line, with the leg inclined
(adducted) to the vertical approximately 3° (Saunders et
al. 1953) (~Fig. 1-13). Krackow (1983) reports that this
3° varus position of the lower limb allows the knee to
../
maintain an optimal parallel orientation to the ground : 3°
during gait (~Fig. 1-13 a). In bipedal stance, with the Midline
feet as wide as the pelvis and the tibia perpendicular to
level ground, the knee joint line would be oriented in 3°
valgus relative to the vertical (~Fig. 1-13b).
Several authors have presented reports on proximal
tibial sagittal plane orientation. Meister et al. (1998) re-
ported that the posterior slope of the proximal tibia in
the sagittal plane is 10.7 ± 1.8°. (PPTA=79.7 ± 1.8°.) Chiu
et al. (2000) reported a PPTA of 78S in a radiographic
study of 25 pairs of Chinese cadaveric tibiae. Matsuda et
al. (1999), using magnetic resonance imaging, reported
separate PPTAs measured from the medial and lateral
tibial plateaus relative to the anatomic axis of the tibia.
They reported a PPTA of 79.3 ± 5° when measured from
the medial tibial plateau and a PPTA of 82±4° when
 (HA PT ER 1 . Normal Lower Limb Alignment and Joint Orientation _

b. At ease standing position At attention standing position

.r"''''.
3·~ 3·
Midline Midline

Fig. 1-13 a, b
a During walking, the limb is in the "at attention" posture, 3°
inclined to the ground. Therefore, the knee joint lines are
parallel to the ground during walking (modified from Kra-
kow 1983).
b The standing alignment of the lower limbs to the ground
changes with the feet apart at a distance equal to the width
of the pelvis ("at ease" standing position) and the feet to-
gether ("at attention" standing position). When the feet are
apart, the knee joint line is 3° inclined to the ground and the
mechanical axis is perpendicular to the ground. When the
feet are together, the knee joint line is parallel to the ground
and the mechanical axis is oriented 3° to the ground (modi-
fied from Krakow 1983).

Fig.1-14~

Proximal tibial knee joint orientation in the sagittal plane.

PPTA according to different authors (mean ± 1 SD).

Shave et aI. , unpublished results 80.4 ± 1.6'

Paley et aI. , 1994 80 ± 3.5 '
. . (H APTER 1 . Normal Lower Limb Alignment and Joint Orientation
PDFA
Shave et ai" unpublished results 83,5 ± 1.9'
Paley et aI. , 1994 83.1 ± 3,6'
Fig.1-15
Distal femoral knee joint orientation in the sagittal plane.
PDFA according to different authors (mean ± 1 SD).
measured from the lateral plateau. In our series (Bhave
et al., unpublished data) of normal volunteers, the PPTA
was 80.4± 1.6° (~Fig. 1-14).
The distal femoral knee joint orientation line in the
sagittal plane has never been studied using the joint line
of the distal femur that we describe. The normal poste-
rior distal femoral angle (PDFA) in our series of normal
volunteers was 83.1±3.6° (~Fig.1-1S).
The orientation of Blumensaat's line was studied by
Bhave et al. (unpublished results). The Blumensaat's line
angle measured 32±2.6° (~Fig.1-16).
Shave et aI., unpublished resu lts 32 ± 2.6 0
Fig. 1-16
Distal femur sagittal plane orientation. The angle formed by
the distal femoral anatomic axis and Blumensaat's line is
shown.
Ankle Joint Orientation
Moreland et al. (1987) reported that the ankle is in slight
valgus (89.8±2.7°). Data from our institution (Paley et
al. 1994) also demonstrated slight valgus (LDTA = 88.6 ±
3.8°), as did the data presented by Chao et al. (1994) (87.1
± 3.3°). This relationship is variable, and up to 8° of val-
gus can be seen (Moreland et al. 1987). Part of this vari-
ation may be projectional because, in most studies, this
angle was measured from radiographs obtained cen-
tered on the knee with the patella forward and without
consideration for foot rotation. Inman (1976) measured
107 cadaver specimens and reported that the average an-
kle joint orientation equated to an LDTA of 86.7 ± 3.2°,
with a range of 80°_92°. Based on these measurements,
we consider the normal LDTA to be 89 ± 3° (Paley and
Tetsworth 1992; Paleyet al. 1994) (~Fig. 1-17). In prac-
tice, it is convenient to use the line perpendicular to the
tibial diaphysis as the joint orientation line for the ankle.
 CHA PT ER 1 . Normal Lower Limb Alignment and Joint Orientation _
Shave et aI. , unpublished results 88 .7 ± 2.7"
Chao et aI. , 1994 87.1 ± 3.3'
Inman,1991 87 ± 2.7'
Paley et aI. , 1994 88.6 ± 3.8'
Fig. 1-17
Ankle joint orientation frontal plane. LDTA according to differ-
ent authors (mean ± 1 SD).
Finally, the normal sagittal plane joint line orienta-
tion of the ankle has been described as the anterior tilt
of the distal tibia (~ Fig. 1-18). In our studies, the values
were 79.8± 1.60 (Paley et al. 1994) and 83.1 ±2.1 0 (Bhave
et al., unpublished results).
References
Chao EY, Neluheni EV, Hsu RW, Paley D (1994) Biomechanics
of malalignment. Orthop Clin North Am 25:379-386
Chiu KY, Zhang SO, Zhang GH (2000) Posterior slope of tibial
plateau in Chinese. J Arthroplasty 15:224-227
Cooke TD, Li J, Scudamore RA (1994) Radiographic assessment
of bony contributions to knee deformity. Orthop Clin North
Am 25:387-393
Cooke TD, Siu D, Fisher B (1987)The use of standardized radio-
graphs to identify the deformities associated with osteoar-
thritis. In: Noble J, Galasko CSB (eds) Recent developments
in orthopaedic surgery. Manchester University Press, Man-
chester
Shave et aI. , unpublished resu lts 83.1 ± 2.1'
Paley et aI. , 1994 79.8 ± 1.6'
Fig.1-18
Ankle joint orientation sagittal plane. ADTA according to dif-
ferent authors (mean ± 1 SD).
Glimet T, Masse JP, Ryckewaert A (1979) Radiologic study of
painless knees in 50 women more than 65 years old: I. Fron-
tal teleradiography in an upright position [in French]. Rev
Rhum Mal Osteoartic 46:589-592
Hsu RW, Himeno S, Coventry MB, Chao EY (1990) Normal ax-
ial alignment of the lower extremity and load-bearing dis-
tribution at the knee. Clin Orthop 255:215-227
Inman VT (1976) The joints of the ankle. Williams & Wilkins,
Baltimore
Krackow KA (1983) Approaches to planning lower extremity
alignment for total knee arthroplasty and osteotomy about
the knee. Adv Orthop Surg 7:69-88
Matsuda S, Miura H, Nagamine R, Urabe K, Ikenoue T, Okaza-
ki K, Iwamoto Y (1999) Posterior tibial slope in the normal
and varus knee. Am J Knee Surg 12:165-168
Meister K, Talley MC, Horodyski MB, Indelicato PA, Hartzel JS,
Batts J (1998) Caudal slope of the tibia and its relationship
to noncontact injuries to the ACL. Am J Knee Surg 11:217-
219
Moreland JR, Bassett LW, Hanker GJ (1987) Radiographic anal-
ysis of the axial alignment of the lower extremity. J Bone
Joint Surg Am 69:745-749
 Normal lower limb and Joint Orientation

Paley D, Tetsworth K (1992)Mechanical axis deviation of the

lower limbs: Preoperative planning of uniapical angular de-
formities of the tibia or femur. Clin Orthop 280:48-64
Paley D, Chaudray M, Pirone AM, Lentz P, Kautz D (1990) Treat-
ment of malunions and mal-nonunions of the femur and
tibia by detailed preoperative planning and the Ilizarov
techniques. Orthop Clin North Am 21:667-691
Paley D, Herzenberg JE, Tetsworth K, McKie J, Bhave A (1994)
Deformity planning for frontal and sagittal plane corrective
osteotomies. Orthop Clin North Am 25:425-465
Yoshioka Y,Siu D, Cooke TD (1987) The anatomy and function-
al axes of the femur. J Bone Joint Surg Am 69:873-880
 CHAPTER 2

Malalignment and Malorientation in the Frontal Plane

-
Malalignment which can be easily erased using an alcohol swab (~ Fig.
2-2a). A long ruler or the edge of another long radio-
Malalignment refers to the loss of collinearity of the hip, graph is used to aid in drawing the lines (~Fig. 2-2b).
knee, and ankle in the frontal plane. Therefore, if the Before drawing any line, it is preferable to mark the joint
MAD exceeds the normal range, there is malalignment center points that need to be connected (e.g., center of
of the hip, knee, and ankle (see ~ Fig. 1-8 a). Frontal plane femoral head and center of knee).
MAD may arise from four anatomic sources (~ Fig. 2-1): A clear plastic protractor or goniometer is used to
(a) femoral frontal plane deformity; (b) tibial frontal measure angles. Protractors are more accurate and reli-
plane deformity; (c) frontal plane knee joint laxity, in- able than are goniometers. Inexpensive or "complimen-
cluding subluxation or dislocation; and (d) femoral or tary" goniometers are often poorly made and are of
tibial condylar deficiency. These sources can be catego- questionable accuracy (±2°).
rized as osseous, interosseous, and condylar.
We designed a malalignment test (MAT) to identify
the source(s) of the MAD (Paley and Tetsworth 1992).
The orientation of the knee joint line in the frontal plane
has a known orientation to the tibial and femoral me-
chanical axes (MPTA and mLDFA) (Paley et al. 1994).
Less than 85° and greater than 90° are considered to be
abnormal for both the mLDFA and the MPTA and iden-
tify the femur and/or tibia as a source of the MAD
(~ Fig. 2-1a and d).
The femoral and tibial frontal plane knee joint lines
should be within 3° of parallel in a standing position
(Paleyet al. 1994). The angle between the femoral and
tibial joint lines is the ILCA.A ILCA greater than 3° is ab-
normal and indicates either ligamentous laxity with
opening of the joint on the lax side or loss of cartilage
height as a source of the MAD (~Fig. 2-1 b and e). An-
other interosseous source of malalignment is medial or
lateral subluxation of the tibia on the femur (~ Fig. 2-1 b
and e). Normally, the midpoints of the tibial plateaus and
femoral condyles correspond within 3 mm.
The femoral and tibial joint lines are actually made
up of two collinear half-lines representing the orienta-
tion of the medial and lateral femoral and tibial
condyles, respectively. If there is a step or angulation be-
tween the two condylar joint lines, this is evidence of a
condylar source of the MAD (~ Fig. 2-1 c and f).
The MAT is performed directly on the radiograph
(~ Fig. 2-2). There is no need to trace the bone onto pa-
per. A sharpened film-marking pencil (e.g., DIXON
Tru/Color Black 2225; Price Modern, Baltimore, MD) is
better than wax markers, which make thick lines that are
more difficult to remove. The pencil produces a fine line,
. . CHAPTER 2 . Malalignment and Malorientation in the Frontal Plane

a. b.
ii
iii

c.
d.
ii iii

~ ~PTA
I > 90'
 CHAPTER 2 . Malalignment and Malorientation in the Frontal Plane . .
e.
Fig. 2-1 a-f
MAT is a test to identify the sources of the MAD. The example
chosen shows the various sources of medial MAD (varus mal-
alignment, a-c) and lateral MAD (valgus malalignment, d-f).
a Osseous malalignment. i, Tibial varus deformity: MPTA
< 85°. ii, Femoral varus deformity: LDFA> 90°. iii, Combined
femoral and tibial varus deformity: LDFA>900 and MPTA
<85°.
b Interosseous malalignment (normal femur and tibia). i, Lat-
eral joint laxity and/or loss of cartilage: JCLA> 2°. ii, Varus
JCLA > 2° plus lateral subluxation.
c Condylar malalignment. i, Depressed or maloriented medial
tibial plateau (normal femur). ii, Depressed or maloriented
medial femoral condyle (normal tibia).
f.
d Osseous malalignment. i, Tibial valgus deformity: MPTA
>90° (normal femur). ii, Femoral valgus deformity: LDFA
<85° (normal tibia). iii, Combined femoral and tibial valgus
deformity: MPTA> 90° and LDFA<85°.
e Interosseous malalignment (normal femur and tibia). i, Me-
dial joint laxity and/or loss oflateral cartilage: JCLA>2°. ii,
Valgus JCLA > 2° plus lateral subluxation.
Condylar malalignment. i, Depressed or maloriented lateral
tibial plateau (normal femur). ii, Depressed or maloriented
lateral femoral condyle (normal tibia).
. . CHAPTER 2 . Malalignment and Malorientation in the Frontal Plane
 CHAPTER 2 · Ma lalignmentandMalorientationintheFrontalPlane _
Fig. 2-2 a-d
Photographs of author performing MAT on a long radiograph
using a pencil.
a Mark the center of the hip, knee, and ankle on the long ra-
diograph with a soft radiograph-marking pencil.
b Use a long ruler or the edge of another long radiograph to
draw the mechanical axis line and measure the MAD.
e Draw the knee joint lines and the femoral and tibial mechan-
ical axis lines. To erase, use an alcohol swab and allow the al-
cohol to dry before drawing over the same area again (oth-
erwise, the emulsion of the radiograph may scratch).
d Measure the mLDFA and the MPTA.
Step 0: Measure the MAD
Draw the joint center points of the hip, knee, and ankle
(~ Fig. 2-3 a). Draw a line from the center of the femoral
head to the center of the ankle (mechanical axis oflimb).
Mark the intersection of this line with the knee joint
line. The perpendicular distance from this intersection
point to the center of the knee is the MAD. The direction
of the MAD (medial or lateral to the center of the knee)
should be indicated. The normal average MAD is
8±7 mm medial.
Step 1: Measure the mLDFA
Draw the distal femoral joint orientation line (~Fig.
2-3 b). Draw the line from the center of the hip to the cen-
ter point of the knee on the femoral knee joint line (fem-
oral mechanical axis). Measure the mLDFA between
these two lines. If the mLDFA is outside the normal
range (85°-90°),the femur is contributing to the MAD.
Step 2: Measure the MPTA
Draw the proximal tibial joint orientation line (~Fig.
2-3c). Draw a line from the center point of the ankle to
the center point of the knee on the tibial knee joint line.
Measure the MPTA between these two lines. If the MPTA
is outside the normal range (85°-90°), the tibia is con-
tributing to the MAD.
EI CHAPTER 2 • Malalignment and Malorientation in the Frontal Plane

Varus Varus

Step 0 Step 1

C. d.

Valgus Valgus
FC
JLCA
~~=..>
"'->
TP

Varus

Step 2 Step 3
 CHAPTER 2 . Malalignment and Malorientation in the Frontal Plane
e.
d =0-3 mm
1- 1
f.
Valgus
Fig. 2-3 a-f
MAT.
a Step O. Measure the MAD. The normal range is 1-15 mm me-
dial, relative to the center of the joint. Medial MAD greater
than 15 mm is considered varus, and lateral MAD is consid-
ered valgus (insets) .
b Step 1. Measure the LDFA. The normal range is 85°-90°.
LDFA less than 85° means that femoral bone deformity is a
source of lateral MAD (valgus). LDFA greater than 90°
means that femoral bone deformity is a source of medial
MAD (varus).
c Step 2. Measure the MPTA. The normal range is 85°_90°.
MPTA greater than 90° means that tibial deformity is a
source of lateral MAD (valgus). MPTA less than 85° means
that tibial deformity is a source of medial MAD (varus).
d Step 3. Measure the ILCA. The normal range is 0°_2° medial
convergence of the joint lines. Medial ILCA convergence of
greater than 2° means that lateralligamento-capsular laxity
or medial cartilage loss is a source of medial MAD (varus).
A lateral JLCA means that medialligamento-capsular laxity
11111
ii
Valgus
or lateral cartilage loss is a source of lateral MAD (valgus).
FC, femoral condyle; TP, tibial plateau.
e Addendum 1. Compare the midpoints of the femoral and tib-
ial joint lines. They should be collinear within 3 mm. If the
midpoint of the tibial joint line is more than 3 mm lateral or
medial to the midpoint of the femoral joint line, knee joint
subluxation is the source of lateral or medial MAD, respec-
tively. d, distance.
f Addendum 2. i, Compare the joint lines of the medial and
lateral plateaus with each other. They should be collinear. If
the lateral plateau is angled or depressed, this is a source
of lateral MAD (valgus). If the medial plateau is angled or
depressed, this is a source of medial MAD (varus). ii, Com-
pare the lines tangential to the medial and lateral femoral
condyles. They should be collinear. If the lateral condyle is
very hypoplastic or is angled or depressed, this is a source of
lateral MAD (valgus). If the medial condyle is very hypoplas-
tic or is angled or depressed, this is a source of medial MAD
(varus).
. . CHAPTER 2 . Malalignment and Malorientation in the Frontal Plane

a. b.

Step 3: Measure the JLCA Addendum 1: Rule Out Knee Joint Subluxation

Measure the ]LCA between the femoral and tibial knee Compare the midpoints of the femoral and tibial knee
joint lines (~ Fig. 2-3 d). For small angles « 5°), use the joint orientation lines (~Fig. 2-3e). Normally, they
Cobb method to measure the JLCA (Cobb 1948). Con- should be within 3 mm of each other. If the two femoral
vergence of the joint line is described as medial or later- and tibial knee joint line midpoints are more than 3 mm
al for varus or valgus convergence, respectively. Normal- from each other, there is frontal plane subluxation of the
ly, the knee joint lines are parallel within 2°. Angles knee, which contributes to the MAD.
greater than 2° are considered to be a source of the MAD.
The ]LCA should be compared between films obtained
with the patient in weight-bearing and non-weight-
bearing positions to separate joint line convergence due
to loss of cartilage height and ligamentous laxity (see
Chap. 13). Stress radiographs can also be used (see
Chaps. 3,14, and 16).
 CHAPTER 2 . Ma lalignment and Malorientation in the Frontal Plane _

c.

Addendum 2: Rule Out Condylar Malalignment Fig . 2-4a-d

Examples of the MAT for medial MAD.

If the tibial knee joint line is not parallel to both pla- a Medial MAD, mLDFA=94°, MPTA=87°, JLCA=O: malalign-
teaus, draw a separate line that best fits each plateau ment due to femoral deformity.
b Medial MAD, mLDFA=87°, MPTA=82°, JLCA=O: malalign-
(~ Fig. 2-30. If the difference is substantial, tibial joint
ment due to tibial deformity.
line incongruity is a source of the MAD. A similar test
C Medial MAD, mLDFA = 94°, MPTA=82°, JLCA=O: malalign-
can be conducted on the femoral condyle knee joint line. ment due to femoral and tibial deformity.
Because the femoral condyles are round, a step or de- d MediaIMAD,mLDFA=87°,MPTA=82°,JLCA=7°:malalign-
pression may not be as obvious or significant. A single ment due to tibial deformity and lateral collateral ligament
straight line can always be drawn tangential to the con- laxity.
vex ends of the condyles. Therefore, alteration in the rel-
ative level of the femoral condyles or in the orientation
of the femoral condyles to each other is often mistaken
for malorientation of the entire distal femur.
Examples of the use of the MAT are shown in ~ Figs.
2-4. It is important to emphasize that the MAT identifies
only which bone or joint source contributes to the MAD
that is measured. It does not identify the level of defor-
mity in the femur or tibia. Identifying the precise level is
discussed in Chap. 4. Also note that the MAT does not
identify any sagittal plane component of deformity.
Ell CHAPTER 2 . Malalignment and Malorientation in the Frontal Plane
Fig. 2-5 a, b
a Malorientation of the ankle joint at or near the level of the
plafond produces no MAD.
b Malorientation of the hip joint at or near the level of the fem-
oral head produces no MAD.
Malorientation of the Ankle and Hip
Malorientation of the knee joint leads to MAD. The MAT
is therefore a malorientation test (MOT) of the knee.
Malorientation of the ankle or hip joints usually leads to
minimal or no MAD because the deformity apex is at or
near the ends of the mechanical axis of the lower limb
(center points of ankle and hip) (~Fig. 2-5). Therefore,
the MAT does not reliably identify the presence of tibial
and femoral deformities around the ankle or hip, respec-
tively. To know whether the ankle or hip joints are nor-
mally oriented to the tibial or femoral mechanical axis
lines, it is necessary to perform separate MOTs for these
joints.
Orientation of the Ankle and Hip
in the Frontal Plane
The normal orientation of the ankle and hip joint lines
to the mechanical and anatomic axes is herein reviewed
briefly; it is discussed in greater detail in Chap. 1. The
frontal plane ankle joint orientation line has the same
orientation to the tibial mechanical and anatomic axes
(~Figs. 2-6 and 2-7). The LDTA is normally 89±3° to
these axes (~Fig. 2-6a).
The trochanter-head line (hip joint orientation line)
is oriented at an average of 90 ± 5° to the mechanical ax-
is (LPFA) and 84±5° to the anatomic axis (MPFA). The
angle formed by the femoral neck line and the mid-dia-
physealline of the femur is the MNSA. The normal aver-
age value of the MNSA is 130±6° (~Fig. 2-6b).
When there is a deformity of the tibia, the MOT
should be performed relative to the mechanical or ana-
tomic axis of the distal diaphyseal segment of the tibia
rather than the mechanical axis of the entire deformed
bone (~Fig. 2-7). Similarly, when there is a deformity of
the femur, the orientation of the hip joint should be
checked relative to the mechanical or anatomic axis of
the proximal diaphyseal segment of the femur (~Fig.
2-8) rather than the mechanical axis of the entire
deformed bone. This is discussed in greater detail in
Chap. 4.
MOT of the Ankle
Consider an example in which the MPTA is normal and
no diaphyseal deformity is present (~ Fig. 2-7). Draw the
ankle joint orientation line. Draw the mechanical axis
line of the tibia. Measure the LDTA. If the LDTA is out-
side the normal range of 89±3°, the ankle joint line is
maloriented to the tibial mechanical axis. Draw the an-
kle joint orientation line. Draw the mid-diaphyseal line
of the tibia and measure the LDTA. If the LDTA is out-
side the normal range of 89 ± 3°, the ankle joint line is
maloriented to the tibial anatomic axis.
Consider an example in which the MPTA is abnormal
or diaphyseal deformity is present (~Fig. 2-7). Draw the
ankle joint orientation line. Draw a line from the center
of the ankle joint parallel to the distal tibial diaphysis.
This is the mechanical axis line of the distal tibia. Mea-
sure the LDTA. If the LDTA is outside the normal range,
the ankle joint line is maloriented to the distal tibial me-
chanical axis line (see Chap.4). Draw the ankle joint ori-
entation line. Draw the mid-diaphyseal line of the distal
tibial diaphysis. Measure the LDTA. If the LDTA is out-
side the normal range, the ankle joint is maloriented to
the distal tibial anatomic axis line.
 CHAPTER 2 · MalalignmentandMalorientation in the Frontal Plane . .

a. b.

mLPFA=
90 ± 5°

iii

Fig.2-6a,b
a Normal ankle joint line orientation to the mechanical (i) and
anatomic (ii) axes of the tibia is 89±3°.
b Normal hip joint orientation can be measured from the tip
of the greater trochanter (1') to center of femoral head (H).
The mechanical (i) and anatomic (ii) axis lines are at mLPFA
=90±5° and aMPFA=84±5°, respectively. The angle be-
tween the neck axis and the anatomic axis of the femur is the
MNSA (iii), which is 130±5°.

a. b.

LDTAIL

ii ii

Fig. 2-7 a, b
Ankle MOT.
a MPTA is normal, and no diaphyseal deformity is present (see
text). i, Using mechanical axis. ii, Using anatomic axis.
b MPTA is abnormal or diaphyseal deformity is present (see
text). i, Using mechanical axis. ii, Using anatomic axis.
m CHAPTER 2 • Malalignmentand Malorientation in the Frontal Plane

a. b.

LPF~

iii iii

MOT ofthe Hip Fig. 2-8 a, b

Hip MOT.
Consider an example in which the LDFA is normal and a LPFA is normal, and no diaphyseal deformity is present (see
no diaphyseal deformity is present (~Fig. 2-8). Draw the text). i, Using mechanical axis. ii, Using anatomic axis. iii, Us-
hip joint orientation line. Draw the mechanical axis line ingNSA.
b LPFA is abnormal or diaphyseal deformity is present (see
of the femur. Measure the LPFA. If the LPFA is outside
text). i, Using mechanical axis. ii, Using anatomic axis. iii, Us-
the normal range of 90 ± 5°, the hip joint line is malori- ingNSA.
ented to the femoral mechanical axis. Draw the hip joint
orientation line. Draw the mid-diaphyseal line of the
femoral diaphysis and measure the MPFA. If the MPFA
is outside the normal range of 84±5°, the hip joint line
is maloriented to the femoral anatomic axis. Draw the References
mid-diaphyseal line of the femoral neck. Draw the mid-
diaphyseal line of the femoral diaphysis. Measure the Cobb JR (1948) Outline for the study of scoliosis in instruction-
MNSA. If the MNSA is outside the normal range of al course lectures: the American Academy of Orthopaedic
130±6°, the femoral head and neck are maloriented to Surgeons, vol 5. JW Edwards, Ann Arbor
Paley D, Herzenberg JE, Tetsworth K, McKie J, Bhave A (1994)
the femoral anatomic axis.
Deformity planning for frontal and sagittal plane corrective
Consider an example in which the MPTA is abnormal osteotomies. Orthop Clin North Am 25:425-465
or diaphyseal deformity is present (~ Fig. 2-8). Draw the Paley D, Tetsworth K (1992) Mechanical axis deviation of the
hip joint orientation line. Draw a line from the center of lower limbs: Preoperative planning of uniapical angular de-
the femoral head parallel to the mid-diaphyseal femoral formities of the tibia or femur. Clin Orthop 280:48-64
line. Because the normal AMA is 7°, draw a line from the
center of the femoral head at 7° to the other two lines.
This is the mechanical axis line of the proximal femur
(for more detail, see Chap. 4). Measure the LPFA. If the
LPFA is outside the normal range, the hip joint line is
maloriented to the mechanical axis line of the proximal
femur. Draw the hip joint orientation line. Draw the mid-
diaphyseal line of the proximal femoral diaphysis. Mea-
sure the MPFA. If the MPFA is outside the normal range,
the hip joint line is maloriented to the proximal femoral
anatomic axis line. Draw the mid-diaphyseal line of the
femoral neck. Draw the mid-diaphyseal line of the prox-
imal femoral diaphysis. Measure the MNSA. If the MNSA
is outside the normal range of 130 ± 6°, the femoral head
and neck are maloriented to the proximal femoral ana-
tomic axis.
 CHAPTER 3 EI
Radiographic Assessment of Lower Limb Deformities

Knee

Radiographs of the lower limbs are obtained in orthog-

onal reference planes: frontal plane, AP view; sagittal
plane, LAT view. The true AP view of the knee is ob-
tained in the knee forward position (patella centered on
the femoral condyles). The knee forward plane corre-
sponds to the frontal plane. For standing radiographs,
the radiography technologists are usually taught to po-
sition the patient with the feet together in the "stand at
attention" posture. If the patient has external or internal
tibial torsion, such positioning will result in the knee-
cap's pointing inward or outward, respectively (~ Figs.
3-1 and 3-2). The correct method is to orient the patella
forward, irrespective of the foot position. To orient the
patella forward, feel the patella with the index finger and
thumb of one hand and rotate the foot until the patella
is pointing forward (~Fig. 3-2). The radiograph con-
firms the correct position, showing the patella centered
between the femoral condyles (~ Fig. 3-1 b).
One pitfall of this method occurs when there is fixed
subluxation or dislocation of the patella. In full exten-
sion, the patella is usually centered on the femoral
condyles, even in patients with patellar instability. How-
ever, patients with large amounts of distal femoral val-
gus often have true lateral patellar subluxation in full
knee extension (~Fig. 3-3a and b). In these cases, the
patella cannot be used to identify the knee forward po-
sition. Because the frontal plane of the knee forward po-
sition is almost the same as the plane of the knee flex- Fig. 3-1 a, b
ion -extension axis, the latter can be used to position the a Frontal plane long radiograph obtained with the patient in a
limb in the frontal plane (Hollister et al. 1993). The limb bipedal stance with both feet forward. The left patella is lat-
should be positioned such that the plane of the knee eral on the femoral condyles because of internal tibial tor-
sion. This radiograph was obtained in the presence of a limb
flexion-extension axis is perpendicular to the beam
length difference without leveling the pelvis.
(parallel to the film) (~ Fig. 3-3 c and d). The plane of the b Another radiograph was obtained of the same patient after
knee flexion-extension axis is approximately 3° exter- rotating the left leg internally to center the patella between
nally rotated to the frontal plane. A difference of less the femoral condyles. A lift was used under the left foot to
than 5° of rotation of the femur does not significantly al- level the pelvis.
ter the joint orientation angles (Wright et al. 1991).
Therefore, whether the radiograph is obtained in the
true frontal plane or perpendicular to the knee flexion
axis, the angles measured should be approximately the
same. In a recent cadaver study (Wright et al. 1991), the
accuracy of achieving the true knee forward position
using the patella was within 5°.
. . CHAPTER 3· Radiographic Assessmentoflower Limb Deformities

)
a. b.

P,..", \

'y
forward

~,---
, ,

Correct
\

Incorrect Correct

Fig. 3-2 a-d

a Illustration of the lower limb of a patient with internal tibial
torsion. When the foot is forward, the patella faces outward.
When the patella is facing forward, the foot points inward.
b To position the knee for a true AP view, the patella is palpat-
ed between the thumb and index finger. The foot is rotated
internally and externally until the patella feels like it is point-
ing forward.
c AP view long radiograph with both feet pointing forward.
The patella on the left side is pointing medially, whereas on
the right side it is centered. The ankles on both sides look the
same. There is external tibial torsion on the left side. It has
already been corrected by derotation osteotomy on the right
side.
d AP view long radiograph with patellae pointing forward
(same patient as shown in c). The knees look the same, but
the ankles look different. The left foot is pointing outward
because this tibia has external torsion. This radiograph rep-
resents the knee forward view and is the correct view with
which to assess the alignment of the knee. The radiograph
shown in c (ankle forward, with both feet pointing forward)
makes the distal femur appear to be in valgus, whereas this
radiograph shows that there is no deformity of the distal fe-
mur.
 CHAPTER 3 · RadiographicAssessmentofLowerLimbDeformities . .

b.

c.

Axis of flexion
and extension

d.

Axis of flexion
and extension

Axis of flexion
and extension

Film
/

Fig. 3-3 a-d

a AP view long radiograph of the femur and tibia with severe
valgus deformity of the distal femur. Note the lateral patellar
subluxation even though the knee is in full extension.
b Illustration of the lateral patellar subluxation shown in a.
The marked valgus deformity leads to lateral displacement
of quadriceps patellar tendon mechanism.
c, d The limb can be oriented into a true AP view based on the
flexion-extension axis of the knee and without consider-
ation of the position of the patella. The limb is positioned so
that the X-ray beam is perpendicular to the flexion-exten-
sion axis of the knee. The knee joint axis is parallel to the
X-ray film cassette.
. . (H APTER 3 . Radiographk Assessment ofLower Limb Deformities
Fig. 3-4 arb
A 3-ft (1 m) film is usually too short for the lower limbs of most
adults. Either the hips (a) or the ankles (b) are cut off.
To study frontal plane alignment, long standing ra-
diographs are preferred for the AP view. The hip, knee,
and ankle can be viewed together on one long film
(~ Fig. 3-1). Most children can fit on a 3-ft (1 m) film. For
most adults, the hips will not be included on a 3-ft film
(~Fig. 3-4). For this reason, a 51-in (1.3 m) cassette
(Global Imaging, Baltimore, MD) is preferred (~Fig.
3-5). This size film and cassette is commonly used for
angiography. If a 51-in cassette is not available, then two
or three standard sized cassettes can be stacked. This is
not ideal and leaves gaps between the films (the width of
the metal edges of the cassettes) that must be taped
together at the correct alignment while maintaining the
correct amount of gap between films.
Alternatively, two separate films can be obtained: one
of the tibia alone and the other of the femur alone
(~Fig. 3-6a and b). The patella should be positioned in
the same manner as described above. Although MAD
cannot be measured from separate films of the femur
and tibia, the MAT can still be performed, measuring the
MPTA and the mLDFA from the tibial and femoral ra-
diographs, respectively. This method is particularly use-
ful in the operating room, where standing long radio-
graphs cannot be obtained. To do this correctly, for the
femur, center the beam on the knee, so that a correct
LDFA can be measured. For the tibia, the beam should
also be centered on the knee, to measure the MPTA. To
ensure that the beam will cover the entire bone length,
it may be necessary to angle the beam generator diago-
nally.
Long radiographs should be obtained with the ra-
diography tube at a distance of 10 ft (305 cm) from the
film (~Fig. 3-5). Magnification on a 51-in (130 cm) cas-
sette at 10 ft is approximately 4%-5%, compared with
10%-20% for radiographs obtained on 17-in (43 cm)
cassettes at a closer distance. The longer beam length
produces less parallax distortion. A magnification
marker positioned in the mid-sagittal axis of the limb
can be used to measure the precise magnification factor.
We use a 3-cm steel ball, available from Eisenlohr Tech-
nologies, Inc., Davis, CA.
For some patients with loose knee ligaments or loss
of cartilage in one knee compartment, the effect of
weight bearing on alignment is important to document.
In such cases, single-leg stance radiographs should be
obtained. It is difficult for most patients to balance and
stand still on one limb. Furthermore, it is good to simu-
late a walking single-leg stance radiograph with which
the center of gravity is medial to the hip. A useful aid is
the placement of bathroom scales under each foot. Tell
the patient to apply full weight on one side and only
20-30 Ibs (10-15 kg) on the other side for balance (~ Fig.
3-7). This "unweights" one leg while most of the load is
placed on the leg of interest. Use the reverse sequence for
the opposite limb.
 fig.3-5a,b
a AP view standing radiographs are obtained with the patient
standing in a bipedal stance in front of the long film cassette.
The radiography tube is positioned 10ft (305 cm) away. The
film cassette should be long enough to include the hips,
knees, and ankles. The magnification with this setup is usu-
ally approximately 5%. The X-ray beam should be centered
on the knee joint.
b Full-length AP view standing radiograph.
. . (H APTER 3 · Radiographic Assessment of lower Limb Deformities

Ij
a.

~PTA
, I \
, I \
,
,
I \

,
\

, ,
,
\
\
\
\
\
, \
\
, I
, \

, \

_17 or 36 in--..
(43 or 91 em)

b.

Fig. 3·6 a,b

In the operating room and in circumstances in which a stand-
ing long radiograph is not possible or available, the MPTA and
the mLDFA can still be measured from separate films of the tib-
ia and femur (a). The radiograph must include the joint above
and below. The radiograph can be oriented in different ways to
maximize the field of intent (b).
 CHAPTER 3· Radiographic Assessment ofLower Limb Deformities _
Full body weight 10-20 Ibs weight
on scale on scale
Fig. 3-7
To obtain single-leg standing radiographs without the prob-
lems of balance, movement, and lurch to the full weight-bear-
ing side, a scale can be used under the side to be unweighted
and 10-20 lbs can be applied for balance.
If there is a limb length discrepancy (LLD), elevate
the shorter limb on blocks adjusted to the approximate
discrepancy (~Figs. 3-1 and 3-8). This prevents the
patient from using compensatory mechanisms such as
contralateral knee flexion, ipsilateral ankle equinus, pel-
vic tilt, and scoliosis to try to compensate for the LLD.
These compensatory mechanisms cause uneven loading
of the limbs and may alter the alignment and leg length
measurement on the radiograph. Leveling the pelvis al-
so allows for more accurate assessment of acetabular
coverage.
-'.
Fig. 3-8
Patients with LLD should have the short side supported on a lift
to eliminate the need for compensatory mechanisms of LLD
that could affect the alignment and length measurements.
When knee joint laxity is present, varus and valgus
stress radiographs (~Figs. 3-9, 3-10, and 3-11) may be
helpful (see Chaps. 11 and 13). It is best to obtain knee
stress radiographs with the patient supine using fluoros-
copy to orient the beam parallel to the tibial plateaus.
Fluoroscopic positioning is especially important if there
is a deformity of the proximal tibia in the sagittal plane.
Stress radiographs should be compared with a supine
AP view of the knees. If there is a knee flexion contrac-
ture, the joint orientation of the distal femur is best as-
sessed using a posteroanterior view rather than an AP
view.
. . CHAPTER 3· Radiographic Assessment ofLower Limb Deformities
a.
c.
Fig. 3-9 a-d
Varus and valgus stress X-ray techniques.
a Bimanual varus single-leg stress method using lead gloves.
b Bimanual valgus single-leg stress method using lead gloves.
c Bilateral varus stress method using fulcrum block.
b.
d Bilateral valgus stress method using fulcrum belt. With bilat-
eral stress radiographs using a block or belt as a fulcrum,
equal force is applied to both knees more consistently than
with the bimanual method. There is also less radiation expo-
sure to the surgeon with the bilateral fulcrum techniques.
 CHAPTER 3· RadiographicAssessmentofLowerLimbDeformities . .

Fig. 3-10 a, b
a Bimanual varus stress radiograph of the knee shows lateral
collateral ligament laxity.
b Bimanual valgus stress radiographs of the knee show medi-
al collateral ligament laxity. i, Beam is not tangential to the
joint surface. ii, Beam oriented tangential to the joint surface.

;---

\~
_ CHAPTER 3 . Radiographic Assessment ofLower Limb Deformities

Fig.3-ll a-c
a AP view varus stress radiographs of the knee using a wood-
en block as a fulcrum.
b AP view valgus stress radiographs of the knee using a belt
across the thighs as a fulcrum.
c Bilateral varus stress radiographs of the knee. i, Wooden
block is used as a fulcrum. Because the knees are rotated ex-
ternally, the varus stress is taken up as knee flexion. ii, When
the knee rotation is properly controlled, the varus joint con-
vergence can be better assessed.

Ankle and Hip radiographs should be obtained, respectively. The beam

The frontal plane orientation of the ankle or hip can be
measured on the knee forward AP view radiograph
when there is no torsional deformity. If there is a rota-
tion deformity, separate ankle forward and hip forward
radiographs may be needed. The ankle forward radio-
graph is obtained of the tibia with the foot pointing for-
ward (~Fig. 3-12). The hip forward radiograph is ob-
tained of the femur with the hip rotated into a neutral
position, halfway between the internal and external ro-
tation range of motion (~Fig. 3-13). When there is de-
formity around the ankle or hip, even in the absence of
rotational malalignment, ankle forward or hip forward
should be centered on the joint being studied, but the
film should be long enough and the distance from the
patient sufficient enough to include the entire bone on
one film. The terminology for this is AP knee to include
tibia or femur (~Fig. 3-14a and b), AP ankle to include
tibia (~Fig. 3-14c), and AP hip to include femur (~Fig.
3-14d).
In deformities about the hindfoot and ankle, it is im-
portant to evaluate the alignment of the calcaneus to the
tibia. It is easy to evaluate the sagittal plane alignment of
the tibia, talus, and calcaneus with a LAT view standing
radiograph of the foot and tibia. In contrast, in the fron-
tal plane, the forefoot bones get in the way of radio-
CHAPTER 3· Radiographic AssessmentofLowerLimb Deformities . .

Ankle forward Knee forward

Fig. 3-12 a-(

a AP view radiograph (i) and photograph (ii) of

the tibia with the ankle forward show a straight
distal tibia. The patella is externally rotated be-
cause of the internal rotation deformity of the
tibia.
b AP view radiograph (i) and photograph (ii) of
the tibia with the knee forward show a varus de-
formity of the distal tibia. The patella is now
centered on the femo ral condyles.
C Schematic diagram of this example showing
ankle forward (left) and knee forward (right).
. . ( HAPTER 3 . Radiographic Assessment ofLower Limb Deformities
Fig. 3-13 a-c
a AP view radiograph of the femur with the patella forward
shows varus femoral deformity (mLDFA=96°). The femoral
neck appears foreshortened because of femoral retroversion
(external rotation deformity).
b AP view radiograph of the femur with the hip forward shows
a different degree offemoral varus (mLDFA = 92°). Note that
the patella is externally rotated in this view because of exter-
nal femoral torsion. The femoral neck appears to be of nor-
mal length because the hip is in its neutral position.
C Schematic diagram of a hip forward and a patella forward
radiograph in a case with external femoral torsion (retrover-
sion).
c. Femoral head
r
rotated posterior
Hip forward Knee forward
graphic imaging of the calcaneus. There are several
methods to radiographically project the body of the cal-
caneus relative to the tibia. An over-penetrated AP view
of the ankle can show the outline of the calcaneus, espe-
cially in children (Cobey 1976). In adults, the overlap-
ping foot bones obscure the outline of the calcaneus. To
see the calcaneus, the beam needs to be angled relative
to the tibia and foot. Angling the beam 45° produces the
standard "axial" view. If the axial view is obtained on a
short film, it shows the calcaneus and subtalar joint only.
The superimposed foot bones usually obscure the ankle
and the distal tibia. If the axial view is obtained on a
longer (l7-in [43 em]) cassette, the tibial shaft is project-
ed onto the film. Normally, the axis of the calcaneus on
this long axial projection is parallel and 5 to 10 mm lat-
eral to the mid-diaphyseal axis of the tibia (~Fig. 3-15).
To obtain this radiograph, the beam is angled 45° to the
tibia with the foot at 90° to the tibia (~ Fig. 3-16). The
"long axial" view can be obtained with the patient su-
pine (~Fig. 3-16a) or standing (~Fig. 3-16b). It can
therefore be used in the operating room to assess heel
alignment during ankle or subtalar fusions. If there is
tibial torsion, the long axial view is obtained in line with
the calcaneus and not the knee. The leg is rotated so that
the beam is in line with the body of the calcaneus. In
 CHAPTER 3 · RadiographicAssessmentoflowerLimbDeformities . .

a. b.

jJ
MPTA

,
, I
I
\
\

I
\ \
I
\
, I
,
\

I
I
\ I
\ I

_17 or 36 in __ ~17 or 36 in---+

(43 or 91 cm) (43 or 91 cm)

c. d.

I I \ ,
I I
I
\
,
I \
\
I \
I \
\
I \
I \
I \
I \
\
I
I

,
I

_170r36in __ ~170r36in_
(43 or 91 cm) (43 or 91 cm)

Fig. 3·14 a-h

a AP knee to include tibia: center X-ray beam on knee and in-
clude entire tibia.
b AP knee to include femur: center X-ray beam on knee and
include entire femur.
AP ankle to include tibia: center X-ray beam on ankle and in-
clude entire tibia.
d AP hip to include femur: center X-ray beam on hip and
include entire femur.
. . (H APTER 3 . Radiographic Assessment ofLower Limb Deformities

most cases, this corresponds to the ankle forward posi-
tion. When there is a large varus or valgus deformity, the
radiograph should be obtained with the beam in line
with the calcaneus and not the tibia. The foot should be
placed plantigrade to the film plate, and the tibia will be
inclined to it.
More recently, another method was described to as-
sess frontal plane alignment of the calcaneus to the tib-
ia (Saltzman and el-Khoury 1995). For this method, the
Fig.3-14 a-h A
e Radiograph: AP knee to include tibia.
f Radiograph: AP knee to include femur.
9 Radiograph: AP ankle to include tibia.
h Radiograph: AP hip to include femur.
Fig.3-16a,b ~

beam is inclined only 20° to the horizontal and the film The long axial radiograph can be obtained with the patient su-
cassette is inclined 20° to the vertical (~Fig. 3-17). Be- pine (a) or standing (b). The foot should be at 90° to the tibia.
cause the radiograph is obtained at a more horizontal The X-ray beam should be 45° to the X-ray plate and foot. The
angle than is the long axial view, it is more representa- X-ray plate should be long enough to include both the tibia and
the heel. The calcaneus should be perpendicular to the tibia,
tive of the standing alignment of the calcaneus relative
and the X-ray beam should be in line with the calcaneus.
to the tibia. It is not as easy to use in the operating room
as is the long axial radiograph. This radiograph not only
demonstrates the calcaneus and tibia but also clearly
shows the ankle joint. One can therefore judge the align-
ment of the calcaneus, talus, and tibia to each other.
 CHAPTER 3 · Radiographic AssessmentofLowerLim bDeformities . .

b. Tibial
- mid-diaphyseal line

Fig.3.15 a,b
a Bilateral long axial radiographs of both heels show normal
alignment on one side (right) and valgus on the other (left).
The body of the calcaneus and the diaphysis of the tibia are
both clearly seen. The alignment is measured between them.
The foot overlaps the ankle; this region is therefore whited
out.
b Illustration of the example shown in a with the axis lines
marked. On the non-deformed side, the calcaneal body mid-
diaphyseal line is lateral and parallel to the tibial mid-dia-
physealline. On the deformed side, the two lines are angled
into valgus relative to each other.

a. b.

", ,
\' ,,
\ \
,,,,
\
\ , ,,
\
\ ,, ' "\

', ,,
\

,, \
,,
,,
,,
,
' .. , ,
'4,

1
_(17 in or __ I
43 em) I+--(17 inem)or - I
43
m (HAPTER 3· Radiographic Assessmentoflower Limb Deformities
Fig. 3-17 a-(
a Alternative method for long axial radiograph using an in-
clined film and stand (modified from Saltzman and el-Kho-
ury 1995).
b Long axial radiograph shows alignment of the hindfoot. The
subtalar joint can usually be seen on this view.
c Saltzman view of foot shown in b. The calcaneus appears
foreshortened compared with the long axial view of the
same foot. The advantage of this view is that it shows the an-
k
e joint as well as the calcaneus and tibia. The subtalar joint
is seen on this view.
Radiographic Examination in the Sagittal Plane
Knee
The true AP view radiograph of the knee is with the knee
forward. Therefore, the true LAT view of the knee is 900
to this view. In the radiograph that is obtained orthogo-
nal to the knee forward (patella centered on femoral
condyles), the posterior aspect of the femoral condyles
are not overlapped (~Fig. 3-18a). The LAT view radio-
graph of the knee with the femoral condyles overlapped
corresponds to the axis of knee flexion and extension
(~Fig. 3-18b). The axis of knee rotation is 30_5 0 exter-
nally rotated to the knee forward plane (Hollister et al.
1993). The axis of knee rotation is perpendicular to the
mechanical axis of the femur and therefore 30 inclined
to the knee joint line (~Fig. 3-18c).
Because the functional position of weight bearing is
with the knee near full extension, it is important to ana-
lyze the relationship between the femur and tibia in
maximum extension. A long LAT view radiograph with
the knee in full extension (~ Fig. 3-18 a, b, and d) should
be obtained at 900 to the knee forward position to assess
the alignment of the tibia to the femur in the sagittal
plane. The long LAT view radiograph includes the entire
femur and tibia and the hip, knee, and ankle. To visual-
ize the hip on the LAT view radiograph, the pelvis must
be rotated out of the way (~Fig.3-18e). This radiograph
should also be obtained from 10 ft (3 m) away. The long
LAT view allows one to visualize the alignment of the
hip, knee, and ankle in terminal stance. The long LAT
view also allows one to evaluate the anterior bow of the
femur. The anterior bow of the femur is normally less
than 50_100 if measured from the intersection of a prox-
imal and distal mid-diaphyseal line.
Because the femur has an anterior bow, the joint ori-
entation of the distal femur is measured relative to the
distal mid-diaphyseal line (~Fig. 3-18d). Therefore, ex-
cept when there is proximal or mid-diaphyseal deformi-
ty of the femur, it is sufficient to obtain a radiograph
Fig. 3-18 a-e
a Orthogonal LAT view of the knee with the patella in the knee
forward position (true AP) should show the back of the fem-
oral condyles not overlapping.
bLAT view obtained with the knee in 3°_5° of external rota-
tion has the condyles overlapping. This LAT view is in line
with the knee flexion-extension axis.
c Orientation of the axis of knee flexion -extension in frontal
(i), sagittal (ii), and transverse (iii) planes (modified from
Hollister et al. 1993). The measurements of the angles of the
axes with the bones in the AP and axial LAT views are as fol-
lows (mean±SD): angle A, 84±2.4°; angle B, 88± 1.2°; angle
C, 89±2.1°; angle D, 4.3±1.00; and angle E, 85±3.5°. The
location of the axes described as a percent of femoral and
 CHAPTER 3 · Radiographic Assessment ofLower Limb Deformities _
c.
Axial lateral
tibial dimensions are as follows (mean±SD): percentage ra-
tio locating tibial axis on AP view (Tm/W), 47.5±4.1; per-
centage ratio locating tibial axis on axial LAT view (Ta/Z),
31.8 ± 10.6; percentage ratio depicting interaxial distance rel-
ative to tibial plateau width (Y/W), 31.6±12.3; percentage
ratio locating femoral axis on axial LAT view (RlX), 35.3±
5.1. i, Diagrammatic representation of axes in AP view with
axis parallel to plate. A, angle that flexion-extension axis
makes with shaft of femur; B, angle between flexion-exten-
sion and longitudinal rotation axes in AP plane; C, angle be-
tween longitudinal rotation axis and tibial plateau; D, dis-
tance between flexion-extension axis and joint surface; W,
AP width of tibia; Tm, medial tibia and longitudinal rotation
iii
-..I.'~-i--+-~fIt"'\ Axis
~ O·
-=====:::'=::==I~ 3·
l<...r-..... Frontal Plane
Transverse view
axis. ii, Diagrammatic representation of axes in axial LAT
view with X-ray beam parallel to the flexion-extension axis.
E,angle between longitudinal rotation axis and tibial plateau
in axial LAT plane; X, distance between anterior femoral
shaft and posteromedial femoral condyle; R, distance be-
tween flexion-extension axis and posteromedial femoral
condyle; Y, perpendicular distance between two axes; Z, AP
dimension of tibia; Ta , distance of longitudinal rotation ax-
is from anterior tibia.
d Long LAT view radiograph is obtained with the knee in full
extension to assess the alignment of the tibia to the femur in
the sagittal plane.
. . CHAPTER 3· Radiographic AssessmentofLower Limb Deformities

e.

aPPTA
51 in
(130 em)
T
1~===~===~~
1- 10ft
(305 em)

View from above

Fig. 3-18 a-e
e For the long LAT view radiograph, the patient is positioned
with the limb of interest in the LAT view. The knee is kept in
full extension. To see the proximal femur, the pelvis is rotat-
ed posteriorly 30°_45° without rotating the knee on the
study side.
from the mid-femur distally with the knee in full exten-
sion (~Fig. 3-19bi). This kind of radiograph can be
obtained with the cassette between the knees. One ad-
vantage of this is that the bipedal stance is more physio-
logical because the pelvis does not have to be rotated out
of the way (~ Fig. 19 b ii). Another advantage is that the
patient does not have to be moved; therefore, a view that
is truly orthogonal to the AP view can be more easily ob-
tained.
Separate LAT view radiographs of the femur and tib-
ia can be used to assess the femur and tibia separately.
Comparison radiographs of the other side serve as a
template in deformity planning if the other side is not
deformed. When a separate radiograph of the femur or
tibia is obtained, it is important to specify where to cen-
ter the beam. To better assess the joint orientation of the
proximal tibia or the distal femur, the radiograph should
be centered on the knee. To better assess the joint orien-
tation of the ankle or hip, the radiograph should be cen-
tered on those joints. Our terminology for such radio-
graphs is LAT knee to include tibia (~Fig. 3-19a), LAT
knee to include femur (~Fig. 3-l9b), LAT ankle to in-
clude tibia (~Fig. 3-19c), and LAT hip to include femur
(~Fig. 3-19d). The first part refers to where to center the
beam, and the second part tells what to include on the
radiograph.
 CHAPTER 3 · RadiographicAssessmentofLowerLimbDeformities . .

a.
aPPTA

-------

10 It
(305 em)

b. i

- - -- ----

~) 10 It
(305 em)
28 in
(71 em)

T
28 or 36 in --- --- ---
(71 or 91 em)
1

10 It
(305 em)

Fig. 3-19 a-h

a LAT knee to include tibia: center X-ray beam on knee and in- bLAT knee to include femur: center X-ray beam on knee and
clude entire tibia. include distal half (i) or entire femur (ii).
_ CHAPTER 3· Radiographic AssessmentofLower Limb Deformities

Level of ankle - - - - _

1 10ft - - - - - - - + ' (
Film (305 em)

ANSA

--- ------

10 It
(305 em)

Fig. 3-19 a-h

c LAT ankle to include tibia: center X-ray beam on ankle and
include entire tibia.
d LAT hip to include femur: center X-ray beam on hip and in-
clude entire femur.
e Radiograph: LAT knee to include tibia.
Viewed from above f Radiograph: LAT knee to include femur.
9 Radiograph: LAT ankle to include tibia.
h Radiograph: LAT hip to include femur.
CHAPTER 3· Radiographic Assessment ofLower Limb Deformities Ell

Ankle

For functional purposes, the LAT view radiograph of the

foot should be obtained with the foot in a weight-bear-
ing plantigrade position (90° angle between the sole of
foot and the shaft of the tibia). The sole of the foot
should be on a radiolucent board that flattens out the
soft tissue of the sole so that the sole of the foot can be
seen as a single line (~ Fig. 3-20). The true LAT view of
the ankle mortise has the lateral and medial malleolus
overlapping each other (~Fig. 3-20). The foot is inter-
nally rotated approximately 10° to obtain this view. The
other LAT view is perpendicular to the lateral border of
the foot (~Fig. 3-20a). Finally, the orthogonal view of
the knee forward position normally has the foot point-
ing externally 5°_10° (~Fig. 3-l8a and d). The most ac-
curate radiograph with which to study the orientation of
the distal articular surface of the tibia is that with the
malleoli overlapping. This is orthogonal to the mortise
view of the ankle. The view that is perpendicular to the
lateral border of the foot and the view that is orthogonal
to the knee forward position are similar to each other in
that the lateral malleolus is posterior to the medial mal-
leolus.
When there is any deformity of the hindfoot, the foot
should be positioned in a simulated plantigrade posi-
tion. The sole of the foot should be pressed onto a radi-
EI CHAPTER 3· Radiographic AssessmentofLower Limb Deformities

Fig. 3-20 a-c

a LAT foot standing to include tibia: shows the standing rela-
tionship between the foot and the tibia. The plantar aspect of
the foot should be visible with the sole of the foot com-
pressed on a radiolucent flat surface. The lateral malleolus is
posterior to the medial malleolus.
b X-ray beam is perpendicular to the lateral border of the foot.
e True LAT view of the ankle, including the tibia. The lateral
and medial malleolus are overlapped.

b.

Level of toes
--------- --------
b.-----
- -
10ft - - - - - - - + T
(305 em)
Film

c.

Level of ankle
- - - - - - ---------::==

·~----10ft-------·
(305 cm)
 CHAPTE R 3 • Radiographic Assessment ofLower Limb D.t'o ..niti_

Fig. 3-21 a-c

If there is an equinus (a) or varus (b) deformity, the foot should
be positioned on a board in a simulated standing position and
a cross-table LAT view radiograph of the foot should be ob-
tained.
c LAT foot to include tibia with simulated weight bearing. Ra-
diograph of equinovarus deformity of foot after ankle fu-
sion of a mal-nonunion positioned on a board.

olucent board in as close to a plantigrade position as Hip

possible. The radiograph should be centered on the foot
and should include the tibia and the foot (~Fig. 3-21).
The radiograph is called LAT foot to include tibia in sim-
ulated weight bearing (~Fig . 3-21).
Sagittal plane assessment of the proximal femur and hip
should include a cross-table LAT view of the hip joint
(~ Fig. 3-22a and b). This radiograph can be obtained
orthogonal to the knee forward position or the hip for-
ward position. It is important to decide the purpose of
this radiograph. To visualize deformities of the proximal
femoral diaphysis distal to the femoral neck, a cross-
table LAT view radiograph of the proximal femur has the
beam oriented perpendicular to the femoral diaphysis
. . CHAPTER 3 · Radiographic AssessmentofLower Limb Deformities

Fig. 3-22 a, b
a Cross-table LAT view radiograph of the hip.
b X-ray beam is oriented perpendicular to the femoral neck.

b.

,,
,,

,,
I ,
""

(~Fig. 3-23a and b). To visualize deformities between

the femoral neck and head, a cross-table LAT view radio-
graph of the hip has the beam oriented perpendicular to
the femoral neck (~Fig. 3-22a and b). Because the fem-
oral neck axis is usually not in the frontal plane, the hip
should be internally or externally rotated to neutralize
the femoral neck version. An AP view radiograph ob-
tained in this position provides the true AP view of the
femoral neck and head. The view that is orthogonal to
the true AP view of the femoral neck is the cross-table
 CHAPTER 3· Radiographic Assessment of Lower Limb Deformities . .
b
LAT view with the hip in 0° version and the tube inclined
approximately 45° to the horizontal (to be exact, the NSA
off the true AP view should be measured and the beam
inclined 90° to the neck orientation [180° NSA to the
horizontal]). The other method with which to obtain a
true LAT view of the femoral neck is to flex the hip 90°
and abduct the thigh 45°. This positions the femoral
neck in the frontal plane. An AP view radiograph ob-
tained with the patient in this position provides the true
LAT view of the femoral neck (Sugioka 1978) (~Fig.
Fig. 3-23 a, b
Pelvis
~f"m
-- ~a b ove
3-24a). The flexion brings the frontal plane NSA into the
transverse plane. The 45° abduction brings the neck hor-
izontal in the transverse plane, assuming that the nor-
mal NSA is 135°. This view can be modified according to
the NSA of the normal AP view of the hip. The higher the
NSA is, the more abduction is required to make the fem-
oral neck horizontal. This view is especially useful in as-
sessing deformities between the head and neck, such as
are seen with slipped capital femoral epiphysis and avas-
cular necrosis (~Fig. 3-24b).
. . CHAPTER 3· Radiographic AssessmentofLower limb Deformities

a.

Hip flexed 90·

Hip abducted 45·

Viewed from foot end

Knee and hip flexed 90· Hip abducted 45·

Fig. 3-24 a, b
a To assess the relationship of the neck to the head, the femur b Sugioka view of bilateral slipped capital femoral epiphysis.
is flexed 90° and abducted 45°. This places the neck in a hor-
izontal position if the NSA is 135° (Sugioka view). Depend-
ing on the magnitude of the NSA, the hip can be abducted
more or less.
 CHAPTER 3 · RadiographicAssessmentoflowerLimbDeformities _

a.

-------------------------------r---
Level of knee
!
10ft
(305 em)

b.

~--------------- 10ft
(305 em)

Radiographic Examination in One Plane When Fig. 3-25 a-d

There Is a Deformity Component in the Other Plane
When there is a sagittal plane component of deformity,
the AP view radiograph obtained in the usual fashion
appears distorted (~Fig. 3-2Sa). To assess the joint ori-
entation, the radiograph should be obtained inclined by
the amount of sagittal plane angulation (~Fig. 3-2Sb
and c). For example, if there is a PPTA of 50° producing
a knee flexion deformity of 30°, the tibial AP view radio-
graph should be obtained with the beam centered on the
knee and inclined from an anterior-proximal to a pos-
terior-distal position at a 30° angle. The radiograph
should include the entire length of the tibia.
When there is a frontal plane component of deformi-
ty, the LAT view radiograph obtained in the usual fash-
ion appears distorted (~Fig. 3-26a). To assess the joint
orientation, the radiograph should be obtained inclined
by the amount of frontal plane angulation (~ Fig. 3-26 b
a The usual technique for positioning and centering the X-ray
beam for an AP erect legs radiograph will not work in the
presence of a knee joint malorientation in the sagittal plane.
In this example, the procurvatum of the distal femur and
recurvatum of the proximal tibia work to orient the joint off-
axis from the central X-ray beam. The result is a view of the
knee in which the subchondral bone surfaces of the femur
and tibia are not clearly seen. With such a radiograph, it is
impossible to mark and measure joint lines and angles.
b In this case, it is necessary to modify the technique by aim-
ing the beam upward, to be tangential to the joint surfaces.
The resultant view of the knee shows the two joint surfaces
in profile.
. . CHAPTER 3· Radiographic Assessment ofLower Limb Deformities
Fig. 3·25 a-d
C Clinical example that corresponds to a. The knee joint sur-
faces are overlapped, making it nearly impossible to mark
joint lines.
d Same patient as shown in c, with the X-ray beam aimed tan-
gential to the knee joint surface. The distal femoral and prox-
imal tibial joint lines can thus be easily and accurately
drawn.
and c). For example, if there is an mLDFA of 70° produc-
ing genu valgum of 20°, the femoral LAT view radio-
graph should be obtained with the beam centered on the
knee and inclined from a lateral-proximal to a medial-
distal position at a 20° angle. The radiograph should in-
clude at least the distal half of the femur.
Fig. 3-26 a-d ~
a The usual technique for positioning and centering the X-ray
beam for a LAT view radiograph will not work in the pres-
ence of knee joint malorientation in the frontal plane. In this
example, the valgus of the distal femur and varus of the prox-
imal tibia work to orient the joint off-axis from the central
X-ray beam. The result is a viewofthe knee in which the sub-
chondral joint surfaces of the femur and tibia are not clear-
ly seen. With this type of X-ray view, it is impossible to mark
and measure joint lines and angles.
b In this case, it is necessary to modify the technique by aim-
ing the beam downward, to be tangential to the joint surfac-
es. The resultant view of the knee shows the two joint surfac-
es in profile.
c Clinical example that corresponds to a. The knee joint sur-
faces are overlapped, making it nearly impossible to mark
joint lines and measure the PPTA or PDFA.
d Same patient as shown in c, with the X-ray beam aimed tan-
gential to the knee joint surface. The distal femoral and prox-
imal tibial joint lines can thus be easily seen to draw the joint
lines. It is then possible to measure the PPTA and PDFA. To
obtain these radiographs, it may be necessary to position the
limb under image intensification or fluoroscopy.
 CHAPTER 3 · Radiographic Assessment ofLower Limb Deformities _

a.

----
---- ----
--- -

Level of knee

~
10 It
(305 em)

28 in
(71 em)

b.

~ ~ ~

~ ~ ~

~ ~ ~
~~~
~~~

~~~l~~ ~--

-
Level of knee

~
10 It
(305 em)

28in
(71 em)
m CHAPTER 3 · Radiographic Assessmentoflower Limb Deformities

References

Cobey JC (1976) Posterior roentgenogram of the foot. Clin

Orthop 118:202-207
Hollister AM, Jatana S, Singh AK, Sullivan WW, Lupichuk AG
(1993) The axes of rotation of the knee. Clin Orthop
290:259-268
Saltzman CL, el-Khoury GY (1995) The hindfoot alignment
view. Foot Ankle lnt 16:572-576
Sugioka Y (1978) Transtrochanteric anterior rotational osteot-
0my of the femoral head in the treatment of osteonecrosis
affecting the hip: a new osteotomy operation. Clin Orthop
130:191-201
Wright JG, Treble N, Feinstein AR (1991) Measurement oflow-
er limb alignment using long radiographs. J Bone Joint Surg
Br 73:721-723
 CHAPTER 4
Frontal Plane Mechanical and Anatomic Axis Planning
Angular deformity of the femur or tibia involves angu-
lation not only of the bone but also of its axes (-. Fig.
4-1). This concept is easier to understand if one starts
with a straight bone and produces an angular deformi-
ty. When a bone is divided and angulated, the mechani-
cal and anatomic axes of the bone are also divided into
proximal and distal segments. The pairs of proximal and
distal axis lines intersect to form an angle. The point at
which the proximal and distal axis lines intersect is
called the center of rotation of angulation (CORA). The
axis line of the proximal bone segment is called the prox-
imal mechanical axis (PMA) or proximal anatomic axis
(PAA) line, and the axis line of the distal bone segment
is called the distal mechanical axis (DMA) or distal an-
atomic axis (DAA) line. The break in the axis lines can
occur at any level in the bone, depending on the level at
which the bone is cut to create the angulation and de-
pending on the point around which the bone is angula-
ted. Therefore, each segment of bone, regardless of how
short, can have its own mechanical and anatomic axis
lines.
In cases of deformed bones, draw the PMA or PAA
and the DMA or DAA lines to identify the CORA at their
points of intersection and measure the magnitude of an-
gulation. In cases of diaphyseal deformity, the anatomic
axis is easily defined by drawing mid-diaphyseal lines. In
cases of metaphyseal and juxta-articular deformities, a
mid-diaphyseal line can be drawn on the diaphyseal side
of the CORA but not on the articular side (-. Fig. 4-2a).
To draw the axis line of the juxta-articular segment, ref-
erence it off the joint line. If the normal intersection
point and angle of the anatomic axis with the joint line
are known, draw the anatomic axis line of the juxta-ar-
ticular bone segment. This concept will form the basis of
anatomic axis planning to find the CORA, which is dis-
cussed in greater detail in this chapter.
To draw the mechanical axes of the proximal and dis-
tal femur or tibia, use a similar strategy (-. Fig. 4-2b).
That the mechanical axis passes through the center
point of the joint is known. Only the orientation of the
mechanical axis to the joint needs to be known to be able
to draw it. The mechanical axis line orientation relative
to the adjacent mid-diaphyseal line or joint orientation
line can be referenced if the angle that the mechanical
axis should be, relative to these landmarks, is known.
This concept will form the basis of mechanical axis plan-
ning to find the CORA, which is discussed in greater de-
tail in this chapter.
Mechanical Axis Planning
The center point of the joint is always a point on the
PMA or DMA of the femur or tibia. It is therefore neces-
sary to know only a reference angle to draw the mechan-
ical axis of the proximal or distal femur or tibia. A refer-
ence angle is drawn to a reference line. The two possible
reference lines that can be used are the joint orientation
line and the mid-diaphyseal line. At the knee, there is
very little variability in the joint orientation angles
(mLDFA and MPTA). At the ankle and hip, the variabil-
ity is much greater (LDTA and LPFA). Therefore, the ref-
erence line preferred near the knee is the joint orienta-
tion line of the knee. The reference line preferred near
the ankle and hip is the adjacent mid-diaphyseal line.
However, when the deformity apex is near the ankle or
hip, the adjacent mid-diaphyseal lines are not available.
In such cases, one must reference from the ankle or hip
joint orientation line. Only when the deformity apex is
near the ankle or hip is the respective ankle or hip joint
orientation line preferred as the reference line.
The reference angle used depends on the reference
lines chosen. When the joint orientation line is chosen as
the reference line, the joint orientation angle from the
opposite side is used if it is normal and available. If it is
not normal or available, an average normal joint orien-
tation angle is used instead. Because correction of the
MAD is one of the goals of treatment, a normal ipsilat-
eral mLDFA can be used to draw the ipsilateral MPTA
and vice versa.
When the adjacent mid-diaphyseal line is used as a
reference line, the AMA is used as the reference angle. In
the tibia, the mid-diaphyseal line is normally parallel to
the mechanical axis line (AMA = 0). In the femur, the
two lines are normally within 7 ± 2° of each other. The
contralateral normal AMA is preferred as a reference
angle to the average normal angle.
. . CHAPTER 4· Frontal Plane Mechanical and Anatomic Axis Planning

a.

~PMA @ Lj2PMA
/j~ ~!.-PAA

Mechanical axis Anatom ic axis Mechanical axis Anatomic axis

Mechanical axis Anatom ic axis

Mechanical axis Anatomic axis

Fig. 4-1 a-c

When the femur or tibia is angulated, the axis line is also angu-
lated. Where there was one axis line to represent the bone, there
are now two axis lines: proximal and distaL In the tibia, because
mechanical and anatomic axes are almost the same, the PMA
and PAA lines are almost the same, as are the DMA and DAA
lines. In the frontal plane femur, because the mechanical and
anatomic axis lines are not the same, the PMA and PAA lines
and the DMA and DAA lines are not the same, respectively.
a Mid-diaphyseal angulation.
b Proximal angulation.
C Distal angulation.

Mechanical axis Anatomic axis

Mechanical axis Anatomic axis

 CHAPTER 4 . Frontal Plane Mechanical and Anatomic Axis Planning
Anatomic axis lines
Fig. 4-2 a, b
a Anatomic axis lines follow an anatomic mid-diaphyseal
course representing the diaphysis of the bone. When there is
a diaphyseal femoral or tibial deformity, it is possible to draw
two mid-diaphyseal points and generate the PAA and DAA
lines. In the metaphyseal end of the bone, the mid-diaphy-
seal line does not correspond to the anatomic axis. There-
fore, a method to define the anatomic axis of the metaphy-
seal or juxta-articular bone segment is needed. This will be
discussed in greater detail and is called anatomic axis plan-
ning.
b Mechanical axis lines follow joint center-to-joint center
course. When the bone is deformed, either two points or a
point and an angle to draw the PMA and DMA line segments
are needed. One point is the center of the joint. The PMA and
DMA line segments can be referenced to the joint line or to
the mid-diaphyseal line. For example, the DMA line of the
femur is referenced to the distal femoral joint line, the PMA
of the femur is referenced to the PAA of the femur, the PMA
of the tibia is drawn referenced to the proximal tibial joint
line, and the DMA of the tibia is referenced to the DAA line.
This will be discussed in greater detail and is called mechan-
ical axis planning.
EI
b.
Mechanical axis lines
Anatomic Axis Planning
The mid-diaphyseal line defines the anatomic axis.
When there is a diaphyseal angular deformity, proximal
and distal mid-diaphyseal lines on either side of the
CORA can be used to determine the level of the CORA.
This is a very standard and well-known method of de-
formity correction planning. When the CORA is at or
near the metaphysis, an accurate mid-diaphyseal line
cannot be drawn on the metaphyseal side. A reference
line and angle are needed to draw the anatomic axis of a
metaphyseal, epiphyseal, or joint segment of a bone.
With mechanical axis planning, the reference point of
the proximal or distal axis line is the center point of the
joint. The intersection point of the anatomic axis with
the joint orientation line is not the center point of the
joint. Each joint has a characteristic intersection point.
These are described according to their distance to the
center of the joint line for frontal plane planning and to
the anterior edge of the joint for sagittal plane planning.
The aJCD is variable among individuals, partially be-
cause of joint size difference. The aJCR is the ratio be-
tween the aJCD and the joint width. The aJCR is less vari-
able than the aJCD because it is independent of joint
width. Because of this variability, the aJCD should be
based on a normal side, if available. If there is no normal
side, the aJCD can be based on average normal values.
After the reference point is determined, the anatom-
ic axis can be drawn to the joint orientation line at a ref-
_ CHAPTER 4· Frontal Plane Mechanical and Anatomic Axis Planning
erence angle. The reference angle should also be based
on the opposite normal side, if available, or on the aver-
age normal values if unavailable.
Anatomic axis planning should always begin with a
drawing of all the mid-diaphyseal lines of the diaphyseal
segments. Even though these may correspond to the out-
line of the bone, there may still be malorientation of the
joints to the anatomic axis lines. It is therefore necessary
to always perform the MOT of the joints at either end of
the anatomic axes when performing anatomic axis plan-
ning. This will avoid missing deformities of the ends of
the bones that would not alter the mid-diaphyseal lines.
Determining the (ORA by Frontal Plane Mechanical
and Anatomic Axis Planning: Step by Step
Before performing mechanical axis planning, it is essen-
tial to perform the MAT on the frontal plane radio-
graphs of both limbs to determine whether MAD is pre-
sent and, if so, from which source. This step is labeled
Step 0 as a reminder that it comes before any step in the
preoperative planning process. It is performed before
tibial and femoral mechanical and anatomic axis plan-
ning of frontal plane deformities.
Step 0: MAT
The mechanical axes of both lower limbs are drawn, and
the MAD is measured. The mLDFA, MPTA, and JLCA are
measured on both sides to determine the source of the
MAD on the deformed side and to determine whether
the other side is normaL If one side is considered nor-
mal, its angles and distances can be used as templates for
the deformed side.
Part I: CORA Method, Tibial Deformities
Mechanical Axis Planning ofTibial Deformities
The following steps are drawn directly on the long radio-
graph.
Step 1
Draw the proximal tibial mechanical axis line (~Fig.
4-3).
A. Normal ipsilateral mLDFA: If the femur is not con-
tributing to the MAD, as revealed by the MAT, its me-
chanical axis line can be extended distally through
the center of the knee to become the proximal tibial
mechanical axis line. This step assumes that the dis-
tal femoral joint line and the proximal tibial joint line
are nearly parallel OLCA < 2°). If they are not, the
planning method is modified (see Chap. 14).
B. Abnormal ipsilateral mLDFA and normal contralat-
eral MPTA: If the ipsilateral femur is contributing to
the MAD, its mechanical axis line should not be used
as the PMA of the deformed tibia. If the contralateral
MPTA is normal, it is used as a "template angle:' The
proximal tibial mechanical axis line on the deformed
side is drawn from the center of the knee at the tem-
plate angle to the tibial plateau joint line.
C. Abnormal ipsilateral mLDFA and contralateral
MPTA: If the ipsilateral femur is contributing to the
MAD and the contralateral tibia has an abnormal
MPTA, neither should be used to generate the PMA of
the deformed tibia. Instead, the average normal MPTA
of 87° is used. The PMA is drawn at an angle 87° to the
tibial plateau joint line through the center of the knee.
Step 2
Draw the distal tibial mechanical axis line, and perform
the MOT of the ankle (~ Fig. 4-4).
A. Normal distal tibial diaphysis: If there is no obvious
distal tibial deformity, the distal tibial mechanical ax-
is line is drawn from the center of the ankle joint line
parallel to the diaphysis of the tibia (the mid-diaphy-
seal axis of the tibia is the anatomic axis, and the me-
chanical and anatomic axes of the tibia are parallel).
Although there may not appear to be a distal tibial de-
formity, the MOT is performed for the ankle after
drawing the DMA line. Therefore, always draw the
ankle plafond line and measure the LDTA to confirm
that it is normal. (Because of the variability in the
normal range of the LDTA, especially the mild nor-
mal valgus tendency, it is best to draw the DMA ref-
erenced off the mid-diaphyseal line rather than the
ankle joint orientation line.)
B. Distal tibial deformity with normal contralateral
LDTA: In cases of distal tibial deformity, there may be
insufficient length of nondeformed distal diaphysis
from which to draw a reference mid-diaphyseal line.
In such cases, reference off the ankle j oint orientation
line. If the contralateral LDTA is normal, use it as a
template angle. The distal tibial mechanical axis line
is drawn as a line extending proximally from the cen-
ter of the ankle at the template angle to the ankle joint
line.
C. Distal tibial deformity with abnormal contralateral
LDTA: In cases of distal tibial deformity, if the oppo-
site LDTA is deformed or unavailable, the normal av-
erage LDTA of 90° is used. The distal tibial mechani-
cal axis is drawn from the center of the ankle at an
angle 90° to the ankle joint line.
 CHAPTER 4· Frontal Plane Mechanical and Anatomic Axis Planning

Step 1
a. b. c.

Fig. 4-3 a-c

Tibial mechanical axis planning. Step 1: Draw the PMA of the
tibia.
a If the ipsilateral femur has a normal mLDFA, extend its
mechanical axis distally to become the mechanical axis of
the proximal tibia.
b If the ipsilateral mLDFA is not normal but the contralateral
MPTA is normal, use the contralateral MPTA to draw the me-
chanical axis of the proximal tibia.
c If the ipsilateral mLDFA and the contralateral MPTA are not
normal, use a normal value (87°) for the MPTA.

Step 2

a. b. c.

LDTA LDTA~!
\\89 0 = 900 ~
-+r-6-L--

Fig.4-4a-e
Tibial mechanical axis planning. Step 2: Draw the mechanical
axis of the distal tibia, and perform the MOT for the ankle.
a Draw a line from the midpoint of the tibial plafond parallel
to the shaft of the tibia (parallel to the anatomic axis mid-di-
aphysealline). Measure the LDTA of the ankle plafond line
to this line.
b If the shaft of the tibia distal to the deformity is very short
and an accurate parallel line cannot be drawn and the oppo-
site LDTA is within normal limits, use it to orient the me-
chanical axis of the distal tibia.
e If the deformity level is very distal and the contralateral
LDTA is not within normal limits, use the normal value of
90° to orient the DMA line.
m CHAPTER 4· Frontal Plane Mechanical and Anatomic Axis Planning

Step 3
a.

Step 3
b.

Obvious
apex
~

Resolved
Mag

Fig.4-S a-c
Tibial mechanical axis planning. Step 3: Decide whether this is
uniapical or multiapical angulation. Mark the CORA(s) and
measure the magnitude(s).
a The intersection point of the PMA and DMA lines is the
CORA. The magnitude of angulation (Mag) is measured be-
tween the proximal and distal axis lines. The CORA corre-
sponds to the obvious apex of angulation. The knee and an-
kle are normally orientated to the proximal and distal axis
lines, respectively. Therefore, this is a uniapical angular de-
formity.
b If the CORA is not at the obvious apex, there is more than
one apex of angulation (i) or there is a translation deformi-
ty (ii). In the former case, draw a third line corresponding to
the mechanical axis of the mid-tibia. Start on the distal axis
line at the level of the obvious apex, and draw the third line
parallel to the tibia. Mark the two CORAs, and measure the
magnitude of angulation of the two deformities.
c If the angle between the DMA line and the ankle plafondline
(LDTA) is not within normal limits, there is an additional
CORA at the level of the ankle joint. Draw the LDTA from the
other side to draw the plafond axis line or, if the other side
LDTA is not normal, use 90° as the normal value to generate
the plafond axis line (third axis line). Measure the magni-
tude of angulation of the angle between the plafond axis line
and the distal tibial mechanical axis.
 CHAPTER 4· Frontal Plane Mechanical and Anatomic Axis Planning _
Step 3
c.
CORA,
--s:o;
:~~~
I \\~
~--~~-
Step 3
Decide whether this is uniapical or multiapical angula-
tion: mark the CORA(s), and measure the magnitude(s)
(~ Fig. 4-5).
A. CORA corresponds to the obvious deformity level: If
the intersection of the proximal and DMA lines cor-
responds to the obvious level of angulation, mark this
as a single CORA and measure the magnitude of an-
gulation at this point.
B. CORA does not correspond to obvious deformity lev-
el: If the CORA does not correspond to an obvious
level of angulation, there is either a second apex of
angulation or a translation deformity. Translation de-
formities are usually obvious and are discussed in
Chap. 8. In cases in which there is a second deformi-
ty apex, a third axis line must be drawn to represent
the mechanical axis of the middle segment. This axis
line is drawn starting with a point at the obvious
apex, on the axis line that passes through the obvious
apex. This third line is referenced parallel to the mid-
diaphyseal line and is extended until it crosses both
proximal and DMA lines, producing two CORAs. One
of the CORAs corresponds to the apex of the obvious
deformity and the other to a hidden apex. Measure
the magnitude of angulation at both CORAs.
e. CORA corresponds to obvious deformity level and
ipsilateral LDTA is abnormal: If the CORA corre-
sponds to the obvious level of angulation but the
LDTA between the DMA and the ankle joint line is
N
OTA
- 88°
N
Mag2
•
\i OTA
=82°
CORA
2
-~~-----
abnormal, there is a second angular deformity caus-
ing ankle joint malorientation. The contralateral
LDTA should be measured, and if it is normal, its val-
ue is used as a template angle. A third line is drawn at
the template angle from the center of the ankle joint
line. If the opposite LDTA is abnormal, use an average
angle of 900 • The center point of the ankle joint is the
level of the second CORA. Measure the magnitude of
angulation at both CORAs.
Although this step-by-step method may seem complex
at first glance, the individual steps are very simple and
follow an easy-to-remember order: Step 1, mechanical
axis of knee joint segment; Step 2, mechanical axis of
ankle joint segment and ankle MOT; and Step 3, decide
whether the angulation is uniapical or multi apical, draw
the third axis line, if applicable, mark the CORA(s), and
measure the magnitude(s) of angulation. The same or-
der of steps is used for femoral mechanical axis plan-
ning. Examples of tibial mechanical axis planning are
illustrated (~Figs. 4-6 through 4-14).
. . CHAPTER 4· Frontal Plane Mechanical and Anatomic Axis Planning

Step 0 Step 1 Step 2 Step 3

Fig.4-6

Step 0 Step 1 Step 2 Step 3

Fig.4-7
 CHAPTER 4 . Frontal Plane Mechanical and Anatomic Axis Planning _

Step 0 Step 1 Step 2 Step 3

Fig. 4·6 Fig.4-S ...

Tibial mechanical axis planning. Step 0, MAT. Medial MAD due
to tibial deformity only, MPTA=72°. Step 1, PMA. The mLDFA
of 87 0 is normal. The JLCA is less than 20. Therefore, the me-
chanical axis of the femur can be extended distally as the me-
chanical axis of the proximal tibia. Step 2, DMA and MOT. The
DMA line is drawn as a line from the center of the ankle paral-
lel to the shaft of the tibia. The LDTA is normal. Step 3, CORA
and magnitude of angulation. The CORA is marked at the in-
tersection of the PMA and DMA lines. The magnitude of angu-
lation of the diaphyseal deformity is 300.
Tibial mechanical axis planning. Step 0, MAT. Medial MAD due
to tibial deformity only, MPTA=74°. Step 1,PMA. The mLDFA
of 87 0 is normal. The JLCA is parallel. Therefore, the mechani-
cal axis of the femur can be extended distally as the mechani-
cal axis of the proximal tibia. Step 2, DMA and MOT. The DMA
line is drawn as a line from the center of the ankle parallel to
the shaft of the tibia. The LDTA is normal. Step 3, CORA and
magnitude of angulation. The CORA is marked at the intersec-
tion of the PMA and DMA lines. The magnitude of angulation
of the metaphyseal deformity is 120.

Fig. 4-7
Tibial mechanical axis planning. Same tibial deformity as in
previous example except with ipsilateral femoral deformity.
Step 0, MAT. Medial MAD due to tibial and femoral deformi-
ties. Step 1, PMA. The ipsilateral mLDFA of 1070 is abnormal,
but the contralateral MPTA is normal. The mechanical axis of
the proximal tibia is drawn as a line from the center of the knee
at the template angle of the opposite MPTA, which is 88 0. Step
2, DMA and MOT. The DMA line is drawn as a line from the
center of the ankle parallel to the shaft of the tibia. The LDTA
is normal. Step 3, CORA and magnitude of angulation. The CO-
RA is marked at the intersection of the PMA and DMA lines.
The magnitude of angulation of the tibial diaphyseal deformi-
ty is 300 •
. . CHAPTER 4 . Frontal Plane Mechanical and Anatomic Axis Planning

Step 0 Step 1 Step 2 Step 3

Fig. 4-9

= 82°
MPTA
= 87°

CORA
%LDTA
II 't' 88°
LDTA
=88° ~
~
Mag
=40°
Step 0 Step 1 Step 2 Step 3

Fig.4-10
 CHAPTER 4 . Frontal Plane Mechanical and Anatomic Axis Planning IIiI

=88°

~
Mag
= 16°
Step 0 Step 1 Step 2 Step 3

Fig. 4-9 Fig.4-11 ...

Tibial mechanical axis planning. Same tibial deformity as in
previous example except with ipsilateral femoral deformity
and contralateral tibial deformity. Step 0, MAT. Medial MAD
due to tibial and femoral deformity on both sides. Step 1, PMA.
The ipsilateral mLDFA of 97° and contralateral MPTA of 74° are
abnormal. The mechanical axis of the proximal tibia is drawn
as a line from the center of the knee at the average normal
MPTA of 87°. Step 2, DMA and MOT. The DMA line is drawn as
a line from the center of the ankle parallel to the shaft of the
tibia. The LDTA is normal. Step 3, CORA and magnitude of an-
gulation. The CORA is marked at the intersection of the PMA
and DMA lines. The magnitude of angulation of the tibial
metaphyseal deformity is 12°.
Tibial mechanical axis planning. Step 0, MAT. Medial MAD is
due to femoral deformity only. The ankle MOT is abnormal,
LDTA =74°. Step 1, PMA. The ipsilateral LDFA of 93° is abnor-
mal, but the contralateral MPTA is normal. The mechanical ax-
is of the proximal tibia is drawn as a line from the center of the
knee at the template angle of the opposite MPTA of 88°. Step 2,
DMA and MOT. The deformity is very distal, and there is not a
long enough segment of distal tibia to orient the DMA line. The
opposite LDTA of 74° is abnormal. The DMA line is drawn as a
line from the center of the ankle at the average normal LDTA
of 90°. Step 3, CORA and magnitude of angulation. The CORA
is marked at the intersection of the PMA and DMA lines. The
magnitude of angulation of the distal metaphyseal deformity is
16°.

Fig.4-10
Tibial mechanical axis planning. Step 0, MAT. Medial MAD due
to tibial deformity only, MPTA=87°. Step 1, PMA. The mLDFA
of 87° is normal. The ILCA is 0°. Therefore, the mechanical ax-
is of the femur is extended distally as the mechanical axis of the
proximal tibia. Step 2, DMA and MOT. The deformity is very
distal, and there is not a long enough segment of distal tibia to
orient the DMA line. The opposite LDTA is normal. The DMA
line is drawn as a line from the center of the ankle at the tem-
plate angle of the opposite LDTA of 88°. Step 3, CORA and mag-
nitude of angulation. The CORA is marked at the intersection
of the PMA and DMA lines. The magnitude of angulation of the
distal metaphyseal deformity is 40°.
Ell CHAPTER 4 · Frontal Plane Mechanical and Anatomic Axis Planning

Resolution
CORA

Step 0 Step 1 Step 2 Step 3

Fig. 4-12

Step 0 Step 1 Step 2 Step 3

Fig. 4-13
 CHAPTER 4 . Frontal Plane Mechanical and Anatomic Axis Planning . .
Step 0 Step 1
Fig. 4-12
Tibial mechanical axis planning. Step 0, MAT. Minimal lateral
MAD due to tibial deformity only. Step 1, PMA. The mLDFA of
87° is normal. The JLCA is 0°. Therefore, the mechanical axis of
the femur is extended distally as the mechanical axis of the
proximal tibia. Step 2, DMA and MOT. The DMA line is drawn
as a line from the center of the ankle parallel to the shaft of the
tibia. The LDTA is normal. Step 3, CORA, magnitude of angu-
lation, and middle axis line. Mark the CORA at the intersection
of the proximal and distal axis lines. The CORA is in the distal
tibia at a level with no apparent deformity. This signals that
there is a multiapical angular deformity. A middle (third) me-
chanical axis line is drawn starting at the level of the obvious
diaphyseal valgus deformity parallel to the anatomic axis of the
distal diaphysis. Where the middle axis line intersects the PMA
and DMA lines are the two CORAs of the multiapical deformi-
ty (true apex CORAs). The magnitude of angulation is mea-
sured at both levels (proximal magnitude of angulation = 14°;
distal magnitude of angulation=300).
Fig. 4-13
Tibial mechanical axis planning. Step 0, MAT. Medial MAD due
to femoral and tibial deformity. Step 1, PMA. The ipsilateral
mLDFA of 102° and the contralateral MPTA of 67° are abnor-
mal. The mechanical axis of the proximal tibia is drawn as a
line from the center of the knee at the average normal MPTA of
87°. Step 2, DMA and MOT. The DMA line is drawn as a line
from the center of the ankle parallel to the shaft of the tibia. The
LDTA is normal. Step 3, CORA and magnitude of angulation.
The CORA is marked at the intersection of the PMA and DMA
lines. The intersection point is lateral to the shaft of the bone
Step 2 Step 3
Fig.4-14 ~
Tibial mechanical axis planning. Step 0, MAT. Lateral MAD due
to tibial deformity only, MPTA = 102°. Step 1, PMA. The mLDFA
of 87° is normal. The JLCA is 0°. Therefore, the mechanical ax-
is of the femur is extended distally as the mechanical axis of the
proximal tibia. Step 2, DMA and MOT. The DMA line is drawn
as a line from the center of the ankle parallel to the shaft of the
tibia. LDTA = 122°. Step 3, CORA and magnitude of angulation.
The CORA corresponds to the obvious valgus diaphyseal apex
and is marked at the intersection of the PMA and DMA lines.
The magnitude of angulation of the diaphyseal deformity is
34°. The abnormal MOT at the ankle indicates that there is a
second apex of angulation at the ankle joint. Therefore, a third
axis line is drawn starting at the center of the ankle joint line.
Because the opposite LDTA of 80° is abnormal, an average nor-
mal LDTA of 90° is used. The magnitude of angulation of the
ankle level deformity is measured between the third axis line
and the distal tibial mechanical axis line.
(resolved apex CORA, magnitude of angulation=37°). There-
fore, this is a multiapical angular deformity. A third mechani-
cal axis line (middle line) is drawn as representative as possi-
ble of the mid-diaphysis. The intersection point of this middle
line with the PMA and DMA lines is marked as the proximal
and distal CORAs. The magnitudes of angulation are 21° and
16°, respectively.
_ CHAPTER 4· Frontal Plane Mechanical and Anatomic Axis Planning
Step 1
a. b. c.
Anatomic Axis Planning ofTibial Deformities
Anatomic axis planning of the tibia is most useful pri-
marily for diaphyseal deformities. Because the mechan-
ical and anatomic axes of the tibia are not significantly
different from each other, the planning methods do not
differ greatly. The primary difference is that the mid-di-
aphyseallines are drawn first and the MOT is performed
at the joint end of every mid-diaphyseal line. In the tib-
ia, the values for MPTA and ADTA are the same for me-
chanical and anatomic axes, although the starting points
differ slightly.
Step 1
A. Draw the mid-diaphysealline(s) to represent the dia-
physis of the tibia. Each mid-diaphyseal line segment
is the anatomic axis line for that segment of bone
(~ Fig. 4-15).
B. Perform the MOT between the proximal and distal-
most mid-diaphyseal lines and the knee and ankle
joint lines, respectively (MPTA and LDTA).
Step 2
Determine whether the MPTA and LDTA are normal. If
abnormal, draw an additional anatomic axis line refer-
enced to the abnormally oriented joint line(s) (~ Fig. 4-
16).
A. 1. If the MPTA is normal, there is no more proximal
CORA or anatomic axis line.
d. e.
= 87°
Fig. 4-15 a-e
Tibial anatomic axis planning. Step 1: Draw the mid-diaphyseal
line(s) to represent the diaphysis of the tibia. In these five ex-
amples (a-e), each mid-diaphyseal line segment is the anatom-
ic axis line for that segment of bone. Perform the MOT. Draw
the proximal and distal joint orientation lines and measure the
MPTA and LDTA relative to the adjacent mid-diaphyseal line
segment.
2. If the MPTA is abnormal, draw an anatomic axis
line referenced to the knee joint orientation line.
The reference point can be obtained from the op-
posite normal side if available or, in an adult, this
line can be drawn from the apex of the medial tib-
ial spine. Use the MPTA of the contralateral nor-
mal side as a template angle, if available. If the op-
posite MPTA is unavailable or abnormal, the
average normal MPTA of 87° is used instead.
B. 1. If the LDTA is normal, there is no more distal
CORA.
2. If the LDTA is abnormal, draw an anatomic axis
line referenced to the ankle joint orientation line.
The reference point can be obtained from the op-
posite normal side if available or, in an adult, this
line can be drawn from a point 4 mm medial to the
ankle joint center point. Use the LDTA of the con-
tralateral normal side as a template angle, if avail-
able. If the opposite LDTA is unavailable or abnor-
mal, the average normal LDTA of 90° is used
instead.
 CHAPTER 4 . Fronta l Plane Mechanical and Anatomic Axis Planning . .

Step 2

a. b. c.

d. e.

Fig. 4-16 a-e

Tibial anatomic axis planning (same five examples as those
shown in Fig. 4-15). Step 2: Determine whether the MPTA and
LDTA are normal.
a,c,e If the MPTA is normal, there is no more proximal CORA
or anatomic axis line.
b, d If the MPTA is abnormal, draw an anatomic axis line ref-
erenced to the knee joint orientation line. The reference
point can be obtained from the opposite normal side, if
available, or, in an adult, this line can be drawn from the apex
of the medial tibial spine. Use the MPTA of the contralateral
normal side as a template angle, if available. If the opposite
MPTA is unavailable or abnormal, the average normal MPTA
of 87° is used instead. Measure the LDTA to the distal-most
tibial mid-diaphyseal line.
a, b, d If the LDTA is normal, there is no more distal CORA.
c, e If the LDTA is abnormal, draw an anatomic axis line refer-
enced to the ankle joint orientation line. The reference point
can be obtained from the opposite normal side, if available,
or, in an adult, this line can be drawn from a point 4 mm me-
dial to the ankle joint center point. Use the LDTA of the con-
tralateral normal side as a template angle, if available. If the
opposite LDTA is unavailable or abnormal, the average nor-
mal LDTA of 90° is used instead.
. . CHAPTER 4· Frontal Plane Mechanical and Anatomic Axis Planning
Step 3
a. b. c.
Mag
=12 0
Fig. 4-17 a-e
Tibial anatomic axis planning (same five examples as those
shown in Figs. 4-15 and 4-16). Step 3: Decide whether this is
uniapical (a,b,c) or multiapical (d,e) angulation. Mark the
CORA(s) and measure the magnitude(s).
Step 3
Decide whether this is uniapical or multiapical angula-
tion: mark the CORA(s), and measure the magnitude(s)
(~ Fig. 4-17).
A. If there is only one pair of anatomic axis lines drawn,
there will be only one CORA and one magnitude.
B. For each additional anatomic axis line, there will be
one additional CORA and magnitude.
Anatomic axis planning is simpler than mechanical axis
planning. It is probably less accurate because the start-
ing point at the medial tibial spine 4 mm medial to the
center of the ankle joint can be very variable and is very
dependent on tibial rotation. Mechanical axis planning
is less affected by tibial torsion. Anatomic axis planning
is particularly useful when using an IMN for fixation.
The center of the medullary canal corresponds to the
mid-diaphyseal line. Anatomic axis planning is used
predominantly with post-fracture deformities, because
the goal of treatment is to restore the pre-fracture align-
ment rather than to correct associated preexisting devi-
ations in knee or ankle joint orientation.
d. e.
Part II: CORA Method, Femoral Deformities
Mechanical Axis Planning of Femoral Deformities
Femoral mechanical axis planning follows exactly the
same steps as those for tibial mechanical axis planning.
There are two apparent differences. First, with tibial
planning, the proximal axis line is the one that originates
at the knee joint and with femoral planning, it is the dis-
tal axis line that originates at the knee joint. Therefore,
Step 1 for femoral planning is actually the DMA line.
Second, with tibial planning, the AMA is 0° whereas with
femoral planning, it is approximately 7°. This makes
Step 2 of femoral planning seem less intuitive and more
complicated even though the steps are the same.
After performing the MAT, the following steps are
drawn directly on the radiograph.
Step 1
Draw the DMA line (~ Fig. 4-18).
A. Normal ipsilateral MPTA: If the tibia is not contribut-
ing to the MAD, as revealed by the MAT, and the JLCA
is 0°, the tibial mechanical axis line can be extended
proximally through the center of the knee joint line to
become the distal femoral mechanical axis line.
B. Abnormal ipsilateral MPTA and normal contralater-
al mLDFA: If the ipsilateral tibia is contributing to the
MAD, its mechanical axis line should not be used as
the DMA of the deformed femur. If the contralateral
mLDFA is normal, it is used as a template angle. The
distal femoral mechanical axis line on the deformed
 CHAPTER 4 . Fronta l Plane Mechanical and Anatomic Axis Planning _
Step 1
a.
= 95'
Fig.4-1Sa-c
Femoral mechanical axis planning. Step 1: Draw the DMA of
the femur through the center of the knee joint.
a If the ipsilateral MPTA is within normal range and the JLCA
is 0 the mechanical axis line of the tibia can be extended
0,
proximally.
b If the ipsilateral MPTA is not within normal range, use the
contralateral mLDFA if it is within normal range.
c If both the ipsilateral MPTA and the contralateral mLDFA
are not within normal range, chose an average normal
mLDFA of 870 •
side is drawn from the center of the knee joint at the
template angle to the femoral condyle line.
C. Abnormal ipsilateral MPTA and contralateral
mLDFA: If the ipsilateral tibia is contributing to the
MAD and the contralateral femur has an abnormal
mLDFA, neither should be used to generate the DMA
of the deformed femur. Instead, the average normal
mLDFA of 87° is used. The DMA is drawn at an angle
87° to the knee joint line through the center of the
knee joint line.
= 95'
Step 2
Draw the mechanical axis of the proximal femur and
perform the MOT of the hip (~Fig. 4-19).
A. Normal proximal femoral diaphysis and contralater-
al normal mLDFA: If there is no obvious proximal
femoral deformity, the proximal femoral mechanical
axis line is referenced off of the mid-diaphyseal line
of the proximal femur. If the opposite femur mLDFA
is normal, measure the femoral AMA on the normal
side. To use this angle as a template angle, first draw
a proximal femoral mid-diaphyseal line on the de-
formed side (first line). Draw a second line from the
center of the femoral head parallel to this mid-dia-
physealline. Finally, draw a third line from the center
of the femoral head at the template AMA to the sec-
ond line. The third line is the mechanical axis of the
proximal femur. To rule out an unrecognized proxi-
mal femoral deformity, the MOT is performed for the
hip after drawing the PMA line.
B. Abnormal contralateral mLDFA: If the opposite fe-
mur is also deformed, its AMA cannot be reliably
used as a template angle. The average normal value
for femoral AMA is 7°. The rest of this step is the same
as in Step 2A above, substituting the chosen normal
AMA for the template angle.
. . CHAPTER 4 · Frontal Plane Mechanical and Anatomic Axis Planning
Step 2
a.
b.
c.
LPFA
= 88·
Fig.4-19 a-d
Femoral mechanical axis planning. Step 2: Draw the mechani-
cal axis of the proximal femur and perform the MOT of the hip.
a Draw a mid-diaphyseal line of the proximal femur (first line)
and then a parallel line passing through the center of the
femoral head (second line). If the contralateral mLDFA is
within normal limits, use the angular relationship between
the contralateral AMA to draw the PMA line. This third line
is drawn from the center of the femoral head at the template
AMA in a direction lateral to the second line (third line, red).
Draw a line from the tip of the greater trochanter to the cen-
ter of the femoral head and measure the LPFA.
d.
LPFA
= 90·
b If the contralateral femur mLDFA is not within normal lim-
its, use the average normal AMA of 7° to generate the PMA
line (third line, red). Then measure the LPFA.
c If the deformation is too proximal to be able to draw a prox-
imal mid-diaphyseal line (first line), use the LPFA of the con-
tralateral side as a template angle (if it is within normal lim-
its) to generate the PMA.
d If the deformation is proximal and the contralateral LPFA is
not within normal limits, use the average normal mLPFA of
90° to generate the PMA of the femur.