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
D. Paley, Principles of Deformity Correction
© Springer-Verlag Berlin Heidelberg 2002
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.
 CHAPTER 4 . Frontal Plane Mechanical and Anatomic Axis Planning _

Step 3 Fig. 4-20 a-c

a.
Femoral mechanical axis planning. Step 3: Decide whether this
is uniapical or multiapical angulation. Mark the CORA(s) and
measure the magnitude(s).
a Mark the CORA at the intersection point of the PMA and
DMA lines, and measure the angle between these two lines
because the CORA corresponds to the level of the obvious
apex and the orientation of the axis lines to the hip and knee
joint orientation lines.
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 middle mechanical axis line
corresponding to the mechanical axis of the mid-femur.
First, mark the level of the diaphyseal apex using the middle
segment mid-diaphyseal line. Mark a point opposite this lev-
el on the PMA line. This point is a CORA. Draw the middle
mechanical axis line from this point to the mid-diaphyseal
line of the middle segment of the femur at an angle of 7° (the
average normal AMA; if the opposite normal AMA is avail-
able and different, use it rather than an average normal val-
ue). This line is the mechanical axis line of the middle seg-
ment. The intersection point of this line with the DMA line
is the second CORA. The magnitudes are measured at each
CORA.

Step 3
b.

ii

Obvious
apex

True
apex
m CHAPTER 4 · Frontal Plane Mechanica l and Anatomic Axis Planning
Step 3
c.
LPFA
110·
Fig. 4-20 a-c
C If the LPFA is not within normal limits, there is an addition-
al CORA at the level of the hip joint. Use the LPFA from the
other side to draw the hip axis line (top right) or, if the other
side LPFA is not normal, use an LPFA of 90° as the normal
value to generate the hip axis line (bottom right). Measure
the magnitudes.
C. Proximal femoral deformity with normal contralat-
eral LPFA: In cases of proximal femoral deformity,
there may be insufficient length of non-deformed
femoral diaphysis from which to draw a reference
mid-diaphyseal line. In such cases, reference off of
the hip joint orientation line. If the contralateral
LPFA is normal, use it as a template angle. The prox-
imal femoral mechanical axis line is drawn as a line
extending distally from the center of the hip at the
template angle to the hip joint line.
D. Proximal femoral deformity with abnormal con-
tralateral LPFA: In cases of proximal femoral defor-
mity, if the opposite LPFA is abnormal or unavailable,
the normal average LPFA of 90° is used. The proximal
femoral mechanical axis is drawn from the center of
the hip joint at an angle 90° to the hip joint line.
LPFA
Step 3
Decide whether this is uniapical or multiapical angula-
tion: mark the CORA(s), and measure the magnitude(s)
(~Fig. 4-20).
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, one must draw a third axis line 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 at the level of the obvious
apex. This third line is referenced to the mid-diaphy-
seal line using the same AMA as that used in the pre-
vious step. It is extended until it crosses both PMA
and DMA lines, producing two CORAs. One of the
CORAs corresponds to the apex of the obvious defor-
 CHAPTER 4 . Frontal Plane Mechanical and Anatomic Axis Planning
Step 1
mity and the other to a hidden apex. Measure the
magnitude of angulation at both CORAs.
C. CORA corresponds to obvious deformity level and
ipsilateral LPFA is abnormal: If the CORA corre-
sponds to the obvious level of angulation but the
LPFA measured in Step 2 above is abnormal, there is
a second angular deformity causing hip joint malo-
rientation. The contralateral LPFA should be mea-
sured, and if it is normal, its value is used as a tem-
plate angle. A third line is drawn at the template angle
from the center of the hip. If the opposite LPFA is
abnormal, use an average normal LPFA of 90°. The
center point of the hip is the level of the second
CORA. Measure the magnitude of angulation at both
CORAs.
Anatomic Axis Planning of Femoral Deformities
Step 1
A. Draw the mid-diaphysealline(s) to represent the dia-
physis of the femur. For these five examples, each
mid-diaphyseal line segment is the anatomic axis line
for that segment of bone (~Fig. 4-21).
B. Perform the MOT between the distal and proximal-
most mid-diaphyseal lines and the knee and hip joint
lines, respectively (MPFA and aLDFA).
Step 2
Determine whether the MPFA and aLDFA are normal. If
abnormal, draw an additional anatomic axis line refer-
enced to the abnormally oriented joint line(s).
III
d. e.
Fig. 4-21 a-e
Femoral anatomic axis planning. Step 1: Draw the mid-diaphy-
sealline(s) to represent the diaphysis of the femur. Each mid-
diaphyseal line segment is the anatomic axis line for that seg-
ment of bone. Perform the MOT. Draw the proximal and distal
joint orientation lines and measure the MPFA and aLDFA rel-
ative to the mid-diaphyseal line segment.
A. 1. If the aLDFA is normal, there is no more distal
CORA or anatomic axis line.
2. If the aLDFA 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 starting 1 cm medial to the cen-
ter point of the knee joint. Use the aLDFA of the
contralateral normal side as a template angle, if
available. If the opposite aLDFA is unavailable or
abnormal, the average normal aLDFA of 81° is
used instead.
B. 1. If the MPFA is normal, there is no more proximal
CORA.
2. If the MPFA is abnormal, draw an anatomic axis
line referenced to the hip 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 passing through the piriformis
fossa. Use the MPFA of the contralateral normal
side as a template angle, if available. If the opposite
MPFA is unavailable or abnormal, the average nor-
mal MPFA of 84° is used instead.
. . CHAPTER 4· FrontalPlaneMechanicalandAnatomicAxisPlanning

Step 2
a. b. c.

d. e.

Fig. 4-22 a-e

Femoral anatomic axis planning (same five examples as those
shown in Fig.4-2l). Step 2: Determine whether the MPFA and
aLDFA are normaL Measure the aLDFA to the distal-most fem-
oral mid-diaphyseal line.
a,c,e If the aLDFA is normal, there is no more distal CORA or
anatomic axis line.
b,d If the aLDFA 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 starting 1 cm
medial to the center point of the knee joint. Use the aLDFA
of the contralateral normal side as a template angle, if avail-
able. If the opposite aLDFA is unavailable or abnormal, the
average normal aLDFA of 81 0 is used instead. Measure the
MPFA to the proximal-most femoral mid-diaphyseal line.
a, b, d If the MPFA is normal, there is no more proximal CORA.
c, e If the MPFA is abnormal, draw an anatomic axis line refer-
enced to the hip 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 passing through the
piriformis fossa. Use the MPFA of the contralateral normal
side as a template angle, if available. If the opposite MPFA is
unavailable or abnormal, the average normal MPFA of 84 0 is
used instead.
 CHAPTER 4 . Frontal Plane Mechanical and Anatomic Axis Planning . .

Step 3
a.
b. c.

d. e.

Magl
= 33°

Step 3 Fig. 4-23 a-e

Decide whether this is uniapical or multiapical angula-
tion: mark the CORA(s), and measure the magnitude(s)
(~Fig. 4-23).
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.
Femoral anatomic axis planning (same five examples as those
shown in Figs. 4-21 and 4-22). Step 3: Decide whether this is
uniapical or multiapical angulation. Mark the CORA(s) and
measure the magnitude(s).
a,b,c If there is only one pair of anatomic axis lines drawn,
there will only be one CORA and one magnitude.
d, e For each additional anatomic axis line, there will be one
additional CORA and magnitude.

The CORAs obtained with mechanical and anatomic ax-

is planning in the femur are not the same points. It is the
bisector line of the deformity that defines the true level
. . CHAPTER 4· Frontal Plane Mechanical and Anatomic Axis Planning

Bisector

\8~
~~~.

Mechanical axis Anatomic axis Mechanical axis Anatomic axis

planning planning planning planning

of angulation (see Chap. 5). The bisector lines of me-
chanical and anatomic planning are similar but not
exactly the same. The difference between them is small
(~ Fig. 4-24). Examples of mechanical and anatomic axis
planning of femoral deformities are illustrated in ~ Figs.
4-25 through 4-39.
Fig. 4-24
Femoral deformities can be planned by using either anatomic
or mechanical axis lines. The CORAs defined by the intersec-
tion of PAA and PMA lines and the DAA and DMA lines, re-
spectively, are different. It is the bisector line and not any indi-
vidual CORA that defines the level of a deformity (see Chap. 5).
The bisector lines are similar but not the same. In the distal fe-
mur, there is little difference, whereas in the proximal femur,
the CORAs are the farthest apart. There is little error in the lev-
el of the CORA from anatomic or mechanical planning.

Fig.4-26 ~

Femoral anatomic axis planning. Same deformity as that

shown in Fig. 4-25. Step 1, Mid -diaphyseal anatomic axis line( s)
and MOT. There is one mid-diaphyseal anatomic axis line. The
MPFA is normal and the aLDFA is abnormal to this line. Step 2,
Joint referenced anatomic axis line(s). Because the aLDFA is
81°, a distal femoral anatomic axis line is drawn using the op-
posite aLDFA and aJCD as templates. The femoral DAA line is
drawn starting 12 mm medial to the knee joint center at an aL-
DFA of 81°. Step 3, CORA and magnitude of angulation. The
magnitude of the distal metaphyseal deformity is 22°.
 CHAPTER 4 . Frontal Plane Mechanical and Anatomic Axis Planning III
AMA

·· =87° = 87'

Step 0 Step 1 Step 2a Step 2b Step 3

Fig. 4-25
Femoral mechanical axis planning. Step 0: MAT. Medial MAD
due to femoral deformity only. Step 1: DMA. The ipsilateral
MPTA and JLCA are normal. Therefore, the mechanical axis of
the tibia is extended proximally as the mechanical axis of the
distal femur. Step 2: PMA and MOT. The PMA line is drawn as
a line from the center of the femoral head referenced to the
mid-diaphyseal line at the template. AMA = 7° of the opposite
normal side. The LPFA is normal. Step 3: CORA and magnitude
of angulation. The magnitude of the distal metaphyseal defor-
mity is 22°.

~ ~
1---1 1---1
aJCD aJCD
= 12mm = 12mm

Step 1 Step 2 Step 3

. . CHAPTER 4· Frontal Plane Mechanical and Anatomic Axis Planning
Step 0
Step 2b
Fig.4-27
Femoral mechanical axis planning. Same femoral deformity as
that shown in the previous example with added ipsilateral tib-
ial deformity. Step 0: MAT. Medial MAD due to femoral and tib-
ial deformity. Step 1: DMA. The ipsilateral MPTA of 79° is ab-
normal, but the contralateral mLDFA is normal. Therefore, the
mechanical axis of the distal femur is drawn as a line from the
Step 1 Step 2a
Step 3
center of the knee at a template angle of the opposite mLDFA
of 87°. Step 2:PMA and MOT. The PMA line is drawn from the
center of the femoral head referenced to the mid-diaphyseal
line at the template AMA of 7° to the opposite normal side. The
LPFA is normal. Step 3: CORA and magnitude of angulation.
The magnitude of the distal metaphyseal deformity is 22°.
 CHAPTER 4 . Frontal Plane Mechanical and Anatomic Axis Planning . .

Slep 0 Step 1 Slep 2a Step 2b Slep 3

Fig. 4-28
Femoral mechanical axis planning. Step 0: MAT. MAD due to
femoral and tibial deformity. The opposite femur is also de-
formed. Step 1: DMA. The MPTA and the opposite mLDFA are
abnormal. Therefore, the mechanical axis of the distal femur is
drawn from the center of the knee joint at the average normal
mLDFA of 87°. Step 2: PMA and MOT. The PMA line is drawn
as a line from the center of the femoral head referenced to the
mid-diaphyseal line at the average normal AMA of 7° because
the opposite femur is abnormal. The LPFA is normal. Step 3:
CORA and magnitude of angulation. The magnitude of the di-
aphyseal deformity is 15°.

Fig.4-29 ~

Femoral anatomic axis planning. Same femoral deformity as

that shown in Fig. 4-28 with contralateral femoral deformity.
Step 1: Mid-diaphyseal anatomic axis line(s) and MOT. Two
mid-diaphyseal anatomic axis lines are drawn. The MPFA and
aLDFA are normal to these lines. Step 2: Joint referenced ana-
tomic axis line(s). Because the MPFA and the aLDFA are nor-
mal, there are no additional deformities present. Step 3: CORA
and magnitude of angulation. The magnitude of the diaphyseal
deformity is 16°.

Steps 1 and 2 Slep 3

. . (. ,vrER •.
,...,,' PI,,' y".,,'
"'''' .......', "'" ""
.,.,

Step 1 Step 2 Step 3

Step 0

fig. 4-30

Step 1 Step 2 Step 3

fig. 4-31
 CHAPTER 4 . Frontal Plane Mechanical and Anatomic Axis Planning _
Step 0
Fig. 4·30
Femoral mechanical axis planning. Step 0: MAT. MAD due to
tibial deformity only. The LPFA is abnormal, but this has no
significant effect on the mLDFA. Step 1: DMA. The MPTA is
abnormal but the opposite mLDFA is normal. Therefore, the
mechanical axis of the distal femur is drawn as a line from the
center of the knee at a template angle of the opposite mLDFA
of 87°. Step 2: PMA and MOT. The PMA line cannot be refer-
enced to the mid-diaphyseal line because the deformity is
proximal. The contralateral LPFA of 89° is used as a template
angle to draw the PMA line. Step 3: CORA and magnitude of
angulation. The CORA is at the center of the femoral head. The
magnitude of the proximal metaphyseal deformity is 32°.
Fig. 4-31
Femoral anatomic axis planning. Same deformity as that
shown in Fig. 4-30. Step 1: Mid-diaphyseal anatomic axis line(s)
and MOT. There is one mid-diaphyseal anatomic axis line. The
aLDFA is normal but the MPFA is abnormal to this line. Step 2:
Joint referenced anatomic axis line(s). Because the MPFA is 52°,
an anatomic axis line is drawn from the piriformis fossa at the
MPTA of the opposite normal side. Step 3: CORA and magni-
tude of angulation. The magnitude of the hip deformity is 32°.
mLPFA
=90·
Step 1 Step 2 Step 3
Fig. 4-32 ~
Femoral mechanical axis planning. Same femoral deformity as
that shown in Fig. 4-31. Step 0: MAT. MAD due to tibial defor-
mity. The LPFA is abnormal, although the hip deformity has
virtually no effect on the mLDFA. Step 1: DMA. The ipsilateral
MPTA and opposite femur are abnormal. Therefore, the me-
chanical axis of the distal femur is drawn as a line from the cen-
ter of the knee at an average normal mLDFA of 87°. Step 2: PMA
and MOT. The PMA line cannot be referenced to the mid-dia-
physealline because the deformity is proximal. The mLPFA of
the opposite side is abnormal. An average normal LPFA of 90°
is used to draw the PMA line. Step 3: CORA and magnitude of
angulation. The magnitude of the proximal metaphyseal defor-
mity is 31°.
Ell CHAPTER 4 . Frontal Plane Mechanical and Anatomic Axis Planning

Step 1 Step 2 Step 3

Fig.4-33
Anatomic axis planning. The same femoral deformity as that
shown in Fig. 4-32 with contralateral femoral deformity pre-
sent. Step 1: Mid-diaphyseal anatomic axis line(s) and MOT.
There is one mid-diaphyseal line. The aLDFA is normal but the
MPFA is abnormal to this line. Step 2: Joint referenced anatom-
ic axis line(s). Because the ipsilateral MPFA is 52° and the con-
tralateral MPFA is also abnormal at 52°, a femoral PAA line is
drawn from the piriformis fossa at the average normal MPFA
of 84°. Step 3: CORA and magnitude of angulation. The magni-
tude of the hip deformity is 31°.
 CHAPTER 4 . Fronta l Plane Mechanical and Anatomic Axis Planning . .

Step 0

S/r

Step 1 Step 2a Step 2b Step 3a Step 3b

Fig. 4-34
Femoral mechanical axis planning. Step 0: MAT. MAD due to
femoral deformity. The opposite femur is also deformed. Step
1: DMA. The MPTA and ILCA are normal. Therefore, the me-
chanical axis of the distal femur is drawn as an extension of the
mechanical axis of the proximal tibia. Step 2: PMA and MOT.
The PMA line is drawn as a line from the center of the femoral
head referenced to the mid-diaphyseal line at the average nor-
mal AMA of 7° because the opposite femur is abnormal. The
LPFA is normal. Step 3A: PMA and DMA are almost parallel
and do not intersect in the femur. There is an obvious diaphy-
seal valgus angular deformity. Therefore, this is a multiapical
angular deformity. Step 3B: CORA and magnitude of angula-
tion. A middle mechanical axis line is referenced from the mid-
diaphyseal line of the adjacent femur. It is drawn at an angle 7°
to this adjacent line, starting on the PMA line, at the level of the
obvious apex. Two CORAs are marked where this line inter-
sects the PMA and DMA lines. The magnitude of the proximal
angulation is 14° and of the distal angulation is 16°.
. . CHAPTER 4 · Frontal Plane Mechan ical and Anatomic Axis Pla nning

I~I
Xi
aJCD
= 10mm

Step 1 Step 2 Step 3

Fig. 4-35
Femoral anatomic axis planning. Same deformity as that
shown in FigA-34. Step 1: Mid-diaphyseal anatomic axis line(s)
and MOT. There are two mid-diaphyseal lines. The MPFA is
normal but the aLDFA is abnormal to these lines. Step 2: Joint
referenced anatomic axis line(s). Because the aLDFA is 97°, a
distal femoral anatomic axis line is drawn starting at an aver-
age normal aJCD of 10 mm medial to the center of the knee and
at an average normal aLDFA of 81 ° (the opposite aLDFA is ab-
normal). Step 3: CORA and magnitude of angulation. There are
two CORAs. (Note how much easier anatomic axis planning is
with multiapical deformities of the femur, compared with
mechanical axis planning.) The magnitude of the proximal
angulation is 14° of valgus and of the distal angulation is 16° of
varus.
 (H APTE R 4 . Frontal Plane Mechanical and Anatomic Axis Planning EI

MPTAt~
.,-'= 87° MPTA
=87°

Step 0

Step 1 Step 2a Step 2b Step 2c Step 3a Step 3b

Fig. 4-36
Femoral mechanical axis planning. Step 0, MAT. MAD due to
femoral and tibial deformity. The opposite femur is also de-
formed. Step 1: DMA. The MPTA and the opposite mLDFA are
abnormal. Therefore, the mechanical axis of the distal femur is
drawn from the center of the knee joint at the average normal
mLDFA of 87°. Step 2A: PMA and MOT. The PMA line is drawn
as a line from the center of the femoral head referenced to the
mid-diaphyseal line at the average normal AMA of 7° because
the opposite femur is abnormal. The LPFA is normal. Step 2B:
CORA and magnitude of angulation. The intersection point
(resolution point CORA, magnitude 40°) of the PMA and DMA
lies lateral to the femur. Therefore, this is a multiapical angular
deformity. Step 3A: A best-fit middle mid-diaphyseal line is
drawn. The middle mechanical axis line is drawn referenced 7°
to the mid-diaphyseal line. Step 3B: CORA and magnitude of
angulation. Two CORAs are marked where the middle mechan-
ical axis line intersects the PMA and DMA lines. The deformi-
ty magnitudes are 20° and IS°, respectively, for proximal and
distal CORAs.
Ell CHAPTER 4· Frontal Plane Mechanical and Anatomic Axis Planning

Step 1 Step 2 Step 3

Fig. 4-37
Femoral anatomic axis planning. Same femoral deformity as
that shown in Fig. 4-36 with contralateral femoral deformity.
Step 1: Mid-diaphyseal anatomic axis line(s) and MOT. There
are two mid-diaphyseal lines. The LPFA is normal and the
aLDFA is abnormal to these lines. Step 2: Joint referenced ana-
tomic axis line(s) and DAA. Because the opposite femur is
abnormal, draw the distal femoral anatomic axis starting at an
average normal aJCD of 10 mm and aLDFA of 81°. Step 3:
CORA and magnitude of angulation. There are two CORAs.
The deformity magnitudes are 20° and 15°, respectively, for
proximal and distal CORAs.
 CHAPTER 4 . Frontal Plane Mechanical and Anatomic Axis Planning . .

··
·
Step 0

Mag :..J'
Mag~
= 26° = 26

Step 1 Step 2a Step 2b Step 3a Step 3b

Fig. 4-38
Femoral mechanical axis planning. Step 0: MAT. MAD due to
femoral deformity. The opposite femur is also deformed. Step
1: DMA. The ipsilateral MPTA of 87° is normal, as is the ILCA.
Therefore, the mechanical axis of the distal femur through the
center of the knee joint is an extension of the tibial mechanical
axis line. Step 2: PMA and MOT. The PMA line is drawn as a line
from the center of the femoral head referenced to the mid-dia-
physealline at the average normal AMA of 7° because the op-
posite femur is abnormal. mLPFA= 112°. Step 3A: Resolved
CORA and magnitude of angulation. The CORA corresponds
to the level of the obvious valgus diaphyseal deformity. The
magnitude of the diaphyseal deformity is 26°. Because the
LPFA is abnormal, there is a second CORA at the hip joint. Step
3B: CORA and magnitude of angulation. Because the opposite
femur is deformed (mLPFA= 106°), an average normal mLPFA
of 90° is used to draw a hip mechanical axis line. The magni-
tude of the hip deformity is 22°.
. . CHAPTER 4· Frontal Plane Mechanica l and Anatomic Axis Planning
Step 1 Step 2
Fig. 4-39
Femoral anatomic axis planning. Same femoral deformity as
that shown in Fig. 4-38 with contralateral femoral deformity.
Step 1: Mid-diaphyseal anatomic axis line(s} and MOT. There
are two mid-diaphyseal anatomic axis lines. The aLDFA is nor-
mal and the MPFA is abnormal to these lines. Step 2: DAA. Joint
referenced anatomic axis line(s}. Because the MPFA is 62°, a
CORAl
Step 3
femoral PAA line is drawn as an average normal MPFA of 84°
(because the opposite MPFA is abnormal). Step 3: CORA and
magnitude of angulation. There are two CaRAs. The magni-
tude of the diaphyseal deformity is 26°. The magnitude of the
hip deformity is 22°.
 CHAPTER 4 . Frontal Plane Mechanical and Anatomic Axis Planning _

Multiapical Deformities a.

We have seen that when the CORA does not correspond

to the obvious apex of angulation, there is either a trans-
lation deformity or a multiapical angular deformity.
What does it mean when the CORA lies outside the
bone? For femoral deformities, the CORA may be out-
side the bone with mechanical axis planning because the
mechanical axis normally runs outside the bone for ap-
proximately one half to two thirds of its proximal
course. In the tibia, the mechanical axis normally never
leaves the bone. The anatomic axes of both the femur
and tibia also never normally leave the bone. Therefore,
a CORA outside the bone with anatomic axis planning
Anatomic Anatomic
of the femur or tibia or mechanical axis planning of the axis axis
tibia indicates that there must be a multiapical angular
deformity. In the distal femur, the mechanical axis is in b,
the bone. Therefore, a mechanical axis of the distal fe-
mur outside the bone indicates a multiapical deformity
(~ Fig. 4-40).

Fig. 4-40 i, b
a The anatomic axis of the femur and tibia never leave the cen-
ter of the bone. Therefore, any deformity with which the
CORA is outside the center of the bone must be multiapical.
b The mechanical axis of the femur is part inside and part out- CORA
side the bone. By mechanical axis planning, deformities of
the proximal half of the femur will have the CORA normal-
ly outside the bone. By mechanical axis planning, deformi-
ties of the lower half of the femur will have the CORA nor-
Mechanical
mally inside the bone. Any deformity with its CORA outside axis
the bone in the lower half of the femur is probably multiapi-
cal.