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Increasing deformity of the lower extremities, as measured by the hip-knee-ankle angle (HKAA), is associated with poor patient outcomes after total hip and knee arthroplasty (THA, TKA). Automated calculation of HKAA is imperative to reduce the burden on orthopaedic surgeons. We proposed a detection-based deep learning (DL) model to calculate HKAA in THA and TKA patients and assessed the agreement between DL-derived HKAAs and manual measurement. We retrospectively identified 1,379 long-leg radiographs (LLRs) from patients scheduled for THA or TKA within an academic medical center. There were 1,221 LLRs used to develop the model (randomly split into 70% training, 20% validation, and 10% held-out test sets); 158 LLRs were considered "difficult," as the femoral head was difficult to distinguish from surrounding tissue. There were 2 raters who annotated the HKAA of both lower extremities, and inter-rater reliability was calculated to compare the DL-derived HKAAs with manual measurement within the test set. The DL model achieved a mean average precision of 0.985 on the test set. The average HKAA of the operative leg was 173.05 ± 4.54°; the nonoperative leg was 175.55 ± 3.56°. The inter-rater reliability between manual and DL-derived HKAA measurements on the operative leg and nonoperative leg indicated excellent reliability (intraclass correlation (2,k) = 0.987 [0.96, 0.99], intraclass correlation (2, k) = 0.987 [0.98, 0.99, respectively]). The standard error of measurement for the DL-derived HKAA for the operative and nonoperative legs was 0.515° and 0.403°, respectively. A detection-based DL algorithm can calculate the HKAA in LLRs and is comparable to that calculated by manual measurement. The algorithm can detect the bilateral femoral head, knee, and ankle joints with high precision, even in patients where the femoral head is difficult to visualize. [ABSTRACT FROM AUTHOR]

The importance of lower-limb compensation in patients with spinal malalignment due to spinal pathologies has been emphasized. The latest whole-body X-ray images (WBX) have enabled evaluations of whole-body alignment from head to toe. However, WBX is still not commonly available. Thus, the present study aimed to examine an alternative measurement method of the femoral angle on usual full-spine X-ray images (FSX) that approximates the femoral angle on WBX. A total of 50 patients (age, 52.8 ± 25.3 years; female, n = 26; male, n = 24) underwent WBX and FSX. The following parameters were measured on lateral view X-rays: WBX and FSX femoral angle (angle between the femoral axis and a perpendicular line); FSX femoral distance (distance from the center of femoral head to the distal femur on FSX); WBX intersection length (length between the center of the femoral head and the intersection point [the point at which the line connecting the center of the femoral head and the midpoint of the femoral condyle intersects the center line of the femur] on WBX). The WBX femoral angle, and FSX femoral angle were 0.16 ± 4.2°, and −0.53 ± 4.1°, respectively. The FSX femoral distance was 102.7 ± 41.1 mm. An ROC curve analysis revealed that the cut-off value of the FSX femoral distance associated with minimal difference in the WBX and FSX femoral angles (<3°) was 73 mm (sensitivity 83.3%, specificity 87.5%, AUC 0.80). The WBX intersection length was 105.3 ± 27.3 mm. To calculate the femoral angle on FSX that approximates the WBX femoral angle, the femoral distance on FSX ≥73 mm is preferable. We suggest using the FSX femoral distance within the range of 80 mm–130 mm as a simple numerical value that meets all criteria. [ABSTRACT FROM AUTHOR]

Background and Objectives: Studies analyzing lower extremity alignment (LEA) LEA among taekwondo subdisciplines athletes are lacking. This study compared LEA in the dominant and nondominant legs intaekwondo athletes. Materials and Methods: Twelve measurements of LEA were analyzed for 157 athletes (63 sparring, 50 demonstration, and 44 poomsae athletes) registered with the Korea Taekwondo Association. LEA was measured in the standing, supine, and prone positions using alignment application, a goniometer, a bubble inclinometer, a height gage, and a palpation meter. Results: The analysis revealed that the dominant leg of poomsae athletes showed greater genu valgum alignment than that of sparring athletes (p < 0.01), whereas the dominant leg of sparring athletes showed greater rearfoot varum alignment than that of demonstration athletes (p < 0.01). Furthermore, the nondominant leg of poomsae athletes showed greater genu valgum alignment than that of sparring and demonstration athletes (p < 0.01), whereas the nondominant leg of sparring athletes showed greater rearfoot varum alignment than that of demonstration athletes (p < 0.01). In addition, demonstration athletes had better forefoot varus alignment than poomsae athletes (p < 0.01). Conclusions: This study revealed that LEA characteristics vary among taekwondo athletes according to their subdiscipline. The results of this study would help in designing training programs tailored to each subdiscipline that would best address their LEA characteristics and help to prevent injuries. [ABSTRACT FROM AUTHOR]

ObjectivesRecurrent patellar dislocation (RPD) greatly affects active young individuals, necessitating the identification of risk factors for a better understanding of its cause. Previous research has connected RPD to lower limb alignment (LEA) abnormalities, such as increased femoral anteversion, tibial external rotation, knee valgus, and flexion. This study aims to use EOS technology to detect RPD-related LEA anomalies, enabling three-dimensional assessment under load conditions.MethodsA total of 100 limbs (50 in the RPD group, 50 in the control group) were retrospectively analyzed. In the RPD group, we included limbs with recurrent patellar dislocation, characterized by dislocations occurs at least two times, while healthy limbs served as the control group. We used EOS technology, including 2D and 3D imaging, to measure and compare the following parameters between the two groups in a standing position: Femoral neck shaft angle (NSA), Mechanical femoral tibial angle (MFTA), Mechanical lateral distal femoral angle (mLDFA), Medial proximal tibial angle (MPTA), Anatomical femoral anteversion (AFA), External tibial torsion (ETT), and Femorotibial rotation (FTR).ResultsThe significant differences between the two groups were shown in NSA 3/2D, MFTA 3/2D, mLDFA 3/2D, MPTA 3D, AFA, FTR. No significant difference was shown in MPTA 2D, ETT between the RPD group and the control group. Further binary logistic regression analysis. Further binary logistic regression analysis was conducted on the risk factors affecting RPD mentioned above. and found four risk factors for binary logistic regression analysis: mLDFA (3D), AFA, NSA(3D), and FTR.ConclusionsEOS imaging identified abnormal LEA parameters, including NSA, MFTA, mLDFA, MPTA, AFA, and FTR, as risk factors for RPD. Children with these risk factors should receive moderate knee joint protection.

Background and Objectives: Studies analyzing lower extremity alignment (LEA) LEA among taekwondo subdisciplines athletes are lacking. This study compared LEA in the dominant and nondominant legs intaekwondo athletes. Materials and Methods: Twelve measurements of LEA were analyzed for 157 athletes (63 sparring, 50 demonstration, and 44 poomsae athletes) registered with the Korea Taekwondo Association. LEA was measured in the standing, supine, and prone positions using alignment application, a goniometer, a bubble inclinometer, a height gage, and a palpation meter. Results: The analysis revealed that the dominant leg of poomsae athletes showed greater genu valgum alignment than that of sparring athletes (p < 0.01), whereas the dominant leg of sparring athletes showed greater rearfoot varum alignment than that of demonstration athletes (p < 0.01). Furthermore, the nondominant leg of poomsae athletes showed greater genu valgum alignment than that of sparring and demonstration athletes (p < 0.01), whereas the nondominant leg of sparring athletes showed greater rearfoot varum alignment than that of demonstration athletes (p < 0.01). In addition, demonstration athletes had better forefoot varus alignment than poomsae athletes (p < 0.01). Conclusions: This study revealed that LEA characteristics vary among taekwondo athletes according to their subdiscipline. The results of this study would help in designing training programs tailored to each subdiscipline that would best address their LEA characteristics and help to prevent injuries.

Background: Alignment and rotation of the lower extremities have been suggested to be predisposing pathologic factors for patellar instability. Purpose: To elucidate the relationship between the lower limb alignment and lower extremity rotation in patients with patellar instability. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Included were 83 patients with patellar instability. Computed tomography scans and standing full-leg radiographs were used to measure the tibial tuberosity–trochlear groove (TT-TG) distance, mechanical femorotibial angle (mFTA), mechanical lateral distal femoral angle (mLDFA), mechanical medial proximal tibial angle (mMPTA), femoral torsion, and tibial torsion of the different segments. The relationships between femoral torsion, tibial torsion of the different segments, and the mFTA, mLDFA, and mMPTA were evaluated. The levels of tibial torsion and femoral torsion in patients with varus, normal, or valgus alignment were compared with 1-way analysis of variance and chi-square test. Results: The total tibial torsion was significantly associated with total femoral anteversion (r = 0.329; P =.002) and mFTA (r = –0.304; P =.005). There were no significant correlations between mFTA and TT-TG distance or femoral anteversion. Compared with patients with valgus malalignment, patients with varus malalignment tended to have higher tibial torsion. Conclusion: Tibial torsion was associated with leg axis alignment and femoral anteversion in patients with patellar instability. Patients with patellar instability, especially those with concurrent leg axis deformities, should undergo further radiological imaging so that tibial torsion can be assessed and a diagnosis of torsion deformity made early in the treatment pathway and the proper surgical plan formulated. [ABSTRACT FROM AUTHOR]

Objective: To develop and validate a convolutional neural network (CNN) capable of predicting the anatomical landmarks used to calculate the hip-knee-ankle angles (HKAAs) from radiographs and thereby quantify lower extremity alignments in children. Materials and methods: A search of the image archive at a large children's hospital was conducted to identify full-length lower extremity radiographs performed in children (≤ 18 years old) for the indication of lower extremity alignment (7/2019–10/2019). A radiologist manually labeled each radiograph's six requisite anatomical landmarks used to measure HKAAs (bilateral centers of the femoral head, tibial spine, and tibial plafond) and defined the resultant labels as ground truth. A 2D heatmap was generated for each ground truth landmark to encode the pseudo-probability of a landmark being at a particular location. A CNN was developed for indirect landmark localization by regressing across a collection of these heatmaps. The landmarks predicted from this model were used to calculate the HKAAs. Absolute prediction error and intraclass correlation were used to assess the accuracy of the HKAA estimates. Results: The study cohort consisted of 528 radiographs from 517 patients (mean age = 10.8 years, SD = 4.2 years). Evaluation of this CNN showed few HKAA prediction outliers (12/1056 [1.1%]), defined as having an absolute prediction error of > 10°. Excluding these outliers, the study cohort's mean absolute prediction error for the HKAA was 0.94° ± 0.84°, and the intraclass correlation between the ground truth and prediction was 0.974. Conclusion: The proposed CNN generated promising results and offers potential for using this model as a computer-aided diagnostic tool. [ABSTRACT FROM AUTHOR]

Purpose: Taekwondo is a martial art and contact sport in which the athletes’ goal is to strike the opponent with maximal force. This fact exposes taekwondo practitioners to the permanent risk of injuries. Therefore, the current prospective study aimed to investigate the internal risk factors of lower extremity injuries in the adolescent male taekwondo players. Methods: In total, 60 adolescent taekwondo players of Iran Premier League voluntarily participated in this research. Before league commencement, navicular drop, Q angle, knee hyperextension angle, the dorsiflexion/plantarflexion range of motion, hamstring flexibility, and their dynamic balance were measured. Then, the injuries of these taekwondo players were recorded during the study time. Results: The injury incidence rate was 7.9 per 1000 hours of exposure (95% confidence interval, 5.33-10.40). The logistic regression analysis data indicated a significant relationship between the Q angle and injuries incidence rate (odds ratio=1.33, P=0.031). The taekwondo players whose Q angles were >14.5 degrees were 1.33 times more prone to lower limb injury. However, no significant relationship was observed between the other risk factors of the study cases and injuries incidence. Conclusion: Regarding the research findings, the Q angle could predict lower limb injuries in the studied taekwondo players. Therefore, it is suggested that this index be considered in the preparticipation evaluation process and preventive strategies.

Abstract Background We assessed the morphological differences in the knee joint related to knee rotation angle in patients with hip dysplasia. These results may explain the anatomy of the knee in patients with hip dysplasia and aid in planning knee surgery. Methods We enrolled 73 women (146 legs, 35.6 ± 9.0 years) with bilateral hip dysplasia and 45 healthy women (90 legs, 49.0 ± 18.9 years) without lumbago, knee symptoms, or osteoarthritic findings of the knee or spine on plain radiographs. We examined the parameters affecting knee rotation angle, such as the condylar twist angle and femoral condyle measurements with a three-dimensional bone model using the correlation coefficients of each parameter. Results The condylar twist angle and the length of the posterior part of the lateral femoral condyle were statistically positively correlated with knee rotation angle in both the normal (condylar twist angle: r = 0.286, p = 0.007, posterolateral: r = 0.429, p

Background: To the best of our knowledge, no prior studies have identified any risk factors for subchondral insufficiency fractures of the medial tibial condyle. This study aimed to explain relationships between subchondral insufficiency fractures of the medial tibial condyle and the meniscus status, lower extremity alignment, or osteoporosis., Methods: This retrospective study included 325 consecutive patients whose chief complaint is knee joint pain and who had visited one institution between April 2016 and March 2021, of which 70 patients (8 men and 62 women) who had suspected subchondral insufficiency fractures of the medial tibial condyle had undergone magnetic resonance imaging and radiographic examination. These patients were divided into two groups based on the results of their magnetic resonance imaging: the insufficiency fracture group included 46 patients who had subchondral insufficiency fractures of the medial tibial condyle and the nonfracture group included 24 patients without fractures. The meniscus injury and medial meniscus extrusion (MME) were evaluated by using magnetic resonance imaging. The Kellgren-Lawrence grade, the femorotibial angle, and the percent mechanical axis (%MA) were evaluated with the use of knee radiographs. T-scores were also measured by using dual-energy X-ray absorptiometry with a bone densitometer., Results: MME were significantly larger and the %MA was significantly smaller in the insufficiency fracture group than that in the nonfracture group. The prevalence of medial meniscus injuries and pathological MME were higher in the insufficiency fracture group than those in the nonfracture group. The prevalence of varus knee and osteoporosis did not vary remarkably different between the two groups., Conclusion: The patients who had insufficiency fractures of the medial tibial condyle tended to have medial meniscus extrusion., Competing Interests: Declaration of competing interest The authors declare no conflicts of interest., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Background and Purpose: Osteoarthritis (OA) leads to destruction of cartilage and mal-alignment of structures in the knee joint leading to anatomic alterations of the joint. It has been identified that mal-alignment in the lower extremity is a potential factor that increases the risk of acute injury and osteoarthritis. Therefore, the purpose of this study was to determine the relationship among selected lower extremity alignment variables in individuals with osteoarthritis of the knee. Methods: A total of 40 individuals (mean ± SD age of 56.35 ± 9.70) with knee Osteoarthritis (KOA) were recruited in this cross sectional observational study. Six anatomical alignment characteristics (Quadriceps angle, Tibiofemoral angle, Tibial Torsion, Femoral anteversion, Genu recurvatum, Navicular drop) were measured on the left and right lower extremities of each participant. Results: There was no significant relationship (P>0.05) among the lower extremity alignment variables in subjects with unilateral symptomatic KOA. There was a significant relationship between Femoral anteversion and Genu recurvatum (r= -0.443, p= 0.039) and between Tibiofemoral angle and Tibial torsion angle (r= -0.445, p= 0.038) respectively in the left and right limbs of participants with symptomatic bilateral KOA. There was also a significance gender difference for Femoral anteversion (t= -2.803, p= 0.016) and Navicular drop (t= 2.335, p= 0.038) in participants with unilateral symptomatic right KOA and significance in gender difference for Quadriceps angle (t= -2.148, p= 0.044) in the right limb of participants with bilateral symptomatic KOA. Discussion: Mal-alignment of the lower extremity exists in individuals with unilateral and bilateral symptomatic KOA. Therefore, emphasis should be placed on not only correcting mal-alignments at the knee but also correcting mal-alignment at other segments of the lower extremity so as to further prevent disease progression in the affected and unaffected limb.

Abstract Background Humans support their bodies exclusively by vertical balance in bipedal locomotion, and the body, especially the lower extremity, generally changes with age. Sex and body constitution are assumed to be associated with lower extremity alignment, but this association remains to be elucidated. This study sought to clarify this association in healthy, elderly, non-obese humans in a Japanese population. Methods The present study investigated 55 healthy volunteers (mean age: 70 ± 6 years). A 3D extremity alignment system was applied under weight-bearing conditions on biplane long lower extremities X-rays using a 3D-to-2D image registration technique. The evaluation parameters included 3D hip-knee-ankle angle (3DHKA) alignment in the coronal (coronal alignment) and sagittal planes (sagittal alignment) and rotational alignment between the femur and tibia. The influences of sex and body constitution on all the alignment were analyzed. Results Multiple linear regression analysis with the dependent variable of each alignment showed that sex was the dominant factor for coronal and rotational alignment (coronal: p

Abstract Background We previously described that the anteroposterior (AP) axis of the tibia is approximately perpendicular to the transverse axis of the anterior pelvic plane (APP) in the standing position in healthy subjects. The purpose of this study was to investigate the rotational alignment between the APP and clinical epicondylar axis and the AP axis of the tibia relative to pelvic coordination in the standing position in normal subjects and in women with developmental dysplasia of the hip (DDH) to aid decision making for surgeons in the alignment of implants in total hip or knee arthroplasty. Methods This study included 77 Japanese women. Twenty-nine in the DDH group underwent curved periacetabular osteotomy; 48 women without lumbago and knee pain were included in the normal group. Femoral neck anteversion (FNA), condylar twist angle, and knee rotation angle were measured in femoral coordination. The angle between the femoral neck axis and clinical epicondylar axis (CEA) was measured, the transverse axis of the APP was also measured, and the angle between the AP axis of the tibia and transverse axis of the APP was calculated. Results There was a moderate negative correlation between FNA and CEA relative to the APP. This finding indicated a trend towards greater FNA leading to more internal rotation. Knee rotation angle (KRA) relative to the APP was 1.65° ± 5.58° in the normal group and − 2.65° ± 7.57° in the DDH group. This finding indicated that the tibia AP axis was approximately perpendicular to the APP in the standing position both in the normal and DDH groups. Conclusion We found that the tibia AP axis was at approximately a right angle to the transverse axis of the APP in the standing position in both the normal and DDH groups, while the KRA was different in the normal and DDH groups. These findings may prove helpful for positional alignment investigations needed for implantation in total hip or knee arthroplasty and gait analysis.

Purpose: Changes in lower extremity alignment in individuals with abnormality of this segments are unclear. The present study aimed to compare lower extremity alignment in subjects with genu valgum and genu varum deformities and healthy subjects in order to understand the lower extremity alignment changes in this group. Methods: This was a causal-comparative study. The sample comprised 120 males selected by convenience sampling method. In total, 40 subjects were assigned to genu valgum group, 40 to genu varum group, and 40 to healthy subject group. Lower extremity alignment was evaluated in anteversion of hip, Q angle, internal and external rotation of hip, knee hyperextension, tibial torsion, tibia vara, and foot arch index, at the laboratory of Tehran University, Tehran, Iran. To compare the mean score of variables between the groups, 1-way Analysis of Variance (ANOVA) was used. The obtained data were analyzed by SPSS. Results: The internal rotation of hip, Q angle, anteversion of hip, knee hyperextension and plantar arch index were significantly higher in the subjects with genu valgum deformity, compared to the subjects with genu varum deformity. The tibia vara value was significantly higher in the subjects with genu varum deformity than those with genu valgum deformity. However, no significant differences was found between the tibial torsion and external rotation of hip in the study groups. Conclusion: The lower extremity alignment changes in the subjects with genu valgum deformity included increased anteversion, Q angle, flatfoot, knee hyperextension, and internal rotation of the hip. Also, the changes in the subjects with genu varum deformity included decreased Q angle, internal rotation of hip, knee hyperextension, but increased tibia vara, and foot arch.

Increased loading in a localized area is a possible cause of pain-related osteochondral lesions of the talus (OLT), but the reported effects of realignment surgery for OLT have been anecdotal. Moreover, no report of realignment surgery for OLT could be found in the English literature. This study reviewed previous articles on lower extremity alignment and OLT to determine if OLT can be treated with realignment surgery. [ABSTRACT FROM AUTHOR]

Increased loading in a localized area is a possible cause of pain-related osteochondral lesions of the talus (OLT), but the reported effects of realignment surgery for OLT have been anecdotal. Moreover, no report of realignment surgery for OLT could be found in the English literature. This study reviewed previous articles on lower extremity alignment and OLT to determine if OLT can be treated with realignment surgery. [ABSTRACT FROM AUTHOR]

Abstract Background We previously reported that the clinical epicondylar axis (CEA) was approximately parallel to the transverse axis of the anterior pelvic plane (APP) in the standing position in normal subjects. The purpose of this study was to investigate the rotational alignment between APP in the standing position and the anteroposterior (AP) axis of the tibia relative to pelvic coordination in normal subjects. Methods This study included 68 healthy Japanese, 24 males and 44 females, without lumbago and knee pain. Femoral neck anteversion (FNA), condylar twist angle, and knee rotation angle were measured in femoral coordination. The angle between the femoral neck axis and CEA transverse axis of APP was also measured, and the angle between the AP axis of the tibia and the transverse axis of APP was calculated. The mean value of knee rotation angle was 0.23° and 2.06° in male and female subjects, respectively. Results There was a moderate positive correlation between FNA and the femoral axis angle relative to the transverse axis of APP. The knee rotation angle relative to APP was 0.33° and 1.56° in male and female subjects, respectively, and the tibia AP axis was approximately perpendicular to the transverse axis of APP in the standing position. Regarding validation, we obtained high interclass correlation coefficients for both intraobserver and interobserver reliability. Conclusion We found that the knee rotation angle was almost 0° and that the tibia AP axis was approximately perpendicular to the CEA. The tibia AP axis was also approximately perpendicular to the transverse axis of the APP in standing position.

Objectives: Recurrent patellar dislocation (RPD) greatly affects active young individuals, necessitating the identification of risk factors for a better understanding of its cause. Previous research has connected RPD to lower limb alignment (LEA) abnormalities, such as increased femoral anteversion, tibial external rotation, knee valgus, and flexion. This study aims to use EOS technology to detect RPD-related LEA anomalies, enabling three-dimensional assessment under load conditions., Methods: A total of 100 limbs (50 in the RPD group, 50 in the control group) were retrospectively analyzed. In the RPD group, we included limbs with recurrent patellar dislocation, characterized by dislocations occurs at least two times, while healthy limbs served as the control group. We used EOS technology, including 2D and 3D imaging, to measure and compare the following parameters between the two groups in a standing position: Femoral neck shaft angle (NSA), Mechanical femoral tibial angle (MFTA), Mechanical lateral distal femoral angle (mLDFA), Medial proximal tibial angle (MPTA), Anatomical femoral anteversion (AFA), External tibial torsion (ETT), and Femorotibial rotation (FTR)., Results: The significant differences between the two groups were shown in NSA 3/2D, MFTA 3/2D, mLDFA 3/2D, MPTA 3D, AFA, FTR. No significant difference was shown in MPTA 2D, ETT between the RPD group and the control group. Further binary logistic regression analysis. Further binary logistic regression analysis was conducted on the risk factors affecting RPD mentioned above. and found four risk factors for binary logistic regression analysis: mLDFA (3D), AFA, NSA(3D), and FTR., Conclusions: EOS imaging identified abnormal LEA parameters, including NSA, MFTA, mLDFA, MPTA, AFA, and FTR, as risk factors for RPD. Children with these risk factors should receive moderate knee joint protection., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Miao, Cai, Zhang and Cai.)

Purpose The aim of our explorative study was to compare the differences in the coronal alignments of the hip, knee and ankle on the slip side and non-slip sides in patients with slipped capital femoral epiphysis (SCFE). Methods The study group consisted of 28 patients. On the full-length standing radiographs, measurements of articulo- trochanteric distance (ATD), neck-shaft angle (NSA), femoral offset, hip-knee-ankle axis, femur-tibial angle, mechanical axis deviation ratio (MAD-r), anatomical medial proximal femoral angle (aMPFA), mechanical lateral proximal femoral angle (mLPFA), anatomical lateral distal femoral angle (aLDFA), mechanical lateral distal femoral angle (mLDFA), knee joint line congruency angle, mechanical medial proximal tibial angle (mMPTA), mechanical lateral distal tibial angle (mLDTA), ankle joint line orientation angle (AJOA), and leg length discrepancy (LLD) were performed. The data from the slip side were compared with those from the non-slip side. Results At skeletal maturity, there were significant differences between the slip side and non-slip side in ATD (p <0.001), NSA (p <0.001), MAD-r (p <0.001), aMPFA (p <0.001), aLDFA (p = 0.03), mLDFA (p = 0.04), mLDTA (p = 0.02), AJOA (p <0.001) and LLD (p<0.001). Conclusion Residual deformity in the proximal femur after epiphyseal slip and premature epiphysiodesis could cause changes in the coronal alignment of the lower extremity. We can add lower extremity alignment examination to follow-up protocol to rule out secondary problems in patients with SCFE. [ABSTRACT FROM AUTHOR]

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Purpose: Abnormalities of lower extremity alignment (LEA) in recurrent patella dislocation (RPD) have been studied mostly by two-dimensional (2D) procedures leaving three-dimensional (3D) factors unknown. This study aimed to three-dimensionally examine risk factors for RPD in lower extremity alignment under the weight-bearing conditions.Methods: The alignment of 21 limbs in 15 RPD subjects was compared to the alignment of 24 limbs of 12 healthy young control subjects by an our previously reported 2D-3D image-matching technique. The sagittal, coronal, and transverse alignment in full extension as well as the torsional position of the femur (anteversion) and tibia (tibial torsion) under weight-bearing standing conditions were assessed by our previously reported 3D technique. The correlations between lower extremity alignment and RPD were assessed using multiple logistic regression analysis. The difference of lower extremity alignment in RPD between under the weight-bearing conditions and under the non-weight-bearing conditions was assessed.Results: In the sagittal and coronal planes, there was no relationship (statistically or by clinically important difference) between lower extremity alignment angle and RPD. However, in the transverse plane, increased external tibial rotation [odds ratio (OR) 1.819; 95% confidence interval (CI) 1.282-2.581], increased femoral anteversion (OR 1.183; 95% CI 1.029-1.360), and increased external tibial torsion (OR 0.880; 95% CI 0.782-0.991) were all correlated with RPD. The tibia was more rotated relative to femur at the knee joint in the RPD group under the weight-bearing conditions compared to under the non-weight-bearing conditions (p < 0.05).Conclusions: This study showed that during weight-bearing, alignment parameters in the transverse plane related to the risk of RPD, while in the sagittal and coronal plane alignment parameters did not correlate with RPD. The clinical importance of this study is that the 3D measurements more directly, precisely, and sensitively detect rotational parameters associated with RPD and hence predict risk of RPD.Level Of Evidence: III. [ABSTRACT FROM AUTHOR]

Background: Malalignment of the lower extremity is commonly seen in patients with severe osteoarthritis undergoing total knee arthroplasty (TKA) and is believed to play a role in quadriceps strength loss. Deformity correction is typically achieved through surgical techniques to provide appropriate ligamentous balancing. Therefore, this study examined the influence of change in lower extremity alignment on quadriceps strength outcomes after TKA.Methods: Seventy-three participants (36 male; mean age, 62 years; and mean body mass index, 29.7 kg/m2) undergoing primary unilateral TKA were used in this investigation. Before surgery and at 1 and 6 months after surgery, measures of isometric knee extensor strength, quadriceps activation, and long-standing plain films were collected. Using the films, measures of mechanical axis, distal femoral angle (DFA), proximal tibial angle, and patellofemoral angle were performed. Hierarchical linear regression was used to evaluate how change in alignment from baseline to 1 and 6 months influenced the change in quadriceps strength.Results: DFA was found to significantly contribute to changes in quadriceps strength at 1 and 6 months after TKA above those contributed by associated covariates. None of the other measures of lower extremity alignment were found to contribute to quadriceps strength in this sample.Conclusion: Reductions in quadriceps strength experienced after TKA are likely to be influenced by changes in lower extremity alignment. Specifically, measures of DFA were found to significantly contribute to these changes. Future work is needed to prospectively examine measures of lower extremity alignment change and recovery after TKA. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study was to determine the predictor factors concerning the lower extremity alignment in non-contact anterior cruciate ligament (ACL) injuries among male athletes.Methods: In a retrospective study, the unilateral navicular drop, the ankle dorsiflexion range of motion (ROM), internal tibia torsion, knee genu recurvatum, quadriceps angle, hip internal and external rotation ROM and hip anteversion were measured in 53 subjects with complete ACL injury and compared with these accepted standard values. To identify predictor factors for lower extremity alignment and non-contact ACL injuries in male athletes, a multiple logistic regression analysis method was performed. All the subjects were primarily assessed with activity modification and without an ACL reconstruction.Results: The results of this study showed significant predictor correlations between the independent variables, ankle dorsiflexion, hip internal rotation and hip anteversion (p < 0.05). However, the differences in navicular drop, internal tibia torsion, knee hyperextension, Q angle and hip external rotation were non-significant.Conclusion: According to these findings, a decreased ROM in ankle dorsiflexion, hip internal rotation and increased hip anteversion appeared to be statistically significant predictors for developing non-contact ACL ligament injuries in male athletes. Based on the results of this study, significant predictor factors between lower extremity alignment and ACL injuries are clinically relevant as it confirms the existence of increased injury risk with certain patterns of skeletal alignment.Level Of Evidence: II. [ABSTRACT FROM AUTHOR]

Purpose: To characterize femoral deformities and determine sex differences in varus knee osteoarthritis (OA), femoral morphology and limb alignment were evaluated by using three-dimensional (3D) assessment, comparing healthy, elderly volunteers with osteoarthritic knees.Methods: A total of 178 lower limbs of 169 subjects with knee osteoarthritis (136 women, 33 men; mean age 74.9 ± 5.2 years) and 80 lower limbs of 45 healthy, elderly subjects (24 women, 21 men; mean age 65 ± 4.9 years) were examined. A 3D extremity alignment assessment system was used to examine the subjects under weight-bearing conditions on biplanar long-leg radiographs using a 3D-to-2D image registration technique. The evaluation parameters were (1) femoral bowing in the coronal plane, (2) femoral bowing in the sagittal plane, (3) femoral neck anteversion, (4) hip-knee-ankle angle, and (5) femoral torsion.Results: Higher femoral lateral bowing and slightly higher femoral internal torsion in the proximal diaphysis were observed in women with OA compared with healthy subjects. No difference in the higher varus malalignment, no alteration in the femoral anterior bowing, and no difference in the lower femoral neck anteversion were found between men and women when comparing healthy and OA subjects.Conclusions: The higher femoral lateral bowing and slightly higher femoral internal torsion in the proximal diaphysis in women are possibly a structural adaptation to mechanical use. The clinical significance is that the femoral deformities and the sex differences in knee OA have the potential to improve the understanding of the aetiology of primary varus knee OA.Level Of Evidence: IV. [ABSTRACT FROM AUTHOR]

Very little is known about the relationship between proximal joint alignment and hallux valgus among young dancers. This study sought to determine the extent to which spinal and lower extremity alignments are involved in hallux valgus, and to identify predicting variables for its development in young dancers. A group of 1336 young female dancers aged 8-16 years, and 226 control participants of the same age cohort were screened for the presence of hallux valgus, body physique characteristics, joint range of motion, and anatomical anomalies. Hallux valgus was common in the 2 young female populations studied. Among the dancers, 40.0% had bilateral hallux valgus and 7.3% unilateral. Among the controls, 32.3% had bilateral and 1.8% unilateral hallux valgus (χ2=8.27, df=1, p=0.004). Following logistic regression analysis, age (OR=1.028, 95% CI=0.968-1.091), genu varum (OR=1.514; CI=1.139-2.013) and scoliosis (OR=2.089; CI=1.113-3.921) were found to be significant predicting factors for hallux valgus in the dancer group, whereas in the control group, the predicting factors were age (OR=0.911, 95% CI=0.801-1.036) and ankle plantar flexion range of motion (OR=0.972; CI=0.951-0.992). In conclusion, it was found that spinal deformity, lower extremity alignment, and joint range of motion are strongly related to hallux valgus. [ABSTRACT FROM AUTHOR]

Abstract: Lower limb malalignment is a common cause of disability that increases risk of osteoarthritis (OA). Treatment of OA may require an osteotomy or arthroplasty, which mandate accurate evaluation of mechanical loading on the limbs to achieve optimal alignment and minimal implant wear. Surgical planning uses a conventional method of mechanical axis deviation (MADC) measured from the center of the femoral head to the center of the ankle. This method fails to account for hindfoot deformity distal to the ankle. We used a computer model to compare MADC with the ground mechanical axis deviation (MADG), drawn from the center of the hip to the ground reaction point. Average anatomic measurements were analyzed with a range of knee and hindfoot angle variation in single leg stance, double leg stance, toe off and heel strike. MADG was consistently higher than MADC, suggesting a more complete estimate of weight-bearing axis that considers hindfoot deformity. [Copyright &y& Elsevier]

Context: A single measure of knee laxity (ie, measurement of laxity in a single plane of motion) is probably inadequate to fully describe how knee joint laxity is associated with anterior cruciate ligament injury. Objective: To characterize interparticipant differences in the absolute and relative magnitudes of multiplanar knee laxity (ie, sagittal, frontal, and transverse planes) and examine physical characteristics that may contribute to these differences. Design: Descriptive laboratory study. Setting: University research laboratory. Patients or Other Participants: 140 participants (90 women, 50 men). Main Outcome Measure(s): Using cluster analysis, we grouped participants into distinct multiplanar knee laxity profiles based on the absolute and relative magnitudes of their anterior knee laxity (AKL), genu recurvatum (GR), and varus-valgus (VV) and internal-external rotation (IER) knee laxity. Using multinomial logistic regression, we then examined associations between the different laxity profile clusters and physical characteristics of sex, age, activity level, general joint laxity, body mass index, thigh strength, and 8 measures of lower extremity anatomical alignment. Results: Six clusters were identified: low (LOW), moderate (MOD) and high (HIGH) laxity overall and disproportionally higher W/IER (MODW/IER), GR (HIGHGR), and AKL (HIGHAKL) laxity. Once all other physical characteristics were accounted for, the LOW cluster was more likely to be older, with longer femur length. Clusters with greater magnitudes of W and IER laxity were more likely to be younger and to have lower body mass index, smaller Q-angle, and shorter femur length (MOD, HIGH, MODW/IER) and less thigh strength (HIGH). The HIGHGR cluster was more likely to be female and to have a smaller tibiofemoral angle and longer femur length. The HIGHAKL cluster was more likely to have greater hip anteversion and navicular drop. Conclusions: The absolute and relative magnitudes of a person's multiplanar knee laxity are not always uniform across planes of motion and can be influenced by age, body composition, thigh strength, and structural alignment. Except in HIGHGR, sex was not a significant predictor of cluster membership once other physical characteristics were taken into account. [ABSTRACT FROM AUTHOR]

Summary: Objective: The recent recognition of the correlation of the hip–knee–ankle angle (HKA) with femur–tibia angle (FTA) on a standard knee radiograph has led to the increasing inclusion of FTA assessments in OA studies due to its clinical relevance, cost effectiveness and minimal radiation exposure. Our goal was to investigate the performance metrics of currently used methods of FTA measurement to determine whether a specific protocol could be recommended based on these results. Methods: Inter- and intra-rater reliability of FTA measurements were determined by intraclass correlation coefficient (ICC) of two independent analysts. Minimal detectable differences were determined and the correlation of FTA and HKA was analyzed by linear regression. Differences among methods of measuring HKA were assessed by ANOVA. Results: All five methods of FTA measurement demonstrated high precision by inter- and intra-rater reproducibility (ICCs≥0.93). All five methods displayed good accuracy, but after correction for the offset of FTA from HKA, the femoral notch landmark method was the least accurate. However, the methods differed according to their minimal detectable differences; the FTA methods utilizing the center of the base of the tibial spines or the center of the tibial plateau as knee center landmarks yielded the smallest minimal detectable differences (1.25° and 1.72°, respectively). Conclusion: All methods of FTA were highly reproducible, but varied in their accuracy and sensitivity to detect meaningful differences. Based on these parameters we recommend standardizing measurement angles with vertices at the base of the tibial spines or the center of the tibia and comparing single-point and two-point methods in larger studies. [Copyright &y& Elsevier]

We asked 12 healthy women to perform a single leg landing on a force plate from a 40 cm board with three lower extremity alignments, Neutral, Knee-in & Toe-out and Knee-out & Toe-in, and electromyographic data and ground reaction force were measured. The maximum muscle discharge and the integral of the rectus femoris muscle, the integral of the lateral vastus muscle and the ground reaction force to inside of the body in the conditions of Kneein & Toe-out were significantly larger than those in Neutral. The ground reaction force to outside of the body in Kneeout & Toe-in was significantly large. The results show that by contracting the rectus femoris and lateral vastus muscles, the tibia is drawn out, and a shear force occures on the inside of the tibia in response to the ground reaction force received by the femur in the Knee-in & Toe-out condition. Thus we consider that ACL damage happens easily. In the Knee-out & Toe in conditions, we consider ACL damage can happen easily because in addition to raising the extension force on the ACL through rotation of the lower leg, a shear force occurs on the outside of the tibia in reaction to the femur. [ABSTRACT FROM AUTHOR]

Context: Little is known about the effects of static alignment on neuromuscular control of the knee during dynamic motion. Objective: To evaluate the isolated and combined effects of quadriceps angle (QA) and navicular drop (ND) on neuromuscular responses to a weight-bearing perturbation. Design: Mixed-model, repeated-measures design. Setting: Sports medicine and athletic training research laboratory. Patients or Other Participants: Seventy-nine National Collegiate Athletic Association Division I collegiate female athletes, classified with below-average ND and QA (LND-LQA); below-average ND and above-average QA (LND-HQA); above-average ND and below-average QA (HND-LQA); or above-average ND and QA (HND-HQA). Intervention(s): A lower extremity perturbation device produced a forward and either internal or external rotation of the trunk and femur on the weight-bearing tibia to evoke a reflex response. Main Outcome Measure(s): Neuromuscular responses were examined in the quadriceps, hamstrings, and gastrocnemius muscles: preperturbation amplitude 50 milliseconds before the perturbation, reflex time, and postperturbation amplitude 150 milliseconds immediately postperturbation. Results: Navicular drop had the greatest effect on preperturbation amplitude of the lateral hamstrings and postperturbation amplitude of all muscles, with greater activation amplitude noted in subjects in the HND classifications. Quadriceps angle primarily affected reflex time of the quadriceps; in subjects with LQA, reflex time was faster for internal rotation than external rotation perturbations. The interaction between ND and QA had the greatest effect on reflex time of the lateral hamstrings.For internal rotation perturbations, subjects in the LND classifications had faster reflex times in the lateral hamstrings if they had HQA values rather than LQA values. With external rotation perturbations, HND-LQA subjects had slower reflex times than those in all other alignment classifications. Conclusions: Navicular drop and QA have both independent and interactive effects on neuromuscular responses to a weight-bearing, rotational perturbation. These interactive effects highlight the importance of considering the entire lower extremity posture rather than a single alignment characteristic, given the potential for one alignment factor to compensate for or interact with another. [ABSTRACT FROM AUTHOR]

Objective: Imageless computer assisted total knee surgical systems have commonly relied on determination of the functional rotational center of the femoral head as a landmark for determining the lower extremity mechanical axis. This has been accomplished through range of motion and center of rotation calculations for the femur with respect to the pelvis as the lower extremity is taken through a range of motion. Our study evaluated the use of this algorithm with and without a pelvic tracker attached to the iliac crest.Materials and Methods: The functional center of the hip joint was also compared to the true radiographic center as determined by spiral CT data. Evaluating the different methods on six lower extremities from three whole-body cadavers revealed significant differences in the location of the calculated hip joint center, but little difference in the resulting lower extremity mechanical axis determination. The functional hip joint centers measured with and without a pelvic tracker differed from one another and from the CT-determined hip center.Results: No differences were found in the coronal plane measurements, but statistically significant differences were found in the sagittal plane measurements.Conclusion: Algorithms that reduce the noise generated by pelvic movement should be devised to eliminate the need for a pelvic tracker.Parts of this research were previously presented at the Fourth Annual Conference of the International Society for Computer Assisted Orthopaedic Surgery (CAOS-International), in Chicago, Illinois, June 2004. [ABSTRACT FROM AUTHOR]

The article assesses the intratester and intertester reliability of clinical measures of lower extremity anatomic characteristics as well as its implications for multicenter studies. The researchers attempt to determine whether multiple examiners could be trained to measure lower extremity anatomic characteristics with acceptable reliability and precision. The investigators have measured various anatomic characteristics. Results have shown that all testers consistently measured each variable between test days. Finally, it can be affirmed that multiple investigators can be trained at different times to measure anatomic characteristics with good to excellent intratester reliability.

• Assistive devices are needed for rice farmers with pronated feet when working in mud. • Corrective insoles designed for disabled persons may also be applicable to rice farmers. • Investigation was conducted on standing barefoot and with insoles for different terrains. • Preliminary results demonstrated insoles to improve alignment and reduce invertor muscle force. Execution of strenuous activities in conjunction with slippery and viscous muddy working terrain in rice cultivation leads to a high prevalence of farmer musculoskeletal disorders and malalignments. Recommended intervention strategies originally designed for congenitally disabled individuals may also be applicable to farmers, including simple corrective wedges to reduce foot eversion. The objective of the present study was to conduct a preliminary investigation of the effects of corrective wedges on lower extremity muscle activity and alignment when subjects stood on flat rigid ground or muddy terrain, simulating typical work conditions encountered by the unique but populous Thai rice farming workforce. Nine healthy farmers with pronated feet were recruited to participate and wedges were custom fabricated for each farmer based on physical therapy assessment and use of rapid prototyping techniques. Participants were asked to stand barefoot or with wedges on the two surface types. Results revealed foot pronation and knee valgus to improve (ranging, on average between 5.5 and 16.1 degrees) when participants were equipped with corrective wedges. The muscle activity of the peroneus longus and the tibialis anterior increased for muddy terrain, as compared with the rigid surface. In general, the wedges induced less tibialis anterior activity and greater peroneus longus activity, compared to when participants were standing barefoot. An elevation in evertor muscle activity may reflect stretching of the shortened muscle as a result of the reduced degree of foot pronation. Findings demonstrate potential benefits of corrective insole usage for farmers with pronated feet, including improved lower extremity alignment and invertor muscle activity reduction for both rigid and muddy terrains. [ABSTRACT FROM AUTHOR]

Aim: The aim of this study was to derive a pure, unbiased, reliable and accurate objective relationship between the local knee axis measurements through a short knee anteroposterior roentgenogram and the lower limb axis measurement through an orthoroentgenogram., Patients and Methods: Radiographs of 114 patients (114 knees) were evaluated by two independent raters for measurement of lower limb axis on an orthoroentgenogram and the local knee axis on short knee anteroposterior X-ray, which was derived by cropping the orthoroentgenogram by a blinded radiology assistant. The raters measured at two different time-points separated by an interval of 30-day period. Intra-rater and inter-rater reliabilities were calculated by intra-class correlation coefficients and three models were built to establish the relationships of X-ray anatomical axis with orthoroentgenogram anatomical axis, orthoroentgenogram anatomical axis with orthoroentgenogram mechanical axis and X-ray anatomical axis with orthoroentgenogram mechanical axis., Results: For three different measurements, intra-class correlation coefficients of Rater 2 were higher than 0.90 which shows perfect reliability, while that for Rater 1 was low. Furthermore, first measurements were more consistent than the second measurement. There was a strong positive correlation in all the three models except for varus cases in the last., Conclusion: The standardized correlation derived between the two different techniques for measuring knee alignment is fairly comparable with the studies in the past and would serve as a reliable template for future studies concerning relationships between the two, in addition to helping knee surgeons make more reliable and accurate interpretations through local knee axis measurements., Competing Interests: Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2020.)

Objective: The aim of study was to analyze the association between Quadriceps Angle (QA) and plantar pressure, navicular height (NH), and calcaneo-tibial angle (CTA)., Methods: A total of 64 volunteers (mean age: 22.25 ± 2.54 (range:19-33)) participated in this cross sectional study. EMED-m (Novel GmbH, Germany) electronic pedobarograph was employed for dynamic plantar pressure measurement using two step protocol. The angle between the vertical axis of calcaneus and the long axis of Achilles tendon for CTA. The height of navicular tubercle from the ground was measured while the subject was standing on both feet for NH. QA was measured while the subject was standing in a relaxed posture where both feet bearing equal weight., Results: There were significant negative correlations between QA and maximum force (MxF) under the 4th. metatarsal head (MH4). The QA was also significantly correlated with MxF and force-time integral (FTI) under the bigtoe (BT). FTI under the 3rd. metatarsal head (MH3), MH4 and 5th. metatarsal head (MH5) were significantly negatively correlated with QA. Pressure-time integral (PTI) under the MH4 and MH5 were found to be significantly negatively correlated with QA. A significant correlation was also found between QA and NH (p < 0.0001), whilst there was no correlation between QA and CTA. Regression analysis showed that NH was appeared as the major contributor for the QA (β = -0.49, p < 0.001) in the dynamic condition, followed by BT-FTI (β = 0.37, p < 0.001) and MH5-MxF (β = -0.21, p < 0.037)., Conclusion: These findings may imply that the NH which can at least be controlled by appropriate shoe inserts may affect QA. This way, loading pattern of both plantar region and whole lower extremity may be altered., Level of Evidence: Level III, Diagnostic Study., (Copyright © 2018 Turkish Association of Orthopaedics and Traumatology. Production and hosting by Elsevier B.V. All rights reserved.)