Femoral Anteversion

Anteverted hip (Femoral Anteversion)
1. Internal rotation of the distal femoral condyles in relation to the femoral neck
2. Femoral head significantly anterior to Femoral neck
3. Associated with Toeing-In (normal in young child)
4. Antetorsion used to describe abnormal anteversion
Normal hip
1. Femoral head slightly anterior to Femoral neck
Retroverted hip
1. Femoral head posterior to Femoral neck
2. Associated with Toeing-Out

Excessive internal rotation of the femur
1. Internal rotation of the distal femoral condyles in relation to the femoral neck
Normal Femoral Neck Anteversion angles
1. Adults: 15-25 degrees
2. Children
  1. Newborn: 30 to 60 degrees
  2. Age 3-12 months: 39 degrees
  3. Age 1-2 years: 31 degrees

Standing appearance: "Kissing Patellae"
Clumsy gait
1. Running appearance: "Egg-Beater"
In-Toeing feet ("Pigeon-Toed")
W-Sitting Position (Inverted W)
1. Sitting with hips flexed and internally rotated (feet at either side of hips)
2. Contrast with most children who would typically sit cross legged
3. Does not worsen Femoral Anteversion, and most comfortable for children with Femoral Anteversion

Observe lower extremity via tunnel view
1. Create imaginary line longitudinally along femur
  1. Femoral neck
  2. Femoral shaft
  3. Midline Patella
  4. Webspace between second and third toes of foot
2. Survey foot from level of iliac crest at Pelvis
  1. In-Toeing of foot suggests Femoral Anteversion
  2. Compare for symmetry
Observe child's gait
1. See Foot Progression Angle (Gait Rotational Angle)
2. Patellae and feet point inward (kissing Patellae)
3. Results in a clumsy, Circumduction Gait
Measure rotation of hip
1. See Hip Rotation Evaluation in Children
2. Increased internal hip rotation (60 to 90 degrees)
3. Decreased external hip rotation (10 to 15 degrees)

Watchful waiting until age 8 years
1. Femoral Anteversion is a common cause of Intoeing in age 3 to 6 years
2. Spontaneously resolves in most children by age 8 years (up to age 11 years)
Avoid non-helpful measures
1. Shoe Modifications
2. Night splints
3. Dennis-Browne splint
4. Twister cables
5. Passive Stretching Exercises
6. Physical Therapy
Femoral Rotational Osteotomy Indications (orthopedic referral)
1. Comorbid neuromuscular disease (e.g. Cerebral Palsy) OR
2. Severe functional Disability at age >8 to 11 (0.1% of cases)
  1. Internal hip rotation >80 degrees

Spontaneously resolves to normal range in 80% of cases by age 8 years
Significant hip internal rotation is unlikely to resolve spontaneously after age 11 years
Compensatory lateral tibial torsion may occur