How much femoral anteversion & tibial torsion is too much?

[ElSquinto]

I'm not 100% certain this is the proper forum for this question - but I think it might be since it concerns whether or not specific surgical procedures are indicated.

I'm a 39 year-old male who, over the past 15 months, has begun to experience chronic anterior patellofemoral pain in both knees.

I have consulted two surgeons during this time period.  Both have stated that my pain is likely to result from "squinting patellae" - which I understand to arise from a combination of greater-than-normal femoral anteversion and greater-than-normal lateral tibial torsion which compensates for the femoral anteversion.

I have heard that derotational osteotomies can be performed to resolve these deformities when "the deformities are excessive".

Well that raises the question - how much femoral anteversion and lateral tibial torsion is considered "excessive"?  It's easy enough to get figures for "average" femoral anteversion and lateral tibial torsion - but I haven't seen figures that establish a threshold for when surgery is indicated or how frequently that threshold may be found in a population (i.e. so-and-so-many standard deviations).

All I know is that my left foot needs to be pointed outward ~45 degrees for my left knee cap to be pointing straight ahead and my right foot needs to be pointed outward about ~25 degrees for my right knee cap to point straight ahead.  And that both knees hurt.   

[Ivy973]

OMG -- I've been looking for someone who is in a similar situation to me! I have both chronic knee and hip pain -- very high levels.  I knew I had excessive femoral anteversion but had no idea I had excessive external tibial torsion as well until today    I know that normal femoral anteversion is 10-15. Version is considered excessive if its over 30. Do you know what you'rs is...?  Mine is 50!!!  I don't know anything about torsion as I have just discovered it.

What surgeons have you seen so far...?

[jenny1000]

Hi, I talked to drmark on here, and he said that he derotates if tibias are over 30-35 degrees, my OS also said that he derotates if tibias are over 35 degrees.  drmark also said that normal femoral rotation is 9-23 degrees internal (I'm pretty sure that was what he said, anyway), and he operates if femurs are less than 0 degrees i.e. any degree of external rotation.  You need to get a CT scan (a full length rotational CT scan, not just a normal one) to get these measurements.

[Ivy973]

Jenny -- thanks for replying!  I am beginning to believe I have no chocie but to get an FO, but may be spared a tibial osteotomy as my numbers there are around 27 and 30.

[jenny1000]

That's ok!  Make sure you get several opinions, see the best surgeon you possibly can, someone who specialises in bone abnormalities/derotation and patellofemoral problems.  Make sure it's someone who performs derotational osteotomies - one of the surgeons I saw said I definitely didn't need that surgery (before I got my CT) as he'd never met a surgeon who did it - nothing to do with my bones, just his inexperience in that subject.  Your surgeon will be able to advise on which operation/s you need.  Our tibias are very similar (mine are 27 and 29), and I don't need my tibias derotating.  I have no idea if just derotating your femurs would cause your feet to point too far in or out - your surgeon would be able to tell you this.  Good luck!

[ElSquinto]

OMG -- I've been looking for someone who is in a similar situation to me! I have both chronic knee and hip pain -- very high levels.  I knew I had excessive femoral anteversion but had no idea I had excessive external tibial torsion as well until today    I know that normal femoral anteversion is 10-15. Version is considered excessive if its over 30. Do you know what you'rs is...?  Mine is 50!!!  I don't know anything about torsion as I have just discovered it.

What surgeons have you seen so far...?

Sorry I didn't reply earlier...part of it had to do with my accidentally posting this question in the wrong forum.

My pain problems are about 90% knee (mostly left, but the right knee is starting to get irritated) and 10% right hip.  I don't have anything other than a "qualitative" diagnosis at this stage regarding my femoral neck anteversion (FNA).  I have been told that I have excess femoral neck anteversion and excess external tibial torsion.  It is possible that I might have a condition called "coxa valga" which is an excessively-high femoral neck-shaft angle.  It is also possible that I have slight hip dysplasia - one surgeon says "yes", one surgeon says "no".  And I'm a bit bow-legged, too.  And one surgeon believed that I might have high Q-angles, too.

To-date I've only had X-rays: AP Hip, Frog-Leg Hip, Faux-View Hip, and AP & Lateral Knee views.  As far as I know, none of these can really "quantity" any deformities - maybe apart from the Center-Edge angle that is used to assess certain hip dysplasia cases.

I've met with two surgeons.  Both appointments were beneficial in the sense that they raised the possibility that I had substantial deformities...but there was significant disagreement as to severity or whether surgical correction was a possibility.  The first surgeon suggested my deformities were severe...and nothing could be done to correct them.  The second surgeon admitted that there were surgical correction procedures (i.e. osteotomies) that could be done...but suggested that the degree of my deformities was not severe enough to warrant them.  Neither ordered any follow-up imaging tests.

I will be meeting with a third surgeon in February.  He is a "hip expert", rather than a "knee expert".  He acknowledges that my issues are predominantly knee-related, but he has done many femoral derotational osteotomies and is aware that excess FNA is often accompanied by excess external tibial torsion.  And he is very much a "'deformity correction" surgeon - this is not a guy who's going to offer to scope my knees and then prescribe me ten useless sessions of PT...

Hopefully it's a start.

[Tarlie86]

Hi all,

Do you or have you ever suffered lower back/lumbar pain with this?

Thanks

[laurenuk]

Hi all,

Do you or have you ever suffered lower back/lumbar pain with this?

Thanks

Hello! I suffer lower back pain due to my femoral anteversion, my consultant thinks its due to my legs not being able to constantly take the weight of everyday life so my back takes the brunt of it! Also gets worse in cold weather and I end up taking a day in bed (just like I am now)