CHAPTER 1 _____________________________________________ 111

Normal Lower Limb Alignment and Joint Orientation

To understand deformities of the lower extremity, it is Furthermore, for purposes of reference, these line
important to first understand and establish the parame- drawings should refer to either the frontal, sagittal, or
ters and limits of normal alignment. The exact anatomy transverse anatomic planes. The two ways to generate a
of the femur, tibia, hip, knee, and ankle is of great impor- line in space are to connect two points and to draw a line
tance to the clinician when examining the lower limb through one point at a specific angle to another line. All
and to the surgeon when operating on the bones and the lines that we use for planning and for drawing sche-
joints. To better understand alignment and joint orien- matics of the bones and joints are generated using one
tation, the complex three-dimensional shapes of bones of these two methods (~Fig.I-2).
and joints can be simplified to basic line drawings, sim-
ilar to the stick figures a child uses to represent a person
(~ Fig. I-I).

a. ~----------------------------------4t

b.
....................~ .
Fig. 1-2a,b
Two methods of drawing a line in space.
a Connect two points.
b Draw a line through one point at a specific angle to another
line.

Mechanical and Anatomic Bone Axes

Each long bone has a mechanical and an anatomic axis

(~Fig. 1-3). The mechanical axis of a bone is defined as
the straight line connecting the joint center points of the
proximal and distal joints. The anatomic axis of a bone
is the mid-diaphyseal line. The mechanical axis is always
a straight line connecting two joint center points, wheth-
Fig.1-1 er in the frontal or sagittal plane. The anatomic axis line
Axis lines. A stick figure can be used as a schematic of a com- may be straight in the frontal plane but curved in the
plex three-dimensional image of a person. In the same fashion, sagittal plane, as in the femur. Intramedullary nails
axis and joint lines can be used to describe alignment and joint (IMN) designed for the femur have a sagittal plane arc
orientation of the bones and joints of the lower limb. to reflect this. In the tibia, the anatomic axis is straight in

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_ CHAPTER 1 NormallowerLimbAlignmentandJointOrientation

a. b.

Mechanical axis Anatomic axis Mechanical axis Anatomic axis

c. d.

Mechanical axis Anatomic axis Mechanical axis Anatomic axis

Fig. 1-3 a-d Fig. 1-4 a, b ~

Mechanical and anatomic axes of bones. The mechanical axis a The tibial mechanical and anatomic axes are parallel but not
is the line from the center of the proximal joint to the center of the same. The anatomic axis is slightly medial to the me-
the distal joint. The mechanical axis is always a straight line chanical axis. Therefore, the mechanical axis of the tibia is
because it is always defined from joint center to joint center. actually slightly lateral to the midline of the tibial shaft. Con-
Therefore, the mechanical axis line is straight in both the fron- verse
y, the anatomic axis does not pass through the center
tal and sagittal planes of the femur and tibia. The anatomic of the knee joint. It intersects the knee joint line at the medi-
axis of a long bone is the mid-diaphyseal line of that bone. In al tibial spine.
straight bones (a,c), the anatomic axis follows the straight mid- b The femoral mechanical and anatomic axes are not parallel.
diaphyseal path. In curved bones (b,d),it follows a curved mid- The femoral anatomic axis intersects the knee joint line gen-
diaphyseal path. The anatomic axis can be extended into the erally 1 cm medial to the knee joint center, in the vicinity of
metaphyseal and juxta-articular portions of a bone by extend- the medial tibial spine. When extended proximally, it usual-
ing its mid-diaphyseal line in either direction. ly passes through the piriformis fossa just medial to the
greater trochanter medial cortex. The angle between the
femoral mechanical and anatomic axes (AMA) is 72.

both frontal and sagittal planes (~Fig. 1-3). Axis lines In the tibia, the frontal plane mechanical and ana-
are applicable to any longitudinal projection of a bone. tomic axes are parallel and only a few millimeters apart.
For practical purposes, we refer only to the two anatom- Therefore, the tibial anatomic-mechanical angle (AMA)
ic planes, frontal and sagittal. The corresponding radio- is 0 (~Fig. 1-4a). In the femur, the mechanical and an-
graphic projections are the anteroposterior (AP) and atomic axes are different and converge distally (~ Fig.
lateral (LAT) views, respectively. 1-4b). The normal femoral AMA is 72.

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 (HA PT ER 1 . Normal Lower Limb Alignment and Joint Orientation _

a.

Mechanical axis Anatomic axis

;V
Mechanical
~natomi
axis
c
axis

b.

Mechanical Anatomic
Mechanical axis Anatomic axis axis axis

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_ CHAPTER 1 NormalLowerLimbAlignmentandJointOrientation

iii

ii

b.

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

\. . _-- ,-. .; ., ./~Tr
-
of f,mo,., "oleh
. .
Modpo'"' of ',mo,., oo""~,,
/ -r."'. ..... . . . . . . . . . . . . Center of tibial spines
s:( '\
\\
' ~' "
......:::::...................../ ................ Midpoint of soft tissue outline

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

c.

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 CHAPTER 1 Normal Lower Limb Alignment and Joint Orientation _

Joint Center Points Joint Orientation Lines

As noted above, the mechanical axis passes through the A line can also represent the orientation of a joint in a
joint center points. Because the mechanical axis is con- particular plane or projection. This is called the joint ori-
sidered mostly in the frontal plane, we need to define entation line (~Fig. 1-6).
only the frontal plane joint center points of the hip, knee,
and ankle (~ Fig. 1-5). Moreland et al. (1987) studied the
joint center points of the hip, knee, and ankle. Ankle
For the hip, the joint center point is the center of the
circular femoral head. The center of the femoral head At the ankle, the joint orientation line in the frontal
can best be identified using Mose circles. Practically, we plane is drawn across the flat subchondral line of the tib-
can use the circular part of a goniometer to define this ial plafond in either the distal tibial subchondral line or
point (~Fig. I-Sa). for the subchondral line of the dome of the talus (~ Fig.
Moreland et al. (1987) evaluated different geometric l-6a). In the sagittal plane, the ankle joint orientation
methods to define the center of the knee joint. They line is drawn from the distal tip of the posterior lip to the
demonstrated that the center of the knee joint is approx- distal tip of the anterior lip of the tibia (~Fig.1-6b).
imately the same using a point at the top of the femoral
notch, the midpoint of the femoral condyles, the center
of the tibial spines, the midpoint of the soft tissue Knee
around the knee, or the midpoint of the tibial plateaus
(~Fig.l-Sb). Using the top of the femoral notch or tibi- The frontal plane knee joint line of the proximal tibia is
al spines is the quickest way to mark the knee joint cen- drawn across the flat or concave aspect of the subchon-
ter point without measuring the width of the bones or dral line of the two tibial plateaus (~Fig. 1-6c). The
soft tissues. frontal plane knee joint orientation line of the distal
Similarly, the ankle joint center point is the same femur is drawn as a line tangential to the most distal
whether measured at the mid-width of the talus, the points on the convexity of the two femoral condyles
mid-width of the tibia and fibula at the level of the pla- (~ Fig. 1-6d). In the sagittal plane, the proximal joint
fond, or the mid-width of the soft tissue outline (~ Fig. line of the tibia is drawn along the flat subchondral line
l-Sc). The mid-width of the talus or the plafond is the of the plateaus (~Fig.1-6e).In the sagittal plane, the dis-
easiest to use. tal femoral articular shape is circular. The distal femoral

""II Fig. 1-5 a-c Fig.1-6a-h ~

a The midpoint of the femoral head is best identified using a Ankle joint orientation line, frontal plane. Connect two
Mose circles (i). If these are unavailable, measure the longi- points at either end of the ankle plafond line.
tudinal diameter of the femoral head and divide it in two. b Ankle joint orientation line, sagittal plane. Connect two
Use this distance to measure from the medial edge of the points from anterior to posterior lip of joint.
femoral head. The center of the femoral head is located c Proximal tibial knee joint orientation line, frontal plane.
where the distance to the medial border of the femoral head Connect two points on the concave aspect of the tibial pla-
is the same as half of the longitudinal diameter (ii). Practi- teau subchondral line.
cally, we can use the circular part of a goniometer to define d Distal femoral knee joint orientation line, frontal plane.
this point (iii). r, radius. Draw a line tangent to the two most convex points on the
b The midpoint of the knee joint line corresponds to the mid- femoral condyles.
point between the tibial spines on the tibial plateau line and e Proximal tibial knee joint orientation line, sagittal plane.
the apex of the intercondylar notch on the femoral articular Draw a line along the fiat portion of the subchondral bone.
surface. These points are not significantly different from the Distal femoral joint orientation line, sagittal plane. Connect
mid condylar point of the distal femur and the mid plateau the two anterior and posterior points where the condyle
point of the proximal tibia (modified from Moreland et al. meets the metaphysis. For children, this is drawn where the
1987). growth plate exits anteriorly and posteriorly.
C The midpoint of the ankle joint line corresponds to the mid- 9 Neck of femur line, frontal plane. Draw a line from the cen-
point of the tibial plafond measured between the medial ar- ter of the femoral head through the mid-diaphyseal point of
ticular aspect of the lateral malleolus and the lateral articu- the narrowest part of the femoral neck.
lar aspect of the medial malleolus. The mid-width of the h Hip joint orientation line, frontal plane. Draw a line from the
talus and the mid-width of the ankle measured clinically proximal tip of the greater trochanter to the center of the
yield the same point (modified from Moreland et al.1987). femoral head.

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. . CHAPTER 1 NormalLowerLimbAlignmentandJointOrientation

b.
a.

d.
c.

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 CHAPTER 1 . NormalLower Limb Alignment and Joint Orientation _

e. I.

Growth plate Growth plate

open closed

g. h.

Fig. 1-6 a-h

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_ CHAPTER 1 NormalLowerLimbAlignmentandJointOrientation

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

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

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

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 CHA PIER 1 . Normll Lo," . Limb Alignment and JointO.ientation . .

b. Anatomic , Sagittal

Z.I MNSA = 130'

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

aLDFA=8" PDFA = 83'

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

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

d. ,.
)

aJCD", piriformis fossa 1

a-JEA = 13

a-JER = 1'5

aJCD '" medial tibial spine

105mm

1
a-JER = /2

aJCD=4:t4mm

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. . (H APTER 1 . Normal Lower Limb Alignment and Joint Orientation

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

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

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 CHAPTER 1 NormalLower Limb AlignmentandJoint Orientation . .

b. c.

Mechanical
tibiofemoral
angle

d.

Shave et aI., unpublished results 1.3 1.3'

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

Fig. 1-8 a-d

a MAD is the perpendicular distance from the mechanical ax-
is line to the center of the knee joint line. The frontal plane
mechanical axis of the lower limb is the line from the center
of the femoral head to the center of the ankle plafond. The
normal mechanical axis line passes 8 7 mm medial to the
center of the knee joint line.
b Knee joint malorientation is present when the angle between
the femoral and tibial mechanical axis lines and their respec-
tive knee joint lines (LDFA and/or MPTA) falls outside of
normal limits (normal=87.52).
c Tibiofemoral mechanical alignment refers to the relation be-
tween the mechanical axes of the femur and tibia (normal =
1.3 varus).
d Tibiofemoral anatomic alignment refers to the relation be-
tween the anatomic axes of the femur and tibia.

Shave et aI. , unpublished results 6.85 1.4'

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_ CHAPTER 1 NormalLowerLimbAlignmentandJointOrientation

ing AP radiographs of the entire lower extremity on a

single cassette (described in greater detail in Chap. 3), so
that one can also assess the MAD.
In the frontal plane, the line passing from the center
of the femoral head to the center of the ankle plafond
is called the mechanical axis of the lower limb (. Fig.
1-8 a). By definition, malalignment occurs when the cen-
ter of the knee does not lie close to this line. Although
normal alignment is often depicted with the mechanical
axis passing through the center of the knee, a line drawn
from the center of the femoral head to the center of the
ankle typically passes immediately medial to the center
of the knee. Moreland et al. (1987) reviewed long stand-
ing AP radiographs of both lower extremities in 25
normal male volunteers and documented that the center Shave et aI. , unpublished results 122 2.6'
Paley et aI., 1994 129.7 6.2'
points of the hip, knee, and ankle are nearly collinear.
Yoshioka et aI., 1987 129'
The angle between the mechanical axis of the tibia and
femur (tibiofemoral angle) was 1.3 2 varus (. Fig.
1-8c). A commonly measured value is the anatomic ti- Fig. 1-9
biofemoral angle. This is usually approximately 6 val- Hip joint orientation in the frontal plane. MNSA according to
gus (. Fig. 1-8d). Hsu et al. (1990) reviewed long stand- different authors (mean 1 standard deviation [SD]).
ing AP radiographs of the lower extremity of 120 normal
volunteers of various ages and reported that the me-
chanical axis generally passes immediately medial to the
center of the knee. In their population, the mechanical
tibiofemoral angle measured 1.2 2.2 varus. In a study
of 50 asymptomatic French women older than 65 years
(Glimet et al. 1979), the mechanical tibiofemoral angle
measured 0. Most recently, Bhave et al. (unpublished re-
suIts) studied a group of 30 adults older than 60 years, all
of whom had no history or evidence of injury, surgery,
arthrosis, or pain in their lower extremities. The me-
chanical tibiofemoral angle measured 1.3 1.3.
The distance between the mechanical axis line and
the center of the knee in the frontal plane is the MAD.
The MAD is described as either medial or lateraL Medi-
al and lateral MADs are also referred to as varus or val-
gus malalignments, respectively. In a retrospective study
of 25 knees in adult patients of different ages, the normal
MAD was 9.76.8 mm medial (Paley et aL 1994) (. Fig.
1-8a). In a recent prospective study of normal lower
limbs in people older than 60 years without any evidence
of pathological abnormality of the knee, the MAD was
4.1 4 mm (Bhave et aL, unpublished results).

Hip Joint Orientation

Previously, hip joint orientation was evaluated using the

neck shaft angle (NSA). The normal NSA is 125-131. Shave et aI., unpublished results 89.4 4.8'
Chao et aI. , 1994 94.6 5.5'
In an anatomic study of isolated cadaver femora, Yoshi- Paley et aI., 1994 89.9 5.2'
oka et al. (1987) determined that the NSA in adult men
normally measures 129 (. Fig. 1-9). A line from the tip
of the greater trochanter to the center of the femoral Fig.l10
head was described by Paley and Tetsworth (1992) to de- Hip joint orientation in the frontal plane. LPFA according to
fine the orientation of the hip in the frontal plane. Chao different authors (mean 1 SD).

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 CHAPTER 1 NormalLower Limb Alignmenta ndJoint Orientation _

Bhave et aI., unpublished resu lts 88 .1 :1: 1S Bhave et aI. , unpublished resu lts 88.3 :1: 2'
Chao et aI. , 1994 88.1 :I: 3.2' Chao et aI., 1994 87.5 :1: 2.6'
Cooke et aI. , 1994 86 :1: 2.1' Cooke et aI. , 1994 86.7 :1: 2.3'
Paley et aI., 1994 87.8 :1: 1.6' Paley et aI. , 1994 87.2 :1: 1.50

Fig. 1-11 Fig. 1-12

Distal femoral knee joint orientation in the frontal plane. Proximal tibial knee joint orientation in the frontal plane.
mLDFA according to different authors (mean 1 SD). MPTA according to different authors (mean 1 SD).

et al. (1994) also measured the LPFA, which they called Knee Joint Orientation
the horizontal orientation angle for the proximal femur,
from long standing radiographs in 127 normal volun- Regarding knee joint orientation, Chao et al. (1994) de-
teers and stratified the study group according to age and termined that the distal femoral articular surface is nor-
gender. There was no significant change noted with age mally in slight valgus relative to the femoral mechanical
in women, and the relationship of this line to the axis, measuring 88.1 3.2. These results were confirmed
mechanical axis of the femur measured 91.S4.6 in by our data (Paley et al. 1994), with the distal femur in
younger women and 92.7 4.9 in older women. In men, slight valgus relative to the mechanical axis of the femur
the relationship of this line relative to the mechanical (mLDFA=87.8 1.6). Cooke et al. (1987,1994) obtained
axis of the femur demonstrated an age-related tendency radiographs of the knee and hip after positioning the
toward increasing varus, measuring 89.2 5.0 in young- patient in a QUE STAR frame to improve reproducibility
er men and 94.6 SS in older men. Data from our insti- of the radiographic technique. In 79 asymptomatic
tution (Paley et al. 1994), based on a smaller group of 25 young adults, the distal femoral orientation line mea-
asymptomatic adults, revealed that this proximal femo- sured valgus of 862.1. In one study of older asymp-
ral joint orientation line measures 89.9 5.2. Another tomatic adults (Bhave et al., unpublished results), the
study from our institution (Bhave et al., unpublished LDFA was 88.1 IS. Based on all these studies, we con-
results) of asymptomatic older adults (>60 years) with- sider the normal mLDFA to be 87.52S (Paley et al.
out gonarthrosis revealed an LPFA of 89.44.8. Based 1994) (~Fig.l-ll).
on these observations, we consider 89.9 5.2 to be the To consider the proximal tibial joint orientation,
normal LPFA (Paley and Tetsworth 1992; Paley et al. Chao et al. (1994) again stratified their data by age and
1990, 1994) (~Fig . 1-10).

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_ (H APTER 1 Normal Lower Limb Alignment and Joint Orientation

gender and found a significant difference when compar- a.

ing older with younger men. In all groups, the proximal
tibial joint orientation line measured slight varus rela-
tive to the mechanical axis of the tibia (87.2 2.1). In
women, there was no age differential. In asymptomatic
young men, there was slightly more varus (MPTA = 85.5
2.9) compared with asymptomatic older men (87.5
2.6). These data suggest that some young men with
more varus later develop symptomatic degenerative ar-
throsis and "drop out" of the asymptomatic group of
older men. This hypothesis is supported by data regard-
ing alignment of elderly normal lower limbs with no
previous history of injury or surgery and with no evi-
dence of knee arthrosis or pain. One study (Glimet et al.
1979) of 50 elderly asymptomatic French women docu-
mented that the mechanical tibiofemoral angle in this
select group measures 0 instead of slight varus as is
seen in the normal population. The second study, from
our institution (Bhave et al., unpublished results), dem-
onstrated an MPTA of 88.3 2 in patients older than
60 years. Cooke et al. (1994) reviewed standardized ra-
diographs obtained using a positioning frame and
found that the MPTA is 86.72.3. These results were
confirmed by our data (Paley et a1.1994), with an MPTA
of 87.2 varus IS, and by the data presented by More-
land et al. (1987), with an MPTA of 87.2 varus IS.
Based on these observations, we consider the normal
MPTA to be 872S (Paleyet al. 1994) (~Fig. 1-12).
The knee joint orientation measures approximately
3 off the perpendicular, such that the distal femoral
joint line is in slight valgus and the tibia is in slight varus
to the proximal tibial joint line (by convention, we al-
ways refer to the distal segment relative to the proximal
segment when describing deformity of the lower ex-
tremity) (Krackow 1983; Moreland et a1.1987; Paleyet al.
1990, 1994). When walking, the feet progress one in front
of the other along the same line, with the leg inclined
(adducted) to the vertical approximately 3 (Saunders et
al. 1953) (~Fig. 1-13). Krackow (1983) reports that this
3 varus position of the lower limb allows the knee to
../
maintain an optimal parallel orientation to the ground : 3
during gait (~Fig. 1-13 a). In bipedal stance, with the Midline
feet as wide as the pelvis and the tibia perpendicular to
level ground, the knee joint line would be oriented in 3
valgus relative to the vertical (~Fig. 1-13b).
Several authors have presented reports on proximal
tibial sagittal plane orientation. Meister et al. (1998) re-
ported that the posterior slope of the proximal tibia in
the sagittal plane is 10.7 1.8. (PPTA=79.7 1.8.) Chiu
et al. (2000) reported a PPTA of 78S in a radiographic
study of 25 pairs of Chinese cadaveric tibiae. Matsuda et
al. (1999), using magnetic resonance imaging, reported
separate PPTAs measured from the medial and lateral
tibial plateaus relative to the anatomic axis of the tibia.
They reported a PPTA of 79.3 5 when measured from
the medial tibial plateau and a PPTA of 824 when

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 (HA PT ER 1 . Normal Lower Limb Alignment and Joint Orientation _

b. At ease standing position At attention standing position

.r"''''.
3~ 3
Midline Midline

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

Fig.1-14~

Proximal tibial knee joint orientation in the sagittal plane.

PPTA according to different authors (mean 1 SD).

Shave et aI. , unpublished results 80.4 1.6'

Paley et aI. , 1994 80 3.5 '

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. . (H APTER 1 . Normal Lower Limb Alignment and Joint Orientation

PDFA

Shave et ai" unpublished results 83,5 1.9' Shave et aI., unpublished resu lts 32 2.6 0
Paley et aI. , 1994 83.1 3,6'

Fig.1-15 Fig. 1-16

Distal femoral knee joint orientation in the sagittal plane. Distal femur sagittal plane orientation. The angle formed by
PDFA according to different authors (mean 1 SD). the distal femoral anatomic axis and Blumensaat's line is
shown.

measured from the lateral plateau. In our series (Bhave Ankle Joint Orientation
et al., unpublished data) of normal volunteers, the PPTA
was 80.4 1.6 (~Fig. 1-14). Moreland et al. (1987) reported that the ankle is in slight
The distal femoral knee joint orientation line in the valgus (89.82.7). Data from our institution (Paley et
sagittal plane has never been studied using the joint line al. 1994) also demonstrated slight valgus (LDTA = 88.6
of the distal femur that we describe. The normal poste- 3.8), as did the data presented by Chao et al. (1994) (87.1
rior distal femoral angle (PDFA) in our series of normal 3.3). This relationship is variable, and up to 8 of val-
volunteers was 83.13.6 (~Fig.1-1S). gus can be seen (Moreland et al. 1987). Part of this vari-
The orientation of Blumensaat's line was studied by ation may be projectional because, in most studies, this
Bhave et al. (unpublished results). The Blumensaat's line angle was measured from radiographs obtained cen-
angle measured 322.6 (~Fig.1-16). tered on the knee with the patella forward and without
consideration for foot rotation. Inman (1976) measured
107 cadaver specimens and reported that the average an-
kle joint orientation equated to an LDTA of 86.7 3.2,
with a range of 80_92. Based on these measurements,
we consider the normal LDTA to be 89 3 (Paley and
Tetsworth 1992; Paleyet al. 1994) (~Fig. 1-17). In prac-
tice, it is convenient to use the line perpendicular to the
tibial diaphysis as the joint orientation line for the ankle.

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 CHA PT ER 1 . Normal Lower Limb Alignment and Joint Orientation _

Shave et aI. , unpublished results 88 .7 2.7" Shave et aI. , unpublished resu lts 83.1 2.1'
Chao et aI. , 1994 87.1 3.3' Paley et aI. , 1994 79.8 1.6'
Inman,1991 87 2.7'
Paley et aI. , 1994 88.6 3.8'

Fig. 1-17 Fig.1-18

Ankle joint orientation frontal plane. LDTA according to differ- Ankle joint orientation sagittal plane. ADTA according to dif-
ent authors (mean 1 SD). ferent authors (mean 1 SD).

Glimet T, Masse JP, Ryckewaert A (1979) Radiologic study of

Finally, the normal sagittal plane joint line orienta-
painless knees in 50 women more than 65 years old: I. Fron-
tion of the ankle has been described as the anterior tilt tal teleradiography in an upright position [in French]. Rev
of the distal tibia (~ Fig. 1-18). In our studies, the values Rhum Mal Osteoartic 46:589-592
were 79.8 1.60 (Paley et al. 1994) and 83.1 2.1 0 (Bhave Hsu RW, Himeno S, Coventry MB, Chao EY (1990) Normal ax-
et al., unpublished results). ial alignment of the lower extremity and load-bearing dis-
tribution at the knee. Clin Orthop 255:215-227
Inman VT (1976) The joints of the ankle. Williams & Wilkins,
References Baltimore
Krackow KA (1983) Approaches to planning lower extremity
alignment for total knee arthroplasty and osteotomy about
Chao EY, Neluheni EV, Hsu RW, Paley D (1994) Biomechanics
the knee. Adv Orthop Surg 7:69-88
of malalignment. Orthop Clin North Am 25:379-386
Matsuda S, Miura H, Nagamine R, Urabe K, Ikenoue T, Okaza-
Chiu KY, Zhang SO, Zhang GH (2000) Posterior slope of tibial
ki K, Iwamoto Y (1999) Posterior tibial slope in the normal
plateau in Chinese. J Arthroplasty 15:224-227
and varus knee. Am J Knee Surg 12:165-168
Cooke TD, Li J, Scudamore RA (1994) Radiographic assessment
Meister K, Talley MC, Horodyski MB, Indelicato PA, Hartzel JS,
of bony contributions to knee deformity. Orthop Clin North
Batts J (1998) Caudal slope of the tibia and its relationship
Am 25:387-393
to noncontact injuries to the ACL. Am J Knee Surg 11:217-
Cooke TD, Siu D, Fisher B (1987)The use of standardized radio-
219
graphs to identify the deformities associated with osteoar-
Moreland JR, Bassett LW, Hanker GJ (1987) Radiographic anal-
thritis. In: Noble J, Galasko CSB (eds) Recent developments
ysis of the axial alignment of the lower extremity. J Bone
in orthopaedic surgery. Manchester University Press, Man-
Joint Surg Am 69:745-749
chester

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 Normal lower limb and Joint Orientation

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

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

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