Pediatric Limb Deformity Pre-Course

Scott Nelson MD
Orthopedic Grand Rounds
November 14, 2018
What you need to know:

• Terminology
• Understand difference between anatomic and mechanical axis
• Know abbreviations
• Normal anatomy
• Memorize all normal joint orientation angles (do not need to memorize
ranges)
• 3 steps for analyzing limb deformity
• Osteotomy rules
• Understand the significance of 57
TERMINOLOGY AND NORMAL ANATOMY
 Normal Mechanical Tibiofemoral Alignment

• A line drawn from the center of the

hip to the center of the ankle is called
the Mechanical Axis of the lower
extremity
• The distance between this line and
the center of the knee is called the
MAD (mechanical axis deviation)

Normal MAD = 8-10 mm medial or varus

Joint Orientation

Refers to the position of each articular

surface relative to the axis of each
individual limb segment
Anatomic vs Mechanical Axis
• Anatomic Axis – mid-diaphyseal line
• Mechanical Axis – straight line connecting the center of
one joint to the center of another joint, whether in the
frontal or sagittal plane
 Mechanical Axis

• The mechanical axis is always a straight line whether in the frontal or sagittal plane
• Do not confuse femur or tibia mechanical axis with mechanical axis of lower extremity
Anatomic Axis

• The anatomic axis may be straight or curved in the frontal or

sagittal plane (i.e. the femur)
Femur
Normal femoral AMA (anatomic mechanical angle) is 7 ± 2°
Tibia
• Normal tibial AMA is 0°
• Mechanical axis is 3mm lat to anatomic axis
• Synonomous
Joint Orientation Angles
Nomenclature
§ M – medial
§ L – lateral
§ A – anterior
§ P – posterior
§ a – anatomic
§ m – mechanical
§ P or D – proximal or distal
Joint Orientation Angles

• The angle of a joint relative to the

mechanical axis of that bone
• Do not measure any joint orientation
angle with mechanical axis of the lower
extremity
Joint Orientation Angles

Always name the anatomically smaller

(more acute) angle to avoid confusion
Frontal Plane
• mLDFA = 88°
• MPTA = 87°
Frontal Plane

• LPFA = 90 ± 5° (mechanical)
Frontal Plane

• LDTA = 89°
JLCA (joint line convergence angle)
• Angle formed between
two joint orientation
lines on the opposite
side of a joint
• Normally parallel in
knee and ankle

(Normal)
Normal Anatomic Axis Alignment
Normal Anatomic Joint Orientation angles

Anatomic Tibiofemoral alignment = ?

6° valgus
Normal Mechanical Joint Orientation Angles

Mechanical Tibiofemoral alignment =?

1.3° varus
6° valgus

1° varus
~1° varus

~6° valgus
 Memorize This!
MAD (0-10 mm)
NSA (130°)
LPFA (90°) MPFA (84°)
mLDFA (88°) aLDFA (81°)
MPTA (87°)
LDTA (89°)
PDFA (83°)
PPTA (81°)
ADTA (80°)

*Don’t need to memorize range for each one

Never forget
§MAD 10 mm
§LDFA 88°
§MPTA 87°
3 Steps for Assessing Limb
Deformity

1. Screening (MAD)
2. Determine which bone(s) and/or joint(s)
affected
3. Analyze deformity
STEP 1 MAD
Limb Deformity Screening

MAD – Mechanical Axis Deviation

• Center of femoral head to center of ankle

• Should be 0-10 mm medial of knee center

• If normal then probably done

Image created on Bone Ninja App

Mechanical Axis of LE
• MAD (mechanical axis deviation) = 10 mm medial or varus
MAD – Example

MAD 75mm varus

STEP 2 JOINT ORIENTATION
Measure Joint Orientation Angles

• Tells you what bone the deformity is in

• Measure mLDFA/MPTA
• Measure hip and ankle joint orientation
• Check JLCA
• Check Sagittal plane
Joint Orientation
LDFA 89°
MPTA 73°
JLCA 7° varus

Check other joint orientation angles

STEP 3: DEFORMITY ANALYSIS/APEX
Find the Apex/CORA (Center of Rotation of Angulation)

• Draw a normal proximal axis – anatomic or mechanical

• Draw a normal distal axis – anatomic or mechanical
• Cannot use mechanical proximal with anatomic
distal/must be the same
• Find the apex of the axes 87°

• If the axex do not cross or it is far away from the

obvious deformity then you need to perform multi-
apical analysis
OSTEOTOMY RULES
Osteotomy Rules and Concepts
• Rule 1 – Osteotomy at apex, correction at apex: then realignment
occurs without translation.
Osteotomy Rules and Concepts
• Rule 2 – Correction
around apex but
osteotomy at a different
level: then angulation
and translation needed
at the osteotomy for
realignment.
Warning!
• If you do not follow rule 1 or 2 a translation will occur
• That is bad
RULE OF 57
360° in a full circle
How do we measure angulation?
• Radians
• Degrees

360°
• Imagine a circle with a circumference of 360mm
(where each degree = 1mm)
• What is the radius of this circle?
Circumference = 3.14159265359(Diameter)
 Radius = 57mm

Circumference = 360mm
• 360 = 2πr
• r = 360/6.28
• r = 57
1°
1mm
57mm
Closing wedge
osteotomy planned for
a 23° varus deformity
of the R distal femur

57mm
? 23°
Imagine
1°
1mm
57mm

23mm 23°

57mm
Base of wedge is 23mm
to correct 23° if width of
cut is 57mm 57mm
? 23°
5 y M genu valgum

• LDFA 73°/78°
• MPTA 90°/90°
Surgery Age 5
• At what rate will this
deformity correct?
• Physeal width ≈57mm

1° 1mm
57mm

• 1mm growth = 1° correction

57mm
• Growth of distal femur is
≈12mm per year
• Correction ≈ 1° per month
 1°
Multiples of 57
57mm 1mm

2mm
114mm

3mm
171mm

4mm
228mm

342mm = 6mm
5mm
399mm = 7mm
285mm
Proportions of 57

⅓ = 19
⅔ = 38
 Proportions of 57

What size wedge should be

removed in order to correct a 12°
varus deformity?
38mm
38mm
(cut width is ≈38mm)
 38/57 = ⅔

12mm 12°
38mm
57mm 38mm

Cut 8mm base

*don’t forget to subtract the kerf

 38mm
≈

60°
?

A 7y old boy has a 90° kyphosis at T11. If you plan to correct 60° of this
through a single osteotomy how much posterior bone would you need to
resect?
Imagine

2/3

60°
20mm
40mm
60mm

19mm

38mm

38 is ⅔ of 57 57mm
40 is ⅔ of 60
 38mm

60°
38mm
40mm
38mm

Isosceles Triangle
 38mm

60°
38mm
40mm
38mm

Base length is 38
Arc length is 40
38/40 = .95
Base is 95% of arc at 60°
How accurate is line vs arc?
98.4% accurate at 30°
95.0% accurate at 60°
89.6% accurate at 90°

Calculation for a 30° angle

2 sin 15° = X/57
2(0.259) = X/57
X = 2(0.259) x 57 = 29.53
29.53/30 = 98.4%
Foot Cavus

Size of dorsal wedge can be estimated to

normalize Meary’s angle

60°
Foot Cavus

Answer
Apex of correction is plantar fascia
Isosceles triangle
All sides equal
Dorsal resection ≈ 40mm 40mm
60°
Distal Radius Malunion
Estimate size of wedge needed to restore the
deformity seen on the lateral x-ray

16° Dorsal Tilt

19mm thickness
Distal Radius Malunion
• Thickness of a distal radius is ≈ 19mm (⅓ of 57)
• 16° + 11° = 27° correction needed
• 1° correction = 1/3mm base of wedge
• Base of wedge should be 9mm

27°
95mm
As the knee straightens the distance of the rod will increase and
require approx 2mm shortening per 1° of correction

95mm
114mm
Cast Wedging

12° Correction needed

Apex 57mm from back of cast and 28 mm from front of cast
Cast Wedging

Open 12mm in back and close 6mm in front

 1°
1mm
57mm

r/57 x angle in degrees = arc length