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FNA Angle
FNA Angle
FNA Angle
[Cibulka MT. Determination and significance of femoral neck anteversion. Phys Ther. 2004;84:550 558.]
Key Words: Femoral neck anteversion, Femoral neck retroversion, Hip rotation, Medial femoral torsion.
550
Michael T Cibulka
Published reports1,35 have suggested that habitual sleeping and sitting postures, in which the hip is held at or
near the end of medial or lateral rotation, may produce
changes in the FNA angle. These extreme postures often
will produce an increase in hip rotation in one direction,
with a corresponding decrease in hip motion in the
opposite direction. As expected, hip joint motion
increases in the direction the hip is held. Habitually
adopting a sleeping or sitting position in which the hip
is held in extreme lateral rotation, therefore, favors an
increase in lateral rotation motion with an equal loss of
medial rotation (Figs. 2 and 3). Maintaining an extreme
hip posture also produces changes in the soft connective
tissue surrounding the hip, shortening the hip joint
capsule and muscles on one side and lengthening the
hip joint capsule and muscles on the other side. These
asymmetrical changes in soft tissue around the hip likely
will create uneven torsional forces placed on the femur.
Examination of children with hemiplegia also lends
support to the theory that changes in hip muscle force
are related to an abnormal FNA angle. Staheli et al14
looked at the hips of children with hemiplegia and
found that the FNA angle on the nonhemiplegic side is
normal, whereas the FNA angle was increased on the
hemiplegic side, as was the motion of medial rotation
when compared with the normal side.
MT Cibulka, PT, MHS, OCS, is Physical Therapist and Owner, Jefferson County Rehab & Sports Clinic, 1330 YMCA Dr, Ste 1200, Festus, MO
63028-2647 (USA) (mcibulka@earthlink.net).
Cibulka . 551
Figure 1.
Illustration of normal, increased, and decreased femoral neck anterversion (FNA) angle.
Figure 3.
Figure 2.
Sitting in the W or reverse tailor position with maximum hip medial
rotation.
Table 1.
Study
11
15
Adults
Svenningsten et al34
Males
Females
51/48
60/44
51/47
58/44
51/42
57/43
46/42
50/42
41/43
48/42
38/43 (8)
52/41 (8)
32/34 (8)
Ellison et al35
38/36 (11)
Staheli et al31
Males
Females
42/45
43/45
52/44
44/42
51/40
40/40
45/38
42/38
46/38
39/39
40/38 (8)
33/38 (8)
Chesworth et al36
43/42 (9)
Figure 4.
Illustration showing cuts used to determine the femoral neck anterversion angle using computerized tomography scan.
The finding of diminished lateral rotation with increased medial rotation and
a large FNA angle also is consistent with
many clinical observations.1,35,8 A
trade-off in medial and lateral rotation
of the hip appears to occuras one
movement or direction increases, the
other usually decreaseswhile the total
hip motion remains equal. For example, as medial rotation increases, lateral
rotation usually decreases. The results
of the study by Swanson et al8 suggest
that femoral torsion deformity exists
when medial rotation exceeds lateral
rotation by more than 30 degrees and
that an abnormal FNA exists when lateral rotation exceeds medial rotation
by more than 30 degrees.
Table 2.
Studies That Examined the Relationship Between Femoral Neck Anteversion (FNA) and Passive Hip Rotationa
Study
Svenningsen et al26
Kozic et al27
MRLR
MRLR
LRMR
30
30
30
89
89
89
24
16
24
16
26
7.7
7.3
16.5
15.7
16.3
2nd exam
Control
Gelberman et al29
MRLR
LRMR
MRLR
Braten et al24
IRER
7 (410)
10 (713)
16 (1521)
1,030
86
24
Study
Age (y)
(69)
(68)
(1418)
(1416)
(1419)
Age (y)
16
8
20
100
5.2 (5.1)
5.5 (5.5)
5.1 (5.2)
35 (1665)
MR
LR
FNA
e-FNA
74 (6.8)
60 (7.2)
53 (8.5)
19 (7.2)
27 (7.8)
37 (5.9)
42 (5.5)
36 (6.3)
28 (8.4)
23
20
16
44
65
23
43
30
58
24 (4.3)
36 (7.3)
14 (7)
24
24
2
47
45
30
31
nm
24
24
15
15
15
78
76
52
63
50
(8)
(10)
(12)
(11)
(9)
16
28
43
30
41
(8)
(10)
(10)
(10)
(8)
MR1
MR2
LR1
LR2
FNA
e-FNA
80 (5)
71 (4)
51 (8)
78 (5)
46 (7)
50 (7)
10 (5)
18 (7)
54 (9)
45 (13)
32 (6)
55 (9)
49 (10)
32 (6)
nm
26
26
26
48 (10)
36 (8)
38 (7)
43 (9.6)
18/14
18/14
MRhip medial rotation, LRhip lateral rotation, e-FNAexpected FNA angle for age using data from study by Fabry et al,2 nmnot measured. Standard
deviations or ranges of values are shown in parentheses. In study by Reikeras and Bjerkreim,28 one control group and one time-series group were examined twice.
In study by Gelberman et al,29 hip MR and LR were measured with hip extended and with hip flexed to 90 degrees. In study by Gelberman et al, superscript 1
measurements were taken with the hip extended to 0 degrees, and superscript 2 measurements were taken with the hip flexed to 90 degrees. In study by Braten
et al,24 superscript 1 measurements are for female subjects, and superscript 2 measurements are for male subjects.
Table 3.
Data From the Study by Davids et al38 on the Trochanteric
Prominence Angle Test (TPAT)a
Side
FNA
Angle
()b
TPAT
()c
R
L
19
35
20
40
12
53
35
14
R
L
30
47
15
20
43
50
R
L
44
48
55
60
29
35
10
R
L
39
37
30
40
13
R
L
40
34
40
60
10
50
50
10
13
R
L
67
57
40
40
Patient
No.
Age
(y)
Sex
12
2
3
4
5
11
10
16
12
13
R
L
46
53
30
25
13
10
R
L
55
30
30
20
14
R
L
24
28
30
45
15
10
R
L
39
34
40
25
16
15
R
L
34
33
30
20
17
10
R
L
24
27
20
20
18
13
R
L
12
44
20
35
10 Haike HJ. Tierexperimentelle untersuchungen zur frag der entstehung der osteochondroose des schenkelkopfes, der coxa vara and
valga sowie der pathologischen anterotorsion des koxalen femurendes. Z Orthop Ihre Grenzgeb. 1965;100:416 439.
11 Bernbeck R. Zur pathologie der luxatio coxae congenital. Virchows
Arch (Pathol Anat). 1951;320:238 263.
12 Salter RB. Role of innominate osteotomy in the treatment of
congential dislocation and subluxation of the hip in the older child.
J Bone Joint Surg Am. 1966;48:14131439.
13 Wilkinson JA. Femoral anteversion in the rabbit. J Bone Joint Surg Br.
1962;44:386 397.
14 Staheli LT, Duncan WR, Schaefer E. Growth alterations in the
hemiplegic child: a study of femoral anteversion, neck-shaft angle, hip
rotation, C.E. angle, limb length and circumference in 50 hemiplegic
children. Clin Orthop. 1968;60:205212.
15 Magilligan DJ. Calculation of the angle of anteversion by means of
horizontal lateral roentgenography. J Bone Joint Surg Am. 1956;38:
12311246.
16 Lee DY, Lee CK, Cho TJ. A new method for measurement of
femoral anteversion: a comparative study with other radiographic
methods. Int Orthop. 1992;16:277281.
17 LaGasse DJ, Staheli LT. The measurement of femoral anteversion:
a comparison of the fluoroscope and biplane roentgenographic methods of measurement. Clin Orthop. 1972;86:1315.
18 Murphy SB, Simon SR, Kijewski PK, et al. Femoral anteversion.
J Bone Joint Surg Am. 1987;69:1169 1176.
19 Sugano N, Noble PC, Kamaric E. A comparison of alternative
methods of measuring femoral anteversion. J Comput Assist Tomogr.
1998;22:610 614.
20 Wissing H, Buddenbrock B. Determining rotational errors of the
femur by axial computerized tomography in comparison with clinical
and conventional radiologic determination. Unfallchirurgie. 1993;19:
145157.
21 Hubbard DD, Staheli LT. The direct radiographic measurement of
femoral torsion using axial tomography: technic comparison with an
indirect radiographic method. Clin Orthop. 1972;86:16 20.
22 Starker M, Hanusek S, Rittmeister M, Thoma W. Validation of
computerized tomography antetorsion angle measurement of the
femur. Z Orthop Iher Grenzgeb. 1998;136:420 427.
23 Sommerville EW. Persistent foetal anteversion of the hip. J Bone Joint
Surg. 1957;39:106 113.
24 Braten M, Terjesen T, Rossvoll I. Femoral anteversion in normal
adults: ultrasound measurements in 50 men and 50 women. Acta Orthop
Scand. 1992;63:29 32.
25 Tonnis D, Heinecke A. Acetabular and femoral anteversion: relationship with osteoarthritis of the hip. J Bone Joint Surg Am. 1999;81:
17471770.
Cibulka . 557
35 Ellison JB, Rose SJ, Sahrmann SA. Patterns of hip rotation range of
motion: a comparison between healthy subjects and patients with low
back pain. Phys Ther. 1990;70:537541.
36 Chesworth BM, Padfield BV, Helewa A, Stitt LW. A comparison of
hip mobility in patients with low back pain and matched healthy
subjects. Physiotherapy Canada. 1994;46:267274.
37 Cibulka MT, Sinacore D, Cromer GS, Delitto A. Unilateral hip
rotation range of motion in patients with sacroiliac joint regional pain.
Spine. 1998;23:1009 1015.
38 Davids JR, Benfanti P, Blackhurst DW, Allen BL. Assessment of
femoral anteversion in children with cerebral palsy: accuracy of the
trochanteric prominence angle test. J Pediatr Orthop. 2002;22:173178.
39 Svenningsen S, Apalset K, Terjesen T, Anda S. Regression of
femoral anteversion: a prospective study of intoeing children. Acta
Orthop Scand. 1989;60:170 173.
40 Gelberman RH, Cohen MS, Desai SS, et al. Femoral anteversion: a
clinical assessment of idiopathic intoeing gait in children. J Bone Joint
Surg Br. 1987;69:7579.
558 . Cibulka