Journal Reading
RADIOLOGICAL APPROACH TO ASSESSMENT
OF LOWER-LIMB ALIGNMENT
—CORONAL AND TRANSVERSE PLANE
ANALYSIS
dr. Sheny Fitshara
Pembimbing :
dr. Ramadhan Ananditia Putra, SpOT., M.Ked.Klin
Departement Orthopaedic And Traumatology
Faculty Of Medicine Sriwijaya University
RSUP Dr. Mohammad Hoesin Palembang
2025
INTRODUCTION
Clinical Utility
Full‑Length Standing • Assess mechanical axis of
AP Radiographs Widely available, the lower limb
Visualize anatomy easily accessible, and • Quantify deformity
from femoral head to cost‑effective magnitude
• Guide preoperative
ankle
corrective planning
AI‑Based Automated
CT & MRI
Measurement
Provide high‑resolution, Emerging tools offer rapid,
cross‑sectional views for reproducible alignment
complex cases and deformity analyses
Scope of This Review
• Comprehensive survey of radiological assessment methods for lower‑limb alignment
• Evaluation of deformity measurement techniques
• Exploration of AI‑enabled imaging analytics
Proper Examination Techniques
Full‑Length Standing AP Radiograph
• Primary modality to evaluate lower‑limb alignment
• Precisely determines mechanical & anatomical axes of femur and tibia
• Measures key lower‑limb angles
Use AP projection with a horizontal X‑ray beam centered on hip, knee, and ankle
• Align patella between femoral condyles (feet rotated 8–10° laterally)
Adjustments for Torsional Deformities
• If patella is off‑ center due to torsion:
• Rotate lower leg internally (IR) or externally (ER) until centered
• ER → appears more varus (less valgus)
• IR → appears more valgus (less varus)
Evaluation of Lower-Limb Alignment
Femoral & Tibial Mechanical Axes
• Femur: Line from center of femoral head → center of femoral intercondylar
notch
• Tibia: Line from interspinous groove → center of talus (tibial plafond)
• (Note: In the tibia, mechanical and anatomical axes nearly coincide)
Mikulicz Line (Overall Lower‑Limb Axis)
• Line from center of femoral head → midpoint of tibial plafond (ankle joint)
• Normal Position: Passes ~4 ± 2 mm medial to knee center
• Alignment Indicators:
• Lateral deviation → valgus alignment
• Medial deviation → varus alignment
Evaluation of Lower-Limb Angles
Anatomical Tibiofemoral (Hip–Knee–Ankle) Angle (TFA/HKA) Angle between anatomical axes of femur & tibia
• Normal Range: 1°–1.5°
Anatomical–Mechanical Femoral Angle (MFA)
• Angle between mechanical & anatomical femoral axes
• Normal Range: 6° ± 1°
Key Torsion Angles
• Femoral Torsion Angle:
• Between femoral head–neck axis and tangent to posterior femoral condyles
• Normal Range: 15.6° ± 6.7°
Tibial Torsion Angle
• Between tangents at posterior proximal tibial condyles and distal transmalleolar axis
• Normal Range: 23.5° ± 5.1°
Lower-Limb Deformities
Misalignment can lead to progressive joint degeneration and disability
Common Deformity Types
• Varus: Medial deviation → increased stress on medial knee compartment
• Valgus: Lateral deviation → increased stress on lateral knee compartment
Assessment via Mikulicz Line
• Line from femoral head to ankle
• Lateral deviation: Valgus deformity
• Medial deviation: Varus deformity
Study of 284 patients: AI-based automated alignment and length measurements on
radiographs matched manual measures in accuracy and reproducibility
Rotation Deformities
Rotational displacement of bone segments along long‐bone axes
Causes
• Congenital (acetabular, femoral, tibial malformations)
• Growth‐related disorders
• Post‐traumatic changes
Clinical Examination
• Physical rotation tests (e.g., foot‐thigh angle)
Radiographic Evaluation
• CT Imaging (Preferred)
• Precise measurement of proximal vs. distal joint axis angles in transverse plane
• Gold standard for femoral and tibial torsion quantification
Rotation Deformities
IMAGING
METHODS
3D Imaging
• Computed Tomography (CT) &
Magnetic Resonance Imaging
(MRI) Detailed volumetric
&
assessment of bone and
soft‑ tissue anatomy
• Intraoperative Navigation
Navigation
Systems Real‑time tracking
of limb position and implant
placement
• Superior accuracy in
alignment measurement
• Reduced variability from
Advantages patient positioning
• Enhanced guidance for
surgical planning and
execution
Studies
CT Method
• Advantages:
• Detects underestimation of proximal tibial varus seen on radiographs [Tarassoli et al., 2023]
• Limitations:
• Positional variability affects axis identification & measurement reproducibility
• Higher ionizing radiation dose [Escott et al., 2013]
3D Model Measurements
• Upright biplanar radiograph–derived 3D models yield length/alignment data comparable to supine CT and
full‑length radiographs [Guggenberger et al., 2014]
MRI vs. CT in Patient‑Specific Cutting Guides (TKA)
• Meta‑analysis: MRI guides produce fewer coronal‑plane limb mechanical axis outliers than CT
• No significant differences for sagittal coronal component placement or femoral axial rotation [Guggemberger
et al., 2014]
Supine MRI vs. Standing Radiographs
• Supine MRI underestimates knee deformity compared to preoperative standing full ‑length radiographs
DISCUSSION
Discussion
Angular Misalignments: Varus, valgus deviations
Rotational Abnormalities: Internal/external torsion
Limb‑Length Discrepancies: Shortening or elongation
Etiology
• Congenital
• Developmental
• Acquired
• Reduced mobility and gait abnormalities
• Functional limitations in daily activities
• Decreased quality of life
Discussion
Study Objectives
• Evaluate lower‑limb alignment on full‑length standing AP radiographs
• Assess rotational deformities in the transverse plane
Imaging Limitation
• Sagittal‑plane assessment hindered by varying X‑ray beam intensities
needed to simultaneously visualize femoral head and knee
Discussions
Ethnic differences affect alignment parameters
Japanese Population
• Smaller mechanical, lateral distal femoral, and medial proximal tibial angles
• Larger HKA angle & higher rate of constitutional varus
Surgical planning must account for anatomical diversity
AI & 3D Modeling in Preoperative Planning
• AI‑driven image processing yields highly accurate, reproducible alignment and length
measurements
• 3D bone models from CT enable automatic, comprehensive quantification of lower ‑limb
alignment
• Enhances efficiency and precision in orthopedic surgery preparation
• Comprehensive quantification of lower-limb alignment parameters with significantly reduced
times compared to manual assessments
CONCLUSION
Full-length standing radiographs in AP projection are useful for obtaining accurate
measurements of the anatomical and mechanical axes, angles, and deviations of the
lower-limb.
These measurements are crucial for effective preoperative planning and the
successful correction of deformities through osteotomy and TKA.
There are promising prospects for the implementation of AI-based automated
measurement systems.
Thank you
