title: Lower limb alignment in children: reference values based on a full-length standing radiograph.
abstract: BACKGROUND
  A full-length standing anteroposterior radiograph of the entire lower extremity has become the standard imaging modality for assessing lower limb alignment. Although reference values of frontal plane deformity parameters based on adult subjects have been established, such values may not be applicable to the pediatric population. The purpose of our study was to establish the reference values of frontal plane alignment and joint orientation angles in children based on a standing full-length radiograph.
  
  
  METHODS
  A database at a single institution was searched for patients who were aged between 1 and 18 years at the time of undergoing a standing full-length radiograph of the lower extremities. Radiographic analysis of lower extremities without any abnormalities was performed by a single observer. Mechanical axis deviation, lateral distal femoral angle (LDFA), medial proximal tibial angle (MPTA), tibiofemoral angle, joint line convergence angle, and mechanical axis station were calculated at yearly intervals. The data were summarized using descriptive statistics, and simple regression analysis was performed to determine the relationship between the patients' age and the magnitude of LDFA and MPTA.
  
  
  RESULTS
  A total of 354 unaffected lower extremities in 253 children were analyzed. Between the ages of 1 and 2 years, the tendency for varus alignment of the lower limb was related to the varus orientation of the distal femur with a mean LDFA of 95 degrees (95% confidence interval [CI], 93-97 degrees). By the age of 3 years, the limb alignment changed to valgus related to a combination of decreasing varus orientation of the distal femur and a mild increase in valgus orientation of the proximal tibia with the mean MPTA changing from 89 degrees (95% CI, 88-90 degrees) to 91 degrees (95% CI, 90-92 degrees). After the age of 7 years, all joint orientation angles were noted to be within the range of reference values that are available for the adult population. Despite changes in limb alignment with growth, the mean mechanical axis of the lower extremity remained within the central half of the knee joint in children older than 1 year of age.
  
  
  CONCLUSIONS
  The change in alignment of the lower limb from 1 to 4 years of life from varus to valgus is primarily related to a progressive decrease in varus orientation of the distal femur. In children younger than 7 years old, age-specific reference values for joint orientation angles of the lower extremity should be used instead of values derived from adult subjects.
authors.affiliation: Department of Orthopedics, University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Newark, NJ 07103, USA. sabharsa@umdnj.edu
authors.forename: Sanjeev
authors.initials: S
authors.lastname: Sabharwal
authors.forename: Caixia
authors.initials: C
authors.lastname: Zhao
authors.forename: Michele
authors.initials: M
authors.lastname: Edgar
mesh_terms: D000293:Adolescent; D000367:Age Factors; D017760:Bone Malalignment / Q000000981:diagnostic imaging*; D002648:Child; D002675:Child, Preschool; D005260:Female; D005269:Femur / Q000000981:diagnostic imaging; D005500:Follow-Up Studies; D006801:Humans; D007223:Infant; D007719:Knee Joint / Q000000981:diagnostic imaging; D035002:Lower Extremity / Q000000981:diagnostic imaging*; D008297:Male; D011859:Radiography / Q000379:methods*; D012016:Reference Values; D012044:Regression Analysis; D012189:Retrospective Studies; D013977:Tibia / Q000000981:diagnostic imaging