summary Femoral Anteversion is a common congenital condition caused by intrauterine positioning which lead to increased anteversion of the femoral neck relative to the femur with compensatory internal rotation of the femur. Diagnosis is made clinically with the presence of intoeing combined with an increase in internal rotation of the hip of greater than 70° with an accompanying decrease in external rotation of the hip of less than 20°. Treatment is observation with parental reassurance as most cases resolve by age 10. Rarely, surgical management is indicated in the presence of less than 10° of hip external rotation in children greater than 10 years of age. Epidemiology Demographics seen in early childhood (3-6 years) twice as frequent in girls than boys can be hereditary Anatomic location often bilateral be cautious of asymmetric abnormalities Etiology Femoral anteversion is characterized by increased anteversion of the femoral neck relative to the femur compensatory internal rotation of the femur lower extremity intoeing There are three main causes of intoeing including femoral anteversion (this topic) metatarsus adductus (infants) internal tibial torsion (toddlers) Pathophysiology a packaging disorders caused by intra-uterine positioning most spontaneously resolve by age 10 Associated conditions can be seen in association with other packaging disorders DDH metatarsus adductus congenital muscular torticollis Anatomy Is based on degree of anteversion of femoral neck in relation to the femoral condyles at birth, normal femoral anteversion is 30-40° typically decreases to normal adult range of 15° by skeletal maturity minimal changes in femoral anteversion occur after age 8 Presentation Symptoms parents complain of an intoeing gait in early childhood child classically sits in the W position (see above image) knee pain when associated with tibial torsion awkward running style when extreme in an older child occasional functional limitations in sports and activities of daily living can occur difficulty with tripping during walking or running activities can be more symptomatic in those with neuromuscular diseases and brace-dependent walkers secondary to lever-arm dysfunction and decreased compensatory mechanisms Physical exam evaluation for intoeing femoral anteversion hip motion (tested in the prone position) increased internal rotation of >70° (normal is 20-60°) decreased external rotation of < 20° (normal 30-60°) anteversion estimated on degree of hip IR when greater trochanter is most prominent laterally trochanteric prominence angle test patella internally rotated on gait evaluation tibial torsion look at thigh-foot angle in prone position normal value in infants- mean 5° internal (range, −30° to +20°) normal value at age 8 years- mean 10° external (range, −5° to +30°) metatarsus adductus adducted forefoot deformity, lateral border should be straight a medial soft-tissue crease indicates a more rigid deformity evaluate for hindfoot and subtalar motion Imaging Radiographs recommended views none required typically CT or MRI may be useful in measuring actual anteversion Treatment Nonoperative observation and parental reassurance indications most cases usually resolve spontaneously by age 10 technique bracing, inserts, PT, sitting restrictions do not change natural history Operative derotational femoral osteotomy indications < 10° of external rotation on exam in an older child (>10 yrs) rarely needed technique typically performed at the intertrochanteric level amount correction needed can be calculated by (IR-ER)/2 Prognosis Multiple studies have been unable to reveal any association with degenerative changes in the hip and knee when increased anteversion persists into adulthood