What is the recommended management for bilateral femoral anteversion (femoral antiversion) in a 5-year-old child?

Management of Bilateral Femoral Anteversion in a 5-Year-Old

Observation with reassurance is the recommended approach for a 5-year-old with bilateral femoral anteversion, as the vast majority of cases spontaneously improve with growth and surgical intervention should be reserved only for children who remain significantly symptomatic beyond age 8-10 years.

Natural History and Expectant Management

• Femoral anteversion spontaneously remodels in nearly all children by age 8, making observation the standard of care for children under this age 1
• In non-operated patients, the anteversion angle decreases substantially during growth—from a mean of 45° at age 7.3 years to 31° at age 15.7 years 2
• Internal hip rotation normalizes progressively as anteversion decreases, with reduction occurring at approximately 0.7° per year 3
• 60-90% of borderline abnormal hips identified in infancy resolve spontaneously, though this data primarily applies to developmental dysplasia rather than isolated anteversion 4

Clinical Assessment at Age 5

At this age, focus your examination on:

• Hip rotation measurements: Internal rotation >70° with external rotation <20° suggests persistent excessive anteversion 1
• Functional limitations: Assess whether the child experiences frequent tripping during activities of daily living or sports 1
• Gait pattern: Look for in-toeing gait, though this alone is not an indication for surgery 3
• The degree of external rotation of the hip determines gait symptoms more than the absolute anteversion angle 2

Indications for Surgical Consideration (Not Applicable at Age 5)

Surgery should only be considered if:

• Age criterion: Child is at least 8-10 years old, as spontaneous remodeling continues until this age 1
• Symptomatic limitation: Persistent complaints of frequent tripping that limits participation in activities of daily living or sports 1
• Rotational measurements: Preoperative internal rotation typically >75-80° with external rotation <15-20° in surgical candidates 1, 5

Surgical Technique (When Eventually Indicated)

If surgery becomes necessary after age 8-10:

• Diaphyseal derotational osteotomy with intramedullary fixation is the preferred modern technique, using a rigid pediatric femoral nail placed through the lateral greater trochanter 6, 1
• This approach offers advantages over traditional plate fixation: quadriceps sparing, minimal blood loss, load-sharing low-profile implant, and rapid recuperation 6
• Healing occurs at a mean of 6 weeks with early mobilization and no casting required 6
• Subtrochanteric osteotomy with plate fixation is an alternative but carries higher complication rates (13 of 95 patients in one series) 5

Important Caveats and Pitfalls

• Avoid premature surgical intervention: Operating before age 8 exposes the child to unnecessary surgical risks when natural remodeling would likely resolve the condition 1, 3
• Complications of surgery are significant: Even with modern techniques, serious complications occurred in 13 of 95 patients in historical series, supporting a conservative approach 5
• Recurrence after surgery: Mean increase of anteversion after osteotomy is 6° (0.7° per year) during remaining growth, though this still maintains functional improvement 3
• Simultaneous varus correction is unnecessary: Derotational osteotomy alone is sufficient; the neck-shaft angle increases only modestly (mean 5°) after surgery 3, 2

Follow-Up Protocol

• Continue clinical hip examinations at all well-child visits through age 5 and beyond 4
• Reassess rotational measurements and functional symptoms annually 2
• Radiographic imaging is not routinely indicated for isolated femoral anteversion without dysplasia 7
• Counsel parents that external torsion of the leg/foot does not develop as compensatory mechanism during growth 2