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Rotational Deformities

Rotational deformities of the lower limbs are common but are hard to recognize. Even experienced doctors will miss these problematic conditions. A rotational deformity of the tibia can be identified when the feet don’t line up with the knees. The feet can either turn inward (internal torsion) or outward (external torsion). 

Miserable malignment syndrome anteversion

External Tibia Rotation -

 Knees Point Inwards

miserable malalignment syndrome

Rotational deformities make activities such as running, yoga, and cycling challenging. Rotational deformities of the femur and hip are more subtle. Patients may walk with the feet and knees turned inward (anteversion) or outward (retroversion). Often femoral anteversion will be accompanied by external tibial torsion creating a complex two-level rotational deformity (miserable malalignment or tetratorsional malalignment). Rotational Deformities may also cause dislocating kneecaps.


Many rotational deformities are congenital which means they occur from the time of birth and affect both lower limbs. Rotational deformities can also occur as a result of trauma to the tibia or femur.

Rotational deformities can also be accompanied by bowlegs or knock knees. Standard treatments for bowlegs or knock knees will not fix the rotational deformity.

External Femoral Rotation - Knees Outwards

External Femoral Rotation With Knock Knees

Symptoms Of Rotation

Rotational deformities do not create the same obvious visual malalignment seen with bowlegs and knock knees. Symptoms may include:


  • Pain in the hip, knee, or ankle

  • Difficulty running, cycling, achieving yoga poses. 

  • Trouble maintaining balance

  • Dislocating Kneecaps

Miserable Malalignment Syndrome

Femoral Anteversion


A rotational deformity is a structural issue that can only be fixed through re-alignment surgery. Fortunately, this is one of the least invasive deformity surgeries and is performed through very small incisions.


The femur and tibia bones are hollow and allow for the insertion of a thin titanium rod which supports the correction. Sometimes the deformity needs to be corrected with a plate or with an external fixator depending on the unique needs of the patient. 

miserable malalignment syndrome

Correction through Femoral Plates and Rods

miserable malalignment syndrome surgery


Surgery is performed at the Hospital for Special Surgery in New York City. Dr. Fragomen personally performs all of the procedures and is supported by a professional surgical team. Patients are admitted to the hospital after surgery for an average of 2 nights where they will receive multimodal pain control from the HSS pain team and physical therapy for crutch training.


Patients can expect to be on crutches for about 6 weeks. Once the osteotomy site has healed patients may resume unrestricted physical activity. Eventually the rods and plates will need to be removed in an ambulatory setting. 

miserable malalignment syndrome

Correction through Femoral Plate
and Tibia Rod

miserable malalignment syndrome

Medical Questions

Dr. Fragomen:

Erica Lenihan, RN:

Zac Edelman, PA:

Eric Lau, PA:

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