Assessment and management of torsional malalignment in paediatric patients with patellofemoral joint instability.

Purpose: Torsional malalignment is an important but frequently underrecognized contributor to patellofemoral instability (PFI) in children and adolescents. This review aimed to provide a clinically focused overview of the development, assessment, imaging evaluation, and contemporary management of femoral and tibial torsional abnormalities associated with PFI. Methods: A literature search of PubMed and Embase was performed from database inception, using the terms ((patella) OR (patellofemoral)) AND ((rotation) OR (torsion)). Titles and abstracts were screened by two authors, followed by full-text review and synthesis of relevant literature. Evidence concerning developmental changes, clinical and dynamic assessment, imaging modalities, associations with PFI, and surgical management was evaluated. Results: Femoral anteversion decreases and tibial external torsion increases during childhood, although substantial physiological variability limits the use of universal normative thresholds. Clinical assessment, including hip rotation, thigh-foot angle, gait, and patellar tracking, is essential but demonstrates inter- and intraobserver variability. CT remains a reference standard for torsional measurement, whereas MRI and EOS imaging provide radiation-sparing alternatives. Increased femoral anteversion, tibial torsion, and tibiofemoral rotation are associated with PFI and may contribute to failure of isolated soft-tissue procedures. In selected symptomatic patients, derotational osteotomy, frequently combined with MPFL reconstruction or other procedures addressing concomitant risk factors, can provide favorable clinical outcomes. Conclusions: Evaluation of pediatric PFI should incorporate torsional. Treatment should be individualized according to symptoms, skeletal maturity, clinical findings, dynamic function, and anatomical contributors rather than imaging values alone. Recognition and correction of clinically significant torsional malalignment may improve stability and reduce treatment failure.