Tibial Torsion Treatment & Management

  • Author: Minoo Patel, MBBS, MS, FRACS; Chief Editor: Carlos J Lavernia, MD, FAAOS   more...
 
Updated: Feb 6, 2012
 

Medical Therapy

Treatment with orthoses generally is ineffective. The condition has a benign natural history. Because most cases resolve spontaneously, observation with yearly review is all that is generally needed. True metatarsus adductus is an intrauterine positional deformity that resolves in 90% of cases by the age of 4 years. If no improvement is seen, cast correction by using a long leg cast can be attempted. A weekly cast change for 4-5 weeks is generally needed.

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Surgical Therapy

Tibial torsion

Osteotomy is indicated if deformity is more than 3 standard deviations (SDs) from the mean (less than -10º or more than +35º). Osteotomies (supramalleolar osteotomy) can be performed at any level.[22, 23]

Femoral torsion

Osteotomy correction is indicated if the deformity is more than 3 SDs from the mean and is a cosmetic or functional problem (ie, internal rotation of 85º, external rotation of < 10º).

Osteotomy can be performed at any level: subtrochanteric, shaft, or distal. Distal osteotomies are easier to fix and are associated with less blood loss and quicker healing.

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Intraoperative Details

The authors prefer supramalleolar osteotomies because they are easier to perform. Attention is directed toward making the bone cuts perpendicular to the long axis to avoid building an angular deformity into the rotational correction. A fibular osteotomy should be created to allow for stress-free tibial rotation. This also preserves the distal tibiofibular articulation. The osteotomy is made 2-3 cm proximal to the distal tibial physis.

Proximal tibial osteotomies must be performed distal to the tibial tuberosity to prevent rotation of the patellar tendon insertion that, if rotated externally, can predispose the patient to patellar maltracking in the trochlea and lateral patellar dislocation.

In younger children, osteotomies can be fixed by using Kirschner wires or small fragment plates. In older children, intramedullary devices, plates, or external fixation can be used. Ilizarov devices can be used with rotational boxes, but the Taylor spatial frame is best suited for rotational correction.

A size mismatch and some translation occur between the proximal and distal segments after significant rotational correction.

The metaphysis is the best place to perform an osteotomy in terms of the speed of healing. Proximal tibial metaphyseal derotation osteotomies alter the patellar tracking and the patellofemoral joint mechanics, and they are not preferred. Also, osteotomies can be performed in the distal tibia and fibula, which can be derotated as one functional piece, avoiding alteration of the ankle mechanics.

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Postoperative Details

The lower extremity is immobilized in a non–weight-bearing short leg cast for 4-6 weeks. The cast merely augments the initial stability achieved by using internal fixation.

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Follow-up

The cast is removed at 4-6 weeks after surgery. The healing is generally solid enough to allow for the removal of the K-wires. Immediate unprotected weight bearing is allowed.

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Contributor Information and Disclosures
Author

Minoo Patel, MBBS, MS, FRACS  Senior Lecturer, Monash University; Director, Centre for Limb Reconstruction and Deformities, Epworth Centre, Melbourne, Australia; Orthopaedic Adult/Pediatric Surgeon, Epworth Hospital, Melbourne, Australia; Consulting Adult/Pediatric Orthopedic Surgeon, Department of Orthopedic Surgery, Monash Medical Center, Australia

Minoo Patel, MBBS, MS, FRACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, AO Foundation, Australian Association of Surgeons, Australian Medical Association, Australian Orthopaedic Association, Bombay Orthopedic Society, Indian Orthopedic Association, Orthopaedic Research Society, Orthopaedics Overseas, and Royal Australasian College of Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

John Herzenberg, MD, FRCSC  Head of Pediatric Orthopedics, Director of International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore

John Herzenberg, MD, FRCSC is a member of the following medical societies: American Academy for Cerebral Palsy and Developmental Medicine, American Academy of Orthopaedic Surgeons, Limb Lengthening and Reconstruction Society ASAMI-North America, and Pediatric Orthopaedic Society of North America

Disclosure: Smith and Nephew, EBI, Orthofix Educational Grant None

Specialty Editor Board

Dennis P Grogan, MD  Clinical Professor, Department of Orthopedic Surgery, University of South Florida College of Medicine; Chief of Staff, Department of Orthopedic Surgery, Shriners Hospital for Children of Tampa

Dennis P Grogan, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Eastern Orthopaedic Association, Irish American Orthopaedic Society, Pediatric Orthopaedic Society of North America, and Scoliosis Research Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Thomas M DeBerardino, MD  Associate Professor, Department of Orthopedic Surgery, Consulting Surgeon, Sports Medicine, Arthroscopy and Reconstruction of the Knee, Hip and Shoulder, Team Physician, Orthopedic Consultant to UConn Department of Athletics, University of Connecticut Health Center

Thomas M DeBerardino, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, and American Orthopaedic Society for Sports Medicine

Disclosure: Arthrex, Inc. Grant/research funds Other; Arthrex, Inc. Consulting fee Speaking and teaching; Genzyme Biosurgery. Inc. Grant/research funds Other; Musculoskeletal Transplant Foundation Grant/research funds Other; Histogenics Grant/research funds None

Dinesh Patel, MD, FACS  Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital

Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Carlos J Lavernia, MD, FAAOS  Adjunct Clinical Professor, Department of Orthopedic Surgery, University of Miami School of Medicine; Medical Director, Orthopedic Institute at Mercy Hospital

Carlos J Lavernia, MD, FAAOS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Hip and Knee Surgeons, Arthritis Foundation, Biomedical Engineering Society, Florida Orthopaedic Society, and Orthopaedic Research Society

Disclosure: Zimmer Stock Implant Designer

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