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Tibial Torsion Treatment & Management

  • Author: Minoo Patel, MBBS, PhD, MS, FRACS; Chief Editor: Thomas M DeBerardino, MD  more...
 
Updated: Jan 03, 2015
 

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 three standard deviations (SDs) from the mean (less than – 10º or more than +35º). Osteotomies (supramalleolar osteotomy) can be performed at any level.[23, 24]

Femoral torsion

Osteotomy correction is indicated if the deformity is more than three 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; if this is rotated externally, it 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 (K-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 a single functional piece, thus avoiding alteration of the ankle mechanics.

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Follow-up

The lower extremity is immobilized in a nonweightbearing short leg cast for 4-6 weeks. The cast merely augments the initial stability achieved by using internal fixation. Once the cast is removed at 4-6 weeks after surgery, the healing is generally solid enough to allow removal of the K-wires. Immediate unprotected weightbearing is allowed.

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Outcomes

Drexler et al conducted a study to evaluate the clinical and radiographic outcomes of 12 patients (15 knees) undergoing tibial derotation osteotomy and tibial tuberosity transfer for recurrent patella subluxation associated with excessive external tibial torsion.[25] Clinical evaluation was carried out using preoperative and postoperative Knee Society Score, Kujala Patellofemoral score, the Western Ontario and McMaster Universities Osteoarthritis Index questionnaire, the short form-12, and a visual analogue score pain scale.

Significant improvement was achieved on all measures.[25] Two patients had a nonunion of the tibial osteotomy site, 1 patient required bone grafting, and another patient required revision to total knee arthroplasty. The investigators concluded that for patients with recurrent patella subluxation secondary to excessive external tibial torsion, satisfactory outcomes in terms of pain relief and improved function can be achieved through tibial derotation osteotomy and tibial tuberosity transfer.

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Contributor Information and Disclosures
Author

Minoo Patel, MBBS, PhD, MS, FRACS Senior Lecturer, Monash University; Director, Centre for Limb Reconstruction and Deformities, Epworth Centre; Chairman, Cabrini Hospital Orthopaedic Surgery Specialty Group; Orthopaedic Adult/Pediatric Surgeon, Epworth Hospital; Fellowship Director, Epworth Kleos Upper Limb and Limb Reconstruction Fellowship; Consulting Adult/Pediatric Orthopedic Surgeon, Department of Orthopedic Surgery, Monash Medical Center, Australia

Minoo Patel, MBBS, PhD, MS, FRACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Australian Association of Surgeons, Australian Medical Association, Australian Orthopaedic Association, Royal Australasian College of Surgeons, Orthopaedic Research Society, AO Foundation, Orthopaedics Overseas, Indian Orthopedic Association, Bombay Orthopedic Society, Shoulder and Elbow Society of Australia, Australian Paediatric Orthopaedic Society, Australian Limb Lengthening and Reconstruction Society, Victorian Hand Surgery Society, Victorian Shoulder and Elbow Society

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, Pediatric Orthopaedic Society of North America, Limb Lengthening and Reconstruction Society, American Academy of Orthopaedic Surgeons

Disclosure: Received educational grant from Smith and Nephew, EBI, Orthofix for none.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Thomas M DeBerardino, MD Orthopedic Surgeon, The San Antonio Orthopaedic Group; Research Director, BRIO of the San Antonio Orthopaedic Group; Consulting Surgeon, Sports Medicine, Arthroscopy and Reconstruction of the Knee, Hip and Shoulder, Team Physician; Adjunct Associate Professor, Uniformed Services University of the Health Sciences, F Edward Hebert School of Medicine

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

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Arthrex, Inc.; Ivy Sports Medicine; MTF; Aesculap; The Foundry, Cotera; ABMT<br/>Received research grant from: Histogenics; Cotera; Arthrex.

Additional Contributors

Dennis P Grogan, MD Clinical Professor (Retired), Department of Orthopedic Surgery, University of South Florida College of Medicine; Orthopedic Surgeon, Department of Orthopedic Surgery, Shriners Hospital for Children of Tampa

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

Disclosure: Nothing to disclose.

References
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Lateral radiograph of 1-year-old child with posteromedial tibial bowing.
 
 
 
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