External Tibial Torsion Research Articles

Lower limb maltorsion and acetabular deformity in children and adolescents with X-linked hypophosphatemia.

X-linked hypophosphatemia (XLH) is a rare monogenetic skeletal disorder. Lower limb deformities contribute substantially to impaired gait quality and burden of disease in patients with XLH. Standardized data regarding onset and severity of lower limb maltorsion are unavailable. This study aimed to evaluate lower limb maltorsion using rotational magnetic resonance imaging (MRI) and computed tomography (CT). Rotational MRI and CT of children and adolescents with verified XLH were evaluated retrospectively. Femoral and tibial torsion, acetabular anteversion, and axial acetabular coverage were measured and compared with published age-adapted radiographic, clinical measurements and MRI data, respectively. Fifteen patients (mean age, 10.7 years) were included in the study. Decreased femoral torsion was observed in 47% (14/30 femora) and femoral retrotorsion in 17% (5/30 femora). Ten of 13 hips with coxa vara deformity presented with decreased femoral antetorsion. Reduced external tibial torsion manifested in 64% (18/28 tibiae). Abnormal axial femoral head coverage was present in 67% (20/30 hips), whereas 53% (16/30 hips) showed increased acetabular anteversion. Femoral and tibial torsional pathologies were found in children and adolescents with XLH. The occurrence of severe femoral retrotorsion in a 2-year-old child prior to ambulation raises questions regarding the biomechanical impact of gait on the development of torsional deformities in XLH.

Double-Level Torsional Osteotomy in Severe Torsional Malalignment: A Surgical Technique

Background: Torsional malalignment of the femur and/or tibia is associated with patellar maltracking, and torsional osteotomies have shown to improve clinical symptoms. In patients with severe torsional malalignment, a double-level torsional osteotomy may be necessary. Indications: Symptomatic torsional malalignment leading to patellofemoral maltracking associated with anterior knee pain and/or patellofemoral instability. Technique Description: A double-level torsional osteotomy correcting both increased internal femoral torsion and increased external tibial torsion, is described. Meticulous preoperative deformity analysis and planning of the osteotomy is mandatory. An arthroscopy of the knee is performed first to evaluate the patellofemoral joint and patellar tracking. Tibial torsional correction is performed by a lateral approach. A biplanar osteotomy is performed, and the amount of torsional correction is controlled by 2 Schanz screws. Osteosynthesis can be done via a bended 5-hole DC-Plate or an angle-stable plate. The femoral osteotomy is performed by a medial approach. A uniplanar osteotomy is performed perpendicular to the mechanical axis of the femur. The amount of torsional correction is controlled by 2 Schanz screws. Osteosynthesis is achieved by an angle-stable plate. Results: Double-level torsional osteotomy has been shown to be an effective treatment for patients with patellar dislocation or subluxation associated with severe torsional malalignment. In a series of 18 patients, double-level osteotomy led to improved patellofemoral stability, decreased pain, and increases subjective outcome scores. Discussion/Conclusion: In patients with patellofemoral problems caused by a combined increased tibial external torsion and increased femoral internal torsion, a double-level torsional osteotomy is able to correct torsional angles to normal. Available clinical data on this procedure are promising. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Trochleoplasty and à-la-carte procedures for patellar instability in young and active patients: Clinical outcomes at minimum 2 Years follow-up

IntroductionPatellar instability is a common condition affecting approximately 6 individuals per 100,000, but among adolescents, this incidence is notably higher. Trochlear dysplasia has been recognized as the pathoanatomic risk factor exerting the most significant biomechanical influence. Over time, various surgical techniques have been developed to address trochlear dysplasia. The purpose of this study is to evaluate the clinical outcomes, return to sport, as well as complications and re-operation rate of sulcus deepening trochleoplasty performed in a cohort of young and active patients using the Bereiter technique. Materials and methodsBetween January 2019 and February 2022, 11 cases of recurrent patellar dislocations underwent trochleoplasty. Preoperative radiological assessment included X-rays, CT scans following the Lyons and MRI. Inclusion criteria for the study and trochleoplasty indications included patients aged 10–25 with recurrent patellar dislocations unresponsive to nonoperative treatment and minimum type B trochlear dysplasia. Clinical follow-up occurred at 1-3-6 months and annually, with control X-rays at these intervals. Patient-reported outcome scores included the Knee Society Score, Kujala score, and Karnofsky performance status scale. ResultsBetween January 2019 and February 2022, 11 patients underwent trochleoplasty and were included in this study. Preoperative radiological measurements indicated mean values: sulcus angle (152.5°), trochlear depth (3.4 mm), Caton-Deschamps index (1.2), tibial tuberosity to trochlear groove (TT-TG) distance (17.5 mm), external patellar tilt angle (6.8°), femoral anteversion (11.5°), and tibial torsion (32°). All patients were followed up for at least 2 years, with an average of 43 months. Concurrent surgeries included tibial tuberosity transposition (100 %), MPFL reconstruction in 9 cases (81.8 %) and 2 patients also underwent division of the external alar ligament (18,2 %). PROMs at final follow-up showed mean values: Knee Society Score (KSS) (80.5), Kujala score (88.3), and Karnofsky performance status scale (88.8). Return to sport was reported by all active patients. Three cases required secondary surgical intervention for removal of the screws. ConclusionTrochleoplasty, especially with the Bereiter "thin flap" approach, improves patellofemoral congruency. Combining trochleoplasty with tibial tuberosity transposition addresses mal-tracking related to severe dysplasia and other à-la-carte procedures like medial patellofemoral ligament (MPFL) reconstruction enhance stability. In young and active patients, it resolves instability issues and reduces the likelihood of further dislocations with high return to sport rates.

Operative Treatment of Patellofemoral Instability: Osteotomies for Torsional and Coronal Malalignment

Patellofemoral instability (PFI) is a prevalent orthopedic issue that leads to significant morbidity and functional limitation. It has a notable incidence, specifically higher amongst adolescent females, and a recurrence rate ranging from 17% to 33%. Recurrent PFI significantly increases the risk of degenerative changes and early-onset osteoarthritis. Patients with multiple risk factors increase recurrence rates significantly, and thus identifying and managing anatomical risk factors is an effective strategy for patients. These include: trochlear dysplasia, patella alta, increased tibial tubercle-to-trochlear groove (TT-TG) distance, increased femoral anteversion, external tibial torsion and valgus limb alignment.This study outlines a comprehensive evaluation and surgical approach focusing on PFI associated with torsional or coronal malalignments. The evaluation includes a detailed patient history, clinical examination, and diagnostic imaging. Surgical interventions are selected based on an algorithmic approach tailored to the specific pathoanatomy of the instability, focusing on both bony and soft-tissue procedures.Surgical techniques for addressing PFI in the presence of malalignment include proximal and distal bony procedures. Specific techniques detailed in this study include femoral torsional osteotomy over an intramedullary nail, distal femur opening and closing wedge osteotomies, and torsional tibial osteotomies fixed with an intramedullary nail or plate.

THE ROLE OF ROTATION IN TOTAL ANKLE ARTHROPLASTY

BackgroundThe importance of total ankle replacement (TAR) implant orientation in the axial plane is poorly understood with major variation in surgical technique of implants on the market. Our aims were to better understand the axial rotational profile of patients undergoing TAR.MethodsIn 157 standardised CT Scans of end-stage ankle arthritis patients planning to undergo primary TAR surgery, we measured the relationship between the knee posterior condylar axis, the tibial tuberosity, the transmalleolar axis(TMA) and the tibiotalar angle. The foot position was measured in relation to the TMA with the foot plantigrade. The variation between medial gutter line and the line bisecting both gutters was assessed.ResultsThe mean external tibial torsion was 34.5±10.3°(11.8–62°). When plantigrade the mean foot position relative to the TMA was 21±10.6°(0.7–38.4°) internally rotated. As external tibial torsion increased, the foot position became more internally rotated relative to the TMA(pearson correlation 0.6;p< 0.0001). As the tibiotalar angle became more valgus, the foot became more externally rotated relative to the TMA(pearson correlation −0.4;p< 0.01). The mean difference between the medial gutter line and a line bisecting both gutters was 4.9±2.8°(1.7°-9.4°). More than 51% of patients had a difference greater than 5°. The mean angle between the medial gutter line and a line perpendicular to the TMA was 7.5°±2.6°(2.8°-13.7°).ConclusionThere is a large variation in rotational profile of patients undergoing TAR, particularly between the medial gutter line and the transmalleolar axis. Surgeon designers and implant manufacturers need to develop consistent methods to guide surgeons towards judging appropriate axial rotation of their implanton an individual basis. We recommend careful clinical assessment and CT scanspre-operatively to enable the correct rotation to be determined.

Surgical treatment for recurrent patellar dislocation with severe torsional deformities:Double-level derotational osteotomy may not have a clear advantage over single-level derotational osteotomy in improving clinical and radiological outcomes.

The purpose of this study was toinvestigate whether double-level (femur + tibia) derotational osteotomy is superior to single-level femoral derotational osteotomy for recurrent patellar dislocation with severe femoral and tibial rotational deformities (femoral anteversion >30° and external tibial torsion >30°). Between January 2015 and June 2020, a total of 115 knees with recurrent patellar dislocation treated with combined medial patellofemoral ligament reconstruction (MPFL-R) and derotational osteotomies were evaluated after a minimum follow-up of 2 years. Among these cases, 15 knees that underwent double-level derotational osteotomy were included in the double-level group, which was propensity-matched in a 1:2 ratio to a single-level group of patients who underwent single-level femoral derotational osteotomy (30 knees). The clinical and radiological outcomes were evaluated and compared between the groups. Furthermore, the foot progression angle was measured preoperatively and 2 years after surgery. The patient-specific variables did not differ significantly between the double-and the single-level groups after propensity score matching. The postoperative mean foot progression angle was significantly lower in the double-level groupthan in the single-level group (9° ± 8° vs. 15° ± 11°; p = 0.014); however, there were no statistically significant differences between the groups in terms of any other clinical and radiological assessments. For patients with severe femoral and tibial torsional deformities (femoral anteversion >30° and external tibial torsion >30°), the double-level derotational osteotomy is superior to single-level osteotomy in maintaining normal foot progression angle, but it does not show an advantage in terms of patient-reported outcomes, radiological resultsand redislocation rate at minimum 2 years of follow-up. Furthermore, concomitant excessive external tibial torsion (>30°) did not have an adverse effect on clinical outcomes in patients who underwent derotational distal femoral osteotomy with MPFL-R due to excessive femoral anteversion. Level III.

Rotational Malalignment After Intramedullary Nailing of Tibial Shaft Fractures Is Predictable.

Intramedullary nailing is the treatment of choice for most tibial shaft fractures (TSF). However, an iatrogenic pitfall may be rotational malalignment. The aim of this retrospective analysis was to determine predictors of rotational malalignment following intramedullary nailing of TSF. Retrospective study. Single level 1 trauma center. Patients who had a unilateral intramedullary nailing for TSF with a low-dose bilateral postoperative CT to assess rotational malalignment. Bivariable analysis followed by multivariable analysis was then undertaken to assess for any independent predictors, such as fracture type/sight, surgeon experience, and side of fracture, predictive of rotational malalignment. In total, 154 patients (71% male, median age 37 years) were included in this study. Thirty-nine percent of variability in postoperative rotational malalignment could be explained using a model including (increased) tibial torsion of the noninjured side (mean [38.9 degrees ± 9.02 degrees] considered normal tibial torsion), side of tibial fracture, and spiral-type tibial fracture (R2 = 0.39, P ≤ 0.001, F = 31.40). In this model, there was a negative linear association between degrees of torsion on the noninjured side and rotational malalignment (-0.45, P < 0.001)-as baseline torsion increased from mean by 1 degree, malrotation in the opposite direction of 0.54 degrees seen. Positive linear associations between right-sided TSF and rotational malalignment (8.59 P < 0.001) as well as spiral fractures and rotational malalignment (5.03, P < 0.01) were seen. This study demonstrates that baseline reduced (internal) tibial torsion of the noninjured limb, spiral fractures, and right-sided TSF are predictive of postoperative external rotational malalignment. Conversely, increased baseline (external) tibial torsion of the noninjured limb and left-sided TSF are predictive of postoperative internal rotational malalignment. Surgeons may use this regression model preoperatively to predict what sort of postoperative rotational difference their patient may be prone to. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Early Surgical Management of Medial Patellar Luxation in Juvenile Dogs.

The aim of this study was to analyse a series of five cases of early surgical treatment in juvenile canine patients with high-grade medial patellar luxation. Canine patients, with immature skeleton, affected by grade III or IV medial patellar luxation and treated by multimodal surgical techniques were selected. Five dogs of different breeds, mean age 7.2 ± 3.0 months, met the inclusion criteria. Simultaneous distal femoral varus and external tibial torsion were identified in three of the five cases, whereas in the others, femoral varus with associated tibial valgus and isolated external tibial torsion were observed. Four of the five patients were treated surgically with closing wedge osteotomy of the distal femur, and three of them underwent tibial tuberosity transposition simultaneously. Only two animals required trochleoplasty. Mean time to beginning of weight bearing was 9.8 ± 5.5 days, whereas time to bone healing was 55 ± 24 days. Bone realignment of the extensor apparatus and return to limb support were achieved in all cases. Postoperative reintervention was needed in one patient; however, it was not linked to the initial surgery. Patients were followed up to 1 year postoperatively, with maintenance of extensor alignment and no late complications. The early surgical approach has been shown to be effective in the definitive treatment of juvenile dogs affected by high-grade medial patellar luxation.

Analysis of lower extremity alignment (LEA) in children with recurrent patellar dislocation by EOS system.

Recurrent patellar dislocation (RPD) greatly affects active young individuals, necessitating the identification of risk factors for a better understanding of its cause. Previous research has connected RPD to lower limb alignment (LEA) abnormalities, such as increased femoral anteversion, tibial external rotation, knee valgus, and flexion. This study aims to use EOS technology to detect RPD-related LEA anomalies, enabling three-dimensional assessment under load conditions. A total of 100 limbs (50 in the RPD group, 50 in the control group) were retrospectively analyzed. In the RPD group, we included limbs with recurrent patellar dislocation, characterized by dislocations occurs at least two times, while healthy limbs served as the control group. We used EOS technology, including 2D and 3D imaging, to measure and compare the following parameters between the two groups in a standing position: Femoral neck shaft angle (NSA), Mechanical femoral tibial angle (MFTA), Mechanical lateral distal femoral angle (mLDFA), Medial proximal tibial angle (MPTA), Anatomical femoral anteversion (AFA), External tibial torsion (ETT), and Femorotibial rotation (FTR). The significant differences between the two groups were shown in NSA 3/2D, MFTA 3/2D, mLDFA 3/2D, MPTA 3D, AFA, FTR. No significant difference was shown in MPTA 2D, ETT between the RPD group and the control group. Further binary logistic regression analysis. Further binary logistic regression analysis was conducted on the risk factors affecting RPD mentioned above. and found four risk factors for binary logistic regression analysis: mLDFA (3D), AFA, NSA(3D), and FTR. EOS imaging identified abnormal LEA parameters, including NSA, MFTA, mLDFA, MPTA, AFA, and FTR, as risk factors for RPD. Children with these risk factors should receive moderate knee joint protection.

Miserable malalignment syndrome associated knee pain: a case for infra-tubercle tibial de-rotation osteotomy using an external fixator

IntroductionMiserable malalignment syndrome is a complex torsional lower limb deformity with limited consensus on surgical treatment. We present the outcome of de-rotation of the tibia alone using an external fixator.MethodsFifteen patients (22 segments) were operated on between 2012 and 2020; 13 presented with anterior knee pain, and two presented with out-toeing. Gait analysis was done in nine patients, and CT scan rotational profile, including tibial tubercle–trochlear groove distance, femoral version, and tibial torsion, were calculated. Kujala knee pain score and visual analogue pain score (VAS) were recorded. All underwent infra-tubercular osteotomy of the tibia and midshaft osteotmy of the fibula and application of a hexapod circular frame to gradually internally rotate the tibia until the foot aligned with the patella.ResultsThere was no preoperative clinical or radiographic evidence for patellar instability, femoral anteversion 30° (21°–54°), and external tibial torsion 50° (37–70). The mean age at surgery was 21 years (12–37) with a mean follow-up of 20 months (9–83). All osteotomies healed, and the frames were removed at a mean of 111 days (80–168). The mean VAS score improved from 8(5–9) to 1(0–4) postoperatively (P < 0.001). The mean Kujala knee pain score increased from 53 (30–75) to 92 (54–100) postoperatively (P < 0.001). The mean preoperative foot progression angle (FPA) was 37° (20°–50°), with 13 postoperatively walking with neutral FPA. One patient walked with symmetrical + 10° and the other with − 5° FPA. All patients reported relief of knee pain and were satisfied with the alignment.ConclusionGradual correction of severe external tibia torsion with a hexapod external fixator and an infra-tubercle tibial osteotomy could provide an optimum method to eliminate knee pain and improve limb alignment in miserable malalignment syndrome.

The association between tibial torsion, knee flexion excursion and foot progression during gait in people with knee osteoarthritis: a cross-sectional study

BackgroundLower limb malalignment is associated with gait kinematics, but there is limited information on the relationship between gait kinematics and tibial torsion in individuals with knee osteoarthritis (OA). This study aimed to investigate possible associations between tibial torsion and early stance kinematics during gait in people with mild and moderate medial knee OA.MethodsForty-seven participants (age: 62.1 ± 6.0 years; female/male: 37/10) diagnosed with medial knee OA were recruited from a regional hospital. Thirty of them had mild and seventeen had moderate knee OA. Lower limb alignment including tibial torsion and valgus/varus alignment were assessed by an EOS biplaner X-ray system with participants in weight-bearing position. Lower limb kinematics during gait was captured using the Vicon motion analysis system. The associations were estimated by partial Pearson correlation coefficient test.ResultsOur results indicated that external tibial torsion was related to early stance knee flexion excursion in participants with moderate knee OA (r = -0.58, p = 0.048), but not in participants with mild knee OA (r = 0.34, p = 0.102). External tibial torsion was associated with external foot progression angle (r = 0.48, p = 0.001), and knee varus/valgus alignment was associated with knee flexion excursion (r = -0.39, p = 0.010) in all participants.ConclusionsBoth horizontal and frontal lower limb alignments were associated with knee flexion excursion at early stance of gait cycle in participants with medial knee OA. The distal rotational profile of lower limb would likely affect knee motion in sagittal plane. It implies that people with moderate knee OA could possibly benefit from correction of rotational alignment of lower limb.

Different Modalities in Management of Recurrent Patellar Dislocation

Background Patellar instability is a complex pathoanatomical phenomenon that requires an intricate understanding in order to properly treat patients. Often, the etiology of this entity is multifactorial, and can be the result of a combination of coronal limb malalignment, patella alta, malrotation secondary to internal femoral or external tibial torsion, a dysplastic trochlea, or disrupted and weakened medial soft tissue, including the medial patellofemoral ligament (MPFL) and the vastus medialis obliquus. Objective To review the currently available different modalities for management of recurrent patellar dislocation. This Review will analyze results concerned with Patellar instability to reach the most efficient modality that gives the best results. Material and Methods This systematic review study based on inclusion and exclusion criteria conducted to evaluate the outcome of different techniques of medial patellofemoral ligament reconstruction analyzing their efficacy and possible complications. This systematic review demonstrates that MPFL surgery for recurrent patellar dislocation isolated or in combination with other procedures results in a significant improvement in Kujala scores, a low redislocation rate, and an acceptable complication rate. Despite this, there is no consensus on indications for MPFL reconstruction, graft type, surgical technique, and rehabilitation program. The inclusion criteria for future studies were highly important, and consensus agreement within an expert panel should be sought prior to undertaking such a study. Data Sources Medline databases (PubMed, Medscape, ScienceDirect. EMF-Portal) and all materials available in the Internet till 2021. Data Extraction If the studies did not fulfill the inclusion criteria, they were excluded. Study quality assessment included whether ethical approval was gained, eligibility criteria specified, appropriate controls, and adequate information and defined assessment measures. Results Several fixation methods have been introduced in medial patellofemoral ligament (MPFL) reconstruction. However, the optimal management of patients with recurrent patellar dislocation remains controversial. This short-term study showed that after MPFL reconstruction (suture anchors or transosseous sutures), patellar stability could be restored. And no significant differences in outcome scores were observed between patients in the transosseous suture and suture anchor groups. Conclusion Evaluate the outcome of different techniques of medial patellofemoral ligament reconstruction analyzing their efficacy and possible complications.

Systematic Literature Review and Meta-Analysis on Miserable Malalignment Syndrome

Background: Miserable malalignment syndrome (MMS) is a rare condition that entails increased femoral anteversion and increased external tibial torsion, as well as the presentation of one, some, or all the following: squinting patella, patella alta, patellar instability, an increased Q angle, genus valgus (knock knees) or genus varum (bow leggedness), genus recurvatum, feet pronation, or pes planus. Methods: The Sample, Phenomenon of Interest, Design, Evaluation, Research type search strategy was used to retrieve eligible studies from databases fitting the established inclusion criteria. Results: All studies agreed that nonoperative treatment is ineffective in improving MMS. Surgical treatment is effective, although it involves osteotomies at 2 levels per limb. Conclusions: Double-level osteotomies were effective in all studies, vastly improving range of motion, chronic knee pain, chronic hip pain, and other factors. Surgical treatment of this condition should only be reserved for severe cases because complications are possible. Level of Evidence: Most articles used were part of a case series, indicating this review article is based on level 4 evidence.

SNAPPING HIP SYNDROME: A SYSTEMATIC REVIEW OF CURRENT SURGICAL MANAGEMENT AND A CASE REPORT OF AN OVERLOOKED CAUSE

IntroductionSnapping hip syndrome is a common condition affecting 10% of the population. It is due to the advance of the iliotibial band (ITB) over the greater trochanter during lower limb movements and often associated with hip overuse, such as in athletic activities. Management is commonly conservative with physiotherapy or can be surgical to release the ITB. Here we carry out a systematic review into published surgical management and present a case report on an overlooked cause of paediatric snapping hip syndrome.Materials &amp; MethodsA systematic review looking at published surgical management of snapping hip was performed according to PRISMA guidelines. PubMed, MEDLINE, EMBASE, CINAHL and the Cochrane Library databases were searched for “((Snapping hip OR Iliotibial band syndrome OR ITB syndrome) AND (Management OR treatment))”. Adult and paediatric published studies were included as few results were found on paediatric snapping hip alone.Results1548 studies were screened by 2 independent reviewers. 8 studies were included with a total of 134 cases, with an age range of 14–71 years. Surgical management ranged from arthroscopic, open or ultrasound guided release of the ITB, as well as gluteal muscle releases. Common outcome measures showed statistically significant improvement pre- and post-operatively in visual analogue pain score (VAPS) and the Harris Hip Score (HHS). VAPS improved from an average of 6.77 to 0.3 (t-test p value &lt;0.0001) and the HHS improved from an average of 62.6 to 89.4 (t-test p value &lt;0.0001).ConclusionsAlthough good surgical outcomes have been reported, no study has reported on the effect of rotational profile of the lower limbs and snapping hip syndrome. We present the case of a 13-year-old female with snapping hip syndrome and trochanteric pain. Ultrasound confirmed external snapping hip with normal soft tissue morphology and radiographs confirmed no structural abnormalities. Following extensive physiotherapy and little improvement, she presented again aged 17 with concurrent anterior knee pain, patella mal-tracking and an asymmetrical out-toeing gait. CT rotational profile showed 2° of femoral neck retroversion and excessive external tibial torsion of 52°. Consequently, during her gait cycle, in order to correct her increased foot progression angle, the hip has to internally rotate approximately 35–40°, putting the greater trochanter in an anterolateral position in stance phase. This causes the ITB to snap over her abnormally positioned greater trochanter. Therefore, to correct rotational limb alignment, a proximal tibial de-rotation osteotomy was performed with 25° internal rotation correction. Post-operatively the patient recovered well, HHS score improved from 52.5 to 93.75 and her snapping hip has resolved. This study highlights the importance of relevant assessment and investigation of lower limb rotational profile when exploring causes of external snapping hip, especially where ultrasound and radiographs show no significant pathology.

Pathologic external tibial torsion as one of the causes of knee joint dysfunction and formation of pronation deformity in children with cerebral palsy

Introduction. One of the complications of the clinical course of cerebral palsy in children is external torsion of the tibia. The issue of localization and the mechanism of its formation, as well as effective methods of its elimination, is debatable. Purpose - to study the mechanisms of the formation of pathological external torsion of the tibia in children with cerebral palsy, its effect on knee joint contracture and foot deformity, and effective methods of their correction. Materials and methods. The data obtained during the observation of 45 patients (90 cases) aged from 6 to 16 years with spastic diplegia, spastic tetraparesis and foot pronation were analyzed. To study the mechanisms of formation of external torsion of the lower leg and its correction, 2 groups of patients were selected. The Group I - 24 patients with internal rotation contractures of the hip joint (10 patients with internal rotation contractures of the hip joint; 10 patients - in combination with pathological antetorsion of the femoral neck; 4 patients - in combination with flexion contractures of the knee joints). The relationship between internal rotation contracture of the hip joint and external torsion of the tibia. The Group II consisted of 21 patients who were diagnosed with flexion contracture of the knee joints in combination with external torsion of the tibia. In order to study the effectiveness of operative treatment of knee flexion contracture and external torsion of the tibia in the Group II, 2 subgroups were distinguished: the subgroup IIA - 9 patients who underwent osteotomy of the tibial bone; the subgroup IIB - 12 patients who only underwent biceps femoris transposition. Results. Based on the study of clinical and radiological indicators, it was established that pathological torsion of the tibial bone is combined with flexion contracture of the knee joints. Proximal derotational osteotomy of the tibia has a positive effect on the results of correction of knee flexion contracture and foot position. Conclusions. The main reason for the formation of external torsion of the tibia is the imbalance of the flexor muscles of the knee joint and the supinator and pronator muscles of the foot. Proximal tibial derotation osteotomy eliminates not only pathological torsion, but also flexion contracture of the knee joints and excessive pronation of the foot. The study was conducted in accordance with the principles of the Declaration of Helsinki. The study protocol was approved by the local ethics committees of all institutions participating in the study. Informed consent of the patients was obtained for the research. No conflict of interests was declared by the authors.

Determination of Standard Values for Knee Version in a Healthy Population

Background: Different measures are used to describe relevant anatomic variations that can result in patellofemoral instability and disorders. Knee version, the relative rotational alignment between the femur and tibia in the axial plane at the level of the knee, may have a decisive effect on the kinematics of the patellofemoral joint. However, data regarding the values of knee version are currently lacking. Purpose: This study aimed to determine standard values for knee version in a healthy population. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 100 healthy volunteers (50 male and 50 female) without patellofemoral disorders or lower extremity malalignment were included in this study and underwent knee magnetic resonance imaging. The torsion values of the femur and tibia were independently measured using the Waidelich and Strecker method. Knee version, defined as static rotation of the tibia with respect to the femur in full extension, was determined by measuring the angle between the tangent lines to the dorsal femoral condyle (DFC) and the dorsal tibial head (DTH; defined by the posterior point of the proximal tibial plateau). Supplementary measurements were obtained as follows: (1) femoral epicondylar line (FEL), (2) tibial ellipse center line (TECL), (3) tibial tuberosity–trochlear groove (TT-TG) distance, and (4) tibial tuberosity–posterior cruciate ligament (TT-PCL) distance. Results: In 200 analyzed legs of 100 volunteers (mean age, 26.5 ± 5.8 years [range, 18 to 40 years]), we identified a mean internal femoral torsion of −23.8°± 9.7° (range, −46.2° to 1.6°), external tibial torsion of 33.2°± 7.4° (range, 16.4° to 50.3°), and external knee version (DFC to DTH) of 1.3°± 3.9° (range, −8.7° to 11.7°). Other measurements were as follows: FEL to TECL, −0.9°± 4.9° (range, −16.8° to 12.1°); FEL to DTH, −3.6°± 4.0° (range, −12.6° to 6.8°); and DFC to TECL, 4.0°± 4.9° (range, −12.7° to 14.7°). The mean TT-TG distance was 13.4 ± 3.7 mm (range, 5.3-23.5 mm), and the mean TT-PCL distance was 11.5 ± 3.5 mm (range, 6.0-20.9 mm). Female participants had significantly greater external knee version than male participants. Conclusion: Coronal- and sagittal-plane alignments of the knee have a well-known effect on the biomechanics of this joint. Additional information about the axial plane may result in new decision-making algorithms for managing knee disorders. This study is the first to report standard values of knee version in a healthy population. As a subsequent step building on this work, we advocate for the measurement of knee version in patients with patellofemoral disorders, as this parameter may assist with new treatment guidelines in the future.

Equation predicting tibial-tuberosity to trochlear-groove distance following supratubercle osteotomy: Radiographic proof of concept

BackgroundSupratubercle tibial rotational osteotomies are useful in patellar stabilizing procedures with high tibial-tuberosity to trochlear-groove distance caused by excessive external tibial torsion. An investigation determined one degree of internal tibial rotation results in 0.68 mm reduction of tibial-tuberosity to trochlear-groove distance, but did not account for anatomical variability. MethodsThis is a radiographic proof of concept for equation validation. We compared two different derived equations, a complex four-variable and simplified two-variable equation, to the literature relationship and true measured value from CT imaging. Bilateral pre-operative CTs of 37 patients, evaluated for malalignment, were reviewed retrospectively. We virtually simulated derotations of five, ten and fifteen degrees, and compared the reduction in tibial-tuberosity to trochlear-groove distance measured radiologically from CTs to the one predicted by our equation. FindingsThe difference between the true change in tibial-tuberosity to trochlear-groove distance and that obtained using our four-variable was statistically insignificant for all derotation angles (p > 0.05), and the two-variable equation it was statistically insignificant for five and fifteen degrees of derotation (p > 0.05). Conversely, the true values were statistically different from those found using the published relationship (p < 0.05 for all). InterpretationThis new equation accounts for individual patient anatomy, for a more accurate relationship between internal rotation of the distal segment of the tibia and the subsequent decrease in the tibial-tuberosity to trochlear-groove distance. The change was overestimated using the linear relationship, which may result in under correction. Future studies will assess true post-operative distance change following osteotomy.

Evaluation of Q Angle in Down syndrome

Background: Down Syndrome is a genetic disorder and the most common chromosomal abnormality. It is predominantly characterized by muscle hypotonia and joint hypermobility. Qangle is the angle formed between two imaginary lines one from ASIS to Center of Patella, another from Tibial tuberosity to the Center of Patella. Objectives: Aim of the study is to evaluate the Q-angle in male children with Down syndrome of 7-16 years of age and compare the values between children with internal and external tibial torsion. Methodology: It is an observational study done with convenient sampling carried out in 12 male children with Down syndrome. The tibial torsion was measured. Based on internal and external tibial torsion they were categorized into Group A and B respectively. Group A consisting of 7 children with internal tibial torsion and Group B consisting of 5 children with external tibial torsion. Q-angle was measured using standard goniometer. Results: There is no significant difference in P-value (P&gt;0.05) between the right and left leg of children in Group A and in Group B. On comparison between Group A and Group B, there was a statistical significance in P-Value of 0.005 and 0.050 when compared mean of Q angle for right leg and left leg respectively. Conclusion: The study concluded that assessing Q-angle helps to evaluate the biomechanical changes in knee. In this study done for the male children with Down syndrome, the Q-angle lies within the normal range of 13.1±3.5. However children with internal tibial torsion has comparatively decreased angle and children with external tibial torsion has comparatively increased angle even though there is no deviation from the normal range for the age.

Tibial Tuberosity Transposition Tool Technique in Combination with Distal Femoral Lateral Closing Wedge Osteotomy for Patellar Luxation Treatment in Five Dogs

AbstractMedial patellar luxation is a multifactorial condition resulting from a misalignment of the stifle extensor mechanism. Several techniques have been described for correcting this condition, depending on the specific morphological changes identified. This case series describes the combination of tibial tuberosity transposition tool techniques and distal lateral femoral closing wedge osteotomy in the treatment of dogs with medial patellar luxation. A combination of these two techniques was used in five dogs with varying degrees of medial luxation of the patella resulting from distal femoral varus and less than 20 degrees distal external torsion of the tibia. The combination of techniques allowed the alignment of the stifle extensor mechanism and corrected medial patellar luxation in all dogs. Radiographic bone union occurred in all dogs, with a mean time of 30 ± 2 days for tibial osteotomy and 48 ± 16 days for the femur. There was no recurrence of patellar dislocation, and no complications developed in any animal during a 1-year-long observation period. This case series demonstrates that the combination of tibial tuberosity transposition tool techniques and distal lateral femoral closing wedge osteotomy can be an effective treatment for medial patellar luxation associated with distal femoral varus with external tibial torsion less than 20 degrees.

Tibial Derotational Osteotomy for Patellofemoral Instability: A Systematic Review.

The etiology of patellofemoral (PF) instability is multifactorial. Excessive external tibial torsion has been associated with recurrent patellar subluxation and persistent anterior knee pain. Several surgical techniques have been historically used to correct this, including medial patellofemoral ligament reconstruction, tibial tuberosity transfer (TTT), trochleoplasty, and tibial derotation osteotomy (TDO). The purpose of this systematic review is to investigate the safety and efficacy of TDO for PF instability and pain. A thorough search of the literature was conducted on July 15, 2022. Seven studies met the inclusion criteria for this systematic review. Among the included studies, there were 179 total subjects and 204 operative knees. Mean follow-up time was 66.31 months (range 11-192). Complication rate was low (12.8%) in studies that reported complications. Average degree of anatomical correction in the transverse plane was 19.9 degrees with TDO. This increased to 34 degrees when combined with TTT. All PROMs assessed were significantly increased postoperatively (p < 0.05). Age greater than 25 years and advanced PF chondromalacia may negatively affect postoperative outcomes. The primary findings of this review were as follows: (1) TDO results in significantly improved pain and PROM ratings in patients with PF pain and/or instability, (2) the likelihood of complication, including recurrent patella subluxation after TDO, is low but may be increased by aging, and (3) the successful anatomical correction of TDO may be augmented by concurrent TTT in some cases.