External Tibial Torsion Research Articles

Effects of lower limb torsion on ankle kinematic data during gait analysis.

VICON Clinical Manager software is widely used for gait analysis and has four methods for computing ankle plantarflexion-dorsiflexion motion and transverse plane ankle rotation profiles. The authors evaluated 14 subjects with a diagnosis of spastic cerebral palsy and tibial torsion ranging from 39 degrees internal torsion to 90 degrees external torsion, using the four different processing methods. It was found that clinically measured tibial torsion >20 degrees external or >15 degrees internal led to significant differences in the calculated ankle plantarflexion-dorsiflexion and transverse plane ankle rotation measurements between the four methods. Pearson correlations indicated that these differences increased with increasing external or internal tibial torsion. The variability was enough to affect conclusions of published articles and clinical decision making.

Effects of lower extremity rotation on prognosis of flexible flatfoot in children.

The aim of this study is to search the effects of tibial torsion on flexible flatfoot. For this purpose, 20 children with flexible flatfoot and external tibial torsion were determined as a study group. The control group which consisted of 10 children with flexible flatfoot without rotational problems was included in the study. Plantar flexion angle of talus, talo-1. metatarsal angle and dorsoplantar talocalcaneal angle were measured on standing foot radiographs. Tibial torsion was measured by computed tomography. Plantar flexion angle of talus and dorsoplantar talocalcaneal angle were found significantly lower in the study group (p<0.005 and p<0.005 respectively), although talo-1. metatarsal angle was not significantly different between the groups (p=.2917). Naviculocuneiform sag was prominent in all cases of study group. In conclusion, abnormal external tibial torsion may affect the foot deformity and this can change the benign nature of the flexible flatfoot.

Internal Derotation Osteotomy of the Tibia: Pre- and Postoperative Gait Analysis in Persons with High Sacral Myelomeningocele

Rotational deformities of the lower extremities are common in patients with myelomeningocele. In these situations, surgical correction is often necessary. We conducted a retrospective review of eight ambulatory patients with high sacral myelomeningocele and external tibial torsion who underwent 10 distal tibia and fibular internal derotation osteotomies. All patients had an increased valgus knee stress preoperatively. Pre-and postoperative three-dimensional gait analysis was used to evaluate coronal plane knee moments and dynamic sagittal plane knee motion. Postoperatively, a significant improvement in the abnormal internal knee varus moment (p < 0.005) as well as a significant increase in the stance phase knee extension (p < 0.01) was seen. Three patients had resolution of preoperative knee pain. We believe that patients with increased knee stress secondary to excessive external tibial torsion will benefit from a tibial derotation osteotomy that could delay or prevent the onset of late degenerative changes about the knee.

External Tibial Torsion and the Effectiveness of the Solid Ankle–Foot Orthoses

The aims of this study were to determine the influence of external tibial torsion on the effectiveness of the ankle-foot orthoses (AFO) in children with lumbosacral myelomeningocele. Forty patients with normal tibial rotation and 18 patients with excessive external tibial torsion were evaluated with three-dimensional gait analysis at their comfortable walking speed. The group with normal tibial rotation showed significantly greater knee extension and lower mean extension moment compared with the group with external tibial torsion (p < 0.05). The posteriorly and laterally deviated ground-reaction force relative to the knee-flexion axis compromises the ability of this force to facilitate knee extension. Patients with torsional magnitudes >20 degrees demand close inspection as candidates for derotation osteotomy. The AFO will continue to stabilize the ankle-foot complex, but improved knee motion, knee-extensor activity, and ultimately walking efficiency may be compromised.

Rotational Profile of Lower Extremities in Bladder Exstrophy Patients with Unapproximated Pelvis: A Clinical and Radiologic Study in Children Older Than 7 Years

Fourteen patients (nine boys, five girls) with bladder exstrophy were analyzed radiologically and clinically. All were older than 7 years and had a pubic diastasis >2 cm. Anteroposterior and lateral center-edge angles were measured by direct radiography. Acetabular version, femoral anteversion, tibial torsion angles, and patellofemoral congruency angle were measured by computed tomography imaging. All were active with regard to their daily life and sports activities. The average foot-progression angle was +8°. Spherical congruency was present in all hips, and none showed dysplasia. The average angle of acetabular version was apparently less than normal, but femoral anteversion angles were found to be increased. Increased external tibial torsion was observed in all patients. Twelve (71%) of 14 patients had positive congruence angles, the average being +6.1°. Two patients had subjective complaints of patellofemoral instability. Increased femoral anteversion and external tibial torsion may lead to patellofemoral instability, and the bladder exstrophy patients should be followed up regarding this problem as well.

Computed tomography for femoral and tibial torsion in children with clubfoot.

Forty-seven children with 70 clubfeet had computed tomography studies performed to determine the degree of femoral, tibial, and total limb torsion in both lower limbs. The total limb torsion angle (angle between the axis of the femoral neck and the axis of the ankle), which describes the relationship between femoral and tibial torsion, was used to evaluate the whole rotational deformity of the lower limb. The children were between the ages of 2 and 10 years (mean, 5 years) at the time of the computed tomography study. The mean femoral torsion was 25 degrees in the limbs with a clubfoot and 23 degrees in the contralateral limbs of patients with a unilateral clubfoot. The mean tibial torsion was 25 degrees in the limbs with a clubfoot and 24 degrees in the contralateral limb of patients with a unilateral clubfoot. The authors observed decreases of anterior femoral torsion corresponding to increases in age, consistent with the observations made by other authors of studies of children without clubfoot. External tibial torsion increased with age, with similar values in limbs with and without clubfoot. Ten limbs (nine with clubfoot, one without clubfoot) had femoral torsion greater than the means plus one standard deviation and 12 limbs (eight with clubfoot, four without clubfoot) had tibial torsion less than the means minus one standard deviation. The authors found four limbs (all with clubfoot) in three patients with lower than the mean minus one standard deviation of the total limb torsion angle (intoeing). Overall, there was no appreciable difference in the amount of femoral or tibial torsion in limbs with and without a clubfoot.

Valgus knee stress in lumbosacral myelomeningocele: a gait-analysis evaluation.

Twenty-five independent community-ambulating patients with lumbosacral-level myelomeningocele (N = 50 limbs) underwent gait analysis. The limbs of these patients were divided into two groups based on thigh-foot angle (TFA): Group I (n = 20) had marked external tibial torsion, TFA > or = 20 degrees, and group II had TFA between 10 and 20 degrees. Ten limbs were excluded because of neutral or internal alignment. Twenty normal limbs with TFA = 10 degrees served as controls. An abnormal internal varus knee stress during stance was identified in all group I limbs and 12 (70%) of 20 limbs group II limbs compared with controls, which demonstrated an internal valgus stress. This internal varus moment was greater in group I limbs than in the abnormal limbs in group II (p < 0.05). Knee flexion was the only other parameter found to correlate with this stress and only in group I limbs. We conclude that (a) in this patient group, increased external tibial torsion is likely to result in an abnormal internal varus knee stress; (b) TFA > 20 degrees appears significantly to increase this stress; and (c) knee flexion is an important related parameter, but only in limbs with TFA between 10 and 20 degrees. We believe that this abnormal stress may predispose the knee to late arthrosis and that derotational osteotomies to normalize the TFA may prove to have a favorable long-term effect.

External tibial torsion in children with spina bifida: Its implication on the effectiveness of the solid AFO

External tibial torsion in children with spina bifida: Its implication on the effectiveness of the solid AFO

EXTERNAL TIBIAL TORSION. AN UNDERRECOGNIZED CAUSE OF RECURRENT PATELLAR DISLOCATION

Seventeen patients (18 knees) with recurrent patellar dislocation were identified with increased quadriceps angles secondary to excessive isolated external tibial torsion. Traditional realignment procedures attempted in these knees were unsuccessful because of failure to align the biomechanical axis of the extensor mechanism. Derotational osteotomies of the tibia just proximal to the patella tendon insertion were used to reduce the quadriceps angle to within normal limits to improve the biomechanics of the extensor mechanism. Seventeen (94%) knees were available for clinical and subjective followup at an average of 25 months (range, 1-3.2 years). Overall, 13 of the 17 knees were graded as good to excellent (76%). Five of the 17 patients also had well established anterior knee pain in addition to recurrent dislocation and were treated with a combined derotational and Maquet type osteotomy, with 4 patients obtaining a good to excellent result. Knees that subjectively and functionally demonstrated less painful symptoms preoperatively were associated with excellent results. Poor outcomes were associated with knees that were operated on multiple times.

Treatment of severe torsional malalignment syndrome.

Over a 7-year period (1984-1991), nine patients (aged 10-18 years) with 13 involved extremities were operatively treated for symptomatic severe torsional malalignment of the lower extremity and associated patellofemoral pathology. Physical examination and analysis of gait revealed severe rotational deformity characterized by excessive femoral anteversion and external tibial torsion. The cosmetic and functional pathologic effect of this torsional malalignment was centered about the knee joint. In all patients, conservative treatment, including therapy for muscle strengthening and nonsteroidal medication, was unsuccessful in alleviating suspected patellofemoral pain. Subsequent definitive operative treatment in all 13 extremities consisted of corrective osteotomies, internally rotating the distal part of the tibia or externally rotating the distal part of the femur or both. Osteotomies were performed as close to the knee joint as possible. No additional soft-tissue procedures were performed directly to affect patellar tracking. All osteotomies healed without complications. At an average follow-up of 2 years + 7 months (range, 18-48 months) overall, patients had an improvement in gait pattern, extremity appearance, and a marked decrease in knee pain.

External Tibial Torsion

Seventeen patients (18 knees) with recurrent patellar dislocation were identified with increased quadriceps angles secondary to excessive isolated external tibial torsion. Traditional realignment procedures attempted in these knees were unsuccessful because of failure to align the biomechanical axis of the extensor mechanism. Derotational osteotomies of the tibia just proximal to the patella tendon insertion were used to reduce the quadriceps angle to within normal limits to improve the biomechanics of the extensor mechanism. Seventeen (94%) knees were available for clinical and subjective followup at an average of 25 months (range, 1-3.2 years). Overall, 13 of the 17 knees were graded as good to excellent (76%). Five of the 17 patients also had well established anterior knee pain in addition to recurrent dislocation and were treated with a combined derotational and Maquet type osteotomy, with 4 patients obtaining a good to excellent result. Knees that subjectively and functionally demonstrated less painful symptoms preoperatively were associated with excellent results. Poor outcomes were associated with knees that were operated on multiple times.

Tibial Torsion in Patients With Medial-Type Osteoarthrotic Knees

Computed tomography (CT) measurements of torsion of the lower extremities were evaluated in 85 knees of 68 patients with medial-type osteoarthrotic knees and in 24 normal knees of 13 adults. In addition, segmental tibial torsion and CT density of the third lumbar vertebra, reflecting general osteoporosis, were measured. Although there were no differences in the degrees of femoral torsion or knee joint rotation, external tibial torsion in the 68 patients was observed to have a mean value of 11.3 degrees, significantly smaller than the 23.5 degrees observed in the 13 normal adults (p < 0.01). Lateral torsion was 14.1 degrees in mild, 11.9 degrees in moderate, and 7.5 degrees in severe stages of osteoarthrosis. The rate of decrease in lateral tibial torsion was 59.6% in the proximal tibia, 4.2% in the tibial shaft, and 36.2% in the distal tibia. The decrease of lateral tibial torsion was correlated with decrease of CT density of the third lumbar vertebra. There is a correlation between reduction of lateral torsion with the radiographic stage of osteoarthrosis of the knee and general osteoporosity.

The Association Between Tibial Torsion and Knee Joint Pathology

To study the association of tibial torsion with knee joint pathology, measurements have been made using a simple tropometer suitable for use in an outpatient clinic. Patient measurements in 11 diagnostic groups were compared with a control group. Two groups differed significantly from the controls. Those patients with patellofemoral instability had greater than normal external tibial torsion, whereas patients with pan-articular osteoarthrosis of the knee had reduced external torsion or true internal torsion. Abnormal torsion causes a gait adaptation, thus affecting external loading on the knee joint, which in turn may lead to osteoarthrosis.

The management of tibial torsion in patients with spina bifida

We reviewed 20 patients with spina bifida who had had surgical management of tibial torsion. Eight had had bilateral procedures and 12 a unilateral procedure, giving a total of 28 limbs for analysis. We performed closed osteoclasis on seven limbs and tibial osteotomy on 21. In the closed osteoclasis group six limbs (85%) had a good result after an average follow-up of nine years (2 to 22). All limbs developed postoperative anteromedial bowing of the tibia which later remodelled. In the tibial osteotomy group 19 (90%) had a good result. The average follow-up was nine years (2 to 28). Complications occurred in seven limbs (33%). We recommend closed osteoclasis of the tibia for the young patient with spina bifida in whom walking is impeded by excessive internal tibial torsion, and supramalleolar tibial osteotomy in the older patient with excessive external tibial torsion and a planovalgus foot.

The Inwardly Pointing Knee

Twelve patients with inwardly pointing knees had chronic knee pain and disability suggestive of patellofemoral subluxation. None had responded well to conservative measures or surgical correction at the level of the soft tissues. Their pattern of limb alignment was studied roentgenographically and was found to differ significantly from the control group of 49 healthy young adults. The deformities primarily related to the tibia were external tibial torsion, excess varus angulation of the tibial plateau, and varus knees. Angulation of the femoral condyles was normal and femoral anteversion did not appear to contribute significantly to the deformity. Surgery in seven cases (nine knees) was by derotation valgus Maquet osteotomy of the tibia and lateral release realignment of the patellae. Outcome assessments after a three-year follow-up period (five knees) were excellent. Early results on the remaining cases were satisfactory.

膝蓋・大腿関節障害を呈した１家系

Six closely related members of one family were found to have hypoplastic patellae. Familial hypoplasia of the patella is a rare condition. The pattern of inheritance of this family studied here is consistent with the transmission of a predisposing factor as an autosomal daminant.The commonest cause is an abnormally high patella although there may be other anomalies such as failure of development of the lateral femoral condyle and of the trochlear groove, and often there is an associated external tibial torsion.

Tibial Torsion in Patients with Medial-type Osteoarthritic Knee

Computed tomography measurements of tibial torsion were evaluated in 85 patients with medial-type osteoarthritic knees and in 24 normal adults. Although there were no differences in the degrees of femoral torsion or knee joint rotation, external tibial torsion was observed to have a mean value of 11.3 degrees, significantly smaller than the 23.5 degrees observed in the normal adults (p less than 0.01). The more advanced the osteoarthritic stage, the greater was the reduction in external tibial torsion. Reduction of external torsion of the tibia was most severe at the proximal tibial metaphysis.

Rotational alignment of the lower limb in osteoarthritis of the knee.

Rotational alignement of the lower limbs in 43 patients with osteoarthritis of the knee was measured by computerized tomography. Eighty-four limbs were classified in three subsets, patello-femoral osteoarthritis (subset P), medial femorotibial osteoarthritis (subset M) and lateral femorotibial osteoarthritis (subset L). The femorotibial angle of subset M was 5 degrees greater than that of subset P on the average. Femoral torsion of subset P was significantly greater than that of subset M. Femoral torsion in osteoarthritis of the knee was correlated with external tibial torsion and external torsion of the leg, which included both external rotation at the knee and external tibial torsion. External torsion of the leg in subset M was less than normal and rotational alignment of subset P was also outside the normal range. Our findings show that the frontal and rotational alignment of the lower limb are aetiological factors in osteoarthritis of the knee.

Rotational deformities of the lower limb in myelomeningocele. Evaluation and treatment.

We studied the results of surgical treatment for rotational deformities of the lower extremity in fifty children. The preoperative rotational deformities were subdivided as follows: (1) external rotation deformity of the hip (nine hips), (2) external tibial torsion (twenty-nine limbs), and (3) toeing-in gait (thirty-one limbs). These were further analyzed as to imbalance between the forces of the medial and lateral hamstrings, that imbalance associated with fixed internal tibial torsion, and isolated internal tibial torsion. The average length of follow-up was four years and six months. For the external rotation deformity of the hip we performed a derotation osteotomy with internal fixation at the subtrochanteric level. That procedure led to eight good results and one fair result. The external tibial torsion was treated by a derotation osteotomy of the tibia and fibula distally, with correction of the valgus deformity of the ankle if that was more than 10 degrees. In twenty patients a good result was obtained. For the toeing-in gait associated with a medial-lateral hamstring imbalance, the semitendinosus was transferred to the biceps and the head of the fibula. Good results were seen in ten of the fourteen patients. In twelve limbs a derotation osteotomy of the distal ends of the tibia and fibula was done alone, with eight good and fair results. In five patients a simultaneous semitendinosus transfer and derotation osteotomy was used. All had a good result. The over-all rate of good and fair results in the entire series was 79.6 per cent.

The Skiing Sequelae of Tibial Torsion

The purpose of this communication is to support the following hypotheses: 1. That variations in tibial torsion are functionally important in parallel skiing. 2. That external tibial torsion in particular is a "deformity" that can interfere markedly with parallel skiing. 3. That even normal individuals have greater external torsion of the right tibia than the left, and that this normal difference may correlate with the preference of many skiers for traversing and maneuvering primarily in one direction. 4. That a relatively small difference in the anatomic alignment of the lower extremities may entail substantial alterations in balance and in distribution of forces in the skier and that these differences should be searched out by centers preparing to equip skiers with bindings and skiis in an attempt to further refine the skier-ski linkage. These hypotheses derive from a blend of the personal experience of the principal author and a detailed search of the English and French literature of the past century relating to rotational alignment, motion, and control of the lower extremity in general, and to tibial torsion in particular.