Tibiofibular Torsion Research Articles

Tibiofibular torsion in congenital clubfoot

Tibiofibular torsion was measured by computed tomography in three series of patients affected by congenital clubfoot who were treated with different protocols. The normal leg of unilateral deformities served as the control. For the bilateral cases, only the right side was included in the study. The angle between the bicondylar axis of the tibia and the bimalleolar axis was the index of tibiofibular torsion. There were 34 clubfeet in the first series, treated with a posteromedial release, and 40 clubfeet in the second series, treated with a modified Ponseti method, whereas the third series included 16 clubfeet, treated with the original Ponseti method. All 90 clubfeet were graded at birth as group 3 according to the Manes classification. No patient had previous treatment. The patients of the first and the second series were followed up to maturity, whereas the patients of the third series were followed up to a maximum of 11 years of age. In the congenital clubfoot, the tibia and the fibula were externally rotated, in comparison with the normal leg; in fact, the average value of the angle of tibiofibular torsion was 32.2° in the first series, 23.9° in the second series, and 21.1° in the third series. In the normal tibiae, the average value of the angle of tibiofibular torsion was 21.4°. The difference between the first series and the normal controls was statistically significant, as was the difference between the first one and the other two series. The value of the tibiofibular torsion angle seems to be related to the manipulation technique used to treat clubfoot: when the manipulation does not allow a progressive eversion of the talus underneath the calcaneus, the external tibial torsion increases. At follow-up, an intoeing gait was present in seven treated clubfeet of the first series. In all of them except one, the highest value of the external tibial torsion angle was observed, with a low value of the Kite's angle and/or residual forefoot adduction. In the treated congenital clubfoot, persistent intoeing is not related to the angle of tibial torsion but rather to the amount of correction of calcaneal inversion and residual forefoot adduction.

Ethnic-, gender-, and age-related differences in femorotibial angle, femoral antetorsion, and tibiofibular torsion: Cross-sectional study among healthy Japanese and Australian Caucasians

The current study was conducted to examine ethnic, gender, and age-related differences in femorotibial angle (FTA), femoral antetorsion and tibiofibular torsion. Healthy Japanese (n = 120) and Australian Caucasian (n = 82) subjects were examined using a series of clinically reliable methods for measuring FTA and torsion of the lower limb. Subjects between 18-29 years of age were categorized as younger, 30-59 years as middle age, and 60 or more as older age. Three-way analysis of variance was utilized for data analysis. The Japanese subjects had significantly greater FTA (more varus) than the Australian subjects (P < 0.001). Femoral antetorsion in the Japanese subjects was significantly smaller in middle and older age groups than younger group (P < 0.05), but did not differ between the age groups in the Australian subjects. Further, tibiofibular torsion in female subjects was significantly greater in younger and middle age groups than the older age group (P < 0.01), but was not different between different age groups in males. The results suggest that healthy Japanese may have more genu varus alignment compared to the corresponding Australian population. Age-related ethnic and gender differences in femoral and tibiofibular torsion are worthy of further study.

A New Concept of Indexing Tibiofibular Torsion

A newly developed clinical method of indexing tibial torsion uses the medial surface of the tibia as the proximal reference; however, the selection of a specific landmark on the medial surface has not been justified. Three different surfaces relating to the tibial tuberosity were tested using 24 dry tibial bones to determine which provides the most accurate and reliable landmark for use as the proximal reference. The medial surface of the tibia at the inferior point of the tibial tuberosity was the most reliable proximal reference that yielded the highest level of association between the newly developed clinical method and true tibial torsion (r = 0.77). The new method has the potential to describe the anatomy of the leg and to improve the clinical measurement of tibiofibular torsion.

Validity and reliability of existing and modified clinical methods of measuring femoral and tibiofibular torsion in healthy subjects: Use of different reference axes may improve reliability

Previous studies have evaluated reliability and validity of clinical measurements of femoral and tibiofibular torsion, however, the results are conflicting, warranting an alternative method. The authors developed modified methods of measuring femoral and tibiofibular torsion using different reference axes, and validity and reliability of the modified and existing methods were examined in healthy subjects. Reference values were established using magnetic resonance imaging (MRI) for the validity study. There were significant differences between all clinical methods and corresponding MRI outcomes (P <0.05), whereas Pearson's correlation coefficients between the clinical methods and MRI ranged from 0.67-0.92. For modified methods, intraclass correlation coefficients were 0.89-0.97, whereas those of existing methods were 0.75-0.81. Modified methods were more precise, with standard error of measurements (SEM) of 1.5-2.9 degrees , compared to existing methods (SEM=4.0-5.1 degrees). These results indicate that clinical methods available currently do not accurately measure true torsion of the femur and tibia. Nevertheless, the clinical methods may be useful for screening and descriptive purposes as indices of true torsion, and use of different reference axes could improve their reliability.

A new concept of estimating tibiofibular torsion: an in vivo reliability study.

This study investigated intrarater reliability of an alternative method of estimating tibiofibular torsion. When compared to a currently used clinical method of measurement, a new method (tibiofibular torsion index or TTI) had less variable measurements with higher intraclass correlation coefficients and a lower standard error of measurement. Therefore, the TTI may be clinically appropriate. TTI would provide useful information if combined with a clinical measurement of knee rotation when measuring lower leg alignment. While TTI may be a more reliable method of estimating tibiofibular torsion in vivo, further in vivo research is essential to compare the TTI measurements with tibiofibular torsion measured with computed tomography to estimate the validity of the method. J Orthop Sports Phys Ther. 2003; 33(2):85–90.

Rotational profile of the lower extremity and foot progression angle: computerized tomographic examination of 50 male adults

Acetabular, femoral and tibial torsion of 50 normal adult male subjects were measured by computerized tomography and the relationship between these angles and foot-progression angle was examined. The mean acetabular anteversion was 15.6 degrees on the right and 15.8 degrees on the left, (range 3 degrees-30 degrees). The mean femoral torsion was 6.5 degrees on the right and 5.8 degrees on the left (range 14 degrees-28 degrees). The mean tibiofibular torsion was 30.9 degrees on the right and 29.1 degrees on the left (range 16 degrees-50 degrees). Although the normal range of torsional measurements of the lower extremity was very broad, subjects usually had out-toeing, with a mean foot-progression angle of 13.7 degrees on the right and 13.0 degrees on the left (range 6 degrees-21 degrees). No correlation was detected on the rotation between different levels of the lower limb. No difference was detected in the lower extremity rotational profile between right and left sides.

Measurement of Tibial Torsion and Thigh-Foot Angle Using Goniometry and Computed Tomography

Three therapists measured tibiofibular torsion and thigh-foot angle (TFA) goniometrically in 17 normal subjects, aged three to 24 years. Tibiofibular torsion was also measured using computed tomography (CT). Differences between testers for the goniometric measures were analyzed using a nonparametric analysis of variance. Wilcoxon's rank sum test was used to determine differences between goniometric and CT measures for tibiofibular torsion. No significant difference for goniometric measures was found between testers for tibiofibular torsion or TFA. A significant difference averaging 5 degrees between goniometric and CT torsion measures was found between testers. Although a significant difference was found between the two measurement methods, the degree of difference may not represent a significant clinical difference, as a range at 5 degrees is commonly reported as the margin of error for goniometric measurements.

Tibial torsion measured by ultrasound in children with talipes equinovarus

Previous clinical studies have studied tibiofibular torsion by measuring the angular difference between a proximal (often bicondylar) plane and a distal bimalleolar plane. We measured the angular difference between the proximal and distal posterior tibial planes as defined by ultrasound scans. We found no significant torsional difference between the right and left tibiae of 87 normal children, nor between their different age groups. The mean external torsion of 58 legs with congenital talipes equinovarus was 18 degrees; significantly less than the mean 40 degrees in the normal children and 27 degrees in the clinically normal legs of the 22 patients with unilateral congenital talipes equinovarus. We did not confirm the previously reported increase in external torsion with increasing age. The relative internal tibial torsion we have demonstrated in patients with congenital talipes equinovarus must be differentiated from the posterior displacement of the distal fibula observed by others and which may result from manipulative treatment. The relative internal tibial torsion we found in the clinically normal legs of children with congenital talipes equinovarus is further evidence that in this condition the pathology is not confined to the clinically affected foot.

Tibiofibular Torsion from the Fetal Period Until Birth

The anatomic findings of Le Damany and Dupuis are still valuable as a reference. However, their measurement of tibial torsion does not correspond to clinical conditions. In fact, the torsion of the tibiofibular functional unit corresponds to the angle between the transverse axis of the proximal tibial epiphyseal plate and the axis through the middle of both malleoli. A comparative morphologic, radiologic, computerized axial tomographic and anatomic study performed on 50 fetuses with this definition has shown different results. Tibiofibular torsion was in the clear lateral position from the beginning of the fetal period, with a positive gradient at birth.

Tibiofibular Torsion from the Fetal Period Until Birth

The anatomic findings of Le Damany and Dupuis are still valuable as a reference. However, their measurement of tibial torsion does not correspond to clinical conditions. In fact, the torsion of the tibiofibular functional unit corresponds to the angle between the transverse axis of the proximal tibial epiphyseal plate and the axis through the middle of both malleoli. A comparative morphologic, radiologic, computerized axial tomographic and anatomic study performed on 50 fetuses with this definition has shown different results. Tibiofibular torsion was in the clear lateral position from the beginning of the fetal period, with a positive gradient at birth.

Measurement of tibial torsion by ultrasound.

A method of measuring tibial torsion with ultrasound, using reference lines on the tibia, was developed and tested on dry adult tibiae. This technique was used for evaluation of a group of children with apparently normal tibiae and another group of children with spina bifida, cerebral palsy, or clubfoot. The study showed that it is possible to measure true tibial torsion (rather than tibiofibular torsion) with ultrasound. The technique was found to be reliable and accurate enough for routine clinical use and had advantages over clinical methods and other radiographic imaging techniques. Values obtained by this technique are higher than those obtained by methods using the bimalleolar axis as the distal reference line.

Tibiofibular torsion in normal and treated clubfoot populations.

Tibiofibular torsion was measured in normal and clubfoot populations. A gradual increase, up to skeletal maturity, was demonstrated in normal legs. Lateral tibiofibular torsion was reduced in patients at the completion of clubfoot treatment, and it was concluded that derotation braces did not influence this result.

THE MEASUREMENT OF TIBIOFIBULAR TORSION

1. It is possible to measure tibiofibular torsion accurately by the roentgenographic method described. 2. The method is applicable to torsion ranging from -45 degrees of medial torsion to +75 degrees of lateral torsion. 3. The method is applicable to both adults and children.