You are in: eMedicine Specialties > Orthopedic Surgery > KNEE Tibial TorsionArticle Last Updated: Nov 1, 2002AUTHOR AND EDITOR INFORMATIONSection 1 of 7
  Author: Minoo Patel, MBBS, MD, MS, FRACS, Senior Lecturer, Monash University; Consulting Adult/Pediatric Orthopedic Surgeon, Department of Orthopedic Surgery, Monash Medical Center, Australia Minoo Patel 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, Orthopaedic Research Society, Orthopaedics Overseas, Pediatric Orthopaedic Society of North America, and Royal Australasian College of Surgeons Coauthor(s): John Herzenberg, MD, FRCSC, Head of Pediatric Orthopedics, Co-director of International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore Editors: 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; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Thomas M DeBerardino, MD, Director, John A Feagin, Jr, Sports Medicine Fellowship at West Point, Associate Professor of Orthopedic Surgery, Uniformed Services University of the Health Sciences and Keller Army Community Hospital; Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital; 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 Author and Editor Disclosure Synonyms and related keywords: tibial torsion, in-toeing, intoeing, pigeon toeing, internal torsion, femoral torsion, femoral anteversion INTRODUCTIONSection 2 of 7
  Normal development Femoral anteversion decreases from approximately 40° at birth to approximately 15° at maturity. Lateral rotation of the tibia increases from approximately 5° at birth to approximately 15° at maturity. ProblemTibial torsion Medial torsion improves with time. Lateral torsion often worsens because the natural progression is toward increasing external torsion. The ability to compensate for tibial torsion depends on the amount of inversion and eversion present in the foot and on the amount of rotation possible at the hip. Internal torsion causes the foot to adduct, and the patient tries to compensate by everting the foot and/or by externally rotating at the hip. Similarly, persons with external tibial torsion invert at the foot and internally rotate at the hip. Femoral torsion The natural history of this condition is to resolve by the time the patient is aged 8-9 years. Beyond this age, all remodeling will have occurred, and any further correction is due to a conscious modification of posture. Femoral anteversion Normal femoral anteversion is 40° in the newborn and decreases to 10-15° by the age of 8 years. The acetabulum is angled forward 15°. Femoral anteversion does not increase the risk of arthritis of the hip. Spontaneous improvement in the anatomic position can occur until the patient is aged 8 years and by improving the gait through conscious effort until adolescence. ClinicalThe patient's history should consist of details of the age at onset, severity, disability, milestones, and family history. Clinical scenarios
Examination The diagnosis is based on clinical findings, and other investigations generally are not required. Examination must include tests to exclude hip dysplasia, hip and ankle ranges of motion, and knee varus or valgus, which can cause apparent errors in examination. In some cases, imaging studies may be helpful (see Imaging Studies). However, not every child who undergoes an evaluation because of torsional issues requires any or all of these imaging tests. Evaluation Parents are generally more concerned about intoeing than the children are. Severe intoeing can cause the child to trip or run awkwardly, and it can interfere with their participation in sports. Excessive wear is seen along the lateral border of the shoe, mainly in the front half, because the child uses this as the presenting border of the foot on the heel- or foot-strike. A rotational profile consists of the following:
The FPA is the angular difference between the axis of the foot and the line of progression. Normal FPA is 10-15° of external rotation. By convention, external rotation values are positive, and internal rotation values are negative. Degrees of intoeing are as follows:
Tibial version or torsion is the degree of rotation of the tibia along its long axis from the knee to the ankle. It is measured with the patient prone with his or her knees flexed to 90°. It is assessed by using the following 2 measures:
Femoral anteversion is the axial angle between the plane of the neck of the femur and the femoral condyles. It can be clinically deduced by measuring the hip rotation. Normal range of external rotation is 45-70°, and internal rotation is 10-45°. As femoral anteversion increases, the amount of internal rotation increases and external rotation decreases. These children can have as much as 90° of internal rotation and 0° of external rotation. They sit in the W position with their legs turned out (a position not attainable by normal adults), but they cannot sit cross-legged. The shape of the foot is best assessed with the patient standing and examined from the back, or the patient is prone and the feet are assessed by looking at the soles of the feet. Metatarsus adductus (or uncommonly, abductus) can be seen. INDICATIONSSection 3 of 7
Tibial torsion Osteotomy is indicated if the deformity is more than 3 standard deviations (SDs) from the mean (less than -10° or more than +35°). 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 85°, external rotation of less than 10°). CONTRAINDICATIONSSection 4 of 7
No absolute contraindications exist, provided that the indications for treatment are satisfied. Relative contraindications include borderline neurovascular status, especially if acute correction is contemplated, a poor skin condition, and a poor surgical risk overall. Lack of inversion is another relative contraindication to the correction of long-standing internal tibial torsion. This condition affects the patient's ability to position the foot down after external rotation correction. Patients with long-standing internal torsion tend to compensate by everting the foot. Excessive hip external rotation coupled with a lack of internal rotation, which is suggestive of retroverted hips, can be a good counter to internal tibial torsion. Tibial correction may lead to excessively externally rotated feet. WORKUPSection 5 of 7
Imaging Studies
TREATMENTSection 6 of 7
Medical therapyTreatment 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. Surgical therapyTibial torsion Osteotomy is indicated if deformity is more than 3 SDs from the mean (less than -10° or more than +35°). Osteotomies can be performed at any level. 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 85°, external rotation of <10°). 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. Intraoperative detailsThe 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. Postoperative detailsThe 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. Follow-upThe 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. REFERENCESSection 7 of 7
Article Last Updated: Nov 1, 2002 |
