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Coronal Plane Knee Moments Improve After Correcting External Tibial Torsion in Patients With Cerebral Palsy

  • Symposium: Current Approaches in Cerebral Palsy, A Focus on Gait Problems
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

External tibial torsion causes an abnormal axis of joint motion relative to the line of progression with resultant abnormal coronal plane knee moments and affects lever arm function of the foot in power generation at the ankle. However, it is unclear whether surgical correction of the tibial torsion corrects the moments and power.

Questions/purposes

We evaluated whether surgical correction of external tibial torsion in patients with cerebral palsy would correct the abnormal coronal plane knee moments and improve ankle power generation.

Methods

We studied 22 patients (26 limbs) with cerebral palsy (Gross Motor Function Classification System Level I or II) who underwent distal internal rotation osteotomies for correction of external tibial torsion as part of a multilevel surgical intervention. There were 10 males and 12 females with a mean age at surgery of 14 years (range, 6.8–20.9 years). All patients had pre- and postoperative standardized clinical evaluation and computerized three-dimensional gait analysis. Minimum followup was 9 months (average, 13 months; range, 9–19 months).

Results

On physical examination, the mean (± SD) transmalleolar axis improved from 43° ± 10° preoperatively to 20° ± 7° postoperatively. Mean knee rotation improved kinematically from 40° ± 9° preoperatively to 21° ± 9° postoperatively. Twenty-two of 26 limbs (88%) improved in one or both peaks of the abnormal coronal plane knee moments. Ankle power generation did not change from preoperative (1.6 ± 0.7 W/kg) to postoperative (1.6 W/kg).

Conclusions

Correction of external tibial torsion in ambulatory patients with cerebral palsy improves the kinematic and kinetic deviations identified by gait analysis.

Levels of Evidence

Level IV, therapeutic series. See Guidelines for Authors for a complete description of levels of evidence.

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References

  1. Aminiam A, Vankoski SJ, Dias L, Novak RA. Spastic hemiplegic cerebral palsy and the femoral derotation osteotomy: effect at the pelvis and hip in the transverse plane during gait. J Pediatr Orthop. 2003;23:314–320.

    Article  Google Scholar 

  2. Bell KJ, Ounpuu S, DeLuca PA, Romness MJ. Natural progression of gait in children with cerebral palsy. J Pediatr Orthop. 2002;22:677–682.

    Article  PubMed  Google Scholar 

  3. Bennett JT, Bunnell WP, MacEwen GD. Rotational osteotomy of the distal tibia and fibula. J Pediatr Orthop. 1985;5:294–298.

    Article  PubMed  CAS  Google Scholar 

  4. Carriero A, Zavatsky A, Stebbins J, Theologis T, Shefelbine SJ. Correlation between lower limb bone morphology and gait characteristics in children with spastic diplegic cerebral palsy. J Pediatr Orthop. 2009;29:73–79.

    Article  PubMed  Google Scholar 

  5. Delgado ED, Schoenecker PL, Rich MM, Capelli AM. Treatment of severe torsional malalignment syndrome. J Pediatr Orthop. 1996;16:484–488.

    Article  PubMed  CAS  Google Scholar 

  6. Dias LS, Jasty MJ, Collins P. Rotational deformities of the lower limb in myelomeningocele: evaluation and treatment. J Bone Joint Surg Am. 1984;66:215–223.

    PubMed  CAS  Google Scholar 

  7. Dodgin DA, DeSwart RJ, Stefko RM, Wenger DR, Ko JY. Distal tibial/fibular derotation osteotomy for correction of tibial torsion: review of technique and results in 63 cases. J Pediatr Orthop. 1998;18:95–101.

    Article  PubMed  CAS  Google Scholar 

  8. Dunteman RC, Vankoski SJ, Dias LS. Internal derotation osteotomy of the tibia: pre- and postoperative gait analysis in persons with high sacral myelomeningocele. J Pediatr Orthop. 2000;20:623–628.

    Article  PubMed  CAS  Google Scholar 

  9. Fabry G, MacEwen GD, Shands AR Jr. Torsion of the femur: a follow-up study in normal and abnormal conditions. J Bone Joint Surg Am. 1973;55:1726–1738.

    PubMed  CAS  Google Scholar 

  10. Hicks J, Arnold A, Anderson F, Schwartz M, Delp S. The effect of excessive tibial torsion on the capacity of muscles to extend the hip and knee during single-limb stance. Gait Posture. 2007;26:546–552.

    Article  PubMed  Google Scholar 

  11. Kay RM, Rethlefsen S, Reed M, Do KP, Skaggs DL, Wren TA. Changes in pelvic rotation after soft tissue and bony surgery in ambulatory children with cerebral palsy. J Pediatr Orthop. 2004;24:278–282.

    Article  PubMed  Google Scholar 

  12. Lai KA, Kuo KN, Andriacchi TP. Relationship between dynamic deformities and joint moments in children with cerebral palsy. J Pediatr Orthop. 1988;8:690–695.

    Article  PubMed  CAS  Google Scholar 

  13. Lee SH, Chung CY, Park MS, Choi IH, Cho TJ. Tibial torsion in cerebral palsy: validity and reliability of measurement. Clin Orthop Relat Res. 2009;467:2098–2104.

    Article  PubMed  Google Scholar 

  14. MacWilliams BA, McMulkin ML, Baird GO, Stevens PM. Distal tibial rotation osteotomies normalize frontal plane knee moments. J Bone Joint Surg Am. 2010;92:2835–2842.

    Article  PubMed  Google Scholar 

  15. Manouel M, Johnson LO. The role of fibular osteotomy in rotational osteotomy of the distal tibia. J Pediatr Orthop. 1994;14:611–614.

    Article  PubMed  CAS  Google Scholar 

  16. Meister K, James SI. Proximal tibial derotation osteotomy for anterior knee pain in the miserably malaligned extremity. Am J Orthop. 1995;24:149–155.

    PubMed  CAS  Google Scholar 

  17. Ounpuu S, DeLuca P, Davis R, Romness M. Long-term effects of femoral derotation osteotomies: an evaluation using three-dimensional gait analysis. J Pediatr Orthop. 2002;22:139–145.

    Article  PubMed  Google Scholar 

  18. Palisano R, Rosenbaum P, Walter S, Russell D, Wood E, Galuppi B. Development and reliability of a system to classify gross motor function in children with cerebral palsy. Dev Med Child Neurol. 1997;39:214–223.

    Article  PubMed  CAS  Google Scholar 

  19. Radler C, Kranzl A, Manner HM, Hoglinger M, Ganger R, Grill F. Torsional profile versus gait analysis: consistency between the anatomic torsion and the resulting gait pattern in patients with rotational malalignment of the lower extremity. Gait Posture. 2010;32:405–410.

    Article  PubMed  Google Scholar 

  20. Rattey T, Hyndman J. Rotational osteotomies of the leg: tibia alone versus both tibia and fibula. J Pediatr Orthop. 1994;14:615–618.

    Article  PubMed  CAS  Google Scholar 

  21. Rethlefsen SA, Healy BS, Wren TA, Skaggs DL, Kay RM. Causes of intoeing gait in children with cerebral palsy. J Bone Joint Surg Am. 2006;88:2175–2180.

    Article  PubMed  Google Scholar 

  22. Ryan DD, Rethlefsen SA, Skaggs DL, Kay RM. Results of tibial rotational osteotomy without concomitant fibular osteotomy in children with cerebral palsy. J Pediatr Orthop. 2005;25:84–88.

    PubMed  Google Scholar 

  23. Saraph V, Zwick EB, Zwick G, Dreier M, Steinwender G, Linhart W. Effect of derotation osteotomy of the femur on hip and pelvis rotations in hemiplegic and diplegic children. J Pediatr Orthop B. 2002;11:159–166.

    Article  PubMed  Google Scholar 

  24. Senaran H, Holden C, Dabney KW, Miller F. Anterior knee pain in children with cerebral palsy. J Pediatr Orthop. 2007;27:12–16.

    Article  PubMed  Google Scholar 

  25. Staheli LS. Practical Approach to Pediatric Orthopedics. 2nd ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2006.

    Google Scholar 

  26. Stefko RM, de Swart RJ, Dodgin DA, Wyatt MP, Kaufman KR, Sutherland DH, Chambers HG. Kinematic and kinetic analysis of distal derotational osteotomy of the leg in children with cerebral palsy. J Pediatr Orthop. 1998;18:81–87.

    Article  PubMed  CAS  Google Scholar 

  27. Steinwender G, Saraph V, Zwick EB, Uitz C, Linhart W. Assessment of hip rotation after gait improvement surgery in cerebral palsy. Acta Orthop Belg. 2000;66:259–264.

    PubMed  CAS  Google Scholar 

  28. Vankoski SJ, Michaud S, Dias L. External tibial torsion and the effectiveness of the solid ankle-foot orthoses. J Pediatr Orthop. 2000;20:349–355.

    Article  PubMed  CAS  Google Scholar 

  29. Williams JJ, Graham GP, Dunne KB, Menelaus MB. Late knee problems in myelomeningocele. J Pediatr Orthop. 1993;13:701–703.

    Article  PubMed  CAS  Google Scholar 

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Acknowledgments

The authors acknowledge Robin Dorociak for her technical assistance in data extraction and analysis.

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Authors and Affiliations

  1. Medical Staff Department, Shriners Hospitals for Children, Portland, 3101 SW Sam Jackson Park Road, Portland, OR, 97239, USA

    Michael Aiona MD, Kosta Calligeros MBBS, BSc & Rosemary Pierce PT

Authors
  1. Michael Aiona MD
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  2. Kosta Calligeros MBBS, BSc
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  3. Rosemary Pierce PT
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Corresponding author

Correspondence to Michael Aiona MD.

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Each author certifies that he or she, or a member of his or her immediate family, has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.

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Aiona, M., Calligeros, K. & Pierce, R. Coronal Plane Knee Moments Improve After Correcting External Tibial Torsion in Patients With Cerebral Palsy. Clin Orthop Relat Res 470, 1327–1333 (2012). https://doi.org/10.1007/s11999-011-2219-x

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  • DOI: https://doi.org/10.1007/s11999-011-2219-x

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