Bilateral double osteotomy in severe torsional malalignment syndrome: 16 years follow-up

Abstract

BackgroundTorsional malalignment syndrome (TMS) is a well defined condition consisting of a combination of femoral antetorsion and tibial lateral torsion. The axis of knee motion is medially rotated. This may lead to patellofemoral malalignment with an increased Q angle and chondromalacia, patellar subluxation and dislocation. Conservative management is recommended in all but the most rare and severest cases. In these cases deformity correction requires osteotomies at two levels per limb.Materials and methodsFrom 1987 to 2002 in our institution three patients underwent double femoral and tibial osteotomy for TMS bilateral correction (12 osteotomies). All patients were reviewed at mean follow-up of 16 years.ResultsAt final follow-up no patients reported persistence of knee or hip pain. At clinical examination both lower limbs showed a normal axis and a normal patella anterior position. Pre-operative femoral version measurement showed an average hip internal rotation of 81.5° (range 80°–85°) and average hip external rotation of 27.2° (10°–40°). Thigh–foot angle measurement showed an average value of 38.6° (32°–45°). At final follow-up femoral version measurement showed an average hip internal rotation of 49° (range 45°–55°) and average hip internal rotation of 44.3° (20°–48°) (Figs. 1, 2, 3, 4, 5, 6). Thigh–foot angles measurement showed an average value of 21.6° (18°–24°) outward.ConclusionWe recommend a clinical, radiographical and CT scan evaluation of all torsional deformity. In cases of significant deformity, internally rotating the tibia alone is not sufficient. Ipsilateral outward femoral and inward tibial osteotomies are our current recommendation for TMS, both performed at the same surgical setting.

Three-dimensional biplanar radiography as a new means of accessing femoral version: a comparitive study of EOS three-dimensional radiography versus computed tomography

“…On average, there is 30-40°of anteversion at birth, and it decreases with time to approximately 10-15°in skeletally mature individuals. However, there can be significant variation between individuals and even between contralateral sides [1][2][3].…”

“…Femoral version contributes to the normal stability and function of the hip and knee joints and is an important clinical factor in many pathologic conditions, including torsional syndromes and their sequelae [2], femoral fractures [1], developmental dysplasia of the hip [4], hip joint arthroplasty [5,6], Legg-Calve-Perthes disease [7] and slipped capital femoral epiphysis [8,9].…”

Comparison of Pediatric and General Orthopedic Surgeons’ Approaches in Management of Blount’s Disease and Torsional Malalignment Syndrome

“…In the torsional malalignment syndrome, conservative management is recommended in all cases except severe ones (7). Some indications for surgical treatment are age > 8 years, medial hip rotation > 85°, and lateral tibial torsion ≥ 30°(7).…”

“…In this study, surgeons in both groups chose double-level osteotomy (femoral and tibial osteotomy) for symptomatic patients. Surgically rotating the tibia, alone, is not usually sufficient because the passive external rotation of the femur is not enough to accommodate the operatively-internally-rotated tibia (7).…”

“…Blount's disease is a developmental disorder that affects the posteromedial portion of the proximal tibial growth plate and is associated with various and internal torsion of the tibia, often with shortening (5,6). Torsional malalignment syndrome is usually a combination of femoral anteversion and excessive outward tibial rotation, as well as medial rotation of the knee motion axis, patellofemoral malalignment, chondromalacia, patellar subluxation, and dislocation (7,8).…”