Clinical assessment of tibial torsion differences. Do we always need a computed tomography?

Abstract

Background Tibial torsional malalignment presents a well-known complication of intramedullary nailing for tibial shaft fractures. Purpose Objective of this study was to investigate the ability to clinically assess tibial torsion differences. Computed Tomography (CT) was used here as the gold standard. Further, intra- and inter-observer reliability of the clinical examination, and radiological measurements were calculated. Methods Fifty-one patients with torsion-difference CTs, obtained for various reasons, were asked to kneel on an examination couch with free hanging feet. All patients are positioned with 90° flexed knee and neutral ankle. A picture of the lower extremities was obtained from the back of the patient. Two blinded orthopedic surgeons were asked to look at the pictures and measure the tibial torsion with a digital goniometer, based on the axis of the femur in relation to the second ray of the foot. To determine the intra-observer variation, the torsional angles were calculated again after 4 weeks. To be able to compare values, two blinded radiologists calculated torsional differences based on computed tomography. Results All patients were able to be positioned for clinical assessment (n = 51). Clinical assessment of torsional difference revealed 4.55° ± 6.85 for the first, respectively, 4.55° ± 7.41 for the second investigator. The second measurement of the first investigator revealed a value of 4.57° ± 6.9. There was a good intra-observer agreement for clinical assessment (ICC 0.993, p < 0.001). Also, the inter-observer agreement showed a good inter-observer agreement (ICC 0.949, p < 0.001). Evaluation of radiological inter-observer assessment could also show a good inter-observer agreement (ICC 0.922, p < 0.001). The clinical method showed a good correlation to the CT method (0.839, p < 0.001). Additionally, the Bland–Altman plot was used to compare graphically both measurement techniques, which proved the agreement. Conclusion In summary, computed tomography-assisted measurement of tibial torsion and clinical assessment correlated significantly good. In addition to that, clinical measurement has a good intra- and inter-observer reliability. Clinical examination is a reliable and cost-effective tool to detect mal-torsion and should be part of the repertoire of every surgeon.

Rotational anomalies in patients with hallux valgus .Observational Study

“…En este estudio, las mediciones en las EEII se tomaron segmentariamente en lugar de globalmente para identificar el origen de una anomalía rotacional en el conjunto de la extremidad inferior. Singh 32 y Hawi 24 sostienen que el ángulo muslo-pie proporciona una alternativa fiable a la tomografía computarizada para medir la TT. Los resultados de este estudio no se desvían de la media de 15° del ángulo muslo-pie en personas sin patología 33 , aunque este valor puede ampliarse a 19°3 4 .…”

“…Se indicó al paciente que no elevara la cadera opuesta durante la rotación de la cadera ni durante el movimiento de relajación de la pierna hacia ambos lados. La TT se evaluó mediante un goniómetro universal de dos ramas; una de las ramas se colocó en la planta del pie, trazando la bisectriz desde el centro del talón hasta el segundo radio, y la otra rama se dirigió al centro sagital del muslo, manteniendo la posición de la articulación subastragalina neutra 24 . En la 1.ª MTPJ, la flexión y extensión pasivas se valoraron colocando el goniómetro en la cara interna del pie, con una rama del goniómetro siguiendo la bisectriz previamente trazada del primer radio y la falange proximal, tras lo cual se forzó el movimiento correspondiente hasta su tope articular 25 (Figura 1).…”

Tibial derotational osteotomy for idiopathic tibial torsion: A systematic review of surgical indications based on clinical presentation and measurement technique

“…A likely reason for this was to avoid unnecessary ionizing radiation, despite the high reliability of measuring tibial torsion using CT imaging. Although CT and MRI provide reliable and accurate measurements to assess tibial torsion, prior literature has noted measurements on clinical exam to strongly correlate with CT imaging measurements [14,19]. Therefore, routine advanced imaging after TDO is not necessary to assess the correction.…”