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Introduction
  • An external rotational deformity of the lower extremity
    • in contrast to in-toeing, external rotational deformity may cause disability and degrade physical performance
  • Epidemiology
    • since the leg externally rotates with physical growth, this deformity usually worsens during late childhood and early adolescence.
    • may be bilateral but if unilateral most commonly involves the right lower extremity.
  • Associated Conditions
    • miserable malalignment syndrome
      • a condition defined as external tibial torsion with femoral anteversion
    • Osgood-Schlatter disease 
    • osteochondritis dessicans 
    • early degenerative joint disease
      • an association between external tibial torsion and early degenerative joint disease has been found
    • neuromuscular conditions
      • may be found with neuromuscular conditions such as myelodysplasia and polio
Anatomy
  • Normal development
    • tibia externally rotates on average 15 degrees during early childhood
    • femoral anteversion decreases on average 25 degrees during this time as well
Presentation
  • Symptoms
    • anterior knee pain 
      • caused by patellofemoral malalignment
  • Physical Exam camera
    • thigh-foot axis measurement  
      • best way to evaluate tibial torsion
        • average during infancy is 5 degrees internal rotation, that slowly derotates
        • average at 8 years of age is 10 degrees external, ranging from -5 to +30 degrees
      • technique
        • lie patient prone with knee flexed to 90 degrees
        • thigh-foot-axis is the angle subtended by the thigh and the longitudinal axis of the foot   
    • transmalleolar axis measurement
      • another way to evaluate tibial torsion
        • average at infancy is 4-5 degrees internal rotation
        • average at adulthood is 23 degrees external (range 0-40 degrees external)
      • technique
        • lie patient supine
          • an imaginary line from medial malleolus to lateral malleolus and another imaginary line from medial to lateral femoral condyle is made
          • the axis is the angle made at the intersection of these two lines
          • this helps to determine the direction and extent of tibial torsion present
Imaging
  • Usually none required.
Treatment
  • Nonoperative
    • rest, rehab, and activity modifications
      • indications
        • first line of treatment
  • Operative
    • supramalleolar derotational osteotomy or proximal tibial derotational osteotomy 
      • indications
        • surgery is reserved for children older than 8 years of age with external tibial torsion greater than three standard deviations above the mean ( >40 degrees external).
        • more likely to require surgery than internal tibial torsion
Techniques
  • Supramalleolar rotational osteotomy
    • technique
      • osteotomy
        • supramalleolar rotational osteotomy is most commonly performed
        • fibula is obliquely osteotomized if the deformity is severe
        • proximal tibial osteotomies are avoided secondary to higher risk factors associated with this procedure
      • plate fixation
        • cross pin fixation or plate fixation
      • intramedullary fixation
        • IM fixation with rotational osteotomy is reserved for skeletally mature adolescents
 

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