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Supramalleolar derotation osteotomy of the tibia, with T plate fixation

Journal of Bone and Joint Surgery, Nov 2004 by Selber, P, Filho, E R, Dallalana, R, Pirpiris, M, Et al

TECHNIQUE AND RESULTS IN PATIENTS WITH NEUROMUSCULAR DISEASE

Torsional deformities of the tibia are common in children, but in the majority both the torsion and the associated disturbance of gait resolve without intervention. There are, however, a significant number of children and adults with neuromuscular disease who present with pathological tibial torsion, which may require surgical correction.

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We conducted a prospective study in two centres, to investigate the outcome of supramalleolar derotation osteotomy of the tibia, using internal fixation with the AO-ASIF T plate. A range of outcome variables was collected, prospectively, for 57 patients (91 osteotomies), including thigh foot angle, foot progression angle, post-operative complications and serial radiographs. Correction of thigh foot angle and foot progression angle was satisfactory in all patients. Three major complications were recorded; one aseptic nonunion, one fracture through the osteotomy site after removal of the plate and one distal tibial growth arrest.

We found that supramalleolar derotation osteotomy of the tibia, with AO-ASIF T plate fixation is an effective method for the correction of torsional deformities of the tibia and the associated disturbances of gait in children and adults with neuromuscular disease, with a 5.3% risk of major complications.

Torsional malalignment in the legs is common and usually self-limiting.1-4 Medial tihial torsion is usually physiological,5 whereas lateral tibial torsion is much more likely to be acquired and is usually seen in patients with neuromuscular disease, such as cerebral palsy and myelomeningocele.6,7 The effects of abnormal tibial torsion may be cosmetic and functional. The majority of patients present with excessive in-toeing or out-toeing and may also complain of tripping, leg pain, poor endurance or brace intolerance. There are many causes of gait disturbance apart from tihial deformity especially in children with cerebral palsy and myelomeningocele.6-9 In patients with neuromuscular disease, torsional deformity of the tibia may cause functional impairment, sometimes referred to as 'lever arm dysfunction'.

When there is malalignment of the foot in relation to the line of gait, the ability to generate an effective extensor moment at the knee level in mid-stance is decreased.6 In addition, deviation of the foot may reduce the efficiency of the muscle-tendon units, especially the ankle plantar flexors decreasing their ability to impart power to the gait cycle and to control forward progression of the tibia during second rocker. This may result in excessive dorsiflexion of the ankle during the stance phase, excessive knee and hip flexion and crouch gait.6 Excessive lateral tibial torsion has heen associated with abnormal internal varus knee moments and an increased risk of degenerative disease in patients with myelomeningocele.10,11 There is no evidence that non-operative management alters the natural history of pathological tibial torsion and the only effective treatment is surgical.1-5

Proximal tibial osteotomy has a high complication rate, including compartment syndromes and nerve palsies.12 It should be reserved for the correction of genu varum and gcnu valgum. A recent report recommends the distal tibia as the ideal site for correction of torsional deformity.13 Other areas of controversy are the need for fihular osteotomy and the type of fixation.13,14 Crossed Kirschncr wire fixation has been recommended.12-14 Internal fixation with straight compression plates and with a single staple have also heen reported.9,15 We report the results of the use of the AO-ASIF T plate for internal fixation in derotation osteotomy of the distal tibia in a prospective cohort study.

Patients and Methods

Two surgical centres were involved in the study, the Association for the Assistance of Crippled Children, Sào Paulo, and the Royal Children's Hospital, Melbourne. Patients with an in-toe or out-toe gait due to pathological tibial torsion, were considered for supramalleolar osteotomy. Between January 1995 and March 2000, 91 tibial derotation osteotomies were undertaken in 57 patients with neuromuscular disease. There were 30 men and boys and 27 women and girls with mean age 13.5 years (4 to 36). The mean follow-up was 44 months (24 to 80). The diagnoses were cerebral palsy in 47 patients and myelomeningocele in ten.

The clinical parameters recorded were the rotational profile of the hip, femoral anteversion, thigh-foot angle and foot progression angle. Thigh-foot angles were measured using a goniometer, with the patient prone and careful attention to detail.1,5,6 Foot progression angles were estimated clinically and from video recordings of gait.

The distance between the tibial osteotomy and the growth plate or ankle joint, and the displacement and angulation of the distal fragment, in both the coronal and sagittal planes, were measured and recorded from standardised radiographs. Sequential plain radiographs were obtained and reviewed for all patients in order to determine the time to union and for possible loss of position after resumption of weight-bearing. Complications were classified as major, if they required additional surgery, led to impairment of the final outcome or caused a major delay in rehabilitation. Complications were classified as minor if they resolved quickly with local treatment and did not impair the final outcome.

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Supramalleolar derotation osteotomy of the tibia, with T plate fixation

Journal of Bone and Joint Surgery, Nov 2004 by Selber, P, Filho, E R, Dallalana, R, Pirpiris, M, Et al

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