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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The two patients who had a superficial infection and a delay in wound healing both had very large corrections (40° and 45°) and marked swelling after surgery. The safe upper limit for a rotational osteotomy in the distal tibia is probably about 40°. For more severe deformities and greater rotational corrections, slow correction with a circular frame may be a better option.17

The principal indication for rotational osteotomy of the tibia in this and previous studies was excessive lateral tibial torsion in patients with cerebral palsy6,9 (Fig. 5). The cause of lateral torsion of the tibia in cerebral palsy is probably the abnormal biomechanical environment during growth. The age at which excessive torsion is recognised and at which surgery is recommended suggests that the torsion is acquired gradually.18 Excessive laterally directed torsional moments, transmitted from toe drag to the distal tibia, because of poor foot clearance, may be contributory.

Early rehabilitation is required and prolonged periods of immobilisation m a cast and/or an inability to weight-bear are undesirable. The concept of internal fixation of the distal tibial osteotomy is attractive if it provides precise control and early mobilisation. The malleable T plate does not in itself afford rigid internal fixation. It controls rotation. The broad horizontal osteotomy and the intact softtissue envelope provide stability. Weight-bearing may commence before bony union in contrast to when percutaneous K-wires or casting alone are used.

No loss of position was seen in our series, a problem encountered in some other series not using a secure fixation system.8

The age range of patients in our series was much wider than in previous reports. In particular, eight osteotomies were undertaken in skeletally mature patients aged between 18 and 36 years. All united without complications.

Derotation osteotomy of the tibia and fibula in the supramalleolar area, combined with T plate fixation, is an effective procedure for the correction of torsional abnormalities of the tibia associated with an in-toe or out-toe gait. It allows early mobilisation and a high rate of union, with an acceptable complication rate in patients with neuromuscular disease, including adolescents and young adults.

No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

References

1. Staheli LT, Corbett M, Wyss C, King H. Lower-extremity rotational problems in children: normal values to guide management. J Bone Joint Surg [Am] 1985;67-A:39-47.

2. Staheli LT. The lower limb. In: Morrissy RT, ed. Lovell and Winter's pediatric orthopaedics. 3rd Edition. Philadelphia: Lippincott, 1990:741-66.

3. Schoenecker PL, Rich MM. The lower extremity. In Morrissy RT, Weinstein SL, eds. Lovell and Winter's pediatric orthopaedics. 5th Edition, Volume 2. Philadelphia, Lippincott. Chapter 27:1059-104.

4. Rang M. Toeing in and toeing out: gait disorders. In:Wenger DR, Rang M, eds. The art of children's orthopaedics. New York: Raven Press 1993:50-76.