Rotational Deformities

Aetiology

1. Physiological
2. Non Physiological
   • Congenital
   • Acquired

Definition

• Torsion
  • Rotation 2 SD <> mean
• Femoral Version
  • Angular difference between Transcervical & Transcondylar Axes
• Tibial Version
  • Angular difference between transcondylar Axis of Knee & TMA
    

Normal Development

• Lower limb bud develops during 4/52
• Great Toe points lateral
• During 7th week bud internally rotates
  • Brings hallux into midline
• For remainder of intrauterine period & childhood limb is externally rotated
  • femoral anterversion decreases
  • tibial external rotation Increased
• Neonates have external rotation hip contracture that masks the femoral Anteversion
• Femoral Anteversion decreases with age
  • 40° Neonate
  • 15° Adult
• Tibia Increased external rotation
  • 5° Neonate
  • 15° Adult
• Internal Rotation In-toe toddlers become external rotation in adults

Classification

• Toeing In
  • Internal Femoral Torsion IFT
  • Internal Tibial Torsion ITT
  • Metatarsus Adductus
• Toeing Out
  • Physiological
  • External Tibial Torsion ETT
  • Pronation / Abduction of the Feet

Assessment

• Initiator of referral
• Reason for presenting
• History
  • Age of onset
  • Severity
  • Disability
  • Previous Management
  • Age first walked
    • If delayed consider CP
  • Family History of In / Out Toeing
• Examination
  • General screening
    • Assess Height percentile
    • Check Spine for Scoliosis
    • Check Hips
    • Examine Feet
• Consider
  • CP (In-toeing)
  • CDH (Limb Asymmetry)
  • SUFE (Out-Toeing)
  • Genu Varum (In-toeing)

• Staheli’s Torsional Profile
  1. Foot Progression Angle
     • Assessed on gait
     • Usually 10° out (0°-30°)
     • (5+/- 10)
  2. Hip Internal Rotation
     • Child prone
     • Usually < 65°
     • > 70° = FAV
     • (45+/-15)
  3. Hip external rotation
     • Usually 40° (20-60°)
     • (45+/- 15)
     • Greater in young child
     • Note Internal Rotation + external rotation should = 90°
  4. Thigh- Foot Angle TFA
     • Child prone & knees flexed
     • Reconstruct foot
     • Usually 15° (0°-30°) external rotation
     • (15 +/-15)
  5. Transmalleolar Axis (TMA)
     • Prone & knees flexed
     • Usually 0 -30° ER
  6. Foot
     • Shape of foot
     • Metatarsus ADD or Everted foot affects FPA
• Normal Examination Figures
  • Foot Progression angle = 5° +/- 10°
  • Thigh Foot angle = 15° +/- 15°
  • ER & Internal Rotation hip = 45° +/- 15°
  • Transmalleolar Axis (TMA) = 0 -30° ER

Investigation

• Required if:
  • Problem complex
  • Intervention planned
• AP Pelvis
  • Acetabular Version
  • DDH
  • SUFE
  • AP & lateral Hip allows calculation of version using tables by Magilligan Tech which converts measurements of neck length into an FAV angle
• CT Scan
  • Direct measurement of femoral & tibial version

Management

• General Principles
  1. Trying to control the sleeping, walking, or sitting of infants & children is impossible
  2. surgery correction effective but carries significant risk
  3. surgery only justified in the child with sev defects that has failed to resolve with time
  4. skewfoot,
     • ITT <-10°
     • ETT>40°
     • FAV>50°
  5. Splints not benefit & interfere with child
  6. Observational Management >99% – only 1 in 1000 need surgery
  7. at least > 8 yrs prior to surgery

Presentations by Age

• 1st Year of Life
  • Feet turn in = MT Adductus
  • One foot external rotation = Metatarsus Adductus Contralatera
  • Both feet turn out = lateral rotation pattern of infants’ hips
• 2nd Year of Life
  • Feet turn in = ITT
• After 3rd Year of Life
  • Feet turn in = FAV
  • Foot turns in = ITT
  • Foot turns out = ETT

TOEING IN

• Most common causes are:
  • femoral Internal Torsion
  • Internal Tibial Torsion
  • MT ADD
  • Talar neck deviation
• Neonate usually 2° MT ADD
• 2 yo usually 2° Internal tibial Torsion
• > 3yo usually 2° FAV
• Mild in-toe helpful for runners

Metatarsus Adductus

• Commonest congenital foot deformity
• Packaging disorder
• Natural History
  • Flexible & resolves Spontaneously in >90%
    • no long term disability if untreated
    • cosmetic only
• Treatment
  • only after 6-9m old (usually resolves prior)
  • POP successful up to 4-5 yo old
    • Above knee cast with knee flexed
    • change casts bi-weekly
  • achieve correction in 2-3 weeks in most
  • if recurs then repeat cast & follow with night splint for 3m
• Operative treatment
  • nearly all correct Spontaneously but if not then at 6-9yo do abductor Halluxis release & MT osteotomy (ie level of deformity)

Metatarsus Varus

• Rigid, plantar crease
• Deforms medial cuneiform
• Often persists & needs treatment
• Cast from age of 3m as above

Skew Foot

• Rare
• Valgus heel, plantar flexed talus, abducted midfoot
• Flexible
• Diagnosis confirmed with AP & lateral XR
  • AP XR – Z due to abd at mid-tarsal jnts & add at MTs
  • Lateral XR – flexion of talus
• Treatment
  • Nonoperative
    • is not helpful
  • Operative
    • Surgery at >/= 6yo
    • opening wedge osteotomy of calcaneus
    • correct midtarsal abduction & to elevate sustentaculum tali under neck of talus to correct talus flexion
    • opening wedge osteotomy of 1st cuneiform to correct forefoot adductus

Dynamic Hallux Adductus

• Searching toe
• No treatment necessary
• Natural History
  • resolves

Internal Tibial Torsion

• Angular difference between Transcondylar Axis of Knee & TMA
• No 1 cause of intoeing in 2 yo
• does not occur in preterm infants
• Natural History – 10% < 2 yrs ITT
  • 2/3 bilateral (ie 1/3 unilateral of these usually left side)
  • associated with MT ADD in 1/3
  • TMA (transmalleolar Axis) Increased 0-5° from age 1 to 2 yrs
  • Tibial external rotation usually continues through childhood
  • presents on walking
  • patella normal position
  • kids tend to trip & appear clumsy
  • Most cases of ITT resolve by 2yo
    • few resolve > 8 yo
  • Resolution not universal
  • +ve FamHistory = Poor prognosis
  • Consider Neuromuscular Disease if:
    • Unilateral
    • Asymmetrical
    • Progressive
  • associated with tibial vara, polio, tibial fractures
• Aetiology
  • ? Packaging defect
  • Prone sleeping with limbs Internal Rotation may delay Spontaneously recovery
• Clinical
  • TFA usually Medial
  • Usually little final deficit
  • May be compensatory pronation & ABD of foot
  • most runners apparently intoe
    • ? advantage
• Treatment
  • almost never required
  • Nonoperative treatment
    • of any sort does not work
    • Splints shown not to work
  • Surgery
    • rarely indicated
    • Supramalleolar Osteotomomy
      • Indications
        • 1 TMA > 3 SD (< -10° or > 40°)
        • 2 Age 10+ years
        • 3 Severe disability

Internal Femoral Torsion

• Transverse plane rotation of the femoral neck axis anteriorly relative to the transcondylar axis
• F:M = 2:1
• Bilateral, symmetrical
• Familial
• Aetiology
  • Unknown
• Natural History
  • Resolves in 95%
  • Compensatory ETT may develops after 5 yo
  • Little final disability
  • >50% of patients with persistent femoral Antetorsion achieve normal gait
  • Doesn’t predispose to OA
• Presentation – Intoeing in early childhood
  • Starts 3 yo
  • Max 4-6 yo
• Examination
  • Squinting patellae
  • Sit in W
  • run like egg beaters & trip over
  • Degree estimated by noting the position of the patella with the GT in the direct lateral position
  • Prone Rotation test – find position where greater trochanter most prominent from neutral
  • Increased Internal Rotation = decreases external rotation = 90°
  • abnormal if Internal Rotation > 70°
  • If severe, no external rotation possible
  • If unilateral or progression of in-toeing then Rule out DDH / CP
• Treatment
  • Nonoperative
    • No evidence for orthoses
    • May produce:
      • Lig problems at Knee & Ankle joints
      • Genu Valgum
      • Severe ETT
        
  • Operative
    • Very severe functional gait disturbance
    • age > 10
    • Rotational criteria
      • 1 Internal Rotation >85°
      • 2 external rotation <10°
      • 3 Measured Anteversion > 50°
    • Cosmesis
• Imaging
  • Xray
    • AP & lateral Hip allows calculation of version using tables by Magilligan Tech which converts measurements of neck length into an FAV angle
  • CT Scan
    • Direct measurement of femoral & tibial version
• Principles
  • leave at least >8-10 because many resolve
  • not needed if 10° external rotation present
  • Derotation osteotomy > 8yo, Better > 12 yo
  • Proximal Intertrochanteric osteotomy best
    • No knee stiffness
    • Cosmesis
    • Better union & fixation
    • Malunion is less obvious
    • Aim Internal Rotation = external rotation

Management Toeing Out

• Normal in neonates
• Due to external rotation hip contractures of hip
• During childhood 2° ETT

External Tibial Torsion

• Presents in late childhood
• Often unilateral
• More often Right side
• Natural History
  • tends to increase
    • rarely a problem until late childhood
    • associated with patellofemoral instability & pain
• Aetiology
  • May occur 2° to IFT; CP; Orthoses for IFT
• Treatment
  • Nonoperative Management
    • useless
  • Operative
    • Osteotomy
      • indicated if TFA > 40°
    • Certain cases of CTEV & NMD

External Femoral Torsion

• associated with OA, Increased stress fracture in LL, SUFE

Torsional Malalignment Syndrome

• “Miserable Malalignment syndrome “
• IFT with compensatory ETT
• Knee Internal Rotation to axis of progression
• Management
  • generally observation only
• Most deformities show
  • Lack of disability
  • Lack of long-term problems
  • Ineffectiveness of Nonoperative Management
• Disability producing defects persist in 1/ 1000

Acetabular Version

• Remains relatively constant through life at 15°
• Not a source of rotational problems
  

Normal Examination Findings

• Foot Progression angle = 5° +/- 10°
• Thigh Foot angle = 15° +/- 15°
• ER & Internal Rotation hip = 45° +/- 15°
• Transmalleolar Axis (TMA) = 0 -30° ER