Paediatric Surgery (Ukraine).2023.1(78): 110-118; doi 10.15574/PS.2023.78.110
Danylov A. A., Gorelik V. V., Shulga A. V., Yachna K. V.
Shupyk National Healthcare University of Ukraine, Kyiv

For citation: Danylov AA, Gorelik VV, Shulga AV, Yachna KV. (2023). Pathologic external tibial torsion as one of the causes of knee joint dysfunction and formation of pronation deformity in children with cerebral palsy. Paediatric Surgery (Ukraine). 1(78): 110-118; doi 10.15574/PS.2023.78.110.
Article received: Oct 04, 2022. Accepted for publication: Mar 14, 2023.

Introduction. One of the complications of the clinical course of cerebral palsy in children is external torsion of the tibia. The issue of localization and the mechanism of its formation, as well as effective methods of its elimination, is debatable.
Purpose – to study the mechanisms of the formation of pathological external torsion of the tibia in children with cerebral palsy, its effect on knee joint contracture and foot deformity, and effective methods of their correction.
Materials and methods. The data obtained during the observation of 45 patients (90 cases) aged from 6 to 16 years with spastic diplegia, spastic tetraparesis and foot pronation were analyzed. To study the mechanisms of formation of external torsion of the lower leg and its correction, 2 groups of patients were selected. The Group I – 24 patients with internal rotation contractures of the hip joint (10 patients with internal rotation contractures of the hip joint; 10 patients – in combination with pathological antetorsion of the femoral neck; 4 patients – in combination with flexion contractures of the knee joints). The relationship between internal rotation contracture of the hip joint and external torsion of the tibia. The Group II consisted of 21 patients who were diagnosed with flexion contracture of the knee joints in combination with external torsion of the tibia. In order to study the effectiveness of operative treatment of knee flexion contracture and external torsion of the tibia in the Group II, 2 subgroups were distinguished: the subgroup IIA – 9 patients who underwent osteotomy of the tibial bone; the subgroup IIB – 12 patients who only underwent biceps femoris transposition.
Results. Based on the study of clinical and radiological indicators, it was established that pathological torsion of the tibial bone is combined with flexion contracture of the knee joints. Proximal derotational osteotomy of the tibia has a positive effect on the results of correction of knee flexion contracture and foot position.
Conclusions. The main reason for the formation of external torsion of the tibia is the imbalance of the flexor muscles of the knee joint and the supinator and pronator muscles of the foot. Proximal tibial derotation osteotomy eliminates not only pathological torsion, but also flexion contracture of the knee joints and excessive pronation of the foot.
The study was conducted in accordance with the principles of the Declaration of Helsinki. The study protocol was approved by the local ethics committees of all institutions participating in the study. Informed consent of the patients was obtained for the research.
No conflict of interests was declared by the authors.
Keywords: tibial torsion, cerebral palsy, pronation deformities of the feet.

REFERENCES

1. Aiona M, Calligeros K, Pierce R. (2012). Coronal plane knee moments improve after correcting external tibial torsion in patients with cerebral palsy. Clin Orthop Relat Res. 470 (5): 1327-1333. https://doi.org/10.1007/s11999-011-2219-x; PMid:22183475 PMCid:PMC3314750

2. Alyakin LN. (1969). Pathological torsion of the leg bones in patients with the consequences of poliomyelitis. Author's abstract Ph.d. L: 18.

3. Andrisevic E, Westberry DE, Pugh LI et al. (2016). Correction of tibial torsion in children with cerebral palsy by isolated distal tibia rotation ostejtomy: a short-term, in vivo anatomic stady. J Pediatr Orthop. 36 (7): 743-748. https://doi.org/10.1097/BPO.0000000000000525; PMid:27603097

4. Carriero A, Zavatsky A, Stebbins J et al. (2009). Correlation between lower limb bone morphology and gait characteristics in children with spastic diplegic cerebral palsy. J Pediatr Orthop. 29 (1): 73-79. https://doi.org/10.1097/BPO.0b013e31819224d; PMid:19098651

5. Chapman MW. (2000). Orthopedic surgery. Philadelphia. 3: 1422.

6. Chen BP-J. (2018). Measuring Femoral and Tibial Torsion in Children with Cerebral Palsy. In book: Cerebral Palsy: 1-20. https://doi.org/10.1007/978-3-319-50592-3_203-1

7. Danylov AA, Pylypchuk OR, Mashurenko VI, Neh AA. (2007). Anatomicheskie izmeneniya bedrenuh i bolshebercovyh kostey u bolnuh cerebralnum paralichom. Khirurhiia dytiachoho viku. ІІІ-2: 8-13.

8. Danylov OA. (2015). Mehanizm formirovaniya i klinicheskoe techenie sgibatelnuh kontraktur kolennuh susnavov u bolnuh s cerebralnum paralichem. Khirurhiia dytiachoho viku. 50-51 (1-2): 61-67.

9. Dodgin DA, De Swart RJ, Stefko RM et al. (1998). Distal tibial/fibular derotation osteotomy for correction of tibial torsion: review of technique and results in 63 cases. J Pediatr Orthop. 18 (1): 95-101. https://doi.org/10.1097/01241398-199801000-00018; PMid:9449109

10. Engel GM, Staheli LT. (1974). The natural history of torsion and other factors influencing gait in childhood. A study of the angle of gait, tibial torsion, knee angle, hip rotation and development of the arch in normal children. Clin Ortop Relat Res. 99: 12-17. https://doi.org/10.1097/00003086-197403000-00002; PMid:4825705

11. Flack NAMS, Nicholson HD, Woodley SJ. (2012). A review of the anatomy of the hip abductor muscles, gluteus medius, gluteus minimus, and tensor fascia lata. Clin Anat. 25 (6): 697-708. https://doi.org/10.1002/ca.22004; PMid:22109658

12. Gafarov KhZ. (1990). Treatment of foot deformities in children. Kazan: 176.

13.Gafarov НZ. (2012). Вiomechanics of torsion development of the tibial bones and foot bones in children. Aktualnue problem medicine. 8 (64): 37-40.

14. Hazlewood ME, Simmons AN, Johnson WT et al. (2007). The Footprint method to assess transmalleolar axis. Gait Posture. 25 (4): 597-603. https://doi.org/10.1016/j.gaitpost.2006.06.011; PMid:16904892

15. Helal AM, El-Negmy EH, Zaky NA. (2022). Impact of femoral anteversion and tibial torsion on balance in children with spastic diplegic cerebral palsy. International Journal of Health Sciences. 6 (S7): 4572-4584. https://doi.org/10.53730/ijhs.v6nS7.12982

16. Kim HY, Lee SK, Lee NK, Choy WS. (2012). An anatomical measurement of medial femoral torsion. J Pediatr Orthop B. 21 (6): 552-557. https://doi.org/10.1097/BPB.0b013e328355e5f1; PMid:22744234

17. King HA et al. (2016). Torsion Problems in Cerebral Palsy. SAGE Journals. 4: 4. https://doi.org/10.1177/107110078400400403; PMid:6714858

18. Krengel 3rd WF, Staheli LT. (1992). Tibial rotational osteotomy for idiopatic torsion. A comparison of the proximal and distal osteotomy levels. Clin Ortop Relat Res. 283: 285-289. https://doi.org/10.1097/00003086-199210000-00042

19. Lee SH, Chung CY, Park MS, Choi IH, Cho T-J. (2009). Tibial torsion in cerebral palsy: validity and reliability of measurement. Clin Orthop Relat Res. 467 (8): 2098-2104. https://doi.org/10.1007/s11999-009-0705-1; PMid:19159112 PMCid:PMC2706340

20. Liu X, Kim W, Drerup B, Mahadev A. (2005). Tibial torsion measurement by surface curvature. Clin Biomech. 20 (4): 443-450. https://doi.org/10.1016/j.clinbiomech.2004.12.008; PMid:15737453

21. Lofterod B, Terjesen T. (2010). Changes in lower limb rotation after soft tissue surgery in spastic diplegia. Acta Orthop. 81 (2): 245-249. https://doi.org/10.3109/17453671003587135; PMid:20175660 PMCid:PMC2895346

22. Manouel M, Johnson LO. (1994). The role of fibular osteotomy in rotational osteotomy of the distal tibia. J Pediatr Orthop. 14 (5): 611-614. https://doi.org/10.1097/01241398-199409000-00011; PMid:7962503

23. Min JJ, Kwon S-S, Kim TK et al. (2021). Evaluation of factors affecting external tibial torsion in patients with cerebral palsy. BMC Musculoskelet Disord. 12; 22 (1): 684. https://doi.org/10.1186/s12891-021-04570-5; PMid:34384415 PMCid:PMC8362246

24. Park H-S, Wilson NA, Zhang L-Q. (2008). Gender differences in passive knee biomechanical properties in tibial rotation. Orthop Res. 26 (7): 937-944. https://doi.org/10.1002/jor.20576; PMid:18383181

25. Ryan DD, Rethlefsen SA, Skaggs DL, Kay RM. (2005). Results of tibial rotational osteotomy without concomitant fibular osteotomy in children with cerebral palsy. J Pediatr Orthop. 25 (1): 84-88. https://doi.org/10.1097/01241398-200501000-00019; PMid:15614066

26. Schrock RD. (1969). Peroneal nerve palsy following derotation osteotomies for tibial torsion. Clin Ortop. 62: 172-177. https://doi.org/10.1097/00003086-196901000-00022; PMid:5774830

27. Staheli LT, Engel GM. (1972). Tibial torsion: a method of assessment and a survey of normal children. Clin Orthop Relat Res. 86: 183-186. https://doi.org/10.1097/00003086-197207000-00028; PMid:5047787

28. Sutherland DH, Davids JR. (1993). Common gait abnormalities of the knee in cerebral palsy. Clin Orthop Relat Res. 288: 139-147. https://doi.org/10.1097/00003086-199303000-00018

29. Turner MS, Smillie IS. (1981). The effect of tibial torsion of the pathology of the knee. J Bone Joint Surg Br. 63-B (3): 396-398. https://doi.org/10.1302/0301-620X.63B3.7263753; PMid:7263753