The management of tibial torsion in patients with spina bifida

Tibial Rotation Osteotomies in a Matched Cohort of Myelodysplasia and Cerebral Palsy Children

BACKGROUND

The purpose of this study is to examine the frequency of complications in children with myelodysplasia (MD) undergoing tibial rotational osteotomies with a matched cohort of children with cerebral palsy (CP). It was postulated that because of the unique health issues facing children with MD more complications would be observed.

METHODS

A retrospective chart review was performed to identify children with MD who underwent primary tibial rotational osteotomy between 1997 and 2012 and had a minimum 2-year follow-up. The 15 children thus identified were matched for age, body mass index, and functional ability with 15 children with CP. Outcome measures were complications that occurred within a year of osteotomy or hardware removal. Major complications were defined as nonunions or malunions, hardware failures, deep infections, fractures, and stage III or IV decubiti. Recurrence of rotational deformity requiring revision osteotomy at any time was also defined as a major complication. Minor wound problems healing within 6 weeks with only local care were considered minor complications.

RESULTS

Fifteen children with MD, who underwent 21 tibial derotational osteotomies, were available for review with a mean 7-year follow-up. The 15 children with CP underwent 22 tibial derotational osteotomies with a mean of 6 years of follow-up. In each cohort there were 3 children classified as GMFCS I, 3 children as GMFCS II, 4 children as GMFCS III, and 5 as GMFCS IV. Three (20%) of the children with MD experienced major complications (1 infected nonunion and 2 children who experienced bilateral malunions requiring revisions). One child with a major complication was classified as GMFCS II and the other 2 as GMFCS IV. None of the children with CP experienced a major complication.

CONCLUSIONS

The majority of children in both groups experienced good results, but children with MD have more frequent major complications. More frequent complications were seen in children with less functional ability.

LEVEL OF EVIDENCE

Level III-prognostic study, case-control study.

A comparison of three methods of measuring tibial torsion in children with myelomeningocele and normally developing children

Abnormal tibial torsion is a common pediatric problem, and there are many existing measurement methods. The purpose of this study was to compare three methods of measuring tibial torsion for its evaluation: computed tomography, physical examination, and motion capture. Twenty healthy children and 20 children with myelomeningocele underwent measures of tibial torsion bilaterally. Measurements were compared using correlation and Bland-Altman plots of the difference between measurements. All three measurements were moderately correlated in controls (r ≥ 0.49, P ≤ 0.002) and in patients (r ≥ 0.51, P ≤ 0.001). In controls, the motion capture measurements were on average 2° more lateral than the clinical measurements whereas motion capture and clinical measurements were 13° and 15° more medial than CT measurements, respectively. Similarly for patients, motion capture measurements were on average 5° more medial than clinical measurements, and motion capture and clinical measurements were 26° and 22° more medial than CT measurements. The approximate 20° difference between the clinical or motion capture measures and the CT measure suggests that clinical evaluation identifies different axes than those defined based on skeletal anatomy. Clinical or motion capture methods may be used in lieu of imaging methods for measuring tibial torsion with the knowledge that these methods provide less lateral measurements than measurements obtained using CT. Clin. Anat. :1043-1048, 2017. © 2017 Wiley Periodicals, Inc.

Tibial derotational osteotomies in two neuromuscular populations: comparing cerebral palsy with myelomeningocele

PURPOSE

To review the outcomes of tibial derotational osteotomies (TDOs) as a function of complication and revision surgery rates comparing a cohort of children with myelodysplasia to a cohort with cerebral palsy (CP).

METHODS

A chart review was completed on TDOs performed in a tertiary referral centre on patients with myelodysplasia or CP between 1985 and 2013 in patients aged > 5 years with > 2 years follow-up. Charts were reviewed for demographics, direction/degree of derotation, complications and need for re-derotation. Two-sample T-tests were used to compare the characteristics of the two groups. Two-tailed chi-square tests were used to compare complications. Generalised linear logit models were used to identify independent risk factors for complication and re-rotation.

RESULTS

The 153 patients (217 limbs) were included. Average follow-up was 7.83 years. Overall complication incidence was 10.14%, including removal of hardware for any reason, with a 4.61% major complication incidence (fracture, deep infection, hardware failure). After adjusting for gender and age, the risk of complication was not statistically significantly different between groups (p = 0.42) nor was requiring re-derotation (p = 0.09). The probability of requiring re-derotation was 31.9% less likely per year increase in age at index surgery (p = 0.005).

CONCLUSION

With meticulous operative technique, TDO in children with neuromuscular disorders is a safe and effective treatment for tibial torsion, with an acceptable overall and major complication rate. The risk of re-operation decreases significantly in both groups with increasing age. The association between age at initial surgery and need for re-derotation should help guide the treatment of children with tibial torsion.

Outcomes of Tibial Derotational Osteotomies Performed in Patients With Myelodysplasia

BACKGROUND

Rotational deformities of the tibia are common in patients with myelodysplasia. The current recommended treatment is tibial derotational osteotomy to improve gait biomechanics. Previously reported complication rates are widely variable. The purpose of this study is to review the outcomes of derotational osteotomies as a function of complication and revision surgery rates as compared with previous studies.

METHODS

A retrospective chart review was performed on all tibial derotational osteotomies performed in patients with myelodysplasia from 1985 to 2010 in patients older than 5 years with > 2 years of follow-up. Charts were reviewed for demographics, amount of derotation at index surgery, incidence of complications, and the need for repeat derotational surgery. Descriptive statistics were used to determine the incidence of complications as well as need for reoperation. Further analysis was performed using Fisher Exact Test and the Student t test to identify independent risk factors for complication and rerotation.

RESULTS

Eighty-two patients (129 limbs) had sufficient data for inclusion. The average follow-up was 7.15 years. Surgery was indicated for symptomatic torsion measuring > 20 degrees. The average amount of derotation was 28 ± 12 degrees. The incidence of complications was 10.85%, with a 3.10% incidence of major complications including fracture, deep infection, and hardware failure. The repeat derotation rate was 16.28%, all in patients initially treated for external tibial torsion. Age at initial surgery had no effect on complication rate or need for reoperation. Level of spinal involvement was not associated with complication risk; however, lumbar-level involvement was an independent risk factor for rerotation.

CONCLUSIONS

With meticulous operative technique, derotational osteotomy of the tibia in patients with myelomeningocele remains a safe and effective method to treat tibial torsion, with an acceptable overall complication rate of 10.85% and a major complication rate of 3.10%. The data presented will aid providers in appropriate counseling of patients considering tibial derotational osteotomy.

Supramalleolar Osteotomies: An Algorithm for the Deformed Ankle

Supramalleolar osteotomies are powerful osteotomies that realign the tibiotalar and optimize hindfoot position in the presence of varus, valgus, procurvatum, recurvatum, as well as internal and external rotation of the tibia. Although used in the pediatric and hemophilic population earlier, supramalleolar osteotomy is a relatively new reconstructive surgical technique that was introduced in 1995. Conducted primarily in cancellous bone, supramalleolar osteotomies offer rapid, reliable bony consolidation compared with dome osteotomies and complex arthrodesis.

Supramalleolar osteotomy: a comparison of fixation methods

BACKGROUND

For children with persistent tibial torsion, a wide variety of osteotomies and fixation methods have been proposed. We set out to compare the outcomes of percutaneous pin fixation versus a plate and screw construct. Our hypothesis was that the pin fixation group would have comparable outcomes without the need for a secondary procedure for implant removal.

METHODS

A retrospective chart review was performed. Data were evaluated on patients undergoing a rotational supramalleolar osteotomy over a 10-year span with follow-up to union. Patient's age, underlying condition, degree of torsion, length of procedure, length of hospital stay, concomitant procedures, complications, recurrence, and secondary procedures were recorded. Statistical analysis utilized the Mann-Whitney U test for evaluation of independent samples.

RESULTS

A total of 125 patients met the selection criteria with 186 tibias operated. Sixty-one cases were bilateral. Pin fixation was performed in 61 patients (87 tibias) and plate fixation in 64 patients (99 tibias). Age ranged from 2.5 to 19.6 (average 10.6) years. Surgical time, length of stay, and recurrence did not demonstrate a statistically significant difference between the pin fixation and the plate fixation groups. Forty-seven patients had secondary surgical procedures for removal of implants, 44 in the plate group and 3 in the pin group. Complications were considered major if they required reoperation or fracture care. In the plate group, 16 patients (12.8%) had complications with 5 major complications. In the pins group 3 patients (2.4%) had complications, which were minor. Recurrence was seen in 4 patients in the pin group and 2 patients in the plate group. Recurrence correlated with underlying neuromuscular disease and age younger than 11 years at the time of surgery.

CONCLUSIONS

The numbers of complications, both major and minor, were significantly greater in the plate group. Therefore, the results of this study did not support our hypothesis that percutaneous pin fixation of supramalleolar osteotomies would have comparable outcomes to plate and screw fixation.

The use of TheraTogs versus twister cables in the treatment of in-toeing during gait in a child with spina bifida

PURPOSE

To present the effects of TheraTogs and twister cables (TCs) on in-toeing during gait in a child with spina bifida while comparing overall parent and patient satisfaction.

CASE DESCRIPTION

The participant was a 2-year-old girl with L4 spina bifida with bilateral in-toeing during gait.

INTERVENTION

The child was given a 6-week intervention of TheraTogs followed by 6 weeks of TCs.

OUTCOMES

Kinematic data indicated optimal foot progression with the use of TCs, achieved by the rotation of the lower leg. Gait data for the use of TheraTogs indicated improved foot progression with external rotation at the hips. Gait characteristics indicated improved gait velocity in TheraTogs, but stride length was better with TCs. The parent reported satisfaction and preference for TheraTogs.

CONCLUSION

As the first step in investigating the 2 interventions, both TheraTogs and TCs were effective in management of in-toeing for the child but parental preference favored TheraTogs.

Limb reconstruction using circular frames in children and adolescents with spina bifida

We report the outcome of 28 patients with spina bifida who between 1989 and 2006 underwent 43 lower extremity deformity corrections using the Ilizarov technique. The indications were a flexion deformity of the knee in 13 limbs, tibial rotational deformity in 11 and foot deformity in 19. The mean age at operation was 12.3 years (5.2 to 20.6). Patients had a mean of 1.6 previous operations (0 to 5) on the affected limb. The mean duration of treatment with a frame was 9.4 weeks (3 to 26) and the mean follow-up was 4.4 years (1 to 9). There were 12 problems (27.9%), five obstacles (11.6%) and 13 complications (30.2%) in the 43 procedures. Further operations were needed in seven patients. Three knees had significant recurrence of deformity. Two tibiae required further surgery for recurrence. All feet were plantigrade and braceable. We conclude that the Ilizarov technique offers a refreshing approach to the complex lower-limb deformity in spina bifida.

Orthopedic management of spina bifida. Part I: hip, knee, and rotational deformities

Children with spina bifida develop a wide variety of congenital and acquired orthopedic deformities. Among these are hip deformities such as contracture, subluxation, or dislocation. Patients may also have problems with the knee joint, such as knee flexion or extension contracture, knee valgus deformity, or late knee instability and pain. In addition, rotational deformities of the lower extremities, either internal or external torsion, are common as well. This paper will review both the overall orthopedic care of a patient with spina bifida and provide a focused review of the diagnosis and management of the above deformities. In addition, this paper will review the incidence, etiology, classification, and prognosis of spina bifida. The use of gait analysis and orthoses will be covered as well. The forthcoming Part II will cover foot and ankle deformities in spina bifida.

Multiplanar supramalleolar osteotomy in the management of complex rigid foot deformities in children

PURPOSE

Residual midfoot and hindfoot deformities in rigidly deformed feet present a very complicated surgical dilemma. A plantigrade foot is desirous for proper lower extremity mechanics in a child with ambulatory potential. In this group of patients, soft tissue procedures are no longer an appropriate option, and well-recognized hindfoot procedures, such as talectomy, have many disadvantages. This study reviews the results obtained using multiplanar supramalleolar osteotomy as a salvage procedure to correct deformities of the complex rigid foot in children.

METHODS

A retrospective review was conducted of 27 multiplanar supramalleolar osteotomies in 18 children. The underlying diagnosis of the patients included seven severely rigid idiopathic clubfeet, five arthrogryposis, two myelodysplasia, one Ellis-van Creveld, one Streeter's, one cerebral palsy, and one severe burn contracture. The average age at surgery was 5.6 years, and follow-up averaged 8 years. A successful outcome was deemed a plantigrade foot on physical exam with follow-up of at least 2 years and no subsequent tibial surgeries. All failures were included regardless of the length of follow-up.

RESULTS

A plantigrade attitude of the hindfoot was obtainable at the time of surgery in all cases. Eighteen of the 27 feet had a successful outcome. Nine of 27 (33%) feet had recurrence of the foot deformity requiring additional surgery. Time to recurrence averaged 5.7 years (9 months-13 years). Complications from the surgery included four minor wound healing problems, two delayed unions, and one screw recession, all of which healed without consequences. There was no evidence of nonunion, growth plate closure, infection, or fracture above or through screw holes.

CONCLUSION

The multiplanar supramalleolar osteotomy appears to be a reasonable salvage procedure for severely scarred and complex rigid foot deformities and can be reinstituted for failures due to remaining growth.

Musculoskeletal complications of neuromuscular disease in children

A wide variety of neuromuscular diseases affect children, including central nervous system disorders such as cerebral palsy and spinal cord injury; motor neuron disorders such as spinal muscular atrophy; peripheral nerve disorders such as Charcot-Marie-Tooth disease; neuromuscular junction disorders such as congenital myasthenia gravis; and muscle fiber disorders such as Duchenne's muscular dystrophy. Although the origins and clinical syndromes vary significantly, outcomes related to musculoskeletal complications are often shared. The most frequently encountered musculoskeletal complications of neuromuscular disorders in children are scoliosis, bony rotational deformities, and hip dysplasia. Management is often challenging to those who work with children who have neuromuscular disorders.

Osteotomy for salvage of the arthritic ankle

Ankle arthrodesis continues to be the procedure of choice for ankle arthritis. Coester and colleagues showed that arthrodesis is a significant risk factor for development of arthritis in the ipsilateral hindfoot and forefoot, however. Total ankle arthroplasty has gained significant interest but is not yet ideally suited for younger active patients because of unacceptable failure rates and complications. Osteotomies can play an important role in re-establishing normal alignment and potentially decreasing the rate of progression of wear on the articular surfaces and decreasing pain, which may allow more time before arthrodesis or arthroplasty are needed. The success of total ankle arthroplasty depends largely on the alignment of the foot and ankle and osteotomies can be used in a staged manner as part of a reconstructive effort including total ankle arthroplasty. Supramalleolar osteotomies can be used to align the tibia; alternatively, osteotomies in the midfoot and hindfoot can be used to balance the foot and ankle making them suitable for arthroplasty in an individual who perhaps would not otherwise have that treatment option. Further studies will continue to clarify the role and indications for osteotomies for treatment of ankle arthritis.

The Haas procedure for the treatment of tibial torsional deformities

This study reviews our 13-year experience with Haas's multiple-longitudinal osteotomy technique for correction of tibial torsion in children. In this procedure, multiple-longitudinal bi-cortical osteotomies are made parallel in the proximal tibia. The deformity is corrected by applying moderate force in the desired plane. Fixation is achieved either with a long cast or with 'pins-in-plaster'. Forty-six osteotomies were performed in 30 children. In all, there were 35 internal tibial torsion deformities and 11 external tibial torsion deformities. Twenty-one (46%) deformities were associated with spastic cerebral palsy and 15 (33%) were associated with clubfeet. Ten (22%) deformities had no underlying musculoskeletal conditions. Thigh-foot angles were corrected by a mean of 24 degrees for internal tibial torsion and -28 degrees for external tibial torsion. Average anesthesia time for unilateral cases was 46 min. No neurologic or infectious complications, postoperative fractures or physeal damage occurred. There was one case of delayed union and one case of postoperative antecurvatum deformity. All five cases of postoperative recurrent deformities were associated with cerebral palsy. This technique is a simple, safe and efficient method for correcting tibial torsional deformities in both healthy children and those with underlying conditions. It allows accurate alignment of different deformities with a uniform osteotomy technique, which preserves bone continuity and provides inherent stability, thus avoiding the use of internal fixation.

Results of tibial rotational osteotomy without concomitant fibular osteotomy in children with cerebral palsy

A retrospective review was performed of 46 consecutive ambulatory children with cerebral palsy and tibial torsion who underwent 72 distal tibial derotational osteotomies without concomitant fibular osteotomy. The average amount of derotation measured at surgery was 21 +/- 5 degrees. The average change in thigh-foot angle at follow-up was 21 +/- 9 degrees. There were eight perioperative complications (11%): three delayed unions, three superficial wound dehiscences, one case of osteomyelitis, and one superficial pin tract infection. There were no incidences of malunion or nonunion. Preoperative and postoperative three-dimensional gait analysis data were used to determine the effect of distal tibial osteotomy on foot progression angle in seven subjects (11 limbs). Foot progression improved significantly. This study shows that distal tibial osteotomy alone (without concomitant fibular osteotomy) is an effective and safe procedure for correcting and maintaining correction of tibial torsion in patients with cerebral palsy.

Spasticity: orthopedic perspective

The orthopedic management of spasticity is based on the effects of this neurologic condition on the bones and tissues of the growing child. The goal of such intervention is to maximize function, reduce disability, and facilitate mobility. Goal-directed treatment plans are tailored for each patient and may include a combination of modalities such as physical and occupational therapy, casting, orthoses, and surgery. Physical and occupational therapy is emphasized up to 4 to 5 years of age, whereas surgery is best between 5 and 7 years of age. Education and psychosocial development should be emphasized beginning at age 7 years through adulthood, with surgery reserved for more involved cases of contracture or bony dysplasia. In adulthood, treatment should be focused on integration into society and maximizing functional independence. Although there are many undisputed benefits of therapy, no consensus exists regarding the most beneficial modality, the age group that would benefit most, or whether continued treatment is beneficial in adulthood. Whereas the use of serial casting and tone-reducing casts has lessened, lower extremity orthoses have gained widespread acceptance with improvements in design and fabrication and have been demonstrated to help restore normal heel-toe gait. Surgical techniques such as tendon lengthening, transfer, bony osteotomy, and joint fusion are time-honored techniques that continue to be refined with current advances in the use of computerized gait analysis for preoperative planning. Further research in long-term results and outcomes measurement will be necessary to fully assess the impact of current treatment.

Internal derotation osteotomy of the tibia: pre- and postoperative gait analysis in persons with high sacral myelomeningocele

Rotational deformities of the lower extremities are common in patients with myelomeningocele. In these situations, surgical correction is often necessary. We conducted a retrospective review of eight ambulatory patients with high sacral myelomeningocele and external tibial torsion who underwent 10 distal tibia and fibular internal derotation osteotomies. All patients had an increased valgus knee stress preoperatively. Pre- and postoperative three-dimensional gait analysis was used to evaluate coronal plane knee moments and dynamic sagittal plane knee motion. Postoperatively, a significant improvement in the abnormal internal knee varus moment (p < 0.005) as well as a significant increase in the stance phase knee extension (p < 0.01) was seen. Three patients had resolution of preoperative knee pain. We believe that patients with increased knee stress secondary to excessive external tibial torsion will benefit from a tibial derotation osteotomy that could delay or prevent the onset of late degenerative changes about the knee.

Distal tibial/fibular derotation osteotomy for correction of tibial torsion: review of technique and results in 63 cases

Despite a tendency for rotational abnormalities of the lower leg in children to improve spontaneously over time, some fail to correct and require corrective derotation osteotomy. In this retrospective study, we report the technique and results of the distal transverse tibial and fibular derotation osteotomy with Kirschner-wire fixation performed in 63 limbs of children with cerebral palsy, clubfoot, idiopathic tibial torsion, and myelomeningocele, as well as other less common conditions. There were no significant infections, neurologic complications, delayed or nonunions, or compartment syndromes as a result of the osteotomy. There were three (4.8%) complications, including late fracture (one), cross-union (one), and distal physeal closure (one). We conclude that transverse, same-level, distal tibial and fibular osteotomy fixated with crossed Kirschner wires is a safe, efficient, and effective surgical approach to the treatment of children with tibial torsion in a variety of clinical conditions.