The management of osteoarthritis of the knee associated with patellar instability secondary to external tibial torsion > 45° is challenging. Patellofemoral biomechanics in these patients cannot be achieved by intra-articular correction using standard techniques of total knee replacement. We reviewed seven patients (eight knees) with recurrent patellar dislocation and one with bilateral irreducible lateral dislocation who had undergone simultaneous total knee replacement and internal tibial derotational osteotomy. All had osteoarthritis and severe external tibial torsion. The mean follow-up was for 47.2 months (24 to 120). The mean objective and functional Knee Society scores improved significantly (p = 0.0001) from 29.7 and 41.5 pre-operatively to 71.4 and 73.5 post-operatively, respectively. In all patients the osteotomies healed and patellar stability was restored. Excessive external tibial torsion should be identified and corrected in patients with osteoarthritis and patellar instability. Simultaneous internal rotation osteotomy of the tibia and total knee replacement is a technically demanding but effective treatment for such patients

We reviewed 20 patients with spina bifida who had had surgical management of tibial torsion. Eight had had bilateral procedures and 12 a unilateral procedure, giving a total of 28 limbs for analysis. We performed closed osteoclasis on seven limbs and tibial osteotomy on 21. In the closed osteoclasis group six limbs (85%) had a good result after an average follow-up of nine years (2 to 22). All limbs developed postoperative anteromedial bowing of the tibia which later remodelled. In the tibial osteotomy group 19 (90%) had a good result. The average follow-up was nine years (2 to 28). Complications occurred in seven limbs (33%). We recommend closed osteoclasis of the tibia for the young patient with spina bifida in whom walking is impeded by excessive internal tibial torsion, and supramalleolar tibial osteotomy in the older patient with excessive external tibial torsion and a planovalgus foot

Measurements of tibial torsion using a tropometer were made in more than 1200 consecutive patients attending an adult knee clinic. In total 1672 readings from 836 patients in 11 diagnostic categories were analysed. Patients with either patellofemoral instability or Osgood-Schlatter disease had a significant increase in lateral tibial torsion. The most important finding was a significant reduction in this torsion in patients with panarticular disease

Previous clinical studies have studied tibiofibular torsion by measuring the angular difference between a proximal (often bicondylar) plane and a distal bimalleolar plane. We measured the angular difference between the proximal and distal posterior tibial planes as defined by ultrasound scans. We found no significant torsional difference between the right and left tibiae of 87 normal children, nor between their different age groups. The mean external torsion of 58 legs with congenital talipes equinovarus was 18 degrees; significantly less than the mean 40 degrees in the normal children and 27 degrees in the clinically normal legs of the 22 patients with unilateral congenital talipes equinovarus. We did not confirm the previously reported increase in external torsion with increasing age. The relative internal tibial torsion we have demonstrated in patients with congenital talipes equinovarus must be differentiated from the posterior displacement of the distal fibula observed by others and which may result from manipulative treatment. The relative internal tibial torsion we found in the clinically normal legs of children with congenital talipes equinovarus is further evidence that in this condition the pathology is not confined to the clinically affected foot

Introduction. A large number of total knee arthroplasty (TKA) patients, particularly in Japan, India and the Middle East, exhibit anatomy with substantial proximal tibial torsion. Alignment of the tibial components with the standard anterior-posterior (A-P) axis of the tibia can result in excessive external rotation of the tibial components with respect to femoral component alignment. This in turn influences patellofemoral (PF) mechanics and forces required by the extensor mechanism. The purpose of the current study was to determine if a rotating-platform (RP) TKA design with an anatomic patellar component reduced compromise to the patellar tendon, quadriceps muscles and PF mechanics when compared to a fixed-bearing (FB) design with a standard dome-shaped patellar component. Methods. A dynamic three-dimensional finite element model of the knee joint was developed and used to simulate a deep knee bend in a patient with excessive external tibial torsion (Figure 1). Detailed description of the model has been previously published [1]. The model included femur, tibia and patellar bones, TKA components, patellar ligament, quadriceps muscles, PF ligaments, and nine primary ligaments spanning the TF joint. The model was virtually implanted with two contemporary TKA designs; a FB design with domed patella, and a RP design with anatomic patella. The FB design was implanted in two different alignment conditions; alignment to the tibial A-P axis, and optimal alignment for bone coverage. Four different loading conditions (varying internal-external (I-E) torque and A-P force) were applied to the model to simulate physiological loads during a deep knee bend. Quadriceps muscle force, patellar tendon force, and PF and TF joint forces were compared between designs. Results. The RP design demonstrated consistently lower medial-lateral (M-L) force at the PF joint than the FB design, with greater differences between designs in later flexion once the patella was engaged in the sulcus groove; root-mean-square (RMS) differences in M-L force averaged 50 N less in the RP design throughout the flexion cycle, and 70 N less after 45° flexion (Figure 2). The FB design aligned for optimal bone coverage demonstrated 15% higher M-L forces than the FB design aligned with the tibial A-P axis. RMS load required by the quadriceps muscle was 60 N lower with the RP design than the FB design throughout the cycle (Figure 2). Discussion. Comparing a RP design with an anatomic patellar component and a FB design with a domed patellar component, the RP design demonstrated lower M-L PF joint and soft-tissue extensor mechanism forces. Differences were more pronounced under conditions of high I-E torque where the RP design accommodated large relative TF rotation. Differences in FB alignment resulted in substantially different PF M-L forces; when the FB component was mal-aligned with respect to the tibial A-P axis (and the line-of-action of the patellar tendon) the resulting M-L PF force was increased. The RP design reduced the demands on the extensor mechanism and loads on the PF joint and facilitated better coverage of the resected tibial bone surface

The development of lateral tibial torsion in the paralysed lower limb is well documented, but its pathogenesis is poorly understood. This paper attempts to provide an explanation for its development when it is associated with a varus or equinovarus deformity of the hindfoot. Correction of the lateral tibial torsion by supramalleolar derotation tibial osteotomy and reorientation of the ankle mortise appear to unlock the talus from the laterally rotated position, correcting a mobile hindfoot varus deformity and altering soft-tissue tensions about the ankle so that the correction achieved is maintained. In the presence of a fixed hindfoot deformity, supramalleolar derotation tibial osteotomy is useful as a first-stage procedure before corrective osteotomies of the foot. The operation described is technically simple and carries a low morbidity. Twenty supramalleolar derotation tibial osteotomies in 18 patients have been performed with satisfactory results and few complications

Patients with spina bifida cystica commonly have significant disability from a combination of valgus deformity of the ankle and subtalar joints with lateral tibial torsion and plano-abduction deformity of the foot. These deformities can be corrected by a single procedure which combines a supramalleolar tibial osteotomy with a lateral inlay triple fusion. This procedure was carried out on 20 feet in 15 patients and the results were reviewed after an average of three years (range 18 months to 7 years). In 75 per cent of feet the combination of deformities was fully corrected, ulcers and callosities were eliminated in 95 per cent, the use of calipers minimised in 95 per cent, and in all patients the problem of shoe-wrecking was reduced. Complications included recurrent valgus deformity, delayed union of the tibial osteotomy and failure of midtarsal fusion

A new method for the measurement of tibial torsion using computerised transverse tomography is presented. Its accuracy is equal to that of cadaveric skeletal measurement. This method may be used in patients with unilateral post-traumatic torsional deformities, especially when these are combined with genu varum or valgum. The study of torsional aberrations in connection with congenital abnormalities of the foot is of further interest

Aims. The prevalence of combined abnormalities of femoral torsion (FT) and tibial torsion (TT) is unknown in patients with femoroacetabular impingement (FAI) and hip dysplasia. This study aimed to determine the prevalence of combined abnormalities of FT and TT, and which subgroups are associated with combined abnormalities of FT and TT. Methods. We retrospectively evaluated symptomatic patients with FAI or hip dysplasia with CT scans performed between September 2011 and September 2016. A total of 261 hips (174 patients) had a measurement of FT and TT. Their mean age was 31 years (SD 9), and 63% were female (165 hips). Patients were compared to an asymptomatic control group (48 hips, 27 patients) who had CT scans including femur and tibia available for analysis, which had been acquired for nonorthopaedic reasons. Comparisons were conducted using analysis of variance with Bonferroni correction. Results. In the overall study group, abnormal FT was present in 62% (163 hips). Abnormal TT was present in 42% (109 hips). Normal FT combined with normal TT was present in 21% (55 hips). The most frequent abnormal combination was increased FT combined with normal TT of 32% (84 hips). In the hip dysplasia group, 21% (11 hips) had increased FT combined with increased TT. The prevalence of abnormal FT varied significantly among the subgroups (p < 0.001). We found a significantly higher mean FT for hip dysplasia (31°; SD 15)° and valgus hips (42° (SD 12°)) compared with the control group (22° (SD 8°)). We found a significantly higher mean TT for hips with cam-type-FAI (34° (SD 6°)) and hip dysplasia (35° (SD 9°)) compared with the control group (28° (SD 8°)) (p < 0.001). Conclusion. Patients with FAI had a high prevalence of combined abnormalities of FT and TT. For hip dysplasia, we found a significantly higher mean FT and TT, while 21% of patients (11 hips) had combined increased TT and increased FT (combined torsional malalignment). This is important when planning hip preserving surgery such as periacetabular osteomy and femoral derotation osteotomy. Cite this article: Bone Joint J 2020;102-B(12):1636–1645

Aims. Abnormal femoral torsion (FT) is increasingly recognized as an additional cause for femoroacetabular impingement (FAI). It is unknown if in-toeing of the foot is a specific diagnostic sign for increased FT in patients with symptomatic FAI. The aims of this study were to determine: 1) the prevalence and diagnostic accuracy of in-toeing to detect increased FT; 2) if foot progression angle (FPA) and tibial torsion (TT) are different among patients with abnormal FT; and 3) if FPA correlates with FT. Patients and Methods. A retrospective, institutional review board (IRB)-approved, controlled study of 85 symptomatic patients (148 hips) with FAI or hip dysplasia was performed in the gait laboratory. All patients had a measurement of FT (pelvic CT scan), TT (CT scan), and FPA (optical motion capture system). We allocated all patients to three groups with decreased FT (< 10°, 37 hips), increased FT (> 25°, 61 hips), and normal FT (10° to 25°, 50 hips). Cluster analysis was performed. Results. We found a specificity of 99%, positive predictive value (PPV) of 93%, and sensitivity of 23% for in-toeing (FPA < 0°) to detect increased FT > 25°. Most of the hips with normal or decreased FT had no in-toeing (false-positive rate of 1%). Patients with increased FT had significantly (p < 0.001) more in-toeing than patients with decreased FT. The majority of the patients (77%) with increased FT walk with a normal foot position. The correlation between FPA and FT was significant (r = 0.404, p < 0.001). Five cluster groups were identified. Conclusion. In-toeing has a high specificity and high PPV to detect increased FT, but increased FT can be missed because of the low sensitivity and high false-negative rate. These results can be used for diagnosis of abnormal FT in patients with FAI or hip dysplasia undergoing hip arthroscopy or femoral derotation osteotomy. However, most of the patients with increased FT walk with a normal foot position. This can lead to underestimation or misdiagnosis of abnormal FT. We recommend measuring FT with CT/MRI scans in all patients with FAI. Cite this article: Bone Joint J 2019;101-B:1218–1229

Introduction and Objective. The geometry of the proximal tibia and distal femur is intimately linked with the biomechanics of the knee and it is to be considered in total knee arthroplasty (TKA) component positioning. The aim of the present study was to evaluate the proximal tibial torsion in relation to the flexion-extension axis of the knee in healthy and pathological cohort affected by knee osteoarthritis (OA). Materials and Methods. We retrospectively analyzed computed tomography scans of OA knee of 59 patients prior to TKA and non-arthritic knee of 39 patients as control. Posterior condylar angle (PCA), femoral tibial torsion (TEAs-PTC and TEAs-PTT), proximal tibial torsion (PTC-PTT and PCAx-PTC) and distance between tibial tuberosity and the trochlear groove (TT-TG) were measured. Results. No differences were found for gender, age, TG-TT and PCAn angles. Statistically significant differences were found for all the other angles considered. Significant relation was found between Tibial Torsion and TEA-PTT angles, between PCAx-PTC and TEA-PTC, between TEA-PTT and TEA-PTC and between PCAx-PTC and TEA-PTT. All measures, except TG-TT and PCAn angles, showed high validity (AUC > 75%) in detecting OA, with TEA-PTT displaying the highest validity with an AUC of 94.38%. Conclusions. This is the first study to find significant differences in terms of proximal tibia geometry and anatomy between non arthritic and OA knees. It is conceivable that such anatomy could be implicated in the development of OA. Based on our data, the TEAs is a valid reference for correct positioning of tibial component in TKA. Indeed, setting the tibial component parallel to TEAs makes the prosthetic knee more similar to the native non-arthritic knee

Background. The importance of total ankle replacement (TAR) implant orientation in the axial plane is poorly understood with major variation in surgical technique of implants on the market. Our aims were to better understand the axial rotational profile of patients undergoing TAR. Methods. In 157 standardised CT Scans of end-stage ankle arthritis patients planning to undergo primary TAR surgery, we measured the relationship between the knee posterior condylar axis, the tibial tuberosity, the transmalleolar axis(TMA) and the tibiotalar angle. The foot position was measured in relation to the TMA with the foot plantigrade. The variation between medial gutter line and the line bisecting both gutters was assessed. Results. The mean external tibial torsion was 34.5±10.3°(11.8–62°). When plantigrade the mean foot position relative to the TMA was 21±10.6°(0.7–38.4°) internally rotated. As external tibial torsion increased, the foot position became more internally rotated relative to the TMA(pearson correlation 0.6;p< 0.0001). As the tibiotalar angle became more valgus, the foot became more externally rotated relative to the TMA(pearson correlation −0.4;p< 0.01). The mean difference between the medial gutter line and a line bisecting both gutters was 4.9±2.8°(1.7°-9.4°). More than 51% of patients had a difference greater than 5°. The mean angle between the medial gutter line and a line perpendicular to the TMA was 7.5°±2.6°(2.8°-13.7°). Conclusion. There is a large variation in rotational profile of patients undergoing TAR, particularly between the medial gutter line and the transmalleolar axis. Surgeon designers and implant manufacturers need to develop consistent methods to guide surgeons towards judging appropriate axial rotation of their implanton an individual basis. We recommend careful clinical assessment and CT scanspre-operatively to enable the correct rotation to be determined

Background. Authors sought to determine the degree of lateral condylar hypoplasia of distal femur was related to degree of valgus malalignment of lower extremity in patients who underwent TKA. Authors also examined the relationships between degree of valgus malalignment and degree of femoral anteversion or tibial torsion. Methods. This retrospective study included 211 patients (422 lower extremities). Alignment of lower extremity was determined using mechanical tibiofemoral angle (mTFA) measured from standing full-limb AP radiography. mTFA was described positive value when it was valgus. Patients were divided into three groups by mTFA; more than 3 degrees of valgus (valgus group, n = 31), between 3 degrees of valgus to 3 degrees of varus (neutral group, n = 78), and more than 3 degrees of varus (varus group, n = 313). Condylar twisting angle (CTA) was used to measure degree of the lateral femoral condylar hypoplasia. CTA was defined as the angle between clinical transepicondylar axis (TEA) and posterior condylar axis (PCA). Femoral anteversion was measured by two methods. One was the angle formed between the line intersecting femoral neck and the PCA (pFeAV). The other was the angle formed between the line intersecting femoral neck and clinical TEA (tFeAV). Tibial torsion was defined as a degree of torsion of distal tibia relative to proximal tibia. It was determined by the angle formed between the line connecting posterior cortices of proximal tibial condyles and the line connecting the most prominent points of lateral and medial malleolus. Positive values represented relative external rotation. Negative values represented relative internal rotation. Results. Greater lateral femoral condylar hypoplasia was related to increased valgus alignment of lower extremity. Correlation coefficient between mTFA and CTA was 0.253 (p < 0.001). Valgus group showed increased CTA, which was 10.2° ± 1.9°. CTA was 7.4° ± 2.5° in neutral group and 6.6° ± 4.8° in varus group. There was significant positive correlation between the degree of valgus alignment and the degree of femoral anteversion (r = 0.145, p = 0.003). pFeAV was 16.7° ± 5.8° in valgus group, 12.1° ± 6.0° in neutral group and 10.9° ± 7.0° in varus group. There was no correlation between degree of valgus alignment and degree of femoral anteversion (r = 0.060, p = 0.218). In terms of tibial torsion, increased valgus malalignment was associated with increased tibial torsion (r = 0.374, p < 0.001). Valgus group showed increased tibial torsion than other groups. Tibial torsion was 32.6° ± 6.2° in valgus group, 26.3° ± 6.9° in neutral group and 22.6° ± 7.2° in varus group. Conclusions. Increased valgus alignment of lower extremity was related to greater lateral femoral condylar hypoplasia. However, increased valgus alignment was not related to degree of femoral anteversion whereas it was related to increased external tibial torsion. Our findings should be considered when determining proper rotational alignment in TKA

Introduction. Snapping hip syndrome is a common condition affecting 10% of the population. It is due to the advance of the iliotibial band (ITB) over the greater trochanter during lower limb movements and often associated with hip overuse, such as in athletic activities. Management is commonly conservative with physiotherapy or can be surgical to release the ITB. Here we carry out a systematic review into published surgical management and present a case report on an overlooked cause of paediatric snapping hip syndrome. Materials & Methods. A systematic review looking at published surgical management of snapping hip was performed according to PRISMA guidelines. PubMed, MEDLINE, EMBASE, CINAHL and the Cochrane Library databases were searched for “((Snapping hip OR Iliotibial band syndrome OR ITB syndrome) AND (Management OR treatment))”. Adult and paediatric published studies were included as few results were found on paediatric snapping hip alone. Results. 1548 studies were screened by 2 independent reviewers. 8 studies were included with a total of 134 cases, with an age range of 14–71 years. Surgical management ranged from arthroscopic, open or ultrasound guided release of the ITB, as well as gluteal muscle releases. Common outcome measures showed statistically significant improvement pre- and post-operatively in visual analogue pain score (VAPS) and the Harris Hip Score (HHS). VAPS improved from an average of 6.77 to 0.3 (t-test p value <0.0001) and the HHS improved from an average of 62.6 to 89.4 (t-test p value <0.0001). Conclusions. Although good surgical outcomes have been reported, no study has reported on the effect of rotational profile of the lower limbs and snapping hip syndrome. We present the case of a 13-year-old female with snapping hip syndrome and trochanteric pain. Ultrasound confirmed external snapping hip with normal soft tissue morphology and radiographs confirmed no structural abnormalities. Following extensive physiotherapy and little improvement, she presented again aged 17 with concurrent anterior knee pain, patella mal-tracking and an asymmetrical out-toeing gait. CT rotational profile showed 2° of femoral neck retroversion and excessive external tibial torsion of 52°. Consequently, during her gait cycle, in order to correct her increased foot progression angle, the hip has to internally rotate approximately 35–40°, putting the greater trochanter in an anterolateral position in stance phase. This causes the ITB to snap over her abnormally positioned greater trochanter. Therefore, to correct rotational limb alignment, a proximal tibial de-rotation osteotomy was performed with 25° internal rotation correction. Post-operatively the patient recovered well, HHS score improved from 52.5 to 93.75 and her snapping hip has resolved. This study highlights the importance of relevant assessment and investigation of lower limb rotational profile when exploring causes of external snapping hip, especially where ultrasound and radiographs show no significant pathology

Purpose: Mal-tracking or dislocation of the patella is often the result of abnormal anatomy. Understanding the anatomy will clarify the treatment options available. The common anatomical causes of dislocation range from the valgus knee to patella alta and external tibial torsion. External tibial torsion results in symptoms ranging from patello-femoral pain to subluzation or dislocation. Many patients become symptomatic after an injury and recognition of the anatomical pathology helps in the treatment decision. Method: A retrospective study was carried out on 232 rotational high tibial osteotomies in 221 patients operated on between 1990–2004. The pre-operative degree of external tibial torsion and ‘Q’ angle was noted. The extent of any patello-femoral pathology was documented, as well as the degree of correction. Assessment was carried out using the HSS score and the Lysholm score. Notation was made of prior surgery, including arthroscopy, patella tendon tarnsfer and patellectomy. Results: Of the 232 cases, 80% showed good to excellent results with resolution of patello-femoral pain and instability. Ten percent had residual pain but no instability and 20 cases proceeded to total knee replacement. The best results were seen in cases of pain and instability with minimal patello-femoral arthritis. Some cases with end-stage patello-femoral arthritis were improved with the improvement in quadriceps function via reduction in the ‘Q’ angle. Conclusion: Rotational osteotomy of the proximal tibia for symptomatic patella instability secondary to significant external tibial torsion results in good to excellent results in 80% of cases

Purpose: The aim of this research was to characterize the correlation of magnetic resonance image (MRI) measurements of femoral anteversion and tibial torsion with transverse plane kinematics from the gait analysis of ten healthy and nine cerebral palsy (CP) children. Methods: The bone morphologies of nine spastic diplegic CP and ten healthy children were obtained by analysis of 3D MRIs. Location of anatomical landmarks along the femur and tibia were detected using medical imaging software. Each point was then defined with respect to bone-embedded femoral and tibial Cartesian coordinates, allowing 3D reorientation of the bone independent of the patient position within the scanner. Femoral anteversion was defined as the angle between the femoral neck and the transcondylar plane. Tibial torsion was defined as the angle between the transcondylar axis of the proximal tibia and the bi-malleolar axis. Three-dimensional motion of the lower limbs was measured using gait analysis. Transverse plane kinematics, including hip rotation and foot progression angles were recorded. Results: A moderate correlation was found between femoral anteversion, and maximum and average hip rotation in CP children (0.64 and 0.65). A high correlation was also seen between tibial torsion and maximum and average values of hip rotation for CP children (0.71 and 0.74). In healthy children, the only correlation observed was between femoral anteversion and average foot progression in stance (0.75). Discussion: In healthy children, femoral anteversion appears to influence foot progression angle, implying that this can lead to an internally rotated gait. In CP children, the correlation between femoral anteversion and hip rotation is only moderate. The interaction between different joints is more complex and the rotation of joints is determined by multiple factors. This study showed that tibial torsion also plays a role in determining hip rotation during gait

Introduction. Torsional malalignment syndrome (TMS) is a unique combination of rotational deformities in the lower limb, often leading to severe patellofemoral joint pain and disability. Surgical management of this condition usually consists of two osteotomies in each affected limb, with simultaneous correction of both femoral anteversion and external tibial torsion. However, we believe that a single supratubercular osteotomy followed by tibial derotation with the Taylor Spatial Frame (TSF) can be used to provide a significant improvement in both appearance and function. Materials and Methods. This is a retrospective case analysis in which we will be reviewing 16 osteotomies performed by one surgeon between 2006 and 2017. The study includes 11 patients with a mean age of 16.7 ± 0.8 years. Pre and post-operatively, patients were fully evaluated through history and physical examination, and CT rotational profiling. Statistical analyses were performed in order to determine whether or not any observed clinical or cosmetic improvements were statistically significant. Results. The results show significant improvements in scores reported on post-operative functional assessment, with mean Oxford Knee Score (OKS) increasing by 18.3 and mean Kujala Anterior Knee Pain Scale (AKPS) also increasing by 31.4. In addition to this, post-operative clinical assessment showed a reduced thigh-foot angle (TFA) in all cases, by a mean value of 31.9o. The angle of the transmalleolar axis (TMA) was successfully reduced in 14/16 cases, by a mean value of 8.6o. Statistical analysis showed all of these results to be statistically significant where p<0.05. Conclusions. The results show that supratubercular osteotomy, followed by gradual correction with TSF, can be used to provide a significant improvement in both appearance and function for patients suffering from TMS

Torsional changes in the lower limbs represent a serious clinical problem. The evaluation of the physiological development of the relationship between femur and tibia in the axial plane is necessary for final assessment. The authors observed 940 patients aged from 4 to 15 years to identify the most important modifications of torsion of the lower limbs during paediatric age. Clinical examination includes assessment in the standing and supine position and observation of the gait features so that the physiological-pathological borderline can be defined, along with peculiar aspects of single and combined deformities, in order to identify indications for osteotomy. The types of torsion are classified as: (1) isolated augmentation of femoral anteversion; (2) isolated reduction of femoral anteversion; (3) isolated medial tibial torsion; (4) isolated lateral tibial torsion; and (5) combined torsion (femoral anteversion combined with lateral tibial torsion). The anatomy and the natural progression of femoral and tibial torsion can be assessed by clinical methods. Radiographic methods such as axial CT views are indicated in cases in which clinical examination does not provide clear information and, in particular, if qualitative and quantitative diagnosis is required in order to establish the therapeutic protocol. The authors conclude by suggesting that the physiological development of torsion should be followed up to skeletal maturity in order to make a general evaluation and to decide on treatment

Purpose: Mal-tracking or dislocation of the patella is often the result of abnormal anatomy. Understanding the abnormal anatomy will clarify the treatment options available. The common anatomical causes of dislocation range from the valgus knee with an elevated ‘Q’ angle to patella alta with a hypo-plastic trochlea, to external tibial torsion, resulting in an excessive ‘Q’ angle. External tibial torsion results in symptoms ranging from patello-femoral pain to subluxation or dislocation. Many patients are asymptomatic prior to an injury. The decision to correct the underlying anatomical abnormality is often a difficult one. Methods: A retrospective study of 232 rotational HTO’s in 221 patients operated on between 1990 and 2003 was conducted. The pre-operative degree of external tibial torsion and ‘Q’ angle was noted as well as the degree of rotation. The extent, if any patello-femoral pathology, was noted. Assessment was carried out using the HSS scoring system and Lysholm score.|Notation was made of prior surgery to the knee ranging from arthroscopy to patella tendon transfer to patellectomy. Results: Of the 232 cases 80% were good to excellent with resolution of patello-femoral pain and instability. 10% had residual pain but no instability and 20 cases had to proceed to total knee replacement.|The best results were seen in cases with pain and instability but minimal patello-femoral pathology. Even cases with end-stage patello-femoral osteoarthritis were improved by maximizing the function of the extensor mechanism. Conclusions: Rotational osteotomy of the proximal tibia for symptoms of patello-femoral instability secondary to significant external tibia torsion provided much better results than isolated patella tendon transfer

This study reviews our 13-years experience with Haas’s multiple-longitudinal osteotomy technique for correction of tibial deformities 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 with either a long cast or with “pins-in-plaster”. Sixty osteotomies were performed in 37 children. Thirty-five cases had internal tibial torsion (ITT), 11 had external tibial torsion (ETT) and 14 had a Tibia Vara deformity. Twenty-one cases had Spastic Cerebral Palsy and 15 cases were associated with Clubfeet. One boy had bilateral tibia vara associated with SMED (Spondylo-meta-epiphyseal dysplasia). Twenty-two (36/7%) of the deformities had no underlying musculoskeletal conditions. Thigh-foot angles were corrected by a mean of 24. °. for ITT and −28° for ETT. Mean correction for tibia vara was 20°. Average anesthesia time for unilateral cases was 47 minutes. No neurologic or infectious complications, postoperative fractures or physeal damage occurred. There was one case of delayed union and 1 case of postoperative antecurvatum deformity. All 7 cases of postoperative recurrent deformities were associated with CP or SMED. This technique is a simple, safe and efficient method for correcting tibial torsional and varus deformities for both healthy children and those with underlying conditions. It allows accurate alignment of different deformities with an uniform osteotomy technique, which preserves bone continuity and provides inherent stability, thus avoiding the use of internal fixation