Distal tibial osteotomy to address internal tibial torsion: Should the fibula be cut?


      • Surgical derotation of pathological tibial torsion may include a fibular osteotomy.
      • ≥10° correction, posterior distal tibiofibular gap is greater without fibular cut.
      • ≥20° correction, proximal tibiofibular joint rotation is greater without fibular cut.
      • ≥20° correction, anterior distal tibiofibular gap is decreased without fibular cut.
      • ≥20° correction, medial tibiotalar space is decreased without fibular cut.


      Rotational tibial osteotomy seeks to address pathologic tibial torsion. Inclusion of fibular osteotomy during this procedure remains controversial. This study aimed to determine how external rotation through a tibial osteotomy, with or without a fibular osteotomy, would influence tibiofibular joint congruity.
      Eight cadaveric legs underwent distal tibial osteotomies. Pins were placed to designate neutral, 10°, 20°, 30° of external rotation. Computed tomography (CT) imaging was performed at each rotation without, then with a fibular osteotomy. Magnetic Resonance Imaging was performed prior to fibular osteotomy to confirm that ligaments remained intact. Custom software calculated tibial torsion using CT scan 3D reconstructions. Proximal tibiofibular joint rotation, distal tibiofibular gapping and ankle mortise were measured on each CT exam. Groups without and with fibular osteotomy were compared.
      There was no difference between tibial osteotomy rotation magnitude with or without the fibular osteotomy (P = 0.2). The group without the fibular osteotomy had greater proximal fibular rotation at the tibiofibular joint at 20°, 30° (P < 0.05), greater posterior distal tibiofibular gap at 10°, 20°, 30° (P < 0.05) and less anterior distal tibiofibular gap at 20°, 30° (P < 0.05). The medial tibiotalar space was narrowed without the fibular osteotomy at 20°, 30° (P < 0.05) compared to pre-rotation.
      Deformity at the proximal tibiofibular and ankle joints become most pronounced at >20° of tibial rotation without a fibular osteotomy. The first joint to be affected is the distal tibiofibular joint. To limit ankle and proximal tibiofibular articular deformation during tibia rotational osteotomy, a fibular osteotomy is recommended when correcting over 20° of rotation.


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        • Andrisevic E.
        • Westberry D.E.
        • Pugh L.I.
        • Bagley A.M.
        • Tanner S.
        • Davids J.R.
        Correction of Tibial torsion in children with cerebral palsy by isolated distal tibia rotation osteotomy: a short-term, in vivo anatomic study.
        J. Pediatr. Orthop. 2016; 36: 743-748https://doi.org/10.1097/BPO.0000000000000525
        • Banks S.W.
        • Evans E.A.
        Simple transverse osteotomy and threaded-pin fixation for controlled correction of torsion deformities of the tibia.
        J. Bone Joint Surg. Am. 1955; 37-A: 193-195
        • Bennett J.T.
        • Bunnell W.P.
        • MacEwen G.D.
        Rotational osteotomy of the distal tibia and fibula.
        J. Pediatr. Orthop. 1985; 5: 294-298https://doi.org/10.1097/01241398-198505000-00007
        • Brooks J.T.
        • Bomar J.D.
        • Jeffords M.E.
        • Farnsworth C.L.
        • Pennock A.T.
        • Upasani V.V.
        Reliability of low-dose biplanar radiography in assessing pediatric torsional pathology.
        J. Pediatr. Orthop. 2021 Jan; 41: 33-39
        • Castle M.
        Tibial rotational osteotomy.
        Clin. Orthop. Relat. Res. 1976; 118: 73-75
        • Dodgin D.A.
        • De Swart R.J.
        • Stefko R.M.
        • Wenger D.R.
        • Ko J.-Y.
        Distal tibial/fibular derotation osteotomy for correction of tibial torsion: review of technique and results in 63 cases.
        J. Pediatr. Orthop. 1998; 18: 95-101
        • Espregueira-Mendes J.
        • Pereira H.
        • Sevivas N.
        • et al.
        Osteochondral transplantation using autografts from the upper tibio-fibular joint for the treatment of knee cartilage lesions.
        Knee Surg. Sports Traumatol. Arthrosc. 2012; 20: 1136-1142https://doi.org/10.1007/s00167-012-1910-0
        • Gage J.R.
        • Novacheck T.F.
        An update on the treatment of gait problems in cerebral palsy.
        J. Pediatr. Orthop. B. 2001; 10: 265-274
        • Goutallier D.
        • Van Driessche S.
        • Manicom O.
        • et al.
        Influence of lower-limb torsion on long-term outcomes of tibial valgus osteotomy for medial compartment knee osteoarthritis.
        J. Bone Joint Surg. Am. 2006; 88: 2439-2447https://doi.org/10.2106/JBJS.E.01130
        • Han H.S.
        • Chang C.B.
        • Seong S.C.
        • Lee S.
        • Lee M.C.
        Evaluation of anatomic references for tibial sagittal alignment in total knee arthroplasty.
        Knee Surg. Sports Traumatol. Arthrosc. 2008; 16: 373-377https://doi.org/10.1007/s00167-008-0486-1
        • Hutchins P.M.
        • Rambicki D.
        • Comacchio L.
        • Paterson D.C.
        Tibiofibular torsion in normal and treated clubfoot populations.
        J. Pediatr. Orthop. 1986; 6: 452-455https://doi.org/10.1097/01241398-198607000-00012
        • Krengel W.F.
        • Staheli L.T.
        Tibial rotational osteotomy for idiopathic torsion. A comparison of the proximal and distal osteotomy levels.
        Clin. Orthop. Relat. Res. 1992; 283: 285-289
        • Lloyd J.
        • Elsayed S.
        • Hariharan K.
        • Tanaka H.
        Revisiting the concept of talar shift in ankle fractures.
        Foot Ankle Int. 2006; 27: 793-796https://doi.org/10.1177/107110070602701006
        • MacWilliams B.A.
        • McMulkin M.L.
        • Baird G.O.
        • Stevens P.M.
        Distal tibial rotation osteotomies normalize frontal plane knee moments.
        J. Bone Joint Surg. Am. 2010; 92: 2835-2842https://doi.org/10.2106/JBJS.J.00147
        • Magnusson R.
        Rotation osteotomy; a method employed in cases of congenital club-foot.
        J. Bone Joint Surg. Am. 1946; 28: 262-264
        • Manouel M.
        • Johnson L.O.
        The role of fibular osteotomy in rotational osteotomy of the distal tibia.
        J. Pediatr. Orthop. 1994; 14: 611-614
        • Rattey T.
        • Hyndman J.
        Rotational osteotomies of the leg: tibia alone versus both tibia and fibula.
        J. Pediatr. Orthop. 1994; 14: 615-618https://doi.org/10.1097/01241398-199409000-00012
        • Rethlefsen S.A.
        • Healy B.S.
        • Wren T.A.
        • Skaggs D.L.
        • Kay R.M.
        Causes of intoeing gait in children with cerebral palsy.
        J. Bone Joint Surg. Am. 2006; 88: 2175-2180https://doi.org/10.2106/JBJS.E.01280
        • Rethlefsen S.A.
        • Blumstein G.
        • Kay R.M.
        • Dorey F.
        • Wren T.A.
        Prevalence of specific gait abnormalities in children with cerebral palsy revisited: influence of age, prior surgery, and Gross Motor Function Classification System level.
        Dev. Med. Child Neurol. 2017; 59: 79-88https://doi.org/10.1111/dmcn.13205
        • Ryan D.D.
        • Rethlefsen S.A.
        • Skaggs D.L.
        • Kay R.M.
        Results of tibial rotational osteotomy without concomitant fibular osteotomy in children with cerebral palsy.
        J. Pediatr. Orthop. 2005; 25: 84-88https://doi.org/10.1097/00004694-200501000-0001
        • Schonecker P.L.
        • Rich M.
        • Gordon J.E.
        • Weinstein S.L.
        • Flynn J.M.
        The lower extremity.
        in: Lovell and Winter’s Pediatric Orthopedics. 7 ed. Lippincott Williams & Wilkins, Philadelphia, PA2014: 1261-1340
        • Song K.M.
        • Concha M.C.
        • Haideri N.F.
        Effects of lower limb torsion on ankle kinematic data during gait analysis.
        J. Pediatr. Orthop. 2001; 21: 792-797
        • Walton D.M.
        • Liu R.W.
        • Farrow L.D.
        • Thompson G.H.
        Proximal tibial derotation osteotomy for torsion of the tibia: a review of 43 cases.
        J. Child. Orthop. 2012; 6: 81-85https://doi.org/10.1007/s11832-012-0384-4
        • Wren T.A.
        • Rethlefsen S.
        • Kay R.M.
        Prevalence of specific gait abnormalities in children with cerebral palsy: influence of cerebral palsy subtype, age, and previous surgery.
        J. Pediatr. Orthop. 2005; 25: 79-83https://doi.org/10.1097/00004694-200501000-00018