Andrisevic Emily, Westberry David E, Pugh Linda I, Bagley Anita M, Tanner Stephanie, Davids Jon R
*Shriners Hospitals for Children-Northern California, Sacramento, CA†Shriners Hospitals for Children-Greenville, Greenville, SC.
J Pediatr Orthop. 2016 Oct-Nov;36(7):743-8. doi: 10.1097/BPO.0000000000000525.
Excessive internal or external tibial torsion is frequently present in children with cerebral palsy. Several surgical techniques have been described to correct excessive tibial torsion, including isolated distal tibial rotation osteotomy (TRO). The anatomic changes surrounding this technique are poorly understood. The goal of the study was to examine the anatomic relationship between the tibia and fibula following isolated distal TRO in children with cerebral palsy.
Twenty patients with 29 limbs were prospectively entered for study. CT scans of the proximal and distal tibiofibular (TF) articulations were obtained preoperatively, at 6 weeks, and 1 year postoperatively. Measurements of tibia and fibula torsion were performed at each interval. Qualitative assessments of proximal and distal TF joint congruency were also performed.
The subjects with internal tibia torsion (ITT, 19 limbs) showed significant torsional changes for the tibia between preoperative, postoperative, and 1 year time points (mean torsion 13.21, 31.05, 34.84 degrees, respectively). Measurement of fibular torsion in the ITT treatment group also showed significant differences between time points (mean -36.77, -26.77, -18.54 degrees, respectively). Proximal and distal TF joints remained congruent at all time points in the study.Subjects with external tibia torsion (ETT, 10 limbs) showed significant differences between preoperative and postoperative tibial torsion, but not between postoperative and 1 year (mean torsion 54, 19.3, 23.3 degrees, respectively). Measurement of fibular torsion in the ETT treatment group did not change significantly between preoperative and postoperative, but did change significantly between postoperative and 1 year (mean torsion -9.8,-16.9, -30.7 degrees, respectively). Nine of 10 proximal TF joints were found to be subluxated at 6 weeks postoperatively. At 1 year, all 9 of these joints had reduced.
Correction of ITT by isolated distal tibial external rotation osteotomy resulted in acute external fibular torsion. The fibular torsion alignment remodeled over time to accommodate the corrected tibial torsional alignment and reduce the strain associated with the plastic deformity of the fibula. Correction of ETT by isolated distal internal TRO resulted in acute subluxation of the proximal TF articulation in almost all cases. Subsequent torsional remodeling of the fibula resulted in correction of the TF subluxation in all cases. Acute correction of TT by isolated distal TRO occurs by distinct mechanisms, based upon the direction of rotational correction.
Level II-Diagnostic.
脑性瘫痪儿童经常存在过度的胫骨内旋或外旋。已经描述了几种手术技术来纠正过度的胫骨扭转，包括孤立的胫骨远端旋转截骨术（TRO）。围绕该技术的解剖学变化了解甚少。本研究的目的是检查脑性瘫痪儿童孤立的胫骨远端TRO术后胫骨与腓骨之间的解剖关系。
前瞻性纳入20例患者共29条肢体进行研究。术前、术后6周和术后1年获取胫腓骨近端和远端关节的CT扫描。在每个时间点测量胫骨和腓骨扭转。还对胫腓骨近端和远端关节的一致性进行了定性评估。
胫骨内旋（ITT，19条肢体）的受试者在术前、术后和1年时间点之间胫骨扭转有显著变化（平均扭转分别为13.21°、31.05°、34.84°）。ITT治疗组腓骨扭转测量在各时间点之间也有显著差异（平均分别为-36.77°、-26.77°、-18.54°）。在研究的所有时间点，胫腓骨近端和远端关节均保持一致。胫骨外旋（ETT，10条肢体）的受试者术前和术后胫骨扭转有显著差异，但术后与1年之间无显著差异（平均扭转分别为54°、19.3°、23.3°）。ETT治疗组腓骨扭转测量术前和术后无显著变化，但术后与1年之间有显著变化（平均扭转分别为-9.8°、-16.9°、-30.7°）。10个胫腓骨近端关节中有9个在术后6周出现半脱位。1年时，所有9个关节均复位。
通过孤立的胫骨远端外旋截骨术纠正ITT导致腓骨急性外旋。随着时间的推移，腓骨扭转对线重塑以适应纠正后的胫骨扭转对线，并减少与腓骨塑性畸形相关的应变。通过孤立的胫骨远端内旋TRO纠正ETT在几乎所有病例中导致胫腓骨近端关节急性半脱位。随后腓骨的扭转重塑在所有病例中导致胫腓关节半脱位的纠正。基于旋转纠正的方向，通过孤立的胫骨远端TRO对胫骨扭转进行急性纠正通过不同的机制发生。
二级诊断性。
