Abstract
Introduction
Tibial torsion can be measured by various clinical and radiological methods. Computed tomography (CT) scan measurement is currently the investigation of choice. The purpose of our study was to compare the clinical and CT scan methods to reveal malrotation after nailing of tibia and also to find out if leg position for distal locking has any influence on incidence of malrotation.
Materials and methods
We have included 106 patients (21–68 years) of tibia nailing, and categorised them as category A (figure of four position n = 54) and category B (knee straight position n = 52) based on limb position for distal locking. The plumb line measurement, Thigh Foot Axis (TFA) and CT scan measurement (using new reference line) were documented and compared with the uninjured limb.
Results
We observed plumb line measurement to be the most inaccurate method followed by TFA method. CT scan measurement was the most accurate method showing external rotations (> 10º) in 32 cases (30.1%) and internal rotation (> − 10º) in five cases (4.71%). The TFA method had a sensitivity of 44% and specificity of 86% in identifying malrotations. The interobserver reliability for CT scan measurement was 0.96. Even though statistically not significant (P value), figure of four position for distal locking leads to larger number of malrotations (both external and internal rotation).
Conclusion
CT scan is the most accurate method of measuring malrotation. The new reference line used in our study provides accurate measurement of malrotation. The two different positions of leg for distal locking do not have a statistically significant influence on incidence of malrotation.
Keywords: CT scan, Leg position, Malrotation, Tibia nailing, Tibial torsion, Rotation, Thigh, Tibia, Tibial fractures, Tomography
Introduction
Tibial torsion has been defined variously as torsion of tibia along its longitudinal axis [1]; relationship between the axis of rotation of the knee and transmalleolar axis [2]; the anatomical twist of the proximal versus distal articular axis of the tibial bone in the transverse plane around the longitudinal axis [3, 4]. Tibial torsion is neutral at birth, i.e., the malleoli are about level. The medial malleolus rotates forwards during growth, causing tibial torsion in the adult of approximately 20° (Le Damany 1909) [5].
Numerous authors have described various anthropometric, clinical and radiographic methods to determine tibial torsion, including direct measurement of cadaver bones [6], clinical assessment of patient’s limbs, and several imaging techniques using plain films [7], fluroscopy [8], CT [5], MRI [9] and ultrasound [10]. The most accurate technique for measuring tibial torsion is anthropometric measurement on necropsy specimens. Although this approach is useful for establishing normative data, it cannot be used clinically [11]. The clinical methods for measurement of tibial torsion include thigh foot angle, bimalleolar angle [12–14], foot progression angle and thigh transmalleolar angle [15]. However, the accuracy of physical examination has not been proven [16].
In cases of tibial fractures fixed with intramedullary nail, distal locking is done with limb either in figure of four position, or with knee in straight position. This may create disparity in the rotational alignment of tibia.
The aim of our study was to determine the incidence and severity of tibial malrotation based on
Alignment of plumb line to second toe.
Measurement of Thigh Foot Axis (TFA).
CT scan measurement (using posterior transcondylar axis as proximal reference line and anterior transmalleolar axis as distal reference line).
and categorising the findings for patients whose distal locking was done with limb in
Figure of four position
Straight position.
Materials and methods
This was a prospective study done over a period of 13 months (from October 2017 to November 2018). The patients were divided into two categories, with category A patients in whom distal locking was done with leg in figure of four position, and category B patients in whom distal locking was done in straight position. In category B patients the proximal jig was dismantled so that the knee could be extended for straight position.
All consecutive cases of closed fracture both bone leg in adults who consented for postoperative CT scan were included in the study. Compliance with ethical requirements was fulfilled. Paediatric patients, open fractures grade II and III, previous ipsilateral tibial trauma, ipsilateral proximal or distal tibial fractures, fractures extending into knee or ankle joint, multiple trauma, patients with pre existing limb deformity and pregnancy were excluded from the study.
The patients were categorised as category A and category B and alternate case was operated positioning the limb either in figure of four position (category A) or straight position (category B) (Fig. 1). Fracture reduction was assessed by indirect methods like (a) shin in proximal fragment falling in line with shin in distal fragment which was revealed by palpation, (b) fluoroscopic guided correction of angulation and matching cortical thickness at fracture site.
Fig. 1.
Distal locking in (a) figure of four position (b) straight position
Once the patient was able to bend the knee to 90°, the patient was made to sit on a table with both the legs suspended from the edge of the table. A plumb line was created by using a device having a thread with one end touching the tibial tuberosity and the other end hanging just anterior to and below toes (Fig. 2). The toe through which the plumb line passed was noted. The same was repeated on the opposite normal side.
Fig. 2.
Plumb line measurement
Next the patient was made to lie prone with knee in 90° of flexion. With the help of a goniometer, the angle subtended between the thigh axis and foot axis (line passing from the centre of the heel to the second toe) was measured and documented (Fig. 3). The same was repeated on the opposite normal side.
Fig. 3.
Thigh Foot Axis measurement
A CT scan of both the legs was done with 3 mm axial cuts. A line drawn along the posterior condyles of tibia in the section just proximal to the fibular head section was considered as “proximal reference line”. Another line drawn along the anterior surface of medial and lateral malleoli in the section just distal to the articular surface section (of ankle) was considered as “distal reference line”.
The proximal and distal sections which were selected according to the previous description were aligned in the computer. The proximal and distal reference lines were drawn as described. The angle subtended between the perpendicular lines drawn to the proximal and distal reference lines was documented (Fig. 4). Similar procedure was performed for the opposite side. The findings were documented as tabular column and statistical analysis was done. The difference in angle was recorded as “positive”, if the operated limb was found to be more externally rotated (ER) when compared to the normal limb. The difference in angle was recorded as “negative”, if the operated limb was found to be internally rotated (IR) when compared to the normal limb. Patients with difference of > 10° between operated and non-operated limbs were considered as malrotation cases. Another observer was assigned the measurement of torsion angles using the same axial cuts. The torsion angle of the contralateral normal tibia was tabulated separately.
Fig. 4.
CT scan measurement method
Statistical analysis
The SPSS software version 20.0 was used for statistical analysis and the statistical significance (P < 0.05) for different methods of assessing external and internal rotation was done by Chi square test (Epi info version 7). The mean and standard deviation for the torsion of normal limbs were also calculated. The inter observer reliability was calculated using Pearson correlation coefficient method.
Results
There were a total of 106 patients in the age group of 21–68 years [mean – 38.3 years] with male, female distribution of 81:25. Out of 106 patients, 54 underwent distal locking in the figure of four position (category A), and the remaining 52 cases underwent distal locking in straight position (category B).
The plumb line was found to be away from second toe in 66 cases. Of these, the line passed medial to the second toe (i.e., denoting external rotation, ER) in 47 cases, and lateral to the second toe (i.e., denoting internal rotation, IR) in 19 cases (Table 1).
Table 1.
Distribution of cases according to plumb line measurement
| Plumb line | Cases | ||
|---|---|---|---|
| Figure of 4 (Cat A) | Straight (Cat B) | Total | |
| n (%) | n (%) | ||
| 1. Second toe | 18 (16.98%) | 22 (20.75%) | 40 |
| 2. Medial to the second toe (ER) | 26 (24.5%) | 21 (19.8%) | 47 |
| 3. Lateral to the second toe (IR) | 10 (9.43%) | 9 (8.49%) | 19 |
The thigh foot axis measurement (compared to normal side) was same in 11 cases, internally rotated (> − 10°) in 3 cases, externally rotated (> 10°) in 21 cases. According to TFA method, the range of difference of external rotation observed was + 2° to + 30°. Similarly, the range of difference of internal rotation observed was − 2° to − 20°.
According to CT scan measurement, the range of difference of external rotation observed was + 2° to + 20°. Similarly, the range of difference of internal rotation observed was − 2° to − 20°. The number of cases with ER > 10° and IR > − 10° were tabulated (Table 2).
Table 2.
Distribution of cases according to TFA measurement and CT scan measurement
| Malrotation | Thigh foot axis n (%) |
CT measurement n (%) |
|---|---|---|
| External rotation > 10° | 21 (19.8%) | 32 (30.1%) |
| Internal rotation > − 10° | 3 (2.83%) | 5 (4.71%) |
The statistical significance between plumb line measurement and CT measurement was calculated (P = 0.03 for ER > 10°, P = 0.04 for IR > − 10°). The statistical significance between TFA and CT measurement was calculated (P = 0.08 for ER > 10°, P = 0.47 for IR > − 10°). The number of cases of malrotation based on the position of the leg for distal locking (i.e., figure of four or straight knee position) was analysed separately and tabulated (Table 3). The statistical significance between figure of four position and straight position was calculated (P = 0.25 for ER > 10°, P = 0.65 for IR > − 10°).
Table 3.
Distribution of cases based on position of limb for distal locking
| Malrotation | Figure of 4 (Cat A) n (%) |
Straight (Cat B) n (%) |
||
|---|---|---|---|---|
| Thigh foot axis | CT | Thigh foot axis | CT | |
| External rotation > 10° | 12 (11.3%) | 19 (17.9%) | 9 (8.49%) | 13 (12.26%) |
| Internal rotation > − 10° | 2 (1.88%) | 3 (2.83%) | 1 (0.94%) | 2 (1.88%) |
The number of true positive cases and true negative cases were tabulated (Table 4) and sensitivity and specificity of TFA measurement was calculated. TFA measurement has a sensitivity of 44% and specificity of 86% when compared to CT measurement.
Table 4.
Diagnosis of malrotation by thigh foot axis
| Method | CT > 10º (ER + IR) | CT < 10º (ER + IR) |
|---|---|---|
| TFA > 10°(ER + IR) (n = 24) |
16 (True positive) |
8 (False positive) |
| TFA < 10°(ER + IR) (n = 82) |
24 (False negative) |
58 (True Negative) |
The tibial torsion angle in the operated tibia measured by two different observer was statistically analysed to calculate the correlation coefficient (inter observer reliability). The correlation coefficient between the two observers was 0.96.
The measurement of torsion angle in contra-lateral normal tibia demonstrated a torsion of 22° to 44° (29.25 ± 5.41) on the right side and a torsion of 20° to 40° (29.80 ± 5.49) on the left side (Table 5).
Table 5.
Tibial torsion in uninjured normal side
| Malrotation axis | No of cases | |
|---|---|---|
| Degrees | Right n (%) |
Left n (%) |
| 20° to 30° | 35 (33.01%) | 28 (26.41%) |
| > 30° | 22 (20.7%) | 21 (19.8%) |
| Total | 57 (53.7%) | 49 (46.2%) |
Discussion
Since tibia is one of the most common fractured long bones managed with intramedullary nailing, the number of patients with malrotations following intramedullary nailing is also high. This may range from subtle malrotations to gross malrotations causing gait alterations. Though clinical methods can be used as an easy measure to calculate the malrotation, most of them are inaccurate. Our study compares the clinical methods with the CT scan methods. Moreover, our study analyses the differences between rotational alignment after distal locking in two different positions of knee (figure of four and straight position).
There is no consensus in the literature regarding proximal and distal reference point in the measurement of torsion [17]. The proximal reference line quoted in the literature is either a line passing through the posterior condylar axis just proximal to the fibula head, or a line passing through the middle of the tibial condyles. The line joining the centre of both malleoli is most used as the distal reference axis [17]. The distal reference axis connecting the centre of the both malleoli may be skewed, since the two points are chosen arbitrarily and may, therefore, decrease the intra and inter-observer reliability. So, we have chosen a line connecting the anterior surface of both malleoli just distal to the articular surface in our study, and it rectifies this limitation of reliability, since we have used fixed landmarks. The measurement of torsion angle according to our method using fixed landmarks demonstrated an inter observer reliability of 0.96 (strong correlation). The difference in measuring methods and in definitions, explain why previous reports on tibial torsion in adult vary, on the average, from 14 to 24 degree [5].
Rotational deformities may lead to early onset osteoarthritis [22].Tibial torsion plays an important role in patellofemoral arthritis [23], genu valgum and varum [24]. However, Bonnevialle et al. demonstrated that there was no correlation between tibial malrotation and arthrosis [25].
Court-Brown et al., and Puno et al. reported 3 and 1 cases of clinically detected malrotation after tibia nailing in groups of 125 and 51 patients, respectively [26, 27]. Detecting malrotation clinically was very difficult and may lead to underestimation of the extent of the problem.
In 1949, Hutter and Scott [7] used X rays to measure the torsion. In 1980, Jakob et al. [12] used CT scan to quantify the torsion. Among the radiological methods, CT measurement is the investigation of choice with good inter- and intra-observer reliability and repeatability [28]. In our study there was over estimation by plumb line method (47 patients) (P value-0.03) and underestimation by TFA method (21 patients) (P value − 0.08) by comparing with CT scan method (32 patients). So the plumb line method seems to be grossly inaccurate followed by TFA method. Moreover, according to our study, sensitivity of TFA measurement was 44% and specificity of TFA was 86%.
According to Trafton’s criteria, rotation deformities of more than 10º is considered as malrotation [29]. In our study, we have considered a difference of > 10º as malrotation. There are few studies which measured tibial malrotation following IMIL nailing. In a study of 22 patients Prasad et al. found a difference of 8º or greater in 36% of patients [30]. In a study of 89 patients Bonnevialle et al. found a difference of 6.84º in 27% of patients [25]. In a study of 25 patients Poluski et al. found malrotation of > 10° in 20% of patients [28]. In a study of 60 patients, Adel Ebrahimpour et al. found a malrotation of > 10° in 30% of patients [31]. In our study we observed tibial malrotation of > 10º in 30.1% (32) of patients.
Assuming that the position of leg for distal locking may have influence on malrotations, we analysed and categorised the malrotations based on leg position for distal locking. To our knowledge, there is no study that compares the malrotations based on leg position for distal locking. We observed external malrotation (> 10°) in 19 patients (17.9%) belonging to category A and 13 patients (12.2%) belonging to category B. Moreover, we have observed internal rotation of > − 10° in 5 cases (4.71%). Of these 5 cases, 3 were category A, and 2 were category B. Even though statistically not significant (P = 0.25 for ER > 10° and P = 0.65 for IR > − 10°), more number of malrotation in category A patients indicates that the figure of four position may lead to more malrotations (both ER and IR). The increased number of malrotations, especially external malrotations in category A may be attributed to difficulty in assessing rotational alignment in figure of four position. Future studies with larger sample size may be helpful to decide upon the impact of limb position for distal locking on the quantum of malrotation.
The tibial torsion in normal tibia was measured by CT scan in few studies. In a study of 50 normal subjects, Olav Reikeras et al. [5] reported a torsion of 32.3 ± 8.5 ° and 30.7 ± 10.4 ° for right and left side, respectively, in females. In the males, the values were 35.3 ± 7 ° and 32 ± 10.3 °, respectively [5]. In a study of 100 legs, Arun B Mullaji et al. [1] reported a torsion of 22.6 ± 7.8 ° and 20.6 ± 7.4 ° for right and left side, respectively, with a significant P value [1]. In the same study the mean left and right difference was 2º [1]. In our study, tibial torsion in uninjured tibia was found to be 29.25 ± 5.41° on right side and 29.80 ± 5.49° on left side. The difference between right and left legs, and hence the statistical significance could not be assessed in our study, because only one tibia was normal in each individual patient and the other tibia was injured.
Limitations of our study
The functional implications of malrotation were not included in the study.
Conclusion
The clinical methods commonly observed for analysing malrotation may underestimate/ overestimate the real extent of the problem. CT scan provides the most accurate measurement of tibial malrotation. Anterior transmalleolar reference line uses fixed landmarks (conventional intermalleolar reference line uses arbitrary landmarks), and, therefore, has a better interobserver reliability. In our study, the two different positions of limb for distal locking did not have a statistically significant influence on the incidence of malrotation. Further studies are needed to establish the impact of positioning of the limb for distal locking on malrotation.
Compliance with ethical standards
Conflict of interest
On behalf of all authors, the corresponding author states that there is no conflict of interest.
Ethical standard statement
This study involved patients with fracture both bones of leg, who were managed in a tertiary care centre with multidisciplinary approach. We have performed only established and time tested procedures on these patients. We have not employed any new experimental methods (including surgical, pharmacological and radiological methods) on these patients. Every procedure was explained in detail to the patient, including the post operative CT scan for measurement of malrotation. We have exercised utmost care to follow the international principles of medical ethics in all our patients. We have also obtained informed consent for surgical aspects as well as for using their clinical and radiological images for scientific study purpose. As a corresponding author, I hold the full responsibility for any ethical related issues in this study.
Informed consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Footnotes
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