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Surgical Management of Persistent Intoeing Gait Due to Increased Internal Tibial Torsion in Children

Davids, Jon R. MD*; Davis, Roy B. PhD; Jameson, Lisa C. BS; Westberry, David E. MD; Hardin, James W. PhD

Journal of Pediatric Orthopaedics: June 2014 - Volume 34 - Issue 4 - p 467–473
doi: 10.1097/BPO.0000000000000173

Background: Intoeing gait is frequently seen in developing children, and in most cases it resolves with growth. However, persistent, extreme intoeing gait, due to increased internal tibial torsion, may disrupt gait function. At our institution, children with symptomatic intoeing gait are evaluated per a standardized protocol, which includes quantitative gait analysis. When the primary cause is increased internal tibial torsion, surgical correction by supramalleolar tibial rotational osteotomy is recommended.

Methods: The study design was a retrospective case series, with normative controls (31 children), of typically developing children with symptomatic intoeing gait who were treated by isolated supramalleolar tibial rotation osteotomy (28 children, with 45 treated extremities). Preoperative and 1-year postoperative physical examination, kinematic, kinetic, and pedobarographic data were compared. Patient-reported and parent-reported outcomes in functional and satisfaction domains were assessed by items on a 7-point questionnaire.

Results: Internal tibial torsion, foot progression angle, and knee rotation were normalized following tibial rotation osteotomy. Compensatory external hip rotation and external knee progression angle were significantly improved but not normalized following tibial rotation osteotomy. An increased coronal plane knee varus moment was significantly decreased following surgery. Increased sagittal and transverse plane knee moments were significantly decreased but not normalized following surgery. Significant improvements were observed with respect to tripping, falling, foot/ankle pain, and knee pain following surgery.

Conclusions: Children with symptomatic intoeing gait because of increased internal tibial torsion have characteristic primary and compensatory kinematic gait deviations that result in increased loading about the knee during the stance phase of gait. Correction of the internal tibial torsion by rotation osteotomy improves, but does not normalize, all the kinematic and kinetic gait deviations associated with intoeing gait. The association between increased internal tibial torsion and degenerative arthritis of the knee in adults may be a consequence of longstanding increased loading of the knee joint due to the kinematic gait deviations seen with intoeing gait.

Level of Evidence: Therapeutic intervention, level III

*Shriners Hospital for Children, Sacramento, CA

Shriners Hospital for Children, Greenville

Department of Epidemiology and Biostatistics, Institute for Families in Society, University of South Carolina, Columbia, SC

Investigation was performed at Shriners Hospital for Children, Greenville, SC; Shriners Hospital for Children, Northern California, and Arnold School of Public Health, University of South Carolina, Columbia, SC.

The authors did not receive any outside funding or grants in support of their research for the preparation of this work.

The authors declare no conflicts of interest.

Reprints: Jon R. Davids, MD, Shriners Hospital for Children, 2425 Stockton Boulevard, Sacramento, CA 95817. E-mail:

© 2014 by Lippincott Williams & Wilkins