A New Instrument for Measuring Tibial Torsion in Pediatric Patients

OBJECTIVE: To develop and test the validity and reliability of a new instrument for measuring the thigh-foot angle (TFA) for the patients with in-toeing and out-toeing gait. METHODS: The new instrument (Thigh-Foot Supporter [TFS]) was developed by measuring the TFA during regular examination of the tibial torsional status. The study included 40 children who presented with in-toeing and out-toeing gaits. We took a picture of each case to measure photographic-TFA (P-TFA) in the proper position and to establish a criterion. Study participants were examined by three independent physicians (A, B, and C) who had one, three and ten years of experience in the field, respectively. Each examiner conducted a separate classical physical examination (CPE) of every participant using a gait goniometer followed by a TFA assessment of each pediatric patient with or without the TFS. Thirty minutes later, repeated in the same way was measured. RESULTS: Less experienced examiner A showed significant differences between the TFA values depending on whether TFS used (left p=0.003 and right p=0.008). However, experienced examiners B and C did not show significant differences. Using TFS, less experienced examiner A showed a high validity and all examiner's inter-test and the inter-personal reliabilities increased. CONCLUSION: TFS may increase validity and reliability in measuring tibial torsion in patients who has a rotational problem in lower extremities. It would be more useful in less experienced examiners.

The Role of Peroneus Longus Insertion on First Metatarsal Against metatarsus varus force / 대한정형외과학회잡지

It is likely that the peroneus longus tendon acts as a structure resisting the varus force upon the first column of the foot. Our study was designed to examine the possibility that absence of the peroneus longus insertion into the first metatarsal and first cuneiform will destabilize the first metatarsal. The fresh frozen cadaveric specimens of the lower leg were obtained. There were six right feet. The specimens appeared normal visually and roentgenographically. The tibial remnant was rodded by an intramedullary rod and the sprcimen was positioned in a specially designed rig so that standing position of the foot was simulated. The tibia was then loaded with twenty pounds. To obtain reproducible radiographic landmarks radioopaque beads were implanted underneath the level of the cortex through small drill holes in the following location : First metatarsal (one bead in the head, another bead in the base). The second metatarsal (again one bead in the head, on e bean in the base). To simulate the contraction of the peroneus longus muscle a suture was placed into the proximal end of the tendon, brought through two pulleys and loaded with a five pound weight. To create a varus force on the first metatarsal a stab incision was made over the base of the first metatarsal at its medial aspect and a suture was passed through the base of the first metatarsal. The suture was guided over a pulley and loaded with ten pounds. The second metatarsal head was fixed to the bottom of the rig with a smooth Steinmann pin. At this point an AP roentgenogram was taken of the footto assure proper positioning of the foot. Thereafter, the soft tissue between the first and second toe were cut sequentially : (1) Transection of the skin of the first web space both dorsally and plantarly. (2) Transection of the adductor hallucis tendon and the intermetatarsal ligament. (3) Transection of the peroneus longus tendon at its insertion. Each step in the transaction of the soft tissues was followed by another X-ray examination. In each roentgenogram the proximal and distal beads in the first and second metatarsal were connected by a line and the angles between those lines were measured. The results were statistically analyzed with the Friedman Chi square test between each step of the ten feet. Following the first and second step angular changes are not significant. Following the final step, adding release of the tendon insertion of the peroneus longus, the angle changes from 15.95 to 20.55 degrees (difference 4.60 degrees) and this is significant (p < 0.05).