Approach

Treatment approach is based on correct diagnosis, understanding the natural history of the condition, and the effectiveness of various treatment options. Managing family concerns is usually the major challenge and can be addressed by providing the correct diagnosis, education, reassurance, and follow-up for worried parents, and by resisting doing something to the child to satisfy the parents. Although lower-limb position and appearance of gait may be a concern to many parents and families, orthopaedic intervention should be based on long-term goals such as avoiding joint degeneration and pain, and preventing a decline in walking ability in children with neuromuscular diseases. Deformities that result in functional deficits during gait (i.e., not well compensated) are addressed with corrective surgery designed to restore normal anatomical alignment.[25]

Healthy (no comorbidities) patients with in-toeing or out-toeing and rotational profile 2 standard deviations within the mean for their age

Treatment of torsional problems in these children is both unnecessary and ineffective.[1][2]

Initial treatment is reassurance and convincing the family that observation is best and that the condition may resolve over several months or years. Infants and toddlers with medial tibial torsion (MTT) should avoid sleeping prone and sitting on their feet. Toddlers and children with increased femoral anteversion should sit cross-legged and avoid sitting in the W position. Non-surgical interventions, such as twister cables, night splints, shoe wedges, physiotherapy, or a combination of these, are ineffective at altering limb alignment or normalising gait.[1][3][74]

Referral to an orthopaedist should be considered for the following: 1) families who require additional reassurance; 2) an uncertain diagnosis or inconclusive screening examination; 3) children with stiff forefoot adductus; and 4) older children or adolescents with leg pain or disability.

Healthy (no comorbidities) patients with in-toeing or out-toeing with rotational profile 2 standard deviations beyond the mean for their age

In-toeing due to MTT: about 1% of children with in-toeing will have persistent MTT into late childhood or adolescence severe enough to cause dissatisfaction with appearance of gait or function.[1][26][28][66][74][75] Treatment with night splints is advocated by some (although with limited supporting evidence) but may be burdensome to the family and the child. Treatment with gait plates (a stiff orthotic inserted inside the shoe) is also advocated by some as they may reduce the rate of tripping and alleviate parental concern as to the aesthetics of the child's in-toeing gait.[76][77] However, further research is needed to demonstrate the benefits of this treatment prior to widespread application to clinical practice.[78] Operative correction is indicated in selected children older than 8 years with significant deformity that disrupts gait function,[26][28] and with a thigh-foot angle >3 standard deviations (SDs) beyond the mean.[79] Femoral alignment must be considered before surgical treatment, as femoral rotation can aggravate or compensate for tibial torsion.

Out-toeing due to lateral tibial torsion (LTT): this is generally more problematic than MTT and more likely to require operative correction. Operative correction is indicated in children older than 8 years with significant functional deformity, and with a thigh-foot angle >40° or 3 SDs beyond the mean.[79]

Medial femoral torsion (MFT) (increased femoral anteversion): in rare cases (<1%), MFT may persist and be severe enough to cause disability in late childhood or adolescence. Operative treatment is never indicated prophylactically. Surgical correction, consisting of a rotational femoral osteotomy (usually performed at the proximal femur), may be indicated in older children with severe deformities >3 SDs beyond the mean, medial hip rotation of 80° to 90° or lateral rotation of 0°, external rotation 20° or less, and significant functional disability.[79]

Torsional malalignment syndrome

Excessive LTT and MFT associated with anterior knee symptoms, including patellofemoral pain, patella subluxation, or, rarely, dislocation, are initially treated conservatively.

Torsional malalignment syndrome in children with cerebral palsy

Torsional deformity is just one factor that contributes to pathological gait in patients with cerebral palsy.[80] Muscle imbalance, spasticity, and contractures may require tone-reducing medications (e.g., botulinum toxin type A)[81][82]or soft-tissue procedures (e.g., tenotomy, tendon transfer, and muscle release) before bony procedures.[11][83] Some patients may benefit from derotation osteotomies to improve limb alignment and gait.[84] Although gait analysis may aid in decision making, indications for operative intervention are less clear in the literature in this population.[45][74]

Metatarsus adductus

Most metatarsus adductus deformities correct spontaneously with little if any long-term disability even with mild to moderate residual deformity.[85][86] A flexible foot (the forefoot can be passively abducted so that the heel-bisector line is beyond the second web space) can be observed. A flexible foot that corrects to midline may be treated with a home stretching programme.[87] A foot that does not correct to midline or does not improve with stretching may be serially casted every 1 to 2 weeks. Casting results are best when initiated before 8 months of age. Surgery is occasionally considered in children >4 years old for feet with severe deformity.

Clubfeet

Patients should be referred to an orthopaedist for treatment.

Flat feet (pes planovalgus)

Flexible, painless, flat feet are typically not pathological and do not predispose a child to foot pain as an adult. Flexible, asymptomatic flat feet do not require intervention and there is no evidence that corrective shoes or inserts are effective for painless flat feet.[46][87] In symptomatic children, initial treatment is reassurance and shoes with a well-formed arch support in older children. A custom orthotic may be prescribed if pain persists despite the use of an off-the-shelf orthotic. Flexible flat feet associated with hindfoot pain resulting from a contracted gastrocnemius-soleus may be treated with Achilles tendon stretching exercises. Painful and stiff flat feet require referral to an orthopaedist.

Blount's disease

In infantile Blount's disease, the deformity is restricted to the proximal tibia (no femoral involvement). Before age 18 months differentiation between physiological bowing and Blount's disease is difficult. In this group, routine radiographical screening and referral are not cost-effective and expose children to unnecessary radiation. For children <3 years old, observation every 3 to 6 months is recommended. Bracing (with a medial upright knee-ankle-foot orthosis) has limited effectiveness in certain patients in the early stages of the disease. Surgical correction is required for brace failure or for severe deformity before age 4 years.

Adolescent Blount's disease requires referral to an orthopaedist for treatment. Surgery to restore the normal anatomical alignment is the mainstay of treatment.

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