Rotational Profile of Anteromedial Surface of Distal Tibia: A Computerized Tomography Study

  • Murat Songür Bulent Ecevit University, Zonguldak
  • Ercan Şahin Bulent Ecevit University, Zonguldak
  • Mehmet Ali Deveci Cukurova University, Adana
  • İbrahim İlker Öz Bulent Ecevit University, Zonguldak
  • Ahmet Bayar Bulent Ecevit University, Zonguldak
  • Selçuk Keser Bulent Ecevit University, Zonguldak
Keywords: Distal tibia, Fracture, Anatomical plate osteosynthesis, MIPO, malrotation


Background: Closed surgical treatment of long bone fractures by minimally invasive percutaneous plate osteosynthesis (MIPO) is prone to malrotation. In this study we aimed to determine the transverse plane torsional axis differences of medial surface of distal tibia and tibial diaphysis, involved in anatomical plate minimal invasive percutaneous osteosynthesis. Materials and method: The computerized tomography (CT) images from PACS archive of computerized tomography unit of the institution were reviewed retrospectively. Tibia scans of forty male cases meeting inclusion and exclusion criteria were evaluated. The inclination of the plane of the surface of the tibia was measured. Plane of the surface is defined as axis of the surface of tibia involved in distal medial plating. Sections were measured starting from one centimeter proximal to the tip of medial malleolus and continued proximally in one centimeter intervals for next twenty-five sections. Results were analyzed after grouping the cases according to average stature (as below average and above average). Results: At the level of 5th cm. proximal to medial malleolus, approximately 13º of external rotation of medial surface of tibia was noted. After 11-12th cm level, external rotation exceeds 20º. At 16-19th cm, amount of rotation reaches 30º. Change in the axis occurs more proximally in cases above average stature. More proximally amount of external rotation decreases gradually. At 26th cm level, a mean of 23.21º of external rotation was measured. Amount of rotation did not differ according to stature. Conclusion: Up to 30º of external rotational plane difference was observed notably after 17-20th cm from the tip of the medial malleolus. Inadvertent leaning of proximal extension of a straight/ untwisted anatomical distal tibial plate may result with significant external rotational malalignment, especially in comminuted fractures where fixation was extended towards tibial diaphysis.

Author Biography

Murat Songür, Bulent Ecevit University, Zonguldak


Khalsa AS, Toossi N, Tabb LP, Amin NH, Donohue KW, Cerynik DL. Distal tibia fractures: locked or non-locked plating? A systematic review of outcomes. Acta Orthop 2014; 85: 299-304.

Helfet DL, Shonnard PY, Levine D, Borrelli J Jr. Minimally invasive plate osteosynthesis of distal fractures of the tibia. Injury 1997; 28 Suppl 1: A42-7; discussion A47-8.

Sitnik AA, Beletsky AV. Minimally Invasive Percutaneous Plate Fixation of Tibia Fractures: Results in 80 Patients. Clin Orthop Relat Res 2013; 471: 2783–9.

Paluvadi SV, Lal H, Mittal D, Vidyarthi K. Management of fractures of the distal third tibia by minimally invasive plate osteosynthesis - A prospective series of 50 patients. J Clin Orthop Trauma 2014; 5: 129-36.

Puloski S, Romano C, Buckley R, Powell J. Rotational malalignment of the tibia following reamed intramedullary nail fixation. J Orthop Trauma 2004; 18: 397-402.

Jafarinejad AE, Bakhshi H, Haghnegahdar M, Ghomeishi N. Malrotation following reamed intramedullary nailing of closed tibial fractures. Indian J Orthop 2012; 46: 312-6.

Cole PA, Zlowodzki M, Kregor PJ. Treatment of proximal tibia fractures using the less 455 invasive stabilization system: surgical experience and early clinical results in 77 fractures. J Orthop Trauma 2004; 18: 528–35.

Ricci WM, Rudzki JR, Borrelli Jr J. Treatment of complex proximal tibia fractures with the less invasive skeletal stabilization system. J Orthop Trauma 2004; 18: 521–7.

Stannard J, Wilson TC, Volgas DA, Alonso JE. The less invasive stabilization system in the treatment of complex fractures of the tibial plateau: short-term results. J Orthop Trauma 2004; 18: 552–8.

Buckley R, Mohanty K, Malish D. Lower limb malrotation following MIPO technique of distal femoral and proximal tibial fractures. Injury, Int. J. Care Injured 2011; 42: 194–9.

Liodakis E, Doxastaki I, Chu K, Krettek C, Gaulke R, Citak M, Kenawey M. Reliability of the assessment of lower limb torsion using computed tomography: analysis of five different techniques. Skeletal Radiol 2012; 41: 305-11.

Duyar I, Pelin C. Body height estimation on tibia length in different stature groups. Am J Phys Anthropol 2003; 122: 23-7.

Svoboda SJ, McHale K, Belkoff SM, Cohen KS, Klemme WR. The effects of tibial malrotation on the biomechanics of the tibiotalar joint. Foot Ankle Int 2002; 23: 102-6.

Theirault B, Turgeon AF, Pelet S. Functional impact of tibial malrotation following intramedullary nailing of tibial shaft fractures. J Bone Joint Surg Am 2012; 94: 2033-9.

Van der Werken C, Marti RK. Post-traumatic rotational deformity of the lower leg. Injury 1983; 15: 38-40.

Strecker W, Keppler P, Gebhard F, Kinzl L. Length and torsion of the lower limb. J Bone Joint Surg Br 1997; 79: 1019–23.

Sayli U, Bölükbasi S, Atik OS, Gündogdu S. Determination of tibial torsion by computed tomography. J Foot Ankle Surg 1994; 33: 144-7.

Schmutz B, Wullschleger ME, Kim H, Noser H, Schütz MA. Fit assessment of anatomic plates for the distal medial tibia. J Orthop Trauma 2008; 22: 258-63.

Tepic S, Remiger AR, Morikawa K, Predieri M, Perren SM. Strength recovery in fractured sheep tibia treated with a plate or an internal fixator: an experimental study with a two-year follow-up. J Orthop Trauma 1997; 11: 14–23.

Szypryt P, Forward D. The use and abuse of locking plates. Orthop Trauma 2009; 23: 289-90.

Wagner M. General principles for the clinical use of the LCP. Injury 2003; 34(Suppl. 2): 31–42.

Original Research