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Clinical Anatomy E76-79 (1994)
Variation in Tibia1 Torsion
Departments of Orthopaedics (D.G.E., R.C.K., J.J. W., B.J.R., Radiology (E.R.S., C.A.A.) and Univenity of Colorado, Denver,
Colorado and Department of Anthropology, University of Colorado, Roulder, Colorado (0.P. VanG.)
A skeletal collection from the African country of Sudan was examined to determine if
torsion of the tibia in an African population varies from established norms for European,
Asian, and American populations. A large variation in tibial torsion was observed.
There was a distinct limb asymmetry with more torsion on the right than left. No
associationof tibial torsion with gender was identified. A small but appreciable increase
in average torsion (7") was identified when this population was compared with previously reported populations. This study documents a variation in tibial torsion not
appreciated in earlier studies.
1994 wiley-Liss, Inc.
Key words: African, black, torsion, rotation, leg, limb
Rotation of the tibia (torsion) begins in utero and
progresses throughout childhood and adolescence to
skeletal maturity (Staheli and Engel, 1972). Average
tibial torsion has been documented in adult Caucasian
and Oriental populations between 20" and 30" (Le
Damany, 1909; Elftman, 1945; Hutter and Scott, 1949;
Elgeti et al., 1980; Jakob et al., 1980; Turner and
Smillie, 1981; Takai et al., 1985; Yagi and Sasaki, 1986;
Clementz, 1989; Yoshioka et al., 1989).
No black skeletal or patient population has been
compared with these studies to determine whether a
variation in tibial torsion exists, despite the fact that
certain morphologic characteristics of the human limb
demonstrate racial variation. For instance, it is well
documented that the average tibia is longer and narrower in black as compared with Caucasian populations
(Dupertuis and Haddon, 1951; Trotter and Gleser,
1958; Farrally and Moore, 1965).
Several studies (Le Damany, 1909; Hutter and Scott,
1949; Clementz, 1989) have addressed the difference
in tibial torsion between right and left limbs, while only
one study has identified variation in tibial torsion based
on gender (Yoshioka et al., 1989). These characteristics
have not been addressed in a black population.
0 1994 Wiley-Liss, Inc.
This study was undertaken to determine if a black
population from Africa demonstrates tibial torsion comparable to previously reported American, European,
and Japanese populations. T h e study was also designed to address issues of variation based on gender
and limb asymmetry.
One hundred and twelve well-preserved skeletons
(224 matched limbs) were examined by goniometry
and computed tomography (CT) scan to determine the
torsion present in both right and left tibiae. These
skeletons are part of an anthropologic collection from
Africa (Sudan) maintained in the Department of Anthropology at the University of Colorado. T h e anthropologic characteristics of this population have been well
documented and reported (Van Gerven et al., 1981).
T h e age and gender of each specimen were determined by an experienced anthropologist (D.P.V.) according to recognized anthropologic techniques and
Received for publication March 8, 1993; revised September 3, 1993.
Address reprint requests to D.G. Eckhoff, Department of Orthopaedics, University Pavilion, 4701 E. Ninth Avenue-Box E203,
Denver, CO 80262.
Variation in Tibial Torsion
established practice (Ubelaker, 1978). Gender was es- two most posterior points of the plateau, and it was
tablished by measurements of pelvic dimensions with determined in this study by the surface upon which
51 males and 61 females. Bone age was established by both condyles of the plateau rested during measureanalysis of the symphysis pubis. All specimens were ment. T h e trans-tibia1 axis of the distal tibia (Fig. 1,
skeletally mature, with an average age of 39 (range, line D) was defined by the line connecting the distal tip
21-51) for females and 36 (range, 20-52) for males. of the medial malleolus and the midpoint of the lateral
Seven right and nine left specimens demonstrating border (fibular sulcus). It was determined by direct
evidence of fracture or traumatic deformity were omitted. visual inspection of the bone or by inspection of approTorsion was defined as the twist of the bone about its priate cross-sectional images on the C T scan.
Direct goniometric measurements were performed
long axis. Torsion was measured in degrees as the angle
between the posterior axis of the proximal plateau (Fig. by resting one arm of the goniometer on the supporting
1, line A) and the trans-tibia1 axis of the ankle (Fig. 1, surface (parallel to the posterior condyles) while the
line D). T h e measured angle of tibial torsion is positive other arm was aligned visually to the distal trans-tibia1
when the distal axis is externally rotated with respect to axis. T h e angle observed between the arms of the
the proximal axis. T h e posterior axis (Fig. 1, line A) of goniometer equalled the recorded angle of tibial torthe proximal plateau was defined as the line joining the sion. This same angle was obtained by CT using the
console computer of the C T scanner. T h e posterior
condylar axis and the distal-tibia1 axis were visually
identified on the scan and traced with the computer
cursor, following which the console provided the angle
between these two axes. This choice of methods and
definition of landmarks are discussed below.
Goniometric and CT measurements were each performed by two independent observers and reported at
two different times. Analysis of the data was performed
using a standard paired t-test.
Analysis of the goniometric data revealed the following. T h e average amount of torsion in right tibiae was
38 ? 11". T h e average amount of torsion in left tibiae
was 33 2 9". T h e combined average tibial torsion by
goniometer was 35 k 9" (Table 1).
Analysis of the CT scan data revealed the following.
T h e average amount of torsion in right tibiae was 40 5
9". T h e average amount of torsion in left tibiae was 32
? 10". T h e combined average tibial torsion by C T scan
was 36 k 9" (Table 1).
Statistical analysis was performed using a paired Student's t-test. This test demonstrated that there was a
significant difference between right and left limbs ( P <
TABLE 1. Data by observer and method
Fig. 1. Tibial torsion is measured as the angle between axes at
the top and bottom of the tibia as illustrated by lines A and D at
center right. Proximal and distal axes of the tibia referenced in this
study and the literature are the following: A, posterior condylar
axis of the tibia connecting the two most posterior points of the
condyles; B, transcondylar axis through the midpoint of each
condyle; C , anterior condylar axis joining the anterior margins of
the medial and lateral articular surfaces of the plateau; D, bimalleolar axis joining the distal tip of the tibial malleolus with the
midpoint of the lateral border (fibular sulcus).
Method of Measure
Right leg
Left leg
CT scan
Right leg
Left leg
Eclchoff et al.
0.05) by both goniometric and C T scan methods. condylar axis is variably defined by a line joining the
There was no significant difference between measure- mid-points of the medial and lateral plateau (line B,
ments made by the two techniques. There was no Fig. 1) or a line passing through the most anterior
significant difference between observations of the points on the articular surface of the medial and lateral
same or different individuals using the C T method. A plateaus (line C, Fig. 1). This axis has also been designificant difference in goniometric measure of the fined (Hutter and Scott, 1949) as the perpendicular
left tibiae was found between the two observers ( P < line to the medial border of the foot.
Comparison of the present study to previous studies
0.001); however, the average difference between the
two observers was only 2". No significant difference can be made based on the proximal axis selected for
existed on the right between observers with the gonio- measurement. There is one reported cadaver study
metric technique. Regression analysis demonstrated (Elftman, 1945) that referenced the posterior tibial
that there was no influence of age or sex on the amount condyles to define the proximal tibial axis. T h e posterior femoral condyles were measured in this study asof torsion present.
suming they parallel the posterior condyles of the tibia.
This is a valid assumption, as the posterior condylar
axis and the posterior tibial axis have been shown to be
Torsion of the tibia has been reported on European, parallel in the non-arthritic knee (Eckhoff et al., 1993).
Asian, and American populations, with averages rang- Comparison of Elftman's average 28" tibial torsion with
ing between 19" and 30" (Table 2). T h e variation of the average 35" presented here reveals 7" more tibial
torsion between these studies can be attributed to the torsion on average in this African population when meamethod of measure and choice of landmarks. In studies sured by goniometer (Table 3).
There are three patient surveys that have defined
reporting rotation of the tibia in the absence of the
proximal axis of the tibia as the posterior tibial
fibula, e.g., cadaver studies, the distal axis is detercondyles
on C T scan (Elgeti et al., 1980; Jakob et al.,
mined only by the morphology of tibia. By contrast, the
et al., 1985). These studies demonstrate
studies based on patient exam, C T scans, or fluoroscopic images include the fibula. T h e distal axis
referenced to the fibula is externally rotated 5" to 6" TABLE 3. Literature torsion vs. this study
when compared with the axis determined by the tibia
Material (method)
(torsion in degrees)
Variation in the measure of tibial torsion also occurs Cadaver
Elftman (28)
as a consequence of the proximal axis of the tibia se(goniometer)
Observer avg this study (35)
lected. T h e principle choices for the proximal refer- Pa tien t
Elgeti (29)
ence axis are the posterior condylar axis and the trans(CT scan)
Jakob (30)
Takai (28)
condylar axis. T h e posterior condylar axis is defined by
Average (29)
the line joining the two most posterior points on the
Observer avg this study (36)
medial and lateral plateau (line A, Fig. 1). T h e transTABLE 2. Comparison of tibial torsion studies'
External tibial torsion (degrees)
Study (population)
Clement2 (Caucasian)
Elftman (Caucasian)
Elgeti (Caucasian)
Hutter (Caucasian)
Jakob (Caucasian)
La Damany (Caucasian)
Takai (Oriental
Turner (Caucasian)
Yagi (Oriental)
Yoshioka (Caucasian)
+ X
+ X
This study (African)
Goniometric method
C T scan method
"Combined (R&L);
+ left.
Variation in Tibial Torsion
29, 30, and 28" of tibial torsion, respectively, for a
combined average of 29" of tibial torsion. By comparison, this study of an African population reports 36"
average tibial torsion or 7" more tibial torsion using CT
scan as the method of measurement (Table 3). T h e
average of left and right data (combined data) was used
for comparison since the three studies being compared
do not report left and right limbs separately.
There are three previous cadaver studies that identify the transcondylar axis as the proximal reference (La
Damany, 1909; Hutter and Scott, 1949; Yoshioka et al.,
1989). These three studies demonstrate a combined
average of 22" of tibial torsion. There is one previous
patient study that references the transcondylar axis on
C T scan (Yagi and Sasaki, 1986) to identify 24" of tibial
torsion. Comparison between these studies and the
African population reported here is difficult due to the
disparate nature of the axes-transcondylar versus posterior condylar. T h e transcondylar axis was not measured in the present study because it is hard to define,
has limited clinical relevance, and was not reproducible
in our hands.
Torsional variation between left and right tibia has
been previously reported, with right tibial torsion consistently greater than the left (Le Damany, 1909; Hutter and Scott, 1949; Clementz, 1989). 'I'he data reported in this study also demonstrate a consistent
difference between the right and left tibial torsion,
with the right significantly greater than the left.
Torsional variation between males and females has
been documented only once (Yoshioka et al., 1989),
with males averaging 21" and females averaging 27".
This variation in tibial torsion based on gender was not
observed in the African population reported here.
All of the studies previously reported document a
large variation of tibial torsion within the populations
studied. This study confirms the wide variability of
tibial torsion between individuals as demonstrated in
the large standard deviations. Clinically, this variation
may be very significant. For instance, it will make the
application of alignment guides, such as those keyed to
rotational landmarks of the tibia in total knee arthroplasty, difficult to apply without individual modification. As additional examples, correction of traumatic
malunion or congenital maltorsion of the tibia may not
be individually accomplished by simply recreating the
average torsion for the population reported in these
studies. In this or any other clinical application of these
studies, individual variation with respect to tibial torsion
should be addressed, given the variability reported.
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deformity with a new fluoroscopic technique. Clin. Orthop.
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