Question: Hi there,

Good Morning,

I am Dr. XXXXXXX Nadeem, working in Insurance Company. I have one of our child member. I Need to have your expert opinion on this case.

Chief complaints/History of present Illness:

This is a 12-year old male member, who is presenting with ankle pain. The parents have also noticed that when running, he externally rotates both feet significantly more than his peers. The patient seems to have a rotational deformity to both lower extremities leading to increase shear forces to the ankle joint, which have led to increased discomfort and affects his gait pattern

Clinical examination
•     Clinically when walking, out toeing is noted.
•     There is no kneeing out seen at this point.
•     The rotation of the hips suggests a decrease in internal rotation, possibly hinting towards the femoral retroversion.
•     The thigh-foot angle measures 30 degrees with external rotation slightly more on the left than on the right.
•     Range of motion of the knees is within normal limits as does the ankle joints show no limitations in range of motion.
•     The muscle tone on the lower extremities seems slightly increased. No clonus, no-hyperreflexia noted.
•     Inspection of the spine is normal.

Plain x-ray on pelvis (AP and Rippstein-Muller II views) done (22/02/2015)
•     Femoral retroversion changes are noted on both sides.
•     The articular surfaces and cartilages of both hips are preserved.
•     No definite acetabular dysplasia.
•     Both sacroiliac joints are preserved.
•     Impression: Bilateral femoral retroversion changes, more on the right than on the left.

CT scan pelvis
•     Femoral anteversion angle, measured at 13.5 degrees on the right, and 14 degrees on the left.
•     The tibial torsion measures 44 degrees bilateral.

Diagnosis
•     Bilateral femoral retroversion.
•     External tibial torsion, bilateral.

It was discussed with the patient the pros and cons of bilateral versus unilateral treatment one at a time. In the doctors opinion, addressing one leg at a time allows the child to use crutches and participate in school a lot better. It has a disadvantage of going through the surgery twice, one leg at a time. Bilateral approach would require the child to non-weight bear for 6 to 8 weeks. Given that this is a strict requirement, post operatively it is more difficult for the family to comply.

Please advise if the requested procedure are medically necessary at this age? what will be the alternative management for this member if the family is not willing to proceed with surgery? what will be post-operative complication the child will face after the surgery.

I will be grateful if you will give me brief answer as per our clinical experience and as per International guidelines for this condition.