We retrospectively reviewed the safety and efficacy of operative treatment of torsional malalignment of the tibia in 44 children, on whom we performed 71 derotational osteotomies of the distal tibia to treat tibial torsion. We placed four pins using an alignment jig, performed a percutaneous osteotomy, and applied an external fixator after derotation. Postoperative radiographs showed accurate tibial derotation and pin placement in all patients. Nine patients developed superficial pin-tract infections that resolved with antibiotic treatment. Two developed fractures after removal of the external fixator, which healed in a plaster cast. Operative treatment of these cases with an external fixator is safe, effective, and well tolerated.