Treatment of congenital pseudarthrosis of the tibia by the Ilizarov method

Three cases of congenital pseudarthrosis were treated by the Ilizarov method. Consolidation was obtained by 3.5 months in three patients who had undergone several previous surgical procedures. Although the length of follow-up was short (maximum 3.5 years), consolidation occurred more quickly than by traditional methods. This technique also permitted both simultaneous correction of axial malalignment and leg lengthening. We think that this method has a place as a salvage procedure except where the distal fragment is very thin or dystrophic.     

Infantile tibia vara

Infantile tibia vara is a developmental condition producing progressive varus deformity of the knee in young children. It appears to have a worse prognosis in the predominantly nonwhite population seen with this condition in the United States than previous studies from Scandinavia would suggest. Early roentgenographic diagnosis is critical, since toddlers can have infantile tibia vara at an early stage instead of physiologic genu varum. Aggressive bracing is appropriate treatment until age three years. Correction to valgus alignment with upper tibial osteotomy predictably can produce complete resolution of the condition if performed by age four years. After that age, the procedure becomes less effective. Prognosis for Langenskiold Grade IV disease is guarded at best, regardless of age, because the physis behaves as if effective growth arrest has already occurred. Young patients with Grade IV or greater lesions should have corrective osteotomy combined with a physeal procedure to attempt restoration of growth in the medial physis. Early effective treatment can prevent permanent intraarticular incongruity.     

Infantile tibia vara

We studied the applicability of Langenski?ld's classification to a predominantly nonwhite population with infantile tibia vara. Age at presentation was younger than that in previously published studies. Forty-seven tibiae averaging 6 years 7 months of follow-up had 66% good results. Poor results increased in proportion to stage at presentation. Brace treatment for early lesions was only 50% effective. Single tibial osteotomy before 4 years of age gave good results in 85% of tibiae, and multiple osteotomies gave good results between 4 and 8 years of age. One-half of tibiae treated with osteotomy developed recurrent varus. This review documents earlier stages at presentation, a more malignant course, and poorer results than Langenski?ld's series would suggest. We question the accuracy of Langenski?ld's estimate of prognosis when applied to this patient group.     

Adolescent tibia vara

Adolescent tibia vara is less common and less well described when compared to infantile tibia vara. Yet, the two share a significant number of features related to their epidemiology and histology. The two diseases differ most in their radiographic appearance. It does not, however, necessarily follow that their etiologies cannot be similar. By its epidemiology and histology, adolescent tibia vara appears to be related to repetitive trauma in the form of abnormal force directed on the medial tibial growth plate due to obesity, the adolescent growth spurt, or residual, incompletely corrected physiologic varus. Such forces may give growth plate suppression by the Heuter Volkman principle similar to what is thought to occur in infantile tibia vara. In the infant, this results in typical radiologic findings related to an epiphyseal ossification center which is cartilagenous and moldable and results in progressive medial wedging. In the adolescent, however, this ossification center is bony and, therefore, will not deform under stress. The growth plate, however, still responds with decreased growth resulting in varus deformity. Thus, adolescent tibia vara, by definition not related to trauma or infection, may in fact reflect the same pathologic process at work as in infantile tibia vara.     

Late-onset tibia vara

Fifteen children with late-onset tibia vara were studied. There were seven unilateral and eight bilateral cases. Eleven children were male, four were female and 13 were black; 14 were obese. All had a history of gradually progressive genu varus (average onset 11 years); 12 had preoperative knee pain. The average age at surgery was 12 years, with a preoperative tibiofemoral angle of 14 degree varus. The average follow-up was 4 years 4 months. The average tibiofemoral angle at follow-up was 0 degrees. There were 15 good, two fair, and six poor final results.     

Infantile tibia vara: Treatment of Langenskiold stage IV

An eight year old girl presented with a progressively increasing deformity of the left proximal tibia since last 2 years. She had no history of trauma, fever and swelling of left knee. There were no obvious signs of rickets/muscular dystrophy. She had 25 degrees of tibia vara clinically with lateral thrust and a prominent fibular head. The radiograph of left knee revealed tibia vara with medial beaking and a significant depression of the medial tibial epiphysis and metaphysis. A computed tomography (CT) scan revealed significant depression of the medial tibial epiphysis but no bony bar in the physis or fusion of the medical tibial epiphysis. There was a posterior slope in addition to the medial one. She was treated with elevation of the medial tibial hemiplateau with subtuberosity valgus derotation dome osteotomy. She also underwent a lateral proximal tibial hemiphysiodesis (temporary stapling). A prophylactic subcutaneons anterolateral compartment fasciotomy was also performed. All osteotomies united in 2 months. All deformities were corrected and she regained a knee range of 0 to 130 degrees. At final followup (4 years), there was no recurrence of varus deformity, knee was stable, with 1cm of leg length discrepancy. In Langenskiold stage IV tibia vara, elevation of medial tibial plateau, a subtuberosity valgus derotation osteotomy and a concomitant lateral hemiephiphysiodesis has given good results.     

A new double elevating osteotomy in management of severe neglected infantile tibia vara using the Ilizarov technique

Neglected infantile Tibia Vara is a very challenging clinical problem with many technical problems including distorted joint line secondary to the medial tibial plateau depression, obesity leading to difficulty in exposure, performing osteotomies and difficulty in osteotomy fixation. The aim of this study is to evaluate the clinical and radiological results of treatment of severe neglected infantile Tibia Vara using a new osteotomy to elevate the depressed medial tibial plateau in conjunction with the Ilizarov technique. Seven tibias in five patients were included in this study. These were all Stage V and VI according to Langenskiold and Riska classification. The average age at surgery was 11.6 years (ranging from 8 to 15), and the average follow-up was 6.2 years (ranging from 3 to 10). A new double osteotomy technique was used to elevate the depressed medial tibial plateau and correct the varus deformity. Correction was done gradually using the Ilizarov Frame. The results were assessed clinically and radiologically. The femoral shaft -- tibial shaft angle improved from an average of 36 degrees of varus preoperatively to 4 degrees of varus. The femoral condyle-tibial shaft angle improved from an average of 58 degrees to 83 degrees. The angle of depressed medial tibial plateau improved from an average of 53 degrees to 10 degrees. We believe that our new double elevating osteotomy in conjunction with Ilizarov technique is an excellent modality for patients with stage V and VI according to the Langenskiold and Riska classification. The advantages of this technique include correction of the deformity with simultaneous correction of the joint architecture, immediate weight bearing, and avoidance of excessive dissection needed for internal fixation.     

应用Ilizarov技术治疗胫骨感染性骨缺损并足下垂

目的 探讨应用Ilizarov技术治疗胫骨感染性骨缺损合并足下垂的临床疗效.方法 应用Ilizarov技术一期治疗胫骨感染性骨缺损伴足下垂13例.术前根据患肢最大周径,内踝到胫骨结节长度,足下垂角度,病灶范围和骨缺损长度设计Ilizarov外固定延长架,手术彻底切除病灶区炎性肉芽、坏死组织及死骨,把外固定延长架套入小腿,在相应胫骨部位进行截骨和穿针,术后8d以1.0 mm/d分3次延长胫骨,同时以3 mm/d的速度矫正足下垂.结果 13例均获得随访,时间12～36个月,平均18个月.所有患者胫骨延长段、骨折段均骨性愈合.结论 对于感染性胫骨缺损合并足下垂的患者,应用Ilizarov技术一期治疗创伤小,避免多次复杂手术,缩短治疗时间和节省治疗费用.     

Ilizarov技术治疗胫骨干感染性骨不连

目的探讨应用Ilizarov技术治疗胫骨干感染性骨不连的临床效果。方法对22例骨创伤后胫骨感染性骨不连患者采取大段病灶切除+旷置并相应的干骺端截骨术。术后10 d以0.25 mm/6 h速度延长,经8～25周固定延长至骨缺损端会师,于骨缺损处两断端加压并继续维持外固定支架至骨愈合。结果 22例均获随访,时间12～24个月。骨延长6～18(9.5±4.5)cm,骨性感染全部治愈。带支架时间6.5～13个月。19例加压固定处及延长部位骨生长良好,达到了骨性愈合;3例断端骨接触后6个月无明显骨愈合,2例行自体髂骨植骨、1例拆除支架后行自体髂骨植骨内固定,4～6个月达到骨性愈合。截骨延长区及骨缺损对合处对位对线良好。结论 Ilizarov技术治疗胫骨感染性骨不连,术后感染控制良好,骨愈合率高。     

Fibular lengthening by Ilizarov method secondary to shortening by osteochondroma of distal tibia

Osteochondroma is the most common benign bone tumour. They most commonly affect the long tubular bones and almost half of osteochondromata are found around the knee. Osteochondroma arising from the distal metaphysis of the tibia typically result in a valgus deformity of the ankle joint secondary to relative shortening of the fibula. This case describes the use of Ilizarov technique for fibular lengthening following excision of a distal tibial osteochondroma. A 12-year-old girl presented with a 3-year history of a large swelling affecting the lateral aspect of the right distal tibia. Plain radiographs confirmed a large sessile osteochondroma arising from the postero-lateral aspect of the distal tibia with deformity of the fibula and 15 mm of fibular shortening. The patient underwent excision through a postero-lateral approach and subsequent fibular lengthening by Ilizarov technique. The patient made excellent recovery with removal of frame after 21 weeks and had made a full recovery with normal ankle function by 6 months. The Ilizarov method is a commonly accepted method of performing distraction osteogenesis for limb inequalities; however, this is mainly for the tibia, femur and humerus. We are unaware of any previous cases using the Ilizarov method for fibular lengthening. This case demonstrates the success of the Ilizarov method in restoring both fibular length and normal ankle anatomy.     

Femoral deformity in tibia vara

BACKGROUND: Previous studies have suggested that compensatory valgus deformity of the femur is common in patients with tibia vara, or Blount disease. The availability and routine use of standing long-cassette radiographs of the lower extremities to assess angular deformities has allowed quantitative evaluation of this hypothesis. METHODS: The cases of all patients with tibia vara, two years of age or older, seen at our institution prior to treatment, over a thirteen-year period, were reviewed. Seventy-three patients with a total of 109 involved lower limbs were identified and were classified as having either infantile tibia vara (thirty-seven patients with fifty-six involved limbs) or late-onset tibia vara (thirty-six patients with fifty-three involved limbs). Standardized standing radiographs of the lower extremity were examined to assess the deformity at the distal part of the femur and the proximal part of the tibia by measuring the lateral distal femoral angle and the medial proximal tibial angle. RESULTS: The distal part of the femur in the children with infantile tibia vara either was normal or had mild varus deformity, with a mean lateral distal femoral angle of 97 degrees (range, 82 degrees to 129 degrees). The mean medial proximal tibial angle in these children was 72 degrees (range, 32 degrees to 84 degrees). Older children with infantile tibia vara were noted to have little distal femoral deformity, with no more than 4 degrees of valgus compared with either normal values or the contralateral, normal limb. Children with late-onset tibia vara had a mean lateral distal femoral angle of 93 degrees (range, 82 degrees to 110 degrees) and a mean medial proximal tibial angle of 73 degrees (range, 52 degrees to 84 degrees). On the average, the varus deformity of the distal part of the femur constituted 30% (6 degrees of 20 degrees) of the genu varum deformity in these patients. CONCLUSIONS: Patients with infantile tibia vara most commonly had normal alignment of the distal parts of the femora; substantial valgus deformity was not observed. Distal femoral varus constituted a substantial portion of the genu varum in children with late-onset disease. When correction of late-onset tibia vara is planned, the surgeon should be aware of the possibility that distal femoral varus is a substantial component of the deformity.     

Treatment of humeral shaft non-unions by the Ilizarov method

Thirty-five humeral shaft non-unions treated by the Ilizarov external fixator were studied after an average of 39 months. Bone union was achieved in all but one. The mean time to union was 5.5 months (range: 3-10 months). Major pin tract problems leading to removal of the Schanz screws occurred in three patients. A radial nerve palsy developed in three patients, two recovered spontaneously and one was treated with a triple tendon transfer.     

Comprehensive treatment of late-onset tibia vara

BACKGROUND: Late-onset tibia vara (Blount disease) can be difficult to treat because of frequent morbid obesity and associated deformities, including distal femoral varus, proximal tibial procurvatum, and distal tibial valgus, that contribute to lower extremity malalignment. We present a comprehensive approach that addresses all components of the deformity and allows restoration of the anatomic and mechanical axes. METHODS: Fifteen consecutive patients (nineteen lower extremities) with late-onset tibia vara were managed with this comprehensive approach. The mean age of the patients at the time of surgery was 14.9 years, and the mean weight was 113 kg. Standing anteroposterior and lateral radiographs were made preoperatively and at the time of the final follow-up. Preoperatively, the mean mechanical axis deviation was 108 mm, the mean lateral distal femoral angle was 95 degrees , and the mean mechanical medial proximal tibial angle was 71 degrees . In all nineteen extremities, the proximal tibial varus deformity was corrected by means of a valgus osteotomy and application of an Ilizarov ring external fixator. Distal femoral varus was corrected by means of either hemiepiphyseal stapling or valgus osteotomy with blade-plate fixation in thirteen of the nineteen extremities. Distal tibial valgus was treated either with hemiepiphyseal stapling or with varus osteotomy and gradual correction with use of the Ilizarov external fixator in eleven of the nineteen extremities. RESULTS: After a mean duration of follow-up of 5.0 years, the mean mechanical axis deviation had improved to 1 mm (range, 20 to -30 mm), the lateral distal femoral angle had improved to 87 degrees (range, 83 degrees to 98 degrees), and the mechanical medial proximal tibial angle had improved to 88 degrees (range, 83 degrees to 98 degrees ). The mean time required for correction of the proximal tibial varus deformity was thirty-one days, and the external fixator was removed at a mean of 4.5 months postoperatively. All patients had development of one or more superficial pin-track infections (mean, 1.9 pin-site infections per patient). No wound infections, nonunions, or neurovascular complications occurred. Eighteen of the nineteen extremities were pain-free at the time of the final follow-up. CONCLUSIONS: This comprehensive approach allowed restoration of the mechanical and anatomic axes of the lower extremity in patients with late-onset tibia vara, resulting in a resolution of symptoms as a result of normalization of the weight-bearing forces across the knee and ankle. We believe that this approach will decrease the risk of early degenerative arthritis of the knee.     

Treatment of congenital pseudoarthrosis of the tibia using the Ilizarov technique.

The principle of treatment of congenital pseudoarthrosis of the tibia (CPT) with the Ilizarov method corrects all angular deformity and maximizes the cross-sectional area of union of the pseudoarthrosis. Fifteen patients with a total of 16 CPT were treated using the Ilizarov apparatus. Various forces were used to treat the pseudoarthrosis site including compression, distraction, open reduction, resection and shortening, resection and bone transport, and invagination of one end in the other. Lengthening was performed in 12 of the 16. Deformity was corrected in all cases. The union rate was 94% with one treatment and 100% with two treatments. There were five refractures, three early and two late. Previous pin sites, residual angular deformity, and natural history were considered predisposing factors for refractures. One patient refractured twice but remained ununited. Fifteen remained united, with a mean follow-up period of four years (range, two to seven). There were two residual deformities, one in the regenerate and one at the level of the CPT.     

The treatment of infected nonunion of the tibia following intramedullary nailing by the Ilizarov method

The purpose of this study was to demonstrate the effectiveness of the Ilizarov method and circular external fixator in order to eradicate the infection and restore bone union, limb anatomy and functionality in cases with infected nonunion of the tibia following intramedullary nailing.During 7 years nine patients suffering from infected nonunion of the tibia after intramedullary nailing were treated in our department. The series comprised seven men and two women with an average age of 39.7 years (range 21-75 years). The patients had previously undergone an average of 4.8 operations (range 3-6 operations). Active purulent bone infection occurred in all nine patients. Bone defect was present in all patients with a mean size of 5 cm (range 2-12 cm). In three cases with bone defect less than 2 cm, monofocal compression osteosynthesis technique was used. In the rest cases where bone defect exceeded 2 cm, bifocal consecutive distraction-compression osteosynthesis technique was applied. Three patients required a local gastrocnemius flap. The mean follow-up period was 26.6 months (range 13-42 months). Results were evaluated using Paley's functional and radiological scoring system.Bone union was achieved in all nine patients without recurrence of infection during the follow-up period. Bone results were graded as excellent in five cases and good in the rest four cases. Functional results were graded as excellent in three cases, good in four and fare in two cases. Mean external fixation time was 187.4 days (range 89-412 days) and mean lengthening index was 32 days/cm (range 27-39 days/cm). Complications observed included eight grade II pin tract infections, axial deformity at the lengthening site in two cases and at the nonunion site in another two cases. Ankle joint stiffness was detected in five cases.The Ilizarov method may be an effective method in infected nonunions of the tibia following intramedullary nailing.     

Natural history of infantile tibia vara

We have observed the natural history without treatment of 46 limbs in 29 patients with infantile tibia vara and a metaphyseal-diaphyseal angle (MDA) of more than 11 degrees. The femorotibial angle (FTA) and MDA were measured, and Langenski?ld's classification of radiological changes in the proximal medial metaphysis of the tibia was used. In 22 limbs which were not in Langenski?ld stages II to III the condition resolved spontaneously without treatment. Of the remaining 24 which were in stages II to III, in 18 it resolved spontaneously by the age of six years, but six showed little or no improvement at the latest follow-up. It was impossible to differentiate by measuring the FTA or MDA whether spontaneous resolution could be expected before the age of four years. There was no difference in the rate of resolution of the deformity between those patients who had been treated by a brace and those who had received no treatment. We advise no initial treatment but review at six-monthly intervals until the age of four years, even in patients with Langenski?ld stage-II to stage-III deformity. When a deformity persisted or progressed we carried out a corrective osteotomy after the age of four years.     

Radiographic measurement of infantile tibia vara

The reproducibility of the radiographic measurement of 30 pairs of tibiae being treated for bowing was evaluated. Two methods of measurement were used. The first was the metaphyseal-diaphyseal angle of Levine and Drennan; the second, a metaphyseal-metaphyseal angle based on Cobb's angle for measuring scoliosis. Statistical analysis comparing the two methods showed no significant differences except for an increase in the angle in more severe cases measured by the metaphyseal-metaphyseal method, indicating distal tibial as well as proximal involvement. Computer digitization correlated extremely well with manual measurements. The metaphyseal-diaphyseal measurement is quite reproducible, and may allow early diagnosis and treatment of tibia vara.     

The Ilizarov method in the treatment of malignant neoplasms of the tibia

A total of 3 malignant neoplasms of the tibia are presented: 1 is a mesenchymal chondrosarcoma of the tibial pylon (male aged 14 years), and 2 are cases of squamous skin carcinoma of the leg with tibial infiltration (1 male and 1 female aged 32 and 64 years, respectively). The resections carried out (16.5 cm on the average) were treated by bone transport. Simple transport was used in the first patient, double in the other two. At the end of transport a second surgical stage involving astragalotibial arthrodesis was performed in the first case, and revision of the junction site of bone segments transported with application of autoplastic bone grafts was performed in the other two.The regenerate obtained was slowly corticalized in the first patient, submitted to various cycles of chemotherapy during the course of distraction. In the other two cases, which were not treated by chemotherapy during distraction, corticalization occurred over a shorter amount of time. Follow-up was obtained after 10 years in the first case, and after 2 years in the other 2 patients. There was no long-term recurrence.