Date: Thurs, 10 Jan 2002 10:20
Subject: S/P Tibial Diaphysectomy
The patient is a 31 y o Afghan refugee female S/P open fx Rt tibia 20 years ago secondary to a simple fall. No immediate medical care was available. Went on to osteomyelitis leading to eventual excision of the tibial diaphysis. No sign of infection since. No medical problems.
The patient is without specific complaints other than difficulty with lateral shoe wear and shoe fitting on the shortened limb and occasional low back pain. She walks painlessly on the shortened limb without any orthotic device. There is a 15 cm leg length discrepancy.
The knee has ROM 0-130 degrees without instability or pain. There is marked instability of the proximal tibia-fibular joint (capable of approx 3-4 cm of translation clinically). The ankle and hindfoot are fused in 20 degrees of plantarflexion, 25 degrees of internal rotation, 15 degrees of inversion. There is an overall 20-25 degree varus alignment of the lower leg. Dorsalis pedis and tibialis posterior pulses are 2/2 and sensation and motor function are normal.
The patient primarily wishes an ankle foot correction to permit normal shoe fitting and wear.
Thank you for your opinions.
Djoldas Kuldjanov, MD
David Karges, DO
Tracy Watson, MD
Detroit Receiving Hospital
Date: Fri, 11 Jan 2002 08:05:52 -0600
From: Steven Rabin
Radiographically this looks like a disaster, but clinically she's doing pretty good. I think this is an example of a case where we should treat the patient instead of treating the x-rays.
She currently has:
I think any operation to make the x-rays look good has a high likelihood of making her worse than she is now. Ilizarov procedures, bone grafts etc. could easily result in active infection, a residual painful limb, contractures and loss of motion, and in the end, still not allow normal shoe wear.
I would suggest limiting treatment to her primary complaint: her inability to wear shoes. Ignoring the mess proximally, I would suggest an osteotomy through the ankle foot fusion area to restore distal alignment. The current 20 degrees of plantarflexion, 25 degrees of internal rotation, 15 degrees of inversion and overall 20-25 degree varus alignment would be difficult to correct with a single cut, but someone experienced with the Taylor spatial frame or really good with a classic Ilizarov could probably correct all aspects of the deformity. Since I personally don't have that kind of experience, I'd probably attempt this in two steps. First an oblique osteotomy which could correct it in two planes (the plantarflexion, varus, and probably some of the inversion) but couldn't correct the rotation. Then after it healed, as a second stage, a derotational osteotomy to correct the residual rotation.
Even this surgery could make her worse than she is, but I think concentrating on the problem (inability to wear shoes) is more likely to be successful than trying to do everything (achieve union, length, alignment, avoid infection, and not cause pain or new problems.)
Date: Fri, 11 Jan 2002 15:24:41 -0500
From: William Obremsky
I agree w/ your rationale and recommendations.
It is possible to do a 3 plane correction w/ a single osteotomy.
Please see: Sangeorzan B. Mathematical Analysis of Single Cut Osteotomy for Complex Long Bone Deformity, Journal of Biomechanics 22:1271-1278, 1989.
In this article the Theta angle is the angle equal to degree of IR or ER.
The "Coronal or "Sagital osteotomy is rotated equal to Theta angle to make single cut to correct IR or ER. This will allow 3 plane correction. Try it on a tibia sawbone.
The other thing to consider is a custom molded shoe w/ a build up.
I think I would favor Ilizaov to allow persistent weightbearing and gradual corrrection.
Find someone experienced.
Date: Fri, 11 Jan 2002 16:22:40 -0600
From: Steven Rabin
Yes, I've read and tried to use Sangeorzan's technique and it is geometrically great, but somehow my measurements and bone cuts are not exactly precise enough. What I've found to work very well, be very reproducible, and not require any precise measurement of angles is Roy Sanders' technique for oblique osteotomy (Oblique Osteotomy for the Correction of Tibial Malunion, JBJS, 77A(2):240-6, 1995). The osteotomy is done by rotating the limb under the c-arm until the planes of maximal and minimal deformity are defined and then the bone cut. I reported our series for tibia and femur malunions 3 years ago at the OTA meeting. Unfortunately, as I said, it does not correct rotation. (It can correct some length, but certainly not enough to be significant in this case.)
I agree that someone with experience should be the one to do it, and if they can correct it with Sangeorzan's technique, the spatial frame, or Ilizarov methods - more power to them!
(p.s. this comes from Tracy Watson's group, and I know he has the Ilizarov experience!)
again, good luck.
Date: Fri, 11 Jan 2002 16:24:07 -0800
From: Bruce Sangeorzan
for clarification, sanders technique DOES introduce rotation. It just wasn't measured in the study and can't be predicted using the described technique alone. Roy's technique is the same as that reported by Merle D'Aubingne 20 years earlier. Both ignore rotation. if it is a long cut angle the rotation will be small and you might not care. if there is no rotation in the deformity you are treating, it may be a problem. If there is rotation and you want to correct it. plot the angle and do a formal oblique osteotomy as Bill O suggests.
Date: Sat, 12 Jan 2002 13:50:53 +0500
From: Alexander Chelnokov
Hello All, especially Steven
SR> Radiographically this looks like a disaster, but clinically she's doing pretty good. I think this is an example of a case where we should treat the patient instead of treating the x-rays.
Also we should treat a patient instead of treating his complaints.
SR> 5. Primarily wishes an ankle foot correction to permit normal shoe fitting and wear.
A treatment plan should be based on some other considerations also. Cynically it may sound like "the patient will soon disappear forever regardless what has been done and let it be headache for someone else" so maybe the patient would have a significant relief with a some propely molded orthotic device without surgical procedures. Maybe a palliative ankle/foot correction is a good choice. But if the clinic would have to provide a life-time observation and treatment of the patient the plan can be much more radical. Apparently the current situation will become worse sooner or later. Such limb length discrepancy is an unconditional indication for limb equalization. There is a number of fibula tibialization techniques (entire fibula transport or longitudinal splitting and medial traction) which can be considered here along with proximal tibio-fibular fusion and the foot correction. We all also know that a good physician is able to convince patient that his completely healthy leg has to be amputated (it is a metaphor only! Don't do it in your practice :) so if the patient is compliant enough, the situation, prognosis and treatment modalities can be discussed with her and an adequate decision be made. Again, the range of options is very wide and what decision is optimal is not a surgical challenge only.