Proximal Tibial Growth Arrest with Varus, Recurvatum, and Shortening After ACL Reconstruction
Limb Lengthening Academic Case Presentation
This is a case of a tibial growth arrest that occurred after anterior cruciate ligament (ACL) reconstruction with a trans-epiphyseal tunnel done at age 12. This resulted in LLD, varus and recurvatum deformity. We describe this case and the correction using distraction osteogenesis in conjunction with a Taylor Spatial Frame (TSF) (Smith & Nephew Inc, Memphis, Tennessee, USA) using the Ilizarov method.
Brief Clinical History:
A 17-year-old male patient had an acquired leg-length discrepancy (LLD) and deformity after ACL reconstruction performed at age 12 after a ski injury. Reconstruction was performed using an Achilles allograft by an experienced surgeon. The graft was fixed in an anatomically placed tibial tunnel in which a plug was countersunk and tied over a button for secure fixation. No tunnel was drilled on the femoral side, and the graft was placed intra-articularly and over the top of the lateral femoral condyle. The Achilles allograft was then put on tension and fixed to the lateral femur using 2 small staples. Over the course of several years, there progressively emerged a deformity of the right tibia associated with an LLD. The patient lived overseas and there was little follow-up with the ACL surgeon. He was referred to our service and came for treatment at age 17, which was 4.5 years after initial ACL surgery.
Preoperative Problem List
- LLD = 4.5 cm
- Predicted LLD = 5.5 cm
- Varus deformity 15 degrees
- Recurvatum deformity 28 degrees
- External rotation deformity 15 degrees
- Damaged proximal tibial growth plate
- Close remaining proximal tibial growth plate to avoid additional deformity
- Calculate the growth remaining from the proximal tibial growth plate which in this case was 1 cm.
- Perform osteotomy at proximal tibia and fibula to correct varus, recurvatum, external rotation.
- Lengthen tibia a total of 5.5 cm (4.5 cm preoperative LLD + 1 cm growth remaining that was stopped)
- Use distraction osteogenesis and the TSF for complex deformity correction and bone lengthening.
- Growth arrest of the antero-medial aspect of the proximal tibial growth plate (presumably related to the tibial bone tunnel and ACL graft) led to a varus and recurvatum deformity.
- The rotational deformity is more difficult to explain but likely occurred from the same etiology
- The oblique plane deformity (apex posterolateral) and rotational deformity will be corrected gradually with distraction osteogenesis using the TSF
- Current LLD is 4.5 cm. Using growth remaining calculations for the proximal tibial growth plate, another 1 cm of growth is expected to occur (His bone age was 15)
- Close proximal tibial growth plate so not additional deformity will occur after the correction.
- Make the proximal ring the reference ring since it is close to the apex of deformity and the origin.
- Use a 2/3 ring proximally so the knee can bend beyond 90 degrees.
- Apply the TSF to match the deformity
- Stabilize the tibia and fibula both proximal and distal with tensioned wire. This will prevent fibula migration.
- Use TSF planning to determine the necessary coronal and sagittal plane translation needed during the lengthening and deformity correction.
Avoiding and Managing Problems
- Avoid recurrence of deformity by closing damaged proximal tibial growth plate
- Avoid LLD by calculating the predicted LLD and over lengthening the affected side.
- Do not remove frame until 3 cortices are seen on bi-planar x-rays.
- Apply long leg cast after frame removal as a transitional phase to prevent fracture
- Valgus and shortening of distal femur from growth arrest treated with monolateral frame. 383256
- Oblique plane deformities of femur and tibia after open fracture treated with TSF. 383216
- Guided growth for partial growth arrest. 383240
- Adolescent with 7-cm Femoral Shortening due to Physeal Growth Deceleration: Femoral Lengthening with PRECICE Retrograde Intramedullary Nail. 383288
References and Suggested Reading
1. Goldman V, McCoy TH, Harbison M, Fragomen AT, Rozbruch SR: Limb Lengthening in Children with Russell-Silver Syndrome: A Comparison to Other Etiologies. J Children’s Orthop 2013, 7:151-6, Epub 2013 Jan 5.
2. Rozbruch SR, Fragomen A, Ilizarov S: Correction of Tibial Deformity Using the Ilizarov/ Taylor Spatial Frame. J Bone Joint Surg Am 88-A 2006, supplement 4, pages 156-174.
3. Rozbruch SR, Segal K, Ilizarov S, Fragomen AT, Ilizarov G: Does the Taylor Spatial Frame Accurately Correct Tibial Deformities? Clin Orthop Rel Res 2010 May :468(5): 1352-61
4. Rozbruch SR, Schachter L, Bigman D, Marx R: Growth Arrest of the Tibia after ACL Reconstruction: Lengthening and Deformity Correction with the Taylor Spatial Frame. Published online before print April 25, 2013, doi: 10.1177/0363546510369318; Am. J Sports Med, 2013, 41(7):1636-1641.
S. Robert Rozbruch, MD
Chief, Limb Lengthening and Complex Reconstruction Service, Hospital for Special Surgery
Director, Osseointegration Limb Replacement Center, Hospital for Special Surgery