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 Clinical Photos:
- Figure 1A,B: Front and side standing views of showing knee deformity and LLD. Growth plates are still open despite his age of 17.
- Figure 2: Preoperative x-rays of the knee (A) AP view showing varus (B) Lateral view showing PPTA of 110 degrees and recurvatum deformity. Note anterior subluxation of the femur on the tibia related to the recurvatum deformity. Note the antero-medial bone plug from the ACL graft. (C) Surgical planning on the lateral view. Proximal joint orientation line is drawn (brown). Distal axis line is drawn (maroon). Intersection between lines is the CORA with a magnitude of 28 degrees.
- Figure 3: Preoperative 51 inch erect leg x-ray with a 3 cm block under the right foot (A) Note the medial MAD and the LLD of 4.5 cm as well as the external rotation of the ankle relative to the knee (B) Surgical planning is shown. The femur does not have deformity. The femoral mechanical axis line (brown) is extended across the knee. The distal tibial axis line (maroon) is drawn in a retrograde fashion and the intersection is the CORA with a magnitude of 15 degrees of varus.
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.
Images During Treatment:
- Figure 4A,B: Front and side view of the TSF frame mounted to the leg to match the varus, recurvatum, external rotation deformity.
- Figure 5A,B: Side view and lateral x-ray at the end of distraction showing correction of deformity and proximal tibial lengthening.
- Figure 6: Erect leg standing x-ray at end of distraction showing equal leg lengths and correction of the MAD line.
- 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.
Outcome clinical photos and radiographs:
- Figure 7A,B: Patient as an 18 year-old with equal leg lengths and correction of deformity.
- Figure 8A,B: AP and lateral x-rays showing healed and remodeled proximal tibial lengthening and deformity correction. The PPTA on the lateral x-ray is normal.
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.