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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 2  |  Issue : 2  |  Page : 82-85

Complications related to fibula resection during tibial lengthening performed with the Taylor Spatial Frame


Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takara machi, Kanazawa, 920 8641, Japan

Date of Submission15-Mar-2016
Date of Acceptance21-Jul-2016
Date of Web Publication16-Sep-2016

Correspondence Address:
Hidenori Matsubara
Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takara-machi, Kanazawa, 920 8641
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2455-3719.190709

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  Abstract 

Context: Previous studies report that valgus deformities of the knee and the ankle joint usually occur due to proximal and distal fibular migration during tibial lengthening with the Ilizarov method.
Aims: This study aimed to evaluate complications related to fibular resection during tibial lengthening with the Taylor Spatial Frame.
Settings and Design: Retrospective study.
Subjects and Methods: We retrospectively reviewed 18 segments (15 patients, mean age 20.5 years) who underwent tibial lengthening of more than one cm with fibular resection. Only Taylor Spatial Frame external fixators were used. The mean follow-up period was 37.8 months. Radiographs were evaluated for proximal fibular migration (PFM), distal fibular migration (DFM), knee and ankle alignment, and the presence of fibular nonunion preoperatively and at the last follow-up. Statistical analysis used: Mann-Whitney U-test.
Results: The mean PFM was 9.7 mm and the mean DFM was 3.9 mm. Neither knee nor ankle valgus deformities was seen. Nonunion occurred in 12 segments and union of the fibula occurred in six segments after lengthening. The mean length of the fibular segment was 12.4 mm in cases with nonunion and 5.8 mm in cases with union at the fibula resection sites.
Conclusions: We verified the presence of proximal and distal fibular migration reportedly associated with knee valgus and ankle valgus. PFM was not regarded as a definite cause of knee valgus, but it is necessary to fix the tibiofibular joints by transfixing wire and/or cannulated screws both at proximal and distal to minimize PFM and DFM.

Keywords: Complications, fibula migration, fibula resection, tibial lengthening, tibiofibular fixation


How to cite this article:
Yoshida Y, Matsubara H, Aikawa T, Ugaji S, Tsuchiya H. Complications related to fibula resection during tibial lengthening performed with the Taylor Spatial Frame. J Limb Lengthen Reconstr 2016;2:82-5

How to cite this URL:
Yoshida Y, Matsubara H, Aikawa T, Ugaji S, Tsuchiya H. Complications related to fibula resection during tibial lengthening performed with the Taylor Spatial Frame. J Limb Lengthen Reconstr [serial online] 2016 [cited 2019 Oct 23];2:82-5. Available from: http://www.jlimblengthrecon.org/text.asp?2016/2/2/82/190709


  Introduction Top


In tibial lengthening with the Ilizarov method, fibular resection and tibiofibular fixation is performed. However, it is reported that valgus deformities of the knee and the ankle joint usually occur due to proximal and distal fibular migration during tibial lengthening with an Ilizarov external fixator. [1],[2] Few reports provide details regarding fibula-related complications. [3] In the present study of 18 lengthened tibial segments using the Taylor spatial frame (TSF), we examined the complications associated with fibula resection and fixation.


  Subjects and Methods Top


We retrospectively studied 18 tibial segments in 15 patients who underwent tibial lengthening at our institution between 2007 and 2014. The inclusion criterion was tibial lengthening of ≥one cm with distraction osteogenesis with the use of a TSF fixator. The mean age at surgery was 20.5 (range, 7-49) years. Nine patients were male and six were female. The etiology was hemihypertrophy in four patients, growth plate injury in three; and Blount's disease, Ollier's disease, posttraumatic malunion, precocious puberty, rickets, spondyloepimetaphyseal dysplasia, tethered cord syndrome, and idiopathic in one each. The average duration of follow-up after the surgery was 37.8 (range, 10-81) months.

A pre-constructed TSF was applied with tensioned wires and threaded screws. The fibula was fixed with tibiofibular transfixing wire and/or a cannulated screw, only at the distal end in 12 limbs, at both proximal and distal ends in four, and neither the proximal nor distal ends in two. Fibular osteotomy was performed at the distal third with a mean segmental resection of 10.2 (range, 2.3-20.3) mm. Tibial osteotomy using the multiple drill-hole method was performed at the level of the center of rotation of angulation or the distal to the tibial tuberosity for gradual lengthening.

Lengthening with or without gradual correction of the deformity was started between the seventh and 14 th postoperative day at a rate of one mm per day. The rate was adjusted according to bone formation detected on radiographs or the patients' experience of pain during follow-ups. After the desired length was achieved and when three cortices out of four were consolidated on frontal and lateral radiographs, the fixator was removed.

The radiographs were evaluated with regard to four parameters: (1) proximal fibular migration (PFM) (mm), [3] which measured the distal migration of the fibular head by comparing the positions of the fibular head relative to the tibial plateau on the preoperative standing radiograph and the radiograph taken at the time of the latest follow-up; (2) distal fibular migration (DFM) (mm), [3] which measured the proximal migration of the lateral malleolus by comparing the positions of the lateral malleolus relative to the medial malleolus on the preoperative standing radiograph and the postoperative standing radiograph taken at the time of the latest follow-up; (3) the joint line convergence angle (JLCA), [4] which was measured on long standing radiographs preoperatively and at the last follow-up to assess the alignment of the knee joint. In this study, knee valgus deformity was defined as a valgus change of five degrees or more in the JLCA after tibial lengthening; and (4) the tibiotalar angle, [5] which was measured at the intersection of the mid-diaphyseal line of the tibia and a line drawn across the flat subchondral line of the talar dome. In this study, we defined ankle valgus deformity as a valgus change of five degrees or more in the tibiotalar angle after tibial lengthening. In addition, we assessed consolidation or nonunion at the fibular osteotomy site by examining the radiograph and/or CT image taken at the time of the last visit.


  Results Top


The average gain in length was 3.6 (1.0-6.0) cm. The mean external fixator index (EFI) was 85.3 (32.4-274.0) days/cm. The mean PFM and mean DFM were 9.7 (0-30.0) mm and 3.9 (0-12.7) mm, respectively [Figure 1] and [Figure 2]. All fibular migrations occurred during lengthening, and there was no change after TSF removal. According to the site of tibiofibular transfixing, 12 limbs, which were fixed only at the distal fibula, showed that the mean PFM and DFM were 10.8 (0-30.0) mm and 4.0 (0-12.7) mm, respectively, and tended to be lesser than the DFM in cases without tibiofibular fixation. In four limbs fixed at both the proximal and distal fibula, the mean PFM and mean DFM were 10.0 (0-21.5) mm and 2.8 (0-4.9) mm. In the two limbs with fixation at neither end of the fibula, the mean PFM and DFM were 2.1 (1.0-3.1) mm and 6.8 (6.4-7.2) mm, respectively, and the DFM tended to be greater than in the others with distal part fixed [Table 1].
Figure 1: Proximal fibula migration (arrow) (14-year-old, girl, precocious puberty)

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Figure 2: Distal fibula migration (arrow) (7-year-old, boy, hemihypertrophy)

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Table 1: Amounts of PFM and DFM at each fixed site


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There were no knee valgus cases that displayed JLCA at last observation that showed five degrees or more among the 18 limbs examined. Likewise, we did not find any cases of ankle valgus. Nonunion occurred in 12 segments, and union of the fibula occurred in six segments after lengthening. None of the cases showed premature consolidation. We confirmed that six limbs displayed bone union at the fibular resection site after a mean of 10.5 (range, 5-19) months. The mean amount of fibular gap was 12.4 (range, 5.5-20.3) mm in nonunion and 5.8 (range, 2.3-8.3) mm in union, and there were significant differences between both cases [Table 2].
Table 2: Amounts of fibula resection and status of each osteotomy site


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  Discussion Top


During tibial lengthening with an external fixator, fibula-related complications, such as valgus deformity of the knee, ankle, or tibial shaft that required surgical intervention are reported. [2],[3],[6] Kim et al. reviewed 120 segments and reported that PFM induced soft tissue resisting forces during the lengthening that caused valgus deformity of the knee and premature consolidation of the fibula. [3] The resisting forces can be soft tissues, interosseous membrane, or the bone itself in tibial distraction. [7],[8] Aldegheri also described that distal migration of the fibular head was a frequent phenomenon in his series of patients, who underwent tibial lengthening without proximal tibiofibular transfixation. [9] In our study, 14 limbs that were not fixed at the proximal fibula showed that PFM did occur, but was not associated with the abnormal alignment of the knee joint after lengthening. One of the reasons could be that the TSF enables easier and more accurate modification of the correction than the Ilizarov fixator. [10],[11] PFM might have an effect, not only on valgus deformity, but also on the function of the knee joint. However, we did not evaluate variables such as the range of motion, muscular force, and instabilities in the present study. As PFM and premature consolidation can increase resistance for planned lengthening and correction, addition of proximal tibiofibular transfixation and maintaining a certain length of the segment of the fibular bone can be undertaken as preventive measures. Hatzokos et al. reported a case of premature consolidation and 12 cases of nonunion among 30 tibial segments and stated that the fibular resection must be approximately one cm in length to avoid early consolidation. [8] Kim et al. reported that when they excised a 0.5-cm segment of fibular bone, premature consolidation and nonunion occurred in ten and 12 segments, respectively, out of 120. [3] Nevertheless, to determine the ideal length of fibular resection, the length of the resection as well as the rate of elongation of the tibia must be considered.

DFM following tibial lengthening was first described as a cause of ankle valgus by Macnicol and Catto. [12] Park et al. reported that a DFM of 5 mm or more was associated with a risk of valgus talar tilting, because loss of the lateral malleolus functions resulted in increased pressure on the lateral tibial plafond that caused subsequent cartilage damage and possible subsidence of the plafond due to collapse of regenerated bone of poor quality or fibular nonunion. [2] Additionally, several soft tissue conditions including deltoid ligament insufficiency, posterior tibial tendon deficiency, an insufficient syndesmotic ligament complex, and a contracted gastrocnemius-soleus complex, are estimated to cause ankle valgus. [1] As our results showed fibular nonunion in 12 segments as well as DFM, but we did not find any cases of ankle valgus. We may have to determine that follow-ups should focus on functional evaluations of the ankle joint.

There are the following limitations in the present study. First, since the number of cases was small, statistical considerations were scarce. Secondly, the amount of lengthening in our series was relatively low compared to cases in previous studies that reported valgus deformity associated with PFM or DFM. [2],[3]


  Conclusions Top


We verified the proximal and distal fibular migration. PFM was not regarded as a definite cause of knee valgus, but we suggest that it is necessary to fix the tibiofibular joint by transfixing wire and/or cannulated screws both at the proximal and distal fibula to minimize PFM and DFM. For the precautions to avoid various complication related fibula resection following tibial lengthening, it is deemed desirable to examine furthermore such as applicable length and site of fibula resection and fibula fixation method with assessments of many more cases.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Gibson V, Prieskorn D. The valgus ankle. Foot Ankle Clin 2007;12:15-27.  Back to cited text no. 1
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2.
Park HW, Kim HW, Kwak YH, Roh JY, Lee JJ, Lee KS. Ankle valgus deformity secondary to proximal migration of the fibula in tibial lengthening with use of the Ilizarov external fixator. J Bone Joint Surg Am 2011;93:294-302.  Back to cited text no. 2
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3.
Kim SJ, Agashe MV, Song SH, Song HR. Fibula-related complications during bilateral tibial lengthening: 60 patients followed for mean 5 years. Acta Orthop 2012;83:271-5.  Back to cited text no. 3
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4.
Paley D. Normal lower limb alignment and joint orientation. In: Kelly D, editor. Principles of Deformity Correction. 1 st ed. New York: Springer-Verlag Berlin Heidelberg; 2002. p. 8-10.  Back to cited text no. 4
    
5.
Snearly WN, Peterson HA. Management of ankle deformities in multiple hereditary osteochondromata. J Pediatr Orthop 1989;9:427-32.  Back to cited text no. 5
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6.
Vargas Barreto B, Caton J, Merabet Z, Panisset JC, Pracros JP. Complications of Ilizarov leg lengthening: A comparative study between patients with leg length discrepancy and short stature. Int Orthop 2007;31:587-91.  Back to cited text no. 6
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7.
Saleh M, Bashir HM, Farhan MJ, McAndrew AR, Street R. Tibial lengthening: Does the fibula migrate? J Pediatr Orthop B 2002;11:302-6.  Back to cited text no. 7
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8.
Aldegheri R. Distraction osteogenesis for tibial lengthening (letter). J Bone Joint Surg Am 2000;82:1195.  Back to cited text no. 8
    
9.
Matsubara H, Tsuchiya H, Sakurakichi K, Watanabe K, Tomita K. Deformity correction and lengthening of lower legs with an external fixator. Int Orthop 2006;30:550-4.  Back to cited text no. 9
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10.
Manner HM, Huebl M, Radler C, Ganger R, Petje G, Grill F. Accuracy of complex lower-limb deformity correction with external fixation: A comparison of the Taylor Spatial Frame with the Ilizarov ring fixator. J Child Orthop 2007;1:55-61.  Back to cited text no. 10
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11.
Hatzokos I, Drakou A, Christodoulou A, Terzidis I, Pournaras J. Inferior subluxation of the fibular head following tibial lengthening with a unilateral external fixator. J Bone Joint Surg Am 2004;86:1491-6.  Back to cited text no. 11
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12.
Macnicol MF, Catto AM. Twenty-year review of tibial lengthening for poliomyelitis. J Bone Joint Surg Br 1982;64:607-11.  Back to cited text no. 12
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    Figures

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