|Year : 2020 | Volume
| Issue : 1 | Page : 40-47
Correction of multiplanar proximal tibial deformities using the taylor spatial frame
Ahmed Mohamed Abdelaziz1, Hosny A Gamal2, Allam S Ahmad2, Abdulalim A Abdulsalam2
1 Department of Orthopedic, Al-Razi Orthopedic Hospital, Ministry of Health, Kuwait
2 Department of Orthopedic, Faculty of Medicine, Benha University, Egypt
|Date of Submission||26-Feb-2020|
|Date of Decision||23-Mar-2020|
|Date of Acceptance||30-Mar-2020|
|Date of Web Publication||30-Jun-2020|
Dr. Ahmed Mohamed Abdelaziz
Ministry of Health, Al-Razi Orthopedic Hospital, P.O. Box: 4235 Safat Code 13043
Source of Support: None, Conflict of Interest: None
Context: The management of multiapical and multidirectional deformities of the proximal tibia is still a challenging task with acute correction. The Taylor spatial frame (TSF) enables gradual correction in all planes. Aims: The study investigated the accuracy of correction for multiplanar proximal tibial deformities which had performed with the preassembled TSF. The complications and functional outcome were investigated. Settings and Design: Retrospectively, we compared the parameters of proximal tibial angles before and after using the preassembled TSF frame technique for correction. We used the mechanical axis deviation (MAD), medial proximal tibial angle (MPTA), posterior proximal tibial angle (PPTA), and tibial rotation as reference parameters for accuracy judgment. The deformities were divided into three main planes, each plane subdivided by two directions of angulations. Subjects and Methods: The study included 15 patients (20 tibiae), who underwent a tibial osteotomy surgery after obtaining informed consent for deformity correction using the TSF (Smith and Nephew, Memphis, TN, USA) between June 2016 and May 2018. Results: The three-plane deformities experienced an accurate correction of MAD. MPTA and PPTA were accurately corrected in patients with coronal and sagittal plane deformities, respectively. Rotational deformities were corrected to a satisfactory degree of accuracy in all cases. TSF correction for multiplanar proximal tibial deformities achieved an excellent result regarding functional outcome. Conclusions: Gradual correction for multiplanar proximal tibial deformities with the TSF is accurate, simple and with few complications.
Keywords: Gradual correction, Taylor spatial frame, tibial deformities
|How to cite this article:|
Abdelaziz AM, Gamal HA, Ahmad AS, Abdulsalam AA. Correction of multiplanar proximal tibial deformities using the taylor spatial frame. J Limb Lengthen Reconstr 2020;6:40-7
|How to cite this URL:|
Abdelaziz AM, Gamal HA, Ahmad AS, Abdulsalam AA. Correction of multiplanar proximal tibial deformities using the taylor spatial frame. J Limb Lengthen Reconstr [serial online] 2020 [cited 2020 Sep 21];6:40-7. Available from: http://www.jlimblengthrecon.org/text.asp?2020/6/1/40/288568
| Introduction|| |
The proximal tibial deformities alter the proper transmission of forces across the knee joint. Even moderate malalignment 5° reportedly initiates or facilitates the progression of osteoarthritis.
The management of multiapical and multidirectional deformities of the lower limb is still a challenging task with acute correction.,
In the last decades, external fixators, especially the circular Ilizarov fixator, have become popular to correct complex deformities.
The Taylor spatial frame (TSF) (Smith and Nephew) was introduced in 1994 and became popular in the following years. It is a modular circular external fixation system using the same methods of frame attachment and the same gradual correction principles as the Ilizarov device.
Our study aimed to investigate the concept of correction for multiplanar proximal tibial deformities which had performed with the TSF.
| Subjects and Methods|| |
This study included 15 patients (20 tibiae) who underwent a tibial osteotomy surgery after obtaining informed consent for deformity correction using the TSF (Smith and Nephew, Memphis, TN, USA) between June 2016 and May 2018. There were 9 females and 6 males with an average age of 21.5 (range, 10–33 years). Five (3 females and 2 males) of the 15 patients had bilateral corrections.
Our indication for the use of the TSF for proximal tibial deformities was multiplanar deformity consisting of coronal plane deformity of a magnitude >10°, sagittal plane deformity, or presence of rotational deformity. Patients with nonunion, patients who primarily underwent tibial lengthening, and patients who underwent deformity correction with a different method than the TSF were all excluded. The contraindications for using TSF were elderly patients who have no ability to care for themselves and patients who have a severe or uncontrolled psychiatric disease.
Clinical preoperative evaluation was carried out including history and physical examination. Frontal and sagittal plane deformities on long lower-limb standing radiograph were analyzed. Limb length discrepancy (LLD), mechanical axis deviation (MAD), and joint orientation angles that are lateral distal femoral angle, medial proximal tibial angle (MPTA), lateral distal tibial angle (LDTA), posterior distal femoral angle, and posterior proximal tibial angle (PPTA) were measured using the methods described by Paley [Figure 1].,
|Figure 1: Long lower-limb standing radiograph with joint orientation angles: (a) Coronal view for varus deformity shows mechanical axis deviation, lateral distal femoral angle, medial proximal tibial angle <85°, and lateral distal tibial angle. (b) Sagittal view for recurvatum deformity shows posterior distal femoral angle and posterior proximal tibial angle >84°|
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Assessment of tibial rotation was done clinically by measuring the thigh–foot axis (TFA) in prone position and measuring the angle between patella up axis and heel bisector axis in supine position.
Each tibial deformity was analyzed with six axes: coronal plane angulation (varus or valgus) and translation (medial or lateral), sagittal plane angulation (procurvatum or recurvatum) and translation (anterior or posterior), and axial plane angulation (internal or external) and translation (short or long).
Preassembled TSF was built preoperatively with chronic mode after inputting the deformity and preliminary mounting parameters into the TSF web-based software (www.spatialframe.com) computer program, the strut lengths were determined by the computer, and the frame was constructed in a manner replicating the deformity. Preassembled frame technique was used to reduce the time of the surgery and adjust the distance between the rings preoperatively, which had led to reduce the number of strut changes postoperatively during correction phase.
Patients underwent surgery on the next day of admission. All surgeries were performed under general anesthesia. Patients were administered prophylactic antibiotic with anesthesia induction. Tourniquet was not used during the procedure. Common peroneal nerve release was done for valgus, rotational deformities, and tibial lengthening cases.,, Fibular osteotomy was performed in all cases. At times, we resected a small section of the fibula if substantial fibular shortening or early fibular consolidation was anticipated. TSF frame had been attached to the bone using one tensioned wire as a reference wire for proximal ring beside three perpendicular coated half pins with hydroxyapatite (HA) (Orthofix, Verona, Italy) [Figure 2]a and [Figure 2]b. For distal ring, three HA-coated half pins in different planes were used for fixation. We used a 2/3 ring proximally to accommodate posterior leg swelling and allow knee flexion.
|Figure 2: Taylor spatial frame proximal ring attachments: (a) Ilizarov wire insertion from lateral to medial side under fluoroscopy guide and check the wire is perpendicular to the proximal tibial mechanical axis. (b) Two half pins placed anteromedial and anterolateral under image guide and directed posterolateral and posteromedial to be perpendicular to each other. (c) Osteotomy is complete under fluoroscopy|
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The osteotomy for the tibia was performed with multiple drill holes and completed with osteotome but left nondisplaced [Figure 2]c. Final mounting parameters were calculated after the placement of the TSF.
After the surgery, patients were allowed to bear weight as tolerated, and range-of-motion exercises for the knee and ankle were encouraged. A daily shower, including washing the pin sites with antibacterial soap, was encouraged 1 week postoperatively. This was followed by pin care with chlorhexidine 0.5% in water and then wrapped with sterile gauze soaked with chlorhexidine 0.5% in water or povidone-iodine 10%.
We entered deformity parameters into web-based software and generated an adjustment schedule postoperatively with total residual operating mode. The program required input of deformity, frame, and mounting parameters, in addition to structures at risk to determine the rate of correction. Deformity correction commenced 5–7 days after the surgery. Patients were discharged mobilizing weight-bearing as tolerated with crutches and instructed to perform gradual adjustments for the six struts of the TSF according to the adjusting schedule three times/day, two struts per each session. Radiographs were taken at 2 weeks to be certain that the osteotomy was moved.
Patients were seen in the clinic every week during the distraction phase. Once the alignment was corrected and the adjustments ended, patients were seen monthly until frame removal. At the end of the schedules, the limb alignment was determined with physical examination and radiograph. On long lower-limb standing radiograph, we measured MAD, MPTA, PPTA, and LLD using the same methods used before the surgery, and we assessed the rotation by patella up test and TFA. When there was a residual deformity, we generated and implemented another correction schedule.
Our criteria for frame removal were the ability to walk with minimal assistance with no pain at the osteotomy site and the presence of bridging callus on three of four cortices using the anteroposterior, internal oblique, external oblique, and lateral radiographs.,
For all patients, we recorded the number of schedules needed, adjusting weeks, total wearing period of the frame, complications, knee and ankle range of motion, and follow-up in months postframe removal.
Deformity parameters, including degree of varus (16 tibias – 2 tibias with medial compartment osteoarthritis) or valgus (2 tibias), procurvatum (8 tibias) or recurvatum (2 tibias), and internal (15 Tibias) or external rotation (4 tibias) deformities, were recorded [Table 1]. This illustrated the magnitude and nature of the preoperative deformity.
|Table 1: Six proximal tibial deformities, number of the cases for each deformity and degree range for the entire cohort, medial proximal tibial angle, posterior proximal tibial angle, thigh foot axis, and postoperative degrees with P value|
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We analyzed the outcomes of MPTA, PPTA, and TFA beside computed tomographic rotational profile in isolated rotational deformity, relative to preoperative measurement. MAD was analyzed according to the planned treatment goal. [Supplementary Material 1].
The aims of the analysis were to confirm a clinically important improvement in certain measurements and its accuracy postoperatively at an average of 11 (range, 6–24 months) of follow-up.
As the TSF follows the same principals of callus distraction such as Ilizarov technique, we have followed the scoring system of the Association for the Study and Application of the Methods of Ilizarov (ASAMI) for evaluation of bony and functional results of the study.
| Results|| |
The software SPSS for Windows Release 10 (SPSS Inc., Chicago, IL, USA) was used for all statistical calculations. Each variable was tested for its normal value using the Kolmogorov–Smirnov test. Significance was set at the P < 0.05 level.
The MAD was postoperatively divided into three results:
- MAD center within 5 mm medial or lateral,
- MAD overcorrection to 6–12 mm medial or lateral depending on the presenting problem in the patients who had unicompartmental arthritis,
- MAD improvement with femoral origin residual deformity.
For patients with tibial origin varus deformity (11 patients), MAD was central with a range of 5 mm medial and 5 mm lateral to midline, and for the patient with tibial and femoral origin varus deformity (one patient), MAD was central with 2 mm medial to midline [Table 2].
|Table 2: Preoperative versus postoperative mechanical axis deviation (mm) with P value|
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In two patients with tibial and femoral origin varus deformity, MAD was overcorrected with a range of 6 mm to 11 mm lateral to the midline [Table 2].
In two patients with tibial and femoral origin varus deformity, MAD was improved with a range of 17 mm to 58 mm lateral to the midline [Table 2].
For one patient with valgus deformity due to tibial origin, MAD was central with 0 mm medial to midline, and for one patient with tibial and femoral origins, MAD was central with 5 mm medial to midline [Table 2].
The corrections of MPTA were accurate, and the MPTA improved from varus or valgus angle to normal orientation angle in patients with a varus or valgus deformity [Table 1].
Sagittal deformities (procurvatum or recurvatum) [Table 1] and axial plane deformities (internal or external rotation) [Table 1] were corrected to a satisfactory degree in all cases.
Statistical analysis for all proximal tibial angles and MAD showed a significant improvement with P < 0.05 using the Kolmogorov–Smirnov test.
Patients had web-based schedules for correction with an average of 2.8 (range, 1–5 schedules), which last on average 5.9 (range, 2–10 weeks), and the total period of wearing the frame averaged 18.9 (range, 12–26 weeks). Although these patients group included only those with deformities, there was associated LLD in some patients; this explained the long distraction time and period of wearing the frame for some patients.
We recorded all the complications occurred with using TSF during this study, there were ten patients had complication: six cases (30%) related to wire infection that improved with wire removal in the clinic, one case (5%) had pin site infection that required removal in the operating room, and one case (5%) had cellulitis that required a 10-day course of intravenous antibiotics. Two cases (10%) had reported osteotomy site pain in the 1st day postoperatively who improved with early compression software program. All the cases (100%) developed pin site reaction during the adjusting or consolidation periods for one or more of the half pins, which was considered as a minor complication because it resolved with daily dressing.
Preassembled frame technique was used to reduce the time of the theater and optimized a strut exchange which was potentially cheaper and more accurate.
There were no cases of joint stiffness, compartment syndrome, deep vein thrombosis, nerve palsy, reflex sympathetic dystrophy, delayed union and nonunion, premature consolidation, hardware failure, or residual deformity.
According to the ASAMI scoring system, the results of the study showed that bony results were excellent in 13 cases (65%), good in 7 cases (35%), and no fair or poor bony results were seen in our study. Functional results were excellent in 20 cases (100%). Good, fair, poor, and failure functional results were not recorded for any patient of our study [Table 3].
|Table 3: Association for the Study and Application of the Methods of Ilizarov score descriptions for bony result and functional result|
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| Discussion|| |
Although deformity correction of the proximal tibia can often be accomplished with an acute correction and the use of internal fixation, this method has limitations.,, The presence of multiplanar deformities, symptomatic LLD, and lack of postoperative adjustability show the limitations of this method. Acute correction of a proximal tibial osteotomy can be associated with significant complications: common peroneal nerve palsy and compartment syndrome; the rate of neurovascular complications had reported to range from 3.3% to 18%.,
The Ilizarov method of deformity correction and limb lengthening was the most important contribution in the field of deformity correction in the last century. Significant disadvantages of the Ilizarov frame include a long learning curve and the need for frame adjustments with creation of additional hinges when correcting multiplanar deformities. When using the Ilizarov ring fixator (IRF) and its hinge system, it may sometimes become difficult or even impossible to place the hinges in the desired position, due to the frame construct itself. Even though the construct of the Ilizarov device theoretically may allow for axial corrections in every possible dimension, the treatment of multidimensional deformities may practically only partially be possible and mostly affords a step-by-step treatment of all deformities. This may lengthen the procedure and is prone to lead to further deformities. Furthermore, the correction of rotational deformities with the Ilizarov frame is a challenging task even for the most experienced surgeons.,
The greatest advantage of the TSF and other hexapod systems is the elimination of the need for frame adjustments because they use six struts of adjustable length attached to universal hinges to move an object in six degrees of freedom. Spatial fixators are based on identical biological properties and host response as those of a traditional Ilizarov fixator, with possibly better mechanical properties and ease of use. With the introduction of hexagonal strut geometry, the precise displacement of the proximal and distal fragments relative to each other is achieved. However, this improvement comes with a price of increased cost. Spatial fixator costs are six to ten times higher than traditional Ilizarov circular external fixators. For this reason, it is essential to identify patients for which spatial fixators would play a significantly effective role.
TSF is able to correct six-axis deformities simultaneously with computer accuracy. Therefore, after the application of the frame the surgeon is needed to perform accurate deformity analysis and input all the parameters to the website program. Undoubtedly, hexapod systems have become the treatment of choice for multiplanar skeletal deformities, especially with rotational components.
Our study concept aimed to investigate the accuracy of correction for multiplanar proximal tibial deformities which had performed with the TSF. We carefully reviewed the literature over the last years and found there is general consensus that the TSF is a very efficient surgical tool that allows the correction of any kind of deformity [Table 4].,,,,,,,,,,
|Table 4: Literature summary on Taylor spatial frame for deformity correction|
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Rodl et al. investigated the workspace of a standard IRF construct compared to a standard TSF construct. According to the results of this experimental study, the TSF provides advantages in the correction of rotational and translational deformities.
Seide et al. reported on 16 cases treated with the Hexapod Ilizarov Fixator (LITOS GmbH & CO KG, Hamburg, Germany), and stressed the easy use of this fixator compared to the IRF when dealing with multidimensional deformity corrections. They found it favorable to use the hexapod to avoid difficult and time-consuming alterations of the IRF construct, as sometimes necessary when dealing with rotational deformities and secondary deformities during the lengthening procedure.
Manner et al. concluded that the TSF allowed for much higher precision in deformity correction compared to the IRF. In multidimensional deformity corrections in particular, the TSF showed clear advantages. This may derive from the TSF-specific combination of a hexapod fixator with the support of an Internet-based software program, enabling precise simultaneous multiplanar deformity corrections.
We investigated the correction for all planes with TSF simultaneous without many frame adjustments using preassembled frame technique and checked the rate of complications. We did not compare our result with a similar cohort of patients treated by classic Ilizarov frame, as our center depends on hexapod frame for the treatment of multiplanar proximal tibial deformities.
There were statistical significance accurate improvements between preoperative and postoperative parameters with using TSF. The patients in our study were very satisfied with the functional outcome, as indicated by the ASAMI score. All the patients indicated that they would undergo the same procedure. The overall clinical results suggest that patients' satisfaction was high with this procedure as long as there were no major complications. We agree that ours is not a very novel concept and that many authors have shown good results in tibial deformity correction as well. We agree that a comparison with deformity correction done using the older Ilizarov fixator would have made the article more useful.
| Conclusion|| |
Based on our results, we think that the TSF allows gradual correction with safe, simple, accurate procedure and in well-tolerated manner [Figure 3]. This is particularly useful when there are multiapical and multidirectional deformities or extensive LLD. Our results compare favorably with the published literature.
|Figure 3: Taylor spatial frame gradual correction of tibial varus deformity after attempt of acute correction during childhood showed in long lower-limb standing radiograph: (a) Right tibial varus deformity with residual hardware. (b) Taylor spatial frame correction completed. (c) Corrected tibial varus deformity after Taylor spatial frame had removed|
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Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4]