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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 52  |  Issue : 2  |  Page : 109-114

Evaluation of combined high tibial osteotomy and ‎ilizarov external fixator in the treatment of late-onset tibia ‎var


Department of Orthopedics Surgery, Benha University, Benha, Egypt

Date of Submission25-Sep-2016
Date of Acceptance02-Nov-2016
Date of Web Publication23-Nov-2017

Correspondence Address:
Mohammed A Meselhy
Orthopedic Department, Benha University, Kafer el gazar, Banha, Qalyubia 13511, Benha University
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/eoj.eoj_26_17

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  Abstract 

Purpose The purpose of this study was to evaluate the results of combined high tibial osteotomy in combination with gradual translation by ilizarov external fixator in the treatment of late-onset tibia vara.
Patients and methods A total of 23 patients with a diagnosis of late-onset tibia vara, 16 (69.6%) male and seven (30.4%) female, were included in this study; in 14 (60.9%) patients the deformity was on the right side, whereas in nine (39.1%) patients the deformity was on the left side. The etiology was Blount’s disease in all patients. The mean age of the patients was 23 years, ranging from 13 to 35 years, and the mean preoperative mechanical axis deviation was 84.39 mm. The mean preoperative medial posterior tibial angle was 61.17°, whereas the mean preoperative proximal posterior tibial angle was 63.09°.
Results The mean duration of external fixator application was 124.6 days, ranging from 90 to 170 days; the mean postoperative medial proximal tibial angle was 86.22°, with a P value of 0.001; the mean postoperative proximal posterior tibial angle was 79.74°, with a P value of 0.001; and the mean postoperative mechanical axis deviation was 10.7 mm, with a P value of 0.001. Residual deformity was present in three (13%) cases, ranging from 5 to 18°; no neurovascular complication was seen in both early and late postoperative periods; and limb length discrepancy was present in five (21.7%) cases, which was between 1.5 and 2.7 cm.
Conclusion High tibial osteotomy in combination with gradual correction by ilizarov is safe and effective in the management of late-onset tibia vara.

Keywords: genu varum, ilizarov, tibia vara, late onset


How to cite this article:
Meselhy MA. Evaluation of combined high tibial osteotomy and ‎ilizarov external fixator in the treatment of late-onset tibia ‎var. Egypt Orthop J 2017;52:109-14

How to cite this URL:
Meselhy MA. Evaluation of combined high tibial osteotomy and ‎ilizarov external fixator in the treatment of late-onset tibia ‎var. Egypt Orthop J [serial online] 2017 [cited 2017 Dec 11];52:109-14. Available from: http://www.eoj.eg.net/text.asp?2017/52/2/109/219093


  Introduction Top


Blount’s disease is one of the most common etiologies of pathological genu varum in children and adolescents [1].

Two types of Blount’s disease are known (early-onset and late-onset), according to whether the deformity appears before or after the age of 4 years [2].

Late-onset tibia vara always presents with a multiaxial tibial deformity, which is a combination of varus, procurvatum, and internal tibial torsion [1].

Although the way of management of tibia vara is still of controversy, corrective osteotomy is the still the best option for management [1].

Gradual correction with distraction osteogenesis has proven to be an effective means for achieving an accurate multiplanar deformity correction especially in patients with late-onset disease [2].

The aim of this study is to evaluate the outcome and the effectiveness of the circular external fixator with high tibial osteotomy in the management of late-onset tibia vara.


  Patients and methods Top


A total of 23 patients from Benha University Hospital with a diagnosis of late-onset tibia vara, 16 (69.6%) male and seven (30.4%) female, were included in this study; in 14 (60.9%) patients the deformity was on the right side, whereas in nine (39.1%) patients the deformity was on the left side ([Table 1]). The study was approaved by ethical committee of Banha University and were in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Table 1 Summary of patients and methods

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The etiology was Blount’s disease in all patients; all cases were treated by the author between April 2012 and September 2015, and the mean follow-up period was about 18 months.

Preoperative plane radiography − anteroposterior and lateral views − were performed for all patients ([Figure 1]); also, computed tomography scanogram was done for the majority of the cases ([Figure 2]). The analysis of the deformity was done using the methodology described by Paley [3].
Figure 1 Pre-operative x aysanteroposterior and lateral views.

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Figure 2 Pre-operative C.T.scanogram of both lower limbs.

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The mean±SD age of the patients was 23±6.07 years, ranging from 13 to 35 years; the mean±SD preoperative mechanical axis deviation was 84.39±13.5 mm; the mean±SD preoperative medial posterior tibial angle was 61.17±8.54°; and the mean±SD preoperative proximal posterior tibial angle was 63.09±10.23°([Figure 3]).
Figure 3 Preoperative clinical photos of varus deformity.

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Technique

Under regional spinal anesthesia, fibular osteotomy was done at its middle third, and then under image intensifier the proximal reference wire was inserted in the upper tibial epiphysis in skeletally immature patients parallel to the joint line, whereas in skeletally mature patients the proximal reference wire was inserted in the upper tibia 1 cm below and parallel to the joint line.

On the other hand, another distal reference wire was inserted at the distal tibia above and parallel to the ankle joint.

Assembly of proximal construct, which is one and half ring proximal to the intended site of osteotomy, where the distal construct composed of two complete rings located distal to the osteotomy site, provided that the two constructs corresponding to the two reference wires.

In late-onset tibia vara, the center of rotation and angulation is close to the articular surface, which makes performance of the osteotomy at the center of rotation and angulation impossible; also, it was harmful for skeletally immature patients as the growth plate lies close to the joint surface, and thus we perform oblique osteotomy just distal to the tibial tuberosity in all patients.

Acute correction of internal tibial torsion was done, and then we put a distractor on the medial side of the fixator and a unidirectional hinge anteriorly, at the center of the tibia above the site of the osteotomy that allows correction of varus deformity and decrease of translation during correction; this hinge is held by a long bolt with two nuts tightened on each other, to make the hinge move freely.

Follow-up

The patient was discharged from the hospital on the third day postoperatively after full neurological and vascular examination, and the patient was informed of pin site care; oral antibiotics such as cephalosporins, analgesics such as ibuprofen and diclofenac sodium, and antiedematous drugs such as α-chymotrypsin were prescribed to the patients.

Marking of the nuts by colored pen was done at the first visit, which is 7 days postoperatively in the outpatient clinic, and the patient was informed and taught how to move the nuts. Correction of the deformity was started 7–10 days postoperatively ([Figure 4] and [Figure 5]).
Figure 4 Early and latefollow up X-Rays.

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Figure 5 Early and late clinical photos ant the beginning and near full correction.

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The patients came every 2 weeks to the outpatient clinic to follow up the correction progress; radiography were performed in each visit, the pin site was examined, stability of the apparatus was assessed, and bowing of the distractor rod on the medial side was corrected.

The correction was continued until the deformity was corrected, and the mechanical axis became between 0 and 10° valgus; the correction was stopped and another connecting rod was inserted to connect the proximal and distal construct for stability.

The apparatus was removed after complete radiological and clinical signs of bone healing ([Figure 6] and [Figure 7]).
Figure 6 X rays after removal of circular external fixator.

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Figure 7 Clinical photos after full correction and fixator removal.

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Statistical analysis

The clinical data were recorded on a report form. These data were tabulated and analyzed using the computer program Statistical Package for the Social Sciences (SPSS) (SPSS, version 16; IBM SPSS Statistics, USA) to obtain the following.
  1. Descriptive data: descriptive statistics were calculated for the data in the form of:
    1. Mean±SD for quantitative data.
    2. Frequency and distribution for qualitative data.
  2. Analytical statistics: In the statistical comparison between the different groups, the significance of difference was tested using paired t test (used to compare the mean of two quantitative variables).


A P value less than 0.05 was considered statistically significant, a P value greater than 0.05 was considered statistically insignificant, and a P value less than 0.01 was considered highly significant in all analyses.


  Results Top


The mean±SD duration of external fixator application was 124.6±21.7 days, ranging from 90–170 days; the mean±SD postoperative medial proximal tibial angle was 86.22±3.66° and a P value of 0.001; the mean±SD postoperative proximal posterior tibial angle was 79.74±2.09° and a P value of 0.001; and the mean±SD postoperative mechanical axis deviation was 10.7±7.6 mm and a P value of 0.001.

Pain was present in all cases especially at the beginning of correction, it was located at the medial side of the tibia mainly because of distraction, and it was controlled by mild analgesics; pin tract infection was present in about 20% of the cases, all of superficial type, mainly at the proximal medial wires because of distraction overload, and it was controlled by administration of oral antibiotics such as cephalosporins for 10 days. Knee range of motion was encouraged during fixator application until 90° flexion, and after removal of the fixator and during the follow-up period all patients had complete knee range of motion.

Residual deformity was present in three (13%) cases, ranging from 5 to 18°; all cases had no neurovascular complication in both early and late postoperative periods. Limb length discrepancy was present in five (21.7%) cases, and it was between 1.5 and 2.7 cm; it had no impact upon the patient gait ([Table 2]).
Table 2 Summary of results

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Psychological support for the patient was needed during the whole period of fixator application ([Table 3]).
Table 3 Summary of current study and comparison of other similar studies

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  Discussion Top


Because of lower limb malalignment, pain and knee osteoarthritis are the end results of untreated Blount’s disease [1].

Proximal tibial osteotomies and acute correction of the deformity are performed for the management of infantile tibia vara, but it was noted that it is less effective in treating late-onset tibia vara, but many complications such as neurological affection and compartmental syndrome could occur with acute deformity correction [1],[2],[4],[5].

Gradual correction with distraction osteogenesis appears to be safe and effective in the management of multiaxial deformity [4],[5],[6],[7],[8].

Amer and Khanfour [1] advocated that the results of gradual angulation and translation by ilizarov external fixator in the management of 20 tibiae of late-onset tibia vara were satisfactory.

Coogan et al. [5] reviewed eight patients with 12 tibias of adolescent tibia vara who were treated by proximal tibial osteotomy and gradual correction by ilizarov circular fixator, and the results were encouraging as the mean varus angle decreased from 18° preoperatively to 2.5° postoperatively.

Stanitski et al. [8] reviewed 17 patients with 25 tibias, managed by high tibial osteotomy and gradual correction by ilizarov external fixator; the varus angle decreased from 27° preoperatively to 5° of normal axis postoperatively.

Alekberov et al. [4] reported the use of ilizarov external fixator in 45 patients, 69 tibias; correction of the deformity was achieved in all patients, except in six patients.

On the other hand, Oto et al. [9] managed six limbs of adolescent tibia vara by lateral plate hemiepiphysiodesis of the proximal tibia, and he concluded that the use of tension band plate hemiepiphysiodesis (eight plate) is not recommended in the treatment of severe adolescent Blount’s disease.


  Conclusion Top


From our study, we concluded that correction of late onset of tibia vara by high tibial osteotomy in combination with gradual correction with ilizarov external fixator is a reliable and effective method for the management of such a type of deformity.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Amer AR, Khanfour AA. Evaluation of treatment of late onset tibia vara using gradual angulation translation high tibial osteotomy. Acta Orthop Belg 2010; 76:360–366.  Back to cited text no. 1
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2.
Sabharwal S. Blount disease. J Bone Joint Surg Am 2009; 91:1758–1776.  Back to cited text no. 2
    
3.
Paley D. Principals of deformity correction. New York: Springer Verlag 2002.  Back to cited text no. 3
    
4.
Alekberov C, Shevtsov VI, Karatosun V, Günal I, Alici E. Treatment of tibia vara by the ilizarov method. Clin Orthop Relat Res 2003; 409:199–208.  Back to cited text no. 4
    
5.
Coogan PG, Fox JA, Fitch RD. Treatment of adolescent Blount disease with the circular external fixation device and distraction osteogenesis. J Pediatr Orthop 1996; 16:450–454.  Back to cited text no. 5
[PUBMED]    
6.
de Pablos J, Azcárate J, Barrios C. Progressive opening-wedge osteotomy for angular long-bone deformities in adolescents. J Bone Joint Surg Br 1995; 77:387–391.  Back to cited text no. 6
    
7.
Gordon JE, Heidenreich FP, Carpenter CJ, Kelly-Hahn J, Schoenecker PL. Comprehensive treatment of late-onset tibia vara. J Bone Joint Surg Am 2005; 87:1561–1570.  Back to cited text no. 7
    
8.
Stanitski DF, Dahl M, Louie K, Grayhack J. Management of late-onset tibia vara in the obese patient by using circular external fixation. J Pediatr Orthop 1997; 17:691–694.  Back to cited text no. 8
[PUBMED]    
9.
Oto M, Yilmaz G, Bowen JR, Thacker M, Kruse R. Adolescent Blount disease in obese children treated by eight plate hemiepiphysiodesis. Eklem Hastalik Cerrahisi 2012; 23:20–24.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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