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PubMedDate not supplied

Congenital pseudarthrosis of the tibia associated with neurofibromatosis-1: treatment with Ilizarov's device.

We reexamined 21 patients with congenital pseudarthrosis of the leg (congenital pseudoarthrosis of the tibia; CPT) associated with neurofibromatosis-1 (NF-1), > or =2 years after the termination of treatment, for a statistical study of the results obtained by using Ilizarov's external fixator. Of the 21 tibias operated on, 17 consolidated after the first treatment, whereas four did not. Of the 17 consolidated tibias, four refractured and were retreated by using a variety of methods. Only one healed. At follow-up, which occurred > or =2 years after the removal of the fixator, the results were nine consolidations without deformities or with shortening <2 cm, five consolidations with axial deviation, and seven nonconsolidations. The statistically significant results were that (a) patients who were aged 5 years or older at operation had better results, and (b) the assembly II (resection of CPT stumps and their short-term compression possibly associated with corticotomy or epiphyseal distraction to correct limb discrepancy) gave better final results compared with the other device assemblies. We conclude that treatment with Ilizarov's fixator allows (a) a good percentage of healing over time (66.7%), especially in cases of normotrophic and cystic CPT; (b) further operations with or without the fixator to correct secondary or residual axial deviation; and (c) correction of limb discrepancy. This treatment avoids risking injury to the healthy contralateral leg. Additionally, for treatments that do not achieve satisfactory results, other treatment methods are not excluded. The CPT still remains a difficult problem for the orthopedic surgeon to solve.

Adolescent↗

PubMedDate not supplied

Management of late-onset tibia vara in the obese patient by using circular external fixation.

Previously published series of surgery for late-onset tibia vara reported a significant number of complications and fair or poor results. Obesity in many of these patients makes surgical intervention an even more daunting prospect. Circular external fixation is applicable to almost any limb size and allows weight bearing as tolerated, with gradual adjustment of alignment. Twenty-five tibiae in 17 patients who exceeded their ideal body weight by > or =50% underwent correction of late-onset tibia vara with the Ilizarov technique. Average age at surgery was 11 years 7 months (range, 7 years 8 months to 15 years 11 months). Mean varus deformity was 27 degrees (range, 10-55 degrees). Treatment time averaged 12 weeks in patients without lengthening and 16.9 weeks in those requiring lengthening (mean, 3.5 cm). All patients achieved alignment within 5 degrees of normal. Complications included one delayed union, premature consolidation in one, and two residual limb-length inequalities. There were no cases of osteomyelitis, compartment syndrome, or nerve palsy. These results are a significant improvement over reports of traditional methods in these difficult patients.

Adolescent↗

PubMed1993

The use of resonant frequency measurements for the noninvasive assessment of mechanical stiffness of the healing tibia.

A study was performed to assess the usefulness of measuring the resonant frequency of vibration of the tibia as a determinant of its flexural rigidity in fracture healing. The measurement system consisted of an electronic tapper that struck the anteromedial distal surface of the tibia and an accelerometer, held against the proximal surface, that received the response. Custom software displayed the frequency spectrum from which the first mode bending frequency of the tibia could be pinpointed. We have found that resonant frequency was highly correlated to the log of tibial flexural rigidity, with an exponent of 0.582 (r2 = 0.815). In human volunteers, a series of four tests at monthly intervals showed a reproducibility of approximately 3% (95% confidence interval) with no significant variability between right and left legs. In 14 patients with healing tibial fractures, resonant frequency ratio (healing/injured leg) was correlated to time ratio (time of test/time healed) by a second-order polynomial fit (r2 = 0.58).

Adolescent↗

PubMed1995

Toxic effects of wound irrigation solutions on cultured tibiae and osteoblasts.

Irrigating wounds with solutions of antiseptic or antibiotic agents is routinely performed in orthopaedic surgery to reduce the incidence of microbial infection. The effects of these agents on healthy bone tissue is unknown. Three commonly employed antiseptic agents (hydrogen peroxide, Betadine solution, Betadine scrub) and one antibiotic solution (bacitracin) were tested on tibiae and osteoblasts isolated from embryonic chicks. Osteoblast function was evaluated by glycolytic energy metabolism (lactate production), cell number (DNA content), and collagen synthesis ([3H]proline hydroxylation). Two series of experiments were performed. To study concentration-related effects, tibiae or cells were exposed to a range of concentrations of the agents (diluted in saline, 0.9% NaCl) for 2 min, rinsed with saline, and incubated for 24 h in medium containing [3H]proline. For the recovery study, the cells were exposed to an effective, but nonlethal, concentration of the antiseptic agents for 2 min, rinsed with saline, and the incubation was continued in complete culture medium for 6, 12, 24, 48, or 72 h with [3H]proline added for the final 6 h. Solutions containing the antiseptic agents were cytotoxic to both bones and cells at concentrations well below those used clinically in irrigation solutions. In contrast, bacitracin at the concentrations tested was safe for osteoblasts and tibiae. These results suggest that the use of irrigation solutions containing H2O2, Betadine solution, or Betadine scrub on exposed bone tissue should be considered with caution.

Animals↗

PubMed1993

The surgical anatomy of the principal nutrient vessel of the tibia.

Large segmental long-bone defects deserve consideration for reconstruction by vascularized, straight, high-density cortical bone grafts of comparable diameter. If available, the tibial diaphysis would be an option superior to the fibula, since the latter has known limitations when a large size discrepancy exists at the recipient site. However, the former choice is unrealistic except in the most unusual circumstances, since the tibia is a nonexpandable bone required for weight bearing. In anticipation of just such a unique opportunity, we have investigated the surgical anatomy of the principal nutrient vessel of the shaft of the tibia in 53 fresh lower limb specimens. Classical descriptions of the pertinent vascular anatomy of the tibial shaft are inadequate, since the origin of its principal nutrient vessel actually may be from the popliteal bifurcation or anterior or posterior tibial vessels. In every dissection at least a single artery and vein of large caliber (both exceeding 1.5 mm in diameter in 85 percent of cadavers) were discovered entering a nutrient foramen, usually at the upper third of the tibia. Lead oxide injection studies of the nutrient artery alone in nine cadavers demonstrated no contiguous muscle or cutaneous communications. The large size of these nutrient vessels would simplify ipsilateral pedicled transfers of an autologous tibial shaft as well as facilitate microanastomoses for its distant transfer to other humeral, femoral, or contralateral tibial defects as in a salvage replantation. Once immunologic barriers have been conquered, these data should have even greater practical clinical significance for the use of vascularized tibial allografts for substitution in lieu of autogenous fibula or other conventional bone donor sites.

Bone Transplantation↗

PubMed2002

Neurovascular calcaneo-cutaneus pedicle graft for stump capping in congenital pseudarthrosis of the tibia: preliminary report of a new technique.

The operative treatment of congenital pseudarthrosis of the tibia, especially when associated with neurofibromatosis type I (Recklinghausen's disease), often leads to failure. Frequently, regardless of the type of deformity, multiple operative procedures end in the amputation of the affected limb. Soft tissue coverage of the amputation stump may confront the surgeon with new problems. Secondary perforation of the soft tissue envelope of the stump owing to terminal overgrowth is not a rare complication. A new technique of stump capping is demonstrated in a 10-year-old boy and a 14-year old girl, both with congenital pseudarthrosis of the tibia of the right leg and neurofibromatosis. During this procedure, a radical resection of the pseudarthrotic tissue is performed although all neurovascular structures supplying the calcaneus are carefully maintained (Arteria, vena et nervus tibialis posterior et peronealis). Subsequently, the tibia and fibula are inserted into the calcaneus. This construct is stabilized with two crossed Kirschner wires. Afterwards, the skin of the lower limb and the hindfoot are sutured together covering the neurovascular bundles, which are arranged in a loop-like fashion. The documented active range of motion was similar to that of the unaffected knee joint. Twelve weeks after operation in both patients, full weight bearing was achieved with a lower-leg prosthesis. This new procedure leads to a durable, full weight-bearing stump with complete sensitive innervation without the risk of future soft tissue perforation caused by the growing bone. The stump fits with an end-bearing lower-leg prosthesis.

Adolescent↗

PubMed2003

Treatment of metastatic disease of the tibia.

Metastatic lesions to bone outnumber primary bone malignancies. Osseous metastases to the tibia tend to be less common than osseous metastases to other long bones. This study examined the treatment options for a population of patients with metastatic disease to the tibia, with surgical intervention being the cornerstone of treatment for the osseous lesion. A multicenter study had 592 patients with metastatic disease to the bone, with 26 lesions occurring in the tibia (4.4%) during a 13-year period. No patient had concurrent metastases distal to the elbow. After confirmation of metastatic disease, treatment consisted of surgical intervention in all patients, including plate osteosynthesis, intramedullary rodding and cementation, endoprosthetic replacement, and in most patients, postoperative radiation therapy. In 96% of patients, the reconstruction outlasted their life expectancy. All patients were satisfied with their reconstruction. Four complications were encountered in the postoperative period, all requiring additional surgery. Aggressive treatment of osseous metastasis is justified in patients with metastatic disease despite a limited life expectancy. Intervention by an orthopaedic oncologist may result in fewer reconstructive failures. Surgical intervention contributes to an improved quality of life and limb function, ease of nursing care, and may help in maintaining patient independence.

Adult↗

PubMed2006

Aseptic loosening is uncommon with uncemented proximal tibia tumor prostheses.

UNLABELLED: Aseptic loosening is a frequent cause of failure of cemented proximal tibia tumor endoprostheses. Uncemented prostheses may lessen this risk. We identified complications including aseptic loosening that affected prosthetic survival, limb survival and functional outcome for 44 consecutive patients after sarcoma resection from the proximal tibia and uncemented endoprosthetic reconstruction. At a mean final followup of 60 months (range, 9-152 months), there were no cases of aseptic loosening. Twelve (27%) patients suffered 14 complications leading to prosthetic failure due to infection (n = 7), stem fracture (n = 2), rotational instability (n = 1), vascular compromise (n = 2) and local tumor relapse (n = 2). However, limb salvage was successful in 37 of 44 (84%) patients. Functional assessment for 35 patients revealed a mean Toronto Extremity Salvage Score of 77/100 (range, 33-98) and Musculoskeletal Tumor Society 1987 and 1993 scores of 25/35 (range, 13-31) and 75/100 (range, 33-97), respectively. Mean knee joint flexion was 91 degrees (range, 0-110 degrees ) and knee extension lag was 6 degrees (range, 0-30 degrees ). Three patients with knee extensor complications had inferior functional outcomes. Aseptic loosening is uncommon with uncemented proximal tibia reconstruction, but decreasing other complications at this location remains challenging. LEVEL OF EVIDENCE: Therapeutic study, level IV-1 (case series).

Adolescent↗

PubMedDate not supplied

A new double elevating osteotomy in management of severe neglected infantile tibia vara using the Ilizarov technique.

Neglected infantile Tibia Vara is a very challenging clinical problem with many technical problems including distorted joint line secondary to the medial tibial plateau depression, obesity leading to difficulty in exposure, performing osteotomies and difficulty in osteotomy fixation. The aim of this study is to evaluate the clinical and radiological results of treatment of severe neglected infantile Tibia Vara using a new osteotomy to elevate the depressed medial tibial plateau in conjunction with the Ilizarov technique. Seven tibias in five patients were included in this study. These were all Stage V and VI according to Langenskiold and Riska classification. The average age at surgery was 11.6 years (ranging from 8 to 15), and the average follow-up was 6.2 years (ranging from 3 to 10). A new double osteotomy technique was used to elevate the depressed medial tibial plateau and correct the varus deformity. Correction was done gradually using the Ilizarov Frame. The results were assessed clinically and radiologically. The femoral shaft -- tibial shaft angle improved from an average of 36 degrees of varus preoperatively to 4 degrees of varus. The femoral condyle-tibial shaft angle improved from an average of 58 degrees to 83 degrees. The angle of depressed medial tibial plateau improved from an average of 53 degrees to 10 degrees. We believe that our new double elevating osteotomy in conjunction with Ilizarov technique is an excellent modality for patients with stage V and VI according to the Langenskiold and Riska classification. The advantages of this technique include correction of the deformity with simultaneous correction of the joint architecture, immediate weight bearing, and avoidance of excessive dissection needed for internal fixation.

Adolescent↗

PubMedDate not supplied

Medial epiphysiolysis in severe infantile tibia vara.

Recurrent varus deformity and shortening frequently result following valgus osteotomy alone for advanced stage infantile tibia vara (ITV), due to the proximal medial physeal dysfunction which resembles a complete growth arrest in Langenskiöld grade III or greater lesions. Epiphysiolysis is a possible treatment alternative which, if successful, can restore symmetric proximal tibial growth and obviate the need for additional complex treatments to address recurrent angular deformity and limb length inequality. We reviewed 24 patients, ages 5-10 years, with 27 affected tibiae, who underwent epiphysiolysis of the proximal medial tibia combined with valgus osteotomy. The procedure was >80% successful in restoring growth and avoiding varus recurrence in children <7 years old. Patients >age 7, patients with relative undercorrection of their mechanical axis at the time of surgery, and patients with previous failed surgical treatment were more likely not to benefit from epiphysiolysis, and consequently alternative methods may be more appropriate.

Bone Cements↗

PubMed2003

Ultrasound velocity through the cortex of phalanges, radius, and tibia in normal and osteoporotic postmenopausal women using a new multisite quantitative ultrasound device.

RATIONALE AND OBJECTIVES: To assess a new multisite quantitative ultrasound (QUS) device (Sunlight Omnisense 7000 S) suitable for the measurement of speed of sound (SOS) in the phalanges, radius, and tibia. METHODS: The study group consisted of 270 healthy Caucasian postmenopausal patients (mean age: 60.0 +/- 7.6 years) and 53 Caucasian postmenopausal patients (mean age: 67.2 +/- 7.4 years) with osteoporotic fractures. Measurements of SOS and bone mineral density (BMD) were carried out in all subjects. RESULTS: Intraobserver in vivo short-term precision was on average 0.76% for the radius, 0.47% for the tibia, and 1.54% for the phalanges. The interobserver precision ranged from 0.77% to 2.39%. Measurements of SOS at the 3 skeletal sites were significantly correlated (r = 0.28-0.44; P < 0.001). Significant correlations were found between SOS at all sites and BMD (r = 0.21-0.41; P < 0.001). The odds ratio for fracture prediction for SOS was 1.47 for tibia, 1.69 for radius, and 2.69 for phalanx. The corresponding odds ratios for BMD at the lumbar spine, femoral neck, and total hip ranged from 2.08 to 3.26. The area under the receiver operating characteristic curve ranged from 0.611 to 0.741 for SOS measurements and from 0.745 to 0.797 for BMD measurements. CONCLUSIONS: The Omnisense multisite QUS device exhibits reproducible performance. Among the QUS variables, the phalangeal SOS provides the best discrimination of fracture patients.

Aged↗

PubMed2004

Long-term results of multiple-stage treatment for posttraumatic osteomyelitis of the tibia.

BACKGROUND: The treatment of posttraumatic osteomyelitis of the tibia requires meticulous debridement and adequate soft tissue coverage. At our institution, we perform a staged procedure consisting of surgical debridement followed by muscle coverage. If necessary, implantation of a cancellous iliac bone graft was always performed as a three-stage treatment. METHODS: We performed a retrospective analysis of 47 patients treated for posttraumatic osteomyelitis of the tibia between 1987 and 1998. RESULTS: Twenty-two patients originally had a Gustilo grade III fracture, 21 patients had a Gustilo grade I or II or closed fracture, the Gustilo grade was not known for 2 patients, and 2 patients had no fracture. Using the Cierny-Mader classification, most patients had a localized osteomyelitis. To cover the debrided area, 20 pedicled muscle transfers and 28 microvascular free flaps were used; one patient had two localizations of osteomyelitis (both proximal and distal) and received two muscle flaps. Flap failure was 8% and was successfully treated by additional flap coverage in two cases; one was closed by a split skin graft and one was closed by secundum. Twenty-six patients received a cancellous bone graft. During an average follow-up of 94 months, 9% had a recurrence of osteomyelitis for which additional surgical interventions were necessary. Finally, all the infections were eventually cured. CONCLUSION: Our staged surgery proved to be an excellent method of treating osteomyelitis after open or closed fractures of the tibia.

Adolescent↗

PubMed1998

Congenital deficiency of the tibia: a report on 22 cases.

Congenital deficiency of the tibia (tibial hemimelia, aplasia, or dysplasia) is very rare, with an incidence of approximately 1 per 1 million live births. The disorder usually is accompanied by other congenital anomalies on the same limb or other parts of the body. A report is made of 22 limbs observed in 18 patients from 1970 to 1987 at San Juan de Dios Hospital in Caracas, Venezuela, with more than a 5-year follow-up. The report includes 11 girls and 7 boys, with observations of 11 left and 11 right tibiae. Familial antecedents were present in four patients: brother and sister and two brothers. According to the classification by Jones, Barnes, and Lloyd-Roberts, there were nine cases of type Ia, four of type Ib, three of type II, two of type III, and four of type IV. The foot of the affected limb was normal in only 12 cases. Treatment, always surgical, consisted of T/K amputation in 10 cases of types Ia and Ib, fibula pro tibia and B/K amputation in 1 case of type II, Syme amputations in 2 cases of type III, and astragalectomy and closure of diastasis in 4 cases of type IV deformity. Patients in five cases refused treatment. The sooner the amputation is performed, the easier and faster the rehabilitation and adaptation to the prosthesis. An early amputation is accepted by the child as a "congenital amputation."

Abnormalities, Multiple↗

PubMed1984

Late-onset tibia vara: a comparative analysis.

We reviewed the clinical and radiographic characteristics and response to treatment of 11 children (16 knees) with idiopathic late-onset tibia vara (adolescent Blount's disease) followed for an average of 5.7 years (range, 3-10 years). The clinical characteristics were very consistent: black race; 2:1 male predominance; normal height; marked obesity; knee pain as the primary presenting complaint; and slowly progressive genu varum deformity that averaged 19 degrees (range, 10-45 degrees). Radiographically, the epiphyses were wedge shaped owing to medial flattening, the physes were irregular in thickness, and there was minimal, if any increased prominence of the proximal medial metaphysis. Nineteen proximal tibial valgus and diaphyseal fibula osteotomies were performed on 15 knees. There was a 50% rate of recurrent deformity in males with clinical onset at less than or equal to 10 years of age. Females and older males had no recurrences. Histopathologic studies of the physis performed on one case demonstrated abnormal cellular islands of hyaline cartilage, small foci of necrotic cartilage, prominent intertrabecular vascularity, and premature medial physeal closure. These data support late-onset tibia vara as a distinct entity closely related to the infantile form. They also suggest three specific forms of tibia vara based on the age at clinical onset: infantile (0-3 years), juvenile (4-10 years), and true adolescent (11 years or older). The juvenile group is characterized by a high rate of recurrence following surgical correction, whereas the others are not.

Adolescent↗

PubMedDate not supplied

The etiology of valgus angulation after metaphyseal fractures of the tibia in children.

We conducted a retrospective study of proximal metaphyseal fractures of the tibia in children who developed valgus deformities. We reviewed the cases in an effort to determine the most likely etiology of post-fracture tibia valga, which occurs despite careful treatment and follow-up. We reviewed seven major theories presented in the literature regarding the etiology of this problem. Our conclusion was that all the theories were not prerequisites for the development of valgus angulation, but rather may be secondary mechanisms. We suggest that the most likely primary mechanism is an increased vascular response causing an asymmetric growth stimulation of the medial metaphysis of the proximal tibia.

Child↗

PubMedDate not supplied

Etiology of late-onset tibia vara: is varus alignment a prerequisite?

One widely held theory on the pathogenesis of adolescent late-onset tibia vara is that obesity coupled with mild preexisting varus alignment produces forces sufficient to retard growth in the medial portion of the proximal tibial physis and initiates the development of the condition. Two cases are presented in which neutral mechanical alignment was clearly documented in an extremity that subsequently developed adolescent late-onset tibia vara within 19 months. We conclude that in at least some cases, preexisting varus alignment is not a prerequisite for the development of adolescent late-onset tibia vara.

Adolescent↗

PubMed1984

Absent tibiae, triphalangeal thumbs and polydactyly: description of a family and prenatal diagnosis.

A family with absent tibiae, triphalangeal thumbs and polydactyly is described. Bilateral absence of tibiae is the most severe manifestation of this syndrome. The pedigree of this family suggests an autosomal dominant inheritance with variable expression. Prenatal diagnosis was made at 20.5 weeks of pregnancy. Fetal radiographs showed the presence of both tibiae; this finding was confirmed at birth.

Abnormalities, Multiple↗

PubMedDate not supplied

Evaluation of the tibia as a source of autogenous cancellous bone in the horse.

A 1 cm defect was created in the proximal medial cortex of 12 tibiae, cancellous bone was removed from the site, and the bones were fractured by loading in torsion. The fractures did not occur through the donor sites and the fracture patterns and loads to fracture were similar for the treated tibiae and their untreated mates. Cancellous bone was harvested from the proximal medial aspect of both tibiae in nine adult horses. The soft tissue wounds were monitored for more than 10 days in seven horses and healing of the osseous defects was evaluated radiographically at regular intervals to month 6 in two horses. The site provided convenient access with the horses in lateral or dorsal recumbency, the anatomic landmarks were reliable, and the surgical procedure was simple and short. Complications occurred in only three incisions.

Animals↗