Journal of Postgraduate Medicine Medknow Publications and Staff Society of Seth GS Medical College and KEM Hospital, Mumbai, India ISSN: 0022-3859 EISSN: 0972-2823 Vol. 49, Num. 3, 2003, pp. 249-251

Journal of Postgraduate Medicine, Vol. 49, No. 3, July-Sept, 2003, pp. 249-251

Case Report

Distal Tibial Transphyseal Osteotomy for Ankle Varus Deformity in an Operated Case of Clubfoot

Trivedi VN, Bacha AR

Department of Paediatric Orthopaedics, B. J. Wadia Hospital for Children, Parel, Mumbai - 400012, India.
Correspondence Address: Department of Pediatric Orthopaedics, B.J.Wadia Hospital For Children, drvikastrivedi@yahoo.co.in

ABSTRACT

Ankle varus deformity arises due to a number of congenital and acquired causes leading to significant functional debility in the patients, especially children. We report a less commonly used technique, the transphyseal osteotomy of distal tibia, for the correction of varus deformity of the ankle joint in a thirteen-year-old boy. Full correction of the deformity could be achieved using this technique. The patient is fully functional with normal gait. No recurrence was detected at follow-up visit 26 months later.

Keywords: Varus deformity, Ankle joint, Transphyseal osteotomy

Varus deformity at the ankle joint can be caused by a traumatic or infectious insult to the distal tibial physis.[4] It is also a common clinical entity in patients with myelomeningocele, poliomyelitis and cerebral palsy. At times it follows corrective surgery for clubfoot. Over the years, several different surgical techniques have been described for the correction of these deformities. These include stapling of the distal tibial physis,[3] fibular Achilles tenodesis,[9] tibial supra-malleolar osteotomy[1],[8] and a distal tibial wave osteotomy.[5] We report in this paper, a less commonly used, but highly effective technique, the transphyseal osteotomy of the distal tibial physis for correction of the varus deformity at the ankle joint.

CASE HISTORY

A 13-year-old boy with bilateral idiopathic clubfoot underwent postero-medial release surgery at the age of 6 months. He had a local infection in the postoperative period, which settled within a month. He was then given splints and boots till the age of 7 years. At the age of 13 years he presented to us with pain at the antero-lateral aspect of the ankle joint, an ill-fitting right shoe and a heel in varus malalignment [Figure-1]. On radiographic analysis, standing antero-posterior view of both the ankle joints showed a disturbed medial tibial physis with a varus deformity of 20 degrees at the right ankle joint [Figure-2]. The lateral view was normal and there was no sagittal plane deformity. A medial opening wedge transphyseal osteotomy was then performed [Figure-3].

The patient was kept in the supine position with a sand bag under the opposite buttock. The affected ankle, leg and contralateral iliac crest were prepared and draped adequately. Under tourniquet control, a medial incision centred over the medial malleolus, extending just distal to the tip of the medial malleolus to about 10 cm proximally on the medial aspect of the tibia was taken.

The periosteum was divided sharply and the distal tibia including the epiphysis was subperiosteally dissected anteriorly and posteriorly. A Kirshner wire was inserted in the proximal part of the tibia perpendicular to it and a second Kirshner wire was inserted just below the physis parallel to the ankle joint at a 20 degrees angle from the horizontal (angle of the varus deformity). Check radiograms were done and the position of the wires was confirmed and accepted. A pilot hole was drilled up through the medial malleolus to a point just proximal to the physis. After this an osteotomy was performed with a power saw through the physis leaving the lateral cortex intact. The osteotomy site was spread open with a spinal lamina spreader until the second Kirshner wire was horizontal, and the desired correction achieved. This was confirmed with an intraoperative radiograph. The osteotomy was then held open by a freshly harvested appropriately sized (3 cm x 2 cm) wedge-shaped tricortical iliac crest graft. The metaphysis was drilled and a malleolar screw was passed through the previously made pilot hole and with tightening, it compressed the graft at the osteotomy site. After wound closure, a below knee cast was applied.

The sutures were removed 2 weeks later and non-weight bearing status was continued for 4 more weeks. As the radiographs showed good healing at that time, full weight-bearing was allowed in a walking below-knee cast for 2 months and then full resumption of normal activities were allowed. At the last follow-up visit (26 months post-surgery), the patient had no symptoms, deformity or functional derangement [Figure-4]. He had a normal gait too.

DISCUSSION

Ankle varus or valgus deformities can cause significant functional problems for patients. Pain, disturbance of normal gait, difficulties with shoe or brace fit and skin problems are the usual consequences. Several different corrective techniques have been described in the literature.[1],[3],[5],[8],[9]

Supra-malleolar osteotomy is popular method for the correction of varus or valgus ankle deformity. Using this technique, a study was carried out by Sharrad and Webb,[8] which consisted of two varus ankle and fourteen valgus ankle deformities in patients with myelomeningocele. Both the varus ankle deformities required a second surgery for relapses and the author suggested a concomitant fibular osteotomy for correction.

Kumar[5] used a new supra-malleolar osteotomy technique, a wave osteotomy to prevent an unappealing step-off of the medial cortex of the distal tibia and shortening, in valgus deformities. This osteotomy addresses and solves many of the shortcomings of supra-malleolar osteotomy, along with saving the distal tibial physis.

Transphyseal osteotomy[6] is more effective because it provides correction close to the site of the deformity. Hence, maximum correction is achieved without creating a secondary deformity. It eliminates further progression of the deformity owing to growth abnormalities of the affected physis, achieves good and rapid healing by doing the osteotomy entirely in the metaphyseal bone, affords simple but rigid internal fixation in compression and does not require a concomitant fibular osteotomy [Table-1].

The major concern was the potential effect of the osteotomy on the limb growth with subsequent development of a limb length discrepancy. Beals and Skyhar[2] and Makin[7] have noted a peculiar physeal role reversal pattern in tibia and fibula with proximal physis dominance after a certain age in lower limb growth. Our patient was 13 years old at the time of surgery and at 15 years of age, he has no leg length discrepancy, is fully functional with no recurrence [Figure-4].

Our report compares favourably with other reports in the literature as described for correction of varus deformity at the ankle joint [Table-2]. Our indication for the osteotomy was a varus deformity at the ankle joint arising as a complication of a corrective surgery done for idiopathic clubfoot 12 years back whereas Lubicky et al[6] have employed it for the correction of deformities mainly in neuromuscular patients. Therefore, through our report we would like to highlight that an old operated case of idiopathic clubfoot may present with secondary varus deformity at the ankle joint; a careful initial corrective surgery and follow-up is necessary in these children.

This osteotomy is an effective treatment alternative for significant varus deformity at the ankle joint that requires acute correction in children above 9 years of age.

REFERENCES

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