Unipolar allograft reconstruction for post-traumatic avascular necrosis of the distal tibia: A review of the literature, technique, and case series

Joint-Preserving Osteotomy of the Lateral Tibial Plafond for Posttraumatic Osteonecrosis: A Prospective Cohort Study

BACKGROUND

Posttraumatic osteonecrosis (ON) of the lateral distal tibia is a rare but severe complication of malleolar fractures. Treatment options include ankle fusion, arthroplasty, osteotomy, and drilling but clinical data on outcomes are limited to single case reports. The aim of this study was to prospectively evaluate the outcome following joint-preserving reconstruction.

METHODS

Over a 10-year period, 10 patients (8 females and 2 males, average age 36 years; range, 27-68 years) with posttraumatic ON were treated with intra-articular osteotomy of the distal tibia and bone grafting. All patients initially sustained a closed pronation injury, 7 with initial tibiotalar subluxation. Chronic syndesmotic instability following initial treatment was present in 4 patients and 5 were smokers. All patients were followed for a median of 68 (range, 12-103) months, 7 returned in person for clinical and radiographic follow-up.

RESULTS

No immediate postoperative complications were seen. Secondary ankle fusion was necessary in 1 case (10%) because of progressive osteoarthritis. At the time of follow-up, anterior ankle arthritis leading to impingement and requiring cheilectomy was noted in 4 cases, partial graft necrosis, and secondary syndesmotic instability requiring revision surgery was seen in 1 case each. Compared with the preoperative values, significant improvement in the Olerud-Molander Ankle Score (P = .012), EuroQuol-5 Score (P = .008), and Foot Function Index (FFI-D pain, P = .028; FFI-D restriction, P = .038) was seen. Average range of motion at the ankle was 45 degrees.

CONCLUSION

In our limited series of patients with posttraumatic ON of the lateral distal tibia, we found that joint-preserving reconstruction using an intra-articular distal tibial osteotomy with autologous bone grafting usually provided significant functional improvement and pain relief. In our cohort secondary fusions by a median 5.5-year follow-up were rare, but secondary, joint-sparing surgeries were common.

LEVEL OF EVIDENCE

Level III, prospective study.

Distal Tibial Reconstruction in the Management of Primary Bone Tumors in Children and Adolescents

BACKGROUND

Distal tibial primary bone tumors are rare, and options for limb salvage surgery are limited and challenging. Importantly, local control has shown to be crucial and necessary for cure, and radical surgery is one of the most important components of therapy for some bone sarcomas. We investigated the feasibility and functional and oncological outcomes of distal tibial reconstruction using endoprosthesis in children with malignant bone tumors.

METHODS

Fourteen patients (median age 13.6 years) with primary bone tumors (4 Ewing sarcoma [ES], 10 osteosarcoma) of the distal tibiae were treated during 2013-2019. All patients had reconstruction using a modular (13 patients) or expandable custom-made titanium bone replacement system (1 patient). All patients received chemotherapy before and after surgery.

RESULTS

Twelve patients (85.7%) are alive with a median follow-up 20 months from diagnosis. Five-year estimates of event-free survival and overall survival were 60.6% and 76.4%, respectively. Three patients had postoperative complications requiring second surgery. Maximum dorsiflexion and plantar flexion of the foot were 20 degrees (range 0-20 degrees) and 20 degrees (range 5-20 degrees), respectively.

CONCLUSION

For select distal tibial sarcomas, after neoadjuvant chemotherapy pretreatment and radical resection, reconstruction using an endoprosthesis as a radical surgery provides an option was associated with a low rate of short-term local complications and relatively good early function.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Reconstructive Challenges of Distal Tibia Bone Tumors: Extracorporeally Irradiated Autograft Combined with a Nonvascularized Autograft Fibula for Superior Reconstruction and Functional Outcomes When Compared to Ipsilateral Pedicled Fibula Transfer Alone

Introduction

Traditionally, centralization of the fibula with fusion across the tibiotalar joint has been used to reconstruct distal tibial defects. Although effective, it requires long periods of protected weight-bearing. The fibula or the fixation often fails before fibular hypertrophy necessitating multiple additional surgeries. A method of using ECRT with the available ipsilateral fibula (nonvascularized) to reconstruct the distal tibia defect with the aim of early return to weight-bearing was evolved. This paper documents our early experience. Patients and Methods. Four patients; with the diagnosis of osteosarcoma in 3 patients and recurrent giant cell tumor of the bone in 1 patient, underwent resection of the distal tibia for tumors between 2017 and 2019. Extracorporeally irradiated (50 Gy) distal tibia along with ipsilateral nonvascularized fibula was used to bridge the defect and fuse the tibiotalar joint. A plate was used to rigidly hold the construct. The final outcome was compared to the historical control group that underwent only pedicled ipsilateral fibula transposition and ankle arthrodesis without recycled autograft or allograft between 2009 and 2017. Oncological reconstruction and functional outcomes were compared for each group. Patient reported outcomes on the acceptability of ankle fusion; cosmesis and function were analyzed and compared between the two groups.

Results

The mean resection length in the study group (4 patients) was 7.75 cm (7 to 8.5 cm). As compared to the historical cohort of 7 patients, the study population showed statistically superior results in all reconstruction, functional, and patient-reported outcomes except time to proximal junction union (p=0.068). There were no reconstruction failures, infection, or nonunions in the study group, whereas the control comparative group had 2 proximal junction nonunions and a mean time to fibular hypertrophy of 143 weeks (82 to 430 weeks) with fibula centralization. Earlier weight-bearing was allowed (mean 26.75 weeks; median 27 weeks) compared to (mean 80.75 weeks; median 80 weeks) in the control group.

Conclusion

We think that ECRT with ipsilateral vascularized fibula is a promising method of reconstructing the distal tibia. The recycled autograft tibia added strength to the distal tibia construct in our study and aided the anatomical reconstruction of the distal tibia. The patient-reported outcomes for cosmesis and acceptability add to the benefits of performing this procedure. Consistent early union across the proximal junction and earlier weight-bearing were clear advantages of this method.

[Fractures of the anterolateral tibial rim : The fourth malleolus]

The anterolateral tibial rim with the anterior tibial tubercle (Tubercule de Tillaux-Chaput) serves as an insertion site of the anterior inferior tibiofibular ligament (AITFL). It can also be termed the anterior malleolus or fourth malleolus. Fractures of the anterolateral tibial rim typically result from an external rotation or abduction mechanism of the talus within the ankle mortise. They are frequently overlooked in plain radiographs. Computed tomography (CT) is needed for an exact visualization of the fracture anatomy and treatment planning. A total of three main types can be differentiated: (1) extra-articular avulsion fracture of the AITFL, (2) fracture of the anterolateral distal tibia with involvement of the joint and tibial incisura and (3) impaction fracture of the anterolateral tibial plafond. Surgical fixation of displaced anterolateral distal tibial fractures aims at bone-to-bone stabilization of the anterior syndesmosis, restoration of the tibial incisura for the distal fibula and joint surface. Displaced extra-articular avulsion fractures (type 1) are fixed with a suture anchor or transosseal suture. Larger fragments involving the tibial incisura and plafond (type 2) are mostly fixed with screws. Impression fractures of the anterolateral tibial plafond (type 3) necessitate elevation with restoration of the joint surface, bone grafting of the impaction zone as needed and anterior buttress plating. Only a few studies have reported the treatment results of anterolateral tibial rim fractures in adults. Conservative treatment of dislocated fragments reportedly leads to non-union and malposition of the distal fibula with incongruence of the ankle mortise requiring revision. Impaction fractures (type 3) can lead to secondary avascular necrosis of the anterolateral tibial plafond.