This article is more than 5 years old. Information may no longer be current.
A 48-year-old man with tibia pain and deformity
Click Here to Manage Email Alerts
The patient is a 48 year-old man with a history of hypothyroidism, obesity (BMI 35), hepatitis B and tobacco use who suffered a midshaft, right tibia-fibula fracture while roller blading 5 months prior to presentation. He underwent right tibia open reduction and internal fixation at an outside hospital.
Upon presentation to our clinic, the patient reported progressive tibia deformity since his surgery, and had not returned to full ambulation or regular activities due to tibia pain. He denied history of wound complications, infection or recurrent trauma/falls. He stated that he had pain “in the tibia” at all times that worsened with activity.
On physical examination, a prior incision over the anterolateral tibia was intact, without evidence of surrounding erythema, edema or warmth. There was an obvious valgus and procurvatum deformity to the tibia. There was tenderness to palpation over the distal to mid-lateral tibia. He tolerated full range of motion at the knee and ankle. He had intact, but weak ankle dorsiflexion, and normal strength with plantarflexion and extensor hallucis longus function. His sensation was intact to light touch throughout the foot. He ambulated with an antalgic gait, utilizing crutches and a CAM walker boot.
Preoperative anteroposterior radiograph of the right tibia demonstrates a cortical lucency with valgus deformity.
Preoperative lateral radiograph of the right tibia demonstrates a cortical lucency with procurvatum deformity.
Images: Blomberg JR
Additional work-up including imaging studies and laboratory analyses were completed. Anteroposterior and lateral radiographs of the right tibia demonstrated a locked medial tibia plate, with the most proximal screw broken. The tibia was noted to be in 21° of valgus and 22° of procurvatum. There was a persistent lucency in the tibia, most prominent anteriorly (Figures 1a and b). Laboratory values were obtained for parathyroid hormone, erythrocyte sedimentation rate, C-reactive protein and white blood cell count, which were all within normal limits. His vitamin D level was low at 13.8 ng/mL (greater than 50 ng/mL is normal).
What is your diagnosis?
See answer on next page.
Tibia nonunion with resultant deformity
This patient’s history, examination and imaging are concerning for a tibia nonunion with resultant deformity. He uses tobacco, which is a known risk factor for nonunion, in addition to his likely contributing comorbidities of hypothyroidism, obesity (BMI 35) and hepatitis B. A CT scan was also obtained as part of the work-up, which confirmed the diagnosis of tibia nonunion. At the initial visit, he was counseled on the importance of discontinuing tobacco use and was started on vitamin D supplementation. Further treatment options were discussed, including hardware removal and fibular osteotomy with placement of a ring fixator, revision open reduction and internal fixation, or intramedullary nail placement.
Aseptic nonunion is most common in the tibia and is often multifactorial. While the traditionally accepted time frame for nonunion is 9 months, this patient was 5 months out from surgery, with no signs of healing and a progressive deformity. Treatment in this patient required correction of the deformity, stable fixation, and compression through the fracture with optimization of host physiology and local biology. Intramedullary nail placement was one option; however, this technique is most effectively utilized in the setting of exchange nailing for tibia nonunion when there is no need for acute deformity correction, unlike the deformity correction needed in the present case. Revision open reduction and internal fixation with plating is an option; however, this technique is less ideal for local biologic augmentation and is more effective in areas of cancellous bone. Furthermore, the patient had already failed this treatment modality (plate and screw construct), though it could be argued that the original stabilization construct was suboptimal.
Treatment with a ring fixator is classically utilized for treatment of tibia nonunions in the setting of extensive bone loss, infection, poor soft tissue envelope and/or with large deformities in need of gradual correction. In this case, it would allow for correction of deformity, compression at the fracture site, minimal disruption of local blood supply and more rapid weight-bearing. In addition, this treatment modality has excellent published results with high rates of union.
One-week postoperative anteroposterior radiograph of the right tibia demonstrates the ring fixator in place with restoration of the appropriate alignment.
One-week postoperative lateral radiograph of the right tibia demonstrates the ring fixator in place with restoration of the appropriate alignment.
Treatment of our patient
The patient underwent hardware removal, fibular osteotomy, placement of a ring fixator and bone grafting with iliac crest autograft. At his 1-week follow-up visit, radiographs revealed a ring fixator in place with restoration of the appropriate alignment (Figures 2a and b) after a minor strut adjustment to address slight varus malalignment. Two weeks following surgery, he was taken to the OR for readjustment of the fixator for acute malreduction of the tibia due to loosening of one of the struts.
At 5 months following surgery, the ring fixator was removed and he transitioned to a short leg cast for 3 weeks, followed by a CAM boot for 1 month, and then progressed to regular shoe wear. At 9 months following surgery, the patient was ambulating in normal shoes without an assisted device. He reported minimal pain only toward the end of the day and was satisfied his outcome. His most recent radiographs revealed a healed tibia shaft fracture in the appropriate alignment (Figures 3a and b).
- References:
- Adams CI, et al. Injury. 2001;doi:10.1016/S0020-1383(00)00121-2
- Court-Brown CM, et al. J Bone Joint Surg Br. 1995;77:407-411.
- Feldman DS, et al. J Orthop Trauma. 2003;17(8):549-554.
- García-Cimbrelo E, et al. Clin Orthop Relat Res. 2004;419:65-70.
- Rozbruch SR, et al. J Orthop Trauma. 2008;doi:10.1097/BOT.0b013e318162ab49.
- Templeman D, et al. Clin Orthop Relat Res. 1995;315:169-175.
- For more information:
- Nicholas M. Brown, MD; and Matthew W. Tetreault, MD, can be reached at Rush University Medical Center, 1611 W. Harrison, Ste. 300, Chicago, IL 60612; Brown’s email: nmb2116@gmail.com; Tetreault’s email: matthew.w.tetreault@gmail.com.
- Joshua R. Blomberg, MD, can be reached at Rockford Orthopedic Associates, 324 Roxbury Rd., Rockford, IL 61107; email: joshua.blomberg@rockfordortho.com.
Disclosures: Brown, Tetreault and Blomberg report no relevant financial disclosures.