SLR - May 2020 - Kelsey J. Millonig

Distal Tibial Distraction Osteogenesis - An Alternative Approach to Addressing Limb Length Discrepancy with Concurrent Hindfoot and Ankle Reconstruction

Reference: Chappell, T. M., Ebert, C. C., McCann, K. M., Hutchinson, B. L., & Rodriguez-Collazo, E. (2019). Distal Tibial Distraction Osteogenesis - An Alternative Approach to Addressing Limb Length Discrepancy with Concurrent Hindfoot and Ankle Reconstruction. Journal of Orthopaedic Surgery and Research, 14(1), 244-019-1264-0. doi:10.1186/s13018-019-1264-0 [doi]

Scientific Literature Review

Reviewed By: Kelsey J. Millonig, DPM, MPH 
Residency Program: Franciscan Health System-St. Francis Hospital – Federal Way, WA

Podiatric Relevance: Treatment of significant tibial bone defects secondary to an array of diagnoses such as total ankle arthroplasty explants, post-traumatic deformity, charcot neuroarthopathy, infection or avascular necrosis of the talus is widely debated in the literature. Limb length discrepancy with concurrent hindfoot and ankle deformity is a very complex condition without a standard of care for surgical intervention. The aim of this study is to determine if distal tibial lengthening in conjunction with reconstructive procedures provides a comparable outcome to other treatment options in the literature.

Methods: A retrospective review of surgical cases from 2009-2014 was completed for CPT codes relating to a distal tibial osteotomy with ilizarov external fixation and concurrent hindfoot or ankle reconstruction. Patients were excluded if they had less than six months of follow-up, were under 18 years old, or had inadequate radiographs. Nineteen patients were included in the study. Acute deformity correction was completed in 6/7 patients with correctable deformity, the remaining patient had gradual correction with the corticotomy as close to CORA as possible. Lengthening corticotomy was done at the distal tibial meta-diaphyseal junction. Previously well-accepted and published radiographic parameters were used to determine results of correction.

Results: Of the patient population 47.37 percent had bone marrow aspirate obtained from the proximal tibia and autograft or allograft was used in 15.79 percent of cases. The mean preoperative limb length discrepancy (LLD) was 2.70 ± 1.22 cm  and the mean operatively induced LLD was 2.53 ± 0.59 centimeters. The average latency period was 9.33 ± 3.47 days, distraction rate was  0.55 ± 0.16 millimeters/day, and average length obtained was 2.14 ± 0.83 cm. The consolidation time was twice the duration of distraction and dynamization yielding average duration of external fixation 146.42 ± 58.69 days and external fixation index 68.42 days/cm. Follow-up was on average  576.13 ± 341.89 days. The most common indication for surgery was a tibial fracture, clubfoot sequela, or talar fracture. The most common adjunct procedure performed was a V osteotomy, talocalcaneal fusion, or total ankle replacement explant. Average time to union was 121 days. Overall fusion rate was 85.71 percent, excellent infection results in 94.7 percent, excellent LLD results in 100 percent, excellent hindfoot and ankle deformity correction in 57 percent and excellent tibial alignment in 58.33 percent. Major complications requiring surgical revision were noted in 4/19 patients and minor complications noted in 3/19. 
Conclusions: The authors concluded that the results of this study suggest a distal tibial corticotomy with distraction osteogenesis in the setting of a LLD with hindfoot and ankle deformity correction is a viable treatment option with comparable outcomes to other reported  techniques and therefore may be considered for patients on an individual basis. 

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