Congenital anterolateral tibial bowing and polydactyly: a case report
Edmond G Lemire Journal of Medical Case Reports 2007, 1:54 doi:10.1186/1752-1947-1-54
Published 23 July 2007
Abstract (provisional) Congenital anterolateral bowing of the tibia is a rare deformity that may lead to pseudarthrosis and risk of fracture. This is commonly associated with neurofibromatosis type 1. In this report, we describe a 15-month old male with congenital anterolateral bowing of the right tibia and associated hallux duplication. This is a distinct entity with a generally favourable prognosis that should not be confused with other conditions such as neurofibromatosis type 1. Previously published cases are reviewed.

SOA Textbook Chapter in preparation
Torsion of the femur and tibia, as well as genu varum and genu valgum, are considered physiological variations of development that occur in normal infants and children. Infants commonly present with anteversion of the femur, medial tibial torsion and genu varum. With growth, the femoral anteversion decreases and the tibia rotates laterally. The genu varum gradually resolves and genu valgum develops. Abnormality of growth or disease can result in malalignment. Adequate management is based on an understanding of the cause and the natural history of the malalignment and the effectiveness of various treatments.

Does Fibular Plating Improve Alignment After Intramedullary Nailing of Distal Metaphyseal Tibia Fractures? Journal of Orthopaedic Trauma. 20(2):94-103, February 2006. Egol, Kenneth A MD *; Weisz, Russell MD +; Hiebert, Rudi ScM *; Tejwani, Nirmal C MD *; Koval, Kenneth J MD ++; Sanders, Roy W MD + Abstract: Objective: Evaluate whether supplementary fibular fixation helped maintain axial alignment in distal metaphyseal tibia-fibula fractures treated by locked intramedullary nailing. Design: Retrospective chart and radiographic review. Setting: Three, level 1, trauma centers. Patients: Distal metaphyseal tibia-fibula fractures were separated into 2 groups based on the presence of adjunctive fibular plating. Group 1 consisted of fractures treated with small fragment plate fixation of the fibula and intramedullary (IM) nailing of the tibia, whereas group 2 consisted of fractures treated with IM nailing of the tibia without fibular fixation. Outcome Measures: Malalignment of the tibial shaft was defined as 1)>5[degrees] of varus/valgus angulation, or 2)>10[degrees] anterior/posterior angulation. Measures of angulation were obtained from radiographs taken immediately after the surgery, a second time 3 months later, and at 6-month follow-up. Leg length and rotational deformity were not examined. Results: Seventy-two fractures were studied. In 25 cases, the associated fibula fracture was stabilized, and in 47 cases the associated fibula fracture was not stabilized. Cases were more likely to have the associated fibula fracture stabilized where the tibia fracture was very distal. In multivariate adjusted analysis, plating of the fibula fracture was significantly associated with maintenance of reduction 12 weeks or later after surgery (odds ratio = 0.03; P = 0.036). The use of 2 medial-lateral distal locking bolts also was protective against loss of reduction; however, this association was not statistically significant (odds ratio = 0.29; P = 0.275). Conclusions: In this study, the proportion of fractures that lost alignment was smaller among those receiving stabilization of the fibula in conjunction with IM nailing compared with those receiving IM nailing alone. Adjunctive fibular stabilization was associated significantly with the ability to maintain fracture reduction beyond 12 weeks. At the present time, the authors recommend fibular plating whenever IM nailing is contemplated in the unstable distal tibia-fibular fracture.

Focal dome osteotomy for the correction of tibial deformity in children. Journal of Pediatric Orthopaedics B. 14(5):340-346, September 2005. Dilawaiz Nadeem, R.; Quick, Thomas J.; Eastwood, Deborah M. Abstract: Tibial deformity in childhood often combines torsional and angular malalignment. A focal dome osteotomy was performed, proximally or distally, in 39 tibiae in 31 patients. In 33 limbs, the primary deformity was varus (with internal torsion). The osteotomy was held with K-wires and a plaster cast. The mean age at surgery was 10.25 years and the minimum follow-up 24 months. All osteotomies united and no compartment syndrome occurred. Postoperatively, two patients (5%) had temporary neurological deficits. Thirty of 31 patients had good clinical and radiological correction of alignment. Recurrent deformity was seen in one patient with hypophosphataemic rickets.

Wheeless IM naling of these fractures is technically difficult and often results in malalignment; surgeons without strong enthusiasm for nailing these fractures should consider lateral plating (for closed fractures)and external fixation for open fractures

AAOS Annual Meeting Abstract 2004 Logic and Clinical Application of Intramedullary Blocking Screws Scientific Exhibitor Number: SE058 Hans-Werner Stedtfeld, MD, Nurnberg, Germany Peter Landgraf, MD, Nurembeg, Germany Mr. Andreas Ewert, Rostock, D Germany Thomas W F Mittlmeier, MD, Rostock, Germany Following intramedullary fixation of metaphyseal long bone fractures high rates of axial malalignment have been reported. Blocking screws have been recommended to enhance primary stability. The logic of positioning these screws, however, and the option to use them as a reduction tool have not been analysed, yet. A 2-D model of an idealized fractured long bone consists of 3 essential elements: the diaphyseal and metaphyseal fragments and a rubber band simulating soft-tissue imbalance and axial deformity. A plastic rod representing an intramedullary nail can be introduced from both sides. Plastic sticks representing blocking screws can be plugged into holes at various positions of the two 'fragments'. The model allowed to derive general rules for positioning of blocking screws valid in any metaphyseal long bone fracture. The standard position of the blocking screw is: 1. in the metaphyseal fragment 2. close to the fracture 3. at the concave side of the axial deformity. In selected situations of high-degree instability an additional screw can be placed at the short fragment, on the convex side of the deformity and distant from the fracture. The basic biomechanical effect is an intramedullary three-point fixation. Clinical application has proven validity of the rules in fractures of the proximal humerus (n = 7), the subtrochanteric area (n = 5), the distal femur (n = 9), the proximal (n = 12) and distal tibia (n = 15) which all healed uneventfully within the limits of <5° of axial deformity.

Mechanical Axis Deviation: Definitions, Measurements and Consequences. Damian McCormack, International Fellow in Paediatric Orthopaedic Surgery, Atlanta Scottish Rite Hospital, Georgia, U.S.A. Mechanical axis deviations in the lower extremity are commonly seen in both paediatric and adult orthopaedic practice. This paper describes, for the trainee, the consequences of such deformity and the methods by which they are quantified.

Report from a Hong Kong surgeon on the 2004 Baltimore Limb Deformity Course

Results of Treatment of 111 Patients With Nonunion of Femoral Shaft Fractures P. K. Beredjiklian, M.D., R. J. Naranja, M.D., R. B. Heppenstall, M.D., C. T. Brighton, M.D., Ph.D., and J. L. Esterhai, M.D. From the Department of Orthopaedic Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA. Abstract: The purpose of this study is to report our experience with the treatment of femoral shaft fracture nonunion and to define poor prognostic indicators in the treatment of this complication. The records and available radiographs of 111 patients treated for nonunion of the femoral shaft in our institution were retrospectively reviewed. The mean duration of follow-up after establishment of nonunion was 62 months. The following factors were found to have an adverse effect on nonunion healing (p <0.05): (1) advanced patient age; (2) presence of osteomyelitis; (3) presence of synovial pseudarthrosis; (4) duration of nonunion; (5) treatment with flexible intramedullary devices; (6) treatment with compression plating; (7) poor bone stock; (8) malalignment in the anteroposterior plane of more than 10 degrees; and (9) malalignment in the lateral plane of more than 20 degrees. (Full Text article)

OTA 2002 - Session 10 Session X - Upper Extremity Sun., 10/13/02 Upper Extremity, Paper #63, 10:10 AM The Impacted Varus Proximal Humeral Fracture. Which Factors Affect Outcome? Charles M. Court-Brown, MD, FRCS; Margaret M. McQueen, MD, FRCS; Royal Infirmary of Edinburgh, Edinburgh, United Kingdom Purpose: A prospective analysis of 99 impacted varus (OTA, A2.2) proximal humeral fractures was undertaken to study the outcome of nonoperative management and to assess whether age, increasing varus deformity during treatment, and physical therapy altered the prognosis. Methods: In a 4-year period, 135 consecutive patients with impacted varus (OTA, A2.2) proximal humeral fractures were treated and prospectively documented in one trauma unit. Two patients were treated operatively and 34 either died or were lost to follow-up. The remaining 99 patients were followed at a research clinic at 6, 13, 26, and 52 weeks after the injury. The Neer score was used to monitor their progress, with patient examinations performed by an independent research physical therapist. Radiological assessment was performed by one surgeon to prevent inter-observer error. Varus displacement was estimated by measuring the angle between the humeral diaphysis and a line drawn between the greater tuberosity and the inferior articular surface on the initial and final radiographs. The effect of age, increasing varus displacement during nonoperative treatment and physical therapy was assessed. Tests for association were undertaken using multiple regression or logistic regression. Results: The average age of all 135 patients, 106 women and 39 men, was 68 years. The mean Neer score of the 99 patients followed throughout the study was 59.7 at 6 weeks, 73.9 at 13 weeks, 81.7 at 26 weeks, and 86.7 at 52 weeks. Application of the Neer outcome criteria showed that 78.5% of patients had a good or excellent result 1 year after injury. Analysis of the effect of age on outcome showed a positive correlation, with a decreasing Neer score at 1 year recorded among older patients. The mean Neer score in patients less than 40 years of age was 94.5 and 82.1 in the over-80-year age group. There was no correlation between increasing varus malalignment during treatment and function or pain at 1 year. Radiological analysis showed a mean increase in varus displacement of the humeral head of 12 o (range, 0° to 41 o ) during treatment. The average Neer score for patients with less than 5 o of varus displacement during treatment was 89.7 compared with 91.1 for patients with 25° to 29 o of varus displacement. The possibility of increasing pain due to greater tuberosity impingement associated with varus displacement was studied by assessing pain, using Neer's criteria, at each examination between 6 and 52 weeks. There was no correlation between pain and varus displacement. Univariate analysis of the use of physical therapy suggested that there might be a correlation with function, but multivariate analysis indicated that the older, less fit patients tended not to receive physical therapy. Our results do not suggest that physical therapy is useful. Discussion: In a recent epidemiological study of proximal humeral fractures, the A2.2 impacted varus fracture was shown to be the third most common proximal humeral fracture. Despite this finding, there has been no previous study of the outcome of this fracture. There is, however, a common assumption that the increasing varus deformity that commonly follows nonoperative treatment of this fracture leads to subacromial impingement, restricted shoulder function, and pain. However, analysis of our data shows that this is not the case. Although progressive varus deformity is common in the A2.2 fracture, it does not cause deterioration in function or increase in pain. The results of nonoperative treatment are good, particularly in younger patients. Older patients have poorer results, but it is unlikely that surgery will improve function in this group of patients. Physical therapy does not appear to help patients. Conclusions: Nonoperative management of the OTA A2.2 proximal humeral fracture gives good results, regardless of the degree of varus displacement during treatment and whether physical therapy is used. The results indicate that the parameter that affects outcome is age.

OTA 2002 - Session 7 Session VII - Tibia Sat., 10/12/02 Tibia, Paper #48, 4:43 PM The Use of Hybrid Fixators in Proximal Tibia Fractures Roberto Varsalona, MD ; Bruce H. Ziran, MD; S. Avondo, MD; Q. Mollica, MD; University of Catagnia, Sicily, Italy; and University of Pittsburgh, Department of Orthopaedics, Pittsburgh, Pennsylvania, USA Purpose: Severe proximal tibia fractures, which include intra- and extraarticular fractures with metaphyseal-diaphyseal dissociation, pose a difficult treatment problem for the surgeon with significant complication rates. Use of external or internal fixation remains the main methods of treatment, with strong advocates for each method. Although there are pros and cons to both methods, we have found that accurate reduction (closed or open) with hybrid fixation has provided the best results. The purpose of this study was to report experience with a series of consecutive severe proximal tibial fractures. Methods: We treated 118 cases of proximal tibia fracture, of which 52 were treated with hybrid external fixation as part of a protocol that used a consistent approach and method of hybrid external fixation. Inclusion criteria for hybrid treatment (as opposed to closed treatment) were severe soft tissue injury, intraarticular displacement, and unstable fracture pattern involvement (AO A2, A3, and C patterns). Patients were treated on a fracture table with calcaneal traction. Reduction was achieved with ligamentotaxis and percutaneous clamps when possible. If necessary, limited incisions were used to elevate depressed fragments and place bone grafts. Articular congruity was assessed with fluoroscopy or arthroscopy or both. Fixation of the condyles was achieved with cannulated screws or beaded olive wires or both. The distal frame consisted of a multi-clamp or a single clamp and used three to four 5-mm half pins. The distal frame was connected to the ring with adjustable components (rods or a monolateral external fixator). A standard postoperative management protocol was followed involving immediate range of motion, weight-bearing as tolerated, and pin care. The management of the rigidity of the external fixations began with three to four rods, and rods were progressively removed or replaced or both with a dynamic axial monotube assembly. Clinical and radiographic evaluation was performed at routine intervals. In addition to routine demographic data, objective data collected included healing, deformity, complications, and motion. Patients were also evaluated with an SF-36 questionnaire 12 months after healing. Results: There were 52 patients with an average age of 42 years (range,17 to 78) with a mean follow-up of 24 months (range, 12 to 30). There were 40 men and 12 women, who sustained 31 fractures of the right leg and 21 fractures of the left leg. The mechanisms of injury were a motorcycle accident (18 patients), a pedestrian-motor-vehicle accident (13 patients), a motor-vehicle accident (9 patients), a fall from a height (9 patients), being struck by an object (2 patients), and sports activity (1 patient). There were 13 open fractures and 3 A2, 3 A3, 16 C1, 12 C2, and 18 C3 injuries. Seven patients had other major fractures of the ipsi- or contralateral limb, involving the femur, the shaft of the tibia, the ankle, the calcaneus, the femur, and the distal part of the other tibia. Two patients had upper limb fractures (one humeral and one wrist fracture). Two patients had a rupture of the patellar ligament, necessitating repair. All proximal tibia fractures healed without additional procedures. All patients were radiographically and clinically healed by 24 weeks. Most patients demonstrated healing by 16 weeks. Full weightbearing was established at a mean of 8.4 weeks (range, 5 to 10). Forty-six patients (88%) achieved full extension, and the remaining 6 (11%) had an extension deficit of less than 10°. Three patients (5%) had less than 90° of flexion, 27 had flexion beyond 100°, and 22 patients were able to flex beyond 110°. Thigh atrophy of more than 1 cm was noted in only one patient. The SF-36 profiles were health state/rate, daily activity, work activity, emotional problems, and pain. There were no intraoperative injuries to nerves or major vessels. Postoperative complications included superficial pin tract infections in 15 K-wires or pins, all of which resolved with local pin care and a short course of oral antibiotics. One patient had a deep venous thrombosis. None required removal of the fixator before healing of the fracture. No patient developed osteomyelitis or septic arthritis. Accuracy of reduction was 0 to 1mm in 28 patients, 2 to 3 mm in 19 patients, 4 to 5 mm in 4 patients, and more than 5 mm in 1 patient. Only 5 (10%) of the 52 patients had an angular malunion greater than 6°. One patient had a loss of reduction during treatment with hybrid external fixation. Four patients developed a mild varus deformity, when compared with the contralateral uninvolved knee. There were no valgus malunions and no nonunions. Final malalignment of the tibiofemoral axis did not exceeded 3° on full-length weight-bearing radiographs. Radiographic and clinical evidence of degenerative arthritis was seen in 12 of 52 patients (23%) 18 months after healing. Ten of these patients had C3 and 2 had C2 fracture patterns. Six of these patients were those that had angular malunions noted above. The remaining six patients had reductions to within 3 mm. Discussion: The benefit of restoration of normal anatomic structure by means of an open procedure must be weighed against the risk of infection, soft tissue complications, and malunion. Traditional open reduction and plating carries a significant incidence of wound complications and unsatisfactory results. Complex proximal tibial fractures sometimes require two plates for optimal fixation, which can result in an unacceptably high rate of infection. A hybrid fixator can maintain length and alignment while spanning a zone of comminution in the metaphyseal-diaphyseal region. It allows for access to any open wounds or compromised soft tissue. The device allows secondary correction of angular or rotational deformities when necessary and also early weightbearing and range of motion of the knee and ankle. We found that in a fairly large series of patients with medium to long-term follow up, the hybrid fixator performed very well from a technical standpoint. The development of radiographic arthrosis seemed to correlate more with the initial articular injury and alignment than to the nature of treatment. Intuitively, the quality of reduction will obviously impact the outcome but we were able to achieve satisfactory reductions in the majority of cases. We found that patients were allowed to bear weight and regain excellent knee motion. Our regimen of beginning with absolute construct rigidity in the first 2 to 6 weeks of healing, followed by gradually decreasing the stiffness of the frame (rod removal and conversion to monotube dynamic tube), allowed for progressively increased load-sharing with the developing fracture callous. In summary, we found that hybrid external fixation is a good alternative method for treatment of meta- or epiphyseal fractures or both. The technique and postoperative management we describe respects soft tissue and bone and allows for early articular mobilization.

18th Annual Meeting of the Orthopaedic Trauma Association New-generation tibial nails incorporate multiple holes in different planes in order to maximize options for interlocking and allow nailing of fractures near the proximal and distal ends of the tibia. Russell Weisz, MD,[25] from Tampa General Hospital in Tampa, Florida, presented "Distal Fourth Tibia-Fibula Fractures Treated with an Intramedullary Nail: Factors Affecting Alignment." This retrospective study evaluated intramedullary nailing of distal tibial fractures with fibula fractures at the same level. Weisz and colleagues performed a radiographic analysis of postoperative malalignment. Malalignment was defined as more than 5° of varus-valgus angulation or more than 10° of anterior-posterior angulation. Immediate malalignment was found in 13% (9/72) of patients. Eight of the 9 malaligned fractures had no supplemental fibular fixation, but this was not statistically significant. Late malalignment was found in 10% of patients; follow-up in the late-malalignment group averaged 25 weeks. None of the malaligned fractures had fibular fixation. No fracture with more than 1 medial-to-lateral distal interlocking bolt had shifted. Distal locking screw configuration was the only variable that was statistically significant for malalignment in the late group. When both the immediate and late groups of malalignment were combined, 14 of the 15 malaligned fractures had no fibular fixation. The study authors concluded that because of limited bony contact during intramedullary nailing of distal tibia fractures, plate fixation of the fibula prior to intramedullary nailing helped to obtain and maintain fracture reduction. To maintain the reduction, at least 2 medial-to-lateral distal locking screws were needed. (other papers also summarized)

Development of Torsional and Angular Alignment Analysis of Deformity of the Femur and Tibia: Authors - Ana Presedo-Rodriquez, MD J. Richard Bowen, MD Alfred I. duPont Hospital for Children Department of Orthopaedics Wilmington, DE 19899
The purpose of this chapter is to describe the torsional and angular variations that occur in the lower limbs, to review the different methods for their assessment and to discuss in which circumstances a treatment would be indicated.

Many proximal metaphyseal tibial fractures will become malaligned even if a lateral entry point is used. Malalignment in proximal tibial fractures is due to the use of improper nail entry sites and poor nail-to-bone contact in the metaphysis. The use of screws inserted in the sagittal plane that contact the nail can be used to improve alignment and stability. The term Poller is derived from the small devices put in roads to guide traffic. Screws known as Poller "blocking" screws can be very useful to overcome iatrogenic deformity. Expert