Case 21: Complex Tibial Deformity: Acute Correction and IM Nail Fixation

Abstract

Complex diaphyseal deformities of long bone may need more than one osteotomy to restore the normal mechanical axis. Difficulties with multiple tibial osteotomies arise when intramedullary fixation is chosen due to short bone segments rendering the fixation unstable. A corrected complex tibial deformity due to congenital tibial dysplasia is better fixed by intramedullary nail due to poor healing capacity of this dysplastic bone and the expected delayed bone-healing time. A major difficulty of correction and fixation of such deformity is the presence of secondary compensatory deformities and the adjustment of leg length to avoid residual leg length discrepancy (LLD). Resolution of the deformities into one CORA (center of rotation of angulation) to achieve correction through one osteotomy is an attractive idea which leaves long enough bone segments for stable fixation. Careful preoperative planning and paper tracing is essential for determination of both the osteotomy level and nail insertion point.

When planning deformity correction, it is helpful to use the full-length standing X-ray in addition to radiographs of the operative bone. The surgical planning is done within the context of the lower extremity mechanical axis. In this case, a long-standing X-ray would reveal the source of the valgus alignment outcome which may be from the femur and/or the proximal tibia. Further realignment surgery may be indicated in this case (SRR).