Procedures

This series consisted of 5 distal tibial angular deformity correction and 5

tibiocalcaneal arthrodesis procedures. All cases were carried out with

simultaneous distal tibial distraction osteogenesis (DTDO) to address

LLD.

Patients and Surgical Concept

Demographics

• The mean patient age was 53.4 years

• There were 6 males and 4 females with a mean BMI of 28.14

• Two patients presented with a history of smoking

• There was a mean of 22.5 years from initial injury to presentation

• The most common cause of deformity was tibial fracture (6/10) with

(2/10) being open at the time of injury

• The second most common cause of deformity was a gun shot

wound & talar fracture, each representing (2/10)

MethodologyPurpose

To address whether reconstructive rearfoot/ankle surgery (RRAS) with concurrent lengthening through a distal tibial

corticotomy (DTC) using circular external fixation (CEF) offers a successful treatment option for patients with limb length

discrepancy (LLD) as a component of their overall deformity.

Discussion• The current study showed a 100% fusion rate, 70% initial consolidation rate with an overall 6 excellent, 3 acceptable,

and 1 good outcomes at a mean follow-up of 16 months similar to previous reports (4,21,22-23).

• Treatment recommendations have been suggested according to defect length (5,24) however, the current literature

does not reflect a strict adherence to these recommendations (3-19).

• This technique of simultaneous lengthening through a DTC was shown to be successful utilizing CEF and yielded a

clinically satisfactory result in patients with substantial preoperative deformity.

• We conclude that the ability to address long-standing or surgically induced LLD at the site of reconstruction using

DTDO is a successful treatment option comparable to other solutions in the literature, however, there is still no ideal

concept for every patient and further studies will be required to elucidate the most effective method for these

challenging cases.

Results • Ten patients underwent DTDO to address long-standing or surgically induced shortening as a result of preoperative

deformity and/or RRAS achieving a final LLD of ≤1.5 cm for all patients.

• The mean latency period was 9.33 days with a mean distraction length of 1.75 ± 0.62 cm.

• The mean duration of external fixation was 177.40 ± 67.05 days resulting in a mean external fixation/lengthening index

of 3.73 ± 1.84 months/cm.

• Five minor complications and four major complications occurred:

• Incomplete regenerate consolidation requiring bone grafting and internal hardware fixation occurred in 3/4, all of

which achieved solid union

• A chronic draining sinus tract excision and bone biopsy was required in 1/4 which resulted in resolution of drainage

• A method for evaluation of rearfoot and ankle deformity correction has been proposed in the literature (Table 3). Our

results are reported according to this method (Table 4).

Literature Review

• Limb length discrepancy >2 - 2.5 cm is poorly tolerated (1-2).

• It has been suggested that patients undergoing rearfoot fusions have improved tolerance with 0.5 – 1 cm limb

shortening to compensate for fusions & provide improved toe clearance in gate (3-4).

• There is no consensus in the literature as to the most favorable method of addressing LLD in the setting of RRAS

(Table 1).

Simultaneous Distal Tibial Distraction Osteogenesis & Lower Extremity

Reconstruction: A Retrospective ReviewTodd M. Chappell, DPM/PGYII1; Casey C. Ebert, DPM/PGYIII1; Byron L. Hutchinson, DPM, FACFAS1; Kevin M. McCann, DPM, FACFAS2

1Franciscan Foot & Ankle Institute, Federal Way, WA2St. Cloud Orthopedics, St. Cloud, MN

Table 2 - Retrospective Review of Clinical & Radiographic Data

Focus

Surgical reconstruction of rearfoot/ankle deformity with

simultaneous distal tibial distraction osteogenesis (DTDO)

to address LLD

CPT code 20692, 27705, 27709, 27715

Dates July 2009 – September 2014

Exclusion

• Under 18 years of age

• Less than 10 months of follow-up

• Incomplete radiographic imaging or clinical data

n= 10

Distal

lengthening

groups

Distal tibial angular

deformity and shortening

Tibiocalcaneal arthrodesis

with loss of height

Mean

follow-up16 months

ProcedureSurgical reconstruction of rearfoot/ankle deformity with

application of CEF and percutaneous DTC

Clinical &

radiographic

review

Demographics and comorbidities as well as peri-operative

analysis including previous surgical interventions, latency

periods, distraction rates, minor and major complications,

and clinical and radiographic review (Table 4)

Notes: CPT: Current Procedural Terminology

Fig. 3. Preoperative weight bearing radiographs of; (A) lateral ankle and (B) AP ankle demonstrating

AVN of the talar body and nonunion of talar neck fracture; (C) intraoperative lateral radiograph

demonstrating talectomy and preparation of tibiocalcaneal fusion; postoperative (D) AP and (E)

lateral radiographs demonstrating compression of fusion site and DTC site with application of CEF.

Distal Tibial Angular Deformity and Shortening (Figure 2)

• Following preoperative evaluation of LLD and angular deformity both

clinically and radiographically, tibial wedge resection was conducted at the

Center of Rotation of Angulation (CORA).

• This was followed by acute reduction of deformity and stabilization with an

intramedullary Steinmann pin during application of CEF.

• The site was then compressed and maintained during the latency period

before distraction was commenced at a rate of 0.5 mm/day for the

preoperatively determined duration to regain adequate limb length.

Fig. 2. Preoperative weight bearing radiographs of (A) 51 in. erect bipedal (B) anteroposterior (AP)

ankle and (C) lateral ankle showing LLD and angular deformity; (D) intraoperative image of laterally

based tibial wedge and (E) acute reduction of deformity and application of CEF.

Table 1 – Variable Methods to Address LLD (3-19)

Acceptance of LLD

Study (author/journal/year) Patients

(n)

Follow-up

(months)

Pathology/Treatment Outcome

Tenenbaum et al. Foot

Ankle Int. 2015

13 26.1 Talar AVN/Tibial rearfoot fusion 100% union and improvement in outcome

measure

Fragomen et al. Clin Orthop

Relat Res. 2012

91 70 Failed ankle fusion/24/91 lengthened 84% union, >2.5 cm deficit recommend

lengthening

Metal Implants

Carlsson. J Foot Ankle

Surg. 2008

3 20.7 Failed ankle replacement/Titanium mesh 100% nonunion Intramedullary nail revision

66% fusion

Bullens et al. Foot Ankle

Surg. 2010

2 9 Failed ankle replacement/Intramedullary nail

and titanium cage

100% union

Sagherian et al. Foot Ankle

Int. 2015

3 57 Failed ankle replacement/Tantalum

trabecular metal

100% union at 3 months and improvement in

outcome scores

Sagherian et al. Foot Ankle

Int. 2012

25 27 Ankle, hindfoot, and/or midfoot pathology

requiring structural graft/Porous tantalum

spacer

100% fusion at 4-6 months with 56% no pain,

40% mild occasional pain, 4% moderate pain

Cohen et al. J Foot Ankle

Surg. 2015

1 21 Talar AVN/Porous tantalum spacer Solid fusion and independent ambulation

Bone Grafting

Myerson et al. J Bone Joint

Surg. 2005

73 42 Multiple pathologies/FFFHA Time to union was 4 months & 92% union rate

Burkowitz et al. Foot Ankle

Int. 2011

24 43.9 Failed ankle replacement/FFFHA w/ internal

fixation(plates and screws)

79% union

Deleu et al. Foot Ankle Int.

2014

17 29.1 Failed ankle replacement/FFFHA with

Internal fixation and Intramedullary nail

76.5% union at 3.7 months

Plaass et al. Foot Ankle Int.

2009

29 43.9 4 ankle nonunion & 9 failed TAR/FFFHA,

DBM, or no graft all with double plating

100% union at 13.2 weeks, 12.3 without graft,

14.3 interposition graft(DBM), 16.2 FFFHA

Distraction Osteogenesis

Green. Clin Orthop Relat

Res. 1994

32 42 Segmental skeletal defects/15 bone graft vs

17 distraction osteogenesis with CEF

1.9 months/cm in both groups, 2/15 vs 7/17

required secondary grafting

McCoy et al. Foot Ankle Int.

2012

7 58 Failed ankle replacement/CEF with 4/7

lengthened ave. 5.7 cm with LATN technique

100% union

Sakurakichi et al. J Orthop

Sci. 2003

6 36 Failed ankle fusion/diaphyseal corticotomy

for <3 cm defects & bone transport for >5 cm,

3 intramedullary nails

100% union with mean length 4.1 cm, 22.1

days/cm, external fixation duration 234 days

Rochman et al. Foot Ankle

Int. 2008

11 35 Talar AVN and infection/8/11 proximal tibial

lengthening

82% union with mean length 4 cm, external

fixation duration 7 months

Schottel et al. J Orthop

Trauma. 2014

3 38.4 Distal tibial periarticular nonunions/Distal

bone distraction

100% union with mean defect 5.1 cm, mean

external fixation duration 7.5 months

Notes: AVN: Avascular Necrosis; FFFHA: Fresh-Frozen Femoral Head Allograft; TAR: Total Ankle Replacement; DBM: Demineralized Bone Matrix;

AVE: Average; LATN: Lengthening and Then Nailing

Table 3 – Method of Evaluation for Osseous Correction (4,21)

Excellent Good Fair Poor

Union Solid Nonunion

Infection Absence Presence

Deformity

• Hindfoot

• Neutral/slight

calcaneus

• Neutral to 5˚

valgus

• External rotation

0-15˚

• Neutral to slight

posterior

translation

• Slight equinus

<5˚

• 5-10˚ valgus or

varus

• <5˚ Internal

rotation

• <1 cm anterior

translation

• 5-10˚ dorsiflexion

or plantarflexion

• 5˚ varus or >10˚

valgus

• <5˚ Internal

rotation

• >1 cm anterior

translation

• Worse than

before

intervention

• Tibial Both coronal and

sagittal planes within

5˚ of normal

Acceptable Neither coronal nor

sagittal planes within

5˚ of normalEither coronal or sagittal plane within 5˚ of

normal

LLD <1.5 cm <3 cm >3 cm

Table 4 – Bone Results

n=10 Excellent Good Fair Poor

Union 10

Infection 10

Deformity

• Hindfoot

n=5

4 1

• Tibial

n=5

Acceptable

2 3

LLD 10

References1. Tellisi N, Fragomen AT, Ilizarov S, Rozbruch SR. Limb Salvage Reconstruction of the Ankle with Fusion and

Simultaneous Tibial Lengthening Using the Iliarov/Taylor Spatial Frame. Hosp Spec Surg J. 2008;4:32-42.

2. Keating JF, Simpson AHR, Robinson CM. The Management of Fractures with Bone Loss. J Bone Joint Surg (Br).

2005;87-B:142-150.

3. McCoy TH, Goldman V, Fragomen AT, Rozbruch SR. Circular External Fixator-Assisted Ankle Arthrodesis Following

Failed Total Ankle Arthroplasty. Foot Ankle Int. 2012;33(11):947-955.

4. Katsenis D, Bhave A, Paley D, Herzenberg JE. Treatment of Malunion and Nonunion at the Site of an Ankle Fusion with

the Ilizarov Apparatus. J Bone Joint Surg. 2005;87-A(2):302-309.

5. Green SA. Skeletal Defects: A Comparison of Bone Grafting and Bone Transport for Segmental Skeletal Defects. Clin

Orthop Relat Res. 1994;301:111-117.

6. Tenenbaum S, Stockton KG, Bariteau JT, Brodsky JW. Salvage of Avascular Necrosis of the Talus by Combined Ankle

and Hindfoot Arthrodesis Without Structural Bone Graft. Foot Ankle Int. 2015;36(3):282-287.

7. Fragomen AT, Borst E, Schachter L, Lyman S, Rozbruch SR. Complex Ankle Arthrodesis Using the Ilizarov Method

Yields High Rate of Fusion. Clin Orthop Relat Res. 2012;470:2864-2873.

8. Carlsson A. Unsuccessful Use of a Titanium Mesh Cage in Ankle Arthrodesis: A Report on Three Cases Operated Due to

a Failed Ankle Replacement. J Foot Ankle Surg. 2008;47(4)337-342.

9. Bullens P, Malefijt MdW, Louwerens JW. Conversion of Failed Ankle Arthroplasty to an Arthrodesis Technique Using and

Arthrodesis Nail and a Cage Filled with Morsellized Bone Graft. Foot Ankle Surg. 2010;16:101-104.

10. Sagherian BH, Claridge RJ. Porous Tantalum as a Structural Graft in Foot and Ankle Surgery. Foot Ankle Int.

2012;33(3):179-189.

11. Sagherian BH, Claridge RJ. Salvage of Failed Total Ankle Replacement Using Tantalum Trabecular Metal: Case Series.

Foot Ankle Int. 2015;36(3):318-324.

12. Cohen MM, Kazak M. Tibiocalcaneal Arthrodesis with a Porous Tantalum Spacer and Locked Intramedullary Nail for

Post-Traumatic Global Avascular Necrosis of the Talus. J Foot Ankle Surg. 2015;54:1172-1177.

13. Myerson MS, Neufeld SK, Uribe J. Fresh-Frozen Structural Allografts in the Foot and Ankle. J Bone Joint Surg. 2005;87-

A(1):133-120.

14. Berkowitz MJ, Clare MP, Walling AK, Sanders RW. Salvage of Failed Total Ankle Arthroplasty with Fusion Using

Structural Allograft and Internal Fixation. Foot Ankle Int. 2011;32(5):493-502.

15. Deleu PA, Bevernage BD, Maldague P, Gombault V, Leemrijse T. Arthrodesis After Failed Total Ankle Replacement.

Foot Ankle Int. 2014;35(6):549-557.

16. Plaass C, Knupp M, Barg A, Hintermann B. Anterior Double Plating for Rigid Fixation of Isolated Tibiotalar Arthrodesis.

Foot Ankle Int. 2009;30(7):631-639.

17. Sakurakichi K, Tsuchiya H, Uehara K, Kabata T, Yamashiro T. Ankle Arthrodesis Combined with Tibial Lengthening

Using the Ilizarov Apparatus. J Orthop Sci. 2003;8:20-25.

18. Rochman R, Hutson JJ, Alade O. Tibiocalcaneal Arthrodesis Using the Ilizarov Technique in the Presence of Bone Loss

and Infection of the Talus. Foot Ankle Int. 2008;29(10):1001-1008.

19. Schottel PC, Muthusamy S, Rozbruch R. Distal Tibial Periarticular Nonunions: Ankle Salvage with Bone Transport. J

Orthop Trauma. 2014;28(6):e146-e152.

20. Ilizarov GA. The Tension-Stress Effect on the Genesis and Growth of Tissues-Part I: The Influence and Stability of

Fixation and Soft-Tissue Preservation. Clin Orthop Relat Res. 1989;238:249-281.

21. Schoenleber SJ, Hutson Jr JJ. Treatment of Hypertrophic Distal Tibia Nonunion and Early Malunion with Callus

Distraction. Foot Ankle Int. 2015;36(4):400-407.

22. Berkowitz MJ, Sanders RW, Walling AK. Salvage Arthrodesis After Failed Ankle Replacement: Surgical Decision Making.

Foot Ankle Clin N Am. 2012;17:725-740.

23. Gross C, Erickson BJ, Adams SB, Parekh SG. Ankle Arthrodesis After Failed Total Ankle Replacement-A Systematic

Review of the Literature. Foot Ankle Spec. 2015;8(2):143-151.

24. DeCoster TA, Gehlert RJ, Mikola EA, Pirela-Cruz MA. Management of Posttraumatic Segmental Bone Defects. J Am

Acad Orthop Surg. 2004;12:28-38.

The concept of Illizarov’s Tension-

Stress Effect suggests a 2-3x increase

in blood flow to the adjacent fusion site

during distraction osteogenesis (20).

These biologic principles suggest a

potential benefit to fusion with

concurrent lengthening though a distal

tibial corticotomy when performing

rearfoot fusion or in acute correction for

distal tibial deformity (Figure 1).

Fig. 1. Schematic representing distal tibial distraction in the setting of talectomy. This is

also representative of the technique for distal tibial angular deformity correction in the

setting of LLD as well as total ankle explantation.

E

Tibiocalcaneal Arthrodesis with Loss of Height (Figure 3)

• Following preoperative evaluation, excision of nonviable bone or total

ankle implant was conducted and both tibial and calcaneal surfaces were

prepared for fusion.

• This was followed by temporary stabilization with an intramedullary

Steinmann pin during application of CEF.

• The fusion site was then compressed and a percutaneous DTC was

conducted and subsequently compressed and maintained during the

latency period before distraction was commenced at a rate of 0.5 mm/day

for the intraoperatively determined duration to regain adequate limb

length.

A B

D

C

E

A B C D