Proximal Tibial Growth Arrest with Varus, Recurvatum, and Shortening After ACL Reconstruction

Abstract

This is a case of a tibial growth arrest that occurred after anterior cruciate ligament (ACL) reconstruction with a trans-epiphyseal tunnel done at age 12. This resulted in LLD, varus and recurvatum deformity. We describe this case and the correction using distraction osteogenesis in conjunction with a Taylor Spatial Frame (TSF) (Smith & Nephew Inc, Memphis, Tennessee, USA) using the Ilizarov method.

Brief Clinical History:

A 17-year-old male patient had an acquired leg-length discrepancy (LLD) and deformity after ACL reconstruction performed at age 12 after a ski injury. Reconstruction was performed using an Achilles allograft by an experienced surgeon. The graft was fixed in an anatomically placed tibial tunnel in which a plug was countersunk and tied over a button for secure fixation. No tunnel was drilled on the femoral side, and the graft was placed intra-articularly and over the top of the lateral femoral condyle. The Achilles allograft was then put on tension and fixed to the lateral femur using 2 small staples. Over the course of several years, there progressively emerged a deformity of the right tibia associated with an LLD. The patient lived overseas and there was little follow-up with the ACL surgeon. He was referred to our service and came for treatment at age 17, which was 4.5 years after initial ACL surgery.

Preoperative Problem List

• LLD = 4.5 cm
• Predicted LLD = 5.5 cm
• Varus deformity 15 degrees
• Recurvatum deformity 28 degrees
• External rotation deformity 15 degrees
• Damaged proximal tibial growth plate

Treatment Strategy

1. Close remaining proximal tibial growth plate to avoid additional deformity
2. Calculate the growth remaining from the proximal tibial growth plate which in this case was 1 cm.
3. Perform osteotomy at proximal tibia and fibula to correct varus, recurvatum, external rotation.
4. Lengthen tibia a total of 5.5 cm (4.5 cm preoperative LLD + 1 cm growth remaining that was stopped)
5. Use distraction osteogenesis and the TSF for complex deformity correction and bone lengthening.

Basic Principles

1. Growth arrest of the antero-medial aspect of the proximal tibial growth plate (presumably related to the tibial bone tunnel and ACL graft) led to a varus and recurvatum deformity.
2. The rotational deformity is more difficult to explain but likely occurred from the same etiology
3. The oblique plane deformity (apex posterolateral) and rotational deformity will be corrected gradually with distraction osteogenesis using the TSF
4. Current LLD is 4.5 cm. Using growth remaining calculations for the proximal tibial growth plate, another 1 cm of growth is expected to occur (His bone age was 15)
5. Close proximal tibial growth plate so not additional deformity will occur after the correction.

Technical Pearls:

1. Make the proximal ring the reference ring since it is close to the apex of deformity and the origin.
2. Use a 2/3 ring proximally so the knee can bend beyond 90 degrees.
3. Apply the TSF to match the deformity
4. Stabilize the tibia and fibula both proximal and distal with tensioned wire. This will prevent fibula migration.
5. Use TSF planning to determine the necessary coronal and sagittal plane translation needed during the lengthening and deformity correction.

Avoiding and Managing Problems

1. Avoid recurrence of deformity by closing damaged proximal tibial growth plate
2. Avoid LLD by calculating the predicted LLD and over lengthening the affected side.
3. Do not remove frame until 3 cortices are seen on bi-planar x-rays.
4. Apply long leg cast after frame removal as a transitional phase to prevent fracture

Cross-References

1. Valgus and shortening of distal femur from growth arrest treated with monolateral frame. 383256
2. Oblique plane deformities of femur and tibia after open fracture treated with TSF. 383216
3. Guided growth for partial growth arrest. 383240
4. Adolescent with 7-cm Femoral Shortening due to Physeal Growth Deceleration: Femoral Lengthening with PRECICE Retrograde Intramedullary Nail. 383288

References and Suggested Reading

1. Goldman V, McCoy TH, Harbison M, Fragomen AT, Rozbruch SR: Limb Lengthening in Children with Russell-Silver Syndrome: A Comparison to Other Etiologies. J Children’s Orthop 2013, 7:151-6, Epub 2013 Jan 5.

2. Rozbruch SR, Fragomen A, Ilizarov S: Correction of Tibial Deformity Using the Ilizarov/ Taylor Spatial Frame. J Bone Joint Surg Am 88-A 2006, supplement 4, pages 156-174.

3. Rozbruch SR, Segal K, Ilizarov S, Fragomen AT, Ilizarov G: Does the Taylor Spatial Frame Accurately Correct Tibial Deformities? Clin Orthop Rel Res 2010 May :468(5): 1352-61

4. Rozbruch SR, Schachter L, Bigman D, Marx R: Growth Arrest of the Tibia after ACL Reconstruction: Lengthening and Deformity Correction with the Taylor Spatial Frame. Published online before print April 25, 2013, doi: 10.1177/0363546510369318; Am. J Sports Med, 2013, 41(7):1636-1641.

Authors