A 53-year-old male twisted his leg while downhill skiing and sustained an OTA classification 43-A2.3 (4) closed fracture of the distal tibia and fibula. Both fractures were treated with open reduction and locking plates in January 2009. A non-union developed with loosening of the osteosynthesis, and 7 months after the initial operation the patient was reoperated with bone allograft and exchange of the plates and screws. The non-union did not heal. The patient was referred to our institution 20 months after the first reoperation. At this time, the tibial plate was loose, with broken screws (Figure 1). The tibia had a varus deformity of 16 degrees and was 2.2 cm shortened (Figure 1). The non-union site was tested clinically and found to be loose.
We operated the patient 24 months after the first reoperation. After removal of all previously inserted implants and screws, except a distal AP screw, the non-union site was found at surgery to be atrophic. The non-union site (3.1 cm bone segment) was resected to vital bone. The fibula was osteotomized at the level of the tibial resection. A proximal percutaneous tibial osteotomy was performed 9 cm from the knee joint line. A custom-made motorized tibial lengthening nail (Fitbone TSA (Tibial Segment Actuator) was inserted. The nail had a length of 35 cm and was capable of 4 cm of bone transport initially and 2 cm of bone lengthening subsequently. The nail had 8 degrees of anterior bending, starting 40 mm from the proximal tip of the nail. The nail was locked with 2 proximal and 2 distal locking screws to the tibia. In addition, a screw was inserted into a sliding hole in the middle part of the tibia, allowing bone transport of the middle tibial segment (Figure 2). A tibio-fibular screw was inserted distally to protect the distal tibio-fibular joint. Acute shortening of the bone defect was not performed. A radiograph taken immediately after surgery showed that 3.1 cm of bone had been resected. Bone transport was initiated 10 days postoperatively at a rate of 1 mm daily (Figure 3). There were no clinical signs of infection and the white blood cell and C-reactive protein levels were normal before surgery. However, biopsies of the resected bone were cultured and showed growth of coagulase-negative staphylococci, which were sensitive to dicloxacillin. Dicloxacillin was therefore administered orally for 3 months.
4 weeks postoperatively, 3.3 mg of recombinant BMP-7 (eptotermin alfa, Osigraft; Stryker) was administered percutaneously to the docking site. A loose proximal locking screw was exchanged at the same surgery and intraoperative fluoroscopy showed that the fibula osteotomy was still loose, allowing lengthening of the fibula. Partial weight bearing was allowed from 2 months postoperatively when the proximal tibia had been lengthened 5 cm (3 cm of bone transport plus 2 cm of leg lengthening). The docking site was united 5 months postoperatively, and full weight bearing was allowed at this time. Healing time for the regenerate was 45 days/cm of bone lengthening. The distal tibio-fibular screw bothered the patient and was removed at 6 months postoperatively. The nail was removed 15 months postoperatively. At the latest follow-up, 18 months after nail insertion and 3 months after nail removal, the patient had no pain or restrictions in daily activities. Motion of the knee and the ankle on the operated side was equal to that on the healthy side. Motion of the knee was from full extension to 140 degrees of flexion and motion of the ankle was from 15 degrees of dorsal flexion to 30 degrees of plantar flexion. An AP radiograph showed no mechanical axis deviation in the operated leg compared to the healthy leg. There was equal leg length. There was a 3-degree varus deformity in the frontal plane. There was no deformity in the sagittal plane on the lateral radiograph. The posterior proximal tibial angle (PPTA) and the anterior distal tibial angle (ADTA) equalled the preoperative values of 78 degrees (PPTA) and 83 degrees (ADTA). There have not been any clinical signs of infection.