Original Research

Improved Function and Joint Kinematics After Correction of Tibial Malalignment

Am J Orthop. 2014 December;43(12):E313-E318

Malunion after tibia fracture can have a negative effect on a patient’s gait, joint kinematics, and functional outcome.

We conducted a study to determine whether surgical correction of malunited tibias improves gait, joint kinematics, and patients’ perception of their health and overall well-being.

Eleven patients with tibial malunions were treated with osteotomy, deformity correction, and open reduction and internal fixation (ORIF). Minimum follow-up was 7 months (mean, 11 months; range, 7-17 months).

In all cases, the osteotomy eventually healed. Two patients needed revision surgery: One had late collapse of the regenerate bone and underwent revision ORIF away from the site of deformity correction; the other required exchange intramedullary nailing. Surgical correction of malunited tibia fractures resulted in significant improvement toward the normative in lower extremity joint kinematic values and patients’ perceptions of their health and overall well-being. Surprisingly, there was little effect on gait.

Symptomatic malunited tibia fractures should undergo surgical correction, as it is likely to improve overall lower extremity function and patient satisfaction.

PDF Download

References

1. Probe RA. Lower extremity angular malunion: evaluation and surgical correction. J Am Acad Orthop Surg. 2003;11(5):302-311.

2. van der Linden W, Larsson K. Plate fixation versus conservative treatment of tibial shaft fractures. A randomized trial. J Bone Joint Surg Am. 1979;61(6):873-878.

3. Kettelkamp DB, Hillberry BM, Murrish DE, Heck DA. Degenerative arthritis of the knee secondary to fracture malunion. Clin Orthop. 1988;(234):159-169.

4. Milner SA, Davis TR, Muir KR, Greenwood DC, Doherty M. Long-term outcome after tibial shaft fracture: is malunion important? J Bone Joint Surg Am. 2002;84(6):971-980.

5. Puno RM, Vaughan JJ, Stetten ML, Johnson JR. Long-term effects of tibial angular malunion on the knee and ankle joints. J Orthop Trauma. 1991;5(3):247-254.

6. Tarr RR, Resnick CT, Wagner KS, Sarmiento A. Changes in tibiotalar joint contact areas following experimentally induced tibial angular deformities. Clin Orthop. 1985;(199):72-80.

7. Ting AJ, Tarr RR, Sarmiento A, Wagner K, Resnick C. The role of subtalar motion and ankle contact pressure changes from angular deformities of the tibia. Foot Ankle. 1987;7(5):290-299.

8. van der Schoot DK, Den Outer AJ, Bode PJ, Obermann WR, van Vugt AB. Degenerative changes at the knee and ankle related to malunion of tibial fractures. 15-year follow-up of 88 patients. J Bone Joint Surg Br. 1996;78(5):722-725.

9. Kristensen KD, Kiaer T, Blicher J. No arthrosis of the ankle 20 years after malaligned tibial-shaft fracture. Acta Orthop Scand. 1989;60(2):208-209.

10. McKellop HA, Sigholm G, Redfern FC, Doyle B, Sarmiento A, Luck JV Sr. The effect of simulated fracture-angulations of the tibia on cartilage pressures in the knee joint. J Bone Joint Surg Am. 1991;73(9):1382-1391.

11. Merchant TC, Dietz FR. Long-term follow-up after fractures of the tibial and fibular shafts. J Bone Joint Surg Am. 1989;71(4):599-606.

12. Paley D, Herzenberg JE, Tetsworth K, McKie J, Bhave A. Deformity planning for frontal and sagittal plane corrective osteotomies. Orthop Clin North Am. 1994;25(3):425-465.

13. Perry J. Gait Analysis: Normal and Pathological Function. Thorofare, NJ: Slack; 1992.

14. Puno RM, Vaughan JJ, von Fraunhofer JA, Stetten ML, Johnson JR. A method of determining the angular malalignments of the knee and ankle joints resulting from a tibial malunion. Clin Orthop. 1987;(223):213-219.

15. Greenwood DC, Muir KR, Doherty M, Milner SA, Stevens M, Davis TR. Conservatively managed tibial shaft fractures in Nottingham, UK: are pain, osteoarthritis, and disability long-term complications? J Epidemiol Community Health. 1997;51(6):701-704.

16. Dehne E, Deffer PA, Hall RM, Brown PW, Johnson EV. The natural history of the fractured tibia. Surg Clin North Am. 1961;41(6):1495-1513.

17. Kitaoka HB, Schaap EJ, Chao EY, An KN. Displaced intra-articular fractures of the calcaneus treated non-operatively. Clinical results and analysis of motion and ground-reaction and temporal forces. J Bone Joint Surg Am. 1994;76(10):1531-1540.

18. Borrelli J Jr, Goldfarb C, Ricci W, Wagner JM, Engsberg JR. Functional outcome after isolated acetabular fractures. J Orthop Trauma. 2002;16(2):73-81.

19. Borrelli J Jr, Ricci WM, Anglen JO, Gregush R, Engsberg J. Muscle strength recovery and its effects on outcome after open reduction and internal fixation of acetabular fractures. J Orthop Trauma. 2006;20(6):388-395.

20. Jaglal S, Lakhani Z, Schatzker J. Reliability, validity, and responsiveness of the lower extremity measure for patients with a hip fracture. J Bone Joint Surg Am. 2000;82(7):955-962.

21. Madsen MS, Ritter MA, Morris HH, et al. The effect of total hip arthroplasty surgical approach on gait. J Orthop Res. 2004;22(1):44-50.

22. Mittlmeier T, Morlock MM, Hertlein H, et al. Analysis of morphology and gait function after intraarticular calcaneal fracture. J Orthop Trauma. 1993;7(4):303-310.

23. Song KM, Halliday SE, Little DG. The effect of limb-length discrepancy on gait. J Bone Joint Surg Am. 1997;79(11):1690-1698.

24. Zlowodzki M, Obremskey WT, Thomison JB, Kregor PJ. Functional outcome after treatment of lower-extremity nonunions. J Trauma. 2005;58(2):312-317.

25. Sanders R, Anglen JO, Mark JB. Oblique osteotomy for the correction of tibial malunion. J Bone Joint Surg Am. 1995;77(2):240-246.

26. Sangeorzan BJ, Sangeorzan BP, Hansen ST Jr, Judd RP. Mathematically directed single-cut osteotomy for correction of tibial malunion. J Orthop Trauma. 1989;3(4):267-275.

27. Borrelli J Jr, Leduc S, Gregush R, Ricci WM. Tricortical bone grafts for treatment of malaligned tibias and fibulas. Clin Orthop. 2009;467(4):1056-1063.

28. Engelberg R, Martin DP, Agel J, Obremsky W, Coronado G, Swiontkowski MF. Musculoskeletal Function Assessment instrument: criterion and construct validity. J Orthop Res. 1996;14(2):182-192.

29. Engelberg R, Martin DP, Agel J, Swiontkowski MF. Musculoskeletal Function Assessment: reference values for patient and non-patient samples. J Orthop Res. 1999;17(1):101-109.

30. Swiontkowski MF, Engelberg R, Martin DP, Agel J. Short Musculoskeletal Function Assessment questionnaire: validity, reliability, and responsiveness. J Bone Joint Surg Am. 1999;81(9):1245-1260.

31. Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care. 1992;30(6):473-483.

32. Graehl PM, Hersh MR, Heckman JD. Supramalleolar osteotomy for the treatment of symptomatic tibial malunion. J Orthop Trauma. 1987;1(4):281-292.

33. Bhave A, Paley D, Herzenberg JE. Improvement in gait parameters after lengthening for the treatment of limb-length discrepancy. J Bone Joint Surg Am. 1999;81(4):529-534.

34. Wu DD, Burr DB, Boyd RD, Radin EL. Bone and cartilage changes following experimental varus or valgus tibial angulation. J Orthop Res. 1990;8(4):572-585.

The tibia is the most commonly fractured long bone in adults, and tibial malunions occur in up to 60% of these patients.^1,2 Persistent tibial malalignment, particularly varus alignment, negatively alters gait and joint kinematics, leading to altered weight-bearing forces across the knee and ankle joints. These altered forces may lead to osteoarthritis.^3-8

Several studies have identified a relationship between extent of tibial malalignment and changes in joint reaction forces.^3,5-7,9-13 Puno and colleagues¹⁴ developed a mathematical model to better define the changes in neighboring joints relative to the pattern of the tibia malalignment. Not surprisingly, their work showed that, with distal tibial malunions, altered stress concentrations were realized at the ankle joint, and more proximal tibial deformities led to larger alterations in the joint stresses at the knee. More recently, van der Schoot and colleagues⁸ found a high prevalence of ipsilateral ankle osteoarthritis with tibial malalignment of 5° or more, and Greenwood and colleagues¹⁵ showed a higher incidence of knee pain, lower limb osteoarthritis, and disability in patients with previous tibia fractures. Given these findings, it would seem that correction of tibial malalignment would lead to normative lower extremity joint kinematic values, joint reaction forces, and overall quality of life (QOL).

The ability to ambulate has been recognized as an important milestone in functional recovery after lower extremity injury.^2,16,17 Gait analysis, assessment of joint kinematics, and QOL and health status questionnaires can provide information to evaluate rehabilitation protocols, treatment algorithms, and surgical outcomes. Recently, these measures have been used to assess patients recovering from acetabular fractures, femoral shaft fractures, and calcaneal fractures.^4,11,17-24 However, no study has used these measures to assess the benefits of surgical correction of malaligned tibias.

We conducted a study to determine improvement in gait, joint kinematics, and patients’ perceptions of overall well-being after surgical correction of tibial malunions. The null hypothesis was that correction of tibial malunion would have no effect on gait, joint kinematics, or patients’ perceptions of function and QOL.

Materials and Methods

This prospective double-time-point study, which was approved by the Institutional Review Board of Washington University/Barnes-Jewish Hospital, evaluated 11 consecutive patients with a varus tibial malunion treated by a single surgeon between September 2003 and January 2006. All patients were treated using a technique that included oblique osteotomy and open reduction and internal fixation (ORIF) or osteotomy and intramedullary nailing. Study inclusion criteria were age 18 years or older; symptomatic varus malunion of the tibia of 10º or more; absence of a developmental or pathologic process leading to the fracture and subsequent deformity; no neurologic deficit of either lower extremity or contralateral lower extremity deformity; and ability to ambulate 9 meters with or without use of an assistive device.

The 11 patients (6 men, 5 women) who met these criteria enrolled in the study. Mean age was 53 years (range, 43-68 years). Eight malunions involved the left tibia. The mechanisms of injury were motor vehicle crash (6 patients), fall from a great height (3), being struck by a motor vehicle (1), and gunshot (1). Mean time from injury to corrective surgery was 16.9 years (range, 1-34 years). Before surgery, each patient had a thorough physical examination, with plain radiographs, including anteroposterior (AP), lateral, and oblique views, obtained to assess degree of limb malalignment. Patients completed the Short Form-36 (SF-36) and the Musculoskeletal Function Assessment (MFA) and underwent joint kinematics and gait analysis. Five malunions were located in the mid-diaphysis of the tibia, 3 in the proximal third, and 2 in the distal third of the tibial shaft. One patient had posttraumatic deformity involving the proximal and the mid-diaphysis (Table 1). After surgery, each patient was followed at regular intervals in the surgeon’s private office. Minimum follow-up was 7 months (mean, 11 months; range 7-17 months). At follow-up, radiographs were obtained, and each patient completed the SF-36 and the MFA and underwent joint kinematics and gait analysis.

We obtained preoperative AP and lateral radiographs of the malaligned and contralateral normal tibias for each patient. Angular deformity was determined in the sagittal and coronal planes to determine location and magnitude of the deformity. Specifically, on each AP and lateral radiograph, a line was drawn the length of the tibia proximal and distal to the area of the deformity. The angle generated by the intersection of these lines on the AP and lateral radiographs was then plotted on a grid to determine the precise plane and magnitude of the deformity (Table 2).^1,12 Clinically, relevant rotational deformity of the involved limb was assessed by physical examination, and the results were compared with those of the contralateral limb. Owing to the lack of considerable rotational deformity in any of these 11 patients, we did not obtain computed tomography scans for further assessment of rotation.