Is there an Increase in Valgus Deviation in Tibial Distraction Using the Lengthening Over Nail Technique?

Abstract

Background During tibial lengthening, the soft tissues of the posterolateral compartment produce distraction-resisting forces causing valgus angulation. Although this occurs with the classic Ilizarov method, whether a valgus deformity develops with the lengthening over nail (LON) technique is questioned, because the intramedullary nail is thought to resist deforming forces and adequately maintain alignment of the distracted bone. Questions/purposes The purposes of this study were to (1) determine the amount of valgus deviation during tibial lengthening with the LON technique; and (2) analyze the factors that may be associated with valgus deviation with the LON technique. Methods Between June 2009 and September 2013, we performed 346 tibial lengthenings using the LON technique, lengthening and then nail technique, or lengthening with an intramedullary lengthening device. Sixty patients (120 tibias) who underwent bilateral lower leg lengthening with the LON technique were enrolled in this retrospective study. To limit the number of variables, we analyzed only the right tibia in all patients (60 tibias). The mean followup was 42 months (range, 26-71 months). The mean age of the patients was 25 years (range, 18-40 years). There were 36 male and 24 female patients. The mean final length gain was 67 ± 9 mm. The mean time for distraction was 100 ± 25 days. The overall valgus deviation was assessed by measuring the change in the medial proximal tibial angle and mechanical femorotibial angle on radiographs obtained before and after surgery and after completion of lengthening. Several demographic, surgical, and distraction-related variables were considered possible factors to prevent valgus deviation: proximal fixation method; presence of a blocking screw; diameter and length of the intramedullary nail; degree of nail insertion; length of the nail in the distal segment after completion of distraction; final length gain; and patient's BMI. During the period studied, the blocking screw was to maintain the mechanical axis in patients who had neutral or valgus alignment preoperatively, or to prevent more valgus change in patients who underwent acute correction of varus deformity intraoperatively. Uni-and multivariate analyses were conducted. Results Valgus deviation occurred during the tibial LON. The medial proximal tibial angle increased from 86°(95% CI, 85°-86°) to 90°(95% CI, 89°-91°) (p \ 0.001). The mechanical femorotibial angle changed from 2.2°varus (95% CI, 3°-1.4°varus) to 2.6°valgus (95% CI, 1.8°-3.4°E

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“…Isik et al 35 applied percutaneous clamps and forceps that were extremely effective in obtaining and maintaining reduction while reaming and during passage of the nail. Previous studies 36,37 showed the application of a femoral distractor to maintain tibial alignment. During surgery, traction pins are placed posterior to the central axis of the proximal tibial metaphysis and the distal end of the tibia.…”