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Scientific Articles   |    
Ankle Valgus Deformity Secondary to Proximal Migration of the Fibula in Tibial Lengthening with Use of the Ilizarov External Fixator
Hui Wan Park, MD1; Hyun Woo Kim, MD1; Yoon Hae Kwak, MD2; Jae Young Roh, MD3; Jae Jeong Lee, MD1; Ki Seok Lee, MD, PhD1
1 Department of Orthopaedic Surgery, Severance Children's Hospital, Yonsei University College of Medicine, 250 Seongsanno, Seodaemun-gu, Seoul 120-752, South Korea. E-mail address for K.S. Lee: leeks@yuhs.ac
2 Department of Orthopaedic Surgery, Hallym University Sacred Heart Hospital, 896 Pyeongchon-dong, Dongan-gu, Anyang-si, Gyeonggi-do 431-796, South Korea
3 Department of Orthopaedic Surgery, Konyang University Hospital, Gasuwon-dong, Seo-gu, Daejeon 302-718, South Korea
View Disclosures and Other Information
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

Investigation performed at Severance Children's Hospital, Yonsei University College of Medicine, Seoul, South Korea

Copyright © 2010 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2011 Feb 02;93(3):294-302. doi: 10.2106/JBJS.I.01316
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Abstract

Background: 

Ankle valgus deformity secondary to proximal migration of the fibula following an Ilizarov tibial lengthening has not been discussed in detail in the literature. The purposes of this study were to determine the underlying mechanism of and to identify factors associated with proximal migration of the fibula that caused ankle valgus deformity after an Ilizarov tibial lengthening.

Methods: 

We reviewed the outcome of seventy-four bilateral Ilizarov tibial lengthenings for short stature in thirty-seven patients. The mean age at the time of surgery was 21.7 years (range, thirteen to thirty-one years), and the mean duration of follow-up was forty-five months. Proximal migration of the fibula was assessed with changes in the malleolar tip distance. A valgus change of =5° in the tibiotalar angle was regarded as ankle valgus deformity following tibial lengthening.

Results: 

The average length gain was 6.9 cm (range, 4.7 to 11.5 cm), and the average lengthening index was 1.5 mo/cm. Valgus deformity developed in six ankles (8%) and fibular nonunion developed in ten (14%). Proximal migration of the lateral malleolus of =5 mm was related to valgus talar tilting. Bifocal tibial lengthening, rapid distraction rate of the fibula (>1 mm per day), and development of a fibular nonunion were factors associated with proximal migration of the distal end of the fibula of =5 mm, which suggests that regenerated bone of poor quality in the distraction gap may cause proximal migration of the distal end of the fibula following tibial lengthening.

Conclusions: 

Proximal migration of the distal end of the fibula following tibial lengthening may occur even with the use of an Ilizarov ring fixator. This migration seems to be caused by collapse of regenerated bone of poor quality or fibular nonunion. Proximal migration of =5 mm is associated with the risk of valgus talar tilting. Surgeons should consider earlier intervention with bone-grafting if there are conditions that compromise regenerated bone formation in the fibular distraction gap, such as can occur with extensive tibial lengthening by bifocal corticotomy.

Level of Evidence: 

Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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