Management of Partial Tibial Absence Resulting from Infection
ALVIN A. FREEHAFER, M.D. WILLIAM SCHWAB, M.D.
Chronic osteomyelitis of the tibia can pose many difficult problems in management. The patient to be presented failed to resolve her infection, developed deformity and shortening, was unable to bear weight on the affected limb for almost two years, and finally had most of the tibia removed.
Partial or total congenital absence of the tibia occurs infrequently, and reports on treatment have described useful methods of salvage 1,2,3,5 . When infection results in loss of the tibia, amputation is often the wisest choice of treatment. When the proximal tibia remains, amputation below the knee has been recommended 4 ; but loss of the upper tibia usually has led to above-knee amputation.
The purpose of this article is to present the case history of a child who lost her infected tibia hut maintained the proximal tibial epiphysis, fibula, and foot. The eventual management by amputation, revision, and prosthetic fitting over a 14-year period will be discussed.
D. S. was born September 23, 1962. She was in normal health until she fell down a flight of steps in mid-March, 1964, and injured her right leg. She was taken to a hospital and released when roentgenograms of the right femur and tibia were reported as normal. However, because of persistent pain, inability to walk, development of fever and toxicity, and convulsions, she was admitted to the same hospital March 29, 1964. She was subsequently transferred to the pediatric service at University Hospitals in Cleveland, April 2, 1964, in critical condition.
She was continued on the penicillin and chloromycetin which had been started on March 29, 1964, and prednisone was added for a two-week period. Pain and swelling were located over the right leg just below the knee. Roentgenograms were normal, and cultures from the throat, blood, and tibial aspiration failed to grow pathogens. By April 14, 1964, the temperature had returned to normal, and roentgenograms showed bone resorption of the proximal tibia and some widening of the proximal epiphyseal plate ( Figure 1 ). There was clinical evidence of motion at the proximal tibial epiphyseal plate. At no time was the blood count above 9,000. The orthopaedic service saw the patient and performed an incision and drainage of the upper right leg, thereby establishing open drainage from the tibial medullary canal, on April 14, 1964. This procedure removed a small amount of thin, watery material, which was negative on culture. The patient was managed in a hip spica after surgery. The tibia showed increased resorption and sequestration on July 9, 1964 ( Figure 2 ). Over the course of the ensuing 10 months the right leg was inspected about once every four weeks. The wound failed to heal, the tibial shaft sequestered and separated from the proximal tibial epiphysis, and the upper one-half of the shaft was exposed. Cultures subsequently grew Staphylococcus aureus, Pseudomonas aeruginosa, and Escherichia coli on different occasions.
Because of the failure to heal, the tibia was excised on February 16, 1965, leaving only the proximal tibial epiphysis. The wound healed, but in the course of the next six months the limb shortened 2.5 cm (1 in.) and developed a varus deviation ( Figure 3-A and Figure 3-B ).
Transplantation of the proximal fibula to the proximal tibial epiphysis was done September 18, 1965, and of the distal fibula above the talus on November 4, 1965. Fusion of the fibula and talus occurred in 90 degrees of equinus, but the proximal fibula displaced to its original position, and bony union to the proximal tibial epiphysis failed to occur. In early 1966 the child was fitted with a molded leather long-leg brace and a built-up shoe with the foot in equinus. She walked with this device but had an undesirable appearance and gait. Figure 4-A and Figure 4-B show the appearance of the leg January 5, 1967.
She was referred to the Children's Amputee Clinic at University Hospitals of Cleveland in August, 1967, for advice. At this time she had a fibrous union between the proximal fibula and the proximal tibial epiphysis and a fusion of the distal fibula to the talus. There was mild genu varum, but this could be corrected passively. The foot was painful, and the mother felt the condition was unacceptable.
Amputation of the foot and prosthetic fitting were recommended; and on September 12, 1967, an amputation was done through the hindfoot distal to the talus, this bone having fused to the fibula. This location was chosen to provide greater length for the stump and to prevent bony overgrowth from occurring in the future. The healed stump was then fitted with a modified patellar-tendon-bearing prosthesis with thigh corset, knee hinges, and a SACH foot. Even though some motion occurred between the fibula and the proximal tibial epiphysis, this motion was well controlled and painless in the prosthesis ( Figure 5-A and Figure 5-B ).
In early 1976 the patient began to have difficulty with proper prosthetic fit because of increasing varus angulation of the stump ( Figure 6-A and Figure 6-B ). On April 30, 1976, the proximal 5 cm (2 in.) of fibula were removed; and the remainder of the fibula was transplanted to the middle of the proximal tibial epiphysis.
She now has a good stump, 18 cm (7 in.) in length, with clinical union of the fibula to the tibial epiphysis. Roentgenograms show bony bridging, although not to the extent that might be desired. The range of motion of the stump is 0 degrees to 90 degrees with normal strength and no pain. Her gait is excellent ( Figure 7-A , Figure 7-B , Figure 8-A , and Figure 8-B ).
With correction of the varus deformity of her stump, the patella now subluxes laterally on flexion of the knee. This deviation is asymptomatic now, but the patella probably should he realigned or removed. Because she is doing so well, the plan is to wait and observe her progress.
It would have been desirable to have diagnosed this child's problem much earlier and to have identified specific bacteria as the etiologic agents. The choice of penicillin and chloromycetin can he questioned, but at least the cultures were negative. The pediatrician apparently felt that the critical nature of the child's illness warranted use of prednisone. What effect this had is not known, but it may have made the infection more difficult to control.
Displacement and nonunion of the fibula at the proximal tibial epiphysis in 1965 made the fibular transplantation a failure. It might have been repeated, but the surgeon felt that infection might recur.
The amputation performed September 12, 1967, gave a result far superior to what would have occurred if the earlier surgery had succeeded. It probably would have been much better to have performed the amputation in 1965.
The patient functioned extremely well for over eight years with a below-knee stump even though she had mild varus deformity and motion between the tibial remnant and upper fibula. The transplantation of the flbula on April 30, 1976, might very well have been done earlier; but because the child was doing well and fear of infection existed, it was delayed until it became necessary.
It is interesting to speculate what might have been done had the entire tibia been missing. At the times of tibular transplantation in 1965 and 1976, there was no evidence of infection grossly, microscopically, or by culture. Transplantation of the entire fibula to construct a knee joint when the entire tibia is absent in cases of previous infection might be worth consideration in children under 3 or 4 years of age.
1. Aiken, G. T., Tibial hemimelia. Selected lower-limb anomalies, a Symposium, National Academy of Sciences, Washington, D.C., 1971.
2. Brown. F. W., Construction of a knee joint in congenital total absence of the tibia
(Paraxial Hemimelia Tibia), A preliminary report. J Bone Joint Surg, 47-A:695-704, 1965.
3. Campbell's Operative Orthopaedics. Ed. A. H. Crenshaw, Fifth Edition, pp 1929-1936. The C. V. Mosby Co., St. Louis, 1971.
4. Freehafer, A. A., M. Wasylik, W. A. Mast, and S. H. Lacey, Amputation as a salvage for patients with incapacitating infected fractures of the lower limbs. J Trauma, 16:27-34, 1976.
5. Putti, V., The treatment of congenital absence of the tibia or fibula. Int Abstr Surg, 50:52, 1930.