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. 2008 Dec;466(12):3003-10.
doi: 10.1007/s11999-008-0489-8. Epub 2008 Sep 18.

Tibial lengthening: extraarticular calcaneotibial screw to prevent ankle equinus

Mohan V Belthur  1 , Dror Paley, Gaurav Jindal, Rolf D Burghardt, Stacy C Specht, John E Herzenberg
Affiliations

Tibial lengthening: extraarticular calcaneotibial screw to prevent ankle equinus

Mohan V Belthur et al. Clin Orthop Relat Res. 2008 Dec.

Abstract

Between 2003 and 2006, we used an extraarticular, cannulated, fully threaded posterior calcaneotibial screw to prevent equinus contracture in 10 patients (four male and six female patients, 14 limbs) undergoing tibial lengthening with the intramedullary skeletal kinetic distractor. Diagnoses were fibular hemimelia (two), mesomelic dwarfism (two), posteromedial bow (one), hemihypertrophy (one), poliomyelitis (one), achondroplasia (one), posttraumatic limb-length discrepancy (one), and hypochondroplasia (one). Average age was 24.5 years (range, 15-54 years). The screw (length, typically 125 mm; diameter, 7 mm) was inserted with the ankle in 10 degrees dorsiflexion. Gastrocnemius soleus recession was performed in two patients to achieve 10 degrees dorsiflexion. Average lengthening was 4.9 cm (range, 3-7 cm). Screws were removed after a mean 3.3 months (range, 2-6 months). Preoperative ankle range of motion was regained within 6 months of screw removal. No neurovascular complications were encountered, and no patients experienced equinus contracture. We also conducted a cadaveric study in which one surgeon inserted screws in eight cadaveric legs under image intensifier control. The flexor hallucis longus muscle belly was the closest anatomic structure noted during dissection. The screw should be inserted obliquely from upper lateral edge of the calcaneus and aimed lateral in the tibia to avoid the flexor hallucis longus muscle.

Level of evidence: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

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Figures

Fig. 1A–B
Fig. 1A–B
(A) The patient had a malunited left tibial fracture with shortening and translational deformity. (B) Postoperative anteroposterior and lateral views show the ISKD in place before the start of lengthening. Note the position of the EAAS screw. A 4.5-mm diameter distal tibiofibular syndesmosis screw was also inserted to prevent disruption of the ankle mortise during lengthening.
Fig. 2A–B
Fig. 2A–B
Intraoperative image intensifier (A) anteroposterior and (B) lateral views show the position of the EAAS screw in a cadaveric specimen. Note the screw starts on the back of the tuberosity of the calcaneus and is angled slightly on the anteroposterior view.
Fig. 3A–B
Fig. 3A–B
Cadaveric dissection shows (A) posterior and (B) lateral views of the EAAS screw and its relation to the sural nerve, posterior tibial nerve, flexor hallucis longus (FHL) muscle belly, and peroneal tendons.
Fig. 4A–E
Fig. 4A–E
(A) The illustration shows a posterior view of the foot with the EAAS screw inserted. (B) A mediolateral view of the EAAS screw shows three cross-sectional levels of interest. (C) The cross-sectional view at level I shows the relationship of the screw to structures at risk. (D) The cross-sectional view at level II shows the close relationship of the EAAS screw to the flexor hallucis longus muscle belly. FHL = flexor hallucis longus muscle. (E) The cross-sectional view at level III is shown.
See this image and copyright information in PMC

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