Nontraumatic Osteonecrosis of the Distal Tibia: A Case Presentation and Review of the Literature

Abstract

Osteonecrosis, although commonly occurring in the hip, can also affect the leg and foot. In the foot, it most commonly occurs in the talus. The incidence of osteonecrosis occurring in the tibia is relatively rare. We report a case of a woman who presented to our clinic with ankle pain that was idiopathic in nature. Subsequent magnetic resonance imaging showed findings consistent with osteonecrosis of the bilateral distal tibias and several other lesions located in the shoulder, hip, and calcaneus. The present report also serves as a review of both etiology and treatment of osteonecrosis as it relates to the lower extremity.

Keywords: alcohol; ankle; avascular necrosis; corticosteroids; diaphyseal metaphyseal bone.

Fig. 1

Magnetic resonance imaging study showing relatively symmetrical lesions of avascular necrosis in the coronal (A), sagittal (B), and transverse (C) slices of the bilateral diaphyseal–metaphyseal junctions of the tibias. (D) Note the osteonecrotic lesion in the tubercle of the left calcaneus. LT, left; RT, right.

Fig. 2

Computed tomography study showing lesions of avascular necrosis in the coronal (A), sagittal (B), and transverse (C) slices of the diaphyseal–metaphyseal junctions of the right tibia.

Fig. 3

Arthroscopic views of the right ankle showing synovitis (A and B); medial shoulder osteochondritis dissecans (C and D); and subsequent curettage and micro-fracture of the lesion (E and F). Note that the tibial cortex is intact with no signs of communication with the osteonecrotic cyst.

Fig. 4

View of 8-cm linear incision along the anterior aspect of the distal tibia just lateral to the course of the anterior tibial tendon. Note the incision sites from the anterior medial and lateral portals from the ankle arthroscopy.

Fig. 5

The cortical window measuring approximately 3 × 2 cm was carefully resected using a sagittal saw.

Fig. 6

An approximately 10-cm³ deficit with intact cortical bone posteriorly.

Fig. 7

The defect was filled with AlloStem^® and geneX^® (A), and the cortical window was placed back into its original orientation (B).

Fig. 8

The defect and cortical window were secured with a Synthes/Depuy mesh plate. Note the 1 screw going directly through the cortical window.

Fig. 9

Radiographs (A) and computed tomography images (B) at 9 weeks postoperatively showing the hardware in good alignment, with no residual avascular necrosis. Incorporation of the bone substitutes into native bone can also be observed.

Fig. 10

Histopathologic slide showing nonviable trabecular bone with empty cellular lacunae indicative of osteonecrosis.

Fig. 11

Final radiographs taken 24 months postoperatively showing native bone incorporation with all hardware intact.