Joint-preserving surgery for idiopathic bilateral osteonecrosis of the distal tibia: A case report

Abstract

Introduction: Osteonecrosis (ON) is a serious pathological condition that can affect weight-bearing areas of the lower limbs, including the distal tibia. Although trauma is a common cause of ON, the condition has multiple possible etiologies. ON has been associated with a range of factors, including trauma, medication use, alcoholism, and vascular disease. Interruption of blood flow to a particular bone region is the first step in the pathophysiology of ON. Conservative management is typically indicated in the early stages of ON, but joint-preserving procedures may be necessary in cases where conservative treatment fails.

Case report: This article presents a case of bilateral ON of the distal tibia in a 38-year-old female patient without a history of trauma or identifiable risk factors. The patient was initially managed conservatively but ultimately underwent joint-preserving surgery due to treatment failure.

Conclusion: Joint-preserving procedures should be considered in cases of early-stage distal tibia ON that do not respond to conservative management to prevent joint collapse. This case highlights the importance of considering ON as a possible diagnosis even in the absence of identifiable risk factors or trauma.

Keywords: Distal tibia; atraumatic; avascular necrosis; bilateral; osteonecrosis.

Figure 1

Anteroposterior (a) and oblique (b) radiographs of the left ankle showing a subtle area of osteonecrosis in the distal tibia.

Figure 2

Anteroposterior (a) and oblique (b) radiographs of the right ankle showing no abnormality.

Figure 3

Axial (a), coronal (b), and sagittal (c) views of the left ankle magnetic resonance imaging Fat-Sat T2 sequence showing osteonecrosis of the distal tibia.

Figure 4

Axial (a–c) and sagittal (d–f) views of the right ankle, magnetic resonance imaging Fat-Sat T2 sequence showing smaller areas of osteonecrosis of the distal tibia.

Figure 5

Anteromedial approach to the left distal tibia (a) and a window made in the distal tibia for AVN curettage (b–d).

Figure 6

Debridement and curettage of the distal tibia avascular necrosis.

Figure 7

Remplissage with bone graft (a) and reapplication of the cortical window (b).

Figure 8

Fixation of the distal tibia with a Mesh Plate and eight screws.

Figure 9

Post-operative anteroposterior (a) and lateral (b) radiographs of the left distal tibia after excision of avascular necrosis, bone grafting, and fixation.

Figure 10

Anteroposterior (a) and lateral (b) radiographs 6-month postoperatively.