In developing countries such as India, fractures of the shaft of the tibia are common due to the higher incidence of road traffic accidents ^[1]. With the proper application of orthopedic principles in the management of fractures, the complications are minimal. However, in our clinical setting and environment, not all patients opt for treatment due to inaccessibility to medical care, lack of monetary funds, or lack of knowledge ^[2]. Following improper treatment, malunion is a frequent complication that can lead to shortening, angular, or rotational malalignment [3-5]. In general, an angulation of 5–8° malrotation of 15–20° and shortening of 2 cm can be well tolerated by a patient ^[5]. In addition to the patient, management of such deformities can be a challenge to a surgeon due to associated soft-tissue contractures along with the bony deformity ^[6]. However, advances in orthopedic principles of operative management have provided necessary treatment solutions for the management of post-traumatic deformities. Corrective osteotomy and internal fixation, external fixation with rods and pins, and Ilizarov ring fixation are some of the treatment options. In severe deformities associated with comorbidities, amputation can act as a last resort [5,7,8].

A 57-year-old female presented to our outpatient department (OPD) with a deformity of her left leg and difficulty in walking. She gave a history of falls, following which she complained of pain and difficulty to weight bear on her left leg and went to a local quack for further treatment. After being splinted for a month, she complained of deformity over her left leg, which subsequently progressed over the course of the next month. She has been unable to bear weight on the affected leg since then and came to our OPD for medical treatment. On local examination, she had an angular deformity in the anteroposterior plane in the middle third of the left leg with no mobility in the mediolateral or anteroposterior plane. There was no tenderness or local rise in temperature. A scar was seen of approximately 1.5 × 1.5 cm over the anteromedial aspect of the left leg. The knee and ankle range of motion was restricted, and there was no neurovascular deficit. Approximately 7 cm shortening of the ipsilateral leg was seen due to angular deformity (Fig. 1).

Anteroposterior and lateral radiographs of the leg showed malunited fractures of the shaft of the tibia and fibula with anterior angulation (Fig. 2).

A complete pre-operative blood investigation was done, and the patient was screened for any signs of active infection. After a thorough explanation regarding the operative treatment and consent from the patient, she was posted for a single-stage deformity corrective surgery with internal fixation. Pre-operative planning included correcting the longitudinal axis of the tibia in both the anteroposterior and lateral planes. The osteotomy level and angle were calculated before surgery (Fig. 3).

A 10 cm skin incision was taken anterolaterally on the apex of the deformity. After soft-tissue dissection, K-wires were inserted at the level of osteotomy, and osteotomy was done with a drill saw (Fig. 4a and b). After deformity correction post-osteotomy, a guidewire was inserted from the tibial plateau, and an intramedullary interlocking nail was inserted through it for internal fixation (Fig. 5-7).

Postoperatively, the patient had an acceptable shortening of 1 cm, was discharged after 3 days, and was advised of protected weight bearing for the initial 3 weeks, followed by full weight bearing thereafter. She was kept under close follow-up to assess clinical and radiological outcomes. No intraoperative or post-operative complications were noted. After 6 months postoperatively, she achieved clinical and radiological union with no complaints at present (Fig. 8-10).

Angular deformity arising from a malunited shaft of tibia fracture can lead to cosmetic and functional derangement for the patient. However, the deformity can be successfully corrected with good clinical and radiological outcomes, as demonstrated by the index case. The choice of surgery for correction of deformity depends on a lot of factors such as the degree of angulation, soft-tissue condition, and experience of the surgeon, as well as the availability of choice of implant [9,10]. Corrective osteotomy for a malunited long bone fracture is of two types, namely: (1) Angulation only or (2) angulation with translational osteotomy. Angulation-only osteotomy is divided into open-wedge and closed-wedge osteotomy. Open wedge osteotomy prevents shortening; however, it runs the risk of fracture gap, thereby further leading to non-union and reoperation if the gap is not filled with bone grafts. Closed-wedge osteotomy may lead to shortening but has lesser non-union and reoperation rates as compared to open-wedge osteotomy ^[11]. The choice of osteotomy, thus largely depends on the choice of a surgeon as well as available resources. In the index case, a closed wedged angulation-only osteotomy was preferred with an acceptable shortening of 1 cm as there was no rotational deformity. After corrective osteotomy, internal fixation can be achieved by intramedullary nailing or using locking plates. In a cohort study done by Barcak and Collinge ^[12], 86 patients treated with either intramedullary nails or locking plates were compared for clinical and radiological outcomes. Marginally enhanced functional outcomes were seen in the group treated with intramedullary nailing as compared to locking plates. Complication rates such as non-union, malalignment, and infection were similar between the two. The intramedullary nail was chosen as the method of fixation in the index case due to the monetary limitations of the patient as well as ease of availability. Acceptable criteria for diaphyseal fractures of the tibia include varus/valgus angulation of <5°, anterior-posterior angulation of <10°, rotational angulation of <10°, and shortening ≤1 cm ^[3]. The patient had an acceptable shortening of 1 cm. The closed-wedge osteotomy with intramedullary nail fixation allowed us to successfully achieve clinical and radiological outcomes by correcting malunion while maintaining the biological stimulus, thereby creating the ideal environment for fracture repair without the need for bone grafts. The only complication we had was of 1 cm shortening which was within the acceptable criteria.

Intramedullary nailing following deformity correction surgery is a useful tool to maintain the length, alignment, and rotation of the limb. It provides for early weight bearing and mobilization of the patient. With a good knowledge of the anatomical axis and the center of the axis of rotation, malunion can be corrected and maintained with a fixation device of the surgeon’s choice. This case report highlights the benefits of using intramedullary nails as a fixation device for post-deformity correction.

The malunited shaft of the tibia with angular deformity can be corrected using an intramedullary nail. Knowledge of the center of rotation of angulation and pre-operative planning can help achieve a good functional outcome even in severe angular deformities.