Double-Level Closing-Wedge Osteotomy Guided by the Center of Rotation of Angulation for a Neglected Distal Tibiofibular Valgus Malunion in a 13-Year-Old Boy: An Observasional Analytic Case Study

Abstract

Background: Pediatric distal tibiofibular fractures treated by traditional bone setters without radiographs may heal in multiplanar valgus malunion, with lateral tibiotalar overload and a risk of early arthrosis.

Objective: To describe the deformity analysis, surgical technique, and one-year outcome of single-stage center of rotation of angulation (CORA)-guided double-level closing-wedge osteotomy for a neglected pediatric distal tibiofibular valgus malunion.

Methods: This study describes a 13-year-old boy seen 12 months after a road-traffic injury treated by a traditional bone setter without radiographs. Preoperative analysis showed a coronal valgus CORA of 16.9° (apex 4.01 cm above plafond), a sagittal CORA of 18.1° (apex 3.59 cm above plafond), a resultant oblique angulation (θ_net) of 24.1°, a tibial anterior surface (TAS) angle of 76.4°, and a tibial lateral surface (TLS) angle of 76.0°. In one operation, a lateral fibular closing-wedge osteotomy was fixed with a one-third tubular plate and an anterolateral, physeal-sparing tibial closing-wedge osteotomy with a distal tibial T-locking plate. Outcomes were recorded from presentation (T0) to 12 months (T4).

Results: At one year (T4), TAS improved from 76.4° to 93.0° and TLS from 76.0° to 84.0°, and coronal and sagittal angulation were corrected to near neutral. Both osteotomies had united, and the patient walked without restriction and squatted fully without pain. No complications occurred.

Conclusion: In this patient, single-stage CORA-guided double-level closing-wedge osteotomy with physeal-sparing locking fixation restored alignment and painless function at one year; the approach may be considered for neglected pediatric distal tibiofibular malunion.