Anterior Distal Femoral Hemiepiphysiodesis Using Coronally Oriented 8-plates for the Correction of Fixed Knee Flexion Deformities in Children-Preliminary Results

INTRODUCTION

The original technique for guided growth of the distal femur for correction of pediatric fixed knee flexion deformities (FKFDs) involves the utilization of two 8-plates inserted on either side of the trochlear groove, a technique that has been frequently linked to the development of persistent postoperative knee pain and crepitus. The present study aimed to assess the preliminary results of a novel technique where the two 8-plates are fixed in the coronal plane, one on each of the medial and lateral surfaces, so that they occupy the anterior part of the distal femur.

METHODS

Our study was a prospective case series that included cases with FKFD of >10 degrees in children with at least 12 months of predicted growth remaining. The preoperative knee flexion contracture angle was documented. The surgical procedure entailed the insertion of 2 coronally oriented 8-plates on the medial and lateral surfaces of the distal femur as anterior as possible to the axis of the femur without encroachment on the trochlear groove. The duration of time required to attain full knee extension and any complications encountered were recorded. Wilcoxon signed-rank was used to compare the preoperative and final contracture angles. The level of statistical significance was set at P <0.05.

RESULTS

Thirteen knees in 8 patients (6 boys and 2 girls) were included. The median age was 11 years (6 to 14). There was a significant improvement in the FKFD for the whole cohort from 25 degrees (14 to 42) to 0 degrees (-9 to 8), P <0.05. The median rate of correction was 2.0 degrees/month (0.9 to 5.8). The time till full correction was 14 months (4 to 25). Postoperative knee pain and metalware-related complications were not reported by any patient during follow-up.

CONCLUSIONS

Guided growth of the distal femur using coronally oriented 8-plates is an effective procedure for the treatment of FKFDs in children. This modified technique may achieve faster correction while minimizing the risk of postoperative knee pain compared with the conventional technique.

LEVEL OF EVIDENCE

Level IV-case series.

Distal radius fracture osteosynthesis by volar locking plate: influence of epiphyseal screw positioning on risk of loss of reduction

Ulnar variance is an important radiological parameter for good functional outcome after distal radius fracture osteosynthesis. Secondary loss of reduction due to radial shortening is a common complication after volar locking plate fixation. Some authors recommend beginning by placing the most ulnar epiphyseal screw, ensuring that it is positioned as close as possible to the distal radioulnar and radiocarpal joints. The hypothesis of our study was that the positioning of the ulnar epiphyseal screw relative to the distal radioulnar and radiocarpal joints influences the maintenance of reduction during follow-up. 190 distal radius fractures were treated with volar locking plate fixation and divided into two cohorts: cohort A with <2 mm and cohort B with ≥2 mm loss of ulnar variance. Minimum follow-up was 45 days. The positioning of the most ulnar epiphyseal screw was evaluated using a single variable, the ulno-distal index. Means were compared using t-tests and proportions using chi-squared tests. The alpha risk was set at 5%. The intra- and inter-observer reliability of the ulno-distal index measurement were assessed. Mean ulno-distal index was significantly lower in cohort A at 11.28 mm, compared to 13.33 mm in cohort B; p < 0.0001. Ulno-distal index <12 mm was a significant protective factor: p < 0.0001 and relative risk 0.558. No other intrinsic or extrinsic factors of secondary loss of reduction significantly influenced the risk of ulnar variance alteration. The study confirmed the hypothesis that, in distal radius fracture treated with volar locking plate fixation, the closer the ulnar epiphyseal screw to the distal radioulnar joint and radiocarpal joint, the lower the risk of ulnar variance alteration.

Microwave Ablation of the Pig Growth Plate: Proof of Concept for Minimally Invasive Epiphysiodesis

BACKGROUND

Different surgical methods for epiphysiodesis of limb length discrepancy (LLD) have been described. Although these methods are variably effective, they are associated with morbidity (pain and limp) and potential complications. Microwave ablation is a less-invasive opportunity to halt growth by selectively destroying the growth plate via thermal energy to treat LLD in children.

QUESTIONS/PURPOSES

In this proof-of-concept study using an in vivo pig model, we asked: (1) What is the durability of response 2 to 4 months after microwave ablation of the tibial growth plate as measured by length and angulation of the tibia via a CT scan? (2) Was articular cartilage maintained as measured by standard histologic staining for articular cartilage viability?

METHODS

To develop an in vivo protocol for microwave ablation, we placed microwave antennas adjacent to the proximal tibia growth plate in the cadaveric hindlimbs of 18 3-month-old pigs. To determine the suitable time, we varied ablation from 90 to 270 seconds at 65-W power settings. After sectioning the tibia, we visually assessed for discoloration (implying growth plate destruction) that included the central growth plate but did not encroach into the epiphysis in a manner that could disrupt the articular surface. Using this information, we then performed microwave ablation on three live female pigs (3.5 to 4 months old) to evaluate physiologic changes and durability of response. A postprocedure MRI was performed to ensure the intervention led to spatial growth plate alterations similar to that seen in cadavers. This was followed by serial CT, which was used to assess the potential effect on local bone and growth until the animals were euthanized 2 to 4 months after the procedure. We analyzed LLD, angular deformity, and bony deformity using CT scans of both tibias. The visibility of articular cartilage was compared with that of the contralateral tibia via standard histologic staining, and growth rates of the proximal tibial growth plate were compared via fluorochrome labeling.

RESULTS

Eighteen cadaveric specimens showed ablation zones across the growth plate without visual damage to the articular surface. The three live pigs did not exhibit changes in gait or require notable pain medication after the procedure. Each animal demonstrated growth plate destruction, expected limb shortening (0.8, 1.2, and 1.5 cm), and bony cavitation around the growth plate. Slight valgus bone angulation (4º, 5º, and 12º) compared with the control tibia was noted. No qualitatively observable articular cartilage damage was encountered from the histologic comparison with the contralateral tibia for articular cartilage thickness and cellular morphology.

CONCLUSION

A microwave antenna placed into a pig's proximal tibia growth plate can slow the growth of the tibia without apparent pain and alteration of gait and function.

CLINICAL RELEVANCE

Further investigation and refinement of our animal model is ongoing and includes shorter ablation times and comparison of dynamic ablation (moving the antennae during the ablation) as well as static ablation of the tibia from a medial and lateral portal. These refinements and planned comparison with standard mechanical growth arrest in our pig model may lead to a similar approach to ablate growth plates in children with LLD.

Operative Treatment of Distal Tibial Fractures in Children Managed With Epiphyseal Screws: A Comparison of Outcomes When Screws Are Retained Versus Removed Following Fracture Union

BACKGROUND

Fractures of the distal tibial epiphysis in children are often accompanied by articular surface disruption. With increased displacement, internal fixation is frequently performed with an epiphyseal screw to close the fracture gap. Despite limited, high-level clinical evidence to support implant removal, epiphyseal screws are commonly removed after fracture healing due to potentially increased contact forces on the tibiotalar joint. The purpose of this study was to investigate and compare outcomes and complications in children that underwent surgical treatment of distal tibial epiphyseal fractures with placement of an epiphyseal screw(s) and had the implant(s) retained versus removed at a minimum of 2-year postoperative follow-up.

METHODS

Children younger than 18 years from two urban tertiary care centers who underwent operative management of distal tibia Salter-Harris III and IV fractures using epiphyseal screws (2013-2020) were divided into two cohorts: retained epiphyseal screws and implant removed. Demographics, intraoperative, postoperative, and radiographic data were collected. Patient-reported outcomes (PROs) using the Foot and Ankle Ability Measure (FAAM) and Single Assessment Numeric Evaluation (SANE) questionnaires were collected at the final follow-up. Statistical analysis, including power analysis, was performed.

RESULTS

Fifty-two children were included (30 males, 22 females) with a mean age of 13.3 years at the time of injury (range, 7.7-16.4 years). Thirty-five children retained the implants; seventeen had implants removed. All completed the FAAM questionnaires at a mean follow-up of 4.4 ± 1.9 years, while 29 completed the SANE questionnaire at a mean follow-up of 4.4 ± 1.7 years. No statistically significant difference in patient demographics, surgical variables, or PROs was observed. Six children experienced complications from the initial surgery, including infections and complex regional pain syndrome, with no difference in complication rates between the cohorts ( P =0.08). Furthermore, no complication was observed as a result of implant removal.

CONCLUSIONS

Children with retained epiphyseal implants have similar functional outcomes as compared with those who had implants removed after distal tibial epiphyseal fracture fixation and union.

LEVEL OF EVIDENCE

Level III-Retrospective comparative study.

[Fractures around the knee in children : Epiphysiolysis and physeal fractures of the distal femur and proximal tibia]

Epiphysiolysis and epiphyseal fractures of the distal femur and proximal tibia are an extremely rare entity, but due to their far-reaching consequences with associated functional restrictions of the knee joint, they must be recognized and treated thoroughly. Complete and correct diagnosis is essential and, diagnostically speaking and in addition to standard x‑rays in two planes, the threshold for cross-sectional imaging examination techniques should be low. A conservative treatment attempt is possible for undisplaced fractures, but surgical retention and stabilization using wires and screws is usually indicated. Growth disorders often and inevitably occur after such injuries. Clinical monitoring of complications only ends once growth is complete.

Endoprosthetic replacement with preservation of the epiphysis for proximal tibial reconstruction after osteosarcoma resection in children: a case report

BACKGROUND

Limb salvage surgery is an important method for treating malignant tumors of the bone involving the adjacent parts of the major joints in children. This technique allows for preservation of limb function, especially in the lower limb. However, the reconstruction of the proximal end of the tibia after removing the tumor mass with a rational scale to preserve the total knee joint and reduce limb length discrepancy presents a challenge.

CASE PRESENTATION

We present a case of osteosarcoma of the proximal tibia. After being treated with an extended tumor resection, the proximal tibia of the child was restructured using endoprosthetic replacement with epiphyseal preservation. This procedure preserves the entire articular surface and growth plate of the knee joint of the affected limb and provides a feasible alternative protocol for retaining the function and growth potential of the affected limb. The patient remained disease-free and normal limb motor function was observed during the 3.5 year follow-up since the initial surgery.

CONCLUSIONS

Preservation of the epiphysis enabled our patient to perform better limb function after limb-saving surgery as a result of his undamaged knee joint and minimized limb-length discrepancy. We believe that endoprosthetic replacement with preservation of the epiphysis can provide the best strategy for reconstruction after resection of focal malignant tumors in long bones without epiphytic involvement.

Staples, tension-band plates, and percutaneous epiphysiodesis screws used for leg-length discrepancy treatment: a systematic review and proportional meta-analysis

BACKGROUND AND PURPOSE

The primary aim of this systematic review and meta-analysis was to evaluate the success rate of 3 different epiphysiodesis techniques with implant usage for the treatment of leg-length discrepancy (LLD) in the pediatric population. The secondary aim was to address effectiveness (final LLD) and the reported complications of staples, tension-band plates (TBP), and percutaneous epiphysiodesis screws (PETS).

METHODS

In this systematic review we searched MEDLINE (PubMed), Embase, Cochrane Library, Web of Science and Scopus for studies on skeletally immature patients with LLD treated with epiphysiodesis with an implant. The extracted outcome categories were effectiveness of epiphysiodesis (LLD measurements pre-/postoperatively, successful/unsuccessful) and complications that were graded on severity.

RESULTS

44 studies (2,184 patients) were included. 455 underwent epiphysiodesis with PETS, 578 patients with TBP, and 1,048 with staples. Successful epiphysiodesis was reported in 76% (95% confidence interval [CI] 61-89) with PETS (9 studies), 67% (CI 54-79) with TBP (10 studies), and 51% (CI 28-65) with Blount staples (8 studies). From pooled analysis, the severe complications rate was 7% for PETS, 17% for TBP, and 16% for Blount staples. Angular deformity was reported in 4% after PETS, 10% after TBP, and 17% after Blount staples.

CONCLUSION

Our results showed that epiphysiodesis with PETS implants was the most successful technique. PETS had a higher success rate, fewer severe complications, and a lower proportion with angular deformity.

Lower extremity length discrepancy solution by modified drilling epiphysiodesis and anthropological prediction methods: long-term results

This study aimed to summarize our experience with modified drilling epiphysiodesis and prediction methods for accurate timing of surgery and to compare the results with those of recent work by other authors. The Macnicol and Gupta modified drilling technique was used. Distal femoral and/or proximal tibial permanent epiphysiodesis was performed in 42 children (21 boys, 21 girls; median age at surgery=12.6 years, age range=9.4-15.4 years) between 2004 and 2016. Based on the groundwork of previous studies, we developed an auxological prediction method. The limb length discrepancy (LLD) was assessed by clinical examination and verified by an x-ray of the hips when standing with blocks under the shorter leg. The predicted shortening was 2.7 cm ± 1.1 cm. The final discrepancy after finishing skeletal growth was 0.5 ± 0.5 cm. In 26 patients (61.9%), equalization of both legs was achieved (0-0.5 cm). In 4 patients (9.5%), the remaining shortening was more than 1.0 cm. Shortening of an initially longer leg occurred in two patients (0.5 cm and 0.6 cm). Failure of growth plate arrest was observed in 1 patient. In another 3 patients, the efficacy of tibial epiphysiodesis was unsatisfactory. Minor complications occurred in 5 cases, but there was no evidence of angular deformity in the frontal and sagittal planes or proximal fibula overgrowth. Three patients (7.1%) returned to the operating room. Compared to published data, more patients achieved complete equalization of leg length. The results of this study verified the accuracy of the auxological prediction algorithm of LLD based on Shapiro's findings. The surgical outcome is comparable between Shapiro patterns 1 and 3. Auxological examination, assessment of bone age, and sexual maturation are crucial tools for accurate timing of surgery.

Operative treatment of isolated epiphyseal fracture of the distal fibula: 1 case report and literature review

Pediatric ankle injuries are common; ankle epiphyseal fractures are also common in children. But isolated distal epiphyseal fibular fractures of the distal fibula are clinically rare. We describe one unusual case of an adolescent with a completely displaced Salter-Harris type II distal fibular epiphyseal fracture. The attempt of closed reduction failed, and the patient required open reduction and internal fixation. The localized periosteum and the superior peroneal retinaculum were avulsed from the distal fibular metaphysis, with the peroneal tendons underneath exposed but no obvious subluxation. To the best of our knowledge, this combination of injuries has not been previously reported.

Retrograde Insertion Approach for Anterior Distal Femoral Hemiepiphysiodesis Procedure: A Case Report

CASE

A 13-year-old adolescent boy with spastic diplegic cerebral palsy (CP) presented with crouch gait and bilateral knee flexion contractures (KFCs). After failure of conservative treatments, the patient was referred to orthopaedics for surgical intervention. Anterior distal femoral hemiepiphysiodesis (ADFH), using a retrograde approach, and Strayer gastrocnemius recession were performed bilaterally. No complications were reported during surgery/follow-up. Full-active knee extension and improved gait were achieved.

CONCLUSION

KFC is prevalent in ambulatory patients with CP, reducing gait function. Retrograde ADFH is an effective surgical intervention to reduce KFC and improve gait, and offers simpler insertion/removal than the traditional antegrade technique.

Effects of bone marrow-derived mesenchymal stem cell transplantation in piglet Legg-Calve-Perthes disease models: a pilot study

This preliminary study investigated the efficacy and safety of bone marrow-derived mesenchymal stem cell transplantation in a piglet Legg-Calve-Perthes disease (LCPD) model. The LCPD model was induced in two Landrace piglets (6- and 7-week-old, weighing 12 and 17 kg, respectively) by ligaturing the femoral neck. In the first piglet, the natural LCPD course was observed. In the second piglet, 4 weeks after ligaturing the femoral neck, simple medium and medium containing 2.44 × 10 7 bone marrow-derived mesenchymal stem cells were transplanted into the right and left femoral heads after core decompression, respectively. Plain radiographs were obtained every 4 weeks, and the epiphyseal quotient was calculated by dividing the maximum epiphysis height by the maximum epiphysis diameter. The piglets were sacrificed at 14 weeks postoperatively. The femoral heads were extracted and evaluated grossly, pathologically, and by using computed tomography. The transplanted cell characteristics were evaluated using flow cytometry. Flattening of the epiphysis was observed in both femoral heads of the first piglet and only in the right hip of the second piglet. The epiphyseal quotients immediately and at 14 weeks postoperatively in the right femoral head of the second piglet were 0.40 and 0.14, respectively, while those of the left femoral head were 0.30 and 0.42, respectively. Hematoxylin and eosin staining did not reveal physeal bar or tumor cell formation. The transplanted cells were 99.2%, 65.9%, 18.2%, and 0.16% positive for CD44, CD105, CD29, and CD31, respectively. Core decompression combined with bone marrow-derived mesenchymal stem cell transplantation prevented epiphyseal collapse.

Factors influencing correction rate following hemiepiphysiodesis using tension band plates for deformities around the knee: a multivariate analysis study

PURPOSE

The aim of this study was to appraise various factors influencing the correction rate in temporary hemiepiphysiodesis (THE) around the knee joint. Specifically, the study analysed the relationship of correction rate with age, gender, aetiology, type and location of deformity.

METHODS

The retrospective study included children who underwent THE for a coronal plane deformity (genu valgus or varum) around the knee joint (distal femur or proximal tibia) over a ten year period (2010-2020). The primary outcome of interest was the correction rate of the deformity.

RESULTS

Thirty-three children (27 females and 6 males) with a mean age of 8.1 years involving 86 plates were included in the study. The mean correction achieved was 12.2° over a treatment period of 13.3 months. Subgroup analysis showed significant differences between the type (varus (0.8° per month), valgus (1.1° per month)) and the location of deformity femur (1.2° per month) and tibia (0.7° per month)]. On multivariate analysis, the location and the duration of treatment showed significant associations with the correction rate.

CONCLUSION

The correction of coronal deformities following temporary hemiepiphysiodesis is influenced by several factors. Valgus, femoral and deformities in younger children correct at a faster rate. Location of deformity and duration of treatment emerged as potential factors affecting the correction rate.

Lateral Femoral Condyle Allograft in the Treatment of Elbow Capitellar Avascular Necrosis: A Case Report

CASE

A 27-year-old woman developed capitellar osteonecrosis after long-term corticosteroid use to treat non-Hodgkin lymphoma. She underwent an osteochondral reconstruction using a lateral femoral condyle (LFC) allograft. This graft was selected because it has a similar radius of curvature to the capitellum. The patient had osseous integration, painless, near full range of motion of her elbow 6 months postoperatively and good shoulder function 1.0 year postoperatively.

CONCLUSION

The LFC allograft should be considered a viable option in treating capitellar osteonecrosis.

Correction of Posttraumatic Medial Growth Arrest of the Distal Tibia in Adolescents

BACKGROUND

Partial growth arrest of the medial part of the distal tibial physis following fractures that penetrated the epiphysis is relatively common. We present the results of treatment, based on a protocol of supramalleolar tibial and fibular osteotomy for ankle alignment correction, and contralateral epiphysiodesis of distal tibia and fibula to balance leg length discrepancy (LLD).

METHODS

This case series study describes the results of 7 patients with a median age of 14 years (range = 10-15 years) who were operated in our institution. All were treated by closed or open reduction and internal fixation after Salter-Harris (SH) types 3 and 4 fractures of the distal tibia. All patients had a partial medial growth arrest, distal tibial varus, relative overlengthening of the distal fibula, and slight leg shortening.

TREATMENT PROTOCOL

Contralateral distal tibial and fibular epiphysiodesis to prevent significant LLD, completion of closure of the ipsilateral epiphysis, supramalleolar osteotomy of the distal tibia and fibula, and insertion of a triangular wedge cortical allograft into the tibial osteotomy creating a normal ankle joint orientation. The osteotomy was supported by a medial anatomically contoured locking plate. The fibula was fixed with an intramedullary wire.

RESULTS

All patients had uneventful healing of the osteotomy after 6 weeks. At the latest follow-up (mean 3 years, range 1.5-5 years), 6 out of 7 patients reached maturity, and the lateral distal tibial angle was within normal limits. The LLD in all patients was less than 8 mm.

CONCLUSIONS

Our protocol provides anatomic correction with the restoration of the ankle joint and prevents the progression of LLD.

LEVELS OF EVIDENCE

Level IV.

Anterior Proximal Tibial Screw Hemiepiphysiodesis Decreases Posterior Tibial Slope in Knee Flexion Contracture: A Case Report

CASE

A 13-year-old adolescent boy with hemiplegic cerebral palsy suffering from fixed knee flexion deformity of 10° despite extensive conservative treatment. Owing to a posterior tibial slope (PTS) of 16°, anterior hemiepiphysiodesis was applied to the proximal tibia. The 2 screws were removed after 9 months. Final follow-up at 16 months showed complete knee extension and a PTS of 4°.

CONCLUSION

The presented technique is a good alternative in knee flexion deformity with an increased PTS and has surprisingly not been described in the literature. This might be worth considering for other pathologies such as pediatric anterior cruciate ligament injury with an increased PTS.

Natural history of Wolcott-Rallison syndrome: A systematic review and follow-up study

BACKGROUND AND AIMS

To systematically review the literature for reports on Wolcott-Rallison syndrome, focusing on the spectrum and natural history, genotype-phenotype correlations, patient and native liver survival, and long-term outcomes.

METHODS

PubMed, Livio, Google Scholar, Scopus and Web of Science databases were searched. Data on genotype, phenotype, therapy, cause of death and follow-up were extracted. Survival and correlation analyses were performed.

RESULTS

Sixty-two studies with 159 patients met the inclusion criteria and additional 30 WRS individuals were collected by personal contact. The median age of presentation was 2.5 months (IQR 2) and of death was 36 months (IQR 50.75). The most frequent clinical feature was neonatal diabetes in all patients, followed by liver impairment in 73%, impaired growth in 72%, skeletal abnormalities in 59.8%, the nervous system in 37.6%, the kidney in 35.4%, insufficient haematopoiesis in 34.4%, hypothyroidism in 14.8% and exocrine pancreas insufficiency in 10.6%. Episodes of acute liver failure were frequently reported. Liver transplantation was performed in six, combined liver-pancreas in one and combined liver-pancreas-kidney transplantation in two individuals. Patient survival was significantly better in the transplant cohort (p = .0057). One-, five- and ten-year patient survival rates were 89.4%, 65.5% and 53.1%, respectively. Liver failure was reported as the leading cause of death in 17.9% of cases. Overall survival was better in individuals with missense mutations (p = .013).

CONCLUSION

Wolcott-Rallison syndrome has variable clinical courses. Overall survival is better in individuals with missense mutations. Liver- or multi-organ transplantation is a feasible treatment option to improve survival.

Correcting for asymmetry of the proximal tibial epiphysis is warranted to determine postoperative alignment deviations in kinematic alignment from planned alignment of the tibial component on the native tibia

BACKGROUND

In total knee arthroplasty, unrestricted kinematic alignment aims to restore pre-arthritic lower limb alignment and joint lines. Joint line orientations of the contralateral healthy proximal tibia might be used to evaluate accuracy of tibial component alignment post-operatively if asymmetry is minimal. Our objective was to evaluate left-to-right asymmetry of the proximal tibial epiphysis in posterior tibial slope and varus-valgus orientation as related to unrestricted kinematic alignment principles.

METHODS

High resolution CT images (0.5 mm slice thickness) were acquired from bilateral lower limbs of 11 skeletally mature subjects with no skeletal abnormalities. Images were segmented to generate 3D tibia models. Asymmetry was quantified by differences in orientations required to shape-match the proximal epiphysis of the mirror 3D tibia model to the proximal epiphysis of the contralateral 3D tibia model.

FINDINGS

Systematic and random differences (i.e. mean ± standard deviation) in tibial slope and varus-valgus orientation were - 0.8° ± 1.2° and - 0.2° ± 0.8°, respectively. Ninety five percent confidence intervals on the means included 0° indicating that systematic differences were minimal.

INTERPRETATION

Since random differences due to asymmetry are substantial in relation to random surgical deviations from pre-arthritic joint lines previously reported, post-operative computer tomograms of the contralateral healthy tibia should not be used to directly assess accuracy of tibial component alignment on a group level without correcting for differences in tibial slope and varus-valgus orientation due to asymmetry.

Epiphyseal-entry cannulated screws for temporary guided growth of the knees: a retrospective review of 89 cases

Guided growth affects the physis in children to produce a desired effect. Several devices achieve alteration of growth, including staples, plates, and screws. Complications can include device failures, failure to modulate growth as expected, and unintended physeal arrest. We present the results of a unique technique designed to minimize these complications. This was a retrospective review of guided growth at the knee at a single institution utilizing cannulated screws with epiphyseal-entry points. Each case was reviewed to determine the presence of complications related to guided growth, including implant breakage, implant pull-out or pull-through, iatrogenic physeal arrest, failure to modulate growth, and the incidence of revision surgeries. There were 89 patients who had 146 epiphyseal-entry guided growth procedures with a total of 221 4.5 mm cannulated screws. There were no iatrogenic physeal arrests. Five (2.26%) screws in 4 (4.49%) patients had either a broken screw or screw pull-out/pull-through requiring revision procedures. Three patients had osteotomies after skeletal maturity. Four had revision-guided growth for other reasons: 2 due to a lack of timely follow-up, 1 for iatrogenic genu varum without implant failure, and 1 due to recurrent deformity after implant removal. Revision procedures were unanticipated in 6 (6.74%) patients. This study describes a technique for placing cannulated screws at the knee with epiphyseal starting points. Our rate of complications and number of revision surgeries compare favorably with those noted for other techniques. Guided growth using epiphyseal-entry cannulated screws is a safe, effective option for most patients.

Anterior Distal Femoral Hemiepiphysiodesis in Children With Fixed Knee Flexion Deformities: Does Screw Position Matter?

BACKGROUND

Anterior distal femoral hemiepiphysiodesis (ADFH) using 2 percutaneous screws is an effective technique for the treatment of fixed knee flexion deformities in children with neuromuscular disorders. The role of sagittal screw position on the outcome of the procedure is unknown.

METHODS

This is a retrospective case series of patients who underwent ADFH at a single pediatric hospital from 2013 to 2020. Radiographs were evaluated for sagittal screw position and the associated change in lateral distal femoral physeal angle over time. The position of the 2 screws was classified as either being both in the anterior third of the physis (AA), one screw in the anterior third and the other screw in the middle third (AM), or both screws in the middle third of the physis (MM).

RESULTS

The study population included 68 knees in 36 patients. The mean physeal angle at the time of surgery was 93 degrees (SD 4.0 degrees), which increased to 102.4 degrees (SD 5.7 degrees) at 12 months, for a change of 9.4 degrees ( P <0.001). At 24 months, the mean physeal angle was 104.6 degrees (SD 6.3 degrees) for a further change of 2.9 degrees ( P <0.001). When stratified by screw position all screw configurations resulted in an increase in the physeal angle at 12 months. At the 24-month follow-up, the physeal angle in knees with AA screws continued to increase another 3.5 degrees ( P <0.05), there was a minimal change in knees with AM screws (1.47°, P >0.05) and knees with MM screws saw a reversal of physeal angle change (-7.1 degrees, P <0.05).

CONCLUSIONS

ADFH using percutaneous screws results in an increase in the lateral distal femoral physeal angle. The rate of correction is largest in the first 12 months after the procedure. As such, this procedure should be considered in patients with less than 2 years of growth remaining. However, initial screw positioning influences the amount of change over time, and close postoperative surveillance until physeal closure is essential for all patients.

LEVEL OF EVIDENCE

Level IV-retrospective case series.

The transphyseal osteotomy for the slipped proximal tibial epiphysis in tibia vara

This study aimed to describe a novel transphyseal osteotomy (TPO) for acute deformity correction in children with bilateral tibia vara and the atraumatic 'slipped proximal tibial epiphysis' (SPTE) entity. We described the clinical and radiological findings in five children (10 limbs) with tibia vara that were treated with the TPO. The criteria for the SPTE were met in nine (9/10) cases. The surgical technique and short-term results of the TPO are reported. The median age was 9 years (range, 6-9), with obesity (BMI > 95th centile) present in all children. The medial tibial plateau was not significantly depressed (the median angle of depression of the medial plateau measured 30° (range, 20°-32°). The mean medial proximal tibial angle of 33° (range, 8°-71°) was corrected to 82° (range, 77°-86°), the mean anatomic posterior proximal tibial angle of 48° (range, 32°-70°) was corrected to 72° (range, 61°-86°), and the median internal tibial rotation of 45° (range, 20°-50° internal rotation) was corrected to neutral rotation (range, 10° internal-10° external rotation). There were two complications: one case of recurrent deformity and one case of intra-articular extension of the osteotomy. We describe a novel TPO that aims to simultaneously correct all aspects of the deformity, stabilise the physis, and prevent recurrence through epiphysiodesis. Further research is required to determine its efficacy and safety. The atraumatic SPTE appears to represent a specific morphological presentation in tibia vara. Level of evidence: 4.

Complete Correction following Temporary Hemiepiphysiodesis using 2-hole Reconstruction Plates among Skeletally Immature Patients with Angular Deformities around Knees: A Descriptive Cross-sectional Study

INTRODUCTION

Studies have shown that 2-hole reconstruction plates can be used effectively as tension band plates for temporary hemiepiphysiodesis. However, limited data is available regarding the effectiveness of such plates in terms of complete correction rates. This study was aimed to find out the prevalence of complete correction following temporary hemiepiphysiodesis using 2-hole reconstruction plates among skeletally immature patients with angular deformities around knees.

METHODS

A descriptive cross-sectional study was carried out among skeletally immature patients with angular deformities around knees undergoing temporary hemiepiphysiodesis after getting approval from the Institutional Review Committee (Reference number: B&BIRC-23-05). The data were collected between 1 January 2012 to 31 December 2018. All skeletally immature patients with angular deformities around knees undergoing temporary hemiepiphysiodesis using 2-hole reconstruction plates were included. Patients who required additional procedures or implants for deformity correction and those who did not provide consent were excluded. Convenience sampling method was used. Point estimate at 95% Confidence Interval was calculated.

RESULTS

Among 102 patients, 66 (64.70%) patients achieved complete correction (59.97-69.43 at 95% Confidence Interval). Mean age of the patients was 8.21±3.11 years and 43 (65.15%) were males and 23 (34.84%) were females.

CONCLUSIONS

The prevalence of complete correction following temporary hemiepiphysiodesis using 2-hole reconstruction plate among skeletally immature patients with angular deformities around knees was lower than that reported in other international studies.

All-epiphyseal anterior cruciate ligament reconstruction yields superior sports performances than the trans-epiphyseal technique in skeletally immature patients: a systematic review

BACKGROUND

Anterior cruciate ligament (ACL) tears in skeletally immature patients are increasingly common. Evidence comparing the outcomes of all-epiphyseal versus trans-epiphyseal ACL reconstruction in skeletally immature patients is limited, and the current literature could benefit from a comprehensive systematic review. The present study compared all-epiphyseal versus trans-epiphyseal ACL reconstruction in skeletally immature patients. The outcomes of interest were to compare joint laxity, patient-reported outcome measures (PROMs), return to sport, and complications.

METHODS

This study was conducted according to the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. In November 2023, the following databases were accessed: PubMed, Web of Science, Google Scholar, and Embase. No additional filters were used in the database search. All the clinical studies investigating ACL reconstruction in skeletally immature patients were accessed. Only articles that clearly stated the surgical technique (all- or trans-epiphyseal) were eligible. Only articles with a minimum of 6 months of follow-up were included. Only articles that clearly stated that surgeries were conducted in children with open physis were eligible.

RESULTS

Data from 1489 patients (1493 procedures) were collected, of which 32% (490 of 1489 patients) were female. The mean length of follow-up was 46.6 months. The mean age of the patients was 12.7 years. No difference was found in joint laxity (Table 3): positive pivot shift (P = 0.4), positive Lachman test (P = 0.3), and mean arthrometer laxity (P = 0.1). No difference was found in PROMs (Table 4): International Knee Documentation Committee (IKDC) (P = 0.3), Lysholm (P = 0.4), and Tegner (P = 0.7). The trans-epiphyseal technique was associated with a greater rate of patients unable to return to sports (1% versus 7%, P = 0.0001) and with a longer time to return to sports (7.7 versus 8.6 months, P = 0.01). Though the trans-epiphyseal technique was associated with a lower rate of return to sport, this difference was not statistically significant (P = 0.8). No difference was evidenced in the rate of patients who had reduced their league or level of sports activity (P = 0.6) or in the rate of patients who had returned to their previous league or level of sports activity (P = 0.7). No difference was found in the rate of complication: re-tear (P = 0.8), reoperation (P = 0.7), increased laxity (P = 0.9), and persistent instability sensation (P = 0.3).

CONCLUSION

Trans-epiphyseal ACL reconstruction was associated with a greater rate of patients unable to return to sport and with a longer time to return to sport compared with the all-epiphyseal technique in skeletally immature patients. Level of evidence Level III, systematic review.

Physeal Migration During Knee-guided Growth With Tension Band Plates: Influence of Implant Position

OBJECTIVE

Physeal migration during guided growth with tension band plates (TBPs) has been poorly described. The positioning factors associated with this phenomenon and its clinical implications are unknown. Our aim is to determine the influence of implant position on the risk of physeal migration during knee-guided growth with TBP.

METHODS

Retrospective study of 491 patients who underwent temporary hemi or epiphysiodesis with TBP around the knee between 2007 and 2019. We identified 29 patients who presented physeal migration during follow-up. Demographic and clinical data were collected, and the following measures were obtained from the immediate postoperative radiographs: epiphyseal screw base-physis distance/epiphyseal screw tip-physis distance, interscrew angle, epiphyseal screw-physis angle(ES-PHa)/metaphyseal screw-physis angle, plate-physis angle, epiphyseal screw-plate angle/metaphyseal screw-plate angle, and epiphyseal screw-physis length ratio. Using follow-up radiographs, the type of physeal migration of the epiphyseal screw (touch, occupy, or traverse) and the status of the physis after implant removal (unaltered, physeal bar, and skeletal maturity) were also recorded. A descriptive analysis of the cases and a case-control comparison of imaging studies were performed.

RESULTS

The median patient age at intervention was 12.2 years (interquartile range: 11.3 to 14.1), and 76% were males. A statistically significant difference between cases and controls was obtained for epiphyseal screw base-physis distance (3.7 vs 6.3; P = 0.029), epiphyseal screw tip-physis distance (3.6 vs 7.85; P = 0.002), ES-PHa (-0.1 vs 7.45; P = 0.007), and plate-physis angle (85.45 vs 88.60; P = 0.012). In a categorical analysis, a significant difference was found for the ES-PHa categories ( P = 0.002) and for the ES-PHa/metaphyseal screw-physis angle categorical pair ( P = 0.018). In 16, 17, and 12 cases the physis was touched, occupied, or traversed, respectively, although we found no physeal alterations after plate removal.

CONCLUSIONS

In our study, physeal migration of TBP is not an uncommon phenomenon, although no physeal abnormalities were detected. Convergent placement of the epiphyseal screw with the base or tip close to the physis should be avoided as this position is associated with a higher risk of physeal migration.

LEVEL OF EVIDENCE

Level III-case-control study.

Does the intercondylar approach provide a better outcome for chondroblastoma of the distal femur in skeletally immature patients?

Aims

The epiphyseal approach to a chondroblastoma of the intercondylar notch of a child's distal femur does not provide adequate exposure, thereby necessitating the removal of a substantial amount of unaffected bone to expose the lesion. In this study, we compared the functional outcomes, local recurrence, and surgical complications of treating a chondroblastoma of the distal femoral epiphysis by either an intercondylar or an epiphyseal approach.

Methods

A total of 30 children with a chondroblastoma of the distal femur who had been treated by intraregional curettage and bone grafting were retrospectively reviewed. An intercondylar approach was used in 16 patients (group A) and an epiphyseal approach in 14 (group B). Limb function was assessed using the Musculoskeletal Tumor Society (MSTS) scoring system and Sailhan's functional criteria.

Results

At final follow-up, the mean MSTS score was 29.1 (SD 0.9) in group A and 26.7 (SD 1.5) in group B (p = 0.006). According to Sailhan's criteria, the knee function was good and fair in 14 (87.5%) and two (12.5%) patients of group A, and eight (57.1%) and six (42.9%) patients of group B, respectively (p = 0.062). The lesion had recurred in one patient (6.2%) in group A and four patients (28.6%) in group B. Limb shortening > 1 cm was recorded in one patient (6.2%) from group A and six patients (42.8%) from group B. Joint degeneration was noted in one patient from group A and three patients from group B.

Conclusion

An intercondylar approach to a chondroblastoma of the middle two-quarters of the distal femoral epiphysis results in better outcomes than a medial or lateral epiphyseal approach: specifically, better limb function, a lower rate of recurrence, and a lower rate of physeal damage and joint degeneration.

99mTc-MDP bone scintigraphy-based growth evaluation and prediction of epiphysis around the knee: a study of paediatric limb salvage for malignant bone tumours

AIM

To investigate the feasibility of bone scintigraphy in the assessment and prediction of bone growth potential after limb-salvage surgery in children with bone tumours.

MATERIALS AND METHODS

Fifty-five skeletally immature patients with primary bone malignancies in distal femur was enrolled. Thirty-two patients received epiphysis minimally invasive endoprosthesis (EMIE) reconstruction, seven received hemiarthroplasty, and 16 received adult-type rotation-hinged endoprosthesis (ATRHE) reconstruction. All enrolled patients underwent radiographic examination at regular intervals and followed-up for >12 months. The actual limb length discrepancy (LLDa) of the tibia was measured on the radiography image. The expected LLD of tibia (LLDp) was calculated according to multiplier method. The uptake ratio of the ipsilateral epiphysis to the contralateral epiphysis (Ri/c) was calculated at bone scintigraphy. The Ri/c value was accommodated in the formula of multiplier method for a modification. The difference and correlation between the modified expected LLD (LLDm), LLDp and LLDa were analysed.

RESULTS

The growth potential of ipsilateral epiphysis was reserved in all patients who underwent hemiarthroplasty and one fourth of EMIE reconstruction. The Ri/c values in the hemiarthroplasty endoprosthesis group were significantly higher than the EMIE and ATRHE groups. There was no significant difference in Ri/c values between the EMIE and ATRHE group. Data from the 26 patients who reached bone maturation showed that there was a significant difference between LLDp and LLDa. LLDm showed a higher correlation with LLDa than LLDp.

CONCLUSION

Bone scintigraphy is helpful to evaluate the growth potential of epiphysis after surgery. The multiplier method modified by Ri/c value improves prediction accuracy of bone growth.