Natural history of avascular necrosis of the patella due to closed global patellar dislocation

This 20-year study of avascular necrosis of the patella indicates that the patella can regain its blood supply and normal joint surface over time. Significant changes in the patella and operative treatment are noted.

Use of bone allograft in tibial plateau fractures

To determine the behaviour of bone allografts in the treatment of tibial plateau fractures, 20 recipients of frozen bone allograft for a depressed tibial plateau fracture were studied. Incorporation of grafts took place in all cases, and no complication secondary to the allograft use has been detected. To avoid donor site morbidity associated with harvesting iliac crest, the use of frozen bone allograft is a good alternative in the treatment of depressed tibial plateau fractures.

Follow-up study of arthroscopic reduction and fixation of type III tibial-eminence fractures

Nine children (average age, 13.1 years) with 10 displaced type III tibial-eminence fractures were reviewed with an average follow-up of 3.5 years. The fractures were treated with arthroscope-assisted reduction and suture fixation. Nine of the 10 knees demonstrated meniscal interposition at the fracture site that contributed to unsuccessful closed reduction. At follow-up, subjective knee function was excellent in all cases, and no clinical or objective evidence of knee laxity or instability was detected in any patient. All patients demonstrated full range of motion of the affected knee compared with the contralateral side.

CLINICAL SIGNIFICANCE

Arthroscopic reduction and fixation allow early mobilization; assists in defining and treating associated knee pathology; assists in fracture reduction; and reduces the morbidity associated with arthrotomy.

[Change in the infradian rhythms of some physiological processes, controlled by the epiphysis, in epiphysectomized rats exposed to a super low frequency variable magnetic field]

The infradian rhythmic of the behavioral parameters, urination, body mass and temperature in epiphysectomized rats exposed to a variable magnetic field of a frequency of 8 Hz and induction of 5 microT influence was studied. It was found that the removal of epiphysis leads to the reorganization of power spectra of biorhythms, a rise of their amplitudes, and the development of desynchronosis. Further exposure of epiphysectomized rats to a variable magnetic field partially normalizes the amplitude-phase relations and decrease the disbalance of the processes. These data indicate the important role of epiphysis in the magnetoreception and formation of the temporal structure of the organism and suggest the existence of other structures sensitive to variable magnetic field.

Long-term results after infantile Blount's disease

A long-term follow-up of 49 patients with an average age of 38 years (range: 25-67 years) who had experienced infantile Blount's disease was done. Thirty-seven patients had bilateral disease, giving a total of 86 affected knees. Thirty-eight knees had conservative or no treatment during childhood; 13 were treated by epiphysiodesis, and 35 by osteotomy. At follow-up, 11 knees showed arthrosis, and 9 were graded as mild. Ten knees had been surgically treated by medial meniscectomy at an average age of 29 years (range: 19-45 years), after the diagnosis of Blount's disease. Four of the knees showed arthrosis. Most of the patients had a straight leg and mild or no pain from their knee. It is concluded that most children with infantile Blount's disease will, at the age of 40 years, have a straight leg without arthrosis and that one third can reach this result without any treatment.

Correction of proximal tibial deformities in adolescents with the T-Garches external fixator

Frontal-plane deformity of the proximal tibia in children has a variety of etiologies. There are also a number of described surgical techniques for correction of these deformities. The authors reviewed their early experience with the use of the Orthofix T-Garches external fixator for correction of 16 proximal tibial deformities in 14 patients. Mean age at surgery was 14.2 years. The most common diagnosis was adolescent Blount's disease. Average deformity was 12 degrees. Total treatment time averaged 13 weeks for those requiring lengthening and 10.8 weeks for those without. Complications included one ring sequestrum treated by curettage, and two patients with subsequent development of femoral deformity. Tibial anatomic axis averaged 1 degree of varus. This device can achieve excellent correction of deformity isolated to the frontal plane with few complications. It allows functional weight bearing and use of adjacent joints during treatment.

Percutaneous epiphysiodesis using transphyseal screws (PETS)

We describe a new technique of percutaneous epiphysiodesis using transphyseal screws (PETS) and our experience with it in 32 cases of limb-length inequality and nine angular knee deformities. A subgroup of 18 patients with postfracture limb overgrowth formed a clinical model for study of the real efficacy of PETS. It proved a reliable method with few complications and many advantages such as simplicity of technique, short operating time, rapid postoperative rehabilitation, and reversibility. Bone-length inequality decreased from a preepiphysiodesis average of 2.47 cm (range, 1.5-4.6) to 0.51 cm at skeletal maturity. The tibiofemoral angle reduced from a preoperative average of 7.66 degrees to 0.86 degrees at maturity. The screws began to exert significant growth inhibition within 6 months of insertion, slowing down the distal femoral and upper tibial physes by 68 and 56%, respectively. They achieved maximum growth retardation over the ensuing 12 months, slowing down the distal femoral physis by 89% and the proximal tibial physis by 95%. At skeletal maturity, total femoral growth was 45% and total tibial growth was 52% that of the normal side. Key

Juvenile Tillaux fracture simulating syndesmosis separation: a case report

The juvenile Tillaux fracture is an avulsion fracture (Salter-Harris type-3) of the anterolateral comer of the distal tibial epiphysis. We present a case in which the severely displaced Tillaux fragment became incarcerated between the distal tibia and fibula, simulating a syndesmotic separation radiographically. To our knowledge, such a fracture pattern as not been previously described. Preoperative computerized tomography provided accurate imaging of the unusual fracture pattern. Open extrication of the fracture fragment was followed by spontaneous reduction of the syndesmosis. The Tillaux fracture healed following open reduction with pin fixation, and the patient had an excellent functional and radiographic result at 2-year follow-up.

[Percutaneous epiphysiodesis. Analysis of a series of 60 full-grown patients]

PURPOSE OF THE STUDY

Percutaneous epiphysiodesis is the actual treatment for mild leg length discrepancy. The authors discuss complications and efficiency of this technique and its accuracy for the prevision of leg length discrepancy.

MATERIAL AND METHOD

We reviewed 60 skeletally mature patients (35 boys, 25 girls). Limb length was defined by clinical and teleradiographic evaluation. Bone age was recorded using Sempé's and Pavia's atlas, using the hand, and Sauvegrain's method, using the elbow. Anticipated discrepancies and timing of epiphysiodesis were calculated using Héchard and Carlioz's graph. The percutaneous curetage was employed in all cases.

RESULTS

The treatment was successful for all cases. Complications occurred postoperatively in 2 children who developed an hematoma. 10 children required a surgical revision: 2 cases had an inverted discrepancy, 4 patients were found to have limb deviation, and in four children this treatment was not adequate. The outcome was excellent in 48.3 per cent of cases, satisfactory in 31.7 per cent, acceptable in 6.7 per cent and bad for 13.3 per cent of cases.

DISCUSSION

Percutaneous epiphysiodesis is well tolerated in childhood with similar results to other techniques (stapling and Phemister's technique). Our experience suggest that:--complications are rare--this treatment is a satisfactory surgical solution--effective previsions for the best time for surgery have not yet been defined.

[Hemi-epiphyseal lengthening of the ulna in Kienboeck's disease]

The authors report the first results of a hemiepiphyseal lengthening of the ulna in a case of Kienböck's disease. Only the articular portion of the inferior epiphysis of the ulna is lengthened, the position of the styloid ulna being left untouched. The results of 17 cases are analysed. There were no cases of pseudarthrosis. The risk of conflict between the styloid ulna and the triquetrum is avoided.

[The effect of local growth in long bones following two different epiphyseal-stimulating procedures: an experimental study]

OBJECTIVE

To study the effect of local growth in long bones of the rabbits following two different epiphyseal-stimulating procedures.

METHODS

These were osteotomy in the metaphysis near the proximal tibial epiphyseal plate and hemicirecumferential periosteal excision on the proximal tibial epiphysis. Tibia roentgenography, tetracycline labelling, histological method and electron microscopy were used.

RESULTS

The local stimulating effect following hemi-circumferential periosteal excision was more evident than following osteotomy.

CONCLUSION

The procedure of periosteal excision could be good for the treatment of children knee' deformity.

Determination of proximal femoral epiphyseal depth for repair of physeal fractures in immature dogs

OBJECTIVE

To determine the depth that implants may be safely placed for repair of proximal femoral physeal fractures.

STUDY DESIGN

Relationships were determined between the depth of the proximal femoral epiphysis (PFE) and the contralateral PFE, and the PFE and pubic bone width.

ANIMALS OR SAMPLE POPULATION

20 immature dog cadavers.

METHODS

Actual PFE depths were determined at the center of the physeal surface and at four other eccentric points. The contralateral intact PFE depth and the width of the cranial aspect of the public bone were measured from radiographs.

RESULTS

Mean ratios of actual central PFE depth to radiographically measured (1) contralateral PFE depth and (2) pubic bone width were 1.04:1, and 1.09:1, and ratios of actual eccentric PFE depths were 0.89:1 and 0.93:1. Body weight was not useful in estimating depth of the PFE.

CONCLUSIONS

For the central epiphysis, pins may safely be placed a distance equal to 75% to 80% of the contralateral intact PFE depth or pubic bone width, measured from a ventrodorsal radiograph, with minimal risk of penetration through the articular surface. Pins placed eccentrically may be safely driven a depth equal to 65% of the radiographically measured contralateral intact PFE depth or pubic bone width.

CLINICAL RELEVANCE

Estimating the safe depth of implant placement into the PFE avoids penetration of the articular surface.

Epiphysiodesis for bilateral irregular closure of the distal radial physis in a gymnast

Wrist pain is a common complaint in gymnasts. Repetitive stress on the distal radial physis may lead to either gradual slipping of the epiphysis or growth disturbances. In some cases growth disturbances of the distal radial physis lead to triangulation of the distal radius and secondary ulnar overgrowth, and eventually a Madelung-like deformity. The present case report is the first to describe the outcome of epiphysiodesis of the distal radial and ulnar growth plates in a skeletally immature gymnast as a surgical treatment to prevent Madelung's deformity.

Determination of safe depth of pin penetration for repair of distal femoral physeal fractures in immature dogs: a comparison of normograde and retrograde pin placement

OBJECTIVE

The purpose of this study was to determine the depth that implants may be safely placed into the distal femoral epiphysis (DFE) for the repair of distal femoral physeal fractures.

STUDY DESIGN

The depth of the DFE was related to the radiographic thickness of the patella in this experimental study.

ANIMALS OR SAMPLE POPULATION

Twenty immature canine cadavers.

METHODS

Patella thicknesses were measured from lateral radiographs. Actual DFE depths were determined for pins driven in normograde fashion and for pins driven retrograde from the central depression between the metaphyseal pegs and from the cranial pegs. The association of DFE depth and patella thickness was evaluated using linear regression analysis. Using 95% confidence intervals, rules for estimating the safe depth of implant placement into the DFE were determined.

RESULTS

DFE depth had significant correlation with patella thickness for pins placed in retrograde fashion from the central depression between the metaphyseal pegs (r2 = .83) and from the cranial pegs (r2 = .82) and for pins placed in normograde fashion (r2 = .65).

CONCLUSIONS

Based on 95% confidence intervals, pins placed in retrograde fashion from the central depression between the metaphyseal pegs may be safely driven into the DFE a distance equal to 140% of patella thickness. Pins placed from the cranial metaphyseal pegs may be driven to a depth equal to 80% of patella thickness, and pins placed in normograde fashion may be driven to a depth equal to 30% of patella thickness.

CLINICAL RELEVANCE

Measurement of patella thickness assists the surgeon in determining the approximate depth that pins may be driven into the DFE without penetrating the articular surface of the stifle joint.

[Special epiphyseal injuries. 5 case examples]

In daily practice, the well-proved Salter-Harris-Rang epiphyseal injuries classification is used worldwide and in Hungary as well. Occasionally there are to be seen epiphyseal injuries which cannot be typed by this classification. The Ogden classification of epiphyseal injuries which enlarges the Salter-Harris-Rang classification with 6 subdivisions and 3 more subdivisions is very useful for the classification of such rare epiphyseal injuries. The authors focus one's attention on Ogden IIB type and Ogden VI type injuries on the basis of their own experience. Ogden IIB is often unstable and susceptible to shortening. In Ogden VI type ligamentous instability beside growing disturbance, caused by meta-epiphyseal bone bridge formation, can be seen. The comminuted growing plate injury caused by high energy direct trauma and healed without growing disturbance in their case, is missed in the Ogden classification. The proper classification is a necessary condition of adequate treatment. We recommend the Ogden classification of rare epiphyseal injuries.

Chronic physeal fractures in myelodysplasia: magnetic resonance analysis, histologic description, treatment, and outcome

Thirteen myelodysplastic children with 19 chronic physeal fractures were treated. All were treated with prolonged immobilization (average, 5.8 months; range, 3-18 months) in either braces or casts; four of the fractures required operative fixation to facilitate healing. All were healed at 4.8-years follow-up but, in four of the fractures, the growth plate closed prematurely. Three of the children underwent magnetic resonance imaging (MRI) of the injured physes, and one underwent physeal biopsy as part of her operative epiphysiodesis. Histologic analysis revealed three distinct zones of physeal pathoanatomy: a normal zone of proliferation; a thickened, disorganized zone of hypertrophy; and a vascularized zone of fibrous tissue adjacent to the metaphysis. On MRI, there was thickening of the physis and irregularity of the zone of provisional calcification. The physeal cartilage and the juxtametaphyseal fibrovascular tissue enhanced with gadolinium. These findings corroborate earlier mechanistic proposals for physeal injury in myelodysplasia: chronic stress or trauma to the poorly sensate limb produces micromotion at the zone of hypertrophy, yielding a widened, disorganized physis, and leading to fracture, displacement, and delayed union.

Idiopathic genu valgum treated by epiphyseodesis in adolescence

Twenty-three patients (13 boys and 10 girls) with the adolescent type of genu valgum were treated by temporary medial epiphyseodesis of both distal femurs with Blount staples (46 knees); 5 also underwent stapling of the proximal tibia. Evaluation before the operation and during the follow up was based on growth charts, photographs and measurement of the intermalleolar distance. The indication for operation was increasing genu valgum with 10 cm or more of intermalleolar separation; the median distance before operation was 13 cm for boys and 12 cm for girls. The staples were removed after a median time of 11 months. At skeletal maturity the median intermalleolar separation was 3 cm for boys and 2 cm for girls. The median frontal angle before operation was 14 degrees for boys and 6 degrees at follow up, the corresponding figures for girls being 14 degrees and 4 degrees. In 2 cases the deformity recurred because the staples were removed too early. In another case a bony bridge formed after the staple was removed and a varus deformity developed; the bridge was resected and the knees became valgus again, but 1 cm of shortening remained on one side. There were no other complications.

Effect of proximal phalangeal epiphysiodesis in the treatment of macrodactyly

The recommended treatment for macrodactyly of the foot will often include epiphysiodesis of the proximal phalanx in an attempt to halt further longitudinal growth of the toe. Nine patients who underwent open epiphysiodesis and debulking of the excess soft tissues involving 11 toes were reviewed to evaluate the effectiveness of this procedure. In 9 of 11 toes, overall length of the proximal phalanx did not change after surgery. Two toes demonstrated continued growth; one of these toes underwent a repeat epiphysiodesis of the phalanx, and the other foot underwent epiphysiodesis of the affected metatarsal. Overall, this surgical approach led to radiographic results that satisfied the surgical goals.

Bilateral epiphysiodesis around the knee as treatment for excessive height in boys

Between 1987 and 1993, six boys who had been predicted to grown to an excessive height were treated with bilateral Phemister epiphysiodesis around the knee. Median predicted adult height was 210.4c (range: 207.4-213.4 c), the median observed adult height was 201.5 c (range: 195.5-206.7 c). Median height reduction was 9.3 c (range: 4.1-15.3 c). Median length of follow-up was 44 months (range: 21-84 months). At final follow-up, all patients had full range of motion, no infections, no pain, no angular deformities, equal leg lengths, and radiographic evidence of physeal closure. Bilateral Phemister epiphysiodesis around the knee is a good alternative to pharmacological treatment for boys with excessive height.

[A unicompartment knee prosthesis: the effect of the positioning of the tibial plate on the functional results]

The authors analyse the results of 51 unicompartmental knee prostheses with 1 to 12 years follow-up (mean follow-up: 5 years). The results were evaluated using the scoring system of the "Knee Group" of the SO.B.C.O.T. (Société Belge de Chirurgie Orthopédique et de Traumatologie). This analysis demonstrates that the quality of the results depends on implant positioning. The authors suggest positioning the tibial implant parallel with the healthy plateau and slightly distal, i.e. to position the tibial implant perpendicular to the epiphyseal axis and not to the mechanical axis, as is systematically done with the usual tibial cutting guides. When this ideal positioning was respected, 77.5% of the patients had a score above 90 points (out of a possible maximum of 100 points) and 12.5% had a score between 75 and 89 points. When this condition was not respected, none of the knees obtained more than 75 points. The difference was statistically significant (p = 0.0001).