[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).

Regnauld procedure in the surgical treatment of metatarsalgia: interpretation of follow-up X-ray imaging

In lesser ray metatarsalgia (rays 2 through 5) due to an altered Lelievre's metatarsal formula (depending on the respective lengths of the metatarsals), the resection of metatarsal heads aims at restoring a correct metatarsal support. This being a destructive procedure, metatarsal head resection is best indicated in the treatment of severe forefoot deformities such as those resulting from rheumatoid arthritis. In all metatarsalgias that recognize biomechanical origin, the enclavement procedure, according to Regnauld's original report, should be preferred. The aim of this study is analysis of the radiographic evolution of the metatarsal epiphysis following the Regnauld procedure on the basis of anatomic and pathological events occurring during the attachment process. The procedure was performed on 31 feet and the patients were followed-up for 24 months postoperatively. The enclavement process evolved favorably in all cases. It consists of four anatomic/pathologic phases corresponding to typical radiographic features. While graft consolidation is achieved in 3 to 4 months postoperatively, complete recovery of the metatarsal bony architecture and functional adaptation requires 18 to 24 months.

Epiphysiodesis using a cannulated tubesaw

A technique for epiphysiodesis using a cannulated tubesaw has been developed to combine the precision of the original Phemister method with newer percutaneous methods. The approach is unilateral, and requires minimal access. Reinsertion of the removed core of bone reduces haemorrhage from the defect and augments arrest of the growth plate. In 35 patients treated by this method predicted discrepancies of 2 to 4.5 cm were reliably reduced to 0.7 +/- 0.6 cm, with no serious complications. The timing of surgery is critical, and relies upon careful monitoring of the pattern of discrepancy over several years, using clinical and radiographic measurements. Undercorrection of the disparity in three patients was the direct result of late referral.

[Retrosternal luxation of the clavicle. Apropos of 4 cases surgically treated using a temporary screwed anterior plate and review of the literature]

The authors report 4 new cases of retrosternal dislocation of the clavicle operated by capsular and ligament restoration, and temporary stabilization by anterior plating. The 4 patients were men with a mean age of 17.5 years. The lesion was caused by a sports injury (football, rugby) in 3 out of 4 cases and was related to an indirect mechanism. Clinical examination allowed the diagnosis, was related to based on painful palpation of a dip over the joint, supported by radiology and computed tomography. CT did not reveal the epiphyseal separation present in two cases. Complications were frequent: 1 case of tracheal compression, 2 cases of temporary paresthesia of the upper limb, 2 cases of venous compression with one case of subclavian and medial jugularis venous thrombosis, 1 hemopneumothorax. Surgical reduction was performed in all 4 cases after 2 failures of attempted orthopedic treatment under general anesthesia. All patients recovered a full range of movement, a painless shoulder and no recurrence has been observed. All complications resolved after reduction. Venous thrombosis responded favourably after 6 months of anticoagulant therapy. One plate breakage was observed with no clinical implications. On the basis of an extensive review of the literature, the authors discuss the epidemiology, pathology and the importance of associated injuries, which are frequent and sometimes serious, justifying urgent reduction. Computed tomography is the most useful radiologic modality, both for diagnosis and for investigation of complications. Orthopedic treatment must be attempted first (especially in children) according to a well systematized technique. One third of attempts fail, and cases of delayed diagnosis and serious vascular complications, then require surgical treatment. The costoclavicular ligament is repaired either by Burrows's ligamentoplasty or by bone suture; the clavicle is stabilized by bone suture or by anterior plating. The authors do not advocate either joint fixation by Kirschner wire, or resection of the medial end of the clavicle.

[Greater trochanter epiphyseodesis in treatment of hip deformity]

A series of 29 patients (33 hips) after greater trochanter epiphyseodesis in treatment for hip deformity has been reviewed. An indication for this surgery was increasing proximal femur deformity due to the damage of subcapital growth plate (avascular necrosis) during the treatment for congenital dysplasia of the hip. The age of patients at surgery was mean 8.1 years, mean follow-up was 10.1 year. Clinical and radiological assessment revealed ineffectiveness of greater trochanter epiphyseodesis in treatment for increasing hip deformity due to avascular necrosis in the age group in question.

Improving the distal fixation of intramedullary nails in osteoporotic bone

Twenty-four mildly osteoporotic human femurs were used to examine the fixation stability of several types of distal locking screws in osteoporotic femoral condylar segments. The fixated femurs were axially loaded to 1000 N at a rate of 100 N/sec to assess the locking screws' resistance to motion and then sinusoidally cycled to 10,000 cycles with a 500 N load to assess axial stability. Of the four screw configurations tested, the standard screws and the standard screws placed at a 30 degree crossing angle were significantly more stable (p < 0.05) than the step screw and osteoporotic bolt.

Totally absorbable fixation in the treatment of fractures of the distal femoral epiphyses. A prospective clinical study

Nine adolescent patients with a femoral fracture involving the physeal plate were treated by using self-reinforced absorbable polyglycolide (SR-PGA) and poly-L-lactide (SR-PLLA) screws with a follow-up for an average of 2 years and 2 months. During the follow-up all but one of the femurs became skeletally mature. In two of nine patients a clinically significant growth disturbance occurred. The average length difference of the femurs was -5 mm (ranging from +8 mm(-)-41 mm). One valgus deformity was noted. In four patients a lengthening and in four patients a shortening of the operated femur were registered at the end of follow-up. Open reduction and fixation with absorbable screws seem to be suitable for the fixation of distal femoral fractures in adolescents.

Screw epiphysiodesis for ankle valgus

Progressive ankle valgus is an insidious deformity that may develop during childhood due to a variety of etiologies including neuromuscular disease, skeletal dysplasia, chromosomal anomalies, and clubfoot. This may be concomitant with, or mistaken for, hindfoot valgus. The surgical options for treatment include supramalleolar osteotomy or hemiepiphysiodesis of the medial distal tibial physis. We report the rationale and technique of retarding medial malleolar growth by means of inserting a single 4.5-mm vertical screw. In a population of 31 children (50 feet), we have observed satisfactory improvement of ankle valgus with low morbidity and without permanent physeal closure. This represents a safe, predictable, and effective solution for children who present with progressive and symptomatic ankle valgus.

Accuracy of MR imaging for estimating intraosseous extent of osteosarcoma

OBJECTIVE

We compared how well T1-weighted and short inversion time inversion recovery (STIR) MR images obtained before and after preoperative chemotherapy reveal the extent of longitudinal intraosseous tumor involvement in osteosarcoma of children.

MATERIALS AND METHODS

MR images were obtained at diagnosis and after preoperative multiagent chemotherapy in 20 children with osteosarcoma arising in the long bones. Images were reviewed to determine the length of the abnormal intraosseous signal intensity on paired longitudinal T1-weighted and STIR images taken at diagnosis and after chemotherapy. These measurements were compared with those made during a review of similarly oriented pathologic sections of the resected bone. Median differences were calculated and analyzed using Wilcoxon's signed-rank test.

RESULTS

Abnormalities detected on T1-weighted images corresponded more closely to pathologic findings than did abnormalities detected on STIR images. On STIR images, readers overestimated tumor extent in 73% of both pre- and postchemotherapy studies. Readers overestimated tumor length on 29 of the 40 STIR images and on 13 of the 40 T1-weighted images. Readers underestimated tumor length on five STIR images and 11 T1-weighted images. Median differences between measurements made at the pathologic examination and on STIR images were statistically significant, both for imaging at diagnosis (p = .001) and for imaging after chemotherapy (p = .005); however, no significant differences were found between measurements made at the pathologic examination and measurements made on T1-weighted images. Measurements of tumor length on either type of imaging did not change significantly after chemotherapy. MR imaging showed 100% sensitivity for epiphyseal tumor spread but poor specificity. False-positive readings occurred in seven of 13 patients with abnormal signal intensity that extended into the adjacent epiphyses.

CONCLUSION

Readers estimated intraosseous tumor extent more accurately on T1-weighted images than on STIR images. Readers overestimated tumor length on STIR images. T1-weighted longitudinal images taken before chemotherapy can be used for early planning of surgical approaches to osteosarcoma in children.

Percutaneous vs modified phemister epiphysiodesis of the lower extremity

Epiphysiodesis of the lower extremity for limb-length discrepancy has been performed on 24 patients by both the modified Phemister and a percutaneous method. The primary complication of epiphysiodesis by both methods was continued growth of the physeal plate (12% and 15%, respectively). Failure of epiphysiodesis was attributed to young skeletal age at surgery in three of five cases. Closer attention to physeal ablation and close follow up should prevent this complication. No angular deformities resulted in any patient. During 16 proximal fibular procedures, there were no neurologic complications. The percutaneous method is preferred due to ease of surgical procedure, minimal incisions, limited disability to the normal extremity, and equal results.

Hemiepiphyseal stapling for knee deformities in children younger than 10 years: a preliminary report

Epiphyseal stapling, which is the only reversible method of growth alteration, has traditionally been reserved for teenagers. We are reporting the application of hemiepiphyseal stapling in a series of 25 children younger than 10 years. With a variety of underlying diagnoses, three children had genu varum and 22 had genu valgum. The technique involved fluoroscopic localization of all growth plates and careful preservation of the periosteum while inserting (and subsequently removing) one or two staples per physis. The mean age at stapling was 6 years + 4 months. Follow-up averaged 3 years + 3 months. The anatomic (tibiofemoral) angle and mechanical axis improved in all patients. One staple broke on removal; there were no other hardware failures. We conclude that hemiepiphyseal stapling is a safe and effective treatment for children younger than 10 years who have angular deformities of the knee. No growth-plate arrests have occurred. In the event of recurrent deformity, stapling may be repeated.

Avulsion of the patellar ligament with combined fracture luxation of the proximal tibial epiphysis: case report and review of the literature

Disruption of the extensor mechanism of the knee joint at the insertion site of the patellar tendon into bone is a somewhat common injury. Avulsion of the patellar ligament associated with fractures of the proximal tibial epiphysis is an extremely rare injury. Only three cases have been published in association with avulsion fracture of the tibial tubercle. We are reporting a case that has previously not been reported to our knowledge: an avulsion of the ligament in a closed fracture of the proximal tibial epiphysis with integrity of the tibial tubercle. We propose a three-type classification of an avulsion patellar ligament injury.

Deficiencies of current methods for the timing of epiphysiodesis

A review of 71 epiphysiodeses with adequate orthoroentgenographic and skeletal-age data was carried out to compare the accuracy of predicting outcome among the methods of Anderson and Green, Menelaus, and Moseley. Differing the methodology did not have a meaningful effect on their similar but limited accuracy. We advocate the use of the Menelaus method, which is simple and based on chronologic age, as it proved as accurate as any other method. The routine use of serial Gruelich and Pyle skeletal-age data could not be shown to increase the accuracy in predicting outcome over serial chronologic-age data, and thus its value in limb-length inequality is limited. Regardless of the method used, unpredictable results occur in a proportion of patients. The patient and parents should be advised of this when planning strategies for limb-length discrepancy.

Epiphyseal lengthening operation--an improved technique

An improved method of epiphyseal lengthening operation and subsequent outer fixation are presented on the basis of experience in 30 cases. The operative technique is described in detail, including the different options of separative traction and osteotomy at subtrochanteric, distal part of the upper femur and lower tibial levels. The physiological and histological research concerning this method is discussed. The authors believe that this procedure is better than the other methods.

Traumatic ulnar physeal arrest after distal forearm fractures in children

A review of the orthopaedic literature suggests that traumatic ulnar physeal arrest associated with radial fracture is a rare occurrence. Twenty-three cases of traumatic ulnar physeal arrest have been reported in patients with distal radius fractures, and we report five additional cases. A classification system for the distal ulnar growth deformities is proposed, and the compensatory radial changes are reviewed. Surgical indications for treatment include cosmetic deformity, progressive carpal subluxation, and decreased range of motion. Surgical options for treatment are discussed and include epiphysiodesis, ulnar lengthening, radial osteotomy, and the Suave-Kapandji procedure.

Epiphysiodesis of the lower extremity: results of the percutaneous technique

The results of 42 percutaneous epiphysiodeses of the lower extremity in 26 patients are reported. All patients achieved physeal arrest radiographically and clinically. No patient developed angular deformity from incomplete arrest. No neurovascular complications or fractures occurred. The average hospital stay for patients undergoing epiphysiodesis alone was 1 day. Percutaneous epiphysiodesis of the lower extremity provides a reliable and safe technique for growth plate arrest. The advantages of this technique include a cosmetic scar, short hospital stay, low incidence of complications, and reliable physeal arrest.

Surgical treatment of Madelung disease by the Sauvé-Kapandji technique

The Madelung deformity, a congenital alteration of growth in the distal radial epiphysis, becomes evident during adolescence, producing serious esthetic and functional disturbances. From 1982 to 1991, 15 patients ranging from 16 to 23 years old, suffering from Madelung deformity were operated by the Sauvé-Kapandji surgical technique (a pseudarthrosis is created on the ulna and an arthrodesis on the distal radio ulnar joint). The esthetic appearance and grip strength were improved. Pain was eliminated and the incidence of complications was very low.

Anterior thoracoscopic epiphysiodesis in the treatment of a crankshaft phenomenon

We report our first performance of a multiple anterior thoracoscopic epiphysiodesis in the treatment of a crankshaft phenomenon. In the last 2 years, video-assisted thoracoscopy has been introduced as a new therapeutic technique in the field of spinal diseases. Its use has been most documented in the treatment of vertebral abscesses and disc herniations, while its performance in treating deformities is less known. The patient in our case was an 11-year-old boy with a 7-year history of aggressive left thoracic idiopathic scoliosis that had previously needed three subcutaneous instrumentations and finally a Cotrel-Dubousset-instrumented arthrodesis. Following these operations, a continuous clinical and radiographical evolution of the curve was recorded and an anterior T6-T11 video-assisted thoracoscopic epiphysiodesis was therefore performed. The patient did not need postoperative narcotics; Argyle chest tubes were removed after 48h with only 150ml of serohaematic drainage, no blood transfusion was required. One year after the intervention, we found a well-consolidated T6-T11 arthrodesis with no evolution of the deformity. The endoscopic technique allowed us to perform an extensive anterior arthrodesis using only three small incisions, with a reduction of bed-confinement to 3 days and reduced postthoracotomy pain.