Epiphysiodesis: a problem of timing

A retrospective review of 67 distal femoral and proximal tibial epiphysiodeses, performed over a 14 year period for correction of leg length inequality, revealed only 22 patients with a final discrepancy of less than 1 cm. Ten of the 45 failures were secondary to inadequate surgical epiphysiodesis. The remaining 35 failures were secondary to errors in timing surgery due to incorrect use of Green and Anderson growth prediction tables. The primary causes of failure would have been decreased by more careful follow-up and the use of the Moseley Graph.

Replacement of epiphyseal bone with methylmethacrylate: its effect on articular cartilage

Methylmethacrylate cement was used as a substitute for the epiphyseal bone of the canine proximal femora, after femoral neck osteotomy. The effects of different volumes of acrylic cement on the integrity of trabecular bone and articular cartilage and the effects of different types of fixation of the osteotomy site were assessed clinically, radiologically and histologically. Degenerative changes occurring in the articular cartilage were greatest when a large area of epiphyseal bone was replaced with methylmethacrylate. These degenerative changes varied proportionately with the rigidity of fixation at the osteotomy site. Rigid fixation resulted in a better clinical and radiographic assessment and a decrease in histopathologic changes in the articular cartilage.

[De-epiphysiodesis and old traumata of the growth apparatus (author's transl)]

Basing themselves on eight cases treated over the past six years, the authors recount their experience of the operative elimination of partial closure of the epiphyseal plate. The closures were due to various causes and involved the lower extremities of the femur or tibia. Operative elimination alone was carried out in three cases, and associated with bone realignment in the remaining five. The results confirm the best prognosis for comparatively recent, localized peripheral epiphyseal plate closures.

Correction of leg inequality in the Klippel-Trenaunay-Weber syndrome

Eight patients with Klippel-Trenaunay-Weber syndrome were treated for leg length inequality of as much as 10 cm in one ten year old, and one thirteen year old. In most cases adequate correction was achieved with epiphyseal stapling during active growth or definitive epiphysiodesis in older children. Bone shortening procedures in full-grown individuals may be indicated but the basic condition may make healing difficult. Ligation of the femoral artery had no effect on the growth of the affected leg.

Intraepiphyseal osteotomy for progressive tibia vara: case report and rationale of management

Tibia vara (Blount's disease) is characterized by two components, the epiphyseal, which is concerned with articular relationships, and physeal/metaphyseal, which may produce angulation of a long bone. Although the initial etiology is not known, it appears that asymmetrical pressure applied to the angulated proximal tibia results in progressive deformity. In the initial stages, medial and posteromedial pressure causes growth retardation of the epiphysis (articular instability) and the physis (tibia vara). Nonsurgical or surgical treatment that relieves the pressure generally permits reconstitution of normal growth. Continued abnormal pressure and shear forces applied to the physis may result in disorderly enchondral ossification and produce a true osteochondrosis, which may lead to permanent physeal arrest. Osteotomy alone to relieve medial pressure may allow the tibia to grow straight, but residual medial epiphyseal compression and joint instability may persist. A case is reported of a 13 1/2 year follow-up of a patient in whom intraepiphyseal osteotomy restored articular congruity without interfering with longitudinal growth. The risks and experimental nature of this procedure are emphasized.

Fractures of the femoral shaft in children. The overgrowth phenomenon

Femoral overgrowth following femoral shaft fracture in children less then 13 years old has been documented by orthoroentgenogram in 74 patients from the time of healing 3 months following fracture until skeletal maturity. The femoral overgrowth averaged 0.92 centimeters (range 0.4-2.7) and was found to be independent of age, level of fracture, or position of fracture at the time of healing. The overgrowth was a universal phenomenon. Ipsilateral tibial overgrowth averaging 0.29 centimeters (0.1-0.5) occurred in 82 per cent of the patients. In the first 18 months following fracture 78 per cent of the overgrowth occurred. There was a time limit to the overgrowth phenomenon in 91 per cent of all patients following which the discrepancy persisted without change. By 18 months following fracture, however, only 12 per cent of the patients had completed the overgrowth and by 3 years and 6 months following fracture 85 per cent had completed their overgrowth. In 9 per cent of the patients overgrowth continued throughout the remaining growth period although at a slower rate than in the first 18 months following fracture.

[Traumatology of the growth plate]

Experiments were carried out on 12 weeks old dogs to determine the reaction of the proximal tibial epiphysis to different implants. The contralateral tibial epiphysis was used as controls. As implants we used Kirschner wires, medullary nails, screws and miniplates, which were inserted through the epiphyseal plate itself. The further development of the epiphysis was followed till completion of growth. The changes observed were proportional to the pressure exerted by the implant and reached from reversible lesions to premature ossification with faulty growth.

Surgical treatment of partial closure of the growth plate

During the period from 1965 to 1980, 43 operations for partial closure of a growth plate were performed on 35 patients. Five of the operations were for recurrent partial closure. At operation, the bone bridge connecting epiphysis to metaphysis was removed and replaced with a free fat transplant as described by the author in 1967 and 1975. Of the operations, 18 were on the distal end of the femur and 13 on either end of the tibia. Closure was due to fracture in 28 growth plates and septic osteomyelitis in 8. Benefit from the procedure was questionable after 7 operations. All other operations resulted in restoration of growth and correction or prevention of deformity. The operation prevents deformation of the joint surface, an effect that cannot be achieved by osteotomy or leg lengthening. Deformity present before operation is often reduced by growth to a normal condition after the procedure. Age, location of the bone bridge, and its size influence the indication for the operation and its results. Free fat, as an interposition material, has some advantages compared to solid materials, which may require a second procedure for removal.

Convex anterior and posterior hemiarthrodesis and hemiepiphyseodesis in young children with progressive congenital scoliosis

Ten children with progressive congenital scoliosis have been treated by convex anterior and posterior epiphyseodesis and arthrodesis. The average curve was 54 degrees, the average age at surgery 3 years, 10 months, and the average follow-up 2 years, 9 months. There were no complications. The curve progression was halted in all cases, no fusion mass bending has been observed to date, and two patients have shown evidence of spontaneous curve improvement. Follow-up for several more years will be necessary before definitive conclusions can be reached.

An epiphyseal stress fracture of the foot and shin splints in an anomalous calf muscle in a runner

The following case is presented as one of unusual foot and leg lesions encountered in an adolescent long-distance runner. The associated problems of a first metatarsal Salter Harris type II epiphyseal stress fracture, and an accessory calf muscle with "shin splints" in the contralateral leg are discussed. Treatment of these conditions is outlined with eventual return to full function by the athlete.