Current techniques of limb lengthening

Limb lengthening is still a major procedure with potentially serious complications. It does not, however, deserve the reputation it gained over the last few years. With a proper understanding of the biology, biomechanics, and strategies of lengthening, excellent results can be consistently obtained with relatively few complications.

Multiplier method for predicting limb-length discrepancy

BACKGROUND

In patients with a congenital or developmental limb-length discrepancy, the short limb grows at a rate proportional to that of the normal, long limb. This is the basis of predicting limb-length discrepancy with existing methods, which are complicated and require multiple data points. The purpose of our study was to derive a simple arithmetic formula that can easily and accurately predict limb-length discrepancy at skeletal maturity.

METHODS

Using available databases, we divided the femoral and tibial lengths at skeletal maturity by the femoral and tibial lengths at each age for each percentile group. The resultant number was called the multiplier. Using the multiplier, we derived formulae to predict the limb-length discrepancy and the amount of growth remaining. We verified the accuracy of these formulae by evaluating two groups of patients with congenital shortening who were managed with epiphysiodesis or limb-lengthening. We also calculated and compared the multipliers for other databases according to radiographic, clinical, and anthropological lower-limb measurements.

RESULTS

The multipliers for the femur and tibia were equivalent in all percentile groups, varying only by age and gender. Because congenital limb-length discrepancy increases at a rate proportional to growth, the discrepancy at maturity can be calculated as the current discrepancy times the multiplier for the current age and the gender. This calculation can be performed with use of a single measurement of limb-length discrepancy. For progressive developmental (noncongenital) discrepancies, the discrepancy at skeletal maturity can be calculated as the current discrepancy plus the growth inhibition times the amount of growth remaining. The timing of the epiphysiodesis can also be calculated with the multiplier. The predictions made with use of the multiplier method correlated well with those made with use of the Moseley method as well as with the actual limb-length discrepancy in both the limb-lengthening and epiphysiodesis groups. The multipliers derived from the radiographic, clinical, and anthropological measurements of femora and tibiae were all similar to each other despite differences in race, ethnicity, and generation.

CONCLUSIONS

The multiplier method allows for a quick calculation of the predicted limb-length discrepancy at skeletal maturity, without the need to plot graphs, and is based on as few as one or two measurements. This method is independent of percentile groups and is the same for the prediction of femoral, tibial, and total-limb lengths. The multiplier values are also independent of generation, height, socioeconomic class, ethnicity, and race. We verified the accuracy of this method clinically by evaluating patients who had been managed with limb-lengthening or epiphysiodesis. The method was also comparable with or more accurate than the Moseley method of limb-length prediction.

Transepiphyseal replacement of the anterior cruciate ligament in skeletally immature patients. A preliminary report

BACKGROUND

Fear of iatrogenic growth disturbance has prevented the routine use, in children, of anatomic methods of anterior cruciate ligament replacement that have proven successful in adults. To minimize the risk of growth disturbance, extra-articular or modified physeal sparing procedures have been performed to stabilize the knee, but these procedures do not provide isometry. This study was performed to evaluate the results of a transepiphyseal replacement of the anterior cruciate ligament in skeletally immature athletes.

METHODS

From 1993 to 1999, twelve patients with a mean age (and standard deviation) of 13.3 +/- 1.4 years underwent replacement of the anterior cruciate ligament with a quadruple hamstring tendon graft performed with an arthroscopic technique and intraoperative fluoroscopic imaging for precise tunnel placement. The femoral and tibial tunnels went through the epiphyses but avoided the physes. Eight of the twelve patients also had a meniscal repair. All patients returned for follow-up, at a mean of 4.1 +/- 1.9 years (range, two to 8.2 years) after surgery.

RESULTS

The mean amount of growth from the time of surgery to the time of follow-up was 16.5 +/- 10.0 cm (range, 8 to 38 cm). The difference between the lengths of the lower limbs, as measured on orthoradiographs, was not clinically relevant. The mean score on the International Knee Documentation Committee (IKDC) subjective knee form was 96.5 +/- 4.4 points (range, 86 to 100 points). Ligament laxity testing with a KT-1000 arthrometer revealed a mean side-to-side difference of 1.5 +/- 1.1 mm. The rating according to the criteria of the objective 2001 IKDC knee form was normal for seven patients and nearly normal for five.

CONCLUSIONS

Transepiphyseal replacement of the anterior cruciate ligament, a technically demanding procedure with a small margin of error, should be attempted only by accomplished knee surgeons. The preliminary results in this small series, however, demonstrate that this surgical technique can be performed in prepubescent patients with efficacy and relative safety.

Anterior cruciate ligament injuries in patients with open physes

From July 1988 to August 1989, six children with open physes and injuries to the anterior cruciate ligament were treated operatively. All injuries involved twisting episodes during sports activities. All six patients had meniscal abnormalities, and, additionally, one patient sustained a Grade III medical ligament tear and had a lateral patellar dislocation. Operative reconstruction used hamstring tendons and place a groove over the front of the tibia and a groove over the top of the femur without violation of the growth plates. The anterior cruciate ligament was primarily repaired (three patients) at the time of reconstruction, if possible. At 3 months, one patient underwent arthroscopic resection of adhesions for arthrofibrosis. There were no other complications. Five patients were evaluated with clinical examination, radiographs, magnetic resonance imaging, and functional testing at an average followup of 33.2 months (range, 25 to 38). Four of the five had returned to their preinjury level of sports participation. Manual maximum KT-1000 arthrometer side-to-side differences averaged 3.6 +/- 1.9 mm. The average Lysholm knee score was 95.2 +/- 2.5; the average Hospital for Special Surgery knee score was 96.6 +/- 2.3. There were no growth plate injuries. Despite the overall clinical stability, magnetic resonance image scans of the five patients consistently demonstrated areas of increased signal in the anterior cruciate ligament grafts.

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.

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.

Partial epiphyseal preservation and intercalary allograft reconstruction in high-grade metaphyseal osteosarcoma of the knee

BACKGROUND

The purpose of this study was to analyze a series of patients with a high-grade metaphyseal osteosarcoma of the knee who had been treated with a transepiphyseal resection, with preservation of the distal femoral and the proximal tibial (articular) portions of the epiphysis, and an intercalary allograft reconstruction.

METHODS

The cases of thirteen patients with a high-grade metaphyseal osteosarcoma around the knee who had transepiphyseal resection and reconstruction with an intercalary allograft were retrospectively reviewed at a mean of sixty-three months. Complications, disease-free survival of the patient, final preservation of the limb and epiphysis, and functional results according to the Musculoskeletal Tumor Society scoring system were documented at the time of the latest follow-up.

RESULTS

At the final follow-up examination, eleven of the thirteen patients continued to be disease-free. One patient died of bone and pulmonary metastases with no evidence of local recurrence, and the remaining patient had no evidence of disease after resection of a local recurrence of the tumor in the soft tissues. No patient had a local recurrence in the remaining epiphysis. Seven patients had complications that included a fracture (three patients), diaphyseal nonunion (two), deep infection (one), and a local recurrence in the soft tissues (one). The allograft was removed in only four of these patients. At the latest follow-up examination, twelve patients were alive with preserved limbs. In one patient, the epiphysis, which originally had been preserved, was resected because of a metaphyseal fracture, and the limb was reconstructed with an osteoarticular allograft. The patients with a preserved epiphysis had an average functional score of 27 points (maximum, 30 points).

CONCLUSIONS

Preservation of the epiphysis in high-grade metaphyseal osteosarcoma at the knee is an alternative in carefully selected patients. Crucial factors needed to obtain local tumor control and achieve an acceptable functional result are a positive response to chemotherapy, accurate preoperative assessment of tumor extension to the epiphysis, and appropriate fixation techniques for intercalary allografts.

LEVEL OF EVIDENCE

Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

Convex growth arrest for progressive congenital scoliosis due to hemivertebrae

Thirteen patients with progressive congenital scoliosis due to hemivertebrae or hemivertebrae associated with other spinal anomalies were treated by convex anterior and posterior hemiarthrodesis and hemiepiphysiodesis. The average curve prior to operation was 46 degrees, average age was 3 years 6 months, and average followup was 6 years 6 months. One patient failed because of an inadequate length of anterior surgery which was successfully salvaged by further surgery. Twelve patients were successes: Seven had only cessation of the progressive curve, and five had progressive curve improvement greater than or equal to 5 degrees due to the arrested convex and persistent concave growth. This procedure is a valuable treatment modality for selected patients with congenital scoliosis.

Limb-length inequality: assessment and treatment options

Assessment and treatment of limb-length inequality, particularly in the growing child, is a challenging task. Evaluation of the discrepancy requires an understanding of the significance of the disparity, as well as the natural history of the disorder, before formulation of a treatment plan. In the immature patient, consistent longitudinal data are essential to avoid pitfalls in the projection of ultimate length difference. Therapeutic options range from no treatment or use of a simple shoe lift to a surgical shortening or lengthening procedure. The current indication for lengthening is a disparity exceeding 5 to 6 cm. Epiphysiodesis or femoral shortening is useful for smaller discrepancies or for residual differences following a contralateral lengthening. Lengthening is done with a circular or cantilever external fixator, which may be combined with an intramedullary rod.

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.

Results of screw epiphysiodesis for the treatment of limb length discrepancy and angular deformity

The purpose of this study was to evaluate the technique of screw epiphysiodesis for effectiveness, predictability, and reversibility. We reviewed the cases of our first 60 patients (105 physes) treated with percutaneous screw epiphysiodesis or hemiepiphysiodesis. All cases were followed up to maturity or screw removal if growth remained after full correction. A total of 30 patients underwent the procedure for limb length inequality. Final inequality was compared with the predicted epiphysiodesis effect. A total of 30 patients (66 physes) underwent screw hemiepiphysiodesis for the correction of angular deformity. The degree of correction per month was calculated, the reversibility of the procedure was analyzed, and complications were evaluated. In the length group, at the end of treatment, the final limb length difference in the femur averaged 0.15 cm (SD, +/-0.37 cm) from the epiphysiodesis effect predicted by using the multiplier method. In the tibia, this difference was 0.05 cm (SD, +/-0.57 cm). In the angular group, the average correction in the distal femur was 6.91 degrees (SD, +/-3.75 degrees) or 0.75 degrees per month (SD, +/-0.45 degrees per month). In the proximal tibia, the average correction was 3.88 degrees (SD, +/-3.57 degrees) or 0.37 degrees per month (SD, +/-0.34 degrees per month). In all 13 cases where the screws were removed at the time of angular correction with significant growth remaining, growth resumed. Complications were minor and were related to incorrect placement of screws or minor hardware irritation. Percutaneous screw epiphysiodesis is a reliable, minimally invasive method with reliable results in both length and angular correction, with minimal morbidity, and with an acceptable complication rate.

Drilled hole defects in mouse femur as models of intramembranous cortical and cancellous bone regeneration

In order to identify pertinent models of cortical and cancellous bone regeneration, we compared the kinetics and patterns of bone healing in mouse femur using two defect protocols. The first protocol consisted of a 0.9-mm-diameter through-and-through cortical hole drilled in the mid-diaphysis. The second protocol was a 0.9-mm-diameter, 1-mm-deep perforation in the distal epimetaphyseal region, which destroyed part of the growth plate and cancellous bone. Bone healing was analyzed by ex vivo micro-computerized X-ray tomography and histology. In the diaphysis, the cortical gap was bridged with woven bone within 2 weeks. This newly formed bone was rapidly remodeled into compact cortical bone, which showed characteristic parameters of intact cortex 4 weeks after surgery. In the epimetaphysis, bone formation was initiated at the deepest region of the defect and spread slowly toward the cortical gap. In this position, newly formed bone quickly adopted the characteristics of trabecular bone, whereas a thin compact wall was formed at its external border, which reached the density of intact cortical bone but failed to bridge the cortical gap even 13 weeks after surgery. This comparative study indicates that the diaphyseal defect is a model of cortical bone healing and that the epimetaphyseal defect is a model of cancellous bone repair. These models enable experimental genetics studies to investigate the cellular and molecular mechanisms of spontaneous cortical and cancellous bone repair and may be useful for pharmacological studies.

Histomorphometric evaluation of titanium implants in osteoporotic rabbits

In this study, the osteointegration of two kinds of titanium implants were analyzed (cylindrical and screw-type) inserted in the tibiae of control (n = 8) and osteoporotic (n = 12) female rabbits. Osteoporosis was induced by the surgical removal of the ovaries (oophorectomy). Bone mass density of all animals was evaluated by densitometry of the tibiae and vertebrae. Densitometry was carried out at the beginning of the study and 4 months after oophorectomy. Mass loss in the tibia was not observed, however, in the vertebrae there was an 11% loss compared with the initial value. The implants remained for 8 weeks, after which the animals were then sacrificed and bone segments were analyzed by histomorphometry. The trabecular volume and mineral apposition rate was significantly greater in control animals than in osteoporotic animals, independent of which type of implant was used. In the osteoporotic animals, the area and osteoid perimeter were greater than in the control animals. By measuring the thickness of the compact layer in the tibia, it was observed that in the control animals, it was 28% thicker than in the osteoporotic animals. This study leads to the conclusion that bone formation was greater in the control animals than in the osteoporotic animals. The screw-type implants yielded the greatest formation of bone both in the control and in the osteoporotic animals.

The Sauvé-Kapandji procedure for chronic dislocation of the distal radio-ulnar joint with destruction of the articular surface

The Sauvé-Kapandji procedure has been performed in 15 non-rheumatoid patients with chronic distal radio-ulnar joint dislocation accompanied by joint damage or deformity. The clinical results were favourable; wrist pain improved in all patients, wrist flexion-extension was increased by more than 10 degrees in nine patients, grip strength of at least 80% of the contralateral wrist was achieved in 11 patients, and forearm rotation was more than 150 degrees in 12 patients. However, X-ray examination revealed an unstable proximal ulnar stump and radio-ulnar convergence in all patients similar to that associated with the Darrach procedure. Although the Sauvé-Kapandji procedure can preserve ulnar support of the wrist and is believed to yield more satisfactory results than the Darrach procedure, its extensive use is not recommended for non-rheumatoid distal radio-ulnar joint disorders, but it is recommended for chronic distal radio-ulnar joint dislocation with articular injury or deformity.

Osteosarcoma around the knee. Intraepiphyseal excision and biological reconstruction with distraction osteogenesis

In 11 patients juxta-articular osteosarcoma around the knee was treated by intraepiphyseal excision of the tumour and reconstruction of the bone defect by distraction osteogenesis. Preoperative and postoperative chemotherapy was given to eight patients with high-grade tumours. The articular cartilage of the epiphysis and a maximum of healthy soft tissues were preserved. Distraction osteogenesis was then carried out. The mean gain in length was 9.7 cm. Full function of the limb was preserved in all except one patient, with a mean follow-up of 53.8 months. Treatment of juxta-articular osteosarcomas around the knee with joint preservation and biological reconstruction using distraction osteogenesis can give excellent functional results.

The gymnast's wrist: acquired positive ulnar variance following chronic epiphyseal injury

Five cases of symptomatic acquired positive ulnar variance are described. All cases occurred due to premature physeal closure of the growth plate in teenage girl gymnasts. All cases demonstrated ulnocarpal impingement, for which we describe a clinical test. Arthroscopic assessment of the wrist allowed us to assess the integrity of the TFCC (triangular fibrocartilaginous complex) and decide on the most appropriate surgery. Two patients needed distal ulna recession and one needed shaving for a TFCC perforation, with a good result.

Endoscopic mechanical spinal hemiepiphysiodesis modifies spine growth

STUDY DESIGN

An in vivo porcine model of progressive scoliosis as an inverse analog of a proposed method of early surgical treatment.

OBJECTIVES

To test the hypothesis that scoliotic curvatures may be repeatedly created using anatomically based vertebral staples and thoracoscopic surgical procedures.

SUMMARY OF BACKGROUND DATA

Staple hemiepiphysiodesis is an established method for treating knee deformities. Similar procedures have so far failed to arrest or correct deformities of the spine. While experimental studies continue to suggest that spine growth is modifiable, no prior clinically translatable method has been shown to clearly and consistently alter vertebral growth.

METHODS

Custom spine staples were implanted into midthoracic vertebrae of seven skeletally immature normal pigs. Each staple spanned an intervertebral disc and two growth plates and was fixed to adjacent vertebrae with screws. The animals were anesthetized biweekly for radiography during the 8-week study period. Final radiographs were taken after spine harvest. Initial and final postoperative Cobb angles were compared statistically.

RESULTS

Five animals completed the protocol with a weight increase of 142% in 8 weeks. Coronal plane curvatures increased significantly with time, from 0.8 (+/-1.8) to 22.4 (+/-2.8; P = 0.0001). On average, sagittal plane curvatures did not increase with time.

CONCLUSIONS

Spinal hemiepiphysiodesis using an anatomically based implant and minimally invasive procedures repeatedly induced spine curvature in a normal porcine model. These techniques may slow, and perhaps even correct, early progressive spine deformity without long rod instrumentation or fusion.

Extra-articular transverse fractures of the base of the distal phalanx (Seymour's fracture) in children and adults

A series of 25 extra-articular transverse fractures of the base of the distal phalanx (Seymour's fracture) in children, adolescents and adults are presented. Prior to closure of the distal phalangeal epiphysis, the fracture line is usually entirely through the metaphyses, 1 to 2 mm distal to the growth plate. In adults, the fracture line is just distal to the insertion of the extensor tendon. Eighteen of these fractures were treated by closed reduction and splinting and one of these developed an infection and three had mild residual flexion deformities of the finger. Five fractures were treated by K-wire fixation and all healed without complications. Two adult patients presented 4 to 5 weeks after injury with malunion, and of these one underwent refracturing and K-wire fixation with an excellent result.

Results of transphyseal anterior cruciate ligament reconstruction using patellar tendon autograft in tanner stage 3 or 4 adolescents with clearly open growth plates

BACKGROUND

Drilling across the physes for intra-articular anterior cruciate ligament reconstruction is considered risky for skeletally immature patients.

HYPOTHESIS

Skeletally immature patients with clearly open growth plates can safely undergo intra-articular anterior cruciate ligament reconstruction with patellar tendon autograft without suffering growth plate disturbance.

STUDY DESIGN

Retrospective review of prospectively collected data.

METHODS

Surgery involved drilling tunnels through the tibial and femoral physes, the bone plugs were placed proximal to the physes, and button fixation was placed on the cortex. Of 272 skeletally immature patients, 16 had clearly open growth plates. Tanner stage of physical development was evaluated. Follow-up evaluation included objective and subjective data.

RESULTS

At the time of surgery, 7 patients were Tanner stage 3 and 9 were Tanner stage 4. Clinical follow-up (mean, 3.4 years after surgery) showed that the mean growth after surgery was 11.7 +/- 4.2 cm for boys and 6.6 +/- 2.3 cm for girls. No patients had growth plate disturbances, gross leg deformities, or gross leg-length discrepancies. Subjective results (mean, 5.6 years after surgery) showed a mean total score of 97.6 +/- 2.9 for the modified Noyes survey and 95.4 +/- 6.9 for the International Knee Documentation Committee survey. All patients returned to competitive sports after surgery.

CONCLUSION

In 16 skeletally immature patients with clearly open growth plates who were Tanner stage 3 or 4, an intra-articular anterior cruciate ligament reconstruction was performed using a patellar tendon autograft with no gross growth disturbance; however, the surgical technique was meticulous for placing the bone plugs proximal to the physes, and the graft was not overtensioned.

Correction of length discrepancies and angular deformities of the leg by Blount's epiphyseal stapling

The management of leg length difference (LLD) and angular deformities of the leg remains controversial. Numerous treatment options have been proposed over the past years depending on the patient's general condition, skeletal age, function, and degree and configuration of the deformity. Our retrospective study consisted of 48 patients with 58 legs treated between 1970 and 1991 by Blount's epiphyseal stapling to equalise length or correct angular deformity. After an average follow-up of 16.5 years, all patients with idiopathic bow-legs or knock-knees (n=12) and 71% of LLD caused by overgrowth (e.g. Klippel-Trenaunay syndrome) showed good and excellent results at skeletal maturity, whereas the results of the treatment of LLD with undergrowth of the leg and angular deformities due to trauma, infection or general dysplasia and malformation were fair to poor because of the difficulty in prediction of growth development and growth potential, allowing only for partial correction of the deformity. Besides the restriction of the stapling procedure due to the aetiology of the deformity, the age of the patients at the time of surgery is important, as it determines the complication rate of this technique (loosening or dislocation of staples). Thus Blount's epiphyseodesis should not be performed before the age of 9 years in girls and 11 years in boys.

CONCLUSION

Blount's epiphyseal stapling can be recommended as a safe procedure with predictably good results in idiopathic angular deformities of the leg and leg length difference caused by overgrowth.

Lengthening of the lower limbs in achondroplastic patients. A comparative study of four techniques

We report our experience of lengthening by over 30% a total of 117 lower limbs in achondroplastic patients. We have compared four methods: transverse osteotomy, oblique osteotomy, callotasis of the shaft and chondrodiatasis of the epiphysis. Chrondrodiatasis of the femur and callotasis of the tibia are the techniques which gave fewest complications.

Complications after epiphyseal reconstruction of the anterior cruciate ligament in prepubescent children

PURPOSE

Reconstruction of the anterior cruciate ligament (ACL) remains a major concern in the prepubescent, skeletally immature patient with wide open growth plates. Different surgical techniques have been proposed. This study reports the results and complications of ACL reconstruction in young children using an all epiphyseal technique.

METHODS

Between 2006 and 2010, 12 patients (10-13 years, median 12.1 years) underwent epiphyseal primary ACL reconstruction, with a total of 13 knee procedures. Patients were assessed retrospectively with a median follow-up of 54 months (range 39-80 months) consisting of a clinical examination, instrumented arthrometer testing and radiological analysis. Functional status was assessed using the Lysholm knee score, Tegner activity scale and IKDC-2000 form.

RESULTS

According to the IKDC examination form, five knees were rated as normal, six near normal and two abnormal. The median IKDC score at follow-up was 88.5 points (range 75-99 points). The mean side-to-side difference in KT-1000 ligament laxity testing was 1.5 mm (±2.5 mm). In two patients, reoperation was necessary due to graft failure. Two patients developed significant leg length inequality; one with 20 mm overgrowth and varus malalignment after re-reconstruction and the second developed arthrofibrosis and overgrowth of 16 mm. Four patients had minor limb length discrepancy ranging between +5 and +10 mm; no growth arrest was noted. One patient with an intact but slightly elongated graft required a meniscal suture 34 months after ACL reconstruction following a traumatic medial meniscal lesion.

CONCLUSION

Despite using the epiphyseal technique in ACL reconstruction, relevant growth discrepancy can occur. Thereby, overgrowth rates appear to potentially pose a major clinical problem, which has remained unreported so far. Overall, there is a considerable high risk of complications in this patient group.

LEVEL OF EVIDENCE

IV.

Proximal femoral radiographic changes after lateral transtrochanteric intramedullary nail placement in children

BACKGROUND

Recent reports have described osteonecrosis of the femoral head after intramedullary nailing of the femur through the piriformis fossa in children. Other reports have raised concerns about the development of femoral neck narrowing and valgus deformity of the proximal part of the femur after intramedullary nailing through the tip of the greater trochanter. We evaluated the radiographic changes in the proximal part of the femur following intramedullary nailing through the lateral trochanteric area at a minimum of two years postoperatively in twenty-five affected extremities. The mean age of the patients at the time of the index procedure was ten years and six months.

METHODS

A retrospective radiographic review was performed to look for proximal femoral changes. Specifically, the radiographs were examined for evidence of osteonecrosis. The articulotrochanteric distance, femoral neck diameter, and neck-shaft angle were measured on the initial and final radiographs.

RESULTS

No patient had evidence of osteonecrosis of the femoral head. The articulotrochanteric distance decreased by a mean of 0.4 mm, the femoral neck diameter increased by a mean of 4.9 mm, and the neck-shaft angle decreased by a mean of 1.4 degrees. Compared with a group of seventeen patients with adequate initial and final radiographs of the contralateral side, the final mean articulotrochanteric distance was 4.5 mm less on the involved side than on the uninvolved side, the mean femoral neck diameter was 0.7 mm less on the involved side than on the uninvolved side, and the mean neck-shaft angle was 3.2 degrees less on the involved side than on the uninvolved side. No patient had development of clinically important femoral neck narrowing or valgus deformity. Statistically, the likelihood that these data represent a group with a mean 3-mm increase in the articulotrochanteric distance is <1%. The likelihood that these data represent a group with a mean 3.2-mm decrease in the ultimate femoral neck diameter is <1%. The likelihood that these data represent a group with a mean 5 degrees increase in the neck-shaft angle is <1%.

CONCLUSIONS

Lateral transtrochanteric intramedullary nailing in children who are nine years of age or older does not produce clinically important femoral neck valgus deformity or narrowing, and we did not observe osteonecrosis of the femoral head after this procedure.

Epidiaphyseal versus other intercalary allografts for tumors of the lower limb

Epidiaphyseal intercalary reconstruction has become possible for bone tumors that extend into the epiphysis because advances in magnetic resonance imaging and chemotherapy allow close resection while sparing the juxtaarticular bone and joint. In a retrospective study, we questioned whether epidiaphyseal reconstructions around the knee had a clinical outcome (measured as long-term survival, complication rate, and functional score) comparable with metadiaphyseal and diaphyseal reconstructions. Between 1988 and 1999, 14 epidiaphyseal, nine metaphyseal, and 12 diaphyseal reconstructions were done, and the median followup was 7.2 years. Kaplan-Meier analysis showed a 10-year survival rate of 79% for epidiaphyseal reconstructions, which did not differ from an 89% rate for metadiaphyseal and a 75% rate for diaphyseal reconstructions. Epidiaphyseal complications included two infections, five fractures, and three nonunion treatments. Complications for all 35 grafts included three infections, 12 fractures, and nine nonunion treatments. Ultimately, six grafts failed, with infection and length of resection as predisposing factors. All epiphyseal osteotomies had tumor-free margins and no local recurrences. The mean Musculoskeletal Tumor Society score for each type of intercalary reconstruction was between 23 and 24. Because the epidiaphyseal reconstruction avoids complications associated with joint reconstruction and the results are comparable with those of other types of intercalary grafts, these reconstructions should be considered if at least 1 cm of tumor-free juxtaarticular bone can be maintained.

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.