Arthroscopic treatment of intercondylar eminence fractures with intraepiphyseal screws in children and adolescents

INTRODUCTION

Tibial intercondylar eminence fracture rarely occurs in childhood. Its treatment requires anatomic reduction to provide knee stability and a rigid fixation to minimize postoperative immobilization time.

HYPOTHESIS

Arthroscopy combined with fluoroscopy with intra-epiphyseal ASNIS screw fixation can meet the requirements of this treatment.

MATERIAL AND METHODS

The series comprised 24 patients (mean age: 11 years) with Meyers and McKeever type II tibial intercondylar eminence fractures (n=15) or type III (n=9), operated on between 2011 and 2013. Fixation with 4-mm ASNIS screws was placed arthroscopically. The demographic data, associated lesions, radiological union, stability, functional result, and the Lysholm score were evaluated.

RESULTS

With a mean follow-up of 2 years, the mean Lysholm score was 99.3 for type II and 98.6 for type III fractures. At the 6th postoperative week, range of motion in the operated knees was identical to the healthy knees. At the 12th postoperative week, there was no sign of anterior laxity. Twelve cases included meniscal entrapment, but no significant difference was observed in the functional results.

DISCUSSION, CONCLUSION

ASNIS screw fixation under arthroscopy can be successfully applied in the treatment of types II and III tibial intercondylar eminence fractures in children. This technique provides excellent stability, allows early weigh-tbearing, and preserves function of the knee and its growth.

LEVEL OF EVIDENCE

IV, retrospective study.

[TREATMENT OF RECURRENT PATELLAR DISLOCATION ASSOCIATED WITH OLD OSTEOCHONDRAL FRACTURE]

OBJECTIVE

To explore the treatment methed of recurrent patellar dislocation associated with old osteochondral fracture and to evaluate its effectiveness.

METHODS

Between August 2010 and August 2014, 12 cases of recurrent patellar dislocation with old osteochondral fracture were treated. There were 4 males and 8 females with an average age of 18.3 years (range, 15-24 years). The left knee was involved in 7 cases and the right knee in 5 cases. All the patients had a history of patellar dislocation, the average interval from injury to first hospitalization was 7.6 months (range, 6-13 months). At preoperation, the range of motion (ROM) of the injured knee was (89.17 ± 13.11)degrees; the Lysholm score was 56.67 ± 18.91; the Q-angle was (17.50 ± 5.28)degrees; and tibial tuberosity-trochlear groove (TT-TG) distance was (18.33 ± 4.03) mm. The Q-angle was more than 20 degrees and TT-TG distance was more than 20 mm in 6 of 12 cases. There were 6 cases of patellar osteochondral fracture, 5 cases of lateral femoral condylar osteochondral fracture, and 1 case of patellar osteochondral fracture combined with lateral femoral condylar osteochondral fracture. After osteochondral fracture fragments were removed under arthroscope, lateral patellar retinaculum releasing and medial patellar retinaculum reefing was performed in 2 cases, medial patellofemoral ligament (MPFL) reconstruction combined with both lateral patellar retinaculum releasing and medial patellar retinaculum reefing in 4 cases, and MPFL reconstruction, lateral patellar retinaculum releasing, medial patellar retinaculum reefing, and tibial tubercle transfer in 6 cases. Results All wounds healed by first intention with no complication of infection, haematoma, skin necrosis, or bone nonunion. All patients were followed up 12-60 months with an average of 24.2 months. At 3 months after operation, all patellar dislocations were corrected; the Q-angle was (13.33 ± 1.37)degrees and the TT-TG distance was (12.17 ± 1.17) mm in 6 patients undergoing tibial tubercle transfer, showing significant differences when compared with preoperative values [(22.50 ± 2.17)degrees and (21.33 ± 2.34 mm (t = 15.25, P = 0.00; t = 8.27, P = 0.00. All patients achieved relief of knee pain and knee locking; the knee ROM and the Lysholm score at last follow-up were (120.42 ± 11.57)degrees and 89.25 ± 9.71, showing significant differences when compared with preoperative ones (t = -11.61, P = 0.00; t = -8.66, P = 0.00).

CONCLUSION

It gas satisfactory short-term effectiveness to remove old osteochondral fragments that can not be rest and to correct patellar dislocation for recurrent patellar dislocation with old osteochondral fracture.

Prediction of Clinically Significant Leg-Length Discrepancy in Congenital Disorders

Leg-length discrepancy greater than 2 to 2.5 cm can potentially have an adverse effect on our walking and standing mechanisms and requires proper correction involving surgical treatment. However, for minor leg-length discrepancy in childhood, decision making for the indications for and timing of epiphysiodesis is difficult because of unpredictable final discrepancy. The purpose of this study was to analyze longitudinal changes of minor leg-length discrepancy in congenital disorders and to determine earlier predictive values for the clinically significant discrepancy. Twenty-one patients with congenital disorders who had minor leg-length discrepancy less than 2 cm at the first presentation were retrospectively evaluated. The patients were divided into 2 groups according to leg-length discrepancy at latest follow-up: the significant group (n=11) had 25 mm or more of leg-length discrepancy and the minor group (n=10) had less than 25 mm of leg-length discrepancy. The authors evaluated longitudinal changes of leg-length discrepancy within the first 10 years by mixed-effects regression model. All patients showed monotonically increasing leg-length discrepancy with age, except for 2 (neurofibromatosis type 1 and macrodactyly of the foot) who demonstrated fluctuating leg-length discrepancy. Mean annual rate of leg-length discrepancy change in the significant group was 2.1 mm across the first decade of life and was significantly larger than that in the minor group (difference in slope, 1.3 mm; P<.0001). In minor leg-length discrepancy associated with congenital disorders, the incidence of clinically significant leg-length discrepancy can be predictable by the annual rate of leg-length discrepancy change in the first decade of life.

[ALLOTRANSPLANTATION OF CRYOPRESERVATED VASCULARIZED BONE IN LIMB SALVAGE SURGERY FOR CHILDREN AND ADOLESCENTS WITH OSTEOSARCOMA]

OBJECTIVE

To investigate the effectiveness and technical key points of limb salvage surgery by allotransplantation of cryopreservated vascularized bone in children and adolescents with osteosarcoma.

METHODS

A retrospective analysis was made on the clinical data of 21 children and adolescents with osteosarcoma receiving limb salvage surgery by allotransplantation of cryopreservated vascularized bone from their relatives between February 2004 and April 2012. There were 13 males and 8 females, aged from 7 to 16 years (mean, 12.6 years). According to Enneking stage system, 15 cases were rated as stage IIA and 6 cases as stage IIB. The tumors located at the distal femur in 10 cases, at the proximal femur in 1 case, at the proximal tibia in 8 cases, at the proximal humerus in 1 case, and at the distal radius in 1 case. Imaging examination showed that epiphyseal extension of malignant bone tumors in 7 cases. The iliac bone allograft with deep iliac vessels was obtained from their lineal consanguinity. After preservation by a two-step freezing schedule, the iliac bone allograft with deep iliac vessels was implanted into the bone defect area after tumor resection. The size of iliac bone flap was 8.0 cm x 3.0 cm x 2.0 cm-14.0 cm x 5.0 cm x 2.5 cm. Reserved joint surgery was performed on 16 cases and joint fusion surgery on 5 cases, and external fixation was used in all cases. The chemotherapy was given according to sequential high-dose methotraxate, adriamycin, and cisplatine before and after operation.

RESULTS

All 21 cases were followed up from 5 months to 11 years (mean, 6.4 years). At 2 weeks after operation, the erythrocyte rosette forming cells accounted for 56.7% ± 3.9%, showing no significant difference when compared with that of normal control (58.3% ± 4.3%) (t = 1.56, P = 0.13), which suggested no acute rejection. At 4 weeks after operation, single photon emission computerized tomography bone scan indicated that the blood supply of bone graft was rich, and the metabolism was active. At 12 weeks after operation, the digital subtraction angiography showed the artery of iliac bone flap kept patency. X-ray films showed that malunion and non-union occurred at 5 and 6 months after operation in 1 case, respectively. The bone graft healed in the other patients, and the healing time was 3.2-6.0 months (mean, 4.4 months). At last follow-up, American Musculoskeletal Tumor Society (MSTS) score was significantly improved to 26.80 ± 2.14 from preoperative value (17.15 ± 1.86) (t = -4.15, P = 0.00). The survival rate was 85.7% (18/21) and the recurrence rate was 9.5% (2/21).

CONCLUSION

Allotransplantation of cryopreservated vascularized bone from the relatives provides a new method for the treatment of osteosarcoma in children and adolescents. A combination of allotransplantation and chemotherapy can achieve the ideal treatment effect. The correct cutting, preservation, and transplantation of the donor bone, and indication are the key to improve the effectiveness.

Fracture-dislocation of the humeral condyles in adults: results of surgical treatment

Fracture-dislocation of the humeral condyle is exceptional in adults. The purpose was to analyze the results of surgical treatment by open reduction and internal fixation without ligamentous repair. There were six men with an average age of 31 years. According to the AO classification, five fractures were classified as AO type B1 and one as B2. Dislocation was reduced in emergency before osteosynthesis. Postoperatively, the joint was held immobile with a brace for 25.40 days. Five patients were reviewed after a mean follow-up of 52.96 months. The median arc of flexion/extension was 104.80° and 157.8° for pronation-supination. All elbows were stable and all fractures were consolidated. Two elbows were painful. The results were satisfactory in five patients. The elbow stability can be ensured only by the synthesis of bone structures. Surgical treatment should restore exact anatomy between the condyle and trochlea. This protocol may provide a joint stability and satisfactory results.

Anterior Longitudinal Osteotomy of the Greater Trochanter in Total Hip Arthroplasty

The extra-articular impingement of the greater trochanter against the ileum is an underrated cause of early dislocation in total hip arthroplasty. In this preliminary study, the authors assess the effectiveness of an anterior longitudinal osteotomy of the greater trochanter for preventing dislocation. A total of 115 patients underwent a total hip arthroplasty through a posterolateral approach. All patients underwent clinical and radiological follow-up at 1, 3, and 6 months. No dislocation was reported. All patients demonstrated fast recovery of range of motion and walking. No trochanter fractures were observed. The osteotomy of the greater trochanter is an effective surgical technique that decreases anterior impingement and consequently lowers the dislocation rate in primary total hip arthroplasty. [Orthopedics. 2015; 38(8):490-493.].

Use of auxiliary locking plates for the treatment of unstable pertrochanteric femur fractures

Pertrochanteric femur fractures are successfully treated by orthopedic surgeons worldwide, but maintaining the reduction status or fixation of the greater trochanter is sometimes difficult in unstable cases in elderly patients. Several biomechanical advantages have been reported in locking plates when compared with conventional plates; locking plates provide angular and axial stability, better rigidity, and no toggling, and they preserve periosteal blood supply. The authors describe the use of auxiliary locking plates in unstable pertrochanteric femur fractures in elderly patients. Mini locking plates are simple, straightforward, and versatile enough to be used in elderly patients.

First metatarsal proximal opening wedge osteotomy for correction of hallux valgus deformity: comparison of straight versus oblique osteotomy

PURPOSE

The aim of this study was to compare clinical and radiographic outcomes of proximal opening wedge osteotomy using a straight versus oblique osteotomy.

MATERIALS AND METHODS

We retrospectively reviewed 104 consecutive first metatarsal proximal opening wedge osteotomies performed in 95 patients with hallux valgus deformity. Twenty-six feet were treated using straight metatarsal osteotomy (group A), whereas 78 feet were treated using oblique metatarsal osteotomy (group B). The hallux valgus angle (HVA), intermetatarsal angle (IMA), distal metatarsal articular angle, and distance from the first to the second metatarsal (distance) were measured for radiographic evaluation, whereas the American Orthopaedic Foot and Ankle Society (AOFAS) forefoot score was used for clinical evaluation.

RESULTS

Significant corrections in the HVA, IMA, and distance from the first to the second metatarsal were obtained in both groups at the last follow-up (p<0.001). There was no difference in the mean IMA correction between the 2 groups (6.1±2.7° in group A and 6.0±2.1° in group B). However, a greater correction in the HVA and distance from the first to the second metatarsal were found in group B (HVA, 13.2±8.2°; distance, 25.1±0.2 mm) compared to group A (HVA, 20.9±7.7°; distance, 28.1±0.3 mm; p<0.001). AOFAS scores were improved in both groups. However, group B demonstrated a greater improvement relative to group A (p=0.005).

CONCLUSION

Compared with a straight first metatarsal osteotomy, an oblique first metatarsal osteotomy yielded better clinical and radiological outcomes.

Surgical interventions for treating distal tibial metaphyseal fractures in adults

BACKGROUND

The distal tibial metaphysis is located in the lower (distal) part of the tibia (shin bone). Fractures of this part of the tibia are most commonly due to a high energy injury in young men and to osteoporosis in older women. The optimal methods of surgical intervention for a distal tibial metaphyseal fracture remain uncertain.

OBJECTIVES

To assess the effects (benefits and harms) of surgical interventions for distal tibial metaphyseal fractures in adults. We planned to compare surgical versus non-surgical (conservative) treatment, and different methods of surgical intervention.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (9 December 2014), the Cochrane Central Register of Controlled Trials (2014, Issue 12), MEDLINE (1946 to November Week 3 2014), EMBASE (1980 to 2014 Week 48), the Airiti Library (1967 to 2014 Week 8), China Knowledge Resource Integrated Database (1915 to 2014 Week 8), ClinicalTrials.gov (February 2014) and reference lists of included studies.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled clinical studies comparing surgical versus non-surgical (conservative) treatment or different surgical interventions for treating distal tibial metaphyseal fractures in adults. Our primary outcomes were patient-reported function and the need for secondary or revision surgery or substantive physiotherapy because of adverse outcomes.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies, assessed the risk of bias in each study and extracted data. We resolved disagreement by discussion and, where necessary, in consultation with a third author. Where appropriate we pooled data using the fixed-effect model.

MAIN RESULTS

We included three randomised trials that evaluated intramedullary nailing versus plating in 213 participants, with useable data from 173 participants of whom 112 were male. The mean age of participants in individual studies ranged from 41 to 44 years. There were no trials comparing surgery with non-surgical treatment. The three included trials were at high risk of performance bias, with one trial also being at high risk of selection, detection and attrition bias. Overall, the quality of available evidence was rated as very low for all outcomes, meaning that we are very unsure about the estimates for all outcomes.The results of two large ongoing trials of nailing versus plating are likely to provide sufficient evidence to address this issue in a future update.

AUTHORS' CONCLUSIONS

Overall, there is either no or insufficient evidence to draw definitive conclusions on the use of surgery or the best surgical intervention for distal tibial metaphyseal fractures in adults. The available evidence, which is of very low quality, found no clinically important differences in function or pain, and did not confirm a difference in the need for re-operation or risk of complications between nailing and plating.The addition of evidence from two ongoing trials of nailing versus plating should inform this question in future updates. Further randomised trials are warranted on other issues, but should be preceded by research to identify priority questions.

Surgical indications for distal tibial epiphyseal fractures in children

The goal of this study was to investigate the treatment methods and surgical indications of distal tibial epiphyseal fractures in children. Two hundred eighty-six children with distal tibial epiphyseal fractures were included in the study. Among these patients, 202 were male and 84 were female. Mean age was 11.7 years. A retrospective study on the postoperative long-term complications and related risk factors was performed. Treatment methods were determined according to the distance of fracture displacement. A long-leg cast was applied after closed reduction for patients with primary fracture displacement less than 2 mm. For cases with more than 2 mm of fracture displacement, K-wire or screw fixation was performed. For patients with less than 2 mm of fracture displacement, closed reduction and internal fixation was performed. Open reduction was performed in patients with more than 2 mm of fracture displacement, even after closed reduction. Mean follow-up was 6.4 years. Premature physeal closure occurred in 42 patients, and, among them, varus and valgus ankle deformities occurred in 16 patients. Associated fibular fractures and cast immobilization after closed reduction for Salter-Harris type III and IV fractures were risk factors for premature physeal closure. It is not effective to determine the surgical procedure according to the distance of preoperative fracture displacement for improving the prognosis of distal tibial epiphyseal fractures in children. Conservative treatment should be performed for patients with Salter-Harris type I and II distal tibial epiphyseal fractures, and surgery should be performed in patients with Salter-Harris type III and IV distal tibial epiphyseal fractures to reduce the incidence of premature physeal closure.

Air physiogram: technique for visualization of the resected physis in percutaneous epiphysiodesis

Obtaining an air physiogram improves visualization of the resected physis and allows the surgeon to assess whether a sufficient amount of growth plate has been removed during percutaneous drilling epiphysiodesis. From 2008 through 2011, the air physiogram technique was used in 37 percutaneous epiphysiodesis procedures about the knee (17 femora, 20 tibiae) in 31 children. Average follow-up was 41 months (range, 19-70 months). Thirty-six of 37 limb segments achieved radiographic fusion after the initial procedure. One tibia appeared to be partially fused and underwent revision epiphysiodesis. At final follow-up, all limb segments had successful epiphysiodesis and showed radiographic evidence of fusion.

[Long-term consequences of resection of 1/3 proximal epiphysis of child's right tibia--a case study]

Authors report a case of a patient with varus deformity of right knee, caused by wide resection of proximal metaphysis and epiphysis of right tibia. Afore mentioned procedure led to loss of right knee joint integrity, with its lateral instability, shortening, and axis deviation of right tibia. Surgical treatment of this complications was performed in several stages and took about 5 years, starting from temporal, lateral hemiepiphysiodesis of proximal tibial epiphysis, subacute epiphysiolysis of proximal tibial epiphysis and high valgus tibia osteotomy, at the end finished with medial tibia condyle reconstruction with autogenic graft and osteoconductive substances. The proper mechanical and anatomical axis of the right limb, with full stability and movement of right knee was achieved after those surgeries. The process of treatment of lower extremity axis deviation takes long time, frequently involves several surgeries and needs firm cooperation between doctor and patient.

Medial malleolar screw hemiepiphysiodesis for ankle valgus in children with spina bifida

Medial malleolar screw hemiepiphysiodesis has been shown to be an effective procedure for the treatment of ankle valgus in children with spina bifida. The purpose of this study was to highlight the guided growth technique and discuss its efficacy. We retrospectively reviewed 10 spina bifida patients with 18 ankle valgus deformities treated with medial malleolar screw hemiepiphysiodesis. Medical reports were obtained to document age at surgery, gender, concurrent operative procedures and postoperative early and late complications. Anteroposterior and lateral weight bearing radiographs of both ankles were evaluated using the tibiotalar angle, pre and postoperatively. The average age at operation was 10.05 years. Average follow up was 15.33 months (11-21 months). During follow-up, the average preoperative distal tibiotalar angle of 16.27 degrees improved to an average of 2.88 degrees with statistical significance (p < 0.05). No major complications were detected. In conclusion, hemiepiphysiodesis is a safe and sufficient method to correct ankle valgus deformity in children with spina bifida, with a low incidence.

[Clinical application of computer navigation in physeal bridge resection in pediatric partial epiphyseal plate closure]

OBJECTIVE

To report our experience of using image-guided computer navigation for bone bridge resection in children.

METHODS

Between August 2008 and March 2011 at our hospital, computed tomography (CT)-based navigation system for bone bridge resection was used in 42 children with lower extremity deformities due to partial physeal growth arrest. There were 26 males and 16 females with an average age of 9.8 (5.0-13.0) years.

RESULTS

Six patients were lost to follow-up. In other 36 patients, the average duration of radiographic and clinical follow-up was 25 (15-44) months. Among them, 13 were corrected to neutral while 15 had insufficient correction. The average correction angle of deformities was 14 (8-25) degrees.

CONCLUSION

The image-guided computer navigation system enhances the accuracy and safety of bone bridge resection in children.

Axial correction of the lower limb deformities in a girl with anauxetic dysplasia

Valgus subtrochanteric osteotomies and hemiepiphyseodesis around the knees have been performed to correct severe coxa vara and genua valga in a girl patient who manifested extreme dwarfism associated with spondylometaepiphyseal dysplasia consistent with anauxetic dysplasia. To the best of our knowledge, this is the first description of the combined orthopaedic intervention in a girl with anauxetic dysplasia.

[Treatment of severe displaced proximal humeral fractures with titanium elastic nails in older children]

OBJECTIVE

To evaluate the effectiveness of titanium elastic nails for severe displaced proximal humeral fractures in older children.

METHODS

Between April 2009 and July 2012, 31 cases of severe displaced proximal humeral fractures were treated with closed or open reduction and fixation with 2 titanium elastic nails, and the clinical data were retrospectively analyzed. There were 23 boys and 8 girls, aged from 10 to 15 years (mean, 12.8 years). The causes of injury were sports injury (16 cases), traffic accident (11 cases), and falling from height (4 cases). The interval from injury to operation was 6 hours to 7 days (mean, 72 hours). According to Neer-Horwitz classification, 17 cases were rated as type III fracture and 14 cases as type IV fracture. There were 21 cases of metaphyseal fractures and 10 cases of epiphyseal fractures.

RESULTS

Satisfactory reduction of fracture and stable fixation were obtained in all patients (closed reduction in 23 cases and open reduction in 8 cases). Primary healing was achieved in all incisions; no infection and neurovascular injury occurred. All patients were followed up 12-36 months with an average of 20 months. X-ray films showed that all fractures healed at 7-10 weeks (mean, 8 weeks). During follow-up, no disturbance of development or angulation deformity caused by premature physeal closure or bone bridge formation was observed. At last follow-up, the average Neer score of the shoulder was 95.7 (range, 83-100). The appearance and motion of the shoulder were normal. There was no significant difference in the upper extremity length between affected side and contralateral side [(67.68 +/- 2.56) cm vs. (67.61 +/- 2.54) cm; t = 1.867, P = 0.072].

CONCLUSION

Titanium elastic nails for severe displaced humeral fractures in older children is a safe and effective method with a low complication incidence.

Phemister epiphysiodesis in leg length inequality treatment--evaluative outcome analysis

BACKGROUND

The aim of this study was to evaluate the efficacy of Phemister epiphysiodesis for leg length inequality (LLI) treatment in comparison with epiphysiodesis techniques currently in use and to determine factors that may influence outcomes.

MATERIALS AND METHODS

Nineteen girls and sixteen boys with a mean skeletal age of 12.2 years and a mean functional LLI of 3.8 cm at the time of surgery were enrolled. Data were retrieved from hospital records and bone ages were determined using standard atlases. Mean follow-up duration was 7 years.

RESULTS

Good results (final LLI < 1.5 cm) were obtained in 74.3% of patients, fair results (final LLI 1.6-2.0 cm.) were seen in 5.7% and poor results (final LLI > 2 cm) were seen in 20%. A mean clinical LLI of 1.7 cm was the treatment outcome for the entire group. Valgus deformity of 7°, 10° and 13° occurred in three patients.

CONCLUSIONS

1. Phemister epiphysiodesis performed for LLI produced the desired correction but was associated with a risk of over- or undercorrection and frontal plane deformity due to inadequate physeal closure. 2. These complications are typical for any kind of epiphysiodesis.

[Epiphysis preserving by physeal distraction for treatment of femur osteosarcoma in children]

OBJECTIVE

To analyze the effectiveness and application value of epiphysis preserving by the method of physeal distraction for treatment of femur osteosarcoma in children's limb saving surgery.

METHODS

Between January 2007 and January 2011, 6 patients with femur osteosarcoma underwent epiphysis preserving operation by physeal distraction. There were 4 males and 2 females with a mean age of 11.4 years (range, 9-14 years). The mean disease duration was 4.8 months (range, 1-9 months). The pathology confirmed osteosarcoma in all patients by core needle or open biopsy, including 1 case of osteogenic sarcoma, 1 case of chondroblastic osteogenic sarcoma, 1 case of osteoblastic osteogenic sarcoma, and 3 cases of no classified osteosarcoma. The clinical stage was IIA in 1 case and IIB in 5 cases according to the Enneking staging system. All patients received 2 cycles of neoadjuvant chemotherapy before operation. Then physeal distraction was performed for 4-7 days (mean, 5.7 days) based on Cañiadell technique. After 1-2 days of physeal distraction, massive allograft bones and interlocking intramedullary nails were used to reconstruct bone defect after tumor resection. All patients received another 4-6 cycles of chemotherapy and were followed up. Bone healing, limb discrepancy, and complications were recorded. Functional outcomes were assessed by the system of the Musculoskeletal Tumor Society (MSTS) and the range of motion (ROM) of both knee joints.

RESULTS

Superficial infection occurred in 1 case and was cured after dressing change, and primary healing was obtained in the other patients. All 6 patients were followed up 2.5 years on average (range, 1-5 years). Symptoms of pain and swelling disappeared. No complication of allograft rejection, loosening or breaking of fixation occurred. No relapse or metastasis happened during follow-up. Bone healing was observed at the metaphysis junction in 5 cases at 6-9 months after operation and in 1 case at 14 months. Delayed union happened at the diaphysis junction in all patients. Different amount of callus formation was seen at the surface of diaphysis junction, but the fracture line remained clear at 12-48 months after operation. At last follow-up, limb discrepancy was 1-3 cm in 4 patients and 3-5 cm in 2 patients; 3 patients had compensatory scoliosis, and 2 patients had claudication. The MSTS score was 27.20 +/- 1.92, showing significant difference (t= -4.12, P=0.00) when compared with preoperative score (19.60 +/- 2.74). The ROM of affected knee was (127.00 +/- 17.89)0, showing no significant differences when compared with preoperative ROM (109.00 +/- 12.45) degrees (t= -1.84, P=0.10) and with ROM of normal knee (126.00 +/- 9.62)degrees (t= 0.11, P=0.92).

CONCLUSION

Limb saving surgery by physeal distraction can be used in young patients with open epiphyseal plate, which has the advantages of simple operation, good effectiveness, and less complications.

[Combined epiphyseal preservation and autograft bone transfer in treatment of children osteosarcoma]

OBJECTIVE

To investigate the clinical application and early results of combined epiphyseal preservation.

METHODS

Between March 2010 and March 2011, and autograft bone transfer for limb salvage in children with osteosarcoma. 3 children with osteosarcoma were treated with epiphyseal preservation and autograft bone transfer. There were 1 boy and 2 girls with the age of 10-14 years. The disease duration was 2 weeks to 3 months. The tumors were rated as type II according to San-Julian radiological classification and as type IIB according to Enneking surgical classification. The locations were the distal femur in 1 case and the proximal tibia in 2 cases. The surgical technique included preoperative neoadjuvant chemotherapy, excision of part of the epiphysis, preservation of subarticular epi physis, external fixation with Ilizarov apparatus and transport osteogenesis treatment. Safe excision border was confirmed by histological examination. Postoperative observation included the wound healing, local recurrence or distant metastasis, length, speed, alignment, and regeneration of transplanted bone, the length and function of the affected limb.

RESULTS

The postoperative histological examination proved the safe surgical margin in all 3 patients. The incision healing by first intention was obtained at distal femur in 1 case and by second intention at proximal tibia in 2 cases at 4 weeks after changes of dressing. Three patients were followed up 12, 18, and 24 months, respectively. There was no local recurrence or distant metastasis during follow-up. Two cases had pin-tract infection at 10 months after external fixation and were cured after changes of dressing and antibiotics administration. The length of transplanted osteogenisis was 18.0, 9.5, and 16.0 cm, respectively. The speed of lengthening was 2.57, 2.07, and 1.20 cm/month, respectively. One patient had alignment deviation during lengthening, which was adjusted under anaesthesia. Bony healing was achieved at 8 months after lengthening end in 2 cases and external fixation was removed; 1 patient had poor bone growth and was given retraction for promoting bone growth. At last follow-up, the length of the affected limbs was 1.0-1.5 cm shorter than that of normal limbs, but no abnormalities was observed at donor sites. The affected knee flexion reached 90 degrees and 120 degrees in 2 patients and poor knee function was observed in 1 patient for external fixation.

CONCLUSION

The combined epiphyseal preservation and transport osteogenesis technique can be used for bone defect repair by lengthening the residual bone. It is a promising limb salvage treatment for children with osteosarcoma.

[Epiphyseal distraction for preservation of epiphysis of osteosarcoma in children]

OBJECTIVE

To investigate the feasibility of the preservation of the epiphysis and joint function of the distal femur in children with osteosarcoma with epiphyseal distraction by external fixator.

METHODS

Between July 2007 and May 2011, 6 children with osteoblastic osteosarcoma of the distal femur underwent epiphyseal distraction by external fixator, combined with tumor resection and repair with massive allograft bone transplantation to preserve the epiphysis and joint function of the distal femur. There were 4 boys and 2 girls, aged from 9 to 14 years (mean, 10.5 years). According to Enneking clinical staging, 4 cases were in stage II A and 2 cases in stage II B. According to San-Julian et al. typing for metaphyseal tumor invasion, 3 cases were in type I and 3 cases in type II. The size of tumor ranged from 6 cm x 4 cm to 12 cm x 9 cm. All patients received 2 cycles of COSS 86 chemotherapy before operation and 4 cycles after operation.

RESULTS

Poor healing of incision was observed in 1 case because of rejection of allograft bone and good healing was obtained after the symptomatic treatment, healing of incision by first intention was achieved in the other children. All 6 cases were followed up 11 to 56 months (mean, 37.5 months). One case died of lung metastasis at 2 years after operation. X-ray films showed no complication of internal fixator loosening and broken or bone nonunion. According to the functional evaluation criteria of International Society of Limb Salvage (ISOLS) at last follow-up, the results were excellent in 3 cases, good in 2 cases, and fair in 1 case; the excellent and good rate was 83.3%. The length of operated limb was (62.97 +/- 7.51) cm, showing significant difference when compared with that of normal limb [(64.03 +/- 7.47) cm] (t=0.246 6, P=0.813 4).

CONCLUSION

On the premise of adaptable indication, effective chemotherapy, and thoroughly tumor resection, the epiphyseal distraction by external fixator can obtain satisfactory results in limb-length and limb function in children with osteoblastic osteosarcoma of the distal femur.

Distal radius definitive epiphysiodesis for management of Kienböck´s disease in skeletally immature patients

PURPOSE

Kienböck's disease is an unusual pathology with unknown aetiology within the pediatric population. Several treatment options have been described in the literature; however, there are neither large series nor homogeneous studies that have clarified which treatment is best. The aim of this study was to describe five cases in which definitive distal radius epiphysiodesis was performed as an alternative method to the classic distal radius shortening osteotomy in skeletally immature patients with Kienböck's disease.

METHODS

The clinical charts and radiographs of four patients (five wrists) diagnosed as having Kienböck's disease and treated by definitive distal radius epiphysiodesis were reviewed.

RESULTS

All patients were symptomatically free with full range of motion at 4.25 months (range, three to six months) after surgery. In all cases, shortening of the distal radius was achieved (p = 0.032).

CONCLUSIONS

This new technique is a simple, effective, and minimally invasive procedure with low morbidity and good clinical and radiological outcomes.

[Treatment of proximal radius epiphyseal injuries of O'Brien type III with titanium elastic nail in children]

OBJECTIVE

To investigate the feasibility and clinical effects of titanium elastic nail (TEN) for treatment of proximal radius epiphyseal injuries of O'Brien type III.

METHODS

From October 2008 to November 2009,19 patients with proximal radius epiphyseal injuries of O'Brien type III were treated with internal fixation, including 13 males and 5 females with an average age of 8.3 years old ranging from 6 to 12 years. The average time from injury to surgery was 3.5 days (2 to 7 days). The reduction situation after operation was assessed by Métaizeau criteria, and the elbow function after operation were evaluated by Broberg-Morrey elbow score.

RESULTS

All patients were followed-up for 8.7 months in average (ranged 6 to 12 months). No infection, TEN brokage, skin bursting and other complications occurrenced. According to Métaizeau criteria, the results were excellent in 7 cases, good in 10 cases and fair in 2 cases. The Broberg-Morrey score rose from preoperative (47.3 +/- 5.1) to (86.6 +/- 6.3) at 3 months followed-up (t=139.17, P=0.0002); the outcome was excellent in 7 cases, good in 9 cases, and fair in 3 cases.

CONCLUSION

Internal fixation with TEN in treatment of proximal radius epiphyseal injuries of O'Brien type III has a limited invasion, cosmetic beauty, safety and reliability advantages. This technique provides a reliable alternative in proximal radius epiphyseal injuries of O'Brien type III.

Adolescent Blount disease in obese children treated by eight-plate hemiepiphysiodesis

OBJECTIVES

The aim of this study is to evaluate the outcomes of eight-plate (Orthofix) use during hemiepiphyseodesis operation for growth modulation in obese children with adolescent Blount disease.

PATIENTS AND METHODS

Six limbs of five consecutive patients who underwent lateral proximal tibial eight-plate (Orthofix) hemiepiphysiodesis were evaluated. The body mass index (BMI) was >30 and the severity of the deformity was in Zone III according to the Mielke and Stevens definition. The mechanical medial proximal tibial angle (MPTA) and the mechanical axis deviation (MAD) were measured preoperatively, postoperatively, and at last follow-up. The outcome of the procedure was established by the degree of tibia vara correction degree at final plate removal or skeletal maturity.

RESULTS

Mean age of the patients and mean BMI at the time of surgery was 13 years (range 12 to 14) and 33.5 kg/m2 (range 31 to 36), respectively. Patients were followed for an average of 22 months (range 13 to 31). Preoperative and last follow-up mean values for MPTA were 81 and 80 degrees, respectively. Outcome of the procedure showed two extremities demonstrated progression of the tibia vara (mean of 6.5 degrees), two extremities had no correction of the deformity, and the remaining two extremities showed minimally improvement (mean 3 degrees). The procedure failed to correct the tibia vara in all extremities and all patients were scheduled for an osteotomy to treat the deformity.

CONCLUSION

We do not recommend the use of a tension band plate hemiepiphyseodesis (eight-plate, Orthofix) to treat severe adolescent Blount disease in obese children.

Hemiepiphyseal stapling for ankle valgus in multiple hereditary exostoses

If left uncorrected, valgus ankle deformity in multiple hereditary exostoses can cause significant disability in skeletally immature children and in adults. Various management methods have been described, including hemiepiphyseal stapling, transphyseal screw placement, fibular-Achilles tenodesis, distal tibial osteotomy, and ablative epiphyseodesis. In this article, we report the cases of 3 skeletally immature children who had undergone hemiepiphyseal stapling of the medial distal tibial epiphysis for correction of valgus ankle deformity in multiple hereditary exostoses. Correction of the tibiotalar axis, in relation to chronological and bone age, was evaluated. Hemiepiphyseal stapling of the medial distal tibial epiphysis provides ipsilateral corrective potential while allowing staple removal for reversal of growth retardation. This procedure is useful in the management of ankle valgus in multiple hereditary exostoses.