Tibia vara deformity after below knee amputation and synostosis formation in children

Surgical Technique for Varus Deformity Correction of Below-Knee Stump in a Paediatric Patient

Paediatric amputation is one of the treatment options for various indications, namely, trauma, infection, tumour and congenital problems, and some may be born with congenital problems. It differs from adult amputation as they have higher physical demands, and special complications may arise. Stump overgrowth by far is the commonest complication in paediatric transosseous amputation, while varus deformity of the tibia stump was reported sparsely in the literature. The growth discrepancy of the proximal tibia and fibula physis coupled with distal tibiofibular synostosis may have resulted in proximal migration of the fibula, which later resulted in varus deformity of the stump. This will cause difficulty in prosthesis fitting and lead to painful stumps due to the pressure at the abnormal bony prominence. We report a case of congenital limb deficiencies in a 12-year-old male who was treated with below-knee amputation (BKA) and experienced progressive varus deformity of the stump that caused pain during prosthetic wear, which interfered with his gait. He had a varus deformity of 15 degrees of the stump, distal tibiofibular synostosis and proximal migration of the fibula head. As the conservative management by modification of the prosthesis had failed, he underwent open wedge proximal tibia corrective osteotomy, division of the synostosis and reduction of the fibula head. The surgical intervention was successful in alleviating his problem. All efforts must be made to ensure optimum prosthetic fitting in paediatric amputation patients to maintain the patient's daily lifestyle and activities.

Hemiepiphysiodesis for correction of angular deformity in pediatric amputees

BACKGROUND

Angular deformities at the knee are common in children with congenital or acquired below-knee or Syme amputations. These deformities can be well compensated and accommodated with prosthetic modifications. However, as children grow, these prosthetic modifications become more difficult and mechanical axis correction becomes necessary. These deformities have previously been treated with osteotomies and internal or external fixation devices, which necessitate prolonged periods without use of their prosthesis. This study examines the results of hemiepiphysiodesis to correct the mechanical axis and improve prosthetic fitting in a pediatric amputee population.

METHODS

Mechanical axis correction using hemiepiphysiodesis in 22 pediatric Symes or transtibial amputees with 22 involved limbs were retrospectively reviewed. Hemiepiphysiodesis was performed with 8-plates (10), staples (6), or drilling and curetting (6). Postoperatively, children were allowed to resume prosthetic use after their wounds healed and they indicated no pain while wearing their prosthesis. Seventeen patients presented with valgus and 5 with varus deformity of their residual limb. Mean age at time of surgery was 11 years and 11 months (range, 7 y and 11 mo to 15 y and 8 mo). Mechanical axis deviation (MAD) was measured before initial surgery and again after hardware removal or physis closure.

RESULTS

The mean preoperative MAD was -29.6 mm for the valgus deformities and +10.6 mm for the varus deformities. The mean postoperative MAD was +3.1 mm for the varus knees and -6.0 mm for the valgus knees The mean total mechanical axis correction was 21.8 mm. One patient failed to achieve any mechanical axis correction and 1 hardware failure (broken 8-plate) occurred. Most patients had the staples or 8-plates removed, either after correction was achieved and physes were still open, or due to hardware prominence after physeal closure.

CONCLUSIONS

Hemiepiphysiodesis provides reliable correction of angular deformity in pediatric amputees. Surgical intervention while skeletally immature allows for correction using guided growth, without the need for osteotomy with internal or external fixation and the resultant disruptions in prosthetic wear.

LEVEL OF EVIDENCE

Case Series, Level IV.

Transtibial Ertl amputation for children and adolescents: a case series and literature review

PURPOSE

Despite advances in limb reconstruction, there are still a number of young patients who require trans-tibial amputation. Amputation osteoplasty is a technique first described by Ertl to enhance rehabilitation after trans-tibial amputation. The purpose of the study reported here was to evaluate the results of the original Ertl procedure in skeletally immature patients and to assess whether use of this procedure would result in a diminished incidence of bony overgrowth.

METHODS

The cases of four consecutive patients (five amputations) treated between January 2005 and June 2008 were reviewed. Clinical evaluation consisted of the completion of the prosthesis evaluation questionnaire (PEQ) and physical examination. Radiographic analysis was performed to evaluate bone-bridge healing, bone overgrowth, and the development of genu varum as measured by the medial proximal tibial angle (MPTA).

RESULTS

The best mean PEQ score in the question section was 91.8 (range 74-100) for 'well being' and the worst mean score was 66.6 (range 50-78) for 'residual limb health'. Examination of the residual limbs revealed no bursae, and all knees were stable with full range of movement. All bony bridges united at an average age of 1.7 (range 1-2) months. One case required stump revision for bony overgrowth, and one case developed asymptomatic mild genu varum.

CONCLUSIONS

The original Ertl osteomyoplasty may serve as one of the options for treatment of trans-tibial amputation in older children.

CLINICAL RELEVANCE

Our results suggest that the Ertl osteomyoplasty is a feasible option in this challenging patient population.

Meningococcal purpura fulminans in children. II: Late orthopedic sequelae management

BACKGROUND

Purpura fulminans is a rare and extremely severe infection, mostly due to Neisseria meningitidis. Nineteen patients were followed up immediately after the initial multivisceral failure in order to diagnose late-onset orthopedic sequelae. We report our experience with these 19 patients, in light of our medical follow-up protocol and surgical management.

MATERIALS AND METHODS

Nineteen patients were referred for acute purpura fulminans between 1987 and 2005 to our institution and followed up prospectively until the present. We collected information on all diagnosed orthopedic sequelae, all surgical procedures performed, and the actual orthopedic outcome.

RESULTS

Fourteen patients developed at least one orthopedic sequel after a mean of 2 years delay, with a mean of 8.65 years follow-up (range 3-22 years). The most common presentation was lower limb physeal growth plate arrest in eight patients involving 18 growth plates, leading to five limb length discrepancies and 12 significant knee and/or ankle deviations. Patients were treated by completing epiphysiodesis in addition to limb lengthening and/or reaxation osteotomies, except for two patients, in which epiphysiolysis was performed. All outcomes are, to date, satisfactory, with both knee and ankle axes within the physiological range. Among the seven patients who underwent below-knee amputation, six needed stump revision because of skin conflict (4) or prosthetics misadaptation due to upper tibial varus (2). Regarding the upper limb, three patients presented with four cicatricial scar bands, one located on a ring finger, two at the first commissure, and one at the wrist (all were successfully treated by enlargement Z-plasties). Two patients developed hip avascular necrosis.

CONCLUSION

It is important for children diagnosed with meningococcal purpura fulminans to be followed up closely starting from the very beginning by a pediatric orthopedic surgeon. It ensures that late-onset orthopedic sequelae will be diagnosed early. In accordance to the literature, this study highlights the high rate of lower limb epiphysiodesis, above all other types of sequelae. This study reports a possible link between purpura fulminans and avascular necrosis of the hip.