Change in angle of depressed medial tibial plateau following extra-articular mechanical realignment surgery in children with Blount's disease who presented late for treatment

INTRODUCTION

The aim of this study was to determine whether any change in degree of medial tibia plateau depression after extra-articular mechanical realignment surgery was observed in children with Blount's disease who presented late for treatment in their adolescence and young adulthood.

METHODS

We retrospectively reviewed the radiographic parameters of 22 patients (32 lower limbs) with Blount's disease who underwent gradual correction of deformity using a ring external fixator without surgical elevation of the depressed medial tibial plateau at a mean age of 15 (range 10-37) years. Preoperative and postoperative angles of depressed medial tibia plateau (ADMTPs) of the same patient were compared for any significant change. Normally distributed data were analysed using Student's t -test when comparing two groups or one-way analysis of variance when comparing more than two groups. Skewed data were analysed using Mann-Whitney test.

RESULTS

After extra-articular mechanical alignment surgery, statistically significant improvements in medial tibial plateau depression were seen in the infantile ( P = 0.03) and juvenile ( P = 0.04) Blount's subgroups. Change in ADMTP was greater in patients who were operated on at age <17 years, before skeletal maturity ( P = 0.001). The improvement was likely due to ossification of unossified cartilage at the posteromedial proximal tibia and the remodelling potential of proximal tibia physis after mechanical realignment.

CONCLUSION

Improvement of medial tibia plateau depression is possible after mechanical realignment without surgical hemiplateau elevation in cases of infantile and juvenile Blount's disease that present late for treatment, especially when the operation is performed before 17 years of age.

Tibial tubercle avulsion fracture following preexisting Osgood-Schlatter disease in an adolescent: a case report

Tibial tubercle avulsion fractures (TTAFs) are rare but typical in children and adolescents and Osgood-Schlatter disease (OSD) may be involved in their pathogenesis. However, few publications have reported the relationship between OSD and TTAF. A 16-year-old healthy male adolescent presented with pain, swelling and limited range of motion of the right knee following sudden acceleration while running. Based on the radiographic evidence, the patient was diagnosed with an avulsion fracture of the right tibial tubercle and OSD. Open reduction and internal fixation were performed using two cannulated screws and two Kirschner wires. The patient returned to preinjury activity levels at the 12-month follow-up postoperatively. This case report aimed to highlight this unique injury pattern. For patients with TTAFs, not only should the fracture be treated, but the cause of the fracture, such as OSD, should also be given appropriate treatment.

Enhanced Pain Relief and Function Improvement in Children with Osgood-Schlatter Disease: Leukocyte-Rich Platelet-Rich Plasma (LR-PRP) as a Complementary Treatment to Standard Conservative Therapy

BACKGROUND Osgood-Schlatter disease (OSD) causes pain and loss of function of the knee in growing children. This study aimed to evaluate pain and function of the knee joint in 152 growing children with chronic OSD before and after treatment with LR-PRP when used with standard conservative treatment. MATERIAL AND METHODS Treatment efficacy was evaluated using the VAS, Tegner, Lyshom, and KOOS scales. Patient satisfaction, post-surgery athletic performance, and X-ray assessment were also used to determine the success of the procedure. RESULTS We found that 75% of the subjects were satisfied with the results of the treatment, and 72% of the subjects returned to full physical activity. The analysis showed a significant decrease in the median VAS score after treatment compared to the pre-treatment score (P<0.05), and an increase in the median scores of the Tegner, Lysholm, and KOOS scales compared to the pre-treatment score (P<0.05; P<0.05; P<0.05, respectively). The results showed that the shorter the duration of the disease, the better the treatment results were received. Return to activity and patient satisfaction were highest in the study group previously rehabilitated. CONCLUSIONS LR-PRP injection of the tibial tuberosity in patients with chronic OSD with open growth cartilage is an effective and uncomplicated method. We did not observe any adverse effects, which suggests the relatively high safety of the procedure. The use of PRP in the earlier phase of the disease and additional rehabilitation before treatment significantly increases the effectiveness of treatment.

Long-term outcome of dogs treated by surgical debridement of proximal humeral osteochondrosis

OBJECTIVE

To evaluate long-term clinical outcomes of dogs surgically treated for proximal humeral osteochondrosis (OC).

STUDY DESIGN

Cross-sectional study.

SAMPLE POPULATION

Twenty dogs (n = 26 shoulders).

METHODS

Dogs treated with surgical debridement of proximal humeral OC lesions >12 months prior were enrolled. Orthopedic examination (including limb circumference and shoulder goniometry), kinetic gait analysis, shoulder radiographs, shoulder computed tomography (CT), and shoulder arthroscopy were performed. All owners completed a dog mobility questionnaire.

RESULTS

Brachial circumference (P = .003) and maximum shoulder extension (P = .013) were decreased and maximum shoulder flexion (P = .008) was increased (ie less flexion) in the OC limb versus the contralateral limb in unilaterally affected dogs. There were no differences in peak vertical force and vertical impulse between affected and unaffected limbs. Dogs demonstrated a 4.4% decrease in load distributed to the operated limb. Osteoarthritis was present in all shoulders treated for OC lesions. The degree of osteoarthritis in OC-affected shoulders was increased compared to the contralateral limb as evaluated on CT (P = .005) and radiography (P = .0001) in unilaterally affected cases. Moderate-to-severe synovitis was seen in all OC-affected joints. Arthroscopically, all lesions were noted to have patchy, incomplete cartilaginous infilling. Median of aggregate Liverpool Osteoarthritis in Dogs (LOAD) scores was 6.

CONCLUSION

All dogs exhibited ipsilateral muscle atrophy and progressive osteoarthritis, with most dogs exhibiting subtle lameness on the subjective gait examination. Despite this, owner-perceived mobility was satisfactory.

CLINICAL SIGNIFICANCE

Progression of joint disease over time should be expected; however, the abnormalities detected on examination appear to be of questionable clinical relevance.

A Predictive Score for Infantile Blount Disease Recurrence After Tibial Osteotomy

INTRODUCTION AND OBJECTIVE

Several predictive factors for infantile Blount disease recurrence after tibial osteotomy were discovered. This study aimed to examine and utilize various predictors to develop a prediction score for infantile Blount disease recurrence after tibial osteotomy.

METHODS

We conducted a retrospective cohort study of infantile Blount disease patients who underwent tibial osteotomy between January 1998 and December 2020. Potential predictors, including clinical and radiographic parameters, were examined for their association with the disease recurrence after receiving tibial osteotomy. A predictive score was subsequently developed based on those potential predictors through multivariable logistic regression modeling.

RESULTS

A total of 101 extremities diagnosed with infantile Blount disease from 58 patients who underwent tibial osteotomy were included. Of those, 15 extremities (14.9%) recurred. Univariable logistic regression analysis identified age older than 42 months [odds ratio (OR)=4.28; P =0.026], Langenskiöld classification stage III (OR=9.70; P <0.001), LaMont classification type C (OR=15.44; P <0.001), preoperative femorotibial angle <-14 degrees (OR=4.21, P =0.021), preoperative metaphyseal-diaphyseal angle >16 degrees (OR=8.61, P =0.006), preoperative medial metaphyseal slope angle >70 degrees (OR=7.56, P =0.001), and preoperative medial metaphyseal beak angle >128.5 degrees (OR=13.46, P =0.001) as potential predictors of infantile Blount disease recurrence after tibial osteotomy. A predictive score comprised of age younger than 42 months, LaMont classification type C, and medial metaphyseal beak angle >128 degrees demonstrated an excellent predictive performance (area under the receiver operating characteristic curve =0.87), good calibration, and high internal validity.

CONCLUSIONS

Our developed predictive score accurately predicted infantile Blount disease recurrence after tibial osteotomy. The results from our developed prediction tool allow physicians to inform prognosis, increase awareness during the follow-up period, and consider additional interventions to prevent disease recurrence.

LEVEL OF EVIDENCE

Level II.

The posterior tibial slope and Insall-Salvati index in operative and nonoperative adolescent athletes with Osgood-Schlatter disease

INTRODUCTION

Osgood-Schlatter disease (OSD) is a common cause of anterior knee pain in adolescent athletes due to repetitive stress on the tibial tubercle. The posterior tibial slope angle (PTSA) and the Insall-Salvati Index (ISI) play a role in knee biomechanics. However, to our knowledge, the posterior tibial slope and patellar height have not been compared in operated versus nonoperative OSD patients. The purpose of the current study is to compare the differences in the PTSA and the ISI between operative and nonoperative patients with OSD.

MATERIALS AND METHODS

The study was approved by the College of Medicine's Institutional Review Board. A retrospective review was performed on 75 adolescent athletes with OSD between 2008 and 2019. The data extracted included: age, sex, body mass index (BMI), sporting activity and type, mechanism of injury (MOI), chronicity of symptoms, PTSA, and the ISI. Descriptive and quantitative statistics were used.

RESULTS

Seventy-five patients (88 knees) with OSD were studied (28 boys, 47 girls). The average age was 12.2 years and the average BMI was 22.3. The mechanism of injury (MOI) included repetitive stress (77%) and trauma (23%). The duration of knee pain averaged 10.3 months. Sixty-six patients were included in the nonoperative cohort. Nine patients were included in the operative cohort and underwent surgery due to persistent symptoms after skeletal maturity with tubercleplasty and/or ossicle excision. The average PTSA was 12.1° ± 1.7° and average ISI was 1.05 ± 0.15. Comparing the operative and nonoperative patients, we found no significant difference in PTSA (11.2° ± 0.73° versus 12.8° ± 1.8°, p < 0.064). However, we did find that patients treated operatively had a lower ISI (0.95 ± 0.18 versus 1.14 ± 0.13, p < 0.001).

CONCLUSION

In patients with OSD, operative and nonoperative patients demonstrated a similar PTSA. On the other hand, the ISI was higher in nonoperative patients. In the current paper, a decreased ISI was helpful in predicting the need for operative intervention in symptomatic patients after skeletal maturity.

Guided Growth for Varus Deformity Following Early Tibial Osteotomy in Infantile Tibia Vara-A Multi-Center Study

BACKGROUND

Despite early osteotomy, many patients with infantile tibia vara (ITV) have persistent or recurrent varus deformity and disordered growth at the medial proximal tibial physis. Our hypothesis was that lateral tibial tension band plating (LTTBP) could guide correction.

METHODS

A retrospective review at 6 centers of 15 patients (16 extremities) was performed of LTTBP for varus deformity following early osteotomy in ITV, diagnosed≤4years of age. Correction of deformity parameters on digital standing anteroposterior lower extremity radiographs determined outcome.

RESULTS

Twenty-two LTTBP procedures were performed at mean age of 7.5 years, including 4 revisions for implant failure and 2 reimplantations for recurrence. Single event LLTBP, improved the medial proximal tibial angle with a mean change of 13.4 degrees (0.39 degrees/month). Eleven limbs had preoperative mechanical lateral distal femoral angle (mLDFA)>90 degrees. While n degree femoral procedures were performed, at study end, 11 femurs had mechanical lateral distal femoral angle≤90°. Pretreatment, 13 extremities had mechanical axis zone (MAZone) III varus (81%) and 3 had MAZone II varus (19%). LTTBP's were able to initially correct 13 limbs to MAZone I or valgus but 4 limbs rebounded to MAZone II varus after implant removal. Final limb alignment, after all surgeries and rebound, included 9 in MAZone I, 5 in MAZone II varus and 2 in MAZone III varus. Average follow-up was 3.0 years at mean 10.7 years of age. Fifteen procedures resulted in improvement in MAZone and 7 had no change. On average, those that improved were younger (7.3 vs. 8.0 y), weighed less (45.5 kg with body mass index 26.5 kg/m 2 vs. 67.8 kg and body mass index 35.7 kg/m 2 ), had lower mechanical axis deviation (37.1 mm vs. 43.9 mm), lower medial physeal slope (61.7 vs. 68.7 degrees) and had a higher percentage of open triradiate phases (87 vs. 57%).

CONCLUSIONS

LTTBP for residual varus, after initial osteotomy in ITV, resulted in 81% of limbs initially achieving MAZone I or valgus with implant failure revisions and femoral remodeling. Rebound after implant removal reduced the corrected rate to 56%. Ninety-four percent avoided osteotomy during the study period.

LEVEL OF EVIDENCE

IV.

Guided growth using a tension-band plate in Blount's disease

Our observational study's objective was to determine how effective guided growth with tension-band plates was to correct the deformity in Blount's disease. We reviewed the records of 14 children (18 limbs) with Blount's disease who were treated with tension-band plates as the only surgical intervention at a single institution over eight years. Five children (seven limbs) had infantile Blount's disease with Langenskiöld stage ≤2. Nine children (11 limbs) had late-onset Blount's disease. The mean age at operation was 7.2 years (SD, 3.1, range, 2.9-11.8). The tension-band plate effectively corrected the varus deformity in 78% (14/18) of limbs. Correction to normal mechanical alignment was achieved in 67% (n = 12) of limbs at a mean of 18 months (SD, 7, range, 9-31). Failure to achieve correction of the mechanical axis was due to delayed implant removal and overcorrection in 11% (2/18), mechanical failure due to screw fixation failure in 11% (2/18) and in 6% (1/18) due to a misplaced epiphyseal screw. There was a greater magnitude of correction in the Infantile Blount's disease group (mean, 26°, SD, 9°) when compared to the children with late-onset Blount's disease (13°, SD, 4°) (P = 0.021). The mean correction rate was 1.8°/month in the Infantile Blount's disease group and 0.7°/month in the late-onset Blount's disease group, respectively (P = 0.014). Our findings support the use of tension-band plating in Blount's disease. Further research is required to determine the ideal indications and to investigate the long-term outcome of guided growth in Blount's disease. Level of evidence: Level 4.

The Medial Elevation Osteotomy for Late-presenting and Recurrent Infantile Blount Disease

BACKGROUND

Late-presenting or recurrent infantile Blount disease (IBD) is characterized by knee instability because of medial tibial plateau depression, multiplanar proximal tibial deformity, and potential distal femoral deformity. The surgical treatment strategy includes medial elevation osteotomy to stabilize the knee, together with proximal tibial osteotomy to correct alignment, and lateral epiphysiodesis to prevent a recurrence. This study's primary aim was to describe the clinical outcomes of medial elevation osteotomy for the management of late-presenting and recurrent IBD.

METHODS

The authors reviewed the records of 48 children (64 limbs) who had medial elevation osteotomies and lateral epiphysiodesis, combined with proximal tibial realignment in 78% (50/64) of cases in the same setting. IBD was bilateral in 33% (16/48), 77% (37/48) were female individuals, and 42% (20/48) were obese.

RESULTS

The mean age at surgery was 8.6 years (SD, 1.6; range, 5.8 to 12.8). The mean preoperative tibiofemoral angle (TFA) was 28±11 degrees (8 to 55 degrees), and the mean angle of depression of the medial plateau (ADMP) was 49±8 degrees (26 to 65 degrees). Distal femoral valgus was present in 27% (17/62) and varus in 10% (6/62) children. At a median follow-up of 3.2 years (range, 1 to 6.2 y), the median TFA was 1-degree valgus (interquartile range, 7-degree varus to 5-degree valgus), whereas the ADMP was corrected to 25±8 degrees (8 to 45 degrees). Obesity was associated with more severe deformity as measured by TFA (P<0.001) but did not affect the extent of medial plateau depression (P=0.113). The good or excellent alignment was achieved in 75% (47/63) limbs. Obesity was associated with an increased risk of recurrence [odds ratio (OR), 5.21; 95% CI, 1.26-21.63; P=0.023]. Age at the surgery or previous surgery was not associated with recurrence (OR, 1.29; 95% CI, 0.88-1.88; P=0.195 and OR, 1.22; 95% CI, 0.36-4.17; P=0.746). Obesity and residual instability were associated with an increased risk of poor alignment at the latest follow-up (OR, 3.24; 95% CI, 1.02-10.31; P=0.047 and OR, 1.21; 95% CI, 1.05-1.40; P=0.008).

CONCLUSION

Late-presenting or recurrent IBD is a surgical challenge. Obesity is associated with more severe deformity. Medial elevation osteotomy combined with lateral proximal tibial epiphysiodesis and metaphyseal tibial realignment osteotomy will result in restoration of lower limb alignment in a high proportion of cases. The recurrent deformity may be the result of failed epiphysiodesis. Obesity and residual instability are associated with an increased risk of poor alignment. Although complications are rare, surgical measures to decrease risk should be followed.

LEVEL OF EVIDENCE

Level IV.

Surface-Modified Poly(l-lactide-co-glycolide) Scaffolds for the Treatment of Osteochondral Critical Size Defects-In Vivo Studies on Rabbits

Poly(l-lactide-co-glycolide) (PLGA) porous scaffolds were modified with collagen type I (PLGA/coll) or hydroxyapatite (PLGA/HAp) and implanted in rabbits osteochondral defects to check their biocompatibility and bone tissue regeneration potential. The scaffolds were fabricated using solvent casting/particulate leaching method. Their total porosity was 85% and the pore size was in the range of 250-320 µm. The physico-chemical properties of the scaffolds were evaluated using scanning electron microscopy (SEM), energy dispersive X-ray spectroscopy (EDX), X-ray diffractometry (XRD), X-ray photoelectron spectroscopy (XPS), Fourier transform infrared spectroscopy (FTIR), sessile drop, and compression tests. Three types of the scaffolds (unmodified PLGA, PLGA/coll, and PLGA/HAp) were implanted into the defects created in New Zealand rabbit femoral trochlears; empty defect acted as control. Samples were extracted after 1, 4, 12, and 26 weeks from the implantation, evaluated using micro-computed tomography (µCT), and stained by Masson-Goldner and hematoxylin-eosin. The results showed that the proposed method is suitable for fabrication of highly porous PLGA scaffolds. Effective deposition of both coll and HAp was confirmed on all surfaces of the pores through the entire scaffold volume. In the in vivo model, PLGA and PLGA/HAp scaffolds enhanced tissue ingrowth as shown by histological and morphometric analyses. Bone formation was the highest for PLGA/HAp scaffolds as evidenced by µCT. Neo-tissue formation in the defect site was well correlated with degradation kinetics of the scaffold material. Interestingly, around PLGA/coll extensive inflammation and inhibited tissue healing were detected, presumably due to immunological response of the host towards collagen of bovine origin. To summarize, PLGA scaffolds modified with HAp are the most promising materials for bone tissue regeneration.

Autologous osteochondral transplantation method of treatment for patellar osteochondral lesions

PURPOSE

This study evaluated the functional and clinical outcomes of the subjects with symptomatic osteochondral lesions on articular surface of patella, who were treated with autologous osteochondral transplantation (AOT) method.

STUDY PLAN

AOT method was applied for the treatment of 14 subjects (eight men and six women; mean age 29.7 years; range 19-49 years) with symptomatic patellar osteochondral lesions between March 2008 and April 2013. After a mean follow-up period of 3.7 years (range 32-80 months), pre- and postoperative clinical and functional evaluations of the patients were performed using Visual Pain Scale (VPS), Lysholm Knee Scoring Scale, and Kujala Anterior Knee Pain Scale. Wilcoxon test was used for statistical evaluation of pre- and postoperative outcomes. Improvement of the lesions was assessed by magnetic resonance imaging (MRI) at year 1 postoperatively at the earliest.

RESULTS

The mean lesion size was 1.32 cm² (range 0.8-1.8 cm²). The mean pre- and postoperative VPS values were calculated to be 75.5 ± 12.32 (range 46-92) and 17.57 ± 10.21 (range 0-40), respectively ( p < 0.01). The mean pre- and postoperative Lysholm knee scores were 44.57 ± 9.35 (range 26-65) and 80 ± 6.9 (range 70-94), respectively ( p < 0.01), and the mean pre- and postoperative Kujala anterior knee pain scores were 48.21 ± 7.78 (range 38-68) and 78.42 ± 7.06 (range 70-96), respectively ( p < 0.01). MRI taken at year 1 postoperatively showed that the autograft bone tissue was sufficiently incorporated into the recipient site in all patients; an even articular surface was formed, but the thickness of the cartilage tissue was mostly uneven between the adjacency of the recipient site and the autograft, which caused no negative effect on clinical and functional outcomes.

CONCLUSIONS

Despite the difference in thickness of the cartilage tissue between the recipient and the donor site, the AOT technique for the treatment of patellar osteochondral lesions resolves the symptoms of the patient and ensures an apparent functional and clinical improvement even if an articular surface could be created.

Hemiepiphyseodesis for Juvenile and Adolescent Tibia Vara Utilizing Percutaneous Transphyseal Screws

BACKGROUND

In juvenile and adolescent tibia vara patients with sufficient growth remaining, implant-controlled hemiepiphyseodesis, or guided growth, can be used to correct deformity. Recent reports have described hardware failure of certain hemiepiphyseodesis implants in overweight patients with tibia vara. We describe our experience using transphyseal screws to correct deformity in this patient population.

METHODS

A retrospective chart and radiograph review was conducted on all juvenile and adolescent tibia vara patients who underwent lateral proximal tibial hemiepiphyseodesis using a single transphyseal screw. Charts were queried for preoperative and postoperative mechanical axis deviation, medial proximal tibial angle, lateral distal femoral angle, and postoperative complications or need for further surgery.

RESULTS

In total, 14 affected limbs in 9 patients (6 males) who underwent lateral proximal tibial transphyseal screw hemiepiphyseodesis were considered. Average chronologic age at implantation was 10.4 years and average body mass index was 31.7 kg/m. At average 23-month follow-up, the average mechanical axis deviation improved from 46 to 0 mm (P<0.001), and the average medial proximal tibial angle improved from 81 to 92 degrees (P<0.001). No limbs underwent further surgery to correct residual deformity. There were no complications or instances of implant failure associated with the transphyseal screws.

CONCLUSIONS

Hemiepiphyseodesis using transphyseal screws is an effective technique to correct deformity in juvenile and adolescent tibia vara patients with sufficient growth remaining. This method can be used safely with few complications and with minimal risk of mechanical failure, even in overweight patients.

LEVEL OF EVIDENCE

Level IV-therapeutic.

Infantile Tibia Vara (Blount Disease) with Iatrogenic Changes Causing Residual Tibial Deformities

Treatment of infantile tibia vara or Blount disease (ITV/BD) in patients < 3 years old and Langenskiold stages I-III consists of orthosis and, in relapsing cases, proximal tibial osteotomy and/or proximal tibial guided growth laterally with a tension band plate. Our aim was to evaluate the results of treatments in a consecutive group. After Institutional Review Board approval, data from 2002 to 2018 were collected. Thirty-nine knees (average age 22.4 months) with ITV/BD were treated with orthoses, and 10 knees failed. Six knees showed hyperintense T2-weighted signal in the medial proximal tibial epiphyseal cartilage on magnetic resonance imaging. Three of six knees with tibial osteotomy failed and underwent guided growth. Tibial plateau slopes were abnormal medially from the ITV/BD and laterally from the guided growth (triangular physis and depressed plateau deformities) because of factors such as orthotic treatment, tibial osteotomy, magnetic resonance imaging "physis severity score," and guided growth. (Journal of Surgical Orthopaedic Advances 29(3):141-148, 2020).

Anterior tibial artery occlusion post total knee arthroplasty: A case report

RATIONALE

Total knee arthroplasty (TKA) is a globally well-accepted surgery because of its good outcome and safety. Although TKA-associated arterial injuries occur, postoperative anterior tibial artery (ATA) occlusion has not been reported yet. Herein, we present a case of ATA occlusion after TKA.

PATIENT CONCERNS

A 42-year-old man with a 6-year history of right knee pain after right patella fracture treated with open reduction was referred to our clinic. Valgus and contracture deformities were detected in the right knee. Severe osteoarthritis (OA) in the right knee and multiple osteochondromas were observed on radiography.

DIAGNOSIS

On the basis of clinical and imaging findings, the patient was diagnosed with OA and multiple osteochondromas.

INTERVENTIONS

TKA was performed in the right knee and the osteochondromas were resected. ATA occlusion was found postoperatively and was treated conservatively.

OUTCOMES

Although the right ATA occlusion did not resolve, the patient recovered well postoperatively, with pain relief and recovery of right knee range of motion.

LESSONS

The clinical outcome in a case of ATA occlusion after TKA demonstrates that conservative treatment could be appropriate in this context.

New Single-stage Double Osteotomy for Late-presenting Infantile Tibia Vara: A Comprehensive Approach

BACKGROUND

Successful surgical treatment of late-presenting infantile tibia vara (ITV) patient requires the correction of oblique deformities. The purpose of this study was to report on a new comprehensive approach to correct and prevent recurrence of these deformities with a single procedure.

METHODS

Medical records of 23 consecutive children (7 to 18 y) with advanced ITV (29 knees) were retrospectively reviewed after a mean of 7.3 years postoperatively (range, 2 to 22 y). Indications for the corrective surgery were any child 7 year or older with a varus mechanical axis angle ≥10 degrees or a varus anatomic axis angle ≥11 degrees and a medial tibial angle (MTA) slope <60 degrees. The deformities were corrected with a dome-shaped osteotomy proximal to the tibial tubercle with a midline vertical extension to the subchondral region of the joint and a lateral hemi-epiphysiodesis.

RESULTS

At latest follow-up, means and medians of each tibial radiographic axis measurement improved significantly from preoperative values (P<0.001): mechanical axis angle from 23 degrees to 4 degrees varus, anatomic axis angle from 25 degrees varus to 1 degree valgus, MTA downward slope from 30 to 78 degrees, posterior MTA from 59 to 80 degrees. In total, 79% and 74% had good to excellent results based on radiographic criteria and clinical questionnaire for satisfaction, pain and function, respectively. Two abnormal medial tibial plateau types were described.

CONCLUSIONS

This is the first study to use a single-stage double osteotomy performed proximal to the tibial tubercle for the late-presenting ITV for children 7 years of age or older. In addition to the effective correction of the 4 major tibial deformities, a lateral proximal tibial hemi-epiphysiodesis minimizes recurrence of tibia vara. A contralateral proximal tibial epiphysiodesis is recommended for treated skeletally immature patients with unilateral disease.

LEVEL OF EVIDENCE

Therapeutic level IV. See instructions for authors for a complete description of levels of evidence.

The Role of Taylor Spatial Frame in the Treatment of Blount Disease

BACKGROUND

Alteration of the posteromedial part of the proximal tibia is the main characteristic of Blount's disease and if left untreated, leg alignment and normal development of the lower limbs may be compromised.

AIM

To report treatment outcomes in children with Blount's disease using the Taylor Spatial Frame (TSF).

MATERIALS AND METHODS

From January 2007 to December 2014, 16 young children (24 tibia) with a mean age of 7.5 years (range of 3-14 yrs) and severe Blount's disease were treated using TSF. Preoperative long standing radiographs were performed and anatomic medial proximal tibial angle (MPTA), diaphyseal-metaphyseal tibial angle (Drennan), femoro-tibial angle and leg length discrepancy (LLD) were measured.

RESULTS

Post-operative improvement of all measurements was observed. MPTA increased from a mean of 71.8° (58° - 79°) to 92.5° (90° - 95°), the Drennan decreased from 16.6° (14° - 18°) to 3.6° (0° - 6°), the F-T angle changed from 15.4° (10° - 25°) of varus to 5.9° (2° - 10°) of valgus and the LLD decreased from 208 mm (150-320) to 69 mm (0- +120). Mean follow-up was 45.6 months. According to Paley's criteria pin track infection was present in 6 tibiae, while in 5 patients software changes were necessary. Recurrence was observed in 3 patients (triplets). Complete restoration of the mechanical axis was obtained at the end of the treatment.

CONCLUSIONS

In the last decades, different surgical treatments have been proposed for Blount's disease (tension band plate, staples, osteotomies using external or internal fixation). External fixation using the TSF allows gradual safe correction of multiplanar deformities and is a well-tolerated technique by patients with Blount's disease.

Opening Wedge Osteotomy for the Correction of Adolescent Tibia Vara

BACKGROUND

Tibia vara, or Blount's disease, is a pathologic angular deformity of upper tibial physis causing a bow leg deformity. Adolescent Blount's disease may be unilateral or bilateral and is diagnosed during or just before the adolescent growth spurt. In addition to predisposing genetic factors, biomechanical overload of the proximal tibial physis causes asymmetric growth leading to a varus deformity.Surgical intervention is usually required for adolescent Blount's disease. Hemiepiphysiodesis has had some success in arresting or correcting the deformity. Tibial osteotomy can achieve correction acutely with internal or external fixation or gradually with external fixation.This article reports the outcomes of correcting adolescent tibia vara with a proximal opening wedge osteotomy (POWO) and internal fixation in nine patients with a primary diagnosis of Adolescent Blount's Disease.

METHODS

We conducted a retrospective review of patients treated with POWO between April 2007 and July 2015. Fifty charts were selected using ICD9 codes for tibia vara and CPT codes for osteotomy. Nine patients (11 tibia) meeting eligibility criteria were identified. In addition to pre-operative data; operative factors, such as blood loss; and post-operative outcomes such as radiographic accuracy of correction, time to healing, time to full weight-bearing, number of office visits and complication rates were collected.

RESULTS

Pre-operative radiographic measurements showed the varus deformity was primarily tibial. Post-operative correction demonstrated a mean correction of 17.64° (range, 7°-26°). Patients returned to full weight bearing status around 67 days after surgery and required very few follow-up visits during the course of treatment. Three of nine patients experienced complications including seroma requiring drainage, metallosis mistaken for infection leading to hardware removal, and a wound abscess treated with antibiotics (one patient each). No patients lost correction, experienced nerve palsy, compartment syndrome nor complained of leg length discrepancy.

CONCLUSIONS

Proximal opening wedge osteotomy (POWO) is a reproducible, safe and effective technique for correction of adolescent tibia vara, with potential advantages of fewer return visits and sooner return to weight bearing than external fixation. In select patients, it is a useful alternative to external fixation or closing wedge osteotomy.Level of Evidence: IV.

Treatment of Osgood-Schlatter disease: review of the literature

BACKGROUND

Osgood-Schlatter disease (OSD) is a self-limiting condition which occurs commonly in adolescence.

PURPOSE

The objective of this article is to review published literature regarding pathophysiology, diagnosis and treatment of OSD.

METHODS

A search of the literature was performed on the electronic databases PubMed, Cochrane and SCOPUS databases between 1962 and 2016 for pathophysiology, diagnosis and treatment of Osgood-Schlatter disease.

RESULTS

OSD, also known as apophysitis of the tibial tubercle, is a common disease with most cases resolving spontaneously with skeletal maturity. In pathophysiology, the most accepted theory is repetitive knee extensor mechanism contraction. The pain is localized to the anterior aspect of the proximal tibia over the tibial tuberosity. They may describe a dull ache exacerbated by jumping or stair climbing. Radiological evaluation may indicate superficial ossicle in the patellar tendon. Osgood-Schlatter is a self-limited disease and generally ceases with skeletal maturity. Treatment is usually symptomatic. Adults with continued symptoms may need surgical treatment if they fail to respond to conservative treatment. Surgical procedures include open, bursoscopic and arthroscopic technique. Arthroscopic surgery is beneficial over an open procedure due to early postoperative recovery, no incisional scar in front of the tuberosity that usually causes discomfort in kneeling with a better cosmetic result and the ability to address concomitant intra-articular pathology.

CONCLUSION

Osgood-Schlatter syndrome runs a self-limiting course, and usually complete recovery is expected with closure of the tibial growth plate. Overall prognosis for Osgood-Schlatter syndrome is good, except for some discomfort in kneeling and activity restriction in a few cases. Arthroscopic techniques seem to be the best choice of treatment of unresolved Osgood-Schlatter lesions.

Reduction Osteotomy of the Prominent Tibial Tubercle After Osgood-Schlatter Disease

PURPOSE

To evaluate the functional and clinical outcome of a new closing-wedge osteotomy for the prominent tibial tubercle after Osgood-Schlatter disease.

METHODS

Between 2010 and 2014, 7 consecutive adults (mean age, 28.6 years; range, 26-35 years) were treated by closing-wedge reduction osteotomy of a painful tibial tubercle. All patients had prior nonsurgical and surgical treatment. Preoperative and postoperative tubercular prominence, Caton-Deschamps index for patellar height, the Kujala Anterior Knee Pain Scale, Lysholm Knee Score as well as visual analog scale score and Tegner activity scores were recorded.

RESULTS

Mean follow-up after reduction osteotomy was 31.3 months (27-41 months). The bony prominence of the tibial tubercle was significantly reduced (mean 8 mm, P < .001) and the Caton-Deschamps index was lowered from 1.29 to 1.09 (P < .001). From preoperative to last follow-up, the Kujala Anterior Knee Pain Scale increased from 54.71 preoperative to 84.71 (P < .001); the Lysholm Knee Score improved from 72.42 to 94.14 (P < .001); the Tegner activity score increased from 3.1 to 5.7 (P < .001), whereas the visual analog scale significantly decreased from 5.8 to 1.2 (P < .001). No complications were recorded, and all patients were satisfied with clinical outcome.

CONCLUSIONS

Closing-wedge osteotomy of the tibial tubercle effectively reduced the bony prominence after Osgood-Schlatter disease and consecutively improved the outcome in terms of knee pain and function. Thus, we can recommend this procedure in selected patients.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Management of adolescent tibia vara using Taylor spatial frame

PURPOSE

Adolescent tibia vara is a multiplanar deformity that can lead to progressive deformity, altered gait, unequal leg lengths, and premature knee arthritis if uncorrected. The purpose of the current study is to report our experience in management of adolescent tibia vara using Taylor Spatial Frame (TSF).

MATERIALS AND METHODS

A prospective study of eleven adolescent tibia vara patients managed by proximal tibial osteotomy gradual deformity correction using TSF.

RESULTS

The average time in the frame was 123.5 (±25.5) days. At final follow up (average 15 (±2) months), the mean post-operative mPTA was 87 (±4) degrees (range 81 to 93 degrees), where the mean preoperative mean mPTA was 68 (±9) degrees (range 49 to 77 degrees) (p value 0.003). The mean postoperative MAD was 12.2(±11.4) mm, range (-1 to 26 mm), where preoperative mean MAD was 75.7(±14.7 mm), range (60 to 107mm) (p value 0.003). The mean postoperative PPTA was 80(±2) degrees, range (77 to 83 degrees), while the preoperative mean PPTA was 72 (±12) degrees, range (42 to 82 degrees) (p value 0.028).

CONCLUSION

Although we have not directly compared the TSF with the Ilizarov fixator, this series serves to highlight the versatility and effectiveness of the TSF in the treatment of complex and often obstinate adolescent tibia vara.

Guided growth for tibia vara (Blount's disease)

Blount's disease is commonly attributed to an intrinsic, idiopathic defect in the posteromedial proximal tibial physis resulting in progressive bowing of the leg, intoeing, and lateral knee thrust. Treatment has historically included bracing, physeal stapling, or corrective osteotomy, and was determined primarily by age at presentation. As we feel the pathology is not necessarily age dependent, we have elected to use the technique of guided growth using a lateral tension band plate to correct limb alignment as a first-line treatment in all patients presenting to our clinic as long as they had growth remaining and no evidence of a physeal bar.We identified 17 patients with tibia vara (27 limbs) who were managed by means of guided growth of the proximal tibia, from age 1.8 years to 15.1 years. Clinical and radiographic parameters were followed pre- and postoperatively. The response to guided growth was documented as were any related complications.Twenty-one (78%) limbs had complete normalization of their mechanical axis (middle 50% of knee). Time to correction averaged 13.5 months (8-19 months). There were no peri-operative complications. We observed hardware failure in 3 patients; 2 with screw breakage and 1 patient with hardware migration, none requiring subsequent osteotomy or further treatment. Two patients had rebound varus: one is being observed and another has undergone a repeat procedure.Patients with pathologic tibia vara present at various ages and have historically undergone various treatments ranging from bracing to tibial osteotomy based on age at presentation. We have found that guided growth utilizing tethering plates can be used effectively as first-line treatment in all patients with growth remaining. This minimally invasive method is predictable and well tolerated. Recurrent deformity, though unlikely, is easily remedied by repeating the process and does not preclude osteotomy if eventually needed. Concomitant resolution of ligamentous laxity and inward torsion can be anticipated as the mechanical axis is restored to neutral. The only contraindications for guided growth include an unresectable physeal bar or skeletal maturity.

Complete Closing Wedge Osteotomy for Correction of Blount Disease (Tibia Vara): A Technique

Treatment of Blount disease (tibia vara) can be daunting in adolescents because of their obesity. The goals in performing osteotomy for Blount disease are to correct the deformity, restore joint alignment, preserve leg length, and prevent recurrent deformity and other complications, such as neurovascular injury, nonunion, and infection. In this article, we report on our treatment of 9 limbs in 8 patients (age range, 13-17 years) with Blount disease. In each case, we performed an oblique complete closing wedge osteotomy of the tibia fixed with a compression plate with oblique screw and a fibular osteotomy. Mean body mass index was 38. In 2 patients, an external fixator (instead of a cast) was used after surgery to increase stability. Mean correction was 26°. The cast was removed at 6 weeks. A hinged knee brace was worn for another 6 weeks. Return to normal activities was allowed after 4 months. The described method, using a closing wedge tibial osteotomy and an oblique fibular osteotomy, is practical and safe and has reproducible results.

Is there a difference in sagittal alignment of Blount's disease between radiographic and clinical evaluation?

BACKGROUND

A procurvatum deformity of the proximal tibia often is seen in patients with Blount's disease. If left untreated, it can lead to progressive angulation in the sagittal plane and altered contact stresses across the knee.

QUESTIONS/PURPOSES

We asked the following questions: (1) Is the mean angle of procurvatum measured from full-length lateral radiographs of the tibia greater than that of procurvatum measured from clinical photographs of the affected lower extremity? (2) Is there a linear relationship between radiographically measured procurvatum and radiographically measured procurvatum?

METHODS

We treated 72 patients surgically for Blount's disease between 1997 and 2012; of those, 29 patients were excluded from this analysis because they did not have adequate photographs or radiographs, leaving 43 patients (60% of the patients treated surgically; 47 limbs total), mean age of 13 years (range, 6-25 years), who underwent surgical realignment for Blount's disease were retrospectively evaluated at a median of 97 months after surgery (range, 24-170 months). Genu procurvatum was measured from full-length lateral radiographs of the tibia and clinical photographs of the affected lower extremity. We then assessed the relationship between radiographically measured procurvatum and clinically measured procurvatum using linear regression analysis.

RESULTS

The mean preoperative radiographically measured procurvatum (12.3°; range -3.1° to 55.2°) was larger than the clinically measured procurvatum (6.0°; range, -1° to 45°; p = 0.024). The mean postoperative radiographically measured procurvatum (4.2°; range -4.8° to 30.3°) was larger than the clinically measured procurvatum (2.1°; range, -2° to 20°; p = 0.041). Preoperatively and postoperatively, radiographically measured procurvatum and clinically measured procurvatum were well correlated (linear regression p < 0.001). After surgical realignment, the mean improvement in radiographically measured procurvatum (8.2°) was larger than that measured for clinically measured procurvatum (3.8°) (p = 0.018).

CONCLUSIONS

In patients with Blount's disease, visual inspection of the extremity can underestimate the procurvatum deformity of the proximal tibia relative to the measurable deformity on radiographs. Furthermore, surgical correction of proximal tibial procurvatum does not lead to clinical hyperextension of the knee.

LEVEL OF EVIDENCE

Level IV, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

The role of Taylor Spatial Frame for the treatment of acquired and congenital tibial deformities in children

This study evaluates the use of the Taylor Spatial Frame (TSF) for the correction of acquired and congenital tibial deformities in children. The purpose is to underline problems, obstacles and complications that can be observed during treatment to reveal the learning curve and potential risk factors and to propose solutions to avoid difficulties during its use 86 tibia deformities were corrected in 66 children during a period of 7 years and were classified according to anatomical and dominant type of deformity. Follow up was 54.2 months. Gradual correction was performed according to the individualized time schedule. We faced 42 difficulties: 29 problems, 10 obstacles and 3 complications, distributed across all years. Significant correlation was found between patient's age and number of difficulties. The incidence of the difficulties was equally spread over the different etiologies, but it was statistically significant across the years. Proximal tibia and complex multi-plane deformities seem to be related to an increased incidence of postoperative difficulties. TSF can yield accurate results, is easy to handle and provides an excellent concomitant 3-direction correction.

Late onset tibia vara. Acute correction strategy: proper case selection and a simple external fixation technique

Following proximal tibial osteotomy for cases of late onset tibia vara, both acute and gradual correction strategies were described, where each has its pros and cons. The aim of this study was to verify the proper selection criteria of cases with late onset tibia vara amenable to successful acute correction strategy using a homogenous patient group with clear inclusion criteria; all the cases were fixed by a low profile semicircular fixator module. Thirty legs in 20 patients (11 boys, nine girls) with late onset tibia vara, treated in our department between January 2005 and February 2008, that complied well with the assigned inclusion criteria constituted the material of this prospective study. Their mean age was 10.4 years (range, 6-14 years). They were all managed using the same modality that was acute correction based on the osteotomy rule II concept and fixed by a low profile miniature Ilizarov fixator module. After a mean follow up period of 5.9 years (range, 5-7) only (13%) of the cases showed recurrence. Proper selection of cases with late onset tibia vara undergoing acute correction strategy is of utmost importance for the sake of a successful outcome. On the other hand, the low profile simplified fixator module used is a handy and a compliant osteotomy fixation tool.

Do we need to do overcorrection in Blount's disease?

PURPOSE

In order to prevent recurrent deformity, overcorrection in Blount's disease has been a common practice by most paediatric orthopaedic surgeons. However, some patients have persistent valgus alignment resulting in awkward deformity. The femoro-tibial angle (FTA) was measured in this series of cases to determine the necessity of such practice.

METHOD

During 1998-2010, patients with Blount's disease stage 2 by Langenskiold, aged from 30 to 40 months who had failed from bracing and underwent valgus osteotomy were included. Seventeen legs had postoperative FTA 7-13° (group 1) and 48 legs had postoperative FTA more than 13° (group 2). ROC curve was used to determine the appropriate FTA that was suitable to prevent recurrence.

RESULTS

Four legs had recurrence (28.6%) in group 1 and six legs (12.5%) had recurrence in group 2. Chi-square test between two groups were not statistically significant in recurrence (p = 0.434). Age and BMI were not statistically significant between recurrent and non-recurrent groups. The ROC curve shows that overcorrection more than 15° did not show benefit to prevent the recurrence in Blount's stage 2.

CONCLUSION

Our study showed that the overcorrection group had non-statistically significant recurrence compared to the non-overcorrection group, and overcorrection more than valgus 15° has no benefit to prevent recurrence.

[Osgood-Schlatter disease in military personnel]

Clinical and radiological manifestations and outcomes of Osgood - Schlatter disease in 141 serviceman held military service are presented. Patients had the late stage of disease. Authors describe four options of radiological signs. Indications for surgical treatment are substantiated. Proved traumatic nature of the disease in the adolescent growth period. Analysis of observational data allows us to conclude that the primary manifestations of trauma of shinbone area can occur in patellar ligament and apophasis of shinbone. In old cases of Osgood-Schlatter disease location and nature of the damage can be determined by hystotope analysis. This disease is one of the manifestations of heterotopic ossification.

Multimodality neurophysiological monitoring during tibial/fibular osteotomies for preventing peripheral nerve injuries

Previously, intraoperative neurophysiological monitoring was not used routinely during tibial osteotomies. In an attempt to improve the post-operative outcomes and reduce known neurologic complications, we used discrete multimodality recording and stimulation models to identify areas of motor and sensory function in eighteen (18) pediatric patients presenting with Tibia Vara (Blount's Disease). By using both posterior tibial and peroneal nerves somatosensory evoked potentials (SSEPs) with transcranial electrical motor evoked potentials (TCeMEPs) precise status of sensory and motor pathways was possible during surgical correction. Similarly, spontaneous electromyography (s-EMG) and triggered electromyography (t-EMG) were used to more accurately localize nerve irritation. Concerns during tibial and fibular osteotomies included ipsilateral lower limb motor and sensory function, especially peroneal nerve injuries due to the location of the osteotomy at the fibular neck. Surgical interventions consisting of additional fibular resection were made during the index procedures for four patients because of real-time monitoring changes noted as the peroneal nerve was entrapped in three patients at the osteotomy site. In fourth patient, the tourniquet pressure was the cause for loss of ipsilateral SSEPs and TCeMEPs. After appropriate surgical intervention, monitoring parameters began to normalize and postoperatively the patients presented with no neurologic deficit. In this study, the application of multimodality recording and stimulation models were utilized including posterior tibial nerve and peroneal nerve SSEP with lumbar potential (LP) identification to compare with contralateral limb recordings. In addition, by using spontaneous and triggered EMG and TCeMEP, we were able to perform monitoring with a high level of confidence throughout surgery.

First-generation autologous chondrocyte implantation in patients with cartilage defects of the knee: 7 to 14 years' clinical and magnetic resonance imaging follow-up evaluation

PURPOSE

The purpose of this study was to evaluate the overall long-term improvement of autologous chondrocyte implantation (ACI) treatment in terms of patient satisfaction, clinical assessment, and magnetic resonance imaging (MRI) evaluation. Furthermore, we aimed to assess the impact of independent variables on clinical outcomes and patient satisfaction.

METHODS

We evaluated 23 patients (mean age, 30.5 ± 8.2 years) with full-thickness chondral lesions of the distal femur who underwent first-generation ACI with periosteum between 1997 and 2004. The Lysholm score, Tegner activity score, subjective International Knee Documentation Committee score, numeric rating scale score, and Short Form 36 score were used for clinical assessment preoperatively, at 1 year postoperatively, and at 7 to 14 years (mean, 9.9 years) after surgery. MRI was performed to evaluate the cartilage preoperatively and at final follow-up, by use of the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score.

RESULTS

ACI resulted in a substantial improvement in all clinical outcome parameters, even as much as 14 years after implantation, although a small deterioration was noticed between intermediate and final evaluations in some outcome parameters. Of the patients, 73.1% stated that they would undergo the operation again. Younger patients with a shorter duration of preoperative symptoms and smaller defect sizes benefited most. MRI findings confirmed complete defect filling in 52.3% of the patients at final follow-up.

CONCLUSIONS

Our long-term results confirm that first-generation ACI is an effective treatment for large full-thickness chondral and osteochondral lesions of the knee joint. Younger patients with a shorter duration of preoperative symptoms and smaller defect size benefited most in our study.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

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.

Limb angular deformity correction using Dyna-ATC: surgical technique, calculation method, and clinical outcome

PURPOSE

Dyna-ATC is a unilateral external fixator with angulator, lengthener, and translator, which allows for angular correction and compensation of the secondary displacement during angular correction. The purpose of this study is to introduce surgical technique and calculation methods and to evaluate the clinical outcome of angular deformity correction using Dyna-ATC.

MATERIALS AND METHODS

The amounts of secondary displacement were calculated with the distances between axis of correction of angulation, Center of Rotational Angulation, and osteotomy and the amount of angular deformity. The rate of angular correction was determined to distract the corticotomy at 1 mm/day. Clinical and radiographic evaluation was performed on 13 patients who underwent deformity correction using Dyna-ATC. There were 8 proximal tibia vara, 1 tibia valga, 2 varus and 4 valgus deformities on distal femur. One patient underwent pelvic support femoral reconstruction. Concomitant lengthening was combined in all femur cases. Mean age at surgery was 17.5 years (7 to 64).

RESULTS

All but one achieved bony healing and normal alignment with the index procedure. Mean mechanical axis deviation improved from 31.9 mm to 3.0 mm. The average amount of angular correction was 11.0° on tibiae and 10.0° on femora. The average length gain on femora was 6.4 cm, and the healing index averaged to 1.1 mo/cm. One patient underwent quadricepsplasty and one patient had three augmentation surgeries due to poor new bone formation.

CONCLUSION

We believe that Dyna-ATC is a useful alternative to bulky ring fixators for selective patients with angular deformity less than 30 degrees in the coronal plane around the knee joint.

Dysplasia epiphysealis hemimelica: a case report

AIMS AND OBJECTIVES

To report the clinical presentation, course, management and associated pathology of DEH seen at the National Orthopaedic Hospital Lagos.

PATIENT AND METHODS

Case review was employed to report the association of an incidental radiologic finding of asymptomatic DEH with Blount disease.

RESULTS

This case is an 11-year-old girl with asymptomatic DEH of both ankles associated with right unilateral Blount disease. The incidental pathology is conservatively managed following the surgical treatment of the Blount disease which is the symptomatic pathology.

CONCLUSION

DEH is an uncommon pathology usually an incidental radiologic finding which may or may not be associated with other skeletal pathologies. The management is essentially conservative but surgery is an option when symptomatic.

One-step bone marrow-derived cell transplantation in talar osteochondral lesions

The ideal treatment of osteochondral lesions is debatable. Although autologous chondrocyte implantation provides pain relief, the need for two operations and high costs has prompted a search for alternatives. Bone marrow-derived cells may represent the future in osteochondral repair. Using a device to concentrate bone marrow-derived cells and collagen powder or hyaluronic acid membrane as scaffolds for cell support and platelet gel, a one-step arthroscopic technique was developed for cartilage repair. We performed an in vitro preclinical study to verify the capability of bone marrow-derived cells to differentiate into chondrogenic and osteogenic lineages and to be supported onto scaffolds. In a prospective clinical study, we investigated the ability of this technique to repair talar osteochondral lesions in 48 patients. Minimum followup was 24 months (mean, 29 months; range, 24-35 months). Clinical results were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) score and the influence of scaffold type, lesion area, previous surgeries, and lesion depth was considered. MRI and histologic evaluation were performed. The AOFAS score improved from 64.4 +/- 14.5 to 91.4 +/- 7.7. Histologic evaluation showed regenerated tissue in various degrees of remodeling although none showed entirely hyaline cartilage. These data suggest the one-step technique is an alternative for cartilage repair, permitting improved functional scores and overcoming the drawbacks of previous techniques.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

[Effect evaluation of treating Freiberg's disease with dorsal wedge osteotomy and absorbable pin fixation]

OBJECTIVE

To investigate the operative technique of treating Freiberg's disease with dorsal wedge osteotomy and absorbable pin fixation, and to evaluate the clinical outcome.

METHODS

From June 2005 to June 2007, 8 patients with Freiberg's disease were treated, including 2 males and 6 females aged 16-66 years old (average 36 years old). X-ray films revealed osteosclerosis, collapse of the metatarsal head and ischemic necrosis of the second metatarsal head. According to Smillie classification system, there were 4 cases of stage II, 3 of stage III and 1 of stage IV. The duration of symptoms was 6-36 months (average 19 months). After dorsal wedge osteotomy, the metatarsal heads were rotated to reconstrust the joint surface, then 3-4 pieces of absorbable pin 1.5 mm in length were implanted for fixation.

RESULTS

All wounds healed by first intention, and no early postoperative complications occurred. Five patients were followed for 11-35 months (average 14 months) and had significant pain relief. At 3 months after operation, the dorsal-flexion of metatarsophalangeal joint was improved by 0-50 degrees (average 21 degrees), and the plantar-flexion was increased by 0-10 degrees (average 5 degrees). X-ray films showed that solid union of the osteotomy was achieved in all patients at 8-13 weeks after operation (average 10 weeks). Average shortening of metatarsal was 1.7 mm (range 1.3-2.0 mm). All patients returned to sports and recreational activities at 4 months after operation, except one case of stage IV who had constant swelling and stiffness in the joint and was improved at 12 months after operation.

CONCLUSION

Dorsal wedge osteotomy in complex with absorbable pin fixation is an effective procedure for stage II and III Freiberg's disease, because it is capable of reconstructing the metatarsophalangeal joint effectively, allowing early joint motion and avoiding a second operation.

Scapulohumeral osteochondrosis. A retrospective study of 32 horses

OBJECTIVES

To review the outcome of equine shoulder osteochondrosis (OC) with surgical or conservative treatment.

METHODS

Retrospective study of 32 horses, less than two years of age, with scapulohumeral joint (SHJ) OC. The lesion severity was graded based on measurements taken from lateromedial radiographs. Follow-up information was obtained from racing records or telephone conversations with owners. Successful outcome was defined as the ability of the horse to perform its intended use.

RESULTS

Sixteen of 32 horses were affected bilaterally (48 joints). Eleven of 16 horses with bilateral OC underwent arthroscopic surgery; five had bilateral arthroscopy, six had unilateral arthroscopy of the most severely affected joint. Eight of 16 horses with unilateral OC underwent arthroscopy. The overall outcome was 'poor'. Only 15.4% (4/26) of potential race horses started a race, whereas 67% (4/6) non-racehorses were 'sound' for the intended use. Statistical analysis evaluating the effect of breed on outcome showed a statistically significant difference. There were no significant interactions between outcome and gender, affected limb, unilateral versus bilateral involvement, treatment or severity of the radiographic lesion. However, radiographic lesion severity on the humerus and glenoid showed significant positive correlation.

CLINICAL SIGNIFICANCE

The overall poor prognosis for shoulder OC in young horses appears to be, in part, dependent on breed and intended use. There was not any difference in outcome between surgically and conservatively treated horses.