Treatment of genu valgus deformity in congenital absence of the fibula

Twenty patients with Syme amputation for congenital absence of the fibula and genu valgus deformity were followed until skeletal maturity. Radiographs were analyzed for genu valgus, mechanical axis, tibial angulation, and the condylar height ratio. This ratio was determined by measuring the greatest perpendicular height from the physis to the joint line and dividing the lateral height by the medial height. A smaller value represented more marked lateral condylar hypoplasia. The presence of medial tibial angulation and the degree of lateral femoral condylar hypoplasia correlated with the degree of genu valgus. Two of three patients who had proximal tibial osteotomies required multiple procedures for recurrent deformity. Medial distal femoral physeal stapling corrected the deformity in five of six limbs. The procedure is simple, allows immediate weightbearing in the prosthesis postoperatively, and has low morbidity. Patients should be followed closely until skeletal maturity. Osteotomy performed before skeletal maturity can result in recurrence of genu valgus deformity.     

Changes in tibiofibular relationships due to growth disturbances after ankle fractures in children

We analyzed the longitudinal growth of the distal tibial and fibular physes and the longitudinal displacement of the distal metaphysis and epiphysis of the fibula relative to the distal metaphysis and epiphysis of the tibia during growth using a roentgenstereophotogrammetric technique in eight children: six with a traumatic growth disturbance in one or both of the distal tibial and distal fibular physes and two with a normal ankle. In the normal ankles the distal fibular metaphysis moved distally in relation to the distal tibial metaphysis and the growth in the distal fibular physis was slower than that in the distal tibial physis. Growth arrest in the distal fibular physis and continued growth in the distal tibial physis resulted in distal displacement of the fibular metaphysis relative to the tibial metaphysis, probably due to traction on the distal ligaments of the fibula or more rapid growth in the proximal fibular physis than in the proximal tibial physis, or both. Valgus deformity of the ankle developed when the growth of the distal tibial physis exceeded the distal sliding of the fibula, as shown by the stereophotogrammetric analyses and orthoroentgenograms. Growth arrest in the distal tibial physis and continued growth in the distal fibular physis resulted in proximal sliding of the fibula, as shown by the roentgenstereophotogrammetric analyses and serial orthoroentgenograms. This mechanism compensated to some extent for the overgrowth of the fibula. Simultaneous growth arrest in both the distal tibial and the distal fibular physis was associated with movement of the distal end of the fibula in a distal direction relative to the tibia, probably due to the more rapid growth in the proximal fibular physis than in the proximal tibial growth plate. Therefore, growth arrest of the distal tibial or fibular physis may result in either proximal or distal sliding of the fibular metaphysis in relation to the tibial metaphysis. Probably growth arrest in the distal fibular physis has a less favorable prognosis than arrest in the distal tibial physis, because after tibial arrest proximal sliding of the fibula may compensate for overgrowth of the fibula better than distal sliding of the fibula can compensate for fibular arrest and overgrowth of the tibia.     

Management and complications of anterior cruciate ligament injuries in skeletally immature patients: survey of the Herodicus Society and The ACL Study Group

Expert opinion regarding experience with the management and complications of pediatric anterior cruciate ligament (ACL) injuries was studied by surveying members of The Herodicus Society and The ACL Study Group. There was large practice variation in initial management and ACL reconstruction technique. There were 15 reported cases of growth disturbance: 8 cases of distal femoral valgus deformity with arrest of the lateral distal femoral physis, 3 cases of tibial recurvatum with arrest of the tibial tubercle apophysis, 2 cases of genu valgum without arrest, and 2 cases of leg length discrepancy. Associated factors included fixation hardware across the lateral distal femoral physis in 3 cases, bone plugs of a patellar tendon graft across the distal femoral physis in 3 cases, large (12 mm) tunnels in 2 cases, fixation hardware across the tibial tubercle apophysis in 3 cases, lateral extra-articular tenodesis in 2 cases, and over-the-top femoral position in 1 case. Based on this experience, we recommend a guarded approach to ACL reconstruction in the skeletally immature patient with careful attention to technique and follow-up.     

Free physeal transplantation in the rabbit. An experimental approach to focal lesions

We have developed a procedure to transplant free autogenous iliac-crest physeal grafts into defects created in the lateral aspect of the distal femoral physis of rabbits. Excision of a portion of the lateral part of the physis led consistently to formation of a bone bridge, growth arrest, and valgus deformity. There was no evidence of increased activity by the persisting physis to fill the defect or of differentiation of mesenchymal cells into a functioning physeal layer. We carried out preliminary studies to define the optimum conditions for obtaining and transplanting a free autogenous iliac-crest physeal graft into the femoral physeal defect. The iliac apophysis is composed of a fibrocartilaginous layer, cartilage similar to epiphyseal cartilage, and a physis. The graft included the physis and some overlying epiphyseal cartilage but the outermost fibrocartilaginous layer and the surrounding perichondrium were removed, as these two tissues were believed to inhibit diffusion. The graft was separated gently from the metaphysis. Histological studies showed that the separation occurred at the lower hypertrophic-chondrocyte zone. After optimum techniques had been developed for transplantation and the feasibility of the procedure had been established in twenty-one rabbits, the capacity of the physeal transplants to prevent bone-bridge formation, growth arrest, and valgus deformity was evaluated in thirty-nine rabbits, three to four months old, using the standardized transplantation procedure. The results were assessed in terms of the gross and radiographic appearance of the femur, measurements of length, and histological characteristics. The transplanted physis retained its normal morphology, united with the residual part of the original femoral physis, and participated in endochondral bone formation. Bone-bridge formation between the femoral epiphysis and metaphysis, growth arrest, and valgus deformity were prevented or minimized in most animals, and the physeal transplants yielded good or excellent results in 60 per cent of the procedures using stringent criteria. The results of this study show that free physeal transplants into focal defects can remain viable and function satisfactorily if they are fashioned properly and inserted gently. CLINICAL RELEVANCE: This study demonstrated that transplantation of an iliac-crest physis into a defect of the lateral aspect of the distal femoral physis can prevent bone-bridge formation, growth arrest, and the development of valgus deformity.(ABSTRACT TRUNCATED AT 400 WORDS)     

Infantile tibia vara

Infantile tibia vara is a developmental condition producing progressive varus deformity of the knee in young children. It appears to have a worse prognosis in the predominantly nonwhite population seen with this condition in the United States than previous studies from Scandinavia would suggest. Early roentgenographic diagnosis is critical, since toddlers can have infantile tibia vara at an early stage instead of physiologic genu varum. Aggressive bracing is appropriate treatment until age three years. Correction to valgus alignment with upper tibial osteotomy predictably can produce complete resolution of the condition if performed by age four years. After that age, the procedure becomes less effective. Prognosis for Langenskiold Grade IV disease is guarded at best, regardless of age, because the physis behaves as if effective growth arrest has already occurred. Young patients with Grade IV or greater lesions should have corrective osteotomy combined with a physeal procedure to attempt restoration of growth in the medial physis. Early effective treatment can prevent permanent intraarticular incongruity.     

Bilateral proximal tibia stress fracture following bilateral distal femoral hemiepiphysiodesis - A rare complication

Correction of lower limb deformities by hemiepiphyseodesis with 8-plates is gaining popularity among deformity surgeons. Complications including metal failure, recurrence of deformity have been reported but stress fracture has not been reported. We have encountered bilateral proximal metaphyseal tibia stress fractures following correction of valgus deformity of both knees by hemiepiphyseodesis of distal femur following inadvertent overcorrection to a varus deformity following loss of follow up. The varus deformity has been reversed by guided growth of distal femoral physis resulting in fracture union and normal gait pattern.We herewith emphasize the importance of timely follow up with removal of 8 plates for hemiepiphysiodesis in deformity correction to prevent unexpected complication. We are reporting a rare complication of proximal tibial stress fractures following distal femur hemiepiphysiodesis done for valgus deformity with 8-plates.     

Outcome of hemiepiphyseal stapling for late-onset tibia vara

BACKGROUND: The results of hemiepiphysiodesis for the treatment of late-onset tibia vara have been reported to be favorable, but the technique requires careful timing and an accurate estimation of skeletal age. Hemiepiphyseal stapling does not require a careful estimation of skeletal age, and it has been reported to yield good results with low morbidity. However, we are not aware of any study evaluating the intermediate-term radiographic results or complications of this procedure. METHODS: Twenty-six patients with thirty-three extremities with late-onset tibia vara were treated with proximal tibial hemiepiphyseal stapling. Fourteen extremities had substantial concomitant distal femoral varus and also had hemiepiphyseal stapling of the distal part of the femur. Eighteen patients (twenty-three involved extremities) had juvenileonset tibia vara and eight patients (ten involved extremities) had adolescent-onset tibia vara. The mean age at the time of stapling was 11.8 years. The mean duration of follow-up was 3.8 years. We reviewed standardized standing radiographs to determine the mechanical axis deviation, the medial proximal tibial angle, the lateral distal femoral angle, and the zone of the knee through which the mechanical axis passed. RESULTS: The mean mechanical axis deviation improved from 58 mm (range, 27 to 157 mm) preoperatively to 22 mm (range, -33 to 117 mm) at the time of the last follow-up, and the mean medial proximal tibial angle improved from 77 degrees (range, 50 degrees to 85 degrees ) to 85 degrees (range, 48 degrees to 95 degrees ). In the fourteen lower extremities in which distal femoral hemiepiphyseal stapling was performed, the mean lateral distal femoral angle improved from 96 degrees (range, 92 degrees to 100 degrees ) to 86 degrees (range, 79 degrees to 97 degrees ). At the time of the final follow-up, seven extremities were considered to be in moderate varus; four, in mild varus; twenty, in normal alignment; and two, in valgus. No differences in radiographic outcome were noted between the juvenile and adolescent forms of tibia vara. Only one of the four extremities with severe preoperative varus was corrected to normal alignment; the remaining three were left with moderate varus. CONCLUSIONS: Hemiepiphyseal stapling of the lateral aspect of the proximal tibial physis and, as needed, the lateral aspect of the distal femoral physis is safe and effective in children with late-onset tibia vara if the physes are sufficiently open and the varus deformity is mild to moderate. Hemiepiphyseal stapling is particularly effective in patients who are ten years of age or younger. LEVEL OF EVIDENCE: Therapeutic Level IV.     

Bending osteotomy through the distal tibial physis in fibular hemimelia for stable reduction of the hindfoot

Fibular hemimelia is associated with a deformity of the distal tibial epiphysis resulting in a convexity with lateral and posterior slope of the distal joint surface. The deformity results into an equinovalgus position of the foot and ankle and frequently consecutive dislocation of the foot. A new procedure is presented, in with a metaphyseal ostotomy is performed towards the physis in order to bend the postero-lateral third of the distal tibial epiphysis forming a concave distal tibial joint surface. This procedure was done in four feet in three patients at ages between 7 and 20 months combined with soft tissue releases and rebalancing the tendons. At a follow-up between 6 and 42 months the position of the feet is well retained.     

Postnatal epiphyseal development: the distal tibia and fibula

At birth, the distal tibial physis is a transverse structure. However, as the tibia enlarges diametrically and the epiphyseal ossification center matures, the physis becomes increasingly undulated, with peripheral lappet formation. The anteromedial area is the first to develop undulation (Poland's hump). This should not be misinterpreted as an injury or premature epiphyseodesis subsequent to trauma. The tibial secondary ossification center forms within the central epiphysis. The medial margin is irregular and may have peripheral foci of ossification. Between the ages of 7 and 8 years, this secondary center extends into the medial malleolus, reaching the distal tip during adolescence. The malleolar tip may develop accessory ossification. Physiologic epiphyseodesis begins over the medial malleolus and then extends laterally, a pattern of closure that affects fracture patterns (e.g., the fracture of Tillaux). The distal fibular physis also begins as a transverse structure that becomes undulated and has extensive peripheral lappet formation. This physis usually becomes level with the articular surface of the distal tibia after the first year. Enchondromalike extensions of the physis into the metaphysis are common. Accessory ossification may develop at the distal end.     

Experimental tibial fractures in rabbits simulating proximal tibial metaphyseal fractures in children

The etiology of valgus deformity after a seemingly innocuous fracture of the proximal tibial metaphysis in children is unknown. The purpose of this work was to identify the etiology of this deformity using a rabbit model. Twenty-two eight-week-old rabbits were divided into two groups. In Group I, the medial periosteum was excised from the left proximal tibial metaphysis. A partial osteotomy was created 5 mm distal to the epiphyseal plate, involving the medial one-half of the tibial metaphysis. Two 0.7-mm Kirschner wires were placed as markers on each side of the osteotomy. In Group II, the identical procedure was performed from the lateral side. Standard roentgenograms were obtained postoperatively and weekly until death by sodium pentobarbital overdose at six weeks. The angular deformity, medial growth, and lateral growth were calculated from the markers on the roentgenograms. All tibias were decalcified and analyzed under light microscopy. In Group I, all 11 rabbits developed valgus deformity averaging 12.2 degrees; asymmetric growth was statistically significant. In Group II, ten of 11 rabbits developed varus deformity averaging 9.8 degrees; asymmetric growth was not statistically significant. Despite obvious asymmetric growth in both groups, light microscopy failed to reveal any asymmetry of the physis. Valgus and varus deformities are secondary to asymmetric growth, which is not demonstrable by light microscopy.     

Premature closure of distal fibular growth plate: a case of longitudinal syndesmosis instability

Post-traumatic premature closure of distal fibular growth plate is a rare entity and results in shortened lateral malleolus. This can lead to lateral wedging of distal tibial epiphysis, valgus ankle and medial ankle instability. Ramsey and Hamilton noted experimentally that loss of fibular length caused a dramatic lateral shift in tibiotalar surfaces. Even a displacement of as little as 1 mm will distort the areas of tibiotalar contact and lead to early joint degeneration. Colton believed it is due to the oblique articular surface of the malleolus is no longer closely applied to the talus. We present a case of premature closure of distal fibular physis with lateral malleolar shortening. Ankle arthroscopy demonstrated syndesmosis instability resulted from shortened lateral malleolus and stability restored after fibular lengthening.     

Infantile Blount's disease treated by hemiplateau elevation and epiphyseal distraction using a specific external fixator: preliminary report

The treatment of infantile Blount's disease remains controversial. The progressive development of epiphysiodesis of the medial tibial physis induced a complex deformity of the lower limb such as severe genu varum, joint incongruity, torsion instability and leg length discrepancy with major functional consequences. Nine knees on eight children (average age was 7 years and 2 months) were treated by a one-time procedure using a specific external fixator that combined elevation of the medial tibial plateau, axial correction in the valgus, complete sterilization of the upper tibial growth cartilage, leg lengthening anticipation and de-rotation if necessary. Magnetic resonance imaging was useful to describe the deformity and to prepare for surgery. Corrections were progressively obtained through the physis plan by means of short incisions and the use of a specific external fixator. The primary results at an average of 24 months were good with a low rate of complications but final evaluation will be conducted at the end of the children's growth period.     

Posttraumatic tibia valga: a case demonstrating asymmetric activity at the proximal growth plate on technetium bone scan

Posttraumatic tibia valga is a well-recognized complication following fracture of the upper tibial metaphysis in young children. We present a case of a child who developed a valgus deformity following fracture of the proximal tibia and fibula in which quantitative bone scintigraphy at 5 months after injury demonstrated increased uptake at the proximal tibial growth plate with proportionally greater uptake on the medial side. This finding suggests that the valgus deformity in this patient was due to a relative increase in vascularity and consequent overgrowth of the medial portion of the proximal tibial physis.     

Correction of ankle valgus by hemiepiphysiodesis using the tension band principle in patients with multiple hereditary exostosis

Background

Ankle valgus is a common deformity in patients with multiple hereditary exostoses (MHE) and a potential risk factor for early degenerative arthritis. In children, medial hemiepiphysiodesis of the distal tibia is a relatively simple surgical technique used to correct this deformity. We present here the first results of applying this procedure using the eight-Plate guided growth system (eight-Plate) for growth guidance.

Methods

Between 2006 and 2011 we performed hemiepiphysiodesis of the distal medial tibia in 30 ankles of 18 children with MHE using the eight-Plate. Weight-bearing total leg radiographs were obtained preoperatively, during follow-up and at the time of implant removal or when the distal tibial physis had closed. The lateral distal tibia angle (LDTA) was measured and fibular shortening assessed using the Malhotra classification. To evaluate the effect of hemiepiphysiodesis, we correlated the LDTA with age.

Results

The mean age at time of surgery was 12.6 (range 9.5–15.0) years, and the mean preoperative LDTA was 76.9° (range 68.5°–83.5°). During follow-up, the implant was removed in 12 extremities and the physis had closed in 18 extremities. The mean LDTA at the time of implant removal or at closure of the physis was 83.6° (range 76.5°–90.0°). Mean correction of LDTA was 6.9° after a mean follow-up period of 22 (range 3–43) months. During follow-up, no changes in the Malhotra classification were found in any of the patients. Correction of the valgus deformity of the ankle was significantly correlated (r = ?0.506) (p = 0.004) with age in all patients.

Conclusion

Temporary medial hemiepiphyseodesis of the distal tibia seems to be an effective strategy for correcting ankle valgus in children with MHE. Timing of the intervention is, however, of importance. Hemiepiphyseodesis alone has no effect on the Malhotra classification.

Level of evidence

IV, retrospective review.

     

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.     

Salter-Harris I and II fractures of the distal tibia: does mechanism of injury relate to premature physeal closure?

INTRODUCTION: The distal tibial physis is the second most commonly injured physis in long bones. Recent reports demonstrate a high rate of premature physeal closure (PPC) in Salter-Harris (SH) type I or II fractures of the distal tibia. METHODS: At our institution, 137 distal tibial SH type I or II fractures were treated from 1994 to 2002. Reviews were performed on all patients and 91 fractures met inclusion criteria. Patients were categorized according to treatment. RESULTS: We report a PPC rate of 39.6% in SH type I or II fractures of the distal tibial physis. We found a difference in PPC based on injury mechanism. The rate of PPC in patients with a supination-external-rotation-type injury was 35%, whereas patients with pronation-abduction-type injuries developed PPC in 54% of cases. Type of treatment may prevent PPC in some fractures. The most important determinant of PPC is the fracture displacement following reduction. DISCUSSION AND CONCLUSION: PPC is a common problem following SH type I or II fractures of the distal tibia. Operative treatment may decrease the frequency of PPC in some fractures. Regardless of treatment method, we recommend anatomic reduction to decrease the risk of PPC.     

Transphyseal osteotomy of the distal tibia for correction of valgus/varus deformities of the ankle

This study is a retrospective review of the results of consecutive cases of a transphyseal osteotomy of the distal tibia. Indications for the procedure are significant valgus or varus deformities of the ankle needing acute correction because of problems with the skin and brace fit as well as progressive deformity. Twenty-one patients with a variety of underlying diagnoses, five with bilateral deformities, underwent this procedure. The technique involved making either a medially based closing or opening wedge with the distal limb of the osteotomy through the physis or the physeal scar so that it was very close to the ankle joint. A fibular osteotomy was not necessary except in three ankles. All osteotomies healed. All patients were able to ambulate and use their braces as soon as their osteotomies healed, and none had any further pressure sores or brace-related problems, although some had mild residual valgus or varus deformities. There were no significant leg-length discrepancy problems as a result of the surgery. This osteotomy is a treatment alternative for significant angular deformities of the ankle that require acute correction.     

Ipsilateral tibial shaft fracture and distal tibial triplane fracture with an intact fibula: a case report

We present a case of an ipsilateral tibial shaft fracture and a distal tibial triplane fracture with an intact fibula in a 14-year-old boy. Computed tomography revealed the distal tibial triplane fracture with a 2.6-mm displaced Tillaux fragment and a posterior malleolar shear fragment. Open reduction and internal fixation was performed to optimise healing and outcome. This is a rare injury, for which a high index of suspicion is needed for diagnosis. Missing the intra-articular distal tibial triplane fracture could result in a disabling angular deformity (mostly varus) or limb-length discrepancy secondary to premature partial closure of the distal physis.     

Validation of a genu valgum model in a rabbit hind limb

Numerous techniques exist to correct pediatric angular deformity by asymmetrically inhibiting physeal growth. Despite decades of surgical experience, little is known about the determinants of success or failure of temporary hemiepiphysiodesis. We lack a basic understanding of tolerances and kinematics of the surgically restrained physis. Furthermore, little is known about the influence of implant design and placement on efficacy of deformity correction and rebound growth.We have undertaken a pilot research study with the goal of producing genu valgum in New Zealand white rabbits. This report comprises our initial experience and observations in performing hemiepiphysiodesis with staples and 2-hole plate techniques.The experimental hypotheses proposed by this article are as follows: (1) a staple or plate applied to the proximal lateral tibial physis of a rabbit hind limb will reliably create a valgus deformity of the knee; (2) the plate or staple will create this deformity without permanently damaging the proximal tibial physis; and (3) provided the implant remains in situ, there will be no difference between the plate and staple constructs with respect to the magnitude or rate of deformity produced. Further studies will aim to use this model to investigate technical issues related to physeal instrumentation.     

Which osteotomy for a valgus knee?

A valgus knee is a disabling condition that can affect patients of all ages. Antivalgus osteotomy of the knee is the treatment of choice to correct the valgus, to eliminate pain in the young or middle age patient, and to avoid or delay a total knee replacement. A distal femoral lateral opening wedge procedure appears to be one of the choices for medium or large corrections and is particularly easy and precise if compared to the medial femoral closing wedge osteotomy. However, if the deformity is minimal, a tibial medial closing wedge osteotomy can be done with a faster healing and a short recovery time.