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Raftis D, Helbing J, Dance S, O'Mara A, Tabaie S. Tension-Band Plating for Infantile Blount Disease: Efficacy and Outcomes Comprehensive Review. Cureus 2024; 16:e62514. [PMID: 38887744 PMCID: PMC11181882 DOI: 10.7759/cureus.62514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2024] [Indexed: 06/20/2024] Open
Abstract
Infantile Blount disease (IBD) is a pathologic varus knee deformity that, if left untreated, can lead to abnormal gait, limb length discrepancy, and pain. Traditionally, bracing and tibial osteotomy have been the primary treatments. More recently, guided growth with tension-band plating (TBP) has gained popularity, although there is a lack of data stratifying between the infantile, juvenile, and adolescent disease types. Therefore, the present review aims to determine the efficacy and complications of TBP in the IBD population. A systematic review was conducted following the PRISMA guidelines. Eligible studies included those focused on guided growth correction for IBD. Studies that did not stratify subjects by subgroup (infantile, juvenile, and adolescent) within their analysis were excluded. The outcomes of interest included demographic information, correction rate, failure rate, recurrence rate, and postoperative complications. Database review identified 541 studies. After screening, seven studies met our inclusion criteria, all of which were retrospective observational studies published between 2012 and 2022. In total, 92 limbs afflicted with Infantile Blount Disease underwent treatment with TBP. The recorded follow-up period ranged from four months to eight years. The age of patients at the time of surgery varied from 1.8 to nine years. On average, there was a 78.99% correction of deformities, with a range of 57.14% to 100%. Six studies provided data on failure and recurrence rates, with an average rate of 23.47%. Notably, infection and hardware failure emerged as the most prevalent postoperative complications, with mean rates of 11.44% and 9.50%, respectively. The average reoperation rate was 29.90%, with a range from 0.00% to 47.06%. The current literature shows a high rate of deformity correction with a relatively low risk of complications after TBP for IBD. Given the reported reoperation rates greatly varied, further data is needed to determine risk factors for reoperation following TBP. Our results suggest that guided growth with TBP may be a preferable first-line treatment for IBD.
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Affiliation(s)
- Daniel Raftis
- Orthopaedic Surgery, The George Washington University School of Medicine and Health Sciences, Washington DC, USA
| | - Jordan Helbing
- Orthopaedic Surgery, The George Washington University School of Medicine and Health Sciences, Washington DC, USA
| | - Sarah Dance
- Orthopaedic Surgery, Children's National Hospital, Washington DC, USA
| | - Alana O'Mara
- Orthopaedic Surgery, The George Washington University School of Medicine and Health Sciences, Washington DC, USA
| | - Sean Tabaie
- Orthopaedic Surgery, Children's National Hospital, Washington DC, USA
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Hanstein R, Schneble CA, Schulz JF, Lo Y, Socci AR, Sharkey MS. The Effect of Guided Growth Surgery on Langenskiold Stage and Mechanical Axis in Early-Onset Blount Disease: A Retrospective Case Series. J Am Acad Orthop Surg 2024; 32:e240-e250. [PMID: 37852243 DOI: 10.5435/jaaos-d-21-00515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 08/16/2023] [Indexed: 10/20/2023] Open
Abstract
INTRODUCTION Our understanding of the efficacy of guided growth surgery with tension-band plating (TBP) in early-onset Blount disease is evolving. Preliminary work has demonstrated that TBP can normalize the mechanical axis, yet its effect on Langenskiöld stage (LS) has not previously been reported. The primary outcome of this study was improvement in LS after TBP. Secondary outcomes were improvement in LS at most recent follow-up and improvement in mechanical axis deviation (MAD), mechanical medial proximal tibial angle, and mechanical lateral distal femoral angle at treatment completion and most recent follow-up. METHODS A retrospective review was done of patients with early-onset Blount disease treated with TBP between January 1, 2010, and December 31, 2019, across two institutions. Inclusion criteria were a radiographic diagnosis of early-onset Blount disease (LS changes present), surgery with TBP, and follow-up beyond implant removal. Radiographs before surgery, at removal of hardware (ROH), and at most recent follow-up were evaluated. RESULTS Twenty-five limbs in 16 children who underwent TBP at a mean age of 5.8 ± 2.3 years were included. Implants were in situ a mean of 1.9 ± 0.7 years. The mean follow-up after ROH was 3.6 ± 1.4 years. LS ranged from 1 to 5 preoperatively with 14 of 25 limbs (56%) staged ≥3. LS improved in 15 of 25 limbs (60%) at ROH and in 21 of 25 limbs (84%) at most recent follow-up. Langenskiöld changes resolved in 7 of 25 limbs (28%) at most recent follow-up. Preoperatively, the MAD was varus in all limbs, but at ROH, the MAD had improved in 22 of 23 limbs with neutral or valgus alignment in 20 of 23 limbs (87%). At most recent follow-up, 16 of 23 limbs (70%) maintained improved alignment. DISCUSSION There was improvement/resolution of LS and varus deformity in early-onset Blount disease in most patients who underwent TBP. Based on these results, TBP for early-onset Blount disease should be the first-line surgical treatment. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Regina Hanstein
- From the Department of Cardiology, Mt. Sinai Health System, New York, NY (Hanstein), Department of Orthopaedic Surgery, Children's Hospital at Montefiore Medical Center, Bronx, NY (Schulz and Sharkey), Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT (Schneble and Socci), and Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY (Lo)
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Ramella M, Depaoli A, Menozzi GC, Gallone G, Cerasoli T, Rocca G, Trisolino G. Recurrence and Complication Rates of Surgical Treatment for Blount's Disease in Children: A Systematic Review and Meta-Analysis. J Clin Med 2023; 12:6495. [PMID: 37892633 PMCID: PMC10607610 DOI: 10.3390/jcm12206495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/05/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Blount's disease is a growth disorder of the proximal tibia that causes progressive genu varum in children. Surgical treatment is recommended if the deformity worsens, but which intervention is best remains controversial. This study aims to identify factors influencing outcomes and determine the most effective surgical approach. METHODS A systematic review was conducted of studies published before January 2022. RESULTS In total, 63 retrospective studies with CEBM IIIb/IV levels were included (1672 knees in 1234 patients). The most commonly reported treatment was acute correction via osteotomy (47%), followed by hemiepiphysiodesis (22%) and gradual correction (18%). Combined procedures were reported in 13% of cases. The overall recurrence rate was 18%, with a significant difference when comparing the recurrence rates after gradual correction with those after hemiepiphysiodesis (7% and 29%, respectively). Major complications beyond recurrence were observed in 5% of cases. A meta-analysis of the available raw data showed a significantly increased recurrence rate (39%) among treated children who were between 4.5 and 11.25 years of age and were followed for a minimum follow-up of 2.5 years. CONCLUSIONS Overall, poor evidence with which to establish an optimal treatment for Blount's disease was found. This study remarked on the need for early diagnosis, classification, and treatment of infantile tibia vara, since a significant rate of recurrence was found in neglected cases.
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Affiliation(s)
| | | | | | | | | | | | - Giovanni Trisolino
- Unit of Pediatric Orthopedics and Traumatology, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (M.R.); (A.D.)
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Walker JL, Dueber DM, Stephenson LP, Scott AC, Lerman JA, Powell KP, Ackman JD, Westberry DE, Nossov SB, Franklin CC. Predicting Success of Deformity Correction With Tension Band Plating in Early-Onset Tibia Vara. J Pediatr Orthop 2023; 43:e350-e357. [PMID: 36962070 DOI: 10.1097/bpo.0000000000002375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/26/2023]
Abstract
BACKGROUND Angular deformity correction with tension band plating has not been as successful in early-onset tibia vara (EOTV) as it has been in other conditions. Our hypothesis is that perioperative factors can predict the success of lateral tibial tension band plating (LTTBP) in patients with EOTV. METHODS A retrospective review was performed at 7 centers evaluating radiographic outcomes of LTTBP in patients with EOTV (onset <7 y of age). Single-event tibial LTTBP outcome was assessed through medial proximal tibial angle (MPTA). The final limb alignment following comprehensive limb growth modulation (CLGM), which could include multiple procedures, was assessed by mechanical axis zone (MAZone), mechanical tibio-femoral angle (mTFA), and mechanical axis deviation (MAD). Preoperative age, weight, deformity severity, medial physeal slope, and Langenskiöld classification +/- modification were investigated as predictors of outcome. Success was defined as the correction or overcorrection to normal age-adjusted alignment. The minimum follow-up was 2 years except when deformity correction, skeletal maturity, or additional surgery occurred. RESULTS Fifty-two patients with 80 limbs underwent 115 tibial LTTBP procedures at a mean age of 5.3 y, including 78 primary, 21 implant revisions, and 15 reimplantations for recurrence. Tibial LTTBP resulted in a mean change of +8.6 o in MPTA and corrected 53% of tibias. CLGM resulted in MAD correction for 54% of limbs.Univariate analysis showed that success was best predicted by preoperative age, weight, MPTA, and MAD. Multivariate analysis identified that preoperative-MPTA/MAD and preoperative-weight<70 kg were predictive of MPTA and MAD correction, respectively. The probability of success tables are presented for reference. CONCLUSION Successful correction of MPTA to age-adjusted norms following a single-event LTTBP occurred in 53% of tibias and was best predicted by preoperative-MPTA and preoperative body weight <70 kg. Comprehensive growth modulation corrected limbs in 54%. The probability of correction to age-adjusted MAD is best estimated by preoperative-MAZone 1 or 2 (MAD ≤40 mm). Limbs with preoperative-MAD>80 mm improved, but ultimately all failed to correct completely with CLGM. Osteotomy may need to be considered with these severe deformities. While modified Langenskiöld classification and medial physeal slope have been shown to predict the outcome of osteotomy, they were not predictive for LTTBP. Change in MPTA was common after physeal untethering. LEVEL OF EVIDENCE Level-III.
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Affiliation(s)
- Janet L Walker
- Shriners Children's and the University of Kentucky Department of Orthopaedic Surgery and Sports Medicine, Lexington KY
- Shriners Hospital for Children, Lexington, KY
| | - David M Dueber
- University of Kentucky Department of Statistics, Lexington, KY
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Walker JL, Dueber DM, Scott AC, Stephenson LP, Lerman JA, Nossov SB, Franklin CC, Powell KP, Westberry DE, Ackman JD. Femoral Deformity in Tibia Vara and Its Response to Growth Modulation. J Pediatr Orthop 2023; 43:303-310. [PMID: 36791409 DOI: 10.1097/bpo.0000000000002358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
BACKGROUND While tibia vara is a disorder of the proximal tibial physis, femoral deformity frequently contributes to the overall limb malalignment. Our purpose was to determine how femoral varus deformity in tibia vara responds to growth modulation, with/without lateral tension band plating (LTBP) to the femur. METHODS One-hundred twenty-seven limbs undergoing LTBP for tibia vara were reviewed. All had tibial LTBP and 35 limbs also had femoral LTBP for varus. Radiographs were measured for correction of the mechanical lateral distal femoral angle (mLDFA) and mechanical axis deviation (MAD). Preoperative-femoral varus was defined with an age-adjusted guide: mLDFA >95 degrees for 2 to below 4 years and mLDFA >90 degrees for 4 to 18 years. The 35 limbs having femoral LTBP were compared with 50 limbs with femoral varus and no femoral LTBP. In addition, 42 limbs that did not have preoperative-femoral varus were followed. Patients with early-onset (below 7 y) tibia vara were compared with those with late-onset (≥8 y). Outcome success was based on published age-adjusted mLDFA and MAD norms. RESULTS Following femoral LTBP, the mean mLDFA decreased from 98.0 to 87.1 degrees. All femurs had some improvement, with 28/35 femurs (80%) achieving complete correction. One limb, with late follow-up, overcorrected, requiring reverse (medial) femoral tension band plating.For the 50 limbs with femoral varus and only tibial LTBP, 16/22 limbs (73%) with early-onset and 11/28 limbs (39%) with late-onset completely corrected their femoral deformities. If the limb had preoperative-femoral varus, femoral LTBP statistically correlated with successful mLDFA correction and improvement of MAD, only in the late-onset group.Forty-two limbs, without preoperative-femoral varus, had no change in their mean mLDFA of 87 degrees. However, 4 femurs (10%) ended with posttreatment varus. CONCLUSIONS Femoral LTBP is effective in correcting femoral varus deformity in the tibia vara. For femoral varus associated with late-onset tibia vara, femoral LTBP should be considered. Those that had femoral LTBP had statistically more successful femoral and overall limb varus correction. However, in early-onset tibia vara, with associated femoral varus, observation is warranted because 73% of femurs are corrected without femoral intervention. This study was underpowered to show additional improvement with femoral LTBP in the early-onset group. Even limbs with normal femoral alignment, should be observed closely for the development of femoral varus, during tibial LTBP treatment for tibia vara. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Janet L Walker
- Department of Orthopaedic Surgery and Sports Medicine, Shriners Children's and University of Kentucky
| | - David M Dueber
- Department of Statistics, University of Kentucky, Lexington, KY
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Growth Modulation by Tension Band Plate in Achondroplasia With Varus Knee Deformity: Comparison of Gait Analysis Measurements. J Pediatr Orthop 2023; 43:168-173. [PMID: 36583511 DOI: 10.1097/bpo.0000000000002342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Limited evidence exists concerning growth modulation by tension band plate (TBP) to correct varus deformity in patients with achondroplasia with limited growth due to FGFR3 gene mutation. We evaluated the efficacy of TBP in children with achondroplasia with genu varum and reported the static radiographic and dynamic motion data to determine parameters that impact the rate of deformity correction. METHODS Patients with achondroplasia with genu varum who underwent TBP surgery for growth modulation were studied. Those with at least 1 year of follow-up with TBP were included. Radiographic parameters were measured. Growth velocity of femoral/tibial length was calculated separately. Patients were deemed successful or unsuccessful. Spearman correlation analysis and Student t test were used to describe statistical results. RESULTS Twenty-two patients (41 limbs; 12 girls) fulfilled our criteria. Mean age at TBP surgery was 7.6±2.4 years. Thirty-six femoral TBP and 41 tibial TBP were in place for 24.5±9.7 months. Mean mechanical axis deviation, mechanical lateral distal femoral angle, and medial proximal tibial angle preoperatively were 30.1±7.6 mm, 97.2±6.4, and 80.3±4.3 degrees, and 11±15.6 mm, 87.4±5.9, and 84.7±5.3 degrees at last follow-up ( P <0.001). Fifteen limbs were successfully straightened; 4 limbs were in more varus than the initial deformity. Twenty-four limbs with TBP were still undergoing correction. In successful limbs, mean age at surgery was 6.5±1.7 years and duration of TBP was 29.9±7.8 months. In 4 unsuccessful limbs, mean age at surgery was 11.7±1.2 years. Analysis in the gait laboratory included physical examination with the measurement of knee varus and kinematic varus based on a posterior view static standing photograph. Photographic measurement of varus was higher than the radiographic measurement. CONCLUSIONS Growth modulation by TBP surgery is a reliable and simple technique to correct genu varum in achondroplasia. An early age at TBP implementation (mean: 6.5 y) is crucial to successfully correct the varus knee deformity. Furthermore, we recommend early and regular surveillance of achondroplasia for progressive varus knee deformity. LEVEL OF EVIDENCE Level IV-cohort study.
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Schultz K, Stüwe D, Westhoff B. [Juvenile osteochondrosis and osteonecrosis]. ORTHOPADIE (HEIDELBERG, GERMANY) 2022; 51:829-843. [PMID: 36064862 DOI: 10.1007/s00132-022-04305-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/09/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Juvenile osteonecrosis is an important topic in orthopedics. A wide variety of body regions of the growing patient are affected, predominantly during adolescence. All are characterized by a usually unknown aetiology as well as a stadium-like course. The main problem is a local osseous circulatory disorder, which causes osteonecrosis. RISK FACTORS Mechanical overloading due to increased body weight, axial misalignment, and sports activity is discussed as a risk factor. Healing depends on the localization and extent of the osseous necrosis. DIAGNOSTICS Diagnostically, radiologic imaging is used, in which the typical bony remodeling can be followed. THERAPY The therapeutic procedure depends on the affected region but is usually accompanied by a reduction of mechanical loading. If the clinical and radiological findings worsen, surgical treatment must be considered. The recognition and treatment of juvenile osteonecrosis is important and significantly influences the further development of the patient.
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Affiliation(s)
- Katharina Schultz
- Klinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Deutschland.
| | - Dominique Stüwe
- Klinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Deutschland
| | - Bettina Westhoff
- Klinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Deutschland
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Walker JL, Scott AC, Stephenson LP, Westberry DE, Lerman JA, Ackman JD, Nossov SB, Franklin CC. Guided Growth for Varus Deformity Following Early Tibial Osteotomy in Infantile Tibia Vara-A Multi-Center Study. J Pediatr Orthop 2022; 42:488-495. [PMID: 35973052 DOI: 10.1097/bpo.0000000000002238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Janet L Walker
- Shriners Children's and University of Kentucky Department of Orthopaedic Surgery and Sports Medicine, Lexington, KY
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Abstract
BACKGROUND Tension band plate and screw implants (TBI) are frequently used for temporary hemiepiphyseodeses to manage angular deformity in growing children. The reported implant breakage rate, when TBI is used for deformities in patients with Blount disease, is much higher than when used in other diagnoses. Our hypothesis is that perioperative factors can identify risks for TBI breakage. METHODS A retrospective case-control study was performed of 246 TBI procedures in 113 patients with Blount disease at 8 tertiary pediatric orthopaedic centers from 2008 to 2018. Patient demographics, age at diagnosis, weight, body mass index (BMI), radiographic deformity severity measures, location, and types of implants were studied. The outcome of implant breakage was compared with these perioperative factors using univariate logistic regression with Bonferroni correction for multiplicity to significance tests. RESULTS There were 30 broken implants (12%), failing at mean 1.6 years following implantation. Most failures involved the metaphyseal screws. Increased BMI was associated with increased implant breakage. Increased varus deformity was directly associated with greater implant breakage and may be a more important factor in failure for those below 7 years compared with those 8 years or above at diagnosis. There was a 50% breakage rate for TBI with solid 3.5 mm screws in Blount disease with onset 8 years or above of age. No demographic or implant factors were found to be significant. CONCLUSIONS Breakage of TBI was associated with increased BMI and varus deformity in patients with Blount disease. Larger studies are required to determine the relative contribution and limits of each parameter. Solid 3.5 mm screws should be used with caution in TBI for late-onset Blount disease. LEVEL OF EVIDENCE Level III.
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Ulusaloglu AC, Asma A, Rogers KJ, Thacker MM, Mackenzie WGS, Mackenzie WG. Risk Factors for Rebound After Correction of Genu Valgum in Skeletal Dysplasia Patients Treated by Tension Band Plates. J Pediatr Orthop 2022; 42:190-194. [PMID: 35051956 DOI: 10.1097/bpo.0000000000002053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Growth modulation using tension band plates (TBPs) is increasingly important for lower limb deformity correction in patients with skeletal dysplasia (SKD). Development of rebound deformity is a concern after TBP removal. Data regarding this complication are rare; therefore, we evaluated the prevalence and risk factors for rebound deformity in children with SKD undergoing correction of genu valgum using TBP. METHODS All patients with SKD with genu valgum treated by TBP at the distal femur or/and proximal tibia at a single center were reviewed. Inclusion criteria were: (1) minimum 2-year follow-up after TBP removal or having revision surgery for rebound deformity and (2) implant removal age for girls 14 years and below and boys 16 years and below. Exclusion criteria were any femoral/tibial osteotomies during TBP treatment or follow-up. A change of ≥3 degrees of mechanical lateral distal femoral and/or medial proximal tibial angle was accepted as rebound deformity and analyzed statistically. RESULTS Thirty-three patients (59 limbs; 52 femur and 29 tibia physes) met our criteria. Mean follow-up after implant removal was 43.7 months. Rebound deformities were seen in 43 limbs (39 femurs and 13 tibias). Boys had more rebound than girls; however, this was not influenced by body mass index. Femurs had more rebound than tibias. Patients in the rebound group were younger than the nonrebound group. Time from application to removal of TBP was shorter in the rebound versus nonrebound group. Overcorrected limbs had more rebound deformity than not overcorrected. The difference in growth velocity of lower limbs in the rebound versus nonrebound group was statistically significant. Patients with epiphyseal dysplasia had more rebound than metaphyseal dysplasia, but this was not statistically significant. CONCLUSION Risk factors for developing a rebound deformity after correction of genu valgum using TBP in SKD included male sex, TBP surgery at a young age, short duration of TBP implantation, overcorrected extremity (mechanical axis deviation ≤1), and high percent growth velocity after TBP removal. LEVEL OF EVIDENCE Level IV-retrospective study.
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Affiliation(s)
- Armagan C Ulusaloglu
- Department of Orthopaedics, Nemours Childrens Hospital, Delaware, Wilmington, DE
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Abstract
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.
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Affiliation(s)
- Pieter Herman Maré
- Department of Orthopaedic Surgery, Grey's Hospital
- Department of Orthopaedic Surgery, School of Clinical Medicine, University of KwaZulu-Natal, South Africa
| | - David Mungo Thompson
- Department of Orthopaedic Surgery, Grey's Hospital
- Department of Orthopaedic Surgery, School of Clinical Medicine, University of KwaZulu-Natal, South Africa
| | - Leonard Charles Marais
- Department of Orthopaedic Surgery, School of Clinical Medicine, University of KwaZulu-Natal, South Africa
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Shin M, Arguelles GR, Cahill PJ, Flynn JM, Baldwin KD, Anari JB. Complications, Reoperations, and Mid-Term Outcomes Following Anterior Vertebral Body Tethering Versus Posterior Spinal Fusion: A Meta-Analysis. JB JS Open Access 2021; 6:JBJSOA-D-21-00002. [PMID: 34179678 PMCID: PMC8225360 DOI: 10.2106/jbjs.oa.21.00002] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Anterior vertebral body tethering (AVBT) is a growth-modulation technique theorized to correct adolescent idiopathic scoliosis (AIS) without the postoperative stiffness imposed by posterior spinal fusion. However, data are limited to small series examining short-term outcomes. To assess AVBT's potential as a viable alternative to posterior spinal fusion (PSF), a comprehensive comparison is warranted. The purpose of this meta-analysis was to compare postoperative outcomes between patients with AIS undergoing PSF and AVBT. Our primary objective was to compare complication and reoperation rates at available follow-up times. Secondary objectives included comparing mid-term Scoliosis Research Society (SRS)-22 scores, and coronal and sagittal-plane Cobb angle corrections. Methods We performed a systematic review of outcome studies following AVBT and/or PSF procedures. The inclusion criteria included the following: AVBT and/or PSF procedures; Lenke 1 or 2 curves; an age of 10 to 18 years for >90% of the patient population; <10% non-AIS scoliosis etiology; and follow-up of ≥1 year. A single-arm, random-effects meta-analysis was performed. Deformity corrections, complication and reoperation rates, and postoperative SRS-22 scores were recorded. Results Ten AVBT studies (211 patients) and 14 PSF studies (1,069 patients) were included. The mean follow-up durations were similar for both groups. Pooled complication rates were 26% for AVBT versus 2% for PSF, and reoperation rates were 14.1% for AVBT versus 0.6% for PSF with nonoverlapping confidence intervals (CIs). The pooled reoperation rate among studies with follow-up times of ≥36 months was 24.7% in AVBT versus 1.8% in PSF. Deformity correction, clinical outcomes, and mid-term SRS-22 scores were similar. Conclusions Our study showed greater rates of complications and reoperations with AVBT compared with PSF. Reoperation rates were significantly greater in AVBT studies with longer follow-up (≥36 months). Deformity correction, clinical outcomes, and mid-term SRS-22 scores were similar. While a potential fusionless treatment for AIS merits excitement, clinicians should consider AVBT with caution. Future long-term randomized prospective studies are needed. Level of Evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Max Shin
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gabriel R Arguelles
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - John M Flynn
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Keith D Baldwin
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jason B Anari
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Lim C, Shin CH, Yoo WJ, Cho TJ. Acute correction of proximal tibial coronal plane deformity in small children using a small monolateral external fixator with or without cross-pinning. J Child Orthop 2021; 15:255-260. [PMID: 34211602 PMCID: PMC8223093 DOI: 10.1302/1863-2548.15.200187] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Surgical correction of proximal tibia deformity in small children can be challenging. We present the surgical technique and outcome of proximal tibia osteotomy fixed with small monolateral external fixator in this patient group. METHODS A total of 17 cases in eight patients younger than nine years of age were study subjects. A proximal tibia osteotomy was fixed with a small monolateral external fixator with or without cross-pinning. Outcome was evaluated by changes of radiographic parameters such as medial proximal tibia angle (MPTA), metaphyseal diaphyseal angle (MDA) and clinical findings of complications, time interval until weight bearing and fixator removal time. RESULTS MPTA improved from a preoperative mean of 73° (sd 4°; 66° to 78°) to an immediate postoperative mean of 90° (sd 3°; 85° to 96°) in varus tibiae, and from 104° (sd 1°; 103° to 105°) to 89° (sd 1°; 88° to 89°) in valgus tibiae. In all, 15 of the 17 cases (88.3 %) achieved postoperative MPTA within the normal range (85° to 90°). MDA improved from a preoperative mean of 19° (sd 5°; 11° to 24°) to an immediate postoperative mean of 0° (sd 4°; -6° to 7°) in varus tibiae, and from -25° (sd 2°; -22° to -24°) to 2° (SD 1°; 1° to 3°) in valgus tibiae. Full weight bearing was possible at mean 1.7 months (0.5 to 3.0). Mean follow-up period was 6.5 years (sd 5.4; 1.0 to 16.0). No complications developed during the follow-up. CONCLUSION Proximal tibia osteotomy fixed with small monolateral external fixator provides accurate, safe and efficient correction in the management of coronal plane angular deformity in small children. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Chaemoon Lim
- Division of Pediatric Orthopaedics, Seoul National University Children’s Hospital, Seoul, Korea,Department of Orthopaedic Surgery, Jeju National University Hospital, Jeju, Republic of Korea
| | - Chang Ho Shin
- Division of Pediatric Orthopaedics, Seoul National University Children’s Hospital, Seoul, Korea
| | - Won Joon Yoo
- Division of Pediatric Orthopaedics, Seoul National University Children’s Hospital, Seoul, Korea
| | - Tae-Joon Cho
- Division of Pediatric Orthopaedics, Seoul National University Children’s Hospital, Seoul, Korea,Correspondence should be sent to Tae-Joon Cho, Division of Pediatric Orthopaedics, Seoul National University Children’s Hospital 101 Daehak-ro Jongno-gu, Seoul 03080, Republic of Korea. E-mail:
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Sattelberger J, Hillebrand H, Gosheger G, Laufer A, Frommer A, Appelbaum S, Abood AAH, Gottliebsen M, Rahbek O, Moller-Madsen B, Roedl R, Vogt B. Comparison of histomorphometric and radiographic effects of growth guidance with tension-band devices (eight-Plate and FlexTack) in a pig model. Acta Orthop 2021; 92:364-370. [PMID: 33461381 PMCID: PMC8231350 DOI: 10.1080/17453674.2021.1873603] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - Temporary hemiepiphysiodesis for growth modulation in skeletally immature patients is a long-known technique. Recently the use of tension-band devices has become popular. This study compares 2 tension-band implants (eight-Plate and FlexTack) regarding their effects on the growth plate.Animals and methods - 12 pigs in 2 equally sized groups (A and B) were investigated. The right proximal medial tibia was treated with either eight-Plate or FlexTack. The left tibia of the same pig was treated with the opposite implant. After 9 weeks all implants were removed. Animals in group B were then hosted for another 5 weeks. Histomorphometric analysis of the growth plate was carried out after 9 and 14 weeks, respectively. Radiographs were taken at implantation, removal, and after 14 weeks.Results - Both tension-band devices achieved a statistically significant and clinically relevant growth inhibition, whereas the effect appeared to be more distinct after the use of FlexTack. Implant-related complications or physeal damage was not observed. After implant removal, rebound phenomenon was radiologically observed in all cases. The growth plates treated with eight-Plate showed a paradox reversal of the zonal distributions, with an increase of the proliferative zones at the previously arrested medial aspect of the physis and a decrease laterally.Interpretation - Both eight-Plate and FlexTack proved to be appropriate devices for growth-guiding treatment. The radiographic evaluation showed a change in angular axes after treatment with each implant, while the correction appeared to be faster with FlexTack. The paradox cartilaginous reaction observed after removal of the eight-Plate might be a histopathological correlate for rebound phenomenon.
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Affiliation(s)
- Julia Sattelberger
- Department of Pediatric Orthopaedics, Deformity Reconstruction and Foot Surgery, University Hospital Muenster, Germany;
| | - Hauke Hillebrand
- Department of Pediatric Orthopaedics, Deformity Reconstruction and Foot Surgery, University Hospital Muenster, Germany;
| | - Georg Gosheger
- General Orthopaedics and Tumour Orthopaedics, University Hospital of Muenster, Germany;
| | - Andrea Laufer
- Department of Pediatric Orthopaedics, Deformity Reconstruction and Foot Surgery, University Hospital Muenster, Germany; ,Correspondence:
| | - Adrien Frommer
- Department of Pediatric Orthopaedics, Deformity Reconstruction and Foot Surgery, University Hospital Muenster, Germany;
| | - Sebastian Appelbaum
- Department of Research Methodology and Statistics in Psychology, University of Witten/Herdecke, Germany;
| | | | - Martin Gottliebsen
- Danish Paediatric Orthopaedic Research, University Hospital Aarhus, Denmark
| | - Ole Rahbek
- Danish Paediatric Orthopaedic Research, University Hospital Aarhus, Denmark
| | | | - Robert Roedl
- Department of Pediatric Orthopaedics, Deformity Reconstruction and Foot Surgery, University Hospital Muenster, Germany;
| | - Bjoern Vogt
- Department of Pediatric Orthopaedics, Deformity Reconstruction and Foot Surgery, University Hospital Muenster, Germany;
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Assan BR, Simon AL, Adjadohoun S, Segbedji GGP, Souchet P, Metchioungbe CS, Fiogbe MA, Ilharreborde B, Gbenou AS. Guided growth vs.Tibial osteotomy at early stage of Blount disease in squelletically immature patients. J Orthop 2021; 25:140-144. [PMID: 35068774 DOI: 10.1016/j.jor.2021.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 05/02/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND There are no comparative study between guided growth and tibial osteotomy in early stage of Blount disease (BD) to our knowledge. The aim of this work was to compare the results of patients treated by these two techniques. METHOD This was a retrospective, descriptive, and analytical study over a period of 5 years in including 17 children (24 Knees) with an early stage of infantile BD in two centers. Patient were classified in two groups: group 1(treated by guided growth), group 2 (treated by Tibial Osteotomy).Preoperative alignment analysis using the tibial femoral angle (HKA) and the proximal medial tibial mechanical angle (mMPTA) were compared with three measurements taken postoperatively in each of the groups. The mean variations of the angles were compared between the two groups. RESULTS Socio-demographic characteristics were similar for the two groups. Median age at surgery was 6.5 ± 2.5 [3-9 years] in group 1 and 6.8 ± 2.9 years [3-9 years]. At a follow-up of 24 ± 3.5 months, the limb alignment was significantly corrected (1,03°/month) in group 1 (median HKA 144°-171°; p = 0,001; median MMPTA 78°-87°, p = 0,018), and in group 2 we observed at a follow-up of 23 ± 15 months a progressive loss (0,52°/month) of the correction obtained immediately postoperatively (median HKA 160°-176°(immediate post operative) to 165,5°; p = 0,31; median MMPTA = 78°-86° (immediate post operative) to 80,5°; p = 0,37).There was a statistically significant difference between the mean variation in HKA between the two groups (group 1 = 22,5; group 2 = 4,5, p = 0.00), as well as for MMPTA; (group 1 = 7; group 2 = 2,5, p = 0,023).The rate of correction was 78% in group 1 with no rebound at a median follow-up after removal of the material of 10 ± 2.4 months. Within group 2, the rate of correction was 10% with a recurrence rate of 60%. CONCLUSION Guided growth appears to be the best treatment for early stage of BD in squelletically immature patients.
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Affiliation(s)
| | - Anne-Laure Simon
- Department of Pediatric Orthopedics, Robert Debre Hospital, Paris, France
| | - Sonia Adjadohoun
- Department of Medical Imaging, National Teaching Hospital Center Hubert Koutoukou MAGA, Cotonou, Benin
| | | | - Philippe Souchet
- Department of Pediatric Orthopedics, Robert Debre Hospital, Paris, France
| | - Codjo Serge Metchioungbe
- Department of Pediatric Surgery, National Teaching Hospital Hubert Koutoukou MAGA, Cotonou, Benin
| | - Michel Armand Fiogbe
- Department of Pediatric Surgery, National Teaching Hospital Hubert Koutoukou MAGA, Cotonou, Benin
| | - Brice Ilharreborde
- Department of Pediatric Orthopedics, Robert Debre Hospital, Paris, France
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Blount's disease - an up-to-date insight with contemporary treatment guidelines deduced from critical analysis of a large 146 surgical case series. J Pediatr Orthop B 2021; 30:239-249. [PMID: 32694440 DOI: 10.1097/bpb.0000000000000769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
To elucidate an up-to-date insight and derive clear treatment guidelines for Blount's disease deduced from critical analysis of 146 surgical case series. Cases were presented and analyzed separately under its two basic clinical groups and the author further derived four subcategories under each of these two groups; the first basic group was the early onset clinical variant; infantile tibia vara (ITV) included 56 cases. The second group was the late onset clinical variant; late onset tibia vara (LOTV) included 90 cases. Different operative procedures used for treatment of these cases were proximal tibial osteotomy (PTO), temporary eight-plate proximal lateral tibial hemiepiphyseodesis (PLTH), or medial plateau elevation either on a monomodal or multimodal line of treatment. After a mean follow-up period of ~5 (2-12) years, the results were critically analyzed using case series descriptive analysis. In ITV variant, both PTO and temporary eight-plate PLTH monomodal line of treatment gave satisfactory results for de-novo (stages I, II, and III) subcategory while multimodal line of treatment was needed for achieving satisfactory results for neglected (stages IV, V, and VI) and relapsed subcategories. For LOTV variant, PTO monomodal line of treatment gave satisfactory results when applied for treatment of its de-novo subcategory. The derived treatment guidelines for Blount's disease can be of value for recruiting the most suitable treatment modality for each case entity of the disease, leading to satisfactory outcome with prevention of recurrence.
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Abstract
BACKGROUND This study aimed to determine the recurrence rate in infantile Blount disease (IBD) in a cohort of patients treated with a tibial osteotomy; and also to identify which factors were associated with recurrence. METHODS We reviewed the records of 20 patients, under the age of 7 years, with IBD (35 involved extremities) treated by proximal tibial realignment osteotomy to physiological valgus at a single institution over 4 years. We then analyzed the data to determine the rate of recurrence and identify the risk factors for recurrence. RESULTS The mean age of the included patients was 4.2 years (range, 2 to 6 y). We observed a recurrence rate of 40% (n=14) at a mean follow-up of 42 months (range, 21 to 72 mo). Knee instability [odds ratios OR, 6.6; 95% confidence interval (CI), 2.0-22.2], Langenskiöld stage (OR, 6.3; 95% CI, 2.0-19.4), and severity of the deformity, as measured by medial physeal slope (MPS) (OR, 1.2; 95% CI, 1.1-1.4), were associated with recurrence. On multiple logistic regression analysis, MPS remained the most relevant predictor of recurrence. Receiver operating curve analysis showed that an MPS ≥60 degrees predicted recurrence with a sensitivity of 79% and specificity of 95% (area under the curve=0.925). Postoperatively, increased varus alignment on weight-bearing as measured by the tibio-femoral angle was indicative of knee instability and associated with increased odds of recurrence (OR, 1.5; 95% CI, 1.1-1.9; P=0.004). CONCLUSIONS We observed a recurrence rate of 40% in children with IBD under 7 years treated with acute correction to a tibio-femoral angle of 5 to 10 degrees valgus through a dome proximal tibial osteotomy. Knee instability, Langenskiöld stage, and MPS were associated with recurrence. Cases with an MPS ≥60 degrees seem to be particularly at risk for recurrence. Further research is needed to validate these findings. LEVEL OF EVIDENCE Level IV.
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18
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Ding J, Wang F, Jin F, Wu ZK, Shen PQ. Finite element and biomechanical analysis of risk factors for implant failure during tension band plating. J Int Med Res 2020; 48:300060520972075. [PMID: 33251889 PMCID: PMC7708725 DOI: 10.1177/0300060520972075] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Objective Tension band plating has recently gained widespread acceptance as a method of
correcting angular limb deformities in skeletally immature patients. We
examined the role of biomechanics in procedural failure and devised a new
method of reducing the rate of implant failure. Methods In the biomechanical model, afterload (static or cyclic) was applied to each
specimen. The residual stress of the screw combined with different screw
sizes and configurations were measured and compared by X-ray diffraction.
With regard to static load and similar conditions, the stress distribution
was analyzed according to a three-dimensional finite element model. Results The residual stress was close to zero in the static tension group, whereas it
was very high in the cyclic load group. The residual stress of screws was
significantly lower in the convergent group and parallel group than in the
divergent group. The finite element model showed similar results. Conclusions In both the finite element analysis and biomechanical tests, the maximum
stress of the screw was concentrated at the position where the screws enter
the cortex. Cyclic loading is the primary cause of implant failure.
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Affiliation(s)
- Jing Ding
- Department of Pediatric Orthopaedics, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Fei Wang
- Department of Pediatric Orthopaedics, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Fangchun Jin
- Department of Pediatric Orthopaedics, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zhen-Kai Wu
- Department of Pediatric Orthopaedics, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Pin-Quan Shen
- Department of Pediatric Orthopaedics, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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Danino B, Rödl R, Herzenberg JE, Shabtai L, Grill F, Narayanan U, Gigi R, Segev E, Wientroub S. The efficacy of guided growth as an initial strategy for Blount disease treatment. J Child Orthop 2020; 14:312-317. [PMID: 32874365 PMCID: PMC7453169 DOI: 10.1302/1863-2548.14.200070] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 07/02/2020] [Indexed: 02/03/2023] Open
Abstract
PURPOSE The aim of this study was to evaluate the success of guided growth by temporal hemiepiphysiodesis of the lateral proximal tibia as a first line treatment option for Blount disease. METHODS This was a retrospective multicentre study conducted in five centres, covering data on 55 limbs in 45 patients, with an average follow-up of 24.5 months following plate insertion. Preoperative alignment analysis was compared with three measurements taken postoperatively. The normalization of the mechanical medial proximal tibia angle (mMPTA) was defined as the primary outcome measure. RESULTS Mean age at surgery was 9.5 years. Average preoperative mMPTA was 77°. On average, at 24.5 months post-surgery, mMPTA was 86.33°, while 43/55 limbs (78.18%) have achieved normalization (mMPTA 85° to 90°). Average rate of correction was 1° per month. When grouping the children as infantile (11 limbs), juvenile (12 limbs) and adolescent (32 limbs), operated on before the age of four years, between four and ten years and after the age of ten years, respectively, 63.63%, 66.67%, 87.5% have completed correction of deformity during the follow-up period. Interestingly, the femoral component of the deformity has achieved correction as well in 33/55 limbs (64%). CONCLUSION Hemiepiphysiodesis is an effective first line treatment for Blount disease. Overall success rate is good but varies according to child's age. Adolescent Blount has the best chance of achieving full correction while same treatment is less effective in infantile Blount.Level of evidence: IV.
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Affiliation(s)
- Barry Danino
- The Department of Pediatric Orthopaedics, Dana Children’s Hospital, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Robert Rödl
- Klinik und Poliklinik für Allgemeine Orthopädie und Tumororthopädie, Universitätsklinikum Münster, Münster, Germany
| | - John E. Herzenberg
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, USA
| | - Lior Shabtai
- Cohen Children’s Hospital, Zucker School of Medicine, New York, USA
| | - Franz Grill
- Orthopedic Hospital Speising Vienna, Vienna, Austria
| | | | - Roy Gigi
- The Department of Pediatric Orthopaedics, Dana Children’s Hospital, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eitan Segev
- The Department of Pediatric Orthopaedics, Dana Children’s Hospital, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shlomo Wientroub
- The Department of Pediatric Orthopaedics, Dana Children’s Hospital, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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The femoral deformity in Blount's disease: a comparative study of infantile, juvenile and adolescent Blount's disease. J Pediatr Orthop B 2020; 29:317-322. [PMID: 32479715 DOI: 10.1097/bpb.0000000000000722] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
An associated femoral deformity in patients with Blount's disease is not commonly described in the literature. The objective of this study is to establish the presence and magnitude of deformity in the coronal plane of the distal femur in children of all ages with Blount's disease and compare this to a matched cohort of children from the same population. This was a retrospective review of patients from an academic hospital. A control group was established by matching for age and gender from a group of unaffected patients with mid to proximal third femur fractures or controls at the same hospital. Study participants were categorized by age at onset of deformity as follows: infantile (<4 years), juvenile (4-10 years) and adolescent (>10 years). The measurements of the anatomic lateral distal femoral angle (aLDFA) were recorded and the Wilcoxon rank-sum test was used to determine statistically significant differences in the LFDA between children with Blount's disease and those without. Seventy-two Black African children were included in the study with 118 affected limbs (27 infantile, 55 juvenile and 36 adolescent). The overall average aLDFA for all patients with Blount's disease was 87° (range 73-100°). Overall, children with Blount's disease had a higher aLDFA than children without (87° vs. 82°). There was a significant association between LDFA in the control group and children with Blount's disease in each of the three groups. This study found distal femoral varus deformity to be present in all groups of children with Blount's disease. In this study population, it was most significant in the infantile and adolescent groups when compared to a control group from the same population. Although further studies are required, the surgeon must always assess the distal femoral component in treating children with Blount's disease.
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Tension Band Plate (TBP)-guided Hemiepiphysiodesis in Blount Disease: 10-Year Single-center Experience With a Systematic Review of Literature. J Pediatr Orthop 2020; 40:e138-e143. [PMID: 31022017 DOI: 10.1097/bpo.0000000000001393] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Primary treatment for Blount disease has changed in the last decade from osteotomies or staples to tension band plate (TBP)-guided hemiepiphysiodesis. However, implant-related issues have been frequently reported with Blount cases. The purpose of our study is to evaluate the surgical failure rates of TBP in Blount disease and characterize predictors for failure. METHODS We performed an Institutional Review Board-approved retrospective chart-review of pediatric patients with Blount disease to evaluate the results of TBP from 2008 to 2017 and a systematic literature review. Blount cases defined as pathologic tibia-vara with HKA (hip-knee-ankle) axis and MDA (metaphyseal-diaphyseal angle) deviations ≥11 degrees were included in the analysis. Surgical failure was categorized as mechanical and functional failure. We studied both patient and implant-related characteristics and compared our results with a systematic review. RESULTS In 61 limbs of 40 patients with mean follow-up of 38 months, we found 41% (25/61) overall surgical failure rate and 11% (7/61) mechanical failure rate corresponding to 11% to 100% (range) and 0% to 50% (range) in 8 other studies. Statistical comparison between our surgical failure and nonfailure groups showed significant differences in deformity (P=0.001), plate material (P=0.042), and obesity (P=0.044) in univariate analysis. The odds of surgical failure increased by 1.2 times with severe deformity and 5.9 times with titanium TBP in the multivariate analysis after individual risk-factor adjustment. All 7 mechanical failures involved breakage of cannulated screws on the metaphyseal side. CONCLUSIONS Most of the studies have reported high failure rates of TBP in Blount cases. Besides patient-related risk factors like obesity and deformity, titanium TBP seems to be an independent risk factor for failure. Solid screws were protective for mechanical failure, but not for functional failure. In conclusion, efficacy of TBP still needs to be proven in Blount disease and implant design may warrant reassessment. LEVEL OF EVIDENCE Level III-retrospective comparative study with a systematic review.
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Guided growth for the Treatment of Infantile Blount's disease: Is it a viable option? J Orthop 2020; 20:41-45. [PMID: 32042227 DOI: 10.1016/j.jor.2020.01.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 01/06/2020] [Indexed: 12/23/2022] Open
Abstract
Introduction Guided growth with temporary hemiepiphysiodesis has gained interest as a less invasive means for the treatment of coronal plane lower extremity deformities as well as leg length discrepancies. Its application to infantile Blount's disease has been less reported. The object of this study was to identify predictive factors of guided growth for treatment of infantile Blount's. Methods A retrospective review was performed of children undergoing guided growth for the treatment of infantile Blount's disease over an eight-year period. Inclusion criteria included treatment with THE for infantile Blount's disease. Clinical information, preoperative Langenskiold classification, and intra-operative and post-operative data. Preoperative variables were used to identify risk factors for speed of correction and the need for subsequent surgery. Results A total of 11 patients, 17 extremities, meeting inclusionary criteria. Preoperatively, 7 extremities were classified as Langenskiold stage ≥3, with 12 being classified as stage ≤2. Overall, the Drennan's angle improved from 18.3° to 0.3° by final follow-up at an average of 4.31 years. Eight extremities demonstrated deformity recurrence/persistence (stage ≤2:33% vs stage ≥3: 100%), requiring 24 reoperations. Children with Langenskiold stage ≥3 demonstrated a significantly higher rate of reoperation. Conclusion Guided growth is a viable treatment option for Infantile Blount's disease presenting with Langenskiold stage ≤2 disease at treatment initiation. The treatment course can expect a 33% rate of recurrent deformity, treated successfully with repeat THE. No child stage ≤2 required corrective osteotomy. Caution should be used when considering guided growth for children presenting with Langenskiold stage ≥3.
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Abstract
There is limited information regarding the use of temporary hemiepiphysiodesis for Blount disease. We performed a systematic review of patients treated for Blount disease using either extraperiosteal staples or plates to identify characteristics affecting clinical outcome, including the need for unplanned procedures. A total of 53 patients (63 bone segments) underwent temporary hemiepiphysiodesis at a mean age of 8.8 years (1.8-14.7 years). Overall, 32/63 (51%) segments achieved neutral mechanical axis and 31/63 (49%) underwent unplanned subsequent procedures, with or without a subsequent osteotomy. On the basis of the available heterogeneous data, neither age at index surgery nor the type of implant correlated with the need for unplanned additional surgeries.
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Rebound Deformity After Growth Modulation in Patients With Coronal Plane Angular Deformities About the Knee: Who Gets It and How Much? J Pediatr Orthop 2019; 39:353-358. [PMID: 31305378 DOI: 10.1097/bpo.0000000000000935] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND With observed success and increased popularity of growth modulation techniques, there has been a trend toward use in progressively younger patients. Younger age at growth modulation increases the likelihood of complete deformity correction and need for implant removal before skeletal maturity introducing the risk of rebound deformity. The purpose of this study was to quantify magnitude and identify risk factors for rebound deformity after growth modulation. METHODS We performed a retrospective review of all patients undergoing growth modulation with a tension band plate for coronal plane deformity about the knee with subsequent implant removal. Exclusion criteria included completion epiphysiodesis or osteotomy at implant removal, ongoing growth modulation, and <1 year radiographic follow-up without rebound deformity. Mechanical lateral distal femoral angle, mechanical medial proximal tibial angle, hip-knee-ankle angle (HKA), and mechanical axis station were measured before growth modulation, before implant removal, and at final follow-up. RESULTS In total, 67 limbs in 45 patients met the inclusion criteria. Mean age at growth modulation was 9.8 years (range, 3.4 to 15.4 y) and mean age at implant removal was 11.4 years (range, 5.3 to 16.4 y). Mean change in HKA after implant removal was 6.9 degrees (range, 0 to 23 degrees). In total, 52% of patients had >5 degrees rebound and 30% had >10 degrees rebound in HKA after implant removal. Females below 10 years and males below 12 years at time of growth modulation had greater mean change in HKA after implant removal compared with older patients (8.4 vs. 4.7 degrees, P=0.012). Patients with initial deformity >20 degrees had an increased frequency of rebound >10 degrees compared with patients with less severe initial deformity (78% vs. 22%, P=0.002). CONCLUSIONS Rebound deformity after growth modulation is common. Growth modulation at a young age and large initial deformity increases risk of rebound. However, rebound does not occur in all at risk patients, therefore, we recommend against routine overcorrection. LEVEL OF EVIDENCE Level IV-retrospective study.
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Effects of Tibial Rotational-guided Growth on the Geometries of Tibial Plateaus and Menisci in Rabbits. J Pediatr Orthop 2019; 39:289-294. [PMID: 31169748 DOI: 10.1097/bpo.0000000000001004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND There are studies on the use of oblique plate over epiphyses for rotational deformities but the effects of this method on bone are not yet known. The purpose of this study was to determine the effect and rebound effect of rotational-guided growth on the geometries of the tibial plateaus and menisci in a rabbit model of tibial axial rotation. METHODS Thirty male rabbits were 6 weeks old when medial and lateral plates were applied to the proximal tibias of the left side. After 4 weeks, 15 rabbits were euthanized (group 1), and the plates from the tibias of the remaining 15 rabbits (group 2) were removed. The rabbits in group 2 were euthanized 4 weeks later. RESULTS In the rabbits of group 1, the most striking differences were a decrease in the lateral tibial slope (from 28.3 to 10.8 degrees) and decrease in the ratio of the lateral plateau covered by the meniscus (from 71.9% to 61.3%). After removing the plates (group 2), the observed values of the rebound effects were 25.9 and 29.8 degrees for the lateral tibial slope, and 76.5% and 77.2% for the ratio of the lateral plateau covered by the meniscus. However, the meniscal geometries continued to change. CONCLUSIONS The rotational-guided growth provided by using plates caused a change in the tibial plateau geometry, and the rebound effect, except in the meniscal geometry, was observed after removing the plates in the growing period of the rabbits. Rotational-guided growth for the restoration of tibial axial rotation deformities may be suggested after determining the clinical effects of the increasing meniscal variables. LEVEL OF EVIDENCE Clinical relevance: the rotational-guided growth needs close follow-up because of possible changes in anatomy of the bone.
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Abstract
Blount disease is an asymmetrical disorder of proximal tibial growth that produces a three-dimensional deformity. Tibia vara is the main component of the deformity. Blount disease exists as two clinical variants, infantile or early-onset, and adolescent or late-onset, defined based on whether the first manifestations develop before or after 10 years of age. The pathophysiological mechanisms are unclear. In the Americas and Caribbean, Blount disease chiefly affects black obese children. Without treatment, the prognosis is often severe, particularly in the infantile form due to the development of medial tibial epiphysiodesis at about 6 to 8 years of age. In other parts of the world, the associations with black ethnicity and obesity are less obvious and the prognosis is often less severe. A consensus exists about the optimal treatment in two situations: before 4 years of age, progressive Blount disease should be corrected, preferably by a simple osteotomy; and once medial tibial epiphysiodesis has developed, both a complementary epiphysiodesis and gradual external fixator correction of the other alignment abnormalities, rotational deformity, and limb length are required. After 4 years of age, the outcome in the individual patient is difficult to predict. Magnetic resonance imaging supplies information on the morphology and vascularisation of the growth regions, thereby helping to guide treatment decisions. In the adolescent form, morbid obesity limits the treatment options. Untreated Blount disease in adults is rarely encountered. A more common occurrence is the presence of residual abnormalities at skeletal maturity in patients treated for Blount disease in childhood. Premature osteoarthritis may develop. In this situation, osteotomy may delay the need for total knee arthroplasty.
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Affiliation(s)
- Marc Janoyer
- Service de chirurgie infantile, CHU de Martinique, Maison de la femme de la mère et de l'enfant, boîte postale 632, 97261 Fort-de-France cedex, Martinique.
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Treatment failures and complications in patients with Blount disease treated with temporary hemiepiphysiodesis: a critical systematic literature review. J Pediatr Orthop B 2018; 27:522-529. [PMID: 29889697 DOI: 10.1097/bpb.0000000000000523] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
UNLABELLED This systematic review sums up the state of knowledge about complications and reasons for failure when children with Blount disease are treated with temporary hemiepiphysiodesis. Twelve studies meet the inclusion criteria. The main reported obstacles were under correction and the poor predictability of the amount of correction that was obtainable. Obese patients with severe deformity are the most challenging groups of patients in the treatment of angular deformities. Patients with Blount disease require a careful evaluation regarding the deformity, age, body weight, and social background to reach the optimal treatment strategy. If hemiepiphysiodesis fails, osteotomy remains the preferred salvage procedure. LEVEL OF EVIDENCE IV.
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Abstract
Although the core principles of managing infantile Blount disease generally remain unchanged, treatment modalities have evolved over the years. Consensus has yet to be reached regarding the efficacy of bracing. Children with Blount disease commonly have advanced bone age, which may impact the timing and magnitude of (over) correction of angular deformity. Techniques of growth modulation, based on the tension band principle, continue to gain popularity. Although there are limited reports in the last decade on proximal tibial osteotomy for this developmental disorder, both acute and gradual correction remain viable treatment options in the appropriate setting. In certain older children (>7 y old) with advanced stages of the disease, a medial hemiplateau elevation combined with lateral proximal tibial hemiepiphysiodesis may be needed to address the epiphyseal deformity. Given the possibility of unpredictable proximal tibial physeal activity, all children with Blount disease should be followed at regular intervals till skeletal maturity. To provide sufficient granularity for pooled analyses and help establish evidence-based clinical guidelines, standardization of reporting clinical outcomes among children with Blount disease is encouraged.
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Wu Z, Ding J, Zhao D, Zhao L, Li H, Liu J. Multiplier method may be unreliable to predict the timing of temporary hemiepiphysiodesis for coronal angular deformity. J Orthop Surg Res 2017; 12:104. [PMID: 28693513 PMCID: PMC5504749 DOI: 10.1186/s13018-017-0604-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2017] [Accepted: 06/18/2017] [Indexed: 11/23/2022] Open
Abstract
Background and purposes The multiplier method was introduced by Paley to calculate the timing for temporary hemiepiphysiodesis. However, this method has not been verified in terms of clinical outcome measure. We aimed to (1) predict the rate of angular correction per year (ACPY) at the various corresponding ages by means of multiplier method and verify the reliability based on the data from the published studies and (2) screen out risk factors for deviation of prediction. Methods A comprehensive search was performed in the following electronic databases: Cochrane, PubMed, and EMBASE™. A total of 22 studies met the inclusion criteria. If the actual value of ACPY from the collected date was located out of the range of the predicted value based on the multiplier method, it was considered as the deviation of prediction (DOP). The associations of patient characteristics with DOP were assessed with the use of univariate logistic regression. Results Only one article was evaluated as moderate evidence; the remaining articles were evaluated as poor quality. The rate of DOP was 31.82%. In the detailed individual data of included studies, the rate of DOP was 55.44%. Conclusion The multiplier method is not reliable in predicting the timing for temporary hemiepiphysiodesis, even though it is prone to be more reliable for the younger patients with idiopathic genu coronal deformity.
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Affiliation(s)
- Zhenkai Wu
- Department of Pediatric Orthopaedics, Xin-Hua Hospital affiliated to Shanghai Jiao Tong University School of Medicine, No. 1665, Kongjiang Road, Shanghai, 200092, China
| | - Jing Ding
- Department of Pediatric Orthopaedics, Xin-Hua Hospital affiliated to Shanghai Jiao Tong University School of Medicine, No. 1665, Kongjiang Road, Shanghai, 200092, China
| | - Dahang Zhao
- Department of Pediatric Orthopaedics, Xin-Hua Hospital affiliated to Shanghai Jiao Tong University School of Medicine, No. 1665, Kongjiang Road, Shanghai, 200092, China
| | - Li Zhao
- Department of Pediatric Orthopaedics, Xin-Hua Hospital affiliated to Shanghai Jiao Tong University School of Medicine, No. 1665, Kongjiang Road, Shanghai, 200092, China. .,Department of Pediatric Orthopaedics, Ying-Hua Medical Group of Bone and Joint Healthcare in Children, No. 358, Haibo Road, Shanghai, 200000, China.
| | - Hai Li
- Department of Pediatric Orthopaedics, Xin-Hua Hospital affiliated to Shanghai Jiao Tong University School of Medicine, No. 1665, Kongjiang Road, Shanghai, 200092, China
| | - Jianlin Liu
- Department of Pediatric Orthopaedics, Xin-Hua Hospital affiliated to Shanghai Jiao Tong University School of Medicine, No. 1665, Kongjiang Road, Shanghai, 200092, China
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Abstract
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.
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Affiliation(s)
- John A. Heflin
- University of Utah School of Medicine Department of Orthopaedics, Salt Lake City, UT
- Correspondence: John A. Heflin, University of Utah School of Medicine Department of Orthopaedics, Primary Childrens Hospital, 100 N Mario Capecchi Dr, Suite 4550, Salt Lake City, UT 84113 (e-mail: )
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Growth Retardation (Hemiepiphyseal Stapling) and Growth Acceleration (Periosteal Resection) as a Method to Improve Guided Growth in a Lamb Model. J Pediatr Orthop 2016; 36:362-9. [PMID: 27159337 DOI: 10.1097/bpo.0000000000000459] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Guided growth corrects pediatric limb deformity by inhibiting growth on the convexity of the bone. Both modular and rigid implants have been used; we endeavor to determine whether a clear advantage of one implant exists. We further hypothesize that improved correction could be realized by accelerating growth with resection of the periosteum. METHODS Sixteen lambs underwent guided growth of the medial proximal tibia (the opposite limb served as a control). Group 1 used a rigid staple (n=5); group 2 a modular plate and screw construct (n=5), and group 3 had a similar device plus periosteal resection (n=6). Radiographs tracked the progression of deformity in the coronal plane. Before sacrifice, pulsed fluorochrome labels allowed for temporal and spatial growth rate analysis. At sacrifice, True Deformity was calculated (and compared with control tibia) from standardized radiographs in the coronal and sagittal planes. Device Efficiencies were normalized by dividing True Deformity produced (degrees) by the Expected Growth gain (mm) from the control limb. RESULTS Group 3 produced greater coronal plane deformity than group 1 by an average of 2.2 degrees per month (P=0.001) and group 2 by an average of 2.4 degrees per month (P=0.0007). At sacrifice, groups 1 and 2 were equally effective at limiting growth to 75% of control; no differences in growth retardation were noted. No differences in Device Efficiency were noted between groups 1 and 2. The Device Efficiency was significantly different between groups 1 and 2 with comparison with group 3 (P=0.05 and P=0.022); with a 2.5 degree/mm faster deformation in the stripped cohort. CONCLUSIONS Rigid implants initially produced deformity quicker than modular constructs; yet ultimately, both implants were equally effective at guiding growth. Device Efficiency for the modular group improved significantly with the addition of periosteal stripping as method to accelerate growth.
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Cobanoglu M, Cullu E, Kilimci FS, Ocal MK, Yaygingul R. Rotational deformities of the long bones can be corrected with rotationally guided growth during the growth phase. Acta Orthop 2016; 87:301-5. [PMID: 26900795 PMCID: PMC4900079 DOI: 10.3109/17453674.2016.1152450] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Background and purpose - Coronal and sagittal plane long bone deformities can be corrected with guided growth, whereas transverse plane rotational deformities require osteotomy and internal or external fixation. We investigated whether rotational changes can be introduced with the plating technique. Methods - 45 rabbits (6 weeks old) were divided into 3 groups. The unoperated right tibia was used as control. In groups 1 and 3, two plates were placed obliquely to the long axis and in different directions. In group 2, a sham operation was performed with screws. Animals in groups 1 and 2 were followed for 4 weeks. In group 3 the implants were removed 4 weeks after the operation to observe rebound effect, and the animals were followed for another 4 weeks. The tibial torsion was assessed on computed tomography (CT). External rotation was accepted as a negative value. Results - In group 1, mean torsion was -20° (SD 7.9) in the right tibia and -2.9° (SD 7.2) in the left tibia (p < 0.001). In group 2, mean torsion was -23° (SD 4.9) in the right tibia and -26° (SD 6.5) in the left tibia (p = 0.2). In group 3, mean torsion was -21° (SD 6.3) in the right tibia and -9.5° (SD 5.3) in the left tibia (p < 0.001). Intergroup evaluation for left torsion showed a significant difference between group 2 and the other groups (p < 0.001). When the rebound effect was evaluated, there was no statistically significant difference between groups 1 and 3 (p = 0.08). Interpretation - A rotational change was attained with this technique. Although a rebound effect was seen after implant removal, it did not reach statistical significance. The final rotational change remained constant.
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Affiliation(s)
- Mutlu Cobanoglu
- Department of Orthopedics and Traumatology, Faculty of Medicine,,Correspondence:
| | - Emre Cullu
- Department of Orthopedics and Traumatology, Faculty of Medicine,
| | | | | | - Rahime Yaygingul
- Department of Surgery, Faculty of Veterinary Medicine, Adnan Menderes University, Aydın, Turkey
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Abstract
Blount disease is a developmental disorder associated with childhood obesity. Based on whether the deformity is first noted before or after 4 years of age, early-onset and late-onset forms of Blount disease have been described. Besides physeal abnormalities of the proximal tibia, compensatory changes in the intra-articular morphology of the medial compartment of the affected knee are often noted on MRI scan. Both guided growth and acute and gradual correction via a proximal tibial osteotomy have roles in the surgical management of these patients. In order to optimize clinical outcome, frequent follow-up until skeletal maturity is recommended.
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Affiliation(s)
- Sanjeev Sabharwal
- Division of Pediatric Orthopedics, Department of Orthopedics, Rutgers New Jersey Medical School, 90 Bergen Street, DOC 7300, Newark, NJ 07103, USA.
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Determining the best treatment for coronal angular deformity of the knee joint in growing children: a decision analysis. BIOMED RESEARCH INTERNATIONAL 2014; 2014:603432. [PMID: 25276801 PMCID: PMC4167958 DOI: 10.1155/2014/603432] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Accepted: 08/11/2014] [Indexed: 01/28/2023]
Abstract
This study aimed to determine the best treatment modality for coronal angular deformity of the knee joint in growing children using decision analysis. A decision tree was created to evaluate 3 treatment modalities for coronal angular deformity in growing children: temporary hemiepiphysiodesis using staples, percutaneous screws, or a tension band plate. A decision analysis model was constructed containing the final outcome score, probability of metal failure, and incomplete correction of deformity. The final outcome was defined as health-related quality of life and was used as a utility in the decision tree. The probabilities associated with each case were obtained by literature review, and health-related quality of life was evaluated by a questionnaire completed by 25 pediatric orthopedic experts. Our decision analysis model favored temporary hemiepiphysiodesis using a tension band plate over temporary hemiepiphysiodesis using percutaneous screws or stapling, with utilities of 0.969, 0.957, and 0.962, respectively. One-way sensitivity analysis showed that hemiepiphysiodesis using a tension band plate was better than temporary hemiepiphysiodesis using percutaneous screws, when the overall complication rate of hemiepiphysiodesis using a tension band plate was lower than 15.7%. Two-way sensitivity analysis showed that hemiepiphysiodesis using a tension band plate was more beneficial than temporary hemiepiphysiodesis using percutaneous screws.
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Sabharwal S, Fragomen A, Iobst C. What's new in limb lengthening and deformity correction. J Bone Joint Surg Am 2013; 95:1527-34. [PMID: 23965706 DOI: 10.2106/jbjs.m.00599] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Sanjeev Sabharwal
- Department of Orthopedics, UMDNJ-New Jersey Medical School, Newark, NJ 07103, USA.
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Abdelgawad AA. Combined distal tibial rotational osteotomy and proximal growth plate modulation for treatment of infantile Blount’s disease. World J Orthop 2013; 4:90-93. [PMID: 23610758 PMCID: PMC3631958 DOI: 10.5312/wjo.v4.i2.90] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2012] [Revised: 01/04/2013] [Accepted: 01/21/2013] [Indexed: 02/06/2023] Open
Abstract
Infantile Blount’s disease is a condition that causes genu varum and internal tibial torsion. Treatment options include observation, orthotics, corrective osteotomy, elevation of the medial tibial plateau, resection of a physeal bar, lateral hemi-epiphysiodesis, and guided growth of the proximal tibial physis. Each of these treatment options has its disadvantages. Treating the coronal deformity alone (genu varum) will result in persistence of the internal tibial torsion (the axial deformity). In this report, we describe the combination of lateral growth modulation and distal tibial external rotation osteotomy to correct all the elements of the disease. This has not been described before for treatment of Blount’s disease. Both coronal and axial deformities were corrected in this patient. We propose this combination (rather than the lateral growth modulation alone) as the method of treatment for early stages of Blount’s disease as it corrects both elements of the disease and in the same time avoids the complications of proximal tibial osteotomy.
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Landauer F, Huber G, Paulmichl K, O'Malley G, Mangge H, Weghuber D. Timely diagnosis of malalignment of the distal extremities is crucial in morbidly obese juveniles. Obes Facts 2013; 6:542-51. [PMID: 24335156 PMCID: PMC5644752 DOI: 10.1159/000357280] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Accepted: 06/26/2013] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND/AIMS To determine i) whether obesity in childhood can be related to malalignment of the distal extremities, ii) the proportion of genu valgum malalignment and abduction setting, and iii) the respective deviation dominance in children who are morbidly obese. METHODS 31 morbidly obese Caucasian children (16 males) recruited for the STYJOBS Study (ClinicalTrials.gov Identifier NCT00482924) with a mean age of 13.9 ± 0.5 years, a mean height of 162.3 ± 2.7 cm, a mean weight of 90.62 ± 5.0 kg, and a mean BMI of 33.8 ± 1.2 kg/m(2) were clinically examined using the Mikulicz line in order to assess load distribution on the knee joint. 21 participants received a whole-leg X-ray because of a clinically estimated malalignment. RESULTS 8/31 participants examined were diagnosed with genu valgum, 1/31 with genu varum, and 22/31 did not have any malalignment of the femur or tibia. The majority of genu valgum presentation was due to femoral deviation. Of those without malalignment, 4/22 participants had an abduction setting, while 2/22 showed an adduction of the leg. CONCLUSION Genu valgum as a predominant malalignment of the distal extremities is frequent in youth with morbid obesity. Timely guided correction of angular deformity of the knee seems pivotal in order to avoid osteotomy or osteoarthritis later in life.
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Affiliation(s)
| | - Gerda Huber
- Department of Pediatrics, Paracelsus Medical University, Salzburg, Austria, Graz, Austria
| | - Katharina Paulmichl
- Department of Pediatrics, Paracelsus Medical University, Salzburg, Austria, Graz, Austria
| | - Grace O'Malley
- Department of Endocrinology and Physiotherapy, Temple Street Children's University Hospital, Dublin, Ireland, Graz, Austria
| | - Harald Mangge
- Clinical Institute of Medical and Chemical Laboratory Diagnosis, Medical University of Graz, Graz, Austria
| | - Daniel Weghuber
- Department of Pediatrics, Paracelsus Medical University, Salzburg, Austria, Graz, Austria
- *Dr. Daniel Weghuber, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Paracelsus Medical University, Müllner Hauptstraße 48, 5020 Salzburg (Austria),
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