CORR Insights®: Periosteal Fiber Transection During Periosteal Procedures Is Crucial to Accelerate Growth in the Rabbit Model.

Abstract

W e know that excessive compressive forces across a physis can inhibit growth [1, 5], while tensile forces may cause growth stimulation. The role of the periosteum as a potential ‘‘tether’’ to the adjacent growth plate has been speculated in previous studies [8, 11]. Furthermore, clinical investigators have implicated the torn (‘‘untethered’’) periosteum as a contributor to limb overgrowth following a pediatric femoral shaft fracture and asymmetric medial physeal growth leading to genu valgum after certain proximal tibial fractures in young children [2, 3, 9]. Although studies have shown that leglength discrepancy can be addressed by transecting or stripping the periosteum of the shorter limb in young patients [4, 6, 8, 10], I believe that few surgeons currently apply these principles in clinical practice. Perhaps due to the reported unpredictability [10] and the lack of robust basic-science support, this seemingly straightforward method of growth stimulation of the short leg has not gained the popularity enjoyed by surgical alternatives, such as gradual lengthening or a contralateral epiphysiodesis. Additionally, it is currently unknown whether the various purported methods of untethering the periosteum are equally effective in inducing and sustaining growth stimulation of the affected extremity. In this well-designed animal study, Halanski and colleagues have dug deeper and studied the effects of four distinct methods of periosteal release on the growth rates and lengths of tibiae in skeletally immature rabbits. They found that simply stripping the periosteum around the proximal tibial metaphysis without transection of the longitudinal fibers did not enhance growth, while circumferentially transecting the periosteum, (with or without its removal) does stimulate growth at the proximal and distal tibial physes, as noted 2 weeks posto peratively. Although this growth stimulation was not sustained 8 weeks after surgery at the proximal tibial physis in the animals undergoing a one-time release, repeat transection at 4 weeks postoperatively seemed to reignite the physis. This latter group of This CORR Insights is a commentary on the article ‘‘Periosteal Fiber Transection During Periosteal Procedures Is Crucial to Accelerate Growth in the Rabbit Model’’ by Halanski and colleagues available at: DOI: 10.1007/ s11999-015-4646-6. The author certifies that he, or any member of his immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/ licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR or The Association of Bone and Joint Surgeons. This CORR Insights comment refers to the article available at DOI: 10.1007/s11999015-4646-6. S. Sabharwal MD, MPH (&) Department of Orthopedics, Rutgers New Jersey Medical School, 90 Bergen Street, Suite 7300, Newark, NJ 07103-2499, USA e-mail: sabharsa@njms.rutgers.edu CORR Insights Published online: 4 January 2016 The Association of Bone and Joint Surgeons1 2015