Open Epiphyses Research Articles

DIAGNOSTIC IMAGING AND OROTRACHEAL INTUBATION IN CLINICALLY HEALTHY WILD SUNDA PANGOLINS (MANIS JAVANICA) IN SINGAPORE.

Pangolins are amongst the most overexploited species in the world and all eight species of pangolins are threatened with extinction. These animals are rare in zoological collections and often suffer high mortality rates in captivity. Maintaining healthy populations in captivity has become more important with the declining populations in the wild, but knowledge of veterinary care of these animals is limited. Interpreting radiography and ultrasonography images in a patient can be challenging without knowledge of normal findings. The Wildlife Healthcare and Research Center (WHRC) at Mandai Wildlife Reserve (MWR) admits an average of 25 Sunda pangolins (Manis javanica) annually, which is a Critically Endangered species native to Singapore. All the pangolins are triaged on admission and anesthetized for a health assessment before release into the wild. Endotracheal intubation using an otoscope and stylet is a novel technique in the species that has been developed and is commonly performed with these pangolins. A retrospective study was done on 20 clinically healthy wild pangolins to determine normal ultrasonography and radiography findings in the species. Notable findings include the presence of radio-opaque particles in the stomachs of all pangolins, the presence of free fluid cranial to the left kidney (13/20), a spleen with multifocal hypoechoic regions (6/20), and open epiphyseal plates of long bones even in large individuals weighing as heavy as 6.8 kg. Ultrasonographic images and measurements of kidney, spleen, and adrenal gland sizes as well as intestinal, gallbladder, and urinary bladder wall thickness were also described. These diagnostic imaging findings can advance the veterinary care of captive and wild pangolins.

Growth-related changes in the ultrastructure of the quadriceps tendon

BackgroundThe purpose of this study was to investigate the effect of growth on the ultrastructural characteristics of the quadriceps tendon (QT). MethodsEighteen included patients were classified into three groups based on age and epiphyseal plate condition: the ‘immature group’ consisted of patients with open epiphyseal plates (11.5 ± 1.6 years old; mean ± standard deviation), the ‘young group’ consisted of patients aged <20 years with closed epiphyseal plates (15.8 ± 1.0 years), and the ‘adult group’ consisted of all patients aged >20 years (29.8 ± 11.3 years) irrespective of epiphyseal plate condition. Tendon tissue samples were used for ultrastructural analysis by transmission electron microscopy. Minimum collagen fibril diameters were measured from the cross sections of collagen fibril images using Image J software. The average number of collagen fibers per sample was 797 ± 109, and the average collagen fibril diameter of each sample was compared using one-way analysis of variance. ResultsThe mean collagen fibril diameter was 89.7 ± 14.4 nm in the immature group, 94.8 ± 16.4 nm in the young group, and 107.2 ± 12.1 nm in the adult group, with significant differences between the immature and adult groups, and between the young and adult groups (P = 0.001 and P = 0.021, respectively); however, no significant differences were observed between the immature and young adult groups (P = 0.49). ConclusionsThe collagen fibril diameter of the QT was found to have increased with growth. The study provided insights into graft selection.

Vosoritide in achondroplasia: a profile of its use

Subcutaneous vosoritide (Voxzogo®), a modified recombinant human C-type natriuretic peptide (CNP) analogue, is the first precision therapy approved for the treatment of achondroplasia in the EU, USA and multiple other countries. It is indicated for patients aged ≥ 2 years with open epiphyses in the EU and those aged ≥ 5 years with open epiphyses in the USA. In a phase 3 trial (study 111-301), vosoritide 15 μg/kg/day significantly improved annualized growth velocity and height Z-score compared with placebo, without worsening upper-to-lower body segment ratio in children with achondroplasia. The growth-promoting effects of vosoritide persisted with continued treatment for up to 60 months. Vosoritide is generally well tolerated, with most adverse events being mild in severity. Longer-term safety data revealed no new safety signals. Achondroplasia is the most common form of skeletal dysplasia and is characterized by short stature with disproportionate bone growth. The condition is caused by a gain-of-function mutation in the gene for fibroblast growth factor receptor 3 (FGFR3), which is a negative regulator of bone growth. With increased understanding of the pathogenesis of achondroplasia, vosoritide (Voxzogo®), a modified recombinant human C-type natriuretic peptide (CNP) analogue, has been approved as the first precision therapy for the treatment of achondroplasia in patients aged ≥ 2 years with open epiphyses in the EU and those aged ≥ 5 years with open epiphyses in the USA. In children with achondroplasia, daily subcutaneous administration of vosoritide was associated with growth-promoting effects. Vosoritide is generally well tolerated, with most adverse events being mild in severity. Thus, vosoritide is a valuable, effective and generally well-tolerated treatment option for children with achondroplasia.

FDA approves Voxzogo for children, first drug to improve growth in most common form of dwarfism

In November 2021, the U.S. Food and Drug Administration (FDA) approved Voxzogo (vosoritide) injection to improve growth in children 5 years of age and older with achondroplasia and open epiphyses (growth plates), meaning these children still have the potential to grow. Achondroplasia is the most common form of dwarfism.

Nonvascularized Free Toe Phalangeal Transfers in Congenital Hand Differences: Radiological, Functional, and Patient/Parent-Reported Outcomes

To evaluate radiologically, functionally and by patient-reported outcome measures, nonvascularized free toe phalangeal transfer (NVFTT) in the reconstruction of congenital short fingers with redundant soft tissue. Nineteen children who underwent NVFTT in 40 digits were studied. Of these, 13 patients with a mean follow-up of 5.2 years were assessed radiologically for epiphyseal patency, growth, growth rate, and length comparison with the contralateral toe. Eight children were available for an in-person follow-up. In these patients, we measured the pinch strength and range of motion. The Pediatric Outcomes Data Collection Instrument; the upper extremity, depression, anxiety, pain interference, and peer relationships domains of the Patient-Reported Outcomes Measurement Information Systems; and the aesthetic component of the Michigan Hand Questionnaire were used for the assessment of psychosocial impact. An open epiphysis was found in 24 of 31 grafts. Among these, 20 of 21 grafts were in 9 children younger than 18 months and 4 of 10 grafts were in children older than 18 months at the time of operation. The mean growth was 3.4 mm. The mean growth rate was 1.3 mm/y. Length was 71.8% of the contralateral phalanx. The key pinch strength was 1.3 kg (2.6 kg on the normal side). The mean range of motion at the metacarpophalangeal joint was-4° to 65° flexion. Two proximal interphalangeal joints were stiff and 2 had range of motion of 0° to 30°. Children evaluated with Pediatric Outcomes Data Collection Instrument had high mean scores in all domains. The Patient-Reported Outcomes Measurement Information Systems scores were low for the upper-extremity domain. On the aesthetic component of the Michigan Hand Questionnaire, children gave higher scores than parents. Donor toes, though short, did not cause a functional disability. NVFTT reliably provides length, stability, and movement in short fingers with redundant soft tissue. In addition to good radiological and clinical outcomes, the patient-reported outcome measures support performing NVFTT in children. Surgery before 18 months, extraperiosteal harvests of grafts, and avoidance of tight skin closures are important. Therapeutic IV.

Evaluation of Quadriceps Strength Post-medial Patellofemoral Ligament Reconstruction Using Quadriceps Tendon Autografts

BACKGROUND: Medial patellofemoral ligament (MPFL) reconstruction using quadriceps tendon (QT) grafts provides favorable results with minimal complications and can be performed in patients with open epiphyseal plates. Following MPFL reconstruction using QT grafts, the outcomes have been evaluated, but the residual quadriceps strength (QS) has never been evaluated.&#x0D; AIM: We analyzed the knee’s range of motion (ROM), thigh circumference (TC), and QS at donor leg sites compared with those at contralateral healthy sites after MPFL reconstruction. The hypothesis was that there is no morbidity at donor sites.&#x0D; MATERIALS AND METHODS: Patients who underwent MPFL reconstruction using QT autografts between January and December 2017 were recruited. The ROM, TC, and QS were measured 6 months postoperatively.&#x0D; RESULTS: Twenty-one patients (8 men, 14 women; mean age, 28.40 ± 10.78 years [range, 16–45]) were included in the study. The TCs at the donor and contralateral sites (medians: 37 and 37.5 cm, respectively) showed no significant difference (p = 0.64). QS measurements showed means of 182 ± 4.6 N and 190 ± 4.7 N at the donor and contralateral sites, respectively (p = 0.376). There were no ROM deficits.&#x0D; CONCLUSIONS: The ROM, TC, and QS at donor sites were similar to those at contralateral sites. The QT is a suitable graft for MPFL reconstruction.

All-Epiphyseal Double-Bundle Anterior Cruciate Ligament Reconstruction for Skeletally Immature Patients

The number of anterior cruciate ligament (ACL) reconstructions in skeletally immature patients has been gradually increasing in recent years owing to the poor outcomes of conservative treatment. However, ACL reconstruction in children is a challenging procedure and may lead to severe complications, such as growth disturbance. Although double-bundle (DB) ACL reconstructions are preferable because of their superior clinical outcomes, there are few reports of DB ACL reconstruction in children with open epiphyses. In this Technical Note, an all-epiphyseal sparing DB ACL reconstruction technique, which is considered to help avoid growth disturbance, is described. This procedure does not create a thick tunnel and may facilitate subsequent revision surgery.

Intramedullary compression screw fixation of metacarpal and phalangeal fractures.

The intramedullary headless compression screw (IMCS) technique represents a reliable alternative to percutaneous Kirschner-wire and plate fixation with minimal complications.Transverse fractures of the metacarpal shaft represent a good indication for this technique. Non-comminuted subcapital and short oblique fractures can also be treated with IMCS.This technique should not be used in the presence of an open epiphysis, infection and, most of all, in subchondral fractures, because of the lack of purchase for the head of the screw.A double screw construct is recommended for comminuted subcapital fractures of the metacarpal to avoid metacarpal shortening. IMCS can even be applied for peri-articular fractures of the proximal third of the phalanx and in some multi-fragmentary proximal and middle phalangeal fractures.Usually the intramedullary screws are not removed. The main indications for screw removal are joint protrusion, infection and screw breakage after new fracture.Cite this article: EFORT Open Rev 2020;5:624-629. DOI: 10.1302/2058-5241.5.190068

Ankle fractures in children and adolescents

In children and adolescents, injuries of the ankle are seen frequently in routine practice. The fracture pattern is less dependent on the mechanism of injury than on the maturity of the growth plate. Therefore, adifferentiation is made between fractures with open epiphyses and fractures with aclosing growth plate in adolescents. The potential for growth-related spontaneous deformity correction is limited, so axial alignment especially in the frontal plane has to be achieved during initial treatment. In displaced articular fractures an anatomical reconstruction of the articular surface and stable osteosynthesis have to be achieved to minimize the risk of early osteoarthritis. Growth arrest is not always avoidable despite an ideal reconstruction and can occur in all fracture types; however, with optimal conservative or surgical treatment, iatrogenic damage of the epiphysis can be avoided thereby reducing the incidence of growth disorders as acomplication of ankle fractures in children and growing adolescents.

The Oxford Spherical Mill for Metaphyseal Debridement in Open Epiphyseal Reduction and Internal Fixation for Slipped Capital Femoral Epiphysis

Slipped capital femoral epiphysis (SCFE) is an adolescent hip disorder characterized by displacement of the proximal femoral epiphysis relative to the metaphysis. The aim of treatment is to stabilize the proximal epiphysis, avoid further displacement and prevent femoral head osteonecrosis. Open reduction and internal fixation is often required to treat chronic and severe SCFE, typically using a Modified Dunn procedure. This allows anterior access to the proximal femur, epiphyseal mobilization and metaphyseal debridement of cervical callus. Debriding the cervical callus concentrically to allow accurate relocation of the epiphysis on the metaphysis can be challenging. This article describes the benefits of using the Oxford Spherical Mill from a partial knee replacement system to assist with metaphyseal debridement during open epiphyseal reduction and internal fixation for SCFE.

Recombinant parathyroid hormone for hypoparathyroidism in children: a narrative review.

The conventional management of hypoparathyroidism in children involves the use of calcium and vitamin D analogs. This therapy effec-tively increases the serum calcium levels but worsens hypercalciuria and its consequences such as nephrocalcinosis and renal insuffi-ciency. Although replacement with the missing parathyroid hormone (PTH) is ideal and available for more than 2 decades, the reported concerns of osteosarcoma prohibited its use in children with open epiphyses. Nevertheless, the data accumulated over the past several years suggests that the fears of bone malignancies were probably overstated. With an aim to review the available data on recombinant PTH (rhPTH) use, we performed a literature search using international databases and identified 15 studies involving approximately 70 children with hypoparathyroidism due to various etiologies who received rhPTH1-34 for durations between 1 day and 13.5 years. All the studies appear to indicate that rhPTH1-34 therapy is an effective short and long-term strategy for treatment of hypoparathyroidism with better metabolic control, lesser effects on renal function and improved quality of life as compared to conventional therapy. A more significant conclusion is the safety of long-term use of rhPTH1-34 with no observed adverse skeletal effects so far. However, all studies mention the importance of a continued surveillance for adverse effects in the treated patients. This narrative review discusses the experi-ence of rhPTH1-34 use exclusively in children.

In vivo ultrasonic evaluation of distal part of radius in their early teens

For the evaluation of small radius of early teens, we have improved the ultrasonic bone measurement system, LD-100 (OYO electric)1, which can evaluate the distal 5.5 % site of the radius of the non-dominant hand. The system measures two longitudinal waves (fast and slow waves) which propagate in the inside cancellous bone. We can also obtain the spatial distribution of wave attenuation during propagation in bone, which can be presented as an attenuation map. In our present teen’s bone evaluation project (ages 12-18, n = 971), we found an open epiphysis at the distal end of radius in some attenuation maps of early teens. The area seems to be the growth plate, which have the ability to lengthen the bone by creating new cartilage within the bone itself. In case of boys, the plates were found at the age of 14 or less. The values of body weights and heights of the teens with the growth plates were smaller than the average, telling that they are growing up. These results show the possibility of growth evaluation using ultrasound techniques. 1. H. Sai, et al., Osteoporos Int. (2010) 21:1781–1790.

The functional reconstruction of medial patellofemoral ligament for Habitual patellar dislocation with open epiphysis

The functional reconstruction of medial patellofemoral ligament for Habitual patellar dislocation with open epiphysis

SUPRACONDYLAR FRACTURE FEMUR

Objectives: Our experience by dynamic condylar screw in the treatment ofsupracondylar femur fracture, which is quite a long time, has stayed challengeable issue inorthopedic surgery, at LUH. Study Design: An observational cross sectional study. Setting:Orthopedic Surgery Department, Liaquat University. Methodology: Cases along both sexeswith additional articular fractures, conceded inside of 2-3 days were incorporate and caseshaving open epiphysis, open fracture, pathological and intra articular fractures were not a pieceof this study. Hospital stay average was 18 days. Follow up was done of every one of thePatients after each third week for two only visits, then every 6th week for about 6 months. Allthe data were recorded on particularly outlined proforma. Results: In this study 19(63.3%) maleand 11 female (36.6%) patients. Mean age was found 35yrs. Commonest cause of injury wasRTA in 80% patients. 65% patients got injury to left lower limb while 35% to right lower limb. Therewere only two infections i.e. the infection rate was 6.66%. Union rate was 93.3% and nonunionrate was 3.3% and there was only one mal union i.e. mal union rate was 3.3% .Bone grafting wasdone in 21 patients. The overall good to excellent results were in 84% cases and fair to poor in16% cases. Conclusions: DCS gives solid fractures fixation after decrease and makes postoperativerecovery simple, so in light of patient’s financial state in Pakistan. DCS is perfect insertfor distal femoral exceptionally for these fractures.

English

Objectives: Our experience by dynamic condylar screw in the treatment ofsupracondylar femur fracture, which is quite a long time, has stayed challengeable issue inorthopedic surgery, at LUH. Study Design: An observational cross sectional study. Setting:Orthopedic Surgery Department, Liaquat University. Methodology: Cases along both sexeswith additional articular fractures, conceded inside of 2-3 days were incorporate and caseshaving open epiphysis, open fracture, pathological and intra articular fractures were not a pieceof this study. Hospital stay average was 18 days. Follow up was done of every one of thePatients after each third week for two only visits, then every 6th week for about 6 months. Allthe data were recorded on particularly outlined proforma. Results: In this study 19(63.3%) maleand 11 female (36.6%) patients. Mean age was found 35yrs. Commonest cause of injury wasRTA in 80% patients. 65% patients got injury to left lower limb while 35% to right lower limb. Therewere only two infections i.e. the infection rate was 6.66%. Union rate was 93.3% and nonunionrate was 3.3% and there was only one mal union i.e. mal union rate was 3.3% .Bone grafting wasdone in 21 patients. The overall good to excellent results were in 84% cases and fair to poor in16% cases. Conclusions: DCS gives solid fractures fixation after decrease and makes postoperativerecovery simple, so in light of patient’s financial state in Pakistan. DCS is perfect insertfor distal femoral exceptionally for these fractures.

Sliding osteotomy of the tibial tuberosity in patellofemoral instability

The development of a stable patellofemoral joint by distal realignment with normal positioning of the patella. Patellofemoral instability with increased tibial tubercle to trochlear groove (TT-TG) distance ≥ 20 mm and higher Caton-Deschamps patellar height index ≥ 1.3. Open epiphyseal and apophyseal plates of the proximal tibia, normal TT-TG distance with normal patellar height, and high-grade chondral lesions of the patellofemoral joint (ICRS grades 3 and 4). Examination of the knee joint under anesthesia and evaluation of stability and mediolateral translation of the patella. Diagnostic knee arthroscopy and treatment of chondral or osteochondral lesions. Lateral approach to the tibial tuberosity with soft tissue mobilization and exposure of the patellar tendon. Osteotomy is performed in the frontal plane, creating a fragment at least 6 cm long. The tuberosity is slid into the desired position, medially and distally, if necessary, according to preoperative analysis and planning, followed by careful drilling of the posterior tibial cortex and lag screw osteosynthesis. Partial weight-bearing of 20 kg in a MECRON knee brace for 6 weeks. Mobilization 0/0/90° from the MECRON knee brace without active knee extension. Isometric training of the thigh muscles with the knee fully extended. With meticulous planning and implementation, and in cases of severe trochlear dysplasia combined with medial patellofemoral ligament reconstruction, the technique of sliding osteotomy of the tibial tuberosity has a high success rate.

Childhood trauma: Methods for the identification of physeal fractures in nonadult skeletal remains.

Today, fractures at the growth plate (or physis) are common injuries in children, but provide challenges of identification in skeletonized remains. Clinical studies provide detailed information on the mechanisms, locations, age of occurrence, and complications associated with physeal fractures, enabling the development of new criteria for identifying this injury in nonadults. To test these criteria, skeletal remains from five rural and urban medieval cemeteries were examined. The sample consisted of 961 skeletons (0-17 years) with open epiphyses. Macroscopic observation looked for any irregularities of the metaphysis or epiphysis, which was consistent with the clinical appearance of physeal fractures or resulting complications. Radiographic examination was applied to identify fracture lines or early growth arrest. This study revealed 12 cases of physeal trauma (1.2%). Physeal fractures occurred predominantly at the distal end (75%), and while they were identified in all age categories, they were most frequent in those aged 12-17 years (0.2% TPR). The humerus was the most commonly affected location (3/12 or 25%). This study highlights the potential for recognizing physeal fractures in children of all ages, enhancing our understanding of nonadult trauma, and enabling us to assign a more precise age of the injury to build up a picture of their activities in the past.

A method of surgical treatment of unstable severe forms of juvenile femoral head epiphysiolysis

Aim. To analyze the long-term results of the designed method for the open epiphysis reduction in patients with severe unstable forms of juvenile femoral head epiphysiolysis. Methods. The article describes the method of surgical treatment of severe forms of unstable juvenile femoral head epiphysiolysis and long-term outcomes in 21 patients. The indications for the method were the unstable form of juvenile femoral head epiphysiolysis and slipped capital femoral epiphysis with a slip angle of more than 40 degrees. The age of patients at time of treatment ranged from 11 to 16 years, follow-up period - from 2 to 15 years. Five patients underwent a comprehensive biomechanical study within one year after surgery. Results. The early and late results of the femoral head epiphysis open reduction were analyzed. Positive results were obtained in 19 cases (good results in 17, satisfactory in 2). The complication rate was 14.3% and included 3 cases of avascular femoral head necrosis, no cases of chondrolysis were revealed. According to biomechanical examination data performed in five patients 1 year after the surgery, almost complete functional recovery of the musculoskeletal system was revealed. Conclusion. Analysis of the results showed that being properly executed the open reduction of the femoral head with a corrective femoral neck osteotomy allowed to restore normal anatomic proportions and function of the affected joint, positive result was maintained for the entire follow-up period.

Treatment outcomes of both-bone diaphyseal paediatric forearm fractures

BackgroundElastic-stable intramedullary nailing (ESIN), is an accepted method for stabilization of unstable forearm shaft fractures in children. This study analyzed the radiographic and functional outcomes of intramedullary nailing of forearm diaphyseal fractures in children. Materials and methodsA retrospective analysis was performed of children with forearm shaft fractures and open epiphyseal plates, treated with ESIN between 2000 and 2012 in our institution. Evaluation of cases was conducted minimum 14 months after osteosynthesis. Clinical results were evaluated according to the criteria developed by Price et al. and Flynn et al. ResultsThe study included 88 (42 boys) children. The average age of children at day injury was 10.5 ± 2.59 years (range 4-16), and at the review clinic was 13.4 ± 1.85 years (range 7-18). Forty six (52.3 %) had right forearm and 42 (47.7%) had left fracture respectively. Open reduction was required in 20 (22.7%) children. Primarily surgically were treated 62 (70.5%) children and 26 (29.5%) were operated as a second procedure after failed conservative management. There was one delayed union. Rotational forearm restriction with values between 11 and 20 degrees was present in nine children. Six children developed radial nerve hypoesthesia which eventually resolved with time. After removal of the implant one child sustained a re-fracture. The overall complication rate was 25%. Complete recovery to the original condition was noted in 76 (86.4%) children, eleven children (12.5%) had good and only one (1.1%) had poor outcome. ConclusionOur study suggests that ESIN osteosynthesis for diaphyseal forearm fractures remains a valid technique with very good functional results.

Giant cell tumor involving radial diaphysis

Giant cell tumor (GCT) of the bone is a benign but locally aggressive & destructive lesion. This tumor is usually seen in patients over 20 years of age. Less than 2% are found in part with open epiphysis. The epiphyseal portion of the bone is characteristic site of giant cell tumor. In rare instances, giant cell tumor can occur in the diaphysis of long tubular bone without involving the epiphysis. Although age, clinical and radiological features are helpful, it is still the histology that helps to clinch the diagnosis. It is important to distinguish giant cell tumor of diaphysis from the giant cell rich lesions, more common in this site.