Physeal Abnormalities Research Articles

Physeal Migration During Knee-guided Growth With Tension Band Plates: Influence of Implant Position.

Physeal migration during guided growth with tension band plates (TBPs) has been poorly described. The positioning factors associated with this phenomenon and its clinical implications are unknown. Our aim is to determine the influence of implant position on the risk of physeal migration during knee-guided growth with TBP. Retrospective study of 491 patients who underwent temporary hemi or epiphysiodesis with TBP around the knee between 2007 and 2019. We identified 29 patients who presented physeal migration during follow-up. Demographic and clinical data were collected, and the following measures were obtained from the immediate postoperative radiographs: epiphyseal screw base-physis distance/epiphyseal screw tip-physis distance, interscrew angle, epiphyseal screw-physis angle(ES-PHa)/metaphyseal screw-physis angle, plate-physis angle, epiphyseal screw-plate angle/metaphyseal screw-plate angle, and epiphyseal screw-physis length ratio. Using follow-up radiographs, the type of physeal migration of the epiphyseal screw (touch, occupy, or traverse) and the status of the physis after implant removal (unaltered, physeal bar, and skeletal maturity) were also recorded. A descriptive analysis of the cases and a case-control comparison of imaging studies were performed. The median patient age at intervention was 12.2 years (interquartile range: 11.3 to 14.1), and 76% were males. A statistically significant difference between cases and controls was obtained for epiphyseal screw base-physis distance (3.7 vs 6.3; P = 0.029), epiphyseal screw tip-physis distance (3.6 vs 7.85; P = 0.002), ES-PHa (-0.1 vs 7.45; P = 0.007), and plate-physis angle (85.45 vs 88.60; P = 0.012). In a categorical analysis, a significant difference was found for the ES-PHa categories ( P = 0.002) and for the ES-PHa/metaphyseal screw-physis angle categorical pair ( P = 0.018). In 16, 17, and 12 cases the physis was touched, occupied, or traversed, respectively, although we found no physeal alterations after plate removal. In our study, physeal migration of TBP is not an uncommon phenomenon, although no physeal abnormalities were detected. Convergent placement of the epiphyseal screw with the base or tip close to the physis should be avoided as this position is associated with a higher risk of physeal migration. Level III-case-control study.

Physeal Abnormalities in Children With High-risk Neuroblastoma Intensively Treated With/Without 13-Cis-Retinoic Acid.

This study aimed to investigate the presence of physeal abnormality and its effect on growth in children with high-risk neuroblastoma treated by intensive multimodal treatment with/without 13-cis-retinoic acid (13-CRA). Fifteen patients diagnosed with high-risk neuroblastomas at the age of 1 to 10 years, who received treatment such as high-dose chemotherapy and autologous stem cell transplantation with/without 13-CRA, and with complete data during their >2-year follow-up were retrospectively reviewed. The physeal abnormalities were investigated by whole-body magnetic resonance imaging, serially performed every 3 to 6 months. The patients' height growth was also investigated and compared with that of age-and-sex-matched patients with brain tumors who also underwent high-dose chemotherapy and autologous stem cell transplantation. Six of 15 patients presented multifocal physeal abnormalities during follow-up, and all lesions occurred in patients with 13-CRA use. The lesions in 3 patients completely resolved spontaneously without any adverse effect on growth, but some lesions in the other 3 patients progressed to disturb the bony growth. Height growth of matched patients with brain tumors were not significantly different, and none of the matched controls showed definite bony deformity during the follow-up. Some children who were treated for high-risk neuroblastomas experienced multifocal physeal insults, probably due to the use of 13-CRA. Most lesions resolved spontaneously, but some led to bony deformity. If the lesions are not followed by premature physeal closure, there seems to be no further adverse effect of 13-CRA on leg length growth. Routine periodic screening for physeal status is needed for the patients with high-risk neuroblastomas using 13-CRA. Level IV-prognostic study.

Assessing the effect of physeal biopsy on angular deformity in a rabbit model.

Obtaining a biopsy of the physis in a pediatric/juvenile could provide the ability to diagnose and manage children with physeal abnormalities. However, it has not yet been determined whether a physeal biopsy procedure affects angular deformity. We employed a rabbit model to collect biopsies of the distal femoral and proximal tibial physes on anesthetized, 8-week old New Zealand rabbits. The contralateral limb served as a control. At 8 (n = 5) and 16 (n = 5) weeks postbiopsy, animals were euthanized. Micro-computed tomography (CT) was employed to estimate percentage of the physis biopsied and assess structural abnormalities resulting from biopsy. Bone samples were embedded in polymethylmethacrylate and analyzed. The percentage of physis sampled was ≤1.5% of the total femoral physis while all but one of the tibiae had ≤2.3% removed. There were no iatrogenic clinical or radiographic deformities (frontal or sagittal). Micro-CT and histological analysis suggested that physeal defects had signs of healing that did not lead to subsequent angular deviation. A defect caused by physeal biopsy may not lead to angular deformity. Long-term data could help determine the safety and efficacy of collecting biopsies for histological analyses. Advanced imaging may demonstrate a detailed picture of anatomic or structural alteration of a given physis, but provides no functional information. The diagnostic and therapeutic information that could be gleaned from one or more serial biopsy samples could be invaluable in decision making and clinical management (e.g. skeletal dysplasias and metabolic conditions), so long as subsequent deformity is not a future possibility.

Transphyseal Anterior Cruciate Ligament Reconstruction in the Skeletally Immature: Quadriceps Tendon Autograft Versus Hamstring Tendon Autograft.

Background:It is unclear what the optimal graft choice is for performing anterior cruciate ligament (ACL) reconstruction in a skeletally immature patient.Purpose:To evaluate outcomes and complications of skeletally immature patients undergoing transphyseal ACL reconstruction with a hamstring tendon autograft versus a quadriceps tendon autograft.Study Design:Cohort study; Level of evidence, 3.Methods:Between 2012 and 2016, 90 skeletally immature patients from a single institution underwent primary transphyseal ACL reconstruction with either a quadriceps tendon autograft or a hamstring tendon autograft based on surgeon preference (n = 3). Patient demographic, injury, radiographic, and surgical variables were documented. Outcome measures included the Lysholm score, Single Assessment Numeric Evaluation (SANE), Tegner activity score, pain, satisfaction, and complications such as graft tears and physeal abnormalities.Results:A total of 83 patients (56 hamstring tendon, 27 quadriceps tendon) were available for a minimum follow-up of 2 years or sustained graft failure. The mean age of the patients was 14.8 ± 1.4 years at the time of ACL reconstruction. No differences in chronological age, bone age, sex, patient size, or mechanism of injury were noted between groups. There were no differences in surgical variables, except that the quadriceps tendon grafts were larger than the hamstring tendon grafts (9.6 ± 0.6 mm vs 7.8 ± 0.7 mm, respectively; P < .001). Patient outcomes at a mean follow-up of 2.8 ± 0.9 years revealed no differences based on graft type, with mean Lysholm, SANE, pain, satisfaction, and Tegner scores of 96, 93, 0.6, 9.6, and 6.6, respectively, for the quadriceps tendon group and 94, 89, 0.9, 9.2, and 7.1, respectively, for the hamstring tendon group. While there were no physeal complications in either group, patients undergoing ACL reconstruction with a hamstring tendon autograft were more likely to tear their graft (21% vs 4%, respectively; P = .037).Conclusion:Skeletally immature patients undergoing ACL reconstruction can be successfully managed with either a quadriceps tendon autograft or a hamstring tendon autograft with good short-term outcomes, high rates of return to sport, and low rates of physeal abnormalities. The primary differences between grafts were that the quadriceps tendon grafts were larger and were associated with a lower retear rate. ACL reconstruction performed with a quadriceps tendon autograft may reduce early graft failure in skeletally immature patients.

Quadriceps Tendon Autografts Have A Lower Early Graft Failure Rate Than Hamstring Tendon Autografts When Performing Transphyseal ACL Reconstructions

Objectives: It is unclear what the optimal graft choice is for performing a transphyseal ACL reconstruction in a skeletally immature patient. The purpose of the current study was to evaluate outcomes and complications of skeletally immature patients undergoing an ACL reconstruction with hamstring tendon autograft versus quadriceps tendon autograft. Methods: Between 2012 and 2016, 104 skeletally immature patients from a single institution underwent a primary transphyseal ACL reconstruction with either quadriceps tendon autograft or hamstring tendon autograft based on surgeon preference. Patient demographic, injury, radiographic, and surgical variables were documented. Outcome measures included Lysholm score, SANE score, pain score, satisfaction, return to sport, and complications such as graft tears and physeal abnormalities. Results: Ninety patients (87%) including 62 hamstring tendon reconstructions and 28 quadriceps tendon reconstructions were available for a minimum follow-up of 2 years. The mean age of the patients was 14.8±1.3 years. No differences in chronologic age, bone age, gender, patient size, or mechanism of injury were noted between patient groups. There were no differences in surgical variables except the quadriceps tendon grafts were larger than the hamstring tendon grafts (9.6 mm vs 7.8 mm; p&lt;0.001). Patient outcomes at a mean follow-up of 2.8 years revealed no differences based graft type with a mean Lysholm score, SANE score, pain score, satisfaction, and Tegner score were 95, 91, 0.8, 9.3, and 6.9 respectively. While there were no physeal complications in either group, patients undergoing a hamstring tendon autograft reconstruction were more likely to tear their graft (19% vs 0%; p= 0.01). Conclusion: Skeletally immature patients undergoing an ACL reconstruction can be successfully managed with either a quadriceps tendon autograft or a hamstring tendon autograft with good short-term outcomes, relatively high rates of return to sport, and low rates of physeal abnormalities. The primary differences between grafts were that the quadriceps tendon grafts were larger and were associated with a lower retear rate. Although a relatively new graft source for skeletally immature ACL reconstructions, the quadriceps tendon is not only a viable graft option, but it may be superior to the hamstrings tendon when it comes to early graft failures.

Transphyseal anterior cruciate ligament reconstruction in adolescents with substantial remaining growth causes temporary growth arrest resulting in subclinical leg-length discrepancy.

The purpose of the present study was to investigate the characteristics of growth disturbances in patients with remaining growth after transphyseal anterior cruciate ligament (ACL) reconstruction who were confirmed to have no definite postoperative physeal abnormalities on magnetic resonance imaging (MRI).Forty adolescents (mean age 15.6 ± 1.0 years [range 12.2–16.8], mean follow-up 2.7 ± 0.7 years [range 2.0–5.5 years]), who underwent transphyseal ACL reconstruction and were confirmed to have no focal physeal disruptions on follow-up MRIs 6 to 12 months after the operation, were retrospectively evaluated. The patients were grouped according to the leg-length growth of the uninjured side, measured on scanograms, obtained before surgery, and at the final follow-up.Leg-length discrepancies (LLD) at the last follow-up were greater in patients with leg growth ≥4 cm than in those with leg growth <4 cm (5.3 ± 9.0 mm vs −0.3 ± 4.2 mm, P = .033); however, no significant difference was observed between subgroup patients with leg growth of 4 to 6 cm or ≥6 cm (5.6 ± 10.4 mm vs 4.8 ± 7.0 mm, P = .958). On multivariate analysis, leg growth was a significant predictive factor for the final LLD (P = .030).Adolescents with additional leg-length growth after transphyseal ACL reconstructions presented with greater LLDs (as shown in the <4 cm vs ≥4 cm groups), but they also presented a ceiling effect (as shown in the 4–6 cm vs ≥6 cm subgroups). Transphyseal ACL reconstructions appeared to cause temporary growth arrest/disturbances in patients with substantial remaining growth which then resumed resulting in clinically insignificant LLDs.

An investigation to validate the equivalence of physes obtained from different anatomic regions in a single animal species: Implications for choosing experimental controls in clinical studies

Control tissue in studies of various orthopedic pathologies is difficult to obtain and presumably equivalent biopsies from other anatomic sites have been utilized in its place. However, for growth plates, different anatomic regions are subject to dissimilar mechanical forces and produce disproportionate longitudinal growth. The purpose of this study was to compare gene expression and structure in normal physes from different anatomic regions within a single animal species to determine whether such physes were equivalent. Thirteen female New Zealand white rabbits (five 15-week-old and eight 19-week-old animals) were euthanized and physes harvested from their proximal and distal femurs and proximal tibiae. Harvested physes were divided into groups for histological, immunohistochemical (IHC), and reverse transcription-quantitative polymerase chain reaction analyses. All physes analyzed demonstrated no apparent differences in morphology or proteoglycan staining intensity on histological examination or in type II collagen presence determined by IHC study. Histomorphometric measures of physeal height as well as gene expression of type II collagen and aggrecan were found to be statistically significantly equivalent (p < 0.05) among the three different bones from the total number of rabbits. Summary data suggest that the structural similarities and statistical equivalence determined among the various physes investigated in the rabbit validate these tissues in this species for use as surrogate controls by which physeal abnormalities may be compared and characterized in the absence of otherwise normal control tissues. Other species may exhibit the same similarities and equivalence among different physes so that such tissues may serve in like manner as controls for assessing a variety of orthopedic conditions, including those occurring in humans.

Evaluating growth failure with diffusion tensor imaging in pediatric survivors of high-risk neuroblastoma treated with high-dose cis-retinoic acid.

The survival of patients with high-risk neuroblastoma has increased with multimodal therapy, but most survivors demonstrate growth failure. To assess physeal abnormalities in children with high-risk neuroblastoma in comparison to normal controls by using diffusion tensor imaging (DTI) of the distal femoral physis and adjacent metaphysis. We prospectively obtained physeal DTI at 3.0T in 20 subjects (mean age: 12.4years, 7 females) with high-risk neuroblastoma treated with high-dose cis-retinoic acid, and 20 age- and gender-matched controls. We compared fractional anisotropy (FA), normalized tract volume (cm3/cm2) and tract concentration (tracts/cm2) between the groups, in relation to height Z-score and response to growth hormone therapy. Tractography images were evaluated qualitatively. DTI parameters were significantly lower in high-risk neuroblastoma survivors compared to controls (P<0.01), particularly if the patients were exposed to both cis-retinoic acid and total body irradiation (P<0.05). For survivors and controls, DTI values were respectively [mean ± standard deviation]: tract concentration (tracts/cm2), 23.2±14.7 and 36.7±10.5; normalized tract volume (cm3/cm2), 0.44±0.27 and 0.70±0.21, and FA, 0.22±0.05 and 0.26±0.02. High-risk neuroblastoma survivors responding to growth hormone compared to non-responders had higher FA (0.25±0.04 and 0.18±0.03, respectively, P=0.02), and tract concentration (tracts/cm2) (31.4±13.7 and 14.8±7.9, respectively, P<0.05). FA, normalized tract volume and tract concentration were linearly related to height Z-score (R2>0.31; P<0.001). Qualitatively, tracts were nearly absent in all non-responders to growth hormone and abundant in all responders (P=0.02). DTI shows physeal abnormalities that correlate with short stature in high-risk neuroblastoma survivors and demonstrates response to growth hormone treatment.

Systematic assessment of the growth plates of the wrist in young gymnasts: development and validation of the Amsterdam MRI assessment of the Physis (AMPHYS) protocol

ObjectivesTo develop and validate a protocol for MRI assessment of the distal radial and ulnar periphyseal area in gymnasts and non-gymnasts.MethodsTwenty-four gymnasts with wrist pain, 18 asymptomatic gymnasts and 24...

Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients: Early Results Using a Hybrid Physeal-Sparing Technique.

Background:Reconstruction of the anterior cruciate ligament (ACL) in the skeletally immature patient is frequently performed in hopes of preventing new or additional chondral damage and meniscal injuries. Patients within a few years of skeletal maturity are more at risk for ACL injuries than prepubescent patients, about whom several physeal-sparing techniques have been described. Reconstruction techniques in the former higher risk group need to be better understood.Purpose:To review a series of adolescent patients with ACL injuries surgically treated with the hybrid physeal-sparing technique.Study Design:Case series; Level of evidence, 4.Methods:Surgical logs of ACL reconstructions (ACLRs) performed at a single pediatric/adolescent sports medicine center over a 6-year period were reviewed. Patients with open physes who had undergone ACLR with a femoral physeal-sparing tunnel and transphyseal tibial tunnel were identified. Their demographics, operative reports, rehabilitative course, time to return to play, outcome scores, and postoperative radiographs were collected and analyzed.Results:Twenty-three patients with a mean chronological age and bone age of 13.0 and 13.6 years, respectively, were identified. Examination and subjective outcome scores were obtained at a mean of 19 months and overall demonstrated positive results, with a mean Pediatric International Knee Documentation Committee (Pedi-IKDC) score of 96.0 and a mean Anterior Cruciate Ligament–Return to Sport after Injury (ACL-RSI) score of 89.1. Full-length mechanical axis films obtained at a mean 21 months postoperatively demonstrated no leg-length discrepancies or angular deformities in 21 of 23 patients. Two patients had an identified growth disturbance in the form of femoral and tibial growth acceleration on the ACL-reconstructed limb.Conclusion:The femoral physeal-sparing with transphyseal tibial drilling “hybrid” technique in skeletally maturing patients appears to have a high rate of success with low morbidity. However, the possibility of physeal abnormalities does exist, which demonstrates the importance of a close postoperative follow-up and evaluation until skeletal maturity is achieved. ACLR in skeletally immature patients is performed on an increasingly regular basis. Establishing the best and safest technique to do so is therefore important.

Drug-induced Physeal Abnormalities in Preclinical Toxicity Studies.

Most toxic physeal changes are characterized microscopically by altered chondrocyte development, proliferation, or maturation in the growth plate and eventually result in disordered appositional bone growth. Many therapeutic drugs directly or indirectly target proteins involved in chondrocytic differentiation and maturation pathways, so toxic physeal injury has become increasingly common in preclinical toxicologic pathology. While physeal dysplasia has been associated with several different drug classes including bisphosphonates, vascular endothelial growth factor receptor inhibitors, fibroblast growth factor receptor inhibitors, transforming growth factor beta receptor inhibitors, and vascular targeting agents, physeal changes often share similar morphologic features including thickening and disorganization of the hypertrophic layer, increased numbers of hypertrophic chondrocytes, altered mineralization of endochondral ossification, and/or increased thickness of subphyseal bone. Knowledge of genetic and nutritional diseases affecting bone growth has been important in helping to determine which specific target drugs may be affecting that could result in toxic physeal lesions. A pathophysiologic mechanism for most physeal toxicants has been determined in detail using a variety of investigative techniques. However, due to the signaling cross talk and the tight regulation required for chondrocyte maturation in the physis, several growth factor pathways are likely to be affected simultaneously with pharmacologic disruption of physeal homeostasis and inhibition of one factor necessary for chondrocyte function often affects others.

Olecranon physeal nonunion in the adolescent athlete: identification of two patterns

This study aimed to present the outcomes of patients undergoing surgical management of persistent, symptomatic olecranon physes. Consecutive patients undergoing surgical management for symptomatic persistent olecranon physeal abnormalities were reviewed. Preoperative data, intraoperative findings, and postoperative clinical outcomes including physical examination findings, radiographs, complications, and reoperations were analyzed. A total of 13 elbows in 12 patients (100% male; average age, 18 ± 4 years) were identified. All patients were pitchers at the high-school or college level. Two unique radiographic patterns were identified: distal persistent olecranon physis (n = 9), identified by an irregular sclerotic lucency at the site of the olecranon physis; and proximal persistent olecranon physis (n = 4), identified by a radiolucency exiting proximal to the triceps insertion at the site of an accessory ossification center that failed to unite. Surgical management included débridement, autograft bone grafting, and internal fixation. There were 3 reoperations (1 for infection, 2 for painful hardware). All patients achieved successful radiographic union (average, 8 ± 2 weeks). At an average follow-up of 4.4 ± 1.2 years, the average postoperative Disabilities of the Arm, Shoulder, and Hand score was 1.1 ± 1.6; the Mayo Elbow Performance Score was 98.5 ± 2.4; the American Shoulder and Elbow Surgeons score was 99.3 ± 0.4; and average Likert score for satisfaction was 9.95 ± 0.2. At final follow-up, there were no significant differences in strength, motion, or stability in comparing the operative with the nonoperative elbow (P > .05 for all). Two unique patterns of olecranon physeal abnormalities in young, overhead throwing athletes have been identified. Open reduction with internal fixation is clinically and radiographically successful in obtaining union and symptom resolution in these patients.

What Is the Association Between Sports Participation and the Development of Proximal Femoral Cam Deformity?

Background: Femoroacetabular impingement (FAI) is recognized as a common cause of hip pain and intra-articular disorders in athletes. Studies have suggested a link between participation in athletics during adolescence and the development of cam-type deformities of the proximal femoral head-neck junction. Purpose: To investigate the association of sporting activity participation during adolescence and the development of cam deformity. Study Design: Systematic review. Methods: The PubMed, EMBASE, and Cochrane databases were searched to identify potential studies. s and manuscripts (when applicable) were independently reviewed by 2 reviewers. Nine studies met the inclusion criteria, including 8 studies that compared the prevalence of cam deformity in athletes with that in controls and 3 studies that compared the prevalence of cam deformity before and after physeal closure (2 with both). A meta-analysis was performed with pooling of data and random-effects modeling to compare rates of cam deformity between athletes and controls. Results: High-level male athletes are 1.9 to 8.0 times more likely to develop a cam deformity than are male controls. The pooled prevalence rate (by hip) of cam deformity in male athletes was 41%, compared with 17% for male controls. The pooled mean alpha angle among male athletes was 61°, compared with 51° for male controls. Conclusion: Males participating in specific high-level impact sports (hockey, basketball, and possibly soccer) are at an increased risk of physeal abnormalities of the anterosuperior head-neck junction that result in a cam deformity at skeletal maturity.

Growth Plate Disturbance After Transphyseal Reconstruction of the Anterior Cruciate Ligament in Skeletally Immature Adolescent Patients

There are concerns of potential growth disturbance after transphyseal reconstruction of the anterior cruciate ligament in skeletally immature patients. The authors used magnetic resonance (MR) imaging to evaluate growth disturbance and associated physeal abnormalities after index surgery. We retrospectively reviewed the follow-up MR imaging studies of 43 patients who underwent transphyseal reconstruction of the anterior cruciate ligament using a soft-tissue graft at the mean age of 14.8 years (range, 12.4 to 16.5 y). Mean time from surgery to follow-up MR imaging was 16 months (range, 6 to 36 mo). Bone tunnel to growth plate cross-sectional area ratios were calculated as percentages. Focal growth disturbances were assessed in the follow-up MR images in terms of physeal tenting, the presence of a focal bone bridge, an asymmetric growth arrest line of Harris, and metaphyseal extension of physeal cartilage. Physeal angles with respect to the longitudinal axes of the corresponding bones were measured in preoperative MR images and compared with those measured in follow-up images. Premature physeal closure was assessed using the proximal fibular growth plate as an internal control. Clinically, growth disturbances were assessed with physical examinations regarding standing pelvic heights and alignments of the lower extremities. The bone tunnel to growth plate ratio was < 3% for proximal tibia and distal femur. A focal bone bridge was observed in 5 patients-4 at the tibial physis and 1 at the femoral physis. Physeal angles did not change significantly during follow-up in either the coronal or sagittal plane. Earlier physeal closure than other physes was observed in 2 proximal tibiae. Clinically, there were no perceived growth disturbances. MR imaging revealed that focal physeal disruption developed after index procedure in 5 of 43 adolescent patients (11.6%) without a perceived clinical growth disturbance. The results suggest that transphyseal reconstruction of the anterior cruciate ligament may not be a benign procedure that can be applied safely to younger children with substantial growth remaining. Retrospective Case Series, Therapeutic Level IV.

Osteochondritis dissecans and Osgood Schlatter disease in a family with Stickler syndrome.

PurposeStickler syndrome is among the most common autosomal dominant connective tissue disorders but is often unrecognised and therefore not diagnosed by clinicians. Despite much speculation, the cause of osteochondrosis in general and osteochondritis dissecans (OCD) and Osgood Schlatter syndrome (OSS) in particular remain unclear. Etiological understanding is essential. We describe a pair of family subjects presented with OCD and OSS as a symptom complex rather than a diagnosis.MethodsDetailed clinical and radiographic examinations were undertaken with emphasis on the role of MRI imaging. Magnetic resonance imaging may allow early prediction of articular lesion healing potential in patients with Stickler syndrome.ResultsThe phenotype of Stickler syndrome can be diverse and therefore misleading. The expectation that the full clinical criteria of any given genetic disorder such as Stickler syndrome will always be present can easily lead to an underestimation of these serious inheritable disorders. We report here two family subjects, a male proband and his aunt (paternal sister), both presented with the major features of Stickler syndrome. Tall stature with marfanoid habitus, astigmatism/congenital vitreous abnormality and submucus cleft palate/cleft uvula, and enlarged painful joints with early onset osteoarthritis. Osteochondritis dissecans (OCD) and Osgood Schlatter syndrome (OSS) were the predominating joint abnormalities.ConclusionWe observed that the nature of the articular and physeal abnormalities was consistent with a localised manifestation of a more generalised epiphyseal dysplasia affecting the weight-bearing joints. In these two patients, OCD and OSS appeared to be the predominant pathologic musculoskeletal consequences of an underlying Stickler's syndrome. It is empirical to consider generalised epiphyseal dysplasia as a major underlying causation that might drastically affect the weight-bearing joints.

Enlargements of the distal third metacarpus and metatarsus in Thoroughbred foals at pasture from birth to 160 days of age

AIMS: To assess the relationship between the radiographic and microscopic appearance of the physeal regions of the distal third metacarpal (Mc3) and metatarsal (Mt3) bones of Thoroughbred foals at 160 days of age, and to clinically assess changes in contour of the distal Mc3 and Mt3 physeal regions from birth to 160 days of age. To assess relationships between maximum clinical physis scores and age, time of year, foal's sex, condition score, growth rate, copper (Cu) concentration in the liver of the foal, and supplementation of the dam with Cu in late gestation. METHODS: Dams were given Cu (n=5 and n=11, in Years 1 and 2, respectively) or saline (n=5 and n=12, in Years 1 and 2, respectively) injections in late gestation. Liver biopsies were harvested from foals in the first week of life, and the whole liver homogenised after the animals were euthanised at around 160 days of age, to determine Cu concentrations. Pasture samples were collected every 4–8 weeks for analysis of mineral composition. During Year 1, 10 foals were weighed and examined every 2 weeks from birth to 160 days of age for evidence of pain and lameness in the distal Mc3/Mt3. In Year 2, 23 foals were weighed, condition-scored and examined for evidence of pain and lameness weekly for the first 5 weeks of life, then every 2 weeks from birth to 160 days of age, and a clinical physis score for the distal Mc3/Mt3 given. Cabinet radiographs of frontal slices of the physeal region of the distal Mc3/Mt3 at around 160 days of age were given a radiographic physis score. Physes were then examined histologically for evidence of abnormal en- dochondral ossification. RESULTS: Gross enlargements of the distal Mc3 and Mt3 were observed in all foals in this study, but were not associated with lameness, pain or inflammation. The most severe clinical physis scores occurred over 2 months in late summer/autumn, and were not influenced by the foal's growth rate, sex, or Cu concentration in the liver, or treatment of dams with Cu in late gestation. The clinical physis score was highly correlated to radiographic evidence of shouldering in the forelimb and hindlimb (both p<0.001). Focal disturbances in endochondral ossification were evident radiographically and histologically in the some of the physes at 160 days of age. The mineral composition of pasture was similar in Years 1 and 2, and concentrations of Cu and zinc were below those currently recommended for growing horses. CONCLUSIONS: Gross enlargements of the distal Mc3 and Mt3 were not consistent with previous descriptions of physitis. Results suggest that while many Thoroughbred foals at pasture will have visible boney enlargements of the distal Mc3/Mt3 in the first 5 months of life, few have physeal cartilage abnormalities or significant compromise of endochondral ossification. The importance of these clinical swellings may be overestimated, and they may more appropriately be called physiological enlargements associated with remodelling of bone.

Interpretation of radiographs in a pediatric limb deformity practice: do radiologists contribute?

Orthopaedic surgeons make treatment decisions based on their interpretation of patient radiographs. Radiologists' reports of these radiographs are routine but may add little to the patient's management. The authors prospectively compared data initially recorded by a pediatric orthopaedist in the assessment of teleoroentgenograms obtained over a 3-month period in a limb deformity clinic with the subsequent reports of these studies by pediatric radiologists. Two hundred and sixty-four (100%) anatomic axes of femora and tibiae were measured and reported by the surgeon compared to 1.9% by the radiologist. Limb lengths were recorded 100% of the time by the orthopaedist and by the radiologist in 80% of cases. Abnormal bone quality was present in 43 of 264 (16.2%) limb segments and reported in all involved cases by the orthopaedist. Only 26 (9.8%) of the abnormalities were noted by the radiologist. Only eight of 20 (35%) physeal abnormalities such as rickets were noted by the radiologist in contrast to 20 of 20 (100%) noted by the surgeon. There were no findings described by the radiologist not previously reported by the orthopaedic surgeon. In no case did the radiology interpretation influence clinical management decisions.

Cartilaginous abnormalities and growth disturbances in Legg-Calvé-Perthes disease: evaluation with MR imaging.

To evaluate the magnetic resonance (MR) imaging appearance of cartilaginous abnormalities in Legg-Calvé-Perthes (LCP) disease and their association with growth arrest. Twenty-seven MR images and radiographs of 25 hips in 23 patients were reviewed for epiphyseal, physeal, and metaphyseal abnormalities. Follow-up radiographs (mean time, 20.5 months) were evaluated for growth arrest. Epiphyseal abnormality seen in 74% of cases was not related to growth disturbances. Transphyseal bone bridging on MR images, the strongest predictor of abnormal growth (P < .01), was found in 63% of femurs. MR imaging helped detect physeal abnormalities with greater sensitivity (94%), specificity (89%), and positive predictive value (94%) than radiography. Metaphyseal extension of physeal cartilage seen in 81% of cases was associated with growth abnormality (P < .01), particularly when detected at radiography. Cartilaginous physeal and metaphyseal abnormalities in LCP disease are common and frequently result in growth arrest.

Determination of skeletal age in children with Osgood-Schlatter disease by using radiographs of the knee.

We determined the skeletal age in 26 children (12 girls, 14 boys) with Osgood-Schlatter disease using knee radiographs. The average chronological age was 13.2 +/- 2.2 years, and the average bone age was 13.1 +/- 2.3 years (p > 0.01). All but one of the skeletal ages fell within the normal range. Skeletal maturation in children with Osgood-Schlatter disease is thus normal. With normal skeletal maturation and normal physes histologically (previously shown), it is unlikely that an abnormality of physeal development or structure is the etiology of Osgood-Schlatter disease. Rather, it is most likely a result of tensile stresses on the tibial tuberosity. This is in contrast to slipped capital femoral epiphysis, another common disorder affecting children of the same ages as those with Osgood-Schlatter disease, in which physeal abnormalities and skeletal maturation anomalies do occur.

Blount's disease: magnetic resonance imaging.

To evaluate the information obtained by magnetic resonance (MR) imaging, the radiographic and MR investigations of nine patients treated for idiopathic tibia vara were reviewed in retrospect. There were six unilateral and three bilateral cases (12 tibiae). Initial radiographs of each patient were assigned a stage according to Catonné's classification. MR imaging was performed with a 0.5- or 1.5-T apparatus. Bony epiphyses were poorly developed in all cases. The cartilaginous component of the epiphyses compensated partially (6/12 cases) or completely (6/12 cases) for the collapse of the physes. In two cases an abnormal area was found between the medial meniscus and the cartilaginous portion of the epiphysis. An abnormally large medial meniscus was noted in four cases; an abnormal signal in the medial meniscus was seen in two cases. MR imaging has several advantages over plain film: it uses no ionizing radiation, it shows the shape of the ossified and cartilaginous epiphysis, and it demonstrates meniscal and physeal abnormalities. MR imaging may influence the choice of treatment.