Proximal Physis Research Articles

Supplementary Fibular-guided Growth in Treatment of Late-onset Blount Disease

Purpose: Blount disease is due to an idiopathic defect in the posteromedial proximal tibial physis resulting in increasing bowing of the leg in addition to lateral knee thrust with lateral collateral ligament laxity. Our rationale is that Blount disease has a bony and ligamentous laxity element of the lateral collateral ligament that can be corrected simultaneously through hemiepiphysiodesis of the tibia and epiphysiodesis of proximal fibula physis by cannulated screws. Patients and Methods: This is a retrospective study conducted on 23 limbs with tibia vara treated between 2010 and 2017 followed up for 2 to 6 years. Ages ranged from 9 to 13 years with a late-onset type of Blount disease. We used a percutaneous transphyseal fully threaded screws traversing the proximal tibial lateral hemiepiphysis, and another screw inserted traversing the proximal fibular epiphysis. Results: There was a statistically significant improvement of the radiographic parameters, especially in the form of joint line congruence angle in both supine and standing positions. All patients were clinically and radiographically completely corrected without complications, except 1 patient with a surgical site superficial infection, treated medically. Conclusion: Fibular-guided growth surgery with lateral proximal tibia epiphysiodesis is a minimally invasive technique that improves the corrective power of hemiepyphysiodesis of the posterolateral compartment of the knee. Level of Evidence: Level IV, retrospective case series.

Can acute correction with simultaneous hemiepiphysiodesis of lateral proximal tibia physis prevent recurrence in neglected infantile Blount's disease?

The treatment of infantile Blount's disease usually includes surgical correction, but high recurrence is still a problem regardless of the procedure. We conducted a cross-sectional study of severely neglected infantile Blount's disease treated with acute correction and simultaneous hemiepiphysiodesis of lateral proximal tibia physis. In this study, we aimed to observe the complication and recurrence. This research is an analytical study with a cross-sectional design using retrospective data collection and total sampling. The subjects were patients with neglected infantile Blount's disease treated from 2018 to 2023 in our institution. Follow-up was conducted in 6, 12, 24, and 36months. A total of 25 legs from twenty patients were recorded. We observed three legs (12.0%) had recurrence. No neurovascular complications and infections were observed. All subjects had significant postoperative improvement of TFA (mean 6.8 ± 0.730 valgus), Drennan angle, MPTA, MTPD, JLCA, and ligamentous laxity grading (p < 0.001). Lower than 5° postoperative valgus overcorrections and preoperative physeal bar were significant factors in patients with recurrence (p = 0.020 and p = 0.010). There was no significant increase in leg-length discrepancy during follow-up (p = 0.052). There were no significant differences between age, BMI, preoperative TFA, pre- and postoperative Drennan angle, MPTA, MTPD, JLCA, Langenskiöld stages, and length of follow-up in patients with recurrence and not. Acute correction with simultaneous hemiepiphysiodesis of lateral proximal tibia physis is an effective technique to prevent deformity recurrence in neglected infantile Blount's disease, provided that the postoperative TFA is more than 5° of valgus and no evidence of physeal bar in the preoperative radiograph.

Radiographic Appearance of the Fore Digit and Carpal Joint in the Mule Foal from Birth to 3 Months of Age.

Few studies have established the normal radiographic anatomical development of the donkey foal and, to date, no data are available for mules. Our aim was thus to evaluate the radiographic development of the fore digit and carpal joint in the mule foal from 0 to 3 months of age. Ten forelimbs of five healthy full-term mule foals were included. Radiographs of the fore digit lateromedial and dorsopalmar and the carpus dorsopalmar were performed weekly for the first month of age, and bi-monthly during the following two months. Fore digit growth plate closure times, morphological, angular, and linear radiographic parameters, and also carpal cuboidal bone mineralization were evaluated. Growth plates were graded as open, closing, and closed. Carpal bone appearance was graded as mature, slightly immature, or immature. Growth plate closure times showed the following: middle phalangeal distal physis (DP) closed at birth, and proximal physis (PP) started to close at around two months; first phalanx DP closed at seven days, and PP started to close at three months; and third metacarpal bone DP started to close at two months. Carpal bones were immature at birth. Distal phalanx (PD) was triangular at birth, palmar processes had developed by one month, and proximal sesamoid bones were trapezoidal by three months. The hoof wall, PD dorsal wall, and palmar angles values changed in parallel, and hoof capsule thickness increased. No PD remodeling evidence within the hoof capsule or variations in the hoof axis with growth were found. We identified a baseline for the interpretation of forelimb radiological features in mule foals. The specific features found were intermediate between those found in horses and donkeys.

Alternative approach for fracture fixation following implant infection in aSalter‐Harris type‐IIfracture of the proximal phalanx in a Warmblood foal

SummaryA 2‐day‐old female Warmblood foal (70 kg) presented with a closed, displaced Salter‐Harris type‐II fracture of the proximal physis of the left hind first phalanx. The fracture was repaired with four 4.5 mm cortical screws and a wire in a figure‐of‐8 pattern applied on the lateral and medial aspect of the phalanx, respectively. A 4.5 mm cortical screw was additionally inserted in lag‐fashion to engage the lateral metaphyseal spike. Three days postoperatively, medial and proximal displacement of the distal fracture fragment and implant infection were apparent and revision surgery was performed. Previous implants were removed and two 4.5 mm transphyseal cortical lag‐screws were placed in proximolateral–distomedial and dorsoproximal–plantarodistal direction across the physis and the fracture line. Postoperatively, the fracture healed rapidly and the implants were removed 6 weeks later. Nineteen months after implant removal, the horse did not show any sign of lameness, despite a shortening of the proximal phalanx compared to the contralateral limb. In cases of postoperative implant instability and infection, implant removal often becomes necessary. However, new implants cannot be placed safely in the previous location. To avoid this problem, this report describes an alternative approach for screw positioning in case of previous implant infection in a Salter‐Harris type‐II fracture of the proximal physis of the first phalanx.

Who Benefits From Allowing the Physis to Grow in Slipped Capital Femoral Epiphysis?

The globally acknowledged treatment for mild to moderate slipped capital femoral epiphysis (SCFE) is single screw in situ fixation, also used for prophylactic contralateral fixation. The Free-Gliding Screw (FG; Pega Medical) is a 2-part free-extending screw system designed to allow the growth of the proximal femur. We aimed to analyze the relationship between skeletal maturity and potential growth of the proximal physis and remodeling of the femoral neck using this implant. Females below 12 years and males below 14 years undergoing in situ fixation for stable SCFE or prophylactic fixation were treated using the implant. Three elements of the modified Oxford Bone (mOB 3 ) score were used to measure maturity (triradiate cartilage, head of the femur, and greater trochanter). Radiographs were analyzed immediately postoperatively and at a minimum of 2 years for a change in screw length, posterior-sloping angle, articulotrochanteric distance, α angle, and head-neck offset. The study group comprised 30 (F:M=12:18) of 39 hips treated with SCFE and 22 (F:M=13:9) of 29 hips managed prophylactically using the free-Gliding screw. In the therapeutic group, chronologic age was a less valuable predictor of future screw lengthening than mOB 3 . An mOB 3 of ≤13 predicted future growth of >6mm but did not reach statistical significance ( P =0.07). Patients with open triradiates showed a mean screw lengthening of 6.6mm compared with those with closed triradiates (4.0mm), but this did not reach significance ( P =0.12). In those with mOB 3 ≤13, the α angle reduced significantly ( P <0.01) and the head-neck offset increased significantly, suggesting remodeling. There was no change in these parameters when mOB 3 ≥14. In the prophylactic group, change in screw length was significant with mOB 3 of ≤13 (mean=8.0mm, P <0.05), as was the presence of an open triradiate cartilage (mean=7.7mm, P <0.05). In both cohorts, posterior-sloping angle and articulotrochanteric distance did not change, indicating no slip progression in either treatment or prophylactic groups and minimal effect on the proximal physeal growth relative to the greater trochanter. Growing screw constructs can halt slip progression while allowing proximal femoral growth in young patients with SCFE. Ongoing growth is better when the implant is used for prophylactic fixation. The results in treated SCFE need to be expanded to demonstrate a clinically meaningful cut-off for significant growth, but SCFE patients with an open triradiate remodel significantly more than those where it is closed. Level III-retrospective comparative study.

Acquired genu recurvatum in a skeletally immature patient treated by physeal distraction: A case report.

The proximal tibia physis' anterior growth arrest is the cause of the uncommon condition known as acquired genu recurvatum, which can also be congenital, idiopathic, or secondary to trauma, infections, cerebrovascular accidents, or neuromuscular diseases. In order to avoid the reported drawbacks that could complicate osteotomies-incomplete correction, patella infera, knee pain or stiffness, and the requirement to remove plate metalwork-physeal distraction and callotasis with external fixation has been suggested. We present the case of a 14-year-old boy who had a 5 cm difference in limb length, with the right leg being shorter, and a right knee that was 30° recurved with flexion restriction beyond 40°. The correction was made in 50 days, and the external fixator was removed in 92 days after we performed a physeal distraction with an axial EF (ST.A.R., Citieffe) through an anterior physeal osteotomy just proximal to the tuberosity in conjunction with simultaneous asymmetrical tibial and femoral contralateral epiphysiodesys. The patient returned to playing football within 8 months despite the persistence of a 3 cm leg length discrepancy and had a symmetric full range of motion of the knee without any complications or persistent pain. The correction of genu recurvatum in adolescents may be achieved safely and effectively through physeal distraction with an axial external fixator.

CORRECTION OF ADOLESCENT BLOUNT`S DISEASE DEFORMITY USING ILIZAROV FRAME A CASE REPORT.

Introduction- Blount's disease is dened as a growth disorder of medial aspect of proximal tibia physis with abrupt medial angulation of proximal tibia distal to epiphysis, leading to varus angulation of proximal tibia and medial rotation of tibia. Epidemiology is not well established and very rarely cases have been reported from Indian subcontinent. It is associated with internal tibial torsion and genu recurvatum. The aim of Objective: this work to evaluate the results of acute correction of adolescent Blount's disease using ilizarov frame constructed for gradual correction taking the benets of acute correction. A 16 year old male adolescent presented with Presentation Of Case- deformity in right foot and altered walking pattern for past 2 years . On examination there was 13 degrees varus deformity in right leg. There was a 15 degree internal tibial rotation on right side. Knee range of motion was 10 degree of hyperextention to 140 degree of full exion. Patient managed by surgical intervention. oblique proximal osteotomy was done. deformity correction was done by ilizarov frame. patient recovered well with correction of deformity and could walk with normal gait pattern. Patient result were assessed both cli Results- nically and radiological .Restoration of mechanical axis ,knee range of movement, weight bearing, range of motion [ROM] external xator time and possible complications were assessed. The average external xator time was 12 weeks. Blount's disease is a very rarely encountered condition in Conclusion- Indian subcontinent but has a characteristic presentation. We conclude that acute correction of adolescent Blount`s disease using a frame constructed for gradual correction is a safe and reliable technique. It combines the benets of both acute and gradual correction allowing for shorter healing time and to correct any operative error at the clinic and reducing the need for intraoperative uoroscopy.

Advantages of Telescopic Screw in Slipped Capital Femoral Epiphysis Treatment: A Retrospective Study and Review of the Literature.

Background: Slipped capital femoral epiphysis is due to proximal femur physis failure in adolescent patients. Early iatrogenic closure of proximal growth cartilage in children with significant residual growth potential causes complications such as coxa breva, coxa vara, and lower limb length inequalities. The Free-Gliding SCFE Screw System is a self-extending cannulated screw used in Slipped Capital Femoral Epiphysis (SCFE) fixation and femoral neck fractures. Materials and Method: We conducted a retrospective study on 16 patients. All patients under 11 years old were treated by telescopic cannulated screws fixation. The youngest patient was 7 years old. Results: Out of the 22 operated hips, 2 screws have failed, thus resulting in a lack of telescoping of the screw. We discovered an average lengthening of approximately 10 mm at 24 months postoperative check-up in 20 hips in which lengthening took place. According to the Notzli method, none of the patients had an alpha angle value greater than 48 degrees. Conclusion: Fixation with telescopic screw for SCFE in patients less than 11 years old, with mild to moderate slippage, allows the continuous growth and remodeling of the proximal femur, thus avoiding deformities such as coxa breva, coxa vara, FAI, AVN, limb length discrepancies and also allows good range of motion.

Simultaneous Gradual Correction of Bilateral Late Onset Tibia Vara using High Tibial Osteotomy with a Mono-Axis Dynamic External Fixator: A Case Report

Tibia vara is a disease characterized by an abrupt angulation of the tibia into varus in the proximal end. This condition is caused by developmental growth defect of the proximal tibia physis. Tibia Vara can be classified into groups according to the age of the patient and the mainstay treatment is either acute or gradual surgical correction.A 21 year-old man with chief complaint bowing of the legs with leg pain since 3 years ago. Physical examination showed bilateral genu varum. The anteroposterior long leg standing X-Ray found that the deformity was of osseous origin at the proximal part of the tibia in varus position. Medial osteotomy of the proximal tibia was performed and a dynamic external fixator was installed. Gradual correction was performed at a rate of 1 mm per day. After 3 months, radiological evaluation showed good union and target angle of correction with acceptable mechanical axis was achieved. Patient had no complaint of pain or instability post-surgery.Gradual correction using external fixator provides a more flexible angle correction with lower risk of neurovascular compromises; but with its own disadvantage such as loss of correction after removal of the external device. In this case, gradual correction of late onset tibia vara using dynamic external fixator provides satisfactory outcome and enable a more fine-tuned angle correction. It also potentially eliminate the need for a second surgery to remove the external device; thus reducing the length of hospitalization.

Change in angle of depressed medial tibial plateau following extra-articular mechanical realignment surgery in children with Blount's disease who presented late for treatment.

The aim of this study was to determine whether any change in degree of medial tibia plateau depression after extra-articular mechanical realignment surgery was observed in children with Blount's disease who presented late for treatment in their adolescence and young adulthood. We retrospectively reviewed the radiographic parameters of 22 patients (32 lower limbs) with Blount's disease who underwent gradual correction of deformity using a ring external fixator without surgical elevation of the depressed medial tibial plateau at a mean age of 15 (range 10-37) years. Preoperative and postoperative angles of depressed medial tibia plateau (ADMTPs) of the same patient were compared for any significant change. Normally distributed data were analysed using Student's t -test when comparing two groups or one-way analysis of variance when comparing more than two groups. Skewed data were analysed using Mann-Whitney test. After extra-articular mechanical alignment surgery, statistically significant improvements in medial tibial plateau depression were seen in the infantile ( P = 0.03) and juvenile ( P = 0.04) Blount's subgroups. Change in ADMTP was greater in patients who were operated on at age <17 years, before skeletal maturity ( P = 0.001). The improvement was likely due to ossification of unossified cartilage at the posteromedial proximal tibia and the remodelling potential of proximal tibia physis after mechanical realignment. Improvement of medial tibia plateau depression is possible after mechanical realignment without surgical hemiplateau elevation in cases of infantile and juvenile Blount's disease that present late for treatment, especially when the operation is performed before 17 years of age.

Biology and technology in the surgical treatment of malignant bone tumours in children and adolescents, with a special note on the very young.

PurposeThe main challenge in reconstruction after malignant bone tumour resection in young children remains how and when growth-plates can be preserved and which options remain if impossible.MethodsWe describe different strategies to assure best possible long-term function for young children undergoing resection of malignant bone tumours.ResultsDifferent resources are available to treat children with malignant bones tumours: a) preoperative planning simulates scenarios for tumour resection and limb reconstruction, facilitating decision-making for surgical and reconstructive techniques in individual patients; b) allograft reconstruction offers bone-stock preservation for future needs. Most allografts are intact at long-term follow-up, but limb-length inequalities and corrective/revision surgery are common in young patients; c) free vascularized fibula can be used as stand-alone reconstruction, vascularized augmentation of structural allograft or devitalized autograft. Longitudinal growth and joint remodelling potential can be preserved, if transferred with vascularized proximal physis; d) epiphysiolysis before resection with continuous physeal distraction provides safe resection margins and maintains growth-plate and epiphysis; e) 3D printing may facilitate joint salvage by reconstruction with patient-specific instruments. Very short stems can be created for fixation in (epi-)metaphysis, preserving native joints; f) growing endoprosthesis can provide for remaining growth after resection of epi-metaphyseal tumours. At ten-year follow-up, limb survival was 89%, but multiple surgeries are often required; g) rotationplasty and amputation should be considered if limb salvage is impossible and/or would result in decreased function and quality of life.ConclusionSeveral biological and technological reconstruction options must be merged and used to yield best outcomes when treating young children with malignant bone tumours.Level of EvidenceLevel V Expert opinion

Deformity Reconstruction Surgery for Blount's Disease.

Blount’s disease is an idiopathic developmental abnormality affecting the medial proximal tibia physis resulting in a multi-planar deformity with pronounced tibia varus. A single cause is unknown, and it is currently thought to result from a multifactorial combination of hereditary, mechanical, and developmental factors. Relationships with vitamin D deficiency, early walking, and obesity have been documented. Regardless of the etiology, the clinical and radiographic findings are consistent within the two main groups. Early-onset Blount’s disease is often bilateral and affects children in the first few years of life. Late-onset Blount’s disease is often unilateral and can be sub-categorized as juvenile tibia vara (ages 4–10), and adolescent tibia vara (ages 11 and older). Early-onset Blount’s disease progresses to more severe deformities, including depression of the medial tibial plateau. Additional deformities in both groups include proximal tibial procurvatum, internal tibial torsion, and limb length discrepancy. Compensatory deformities in the distal femur and distal tibia may occur. When non-operative treatment fails the deformities progress through skeletal maturity and can result in pain, gait abnormalities, premature medial compartment knee arthritis, and limb length discrepancy. Surgical options depend on the patient’s age, weight, extent of physeal involvement, severity, and number of deformities. They include growth modulation procedures such as guided growth for gradual correction with hemi-epiphysiodesis and physeal closure to prevent recurrence and equalize limb lengths, physeal bar resection, physeal distraction, osteotomies with acute correction and stabilization, gradual correction with multi-planar dynamic external fixation, and various combinations of all modalities. The goals of surgery are to restore normal joint and limb alignment, equalize limb lengths at skeletal maturity, and prevent recurrence. The purpose of this literature review is to delineate basic concepts and reconstructive surgical treatment strategies for patients with Blount’s disease.

Cross-Union Surgery for Congenital Pseudarthrosis of the Tibia.

Congenital Pseudoarthrosis of the Tibia (CPT) is a rare condition with a reputation for recurrent fractures and failure to achieve union. A large variety of surgical procedures have been attempted for the treatment of fractured cases of CPT with an average rate of union without refracture of only 50%. Intentional cross-union between the tibia and fibula has been reported to improve these results to 100% union with no refractures. This is a retrospective study of 39 cases of CPT in 36 patients treated by the Paley cross-union protocol with internal fixation, bone grafting, zoledronic acid infusion and bone morphogenic protein 2 (BMP2) insertion. All 39 cases of CPT united at the tibia and developed a cross-union to the fibula. Two patients had a persistent fibular pseudarthrosis, one that was later treated at the time of planned rod exchange and one that has remained asymptomatic. There were few postoperative complications. There were no refractures during the up to 7-year follow-up period. The most common problem was the Fassier-Duval (FD) rod pulling through the proximal or distal physis into the metaphysis (66.7%). This did not negatively affect the results and was remedied at the time of the planned rod exchange. The Paley Cross-Union Protocol is very technically demanding, but the results have radically changed the prognosis of this once sinister disease.

Pediatric Radial Neck Fractures: Which Ones Can Be Successfully Closed Reduced in the Emergency Department?

The purpose of this study is to examine pediatric patients with a radial neck fracture and determine the factors associated with a failed closed reduction (CR) in the emergency department (ED). A total of 70 patients with acute radial neck fractures were retrospectively reviewed. Inclusion criteria were: age 18 years or younger at time of injury, diagnosis of radial neck fracture without other associated elbow fractures, an attempt at CR with manipulation in the ED or immediate surgery, open proximal radial physis, and appropriate imaging to categorize the injury. Charts were reviewed and demographic data was obtained. Initial injury films were reviewed and the Judet classification was used to define fracture types/categories. CR was attempted on 41 patients. Twenty-nine patients went straight to surgery without a CR attempt. Compared with patients that had an attempted CR in the ED, patients that went straight to surgery had longer mean time from injury to ED presentation (5.6 d; P=0.0001), greater mean fracture angulation (55.0 degrees; P=0.001), and greater fracture translation (46.2%; P=0.001). When analyzing the patients that had a CR attempted in the ED, univariate statistical analysis demonstrated that ≥Judet 4 classification (P=0.03), greater amounts of fracture angulation (P=0.003), and a treatment delayed >24 hours from injury (P=0.007) were significant risk factors for failure of CR in the ED. Zero (0/10) patients with fracture angulation ≥60 degrees had a successful CR. Only 1/14 patients presenting >24 hours after injury had a successful CR in the ED. Circumventing sedation in the ED, and instead splinting for a planned surgical intervention may be a more efficient treatment method for pediatric radial neck fractures that present to the ED>24 hours after injury and/or have angulations ≥60 degrees. Adopting this new strategy may save time, reduce costs, and avoid possible harm/complications associated with sedation in the ED. Level III-prognostic.

Presumed bilateral patella cubiti in a six-month-old German shepherd dog

A six-month-old entire male German shepherd dog was presented for lameness of left thoracic limb and bilateral elbow deformity without trauma reported. Elbow radiographs and CT showed a large bony...

Leg Injury - Football

HISTORY: A 12-year old male quarterback sustained a right leg injury while cutting back across the field. He was running across the field and made a lateral cut to change directions, as this happened he tripped over himself and fell without a twisting motion. He landed on his right lateral leg with immediate pain to the fibular head. There was no numbness, tingling, weakness or radiation of pain however he had a noticeable limp. He presented to clinic 2 days later and denied any prior injuries or trauma to the area. PHYSICAL EXAMINATION:2 days post injury (PCP office) — No deformity, normal knee and ankle exams, no bony tenderness, moderate postero-lateral edema of proximal right lower leg, painful/antalgic gait, TTP lateral gastrocnemius and soleus, negative Thompson's.4 days post injury (Sports Medicine Clinic) — Consistent with prior exam, new findings: point TTP just distal to fibular head, decreased edema, negative squeeze test, negative ER test. DIFFERENTIAL DIAGNOSIS: 1. R fibular contusion 2. R knee apophysitis 3. LCL sprain 4. Gastrocnemius contusion/strain 5. Distal Bicep Femoris strain TEST AND RESULTS: XR: R Tib/Fib AP and Lateral radiographs 2 days after injury — Bones/joints/soft tissue appear unremarkable. Repeat XR 13 days post injury — subtle irregularity along the lateral aspect of the proximal fibula physis with associated periostitis. Final XR 20 days post injury — Noted irregularity along the lateral aspect of the proximal fibula physis with increased benign periostitis. FINAL WORKING DIAGNOSIS: Salter-Harris II fracture of R proximal fibula physis TREATMENT AND OUTCOMES: 1. Cam walker boot 3 weeks with weekly exams/XRs 2. 20 days out from injury completely normal RLE exam, no pain, full ROM, XRs suggestive for healing SH2 fracture; patient was able to return to football as tolerated. DISCUSSION: In isolation this is a very rare injury. There was one reported case of a SH-3 fracture that presented with initial knee injury and ROM deficits that was treated non-operatively. Most injuries to the proximal physis of the fibula occur in combination with an interosseous membrane/syndesmotic and distal tibiofibular injury - must rule out a Maisonneuve injury. The presenting complaint was pain and edema in the region of the soleus this may have been a soleus traction injury to the apophysis vs direct trauma from the fall.

The potential role of the Alsberg angle as a predictor of lateral growth disturbance of the capital femoral epiphysis in children with developmental dysplasia of the hip treated by closed reduction.

PurposeEarly diagnosis and prevention of lateral growth disturbance of the capital femoral epiphysis is challenging after treatment for developmental dysplasia of the hip (DDH). The aim of the study was to evaluate the radiographic changes of the Alsberg angle (AA) in normal children and those with DDH, and to assess the role of AA as a potential predictor of lateral growth disturbance of the capital femoral epiphysis.MethodsAA was measured on the anterior-posterior pelvic radiographs of 1000 normal children ranging in age from one to ten years and in 66 children (92 hips) with DDH treated by closed reduction (CR). A comparative analysis was performed.ResultsIn the normal children, mean AA decreased linearly with age, from 76° at age one year to 65° at age ten years, irrespective of gender and laterality. In children with DDH, the average AA was 81.5°(sd 3.9°; 74° to 87°) prior to CR; it was 75.9° (sd 4.5°; 68° to 83°) in normal children of the same age (p < 0.001). Among the 42 children (64 hips) with successfully and uneventfully treated DDH, AA reached normal values between the ages of five and six years. In contrast, children with lateral growth disturbance of the proximal femur physis (24 children, 28 hips) showed significantly higher AA values in comparison with the age-matched controls.ConclusionIn DDH patients with successful CR, AA could be expected to match normal values in children between the ages of five and six years. On the other hand, AA can be used as an early predictor for lateral growth disturbance of the capital femoral epiphysis.Level of EvidenceLevel III

Factors affecting the outcome in the correction of angular deformities around the knee using extraperiosteal tension band plate: A local experience

Objectives: The aim of this study is to reflect on our local experience with extraperiosteal tension band plate around the knee and the factors that affect the outcome. Methods: This is a retrospective review of 21 patients (34 limbs) and involving 35 segments gathered and treated during a period from 2007 to 2018 by a single surgeon employing a standardized technique. The inclusion criteria were all patients with coronal plane deformities around the knee with an open physis, regardless of pathological background. Patients who had previous or concurrent surgeries for the same problem were excluded from the study. Patients' age and body mass index were recorded. Mechanical axis deviation (MAD) distance, tibio-femoral (T-F) angle, mechanical lateral distal femoral angle, and mechanical medial proximal tibia angle were measured from a standing anteroposterior radiograph. Results: The average age was 6.5 years, and the mean duration of treatment was 13.6 months, with “sick physis” requiring longer durations. The mean rate of correction of T-F angle was 1.5°/month. The MAD distance improved at an average rate of 2.4 mm/month. The distal femur physis improved at a rate of 0.69°/month, while the proximal tibia physis improved at a rate of 0.58°/month. Conclusion: The severity of preoperative deformity influenced the rate of correction, and this is further influenced by the pathological background and physis treated, femora faster than tibiae. Patients with more than 3 years of growth remaining showed faster correction.

Bilateral radial and ulnar fractures in a red kangaroo (Macropus rufus).

An 11-month-old sexually intact male red kangaroo (Macropus rufus) was examined because of bilateral radial and ulnar fractures. Radiography of the forelimbs revealed bilateral, short oblique fractures in the proximal to mid diaphyses of the radii and ulnae. Fractures were overriding and moderately displaced. Wider than expected gaps were evident in the humeroulnar and humeroradial joints bilaterally. Although several physes remained open, no proximal radial physis was radiographically evident. Dual bone fixation was performed bilaterally, and dynamic luxation of the left radial head was identified and stabilized intraoperatively. Although satisfactory function of both forelimbs was evident at 8 weeks and 26 months after surgery, a persistent gait abnormality affecting the right forelimb was noted. Twenty-six months after surgery, radiography revealed bilateral proximal radial physes and resolution of the abnormally wide gaps in the humeroradial and humeroulnar joints. Despite dual bone fixation, synostoses formed bilaterally and may have contributed to the persistent lameness in the kangaroo's right forelimb. Veterinarians treating kangaroos should be aware of difficulties in determining skeletal maturity and planning fracture stabilization because of potential differences in skeletal growth and fracture healing, compared with other species. We described critical issues observed in the treatment and outcome of the kangaroo of the present report and provided lessons learned as well as potential explanations of these issues to facilitate future treatment of kangaroos with forelimb fractures.

Limb Salvage Using Non-hinged Endoprosthesis and Staged Correction of Leg-length Discrepancy for Children with Distal Femoral Malignant Tumors.

ObjectiveLimb salvage in pediatric patients remains a challenge. We describe a staged strategy. The procedure includes: (i) tumor removal and non‐hinged static endoprosthesis reconstruction; (ii) leg length discrepancy (LLD) correction by shoe lift or distraction osteogenesis; and (iii) maturity reconstruction by regular endoprosthesis. The aim of the study was to investigate the results of non‐hinged static megaprosthesis reconstruction and staged LLD correction in the treatment of malignant tumors in the distal femur in children.MethodsNon‐hinged megaprostheses were implanted in 12 pediatric patients with osteosarcoma in the distal femur. The prosthesis consists of a femoral component with constrained condylar knee (CCK) design, and a tibial component with a small‐diameter press‐fit stem and derotation fins. A posterior stabilizing polyethylene component is fixed on the tibial component. The cases were prospectively followed up with focus on the growth rate of adjacent uninvolved bone in the salvaged limb, joint stability, knee stability, function outcome, length discrepancy, and surgery‐related complications.ResultsThere were five girls and seven boys included in the study, with an average age at the time of primary surgery of 10.0 years (range, 8–12 years). All the tumors were located in the distal femur. The average follow up was 76.3 months (range, 24–139 months). The Ligament Augmentation and Reconstruction System (LARS) ligament was used in two patients to enhance the soft tissue reattachment and reconstruct medial collateral ligament (MCL). Ten patients were alive at the final follow‐up and two had died of lung metastases. Expected LLD was 6.7 cm (range, 3.0–13.2 cm) at initial surgery. At the final follow‐up, nine patients reached skeletal maturity and the actual LLD at the femur was 5.3 cm (range, 3.0–10.1 cm), excluding 1 cm correction at initial surgery by endoprosthesis. The proximal tibia physis showed an average of 86.7% (range, 56.5%–100%) growth of the contralateral side. The mean reduction in tibial length was 1.2 cm (range, 0.5–4.7 cm). Six patients received distraction osteogenesis at a mean length of 5.4 cm (range, 3.0–9.1 cm). Range of knee movement was between 85° and 125°, with an average of 102.5°. The Musculoskeletal Tumor Society 93 score of patients alive was 80.6 (range, 60–90).ConclusionNon‐hinged static megaprosthesis followed by LLD correction with shoe lift or staged distraction osteogenesis appears to be an alternative option to treat children with malignant bone tumors around the knee.