Risk Of Growth Disturbance Research Articles

Disturbance of Growth in Pediatric Patients Due to Osteomyelitis Caused by Growth Plate Infection.

Osteomyelitis, a severe bone infection, poses a multifaceted challenge to healthcare professionals. While its pathophysiology and treatment have been extensively studied, the impact of osteomyelitis on skeletal growth, particularly in pediatric patients, is an area that warrants attention. This abstract highlights the significance of understanding and managing growth disturbances in osteomyelitis, providing key findings and recommendations for clinicians. Understanding growth disturbance in osteomyelitis is essential because it can lead to lifelong consequences for pediatric patients. The infection may affect the growth plate, leading to limb length discrepancies, angular deformities, and functional impairments. These complications not only diminish the quality of life but also pose a substantial economic burden on the healthcare system. Therefore, early recognition and intervention are crucial. Key findings indicate that the risk of growth disturbances in osteomyelitis is particularly high in pediatric patients due to the vulnerability of the growth plate. Timely diagnosis, appropriate management, and targeted interventions can mitigate the long-term sequelae of growth disturbances. These include utilizing advanced imaging techniques to assess the extent of growth plate involvement, optimizing antibiotic therapy, and employing surgical techniques like epiphysiodesis, guided growth, or corrective osteotomies. Additionally, fostering a multidisciplinary approach that involves orthopedic surgeons, infectious disease specialists, and pediatric endocrinologists is vital to achieving successful outcomes. Recommendations for managing growth disturbance in osteomyelitis encompass early detection, meticulous monitoring, and a tailored treatment plan. Healthcare providers should remain vigilant for signs of growth plate involvement in osteomyelitis patients, especially in the pediatric population. A thorough evaluation, including advanced imaging and clinical assessment, is essential for accurate diagnosis. Close collaboration between specialists to address the infection and its skeletal consequences is crucial. Furthermore, patient and family education plays a pivotal role in fostering compliance with the treatment regimen. In conclusion, understanding and managing growth disturbances in osteomyelitis is paramount, particularly in pediatric patients. The implications of growth plate involvement are significant, and timely intervention is essential to prevent lifelong consequences. By implementing a comprehensive approach that combines accurate diagnosis, multidisciplinary collaboration, and patient education, healthcare professionals can enhance the quality of life and well-being of those affected by this challenging condition.

The Risk of Growth Disturbance Is Low After Pediatric Anterior Cruciate Ligament Reconstruction With a Femoral Growth Plate Sparing Technique

To evaluate radiological tibial and femoral length and axis growth disturbances, as well as clinical outcome in skeletal immature anterior cruciate ligament reconstruction (ACLR) patients treated with a femoral growth plate-sparing ACLR technique. Skeletally immature patients who underwent operation between 2013 to 2019 with ALCR using the femoral growth plate-sparing technique were investigated with follow-up after growth plate closure. The inclusion criteria were isolated ACL rupture in patients with open physis in the distal femur and proximal tibia seen at plain radiography. The minimum follow-up time was 29 months. Patients were evaluated with full extremity radiographs measuring limb length discrepancy and coronal knee alignment compared to contralateral leg, as well as clinical evaluation with Rolimeter measurements and the Knee Osteoarthritis Outcome Score (KOOS), the International Knee Documentation Committee subjective knee form (IKDC), and Tegner Activity Scale scores. Sixty-five patients were examined with radiography, and 52 patients were assessed with clinical examination. The mean follow-up time was 68 (range, 29-148) months. No limb-length discrepancy (-0.65 mm [confidence interval {CI},-2.21 to 0.92]) or angular deformity at tibia (-0.25° [CI,-0.78° to 0.28°]) was found. There was a small but statistically significant different angular deformity at the distal femur compared to the contralateral leg (-1.51° [CI,-2.31 to-0.72]) at follow-up. The side-to-side difference in knee laxity at follow-up was 2.4 mm. At follow-up the KOOS Sport, KOOS Quality of Life (QoL), IKDC, and Tegner scores were 80, 75, 86, and 5, respectively. Sixty-seven percent of the patients met the Patient Acceptable Symptom State, and 52% reported results exceeding the KOOS Sport MCID Level and 69% the KOOS QoL level. Femoral physis-sparing ALCR is associated with a low risk of alignment and length disturbances. The technique provides otherwise good subjective clinical outcome and knee stability. Level IV, therapeutic case series.

Analysis of Growth After Transphyseal Anterior Cruciate Ligament Reconstruction in Children.

Pediatric transphyseal anterior cruciate ligament reconstruction (ACLR) bears several advantages and is widely used. The main concern is the risk of growth disturbance. Our purpose was to investigate the incidence and risk factors of growth disturbance in skeletally immature patients who underwent transphyseal ACLR. We hypothesized that this procedure would generate neither clinically relevant limb length discrepancy (LLD) nor axis deviation. This prospective, consecutive, single-center series included skeletally immature patients who underwent primary transphyseal ACLR using semitendinosus tendon autograft, with a 2-year follow-up bone length standing radiograph of both lower limbs from pelvis to ankle in anterior posterior view. Lower limb length, mechanical axis deviation (MAD), lateral distal femoral angle (LDFA), and medial proximal tibial angle (MPTA) were measured. The definition of postoperative growth disturbance was defined as ≥10mm for LLD or ≥3 degrees for axis deviation in comparison to the contralateral lower limb. Predictive variables included age at surgery, gender, side, and diameter of bone tunnels. Student or Mann-Whitney test was used for numerical variables, and Chi-square test or Fisher exact test was used for categorical variables. P values <0.05 were considered statistically significant. Fifty consecutively treated patients were included. Forty-seven patients (31 boys, 16 girls) with a mean age of 13.2 years (range, 9 to 16) at the time of surgery were available for analysis. Six patients had an LLD of at least 10mm. Twenty-five patients had a difference in MPTA of a least 3 degrees (range, 5 to 8). Sixteen patients had a difference in LDFA of a least 3 degrees (range, 4 to 9). No patients presented with a clinical deformity or related symptoms. Regarding coronal alignment, there was no statistical difference in mechanical axis deviation, LDFA, or MPTA. Gender, side, age, and bone tunnel diameter did not influence growth disturbance. Transphyseal pediatric ACLR generated a high rate of growth disturbances (leg length discrepancy and axis deviation) although none clinically relevant. Mild proximal tibial axis deviation in patients operated on near skeletal maturity should be further investigated. Level III. Case-control study.

Lateral Meniscus Allograft Transplantation in a Skeletally Immature Patient

Background: Lateral meniscus deficiency in young patients typically results from irreparable lateral meniscus tears, often associated with discoid meniscus. Such cases present a challenging clinical scenario given the known natural history of meniscus deficiency leading to degenerative lateral knee compartment changes. Managing this problem in a skeletally immature patient presents additional clinical and surgical considerations. Indications: Lateral meniscus allograft transplantation (LMAT) is indicated in patients with prior total or subtotal lateral meniscectomy resulting from irreparable lateral meniscus tears, with the goal of providing chondroprotection to the lateral compartment of the knee. Patients are assessed preoperatively for ligamentous stability of the knee, mechanical alignment, and associated chondral injuries to determine whether secondary procedures may be indicated. Technique Description: We present an all-arthroscopic technique for LMAT using small bone plugs in the anterior and posterior meniscus roots secured through 2 separate anatomic root drill tunnels tied over a bone bridge. The meniscus allograft is further secured using an outside-in suture repair technique. Special attention is given to meniscus allograft preparation, anatomic meniscus root identification, and drilling using a minimally disruptive transphyseal technique. Graft passage, suture management, and meniscus fixation and repair are also highlighted. Results: Anticipated outcomes from LMAT in skeletally mature patients are excellent, particularly if preexisting chondral degenerative changes are not present. Prior studies with greater than 7-year follow-up in adolescent patients undergoing meniscus allograft transplantation have shown reoperation rates of less than 6% with no growth disturbances noted, with most patients able to return to their prior level of sport. Computed tomography modeling data using this technique shows a proximal tibial physeal surface area disruption of less than 2.5%; therefore, the risk of growth disturbance is very low. Discussion/Conclusion: The surgical technique demonstrated here offers a safe and effective approach for the management of lateral meniscus deficiency after subtotal lateral meniscectomy for irreparable meniscus tears in skeletally immature patients. The chondroprotective effect of the lateral meniscus can be restored with an anatomically placed lateral meniscus allograft with minimal disruption to the proximal tibial physis.

Effect of Psychosocial Factors on Growth

Genes, hormones and factors such as nutrition and psychosocial environment affect growth. What is the significance of various psychosocial factors on growth? Evaluation of results of a working meeting of paediatric endocrinologist with current literature research. Psychosocial deprivation in children can be associated with growth hormone deficiency (GHD) and short stature. GHD can be reversed by a change of environment and psychosocial support. War and migration are often associated with underweight, growth disturbances and poor health care. These factors can improve after the end of conflicts, but children often remain too short. Consumption of alcohol or opiates during pregnancy are associated with lower birth weight and increased risk of early and small for gestational age (SGA) childbirth. Children with attention deficit hyperactivity disorder show a slight slowdown in growth after they started stimulant therapy. However, they reach normal adult height. In children with idiopathic short stature, psychosocial causes should be taken into account in the differential diagnosis. Notably there is an increased risk of growth disturbances in children from conflict regions or after prenatal drug exposure.

Arthroscopic Suture Fixation of Comminuted Tibial Eminence Fractures: Hybrid All-Epiphyseal Bone Tunnel and Knotless Anchor Technique

Tibial eminence fractures most commonly occur in young children and adolescents with open physes. Displaced fractures are typically treated with surgical reduction and fixation. Multiple arthroscopic techniques and fixation constructs have been described. However, many of these techniques violate the physis with a risk of growth disturbance and deformity from asymmetrical physeal growth. This technical note details a surgical technique of arthroscopically assisted suture fixation of a comminuted tibial spine fracture using all-epiphyseal bone tunnels and knotless anchors. In this construct, sutures passing through the substance of the anterior cruciate ligament help to eliminate residual laxity, all-epiphyseal bone tunnels avoid growth disturbance, and suture anchors reduce persistently displaced anterior comminution.

RE-TEAR AND RE-OPERATION RATES FOR PEDIATRIC AND ADOLESCENT ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION

BACKGROUND Anterior cruciate ligament (ACL) injuries have become increasingly common in pediatric and adolescent patients over the last several decades, as this population has become more involved in athletic competition. ACL injuries in skeletally immature patients had historically been treated conservatively with bracing and activity modification; however, poor outcomes including extensive chondral and meniscal damage, increased recurrent instability, and increased sports drop out rates have been observed. Recognition of these poor outcomes has led to a shift towards early operative treatment, resulting in a significant rise in the number of pediatric ACL reconstructions being performed. Yet, a higher failure rate has been noted in this younger population within larger adult cohort studies. The purpose of this study was to evaluate the re-tear and re-operation rates in pediatric and adolescent ACL reconstruction. METHODS The was a retrospective review of pediatric and adolescent patients treated at a single tertiary children’s hospital for ACL reconstruction from 2011 to 2017 by the same pediatric orthopedic surgeon. Review of the electronic medical record was performed to obtain patient demographics, preoperative clinical and radiographic findings, operative notes, and postoperative outcomes. Re-tear and re-operation rates were calculated. RESULTS A total of 308 patients were identified during the study period of which sixty-six percent were female. The mean age of patients was 15.8 years with a mean follow-up of 1.8 +/- 0.8 years. Two-hundred fifty-three hamstring autografts (mean age 15.7+/- 4.1 years) and 55 bone tendon bone autograft (mean age 16.9 +/- 1.45 years) were performed. Two hundred forty-three patents had adult-style reconstructions performed, 40 had transphyseal reconstructions, 24 had partial transphyseal reconstruction, and 1 patient had an all-epiphyseal reconstruction. Average hamstring graft size was 8.3 mm +/- 0.5 mm and all BTB graft were 9 mm. The overall graft re-tear rate was 8.2%. The overall re-operation rate was 13.2% (17 revisions, 5 medial meniscus repairs, 3 I+D’s, 2 cyclops debridements, 1 removal of hardware, and 1 manipulation under anesthesia). The highest re-tear (12.5%) and re-operation (22.5%) rates were found in patients who underwent a transphyseal reconstruction. No growth disturbances which required surgical intervention were noted. CONCLUSIONS / SIGNIFICANCE Pediatric and adolescent ACL reconstruction can be performed safely without a risk of growth disturbance. Patients had a high re-tear and re-operation rate; particularly in patients who underwent transphyseal reconstruction. Strategies must be developed to decrease the re-tear and re-operation rate in this population.

Osteotomy of Malunited Metacarpals and Phalanges in Pediatric Patients

Objectives: Malunion of the phalanges and metacarpals in the hand cause malposition, pain, and functional impairment that can be treated by osteotomy of malunited bone. Posttraumatic malunion in pediatric hand is a rare condition. Growing bone and its small size need “special” approach to the problem. Procedure must preserve growing ability, osteosynthetic material must be fine, and postoperative care has to be aimed not only on deformity correction but also on preserving range of motion. Authors present group of 12 pediatric patients treated by osteotomy of the phalanx or metacarpal. They describe specifics of the technique used, present results, and discuss complications. Patient and Methods: Thirteen osteotomies in 12 patients with “virgin“—nonoperated posttraumatic malunion of phalanges and metacarpals were performed by senior author between 2001 and 2014. Four intraarticular corrections and 7 extraarticular corrections were used for various malunions. Authors used different approaches to reflect bone from dorsal, dorsolateral or lateral side, according to type of deformity and type of osteotomy. Eight cases were corrections of proximal phalanx in proximal interphalangeal joint region, 2 at the base of proximal falanx, 1 at the base of middle phalanx, 1 at the head of middle phalanx and 1 at the base of first metacarpal. One patient was treated by sequential osteotomy repeated after 3 years due to growth disturbance at the base of middle phalanx. In 3 patients bone graft from distal radius was used to fill the gap in open wedge osteotomy. Removal of osteosynthetic material was performed in 4 cases. In 3 patients and 4 osteotomies no osteosynthetic material was used. All patients had a cast for 1 to 2 weeks after surgery followed by protected mobilization until x-ray healing of the bone. Results: All patients healed uneventfully. Deformity was fully reconstructed in 9 patients and 3 had some residual deformity with functionally and aesthetically much better result. Range of motion was preserved or reconstructed in all. Functional impairments like triggering or scissoring of the fingers were relieved. Pain subsided to zero in all. Discussion: Symptomatic malunion in fingers and metacarpals causing functional impairment is indicated to surgical treatment and osteotomy of malunited bone. Soft tissue coverage and small size of the bone put great requirements to the operating surgeon due to risk of breakage of the bone, necrosis of small bony fragments, loosening or interference of osteosynthetic material, malposition of the bone, and functionally risk of loosing range of motion after correction. Malunion in children enhances these requirements by risk of growth disturbance and smaller size of the operated bone. Anyway if functional impairment is present, osteotomy is indicated. With individualized approach to osteotomy, osteosynthesis, and postoperative care, it leads to a good functional result.

Long-term Clinical and Radiographic Results After Delayed Anterior Cruciate Ligament Reconstruction in Adolescents

Background: The risk of further intra-articular damage associated with nonoperative or delayed anterior cruciate ligament (ACL) reconstruction must be considered against the risk of growth disturbance with early reconstruction and transphyseal drilling. Long-term follow-ups after the surgical treatment of ACL injuries in adolescents are rare. Purpose: To evaluate results 10 to 20 years after ACL reconstruction in terms of the radiographic presence of osteoarthritis, clinical assessments, and health-related quality of life in patients who were adolescents at the time of surgery. Study Design: Case series; Level of evidence, 4. Methods: Thirty-two adolescents (mean age, 15.2 years [range, 12-16 years]; 11 boys, 21 girls), with a symptomatic unilateral ACL rupture, underwent reconstruction using bone–patellar tendon–bone (n = 10) or hamstring tendon (n = 22) autografts at an almost skeletally mature age according to Tanner stage 4. Twenty-nine patients (91%) underwent clinical, radiographic, and health-related quality of life assessments after 10 to 20 years (mean, 175 months). Results: The mean time between the injury and index surgery was 11.6 months. The reconstructed knee had significantly more osteoarthritic changes compared with the noninvolved contralateral knee (P = .001). Preoperatively, the median Tegner activity level was 4 (range, 2-8), and the median Lysholm knee score was 75 (range, 50-90) points. At follow-up, the respective median values were 4 (range, 1-7) and 84 (range, 34-100) points (P = not significant [preoperatively vs follow-up]). The median finding for the single-legged hop test was 84% (range, 0%-105%) preoperatively and 93% (range, 53%-126%) at follow-up (P = .01). At follow-up, muscle strength measurements displayed more than 90% of the noninvolved leg in both extension and flexion. The manual Lachman test result was significantly improved at follow-up compared with preoperatively (P < .001). The 36-item Short Form Health Survey (SF-36) revealed scores comparable with those of healthy controls. The mean EuroQol (EQ-5D) score was 0.86 ± 0.12. The Knee injury and Osteoarthritis Outcome Score (KOOS) values were lower in all dimensions compared with age-matched healthy controls. Conclusion: In the long term, patients who were adolescents at the time of ACL reconstruction revealed significantly more radiographically visible osteoarthritic changes in their operated knee than in their noninvolved contralateral knee. Clinical outcomes and health-related quality of life are comparable with those of healthy controls.

Paediatric bone and joint infections are more common in boys and toddlers: a national epidemiology study

Little is known about bone and joint infections (BJIs) in children, despite the risk of growth disturbance. This study examined BJIs epidemiology using the French National Hospital Discharge Database (HD). Any child <15years hospitalized with an HD diagnosis of BJI, alone or in combination with sepsis or orthopaedic procedure, was included. The majority of BJIs (96%) were haematogenic infections. We conducted descriptive analyses to evaluate epidemiological and economic outcomes of paediatric haematogenic BJIs. There were 2592 paediatric patients with 2911 BJI hospitalizations and an overall incidence of 22 per 100000. BJIs occurred more frequently in boys than girls (24 vs 19 per 100000) and in toddlers. Septic arthritis (52%) and osteomyelitis (44%) were the most frequent infections, 16.6% of patients had a micro-organism coded (61% were Staphylococci) and 13% of had comorbidities. The mean hospital stay was 8.6days, costing approximately €5200 per BJI stay. This national study of paediatric BJIs in France showed a higher prevalence in toddlers and boys and demonstrated that the HD database can be used to study BJIs. However, the number of BJI cases was maybe overestimated by coding reactive arthritis as septic arthritis in the absence of bacterial evidence.

Current Concepts of Diagnosis and Management of ACL Injuries in Skeletally Immature Athletes

Anterior cruciate ligament (ACL) injuries in skeletally immature athletes are encountered with increasing frequency. The management of such injuries is controversial. Nonsurgical management often results in functional instability and a higher risk of meniscal and chondral injury to the knee. Conventional methods of ACL reconstruction carry the risk of growth disturbance because of iatrogenic damage to the physes around the knee. Multiple cases of growth disturbance have been reported. This article discusses the relevant anatomy, natural history, risk factors, treatment, and prevention of ACL injuries in skeletally immature patients. Surgical treatment is based on physiologic age. For prepubescent patients, we recommend physeal-sparing combined intra-articular/extra-articular reconstruction with autogenous iliotibial band. In adolescent patients with significant growth remaining, we recommend transphyseal ACL reconstruction with hamstrings autograft and fixation away from the physes. In older adolescent patients, we recommend conventional adult ACL reconstruction with autogenous hamstrings or patellar tendon.

All-epiphyseal Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients

Treating ACL injuries in prepubescent patients requires balancing the risk of chondral and meniscal injuries associated with delaying treatment against the risk of growth disturbance from early surgical reconstruction. Multiple physeal respecting techniques have been described to address this vulnerable population; however, none restore the native ACL attachments while keeping the graft and fixation entirely in the epiphysis. We describe a technique of all-epiphyseal ACL reconstruction for use in prepubescent skeletally immature patients. Intraoperative CT scanning with three-dimensional (3-D) reconstruction was used to confirm the precise localization of the all-epiphyseal femoral and tibial tunnels. The femoral tunnel is drilled entirely in the epiphysis of the lateral femoral condyle. The tibial tunnel is drilled from inside-out to the level of the tibial physis using a retrograde drill. Fixation of the soft tissue graft is achieved with a retrograde interference screw in the tibia and an interference screw in the femur. Case examples are presented for three boys aged 10-12, Tanner Stage 1 development, with a minimum followup of 1 year. All three patients had stable knees based on Lachman and KT-1000 testing and no evidence of growth disturbance. All had full ROM and symmetric strength for knee flexion and extension. All patients returned to their sports activities using a custom ACL brace. Although longer-term followup will be necessary, this technique provides for an anatomic all-epiphyseal-based ACL reconstruction using intraoperative 3-D imaging to minimize the risk of growth disturbance. Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Hamstring Allograft Anterior Cruciate Ligament Reconstruction in the Skeletally Immature Patient

Reconstruction of the anterior cruciate ligament (ACL) remains the most appropriate treatment for adolescent patients who are ACL deficient. This article reviews the indications for adolescent ACL reconstruction, potential risks, and the technique for allograft HISTORICAL PERSPECTIVE In the last 20 years, there has been an increase in the literature pertaining to the management of a skeletally immature patient with anterior cruciate ligament (ACL) injuries. With increasing involvement of children in sports, an increase in ACL injuries in this population has been reported.' In a survey of members of the Herodicus Society and the ACL Study Group, Kocher et al2 reported that the members studied a mean of 5.8 pediatric patients with ACL injuries annually. In addition, 78% of those surveyed stated that they had performed an ACL reconstruction on a skeletally immature patient within the previous year. Historically, ACL reconstruction in skeletally immature patients has been discouraged because of the theoretical risks of damage to the physes and the risk of growth disturbance. However, the case series data available in the literature have not supported a significant pattern of leg length discrepancy or angular deformity caused by ACL reconstruction in adolescent patients.310 Controversy still exists between nonoperative management and surgical reconstruction of these patients based on the potential risks of both treatment options. Nonsurgical treatment risks an unstable knee and further damages the meniscal structures and articular cartilage. Anterior cruciate ligament injuries in adolescents behave similarly to those injuries in adults; chondral and meniscal injuries are common. Operative reconstruction risks potential damage to the growth plate. Previous research has shown that 21% to 100% of pediatric patients with ACL injuries will have a concomitant meniscal injury.1'4'5'1014 In addition, there is a risk of exacerbating initial injury or new meniscal damage if the knee remains chronically unstable.5'15'16 Growth plate arrest after ACL reconstruction, although a concern, has only been infrequently reported.2'17'18 Furthermore, the treatment of physeal arrest is soft tissue interposition, and for this reason, hamstring tendon grafts have

Growth disturbances associated with untreated benign bone cysts.

The occurrence of benign bone cysts adjacent to an active physis may be associated with a physeal arrest. That arrest may result from physeal penetration of the cysts itself, secondary pathologic fracture or the result of surgical curettage. The pre-treatment X-rays of patients attending the Bone Tumor Clinic at the Children's Hospital and Medical Center were reviewed. Those patients presenting with a bone cyst were identified and the affected side was compared to the normal side in order to determine growth discrepancies. Three cases of benign bone cysts are presented that were located adjacent to a growing physis nad produced growth disturbance in the absence of surgical intervention. The risk of growth disturbance in itself should not be a contraindication to surgical intervention.

Physeal Fractures About the Knee

The knee is the most common site of injury in childhood sports, and with increased participation in organized sports, the potential for knee injuries has accordingly increased. The epiphyses and apophyses provide a site of injury unique to the immature patient. The distal femoral and proximal tibial physes and the tubercle apophysis respond differently to acute and repetitive load and often provide less resistance to traumatic forces than do surrounding ligament and bone. Treatment of displaced physeal fractures about the knee remains one of the more difficult problems in orthopaedics. Even with appropriate conservative or surgical treatment, a successful outcome is not ensured. The Salter-Harris classification system provides general guidelines regarding the risk of growth disturbance, but there are no clinical methods for quantifying the true extent of physeal damage in an acute injury. Ultimately, the value of a treatment method must be evaluated on the basis of not only the restoration of articular congruity and physeal anatomy but also the restoration of physeal function, as evidenced by the continuation of normal growth. The mechanism of injury, clinical evaluation, treatment, and outcomes for all epiphyseal injuries about the knee are discussed, as well as differences from adult injuries.