Tibial Physis Research Articles

Oblique proximal tibial osteotomy for the correction of tibia vara in the young.

Proximal tibial osteotomy in the growing patient historically has been associated with a high rate of neurovascular complications and malunion. Here is reported a technique of valgus proximal tibial osteotomy, of the incomplete closing wedge type, that has avoided neurovascular compromise while achieving reliable correction and rapid bony union. Oblique proximal tibial valgus osteotomies with lateral tension plate fixation were performed on 18 tibiae in 14 patients (age range, 5-25 years) with tibia vara. The primary diagnosis was Blount's disease in 13 tibiae, achondroplasia in 2 tibiae, multiple epiphyseal dysplasia in 2 tibiae, and hypochondroplasia in 1 tibia. No postoperative plaster immobilization was necessary. All patients were able to bear weight fully by 8 weeks after surgery. Average angular correction was 18 degrees. One patient had overcorrection because of an unrecognized intraoperative fracture of the media] tibial cortex. There were no neurovascular complications. No growth disturbance of the proximal tibial physis was noted. Oblique proximal tibial osteotomy with tension plate fixation successfully corrected varus deformity of the proximal tibia in the growing patient without damage to the proximal tibial physis or neurovascular compromise.

Longitudinal deficiency of the fibula. Operative treatment.

We reviewed the results of early amputation and prosthetic fitting in twenty-five children (thirty-one extremities) who had longitudinal deficiency of the fibula and were managed between 1977 and 1992. The median age at the time of the initial operation was thirteen months (range, eight months to nine years and eight months). The median duration of follow-up was eight years and ten months (range, two years and six months to sixteen years and eleven months). A Syme amputation was performed on fifteen extremities (thirteen children), and a modified Boyd amputation (which included resection of the distal tibial physis) was performed on sixteen extremities (thirteen children). (One child had a Syme amputation on one side and a Boyd amputation on the other and is thus included in both groups). In twenty-seven extremities, simultaneous excision of the fibular anlage was performed to prevent the development of a deformity secondary to the potential tethering effect. In twelve extremities, a diaphyseal osteotomy of the tibia also was performed to correct tibial bowing and to improve the mechanical alignment of the extremity. At the time of follow-up, the patients who had had a Syme amputation had more problems related to reformation of the calcaneus, instability of the heel pad, prosthetic suspension, and excessive length of the residual extremity. The modified Boyd amputation improved the function of the heel pad and the prosthetic suspension and provided the optimum length of the residual extremity. We also found that an early diaphyseal osteotomy of the tibia to correct severe bowing improved prosthetic fitting. This study did not support the concept that early resection of the fibular anlage or a diaphyseal osteotomy of the tibia prevents the development of hypoplasia of the lateral femoral condyle and associated genu valgum deformity.

Acute fracture of the distal tibial physis: role of gradient-echo MR imaging versus plain film examination.

Recent reports indicate that, compared with MR imaging, plain film radiography often underestimates the extent of injury in children with physeal fracture-separation. Such underestimation may have significant therapeutic and prognostic outcomes. We performed this study to assess the benefit of MR imaging compared with plain film radiography in the diagnosis and immediate treatment of acute fractures of the distal tibial physis. Twenty-nine patients with acute fractures, including 15 Salter-Harris II, four Salter-Harris III, four Salter-Harris IV, and six triplane fractures, were prospectively examined by MR imaging with gradient-echo sequences. The MR images were compared with plain film radiographs. All cases were reviewed in a blind fashion by two experienced radiologists to determine the Salter-Harris classification on the basis of first plain film radiographs and then MR images. Two experienced pediatric surgeons were asked to propose treatment on the basis of first plain film radiographs and then MR images. Both the radiologists and the surgeons were asked to rate the two techniques in terms of degree of confidence and overall diagnostic effectiveness. Only 1 or 29 fractures (3%) was misclassified by plain film radiography. MR imaging never caused the treatment plan to be modified. However, the position of fracture fragments in Salter-Harris IV and triplane fractures was always better appreciated on MR images, facilitating more accurate surgical treatment. Except for those in the misclassified fracture, all other fracture lines were seen on both plain film radiographs and MR images but were more easily seen on MR images. Gradient-echo MR imaging allowed easier assessment of fracture lines than did plain film radiography, but the latter technique remains the primary means of evaluating epiphyseal injuries. For acute fractures of the lower extremity of the tibia, gradient-echo MR imaging should be limited to complex fractures and to cases in which the classification of a fracture on the basis of plain film evaluation is uncertain.

Direct Reduction with Indirect Fixation of Distal Tibial Physeal Fractures: A Report of a Technique

Summary Displaced intraarticular fractures of the distal tibia in children often require open reduction and internal fixation. Displaced epiphyseal fractures in the sagittal plane may be difficult directly to visualize from a standard medial malleolar incision, so accurate reduction may be impossible. Approaching the ankle joint by anterior arthrotomy, the fracture line can be directly visualized and accurately manipulated and reduced. However, access to the medial malleolus for insertion of internal fixation devices may be difficult from an anterior incision. We have found that after anterior arthrotomy and open reduction, rigid fixation can be placed percutaneously from medially or, in exceptional cases, from laterally under fluoroscopic control. The physis and talocrural joint can be seen and avoided in the growing child. Thirteen cases fixed by this method are reported. At 12.2-month average follow-up, clinical results were excellent. There were no instances of joint degenerative changes but one growth derangement.

Medial physeal stapling for primary and secondary genu valgum in late childhood and adolescence

We report the results of medial physeal stapling in 16 knees with primary genu valgum and 27 with secondary genu valgum. In the primary group, stapling was undertaken at a mean chronological age of 12 years in girls and 13 years in boys. The medial femoral physis was stapled in ten knees and the medial femoral and tibial physes in six knees. At skeletal maturity, all patients had excellent or good leg alignment. Secondary genu valgum is due to skeletal dysplasia, haematological or endocrine disorders, or to juvenile chronic arthritis. Stapling was at a mean chronological age of 11 years in girls and 14 years in boys. The medial femoral physis was stapled in 13 knees, the medial tibial physis in three and both in 11 knees. At skeletal maturity, 85% had excellent or good leg alignment, and correction had occurred within one year. Two of the poor results were due to staple extrusion from osteoporotic bone, and two to overcorrection. Rebound growth was minimal and unpredictable after the removal of staples. Medial physeal stapling is a suitable method of treatment for both primary and secondary genu valgum in late childhood and in adolescence. At least one year of knee growth is required to achieve correction, and care is needed to avoid overcorrection of the secondary genu valgum.

Pediatric tibial eminence fractures: Arthroscopic cannulated screw fixation

Two pediatric tibial eminence fractures were arthroscopically reduced and fixed with cannulated screws. At 2-year follow-up, anterior tibial translatory laxity was normal and the pivot shift test was negative. In one case, the screw transgressed the proximal tibial physis; however, neither case showed evidence of proximal tibial growth arrest.

Normal maturing distal tibia and fibula: changes with age at MR imaging.

To describe the normal appearance of the maturing distal tibia and fibula at magnetic resonance (MR) imaging. The authors retrospectively studied 50 MR examinations of patients aged 2 months to 21 years, dividing them into six developmental groups according to the appearance of the distal tibia and fibula. Epiphyseal ossification, physeal closure, and the signal characteristics of physeal cartilage were evaluated. Distal tibial epiphyseal ossification and physeal closure both began anteromedially and usually occurred earlier than in the fibula. The tibial physis developed an anteromedial undulation (Kump hump) before closure; volume averaging at the Kump hump simulated premature closure. The cartilaginous epiphysis had a lower signal intensity than the physis on T2-weighted images. The physis was most conspicuous on gradient-recalled-echo and fat-suppressed spin-echo proton-density-weighted images. Developmental cartilaginous and bone changes in the distal tibia and fibula follow a definite pattern and are well seen at MR imaging.

Percutaneous epiphyseodesis.

The records of 29 patients who underwent epiphyseodesis of 56 physes in which a percutaneous (minimal incision) technique was used were reviewed. Length of surgery averaged 36 min per physis. Growth arrest was achieved in every instance. There were no cases of unplanned angular growth, no deep infections, and no difficulties in regaining full joint motion were reported. Epiphyseodesis of the proximal tibial physis was performed on 16 patients without epiphyseodesis of the proximal fibula, yet symptoms attributable to fibular overgrowth were not reported. Some technical variations that have evolved in our procedure are described.

Oblique metaphyseal tibial osteotomy for correction of adolescent Blount's disease

An oblique osteotomy of the proximal tibia allows for correction of the multiplanar deformity of adolescent Blount's disease. The procedure is performed through a small, cosmetically acceptable incision, minimizing soft tissue dissection, and avoids the tibial physis. The single plane of the oblique osteotomy simultaneously corrects angulation and rotation and maintains maximum bony contact for rapid, healing. With this procedure, the tibia may be stabilized by a cast or external fixation. Results of the procedure are good, and the complications are less than those reported by other types of osteotomies of the proximal tibia for Blount's disease.

けい骨粗面部成長軟骨損傷後に生じた反張膝の治療経験

The formation of a genu recurvatum after partial growth arrest of the proximal tibial physis is uncommon. We report the case of a 16 years old male patient with a genu recurvatum of 30 degrees. He sustained a femoral fracture in a traffic accident when he was 9 years old, and we believe that he incurred a physeal injury at the same time. He was managed successfully by an open wedge osteotomy and bone-grafting.

Tibial physeal changes in renal osteodystrophy: lateral Blount's disease.

In a group of 27 children with chronic renal failure and renal osteodystrophy, we identified eight patients with significant involvement of the proximal tibial physis (15 knees). The radiographic changes observed were analogous to those observed in tibia vara (Blount's disease) but involved the lateral physis rather than the medial physis. This observation is offered as further evidence that such changes are related to eccentric weight-bearing rather than alternative etiologies such as trauma, infection, or heredity.

Proximal Tibial Skeletal Traction for Femoral Shaft Fractures in Children

A proximal tibial skeletal traction in the treatment of femoral shaft fractures in the growing child has been reported to result in complications such as knee pain, knee joint subluxation, and growth disturbance. For the last 15 years, the authors used a single screw (instead of the Kirschner wire) inserted in the tibia perpendicular to the surface and well below the tibial tubercle physis. With the traction applied to this screw and the leg in a 90-90 position or resting on a Braun splint, none of the previously described complications were observed. This modification of the proximal tibial skeletal traction is a simple, quick, and safe method in the treatment of femoral shaft fractures in children.

Compression (Salter-Harris Type V) Physeal Fracture

Histologic evidence of damage to the proximal tibial physis of immature rats was documented in greater than 30% of hind limbs subjected to a valgus and compressive force. The lesion was consistent with that theorized for the Salter-Harris Type V fracture. Two additional groups of immature rats were subjected to the same insult and followed to maturity. One of the groups sustained an intentional concomitant ipsilateral femoral shaft fracture. No tibia demonstrated a growth disturbance in the absence of the femoral fracture, while similar angular deformities were noted in four tibiae (13%) in the presence of a fractured femur. Previously theorized traumatic physeal injuries, implicated in subsequent growth disturbances and seen clinically in association with ipsilateral long bone fractures, were identified in this animal study.

Remodelling of bone around intramedullary stems in growing patients

The remodelling of bone around intramedullary cemented stems, used for the fixation of massive distal femoral replacements in young patients, has been studied. Several types of remodelling have been identified, and this is common to all of the retrieved specimens that have been in situ for periods of 6 to 18 months. Transection of cortical bone and the insertion of a massive prosthesis leads to (a) the formation of a pedicle of bone or bony bridge that grows from the transection site over the shaft of the prosthesis, (b) bone resorption at the transection site, (c) the development of an inner porotic cortex surrounding the intramedullary stem and subperiosteal bone formation, and (d) a shell of bone around the acrylic cement. The tibial component that allows continued growth of the proximal tibial physis consists of a press fit metallic plateau with a stem that slides into an ultra-high-molecular-weight polyethylene sleeve inserted below the growth plate. A sclerotic layer of bone forms adjacent to a soft-tissue interface around both the sleeve and the metallic component. Remodelling of bone around intramedullary stems is attributed either to a redeveloping blood supply or to load adaptive changes.

Focal Fibrocartilaginous Dysplasia: Consideration of Healing Process

We report two patients with unilateral tibia vara due to focal fibrocartilaginous dysplasia of the medial aspect of the proximal tibia. It appears that tibia vara, caused by a primary self-limited lesion at the proximal medial metaphysis, is corrected by the response of the proximal tibial physis. This finding would indicate that an infantile growth plate of the proximal tibia has a rather large potential to correct an angular deformity at the adjacent metaphysis.

Tibia valga after fracture: Documentation of mechanism

Tibia valga following fracture in the proximal metaphysis of the tibia in children was previously attributed to various mechanisms. This case report offers an additional explanation based on bone scintigraphy 10 months after injury. Decreased radionuclide uptake at the lateral proximal tibial physis without evidence of increased uptake on the medial side suggests that a Salter type V injury to the lateral growth plate can occur in conjunction with a medial metaphyseal fracture, resulting in the development of tibia valga.

Tibial Physeal Closure and Genu Recurvatum After Femoral Fracture

Two cases of premature closure of the anterior portion of the proximal tibial physis with associated genu recurvatum deformity in adolescent males who had sustained a closed femur fracture are reported. In both cases, physeal closure occurred without use of a proximal tibial traction pin. In one patient, treatment included distal femoral pin traction; the other patient was treated with skin traction followed by spica cast. We believe that development of recurvatum of the tibia after femoral fracture in children is not necessarily iatrogenic and related to a tibial traction pin, but instead may result from physeal injury incurred at the time of the original trauma.

Effect of Interposition Material on Mechanical Behavior in Partial Physeal Resection: A Canine Model

A canine model was used to investigate the mechanical properties of the partially resected physis and the role of load-sharing interposition material. Ten puppy knees were loaded axially, with strain gauges placed across the proximal tibial physis. After partial physeal resections, the knees were retested with and without polymethylmethacrylate (PMMA) in the resection gap. PMMA interposition moderated the change in physeal displacement noted with increasing areas of resection. The Heuter-Volkman law predicts decreased growth in response to increased physeal stress. We therefore recommend use of a load-sharing interposition material in resection of large physeal arrests in weightbearing areas.

Type V Physeal Injury: A Case Report

Summary: A case report is presented to support the recently challenged Salter-Harris classification of type V physeal injury. Asymmetric premature closure of a proximal tibial physis, previously not suspected as injured, supports the classification of this injury as a separate entity. Furthermore, varus or valgus forces, as well as shearing forces, probably play an important role in the etiology of this injury rather than longitudinal compression alone.

Type V Physeal Injury: A Case Report

A case report is presented to support the recently challenged Salter-Harris classification of type V physeal injury. Asymmetric premature closure of a proximal tibial physis, previously not suspected as injured, supports the classification of this injury as a separate entity. Furthermore, varus or valgus forces, as well as shearing forces, probably play an important role in the etiology of this injury rather than longitudinal compression alone.