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Chandankere V, Reddy MV, Reddy AVG. Outcomes of late-stages infantile Blount's disease managed by acute single stage: medial hemi-plateau elevation and metaphyseal osteotomy. Eight case series. J Pediatr Orthop B 2024; 33:560-567. [PMID: 38047570 DOI: 10.1097/bpb.0000000000001143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2023]
Abstract
This study aimed to evaluate the clinical and radiological outcomes of surgical intervention involving acute medial hemi-plateau elevation and metaphyseal osteotomy with internal fixation and growth modulation for late-stages Blount's disease. A retrospective analysis was conducted on consecutive patients with late-stages infantile tibia vara between 2014 and 2020. Inclusion criteria consisted of children aged 8 years and older with Blount's disease with Langenskiold stage IV, V or VI, tibia vara more than 30*, medial plateau depression angle (MPDA) exceeding 25* and knee instability with a minimum follow-up period of 3 years. Patients with Limb length discrepancy greater than 5 cm were excluded. Data collection included assessments of age, weight, disease stage, clinical tibiofemoral angle (TFA), mechanical medial proximal tibial angle (mMPTA), MPDA, tibial torsion and knee instability. Functional outcomes were evaluated using modified Pediatric Outcome Data Collection Instruments (PODCI) scores. The study included 5 children with 8 affected limbs. Among them, three children with five limbs had recurrent deformities after previous surgeries. All cases showed significant improvements in TFAs, mMPTA, tibial torsion, knee instability and modified PODCI scores. Complications included 4 cases of superficial infections, 1 intra-articular fracture, 2 minor screw breakage and 2 on-table under correction. Surgical intervention involving acute Single-stage medial hemi-plateau elevation and metaphyseal osteotomy leads to satisfactory outcomes in late-stages Blount's disease among older children. It is crucial to achieve proper correction of all deformity components during surgery, with epiphysiodesis on the lateral side to prevent further recurrence. Continuous follow-up until skeletal maturity is essential for optimal results.
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Zulkarnain A, Martanto TW, Yazid H, Sari DAP, Hutagalung MBZ, Muhammad H. Severe complex neglected infantile Blount disease acute correction by Ilizarov frame: A case report. Int J Surg Case Rep 2024; 121:109909. [PMID: 38917699 PMCID: PMC11254221 DOI: 10.1016/j.ijscr.2024.109909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 06/10/2024] [Accepted: 06/13/2024] [Indexed: 06/27/2024] Open
Abstract
INTRODUCTION Blount disease is a disorder causing three proportions of deformity, including varus deformity, procurvatum deformity, and internal tibial rotational deformity. The standardized treatment remains controversial despite extensive reviews. The application of Ilizarov external fixators for circumspect corrections is established. The SCARE 2023 criteria have been followed in reporting the case report. CASE PRESENTATION We present the case of a nine-year-old girl who's complaining about bowing on both of her knees. From the examination, we found that the metaphyseodiaphyseal angle of both knees was 50 degrees. On the right knee, there is 125 degrees of procurvatum deformity and 115 degrees of deformity on the left knee. After performing deformity correction with the Ilizarov application, there's clinical improvement in the patient. CLINICAL DISCUSSION Some experts advise using physeal distraction to manage the deformity in order to achieve correction. The limited popularity of physeal distraction technique may be attributed to the risks of premature closure of the growth plate that we manage to avoid. The Ilizarov frame provides maximum adjustability for aligning all planes, making it suitable for treating severe deformities. Secure fixation, improved patient mobility, being able to assess patient alignment in a functional standing position, and precision. CONCLUSION Acute correction and fixation using circular frames as a treatment option for Blount disease show positive outcomes without any significant complications.
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Affiliation(s)
- Arif Zulkarnain
- Pediatric Sub-Division, Orthopaedic and Traumatology Division, Department of Surgery, Dr. Sutomo General Hospital, Faculty of Medicine, Airlangga University, Surabaya, Indonesia
| | - Tri Wahyu Martanto
- Pediatric Sub-Division, Orthopaedic and Traumatology Division, Department of Surgery, Dr. Sutomo General Hospital, Faculty of Medicine, Airlangga University, Surabaya, Indonesia
| | - Hizbillah Yazid
- Pediatric Sub-Division, Orthopaedic and Traumatology Division, Department of Surgery, Dr. Sutomo General Hospital, Faculty of Medicine, Airlangga University, Surabaya, Indonesia
| | - Dyah Ayu Pratama Sari
- Resident of Orthopaedic and Traumatology Division, Department of Surgery, Dr. Sardjito Hospital, General Faculty of Medicine, Public Health and Nursing, Gadjah Mada University, Yogyakarta, Indonesia
| | - Muhammad Bayu Zohari Hutagalung
- Resident of Orthopaedic and Traumatology Division, Department of Surgery, Dr. Sutomo General Hospital, Faculty of Medicine, Airlangga University, Surabaya, Indonesia
| | - Hilmi Muhammad
- Pediatric Sub-Division, Orthopaedic and Traumatology Division, Department of Surgery, Dr. Sardjito General Hospital, Faculty of Medicine, Public Health and Nursing, Gadjah Mada University, Yogyakarta, Indonesia; Orthopaedic and Traumatology Division, Department of Surgery, Dr. Sardjito General Hospital, Faculty of Medicine, Public Health and Nursing, Gadjah Mada University, Yogyakarta, Indonesia.
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Ramella M, Depaoli A, Menozzi GC, Gallone G, Cerasoli T, Rocca G, Trisolino G. Recurrence and Complication Rates of Surgical Treatment for Blount's Disease in Children: A Systematic Review and Meta-Analysis. J Clin Med 2023; 12:6495. [PMID: 37892633 PMCID: PMC10607610 DOI: 10.3390/jcm12206495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/05/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Blount's disease is a growth disorder of the proximal tibia that causes progressive genu varum in children. Surgical treatment is recommended if the deformity worsens, but which intervention is best remains controversial. This study aims to identify factors influencing outcomes and determine the most effective surgical approach. METHODS A systematic review was conducted of studies published before January 2022. RESULTS In total, 63 retrospective studies with CEBM IIIb/IV levels were included (1672 knees in 1234 patients). The most commonly reported treatment was acute correction via osteotomy (47%), followed by hemiepiphysiodesis (22%) and gradual correction (18%). Combined procedures were reported in 13% of cases. The overall recurrence rate was 18%, with a significant difference when comparing the recurrence rates after gradual correction with those after hemiepiphysiodesis (7% and 29%, respectively). Major complications beyond recurrence were observed in 5% of cases. A meta-analysis of the available raw data showed a significantly increased recurrence rate (39%) among treated children who were between 4.5 and 11.25 years of age and were followed for a minimum follow-up of 2.5 years. CONCLUSIONS Overall, poor evidence with which to establish an optimal treatment for Blount's disease was found. This study remarked on the need for early diagnosis, classification, and treatment of infantile tibia vara, since a significant rate of recurrence was found in neglected cases.
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Affiliation(s)
| | | | | | | | | | | | - Giovanni Trisolino
- Unit of Pediatric Orthopedics and Traumatology, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (M.R.); (A.D.)
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Nada AA, Hammad ME, Eltanahy AF, Gazar AA, Khalifa AM, El-Sayed MH. Acute Correction and Plate Fixation for the Management of Severe Infantile Blount's Disease: Short-term Results. Strategies Trauma Limb Reconstr 2021; 16:78-85. [PMID: 34804223 PMCID: PMC8578239 DOI: 10.5005/jp-journals-10080-1527] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Purpose The purpose of this study is to evaluate the short-term results of lateral closing wedge osteotomy with medial hemiplateau elevation for the management of severe infantile Blount's disease. Materials and methods In this prospective study, 11 cases of severe Blount's disease (Langenskiold stages five and six) were managed in the period between January 2017 and January 2020. Double osteotomy technique was applied, namely a metaphyseal closing wedge and a medial hemiplateau elevation, through a single midline incision. Fixation was achieved by a medial anatomical locked plate. Patients were evaluated clinically according to a modified version of paediatric outcomes data collection Instrument (PODCI) and radiologically by measuring the angle between the tibial and the femoral shaft, the mechanical axis deviation (MAD) and the angle of the medial tibial plateau (MTP) depression. Results The average follow-up period was 2 years. Healing of the osteotomies was achieved in all cases after the index operation within an average of 3 months. Based on our modification of the PODCI score, five cases had an excellent outcome, five were good, and one case ended with a fair outcome. No major complications were encountered in this study. Conclusion The management of severe Blount's disease by acute correction using the aforementioned technique has been proven to achieve acceptable clinical and radiological outcomes without significant complications. Level of evidence Level IV case series study. How to cite this article Nada AA, Hammad ME, Eltanahy AF, et al. Acute Correction and Plate Fixation for the Management of Severe Infantile Blount's Disease: Short-term Results. Strategies Trauma Limb Reconstr 2021;16(2):78–85.
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Affiliation(s)
- Abdullah A Nada
- Unit of Pediatric Orthopaedics, Department of Orthopaedics, Tanta School of Medicine, Tanta University, Tanta, Egypt
| | - Mostafa E Hammad
- Unit of Pediatric Orthopaedics, Department of Orthopaedics, Tanta School of Medicine, Tanta University, Tanta, Egypt
| | - Ahmed F Eltanahy
- Unit of Pediatric Orthopaedics, El-Menshawy General Hospital, Tanta, Egypt
| | - Ahmed A Gazar
- Unit of Pediatric Orthopaedics, Mehalla General Hospital, El-Mahalla el-Kubra, Egypt
| | - Ahmed M Khalifa
- Unit of Pediatric Orthopaedics, National Institute of NeuromotorSystem, Cairo, Egypt
| | - Mohamed H El-Sayed
- Unit of Pediatric Orthopaedics, Department of Orthopaedics, Tanta School of Medicine, Tanta University, Tanta, Egypt
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Robbins CA. Deformity Reconstruction Surgery for Blount's Disease. CHILDREN (BASEL, SWITZERLAND) 2021; 8:566. [PMID: 34209445 PMCID: PMC8303124 DOI: 10.3390/children8070566] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 06/14/2021] [Accepted: 06/22/2021] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Craig A Robbins
- Paley Orthopedic & Spine Institute, West Palm Beach, FL 33407, USA
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Blount's disease - an up-to-date insight with contemporary treatment guidelines deduced from critical analysis of a large 146 surgical case series. J Pediatr Orthop B 2021; 30:239-249. [PMID: 32694440 DOI: 10.1097/bpb.0000000000000769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
To elucidate an up-to-date insight and derive clear treatment guidelines for Blount's disease deduced from critical analysis of 146 surgical case series. Cases were presented and analyzed separately under its two basic clinical groups and the author further derived four subcategories under each of these two groups; the first basic group was the early onset clinical variant; infantile tibia vara (ITV) included 56 cases. The second group was the late onset clinical variant; late onset tibia vara (LOTV) included 90 cases. Different operative procedures used for treatment of these cases were proximal tibial osteotomy (PTO), temporary eight-plate proximal lateral tibial hemiepiphyseodesis (PLTH), or medial plateau elevation either on a monomodal or multimodal line of treatment. After a mean follow-up period of ~5 (2-12) years, the results were critically analyzed using case series descriptive analysis. In ITV variant, both PTO and temporary eight-plate PLTH monomodal line of treatment gave satisfactory results for de-novo (stages I, II, and III) subcategory while multimodal line of treatment was needed for achieving satisfactory results for neglected (stages IV, V, and VI) and relapsed subcategories. For LOTV variant, PTO monomodal line of treatment gave satisfactory results when applied for treatment of its de-novo subcategory. The derived treatment guidelines for Blount's disease can be of value for recruiting the most suitable treatment modality for each case entity of the disease, leading to satisfactory outcome with prevention of recurrence.
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Maré PH, Thompson DM, Marais LC. The Medial Elevation Osteotomy for Late-presenting and Recurrent Infantile Blount Disease. J Pediatr Orthop 2021; 41:67-76. [PMID: 33298764 DOI: 10.1097/bpo.0000000000001722] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Late-presenting or recurrent infantile Blount disease (IBD) is characterized by knee instability because of medial tibial plateau depression, multiplanar proximal tibial deformity, and potential distal femoral deformity. The surgical treatment strategy includes medial elevation osteotomy to stabilize the knee, together with proximal tibial osteotomy to correct alignment, and lateral epiphysiodesis to prevent a recurrence. This study's primary aim was to describe the clinical outcomes of medial elevation osteotomy for the management of late-presenting and recurrent IBD. METHODS The authors reviewed the records of 48 children (64 limbs) who had medial elevation osteotomies and lateral epiphysiodesis, combined with proximal tibial realignment in 78% (50/64) of cases in the same setting. IBD was bilateral in 33% (16/48), 77% (37/48) were female individuals, and 42% (20/48) were obese. RESULTS The mean age at surgery was 8.6 years (SD, 1.6; range, 5.8 to 12.8). The mean preoperative tibiofemoral angle (TFA) was 28±11 degrees (8 to 55 degrees), and the mean angle of depression of the medial plateau (ADMP) was 49±8 degrees (26 to 65 degrees). Distal femoral valgus was present in 27% (17/62) and varus in 10% (6/62) children. At a median follow-up of 3.2 years (range, 1 to 6.2 y), the median TFA was 1-degree valgus (interquartile range, 7-degree varus to 5-degree valgus), whereas the ADMP was corrected to 25±8 degrees (8 to 45 degrees). Obesity was associated with more severe deformity as measured by TFA (P<0.001) but did not affect the extent of medial plateau depression (P=0.113). The good or excellent alignment was achieved in 75% (47/63) limbs. Obesity was associated with an increased risk of recurrence [odds ratio (OR), 5.21; 95% CI, 1.26-21.63; P=0.023]. Age at the surgery or previous surgery was not associated with recurrence (OR, 1.29; 95% CI, 0.88-1.88; P=0.195 and OR, 1.22; 95% CI, 0.36-4.17; P=0.746). Obesity and residual instability were associated with an increased risk of poor alignment at the latest follow-up (OR, 3.24; 95% CI, 1.02-10.31; P=0.047 and OR, 1.21; 95% CI, 1.05-1.40; P=0.008). CONCLUSION Late-presenting or recurrent IBD is a surgical challenge. Obesity is associated with more severe deformity. Medial elevation osteotomy combined with lateral proximal tibial epiphysiodesis and metaphyseal tibial realignment osteotomy will result in restoration of lower limb alignment in a high proportion of cases. The recurrent deformity may be the result of failed epiphysiodesis. Obesity and residual instability are associated with an increased risk of poor alignment. Although complications are rare, surgical measures to decrease risk should be followed. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
| | | | - Leonard Charles Marais
- Department of Orthopaedic Surgery, School of Clinical Medicine, University of KwaZulu-Natal, KwaZulu-Natal, South Africa
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Abak AA, Khoshhal KI. Acute "three-in-one" surgery for the treatment of severe Blount's disease: Surgical technique and report of two cases. J Taibah Univ Med Sci 2020; 15:422-430. [PMID: 33132813 PMCID: PMC7565016 DOI: 10.1016/j.jtumed.2020.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 07/30/2020] [Accepted: 08/04/2020] [Indexed: 12/03/2022] Open
Abstract
The treatment of Blount's disease has historically remained controversial. All the described techniques for its treatment have their own advantages and disadvantages, and no consensus has been reached on a single surgical approach. The aim of this report is to share the early results of a combination technique in which we have collated three well-known surgical steps in one procedure. This combined procedure is indicated for severe and recurrent cases. Our ‘three-in-one’ technique combines an intra-epiphyseal plateau elevating osteotomy with a tibial metaphyseal osteotomy and a lateral tibial temporary hemi-epiphysiodesis. We also report initial results of three limbs in two patients who were treated using this technique. The first case was that of an adolescent with severe left Blount's disease (Langenskiold stage IV) and a lateral thrust. The second case was that of bilateral severe infantile Blount's disease (Langenskiold stage V) and the infant had a lateral thrust. All measurements remarkably improved in both patients during the post-surgical assessment. The limb length discrepancy was 0.6 cm in the first case and 0.5 cm in the second. The preoperative internal tibial rotation and lateral thrust were corrected spontaneously. No complications were recorded in either patient. The three-in-one technique is a safe and versatile surgical approach that can be used in severe, refractory, and recurrent cases of open physis. Furthermore, it can potentially solve the problems of lateral thrust and internal tibial rotation. More cases should be studied before we can endorse the safety and effectiveness of this technique.
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Affiliation(s)
| | - Khalid I Khoshhal
- Department of Orthopedics, College of Medicine, Taibah University, Almadinah Almunawwarah, KSA
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Abraham E, Toby D, Welborn M, Helder CW, Murphy A. New Single-stage Double Osteotomy for Late-presenting Infantile Tibia Vara: A Comprehensive Approach. J Pediatr Orthop 2019; 39:247-256. [PMID: 30969255 PMCID: PMC5498283 DOI: 10.1097/bpo.0000000000000926] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Successful surgical treatment of late-presenting infantile tibia vara (ITV) patient requires the correction of oblique deformities. The purpose of this study was to report on a new comprehensive approach to correct and prevent recurrence of these deformities with a single procedure. METHODS Medical records of 23 consecutive children (7 to 18 y) with advanced ITV (29 knees) were retrospectively reviewed after a mean of 7.3 years postoperatively (range, 2 to 22 y). Indications for the corrective surgery were any child 7 year or older with a varus mechanical axis angle ≥10 degrees or a varus anatomic axis angle ≥11 degrees and a medial tibial angle (MTA) slope <60 degrees. The deformities were corrected with a dome-shaped osteotomy proximal to the tibial tubercle with a midline vertical extension to the subchondral region of the joint and a lateral hemi-epiphysiodesis. RESULTS At latest follow-up, means and medians of each tibial radiographic axis measurement improved significantly from preoperative values (P<0.001): mechanical axis angle from 23 degrees to 4 degrees varus, anatomic axis angle from 25 degrees varus to 1 degree valgus, MTA downward slope from 30 to 78 degrees, posterior MTA from 59 to 80 degrees. In total, 79% and 74% had good to excellent results based on radiographic criteria and clinical questionnaire for satisfaction, pain and function, respectively. Two abnormal medial tibial plateau types were described. CONCLUSIONS This is the first study to use a single-stage double osteotomy performed proximal to the tibial tubercle for the late-presenting ITV for children 7 years of age or older. In addition to the effective correction of the 4 major tibial deformities, a lateral proximal tibial hemi-epiphysiodesis minimizes recurrence of tibia vara. A contralateral proximal tibial epiphysiodesis is recommended for treated skeletally immature patients with unilateral disease. LEVEL OF EVIDENCE Therapeutic level IV. See instructions for authors for a complete description of levels of evidence.
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Affiliation(s)
- Edward Abraham
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, IL, United States
- The Princess Elizabeth Medical Centre, Port of Spain, Trinidad and Tobago
| | - David Toby
- The Princess Elizabeth Medical Centre, Port of Spain, Trinidad and Tobago
| | | | - Cory W Helder
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, IL, United States
| | - Angela Murphy
- The Princess Elizabeth Medical Centre, Port of Spain, Trinidad and Tobago
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Terjesen T, Anticevic D. Blount's disease successfully treated with intraepiphyseal osteotomy with elevation of the medial plateau of the tibia-a case report with 65 years' follow-up. Acta Orthop 2018; 89:699-701. [PMID: 30328743 PMCID: PMC6300735 DOI: 10.1080/17453674.2018.1516179] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Affiliation(s)
- Terje Terjesen
- Orthopaedic Department, Oslo University Hospital, Rikshospitalet, Oslo, Norway; ,Correspondence:
| | - Darko Anticevic
- Department of Paediatric Orthopaedics, Zagreb Children’s Hospital, Zagreb, Croatia
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Lin D, Wang X, Choi SYC, Ci X, Dong X, Wang Y. Immune phenotypes of prostate cancer cells: Evidence of epithelial immune cell-like transition? Asian J Urol 2016; 3:195-202. [PMID: 29264187 PMCID: PMC5730833 DOI: 10.1016/j.ajur.2016.08.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2016] [Revised: 07/19/2016] [Accepted: 08/09/2016] [Indexed: 12/19/2022] Open
Abstract
Prostate cancers (PCa) have been reported to actively suppress antitumor immune responses by creating an immune-suppressive microenvironment. There is mounting evidence that PCas may undergo an ''Epithelial Immune Cell-like Transition'' (EIT) by expressing molecules conventionally associated with immune cells (e.g., a variety of cytokines/receptors, immune transcription factors, Ig motifs, and immune checkpoint molecules), which subsequently results in the suppression of anti-cancer immune activity within the tumor microenvironment. Recent progress within the field of immune therapy has underscored the importance of immune checkpoint molecules in cancer development, thus leading to the development of novel immunotherapeutic approaches. Here, we review the expression of select immune checkpoint molecules in PCa epithelial and associated immune cells, with particular emphasis on clinical data supporting the concept of an EIT-mediated phenotype in PCa. Furthermore, we summarize current advances in anti-immune checkpoint therapies, and provide perspectives on their potential applicability.
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Affiliation(s)
- Dong Lin
- Vancouver Prostate Centre & Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
- Department of Experimental Therapeutics, BC Cancer Agency, Vancouver, BC, Canada
| | - Xinya Wang
- Vancouver Prostate Centre & Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
| | | | - Xinpei Ci
- Vancouver Prostate Centre & Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Xin Dong
- Department of Experimental Therapeutics, BC Cancer Agency, Vancouver, BC, Canada
| | - Yuzhuo Wang
- Vancouver Prostate Centre & Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
- Department of Experimental Therapeutics, BC Cancer Agency, Vancouver, BC, Canada
- Corresponding author. Department of Urologic Sciences/Vancouver Prostate Centre, University of British Columbia, 2660 Oak Street, Vancouver, BC V6H 3Z6, Canada. Fax: +1 604 675 8019.Department of Urologic Sciences/Vancouver Prostate CentreUniversity of British Columbia2660 Oak StreetVancouverBCV6H 3Z6Canada
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Feldman DS, Goldstein RY, Kurland AM, Sheikh Taha AM. Intra-Articular Osteotomy for Genu Valgum in the Knee with a Lateral Compartment Deficiency. J Bone Joint Surg Am 2016; 98:100-7. [PMID: 26791030 DOI: 10.2106/jbjs.o.00308] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND A deficiency of the lateral compartment of the knee, often in the setting of skeletal dysplasia, is an intra-articular deformity resulting in genu valgum. Historically, this abnormality has been treated using an extra-articular approach. Lateral hypoplasia of the femoral condyle can be treated with advancement of the lateral femoral condyle without creating a secondary deformity. The purpose of this study was to present the technique and results of lateral condylar advancement, with or without tibial hemiplateau elevation, in patients with intra-articular valgus deformity secondary to skeletal dysplasia. METHODS A retrospective review of the cases of five patients, from seven to twenty-one years old, with skeletal dysplasia and unilateral or bilateral severe genu valgum deformity was performed. For all patients, the etiology of the deformity was a deficient lateral compartment of the knee-that is, lateral femoral condylar hypoplasia with or without concomitant lateral hemiplateau depression. Lateral femoral condylar advancement with or without lateral tibial hemiplateau elevation was performed in eight knees. RESULTS The average tibiofemoral angle was 34.7° of valgus preoperatively and improved to 9.4° of valgus at the most recent follow-up. The average length of follow-up was 2.9 years (range, 1.0 to 5.2 years). The average range of motion at the time of final follow-up was an arc of 108° starting from full extension. All osteotomies healed uneventfully. All five patients were satisfied with both the cosmetic appearance and the function of the involved limb and were able to walk without assistive devices. CONCLUSIONS In patients with a deficient lateral compartment of the knee, lateral femoral condylar advancement with or without hemiplateau elevation allowed correction of severe genu valgum without the creation of an oblique joint line. This technique allows correction of the overall mechanical axis, restoring both function and the cosmetic appearance of the limb. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- David S Feldman
- Division of Pediatric Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York
| | - Rachel Y Goldstein
- Division of Pediatric Orthopaedics, Children's Hospital Los Angeles, Los Angeles, California
| | - Adam M Kurland
- Division of Pediatric Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York
| | - Abdel Majid Sheikh Taha
- Division of Pediatric Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York
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Proximal tibial osteotomy and Taylor Spatial Frame application for correction of tibia vara in morbidly obese adolescents. J Pediatr Orthop 2013; 33:276-81. [PMID: 23482263 DOI: 10.1097/bpo.0b013e31828800fe] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Four percent of children and adolescents in the United States are morbidly obese. Treatment for tibia vara includes proximal tibial osteotomy and correction with a Taylor Spatial Frame (TSF). There are no reports that specifically examine the success of this technique in morbidly obese adolescents. METHODS A retrospective review was conducted of patients between 12 and 18 years of age with a body mass index for age at or above the 99th percentile who had undergone gradual correction of tibia vara with proximal tibial osteotomy and application of a TSF at our institution between 2005 and 2009. Deformity analysis was performed on full-length standing anteroposterior radiographs of both lower extremities and lateral radiographs of the involved tibia obtained preoperatively and at latest follow-up. All complications were recorded. RESULTS Fourteen patients met the inclusion criteria. The mean age was 13 years. The average body mass index was 45 kg/m. Preoperative deformity analysis demonstrated a mean mechanical axis deviation of 90 mm, mean mechanical medial proximal tibial angle of 66 degrees, and mean posterior proximal tibial angle of 80 degrees. Analysis at an average follow-up of 14 months demonstrated a mean mechanical axis deviation of 10 mm, mean mechanical medial proximal tibial angle of 88 degrees, and mean posterior proximal tibial angle of 81 degrees. Complications specifically related to the TSF occurred in 2 patients. Both experienced strut disengagement and loss of osteotomy position. This was treated with refastening of the strut and a new program of deformity correction. Complications related to the deformity correction occurred in 3 patients. One had premature fibular consolidation requiring repeat osteotomy, 1 developed a transient partial deep peroneal nerve palsy, and 1 experienced thigh soft tissue irritation from the proximal ring necessitating early TSF removal. One patient had a residual leg-length discrepancy that required tibial lengthening. CONCLUSIONS Correction of tibia vara with proximal tibial osteotomy and application of a TSF is an effective treatment option in morbidly obese adolescents. Associated complications are minimal. LEVEL OF EVIDENCE Level IV-therapeutic study.
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Atmaca H, Özkan A, Mutlu I, Celik T, Ugur L, Kisioglu Y. The effect of proximal tibial corrective osteotomy on menisci, tibia and tarsal bones: a finite element model study of tibia vara. Int J Med Robot 2013; 10:93-7. [PMID: 23983147 DOI: 10.1002/rcs.1528] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Revised: 07/13/2013] [Accepted: 07/30/2013] [Indexed: 11/10/2022]
Abstract
BACKGROUND Proximal tibial open wedge osteotomy (PTO) is a corrective operation used in the surgery of lower extremities and is applied to patients with varus deformities for sufficient correction. The aim of the study was to evaluate whether the PTO can achieve decreased stress-bearing on the tibia and tarsal bones in addition to correcting the mechanical axis of the lower limb in patients with tibia vara. METHODS Three-dimensional (3D) solid modelling of the lower extremity was carried out using computed tomography (CT) and magnetic resonance (MR)-containing images of all of the bony elements and non-bony structures. PTO was applied to the obtained deformed model in the computer environment and the correction was carried out. RESULTS Stress distributions in menisci, tibia and tarsal bones were calculated. With respect to loading on the tarsal bones, the maximum equivalent stresses on all bones decreased except for the navicula in the PTO-simulated model in the current study. CONCLUSION These results clearly indicate that PTO can achieve decreased stresses on the tarsal bones in patients with tibia vara.
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Affiliation(s)
- Halil Atmaca
- Department of Orthopaedics and Traumatology, Akdeniz University, Antalya, Turkey
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15
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Abdelgawad AA. Combined distal tibial rotational osteotomy and proximal growth plate modulation for treatment of infantile Blount’s disease. World J Orthop 2013; 4:90-93. [PMID: 23610758 PMCID: PMC3631958 DOI: 10.5312/wjo.v4.i2.90] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2012] [Revised: 01/04/2013] [Accepted: 01/21/2013] [Indexed: 02/06/2023] Open
Abstract
Infantile Blount’s disease is a condition that causes genu varum and internal tibial torsion. Treatment options include observation, orthotics, corrective osteotomy, elevation of the medial tibial plateau, resection of a physeal bar, lateral hemi-epiphysiodesis, and guided growth of the proximal tibial physis. Each of these treatment options has its disadvantages. Treating the coronal deformity alone (genu varum) will result in persistence of the internal tibial torsion (the axial deformity). In this report, we describe the combination of lateral growth modulation and distal tibial external rotation osteotomy to correct all the elements of the disease. This has not been described before for treatment of Blount’s disease. Both coronal and axial deformities were corrected in this patient. We propose this combination (rather than the lateral growth modulation alone) as the method of treatment for early stages of Blount’s disease as it corrects both elements of the disease and in the same time avoids the complications of proximal tibial osteotomy.
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Putzeys P, Wilmes P, Merle M. Triple tibial osteotomy for the correction of severe bilateral varus deformity in a patient with late-onset Blount's disease. Knee Surg Sports Traumatol Arthrosc 2013; 21:731-5. [PMID: 22644074 DOI: 10.1007/s00167-012-2061-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2012] [Accepted: 05/11/2012] [Indexed: 10/28/2022]
Abstract
A 14-year-old girl suffering from severe bilateral late-onset Blount's disease was treated by triple proximal tibial osteotomy. Surgical procedures included dome, respectively, closing wedge valgus osteotomy of the tibia, elevating osteotomy of the medial tibial plateau and lateralising osteotomy of the anterior tibial tuberosity. Mechanical leg axis was restored close to normal, the depression of the medial tibial plateau corrected and the extensor apparatus of the knee realigned. At 7.5 (right side) and 5.5 (left side) months of follow-up, all osteotomies had radiologically consolidated and the patient did not complain of knee pain or instability. Level of evidence IV.
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Affiliation(s)
- P Putzeys
- Groupe Ortholux, Hôpital Kirchberg, 9 rue Edward Steichen, 2540, Luxembourg, Luxembourg
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17
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Gkiokas A, Brilakis E. Management of neglected Blount disease using double corrective tibia osteotomy and medial plateau elevation. J Child Orthop 2012; 6:411-8. [PMID: 24082956 PMCID: PMC3468733 DOI: 10.1007/s11832-012-0443-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2012] [Accepted: 09/19/2012] [Indexed: 02/03/2023] Open
Abstract
PURPOSE A double osteotomy for correcting tibial deformity in combination with medial plateau elevation is recommended for the management of neglected Blount disease cases. We report our clinical experience with the application of this surgical technique and describe the long-term follow-up of the patients who were operated on. METHODS During a 10-year period, eight children (8 boys) with mean age of 12 years (range 9-14 years) underwent surgery (9 operations) due to neglected infantile tibia vara. All patients suffered from stage V or VI Blount disease according to the Langenskiold and Riska classification. Two simultaneous combined osteotomies were performed for medial plateau elevation and for correction of the tibial deformity. The correction was immediate using K-wires for stabilization and a long-leg cast for immobilization. The mean duration of follow-up was 10 years (range 5-15 years), and the evaluations were based on clinical and radiological criteria. RESULTS At the latest follow-up, there was no observable knee flexion or extension restriction and no signs of instability or lateral thrust. All patients had returned to a higher activity level. Leg-lengthening surgery was performed in one child, but the length discrepancy was already present before the double osteotomy was performed. No other complications were noticed. All the angles measured on X-rays had been corrected, and this correction was retained until the latest follow-up. CONCLUSIONS This method results in very good outcomes in patients who suffer from Blount disease of stage V or greater. With this technique, the tibial deformity is corrected, the articular surface is restored, and future recurrence is prevented.
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Affiliation(s)
- Andreas Gkiokas
- 1st Orthopaedic Department, General Children’s Hospital “P. & A. Kyriakou”, 18 str. Aristophanous, 18533 Piraeus, Athens, Greece
| | - Emmanuel Brilakis
- 1st Orthopaedic Department, General Children’s Hospital “P. & A. Kyriakou”, 18 str. Aristophanous, 18533 Piraeus, Athens, Greece
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Fixator-assisted medial tibial plateau elevation to treat severe Blount's disease: outcomes at maturity. Orthop Traumatol Surg Res 2011; 97:172-8. [PMID: 21349783 DOI: 10.1016/j.otsr.2010.10.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2009] [Revised: 08/02/2010] [Accepted: 10/19/2010] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Severe forms of Blount's disease may be associated with medial tibial plateau (MTP) depression. Management should then take account of joint congruence, laxity, limb axis, torsional abnomality, leg length discrepancy (LLD) and eventual recurrence history. PATIENTS AND METHODS Eight knees (six patients) were managed in a single step comprising MTP elevation osteotomy, lateral epiphysiodesis and proximal tibia osteotomy to correct varus and rotational deformity. Fixation was achieved using an Ilizarov external fixator. Mean age was 10.5 years. Mean hip-knee-ankle (HKA) angle was 151°; distal femoral varus, 94°; metaphyseal-diaphyseal angle (MDA), 27°; and angle of depression of the medial tibial plateau (ADMTP), 42°. Predicted residual proximal tibial growth was 2.6 cm. RESULTS At a mean 48 months' follow-up, results were good in six cases, medium in one and poor (due to incomplete lateral epiphysiodesis) in one. Mean lateral tibial torsion was 9° and final LLD 11 mm. Weight-bearing was resumed at 2 months, and the fixator was removed at 5.5 months postoperatively. At end of follow-up, mean HKA angle was 179.6°, MDA 7.3° and ADMTP 5.4°. DISCUSSION This technically demanding procedure gave satisfactory results in terms of axes and congruence; longer term assessment remains needed. LEVEL OF EVIDENCE Level IV. Retrospective study.
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19
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Hefny H, Shalaby H. A safer technique for the double elevation osteotomy in severe infantile tibia vara. Strategies Trauma Limb Reconstr 2010; 5:79-85. [PMID: 21811903 PMCID: PMC2918741 DOI: 10.1007/s11751-010-0088-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2009] [Accepted: 04/26/2010] [Indexed: 11/28/2022] Open
Abstract
Infantile tibia vara is a deformity of abrupt angulation into varus due to an affection of the postromedial aspect of the proximal tibial physis. The deformity often includes internal tibial torsion and limb length discrepancy. Gradual correction of the deformity is currently the treatment of choice for these challenging cases as it requires less invasive surgery, allows progressive and adjustable correction, permits bone lengthening if needed and achieves a more accurate correction compared to acute correction. Elevation of the depressed medial tibial condyle allows restoration of the joint architecture. Different techniques described to elevate the depressed medial tibial plateau are all technically demanding and carry potential risks of unsalvageable intra-operative complications. The aim of this study is to report the results of a safer technique for the double elevation osteotomy combined with gradual correction using the Ilizarov frame, allowing it to be more reproducible, less technically demanding and avoid those potential complications. This study included 12 limbs in 8 patients (mean age 9 years), all were classified as stage V or VI according to the Langenskiold classification. All osteotomies healed completely in all patients. The mean time in the frame was 23 weeks. The mean preoperative femoral shaft-tibial shaft angle was 36° of varus. This improved to 5° of varus. The mean preoperative femoral condyle-tibial shaft angle was 58°. This improved to 84°. The mean preoperative angle of depressed medial tibial plateau was 63°. This improved to 8°. All patients were maintaining full extension of the knee at the final follow-up, and all patients noticed a significant improvement in their gait pattern. We believe that this technique is safer and less invasive compared to traditional and even newly described techniques for elevating the depressed medial tibial plateau and correcting the deformity in severe infantile tibia vara, which will allow it to be more reproducible.
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Affiliation(s)
- Hany Hefny
- Orthopedic Department, Demerdash Hospital, Ain Shams University, Abbasseia Square, Cairo, Egypt,
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20
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Abstract
BACKGROUND Idiopathic tibia vara (Blount disease) is an acquired form of tibial deformity found mainly in children who are Afro-Caribbean and obese. It is uncommon. Several methods have been described for the surgical treatment of this condition, which can be categorized as either acute or gradual correction. The aim of this study is to review the evidence comparing the outcome of acute versus gradual correction of childhood tibia vara using accuracy of reduction as the primary outcome measure. METHODS A systematic search was made of the literature across multiple databases to find all studies describing acute or gradual correction of this condition that reported radiographic correction as an outcome measure. RESULTS One retrospective comparative series was found that provided weak evidence of an improvement in mechanical axis deviation using gradual correction with a Taylor Spatial Frame compared with acute correction. Seventeen other case series were found, from which, there was no evidence of an advantage for either form of treatment. CONCLUSIONS There is very little evidence to recommend one form of correction over the other. LEVEL OF EVIDENCE Systematic review of case series (level IV).
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21
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Bar-On E, Weigl DM, Becker T, Katz K. Treatment of severe early onset Blount's disease by an intra-articular and a metaphyseal osteotomy using the Taylor Spatial Frame. J Child Orthop 2008; 2:457-61. [PMID: 19308542 PMCID: PMC2656861 DOI: 10.1007/s11832-008-0140-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2008] [Accepted: 09/24/2008] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Severe Blount's disease results in a multiplanar deformity of the lower limb. The mechanical axis is disrupted, there is a rotational deformity, and also shortening of the limb. A depression of the medial tibial plateau causes joint incongruity and instability. The purpose of this study is to review the results of treatment addressing all the aspects of the deformity. METHODS Four patients were treated for severe Blount's disease. The index procedure consisted of a medial tibial plateau elevating osteotomy, a lateral tibial and proximal fibular epiphysiodesis, a proximal tibial metaphyseal osteotomy, and the application of the Taylor Spatial Frame programmed for correction of varus, rotation and shortening, and preemptive lengthening to compensate for growth arrest. RESULTS Mechanical axis was corrected from a mean 23 degrees (13 degrees -30 degrees ) to 0 degrees in three patients and 6 degrees valgus in 1. Tibias were lengthened by 1-4 cm. At follow-up, the mechanical axis was 0 degrees in two patients and 7 degrees varus in two. The overlengthening was diminishing as planned. CONCLUSIONS The double osteotomy and Taylor Frame correction was found to be accurate, safe, and effective for multiplanar deformity correction in severe Blount's disease.
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Affiliation(s)
- Elhanan Bar-On
- />Pediatric Orthopedic Unit, Schneider Children’s Medical Center, 14 Kalpan St., 49202 Petah Tikva, Israel , />Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - Daniel Martin Weigl
- />Pediatric Orthopedic Unit, Schneider Children’s Medical Center, 14 Kalpan St., 49202 Petah Tikva, Israel , />Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - Tali Becker
- />Pediatric Orthopedic Unit, Schneider Children’s Medical Center, 14 Kalpan St., 49202 Petah Tikva, Israel , />Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - Kalman Katz
- />Pediatric Orthopedic Unit, Schneider Children’s Medical Center, 14 Kalpan St., 49202 Petah Tikva, Israel , />Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
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22
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Abstract
Although varus malalignment of the proximal tibia is the primary pathology in Blount disease, other deformities may exist. To assess multiplanar lower limb deformities, children with previously untreated early- and late-onset Blount disease who subsequently needed surgical correction were identified. Preoperative frontal and sagittal plane deformity analysis using Paley's methodology and rotational profile assessment using prone clinical examination were performed by a single examiner. Results were compared between the 2 groups and with uninvolved limbs within each group. Additionally, rotational profile of the lower limb was compared with age-matched values. Over an 8-year period, 60 limbs (40 patients) including 26 with early-onset and 34 with late-onset Blount met the inclusion criteria. Although both groups exhibited proximal tibial varus, procurvatum, and internal torsion, patients with early-onset Blount disease had greater severity. Unlike the younger patients, approximately one third of the varus malalignment of the affected extremity was attributed to the distal femur in the late-onset patients. Neither group showed any significant deformity of the proximal femur and distal tibia or sagittal plane deformity of the distal femur. There was a correlation between the severity of varus malalignment of the limb with magnitude of proximal tibial deformities in both groups and with distal femoral varus in the late-onset group of patients. Multiplanar deformity analysis is a valuable tool in the comprehensive evaluation of children with Blount disease.
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Affiliation(s)
- Sanjeev Sabharwal
- Department of Orthopedics, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, New Jersey 07103, USA.
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van Huyssteen AL, Hastings CJ, Olesak M, Hoffman EB. Double-elevating osteotomy for late-presenting infantile Blount’s disease. ACTA ACUST UNITED AC 2005; 87:710-5. [PMID: 15855377 DOI: 10.1302/0301-620x.87b5.15473] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We reviewed 34 knees in 24 children after a double-elevating osteotomy for late-presenting infantile Blount’s disease. The mean age of patients was 9.1 years (7 to 13.5). All knees were in Langenskiöld stages IV to VI. The operative technique corrected the depression of the medial joint line by an elevating osteotomy, and the remaining tibial varus and internal torsion by an osteotomy just below the apophysis. In the more recent patients (19 knees), a proximal lateral tibial epiphysiodesis was performed at the same time. The mean pre-operative angle of depression of the medial tibial plateau of 49° (40° to 60°) was corrected to a mean of 26° (20° to 30°), which was maintained at follow-up. The femoral deformity was too small to warrant femoral osteotomy in any of our patients. The mean pre-operative mechanical varus of 30.6° (14° to 66°) was corrected to 0° to 5° of mechanical valgus in 29 knees. In five knees, there was an undercorrection of 2° to 5° of mechanical varus. At follow-up a further eight knees, in which lateral epiphysiodesis was delayed beyond five months, developed recurrent tibial varus associated with fusion of the medial proximal tibial physis.
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Affiliation(s)
- A L van Huyssteen
- University of Cape Town, 7 Marne Avenue, Newlands 7700, Cape Town, South Africa
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24
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Abstract
Three-dimensional computed tomography reconstructions were done in the preoperative workup of five patients receiving Ilizarov correction for relapsed infantile Blount's disease. There were four girls and one boy with a mean age of 9 years 11 months. In all patients, the computed tomography reconstruction images made assessment of the deformity easier and revealed abnormalities not readily seen on plain radiographs. This information has particular relevance to medial plateau elevation using the Ilizarov frame because it is possible to correct a medial and posterior slope of the tibial plateau using this technique. Also, this imaging modality is safe, easy to do, and is a useful adjunct for planning before surgical correction of relapsed Blount's disease.
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Affiliation(s)
- Harish S Hosalkar
- Division of Paediatric Orthopaedics, The Hospital for Sick Children, Great Ormond Street Hospital, Southwood Building, London WC1N 3JH, England, UK
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25
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Abstract
The treatment of late-onset tibia vara has not been well described. High tibial corticotomies and use of the Orthofix T-Garche fixator were performed on 11 children (14 knees) with late-onset tibia vara. The average age at surgery was 12 years, and follow-up was 2 years. Minimum follow-up was until completion of growth. Angular deformities were measured by using the tibiofemoral angle, metaphyseal-diaphyseal angle, and the mechanical axis both preoperatively and on removal of the fixation device. Union was accomplished in 7-12 weeks, and the total time with the appliance averaged 9 weeks. Complications included superficial pin-tract infections (two) and a transient nerve palsy (one). High tibial corticotomy followed by corrective gradual distraction osteosynthesis by using the Orthofix T-Garche fixator is effective in correcting angular deformity and alleviating knee pain. Advantages of this technique include ease of application, immediate weight bearing, and minimal discomfort with hardware removal. Disadvantages include difficulty in obtaining adequate radiographs with the anteriorly based fixation device, pin-tract infections, and the high degree of patient compliance needed.
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Affiliation(s)
- R Gaudinez
- Department of Orthopaedic Surgery, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
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