Aims. The aim of this retrospective cohort study was to assess and investigate the safety and efficacy of using a distal tibial osteotomy compared to proximal osteotomy for limb lengthening in children. Methods. In this study, there were 59 consecutive tibial lengthening and deformity corrections in 57 children using a circular frame. All were performed or supervised by the senior author between January 2013 and June 2019. A total of 25 who underwent a distal tibial osteotomy were analyzed and compared to a group of 34 who had a standard proximal tibial osteotomy. For each patient, the primary diagnosis, time in frame, complications, and lengthening achieved were recorded. From these data, the frame index was calculated (days/cm) and analyzed. Results. All patients ended their treatment with successful lengthening and deformity correction. The frame index for proximal versus distal osteotomies showed no significant difference, with a mean 48.5 days/cm (30 to 85) and 48.9 days/cm (28 to 81), respectively (p = 0.896). In the proximal osteotomy group, two patients suffered complications (one refracture after frame removal and one failure of regenerate maturation with subsequent valgus deformity) compared to zero in the distal osteotomy group. Two patients in each group sustained obstacles that required intervention (one necessitated guided growth, one fibula lengthening, and two required change of wires). There was a similar number of problems (pin-site infections) in each group. Conclusion. Our data show that distal tibial osteotomies can be safely employed in limb lengthening for children using a circular frame, which has implications in planning a surgical strategy; for example, when treating a tibia with shortening and distal deformity, a second osteotomy for proximal lengthening is not required. Cite this article: Bone Joint J 2022;104-B(11):1273–1278

Background: Locking plates are used frequently in distal tibial fractures. We tested two different types of locking compression plates (LCP): the metaphyseal plate (MP) and the distal tibial plate (DTP). We evaluated the strain imposed on an experimental tibial osteotomy, and the stability of plate-tibia (composite bone) construct using LCP-MP and LCP-DTP.

Materials and methods: Twin strain gauged special composite tibial bones were used to simulate the human tibiae. We tested 5 tibiae: one was used as control, two tibiae were tested using LCP-MP, and two with LCP-DTP. Strain was measured by subjecting each construct to a cyclic load of 700 N at 3 Hz in neutral, flexion, extension and torsion to simulate the normal walking cycle.

Results: When compared with the control tibia, strain during the neutral moment at the proximal and distal strain gauge site in the LCP-MP and LCP-DTP constructs decreased by 6.4%/−41.5% and −39%/−47%, respectively. In flexion, the strain increased consistently in both the proximal and distal strain gauge sites using the LCP-MP by 34% and 109%. Using the LCP-DTP, the strain at the proximal strain gauge site decreased by 0.2% and increased by 18% at the distal strain gauge site. In extension, strain decreased by 25% at the proximal strain gauge site, and by 60% at the distal strain gauge site in the LCP –MP construct. In the LCP-DTP construct, the strain decreased by 13% at the proximal strain gauge site, and by 21% at the distal strain gauge site. There were no statistically significant torsional differences between LCP-MP and LCP-DTP group (P=0.121). In this experimental setup, the LCP-DTPs offer greater control of strain than LCP-MPs. They also confer greater resistance to fracture macro-movements, and improved stiffness consistently in neutral, flexion, and torsion than LCP-MPs.

Conclusion: The strain from osteotomised tibiae stabilised with LCP-MPs and LCP-DTPs were close to the strain of the control tibia. Both these locking plates were equally good and conferred greater stiffness in all loading positions.

Introduction. Limb deformity is usually assessed clinically assisted by long leg alignment radiographs and further imaging modalities (MRI and CT). Often decisions are made based on static imaging and simple gait interpretation in clinic. We have assessed the value of gait lab analysis in surgical decision making comparing surgical planning pre and post gait lab assessment. Materials & Methods. Patients were identified from the local limb reconstruction database. Patients were reviewed in the outpatient clinic and long leg alignment radiographs and a CT rotational limb profile were performed. A surgical plan was formulated and documented. All patients then underwent a formal gait lab analysis. The gait lab recommendations were then compared to the initial plan. Results. Twelve patients (8 female) with mean age of 14 (range 12–16) were identified. Nine were developmental torsional malalignments, one arthrogryposis, one hemiparesis secondary to spinal tumour resection and one syndromic limb deficiency. The gait lab recommended conservative management in four patients and agreed with eight surgical plans with one osteotomy level changing. Five patients are post-operative: two bilateral distal tibial osteotomies, two de-rotational femoral osteotomy with de-rotational tibial osteotomies and one bilateral femoral de-rotational osteotomies. Conclusions. Limb deformity correction is major surgery with long rehabilitation and recovery period. Gait lab analysis can identify who would benefit from conservative management rather than surgery with our study showing changes to surgical planning in one third of patients. The gait lab analysis helps to identify patients with functional and neuromuscular imbalances where correcting the bony anatomy may not actually benefit the patient

Aim: Pure torsional deformities of the tibia can be treated with either a proximal or distal tibial osteotomy. It is noted that the relative advantages of these osteotomies are controversial and maybe influenced by other factors. A retrospective study was undertaken to assess the two methods. Materials and Methods: Between 1997 and 2003, a retrospective study of 48 osteotomies was undertaken. Clinical records and X-rays were reviewed. There were 27 proximal osteotomies and 21 distal osteotomies. 24 were stabilised with plate fixation and 23 with percutaneous wires. The osteotomies were not matched with variables in age, site and fixation type. The sex distribution was similar. The majority of proximal osteotomies were fixed with a plate and distal osteotomies with pins. Results: There were 2 cases of proximal osteotomy which developed a non-union. In general however, the time to radiological union in the two groups was similar. Conclusion: It was felt that distal osteotomies were technically easier and therefore should be advocated. As in previous literature reviews, there is an increased risk of neuro-vascular complications in proximal osteotomies

We treated 31 feet in 17 children with myelomeningocele by extra-articular subtalar arthrodesis. Two patients were lost to follow-up. In the rest, we assessed the correction of valgus deformity and the growth of the tarsal bones. At operation the mean age of the eight girls and nine boys was 6.3 years (3 to 9). At a mean follow-up period of 5.5 years (3 to 9) patients were evaluated clinically and radiologically. We assessed calcaneal growth by calculating the ratio of calcaneal and naviculo-metatarsal longitudinal length on the preoperative and follow-up lateral radiographs. Results of valgus correction were good in 19 feet. In eight they were unsatisfactory owing to progressive valgus of the ankle. Orthotic fitting was difficult and pressure sores over the medial malleolus often developed. Four of the patients underwent further correction by distal tibial osteotomy. The growth ratio was increased in 15 feet, remained the same in seven and decreased in five. Extra-articular subtalar arthrodesis produced satisfactory partial correction of a complex valgus deformity and stability of the hindfoot, and did not have a detrimental effect on the growth of the calcaneus

The parameters of cellular proliferation and growth in the growth plates of immature rats were measured after unilateral tibial osteotomy and used to calculate growth rates. Distal osteotomy of one tibia was followed by a bilateral increase in the calculated growth rate of the distal growth plates. However, the ipsilateral distal growth plate grew faster than the contralateral between 12 and 18 days after operation, which appeared to be related to increased cell proliferation and height. Proximal osteotomy led to an increase in growth rates proximally which was more marked on the contralateral side. The lesser response of the ipsilateral growth plate may have been due to local impairment of blood supply, or to greater local release of metabolites after bony damage. Distal tibial osteotomy gave similar results to circumferential release of the distal tibial periosteum. Proximal osteotomy, however, produced a relative impairment of growth on the operated side. This may be of importance in the correction of childhood deformities associated with inequality of leg length

Introduction & Aim: The usual clinical presentation in Fibular hemimelia involves equinovalgus deformity of the foot and ankle instability with absence of the lateral rays of the foot. The aim of this study is to evaluate the results of ankle joint reconstruction, using remnants of the fibula, fibular analge or contra lateral fibular graft, in conjunction with the Ilizarov Technique. Methods: We reviewed 13 limb segments in 12 patients with fibular hemimelia, with an average age of 4.7 years. According to Catagni’s classification 2 limbs were type I, 1 limb was type II and 10 limbs were type III. The ankle joint was reconstructed using remnants of the fibula if present in type I, fibular analge or a contra lateral fibular graft. The Ilizarov technique was then used to correct limb length discrepancy and any concomitant deformities. Results: The results were assessed by the satisfaction of patients and families, the functional outcome in terms of daily activities and clinical examination of the patients. A satisfactory stability of the ankle foot complex was achieved in all patients. The average lengthening achieved using the frame was 5.6 cm and all limbs were equalized to within 2 cm. Conclusion: Reconstruction of the ankle joint bring the foot in good position, preserves the ankle joint motion, facilitate fitting shoes and stabilize the joint in a more normal way compared to distal tibial osteotomies. The ilizarov technique corrects the concomitant deformity and achieves an equal limb length. The combination of both techniques provides a better outcome compared to other treatment modalities

Introduction: The usual clinical presentation of fibular hemimelia is of leg discrepancy, an equinovalgus deformity of the foot, ankle instability and the absence of the lateral rays of the foot. The aim of this study is to evaluate the results of ankle joint reconstruction, using remnants of the fibula, fibular analge or contra lateral fibular graft, in conjunction with the Ilizarov Technique. Methods: Thirteen limb segments in 12 patients with fibular hemimelia were reviewed, with an average age of 4.7 years. According to Catagni’s classification 2 limbs were type I, 1 limb was type II and 10 limbs were type III. The ankle joint was reconstructed using remnants of the fibula if present in type I, fibular analge or a contra lateral fibular graft. The Ilizarov technique was the used to correct limb length discrepancy and any concomitant deformities. Results: The functional outcome was assessed by the ability to undertake daily activities. All cases were clinically examined and the satisfaction of the patients and family were assessed. A satisfactory stability of the ankle foot complex was achieved in all patients. The average lengthening achieved using the frame was 5.6 cm and all limbs were equalized to within 2 cm of the contralateral side. Discussion: Reconstruction of the ankle joint brings the foot into a good position, preserves the ankle joint motion, facilitates fitting shoes and stabilizes the joint in a more normal position compared to distal tibial osteotomies. The Ilizarov technique corrects the concomitant deformity and achieves a near normal limb length. The combination of both techniques provides a better outcome compared to other treatment modalities

Aims

We have previously reported cryoablation-assisted joint-sparing surgery for osteosarcoma with epiphyseal involvement. However, it is not clear whether this is a comparable alternative to conventional joint arthroplasty in terms of oncological and functional outcomes.

Survivors of meningococcal septicaemia often develop progressive skeletal deformity secondary to physeal damage at multiple sites, particularly in the lower limb. Distal tibial physeal arrest typically occurs with sparing of the distal fibular physis leading to a rapidly progressive varus ankle deformity. There is no previous literature reporting this ankle deformity following meningococcal septicaemia. We report the management of this deformity in 13 ankles in 10 consecutive patients 36 months after meningococcal septicaemia. Plain radiographs and MRI were used to define the deformity and the extent of growth plate involvement. The Taylor Spatial Frame (TSF) with a distal tibial metaphyseal osteotomy was used to restore the distal tibio-fibular joint. Distal fibular epiphysiodesis was performed in all ankles at the initial procedure. Distal tibial epiphysiodesis was performed at the time of fixator removal. The age at operation ranged from 3–14 years (mean 8). The preoperative ankle varus deformity ranged from 9–29 degrees (mean 19). The differential shortening of the tibia with respect to fibula was on average 1.2 cms. The mean time in frame was 136 days. After a mean follow-up of 1.7 years results were excellent in all patients with complete correction of deformity and shortening. Mechanincal axis was corrected in all patients. Complications included, 4 superficial pin site infections, 1 lateral peroneal nerve palsy which recovered completely. There were no major nerve or vascular complications. We consider that this approach provides a powerful method of correction for this difficult group of patients

Aims

There is little information about how to manage patients with a recurvatum deformity of the distal tibia and osteoarthritis (OA) of the ankle. The aim of this study was to evaluate the functional and radiological outcome of addressing this deformity using a flexion osteotomy and to assess the progression of OA after this procedure.

Aims

A flexed knee gait is common in patients with bilateral spastic cerebral palsy and occurs with increased age. There is a risk for the recurrence of a flexed knee gait when treated in childhood, and the aim of this study was to investigate whether multilevel procedures might also be undertaken in adulthood.

The traditional techniques involving an oblique tunnel or triangular wedge resection to approach a central or mixed-type physeal bar are hindered by poor visualisation of the bar. This may be overcome by a complete transverse osteotomy at the metaphysis near the growth plate or a direct vertical approach to the bar. Ilizarov external fixation using small wires allows firm fixation of the short physis-bearing fragment, and can also correct an associated angular deformity and permit limb lengthening.

We accurately approached and successfully excised ten central- or mixed-type bars; six in the distal femur, two in the proximal tibia and two in the distal tibia, without damaging the uninvolved physis, and corrected the associated angular deformity and leg-length discrepancy. Callus formation was slightly delayed because of periosteal elevation and stretching during resection of the bar. The resultant resection of the bar was satisfactory in seven patients and fair in three as assessed using a by a modified Williamson–Staheli classification.

Cite this article: Bone Joint J 2015;97-B:1726–31.

Septicaemia resulting from meningococcal infection is a devastating illness affecting children. Those who survive can develop late orthopaedic sequelae from growth plate arrests, with resultant complex deformities. Our aim in this study was to review the case histories of a series of patients with late orthopaedic sequelae, all treated by the senior author (CFB). We also describe a treatment strategy to address the multiple deformities that may occur in these patients.

Between 1997 and 2009, ten patients (seven girls and three boys) were treated for late orthopaedic sequelae following meningococcal septicaemia. All had involvement of the lower limbs, and one also had involvement of the upper limbs. Each patient had a median of three operations (one to nine). Methods of treatment included a combination of angular deformity correction, limb lengthening and epiphysiodesis. All patients were skeletally mature at the final follow-up. One patient with bilateral below-knee amputations had satisfactory correction of her right amputation stump deformity, and has complete ablation of both her proximal tibial growth plates. In eight patients length discrepancy in the lower limb was corrected to within 1 cm, with normalisation of the mechanical axis of the lower limb.

Meningococcal septicaemia can lead to late orthopaedic sequelae due to growth plate arrests. Central growth plate arrests lead to limb-length discrepancy and the need for lengthening procedures, and peripheral growth plate arrests lead to angular deformities requiring corrective osteotomies and ablation of the damaged physis. In addition, limb amputations may be necessary and there may be altered growth of the stump requiring further surgery. Long-term follow-up of these patients is essential to recognise and treat any recurrence of deformity.

A percutaneous supramalleolar osteotomy with multiple drill holes and closed osteoclasis was used to correct rotational deformities of the tibia in patients with cerebral palsy. The technique is described and the results in 247 limbs (160 patients) are reported. The mean age at the time of surgery was 10.7 years (4 to 20). The radiographs were analysed for time to union, loss of correction, and angulation at the site of the osteotomy.

Bone healing was obtained in all patients except one in a mean period of seven weeks (5 to 12). Malunion after loss of reduction at the site of the osteotomy developed in one tibia.

Percutaneous supramalleolar osteotomy of the tibia is a safe and simple surgical procedure.

Using human cadaver specimens, we investigated the role of supplementary fibular plating in the treatment of distal tibial fractures using an intramedullary nail. Fibular plating is thought to improve stability in these situations, but has been reported to have increased soft-tissue complications and to impair union of the fracture. We proposed that multidirectional locking screws provide adequate stability, making additional fibular plating unnecessary. A distal tibiofibular osteotomy model performed on matched fresh-frozen lower limb specimens was stabilised with reamed nails using conventional biplanar distal locking (CDL) or multidirectional distal locking (MDL) options with and without fibular plating. Rotational stiffness was assessed under a constant axial force of 150 N and a superimposed torque of ± 5 Nm. Total movement, and neutral zone and fracture gap movement were analysed.

In the CDL group, fibular plating improved stiffness at the tibial fracture site, albeit to a small degree (p = 0.013). In the MDL group additional fibular plating did not increase the stiffness. The MDL nail without fibular plating was significantly more stable than the CDL nail with an additional fibular plate (p = 0.008).

These findings suggest that additional fibular plating does not improve stability if a multidirectional distal locking intramedullary nail is used, and is therefore unnecessary if not needed to aid reduction.

Cite this article: Bone Joint J 2014;96-B:385–9.

We undertook a prospective study to analyse the outcome of 48 malunited pronation-external rotation fractures of the ankle in 48 patients (25 females and 23 males) with a mean age of 45 years (21 to 69), treated by realignment osteotomies. The interval between the injury and reconstruction was a mean of 20.2 months (3 to 98).

In all patients, valgus malalignment of the distal tibia and malunion of the fibula were corrected. In some patients, additional osteotomies were performed. Patients were reviewed regularly, and the mean follow-up was 7.1 years (2 to 15).

Good or excellent results were obtained in 42 patients (87.5%) with the benefit being maintained over time. Congruent ankles without a tilted talus (Takakura stage 0 and 1) were obtained in all but five cases. One patient required total ankle replacement.

Survivors of infantile meningococcal septicaemia often develop progressive skeletal deformity as a result of physeal damage at many sites, particularly in the lower limb. Distal tibial physeal arrest typically occurs with sparing of the distal fibular physis leading to a rapidly progressive varus deformity. There have been reports of isolated cases of this deformity, but to our knowledge there have been no papers which specifically describe the development of the deformity and the options for treatment.

Surgery to correct this deformity is complex because of the patient’s age, previous scarring and the multiplanar nature of the deformity. The surgical goal is to restore leg-length equality and the mechanical axis at the end of growth. Surgery should be planned and staged throughout growth in order to achieve the best functional results.

We report our experience in six patients (seven ankles) with this deformity, who were managed by corrective osteotomy using a programmable circular fixator.

In a retrospective study we compared 32 HINTEGRA total ankle replacements (TARs) and 35 Mobility TARs performed between July 2005 and May 2010, with a minimum follow-up of two years. The mean follow-up for the HINTEGRA group was 53 months (24 to 76) and for the Mobility group was 34 months (24 to 45). All procedures were performed by a single surgeon.

There was no significant difference between the two groups with regard to the mean AOFAS score, visual analogue score for pain or range of movement of the ankle at the latest follow-up. Most radiological measurements did not differ significantly between the two groups. However, the most common grade of heterotopic ossification (HO) was grade 3 in the HINTEGRA group (10 of 13 TARs, 76.9%) and grade 2 in the Mobility group (four of seven TARs, 57.1%) (p = 0.025). Although HO was more frequent in the HINTEGRA group (40.6%) than in the Mobility group (20.0%), this was not statistically significant (p = 0.065).The difference in peri-operative complications between the two groups was not significant, but intra-operative medial malleolar fractures occurred in four (11.4%) in the Mobility group; four (12.5%) in the HINTEGRA group and one TAR (2.9%) in the Mobility group failed (p = 0.185).

Cite this article: Bone Joint J 2013;95-B:1075–82.