Treatment of Post-traumatic Pediatric Ankle Varus Deformity with Physeal Bar Resection and Hemi-Epiphysiodesis

Abstract

Children presenting with partial physeal arrest and significant remaining growth may benefit from physeal bar resection, although the operation is a technique demanding procedure. This study evaluates the treatment of post-traumatic pediatric ankle varus deformity using physeal bar resection and hemi-epiphysiodesis with the assistance of two operative methods. Forty-five patients presenting with a distal tibial medial physeal bridge as well as ankle varus deformity following traumatic ankle physeal injury between 2009 and 2017 were followed. These patients were treated with physeal bar resection and hemi-epiphysiodesis, with the assistance of either fluoroscopy (10 cases) or intraoperative three-dimensional navigation (35 cases). Of the 45 cases, the median age was 9.0 years (range: 3–14 years) with 28 male and 17 female patients. The median of pre-operation ankle varus angle was 20 degrees (IQR 15–25) and 5 degrees (IQR 0–20) at the time of final follow up, representing a statistically significant difference (P<0.05). No differences were observed with regards to age, gender, and surgical history between effective group and ineffective group (P>0.05). The median of pre-operative ankle varus angles of the navigation and fluoroscopy groups were both 20 degrees (P>0.05). The median correction angle of the navigation and fluoroscopy groups was 10 and 15 degrees, respectively (P>0.05). Our results indicate that physeal bar resection and hemiepiphysiodesis are effective treatments for correcting ankle varus deformity due to traumatic medial physeal arrest of the distal tibia. We observe no difference in outcome between fluoroscopy group and three-dimensional navigation group during the procedures.

References

[1] GalanoGJ, VitaleMA, KesslerMW, et al.. The most frequent traumatic orthopaedic injuries from a national pediatric in patient population. J Pediatr Orthop, 2005, 25(1): 39-44

[2] RussoF, MoorMA, MubarakSJ, et al.. Salter-Harris II fractures of the distal tibia: does surgical management reduce the risk of premature physeal closure?. J Pediatr Orthop, 2013, 33(5): 524-529

[3] BarmadaA, GaynorT, MubarakSJ. Premature physeal closure following distal tibia physeal injuries. J Pediatr Orthop, 2003, 23(5): 733-739

[4] RohmillerMT, GaynorTP, PawelekJ, et al.. Salter-Harris I and II fractures of the distal tibia: dose mechanism of injury relate to premature physeal closure. J Pediatr Orthop, 2006, 26(3): 322-328

[5] WuerzTH, GurdDP. Pediatric Physeal Ankle Fracture. J Am Acad Orthop Surg, 2013, 21(4): 234-244

[6] VrettakosAN, EvaggelidisDC, KyrosMJ, et al.. Lower limb deformity following proximal tibia physeal injury: long-term follow-up. J Orthop Traumatol, 2012, 13(1): 7-11

[7] SeelEH, NobleS, ClarkeNM, et al.. Outcome of distal tibial physeal injuries. J Pediatr Ortop B, 2011, 20(4): 242-248

[8] KimizukaM, KurosawaH, FukubayashiT. Loadbearing pattern of the ankle joint. Contact area and pressure distribution. Arch Orthop Trauma Surg, 1980, 96(1): 45-49

[9] OgdenJA. Current concepts review: the evaluation and treatment of partial physeal arrest. J Bone Joint Surg Am, 1987, 69(8): 1297-1302

[10] PetersW, IrvingJ, LettsM. Long-term effects of neonatal bone and joint infection on adjacent growth plates. J Pediatr Orthop, 1992, 12(6): 806-810

[11] KhoshhalKI, KieferGN. Physeal bridge resection. J Am Acad Orthop Surg, 2005, 13(1): 47-58

[12] LoderRT, SwinfordAE, KuhnsLR. The use of helical computed tomographic scan to assess bony physeal bridges. J Pediatr Orthop, 1997, 17(3): 356-359

[13] EcklundK, JaramilloD. Patterns of premature physeal arrest: MR imaging of 111 children. Am J Roentgenol, 2002, 178(4): 967-972

[14] CarlsonWO, WengerDR. A mapping method to prepare for surgical excision of a partial physeal arrest. J Pediatr Orthop, 1984, 4(2): 232-238

[15] KwokSL. Computer assisted orthopaedic surgery: present status and future perspectives. Chin Med J, 2010, 123(21): 2969-2973

[16] IeguchiM, HoshiM, TakadaJ, et al.. Navigation-assisted surgery for bone and soft tissue tumors with bony extension. Clin Orthop Relat Res, 2012, 470(1): 275-283

[17] QureshiS, LuY, McAnanyS, et al.. Three-dimensional Intraoperative Imaging Modalities in Orthopaedic Surgery. J Am Acad Orthop Surg, 2014, 22(12): 800-809

[18] YoshidaT, KimWC, TsuchidaY, et al.. Experience of bone bridge resection and bone wax packing for partial growth arrest of distal tibia. J Orthop Trauma, 2008, 22(2): 142-147

[19] KangHG, YoonSJ, KimJR. Resection of a physeal bar under computer assisted guidance. J Bone Joint Surg Br, 2010, 92(10): 1452-1455

[20] MarshJS, PolzhoferGK. Arthroscopically Assisted Central Physeal Bar Resection. J Pediatr Orthop, 2006, 26(2): 255-259