[Physiolysis with Resection of Vickers' Ligament in Adolescent Patients with Madelung's Deformity]. / Physiolyse mit Resektion des Vickers-Bandes bei adoleszenten Patienten mit Madelung-Deformität.

BACKGROUND: Madelung's deformity is a congenital or acquired growth disorder of the forearm that can lead to significant impairments in the quality of life of affected patients. Various surgical treatment options for the condition have been described in the literature. This study aimed to investigate whether physiolysis with resection of the Vickers ligament can successfully halt the progression of the disease in a cohort of young patients, as would be expected based on existing literature on this topic. MATERIAL AND METHODS: An analysis was performed on the records of all patients with Madelung's deformity who were primarily treated with physiolysis with resection of the Vickers ligament between January 2001 and June 2017. Patients were invited for follow-up examinations, and surgical outcome was assessed. Parameters evaluated included pain at rest and under load, range of motion of the wrists, and activity level. Additionally, standard X-rays and radiological measurements were performed for each operated wrist. The collected data was compared with the preoperative data from patient records. RESULTS: Nine wrists were included in the study. The average age at the time of surgery was 13.2 years, and the average follow-up period was five years. Extension and ulnar abduction showed a slight decrease from preoperative to follow-up, while flexion improved minimally, and radial abduction and forearm rotation showed noticeable improvement. The visual analogue scale score for pain at rest increased from preoperative 0.25 points to 1.88 points at follow-up. Under load, the average pain score increased from 2.00 to 4.25 points. The mean DASH score increased from 6.04 points before the surgical procedure to 12.20 points at follow-up. The average values of two out of the five measured McCarroll parameters increased, the increase being statistically significant for lunate subsidence. A follow-up procedure was required in one wrist. CONCLUSION: In our cohort, the progression of Madelung's deformity was only partially halted by physiolysis with resection of the Vickers ligament, and a significant increase in pain symptoms during the study period could not be avoided. Therefore, this procedure should be used cautiously in skeletally immature patients.

Enhanced Pain Relief and Function Improvement in Children with Osgood-Schlatter Disease: Leukocyte-Rich Platelet-Rich Plasma (LR-PRP) as a Complementary Treatment to Standard Conservative Therapy.

BACKGROUND Osgood-Schlatter disease (OSD) causes pain and loss of function of the knee in growing children. This study aimed to evaluate pain and function of the knee joint in 152 growing children with chronic OSD before and after treatment with LR-PRP when used with standard conservative treatment. MATERIAL AND METHODS Treatment efficacy was evaluated using the VAS, Tegner, Lyshom, and KOOS scales. Patient satisfaction, post-surgery athletic performance, and X-ray assessment were also used to determine the success of the procedure. RESULTS We found that 75% of the subjects were satisfied with the results of the treatment, and 72% of the subjects returned to full physical activity. The analysis showed a significant decrease in the median VAS score after treatment compared to the pre-treatment score (P<0.05), and an increase in the median scores of the Tegner, Lysholm, and KOOS scales compared to the pre-treatment score (P<0.05; P<0.05; P<0.05, respectively). The results showed that the shorter the duration of the disease, the better the treatment results were received. Return to activity and patient satisfaction were highest in the study group previously rehabilitated. CONCLUSIONS LR-PRP injection of the tibial tuberosity in patients with chronic OSD with open growth cartilage is an effective and uncomplicated method. We did not observe any adverse effects, which suggests the relatively high safety of the procedure. The use of PRP in the earlier phase of the disease and additional rehabilitation before treatment significantly increases the effectiveness of treatment.

Detection of fragment migration into the biceps tendon sheath originating from a humeral osteochondrosis lesion - A case report and review of the literature.

The purpose of this report is to demonstrate that radiographic evaluation of the canine shoulder joint alone is not sensitive enough to detect migrated osteochondral fragments within the biceps tendon sheath, as a sequela to osteochondrosis dissecans of the caudal humeral head. A 6-months-old, male, 35 kg Hovawart was referred due to chronic intermittent lameness on the left forelimb. Survey radiographs revealed a semilunar radiolucency surrounded by a moderately sclerotic rim at the caudal aspect of the left humeral head, referred to as osteochondrosis dissecans. However, only computed tomography combined with ultrasonography could clearly confirm a dislodged osteochondral fragment within the left biceps tendon sheath and a consequent tenosynovitis. Arthroscopic treatment on the clinically affected left forelimb followed by an additional approach over the left biceps tendon sheath to remove the migrated fragment resulted in a complete remission of the lameness until the last follow-up one year after surgery. In our opinion, computed tomography should be applied in the medical work up of canine shoulder osteochondrosis (OC) as standard. Combined with ultrasonography, it can further aid in complete evaluation of the shoulder joint and reliable exclusion of displaced osteochondral fragments, which might also be missed during arthroscopy when located too far distally.

Long-term outcome of dogs treated by surgical debridement of proximal humeral osteochondrosis.

OBJECTIVE: To evaluate long-term clinical outcomes of dogs surgically treated for proximal humeral osteochondrosis (OC). STUDY DESIGN: Cross-sectional study. SAMPLE POPULATION: Twenty dogs (n = 26 shoulders). METHODS: Dogs treated with surgical debridement of proximal humeral OC lesions >12 months prior were enrolled. Orthopedic examination (including limb circumference and shoulder goniometry), kinetic gait analysis, shoulder radiographs, shoulder computed tomography (CT), and shoulder arthroscopy were performed. All owners completed a dog mobility questionnaire. RESULTS: Brachial circumference (P = .003) and maximum shoulder extension (P = .013) were decreased and maximum shoulder flexion (P = .008) was increased (ie less flexion) in the OC limb versus the contralateral limb in unilaterally affected dogs. There were no differences in peak vertical force and vertical impulse between affected and unaffected limbs. Dogs demonstrated a 4.4% decrease in load distributed to the operated limb. Osteoarthritis was present in all shoulders treated for OC lesions. The degree of osteoarthritis in OC-affected shoulders was increased compared to the contralateral limb as evaluated on CT (P = .005) and radiography (P = .0001) in unilaterally affected cases. Moderate-to-severe synovitis was seen in all OC-affected joints. Arthroscopically, all lesions were noted to have patchy, incomplete cartilaginous infilling. Median of aggregate Liverpool Osteoarthritis in Dogs (LOAD) scores was 6. CONCLUSION: All dogs exhibited ipsilateral muscle atrophy and progressive osteoarthritis, with most dogs exhibiting subtle lameness on the subjective gait examination. Despite this, owner-perceived mobility was satisfactory. CLINICAL SIGNIFICANCE: Progression of joint disease over time should be expected; however, the abnormalities detected on examination appear to be of questionable clinical relevance.

Guided Growth for Varus Deformity Following Early Tibial Osteotomy in Infantile Tibia Vara-A Multi-Center Study.

BACKGROUND: Despite early osteotomy, many patients with infantile tibia vara (ITV) have persistent or recurrent varus deformity and disordered growth at the medial proximal tibial physis. Our hypothesis was that lateral tibial tension band plating (LTTBP) could guide correction. METHODS: A retrospective review at 6 centers of 15 patients (16 extremities) was performed of LTTBP for varus deformity following early osteotomy in ITV, diagnosed≤4years of age. Correction of deformity parameters on digital standing anteroposterior lower extremity radiographs determined outcome. RESULTS: Twenty-two LTTBP procedures were performed at mean age of 7.5 years, including 4 revisions for implant failure and 2 reimplantations for recurrence. Single event LLTBP, improved the medial proximal tibial angle with a mean change of 13.4 degrees (0.39 degrees/month). Eleven limbs had preoperative mechanical lateral distal femoral angle (mLDFA)>90 degrees. While n degree femoral procedures were performed, at study end, 11 femurs had mechanical lateral distal femoral angle≤90°. Pretreatment, 13 extremities had mechanical axis zone (MAZone) III varus (81%) and 3 had MAZone II varus (19%). LTTBP's were able to initially correct 13 limbs to MAZone I or valgus but 4 limbs rebounded to MAZone II varus after implant removal. Final limb alignment, after all surgeries and rebound, included 9 in MAZone I, 5 in MAZone II varus and 2 in MAZone III varus. Average follow-up was 3.0 years at mean 10.7 years of age. Fifteen procedures resulted in improvement in MAZone and 7 had no change. On average, those that improved were younger (7.3 vs. 8.0 y), weighed less (45.5 kg with body mass index 26.5 kg/m 2 vs. 67.8 kg and body mass index 35.7 kg/m 2 ), had lower mechanical axis deviation (37.1 mm vs. 43.9 mm), lower medial physeal slope (61.7 vs. 68.7 degrees) and had a higher percentage of open triradiate phases (87 vs. 57%). CONCLUSIONS: LTTBP for residual varus, after initial osteotomy in ITV, resulted in 81% of limbs initially achieving MAZone I or valgus with implant failure revisions and femoral remodeling. Rebound after implant removal reduced the corrected rate to 56%. Ninety-four percent avoided osteotomy during the study period. LEVEL OF EVIDENCE: IV.

Guided Growth Procedures: Broken Tension Band Implants in Patients With Blount Disease.

BACKGROUND: Tension band plate and screw implants (TBI) are frequently used for temporary hemiepiphyseodeses to manage angular deformity in growing children. The reported implant breakage rate, when TBI is used for deformities in patients with Blount disease, is much higher than when used in other diagnoses. Our hypothesis is that perioperative factors can identify risks for TBI breakage. METHODS: A retrospective case-control study was performed of 246 TBI procedures in 113 patients with Blount disease at 8 tertiary pediatric orthopaedic centers from 2008 to 2018. Patient demographics, age at diagnosis, weight, body mass index (BMI), radiographic deformity severity measures, location, and types of implants were studied. The outcome of implant breakage was compared with these perioperative factors using univariate logistic regression with Bonferroni correction for multiplicity to significance tests. RESULTS: There were 30 broken implants (12%), failing at mean 1.6 years following implantation. Most failures involved the metaphyseal screws. Increased BMI was associated with increased implant breakage. Increased varus deformity was directly associated with greater implant breakage and may be a more important factor in failure for those below 7 years compared with those 8 years or above at diagnosis. There was a 50% breakage rate for TBI with solid 3.5 mm screws in Blount disease with onset 8 years or above of age. No demographic or implant factors were found to be significant. CONCLUSIONS: Breakage of TBI was associated with increased BMI and varus deformity in patients with Blount disease. Larger studies are required to determine the relative contribution and limits of each parameter. Solid 3.5 mm screws should be used with caution in TBI for late-onset Blount disease. LEVEL OF EVIDENCE: Level III.

The posterior tibial slope and Insall-Salvati index in operative and nonoperative adolescent athletes with Osgood-Schlatter disease.

INTRODUCTION: Osgood-Schlatter disease (OSD) is a common cause of anterior knee pain in adolescent athletes due to repetitive stress on the tibial tubercle. The posterior tibial slope angle (PTSA) and the Insall-Salvati Index (ISI) play a role in knee biomechanics. However, to our knowledge, the posterior tibial slope and patellar height have not been compared in operated versus nonoperative OSD patients. The purpose of the current study is to compare the differences in the PTSA and the ISI between operative and nonoperative patients with OSD. MATERIALS AND METHODS: The study was approved by the College of Medicine's Institutional Review Board. A retrospective review was performed on 75 adolescent athletes with OSD between 2008 and 2019. The data extracted included: age, sex, body mass index (BMI), sporting activity and type, mechanism of injury (MOI), chronicity of symptoms, PTSA, and the ISI. Descriptive and quantitative statistics were used. RESULTS: Seventy-five patients (88 knees) with OSD were studied (28 boys, 47 girls). The average age was 12.2 years and the average BMI was 22.3. The mechanism of injury (MOI) included repetitive stress (77%) and trauma (23%). The duration of knee pain averaged 10.3 months. Sixty-six patients were included in the nonoperative cohort. Nine patients were included in the operative cohort and underwent surgery due to persistent symptoms after skeletal maturity with tubercleplasty and/or ossicle excision. The average PTSA was 12.1° ± 1.7° and average ISI was 1.05 ± 0.15. Comparing the operative and nonoperative patients, we found no significant difference in PTSA (11.2° ± 0.73° versus 12.8° ± 1.8°, p < 0.064). However, we did find that patients treated operatively had a lower ISI (0.95 ± 0.18 versus 1.14 ± 0.13, p < 0.001). CONCLUSION: In patients with OSD, operative and nonoperative patients demonstrated a similar PTSA. On the other hand, the ISI was higher in nonoperative patients. In the current paper, a decreased ISI was helpful in predicting the need for operative intervention in symptomatic patients after skeletal maturity.

Guided growth using a tension-band plate in Blount's disease.

Our observational study's objective was to determine how effective guided growth with tension-band plates was to correct the deformity in Blount's disease. We reviewed the records of 14 children (18 limbs) with Blount's disease who were treated with tension-band plates as the only surgical intervention at a single institution over eight years. Five children (seven limbs) had infantile Blount's disease with Langenskiöld stage ≤2. Nine children (11 limbs) had late-onset Blount's disease. The mean age at operation was 7.2 years (SD, 3.1, range, 2.9-11.8). The tension-band plate effectively corrected the varus deformity in 78% (14/18) of limbs. Correction to normal mechanical alignment was achieved in 67% (n = 12) of limbs at a mean of 18 months (SD, 7, range, 9-31). Failure to achieve correction of the mechanical axis was due to delayed implant removal and overcorrection in 11% (2/18), mechanical failure due to screw fixation failure in 11% (2/18) and in 6% (1/18) due to a misplaced epiphyseal screw. There was a greater magnitude of correction in the Infantile Blount's disease group (mean, 26°, SD, 9°) when compared to the children with late-onset Blount's disease (13°, SD, 4°) (P = 0.021). The mean correction rate was 1.8°/month in the Infantile Blount's disease group and 0.7°/month in the late-onset Blount's disease group, respectively (P = 0.014). Our findings support the use of tension-band plating in Blount's disease. Further research is required to determine the ideal indications and to investigate the long-term outcome of guided growth in Blount's disease. Level of evidence: Level 4.

Surgical treatment of atraumatic osteochondrosis dissecans of the immature talus-Clinical results and prevalence of radiographic joint degeneration after a median follow-up of 72.5 months.

BACKGROUND: This study aimed to assess the clinical and radiographic outcomes of different surgical procedures in atraumatic osteochondrosis dissecans (OCD) of the talus in youth and adolescence. METHODS: 32 joints in 30 patients (mean age 14.7 ± 2.2 years) were evaluated. Numeric Rating Scale (NRS), Foot and Functional Index (FFI), American Orthopedic Foot and Ankle Society ankle-hindfoot score (AOFAS), Pediatric Outcome Data Collection Instrument (PODCI), and sport participation were recorded. We compared preoperative and follow-up ankle radiographs to identify specific features in the OCD morphology and any signs of joint degeneration. RESULTS: After a median follow-up period of 72.5 months the drilling group showed significantly better scores than the combined fixation and reconstruction groups (AOFAS, p = 0.024; PODCI, p = 0.003; NRS, p = 0.027). Signs of joint degeneration were observed in 50% of all ankles, especially in those treated by OCD-fixation and reconstruction. CONCLUSIONS: Advanced fixation and reconstruction procedures in unstable and non-salvageable atraumatic talar OCD resulted in inferior clinical scores and a higher prevalence of joint degeneration than drilling procedures in stable OCD in young patients.

Influence of osteochondrosis on the longevity and racing performance of standardbred trotters and pacers.

OBJECTIVE: To determine the influence of clinical osteochondrosis (OC) on the short-term (2, 3, and 4-year-old) and long-term racing performance and longevity of standardbred racehorses. STUDY DESIGN: Retrospective case-control study. SAMPLE POPULATION: Standardbred racehorses from a single breeding farm born between 2009 and 2017 that survived to racing age (n = 2711). Three hundred eighty-two (14%) horses were OC-affected (829 lesions confirmed arthroscopically during surgical treatment), and 2329 (86%) horses were nonaffected. METHODS: Racing performance data were obtained from an online database and evaluated with multiple linear regression models. RESULTS: Trotters were more likely than pacers to be affected by OC (odds ratio [OR] = 1.4, 95% CI = 1.1-1.9, P = .006). Compared with nonaffected horses, long-term OC-affected horses had 8.8 fewer starts (95% CI = -14.4 to -3.2, P = .002), 1.0 fewer wins (95% CI = -1.9 to -0.1, P = .030), and 3.8 fewer total number of first through third place finishes (95% CI = -6.2 to -1.4, P < .0001). Nonaffected horses had longer careers compared with OC-affected horses, racing 0.32 years longer (95% CI = -0.52 to -0.12, P = .002). Osteochondrosis had no impact on short-term racing performance. Horses with lesions at the distal intermediate ridge of the tibia or lateral trochlear ridge of the talus had decreased performance compared with horses without these lesions. CONCLUSION: Pacers were less likely than trotters to be affected by OC. Affected horses had fewer starts and shorter careers, despite early surgical intervention. CLINICAL SIGNIFICANCE: Osteochondrosis decreases long-term racing performance in racing standardbreds.

Radiographic diagnosis and surgical management for successful outcomes for osteochondrosis in Japanese Black calves.

Osteochondrosis (OC) is not well recognized in cattle. Japanese Black (JB) cattle are valued for their beef and studies regarding OC are scarce. Hence, the aim of this study was to retrospectively discuss clinical and radiographical findings, diagnosis and treatment options for OC in JB cattle for successful outcomes. Medical records of 11 calves affected with OC were reviewed, retrospectively. Clinical and radiographic findings, treatment and outcomes and postmortem examination findings were analyzed. All calves had lameness. Stifle (4/14) and tarsal (4/14) were the most affected joints. Subchondral bone lucencies were observed in all joints (14/14) and accompanied with sclerosis (10/14). Radiographic grading was performed in calves. Calves were treated surgically (8/11) or conservatively (1/11). Surgically treated calves were auctioned (5/8). Postmortem examination was performed (2/11). Gross findings revealed ulcerative lesion at articular surface. Histopathologically, cartilage layer was defected at lesion. Inflammation (2/2) and granulation tissue (1/2) was also observed. In conclusion, OC in JB cattle can be diagnosed on the basis of radiography with history and clinical signs in clinical setting. Surgery should be performed in mild cases for successful outcomes. A modified radiographic grading criteria for clinical cases may hold potential in evaluating prognosis and outcomes.

The Medial Elevation Osteotomy for Late-presenting and Recurrent Infantile Blount Disease.

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.

Predictive Factors for Recurrence in Infantile Blount Disease Treated With Tibial Osteotomy.

BACKGROUND: This study aimed to determine the recurrence rate in infantile Blount disease (IBD) in a cohort of patients treated with a tibial osteotomy; and also to identify which factors were associated with recurrence. METHODS: We reviewed the records of 20 patients, under the age of 7 years, with IBD (35 involved extremities) treated by proximal tibial realignment osteotomy to physiological valgus at a single institution over 4 years. We then analyzed the data to determine the rate of recurrence and identify the risk factors for recurrence. RESULTS: The mean age of the included patients was 4.2 years (range, 2 to 6 y). We observed a recurrence rate of 40% (n=14) at a mean follow-up of 42 months (range, 21 to 72 mo). Knee instability [odds ratios OR, 6.6; 95% confidence interval (CI), 2.0-22.2], Langenskiöld stage (OR, 6.3; 95% CI, 2.0-19.4), and severity of the deformity, as measured by medial physeal slope (MPS) (OR, 1.2; 95% CI, 1.1-1.4), were associated with recurrence. On multiple logistic regression analysis, MPS remained the most relevant predictor of recurrence. Receiver operating curve analysis showed that an MPS ≥60 degrees predicted recurrence with a sensitivity of 79% and specificity of 95% (area under the curve=0.925). Postoperatively, increased varus alignment on weight-bearing as measured by the tibio-femoral angle was indicative of knee instability and associated with increased odds of recurrence (OR, 1.5; 95% CI, 1.1-1.9; P=0.004). CONCLUSIONS: We observed a recurrence rate of 40% in children with IBD under 7 years treated with acute correction to a tibio-femoral angle of 5 to 10 degrees valgus through a dome proximal tibial osteotomy. Knee instability, Langenskiöld stage, and MPS were associated with recurrence. Cases with an MPS ≥60 degrees seem to be particularly at risk for recurrence. Further research is needed to validate these findings. LEVEL OF EVIDENCE: Level IV.

Blount's disease - an up-to-date insight with contemporary treatment guidelines deduced from critical analysis of a large 146 surgical case series.

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.

Infantile Tibia Vara (Blount Disease) with Iatrogenic Changes Causing Residual Tibial Deformities.

Treatment of infantile tibia vara or Blount disease (ITV/BD) in patients < 3 years old and Langenskiold stages I-III consists of orthosis and, in relapsing cases, proximal tibial osteotomy and/or proximal tibial guided growth laterally with a tension band plate. Our aim was to evaluate the results of treatments in a consecutive group. After Institutional Review Board approval, data from 2002 to 2018 were collected. Thirty-nine knees (average age 22.4 months) with ITV/BD were treated with orthoses, and 10 knees failed. Six knees showed hyperintense T2-weighted signal in the medial proximal tibial epiphyseal cartilage on magnetic resonance imaging. Three of six knees with tibial osteotomy failed and underwent guided growth. Tibial plateau slopes were abnormal medially from the ITV/BD and laterally from the guided growth (triangular physis and depressed plateau deformities) because of factors such as orthotic treatment, tibial osteotomy, magnetic resonance imaging "physis severity score," and guided growth. (Journal of Surgical Orthopaedic Advances 29(3):141-148, 2020).

Guided Growth with Hemiplateau Elevation as an Alternative to Epiphysiodesis for Treatment of a Young Patient with Advanced Infantile Blount Disease: A Case Report.

CASE: Infantile Blount disease results from deceleration of growth by the proximal posteromedial tibial physis causing tibia vara. In advanced disease stages, surgical treatment is indicated. Owing to the young age and advanced Langenskiöld stage in this patient, a novel technique was performed combining lateral proximal physeal tethering with medial hemiplateau elevation osteotomy to correct the articular surface and unload the medial proximal tibial physis. CONCLUSION: Together, these procedures allow for correction of alignment while preserving growth potential. This technique was successful in correcting tibia vara due to infantile Blount disease while allowing continued growth in a 5-year-old patient.

Double Level Osteotomy Assisted by 3D Printing Technology in a Patient with Blount Disease: A Case Report.

CASE: We describe the case of a 26-year-old patient diagnosed with Blount disease. She underwent a medial oblique supracondylar biplanar closing-wedge osteotomy of the distal femur followed by a medial oblique biplanar opening-wedge osteotomy of the proximal tibia. 3D printed cutting guides were used for the procedures. At 18 months after surgery, the patient is pain-free and walks without aids. CONCLUSIONS: Using 3D printed guides allowed for accurate correction of the deformity and reduced the risk of damaging critical structures. These guides could be an appropriate alternative for the surgical treatment of patients with Blount disease.

Blount Disease and Obstructive Sleep Apnea: An Under-recognized Association?

BACKGROUND: Obesity is strongly associated with both Blount disease and obstructive sleep apnea (OSA). Obesity increases risks for anesthetic and postoperative complications, and OSA can further exacerbate these risks. Since children with Blount disease might have both conditions, we sought to determine the perioperative complications and the prevalence of OSA among these children. METHODS: Patients younger than 18 years undergoing corrective surgery for Blount disease were identified from 2 sources as follows: a retrospective review of records at a single institution and querying of the Kids' Inpatient Database, a nationally representative database. RESULTS: At our institution, the prevalence of OSA among patients surgically treated for Blount disease was 23% (42/184). Blount patients were obese (100%), and predominately African American (89%), and male (68%). Patients were treated for OSA before surgery, and 2 patients (1%) had postoperative hypoxemia. In contrast, of 1059 cases of Blount disease from the Kids' Inpatient Database, 3% were diagnosed with OSA. In total, 4.4% of all the Blount children experienced complications, including hypoxemia, respiratory insufficiency, atelectasis, and arrhythmias. Complications were associated with 4.3 additional days of hospitalization (P<0.0001) and 39% additional hospital charges (P=0.002). CONCLUSIONS: Data from the national database showed a low rate of OSA prevalence but high respiratory and OSA-associated complications, perhaps indicating that OSA may be underdiagnosed in children with Blount disease. Affected patients, especially ones with untreated OSA, sustain increased surgical morbidity. A high index of suspicion and preoperative planning helps alleviate the burden of OSA among these patients. LEVEL OF EVIDENCE: Level III-case-control study.

Do Different Tibial Osteotomy Techniques Affect Sagittal Alignment in Children with Blount Disease?

OBJECTIVE: To determine the radiographic outcomes following dome or wedge-shaped proximal tibial osteotomy in the management of infantile Blount disease with a particular interest in sagittal alignment of the knee joint. METHOD: Medical records of patients with Langenskiöld stage 2 Blount disease (aged ≤5 years) who underwent surgical correction between January 2005 and November 2019 were retrospectively identified. Patients with metabolic bone disease, bone tumors, prior traumatic fractures, congenital anomalies, inadequate plain films, and incomplete medical documents were excluded. Patient characteristics (e.g. age, gender, and body mass index [BMI]) and surgical characteristics (e.g. side, type of surgery, and follow-up times) were recorded. Antero-posterior (AP) and lateral knee radiographs were analyzed. Data were categorized by surgical technique as dome-shaped proximal tibial osteotomy or wedge-shaped proximal tibial osteotomy. The femorotibial angle (FTA) was used to evaluate the correction angle in varus deformities. Sagittal alignment of the lower limbs using the posterior tibial slope (PTS) angle was measured postoperatively at 3, 6, 12, and 24 months, and at the final follow-up visit. RESULTS: The present study included 72 surgeries of 46 patients who had undergone proximal tibial osteotomy. Twenty-nine (63%) were male. The mean age of patients at the time of surgery was 34.50 months (range, 26-47). The mean weight was 23.11 ± 4.98 kg (mean ± SD); the mean height was 95.33 ± 6.36 cm, and the mean BMI was 25.32 ± 4.36 kg/m2 . The mean duration of follow up was 4.77 ± 2.78 years. Sixty-four patients (88.90%) received dome-shaped proximal osteotomy of the tibia, while 8 (11.10%) received wedge-shaped proximal osteotomy of the tibia. The average FTA of the total correction measured was 29.32° ± 7.98°. The demographic data of the two groups were not significantly different for gender, age, BMI, side follow-up times, and the total correction of varus deformities. In the dome-shaped osteotomy group, the mean correction of the FTA was 29.59° ± 7.45°. The mean degree of the PTS angle was 6.50° at 3 months, 6.38° at 6 months, 5.32° at 12 months, 5.17° at 24 months, and 5.53° at the final follow-up visit. In the wedge-shaped proximal tibial osteotomy group, the mean correction of the FTA was 27.25° ± 11.77°. The PTS was 6.00° at 3 months, 7.50° at 6 months, 7.00° at 12 months, 5.40° at 24 months, and 5.57° at the final follow-up visit. No significant difference was observed in the radiological outcome between surgical techniques. CONCLUSION: Dome and wedge-shaped proximal tibial osteotomies did not demonstrate significant differences in the PTS angle in children with Blount disease.