Safety and efficacy of tranexamic acid in children with cerebral palsy undergoing femoral varus derotational osteotomy: a double cohort study.

AIMS: The safety and efficacy of tranexamic acid (TXA) in reducing blood loss after total joint arthroplasty and spinal fusion surgery has been well documented. However, little data exist regarding the effectiveness of intraoperative TXA in children with cerebral palsy (CP). The aim of this double cohort study is to investigate the safety and efficacy of intraoperative TXA in reducing blood loss and transfusion requirements for children with CP undergoing a proximal unilateral or bilateral femoral varus derotational osteotomy (VDRO). PATIENTS AND METHODS: A retrospective review was performed of all paediatric theatre lists between May 2012 and January 2019 for all paediatric (< 16 years old) CP patients who underwent unilateral or bilateral VDRO combined with soft tissue release at our institution. Fifty-one patients were included in our study further subdivided into two individual groups, unilateral and bilateral VDRO. RESULTS: No statistically significant differences were found in demographics such as age, weight, ASA, GMFCS and antiepileptic medication between the groups. However, there were significant statistically differences in TBL and transfusion rates between the groups that received TXA and those that did not, both in unilateral [241 ml (TXA) vs. 369 ml (non-TXA)] and bilateral [287 ml (TXA) vs. 467 ml (non-TXA)] operations. CONCLUSION: TXA successfully reduced TBL (in both TXA subgroups) and the transfusion rates without associated complications. TXA's safety and efficacy should be explored further in adequately powered randomized controlled trials.

Transfixing Kirshner wires for fixation of intertrochanteric valgus osteotomies in management of pediatric coxa vara.

BACKGROUND: Coxa vara is a radiological term describing a decrease in the neck-shaft angle to 120° or less. Coxa vara is associated with pathomechanical changes that can manifest clinically. If left untreated, coxa vara can affect the normal development of the pediatric hip. Valgus osteotomy is the standard surgical treatment for coxa vara, but there is no consensus regarding the optimal osteotomy technique and fixation method. The work reported here aimed to highlight transfixing wires as a fixation method for valgus osteotomy applied as treatment for various types of pediatric coxa vara. MATERIALS AND METHODS: This study included 16 cases of pediatric coxa vara with different etiologies in 9 patients with a mean age of 39.9 ± 15.2 months. Radiological and clinical evaluations and scoring of the condition of each patient according to the Iowa Hip Score were performed pre- and postoperatively. Transfixing wires and a protective spica were used for the fixation of a V-shaped, laterally based, closing-wedge valgus osteotomy in all cases. The postoperative follow-up period ranged from 14 to 102 months, with a mean duration of 33.3 ± 27.7 months. RESULTS: The mean Hilgenreiner epiphyseal angle (HEA) was corrected from 81.7 ± 2.2° to 24.3 ± 3.5° and the mean femoral neck-shaft angle (FNSA) was improved from 86.9 ± 4.2° to 138.6 ± 3.5°. No recurrence of the deformity was observed during the follow-up periods considered here. The osteotomy site united after an average of 11.7 ± 2.2 weeks with no secondary displacement, and in cases of developmental coxa vara there was progressive ossification of the neck defect with no surgery-related complications. Clinical results were markedly improved by the osteotomy, with a mean postoperative Iowa Hip Score at last follow-up of 95.06 ± 2.6, compared to a mean preoperative score of 57.4 ± 3.6. CONCLUSIONS: Transfixing wires protected in a hip spica cast represent a simple, easy, and reliable fixation method for valgus osteotomies performed to correct pediatic coxa vara. It assures stable fixation and rapid healing of the osteotomy without loss of the achieved correction, it completely avoids the femoral neck affording marked protection to the growth plate. LEVEL OF EVIDENCE: IV.

[Accuracy of proximal femur correction achieved with LCP paediatric hip plates]. / Presnost korekce proximálního femuru s fixací LCP detskými kycelními dlahami.

PURPOSE OF THE STUDY: The aim of the study was to evaluate, in comparison with the pre-operative planning, the accuracy of proximal femur correction achieved with the use of locking compression paediatric hip plates (LCP) in children and adolescents and to assess pre- and post-operative complications. MATERIAL AND METHODS: A group of 52 patients in whom proximal femoral osteotomy using the LCP was performed on a total of 55 hips between September 2009 and February 2013 were retrospectively evaluated. The following diagnoses were treated: unstable hip in cerebral palsy, 18 operations; Legg-Calvé-Perthes disease, 10 operations; coxa vara of aetiology other than coxa vara adolescentium (CVA), eight operations; true CVA, six operations; femoral shortening by the Wagner method, six procedures; proximal femoral derotation osteotomy, four procedures; and post-traumatic pseudoarthrosis of the proximal femur, three operations. RESULTS: Compared with the pre-operative plan, the average deviation of the colodiaphyseal angle was 5.2° (1° to 11°) in 18 unstable hips; 4.7° (1° to 10°) in 10 cases of Legg-Calvé-Perthes disease; 4.5° (3° to 6°) in eight hips with coxa vara of aetiology other than CVA; 6.5° (2° to 13°) in six CVA hips; 4.5° (1° to 10°) in six cases of femoral shortening; 3.5° (1° to 5°) in four derotation osteotomies; and 3.7° (0° to 6°) in three corrections of pseudoarthrosis. In one patient, osteosynthesis failed due to screws being pulled out from the proximal fragment; re-osteosynthesis was carried out using a conventional angled blade plate. DISCUSSION: As in other international studies, our results confirmed a high accuracy of proximal femur correction with use of the LCP instrumentation. The reported higher time requirement for this technique seems to be related to the learning curve and, with more frequent use, will probably be comparable to the time needed for application of conventional hip angled plates. CONCLUSIONS: The up-to-date LCP fixation system using the principle of angular stability for correction of the proximal femur in children is a clear advancement and its higher costs are certain to be outweighed by its higher accuracy and thus better results.

Operative treatment of avascular necrosis of the femoral head after proximal femur fractures in adolescents.

PURPOSE: Our aim was to assess operative treatment for post-traumatic avascular necrosis of the femoral head (ANFH) in adolescents. METHODS: Eleven patients with an average age of 17 (range 14-26) years were operated up on for ANFH after proximal femoral fractures. The average interval between injury and reconstructive surgery was four (range two to eight) years. The average follow-up of the entire cohort was 89 (range 48-132) months. Five patients with total ANFH were treated by total hip replacement (THR). Six patients with partial ANFH were treated with valgus intertrochanteric osteotomy (VITO). RESULTS: In all patients, operation improved hip function. The average preoperative Harris Hip Score (HHS) was 70 points and average postoperative HHS was 97 points. Comparison of magnetic resonance imaging (MRI) scans before and after VITO demonstrated resorption of the necrotic segment of the femoral head and its remodelling in all six patients with partial ANFH. A complication was encountered in one patient. CONCLUSION: Patients treated for ANFH had good medium-term outcomes after THR for total necrosis and also after VITO for partial necrosis.

Valgus intertrochanteric osteotomy for coxa vara of Bucholz-Ogden Types II and III in patients older than 30 years.

BACKGROUND: Ischemic necrosis of the proximal femur resulting in coxa vara is a severe iatrogenous complication of the treatment of developmental dysplasia of the hip (DDH). Severe relative overgrowth of the greater trochanter and reduction of the neck result in insufficiency of hip abductors. Unequal limb length causes obliquity of the pelvis, compensatory scoliosis of the lumbar spine and valgus deformity of the ipsilateral knee. The purpose of this study was to investigate the effect of valgus intertrochanteric osteotomy in patients with coxa vara older than 30 years. METHODS: Fifteen female patients of the average age 43 years (range 31-60) with postdysplastic varus deformity of the proximal femur and shortening of affected limb of 2-4 cm were treated with valgus intertrochanteric osteotomy. None of them was operated on before. In eight cases, the varus deformity of the proximal femur was evaluated as Bucholz-Ogden Type II, in seven cases as Bucholz-Ogden Type III. The average follow-up was 10 years (range 5-20). RESULTS: By the time of the last functional follow-up, three patients had already underwent conversion of osteotomy to total hip arthroplasty (THA), namely, 7.5, 11, and 12 years after osteotomy. All the patients evaluated the effect of osteotomy positively, including those treated later with THA. The average preoperative Harris Hip Score was 83, the postoperative one was 93. CONCLUSIONS: Based on results, the valgus intertrochanteric osteotomy appears to be a reliable treatment for postdysplastic coxa vara in patients older than 30 years.

Excision of fibrous band and application of tension band plating in focal fibrocartilaginous dysplasia: A case report and literature review.

Focal fibrocartilaginous dysplasia (FFCD) is a rare disease that can cause angular deformities of long bones. The common pathologic finding is a thick fibrotic band extending from epiphysis to metaphysis on one side of the bone. The tethering effect of the fibrotic band around the growth plate is thought to be the main etiology for the development and progression of the deformity. FFCD mostly affects the proximal tibia and the distal femur. The literature contains different treatment options. Here, we present the case of a 20-month-old girl with FFCD on the medial side of the distal femur causing varus deformity. Our treatment protocol included excision of the fibrotic band from the medial side and application of a two-hole plate for guided growth on the lateral side of the distal femur. Deformity correction was achieved rapidly with no complications. A literature review is also presented along with pathologic and magnetic resonance imaging findings.

Multiple needle puncture combined with repetitive knee manipulation in total knee arthroplasty for correcting varus deformity.

PURPOSE: Multiple needle punctures (MNPs), for gap balancing in total knee replacement, have less variability in gap widening compared to the conventional released technique. This study aimed to evaluate the outcome of gap-balancing techniques in varus osteoarthritis (OA) knees, by serial MNP, after a total knee prosthesis trial component was placed, combined with repetitive knee manipulation. METHODS: This study was a retrospective, case-matched study of 161 patients. The data were collected from varus OA knee patients, who had total knee arthroplasty by a single surgeon. Sixty-eight patients required MNP, combined with repetitive knee manipulation for gap balancing, and 93 patients did not. Both groups of MNP patients underwent the same surgical technique and postoperative care protocols. RESULTS: Knee society scores, in terms of knee score and functional score, were not different in both groups when we started the study, at 6-month and 1-year follow-ups (p > 0.05). The femorotibial angle was not significantly different between groups at the start of the study, initial postoperative, 6 months, and 1 year (p = 0.74, 0.45, 0.99, and 0.82, respectively). Medial joint opening in knee radiographic was found in 3% of the patients in the MNP group and in 4% of patients in the control group at 1-year follow-up (p = 0.65). CONCLUSION: This study found MNP combined with repetitive knee manipulation was effective, reproductive, and a safe method for varus OA knee. We believe that the cycle of performed needle punctures, knee manipulation, and reevaluation could gradually lengthen the medial soft tissue without risk of over lengthening or medial collateral ligament rupture.

Can we predict failure of percutaneous fixation of femoral neck fractures?

PURPOSE: This study evaluated a series of geriatric femoral neck fracture treated with closed reduction percutaneous pinning (CRPP) at a single level-1 trauma center to determine if there are any simple, reliable, radiographic characteristics that can be used to predict increased risk of post-operative failure in nondisplaced and valgus impacted fracture patterns. METHODS: We conducted a retrospective cohort study of all patients with femoral neck fractures (AO/OTA 31B) who underwent CRPP over a 12-year period at a single Level 1 trauma center. Failure was defined as radiographic failure within the first year after the index operation requiring revision surgery. Common patterns identified on initial review were the presence of a visible medial transcervical line (MTL) felt to indicate a tension-sided failure, a straight inferior calcar (SIC) indicating severe valgus impaction, and quality of intra-operative screw positioning. X-rays of patients were then reviewed for these characteristics in a blinded manner by three different trauma-fellowship trained orthopedic surgeons. Inter-rater reliability was calculated using Fleiss' Kappa Coefficient. Comparisons of failure rates between groups were made using a Fisher's Exact test. RESULTS: 139 patients who underwent CRPP for a femoral neck fracture and follow-up for at least 90 days were identified and reviewed. There were a total of 19 failures (13.6%) within one year. The patients with a varus fracture had a failure rate of 9/24 (37.5%). Of the valgus/nondisplaced fractures, MTL was identified in 42/115 (36%) patients. Inter-rater agreement was high for the presence of an MTL (84%, Kappa 0.69). Patients with an MTL had a fourfold increase in risk of failure (7/42=17% with an MTL vs. 3/73=4% without, p  0.03). The presence of a SIC and quality of screw placement were not predictive of failure. CONCLUSION: Varus femoral neck fractures fixed with CRPP have a high rate of failure (37.5%). Nondisplaced or valgus impacted fractures with the presence of a visible medial transcervical line on pre-operative radiographic imaging resulted in a fourfold increase in the risk of failure after CRPP. Identification of the MTL will help treating surgeons better council patients when making pre-operative decisions between arthroplasty and CRPP.

An alternative fixation method for femoral varus derotational osteotomy in spastic cerebral palsy: the Rush rod.

The objective of this study is to present the clinical and radiographic data collected from patients who were treated with a varus derotational osteotomy using Rush rod fixation and compare this to published norms of outcomes using blade plate fixation. A retrospective chart and radiograph review was conducted after identifying 44 patients with 61 hips who underwent varus derotational osteotomy with Rush rod fixation at our institution between 2006 and 2016. We identified 44 patients with 61 hips who underwent the procedure. Information from follow-up clinic visits was gathered and any complications were noted. The patients' radiographs were analyzed to measure neck-shaft angle, center-edge angle, and acetabular index. At the time of surgery, 44 patients (61 hips) also had soft tissue releases performed, 44 (61 hips) had an open reduction of the hip, and 39 (55 hips) had Dega acetabular osteotomies performed as well. The average pre-operative neck-shaft angle was measured at 163.0° (range 128-180) with average post-operative neck-shaft angles measuring 111.3° (range 85-167). The acetabular index improved from an average of 33.3° (range 16-60) to 16.4 (range 4-35). Post-operative Center-Edge Angle measured 29.7° (range 5-45). There were no infections or cases of avascular necrosis of the femoral head. We present an alternative fixation method for performing varus derotational osteotomy of the proximal femur in children with cerebral palsy using the Rush rod. In our retrospective analysis of 61 hips undergoing this procedure, we present comparable radiographic outcomes with decreased complication rates. Level of evidence: Retrospective comparative study to previously published results, Level III.

Femoral Neck Fractures in Children: Issues, Challenges, and Solutions.

Femoral neck fractures in children are rare injuries resulting from high-energy trauma. Different methods of treatment, lack of standard management protocols, and the high risk of complications make this injury one of the biggest challenges that an orthopaedic surgeon can face. This review focuses on the general aspects of the pediatric femoral neck fracture management as well as its complications and possible solutions.

Acute effects of different orthotic interventions on knee loading parameters in knee osteoarthritis patients with varus malalignment.

BACKGROUND: Knee osteoarthritis (KOA) is the most common form of arthritis with an estimated lifetime prevalence of 45%. The use of orthotic devices is a generally accepted conservative therapy in KOA. A new conservative treatment is an ankle-foot orthosis (AFO); however, studies on the biomechanical effects are limited. The aim of this study was to examine the acute effects of different orthotic devices (AFO, knee brace and wedged shoes) on (un)loading parameters in subjects with KOA. METHODS: Fifty-two medial KOA patients (mean age 59 (standard deviation (SD) 10) years and mean body mass index 27.5 (SD 4.9) kg/m2) were recruited. Three-dimensional gait analysis was undertaken with different interventions in a randomized order: control (own shoes), new AFO, conventional unloader brace and laterally wedged shoes (six degrees). RESULTS: Significant decreases of 27% and nine percent in first peak knee adduction moment (KAM) were observed for the AFO and wedged shoes, respectively, in comparison with the control. Significant decreases of 21%, seven percent and 18% in the KAM impulse were observed for the AFO, brace and wedged shoes, respectively, compared to the control. The knee flexion moment (KFM) increased compared to the control for all conditions, but only significantly while using the AFO, showing an increase of 26% as compared to the control. CONCLUSIONS: The AFO and wedged shoes were more effective in unloading the medial compartment of the knee compared to the unloader brace. However, the effect of an increased KFM on KOA remains unclear and requires further investigation.

Management of Pediatric Femoral Neck Fracture.

In the pediatric population, femoral neck fracture is a relatively uncommon injury with a high complication rate, despite appropriate diagnosis and management. The anatomy and blood supply of the proximal femur in the skeletally immature patient differs from that in the adult patient. Generally, these fractures result from high-energy trauma and are categorized using the Delbet classification system. This system both guides management and aids the clinician in determining the risk of osteonecrosis after these fractures. Other complications include physeal arrest, coxa vara, and nonunion. Multiple fracture fixation methods have been used, with the overall goal being anatomic reduction with stable fixation. Insufficiency fractures of the femoral neck, although rare, must also be considered in the differential diagnosis for the pediatric patient presenting with atraumatic hip pain.

Coxa vara in postseptic arthritis of the hip in children.

The behavior and treatment of coxa vara and pseudarthrosis of the proximal femur secondary to sepsis is not well described. The aim of this study is to describe the pathoanatomy for coxa vara and pseudarthrosis in postseptic hips, evaluate progression of neck shaft angle (NSA), and discuss treatment. This is a retrospective case series of 20 patients (21 hips). There were 11 hips with predominant avascular necrosis of the capital femoral epiphysis without pseudarthrosis (type 1) and 10 with pseudarthrosis (type 2). The interobserver κ value was 0.79. There was a decrease in NSA from 110.3° to 99.3° during an average follow-up duration of 5.2 years (range: 2-14 years). The average change in NSA between the initial presentation and the final follow-up was 5.5° in type 1 and 17.1° in type 2. Nine patients underwent a surgical intervention. In cases where subtrochanteric valgus osteotomy was performed, the mean preoperative NSA was 94° and the mean NSA at the final follow-up was 128°; all operated pseudarthroses healed without bone grafting. Acetabuloplasty is not necessary in most cases.

Management of Coxa Vara Septica and Pseudoarthrosis of the Femoral Neck: A Case Report.

BACKGROUND Coxa vara and pseudoarthrosis of the femoral neck after septic hip arthritis is a very rare disease. The aim of this study was to present a case with pseudoarthrosis of the femoral neck, with coxa vara after neonatal septic arthritis of the right hip, and treatment of the pseudarthrosis with proximal femoral valgus osteotomy. CASE REPORT A 12-month-old female, who had suffered neonatal septic arthritis with a five-day history of fever and painful right hip now demonstrated painless limping to the right hip, pelvic obliquity, Trendelenburg-Duchenne gait, limitation of hip abduction, lower-extremity length discrepancy with 3.0 cm of shortening of right femur, and walking on her tiptoes. In addition, a viable femoral head, coxa vara, and pseudoarthrosis of the femoral neck were observed. At the age of 26-months, the patient had a realignment valgus osteotomy of the proximal femur and adductor tenotomy was performed. At the last follow-up postoperative evaluation, at the age of four and a half years, the patient showed successful consolidation of pseudoarthrosis, correction of Trendelenburg gait, restored right lower extremity alignment, and corrected lower-extremity length discrepancy. CONCLUSIONS In the case of coxa vara and pseudoarthrosis of the femoral neck, realignment of the proximal femoral valgus osteotomy and bone grafting of the pseudoarthrosis resulted in ossification of the femoral neck as the epiphyseal plate was placed at right angle to the compressive forces.

Phenotypic Spectrum in Osteogenesis Imperfecta Due to Mutations in TMEM38B: Unraveling a Complex Cellular Defect.

Context: Recessive mutations in TMEM38B cause type XIV osteogenesis imperfecta (OI) by dysregulating intracellular calcium flux. Objectives: Clinical and bone material phenotype description and osteoblast differentiation studies. Design and Setting: Natural history study in pediatric research centers. Patients: Eight patients with type XIV OI. Main Outcome Measures: Clinical examinations included bone mineral density, radiographs, echocardiography, and muscle biopsy. Bone biopsy samples (n = 3) were analyzed using histomorphometry, quantitative backscattered electron microscopy, and Raman microspectroscopy. Cellular differentiation studies were performed on proband and control osteoblasts and normal murine osteoclasts. Results: Type XIV OI clinical phenotype ranges from asymptomatic to severe. Previously unreported features include vertebral fractures, periosteal cloaking, coxa vara, and extraskeletal features (muscular hypotonia, cardiac abnormalities). Proband lumbar spine bone density z score was reduced [median -3.3 (range -4.77 to +0.1; n = 7)] and increased by +1.7 (1.17 to 3.0; n = 3) following bisphosphonate therapy. TMEM38B mutant bone has reduced trabecular bone volume, osteoblast, and particularly osteoclast numbers, with >80% reduction in bone resorption. Bone matrix mineralization is normal and nanoporosity low. We demonstrate a complex osteoblast differentiation defect with decreased expression of early markers and increased expression of late and mineralization-related markers. Predominance of trimeric intracellular cation channel type B over type A expression in murine osteoclasts supports an intrinsic osteoclast defect underlying low bone turnover. Conclusions: OI type XIV has a bone histology, matrix mineralization, and osteoblast differentiation pattern that is distinct from OI with collagen defects. Probands are responsive to bisphosphonates and some show muscular and cardiovascular features possibly related to intracellular calcium flux abnormalities.

Varus will have varus; a radiological study to assess and predict varus stem placement in uncemented femoral stems.

BACKGROUND: Varus inclination of the uncemented stem is not necessarily a technical error. The proximal femoral anatomy of hips with a coxa vara deformity frequently predisposes varus inclination. METHODS: We reviewed a series of 200 patients undergoing primary uncemented THA with the Corail® hip system. Preoperative data were based on patient demographics, diagnosis, and radiographic information (preoperative templating-CT measurements), and compared postoperative alignment for each stem and type of stem used. Proximal femoral traits which can alert surgeons, when templating preoperatively, to potential varus alignment were noted. RESULTS: All stems were inserted either in neutral or varus alignments. Low neck shaft angle is strongly predictive of increased varus stem alignment (p<0.001). Stems inserted with higher varus alignment were associated with the preoperative morphological traits associated with coxa vara hip deformities - increased femoral offset (p<0.001), greater trochanteric overhang (p<0.001), greater trochanteric height (p<0.046), and a lower canal flare index (p<0.046). CONCLUSIONS: Varus stem alignment is neither unexpected nor necessarily a technical failure when using this particular uncemented stem system. Coxa vara deformities, due to a combination of morphological traits, are more likely to be inserted with higher varus alignment than hips with normal or higher neck shaft angles. Surgeons need to be aware of this when carrying out preoperative templating and intraoperative assessment, in order to prevent over-compensation for offset, length or stability.

Varus deformity of the left lower extremity causing degenerative lesion of the posterior horn of the left medial meniscus in a patient with Paget's disease of bone.

We report on a 42-year-old woman who presented with persistent pain in her left knee with no history of trauma. Sagittal T1-weighted MRI of the left knee showed discontinuity between the anterior and posterior horns of the left medial meniscus, causing effectively the development of degenerative lesion of the posterior horn. The latter was correlated to varus deformity of the left lower extremity associated with subsequent narrowing of the medial knee joint. The unusual craniofacial contour of the patient, the skeletal survey and the elevated serum alkaline phosphatase were compatible with the diagnosis of Paget's disease of the bone. To alleviate the adverse effect of the mal-alignment of the left femur onto the left knee, corrective osteotomy of the left femoral diaphysis by means of fixators was performed. To the best of our knowledge this is the first clinical report describing the management and the pathological correlation of a unilateral varus deformity of the femoral shaft and degenerative lesions of the left knee in a patient with Paget's disease of the bone.

The kinematics and stability of single-radius versus multi-radius femoral components related to mid-range instability after TKA.

There continues to be some dissatisfaction with the function of total knee arthroplasties (TKA). "Mid-range instability" has been linked to multi-radius femoral components allowing transient ligament slackness and instability during knee flexion. Single-radius designs have been introduced to avoid this. We compared the kinematics and stability of eight natural knees versus multi-radius and single-radius TKAs in vitro. The loading conditions imposed across the range of active knee extension were anterior-posterior drawer forces, internal-external rotation torques, and varus-valgus moments. Significant differences were not found between the biomechanical behavior of the two TKAs. Both were significantly different from the natural knee in allowing greater anterior drawer laxity near extension, probably caused by excision of the anterior cruciate ligament, but no difference occurred beyond 30° flexion. No differences were found for any of the other degrees-of-freedom of movement. A geometric analysis suggested that the multi-radius design may tense the MCL more than the single-radius in mid-flexion, contrary to expectation. These kinematic and stability tests did not find mid-range instability of the knees, and so they could not demonstrate enhanced mid-range stability of the single-radius TKA over the older multi-radius implant. This suggests that mid-range instability may relate to unrecognized ligament laxity during surgery, rather than being inherent to a specific feature of implant design.

[Crooked legs- just an aesthetic problem]. / Krumme Beine - mehr als ein ästhetisches Problem?

Because the lower extremities are weight bearing, malalignment plays a key role in the development of degenerative disease of the joints. This is particularly true as degenerative arthropathy is of mechanical and not inflammatory cause. Deviation of the axis has been shown to alter the load and force distribution in the joint and thereby causing excessive wear. Whether or not a deformity is clinically relevant or not depends on the symptoms, the amount of the deformity and the location of the deformity. Relevant deformities can be treated with orthotics or corrective osteotomies in early stages. In late stages fusions or joint replacement is the mainstay of treatment.

Parce que les extrémités inférieures portent un poids, un mauvais alignement de ces dernières joue un rôle clé dans le développement des atteintes dégénératives des articulations. Cela est particulièrement vrai puisque l'arthropathie dégénérative est d'origine mécanique et non pas inflammatoire. Une déviation axiale a été montrée modifier la répartition des charges et des forces dans l'articulation et provoquer ainsi un poids excessif. Qu'une déformation soit significative ou non sur le plan clinique dépend des symptômes, de l'importance et de la localisation de la déformation. Les déformations significatives peuvent être traitées dans des stades précoces par des ostéotomies orthotiques ou correctrices. Dans les stades tardifs des fusions ou des remplacements articulaires représentent les options thérapeutiques principales.

Spontaneous correction of partial physeal arrest: report of a case and review of the literature.

This study describes the rare phenomenon of partial physeal arrest spontaneous correction. It concerns a case of a 3.5-year-old girl who suffered from a Salter-Harris IV fracture of the distal tibial epiphysis, which was managed conservatively. After fracture healing an osseous bridge was formed at the medial part of the physis, leading to a varus deformity. The parents refused the operation, but 6 years later, both the ankle's deformity and the shortening of the extremity had been spontaneously corrected. It seems that the growth potential of the physis healthy portion is able to break the already transformed osseous bridge.