Ralf Stücker

Temporary screw epiphyseodesis of the distal tibia: a therapeutic option for ankle valgus in patients with hereditary multiple exostosis.

Background Ankle valgus in multiple hereditary exostoses (HME) is frequently seen and may result in activity related pain, deformity, or even early degenerative arthritis. Standard treatment protocols do not exist. The effect of medial screw hemiepiphysedesis of the distal tibia to correct ankle valgus is evaluated in this patient population. Methods A retrospective review of 9 patients with HME and ankle valgus deformity (15 affected extremities) who were treated by a screw hemiepiphyseodesis of the medial physis of the distal tibia is presented. Mean age at time of operation was 11.8±1.6 years (range: 9.6 to 14.7 y). All patients underwent clinical and radiological evaluation. To define the magnitude of ankle valgus we evaluated tibial tilt angle and Malhotra stations preoperatively, at time of screw removal and/or at time of the most recent clinical follow-up. Results In 11 extremities the screws were removed after an average time of 22.6±8.0 months (range: 12 to 35 mo) and all patients were examined after a mean time of 36.7±18.7 months after hemiepiphyseodesis (range: 13 to 69 mo). The mean preoperative tibiotalar tilt was 14.3±4.4 degrees (range: 9 to 22 degrees). At time of screw removal the tibiotalar tilt was normalized to 0.4±1.7 degrees (range: −2 to 4 degrees), according to a mean rate of correction of 0.58±0.23 degrees by the month (range: 0.23±0.92 degrees). With follow up 4 ankles demonstrated a change in the fibular station. None of the patients overcorrected into a severe varus, one patient developed a recurrent ankle valgus. Conclusions The temporary screw hemiepiphyseodesis of the distal tibial physis is an effective, technically simple, and minimally invasive technique to correct ankle valgus deformity in children with HME. Level of Evidence IV.

Preliminary Results of Magnetically Controlled Growing Rods for Early Onset Scoliosis.

Background: Growth-sparing techniques for the treatment of early onset scoliosis (EOS) have developed significantly over the last years. Traditional growing rods (GRs) require repeated surgical lengthening under anesthesia. Since June 2011 we have been using the magnetically controlled growing rods (MCGR) to treat patients with progressive EOS. Methods: Thirty-five patients with EOS of different etiologies underwent treatment with MCGR. We record about our preliminary results of 24 patients who fulfilled the inclusion criteria of a minimum follow-up (FU) of 12 month and >3 lengthenings. The mean age at surgery was 8.9±2.5 years. Correction of the primary curve after the index surgery and after lengthenings was measured on standing radiographs using the Cobb technique. T1-T12 and T1-S1 spinal length were also measured. Intraoperative and postoperative complications were recorded. Results: The mean FU was 21.1±7.3 months. All patients had a minimum of 3 outpatient lengthenings [mean, 4.6±1.5 (range, 3 to 8)]. The mean primary curve was 63±15 degrees (range, 40 to 96 degrees) and improved to 29±11 degrees (range, 11 to 53 degrees; P<0.001) after MCGR. The mean major curve after most recent lengthening was 26 degrees (range, 8 to 60 degrees; P<0.07). The T1-T12 as well as the T1-S1 length increased significantly (P<0.001). The mean preoperative thoracic kyphosis decreased from 43±24 degrees (range, −32 to 86 degrees) to 27±12 degrees (range, 9 to 50 degrees; P<0.001) after surgery, respectively, and measured 32±12 degrees (range, 12 to 64 degrees; P<0.05) at last FU. In 1 patient a loss of distraction occurred making rod exchange necessary. Three patients developed a proximal junctional kyphosis and in another patient a screw pull out occurred that required revision surgery. Conclusions: Our results demonstrate that MCGR is a safe and effective nonfusion technique in the treatment of progressive EOS avoiding repeated surgical lengthening procedures. It provides adequate distraction similar to standard GR. The magnetically induced transcutaneous lengthening allows noninvasive distraction achieving spinal growth comparable to conventional GR techniques. Level of Evidence: Level IV—retrospective nonrandomized objective study.

Temporary epiphyseodesis for limb-length discrepancy: 8- to 15-year follow-up of 34 children

Background and purpose — For the treatment of leg-length discrepancies (LLDs) of between 2 and 5 cm in adolescent patients, several epiphyseodesis options exist and various complications have been reported. We reviewed the 8- to 15-year outcome after temporary epiphyseodesis in patients with LLD. Patients and methods — 34 children with LLD of up to 5 cm were included in the study. Mean age at epiphyseodesis was 12.8 (10–16) years. Temporary epiphyseodesis was performed with Blount staples or 8-plates. The LLD was reviewed preoperatively, at the time of implant removal, and at follow-up. Every child had reached skeletal maturity at follow-up. Long-standing anteroposterior radiographs were analyzed with respect to the mechanical axis and remaining LLD at the time of follow-up. Possible complications were noted. Results — The mean LLD changed from 2.3 (0.9–4.5) cm to 0.8 (–1.0 to 2.6) cm at follow-up (p < 0.001). 21 patients had a final LLD of < 1 cm, and 10 had LLD of < 0.5 cm. At the time of follow-up, in 32 patients the mechanical axis crossed within Steven’s zone 1. No deep infections or neurovascular lesions were seen. 4 implant failures occurred, which were managed by revision. Interpretation — Temporary epiphyseodesis is an effective and safe option for the treatment of LLD. The timing of the procedure has to be chosen according to the remaining growth, facilitating a full correction of the LLD. If inaccurate placement of staples is avoided, substantial differences between the mechanical axes of both legs at skeletal maturity are rare.

Posttraumatic popliteal pseudoaneurysm caused by a femoral osteochondroma.

We report an exceptional case of a 12-year-old-boy with a pseudoaneurysm of the popliteal artery caused by an osteochondroma on the lower femoral metaphysic after a hyperextension trauma. On account of the absence of the most constant findings, the pulsation of a soft tissue mass and elevated inflammation blood parameters, we preoperatively assumed an infected haematoma. This patient was successfully operated upon with resection of the osteochondroma and saphenous vein femoropopliteal bypass. Owing to the severity of potential vascular complication, preventive resection of osteochondromas in the course of an artery and the need for a vascular surgeon on stand-by should be discussed.

Growth modulation with a medial malleolar screw for ankle valgus deformity. 79 children with 125 affected ankles followed until correction or physeal closure.

Background and purpose — Growth modulation with a medial malleolar screw is used to correct ankle valgus deformity in children with a wide spectrum of underlying etiologies. It is unclear whether the etiology of the deformity affects the angular correction rate with this procedure. Patients and methods — 79 children (20 girls) with ankle valgus deformity had growth modulation by a medial malleolar screw (125 ankles). To be included, patients had to have undergone screw removal at the time of skeletal maturity or deformity correction, or a minimum follow-up of 18 months, and consistent radiographs preoperatively and at the time of screw removal and/or follow-up. The patients were assigned to 1 of 7 groups according to their underlying diagnoses. The lateral distal tibial angle (LDTA) was analyzed preoperatively, at screw removal, and at follow-up. Results — Mean age at operation was 11.7 (7.4–16.5) years. The average lateral distal tibial angle normalized from 80° (67–85) preoperatively to 89° (73–97) at screw removal. The screws were removed after an average time of 18 (6–46) months, according to an average rate of correction of 0.65° (0.1–2.2) per month. No significant differences in the correction rate per month were found between the groups (p = 0.3). Interpretation — Growth modulation with a medial malleolar screw is effective for the treatment of ankle valgus deformity in patients with a wide spectrum of underlying diagnoses. The individual etiology of the ankle valgus does not appear to affect the correction rate after growth modulation. Thus, the optimal timing of growth modulation mainly depends on the remaining individual growth and on the extent of the deformity.

Rebound of ankle valgus deformity in patients with hereditary multiple exostosis.

Background: Temporary screw epiphysiodesis of the distal tibia is employed to correct ankle valgus deformity in patients with a wide spectrum of underlying etiologies. For patients with hereditary multiple exostosis it is unclear whether a rebound phenomenon may play a role after screw removal (SR) and successful management of ankle valgus deformity. Methods: From January 2002 to July 2013, 10 boys and 2 girls with HME and an ankle valgus deformity were included in this study. To be included the following criteria had to be met: patients had to have undergone temporary medial malleolar screw epiphysiodesis, SR at the time of skeletal maturity or correction of the deformity, a follow-up (FU) at least 6 months after SR, and consistent radiographs obtained preoperatively at the time of SR as well at FU. The average age at the time of operation was 11.6±1.5 years (range, 9.6 to 14.7 y). The tibiotalar tilt (TT) was analyzed preoperatively, at SR and at FU. Results: The average preoperative TT was 13.2±4.9 degrees. Twenty-four months (±10) after epiphysiodesis all screws were removed. At SR, the TT was normalized to 0.8±4.8 degrees (P<0.001), according to an average rate of correction of 0.63±0.28 degrees per month. Twenty-two months (±13) after SR, the TT increased up to 3.2±4.9 degrees (P<0.05), a rebound (>5 degrees) occurred in 43%, managed by repeated epiphysiodesis. No deep infections or implant complications occurred. No permanent damage of the physis was observed in any case. Conclusions: Medial malleolar screw epiphysiodesis is a successful treatment for the correction of ankle valgus deformity in patients with HME. A rebound after SR in the growing child or adolescent occurs in almost 50% of patients with HME, which can easily be managed by repeated epiphysiodesis. Therefore, we do not recommend overcorrection into a slight varus deformity. Because of the varying correction and recurrence rates, close FUs are of paramount importance. Level of Evidence: Level IV.

Growth Disturbance of the Distal Tibia in Patients With Idiopathic Clubfeet: Ankle Valgus and Anteflexion of the Distal Tibia.

Background: The aim of this study was to evaluate the incidence of deformities of the distal tibia in patients with idiopathic clubfeet who had undergone surgical intervention with a circumferential release through a Cincinnati incision in early infancy. Methods: A retrospective follow-up evaluation of children with idiopathic clubfoot was conducted. We reviewed children who had undergone surgical treatment by a circumferential release in our department after unsuccessful casting, and who were at least 10 years of age. Main focus was the measurement of anteroposterior and lateral view radiographs for distal tibia deformities. Of 65 patients (93 feet) who had surgery for idiopathic clubfoot from 1998 to 2002, radiographic data of 35 patients (52 feet) were analyzed. Results: An anteflexion deformity was present in 25 of 52 feet (48.1%) and a valgus deformity in 29 of 52 feet (55.8%). A flat-top talus was evident to some degree in all cases. An abnormal lateral talocalcaneal angle was evident in 42.3%. Conclusions: These results show the importance of conducting follow-up evaluations on patients with idiopathic clubfoot for secondary deformities of the distal tibia. This is the first study, to our knowledge, highlighting the high incidence of distal tibial deformities after surgery for idiopathic clubfoot. It is unclear at this time whether this is also true for clubfeet after conservative treatment. However, patients with clubfeet should have radiographs of the ankle joint between the age of 10 and 12 years to be able to treat possible deformities through guided growth. Level of Evidence: Level III.

[Non-fusion techniques for treatment of pediatric scoliosis].

The primary goal of treatment in children with early onset scoliosis (EOS) is to control the deformity and to allow spinal and chest wall growth to continue and improve pulmonary function. In skeletally immature children spondylodesis leads to fusion of the instrumented segments with associated nonsymmetrical growth and pulmonary insufficiency. Non-fusion, techniques such as growing rods, vertical expandable prosthetic titanium rib® (VEPTR) and staples have evolved over the past years. Each technique has its different spectrum of indications which the surgeon has to follow accurately to prevent the patient from developing complications. A new trend started by using magnetically controlled growing rods to avoid the need for anesthesia and open surgery during adaptive growth. The intention of this article is to give the reader a synopsis about the three most important non-fusion techniques based on own experience and the current literature.

Nonfusionstechniken zur Behandlung der kindlichen Skoliose

The primary goal of treatment in children with early onset scoliosis (EOS) is to control the deformity and to allow spinal and chest wall growth to continue and improve pulmonary function. In skeletally immature children spondylodesis leads to fusion of the instrumented segments with associated nonsymmetrical growth and pulmonary insufficiency. Non-fusion, techniques such as growing rods, vertical expandable prosthetic titanium rib® (VEPTR) and staples have evolved over the past years. Each technique has its different spectrum of indications which the surgeon has to follow accurately to prevent the patient from developing complications. A new trend started by using magnetically controlled growing rods to avoid the need for anesthesia and open surgery during adaptive growth. The intention of this article is to give the reader a synopsis about the three most important non-fusion techniques based on own experience and the current literature.

Strategies for treating scoliosis in early childhood

BACKGROUND Scoliosis in early childhood is defined as abnormal curvature of the spine of any etiology that arises before age 10. The affected children are at high risk of developing restrictive pulmonary dysfunction. The treatment presents major challenges because of the complexity and high morbidity of the disease. METHODS This article is based on pertinent articles retrieved by a selective literature search, and on the results of a retrospective study by the authors. RESULTS In addition to conservative treatment methods including physiotherapy, casts, and corsets, progressive scoliosis usually requires early surgical intervention. In recent years, many different so-called non-fusion techniques have been developed for the surgical treatment of early childhood scoliosis. The goal of this new strategy is to avoid early fusion procedures and to enable further growth of the rib cage, lungs, and spine in addition to correcting the scoliosis. The authors also present their own intermediate-term results with a novel growth-preserving spinal operation that exploits magnet technology. CONCLUSION Because of the low prevalence and heterogeneous etiology of early childhood scoliosis, the literature to date contains no randomized controlled therapeutic trials concerning this small group of high-risk patients. For the treatment to succeed, it is essential for specialists from all of the involved medical disciplines to work closely together. Conservative measures such as physiotherapy, casts, and corsets can delay the (frequent) need for surgery or even make surgery unneces - sary, particularly in the idiopathic types of early childhood scoliosis. The new non-fusion techniques enable continued growth of the spine, rib cage, and lung in addition to correcting the scoliosis.