|Year : 2020 | Volume
| Issue : 1 | Page : 67-72
Azhar dome physioclasis: A new surgical technique of treating patients with late presenting blount's disease
Y Elbatrawy1, Ahmed I Hammouda1, Mohamed Khaled2
1 Department of Orthopedic Surgery and Trauma, Al-Azhar University Hospitals, Cairo, Egypt
2 Department of Orthopedic and Traumatology, Assiut University, Assiut, Egypt
|Date of Submission||09-May-2020|
|Date of Decision||01-Jun-2020|
|Date of Acceptance||05-Jun-2020|
|Date of Web Publication||30-Jun-2020|
Prof. Y Elbatrawy
Villa 26 E, Mayfair, Elsherouk City, 11837, Cairo
Source of Support: None, Conflict of Interest: None
Introduction: Surgical treatment of patients with multi-planar deformity secondary to Late Presenting Blount disease (LPBD). Is there a new method for acute deformity correction of tibial deformity in patients with LPBD? The new method entailed acute deformity correction of the deformity by manual rotation of the deformed limb relative to the CORA in the physis itself. Patients and Methods: A prospective case study performed on two patients. First patient was eleven years old boy with LPBD and bilateral affection. Patient's height was 127cm, and weight was 60 kg; with BMI was 37.2 kg/m2. Both sides were done, left sided correction preceded the right side by 6 weeks. The second patient was twelve years old female. Her height was 145cm, and weight was 67kg with BMI 31.8 kg/ m2. Results: Acute correction of the varus, procurvatum and internal rotation was achieved intraoperatively with corrected mechanical axis. Average follow up was 20 months. No complications encountered in either limb. Conclusion: “Dome Physioclasis” is a new novel surgical technique that allows acute tibial multi-plane deformity correction in patients with LPBD. This method is suitable for selected cases where patients complain from severe deformity and near skeletal maturity. Future more experience in the technique may improve its understanding.
|How to cite this article:|
Elbatrawy Y, Hammouda AI, Khaled M. Azhar dome physioclasis: A new surgical technique of treating patients with late presenting blount's disease. J Limb Lengthen Reconstr 2020;6:67-72
|How to cite this URL:|
Elbatrawy Y, Hammouda AI, Khaled M. Azhar dome physioclasis: A new surgical technique of treating patients with late presenting blount's disease. J Limb Lengthen Reconstr [serial online] 2020 [cited 2020 Jul 2];6:67-72. Available from: http://www.jlimblengthrecon.org/text.asp?2020/6/1/67/288564
| Introduction|| |
Blount's disease occurs among children in infantile or adolescent age and characterized by proximal tibia varus deformity due to proximal physeal illness along its medial aspect. Patients with Blount's disease usually present with a combination of complex multi-planar deformity in the form of genu varum, procurvatum, and internal tibial rotation. In severe cases, depression of the posteromedial tibial plateau, or even slippage of the upper tibial epiphysis may be present.
Conservative treatment is not valid in late presented Blount's (LPB) patients due to limited capacity of physeal control and severity of the deformity. Common surgical treatment options include proximal tibial osteotomy ± medial tibial plateau elevation. Patients with healthy physis and milder deformity could be corrected by physeal control including lateral hemi-epiphysiodesis using eight plates or staples. Gradual physeal distraction is another option reported in the literature. Fixation methods include either internal fixation in cases of acute deformity correction, or external fixation in cases of gradual correction.,,
In current study, we are presenting our new novel method of correcting patients with LPB. This method called “Dome Physioclasis” and includes acute deformity correction by manual rotation of the tibia relative to the hinge located at the level of the physis. We assume this new method is suitable for LPB patients who don't have medial plateau depression and so not in need for medial plateau elevation. We consider this method is as effective as other surgical methods or may be better in saving healing time.
| Patients and Methods|| |
This prospective study involved demonstration of our new method of surgical treatment of children with severe deformity secondary to LPB. It included two patients (3 limbs). Anteroposterior and lateral erect long film radiographs were performed on both lower limbs to identify planes of the deformity and accordingly, surgical planning was performed. Rotational deformity was assessed clinically based on Staheli profile of clinical examination.
First patient was 11-year-old boy with bilateral affection. Patient's height was 127 cm, and weight was 60 kg; with body mass index (BMI) was 37.2 kg/m2 [Figure 1]. Past medical or family history was negative for associated problems. Preoperative radiological and clinical examination confirmed the severe bilateral upper tibial varus (70° in the right; 69° in the left), procurvatum (10° in the right; 8° in the 70 left), and bilateral internal tibial rotation (15°) deformity. Deformity analysis identified the CORA at the level of proximal tibial physis. There was slight medial slippage of the epiphysis over the dome shaped metaphysis (more in the right) without the presence of a bony bridge across the physis. Patient underwent bilateral acute surgical correction of the deformity was performed using the new innovation of Dome Physioclasis; left sided preceded the right side by 6 weeks [Figure 2].
|Figure 1: 11-year-old boy. Clinical phto and scanogram of both lower limbs showing severe ABD with proximal tibia varus and internal rotation|
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The second patient was 12-year-old girl with the left side affected. Her height was 145 cm, and weight was 67 kg with BMI 31.8 kg/m2. No past family or surgical history for the left side. Preoperative radiological and clinical examination confirmed upper tibial complex deformity of varus 47° and internal rotation deformity 10â; without the presence of a bony bridge across the physis. Acute correction of the deformity of the left side was performed with Dome Physioclasis.
Under the C-arm guidance and with tourniquet use, we first do separation of the proximal fibular physis is performed using a 2.7 mm drill bit, with care to avoid injury of the common peroneal nerve. This separation is useful for later acute correction plus it guarantees and prevents proximal fibula growth after correction. Then, a multiple small transverse incisions are made along the proximal tibia at the level of its proximal physis with deep dissection medial and lateral taking care not to harm the patellar ligament and its paratenon. A 3.5 mm drill bit is used to drill along the tibial physis. Straight and curved low profile sharp osteotomes are then used to do gentle elevation of the tibial and fibular physes, with care to avoid posterior penetration beyond the posterior cortex which may put the popliteal neurovascular structures under risk of injury. Manual acute correction of the deformity is then performed by moving the leg from varus to valgus around the hinge in the physis (physioclasis) while the assistant supporting the knee proximal to the level of the moving physis. Sagittal (procurvatum) and axial (internal rotation) deformity are corrected as well by moving the leg from flexion to extension and from internal to external rotation. Prophylactic release of the common peroneal nerve was not mandatory in the current study since the deformity was varus and therefore the nerve was not under risk with acute correction. Internal fixation of the corrected position is performed through 2 cannulated 6.5 mm partially threaded cancellous screws over guide wires and inserted crossing each other from inferomedial and inferolateral to superolateral and superomedial, respectively. Care is taken to avoid penetration of the knee joint. Since this was our first experience and since the patients were heavy, so we felt it was important to secure fixation by using simple Ilizarov frame (in the first patient) with pins fixed to tibia and femur and expanding the knee joint stabilizing it in extension [Figure 3] and [Figure 4], and above knee plaster cast for 6 weeks in the second patient.
|Figure 3: Steps of dome physioclasis: (a) Proximal fibular separation. (b) Proximal tibial separation. (c) Accute correction of the deformity relative to a hinge at the physis. (d) Internal fixation using 2 cannulated 6.5 mm screws. (e) Secure fixation using a simple Ilizarov frame spanning the knee joint. (f) Intra operative X-ray showing the knee joint after correction. (g) Intra operative X-ray showing proximal tibia after fixation by 2 screws with care not to penetrate the joint. (h) Intra operative photo showing the left lower limb straight after full correction of the deformity|
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|Figure 4: The Case of the study: (a) Preoperative scanogram showing the deformity. (b and c): Postoperative correction antero posterior and lateral X-rays showing the deformity after correction and fixation with internal screws and external circular fixator. (d and e) 3 months after surgery showing healing of the physis and fixator removed. (f) Scanogram 9 months after surgery showing bilateral corrected deformity and mechanical axes. (g and h) Clinical photos showing bilateral corrected deformity and range of knees joint motion|
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Ilizarov (in the first patient) or casting (in the second patient); either was used for augmentation of fixation. Weight bearing was avoided for the first 6 weeks after surgery to allow the corrected physis to heal with no stress on the fixation. Then partial weight bearing (50% of weight) was allowed for the next 6 weeks. After that, patient had instructions to wear hinged knee brace, with allowance of full weight bearing and knee range of motion. Patient received regular active and passive physiotherapy after frame or cast removal to maintain normal knee joint motion and prevent contractures.
Radiographs were obtained every 2 weeks for the first 6 weeks, then every month until complete healing. Postoperative antibiotic therapy (for 5 days) and medications for thromboprophylaxis (for 3 weeks) was part of the instructions. Outcomes reported in the study are the mechanical axis deviation (MAD), medial proximal tibial angle (MPTA), mechanical lateral distal femoral angle, posterior proximal tibial angle, and joint line conversion angle (JLCA). These measures were recorded immediate preoperative, immediate postoperative, and at 24 month FU.
| Results|| |
First patient underwent surgery for bilateral limbs (the left side preceded the right with 6 weeks interval in-between). Acute correction was achieved intraoperatively with corrected mechanical axis. Deformity parameters pre and post correction are shown in [Table 1]. Bilateral internal rotation deformity was corrected as well. External fixator frame was maintained for 6 weeks. For the second patient, deformity parameters pre and post correction are shown in [Table 1]. Cast was removed after 6 weeks.
Although mechanical alignment was corrected perfectly in the first patient after this technique, but radiological follow up showed medial MAD of 2 cm on the left and 2.5 cm on the right (measured on the standing long X-ray films). This was due to chronic lateral collateral ligament laxity due to long standing deformity in heavy patient, and this also explained abnormal JLCA at final FU. This improved gradually by using external hinged above knee brace during the day. By end of follow up of this patient (24 m), there was 1 and 1.5 cm medial MAD in the left and right sides, respectively.
In the second case, immediate postoperative x-ray showed slight loss of complete correction of the MPTA that achieved intra-operatively. This mostly occurred because the first screw tightened was from lateral to medial so it pulled on medial plateau and cause this under-correction. So it is recommended after checking the alignment to first insert the screw from medial to lateral following this by the one from lateral to medial to secure fixation and avoid tilting of tibial plateau and under-correction.
| Discussion|| |
LPB is characterized by upper tibia varus, procurvatum, and internal tibial torsion; with an apparent leg shortening due to the deformity. Langenskiold staging classification is appropriate only in cases of early onset Blount's with no data in the literature supporting its role in LPB cases. Less invasive methods of treatment have been described for treatment of patients with LPB; however, with non-satisfactory outcomes. The authors referred this to the radiographic and histologic evidence of severe injury to the medial part of the proximal tibial physis in adolescent Blount's patients. In another study, McIntosh et al. reported only 33% (21 out of 64 extremities) of successful radiographic outcomes in their study of lateral proximal tibia hemiepiphysiodesis for patients with ABD. They observed this poor result in relatively old and obese children 194 with severe deformity. Growth modulation showed unsatisfactory results in most patients with late severe forms due to sickness of medial part of the physis, and therefore, its use must be confined only to selected patients with careful follow-up.,,, Insufficient correction had been reported by Heflin et al., in up to 50% of their cohort of patients with LPB treated by guided growth technique.
For the above reasons, acute or gradual corrective osteotomy is mandatory when treating most of patients with LPB., Options of treating such complex deformity have been reported either in single step or multi-step surgeries; all including medial tibial plateau elevation to restore the knee joint congruence.,, In younger patients, permanent physiodesis might be required in addition; to prevent recurrence of the deformity during the remaining growth period. When comparing acute versus gradual correction methods, the former is suitable for patients with < 15° deformity and usually internal fixation is the method of choice. Larger deformity usually mandates fibular osteotomy and may be complicated by soft tissue and neurovascular problems; in addition to hardware failure especially in obese patients treated acutely., Fibular osteotomy was performed as an essential step while treating severe deformities; however, Eidelman et al. in their study reported correction of the deformity using Taylor Spatial Frame without the need for fibular osteotomy by placing the hinge proximal to the level of proximal tibio-femoral joint. External fixators allow gradual deformity correction, postoperative adjustment, and lengthening if needed in some unilateral ABD cases; however, they are much more uncomfortable for the patients especially the obese.,
Utilizing the physis for gradual deformity correction and lengthening (chondrodiastasis) procedures has been reported in the literature with various results and without the need for osteotomy., To be accomplished, careful placement of external fixator pins in the narrow epiphysis is mandatory without penetration into the joint. Being intra-capsular, these pins danger introducing septic knee arthritis and fulminant infection. This technique has been successfully used in patients with ABD. In the current study, we utilized the physis for one step acute correction of the three plane deformity in patients with LPB and named the method by “Dome Physioclasis.” Using this method, correction is achieved acutely at the level where the CORA of the deformity is present; minimizing the amount of displacement, providing wide surface area better for union, and correcting epiphyseal displacement if present. Moreover, healing through the physis is rapid with formation of solid union and thus, no recurrence of deformity is possible. Correction of the 3 planes was achieved by moving the limb into valgus (coronal plane), extension (sagittal plane), and external rotation (axial plane). Frontal plane alignment was checked using diathermy cable. Care was taken to avoid injury to the posterior neurovascular structures by avoiding sharp penetration of the osteotomes past the posterior tibial cortex and by flexing the knee joint to relax these structures while separating through the physis. We didn't observe patellar maltracking since the correction was proximal to patellar tendon insertion. We refer this to the fact that we correct a varus deformity to neutral and hence not expected to change patellar position.
In our study, fibular physioclasis was an essential step to allow for moving the tibia with no obstacles and without stressing the fibula proximal physis. This step is concomitant to another study recommended fibular osteotomy as a vital procedure while acutely correcting patients with LPB; although, it is not essential if gradual correction was the plan. We used partially threaded 6.5 mm crossing cannulated screws headed from distal to proximal as a tool for internal fixation after correction. Although solid screws might be better in obese LPB patients,, but cannulated systems allow precise screw trajectory insertions with care to avoid piercing the joint and avoiding the chance of losing the correct drilling track if non-cannulated systems were used. Moreover, recommendations to insert the medial to lateral screw first before the lateral to medial one to avoid any loss of complete correction as that occurred in our second patient. For securing fixation, simple non-hinged Ilizarov frame should be applied and spanned to the knee with pins fixed proximally to the lower femur and distally to the upper tibia. As an alternative, above knee plaster cast could be used for the same purpose. We felt this extra fixation was necessary especially for obese patients; adding stability and preventing failure of implants.
The frame or the cast was kept in position for 6 weeks, after which healing was evident and this additional fixation was removed to allow regular active and passive physiotherapy and knee ROM. In first patient, left knee ROM was scored as (0°–90°), compared to the right side (0°–70°). This may be due to the more severe the deformity on the right than the left; in addition to the previous past surgical history to the right side with skin and soft tissue impairment and previous subcutaneous adhesions. The second patient regained full knee motion 3 months after cast removal.
Previous study in similar; but, younger three patients with a variant of Blount's characterized by slippage of the epiphysis over the metaphysis with open and health physis, had been reported by Sanghrajka et al. They corrected the deformity using metaphyseal osteotomy and Ilizarov application to gradually realign the deformity without harming the patent physis. However, we assume their way of correction was out of the scope of basics of deformity correction as the CORA was in the physis and correction was performed away from it through metaphyseal osteotomy. This might be explained by the younger age in their cohort. In the current study, we corrected the complex deformity acutely utilizing the physis with no fear to permanently damaging it in these cases with LPB.
Acute correction of severe deformities usually increases the risk of complications such as skin problems, neurovascular compromise, under or over correction, and risk for nonunion., In our study, there was solid and quick union since we utilized the physis instead of cutting the bone. Physioclasis resembles dome bone osteotomy that allows correction by rotating the limb around a physeal hinge with less bone displacement and with no need for bone grafting, compared to open wedge osteotomy in severe deformity correction. In cases with present or expected limb length discrepancy (LLD), we highly recommend accurate preoperative planning using radiographic erect films and the “Multiplier” smart application for expected limb length discrepancy after permanently closing the affected physis during the process of “Physioclasis.”
This current study has few limitations. The first and the most important is the few number of limbs. However, we believe this is the first study ensuring the new treatment method in this category of patients with LPB. Being a new different way of treatment is another limitation. However, this method might help specialized surgeons to think different ways of treating targeted patients.
| Conclusion|| |
“Dome Physioclasis” is considered a new novel surgical technique in the field of pediatric orthopedics. It allows acute multi-plane deformity correction with the hinge located exactly where the CORA presents. Solid and fast union is obtained. Recurrence of deformity is not possible since the physis is permanently fused. Careful physeal separation is mandatory avoiding harming neurovascular structures. We assume this method is a new golden treatment option in correcting proximal tibia deformity secondary to LPB. However, it must be reserved for selected cases where patients complain from severe deformity and near skeletal maturity without depression of the medial tibia plateau and with or without slippage of the epiphysis over metaphysis. Future more experience in the technique may improve its understanding. Further studies on bigger cohorts and wider applications are needed to confirm our results.
Financial support and sponsorship
This study and manuscript were performed without external funding.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]