C LINICAL A RTICLE. Abstract. Introduction. Page 52 / SA ORTHOPAEDIC JOURNAL Summer 2007

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1 Pge 52 / SA ORTHOPAEDIC JOURNAL Summer 2007 C LINICAL A RTICLE Physel r resetion for prtil growth plte rrest HR Hos,* Registrr S Dix-Peek,* FCS(SA)Orth, Consultnt RN Dunn,* FCS(SA)Orth, Consultnt N Wieselthler,** FC Rd(Dig SA), Consultnt EB Hoffmn,* FCS(SA)Orth, Assoite Professor *Deprtment of Orthopedis **Deprtment of Rdiology Mitlnd Cottge Hospitl nd Red Cross Children s Hospitl, University of Cpe Town, Cpe Town, South Afri. Reprint requests: Prof EB Hoffmn 7 Mrne Avenue Newlnds 7700 Cpe Town, South Afri. Tel: (021) Fx: (021) E-mil info@mh.org.z Astrt The results of 21 physel r resetions for growth plte rrest performed over 17-yer period ( ) were ssessed retrospetively. Five (24%) of the growth pltes filed to resume growth. The remining 16 were followed up for 2 to 8 yers (11 to mturity). Eight (38%) growth pltes (six to mturity) hd n exellent result nd growth exeeded the expeted norml. Eight (38%) growth pltes (five to mturity) hd good result nd resumed norml growth. All five filures ourred in ptients with the ommonest etiologies, i.e. distl femorl physel frtures (three of five) nd meningool septiemi (two of five). We onluded tht physel r resetion ws worthwhile proedure if the size of the r ws 30%. In growth plte rrest due to distl femorl physel frtures nd meningool septiemi, the prognosis, however, is gurded. Introdution Injury to growth plte n result in physel rrest. This ours due to trum, most ommonly growth plte frture, or due to deresed lood supply to the germinl ells, e.g. due to vsulitis in meningool septiemi. Lngenskiöld 1,2 first desried the priniples of growth plte rrest nd resetion. He showed tht following growth plte injury, the formtion of ony r etween the epiphysis nd the metphysis n e prevented y interposition mteril. One ony r exists, it n e exised nd interposition mteril llows regenertion of the growth plte from the djent physis. Initil reports of growth plte resetion showed good results. Lngenskiöld 3 used ft s interposition mteril nd hd 83% good results in 43 ptients. Bright 4 using silioneruer s interposition mteril reported 81% good results in 100 ptients. Peterson 5 used minly methyl methrylte (rnioplst) nd reported 83% good results in 114 ptients. He lso showed orretion of ngultory deformity if 20º. This initil enthusism hs een tempered y susequent reports. Willimson nd Stheli 6 report poor results if the physel r exeeded 30% of the growth plte. Birh 7 reported only 33% suess rte nd Hsler nd Foster 8 40% suess rte. An erlier edition of stndrd peditri orthopedi textook 5 hd full hpter on prtil growth plte rrest. In the most reent edition 9 it is limited to only three pges in the hpter on growth plte frtures.

2 SA ORTHOPAEDIC JOURNAL Summer 2007 / Pge 53 Tle I: Aetiology, sites, size nd results of 21 physel r resetions Aetiology N = 21 Site Slter Size Follow-up Result Hrris (m = mturity) type Growth plte frture 8 Distl femur = 5 I 20% 2 yrs Exellent II 30% - Poor II 30% m Good III 30% - Poor IV 50% - Poor Proximl tii = 1 II 15% 2 yrs Exellent Distl tii = 2 IV 30% m Good IV 20% m Exellent Meningool 5 Distl femur = 1 40% - Poor septiemi Proximl tii = 3 40% - Poor 30% 3 yrs Good 20% 3 yrs Good Distl tii = 1 20% m Exellent Osteitis 3 Distl femur = 2 (neontl) 15% m Good 30% m Exellent Distl tii = 1 20% m Exellent Dysplsi 3 Distl femur = 2 25% m Good 25% m Good Proximl tii = 1 (Blount's) 25% m Good Gunshot 1 Distl femur 20% m Exellent Idiopthi 1 Distl femur 20% 4 yrs Exellent Unpreditle results for physel r resetion following distl femorl physel frtures mkes ompletion of the epiphysiodesis nd ontrlterl epiphysiodesis etter option in dolesent ptients. To ssess whether physel r resetion is worthwhile proedure nd still hs role in peditri orthopedi prtie, we retrospetively reviewed 21 growth plte resetions in 19 ptients performed in the 17-yer period ( ). Ptients nd methods Two of the 19 ptients hd ilterl sites (dysplsi nd meningool septiemi). The verge ge ws 8.3 yers (rnge 3 to 12 yers). Aetiology nd sites Tle I shows the etiology, site nd size of the 21 physel rs nd the results of the physel r exisions. The most ommon use ws growth plte frtures (eight), of whih five were t the distl femur. The seond ommonest use (five) ws growth plte rrest due to meningool septiemi. The ommonest site ws the distl femur (12), followed y the proximl tii (five) nd the distl tii (four). Evlution of the physel r The physel r ws evluted for lotion nd size, initilly y iplnr tomogrphy (8), susequently iplnr tomogrphy nd MRI (8) nd urrently our preferene is just MRI (5). Antero-posterior nd lterl tomogrphy nd/or MRI ws done nd then synthesised onto rosssetionl digrmmti representtion or mp of the growth plte s desried y Crlson nd Wenger (1984) 10 (Figure 1). MRI ws performed with 1.5 Tesl mgnet (Siemens, Symphony). The sequenes done were T1 (TR 512, TE 13) nd Grdient Rephsed Eho (GRE) (TR 905, TE 26) in oronl nd sgittl plnes, perpendiulr to the growth plte. The slie thikness used ws 3 mm nd field of view 200 mm.

Pge 54 / SA ORTHOPAEDIC JOURNAL Summer 2007 Figure 1: Posterolterl physel r plotted onto mp of distl femorl growth plte Figure 2: Clssifition of physel rs, from

following Slter Hrris II frture The T1 sequene shows the physis (rtilge) s low signl intensity ginst the high signl intensity mrrow (Figures 4-7,9) nd the GRE

The verge size of the physel rs ws 25% (rnge 15% to 50%). Only three physel rs exeeded 30% in size.

3 Pge 54 / SA ORTHOPAEDIC JOURNAL Summer 2007 Figure 1: Posterolterl physel r plotted onto mp of distl femorl growth plte Figure 2: Clssifition of physel rs, from left to right: peripherl, entrl nd liner Figure 1 & : Biplnr tomogrphy of 10-yer-old oy showing posterolterl physel r of the right distl femorl growth plte following Slter Hrris II frture The T1 sequene shows the physis (rtilge) s low signl intensity ginst the high signl intensity mrrow (Figures 4-7,9) nd the GRE shows the physis s high signl intensity ginst the low signl intensity mrrow nd even lower signl intensity one (Figure 10). The verge size of the physel rs ws 25% (rnge 15% to 50%). Only three physel rs exeeded 30% in size. Figure 3: Digrmmti representtion showing ontouring of defet s ollr utton into the epiphysis The mjority of the physel rs were peripherl (15), one ws entrl (meningool septiemi) nd five liner (two neontl osteitis, two Slter Hrris type IV growth plte frtures nd one idiopthi) (Figure 2).

SA ORTHOPAEDIC JOURNAL Summer 2007 / Pge 55 d d Figure 4: Anteroposterior rdiogrph of 10-yer-old girl with physel r following

postopertive view Figure 4d: At mturity, growth of 18 mm over 4 yers ws hieved (112% of expeted) Figure 5: Anteroposterior

Figure 5: T1 oronl MRI shows peripherl r Figure 5: Immedite postopertive view Figure 5d: At mturity, growth of 42 mm over 7 yers

nd/or gouge until norml physis ws visile irumferentilly.

defet. The defet nd interposition mteril ws ontoured s ollr utton into the epiphysis (Figure 3).

Follow-up Five (24%) physel r exisions filed to resume growth. They susequently hd ompletion of the epiphysiodesis.

The remining 16 physel r exisions were followed up from 2 to 8 yers, 11 to mturity.

An nteroposterior nd lterl rdiogrph of the femur or tii with similr distne (100 m) etween the plte nd the tue s on the immedite

4 SA ORTHOPAEDIC JOURNAL Summer 2007 / Pge 55 d d Figure 4: Anteroposterior rdiogrph of 10-yer-old girl with physel r following Slter Hrris IV frture of the medil mlleolus of the left nkle Figure 4: T1 oronl MRI shows liner, sleroti ony r Figure 4: Immedite postopertive view Figure 4d: At mturity, growth of 18 mm over 4 yers ws hieved (112% of expeted) Figure 5: Anteroposterior rdiogrph of 6-yer-old girl with posteromedil physel r of the distl tiil growth plte of the left nkle following meningool septiemi Figure 5: T1 oronl MRI shows peripherl r Figure 5: Immedite postopertive view Figure 5d: At mturity, growth of 42 mm over 7 yers ws hieved (150% of expeted) Tehnique The norml physis ws defined t the periphery of the r, nd the r ws then removed using urr nd/or gouge until norml physis ws visile irumferentilly. In the first five ses we used ft s interposition mteril, ut susequently we used rnioplst s it is more hemostti nd strengthens the defet. The defet nd interposition mteril ws ontoured s ollr utton into the epiphysis (Figure 3). Prllel Kirshner wires were then inserted s metl mrkers into the epiphysis nd metphysis in order to mesure growth (Figures 4-8). Follow-up Five (24%) physel r exisions filed to resume growth. They susequently hd ompletion of the epiphysiodesis. In the ontrlterl leg n epiphysiodesis or leg lengthening ws done, depending on the ge of the hild. The remining 16 physel r exisions were followed up from 2 to 8 yers, 11 to mturity. At follow-up the leg lengths were ssessed linilly with tpe mesure nd on loks. An nteroposterior nd lterl rdiogrph of the femur or tii with similr distne (100 m) etween the plte nd the tue s on the immedite postopertive view ws done. The inrese in distne etween the metl mrkers nd the orretion of the ngulr deformity ws mesured. A good result implied norml growth, i.e. 10 mm per yer for the distl femur, 6 mm for the proximl tii nd 4 mm for the distl tii. In n exellent result the growth hieved exeeded the expeted growth. Completion of the epiphysiodesis nd ontrlterl epiphysiodesis etter option in dolesent ptients

Pge 56 / SA ORTHOPAEDIC JOURNAL Summer 2007 Figure 6: Anteroposterior rdiogrph of 3-yer-old girl

sleroti liner r Figure 6: Immedite postopertive view Figure 6d: At 4 yer follow-up, growth of 60

left lterl distl femorl growth plte following gunshot Figure 7: Immedite postopertive view showing

ngultion ws unorreted Results There were eight (38%) exellent results (six followed up to mturity)

Of the 11 ptients followed to mturity there ws no leg length disrepny tht exeeded 1 m.

Up to now there hve een no premture rrests.

Three of the five filed due to distl femorl growth plte frtures; two were 30% nd one ws 50% in

Only five physel r exisions ould e ssessed for orretion of ngulr deformities.

the five filures, six of whom hd onomitnt osteotomies nd three with too short follow-up of only 2

5 Pge 56 / SA ORTHOPAEDIC JOURNAL Summer 2007 Figure 6: Anteroposterior rdiogrph of 3-yer-old girl with n idiopthi physel r of the right distl femorl growth plte Figure 6: T1 oronl MRI shows sleroti liner r Figure 6: Immedite postopertive view Figure 6d: At 4 yer follow-up, growth of 60 mm ws hieved (150% of expeted) d Figure 7: T1 oronl MRI of 5-yer-old oy with peripherl r of the left lterl distl femorl growth plte following gunshot Figure 7: Immedite postopertive view showing 20º vlgus deformity Figure 7: At 6-yer follow-up, growth of 70 mm ws hieved (116% of expeted), ut ngultion ws unorreted Results There were eight (38%) exellent results (six followed up to mturity) (Figures 4-8), nd eight (38%) good results (five followed up to mturity). Of the 11 ptients followed to mturity there ws no leg length disrepny tht exeeded 1 m. The five growth plte exisions tht did not resume growth filed from the strt. Up to now there hve een no premture rrests. These five filures ourred in the most ommonly seen etiologies. Three of the five filed due to distl femorl growth plte frtures; two were 30% nd one ws 50% in size. Two of the five filed due to meningool septiemi; oth were 40% in size. Only five physel r exisions ould e ssessed for orretion of ngulr deformities. This exluded two liner rs whih were situted in the middle of the joint nd hd no ngulr deformity, the five filures, six of whom hd onomitnt osteotomies nd three with too short follow-up of only 2 to 3 yers. Figure 8: Postopertive nteroposterior rdiogrph of 10-yer-old oy with peripherl r of the left distl tiil growth plte following osteitis, showing 20º vrus deformity Figure 8: At mturity, growth of 37 mm over 6 yers (150% of expeted) nd ngulr orretion of 20º ws hieved Angulr orretion ws not preditle

Pge 58 / SA ORTHOPAEDIC JOURNAL Summer 2007 Figure 9: T1 oronl MRI of n 11-yer-old oy with lterl physel r following Slter Hrris II frture of the right distl femorl growth plte.

growth plte The remining five physel r exisions orreted ngulr deformities of 0º-20º over period of 4 to 6 yers.

Disussion This study shows 76% good nd exellent results, whih inreses to 89% if physel rs lrger thn 30% re exluded.

6 Pge 58 / SA ORTHOPAEDIC JOURNAL Summer 2007 Figure 9: T1 oronl MRI of n 11-yer-old oy with lterl physel r following Slter Hrris II frture of the right distl femorl growth plte. Note smll seondry tether in medil Thurston Hollnd frgment Figure 10: Anteroposterior rdiogrph of the right distl femur of 5-yer-old girl following meningool septiemi showing n norml medil femorl growth plte The remining five physel r exisions orreted ngulr deformities of 0º-20º over period of 4 to 6 yers. Angulr orretion ws therefore not preditle, lthough Figure 8 shows orretion of 20º over 6 yers. Disussion This study shows 76% good nd exellent results, whih inreses to 89% if physel rs lrger thn 30% re exluded. We therefore do not shre the urrent pessimism towrds physel r resetion for prtil growth plte rrest. 9,11 We feel tht resetion of physel r 30% in the young hild with more thn 5 yers of growth remining, is worthwhile proedure nd wrrnts ple in peditri orthopedis. The five filures ourred in the ommonest etiologies, i.e. distl femorl growth plte frtures nd meningool septiemi. Distl femorl growth plte frtures re notorious for physel rrest euse of the undulting nture of the growth plte whih results in dmge t the time of injury. 12,13 The high inidene of filure following physel r resetion in these ptients is most likely due to seondry tethers whih re present t n re seprte from the physel r. 8,14 This smll seondry tether my not lwys e visile on plin rdiogrphs, ut n e seen on MRI (Figure 9). We gree tht in the dolesent ptient with physel rrest due to distl femorl growth plte frtures, ompletion of the rrest with epiphysiodesis is more preditle option. Sine 1998 we hve pplied this poliy in five ptients with onomitnt epiphysiodesis of the ontrlterl leg. Figure 10: Grdient rephsed eho (GRE) MRI shows smll tented physel r of the medil ondyle with loss of viility of the growth plte t the pex In meningool septiemi, whih ours in muh younger ptients, the growth plte is dmged y ishemi (vsulitis nd disseminted intrvsulr ogultion) nd the inflmmtory response (osteitis) of the surrounding one. 15 Dmge to the growth plte my mnifest s prtil growth plte rrest (Figure 5), or premture physel losure (proly due to reltive vsulrity of the physis).

7 Pge 60 / SA ORTHOPAEDIC JOURNAL Summer 2007 The high filure rte in physel r resetion in meningool septiemi is most likely due to two ftors: seondry tethers, similr to distl femorl growth plte frtures, whih my not lwys e lerly visile on plin rdiogrphs, ut my e seen on MRI (Figure 10), or unpreditle premture physel losure. Three of the filures hd physel rs > 30%. This my hve een ontriuting ftor, ut Peterson (1990) 5 reported good results in rs onstituting up to 50% of the growth plte. Sine Willimson nd Stheli (1990) 6 reported poor results in rs > 30%, we do not ttempt to exise rs > 30%. We found good orreltion etween the size nd lotion of the r t surgery nd the mp drwn pre-opertively from iplnr tomogrphy nd MRI. We urrently prefer MRI. MRI hs no rdition nd elegntly demonstrtes exellent tissue ontrst s well s llowing multiplnr imging without hnging the position of the ptient. Any interruption of the physis whether y ony or rtilginous r or ny interruption mesuring just few millimetres ffeting the viility of the physis n e well seen on MRI. 16 We hve no experiene with 3-D MRI reonstrution 17,18 nd helil CT. 19 At surgery it is importnt to ensure tht norml physis is visile irumferentilly nd tht there re no residul tethers. We ttempted to ontour the defet s ollr utton into the epiphysis in ll our ptients (Figure 3). In ll the ptients however, exept the ptient shown in Figure 6, the defet styed in the metphysis. This did not influene the result. Only five physel r resetions ould e ssessed for ngulr orretion. Angulr orretion ws not s preditle s reported y Peterson (1990) 5 nd rnged from 0-20º over 4 to 6 yers. Our urrent poliy is to do onomitnt osteotomy if the ngultion exeeds 20º. If the ngultion is 20º we will wit possile orretion nd perform n osteotomy t mturity if required. Growth plte frtures re followed up t 3 nd 6 months post injury, to try nd dignose growth disturne erly efore deformity ours. A growth rrest or Hrris line tht is olique (not prllel to the physis) or hs fol defet suggests erly physel rrest. 20 The physel r n then e onfirmed with MRI. 21 We onlude tht physel r resetion for prtil growth plte rrest in the younger ptient is worthwhile proedure if the r does not exeed 30% of the size of the physis. In physel rs due to distl femorl growth plte frtures nd meningool septiemi, the prognosis is gurded. Referenes 1. Lngenskiöld A. The possiilities of eliminting premture prtil losure of n epiphysel plte used y trum or disese. At Orthop Snd 1967;38: Lngenskiöld A. An opertion for prtil losure of n epiphysil plte in hildren, nd its experimentl sis. J Bone Joint Surg 1975;57-B: Lngenskiöld A. Surgil tretment of prtil losure of the growth plte. J Peditr Orthop 1981;1: Bright RW. Prtil growth rrest; identifition, lssifition, nd results of tretment. Orthop Trns 1982;6: Peterson HA. Prtil growth plte rrest. In: Morrissy RT (ed). Lovell nd Winter s Peditri Orthopedis. Third edition. Phildelphi: JB Lippinott Compny; 1990: Willimson RV, Stheli LT. Prtil physel growth rrest: tretment y ridge resetion nd ft interposition. J Peditr Orthop 1990;10: Birh JG. Surgil tehnique of physel r resetion. Instr Course Let 1992;41: Hsler CC, Foster BK. Seondry tethers fter physel r resetion. A ommon soure of filure? Clin Orthop 2002;405: Prie CT, Flynn JM. Mngement of frtures. In: Morrissy RT, Weinstein SL (eds). Lovell nd Winter s Peditri Orthopedis. Sixth edition. Phildelphi: Lippinott Willims & Wilkins; 2006: Crlson WO, Wenger DR. A mpping method to prepre for surgil exision of prtil physel rrest. J Peditr Orthop 1984;4: Rthjen KE, Birh JG. Physel injuries nd growth disturnes. In: Bety JH, Ksser JR (eds). Rokwood nd Wilkins Frtures in Children. Sixth edition. Phildelphi: Lippinott Willims & Wilkins; 2006: Riseorough EJ, Brnett IR, Shpiro F. Growth disturnes following distl femorl physel frture-seprtions. J Bone Joint Surg 1983;65-A: Eid AM, Hfez MA. Trumti injuries of the distl femorl physis. Retrospetive study of 151 ses. Injury 2002;33: Skggs DL. Extr-rtiulr injuries of the knee. In: Bety JH, Ksser JR (eds). Rokwood nd Wilkins Frtures in Children. Sixth edition. Phildelphi: Lippinott Willims & Wilkins; 2006: Grogn DP, Love SM, Ogden JA et l. Chondro-osseous growth normlities fter meningooemi. J Bone Joint Surg 1989; 71-A: Gel GT, Peterson HA, Berquist TH. Premture prtil physel rrest. Dignosis y mgneti resonne imging in two ses. Clin Orthop 1991;272: Bors JJ, Peterson HA, Ehmn RL. MR imging of physel rs. Rdiol 1996;199: Silhn F, Chotel F, Guil AL, et l. Three-dimensionl MR imging in the ssessment of physel growth rrest. Eur Rdiol 2004;14: Loder RT, Swinford AE, Kuhns LR. The use of helil omputed tomogrphi sn to ssess ony physel ridges. J Peditr Orthop 1997;17: Hynes D, O Brien T. Growth disturne lines fter injury of the distl tiil physis: their signifine in prognosis. J Bone Joint Surg 1988;70-B: Smith BG, Rnd F, Jrmillo D, Shpiro F. Erly MR imging of lower-extremity physel frture-seprtions: preliminry report. J Peditr Orthop 1994;14: SAOJ

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