3/21/2023 0 Comments Attachment tamer for mail 8.29, 12, 14, 15 This technique is infrequently discussed in the literature and to the best of our knowledge there are no previous reports employing rigid internal fixation methods for both osteotomies. MP elevation combined with a second metaphyseal osteotomy is often termed a double-elevating osteotomy. 8, 14, 17, 18, 21 In addition, many of the reported internal fixation methods did not offer optimum rigidity, stable enough to preclude the use of a postoperative plaster immobilization and start early knee range of movement (ROM), with the risk of medial condyle displacement, loss of correction and revision surgeries. Gradual distraction using Ilizarov/external fixation methods may be adversely associated with pin-site irritation, interference with rehabilitation, pin-tract infection, pin breakage, premature consolidation, undercorrection and deformity recurrence. 15, 20 This has also raised difficulty in decision-making about fixation methods, acute versus gradual elevation, need for bone grafting and single-stage versus two-stage correction. The previously described techniques for MP elevation are technically demanding and carry potential risks of intra-articular fractures, medial condyle displacement and inadequate MP elevation with persistent lateral laxity. Furthermore, MP elevation osteotomy adds to the complexity of surgical treatment and increases the risk of complications. 2, 8, 10, 11, 13, 14, 16- 19 Nonetheless, consensus on osteotomy details and methods of fixation has not been established. Attempts to restore the congruency of the tibiofemoral articular surfaces by MP elevation have been described with encouraging clinical results. 8, 13- 15 A simple metaphyseal osteotomy may correct the metaphyseal source of varus and ITT, but does not restore the normal knee anatomy and joint congruence with persistent varus instability and varus thrust. 5 Additionally, different fixation methods have been employed, including cast immobilization, 10 Kirschner-wires, screws, 11 plates 12 and external fixators. 2 Different techniques have been described for angular and rotational correction, including closing wedge, opening wedge, dome, serrated and oblique osteotomies. The goal of treatment of Blount’s disease is to restore a normal limb alignment, congruence of tibiofemoral articular surfaces, equal limb lengths at skeletal maturity and to prevent recurrence. 8, 9 Long-term reports have confirmed the progressive nature of the disease, ending up with an awkward gait, excessive varus thrust, knee pain and premature arthritis. 3- 7 Premature fusion of the medial proximal tibial physis in stage VI leads to rapid deformity progression, limb-length discrepancy (LLD) and inevitable recurrence after simple osteotomies with reported rates up to 60%. The knee instability arises from the incongruency of the tibiofemoral articular surfaces with excessive varus thrust during stance phase of gait, and significantly affects lower limb function and gait kinematics. In late-presenting cases (stages V and VI), an excessive downward sloping of the MP results in increased ligamentous laxity. Langenskiold and Riska 6 classified infantile Blount’s disease into six progressive stages based on their radiographic appearance. Infantile Blount’s disease occurs before four years of age, and when not managed early, the deformity progresses with depression of the medial plateau (MP). 2- 4 This comprises proximal tibial varus, procurvatum and internal tibial torsion (ITT). Although the initial description by Blount 1 referred to the condition as “tibia vara”, implying a solely coronal malalignment, subsequent studies revealed a complex multiplanar deformity of the lower limb. Blount’s disease is a developmental condition that results from disordered endochondral ossification of the posteromedial part of the proximal tibial physis.
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