LaMont Lauren E, McIntosh Amy L, Jo Chan Hee, Birch John G, Johnston Charles E
Texas Scottish Rite Hospital for Children, Dallas.
Cook Children's Hospital, Fort Worth, TX.
J Pediatr Orthop. 2019 Feb;39(2):65-70. doi: 10.1097/BPO.0000000000000933.
To propose a modified classification of infantile tibia vara based on the morphology of the metaphyseal/epiphyseal tibial slope that better correlates with treatment outcomes than the traditional Langenskiold classification.
We performed a retrospective review of 82 patients and 115 limbs that underwent surgery for infantile tibia vara over a 22-year period (1990 to 2012) at a single institution. A modified Langenskiold classification was applied to all patients preoperatively and the outcomes were assessed. The modified system created a 3-stage classification (types A, B, and C): type A has a partially lucent medial metaphyseal defect, with or without "beaking"; type B deformity has downward-sloping curvature of the lateral and inferior rim of a completely lucent metaphyseal defect, which then has an upslope at the medial rim, resembling a ski-jump, with no epiphyseal downward slope; type C has vertical, downsloping deformity of both the epiphysis and metaphysis, with no upward curvature projecting medially at the inferior extent, while the epiphysis slopes downward into the metaphyseal defect.
Sixty-seven limbs did not develop recurrence following corrective osteotomy, whereas 48 limbs required at least 1 repeat surgery for recurrent deformity. Preoperative mechanical axis deviation, medial proximal tibial angle, lateral distal tibial angle, and body mass index did not differ significantly between those with recurrence and those with without. Mean age at surgery was significantly different for those who developed recurrence compared with those who did not. Patients without recurrence were 4.3 years of age (range, 2.4 to 10.3 y) compared with 6.2 years of age (range, 2.9 to 10.1 y) for those who recurred (P<0.01). Of patients who developed recurrent deformity, there were significantly more patients with type C changes (71.7%, P<0.01) then either type A (22.5%) or type B (20.7%). High rates of recurrence were seen for both Langenskiold stage III (50%) and stage IV (69.6%).
Consistent with prior studies, age 5 seems to be a critical transition in the risk for recurrent deformity after tibial osteotomy. Extreme vertical sloping of the medial metaphyseal defect, as in some classic Langenskiold III lesions and more precisely described by type C in a newer, modified classification, carries a poor prognosis for successful correction by high tibial osteotomy alone or in combination with epiphysiolysis.
Level II.
基于干骺端/骨骺胫骨斜率的形态学提出一种改良的婴儿型胫骨内翻分类方法，该方法比传统的兰根斯乔德分类法与治疗结果的相关性更好。
我们对一家机构在22年期间（1990年至2012年）接受婴儿型胫骨内翻手术的82例患者和115条肢体进行了回顾性研究。术前对所有患者应用改良的兰根斯乔德分类法并评估结果。改良系统创建了一个三阶段分类（A、B和C型）：A型有部分透亮的内侧干骺端缺损，有或无“喙突”；B型畸形表现为完全透亮的干骺端缺损的外侧和下缘向下倾斜的弯曲，然后在内侧缘有一个上坡，类似跳台滑雪，无骨骺向下倾斜；C型表现为骨骺和干骺端均有垂直向下倾斜的畸形，在下缘内侧无向上突出的弯曲，而骨骺向下倾斜进入干骺端缺损。
67条肢体在截骨矫正后未出现复发，而48条肢体因畸形复发至少需要再次手术1次。复发组和未复发组术前的机械轴偏差、胫骨近端内侧角、胫骨远端外侧角和体重指数无显著差异。复发组与未复发组的平均手术年龄有显著差异。未复发患者的年龄为4.3岁（范围2.4至10.3岁），而复发患者为6.2岁（范围2.9至10.1岁）（P<0.01）。在出现畸形复发的患者中，C型改变的患者（71.7%，P<0.01）明显多于A型（22.5%）或B型（20.7%）。兰根斯乔德III期（50%）和IV期（69.6%）的复发率均较高。
与先前的研究一致，5岁似乎是胫骨截骨术后畸形复发风险的关键转折点。内侧干骺端缺损的极端垂直倾斜，如一些经典的兰根斯乔德III期病变，在新的改良分类中更准确地描述为C型，单独进行高位胫骨截骨术或联合骨骺松解术成功矫正的预后较差。
II级。
