Maré Pieter Herman, Thompson David Mungo, Marais Leonard Charles
Grey's Hospital.
Department of Orthopaedic Surgery, School of Clinical Medicine, University of KwaZulu-Natal, KwaZulu-Natal, South Africa.
J Pediatr Orthop. 2021 Feb 1;41(2):67-76. doi: 10.1097/BPO.0000000000001722.
Late-presenting or recurrent infantile Blount disease (IBD) is characterized by knee instability because of medial tibial plateau depression, multiplanar proximal tibial deformity, and potential distal femoral deformity. The surgical treatment strategy includes medial elevation osteotomy to stabilize the knee, together with proximal tibial osteotomy to correct alignment, and lateral epiphysiodesis to prevent a recurrence. This study's primary aim was to describe the clinical outcomes of medial elevation osteotomy for the management of late-presenting and recurrent IBD.
The authors reviewed the records of 48 children (64 limbs) who had medial elevation osteotomies and lateral epiphysiodesis, combined with proximal tibial realignment in 78% (50/64) of cases in the same setting. IBD was bilateral in 33% (16/48), 77% (37/48) were female individuals, and 42% (20/48) were obese.
The mean age at surgery was 8.6 years (SD, 1.6; range, 5.8 to 12.8). The mean preoperative tibiofemoral angle (TFA) was 28±11 degrees (8 to 55 degrees), and the mean angle of depression of the medial plateau (ADMP) was 49±8 degrees (26 to 65 degrees). Distal femoral valgus was present in 27% (17/62) and varus in 10% (6/62) children. At a median follow-up of 3.2 years (range, 1 to 6.2 y), the median TFA was 1-degree valgus (interquartile range, 7-degree varus to 5-degree valgus), whereas the ADMP was corrected to 25±8 degrees (8 to 45 degrees). Obesity was associated with more severe deformity as measured by TFA (P<0.001) but did not affect the extent of medial plateau depression (P=0.113). The good or excellent alignment was achieved in 75% (47/63) limbs. Obesity was associated with an increased risk of recurrence [odds ratio (OR), 5.21; 95% CI, 1.26-21.63; P=0.023]. Age at the surgery or previous surgery was not associated with recurrence (OR, 1.29; 95% CI, 0.88-1.88; P=0.195 and OR, 1.22; 95% CI, 0.36-4.17; P=0.746). Obesity and residual instability were associated with an increased risk of poor alignment at the latest follow-up (OR, 3.24; 95% CI, 1.02-10.31; P=0.047 and OR, 1.21; 95% CI, 1.05-1.40; P=0.008).
Late-presenting or recurrent IBD is a surgical challenge. Obesity is associated with more severe deformity. Medial elevation osteotomy combined with lateral proximal tibial epiphysiodesis and metaphyseal tibial realignment osteotomy will result in restoration of lower limb alignment in a high proportion of cases. The recurrent deformity may be the result of failed epiphysiodesis. Obesity and residual instability are associated with an increased risk of poor alignment. Although complications are rare, surgical measures to decrease risk should be followed.
Level IV.
迟发性或复发性婴儿型布朗特病（IBD）的特征是由于胫骨内侧平台凹陷、多平面近端胫骨畸形以及潜在的远端股骨畸形导致膝关节不稳定。手术治疗策略包括内侧抬高截骨术以稳定膝关节，同时进行近端胫骨截骨术以矫正对线，以及外侧骨骺阻滞术以防止复发。本研究的主要目的是描述内侧抬高截骨术治疗迟发性和复发性IBD的临床结果。
作者回顾了48例儿童（64条肢体）的记录，这些儿童接受了内侧抬高截骨术和外侧骨骺阻滞术，其中78%（50/64）的病例在同一情况下还进行了近端胫骨重新对线。IBD为双侧病变的占33%（16/48），女性占77%（37/48），肥胖者占42%（20/48）。
手术时的平均年龄为8.6岁（标准差，1.6；范围，5.8至12.8岁）。术前平均胫股角（TFA）为28±11度（8至55度），内侧平台平均凹陷角度（ADMP）为49±8度（26至65度）。27%（17/62）的儿童存在远端股骨外翻，10%（6/62）的儿童存在内翻。在中位随访3.2年（范围，1至6.2年）时，中位TFA为1度外翻（四分位间距，7度内翻至5度外翻），而ADMP矫正至25±8度（8至45度）。根据TFA测量，肥胖与更严重的畸形相关（P<0.001），但不影响内侧平台凹陷程度（P=0.113）。75%（47/63）的肢体实现了良好或优秀的对线。肥胖与复发风险增加相关[比值比（OR），5.21；95%置信区间，1.26 - 21.63；P=0.023]。手术时的年龄或既往手术与复发无关（OR，1.29；95%置信区间，0.88 - 1.88；P=0.195和OR，1.22；95%置信区间，0.36 - 4.17；P=0.746）。肥胖和残留不稳定与最新随访时对线不良风险增加相关（OR，3.24；95%置信区间，1.02 - 10.31；P=0.047和OR，1.21；95%置信区间，1.05 - 1.40；P=0.008）。
迟发性或复发性IBD是一项手术挑战。肥胖与更严重的畸形相关。内侧抬高截骨术联合近端胫骨外侧骨骺阻滞术和胫骨干骺端重新对线截骨术在大部分病例中可使下肢对线恢复。复发畸形可能是骨骺阻滞术失败的结果。肥胖和残留不稳定与对线不良风险增加相关。尽管并发症罕见，但应采取手术措施降低风险。
四级。
