Damage to the physeal cartilage can result in growth arrest. Partial physeal arrest in a child with growth remaining may benefit from the takedown of the bony bar responsible for the arrest. Untreated physeal arrest results in angular deformity and/or shortening of the limb. Several methods have been described for bar resection. This cohort includes 32 consecutive bar resections performed using an arthroscope through a metaphyseal window to directly visualize the physis. The following were indication for surgery: (1) up to 75% of physeal closure on preoperative mapping studies, (2) more than 2 years of skeletal growth remaining, and (3) predicted leg length discrepancy of more than 2cm.
The technique of bar resection follows the pioneer work of Langenskiold and Peterson. The difference in the technique is the use of the arthroscope. Using fluoroscopy, a metaphyseal window is made followed by the introduction of dental burr. The burr is advanced by using biplane fluoroscopy until the bar is encountered. The burr is then passed into the epiphysis, creating a window through the physeal bar. The cavity is then irrigated and a 5mm, 30-degree arthroscope is introduced. The arthroscope assists in the removal of bone until a complete ring of cartilage is identified. Caution must be taken to avoid both excessive removal of physeal cartilage and inadequate removal of bridging bone. After resection, fat is obtained locally and placed into the area. The tourniquet is not deflated before wound closure in an attempt to hold the fat graft in place.
Thirty patients were available for follow-up through skeletal maturity or physeal closure. The location of the growth arrest was the distal femur in 15 patients, the proximal tibia in 9, the distal tibia in 6, and the distal radius in 2 patients. Average area of physeal arrest was 24%. Amazingly, 21 of 23 patients achieved 70% of limb length that was within 2cm of the contralateral side and angulation of less than 9-degrees, which defined as an excellent result. Five patients had partial longitudinal growth that still required contralateral limb epiphysiodesis or lengthening for residual limb equality. Four patients had inadequate or no response to physeal surgery and were deemed as failures.
The authors have expanded on the previous technique of bar resection utilizing the arthroscope. These results are similar to previous reported success for physeal growth but added an addition element of visualization. The arthroscope is used within the bone to ensure adequate resection. The term may be considered “osteoscope,” meaning placing the arthroscope within the bone to visualize the ring of cartilage. This technique may offer considerable advantages to assess adequate resection of the bar. However, one must carefully select the patient who is a candidate for this technique to maximize the outcome.
Journal of Pediatric Orthopaedics