Ankle Deformity After Growth Arrest In Children:A Report Of 4 Cases And Literature Review

Objective: Clinical features and course of treatment of 4 cases of pediatric distal tibial physeal injury deformity,with national and international literature review to improve the knowledge of the condition,to understand the advantages of Ilizarov ring fixator for limb lengthening and 8 plate for hemiepiphysiodesis to treat such complex deformities.Methods: Retrospective analysis of 4 cases treated from July 2016 to May 2018 at Department of trauma and hand surgery in the first affiliated hospital of Guangxi Medical University were done.Among them,3 cases had ankle varus deformity due to distal tibial epiphyseal injury and 1 case had ankle valgus deformity due to distal fibular epiphyseal injury.The average limb length discrepancy was 4cm.Ilizarov ring fixator and 8 plate were used for the treatment and preoperative and post-operative AOFAS score and ASAMI bone and functional scores were compared.Zhongzhi,Wangfang and Pubmed databases were used to analyse related literature reviews and summarized the clinical characteristics of the deformities.Results:(1)Our hospital case data:(1)4 pediatric trauma cases of 3 with distal tibial epiphyseal injury and of 1 with distal tibial and fibular epiphyseal injury.Did Ilizarov ring fixation with one or two debridments or internal fixation,1 case underwent supramalleolar osteotomy with K-wire fixation and 8 plate fixation,1 case underwent fibular lengthening,1 case had clinical growth arrest of ankle epiphysis.(2)Ankle deformity was accompanied with leg length discrepancy.Prior to the surgery,Bone Ninja application and 3D model bone prints were used to determine the ideal position of 8 plate and correct angle and direction of osteotomy.The common peroneal nerve and tibial nerve were released in all the cases.The angular deformities were corrected with supramalleolar osteotomy and the rotation and leg length discrepancy were corrected with proximal tibiofibular osteotomy.(3)After 5.5 months of mean Ilizarov ring fixation time and 3 months to 2 years of follow up course: Case 1:AOFAS ankle hind foot score improved from 64 to 93,ASAMI bone and functional score were excellent and leg length discrepancy improved from-5cm to +2cm.Case 2: AOFAS ankle hind foot score improved from 60 to 95,ASAMI bone and functional score were excellent and leg length discrepancy improved from-3cm to +1cm.Case 3: AOFAS ankle hind foot score improved from 59 to 93,ASAMI bone and functional score were excellent and leg length discrepancy improved from-4cm to +1cm.Case 4: AOFAS ankle hind foot score improved from 52 to 92,ASAMI bone and functional score were excellent and leg length discrepancy improved from-4cm to +1cm.(2)Chinese and English literature review result: pediatric ankle epiphyseal injury can easily lead to growth plate injury,leg length discrepancy and/or angular deformity and affects the growth of the limb.Salter Harris type II epiphyseal fracture is the most commonly seen although type III,IV and V cause higher frequency of growth arrest leading to distal tibial premature physeal closure,bony bar formation and joint and limb deformity.Excision of bony bar,open physeal plate surgery,osteotomy and internal fixation,8 plate epiphysiodesis,Ilizarov ring fixator application for limb length discrepancy and deformity correction are available mode of treatment.The treatment method depends upon the type and extent of the epiphyseal injury and the possible complication.Conclusion: Pediatric distal tibial epiphyseal injury leads to premature physeal closure and angular deformity.Hemiepiphysiodesis,soft tissue release,osteotomy and Ilizarov ring fixation surgeries combined with post-operative active rehabilitation,can minimize the complications and reduce the incidence of early ankle joint osteoarthritis.