Primary epiphyseal transplants and bone overgrowth in childhood amputations

Case Report: Halting terminal osseous overgrowth post tibia amputation in children: a report of three cases

Terminal osseous overgrowth is a common complication after trans-diaphyseal amputation in children, leading to pain, soft tissue problems, and recurrent surgical procedures. We report three different cases with post-amputation issues of osseous overgrowth, ulceration, and deformity over the amputation site. The first case involves a 9-year-old boy with a right leg congenital amputation secondary to amniotic band syndrome. The right below-knee stump later experienced recurrent episodes of osseous overgrowth, leading to ulceration. After the prominent tibia was resected and capped with the ipsilateral proximal fibula, a positive outcome was achieved with no more recurrent overgrowth over the right leg stump. The second case involves a 9-year-old girl born with an amniotic constriction band over both legs. Her left leg remained functional after a circumferential Z-plasty, but the right leg was a congenital below-knee amputation. Multiple refashioning surgeries were performed on the right leg due to osseous overgrowth but the patient continued to experience recurrent overgrowth causing pain and difficulty fitting into a prosthesis. We performed osteocartilaginous transfer of the proximal part of the ipsilateral fibula to the right tibial end, successfully preventing the overgrowth of the tibia without any complications. The third case involves an 11-year-old boy with a history of meningococcal septicemia who underwent a right below-knee amputation and left ankle disarticulation due to complications of septic emboli. He experienced a prominent right distal tibia stump, which later developed into valgus deformity as a result of the previous insult to the proximal tibial growth plate. We performed a corrective osteotomy over the proximal right tibia and capped the entire tibia with the ipsilateral fibula as an intramedullary splint for the osteotomy site. Post-operatively, we achieved satisfactory deformity correction and successfully halted the recurrent overgrowth over the right tibia stump. The method of ipsilateral fibula capping is safe and effective in managing the osseous overgrowth complications in trans-diaphyseal amputations among children. Therefore, it is a reasonable option during primary below-knee amputations in children compared to multiple refashioning surgeries.

Unsuccessful Osteochondral Allograft Cap to Prevent Overgrowth in a Pediatric Patient with Previous Transtibial Amputation: A Case Report

CASE

This case demonstrates the attempted utilization of an osteochondral allograft for the prevention of bony overgrowth in a patient with fibular hemimelia and previous transtibial amputation with failure of Teflon capping. Additionally, we describe a novel technique to provide additional padding and increase the width of the residual limb using a dermal allograft.

CONCLUSIONS

Bony overgrowth after pediatric amputations is common and often necessitates revision procedures secondary to infection, ulceration, pain, and discomfort with prosthesis use. Our use of an osteochondral allograft cap to prevent bony overgrowth ultimately failed 13 months following the procedure, and further research on various graft options and other treatment modalities is warranted, especially if the proximal fibula is unavailable or there is concern for donor site morbidity associated with harvesting autologous grafts.

Inflammation in bone physiology and pathology

PURPOSE OF REVIEW

Bone is constantly being remodeled throughout adult life through constant anabolic and catabolic actions that maintain tissue homeostasis. A number of hormones, cytokines growth factors, and the proximity of various cells to bone surfaces influence this process. Inflammatory changes at the bone microenvironment result in alterations leading to both excessive bone loss and bone formation. Detailed understanding of the physiological and pathological mechanisms that dictate these changes will allow us to harness inflammatory signals in bone regeneration.

RECENT FINDINGS

Recent reports have suggested that inflammatory signals are able to stimulate transcription factors that regulate osteoblast differentiation from their precursors.

SUMMARY

In this review, we summarized current understanding of the roles of inflammation in bone resorption and bone formation, which give rise to different disorders and discuss the huge potential of harnessing these inflammatory signals to achieve bone regeneration.

Acute femoral shortening for reconstruction of a complex lower extremity crush injury

Traumatic through-knee or transfemoral amputations with concomitant ipsilateral femoral fractures are extremely rare injuries. The initial goal of management is patient resuscitation and stabilization. Subsequent interventions focus on limb salvage and the creation of a residual limb that can be fitted successfully for a functional lower extremity prosthesis. We present the case of a patient who sustained a traumatic through-knee amputation ipsilateral to an open comminuted femoral fracture. Soft tissue injury prohibited initial primary closure over the distal femoral condyles. A functional residual limb was achieved with acute femoral shortening, maintenance of the femoral condyles and fracture stabilization with a short retrograde intramedullary nail. This approach allowed maintenance of muscular attachments to the femur, soft tissue closure and resulted in a residual limb of acceptable length with a broad weight-bearing surface that was fitted with a prosthesis successfully.

Management of Terminal Osseous Overgrowth of the Humerus With Simple Resection and Osteocartilaginous Grafts

BACKGROUND

Osseous overgrowth is a common complication in children after humeral transcortical amputation. Capping tibial overgrowth with the proximal fibula has been shown to be the most effective treatment. However, best treatment practices are not clear for the humerus. We compared patients treated surgically for humeral osseous overgrowth with simple resection or autologous osteocartilaginous graft to determine if this treatment were as effective in the humerus as it has been in the tibia.

METHODS

A retrospective review of humeral amputees from 1987 to 2011 at a pediatric hospital was performed. Patients with 2 years follow-up who underwent surgical treatment for established humeral overgrowth were included. Patients initially managed with simple resection were compared with those managed with autologous osteocartilaginous grafts. Descriptive statistics were calculated for demographic and outcome variables. T tests and χ tests were used to compare differences between groups.

RESULTS

Eighteen humeri in 16 patients met inclusion criteria. Mean age at surgery was 8.3 (2.6 to 13.6) years and mean follow-up was 6.3 (1.5 to 10.4) years. Thirteen humeri underwent simple resection, with recurrent overgrowth in 9, and revision surgery in 8 at a mean 2.6 years. Five humeri were primarily managed with autologous osteocartilaginous grafts. Two developed non-overgrowth-related complications at 1 and 42 months. Including revision procedures after simple resection, 10 humeri were managed with autologous osteocartilaginous grafts. Thirty percent (3/10) required revision surgery; however, there were no cases of recurrent overgrowth. χ comparison showed lower rates of complications (P=0.004) and reoperation (P=0.012) with capping as compared with simple resection.

CONCLUSIONS

Autologous osteocartilaginous capping of the humerus has a significantly lower rate of complications and reoperation compared with simple resection. However, the capping procedure has the potential for other complications related to difficulty with graft fixation. Surgeons should be aware that the outcomes are not as consistent as when the technique is applied to osseous overgrowth of the tibia and anticipate the possibilities of hardware prominence and difficulty with fixation.

LEVEL OF EVIDENCE

Level 3-therapeutic-retrospective comparative.

The use of vascularised bone capping to prevent and treat amputation stump spiking in the paediatric population

BACKGROUND

Overgrowth of the stump skeleton is a major complication seen in children after an amputation. In advanced cases, perforation of the bone spike through the skin can occur. Many surgical treatments have been employed to treat and prevent this, with best results seen when non-vascularised osteo-chondral bone grafts are placed to try to mimic a trans-articular amputation. We reviewed our outcomes using vascularized bone flaps to prevent and treat spiking.

PATIENTS AND METHODS

Between 2000 and 2016 we carried out six vascularised osteo-cartilaginous bone capping procedures. Five patients underwent the procedure as an adjunct to primary amputation and in a single patient it was used to treat established bone spiking. Trauma accounted for three cases, with the other three being tumour, vascular malformation and ischemia. Three patients had pedicled bone flaps placed on the amputation stump and three underwent free tissue transfer (free calcaneus, free scapular angle, and free proximal tibia). Five cases involved lower limb amputations, with one in the upper limb.

RESULTS

One patient had an early post-operative complication in the form of partial skin flap necrosis that required debridement and skin grafting. All bone flaps survived. Mean follow-up was 6.5 years. All patients had bony union with no development of stump spiking. Two patients required further procedures unrelated to the bone flaps.

CONCLUSION

Vascularised bone flaps to cap amputation stumps may be a safe and effective method of preventing and treating long-bone stump spiking following amputation in children.

Osteocartilaginous transfer of the proximal part of the fibula for osseous overgrowth in children with congenital or acquired tibial amputation: surgical technique and results

BACKGROUND

Osseous overgrowth is a common problem in children after tibial transcortical amputation. We present the results of forty-seven children (fifty tibiae) treated for tibial osseous overgrowth with an autologous osteocartilaginous cap from the proximal part of the ipsilateral fibula.

METHODS

We reviewed the records of all patients who underwent amputation at a single pediatric hospital from 1990 to 2011. All patients who had been followed for a minimum of two years after undergoing osteocartilaginous capping with the proximal part of the ipsilateral fibula to treat established tibial overgrowth were included. Patients with acquired and congenital amputations were compared.

RESULTS

Fifty tibiae in forty-seven patients met our inclusion criteria. There were thirty-one acquired and nineteen congenital amputations. The mean age at surgery was 7.6 years (range, 2.1 to 15.6 years), and the mean duration of follow-up was 7.2 years (range, 2.2 to 15.4 years). Five tibiae (10%) in four patients had recurrence of the overgrowth at a mean of 5.4 years (range, 2.8 to 7.6 years) after the osteocartilaginous transfer. There was no significant difference in the results between children with an acquired amputation and those with a congenital amputation.

CONCLUSIONS

At a mean of 7.2 years after autologous osteocartilaginous capping with the proximal part of the fibula, 90% of the limbs had not had recurrent overgrowth. This is a safe and effective treatment of long-bone overgrowth following either congenital or acquired amputation in children.

Transtibial Ertl amputation for children and adolescents: a case series and literature review

PURPOSE

Despite advances in limb reconstruction, there are still a number of young patients who require trans-tibial amputation. Amputation osteoplasty is a technique first described by Ertl to enhance rehabilitation after trans-tibial amputation. The purpose of the study reported here was to evaluate the results of the original Ertl procedure in skeletally immature patients and to assess whether use of this procedure would result in a diminished incidence of bony overgrowth.

METHODS

The cases of four consecutive patients (five amputations) treated between January 2005 and June 2008 were reviewed. Clinical evaluation consisted of the completion of the prosthesis evaluation questionnaire (PEQ) and physical examination. Radiographic analysis was performed to evaluate bone-bridge healing, bone overgrowth, and the development of genu varum as measured by the medial proximal tibial angle (MPTA).

RESULTS

The best mean PEQ score in the question section was 91.8 (range 74-100) for 'well being' and the worst mean score was 66.6 (range 50-78) for 'residual limb health'. Examination of the residual limbs revealed no bursae, and all knees were stable with full range of movement. All bony bridges united at an average age of 1.7 (range 1-2) months. One case required stump revision for bony overgrowth, and one case developed asymptomatic mild genu varum.

CONCLUSIONS

The original Ertl osteomyoplasty may serve as one of the options for treatment of trans-tibial amputation in older children.

CLINICAL RELEVANCE

Our results suggest that the Ertl osteomyoplasty is a feasible option in this challenging patient population.

Congenital pseudarthrosis of the tibia

Congenital pseudarthrosis of the tibia is characterized by anterolateral deformity of the tibia and shortening of the limb. Its etiology remains unclear. Although several classification systems have been proposed, none provides specific guidelines for management. Treatment remains challenging. The goal is to obtain and maintain union while minimizing deformity. The basic biologic considerations with surgical intervention include resection of the pseudarthrosis and bridging of the defect with stable fixation. Intramedullary stabilization, free vascularized fibula, and Ilizarov external fixation are among the most frequently used methods of treatment. In addition, bone morphogenetic protein recently has shown promise. Nevertheless, despite improvements in healing rates with congenital pseudarthrosis of the tibia, the potential for amputation in failed cases persists.

Surgical management of juvenile amputation overgrowth with a synthetic cap

Seventeen amputations (in 14 children) with established overgrowth were treated by capping of the residual limb with a polytetrafluoroethylene (PTFE) felt pad. Average age at the time of the procedure was 7 years 10 months. Mean follow-up was 4 years 9 months. Statistical comparisons were made to historical controls, treated by resection revision or biologic capping, from a prior overgrowth study from the authors' institution. Revision surgery was necessary in 86% of resection revisions, 29% of biologic caps, and 29% of PTFE caps. Kaplan-Meier analysis estimated survival times of 3 years 3 months for resection revision, 6 years 1 month for biologic caps, and 7 years 2 months for PTFE caps. PTFE and biologic caps were both statistically better than resection revision with regard to need for subsequent operation and survivorship, but were not statistically different from each other. Complications associated with PTFE capping and biologic capping were distinct.

Skeletal scintigraphic appearance of an auto-transplanted osteoarticular plug: epiphyseal transplant

Nuclear medicine bone scan is an essential diagnostic imaging tool both for the diagnosis and staging of bone tumors and in the follow-up of these patients. It is very important that we be able to discriminate between normal variants, changes related to altered physical stress, and recurrent disease in order to interpret the bone scan meaningfully. We wish to report the appearance of the isotope bone scan, technetium 99m-labeled methylene diphosphonate ((99m)Tc-MDP), associated with an auto-transplanted osteoarticular plug (epiphyseal transplant) performed following limb amputation. This reconstructive surgery can give a potentially misleading appearance on the nuclear medicine bone scan if one is unfamiliar with this surgical technique.

Rehabilitation in limb deficiency. 2. The pediatric amputee

This self-directed learning module highlights advances in the evaluation and management of the pediatric amputee. It is part of the chapter on rehabilitation in limb deficiency in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article discusses the etiology and terminology of childhood limb deficiency. Developmental milestones are used as a guide to prescribing prosthetic devices for children, and tables suggesting such guidelines are included. Specific clinical examples are provided to illustrate management issues. Advances that are covered include limb-sparing procedures in the management of lower extremity malignancy.

Operative treatment of bone overgrowth in children who have an acquired or congenital amputation

Fifty-three children who were less than thirteen years old were followed for a median of seven years and ten months (range, two years and nine months to fourteen years and six months) after operative treatment for overgrowth of the tibia or humerus after amputation. During the thirty-one years in which these children were managed, three operative techniques were used in successive periods. Thus, the fifty-three children could be divided into three groups: thirty-one who had had a resection and revision, nine in whom the bone had been capped with a synthetic device, and thirteen in whom the bone had been capped with an autogenous tricortical bone graft from the iliac crest. A retrospective review was performed to determine the result and complications associated with each of these techniques. Survival analysis revealed that subsequent procedures were performed in twenty-six (84 per cent) of the thirty-one patients who had had a resection and revision, in seven of the nine in whom the bone had been capped with a synthetic device, and in four of the thirteen in whom the bone had been capped with an autogenous bone graft. The estimated mean survival time (that is, the time to a subsequent procedure) was five years in the group that had had the bone capped with an autogenous graft and three years and six months in the group that had had resection and revision; the difference is significant (p = 0.003).(ABSTRACT TRUNCATED AT 250 WORDS)