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Use of a Core Reamer for the Resection of a Central Distal Femoral Physeal Bone Bridge: A Novel Technique with 3-Year Follow-up
ABSTRACT
A central distal femoral physeal bone bridge in a boy aged 5 years and 7 months was resected with a fluoroscopically guided core reamer placed through a lateral parapatellar approach. At 3-year follow-up, the boy’s leg-length discrepancy was 3.0 cm (3.9 cm preoperatively), and the physeal bone bridge did not recur. The patient had full function and no pain or other patellofemoral complaints. This technique provided direct access to the physeal bone bridge, and complete resection was performed without injury to the adjacent physeal cartilage in the medial and lateral columns of the distal femur, which is expected to grow normally in the absence of the bridge.
A physeal bone bridge is an osseous connection that forms across a physis. It may cause partial premature physeal arrest. Angular deformity and limb-length discrepancy are the main complications caused by physeal bone bridges.1-4 The indications for the treatment of physeal bridges are well documented.1-5 Trauma and infection are common causes of distal femoral physeal bone bridges. Arkader and colleagues6 showed that among different types of physeal bridges, the Salter-Harris type is significantly associated with complications, among which growth arrest is the most common and occurs in 27.4% of all patients.
The treatment of distal femoral physeal bone bridges is technically difficult and provides variable results. Poor results are reported in 13% to 40% of patients.7-10 Procedure failure has been attributed to incomplete resection with the persistent tethering and dislodgement of the graft.11 Methods with improved efficacy for the removal of central physeal bridges will help prevent reformation after treatment. We have used a novel technique that allows the direct resection of a central physeal bone bridge in the distal femur through the use of a fluoroscopically guided core reamer. This technique enables the complete removal of the bone bridge and the direct visual assessment of the remaining physis. The patient’s parents provided written informed consent for print and electronic publication of this case report.
CASE
A 3-year-old boy with a history of hemifacial microsomia presented for the evaluation of genu valgum and leg-length discrepancy. His intermalleolar distance at that time was 8 cm. A standing radiograph of his lower extremities demonstrated changes consistent with physiologic genu valgum. He had no history of knee trauma, infection, or pain.
At the age of 5 years and 7 months, the patient returned for a repeat evaluation and was noted to exhibit the progressive valgus deformity of the right leg and a leg-length discrepancy of 3.9 cm (Figure 1). 
Continue to: With the patient supine on the operating...
OPERATIVE TECHNIQUE
With the patient supine on the operating table and after the administration of general anesthesia, 3-dimensional (3-D) fluoroscopy was used to localize the bone bridge, which confirmed the fluoroscopic location that was previously visualized through preoperative 3-D imaging. The leg was elevated, and a tourniquet was applied and inflated. A lateral parapatellar approach was used to isolate the distal femoral physis anteriorly because the bone bridge was centered just lateral to the central portion of the distal femoral physis. A Kirschner wire was placed in the center of the bridge under anteroposterior and lateral fluoroscopic imaging (Figures 3A-3E). 
OUTCOME
The patient healed uneventfully, and early range-of-motion exercises were started 6 weeks postoperatively. At 6-month follow-up, his leg-length discrepancy was 2.7 cm, and the bone bridge did not recur. At 3-year follow-up, his leg-length discrepancy was 3.0 cm, and the bone bridge did not recur. Over the 3 years postoperatively, the patient exhibited 9.8 cm of growth on his operative side and 9.5 cm on his nonoperative side (Figure 5). 
DISCUSSION
Given the considerable growth potential of the distal femoral physis,1,14-16 an injury to the distal femoral physis and the formation of a physeal bone bridge can have a profound effect on a young patient in terms of leg-length discrepancy and angular deformity. Fracture from trauma or infection is a common cause of physeal bone bridges.6,17-19 The etiology of our patient’s distal femoral physeal bone bridge is idiopathic, which is considerably less common than other etiologies, and the incidence of idiopathic physeal bone bridge formation is not well established in the literature. Hresko and Kasser21 identified atraumatic physeal bone bridge formations in 7 patients. Among the 13 patients with physeal bone bridges described by Broughton and colleagues,20 the cause of bridge formation is unknown in 1.
Physeal bone bridges that form centrally are particularly challenging because they are difficult to visualize through a peripheral approach. A number of methods for resecting central physeal bone bridges have been described. These methods have varying degrees of success. In 1981, Langenskiöld7 first described the creation of a metaphyseal mirror and the use of a dental mirror for visualization. This technique, however, yielded unfavorable results in 16% of patients. Williamson and Staheli9 reported poor results in 23% of patients. Loraas and Schmale4 described the use of an endoscope, termed an osteoscope, for visualization, citing advantages of superior illumination and potential for image magnification and capture. Marsh and Polzhofer8 also showed this technique to have low morbidity but poor results in 13% of patients, whereas Moreta and colleagues10 reported poor results in 2 out of 5 patients. The rate of poor results of these methods may be related to the technical difficulty of using dental mirrors and arthroscopes and can be improved by highly efficient direct methods with improved visualization, such as the method described in this article.
Continue to: Proper imaging is necessary for...
Proper imaging is necessary for the accurate quantification of bone bridges to determine resectability and to identify the best surgical approach to resection. MRI with software for the generation of 3-D physeal maps is a reproducible method with good interobserver reliability.22,23 Intraoperative computer-assisted imaging also is beneficial for determining the extent and location of the resection to ensure complete bone bridge removal.24
To our knowledge, a direct approach through parapatellar arthrotomy for the resection of a centrally located distal femoral physeal bone bridge has not been previously described. This novel technique provided direct access to the physeal bone bridge and was performed without injuring the adjacent physeal cartilage in the medial and lateral columns of the distal femur, which may grow normally in the absence of the bridge. Instead of using a lateral or medial approach with a metaphyseal window,4 we directly approached this central bar through a parapatellar approach and were able to completely resect it under direct visualization. This obviated the need for an arthroscope or dental mirror. To remove the entire physeal bone bridge, we needed to resect completely from the anterior cortex to the posterior cortex. Although this technique potentially increased the risk of iatrogenic fracture, we believed that this risk would not differ greatly from that of disrupting the medial or lateral metaphysis and would be more stable with either axial and torsion load. At 3-year follow-up, the patient exhibited restored normal growth in his operative limb relative to that in his nonoperative limb, had not developed angular deformity, and had maintained his previously developed limb-length discrepancy that could be corrected with the epiphysiodesis of his opposite limb at a later date.
The limitations to this technique include the fact that it may be most effective with small-to moderate-sized central physeal bone bridges, although resection has shown good results with up to 70% physeal involvement.8 In this patient, the bone bridge was moderately sized (30% of the physis), centrally located, and clearly visible on fluoroscopy. These characteristics increased the technical safety and ease of the procedure. The resection of large, peripheral bridges may destabilize the distal femur. The destabilization of the distal femur, in turn, can lead to fracture. Patellofemoral mechanics may also be affected during the treatment of distal femoral physeal bone bridges. This patient has not experienced any patellofemoral dysfunction or symptoms. Given the patient’s age and significant amount of remaining growth, he will need close monitoring until he reaches skeletal maturity.
This paper will be judged for the Resident Writer’s Award.
1. Murphy GA. Disorders of tendons and fascia and adolescent and adult pes planus. In: Canale ST, Beaty JH, eds. Campbell’s Operative Orthopaedics. 12th edition. Philadelphia, PA: Mosby-Elsevier; 2013:3966-3972.
2. Khoshhal KI, Kiefer GN. Physeal bridge resection. J Am Acad Orthop Surg. 2005;13(1):47-58. doi:10.5435/00124635-200501000-00007.
3. Stans AA. Excision of physeal bar. In: Wiesel SW, ed. Operative Techniques in Orthopaedic Surgery. Philadelphia, PA: Lippincott Williams & Wilkins; 2011:1244-1249.
4. Loraas EK, Schmale GA. Endoscopically aided physeal bar takedown and guided growth for the treatment of angular limb deformity. J Pediatr Orthop B. 2012;21(4):348-351. doi:10.1097/BPB.0b013e328346d308.
5. Inoue T, Naito M, Fuhii T, Akiyoshi Y, Yoshimura I, Takamura K. Partial physeal growth arrest treated by bridge resection and artificial dura substitute interposition. J Pediatr Orthop B. 2006;15(1):65-69. doi:10.1097/01202412-200601000-00014.
6. Arkader A, Warner WC Jr, Horn BD, Shaw RN, Wells L. Predicting the outcome of physeal fractures of the distal femur. J Pediatr Orthop. 2007;27(6):703-708. doi:10.1097/BPO.0b013e3180dca0e5.
7. Langenskiöld A. Surgical treatment of partial closure of the growth plate. J Pediatr Orthop. 1981;1(1):3-11. doi:10.1097/01241398-198101010-00002.
8. Marsh JS, Polzhofer GK. Arthroscopically assisted central physeal bar resection. J Pediatr Orthop. 2006;26(2):255-259. doi:10.1097/01.bpo.0000218533.43986.e1.
9. Williamson RV, Staheli LT. Partial physeal growth arrest: treatment by bridge resection and fat interposition. J Pediatr Orthop. 1990;10(6):769-776. doi:10.1097/01241398-199011000-00012.
10. Moreta J, Abril JC, Miranda C. Arthroscopy-assisted resection-interposition of post-traumatic central physeal bridges. Rev Esp Cir Orthop Traumatol. 2013;57(5):333-339. doi:10.1016/j.recot.2013.07.004.
11. Hasler CC, Foster BK. Secondary tethers after physeal bar resection: a common source of failure? Clin Orthop Relat Res. 2002;405:242-249.
12. Paley D, Bhave A, Herzenberg JE, Bowen JR. Multiplier method for predicting limb-length discrepancy. J Bone Joint Surg Am. 2000;82(10):1432-1446. doi:10.2106/00004623-200010000-00010.
13. Khoshhal KI, Kiefer GN. Physeal bridge resection. J Am Acad Orthop Surg. 2005;13(1):47-58. doi:10.5435/00124635-200501000-00007.
14. Rathjen KE, Kim HKW. Physeal injuries and growth disturbances. In: Flynn JM, Skaggs DL, Waters PM, eds. Rockwood and Wilkins’ Fractures in Children. 8th edition. Philadelphia, PA: Wolters-Kluwer; 2015:135-137.
15. Peterson CA, Peterson HA. Analysis of the incidence of injuries to the epiphyseal growth plate. J Trauma. 1972;12(4):275-281. doi:10.1097/00005373-197204000-00002.
16. Pritchett JW. Longitudinal growth and growth-plate activity in the lower extremity. Clin Orthop Relat Res. 1992;275:274-279.
17. Cassebaum WH, Patterson AH. Fracture of the distal femoral epiphysis. Clin Orthop Relat Res. 1965;41:79-91. doi:10.1097/00003086-196500410-00009.
18. Dahl WJ, Silva S, Vanderhave KL. Distal femoral physeal fixation: are smooth pins really safe? J Pedatir Orthop. 2014;34(2):134-138. doi:10.1097/BPO.0000000000000083.
19. Roberts J. Fracture separation of the distal femoral epiphyseal growth line. J Bone Joint Surg Am. 1973;55:1324.
20. Broughton NS, Dickens DR, Cole WG, Menelaus MB. Epiphyseolysis for partial growth plate arrest. Results after four years or at maturity. J Bone Joint Surg Br. 1989;71(1):13-16. doi:10.1302/0301-620X.71B1.2914983.
21. Hresko MT, Kasser JR. Physeal arrest about the knee associated with non-physeal fractures in the lower extremity. J Bone Joint Surg Am. 1989;71(5):698-703. doi:10.2106/00004623-198971050-00009.
22. Lurie B, Koff MF, Shah P, et al. Three-dimensional magnetic resonance imaging of physeal injury: reliability and clinical utility. J Pediatr Orthop. 2014;34(3):239-245. doi:10.1097/BPO.0000000000000104.
23. Sailhan F, Chotel F, Guibal AL, et al. Three-dimensional MR imaging in the assessment of physeal growth arrest. Eur Radiol. 2004;14(9):1600-1608. doi:10.1007/s00330-004-2319-z.
24. Kang HG, Yoon SJ, Kim JR. Resection of a physeal bar under computer-assisted guidance. J Bone Joint Surg Br. 2010;92(10):1452-1455. doi:10.1302/0301-620X.92B10.24587.
ABSTRACT
A central distal femoral physeal bone bridge in a boy aged 5 years and 7 months was resected with a fluoroscopically guided core reamer placed through a lateral parapatellar approach. At 3-year follow-up, the boy’s leg-length discrepancy was 3.0 cm (3.9 cm preoperatively), and the physeal bone bridge did not recur. The patient had full function and no pain or other patellofemoral complaints. This technique provided direct access to the physeal bone bridge, and complete resection was performed without injury to the adjacent physeal cartilage in the medial and lateral columns of the distal femur, which is expected to grow normally in the absence of the bridge.
A physeal bone bridge is an osseous connection that forms across a physis. It may cause partial premature physeal arrest. Angular deformity and limb-length discrepancy are the main complications caused by physeal bone bridges.1-4 The indications for the treatment of physeal bridges are well documented.1-5 Trauma and infection are common causes of distal femoral physeal bone bridges. Arkader and colleagues6 showed that among different types of physeal bridges, the Salter-Harris type is significantly associated with complications, among which growth arrest is the most common and occurs in 27.4% of all patients.
The treatment of distal femoral physeal bone bridges is technically difficult and provides variable results. Poor results are reported in 13% to 40% of patients.7-10 Procedure failure has been attributed to incomplete resection with the persistent tethering and dislodgement of the graft.11 Methods with improved efficacy for the removal of central physeal bridges will help prevent reformation after treatment. We have used a novel technique that allows the direct resection of a central physeal bone bridge in the distal femur through the use of a fluoroscopically guided core reamer. This technique enables the complete removal of the bone bridge and the direct visual assessment of the remaining physis. The patient’s parents provided written informed consent for print and electronic publication of this case report.
CASE
A 3-year-old boy with a history of hemifacial microsomia presented for the evaluation of genu valgum and leg-length discrepancy. His intermalleolar distance at that time was 8 cm. A standing radiograph of his lower extremities demonstrated changes consistent with physiologic genu valgum. He had no history of knee trauma, infection, or pain.
At the age of 5 years and 7 months, the patient returned for a repeat evaluation and was noted to exhibit the progressive valgus deformity of the right leg and a leg-length discrepancy of 3.9 cm (Figure 1).
Continue to: With the patient supine on the operating...
OPERATIVE TECHNIQUE
With the patient supine on the operating table and after the administration of general anesthesia, 3-dimensional (3-D) fluoroscopy was used to localize the bone bridge, which confirmed the fluoroscopic location that was previously visualized through preoperative 3-D imaging. The leg was elevated, and a tourniquet was applied and inflated. A lateral parapatellar approach was used to isolate the distal femoral physis anteriorly because the bone bridge was centered just lateral to the central portion of the distal femoral physis. A Kirschner wire was placed in the center of the bridge under anteroposterior and lateral fluoroscopic imaging (Figures 3A-3E).
OUTCOME
The patient healed uneventfully, and early range-of-motion exercises were started 6 weeks postoperatively. At 6-month follow-up, his leg-length discrepancy was 2.7 cm, and the bone bridge did not recur. At 3-year follow-up, his leg-length discrepancy was 3.0 cm, and the bone bridge did not recur. Over the 3 years postoperatively, the patient exhibited 9.8 cm of growth on his operative side and 9.5 cm on his nonoperative side (Figure 5).
DISCUSSION
Given the considerable growth potential of the distal femoral physis,1,14-16 an injury to the distal femoral physis and the formation of a physeal bone bridge can have a profound effect on a young patient in terms of leg-length discrepancy and angular deformity. Fracture from trauma or infection is a common cause of physeal bone bridges.6,17-19 The etiology of our patient’s distal femoral physeal bone bridge is idiopathic, which is considerably less common than other etiologies, and the incidence of idiopathic physeal bone bridge formation is not well established in the literature. Hresko and Kasser21 identified atraumatic physeal bone bridge formations in 7 patients. Among the 13 patients with physeal bone bridges described by Broughton and colleagues,20 the cause of bridge formation is unknown in 1.
Physeal bone bridges that form centrally are particularly challenging because they are difficult to visualize through a peripheral approach. A number of methods for resecting central physeal bone bridges have been described. These methods have varying degrees of success. In 1981, Langenskiöld7 first described the creation of a metaphyseal mirror and the use of a dental mirror for visualization. This technique, however, yielded unfavorable results in 16% of patients. Williamson and Staheli9 reported poor results in 23% of patients. Loraas and Schmale4 described the use of an endoscope, termed an osteoscope, for visualization, citing advantages of superior illumination and potential for image magnification and capture. Marsh and Polzhofer8 also showed this technique to have low morbidity but poor results in 13% of patients, whereas Moreta and colleagues10 reported poor results in 2 out of 5 patients. The rate of poor results of these methods may be related to the technical difficulty of using dental mirrors and arthroscopes and can be improved by highly efficient direct methods with improved visualization, such as the method described in this article.
Continue to: Proper imaging is necessary for...
Proper imaging is necessary for the accurate quantification of bone bridges to determine resectability and to identify the best surgical approach to resection. MRI with software for the generation of 3-D physeal maps is a reproducible method with good interobserver reliability.22,23 Intraoperative computer-assisted imaging also is beneficial for determining the extent and location of the resection to ensure complete bone bridge removal.24
To our knowledge, a direct approach through parapatellar arthrotomy for the resection of a centrally located distal femoral physeal bone bridge has not been previously described. This novel technique provided direct access to the physeal bone bridge and was performed without injuring the adjacent physeal cartilage in the medial and lateral columns of the distal femur, which may grow normally in the absence of the bridge. Instead of using a lateral or medial approach with a metaphyseal window,4 we directly approached this central bar through a parapatellar approach and were able to completely resect it under direct visualization. This obviated the need for an arthroscope or dental mirror. To remove the entire physeal bone bridge, we needed to resect completely from the anterior cortex to the posterior cortex. Although this technique potentially increased the risk of iatrogenic fracture, we believed that this risk would not differ greatly from that of disrupting the medial or lateral metaphysis and would be more stable with either axial and torsion load. At 3-year follow-up, the patient exhibited restored normal growth in his operative limb relative to that in his nonoperative limb, had not developed angular deformity, and had maintained his previously developed limb-length discrepancy that could be corrected with the epiphysiodesis of his opposite limb at a later date.
The limitations to this technique include the fact that it may be most effective with small-to moderate-sized central physeal bone bridges, although resection has shown good results with up to 70% physeal involvement.8 In this patient, the bone bridge was moderately sized (30% of the physis), centrally located, and clearly visible on fluoroscopy. These characteristics increased the technical safety and ease of the procedure. The resection of large, peripheral bridges may destabilize the distal femur. The destabilization of the distal femur, in turn, can lead to fracture. Patellofemoral mechanics may also be affected during the treatment of distal femoral physeal bone bridges. This patient has not experienced any patellofemoral dysfunction or symptoms. Given the patient’s age and significant amount of remaining growth, he will need close monitoring until he reaches skeletal maturity.
This paper will be judged for the Resident Writer’s Award.
ABSTRACT
A central distal femoral physeal bone bridge in a boy aged 5 years and 7 months was resected with a fluoroscopically guided core reamer placed through a lateral parapatellar approach. At 3-year follow-up, the boy’s leg-length discrepancy was 3.0 cm (3.9 cm preoperatively), and the physeal bone bridge did not recur. The patient had full function and no pain or other patellofemoral complaints. This technique provided direct access to the physeal bone bridge, and complete resection was performed without injury to the adjacent physeal cartilage in the medial and lateral columns of the distal femur, which is expected to grow normally in the absence of the bridge.
A physeal bone bridge is an osseous connection that forms across a physis. It may cause partial premature physeal arrest. Angular deformity and limb-length discrepancy are the main complications caused by physeal bone bridges.1-4 The indications for the treatment of physeal bridges are well documented.1-5 Trauma and infection are common causes of distal femoral physeal bone bridges. Arkader and colleagues6 showed that among different types of physeal bridges, the Salter-Harris type is significantly associated with complications, among which growth arrest is the most common and occurs in 27.4% of all patients.
The treatment of distal femoral physeal bone bridges is technically difficult and provides variable results. Poor results are reported in 13% to 40% of patients.7-10 Procedure failure has been attributed to incomplete resection with the persistent tethering and dislodgement of the graft.11 Methods with improved efficacy for the removal of central physeal bridges will help prevent reformation after treatment. We have used a novel technique that allows the direct resection of a central physeal bone bridge in the distal femur through the use of a fluoroscopically guided core reamer. This technique enables the complete removal of the bone bridge and the direct visual assessment of the remaining physis. The patient’s parents provided written informed consent for print and electronic publication of this case report.
CASE
A 3-year-old boy with a history of hemifacial microsomia presented for the evaluation of genu valgum and leg-length discrepancy. His intermalleolar distance at that time was 8 cm. A standing radiograph of his lower extremities demonstrated changes consistent with physiologic genu valgum. He had no history of knee trauma, infection, or pain.
At the age of 5 years and 7 months, the patient returned for a repeat evaluation and was noted to exhibit the progressive valgus deformity of the right leg and a leg-length discrepancy of 3.9 cm (Figure 1).
Continue to: With the patient supine on the operating...
OPERATIVE TECHNIQUE
With the patient supine on the operating table and after the administration of general anesthesia, 3-dimensional (3-D) fluoroscopy was used to localize the bone bridge, which confirmed the fluoroscopic location that was previously visualized through preoperative 3-D imaging. The leg was elevated, and a tourniquet was applied and inflated. A lateral parapatellar approach was used to isolate the distal femoral physis anteriorly because the bone bridge was centered just lateral to the central portion of the distal femoral physis. A Kirschner wire was placed in the center of the bridge under anteroposterior and lateral fluoroscopic imaging (Figures 3A-3E).
OUTCOME
The patient healed uneventfully, and early range-of-motion exercises were started 6 weeks postoperatively. At 6-month follow-up, his leg-length discrepancy was 2.7 cm, and the bone bridge did not recur. At 3-year follow-up, his leg-length discrepancy was 3.0 cm, and the bone bridge did not recur. Over the 3 years postoperatively, the patient exhibited 9.8 cm of growth on his operative side and 9.5 cm on his nonoperative side (Figure 5).
DISCUSSION
Given the considerable growth potential of the distal femoral physis,1,14-16 an injury to the distal femoral physis and the formation of a physeal bone bridge can have a profound effect on a young patient in terms of leg-length discrepancy and angular deformity. Fracture from trauma or infection is a common cause of physeal bone bridges.6,17-19 The etiology of our patient’s distal femoral physeal bone bridge is idiopathic, which is considerably less common than other etiologies, and the incidence of idiopathic physeal bone bridge formation is not well established in the literature. Hresko and Kasser21 identified atraumatic physeal bone bridge formations in 7 patients. Among the 13 patients with physeal bone bridges described by Broughton and colleagues,20 the cause of bridge formation is unknown in 1.
Physeal bone bridges that form centrally are particularly challenging because they are difficult to visualize through a peripheral approach. A number of methods for resecting central physeal bone bridges have been described. These methods have varying degrees of success. In 1981, Langenskiöld7 first described the creation of a metaphyseal mirror and the use of a dental mirror for visualization. This technique, however, yielded unfavorable results in 16% of patients. Williamson and Staheli9 reported poor results in 23% of patients. Loraas and Schmale4 described the use of an endoscope, termed an osteoscope, for visualization, citing advantages of superior illumination and potential for image magnification and capture. Marsh and Polzhofer8 also showed this technique to have low morbidity but poor results in 13% of patients, whereas Moreta and colleagues10 reported poor results in 2 out of 5 patients. The rate of poor results of these methods may be related to the technical difficulty of using dental mirrors and arthroscopes and can be improved by highly efficient direct methods with improved visualization, such as the method described in this article.
Continue to: Proper imaging is necessary for...
Proper imaging is necessary for the accurate quantification of bone bridges to determine resectability and to identify the best surgical approach to resection. MRI with software for the generation of 3-D physeal maps is a reproducible method with good interobserver reliability.22,23 Intraoperative computer-assisted imaging also is beneficial for determining the extent and location of the resection to ensure complete bone bridge removal.24
To our knowledge, a direct approach through parapatellar arthrotomy for the resection of a centrally located distal femoral physeal bone bridge has not been previously described. This novel technique provided direct access to the physeal bone bridge and was performed without injuring the adjacent physeal cartilage in the medial and lateral columns of the distal femur, which may grow normally in the absence of the bridge. Instead of using a lateral or medial approach with a metaphyseal window,4 we directly approached this central bar through a parapatellar approach and were able to completely resect it under direct visualization. This obviated the need for an arthroscope or dental mirror. To remove the entire physeal bone bridge, we needed to resect completely from the anterior cortex to the posterior cortex. Although this technique potentially increased the risk of iatrogenic fracture, we believed that this risk would not differ greatly from that of disrupting the medial or lateral metaphysis and would be more stable with either axial and torsion load. At 3-year follow-up, the patient exhibited restored normal growth in his operative limb relative to that in his nonoperative limb, had not developed angular deformity, and had maintained his previously developed limb-length discrepancy that could be corrected with the epiphysiodesis of his opposite limb at a later date.
The limitations to this technique include the fact that it may be most effective with small-to moderate-sized central physeal bone bridges, although resection has shown good results with up to 70% physeal involvement.8 In this patient, the bone bridge was moderately sized (30% of the physis), centrally located, and clearly visible on fluoroscopy. These characteristics increased the technical safety and ease of the procedure. The resection of large, peripheral bridges may destabilize the distal femur. The destabilization of the distal femur, in turn, can lead to fracture. Patellofemoral mechanics may also be affected during the treatment of distal femoral physeal bone bridges. This patient has not experienced any patellofemoral dysfunction or symptoms. Given the patient’s age and significant amount of remaining growth, he will need close monitoring until he reaches skeletal maturity.
This paper will be judged for the Resident Writer’s Award.
1. Murphy GA. Disorders of tendons and fascia and adolescent and adult pes planus. In: Canale ST, Beaty JH, eds. Campbell’s Operative Orthopaedics. 12th edition. Philadelphia, PA: Mosby-Elsevier; 2013:3966-3972.
2. Khoshhal KI, Kiefer GN. Physeal bridge resection. J Am Acad Orthop Surg. 2005;13(1):47-58. doi:10.5435/00124635-200501000-00007.
3. Stans AA. Excision of physeal bar. In: Wiesel SW, ed. Operative Techniques in Orthopaedic Surgery. Philadelphia, PA: Lippincott Williams & Wilkins; 2011:1244-1249.
4. Loraas EK, Schmale GA. Endoscopically aided physeal bar takedown and guided growth for the treatment of angular limb deformity. J Pediatr Orthop B. 2012;21(4):348-351. doi:10.1097/BPB.0b013e328346d308.
5. Inoue T, Naito M, Fuhii T, Akiyoshi Y, Yoshimura I, Takamura K. Partial physeal growth arrest treated by bridge resection and artificial dura substitute interposition. J Pediatr Orthop B. 2006;15(1):65-69. doi:10.1097/01202412-200601000-00014.
6. Arkader A, Warner WC Jr, Horn BD, Shaw RN, Wells L. Predicting the outcome of physeal fractures of the distal femur. J Pediatr Orthop. 2007;27(6):703-708. doi:10.1097/BPO.0b013e3180dca0e5.
7. Langenskiöld A. Surgical treatment of partial closure of the growth plate. J Pediatr Orthop. 1981;1(1):3-11. doi:10.1097/01241398-198101010-00002.
8. Marsh JS, Polzhofer GK. Arthroscopically assisted central physeal bar resection. J Pediatr Orthop. 2006;26(2):255-259. doi:10.1097/01.bpo.0000218533.43986.e1.
9. Williamson RV, Staheli LT. Partial physeal growth arrest: treatment by bridge resection and fat interposition. J Pediatr Orthop. 1990;10(6):769-776. doi:10.1097/01241398-199011000-00012.
10. Moreta J, Abril JC, Miranda C. Arthroscopy-assisted resection-interposition of post-traumatic central physeal bridges. Rev Esp Cir Orthop Traumatol. 2013;57(5):333-339. doi:10.1016/j.recot.2013.07.004.
11. Hasler CC, Foster BK. Secondary tethers after physeal bar resection: a common source of failure? Clin Orthop Relat Res. 2002;405:242-249.
12. Paley D, Bhave A, Herzenberg JE, Bowen JR. Multiplier method for predicting limb-length discrepancy. J Bone Joint Surg Am. 2000;82(10):1432-1446. doi:10.2106/00004623-200010000-00010.
13. Khoshhal KI, Kiefer GN. Physeal bridge resection. J Am Acad Orthop Surg. 2005;13(1):47-58. doi:10.5435/00124635-200501000-00007.
14. Rathjen KE, Kim HKW. Physeal injuries and growth disturbances. In: Flynn JM, Skaggs DL, Waters PM, eds. Rockwood and Wilkins’ Fractures in Children. 8th edition. Philadelphia, PA: Wolters-Kluwer; 2015:135-137.
15. Peterson CA, Peterson HA. Analysis of the incidence of injuries to the epiphyseal growth plate. J Trauma. 1972;12(4):275-281. doi:10.1097/00005373-197204000-00002.
16. Pritchett JW. Longitudinal growth and growth-plate activity in the lower extremity. Clin Orthop Relat Res. 1992;275:274-279.
17. Cassebaum WH, Patterson AH. Fracture of the distal femoral epiphysis. Clin Orthop Relat Res. 1965;41:79-91. doi:10.1097/00003086-196500410-00009.
18. Dahl WJ, Silva S, Vanderhave KL. Distal femoral physeal fixation: are smooth pins really safe? J Pedatir Orthop. 2014;34(2):134-138. doi:10.1097/BPO.0000000000000083.
19. Roberts J. Fracture separation of the distal femoral epiphyseal growth line. J Bone Joint Surg Am. 1973;55:1324.
20. Broughton NS, Dickens DR, Cole WG, Menelaus MB. Epiphyseolysis for partial growth plate arrest. Results after four years or at maturity. J Bone Joint Surg Br. 1989;71(1):13-16. doi:10.1302/0301-620X.71B1.2914983.
21. Hresko MT, Kasser JR. Physeal arrest about the knee associated with non-physeal fractures in the lower extremity. J Bone Joint Surg Am. 1989;71(5):698-703. doi:10.2106/00004623-198971050-00009.
22. Lurie B, Koff MF, Shah P, et al. Three-dimensional magnetic resonance imaging of physeal injury: reliability and clinical utility. J Pediatr Orthop. 2014;34(3):239-245. doi:10.1097/BPO.0000000000000104.
23. Sailhan F, Chotel F, Guibal AL, et al. Three-dimensional MR imaging in the assessment of physeal growth arrest. Eur Radiol. 2004;14(9):1600-1608. doi:10.1007/s00330-004-2319-z.
24. Kang HG, Yoon SJ, Kim JR. Resection of a physeal bar under computer-assisted guidance. J Bone Joint Surg Br. 2010;92(10):1452-1455. doi:10.1302/0301-620X.92B10.24587.
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2. Khoshhal KI, Kiefer GN. Physeal bridge resection. J Am Acad Orthop Surg. 2005;13(1):47-58. doi:10.5435/00124635-200501000-00007.
3. Stans AA. Excision of physeal bar. In: Wiesel SW, ed. Operative Techniques in Orthopaedic Surgery. Philadelphia, PA: Lippincott Williams & Wilkins; 2011:1244-1249.
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8. Marsh JS, Polzhofer GK. Arthroscopically assisted central physeal bar resection. J Pediatr Orthop. 2006;26(2):255-259. doi:10.1097/01.bpo.0000218533.43986.e1.
9. Williamson RV, Staheli LT. Partial physeal growth arrest: treatment by bridge resection and fat interposition. J Pediatr Orthop. 1990;10(6):769-776. doi:10.1097/01241398-199011000-00012.
10. Moreta J, Abril JC, Miranda C. Arthroscopy-assisted resection-interposition of post-traumatic central physeal bridges. Rev Esp Cir Orthop Traumatol. 2013;57(5):333-339. doi:10.1016/j.recot.2013.07.004.
11. Hasler CC, Foster BK. Secondary tethers after physeal bar resection: a common source of failure? Clin Orthop Relat Res. 2002;405:242-249.
12. Paley D, Bhave A, Herzenberg JE, Bowen JR. Multiplier method for predicting limb-length discrepancy. J Bone Joint Surg Am. 2000;82(10):1432-1446. doi:10.2106/00004623-200010000-00010.
13. Khoshhal KI, Kiefer GN. Physeal bridge resection. J Am Acad Orthop Surg. 2005;13(1):47-58. doi:10.5435/00124635-200501000-00007.
14. Rathjen KE, Kim HKW. Physeal injuries and growth disturbances. In: Flynn JM, Skaggs DL, Waters PM, eds. Rockwood and Wilkins’ Fractures in Children. 8th edition. Philadelphia, PA: Wolters-Kluwer; 2015:135-137.
15. Peterson CA, Peterson HA. Analysis of the incidence of injuries to the epiphyseal growth plate. J Trauma. 1972;12(4):275-281. doi:10.1097/00005373-197204000-00002.
16. Pritchett JW. Longitudinal growth and growth-plate activity in the lower extremity. Clin Orthop Relat Res. 1992;275:274-279.
17. Cassebaum WH, Patterson AH. Fracture of the distal femoral epiphysis. Clin Orthop Relat Res. 1965;41:79-91. doi:10.1097/00003086-196500410-00009.
18. Dahl WJ, Silva S, Vanderhave KL. Distal femoral physeal fixation: are smooth pins really safe? J Pedatir Orthop. 2014;34(2):134-138. doi:10.1097/BPO.0000000000000083.
19. Roberts J. Fracture separation of the distal femoral epiphyseal growth line. J Bone Joint Surg Am. 1973;55:1324.
20. Broughton NS, Dickens DR, Cole WG, Menelaus MB. Epiphyseolysis for partial growth plate arrest. Results after four years or at maturity. J Bone Joint Surg Br. 1989;71(1):13-16. doi:10.1302/0301-620X.71B1.2914983.
21. Hresko MT, Kasser JR. Physeal arrest about the knee associated with non-physeal fractures in the lower extremity. J Bone Joint Surg Am. 1989;71(5):698-703. doi:10.2106/00004623-198971050-00009.
22. Lurie B, Koff MF, Shah P, et al. Three-dimensional magnetic resonance imaging of physeal injury: reliability and clinical utility. J Pediatr Orthop. 2014;34(3):239-245. doi:10.1097/BPO.0000000000000104.
23. Sailhan F, Chotel F, Guibal AL, et al. Three-dimensional MR imaging in the assessment of physeal growth arrest. Eur Radiol. 2004;14(9):1600-1608. doi:10.1007/s00330-004-2319-z.
24. Kang HG, Yoon SJ, Kim JR. Resection of a physeal bar under computer-assisted guidance. J Bone Joint Surg Br. 2010;92(10):1452-1455. doi:10.1302/0301-620X.92B10.24587.
TAKE-HOME POINTS
- Central physeal arrest of the distal femur is challenging, but this surgical technique provides an option for treatment.
- Partial bone bridges can be resected, but advanced imaging with MRI or CT, or both, is helpful in preoperative planning.
- Regardless of the type of physeal bar resection that is chosen, it is unlikely that complete, normal bone growth will be restored and closed follow up will be needed.
