PMC9411980_01
Anteroposterior X-ray view of a 7.5 years old boy shows the ankle joint in varus at 20 months after the Salter type VI physeal injury (A). Post-operative X-ray shows a wedge-shaped iliac apophyseal bone autograft (B). Five months post-operative X-ray shows the united iliac crest apophyseal autograft (C). A physeal bar on the distal medial tibia was observed 20 months after reconstructive surgery (D). On 36 months follow up after reconstructive surgery, the reconstructed medial malleolus (E) compared with the contralateral side (F).
fped-10-950211-g0001.jpg
PMC9411980_01_fped-10-950211-g0001.jpg
F1
Radiographic examination revealed the medial malleolus defect with cavovarus deformity of the right ankle (Figure 1A). The graft was then held by 4 mm cannulated screws (Asnis III stainless steel screws, Stryker, France) and 1.5 mm Kirschner wires (K-wires) (Figure 1B). The external fixator was removed after 3 months when the radiological evidence of graft union was present (Figure 1C), and the remaining implants were removed after 12 months following the second surgery. After 20 months following the reconstruction, a physeal bar on the distal medial tibia appeared on the radiograph (Figure 1D), which was excised using the Langenskiold procedure. Despite such an effort, the reconstructed medial malleolus did not develop as expected compared to the contralateral side (Figures 1E,F).
An illustration of the surgical plan using an iliac crest apophyseal autograft. The graft is held together by screws and k-wires, and the ankle is held by the external fixator.
fped-10-950211-g0002.jpg
PMC9411980_01_fped-10-950211-g0002.jpg
F2
In the second stage, the boy was treated with the reconstruction of the medial malleolus using an autogenous iliac crest apophyseal graft (Figure 2) by pediatric orthopedic surgeons.
Debridement and location of the distal tibial physis with a K-wire (a). Harvested iliac crest apophyseal autograft, ready to insert in an appropriate place (b). The cartilage of the iliac crest autograft was positioned to meet the medial aspect of the talus (c). (d-f) Are the fluoroscopic images taken during the surgery.
fped-10-950211-g0003.jpg
PMC9411980_01_fped-10-950211-g0003.jpg
F3
In this procedure, the graft was placed on the medial malleolus in such a way that the physeal line of the iliac crest graft was parallel to the physeal line of the distal tibia (Figure 3).
At 36 months follow-up after reconstructive surgery, the apparent deformity was not evident (a,b), the functional and cosmetic outcomes of the operated ankle (c,d).
fped-10-950211-g0004.jpg
PMC9411980_01_fped-10-950211-g0004.jpg
F4
Despite the residual deformity, functional and cosmetic evaluation score was satisfactory, and further supra malleolar osteotomy was not required (Figure 4).