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CASE REPORT

© 2016 Human Kinetics - IJATT 21(2), pp. 17-24 http://dx.doi.org/10.1123/ijatt.2015-0005 High Tibial to Correct Complications of a Proximal Tibial Salter-Harris I Fracture in an Adolescent Athlete

Matthew T. Sims, BS, ATC, LAT • Oklahoma State University Center for Health Sciences; Aric J. Warren, EdD, ATC, LAT • Oklahoma State University and Oklahoma State University Center for Health Sciences

High tibial osteotomy (HTO) is a surgical peroneal nerve, detachment of lateral procedure mainly performed in middle-aged muscles, possible limb shortening, possible patients to alleviate pain, medial collateral ligament (MCL) instability, permit unrestricted and a fibular osteotomy while permitting Key Points activity, correct varus little intraoperative adjustment after wedge High tibial osteotomy (HTO) is commonly deformity, and resection.1,2,4,5 performed in middle age, not in athletic delay the need for a total The primary pathology for HTO surgical adolescent patients. knee replacement.1–3 intervention is to treat in the HTO is becoming a due to . An HTO is HTO is commonly used in the treatment of common surgical proce- performed to redistribute the weight-bearing osteoarthritis but was performed to correct dure for the treatment of load from a diseased compartment of the a rare anterior tibial slope from growth medial compartmental knee toward a compartment of healthier asymmetry. osteoarthritis.1,3–7 There articular .2,8 HTO uses either an are many documented autogenous iliac graft, allograft, sub- Using HTO in an adolescent athlete to cases on the use of stitute, or without bone graft or bone substi- correct adverse effects from a Salter-Harris medial opening-wedge tute.9 The autogenous iliac graft is considered I fracture led to successful outcomes and a HTO to correct a varus the gold standard for treatment in filling the full return to competition. deformity with medial osteotomy defect10,11 as it avoids potential Knowledge and early recognition of epiph- compartmental osteo- exposure to communicable diseases and 1,4,5 yseal injuries in adolescent athletes is of of the knees. provides better osteoproductive material 10 great importance due to possible growth An alternative proce- to facilitate healing. Allograft procedures disturbances. dure known as a lateral present other benefits such as sparing the closed-wedge osteot- patient a second surgical site, shorter surgical Careful follow-up should take place to omy is also performed, procedure time, and additional blood loss;10 prevent development of deformity forma- though not as common however, allograft procedures were found to tion and assist in appropriate management due to the potential have a sixfold higher failure rate compared of physeal injury in the proximal . complications it pres- with autograft sites in open-wedge tibial ents with the common .10 Overall estimates of success

INTERNATIONAL JOURNAL OF ATHLETIC THERAPY & TRAINING MARCH 2016 ❚ 17 following HTO have been between 85–95% at fi e after fi e weeks using a functional knee brace. Upon full years, and 75–80% success 10 years posttreatment.12,13 return to competition, home rehabilitation exercises In this case study, we present the rarity of an were discontinued. The patient returned to team con- anterior opening-wedge HTO allograft procedure in a ditioning with minor temporary modifications applied 17-year-old athlete who underwent this procedure to in knee extension and fl xion exercises. correct a recurvatum postural deformity resulting from Seven months after injuring the PCL, and after the adverse healing effects of a previous bilateral prox- return to participation, the patient stated that his left imal tibial and fibular to correct and instability had not subsided and that a Salter-Harris I fracture. This postural deformity pre- he had noticed an increase in popping sensations, disposed the knee to a hyperextension mechanism. pseudolocking, and pain with functional activities such Although HTO is an increasingly common procedure as walking and ascending and descending stairs, and in the middle-aged population in correcting osteoar- sport-related movements. On a 10-point pain scale, thritis in the knee’s medial tibial compartment,3,5,14 the intensity of pain was reported as a 5 at rest, but it after a review of the literature, to our knowledge there quickly increased with activity. The patient reported a is no documentation of an anterior opening-wedge sharp and aching pain that was greatest at night and osteotomy or HTO being used to correct an anterior during activity. There was stiffness in the morning, tibial slope resulting from surgical treatment for a Salt- difficulty falling asleep, and difficulty staying asleep er-Harris I fracture in an adolescent athlete. In addition, throughout the night. These symptoms were present since the autogenous iliac graft is considered the gold from return to play and progressively increased in standard for HTO procedures, the allograft procedure severity over the seven-month period, prompting the as used in this patient is used less frequently, adding patient to seek a follow-up and secondary orthopedic to the uniqueness of this case. evaluation. At seven months post PCL injury, a second ortho- Case History pedist opinion was conducted revealing a > 15° asymmetric recurvatum with guarding as well as This unique case began with an 11-year-old male ath- guarding during the stance phase of gait to prevent lete who experienced a hyperextension mechanism hyperextension. The patient presented with slight effu- during baseball competition resulting in a Salter-Harris sion, warmth, and winking . There was slightly I fracture of the left proximal tibia. The epiphyseal decreased quadriceps bulk in the left leg with a visual, growth plate fracture was treated with bilateral prox- bilateral comparison. However, knee movements in all imal tibial and fibular epiphysiodesis. At age 16, fi e planes had full strength. years after the epiphyseal fracture, the same athlete The orthopedist ordered coronal T1 and sagittal (height, 165.1 cm; weight, 74.8 kg) complained of left T2 weighted MRI without intravenous contrast and anteromedial knee pain and instability after a hyper- radiographs. The MRI was ordered to determine the extension episode during a football game. Following ligamentous structure and cartilaginous integrity of the athletic trainer referral, the patient reported to the team knee . It showed some evidence of prior interstitial physician and was diagnosed with a grade II sprain of injury to the PCL, but it was in continuity and healed; the left posterior cruciate ligament (PCL) with moder- there was no menisci, ligamentous, or cartilaginous ate MCL damage as confirmed by magnetic resonance damage. Telos (Marburg, Germany) stress radiographs imaging (MRI). Radiographs were also taken to rule showed an 8-mm difference in posterior translation of out fracture and potential reinjury to the epiphyseal the left knee at 90° knee fl xion compared with the fracture site. The patient was treated nonoperatively normal right knee. The tibial slope calculated from the for the PCL and MCL injury with a full knee immobi- radiographs revealed an 18° difference as compared lizer and progressive weight bearing for two weeks. with the noninjured limb (Figure 1). The difference in Corticosteroid medication and simple home therapy tibial slope of the injured left knee contributed to the range of motion (ROM) exercises were also prescribed patient’s recurvatum posture, pain, and dysfunction, during this period. ROM exercises consisted of active and was attributed to adverse healing from the pre- movements of knee fl xion and extension with the vious surgical procedure to correct the proximal tibia addition of minimal resistance band movements as Salter-Harris I fracture occurring fi e years prior. The tolerated. The patient was released to full competition malformed healing of the surgically-treated left tibial

18 ❚ MARCH 2016 INTERNATIONAL JOURNAL OF ATHLETIC THERAPY & TRAINING