eMedicine Specialties > Orthopedic Surgery > Pediatrics

Genu Valgum, Pediatrics: Follow-up

Author: Peter M Stevens, MD, Professor, Director of Pediatric Orthopedic Fellowship Program, Department of Orthopedics, University of Utah School of Medicine
Coauthor(s): Michael C Holmstrom, MD, Consulting Surgeon, Department of Orthopedics, The Orthopedic Specialty Hospital (TOSH)
Contributor Information and Disclosures

Updated: Jul 19, 2007

Outcome and Prognosis

Provided the aforementioned criteria are met (ie, sufficient growth remaining, careful analysis and preoperative planning, proper staple selection and insertion, periodic follow-up), the results of guided growth are uniformly gratifying. The parents and the surgeon must be patient, however, because growth is a slow process. The immediate satisfaction (carpentry) of osteotomies is supplanted by delayed gratification (gardening). The success of this technique is predicated on skillful harnessing of the inherent power of the growth plate. Even a sick physis can respond, given enough time; this is why the procedure works even in patients with skeletal dysplasias and vitamin D–resistant rickets.

Patient and family satisfaction are excellent; this is not surprising in light of the fact that, in comparison to osteotomy, guided growth is minimally invasive, relatively painless, cost effective, and less risky. Minimal down time is associated with the procedure, and educational and recreational activities are only temporarily interrupted. Consequently, previous arbitrary guidelines pertaining to minimum age and diagnoses have been abandoned. In this author's opinion, guided growth with the 8-plate has become the treatment of choice for most angular deformities of the knee. Osteotomy can still be performed if guided growth is unsuccessful (or vice versa).

Future and Controversies

Since stapling was introduced in the 1950s, its popularity has waxed and waned. Some of the failures and criticisms were a direct result of poor technique (wrong staples, periosteal elevation). By the 1970s, this technique had been abandoned by many; even recent review articles and book chapters pertaining to correction of angular deformities or limb length inequality dismiss stapling as a risky, unpredictable, or outmoded technique. The problem is that osteotomies, whether secured by cast or internal or external fixation, are not without occasional serious consequences.

Percutaneous epiphysiodesis, recently popularized, offers the theoretical advantages of a smaller scar and no hardware to retrieve. However, it is not reversible; therefore, the timing must be perfect to avoid overcorrection. This technique, therefore, is limited to use in adolescent patients, in whom the surgeon strives to achieve a neutral mechanical axis at maturity. Determination of bone age is known to be inexact, with an error of ± 1 year. This variation represents a significant source of error in determining the optimal age for permanent epiphysiodesis.

Despite many successes with staples, and in response to its drawbacks of hardware rigidity, migration, and breakage, the author has devised a preferable method for guided growth. This involves the use of a nonlocking 2-hole titanium 8-plate (Orthofix; McKinney, Tex). Applying a single plate per physis, the directional control afforded allows the correction of frontal-, sagittal-, or oblique-plane deformities. This is performed in an outpatient setting, allowing safe and gradual correction of complex, multilevel, and bilateral deformities by harnessing the power of the growth plate. The same device may be used on both large (170 kg) and small (13 kg) patients with diverse pathology. Osteotomy may be reserved for mature patients or those who require additional length or rotational correction.

 


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References
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References

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  2. Blount WP, Clarke GR. The classic. Control of bone growth by epiphyseal stapling. A preliminary report. Journal of Bone and Joint Surgery, July, 1949. Clin Orthop. 1971;77:4-17. [Medline].

  3. Boakes JL, Stevens PM, Moseley RF. Treatment of genu valgus deformity in congenital absence of the fibula. J Pediatr Orthop. Nov-Dec 1991;11(6):721-4. [Medline].

  4. Bowen JR, Johnson WJ. Percutaneous epiphysiodesis. Clin Orthop. Nov 1984;(190):170-3. [Medline].

  5. Bylski-Austrow DI, Wall EJ, Rupert MP, et al. Growth plate forces in the adolescent human knee: a radiographic and mechanicalstudy of epiphyseal staples. J Pediatr Orthop. Nov-Dec 2001;21(6):817-23. [Medline].

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  7. Goff CW. Histologic arrangements from biopsies of epiphyseal plates of children before and after stapling. Correlated with roentgenographic studies. Am J Orthop. May 1967;9(5):87-9. [Medline].

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  19. Stevens PM, MacWilliams B, Mohr RA. Gait analysis of stapling for genu valgum. J Pediatr Orthop. Jan-Feb 2004;24(1):70-4. [Medline].

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Further Reading

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Keywords

physiologic genu valgum, pathologic genu valgum, adolescent idiopathic genu valgum, knock-knee deformity, osteotomy, hemiphyseal stapling, vitamin D resistant rickets, vitamin D-resistant rickets, guided growth, 8-plate

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Contributor Information and Disclosures

Author

Peter M Stevens, MD, Professor, Director of Pediatric Orthopedic Fellowship Program, Department of Orthopedics, University of Utah School of Medicine
Peter M Stevens, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, Limb Lengthening and Reconstruction Society ASAMI-North America, Pediatric Orthopaedic Society of North America, Utah Medical Association, and Western Orthopaedic Association
Disclosure: Nothing to disclose.

Coauthor(s)

Michael C Holmstrom, MD, Consulting Surgeon, Department of Orthopedics, The Orthopedic Specialty Hospital (TOSH)
Michael C Holmstrom, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, Arthroscopy Association of North America, Pediatric Orthopaedic Society of North America, and Utah Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Mininder S Kocher, MD, MPH, Associate Professor of Orthopedic Surgery, Harvard Medical School/Harvard School of Public Health; Associate Director, Division of Sports Medicine, Department of Orthopedic Surgery, Children's Hospital Boston
Mininder S Kocher, MD, MPH is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for the History of Medicine, American Medical Association, American Orthopaedic Society for Sports Medicine, and Massachusetts Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

George H Thompson, MD, Professor of Orthopedic Surgery and Pediatrics, Department of Pediatric Orthopedic Surgery, Case Western Reserve University; Director, Rainbow Babies and Children's Hospital
George H Thompson, MD is a member of the following medical societies: American Academy for Cerebral Palsy and Developmental Medicine, American Academy of Orthopaedic Surgeons, American Academy of Pediatrics, and Ohio State Medical Association
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Dennis P Grogan, MD, Clinical Professor, Department of Orthopedic Surgery, University of South Florida College of Medicine; Chief of Staff, Department of Orthopedic Surgery, Shriners Hospital for Children of Tampa
Dennis P Grogan, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Eastern Orthopaedic Association, Irish American Orthopaedic Society, Scoliosis Research Society, and Southern Orthopaedic Association
Disclosure: Nothing to disclose.

 
 
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