Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Pediatric Genu Valgum Treatment & Management

  • Author: Peter M Stevens, MD; Chief Editor: Dennis P Grogan, MD  more...
 
Updated: Apr 24, 2014
 

Medical Therapy

For the child with specific and identifiable bone dysplasia, medical treatment may have an important role, influencing the outcome. For example, the child with vitamin D–resistant rickets should be on appropriate medication to optimize bone formation and mineralization. Likewise, children with osteogenesis imperfecta may benefit from treatment with bisphosphonates to increase bone density and decrease the risk of fractures. Recognizing the need for holistic care, even optimal medical management does not correct preexisting genu valgum. However, treatment may slow the progression of the condition and prevent recurrence. Bracing and physical therapy may provide a temporary reprieve of symptoms, but they do not afford long-term symptomatic relief.

Next

Surgical Therapy

Guided growth has emerged as the treatment of choice in the growing child; osteotomy should be reserved as a salvage option (or for mature patients). Despite the age of the child or the etiology of the valgus, even children with "sick physes" may be well served by the application of an extraperiosteal 2-hole plate at the apex (or apices) of the deformity. The ensuing growth should correct the deformity within an average of 12 months. This is documented with quarterly follow-up evaluations, including full-length radiographs with the legs straight.

When the mechanical axis has been restored to neutral, the implants are removed. Growth should be monitored because if the valgus recurs, guided growth may need to be repeated. The goal is to correct the deformity, which alleviates the pain and gait disturbance and protects the knee throughout the growing years. If this requires repeated, yet minor, intervention, the benefits still outweigh the cost and risks of (sometimes) repeated osteotomies. If recurrence is anticipated, an option is to percutaneously remove the metaphyseal screw, monitor subsequent growth, and insert another screw as needed.

Previous
Next

Preoperative Details

The importance of recognizing the difference between physiologic and pathologic valgus and reserving treatment for the latter cannot be overemphasized. Consider the symptoms and document the degree and progression of genu valgum before considering surgical intervention. Apart from encroaching skeletal maturity, time is not of the essence here, unless progressive pain manifests. The patient's height should be recorded, along with the limb lengths and the intermalleolar distance (IMD), measured with the patient standing with his or her knees touching.

Preoperative planning should be undertaken using the full-length radiographs in order to select the optimal solution, predict the outcome, and convey this information to the family. When considering guided growth, it is prudent to address any significant valgus deformity at its primary site(s) to preserve a horizontal knee axis while neutralizing the mechanical axis so that it bisects the knee. For idiopathic genu valgum, the distal femur is the preferred site of plate application, while for various skeletal dysplasias and metabolic problems, both femur and tibia may be appropriate plating sites. Only one plate is needed per level, serving as a tension band (compression of the physis is not the principle here).[9]

Remember to evaluate sagittal alignment of the knee, because concomitant deformities may be addressed simultaneously. For example, a flexion/valgus or oblique-plane deformity of the knee may be resolved by anteromedial femoral plate application; likewise, flexion/varus warrants a single anterolateral plate. For fixed-knee flexion deformities (not the topic of this article), 2 plates are used; one is just lateral to the sulcus and one is medial. This permits unobstructed gliding of the patella. Length discrepancies may be corrected by modular guided growth—adding or removing plates as the child grows, so that equal limb lengths are achieved at maturity, without having to resort to distraction osteogenesis.

Previous
Next

Intraoperative Details

The patient should be supine on a radiolucent operating table. An image intensifier is used to localize the physes of the distal femur, proximal tibia, or both.

For femoral plating, the medial incision is centered over the adductor tubercle. An oblique incision is made in the vastus medialis fascia, mobilizing this muscle and retracting it anteriorly. The periosteum is left undisturbed to avoid premature physeal closure. A needle is inserted into the medial physis. A titanium (or stainless steel) 2-hole (nonlocking) plate is placed over the needle, and the plate is centered on the physis. The extraperiosteal plate is then secured to the bone by first introducing the 1.6-mm. guide pins, epiphyseal first, then metaphyseal. After starter holes are drilled to a depth of 5 mm with the cannulated 3.2-mm drill, the plate is securely attached with 2 of the 4.5-mm. cannulated, self-tapping screws. While the screws do not need to be parallel, they should not violate the physis or the joint. Ideally, the plate should be placed mid sagittally, so as to avoid an iatrogenic recurvatum deformity.

For the proximal tibia, the medial physis is approached through a separate longitudinal incision and the superficial tibial collateral ligament is split, again leaving the periosteum intact. A needle is inserted, followed by the extraperiosteal 8-plate, which is secured according to the technique described above. The titanium 8-plate comes in 2 sizes, namely 12 or 16 mm (measured from center hole to center hole). They are both low profile and of equal thickness, with a center hole for the needle to allow for accurate placement.

The screws are titanium (or stainless steel), cannulated, and self-tapping; they come in 3 lengths, which are 16 mm (for the ankle, wrist, or elbow), 24 mm (often used for the tibia), and 32 mm (for the femur). The plates and screws are painted and color-coded for ease of identification, but the surgeon may mix and match as dictated by the local anatomy. This is intentionally not a locking plate; the principal is to deflect the physis (tension band) rather than overpower it. Thus, it is a paradigm shift and departure from compressive (stapling, Metaizeau) or ablative (physeal drilling) methodologies.

Images of corrected genu valgum in individual patients are provided below:

This 14-year-old boy broke his distal femur 1 year This 14-year-old boy broke his distal femur 1 year previously. He was treated with internal fixation using a condylar plate, and the fracture healed uneventfully. However, he developed medial overgrowth of the femur, which caused progressive and painful genu valgum. Note the lateral displacement of the mechanical axis into zone 2. One alternative is to perform a supracondylar osteotomy with exchange of the plate; this was declined.
Two options for instrumented and reversible hemi-e Two options for instrumented and reversible hemi-epiphysiodesis are multiple staples versus a tension band plate. The latter, being flexible yet secure, avoids the potential risks of hardware breakage or migration. Furthermore, growth is facilitated rather than restricted and the alignment is restored more rapidly.
One year following guided growth of the femur with One year following guided growth of the femur with an 8-plate, his mechanical axis is neutral, his limb lengths are equal, and his symptoms have abated; the plate was then removed. Neither procedure required hospitalization or immobilization. Each time he was able to rapidly resume sports participation.
A 17-year-old male who underwent an arthroscopic r A 17-year-old male who underwent an arthroscopic reconstruction of his left anterior cruciate ligament utilizing braided semitendinosis 1 year prior to this film. With ensuing growth he developed progressive genu valgum with medial and anterior knee pain and difficulty running.
A fluoroscopic close-up view of the left knee demo A fluoroscopic close-up view of the left knee demonstrates, despite his chronologic age of 17, that he has significant growth remaining. (Note arrows pointing to the physis = growth plate). It was felt that the most expedient and safe treatment would be guided growth. Considering his relative skeletal maturity, it was elected to apply tension band plates to the femur and tibia simultaneously, for the sake of time.
The patient's legs are straight 11 months followin The patient's legs are straight 11 months following pan-genu guided growth of the medial femur and tibia. His pain has resolved and he has resumed a fully active lifestyle. His limb lengths are equal and his knee remains stable.
A standing AP radiograph of the legs confirms the A standing AP radiograph of the legs confirms the clinical findings; the plates were therefore removed.
This 6-year-old girl, born with tibial dysplasia, This 6-year-old girl, born with tibial dysplasia, underwent foot ablation at age 2 years, combined with surgical synostosis of the distal fibula to the tibial stump. She developed progressive genu valgum necessitating that the prosthetist move the post medially. However, she then experienced medial knee pain and stump irritation. This full-length weight-bearing radiograph demonstrates lateral displacement of the mechanical axis (red dotted line) to the joint margin.
Treatment options are limited to osteotomy or guid Treatment options are limited to osteotomy or guided growth. An osteotomy would require "down time" - out of her prosthesis and non weight-bearing while the cut bone is healing.
The family chose the option of guided growth, and The family chose the option of guided growth, and plates were applied to the distal medial femur and proximal medial tibia. She resumed full activities in her prosthesis and this full-length radiograph, taken one year later, demonstrates normalization of the mechanical axis. At this point the prosthetist moved her post laterally. Her knee pain and stump irritation have abated.
A close-up view demonstrating the neutral mechanic A close-up view demonstrating the neutral mechanical axis and open growth plates. Note the divergence of the screws. At this point, the plate was removed. Further growth will be monitored, repeating guided growth if needed.
A clinical photograph showing her alignment just p A clinical photograph showing her alignment just prior to hardware removal.
Previous
Next

Postoperative Details

Following the layered closure, the tourniquet is deflated, and a soft compression dressing is applied to the knee. No immobilization is required; immediate weight bearing is encouraged, and progressive activities are permitted as tolerated. This procedure is routinely accomplished on an outpatient basis, and physical therapy is rarely required.

Previous
Next

Follow-up

Guided growth mandates periodic follow-up evaluations (typically at 3-mo intervals) so that the rate of correction can be assessed to determine the optimal timing for plate removal. The parents should be instructed in how to monitor the intermalleolar distance (IMD); overcorrection into varus can be averted if parents are educated and involved. When the knees and ankles touch simultaneously (IMD = 0), a full-length radiograph should be obtained to measure the mechanical axis and limb lengths. The plate(s) (or just the metaphyseal screws) should be removed when the mechanical axis is neutral and further growth should be monitored. Guided growth may be safely repeated for angular and/or length discrepancies, according to the needs of the individual patient.

Previous
Next

Complications

For this meticulous but relatively simple operative procedure, complications are rare. Minimal dissection is involved; therefore, wound-healing problems such as hematoma, infection, or dehiscence are uncommon. If keloid formation is a problem, the scar may be excised at the time of plate removal.

With the switch from staples to the tension band plates, the problems of hardware migration or fatigue have been solved. The screws intentionally diverge with growth; however, this does not require screw exchange. They are relatively thin (2 mm). By design, the plates have a narrow waist, enabling reverse bending if additional angular correction is required. There have been no reports of broken plates. Rare instances of broken metaphyseal screws have been reported. This may result from a technical error. If a gap is left between the plate and the metaphysis, the screw will be subject to 3-point bending stress and may fatigue. Because the bone is not divided, no need exists to wait for bone healing. The means of avoiding this include increasing the convex contour of the plate and, alternately, tightening each screw after removing the guide pins in order to ensure tight fit of the plate against the bone.

This procedure does not place the patient at risk for nonunion, delayed union, compartment syndrome, or neurologic damage, all of which have been reported with osteotomy of the distal femur or proximal tibia/fibula.

The issue of rebound growth remains ill defined. While this was reported with stapling, especially in children younger then 10 years, it seems less common with the plate technique. Perhaps this reflects a different biology; one not applying a rigid construct (multiple staples) to a dynamic physis. The result may reflect a more physiologic response with less propensity for rebound. However, in the event of recurrent deformity, repeat plate (or metaphyseal screw) application is warranted if rebound growth occurs to the point the mechanical axis drifts into lateral zone 2 or 3. This underscores the need for parental education and periodic follow-up evaluations.

Permanent physeal closure does not occur, provided meticulous care is taken to place (and remove) plates without disturbing the periosteum. In 10 years of plating, including more than 1000 children with the full spectrum of diagnoses, this author has yet to observe this complication. Remember that all of these patients would have had 1 or more osteotomies if they had not undergone guided growth.

Previous
Next

Outcome and Prognosis

Provided the aforementioned criteria are met (ie, sufficient growth remaining, careful analysis and preoperative planning, proper plate 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.[10]

Patient and family satisfaction are excellent; this is not surprising in light of the fact that, in comparison with 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 a tension band 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).

Previous
Next

Future and Controversies

Since stapling was introduced in the 1950s, its popularity has 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. Meanwhile, 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 tension band plate to provide a flexible, yet secure tether. 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.

Previous
 
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: Pediatric Orthopaedic Society of North America, Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Orthopaedic Association

Disclosure: Received royalty from Orthofix Inc for independent contractor; Received royalty from Orthopediatrics, Inc for independent contractor; Received honoraria from Orthopediatrics, Inc for speaking and teaching.

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, Arthroscopy Association of North America, Pediatric Orthopaedic Society of North America, American Medical Association, Utah Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

George H Thompson, MD Director of Pediatric Orthopedic Surgery, Rainbow Babies and Children’s Hospital, University Hospitals Case Medical Center, and MetroHealth Medical Center; Professor of Orthopedic Surgery and Pediatrics, Case Western Reserve University School of Medicine

George H Thompson, MD is a member of the following medical societies: American Orthopaedic Association, Scoliosis Research Society, Pediatric Orthopaedic Society of North America, American Academy of Orthopaedic Surgeons

Disclosure: Received none from OrthoPediatrics for consulting; Received salary from Journal of Pediatric Orthopaedics for management position; Received none from SpineForm for consulting; Received none from SICOT for board membership.

Chief Editor

Dennis P Grogan, MD Clinical Professor (Retired), Department of Orthopedic Surgery, University of South Florida College of Medicine; Orthopedic Surgeon, Department of Orthopedic Surgery, Shriners Hospital for Children of Tampa

Dennis P Grogan, MD is a member of the following medical societies: American Medical Association, American Orthopaedic Association, Scoliosis Research Society, Irish American Orthopaedic Society, Pediatric Orthopaedic Society of North America, American Academy of Orthopaedic Surgeons, American Orthopaedic Foot and Ankle Society, Eastern Orthopaedic Association

Disclosure: Nothing to disclose.

Additional Contributors

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 College of Sports Medicine, Pediatric Orthopaedic Society of North America, American Association for the History of Medicine, American Orthopaedic Society for Sports Medicine, Massachusetts Medical Society

Disclosure: Received consulting fee from Smith & Nephew Endoscopy for consulting; Received consulting fee from EBI Biomet for consulting; Received consulting fee from OrthoPediatrics for consulting; Received stock from Pivot Medical for consulting; Received consulting fee from pediped for consulting; Received royalty from WB Saunders for none; Received stock from Fixes-4-Kids for consulting.

References
  1. Wiemann JM 4th, Tryon C, Szalay EA. Physeal stapling versus 8-plate hemiepiphysiodesis for guided correction of angular deformity about the knee. J Pediatr Orthop. 2009 Jul-Aug. 29(5):481-5. [Medline].

  2. Stevens PM, Novais EN. Multilevel guided growth for hip and knee varus secondary to chondrodysplasia. J Pediatr Orthop. 2012 Sep. 32(6):626-30. [Medline].

  3. Jelinek EM, Bittersohl B, Martiny F, Scharfstädt A, Krauspe R, Westhoff B. The 8-plate versus physeal stapling for temporary hemiepiphyseodesis correcting genu valgum and genu varum: a retrospective analysis of thirty five patients. Int Orthop. 2012 Mar. 36(3):599-605. [Medline]. [Full Text].

  4. Khoury JG, Tavares JO, McConnell S, Zeiders G, Sanders JO. Results of screw epiphysiodesis for the treatment of limb length discrepancy and angular deformity. J Pediatr Orthop. 2007 Sep. 27(6):623-8. [Medline].

  5. De Brauwer V, Moens P. Temporary hemiepiphysiodesis for idiopathic genua valga in adolescents: percutaneous transphyseal screws (PETS) versus stapling. J Pediatr Orthop. 2008 Jul-Aug. 28(5):549-54. [Medline].

  6. Stevens PM. Guided growth for angular correction: a preliminary series using a tension band plate. J Pediatr Orthop. 2007 Apr-May. 27(3):253-9. [Medline].

  7. Burghardt RD, Herzenberg JE, Standard SC, Paley D. Temporary hemiepiphyseal arrest using a screw and plate device to treat knee and ankle deformities in children: a preliminary report. J Child Orthop. 2008 Jun. 2(3):187-97. [Medline].

  8. Stevens PM, Arms D. Postaxial hypoplasia of the lower extremity. J Pediatr Orthop. 2000 Mar-Apr. 20(2):166-72. [Medline].

  9. Guzman H, Yaszay B, Scott VP, Bastrom TP, Mubarak SJ. Early experience with medial femoral tension band plating in idiopathic genu valgum. J Child Orthop. 2011 Feb. 5(1):11-7. [Medline]. [Full Text].

  10. Stevens PM, Klatt JB. Guided growth for pathological physes: radiographic improvement during realignment. J Pediatr Orthop. 2008 Sep. 28(6):632-9. [Medline].

  11. Blair VP 3rd, Walker SJ, Sheridan JJ, Schoenecker PL. Epiphysiodesis: a problem of timing. J Pediatr Orthop. 1982 Aug. 2(3):281-4. [Medline].

  12. 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].

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

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

  15. 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. 2001 Nov-Dec. 21(6):817-23. [Medline].

  16. Gabriel KR, Crawford AH, Roy DR, et al. Percutaneous epiphyseodesis. J Pediatr Orthop. 1994 May-Jun. 14(3):358-62. [Medline].

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

  18. Healy WL, Anglen JO, Wasilewski SA, Krackow KA. Distal femoral varus osteotomy. J Bone Joint Surg Am. 1988 Jan. 70(1):102-9. [Medline].

  19. Horton GA, Olney BW. Epiphysiodesis of the lower extremity: results of the percutaneous technique. J Pediatr Orthop. 1996 Mar-Apr. 16(2):180-2. [Medline].

  20. Koshino T. Osteotomy around young deformed knees: 38-year super-long-term follow-up to detect osteoarthritis. Int Orthop. 2009 Sep 24. [Medline].

  21. Kramer A, Stevens PM. Anterior femoral stapling. J Pediatr Orthop. 2001 Nov-Dec. 21(6):804-7. [Medline].

  22. Liotta FJ, Ambrose TA 2nd, Eilert RE. Fluoroscopic technique versus Phemister technique for epiphysiodesis. J Pediatr Orthop. 1992 Mar-Apr. 12(2):248-51. [Medline].

  23. Little DG, Nigo L, Aiona MD. Deficiencies of current methods for the timing of epiphysiodesis. J Pediatr Orthop. 1996 Mar-Apr. 16(2):173-9. [Medline].

  24. Métaizeau JP, Wong-Chung J, Bertrand H, Pasquier P. Percutaneous epiphysiodesis using transphyseal screws (PETS). J Pediatr Orthop. 1998 May-Jun. 18(3):363-9. [Medline].

  25. Mast, N, Brown N, Stevens, P. Validation of a Genu Valgum Model in a Rabbit Hind Limb. Journal of Pediatric Orthopaedics. April/May 2008. 28:375-380.

  26. Mielke CH, Stevens PM. Hemiepiphyseal stapling for knee deformities in children younger than 10 years: a preliminary report. J Pediatr Orthop. 1996 Jul-Aug. 16(4):423-9. [Medline].

  27. Phemister D. Operative arrestment of longitudinal growth of bones in the treatment of bones in the treatment of deformities. J Bone Joint Surg Am. 1933. 15:1-15.

  28. Salenius P, Vankka E. The development of the tibiofemoral angle in children. J Bone Joint Surg Am. 1975 Mar. 57(2):259-61. [Medline].

  29. Stevens PM. Guided Growth: 1933 to the Present. Strategies in Trauma and Limb Reconstruction. 12/2006. 1(1):29-35.

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

  31. Stevens PM, Maguire M, Dales MD, Robins AJ. Physeal stapling for idiopathic genu valgum. J Pediatr Orthop. 1999 Sep-Oct. 19(5):645-9. [Medline].

  32. Stevens, P, Klatt, J. Guided Growth for Fixed Knee Flexion Deformity. Journal of Pediatric Orthopaedics. Sept. 2008. 28:632-639.

 
Previous
Next
 
This diagram depicts genu valgum involving the right leg (lighter shade), where the mechanical axis falls outside the knee. The goal of treatment is to realign the limb and neutralize the mechanical axis (dotted red line), thereby mitigating the effects of gravity through guided growth of the femur and/or tibia (whatever is required to maintain a horizontal knee joint axis). The darker shade depicts normal alignment with the mechanical axis now bisecting the knee.
This 9-year-old patient has symmetrical and progressive genu valgum caused by a hereditary form of metaphyseal dysplasia. One method of treatment is to undertake bilateral femoral and tibial/fibular osteotomies, securing these with internal plates or external frames. However, the hospitalization and the attendant cost and risks, including peroneal nerve palsy and compartment syndrome, make this a daunting task for the surgeon and family alike. Furthermore, mobilization and weightbearing may require physical therapy but must be delayed pending initial healing of the bones.
Heretofore, stapling was a viable option. This outpatient procedure permitted simultaneous and multiple deformity correction, without casts or delayed weightbearing. However, the concept of compressing and overpowering the physes has the drawbacks of slower correction because the fulcrum is within the physis. Provided the rigid staples did not dislodge or fatigue, satisfactory correction could be realized. If the hardware failed prematurely, the correction was either abandoned or the hardware exchanged. Compared with osteotomies, it was a risk worth taking, that is, until the advent of a better option.
The application of a single 8-plate per physis permits the same correction as stapling, without the potential drawbacks of implant migration or fatigue failure. Based on the principle of facilitating rather than compressing the physes, the correction occurs more rapidly and rebound growth, though possible, may be less frequent. When the mechanical axis has been restored to neutral, the plates (or metaphyseal screws) are removed (and replaced as necessary if recurrent deformity ensues).
This 14-year-old boy, weighing 132 kg, presented with activity-related anterior knee pain, circumduction gait, and difficulty with running and sports. His symptoms had been progressive over a period of 18 months despite nonoperative measures including physical therapy, activity restrictions, and nonsteroidal anti-inflammatory drug therapy.
Nine months following the insertion of 8-plates in the distal femora (1 per knee), the mechanical axis is approaching neutral and his symptoms abated. The plates were removed 2 months later, allowing for full correction of his valgus deformities. He has not had recurrence.
This 14-year-old boy broke his distal femur 1 year previously. He was treated with internal fixation using a condylar plate, and the fracture healed uneventfully. However, he developed medial overgrowth of the femur, which caused progressive and painful genu valgum. Note the lateral displacement of the mechanical axis into zone 2. One alternative is to perform a supracondylar osteotomy with exchange of the plate; this was declined.
Two options for instrumented and reversible hemi-epiphysiodesis are multiple staples versus a tension band plate. The latter, being flexible yet secure, avoids the potential risks of hardware breakage or migration. Furthermore, growth is facilitated rather than restricted and the alignment is restored more rapidly.
One year following guided growth of the femur with an 8-plate, his mechanical axis is neutral, his limb lengths are equal, and his symptoms have abated; the plate was then removed. Neither procedure required hospitalization or immobilization. Each time he was able to rapidly resume sports participation.
A 17-year-old male who underwent an arthroscopic reconstruction of his left anterior cruciate ligament utilizing braided semitendinosis 1 year prior to this film. With ensuing growth he developed progressive genu valgum with medial and anterior knee pain and difficulty running.
A fluoroscopic close-up view of the left knee demonstrates, despite his chronologic age of 17, that he has significant growth remaining. (Note arrows pointing to the physis = growth plate). It was felt that the most expedient and safe treatment would be guided growth. Considering his relative skeletal maturity, it was elected to apply tension band plates to the femur and tibia simultaneously, for the sake of time.
The patient's legs are straight 11 months following pan-genu guided growth of the medial femur and tibia. His pain has resolved and he has resumed a fully active lifestyle. His limb lengths are equal and his knee remains stable.
A standing AP radiograph of the legs confirms the clinical findings; the plates were therefore removed.
This 6-year-old girl, born with tibial dysplasia, underwent foot ablation at age 2 years, combined with surgical synostosis of the distal fibula to the tibial stump. She developed progressive genu valgum necessitating that the prosthetist move the post medially. However, she then experienced medial knee pain and stump irritation. This full-length weight-bearing radiograph demonstrates lateral displacement of the mechanical axis (red dotted line) to the joint margin.
Treatment options are limited to osteotomy or guided growth. An osteotomy would require "down time" - out of her prosthesis and non weight-bearing while the cut bone is healing.
The family chose the option of guided growth, and plates were applied to the distal medial femur and proximal medial tibia. She resumed full activities in her prosthesis and this full-length radiograph, taken one year later, demonstrates normalization of the mechanical axis. At this point the prosthetist moved her post laterally. Her knee pain and stump irritation have abated.
A close-up view demonstrating the neutral mechanical axis and open growth plates. Note the divergence of the screws. At this point, the plate was removed. Further growth will be monitored, repeating guided growth if needed.
A clinical photograph showing her alignment just prior to hardware removal.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.