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Pediatric Ankle Valgus Treatment & Management

  • Author: Peter M Stevens, MD; Chief Editor: Dennis P Grogan, MD  more...
 
Updated: Sep 21, 2015
 

Approach Considerations

The indications for treatment of ankle valgus are as follows:

  • Presence of related discomfort
  • Excessive shoe wear
  • Documented progression

There are no contraindications to the surgical correction of ankle valgus. If the physis is closed, an osteotomy is required; if it is open, guided growth is preferred in most circumstances. Medical therapy has no impact on the natural history of ankle valgus.

Although one may temporize and treat mild deformities with lateral heel wedges or orthoses of varying designs, the underlying growth disturbance will persist and is likely to progress. As the child grows and gains body mass, these measures will eventually prove inadequate.

One surgical option is to perform a supramalleolar osteotomy. Because the deformities are often bilateral, the patient will have to be immobilized and nonweightbearing for 6 weeks. For deformities less than 20º, a closing wedge osteotomy that leaves the fibula intact is relatively simple and well tolerated. When the deformity is more than 20º, it is necessary to cut the fibula and translocate the distal tibia-fibula to restore the mechanical axis; this requires more fixation and carries higher risks.

Unfortunately, depending on the age of the patient and the etiology of the deformity, recurrent ankle valgus is common with further growth, and the procedure(s) may have to be repeated.

As an alternative, guided growth, aimed at redirecting the distal tibial physis, is a good option for patients of virtually any age, regardless of the etiology. A transmalleolar screw or an eight-Plate (Orthofix, Verona, Italy) is necessary. The screw is economical and simple to insert; however, there may be major challenges when it comes time to remove the implant. The eight-Plate offers some advantages: It is simple to apply; the flexible tension band offers a fulcrum that is medial to the physis; the correction is more rapid; and the eight-Plate is simpler to remove.[17]

The era of rigid physeal constraint (transphyseal screws) may be drawing to a close. The advantages of a flexible tension band are evident in more rapid correction with fewer hardware-related problems. However, plate retrieval is still necessary. Perhaps, in the future, biodegradable implants will become available. The challenges of control and “planned obsolescence” of such implants remain to be elucidated. Guided growth via chemical or electrical manipulation may someday become a reality.

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Surgical Therapy

Surgical options

Surgical treatment of ankle valgus has an interesting history. Initially, there was some enthusiasm for fibular-Achilles tenodesis to stimulate fibular growth[18] ; this was mainly applied in patients with evolving ankle valgus resulting from poliomyelitis or spina bifida. However, such tethering procedures afford slow and sometimes erratic correction. By comparison, bony procedures are more predictable and effective:

Distal tibiofibular synostosis

Commonly performed (temporarily) with a transdesmosis screw, distal tibiofibular synostosis is a prophylactic strategy designed to prevent the complication of iatrogenic ankle valgus during lengthening of the tibia and fibula or during fibular harvest for vascularized bone graft procedures. In some conditions, surgeons have actually bone-grafted the syndesmosis, hoping to preserve permanent parity between the distal tibia and fibula. A bony synostosis will not correct ankle valgus, however.[19]

Fibular lengthening

The technology exists to accomplish isolated fibular lengthening, either rapidly with an intercalary graft or gradually with distraction osteogenesis. This technique has associated complications and drawbacks, however. Given the small diameter and the dense cortical nature of the distal fibula, healing may be slow. The focus upon acquired (posttraumatic) fibular shortening in adults need not be extrapolated to children. Basically, if one can provide the latter with a horizontal plafond, correcting ankle valgus, the relative fibular length seems to be unimportant. (See the image below.)

The fibula may not respond in a synchronous manner The fibula may not respond in a synchronous manner. However, as lateral impingement is alleviated, symptoms abate and there are no functional consequences. In children, it is not necessary to lengthen the fibula or fuse it to the distal tibia.

Osteotomy

Supramalleolar varus-producing osteotomy is indicated if there is physeal closure or if skeletal maturity has been reached. If the deformity is less than 15º, a simple closing wedge osteotomy, leaving the fibula intact, works well. For larger deformities, including those with rotational deformity, osteotomies of the tibia and fibula may be preferred, with lateral translocation of the distal fragments to preserve the mechanical axis and avoid undue prominence of the medial malleolus. Fixation is either internal, supplemented with a cast, or external, provided by a frame.

Weightbearing is delayed until healing is well under way. Because the procedure is often bilateral, the patient may need to use a wheelchair initially. The many techniques of osteotomy and fixation options are well detailed in standard texts.[20]

Guided growth (hemiepiphysiodesis)

Guided growth remains the simplest option. To achieve meaningful correction, there should be at least 1 year of skeletal growth remaining. When in doubt, a hand film for bone age may be helpful. With temporary restraint of the medial tibial physis, the lateral aspect of the physis is free to continue growing, rendering the plafond horizontal.[21]

Sick physes are not a contraindication to medial m Sick physes are not a contraindication to medial malleolar epiphysiodesis, even with screws. Note the remodeling of the distal tibial epiphysis as the ground reaction force is restored to neutral and the plafond rendered horizontal.
Ankle valgus is relatively common in children with Ankle valgus is relatively common in children with previously operated clubfeet. While these feet may be presumed to be overcorrected, ankle films may reveal ankle valgus and lateral impingement. If the feet are flexible, it may be preferable to deliberately overcorrect into 5º of ankle varus before removing the plates. Continue to observe the child annually until maturity, and repeat as needed.

Depending on the etiology, it may be advantageous to allow slight overcorrection amounting to as much as 5º of varus, anticipating the potential for rebound growth. This will delay the need to repeat the procedure after implant removal. The fibula will grow at its own predetermined rate. Thus, even with a horizontal plafond, the fibular station may be elevated. However, this does not seem to adversely affect the clinical outcome. It is not necessary to lengthen the fibula or to fuse it to the distal tibia.

One approach involves insering a single 4.5-mm cannulated screw vertically into the medial malleolus to tether the physis.[22] This is placed percutaneously and is well tolerated. However, the potential disadvantages may include violation of the physis, relatively slow correction because the fulcrum is within the physis, and problems retrieving the screw after the requisite 18-24 months (or longer). (See the images below.)

Transmalleolar screws, though easy to insert, may Transmalleolar screws, though easy to insert, may be difficult to remove. Shown here are two complications: screw breakage and intra-articular migration of the screw head, reflecting the drawbacks of imposing a rigid restraint on a dynamic and growing physis.
This patient (see also image below) failed to retu This patient (see also image below) failed to return for follow-up for 24 months following medial malleolar epiphysiodeses. There is obvious iatrogenic varus with tenting of the physes and risk of premature closure.
These screws were removed (with difficulty) on an These screws were removed (with difficulty) on an urgent basis (see also image above).
This patient had asynchronous medial malleolar epi This patient had asynchronous medial malleolar epiphysiodeses. The screw on the left could not be retrieved. His opening wedge osteotomy to correct iatrogenic varus collapsed into a nonunion, necessitating salvage with a Taylor spatial frame. This unfortunate sequence would not have happened with an eight-Plate.

A second approach involves the use of an eight-Plate. This two-hole plate is applied in an extraperiosteal position and secured with two cannulated screws. Because it is flexible (nonlocking), does not violate the physis, and provides a medial fulcrum at the center of rotational axis (CORA), the angular correction is more rapid. In addition, hardware retrieval is simple. This technique may be repeated as necessary during growth. There may be asynchronous growth of the short fibula; however, if the plafond is horizontal, this causes no functional problems. It is not necessary to lengthen the fibula or fuse it to the tibia. (See the images below.)

A drawback of the intraphyseal fulcrum is the rigi A drawback of the intraphyseal fulcrum is the rigid constraint of the physis. Correction is relatively slow and inefficient when compared to the flexible, extraphyseal eight-Plate.
The nonlocking eight-Plate is placed superficial t The nonlocking eight-Plate is placed superficial to the intact periosteum. As lateral growth occurs, the screws diverge, permitting safe and gradual correction of the valgus deformity. The ground reaction force moves medially, toward the center of the ankle. The distal tibial physis can expand and grow laterally; the articular cartilage is spared from harmful shear forces.
The fibula may not respond in a synchronous manner The fibula may not respond in a synchronous manner. However, as lateral impingement is alleviated, symptoms abate and there are no functional consequences. In children, it is not necessary to lengthen the fibula or fuse it to the distal tibia.

In a retrospective study comparing temporary medial malleolar transphyseal screw (MMS) hemiepiphysiodesis with tension-band plate (TBP) hemiepiphysiodesis for treatment of ankle valgus in skeletally immature patients, Driscoll et al found that both techniques can be successful, that the former technique may correct the deformity more quickly, and that the latter technique may be associated with a lower rate of hardware-related complications.[23]

Procedural details

The preoperative clinical examination should include evaluation of the stance-and-gait pattern, with care taken to identify any associated deformities of the extremity (eg, genu valgum, crouch gait, and limb-length discrepancy). Other deformities may have to be addressed at the time of the ankle surgery.

The feet must be carefully assessed for flexibility, deformities, contracture, or muscle imbalance. Corrective foot surgery may be combined with guided growth of ankle valgus. Weightbearing radiographs of the ankles and feet are a prerequisite for intervention.[16]

The following guidelines pertaining to guided growth may prove sufficient for the vast majority of cases of pediatric ankle valgus correction, regardless of the etiology (see the images below)[20] :

  • Perform supine (tourniquet control) fluoroscopic imaging
  • Localize the distal medial tibial physis, and mark a 2-cm incision
  • Infiltrate (optional) with 0.25% bupivacaine with epinephrine
  • Incise skin/subcutaneous tissues, but be sure to preserve the periosteum
  • Insert a Keith or similar needle into the physis (midsagittal)
  • Insert a 12-mm eight-Plate over the needle
  • Place the distal (epiphyseal) guide pin first; avoid the joint or physis
  • Place the metaphyseal guide pin
  • Insert a cannulated 4.5-mm screw over each guide pin (length, 16 or 24 mm)
  • It is permitted to mix hardware lengths and colors (all are titanium)
  • Remove the guide pins, and countersink the screws into the plate
Through a 2.5-cm incision, one can place a Keith n Through a 2.5-cm incision, one can place a Keith needle into the distal tibial physis, preserving the periosteum. Center the eight-Plate on the physis, and secure it with the 4.5-mm cannulated screws (either 16 or 24 mm). Place the epiphyseal screw first, with care to avoid the ankle joint or physis.
Fluoroscopic sequence showing the steps. The 24-mm Fluoroscopic sequence showing the steps. The 24-mm screws are preferable if there is enough space to insert them.

By design, these titanium plates are nonlocking. Their strength is predicated on their serving as a flexible tension band that can bend as the screws reach their maximum divergence (~30º; most ankle valgus deformities are <25º). The length of the screw is not critical, as long as it does not violate the far cortex.

Depending on the circumstances, this is typically an outpatient procedure. A soft dressing will suffice. Immediate range of motion and weightbearing are encouraged.

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Complications

Osteotomy

The potential complications of supramalleolar osteotomy include overcorrection, undercorrection, loss of fixation, would-healing problems, and recurrent deformity.

Guided growth

Occasional problems with hardware retrieval have been eliminated by the use of the eight-Plate. Because of the flexible construct that does not violate the physis, the observed correction is more rapid and hardware removal is simplified.

Biologic

Generally, premature physeal closure will not occur if the periosteum is preserved.

Rebound growth is a poorly understood biologic phenomenon and is not necessarily a reflection of the hardware. As long as the parents are informed beforehand, this complication is readily managed by repeat guided growth if necessary. This is certainly more acceptable than a repeat osteotomy would be.

Overcorrection is a matter of judgment; the author often allows slight overcorrection (up to 5º), which may compensate for flexible or rigid hindfoot valgus. If a patient is lost to follow-up and has more overcorrection, one may remove the eight-Plate and maintain closer observation. To date, the author has not had to reverse the guided growth or perform an osteotomy.

Skin breakdown may occur. In very slender children who are wearing ankle-foot orthoses, it is important to shape and pad the orthoses so as to minimize friction on the medial malleolus. As the valgus improves, the hardware prominence lessens proportionally.

If a wound infection develops, the implant should be removed (temporarily).

Mechanical

Plate breakage has not been observed.

Screw migration may occur. The solution is to redirect the screw percutaneously under fluoroscopic guidance. If a 16-mm screw does not provide sufficient purchase, a 24-mm screw may be used instead.

Screw breakage has not been observed.

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Long-Term Monitoring

In view of the slow growth at the distal tibia, follow-up every 6 months is sufficient. Allow for up to 5º of varus overcorrection, depending upon hindfoot alignment. Remove the plate(s) when the desired correction is obtained. Continue to monitor, and repeat guided growth as needed.

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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: 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.

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.

Paul E Di Cesare, MD 

Paul E Di Cesare, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons

Disclosure: Nothing to disclose.

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.

References
  1. Lewin SO, Opitz JM. Fibular a/hypoplasia: review and documentation of the fibular developmental field. Am J Med Genet Suppl. 1986. 2:215-38. [Medline].

  2. Lundberg A. Kinematics of the ankle and foot. In vivo roentgen stereophotogrammetry. Acta Orthop Scand Suppl. 1989. 233:1-24. [Medline].

  3. Tickle C. Genetics and limb development. Dev Genet. 1996. 19(1):1-8. [Medline].

  4. Cuervo M, Albiñana J, Cebrian J, Juarez C. Congenital hypoplasia of the fibula: clinical manifestations. J Pediatr Orthop B. 1996 Winter. 5(1):35-8. [Medline].

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

  6. Stevens PM, Aoki S, Olson P. Ball-and-socket ankle. J Pediatr Orthop. 2006 Jul-Aug. 26(4):427-31. [Medline].

  7. Stevens PM, Otis S. Ankle valgus and clubfeet. J Pediatr Orthop. 1999 Jul-Aug. 19(4):515-7. [Medline].

  8. Malhotra D, Puri R, Owen R. Valgus deformity of the ankle in children with spina bifida aperta. J Bone Joint Surg Br. 1984 May. 66(3):381-5. [Medline].

  9. Lampasi M, Antonioli D, Di Gennaro GL, Magnani M, Donzelli O. Congenital pseudarthrosis of the fibula and valgus deformity of the ankle in young children. J Pediatr Orthop B. 2008 Nov. 17(6):315-21. [Medline].

  10. Takikawa K, Haga N, Tanaka H, Okada K. Characteristic factors of ankle valgus with multiple cartilaginous exostoses. J Pediatr Orthop. 2008 Oct-Nov. 28(7):761-5. [Medline].

  11. Gibson V, Prieskorn D. The valgus ankle. Foot Ankle Clin. 2007 Mar. 12(1):15-27. [Medline].

  12. Nabeshima Y, Mori H, Fujii H, Ozaki A, Mitani M, Fujioka H. Ankle valgus and subtalar varus in treated clubfoot. J Foot Ankle Surg. 2009 Nov-Dec. 48(6):615-9. [Medline].

  13. Takakura Y, Tanaka Y, Kumai T, Sugimoto K. Development of the ball-and-socket ankle as assessed by radiography and arthrography. A long-term follow-up report. J Bone Joint Surg Br. 1999 Nov. 81(6):1001-4. [Medline].

  14. Burghardt RD, Tettenborn LP, Stücker R. Growth Disturbance of the Distal Tibia in Patients With Idiopathic Clubfeet: Ankle Valgus and Anteflexion of the Distal Tibia. J Pediatr Orthop. 2015 May 14. [Medline].

  15. Machen MS, Stevens PM. Should full-length standing anteroposterior radiographs replace the scanogram for measurement of limb length discrepancy?. J Pediatr Orthop B. 2005 Jan. 14(1):30-7. [Medline].

  16. Stevens PM. Effect of ankle valgus on radiographic appearance of the hindfoot. J Pediatr Orthop. 1988 Mar-Apr. 8(2):184-6. [Medline].

  17. Aurégan JC, Finidori G, Cadilhac C, Pannier S, Padovani JP, Glorion C. Children ankle valgus deformity treatment using a transphyseal medial malleolar screw. Orthop Traumatol Surg Res. 2011 Jun. 97(4):406-9. [Medline].

  18. Stevens PM, Toomey E. Fibular-Achilles tenodesis for paralytic ankle valgus. J Pediatr Orthop. 1988 Mar-Apr. 8(2):169-75. [Medline].

  19. Hou ZH, Zhou JH, Ye H, Shi JG, Zheng LB, Yao J, et al. Influence of distal tibiofibular synostosis on ankle function. Chin J Traumatol. 2009 Apr. 12(2):104-6. [Medline].

  20. Paley D, Herzenberg JE. Principles of Deformity Correction. Berlin Heidelberg New York: Springer-Verlag; 2002.

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  23. Driscoll MD, Linton J, Sullivan E, Scott A. Medial malleolar screw versus tension-band plate hemiepiphysiodesis for ankle valgus in the skeletally immature. J Pediatr Orthop. 2014 Jun. 34 (4):441-6. [Medline].

 
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Normal ankle alignment. The lateral distal tibial angle (LDTA) is 87º, and the fibular physis is at or distal to the level of the plafond, which is horizontal and, thus, perpendicular to gravity.
Malhotra classified progressive ankle valgus, which is directly proportional to the degree of fibular physis elevation (stage 0 = normal). The described triad of fibular physis elevation, wedging of the lateral tibial epiphysis, and ankle tilt may be accompanied by horizontal expansion of the fibular epiphysis (impingement), medial clear space widening, and avulsion injuries of the tip of the medial malleolus.
Lateral impingement may be due to ankle valgus, hindfoot valgus, or both. This is an extreme example.
One needs to differentiate between ankle valgus (shown here) and hindfoot valgus. It is imperative to obtain a standing anteroposterior radiograph of the ankle when evaluating foot problems.
Patients may have valgus at more than just the hindfoot and ankle. This boy with congenital clubfeet has genu valgum compounding his gait problems.
Transmalleolar screws, though easy to insert, may be difficult to remove. Shown here are two complications: screw breakage and intra-articular migration of the screw head, reflecting the drawbacks of imposing a rigid restraint on a dynamic and growing physis.
This patient (see also image below) failed to return for follow-up for 24 months following medial malleolar epiphysiodeses. There is obvious iatrogenic varus with tenting of the physes and risk of premature closure.
These screws were removed (with difficulty) on an urgent basis (see also image above).
This patient had asynchronous medial malleolar epiphysiodeses. The screw on the left could not be retrieved. His opening wedge osteotomy to correct iatrogenic varus collapsed into a nonunion, necessitating salvage with a Taylor spatial frame. This unfortunate sequence would not have happened with an eight-Plate.
A drawback of the intraphyseal fulcrum is the rigid constraint of the physis. Correction is relatively slow and inefficient when compared to the flexible, extraphyseal eight-Plate.
The nonlocking eight-Plate is placed superficial to the intact periosteum. As lateral growth occurs, the screws diverge, permitting safe and gradual correction of the valgus deformity. The ground reaction force moves medially, toward the center of the ankle. The distal tibial physis can expand and grow laterally; the articular cartilage is spared from harmful shear forces.
The fibula may not respond in a synchronous manner. However, as lateral impingement is alleviated, symptoms abate and there are no functional consequences. In children, it is not necessary to lengthen the fibula or fuse it to the distal tibia.
Through a 2.5-cm incision, one can place a Keith needle into the distal tibial physis, preserving the periosteum. Center the eight-Plate on the physis, and secure it with the 4.5-mm cannulated screws (either 16 or 24 mm). Place the epiphyseal screw first, with care to avoid the ankle joint or physis.
Fluoroscopic sequence showing the steps. The 24-mm screws are preferable if there is enough space to insert them.
Sick physes are not a contraindication to medial malleolar epiphysiodesis, even with screws. Note the remodeling of the distal tibial epiphysis as the ground reaction force is restored to neutral and the plafond rendered horizontal.
Ankle valgus is relatively common in children with previously operated clubfeet. While these feet may be presumed to be overcorrected, ankle films may reveal ankle valgus and lateral impingement. If the feet are flexible, it may be preferable to deliberately overcorrect into 5º of ankle varus before removing the plates. Continue to observe the child annually until maturity, and repeat as needed.
Presenting with an anterolateral bow and initially intact fibula, this child went on to a fibular fracture/pseudarthrosis and ankle valgus by age 3 years. Note the medial widening. It is not necessary to fix, bone-graft, or lengthen the fibula, nor is it helpful to create a tibia-fibular synostosis.
The medial malleolar screw was placed at age 4 years, and over the ensuing 2 years, the valgus corrected into slight varus. This procedure was repeated at age 7 years and again at 9 years, employing the eight-Plate.
This 12-year-old boy with hemiplegia underwent a rotational supramalleolar osteotomy. Despite the fibula being left intact, he drifted into valgus over the ensuing year.
This 10-year-old boy demonstrates the stigmata of hereditary multiple exostoses, with concurrent knee and ankle valgus. These deformities were managed by eight-Plates applied to the distal medial femora and distal medial tibiae. The deformities corrected over the ensuing year, and the plates were then removed.
This 9-year-old patient with spina bifida had progressive and symptomatic ankle valgus. One year following eight-Plate insertion, it is evident that the 16-mm screws are losing their grip. The goal was to achieve slight varus overcorrection.
In this patient (see also image above),the plates were moved distally and resecured with 24-mm screws.
 
 
 
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