Pediatric Ankle Valgus Workup

Author: Peter M Stevens, MD; Chief Editor: Dennis P Grogan, MD more...

Updated: Nov 21, 2011

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Laboratory Studies
Imaging Studies
Other Tests
Diagnostic Procedures
Histologic Findings
Staging
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References

Laboratory Studies

There are no particular laboratory studies that are a prerequisite to correction of ankle valgus.

Imaging Studies

The most relevant imaging studies include weight-bearing AP and lateral radiographs of the ankles and feet. In the presence of concomitant limb deformities, a full-length standing AP of the legs is useful.

Unless a traumatic or other physeal bar is suspected, advanced imaging such as CT scan or MRI is not warranted. At the time of surgery, an arthrogram may be useful in outlining the cartilaginous anlage of the distal tibia-fibula. This is sometimes helpful in young children with skeletal dysplasias.

Other Tests

For generalized conditions, gait analysis may be interesting to document. In particular, comparison of pretreatment and posttreatment pedobarographs may be revealing as foot pronation improves.

Diagnostic Procedures

There may be an occasional need for consultation by a geneticist or neurologist, especially for children with suspected syndromes. There may also be indications for EMG, nerve conduction, or muscle biopsy. However, the majority of patients with progressive ankle valgus have well-established and chronic conditions such as cerebral palsy, spina bifida, and arthrogryposis (amyoplasia).

Histologic Findings

There are no relevant histologic findings that pertain to the surgical treatment of ankle valgus.

Malhotra staging

The staging proposed by Malhotra is germane and may be used to document the severity and progression of untreated ankle valgus (see Image below).^[8]Generally, the symptoms correlate with the stage of valgus and include the following:

Lateral impingement – ankle pain
Rapid shoe destruction
Brace intolerance
Medial skin breakdown (advanced cases)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. (Click Image to enlarge.)

Valgus of up to 6º(normal = 3º) or LDTA less than 84º (normal = 87º) may be observed unless there are related symptoms. Progressive deformities are frequently encountered as children grow older and will warrant intervention.

Proceed to Treatment & Management

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: Orthofix Inc Royalty Independent contractor

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: Medscape Salary Employment

Paul E Di Cesare, MD, FACS Professor and Chair, Department of Orthopedic Sugery, University of California, Davis, School of Medicine

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

Disclosure: Stryker Consulting fee Consulting

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

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, Pediatric Orthopaedic Society of North America, and Scoliosis Research Society

Disclosure: Nothing to disclose.

References

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Cuervo M, Albiñana J, Cebrian J, Juarez C. Congenital hypoplasia of the fibula: clinical manifestations. J Pediatr Orthop B. Winter 1996;5(1):35-8. [Medline].
Stevens PM, Arms D. Postaxial hypoplasia of the lower extremity. J Pediatr Orthop. Mar-Apr 2000;20(2):166-72. [Medline].
Stevens PM, Aoki S, Olson P. Ball-and-socket ankle. J Pediatr Orthop. Jul-Aug 2006;26(4):427-31. [Medline].
Stevens PM, Otis S. Ankle valgus and clubfeet. J Pediatr Orthop. Jul-Aug 1999;19(4):515-7. [Medline].
Malhotra D, Puri R, Owen R. Valgus deformity of the ankle in children with spina bifida aperta. J Bone Joint Surg Br. May 1984;66(3):381-5. [Medline].
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. Nov 2008;17(6):315-21. [Medline].
Takikawa K, Haga N, Tanaka H, Okada K. Characteristic factors of ankle valgus with multiple cartilaginous exostoses. J Pediatr Orthop. Oct-Nov 2008;28(7):761-5. [Medline].
Gibson V, Prieskorn D. The valgus ankle. Foot Ankle Clin. Mar 2007;12(1):15-27. [Medline].
Nabeshima Y, Mori H, Fujii H, Ozaki A, Mitani M, Fujioka H. Ankle valgus and subtalar varus in treated clubfoot. J Foot Ankle Surg. Nov-Dec 2009;48(6):615-9. [Medline].
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. Nov 1999;81(6):1001-4. [Medline].
Machen MS, Stevens PM. Should full-length standing anteroposterior radiographs replace the scanogram for measurement of limb length discrepancy?. J Pediatr Orthop B. Jan 2005;14(1):30-7. [Medline].
Stevens PM. Effect of ankle valgus on radiographic appearance of the hindfoot. J Pediatr Orthop. Mar-Apr 1988;8(2):184-6. [Medline].
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. Jun 2011;97(4):406-9. [Medline].
Stevens PM, Toomey E. Fibular-Achilles tenodesis for paralytic ankle valgus. J Pediatr Orthop. Mar-Apr 1988;8(2):169-75. [Medline].
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. Apr 2009;12(2):104-6. [Medline].
Paley D, Herzenberg JE. Principles of Deformity Correction. Berlin Heidelberg New York: Springer-Verlag; 2002.
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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. (Click Image to enlarge.)

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. (Click Image to enlarge.)

Lateral impingement may be due to ankle valgus, hindfoot valgus, or both. This is an extreme example. (Click Image to enlarge.)

One needs to differentiate between ankle valgus (shown here) and hindfoot valgus. It is imperative to obtain a standing AP radiograph of the ankle when evaluating foot problems. (Click Image to enlarge.)

Patients may have valgus at more than just the hindfoot and ankle. This boy with congenital clubfeet has genu valgum compounding his gait problems. (Click Image to enlarge.)

Transmalleolar screws, though easy to insert, may be difficult to remove. Shown here are 2 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. (Click Image to enlarge.)

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 8-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 8-plate.

The nonlocking 8-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 8-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 8-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 8-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 8-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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