Indications and timing in isolated medial femoral hemiepiphysiodesis for idiopathic genu valgum: A systematic review

An International Consensus on Evaluation and Management of Idiopathic Genu Valgum: A Modified Delphi Survey

BACKGROUND

Idiopathic genu valgum beyond physiological limits may require treatment, which is based on age, growth remaining, and the magnitude of the deformity. There is no consensus on clinical, or radiologic evaluation, indications, and management of idiopathic genu valgum, which can range from observation to surgical treatment using various modalities. If available, such guidelines will help surgeons offer optimal treatment to their patients. The aim of our study was to establish an expert consensus on the evaluation and treatment of idiopathic genu valgum.

METHODS

An international panel of 29 pediatric orthopaedic surgeons from 17 countries with clinical and research experience in the management of limb deformity participated in a modified Delphi survey. Surgeons were provided with patient and deformity characteristics and voted on 46 statements on history, clinical examination, radiographic evaluation, and treatment options for idiopathic genu valgum in round 1. Consensus was defined as when statements received ≥70% votes. Statements that were important but received <70% votes were reworded for clarity in round 2 (n=13).

RESULTS

Consensus was achieved for 28/46 statements and included obtaining a full-length standing radiograph of the lower extremities and measuring joint orientation angles. Participants did not agree to offer surgical treatment based only on the intermalleolar distance. They recommended surgical treatment if the mechanical axis falls in zone 2 or beyond on the lateral side and using guided growth by tension-band plating when the growth remaining is at least 2 years. The panel agreed on performing common peroneal nerve decompression for specific indications such as acute, opening wedge osteotomy of >20 degrees, but not for gradual correction. Consensus was not reached for indications and methods of bone age assessment, treatment when growth remaining is <1 year, indications for implant removal after guided growth in younger children, and the type of osteotomy for acute deformity correction.

CONCLUSIONS

We have generated consensus statements to guide the management of idiopathic genu valgum. Statements that lack consensus are areas for future multicenter research.

LEVEL OF EVIDENCE

Level V.

Unilateral genu valgum associated to vitamin D deficiency: A multidisciplinary approach in a patient followed from 3 to 21 years - A case report

INTRODUCTION

Lower limb postural deformities are usually bilateral and in the majority of cases tend to spontaneous correction without any treatment. On the contrary, unilateral genu valgum is a rare deformity in children, it is frequently associated with systemic pathological conditions and require a specific treatment.

PRESENTATION OF CASE

A three-year-old child affected by severe unilateral left genu valgum was followed by a multidisciplinary team. The initial treatment was medical, based on 10,000 IU of cholecalciferol every 2 months without any improvement after 6 months. Therefore, the patient was surgically treated by hemiepiphysiodesis of distal femur and proximal tibia with eight-plate obtaining a complete correction of the deformity in 10 months. Medical treatment continued for 4 years since the diagnosis. At follow-up, 18 years later, an excellent clinical result was observed.

DISCUSSION

The association between unilateral genu valgum and vitamin D deficiency is extremely rare. In case of unilateral limb deformity, it is essential to investigate the aetiology to obtain a correct diagnosis and perform a specific multidisciplinary treatment. The goal of the management is to correct the deformity and avoid any recurrence.

CONCLUSIONS

We believe that in unilateral genu valgum is always necessary a correct multidisciplinary diagnosis and treatment. The peculiarity of our case is the long-term follow-up and the absence of recurrence despite early surgical treatment. Further studies are necessary to better define the correlation between unilateral axial deformity and vitamin D deficiency.

The Effectiveness of Temporary Hemiepiphysiodesis for Non-idiopathic Coronal Angular Deformity of the Knee in Children: A Comparison of Hinge Eight-Plate and Traditional Eight-Plate

OBJECTIVE

Temporary hemiepiphysiodesis (TH) is a very common technique for coronal angular deformity of the knee in children, especially non-idiopathic. However, there is currently a dearth of comparative research on the hinge eight-plate (HEP) and traditional eight-plate (TEP). This study aimed to assess the clinical effectiveness and implant-related complication rates of TH using TEP and HEP for non-idiopathic coronal angular deformity, as well as to identify clinical factors affecting correction velocity.

METHODS

We retrospectively observed a consecutive series of patients with non-idiopathic coronal angular deformity of the knee who underwent TH using HEP or TEP and completed the deformity correction process from July 2016 to July 2022. According to the kind of eight plates, we divided those patients into the HEP group and the TEP treatment group. Relevant clinical factors, including the mechanical lateral distal femoral angle (mLDFA), mechanical medial proximal tibial angle (mMPTA), screw divergence angle (SDA), angle of plate and screw (APS), hinge angle of HEP (HA), and the knee zone location of the lower extremity mechanical axis, were documented. Additionally, deformity correction velocity, complications, and clinical efficacy were assessed. Categorical variables were analyzed using the chi-squared test, Fisher exact test, or Wilcoxon test, while continuous variables were evaluated using the t-test or analysis of variance (ANOVA).

RESULTS

There were 29 patients in the HEP treatment group (seven girls and 22 boys) and 33 patients (12 girls and 21 boys) in the TEP treatment group. In all, 91.86% (79/86 knees) of the genu angular deformities were completely corrected, 6.98% (6/86 knees) had the overcorrection condition, and 10.47% (9/86 knees) had screw loosening. The swayback HEP rate was 11.29% (7/62 HEPs), which was related to the screw loosening in the HEP group (p < 0.001). The overall correction velocities and screw divergence angle change speeds in the HEP group were all significantly faster than those in the TEP group (p < 0.05). The initial APS of the HEP implanted was higher than that of TEP (p < 0.01), and multisite changes of APS during deformity correction of the HEP group were smaller than that of the TEP group.

CONCLUSION

HEP proved to be an appropriate device for TH for non-idiopathic coronal angular deformities of the knee with high correction velocity in children. Avoiding the occurrence of the swayback phenomenon may reduce the complications of HEP.

Simultaneous Meniscal Repair and Temporary Guided Growth Using a Tension Band Plate to Correct Alignment in Pediatric Discoid Lateral Meniscus Patients With Valgus Knee

Meniscal stabilization with saucerization has recently been recommended for discoid lateral meniscus (DLM) to preserve the meniscus shape and prevent the progression of osteoarthritis. However, axial alignment of the lower limb causes a significant valgus change after arthroscopic partial meniscectomy and can lead to progressive lateral osteoarthritic changes. Thus, valgus knees in patients with DLM are a suspected predictive factor for poor outcomes after DLM surgery. Valgus malalignment in pediatric patients can be corrected by temporarily tethering one side of the open physis using implant-mediated guided growth to generate differential growth in the coronal plane. This Technical Note describes simultaneous arthroscopic meniscal surgery and temporary hemiepiphysiodesis to treat DLM with valgus deformities to reduce the risk of future chondral damage to the lateral knee compartment.

Ultrasound supports clinical decision-making in determining the Sanders' skeletal maturity score of the hand

PURPOSE

The Sanders Scoring System has revolutionized the way we assess the remaining growth potential of the skeleton. However, because it involves radiation exposure, it must be used with caution in children. The purpose of the study was to evaluate whether the Sanders skeletal maturity score (SMS) could be accurately determined using ultrasound (U).

METHODS

We took radiographs (R) of the hand and performed U of the thumb and index finger in 115 patients between six and 19 years of age who were undergoing treatment for scoliosis or limb deformities. Paediatric orthopaedic surgeons, a paediatrician, and a paediatric radiologist were evaluated the blinded images. Those classified images are based on the SMS and the Thumb Ossification Composite Index (TOCI).

RESULTS

Intrarater reliability was high for SMS and slightly weaker for TOCI, but still significant. Interrater reliability was clear for R and weaker for U in both staging systems. Ultimately, SMS 3 and 7 achieved the highest percentage of concordance (P) of 71.7% and 66.0%, respectively, when U was performed. Combining the clinically relevant groups of SMS 3&4 and SMS 7&8 also significantly increased peak scores (SMS 3 and 4 P = 76.7%; SMS 7 and 8 P = 79.7%). The probabilities of peak scores were significantly weaker when the TOCI score was examined.

CONCLUSION

Our study shows that U can be used effectively especially to measure stages 3 and 4 and stages 7 and 8 of SMS. The U method is easy to use and therefore may offer advantages in clinical practice without the need for radiation exposure.

Factors influencing correction rate following hemiepiphysiodesis using tension band plates for deformities around the knee: a multivariate analysis study

PURPOSE

The aim of this study was to appraise various factors influencing the correction rate in temporary hemiepiphysiodesis (THE) around the knee joint. Specifically, the study analysed the relationship of correction rate with age, gender, aetiology, type and location of deformity.

METHODS

The retrospective study included children who underwent THE for a coronal plane deformity (genu valgus or varum) around the knee joint (distal femur or proximal tibia) over a ten year period (2010-2020). The primary outcome of interest was the correction rate of the deformity.

RESULTS

Thirty-three children (27 females and 6 males) with a mean age of 8.1 years involving 86 plates were included in the study. The mean correction achieved was 12.2° over a treatment period of 13.3 months. Subgroup analysis showed significant differences between the type (varus (0.8° per month), valgus (1.1° per month)) and the location of deformity femur (1.2° per month) and tibia (0.7° per month)]. On multivariate analysis, the location and the duration of treatment showed significant associations with the correction rate.

CONCLUSION

The correction of coronal deformities following temporary hemiepiphysiodesis is influenced by several factors. Valgus, femoral and deformities in younger children correct at a faster rate. Location of deformity and duration of treatment emerged as potential factors affecting the correction rate.

Guided Growth Technique for Epiphysiodesis and Hemiepiphysiodesis: Safety and Performance Evaluation

BACKGROUND

Guided-growth modulation is a first-line treatment widely adopted to correct lower-limb angular deformities and limb-length discrepancies (LLD) in the paediatric population.

METHODS

We conducted a retrospective study to evaluate the safety and performance of a new construct (8-Plate Plus or Guided-Growth Plate System Plus, Orthofix S.r.l) used to correct angular deformities and LLD in non-skeletally mature children. The primary endpoint was safety (from plate implantation to removal). The secondary endpoint was performance; patients treated for LLD achieved complete correction if a pre- and post-surgery difference of <0 was observed; angular deformities performance was measured in terms of IMD, ICD, mMPTA, and mLDFA.

RESULTS

We performed 69 procedures in 41 patients. A total of 10 patients had an LLD, and 31 had an angular deformity. We observed nine minor complications in the hemiepiphysiodesis group. One patient experienced rebound. All 10 LLD patient treatments were successful. A total of 30/31 patients with an angular deformity had a successful treatment; the remaining patient had a partial correction.

CONCLUSIONS

Guided-growth by temporary epiphysiodesis or hemiepiphysiodesis was safe and effective for angular deformities and limb-length discrepancies. Further prospective and/or randomized controlled trial studies assessing more significant cohorts of patients and a comparison group could add evidence to our findings.

First Metatarsal Hemiepiphysiodesis for the Treatment of Juvenile Hallux Valgus: A Systematic Review

INTRODUCTION

Juvenile hallux valgus (JHV) is a pediatric deformity characterized by the varus deviation of the first metatarsal and valgus deviation of the proximal phalanx. Among the several surgical techniques available, hemiepiphysiodesis consists of the unilateral growth arrest of the first metatarsal physis. Despite this technique has been proposed over 70 years ago, only a few studies including clinical and radiological outcomes have been published, making the procedure unclear in terms of results. This systematic review aimed to evaluate the outcomes of hemiepiphysiodesis of the first metatarsal in the treatment of JHV.

METHODS

Google Scholar, Embase, PubMed, and Cochrane databases were searched for all the articles reporting on clinical and radiological results of hemiepiphysiodesis of the first metatarsal in the treatment of JHV. The selected articles were reviewed to extract demographic data, surgical techniques, complications, clinical outcomes, and radiological parameters.

RESULTS

Six articles were included in the qualitative analysis. A total of 85 patients with 144 halluces valgus were treated through hemiepiphysiodesis of the first metatarsal. The mean age at surgery was 10.7 years (range 5 to 15). The mean follow-up was 2.7 years (range 1 to 7.5). Hemiepiphysiodesis was performed through 2 different techniques. Eighteen (12.5%) complications occurred. The mean American Orthopaedic Foot and Ankle Society (AOFAS) score increased from 70.6 (range 49 to 93) preoperatively to 89.4 (range 72 to 100) postoperatively. The mean HVA improved from 28.3 (range 14 to 46) to 24.03 degrees (range 0 to 54), and the mean IMA improved from 13 (range 8 to 33) to 10.9 degrees (range 8 to 33).

CONCLUSIONS

This review showed that hemiepiphysiodesis of the first metatarsal is a safe treatment for JHV. Improvement in both clinical and radiological results has been observed in all the studies, sometimes being statistically significant. Despite the improvement, mean postoperative radiological angles remained altered and consistent with mild-moderate hallux valgus. This suggests that hemiepiphysiodesis plays a bigger role in preventing the worsening of the deformity rather than correcting it. Randomized controlled trials with longer follow-up and a larger number of patients are needed to further investigate the efficacy and safety of this treatment.