Peter M. Stevens

Guided growth for angular correction: a preliminary series using a tension band plate.

The classic treatment of pathological angular deformities of the extremities is corrective osteotomy; however, osteotomies require hospitalization, pain management, immobilization, and delayed weight bearing. The associated risks, inconvenience, and cost of osteotomy make hemiepiphysiodesis or guided growth an attractive option. Although stapling has a long and proven track record, reported drawbacks related to implant failure, including migration or breakage of staples, have led some to abandon this technique. This report describes a prospective series of 34 consecutive patients who presented with a total of 65 deformities (femur and/or tibia) due to a variety of pathological conditions and who underwent guided growth using a nonlocking extraperiosteal 2-hole plate and screws. This technique relies upon the tension band principle rather than physeal compression. With follow-up ranging from 14 to 26 months (from implantation) in this series, 32 of 34 patients (63 deformity levels) have corrected to neutral at a mean of 11 months and the hardware has been removed. The observed rate of correction was approximately 30% more rapid than noted with stapling, and there have been no permanent growth arrests. Four patients with bilateral idiopathic genu valgum experienced rebound deformity and have since undergone repeat guided growth using the same technique. Only 2 patients with adolescent Blount disease have experienced insufficient correction; each may need a corrective osteotomy of the tibia. Having prevented 63 (97%) of 65 osteotomies in this series of patients, it is evident that guided growth holds promise for postponing if not preventing more invasive surgery. These patients will be observed up to maturity to support my conclusion that the concept of osteotomy as a first resort and criterion standard has become outdated.

Hemiepiphyseal stapling for knee deformities in children younger than 10 years : A preliminary report

Epiphyseal stapling, which is the only reversible method of growth alteration, has traditionally been reserved for teenagers. We are reporting the application of hemiepiphyseal stapling in a series of 25 children younger than 10 years. With a variety of underlying diagnoses, three children had genu varum and 22 had genu valgum. The technique involved fluoroscopic localization of all growth plates and careful preservation of the periosteum while inserting (and subsequently removing) one or two staples per physis. The mean age at stapling was 6 years + 4 months. Follow-up averaged 3 years + 3 months. The anatomic (tibiofemoral) angle and mechanical axis improved in all patients. One staple broke on removal; there were no other hardware failures. We conclude that hemiepiphyseal stapling is a safe and effective treatment for children younger than 10 years who have angular deformities of the knee. No growth-plate arrests have occurred. In the event of recurrent deformity, stapling may be repeated.

Physeal stapling for idiopathic genu valgum

Adolescent idiopathic genu valgum may cause anterior knee pain, patellofemoral instability, circumduction gait, and difficulty running. The purpose of this study was to evaluate and discuss what we consider to be an ideal treatment protocol using hemiphyseal stapling. We reviewed 76 patients (152 knees) who underwent hemiphyseal stapling for idiopathic adolescent genu valgum and were followed up to maturity. Clinical evaluation included assessment of gait, limb length, alignment, and patellofemoral stability. Radiographic evaluation included measurement of the distal femoral angle (DFA), the anatomic femoral tibial angle (FTA), and the mechanical axis (MA) before stapling, at the time of staple removal, and at skeletal maturity. After stapling, we noted improvement in gait, clinical symptoms, and all radiographic parameters. Our conclusion is that adolescent genu valgum may cause significant symptoms including anterior knee pain and gait problems. Hemiphyseal stapling addresses the anatomic malalignment, alleviating symptoms while offering a high degree of patient satisfaction. It is safe and effective, with no premature physeal closures noted in our series. The procedure, which is well tolerated, obviates the need for corrective femoral osteotomies.

Meralgia paresthetica in children.

We reviewed the findings in twenty children and adolescents who had meralgia paresthetica, a common entity in adults that has only rarely been reported in children. Ten patients had bilateral involvement; thus, the study included thirty lesions. Twenty-four lesions were eventually treated with open decompression of the lateral femoral cutaneous nerve; the results of twenty-one of these operations were followed for at least two years. The presenting symptom was severe pain resulting in marked restriction of activities. The pain could be reproduced with palpation of the nerve, and a trial injection of Xylocaine (lidocaine) always produced transient relief of symptoms. The average age at the onset of the symptoms was ten years (range, one to seventeen years); the diagnosis was missed initially in ten patients, which resulted in multiple, unnecessary diagnostic tests being done. The average duration of the symptoms before the patient was first seen was twenty-four months (range, two to eighty-four months), and the average duration of follow-up after the twenty-one operations was thirty-eight months (range, twenty-five to sixty months). Fourteen of the twenty-one operations led to an excellent result, with complete relief of pain and no restriction of activities; five led to a good result, with occasional pain but no limitation of sports or other activities; and two led to a fair result, with pain that interfered with sports activities but not with walking. We believe that meralgia paresthetica is much more common in children than has been previously recognized.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical correction of miserable malalignment syndrome.

Anterior knee pain is one of the more frustrating problems that orthopaedic surgeons treat. This study investigates the results of surgical correction of miserable malalignment syndrome associated with significant patellofemoral pain. The authors identified and retrospectively reviewed 14 consecutive patients with 27 limbs associated with excessive femoral anteversion, excessive tibial outward rotation, and patellofemoral pain. All of the patients were initially reviewed by the senior author and subsequently treated by ipsilateral outward femoral osteotomy and inward tibial osteotomy. All of the patients had failed nonoperative treatment. No persistent complications were seen. Subjectively and clinically, all of the patients were reviewed at an average of 5.2 (range 2.0–12) years after surgery. All of the patients reported full satisfaction with their surgery and outcomes. Most of the current literature discusses alignment in association with patellofemoral pain in the form of the extensor mechanism alignment. When evaluating patients with patellofemoral pain, it is imperative to assess the rotational profiles of the femur and tibia. The authors recommend that rotational osteotomies be performed in patients with patellofemoral pain and associated excessive femoral and tibial torsion, otherwise known as miserable malalignment syndrome.

Grice subtalar arthrodesis followed to skeletal maturity

A retrospective review of 45 patients (62 feet) who had undergone a Grice subtalar arthrodesis and who had reached skeletal maturity was undertaken. Preoperative deformities were due to flaccid and spastic paralysis, as well as congenital abnormalities. There were failures in 32% and poor results in 61%. Unrecognized ankle valgus, overcorrection of the hindfoot into varus, uncorrected calcaneus deformity, and anterior graft orientation largely contributed to the poor results. Weight-bearing radiographs of the feet and ankles are necessary to distinguish ankle valgus from hindfoot valgus. A subtalar arthrodesis cannot be used to compensate for ankle valgus, nor can it be used to correct the calcaneus component of a deformity without appropriate muscle-balancing procedures or osteotomies.

Chronic Monteggia fractures in children: outcome after treatment with the Bell-Tawse procedure.

Late recognition of Monteggia fracture-dislocations of the elbow continues to pose a treatment challenge. The 15 children in our series with such chronic injuries were all treated with the modified Bell–Tawse annular ligament reconstruction. At an average follow-up of 30 months, all regained flexion–extension arcs in the functional range and no nerve palsies were noted. Some loss of pronation and supination was common, but none had activity restrictions or functional deficits. Four children had recurrent, asymptomatic radial head subluxation; measuring 3–4 mm in the anterior direction. We recommend that late annular ligament reconstruction be considered for most chronic Monteggia fractures to improve long-term function and prevent the need for late excision of the painful, chronically dislocated radial head.

Screw epiphysiodesis for ankle valgus

Progressive ankle valgus is an insidious deformity that may develop during childhood due to a variety of etiologies including neuromuscular disease, skeletal dysplasia, chromosomal anomalies, and clubfoot. This may be concomitant with, or mistaken for, hindfoot valgus. The surgical options for treatment include supramalleolar osteotomy or hemiepiphysiodesis of the medial distal tibial physis. We report the rationale and technique of retarding medial malleolar growth by means of inserting a single 4.5-mm vertical screw. In a population of 31 children (50 feet), we have observed satisfactory improvement of ankle valgus with low morbidity and without permanent physeal closure. This represents a safe, predictable, and effective solution for children who present with progressive and symptomatic ankle valgus.

Coxa vara : Surgical outcomes of valgus osteotomies

Since the 1950s, valgus-producing femoral osteotomy has been the preferred treatment for significant coxa vara. Despite well-performed surgeries, the literature cites recurrence rates of 30-70%. The present study reviews our past 15 years of surgical experience for coxa vara; 26 children with 37 affected hips were retrospectively evaluated for outcome following valgus osteotomy. Both congenital and acquired types of coxa vara were included. Overall recurrence rate following valgus osteotomy was 50%. Age at time of surgery, type of surgery, and type of implant and etiology were found to have no bearing on recurrence. However, if Hilgenreiners epiphyseal angle was corrected to < 38 degrees, 95% of children had no recurrence of varus. In contrast, head-shaft angle was found not to be a reliable indicator of appropriate correction. Only six of 37 hips required pelvic osteotomy (five Pemberton, one Chiari) for dysplasia, and four of these had developmental dysplasia of the hip as the underlying etiology for their coxa vara. However, if the proximal femur was corrected and maintained before age 10, 83% of children had excellent acetabular depth, spherical congruency, relief from pain, and correction of Trendelenburg gait at latest follow-up.

Postaxial hypoplasia of the lower extremity

Congenital deficiency of the fibula may present a variety of patterns. In a series of 20 patients with this diagnosis, we have observed limb-length inequality and a spectrum of musculoskeletal anomalies involving the ipsilateral hip, femur, knee, tibia/fibula, ankle, and foot. Considering the frequently associated abnormalities of the lower extremity, the term postaxial hypoplasia may be more descriptive than the traditional terms fibular hemimelia or fibular a/hypoplasia. By raising the awareness of associated deformities, the clinician is better prepared to advise patients and to intercede accordingly. Based on our experience, we advocate a modular treatment approach combining limb lengthening with hemiepiphysiodesis of the distal femur and/or ankle to correct valgus alignment and establish a neutral mechanical axis. Contralateral epiphysiodesis as an adjunct may be preferable to double or repeated lengthening. The goal is to achieve symmetry and stable joints at skeletal maturity with a minimal number of well-timed surgical interventions. By using this strategy and with minimal morbidity, 10 of our patients who have reached skeletal maturity have achieved a satisfactory outcome.