Hemiepiphysiodesis for Genu Valgum in Patients With Multiple Hereditary Exostoses.

BACKGROUND: Genu valgum is a well-known feature of multiple hereditary exostoses (MHE). Though prior reports have demonstrated successful treatment with hemiepiphysiodesis, details regarding the correction rate and comparison to an idiopathic population are lacking. This study aimed to detail our institution's experience with guided growth of the knee in patients with MHE and compare this to an idiopathic population. METHODS: All pediatric patients (age 18 and younger) with MHE who underwent lower extremity hemiepiphysiodesis at a tertiary care medical center between January 2016 and December 2022 were retrospectively reviewed. Preoperative and postoperative mechanical lateral distal femoral angle (mLDFA) and medial proximal tibial angle (MPTA, the primary outcomes) were measured in addition to mechanical axis deviation (MAD) and hip-knee-ankle angle (HKA). Patients were 1:2 matched based on age, sex, and physes instrumented to a cohort with idiopathic genu valgum. RESULTS: A total of 21 extremities in 16 patients with MHE underwent hemiepiphysiodesis of the distal femur, proximal tibia, and/or distal tibia. The mean age at surgery was 11.7±2.2 years. Mean MAD corrected from zone 1.9±0.7 to -0.3±1.5, while mLDFA corrected from 83.4±2.9 to 91.7±5.2 degrees and MPTA corrected from 95.3±3.6 to 90.5±4.0 degrees in distal femurs and proximal tibias undergoing guided growth, respectively. Three extremities (14.3%) experienced overcorrection ≥5 degrees managed with observation. There were no differences in correction rates per month for mLDFA (0.54±0.34 vs. 0.51±0.29 degrees, P =0.738) or MPTA (0.31±0.26 vs. 0.50±0.59 degrees, P =0.453) between MHE and idiopathic groups. For 11 extremities in the MHE group with open physes at hardware removal, they experienced a mean recurrence of HKA of 4.0±3.4 degrees at 19-month follow-up. CONCLUSION: Hemiepiphysiodesis corrects lower extremity malalignment in patients with MHE at a similar rate compared with an idiopathic coronal plane deformity population. Rebound deformity of 4 degrees at 19 months after hardware removal in patients with remaining open growth plates should make surgeons conscious of the remaining growth potential when planning deformity correction. LEVEL OF EVIDENCE: Level III.

Factors Affecting Postoperative Courses After Removal of Transphyseal Screws Inserted for Correction of Genu Valgum.

BACKGROUND: The aim of this study was to investigate factors determining the final outcomes of hemipercutaneous epiphysiodesis using transphyseal screw (PETS) for the genu valgum, especially focusing on postoperative courses after screw removal. METHODS: Fifty-five patients with idiopathic genu valgum treated with hemi-PETS were included. The mechanical lateral distal femoral angle (mLDFA) and medial proximal tibial angle (MPTA) were measured to calculate the degree of correction and rebound. Regarding factors related to surgical techniques, the number of screw threads beyond the physis, the moment arm of the screw, and screw insertion angles were measured. RESULTS: In 54 femoral segments (randomly selected in bilateral cases), hemi-PETS was performed with a growth remaining of 2.0±0.6 years. The screw was removed after 6.5±2.1 months, and the degree of correction was 5.0±1.5 degrees. The mean rebound angle was -0.4±2.4 (the negative value means further correction after screw removal). A late time of surgery and an extreme peripheral position of a screw were associated with the growth inhibition. In 50 tibial segments (also randomly selected in bilateral cases), a screw was inserted with a growth remaining of 2.0±0.6 years and removed after 6.3±1.9 months. The degree of correction was 2.9±1.7 degrees during the interval, and the rebound angle was 0.8±1.7 degrees. An earlier time of surgery and a greater correction angle before screw removal were associated with the rebound phenomenon. CONCLUSIONS: Growth inhibition of >1.6 degrees was observed in about one-fourth of femoral segments. An extreme peripheral position of a screw should be avoided when performing hemi-PETS at the distal femur. We also recommend not performing hemi-PETS at distal femur with too short a period of growth remaining. LEVEL OF EVIDENCE: Level III-retrospective comparative series.

MPFL Reconstruction and Implant-Mediated Guided Growth in Skeletally Immature Patients With Patellar Instability and Genu Valgum.

BACKGROUND: There is a higher rate of failure of isolated MPFL reconstruction in skeletally immature patients with patellar instability compared to skeletally mature patients. Genu valgum is a known risk factor for patellar instability. There is potential for concomitant surgical correction of genu valgum to achieve better clinical outcomes and to decrease failure rates of MPFL reconstruction. PURPOSE: To evaluate outcomes of combined medial patellofemoral ligament (MPFL) reconstruction and implant-mediated guided growth (IMGG) in skeletally immature patients with patellar instability and genu valgum. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: In a multicenter study, all skeletally immature patients with recurrent patellar instability and genu valgum who underwent MPFL reconstruction using hamstring graft and IMGG using a transphyseal screw or tension band plate for the distal femur and/or proximal tibia were included. The knee valgus angle and mechanical axis were measured on full-length radiographs and anatomic risk factors were measured on MRI. Patients were followed until correction of their lower limb alignment and implant removal or until skeletal maturity. Clinical outcomes, including complications, were analyzed. RESULTS: A total of 31 patients (37 knees) were included in the study. The mean age and skeletal age of the cohort were 12.4 and 12.9 years, respectively. Simultaneous MPFL reconstruction and IMGG were performed in 26 of 37 knees; 11 underwent staged procedures. Twenty knees had transphyseal screws and 17 knees had tension band plates for IMGG. The knee valgus corrected from a mean of 12.4° to 5.1° in 12.1 months. Implants were removed from 22 of 37 knees once genu valgum was corrected. There was no significant difference (P = .65) in the correction rate between plates (0.7 deg/month) and screws (0.6 deg/month). Ten complications occurred in 4 patients (7 knees) and included 5 patellar redislocations, 2 rebound valgus, 1 varus overcorrection, 1 knee arthrofibrosis, and 1 implant loosening. For children <10 years of age, 3 of 6 (50%) knees had patellar redislocations and 5 of 6 knees had a complication. This was statistically significant (P = .003) compared with patients >10 years of age. Similarly, for patients with bilateral knee involvement, 5 of 12 (42%) knees had patellar redislocations and a total of 8 complications occurred in this subset. This was statistically significant (P < .001) compared with patients with unilateral involvement. CONCLUSION: IMGG with plates or screws in the setting of combined MPFL reconstruction improves genu valgum. Children <10 years of age and those with bilateral instability with genu valgum remain difficult subsets to treat with higher complication rates.

Mid-term outcomes of temporary medial distal femoral hemiepiphysiodesis with and without medial patellofemoral ligament repair for recurrent patellar instability in skeletally immature patients with genu valgum.

Genu valgum contributes to patellar instability, though outcomes following temporary hemiepiphysiodesis via eight plating are less understood. The purpose of this study was to evaluate the outcomes and need for additional procedures following temporary hemiepiphysiodesis for the treatment of pediatric genu valgum and patellar instability, as well as evaluating the utility of a concurrent medial patellofemoral ligament (MPFL) repair. Patients who underwent medial distal femoral epiphysiodesis for the treatment of genu valgum and recurrent patellar instability were identified. Inclusion criteria were minimum 1-year follow-up and lack of concurrent ligamentous reconstruction. Patients were contacted to complete a questionnaire which included the International Knee Documentation Committee (IKDC) form and questions pertaining to knee function and patient satisfaction. Thirty-one patients aged 12.0 ± 1.9 years underwent 47 guided growth procedures and were included in final analysis. Seventeen knees (36%) required subsequent surgery for patellar instability. All patients requiring subsequent surgery were female, compared with 70% of patients not requiring subsequent surgery ( P  = 0.017). The MPFL repair group underwent fewer subsequent procedures to address instability, though this difference was NS (17 vs. 46%, P  = 0.318). Mean IKDC score at 5.3 years follow-up among 18 survey respondents was 78.6. Medial distal femoral hemiepiphysiodesis may partially address recurrent patellar instability in skeletally immature patients with genu valgum. Concurrent MPFL repair may minimize the need for subsequent procedures to address recurrent instability. While correcting alignment may be helpful, patients should be aware of the potential need for further patellar instability surgery. Level of evidence: IV, case series.

Genu Valgum in Pediatric Patients Presenting With Patellofemoral Instability.

BACKGROUND: Lower extremity valgus is a commonly described factor associated with patellofemoral instability (PFI) and, if identified before skeletal maturity, can be treated with guided growth. The prevalence of valgus alignment in the pediatric and adolescent PFI population is largely unknown. PURPOSE: The aim of this study was to report the prevalence of valgus alignment in adolescent patients presenting with PFI; with secondary assessment of high-grade valgus (zone II or III), coronal asymmetry, and associations of these findings with body mass index (BMI). STUDY DESIGN: A retrospective cohort study. METHODS: A total of 279 consecutive patients (349 knees) with a diagnosis of PFI presenting to a single orthopedic pediatric sport medicine surgeon were identified. A retrospective chart review was performed to collect demographic and clinical data, chronologic and bone age, sex, BMI, mechanism of injury, and the presence of osteochondral fracture. Full-length standing hip-to-ankle alignment radiographs were graded for knee alignment mechanical zone utilizing standard linear femoral head center to talar center assessment. In addition, mechanical axis deviation, mechanical lateral distal femoral angle and medial proximal tibial angle (MPTA) were also calculated. RESULTS: Mean patient age was 14.0±2.5 years. There were 162 (58.1%) females and mean BMI was 24.3±6.4. Seventy patients (25.1%) had bilateral PFI. Standing alignment radiographs were available for 81.4% of knees (n=284). Valgus alignment was present in 172 knees with PFI (60.6%). High-grade valgus, defined as zone 2 or greater, was present in 66 knees (23.3%). Overall, 48.9% had asymmetry of coronal alignment (n=139). The mean mechanical lateral distal femoral angle was 85.4±2.8 and the mean MPTA was 88.2±2.6. There was a greater MPTA in female patients (88.8±2.4 vs. 87.5±2.7, P <0.001). A higher BMI (24.87±6.95, P =0.03) was associated with valgus alignment. CONCLUSIONS: There is a high (60%) prevalence of lower extremity valgus in adolescent patients presenting with PFI, with nearly 1 in 4 presenting with high-grade valgus. The treatment team should be aware of this association as it may be an important consideration in the pediatric and adolescent PFI populations. LEVEL OF EVIDENCE: Level III.

Nonossifying fibroma of the lower femur with genu valgum: a case report.

BACKGROUND: Nonossifying fibroma is common in children and adolescents, and nonossifying fibroma with genu valgum is rare in the clinic. This article evaluated the effectiveness of treatment in a case of nonossifying fibroma of the lower femur with genu valgum. CASE PRESENTATION: A 16-year-old girl complained of pain in the lower part of her right thigh for one year. She was diagnosed as non ossifying fibroma of the right femur with secondary valgus deformity of the right knee, and was treated in our hospital. We performed curettage, bone grafting and internal fixation,and corrected the valgum deformity at the same time. The patient's incision healed well, the pain was disappeared, and the mechanical axis of lower limbs was corrected. No tumor recurrence was found on X- ray examination one year after operation, and the fracture end was healed. The patient could walk normally, and she was satisfied with her limb function. CONCLUSION: Nonossifying fibroma with genu valgum is rare in the clinic. The patient was satisfied with our treatment, which achieved a good curative effect.

TT-TG distance decreases after open wedge distal femoral varization osteotomy in patients with genu valgum & patellar instability. A pilot 3D computed tomography simulation study.

BACKGROUND: Genu valgum is considered to be a risk factor for patellar instability. Correction of valgus alone or combined with a tibial tuberosity medialization has been described. However, changes occurring in the tibial tuberosity-trochlear groove (TT-TG) distance after a lateral distal femoral opening wedge osteotomy (LDF-OWO) are not known. PURPOSE: This study aimed to define changes in TT-TG distance with increasing amounts of valgus correction after LDF-OWO. METHODS: Three-Dimensional Computed Tomography (3D-CT) scans of six patients (two females and four males) aged between 19 and 35 years with genu valgum and patellar instability were analyzed. 3D models of femoral, tibial, and patellar bones were created with the advanced segment option of Mimics 21® software. An oblique lateral opening wedge osteotomy of the distal femur was simulated in 2-degree increments up to 12 degrees of varus opening. Change in TT-TG distance was measured in mm on 3D models of the knee. RESULTS: Compared to baseline without osteotomy, the TT-TG distance decreased significantly (p < 0.05) for all corrections from 2 to 12 degrees in 2° steps. The TT-TG distance decreased by an average of 1.7 mm for every 2 degrees of varus opening. CONCLUSION: Lateral opening wedge distal femoral osteotomy causes a decrease in TT-TG distance. The surgeon should be aware of the magnitude of this change (1.7 mm decrease for every 2° increment of valgus opening).

Single-Stage Correction of Genu Valgum Recurvatum by Distal Femoral and High Tibial Opening Wedge Osteotomies: A Case Report.

CASE: A 32-year-old woman with genu valgum recurvatum presented to clinic complaining of long-standing anterior knee pain. Radiographs demonstrated a 13° anterior tibial slope and 15° valgus malalignment. She underwent a single-stage 2-level osteotomy at the distal femur and proximal tibia to simultaneously correct genu valgum and recurvatum. This procedure achieved precise correction in both planes. At 1 year, the patient was pain-free and ambulated without restriction. CONCLUSION: This procedure should be considered among the available surgical options when treating genu valgum recurvatum because it produced excellent results for the studied patient.

The Fate of Overcorrection After Hemiepiphysiodesis in Valgus Deformities Around the Knee.

BACKGROUND: Tension band plating is widely used in the surgical treatment of coronal plane deformities around the knee. The rebound phenomenon after implant removal is a common complication of this technique. Overcorrection of joint orientation angles is a method to minimize the effect of the rebound phenomenon. This study aims to investigate the natural course of overcorrected joint orientation angles after plate removal in patients with genu valgum deformity. METHODS: Patients who underwent hemiepiphysiodesis with tension band plating due to genu valgum deformity between 2010 and 2019 were retrospectively analyzed. Mechanical lateral distal femoral angles (mLDFA) and mechanical medial proximal tibial angles were calculated before plate application, before implant removal, and at the last follow-up. At the implant removal, mLDFA>90 degrees and mechanical medial proximal tibial angles <85 degrees were accepted as overcorrected. RESULTS: Seventy-two segments from 45 patients were included. For femoral valgus deformities (n=59), the mean mLDFAs at index surgery, implant removal, and the last follow-up were 79.8±3.9 degrees, 95.5±3.7 degrees, and 87.3±5.1 degrees, respectively. In the more and less than 10 degrees rebound groups, the median age of patients at index surgery were 66 and 101 months ( P =0.04), the mLDFA during implant removal were 97.8 degrees and 94.4 degrees ( P =0.005), and the mean amount of correction in mLDFA was 17 degrees and 13 degrees ( P =0.001), respectively. At the last follow-up, joint orientation angles were found to be still overcorrected in 16 (22%), within normal limits in 36 (50%), and undercorrected in 20 (28%) segments. Ten (13%) segments required additional surgery due to residual deformity. CONCLUSIONS: Overcorrection with tension band plating is an effective modality in the treatment of genu valgum deformity. Rebound after plate removal increases as the age at index surgery decreases and the amount of conscious overcorrection increases. Most segments return to normal joint orientation angle limits after overcorrection. We recommend a mean of 5 degrees routine overcorrection in patients with genu valgum deformity to overcome the rebound phenomenon and to make future interventions easier if ever needed. LEVEL OF EVIDENCE: Level III.

Hemiepiphysiodesis for Lower Extremity Coronal Plane Angular Correction in the Distal Femur and Proximal Tibia in Children With Achondroplasia.

BACKGROUND: Achondroplasia is the most prevalent form of skeletal dysplasia, affecting more than 250,000 individuals. Lower extremity angular deformities, particularly genu varum, are common in children with achondroplasia, often resulting in pain and limitation of function. The authors aim to determine the utility of lower extremity growth modulation with hemiepiphysiodesis in children with achondroplasia for correction of coronal plane deformities about the knee. METHODS: The authors performed a retrospective chart review of a single center from 1/1/2000 to 12/31/2020 to identify pediatric patients with achondroplasia treated with hemiepiphysiodesis as their initial procedure at the distal femur and/or proximal tibia. Patients with adequate records and who had completed their treatment were included. Data collected included duration of treatment, complications, need for osteotomy, and radiographic measurements including initial and final mechanical axis deviation, knee mechanical axis zone, mechanical lateral distal femoral angle and medial proximal tibia angle. RESULTS: Ten patients with 17 limbs met our criteria. Nine patients (15 limbs) were treated for genu varum and 1 patient (2 limbs) was treated for genu valgum. Prior to treatment, the mechanical axis fell in zone 3 in 59% of limbs and zone 2 in 41%. Average correction in mechanical axis deviation was 26.1 mm. Average change in mechanical lateral distal femoral angle was 10.3 degrees per limb, and average change in medial proximal tibia angle was 7.1 degrees per limb. Average treatment duration was 909 days. At final follow up, 81% (14/17) of limbs had the mechanical axis in zone 1, with the remaining 18% (3/17) in zone 2. No patient/limb underwent subsequent distal femur or proximal tibia osteotomy for coronal plane alignment. CONCLUSIONS: Children with achondroplasia can successfully be treated with hemiepiphysiodesis to correct coronal plane deformities at the distal femur and proximal tibia. Using this technique, no patient in our series required an osteotomy for genu varum/valgum. LEVEL OF EVIDENCE: Therapeutic level IV, Case series.

Is lateral femoral condyle hypoplasia a feature of genu valgum? A morphological computed tomography study of 200 knees.

BACKGROUND: Young surgeons are taught that genu valgum deformity is associated with hypoplasia of the lateral femoral condyle, despite the absence of supporting evidence. The objective of this study was to determine whether the lateral condyle was hypoplastic in genu valgum, by assessing the morphological features of the distal femur and their variations according to the severity of the coronal deformity. HYPOTHESIS: The lateral femoral condyle is not hypoplastic in genu valgum deformity. MATERIAL AND METHODS: The 200 included patients treated by unilateral total knee arthroplasty were divided into five groups based on their preoperative hip-knee-ankle (HKA) angle. The HKA angle, valgus cut angle (VCA), and anatomical lateral distal femoral angle (aLDFA) were measured on long-leg radiographs. Computed tomography images were then used to measure the medial and lateral anterior-posterior condylar lengths (mAPCL and lAPCL) and condylar thicknesses (mCT and lCT), distal femoral torsion (DFT), medial and lateral posterior condylar heights (mPCH and lPCH), and medial and lateral condylar volumes (mCV and lCV). RESULTS: No significant differences were demonstrated across the five mechanical-axis groups for mAPCL, lAPCL, mCT, lCT, mPCH, or lPCH. The groups differed significantly regarding the VCA (p<0.0001), aLDFA (p<0.0001), DFT (p<0.0001), and mCV/lCV ratio (p<0.0001). VCA and aLDFA were smaller when the valgus exceeded 10°. DFT was similar in all varus knees (2.2°-2.6°) but significantly greater for knees with moderate (4.0°) or severe (6.2°) valgus. Finally, lCV was greater than mCV in valgus knees compared to varus knees. CONCLUSION: The presence of lateral condyle hypoplasia in knees with genu valgum seems open to question. Apparent hypoplasia noted during the standard physical examination may be chiefly ascribable to distal valgus of the femoral epiphysis in the coronal plane and, with the knee flexed, to distal epiphyseal torsion, whose severity increases with the degree of valgus deformity. These considerations should be taken into account when performing distal femoral cuts for TKA, to ensure the restoration of normal anatomy in patients with genu valgus. LEVEL OF EVIDENCE: IV.

Simultaneous anterior cruciate ligament reconstruction and implant-mediated guided growth to correct genu valgum in skeletally immature patients.

OBJECTIVES: Adolescents with anterior cruciate ligament (ACL) tears can present with concomitant lower extremity coronal plane angular deformity (CPAD) that both predispose to injury as well as may increase the risk of graft rupture following ACL reconstruction (ACLR). The goal of this study was to examine the safety and efficacy of concomitant ACLR with implant-mediated guided growth (IMGG) compared to isolated IMGG procedures in paediatric and adolescent patients. METHODS: Operative records of all paediatric and adolescent patients (age ≤ 18 years) that underwent simultaneous ACLR and IMGG by one of two paediatric orthopaedic surgeons between 2015 and 2021 were retrospectively reviewed. A comparison cohort of isolated IMGG patients was identified and matched based on bone age within one year, sex, laterality, and fixation type (i.e. transphyseal screw vs. tension band plate and screw construct). Pre- and post-operative mechanical axis deviation (MAD), angular axis deviation (AAD), lateral distal femoral angle (LDFA), and medial proximal tibial angle (MPTA) were recorded. RESULTS: A total of 9 participants who underwent concomitant ACLR and IMGG (ACLR â€‹+ â€‹IMGG) were identified, with 7 of these participants meeting the final inclusion criteria. The participants had a median age of 12.7 (IQR â€‹= â€‹12.1 - 14.2) years and median bone age of 13.0 (IQR â€‹= â€‹12.0 - 14.0) years. Of the 7 participants that underwent ACLR and IMGG, 3 underwent a modified MacIntosh procedure with ITB autograft, 2 received quadriceps tendon autograft, and 1 underwent hamstring autograft reconstruction. There were no significant differences in the amount of correction obtained between ACLR â€‹+ â€‹IMGG and matched IMGG subjects with respect to any measurement variable (MAD difference: p â€‹= â€‹0.47, AAD difference: p â€‹= â€‹0.58, LDFA difference: p â€‹= â€‹0.27, MPTA difference: p â€‹= â€‹0.20). There were also no significant differences in alignment variables per unit time between cohorts (MAD/month: p â€‹= â€‹0.62, AAD/month â€‹= â€‹0.80, LDFA/month â€‹= â€‹0.27, MPTA/month â€‹= â€‹0.20). CONCLUSION: The results of the current study indicate that concomitant ACLR and lower extremity CPAD correction is a safe approach to treat CPAD concomitantly with ACLR in young patients who present with an acute ACL tear. Furthermore, one can expect reliable correction of CPAD after combined ACLR and IMGG, no different than the correction obtained in the setting of IMGG alone. LEVEL OF EVIDENCE: III.

Patient-reported Outcomes of Adolescents Treated With Guided Growth to Correct Idiopathic Genu Valgum.

BACKGROUND: Guided growth is commonly used to treat frontal plane alignment deformities in skeletally immature individuals. Treatment aims are to correct the biomechanical loading of the knee and to avoid more invasive surgery that would be required after skeletal maturity. There is little published evidence of pain perception or functional limitations in this population. In addition, the intervention has the potential to worsen pain and function with hardware implantation, and symptoms may not fully resolve after removal. Understanding of pain and function limitations in this population is important to guide the clinical expectations. METHODS: Individuals with idiopathic knee genu valgum who underwent hemiepiphysiodesis with tension plate constructs were identified through a medical records database search. Patient-reported outcomes measurement information system Physical Function/Mobility and Pain Interference domain scores were assessed before hemiepiphysiodesis, immediately before hardware removal, and after hardware removal. Radiographs were also assessed at these times to record the zones and angles of deformity and correction. RESULTS: Twenty-eight subjects (53 operative limbs) contributed to the analysis. Mobility and pain interference as measured by the patient-reported outcomes measurement information system were below typical values in a small percentage of the population studied, only 3.6% scored in the moderate and none in the severe categories for both domains. Valgus by radiographic zone was corrected in all patients without significant rebound at follow-up. Compared with preoperative levels, mobility scores improved before hardware removal. Pain Interference scores improved both before hardware removal and at the final follow-up. CONCLUSIONS: Frontal plane knee deformities in the idiopathic population do not cause pain or limit mobility in most subjects. This is critical information, emphasizing that surgical decisions may be made based on the deformity alone, presence of symptoms, and possible future morbidity secondary to valgus deformity. If surgery is postponed because an individual is asymptomatic, the window for correction with guided growth may be lost. Individuals undergoing hemiepiphysiodesis can expect that their pain and function will not be worse during the time that hardware is in place and that surgery is likely to improve any pain they may be experiencing. LEVEL OF EVIDENCE: Level III; retrospective comparative study.

Combined distal femoral osteotomy and tibial tuberosity distalization is effective in patients presenting with patellar instability and patellofemoral pain due to patella alta and femoral malalignment.

INTRODUCTION: Patellar malalignment has been considered one of the major pathomechanical causes of patellofemoral instability and pain. The results have been reported after femoral varization/torsional osteotomy and tibial tuberosity distalization osteotomy (TTD-O). However, the combination of a femoral deformity (genu valgum/increased femur antetorsion) and patella alta remains underreported. Therefore, the aim of this study was to investigate the clinical outcomes of patients simultaneously treated by distal femoral osteotomy and TTD-O. The hypothesis was that restoration of patellofemoral (PF) alignment via the abovementioned osteotomies would achieve good patient-reported outcome measures. MATERIALS AND METHODS: Between 2016 and 2019, a series of 25 knees in 20 patients were treated by a distal femoral osteotomy combined with a TTD-O aiming to correct patellofemoral malalignment consisting of genu valgum and/or increased femur antetorsion and patella alta. Six patients were lost to follow-up, and one patient refused to participate. Thus, 17 knees in 13 patients (male/female 1/12; age 27.4 ± 5.4 years) were included and comprised the study group for this investigation. Patients were evaluated after a mean of 3.1 ± 0.9 years postoperatively. The Kujala anterior knee pain scale and the PF-subscale of the Knee Osteoarthritis and Outcome score (KOOS-PF) were used to assess patients' reported outcome measures from pre- to postoperatively. RESULTS: The mean amount of torsional correction, valgus correction, and tibial tuberosity distalization averaged 14° (10°-18°), 5.2° (3.8°-8°), and 9 mm (6°-15 mm), respectively. The Kujala score increased by an average of 24.18 points from a mean of 66.6 ± 18.3 points (34-93 points) preoperatively to 90.8 ± 14.2 points (44-100 points) postoperatively (95% CI - 33.0 to - 15.3; p < 0.0001). The KOOS-PF score increased by an average of 33.7 points from a mean of 49.5 ± 24.5 points (9.1-88.6 points) preoperatively to 83.2 ± 21.6 points (15.9 -100 points) postoperatively (95% CI - 47.5 to - 19.9; p < 0.0001). CONCLUSION: The findings of this study indicate that the combination of a distal femoral osteotomy and a tibial tuberosity distalization osteotomy is effective in patients presenting with patellar instability and patellofemoral pain due to patella alta and femoral malalignment.

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

INTRODUCTION: Temporary isolated medial femoral hemiepiphysiodesis (TIMFH) represents a safe and effective technique widely used to treat idiopathic genu valgum. Recent studies mainly concentrated on comparing outcomes of different implants, while less attention has been reserved to the proper indications and timing for surgery. The aim of this systematic review was to provide evidence-based guidelines about indications for device implant and removal and postoperative management. METHODS: A comprehensive literature search was performed across three databases to select articles concerning TIMFH in the treatment of idiopathic genu valgum. Studies involving other etiologies or concomitant surgical procedures were excluded. Quality assessment of the included studies was conducted through the Newcastle-Ottawa Scale. RESULTS: Ten studies involving 237 patients for a total of 446 knees were included in the analysis. Mean age at surgery was 11,4 years. Patients were considered for surgery using various clinical and radiological parameters. Intermalleolar distance (IMD) and mechanical lateral distal femoral angle (mLDFA) were the most common evaluated. Mean treatment time was 12 months. Rebound of the deformity occurred in 6,7% of cases. CONCLUSION: Results of this review showed good consensus among authors. Patients undergoing TIMFH for IGV should be minimum 8 years old, with an IMD greater than 8 cm and a mLDFA lower than 87°. Postoperative management should comprise of quarterly clinic evaluations, and follow-up should last until skeletal maturity. The application of more uniform parameters in clinical practice may improve the establishment of the optimal timing for implant removal.

Pitfalls in the Diagnosis of Primary Hyperparathyroidism in a Sudanese Adolescent Boy; a case disguised as rickets.

BACKGROUND: Juvenile primary hyperparathyroidism (PHPT) is a rare endocrine disease. Its diagnosis might be masked by clinical, biochemical, and radiological features of rickets. CASE PRESENTATION: A 12-year-old Sudanese boy presented with progressive lower limbs deformity and difficulty in walking for six months. It was associated with fatigability, poor appetite, and generalized bone pain. On examination, he was thin, disproportionately short and pubertal, and had bilateral genu valgum deformity. X-rays showed osteopenia and signs of rickets. Biochemical workup revealed mildly elevated serum calcium, low phosphate, high alkaline phosphatase, and high parathyroid hormone with low 25-hydroxy vitamin D3. Celiac screening, liver function test and renal profile were normal. Serum calcium rose dramatically after vitamin D therapy. Genetic testing was negative for CYP2R1 and MEN1 genes. Ultrasound neck showed left inferior parathyroid adenoma which was surgically excised. Histopathology confirmed the diagnosis of parathyroid adenoma. Postoperatively, he had hypocalcemia which was treated with calcium and alfacalcidol. Corrective surgery is planned for the genu valgum deformity which markedly improved after parathyroidectomy. CONCLUSION: Although PHPT is extremely rare in the young population, it should be considered in patients with rickets and elevated serum calcium at baseline or after initiating vitamin D therapy.

Lower limb alignment correction can improve knee stability in congenital absence of anterior cruciate ligament.

We report the 4-year postoperative outcome of a child with Manner Type I aplasia of the anterior cruciate ligament (ACL) in her left knee and severe genu valgum. The child was experiencing pain, reduced mobility, and frequent left knee locking and instability. The patient was successfully treated with hemiepiphysiodesis (guided growth procedure) of the left knee joint to treat genu valgum deformity using 8-plates, resulting in improvement of knee stability. This spared her major ligament reconstruction of the knee to treat the aplastic ACL, and the patient was able to fully participate in physical activities with peers with no symptoms.

[Temporary Hemiepiphysiodesis in the Correction of Axial Deformities for Genua Valga: Retrospective Assessment and Comparison of Outcomes Achieved with the Use of Eight-Figure Plates and Blount Staples]. / Temporární hemiepifyzeodéza pri korekci osových deformit pro genua valga: retrospektivní zhodnocení a srovnání výsledku pri pouzití osmickových dlah a Blountových skob.

PURPOSE OF THE STUDY Axial deformities of the lower limbs of various aetiologies are relatively common orthopaedic diagnoses in paediatric population. Fixed deformity is an indication for correction in order to reduce the pain and to delay the early osteoarthrosis of adjacent joints and pain. Temporary hemiepiphysiodesis is technically a fairly simple method for modulating growth at the level of the growth plate and thus correcting the skeletal axis. MATERIAL AND METHODS 59 patients who underwent axial deformity correction of lower limbs at KDCHOT FN Brno were retrospectively analysed. Group 1 consisted of 21 patients with Blount staples implantation, Group 2 consisted of 38 patients to whom eight-figure plates had been applied. Anthropometric parameters (BMI, age, gender, intermalleolar distance (IMD)), duration of therapy, X-ray parameters (anatomical lateral distal femoral angle (aLDFA), anatomical medial proximal tibial angle (aMPTA)) and complications were recorded. The rate of correction was evaluated as the difference in X-ray parameters before and after surgery with respect to the time interval of the therapy. RESULTS The groups were comparable in terms of anthropometric parameters (BMI (p=0.800), IMD (p=0.334), gender (p=0.87)). The only statistically significant difference was found when comparing the mean age of the groups (p=0.005), with Group 1 (12.7±0.7) containing patients with a higher mean age than Group 2 (11.6±1.5). The groups were also comparable in terms of the average rate of correction over a one-month interval (aLDFA p=0.393; aMPTA p=0.831). The mean correction rate for Group 1 was: aLDFA 0.52±0.20/month, aMPTA 0.12±0.08/month; for Group 2: aLDFA 0.56±0.28/month, aMPTA 0.12±0.20/month. Individual implants differed in the type of complications, but no significant statistical difference in the incidence of complications was found between the analysed groups (p=0.526). DISCUSSION Recently, the system of eight-figure plates has been adopted as a standard method for correction of axial deformities of limbs. Although the benefits of this system are indisputable, when comparing the average monthly correction rate, no significant difference was found between the system of eight-figure plates and Blount staples in our study. Another monitored parameter was the occurrence of complications, which was evaluated fairly strictly. Even in this case, no statistically significant difference was found. We believe that the issue of using eight-figure plates is still open, as evidenced by studies, which often produce different results and conclusions. Therefore, a precise evaluation of the indication for correction, including individual characteristics of patients, is needed. CONCLUSIONS Based on the results, it can be concluded that the use of eight-figure plates in comparison with Blount staples provides neither faster correction of axial deformities nor lesser occurrence of complications. It can therefore be argued that the Blount staples still have their place in the indication of correction of axial deformities. The use of eight-figure plates represents a suitable solution for children of younger age to whom anchoring of the screws of eight-figure plates is a suitable solution in the cartilaginous epiphysis of long bones of younger children. Key words: temporary hemiepiphysiodesis, growth plate, Blount staples, eight-figure plates.

Genu Valgum After Distal Femur Extension Osteotomy in Children With Cerebral Palsy.

BACKGROUND: Distal femur extension osteotomy (DFEO) is a common treatment for knee flexion contracture and crouch gait in patients with cerebral palsy (CP), but skeletally immature patients tend to develop genu valgum deformities after DFEO. This study aimed to report the tendency of valgus changes after DFEO and determine the risk factors for subsequent surgery for excessive genu valgum. METHODS: This retrospective case-control study included 25 children with CP who underwent DFEO in 44 limbs for knee flexion contractures ≥15 degrees at a mean age of 11.0 years. Radiologic measurements included the anatomic lateral distal femoral angle (aLDFA), anatomic tibiofemoral angle (aTFA), medial proximal tibia angle, and plate-condyle angle, postoperatively and at the latest follow-up. Age, sex, preoperative knee flexion contracture angle, Gross Motor Function Classification System level, and radiographic measurements were compared between children with and without subsequent guided growth for genu valgum. RESULTS: A significant valgus change was observed at the distal femur in the first postoperative year (aLDFA from 83.6 to 80.1 degrees, P<0.001; aTFA from 176.1 to 172.5 degrees, P<0.01; plate-condylar angle from 5.3 to 9.5 degrees, P<0.001). Valgus changes occurred in 36 of the 44 limbs (82%) by an average of -4.6 degrees in the aLDFA, and subsequent guided growth was performed in 5 patients (20%). Guided growth for genu valgum was associated with a greater postoperative valgus angle (aLDFA: 78.0 vs. 84.9 degrees, P<0.01) but not with age, Gross Motor Function Classification System level, or preoperative flexion contracture. CONCLUSIONS: Distal metaphyseal osteotomies and distally placed angled plates near the physis are associated with valgus changes following growth. We recommend making a slight varus alignment during DFEO to compensate for subsequent valgus changes. LEVEL OF EVIDENCE: Level III-therapeutic, retrospective comparative study.

Factors Affecting Rebound Phenomenon After Temporary Hemiepiphysiodesis and Implant Removal for Idiopathic Genu Valgum in Adolescent Patients.

BACKGROUND: The aim of this study was to investigate factors determining postoperative courses, especially focusing on the rebound phenomenon, in adolescent patients with idiopathic genu valgum who underwent temporary hemiepiphysiodesis and implant removal. METHODS: We identified and reviewed patients with idiopathic genu valgum treated with temporary hemiepiphysiodesis [using tension-band plates (plate group, PG) or transphyseal screws (screw group, SG)] and followed-up to skeletal maturity. RESULTS: In our cohort [68 patients and their 68 limbs (randomly selected in bilateral cases)], the mean hip-knee-ankle alignment was -5.4±1.8 degrees at the time of temporary hemiepiphysiodesis (negative means valgus), 2.6±2.1 degrees at the time of implant removal, and 0.7±2.6 degrees at the last follow-up, respectively. Regarding the implants, the correction speed was not significantly different (P=0.192-0.315) between the PG (total 1.29±0.37 degrees/mo, 0.71±0.23 degrees/mo at distal femur, 0.59±0.16 degrees/mo at proximal tibia, n=19) and the SG (total 1.22±0.49 degrees/mo, 0.65±0.25 degrees/mo at distal femur, 0.57±0.23 degrees/mo at proximal tibia, n=49). The magnitude of rebound phenomenon in the PG (4.1±1.9 degrees) was greater (P<0.001) than that in the SG (1.1±3.1 degrees). The use of plates and faster correction speed, rather than more severe preoperative deformity or greater correction angle, were positively associated with the rebound phenomenon in regression analyses. Among the 68 knees, 1 showed valgus alignment ≥5 degrees and 5 showed varus alignment ≥5 degrees at the last follow-up. All the 6 cases were observed in the SG. Surgical wound dehiscence was observed in 1 patient in the PG. CONCLUSIONS: The use of plates and faster correction speed were positively associated with the rebound phenomenon. Careful attention will be needed with the corresponding conditions for optimal results. Progressive genu varum after transphyseal screw removal, which was observed in this study, should be explored in future research. LEVEL OF EVIDENCE: Level III-retrospective comparative series.