See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/311534524

Temporary Epiphysiodesis In The Correction Of Angular Knee Deformities

Using Guided Growth Principle With Eight-Plate

Article · June 2014

CITATIONS READS

0 701

3 authors:

Yasser Elbatrawy Mahmoud A. Mahran

Al-Azhar University faculty of medicine for girls Ain Shams University
13 PUBLICATIONS 99 CITATIONS 29 PUBLICATIONS 90 CITATIONS

SEE PROFILE SEE PROFILE

Mohamed Elgebeily
Ain Shams University
11 PUBLICATIONS 31 CITATIONS

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Multiplaner Fixator as an effective alternative method in management of peritrochateric fractures View project

Involucrum Manipulation for Management of Chronic Femoral Osteomyelitis versus excision segment transfer. A New radiological classification View project

All content following this page was uploaded by Yasser Elbatrawy on 09 December 2016.

The user has requested enhancement of the downloaded file.

 Original Article

Temporary Epiphysiodesis In The Correction Of Angular Knee Deformities Using

Guided Growth Principle With Eight-Plate
Yasser ElBatrawy,MD *; Mahmoud Mahran, MD**; Mohamed A. EL Gebeily** ,MD
* Orthopedic Surgery Department, Al-Azhar University, Cairo, Egypt.
** Orthopedic Surgery Department, Ain-Shams, University, Cairo, Egypt

ABSTRACT:

Aim of the study: Evaluation of the guided growth principle in correcting knee
angular deformities, in skeletally immature patients.

Material and methods: Our series included application of 43 eight-plates in 22

patients, 14 patients were males and 8 were females. The average age at surgery was
6.1 years, and average follow up was 3.4 years. Fourteen cases were in varus and 8
had valgus knees. Thirteen cases were bilateral. In 4 of them, the deformity was both
femoral and tibial. The eight plates were applied on the healthy side of the physis
extra periostealy according to the preoperative plan to decrease its rate of growth.
The patients were followed up by x-ray every month to monitor the progression of
correction which was assessed by the mechanical axis deviation. The plates were
removed after achieving full correction.

Conclusion: Guided growth technique is proved to be safe and effective in the

treatment of angular knee deformities with advantages over other commonly used
techniques.

INTRODUCTION
Lower extremity angular alignment changes
from bow legs (varus) to knock knees (valgus) in
early childhood. Varus alignment at birth is
usually about 15°, gradually starting to change to
valgus at about 24 months. Valgus alignment
reaches a maximum of 8–10° at approximately 3–
4 years of age, subsequently decreasing to 6–7°
of valgus at the age of 5–6 years [1].
During skeletal growth, many factors can
compromise the alignment of the extremities and
the stature of the individual. The physis may be
structurally deficient or pathological in patients
with generalized conditions affecting skeletal
growth, including rickets, endocrinopathies, and
skeletal dysplasias.[2]
Appropriate medical management of such
conditions is paramount to achieving a good
outcome but may not prevent the need for
surgical realignment of the lower limbs. In
addition, attempts of conservative management,
such as the use of braces, to control evolving
deformities may be ineffectual, necessitating
eventual surgical intervention.[3]
There are many options for the correction of
angular deformity; the standard treatment method
is osteotomy, but immobilization and delayed
weight-bearing are still required during
recuperation. Also, the high rate of complications
and the degree of difficulty associated with an
osteotomy and acute correction have led
orthopaedic surgeons to search for other less
invasive options.[4] Distraction osteogenesis with
external fixation provides a reliable method for
correction of angular deformity; however, it has
the disadvantages of poor patient compliance, and
a long period wearing the device.[5]
 El Batrawy et al.,
Temporary epiphysiodesis
Physeal manipulation or guided growth provides
a means for correction of angular deformity that
carries a much smaller morbidity than an
osteotomy. It includes physeal bridge resection,
physeal distraction (chondrodiastasis), and partial
growth arrest, which can be done as a permanent
procedure (hemiepiphysiodesis) or as temporary
physeal stapling. The least invasive of these
options is a temporary partial growth arrest.[6]
PATIENTS AND METHODS:
This is a prospective study done on 35 angular
deformities of the knee in 22 patients (14 boys
and 8 girls) treated by the guided growth
technique using the original Orthofix©eight-plate
with two 4.5-mm cannulated non-locked titanium
screw system. The study was conducted in Ain-
Shams & AlZahraa University Hospitals, between
2006 and 2011.
All patients were skeletally immature, and the
mean age at time of the operation was 6.1 years
(range, 3–12 years). Deformities of the knees
were mainly in the coronal plane, with 14 cases
of genu varum and 8 cases of genu valgum.
Thirteen cases were bilateral of which 4 cases had
both femoral and tibial sides’ affection. Patients’
demographics are shown in (Table 1).
Preoperative workup included measurement of
limb lengths, clinical assessment of both angular
and rotational deformities and clinical gait
assessment. The inter-condylar and intermalleolar
distances were recorded for genu varum and genu
valgum patients retrospectively. Patellar tracking
and ligamentous laxity were noted as well.
Radiographic evaluation included a full length
weight bearing anterior-posterior view of both
whole lower limbs taken with the patellae facing
forward. The mechanical axis of the lower limb
was drawn from the center of the hip to the center
of the ankle passing by the knee joint and the
amount of mechanical axis deviation (MAD) was
measured from the center of the knee joint. The
The knee is divided into 4 quadrants
longitudinally with the mechanical axis normally
bisecting the knee. Medial or lateral zones 1 are
considered to be normal variance, worthy of
observation. If the mechanical axis was displaced
into zone 2 or 3, this served as justification for
intervention, provided that the patient had a
progressive & symptomatic deformity (Figure
1)[7-8]
Figure 1: Mechanical axis zones.
If you divide the knee into quadrants, the ideal
mechanical axis would bisect the knee (0), with
medial zone (-1) or lateral zone (+1) being within
physiologic range. With the notable exception of
physiologic varus < age 2 and physiologic valgus
< age 6, medial or lateral zones 2 or 3 would
likely manifest symptoms and gait disturbance
and thereby warrant surgical intervention. [8]
The mechanical lateral distal femoral angle
(mLDFA) and the medial proximal tibial angle
(MPTA) were measured to determine the origin
of the deformity, whether femoral, tibial or
combined.
In patients in whom a physeal bar is
suspected, a CTscan or MRI is ordered to confirm
the diagnosis. When indicated, the multiplier
method was used to determine if there is
sufficient predicted growth remaining to achieve
the desired correction through guided growth. To
establish informed consent, the patients were
offered the options of continued observation,
osteotomy, or guided growth.
Operative Technique: All surgical interventions
were done as a day case surgery under general
anaestheisa, with patient in supine position and
under tourniquet control.
Using fluoroscopic guidance 2-3 cm long
incision centered on the physis was done either
laterally or medially depending upon where is the
healthy side; the dissection is carried through
 El Batrawy et al.,
Temporary epiphysiodesis

fascia, between muscles, and leaves the we often attempted to slightly over correct the
periosteum undisturbed. A needle is inserted deformity in cases in which rebound was
through the perichondrial ring to localize the anticipated (Figure 3)
physis (confirmed fluoroscopically) before
applying the 8-plate. Because it serves as a
tension band, one plate per physis is sufficient
and a 12 or 16 mm plate is chosen. Threaded
guide pins are inserted with fluoroscopic control
through the centers of holes in the plate. It is not
essential that the guide pins are parallel.
A 3.2 mm drill bit is used over the guide wire.
Thentwo 4.5-mm screwsare applied. Theseare
self-tapping with lengths 16, 24 and 32 mm.
length is chosen so that the screw does not pass
the midline. Following wound closure, a
compression bandage is sufficient; no casts are
necessary. Immediate motion and weightbearing
are recommended, with crutches as needed for
comfort.Periodic monthly follow up is mandatory
to document deformity correction. When the
leg(s) is/are straight, follow-up radiographs are
taken to document the correction and plate
removal is scheduled accordingly (figure 2).

RESULTS:
A total of 22 patients (35 limbs and 43 eight-
Plates) were followed through completion of
treatment. The average time between insertion
and removal of the eight-Plate was 8.8 months
(range 6–13 months). The follow up was 40
months (range 18-94 months) after plate removal.
Five patients reached skeletal maturity at the time
of the final follow up.
Fig 2: Preoperative and final clinical picture and x-ray of a
Of the 43 eight-plates, 13 were inserted on the patient with genu varum (femoral in origin) where eight
plates are applied on the lateral side of the femur.
lateral distal femur (figure 2), 6 on the medial
distal femur and 2 on the medial proximal tibiae.
Sixteen eight-plates where applied on 4 patients Alignment improved in all cases except 2. The
on both femur and tibia bilaterally. average mLDFA and MPTA improved by10° and
8.75°respectively.
All patients who underwent eight-Plate removal
achieved complete deformity correction with the In Genu valgum cases when the origin of the
exception of 2 cases: one case of Blount’s disease deformity was femoral, the average mLDFA
where a bony bar prevented the correction and the increased from 78.3° to 86.5°. This constitutes an
other case was post infectious genu varum whose average change of 8.2°. When the origin of
growth plate had been damaged from deformity was tibial, the average MPTA
osteomyelitis of proximal tibia. decreased from 100° to 89.5°. This constitutes an
average change of 10.5°. In Genu varum cases
Complete correction was defined as reaching a when the origin of the deformity was femoral, the
neutral mechanical axis with no MAD. However,
 El Batrawy et al.,
Temporary epiphysiodesis
average of mLDFA decreased from 98.4° to
86.6°, which constitutes an average change of
11.8°, and when the origin of deformity was
tibial, the average MPTA increased from 77.4° to
84.4° which constitute an average change of 7°.
No perioperative or postoperative
complications, such as infections, wound
dehiscence, reactive synovitis, or hardware
failures, were observed. None of the patients
required an osteotomy or repeat eight-Plate
insertion.
Fig. 3: Preoperative clinical photo for patient with genu
valgum femoral in origin and follow up scanogram and
clinical photo showing slight over correction.
DISCUSSION:
Temporary hemiepiphysiodesis is an
appealing technique for correction of angular
deformities of the lower extremity in children
through the principle of ‘‘guided growth.’’ The
creation of a tether on the side of the physis that
is on the convex side of an angular deformity and
subsequent growth from the unarrested side
allows correction of the angular deformity. This
is achieved with a minimally invasive surgical
technique, which carries a very low morbidity
and can be suspended once the adequate
(5)
alignment is obtained.
Historically, staple hemiepiphysiodesis was
performed near the anticipated physiologic
cessation of physeal growth: damage to the physis
from the procedure would be eclipsed by
anticipated physeal closure. Inserting physeal
staples involves hammering in 2 or 3 staples, all
of which span but do not violate the physis.
Furthermore, the staples apply an inhibitory force
across their entire depth that may cover an
unacceptably large percentage of the physeal
width, particularly in young children or small
[9]
bones
The logic behind the eight-plate concept lies
in the placement of a non-rigid extraperiosteal
plate and two screws, serving as a focal hinge at
the perimeter of the physis. Because the fulcrum
of the plate falls outside the physis, it has a longer
moment arm and does not exert a relative
compression effect on the physis without limiting
the growth potential [9]. In our series, the diversion
of two screws was observed while the knee
deformities were corrected. Also, the screw heads
were angled at the interface between the screw
and the plate, as the screw was not locked at the
plate-hole. One potential advantage of the 8-plate
is that the screws toggle in the plate such that it
applies a tether only at the periphery of the
physis, which unlike staples, makes the technique
more likely to work in smaller children. (9)
When a staple is inserted in the limb of a
young child, there is a tendency for the staple to
back out(10). Extrusion occurs because the
epiphysis is largely unossified in young children,
so only the tip of each tine is lodged in bone.
Most of the length of each tine is embedded in
 El Batrawy et al.,
Temporary epiphysiodesis
unossified cartilage. The eight-Plate eases the
problem of extrusion by using threaded screws to
anchor the eight-Plate into the bone. Screws offer
much better purchase than smooth staples. None
of the screws broke or backed out in our series
because the screws are free to pivot in the plate
holes. Pivoting of screws might apply less
pressure to the physis offering the advantage of
physeal preservation through reducing the risk of
bar formation.
There are many reviews of physeal
manipulation; a study by Park et al(11)
demonstrated that hemiepiphyseal stapling of the
lateral aspect of the proximal tibial physis and, as
needed, the lateral aspect of the distal femoral
physis is safe and effective in children with late-
onset tibia vara if the physes are sufficiently open
and the varus deformity is mild to moderate.
These authors stated that the procedure is most
effective in patients younger than 10 years. But
our series included 3 patients over the age of 10
years and responded quiet well to this technique.
REFERENCES:
1. MacMahon EB, Carmines DV, Irani RN. Physiologic
bowing in children: an analysis of the pendulum
mechanism. J Pediatr Orthop B 1995; 4:100–105.
2. Stevens PM1, Klatt JB.. Guided Growth for Pathological
Physes: Radiographic Improvement During Realignment. J
Pediatr Orthop. 2008:28(6):632-639.
3. Stevens PM. Guided growth for angular correction: a
preliminary series using a tension band plate. J Pediatr
Orthop. 2007;27:253-259.
4. Surdam JW, Morris CD, DeWeese JD, et al. Leg length
inequality and epiphysiodesis: review of 96 cases. J Pediatr
Orthop. 2003;23(3):381-384.
5. Castañeda P, Urquhart B, Sullivan E, Haynes RJ.
Hemiepiphysiodesis for the Correction of Angular
Deformity About the Knee. J Pediatr Orthop. Volume
28(2), March 2008, pp 188-191
6. Raab P, Wild A, Seller K, et al. Correction of length
discrepancies and angular deformities of the leg by
Blount‘s epiphyseal stapling. Eur J Pediatr.
2001;160(11):668-674.
One patient didn’t achieve full correction, but this
was due to the nature of the pathology and not
due to age.
This paper presents our preliminary results
with a small sample size. Additional studies are
needed to be conducted with a larger sample size
and longer follow-up to determine whether the
results from this study can be validated. Further
follow-up studies are needed to confirm that
growth will reliably resume after eight-Plate
removal. Parents should be cautioned that
subsequent growth could be asymmetrical,
leading to relapse of the deformity.
Our results have shown that the eight-plate
with its pivoting screw and plate design is a valid
concept and that it effectively corrects angular
deformity. The 2 failures in our study resulted
from poor patient selection, not device
malfunction. So, we recommend using eight-Plate
in correcting angular deformities around the knee
with proper patient selection.
7. Muller K, Muller-Farber J. Indications, localization and
planning osteotomies .about the knee. In: Hierholzer G,
Muller K, eds. Corrective osteotomies of the lower
extremity after trauma. Berlin: Springer-Verlag, 1984:195-
223.
8. P.M. Stevens. Guided growth: 1933 to the present.
StratTraum Limb Recon (2006) 1:29–35
9. Wiemann JM, Tryon C and Szalay EA,. Physeal Stapling
Versus 8-plate Hemiepiphysiodesis for Guided Correction
of Angular Deformity about the Knee. J Pediatr Orthop.
Volume 29, Number 5, July/August 2009
10. Mielke CH, Stevens PM (1996) Hemiepiphyseal
stapling for knee deformities in children younger than 10
years: a preliminary report. J Pediatr Orthop 16:423–429.
11. Park SS, Gordon JE, et al. Outcome of hemiepiphyseal
stapling for late-onset tibia vara. J Bone Joint Surg Am.
2005;87(10):2259-2266
12. Bowen JR, Leahey JL, Zhang ZH, et al. Partial
epiphysiodesis at the knee to correct angular deformity.
Clin Orthop Relat Res. 1985;(198): 184-190.
 El Batrawy et al.,
Temporary epiphysiodesis

Table 1: Patients’ Demographics

Duratio
No. Sex Age Side Def. Bone Pre Op. angles Post Op. angles
n
1 M 7 Bil Valgus Femur LDFA: 80 88 7.5 ms

2 M 9 Bil Varus Femur LDFA: 98 87 9 ms

3 M 6 Bil Valgus Femur / Tibia LDFA:80/MPTA: 97 LDFA:87/MPTA: 86 9 ms

4 M 6 Uni Valgus Tibia MPTA: 98 90 6 ms

5 M 12 Bil Valgus Femur / Tibia LDFA: 77/MPTA:94 LDFA:85/MPTA: 87 8 ms

6 M 3 Bil Varus Femur LDFA: 103 89 11 ms

7 M 3 Bil Varus Femur LDFA: 100 87 12 ms

8 F 4 Bil Valgus Femur LDFA: 79 88 9 ms

9 M 6 Bil Varus Femur LDFA: 97 85 10 ms

10 F 4 Bil Varus Tibia MPTA: 78 86 6 ms

11 F 4 Bil Varus Femur / Tibia LDFA:96/MPTA: 80 LDFA:89/MPTA: 87 6 ms

12 F 10 Uni Valgus Femur LDFA: 79 86 6 ms

13 M 3 Bil Varus Femur LDFA: 95 86 10 ms

14 M 3 Uni Varus Femur LDFA: 92 85 5 ms

15 M 12 Uni Varus Tibia MPTA: 74 80 12 ms

16 M 11 Uni Varus Tibia MPTA: 78 88 10 ms

17 F 6 Uni Varus Tibia MPTA: 80 87 6 ms

18 F 5 Uni Varus Tibia MPTA: 77 81 12 ms

19 M 7 Uni Valgus Femur LDFA: 75 87 11 ms

20 F 4 Uni Valgus Tibia MPTA: 102 89 12 ms

21 M 3 Bil Varus Femur LDFA: 104 89 12 ms

22 F 8 Bil Varus Femur / Tibia LDFA:97/MPTA: 78 LDFA:87/MPTA: 88 8 ms

View publication stats