318 Case report
The successful treatment of genu recurvatum as
a complication following eight-Plate epiphysiodesis in
a 10-year-old girl: a case report with a 3.5-year follow-up
Arthur J. Kievita, Dennis C. van Duijvenbodeb and Michel H.J. Stavenuiterb
We report a case of genu recurvatum following
eight-Plate epiphysiodesis and the successful treatment
of this complication. A 10-year-old patient underwent
epiphysiodesis of the knee with eight-Plates.
She was followed up and genu recurvatum developed
as a complication. At the 12-month follow-up after
epiphysiodesis, the treated knee showed a flexion
of 1358 and an extension of 358. Lateral radiograph
evaluation showed an extension change of the
femur. During reoperation, the eight-Plates were
repositioned more posterior, which resulted in
successful treatment of the hyperextension. Eight-Plates
can lead to (treatable) articular surface angle changes
Introduction
If left untreated, growth disorders of the long bones of
the lower limb can affect quality of life, induce gait
disturbances, and lead to pain, and in some cases,
instability. Furthermore, it can affect joints such as the
hip or the ankle and may lead to early osteoarthritis [1,2].
Growth disorders can be treated with epiphysiodesis, for
which several techniques have been described [1,3–5].
Epiphysiodesis is a surgical technique in which the
growth of specific growth plates is halted by fixation. The
use of eight-Plates (Orthofix, McKinney, Texas, USA) as
introduced by Stevens is a relatively new method for
fixation, where staples and screws have been used for
decades [6–12]. The advantages of eight-Plates are fewer
hardware failures, except if used in Blount’s disease [13],
easy insertion technique with guided growth instead
of compressive force, and they leave the epiphysis
untouched if performed correctly [1,2]. There are studies
comparing eight-Plates with staples that suggest that
eight-Plates are a good alternative for staples as they show
less hardware failure and guide growth in a more
controlled manner [2,14]. Usually, these methods are
used for hemiepiphysiodesis. To our knowledge, no report
has described total epiphysiodesis using eight-Plates.
This report provides an insight into what happens with
the femoral condyles with different locations of placing
eight-Plates. The goal of this case report is to report our
experience with this technique and to warn of the
possibility of the following rare complication. It also
shows how this complication can be treated if diagnosed
early.
1060-152X c 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
in the sagittal plane. J Pediatr Orthop B 22:318–321 c
2013 Wolters Kluwer Health | Lippincott Williams & Wilkins.
Journal of Pediatric Orthopaedics B 2013, 22:318–321
Keywords: complication, eight-Plate, guided growth, leg-length discrepancy,
pediatric
a
Department of Orthopaedic Surgery, Orthopaedic Research Center Amsterdam
(ORCA), Amsterdam Medical Center, University of Amsterdam, Amsterdam and
b
Department of Orthopaedic Surgery, Center for Orthopaedic Research Alkmaar
(CORAL), Medical Center Alkmaar, Alkmaar, The Netherlands
Correspondence to Arthur J. Kievit, MD, MSc, Department of Orthopaedic
Surgery, Orthopaedic Research Center Amsterdam (ORCA), Academic Medical
Center, University of Amsterdam, Room G4-242, Meibergdreef 9, 1105 AZ
Amsterdam, The Netherlands
Tel: + 31 205 667 736; fax: + 31 205 669 117; e-mail: a.j.kievit@amc.nl
Case report
On 15 August 2008, a 10-year-old Somalian girl, at that
time, otherwise healthy, was referred to our department
by our pediatric colleagues for examination and treatment
of a 30 mm leg-length difference because of hemihyper-
trophy of the left lower limb. The cause of the
hypertrophy was investigated, but not found. At first,
she was referred to an orthopedic shoemaker for adjusted
shoe wear. However, the patient was unsatisfied with the
cosmetic appearance of the shoe adjustment. It was
decided to treat the growth difference by a surgical
intervention by performing a temporary epiphysiodesis on
6 August 2009 with bilateral eight-Plates on the distal
femur and the proximal tibia, unilateral on the fibula in
accordance with the previous literature [15]. The leg-
length discrepancy was because of both the femur length
and the tibia length; therefore, the choice was made to
perform guided growth of both the femur and the tibia.
The leg-length difference and the plates on the femur as
well as the tibia and fibula are shown in Fig. 1.
Before surgery, flexion was 1501 in both knees and there
was bilateral hyperextension of about 201. The leg-length
difference at the 12-month check-up was 20 mm. Physical
examination showed an increase in extension and a
decrease in flexion of the left knee. It seemed that the
trajectory of movement of the articular surface had
changed. Flexion for the left leg was now 1351 and
extension was 351; for the right leg, this was 160 and 201,
respectively. Two directional radiographs were made. The
anterior–posterior (AP) radiograph showed diverting
screws in all eight-Plates. This confirmed that all plates
DOI: 10.1097/BPB.0b013e3283623b2c

Fig. 1
Leg-length difference both in the femur and in the tibia and fluoroscopy
of the first operation with positioning of the eight-Plates on 6 August
2009.
were placed over the epiphysis. The lateral radiograph
showed an extension rotation of the articular surface of
the femur of roughly 151 (Fig. 2). To correct this
deformity, a reoperation was performed on 22 October
2010. During this procedure, the tibial and fibular eight-
Plates were removed. The femoral eight-Plates were first
removed, after which new eight-Plates were placed.
These were placed slightly posterior to the original
position to allow the knee to correct the angular
deformity by allowing growth on the anterior side while
the posterior growth was inhibited. With regular follow-up
and close monitoring, it was found that the angle of the
epiphysis to the femur shaft on lateral radiograph reduced
from 60.41 preoperative to 71.71 at 7 months and 77.51 at
10 months. At 14 months postoperatively, the leg-length
difference was reduced to 10 mm. Flexion for the left leg
was now 1351 and extension was 101. The angle between
the femur shaft and the epiphysis was reduced to 83.21
compared with 60.41 just before the second operation.
The healthy contralateral side showed an angle of 85.81
on the lateral control radiograph. Figure 3 shows the
clinical situation at reoperation and at 14 months after
the second operation. Figure 4 shows the evolution of the
femur shaft–epiphysis angle over time.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Hyperextension after eight-Plates Kievit et al. 319
Fig. 2
Situation before reoperation showing angular deformity of the femur on
23 September 2010.
Discussion
It is hypothesized that the fact that the eight-Plates were
positioned too far anterior led to rotation of the articular
surface into a position of genu recurvatum. As described
in previous studies, the eight-Plates have a good grip on
the bone and less tendency to extrude than staples [1].
Anterior-positioned eight-Plates have been used to
correct flexion deformity in children with arthrogrypo-
sis [4]. In these patients, creating more extension was the
goal and eight-Plates were placed AP. These results
support the hypothesis that the anterior placement of the
eight-Plates led to the angular deformity of the knee in
our case. One previous case of recurvatum was described
with epiphysiodesis using screws placed too anterior but
we have found no previous reports on this complication
with eight-Plates [16]. In this report, there was no
recommendation on what to do with this finding and how
to correct it.
The case presented in the current study stresses the
importance of positioning of the eight-Plates. The
operative guide does not provide advice on positioning.
We advise positioning the eight-Plates exactly in the
middle of the femur when viewed laterally with 50%
epiphysis anterior and 50% posterior. In our case, the
intraoperative fluoroscopic image was slightly rotated.
Because of this rotation, the sagittal position was more
difficult to judge accurately. It is recommended to check
for accurate positioning of the fluoroscope so that a true
320 Journal of Pediatric Orthopaedics B 2013, Vol 22 No 4

lateral image is obtained intraoperative; the operating
room should not be left without having obtained a good
straight lateral radiograph. In hindsight, on the initial
Fig. 3
Clinical situation at reoperation on (a) 22 October 2010 and at the
14-month follow-up at (b) 13 January 2012.
intraoperative AP, the plate on the medial side did not
seem fully lateral, but was placed medial to the most
medial aspect of the bone. This is an indication on the AP
that the plate must be AP (given that the anatomy is
most likely anterior).This also seems the case with the
lateral femoral plate as it is not a simple flat lateral profile
but slightly rotated. Similarly, for the tibial plates, they
seem somewhat anterior, which may or may not have
contributed toward the problem with alignment in this
case (Fig. 1).
Growth retardation and leg-length comparison with the
healthy contralateral side is measured in AP leg-length
radiographs. To detect angular deformities in the sagittal
plane, it is important to always include a perfect lateral
radiograph in the follow-up examination during guided
growth. If detected in time, correction of genu recurva-
tum is easy by repositioning the eight-Plates more
posterior. The recovery will coincide with the growth
speed of the epiphysis, which is dependent on the growth
stage and the age of the patient. The timeline shows a
relatively linear hyperextension growth of 1.31/month
average in the first year following initial placement and a
similar – 1.61 of recovering flexion per month in the years
following the reoperation (Fig. 5). After the reoperation,
the patient had a higher growth rate, which resulted in
faster recovery of the angular deformity than the initial
onset of hyperextension.
Although this is a single report, we believe that it is likely
that the design of the eight-Plates, and the positioning of
use, was responsible for the hyperextension. The new
Quadplates might reduce the risk of unwanted angular
deformities because of the fact that there is a four-point
rigid construction that is less likely to result in unwanted
sagittal deformities. However, this statement is only true
if the principle of central placement of the plate is
not violated. Perhaps it may be more difficult to place
the plate too anterior or posterior, but most likely,

Fig. 4

27-10-2009 23-9-2010 29-11-2010 16-5-2011 28-8-2011 13-01-2012

76° 60.8° 60.4° 71.7° 77.5° 83.2°

Eight-Plates placed more posterior

Development and correction of the extension of articular surface of the femur over time.

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Fig. 5
90.00
80.00
Rotation in degrees
70.00
60.00
50.00
1 January 1 July
2010 2010
Date of radiograph
Graph showing angular growth over time; the angle is the angle in degrees calculated between the femur shaft and the epiphysis of the femur.
asymmetric placement even of the quad plate would lead
to asymmetric growth.
Conclusion
Care should be taken in the positioning of eight-Plates in the
sagittal plane. Preoperative angle measurements of the target
joint surface should be made to check for angular deformities
during follow-up. The operating room should not be left
without having obtained a good straight lateral radiograph and
lateral radiographs should be standard in the follow-up of
patients with bilateral eight-Plates for leg-length discrepan-
cies. Careful attention in evaluating clinical sagittal alignment
and range of motion upon initial evaluation and follow-up is
critical in not missing any unexpected changes in sagittal
alignment because of inadvertent misplacement of plates. If
found in time, operative correction of the eight-Plate
localization is a relatively easy procedure and will stop and
reverse the progression of angulation and will prevent the
possible need for osteotomy in the future.
Acknowledgements
Conflicts of interest
There are no conflicts of interest.
References
1 Ghanem I, Karam JA, Widmann RF. Surgical epiphysiodesis indications and
techniques: update. Curr Opin Pediatr 2011; 23:53–59.
2 Wiemann JM, Tryon C, Szalay EA. Physeal stapling versus 8-plate
hemiepiphysiodesis for guided correction of angular deformity about
the knee. J Pediatr Orthop 2009; 29:481–485.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Hyperextension after eight-Plates Kievit et al. 321
1 January 1 July 1 January
2011 2011 2012
3 Campens C, Mousny M, Docquier PL. Comparison of three surgical
epiphysiodesis techniques for the treatment of lower limb length
discrepancy. Acta Orthop Belg 2010; 76:226–232.
4 Palocaren T, Thabet AM, Rogers K, Holmes L Jr, Donohoe M, King MM,
Kumar SJ. Anterior distal femoral stapling for correcting knee flexion
contracture in children with arthrogryposis – preliminary results. J Pediatr
Orthop 2010; 30:169–173.
5 Horton GA, Olney BW. Epiphysiodesis of the lower extremity: results of the
percutaneous technique. J Pediatr Orthop 1996; 16:180–182.
6 Burghardt RD, Specht SC, Herzenberg JE. Mechanical failures of
eight-plateguided growth system for temporary hemiepiphysiodesis.
J Pediatr Orthop 2010; 30:594–597.
7 Stevens PM, Klatt JB. Guided growth for pathological physes:
radiographic improvement during realignment. J Pediatr Orthop 2008;
28:632–639.
8 Raab P, Wild A, Seller K, Krauspe R. Correction of length discrepancies and
angular deformities of the leg by Blount’s epiphyseal stapling. Eur J Pediatr
2001; 160:668–674.
9 Hasler CC. Leg length inequality. Indications for treatment and importance
of shortening procedures. Orthopade 2000; 29:766–774.
10 Metaizeau JP, Wong-Chung J, Bertrand H, Pasquier P. Percutaneous
epiphysiodesis using transphyseal screws (PETS). J Pediatr Orthop 1998;
18:363–369.
11 Frantz CH. Epiphyseal stapling: a comprehensive review. Clin Orthop Relat
Res 1971; 77:149–157.
12 Stevens PM. Guided growth for angular correction: a preliminary series
using a tension band plate. J Pediatr Orthop 2007; 27:253–259.
13 Schroerlucke S, Bertrand S, Clapp J, Bundy J, Gregg FO. Failure of orthofix
eight-Plate for the treatment of Blount disease. J Pediatr Orthop 2009;
29:57–60.
14 Goyeneche RA, Primomo CE, Lambert N, Miscione H. Correction of bone
angular deformities: experimental analysis of staples versus 8-plate.
J Pediatr Orthop 2009; 29:736–740.
15 McCarthy JJ, Burke T, McCarthy MC. Need for concomitant proximal
fibular epiphysiodesis when performing a proximal tibial epiphysiodesis.
J Pediatr Orthop 2003; 23:52–54.
16 Khoury JG, Tavares JO, McConnell S, Zeiders G, Sanders JO. Results of
screw epiphysiodesis for the treatment of limb length discrepancy and
angular deformity. J Pediatr Orthop 2007; 27:623–628.