Epiphyseal Stapling

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Dear surgeon pods

I wonder if you could give me your opinions on Epiphyseal stapling as a treatment option for Genu Valgum in children over 11 years of age.

I have a young female patient of 10 yrs old who has genu valgum of about 15dgs.
The knee is compliant to adduction moments until the straight position. In gait the right knee abducts to about a 20dgs Q angle and the left to about a 15dg Q angle. The STJ's, which are very medially rotated, pronate and the lateral foot barely contacts the ground. This has resulted in curly varus toes as they have attempted to stabilise the foot on the ground. This was her initial complaint, her 5th tucks under the 4th and is painful when doing sports especially climbing activities.

In gait at weight acceptance the ipsilateral hip internally rotates and adducts, at the same time the pelvis rotates in the frontal plane and the contralateral hip drops as the weight bearing hip raises. This results in a tibial shank that is perpendicular to the ground during stance while the ipsilateral hip is displaced laterally, giving a high Q angle and pronated STJ.

Presently I am intending to use orthoses to increase adduction moments in the stance phase and physiotherapy to stretch and strengthen relevant muscle groups, at present both knee abduct under muscle tension when non weight bearing on couch.

I was wondering about a surgical referral at a later stage if the conservative methods do not work well. Hence the original query. She has been through NHS but has had no treatment offered apart from surgery to straighten the toes. At present the parents are not keen on any type of surgery until other avenues have been explored. Reading about Epiphyseal stapling it appears to be quite reliable with good outcomes and is recommended between the ages of 11 and 15yrs.

Epiphyseal stapling for angular deformity at the knee. Zuege R C et al JBJS 1979
The Correction of genu valgum by epiphyseal stapling. Pistevos C et al JBJS 1977

Obviously these studies are old and I wonder if they are still relevant?

This one is published 2009 and has the same basic conclusions however.

Hemiepiphyseal Stapling for Angular Deformity Correction Around the Knee Joint in Children With Multiple Epiphyseal Dysplasia. Cho JT ea al Journal of Pediatric Orthopaedics 29 (1) 52-56 2009


Many thanks for your attention Dave Smith

 

Hi all

Tried to put a video up but file size was too big. So have put PDF copy in a report style for you to view. If you view the PDF in 'full screen mode' then use the right / left arrows on your key board to flick thru pages it gives the impression of walking.

Cheers Dave

 

Hi David:

My license doesn't extend to the proximal tibial epiphysis. Perhaps a pediatric ortho arena might be better information source.
I only know one pediatric orthopedic and she's a stick in the mud.
I've lost Tachdjian's e-mail address!
(that's a joke)

Steve

 

DrSarbes


Thanks for your reply,
I thought that this procedure may be outside the scope of practice of Pod surgeons but I thought that some may have collaborated with orthopaedic surgeons in this area where there was a common interest in a patient's on going care. In this case they may have been able to pass on their experience of this procedure. I have e mailed orthopaedic surgeons who refer to me with the same question but so far had no reply.

All the best Dave Smith

 

Dave:

Epiphseal stapling has been used for correcting tibial deformities for at least the last 60 years with apparent good success. The problem seems to be in predicting exactly how much growth will occur within the unstapled side of the epiphseal plate after the surgery and before the epiphyseal plate eventually fuses.

Epiphyseal stapling is not an exact science and I have seen patients both with good and not so good results from this procedure. Like any surgery, finding a surgeon that has done a number of these surgeries is going to be the key to obtaining optimal aligninment of the lower extremity in adulthood for this young lady.

Here is one of the original articles for those that are interested in learning more about the procedure.