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Temporary Screw Epiphysiodesis for Ankle Valgus in Children

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Temporary Screw Epiphysiodesis for Ankle Valgus in Children Acta Orthop. Belg., 2020, 86 e-supplement 1, 37-43 ORIGINAL STUDY Temporary screw epiphysiodesis for ankle valgus in children Stefan Gaukel, Svenja Leu, Samuel R. SkovGaard, C. aufdenblatten, Leonhard E. ramseier, Raphael N. vuille-dit-bille From the Pediatric Surgery, Children’s Hospital Colorado, Aurora, CO The aim of this case series was to assess clinical different etiologies including multiple exostoses, outcomes and achievable correction grades following Ollier’s disease, Larsen’s syndrome, type 1 temporary percutaneous medial malleolar screw neurofibromatosis, and neurological disorders have epiphysiodesis. been implicated (1). Ankle valgus generally leads A retrospective chart review of 16 consecutive children to gait instability, pain, and problems wearing with ankle valgus (23 ankles) treated with medial shoes. Treatment options consist of supramalleolar malleolar screw epiphysiodesis in one single institution was performed. Tibiotalar angle, fibular station, and osteotomy and medial malleolar screw epiphysiodesis. the lateral distal tibial angle were measured before While supramalleolar osteotomy reflects an invasive screw epiphysiodesis, and before and after hardware procedure requiring hospitalization, immobilisation removal. and delayed weight bearing, medial malleolar screw Mean mechanical and anatomical lateral distal tibial epiphysiodesis offers a less invasive therapy with angles were significantly improved by epiphysiodesis satisfactory outcomes (16,9). Screw epiphysiodesis (75.6° to 85.2° and 75.7° to 85.3°, respectively, p was first described by Métaizeau in 1998 (11). < 0.005). Similarly, mean tibiotalar angle was The aim of the present study was to assess the significantly improved by screw epiphysiodesis when correction of ankle valgus following temporary comparing to the last follow-up before screw removal (5.8° to 14.2°, p < 0.005). We observed a slight rebound following screw removal. n Gaukel Stefan1*, MD. Temporary medial malleolar screw epiphysiodesis is n Leu Svenja2*. an effective method to treat ankle valgus in children. n Skovgaard Samuel R.3, MD. n Aufdenblatten, C.4, MD. Level of Evidence: Level 4 n Ramseier Leonhard E.5, MD. 6 Keywords: Screw epiphysiodesis ; ankle valgus. n Vuille-dit-Bille Raphael N. , MD, PhD. 1Department of Orthopaedic Surgery and Traumatology, Cantonal Hospital Winterthur, Switzerland; 2University of Zurich, Switzerland; 3University of Arizona School of Medicine INTRODUCTION | Department of Surgery 4Department of Orthopaedic Surgery and Traumatology, University Children’s Hospital of Zurich, Ankle valgus is defined as an eversion of the Switzerland; 5OrthoClinic Zurich, Switzerland; 6Department calcaneus relatively to the tibia resulting in foot of Pediatric Surgery, Children’s Hospital Colorado Correspondence: Raphael N. Vuille-dit-Bille, Pediatric pronation and sometimes lateral translocation of Surgery, Children’s Hospital Colorado, 13123 E 16th Ave, the talus (4). This deformity is rare in children and Aurora, CO 80045, phone: +1 720 473 30 13 E-mail : [email protected] ©2020, Acta Orthopaedica Belgica. Conflict of interest: All authors declare that they have not received any funding or other benefits in support of this study. No relevant financial relationships to disclose. Acta Orthopædica Belgica, Vol. 86 e-Supplement - 1 - 2020 38 Gaukel et al. screw ephiphysiodesis using a transphyseal medial Table I. — Patients’ data malleolar screw. Mechanical and anatomical lateral Total number (n) of 23 distal tibial angle (LDTA), tibiotalar angle and extremities fibular station were hence assessed before screw Total number (n) of patients 16 epiphysiodesis, as well as before and after implant Unilateral/Bilateral 9/7 removal. Gender (Male/Female) 9/7 Laterality (Left/Right) 10/13 Age at epiphysiodesis PATIENTS AND METHODS 145 (132.2 - 157.5) [months] Age at screw removal 161.4 (149.6 - 173.2) In the current study 23 ankles in 16 patients (7 [months] females and 9 males), who underwent temporary Mean time screw in situ 16 (12.7 - 19.3) epiphysiodesis using a transphyseal medial [months] malleolar screw between 2010 and 2014 at one Values are given as absolute values or as mean with 95% single institution in Zurich, Switzerland, were Confidence Intervals in brackets included. All included patients were diagnosed with ankle valgus as confirmed by clinical exam implantation or removal, respectively. Hence no and radiographs. Patients’ charts including their re-operation due to complications was necessary. pre-, postoperative and follow-up x-ray images Several patients had concomitant diseases, were retrospectively reviewed. Angles were including clubfoot (one patient), myelomeningocele digitally measured using the picture archiving and (three patients), Down Syndrome (one patient), communication system (PACS) by two independent dysmorphia syndrome (one patient), cerebral palsy observers (SG and SL). (one patient), and Pseudoachondroplasia (one All patients underwent screw removal during patient). the study period and follow-up radiological images Patient’s bone age was assessed according to the were available. Two patients received additional ‘Greulich and Pyle method’ based on x-rays of the distal tibial osteotomy during screw removal. left hand, fingers, and wrist that are compared to the In total 10 left-sided (43,5%) and 13 right-sided bones of a standard atlas. (56,5%) screw epiphysiodeses were performed. The present study was approved by the local Seven (30%) patients had bilateral surgery. Mean ethics committee. Informed consent was obtained patients’ age at first surgery was 12 years (ranging from all patients’ parents or legal representatives. from 8.6 to 16.3 years). Mean patients’ body mass Four different outcomes were assessed in the index (BMI) was 18.41 kg/m2 (ranging from 14.8 present study: Mechanical (i) and anatomical (ii) to 23.2 kg/m2). Screw removal was carried out 16 lateral distal tibial angle (LDTA), tibio-talar angle months after epiphysiodesis on average (ranging (iii), and fibular station (iv). from 3 to 31 months). Last follow-up before Lateral distal tibial angle describes the angle removal was carried out following 14.1 months between mechanical or anatomical axis of tibia (ranging from 3 to 31 months) after implantation, and tibial plafond with a norm of 89 +/- 3 degrees. respectively 1,7 months (0 - 11 months) before (11) Hence valgus deformity was diagnosed when screw removal. Follow-up after screw removal was LDTA was < 86° (7). carried out 6.7 months (2 - 22 months) thereafter Tibiotalar angle describes the angle between (Table I). Of note, in 20 of 23 screw implantations anatomical axis of tibia and tangential line to the and in 22 of 23 implant removals, additional talar dome minus 90 degrees. Hereby a tibiotalar surgical procedures not aiming at correcting a angle of >10° was considered to be a valgus valgus deformity of the ankle were performed. deformity (2). Fibular station in relation to the No complications (such as wound infections, distal tibio-talar joint was assessed in weight- non-healing wounds, implant failures, screw bearing antero-posterior radiographs according to dislocations, etc.) occurred following screw Malthora’s classification (10). Acta Orthopædica Belgica, Vol. 86 e-Supplement - 1 - 2020 temporary screw epiphysiodesis for ankle valGus in children 39 Digital measurements were executed using the RESULTS build-in PACS viewing system SECTRA Workstation IDS7 (16.2.30.2401, 2015, Sectra AB, Linköping, Mean mechanical and anatomical LTDA were Sweden). All radiographic measurements were significantly (p < 0.001) improved on last follow- performed twice independently by two authors up before implant removal (85.2° and 85.3° on (SL and SG). Differences in measurements of average, respectively) when compared to values mechanical and anatomical LDTA greater than prior epiphysiodesis (75.6° and 75.7° on average, 5 degrees were re-evaluated by both authors and respectively). After screw removal values for angles resulted in independent re-measurements. decreased to 82.5° and 82.9° on average (excluding Ankle valgus was documented with long two patients with additional osteotomy during implant radiographs (overall lower extremity) as well as removal), but still showed significant improvement anteroposterior view radiographs of knee to foot compared to initial angles (Figure 1a and 1b). and foot with ankle preoperatively, prior to screw Similarly, mean tibiotalar angle was significantly removal, and at follow-up after screw removal. (p < 0.001) larger (14.2°) before screw epiphysiodesis Mechanical LDTA, anatomical LDTA , tibio-talar when comparing to the last follow-up before screw angle, and fibular station were measured for all removal (5.8°) (Figure 1c). these radiographs. Mean degree of angle correction with screw in Surgery was performed by four orthopedics situ was 1.17°/month in mechanical axis, 1.19°/ surgeons or under their direct supervision. A small month in anatomical axis and -0.5°/month in incision over the tip of the medial malleolus was tibiotalar angle. performed. An unthreaded K-wire was inserted Excluding two patients receiving additional under fluoroscopic control. Finally, a cannulated osteotomy during implant removal, we observed 4.0 mm (in diameter) screw was placed over the a mean rebound of angles after screw removal of wire, and the wound was closed. -2.7° in mechanical axis, -2.4° in anatomical axis Patients were allowed to bear weight fully and 3.0° in tibiotalar angle. Rebound seemed to be immediately
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