Orthopedics

Review Article 

Hemiepiphysiodesis for Idiopathic Genu Valgum Using Physeal Staples Versus Tension-Band Plating: A Systematic Review

Derrick M. Knapik, MD; James Buschbach, BS; Sanjeev Sabharwal, MD; Raymond W. Liu, MD

Abstract

This review assesses the outcomes of hemiepiphysiodesis in patients with idiopathic genu valgum (IGV) treated with physeal staples vs tension-band plating (TBP). A systematic review of the literature was conducted to identify articles examining the use of physeal staples vs TBP for the treatment of IGV in skeletally immature patients. No significant difference in overall mean deformity correction (P=.92) or correction per month (P=.61) was observed between groups. Repeat hemiepiphysiodesis was more common in patients who underwent TBP vs physeal staples (P=.05). Tension-band plating did not yield significantly improved results compared with physeal staples in skeletally immature patients with IGV. [Orthopedics. 201x; xx(x):xx–xx.]

Abstract

This review assesses the outcomes of hemiepiphysiodesis in patients with idiopathic genu valgum (IGV) treated with physeal staples vs tension-band plating (TBP). A systematic review of the literature was conducted to identify articles examining the use of physeal staples vs TBP for the treatment of IGV in skeletally immature patients. No significant difference in overall mean deformity correction (P=.92) or correction per month (P=.61) was observed between groups. Repeat hemiepiphysiodesis was more common in patients who underwent TBP vs physeal staples (P=.05). Tension-band plating did not yield significantly improved results compared with physeal staples in skeletally immature patients with IGV. [Orthopedics. 201x; xx(x):xx–xx.]

Angular deformities of the knee in pediatric orthopedic patients arise from extreme variations in normal development. Children normally possess varus angulation of the knee during the first 2 years of life followed by a peak in valgus angulation after age 3.1 By age 6, the tibiofemoral angle (TFA) corrects to 5° to 7° of valgus, which is maintained throughout maturity and into adulthood.1–3 In a small percentage of children, the TFA fails to correct or worsens during growth; this is labeled as pathologic genu valgum, which is defined by valgus angulation measuring more than 10° that persists in children older than 8 years.1,4,5 Approximately 80% of cases are of idiopathic origin, with remaining cases secondary to trauma, metabolic bone disorders, skeletal dysplasias, or other causes.6 When symptomatic, genu valgum may cause pain, joint instability, abnormal gait, and cosmetic concerns, as well as degenerative arthritic knee changes in chronic uncorrected cases.7–10

In skeletally immature patients, hemiepiphysiodesis can temporarily inhibit growth across the medial distal femoral physis, allowing for natural angular correction of the deformity with growth. Hemiepiphysiodesis using physeal stapling to compress the physis traditionally has been used for the treatment of both genu varum and genu valgum. However, reported complications include staple breakage, migration, and premature physeal closure.11,12 In the past decade, the use of tension-band plating (TBP) with nonrigid screws has emerged as an alternative and preferred treatment option. Due to the ability of screws to pivot within the plate with growth at the epiphyseal plate, TBP has been theorized to result in lower rates of premature physeal closure and mechanical failure.12 Furthermore, authors have reported shorter operative times with TBP.13 However, the high cost associated with a TBP implant (approximately US $475 for plate, screws, and guide pins) with a Blount staple (US $75) must be taken into consideration.14

Despite the known advantages and disadvantages of each method, no study has systematically reviewed the literature to demonstrate the efficacy and safety of one treatment option over another for pediatric patients with idiopathic genu valgum (IGV). The purpose of this review was to examine the literature to assess outcomes and complications of hemiepiphysiodesis in skeletally immature patients with IGV treated with either physeal stapling or TBP. Specifically, the authors focused on the outcomes of each technique in terms of the extent of deformity correction, rebound growth, and the prevalence of other associated complications. A secondary analysis examined outcomes based on body mass index (BMI), sex, patient age, and use of single or multiple staples or plates to better understand treatment outcomes based on patient-specific factors.

Materials and Methods

Inclusion Criteria

A systematic review of the literature was conducted to identify articles examining the use of hemiepiphysiodesis for the treatment of IGV in skeletally immature patients. Databases searched included PubMed, Biosis Previews, SPORTDiscus, PEDro, and EMBASE. Searches included a combination of the following terms: “idiopathic genu valgum,” “pediatric,” “angular deformity,” “hemiepiphysiodesis,” “staples,” and “tension-band plating.” The database search was conducted on May 8, 2017.

The inclusion criteria were human subjects, Level I–IV evidence, patients with a chronologic age younger than 18 years at the time of hardware implantation, and primary diagnosis of IGV undergoing surgical procedure for temporary hemiepiphysiodesis using physeal staples or TBP. Exclusion criteria were animal subjects, Level V evidence studies, patients 18 years or older, genu valgum of nonidiopathic etiology (eg, post-traumatic, skeletal dysplasia, metabolic), and permanent epiphysiodesis. A total of 132 citations were identified from the database search. After applying the inclusion and exclusion criteria, 11 studies were identified for further review (Table 1).

Overview of Studies Included in the Review

Table 1:

Overview of Studies Included in the Review

The following values were recorded in regard to measurements of correction values: intermalleolar distance (IMD), hip-knee-ankle angle (HKA), TFA, mechanical and anatomic lateral distal femoral angle (mLDFA and aLDFA, respectively), and mechanical axis deviation. As a means of standardizing correction values, the authors assumed equivalence between HKA, TFA, mLDFA, and aLDFA values. Due to the lack of a defined standardized difference for the studies included, the authors assumed degrees of “rebound growth” and “deformity recurrence” were equal and were defined solely as “rebound growth.” Moreover, not all of the studies defined “obesity” based on BMI; as such, the authors differentiated “obese” and “non-obese” patients by the way they were reported in the studies used. Unplanned repeat surgery was defined as any surgical revision that did not include planned removal of surgical hardware.

Statistical Analysis

Statistical analysis was performed to evaluate the differences in mean deformity correction, time from implant placement to removal, and overall complication rate in patients treated with physeal staples vs TBP for IGV. A secondary analysis was performed to assess for variables predictive of differences in mean correction rate, mean rebound growth, and need for repeat hemiepiphysiodesis in groups of patients treated with either physeal staples or TBP. These variables consisted of obesity status based on BMI, patient sex, patient age, and whether patients underwent hemiepiphysiodesis at 1 or 2 physes at the time of surgery. Continuous variables were compared using t test, and categorical variables were compared using the chi-square test; P<.05 was considered statistically significant. All statistical analyses were performed using SPSS version 23 software (IBM, Armonk, New York).

Results

Deformity Correction

Deformity correction was reported in 252 patients (n=501 knees) in the 11 studies identified, consisting of 175 (n=349 knees) patients treated with physeal stapling and 77 patients (n=152 knees) undergoing TBP (Table 1). Mean time from implant insertion to removal was similar for patients treated with physeal staples (12.8±7 months) and TBP (11.9±1.9 months) (P=.80).

Mean angular deformity correction based on HKA, TFA, mLDFA, and aLDFA values at final follow-up were not significantly different overall in patients undergoing physeal stapling (7.6°±2.7°) vs TBP (7.5°±2.4°) (P=.92). Overall deformity correction per month based on HKA, TFA, mLDFA, and aLDFA values also were not significantly different for patients undergoing physeal stapling (0.73°±0.4° per month) vs TBP (0.64°±0.3° per month) (P=.61). Four studies6,15–17 that reported IMD correction following physeal stapling found a mean correction of 9.1±2.2 cm; only one study15 recorded IMD change of 9.7 cm following TBP, preventing any statistical analysis.

Rebound Growth

Three studies6,9,18 examining 258 knees treated with physeal staples reported on the degree of rebound growth based on TFA and LDFA values in patients treated with staples with a mean rebound of 3.8° at the time of maturity. Volpon17 reported 2 cases of rebound based on IMD changes of 7 cm and 8 cm following staple removal. Only Burghardt and Herzenberg19 reported on rebound following TBP, which occurred in a single patient with a 3° LDFA following implant removal from the distal femur. Kulkarni et al20 reported rebound growth in 2 patients treated with TBP requiring repeat surgery; however, values were not provided.

Complications

Patients undergoing TBP had a significantly higher risk of requiring repeat surgery due to recurrent deformity (8.8%) compared with patients undergoing stapling (3%) (P=.05) (Table 2). No statistically significant differences in undercorrection, overcorrection, iatrogenic deformity, or hardware failure following hemiepiphysiodesis using physeal stapling or TBP were found. One patient treated with revision surgery to replace loose staples developed a physeal bar formation.17

Complication Rates for Patients Treated With Physeal Staples Versus Tension-Band Plating

Table 2:

Complication Rates for Patients Treated With Physeal Staples Versus Tension-Band Plating

Factors Affecting Correction, Rebound Growth, and Repeat Surgery

A trend toward faster correction rates was appreciated following physeal stapling in nonobese (P=.05), male (P<.01), and younger (<11 years in females, <13 years in males; P<.01) patients, along with those treated with TBP at 2 physes compared with 1 physis (P=.03) (Table 3). Patients treated with staples at 2 physes compared with 1 physis possessed significantly greater rebound growth based on HKA measurements (P=.04). Patients younger than 12 years treated with TBP were found to be at significantly higher risk for repeat hemiepiphysiodesis compared with patients 12 years and older (P<.01). No significant variable was associated with an increased risk for repeat surgery in patients treated with physeal staples (Table 4).

Subgroup Analysis of Mean Deformity Correction and Rebound Growth

Table 3:

Subgroup Analysis of Mean Deformity Correction and Rebound Growth

Subgroup Analysis on Prevalence of Repeat Hemiepiphysiodesis

Table 4:

Subgroup Analysis on Prevalence of Repeat Hemiepiphysiodesis

Discussion

The purpose of this systematic review of the literature was to identify outcomes and patient-specific factors affecting outcomes in pediatric patients with IGV treated with either physeal stapling or TBP. The primary findings from this study were that no significant differences in correction rates or complication rates were observed between treatment groups. Moreover, faster correction rates were observed in patients treated with physeal staples who were nonobese, male, and younger (<11 years in females and <13 years in males), as well as in patients treated with TBP at 2 physes compared with 1 physis. Finally, patients younger than 12 years were found to be at higher risk for repeat hemiepiphysiodesis compared with patients 12 years and older.

Although no significant differences in correction time were appreciated, because of the various measures of correction reported in the literature, comparing deformity correction across all of the studies was not possible. When initially introduced, TBP was proposed to have a 30% faster correction rate compared with traditional stapling methods.12 However, subsequent studies have shown no significant difference between TBP and stapling in correcting angular deformities of varying etiologies.13,15,19,21,22 When examining patients specifically with IGV, Gottliebsen et al15 found similar correction rates in patients treated with physeal staples (n=10) and plates (n=10). However, the study was limited by small sample size and being underpowered, with a possible gender bias as more females underwent TBP than males. As such, this review provides little evidence regarding the efficacy of 1 treatment option over the other in regard to deformity correction, warranting long-term prospective studies incorporating homogenous measures of correction.

No significant differences in complication rates were found when comparing physeal stapling with TBP. This finding corroborates the results reported in 2 previous studies comparing physeal stapling and TBP.13,21 Gottliebsen et al15 theorized that lack of complication differences could be related to the biologic effect about the knee being equal in both techniques. The potential for premature physeal closure traditionally was believed to be a limitation in the treatment of preadolescent patients with physeal staples.18,23,24 However, this review identified only a single case in a patient undergoing epiphyseal stapling, whereas the investigation by Mielke and Stevens25 of 25 children younger than age 10 undergoing stapling found no cases of premature physeal closure. In regard to hardware failures, poor insertion techniques were cited as a significant factor, with Pistevos and Duckworth26 citing such mistakes resulted in staple extrusion and Aslani et al27 reporting incorrectly selected screws (4-mm noncannulated cancellous instead of cortical screws) resulted in plate failures. Furthermore, staple extrusion and screw breakage in TBP is reported more frequently in cases of pathologic genu varum, especially in patients with Blount disease.19,28

A trend toward faster correction was found in nonobese, male, younger patients with IGV treated with physeal stapling or patients undergoing TBP treated at more than 1 physes. The suppression of the medial distal femoral growth plate in obese patients has been documented in Blount disease, and a similar albeit less severe process may occur in obese IGV patients.29 Furthermore, potential metabolic factors likely play a role in the slowed correction rate. Increased correction and repeat hemiepiphysiodesis in younger patients is likely caused by the inherent sustained amount of growth possible following hardware removal.25 This also may account for the increased rates seen in males, who typically undergo puberty with continued growth 2 years after females generally reach the end of puberty. However, further research is necessary to better understand the impact of patient-specific factors on outcomes following physeal stapling and TBP.

Compared with traditional techniques of deformity correction, namely tibial osteotomies, the use of either physeal staples or TBP possess potential advantages. Both growth modulation techniques represent minimally invasive approaches to facilitate guided growth, minimizing risks of neurovascular injury, compartment syndrome, and growth plate injury compared with more invasive osteotomy procedures.30,31 Moreover, studies have demonstrated successful growth modulation using even less invasive, percutaneous techniques for the placement of both physeal staples32 and TBP, resulting in decreased operative time, radiation exposure, and incision size.33 As such, despite the higher cost associated with TBP compared with physeal staples, advancements in both techniques have led to cost savings with shorter operative and healing times.

Limitations

This review was not without limitations. Due to the inherent weaknesses of the individual studies included in the analysis and the absence of reported outcomes in many studies, the authors were limited in their ability to test for additional difference between the treatment methods. Moreover, studies did not differentiate between rebound growth and recurrence of deformity in regard to redemonstration of valgus angulation following device removal. As such, the authors combined values from both reported measurements.

This study also focused only on the effects of hemiepiphysiodesis in children with IGV, excluding those with genu valgum of pathologic etiology. Studies have shown that normal and pathologic physes have different outcomes in response to hemiepiphysiodesis, with pathologic physes demonstrating slower rates of correction and higher rates of failure and complications.7,21,24 Consequently, the findings reported in this review cannot be generalized to include nonidiopathic causes and their outcomes following hemiepiphysiodesis.

Few studies recorded surgical times, preventing any meaningful statistical analysis from being performed to compare differences between patients treated with physeal staples vs patients treated with TBP. Moreover, due to the small sample size in each subgroup, the authors were unable to perform any multivariable analysis based on obesity, chronologic age, and the number of physes treated. Further research is necessary to evaluate the use of physeal staples and TBP in the context of pathologic causes of genu valgum, as one device might prove more effective in pathologic situations.

Conclusion

Despite the growing popularity of TBP over physeal staples due to concern for breakage, migration, and premature physeal closure related to physeal stapling, no significant differences in the angular correction rate or complication rate were noted in pediatric patients treated with temporary hemiepiphysiodesis for IGV. Faster deformity correction rates were seen in patients treated with physeal staples who were nonobese, younger (<11 years in females and <13 years in males), and male, as well as patients treated with TBP at 2 physes vs 1 physis. Randomized, prospective clinical studies using homogenous measurement parameters of deformity correction and rebound growth, factoring in surgical, implant, and complication-related costs, as well as the incidence of inadvertent premature physeal closure, are needed to further elucidate the ideal implant type for temporary hemiepiphysiodesis in pediatric patients with IGV.

References

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Overview of Studies Included in the Review

StudyLevel of EvidenceJournal (Year)Operative TreatmentImplant LocationNo. of Patients (Knees)Treatment Time, moCorrection Values

IMDHKA/TFALDFA
Gottliebsen et al15IIIActa Orthop (2013)3 staplesDF10 (20)119.5 cmNRmLDFA: 8.3°
Degreef et al6IVActa Orthop (2003)3 staplesDF/PT44 (88)711 cmHKA: 9°NR
Courvoisier et al16IVJ Child Orthop (2009)Single staplePT9 (18)256 cmHKA: 9°mLDFA: 2°
Stevens et al9IVJ Pediatr Orthop (1999)2 staplesDF76 (152)10NRTFA: 9.4°aLDFA: 9°
Volpon17IVInt Orthop (1997)3 staples36 DF, 10 DF/PTMale, 13 (26); female, 10 (20)11Male, 10 cm; female, 10 cmTFA: male, 8°; female, 10°NR
Zuege et al18IVJBJS (1979)2 to 3 staplesPT or DF13 (25)NRNRTFA: 5°NR
Gottliebsen et al15IIIActa Orthop (2013)TBPDF10 (20)119.7 cmNRmLDFA: 6.5°
Burghardt and Herzenberg19IVJ Orthop Sci (2010)TBP8 DF, 3 PT6 (11)14NRNRmLDFA: 6°
Boero et al7IVJ Child Orthop (2011)TBPPT, DF, or DF/PT30 (60)11NRTFA: 9°NR
Guzman et al8IVJ Child Orthop (2011)1 or 2 TBP41 DF, 6 DF/PT24 (47)13.5NRTFA: 5.2°aLDFA: 5°
Kulkarni et al20IVIndian J Orthop (2015)TBPNR1 (2)13NRTFA: 11.5°NR
Niethard et al22IVZ Orthop Unfall (2010)TBP9 DF, 3 DF/PT6 (12)9NRNRmLDFA: 9°

Complication Rates for Patients Treated With Physeal Staples Versus Tension-Band Plating

ComplicationTreatmentNo. of PatientsComplication RateP
UndercorrectionStaples2340.9%.95
TBP1090.9%
OvercorrectionStaples2342.1%.12
TBP1090%
Repeat surgeryStaples2343.0%.05
TBP578.8%
Iatrogenic deformity (recurvatum, LLD)Staples2343.0%.53
TBP1091.8%
Hardware failureStaplesa2341.7%-
TBP1000%

Subgroup Analysis of Mean Deformity Correction and Rebound Growth

SubgroupNo. of KneesMean Rate of Correction (Monthly)PNo. of KneesMean ReboundP
Staples
  Obese38HKA: 1.30°.05a38HKA: 4.00°.33
  Nonobese50HKA: 1.65°50HKA: 4.58°
  Male52HKA: 1.79°<.01a62HKA: 4.18°.14
  Female36HKA: 1.08°44HKA: 3.75°
  Age ≥13 y, male78HKA: 1.31°90HKA: 3.89°.18
  Age ≥11 y, female<.01a
  Age <13 y, male10HKA: 2.97°16HKA: 6.19°
  Age <11 y, female
  1 physisNANA20HKA: 2.75°.04a
  2 physesNA86HKA: 4.58°
Plates
  ObeseNANANA
  NonobeseNANA
  Male9LDFA: .88°.70
  Female11LDFA: .95°
  Age ≥13 y, male5LDFA: .82°
  Age ≥11 y, female.64
  Age <13 y, male15LDFA: .95°
  Age <11 y, female
  1 physis19MAD: 2.26.03a
  2 physes3MAD: 4.28

Subgroup Analysis on Prevalence of Repeat Hemiepiphysiodesis

SubgroupTotal No. of PatientsNo. of Repeat SurgeriesP
Staples
  Obese191 (5.3%).84
  Nonobese251 (4%)
  Male531 (1.9%).81
  Female381 (2.6%)
  Age ≥12 y592 (3.4%).58
  Age <12 y90 (0)
  1 physis1455 (3.5%).44
  2 physes582 (3.5%)
Plates
  ObeseNANANA
  NonobeseNANA
  MaleNANANA
  FemaleNANA
  Age ≥12 y320 (0)<.01a
  Age <12 y154 (26.7%)
  1 physisNANANA
  2 physesNANA
Authors

The authors are from the Department of Orthopaedic Surgery (DMK, RWL), University Hospitals, and Rainbow Babies and Children's Hospital (DMK, JB, RWL), Case Western Reserve University School of Medicine, Cleveland, Ohio; and Rutgers New Jersey Medical School (SS), Newark, New Jersey.

Dr Knapik, Mr Buschbach, and Dr Sabharwal have no relevant financial relationships to disclose. Dr Liu receives royalties from Orthopediatrics Corporation.

Correspondence should be addressed to: Derrick M. Knapik, MD, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, 11100 Euclid Ave, Cleveland, OH 44106 ( derrick.knapik@gmail.com).

Received: August 30, 2018
Accepted: November 02, 2018
Posted Online: July 26, 2019

10.3928/01477447-20190723-04

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