Correction and Recurrence of Ankle Valgus in Skeletally Immature Patients With Multiple Hereditary Exostoses

Abstract

Background:

Ankle valgus is encountered in children with a variety of congenital musculoskeletal disorders, including multiple hereditary exostoses (MHE). Guided growth with temporary distal tibial medial hemiepiphysiodesis (DTMH) may correct the deformity; however, exostoses about the ankle commonly observed in MHE patients may hinder correction and increase the risk of recurrence. Thus, the purpose of this study was to review the outcomes of DTMH in treatment of ankle valgus in MHE versus other diagnosis (non-MHE).

Methods:

Medical records and radiographs of patients undergoing DTMH for ankle valgus between January 1, 2005, and November 1, 2010, at a single pediatric orthopedic hospital were retrospectively analyzed. Radiographs obtained preoperatively and at 6-month intervals postoperatively were reviewed and the tibiotalar angle was measured.

Results:

Fifty-eight ankles in 41 patients met inclusion criteria, with minimum follow-up of 12 months (mean, 34 months). Mean age was 10 years (range, 4-14 years). MHE was the most common underlying diagnosis (19 ankles, 33%). The rate of tibiotalar angle correction (mean ± standard deviation) with hardware in place was 0.37 ± 0.28 deg/mo in MHE ankles and 0.51 ± 0.42 deg/mo in non-MHE ankles (P = .161). Following hardware removal, the rate of recurrence was faster in MHE (0.29 ± 0.25 deg/mo) compared with non-MHE ankles (0.12 ± 0.19 deg/mo) (P = .059), and more total recurrent valgus deformity was observed in MHE (7.8 ± 8.2 degrees) than non-MHE ankles (3.4 ± 4.6 degrees) (P = .08) over a similar follow-up period (mean 23.4 vs 23.6 months, respectively), with differences approaching statistical significance.

Conclusion:

MHE is a common cause of ankle valgus in children. Guided growth interventions in this population can be successful but require special consideration given the potential for relatively gradual deformity correction and rapid recurrence following hardware removal in the skeletally immature.

Level of Evidence:

Level III, retrospective comparative study.

Keywords

pediatric tumors ankle valgus multiple hereditary exostoses hemiepiphysiodesis

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References

Chin

Kharrazi

Miller

. Osteochondromas of the distal aspect of the tibia or fibula: natural history and treatment. J Bone Joint Surg Am. 2000;82(9):1269-1278.

Davids

Valadie

Ferguson

. Surgical management of ankle valgus in children: use of a transphyseal medial malleolar screw. J Pediatr Orthop. 1997;17(1):3-8.

De Brauwer

Moens

. Temporary hemiepiphysiodesis for idiopathic genua valga in adolescents: percutaneous transphyseal screws (PETS) versus stapling. J Pediatr Orthop. 2008;28(5):549-554.

Hilton

Gutiérrez

Martinez

. EXT1 regulates chondrocyte proliferation and differentiation during endochondral bone development. Bone. 2005;36(3):379-386.

McCornack

. The surgical management of hereditary multiple exostoses. Orthop Rev. 1981;10:57.

Noonan

Feinberg

Levenda

. Natural history of multiple hereditary osteochondromatosis of the lower extremity and ankle. J Pediartr Orthop. 2002;22(1): 120-124.

Shapiro

Simon

Glimcher

. Hereditary multiple exostoses: anthropometric, roentgenographic, and clinical aspects. J Bone Joint Surg Am. 1979;61(6A):815-824.

Shin

Cho

Park

. Angular deformity correction by asymmetrical physeal suppression in growing children: stapling versus percutaneous transphyseal screw. J Pediatr Orthop. 2010;30(6):588-593.

Stevens

Belle

. Screw epiphysiodesis for ankle valgus. J Pediatr Orthop. 1997;17(1):9-12.

10.

Stevens

Kennedy

Hung

. Guided growth for ankle valgus. J Pediatr Orthop. 2011;31(8):878-883.

11.

Takikawa

Haga

Tanaka

. Characteristic factors of ankle valgus with multiple cartilaginous exostoses. J Pediatr Orthop. 2008;28(7):761-765.

12.

Zak

Schuksz

Koyama

. Compound heterozygous loss of Ext1 and Ext2 is sufficient for formation of multiple exostoses in mouse ribs and long bones. Bone. 2011;48(5):979-987.