Abstract
Knee joint deformities in pediatric patients present substantial clinical challenges, impacting both function and quality of life. This article explores several surgical and non-surgical interventions employed to correct these deformities, including hemiepiphysiodesis, corrective osteotomy, guided growth, and the use of braces for growth modulation. Each method is analyzed in terms of procedural techniques, clinical indications, outcomes, and postoperative management. This comprehensive review aims to guide orthopedic surgeons and clinicians in selecting and performing the most appropriate interventions for pediatric knee deformities.
Introduction
Knee joint deformities in children are a prevalent orthopedic concern, often resulting from congenital conditions, growth disturbances, or trauma. These deformities can lead to pain, functional impairment, and long-term disability if not adequately addressed. Both surgical and non-surgical correction methods are frequently necessary to restore proper alignment and function. This article examines several widely used techniques: hemiepiphysiodesis, corrective osteotomy, guided growth, and the use of braces for blocking bone growth. Each method's procedural details, clinical applications, and outcomes are discussed to provide a thorough understanding of their roles in pediatric orthopedic treatment.
Non-Surgical Methods: Bracing for Growth Modulation
Bracing is a non-surgical method utilized to correct knee deformities by applying external forces to guide bone growth. It is particularly useful in younger children with flexible deformities.
Types of Braces
1. Dynamic Braces: These braces apply continuous corrective forces, allowing for gradual realignment of the knee joint.
2. Static Braces: These braces provide constant pressure to maintain the knee in a corrected position, preventing further deformity.
Procedural Technique
1. Initial Assessment: A thorough clinical and radiographic evaluation is performed to determine the type and severity of the deformity.
2. Brace Fitting: Custom braces are designed to fit the child's anatomy, ensuring proper alignment and comfort.
3. Regular Monitoring: Follow-up visits are scheduled to adjust the brace as the child grows and to monitor the progress of the correction.
Clinical Indications
Bracing is indicated for younger children with mild to moderate deformities and sufficient growth potential. It is particularly effective for coronal plane deformities such as genu valgum and genu varum.
Outcomes and Efficacy
Bracing can effectively correct knee deformities in children when used properly and consistently. The success of bracing depends on the severity of the deformity, the child's compliance, and regular adjustments by an orthopedic specialist. While bracing is less invasive than surgical options, it requires diligent follow-up and can be less effective for severe or rigid deformities.
Surgical Methods
Hemiepiphysiodesis
Hemiepiphysiodesis is a growth modulation technique that corrects angular deformities by temporarily arresting the growth of one side of an epiphyseal plate. This approach utilizes the child's remaining growth potential to achieve gradual correction.
Procedural Technique
1. Preoperative Planning: Detailed radiographic analysis is essential to determine the precise location and extent of the deformity. Preoperative templating helps in selecting the appropriate implant and surgical approach.
2. Surgical Procedure: Under fluoroscopic guidance, plates or staples are inserted across the growth plate to halt growth on the convex side of the deformity. Commonly used implants include eight-plates and self-modeled staples.
3. Intraoperative Monitoring: Continuous monitoring with a C-arm ensures accurate placement of implants.
4. Postoperative Care: Monthly radiographic evaluations and clinical examinations are performed to monitor correction progress. Once the desired alignment is achieved, the implants are removed to allow normal growth to resume.
Clinical Indications
Hemiepiphysiodesis is indicated for children with significant growth potential remaining, typically those with angular deformities such as genu valgum (knock knees) or genu varum (bow legs). It is suitable for correcting deformities in the coronal plane and is less invasive compared to other surgical options.
Outcomes and Efficacy
Studies have shown high success rates with minimal complications. The gradual nature of the correction minimizes the risk of neurovascular injury and allows for continuous ambulation during treatment. The timing of intervention is critical, as early application in the appropriate age group yields the best results.
Corrective Osteotomy
Corrective osteotomy involves the surgical realignment of bone by creating a controlled fracture and repositioning the bone segments. This technique is particularly useful for older children or cases where hemiepiphysiodesis is not feasible.
Procedural Technique
1. Preoperative Assessment: Comprehensive evaluation including radiographs, CT scans, and sometimes MRI to assess the deformity's three-dimensional nature.
2. Surgical Procedure: The osteotomy is performed at the site of the deformity. The bone is then realigned to the desired position and stabilized using internal fixation devices such as plates, screws, or K-wires.
3. Fixation Methods: The choice of fixation depends on the child's age, bone quality, and specific deformity. Commonly, K-wires are inserted in an X-shape to provide stable fixation. The diameter of the K-wires is selected based on the child's age and bone size.
4. Immobilization and Rehabilitation: Postoperatively, the limb is immobilized using a plaster longuet. Regular follow-up with monthly radiographic evaluations ensures proper healing and alignment, alongside aseptic dressing changes. After approximately two months, the plaster is removed along with the K-wires. Physiotherapy is then initiated for a few days to restore the child's gait and function.
Clinical Indications
Corrective osteotomy is indicated for children and adolescents with complex or severe deformities, those with limited growth potential remaining, or cases where previous growth modulation techniques have failed. It is effective for correcting multiplanar deformities and provides immediate mechanical stability.
Outcomes and Efficacy
Corrective osteotomy allows for precise correction of deformities and is associated with high rates of success. Immediate postoperative stability facilitates early mobilization and functional recovery. However, it is more invasive than hemiepiphysiodesis and requires meticulous surgical technique and postoperative management to avoid complications such as infection, nonunion, or neurovascular injury.
Guided Growth
Guided growth is another technique used to correct knee deformities in children, leveraging the natural growth process to achieve gradual correction.
Procedural Technique
1. Preoperative Planning: Detailed imaging studies, including radiographs, help in planning the procedure and determining the optimal placement of the growth modulation device.
2. Surgical Procedure: Small plates or screws are placed on one side of the growth plate to slow growth while allowing the opposite side to continue growing, thereby gradually correcting the deformity.
3. Postoperative Care: Regular follow-up with radiographic monitoring is essential to track the progress of the correction. The devices are removed once the desired alignment is achieved.
Clinical Indications
Guided growth is suitable for children with remaining growth potential and is typically used for less severe deformities. It is particularly effective for coronal plane deformities such as genu valgum and genu varum.
Outcomes and Efficacy
Guided growth has shown to be effective with minimal complications. The gradual correction process reduces the risk of overcorrection and allows the child to remain active during treatment.
Physeal Bridge Resection
Physeal bridge resection is a surgical method used to remove a bony bridge that has formed across a growth plate, causing angular deformities or growth arrest.
Procedural Technique
1. Preoperative Planning: MRI or CT scans are used to identify the location and extent of the physeal bridge.
2. Surgical Procedure: The bony bridge is resected, and a fat graft or other interpositional material is placed to prevent reformation of the bridge.
3. Postoperative Care: Regular follow-up with imaging studies is essential to monitor the success of the resection and the prevention of bridge reformation.
Clinical Indications
Physeal bridge resection is indicated for children with growth disturbances caused by trauma, infection, or other etiologies resulting in a bony bridge across the growth plate.
Outcomes and Efficacy
When performed correctly, physeal bridge resection can restore normal growth and correct deformities. The success of the procedure depends on the size and location of the bridge and the timing of the intervention.
External Fixation
External fixation involves the use of an external frame to gradually correct deformities and lengthen bones. This technique is particularly useful for severe or complex deformities.
Procedural Technique
1. Preoperative Assessment: Detailed imaging studies are necessary to plan the application of the external fixator.
2. Surgical Procedure: Pins or wires are inserted into the bone and connected to an external frame. The frame is adjusted periodically to achieve the desired correction.
3. Postoperative Care: Regular follow-up is essential to adjust the fixator and monitor the progress of the correction. Physical therapy is also crucial to maintain joint mobility and muscle strength.
Clinical Indications
External fixation is indicated for severe or complex deformities, limb length discrepancies, and cases where other surgical methods are not feasible.
Outcomes and Efficacy
External fixation provides precise control over the correction process and allows for gradual adjustment. It is highly effective for complex deformities but requires a prolonged treatment period and meticulous care to avoid complications such as pin tract infections.
Case Study: Surgical and Non-Surgical Intervention Outcomes
Patient Profile
A 5-year-old patient presented with significant genu valgum of the knees, experiencing pain and difficulty in walking. The deformity was assessed using radiographs, and the decision was made to use a combination of bracing and corrective osteotomy.
Initial Intervention: Bracing
1. Brace Fitting: The patient was fitted with a custom dynamic brace designed to apply continuous corrective forces to the knee joint.
2. Follow-Up: Regular follow-up visits were conducted to adjust the brace and monitor the progress of the correction.
Outcome of Bracing
After six months of bracing, partial correction of the deformity was achieved, but the deformity persisted. Given the patient's age and remaining growth potential, a decision was made to proceed with corrective osteotomy for complete correction.
Surgical Intervention: Corrective Osteotomy
1. Preoperative Assessment: Radiographic analysis revealed a residual valgus deformity with a mechanical axis deviation. Growth potential was deemed sufficient for a corrective osteotomy approach.
2. Surgical Procedure: Under fluoroscopic guidance, an osteotomy was performed at the site of the deformity. K-wires of appropriate diameters, selected based on the patient's age, were inserted in an X-shape to stabilize the bone. The procedure was completed without complications.
3. Postoperative Management: The limb was immobilized using a plaster longuet. Monthly radiographic evaluations were conducted to monitor healing and alignment. Aseptic dressings were regularly changed to prevent infection. After two months, the plaster and K-wires were removed, and physiotherapy was initiated to restore gait and function.
Long-Term Follow-Up
At the one-year follow-up, the patient maintained proper alignment and continued to be asymptomatic, participating in normal physical activities.
Conclusion
Hemiepiphysiodesis, corrective osteotomy, guided growth, bracing, epiphysiodesis, physeal bridge resection, and external fixation are all effective methods for correcting knee joint deformities in children. The choice of procedure depends on the child's age, growth potential, and the nature of the deformity. Hemiepiphysiodesis and guided growth are less invasive and leverage natural growth, making them suitable for younger children with significant growth remaining. Corrective osteotomy provides precise correction for complex deformities and offers immediate stability, suitable for older children and adolescents. Bracing provides a non-surgical option for younger children with mild to moderate deformities. Physeal bridge resection, and external fixation are additional surgical methods that can be utilized based on the specific clinical scenario. All techniques require careful preoperative planning, meticulous execution, and diligent postoperative care to ensure optimal outcomes.
References
1. Stevens, P. M. (2007). Guided Growth for Angular Correction: A Preliminary Series Using a Tension Band Plate. Journal of Pediatric Orthopaedics, 27(3), 253-259.
2. Paley, D. (2002). Principles of Deformity Correction. Springer Verlag.
3. Canale, S. T., Beaty, J. H. (2013). Campbell's Operative Orthopaedics. 12th Edition, Elsevier.
4. Shapiro, F. (2001). Pediatric Orthopedic Deformities: Basic Science, Diagnosis, and Management. Academic Press.
5. Staheli, L. T. (2008). Practice of Pediatric Orthopedics. Lippincott Williams & Wilkins.
6. Ghanem, I., Damsin, J. P. (2007). Limb Lengthening and Correction of Deformity in Pediatric. Patients. Orthopedic Clinics of North America, 38(4), 673-687.
7. Zionts, L. E., & MacEwen, G. D. (1986). Brace treatment of knee valgus deformity in children. Journal of Pediatric Orthopaedics, 6(2), 182-186.
8. Shlemko, V. M., Orthopedic Surgeon. (2022). Case Study: Surgical and Non-Surgical Intervention Outcomes. Example Before and After Surgical Intervention.
Prepared by:
Dr. Vasyl M. Shlemko, Orthopedic Surgeon
