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The Successful Treatment of Genu Recurvatum As Following Eigght-Plate Epiphysiodesis
The Successful Treatment of Genu Recurvatum As Following Eigght-Plate Epiphysiodesis
We report a case of genu recurvatum following in the sagittal plane. J Pediatr Orthop B 22:318–321 c
eight-Plate epiphysiodesis and the successful treatment 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins.
of this complication. A 10-year-old patient underwent Journal of Pediatric Orthopaedics B 2013, 22:318–321
epiphysiodesis of the knee with eight-Plates.
She was followed up and genu recurvatum developed Keywords: complication, eight-Plate, guided growth, leg-length discrepancy,
pediatric
as a complication. At the 12-month follow-up after
a
epiphysiodesis, the treated knee showed a flexion Department of Orthopaedic Surgery, Orthopaedic Research Center Amsterdam
(ORCA), Amsterdam Medical Center, University of Amsterdam, Amsterdam and
of 1358 and an extension of 358. Lateral radiograph b
Department of Orthopaedic Surgery, Center for Orthopaedic Research Alkmaar
evaluation showed an extension change of the (CORAL), Medical Center Alkmaar, Alkmaar, The Netherlands
femur. During reoperation, the eight-Plates were Correspondence to Arthur J. Kievit, MD, MSc, Department of Orthopaedic
repositioned more posterior, which resulted in Surgery, Orthopaedic Research Center Amsterdam (ORCA), Academic Medical
Center, University of Amsterdam, Room G4-242, Meibergdreef 9, 1105 AZ
successful treatment of the hyperextension. Eight-Plates Amsterdam, The Netherlands
can lead to (treatable) articular surface angle changes Tel: + 31 205 667 736; fax: + 31 205 669 117; e-mail: a.j.kievit@amc.nl
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Hyperextension after eight-Plates Kievit et al. 319
Fig. 1 Fig. 2
Leg-length difference both in the femur and in the tibia and fluoroscopy
of the first operation with positioning of the eight-Plates on 6 August Discussion
2009.
It is hypothesized that the fact that the eight-Plates were
positioned too far anterior led to rotation of the articular
surface into a position of genu recurvatum. As described
in previous studies, the eight-Plates have a good grip on
were placed over the epiphysis. The lateral radiograph the bone and less tendency to extrude than staples [1].
showed an extension rotation of the articular surface of Anterior-positioned eight-Plates have been used to
the femur of roughly 151 (Fig. 2). To correct this correct flexion deformity in children with arthrogrypo-
deformity, a reoperation was performed on 22 October sis [4]. In these patients, creating more extension was the
2010. During this procedure, the tibial and fibular eight- goal and eight-Plates were placed AP. These results
Plates were removed. The femoral eight-Plates were first support the hypothesis that the anterior placement of the
removed, after which new eight-Plates were placed. eight-Plates led to the angular deformity of the knee in
These were placed slightly posterior to the original our case. One previous case of recurvatum was described
position to allow the knee to correct the angular with epiphysiodesis using screws placed too anterior but
deformity by allowing growth on the anterior side while we have found no previous reports on this complication
the posterior growth was inhibited. With regular follow-up with eight-Plates [16]. In this report, there was no
and close monitoring, it was found that the angle of the recommendation on what to do with this finding and how
epiphysis to the femur shaft on lateral radiograph reduced to correct it.
from 60.41 preoperative to 71.71 at 7 months and 77.51 at
10 months. At 14 months postoperatively, the leg-length The case presented in the current study stresses the
difference was reduced to 10 mm. Flexion for the left leg importance of positioning of the eight-Plates. The
was now 1351 and extension was 101. The angle between operative guide does not provide advice on positioning.
the femur shaft and the epiphysis was reduced to 83.21 We advise positioning the eight-Plates exactly in the
compared with 60.41 just before the second operation. middle of the femur when viewed laterally with 50%
The healthy contralateral side showed an angle of 85.81 epiphysis anterior and 50% posterior. In our case, the
on the lateral control radiograph. Figure 3 shows the intraoperative fluoroscopic image was slightly rotated.
clinical situation at reoperation and at 14 months after Because of this rotation, the sagittal position was more
the second operation. Figure 4 shows the evolution of the difficult to judge accurately. It is recommended to check
femur shaft–epiphysis angle over time. for accurate positioning of the fluoroscope so that a true
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320 Journal of Pediatric Orthopaedics B 2013, Vol 22 No 4
lateral image is obtained intraoperative; the operating intraoperative AP, the plate on the medial side did not
room should not be left without having obtained a good seem fully lateral, but was placed medial to the most
straight lateral radiograph. In hindsight, on the initial medial aspect of the bone. This is an indication on the AP
that the plate must be AP (given that the anatomy is
Fig. 3 most likely anterior).This also seems the case with the
lateral femoral plate as it is not a simple flat lateral profile
but slightly rotated. Similarly, for the tibial plates, they
seem somewhat anterior, which may or may not have
contributed toward the problem with alignment in this
case (Fig. 1).
Growth retardation and leg-length comparison with the
healthy contralateral side is measured in AP leg-length
radiographs. To detect angular deformities in the sagittal
plane, it is important to always include a perfect lateral
radiograph in the follow-up examination during guided
growth. If detected in time, correction of genu recurva-
tum is easy by repositioning the eight-Plates more
posterior. The recovery will coincide with the growth
speed of the epiphysis, which is dependent on the growth
stage and the age of the patient. The timeline shows a
relatively linear hyperextension growth of 1.31/month
average in the first year following initial placement and a
similar – 1.61 of recovering flexion per month in the years
following the reoperation (Fig. 5). After the reoperation,
the patient had a higher growth rate, which resulted in
faster recovery of the angular deformity than the initial
onset of hyperextension.
Although this is a single report, we believe that it is likely
that the design of the eight-Plates, and the positioning of
use, was responsible for the hyperextension. The new
Quadplates might reduce the risk of unwanted angular
deformities because of the fact that there is a four-point
rigid construction that is less likely to result in unwanted
sagittal deformities. However, this statement is only true
Clinical situation at reoperation on (a) 22 October 2010 and at the if the principle of central placement of the plate is
14-month follow-up at (b) 13 January 2012. not violated. Perhaps it may be more difficult to place
the plate too anterior or posterior, but most likely,
Fig. 4
Development and correction of the extension of articular surface of the femur over time.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Hyperextension after eight-Plates Kievit et al. 321
Fig. 5
90.00
80.00
Rotation in degrees
70.00
60.00
50.00
1 January 1 July 1 January 1 July 1 January
2010 2010 2011 2011 2012
Date of radiograph
Graph showing angular growth over time; the angle is the angle in degrees calculated between the femur shaft and the epiphysis of the femur.
asymmetric placement even of the quad plate would lead 3 Campens C, Mousny M, Docquier PL. Comparison of three surgical
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Care should be taken in the positioning of eight-Plates in the contracture in children with arthrogryposis – preliminary results. J Pediatr
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Conflicts of interest eight-Plate for the treatment of Blount disease. J Pediatr Orthop 2009;
29:57–60.
There are no conflicts of interest.
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angular deformities: experimental analysis of staples versus 8-plate.
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