International Orthopaedics (2023) 47:763–771

https://doi.org/10.1007/s00264-023-05688-y

ORIGINAL PAPER

Temporary hemiepiphysiodesis using eight‑plates for angular

deformities of the lower extremities in children with X‑linked
hypophosphataemic rickets
Wei‑Jia Feng1 · Zhen‑Zhen Dai1 · Qing‑Guang Xiong2 · Zhen‑Kai Wu1

Received: 5 October 2022 / Accepted: 22 December 2022 / Published online: 16 January 2023
© The Author(s) under exclusive licence to SICOT aisbl 2023

Abstract
Purposes Temporary hemiepiphysiodesis (TH) using eight-plates is one of the most frequently performed surgeries for
correcting angular deformities of the lower extremities in adolescents. Rarely have studies examined children with X-linked
hypophosphataemic rickets (X-LHPR) treated with TH using eight-plates. This study was conducted to investigate the effi-
cacy, the endpoint, and the complications of TH using eight-plates to correct angular deformities of the lower extremities
in skeletally immature children.
Methods We reviewed a total of 26 children (86 physes, 52 knees) with X-LHPR (mean age of 6.2 years, range from 2 to
13 years) who underwent TH using eight-plate to correct angular deformities of the lower extremities. Radiographs and
clinical records of these patients were evaluated for demographic data and related clinical factors.
Results The average correction of the mechanical lateral distal femoral angle (mLDFA) was 11.7 ± 8.7° (range from 1.0 to
29.7°), and the average correction of the mechanical medial proximal tibial angle (mMPTA) was 8.4 ± 5.0° (range from 0.3
to 16.7°). The mean deformity correction time was 22.7 months (range from 7 to 60 months), and the mean follow-up after
eight-plate removal was 43.9 months (range from 24 to 101 months). Overall, 76.9% (20/26 patients) of the angular deformities
of the knee were completely corrected and 15.4% (4/26) of the patients received osteotomy surgery. The femoral correction
velocity (0.9° per month) was significantly higher than the proximal tibial (0.6° per month) (p = 0.02). The correction velocity
of the mLDFA and mMPTA with the TH procedure was faster than that in the absence of intervention (0.9° vs. 0.2°, 0.7° vs.
0.4° per month, p < 0.05). The correction velocity of the mLDFA (1.2° vs. 0.5° per month, p < 0.001) and mMPTA (0.7° vs.
0.5° per month, p = 0.04) of patients whose age ≤ five years old was faster than that of patients whose age > five years old. A
total of 69.2% (18/26) patients experienced one TH procedure using eight-plates only. Two patients had screw loosening (2/26,
7.7%). One patient (1/26, 3.8%) had a rebound phenomenon after the removal of eight-plate and had the TH procedure again.
There was no breakage, infection, physis preclosure, or limited range of movement found in the follow-up.
Conclusion TH using eight-plates is a safe and effective procedure with a relatively low incidence of complication and
rebound, and it could be used as part of a streamlined treatment for younger X-LHPR patients with resistant or progressive
lower limb deformity despite optimal medical treatment. Early intervention can achieve better results.

Keywords Temporary hemiepiphysiodesis · Angular deformities of the lower extremities · X-linked hypophosphataemic
rickets · Eight-plate · Children

Introduction

X-linked hypophosphataemic rickets (X-LHPR), mainly

Wei-Jia Feng and Zhen-Zhen Dai contributed equally.
caused by pathogenic variants of the phosphate regulat-
* Qing‑Guang Xiong ing endopeptidase homolog X-linked (PHEX) gene or be
guanggu.1988@163.com de novo mutation, is the most common inherited form of
* Zhen‑Kai Wu rickets with a prevalence of 1:20,000–60,000 and presents
wuzhenkai@xinhuamed.com.cn therapeutic challenges with growth and bone development
Extended author information available on the last page of the article [1–3]. It could lead to severe deformities of the lower limbs,

13
Vol.:(0123456789)
764
bone and muscular pain, stunted growth, and reduced quality
of life [3, 4]. Treatment of patients with XLH traditionally
involves multiple daily doses of inorganic oral phosphate
salts along with vitamin D active analogues, usually calci-
triol or alfacalcidol [3]. For these cases with severe angular
deformities of the lower extremities when conservative treat-
ment fails [5–7], the main treatment methods are guided
growth with temporary hemiepiphysiodesis, TH technique
in the skeletally immature child and osteotomy in mature
patients. Stevens’ eight-plate [8] is currently the most popu-
lar implant used in TH surgery due to its simplicity and low
complication rate [9, 10]. Few studies, however, have looked
separately at TH using eight-plate to correct angular deform-
ities of the lower extremities in children with X-LHPR [1].
The primary purpose of the present research was to investi-
gate the efficacy, the endpoint, and the complications of TH
using eight-plates to correct angular deformities of the lower
extremities in skeletally immature children.
Patients and methods
After approval by the institutional review board (IRB), we
reviewed a consecutive patient cohort with X-LHPR and
angular deformities of the lower extremities treated with
TH procedures using the eight-plate in the Department of
Paediatric Orthopaedics in our hospital from January 2010
to December 2019 (Fig. 1).
The inclusion criteria were as follows: (1) patients with
documented X-LPHR and with open physis confirmed by
radiographs, (2) diagnosed with angular deformities by the
Fig. 1  Flow diagram that details
the patient’s screening
13
International Orthopaedics (2023) 47:763–771
lower limb mechanical alignment by the whole full-length
lower extremity standing anteroposterior radiograph, (3)
more than one-year systematic endocrine therapy and no
any previous treatment (surgical/orthosis) before TH proce-
dure, with continued therapy after surgery, and (4) complete
medical data with surgical treatment of angular deformities
of the lower extremities.
The exclusion criteria were (1) another type of rickets
disease and (2) epiphyseal plate abnormalities due to other
causes.
Routinely, in our hospital, for the X-LHPR children with
angular deformities of the lower extremities (mechanical
axis located at zone 3 or − 3), who have no improvement
after at least 12 months of optimized medical treatment
consisting of phosphate and 1-alfacalcidol supplementation
and at least one-year observation, TH using an eight-plate
is recommended. We usually evaluated the condition of the
physis pre-operatively and ensure adequate growth potential.
Generally, the age of patients is less than 12 years old in
girls and less than 14 years old in boys. After pre-operative
clinical and radiograph evaluation, we selected the ideal
site(s) for eight-plate placement according to the methods
of Stevens [8] based on the location of the deformity and
the orientation of the knee joint axis [1]. The TH procedures
were accomplished by three senior paediatric orthopedists.
Post-operatively, early weight-bearing for one week
and physical activity without any limitation for two weeks
and regular follow-up at three-month intervals were done
[11]. 88° for mLDFA and 87° for mMPTA were consid-
ered the normal values [12]. Once there was the neutrali-
zation of the mechanical axis to zone − 1 to 1, the TH
International Orthopaedics (2023) 47:763–771 765

implants were removed [5, 6, 13, 14]. When children
reached bone maturity and the lower limbs were not cor-
rected successfully, osteotomy was recommended. Oste-
otomy was considered one study endpoint of observation.
Clinical data including demography, radiography, and
outcome were collected. Radiographs were obtained and
measured by two senior physicians in PACS (Picture
Archiving and Communication Systems, Uni-Wed, 6.1,
EBM Technologies, Shanghai), including the mechani-
cal lateral distal femoral angle (mLDFA), the mechani-
cal medial proximal tibial angle (mMPTA), and the loca-
tion of the center of the mechanical axis (zones 1, 2,
3, − 1, − 2, and − 3) [14, 15].
Complications, such as screw loosening, screw or plate
breakage, post-operative infection, physis premature, and
limited range of movement, were reviewed.
Statistical analysis
The Fisher exact test or Wilcoxon test was used for categori-
cal variables and the t-test or analysis of variance (ANOVA)
for continuous variables. Statistical tests were considered
significant at p < 0.05. Analysis was performed with the
statistical software Stata/SE for Windows (version 15.0;
StataCorp LLC).
Results
Twenty-six patients with 86 physes (52 knees) were included
in our study (Table 1), 14 boys and 12 girls. The mean age
at the time of surgery was 6.2 years, ranging from two to
13 years. All patients had bilateral angular deformities of
the lower extremities, and 88.5% (23/26) had a uniform
direction of the deformity. Eighty-six knee segments (47

Table 1  Demographics, Variable Study cohort (n = 26) [52 limbs]

treatment characters, and
outcome Age (yrs) [range] 6.2 ± 3.2 [2–13]
Gender (no. [%])
Male 14 (53.9%)
Female 12 (46.2%)
Height (cm) [range] 111.8 ± 15.4 [85–143]
Weight (kg) [range] 21.6 ± 8.5 [12–44]
Bilateral (no. [%]) 26 (100.0%)
Uniform direction of deformity (no. [%]) 23/26 (88.5%)
Direction of deformity (limbs)# (no. [%])
Genu varum 31/52 (59.6%)
Genu valgum 21/52 (40.4%)
Osteotomy surgery as endpoint (no. [%]) 4/26 (15.4%)
Eight-plate implantation location at first TH surgery using eight-plate#
(no. [%])
Distal femur alone 13 (25.0%)
Proximal tibia alone 5 (9.6%)
Both sites 34 (65.4%)
The correction success rate using eight-plate (no. [%]) 20 (76.9%)
Deformity correction time using eight-plate (months) [range] 22.7 ± 13.6 (7–60)
The surgery time using eight-plate (time) (no. [%])
1 18 (69.2%)
2 8 (30.8%)
The preoperative location of center of the mechanical axis*#
2 36 (69.2%)
3 16 (30.8%)
Complication (no. [%]) 4/26 (15.4%)
Follow-up (months) [range] 43.9 ± 20.5 (24–101)

Values were presented as mean ± SD (range) or frequency (percentage)

#
Calculated according to the number of limbs
*
Absolute value of the location of center of the knee mechanical axis preoperatively (zones 1, 2, 3, − 1, − 2,
and − 3)

13
766
distal femora and 39 proximal tibiae) were treated in 52
knees, 59.6% (31/52) knees were genu varum (case shown
in Fig. 2), whereas 40.4% (21/52) knees were genu valgum
(case shown in Fig. 3). Sixty-five percent (34/52) of the
knees had plates inserted into both the distal femur and the
proximal tibia. The mean deformity correction time was
22.7 months (range from 7 to 60 months), and the mean
follow-up after eight-plate removal was 43.9 months (range
from 24 to 101 months) (Table 1). The average correction of
Fig. 2  A 4-year-old boy with bilateral genu varum deformity caused
by X-linked hypophosphataemic rickets and treated by TH proce-
dure using eight-plates: A pre-operation; B 3-month TH surgery; C
13
International Orthopaedics (2023) 47:763–771
mLDFA was 11.7 ± 8.7° (range from 1.0 to 29.7°), and the
average correction of mMPTA was 8.4 ± 5.0° (range from
0.3 to 16.7°).
The overall femoral correction velocity (0.9° per month)
was significantly higher than for the proximal tibial (0.6° per
month) (p = 0.02). The correction velocity of the mLDFA
(1.2° vs. 0.5° per month, p < 0.001) and mMPTA (0.7° vs.
0.5° per month, p = 0.04) of patients whose age ≤ five years
old was faster than that of patients whose age > five years
6-month TH surgery; D 16.5-month TH surgery; E before remov-
ing the implant (18.5-month TH surgery); F the last follow-up
(19 months after implant removal)
International Orthopaedics (2023) 47:763–771 767

Fig. 3  A 6-year-old girl with bilateral genu valgus deformity caused implant (6-month TH surgery); C 9.5-month TH surgery; D before
by X-linked hypophosphataemic rickets and treated by TH proce- removing right knee implant (15.5-month TH surgery)
dure using eight-plates: A pre-operation; B before removing left knee

old. The correction velocity of the mLDFA and mMPTA
for the TH procedure using eight-plate intervention was
faster than in the absence of intervention (0.9° vs. 0.2° per
month, 0.7° vs. 0.4° per month, p < 0.05, Table 2). And
the correction velocity of the mMPTA of patients whose
age ≤ five years old (0.8° vs. 0.1° per month, p < 0.001)
and mLDFA of patients whose age > five years old (0.6°
vs. 0.1° per month, p < 0.001) for the TH procedure using
eight-plates intervention was faster than in the absence of
intervention (Table 2). We found that the overall femo-
ral correction velocity of patients with genu varum was
faster than that of genu valgum (1.1° vs. 0.5° per month,
p < 0.001), and the femoral amount of correction in patients
with genu varum was higher than that with genu valgum
(15.6° vs. 5.9°, p < 0.001), but there were no differences
in the proximal tibial correction velocity (0.6° per month
vs. 0.6° per month, p = 0.83), the tibial amount of correc-
tion (9.0° vs. 7.5°, p = 0.33), the correction time (16.5 vs.
14.5 months, p = 0.25), and the complication rate (6.5% vs.
9.5%, p = 0.68).
69.2% (18/26) patients had only one TH procedure using
eight-plate, while the other patients (30.8%, 8/26) had a revi-
sion of the eight-plates. Two patients with screw loosening
had an early revision, and six patients had a revision of the
eight-plates due to greater than 24 months of implant reten-
tion time.
At the final follow-up, 23.1% (6/26) had deformity correc-
tion failure, and 15.4% (4/26) underwent osteotomy surgery
(Table 1). No significant difference was found in patients’
age between the successful eight-plate correction group and
the failure group (5.5 ± 2.9 vs. 8.5 ± 3.3 years, p = 0.07).
There was no significant difference in patients’ age between
the osteotomy group and the successful eight-plate correc-
tion group (9.5 ± 3.7 vs. 5.4 ± 2.9 years, p = 0.11), although
75% (3/4) in the osteotomy group were older than ten years.

Table 2  Rate of correction of all physes in patients who had surgery around the knee for guided growth

Mean rate of correction for all Surgery No intervention p

patients (degrees/mth) (range)

Overall
(N = 26, 52 knees)
Age <  = 5 years old
(N = 13, 26 knees)
Age > 5 years old
(N = 13, 26 knees)
mLDFA 0.9 ± 0.7 (0.1–3.3) 0.9 ± 0.7 (0.1–3.3) 0.2 ± 0.2 (0.1–0.6) < 0.001
mMPTA 0.6 ± 0.4 (0.0–1.8) 0.7 ± 0.4 (0.0–1.8) 0.4 ± 0.3 (0.1–1.0) 0.01
mLDFA 1.2 ± 0.7 (0.2–3.3) 1.2 ± 0.7 (0.2–3.3) 0.6 (n = 1) N/A
mMPTA 0.7 ± 0.5 (0.0–1.8) 0.8 ± 0.5 (0.0–1.8) 0.1 ± 0.0 (0.1–0.1) < 0.001
mLDFA 0.5 ± 0.5 (0.1 ± 1.8) 0.6 ± 0.5 (0.1–1.8) 0.1 ± 0.0 (0.1–0.1) < 0.001
mMPTA 0.5 ± 0.3 (0.0–1.2) 0.5 ± 0.3 (0.0–1.2) 0.4 ± 0.3 (0.1–1.0) 0.69

Bold values are statistically significant p < 0.05

mLDFA the mechanical lateral distal femoral angle, mMPTA the mechanical medial proximal tibial angle, N/A not applicable

13
768
Screw loosening was seen in two patients (2/26, 7.69%)
(case shown in Fig. 4). One patient (1/26, 3.84%) experi-
enced a rebound phenomenon after the removal of the eight-
plate and performed the TH procedure again. One patient
had wound effusion after eight-plate removal because of fat
liquefaction. The condition improved after wound dressing
changes. No other complications, such as screw or plate
breakage, infection, premature physis closure, or limited
range of movement, were seen at the follow-up.
Discussion
For adolescents with angular deformities of the lower
extremities, eight-plate TH treatment is a common treatment
method [11, 16] and previous literature has confirmed it to
be a simple, safe, and effective surgery [17–19]. Few studies,
however, have looked separately at TH using eight-plate to
correct angular deformities of the lower extremities in chil-
dren with X-LHPR [1, 4, 5, 20–24] (Table 3). The efficacy,
the endpoint, and the complications of TH using eight-plate
to correct angular deformities of the lower extremities in
skeletally immature children with X-LHPR remain unclear.
In our study, the mean patient age was 6.2 years and
ranged from two to 13 years. 76.2% (20/26) patients were
corrected to standard lower limb alignment (center of the
mechanical axis zone: − 1 to 1), and 15.4% (4/26) received
osteotomy surgery. In the past, the treatment of rachitic bone
involved osteotomy, preferably at skeletal maturity, using a
Fig. 4  The angular deformity of the knee in a boy with X-LHPR was
aggravating gradually, although he underwent systematic endocrine
therapy. He had an inconsistent direction deformity (right: genu val-
gum; left: genu varum). And he was treated by TH procedure using
eight-plates to correct the angular deformity of the knee. A 3.5 years
13
International Orthopaedics (2023) 47:763–771
variety of internal and external fixation devices [1, 4]. The
complication rate is relatively high and includes hypercal-
caemia, loss of fixation, delayed union or nonunion, neuro-
vascular risk, and recurrent deformities [4]. There are few
published studies on the use of guided growth in patients
with X-LHPR. Horn et al. reported that 16/23 (70%) limbs
were restored to the neutral mechanical axis in patients who
had completed follow-ups. The study by Gigante et al. [25]
addressed seven patients with renal osteodystrophy with
guided growth, but three deformities recurred, requiring
additional surgery. According to Novais and Stevens [4], 7/9
of the X-LHPR patients treated with the TH procedure had
partial or full correction of their deformities. This suggests
that the correction success rate of guided growth for patients
with X-LHPR is relatively good, and it greatly reduces the
probability of later osteotomy correction. Interestingly, we
found that the femoral and tibial diaphyseal bowing also
improved during the correction procedure, and it had been
mentioned in other literature [1, 14, 20]. Bonnet-Lebrun
et al. reported that the deformities in X-LHPR patients are
mainly in the femoral shaft through the quantitative radio-
logical parameters derived from 3D reconstructions (EOS
system) [24]. But we did not evaluate the femur bowing rou-
tinely. Further research will focus on evaluating the femur
bowing condition.
In our study, there was no significant difference in
patients’ age between the osteotomy group and eight-plate
correction success group (9.5 ± 3.7 vs. 5.5 ± 2.9 years old,
p = 0.11). However, 75% (3/4) of patients in the osteotomy
old; B preoperation (8 years old); B 3-month TH surgery; C 6-month
TH surgery; D 22-month TH surgery. And we found that the eight-
plate of the left femur cut the lateral epiphyseal of the femur because
of the loosening screw (red arrow). So he had an early revision of the
eight-plates
International Orthopaedics (2023) 47:763–771 769

Table 3  The comparison of correction rate between other literature about rickets patients and our results
Literature Etiology Age# Rickets cases Implant type Implant loosening The mean rate*
mLDFA mMPTA

Our results X-LHPR 6.2 26 8-plate (26) 2/26 patients, 7.69% 0.9 0.6
Novais et al. (2006)4 Hypophosphatemic 7 years 7 months 10 Staple (10) 6/38 staples, 16% – –
rickets
Stevens et al. Rickets 4–14 14 8-plate (4) 24/53 staples, 45% – –
(2008)20 Staple (10) 0/15 8-plates, 0%
Kulkarni et al. Rickets + other 5 years 3 months 12 8-plate (12) 2/12 patients, 16.7% – –
(2015)5 etiology
1
Horn et al. (2017) X-LHPR 10.3 24 8-plate (13) 1/13 patients, 7.7% 0.7 0.3
El-Sobky et al. Nutritional rickets 3.8 50 8-plate (50) 7/50 patients, 14% – –
(2020)23
Bonnet-Lebrun et al. X-LHPR 9.9 35 Nonsurgical treat- mLDFA related to the FTA (r2 = 0.73)
(2021)24 ments and HKS (r2 = 0.69)

X-LHPR X-linked hypophosphatemic rickets, FTA femorotibial angle, HKS angle between the mechanical axis and the femoral shaft
*
Degrees/month
#
Age at the time of surgery (years) or range

group were older than 10 years. No significant difference
was found in patients’ age between the eight-plate cor-
rection success group and the failure group (5.5 ± 2.9 vs.
8.5 ± 3.3 years old, p = 0.07), although the eight-plate cor-
rection failure group tended to be older.
Younger age at surgery predicts a better response to
guided growth [1, 4, 20, 26]. Kulkarni et al. [5] found that
TH using eight-plates is an effective procedure for angular
deformity of the lower extremities in patients younger than
ten years, which was consistent with Dai’s study [7]. In our
study, we found that the correction velocity of the mLDFA
and mMPTA under the TH procedure using eight-plate inter-
vention was faster than that in the absence of intervention
(0.9° vs. 0.2°, 0.7° vs. 0.4° per month, p < 0.05). The cor-
rection velocity of the mLDFA (1.2° vs. 0.5° per month,
p < 0.001) and mMPTA (0.7° vs. 0.5° per month, p = 0.04)
of patients whose age ≤ five years old was faster than that
of patients whose age > five years old. Owing to the lower
growth potential and poor correction ability of children
with X-LHPR [27], we believe that TH using eight-plate
should be considered as soon as the deformity of patients
with X-LHPR does not improve after one year of conserva-
tive treatment.
We found that the overall femoral correction velocity of
patients with genu varum was faster than that with genu
valgum (1.1° vs. 0.5° per month, p < 0.001), and the femoral
amount of correction in patients with genu varum was higher
than with genu valgum (15.6° vs. 5.9°, p < 0.001). The previ-
ous study had shown that the correction velocity for varum
deformities of the mLDFA was significantly higher than
that for valgum deformities (1.50° vs. 1.16° per month,
p = 0.033) [7], which was consistent with our results. But
we think the sample of our study was relatively small, and
the confounding factor of patients’ age cannot be completely
excluded. More evidence was needed to support the result.
In our study, one patient (1/26, 3.8%) experienced a
rebound phenomenon after the removal of the eight-plate
so the TH procedure was repeated, which was similar to
that in Kumar’s systematic review (2.3%, 8/350 knees had
rebound deformity) [17]. Gigante et al. [25] used guided
growth in seven patients with renal osteodystrophy; three
recurred and required further surgery. The prevalence of
the rebound phenomenon after the removal of eight-plate
in Dai’s study was 3.0% (3/101 knees) [7]. In Horn et al.’s
study [1], they did not think that recurrent deformity was
a failure of TH management as they believed that simple
treatment, even if repeated, may be more acceptable than
an osteotomy. For patients who were diagnosed with angu-
lar deformity of the lower extremities with medically stable
X-LHPR, the probability of recurrence after the removal of
eight-plate is relatively low.
Screw loosening was seen in two patients (2/26, 7.7%),
which was higher than that of previous studies of idio-
pathic aetiology (3.4–4%) [17, 28]. It was reported that
eight-plate placement across the physis may result in une-
ven distribution of stress in the physis, the screw, and the
eight-plate [29]. Complications such as screw loosening
are believed to be more likely in patients with abnormal
morphology of epiphyseal plate (Blount disease, MHE,
or X-LHPR) [30, 31]. Jain et al. [32] in their research on
Blount disease combined with a systematic review of the
literature reported that severe deformity, titanium ten-
sion band plate (TBP), and obesity were more likely to
experience surgical failure. In our study, 23.1% (6/26) had
deformity correction failure. Four (4/6, 66.7%) were older
than ten years, and the other two patients did not take

13
770
medication regularly during TH treatment. We believe
that older age and irregular medication compliance are
the main reasons for our correction failure. We suggest
that younger children with X-LHPR might be better can-
didates for the TH procedure, with regular endocrine ther-
apy being the key to the success of lower limb deformity
correction.
Several limitations of this study need to be addressed.
First, the intrinsic limits of a retrospective study in a single
centre cannot be avoided completely. Second, the limited
number of patients with X-LHPR included may weaken the
strength of the results. However, as we have known, the pre-
sent study has the largest sample size for the population with
X-LHPR which was treated with TH using eight-plate for the
management of knee deformity. Finally, we found the femo-
ral and tibial diaphyseal bowing improved during the cor-
rection procedure, and we believe that early treatment may
facilitate improvement in the diaphyseal bowing. But we did
not evaluate the femur bowing routinely. Further research
will focus on evaluating the femur bowing condition.
Conclusions
TH using eight-plates is a safe and effective procedure with a
relatively low incidence of complication and rebound, and it
could be used as part of a streamlined treatment for younger
X-LHPR patients with resistant or progressive lower limb
deformity despite optimal medical treatment. Early interven-
tion may achieve better results.
Author contribution All authors participated in the design, interpreta-
tion of the studies, and analysis of the data and review of the manu-
script. Feng WJ and Wu ZK did the design of the study; Xiong QG, Dai
ZZ, and Feng WJ reviewed the patients and analyzed the data; Feng
WJ and Wu ZK wrote the manuscript. All authors read and approved
the final manuscript.
Funding This work was supported by High-level Hospital Construction
Research Project of Maoming People’s Hospital, and Maoming Science
and Technology Project (2022166).
Data availability The datasets analyzed in this study are available from
the corresponding author upon reasonable request.
Code availability Not applicable.
Declarations
Ethics approval This study was performed in line with the principles of
the Declaration of Helsinki. Approval was granted by the Ethics Com-
mittee of Xin Hua Hospital Affiliated to Shanghai Jiao Tong University
School of Medicine (Approval number: XHEC-D-2022–192).
Consent to participate Written informed consent was obtained from
the parents.
13
International Orthopaedics (2023) 47:763–771
Consent for publication The authors affirm that human research par-
ticipants provided informed consent for publication of the images in
Figs. 2, 3, and 4.
Competing interests Financial interests: Feng WJ, Dai ZZ, and Wu
ZK declare they have no financial interests. Xiong QG has received
research funding from High-level Hospital Construction Research Pro-
ject of Maoming People’s Hospital and Maoming Science and Technol-
ogy Project (2022166).
References
1. Horn A, Wright J, Bockenhauer D, Van’t Hoff W, Eastwood DM
(2017) The orthopaedic management of lower limb deformity in
hypophosphataemic rickets. J Child Orthop 11:298–305. https://​
doi.​org/​10.​1302/​1863-​2548.​11.​170003
2. Bitzan M, Goodyer PR (2019) Hypophosphatemic rickets. Pediatr
Clin North Am 66:179–207. https://d​ oi.o​ rg/1​ 0.1​ 016/j.p​ cl.2​ 018.0​ 9.​
004
3. Baroncelli GI, Mora S (2021) X-linked hypophosphatemic rick-
ets: multisystemic disorder in children requiring multidisciplinary
management. Front Endocrinol (Lausanne) 12:688309. https://d​ oi.​
org/​10.​3389/​fendo.​2021.​688309
4. Novais E, Stevens PM (2006) Hypophosphatemic rickets: the role
of hemiepiphysiodesis. J Pediatr Orthop 26:238–244. https://​doi.​
org/​10.​1097/​01.​bpo.​00002​18531.​66856.​b7
5. Kulkarni RM, Ilyas Rushnaiwala FM, Kulkarni GS, Negandhi R,
Kulkarni MG, Kulkarni SG (2015) Correction of coronal plane
deformities around the knee using a tension band plate in children
younger than 10 years. Indian J Orthop 49:208–218. https://​doi.​
org/​10.​4103/​0019-​5413.​152484
6. Kumar A, Gaba S, Sud A, Mandlecha P, Goel L, Nayak M (2016)
Comparative study between staples and eight plate in the man-
agement of coronal plane deformities of the knee in skeletally
immature children. J Child Orthop 10:429–437. https://​doi.​org/​
10.​1007/​s11832-​016-​0758-0
7. Dai Z-Z, Liang Z-P, Li H, Ding J, Wu Z-K, Zhang Z-M, Li H
(2021) Temporary hemiepiphysiodesis using an eight-plate
implant for coronal angular deformity around the knee in chil-
dren aged less than 10 years: efficacy, complications, occurrence
of rebound and risk factors. BMC Musculoskel Dis 22:53. https://​
doi.​org/​10.​1186/​s12891-​020-​03915-w
8. Stevens PM (2007) Guided growth for angular correction: a
preliminary series using a tension band plate. J Pediatr Orthop
27:253–259. https://​doi.​org/​10.​1097/​BPO.​0b013​e3180​3433a1
9. Danino B, Rodl R, Herzenberg JE, Shabtai L, Grill F, Naray-
anan U, Segev E, Wientroub S (2019) Growth modulation in idi-
opathic angular knee deformities: is it predictable? J Child Orthop
13:318–323. https://​doi.​org/​10.​1302/​1863-​2548.​13.​190033
10. Ding J, Zhu T, Jin FC, Wu ZK, Li H (2019) The effect of tem-
porary hemiepiphysiodesis in the treatment of skeleton imma-
ture posttraumatic genu angular deformity: a retrospective study
of 27 cases. J Orthop Surg Res 14:381. https://​doi.​org/​10.​1186/​
s13018-​019-​1426-0
11. Lee HJ, Oh CW, Song KS, Kyung HS, Min WK, Park BC (2012)
Guided growth with a noncannulated screw-plate system for angu-
lar deformity of the knee: a preliminary report. J Pediatr Orthop
B 21:339–347. https://​doi.​org/​10.​1097/​BPB.​0b013​e3283​547198
12. Park SS, Kang S, Kim JY (2016) Prediction of rebound phenom-
enon after removal of hemiepiphyseal staples in patients with idi-
opathic genu valgum deformity. Bone Joint J 98-B:1270–1275.
https://​doi.​org/​10.​1302/​0301-​620X.​98B9.​37260
International Orthopaedics (2023) 47:763–771
13. Mielke CH, Stevens PM (1996) Hemiepiphyseal stapling for
knee deformities in children younger than 10 years: a preliminary
report. J Pediatr Orthop 16:423–429
14. Stevens PM, Pease F (2006) Hemiepiphysiodesis for posttraumatic
tibial valgus. J Pediatr Orthop 26:385–392
15. Stevens PM, Maguire M, Dales MD, Robins AJ (1999) Physeal
stapling for idiopathic genu valgum. J Pediatr Orthop 19:645–649
16. Eltayeby HH, Iobst CA, Herzenberg JE (2019) Hemiepiphysiode-
sis using tension band plates: does the initial screw angle influence
the rate of correction? J Child Orthop 13:62–66. https://​doi.​org/​
10.​1302/​1863-​2548.​13.​180086
17. Kumar S, Sonanis SV (2018) Growth modulation for coronal
deformity correction by using eight plates-systematic review. J
Orthop 15:168–172. https://​doi.​org/​10.​1016/j.​jor.​2018.​01.​022
18. Burghardt RD, Herzenberg JE, Standard SC, Paley D (2008)
Temporary hemiepiphyseal arrest using a screw and plate device
to treat knee and ankle deformities in children: a preliminary
report. J Child Orthop 2:187–197. https://​d oi.​o rg/​1 0.​1 007/​
s11832-​008-​0096-y
19. Burghardt RD, Herzenberg JE (2010) Temporary hemiepi-
physiodesis with the eight-Plate for angular deformities: mid-
term results. J Orthop Sci 15:699–704. https://​doi.​org/​10.​1007/​
s00776-​010-​1514-9
20. Stevens PM, Klatt JB (2008) Guided growth for pathological
physes: radiographic improvement during realignment. J Pediatr
Orthop 28:632–639. https://​doi.​org/​10.​1097/​BPO.​0b013​e3181​
841fda
21. Zajonz D, Schumann E, Wojan M, Kübler FB, Josten C, Bühligen
U, Heyde CE (2017) Treatment of genu valgum in children by
means of temporary hemiepiphysiodesis using eight-plates: short-
term findings. BMC Musculoskel Dis 18:456. https://​doi.​org/​10.​
1186/​s12891-​017-​1823-7
22. Narayana Kurup JK, Shah HH (2020) Hemiepiphysiodesis using
2-holed reconstruction plate for correction of angular deformity of
the knee in children. J Orthop 20:54–59. https://d​ oi.o​ rg/1​ 0.1​ 016/j.​
jor.​2020.​01.​001
23. El-Sobky TA, Samir S, Baraka MM, Fayyad TA, Mahran MA,
Aly AS, Amen J, Mahmoud S (2020) Growth modulation for knee
coronal plane deformities in children with nutritional rickets a
prospective series with treatment algorithm. J Am Acad Orthop
Surg Glob Res Rev 4(1):e19.00009. https://​doi.​org/​10.​5435/​
JAAOS​Global-​D-​19-​00009
24. Bonnet-Lebrun A, Linglart A, De Tienda M, Ouchrif Y, Berk-
enou J, Assi A, Wicart P, Skalli W (2021) Quantitative analysis
of lower limb and pelvic deformities in children with X-linked
Authors and Affiliations
Wei‑Jia Feng1 · Zhen‑Zhen Dai1 · Qing‑Guang Xiong2 · Zhen‑Kai Wu1
1 2
Department of Pediatric Orthopedics, Xin Hua Hospital
Affiliated to Shanghai Jiao Tong University School
of Medicine, Shanghai, China
771
hypophosphatemic rickets. Orthop Traumatol Surg Res:103187.
https://​doi.​org/​10.​1016/j.​otsr.​2021.​103187.
25. Gigante C, Borgo A, Corradin M (2017) Correction of lower
limb deformities in children with renal osteodystrophy by guided
growth technique. J Child Orthop 11:79–84. https://​doi.​org/​10.​
1302/​1863-​2548-​11-​160172
26. Danino B, Rödl R, Herzenberg JE, Shabtai L, Grill F, Narayanan
U, Segev E, Wientroub S (2018) Guided growth: preliminary
results of a multinational study of 967 physes in 537 patients.
J Child Orthop 12:91–96. https://​doi.​org/​10.​1302/​1863-​2548.​12.​
170050
27. Alkhatib N, Bouri F, Hegazy A, Ibrahim T (2018) Vitamin D and
tibiofemoral joint orientation angles in children. J Pediatr Orthop
B 27:467–471. https://​doi.​org/​10.​1097/​BPB.​00000​00000​000457
28. Shabtai L, Herzenberg JE (2016) Limits of growth modu-
lation using tension band plates in the lower extremities. J
Am Acad Orthop Surg 24:691–701. https://​doi.​org/​10.​5435/​
JAAOS-D-​14-​00234
29. Burghardt RD, Specht SC, Herzenberg JE (2010) Mechanical fail-
ures of eight-plateguided growth system for temporary hemie-
piphysiodesis. J Pediatr Orthop 30:594–597. https://​doi.​org/​10.​
1097/​BPO.​0b013​e3181​e4f591
30. Burghardt RD, Herzenberg JE, Andre S, Bernius P, Kazim MA
(2018) Treatment failures and complications in patients with
Blount disease treated with temporary hemiepiphysiodesis: a criti-
cal systematic literature review. J Pediatr Orthop B 27:522–529.
https://​doi.​org/​10.​1097/​BPB.​00000​00000​000523
31. Griswold BG, Shaw KA, Houston H, Bertrand S, Cearley D
(2020) Guided growth for the treatment of infantile Blount’s dis-
ease: is it a viable option? J Orthop 20:41–45. https://​doi.​org/​10.​
1016/j.​jor.​2020.​01.​007
32. Jain MJ, Inneh IA, Zhu H, Phillips WA (2020) Tension band plate
(TBP)-guided hemiepiphysiodesis in blount disease: 10-year
single-center experience with a systematic review of literature. J
Pediatr Orthop 40:e138–e143. https://d​ oi.o​ rg/1​ 0.1​ 097/B
​ PO.0​ 0000​
00000​001393
Publisher's note Springer Nature remains neutral with regard to
jurisdictional claims in published maps and institutional affiliations.
Springer Nature or its licensor (e.g. a society or other partner) holds
exclusive rights to this article under a publishing agreement with the
author(s) or other rightsholder(s); author self-archiving of the accepted
manuscript version of this article is solely governed by the terms of
such publishing agreement and applicable law.
Department of Orthopedics, Maoming People’s Hospital,
Maoming, Guangdong, China
13