|Year : 2021 | Volume
| Issue : 1 | Page : 32-37
A novel technique of stabilization of supracondylar femoral dome osteotomy with proximal humeral locking plate for surgical management of genu valgum deformity
Mukul Mohindra1, VK Gautam2, Amit Meena3, Navdeep Gupta4, Jagannath Desai5, Sumon Singphow Saikia3
1 Central Institute of Orthopaedics and CGHS Wing, VMMC and Safdarjung Hospital, New Delhi, India
2 Department of Orthopaedics, MAMC and LNJP Hospital, New Delhi, India
3 Central Institute of Orthopaedics, VMMC and Safdarjung Hospital, New Delhi, India
4 Department of Orthopaedics, Navdeep Hospital, Panchkula, Haryana, India
5 Department of Orthopaedics, Koppal Institute of Medical Sciences, Koppal, Karnataka, India
|Date of Submission||21-Jun-2020|
|Date of Acceptance||11-Apr-2021|
|Date of Web Publication||16-Jun-2021|
Dr. Amit Meena
Senior Resident, Central Institute of Orthopaedics,VMMC and Safdarjung Hospital, New Delhi - 110029
Source of Support: None, Conflict of Interest: None
Background: Genu valgum is a common deformity in the developing world. When the patient presents after a second growth spurt, corrective surgery remains the only treatment option. Different types of osteotomies and fixation methods have been described in the literature, but the choice of the method remains debatable. We evaluated the outcome of the proximal humeral locking plate used for stabilization of supracondylar femoral dome osteotomy (DO). Methods: In this prospective study, we performed 39 osteotomies for genu valgum deformity on 24 patients who satisfied inclusion criteria (15 bilateral and 9 unilateral) between May 2015 and May 2017. The mean age was 13 years (11–20), 16 were male and 8 were female patients. All patients underwent supracondylar femoral DO and stabilization with the proximal humeral locking plate. Informed consent was obtained from all patients. All patients were evaluated preoperatively and postoperatively by using the Bostman knee score, intermalleolar distance (IMD), tibiofemoral angle (TFA), and lateral distal-femoral angle (LDFA). Patients with a minimum follow-up of 2 years were included in the study. Results: The preoperative LDFA was 73.4 ± 2.1 which improved to 87.2 ± 0.6 postoperatively while clinical and radiological TFA improved from 19.7 ± 21 and 21.4 ± 2.1 to 7.3 ± 0.8 and 8.6 ± 0.8, respectively. The mean Bostman score improved significantly. Two patients (2 limbs) had a good score (20–27), while the rest had an excellent score (28–30). IMD, TFA, and LDFA also improved statistically significantly (P < 0.001). All the patients were satisfied with the cosmetic correction. There were no implant failures, re-operations, and any loss of correction. Conclusion: This novel technique of stabilizing supracondylar femoral DO with the proximal humeral locking plate is cost-effective and has encouraging early results.
Keywords: Genu valgum, proximal humeral locking plate, supracondylar femoral dome osteotomy, surgical correction
|How to cite this article:|
Mohindra M, Gautam V K, Meena A, Gupta N, Desai J, Saikia SS. A novel technique of stabilization of supracondylar femoral dome osteotomy with proximal humeral locking plate for surgical management of genu valgum deformity. J Orthop Traumatol Rehabil 2021;13:32-7
|How to cite this URL:|
Mohindra M, Gautam V K, Meena A, Gupta N, Desai J, Saikia SS. A novel technique of stabilization of supracondylar femoral dome osteotomy with proximal humeral locking plate for surgical management of genu valgum deformity. J Orthop Traumatol Rehabil [serial online] 2021 [cited 2021 Dec 4];13:32-7. Available from: https://www.jotr.in/text.asp?2021/13/1/32/318417
| Introduction|| |
Genu valgum is a common deformity in childhood in the developing world. Although deformities up to the age of 12 years can be corrected by epiphysiodesis with stapling, mini-plate, and external fixator, when the patient presents after the second growth spurt, a corrective osteotomy is the treatment of choice. Genu valgum deformity may arise from the distal femur, proximal tibia, or knee joint,,, but usually, it arises from the distal femur which may be confirmed by clinical examination as well as by various angle measurements on radiographs.
For the deformities arising from distal femur, various types of corrective osteotomies have been described in the literature which includes a medial close wedge, lateral open wedge, dome osteotomy (DO), wedge-less “V” osteotomy, and wedge-less spike osteotomy.,,,,,,,,,, Limb length discrepancy (LLD), mismatch of osteotomy ends, and the need for translation of the distal fragment are some known drawbacks of wedge osteotomy. In DO, circular bone cuts are taken so that deformity correction is achieved without any LLD, there is no mismatch of osteotomy ends, and there is no need for segment translation.
DO is a cylindrical osteotomy,, where the corresponding bone cuts rotate around the central axis of the cylinder. Brackett performed proximal femur DO for the treatment of a nonunited neck of femur fracture. To realign the proximal and distal axes in focal DO (FDO), there is no need for translation at the osteotomy site.,, Although osteotomy is the standard treatment, the choice of an implant to stabilize the osteotomy is debatable. A wide range of fixation methods have been tried, ranging from cast to precontoured locking compression plates. In our study, we used proximal humeral locking plate (local manufacturer) for fixation of distal femoral DO due to many advantages which include: (1) no need for postoperative plaster immobilization, so the range of motion exercise can be started early, hence decreasing the chances of knee joint stiffness and quadriceps atrophy; (2) decrease chances of fixation loss, hence decreasing the incidence of nonunion at osteotomy site; (3) wide availability and cost-effectiveness of proximal humeral locking plate compared to the customized pediatric plate which is expensive as well as availability is an issue in the developing countries. This is the novel technique and to our knowledge, it was not described previously. We hypothesized that the use of the proximal humeral locking plate for fixation of distal femoral DO in genu valgum deformity results in good functional outcomes.
| Methods|| |
In this prospective study, we performed 39 osteotomies for genu valgum deformity on 24 patients (15 patients had bilateral deformities and 9 patients had unilateral deformity) between May 2015 and May 2017 at a tertiary care referral, teaching hospital. The average age at operation was 13 years (range: 11–20). There were 16 females and 8 males. Informed consent was taken from all the patients, and ethical clearance was taken from an ethical board. According to inclusion criteria, patients with genu valgum were selected from the outpatient department of the hospital. Clinical, radiological, and biochemical examinations were done for all patients. Deformity was found in the femur in all cases. Patients with intermalleolar distance (IMD) of more than 10 cm and a tibiofemoral angle (TFA) of more than 15° (15°–24°) were included in the study. Patients with a 2-year minimum follow-up were included. Patients who had unstable knee with evidence of subluxation, severe collateral ligament instability, fixed flexion deformity >15°, or genu recurvatum were excluded. All patients were examined for metabolic and developmental disorders. The deformity was corrected by supracondylar femoral DO with fixation by proximal humeral locking plate. The deformity assessment was done clinically and radiologically. Clinically, the IMD was measured in a standing position where the patient stands with full extension and neutral rotation at hip and knee and both knees touching each other [Figure 1]a. By using a goniometer, clinical tibio-femoral angle was measured with the patient standing in anatomic position. It is the angle between the anterior superior iliac spine to the center of the patella and center of the patella to the center of the ankle joint. Standing full-length anteroposterior radiographs of the limb including the hip, knee, and ankle joint were taken [Figure 1]b. The radiologically measured TFA is the angle between anatomical axes of the tibia and anatomical axes of the femur. A line from the center of the femoral head to the center of the ankle is the mechanical axis of the lower limb. The angle between the mechanical axis of the femur and the articular surface of the distal femur is the lateral distal-femoral angle (LDFA). In our study, all radiological measurements were done by the same radiologist by using the same system to eliminate interobserver bias. Preoperative and postoperative results of IMD, TFA, LDFA, and Bostman knee score were evaluated. All patients were called in the outpatient department at 2-year postsurgery for final Bostman knee score.
|Figure 1: (a) Preoperative clinical photograph of the patient which shows gene valgus deformity, (b) Anteroposterior radiograph of the bilateral hip, knee, and ankle showing genu valgum deformity|
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Surgery was performed on a standard operating table, with the patient in the supine position. An ECG electrode was pasted to the skin at the center of the hip joint which was confirmed by an image intensifier to help in the identification of this point under the drapes. The knee was kept in 30° of flexion, with the help of a sandbag. A pneumatic tourniquet was routinely used. A 10-cm-long incision was made over the anterolateral aspect of the distal one-third of the thigh, extending the superolateral border of the patella and, the whole of the anterior supracondylar region of the femur was exposed by developing plane between rectus femoris and vastus lateralis and splitting vastus intermedius. The dome was marked using a divider, which could be fixed at a particular radius. One limb of the divider was kept over the center of rotation of angulation (CORA), which was at the center of the knee joint or femoral condyle level in all cases, hence it ensures a FDO. In FDO, both CORA and center of dome coincide. This point corresponds approximately to the lower border of the patella with the knee in full extension, and after correlating this point with the joint line, one limb of the divider was sunk into this part of the patella and the radius of the dome was adjusted about 5 mm proximal to the adductor tubercle to avoid the lower femoral epiphysis. An arc was now drawn over the lower femur. Multiple drill holes were made anteroposteriorly over the marked dome, perforating both femoral cortices. The DO was now completed using small thin osteotomes. Care was taken to keep the knee flexed so that neurovascular structures fall away. Now, by holding the upper leg and keeping the knee straight, osteotomy was rotated, thereby correcting the deformity. It was often observed that the medial most portion of the proximal fragment hampered the rotation of the distal fragment. A triangular bony projection was occasionally removed from this area to facilitate rotation. The alignment was checked using a telescopic rod [Figure 2]a about 1 m long so that the center of the hip, knee, and ankle becomes co-linear. A 2.5-mm Steinman pin was inserted percutaneously for provisional stability of osteotomy, starting from anteromedial to posterolaterally crossing the osteotomy site up to the opposite femoral cortex, and osteotomy was then fixed using appropriate length proximal humeral locking plate [Figure 2]b and [Figure 2]c. Stability of fixation was confirmed intraoperatively clinically and under an image intensifier. We put the drain, surgical wounds closed in layers, and a knee brace was applied which can be removed during the range of movement (ROM) exercises.
|Figure 2: (a) Intraoperative use of the telescopic rod to check the alignment. And, the use of 2.5-mm Steinman pin for provisional fixation of osteotomy, (b) intraoperative photograph of dome osteotomy, (c) fixation of the dome osteotomy by proximal humeral locking plate|
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The drain was removed on the 2nd postoperative day. Sutures were removed after 2 weeks of surgery. Knee range of motion and quadriceps exercises started from the 3rd postoperative day. Weight-bearing was not allowed for the first 3 weeks and the patient used crutches for ambulation. Toe-touch walking started at 3 weeks followed by a gradual transition to full weight-bearing. We allowed full weight-bearing and more demanding activities according to the patient's muscle strength and symptoms. Patients were called for follow-up at 4 weeks, 12 weeks, 6 months, 12 months, and 24 months postsurgery and assessed for the outcome. Both anteroposterior and lateral standing radiographs were taken in the immediate postoperatively and at follow-up visits [Figure 3] and [Figure 4]. Clinical and radiological evaluations were done for alignment and union. At each visit, range of motion of the knee joint was also evaluated. The Bostman knee score was used preoperatively and at the final follow-up visit to assess the functional outcome. A score between 28 and 30 was classified as an excellent outcome. A score between 20 and 27 was classified as good, while a score below 20 classified as unsatisfactory.
|Figure 3: Immediate postoperative anteroposterior (a) and lateral (b) radiographs of the knee showing fixation of the dome osteotomy by proximal humeral locking plate|
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|Figure 4: Anteroposterior (a) and lateral (b) radiographs of the knee showing union at osteotomy site at 12-week postoperative period|
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The Student's t-test and Mann–Whitney U-test were used to evaluate the difference between the mean of Bostman knee score, IMD, and tibio-femoral angle, and LDFA values were obtained preoperatively and postoperatively. P < 0.05 was considered statistically significant.
| Results|| |
The mean IMD preoperatively was 17.9 cm (range 12–23 cm), whereas the postoperative mean IMD was 2.4 cm (0–4 cm). The mean preoperative clinical TFA was 19.7° (15°–24°) and the radiological TFA was 21.4° (16°–27°), whereas the postoperative mean value was 7.3° (5°–9°) and 8.6° (6°–10°), respectively. The mean preoperative LDFA was 73.4° (68°–82°), whereas the postoperative mean value was 87.2° (84°–91°). IMD, TFA, and LDFA improved significantly (P < 0.001) [Table 1]. The mean Bostman score also improved significantly from 20.8 (18–22) to 29.1 (27–30) (P < 0.001), and only 2 patients (2 limbs) had a good score (20–27) and the rest had excellent score (28–30). All the patients were satisfied with the cosmetic correction. Most knees regained 90° flexion within 2 weeks of surgery and almost full ROM at 3 months after surgery. Three knees had restricted ROM at 3 months; one of these had postoperative wound infection. At 1 year, this patient had 30° restrictions of knee flexion, leading to difficulty in squatting. The other two had full ROM.
|Table 1: Preoperative and postoperative clinical and radiological parameters|
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There was one deep infection that responded to conservative measures. One patient with epiphyseal dysplasia complained of pain in the knees and despite a good cosmetic correction was not satisfied. Four knees had unsightly hypertrophic scars. There were no implant failures, re-operations, and any loss of correction.
| Discussion|| |
Our study aimed to analyze the clinical and radiological results of genu valgum deformity treated by supracondylar femoral DO, with fixation of osteotomy by the proximal humeral locking plate. The main findings of the study were that (1) excellent results can be achieved based on a clinical grading scale of Bostman, (2) knee function measured by Bostman score and other parameters (IMD, TFA, and LDFA) were improved significantly, and (3) complications were uncommon.
Genu valgum deformity is a common deformity in adolescents and young adults in the developing world and it is a frequent cause of orthopedic referral. Genu valgum may increase the risk of osteoarthritis due to abnormal biomechanical loads on the knee. Maligned mechanical axis may cause patella-femoral instability and anterior knee pain. Patients with genu valgum deformity usually present with circumduction gait and face quite a difficulty in running. Hence, surgical intervention is needed to improve the biomechanics, which results in improved appearance, gait, and function in significant valgus deformity. Realignment osteotomy corrects limb alignment and decreases the risk of osteoarthritis development and progression. Wedge osteotomies are also a considerable option for coronal plane deformity correction, but we preferred DO instead of a wedge osteotomy as closing wedge osteotomy results in limb shortening, whereas opening wedge osteotomy results in delayed union with more restrictive weight-bearing. The DO provides a larger surface area and maximum bone contact, which results in better healing. Small bone spikes were produced by multiple drill holes and these spikes hold the proximal and distal end of the osteotomy so that segment motion was reduced during fixation of the osteotomy intraoperatively. Moreover, these spikes provide added stability and reduced stress on the plate and screws. This results in early rehabilitation including partial weight-bearing. The DO allows high degrees of correction in the coronal plane. The DO is a technically demanding surgery where the creation of the arc needs experience and precision. A surgeon can avoid inadvertent propagation and expect excellent segment rotation and good bone contact once the circular contour of the dome gets created.
Another important point to support the DO is the concept of deformity correction where the axis of deformity correction should pass through the CORA of deformity for the re-alignment of proximal and distal mechanical axis after the osteotomy and if this criterion does not meet, then the proximal and distal axes will be translated to each other after correction which results in lazy-S deformity and a geometrically unsound correction. In FDO, central axis corresponds with the CORA. In genu valgum, the apex or CORA is at the knee joint itself where osteotomy is technically not possible. However, in FDO, the apex of deformity and the apex of osteotomy coincide over the knee joint. This leads to complete realignment of axes of the proximal and distal osteotomy fragments after the desired correction is achieved. While in open and close wedge osteotomies, secondary translational deformity occurred because osteotomies are being carried out away from the CORA. This translation deformity may predispose to joint degeneration due to abnormal loading of forces transmitted through the hip, knee, and ankle joint following correction of deformity.
Gautam et al. found satisfactory results with FDO, but they fixed the osteotomy with two crossed Steinman pins and they applied a long leg plaster of pariscast (POP) for 6 weeks. This 6-week complete immobilization of knee joint may lead to knee stiffness, so they used intermittent Continuous passive motion (CPM) after cast removal till patients regained 90° range of motion. El Ghazaly and El-Moatasem also found good results with FDO where they used buttress condylar plate or “T” plate for fixation of the osteotomy, but their study size was very small (12 patients).
Finding an appropriate fixation device for supracondylar osteotomies in children and adolescents is a relatively tedious job. Different types of fixation methods have been described in the literature, which include specialized pediatric angled blade-plates, retrograde femoral nail, external fixator, and buttress condylar plate. We used the adult proximal humeral locking plate, which is routinely used in adult proximal humeral fractures for cost-effectiveness and remotely available specialized pediatric plates. In our country, the locally manufactured proximal humeral locking plates are almost three times cheaper than a specialized pediatric plate. In addition, proximal humeral locking plate offers insertion of fixed-angle locking screws in multiple directions to enhance structural stability and it can be contoured according to the contour of the femoral condyle. Condylar buttress plates are broad in comparison to the anteroposterior dimension of the distal femur in adolescents, which makes these implants unsuitable for fixation of the osteotomy. However, the dimension of the proximal humeral locking plate is comparable with the anteroposterior dimension of the distal femur in adolescents, and we did not find any difficulty in the fixation of distal femur osteotomy. We put at least four screws in the distal fragment which gave sufficient stability until osteotomy union. However, condylar buttress plates are stronger than proximal humeral locking plate, but, in our study, we did not encounter implant failure. Seah et al. performed a comparative study for the fixation of distal femur osteotomy. They used internal and external fixation methods and did not find any significant differences. They concluded that the surgeon should individually choose the fixation method.
Nonunion and fixation failure are common complications of osteotomies. To overcome these complications, stable fixation and good bone apposition are required. We used proximal humeral locking plate for stable fixation and DO for better bone apposition, which results in the good union at the osteotomy site. We did not use postoperative plaster immobilization so ROM exercise can be started early, hence decreasing the chances of knee joint stiffness and quadriceps atrophy. However, we obtained satisfactory results with the proximal humeral locking plate for fixation of distal femoral DO in genu valgum deformity, but a small sample size and relatively shorter follow-up are the limitations of this study. Because this study is not comparative or randomized, we would not be able to provide statistical differences in different procedures. Moreover, our study is a single-center trial and the method can be best established if it carried out in different regions by different surgeons with a larger number of cases and longer follow-up.
| Conclusion|| |
Correction of genu valgum deformity by FDO, via lateral approach, can be accomplished very well using proximal humeral locking plate for fixation. Being a cost-effective and easily available implant, the proximal humeral locking plate has encouraging results at short to mid-term follow-up.
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]