Comparison between Role of Epiphysiodesis Vs Tibial Osteotomy in Treatment of Varus Deformity of the Tibia

Abstract

Genu varum or bowleg is a common childhood deformity and one of the most common causes of parental concern. In the majority of cases, it is physiologic in origin and will correct with normal growth and development, however, there are pathologic genu varum disorders that may progress and produce functional impairment (12). The goal of treatment in varus deformity of the knee is to obtain a well-aligned lower extremity with normal joint orientation and equal leg lengths that are maintained beyond skeletal maturity(1). Once the diagnosis of disease is certain, treatment is recommended since patients that treated in early stages of the disease have a better prognosis(2). The indications for the surgical treatment of varus deformity are progressive, painful or disabling deformity(9,10,11). The goals of surgery are to relieve pain, when present and to correct limb alignment with a horizontal knee joint for weight-bearing(12). There are many techniques for treatment of the varus deformity of the knee as hemiepiphysiodesis and high tibial osteotomy. Osteotomy of the proximal part of the tibia is indicated for the child who is first seen for treatment after the age of three years, who is a poor candidate for brace therapy and for the three-year-old child who has persistent genu varum despite brace therapy. Multiple techniques have been described for the performance of this procedure in children(13,14,15). All involve placement of the osteotomy distal to the tibial tubercle to prevent damage to the tibial apophysis and subsequent genu recurvatum. Concomitant osteotomy of the fibula is necessary to permit adequate correction of the genu varum and internal tibial torsion(4). The osteotomy should restore normal alignment of mechanical axis, restore the parallel orientation of the knee and ankle, regain effective length, and address the deformity in three planes. In addition, the osteotomy should avoid injury to the physis and joint, and be of stable configuration to allow early knee motion and weight bearing(16) Hemiepiphysiodesis by any of several techniques is indicated if the growth plates are still open and the varus deformity is not too severe. This can be accomplished in a variety of ways, including permanent physeal ablation, physeal screw placement, staples and recently, the tension band plate (eight-Plate). The permanent methods of physeal ablation require exact timing of the surgery because overcorrection can occur if growth estimates are incorrect, thus, relegating this technique to adolescents only(21). Once hemiepiphysiodesis is performed, it is critical to follow up the patients closely with clinical and radiographic examinations to monitor the correction obtained and possible staple displacement and/or breakage. If complete deformity correction is obtained, staple removal may be necessary to prevent overcorrection(8)