Valgus KneeDeformities Children with Juvenile Chronic ... · insoles prevented the subtaloid valgus...
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Archives of Disease in Childhood, 1970, 45, 388. Valgus Knee Deformities in Children with Juvenile Chronic Polyarthritis Treated by Epiphysial Stapling B. M. ANSELL, G. P. ARDEN, and I. McLENNAN* From M.R.C. Rheumatism Research Unit, Canadian Red Cross Memorial Hospital, Taplow, and Heatherwood Hospital, Ascot, Berks. Ansell, B. M., Arden, G. P., and McLennan, I. (1970). Archives of Disease in Childhood, 45, 388. Valgus knee deformities in children with juvenile chronic polyarthritis treated by epiphysial stapling. Stapling of the epiphysis to the diaphysis on the medial aspect of the lower end of the femur and the upper end of the tibia has been shown to correct valgus deformities of the knees in 3 children with juvenile chronic polyarthritis, whose growth had been considerably retarded during prolonged corticosteroid therapy. Satisfactory correction was obtained in all 3 without loss of function. We stress the need for supervision in the immediate post- operative period, as well as later, since over-rapid correction of the deformity may occur during the growth spurt after stopping corticosteroid therapy, requiring removal of the staples after a few months. To obtain similar correction in those whose growth rate is slower, the staples should be left in situ for longer. Children with juvenile chronic polyarthritis who are treated with even small doses of corticosteroids over a prolonged period fail to grow in height (Ansell, 1965). These children may develop severe valgus deformities of the knees, while bone age is frequently retarded. When corticosteroid therapy is reduced or withdrawn growth is resumed. In 1945 Haas presented evidence that differential growth could be obtained in dogs by fixing the epiphyses to the diaphyses with wire loops. Subse- quently, Blount and Clarke (1949) applied this principle to children using staples to halt epiphysial growth. This paper reports the results of stapling the epiphysis to the diaphysis on the medial aspect of both the lower end of the femur and the upper end of the tibia in 3 children in an attempt to improve their valgus deformities when growth was resumed, after stopping or reducing corticosteroid therapy. Case Reports Case 1. This girl had suffered from juvenile chronic polyarthritis from the age of 4, which had been treated with systemic corticosteroids to the age of 13. When transferred to Taplow for further management because of severe joint deformities and continuing activity, Received 10 September 1969. *In receipt of a grant from the Arthritis and Rheumatism Council. there were flexion contractures of the hips and knees, and these were associated with marked genu valgum (Fig. la) and both subtalar joints tended to go into valgus on standing. The disease activity was controlled with enseal aspirin 3 g. daily and indomethacin 75 mg. daily. Flexion contractures of the hips were treated with active exercises in the hydrotherapy pool, and in slings, alternating with prone lying. Serial splinting corrected the flexion deformities of the knees, and valgus insoles prevented the subtaloid valgus on standing. The epiphyses were still open, and in order to overcome the persisting valgus deformity staples were inserted on the medial side of the upper tibial and lower femoral epiphyses of both knees (Fig. 2). The operation was performed under general anaesthesia without corti- costeroid cover but careful post-operative observations were made for signs of steroid deficiency. The need for administration of hydrocortisone did not arise. Post-operatively, quadriceps exercises were performed without knee flexion from day 3. Knee flexion was started at 14 days and walking at 21 days. During the next 8 months she grew 7 - 5 cm., with marked reduction of knee valgus (Fig. lb). Staples were removed at 8 months because of a tendency to genu varus deformities, particularly on the left side, which have, subsequently, corrected (Fig. lc). Case 2. This girl experienced onset of juvenile chronic polyarthritis at the age of 18 months. After 14 months of continuous activity, prednisone was given for 3 months with benefit but relapse occurred on 388 on January 29, 2020 by guest. Protected by copyright. http://adc.bmj.com/ Arch Dis Child: first published as 10.1136/adc.45.241.388 on 1 June 1970. Downloaded from
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Archives of Disease in Childhood, 1970, 45, 388.
Valgus Knee Deformities in Children with JuvenileChronic Polyarthritis Treated by Epiphysial Stapling
B. M. ANSELL, G. P. ARDEN, and I. McLENNAN*From M.R.C. Rheumatism Research Unit, Canadian Red Cross Memorial Hospital, Taplow, and
Heatherwood Hospital, Ascot, Berks.
Ansell, B. M., Arden, G. P., and McLennan, I. (1970). Archives of Diseasein Childhood, 45, 388. Valgus knee deformities in children with juvenilechronic polyarthritis treated by epiphysial stapling. Stapling of the epiphysisto the diaphysis on the medial aspect of the lower end of the femur and the upperend of the tibia has been shown to correct valgus deformities of the knees in 3 childrenwith juvenile chronic polyarthritis, whose growth had been considerably retardedduring prolonged corticosteroid therapy. Satisfactory correction was obtained inall 3 without loss of function.We stress the need for supervision in the immediate post- operative period, as well
as later, since over-rapid correction of the deformity may occur during the growthspurt after stopping corticosteroid therapy, requiring removal of the staples after afew months. To obtain similar correction in those whose growth rate is slower,the staples should be left in situ for longer.
Children with juvenile chronic polyarthritis whoare treated with even small doses of corticosteroidsover a prolonged period fail to grow in height(Ansell, 1965). These children may develop severevalgus deformities of the knees, while bone age isfrequently retarded. When corticosteroid therapyis reduced or withdrawn growth is resumed. In1945 Haas presented evidence that differentialgrowth could be obtained in dogs by fixing theepiphyses to the diaphyses with wire loops. Subse-quently, Blount and Clarke (1949) applied thisprinciple to children using staples to halt epiphysialgrowth. This paper reports the results of staplingthe epiphysis to the diaphysis on the medial aspectof both the lower end of the femur and the upperend of the tibia in 3 children in an attempt toimprove their valgus deformities when growth wasresumed, after stopping or reducing corticosteroidtherapy.
Case ReportsCase 1. This girl had suffered from juvenile chronic
polyarthritis from the age of 4, which had been treatedwith systemic corticosteroids to the age of 13. Whentransferred to Taplow for further management becauseof severe joint deformities and continuing activity,
Received 10 September 1969.*In receipt of a grant from the Arthritis and Rheumatism Council.
there were flexion contractures of the hips and knees,and these were associated with marked genu valgum(Fig. la) and both subtalar joints tended to go intovalgus on standing. The disease activity was controlledwith enseal aspirin 3 g. daily and indomethacin 75 mg.daily. Flexion contractures of the hips were treatedwith active exercises in the hydrotherapy pool, and inslings, alternating with prone lying. Serial splintingcorrected the flexion deformities of the knees, and valgusinsoles prevented the subtaloid valgus on standing.The epiphyses were still open, and in order to overcomethe persisting valgus deformity staples were inserted onthe medial side of the upper tibial and lower femoralepiphyses of both knees (Fig. 2). The operation wasperformed under general anaesthesia without corti-costeroid cover but careful post-operative observationswere made for signs of steroid deficiency. The needfor administration of hydrocortisone did not arise.Post-operatively, quadriceps exercises were performedwithout knee flexion from day 3. Knee flexion wasstarted at 14 days and walking at 21 days. During thenext 8 months she grew 7 - 5 cm., with marked reductionof knee valgus (Fig. lb). Staples were removed at 8months because of a tendency to genu varus deformities,particularly on the left side, which have, subsequently,corrected (Fig. lc).
Case 2. This girl experienced onset of juvenilechronic polyarthritis at the age of 18 months. After14 months of continuous activity, prednisone was givenfor 3 months with benefit but relapse occurred on
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ValgMs Knee Deformities in Children with Juvenile Chronic Polyarthritis
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389
FIG. 1.-Case 1. (a) Age 13j years, 3 months after stopping corticosteroid and 4 months before stapling; (b) age 14 I
years, 8 months after stapling and immediately before removal of staples; (c) age 16 years.
(a) (b)FIG. 2.-Case 1. Knee x-ray: (a) before stapling showing that epiphyses are still widely open at the age of 13k; (b) 8 months
after staples have been inserted, epiphyses on medial aspect are narrowing satisfactorily compared to lateral aspect.
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390 Ansell, Arden, and McLennan
FIG. 3.-Growth chart of Case 2 showing marked growth spurt when corticosteroids were stopped.
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(a) (b) (c)FIG. 4.-Case 2. (a) Age 3 years, shortly after start of maintenance corticosteroid therapy; (b) age llj years, one mo
after stapling; (c) age 12j years, at time of removal of staples.
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Valgus Knee Deformities in Children with Juvenile Chronic Polyarthritis 391
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2 3 4 5 6 7 8 9 1o ;I 12 13 i1.6. ii 18 1.9FIG. 5.-Growth chart of Case 3 showing poor growth rate.
(a) (b) (c)FIG. 6.-Case 3. (a) At 21 years; (b) at 10 years showing increase in valgus deformity together with impairedgrowth;
(c) at 14-l- years, 18 months after staples had been inserted.
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392 Ansell, Arden, and McLennanstopping. As this was repeated on two occasions,maintenance prednisone therapy at 4 mg. daily wasstarted (Fig. 4a). Because of obesity, one year later thiswas changed to triamcinolone 3 mg. daily. She remainedon between 2 and 3 mg. triamcinolone for the next 4years (Fig. 3). She was weaned off corticosteroids,with the help of sodium aurothiomalate, and laterdeveloped a rash followed by typical psoriasis. Despitea marked growth spurt (Fig. 3) valgus deformity of theknees did not decrease and bilateral stapling operationswere undertaken on the medial aspect of the lowerfemoral and upper tibial epiphyses. During thefollowing 16 months she grew 3 2 cm. with correctionof the deformity; the staples were then removed.Though there has been excellent improvement in theposition of the legs, psoriasis has recurred around someof the scars (Fig. 4b and c).
Case 3. This girl developed juvenile chronicpolyarthritis at the age of 19 months. Because ofsevere iridocyclitis, as well as very active joint disease,corticosteroid therapy was started. After 8 years on5 mg. prednisone daily, because of failure to grow inheight she was given human growth hormone (10 x2 weekly) for 1 year during which time her growth ratedid not improve (Ward, Hartog, and Ansell, 1966). Itwas, therefore, decided to reduce her prednisone to a levelcompatible with growth, and at the time of stapling shewas on 3 mg. prednisone daily, later reduced to 2 mg.daily. As her disease became more active, she waschanged to alternate day single dose (10 mg.) regimen.Her growth rate, illustrated in Fig. 5, was considerablyless than that expected for her age, being barely 2 -5cm. in the year following stapling, and 2 5 cm. in the2nd year after stapling. Correction of her valgusdeformities was very much slower and the staples wereleft in situ for 18 months. Despite the slow growthrate, satisfactory correction of the valgus deformity wasachieved (Fig. 6).
DiscussionThe introduction of staples to control epiphysial
growth (Blount and Clarke, 1949) has enabledsurgeons to correct knock-knee deformities ingrowing children with precision, over a period of6-9 months; after removal of the staples, normalepiphysial growth at the operated site restarts.The operation is simple to perform and full kneefunction soon returns.
In juvenile chronic polyarthritis, corticosteroidtherapy, as well as causing failure to grow in height,may aggravate valgus deformity of the knees anddelay epiphysial union. When growth is resumedafter the cessation or reduction of corticosteroid
dosage, if there is no improvement in the valideformity, stapling should be considered. Orthe staples are inserted the child must be watchcarefully as rapid correction can take place durithe growth spurt which occurs immediately aftherapy has stopped (Fig. 3). In Case 1 when 1staples were inserted 8 months after stoppiprednisone they had to be removed 8 months labecause of incipient varus deformity. In Casewhere this stage had alreadybeen passed and the chwas growing more slowly, it took 16 months, ain Case 3, where growth was even slower, 18 monito get satisfactory correction.
Despite the suggestion of Poirier (1968) tlinstability can arise, none was seen in any of th,knees post-operatively, and the range of movem(returned to that of the pre-operative state (Tab]
TABLEIntermalleolar Distance and Range of Movement
Knees Before and 1 Year After Operation
Intermalleolar Range of Movement at KneeDistance (cm.) (degrees)
Right LeftPre-op. 1 yr.
Pre-op. 1 yr. Pre-op. I1 y
Case 1 12*5 0*0 20/100 0/95 10/100 0!/9Case 2 9 *5 1*25 0/90 0/100 0/90 0/9(Case 3 15-0 3-75 5!130 0/100 10/130 0/1,
REFERENCES
Ansell, B. M. (1965). Still's disease. In Progress in ClinRheumatology, p. 95. Ed. by A. St. J. Dixon. ChurclLondon.
Blount, W. P., and Clarke, G. R. (1949). Control of bone groiby epiphyseal stapling: a preliminary report. Journal of Band Joint Surgery, 31A, 464.
Haas, S. L. (1945). Retardation of bone growth by a wire loJournal of Bone and Joint Surgery, 27, 25.
Poirier, H. (1968). Epiphyseal stapling and leg equalizatiJournal of Bone and Joint Surgery, 50B, 61.
Ward, D. J., Hartog, M., and Ansell, B. M. (1966). Corticostereinduced dwarfism in Still's disease treated with human groNhormone. Annals of the Rheumatic Diseases, 25, 416.
AddendumSince this paper was prepared, satisfactory correcti
of valgus knee deformities has been carried out infurther cases using this technique.
Correspondence to Dr. B. M. Ansell, Rheumati,iResearch Unit, Canadian Red Cross Memorial HospitTaplow, Maidenhead, Berkshire.
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