External Fixation and Stapling for Angular Deformities
and Limb Length Discrepancies in Multiple Hereditary Exostosis (MHE)
Abstract 2005 MHE Conference
John E. Herzenberg, MD, FRCSC
Head of Pediatric Orthopaedics, Sinai Hospital of Baltimore
Co-Director, International Center for Limb Lengthening
Rubin Institute for Advanced Orthopedics Baltimore, MD 21215
General considerations: MHE causes valgus in the knee and ankle.
The cause is tethering of the growth plates, leading to asymmetric growth and limb length discrepancy. Treatment of valgus
(knock knee) deformity improves awkward gait, and prevents abnormal joint loading that can cause premature knee arthritis.
Treating leg length discrepancy improves gait mechanics and prevents low back pain caused by pelvic tilt. Mild angulations in
growing children can be treated with hemi-epiphyseal stapling using Blount staples (Zimmer) in pre-teens, or the new 8-plate
(Orthofix) in children as young as 3 years (where staples might dislodge).For children near skeletal maturity, and for adults,
osteotomy and gradual correction with external fixators is the most accurate way to correct angulation and length problems.
The TSF (Smith & Nephew) and MAC (EBI) enable multiplanar correction with simultaneous lengthening. For adults without
angulation, there is an implantable telescopic lengthening nail called the ISKD (Orthofix) which lengthens the femur or tibia
without an external fixator.
Valgus knee: Assess angulation on a long standing x-ray that includes hip, knee and ankle on a single cassette and a long
lateral film. Measure the mechanical axis deviation (MAD), lateral distal femoral angle (LDFA), medial proximal tibial angle (MPTA),
posterior proximal tibial angle (PPTA) and posterior distal femoral angle (PDFA). These tests usually localize the problem to the
proximal tibia. Consider stapling for young patients with sufficient growth. Older children are treated with gradual correction
using an external fixator and corticotomy. Consider simultaneous peroneal nerve decompression and resection of the fibular
head osteochondroma.
Valgus ankle: Assess angulation on standing films centered on the ankle. Measure the lateral distal tibial angle (LDTA) and
anterior distal tibial angle (ADTA). Evaluate for presence of compensatory subtalar contractures. Staple the medial distal tibia
for younger patients without subtalar contractures. If there is an established subtalar contracture that makes the foot
plantigrade, then the valgus tilt of the ankle might best be left untreated.
Leg length discrepancy: For discrepancies under 2 cm, use shoe lifts. In skeletally immature patients, consider epiphyseodesis
of the long leg. Lengthening the short leg is preferred if there is residual angular deformity to be corrected. Predicting adult
height and limb length discrepancy with the Multiplier method helps families to decide which option to choose. In mature
patients, without angulation, lengthen either with ISKD or lengthening over nail (LON) methods to eliminate or decrease
external fixation time. Shortening the long leg in adults by up to 4 cm can be safely done in the femur over an intramedullary
nail as an alternative to lengthening.
Forearm problems: For the short ulna without angulation in young children, lengthen the ulna with an external fixator to
prevent the secondary changes of distal radius ulnar deviation and radial head dislocation. Older children need more complex
treatment: ulnar lengthening with distal radio-ulnar fixation to gradually reduce the dislocated radial head, followed by staged
distal radial osteotomy for angular correction. Mild ulnar deviation of the distal radius may be amenable to hemi-epiphyseal
stapling techniques.
and Limb Length Discrepancies in Multiple Hereditary Exostosis (MHE)
Abstract 2005 MHE Conference
John E. Herzenberg, MD, FRCSC
Head of Pediatric Orthopaedics, Sinai Hospital of Baltimore
Co-Director, International Center for Limb Lengthening
Rubin Institute for Advanced Orthopedics Baltimore, MD 21215
General considerations: MHE causes valgus in the knee and ankle.
The cause is tethering of the growth plates, leading to asymmetric growth and limb length discrepancy. Treatment of valgus
(knock knee) deformity improves awkward gait, and prevents abnormal joint loading that can cause premature knee arthritis.
Treating leg length discrepancy improves gait mechanics and prevents low back pain caused by pelvic tilt. Mild angulations in
growing children can be treated with hemi-epiphyseal stapling using Blount staples (Zimmer) in pre-teens, or the new 8-plate
(Orthofix) in children as young as 3 years (where staples might dislodge).For children near skeletal maturity, and for adults,
osteotomy and gradual correction with external fixators is the most accurate way to correct angulation and length problems.
The TSF (Smith & Nephew) and MAC (EBI) enable multiplanar correction with simultaneous lengthening. For adults without
angulation, there is an implantable telescopic lengthening nail called the ISKD (Orthofix) which lengthens the femur or tibia
without an external fixator.
Valgus knee: Assess angulation on a long standing x-ray that includes hip, knee and ankle on a single cassette and a long
lateral film. Measure the mechanical axis deviation (MAD), lateral distal femoral angle (LDFA), medial proximal tibial angle (MPTA),
posterior proximal tibial angle (PPTA) and posterior distal femoral angle (PDFA). These tests usually localize the problem to the
proximal tibia. Consider stapling for young patients with sufficient growth. Older children are treated with gradual correction
using an external fixator and corticotomy. Consider simultaneous peroneal nerve decompression and resection of the fibular
head osteochondroma.
Valgus ankle: Assess angulation on standing films centered on the ankle. Measure the lateral distal tibial angle (LDTA) and
anterior distal tibial angle (ADTA). Evaluate for presence of compensatory subtalar contractures. Staple the medial distal tibia
for younger patients without subtalar contractures. If there is an established subtalar contracture that makes the foot
plantigrade, then the valgus tilt of the ankle might best be left untreated.
Leg length discrepancy: For discrepancies under 2 cm, use shoe lifts. In skeletally immature patients, consider epiphyseodesis
of the long leg. Lengthening the short leg is preferred if there is residual angular deformity to be corrected. Predicting adult
height and limb length discrepancy with the Multiplier method helps families to decide which option to choose. In mature
patients, without angulation, lengthen either with ISKD or lengthening over nail (LON) methods to eliminate or decrease
external fixation time. Shortening the long leg in adults by up to 4 cm can be safely done in the femur over an intramedullary
nail as an alternative to lengthening.
Forearm problems: For the short ulna without angulation in young children, lengthen the ulna with an external fixator to
prevent the secondary changes of distal radius ulnar deviation and radial head dislocation. Older children need more complex
treatment: ulnar lengthening with distal radio-ulnar fixation to gradually reduce the dislocated radial head, followed by staged
distal radial osteotomy for angular correction. Mild ulnar deviation of the distal radius may be amenable to hemi-epiphyseal
stapling techniques.
Research authored by Dr. Herzenberg
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List of Publications via PubMed
(NIH National Library of Medicine)
List of Publications via PubMed
(NIH National Library of Medicine)
| John E. Herzenberg, M.D., FRCSC |
| Dr. Herzenberg's Clinal Presentation |
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