Strategies in Trauma and Limb Reconstruction

Register      Login

VOLUME 13 , ISSUE 2 ( August, 2018 ) > List of Articles

Original Article

Cozen\'s deformity: resolved by guided growth

Matthew Morin, Joshua Klatt, P. M. Stevens

Keywords : Cozen\'s phenomenon, Tibial valgus, Guided growth

Citation Information : Morin M, Klatt J, Stevens PM. Cozen\'s deformity: resolved by guided growth. 2018; 13 (2):87-93.

DOI: 10.1007/s11751-018-0309-y

License: CC BY-NC-SA 4.0

Published Online: 31-08-2018

Copyright Statement:  Copyright © 2018; Jaypee Brothers Medical Publishers (P) Ltd.


Abstract

Proximal tibial metaphyseal fractures in children can lead to progressive and symptomatic tibial valgus. Corrective osteotomy has been abandoned, due to frequent complications, including recurrent valgus deformity. While spontaneous remodelling has been reported, this is not predictable. For children with persistent deformities, we have resorted to guided growth of the tibia. We present 19 patients who were successfully treated with guided growth, tethering the proximal medial physis. There were ten boys and nine girls, ranging in age from two to 13.6 years at the time of intervention. The mean follow-up from injury was 7.3 years. We documented the intermalleolar distance, mechanical axis deviation (by zone), medial proximal tibial angle (MPTA), and leg length discrepancy. Removal of the plate, or more recently, the metaphyseal screw, was undertaken upon normalization of the mechanical axis. Including the four patients who have undergone repeat tethering for recurrent valgus (one patient—twice), we are effectively reviewing 24 Cozen\'s phenomena, making this the largest series reported in the literature. Correction of the mechanical axis and the proximal medial tibial angle was achieved in all but one patient. Limb length inequality at follow-up ranged from 0.1 to 1.5 cm, with a mean of 0.5 cm. There have been five recurrences in four patients to date; four corrected with repeat tethering and one is pending. Two patients developed significant over correction because of parental failure to pursue timely follow-up. Both have corrected to neutral with lateral tibial physeal tethering. Ten patients have attained skeletal maturity and required no further treatment. The remaining nine patients will be followed until maturity. Guided growth is an excellent choice for the management of post-traumatic tibial valgus. Our rationale for restricting medial overgrowth is twofold: (1) to restore the MPTA and (2) to reduce the length discrepancy due to tibial overgrowth caused by the fracture. Recognizing the potential for recurrent deformity following implant removal, our standard practice now includes removal of just the metaphyseal screw and subsequent reinsertion, in the event of rebound valgus deformity. Level of evidence Therapeutic IV, retrospective series/no control cohort.


PDF Share
  1. Bahnson DH, Lovell WW (1980) Genu valgum following fracture of the proximal tibial metaphysis. Orthop Trans 4:306
  2. Best TN (1973) Valgus deformity after fracture of the upper tibia in children. J Bone Joint Surg 55B:222
  3. Green N (1983) Tibia valga caused by asymmetrical overgrowth following a non-displaced fracture of the proximal tibial metaphysics. J Pediatr Orthop 3:235-237
  4. Herring JA (1981) Post-traumatic valgus deformity of the tibia. J Pediatr Orthop 1:435-439
  5. Jordan SE, Alonso JE, Cook FF (1987) The etiology of values angulation after metaphyseal fractures in children. J Pediatr Orthop 7:450-457
  6. Jackson DW, Cozen L (1971) Genu valgum as a complication of proximal tibial metaphyseal fractures in children. J Bone Joint Surg 53A:1571-1578
  7. Cozen L (1953) Fracture of the proximal portion of the tibia in children followed by valgus deformity. Surg Gynecol Obstet 97:183-188
  8. Tuten HR, Keeler KA, Gabos PG et al (1999) Post-traumatic tibia valga in children: a long-term follow-up note. J Bone Joint Surg Am 81(6):799-810
  9. Zionts LE, McEwen GD (1986) Spontaneous improvement of post-traumatic tibial valga. J Bone Joint Surg Am 68A:680-686
  10. Robert M, Kouri N, Carlioz H et al (1987) Fractures of the proximal tibial metaphysis in children: Review of a series of 25 cases. J Pediatr Orthop 7:444-449
  11. Tarr RR, Resnick CT, Wagner KS et al (1985) Changes in tibiotalar joint contact following experimentally induced tibial angular deformity. Clin Orthop 199:72-80
  12. Dietz FR, Merchant TC (1990) Indications for osteotomy of the tibia in children. J Pediatr Orthop 10:486-490
  13. Mycoskie P (1981) Complications of osteotomies about the knee in children. Orthopedics 4:1005-1015
  14. Bowen JR, Leahey JL, Zhang ZH et al (1985) Partial epiphysiodesis at the knee to correct angular deformity. Clin Orthop 198:184-190
  15. Phemister DB (1933) Operative arrestment of longitudinal growth of bones in the treatment of deformities. J Bone Joint Surg 15:1-15
  16. Anderson M, Green WT, Messner MB (1963) Growth and predictions of growth in the lower extremities. J Bone Joint Surg 45A:1-14
  17. Frost HM (1983) The regional acceleratory phenomenon: a review. Henry Ford Hosp Med J 31(1):3-9
  18. Zionts LE (2002) Fractures around the knee in children. J Am Acad Orthop Surg 10(5):345-355
  19. Stevens P, MacWilliams B, Mohr A (2004) Gait analysis of stapling for genu valgum. J Pediatr Orthop 24:70-74
  20. Heflin J, Ford S, Stevens P (2016) Guided growth for tibia vara (Blount's Disease). Medicine 95(41):e4951
  21. Stevens P, Pease F (2006) Hemiepiphysiodesis for post-traumatic tibial valgus. J Pediatr Orthop 26:385-392
  22. Farr S, Alrabai H, Melzer E et al (2016) Rebound growth of frontal plane malalignment after tension band plating. J Pediatr Orthop. https://doi.org/10.1097/BPO.0000000000000846
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.