ORIGINAL ARTICLE
Multilevel Guided Growth for Hip and Knee Varus
Secondary to Chondrodysplasia
Peter M. Stevens, MD and Eduardo N. Novais, MD
Background: Young children with chondrodysplasia may de-
velop multilevel varus deformities that compromise comfort and
gait. The classic treatment of performing corrective, staged os-
teotomies, at each level of deformity, is a daunting prospect that
is fraught with potential complications. To avoid this scenario,
we have adopted single-event, multilevel surgery, using guided
growth to simultaneously address bilateral varus deformities of
the knee and hip, with good results.
Methods: Three cousins with Schmid-type metaphyseal dyspla-
sia, presented for treatment of progressive varus deformities. In
lieu of osteotomies, we used simultaneous guided growth of the
proximal and distal lateral femora and proximal lateral tibiae,
while ignoring the distal tibial deformity. The pan-genu 8-plates
served to neutralize the mechanical axis while preserving a
horizontal knee. The rationale for applying the trochanteric
8-plate was to stabilize the proximal femoral chondroepiphysis,
hoping to postpone or avert intertrochanteric osteotomy. The
average age at surgery was 28 months, with a range of 19 to 33
months, and follow-up has ranged from 28 to 59 months
(average 48 mo). The pan-genu 8-plates were removed after an
average of 12 months, leaving the trochanteric implants in situ,
pending further growth.
Results: Neutralization of the mechanical axis resolved lateral
knee thrust and intoeing. As the femur is effectively adducted by
knee realignment, the greater trochanteric impingement on the
ilium is alleviated. Lateral tethering of the trochanteric apophysis
served to increase the femoral neck-shaft angle, improving the
abductor lever arm. Each patient experienced complete resolution
of the fatigue hip pain and Trendelenburg gait. As knee alignment
was restored, the ankle varus resolved spontaneously, requiring
no direct treatment. The clinical improvement was reflected in
trending of the radiographic angles and axes toward normal.
Conclusions: These children have benefited from outpatient
guided growth, rather than the anticipated osteotomies, to
correct multilevel varus deformities. Our goal is to exclusively
use guided growth, repeatedly as needed, to avoid osteotomies
altogether. Annual follow-up until skeletal maturity is planned.
Level of Evidence Level IV—retrospective case series.
From the Department of Orthopaedics, University of Utah, Salt Lake
City, UT.
The authors received no financial support for this study.
Dr Stevens receives royalties form Orthofix, Inc on the 8-plate. The other
author declares no conflict of interest.
Reprints: Peter M. Stevens, MD, Department of Orthopaedics, Uni-
versity of Utah, P.O. #58246, Salt Lake City, UT 84158. E-mail:
peter.stevens@hsc.utah.edu.
Copyright r 2012 by Lippincott Williams & Wilkins
626 | www.pedorthopaedics.com
Key Words: coxa vara, genu varum, Schmid-type chon-
drodysplasia, guided growth, 8-plate
(J Pediatr Orthop 2012;32:626–630)
C hildren with chondrodysplasia often present as tod-
dlers with parental concerns focusing upon bowed
legs, limping, and decreased walking tolerance due to
fatigue and pain. These symptoms and findings are non-
physiological in nature and usually progress without
treatment. In addition to the obvious genu varum and
intoeing, coxa vara and ankle varus contribute to the
complex clinical and radiographic picture. The traditional
means of managing these deformities is to perform re-
alignment osteotomies.1–3 If one strictly adheres to the
center of rotational axis of deformity principles, this
would require 12 osteotomies (proximal and distal fem-
ora, proximal and distal tibiae, and fibulae) to address all
of the deformities. They would have to be staged, re-
quiring several hospitalizations and serial cast immobili-
zation. Even with optimal realignment, recurrent deformity
may occur in 30% to 70% of the cases.4,5
There has been increasing acceptance of guided
growth for pediatric knee deformity correction.6,7 Cor-
rection of genu varum effectively adducts the femora and
indirectly improves the Hilgenreiner angle,8 while allevi-
ating greater trochanteric abutment against the ileum. In
an analogous manner, the added benefit of rendering the
tibia vertical, through knee correction, is to mitigate the
apparent varus of the ankle.
We reasoned that the same technique and principles
of guided growth should benefit the hip and further im-
prove abductor efficiency by preventing trochanteric
“overgrowth.” Mindful that the proximal femur is capped
by a common chondroepiphyses, we have recently
switched from intertrochanteric osteotomy to guided
growth, tethering the trochanteric apophysis laterally
with a tension band 8-plate. For chondrodysplasia man-
agement, our intent is to stabilize the proximal femur,
allowing the femoral neck stress fracture (“triangular
metaphyseal defect”) to heal. This alleviates the fatigue
pain and Trendelenburg gait, while improving the range
of hip abduction. In this report, we review the rationale
and initial results of this minimally invasive technique of
single-event, multilevel guided growth. We recognize that
longer follow-up will be required before we can determine
whether this represents a definitive approach.
J Pediatr Orthop  Volume 32, Number 6, September 2012
J Pediatr Orthop  Volume 32, Number 6, September 2012 Multi-level Guided Growth for Hip and Knee Varus

METHODS
This series includes 2 boys and 1 girl (all cousins) HILGENRIENER’S
who underwent hip and knee guided growth for the ANGLE H LINE
treatment of bilateral and symmetrical, multilevel varus
deformities resulting from Schmid-type metaphyseal
chondrodysplasia. Each subject presented with fatigue
pain and gait disturbance due to symmetrical and pro-
gressive varus deformities of the hips, knees, and ankles.
Interestingly, an affected parent of each child had pre- FEMORAL
viously been treated by the senior author (P.M.S.) with PHYSIS/PHYSIS - ZONES +
staged, bilateral, multilevel, valgus-producing osteoto- ANGLE
mies of the proximal and distal femora, as well as the MECHANICAL AXIS
proximal tibia/fibula. This had required multiple hospi- ZONE-3
talizations with the requisite cast immobilization and 3 2 1 1 2 3
delayed weight bearing, after the osteotomies. These pa-
rents were exceptionally well informed and fully suppor-
TIBAL
tive of the strategy of guided growth as a means of PHYSIS/PHYSIS
forestalling, or perhaps preventing, osteotomies. The ANGLE
possibility of rebound deformity was fully discussed,
along with the options of repeating guided growth versus
eventual osteotomy.
The medical records were retrospectively reviewed
for collection of clinical data before and after surgical
intervention including assessment of gait pattern,
Trendelenburg sign, range of hip abduction (standing),
standing femoral intercondylar distance, and doc- FIGURE 1. Radiographic measurements: Coxa vara meas-
urements included Hilgenreiner’s angle (H-A) = verticality of
umentation of ligamentous laxity and torsional profile. the femoral neck physis relative to a horizontal H line and
We reviewed the preoperative and follow-up ante- physis/physis angle (P/P-/A). The latter measurement proved
roposterior standing radiographs of the lower limbs to to be the most specific and reliable. The mechanical axis de-
measure the mechanical axis deviation and displacement viation is depicted on the left leg. See table for pre to post-
by zones (Fig. 1) and the orientation of the proximal/ operative comparisons.
distal femoral physes and the proximal/distal tibial
physes, relative to each other. We felt that in this age and guide pins inserted into the cartilaginous trochanter
group, these measurements were more reproducible and and metaphysis of the femur. Although it may be coun-
relevant than assessing anatomic angles such as the lateral terintuitive to place a screw in cartilage, indeed it had
distal femoral angle, proximal medial tibial angle, and good purchase and none have failed to date. Two fully
lateral distal tibial angle. We also reviewed preoperative threaded, cannulated 4.5-mm screws are used to secure
and follow-up anteroposterior pelvic radiographs, with
the legs rotated inward 15 degrees, to demonstrate the
metaphyseal defect that is indicative of a stress fracture,
presumably exacerbated by vertical shear (Fig. 2). The
Hilgenreiner-epiphyseal angle, the epiphyseal-diaphyseal
angle, head-shaft angle, and the neck-shaft angle were
recorded.
TROCHANTERIC
IMPINGEMENT
Surgical Technique
The optimal age for tethering the proximal femoral
chondroepiphysis is between 2 and 3 years old. This
promotes healing of the medial “triangular defect” (stress
fracture) of the femoral neck. The hip portion of the
surgery is described herein. With the patient supine, a
bump was placed under the sacrum, allowing them to be STRESS FRACTURE

rolled toward the opposite side and elevating the tro-
chanter off the surgical table. This reveals the proximal
femur in profile, including the true neck-shaft angle and
the metaphyseal defect. A 3 to 4 cm lateral incision is
centered at the base of the trochanter, and the iliotibial
band is split. A Keith needle is inserted into the physis,
parallel to its plane. The plate is centered on the needle
A.I.R. VIEW
FIGURE 2. On an abduction, inward rotation view (AIR) the
stress factures on the medial femoral neck metaphyses are
readily apparent. Much of the greater trochanter is unossified
(dotted line).

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Stevens and Novais
FIGURE 3. Intraoperative fluoroscopic view showing proper
placement of the 8-plate. The proximal screw purchase in
cartilage +/ bone is secure.
the plate to the femur, confirming this with the fluoro-
scope (Fig. 3). The wound is closed in layers and a soft
dressing applied. In a similar manner, under sterile
tourniquet control, we applied 8-plates to the distal lat-
eral femur and the proximal lateral tibia as previously
described.6 We found it unnecessary to perform a fibular
epiphysiodesis. We did not address the ankle varus. The
triple level guided growth was performed on an out-
patient basis, applying an 8-plate (Orthofix, Verona,
Italy). No cast immobilization or restriction of activities
was required.
RESULTS
The 3 patients included in this series were followed
for an average of 4 years (range, 28 to 59 mo). The first
patient had plates applied to the greater trochanter at the
time of pan-genu plate removal. The other 2 underwent
simultaneous guided growth of the proximal femur at the
same time as pan-genu plate insertion. All patients healed
without complications. The fatigue hip pain resolved
within 3 months and the waddling gait by 6 months. At
follow-up, each patient has a normal gait, improved hip
abduction, negative Trendelenburg sign, alleviation of hip
pain, and no functional limitations. The femoral neck
“triangular defect” (presumed stress fracture) healed in all
patients. Similarly, the radiographic parameters of coxa
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J Pediatr Orthop  Volume 32, Number 6, September 2012
vara improved in all patients (Table 1). With respect to
the knees, all 3 patients have demonstrated complete
correction of genu varum and with neutralization of the
mechanical axis, accompanied by resolution of lateral
thrust and inward torsion. In each patient, the ankle
varus has resolved, without need for intervention. They
are now being seen on an annual basis and this will be
continued until skeletal maturity.
Each patient had the pan-genu plates removed when
the mechanical axis was rendered neutral. All of the tro-
chanteric 8-plates remain in situ and intact; they will be
removed only if and when they become symptomatic.
After eventual trochanteric 8-plate removal, the children
will be observed for recurrent varus and treated
accordingly–either with guided growth or with inter-
trochanteric osteotomy. The parents, who had experi-
enced the traditional approach of multiple osteotomies,
hospitalizations, and casts, are very enthusiastic about the
changing paradigm of treatment for their progeny.
Case #1
T.F. presented at the age of 19 months with a
waddling gait, fatigue hip pain, genu varum, lateral
thrust, and intoeing. His father had undergone bilateral
osteotomies of the distal femora and tibias, as well as
intertrochanteric osteotomies. Reasoning that he was too
young for the intertrochanteric osteotomies but in need of
knee correction, T.F. underwent pan-genu guided growth
with 8-plates in the lateral distal femora and lateral
proximal tibias. His angular and rotational deformities
corrected to neutral, and he was fully active, without
complaints. However, the proximal femoral varus re-
mained unchanged; rather than subject him to inter-
trochanteric osteotomies at the time of pan-genu plate
removal, 8-plates were applied to the trochanteric
apophyses. Nearly 6 years later, he has no symptoms, no
limp, and no functional limitations. The plates will be left
in situ pending further growth.
Case #2
O.G. presented at the age of 2 and ½ with the same
clinical and radiographic findings. Simultaneous guided
growth was undertaken, applying bilateral 8-plates to the
proximal and distal lateral femora, as well as to the
proximal lateral tibiae. At 18 months of follow-up (age 4),
the mechanical axis and torsional profile were neutral and
the pan-genu plates removed. His Trendelenburg gait has
resolved and he has no complaints of pain or fatigue. He
is now at 4 and ½ years status post–guided growth for
coxa vara, and the trochanteric plates remain in situ. It is
noteworthy that his mother had had staged, pan-genu
osteotomies but never had her hips treated. At the age of
30, she is now quite symptomatic with progressive hip
discomfort, limited abduction, and Trendelenburg gait
and is seeking treatment (Fig. 4).
Case #3
D.F. first presented at the age of 11 months for
evaluation, already manifesting the stigmata of Schmid
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J Pediatr Orthop  Volume 32, Number 6, September 2012 Multi-level Guided Growth for Hip and Knee Varus

TABLE 1. Radiographic Measurements Pre- and Postoperative

HEA (deg.) ESA (deg.) HSA (deg.) NSA (deg.) MAD (mm) Femur Physes-Physes (deg.) Tibia Physes-Physes (deg.)
Age FUP
Sex (y) (y) Side Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post
M 2.7 4.8 R 59 41 30 34 116 121 98 106 49 0 56 42 22 1
L 61 39 32 35 116 123 99 105 48 6 58 41 25 1
M 2.7 4.4 R 70 45 38 44 122 129 104 112 48 0 63 46 23 3
L 71 46 42 45 123 132 105 113 50 2 58 45 27 4
F 1.5 2 R 61 42 36 52 120 134 98 115 34 3 67 40 20 2
L 58 41 40 56 126 136 104 115 47 0 57 42 29 3
ESA indicates epiphysis-shaft angle; FUP, follow-up period; HAS, head-shaft angle; HEA, Hilgenreiner-epiphyseal angle; MAD, mechanical axis deviation (from
center of knee); NSA, neck-shaft angle.

dysplasia, including the characteristic metaphyseal defects DISCUSSION

in the femoral neck and genu varum. At the age of 19
months, she underwent combined pan-genu and proximal
femoral guided growth, without cast immobilization or
hospitalization. At 12 months of follow-up, she had
neutral mechanical axes and the pan-genu plates were
recently removed, again leaving the hip plates in situ
(Fig. 5B). She continues to do well at the age of 3 years,
11 months. Her mother had been treated by means of
multiple osteotomies and was therefore expecting the
same for the daughter.
+3 cm.
FIGURE 4. The concept of 3 level guided growth is to increase
the effective neck shaft angle while adducting the leg and
correcting the genu varum, without the need for osteotomy or
immobilization. This is not a “growth arrest”; note the 3 cm.
gain in limb length (dotted arrow) and improvement in the
abductor lever arm.
We report a series of 3 consecutive patients who
underwent guided growth for the treatment of coxa vara
and genu varum secondary to Schmid-type metaphyseal
chondrodysplasia. At an average of 4 years of follow-up,
we observed normal alignment of the lower extremities on
all patients and continuous improvement of the varus
deformity of the proximal femur.
Schmid-type metaphyseal chondrodysplasia is the
most common form of metaphyseal dysplasia.9 The family
history, combined with obvious genu varum and restricted
hip abduction typically suggest the diagnosis in infancy. By
the time the child commences weight bearing, the com-
bined effects of gravity and muscle loading across joints
serve to accelerate varus deformity at all levels. In the
ambulatory child, complaints of fatigue pain and intoeing
often precipitate medical consultation. Serial standing
radiographs will reveal the severity and progression of
deformities noted at the hip, knee, and ankle. The classic
teaching for treatment of multilevel varus secondary to
chondrodysplasia involves surgical correction by means of
femoral intertrochanteric osteotomt.2,4,5,10,11 Despite well-
done osteotomies, however, recurrence of coxa vara is cited
in the literature as ranging from 30% to 70%.2,10,12 Sur-
gery in very young child may offer the advantages of op-
timizing abductor efficiency and avoiding progression of
acetabular dysplasia. In contrast, in a very young child, the
proximal femur is mainly cartilaginous that may difficult
fixation and increase the risk of recurrence.5
Guided growth is based upon the concept that a
tension band plate, applied to one side of the physis, will
reversibly inhibit growth on that side while permitting the
opposite side to grow in a normal or possibly accelerated
manner.6 This technique has been well documented in the
literature for correcting knee deformity associated with
osteochondrodysplasias.8,13 Heretofore, there have been
no reports of its use in the proximal femur. Knowing the
risks and vagaries of valgus intertrochanteric osteotomies,
including recurrent varus,5 we were reticent to subject our
patients to this procedure at such a young age. At the
same time, we felt that stabilization of the upper femur
would alleviate pain and allow the fatigue fracture to
heal. Guided growth of the proximal femur serves as an
adjunct, optimizing medial growth and reducing the shear

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Stevens and Novais
A B
19 mos.
AGE
31 mos.
OUT PATIENT
NO SPICA CAST PANGENU
IMMEDIATE MOBILIZATION PLATES
REMOVED
FIGURE 5. A, B, Pre- and postoperative comparison (patient 2) showing the interval change over 12 months. The pan-genu plates
were removed and the trochanteric plates were left in situ. C, Age 4 correection maintained. D, Clinical abduction – asympto-
matic/Trendelenburg negative gait.
stresses by rendering the femoral neck physis more per-
pendicular to the force of gravity. As demonstrated in our
patients, the surgical procedure is well tolerated and can
be done on an outpatient basis. Furthermore, no post-
operative immobilization is necessary. It may also be
done simultaneously with bilateral hemiepiphysiodesis at
the knee level. At follow-up, we noted steady improve-
ment in the femoral physis to physis angle. The distal
plates were removed when the mechanical axis was neu-
tral; the proximal plates have been left in to allow further
correction of this angle. It seems unlikely that these
asymptomatic children will need valgus intertrochanteric
osteotomies in the future. Although ankle varus could be
addressed by guided growth of the lateral distal tibia,
there is limited space and potential interference of the
fibula. By correcting genu varum, we were pleasantly
surprised to note the spontaneous correction of distal
varus as the tibia was aligned with the ground reaction
forces. The tibial proximal physis to distal physis angle
trended toward a normal value of 0 degree.
On the basis of our experience, we feel that guided
growth of the proximal femur may be combined with pan-
genu hemiepiphysiodesis, allowing the surgeon to address
the clinical and radiographic abnormalities in a young
population without resorting to osteotomies. No bridges
have been burned; interteochanteric osteotomy may be
undertaken, if necessary, when the children are older,
with less risk of recurrence and less chance of secondary
acetabular dysplasia, due to optimization of the abductor
lever arm during growth.
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J Pediatr Orthop  Volume 32, Number 6, September 2012
C D
Age 4
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