The Perils of Sleeper Plates in Multiple Hereditary Exostosis: Tibial Deformity Overcorrection Due to Tether at Empty Metaphyseal Hole

Abstract

Background: Hemi-epiphysiodesis is the mainstay of treatment for angular deformities at the knee in children with multiple hereditary exostosis (MHE). Upon deformity correction, the metaphyseal screw may be removed from the hemi-epiphysiodesis plate, the sleeper plate technique, with anticipated reimplantation of the metaphyseal screw should the original deformity recur. The aim of the present study is to compare the incidence of complications with the sleeper plate technique with complete plate removal in an MHE cohort. Methods: Patients under the age of 18 with MHE who underwent hemi-epiphysiodesis of the proximal tibia and/or distal femur between February 1, 2016, and February 6, 2022 with a minimum 2-year follow-up or follow-up to skeletal maturity were identified via ICD-10 codes. Patient charts and radiographic images were reviewed to assess for the bone(s) treated, the use of sleeper plates, and whether any complication occurred, including overcorrection from bony ingrowth at the empty holes or deformity recurrence. Results: In 13 patients, 19 knees underwent hemi-epiphysiodesis at 30 sites; 13 distal femoral and 17 proximal tibial. Of 30 plates, 18 (60%) were removed completely upon deformity correction and 3 (10%) did not require removal due to skeletal maturity. Four of 13 (30.8%) femoral plates and 5 of 17 (29.4%) tibial plates were left as sleeper plates. All 5 tibial sleeper plates developed bony ingrowth into the empty metaphyseal screw hole, which led to unintended progressive deformity overcorrection. In the majority of cases, the deformity was addressed by the removal of the plate and exophytic bone and hemi-epiphysiodesis on the other side of the affected proximal tibia with subsequent resolution of the deformity. Conclusions: All tibial sleeper plates developed bony ingrowth into the screwless metaphyseal hole. The bony ingrowth functioned as a tether, resulting in progressive deformity overcorrection. Sleeper plates should be avoided at the proximal tibia in patients with MHE, and extreme caution should be exercised when considering this technique at the distal femur or other sites. Levels of Evidence: Level III—retrospective comparative study.

Effective time, correction speed and termination time of hemi-epiphysiodesis in children

“…If only metaphyseal screws are removed, close follow-up is required. But Retzky[ 60 ] indicated that Sleeper plates technique should be avoided to use in patients with proximal tibia MHE, surgeons should be extreme caution when considering this technique.…”

What’s New in Pediatric Orthopaedics

“…An interesting study of sleeper plates used for the treatment of proximal tibial deformity in multiple hereditary exostosis found osseous overgrowth and tethering resulting in progressive deformity overcorrection 21 . However, none of the sleeper plates used on the distal femur to treat similar deformity exhibited this phenomenon.…”

“…T H E J O U R N A L O F B O N E & JOINT SURGERY d J B J S . O R G VOLUME 106-A d NUMBER 4 d F E B RUA RY21, 2024 …”