Pediatric Ankle Valgus
Fibular development and its impact on the kinematics of the ankle and foot are complex topics. [1, 2, 3] The normal fibula is approximately equal in length to the tibia, but its distal tip extends more caudad. Thus, the fibula acts as a lateral buttress, bearing approximately 15% of the body weight during gait. Ankle valgus is an insidious deformity that results in pronation of the foot and medial malleolar prominence. The causes are varied and include neuromuscular disorders, skeletal dysplasia, and clubfoot. [4, 5, 6, 7, 8]
Left untreated, this deformity may progress, despite the use of orthotics or corrective shoes, resulting in the medial collapse of the ankle and foot. After skeletal maturity, the only remedy is to perform a supramalleolar osteotomy. However, in growing children, there is the opportunity to intervene by means of guided growth or hemiepiphysiodesis of the distal medial tibia.
This article focuses on discussing the pathophysiology and evolution of ankle valgus and elucidating the role of guided growth (prior to skeletal maturity) to reverse this problem, without the need for osteotomy. If the physis has closed, an osteotomy will be required.
Normal ankle anatomy (see the image below) has the following characteristics:
Ankle valgus has the following characteristics:
In the normally aligned extremity, the mechanical axis bisects the knee and ankle, at an angle of 3º with respect to the vertical (gravity). The tip of the fibula is caudad to the medial malleolus, and the fibula serves as a lateral buttress to the ankle, bearing up to 15% of the weight. This preserves a horizontal plafond and ameliorates strain on the deltoid and tibiofibular ligaments.
The alignment of the tibial and fibular physes, along with the ankle plafond, parallel to the floor and perpendicular to gravity permits the physeal and articular cartilage chondrocytes to resist compression—a task for which they are well suited—while sparing them from shear forces.
If the fibula is foreshortened because of developmental, posttraumatic, or iatrogenic causes, the lateral buttress effect is lost. As the ankle tilts and the ground reaction force shifts laterally, the balance changes. The deltoid and interosseous ligaments are subject to strain, and the lateral distal tibial epiphysis is compressed, resulting in characteristic wedging. The distal fibular epiphysis may enlarge, reflecting the Heuter-Volkmann principle as it impinges on the hindfoot and assumes increased weightbearing stresses (see the image below).
This process continues in a vicious circle that is refractory to shoe modification or bracing; eventually, surgical intervention is needed. Ankle valgus may also contribute to progressive outward rotation of the tibia and result in secondary valgus strain on the knee.
The severity and progression of ankle valgus may be assessed on the basis of the Malhotra grading system (see Workup).
In a retrospective study by Burghardt et al, ankle valgus was found to have developed postoperatively in 55.8% of feet in a group of pediatric patients who had undergone surgery for idiopathic clubfoot. 
All told, ankle valgus is considerably more common than (bony) ankle varus. Often bilateral, it may be seen in conjunction with other limb malalignment problems, including subtalar valgus (or varus) and genu valgum. When unilateral, it may contribute to relative foreshortening of the limb as a consequence of lateral tilt and translocation of the hindfoot. This will not be appreciated on a scanogram; a standing anteroposterior (AP) radiograph of the ankles is necessary to document its contribution. [15, 16]
Depending on the etiology, ankle valgus is often bilateral; its overall frequency is unknown. It is far more common than ankle varus and may accompany (or mimic) hindfoot deformities, compounding their management. Developing during childhood, if left untreated, it may become relatively disabling by the time of skeletal maturity.
As ankle valgus corrects, bracing is facilitated or (in some cases) obviated, and shoewear improves. Lateral impingement and subfibular pain are ameliorated.
Compared to the knee, where rapid improvement is noted, the ankle grows slowly. This is especially true in patients with neuromuscular compromise or skeletal dysplasias. Nevertheless, over the course of 18-24 months, most children will manifest signs of clinical and radiographic improvement. The flexible extraphyseal implant may be left in situ longer, if necessary. The theoretical risk of physeal closure is progressive ankle varus (not encountered to date); this may be remedied with an opening wedge supramalleolar osteotomy.
Lewin SO, Opitz JM. Fibular a/hypoplasia: review and documentation of the fibular developmental field. Am J Med Genet Suppl. 1986. 2:215-38. [Medline].
Lundberg A. Kinematics of the ankle and foot. In vivo roentgen stereophotogrammetry. Acta Orthop Scand Suppl. 1989. 233:1-24. [Medline].
Tickle C. Genetics and limb development. Dev Genet. 1996. 19 (1):1-8. [Medline].
Cuervo M, Albiñana J, Cebrian J, Juarez C. Congenital hypoplasia of the fibula: clinical manifestations. J Pediatr Orthop B. 1996 Winter. 5 (1):35-8. [Medline].
Stevens PM, Arms D. Postaxial hypoplasia of the lower extremity. J Pediatr Orthop. 2000 Mar-Apr. 20 (2):166-72. [Medline].
Stevens PM, Aoki S, Olson P. Ball-and-socket ankle. J Pediatr Orthop. 2006 Jul-Aug. 26 (4):427-31. [Medline].
Stevens PM, Otis S. Ankle valgus and clubfeet. J Pediatr Orthop. 1999 Jul-Aug. 19 (4):515-7. [Medline].
Malhotra D, Puri R, Owen R. Valgus deformity of the ankle in children with spina bifida aperta. J Bone Joint Surg Br. 1984 May. 66 (3):381-5. [Medline].
Lampasi M, Antonioli D, Di Gennaro GL, Magnani M, Donzelli O. Congenital pseudarthrosis of the fibula and valgus deformity of the ankle in young children. J Pediatr Orthop B. 2008 Nov. 17 (6):315-21. [Medline].
Takikawa K, Haga N, Tanaka H, Okada K. Characteristic factors of ankle valgus with multiple cartilaginous exostoses. J Pediatr Orthop. 2008 Oct-Nov. 28 (7):761-5. [Medline].
Gibson V, Prieskorn D. The valgus ankle. Foot Ankle Clin. 2007 Mar. 12 (1):15-27. [Medline].
Nabeshima Y, Mori H, Fujii H, Ozaki A, Mitani M, Fujioka H. Ankle valgus and subtalar varus in treated clubfoot. J Foot Ankle Surg. 2009 Nov-Dec. 48 (6):615-9. [Medline].
Takakura Y, Tanaka Y, Kumai T, Sugimoto K. Development of the ball-and-socket ankle as assessed by radiography and arthrography. A long-term follow-up report. J Bone Joint Surg Br. 1999 Nov. 81 (6):1001-4. [Medline].
Burghardt RD, Tettenborn LP, Stücker R. Growth Disturbance of the Distal Tibia in Patients With Idiopathic Clubfeet: Ankle Valgus and Anteflexion of the Distal Tibia. J Pediatr Orthop. 2016 Jun. 36 (4):343-8. [Medline].
Machen MS, Stevens PM. Should full-length standing anteroposterior radiographs replace the scanogram for measurement of limb length discrepancy?. J Pediatr Orthop B. 2005 Jan. 14 (1):30-7. [Medline].
Stevens PM. Effect of ankle valgus on radiographic appearance of the hindfoot. J Pediatr Orthop. 1988 Mar-Apr. 8 (2):184-6. [Medline].
Stevens PM, Toomey E. Fibular-Achilles tenodesis for paralytic ankle valgus. J Pediatr Orthop. 1988 Mar-Apr. 8 (2):169-75. [Medline].
Aurégan JC, Finidori G, Cadilhac C, Pannier S, Padovani JP, Glorion C. Children ankle valgus deformity treatment using a transphyseal medial malleolar screw. Orthop Traumatol Surg Res. 2011 Jun. 97 (4):406-9. [Medline].
Hou ZH, Zhou JH, Ye H, Shi JG, Zheng LB, Yao J, et al. Influence of distal tibiofibular synostosis on ankle function. Chin J Traumatol. 2009 Apr. 12 (2):104-6. [Medline].
Chu A, Ong C, Henderson ER, Van Bosse HJ, Feldman DS. Distraction Osteogenesis of the Fibula to Correct Ankle Valgus in Multiple Hereditary Exostoses. Bull Hosp Jt Dis (2013). 2016 Nov. 74 (4):249-253. [Medline].
Paley D, Herzenberg JE. Principles of Deformity Correction. Berlin Heidelberg New York: Springer-Verlag; 2002.
van Oosterbos M, van der Zwan AL, van der Woude HJ, Ham SJ. Correction of ankle valgus by hemiepiphysiodesis using the tension band principle in patients with multiple hereditary exostosis. J Child Orthop. 2016 Jun. 10 (3):267-73. [Medline]. [Full Text].
Stevens PM, Klatt JB. Guided growth for pathological physes: radiographic improvement during realignment. J Pediatr Orthop. 2008 Sep. 28 (6):632-9. [Medline].
Stevens PM, Belle RM. Screw epiphysiodesis for ankle valgus. J Pediatr Orthop. 1997 Jan-Feb. 17 (1):9-12. [Medline].
Driscoll MD, Linton J, Sullivan E, Scott A. Medial malleolar screw versus tension-band plate hemiepiphysiodesis for ankle valgus in the skeletally immature. J Pediatr Orthop. 2014 Jun. 34 (4):441-6. [Medline].
Peter M Stevens, MD Professor, Director of Pediatric Orthopedic Fellowship Program, Department of Orthopedics, University of Utah School of Medicine
Peter M Stevens, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, Pediatric Orthopaedic Society of North America
Disclosure: Received royalty from Orthofix Inc for independent contractor; Received royalty from Orthopediatrics, Inc for independent contractor; Received honoraria from Orthopediatrics, Inc for speaking and teaching. for: Orthodox, Orthopediatrics.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
Paul E Di Cesare, MD
Paul E Di Cesare, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons
Disclosure: Nothing to disclose.
Jeffrey D Thomson, MD Professor of Orthopedic Surgery, University of Connecticut School of Medicine; Director of Orthopedic Surgery, Connecticut Children’s Medical Center; Vice President of Medical Staff, Connecticut Children’s Medical Center
Jeffrey D Thomson, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Pediatric Orthopaedic Society of North America, Scoliosis Research Society
Disclosure: Nothing to disclose.
Pediatric Ankle Valgus
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