ki hyuk sung, md department of orthopaedic surgery seoul national university bundang hospital
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Rate of correction after asymmetrical physeal suppression in valgus deformity: Analysis using a Linear mixed model application. Ki Hyuk Sung, MD Department of Orthopaedic Surgery Seoul National University Bundang Hospital. Introduction. - PowerPoint PPT PresentationTRANSCRIPT
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Ki Hyuk Sung, MD
Department of Orthopaedic SurgerySeoul National University Bundang Hospital
Rate of correction after asymmetrical physeal suppression in valgus deformity:
Analysis using a Linear mixed model application
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Introduction
• Coronal angular deformity of the lower limb is a
common finding in growing children
• Permanent (irreversible) hemiepiphysiodesis
• Temporary (reversible) hemiepiphysiodesis using
staples, percutaneous screws, or a tension band
plate (eight-plate)
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Introduction
• Measuring the rate of correction is necessary to predict
the time to end point
• The rate of angular correction has been calculated
simply by averaging.
• Other factors (age, surgical method, direction of
deformity, etiology, physis) must be considered while
estimating the rate of correction
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Introduction
• A linear mixed model (LMM) is useful in settings where
multiple correlated measurements are made on the
same statistical units
• LMM consists of fixed effects and random effects
• Estimation of the correction rate by using a mixed model
application may confer more practical information to
clinicians
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Purpose
• To estimate the rate of angular correction
after asymmetrical physeal suppression
• To analyze the factors that influence the rate
of correction by using a linear mixed model
application
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Material and methods
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Inclusion criteria
• Patients with valgus angular deformity of the
lower limb who underwent asymmetrical physeal
suppression
• A minimum follow-up of 3 months
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Exclusion criteria
• Patients who visited our hospital less than two
times
• Patients who had inadequate preoperative or
postoperative radiographs available for review
• Patients who underwent any other bony
procedures such as an osteotomy
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Radiographic measurements
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Building a linear mixed model
• Three groups
• Distal femoral, proximal tibial, and distal tibial
• The rate of angular correction was adjusted by
multiple factors by using LMM
• Age, gender, and surgical method as the fixed effects
• Each subject as the random effect
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Individual pattern of correction rate
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Building a linear mixed model
• The estimates were fitted using the restricted
maximum likelihood estimation (REML) method
• The final model
• Age and surgical method specific rate
• Sex and surgical method specific intercept
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Statistical Methods
• Univariate analysis
• LMM was used to model the correction rates and assess
covariate effects.
• Multivariate analysis
• For the final model to examine the significantly
contributing factor to the rate of valgus deformity
correction
• R (Version 2.13.1) using nlme package
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Results
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Patients’Demographics
Physis treated Distal femurProximal
tibiaDistaltibia
Total
No. of physes 72 70 33 175
No. of measurements 276 305 128 709
Gender (Male/ Female) 43/29 38/32 26/7 107/68
Limb (Left/ Right) 35/37 36/34 15/18 86/89
Age at surgery(years, mean±SD) 12.0±2.3 11.7±3.1 11.6±2.6 11.8±2.7
Surgical method
Staple/Screw/Permanent 24/44/4 20/47/3 0/28/5 44/119/12
Anatomical angle at initial(°, mean±SD) 76.1±4.5 85.0±5.0 77.9±5.1 80.0±6.3
Anatomical angel at final(°, mean±SD) 83.4±5.4 90.2±6.5 87.3±8.2 86.9±7.1
Mean amount of correction(°, mean±SD) 7.3±6.0 5.2±4.8 9.4±7.4 6.8±6.0
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Univariate analysis of the correction rate for distal femur
Factor CodingRate of
correction (°/month)
95% Confidence
intervalp-value
Sex Male (referent) 0.55 0.41 to 0.68 <0.001*
Female 0.75 0.54 to 0.97 0.062
Method Staple (referent) 0.64 0.46 to 0.82 <0.001*
Screw 0.64 0.42 to 0.87 0.968
Permanent 0.25 -0.24 to 0.74 0.124
Age F<12/M<14 (referent) 0.71 0.59 to 0.84 <0.001*
F≥12/M≥14 0.39 0.17 to 0.61 0.006*
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Univariate analysis of the correction rate for proximal tibia
Factor CodingRate of
correction (°/month)
95% Confidence
intervalp-value
Sex Male (referent) 0.36 0.25 to 0.47 <0.001*
Female 0.37 0.20 to 0.53 0.941
Method Staple (referent) 0.26 0.11 to 0.41 0.001*
Screw 0.42 0.24 to 0.60 0.085
Permanent 0.28 -0.12 to 0.69 0.909
Age F<12/M<14 (referent) 0.40 0.30 to 0.51 <0.001*
F≥12/M≥14 0.29 0.12 to 0.46 0.205
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Univariate analysis of the correction rate for distal tibia
Factor CodingRate of
correction (°/month)
95% Confidence
intervalp-value
Sex Male (referent) 0.52 0.39 to 0.64 <0.001*
Female 0.39 0.15 to 0.62 0.270
Method Screw (referent) 0.43 0.32 to 0.55 <0.001*
Permanent 0.63 0.39 to 0.86 0.101
Age F<12/M<14 (referent) 0.48 0.36 to 0.60 <0.001*
F≥12/M≥14 0.48 0.18 to 0.76 0.947
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Multivariate analysis of the correction rate for distal femur
Factor CodingRate of
correction (°/month)
95% Confidence
intervalp-value
Baseline Staple, F<12/M<14 0.79 0.60 to 0.97 <0.001*
Age F≥12/M≥14 0.51 0.27 to 0.75 0.025*
Method Screw 0.66 0.43 to 0.83 0.241
Permanent 0.58 0.06 to 1.11 0.441
* The difference in the rate of correction between the younger children and the older children is significant.
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Multivariate analysis of the correction rate for proximal tibia
Factor CodingRate of
correction (°/month)
95% Confidence
intervalp-value
Baseline Staple, F<12/M<14 0.29 0.14 to 0.44 <0.001*
Age F≥12/M≥14 0.14 -0.04 to 0.32 0.098
Method Screw 0.48 0.29 to 0.67 0.046*
Permanent 0.38 -0.03 to 0.79 0.660
* The difference in the rate of correction between the younger children and the older children is significant.
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Multivariate analysis of the correction rate for distal tibia
Factor CodingRate of
correction (°/month)
95% Confidence
intervalp-value
Baseline Staple, F<12/M<14 0.44 0.33 to 0.55 <0.001*
Age F≥12/M≥14 0.35 0.07 to 0.64 0.552
Method Permanent 0.68 0.44 to 0.92 0.057
* The difference in the rate of correction according to the age and the method is not significant.
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Conclusion
• Asymmetrical physeal suppression with staples,
percutaneous transphyseal screws, and permanent
method all are effective methods for treating
valgus deformity in growing children.
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Conclusion
• When we treat valgus deformity in growing
children, we should take into consideration the fact
that the rate of correction at the distal femur is
lower in older children.
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