We have treated 15 children with end-stage renal disease (ESRD), renal osteodystrophy, and genu valgum in the last 22 years. In a retrospective review, we determined that periods of metabolic instability, best characterized as an alkaline phosphatase of 500 U for at least 10 months, were associated with progression of deformity. Histomorphometric bone biopsy provided information that proved essential for effective evaluation and treatment in this group. Complications of corrective osteotomy were related to perioperative metabolic instability. A surgical treatment protocol is described, emphasizing preoperative assessment by histomorphometric bone biopsy and multimodal medical management to maintain metabolic stability perioperatively.
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