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Operative arrestment of longitudinal growth of bone in the treatment of deformities
... Recently, a novel rigid staple for tED (RigidTack ™ , Merete, Berlin, Germany) has been introduced which combines the advantages of staples and plates [11,15]. pED has historically been conducted according to the techniques originally described by Phemister [16] and Bowen [17]. However, while the Phemister technique is deemed inappropriately invasive, percutaneous drilling is associated with an increased fluoroscopy time and demands precise execution [3]. ...
... mean age at the time of the last follow-up was 13.6 years (range[12][13][14][15][16] in girls and 15.8 years (range[14][15][16][17] in boys in the tED group, and 14.4 years (range[13][14][15][16] in girls and 15.6 years (range[14][15][16][17][18][19] in boys in the pED group. In the total cohort, the mean age at the last follow-up was 14.9 years (range 12-19), with a mean age of 14.2 years (range 12-16) in girls and 15.7 years (range[14][15][16][17][18][19] in boys. ...
... mean age at the time of the last follow-up was 13.6 years (range[12][13][14][15][16] in girls and 15.8 years (range[14][15][16][17] in boys in the tED group, and 14.4 years (range[13][14][15][16] in girls and 15.6 years (range[14][15][16][17][18][19] in boys in the pED group. In the total cohort, the mean age at the last follow-up was 14.9 years (range 12-19), with a mean age of 14.2 years (range 12-16) in girls and 15.7 years (range[14][15][16][17][18][19] in boys. ...
Background
In the treatment of tall stature, the reduction of excessive predicted final height can either be achieved by hormonal treatment or surgically by temporary (tED) or permanent (pED) epiphysiodesis. The present study evaluates the preliminary results of two novel devices for tED and pED around the knee to reduce the predicted final height.
Materials and methods
A retrospective analysis was performed to evaluate the clinical and radiographic outcome after bilateral epiphysiodesis for the treatment of tall stature. A cohort of 34 patients (16 girls, 18 boys) who underwent either tED or pED between 2015 and 2020 were eligible for analysis based on the electronic patient records and picture archiving and communication system of our orthopaedic teaching hospital. tED was conducted in 11 patients (32%) through bilateral implantation of four RigidTacks™ (Merete, Berlin, Germany) around the knee. Twenty-three patients (68%) received pED, performed with an EpiStop™ trephine (Eberle, Wurmberg, Germany). The mean overall follow-up time was 2.9 years.
Results
The mean age at surgery was 12.3 years in girls and 13.2 years in boys. Patients had a mean body height of 175.2 cm in girls and 184.7 cm in boys at surgery. The mean predicted final height was 191.4 cm in girls and 210.4 cm in boys. At the last follow-up, 26 patients (76.5%) had achieved skeletal maturity. The mean height of skeletally mature patients was 187.2 cm in girls and 198.5 cm in boys. A mean reduction of the predicted final height of 5.9 cm in girls and 8.7 cm in boys was achieved, corresponding to a reduction in remaining growth of 46% in girls and 38% in boys. Secondary frontal plane deformities of the knee were detected in 5/11 patients (45.5%) in the tED group and 1/23 treatments (4.3%) in the pED group.
Conclusions
tED and pED have both proven to be efficient at achieving growth inhibition to reduce excessive predicted height. However, tED has been associated with an increased risk of secondary angular deformities of the knee. Furthermore, the risk of implant-related complications and the necessity of a subsequent surgical intervention for implant removal have led our study group to abandon tED when treating tall stature. Long-term results of both procedures are pending.
Level of evidence
4.
... Temporary growth guidance is generally provided by implants (e.g., Blount clamp, eight-Plates ® (for example company Orthofix), etc.), which can be removed once the correction is achieved. In older children, definite epiphysiodesis as proposed by Phemister [4] and Canale [5] can be performed to stop growth in the desired area. Both methods are serious surgical procedures that involve either removal of already existing bone material or a thorough curettage of the entire growth plate, which must be performed under radiographic guidance [4,5]. ...
... In older children, definite epiphysiodesis as proposed by Phemister [4] and Canale [5] can be performed to stop growth in the desired area. Both methods are serious surgical procedures that involve either removal of already existing bone material or a thorough curettage of the entire growth plate, which must be performed under radiographic guidance [4,5]. ...
... The presented thermal ablation approach has the potential to replace or to be used in addition to conventional surgical methods [4,5], with possibly fewer side effects due to incision-related scar tissue, hematoma, and swelling, as well as implant displacement and secondary surgery. Because of the local effect of thermal ablation, as demonstrated in the histological examination, a controlled hemiepiphyseodesis with subsequent axial correction seems very possible. ...
(1) Background: Thermal ablation has been demonstrated to affect the bone growth of osteoid osteoma in adolescents. Growth modulation due to thermal heat in children is conceivable, but has not yet been established. We used lamb extremities as a preclinical model to examine the effect of thermal ablation on growth plates in order to evaluate its potential for axial or longitudinal growth modulation in pediatric patients. (2) Methods: Thermal ablation was performed by electrocautery on eight different growth plates of the legs and distal radii of a stillborn lamb. After treatment, target hits and the physical extent of the growth plate lesions were monitored using micro-computed tomography (micro-CT) and histology. (3) Results: Lesions and their physical extent could be quantified in 75% of the treated extremities. The histological analysis revealed that the disruption of tissue was confined to a small area and the applied heat did not cause the entire growth plate to be disrupted or obviously damaged. (4) Conclusions: Thermal ablation by electrocautery is minimally invasive and can be used for targeted disruption of small areas in growth plates in the animal model. The results suggest that thermal ablation can be developed into a suitable method to influence epiphyseal growth in children.
... Permanent epiphysiodesis refers to an irreversible intervention, where the growth plate is closed permanently, and the goal is to achieve leg-length equality while minimizing the risk of complications associated with more invasive surgical procedures, such as limb lengthening [7]. The most used techniques for permanent epiphysiodesis are percutaneous epiphysiodesis (PE) with drills/curettes and Phemister/modified Phemister technique [8,9]. ...
... By permanently closing the growth plate, permanent epiphysiodesis is an irreversible operation that aims to achieve leg length equality while reducing the risk of complications associated with more invasive surgical treatments, such as limb lengthening [7]. Percutaneous epiphysiodesis with drills or curettes and Phemister/modified Phemister technique are the most commonly utilized methods for permanent epiphysiodesis [8]. ...
The aim of this study is to comprehensively investigate the recent literature on the management of leg length discrepancy (LLD). A thorough search of pertinent databases was done in order to find studies that satisfied the requirements for inclusion. A thorough search of PubMed, Web of Science, Scopus, and Science Direct was conducted to find pertinent literature. Rayyan Qatar Computing Research Institute (QRCI, Ar Rayyan, Qatar) was utilized during the whole operation. Eight studies, including a total of 345 patients, were included in our data, and 206 (59.7%) of them were males. Percutaneous epiphysiodesis was the surgical intervention of choice in four studies. LLD can be effectively corrected by temporary and permanent epiphysiodesis. One study reported the incidence of angular deformities following temporary epiphysiodesis. Circumferential periosteal and dual tension-band plating significantly reduced LLD, but reported the incidence of an "over-shoot" in some patients. Bilateral motion control shoes and orthotic insole both were found to improve the patient's gait and trunk symmetry, evidenced by longer and faster steps, reduced ground impact at heel strike, and lower peak plantar pressure in both limbs. Our findings confirm that no inferences about the superiority of a particular management approach for the treatment of LLD can be made. The poor quality of the studies shows that more randomized control trials and prospective studies on the subject are required.
... Permanent epiphysiodesis refers to an irreversible intervention, where the growth plate is closed permanently, and the goal is to achieve leg-length equality while minimizing the risk of complications associated with more invasive surgical procedures, such as limb lengthening [9]. Most used techniques for permanent epiphysiodesis are percutaneous epiphysiodesis (PE) with drills/curettes and Phemister/ modified Phemister technique [10,11]. ...
... The growth plate is then scraped out (curetted), and the bone blocks are reinserted after undergoing a 180-degree rotation. This results in the formation of a bone bridge that circumvents the growth plate [10]. ...
Epiphysiodesis is considered the preferred treatment for children predicted to have leg length discrepancies (LLDs) 2–5 cm at maturity. The aim of this study was to systematically review the existing literature on the effectiveness of permanent epiphysiodesis for LLD treatment, and secondarily to address the reported complications of permanent epiphysiodesis techniques. This systematic review was performed according to PRISMA guidelines. We searched MEDLINE (PubMed), Embase, Cochrane Library, Web of Science and Scopus for studies on skeletally immature patients with LLD treated with permanent epiphysiodesis. The extracted outcome categories were effectiveness of epiphysiodesis (LLD measurements pre/post-operatively, successful/unsuccessful), physeal fusion/arrest, and complications that were graded on severity. Forty-nine studies (3051 patients) were included, 1550 underwent Phemister/modified Phemister epiphysiodesis and 1501 percutaneous epiphysiodesis (PE). Total successful permanent epiphysiodesis surgeries (16 studies) were 73.7% (516/700). Only 13 out of 23 studies had a mean final LLD of less than 1.5 cm. In total, 17.5% (513/2936) of complications were reported. 57 angular deformities were reported (1.9%). Phemister technique had higher percentage of complications (39%) than PE (19.1%) in total, but when failure to achieve adequate reduction in LLD was not included, complication rates for both were close to 14%. However, severe complications were 10.2% for Phemister group and 5.1% for PE. The high complication rates and the relative low success rate call for optimization of the timing and the applied techniques when treating LLD with permanent epiphysiodesis. Phemister technique was found to have higher percentage of severe complications than PE. Registration: PROSPERO (CRD42023435177).
... The concept of epiphysiodesis to correct modest LLD was first introduced by Phemister in 1933. 5 Blount introduced the concept of physeal stapling soon afterwards. 6 These two methods (Fig. 3) were practiced widely for decades. ...
... The following observations were made: (1) growth deceleration with TBP is effective; (2) it is reversible and, therefore, applicable in younger patients who are symptomatic due to LLD greater than or equal to 2 cm; (3) a divergent placement of the screws is recommended because it averts a latency period. This also mitigates against bending of screws potentially averting the production of intra-articular deformity; (4) TBP is recommended at least a year sooner than typically advocated for other methods of epiphysiodesis; (5) in adolescents, the White-Menelaus method is well suited for planning for this method of epiphysiodesis. While subtle and more anticipatory as compared to permanent methods, TBP deserves a place in the current armamentarium of treatment modalities for LLD. ...
Objective:
There are several alternative methods for accomplishing epiphysiodesis of the longer limb to address limb length discrepancy (LLD). Consensus is lacking regarding the optimal timing of the intervention and which method is most efficacious. We reviewed a large group of patients with anisomelia treated by tethering with tension band plates (TBP) and who had attained skeletal maturity. We discuss our preferred timing and technique while noting the complications and how they were managed.
Materials and methods:
With IRB approval, we reviewed 66 subjects including 32 boys and 34 girls, ranging in age from 3 to 16.6 years at the time of physeal tethering, who were destined to have between 2 and 9 cm LLD at maturity. Inclusion criteria were: (1) at least 1 year of predicted growth at the time of tethering; (2) minimum 18-month follow-up and (3) minimum Risser stage 1 (R1) in the last radiologic study. There were 35 distal femoral, 25 pan genu and five proximal tibial procedures. Patients were seen bi-annually with weight-bearing full-length radiographs to ascertain neutral alignment and assess limb lengths.
Results:
We defined a successful outcome to be <1.5 cm of residual discrepancy. Iatrogenic mechanical axis deviation, observed in nine patients (five varus and four valgus), was successfully managed by repositioning the implants. While the under-corrected patients presented too late to achieve equalization, they benefited from partial improvement. Due to lack of timely follow-up, one patient over-corrected by 2 cm and had a femoral shortening at the time of correcting contralateral femoral anteversion. One patient required a distal femoral osteotomy to correct recurvatum at maturity.
Conclusion:
Properly timed and executed, TBP is an efficacious and reversible means of growth deceleration, rather than growth arrest, that may be applied in a wide age range of patients with modest anisomelia regardless of aetiology. This method offers potential advantages over purportedly rapid and definitive techniques such as percutaneous epiphysiodesis (PE) or percutaneous epiphysiodesis with transphyseal screws (PETS).
Level of evidence:
Level III. Retrospective series without controls.
How to cite this article:
Stevens P, Desperes M, McClure PK, et al. Growth Deceleration for Limb Length Discrepancy: Tension Band Plates Followed to Maturity. Strategies Trauma Limb Reconstr 2022;17(1):26-31.
... Epiphysiodesis of the contralateral distal femur and/or proximal tibia is a potential treatment option to reduce the LLD before skeletal maturity. 26 When timed correctly it is a relatively safe surgical option, with low risk of complications and potential to correct large leg-length differences. 26,27 This is reflected by our results with a reduction in the mean difference from 2.7 cm at time of epiphysiodesis to 1.3 cm at skeletal maturity. ...
... 26 When timed correctly it is a relatively safe surgical option, with low risk of complications and potential to correct large leg-length differences. 26,27 This is reflected by our results with a reduction in the mean difference from 2.7 cm at time of epiphysiodesis to 1.3 cm at skeletal maturity. Nevertheless, it should be recognized that in these patients, the intervention altered the proportions of the subtrochanteric segment. ...
Aims
Perthes’ disease (PD) often results in femoral head deformity and leg length discrepancy (LLD). Our objective was to analyze femoral morphology in PD patients at skeletal maturity to assess where the LLD originates, and evaluate the effect of contralateral epiphysiodesis for length equalization on proximal and subtrochanteric femoral lengths.
Methods
All patients treated for PD in our institution between January 2013 and June 2020 were reviewed retrospectively. Patients with unilateral PD, LLD of ≥ 5 mm, and long-leg standing radiographs at skeletal maturity were included. Total leg length, femoral and tibial length, articulotrochanteric distance (ATD), and subtrochanteric femoral length were compared between PD side and the unaffected side. Furthermore, we compared leg length measurements between patients who did and who did not have a contralateral epiphysiodesis.
Results
Overall, 79 patients were included, of whom 21 underwent contralateral epiphysiodesis for leg length correction. In the complete cohort, the mean LLD was 1.8 cm (95% confidence interval (CI) 1.5 to 2.0), mean ATD difference was 1.8 cm (95% CI -2.1 to -1.9), and mean subtrochanteric difference was -0.2 cm (95% CI -0.4 to 0.1). In the epiphysiodesis group, the mean LLD before epiphysiodesis was 2.7 cm (95% CI 1.3 to 3.4) and 1.3 cm (95% CI -0.5 to 3.8) at skeletal maturity. In the nonepiphysiodesis group the mean LLD was 2.0 cm (95% CI 0.5 to 5.1; p = 0.016). The subtrochanteric region on the PD side was significantly longer at skeletal maturity in the epiphysiodesis group compared to the nonepiphysiodesis group (-1.0 cm (95% CI -2.4 to 0.6) vs 0.1 cm (95% CI -1.0 to 2.1); p < 0.001).
Conclusion
This study demonstrates that LLD after PD originates from the proximal segment only. In patients who had contralateral epiphysiodesis to balance leg length, this is achieved by creating a difference in subtrochanteric length. Arthroplasty surgeons need to be aware that shortening of the proximal femur segment in PD patients may be misleading, as the ipsilateral subtrochanteric length in these patients can be longer. Therefore, we strongly advise long-leg standing films for THA planning in PD patients in order to avoid inadvertently lengthening the limb. Cite this article: Bone Joint J 2021;103-B(11):1736–1741.
... The concept of influencing bone growth by manipulating the physis dates back to the 19th century, with early observations by surgeons like Hueter, Volkmann, and Delpech, who noted the effects of pressure on physeal growth [5]. This foundational understanding eventually led to the development of open epiphysiodesis techniques to achieve permanent growth arrest for corrective purposes, as first described by Phemister in 1933 [6,7]. Later, Haas introduced instrumentation that enabled reversible growth inhibition by removing the device after achieving the desired correction [8]. ...
Background
Angular knee deformities such as genu varum and genu valgum are common in children and can impact their functional mobility and quality of life. Although surgical interventions like guided growth plates or tension-band plates (TBP) and percutaneous epiphysiodesis transphyseal screws (PETS) are commonly used, comparative analyses of their efficacy and safety are limited. This study aims to evaluate the correction rates and safety profiles of TBP and PETS in treating pediatric coronal angular knee deformities.
Methods
A comprehensive literature search was conducted in Scopus, Web of Science, and PubMed until November 2024. Only comparative clinical studies comparing PETS and TBP in pediatric patients with coronal knee deformities were included.
Results
A total of five studies encompassing 473 physes were included. Their methodological quality was assessed using the MINORS criteria, with scores ranging from 18 to 19, indicating a low risk of bias. PETS demonstrated significantly higher correction rates compared to TBP, with an overall pooled mean difference in angular correction of 0.17°/month (p < 0.0003). In the femoral subgroup analysis (LDFA), the mean difference correction rate was 0.21°/month in favor of PETS (p = 0.01). Additionally, the PETS group achieved a statistically significant mechanical axis deviation mean difference correction rate of 1.02 mm/month (p = 0.006). Complication rates were relatively lower with PETS across all included studies.
Conclusion
PETS achieves faster angular and mechanical axis deviation correction rates compared to TBP, highlighting its efficiency in treating pediatric coronal angular knee deformities. Additionally, PETS demonstrates relatively fewer complications, reinforcing its position as a more effective and cost-efficient option for guided growth in children.
Clinical trial number
Not applicable.
Level of evidence
II.
... 9 Limb length discrepancy can be congenital or acquired, 10 but shortening is more common than overgrowth. 4 In the POSNA study guide, LLD ≥ 2 cm is the threshold for initiating treatment, 4,11 and a difference of 2-4 cm is treated conservatively or surgically. 4 Based on our 30 years of clinical experience, epiphysiodesis is the treatment of choice in cases with a predicted final shortening of 2-5 cm or overgrowth of 2-6 cm. ...
This study aimed to summarize our experience with modified drilling epiphysiodesis and prediction methods for accurate timing of surgery and to compare the results with those of recent work by other authors. The Macnicol and Gupta modified drilling technique was used. Distal femoral and/or proximal tibial permanent epiphysiodesis was performed in 42 children (21 boys, 21 girls; median age at surgery=12.6 years, age range=9.4-15.4 years) between 2004 and 2016. Based on the groundwork of previous studies, we developed an auxological prediction method. The limb length discrepancy (LLD) was assessed by clinical examination and verified by an x-ray of the hips when standing with blocks under the shorter leg. The predicted shortening was 2.7 cm ± 1.1 cm. The final discrepancy after finishing skeletal growth was 0.5 ± 0.5 cm. In 26 patients (61.9%), equalization of both legs was achieved (0-0.5 cm). In 4 patients (9.5%), the remaining shortening was more than 1.0 cm. Shortening of an initially longer leg occurred in two patients (0.5 cm and 0.6 cm). Failure of growth plate arrest was observed in 1 patient. In another 3 patients, the efficacy of tibial epiphysiodesis was unsatisfactory. Minor complications occurred in 5 cases, but there was no evidence of angular deformity in the frontal and sagittal planes or proximal fibula overgrowth. Three patients (7.1%) returned to the operating room. Compared to published data, more patients achieved complete equalization of leg length. The results of this study verified the accuracy of the auxological prediction algorithm of LLD based on Shapiro's findings. The surgical outcome is comparable between Shapiro patterns 1 and 3. Auxological examination, assessment of bone age, and sexual maturation are crucial tools for accurate timing of surgery.
... Considering all variables related to the etiopathogenesis of the angular deformity of the knee, the age of observation and the different surgical options, the optimal timing for treatment and the surgical procedure are still causes of concerns and debated. [2][3][4][5][6][7][8] Moreover socio-economic environment and health care assistance could affect the approach to the patients and the possibility to consider all the different options of treatment and finally to prejudice adequate patient's follow-up, as it often happens in low-and-middle-income countries (LMICs). Severe knee malalignment, particularly secondary to Blount's or metabolic diseases, is more frequent in African people than in Caucasian, and in LMICs, children often come late to medical observation after they have already developed a severe deformity. ...
Aim : Severe knee malalignment in children usually needs surgery with different options available in surgical approaches. The aim of this study was to report the results of the surgical correction of severe knee malalignment in children treated with femoral and tibial osteotomy, temporarily fixed with percutaneous Kirschner wires, in a low- and middle-income country (LMIC), with limited medical resources.
Materials and methods : Thirty children (age range 4–9 years) with severe knee malalignment were observed and surgically treated in a small children hospital located in the Tanzanian rural outback. A total of 53 deformities were treated. Thirty-two knees presented varus deformity and 21 knees presented valgus deformity. In 9 cases, femoral osteotomy alone was performed, tibial osteotomy alone in 28 cases, combined femoral and tibial osteotomy in 16 cases. Fixation was obtained with crossed percutaneous Kirschner wires, and a post-operative long-leg cast immobilization was applied.
Results : Mean pre-operative varus passed from 40°±4 to post-operative 5°±6 valgus. Mean pre-operative valgus passed from 39°±4 to post-operative 8°±5 valgus. Complications included delayed healing of the wounds, skin suffering at the outlet of Kirschner wires, knee stiffness, undercorrection and overcorrection of the deformity. Results were considered excellent in 18 cases, good in 21, fair in 11, poor in 3.
Conclusions : This technique allowed us to obtain satisfactory correction of severe knee malalignment with less invasive surgery. Inexpensive hardware such as Kirschner wires, combined with cast immobilization, allowed satisfactory fixation of the osteotomy, and reduction of the overall cost of surgery, as it should be desirable in LMICs.
... Phemister extended this work and described the bone block epiphysiodesis around the distal femur and proximal tibia to correct leg length differences. 26 Phemister's procedure involved removing a central block of bone from the side of the operative physis, rotating it 180 degrees and then replacing it so that the physis within the bone block was no longer aligned with the remainder of the physis. As the block healed in its new position, the physis at the operative site ultimately progressed to closure. ...
Guided growth is one of the most utilized surgical techniques for managing limb deformity in skeletally immature patients. Our understanding of this technique and the types of implants utilized have evolved over the past century. Many of the known risks of this surgery, such as over-correction, under-correction, and rebound deformity, are the same risks initially described when hemiepiphysiodesis and guided growth techniques were first published. The staple has been a powerful tool for deformity correction but its high rates of implant backout and breakage as well as unpredictable rates of premature physeal closure after removal have contributed to this implant being used less frequently today. Many studies on percutaneous transepiphyseal screws (PETS) are promising but have little follow-up, so the risks of this technique with regard to premature physeal closure are not well understood. Tension band plating is currently the most utilized method. However, in specific patient subgroups, the perioperative complication and failure of correction rates are high. Despite the abundance of literature on these techniques, our understanding of guided growth is still quite limited, as most studies are small and do not follow patients to skeletal maturity. Guided growth surgery also can restore the mechanical axis of the limb while leaving patients with significant residual diaphyseal or peri-articular deformity and the implications of these secondary deformities have not been studied. Key Concepts • An understanding of the patient's skeletal maturity and predicted growth remaining is essential prior to performing guided growth surgery. • Regular patient follow-up is critical to prevent over-correction of deformity. • Staples are an effective implant for angular deformity correction but have higher rates of implant backout, breakage, and premature physeal arrest compared to other devices.
... In growing patients, (hemi-)epiphysiodesis of the distal femur and proximal tibia is an established treatment to correct leg length discrepancies (LLD) and angular lower limb deformities [1][2][3][4][5][6]. For correction of LLD, permanent or temporary operation techniques are commonly employed [1,2,[7][8][9]. For gradual correction of angular deformities of the lower limb in skeletally immature patients, temporary hemi-epiphysiodesis is the preferred surgical treatment [4][5][6]10]. Several previous studies have shown that epiphysiodesis is a reliable approach with few complications [1,4,6,11,12]. ...
Background and purpose: For correction of leg-length discrepancy or angular deformity of the lower limb in skeletally immature patients temporary or permanent (hemi-)epiphysiodesis can be employed. These are reliable treatments with few complications. Recently, radiographic analysis of treatment-related alterations of the central knee anatomy gained interest among pediatric orthopedic surgeons. To date the comparison and adequate interpretation of potential changes of the central knee anatomy is limited due to the lack of defined standardized radiographic references. We aimed to establish new reference values of the central knee anatomy.
Patients and methods: A retrospective analysis of calibrated longstanding anteroposterior radiographs of 254 skeletally immature patients with a chronological age ranging from 8 to 16 years was conducted. The following radiographic parameters were assessed: (1) femoral floor angle, (2) tibial roof angle, (3) width at femoral physis, and (4) femoral notch–intercondylar distance.
Results: All observed radiographic parameters were normally distributed with a mean age of 12.4 years (standard deviation [SD] 2, 95% confidence interval [CI] 12.2–12.6). Mean femoral floor angle was 142° (SD 6, CI 141.8–142.9), mean tibial roof angle was 144° (SD 5, CI 143.7–144.1), mean width at femoral physis was 73 mm (SD 6, CI 72.8–73.9), and mean femoral notch–intercondylar distance was 8 mm (SD 1, CI 7.5–7.7). The estimated intraclass correlation coefficient values were excellent for all measurements.
Conclusion: This study provides new radiographic reference values of the central knee anatomy for children between 8 and 16 years and we suggest considering values within the range of 2 SD as the physiological range.
... Historically, this was done through an open excision of the physis and replacement of a bone block. 3 This has since been replaced with a variety of percutaneous techniques including drilling of the physis itself, physeal spanning plates, and isolated screws. Percutaneous epiphysiodesis using transphyseal screws (PETS) is now one of the most common of these techniques and utilizes the compressive forces of cannulated screws to inhibit activity at growth plate. ...
Percutaneous epiphysiodesis using transphyseal screws (PETS) is a commonly used technique for guided growth. Technical challenges specific to the distal femur include difficulty obtaining a start point, accurately predicting trajectory across the physis, and achieving adequate thread purchase in the epiphysis. A previously unreported complication is peri-implant fracture. We present a case of peri-implant fracture after epiphysiodesis for leg length discrepancy, ultimately treated with retrograde intramedullary nail fixation. We recommend a modified PETS technique and close attention to orthopedic principles to avoid this unfortunate complication.
... Epiphysiodesis is often performed in order to correct leglength discrepancy (LLD). Phemister 1 first described an open procedure in 1933, destroying the growth plates on a permanent basis between the epiphysis and metaphysis through excised windows on both condyles. Canale and Christian 2 depicted a drill and curettage technique to destroy either the distal femoral physis, proximal tibial physis or both physes. ...
... Jejich operační postup spočíval v osteotomii, prováděné ve středu diafýzy, v zavedení hřebu do patní kosti a v sádrové fixaci. V roce 1933 Phemister (30) zavedl techniku epifyzeodézy, v r. 1942 Gill a Abbot (12) naznačili, že růst je úměrný kostnímu věku a teprve v r. 1948 Anderson a Green (4) publikovali základní údaje o délce dolních končetin u chlapců a dívek. Zásadní pokrok v chirurgickém prodlužování končetin znamenala až práce Ilizarova (19), který položil teoretické základy tvorby autoregenerátu při postupné distrakci. ...
PURPOSE OF THE STUDY Limb lengthening has always belonged to the most complex surgical techniques in paediatric orthopaedics. In our study, we compared the results of femoral and tibial lengthening using three different surgical techniques. The presented study aimed to shorten the duration of external fixation to a minimum and to reduce the complication rate. MATERIAL AND METHODS The retrospective study compared 74 patients (38 boys, 36 girls) who had undergone stepwise progressive lengthening of the femur or tibia between the years 2007 and 2019. The most frequent indication was the proximal focal femoral deficiency (PFFD, 33 patients). The total number of lengthening procedures was 130 (femur 72, tibia 58), the follow-up period was 2-14 years. The following modifications of surgical techniques were used: (i) standard approach, i.e. corticotomy with a two-stage removal of the fixator, (ii) preventive fixation with elastic stable intramedullary nails (ESIN) and also with a two-stage removal of the fixator, and (iii) standard approach with an early removal of the external fixator and plate osteosynthesis. RESULTS The mean lengthening achieved was 56 ± 18 (27-114) mm in femur and 54 ± 16 (25-110) mm in tibia. There was no statistical difference in the lengthening achieved by different modifications. The mean duration of external fixation in femur and tibia lengthening was comparable (166 and 164 days). The complications were observed in 60% of lengthening procedures, the most frequent being the pin release or axial malalignment of the lengthening (33 cases, 25%). The patients with ESIN displayed statistically the lowest complication rate (26%), the highest complication rate was seen in children with osteosynthesis using a plate (80%). CONCLUSIONS It follows from our results that fixation with intramedullary nails in comparison with the standard approach and plate osteosynthesis helped decrease the number of complications by more than 50%. The plate osteosynthesis is indicated in patients with repeated lengthening (achondroplasia, hypochondroplasia or PFFD with pronounced shortening) since it significantly reduces the duration of external fixation. Key words: limb lengthening, femur, tibia, surgical techniques, complications.
... The classic technique was described by Phemister [38] for LLD. Bowen et al. [39] described technical modifications using a 2 cm incision, after which a bone physeal-centered square was removed 1 cm in length and 0.5 cm in depth. ...
Purpose of review:
This study aimed to review the established concepts and advances related to growth modulation for treating knee angular deformities. Although they are considered well tolerated procedures, careful indications and accurate techniques are necessary to ensure good results.
Recent findings:
In addition to general clinical and radiographic evaluations, new tools such as two-dimensional low-dose radiography and gait analysis have been used to clarify angular and torsional combinations and the impact of mild angulations on the knee joint. Temporary epiphysiodesis is commonly the choice, and it can be performed with different implants such as staples, tension band plates (TBP), percutaneous transphyseal screws (PETS), sutures, and screws.
Summary:
Considering its principles, TBP has been preferred for younger children. Cost can be a limitation, and research for alternative implants such as screws and nonabsorbable sutures indicate they might be an alternative in the future. In adolescents, PETS becomes an attractive alternative; however, its reversible character has been controversial, and further studies are needed to establish limits in younger patients.
... Different surgical techniques can be performed with their pros and cons. In 1933 Phemister was the first to describe an open procedure epiphysiodesis [2]. We are prone to use the percutaneous epiphysiodesis with transphyseal screws (PETS) developed by Métaizeau using a fluoroscopic guided technique that consists in crossing two screws in X by percutaneously placing them in the physis. ...
Percutaneous femoral distal epiphysiodesis using transphyseal cannulated screws is commonly used for correcting anisomelia and angular deformity in adolescent patients. Method: We report a case of previously unreported complication using cannulated screws: The thread being damaged, the screw failed to block growth in the physis showed by the releasing of a metal filament in the bone marrow after the screw's removal. Results: The patient showed a limb length discrepancy necessitating a surgical correction. The screw thread was damaged by the other device releasing a metal filament lodged in the bone marrow. The metal filament was released during the first operative gesture for Patient A, whereas it occurred on the removal of the hardwire on the other example. Images: Conclusion: This report illustrates an uncommon complication using transphyseal screws inherent to the Metaizeau surgical technique.
... 10,11 In the 1940s, Phemister put forward firstly the concept of treating children's bone deformities by epiphyseal block. 12 Subsequently, Stevens further proposed the concept of guided growth based on Phemister's idea. 13 Combined with engineering mechanics, the growth of one epiphyseal plate was inhibited by internal fixation, and the normal growth of the opposite epiphyseal plate was retained, so as to correct bone angulation deformity. ...
Objective:
There has been a lack of suitable epiphysis blocking materials due to the characteristics of less tissue coverage and narrow epiphysis in children's distal tibial medial malleolus. Therefore, this study is to investigate the clinical efficacy and safety of a new "U"-shaped staple in the treatment of postoperative ankle valgus of congenital pseudarthrosis of the tibia (CPT).
Method:
According to the inclusion and exclusion criteria, 33 patients with postoperative ankle valgus of CPT were treated with new "U"-shaped staples from May 2013 to September 2019. The deformity of ankle valgus was gradually corrected by implanting a new "U"-shaped staple on the medial side of the distal tibia. Clinical indexes such as the operation time, intraoperative bleeding and hospital stay were observed. Tibiotalar angle was selected as the evaluation index of ankle valgus. American Orthopedic Foot & Ankle Society (AOFAS) scale was used for clinical evaluation of ankle function. The tibiotalar angle, deformity correction rate and complications were evaluated by preoperative, postoperative and last follow-up imaging data. Student's t-test was used for statistical analysis.
Results:
Thirty-three patients, including 12 males and 21 females were included. All the patients were followed up for at least 14 months, with an average of 35 months. The average operation time was 23 (15-40) min, the average amount of intraoperative bleeding was 7.5 (4-10) mL, and the average hospital stay was 4.2 (3-6) days. The intraoperative tibiotalar angles of all patients were 74.2° ± 4.6°, the tibiotalar angle were 86.8° ± 4.9° when internal fixation was removed, and the tibiotalar angles at the last follow-up were 84.3° ± 5.9°. The average orthopedic rate was 0.68° per month. No patients suffered from serious complications such as screw prolapse, osteomyelitis, wound infection, etc. Postoperative wound pain complications occurred in two patients, which were relieved after conservative treatment. The AOFAS score improved from 46.2 ± 9.4 before the operation to 74.6 ± 5.7 at the last follow-up (P < 0.01). The ankle movement was good without joint stiffness. There was no epiphyseal plate injury after the removal of internal fixation.
Conclusion:
The new "U"-shaped staple is characterized by simple implantation, low notch, lower risk of fixation failure and close fitting with cortical bone. It is a safe and effective internal fixation system for the treatment of ankle valgus in children.
... Using staples, the physis (epiphyseal plate) can be relatively simply restrained either on both sides when correcting limb length discrepancy (i.e., "epiphysiodesis") or only on one side when correcting angular deformities (i.e., "hemiepiphyseodesis") (see Figures 1 and 2). Unlike the irreversible method of permanent epiphysiodesis, see [8], epiphyseal stapling does not destroy the epiphyseal plate and, therefore, allows resumption of the growth once the optimal correction is achieved; see [4]. Recently, the tension band technique, introduced by Stevens in 2007 [9], using nonlocking plates (similar to those used for osteosynthesis) and screws almost in the same position as staples, has gradually become a preferable alternative to stapling. ...
Limb asymmetry can, and often does, cause various health problems. Blount bone staples (clips) are used to correct such uneven growth. This article analyzes the performance of a biomechanical staple during bone (tibia) growth arrest. The staples considered in this study were made of 1.4441 stainless steel, the model of tibia consisted of two materials representing corticalis and spongiosis. Hooke’s law was used for modeling materials’ behaviors for finite element analysis (FEA). The maxima of stress and total staple displacement were evaluated using the finite element method and verification of the results, along with the determination of the maximum loading (growing) force that the staples are capable of withstanding, was performed experimentally. The presented method can be used to determine the safety and usability of staples for bone growth arrest. According to our results, the design of Blount staples considered in this paper is safe and suitable for orthopedic treatment.
... As early as the 1940s, Phemister rst proposed the idea of treating children's bone deformity by epiphyseal plate block [17]. Subsequently, Stevens further proposed the concept of "guiding growth", that is to restrain the growth of epiphyseal plate of one side by internal xation under engineering mechanics, and to retain the normal growth of epiphyseal plate of the opposite side, so as to correct bone angulation [9,18]. ...
Background: Congenital pseudarthrosis of the tibia is a complex and serious disease in orthopedics which often requires multiple operations for treatment. Postoperative ankle valgus deformity is easily seen after the operation of congenital pseudarthrosis of the tibia. The aim of this study is to retrospectively evaluate the safety of three different implants for treating postoperative ankle valgus after congenital pseudarthrosis of the tibia.
Methods: A total of 41 patients with postoperative ankle valgus after congenital pseudarthrosis of the tibia from December 2010 to July 2019 were selected. Out of these 41 patients, 23 patients were treated with “U”-shaped tension screw, 10 patients were treated with hollow screw and 8 patients were treated with cortical bone screw. The evaluation index was tibiotalar angle. The general data, preoperative, postoperative and final follow-up imaging data were recorded, and the deformity correction rate and complications were compared.
Results: all the patients were performed with postoperative follow-up visit for at least 12 months (31 months on average). In the “U”-shaped tension screw group, the preoperative tibiotalar angle was (74.8±4.8°), the tibiotalar angle was (85.8±4.5°) when the internal fixation was removed; in the hollow screw group, the average preoperative tibiotalar angle was (72.2±6.1°), the average tibiotalar angle was (88.4±5.1°) when the internal fixation was removed; in the cortical bone screw group, the average preoperative tibiotalar angle was (75.1±4.2°), the average tibiotalar angle was (88.4±5.1°) when the internal fixation was removed. The correction effect of the “U”-shaped tension screw group was better than that of the other two groups, but the difference was not significant (the correction rate of the “U”-shaped tension screw group was 0.71°/month, with that of in the hollow screw group and cortical bone screw group being 0.64°/month and 0.61°/month respectively, P＞0.05). One case of internal fixation complication was reported in the hollow screw group; two cases of missing correction effect were reported, one in cortical bone screw group and one in hollow screw group; and two cases showing symptom of wound pain were reported in the “U”-shaped screw group.
Conclusion: Ankle valgus is a common postoperative complication of congenital tibial pseudarthrosis. Temporary hemiepiphyseal is an effective treatment for postoperative ankle valgus deformity of congenital pseudarthrosis of the tibia in children. Through comparison, the "U"-shaped tension screw provides relatively better orthopedic results and has a lower rate of internal fixation complications.
... The Phemister technique is an open procedure utilizing a cortical bone block and physeal plate curett age to arrest limb growth. 4,5 Percutaneous drilling-curett age (drill) epiphysiodesis later emerged as a less-invasive technique. Drill epiphysiodesis can be utilized to destroy the distal femoral, proximal tibial, or both physes. ...
Research has demonstrated similar efficacy of drill epiphysiodesis and percutaneous epiphysiodesis using transphyseal screws for the management of adolescent leg length discrepancy. A cost analysis was performed to determine which procedure is more cost-effective. Patients seen for epiphysiodesis of the distal femur and/or proximal tibia and fibula between 2004 and 2017 were reviewed. A decision analysis model was used to compare costs. Two hundred thirty-five patients who underwent either drill (155/235, 66%) or screw (80/235, 34%) epiphysiodesis were analyzed with an average age at initial procedure of 13 years (range, 8.4 to 16.7 years). There was no significant difference in average initial procedure cost or total cost of all procedures across treatment groups (n = 184). The cost difference between drill and screw epiphysiodesis is minimal. In order for screw epiphysiodesis to be cost-favored, there would need to be a significant decrease in its cost or complication rate. (Journal of Surgical Orthopaedic Advances 30(3):181-184, 2021).
... In the 19th century, Hueter, Volkmann, and Delpech described the effect of physeal pressure on bone growth. 1 Phemister was the first surgeon to describe an open epiphysiodesis technique in 1933. 2 This procedure consisted of the removal of a rectangular bone block from the medial and lateral physes, which included part of the adjacent metaphysis and epiphysis. This block would then be replaced in reverse position, producing ultimately a bar across the growth plate. ...
Growth modulation (GM) with tension-band plates (TBPs) by tethering part of the growth plate is an established technique for the correction of angular deformities in children, and it has increasingly supplanted more invasive osteotomies. Growth modulation with TBPs is a safe and effective method to correct a variety of deformities in skeletally immature patients with idiopathic and pathological physes. The most common indication is a persistent deformity in the coronal plane of the knee exceeding 10°, with anterior and/or lateral joint pain, patellofemoral instability, gait disturbance, or cosmetic concerns. GM has also shown good results in patients with fixed flexion deformity of the knee and ankle valgus. This paper reviews the history of the procedure, current indications, and recent advances underlying physeal manipulation with TBPs.
Cite this article: EFORT Open Rev 2021;6:658-668. DOI: 10.1302/2058-5241.6.200098
... A múlt század közepéig az egyetlen megoldási lehetőségként a különböző osteotomiákat használták. 1933-ban Phemister közölte módszerét, amely a növekedési porcok végleges lezárásával célozta a végtaghossz-különbségek, illetve tengelyeltérések korrekcióját (11). Az 1949ben Blount által ismertetett, ácskapoccsal végzett epiphyseodesis a növekedési porc roncsolása nélkül, kisebb beavatkozással, rövidebb kórházi tartózkodással, gipszrögzítés és tehermentesítés nélkül tette lehetővé, hogy tengelykorrekciót végezzünk (2). ...
... Several techniques exist for epiphysiodesis. Irreversible growth plate destruction can be performed percutaneously with drills and curettes or through more invasive open techniques such as the Phemister [87]. Instrumented techniques include screws, staples, and tension bands and can be reversible especially if the physis itself is not violated. ...
Blount’s disease is an idiopathic developmental abnormality affecting the medial proximal tibia physis resulting in a multi-planar deformity with pronounced tibia varus. A single cause is unknown, and it is currently thought to result from a multifactorial combination of hereditary, mechanical, and developmental factors. Relationships with vitamin D deficiency, early walking, and obesity have been documented. Regardless of the etiology, the clinical and radiographic findings are consistent within the two main groups. Early-onset Blount’s disease is often bilateral and affects children in the first few years of life. Late-onset Blount’s disease is often unilateral and can be sub-categorized as juvenile tibia vara (ages 4–10), and adolescent tibia vara (ages 11 and older). Early-onset Blount’s disease progresses to more severe deformities, including depression of the medial tibial plateau. Additional deformities in both groups include proximal tibial procurvatum, internal tibial torsion, and limb length discrepancy. Compensatory deformities in the distal femur and distal tibia may occur. When non-operative treatment fails the deformities progress through skeletal maturity and can result in pain, gait abnormalities, premature medial compartment knee arthritis, and limb length discrepancy. Surgical options depend on the patient’s age, weight, extent of physeal involvement, severity, and number of deformities. They include growth modulation procedures such as guided growth for gradual correction with hemi-epiphysiodesis and physeal closure to prevent recurrence and equalize limb lengths, physeal bar resection, physeal distraction, osteotomies with acute correction and stabilization, gradual correction with multi-planar dynamic external fixation, and various combinations of all modalities. The goals of surgery are to restore normal joint and limb alignment, equalize limb lengths at skeletal maturity, and prevent recurrence. The purpose of this literature review is to delineate basic concepts and reconstructive surgical treatment strategies for patients with Blount’s disease.
... Die erste Beschreibung eines Verfahrens zur kontrollierten operativen Manipulation der Epiphysenfuge erfolgte bereits 1933 durch Phemister. Mit dem Ziel einer epiphysiodiaphysialen Fusion wurde ein Knochenblock aus dem peripheren Fugenbereich reseziert und nach Kürettage der Fuge um 180°gedreht wieder implantiert [32]. Mit dem Einzug mobiler Röntgenbildverstärker wurde dieses vergleichsweise invasive, komplikationsträchtige und kosmetisch ungünstige Vorgehen in den 1980er-Jahren durch eine perkutane Aufbohrung und Kürettage der Fuge abgelöst [45]. ...
The correction of angular deformities of the lower limb is a key task in paediatric orthopaedic surgery. The growth potential of the physis can be employed for the correction of these malalignments in childhood and adolescence. Hemiepiphysiodesis (HED) is a surgical technique used for growth modulation by permanent or temporary asymmetrical arrest of the growth plate. In permanent HED, exact timing of the procedure is mandatory to achieve optimal correction. Temporary HED through tension band devices such as two-hole-plates or flexible staples has been established as the treatment of choice for growth guidance with excellent results. Implant-associated complications have been significantly reduced through implant modifications. Several experimental procedures have the potential to achieve growth modulation even without the requirement of surgical intervention.
... Physeal guided growth technique, also known as hemiepiphysiodesis, for angular deformities in growing children often eliminates the need for osteotomies. 9,10 In 1949, Blount and Clarke described physeal stapling, which stopped growth rapidly and almost completely. [11][12][13] Complications included superficial wound infections, staple malposition, extrusion, bending and breakage and difficulty in removing the staples. ...
Background:
We modified the original technique for percutaneous transphyseal screw which was described in 1998 by Metaizeau and colleagues for distal femoral coronal angular deformity correction; the modification is related to the screw direction, whereas the screw is administered in a retrograde pattern, starting from the epiphysis and directed toward the metaphysis. This technique opposes the original technique that was started with a metaphyseal entry point which aimed toward the epiphysis. This study evaluates the efficacy of the newly suggested surgical technique regarding the rate of correction and growth resumption after screw removal.
Methods:
This prospective study looked at 40 patients (65 distal femoral physes), who underwent a percutaneous retrograde transphyseal guided growth screw procedure, from October 2017 to September 2019. All the patients included had distal femoral coronal angular deformities; 52 in valgus and 13 in varus deformities. The study included 17 females with an average age of 11.75 (range: 8.4 to 14.5 y) for 29 femurs and 23 males with an average age of 13.75 (range: 11.75 to 15.6 y) for 36 femurs. The mechanical lateral distal femoral angle was measured initially, and then again was measured after reaching the desired corrected orientation. The patients were then followed up after the screw removal and followed up to maturity, if the physis had continued to grow postcorrection. The degree of correction per month was calculated, and the consequence of screw removal was detected. Follow-up average time was 12.6 months (range: 30 to 6 mo).
Results:
The average correction in the distal femur was 1.3 degrees per month (range: 0.5 to 1.857 degrees/mo). In all of the 65 segments (61 femurs had significant growth remaining and 4 femurs had reached skeletal maturity with suboptimal mechanical lateral distal femoral angle correction), the screws were removed at the time of angular correction. Rebound growth was observed in 15 physes with an average of 1.8 degrees (range: 2 to 3 degrees); they were stable in 42 physes and progressed in 4 physes with an average of 1.6 degrees (range: 1 to 2 degrees). Complications were minor and related to entrapment of soft tissue under the screw washer.
Conclusion:
Percutaneous retrograde transphyseal guided growth screw for distal femur coronal angular deformity is a minimally invasive procedure, with a statistically significant correction rate when compared with the original transphyseal screw technique. The new technique has proven to have growth resumption after screw removal with minimal complication risk.
Level of evidence:
Level III-prospective observational study.
Background
Genu valgum is the most common reason for pediatric orthopedic consultations. Osteotomies are frequently unnecessary when hemiepiphysiodesis is performed on growing children with angular deformities.
Aim
To assess clinical and radiological outcomes of idiopathic genu valgum deformity treatment in the pediatric population with percutaneous retrograde transphyseal screw and evaluate its efficacy and safety.
Patients and methods
This prospective study involved 11 patients aged 8–14 years, encompassing both sexes, with genu valgum deformity of knee more than 20°. All patients were subjected to retrograde percutaneous transphyseal screw application.
Results
Mechanical lateral distal femoral angle was significantly higher after 3 months, after 6 months, after 9 months, and after 1 year than preoperative ( P <0.001). The rate of correction was significantly higher after 6 months, after 9 months, and after 1 year than after 3 months ( P <0.05). The rate of correction was significantly higher after 3 months and after 1 year in patients. The mean of improvement was 90.3±3.19%. The complication of this technique: rebound was defined after 6 months occurred in one (5%) patient. Flexion contraction occurred in two (10%) patients. Irritation of the medial collateral ligament occurred in two (10%) patients. Painful flexion occurred in one (5%) patient.
Conclusion
A safe and successful way for treating idiopathic genu valgum abnormalities in juvenile patients was the retrograde percutaneous transphyseal screw procedure. A faster rate of correction was seen in younger individuals, although the mechanical lateral distal femoral angle improved significantly and gradually with time in the research.
Assessment of angular and torsional relationships of the lower extremities is essential in pediatric orthopedics to differentiate between physiological developmental processes and pathological deformities. Frontal angular deformities usually show a favorable spontaneous course but can cause biomechanical consequences and complaints in the case of persistent or very pronounced deformities. Growth guidance using temporary hemiepiphysiodesis is established as the gold standard for correction. Torsional deformities of the lower limb require differentiated diagnostics and if therapy is required have so far primarily been treated by correction osteotomies. Although there are initial approaches to growth-modulating procedures for torsional correction, these are not yet regularly used clinically. Regular follow-up checks and the correct timing of growth-guiding procedures are crucial for treatment success.
Background
Distal radius physeal injuries can result in growth arrest and progressive deformity in children. Ulnar epiphysiodesis may be used to prevent deformity in the skeletally immature child; however, predicting success may be challenging. The purpose of this study was to (1) develop a method to predict successful ulnar epiphysiodesis, and (2) determine the utility of adding a sliding bone autograft as an adjunct to achieving successful epiphysiodesis.
Methods
A radiographic assessment of children who underwent isolated ulnar epiphysiodesis for premature radial physeal closure at a single institution was performed, evaluating ulnar variance measurements pre-op, immediate post-op, time of physeal arrest, and final ulnar variance. Surgical technique, including ulnar epiphysiodesis with and without adjunctive sliding bone autograft, was recorded to develop two cohorts to compare the duration of successful physeal closure based on the methodology developed.
Results
Eighty-seven wrists met the criteria (age 14.1±1.3 y) with an overall radiographic success of 99% with a mean radiographic follow-up of 6.6±5.9 months. Fifty-four wrists had repeat radiographs after defined radiographic physeal closure to confirm that when >50% of the ulnar physis demonstrated bridging bone formation, there was a longitudinal cessation of growth in 100% of these patients. Forty-five children had ulnar epiphysiodesis without bone graft, and 42 had ulnar epiphysiodesis with adjunct sliding bone autograft. Time to radiographic physeal arrest in the sliding bone autograft cohort was 1.3±0.7 (0.6 to 3.7) months compared with those without a bone graft of 2.9±2.2 (0.7 to 8.3) months; P <0.001.
Conclusions
Greater than 50% of opacity across the ulnar physis reliably indicates a successful arrest following ulnar epiphysiodesis. Although the adjunct of a sliding bone autograft did not significantly change the ability to achieve an arrest, it did reduce the duration of time to achieve the arrest. The metric of 50% opacity as a marker for successful cessation of growth can be adapted to limit additional follow-up radiographs. Ulna epiphysiodesis with adjunct sliding bone autograft can be employed when faster cessation is needed.
Level of Evidence
Level III—comparative study.
The objective of this study was to analyze the treatment of recurrent valgus knee in fibular hemimelia patients with hemiepiphysiodesis and define associated variables for deformity relapse. Sixteen consecutive patients with fibular hemimelia treated with hemiepiphysiodesis (57 physis) were compared to 21 physis of idiopathic cases, in terms of magnitude, speed, and time of correction. Correction of valgus deformity was successfully achieved in all cases. In the fibular hemimelia group, children 4 years and younger had a bigger magnitude of correction than older ones (11° versus 6.9°) and greater speed (1° versus 0.6°), with statistical significance ( P = 0.018 and P = 0.009, respectively), while time for correction was similar among these groups (11.6 months versus 12.3 months). Femoral distal physis corrected faster than proximal tibial physis (10.8 months versus 16.8 months), with statistical significance ( P = 0.032). Thirty-three physis (57.9%) were isolated and 24 (42.1%) were tibia and femur. We found no statistical difference between the two groups regarding time for correction, magnitude, or speed ( P = 0.526, P = 0.910, P = 0.803, respectively). Relapse was observed in 49 physis (86%) of the fibular hemimelia patients. These had a mean age of 5.5 years versus 3.9 years for those without a relapse, with statistical significance ( P = 0.204). Relapse occurred after 2 years of the first procedure. Recurrent valgus deformity in fibular hemimelia can be successfully treated with single or multiple hemiepiphysiodesis with tension band plates in skeletally immature patients in an effective and gradual manner. Level of Evidence: Level III, therapeutic study.
When correcting pediatric limb deformities, the ultimate goals are to restore the mechanical axis to neutral and achieve equal limb lengths by maturity, ideally without resorting to an osteotomy. Employing guided growth, proper alignment is accomplished gradually, without neurovascular risks. To optimize the outcome of guided growth, children should be followed until skeletal maturity. Guided growth is applicable in virtually any aged child with any etiology of deformity, provided the physes are open and at least a year of growth is anticipated. The only recognized contraindications to guided growth are physiologic deformities (such as genu varum < 2 years and genu valgum < 6 years—or projected limb length discrepancy <1.5 cm) at maturity and physeal closure due to damage or skeletal maturity. In addition to correction of coronal knee deformities, guided growth is also applicable for progressive hip, ankle, elbow, and wrist deformities, as well as for sagittal or oblique plane deformity.
Objectives
There are currently two major types of implants used to treat varus/valgus deformities in children: tension band plates (TBPs) and percutaneous epiphysiodesis transphyseal screws (PETS). While reports about TBP abound, there is a paucity of reports on PETS. In this preliminary report, we compared the clinical results for hemiepiphysiodesis using TBP to PETS.
Materials and Methods
The retrospective single European center study included 44 patients with varus/valgus deformities who underwent guided growth between 2010 and 2016. Follow-ups occurred from implantation through implant removal or skeletal maturity. Limb alignment was assessed through full-length standing radiographs.
Results
In the group treated with TBP, the average age at implantation was 11.3 years (range, 3.6–15.8 years). Plates were inserted for an average of 14.6 months (range, 3.0–42.0 months). The mechanical axis deviation (MAD) changed an average of 2.5 mm/month (range, 0.1–8.0 mm/month). In the PETS group, the mean age at implantation was 13.1 years (range, 10.9–15.8 years). Screws were inserted for an average of 10.0 months (range, 2.0–25.0 months). The change of MAD was 2.9 mm/month (range, 0.2–10.3 mm/month).
Conclusions
PETS had a comparable correction effect with TBP. Besides the different implant types, the correction effect and the treatment time are influenced by the growth rate, the extent of the deformity, and the underlying disease. TBP is less likely to lose purchase than PETS, especially in younger children. PETS have a sufficient grip in adolescents, are less expensive, and can be inserted through smaller surgical incisions which provide better cosmetic outcomes. The ideal age for switching from TBP to PETS has yet to be determined.
Level of Evidence
III.
A hemiepifisiodese com implantes em banda de tensão tipo “placas em oito” trouxe grande versatilidade para as correções angulares em ortopedia infantil, devido a técnica minimamente invasiva, sem necessidade de imobilização, e correção gradual. Descrevemos a correção de uma deformidade importante em valgo, com obtenção do alinhamento adequado em 7 meses.
BACKGROUND: After surgical treatment of proximal femoral deformities in children, secondary deformities can often develop. They can be corrected successfully by epiphysiodesis — a method of working with growth zones. AIM: To analyze the literature about the development of epiphysiodesis, a proximal femoral technique, and the results of its use in pediatric patients with hip joint pathologies. MATERIALS AND METHODS: The results of using epiphysiodesis for treating secondary deformities in children with hip joint pathologies were analyzed. The literature search was performed in open electronic scientific databases eLibrary and PubMed for the period from 1933 to 2022. RESULTS: Most authors reported good and satisfactory results in the correction of secondary proximal femoral deformities in children. They also suggested that the development of these deformities could be prevented by epiphysiodesis in time frames, which should be chosen correctly. However, no consensus has been established on the timing of surgical intervention and methods of its implementation. CONCLUSIONS: Proximal femoral deformities in children, such as valgus deformity of the femoral neck and its recurrence, consequences of Kalamchi type II avascular necrosis, and hypertrophy of the greater trochanter, were corrected for a long time by a complex surgical intervention–intertrochanteric osteotomy of the femur. Improvement in examination methods and a deeper understanding of the growth zone functioning of the proximal femur allow orthopedists to introduce into practice less invasive and less traumatic but effective methods for correcting these proximal femoral deformities by controlled blocking of the growth zones.
Guided growth affects the physis in children to produce a desired effect. Several devices achieve alteration of growth, including staples, plates, and screws. Complications can include device failures, failure to modulate growth as expected, and unintended physeal arrest. We present the results of a unique technique designed to minimize these complications. This was a retrospective review of guided growth at the knee at a single institution utilizing cannulated screws with epiphyseal-entry points. Each case was reviewed to determine the presence of complications related to guided growth, including implant breakage, implant pull-out or pull-through, iatrogenic physeal arrest, failure to modulate growth, and the incidence of revision surgeries. There were 89 patients who had 146 epiphyseal-entry guided growth procedures with a total of 221 4.5 mm cannulated screws. There were no iatrogenic physeal arrests. Five (2.26%) screws in 4 (4.49%) patients had either a broken screw or screw pull-out/pull-through requiring revision procedures. Three patients had osteotomies after skeletal maturity. Four had revision-guided growth for other reasons: 2 due to a lack of timely follow-up, 1 for iatrogenic genu varum without implant failure, and 1 due to recurrent deformity after implant removal. Revision procedures were unanticipated in 6 (6.74%) patients. This study describes a technique for placing cannulated screws at the knee with epiphyseal starting points. Our rate of complications and number of revision surgeries compare favorably with those noted for other techniques. Guided growth using epiphyseal-entry cannulated screws is a safe, effective option for most patients.
For paediatric orthopaedic surgeons treating leg length discrepancy, knowledge of the available procedures and their options and limits is just as important as mastery of the very different surgical methods and implants, as well as the possible complications,
in order to be able to advise and treat the children and adolescents and their parents comprehensively and in the best interests. Both the growth inhibiting procedures and the complex bone lengthening procedures require a great deal of experience to successfully guide patients and families through what is often a lengthy and sometimes complicated treatment process. Careful preoperative indications and planning, precise surgical techniques with suitable instruments and implants, and attentive postoperative check-ups are mandatory prerequisites for the desired therapeutic success.
[Wenn man als operativ tätige(r) Orthopäd:in Beinlängendifferenzen im Wachstumsalter behandeln möchte, ist die Kenntnis über die verfügbaren Verfahren und ihrer Möglichkeiten und Grenzen ebenso wichtig wie die Beherrschung der sehr unterschiedlichen Operationsmethoden und Implantate sowie der möglichen Komplikationen, um die Kinder und Jugendlichen und deren Eltern umfassend und im besten Sinne beraten und behandeln zu können. Sowohl die wachstumsbremsenden Prozeduren als auch die aufwendigen Verfahren zur Knochenverlängerung erfordern ein großes Maß an Erfahrung, um die Patient:innen und Familien erfolgreich durch den häufig langwierigen und teilweise komplikationsträchtigen Behandlungsprozess zu führen. Sorgfältige präoperative Indikationsstellungen und Planungen, präzise Operationstechniken mit geeigneten Instrumenten und Implantaten sowie achtsame postoperative Kontrolluntersuchungen sind zwingende Voraussetzungen für den gewünschten Therapieerfolg.]
Guided growth for coronal plane knee deformity has successfully historically been utilized for knee valgus, and knee varus. More recent use of this technique has expanded its indications to correct other lower and upper extremity deformities such as hallux valgus, hindfoot calcaneus, ankle valgus and equinus, rotational abnormalities of the lower extremity, knee flexion, coxa valga, and distal radius deformity. Guiding the growth of the extremity can be successful and is a low morbidity method for correcting deformity and should be considered early in the treatment of these conditions, when the child has a minimum of 2 years of growth remaining. Further expansion of the application of this concept in the treatment of pediatric limb deformities should be considered
Background:
Percutaneous epiphysiodesis using transphyseal screws (PETS) is a common procedure to correct lower extremity limb-length discrepancies in the pediatric population. A potential complication of this procedure is development of tibial valgus deformity, which may occur secondary to decreased screw purchase in the thinner medial proximal tibial epiphysis. The thickness of the proximal tibial epiphysis has not yet been well quantified, which was the aim of this study.
Methods:
Three-dimensional surface scans of 32 cadaveric proximal tibial epiphyses in specimens aged 3 to 17 years old were obtained and computer modeling software was utilized to measure the thickness of the proximal tibial epiphysis at 20 standardized potential screw insertion points according to a generated 5×4 map.
Results:
When normalized to the total width of the proximal tibial epiphysis, the lateral side is thicker compared with the medial side. The positions with the greatest thickness are located at the midline in the sagittal plane and 33% of the total physeal width away from the medial and lateral edges in the coronal plane (0.265 and 0.261 normalized thickness, respectively). The proximal tibial epiphysis is particularly thin 25% from the medial edge (normalized thickness range: 0.196 to 0.221). Multiple regression analysis revealed a significant relationship between increasing age and female sex with thinner normalized medial and lateral heights.
Conclusions:
During PETS, areas for greater screw purchase are located centrally in the sagittal plane and 33% of the total width away from the medial and lateral edges of the proximal tibial epiphysis in the coronal plane. Caution should be taken when inserting screws in the medial 25% of the proximal tibial epiphysis as it is thinner relative to the lateral edge, particularly in females.
Clinical relevance:
This study provides quantitative, anatomic data on the thickness of the proximal tibial epiphysis, which can direct screw placement during PETS for correcting limb-length discrepancies. These data may help lessen the risk of developing tibial valgus deformity although future clinical studies are necessary to fully evaluate this possibility.
Premature physeal arrest has an unpredictable course after an osteoarticular infection. The prognosis depends on the age of the child, the type of injury (partial or total bony bar), the proportion of the physeal surface affected and the bone compromised. Peripheral injuries lead to limb deformities while central bars, when big enough determine limb length discrepancies. Surgical treatment should be oriented to preserve physeal function, allowing normal growth to resume. In those cases where it is not possible, the surgeon must deal with the sequelae, namely, limb length discrepancies and/or bone deformities.
Zusammenfassung
Durch das Prinzip der Wachstumsblockade mittels Epiphysiodese und der Wachstumslenkung durch Hemiepiphysiodese können sowohl Beinlängendifferenzen als auch sagittale, koronare und schräge Achsdeformitäten an der unteren Extremität während des Wachstums korrigiert werden. Es werden temporäre und permanente Techniken unterschieden. Der große Vorteil liegt in der minimal-invasiven Anwendung und den geringen Komplikationen. Essenziell sind die genaue Planung sowie das exakte Timing, besonders wenn permanente Verfahren angewandt werden. Die Anwendung rund um das kindliche Kniegelenk kann als Goldstandard der Behandlung von Beinlängendifferenzen und Varus- und Valguskorrekturen bezeichnet werden. Die Wachstumslenkung an der unteren Extremität hat über die letzten Jahre viele neue Einsatzmöglichkeiten an der Hüfte und am Sprunggelenk gefunden. Die erfolgreichen klinischen Ergebnisse mit geringen Komplikationen unterstützen die breite Anwendung der Hemiepiphysiodese und Epiphysiodese am wachsenden Skelett bei Achsfehlstellungen und Beinlängendifferenzen.
Background:
Congenital pseudarthrosis of the tibia (CPT) is a complex and serious disease in orthopaedics which often requires multiple operations for treatment. Postoperative ankle valgus deformity is easily seen after the operation of CPT. The aim of this study is to retrospectively evaluate the effectiveness of three different implants for treating postoperative ankle valgus after CPT.
Methods:
A total of 41 patients with postoperative ankle valgus after CPT from December 2010 to July 2019 were selected. Of these 41 patients, 23 patients were treated with "U"-shaped staple, 10 patients were treated with hollow screw and 8 patients were treated with cortical bone screw. The evaluation index was tibiotalar angle. The general data, preoperative, postoperative, and final follow-up imaging data were recorded, and the deformity correction rate and complications were compared.
Results:
All the patients were performed with postoperative follow-up visit for at least 12 months (31 mo on average). In the "U"-shaped staple group, the preoperative tibiotalar angle was 74.8±4.8 degrees, the tibiotalar angle was 85.8±4.5 degrees when the internal fixation was removed; in the hollow screw group, the average preoperative tibiotalar angle was 72.2±6.1 degrees, the average tibiotalar angle was 88.4±5.1 degrees when the internal fixation was removed; in the cortical bone screw group, the average preoperative tibiotalar angle was 75.1±4.2 degrees, the average tibiotalar angle was 88.4±5.1 degrees when the internal fixation was removed. The correction rate of the "U"-shaped staple group was 0.71 degrees/month, with that of in the hollow screw group and cortical bone screw group being 0.64 degrees/month and 0.61 degrees/month, respectively. There was no significant difference in the correction rate between the 3 groups. One case of internal fixation complication was reported in the hollow screw group; 2 cases of missing correction effect were reported, 1 in cortical bone screw group and 1 in hollow screw group; and 2 cases showing symptom of wound pain were reported in the "U"-shaped staple group.
Conclusion:
Ankle valgus is a common postoperative complication of congenital tibial pseudarthrosis. Temporary hemiepiphysiodesis with "U"-shaped staple or screws is an effective treatment for postoperative ankle valgus deformity of CPT in children.
Level of evidence:
Level IV-retrospective study.
Congenital spinal deformities result from anomalous vertebrae that produce deformities in the coronal and sagittal planes due to the longitudinal growth imbalances. Modulation of vertebral growth on either the convex or concave side of the curve may be used as an early treatment alternative for the growing spine. Convex growth arrest (CGA) aims to control the convex side, and in well-selected cases not only stops the progression but may also lead to spontaneous correction given that the concave side has growth potential. The originally defined indications of the procedure are curves with five or less anomalous vertebrae, less than 70°, and without significant sagittal plane abnormalities in children 5 years of age or less. However, the unpredictability of curve behavior and less than optimal correction magnitudes has decreased the enthusiasm for this technique.Modifications of the technique have been reported to obviate an anterior surgery and to achieve a better initial correction, continued correction, and growth. All posterior CGA with instrumentation and concave distraction may offer immediate trunk balance and curve correction along with continued correction of the deformity while preserving spinal growth.KeywordsConvex hemiepiphysiodesisConcave distractionGrowth arrestGrowth modulationEarly-onset scoliosis
Purpose of review:
Lower extremities axis alterations are a frequent cause for consultation in the medical practice of the care of paediatric patients. When it corresponds to pathological situations, guided growth surgery has been positioned as a possibility of well tolerated, reproducible and predictable resolution. For this reason, its use has increased significantly in recent years. In this review, its current indications, preoperative study, results and complications described in the updated literature will be discussed.
Recent findings:
The success of the technique remains high in the current literature, expanding the technique to other segments and disorders, and describing new ways of performing tension band with sutures. In addition, there is an increase in its incidence and a decrease in the associated hospitalized days, which can associate with techniques of lower morbidity.
Summary:
As guided growth surgery allows for successful correction of axis alterations, to achieve this, it is important to know the main indications, preoperative analysis and theoretical bases on which this technique is based, to carry it out in an adequate and timely manner, seeking an adequate resolution of the child's problem.
Introducción:
La modulación quirúrgica del crecimiento fisiario, más conocida actualmente como “Crecimiento Guiado”, es un procedimiento utilizado como tratamiento para las diferencias de longitud o altera ciones de ejes de las extremidades. Si bien su uso se considera en aumento por el desarrollo de nue vas técnicas menos invasivas, no existen análisis estadísticos en la literatura que comprueben dicha afirmación.
Objetivo:
Evaluar la incidencia de la cirugía codificada como “Epifisiodesis (Fémur y/o Tibia)” en la población chilena desde el 1 de enero del 2010 al 31 de diciembre del 2019, los días de estadía hospitalaria relacionada con dicho código, y los datos demográficos de la población estudiada.
Pacientes y Método:
Se obtuvo desde la base de datos del Departamento de Estadísticas e Informa ción de Salud (DEIS) de Chile, todos los egresos hospitalarios desde el 1 de enero del 2010 al 31 de diciembre del 2019, desde donde se extrajeron los resultados con el código de “Epifisiodesis (Fémur y/o Tibia)”, en menores de 15 años. Se analizó el número de procedimientos por año, número de días de estadía hospitalaria, edad y sexo de los pacientes.
Resultados:
El número de procedimientos codificados como “Epifisiodesis (Fémur y/o Tibia)” fue en aumento en Chile, durante el período analizado. Los días de estadía hospitalaria asociados a dicho procedimiento disminuyeron de forma progresiva entre los años 2012 y 2017. El procedimiento se realizó principalmente en mujeres, y en el grupo de 5-9 años, mostrando una tendencia al alza en niños del grupo de 10-14 años entre los años 2015 y 2019.
Conclusiones:
Se debe realizar mayores análisis para determinar los factores que produ cen estos resultados, los que probablemente se relacionen a acceso a técnicas más eficaces y sencillas, con menor morbilidad.
Resumen
El crecimiento guiado es una opción quirúrgica de uso creciente para la corrección de las deformidades angulares de extremidades inferiores en pacientes esqueléticamente inmaduros. Es posible de realizar en múltiples planos o segmentos, con excelentes resultados. Su uso más frecuente es en deformidades del plano coronal alrededor de la rodilla. La epifisiodesis permanente se puede realizar en pacientes dentro de los dos años previos al término del crecimiento longitudinal del segmento a tratar, considerando la epifisiodesis temporal para los pacientes con más de 2 años de crecimiento restante.
En casos leves a moderados las tasas de éxito llegan incluso al 100% en algunas series, en tanto, pacientes con enfermedad de Blount, obesidad, edad esquelética avanzada o deformidades severas, tienen menos posibilidades de lograr una corrección completa.
Independientemente de la técnica quirúrgica, es necesario una adecuada planificación preoperatoria, educación familiar y un seguimiento estricto para así minimizar las complicaciones y permitir una excelente corrección de la deformidad con una morbilidad mínima.
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