Introduction. Epiphysiodesis, defined as the process of closing the growth plate (physis), have been used for several years as a treatment option of cases where the predicted leg-length discrepancy (LLD) falls between 2 to 5 cm. The aim of this study was to systematically review the existing literature on the effectiveness of three different epiphysiodesis techniques with implant usage for the treatment of leg-length discrepancy in the pediatric population. The secondary aim was to address the reported complications of staples, tension-band plates (TBP) and percutaneous epiphysiodesis screws (PETS). Method. 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 epiphysiodesis with an implant. The extracted outcome categories were effectiveness of epiphysiodesis (LLD measurements pre/post-operatively, successful/unsuccessful) and complications that were graded on severity. Result. Forty-four studies (2184 patients) were included, from whom 578 underwent TBP, 455 PETS and 1048 staples. From pooled analysis of the studies reporting success rate, 64% (150/234) successful TBP surgeries (10 studies), 78% (222/284) successful PETS (9 studies) and 52% (212/407) successful Blount staples (8 studies). Severe complications rate was 7% for PETS, 17% for TBP and 16% for Blount staples. TBP had 43 cases of angular deformity (10%), Blount staples 184 (17%) while PETS only 18 cases (4%). Conclusion. Our results highlighted that PETS seems to be the most successful type of epiphysiodesis surgery with an implant, with higher success rate and lower severe complications than TBP or Blount staples

Purpose: Surgical epiphysiodesis is one technique used to correct lower limb length discrepancy. Methods described include: in situ graft (Phemister, 1993), stapling (Blount, 1949), percutaneous curettage (Bowen, 1984). The purpose of this work was to evaluate a new technique described in 1998 (Metaizeau) which uses two percutaneous transphyseal screws. Material and methods: Forty-two patients (29 boys, 13 girls), mean age 13.1 years underwent the procedure. The cause of leg length discrepancy was unknown (n=12), fracture (n=16), congenital (n=7), other (n=7). Epiphysiodesis using two percutaneous screws was performed on the distal femur (n=24), the proximal tibia (n=7), both (n=11). Stance radiograms were obtained of the lower limbs before the intervention and at last follow-up to measure length of the lower limb, the tibia, and the femur. Difference with the healthy limb was determined as well as the percentage of growth comparing the healthy and epiphysiodesis sides. The operative time, duration of hospital stay and complications were studied. Results: Preoperatively, mean limb length discrepancy was 22.3 mm (10 to 70); at skeletal maturity, the difference measured 11 mm (28 to −20). Mean percent growth from epiphysiodesis to last follow-up was 3.15% for the epiphysidesis side and 6.26% for the contralateral side. Mean operative time was 20 min per bone (15–40). Complication rate was 16% including 7% stiff knee postoperatively with total recovery in two weeks, and 9% discomfort due to the presence of the screws. The growth curves showed that the epiphysiodesis was effective before three months. Mean hospital stay was 1.3 days (1–4). Discussion: The final outcome in terms of leg length discrepancy were comparable with other techniques. The rate of complications appears to be more favourable since there were no infections, no frontal or sagittal deviations, no vascular or nerve injuries, and since all complications resolved without sequelae. This intervention can be proposed as an outpatient procedure. Epithysiodesis is always obtained within three months. Conclusion: Epiphysiodesis using a percutaneous transphyseal screw is a simple method with minimal complications which provides reliable results and many advantages compared with other methods

Aim: To review our experience with epiphysiodesis using three different methods to correct LLD and to establish the efficacy of these procedures. Method: A retrospective review of 42 patients from 1999 to 2008 with at least one year follow-up recorded type and location of the epiphysiodesis, average operating time and hospital stay, complications, method of prediction, timing and the final LLD. CT scanograms and mechanical axis view with grids were used to assess LLD. Results: Epiphysiodesis was as per Canale for 26, by Metaizeau screw in 14 and by staples in 2. Average operation time was 42 minutes for Canale type, 45 minutes for the screws and 56 minutes for the staple cases. The pre operative LLD of 3.7 cms In the Canale group, improved to 1.2 cms over an average follow-up of 2.1 yrs. There were 4 minor and 2 major complications with a 92% success rate. For the screw group, the mean change was 1.8 cms over 2.2 yrs with 2 minor and 2 major complications giving a success rate of 85%. With staples the success rate was 100% and the mean change was 1.8 cms at an average of 2.3 yrs. In 14 cases where bone age reports were available, the multiplier method seemed better at predicting estimated LLD at skeletal maturity and timing of epiphysiodesis than the Moseley chart. Conclusions: Percutaneous epiphysiodesis by any method is reliable, minimally invasive and with acceptable complication rate when compared to a corrective osteotomy or open Phemister-type epiphysiodesis. Our experience suggests that the Canale method has the least complications and best success rate. Paleys multiplier method was better at predicting LLD and timing of epiphysiodesis than the Moseley Chart

Introduction

Legg-Calvé-Perthes disease (LCPD) often results in femoral head deformity and leg length discrepancy (LLD). Objective of this study was to analyse femoral morphology in LCPD patients at skeletal maturity to assess where the LLD originates, and evaluate the effect of contralateral epiphysiodesis for length equalisation on proximal and subtrochanteric femoral lengths.

Aim

To investigate the effect of the eight plate position in sagittal plane on tibial slope in temporary epiphysiodesis technique applied to the proximal tibia and whether there is a rebound effect after removing the plate.

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.

A technique for epiphysiodesis using a cannulated tubesaw has been developed to combine the precision of the original Phemister method with newer percutaneous methods. The approach is unilateral, and requires minimal access. Reinsertion of the removed core of bone reduces haemorrhage from the defect and augments arrest of the growth plate.

In 35 patients treated by this method predicted discrepancies of 2 to 4.5 cm were reliably reduced to 0.7 ± 0.6 cm, with no serious complications. The timing of surgery is critical, and relies upon careful monitoring of the pattern of discrepancy over several years, using clinical and radiographic measurements. Undercorrection of the disparity in three patients was the direct result of late referral.

The 8-plate (Orthofix, SRL, Italy) is a titanium extraperiosteal plate with 2 screws which acts as a hinge at the outer limits of the physis. It has been used for correction of both angular and sagittal deformity around the knee. To our knowledge this is the first study describing the use of 8-plates in leg length discrepancy (LLD) correction.

We aimed to evaluate outcomes of temporary 8-plate epiphysiodesis in LLD, and to assess the complications associated with its usage.

This retrospective study included 30 patients between 2007 and 2010 whom underwent 8-plate epiphysiodesis to address LLD.

Leg length measurements were recorded using erect full leg length scanograms and comparison made between pre-operative, interval and final scanograms. Any deviations of the mechanical axis were also recorded.

During the study period 34 epiphysiodeses were performed on 30 patients. There were 17 males and 14 females. The average age at the time of procedure was 10.7 years (range 3–15). Average time to final follow-up was 24 months (range 52–10). The average pre-operative LLD was 2.5 cm (range 1.5–6 cm). The mean overall rate of correction was 1.0 cm per year. The mean residual LLD at end of treatment was 1.1 cm (range 0–4.5 cm). Two patients experienced genu recurvatum deformity. This was associated with placement of distal femoral plates anterior to the mid-lateral line.

Based on our experience 8-plate epiphysiodesis is a reversible, minimally invasive procedure with reliable results in length correction. However, careful device placement is required to prevent deformity.

Recurvatum genu can develop as a results of both chronic diseases “maladie des enfants alités” (Lefort), though rarely, and after trauma, which occurs more often. Surgical treatment might consist either in a de-epiphysiodesis according to Langenskield, when a bone bridge is present, or by Ilizarov technique, which allows a correction of segmentary shortening.

This kind of trauma often occurs after bone growth has ceased and this is why in our study we performed osteotomies. Femoral osteotomies are all closed wedge procedures with medial access and 90° angle blade-plate fixation. This allows early mobilisation and avoids overcorrection. Without performing this kind of procedure posteriorisation of the trochlea might occur and, consequently, over time, patellofemoral arthritis could develop. For the tibia we applied an anterior open wedge osteotomy with ATT avulsion, according to Lecuire, with which secondary low patella can be avoided. As fixation we first used screws, actually a plate to correct the co-existing valgus.

The good results of this kind of surgery justify autologus bone graft. We have not employed the the procedure described by Bowen.

We evaluated the use of percutaneous screw epiphysiodesis to treat genu valgum deformity in adolescents, and the possibilities of extending its use to younger patients with different causes of angular deformities or leg length discrepancies. To date, the surgical options for adolescent idiopathic genu valgum have been medial physeal retardation by stapling, growth arrest by epiphysiodesis of the distal femur and/or tibia, or osteotomy.

From September 1999, we prospectively studied 16 patients, 11 of whom had angular knee deformities (20 legs) and five limb length inequality.

From a preoperative mean of 12.25( the tibiofemoral angle reduced to 6.4° at the latest assessment.

Percutaneous epiphysiodesis using transphyseal screws proved to be a reliable method with few complications and the advantages of simplicity, short operating times, rapid postoperative rehabilitation and reversibility.

1. Experimental epiphysiodesis was performed on either the upper or lower epiphysial cartilage of one tibia of young rabbits, the other tibia serving as a control.

2. Subsequent growth was observed at each epiphysis by radiography.

3. After both operations the normal deceleration of growth rate of the uninjured epiphysis on the experimental side was reduced and this epiphysis made a greater contribution than its control to the final length of the bone.

4. Serial sections of the injured epiphysis revealed that the arrest of growth was due to the formation of a narrow bony bridge between the epiphysial and metaphysial bone.

5. The additional growth of the uninjured epiphysis appeared to have a direct relationship to the deficiency of growth at the epiphysis that had been injured by operation.

6. The results may indicate the existence of a local system of growth control.

Purpose: Partial epiphysiodesis of the growth plate due to physeal aggression is a common problem in paediatric patients. Surgical management requires precise imaging. We recall other imaging techniques currently employed and describe a novel method for studying the characteristic features of epiphysiodesis bridges of the growth plate: 3D-magnetic resonance imaging (3D-MRI).

Material and methods: We analysed retrospectively MRI series of 27 epiphysiodesis bridges in 23 children (ten boys and thirteen girls) aged 11.3 years (range 2.5 – 15). We recorded information concerning the cause of the physeal aggression, the joint involved, the type of bony bridge (Ogden classification), the clinical deformation, and the proposed treatment. The 27 bridges were studied on coronal MRI acquired with echo-gradient and fat suppression sequences. Data were processed with a manual 3D reconstruction program in 15 minutes to precisely define the localisation, the volume, and the morphology of the bony bridge and the active physis.

Results: The epiphysiodeses were caused by trauma (65%), iatrogenic aggression (17%), ischemia-infection (purpura fulminans) (9%), juxta-physeal essential cyst (4.5%), and unknown causes (4.5%). Eighty-seven percent involved a lower limb joint, 75% of which involved the tibia. The surface of the epiphysiodesis bridge covered 20% of the physis. The bridges were peripheral (46.5%), central (46.5%), and linear (7%).

Discussion: It is difficult to determine the position and the 3D relations of an epiphysiodesis bridge in a healthy active physis with imaging techniques such as plain x-rays, scintigraphy, tomography and computed tomography. The 3D-MRI method described here provides a sure way to distinguish the active growth plate which gives a high intensity signal and the epiphyseal bridge which gives a low intensity signal. Morphological (size, form) and topographic characteristics of the bony bridge and the physis can be described with precision facilitating therapeutic decision making and guiding surgery. The lack of radiation risk is also an advantage of MRI.

Conclusion: The quality of the images obtained, the safety of MRI and the easy interpretation of 3D reconstructions makes this imaging technique an excellent method for pre-therapeutic analysis of epiphysiodesis bridges.

Study design: A retrospective review of patient records with recent clinical and radiographic assessment.

Objective: Long-term evaluation of the Luque trolley for posterior instrumentation in congenital scoliosis.

Summary of background data: From a group of 51 cases treated with the Luque trolley, we review 10 patients with progressive congenital scoliosis (5male, 5female) for a mean follow-up period of 14.8 years, to mean age of 19 years. The mean Cobb angle of the primary curve before surgery was 69.5 degrees. The mean Cobb angle of the secondary cervico-thoracic curve before surgery was 37.1 degrees and of the caudal secondary curve was 26.4 degrees. The mean age at surgery was 5.0 years. 8 patients had a selective epiphysiodesis procedure, 2 with hemi-vertebrectomy, and all underwent single- stage (7 patients) or dual-staged (3 patients) posterior instrumentation with a Luque trolley growing construct.

Method: Clinical evaluation and sequential measurements of Cobb angle were done, with recording of further surgical procedures, associated complications, and final coronal balance. The thoracolumbar longitudinal spinal growth (T1-S1) and growth in the instrumented segmented were also calculated.

Results: The mean preoperative primary curve Cobb angle of 69.5degrees, corrected to a mean postoperative angle of 30.6 degrees, with progression from here to curve magnitude of 38.8 degrees on latest follow up (approximate rate of progression of 0.55 degrees per year).

The mean pre-operative cephalic (cervico-thoracic) Cobb angle of 37.1degrees, corrected to 22 degrees, with progression to 26.6 degrees.

The mean pre-operative caudal (lumbar) Cobb angle of 26.4degrees, corrected to16.2 degrees, this later progressed to 20.6 degrees.

Coronal plane translation measured 1.68 cm at latest follow up [range 0.5–5.1cm].

The thoracolumbar longitudinal growth measured a mean of 8.81cm (approx0.8 cm/year) with a recorded lengthening of 2.54 cm (approx 0.23cm/year) in the instrumented segmented. Half the patients did not require further surgery.

Conclusion: Selective fusion does not always prevent further deformity in congenital scoliosis. The addition of posterior growing construct instrumentation did demonstrate capacity for good correction of primary and secondary curvatures and a limited capacity for further longitudinal growth.

Congenital or acquired recurvatum genu might be caused by bone and/or soft tissue disorders. In bone recurvation, tibial deformity is more common; femoral deformity has clinical and X-ray features that are less important and often unidentified. We found this type of deformity in only four of 40 cases of bone recurvation.

Bone recurvation can follow a tibial or femoral fracture as well as injury with no X-ray signs. Some months later an anterior epiphysiolisis might be recognised on X-ray. This fact allows a retrospective diagnosis of fifth type Salter-Harris epiphysiolisis. Clinically a harmonious recurvatum genu would be recognised, which is difficult to distinguish from a capsulo-ligamentous disorder.

According to a subjective profile, it is featured with no objective laxity. On X-rays there are no peculiarities in the anterior view, but on the lateral view femoral condylar flattening with anterior rotation, in particular in the lateral one, can be observed. It might be useful to compare the X-ray findings to define a geometrical point termed the femoral diaphysealintercondylar angle. This has been already described and is measured between two lines, one which represents the axes of the femoral shaft, the other one the Blumensaat line; in a normal knee this angle measures 33° (±3). In knees with femoral recurvation this is higher: in our four patients the range of the angle was 45°–58°.

Procurving femoral osteotomy is the gold standard; in fact femoral closed wedge osteotomy allows a complete correction. Surgeons must avoid an overcorrection with subsequent femoral trochlear rotation and at the same time a tibial osteotomy must be avoided, which would lead to a double articular deformity, wherever it would fit with a capsulo-ligamentous recurvation.

The aims of this study were to compare the outcome of epiphysiodesis in patients with limb length discrepancy (LLD) as a result of cerebral palsy with those as a result of other causes in order to test our hypothesis that the hemiplegic / monoplegic limb may respond differently to epiphysiodesis, to evaluate the accuracy of the Moseley method and evaluate whether there is any difference between the outcomes of left or right hemiplegic limbs with LLD bearing in mind that the left hand is used for bone age calculations.

We reviewed the case notes and radiographs of 34 children who had undergone epiphysiodesis for the management of LLD by the same surgeon, using the Moseley method between February 1999 and May 2005 to final follow up at skeletal maturity. Of the 34 patients, 9 had a LLD as a result of cerebral palsy (4-Left, 5-Right) and 25 as a result of other causes. In the cerebral palsy group the mean residual LLD was 0.59cm and in the other group it was 1.18cm. Both groups were similar in terms of age and sex distribution. There was no demonstrable statistically significant difference in outcome between the 2 groups (unpaired T test, P=0.734). The Moseley method appeared accurate and there was no difference demonstrated in the outcome between left and right hemiplegic LLD.

We conclude that the Moseley method is reliable. We have not found any evidence that the hemiplegic limb behaves any differently. We have not demonstrated any difference in the outcome of left or right hemiplegic limbs.

Introduction: Anterior convex epiphysiodesis and posterior concave distraction has not been previously described in the literature for the treatment of thoracolumbar hemivertebrae. We describe our experience with long-term follow-up.

Method: Six consecutive patients with a mean age of 3.4 years were operated on with this technique. Levels of fusion extended two levels above and below the hemi-vertebra, while the instrumentation span the full length of the curve. Further concave distraction was carried out when there was evidence of loosening of the hooks.

Results: The average follow-up was 10.8 years (range 8 to 14). The mean Cobb angle before surgery was 49°, and at the latest follow-up was 26°. There was a mean 41% improvement in the scoliosis. In 5 of these cases, this correction was achieved immediately after surgery and did not significantly change despite repeated distraction.

Conclusion: The addition of concave distraction provided better correction than convex epiphysiodesis alone. It is technically easier and safer than hemivertebra excision in the correction of such deformities. This method of treatment is recommended for patients with single fully segmented hemivertebrae located at the thoracolumbar junction that has a significant deformity.

We reviewed the results in 24 children (34 knees) following double-elevating osteotomy for late presenting infantile Blount’s disease.

The mean age of our seven male and 17 female patients was 9.1 years (7 to 13.5). Obesity was noted in 15 (above the 95th percentile). Previous valgus osteotomy had been performed on nine knees.

Ten knees were Langenskîld stages IV, six stage V and 18 stage VI. The surgical technique addressed the medial joint line depression with an elevating osteotomy, which was maintained by insertion of a tricortical wedge from the iliac crest and the excised fibula. The tibial varus and internal torsion was corrected with an osteotomy proximal to the apophysis. In the more recent patients, a proximal lateral tibial and fibular epiphysiodesis was done concomitantly.

The mean preoperative mechanical varus of 30.6( (14( to 60() was corrected to 0( to 4( mechanical valgus in 29 knees. In five knees there was under-correction to 2( to 4( mechanical varus. At follow-up a further eight knees developed varus owing to late epiphysiodesis. The tibial varus angle (the angle subtended by the mechanical axis of the tibia and a line along the lateral tibial joint line) increased at a mean of 1( a month due to inevitable medial growth plate fusion.

The mean preoperative joint depression angle of 49( (40( to 60() was corrected to 26( (20( to 30(), which was maintained at follow-up. There was no noteworthy femoral valgus or varus present preoperatively to warrant femoral osteotomy.

Unstable slipped capital femoral epiphysis (SCFE) has an increased incidence of avascular necrosis (AVN). The purpose of this study was to determine if early identification and intervention for AVN may help preserve the femoral head.

We retrospectively reviewed 48 patients (50 hips) with unstable SCFE managed between 2000 and 2014. Based on two different protocols during the same time period, 17 patients (17 hips) had a scheduled MRI between 1 and 6 months from initial surgery, with closed bone graft epiphysiodesis (CBGE) or free vascularised fibular graft (FVFG) if AVN was diagnosed. Thirty-one patients (33 hips) were evaluated by plain radiographs. Outcomes analysed were Steinberg classification and subsequent surgical intervention. We defined Steinberg class IVC as failure in treatment because all of the patients referred for osteotomy, arthoplasty, or arthrodesis in our study were grade IVC or higher.

Overall, 13 hips (26%) with unstable SCFE developed AVN. MRI revealed AVN in 7 of 17 hips (41%) at a mean of 2.5 months postoperatively (range, 1.0 to 5.2 months). Six hips diagnosed by MRI received surgical intervention (4 CBGE, 1 FVFG, and 1 repinning due to screw cutout) at a mean of 4.1 months (range, 1.3 to 7.2 months) postoperatively. None of the 4 patients treated with CBGE within two months postoperatively progressed to stage IVC AVN. The two patients treated after four months postoperatively both progressed to stage VC AVN. Radiographically diagnosed AVN occurred in 6 of 33 hips (18%) at a mean of 6.8 months postoperatively (range, 2.1 to 21.1 months). One patient diagnosed with stage IVB AVN at 2.4 months had screw cutout and received CBGE at 2.5 months from initial pinning. The remaining 5 were not offered surgical intervention. Five of the 6 radiographically diagnosed AVN, including the one treated with CBGE, progressed to stage IVC AVN or greater.

None of the 4 patients with unstable SCFE treated with CBGE within 2 months post pinning developed grade IVC AVN, while all patients treated with other procedures after 2 months developed IVC or greater AVN. Early detection and treatment of AVN after SCFE may alter the clinical and radiographic progression.

Aims

Guided growth using eight-plates is commonly used for correction of angular limb deformities in growing children. The principle is of tethering at the physeal periphery while enabling growth in the rest of the physis. The method is also applied for epiphysiodesis to correct limb-length discrepancy (LLD). Concerns have been raised regarding the potential of this method to create an epiphyseal deformity. However, this has not been investigated. The purpose of this study was to detect and quantify the occurrence of deformities in the proximal tibial epiphysis following treatment with eight-plates.

Introduction: Percutaneous epiphysiodesis is a well established procedure in the treatment of leg length discrepancy. Many techniques have been described ranging from an open technique to the more recently described percutaneous technique. This study assesses the percutaneous single portal technique, in combined distal femoral and proximal tibial lower limb epiphysiodesis, performed by a single surgeon.

Methods: We performed a retrospective review of cases performed in a single institution by a single surgeon from 1994 to present. A total of 45 combined epiphysiodesis were performed. 40 patients qualified for the study group with at least 2 years follow up. There were 19 female and 21 male patients, with the operative side equally shared between left and right.

Results: The mean predicted leg length discrepancy using the Mosley Straight Line Graph was 2.43 cm. The mean final leg length discrepancy, at an average follow up of 31 months, was 1.5 cm with a range of 0 to 2.81 cm. There were no angular deformities at follow up. One female patient had a knee effusion which resolved spontaneously. One male patient complained of anterior knee pain initially post surgery however this resolved at final follow up without treatment. The majority of patients (n=34) were inpatients, however more recently this procedure has been successfully carried out as a day case (n=6).

Discussion: Percutaneous epiphysiodesis has been accepted as a standard technique to treat leg length discrepancy of 2 cm to 5 cm. Several techniques have been described in the literature with varying complication rates. This study shows that single portal combined epiphysiodesis is successful and has a relatively low complication rate.