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Brenneis M, Thewes N, Holder J, Stief F, Braun S. Validation of central peak height method for final adult height predictions on long leg radiographs. Bone Jt Open 2023; 4:750-757. [PMID: 37813396 PMCID: PMC10562078 DOI: 10.1302/2633-1462.410.bjo-2023-0105.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/11/2023] Open
Abstract
Aims Accurate skeletal age and final adult height prediction methods in paediatric orthopaedics are crucial for determining optimal timing of growth-guiding interventions and minimizing complications in treatments of various conditions. This study aimed to evaluate the accuracy of final adult height predictions using the central peak height (CPH) method with long leg X-rays and four different multiplier tables. Methods This study included 31 patients who underwent temporary hemiepiphysiodesis for varus or valgus deformity of the leg between 2014 and 2020. The skeletal age at surgical intervention was evaluated using the CPH method with long leg radiographs. The true final adult height (FHTRUE) was determined when the growth plates were closed. The final height prediction accuracy of four different multiplier tables (1. Bayley and Pinneau; 2. Paley et al; 3. Sanders - Greulich and Pyle (SGP); and 4. Sanders - peak height velocity (PHV)) was then compared using either skeletal age or chronological age. Results All final adult height predictions overestimated the FHTRUE, with the SGP multiplier table having the lowest overestimation and lowest absolute deviation when using both chronological age and skeletal age. There were no significant differences in final height prediction accuracy between using skeletal age and chronological age with PHV (p = 0.652) or SGP multiplier tables (p = 0.969). Adult height predictions with chronological age and SGP (r = 0.769; p ≤ 0.001), as well as chronological age and PHV (r = 0.822; p ≤ 0.001), showed higher correlations with FHTRUE than predictions with skeletal age and SGP (r = 0.657; p ≤ 0.001) or skeletal age and PHV (r = 0.707; p ≤ 0.001). Conclusion There was no significant improvement in adult height prediction accuracy when using the CPH method compared to chronological age alone. The study concludes that there is no advantage in routinely using the CPH method for skeletal age determination over the simple use of chronological age. The findings highlight the need for more accurate methods to predict final adult height in contemporary patient populations.
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Affiliation(s)
- Marco Brenneis
- Department of Orthopedics (Friedrichsheim), University Hospital, Goethe University Frankfurt, Frankfurt, Germany
| | - Niklas Thewes
- Department of Orthopedics (Friedrichsheim), University Hospital, Goethe University Frankfurt, Frankfurt, Germany
| | - Jana Holder
- Department of Orthopedics (Friedrichsheim), University Hospital, Goethe University Frankfurt, Frankfurt, Germany
- Department of Sport and Exercise Science, University of Salzburg, Salzburg, Austria
| | - Felix Stief
- Department of Orthopedics (Friedrichsheim), University Hospital, Goethe University Frankfurt, Frankfurt, Germany
- Dr. Rolf M. Schwiete Research Unit for Osteoarthritis, Department of Orthopedics (Friedrichsheim), University Hospital, Goethe University Frankfurt, Frankfurt, Germany
| | - Sebastian Braun
- Department of Orthopedics (Friedrichsheim), University Hospital, Goethe University Frankfurt, Frankfurt, Germany
- Center for Musculoskeletal Surgery, Charité - University Hospital Berlin, Berlin, Germany
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[Epiphysiodesis and hemiepiphysiodesis : Physeal arrest and guided growth for the lower extremity]. DER ORTHOPADE 2022; 51:415-432. [PMID: 35357554 PMCID: PMC9050799 DOI: 10.1007/s00132-022-04219-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 01/17/2022] [Indexed: 10/27/2022]
Abstract
The principals of growth arrest by epiphysiodesis and growth guidance by hemiepiphysiodesis are effective and powerful surgical techniques in pediatric orthopedics. These procedures can be used to correct leg length discrepancies as well as sagittal, coronal and oblique deformities. A differentiation is made between temporary and permanent techniques. The most significant advantage is that these techniques are minimally invasive and have low complication rates compared to acute osteotomy and gradual deformity correction. For optimal outcome an exact preoperative planning is needed to ensure accurate timing of the procedure, especially when permanent epiphysiodesis techniques are used. Although epiphysiodesis and hemiepiphysiodesis around the pediatric knee are most frequently used and can be considered the gold standard treatment of coronal plane deformities and leg length discrepancies, novel techniques for the hip and ankle are increasingly being performed. The successful clinical results with low complications support the broad use of hemiepiphysiodesis and epiphysiodesis for a variety of indications in the growing skeleton with deformities and leg length differences.
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Ahn KS, Bae B, Jang WY, Lee JH, Oh S, Kim BH, Lee SW, Jung HW, Lee JW, Sung J, Jung KH, Kang CH, Lee SH. Assessment of rapidly advancing bone age during puberty on elbow radiographs using a deep neural network model. Eur Radiol 2021; 31:8947-8955. [PMID: 34115194 DOI: 10.1007/s00330-021-08096-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 05/10/2021] [Accepted: 05/25/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Bone age is considered an indicator for the diagnosis of precocious or delayed puberty and a predictor of adult height. We aimed to evaluate the performance of a deep neural network model in assessing rapidly advancing bone age during puberty using elbow radiographs. METHODS In all, 4437 anteroposterior and lateral pairs of elbow radiographs were obtained from pubertal individuals from two institutions to implement and validate a deep neural network model. The reference standard bone age was established by five trained researchers using the Sauvegrain method, a scoring system based on the shapes of the lateral condyle, trochlea, olecranon apophysis, and proximal radial epiphysis. A test set (n = 141) was obtained from an external institution. The differences between the assessment of the model and that of reviewers were compared. RESULTS The mean absolute difference (MAD) in bone age estimation between the model and reviewers was 0.15 years on internal validation. In the test set, the MAD between the model and the five experts ranged from 0.19 to 0.30 years. Compared with the reference standard, the MAD was 0.22 years. Interobserver agreement was excellent among reviewers (ICC: 0.99) and between the model and the reviewers (ICC: 0.98). In the subpart analysis, the olecranon apophysis exhibited the highest accuracy (74.5%), followed by the trochlea (73.7%), lateral condyle (73.7%), and radial epiphysis (63.1%). CONCLUSIONS Assessment of rapidly advancing bone age during puberty on elbow radiographs using our deep neural network model was similar to that of experts. KEY POINTS • Bone age during puberty is particularly important for patients with scoliosis or limb-length discrepancy to determine the phase of the disease, which influences the timing and method of surgery. • The commonly used hand radiographs-based methods have limitations in assessing bone age during puberty due to the less prominent morphological changes of the hand and wrist bones in this period. • A deep neural network model trained with elbow radiographs exhibited similar performance to human experts on estimating rapidly advancing bone age during puberty.
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Affiliation(s)
- Kyung-Sik Ahn
- Department of Radiology, Korea University Anam Hospital, Seoul, Republic of Korea
| | | | - Woo Young Jang
- Department of Orthopedic Surgery, Korea University Anam Hospital, 73, Goryeodae-ro, Seongbuk-gu, Seoul, 02841, Republic of Korea.
| | - Jin Hyuck Lee
- Department of Sports Medicine, Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Saelin Oh
- Department of Radiology, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Baek Hyun Kim
- Department of Radiology, Korea University Ansan Hospital, Gyeonggi-do, Republic of Korea
| | - Si Wook Lee
- Department of Orthopedic Surgery, Keimyung University, School of Medicine, Dongsan Medical Center, Daegu, Republic of Korea
| | - Hae Woon Jung
- Department of Pediatrics, Kyung Hee University Hospital, Seoul, Republic of Korea
| | | | | | | | - Chang Ho Kang
- Department of Radiology, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Soon Hyuck Lee
- Department of Orthopedic Surgery, Korea University Anam Hospital, 73, Goryeodae-ro, Seongbuk-gu, Seoul, 02841, Republic of Korea
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Cheng YH, Lee WC, Tsai YF, Kao HK, Yang WE, Chang CH. Tension band plates have greater risks of complications in temporary epiphysiodesis. J Child Orthop 2021; 15:106-113. [PMID: 34040656 PMCID: PMC8138785 DOI: 10.1302/1863-2548.15.200180] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE This study aimed to compare the efficacy of decreasing leg-length discrepancy (LLD) and postoperative complications between tension band plates (TBP) and percutaneous transphyseal screws (PETS). METHODS This retrospective study reviewed LLD patients who underwent temporary epiphysiodesis at the distal femur and/or proximal tibia from 2010 to 2017 (minimum two years follow-up). Efficacy of decreasing LLD was assessed one and two years postoperatively. Complications were classified with the modified Clavien-Dindo-Sink complication classification system. Knee deformities were assessed by percentile and zone of mechanical axis across the tibial plateau. RESULTS In total, 53 patients (25 boys, 28 girls) underwent temporary epiphysiodesis (mean age, 11.4 years). The efficacy of decreasing LLD at two years between the TBP (n = 38) and PETS (n = 15) groups was comparable. Seven grade III complications were recorded in six TBP patients and in one PETS patient who underwent revision surgeries for knee deformities and physis impingement. Four grade I and two grade II complications occurred in the TBP group. The mechanical axis of the leg shifted laterally in the PETS group and medially in the TBP groups (+7.1 percentile versus -4.2 percentile; p < 0.05). Shifting of the mechanical axis by two zones was noted medially in four TBP patients and laterally in two PETS patients. CONCLUSION More implant-related complications and revision surgeries for angular deformities were associated with TBP. A tendency of varus and valgus deformity after epiphysiodesis using TBP and PETS was observed, respectively. Patients and families should be informed of the risks and regular postoperative follow-up is recommended. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- You-Hung Cheng
- Department of Pediatric Orthopedics, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Wei-Chun Lee
- Department of Pediatric Orthopedics, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Yi-Feng Tsai
- Department of Pediatric Orthopedics, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Hsuan-Kai Kao
- Department of Pediatric Orthopedics, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Wen-E Yang
- Department of Pediatric Orthopedics, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Chia-Hsieh Chang
- Department of Pediatric Orthopedics, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan,Correspondence should be sent to Chia H. Chang, Department of Pediatric Orthopedics, Chang Gung Memorial Hospital, Chang Gung University. 5 Fushing Street, Kweishan Township, Taoyuan 333, Taiwan. E-mail:
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Willegger M, Schreiner M, Kolb A, Windhager R, Chiari C. Epiphysiodesis for the treatment of tall stature and leg length discrepancy. Wien Med Wochenschr 2021; 171:133-141. [PMID: 33738632 PMCID: PMC8016792 DOI: 10.1007/s10354-021-00828-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 02/10/2021] [Indexed: 12/14/2022]
Abstract
Painful orthopedic conditions associated with extreme tall stature and leg length discrepancy (LLD) include back pain and adopting bad posture. After failure of conservative treatment options, blocking of the growth plates (epiphysiodesis) around the knee emerged as gold standard in patients with tall stature and LLD in the growing skeleton. Surgical planning includes growth prediction and evaluation of bone age. Since growth prediction is associated with a certain potential error, adequate planning and timing of epiphysiodesis are the key for success of the treatment. LLD corrections up to 5 cm can be achieved, and predicted extreme tall stature can be limited. Percutaneous epiphysiodesis techniques are minimally invasive, safe and efficient methods with low complication rates. In general, a multidisciplinary approach should be pursued when treating children and adolescents with tall stature.
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Affiliation(s)
- Madeleine Willegger
- Department of Orthopedics and Trauma Surgery-Division for Orthopedics, Comprehensive Center for Pediatrics, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.,Vienna Bone and Growth Center, Vienna, Austria
| | - Markus Schreiner
- Department of Orthopedics and Trauma Surgery-Division for Orthopedics, Comprehensive Center for Pediatrics, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.,Vienna Bone and Growth Center, Vienna, Austria
| | - Alexander Kolb
- Department of Orthopedics and Trauma Surgery-Division for Orthopedics, Comprehensive Center for Pediatrics, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.,Vienna Bone and Growth Center, Vienna, Austria
| | - Reinhard Windhager
- Department of Orthopedics and Trauma Surgery-Division for Orthopedics, Comprehensive Center for Pediatrics, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.,Vienna Bone and Growth Center, Vienna, Austria
| | - Catharina Chiari
- Department of Orthopedics and Trauma Surgery-Division for Orthopedics, Comprehensive Center for Pediatrics, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria. .,Vienna Bone and Growth Center, Vienna, Austria.
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Naik P, Ganjwala D, Bhatt C, Vora KS. Usefulness of the Sauvegrain Method of Bone Age Assessment in Indian Children. Indian J Orthop 2020; 55:116-124. [PMID: 33569105 PMCID: PMC7851268 DOI: 10.1007/s43465-020-00189-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 06/25/2020] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Bone age estimation is very useful in children undergoing epiphysiodesis or guided growth surgery especially during the years of accelerated growth. It may be noted that no data are available on bone age estimation for Indian children of this age group. Sauvegrain (French) method is a very useful and simple method for bone age assessment during the years of accelerated growth. We decided to check the usefulness and the accuracy of the Sauvegrain method in Indian children. MATERIALS AND METHODS A team of two pediatric orthopaedic surgeons and a radiologist scored elbow X-rays of 80 healthy children (40 boys and 40 girls), using the Sauvegrain method twice. Interobserver reliability and intraobserver reproducibility of the Sauvegrain scoring were assessed. RESULTS There was a very strong correlation between all observers in both rounds (r = > 0.8) and an excellent reproducibility by the same observer in both rounds (r = 0.955). Chronological and bone age are considered the same if the difference between them is less than 6 months. With this criterion bone and chronological ages matched in > 37% of boys and girls, similar to the study done in French children. In the nonmatching group, more children had delayed bone age compared to their chronological age. CONCLUSION The Sauvegrain method of bone age assessment described for French children was found to be useful in estimating bone age in Indian children. It is especially helpful in the clinical practice for detecting mismatch between the chronological and the radiological age before undertaking guided growth or epiphysiodesis.
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Affiliation(s)
- Premal Naik
- Rainbow Superspeciality Hospital and Children’s Orthopaedic Centre, Next To Asia School, Behind HDFC Bank, Opposite Drive in Cinema Bodakdev, Ahmedabad, Gujarat 380054 India ,Smt S C L Hospital, Smt NHL Municipal Medical College, Ahmedabad, Gujarat India
| | - Dhren Ganjwala
- Ganjwala Orthopedic Hospital, 302, Anshi Avenue, Polytechnic, Ahmedabad, Gujarat 380015 India
| | - Chhaya Bhatt
- Smt NHL Municipal Medical College and Sardar Vallabhbhai Patel Institute of Medical Sciences & Research, Ahmedabad, Gujarat India
| | - Kranti Suresh Vora
- Indian Institute of Public Health Gandhinagar, Opp. Airforce quarters, Lekawada, Gandhinagar, Gujarat India ,University of Canberra, Bruce, Australia
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Shahrestani S, Makarov MR, Jo CH, Birch JG. Comparison of Moseley and Rotterdam straight-line graphs in predicting leg lengths and leg-length discrepancy at maturity. J Child Orthop 2019; 13:536-542. [PMID: 31695822 PMCID: PMC6808076 DOI: 10.1302/1863-2548.13.190086] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE One method of predicting leg-length discrepancy at maturity is the Moseley straight-line graph. Beumer et al developed an alternative graph, using a more modern Dutch population. The purpose of this study was to compare the prediction accuracy of these two graphs in a cohort of patients treated at our institution using epiphysiodesis. METHODS We identified 76 patients treated using epiphysiodesis for leg-length discrepancy who were followed to maturity and had adequate preoperative radiographic assessment for straight-line graph construction. We compared predicted long leg length (after epiphysiodesis), short leg length, and residual leg-length discrepancy to actual outcome for both methods, using both chronological and skeletal ages. RESULTS Both methods were more accurate using skeletal age rather than chronological age. The Rotterdam graph showed modest improved accuracy compared to the Moseley graph in developmental aetiologies and in Hispanic patients. Using a difference of one centimetre in prediction error as clinically relevant (long leg [after epiphysiodesis], short leg, and leg-length discrepancy in each of the 76 patients, 228 predictions), we found comparable predictions in 171, more accurate prediction using the Rotterdam in 32, and using the Moseley in 25 predictions. CONCLUSIONS Straight-line graphs provide a generally more accurate prediction of leg lengths at maturity by virtue of multiple preoperative evaluations. The Rotterdam straight-line graph was equal to or superior to the Moseley graph in most patients in this cohort. Use of skeletal age resulted in more accurate predictions than chronological age. Clinicians should remain familiar with the concept and use of the straight-line graph. LEVEL OF EVIDENCE III, case-control study.
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Affiliation(s)
- S. Shahrestani
- Texas Scottish Rite Hospital for Children, Dallas, Texas, USA
| | - M. R. Makarov
- Texas Scottish Rite Hospital for Children, Dallas, Texas, USA
| | - C.-H. Jo
- Texas Scottish Rite Hospital for Children, Dallas, Texas, USA
| | - J. G. Birch
- Texas Scottish Rite Hospital for Children, Dallas, Texas, USA,Correspondence should be sent to J. G. Birch, Texas Scottish Rite Hospital for Children, 2222 Welborn Street, Dallas, Texas 75219, USA. E-mail:
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Burger K, Farr S, Hahne J, Radler C, Ganger R. Long-term results and comparison of the Green-Anderson and multiplier growth prediction methods after permanent epiphysiodesis using Canale's technique. J Child Orthop 2019; 13:423-430. [PMID: 31489050 PMCID: PMC6701443 DOI: 10.1302/1863-2548.13.190024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE The aim of the study was to evaluate the accuracy and radiographic outcomes of Canale's method in patients with idiopathic leg-length discrepancy (LLD) following percutaneous epiphysiodesis. The accuracy of two common growth prediction methods was assessed. METHODS A total of 18 patients with 26 affected bones (eight distal femur, two proximal tibia, five combined) were clinically and radiologically analyzed after reaching skeletal maturity. We compared the final effect of epiphysiodesis at maturity with the expected effect of epiphysiodesis before surgery; these measures were calculated using the Green-Anderson and multiplier methods, respectively. We furthermore compared pre- and postoperative frontal and lateral plane radiographs. RESULTS The average LLD was 21.2 mm before surgery and 7.9 mm after epiphysiodesis. The final effect of both methods was not significantly different compared with the expected effect of epiphysiodesis before surgery. However, the prediction by the Green-Anderson method was closer to the definitive epiphysiodesis effect. The frontal plane radiographic deformity parameters did not change significantly after epiphysiodesis. The postoperative sagittal plane radiographic deformity parameters were in the normal range. CONCLUSION The Canale technique is a reliable method to reduce LLD in children. With regards to growth prediction, the Green-Anderson method using bone age seems to be more accurate than the multiplier method using chronological age. However, a relative over-estimation was observed with both methods in several cases, which might result in an insufficient correction. LEVEL OF EVIDENCE IV, Therapeutic study.
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Affiliation(s)
- K. Burger
- Orthopaedic Hospital Speising, Department of Pediatric Orthopaedics and Adult Foot and Ankle Surgery, Vienna, Austria
| | - S. Farr
- Orthopaedic Hospital Speising, Department of Pediatric Orthopaedics and Adult Foot and Ankle Surgery, Vienna, Austria,Correspondence should be sent to Sebastian Farr, Associate Professor of Orthopedic Surgery, Orthopaedic Hospital Speising, Department of Pediatric Orthopaedics and Adult Foot and Ankle Surgery, Speisingertrasse 109, A-1130, Vienna, Austria. E-mail:
| | - J. Hahne
- Orthopaedic Hospital Speising, Center of Excellence for Orthopedic Pain Management (CEOPS), Vienna, Austria
| | - C. Radler
- Orthopaedic Hospital Speising, Department of Pediatric Orthopaedics and Adult Foot and Ankle Surgery, Vienna, Austria
| | - R. Ganger
- Orthopaedic Hospital Speising, Department of Pediatric Orthopaedics and Adult Foot and Ankle Surgery, Vienna, Austria
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Abstract
PURPOSE Little data is available on the efficiency of different implants for epiphysiodesis. The purpose of this study is to compare the efficacy between plates and staples in decreasing leg-length discrepancy. METHODS A retrospective review of 19 children who underwent temporary epiphysiodesis of the legs was conducted, with a minimum of two years of follow-up. The bone length and length ratio to the short side were measured at six months, one year and two years postoperatively. The change in discrepancy was compared between staples and plates by an independent t-test, and the shortest time to a significant decrease in discrepancy was determined using a paired t-test. RESULTS Ten patients underwent 13 staple procedures in nine femurs and four tibias for a 2.8-cm discrepancy at age 11.8 years, and nine patients underwent 14 plate procedures in seven femurs and seven tibias for a 3.1-cm discrepancy at age 12.4 years. Patients were followed up to skeletal maturity, except two. The use of staples decreased the discrepancy in the bone ratio from +4.8% to +1.2% in two years, and the use of plates decreased this ratio from +5.1% to +3.3% in two years. The change in the length ratio was significantly greater after stapling. Six months were required after stapling before the first significant decrease in discrepancy; it took two years after plating. CONCLUSIONS This study showed a significantly lower efficacy for decreasing leg-length discrepancy by tension band plating. Orthopaedic surgeons should be aware of the limitations of using plates for suppressing bone growth. LEVEL OF EVIDENCE III.
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Affiliation(s)
- W.-C. Lee
- Department of Paediatric Orthopaedics, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - H.-K. Kao
- Department of Paediatric Orthopaedics, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - W.-E. Yang
- Department of Paediatric Orthopaedics, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - C.-H. Chang
- Department of Paediatric Orthopaedics, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan, Correspondence should be sent to Chia-Hsieh Chang, MD, Department of Pediatric Orthopedics, Chang Gung Memorial Hospital, 5 Fu-Hsin Street, Kueishan Area, Taoyuan City, Taiwan (333). E-mail:
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Aird JJ, Cheesman CL, Schade A.T, Monsell FP. Validation of the multiplier method for leg-length predictions on a large European cohort and an assessment of the effect of physiological age on predictions. J Child Orthop 2017; 11:71-76. [PMID: 28439312 PMCID: PMC5382340 DOI: 10.1302/1863-2548-11-160084] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE The Avon Longitudinal Study of Parents and Children (ALSPAC) prospective cohort was used to determine the accuracy of the Paley multiplier method for predicting leg length. Using menarche as a proxy, physiological age was then used to increase the accuracy of the multiplier. METHODS Chronological age was corrected in female patients over the age of eight years with documented date of first menses. Final sub-ischial leg length and predicted final leg length were predicted for all data points. RESULTS Good correlation was demonstrated between the Paley and ALSPAC data. The average error in prediction depended on the time of assessment, tending to improve as the child got older. It varied from 2.2 cm at the age of seven years to 1.8 cm at the age of 14 years. When chronological age was corrected, the accuracy of multiplier increased. Age correction of 50% improved multiplier predictions by up to 28%. CONCLUSION There appears to have been no significant change in growth trajectories of the two populations who were chronologically separated by 40 years. While the Paley data were based on extracting trends from averaged data, the ALSPAC dataset provides descriptive statistics from which it is possible to compare populations and assess the accuracy of the multiplier method. The data suggest that the accuracy improves as the patient gets close to the average skeletal maturity but that results need to be interpreted in conjunction with a radiological assessment of the growth plates. The magnitude of the errors in prediction suggest that when using the multiplier, the clinician must remain vigilant and prepared to perform a contralateral epiphyseodisis if the prediction proves to be wrong. The data suggest a relationship between the multiplier and menarche. There appears to be a factorisation and when accounting for physiological age, one needs to correct by 50% of the difference between chronological and physiological age.
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Affiliation(s)
- J. J. Aird
- Orthopaedic Department, Derriford Hospital Plymouth, PL6 8DH, UK,Correspondence should be sent to: James Aird, Derriford Hospital, Plymouth.
| | - C. L. Cheesman
- Orthopaedic Department, Royal Hospital for Children, Bristol, BS2 8BJUK
| | - A .T. Schade
- University of Bristol Medical School, Bristol, UK
| | - F. P. Monsell
- Orthopaedic Department, Bristol Royal Hospital for Children, Bristol, BS2 8BJ. UK
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Monier BC, Aronsson DD, Sun M. Percutaneous epiphysiodesis using transphyseal screws for limb-length discrepancies: high variability among growth predictor models. J Child Orthop 2015; 9:403-10. [PMID: 26423270 PMCID: PMC4619365 DOI: 10.1007/s11832-015-0687-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 09/05/2015] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Percutaneous epiphysiodesis using transphyseal screws (PETS) was developed as a minimally invasive outpatient procedure to address limb-length discrepancy (LLD) that allowed immediate postoperative weight bearing and was potentially reversible by removing the screws. The aims of our study were to report our results using PETS for LLD and evaluate the accuracy of three growth predictor models. METHODS Sixteen patients with an average age of 14 years were treated for LLD using PETS. Thirteen patients had screws inserted in a parallel fashion and 3 had crossed screws. We compared the predicted LLD at skeletal maturity using the three growth predictor methods with the actual LLD at skeletal maturity and preoperative LLD with the final LLD at skeletal maturity. RESULTS The mean LLD at skeletal maturity between the predicted and final measurements was 0.2 cm using the Green-Anderson method, 1.4 cm using the Moseley method, and -0.1 cm using the Paley method. The mean preoperative LLD of 3.1 cm was corrected to 1.7 cm at skeletal maturity (p < 0.001). Six patients complained of pain over the screw heads; however, no patient developed an infection or angular deformity. CONCLUSIONS The three growth predictor methods predicted the final LLD within an average of 1.4 cm, but there was high variability. Although PETS improved the LLD by a mean of 1.4 cm, we believe the results would have been better if PETS was performed at an earlier skeletal age.
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Affiliation(s)
- Bryan C Monier
- Department of Orthopaedics and Rehabilitation, University of Vermont College of Medicine, Robert T. Stafford Hall, 4th Floor, 95 Carrigan Drive, Burlington, VT, 05405-0084, USA.
| | - David D Aronsson
- Department of Orthopaedics and Rehabilitation, University of Vermont College of Medicine, Robert T. Stafford Hall, 4th Floor, 95 Carrigan Drive, Burlington, VT, 05405-0084, USA.
| | - Michael Sun
- University of Vermont College of Medicine, Office of the Dean, E-126 Given Building, 89 Beaumont Ave, Burlington, VT, 05405-0068, USA
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Lauge-Pedersen H, Hägglund G. Eight plate should not be used for treating leg length discrepancy. J Child Orthop 2013; 7:285-8. [PMID: 24432088 PMCID: PMC3799924 DOI: 10.1007/s11832-013-0506-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2013] [Accepted: 06/15/2013] [Indexed: 02/03/2023] Open
Abstract
PURPOSE The Blount staple has been widely used for treating angular deformities and leg length discrepancy (LLD) of the lower limbs. In recent years, the Eight plate has replaced the Blount staple for treating angular deformities in many centres. Although not described in the literature, it has been proposed that the Eight plate could also be used for treating LLD. We studied the effectiveness of the device for this indication. METHODS Ten patients with LLD were included prospectively. Medial and lateral plates were inserted for symmetrical growth reduction and the patients were followed by radiostereometric analysis (RSA) 0, 3, 6, 9, 12, 24, 52 and 80 weeks postoperatively. The error of measurement with this technique is less than 0.05 mm. RESULTS Case 1 continued to grow an average of 0.08 mm per week (6.7 mm longitudinal growth in 1.5 years) postoperatively, while Case 2 showed 0.07 mm longitudinal growth per week (5.6 mm longitudinal growth in 1.5 years). The longitudinal growth, in both children, showed only slight growth retardation throughout the follow-up period. The study was interrupted and no further subjects were included after the results indicated that only minor growth reduction had occurred in both patients. CONCLUSION The Eight plate does not significantly reduce growth when applied both medially and laterally in a symmetrical way at the proximal tibial physis.
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Affiliation(s)
| | - Gunnar Hägglund
- Department of Orthopaedics, University Hospital, 221 85 Lund, Sweden
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Guzman H, Yaszay B, Scott VP, Bastrom TP, Mubarak SJ. Early experience with medial femoral tension band plating in idiopathic genu valgum. J Child Orthop 2011; 5:11-7. [PMID: 21415941 PMCID: PMC3024485 DOI: 10.1007/s11832-010-0310-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2010] [Accepted: 11/22/2010] [Indexed: 02/03/2023] Open
Abstract
PURPOSE For correction of angular deformity, tension band plating has been proposed as a safe and minimally invasive technique. The purpose of this study was to assess the experiences and report the rate of correction obtained with this procedure in patients with idiopathic genu valgum. METHODS This study was a retrospective review of 47 valgus deformities of the knee treated with medial hemiepiphysiodesis using a tension band plate. The tibiofemoral angle (TFA) and the anatomic lateral distal femoral angle (aLDFA) were assessed on anteroposterior (AP) radiographs of the lower extremity taken at multiple time intervals. The values were charted to determine the change in orientation of the joint surface over time. Pearson's correlation was used to analyze the correction over time. A subanalysis was performed evaluating the effect of age and the number of plates utilized. RESULTS A total of 47 deformities in 25 patients were reviewed. The average time of follow-up from index surgery was 12.7 months, with an average correction of 0.96° every 3 months or 3.8° per year. The aLDFA corrected at a faster rate in knees with two plates per hemiepiphysiodesis than those with one plate, 4.2° and 3.3° per year, respectively (P = 0.035). Girls <11 years of age and boys <13 years of age corrected at a rate of 4.5°, while older children corrected at a rate of 3.4° per year (P = 0.39). There were no complications or instrumentation breakages. CONCLUSION Hemiepiphysiodesis with tension band plating provides an effective and predictable correction of idiopathic genu valgum. Two plates appear to provide a greater rate of correction. There is also a trend toward faster correction in younger patients as well.
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Affiliation(s)
- Humberto Guzman
- Department of Orthopedics, University of Puerto Rico, San Juan, PR USA
| | - Burt Yaszay
- Pediatric Orthopedics and Scoliosis, Rady Children’s Hospital, 3030 Children’s Way, Suite 410, San Diego, CA 92123 USA
| | - Vanessa P. Scott
- Pediatric Orthopedics and Scoliosis, Rady Children’s Hospital, 3030 Children’s Way, Suite 410, San Diego, CA 92123 USA
| | - Tracey P. Bastrom
- Pediatric Orthopedics and Scoliosis, Rady Children’s Hospital, 3030 Children’s Way, Suite 410, San Diego, CA 92123 USA
| | - Scott J. Mubarak
- Pediatric Orthopedics and Scoliosis, Rady Children’s Hospital, 3030 Children’s Way, Suite 410, San Diego, CA 92123 USA
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Possible mistakes in prediction of bone maturation in fibular hemimelia by Moseley chart. INTERNATIONAL ORTHOPAEDICS 2010; 35:755-9. [PMID: 20306192 DOI: 10.1007/s00264-010-0988-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2009] [Revised: 02/10/2010] [Accepted: 02/11/2010] [Indexed: 10/19/2022]
Abstract
The purpose of this study was to establish a nomogram in order to predict limb length discrepancies in children with unilateral fibular hemimelia more accurately. In 31 children with unilateral fibular hemimelia the femoral-tibial length and skeletal age were determined an average of seven times per case by sequential radiographs during growth. From the data, a skeletal age nomogram was developed which shows a steeply declining mean skeletal age pattern in unilateral fibular hemimelia (the slope in girls was -0.59 and in boys -0.64). This nomogram crosses the normal mean skeletal age line of the Moseley straight-line graph at 10.5 years in girls and at 12 years in boys, and continues to decline until maturity. The results demonstrate an abnormal skeletal maturation process in patients with unilateral fibular hemimelia. The consistently declining steep skeletal age nomogram in unilateral fibular hemimelia makes prediction of skeletal maturity and limb length discrepancy inaccurate by the standard predictive methods particularly when using early skeletal ages. The skeletal age nomogram from our data determines skeletal maturation in children with unilateral fibular hemimelia more accurately, and allows a correct prediction of limb length discrepancy.
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Kelly PM, Diméglio A. Lower-limb growth: how predictable are predictions? J Child Orthop 2008; 2:407-15. [PMID: 19308536 PMCID: PMC2656868 DOI: 10.1007/s11832-008-0119-8] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2008] [Accepted: 07/03/2008] [Indexed: 02/03/2023] Open
Abstract
PURPOSE The purpose of this review is to clarify the different methods of predictions for growth of the lower limb and to propose a simplified method to calculate the final limb deficit and the correct timing of epiphysiodesis. BACKGROUND Lower-limb growth is characterized by four different periods: antenatal growth (exponential); birth to 5 years (rapid growth); 5 years to puberty (stable growth); and puberty, which is the final growth spurt characterized by a rapid acceleration phase lasting 1 year followed by a more gradual deceleration phase lasting 1.5 years. The younger the child, the less precise is the prediction. Repeating measurements can increase the accuracy of predictions and those calculated at the beginning of puberty are the most accurate. The challenge is to reduce the margin of uncertainty. Confrontation of the different parameters-bone age, Tanner signs, annual growth velocity of the standing height, sub-ischial length and sitting height-is the most accurate method. Charts and diagrams are only models and templates. There are many mathematical equations in the literature; we must be able to step back from these rigid calculations because they are a false guarantee. The dynamic of growth needs a flexible approach. There are, however, some rules of thumb that may be helpful for different clinical scenarios. CALCULATION OF LIMB LENGTH DISCREPANCY For congenital malformations, at birth the limb length discrepancy must be multiplied by 5 to give the final limb length discrepancy. Multiple by 3 at 1 year of age; by 2 at 3 years in girls and 4 years in boys; by 1.5 at 7 years in girls and boys, by 1.2 at 9 years in girls and 11 years in boys and by 1.1 at the onset of puberty (11 years bone age for girls and 13 years bone age for boys). TIMING OF EPIPHYSIODESIS For the timing of epiphysiodesis, several simple principles must be observed to reduce the margin of error; strict and repeated measurements, rigorous analysis of the data obtained, perfect evaluation of bone age with elbow plus hand radiographs and confirmation with Tanner signs. The decision should always be taken at the beginning of puberty. A simple rule is that, at the beginning of puberty, there is an average of 5 cm growth remaining at the knee. There are four common different scenarios: (1) A 5-cm discrepancy-epiphysiodesis of both femur and tibia at the beginning of puberty (11 years bone age girls and 13 years in boys). (2) A 4-cm discrepancy-epiphysiodesis of femur and tibia 6 months after the onset of puberty (11 years 6 months bone age girls, 13 years 6 months bone age boys, tri-radiate cartilage open). (3) A 3-cm discrepancy-epiphysiodesis of femur only at the start of puberty, (skeletal age of 11 years in girls and 13 years in boys). (4) A 2-cm discrepancy-epiphysiodesis of femur only, 1 year after the start of puberty (12 years bone age girls and 14 years in boys).
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Affiliation(s)
- Paula M. Kelly
- Department of Paediatric Orthopaedic Surgery, CHU Lapeyronie, Montpellier, France
| | - Alain Diméglio
- Department of Paediatric Orthopaedic Surgery, CHU Lapeyronie, Montpellier, France
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Canavese F, Charles YP, Dimeglio A. Skeletal age assessment from elbow radiographs. Review of the literature. ACTA ACUST UNITED AC 2008; 92:1-6. [PMID: 18408902 DOI: 10.1007/s12306-008-0032-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2005] [Accepted: 11/27/2007] [Indexed: 11/25/2022]
Abstract
Skeletal age is important to evaluate remaining growth. In 50% of normal children and adolescents, skeletal age does not differ from chronological age. During puberty, skeletal age is an important tool when performing a lower limb epiphysiodesis or when treating (conservatively or surgically) patients with spinal deformities. Skeletal age alone is not enough and should be assessed together with other clinical and radiological findings such as standing and sitting heights, Risser sign, Tanner stages and annual growth rate. Puberty starts at 11 years of skeletal age and ends at 13 years of skeletal age in girls; in boys, puberty starts two years later (13 years of skeletal age) and then ends at a skeletal age of 15. Most current clinical and radiographic markers do not help paediatric orthopaedic surgeons to clearly distinguish maturity levels prior to Risser I. Sauvegrain et al. developed a method to assess skeletal age by using elbow radiographs (AP and lateral projections). Between 11 and 13 years of skeletal age in girls and between 13 and 15 years of skeletal age in boys, the olecranon apophysis is characterised by a clear morphological development. This method is a reliable tool to assess skeletal age during puberty because significant morphological changes in the elbow happen every six months.
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Affiliation(s)
- Federico Canavese
- Service de Chirurgie Orthopédique Pédiatrique, Hopital Lapeyronie-CHU Montpellier, 371, av. Du Doyen G. Giraud, F-34295, Montpellier, France.
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Abstract
The most common tumors of bone, osteosarcoma and Ewing sarcoma, commonly occur in the skeletally immature patient. Historically, amputation was the procedure of choice; however, improved oncologic outcome and technical advances in limb salvage surgery have made limb salvage therapy a feasible and valuable treatment option. Nevertheless, depending on the extent of the lesion within the long bone, it may be difficult to spare the physis, and hence, in the skeletally immature patient, resection of a sarcoma of bone can create a limb-length discrepancy and gait abnormalities. This article reviews the limb salvage options available for the skeletally immature patient who requires reconstruction of a segmental long bone defect.
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Affiliation(s)
- Valerae O Lewis
- University of Texas M.D. Anderson Cancer Center, Houston, TX 77230, USA.
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