Epiphyseal stapling: with special reference to complications

Guided Growth With Minifragment Plates for Angular Deformities in the Distal Radius in Skeletally Immature Patients. Preliminary Results

INTRODUCTION

Growth modulation allows correction of progressive ulnar deviation of the distal radius in skeletally immature patients, which may occur as a consequence of various pathologies. The aim of this study is to evaluate the radiographic results and complication rate in a series of patients treated with minifragment plates.

METHODS

The medical records of 12 patients who underwent guided growth with a minifragment plate on the radial aspect of the distal radius as a consequence of angular deformities in the distal radius were retrospectively reviewed. Demographic data, radiographic changes, and complication rate were analyzed.

RESULTS

A total of 14 wrists and forearms were evaluated. The mean age at which surgery was performed was 10.5 years (interquartile range: 9.0 to 11.3). The average time between placement and removal of the material was 28.7 months (SD: 8,89). In each case, a general improvement of the radiographic parameters was obtained. There were 3 postoperative complications, but only 1 of them required reintervention (broken metaphyseal screw).

CONCLUSIONS

Hemiepiphysiodesis using a minifragment plate is a treatment that respects the surgical anatomy and offers an alternative surgical option for angular deformities of the distal radius in children.

LEVEL OF EVIDENCE

Level IV.

Hemiepiphysiodesis for Idiopathic Genu Valgum: Percutaneous Transphyseal Screw Versus Tension-band Plate

BACKGROUND

The aim of this study was to compare the outcomes of angular deformity correction by percutaneous hemiepiphysiodesis using transphyseal screw (PETS) or tension-band plating (TBP) in growing children with idiopathic genu valgum with emphasis on the rate of deformity correction.

METHODS

We retrospectively reviewed cases of hemiepiphysiodesis for angular deformity in lower extremities between 2009 and 2014. A total of 90 limbs in 33 patients received PETS and 60 limbs in 24 patients received TBP. Angular measurements were compared preoperatively and at the time of hardware removal. The amount and rate of angular deformity correction were compared between the 2 groups. Potential factors affecting correction velocity were investigated using multivariate analysis.

RESULTS

Angular correction was achieved in all patients. The mean rate of correction was more rapid with PETS than with TBP at both the distal femur (0.92 vs. 0.64 deg./mo, respectively; P<0.001) and proximal tibia (0.72 vs. 0.55 deg./mo, respectively; P=0.019). Multivariate analysis showed that the used implant significantly affected the rate of correction: PETS demonstrated faster correction velocity than TBP (-0.26, 95% confidence interval, -0.35 to -0.17, P<0.001).

CONCLUSIONS

Both PETS and TBP techniques result in satisfactory correction of coronal angular deformity in patients with idiopathic genu valgum. However, the observed rate of correction was faster with PETS than TBP. Correction with PETS, rather than TBP, may better serve patients near skeletal maturity.

LEVEL OF EVIDENCE

Level III-retrospective comparative series.

Correction of coronal plane deformities around the knee using a tension band plate in children younger than 10 years

BACKGROUND

Guided growth through temporary hemiepiphysiodesis has gained acceptance as the preferred primary treatment in treating pediatric lower limb deformities as it is minimally invasive with a lesser morbidity than the traditional osteotomy. The tension band plate is the most recent development in implants used for temporary hemiepiphysiodesis. Our aim was to determine its safety and efficacy in correcting coronal plane deformities around the knee in children younger than 10 years.

MATERIALS AND METHODS

A total of 24 children under the age of 10 were operated for coronal plane deformities around the knee with a single extra periosteal tension band plate and two nonlocking screws. All the children had a pathological deformity for which a detailed preoperative work-up was carried out to ascertain the cause of the deformity and rule out physiological ones. The average age at hemiepiphysiodesis was 5 years 3 months (range: 2 years to 9 years 1 month).

RESULTS

The plates were inserted for an average of 15.625 months (range: 7 months to 29 months). All the patients showed improvement in the mechanical axis. Two patients showed partial correction. Two cases of screw loosening were observed. In the genu valgum group, the tibiofemoral angle improved from a preoperative mean of 19.89° valgus (range: 10° valgus to 40° valgus) to 5.72° valgus (range: 2° varus to 10° valgus). In patients with genu varum the tibiofemoral angle improved from a mean of 28.27° varus (range: 13° varus to 41° varus) to 1.59° valgus (range: 0-8° valgus).

CONCLUSION

Temporary hemiepiphysiodesis through the application of the tension band plate is an effective method to correct coronal plane deformities around the knee with minimal complications. Its ease and accuracy of insertion has extended the indication of temporary hemiepiphysiodesis to patients younger than 10 years and across a wide variety of diagnosis including pathological physis, which were traditionally out of the purview of guided growth.

Distal tibial physeal bridge: a complication from a tension band plate and screw construct. Report of a case

We report on a case of a tension band plate and screw construct (Eight Plate) used over the anterior distal tibia in an 9-year-old girl in an attempt to induce recurvatum of the ankle joint to correct a recalcitrant equinus deformity. With growth of the distal tibial physis, the epiphyseal screw was drawn through the physis into the distal tibial metaphysis, resulting in the creation of a transphyseal bony bar. Caution should be exercised when attempting temporary hemiepiphyseodesis using a plate and screw construct in small epiphyses or in an osteopenic bone.

Angular deformity correction by asymmetrical physeal suppression in growing children: stapling versus percutaneous transphyseal screw

PURPOSE

The aim of this study was to compare the outcomes of angular deformity correction by hemiepiphyseal stapling versus percutaneous hemiepiphysiodesis using transphyseal screw in growing children.

METHODS

Forty-three physes in 19 patients underwent hemiepiphyseal stapling, and 37 physes in 23 patients underwent percutaneous transphyseal screw placement. All cases were followed up to skeletal maturity or for more than 1 year after hardware removal. Amounts and rates of angular deformity correction, physeal behaviors after hardware removal, and postoperative courses were compared between the 2 groups.

RESULTS

The goal of angular correction was achieved in all except 2 patients, who reached skeletal maturity precociously. The mean rates of angular correction were not significantly different between the 2 groups, in both distal femur and proximal tibia. Hardware was removed before skeletal maturity from 56 physes. Angular change remained within 3 degrees for 43 physes (76.8%) at more than 1 year postoperatively, and the rebound phenomenon was observed in 12 (21.4%). No significant difference was observed between the 2 groups in terms of physeal behavior after hardware removal. Patients in the screw group were administered less postoperative pain medication, had shorter hospital stays, and smaller operation scars. In the stapling group, 1 case was complicated due to an extruded staple, and another case experienced premature physeal arrest at 1.5 years postoperatively. One case in the screw group experienced correction failure, probably because of a technical error during screw placement.

CONCLUSIONS

Hemiepiphysiodesis using percutaneous transphyseal screw is as effective as hemiepiphyseal stapling in terms of angular deformity correction. Furthermore, hemiepiphysiodesis using transphyseal screw has the advantage of being a minimally invasive procedure, and in this series, did not cause permanent physeal arrest.

LEVEL OF EVIDENCE

Level III.

Mechanical axis following staple epiphysiodesis for limb-length inequality

BACKGROUND

Staple epiphysiodesis is an option for the treatment of limb-length discrepancies, but it is not without complications. The purpose of this study was to review the outcomes of staple epiphysiodesis, including changes in the mechanical axis.

METHODS

The study included patients who underwent, between 1990 and 2005, staple epiphysiodesis of the femur or tibia, or both, to address limb-length discrepancy. We reviewed preoperative, postoperative, and final long standing anteroposterior radiographs of fifty-four patients to assess limb-length discrepancy, shifts in the mechanical axis, changes in the mechanical axis zone, and changes in the anatomic lateral distal femoral angle and the medial proximal tibial angle. Postoperative radiographs were also reviewed to assess the adequacy of staple placement.

RESULTS

Three staple epiphysiodesis groups were identified: fifteen patients who underwent a distal femoral staple epiphysiodesis, eighteen who underwent a proximal tibial procedure, and twenty-one who underwent combined distal femoral and proximal tibial procedures. Fifty percent (twenty-seven) of the fifty-four patients showed a shift in the mechanical axis of > or =1 cm as compared with the preoperative measurement. Eighty-nine percent of these large shifts were varus in nature. The proximal tibial and combined epiphysiodeses resulted in significantly larger shifts in the mechanical axis (p = 0.002 and p = 0.006, respectively) and zone changes (p = 0.009 and p = 0.006, respectively) than did the distal femoral procedures. Six patients ultimately underwent a high tibial osteotomy to correct a post-stapling varus deformity. The proximal-lateral aspect of the tibia was by far the most common location for inadequate staple placement.

CONCLUSIONS

Mechanical axis deviation is common following staple epiphysiodesis for the treatment of limb-length discrepancy. Proximal tibial and combined distal femoral and proximal tibial staple epiphysiodeses, even if done well technically, lead to clinically relevant shifts in the mechanical axis of the lower extremity more than half of the time. Distal femoral staple epiphysiodesis may still be a safe option for the treatment of limb-length discrepancy, but we advise caution when utilizing proximal tibial staple epiphysiodesis to treat limb-length inequality.

Electrical stimulation of the growth plate: A potential approach to an epiphysiodesis

Epiphysiodesis is an operative procedure that induces bony bridges to form across a growth plate of a bone to stop longitudinal growth. This is a very common orthopedic procedure to correct disproportional long-bone growth discrepancies; however, present techniques require an operation and anesthesia. Our study was designed to develop a minimally invasive method of epiphysiodesis by using electrical stimulation with DC current. In a rabbit model, a thin titanium electrode was inserted into a single location of the distal femoral growth plate in three groups: one without current (control), one group with a constant 10 microA (low current, LC), and one group with a 50 microA (high current, HC). The current was delivered for 2 weeks. The nontreated femur served as a control for each animal. Femur lengths were measured and comparisons were made between operated (left) and nonoperated (right) femurs. Digitized histomorphometric and volumetric analyses were performed on each growth plate, and detailed assessments were made of any morphological changes. Using length measurements, the difference in femur length was significantly larger in the HC group and not in the LC or control groups, showing bone growth inhibition at the higher current. In the HC group, bony bridges and disorganized growth plates were observed. This study shows that delivery of an electrical current of 50 microA for as little as 2 weeks can markedly affect bone growth as evidenced by changes in epiphyseal plate volume and architectural organization, and the study supports the use of this minimally invasive approach as a potential method of achieving an epiphysiodesis.

Hemiepiphysiodesis around the knee by percutaneously guided and grooved staple

One option for correcting angular deformities around the knee is hemiepiphyseal stapling. We have invented a percutaneously guided grooved staple which allows placing of the staple exactly, with a minimal incision and little surgical time. We used this technique on five children (16 bones). The deformities were fully corrected in all except one patient in whom staples were used to postpone definitive surgery until skeletal maturity. The mean time of surgery per physis was 7 min (range, 4-13 min). Less than 10 min was required to insert each staple. Using grooved staples allowed the surgeon to perform hemiepiphysiodesis efficiently and precisely.

Limb-length inequality: assessment and treatment options

Assessment and treatment of limb-length inequality, particularly in the growing child, is a challenging task. Evaluation of the discrepancy requires an understanding of the significance of the disparity, as well as the natural history of the disorder, before formulation of a treatment plan. In the immature patient, consistent longitudinal data are essential to avoid pitfalls in the projection of ultimate length difference. Therapeutic options range from no treatment or use of a simple shoe lift to a surgical shortening or lengthening procedure. The current indication for lengthening is a disparity exceeding 5 to 6 cm. Epiphysiodesis or femoral shortening is useful for smaller discrepancies or for residual differences following a contralateral lengthening. Lengthening is done with a circular or cantilever external fixator, which may be combined with an intramedullary rod.