The single portal percutaneous epiphysiodesis technique for treatment of leg length inequality stops growth as expected

Are percutaneous epiphysiodesis and Phemister technique effective in the treatment of leg-length discrepancy? A systematic review

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).

Angular deformities after percutaneous epiphysiodesis for leg length discrepancy

PURPOSE

The purpose of this study was to systematically analyze the presence of secondary angular deformities after percutaneous epiphysiodesis based on long-standing radiographs, and to see if the occurrence and magnitude of angular deformities after percutaneous epiphysiodesis correlated with the amount of remaining growth at the time of surgery.

METHODS

From a local Health Register consisting of patients investigated using the Moseley Straight-Line Graph, we identified 269 patients who had undergone percutaneous epiphysiodesis from 2002 until 2020. Radiographic analysis included the measurement of mechanical axis and joint orientation angles on long-standing anterior-posterior radiographs. Remaining growth was analyzed based on the Menelaus method.

RESULTS

One hundred and forty epiphysiodeses (71 femurs and 69 tibiae) in 88 patients (39 girls and 49 boys) could be included in the study. Mean age at surgery was 13.2 (10-16.8) years, and mean skeletal age at surgery was 13.0 (9.8-15.7) years. A change of the MA (Mechanical axis) ≥10 mm was found in eight patients (9%). Secondary frontal plane deformities after percutaneous epiphysiodesis correlated significantly with the remaining growth at the time of surgery (p = 0.003).

CONCLUSION

We found a high rate of secondary angular deformities after percutaneous epiphysiodesis, and the magnitude of the deformities correlated with the amount of remaining growth at the time of surgery. A modification of the original surgical method for percutaneous epiphysiodesis to also include ablation of central parts of the growth plate might be considered. Patients should be enrolled in a systematic follow-up scheme which allows for the early detection of possible angular deformities.

LEVEL OF EVIDENCE

level III study.