Tension band plating is less effective in achieving equalization of leg length

Staples, tension-band plates, and percutaneous epiphysiodesis screws used for leg-length discrepancy treatment: a systematic review and proportional meta-analysis

BACKGROUND AND PURPOSE

The primary aim of this systematic review and meta-analysis was to evaluate the success rate of 3 different epiphysiodesis techniques with implant usage for the treatment of leg-length discrepancy (LLD) in the pediatric population. The secondary aim was to address effectiveness (final LLD) and the reported complications of staples, tension-band plates (TBP), and percutaneous epiphysiodesis screws (PETS).

METHODS

In this systematic review 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-/postoperatively, successful/unsuccessful) and complications that were graded on severity.

RESULTS

44 studies (2,184 patients) were included. 455 underwent epiphysiodesis with PETS, 578 patients with TBP, and 1,048 with staples. Successful epiphysiodesis was reported in 76% (95% confidence interval [CI] 61-89) with PETS (9 studies), 67% (CI 54-79) with TBP (10 studies), and 51% (CI 28-65) with Blount staples (8 studies). From pooled analysis, the severe complications rate was 7% for PETS, 17% for TBP, and 16% for Blount staples. Angular deformity was reported in 4% after PETS, 10% after TBP, and 17% after Blount staples.

CONCLUSION

Our results showed that epiphysiodesis with PETS implants was the most successful technique. PETS had a higher success rate, fewer severe complications, and a lower proportion with angular deformity.

The Influence of Temporary Epiphysiodesis of the Proximal End of the Tibia on the Shape of the Knee Joint in Children Treated for Leg Length Discrepancy

Background: Leg length discrepancy (LLD) is a common problem in the daily clinical practice of pediatric orthopedists. Surgical treatment using LLD temporary epiphysiodesis with eight-plate implants is a minimally invasive, safe, and well-tolerated procedure that provides good treatment effects with a relatively low percentage of complications. The main aim of this retrospective study was to determine the effect of epiphysiodesis on the shape of the proximal tibia. Methods: The retrospective study was based on medical records from 2010 to 2019. Radiographs taken before the epiphysiodesis and at 6-month intervals until the end of the treatment were investigated. A total of 60 patients treated for LLD were included in the study (24 girls, 36 boys). They were divided into three groups depending on the duration of the LLD treatment: group I (18 months), group II (30 months), and group III (42 months of treatment). Radiological parameters were assessed, including the roof angle (D), the slope angles (α and β), and the specific parameters of the tibial epiphysis, namely LTH (lateral tubercle height), MTH (medial tubercle height), and TW (tibial width). Results: The roof angle decreased in all the groups, which was accompanied by an increase in the β or α angle. LTH, MTH and TW also increased, and the differences before and after the treatment for the treated legs were statistically significant in all the studied groups. The greatest change in the shape of the articular surface of the proximal tibia occurred after 42 months of treatment. Conclusions: The study showed that epiphysiodesis affects the proximal tibial articular surface over prolonged treatment. Thus, there is a need for future long-term follow-up studies to elucidate the potential effects of LLD egalization.

The efficacy of two-hole tension band plates in the treatment of lower extremity limb length discrepancy

The main purpose of our study was to investigate the efficacy of dual two-hole tension band plates in the treatment of lower extremity limb length discrepancy (LLD). We retrospectively reviewed patients who underwent epiphysiodesis utilizing dual two-hole tension band plates due to lower extremity LLD between January 2012 and June 2018. The efficacy of epiphysiodesis was defined as the inhibited percentage of the expected growth of the physis between two time intervals and was calculated between 0-6 months and 6-18 months as the primary outcome. The relationship of efficacy of epiphysiodesis with time intervals, bone segments, physeal coverage percentage by the screws, age and interscrew angle and physeal health was also assessed. A total of 11 patients' 17 bone segments (9 femurs and 8 tibias) with a mean age of 8.7 ± 2.3 were included. The mean efficacy of the epiphysiodesis in the first 6 months for femurs was 23 ± 20 % (range, 0-53%) and for tibias was 21 ± 19 % (range, 0-53%); between 6 and 18 months it was 27 ± 19 % (range, 0-56%) for femurs and 15 ± 19 % (range, 0-50%) for tibias. In the first 6 months, physeal coverage percentage by the screws (r = 0.503, P = 0.04) and age (r = -0.534, P = 0.027) had a strong correlation with the epiphysiodesis efficacy. Dual two-hole tension band plating has variable efficacy in the treatment of LLD. Age and physeal coverage percentage by the screws could be related to epiphysiodesis efficacy.

Tension band plates have greater risks of complications in temporary epiphysiodesis

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.

What's New in Pediatric Limb Lengthening and Deformity Correction?

Over the past 5 years, published literature regarding treatment of pediatric limb deformity and limb length discrepancy demonstrates much interest in better understanding, categorizing and treating these challenging problems. Many studies explore expanding and refining indications for traditional treatment methods like guided growth techniques. Other studies have evaluated the results of new techniques such as lengthening via mechanized intramedullary nails. Additionally, series comparing older and newer techniques such as lengthening with external devices versus mechanized nails are becoming increasingly available.