Guided Growth Technique Research Articles

Guided growth with tension band plate or definitive epiphysiodesis for treatment of limb length discrepancy?

BackgroundIt is not exactly known whether guided growth or definitive epiphysiodesis techniques are superior in treating limb length discrepancy (LLD). The purpose of the present study was therefore to find out if definitive epiphysiodesis is associated with more powerful LLD correction than tension band plate epiphysiodesis.MethodsPediatric patients with LLD treated either with tension band plating as a guided growth technique (temporary epiphysiodesis) or a percutaneous drilling technique (definitive epiphysiodesis) around the knee and a minimum follow-up of 12 months were included in this retrospective study. Radiographic measurements were performed by two independent reviewers. The reduction in side difference between preoperative radiographs and last follow-up was calculated and compared between surgical techniques.ResultsThirty-eight patients (mean age 13.6 years) were included, 17 treated with temporary and 21 with definitive epiphysiodesis. Average follow-up was at 578 days. The reduction of the LLD in 12 months was 5.7 mm in patients treated with temporary epiphysiodesis and 8.4 mm with definitive epiphysiodesis, respectively (p = 0.22). In both groups, LLD could be statistically significantly reduced after 12 and 24 months. Definitive epiphysiodesis had a lower revision rate (4.8% vs. 17.6%). Intra- and interobserver reliability of the measurements was excellent.ConclusionsAs in earlier studies supposed, temporary epiphysiodesis with tension band plating seems to correct LLD less powerful compared to definitive percutaneous epiphysiodesis. However, in the present study, the differences of LLD correction were not statistically significant. We do not recommend the use of tension band plates for LLD correction due to inferior correction with higher complication and revision rate.

Orthopaedic Management of Leg-length Discrepancy in Proteus Syndrome: A Case Series.

Proteus syndrome (PS) is a rare mosaic disorder comprising asymmetric bony and soft tissue overgrowth leading to significant morbidity. Placement of growth inhibition hardware with subsequent epiphyseal arrest improves leg-length and angular deformities in pediatric patients without PS. The purpose of this study was to review the surgical approach and present outcomes, complications, and recommendations in 8 patients with PS and leg-length discrepancy (LLD). We conducted a retrospective chart review of 8 patients with PS whose primary reason for surgery was LLD. Patients were eligible if they met clinical diagnostic criteria for PS and if the National Institutes of Health team performed at least 1 of their surgical interventions between 2005 and 2015. Surgical techniques included growth inhibition, with tension band plates, applied ≥1 times, and epiphyseal arrest. Eight patients, followed for an average of 4.6 years (range, 1.0 to 7.1 y) after the index procedure, were included in this analysis. Average age at first LLD surgery was 9.4 years (range, 6.1 to 13.6 y); the average LLD was 3.4 cm (range, 0.4 to 7.0 cm) at presentation, and 5.0 cm (range, 1.8 to 10.0 cm) at the time of the first LLD surgery. Participants underwent 23 total surgeries (range, 1 to 5 per patient) and 7 patients have completed surgical intervention. For the 7 patients who did not require overcorrection the average LLD at the last clinical encounter was 2.6 cm (range, 0.6 to 7.2 cm). We encountered 2 complications: 2 patients developed mild knee valgus, which responded to standard guided growth techniques. This case series suggests that growth inhibition and epiphyseal arrest in children with PS can reduce LLD with few complications. Careful monitoring, rapid mobilization, deep venous thrombosis prophylaxis, and sequential compression devices were also integral elements of our surgical protocol. Level IV.

The Using of "Guided Growth" for Correction of Coronal Deformities around the Knee in Skeletally Immature Children (Systematic review and Metaanalysis)

Introduction: Angular deformities of the lower limbs are common during childhood. The concept of guided growth using a tension band plate is a breakthrough in the surgical correction of angular deformities. This approach has yielded satisfactory results and has low complication rates. Patients and methods: We reviewed 210 papers with overall 433 patients and 809 deformities. Inclusion criteria included papers published from 2010 to 2017 in English literature. A Meta-analysis was done on 16 papers with seven outcomes: Change in mechanical axis deviation, Tibiofemoral angle, rate of excellent outcomes, implant breakage, implant migration, inadequate reduction and rebound phenomenon. Results: Thirty two studies were included. Fifteen of them studied treatment of angular deformities by guided growth, three of them discussed the complications of using guided growth and five studies discussed Biomechanics of using guided growth. Sixteen studies were included in our cumulative meta-analysis. Conclusion: Guided growth is effective in treating coronal deformities around the knee in skeletally immature children wither the cause was idiopathic or pathological. There is no limitation except if physeal bar is developed or the patient near maturity. Few complications are associated with guided growth techniques including rebound phenomenon, inadequate reduction, implant breakage and implant migration. Level of Evidence: 3 (systematic review of type 1, 2, 3 studies).

Guided Growth: Current Perspectives and Future Challenges.

* Guided growth by tethering part of the growth plate is an established technique for the correction of frontal angular deformities about the knee in children.* A better understanding of the underlying conditions, factors affecting longitudinal growth, and mechanism of response of the growth plate to retardation forces could lead to improvement and expansion of this technique to other sites and indications.* This review article highlights areas of future research and outlines the possible future of guided growth techniques.

Orthopaedic management of leg length discrepancy in Proteus syndrome: a case series

Introduction Proteus syndrome (PS) is a rare mosaic disorder comprising asymmetric bony and soft tissue overgrowth leading to significant morbidity. Placement of growth inhibition hardware with subsequent epiphyseal arrest improves leg-length and angular deformities in pediatric patients without PS. The purpose of this study was to review the surgical approach and present outcomes, complications, and recommendations in 8 patients with PS and leg-length discrepancy (LLD). Methods We conducted a retrospective chart review of 8 patients with PS whose primary reason for surgery was LLD. Patients were eligible if they met clinical diagnostic criteria for PS and if the National Institutes of Health team performed at least 1 of their surgical interventions between 2005 and 2015. Surgical techniques included growth inhibition, with tension band plates, applied ≥1 times, and epiphyseal arrest. Results Eight patients, followed for an average of 4.6 years (range, 1.0 to 7.1 y) after the index procedure, were included in this analysis. Average age at first LLD surgery was 9.4 years (range, 6.1 to 13.6 y); the average LLD was 3.4 cm (range, 0.4 to 7.0 cm) at presentation, and 5.0 cm (range, 1.8 to 10.0 cm) at the time of the first LLD surgery. Participants underwent 23 total surgeries (range, 1 to 5 per patient) and 7 patients have completed surgical intervention. For the 7 patients who did not require overcorrection the average LLD at the last clinical encounter was 2.6 cm (range, 0.6 to 7.2 cm). We encountered 2 complications: 2 patients developed mild knee valgus, which responded to standard guided growth techniques. Conclusions This case series suggests that growth inhibition and epiphyseal arrest in children with PS can reduce LLD with few complications. Careful monitoring, rapid mobilization, deep venous thrombosis prophylaxis, and sequential compression devices were also integral elements of our surgical protocol. Level of evidence Level IV.

Correction of lower limb deformities in children with renal osteodystrophy by guided growth technique.

PurposeRenal osteodystrophy (ROD) may cause severe lower limb deformities in children. The purpose of this study is to evaluate the efficacy of the temporary hemiepiphysiodesis for the correction of lower limb deformities in children with ROD.MethodsGuided growth correction by hemiepiphysiodesis has been performed in skeletally immature patients with deformities of the lower limbs caused by ROD. The correction of the mechanical axes of the lower limbs and its correction speed have been evaluated.ResultsA total of seven patients with ROD, five males and two females, were treated with the above technique. The average age of the patients at their first surgery was 7.8 years (2.9 to 13.6). The average follow-up time 5.2 years (2.3 to 8). There were 13 valgus deformities and one varus deformity of the knee. The measure of the lower limb angular deformity was in the range of 10° to 47°. Restoration of normal mechanical axis was achieved in all patients at the final follow-up. Three patients relapsed and required further hemiepiphysiodesis. The average time for correction was 20 months (7 to 30). The average speed of correction was 0.49° per month for a tibia and 1.73° per month for a femur. There were two minor complications: a screw mobilisation and a screw breakage occurred during removal.ConclusionGuided growth technique by hemiepiphysiodesis is a mini-invasive surgical procedure that has been found to be effective for the correction of misalignment due to ROD in skeletally immature patients. The method has allowed progressive correction of the deformities at any age in childhood. These patients are predisposed to relapse to their deformities, thus a strict follow-up is required.

Lower limbs deformities in patients with McCune-Albright syndrome: Tomography and treatment.

The skeletal changes in McCune-Albright disease are usually severe because of the polyostotic form of the disease. Trendelenberg gait and limited mobility are the most common presenting features. The constellation of Café-au lait spots and polyostotic bone involvement is commonly referred to as McCune-Albright's syndrome (MAS). One boy and 4 girls (7-16 years) were sought in our departments from 1998 to 2012. Limb length discrepancy was the main clinical presentation. Repetitive micro-fractures caused the development of 'Shepherd crook' deformity with pain were the main burden. Because of the repetitive micro-fractures and the significant deformity that distorted the integrity of the long bones which were associated with pain. We referred to re-alignment valgus osteotomy with internal fixation to preserve proper alignment. Moreover, guided growth technique with 8-plates was performed in 1 case. Tendency to progressive unilateral lower limb deformity in patients with MAS is usually associated with thinning and expansion of the cortex and distortion of the normal lower limb integrity secondary to repetitive micro-fractures. The latter is a situation which warrants surgical treatment to re-align the deformity and to preserve function. Prophylactic intramedullary nailing via the application of locking nails to ensure stabilisation of the femoral neck was found to be effective. However, nevertheless, the mosaic nature of MAS means any cell, tissue and organ in any site of the body could be affected to varying degrees. The clinical manifestations are a diversity of the disorder ranging from mild clinical signs to severe life-threatening disease.

Contemporary Medical and Surgical Management of X-linked Hypophosphatemic Rickets.

X-linked hypophosphatemia is an inheritable disorder of renal phosphate wasting that clinically manifests with rachitic bone pathology. X-linked hypophosphatemia is frequently misdiagnosed and mismanaged. Optimized medical therapy is the cornerstone of treatment. Even with ideal medical management, progressive bony deformity may develop in some children and adults. Medical treatment is paramount to the success of orthopaedic surgical procedures in both children and adults with X-linked hypophosphatemia. Successful correction of complex, multiapical bone deformities found in patients with X-linked hypophosphatemia is possible with careful surgical planning and exacting surgical technique. Multiple methods of deformity correction are used, including acute and gradual correction. Treatment of some pediatric bony deformity with guided growth techniques may be possible.

Complex orthopaedic management of patients with skeletal dysplasias

Skeletal dysplasias are challenging for diagnostics and treatment. We present a series of fifteen patients with different forms of skeletal dysplasias with age ranged from 6 to 17 years with variable clinical presentations managed as a part of the project of scientific cooperation between Turner Paediatric Orthopaedic Institute and Orthopaedic Hospital Vienna-Speising. The spectrum of diagnoses included multiple epiphyseal dysplasia, spondyloepiphyseal dysplasia congenita, diastrophic dysplasia, metaphyseal dysplasia, spondylometaphyseal dysplasia, Stickler syndrome, Kniest dysplasia, and anauxetic dysplasia. Complex treatment, which included axial correction and juxta-articular realignment, was performed as a single-stage, or consecutive surgery. Surgical techniques included corrective osteotomies with internal fixation, guided growth technique and external fixation devices. Best results (full axial correction, normal alignment of the joint) were achieved in 8 patients, including 2 patients with metaphyseal dysplasia, 2 patients with multiple epyphyseal dysplasia, 2 patients with spondyloepyphyseal dysplasia, patient with Stickler syndrome and patient with spondylometaphyseal dysplasia. Good results (partial correction at the present time) were seen in 4 patients (2 patients with Kniest dysplasia, 1 - with multiple epyphyseal dysplasia and 1 - with anauxetic dysplasia). Satisfactory results (non-progressive condition in previous progression) were obtained in 2 patients with diastrophic dysplasia, and poor results (progression of the deformity) - in 1 patient with diastrophic dysplasia. Positive results in most of the cases of our series make promising future for usage of complex approach for orthopedic management of children with skeletal dysplasias; advanced international cooperation is productive and helpful for diagnostics and management of rare diseases.

Guided Growth Technique for Correction of Lower Extremity Deformities in Children

Guided growth technique with temporary epiphysiodesis is used for the correction of lower extremities axial deformities in children before skeletal maturity. From 2009 to 2013 one hundred fifty epiphysiodesis procedures were performed in 93 children aged 3–15 years. Technique was performed both in patients with idiopathic deformities and in patients with severe systemic pathology (skeletal dysplasias, neuromuscular disorders, metabolic nephropathies). Treatment results were assessed at terms from 12 to 48 months after surgical intervention. Good results were achieved in 67 (72%), satisfactory — in 18 (19.3) and poor — in 8 (8.6%) patients. Mean rate of correction made up 0.81±0.17° per 1 month of epiphyseodesis with its maximum in valgus knee and ankle deformities. Advantages of the procedure included low invasiveness and simplicity of performance, low complication rate, possibility of simultaneous intervention on several levels as well as combination with other interventions. Thorough selection of patients, proper intervention technique and regular postoperative followup enable to avoid complications and unsatisfactory results.

Guided Growth of the Proximal Femur

The concept of guided growth has been used for decades in the lower extremities of children, but has not been applied to correct varus or valgus deformity in the hip, such as those that occur in children with cerebral palsy or developmental dysplasia of the hip. The purpose of this study is to determine whether guided growth techniques are effective at altering the morphology of the proximal femur in a lamb model. Ten, 2-month-old mixed-breed male lambs underwent hemiepiphyseal drilling and screw placement. Drilling occurred eccentrically (inferiorly) in an attempt to close only a portion of the growth plate. In 5 lambs, a sham surgery was performed in which the screw did not cross the proximal femoral physis. Growth was compared between groups and with the opposite hip in which no procedure was performed in both groups. Standardized radiographs were obtained preoperatively and monthly. A 3-dimensional computed tomography scan and standard histology were obtained postnecropsy. Version and neck shaft angle (NSA) was determined and recorded at the time of the index procedure with the aid of fluoroscopy. Radiographs were assessed by measurement of the NSA and the articular trochanteric distance (ATD). Results were compared by using the t test: paired 2 sample for means. The NSA and ATD were compared preoperatively and at a mean of 3.3 months after surgery. They were no significant differences preoperatively between the screw or sham group. Postoperatively, the NSA was 132 versus 143 (P=0.006) and the ATD -0.6 mm versus 10 mm (P=0.033) for the screw and sham hips, respectively. The sham group showed no statistical differences between the operative and nonoperative sides postoperatively, although the ATD trended toward a larger number on the "sham" side, possibly because of a growth stimulation effect. Screw hemiepiphysiodesis seems to alter the growth of the proximal femur in the lamb model. Further studies are ongoing and with more research this technique could be used to correct or prevent proximal femoral deformity in the growing child. Level II.

Correcting genu varum and genu valgum in children by guided growth

A total of 25 children (37 legs and 51 segments) with coronal plane deformities around the knee were treated with the extraperiosteal application of a flexible two-hole plate and screws. The mean age was 11.6 years (5.5 to 14.9), the median angle of deformity treated was 8.3 degrees and mean time for correction was 16.1 months (7 to 37.3). There was a mean rate of correction of 0.7 degrees per month in the femur (0.3 degrees to 1.5 degrees ), 0.5 degrees per month in the tibia (0.1 degrees to 0.9 degrees ) and 1.2 degrees per month (0.1 degrees to 2.2 degrees ) if femur and tibia were treated concurrently. Correction was faster if the child was under 10 years of age (p = 0.05). The patients were reviewed between six and 32 months after plate removal. One child had a rebound deformity but no permanent physeal tethers were encountered. The guided growth technique, as performed using a flexible titanium plate, is simple and safe for treating periarticular deformities of the leg.