Epiphysiodesis

Epiphysiodesis is a pediatric orthopedic surgery procedure that aims at altering or stopping the bone growth naturally occurring through the growth plate also known as the physeal plate. There are two types of epiphysiodesis: temporary hemiepiphysiodesis and permanent epiphysiodesis. Temporary hemiepiphysiodesis is also known as guided growth surgery or growth modulation surgery. Temporary hemiepiphysiodesis is reversible i.e. the metal implants used to achieve epiphysiodesis can be removed after the desired correction is achieved and the growth plate can thus resume its normal growth and function. In contrast, permanent epiphysiodesis is irreversible and the growth plate function cannot be restored after surgery. Both temporary hemiepiphysiodesis and permanent epiphysiodesis are used to treat a diverse array of pediatric orthopedic disorders but the exact indications for each procedure are different.

Epiphysiodesis
ICD-9-CM78.2

Guided growth temporary hemiepiphysiodesis

Temporary hemiepiphysiodesis is widely used to treat angular or coronal plane deformities around the knee in children i.e. deformities occurring in the medial/lateral plane as genu varum/ genu valgum. Additionally, it has been used to treat sagittal plane deformities i.e. deformities arising the anterior/posterior plane. Temporary hemiepiphysiodesis has also been used to treat deformities around the hips and ankles[1][2][3] and in the upper extremity growth plates such as the distal radius growth plate.[4] Temporary hemiepiphysiodesis works through arresting or inhibiting the physeal growth at one hemi-side of the growth plate. In consequence the other hemi-side is allowed to grow normally and unhindered. This process occurs gradually and steadily and eventually leads to correction of the angular deformity in most cases. Temporary hemiepiphysiodesis or guided growth surgery has been used to treat angular deformities in children with diverse bone and joint disorders such as rickets,[5] Blount's disease,[6][7] osteochondrodysplasias,[8] arthrogryposis multiplex congenita,[9] idiopathic, trauma,[10] and renal osteodystrophy[11] among others. Temporary hemiepiphysiodesis is increasingly been viewed as more simple and efficient alternative to the classic time-honored osteotomy or bone cutting practice. Bone osteotomy achieve deformity correction immediately while temporary hemiepiphysiodesis does so gradually. A variety of metal implants have been used to perform temporary hemiepiphysiodesis or guided growth surgery as a two-hole plate and screws and staples. Figure 1 Any metal implant originally used to achieve temporary hemiepiphysiodesis should be removed once the intended deformity correction is reached. Otherwise the child will go into the reverse deformity, a phenomenon known as overcorrection. For example, failure to remove the metal implant in due time for a child that was being treated for a genu varum can result in overcorrection to a genu valgum deformity and vice versa.

Outcome and complications

Generally, the results of temporary hemiepiphysiodesis or guided growth surgery are satisfactory. In contrast to osteotomy or external fixation correction, it is considered as a less traumatic and safe surgical method. The complications are of low profile in terms of severity and frequency generally.[2][5] Yet, there are concerns about the use of temporary hemiepiphysiodesis in certain diseases as Blount's disease and osteochondrodysplasias. Mechanical failure of the metal implant as plate and screws and failure to achieve full correction of the deformity has been closely associated with the Blount's disease.[6][7] Additionally, recurrence of bone deformity or rebound phenomenon and subsequent repeated surgeries has been closely linked to bone deformities arising from osteochondrodysplasias. Generally, children should be followed up for deformity recurrence or rebound after removal of the metal implant used to achieve deformity correction.[8]

Permanent epiphysiodesis

Outcome and complications

The procedure must be performed for an appropriate duration during the patient's adolescent growth phase so that the limbs are near-equal in length by the end of skeletal growth. Poor timing can lead to a length mismatch, resulting in poor outcomes and significant patient morbidity.

References
  1. Journeau, Pierre (2020). "Update on guided growth concepts around the knee in children". Orthopaedics & Traumatology: Surgery & Research. 106 (1S): S171–S180. doi:10.1016/j.otsr.2019.04.025. PMID 31669550.
  2. Yang, Irene; Gottliebsen, Martin; Martinkevich, Polina; Schindeler, Aaron; Little, David G. (November 2017). "Guided growth: Current perspectives and future challenges". JBJS Reviews. 5 (11): e1. doi:10.2106/JBJS.RVW.16.00115. PMID 29112518. S2CID 30704556.
  3. Bouchard, Maryse (September 2017). "Guided Growth: Novel Applications in the Hip, Knee, and Ankle". Journal of Pediatric Orthopaedics. 37: S32–S36. doi:10.1097/BPO.0000000000001022. PMID 28799992. S2CID 43864161.
  4. EL-Sobky, Tamer A.; Samir, Shady; Atiyya, Ahmed Naeem; Mahmoud, Shady; Aly, Ahmad S.; Soliman, Ramy (21 March 2018). "Current paediatric orthopaedic practice in hereditary multiple osteochondromas of the forearm: a systematic review". SICOT-J. 4: 10. doi:10.1051/sicotj/2018002. PMC 5863686. PMID 29565244.
  5. EL-Sobky, Tamer A.; Samir, Shady; Baraka, Mostafa M.; Fayyad, Tamer A.; Mahran, Mahmoud A.; Aly, Ahmad S.; Amen, John; Mahmoud, Shady (January 2020). "Growth Modulation for Knee Coronal Plane Deformities in Children With Nutritional Rickets: A Prospective Series With Treatment Algorithm". JAAOS: Global Research and Reviews. 4 (1): e1900009. doi:10.5435/JAAOSGlobal-D-19-00009. PMC 7028784. PMID 32159063.
  6. Burghardt, Rolf D.; Herzenberg, John E.; Andre Strahl; Bernius, Peter; Kazim, Murteza A. (November 2018). "Treatment failures and complications in patients with Blount disease treated with temporary hemiepiphysiodesis: A critical systematic literature review". Journal of Pediatric Orthopaedics B. 27 (6): 522–529. doi:10.1097/BPB.0000000000000523. PMID 29889697. S2CID 48361879.
  7. Fan, Bensen; Zhao, Caixia; Sabharwal, Sanjeev (January 2020). "Risk factors for failure of temporary hemiepiphysiodesis in Blount disease: A systematic review". Journal of Pediatric Orthopaedics B. 29 (1): 65–72. doi:10.1097/BPB.0000000000000603. PMID 30741749. S2CID 73445376.
  8. Ashby, Elizabeth; Eastwood, Deborah (June 2015). "Characterization of knee alignment in children with mucopolysaccharidosis types I and II and outcome of treatment with guided growth". Journal of Children's Orthopaedics. 9 (3): 227–233. doi:10.1007/s11832-015-0661-0. PMC 4486501. PMID 26076735.
  9. Trofimova, Svetlana I.; Buklaev, Dmitry S.; Petrova, Ekaterina V.; Mulevanova, Svetlana A. (14 December 2016). "Guided Growth for Correction of Knee Flexion Contracture in Patients with Arthrogryposis: Preliminary Results". Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 4 (4): 64–70. doi:10.17816/PTORS4464-70.
  10. Ding, Jing; Zhu, Ting; Jin, Fang-chun; Wu, Zhen-kai; Li, Hai (21 November 2019). "The effect of temporary hemiepiphysiodesis in the treatment of skeleton immature posttraumatic genu angular deformity: a retrospective study of 27 cases". Journal of Orthopaedic Surgery and Research. 14 (1): 381. doi:10.1186/s13018-019-1426-0. PMC 6868743. PMID 31752945.
  11. Gigante, C.; Borgo, A.; Corradin, M. (February 2017). "Correction of lower limb deformities in children with renal osteodystrophy by guided growth technique". Journal of Children's Orthopaedics. 11 (1): 79–84. doi:10.1302/1863-2548-11-160172. PMC 5382342. PMID 28439314.
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