Guided Growth for the Correction of Pediatric Lower Limb Angular Deformity

dr Michael John T Pembimbing : dr Muh Andry Usman, SpOT

Introduction
Guided growth (ie, growth manipulation) is a

useful technique to correct angular deformities in children. Using either temporary or permanent hemiepiphysiodesis. Function by tethering one side of a growing physis allowing for differential growth. Common problems are undercorrection and overcorrection.

Introduction
Guided growth is most commonly used to

address coronal plane deformity about the knee. Guided growth can be used to manage deformity in any plane on any extremity.

History of Growth Manipulation

Osteotomy is the most common technique for

correction of angular deformity of a limb.

Etiology of Angular Deformity

Indications for Correction of Deformity

Studies have shown that there is an

association between varus and valgus malalignment of the knee and osteoarthritis (OA). No evidence showed that malalignment caused the OA. Evidence suggested that malalignment maybe contribute to the development of knee OA.

Biomechanical and gait studies

Varus alignment increases medial load during

gait. Valgus alignment is associated with increases in lateral compartment peak pressures, and that. Varus and valgus malalignment increase medial and lateral load.10-13

Indications for Correction of Deformity

The risk of OA is often cited as a reason to

consider management of angular lower extremity malalignment. Primary indication for guided growth is a clinically unacceptable deformity in a patient with open physes. Sagittal plane deformity is more likely to produce functional impairment than coronal plane abnormality.

Indications for Correction of Deformity

Other indications include impairment

producing deformity and a physis with adequate growth remaining (approximately 1 year) to allow correction.15

Preoperative Assessment
The deformity can be diagnosed based on the

patient history, physical examination, and radiographic imaging. The physical examination assess the limb length, coronal and sagittal alignment in the standing position and static and dynamic knee stability (ie, lateral thrust).

Preoperative Assessment
The preferred radiographic view for

assessment of lower extremity deformity is a standing film that includes the hip and the ankle.

Determining the amount of growth remaining

Before performing hemiepiphysiodesis,

determine skeletal age by comparing a radiograph of the left hand to the standards published by Greulich and Pyle.16 There is also clinical parameters such as the Tanner stages and onset of menses. Radiographs of the elbow and pelvis

Timing of Hemiepiphysiodesis
Estimating remaining growth based on skeletal

age is an inexact process because the health of the physis must be considered too. Several conditions are associated with abnormal physeal growth : skeletal dysplasias, trauma, and irradiation. It will leads to slower correction.

compression and tension forces at the physis

can cause physeal growth inhibition and acceleration (The Heuter-Volkmann principle)

Temporary (ie, reversible) hemiepiphysiodesis

is an option in younger patients. Once angular correction has been achieved, the tethering device (ie, staple, screw, plate) may be removed. Response of the physis is unpredictable. Recurrence of deformity called rebound effect (ie, accelerated growth on the side of the physis that was temporarily restrained) is common.

Delaying removal of the tethering implants

until a small amount (5) of overcorrection has occurred. The tethered side of the physis may close before the untethered side.7 A contralateral hemiepiphysiodesis of the untethered side may be required to prevent permanent overcorrection.

For patients who are near skeletal maturity,

permanent hemiepiphysiodesis is an option because it eliminates the possibility of implant- related complications and the unpredictability associated with the rebound effect. Correct timing is necessary.

Timing of Hemiepiphysiodesis

Temporary Hemiepiphysiodesis Staples

First described by Blount and Clarke in 1949 Under fluoroscopic guidance, three staples are

used to span the physis The entire procedure is extraperiosteal. Care must be taken to avoid damaging the physis or the zone of Ranvier permanent hemiepiphysiodesis.

Staples
Be Careful of rebound growth Average of 5 (2 - 11) in 22 patients of 35

patients. Overcorrection of approximately 5 was recommended for patients with significant growth remaining.

Temporary Hemiepiphysiodesis Screws

In 1998, Mtaizeau et al described a new

technique for percutaneous epiphysiodesis using transphyseal screws. With average of 7 (4 - 12) of genu valgum correction within 3 of anatomic mechanical alignment (9 patients) Average of 12.5 of correction by 2.6 years using percutaneous epiphysiodesis with transphyseal screws in 18 knees with an average initial angular deformity of 18 (Nouh and Kuo)

Screws
A major criticism of this study was the mild

initial deformity. However, other studies have confirmed the validity of this technique in patients with greater deformity.

Temporary Hemiepiphysiodesis Tension Band Plate

Associated with the use of staples there are

concerns regarding implant breakage and migration, also the potential for physeal arrest Stevens used this plate in 34 patients. A 30% higher rate of correction was reported with plating than with staples. All patients achieved full correction. No premature physeal arrests were reported.

Tension Band Plate

Four patients aged <11 years with bilateral

idiopathic genu valgum developed bilateral rebound growth and recurrence of deformity after removal of the device. Ease of application and the excellent results to date have led to widespread use of tension band plating for guided growth.

Permanent Hemiepiphysiodesis
This technique is that it must be done near

skeletal maturity Permanent hemiepiphysiodesis can be done open or percutaneously. Although many surgeons now favor the percutaneous technique, the open method remains the gold standard for achieving permanent epiphysiodesis, mainly because it offers visual confirmation of appropriate physeal ablation at the time of surgery

Fibular Epiphysiodesis
McCarthy et al showed that the proximal fibula

overgrows approximately 3 mm per year when the proximal tibia undergoes epiphysiodesis. Fibular overgrowth >1 cm resulted in a prominent fibular head. Recommended fibular epiphysiodesis when overgrowth is expected to exceed 1-2 cm.

Complications
Complications associated with guided growth

can be classified as :
Physiologic (eg, infection, swelling, stiffness) Hardware-related (eg, implant extrusion,

breakage, prominence) Growth-related (eg, undercorrection, overcorrection, permanent physeal injury)

THANK YOU

References
1. Phemister DB: Operative arrestment of

longitudinal growth of bones in the treatment of deformities. J Bone Joint Surg Am 1933;15:1-15. 2. Bowen JR, Leahey JL, Zhang ZH,MacEwen GD: Partial epiphysiodesis at the knee to correct angular deformity.Clin Orthop Relat Res 1985;198:184-190 3. Venable CS, Stuck WG, Beach A: The effects on bone of the presence of metals; based upon electrolysis: An experimental study. Ann Surg 1937;105(6):917-938.

References
4. Haas SL: Retardation of bone growth by a

wire loop. J Bone Joint Surg Am 1945; 27:2536. 5. Haas SL: Mechanical retardation of bone growth. J Bone Joint Surg Am 1948;30(2):506512. 6. Blount WP, Clarke GR: Control of bone growth by epiphyseal stapling: A preliminary report. J Bone Joint Surg Am 1949;31(3):464478.

References
7. Zuege RC, Kempken TG, Blount WP:

Epiphyseal stapling for angular deformity at the knee. J Bone Joint Surg Am 1979;61(3):320-329. 8. Mtaizeau JP, Wong-Chung J, Bertrand H, Pasquier P: Percutaneous epiphysiodesis using transphyseal screws (PETS). J Pediatr Orthop 1998;18(3):363-369. 9. Stevens PM: Guided growth for angular correction: A preliminary series using a tension band plate. J Pediatr Orthop 2007;27(3):253-259.

References
10.Morrison JB: The mechanics of the knee

joint in relation to normal walking. J Biomech 1970;3(1):51-61. 11. Bruns J, Volkmer M, Luessenhop S: Pressure distribution at the knee joint: Influence of varus and valgus deviation without and with ligament dissection. Arch Orthop Trauma Surg 1993;113(1):12-19. 12. Tetsworth K, Paley D: Malalignment and degenerative arthropathy. Orthop Clin North Am 1994;25(3):367-377.