Epiphysesodesis

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The epiphysiodesis (also epiphysiodesis, from gr. Epiphyesthai - grow on, arise and gr. Desis - to bind) is a surgical procedure to block the growth of long tubular bones or vertebral bodies by bridging or destroying the growth plate . This technique can only be used until the growth is complete, before the growth plate finally closes.

A distinction is made between a temporary interruption of growth (temporary epiphyseodesis) and a definitive, irreversible (permanent) epiphyseodesis. In the Hemiepiphyseodese (. B. at z knock knees and bow legs ), only one side of the growth plate closes, resulting in a growth steering. If an apophyseal plate is blocked, it is also called an epiphysesodesis. An epiphysesodesis is done either to fix the epiphysis (e.g. in the case of a detachment of the epiphysis) or to guide growth (e.g. in the case of overgrowth, scoliosis , knock knees or bowlegs). The most common application concerns the two growth plates near the knee, the knee near the femur (distal femur ) and the knee near the tibia (proximal tibia ), which at the same time represent the two growth plates of the body with the greatest growth potential.

application areas

Fixation of the epiphysis after detachment of the epiphysis

In the event of a traumatic epiphyseal detachment ( epiphysiolysis ) or chronic slipping of the epiphysis, usually on the femoral head, an epiphysis must be performed to prevent the epiphysis from slipping further. After traumatic epiphyseolysis, this can be done with a temporary epiphyseodesis with K-wires , as well as with the prophylactic treatment of the unaffected side as part of a youthful femoral head solution .

On the other hand, with the young femoral head solution, permanent epiphysodesis takes place on the affected side to permanently block the growth plate. While in the past the three-lamellar nail (see below) was mainly used, today it is mostly short-thread screws. An alternative is the insertion of an autologous bone graft spanning the joints, which is also permanent epiphysodesis.

Growth control

The classical indications are knock-knees and bow legs , which usually takes place a temporary Hemiepiphyseodese on the convex side, thus with knock knees inside and bow legs outside. Since the two growth plates of the shinbone (tibia) and thighbone (femur) close to the knees have the greatest growth potential, even large deformities can be corrected with a timely indication.

In principle, all growth disorders are possible as long as they affect bones with growth plates. Epiphysodesis has also been described for less common deformities . This is not always the standard procedure, but it is a therapeutic option in pediatric orthopedic centers:

  • Axial deviations of the extremities , e.g. B. due to a tibia vara Blount on the knee or a Madelung deformity with excess length of the ulna.
  • Excess length of an extremity , e.g. B. macrodactyly of a finger , or less often with a leg length difference (here, however, other methods are preferred). Epiphyseodesis is also possible after one-sided growth stimulation, and it has also been applied to both legs simultaneously when the patient is very tall. Epiphyseodesis is also used in genetic diseases that are associated with a giant growth of an extremity ( hemihypertrophy ) or part of it, such as in Proteus syndrome , neurofibromatosis and the like. a.
  • Growth inhibition of the healthy extremity : A permanent epiphysodesis of the opposite side occurs occasionally in malignant bone or soft tissue tumors after these have been removed and the growth plate on the affected side has been destroyed in order to avoid a later leg length difference. In the past, this method was often used for one-sided shortening of the legs due to poliomyelitis .
  • Congenital kyphosis and scoliosis : Through selective epiphysesodesis of the ring apophyses of the most strongly tilted vertebrae, targeted growth can take place out of the deformity. Occasionally, memory metal Blount clips are used. Since this procedure is mainly used in young children with severe kyphosis or scoliosis, temporary epiphysodesis is preferred. Due to the difficulty of surgical access and the required experience in selecting the epiphyses to be blocked, this method is only used in individual, highly specialized centers for pediatric orthopedics.
  • Growth inhibition of an apophysis : In Perthes disease , the deformity of the femoral head and the frequent varus deformity of the femoral neck lead to a relatively excessive length of the trochanter . Some centers therefore use epiphysesodesis of the trochanteric apophysis.

Correct compensation of a difference in length or axis deviation is only possible if the epiphyseodesis takes place “at the correct point in time, which is difficult to calculate” (F. Hefti). This means that inadequate compensation or a deformity in the opposite direction is always possible - in the case of epiphysodesis on the inside of the knee, bow-legged legs can eventually lead to overcorrection and knock knees. Especially in the period of puberty, the growth in size is difficult to predict and thus the variability increases.

Moseley's nomograms, the so-called "straight-line graph " method, are mostly used to plan the correct time for epiphysodesis and to calculate the remaining growth of the individual growth plates on the knee . Using annual x-ray examinations on fifty boys and fifty girls in the United States in the 1950s and 1960s, Anderson and Green observed the growth of the femur near the knee and the shin near the knee from toddler age to completion. From this, Moseley developed the graphs that enable a prediction of the remaining growth. The joint closure occurs close to the knee in boys with an average of 16 years of age (skeletal age), in girls with 14 years. From the age of 8, z. B. on the thigh near the knee (distal femur) mean growth of 4.1 cm, with a variation between 2.2 and 7.2 cm. The prepubertal growth spurt in particular leads to significant planning uncertainty - the later epiphysodesis occurs, the more predictable it is. Another criticism concerns the fact that Moseley's nomograms only include American children from almost fifty years ago, and are not applicable to stunted growth. A study of thirty children who received Blount staples showed nine children (30%) with a remaining deviation of more than 1.5 cm.

techniques

The numerous procedures for epiphysesodesis can be divided into three groups. In addition to permanent epiphyseodesis, in which the growth plate is mostly destroyed, there are temporary epiphyseodesis methods in which the growth plate is crossed and thus injured, and those in which an external osteosynthesis is used to bridge the gap and thus the growth plate itself is not damaged :

Temporary epiphysis, the osteosynthesis penetrates the growth plate

  • PETS / Technique according to Metaizeau , screw osteosynthesis : Starting from the epiphysis, a drill channel is drilled at an angle towards the metaphysis and a short-thread cancellous screw is then inserted. The thread lies entirely in the metaphysis and not in the growth plate. Therefore, the procedure is reversible after screw removal, there is further growth. Since the bone bridge that fills the borehole is not large enough, it is broken up by further growth. In many cases, however, due to the prognosis uncertainty after the removal of the material, this procedure is planned in such a way that the screws remain as permanent epiphysodesis until after growth has been completed. In French-speaking countries, this is now largely the method of choice.
  • Wire osteosynthesis to fix the epiphysis z. B. in the context of epiphyseal fractures or epiphyseal sliding. Since the Kirschner wires are only of a very small diameter, even a bone bridge that forms in the drill holes after the wire is removed cannot stop growth.
  • Three-lamellar nail is a lamellar nail that was inserted from the femoral neck through the growth plate into the femoral head, and through the lamellae also secures the slipped femoral head against rotation. After removing the nail, only a small bone bridge forms, which can be broken again through further growth. However, since the femoral head can become detached further on the one hand, and the nail can also wander backwards on the other hand, this method has currently largely been abandoned.

Temporary epiphyseodesis, the osteosynthesis bridges the growth plate on the outside

Epiphysesodesis with two-hole plates around the epiphyseal plates of the femur and tibia near the knee joint to correct a difference in leg length

In the case of the temporary epiphyseodesis procedure (in contrast to permanent epiphyseodesis) there is great uncertainty about the prognosis of the regular growth that is still possible after removal of the respective osteosynthesis. Damage to the vessels on which the growth plate is located, a possibly created bone bridge or intraoperative injury to the growth plate itself can lead to a complete stoppage of growth. Stimulation with overgrowth is also possible. On the other hand, all procedures of temporary epiphyseodesis by leaving the osteosynthesis in place until the end of growth can also be regarded as permanent epiphyseodesis.

  • Blount braces have long been the standard technique of temporary epiphysodesis to direct growth. The clamps are placed across the growth plate under X-ray control and block the growth locally in the clamp area by compression. Usually two to three staples are used in parallel on each side. Steel clips were initially used, but Blount later used Vitallium clips with reinforced shoulders. Occasionally, however, the clamp arms / cramps can break off.
  • Memory staples , like the Blount clamps, inhibit growth by pinching the growth plate. They are also placed across the joints under x-ray control. By warming up to body temperature, they take on an original shape, which immediately leads to greater compression. The procedure is mainly used on vertebral bodies in congenital kypho- scoliosis . Studies with larger patient groups or longer experience are pending.
  • Two-hole plate : The modified plate osteosynthesis is inserted across the growth plate under x-ray control and fixed with a screw on each side of the joint. As a result, the plate lying on the outside of the periosteum acts like a tension belt . As with the Blount brackets, compression of the growth plate stops growth in the area of ​​the plate fixation.
    This process was first presented in 2006 by the American PM Stevens, who developed the patented first special titanium two-hole plate without angle-stable 4.5 mm screw anchoring for the     Orthofix company, known as the eight-plate . In the years that followed, several competing products were brought onto the market based on the same principle. Some of the screws are anchored at a stable angle, some are not, e.g. B. PediPlate . This technique established itself within a few years and is now the most widely used. Initial studies on knock knees and bow legs are promising and show results that are comparable to better than the other methods. In an overview of the published articles on axial deviations in the frontal plane , i.e. knock knees and bow legs, the desired correction was achieved in 87.6%. In epiphysodesis for the treatment of Blount's disease , for the treatment of misalignments with partially closed growth plates, and in overweight children, however, the results are not convincing. As with the other procedures, screw fractures and a rebound phenomenon after removal of the plate were described as complications .

Permanent epiphyseodesis

  • The Phemister technique is the removal of a cortical bone cover over the growth plate ; which is then inserted again rotated by ninety degrees. This creates a solid bone bridge with a permanent growth stop. This method was first described by Phemister in 1933 and, as it is irreversible, can only be used shortly before the end of growth.
  • Percutaneous epiphyseodesis : A wide oscillating drill is inserted into the growth plate through small percutaneous stab incisions in the skin under X-ray control, and the entire joint is drilled and destroyed. A solid bone bridge is formed, so the procedure is irreversible. There are numerous variants of this procedure that produce the cosmetically cheapest and smallest scars. It is the method with the shortest hospital stay and the fastest mobilization of the knee according to Herring. It was first used in 1984 by Ogilvie and in 1994 by Gabriel et al. described. This technology is currently experiencing increasing importance

Complications

Typical complications are an effusion or bruise in the adjacent knee joint, as well as a bruise over the surgical site, as numerous vessels lie on the bone in the area of ​​the growth plate. Nerve injuries have also been described, v. a. in the outer (lateral) epiphysesodesis of the tibia, since the common peroneal nerve runs close there. In the case of temporary epiphysis, in particular, where the osteosynthesis is located close to the skin, there is occasional permanent irritation. Postoperative mobilization is also more often severely delayed with persistent pain. In addition, the implants, especially the Blount brackets, can loosen, so that new interventions are necessary.

Typical of epiphysodesis is the risk of overcorrection as well as undercorrection. Particularly in the case of temporary epiphysodesis, the further growth behavior after removal of the epiphysodesis is uncertain, growth can come to a standstill or excessive growth. In addition, asymmetrical growth is possible.

There is also a risk of damaging the epiphyseal plate with temporary epiphysesodesis by damaging the periosteum or the perichondrium, which contains numerous vessels. Furthermore, bone bridges can form in the area of ​​the implant, which also lead to permanent epiphysodesis. The remaining growth of the growth plate after removal of the temporary epiphyseodesis cannot be predicted. Some pediatric orthopedic surgeons avoid temporary epiphysodesis almost completely in favor of permanent procedures: "My experience with stapling has significantly narrowed my indications to nearly never" (JA Herring, p. 1063, also F. Hefti).

Epiphysisoclasia

Before the introduction of aseptic surgical techniques and general anesthesia, fractures were often carried out manually or with aids ( osteoclasia ) in order to correct severe malpositions. In the case of the special form of epiphysealism, the growth plate was broken: “... a manual or machine correction, especially in the epiphyseal plate, which was used especially in Italy to correct the genoa valga. The treatment method is praised, but seems so unlikely to me that I never wanted to use it ”(p. 152) , wrote the Stockholm Ordinarius of Orthopedics Patrik Haglund in his then very well-known German orthopedic textbook in 1923 .

Sources and individual references

  1. ↑ a b c d F. Hefti: Pediatric orthopedics in practice . Springer-Verlag, Berlin 1997, ISBN 3-540-61480-X
  2. ^ CF Moseley: A straight-line graph for leg-length discrepancies. In: J Bone Joint Surg Am 1977; 59-A; 174
  3. ↑ MB Menelaus: Correction of leg-length discrepancy by epihyseal arrest. J Bone Joint Surg 1966; 48-Br; 336
  4. ↑ a b c J. A. Herring: Tachdijan's Pediatric Orthopedics. (3rd edition, in three volumes) WB Saunders Company, Philadelphia (USA) 2002
  5. ↑ JP Métaizeau, J. Wong-Chung, H. Bertrand et al .: Percutaneous epiphyseodesis using transphyseal screws (PETS). J Pediatr Orthop 1998; 18: 363
  6. ^ WB Blount, GR Clarke: Control of bonegrowth by epiphyseal stapling. Journal of Bone and Joint Surgery 1949; 31- Am: 464-478
  7. ↑ RD Burghardt, JE Herzenberg, SC Standard, D. Paley: Temporary hemiepiphyseal arrest using a screw and plate device to treat knee and ankle deformities in children: a preliminary report. J Child Orthop 2008; 2: 187-197
  8. ↑ Sudhir Mahapatra, Aravind Hampannvar, Madan Sahoo: Tension and plating in growth Modulation: a Review of current evidences Acta Orthopædica Belgica 2015, Volume 81, Issue 3, pages 351-357.
  9. ↑ DB Phemister: Operative arrestment of longitudinal growth in bones in the treatment of deformities. Journal of Bone and Joint Surgery 1933; 15: 1
  10. ^ JW Ogilvie: Epiphyseodesis: evaluation of a new technique. J Pediatr Orthop 1986; 6: 147
  11. ^ KR Gabriel, AH Crawford, DR Roy, MS True, S. Sauntry: Percutaneous epiphyseodesis. J Pediatr Orthop 1994; 14: 358-362
  12. ↑ Patrik Haglund: The principles of orthopedics . Publishing house by Gustav Fischer, Jena 1923