Epiphysiodesis

The Epiphyseodese (also epiphysiodesis of gr epiphyesthai - it grow, develop and gr desis - binding ) is a surgical procedure to block the growth of long bones or vertebral bodies by bridging or destruction of the growth plate. This technique can be applied only until the end of growth before the growth plate closes permanently.

A distinction is a temporary interruption of growth ( temporary Epiphyseodese ) of a final, irreversible (permanent) Epiphyseodese. When Hemiepiphyseodese (eg knock knees and bow legs ) only one side of the growth plate is closed, resulting in a growth steering. If a Apophysenfuge blocked, one also speaks of a Epiphyseodese. A Epiphyseodese made ​​either to fix the epiphysis (eg epiphysis ), or for growth control ( for example, in case of growth, scoliosis, X or bow legs ). The most common application concerns the two Wachtumsfugen in knee near the knee near Oberschenkelfuge (distal femur) and the knee near Schienbeinfuge ( proximal tibia), which are also the two growth plates of the body with the greatest growth potency.

• 2.1 Temporary Epiphyseodese, osteosynthesis penetrate the growth plate
• 2.2 Temporary Epiphyseodese, osteosynthesis bridges outside the growth plate
• 2.3 Permanent Epiphyseodese

Areas of application

Fixation of the epiphysis after epiphyseal

In traumatic epiphyseal separation ( epiphysiolysis ) or a chronic slipping of the epiphysis, usually the femoral head, a Epiphyseodese must be done to prevent further slipping of the epiphysis. After traumatic Epiphyseolysen this can be accomplished through a temporary Epiphyseodese with K- wires, as well as in the prophylactic supply the unaffected side in a juvenile Hüftkopflösung.

In contrast, in the young Hüftkopflösung on the affected side there is a permanent Epiphyseodese for permanent blocking of the growth plate. While in the past mainly of three slats nail (see below ) was used, it is usually short- threaded screws today. An alternative is the establishment of a joint- spanning autologous bone graft, this is also a permanent Epiphyseodese.

Growth Steering

The classic indications X - legs and bow legs, in which usually a temporary Hemiepiphyseodese carried on the convex side, ie, at the X- legs, the inside and outside of the O- legs. Since the two close to the knee growth plates of tibia ( tibia) and thighbone (femur ), the largest growth potency, can be corrected by a timely indication large misalignments.

In principle, all growth disorders in question, as they relate to bone growth plates. Thus Epiphyseodese has also been described for rare deformities. This is not always the standard method, but provides a therapeutic option in children orthopedic centers is:

• Axis deviation of the limbs, for example, due to a tibia vara Blount at the knee or a Madelung deformity with excessive length of the ulna.
• About the length of a limb, such as a finger Makrodaktylie, or rarely, in leg length difference ( in this case be preferred, however other methods are used ). Even after unilateral stimulation of growth a Epiphyseodese is possible, as it was applied simultaneously even with gigantism in both legs. The Epiphyseodese is also used in genetic disorders that are associated with an overgrowth of a limb ( hemihypertrophy ) or a part thereof, as in Proteus syndrome, neurofibromatosis, among others
• Growth inhibition of the healthy limb: A permanent Epiphyseodese the opposite side is of an occasional malignant bone or soft tissue tumors, when removed, while at the affected side, the growth plate was destroyed in order to avoid a subsequent leg length difference. Previously, this method was often used in a unilateral leg shortening due to poliomyelitis.
• Congenital kyphosis and scoliosis: can be a targeted growth of the deformity out by selective Epiphyseodesen the Ringapophysen the most tilted vertebrae. Occasionally Blount staples of memory metal are used. Since this method is used primarily in young children with severe kyphosis or scoliosis, a temporary Epiphyseodese is preferred. Due to the difficulty in surgical access and the necessary experience in the selection of blocked epiphyses, this method is used only in certain highly specialized centers for pediatric orthopedics.
• Growth inhibition of apophysis: When Perthes disease occurs by the deformation of the femoral head and the frequent varus deformity of the femoral neck to a relative excess length of the trochanter. Therefore, some centers use a Epiphyseodese the trochanteric apophysis.

A correct balance a difference in length or axial deviation is only possible if the Epiphyseodese " to richtgen time, which is, however, difficult to calculate " takes place (F. Hefti ). For a poor match or a deformity in the opposite direction are always possible - so it may eventually come to overcorrection and knock knees at a Epiphyseodese at the knee inside with bow legs. Especially in the period of puberty the growth in size is hard to predict, and thus increases the variability.

To plan the proper timing of Epiphyseodese and to calculate the remaining growth of the individual growth plates at the knee usually the nomograms of Moseley, the so-called "straight -line graph " method can be used. Based on the annual X-ray checks at fifty boys and fifty girls Anderon and Green have observed in the fifties and sixties in the U.S., the growth at close to the knee femur and the tibia close to the knee from infancy to the end of growth. It Moseley has then developed the graphs that allow a prediction of the remaining growth. The joint lock occurs kneeling next to boys with an average age of 16 (skeletal age) a, in girls at age 14. From the age of 8 thus remain, for example, the thigh close to the knee ( distal femur) average 4.1 cm growth, with a variation between 2.2 to 7.2 cm. Especially the prepubertal growth spurt leads to a significant uncertainty in planning - the later a Epiphyseodese done, the more predictable it is. Another criticism concerns the fact that the nomograms of Moseley include only American children from the time almost fifty years ago, are also not applicable for growth disorders. A study of thirty children who received Blount's staples, showed nine children (30 %) had a remaining deviation of more than 1.5 cm.

Techniques

The numerous methods for Epiphyseodese can be divided into three groups. In addition to the permanent Epiphyseodesen where the growth plate is usually destroyed, there is among the temporary Epiphyseodesen methods wherein the growth plate is crossed and thus hurt, and those in which a fixation is used externally bridging and thus the growth plate itself is not violated:

Temporary Epiphyseodese, osteosynthesis penetrate the growth plate

• PETS / Technology according to Metaizeau, screw fixation: Starting from the pineal gland, a drill hole is drilled obliquely toward metaphysis and then introduced a short threaded cancellous screw. The thread is completely in the metaphysis and not in the growth plate. Therefore, the process is reversible upon removal of screws, there is a further growth. As the well fills bone bridge is not big enough, it was blown up by further growth. In many cases this method, however, as planned because of the uncertainty of forecasts by material removal that the screws remain as permanent Epiphyseodese until after completion of growth. In francophone countries, this is now largely the method of choice.
• Wire osteosynthesis for fixation of the epiphysis eg in the context of epiphyseal fractures or Epiphysengleiten. Since the K-wires only have a very small diameter, even a bone bridge that forms after wire removal in the drill holes, the growth does not stop.
• Three slats nail is a nail laminated, which was introduced by the femoral neck forth through the growth plate in the femoral head, and through the blades slid down the femoral head also secures against rotation (rotation). After removal of the nail only a small bridge of bone that can be blown up again by further growth forms. But since on the one hand may come when introduced to further detachment of the femoral head, on the other hand, the nail can also migrate out backwards again, this method is currently largely abandoned.

Temporary Epiphyseodese, osteosynthesis bridges outside the growth plate

In the methods of temporary Epiphyseodese exists (as opposed to permanent Epiphyseodese ) a great deal of uncertainty about the prognosis of the still possible regular growth after removal of the respective osteosynthesis. Due to violation of the vessels, the rest of the growth plate, by a possibly formed bone bridge or intraoperative injury to the growth plate itself may lead to a complete cessation of growth. Similarly, stimulation with overgrowth is possible. On the other hand, all methods of temporary Epiphyseodese can be viewed as a permanent Epiphyseodese by leaving the osteosynthesis until the end of growth.

• Blount's staples have long been the standard method of temporary Epiphyseodese for growth steering. The staples are placed under fluoroscopic control across the growth plate and thus block the growth locally in the clip area by compression. Usually two to three brackets are used in parallel to each other on each side. Initially steel brackets were used, but Blount has been later used Vitallium brackets with reinforced shoulders. Occasionally, however, the clamp arms / staples stop ..
• Memory Staples act like the Blount staples inhibiting growth by pinching the growth plate. You will also be under x-ray control across the joints. By heating to body temperature they take on an original form, which immediately leads to greater compression. The method is mainly applied to the vertebral bodies in congenital kyphosis - scoliosis. Studies with larger patient groups and longer experience stand out.
• Eight - Plate is a ( proprietary ) redevelopment of the Orthofix and illustrates a modified two-hole plate is introduced under fluoroscopic control across the growth plate and is fixed on both sides of the joint with a single screw. As with Blount staples occurs by compression of the growth plate to growth arrest in the field of plate fixation. Initial studies with knock knees and bow legs are promising, screw fractures were also described.

Permanent Epiphyseodese

• Technology by Phemister is the removal of a cortical bone cover above the growth plate; is used, then again rotated ninety degrees. Thus, a solid bone bridge with a permanent growth arrest forms. This method was first described by Phemister in 1933 and, since it is irreversible, are used only shortly before the end of growth.
• Percutaneous Epiphyseodese: About small percutaneous stab incisions in the skin, a wide oscillating drill is inserted under fluoroscopic control in the growth plate and thus drilled and destroyed the entire joint. It forms a solid bridge of bone, thus the process is irreversible. There are numerous variations of this process, which produces the best cosmetically and smallest grain. It is the method with the shortest hospital stay and the fastest mobilization of the knee according to Herring. It was first in 1984 by Ogilvie and 1994 by Gabriel et al. described. This technique is currently experiencing an increasing importance

Complications

Typical complications are an effusion or hematoma in neighboring knee and a bruise on the surgical site, since the bone in the area of the growth plate resting numerous vessels. Also nerve injuries have been described, especially on the outside ( lateral ) Epiphyseodese of the tibia (tibia), because there the common peroneal nerve runs close. Especially with the temporary Epiphyseodesen in which the fixation is close under the skin, it does occasionally cause permanent irritation. The postoperative mobilization is often severely delayed with persistent pain. In addition, it can be used for loosening of the implants, particularly the Blount staples come, so that re- interventions are necessary.

Typical of a Epiphyseodese the risk of over-correction is the same as that of under-correction. Especially with the temporary Epiphyseodesen further growth behavior after removing the Epiphyseodese is uncertain, it may cause cessation of growth or overgrowth. In addition, an asymmetric growth is possible.

A risk of injury to the growth plate also exists in the temporary Epiphyseodese by injury of the periosteum ( periosteal ) or the perichondrium, which contains numerous vessels. Furthermore, can form bone bridges which also lead to any permanent Epiphyseodese in the area of the implant. The residual growth in the growth plate after removal of the temporary Epiphyseodese is not predictable. Therefore avoid Some children orthopedists temporary Epiphyseodese favor permanent process almost complete: " My experience with stapling Has Significantly Narrowed my indications to nearly never" (JA Herring, S. 1063, as F. Hefti ).

Epiphyseoklasie

Before the introduction of aseptic surgical techniques and anesthesia often fractures were manually or with tools running ( osteoclasis ) to thereby correct severe deformities. In the special form Epiphyseoklasie the growth plate was broken: " ... a manual or automatic correction straight in the growth plate, which was used especially in Italy for the correction of Genoa valga The treatment method is praised, but it seems so little sympathetic to me, and I will. never wanted to use "(p. 152), wrote in 1923 the Stockholm professor of orthopedics Prof. Patrik Haglund for his then well-known German orthopedic textbook.

Sources and References

• Pediatric traumatology
• Therapeutic procedures in orthopedics and trauma surgery
• Invasive therapeutic procedures