Strategies in Trauma and Limb Reconstruction

Register      Login

VOLUME 17 , ISSUE 1 ( January-April, 2022 ) > List of Articles

Original Article

Growth Deceleration for Limb Length Discrepancy: Tension Band Plates Followed to Maturity

Peter M. Stevens, Matias Desperes, Angela Presson, Jennifer Herrick

Keywords : Anisomelia, Epiphysiodesis, Limb length inequality, Tension band plating

Citation Information : Stevens PM, Desperes M, Presson A, Herrick J. Growth Deceleration for Limb Length Discrepancy: Tension Band Plates Followed to Maturity. 2022; 17 (1):26-31.

DOI: 10.5005/jp-journals-10080-1548

License: CC BY-NC-SA 4.0

Published Online: 24-05-2022

Copyright Statement:  Copyright © 2022; The Author(s).


Abstract

Objective: There are several alternative methods for accomplishing epiphysiodesis of the longer limb to address limb length discrepancy (LLD). Consensus is lacking regarding the optimal timing of the intervention and which method is most efficacious. We reviewed a large group of patients with anisomelia treated by tethering with tension band plates (TBP) and who had attained skeletal maturity. We discuss our preferred timing and technique while noting the complications and how they were managed. Materials and methods: With IRB approval, we reviewed 66 subjects including 32 boys and 34 girls, ranging in age from 3 to 16.6 years at the time of physeal tethering, who were destined to have between 2 and 9 cm LLD at maturity. Inclusion criteria were: (1) at least 1 year of predicted growth at the time of tethering; (2) minimum 18-month follow-up and (3) minimum Risser stage 1 (R1) in the last radiologic study. There were 35 distal femoral, 25 pan genu and five proximal tibial procedures. Patients were seen bi-annually with weight-bearing full-length radiographs to ascertain neutral alignment and assess limb lengths. Results: We defined a successful outcome to be <1.5 cm of residual discrepancy. Iatrogenic mechanical axis deviation, observed in nine patients (five varus and four valgus), was successfully managed by repositioning the implants. While the under-corrected patients presented too late to achieve equalization, they benefited from partial improvement. Due to lack of timely follow-up, one patient over-corrected by 2 cm and had a femoral shortening at the time of correcting contralateral femoral anteversion. One patient required a distal femoral osteotomy to correct recurvatum at maturity. Conclusion: Properly timed and executed, TBP is an efficacious and reversible means of growth deceleration, rather than growth arrest, that may be applied in a wide age range of patients with modest anisomelia regardless of aetiology. This method offers potential advantages over purportedly rapid and definitive techniques such as percutaneous epiphysiodesis (PE) or percutaneous epiphysiodesis with transphyseal screws (PETS). Level of evidence: Level III. Retrospective series without controls.


HTML PDF Share
  1. Machen MS, Stevens PM. Should full-length standing anteroposterior radiographs replace the scanogram for measurement of limb length discrepancy? J Pediatr Orthop (B) 2005;14(1):30–37. DOI: 10.1097/01202412-200501000-00005.
  2. White JW, Stubbins SG. Growth arrest for equalizing leg lengths. Journal of the American Medical Association 1944;126(18):1146–1149. DOI: 10.1001/jama.1944.02850530024006.
  3. Menelaus MB. Correction of leg length discrepancy by epiphyseal arrest. J Bone Joint Surg (B) 1966;48(2):336–339. PMID: 5937598.
  4. Westh R, Menelaus M. A simple calculation for the timing of epiphyseal arrest: a further report. J Bone Joint Surg 1981;63(B): 117–119. DOI: 10.1302/0301-620X.63B1.7204464.
  5. Phemister D. Operative arrestment of longitudinal growth of bones in the treatment of deformities. J Bone Joint Surg 1933;15(1):1–15.
  6. Blount WP, Clarke GR. Control of bone growth by epiphyseal stapling. J Bone Joint Surg 1949;31(A3):464–478. PMID: 18153890.
  7. Bowen JR, Johnson WJ. Percutaneous epiphysiodesis. Clin Orthop Relat R 1984;190:170–173. PMID: 6488627.
  8. Metaizeau JP, Wong-Chung MC, Bertrand H, et al. Percutaneous epiphysiodesis using transphyseal screws (PETS). J Pediatr Orthop 1998;18(3):363–369. PMID: 9600565.
  9. Green W, Anderson M. Skeletal age and the control of bone growth. Instr Lect Am Acad Orthop Surg 1960;17:199–217. PMID: 13708221.
  10. Moseley C. A straight-line graph for leg length discrepancies. Clin Orthop Relat R 1978;136:33–40. PMID: 215368.
  11. Paley D, Bhave A, Herzenberg JE, et al. Multiplier method for predicting limb-length discrepancy. J Bone Joint Surg 2000;82(10):1432–1446. DOI: 10.2106/00004623-200010000-00010.
  12. Makarov MR, Jackson TJ, Smith CM, et al. Timing of epiphysiodesis to correct leg-length discrepancy: a comparison of prediction methods. J Bone Joint Surg 2018;100(14):1217–1222. DOI: 10.2106/JBJS.17.01380.
  13. Song H, Eun-Seok C, Seok M, et al. Percutaneous epiphysiodesis using transphyseal screws in the management of leg length discrepancy: optimal operation timing and techniques to avoid complication. J Pediatr Orthop 2015;35(1):89–93. DOI: 10.1097/BPO.0000000000000214.
  14. Dimeglio A, Kelly P. Lower-limb growth: how predictable are predictions? J Child Orthop 2008;2(6):407–415. DOI: 10.1007/s11832-008-0119-8.
  15. Birch JG, Makarov MA, Jackson TJ, et al. Comparison of Anderson-Green graphs and white-menelaus predictions of growth remaining in the distal femoral and proximal tibial physes. J Bone Joint Surg Am 2019;5;101(11):1016–1022. DOI: 10.2106/JBJS.18.01226.
  16. Lee SC, Shim JS, Seo SW, et al. The accuracy of current methods in determining the timing of epiphysiodesis. J Bone Joint Surg 1995;7:993–1000. DOI: 10.1302/0301-620X.95B7.30803.
  17. Pendleton A, Stevens PM, Hung M. Guided growth for the treatment of moderate leg-length discrepancy. Orthopedics 2013;36(5): e575–e580. DOI: 10.3928/01477447-20130426-18.
  18. Gaumetou E, Mallet C, Souchet P, et al. Poor efficiency of eight-plates in the treatment of lower limb length discrepancy. J Pediatr Orthop 2016;37(7):715–719. DOI: 10.1097/BPO.0000000000000518.
  19. Bayhan I, Karatas A, Rogers K, et al. Comparing percutaneous epiphysiodesis for the treatment of limb length discrepancy. J Pediatr Orthop 2017;37(5):323–327. DOI: 10.1097/BPO.00000000 00000647.
  20. Borbas P, Agten C, Rosskopf A, et al. Guided growth with tension band plate or definitive epiphysiodesis for treatment of limb length discrepancy? J Orthop Surg Res 2019;14(1):99. DOI: 10.1186/s13018-019-1139-4.
  21. Lauge-Pedersen H, Hagglund G. Eight plate should not be used for leg length discrepancy. J Child Orthop 2013;7(4):285–288. DOI: 10.1007/s11832-013-0506-7.
  22. Stewart D, Cheema A, Szalay E. Dual 8-plate technique is not as effective as ablation for epiphysiodesis about the knee. J Pediatr Orthop 2013;33(8):843–846. DOI: 10.1097/BPO.0b013e3182a 11d23.
  23. Stevens PM. Invalid comparison between methods of epiphysiodesis. J Pediatr Orthop 2018;38(1):e29–e30. DOI: 10.1097/BPO.0000000000001020.
  24. Kaymaz B, Komurcu E. Comment on the article “Dual 8-plate technique is not as effective as ablation for epiphysiodesis about the knee” by Stewart et al. J Pediatr Orthop 2014;34(8):e67. DOI: 10.1097/BPO.0000000000000314.
  25. Lykissas M, Jain V, Manickam V, et al. Guided growth for the treatment of limb length discrepancy: a comparative study of the three most commonly used surgical techniques. J Pediatr Orthop (B) 2013;22(4):311–317. DOI: 10.1097/BPB.0b013e32836132f0.
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.