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Complications Associated with Epiphysiodesis and Hemiepiphysiodesis
Introduction
Angular limb deformity and limb length discrepancy (LLD) are among the most commonly treated pediatric orthopedic conditions and have potential for significant physical, social, and psychological effects on children and their families. Whereas classic treatment of LLD and angular deformity focused on bone-shortening operations and osteotomies, procedures aimed at altering physeal growth, both permanently and temporarily, have become commonplace since initial introduction of the concept by Phemister in 1933. Over time, these procedures have proven to be successful and well-tolerated operations, with an increasingly lower rate of complications. Despite these advances, the potential for significant complications still exists, with epiphysiodesis and hemiepiphysiodesis having distinctly different risk profiles based on the intended permanence of growth disturbance. However, both of these procedures share significant common complications, such as timing of surgical intervention and the need for close postoperative follow-up. Given that selective growth arrest and growth modulation are very common procedures for any orthopedic surgeon caring for skeletally immature patients, a thorough understanding of the preoperative pitfalls, intraoperative complications, and postoperative considerations is essential in obtaining a successful and lasting surgical outcome.
Epiphysiodesis
Epiphysiodesis to correct LLD is a widely utilized surgical treatment, classically recommended for discrepancies less than 4 to 5 cm and most commonly performed around the knee, but is also employed in greater discrepancies to minimize the amount of required limb lengthening. Since its initial description by Phemister and the implementation of potentially reversible techniques by Blount in 1949, numerous refinements have been made over the intervening years with both open and percutaneous ablation methods, as well as instrumented methods of surgical epiphysiodesis, with all being valid options for addressing LLD. Despite technical advances, however, complication rates of 0% to 49% have been reported, ranging from errors in preoperative planning to incomplete postoperative growth arrest and iatrogenic deformity.
Preoperative Complications
To successfully treat LLD, the orthopedic surgeon must have an accurate understanding of the measurement of the overall leg length discrepancy, the abnormal segment or segments in question, skeletal growth remaining, and patient and family preferences in regard to treatment modality. Ideally, the surgeon should obtain serial full-length radiographs or scanograms of the lower extremities, concomitantly identify the patient’s skeletal age, most commonly using a hand/wrist radiograph, and conduct a thorough discussion with the family as to potential complications. In addition, the family must share the treating surgeon’s definition of a successful outcome, with improvement in LLD to within 1 to 2 cm likely representing a functionally excellent result. Finally, epiphysiodesis requires a compliant family that will return for scheduled follow-up appointments so unexpected complications can be identified early and addressed before a secondary deformity can occur.
Even with an appropriate understanding of the deformity, however, one of the largest sources of error in implementing an epiphysiodesis is predicting the appropriate timing for surgical intervention. Several methods for prediction of expected LLD exist, including the Green-Anderson growth remaining chart, the multiplier method, Moseley and Rotterdam straight-line graphs, and the White-Menelaus method. However, there is some degree in error in all of these methods, with Blair et al. finding that 67% of their patients had a final discrepancy of greater than 1 cm, mostly attributed to incorrect use of the Green-Anderson prediction tables, and Little et al. finding a 10% to 27% rate of poor outcomes, defined as residual leg length discrepancy of greater than 2 cm, with available methods. More recent literature has also demonstrated inaccuracies in predicted LLD as a significant potential source of error and suggested that the White-Menelaus method used with Gruelich and Pyle hand/wrist skeletal age is the most accurate for predicting the timing of intervention compared to the other techniques. Further work is forthcoming, with the goal of automating bone age measurements, thereby reducing analysis time and improving inter- and intrarater accuracy.
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