1. Clinical Application of Growth Modulation
Norman Ramírez MD FAAOS/FAAP
Pediatric Orthopedic Department
Hospital De La Concepción
San Germán – Puerto Rico

2. Hueter - Volkmann
Mechanical compression slow longitudinal growth in the
growth plate,
sustained distraction produces increase growth,
but the compression effect is greater.
Mechanical effects on skeletal growth Stokes J Musculokel Neuron Interact 2002

3. GROWTH MODULATION The treatment of some childhood
deformities such as angular deformities or
length discrepancies is based on the
concept of mechanically suppressing
growth effect.
Growth plate forces in the adolescent human knee: A radiographic and mechanical study of
epiphyseal staples Bylski-Austrow JPO 2001

4. HISTORY In 1932, Phemister introduced concept of growth
modulation through physeal arrest
Leg length discrepancy
Angular deformity
In 1945, Haas demonstrated growth could be held
back by a wire loop around physis
More importantly, proved that growth resumed when wire was removed
Haas, S. JBJS., 27:25-36, Jan. 1945
Operative arrestment of longitudinal growth of
bone in treatment of deformities Phemister
JBJS 1933

5. Control of bone growth by epiphyseal stappling Blounts JBJS 1949
HISTORY
In 1949, Blount set standard with epiphyseal stapling
Direct mechanical compression
Widely utilized and clinically proven
Control of bone growth by epiphyseal stappling Blounts JBJS 1949

7. COMPLICATIONS Breakage Migration Physeal closure Difficult removal
Poor correction

8. The old center of growth modulation…..

9. The newer center of growth modulation….

10. HISTORY In 2007 , Stevens proposed use of extraperiosteal nonlocking
plate
Tension band construct
Long moment arm for correction
Hinges at edge of physis
Non rigid
Less concern of physeal arrest
Younger patients
One plate per physis

11. Guided growth for angular correction Stevens JPO 2007
Why eight plates?
Guided growth for angular correction Stevens JPO 2007

12. HISTORY
In 1998, Metaizieau described using cannulated screws for distal femoral and proximal tibial Epiphysiodesis. He recommended fully threaded screws with at least 4 threads across the physis to create a physeal tether rather than a lag effect.
Percutaneous Epiphysiodesis using transphyseal Srews Métaizeus JPO 1998

14. Permanent Closure Of the
Complications
Permanent Closure Of the
Growth Plate

15. Growth Modulation Systems

16. Goyeneche JPO 2009 Less extrusion in small children ( 8-plates)
Correction was achieved in less time with staples
Longitudinal growth inhibition is lower with 8
Plates
Correction of bone angular deformities : Experimental analysis of staples versus 8- plates Goyeneche JPO 2009

17. Wiemann JM JPO 2009 63 limbs staples: 39 limbs eight plates: 24 limbs
same correction rate
same complication rate
Physeal stapling versus 8-plates hemiepiphysiodesis for guide correction of angular
deformity about the knee JPO 2009

18. Eric Gordon et al Posna 2011
Angular deformity: 188 pts Staples: 189 limbs Eight plates: 66 limbs Same correction rate ( 60 vs 68 %) Eight plates : less complication rates

19. Jelinek Int Orthop. 2012
Both Blount stapling and the 8-plate technique are methods for correction of genu varum and valgum deformity in skeletally immature patients A shorter operating time for implantation and removal was noted for the 8-plate technique
The 8-plate versus physeal stapling for temporary hemiepiphyseodesis correcting genu valgum and genu varum: a retrospective analysis of thirty five patients.
Jelinek EM Int Orthop. 2012

20. Gottliebsen M Acta Orthop. 2013
Treatment time for the 2 treatment modalities was not significantly different in this randomized clinical trial. Tension-band plating and stapling appeared to have a similar effect regarding correction of genu valgum.

21. Park JPO 2016
Both techniques result in satisfactory correction of coronal angular deformity in patients with idiopathic genu valgum.
The observed rate of correction was faster with PETS than TBP
Hemiepiphysiodesis for Idiopathic Genu Valgum: Percutaneous Transphyseal Screw Versus Tension-band Plate Park JPO 2017

22. Treatment goals
Normalize the mechanical axis Alleviate the symptoms Obviate the need for a corrective osteotomy
Physeal stapling for idiopathic genu valgum Stevens JPO 1999

23. Indications
Skeletally immature patients with significant and symptomatic angular deformity.
Physeal stapling for idiopathic genu valgum Stevens JPO 1999

24. Indications
Genun Valgum Genun Varus Angular deformities Leg Length Discrepancy Scoliosis

25. Radiological Parameters
Lateral Distal Femoral Angle (LDFA)
Medial Proximal Tibia Angle (MPTA)
Mechanical Axis (MA)
Comprehesive treatment of late –onset tibia vara
Gordon JBJS 2005

26. Genum Valgum 10-20° of valgus in a patient <10 years of age
if line drawn from center of femoral head to
center of ankle falls in lateral quadrant
of tibial plateau in patient > 10 yrs of age
Physeal stapling for idiopathic genu valgum Stevens JPO 1999

29. Genum Varus if line drawn from center of femoral
head to center of ankle falls in
medial quadrant of tibial
plateau in patient > 10 yrs of age

30. Castañeda et al JPO 2008 48 pts Correction rate:
Proximal tibia : 5.5 degrees per year
Distal Femur : 6.7 degrees per year
Hemiepiphysiodesis for correction of angular deformity about the knee
Castañeda JPO 2008

32. Transphyseal Screws
Results of screw epiphysiodesis for the treatment of limb lenght discrepancy and angular deformities Khoury JPO 2007

33. Leg Length Discrepancy

35. Concepts…..
Leg Length Discrepancy: 2cm to 5 cm projected Distal Third Femur: 1cm by year Proximal Third Tibia: 0.6cm by year No more of two years: Permanent Closure By Stages : 2years / off / 2 years
The role of guided growth as it relates to limb lengthening
Peter M. Stevens J Child Orthop 2016

36. Scoliosis 35 22 12 yrs old, Risser 0, premenarche 4 yrs P/O
Vertebral Body Stapling: a fusion less
treatment option for growing child
with moderate idiopathic scoliosis
Betz Spine 2010
12 yrs old, Risser 0,
premenarche
4 yrs P/O