|
 
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| EDITORIAL |
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| Year : 2022 | Volume
: 8
| Issue : 1 | Page : 1-2 |
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Epiphysiodesis: Not just for equalization
Philip K McClure, John E Herzenberg
International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| Date of Submission | 23-May-2022 |
| Date of Acceptance | 23-May-2022 |
| Date of Web Publication | 30-Jun-2022 |
Correspondence Address:
Philip K McClure
International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
USA
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jllr.jllr_21_22
How to cite this article:
McClure PK, Herzenberg JE. Epiphysiodesis: Not just for equalization. J Limb Lengthen Reconstr 2022;8:1-2 |
An old canard in the limb lengthening world says, “For discrepancies <2 cm do nothing, 2–5 cm do epiphysiodesis, and >5 cm do lengthening.” As lengthening surgery technology has progressed beyond external fixator methods toward more patient-friendly implantable internal lengthening devices, one author has proposed lowering the bar for lengthening, effectively relegating epiphysiodesis to an ever-smaller role in limb equalization.[1] The technological advance of the reliable internal lengthening nail appears to have taken the limb lengthening world by storm.[2],[3] Perhaps, someday soon, epiphysiodesis will be painted into an ever-smaller corner, rarely performed.
The inherent challenge with epiphysiodesis is the uncertainty of timing. Despite advances in calculating formulas, multipliers, and bone age determination, the goal of determining accurate timing of epiphysiodesis remains stubbornly elusive.[4],[5],[6],[7],[8] Even with multiple attempts to improve the accuracy or find an optimal prediction algorithm, accuracy results for standalone epiphysiodesis leave something to be desired. In fact, they are rarely exact at all. While this weakness is well documented, it should not be considered a fatal flaw that relegates the concept to the dustbin of orthopedic history.
Like many tables within textbooks, the simplistic guidelines for observation, epiphysiodesis, and lengthening are inadequate when it comes to guiding the practice of pediatric orthopedic surgeons. We should stop looking at epiphysiodesis as only a method for equalization. In our practice, a major indication for epiphysiodesis is limb length mitigation, not equalization. What do we mean? Any expert in limb lengthening will say the greater the amount of lengthening, the greater the risk of complications.
In certain situations, decreasing the total anticipated discrepancy through epiphysiodesis on the long limb can be the difference between success and failure, though this can only truly be known in retrospect. An adroit surgical plan should consider all possible routes to achieving functionally equal leg lengths. Even a mere 2 cm mitigation through epiphysiodesis would be expected to decrease lengthening duration by a few weeks and consolidation time by an estimated 2 months.[2],[9],[10],[11],[12] This could easily be the difference between making it back to social obligations without the need for crutches versus still being dependent on assistive devices. In select scenarios, the same 2 cm mitigation could be the difference between a single lengthening or requiring two separate episodes of distraction osteogenesis.
Accordingly, there is value in reducing the discrepancy by 2–3 cm, so you can achieve the goal of equalization with a lower risk profile. Our own LLRS AIM index comparison criteria recognizes this, giving added severity points for bigger versus smaller lengthening.[13]
Any experienced distraction osteogenesis surgeon knows full well the occasional difficulty of getting that last centimeter or two when treating patients with large discrepancies associated with congenital deficiencies. Hypoplastic joints are particularly sensitive to lengthening and require the dedicated care of expert physical therapists, often preceded by preparatory surgery to make them more stable. When considering a life plan for equalization, a conscientious surgeon will realize that though the epiphysiodesis may be done as the initial surgical intervention, it is the last few centimeters of lengthening that are avoided, not the first.
The distinguished Ilizarov trailblazer Mark Dahl has said, “The only thing that gets better in lengthening is length.” The corollary is that many things can get worse: joint stiffness, muscle strength, and function. Our message to readers is to embrace epiphysiodesis as a technique to mitigate the amount of lengthening performed. In many cases of smaller limb length discrepancies, epiphysiodesis can eliminate the need for any lengthening, provided you are willing to accept the potential inaccuracies.
Once you start to see epiphysiodesis as a tool for mitigation rather than only for equalization, you are instantly liberated and relieved from the Sisyphean task of trying to make epiphysiodesis accurate in terms of equalization. Proceed boldly, do your mitigation epiphysiodesis at age 11–13, achieve what you achieve, and know that when you descend into the cauldron of limb lengthening at skeletal maturity, your task will be lighter, your complication rate lower, and you will be working with a child who is more mature and better able to withstand the slings and arrows of lengthening misfortune.
Are there nuances? Of course! Limb lengthening is more art than science. Not all families will allow you to lessen the natural biologically determined height of the long leg. Heightism is real. Studies have even shown that on average, tall men make more money than short men. Some patients are wary of doing anything to their “normal” leg. In brief, one size or strategy does not fit all.
In summary, please do not forget that epiphysiodesis is a simple, yet effective tool for limb equalization. We have allowed ourselves to be mesmerized by the ever more intricate and ingenious tools for lengthening: monolateral frames, circular frames, hexapod frames, and internal lengthening nails. Even our very name “Journal of Limb Lengthening and Reconstruction” emphasizes our obsession with LENGTHENING. Perhaps, we should rename our institutes, societies, and journals: International Center for Limb Equalization; Limb Equalization and Reconstruction Society; Journal of Limb Equalization and Reconstruction (JLER)…long live the JLER!
| References | |  |
| 1. | Nichols LR. Has the threshold for epiphysiodesis versus lengthening changed in the era of magnetically controlled nails? J Pediatr Orthop 2021;41:S24-32.  |
| 2. | Makarewich CA, Herzenberg JE, McClure PK. Latest advances in limb lengthening using magnetically controlled intramedullary lengthening nails. Surg Technol Int 2020;36:404-11. |
| 3. | Green SA. The evolution of remote-controlled intramedullary lengthening and compression nails. J Orthop Trauma 2017;31 Suppl 2:S2-6. |
| 4. | Makarov MR, Jackson TJ, Smith CM, Jo CH, Birch JG. Timing of epiphysiodesis to correct leg-length discrepancy: A comparison of prediction methods. J Bone Joint Surg Am 2018;100:1217-22. |
| 5. | Birch JG, Makarov MR, Sanders JO, Podeszwa DA, Honcharuk EM, Esparza M, et al. Lower-extremity segment-length prediction accuracy of the sanders multiplier, paley multiplier, and white-menelaus formula. J Bone Joint Surg Am 2021;103:1713-7. |
| 6. | Mills G, Nelson S. An improved spreadsheet for calculating limb length discrepancy and epiphysiodesis timing using the multiplier method. J Child Orthop 2016;10:313-9. |
| 7. | Aguilar JA, Paley D, Paley J, Santpure S, Patel M, Herzenberg JE, et al. Clinical validation of the multiplier method for predicting limb length discrepancy and outcome of epiphysiodesis, part II. J Pediatr Orthop 2005;25:192-6. |
| 8. | Burger K, Farr S, Hahne J, Radler C, Ganger R. Long-term results and comparison of the green-anderson and multiplier growth prediction methods after permanent epiphysiodesis using Canale's technique. J Child Orthop 2019;13:423-30. |
| 9. | Green SA, Fragomen AT, Herzenberg JE, Iobst C, McCarthy JJ, Nelson SC, et al. A magnetically controlled lengthening nail: A prospective study of 31 individuals (The PRECICE intramedullary nail study). J Limb Lengthen Reconstr 2018;4:67. [Full text] |
| 10. | Calder PR, McKay JE, Timms AJ, Roskrow T, Fugazzotto S, Edel P, et al. Femoral lengthening using the precice intramedullary limb-lengthening system: Outcome comparison following antegrade and retrograde nails. Bone Joint J 2019;101-B: 1168-76. |
| 11. | Hammouda AI, Jauregui JJ, Gesheff MG, Standard SC, Conway JD, Herzenberg JE. Treatment of post-traumatic femoral discrepancy with PRECICE magnetic-powered intramedullary lengthening nails. J Orthop Trauma 2017;31:369-74. |
| 12. | Hammouda AI, Jauregui JJ, Gesheff MG, Standard SC, Herzenberg JE. Trochanteric entry for femoral lengthening nails in children: Is it safe? J Pediatr Orthop 2017;37:258-64. |
| 13. | McCarthy JJ, Iobst CA, Rozbruch SR, Sabharwal S, Eismann EA. Limb lengthening and reconstruction society AIM index reliably assesses lower limb deformity. Clin Orthop Relat Res 2013;471:621-7. |
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