2.2. Indication, Operative Technique, and Applied Implants

In children with sufficient residual growth and a predicted LLD between 2 and 5 cm distal femoral epiphysiodesis and PTE was considered to equalize or reduce LLD. Referring to previous recommendations [1,11], PFE was conducted if the remaining tibial growth was estimated greater than 1.5–2.5 cm at the surgeon’s discretion. Surgical treatment of LLD ≥ 5 cm consisted of lengthening by distraction osteogenesis either using external fixators or intramedullary lengthening nails. For conservative treatment of LLD insoles, shoe lifts, and orthotic fittings were applied. After application of intravenous antibiotic (Cefuroxime) the patients were placed on a radiolucent table with a tourniquet on thigh level. The tibial growth plate was fluoroscopically localized and the implants were inserted medially and laterally through minimal invasive approaches preserving the periosteum. For concomitant PFE a cannulated screw was implanted in a K-wire guided technique from the proximal lateral towards the distal medial aspect of the fibula head (Figure 3).

Operative technique of proximal fibular epiphysiodesis. (a) Intraoperative lateral radiograph of proximal fibular epiphysiodesis with a cannulated fully threaded screw implanted in a K-wire guided technique concomitantly with distal femoral and proximal tibial temporary epiphysiodesis in a 12-year-old boy. (b) Intraoperative lateral radiograph of same patient after implantation. (c) Intraoperative anteroposterior radiograph of same patient after implantation.

Patients were routinely followed every six months by clinical and radiographic examination. After equalization of LLD or closing of the growth plates implants were removed (mean time of treatment: 26.5 months; range 8.4 to 77.9). After implantation and removal surgery immediate full weight bearing was permitted.