Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Surgical epiphysiodesis indications and techniques: update Ismat Ghanem a , Joseph A. Karam a and Roger F. Widmann b Introduction It is well known that longitudinal growth of long bones takes place at the growth plate or physis. Better under- standing of the growth plate physiology helped pediatric orthopedic surgeons find a way to modulate growth. Indeed, many pediatric orthopedic deformities are more and more treated by surgical intervention on the physis, through alteration of its physiological or abnormal beha- vior, either partially or totally, permanently or transiently. This procedure is called epiphysiodesis. Ever since its first description by Phemister in 1933 [1], epiphysiodesis has witnessed increasing indications and substantial advances in techniques. This article reviews the main indications, pre-operative planning and various tech- niques of epiphysiodesis, and sheds some light on recent advances in the field. Indications for epiphysiodesis The most common indications for epiphysiodesis are limb length discrepancies (LLD) and angular deformities in the lower extremities, which are common complaints in the pediatric population. Other indications have included upper limb deformities [2], excessive predicted height in boys (>205 cm) [3] and fixed knee flexion deformity of more than 108 [4,5]. Growth modulation of the spine is also gaining interest in surgical manage- ment of scoliosis in children [6]; tethering of the con- vexity by bridging the vertebral endplates produces a gradual decrease in the curve magnitude by allowing the concave side to grow. This technique is intended to compensate for the excessive growth on one side of the spine. Lower limb length inequality can result from a wide variety of conditions but it is most frequently idiopathic, congenital or posttraumatic [7–9,10  ]. It results in many problems such as gait disturbance with compensatory mechanisms, low back and knee pain, and alteration of appearance, with an overall considerable impact on qual- ity of life [11–14]. Epiphysiodesis is indicated in pre- dicted LLD at maturity of 2–5 cm, in children with enough growth remaining to correct the discrepancy [12,14,15  ,16–18]. Discrepancies less than 2 cm are usually asymptomatic and can be managed with a shoe-lift if needed; those measuring more than 5 cm require lengthening procedures. In some cases with large inequalities, epiphysiodesis can be performed in addition to lengthening. Coronal angular deformities of the lower limbs (i.e., bow- legs and knock-knees) are also a common finding in childhood. However, most of the cases are physiologic and resolve spontaneously. When significant and pro- gressive, they disturb the quality of life and induce gait disturbance, pain, and, in some severe cases, joint instability. They may also indirectly affect other joints such as the hip and ankle, and, most importantly, they predispose to early osteoarthritis [19  ,20,21  ,22,23]. The standard treatment has been corrective osteotomy but this is an invasive procedure with significant morbidity and long recovery periods [19  ,20,21  ,23]. Hence, hemi- epiphysiodesis (i.e., partial epiphysiodesis) at the convex a Department of Orthopaedic Surgery, Hotel-Dieu de France Hospital, Boulevard Alfred Naccache, Ashrafieh, Beirut, Lebanon and b Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, New York, USA Correspondence to Ismat Ghanem MD, Department of Orthopaedic Surgery, Hotel-Dieu de France Hospital, Boulevard Alfred Naccache, Ashrafieh, Beirut, Lebanon Tel: +961 1 615 300 x9112; e-mail: ismat.ghanem@gmail.com Current Opinion in Pediatrics 2011, 23:53–59 Purpose of review To present a summary of epiphysiodesis indications and to report most recent advances in the field, along with their clinical relevance. Recent findings Percutaneous epiphysiodesis using transphyseal screws (PETS) and guided growth using eight plates represent the most recent techniques used for hemiepiphysiodesis. Summary PETS and guided growth have yielded very good results and low rates of complications and are the current standard for the management of angular deformities of the lower extremities in children. Permanent percutaneous epiphysiodesis remains the preferred method for the treatment of limb length discrepancies. Keywords eight-plate, angular deformity, epiphysiodesis/hemiepiphysiodesis, guided growth, limb length discrepancy, physeal stapling, radio frequency, transphyseal screws Curr Opin Pediatr 23:53–59 ß 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 1040-8703 1040-8703 ß 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins DOI:10.1097/MOP.0b013e32834231b3