In pediatric guided growth of the knee, we are all drawn to a simple promise: correct better, correct sooner, correct with less morbidity. This is understandable. When we have a child or adolescent with progressive genu valgum or genu varum, the growth window is not infinite. Time matters. However, precisely because time matters, we risk overemphasizing a single parameter: the speed of correction.
The work by Gupta and colleagues, published online in 2026 in the Journal of Pediatric Orthopaedics, addresses precisely this topic: comparing the effectiveness of PETS — Percutaneous Epiphysiodesis using Transphyseal Screws — versus tension band plates, the classic 8-plates, in correcting coronal plane knee deformities in skeletally immature patients [1].
The authors conducted a systematic review on PubMed, Embase, and Web of Science, including studies from 2004 to January 2025. From 603 identified papers, 13 studies were included: 8 non-comparative and 5 comparative. Methodological quality was assessed using ROBINS-I and MINORS, and meta-analysis compared the correction speeds of mLDFA, MPTA, and MAD [1].
The main finding is quite clear, but it needs careful interpretation. PETS are effective, with reported correction speeds for mLDFA between 0.64 and 1.3°/month, for MPTA between 0.52 and 0.86°/month, and for MAD between 1.3 and 3 mm/month [1]. In comparison with plates, the effect direction favors PETS: faster correction for mLDFA, MPTA, and MAD. However, statistical significance is not robustly achieved: mLDFA reaches the limit, while MPTA and MAD remain non-significant. Even in the analysis of idiopathic patients alone, the trend persists, but without a definitive statistical difference [1].
So the correct message is not "PETS are superior." It's more nuanced: PETS appear to correct more rapidly, but the available literature is not yet sufficient to say that they should replace 8-plates as the standard choice.
This is the point that, personally, I find most interesting. I routinely use 8-plates, and I remain quite cautious about the idea that speed alone is a sufficient reason to change strategy. Not because PETS are not a valid technique. On the contrary, the rationale is strong: percutaneous technique, simple implantation, efficient correction. The problem is another: in guided growth, we are not just "pushing" a deformity towards correction. We are trying to intercept the right moment, avoid overcorrection, control rebound, choose when to remove the implant, and leave manageable residual growth.
A second meta-analysis, published in 2025 in BMC Musculoskeletal Disorders, reinforces the theme but does not close it. That work included 5 comparative studies for 473 physes. The authors report a faster angular correction with PETS compared to tension band plates, with an overall mean difference of 0.17°/month; in the femoral subgroup, the difference was 0.21°/month in favor of PETS, and MAD correction was also faster [2]. This is data favorable to PETS, certainly. But here too, we are talking about non-randomized comparative studies, with not perfectly overlapping populations and indications [2].
This is why, in my opinion, the real debate should shift. It's not enough to ask: "which implant corrects faster?" The more useful question is: "which implant gives me the most predictable correction for that child, with that residual growth, that deformity, and that margin of error?"
8-plates have an obvious drawback: they can be slower. But in practice, they also offer a certain gradualness, a dynamic that many surgeons are familiar with, a generally familiar removal process, and behavior that, while not perfect, has become part of our way of planning controls and timing. This does not automatically make them better. However, it makes them more "readable" for those who use them often.
PETS, on the contrary, are attractive precisely because they seem more efficient. But efficiency can become a double-edged sword if the control window is narrow. In an adolescent near the end of growth, faster correction can be a huge advantage. In a younger child, or in a deformity where prediction is already difficult, speed could make the timing of removal more delicate. This is clinical reasoning, not a definitive conclusion from the literature: but it is precisely the kind of caution that these studies, in my opinion, should stimulate.
Another unresolved aspect is rebound. Many guided growth studies measure correction speed very well, but less well what happens afterward: partial loss of correction, need for new procedures, different behavior between femur and tibia, differences between idiopathic, metabolic, syndromic, or post-traumatic cases. Yet, in real life, the result is not the X-ray on the day of removal. The result is the axis that remains acceptable over time.
The merit of Gupta's paper is not to close the discussion. It is to open it in the right way. PETS are a credible, effective, and probably faster technique in many situations. But 8-plates remain a solid, known, and still very defensible solution. Today, based on the available literature, I do not see a sufficient reason to say that one should systematically replace the other.
If I had to summarize the message in one sentence, I would say this: in pediatric guided growth, correcting more rapidly is interesting; correcting predictably, controllably, and stably over time is even more important.
Disclaimer
This content is for informational purposes only and does not replace an individual clinical evaluation.
References
[1] Gupta R, Sriwastwa A, Low D, Patel S, Jain V, Parikh SN. Systematic Review of the Effectiveness of Transphyseal Screws for Correction of Coronal Plane Knee Deformities and Meta-analysis of Comparative Studies With Tension Band Plates. J Pediatr Orthop. 2026 Mar 18. doi:10.1097/BPO.0000000000003238. PMID: 41848372.
[2] Sabry AO, Genedy MKA, Abouelwafa S, Khalil AA, Mady O, Mostafa N, Elsayed RAA, Elbarbary H, Hegazy M, Abdelgawad A. Percutaneous epiphysiodesis transphyseal screw versus tension-band plating as hemiepiphysiodesis in treating coronal angular knee deformities: a systematic review and meta-analysis of comparative studies. BMC Musculoskelet Disord. 2025;26:355. doi:10.1186/s12891-025-08540-z. PMID: 40217231.
