5/19/2014. Malicious Malalignment. Malicious/Malignant malalignment. Malicious/Malignant malalignment

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1 5/19/2014 Malicious Malalignment J. Eric Gordon M.D. Washington University St. Louis, Missouri Disclosures: Consultant for Orthopediatrics Malicious/Malignant malalignment Increased femoral anteversion External tibial torsion Presents with knee pain Parents describe odd run Rotation creates sheer across knee joint leading to pain Malicious/Malignant malalignment Often diagnosed as anterior knee pain (chondromalacia, patello-femoral pain) Most often does not respond to physical therapy Present between ages of

2 5/19/2014 Malicious/Malignant malalignment Gait shows feet usually straight ahead Knees turned in When running, legs come up laterally with knees turned in Sometimes also complain of hip or ankle pain Malicious/Malignant malalignment Treatment Physical therapy rarely successful Surgery Derotate Femur Derotate tibia Placement through lateral aspect of greater trochanter Avoid tip of trochanter entry 2

3 5/19/2014 To OR for bilateral femoral derotational osteotomies First, 5mm incision made in lateral thigh Multiple perforations made in femur using 4.5mm drill bit Technique Arc C- arm over to obtain true AP of hip Proximal fragment tends to externall y rotate Technique Place guide pin on skin pointed toward middle of greater trochanter Trajectory should be toward bottom of lesser trochanter Aim slightly anterior 3

4 5/19/2014 Technique Push guide pin through skin to middle of greater trochanter Trajectory should be toward bottom of lesser trochanter Drive in until against medial femur Technique Possibly most important step Avoid being too transverse with this entry This will cause too much bend in guide wire and difficulty reaming Also check on lateral Technique Incise skin proximally Place soft tissue protector over guide pin 4

5 5/19/2014 Technique Insert rigid reamer through soft tissue protector Drive reamer into canal Technique Remove rigid reamer using obturator to leave guide pin in place Technique Place small tube over guide pin into canal of femur 5

6 5/19/2014 Technique Remove guide pin Leave small exchange tube in place Technique Place Ball tipped guide wire Drive down canal Rigid reamer passed into canal Ball tip guide wire then passed into canal down to 1cm proximal to physis 30cm nail measured Reaming with flexible reamer 9.0mm Second pass with 9.5mm reamer 8.0mm nail selected 6

7 5/19/2014 Exchange tube used to change to 2mm smooth, non ball tip guide wire Nail mounted and passed to osteotomy site Osteotomy completed Technique Use nail measuring gauge to measure length of nail Technique Place soft tissue protector again and begin reaming Usually start at 8-9mm Usually no need to use very small reamers Ream down to bend in guide wire 7

8 5/19/2014 Technique Ream to 1.5 to 2.0mm larger than proposed nail diameter Place flexible exchange tube past fracture site Remove ball tip guide wire Technique Place smooth guide wire Remove tube Place Nail Technique Do not rotate inserter anteriorly 8

9 5/19/2014 Technique Drive nail past fracture site Technique Remove guide wire Technique Impact nail into distal femur Look for junction of nail with inserter proximally 9

10 5/19/2014 Nail then impacted down canal Locking proximally carried out using a single screw Femur then derotated Nail distally Interlocked Proximal guide removed Wounds closed Repeated for contralateral side Allowed WBAT Most patients do transfers to wheelchair for 3 weeks 10

11 5/19/2014 Returns 4 weeks Post op Walking short distances Minimal discomfort Returns 7 weeks Post op Walking well with mild limp No pain Rotation IR - 40 ER - 60 Foot progression angle 5 ER Tibial Torsion 11

12 5/19/2014 Correction of tibial torsion Malicious malalignment associated with external tibial torsion Distal derotational osteotomy Should be metaphyseal not diaphyseal Stabilization by: K-wires Plate/screws Locking plate/screws Controversies Fixation type Fibular osteotomy If done should be done through separate lateral incision Complications Nonunion Skin breakdown Infection Superficial Deep Neurovascular injury 12

13 5/19/2014 Complications K-Wires Advantages Inexpensive Simple Disadvantages Often LLC Minimal control Plate Advantages Increased stability Often SLC or CAM walker Disadvantages More expensive Medial Approach Straight medial incision Technique - Approach Avoid Saphenous vein Avoid developing flaps Subperiosteal dissection Extend down to but not into physis medially Anterior Approach Interval between TA and EHL Avoid NV bundle lateral to EHL Subperiosteal dissection Avoid tension on skin edges Technique - Approach Tibialis Anterior Extensor Halicus Longus 13

14 5/19/2014 Retractors placed to protect structures Osteotomy started with saw and completed with osteotome or saw Osteotomy perpendicular to long axis of tibia JE Gordon Washington University St. Louis Secure plate proximally to tibia (locking and nonlocking screws) Derotate tibia Thigh foot ankle with knee flexed and foot in neutral Place distal screws 3 or 4 locking Recheck alignment JE Gordon Washington University St. Louis Similar for anterior plates JE Gordon Washington University St. Louis 14

15 5/19/2014 Cast or CAM Walker placed after closure NWB for 3 weeks Then return for radiographs After 3 weeks WBAT in cast or CAM walker JE Gordon Washington University St. Louis Returns 6 weeks PO Allowed WBAT out of immobilizatio n Begin PT for ROM and strengthening Radiographs at 12 weeks JE Gordon Washington University St. Louis I tend to combine osteotomies and do as much at one sitting as possible 4 bones OK JE Gordon Washington University St. Louis 15

16 5/19/2014 Thank You 16

17 PHYSEAL TETHERING History / Frequent Applications Peter M. Stevens, MD University of Utah VuMedi 05/14 NORMAL ALIGNMENT EQUAL LEG LENGTHS KNEES / ANKLES TOUCH KNEE JOINT HORIZONTAL GRAVITY BISECTS KNEE 1

18 A DECADE OF GUIDED GROWTH: WORLDWIDE STATIC vs. DYNAMIC MOVING FULCRUM / MIGRATING STAPLE (?) STAPLES: observed problems MIGRATE BEND BREAK 2

19 DYNAMIC 5/20/2014 BLOUNT STAPLES DYNAMIC PHYSIS vs. RIGID IMPLANT 2003 DYNAMIC vs. DYNAMIC FLEXIBLE TENSION BAND vs. COMPRESSION 3

20 HOME MADE: TOO RIGID WON T REVERSE BEND SCREW HEADS PROMINENT A DECADE OF GUIDED GROWTH PEDI-PLATE Orthopediatrics 2014 TEMPORARY EPIPHYSIODESIS STAPLES X YIELD 1949 SCREW 1994 PLATE

21 GUIDED GROWTH REVERSIBLE RESTRAINT OF THE PHYSIS = TENSION BAND PLATING X vs. Phemister percutaneous drilling Blount staples Metaizeau (PETS) ABLATIVE or COMPRESSIVE BIOLOGIC EFFECTS ALTOGETHER DIFFERENT WINDOW OF OPPORTUNITY extended /c flexible tether BIRTH MATURITY SIZE RANGE 14 Kgs. 185 Kgs. 5

22 TECHNIQUE EQUIPMENT 1.6 mm DRILL GUIDE 3.2 mm PRE-CONTOURED + CANNULATED SCREWDRIVER SELF TAPPING TECHNIQUE INSERT PLATE TECHNIQUE SCREWS DON T HAVE TO BE PARALLEL FLUORO AP / LAT 6

23 INDICATIONS: * ANY AGE / SIZE / ETIOLOGY DIRECTION / LOCATION * PHYSIS MUST BE OPEN CONTRAINDICATIONS: CONTRAINDICATIONS: GUIDED GROWTH PHYSIOLOGIC DEFORMITIES SKELETAL MATURITY EXTENSIVE PHYSEAL DAMAGE IDIOPATHIC GENU VALGUM Age 14 7

24 SUBMUSCULAR EXTRAPERIOSTEAL MIDSAGITTAL HOW RAPID? 10/06/06 11/06/06 11/13/06 11/19/06 12/03/06 /p 4 Mos. 12/18/06 12/31/06 1/21/07 1/29/07 2/19/07 CORRECTED IN 4 MONTHS Age 15 8

25 DEGREES 5/20/2014 GOAL: NEUTRALIZE MECHANICAL AXIS ANATOMIC ANGLES ZONES FOLLOW-UP TO MATURITY PARENTAL EDUCATION / VIGILANCE REBOUND physiologic range TIME REPEATED GUIDED GROWTH PRN TO RESTORE ALIGNMENT AND PREVENT OSTEOTOMY 5/13 10/13 2 yrs. GROWTH REMAINING 9

26 ANTICIPATE REBOUND? PERCUTANEOUS REMOVAL OF METAPHYSEAL SCREW 5/14 CONTINUE FOLLOW-UP OBSERVE MECH. AXIS REINSERT SCREW P.R.N. 10

27 MODULAR APPROACH PRIORITY MECHANICAL DEVIATION HARMFUL ANGULAR > ROTATION > LENGTH OFTEN OBSERVE 2 0 IMPROVEMENT GAIT JOINT LAXITY LIMB LENGTH TORSION INFANTILE TIBIA VARA - Blount s 2+10 y.o. 2/09 10/09 OSTEOTOMY ENTHUSIASTS: IMMEDIATE CORRECTION Oblique Tibial Rab, G. JPO 1988 Osteotomy for Blount s Disease GOLD STANDARD? 11

28 INFANTILE TIBIA VARA 2+10 y VARUS VARUS OSTEOTOMY 2/09 GOAL SINGLE PLATE MID-SAGITTAL? /p 8 mos. 12

29 INFANTILE TIBIA VARA LENGTH RESTORED /p 18 mos. LATERAL THRUST RESOLVED TORSION HAS CORRECTED CORRECT ANGLE 1 ST 10/11 Age 4 Age 6 13

30 TRANSVERSE PLANE 13 y.o. FEMALE WITH DISLOCATING PATELLAE HYPOPLASTIC LATERAL FEMORAL CONDYLES SHALLOW SULCUS PATELLOFEMORAL DYSPLASIA ALGORITHM FOR PATELLAR INSTABILITY AMTTT vs. MPFL? 13 y.o. FEMALE WITH DISLOCATING PATELLAE 14

31 PANGENU GUIDED GROWTH (patella is a decoy) Pre-op /p 5 mos. /p 10 mos. DISLOCATING /p 10 months STABLE PATELLO-FEMORAL DYSPLASIA - SEEMINGLY RESOLVED 15

32 GROUND REACTION FORCE 5/20/2014 FKFD - PATHOMECHANICS extensor moment patella alta avulsion Fixed Knee Flexion Deformity Exacerbated by: weak quadriceps strong/spastic hamstrings gravity ligament stretch avulsion Cerebral palsy Spina bifida Arthrogryposis Syndromes RADIOGRAPHIC FINDINGS avulsion avulsion FIXED KNEE FLEXION DEFORMITY CONSERVATIVE MANAGEMENT BRACING = EXERCISE IN FUTILITY 16

33 OSTEOTOMY : RECURRENT DEFORMITY 4 year old boy /c arthrogryposis - bilateral supracondylar osteotomies x 3 as he grew up SURGICAL MANAGEMENT: OSTEOTOMIES year old /c spastic diplegia OSTEOTOMY: FIXATION PROBLEMS undercorrected loss of fixation 6 weeks /p supracondylar femoral osteotomies + patellar tubercle advancement 17

34 SEMLS Hamstring release Single Event Multi-Level Surgery 49% pelvic tilt 35% recurvatum long term results deteriorate recurrence and overcorrection RATIONALE GUIDED GROWTH - ADVANTAGES SAFE / GRADUAL CORRECTION (24 x 7) IMMEDIATE MOBILIZATION + WT. BEARING INCREASED ROM ALLEVIATE CROUCH GAIT / PAIN CORA GUIDED GROWTH 18

35 2 PLATES : ONE ON EACH SIDE OF THE SULCUS MEDIAL LATERAL GUIDED GROWTH - TECHNIQUE FLUOROSCOPE 2 ANTERIOR INCISIONS ONE 8-PLATE ON EACH SIDE OF SULCUS COMBINE WITH OTHER PROCEDURES PRN IMMEDIATE MOBILIZATION IMMEDIATE WT. BEARING TECHNIQUE 19

36 FOLLOW-UP 6 MONTH INTERVALS REMOVE SCREW or PLATES PRN. WHEN FULL EXTENSION IS RESTORED 8-plates 12 0 floor reaction brace vs. fixed knee flexion deformity KNEE EXTENSION IS GAINED WITHOUT LOSING FLEXION (vs. OSTEOTOMY OR FRAME TECHNIQUES) 20

37 month interval CORA / 7 GRADUALLY GAIN HEIGHT GAIN EXTENSION PRESERVE FLEXION RED = NORMAL BLUE = PREOP GREEN = POSTOP NORMALIZATION IN SAGITTAL PLANE THINK GLOBALLY, ACT LOCALLY 21

38 S.L.M.E.S. PELVIS Single Level Multi- Event Surgery HIP KNEE ANKLE 8 y.o. 1 yr /p trampoline injury 8 y.o. RECURVATUM /p PROXIMAL TIBIA FRACTURE POSTERIOR PROXIMAL TIBIAL ANGLE

39 97 0 /p 6 mos /p 12 mos. 23

40 S.L.M.E.S. PELVIS Single Level Multi- Event Surgery HIP KNEE ANKLE 03/14 /p 20 mos. STRATEGY: REMOVE METAPHYSEAL SCREW 24

41 PERCUTANEOUS REMOVAL METAPHYSEAL SCREW TIMING Warren White Method* (Menelaus) FEMALES MALES DISTAL FEMUR 0.9 cm PROXIMAL TIBIA 0.6 cm 1.5 cm./y.r *APPROXIMATION OK IF USING A REVERSIBLE PROCESS. LATENCY PERIOD Reiko Murakami, M.D. (Japan) 25

42 TECHNIQUE VARIATION ANGLE LENGTH SCREWS +/- PARALLEL TENSION BAND NO LAG NO TIME LIMIT SCREWS DIVERGENT PASSIVE COMPRESSION LAG EFFECT (3-6 mos.) < 2 YEARS / REPRIEVE TIMING OF EPIPHYSIODESIS PREDICT MATURITY (Anderson table / Gruelich and Pyle / Mosely Demiglio / Paley multiplier etc) ANTICIPATE LAG PERIOD (1 yr. sooner) DEFINITIVE > 10 yrs. DDH 26

43 DEFINITIVE > 10 yrs. AGE 6 AGE 10 DEFINITIVE > 10 yrs. AGE 12 3 cm. LIFT DEFINITIVE > 10 yrs. AGE 12 AGE 15 3 cm. lift no lift 27

44 ANISOMELIA GUIDED GROWTH STRATEGIES: (2-5 cm.) > 10 Yrs. DEFINITIVE < 10 Yrs. TEMPORIZING ANGULAR - ADJUST MECH. AXIS ADJUNCT TO LENGTHENING 16 Mos. /p LEFT TIBIAL FRACTURE 3 ½ y.o. COZEN S PHENOMENON + 1 cm. LLD ( tibial overgrowth ) ZONE +1 ZONE +3 physiologic valgus pathologic valgus 2/09 OSTEOTOMY 28

45 COZEN S ARTHROGRAM 3 ½ y.o. GUIDED GROWTH NOT TIME SENSITIVE COZEN S OUTLINE CHONDROEPIPHYSES COZEN S 29

46 COZEN S /p 8 mos. 2/09 10/09 1/10 /p 11 mos. 30

47 +3 cm. 6/12 Age 5 ANKLE VALGUS 2 Dx: Cozen s + HEMANGIOMA (hemi-hypertrophy) 31

48 RIGID FULCRUM WITHIN DYNAMIC PHYSIS MAY: BEND BREAK MIGRATE MEDIAL MALLEOLAR SCREW - is there a better option? bend DIFFICULT TO REMOVE. EXTRA-PERIOSTEAL FLEXIBLE TETHER 32

49 Age 8 STRATEGY: REMOVE METAPHYSEAL SCREWS /p 2 Yrs.(6/14) REINSERT /p 6 Mos. Age 8 2 cm. 33

50 2 cm. PERCUTANEOUS REMOVAL METAPHYSEAL SCREWS 5/14 FOLLOWUP 6 mos. REINSERT PRN TEMPORIZING < 10 yrs. HEMANGIOMA 4 cm. possible maturity = 6-7 cm. Lengthen normal leg? Shorten involved leg? STANDING AP AGE

51 TEMPORIZING < 10 yrs. HEMANGIOMA AGE 6 TEMPORIZING < 10 yrs. 2/09 age cm. DISCREPANCY STRATEGY: 1.Add femoral plates 2. d/c metaphyseal screws 3. Confirm physeal growth 4. Reinsert in 6-12 months 2.5 cm. lift 35

52 TEMPORIZING < 10 yrs. SCREW REMOVAL 6/09 TEMPORIZING < 10 yrs. GOAL: EQUALIZE LIMB LENGTHS BY SKELETAL MATURITY /s OSTEOTOMY METAPHYSEAL SCREWS REINSERTED 1/10 5/12 36

53 5/13 (D.O.B. 8/02 nearly 11 yrs. old) 6/07 Plates proximal tibia 7/09 d/c metaph screws + plates femur 11/09 reinsert tibial screws 8/11 d/c tibial / femoral screws 9/11 lateral tibial screws / drill fibula (varus) 12/12 reinsert femoral and medial tib. srews NO: shoe lift hospitalization cast osteotomy frame AGE 11 1/2 EQUAL LIMB LENGTHS 12/13 PLAN: - FOLLOWUP Q 6 Mos. - REINSERT METAPH. SCREWS PRN 37

54 CONCLUSION: GUIDED GROWTH WIDE RANGE OF APPLICATIONS DIVERSE / MODULAR SOLUTION PREFERABLE TO OSTEOTOMY BIOLOGIC EFFECTS OF A FLEXIBLE TETHER UNIQUE / DIFFERENT peter.stevens@hsc.utah.edu THANK YOU 38