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Growth Guided Hemiepiphysiodesis

Planning

B

Preoperative Plan

1

Radiographic templating of plating

  • Obtain a weight bearing, full length hip to ankle AP XR with knees in neutral (pointing anterior)
  • In cases of real or apparent leg length discrepancy, blocks are placed under the shorter side to level the pelvis

2

Execute surgical walkthrough

  • describe key steps of the operation verbally to attending prior to beginning of case.
  • description of potential complications and steps to avoid them
C

Room Preparation

1

Surgical instrumentation

  • guided growth plate and screws

2

Room setup and equipment

  • standard radiolucent operative table
  • C-arm fluoroscopy

3

Patient positioning

  • patient supine
  • tourniquet high on thigh

Technique

D

Skin Incision and Sharp Dissection Avoiding the Periosteum

1

Mark the incision

  • mark 3 cm incision over the physis ( most commonly distal femoral and/or proximal tibia physis)
  • this should be on the convexity of the deformity, ideally at or near the apex
  • for valgus deformity, apply plate and screws on medial side
  • for varus deformity, apply plate and screws on lateral side
  • it is helpful to confirm the position of the physis prior to making an incision with C-arm fluoroscopy
  • in most cases the distal femoral physis is at the junction of the upper 1/3 and middle 1/3 of the patella
  • exsanguinate the limb and inflate tourniquet
  • consider infiltrating the skin with local anesthetic with epinephrine, e.g. bupivicaine with epinephrine

2

Perform the skin incision

  • make the skin incision with a scalpel

3

Deepen the skin incision with sharp dissection and divide the fascia

  • at the distal femur, divide the fascia of the vastus medialis (medially) or IT band (laterally) in line with its fibers
  • be sure not to disturb the periosteum underneath- THIS IS VERY IMPORTANT AS DOING SO COULD DISTURB THE PHYSIS and CAUSE GROWTH ARREST/PHYSEAL BAR FORMATION
E

Positioning of the Plate

1

Place needle for centering the plate

  • insert a needle (keith or hypodermic) or small guidepin into the physis

2

Check the position with fluoroscopy in both AP and lateral planes

  • ideally the position of the needle should be at or slightly posterior to the midsagittal plane
  • if pin is anterior to the midsagittal plane it may create recurvatum with growth

3

Once the needle is in satisfactory position, the plate can be slid over this

  • take care to place plate in line with midsagittal plane
  • several guided growth plate systems are available but they are similar in appearance and look like the number "8" with a hole for the epiphyseal screw and one for a metaphyseal screw
F

Place Guidepins and Predrill

1

Center the plate in the appropriate position

2

Insert guidepins

  • insert the epiphyseal guide pin first as there is less room for this trajectory
  • then insert the metaphyseal guide pin
  • confirm position of guidepins with fluoroscopy
  • it is not necessary that these be parallel
  • it is critical that neither pin violates the adjacent joint or the physis
  • in small children it may helpful to do an arthrogram to improve visualization

3

After confirming guidepin position, predrilll using a cannulated drill (3.2mm in most systems) to about 5mm

  • drilling further than this may decrease screw purchase or displace guidepin
G

Screw Placement

1

Insert screws

  • insert a 4.5 mm cannulated screw over each guide pin

2

Sequentially tighten the screws

3

Remove guide pin and countersink screws

H

Wound Closure

1

Deep closure

  • 2-0 vicryl for fascia and subcutaneous layer

2

Superficial closure

  • running monofilament suture for skin

3

Dressings and immobilization

  • tegaderm and occlusive dressings
  • alternatively, ace wrap or bias stockinette wrapped over gauze dressings applied directly on incision

Patient Care

K

Preoperative H & P

1

Obtain history and perform physical exam

  • History
  • Age
  • Gender
  • Family history
  • Physical Exam
  • range of motion
  • analysis of gait pattern
  • analysis of rotational profile of femur, tibia and foot

2

Order appropriate imaging studies

  • Obtain a weight bearing, full length hip to ankle AP XR with knees in neutral (pointing anterior)
  • In cases of real or apparent leg length discrepancy, blocks are placed under the shorter side to level the pelvis

3

Perform operative consent

  • describe complications of surgery including
  • recurrence/rebound deformity (more than anticipated)
  • undercorrection (reaches skeletal maturity prior to sufficient correction)
  • overcorrection if lost to followup
  • infection
  • physeal arrest if periosteum is violated
  • broken screws
L

Perioperative Inpatient Management

1

Discharges patient appropriately

  • pain meds
  • weight bearing as tolerated, crutches for comfort
  • schedule follow up in 1-2 weeks
 

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