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Preoperative Patient Care
Operative Techniques
E

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
F

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
G

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
H

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
I

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
J

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

K

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
Postoperative Patient Care
 

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