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3. Don’t Rush. Where’s The Fire? Guided Growth to ...
3. Don’t Rush. Where’s The Fire? Guided Growth to Correct Malalignment for Chondral Pathology
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Hello. My name is Daniel Green. Thanks for the opportunity to talk to you today. I'm going to be discussing guided growth in chondral pathology and a role in treating knees. These are the kind of cases we're talking about. You can see this patient has had previous treatment for SCFI, has significant genuvalgum, then underwent tension plate placement. As you can see, the right leg was a little more valgus than the left with two distal femur and proximal tibia on the right and distal femur on the left. And you can see that usually within a year, sometimes a year and a half, with a patient who's immature and growing, you can get excellent correction of a valgus deformity. So what are the different terms used for implant-mediated guided growth? In terms of CPT or billing, it's usually referred to as hemi-epiphyseodesis. Some people refer to it still as stapling. Other people refer to it as just guided growth. I like to use the term implant-mediated guided growth. What are the indications and contraindications for implant-mediated guided growth? Really, it's ideal for uniplanar deformity. The majority in my practice dealing with the knees is valgus, but it could also be used in varus. You have to have a population or a patient that agrees to good follow-up. You don't want to leave the plates in too long, or you could have the opposite deformity develop. It's also important to know that these are not indicated for multiplanar deformities if you have extreme rotational malalignment, flexion extension deformities, in addition to varus valgus, or significant leg length issues. It's also contraindicated if you have less than two years of growth remaining. And it should never be used with a FICO bar. Don't expect to see correction if you place it with a FICO bar. Next slide, let's see. There we go. What about the history of implant-mediated guided growth? Really, the birth of orthopedics, ortho, straight, pedes, child, to make a child straight. There are many ways to do implant-mediated guided growth. The first really began with Dr. Blown to use staples. He noticed the staples were bending, and then he developed a titanium, a vitalium staple alloy in 1955. And until 2004, that's what was used in orthopedics for implant-mediated guided growth. And then a number of tension plates have been developed for implant-mediated guided growth. And you can use screws, as we'll talk about. Most of the tension plate systems allow kind of a hinge effect or divergence of the screw at the size of the plate to help facilitate guided growth. And just reviewing some of the principles, remember young kids are often in a varus position physiologically till age two or three. Then they often will drift into valgus, and that valgus should resolve by age kind of eight or 10. How do we know when to indicate a kid what is too much valgus or too much varus? Dr. Stevens describes getting long leg x-rays from the center of the hip to center of the ankle. And if that axis goes into the outer quadrant of the knee or beyond, then that's pathologic valgus and is indicated or at least discussed the option of implant-mediated guided growth in the over 10 kids. Here's a little algorithm that recently published about implant-mediated guided growth. And if I could draw your eyes here. So we got genuvarum genuvalgum. We got the appropriate age. We got a long leg x-ray. And if the x-ray is not normal, if it's multi-deformity, it goes on the osteotomy. If it's not multi-deformity, then it goes to growth remaining assessment. If the growth, if there's enough growth remaining, we can go on to consider hemiephyseodesis. We mentioned tension plates. Here's an example of screw epiphyseodesis. Many of the surgeons who use screw epiphyseodesis believe that this does not lead to permanent growth disturbance. And when you take out the screw, the growth continues to grow. And that seems to be the case in the majority of cases. But this asymmetric screw placement can also lead to deformity correction like you see in this nice case. Here's a case of a multiple epiphyseal dysplasia with severe valgus that was treated with tension plating. And you can see the nice correction here on the right. Genuvalgum is by far the most common indication. Typically, the deformity is at the distal femur. That's where the tension plates are placed. And you can see nice resolution of the deformity, usually between one and two years after correction. It's important to have these children come back every four months for deformity alignment correction and to not allow the plates to be in too long if the child's growing and to remove them once they have just a little bit of overcorrection, just beyond neutrals when we typically remove these plates. Here's a case of genuvarum treated successfully with lateral plates placed on the distal femoral physis and proximal tibia physis. And then this classic physio stapling article by Dr. Stevens. So let's talk a little bit about cartilage cases. How do we use this in the sports clinic? Here's a teenage cheerleader who had growth remaining, about two years of growth remaining, had a hint of valgus. But she had had her previous surgery. She was referred to our institution for a lateral meniscal transplant. She had a previous saucerization and excision of her discoid meniscus, and it was symptomatic. But we noticed this malalignment, a mild genuvalcum. So we thought it would be good to see if shifting the weight bearing to the medial side of the knee would improve the symptoms. So we did implant-mediated guided growth on the femur and tibia. And as you can see, in five months, started to get correction in nine months. And we removed the plates at about a year. And you can see now, the patient's had a mild varus on the right, and more weight load is going on the medial side, the lateral side, and her pain is resolved. So we didn't have to do a lateral meniscal transplant, in this case. Here's the pre-op and post-operative x-ray. I really think that implant-mediated guided growth should be the treatment of choice for all these pediatric patients with angular deformities, not associated with multi-plane deformities or limb-length discrepancies. And we need to go out and educate folks, our pediatricians, our parents, and sports surgeons, about how powerful this tool is. Here's another case of a 14-year-old male. Rope plates are open with a large, unstable osteochondritis, desiccant lesion, lateral femoral condyle. So we know how to treat that. We know it's unstable. We need to stabilize it. We need to repair it. But notice the valgus. This is going to load that area of repair. So when we did the OCD repair, we also did implant-mediated guided growth. Here's the MRI two years post-op. Look at the nice integration of healing. And look at the improvement out of valgus. Two years post-op, the kid's valgus has resolved. Take the plate removal. Here's another kid. This is a little more complicated because, as you can see, there's mild valgus. There's a torn discoid meniscus. But there's also a medial femoral OCD. So we aggressively drilled the OCD. We treated the discoid meniscus. And we unloaded the discoid meniscus by correcting the valgus with implant-mediated guided growth. Here's another similar case. A 12-year-old female who had previously had this discoid meniscus sacerized came back a few years later with an OCD of the lateral femoral condyle, a hint of meniscal insufficiency, and mild valgus, and was treated with implant-mediated guided growth. And at five months, we already see dramatic improvement of the child's valgus. The child certainly still has the plates in. And we won't take these plates out until there's correction in neutral or just beyond. We recently just did a review of patients in our practice, Dr. Fabrikens and our patients undergoing simultaneous surgery and for knee pathology with implant-mediated guided growth. There were five patients with genu-valgum and patella instability, five patients with genu-valgum and ACL tears, four patients with OCD lesions, one patient with meniscus. And basically, this group showed good restoration of anatomic alignment and behaved similar to the previously reported literature on implant-mediated guided growth without knee pathology. And that's what I got. Don't forget about this powerful tool of implant-mediated guided growth. Please get standing alignment x-rays hip to ankle with any of your lateral, any time you suspect valgus or varus, especially in light of an active knee pathology, such as OCD, meniscal insufficiency, or patella instability. Thank you very much.
Video Summary
In this video, Dr. Daniel Green discusses guided growth in chondral pathology and its role in treating knees. He explains that implant-mediated guided growth is often referred to as hemi-epiphyseodesis in terms of CPT or billing. This method is ideal for uniplanar deformities such as valgus or varus, but is not suitable for multiplanar deformities, extreme rotational malalignment, flexion extension deformities, or significant leg length issues. The video showcases various cases where implant-mediated guided growth was used successfully to correct genuvalgum and genuvarum deformities. Dr. Green emphasizes the importance of proper follow-up and removal of the plates once there is correction in neutral or just beyond. He highlights the effectiveness of implant-mediated guided growth in treating knee pathologies such as meniscal insufficiency, ACL tears, and osteochondritis dissecans. Overall, Dr. Green advocates for the use of implant-mediated guided growth as a powerful tool in treating pediatric patients with angular deformities.
Asset Caption
David W. Green, MD
Keywords
guided growth
implant-mediated guided growth
uniplanar deformities
knee pathologies
pediatric patients
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