from Scottish Rite in Dallas Texas. I'm going to present deformity correction in the skeletal immature patient as a case-based presentation today. This was rescheduled due to the timing of the course yesterday. I would encourage you guys to find me via email, phone, text to ask me any questions regarding deformity correction in the skeletal immature patient as it is a big part of my practice. Considerations for deformity really come in a lot of different pathologies in the pediatric world, not just arthropathy, but you can have it with ligament instability, OCDs, meniscal deficiencies, as well as patellofemoral instability. In alignment considerations in the skeletal mature patient, this is a little bit of a laundry list of all the diagnoses in which you should be considering malalignment or coronal plane deformity. When looking at sagittal plane deformity, this list also includes overuse injuries as we knew that things like Oshkod-Slaughter and Sidney Larson-Johansson syndrome can be associated with increase in posterior tibial slope. As we all know and we have seen is that fissile deformity or a fissile rest from an injury to the proximal tibia can cause changes to the slope as well. So today I'm going to present you a skeletal mature patient who had a first time patellofemoral instability episode and Valgas is this gentleman in the picture you see here certainly presents with Valgas. His feet are a little bit internally rotated as are his patellas. He loves football. It's his primary sport. He plays it with his buddies. He's had anterior knee pain for quite some time and he actually does complains about the cosmesis of the deformity as well. Overall his patella is bilaterally. There are no fusions, neutral tracking, no j-sign, no apprehension. He has a negative Bidens. MRI demonstrates some evidence of mild trochlear dysplasia and abnormal patellar morphology but there's no chondral or osteochondral injury or edema or subchondral bone edema. His rotational profile demonstrates in a prone position. His internal rotation is at 55 degrees. His thigh foot angle is 30 degrees. Looking at some of his imaging here, two views of bilateral knees. You can see other than the open physis, no other impressive findings that we can see here. The lateral images demonstrate some abnormal patellar morphology on the left side, a CD ratio that's just on the high end of normal or just mild patella alta if you will. Patellas are relatively neutral, not a lot of significant tilt. This is a hyperflexed knee so very difficult to really make any comments about trochlear dysplasia here. This is his alignment as you can see here. Demonstrates that he has grade three genuvelgum and in my practice looking at the skeletal mature patient, I like to look at a bone age. This is what I call a stop sign bone age. It gives me two pieces of information. Number one is I like to look at the olecranon apophysis. If the olecranon apophysis is present but not fused, that means they're in their growth spurt which we call the peak growth velocity. And then the hand, I use the Sanders criteria for the hand, can further tell me how far along after the growth spurt are they. This can help me identify how many years of growth left remaining that may come into play for a decision making. If you're taking care of anyone with patellofemoral instability, I'm going to tell you that you're going to see kids with valgus. If you haven't yet, it's seen you. I looked at my patients, 284 first-time patellar instability patients. This is currently impressed with JPO, mean age of 14.1 years old. My question for you is what percent do you think have some form of valgus? Well in my population, 16.6 had some degree of valgus. 50% of that was asymmetric valgus, not always on the side of patellar instability. Just about a fourth of them were zone 2 or greater which I would call correctable valgus or valgus you may need to address in the face of patellar instability. So I go back to this case, opportunity for some reflection and some discussion. First thing is, you know, do you address the valgus? Are you going to address the valgus? It's a first time dislocation. He's at anterior knee pain, may have a shred ephemeral anaversion. I did not get a rotational profile on him. So the question is, is what technique? Does he have enough growing left to consider a guided growth technique? Are you going to use screws, staples, plates and screws construct? I'll talk a little bit more about that in a second. Are you going to address his rotation? You know, this has got to be done with an osteotomy is a guided growth or manipulating the growth plates really hasn't been demonstrated to be successful in rotational deformity. Other considerations are, are you going to address the MPFL? Are you going to do a reconstruction, reefing repair? Are you going to do this during the primary correction? Are you going to do it after he corrects? And then soft tissue ballasting, consideration of a lateral release, some reefing or a lateral lengthening could be considered. And then obviously you can do this all in one setting, or you can wait for him to correct and then consider an MPFL reconstruction. All of those are pertinent discussion points in this case. Guided growth or hemipipsoidesis. Like I said before, this has been a really an enormous part of my practices. I think it is so critical because it's easy. And if you just think about it, it is very simple surgically with low morbidity to adjust the physis, particularly at the tail end of growth. If you've got one or two years left of growing an easy plate screw construct, either putting a screw through the physis or doing the plate screws is just technically easy, low morbidity. And so it's something that we should be considering. And you should be considering in your practice. If you see it a permanent hemipipsoidesis use the Femister technique or drilling percutaneous, where you literally go in there and you obliterate the physis, various techniques. I tend to use temporary techniques. I like to have that option if they start to overcorrect. And my estimations of how much growth they have left were not as exact as I'd hoped. Staples were historical. Some still use those, a plain screw that you can see down low and then percutaneous hemipipsoidesis with the transvisial screw or a PETS technique. And that's really my preferred technique, particularly in the peri-adolescent phase. There's one of our publications in JBJS this year, where we compared a match cohort of those that are when a plain screw construct versus just a screw. And you can see I go from high lateral to inferior medial across the physis for correction. This article demonstrated they really have equivalent outcomes. But what's more importantly is the screw actually tethers the physis a little bit more aggressively in the first six months. So you can expect about one degree per month using a transvisial screw of correction versus a plate, which is about a half a degree or 0.6 degree per month correction. You have to be careful with a transvisial screw as if you do it too early, you can put the growth plate at risk. It can fuse once you take the screw out. This happens occasionally and rarely in my practice. It happened 5% of the time. So in those with greater than two years of growth remaining, I prefer a plate and a screw construct. Those that have less than two years of growth remaining, I like to put the screw in and try to plan to put the screw in and not take it out if needed. So going back to this case, the question is, what did I do? Well, as you can tell, I like the transvisial screw or PETS technique. So I put a percutaneous screw. This is a 7-0 fully threaded cannulated screw. I go from proximal lateral to distal medial across the growth plate. I get as far over to the medial physis as I can without puncturing the medial cortex. This can be symptomatic if you do so. Otherwise, these are relatively asymptomatic. In my hands, I put these screws in. They can walk out of the operating room and they can return to full sports within two weeks. Oftentimes, I find majority of my patients will correct within the first six months. And then we can take the screws out or leave them in if we scheduled it. Looking at this case over time, you can see over correction, you can see that he had a great correction. I still wasn't terribly pleased with the left side, so I kept the screw in. And now you can see he's skeletally mature. And so removing that screw will be an elective procedure if he chooses to do so. But you can see here, I did not address the soft tissue. I did not do a knee arthroscopy. I did not do soft tissue balancing. He had a neutral tracking patella, no apprehension. Thus, he is now three years out, no patellar instability, no apprehension, and he's back to playing football. And he's started to develop some muscle mass, as you can see there, going through the stages of puberty. Just to present another case, just to highlight the value of guided growth, 12-year-old anterior knee pain. He's got osteochondritis desiccans lesion over the medial femoral condyle bilaterally. You can see on that standing majority of his deformity on the left side is from the tibia. And the weight-bearing zone goes straight through this OCD lesion. So in my hands, this is an excellent opportunity to not only address the OCD, but to consider guided growth to move that weight-bearing axis away from that lesion itself. I perform arthroscopic. You can see it's a cue ball lesion. There's no curves, relatively stable. I do a percutaneous, a retroarticular drilling. I do retroarticular or transarticular drilling, depending on the lesion. We just came out with a randomized controlled trial from the Rock Study Group demonstrating that transarticular has a slightly faster correction, but overall outcomes at two years and healing rates are really no different. In this particular case, I then placed a plate and a screw construct because he was so young. Therefore, I can take it out once he corrects. You can see over time, he's demonstrated some correction. And I'm going to keep the plate in for just a little bit longer until he fully corrects. One last case. This is not mine. This is Percy of Mark Tompkins. This is an area of particular interest to me, having done a few of these, but not with the amount of follow-up that this case demonstrates. So you can see a skeletally mature patient with an ACL tear and significant posterior tibial slope underwent anterior guided growth of plate and screw construct. And you can see 20 months later, the plates are out, and you can see he has an improvement of his overall position of his posterior slope. He also went into ACL reconstruction during the index procedure. So when to address alignment, you know, skeletally mature patient is the ideal time to correct the malalignment, low morbidity, technically easily surgery, but you got to think about when you're going to do it to be sure that you don't cause a permanent deformity that will make the need for an osteotomy in the future. It's an excellent option for coronal plane malalignment. Transfossil techniques are great options. If you have less than two years of growth remaining, greater than that, I use a plane screw construct so I don't violate the physis. The sagittal plane is an area of interest to me and as well to many in the field. We still don't know a lot about the correction and whether it holds the correction, but I would expect in the next two to five years, we're going to see a lot more of that. I've not figured out a way to correct it in a rotational plane, so that's just not an option at this time. So when to address malalignment in my practice, you can see I may be a little bit more aggressive because I think there is a sweet spot of time to correct malalignment. I do think it's patient and disease specific. I oftentimes have lengthy conversations with the family to try to convince them to strongly consider us because it's really easy to fix when they're 12, 13, or 14, but much more difficult with higher morbidity at 16, 17, 18 years old. You can see my relative indications when I start the discussion, and I would say I hold pretty true to a majority of these in terms of my indications. In my practice, OCD and telephore emulsifilum is common indications for correction, and I'm finding myself correcting almost more than half of these lesions that present to me in my clinic. Thank you so much. I appreciate your time. I apologize we didn't get a chance to do this in person, but I would encourage you to please reach out to me if you have a pediatric case, particularly one that involves deformity. I would be glad to help talk through some options when it comes to a guided growth, hemiplegic disease, or manipulative deficits. Thanks.

deformity correction

skeletally immature patients

guided growth

malalignment

patellofemoral instability