C 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
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
O Perioperative Inpatient Management 1 Discharges patient appropriately pain meds weight bearing as tolerated, crutches for comfort schedule follow up in 1-2 weeks