A panel discusses "Case Presentations – Lower Limb Differences" at the UCSF Pediatric Musculoskeletal and Sports Medicine Conference 2023 in Berkeley, CA.
So, um we'll move on to our next session. Um It will be a uh panel or case presentation. It will be led by uh doctor uh Sanji Saber. So I call our uh panel speakers to sit up front, please. Um So, so doctor Sara is one of our pediatric orthopedic surgeons. Um He trained uh for orthopedic residency at uh University of British Columbia, followed by a fellowship um in pediatrics at Jones Hospital L A and Shiners Jones Hospital. He also completed a second fellowship in limb lengthening and reconstruction at the International Center for Limb Lengthening in Baltimore uh at U CS F. He is our uh director for the Multidisciplinary limb lengthening and complex reconstruction Center at uh Jones Hospital in Oakland. Uh He will be uh joined by Doctor Kate Sfor, doctor uh Sigurd um is a pediatric physical medicine and rehabilitation specialist. Uh Doctor Sigurd earned uh her their uh medical degree at U C Davis and completed a residency in pediatric um physical medicine and rehabilitation at Stanford, followed by a fellowship in pediatric uh rehab medicine at University of Minnesota Twin Cities. Doctor Sigurd sees Children uh with conditions that include C P brain injury, spina bifida, uh spinal cord injuries, neurotrauma, torticollis, and gate impairment. Uh Also part of this uh panel is Brent. Brent is a physical therapist who specializes in caring for Children who want to start and maintain or return to an active lifestyle. Uh Brent earned his bachelor's degree uh for exercise biology from U C Davis and then his doctor of physical therapy at Samuel Merritt University and is a board certified uh orthopedic uh clinical specialist. In addition to treating sports injuries, he is the physical therapy lead for the pediatric limb lengthening and complex reconstruction center. And then last but not least we have Alexander Geraldi. Alex is a physician assistant who cares for Children and young adults uh undergoing orthopedic surgeries. Uh Alex earned his master's degree in physician assistant Sciences at Lo Melinda University. Uh and he cheats uh a wide range of musculoskeletal um conditions and is part of our limb uh reconstruction center. So I'll pass the mic on to doctor. Uh All right, thanks, Doctor De Boro. And um as, as doctor de Bora said, you know, we, we're lucky to have a panelists who are very well embedded in the sort of limb difference uh center here uh at children's uh Oakland. Um So, um the format is gonna be a little bit different than the previous few talks in that we're gonna show a few cases and then, you know, open it up for discussion, ask you guys, if you have any questions and then also, uh, pick on our panelists at appropriate uh spots. And I was listening to the last section and it was a perfect segue because this thing came up with both legs and blunts, et cetera. So, um, let's get started and I'm assuming it's, uh, the audience is a combination of physical therapists and primary care physicians, right? How many physical therapists in the group? Oh, nice and primary care. All right, perfect. All right. Let's get started. And please um you could just speak up at any point, you could raise your hand and you know, it's gonna be, I think we've got about 45 50 minutes, 50 minutes. So yeah, we'll just go back and forth and I've got maybe three or four cases that on two themes. Uh So we'll get started. OK? If I can figure that, oh, there we go. Oops. Too much. I'm gonna get it. OK. My disclosures case one. So this is a four year old boy who presented to us with left sided bod leg. OK. So, you know, so the question is, is this physiologic, is this pathologic? Why do you think either of those options? And what would be the next steps? So we'll just open it up. Can you guys see uh you can see the screen? OK. Um Anybody. OK. Let's start with the first part. Is this physiologic or pathologic? How many say physiologic? OK? So it's pathologic and why do you say it's pathologic, one sided unilateral? Ok. What else? Age? Perfect. Right. So, like, uh Doctor Livingston said earlier, yeah, 18 months to two years. So, you know, one side straight even clinically if you look at the left picture and the other one looks bored. Ok. Um, so any sense of what it is, diagnosis, we'll just jump ahead. What could this be? Oh, awesome. Who said that? All right. Why do you say that li little louder, please? OK. Awesome. I don't have a pointer, but I could just walk up and you're talking about this part, right? Excellent. OK. That's what it is. And so what would be the next step? Awesome. OK. All right. Good. OK. Any of our panelists want to say anything about this? No. OK. We'll just keep going then. OK. So you're right. So Brown's disease for exactly the same reason you said, right? So blas disease for anybody who doesn't really know this is a growth plate abnormality. It's considered a developmental problem, not a congenital problem. And it happens with growth and the growth played around typically the proximal medial aspect of the tibia is sick. It doesn't grow as well as the rest of the growth plate, which then biologically creates this ongoing deformity, right? So, OK, so there's two types but just like scoliosis, like there's early onset, late onset, right? So early onset is having these bounced like uh clinical picture before age of four years. In terms of onset, late onset is any time after four, that can be subdivided into juvenile and adolescent, but that's really not very consequential, but early onset and late onset are very different diseases. Ok. So what do you recommend observation, a brace, like a knee, ankle, foot orthosis guided growth, which we'll talk about a little bit more, which is like a hemi epiphysiodesis or a nasty arty, which I think you all know means cutting the bone and straightening it out. So maybe I'll just poll how many for observation? Ok. You gotta raise your hand at one point for these four. OK. How about for bracing? OK. And guided growth. Look at that and osteotomy, OK. You guys are so good. I should stop. There you go. All right. So, yeah. So what is the concept of guided growth? Anybody wants to take a stab at it? What is guided growth? Is that watching with the orthopedics? Like looking at the, um, x-rays and, and alignment and uh, I don't know, every three months, every six months. Yeah, it does involve a procedure. Yeah, but you're right. That's the concept is you just use sort of guide nature, but you have to do something to manipulate the feces. So there's differential growth in the other direction, right? So here we said the medial side of the was not working. So where would you put an implant? Sort of like a dental procedure. Where would you put an implant to kind of guide it on the other side? Right. So you put it on the lateral side. So that's the fancy word is he? But that's what it is, right? So, you, um, ok, I simply can't, ok, we'll get to the bracing and, ok, let's start with bracing. Just, we'll, we'll run down the list. So bracing can work, sort of like scoliosis, right? Something is flexible. The kids still growing, you kind of just tweak it a little bit. But in reality, a lot of these Children don't tolerate a brace just like they don't tolerate the night time stretching, splint, you know, for, uh, heal. And, um, the question is, how long do you keep it on? When do you keep it on? Is it day time, night time, all the time? You know, um, and then, you know, the studies that are out there are kind of confusing because sometimes it's hard to say in a two year old, is this really physiologic or is it early onset blound? So, some of these patients who are included in series with bracing are actually you could question that. It's probably not even. So the water is very muddy. Um, but the general, um, feeling, I think for most pediatric orthopedic practices is that bracing doesn't really work that well, doesn't mean it should not be tried ever. But at least in my practice it's, it's, uh, it's not that commonly done. OK. And so these are all the reasons we talked about. OK. So guided growth um is based on a couple of biologic principles based on biomechanics and growth that if you squish or compress a growth plate for a certain period of time, it's gonna cause growth inhibition, right? So what you, what you're doing is you're differentially again compressing the growth plate on the other side. So this side can grow. And I mean, this is really taken off after these implants, which is a simple little plate with two screws came about. In the past, we used to use staples which would back out and you know, not be that effective. So once the implants change to screws and this extra perio plate, so you can think of it like uh internal brace. So it's there. But the concept is that not that it's a permanent thing. Once the leg is straight, then you can take it out. So there's some inherent reversibility in it and it's a same day procedure unlike an osteotomy, which is a bigger deal, you still have the recurrence, et cetera. So, um and again, it's best to use it when the growth plate is sick but not dead, right? So it's still got some potential on the sick side to wake up is when you would use. And obviously the kid needs to be growing. So when, when is it not indicated if it's a huge deformity in an older kid and especially if there's a huge leg length difference because just doing a hemi isn't gonna correct the leg length unlike an osteotomy with lengthening. So, so this is what it looks like. And, you know, we've done a little art program in the operating room. So you simply put a little screw in the and the metaphors and it's literally a half an hour operation. The kid can wait there right away and go home the same day compared to osteotomies and things. So, you know, very sort of straightforward procedure for the most part. And, um, but then you gotta tell the family the legs still gonna look the same right after the surgery, it's over time, right? And follow up is key. Um, so we intentionally then overcorrect the leg from bow leg. So this is in a matter of 14 months. See, it went from bow legged to actually intentional, not ness. And that's intentional because the kid is only five right now and he's gonna grow till age 15, 16, right? So you don't want to leave this in otherwise he's gonna get way over corrected and that's not good. So, but you sort of, and that's the art and not so much the science, you sort of overcorrect it a little bit depending on a multi multitude of factors. And then you take the implant out, which again is a same day procedure and just like we saw in this case, there's a little bit of a rebound growth which can happen, sort of like a pressure cooker. You know, you suddenly take the laid off and, you know, the steam or the growth sort of rebounds doesn't always happen. And that's the little unpredictability. So you don't want to leave these implants in for many, many years. Right? Because then you could have a permanent problem with the growth plate. Ok. Another kid with blo very, you know, simple, straightforward, easy diagnosis, right, worse than left. Um You can sometimes do an advanced imaging and when it looks like there's nothing on that medial side, on the growth plate or on the proximal tibia, like right here, if you did an advanced imaging or an art program, which is, you know, putting a little dye in the joint to sort of look at the outline of the cartilage, which is not radio DSE, you'll actually see that there's cartilage there, which is unossified, right? It's not turned to bone yet and then the meniscus is a little thick which really doesn't matter. Um But so this is a different problem, right? So here it's too severe and we said guided. So in this case, I think on the one side, we did a guided growth and on the other side, we did an osteotomy but not just an osteotomy because the more severe the deformity, at least in browns, the more it is associated with limb shortening, right? Because it's a it's suffices that's not growing. So it's not just growing in angulation but also in length, right? So here this child needed sort of a multiplanar correction, not just in the frontal plane, but also in the sagittal or the side plane and needed length. So here we did a gradual correction with external fixation. So I'm gonna stop there and pick on our panelists here a little bit. So maybe I'll start with uh Alex Giraldi, who is our physician assistant lead. So Alex, what's our postoperative protocol for a patient like this? Yeah, sure. So initially these kids are obviously operative post op day zero. Um We finish up in the operating room and from there, it's transitioned to the four. Um I like to kind of look at these next seven days as pretty much really just treating the patient and not necessarily treating anything in regards to like o or bone standpoint because it really is important to get these kids kind of understanding what's going on over the course of potentially the next like three plus months. Um So initially post stop Day zero, it's really just making sure they're comfortable. Pain management is really important. Um Making sure that they're understanding ultimately what's on their leg and what will be there for the next three months. So it's, it's care for the parents, it's care for the child and making sure they're comfortable. Um And then from there as we look forward, kind of post up day one to post up day 67. It's um making sure that their understanding the frame and how to care for the frame. Um not only during this time is important for education, but this is also where physical therapy comes in and plays a very important role um in just teaching Children and family specifically, parents, like what this movement is going to look like, how they're able to get both out of bed to the bathroom, transitioning to school and just getting them comfortably from a mental standpoint. Once we kind of get to post day 67, this is where we start talking about healing occurring and and ultimately wanting to start the actual gradual adjustment. So what's on the child's leg is an external fixator. And through that device, we utilize very small millimeter type movements that help to correct this deformity and this deformity gets changed over again months at a time. So we provide them with this schedule and how things will look over the next month. And then we explain to them how to actively utilize um this external fixator. So it's it's a very extensive process, but traditionally starting post day seven is where we begin to lengthen. We have them start cleaning the pin site. So there's six uh half pins is the term that we use that are attached to the leg and teaching them how to care for these pins over the course of the next three months and then teaching them the schedule and then ultimately them understanding weight bearing precautions again through physical therapy is kind of how things look initially. Thanks Alex. And I'm gonna carry on with the discussion and ask Doctor Sigurd. And, and as I said, we, we are a sort of a very um you know, comprehensive team with multiple special specialist in here. So, excuse me, so doctor Sigurd can tell us about inpatient rehab uh which we have a unit. Yeah. So Alex alluded to getting these kids back to being able to being able to be mobile, figuring out how to get around, how to get out of bed, do all these things with this large frame on their legs and depending on the size of the kid and the amount of work Doctor Saal has done sometimes the frame looks bigger than the kid and it can be uh and a bit of an intimidating prospect. So very often we bring these kids to acute inpatient rehabilitation for some portion of the 7 to 10 days that they're in the hospital that lets them get into the uh intense physical and occupational therapy uh services that are available to an acute inpatient rehab kid. They're generally good candidates because these are kids who are otherwise in good health and able to participate. Um They are kids who were previously who were previously functioning well and now have uh and now have experienced a decline in functioning. It is an intentionally surgically caused decline in functioning, but it still is a decline that they need to learn how to, to work with. Um, generally, the surgery is done on a Thursday. The in the rehab is called the rehab consult is called on a Friday. And they admit the following Monday, they will then stay on rehab for the rest of that week, maybe into the next week, depending on how long it takes the child to learn to mobilize the parents, to learn to care for the frame and the child and for everybody to feel comfortable with going home. We use that time to have the physical and the occupational therapists work on how to be uh on the basic beginning of mobility skills on how to get dressed, how to get a shower and all those basic everyday things that all of a sudden have become a much more daunting task. Uh The orthopedic nurses also do a really good job teaching the families how to take care of the frame and greatly reducing the anxiety and stress that everybody has around this. Uh We often see kids go from terrified of the whole thing to wanting to do their own pin care during the course of the rehab. Great, great. Any questions because I know this is a little different and it kind of scares the kids and the parents and sometimes the primary caretakers too. So, um All right. So let's keep going and we'll pick on, uh, Brent in a minute. Yeah. Ok. So there she is, you know, legs are straight but it's not over because remember the growth plate was sick. So, you know, we still have to watch her over the years to see. And there is a chance some of this may recur. Ok. So here's one where things didn't go as planned. So I wanted to show you not just the good cases, but you know what happens when we don't play by the rules or others don't play by the rules. So a little older kid, seven year old browns, again, pretty classic, right? Both sides, right, worse than left. And you can see the right side is shorter and that's why we have a picture with him standing on a, on a left just to level the pelvis. And by the way, that's how we get x-rays also. So if you look at the x-rays, the pelvis is level and that helps us, you know, sort of, um more accurately measure all the lines and angles as opposed to somebody sit standing with a tilted pelvis and a flexed knee on the long side. So anyway, this kid was a great teaching case, uh seven year old. So we, we opted for a guided growth on the left and asked, uh actually, yeah, and then asked the army on the right. Um And if you look at the follow up in the bottom. This is at my previous practice. And so 2009 and, um, he came in nine months, he was starting to recur a little bit on the right side. The left was nicely correcting and then he missed follow up. So, you know, again, guided growth, follow up. Very important. Right. So here he is, he's got this so called windswept deformity. So what happened? The right side actually got worse, the left overcorrected. So it went from bow legged mess to not neatness and guess what? He's getting older. So, what did we do? We took that broken plate out on the left and on the right. Oops. Ok. I don't know how to drive this. Uh, on the right, we did this thing called a tibial plateau elevation. So it was a bigger, much bigger deal than a guided growth where you cut the bone in the joint lift that plateau, medial plateau up and put a chunk of somebody else's bone all graphed and then fix it with plates and screws. So a big deal. And then on the left side, all we did is take the implant out and you could see the power of the growth plate, right? So the growth plate, the plate was gone, the implant was gone on the left knee. And so it went from bow leggedness to knock kneedness. And now it's sort of going back to bow leggedness on the left side. Um And then it just kept going on the left, it went, you know, so it went and so why did that happen? Because as the kid grew that so called reversible changes in the growth plate became permanent, right? So as kids get older, some of these, and that's why it's good to see them early because when they get permanent then even um so there's no growth potential on the six side. So he ended up having another plateau elevation on the left as time went on. And then here he is that skeletal majority. So, you know, a little bit of a win after all these procedures, you know, the legs are straight and he's done growing. So hopefully he's not going to recur but some of this is related to um not seeing him uh for one reason or another, you know, in the follow up that was needed, right? Uh And actually the other is that he presented late, he was age seven compared to age four. So when you see someone like this at age 34 and their legs aren't meant to be bored anymore, then obviously, you know, you got to think of it, especially if it's unilateral but doesn't always have to be unilateral. So what's the lesson learned here? One is that growth modulation while a technically simple operation for the most part for the orthopedic surgeon is really can turn into very complicated problems if you don't do the right patient selection. And you don't sort of chase them if they miss their follow up. So that needs to be done and a reverse. And you know, the second part as we saw in this patient's left leg, something that's reversible at a younger age with time can become irreversible. So again, early diagnosis is, is good. OK? Any questions I'm gonna move on to the, how much time do we have? OK, good. Oh yeah, we got time. OK. So this is just one more case and then you know, we're gonna open it up for more questions. So this is again a growth plate problem, but this one's a fracture. OK. So this was actually um in our practice, one of my partners uh was presented with this uh 10 year old with a Salter Harris too of the distal femur fracture. I think you can all see it, right? It's subtle but not that subtle, right? So it's like that. So she's 10. She had this and got appropriate initial treatment which is, you know, a close reduction and these smooth little wires and a cast so smooth because you don't want threads to go across the growth plate because that can cause more pro pro uh permanent problems, right? Um Anybody wants to take a guess what could happen to this fracture? Like what's, what's a long term problem? Hm. Oh I'm so sorry here. Oh my God now, jeez. So sorry. OK. Go ahead. Yeah, sure. Um So what's the long term problem with um this kind of a fracture which is a growth plate fracture of the digital femur. And by the way, how fast does the distal femur um grow? Is it like in the top one or two fastest growing growth plates? The most slow growing growth plate are somewhere in between? Hm. So it turns out to be the fastest growing growth plate. Ok. So you've got an insult to and, and, and this growth plate, unlike a distal radius is more sort of up and down. You know, it's not a smooth little growth plate and it takes so much more energy to break a distal femur than a distal radius, right? So if you put it all together, so here there is a growth plate fracture in a growing child in the fastest growing growth rate. What can happen? Yeah, go ahead. Yes, exactly. So they can have a premature arrest, right? OK. So that's what happened. So I I and you know, so one of my partners tried to control that. So, and interestingly, this is a little complicated that it's not just a frontal brain problem like bull legs or knock knees, but you got to look at the side too. So on the side, she had a growth plate in the back of her distal femur. So the front kept growing. So the leg got short and it was bent, right? It was flexed and initially they thought it's a flexion contracture. Um, but I'm gonna ask Brent, um, that, you know, is this a contractor or is this a bony problem? And I know it's a little bit sort of beyond your thing. But, ok, I'll, I'll start by saying why is it not a contractor? And why should a patient like this not get physical therapy as the primary mode of treatment? And by the way, we haven't preempted. So this is a bad way. It's not a contracture because the knee functionally can't go any farther. So we can stretch it as much as we want. But we're just gonna be jamming up into this, you know, ill formed knee. So physical therapy is not gonna be the primary mode of treatment for them. So, thank you, thank you and sorry for the set up. So, uh so this is, and that's what happens a lot of times, you know, it's a bony problem and they're like, ok, the leg or the joint or whatever cannot get straight. So let's just do physical therapy. But at some point, we have to recognize if it's a bony problem, you know, therapy is not the answer if anything, the tissues are gonna try stretching out to compensate anyway. So you don't want to do that. So, um so she underwent and external because the leg was short, it was multiplanar deformity. So once again, this is not our sort of first mode of treatment, but when nothing else seems to work. Then we gotta go to the big guns, which is external fixation, gradual correction, inpatient rehab, like doctor sick and said, and so, but here's the problem. So I'll just fast forward. We got her leg straight, but it was a little short. She was still short and she's like, I don't want this monster on my leg, take it off. So it goes back to, you know what doctor sick was saying, you know, we gotta counsel them appropriately and then have a backup plan. So maybe very briefly, Doctor Stick, how do you assess and counsel preoperatively to see if this patient and family can, you know, can go through the journey? Well, even before you talk to them, you can look and see what has happened with treatment for problems previously in the life. Has this been someone who has been sent to physical therapy and missed half of their visits and rescheduled the other half six times. Has this been someone who has missed multiple appointments? Has this been someone, is this someone who is there on exact time every time has done everything you've told them to? There's your first, there's your first thing to look at how, where, where is the family starting? Um Second is to make sure that you really give them a clear picture of what's of what's going to happen and what might happen. There is going to be this very large enormous frame and I hope you have one in or that you show people. Um, I figured and that it will be there for months and months and if you don't make it through to the end, you will not get the results you want. And maybe you shouldn't have started in the first place because you will have worn this thing for a while for no good reason. Um, I find that as much as my natural tendency is to want to be very soft and gentle and sugar coat things. There is a time and a place for saying this is what will happen. This is what needs to happen and you need to understand that. Um And I think it's a so part of it is as well just on our side, avoiding vague language like gosh, we think this could take about three months, but we'll see and then it could be good. It, it will be at least three months if you want it to work. Perfect. Yeah, a little bit of militancy doesn't hurt. Ok. Thank you. Um So just so um here we go. Ok. Oh my God. All right. So um the leg is straight, both in the front and in the side, she actually has full mobility and she actually disappeared for maybe three years or so. There was some, you know, situation with housing psychosocial problems, et cetera, et cetera. The the parents were going through some rough times. So now she comes back actually more recently last year and says my back hurts and I have a leg difference. I don't want to use a shoe lift. What do I do? Um, so I'm gonna ask, um, both Doctor Sigurd and brand very quickly to talk about shoe lifts because that's a common problem. Right. And there's many issues to this. Do you get an over the counter thing? Do you just get a little heel thing? Do you get a full length? How much can you put inside the shoe? How much do you put on the outside? Who do you ask for a shoe lift? Do you just go on the internet? Do you send them to an Ortho or do you just simply send them to a cobbler which are very hard to find these days? Yeah. Ok. Well, they, that's ok. Where's, um, the first question is how much difference do you need to make up in most shoes? You won't fit more than about a centimeter or half an inch comfortably? And even that in the heel of the shoe, you'll get that much distance as a full length lift. Uh, it will be much harder to get through the full, through the full insole. They're just, the shoes aren't that big and the feet are, and the feet take up most of the space. So your first question is, how much space do you, how much difference do you need to make up? Um, if you can do it inside the shoe. That would be where you want to do it. Uh And those, if you just need a small one, you can buy a heel lift over the counter or from Amazon because Amazon sells everything. Um, and with the appropriate guidance from your physician, you can get, you can get the right height and get it in there real cheap, real simple way to go. You can have as many as you have shoes and not be losing it and changing it from shoe to shoe. If you need a full length one, those are a little harder to get over the counter. But still possible, you may end up starting to need to work with an oric depending on the exact, um, depending on the exact dimensions. About four months ago, I saw a guy who was having, uh who was having pain, migratory pain, every part of his body hurt some at some point in, in every day because of his leg length difference for him. I did use an orthotist because I wanted, um, I wanted to keep the lift inside the shoe, but he was right at that margin of what would do it. So I went as thick as possible in the heel tapering down towards the toe because of the less because there's less space in the shoe in the toe box than there is at the heel. Um, go outside the shoe if you have to, if you can't fit it inside because that way, once you've modified the shoe, you can only wear the shoes you've changed over. And how many pairs of shoes are you gonna change? Not as many as a lot of people want to wear. Um, most insurance won't cover. Most cobblers will be cheaper than most orthos if you can find a cobbler who can do it. That's your, that's your choice. Any other words of. So, the other thing that we consider when we're looking at from an outpatient physical therapy perspective is especially if they're right on the edge of, you know, what kind of shoe lift that they need. Um We're also gonna look at the patient and see is the leg length discrepancy actually, what's causing their pain, you know, maybe they have a very subtle leg length discrepancy, but they have all of these other compensations or muscular weakness, movement pattern dysfunctions that we could address first, especially if, say, maybe this family is financially limited, they can't afford or they're gonna have difficulty affording, you know, shoe lifts or a cobbler, something like that like, hey, uh we could try and correct some of these deficits first, see if that completely resolves or improves your problem to a level that you're satisfied with and then you don't have to go and you know, look into external supports like shoes. Great. Great. Yeah. And one last point like a lot of kids and patients who have had a leg difference for their lifetime will have a tendency to walk on their tip toes on the short side. So if you just give them a heel lift, you're actually perpetuating that equinus contractor. So if everything else is equal, I think a full length lift for the short side makes more sense. At least for me. Yes. Go ahead on third if the doctor. Ok. Well, that's, that's good to know. And, you know, I think at least in, in the east coast where I was practicing, they actually, a lot of insurance companies will pay for a shoe as well. I don't know if that's the case here or not. Probably not. Ok. Good. Anything else? All right. So the key, if, if you're gonna get insurance to cover the shoe, you gotta, you gotta make it very clear in your note that, that the modified shoe is a critical part of your medically prescribed treatment. It still may not work, but you won't get any chance. Yeah. Ok. Good. All right. So, so here she is, she didn't want to use a shoe lift. She did have back pain. She did have a significant leg difference. So, you know, what's significant? I think anything more than 1.5 to 2 is, is significant, especially if it's associated with an angular deformity. This one was not, um, did not have an angular deformity at this point. Um ok. So, so this is what we did. So, I'm just gonna, so this is towards the last part of this talk. So, you know, we have evolved. So yes, we showed you a couple of cases of external fixation and you know, the psychosocial toll it takes. Um and it's not great for muscle impalement by the half pins, et cetera. So as you probably may have heard, so now there's a new implant in the market which is internal magnetic, lengthening nail. I, I don't have any financial ties to it, but I tell you, it is a game changer for the femur. So now for the femur, if everything else is equal, we try to do an intra magnetic lengthening and it, it's sort of, so there's much better uh patient experience. Um there's physical therapy involved but um it's uh it's much less. Um and um, but there are obviously downsides and certain things you cannot do with an internal lengthening nail that you can do with an external. So here she is, um, you know, we just put this rod and I don't know if you guys can see it from the back, but it's sort of a telescoping rod and there's a magnet in here. So what the patient and the family does is instead of turning, you know, knobs and struts, et cetera, they just put this thing called an er c external remote control. Um, on the thigh, we just sort of have a, uh a sort of a cross on the thigh where, uh, the magnet is in the nail and they push the on button and it goes on for like 90 seconds and the nail automatically lengthens. And so they do it, you know, 2 to 3 times. So, you know, here's technology that sort of evolved and as I said, it's a game changer, but again, you can't use it in a 34 year old and it's more effective in the femur in a kid because you could put this nail at the greater. Um and you don't have to sort of go across all the other growth plays in the tibia. It's a little bit more challenging because, you know, there's growth plates on the top and bottom. And so, unless it's nearly Scully mature patient, the tibia is not as reliable or as indicated. So there she is, she maintained her knee mobility and had actually a very smooth course. And I tell you, I've had a whole bunch of patients who've had both devices have had an external fixation and internal and there's no question that this is a better experience for them. Um And so here she is three months later and her legs are straight and she maintained mobility. And, you know, at, at the first uh sort of lengthening time, she was an inpatient rehab patient. I think the second time she was outpatient rehab. Um So there we go. And then, you know, so what's the take home? You know, limb reconstruction as you can see is a team effort. You know, a surgeon cannot do this because you need therapy, you need rehab, you need psychosocial. So we have a social worker, we have a child life, we have an artist. So everybody has to work in unison and they, they need to be sort of, you know, in sync with what's expected. Um treatment needs to be individualized and like we showed in the first case or two that try the simple things first, if, if a guided growth works, then you know, do that as opposed to this big operation with a bulky device and watch out for recurrence and overcorrection. So, you know, Yogi Berra, right? It's not over till it's over. So it's not over till growth is over. So you got to follow these kids till skeletal maturity and then uh yeah, and there you go. And just one final plug, shameless plug, we have a webinar that's coming up um um on, you know, limb deformity and this is more. So we also do some global work um in middle income countries. So this is a interesting webinar looking at how pediatric limb deformities are being treated, you know, around the globe. And what and there's this whole concept of frugal innovation, you know, what could we do with less expensive techniques and devices that are locally applicable? And you know, this concept of bidirectional learning and you can always visit our website, et cetera and uh email us if you want to just have a question, you could just look at limb difference at U CS F and it goes to multiple people and you know, one of us can answer any questions. Thank you.
