CME OnDemand: Pediatric Foot and Ankle Management: Deformities and Sports Injuries-Pediatric Foot and Ankle Management: Deformities and Sports Injuries

Pediatric Foot and Ankle Management: Deformities and Sports Injuries

Video Transcription

On behalf of AOFAS, I want to welcome you to tonight's webinar, Pediatric Foot and Ankle Management, Deformities and Sports Injuries. Tonight's moderator is Dr. Jacob Zeid.  Joining him are Drs. Elizabeth Hubbard, Philip McClure, and Ariana Janakis. You can find their full biographies and disclosures, as well as disclosures for program planners  in the program document posted in the chat box and in the AOFAS On Demand Education Center. 2024 webinars are provided free to AOFAS members and orthopedic residents, fellows,  and medical students with funding from the Orthopedic Foot and Ankle Foundation, supported in part by a grant from Stryker.  To support education programs like this, donate to the foundation on our website or by texting GIVEAOFAS to 41444.  I'd like to run through a few housekeeping items before we kick off the presentations. For technical difficulties, please try closing your browser and logging back in the same  way you did the first time. Registered attendees may earn one hour of AMA, PRA, Category 1 CME credit by completing the evaluation and CME claim form at the end of the webinar.  You can find the link to Claim CME in the chat tab, and we will follow up with an email following the conclusion of this broadcast.  The webinar is being recorded and will be available for on-demand viewing on the On Demand Education Center content library in approximately 24 hours.  We encourage you to ask questions during the presentations. To send your question to the faculty, click on the Q&A tab on your navigation bar.  If you cannot get to your question during the live broadcast, the faculty will reach out to you following the broadcast to respond.  Finally, please visit our website to register for upcoming events, including the 2024 Annual Meeting in Vancouver, Canada. I will now turn the program over to Dr. Seide to begin.  Thank you. Thanks, Lucas. All right. Good evening, everybody. Thanks for joining us. Excited to do this discussion with some really excellent panelists.  We're very fortunate to be joined by two of our PASNA colleagues, Dr. Hubbard and Dr. McClure. And then, of course, we've got Dr. Janakis with her sports focus, who's going to talk  to us about sports-related injuries in pediatrics and adolescents. So we're going to get things kicked off with Dr. Hubbard.  She's down at Scottish Rite here in Dallas, and she's going to talk about clubfoot and its sequelae. Go ahead, Liz. Thanks. Thank you. So my name is Liz Hubbard.  I'm a pediatric orthopedist at Scottish Rite for Children, and we'll be just reviewing some aspects of pediatric clubfoot. These are my disclosures.  So clubfoot really is a clinical diagnosis. There's multiple components that make up the deformity, and it's important to kind of understand each one of them.  So there's cavus, adductus, varus, and aquinus. And it's important not just to recognize the components, but it's really helpful to understand  why each of these deformities is occurring. So the cavus is created by this relative midfoot pronation relative to the hindfoot.  There's deformities within both the structure of the talus, as well as the positioning of the talus that contribute to that forefoot adductus and the hindfoot varus.  The biggest thing is really the external rotation of the talus within the plafond that really kind of leads to that hindfoot varus position.  And then these kids, as you kind of cast them out and get rid of the cavus and the forefoot adductus and the hindfoot varus, you really unmask a significant aquinus deformity.  So when we're casting children and even older patients, the first thing to really try to address is the cavus.  And so the way you do that is you're lifting up on that first metatarsal. And really what this is doing is it's just bringing that midfoot and forefoot into better  alignment with the hindfoot. So you're just trying to match that supination of the hindfoot to the forefoot here.  Once you correct the cavus, then trying to correct the adductus at the midfoot and forefoot. And the way you do this is you're trying to rotate around the tailor head.  So that's your fulcrum. So finding that tailor head in a child is a little bit, can be a little bit tricky,  but a good tip is to feel that lateral malleolus and then slide your thumb a little bit distal and kind of dorsal anterior, and you'll go right onto that uncovered tailor head.  So you're just trying to unwind the foot around the talus. And as you're unwinding that foot, the hindfoot unlocks that subtalar joint unlocks and it  transitions from a varus position to neutral and then slight valgus. And then the last aspect of the deformity that we try to correct is that aquinus.  And for most babies, when I'm doing this, I'd tell families I've got a 95% right of doing an Achilles tenotomy, because if you try to cast out the aquinus, it's so stiff  and difficult, you can actually kind of cause that rocker bottom deformity and you can cause some disruptions to some of the blood supply to the talus and to the midfoot.  So it's much safer to do an Achilles release in these kids to try to address that deformity. And what we know is, is this is one of the kind of major changes in orthopedics in the  past century in terms of how we treat an orthopedic condition. So in the 1990s, the gold standard really was doing these large intra-articular releases.  And then studies from Iowa with extensive follow-ups started being published. And what we were seeing was good to excellent results at long-term follow-up using, you  know, Achilles tenotomy, 50% rate of soft tissue transfers, like anterior tibialis transfer.  And when we compared how these kids were doing to the larger, the kids who had the larger soft tissue releases, just complete inverse with kids undergoing Pancetti treatment, just  functionally being much better, much stronger, better motion, better functional outcomes than kids with the intra-articular releases.  And so as this has become kind of the gold standard worldwide, what we know is that we can utilize this same treatment for adolescents and even adults to try to correct some of  the deformity. So this is just a recent kind of slightly older patient who I've been treating. She came in, she's just under age four. This is her initial deformity.  We've been doing some casts. And then just last week, I took her to the operating room and this is kind of her foot  position right before we did a TAO and an anterior tibialis tendon transfer as hopefully kind of the last stage of her treatment before we current this near to a brace and kind of  let her get back to regular shoes. So what we've seen over the past several decades is that as the Pancetti method has become  more widely utilized, the amount of surgery that's happening for idiopathic clubfoot is just drastically declining. And even more data keeps coming out from Iowa.  The same group just presented on their 68 year outcomes two weeks ago at PASNA. And so what we see is really good functional outcomes at long-term, but that relapse rate  is incredibly high, almost 70%. I think it was 70% when they presented on the podium two weeks ago.  And so I think that the main thing that as an adult orthopedist, which you might be seeing is not so much the idiopathic clubfoot, but these older kids coming in with a recurrent  clubfoot. And so I wanted to talk mostly about kind of what are the principles in terms of approaching the deformities that these adolescents and these adults can present with.  So when you're looking at a clubfoot, what's really important is kind of understanding each of the segmental deformities that are contributing to what you're seeing.  It also becomes important, especially in someone who's had prior surgical releases and really understanding what that tibiotailor and subtailor joint health looks like.  So are these really healthy looking joints, or are they arthritic? Sometimes kids will have autofusions.  And so kind of the status of those joints is really going to play a huge role in determining how you approach correcting these deformities.  And then certainly paying attention to things like the soft tissue, and then just trying to map out a plan in terms of what can you do acutely, what needs to be done gradually,  how much can you do just through osteotomies. So if we start looking at the different components of the deformity, we'll start in the midfoot and the forefoot.  So for the cavus, a big soft tissue perpetrator here is going to be the plantar fascia. So in trying to address the cavus, a plantar fascia release can be really helpful.  And kind of not just doing the plantar fascia release, but adding in a Steinler stripping and adductor hallucis lengthening.  And then if you need to, a talenevicular capsulotomy, and then using kind of various osteotomies in the midfoot to help with that residual cavus.  So just as an example, now this is not a patient with a clubfoot. This is one of my patients who has Charcot-Marie-Tooth, but she has really extensive cavus deformity.  And so this is what I like to use in addition to doing a plantar fascia release. What we've done here is a dorsal closing wedge osteotomy of the first metatarsal, and then  using that wedge to create a plantar-based opening wedge of the medial cuneiform. And so what I like about this is it really helps kind of address some of the significant  cavus that these patients can have, but it doesn't really change the length of the first ray.  So I think that this is a really powerful tool, but certainly just one of the components that that child needed.  And looking at the forefoot, remembering that that forefoot has this relative pronation compared to the hind foot. And so addressing that with the soft tissue releases.  But then it's important to understand the tibialis anterior tendon is really playing a major role in these kids.  A lot of them have an imbalance between the tibialis anterior tendon being quite strong and the peroneals being quite weak.  And so for the more flexible club feet, doing a tendon transfer and moving that anterior tib over to the lateral cuneiform or the cuboid can really help kind of restore some of that  muscle imbalance, and it helps prevent recurrence. This is just a schematic kind of showing the position of the hind foot, that rotation of  the forefoot, and then this is the pole of the anterior tibialis tendon. And so to address that, we can do an anterior tibialis tendon transfer in a really young child.  I'll tie this over a button, but as kids get older, using like an arthrodesis screw to secure the transfer is really helpful. Looking at the hind foot.  So certainly if there's flexibility in the joints, then doing soft tissue releases, or I still really strongly believe in casting, even for the older kids, can be really helpful.  But a nice posterior release in addition to a tendon Achilles lengthening can be really helpful in these kids.  If you can't get the correction through soft tissue releases alone, then calcaneal osteotomies are useful, like a heel slide, combining a heel slide with a closing wedge or doing a  step cut osteotomy are all kind of different osteotomies that you should have in your armamentarium that can be helpful here.  And then at that, looking at that residual aquinas deformity again, if they have healthy subtalar and tibiotalar joints, you can try some soft tissue releases, but certainly if  there's any evidence of incongruity or degenerative changes, then you're probably not going to get much motion out of that joint.  So in a setting like that, you might consider kind of getting some correction through the distal tibia, through maybe a dorsiflexion osteotomy of the distal tibia, or doing an  osteotomy of the calcaneus and trying to slide that down and lateralizing it to address the hind foot varus and add a little bit of length.  So just a few examples, this is a patient I've seen very recently. He's a perfect example.  I would hope that these are all of the residual clubfoots that you guys are taking care of. He's an 18 year old.  He's never had a surgery. He had serocasting as an infant, and he came in not because he was having any pain, but  just because he's noticed over the past couple of years that his foot seems to be curving. He's walking on the lateral side of the foot.  And honestly, I think a large portion of what bothers him is just that small kind of size at a calf. So these are his x-rays.  And so on his APV, you can see there's a little bit of uncoverage of the tailor head and that navicular sitting just a little bit medial. He's got that forefoot adductus.  He's got some cavus, and we've got some deformities in the hind foot. But overall, his tibiotailor and subtailor joints look really healthy, and clinically,  he's got good motion in both joints. And so this is someone who, even though he's got the different segmental deformities that  kind of make up a clubfoot, he's got really healthy soft tissues. We know that his anterior tibialis is kind of contributing to some of that forefoot supination.  And there's really not a lot of limiting factors here. And so for him, my plan was going to be serial casting to try to see how much of his deformities  I can just gently stretch out with a cast. And usually I'll do this for a minimum of two casts.  And if things kind of seem to be really correcting nicely, I might continue up to four. If I stall out in casting, then surgery is used to address any kind of residual deformity.  And once I ensure that he's got good dorsiflexion, an anterior tibialis tendon transfer is really what helps maintain the correction for these kids.  Unfortunately, when you start taking care of adults, you start taking care of adult problems. And so right now, he really likes vaping more than he wants his foot fixed.  So until we can get him off of the nicotine, he's on hold. But he is a nice example of what an ideal kind of clubfoot recurrence looks like.  Unfortunately, this is my more common clubfoot recurrence. This is an 18-year-old. In addition to clubfeet, she has arthrogryposis.  And so she's got a really kind of marked not just deformity of the hind foot and midfoot. She's got these flexion contractures of her toes, especially her great toes, and everything  is fixed. There's really no mobility here. And looking at her joints, she's got some arthrodesis between the talus and the calcaneus already on the right side.  The joint space certainly doesn't look healthy on the left side. Tibiotalar joints are not normal. And her skin is just really stiff.  So she also has kind of multiple components of a clubfoot in addition to some additional kind of toe deformities that we did not see with the last patient.  And everything is stuck down. Everything is deformed. And she already has some fusions. And we have some incisions to work around as well.  So in terms of patients, she's a pretty low-demand patient. She's mostly, she's ambulatory, but she uses a wheelchair for distances.  So her goal was really just to get plantar grade foot position. She wants to get rid of braces. She wants to wear regular shoes, but she's not out looking to run kind of a marathon.  And so for me, she was a really good candidate to try to get everything done acutely. And since we're starting with a stiff foot, all I wanted to do was basically try to translate  a stiff foot into a better plantar grade position for her. So I felt like she was a really good candidate to do a triple arthrodesis, to really try  to correct most of her clubfoot deformities through the talonevicular and subtalar and  calcaneohuboid joints. We also did an arthrodesis of her great toe and a dorsiflexion osteotomy for first metatarsal.  And then that little bit of residual aquinas, as well as some external tibial torsion was corrected through a tibial osteotomy. We did the same procedures for both sides.  So clinically, this is how she's looking and she's pretty happy so far.  And then this is probably one of the most severe recurrent clubfoots that we see. This is actually my partner's patient. He was kind enough to let me use these lines.  So what we see here is a child who's had multiple attempted clubfoot corrections.  And he's got a lot of deformity kind of all throughout. And he's got terrible subtalar and tibiotalar joint space.  So we've got varus, incavus, pronation, adductus. But he's got a rigid aquinas and that talus is just completely flat. So there's really no good motion through the tibiotalar joint.  And just like our last patient, he's got everything is stuck down, but his is stuck down because of all of his prior surgeries.  And his deformity, the amount of aquinas that he has is really significant. So to try to correct this acutely would require a lot of shortening and probably leave him  with a foot that's really small and not particularly functional for him.  And so approaching him in a different way to try to get him a foot that he can not just walk on, but he likes to exercise. He likes to lift weights. He's pretty athletic.  So we want to get him a really good foot. So an acute correction through the tibia to address some of that aquinas deformity and  then gradual correction of his foot using a using a hexapod frame.  And so one nice technique to do this is to use a jiggly saw to do your midfoot osteotomy. So usually kind of passing this first and then mounting your frame around it.  And then once everything's mounted, then completing your osteotomy.  This is what the frame looks like. And this is after correction where we put these rocker rails on so patients can stand and can walk. And this guy is just a true champion.  I mean, like days after surgery, he's out really doing everything. So he's a pretty exceptional patient.  And I love this slide that Tony has where it's like before too long, you go from this really rigid foot to a foot that's in a much better position.  But realistically, if you've ever done a frame like this, there's a lot of stuff happening between those two x-rays. And one thing is that these are pretty intense frames.  These struts are really acute angles. And so this is a frame where you're probably going to have to do one, maybe even multiple  strut adjustments or strut exchanges to kind of get the correction done. And then everything I always tell families when I'm doing an acute or a gradual correction  with an external fixator, that it's going to take more than one program because we correct  and then clinically we reevaluate the alignment of the foot or the limb, whatever we're working on. And then we dial in some additional corrections.  So it's really common to have to do more than one prescription. So yes, you can get from point A to point B and get a really nice result, but there's  probably a lot of work in between to be able to get there. But it's really worth it for these kids who have really severe deformity because clinically  kind of this is where he ended up. And if you really look at how he's bearing weight to that foot post-op, it's really impressive. It's a nice correction.  And what's even more important is how he's doing functionally, which is great.  So in summary, when you're addressing these clubfoot deformities, it's really important  to look at the ankle and the foot and determine what are the segmental components of the deformity. I strongly believe in casting.  So I think there's always a role for casting if there's any flexibility in the foot, and then you need to break things down into what can be done safely, acutely from a soft tissue  standpoint, from a bony standpoint. And if it's a really severe deformity, then considering a way to do something kind of  gradually with an external fixator can get you a lot of correction. Thank you so much.  Thanks, Liz. That was great.  I'm going to keep us rocking along. I just want to remind everyone, if you have questions, you can ask them in the Q&A tab,  and we will be happy to talk through those once we get through everyone's talk. Next, we're going to have Dr. McClure, who is the director, hang on, I'm going to make  sure I don't mess this up, the director of the International Center for Limb Lengthening  in Baltimore, and he's going to talk about Dyslativial Growth Arrest and Management of Post-Traumatic Deformity. Take it away, Phil. Thanks.  Great, thank you. So I'd like to do this similar to the way Liz had with a few cases, but we'll start by having trouble advancing the slides. There we go.  I do have some disclosures I must have forgotten to give you, Jacob, but relevant to this, I do have a teaching consultant role with OrthoFix.  So pediatric distal tibial fascial fractures.  In the literature, you'll find various reports of how bad they are.  15% incidence of growth disturbance, which is maybe not so big of a deal, but when you get to high energy, you have 86% growth arrests and motor vehicle accidents.  No sagittal deformities. I would be very cautious evaluating for sagittal deformity in the literature because it's very, often very poorly done.  I see a fair amount of sagittal deformity, to be honest. And I definitely see leg length discrepancy, but that may be a selection bias in patients who choose to travel.  There've been a couple of different efforts to try to figure out which ones are the worst. You know, medium alveolar fractures  tend to be one of the higher risk growth arrest fractures,  that require anatomic open reduction internal fixation  with, you know, previous reports of as high as 40% rate of growth arrest. If anatomically reduced, then it can decrease to maybe two to 4%.  Salter-Harris II, you know, my previous education until I was digging around for this talk some time ago, was that they're really not that big of a deal,  but 42% growth arrest rate in this series is pretty discouraging. Interestingly, open reduction for these fractures increases the risk for subsequent surgery  and does not prevent growth arrest. So these are fractures that tend to need to be watched.  And then, you know, this is the biggest series I could find trying to really nail it down. The tallow fractures really don't have to worry about that much.  Of course, those happen as they're starting to close. Anyway, Salter-Harris II's a little more of a bad actor than I'd originally been taught.  And then the medial malleolar Salter-Harris III and IV, very problematic. Initial displacement, some series say this is the biggest predictor, others say it doesn't really matter.  There's a general acceptance that the very high energy fractures are more problematic. So what I'd like to do now is just go through a few different cases,  looking at basically the simplest management and sort of stepping up from there. This is a 12-year-old female. She's a year after a distal tibial fracture.  I don't have her injury films,  but the family had said the doctor was really worried about this one, so I'm assuming it was a three or a four. And she presents with a relatively  minor leg length discrepancy of seven millimeters measured from stem to stern. But you can see a very clear central bar with some varus increasing lateral distal tibial angle  and distal migration of the fibular fysis that should be at the level of the tibial tailor joint.  So the options for management of this are pretty broad, but if the family says, hey, I want to keep it simple. I don't want to have something that will not work.  I don't want to have a big surgery. I just don't want to have to worry about this leg length discrepancy that the referring doctor is worried about.  Here's her x-rays and CT compared to contralateral side. She does have a sagittal deformity of about four degrees, but not enough that I would worry about.  And her varus with a supple subtailor joint I thought was within an acceptable range. And her bar, although potentially resectable, this is a patient who wants to keep it simple.  So they decided to undergo bilateral distal tib-fib completion of FCDs. So I'd go and scrape out the back of the remaining fysis on the injured side  or whichever part seems to be driving this growth disturbance because it varies from patient to patient. And then you have to make sure to shut down the fibula on the injured side.  And the fibula is a real bear to try to close for whatever reason. It's for me, the hardest physis to get to give up on growth. So I've started scraping them out aggressively.  I have not had one fracture and then I've been putting a fully threaded cannulated screw to try to drive an earlier closure. That would be an interesting thing to discuss  with the panel here if anyone's had better luck than me.  So the next patient sort of stepping up in at least management intensity, a 12 plus eight female. She's a year out from a ankle fracture.  She's having increasing discomfort with long distances. She feels there's a difference in the angle of her foot. On physical exam, her ankle looks to be invarious  and her subtalar joint, as you know, this crowd is probably very sensitive to, has not really been able to fully compensate for this such that she can be neutral and max eversion  and she has excessive inversion range. So here's her EOS film. She's got an increasing lateral distal tibial angle in contrast to the previous patient.  She's noticing this difference and her discrepancy is more in the range of 1.2 centimeters already, just one year after this distal tibial growth arrest.  Her bone age is more or less commensurate with her clinical age. And she has a discrete bar that spans from anterior to posterior  and is relatively close to the anterior surface of the bone.  For her, you know, of course, we discussed completion of FCDs as impossible osteotomy. They were worried about length since she had already developed a significant discrepancy  just from the one year of injury.  And so we go through a sort of endoscopic fissile bar resection. There are several different ways to do this, but when there's a minimal growth plate in front, that's viable.  This is the simplest way. This trick was taught to me by Dr. Birch. And then you can use an arthroscope to visualize a nice, healthy band of fissus.  And you just keep going with your reamers until you can see the band crossing through all surfaces.  There's various ways you can fill the gap, but you wanna see this, you know, sort of bone and then cartilage and bone. Circumferentially, historically fat has been proposed  as the ideal. Some people have used methyl methacrylate or cranioplast. I just fill it with wax. My theory is if all surfaces are waxed, then it can't recur.  And it's not a giant wax plug. It's just a layer of wax along all surfaces of the bone.  I used to use marker wires. This case will show you why I stopped. But here's a resection with healthy growth plate, visible medial and lateral.  And she gets this nice little comet tail as the growth starts recurring again. You can see the equator of our old resection, now about a centimeter proximal.  And the pin has had to be removed because as it moved proximally and the metathesis tapered into the diaphysis, it started to irritate her tibia and tendon.  So I now just use growth as my marker because I don't have access to fancy tantalum beads.  This one to me reminds me that maybe the predictors we have for remaining growth aren't so great. So I try to watch the physis until it closes.  She grew another, I think, centimeter after this at two-year followup before where the growth plate closed.  She did not improve her leg length discrepancy,  but it didn't worsen either. So for bar excision, ideally you want to have a discrete and accessible bar. Ideally it's trauma, less than 50% of surface area,  certainly, ideally, significantly less than 50%. And hopefully you've got two years of growth remaining so that the juice is worth the squeeze.  At three-year followup, she had completed and she has a lift. So her discrepancy did not correct, but it did not worsen. Here's another eight-year-old female.  I was able to track down her injury film. She has a displaced medial malleolus fracture that was relatively high energy with an associated distal fibular fracture.  It was fixed pretty well, but you can see this angulated growth arrest line indicating that it's going into varus, or at least I can. Hopefully it's coming across reasonably well.  Two years post-injury, it's progressed, and she has symptoms and her growth plates are closed. Here it's very important to make sure that when you correct to anatomic alignment  in both the AP and sagittal plane, that you've got the subtalar joint motion available so that she will contact the floor square after you square up the ankle joint.  For the acute correction in younger kids, sometimes they don't worry about the fibular fixation because they feel that hardware is more likely to be symptomatic,  and older kids obviously start to treat them like adults with the fixation that I was showing in the previous case. You do want to angle the osteotomy such that the hinge point,  where your sort of bone is staying in contact if you need an opening wedge, is at the physis, which will be the apex of the deformity for all of these post-traumatic injuries,  at least post-traumatic physio growth arrests.  And here's our last case in the fractures, and then we have a bonus case for post-septic if anyone's interested. So this kid, 15, two years after distal tibia fracture,  his complaint was ankle deformity, and I think maybe my legs aren't straight. So this happened at 13, and he showed up with this really quite striking distal tibial deformity  and a significant leg length discrepancy, really driving me to question,  how good really are we in predicting how much growth is remaining? For a 13 and a half year old male, I would not have predicted him to generate several centimeters of discrepancy  and 30 degrees of deformity, but he did. So I can't argue that it wasn't possible.  His deformity was enough that he actually had some mechanical axis deviation. So we planned this out with digital paper, basically, trying to make sure that our distal tibial angle  is both normal and puts the anatomic axis of the tibia right into the talus. And here's our opening wedge. You can see you have to keep a very low fibular osteotomy  in order to avoid impingement or pain or disruption of the syndesmosis as you go through these corrections. Everything but distal tibial osteotomies,  I tend to just cut in the mid fibula for these gradual corrections. I felt that this was too much to go through with an acute correction.  For smaller ones with leg length discrepancy, you could certainly do an acute correction with a plate and lengthening with an internal nail.  But this guy ended up with an external fixer with the sort of lowest osteotomy I could get of both the tibia and fibula. He got his length and his correction  and his previously stiff subtalar joint, actually, as he was able to walk with no foot ring,  loosened up and was doing very, very nicely with this neutral lateral distal tibial angle and restoration of length at his last follow-up.  The gradual distraction, as long as you don't have to bridge the foot, is actually very well tolerated. It's not particularly painful, at least the way we've been setting up  with a very stable fixation. It's really important that you get enough fixation, at least three pins or two pins and a wire in the distal tibial block.  If you can't get that, or you're not confident the bone stock is good, you may need to bridge to the foot. And consider where your fibular osteotomy needs to be  in order to allow the correction of the distal tibia.  Doctors, do you want me to do one more or should we move on?  Yeah, you've got time. Go for it. So this is sort of adjacent to trauma, but I think something that would also have a tendency to show up in some foot and ankle specialist's office.  She's nine years old. She had staff, a pediatric orthopedist sort of outside in another state, saved her life. She spent some time in the ICU  and presented with a septic bone defect, varus deformity, leg length discrepancy, and obviously sequela of a very severe infection tracking all the way up her tibia.  Here's our closeup. You can see perhaps a viable physis, approximately migrated distal tibia with a bone defect and varus. Her sagittal plane, fortunately not so bad.  And her joint radiographically looks okay, clinically a little hard to know what's going on with the septic non-union so close by.  On the CT scan, still some suggestion that perhaps that growth plate might be alive, although very unclear. You can see the orientation of the articular surface  as well as perhaps viable joint surface as well.  So the first stage of the CT scan is a very simple CT scan.  So the first stage for her was to prove that the infection was still gone. I opened it up, debrided it, took cultures and specimens,  left the antibiotic PMMA spacer that I pinned in place  and cast her while we waited for cultures. We actually had to do the spacer twice, but we're able to get to clear the infection and subsequently complete the mascalade  with a bridged external fixator. I was able to get two wires and a half pin into that distal tibial segment with the half pin in the medial malleolus  you can see just above the distal hexapod. And then two crossing wires holding the plafond and skipping the fibula so that we can correct.  As that starts to consolidate, we simplify the frame, let go of her foot so we can be sure she's comfortable with how it's contacting the ground.  And reduce the number of radiographic blockers so that we can see that consolidate. And five months post grafting, she has a nice lateral distal tibial angle,  a little bit of medial translation of the plafond relative to the anatomic axis of the tibia, which is a little bit embarrassing, but it was the best I could get it to be.  And her sagittal plane looks good. And her joint looks, I would say, a little bit better than the rest of her body. I would say debatable, but it's moving,  she's happy, she's playing soccer and reasonably comfortable. Here it is nine months, maybe some increasing of the articular thickness, no joint pain, not phenomenal motion,  but doing very well.  With the septic growth arrests, it's very hard to know what you should anticipate for residual fissile growth. Certainly that distal tibia,  as I look back in retrospect, was dead from the beginning. Her proximal tibia also seems to have suffered some residual effects.  And so she goes through a simple proximal tibial frame and lengthening, capturing a shindysmosis proximally and distally to protect the ankle joint,  long leg films to prove the alignment is acceptable. And she's still, this was, I did this just maybe two, three months ago,  and she's still waiting to finish consolidating and get her frame off.  So the take home, you always wanna aim for anatomic when you're reducing these fractures. The possibility of a growth arrest should be discussed,  I think, before any distal tibial growth, growth plate fracture, except perhaps the salt of the Harris ones. There's nothing more disappointing to a family  than to have it happen and not have expected it.  Watch for that asymmetric growth arrest line that we reviewed. And then remember, you have a full gamut of options that you can offer, bilateral epipsedesis,  don't forget the fibula. Bar resection and monitoring, you could also do bar resection and tethering. You could put an antilateral eight plate for Varus  or a medial screw for Valgus.  Acute deformity correction with an osteotomy, probably one of the favorites in this group, I would assume. But don't forget about gradual deformity correction  with distraction osteogenesis for the more severe and large magnitude deformities. I will drop a little plug for the limb deformity course. If you're interested in more  of these gradual deformity techniques, I would be happy to have you. There's scholarships available for residents.  And feel free to email me. This is my work email, hopefully with no typos.  Thank you. Thanks, Phil, that was great, man.  Okay, now we're going to have Dr. Giannakos  go through osteochondral injuries. And so we'll sort of switch gears and get into a little bit more sportsy talk.  Arianna is at Yale. She's AOFAS in foot and ankle training, but has done some additional training in sports. So she is a wealth of knowledge. So thank you very much.  Great, thanks for having me. And yes, I love being on these webinars because I learned so much from my colleagues and just having the pediatric insight.  It's really amazing and incredible what you can do, especially with that limb lengthening. And it's nice that we have people like you that we can collaborate with.  And I'm very lucky at Yale. I have great team members, both in the sports department and pediatric department. And I get to do a little bit of overlap in sports and PEDS  and taking care of some of the young athletes. So my focus is going to be really focused on trauma-related osteochondral injuries in our adolescent athletes.  So these are my disclosures. So I'm going to just start off, not going to get too detailed into the first three cases, just to put these out there.  And then we'll refer back to these later on. So this is a 10-year-old female, status post fall off of the trampoline. Whenever I hear trampoline, I get really nervous.  And you can see this is an acute injury where you see there's a fragment loose in the joint. And then the second case we'll go over is a 15-year-old male,  status post an ankle inversion injury approximately a year ago. He had chronic pain and was unable to return to sport. And then our third case is a 13-year-old male  who had a left ankle injury while playing basketball approximately two years ago. He was able to get back somewhat to sports, but then had another incident  where he had a motorbike injury about a year ago and never got back to his activities and continued to have pain and swelling within the ankle.  So as I was putting this talk together, I did come across this really nice consensus statement that was published real recently in 2022 in the Journal of Issacas,  which really focuses on pediatric ankle cartilage lesions. So I'm gonna refer back to this throughout the talk. But ankle sprains are incredibly common,  particularly in the adolescent population. And inversion injuries can result in an osteochondral injury in almost 50% of these ankle sprains.  And oftentimes these are overlooked and often misdiagnosed. Patients come in though with this chronic deep ankle pain. They feel like the ankle is locking, clicking.  Sometimes they have feelings of instability and it limits their sports participation. And when this is a pediatric or adolescent patient, this can be incredibly concerning  for them and their family members. So in general, from the consensus statement, how can these lesions in the pediatric population be defined?  And it can be in terms of skeletal maturity. Now, just to touch on osteochondritis dissecans, which is umbrellaed in this talk a bit, this is non-traumatic in nature.  Many people have this and it's incidental findings on imaging. It's typically bilateral, usually on the medial aspect of the talar dome.  Etiology is still a bit unclear. It's been attributed to ossification defects, vascular anomalies, emboli, endocrine abnormalities, and most of the time these  injuries can be treated nonoperatively. The ones we're going to focus on, though, is some sort of trauma-induced injury where these patients have more chronic symptoms.  So how did the consensus statement define these two conditions? So OCD affects the subchondral  bone in the form of a subchondral fragment and a clear sclerotic layer, whereas a traumatic osteochondral lesion primarily affects the cartilage. And lateral lesions are typically  more trauma in nature, and they tend to be on the middle and anterior third of the talar dome,  while medial lesions, although more prevalent for osteochondritis dissecans, there's almost a 60%  to 80% history of trauma for these medial lesions, so still be suspicious that there could be something else going on. A lot of the times they're a little bit more posteriorly  located, though. So the workup is standard. We get our radiographs, although oftentimes some of  these lesions can be small, so further imaging is warranted. An MRI is useful in assessing  fragment stability, and a CT is often incredibly helpful because it can assess bony involvement,  and more so, you know, MRI really can overestimate the size of these lesions due to the bony edema  that we see in there, so the CT gives us a better estimation of the actual size of the defect. Now,  there's various classifications. I just went back to the original in this slide for Burt and Hardy,  you know, talking about subcultural compression and then detachment of the fragments, complete  detachment, and then ultimately displaced fragments. So what are some prognostic factors that we should consider in our pediatric population? Well, this thing, from the consensus  statement, they look at lesion size, the integrity of the overlying cartilage, hind foot alignment,  lesion containment, ankle stability, and if they had any previous treatment. Other things to consider is that partial thickness injuries really do have a limited capacity to repair,  as we know that cartilage is usually avascular in nature. If there's a subchondral bone injury,  this may allow additional healing with fibrinous scar, and in general, age is really a good prognosis if they're younger, so younger patients have an increased ability to heal.  So which symptomatic pediatric ankle cartilage lesions can be managed non-operatively? Well, most actually can be, unless there is a displaced fragment, and typically, treatment can  be a period of mobilization, six to eight weeks, followed by physical therapy. So this was a nice  study, actually, by one of my colleagues and friends, Jen Weiss, who performed a retrospective  review with her group, looking at osteochondritis disticans, and she found that patients who had  some sort of underlying injury ended up requiring surgical intervention about 22% of the time,  and that those who were a little bit older, so between that 12- to 19-year-old category, were eight times more likely to require surgical interventions. So what are the surgical  interventions that we can consider for these lesions? Well, we have internal fixation, with or without bone grafting, retrograde drilling, debridement, with or without bone  marrow stimulation, and there are various other types of autograft transplantation options as well.  So this was a nice study that really only looked at six ankles, but demonstrated that there was  good outcomes with arthroscopic retrograde drilling, with 100% of their patients being  asymptomatic at seven months, although there was only 50% complete radiographic healing. That's not  uncommon with this, but overall, the patients did well. This was a retrospective chart review  that actually looked at several different methods of treatment, although they clumped them all  together, but found that there was a 27% reoperation rate even with one of these treatments,  although there was a fairly good return to sport in the patients that did well. Female sex and  higher BMI had negative prognosis regardless of the treatment. This study, actually from  Across the Pond, conducted by Gino Kirchhoff, who actually is someone who does a lot of cartilage  work, particularly in the adult population, performed a systematic review looking at 20  different studies and 381 lesions, all different treatment methods, and essentially reported that  they felt that the fixation groups had better return to sport, better functional outcomes  overall, but for the most part, regardless of what treatment was performed, patients did fairly  well. Reoperation rates have been looked into, and unfortunately, once again, the reoperation  rates tend to be up to 25% regardless of the type of procedure you're having, and higher rates are  found in more advanced cartilage injury, which does make a bit more sense. So by comparison to  ankle cartilage lesions in the adult population, what are some considerations in our pediatric  population? Well, the status of the thymisis is important. How do you access the joint? That's  important, and then overall hindfoot alignment. So getting back to some of these cases, so this  is a 10-year-old girl. She had right ankle pain. She had a fall from a trampoline and had an  inversion injury. On exam, she had a lot of pain and swelling over the lateral aspect of her ankle,  but also deep within the ankle joint, and she was positive and tenderness to palpation over the  fibula and ATFL, and this was actually first seen by one of my pediatric colleagues who showed me  this image and had asked if there was something I could do potentially arthroscopically for this  patient. These are her CT scans, which you can see that there is a displaced fragment within the  joint on the lateral aspect and the posterior aspect of the joint, and so I did utilize needle  arthroscopy in order to remove the loose fragment and really assess the joint, and you can see that  we were able to take that piece out. You can also see the defect that it's left behind, so I did a  little bit of shaving. I don't really do microfracture anymore. Most of my bone marrow  stimulation is just light shaving down to bone, although I did have a NanoPIC, and I did poke one  or two little holes just to stimulate for healing, although, once again, didn't want to be too  aggressive, particularly in this really young patient. She is over a year out, so she has been  doing very, very well. We just had her one-year follow-up. She's back to sport, no problems  whatsoever, very happy, and you can see, actually, even on the imaging, everything looks like it's  filled in nicely. So then we have case number two, which is a 14-year-old boy. He's a soccer player.  He had come to me with chronic left ankle pain about six months or so, and so he had had a prior  injury about a year ago at a water park. He had inverted his ankle. He was able to return at that  point to walking but never really got back to the sports he wanted to do, and when he presented to  me, he had really deep-rooted ankle pain. It was worse with weight-bearing. He felt like there was  some instability, felt like there was some locking sensations. He had a lot of tenderness over  palpation over the medial talar dome, particularly when I plantar flexed the foot, and just global  tenderness, and he could not get back to soccer, which was something he really loved to do, and you can see on images there is a small little defect over the medial talar dome,  hard to identify and really define them, and then you can see on the CT scan that he does look like  he had osteochondritis dissecans, which once again was probably there his whole life, but we  see that there's a flipped fragment, and this indicates that there was significant trauma to  this joint, and the fact that he had trialed conservative intervention for almost a year, we decided to do something once again arthroscopically, so for this case, I went in  once again with the needle scope. I was able to remove that loose posterior fragment. When I looked  at the cartilage, it was flipped up a bit. You can somewhat make that out in the picture below,  and I decided, although I treat more adults, I treated him somewhat as an adult where I did some bone marrow stimulation, did some bio cartilage with CBMA, and covered that with  fiber and glue, and now he's eight months out. He is full return to sport. He's playing soccer. He  has no clicking, no locking. Oftentimes in my cartilage injury patients, I will sometimes get  a repeat MRI after a year out depending on the patient to really check how well the cartilage  is doing. He's a young kid, so I likely won't, but overall clinically he's doing well, so hopefully  he continues that way. One of the consensus statements asked if there was a role for biologics  or scaffolds in the management of pediatric ankle, and the 84% consensus rate was that the use of  biologics and scaffolds can be considered, so it's a little bit variable, probably a bit controversial,  but there's nice literature in the adult population that CBMA and bio cartilage can help enhance repair in some of these smaller lesions. And then lastly, this is a 13-year-old  male. He had a left ankle injury playing basketball two years ago. He did get back to walking,  not really 100%, but was able to get around well enough, and then unfortunately sustained a second  injury a year after that original injury on a motorbike, and after that he was unable to do  much. He was really limping around, had significant swelling in the ankle, and so this is now  technically two years out from the injury, and you can see on the MRI that there is a significant  defect here. There is a lot of signal in the talus and on the CT. Once again, this isn't an  overestimation on the MRI. This is something that is very concerning that he's got this cavity that  is going to need some grafting. So my plan going into this was a more open approach. Since he was  younger, I wanted to avoid any type of osteotomy through the physis if I could, so I chose to do  an anterolateral approach, and I took down some of the lateral ligaments. Fortunately, he was  pretty lax at baseline, so I was able to plantar flex the foot and go through the soft tissue in  order to access the lesion, and then I did a lift and fill technique, which I have here some of the  images. So when we got down, it was completely displaced, even though the frayer's in there.  That's exactly how it looked when we saw it. This is us lifting it up. I did utilize some bone graft  that I did put in. I used a chondral dart as well as a little bit of fiber and glue around the edges  in order to sink that down and fix that, so I did more of a fixation technique, which I know  there's a variety of ways you can fix these fragments, but that was what I went with, and he is now six months out, so not too much follow-up. These cases are all within the last  year, but he is back to sports. He still gets some episodic swelling. He has zero out of 10 pain.  His mother, since he was doing well, bought him a new motorbike, which I am not sure why she did  that, but I'm hoping that he does not fall into that 25% category that might need a revision,  but at this point, I think he's been very successful. He is someone who I may, down the road,  get some further imaging just to check in on him periodically to make sure that the cartilage is  integrated well, and then lastly, the consensus statement about approach. If an osteotomy is  required in the pediatric population, what are some of the appropriate approaches? So obviously,  if necessary, if you can avoid this in anyone who has an open physis, that's the method of  choice, but you can still do a tibial osteotomy or a fibular osteotomy depending on what you need  in order for, but once again, this is something you, you know, if they're a little bit older,  maybe okay, but in the younger patients, it's something I'd be very concerned about doing.  So in summary, adolescent osteochondral injuries are very complex, actually. There's a lot of  literature out there, but it's so variable. There's so many different techniques and strategies. You know, myself managing more of the young athletes and the young adolescent,  I don't know if there's one right way to do it, but you have to go with what's in your toolbox,  but initial management for these should really be conservative because a lot do well unless  they're super displaced. And then once again, if they're associated with trauma, be a little  bit cognizant that they may require surgical intervention, but there's promising outcomes overall, regardless of the procedure. Thank you. Thanks so much, Erin. That was great.  Well, there's only one question right now in the Q and A, and so, oh, here's another one that just popped up. So the first one is how do you assess flat top talus with x-ray or CT?  Liz, you want to take that? Yeah, sure. So I feel like normally with really good x-rays of the ankle  and the foot, you can usually see some of the tailor deformity, but I do find myself ordering  CT scans in some of these kids, mostly just to kind of really look at the more of the subtalar  joint. And if I'm suspicious that there's other fusions kind of within the midfoot or forefoot. So I think CT is useful, but for the most impressive flat top talus, you can usually  get a sense on x-ray. I just want to point out, I agree, I think most of the time on a decent  lateral x-ray, you just have to make sure you actually get a true lateral because there's so  much deformity. Oftentimes your lateral is more of a obliquish kind of a film. And I just want  a little, just a little something to drop into your head that in my mind, the reason that the  assessment of flat top talus is so important is because oftentimes we'll see these patients and  they have limited dorsiflexion and they'll have been treated by somebody else and they'll complain  of their inability to get out of Aquinas and they'll be treated with Achilles lengthening, but with a flat top talus, that does nothing. So it's really important that they have  a true and normal tailor dome to get anything out of an Achilles lengthening. If it's a flat top talus and they are in Aquinas, you're going to have to be thinking  about a tibial osteotomy. And then the next question that came up, Arianna, I think this  one's for you. Have you come across an adolescent with an OCL of their tibial plafond and how do  you approach that? Yeah, that's a great question. It's not as common, particularly in the pediatric  or adolescent population. I find that a lot of the times as patients have recurrent ankle sprains and  they can get these kissing lesions where the talus and the tibia are involved. If it is the  tibia, it's a much different beast, unfortunately. I always believe less is more on those. If it's  really symptomatic, then sometimes going in with a scope, cleaning and debriding is the extent of  what I will do for that. Depending on if there is a cyst associated with it, how intact the cartilage  is, that's when you start getting into a little bit more dicier procedures where you sometimes  can actually take a little like jamshidi needle or a drill hole and you actually come from the  tibia down and you're looking at the joint inter-articularly with your camera and assessing  to see if there's any communication. And if there is, you can actually pack some bone graft in  through the jamshidi or through your haywire, whatever you're using. And then you can pack  it up with some biocartilage and fiber and glue. But the problem is we say that and actually Rick  who is a cartilage legend, he was in an AOSICL with me and his whole talk was on tibial osteochondral  injuries. And it's all nice to do all of that, but in reality, because of gravity in itself,  we don't know if that's falling out. We don't know how well that is. Now putting the patient  in ankle dorsiflexion and splinting them, that's going to help compress the joint. So we think that  it stays up there. But a lot of the, even in the adult population, I find that once you start going  after a tibial lesion, sometimes it can get really dicey and really start to spread and get worse  and worse and worse. So in the younger group, I probably would limit as much as I can and just do  a simple chondral debridement on it and call it a day because we know that the young patients  tend to heal really well. So I have a less is more attitude when it comes to these young athletes.  Yeah, I think all of us loathe the days that tibial OCDs come into our clinics.  Okay. I'm going to jump one question. There's a question here about hemi implants for talus. I  don't know if you guys have much or any experience with that. I've certainly seen in the European  studies as well. I'm going to jump that question for a second because I want to get down to this  other question talking about knee valgus, hind foot varus, club foot. It seems to be a compensated  situation. Then they have lateral impingement symptoms. So just sort of knee deformity  associated with club foot deformity. I don't know. I want to ask Phil, in your limb reconstruction  service, I can't think of a time I've run into that particular issue. Have you seen that before?  And if so, or something akin to it, and if so, sort of how do you think about  knee deformity with associated foot deformity or compensated foot deformity?  I've certainly seen knee valgus with some clubfoot kids, probably just  in a random population average kind of way. I can't see I've seen it with something that I  thought was like lateral impingement. I assume you're talking about like subfibular impingement  on the peroneals. But I feel pretty strongly, we used to talk about good combination, bad  combination at just the knee where there's no real working distance that it was okay to have a  valgus tibia with a varus femur. This adult sports guys have kind of shown that's bogus. You really  can't tolerate oblique joint lines. So if I felt I was in this situation, which I can't say I've  been in, or maybe it's seen me and I haven't seen it, I would correct both. I wouldn't try to  make an average in the middle for something like this, at least leaving an oblique joint line.  I have sometimes done midshaft tibial osteotomies with lengthening in dwarves who have double  level deformities at the knee and ankle. But for this, I think I would probably tackle both,  but separately, at least at separate levels, maybe all at the same time, though.  Liz, you have a thought on that? Have you seen that?  Yeah, I was trying to think if I've seen that exact combination. And I can't think of one  where I've seen it specifically in clubfoot. But I agree, if you've got substantial deformities at  two levels, I'd probably address them both individually than trying to find kind of just some resolution point in the middle. I will say if your department is fairly  territorial and they don't want you doing HTOs, fix the foot relative to the distal tibia,  let somebody else worry about the knee. Yes, you'll be a little funny coming down to the floor,  especially if it's really stiff. But you don't want to be, if you think they're symptomatic from the knee, after they correct the knee, now your foot's going to be screwed up again.  That is a great point. Okay. Well, let's, here, Arianna, let's just quickly tackle this question about the hemi-implant because we're coming up on time for the end of this webinar.  Sure. I don't have that. Any comments? Yeah, I don't have as much experience with a hemi-implant. I think for the pediatric  adolescent population, I probably would be very hesitant to do something like that.  I do know that they have pretty decent data over in Europe, so I do agree with the comment.  But unfortunately, it's not something I usually jump to unless someone really has a large, large defect. In this 13-year-old, I'm just hesitant to place an implant for someone that  young. And I don't know that I can say I know the data for the pediatric population for something  like that or if there even is that. But it's a great question. I think what it shows is that we have a long ways to go with cartilage regeneration and repair. And especially in  these young kids with these larger defects, we don't have a right way. So, I'm interested to see what will happen in the future with something like that.  All right, guys. Well, that's 9 o'clock. I really want to thank our panelists for being here this  evening. I think that I love going through pediatric topics, and it's certainly something  that's a bit overlooked oftentimes by our, you know, in our adult society. And so, I felt this was great. I just really appreciate all of you being here tonight. Thanks so much.

Video Summary

In this webinar, our panelists discussed pediatric foot and ankle management, including deformities and sports injuries. The cases presented included a 10-year-old with a loose fragment in the ankle joint from a trampoline fall, a 15-year-old with chronic ankle pain following an inversion injury, and a 13-year-old with recurrent issues after a motorbike accident. The importance of accurate imaging, such as X-rays and CT scans, was emphasized to assess and classify the extent of the injuries. Treatment options ranged from conservative management to surgical interventions, with considerations for bone grafting, debridement, and bone marrow stimulation. With a focus on the pediatric population, the panelists highlighted the need for individualized treatment plans and monitoring for optimal outcomes. Thank you for joining us in this discussion on pediatric foot and ankle conditions.

Asset Subtitle

Moderator: Jacob R. Zide, MD
Faculty: Elizabeth Hubbard, MD; Philip McClure, MD; Arianna L. Gianakos, DO

This webinar will delve into common pediatric deformities and sports injuries often seen in adult foot and ankle clinic. Renowned experts in pediatric deformities from POSNA and AOFAS will share clinical insights and strategies for managing pediatric and adolescent deformities, along with sports injuries.

At the conclusion of this webinar, learners will be able to:

Recognize and diagnose prevalent pediatric deformities and their sequelae
Comprehend and indicate conservative surgical management of club foot, growth plate injuries and their sequential deformities
Gain insight into special considerations for managing pediatric and adolescent sports injuries

Funding for the 2024 Foot and Ankle Focus webinars is provided by the Orthopaedic Foot & Ankle Foundation, supported in part by a grant from Stryker.

Keywords

pediatric foot and ankle management

deformities

sports injuries

trampoline fall

chronic ankle pain

inversion injury

accurate imaging

X-rays

CT scans

surgical interventions