Boys,

I was going through Peds and found my Hamdy sessions notes. I thought you might like
to get in on them. At least I got something for my three months of pain and illegal
amount of call. I’m only going to include the tasty morsels from the Hamdyman here,
we’ve all read the review articles and Wheeless for the basics.

LCP
He started off by asking most likely dx in setting of hip pain/limp in a 18mo old, 6yr old,
and 12yr old – DDH, LCP, SCFE – don’t forget to r/o septic

Emphasized that if this is a case, state to the parent/examiner that treatment of this is
controversial. That most kids <8 do well no matter what you do. >8 and Herring C’s
don’t do so hot regardless of treatment.

My reading has revealed 2 principles of treatment – ROM and Containment. Dark

Helmet breaks it into 3 – Acute presentation/synovitis, ROM, and Containment
Synovitis- NSAIDS, short term bed rest
ROM- Physio x 6 weeks, if fails then inpt traction for two weeks with pt coming
Out of traction three times a day for intensive physio (meds prn to aid PT,
Traction really is just to keep the kid NWB and decrease activity level as
We know that studies show transfers or getting on a bed pan in a bed still
Puts several times bodyweight through the hip- which is why NWB after
Cementless THA doesn’t make sense).
If fails then Adductor tenotomy/arthrogram/Petrie cast (6wks).
(Arthrogram to asses shape of head, best position for containment by
Casting, and asses for hinge abduction).
Containment- He said if you need to do anything surgical more than ROM stuff
Just think Salter. You can say that there are many options, but none are
Proven the best. Just think Salter. Consent for Salter +/- Varus
osteotomy (Possible derotation) just in case they say you do the Salter and
you still don’t have containment intra-op. AB/IR pelvis film pre-op shows
you what you’d get from VDRO

Hamdy said this was a case for him on his exams and we know it was a case 2 years ago.
What is likely going to happen in the scenario is you eventually get the patient presenting
at 15 years old with a destroyed hip (DH). Don’t forget to r/o infection if previously had
surgery.
DH + pain- fuse (Cobra is out, want to keep Abductors in tact for future THA,
Remember pt needs all other lower extremity joints ok including spine,
Pick a fusion technique and know it)
DH no pain + varus deformity (likely prior VDRO)- Reallign with Valgus
Osteotomy (this is where a valgus osteotomy for LCP comes into play,
Also –just me thinking not from Hamdy- maybe consider Shelf)
DH no pain no deformity- Leave that shit alone
Concerning Varus and Valgus osteotomies, stated that you need 30 deg of Abduction
pre-op for a Varus, 30 deg of adduction pre-op for a Valgus.

Herring Classification is the best.

Know your head-at-risk signs. (Calcification lateral to the epiphysis, metaphyseal cysts,
lateral extrusion of head, Gage’s V-sign, horizontal physis)
Remember to say you would consult or at least discuss the case with an experienced
Pedipod at least by the time you get to an osteotomy for containment.
Pts at extremes of presentation consider metabolic etc. With a normal presentation in an
appropriately aged patient do not need to work up metabolic or hematologic angle.
Think dysplasia if B/L, especially if symmetric. B/L 10% of time normally but usually in
different stages.

Cavus Foot
In general, pick a few milestones and know them. This came up because we did this as
an oral case and in the history we asked for PMH, birth hx, milestones, etc. He said if
you’re going to ask for it, know what you’re looking for – don’t just randomly ask
everything on your template. I’m picking rolling over 5mo, pull to stand 10mo, good
walking 15mo, hop on one foot 5yr (Denver Developmental Exam). Save Moro,
Parachute, Neck Tonic, etc. for CP (know these)

The Hamster seems to think we should be able to discuss Charcot-Marie-Tooth

relatively intelligently.

Keys in History – family history, ankle instability, pain (1st MT head, lateral border),
callosities, claw toes, progressive, shoe wear, neurologic associated symptoms.

Hamdy’s OR – “I would address both the muscular imbalance and bony allignment.”
He does the following in order, but stops to re-evaluate varus correction of heel along the
way. He doesn’t just go by stiff Coleman Block = calc osteotomy (but on exam I think
stiff varus does indeed = Dwyer).
Tib Post- release first thing, actual transfer is the last thing. He transfers Tib
Post Every time
Radical Plantar release- dissect out n-v bundle first, plantar fascia and AbHL,
QP, AbDQ all are released off of calcaneous proximally
Medial Release- FDL, FHL, Spring lig, short and long Plantar lig
Capsulotomies- Talonavic, tibiotalar, subtalar, claccuboid
Dorsal closing wedge of 1st MT- CMT has a pronated-plantarflexed 1st ray from
Trying to tripod
Dwyer
Midfoot osteotomy

Triple is the salvage

Jones Procedure for rigid claw toes- capsulotomy, extensor transfer, cut flexors,
k-wire
I got worked up during this case (go figure) and started addressing the surgical issues
before getting a diagnosis. As I’m sure you all know, MUST HAVE A DIAGNOSIS
PRIOR TO STARTING TREATMENT. MRI spine, Ped Neurologist consult (EMG/
Conduction studies), Ped Neurosurg consult if find something. Remember Cavus is
not the diagnosis, it’s the manifestation.

Tibial Hemimelia
Quick over view of tibial bowing came first
Posteromedial- Physiologic and benign, tell parents deformity will correct over
Time, there will be a LLD wich may or may not need treatment,
Associated with calcaneovalgus feet (also benign).
Anteromedial- Fib Hemimelia (will discuss next)
Anterolateral- Congenital pseudarthrosis (50% have NF, but only 10% of NF
Have it)

Only long bone deficiency with a known inheritence pattern (AD).

Work up for VACTERL is the most important thing about this case if it is one. They
often have other bony abnormalities as well (lobster claw hand, severely supinated
equinovarus feet with the sole of the foot facing the perineum).

Second most important thing is determining if there is an intact extensor mechanism.

IB lesions intially show no proximal tibia, but there is (say it with me) an anlage. I love
that word. He said not to sweat classifications in general. Just describe what you see.
There’s either complete absence, the proximal is there, the distal is there, or there’s a
diastasis. The Hamdyman doesn’t think this is very likely case to get, but whatever.

Treatment- just pick an algorithm from reading and use it. Severe deformities get a
knee disarticulation, or you can try a synostosis and a Symes to create a functional
BKA. This did bring up a good discussion about amputations.
In kids, it is always better to disarticulate than amputate through a bone.
Amputations should be done before 1 year- this coincides with walking
age, but most importantly for kids- it is better psychologically because if it
is done before 1 year they won’t remember ever having the amputated
part.

Fibular Hemimelia
Most common long bone deformity. Bows anteromedial. Biggest issue is determining
if there is a salvageable foot and dealing with the LLD. Also associated with PFFD,
hypoplastic patella, hypoplastic lateral femoral condyle, cruciate instability, valgus
unstable ankle, and absent lateral rays.

Ball and socket ankle- yes there are coallitions, but he said to think about it as an ankle
with no lateral buttress therefore the incresed degrees of freedom create a ball and socket
joint as opposed to the regular hinge. Therefore it’s not just the coallitions that create it.
Again, screw the classification (especially that rediculous one that the tool box from the
Florida Shriners present at Rogala a few years ago), just go with hypoplastic or absent.

If there is a salvageable (sp?) foot i.e. not too many rays absent and can have an end
result with a functional and stable foot and ankle, you can try reconstruction and deal
with the LLD (more later on LLD). If not, Symes by 1 year. If family is absolutely
100% positively not aggreeable to amputation even if indicated, you still need to treat the
patient. Go conservative first with bracing, even getting into lengthenings. However,
Hamdy and Fassier both have stories of patients undergoing multiple surgeries, with
multiple complications and infections that asked for their legs to be whacked off when
they were older. Need to stress these complications to the family when getting into
treatment options.

This got us into a good discussion about LLD in general.

“To base my treatment I would calculate the patient’s expected LLD at
maturity.”
Simple on the spot method- girls grow until 14, boys 16. Length roughly 2cm
Per year (.9 distal fem, .6 prox tib) Also know that ankle and hip each
Give another 2mm/year. (In the arm it is opposite- prox humerus and
Wrist give the most longitudinal growth).
Mosely growth chart- be able to bluff your way through a description of how to
Use it.
Always, always start with conservative- nothing, shoe lift, extension brace. I
Prepared a Rogala case last year (yes-one of the two that was useable)
Where this kid had PFFD and at least a 30cm LLD that was walking
Around ok with an extension brace (regular foot locked into a platform
With a long post and strap around waist)
<2cm- usually nothing or a shoe lift. If using more than 1cm of lift then have it
applied to the outside of the shoe.
2-5cm-traditionally stated as planned epiphyseodesis. However, you can do a
lengthening, or even a shortening of the contralateral, or combo platter.
Shortening- if done, do it at skeletal maturity. Also >5cm shortening bunches
Up the soft tissues (functionally lengthening the muscles and making
them less efficient) with the big problem being kinking of the N-V
structures.
5-15cm- Traditionally lenghtening. But again, can use all you got in the
armamentarium.
>15cm- Traditionally do the chop. However, these crazy bastards can +/- will
Lengthen just about anything while also using all other methods.
Lengthening- 1 month in the frame/cm of lengthening. Can do multiple
Lengthenings. People usually stop at two, but the boys have done 3.
Each time can lengthen up to 30% of bone’s length at that time. Ouellet
Actually did a research paper with them as a resident and found that
>30% at once dramatically increased the complication rate. Also need
to pre-op warn parents of complications.
Hole in Bone
This was an awesome session, he just put up xray after xray and we went through the
differential. However, that means I didn’t take any notes and have forgotten all the
Hamdy nuggets of info above and beyond what we have already prepared and read 

DDH
Benny suprisingly was very good with this, nothng really to add from the Helmet.