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Hello, everyone. Uh Thank you very much for coming today. Um We've got a lot of very interesting talks planned for us. Um, but before I begin, could I just confirm, um, that everyone can see and hear me if someone could type something in the messages box? Perfect. Thank you. Um, so, uh I'm just gonna start with a bit of an introduction. Um So what is Bs Os? So, Bs Os stands for the British Society for Children's Orthopedic Surgery. It was founded in 1984 to promote pediatric orthopedic surgery in the UK. So what do they offer medical students? Well, the annual meeting is coming up, uh on and it's on the 7th and 8th of March. Um, so save that date and if you're a medical student and you want to present audit or research, um, at the meeting, then we've got a special offer for you because it's free to attend. However, if you're not going to present anything, um, we do have discounted tickets. So, um, that is another benefit of being a member. We've also got the medical student Bursary which covers up to 500 lbs if you've got an elective or if you're presenting some research at a different um at a different conference about pediatric orthopedic surgery. Uh And last, but not least we give medical students the opportunity to network and find mentors. So I'm also gonna give you a quick intro about SAR. So Bomb SAR stands for the British Orthopedic Medical Students Association and this is a student led society uh aiming to enhance early and positive exposure to torment orthopedics through various ways such as mentorship, research opportunities, conferences and events and educational lectures and webinars. They also allow and facilitate collaborations between medical schools to create collaborative events and they are here to support your journey on becoming an orthopedic surgeon. So just uh to go through the agenda and some housekeeping rules. So first, um we'll be hearing about neuromuscular de disease uh from Mr Peterson who unfortunately can't make um the event today, but he's kind very kindly since it's a recording which we're gonna play, then we're going to hear about hips from MS Janet mccall. Then we're going to hear about limb reconstruction from Mr Mike Reedy. And we're going to hear about Club foot from Mrs Laura De and then we're going to have a discussion forum uh where we're going to talk about things like work life balance and training and any other questions that you have. So throughout the um whole event, if you've got any questions at all, make a note, uh we'll also have time for questions and questions and answers at the end of each talk. Um, but if you don't get to ask your question, uh, keep it for the end because, er, hopefully we can get that answered. Er, and please be respectful. Um, if you post anything in the chat and last, but not least, and most importantly, make sure you have fun. So, without further ado I'm just going to try and share Mr Peterson's talk on um sorry, limb, it's uh limb reconstruction. I, so I think I've accidentally got the wrong order, but we'll go with it. Good evening. And thank you to the organizers of, of this cu why you should become a pediatric orthopedic surgeon webinar. My name is Nick Peterson. I'm a limb reconstruction surgeon from Liverpool and I am gonna try and persuade you that not only should you become a pediatric orthopedic surgeon but a pediatric limb reconstruction surgeon. Apologies for not being able to join you live. Unfortunately, if you're watching this, it means that I've had a problem after landing uh in Germany and er, been unable to log on or perhaps the flight's been delayed and I'm still in the air er, at the time of recording. I am still hoping to join you, but we'll see what happens. So I'm fortunate enough to live and work in Liverpool, which I think we would all agree is one of the greatest cities on Earth and certainly in the United kingdom and that's not just for orthopedics, although in the world of orthopedic surgery, Liverpool does hold a particularly central position. Er, the person here in the middle of the photograph is Hugh Owen Thomas. And to his left is Robert Jones. Those two very famous names in the development of orthopedics, as we know it, er, both came from and worked in Liverpool for much of their lives and there have been many famous professors and influential thinkers that have come from Liverpool over the years. Um, you'll have all heard of, er, Dan Perry, er, who I am lucky enough to work with at the, er, new iteration of older Hay Children's Hospital in Liverpool. And I also work with a huge number of other people in a very exciting and dynamic team, er, that, that, um, delivers limb reconstruction surgery as well as children's orthopedics in older hay in Liverpool. So pediatric orthopedics, children's orthopedics is where the rest of orthopedics originates. This picture which you'll recognize as the symbol of orthopedics for almost every orthopedic society around the world is the tree of Andri. Andri was a Parisian er, physician who in 17 41 published this work, the art of preventing and correcting the deformities of Children. And it's from this work that we get the first use of the word orthopedic, meaning straight or free from deformity and child. So, straightening a child correcting deformity in a child that is the origin of orthopedics therefore, limb reconstruction in a child is the origin of orthopedics. So, pediatric limb reconstruction is in its very essence orthopedics. So, what do we do in limb reconstruction? Well, we, we look to prevent and correct deformity and the prevention is, is something we can do to a much greater extent in Children than we can in adults. We also manage complex injuries. We manage delayed non union and mao union occasionally and we, we manage um bone infection. So most people are familiar with er Paley, a famous orthopedic surgeon from America who came up with a number of rules relating to deformity correction. And most people think about limb reconstruction as involving these lines drawn as part of the mal alignment of mala orientation tests and then axis being drawn to define a geometric point that can be known as a cora and that core then being divided into a transverse bisector line and that transverse bisector line then having um the one cora defined and you can decide where you put your osteotomy. You can decide where you're going to put your um axis of correction of angulation. And you can apply these principles in real life cases. You can see in this adolescent patient. And by the way, that's the great thing about pediatric orthopedist. You don't just treat Children, you also treat adolescents who are essentially adults. So you get to do everything you get to do the best of both worlds. But we can apply those principles that planning deformity analysis. We can use software, simple software to simulate our deformity correction and plan our cases. And then we can deliver that with really exciting technologies. So this is an example of a type of Hexapod combined, combined with a circular frame to produce a lengthening of bone and a correction of deformity and to reduce the frame time, we've taken away the, the frame here and apply the plate and this has allowed the child to come out of that frame so that they don't have to spend too long there and look at what's happening there. Bone is filling the gap, distraction, osteogenesis. So bone forming where it's been gently, slowly dragged out and actually not just bone has formed there, all sorts of new tissue has formed distraction hist as described and developed by this man Gavril Ilizarov. But we look to try and push the boundaries as well in the reconstruction. So we know that you can use external frames, external fixators to correct deformities. But we also know that Children don't particularly like that and often have a difficult time of it. And we know that we can use our technology to look at the bone age and work out how, how much growth someone has left in this same patient a few years later who's had a poor experience with lengthening with a fixator. We've elected this time because he's very close to growth even though he has an open physis to lengthen, actually using an intramedullary lengthening. Now. So here I'm positioning the intramedullary lengthening. Now, it's now in that distal femur and you can see the cable that's tunneled out of the epi epiphysis, not er not across the ps er, and that allows us to um prevent damage to the growth plate. And you can see here that not only is the distraction, osteogenesis, distraction histogenesis happened with the lengthening now. But also if you look very carefully, you can see that distal femoral physis continuing to grow. And this young man on his second bout of lengthening, er had to only wear this extension splint to maintain his knee range. Just an example of the use of innovative technology in limb reconstruction. So let's go through some other cases and things you might be involved with if you chose to do pediatric limb reconstruction. So we're often asked to deal with complex trauma by our colleagues. This young lady came in as they tend to do very late in the evening. And there are some clues here on the x-ray due to the soft tissues that this was not A I DS straightforward injury. Er And indeed, when you look at the soft tissues more carefully, it's clear that this er is er not just a a significant mechanism of injury, but it has damaged the soft tissue envelope to the extent that this is an open fracture and it's important to work closely with your colleagues. So we have strong links with our plastic surgery colleagues. And even though this looks like a very small hole, the extent of degloving and the high energy nature of this injury meant that after an adequate debridement of the dead skin, this is what we were left with. And so as a a combined team, we produced a temporary skeletal stabilization. After appropriately debriding and removing the dead bone, we stabilized to the point that our colleagues could access and produce a free flap as well as split skin graft for coverage. And then due to the loss of bone, we were able to go back and apply a frame for lengthening and deformity correction. So as to achieve equal limb lengths and effective treatment with union and the growth plates, you can see again, have remained intact. So that's dealing with some acquired pathologies. What about some congenital pathology? Well, one of the nice things about limb reconstruction is you're not confined to one limb or one body part, you can treat upper limb and lower limb. And that's certainly the case in pediatric orthopedics much more than in adults. So, in radial aplasia, here we have a very young child. Often this involves an awful lot of multidisciplinary working because of association with syndromes such as Vatel and there are many others associated with radial aplasia, but that can affect the development of the organ systems in the body. But once that's been sorted out with your colleagues, you can move on to looking at whether correction might be the best option. Um And this is an example of er centralization. Er so you can see the initial position here of that er er hand and arm in this unilateral case after er MDT assessment and counseling that parents opted for correction. This is the again application of the principle call with the identification of a cora the simulation and planning leading to execution in the operating theater and the correction of a a severe deformity to the point where now um there is a hand on the end of the forearm, much, much more functional than it had been before proximal femoral focal deficiency or um a type of longitudinal deficiency. These cases are extremely rare. But if you do pediatric orthopedics as a subspecialty, you tend to work in a specialist center. And if you do limb reconstruction, again, you tend to work in a tertiary referral specialist center. So we get to see a lot of these really exciting and rare cases. So you can see in this very immature patient um who is taken very shortly after birth within the first year of life. It's very difficult to see that proximal femur. You can just about pick up the femoral epiphysis in the acetabulum on the right hand side. But the rest of the proximal femur does not look very normal at all and much later in life at the point where I met him and this was the position and you can see something quite strange happening there in the proximal femur. You can see that there has been treatment using a Symes amputation. Prosthetic reconstruction is often just as good, if not better than, than reconstructive surgery itself. But this lad had got to adolescence or just getting to adolescence and um was at a point where his hip was really causing him problems. And you can see with this 3d reconstruction of the proximal femur, the knee and the leg on the right side, that the reason he's getting some symptoms of pain and discomfort around his right hip is that he has a classical deformity that's associated with PFD proximal femoral focal deficiency where the proximal femur is abducted, flexed, it's rotated and the hip abductors are really def functioned. So this young man was essentially functioning as an above knee amputee. Would he had an issue bearing er prosthetic limb which was had to have a sling around his body and he was really struggling to get by. So again, after MDT counseling and with a lot of heads together, myself and my colleagues went in and produced a procedure called A to MDT Counseling. And with a lot of heads together, myself and my colleagues went in and produced um a uh uh a procedure called a super hip where we've reconstructed the proximal femoral anatomy. You can see the relatively small size here of the limb we've opened. Um and the osteotone there is in the pelvis. Er, you can see the retractor there posteriorly, um which is round at the sciatic notch. You can see there is a blade plate that's been positioned in the femoral neck and we go on to er, correct both the pelvic anatomy by reducing the acetabular index and producing a stable hip, but also the femoral anatomy by shortening and um bringing the femoral neck and the proximal femur back into a more normal relationship with the distal femur. And this results with the image on the left of your screen showing immediately postoperatively and then the image on the right showing an x-ray taken just last week in my clinic ahead of his metalwork removal, you can see how the proximal and distal femoral growth plates are both growing. And this young man um was able to demonstrate to me how he can now walk independently without walking aids in his new prosthetic limb. This video was taken just last week. He showed me that he can now voluntarily ad duct, his right lower limb, um which he wasn't able to do prior to surgery. He also showed the new prosthetic limb which had been fitted just the week before. So he's awaiting a def definitive um limb. But you can see here, the the socket here is no longer an issue bearing there's no suspension around the waist or the body. This essentially is a below knee type prosthetic accommodating his previous sons, amputation and allowing him to walk independently and giving him the confidence to um, get on with life in a way he couldn't do before. I didn't record the video of him clicking his heels together, er, as he left the clinic but he's had a really successful outcome. This young man was also, um, er, kind enough to share some photographs of his recent, er exploits with the England Amputee Football Association where it looks like he is a er a new star striker. So in general doing pretty well, tibial, he emilia has an incidence of around one in a million and therefore, it's extremely unlikely that you will come across a condition such as tibial hemimelia unless you are working in pediatric limb reconstruction. So when, when our team met this young man, he was very young and you can see from the er radiographs here that there is an abnormal relationship between tibia fibula, talus, calcaneum and foot. And you can see here that there is diastasis of the two joints here, an abnormal development of the distal part of the tibia, particularly you can see here, the foot and ankle rising up to lie between the tibia and fibula. And these clinical images show how the foot is in completely the wrong position. Um and this was causing significant issues with mobility and his parents were concerned that this would get worse over time. So again, after a long consultation process with multidisciplinary involvement, including potentially the option of amputation and consultation with prosthetist and rehab physicians. This family elected to have treatment using a technique to bring the feet down to the correct position and then in that corrected position to hold them there and try to try to affect an ankle fusion and he has a significant amount of treatment ahead of him. Um but we've had a number of very positive er um contacts from family showing his first days in preschool and school and his independent mobilization with his feet in a chewable plantar grade position. I'm going to finish off with um one of the most unusual procedures that you may come across in orthopedics. Another case of proximal femoral focal deficiency, but this time without any proximal femur present at all, no evidence of a femoral head. Um and a complete er aplasia of the, of the proximal part of the femur. You can see here, the 3D model that was produced from a CT angiogram and you can see the, the plain films showing the presence of a knee and ankle joint. Er, but the absence of the proximal femur, there are many options and prosthetic reconstructive surgery is certainly one of them. So, an extension prosthesis or a simes amputation would certainly have been options. But again, with the experience of our unit and after consultation with the parents who'd done a lot of due diligence and spoken to limb reconstruction colleagues around the world, they elected to go ahead with a rotation plasty and we were able to join forces in the UK um with James Fernandez from Sheffield joining my colleagues and myself in Liverpool, er and affecting this treatment, er a rotation plasty um which has successfully resulted in a young lady who can now independently mobilize and having achieved union er has now actually left the country and the parents were able to share with us some pictures as she starts her her journey after er rotation plasty, going to school and continuing on with her life. So I hope that this very brief talk and a quick insight into some of those cases has wetted your appetite uh as to what a career in pediatric limb reconstruction might be like, it is a real privilege to work with such a fantastic team as there is at every center for limb reconstruction and every center for pediatric orthopedics around the world. And it really is a global specialty. The opportunities for travel and for improving your understanding are pretty much endless. Our unit has links in the United States in South Africa, in Australia, in New Zealand, and the rest of Europe, it goes on and on and it really is a fantastic specialty that is pushing the boundaries and looking to further improve outcomes for the Children and young people that we have the privilege to treat. I would encourage you all to seriously consider a career in pediatric orthopedic surgery. We've established that limb reconstruction orthopedics, straightening the child. That is what orthopedics is literally all about. So, if you any questions or any, um, if you are interested and you want some more information, please do get in touch, you can find contact details on the website here or directly through B KOS. Er, and I wish you all the very best, er, for the rest of the evening. And thanks again for having me, my sincere apologies for not being able to make it live well. I think, um, after that amazing talk, at least a small proportion of our audience would have chosen to go into pediatric orthopedics. But if not, they're not, we've still got a few more talks to convince you.